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Farina R, Garofalo A, Valerio Foti P, Inì C, Motta C, Galioto S, Clemenza M, Ilardi A, Gavazzi L, Grippaldi D, D'Urso M, Basile A. Alagille syndrome with unusual common bile duct hypoplasia and gallbladder dysmorphism: Lesson based on a case report. Radiol Case Rep 2024; 19:4082-4086. [PMID: 39104448 PMCID: PMC11298873 DOI: 10.1016/j.radcr.2024.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/24/2024] [Accepted: 06/08/2024] [Indexed: 08/07/2024] Open
Abstract
Alagille syndrome is an autosomal dominant and multisystemic disease that generally manifests itself with intrahepatic bile ducts paucity, chronic cholestasis, xanthomas and with other less frequent clinical manifestations such as congenital heart disease, skeletal abnomalies, ophthalmic, vascular, renal and growth failure. Symptoms can be subclinical or very severe. Is caused by various genetic mutations and the majority of patients have a detectable mutation in JAG1 (90%), the remainder have mutations in NOTCH2. The diagnosis is molecular and the incidence is approximately 1 in 30,000 - 50.000. Patient management can be very complex and treatment depends on the district affected and on the symptoms. In more serious cases, with terminal liver disease, liver transplantation is used. We describe a case with main bile duct hypoplasia, intrahepatic bile ducts paucity, cholestasis and gallbladder dimorphism associated with renal malrotation and butterfly vertebrae.
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Affiliation(s)
- Renato Farina
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”. University of Catania, Italy
| | - Alfredo Garofalo
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”. University of Catania, Italy
| | - Pietro Valerio Foti
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”. University of Catania, Italy
| | - Corrado Inì
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”. University of Catania, Italy
| | - Claudia Motta
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”. University of Catania, Italy
| | - Sebastiano Galioto
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”. University of Catania, Italy
| | - Mariangela Clemenza
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”. University of Catania, Italy
| | - Adriana Ilardi
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”. University of Catania, Italy
| | - Livio Gavazzi
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”. University of Catania, Italy
| | - Daniele Grippaldi
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”. University of Catania, Italy
| | - Mattia D'Urso
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”. University of Catania, Italy
| | - Antonio Basile
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”. University of Catania, Italy
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Reis LM, Seese SE, Costakos D, Semina EV. Congenital anterior segment ocular disorders: Genotype-phenotype correlations and emerging novel mechanisms. Prog Retin Eye Res 2024; 102:101288. [PMID: 39097141 DOI: 10.1016/j.preteyeres.2024.101288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/30/2024] [Accepted: 07/31/2024] [Indexed: 08/05/2024]
Abstract
Development of the anterior segment of the eye requires reciprocal sequential interactions between the arising tissues, facilitated by numerous genetic factors. Disruption of any of these processes results in congenital anomalies in the affected tissue(s) leading to anterior segment disorders (ASD) including aniridia, Axenfeld-Rieger anomaly, congenital corneal opacities (Peters anomaly, cornea plana, congenital primary aphakia), and primary congenital glaucoma. Current understanding of the genetic factors involved in ASD remains incomplete, with approximately 50% overall receiving a genetic diagnosis. While some genes are strongly associated with a specific clinical diagnosis, the majority of known factors are linked with highly variable phenotypic presentations, with pathogenic variants in FOXC1, CYP1B1, and PITX2 associated with the broadest spectrum of ASD conditions. This review discusses typical clinical presentations including associated systemic features of various forms of ASD; the latest functional data and genotype-phenotype correlations related to 25 ASD factors including newly identified genes; promising novel candidates; and current and emerging treatments for these complex conditions. Recent developments of interest in the genetics of ASD include identification of phenotypic expansions for several factors, discovery of multiple modes of inheritance for some genes, and novel mechanisms including a growing number of non-coding variants and alleles affecting specific domains/residues and requiring further studies.
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Affiliation(s)
- Linda M Reis
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
| | - Sarah E Seese
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
| | - Deborah Costakos
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
| | - Elena V Semina
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA; Department of Pediatrics and Children's Research Institute, Medical College of Wisconsin and Children's Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA; Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
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3
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Law C, Pattathil N, Simpson H, Ward MJ, Lampen S, Kamath B, Aleman TS. Intraretinal hemorrhages and detailed retinal phenotype of three patients with Alagille syndrome. Ophthalmic Genet 2024:1-10. [PMID: 38956866 DOI: 10.1080/13816810.2024.2362214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/27/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE To explore patterns of disease expression in Alagille syndrome (ALGS). METHODS Patients underwent ophthalmic examination, optical coherence tomography (OCT) imaging, fundus intravenous fluorescein angiography (IVFA), perimetry and full-field electroretinograms (ffERGs). An adult ALGS patient had multimodal imaging and specialized perimetry. RESULTS The proband (P1) had a heterozygous pathogenic variant in JAG1; (p.Gln410Ter) and was incidentally diagnosed at age 7 with a superficial retinal hemorrhage, vascular tortuosity, and midperipheral pigmentary changes. The hemorrhage recurred 15 months later. Her monozygotic twin sister (P2) had a retinal hemorrhage at the same location at age 11. Visual acuities for both patients were 20/30 in each eye. IVFA was normal. OCT showed thinning of the outer nuclear in the peripapillary retina. A ffERG showed normal cone-mediated responses in P1 (rod-mediated ERGs not documented), normal ffERGs in P2. Coagulation and liver function were normal. An unrelated 42-year-old woman with a de-novo pathogenic variant (p. Gly386Arg) in JAG1 showed a similar pigmentary retinopathy and hepatic vascular anomalies; rod and cone function was normal across large expanses of structurally normal retina that sharply transitioned to a blind atrophic peripheral retina. CONCLUSION Nearly identical recurrent intraretinal hemorrhages in monozygotic twins with ALGS suggest a shared subclinical microvascular abnormality. We hypothesize that the presence of large areas of functionally and structurally intact retina surrounded by severe chorioretinal degeneration, is against a predominant involvement of JAG1 in the function of the neurosensory retina, and that instead, primary abnormalities of chorioretinal vascular development and/or homeostasis may drive the peculiar phenotypes.
