Severe insulin resistance and diabetes mellitus in mandibuloacral dysplasia

Mandibuloacral dysplasia (MAD) is a syndrome with onset in midchildhood. The predominant characteristics of MAD include flexion contractures; mandibular hypoplasia; loss of body fat; atrophic, speckled skin; and progressive osteolysis of the clavicles. We studied three males with MAD. Each had lipodystrophy of the extremities, with sparing of the face and neck. All had moderate hyperlipidemia. In response to oral glucose, each had a diabetic response, with peak insulin levels between 2870 and 22,960 pmol/L. Insulin-stimulated glucose disposal was determined in two patients with MAD. At an insulin infusion rate of 120 mU/m2 per minute, glucose disposal was less than 25% of that measured at similar levels of insulinemia in nondiabetic control subjects, indicating marked insulin resistance in patients with MAD. The insulin resistance occurred without obesity, excessive levels of counterregulatory hormones, or anti-insulin-receptor antibodies. We suggest that MAD is a previously undescribed form of lipodystrophic insulin-resistant diabetes mellitus.

New syndrome: mother and son with hypertelorism, downslanting palpebral fissures, malar hypoplasia, and apparently low-set ears associated with joint and scrotal anomalies

We report on a mother and son with a similar syndrome of hypertelorism and telecanthus, epicanthal folds, downslanting palpebral fissures, ptosis, broad nasal bridge, malar hypoplasia, thin upper lip, smooth philtrum, and apparently low-set prominent ears. The son also has a hypoplastic shawl scrotum, cryptorchidism, and genu valgum. His language development was delayed at 18 months, but subsequently improved and was normal at age 3. The mother has the additional findings of marked cubitus valgus, hyper-extensible joints, dull normal intelligence and a bleeding diathesis. This pattern of multiple congenital anomalies may represent a new syndrome.

Neu Laxova syndrome in two Egyptian families

We report on 2 Egyptian girls from 2 families with 8 affected relatives, 4 in each family. The 2 propositae had unusual facial appearance, severe microcephaly, generalized edema, contractures of limbs, and generalized ichthyotic skin lesions. Findings in the present 2 patients were compared with those in previously reported cases of Neu Laxova syndrome. In our cases, consanguinity, affected sibs, and affected cousins were noted. Autosomal recessive inheritance and lethality are emphasized. A high frequency of the Neu Laxova syndrome in Egyptians is suspected as a result of the increased consanguinity rate.

A new form of autosomal dominant arthrogryposis

We report a man and his son with congenital limb contractures, limitation of ocular movements, and an electroretinal abnormality. They appear to have an autosomal dominant form of arthrogryposis, distinguishable from other previously classified forms of this disorder.

Familial Ebstein's anomaly: a report of six cases in two generations associated with mild skeletal abnormalities

In a family of 11 persons in three generations six had Ebstein's anomaly. Five of the six showed mild skeletal anomalies--that is, restricted finger extension, with or without limitation of larger joints, and externally rotated little toes. Two other members of the family had the skeletal features without Ebstein's anomaly. The findings suggest a dominantly inherited syndrome of Ebstein's anomaly and skeletal abnormalities. The four female patients were all mildly affected whereas three of the four male patients were severely affected.

Pachygyria, joint contractures, and facial abnormalities: a new lethal syndrome

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Unknown syndrome: pachygyria, joint contractures, and facial abnormalities

A male infant, the offspring of a father-daughter mating, is described. He had a lethal condition consisting of brachycephaly, large fontanelles, a flat face, a small nose with thin nares, hypertelorism, small ears with cystic pinnae, camptodactyly, talipes equinovarus, and hypoplastic lungs and kidneys. The brain was very short in the anterior-posterior diameter with simplified broad convolutions (a form of pachygyria).

