Keratoconjunctivitis sicca associated with achalasia of the cardia, adrenocortical insufficiency, and lacrimal gland degeneration: Keratoconjunctivitis sicca secondary to lacrimal gland degeneration may parallel degenerative changes in esophageal and adrenocortical function

Hypolacrimia and Alacrimia as Diagnostic Features for Genetic or Congenital Conditions

As part of the lacrimal apparatus, the lacrimal gland participates in the maintenance of a healthy eye surface by producing the aqueous part of the tear film. Alacrimia and hypolacrimia, which are relatively rare during childhood or young adulthood, have their origin in a number of mechanisms which include agenesia, aplasia, hypoplasia, or incorrect maturation of the gland. Moreover, impaired innervation of the gland and/or the cornea and alterations of protein secretion pathways can lead to a defective tear film. In most conditions leading to alacrimia or hypolacrimia, however, the altered tear film is only one of numerous defects that arise and therefore is commonly disregarded. Here, we have systematically reviewed all of those genetic conditions or congenital disorders that have alacrimia or hypolacrimia as a feature. Where it is known, we describe the mechanism of the defect in question. It has been possible to clearly establish the physiopathology of only a minority of these conditions. As hypolacrimia and alacrimia are rare features, this review could be used as a tool in clinical genetics to perform a quick diagnosis, necessary for appropriate care and counseling.

The use of topical cyclosporine A 0.05% as treatment for primary alacrimia in Allgrove syndrome

INTRODUCTION

The purpose is to report a case on the use of cyclosporine A 0.05% for primary alacrimia in Allgrove syndrome or triple A syndrome (alacrimia, achalasia, and adrenal insufficiency).

CASE DESCRIPTION

A 37-year-old man with achalasia treated surgically 11 years ago presented with sensation of a foreign body, irritation, and intermittent ocular redness for several years. Ophthalmological examination revealed bulbar hyperemia, Oxford grade 4 corneal staining, anisocoria, and optic atrophy. The patient was initially treated with washing with serum and lubricants. Due to the persistence of symptoms, treatment with cyclosporine A 0.05% was started observing a clinical improvement with a decrease in the symptoms caused by tear deficiency.

CONCLUSION

It is important to emphasize the relevance of establishing an early diagnosis through a complete multidisciplinary clinical examination and a study of adrenal function. The treatment of dry eye in these patients is difficult to manage, with topical immunomodulators such as cyclosporine A as a good alternative when lubricants are insufficient. To our knowledge this is the first case of subjective and objective improvement of dry eye using cyclosporine A 0.05% in a case of alacrimia in triple A syndrome. Allgrove syndrome presentation does not always manifest with the classic triad and some symptoms may be not present at the time of diagnosis. Ophthalmologist and pediatrician should consider this syndrome in patients with symptoms as complex as lack of growth, crying without tears, and convulsions.

Congenital alacrima

The congenital absence of tear production or alacrima is a distinctively unusual clinical sign that harbors a wide variety of etiologies. While alacrima can be only isolated to the lacrimal system, it is more often associated with progressive multisystem involvement from underlying genetic disorders. Recognizing the subtle ocular signs in these diseases will promote a timely diagnosis and management before potential life-threatening consequences occur. Hence, the current article will review the ophthalmological findings, systemic manifestations, genetic associations, and differential diagnosis of congenital alacrima.

Triple A syndrome: a case report

Triple A syndrome is a rare autosomal recessive disorder characterised by alacrimia, achalasia and adrenal failure. It was first reported by Allgrove in 1978 and 100 cases have been reported worldwide. This case report concerns a 24-year-old woman who was referred for evaluation of dysphagia and was finally diagnosed as such a case. A high degree of suspicion enables all the components of this syndrome to be searched for, as early diagnosis can reduce the morbidity and mortality.

A broad range of symptoms in allgrove syndrome: single center experience in Southeast Anatolia

BACKGROUND

Allgrove syndrome (OMIM 231550) is a rare autosomal recessive disease characterized by non-CAH primary adrenal insufficiency (non-CAH PAI), alacrima, and achalasia. It is caused by mutations in the AAAS gene. The syndrome is also associated with variable progressive neurological impairment and dermatological abnormalities.