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Affiliation(s)
- Christine Law
- Queen's University School of Medicine, Kingston, Ontario, Canada
- Department of Ophthalmology, Queen's University and Kingston Health Sciences Centre, Kingston, Canada
| | | | - Hailey Simpson
- Department of Ophthalmology, Queen's University and Kingston Health Sciences Centre, Kingston, Canada
| | - Michael J Ward
- Division of Ophthalmology, Department of Surgery, Chester County Hospital and Chester County Eye Care Associates, West Chester, Pennsylvania, USA
| | - Shaun Lampen
- Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Binita Kamath
- Division of Gastroenterology, Hepatology and Nutrition, Sick Kids Hospital, Toronto, Ontario, Canada
| | - Tomas S Aleman
- Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Patel R, Nair S, Choudhry H, Jaffry M, Dastjerdi M. Ocular manifestations of liver disease: an important diagnostic aid. Int Ophthalmol 2024; 44:177. [PMID: 38622271 PMCID: PMC11018673 DOI: 10.1007/s10792-024-03103-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 03/24/2024] [Indexed: 04/17/2024]
Abstract
PURPOSE This review examined existing literature to determine various ocular manifestations of liver pathologies, with a focus on metabolic deficiencies as well as viral and immune liver conditions. METHODS Recent data were compiled from PubMed from 2000 to 2020 using keywords that were relevant to the assessed pathologies. Ocular presentations of several liver pathologies were researched and then summarized in a comprehensive form. RESULTS Several ocular manifestations of liver disease were related to vitamin A deficiency, as liver disease is associated with impaired vitamin A homeostasis. Alcoholic liver cirrhosis can result in vitamin A deficiency, presenting with Bitot spots, xerosis, and corneal necrosis. Congenital liver diseases such as mucopolysaccharidoses and peroxisomal disorders are also linked with ocular signs. Viral causes of liver disease have associations with conditions like retinal vasculitis, keratoconjunctivitis sicca, retinopathies, Mooren's ulcer, and Sjogren's syndrome. Autoimmune hepatitis has been linked to peripheral ulcerative keratitis and uveitis. CONCLUSIONS Building strong associations between ocular and liver pathology will allow for early detection of such conditions, leading to the early implementation of management strategies. While this review outlines several of the existing connections between hepatic and ophthalmic disease, further research is needed in the area in order to strengthen these associations.
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Affiliation(s)
- Riya Patel
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, USA
| | - Smriti Nair
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, USA
| | - Hassaam Choudhry
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, USA.
| | - Mustafa Jaffry
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, USA
| | - Mohammad Dastjerdi
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, USA
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Umemura K, Fujita K, Kamei M. THREE-YEAR FOLLOW-UP OF PROGRESSIVE CHORIORETINAL ATROPHY IN ATYPICAL ALAGILLE SYNDROME: A CASE REPORT. Retin Cases Brief Rep 2024; 18:247-250. [PMID: 36730824 PMCID: PMC10898537 DOI: 10.1097/icb.0000000000001368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 10/25/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE To report a case of atypical Alagille syndrome with progressive chorioretinal atrophy. METHODS Case Report. RESULTS A 42-year-old Japanese man presented with atypical Alagille syndrome. At the first visit, funduscopy revealed anterior circumferential chorioretinal atrophy in the peripheral retina and peripapillary region with posterior pole sparing in both eyes. Fundus autofluorescence showed hypoautofluorescence in the peripheral and peripapillary regions, but normal findings in the macular region. After follow-up for 3 years, hypopigmented area with well visualized large choroidal vessels extended to mid-peripheral region. On Fundus autofluorescence images, hypoautofluorescence newly appeared in macular region in both eyes. Perivascular hypoautofluorescence and granular hyperautofluorescence scattering within the posterior pole were also observed. BCVA deteriorated and concentric visual field contraction worsened progressively. CONCLUSION Alagille syndrome is known to have many ophthalmic manifestations, most of which are stable with minimal threat to vision. In the present case, chorioretinal atrophy progressed during 3-year follow-up, suggesting that progression of chorioretinal atrophy with vision loss may occur over time in Alagille syndrome.
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Affiliation(s)
- Kyohei Umemura
- Department of Ophthalmology, Aichi Medical University, Nagakuteshi, Aichi, Japan
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Virth J, Mack HG, Colville D, Crockett E, Savige J. Ocular manifestations of congenital anomalies of the kidney and urinary tract (CAKUT). Pediatr Nephrol 2024; 39:357-369. [PMID: 37468646 PMCID: PMC10728251 DOI: 10.1007/s00467-023-06068-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 07/21/2023]
Abstract
Congenital anomalies of the kidney and urinary tract (CAKUT) are among the most common birth defects worldwide and a major cause of kidney failure in children. Extra-renal manifestations are also common. This study reviewed diseases associated with the Genomics England CAKUT-associated gene panel for ocular anomalies. In addition, each gene was examined for expression in the human retina and an ocular phenotype in mouse models using the Human Protein Atlas and Mouse Genome Informatics databases, respectively. Thirty-four (54%) of the 63 CAKUT-associated genes (55 'green' and 8 'amber') had a reported ocular phenotype. Five of the 6 most common CAKUT-associated genes (PAX2, EYA1, SALL1, GATA3, PBX1) that represent 30% of all diagnoses had ocular features. The ocular abnormalities found with most CAKUT-associated genes and with five of the six commonest were coloboma, microphthalmia, optic disc anomalies, refraction errors (astigmatism, myopia, and hypermetropia), and cataract. Seven of the CAKUT-associated genes studied (11%) had no reported ocular features but were expressed in the human retina or had an ocular phenotype in a mouse model, which suggested further possibly-unrecognised abnormalities. About one third of CAKUT-associated genes (18, 29%) had no ocular associations and were not expressed in the retina, and the corresponding mouse models had no ocular phenotype. Ocular abnormalities in individuals with CAKUT suggest a genetic basis for the disease and sometimes indicate the affected gene. Individuals with CAKUT often have ocular abnormalities and may require an ophthalmic review, monitoring, and treatment to preserve vision.
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Affiliation(s)
- James Virth
- Department of Medicine (Melbourne Health and Northern Health), Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, 3050, Australia
| | - Heather G Mack
- University Department of Surgery (Ophthalmology), Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, 3002, Australia
| | - Deb Colville
- University Department of Surgery (Ophthalmology), Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, 3002, Australia
| | - Emma Crockett
- Department of Medicine (Melbourne Health and Northern Health), Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, 3050, Australia
| | - Judy Savige
- Department of Medicine (Melbourne Health and Northern Health), Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, 3050, Australia.