Osteogenesis imperfecta with congenital joint contractures (Bruck syndrome)

Five children from three unrelated families were born with symmetrical contractures of the knees, ankles and feet. An initial diagnosis of arthrogryposis multiplex was made, but frequent fracturing occurred after walking commenced and it was then recognised that the children had osteogenesis imperfecta. The pathogenesis of the congenital contractures is unknown, but the symmetry and lack of evidence of prior fracturing is suggestive of articular immobility during early intra-uterine development. The consistency of the anatomical distribution of the contractures, in the setting of a uniform OI phenotype, is suggestive of syndromic identity. A similar case was documented by Alfred Bruck in 1897 and we propose that the eponymous designation "Bruck syndrome" should be applied to the disorder.

Radiographic diagnosis of hereditary chondrodysplasia in newborn lambs

Normal appearing Suffolk lambs affected with hereditary chondrodysplasia (HC) and normal appearing unaffected lambs were radiographed at birth, and at 2, 4, and 8 weeks of age. In affected lambs, lesions were seen consistently in the elbows, shoulders, sternum, and spine. Similar lesions were not identified in unaffected lambs. A malformed Corriedale lamb was radiographed to compare its lesions to those seen in HC. The Corriedale lamb had islands of ossification of the anconeal process similar to those identified in lambs with signs of HC at birth. The islands of ossification seen in the Corriedale lamb were fused by 2 months of age, whereas elbow lesions seen in lambs with HC increased in severity during the same period.

A further patient with the lethal type of Larsen syndrome

We present a female infant with multiple joint dislocations, flat facies, cleft soft palate, redundant neck skin, pulmonary hypoplasia, and skeletal abnormalities.

[A complex symphalangia syndrome with brachydactyly, humeroradial synostosis and other multiple joint dysplasias]

Two members of a family affected with autosomal dominant multiple synostosis syndrome and malformations of various joints are presented, the most prominent signs being humeroradial synostosis and symphalangism. Moreover, dysplastic hip joints and familial conductive deafness as well as craniofacial abnormalities are observed. The present report may serve as an introduction to the complex radiological pattern in patients with hereditary brachydactyly syndrome.

Failure of articular process (zygaphophyseal) joint development as a cause of vertebral fusion (blocked vertebrae)

Examination of congenitally fused (blocked) vertebrae in this study suggests that non-development of the joint between articular facets results in fusion of the vertebral arches which in turn leads to secondary fusion of the bodies and hypoplasia of the intervertebral discs. The presence of independent pedicles and transverse processes do not favour the concept that such an abnormality is the result of non-segmentation of the sclerotome. The condition is probably linked to a defect of an inductor substance which influences normal morphogenesis of the vertebral arch in the embryonic period.

Congenital elbow dislocations

Three categories of congenital elbow dislocations are described in the literature: humeroulnar, humeroradial, and dislocation or joint laxity with other congenital anomalies. Congenital humeroulnar dislocation is a well-defined problem that occurs predominantly in small breeds of dogs and causes severe limb deformity and dysfunction. Early reduction and stabilization are simple to achieve and have provided good results. Radial head dislocations occur most often as a result of growth disturbance of the radius and ulna. There is a lack of conclusive information on congenital radial head dislocations. Regardless of the etiology, radial head dislocation causes rather mild deformity and lameness and can be treated by conservative management, surgical correction, or radial head ostectomy. Dislocation of the elbow may occur concurrently with other rare congenital anomalies and has been described with ectrodactyly and polyarthrodysplasia.

The origin of prenatal and postnatal deformities

Deformities are abnormalities of shape or form caused by abnormal or imbalanced mechanical forces. In prenatal deformation, most infants are intrinsically normal and the deformation results from extrinsic constraining forces. Most prenatal deformities will resolve spontaneously or with the application of counteracting forces. In contrast, postnatal deformities result from either extrinsic pathologic processes, affecting the bones, nervous system, or muscle and resulting in the application of abnormal forces to bone, or normal forces acting on intrinsic diseases of bone. While many postnatal deformities can be contained or corrected by the application of counteracting forces, aggressive physical therapy, casting, or surgery is often required for correction.