METHODS AND RESULTS

We diagnosed 23 patients from 14 families with Allgrove syndrome, based on the presence of at least two characteristic symptoms, usually adrenal insufficiency and alacrima, between 2008 and 2018. A previously described nonsense variant of AAAS was detected in 19 patients from 12 families at homozygous state. Another novel homozygous mutation (c.394-397delCTGT) in AAAS was detected in four patients from two families. Presenting symptoms were alacrima (23/23; 100%), adrenal insufficiency (18/23; 78%), achalasia (13/23; 57%), short stature/growth retardation (16/23; 70%), hyperreflexia (15/23; 65%), palmoplantar hyperkeratosis (13/23; 57%), hyperpigmentation of the skin (10/23; 43%), hypoglycemia-induced convulsion (7/23; 30%), swallowing difficulty and vomiting (6/23; 26%). Serum DHEAS concentrations were low in all patients (23/23; 100%).

CONCLUSIONS

Clinical symptoms vary even among patients carrying the same mutation. Triple A syndrome should be considered in the etiology of non-CAH PAI in Arab populations and in Southeast Turkey. Any child with non-CAH PAI should be evaluated for the presence of alacrima and/or achalasia or family history of alacrima and/or achalasia. Children with alacrima and/or achalasia should also be investigated for adrenal insufficiency. Definitive molecular diagnosis is essential for early diagnosis and management of adrenal insufficiency, neurological symptoms, and growth retardation in patients and early diagnosis of as yet asymptomatic cases in the family, together with genetic counseling.

ACTH Resistance Syndrome: An Experience of Three Cases

The term adrenocorticotropin (ACTH) resistance syndrome is used for a group of rare inherited disorders, which present with primary adrenal insufficiency during childhood. The syndrome includes two disorders inherited in an autosomal recessive fashion - familial glucocorticoid deficiency and triple A syndrome. Herein, we report our experience of three cases with ACTH resistance syndrome, highlighting the approach to diagnosis and management in such patients.

Alacrima, a rare cause of pediatric dry eye

We report the case of a 12-year-old boy who presented with a history of 4-5 years of severe bilateral photophobia, with exacerbation and increased ocular pain for 3-4 days. There were no systemic signs, and serology tests were negative; however, parents noted crying without tears since birth. Computerized tomography of the orbits revealed bilateral hypoplasia of lacrimal glands. A clinico-radiological correlation suggested a diagnosis of alacrima, a rare entity that should be considered in the differential diagnosis of severe pediatric dry eye, which is itself a commonly overlooked condition. In addition to artificial tears, permanent punctal occlusion with cautery provided symptomatic relief to the patient.

[Congenital alacrima revealing a Allgrove syndrome: report of three cases]

Le syndrome d'Allgrove ou triple A syndrome est une affection autosomique récessive constatée chez la population pédiatrique, associant dans sa forme complète: Achalasie œsophagienne, Alacrymie, maladie d'Addison (insuffisance surrénale), une dégénérescence neurologique et occasionnellement une instabilité du système autonome. Nous rapportons les cas de 3 enfants issus de mariages consanguins, chez qui l'examen ophtalmologique a révélé une sécheresse sévère avec dans deux cas une kératite envahissant l'axe visuel, ainsi qu'une paresse du reflexe photomoteur. Le bilan radiologique: transit œsogastroduodénal (TOGD) et fibroscopie œsogastroduodénale (FOGD) a révélé un mégaoesophage associé dans un cas à une œsophagite. Un traitement à base de larmes artificielles est instauré aussitôt, ainsi qu'un traitement chirurgical par voie laparoscopique. La connaissance de cette pathologie permettra une prise de conscience de la gravité de cette maladie en plus de suggérer sa prise en charge.

Longitudinal neuropsychological profile in a patient with triple a syndrome

Triple A syndrome is an autosomal recessive disorder characterized by the triad of adrenocorticotropic hormone resistant adrenal insufficiency, achalasia, and alacrima. Our aim was to describe the neuropsychological characteristics and the cooccurring psychopathological and neurological disorders in an Italian male child suffering from Triple A syndrome at the time of admission (T0) and after one year of follow-up (T1). Many difficulties were observed in the motor domain, as well as in manual dexterity and static/dynamic balance domains of the motor task over time. In sharp contrast with previous literature reports on frequent mild cognitive dysfunction in patients with Triple A syndrome, our child did not show any mental retardation. By contrast, he showed an average IQ at T0 with a slight improvement at T1. To our knowledge, this report is the first describing neuropsychological profile and co-occurring psychopathological problems in a child with Triple A syndrome. Considering that the Triple A syndrome is a progressive disorder which can take years to develop the full-blown clinical picture, these patients require periodical medical controls. Moreover, assessment of neuropsychological and psychopathological features should be performed in patients with this disease, in order to underline the variability of this syndrome.