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Shalev D, Koolen DA, de Vries BBA, Blum Meirovitch S, Mandel JL, Burger P, Rosenfeld A, Ben Simon GJ, Landau Prat D. Ocular manifestations in Koolen-de Vries syndrome: an international study. CANADIAN JOURNAL OF OPHTHALMOLOGY 2023:S0008-4182(23)00379-4. [PMID: 38145626 DOI: 10.1016/j.jcjo.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/10/2023] [Accepted: 11/26/2023] [Indexed: 12/27/2023]
Abstract
OBJECTIVES Koolen-de Vries Syndrome (KdVS) is a rare multisystem neurodevelopmental disorder. Ocular manifestations, including strabismus, ptosis, and hyperopia, have been reported in KdVS patients, but detailed clinical data are limited. This study aims to investigate the already known ocular malformations and their frequency while uncovering novel ocular associations. METHODS This was an international cross-sectional study. An anonymous questionnaire was sent to 237 KdVS patients registered in the GenIDA database. The questionnaire inquired about demographic data, ocular symptoms, findings reported by ophthalmologists, and ophthalmologic surgical interventions. The main outcome measures included ocular findings and surgical interventions. RESULTS Sixty-seven respondents worldwide completed the questionnaire, most (n = 53; 79%) under 18 years of age. Ophthalmologic abnormalities, noted in 79% of patients, included refractive errors (n = 35; 52.2%), strabismus (n = 23; 34.3%), amblyopia (n = 13; 19.5%), and eyelid ptosis (n = 9; 13.4%). Lacrimal disorders were present (n = 6; 9.0%), as were retinal findings (n = 7; 10.4%), including retinal hyperpigmentation or hypopigmentation (n = 4; 7.5%), Sjögren's pigment epithelial reticular dystrophy (n = 1; 1.5%), and macular chorioretinal coloboma (n = 1; 1.5%). Other manifestations included ocular surface disorders (n = 5; 7.5%), cataracts (n = 3; 4.5%), Brown syndrome (n = 1; 1.5%), glaucoma (n = 1; 1.5%), cerebral visual impairment (n = 1; 1.5%), and optic atrophy (n = 1; 1.5%). Fourteen patients (20.8%) had undergone surgical interventions. CONCLUSIONS KdVS is associated with various ophthalmic findings, such as amblyopia, refractive errors, strabismus, and eyelid ptosis. We describe, for the first time, a high rate of nasolacrimal disorders and retinal abnormalities consisting mainly of pigmentary findings, including a rare case of Sjögren's pigment epithelial reticular dystrophy. A comprehensive ophthalmic evaluation is therefore recommended for all KdVS patients at initial diagnosis or at 4-6 months of age for diagnosed newborns.
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Affiliation(s)
- Dafna Shalev
- Division of Ophthalmology, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David A Koolen
- Department of Human Genetics, Radboudumc, Donders Institute for Brain, Cognition, and Behavior, Nijmegen, The Netherlands
| | - Bert B A de Vries
- Department of Human Genetics, Radboudumc, Donders Institute for Brain, Cognition, and Behavior, Nijmegen, The Netherlands
| | | | - Jean-Louis Mandel
- GenIDA, Institute of Genetics and Molecular and Cellular Biology (IGBMC), Department of Neurogenetics and Translational Medicine, University of Strasbourg, Illkirch, France; Institute for Advanced Studies of the University of Strasbourg (USIAS), University of Strasbourg, Strasbourg, France
| | - Pauline Burger
- GenIDA, Institute of Genetics and Molecular and Cellular Biology (IGBMC), Department of Neurogenetics and Translational Medicine, University of Strasbourg, Illkirch, France
| | - Alik Rosenfeld
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Ophthalmology, Edith Wolfson Medical Center, Holon, Israel
| | - Guy J Ben Simon
- Division of Ophthalmology, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Sheba Talpiot Medical Leadership Program, Tel Hashomer, Israel
| | - Daphna Landau Prat
- Division of Ophthalmology, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Sheba Talpiot Medical Leadership Program, Tel Hashomer, Israel.
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Cheng K, Rosenthal P. Diagnosis and management of Alagille and progressive familial intrahepatic cholestasis. Hepatol Commun 2023; 7:e0314. [PMID: 38055640 PMCID: PMC10984671 DOI: 10.1097/hc9.0000000000000314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/12/2023] [Indexed: 12/08/2023] Open
Abstract
Alagille syndrome and progressive familial intrahepatic cholestasis are conditions that can affect multiple organs. Advancements in molecular testing have aided in the diagnosis of both. The impairment of normal bile flow and secretion leads to the various hepatic manifestations of these diseases. Medical management of Alagille syndrome and progressive familial intrahepatic cholestasis remains mostly targeted on supportive care focusing on quality of life, cholestasis, and fat-soluble vitamin deficiency. The most difficult therapeutic issue is typically related to pruritus, which can be managed by various medications such as ursodeoxycholic acid, rifampin, cholestyramine, and antihistamines. Surgical operations were previously used to disrupt enterohepatic recirculation, but recent medical advancements in the use of ileal bile acid transport inhibitors have shown great efficacy for the treatment of pruritus in both Alagille syndrome and progressive familial intrahepatic cholestasis.