[Pathogenesis of radiation-induced abnormalities of the bones and joints of white rat embryos]

After X-radiation of pregnant rats on the 10th day of pregnancy, in 50% of the fetuses studied subtotal aplasia of the tibial bone anlage and decreasing number of the metatarsus and finger phalanges anlages are observed. Radiation on the 11th day of embryogenesis does not result in anomaly formation of the thoracic and pelvic extremities. After radiation on the 12th day of embryogenesis, the most specific anomaly of the pelvic extremity is phocomelia. The thoracic extremity skeleton lesions are revealed as an ulnar type of distal ectromelia, or axial ectromelia. After radiation on the 13th--14th day, hypoplasia of the bone anlages, that make zeugopodium, autopodium, is observed. After radiation on the 13th day, a partial or total aplasia of the fibular bone anlage can take place. In all the fetuses a sharp decrease in number of the hand and foot bone anlages is observed; it is connected with a total aplasia of some of them and with fusion of the others. A specific feature for radiation lesions of the extremity skeleton is that the oppositely situated anlages of the bones do not separate from each other. This results from certain disturbances in the joint interzone formation at early stages of embryogenesis and from underdevelopment of the joint cleft. Qualitatively different radiation anomalies of the extremity skeleton development are formed as consequence of disturbances in morphogenetic processes of determination: migration, proliferation, morphogenetic cell death and differentiation.

Weill-Marchesani syndrome with bilateral angle-closure glaucoma

To our knowledge this is the first reported case of cyclopentolate induced bilateral acute angle-closure glaucoma associated with the Weill-Marchesani syndrome without lens subluxation. The diagnosis of Weill-Marchesani syndrome was not initially suspected, and Pilocarpine was used in an attempt to break the acute attack. Treatment with Pilocarpine-induced myosis only worsened the glaucoma by causing a severe pupillary block. This case is important because it demonstrates that mid-dilatation and cycloplegia can induce acute glaucoma in patients with the Weill-Marchesani syndrome and points out the importance for considering the diagnosis of Weill-Marchesani syndrome in any case of acute glaucoma in childhood.

Duplication of hands and feet, multiple joint dislocations, absence of corpus callosum and hypsarrhythmia: acrocallosal syndrome?

We describe a 14-month-old female infant with absence of corpus callosum, atrophy of optic nerve, peculiar face, complex polydactyly, multiple joint abnormalities, and femoral shortness. The similarities to and differences from previously reported cases of this kind suggest that our patient has a new type of acrocallosal syndrome.

Diagnostic considerations in arthrogryposis syndromes in South Africa

Congenital rigidity of multiple joints poses a difficult diagnostic and therapeutic problem. There are also semantic difficulties as the non-specific term "arthrogryposis" is often used for any individual with congenital limitation of joint movement. Many distinct syndromes present in this way and as they differ in their course, prognosis and genetic implications, diagnostic precision is crucial. A diagnostic analysis is given of 247 South African patients in whom "arthrogryposis" had been recorded, and the pathogenesis and nosology of congenital contractures are discussed in this paper. Three of these stiff joint conditions were originally described in South African patients, i.e. Liebenberg synostosis syndrome, digitotalar dysmorphism, and the Gordon syndrome of autosomal dominant cleft palate, camptodactyly and club feet.

The Neu-COFS (cerebro-oculo-facio-skeletal) syndrome: report of a case

A newborn female with a phenotype intermediate between the Neu and the COFS syndromes is described. The hypothesis of the two conditions representing different degrees of severity of the same autosomal recessive mutation in the homozygote state is discussed.

Arthro-osteo-renal dysplasia. Report of a case

A rare case of bone dysplasia with moderate modelling anomalies of the long bones, joint dislocation, osteolysis, a congenital calvarial defect, a patent ductus arteriosus, a mild degree of hypospadias and hypertensive renal cystic dysplasia is presented. In spite of many similarities with the Hajdu - Cheney Syndrome (HCS), important dissimilarities indicate that this case may be either an extreme variant of HCS, or a closely related, separate entity for which the term Arthro-Osteo-Renal Dysplasia is proposed.