Achalasia cardia in a premature infant

Achalasia cardia is defined as a neuromuscular disorder of the oesophagus with abnormal motility and failure of relaxation of the distal oesophagus. It is an uncommon but well-recognised entity in infants and children. However, achalasia in a preterm baby has not been previously described. We report the condition in a premature infant with unusual presentation, treated successfully with Heller's oesophagomyotomy and fundoplication.

Recent advances in the surgical treatment of achalasia and gastroesophageal reflux disease

Achalasia and gastroesophageal reflux disease (GERD) represent diverse physiologic disorders both of which result from lower esophageal sphincter (LES) dysfunction. Fortunately, both diseases are benign and amenable to surgically corrective therapies. Achalasia is characterized by destruction of the smooth muscle ganglion cells of the myenteric plexus (Auerbach) resulting in motor dysfunction, incomplete LES relaxation, and progressive esophageal dilation. GERD is frequently characterized by hypotonia or shortening of the LES. Local anatomical derangements such as a hiatal hernia (eg, sliding type I hernia) can predispose to GERD. Other predisposing factors for GERD include obesity, smoking, alcohol, and pregnancy. Transient LES relaxation is the most significant factor in the development of GERD. Transient LES relaxations last from 10 to 45 seconds and are not related to swallowing. The diagnostic workup of achalasia and GERD may include barium esophagram, upper gastrointestinal endoscopy, pH monitoring, and esophageal manometry. The different medical treatment options for achalasia comprise pharmacologic treatment, botulinum toxin, and balloon dilation. Surgical interventions include Heller myotomy, which is usually combined with a partial fundoplication. GERD is managed by treating the predisposing factors, using medications (ie, anatacids or proton pump inhibitors) and surgery (ie, fundoplication). Recently, endoluminal therapy has been employed in the treatment of GERD with promising short-term results.

Pediatric autonomic disorders

The scope of pediatric autonomic disorders is not well recognized. The goal of this review is to increase awareness of the expanding spectrum of pediatric autonomic disorders by providing an overview of the autonomic nervous system, including the roles of its various components and its pervasive influence, as well as its intimate relationship with sensory function. To illustrate further the breadth and complexities of autonomic dysfunction, some pediatric disorders are described, concentrating on those that present at birth or appear in early childhood.

Genotypic heterogeneity and clinical phenotype in triple A syndrome: a review of the NIH experience 2000-2005

Triple A syndrome (AAAS, OMIM#231550) is an autosomal recessive condition characterized by adrenal insufficiency, achalasia, alacrima, neurodegeneration and autonomic dysfunction. Mutations in the AAAS gene on chromosome 12q13 have been reported in several subjects with AAAS. Over the last 5 years, we have evaluated six subjects with the clinical diagnosis of AAAS. Three subjects had mutations in the AAAS gene-- including one novel mutation (IVS8+1 G>A)-- and a broad spectrum of clinical presentations. However, three subjects with classic AAAS did not have mutations in the AAAS gene on both alleles. This finding supports the notion of genetic heterogeneity for this disorder, although other genetic mechanisms cannot be excluded.

Apoptosis and autoimmunity as proposed pathogenetic links between Helicobacter pylori infection and idiopathic achalasia