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Affiliation(s)
- Katherine Cheng
- Department of Pediatrics Gastroenterology, Hepatology and Nutrition, University of California San Francisco, San Francisco, California, USA
| | - Philip Rosenthal
- Department of Pediatrics Gastroenterology, Hepatology and Nutrition, University of California San Francisco, San Francisco, California, USA
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
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Reis LM, Amor DJ, Haddad RA, Nowak CB, Keppler-Noreuil KM, Chisholm SA, Semina EV. Alternative Genetic Diagnoses in Axenfeld-Rieger Syndrome Spectrum. Genes (Basel) 2023; 14:1948. [PMID: 37895297 PMCID: PMC10606241 DOI: 10.3390/genes14101948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 10/12/2023] [Accepted: 10/14/2023] [Indexed: 10/29/2023] Open
Abstract
Axenfeld-Rieger anomaly (ARA) is a specific ocular disorder that is frequently associated with other systemic abnormalities. PITX2 and FOXC1 variants explain the majority of individuals with Axenfeld-Rieger syndrome (ARS) but leave ~30% unsolved. Here, we present pathogenic/likely pathogenic variants in nine families with ARA/ARS or similar phenotypes affecting five different genes/regions. USP9X and JAG1 explained three families each. USP9X was recently linked with syndromic cognitive impairment that includes hearing loss, dental defects, ventriculomegaly, Dandy-Walker malformation, skeletal anomalies (hip dysplasia), and other features showing a significant overlap with FOXC1-ARS. Anterior segment anomalies are not currently associated with USP9X, yet our cases demonstrate ARA, congenital glaucoma, corneal neovascularization, and cataracts. The identification of JAG1 variants, linked with Alagille syndrome, in three separate families with a clinical diagnosis of ARA/ARS highlights the overlapping features and high variability of these two phenotypes. Finally, intragenic variants in CDK13, BCOR, and an X chromosome deletion encompassing HCCS and AMELX (linked with ocular and dental anomalies, correspondingly) were identified in three additional cases with ARS. Accurate diagnosis has important implications for clinical management. We suggest that broad testing such as exome sequencing be applied as a second-tier test for individuals with ARS with normal results for PITX2/FOXC1 sequencing and copy number analysis, with attention to the described genes/regions.
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Affiliation(s)
- Linda M. Reis
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (L.M.R.); (S.A.C.)
- Department of Pediatrics and Children’s Research Institute, Medical College of Wisconsin and Children’s Wisconsin, Milwaukee, WI 53226, USA
| | - David J. Amor
- Murdoch Children’s Research Institute, Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia;
| | - Raad A. Haddad
- Division of Endocrinology, Diabetes, and Metabolic Diseases, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Catherine B. Nowak
- Division of Genetics and Metabolism, MassGeneral Hospital for Children, Boston, MA 02114, USA;
| | - Kim M. Keppler-Noreuil
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53726, USA;
| | - Smith Ann Chisholm
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (L.M.R.); (S.A.C.)
| | - Elena V. Semina
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (L.M.R.); (S.A.C.)
- Department of Pediatrics and Children’s Research Institute, Medical College of Wisconsin and Children’s Wisconsin, Milwaukee, WI 53226, USA
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Hankeova S, Van Hul N, Laznovsky J, Verboven E, Mangold K, Hensens N, Adori C, Verhoef E, Zikmund T, Dawit F, Kavkova M, Salplachta J, Sjöqvist M, Johansson BR, Hassan MG, Fredriksson L, Baumgärtel K, Bryja V, Lendahl U, Jheon A, Alten F, Fahnehjelm KT, Fischler B, Kaiser J, Andersson ER. Sex differences and risk factors for bleeding in Alagille syndrome. EMBO Mol Med 2022; 14:e15809. [PMID: 36345711 PMCID: PMC9728057 DOI: 10.15252/emmm.202215809] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 09/27/2022] [Accepted: 10/05/2022] [Indexed: 11/11/2022] Open
Abstract
Spontaneous bleeds are a leading cause of death in the pediatric JAG1-related liver disease Alagille syndrome (ALGS). We asked whether there are sex differences in bleeding events in patients, whether Jag1Ndr/Ndr mice display bleeds or vascular defects, and whether discovered vascular pathology can be confirmed in patients non-invasively. We performed a systematic review of patients with ALGS and vascular events following PRISMA guidelines, in the context of patient sex, and found significantly more girls than boys reported with spontaneous intracranial hemorrhage. We investigated vascular development, homeostasis, and bleeding in Jag1Ndr/Ndr mice, using retina as a model. Jag1Ndr/Ndr mice displayed sporadic brain bleeds, a thin skull, tortuous blood vessels, sparse arterial smooth muscle cell coverage in multiple organs, which could be aggravated by hypertension, and sex-specific venous defects. Importantly, we demonstrated that retinographs from patients display similar characteristics with significantly increased vascular tortuosity. In conclusion, there are clinically important sex differences in vascular disease in ALGS, and retinography allows non-invasive vascular analysis in patients. Finally, Jag1Ndr/Ndr mice represent a new model for vascular compromise in ALGS.
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Affiliation(s)
- Simona Hankeova
- Department of Cell and Molecular BiologyKarolinska InstitutetStockholmSweden,Department of Experimental BiologyMasaryk UniversityBrnoCzech Republic
| | - Noemi Van Hul
- Department of Cell and Molecular BiologyKarolinska InstitutetStockholmSweden
| | - Jakub Laznovsky
- CEITEC – Central European Institute of TechnologyBrno University of TechnologyBrnoCzech Republic
| | - Elisabeth Verboven
- Department of Cell and Molecular BiologyKarolinska InstitutetStockholmSweden
| | - Katrin Mangold
- Department of Cell and Molecular BiologyKarolinska InstitutetStockholmSweden
| | - Naomi Hensens
- Department of Cell and Molecular BiologyKarolinska InstitutetStockholmSweden,University of Applied Sciences UtrechtUtrechtThe Netherlands
| | - Csaba Adori
- Department of NeuroscienceKarolinska InstitutetStockholmSweden
| | - Elvira Verhoef
- Department of Cell and Molecular BiologyKarolinska InstitutetStockholmSweden,University of Applied Sciences UtrechtUtrechtThe Netherlands
| | - Tomas Zikmund
- CEITEC – Central European Institute of TechnologyBrno University of TechnologyBrnoCzech Republic
| | - Feven Dawit
- Department of Pediatrics, Clinical Science, Intervention and Technology (CLINTEC)Karolinska Institutet and Karolinska University HospitalHuddingeSweden
| | - Michaela Kavkova
- CEITEC – Central European Institute of TechnologyBrno University of TechnologyBrnoCzech Republic
| | - Jakub Salplachta
- CEITEC – Central European Institute of TechnologyBrno University of TechnologyBrnoCzech Republic
| | - Marika Sjöqvist
- Department of Cell and Molecular BiologyKarolinska InstitutetStockholmSweden