Mannosidosis in two brothers: prolonged survival in the severe phenotype

Two cases of mannosidosis are reported in brothers, one aged 41 years at death, the other aged 40 years and still alive. These patients are the oldest reported in the literature. Prolonged survival has previously been associated with the milder Type II phenotype. In addition to the characteristic clinical and radiological features of mannosidosis, both had severe joint destruction, which may be related to abnormal lysosomal enzymes in cartilage. The activity of acidic alpha-mannosidase was markedly reduced in plasma, leucocytes and fibroblasts, and the altered kinetic and physical properties are described.

The Antley-Bixler syndrome

Three unrelated children (two girls and one boy) with the Antley-Bixler syndrome have been evaluated, bringing to five the number of patients reported with this disorder. All have had brachycephaly, midface hypoplasia, dysplastic ears, radiohumeral synostosis, and joint contractures. Craniosynostosis has been documented radiographically in four of the five patients. All five have had a severely shortened cranial base. Femoral bowing with neonatal fractures has been a variable feature. All have represented sporadic occurrences in otherwise normal families.

Articular and soft tissue abnormalities in a "normal" population

One hundred twenty-three medical students underwent comprehensive locomotor physical examinations as part of their sophomore physical diagnosis course. Sixty-nine point one per cent of subjects were found to have between 1 and 7 separate congenital, developmental, post-traumatic, inflammatory or idiopathic abnormalities. More than 30 different types of abnormalities were noted. The data presented suggest a high prevalence of locomotor abnormalities in a "normal" population, and supports the need for history and physical examinations in the selection of control subjects for clinical studies.

Brief clinical report and review: the Marden-Walker syndrome

We have studied a sibship with one confirmed and three probable cases of the Marden-Walker syndrome (MWS). Our patient had the major manifestations of blepharophimosis and squint; narrowly arched palate with micrognathia; small mouth and mouth-breathing; facial deformities and distortions; congenital muscle weakness with resulting scoliosis; mild pectus excavatum; camptodactylies and hip and finger joints subluxation. In addition, he had small, apparently low-set and slightly malformed auricles with a unilateral preauricular tag. However, he had no apparent renal or cardiovascular involvement. Results of CPK, EMG, and of histochemical, light microscopic, and ultrastructural studies of muscle biopsy do not suggest a primary myopathy but rather CNS related weakness/hypotonia with small muscle mass and hypoactive DTRs. This pathogenetic hypothesis is confirmed by the presence of severe mental retardation and minor brain changes suggesting cortical atrophy. In five previously reported cases there has been microcephaly. Phenotype analysis does not convince that the MWS is a true malformation syndrome, but rather hints at the possibility of a congenital metabolic dysplasia. Genetic analysis demonstrated autosomal-recessive inheritance in this and two other instances; primarily sporadic occurrence leaves open the possibility of genetic heterogeneity.

Postural deformities in congenital nephrotic syndrome

Six successive cases of congenital nephrotic syndrome are described. Each one showed flexion deformities of the knees and hips, widely open anterior and posterior fontanelles, and wide separation of the skull sutures. These abnormalities were present not only in cases in which the renal histology was of the microcystic Finnish type of congenital nephrotic syndrome, but also in those in which the histological picture was one of the variants associated with congenital nephrotic syndrome. It is suggested that such abnormalities are postural deformities, possibly produced by the large placenta.

Neuronal ceroid lipofuscinosis and arthropathy: a family study

A family is described in which three children have neuronal ceroid lipofuscinosis and two of them also have an arthropathy. Clinically the children have the late infantile form but pathological evidence shows the recognised overlap with the juvenile form. A fourth child with joint involvement but with normal skin biopsies is described. It is suggested that this family have a specific form of neuronal ceroid lipofuscinosis with arthropathy and that accumulation of metabolites in this storage disease may be age dependent.

Pentasomy X: report of patient and studies of X-inactivation

A five-year-old girl presented with mental retardation (MR), microcephaly, short stature, ptosis, malocclusion, abnormal elbows, fifth finger clinodactyly, joint hyperextensibility in hands and feet, renal hypoplasia, nonobstructive ureteral stasis, pyelonephritis, and renal failure. Five X chromosomes (49,XXXXX) were found in all peripheral blood lymphocytes and skin fibroblasts examined. Xa RBC typing, utilizing serial dilutions of antiserum, gave agglutination at a higher titer than in either Xg(a+) positive parent; the patient's serum IgM was also elevated. These immunological findings imply a lack of dosage compensation and incomplete inactivation of some X-linked loci.