Achalasia is a disorder of the oesophagus characterised by increased lower oesophageal sphincter (LOS) tone, lack of LOS relaxation with swallowing and aperistalsis of the body of the oesophagus. The aetiology and pathogenesis of idiopathic achalasia are still unclear, although a viral cause, genetic influences (associations with HLA loci) and autoimmune processes have been postulated. Degeneration and significant loss of nerve fibres, associated with an inflammatory infiltrate of the myenteric plexus in idiopathic achalasia, provide evidence of an immune mediated destruction of the myenteric plexus, possibly through apoptotic process. This concept is reinforced by the concomitant appearance of achalasia and Guillain-Barré syndrome (GBS) and/or Parkinson's disease, where inappropriate initiation of apoptosis has been proposed to underlie the neuronal attrition. In the same respect, Helicobacter pylori (H. pylori) infection has been associated with gastric autoimmunity, and patients infected with H. pylori have been shown to possess autoantibodies that cross-react with antigens expressed on the gastric mucosa. Furthermore, H. pylori is thought to be associated with the development of autoimmune sequelae observed in peripheral neuropathies and GBS, where autoantibodies to specific neural targets have been found to impair native neural function by inducing nerve tissue damage, possibly by apoptosis. Taken together, we assume that H. pylori infection might be a pathogenetic factor of achalasia through induction of autoimmunity and apoptosis. Whether eradication of H. pylori infection may indirectly offer benefit to the pathophysiology of idiopathic achalasia by ameliorating the apoptotic loss of ganglion cells and their axons in the oesophageal wall remains to be elucidated.

Congenital Alacrima in Pierre Robin Sequence

PURPOSE

To report the presence of congenital alacrima in a patient with Pierre Robin (PR) sequence.

METHODS

A 6-month-old child with diagnosed PR sequence presented to us with dysfunctional lacrimation present since birth. The child subsequently developed bilateral corneal ulcers. This unusual presentation and its management are described in detail, and other ocular associations of the PR sequence are discussed.

RESULTS

Continuous tear supplementation and appropriate treatment with antibiotics controlled the microbial infection. However, the long-term prognosis for visual rehabilitation remained poor in this patient because of the presence of central corneal opacities, persistent dry eye, which would preclude future optical keratoplasty, and possible sensory deprivation amblyopia.

CONCLUSIONS

Alacrima can cause significant ocular morbidity, because persistent ocular surface dryness can be very difficult to manage. Lifelong tear supplementation may be necessary. The association or coexistence of congenital alacrima and the Pierre Robin sequence has not been described before this report.

Triple-A syndrome with prominent ophthalmic features and a novel mutation in the AAAS gene: a case report

Background

Triple-A syndrome (Allgrove syndrome) is an autosomal recessive disorder characterized by adrenal insufficiency, alacrima, achalasia, and – occasionally – autonomic instability. Mutations have been found in the AAAS gene on 12q13.

Case presentation

We present the case of a 12 year-old boy with classic systemic features of triple-A syndrome and several prominent ophthalmic features, including: accommodative spasm, dry eye, superficial punctate keratopathy, and pupillary hypersensitivity to dilute pilocarpine. MRI showed small lacrimal glands bilaterally. DNA sequencing of PCR-amplified fragments from the 16 exons of the AAAS gene revealed compound heterozygosity for a new, out-of-frame 5-bp deletion in exon 15, c1368-1372delGCTCA, and a previously-described nonsense mutation in exon 9, c938C>T, R286X.

Conclusions

In addition to known ophthalmic manifestations, triple-A syndrome can present with accommodative dysregulation and ocular signs of autonomic dysfunction.

Pediatric alacrima, achalasia, and mental retardation

Absence or deficiency of tear volume (alacrima) is rarely seen in pediatric ophthalmology. It is often a part of the multiple systemic anomalies like Riley-Day syndrome and anhidrotic ectodermal dysplasia, or it may be associated with adrenal gland insufficiency, achalasia, and neurologic disorders like Allgrove's syndrome. We report on a 7-year-old girl presenting alacrima, achalasia, and mental retardation with normal adrenocortical function.

Ophthalmic manifestations of Allgrove syndrome: report of a case

A male patient with the ocular manifestations of Allgrove or triple-A syndrome is described. The need for early diagnosis based on alacrima, anisocoria and optic atrophy of this potentially fatal condition is stressed.

Esophageal motor disorders

A consolidation of ideas regarding the pathogenesis and management of esophageal motor disorders occurred over the past year. The development and application of diagnostic techniques has stimulated new thinking about the events responsible for peristalsis and has provided novel avenues for studying mechanisms of symptom production. Achalasia remains the most investigated and understood motor disorder, and the year's research focused heavily on management approaches for this important condition. Other topics addressed in this review include proximal esophageal symptoms and disorders, spastic disorders, and esophageal hypomotility.