| | - Bengt R Johansson
- EM Unit, Institute of BiomedicineUniversity of GothenburgGothenburgSweden
| | - Mohamed G Hassan
- University of San FranciscoSan FranciscoCAUSA,Department of OrthodonticsFaculty of DentistryAssiut UniversityAssiutEgypt
| | - Linda Fredriksson
- Department of Medical Biochemistry and BiophysicsKarolinska InstitutetStockholmSweden
| | | | - Vitezslav Bryja
- Department of Experimental BiologyMasaryk UniversityBrnoCzech Republic
| | - Urban Lendahl
- Department of Cell and Molecular BiologyKarolinska InstitutetStockholmSweden
| | | | - Florian Alten
- Department of OphthalmologyUniversity of Muenster Medical CenterMünsterGermany
| | - Kristina Teär Fahnehjelm
- Department of Pediatric Ophthalmology, Strabismus, Electrophysiology and Ocular Oncology, St. Erik Eye HospitalKarolinska InstitutetStockholmSweden,Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
| | - Björn Fischler
- Department of Pediatrics, Clinical Science, Intervention and Technology (CLINTEC)Karolinska Institutet and Karolinska University HospitalHuddingeSweden
| | - Jozef Kaiser
- CEITEC – Central European Institute of TechnologyBrno University of TechnologyBrnoCzech Republic
| | - Emma R Andersson
- Department of Cell and Molecular BiologyKarolinska InstitutetStockholmSweden
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11
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Atypical Focal Choroidal Excavation with Macular Hole in a Patient with Alagille Syndrome. Case Rep Ophthalmol Med 2022; 2022:8136115. [PMID: 36105151 PMCID: PMC9467701 DOI: 10.1155/2022/8136115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 08/25/2022] [Indexed: 11/18/2022] Open
Abstract
This study is aimed at reporting a rare and unusual focal choroidal excavation with a macular hole in a patient with Alagille syndrome (AGS). A 21-year-old woman with an established early-life AGS diagnosis was referred to our hospital prior to liver transplantation. Examination revealed best-corrected visual acuity of 16/20 and 20/20 in the right and left eye, respectively. Slit-lamp examination was positive for posterior embryotoxon in both eyes. Fundoscopy revealed diffuse choroidal hypopigmentation with increased visibility of the choroidal blood vessels and circumferential chorioretinal atrophy in the mid-peripheral and peripheral retina in both eyes. A full-thickness macular hole with underlying focal choroidal excavation was observed in the right eye. Optical coherence tomography through the macula confirmed choroidal excavation with a full-thickness macular hole in the right eye. To our knowledge, this is the first report describing focal choroidal excavation with a macular hole in an AGS patient.
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12
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Ayoub MD, Kamath BM. Alagille Syndrome: Current Understanding of Pathogenesis, and Challenges in Diagnosis and Management. Clin Liver Dis 2022; 26:355-370. [PMID: 35868679 DOI: 10.1016/j.cld.2022.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Alagille syndrome (ALGS) is a complex heterogenous disease with a wide array of clinical manifestations in association with cholestatic liver disease. Major clinical and genetic advancements have taken place since its first description in 1969. However, clinicians continue to face considerable challenges in the management of ALGS, particularly in the absence of targeted molecular therapies. In this article, we provide an overview of the broad ALGS phenotype, current approaches to diagnosis and with particular focus on key clinical challenges encountered in the management of these patients.
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Affiliation(s)
- Mohammed D Ayoub
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Department of Pediatrics, Rabigh Branch, King Abdulaziz University, PO Box 80205, Jeddah 21589, Saudi Arabia
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
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13
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Alwadani S, Alward WLM, Syed NA, Bouhenni RA, Brownstein S, Edward DP. Posterior Embryotoxon Revisited: An Immunohistologic Study. Ophthalmol Glaucoma 2022; 5:396-401. [PMID: 35131519 DOI: 10.1016/j.ogla.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 01/22/2022] [Accepted: 01/31/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE This series describes the immunopathologic features of posterior embryotoxon (PE) and demonstrates that it is not an anterior displaced Schwalbe's line as commonly described, but a peripheral corneal stromal nub variable in location with abnormal extracellular matrix. DESIGN Case series. PARTICIPANTS Archived specimens from patients with PE. METHODS Sections from archived formalin-fixed, paraffin-embedded specimens (n = 9; 7 autopsy and 2 trabeculectomy specimens) were examined by light microscopy. Immunohistochemistry was performed on 5 specimens to characterize the extracellular matrix composition of PE. RESULTS Posterior embryotoxon appeared as nubs of whorled collagen extending from the corneal stroma, lined in some instances, by Descemet membrane. These nubs were located anterior to Schwalbe's line (n = 4), posteriorly (n = 1), partially embedded in the trabecular meshwork (n = 1), or at Schwalbe's line (n = 2). Qualitatively, collagen I labeling of the PE stroma was similar or weaker than the corneal stroma, whereas collagen III staining was focal and slightly more intense compared with the corneal stroma. Lumican and keratan sulfate staining was similar or less intense in PE compared with the corneal stroma. MAIN OUTCOME MEASURES Identify location of PE and its immunohistochemical features. CONCLUSIONS In contrast to the widely accepted definition of PE as a prominent, anteriorly displaced Schwalbe line, histologic evidence suggests that it is a direct extension of the corneal stroma with variable locations that may displace the attenuated Descemet membrane when located anterior to or at Schwalbe's line. Immunohistochemical examination revealed that the composition of PE's extracellular matrix was similar to corneal stroma but with some variability in staining intensity.
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Affiliation(s)
- Saeed Alwadani
- King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia; Department of Ophthalmology, King Saud University School of Medicine, Riyadh, Saudi Arabia
| | - Wallace L M Alward
- Department of Ophthalmology and Visual Sciences and, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Nasreen A Syed
- Department of Ophthalmology and Visual Sciences and, University of Iowa Carver College of Medicine, Iowa City, Iowa; Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | - Seymour Brownstein
- Departments of Ophthalmology and of Pathology, Faculty of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Deepak P Edward
- King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia; Department of Ophthalmology and Visual Sciences and Department of Pathology, University of Illinois at Chicago, Chicago, Illinois.