Peculiar face, pectus carinatum and joint laxity in brother and sister

This report describes a probably new syndrome seen in a brother and sister and characterized by joint laxity, pectus carinatum and a peculiar face with mild frontal bossing, low nasal bridge, lateral displacement of the inner malar hypoplasia, parrot-like nose, chubby cheeks, striking philtrum and arched upper lips.

Teratological hip dislocation

The hallmark of teratological congenital hip dislocation is its advanced severity at birth, signifying longer antenatal duration and accentuation of distortion. There may be contributions from a multiplicity of unrelated syndromes, such as local intrauterine factors, failure of proper formations early in the embryonic period, or genetically determined disorders. Treatment is generally difficult and the end result is uncertain.

Hajdu-Cheney syndrome

Hadjdu-Cheney syndrome is a rare type of syndrome characterized by acro-osteolysis, dolichocephaly with multiple Wormian bones, absence of frontal sinuses and joint laxity. A case of this syndrome is presented. A histological study of the osteolytic lesion revealed destruction characterized by microfractures with a poor reparative process. It is postulated that an abnormality of osteoblast or osteoid function is the pathogenesis of this syndrome.

The Bowen-Conradi syndrome -- a highly lethal autosomal recessive syndrome of microcephaly, micrognathia, low birth weight, and joint deformities

This paper describes six Hutterite children from five families who appear to have been affected by the same syndrome that was described in two brothers by Bowen and Conradi [1]. Our additional cases confirm that the major features of the syndrome include porportionate intrauterine growth retardation, microcephaly, micrognathia, a prominent nose, rocker-bottom feet, joint limitation, and failure to thrive, with death within the first year of life. Bowen-Conradi syndrome is an autosomal recessive trait and pedigree records show that all six families now known are related to each other through two couples born in the late 1700s but that there are additional earlier possible sources of the responsible gene. The differential diagnosis of this syndrome is discussed.

The Marden-Walker syndrome

The characteristic facies, joint contractures, muscular hypotonia, and growth and developmental delay of the Marden-Walker syndrome were present in a 19-month-old boy. Extensive evaluation of the neuromuscular system failed to identify a specific abnormality. Electromyography was normal with low amplitude. Light and electron microscopy of a skeletal muscle biopsy was normal. Histochemical study of this biopsy material was also normal. The pathogenesis of the syndrome is discussed.

Partial deletion of long arm of chromosome 11: del (11) (q23)

The cytogenetic analysis of an infant with multiple congenital anomalies revealed a small deletion of the long arm of one No. 11 chromosome: 46,XX,del(11)(q23). The main clinical manifestations included: ocular colobomata, absent philtrum, severe congenital heart disease, contractures of the large joints and skin pigmentation. Both parents showed a normal chromosome constitution. In comparison to the previously reported cases of 11q-, the patient presented here had more severe congenital anomalies. The correlation of the size of the deletion, and the location of the break, with the physical findings is discussed.

The Stickler syndrome (hereditary arthro-ophthalmopathy)

Three patients with Stickler syndrome are reported. Two of the patients were found among the 26 children attending a special pre-school for the visually impaired. One of the patients had bilateral choanal atresia which may represent an extreme example of the mid-facial hypoplasia commonly seen in these patients. It appears that Stickler syndrome may not be as rare as previously thought.

Porokeratosis of Mibelli with unusual features

A 35-year-old male patient having combination of porokeratosis of Mibelli and porokeratosis plantaris palmaris et disseminata is being reported. In addition, the patient had unusual features of resorption of tips of the fingers and toes along with flexion deformities at the interphalangeal joints and chronic indolent ulcers over the hands and feet.

Multiple epiphyseal dysplasia. A family case report

Six cases of multiple epiphyseal dysplasia were found in a 30-member kindred. The kindred showed an increased incidence of other joint abnormalities. A dominant pattern of inheritance was not confirmed.