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14
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Pfister ED, Dröge C, Liebe R, Stalke A, Buhl N, Ballauff A, Cantz T, Bueltmann E, Stindt J, Luedde T, Baumann U, Keitel V. Extrahepatic manifestations of progressive familial intrahepatic cholestasis syndromes: Presentation of a case series and literature review. Liver Int 2022; 42:1084-1096. [PMID: 35184362 DOI: 10.1111/liv.15200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/02/2022] [Accepted: 02/11/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS Progressive familial intrahepatic cholestasis (PFIC) is a collective term for a heterogenous group of rare, inherited cholestasis syndromes. The number of genes underlying the clinical PFIC phenotype is still increasing. While progressive liver disease and its sequelae such as portal hypertension, pruritus and hepatocellular carcinoma determine transplant-free survival, extrahepatic manifestations may cause relevant morbidity. METHODS We performed a literature search for extrahepatic manifestations of PFIC associated with pathogenic gene variants in ATP8B1, ABCB11, ABCB4, TJP2, NR1H4 and MYO5B. To illustrate the extrahepatic symptoms described in the literature, PFIC cases from our centres were revisited. RESULTS Extrahepatic symptoms are common in PFIC subtypes, where the affected gene is expressed at high levels in other tissues. While most liver-associated complications resolve after successful orthotopic liver transplantation (OLT), some extrahepatic symptoms show no response or even worsen after OLT. CONCLUSION The spectrum of extrahepatic manifestations in PFIC highlights essential, non-redundant roles of the affected genes in other organs. Extrahepatic features contribute towards low health-related quality of life (HRQOL) and morbidity in PFIC. While OLT is often the only remaining, curative treatment, potential extrahepatic manifestations need to be carefully monitored and addressed.
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Affiliation(s)
- Eva-Doreen Pfister
- Division of Paediatric Gastroenterology and Hepatology, Department of Paediatric Liver, Kidney and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Carola Dröge
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Medical Faculty of Otto von Guericke University, Magdeburg, Germany
| | - Roman Liebe
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Amelie Stalke
- Division of Paediatric Gastroenterology and Hepatology, Department of Paediatric Liver, Kidney and Metabolic Diseases, Hannover Medical School, Hannover, Germany.,Department of Human Genetics, Hannover Medical School, Hannover, Germany
| | - Nicole Buhl
- Division of Paediatric Gastroenterology and Hepatology, Department of Paediatric Liver, Kidney and Metabolic Diseases, Hannover Medical School, Hannover, Germany.,Department of Human Genetics, Hannover Medical School, Hannover, Germany
| | - Antje Ballauff
- Department of Paediatrics, Helios Hospital, Krefeld, Germany
| | - Tobias Cantz
- Translational Hepatology and Stem Cell Biology, Department of Gastroenterology, Hepatology and Endocrinology, REBIRTH-Center for Translational Regenerative Medicine, Hannover Medical School, Hannover, Germany
| | - Eva Bueltmann
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Jan Stindt
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ulrich Baumann
- Division of Paediatric Gastroenterology and Hepatology, Department of Paediatric Liver, Kidney and Metabolic Diseases, Hannover Medical School, Hannover, Germany.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Verena Keitel
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Medical Faculty of Otto von Guericke University, Magdeburg, Germany
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15
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Paez-Escamilla M, Scanga HL, Liasis A, Nischal KK. Macular atrophy in JAG1-related Alagille syndrome: a case series. Ophthalmic Genet 2021; 43:230-234. [PMID: 34886763 DOI: 10.1080/13816810.2021.2004432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND : Alagille syndrome (AS) is a multisystem disorder associated with a range of ocular anomalies affecting the anterior and posterior segments. While chorioretinal abnormalities have been reported in Alagille Syndrome, identification of macular dystrophy and detailed clinical and electrophysiologic descriptions are scarce. MATERIALS AND METHODS : A retrospective review was conducted to identify patients with a diagnosis of AS and retinal disease who were evaluated in the Division of Pediatric Ophthalmology, Strabismus, and Adult Motility at UPMC Children's Hospital of Pittsburgh. Criteria of AS included biopsy-proven bile duct hypoplasia, presence of major clinical features of AS, and molecular confirmation of the JAG1 gene. RESULTS : This cohort included three patients, two females and one male, diagnosed with JAG1-Alagille syndrome. The diagnosis was made before 2 years of life in all patients. The mean follow-up period in our center was 8 years. All patients were found to have retinal pigmentary changes, macular atrophy, choroidal thinning, optic disc anomalies, and progressive decrease in vision. Marked retinal and macular dysfunction were found in electrophysiological studies. CONCLUSIONS : Three patients with molecularly confirmed Alagille syndrome demonstrated unusual retinal and macular findings, with two showing progressive vision loss. Due to the rarity of retinal findings in AS and the observed progression of disease in our patients, clinical genetic testing for retinal dystrophies could be completed in two cases. These investigations failed to reveal a separate molecular cause for the observed retinal dystrophy, helping to confirm the association with JAG1-related AS.
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Affiliation(s)
- Manuel Paez-Escamilla
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hannah L Scanga
- Division of Pediatric Ophthalmology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alkiviades Liasis
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ken K Nischal
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Division of Pediatric Ophthalmology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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16
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Kato N, Haruta M, Takase R, Watanabe Y, Yoshida S. Ultra-widefield and anterior-segment optical coherence tomography in Alagille syndrome. Am J Ophthalmol Case Rep 2021; 24:101213. [PMID: 34632159 PMCID: PMC8487889 DOI: 10.1016/j.ajoc.2021.101213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 07/26/2021] [Accepted: 09/20/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose We describe the ocular findings in a patient with Alagille syndrome, included those obtained with ultra-widefield and anterior-segment optical coherence tomography (AS-OCT) imaging. Observations A previously asymptomatic 29-year-old woman with a heterozygous pathogenic variant in the JAG1 gene was referred for an ophthalmic evaluation. The ocular abnormalities included bilateral posterior embryotoxon, iris atrophy, retinal pigmentary changes in the peripheral and peripapillary regions, and optic disc elevation. Ultra-widefield OCT showed bilateral retinal thinning with increased choroidal hyperreflectivity in the areas of peripheral retinopathy and optic disc elevation. AS-OCT confirmed bilateral iris atrophy. Conclusions and Importance The ocular abnormalities observed in the present case represent clinical features characteristic of Alagille syndrome. Both ultra-widefield and AS-OCT were useful for assessing the ocular abnormalities in Alagille syndrome.
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Affiliation(s)
- Nobuhiro Kato
- Department of Ophthalmology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Masatoshi Haruta
- Department of Ophthalmology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Ryuta Takase
- Department of Pediatrics and Child Health, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Yoriko Watanabe
- Department of Pediatrics and Child Health, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Shigeo Yoshida
- Department of Ophthalmology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
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17
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Prasad D, Bhriguvanshi A. Ocular manifestations of liver disease in children: Clinical aspects and implications. Ann Hepatol 2021; 19:608-613. [PMID: 31901314 DOI: 10.1016/j.aohep.2019.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/18/2019] [Accepted: 11/25/2019] [Indexed: 02/04/2023]
Abstract
Liver and eyes are interlinked to each other in various medical conditions. There are certain ocular findings which directly indicate specific liver disorders. Thus, it becomes critical to identify disorders of liver and eyes early in the course of illness, so that prompt management may be initiated before the commencement of complications. It is highly advantageous in metabolic liver disorders as it offers prognostic value and spares the patient of unnecessary invasive and detailed work up. However, due to its silent and heterogeneous presentation, it is often unrecognized and ignored. Eye abnormalities could be due to, either direct toxic effects of abnormal metabolites, excess of normal metabolites, or by deficient energy metabolism. A number of inherited liver conditions have associated ocular lesions such as Kayser-Fleischer rings in Wilson's disease, posterior embryotoxon or optic drusen in Alagille's syndrome, and cherry-red spot in Niemann-Pick's type A. A thorough eye examination is important in distinguishing between several different forms of familial intrahepatic cholestasis which are associated with anomalies of the heart, bones, or kidneys. Early diagnosis is important, as in most cases, dietary restriction and early therapy prevents the onset of disability. The aim of this review is to sensitize and make pediatricians, hepatologists and ophthalmologists aware of specific ocular findings, suggestive of certain hepatobiliary disorders, thus helping in early referral. The pediatric and adult literature was thoroughly reviewed to organize the present review.
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Affiliation(s)
- Durga Prasad
- Department of Pediatric Gastroenterology, Apollomedics Super Speciality Hospital, Lucknow, Uttar Pradesh, India.
| | - Arpita Bhriguvanshi
- Department of Pediatrics, King George's Medical University, Lucknow, Uttar Pradesh, India.
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18
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da Palma MM, Igelman AD, Ku C, Burr A, You JY, Place EM, Wang NK, Oh JK, Branham KE, Zhang X, Ahn J, Gorin MB, Lam BL, Ronquillo CC, Bernstein PS, Nagiel A, Huckfeldt R, Cabrera MT, Kelly JP, Bakall B, Iannaccone A, Hufnagel RB, Zein WM, Koenekoop RK, Birch DG, Yang P, Fahim AT, Pennesi ME. Characterization of the Spectrum of Ophthalmic Changes in Patients With Alagille Syndrome. Invest Ophthalmol Vis Sci 2021; 62:27. [PMID: 34185059 PMCID: PMC8254011 DOI: 10.1167/iovs.62.7.27] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Purpose The purpose of this study was to characterize the phenotypic spectrum of ophthalmic findings in patients with Alagille syndrome. Methods We conducted a retrospective, observational, multicenter, study on 46 eyes of 23 subjects with Alagille syndrome. We reviewed systemic and ophthalmologic data extracted from medical records, color fundus photography, fundus autofluorescence, optical coherence tomography, visual fields, electrophysiological assessments, and molecular genetic findings. Results Cardiovascular abnormalities were found in 83% of all cases (of those, 74% had cardiac murmur), whereas 61% had a positive history of hepatobiliary issues, and musculoskeletal anomalies were present in 61% of all patients. Dysmorphic facies were present in 16 patients, with a broad forehead being the most frequent feature. Ocular symptoms were found in 91%, with peripheral vision loss being the most frequent complaint. Median (range) Snellen visual acuity of all eyes was 20/25 (20/20 to hand motion [HM]). Anterior segment abnormalities were present in 74% of the patients; of those, posterior embryotoxon was the most frequent finding. Abnormalities of the optic disc were found in 52%, and peripheral retinal abnormalities were the most frequent ocular finding in this series, found in 96% of all patients. Fifteen JAG1 mutations were identified in 16 individuals; of those, 6 were novel. Conclusions This study reports a cohort of patients with Alagille syndrome in which peripheral chorioretinal changes were more frequent than posterior embryotoxon, the most frequent ocular finding according to a number of previous studies. We propose that these peripheral chorioretinal changes are a new hallmark to help diagnose this syndrome.
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Affiliation(s)
- Mariana Matioli da Palma
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, United States.,Department of Ophthalmology and Visual Sciences, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Austin D Igelman
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, United States
| | - Cristy Ku
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, United States
| | - Amanda Burr
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, United States
| | - Jia Yue You
- Departments of Ophthalmology, Human Genetics, and Pediatric Surgery, Montreal Children's Hospital, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Emily M Place
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, United States
| | - Nan-Kai Wang
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York, New York, United States
| | - Jin Kyun Oh
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York, New York, United States.,State University of New York, Downstate Medical Center, Brooklyn, New York, United States
| | - Kari E Branham
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, United States
| | - Xinxin Zhang
- Duke Eye Center, Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, United States
| | - Jeeyun Ahn
- UCLA Stein Eye Institute, Division of Retinal Disorders and Ophthalmic Genetics, Department of Ophthalmology, David Geffen School of Medicine, UCLA, Los Angeles, California, United States.,Department of Ophthalmology, Seoul National University, College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Michael B Gorin
- UCLA Stein Eye Institute, Division of Retinal Disorders and Ophthalmic Genetics, Department of Ophthalmology, David Geffen School of Medicine, UCLA, Los Angeles, California, United States.,Department of Human Genetics, David Geffen School of Medicine, UCLA, Los Angeles, California, United States
| | - Byron L Lam
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida, United States
| | - Cecinio C Ronquillo
- John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, United States
| | - Paul S Bernstein
- John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, United States
| | - Aaron Nagiel
- The Vision Center, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, California, United States.,Roski Eye Institute, Department of Ophthalmology, University of Southern California, Los Angeles, California, United States
| | - Rachel Huckfeldt
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, United States
| | - Michelle T Cabrera
- Department of Ophthalmology, University of Washington, Seattle, Washington, United States.,Department of Ophthalmology, Seattle Children's Hospital, Seattle, Washington, United States
| | - John P Kelly
- Department of Ophthalmology, Seattle Children's Hospital, Seattle, Washington, United States
| | - Benjamin Bakall
- Department of Ophthalmology, University of Arizona College of Medicine, Phoenix, Arizon, United States
| | - Alessandro Iannaccone
- Duke Eye Center, Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, United States
| | - Robert B Hufnagel
- Ophthalmic Genetics and Visual Function Branch, National Eye Institute, National Institutes of Health, Bethesda, Maryland, United States
| | - Wadih M Zein
- Ophthalmic Genetics and Visual Function Branch, National Eye Institute, National Institutes of Health, Bethesda, Maryland, United States
| | - Robert K Koenekoop
- Departments of Ophthalmology, Human Genetics, and Pediatric Surgery, Montreal Children's Hospital, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - David G Birch
- Retina Foundation of the Southwest, Dallas, Texas, United States
| | - Paul Yang
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, United States
| | - Abigail T Fahim
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, United States
| | - Mark E Pennesi
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, United States
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19
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Anisimova N, Arbisser L, Tzamalis A, Petrovski BÉ, Shilova N, Petrovski G, Anisimov S, Malyugin B. Corectopia grading: A novel classification system. Semin Ophthalmol 2021; 37:105-110. [PMID: 34057013 DOI: 10.1080/08820538.2021.1926517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objectives: To present and validate the novel grading system for objective classification of corectopia.Subjects and Methods: We evaluated 28 eyes of 28 patients with or without corectopia and validated the grading and classification system for corectopia according to three major criteria: (i) direction, (ii) extent, and (iii) alteration of mydriasis. Intraclass correlation coefficient (ICC) and inter-rater agreement between 7 inexperienced and 1 experienced ophthalmologist against a golden standard (GS) were calculated.Results: The ICC for the 7 inexperienced ophthalmologists regarding the grading of direction and centration of the pupil was 0.83 (95% confidence interval (CI), 0.74 to 0.90; p < .001) and 0.57 (95% CI, 0.43 to 0.72; p < .001), respectively. The inter-rater agreement was the same or almost the same in cases of pupil decentration between the inexperienced, experienced ophthalmologists and the GS (k = 0.82; 95% CI, 0.64-1.00; p < .001). In assessing the direction of pupil displacement, the inter-rater agreement was almost perfect between the inexperienced (k = 0.93; 95% CI, 0.84-1.00; p < .001) and experienced (k = 0.92; 95% CI: 0.82-1.02; p < .001) ophthalmologists and the GS.Conclusion: The first detailed clinical classification is proposed for objective corectopia grading particularly relevant in documenting and assessing progressive disease. It was confirmed to be acceptable for clinical use by inexperienced and experienced ophthalmologists alike.
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Affiliation(s)
- Natalia Anisimova
- Department of Eye Diseases, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia.,Private Eye Center Vostok-Prozrenie, Moscow, Russia
| | - Lisa Arbisser
- Department of Ophthalmology, John A. Moran Eye Center University of Utah, Salt Lake City, Utah, USA
| | - Argyrios Tzamalis
- Department of Ophthalmology, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Beáta Éva Petrovski
- Center for Eye Research Department of Ophthalmology, Institute of Clinical MedicineFaculty of Medicine, University of Oslo, Oslo, Norway
| | - Natalya Shilova
- Department of Cataract and Implant Surgery, S. Fyodorov Eye Microsurgery Federal State Institution, Moscow, Russia
| | - Goran Petrovski
- Center for Eye Research, Department of Ophthalmology, Oslo University Hospital and Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Sergey Anisimov
- Department of Eye Diseases, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia.,Private Eye Center Vostok-Prozrenie, Moscow, Russia
| | - Boris Malyugin
- Department of Eye Diseases, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia.,Department of Cataract and Implant Surgery, S. Fyodorov Eye Microsurgery Federal State Institution, Moscow, Russia
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20
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Long-term follow-up of a patient with JAG1-associated retinopathy. Doc Ophthalmol 2021; 143:237-247. [PMID: 33877487 DOI: 10.1007/s10633-021-09836-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 04/02/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE To report the long-term structural and functional changes in the posterior segments of an adult with an unusual retinal dystrophy caused by a novel mutation in JAG1. METHODS A 33-year-old female underwent comprehensive ophthalmic examination, including best corrected visual acuity (BCVA) measurement, dilated fundus imaging (wide-angle fundus colour and short wavelength autofluorescence imaging), macular and peripheral spectral-domain optical coherence tomography (SD-OCT) and electroretinography (ERG) at baseline and 10 years later at the age of 43. The patient also underwent systemic review with detailed cardiac, brain and renal investigations. During follow-up, genetic analysis using whole-exome sequencing was performed on the patient and her parents to identify disease-causing variants. RESULTS The patient's main complaint was of a recent onset of bilateral photophobia and blurred vision in the left eye. On examination, the most striking retinal finding was of bilateral well-demarcated, anterior circumferential chorioretinal atrophy with scattered pigment clumping from the mid periphery to the ora. In addition, she had posterior pole RPE hypopigmentation, peripapillary chorioretinal atrophy, left macular choroidal folds and retinal vasculature tortuosity with atypical branching. Her retinal electrophysiology was consistent with a cone rod photoreceptor dystrophy and left macular dysfunction. Ten years later, her BCVA, the anterior circumferential chorioretinal atrophy and her visual field constriction all remained stable. Her retinal electrophysiology demonstrated deterioration of left rod function, while cone dysfunction remained stable. Macular function deteriorated in both eyes. During follow-up, she was also noted to have progressive aortic root dilatation, posterior embryotoxon and an x ray diagnosis of butterfly vertebrae. Whole-exome sequencing revealed a novel c.2412C > A p.(Tyr804Ter) truncating mutation in JAG1 that was predicted to be pathogenic and suggested a diagnosis of Alagille syndrome. CONCLUSION This is the first report of the long-term detailed follow-up of a patient with Alagille syndrome whose most striking ophthalmic finding was bilateral well-demarcated, anterior circumferential chorioretinal atrophy. During follow-up, this finding remained stable, suggesting that this may be developmental in origin. This is in contrast with the progressive deterioration in the posterior pole retinal and macular function.
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Ayoub MD, Kamath BM. Alagille Syndrome: Diagnostic Challenges and Advances in Management. Diagnostics (Basel) 2020; 10:E907. [PMID: 33172025 PMCID: PMC7694636 DOI: 10.3390/diagnostics10110907] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/21/2022] Open
Abstract
Alagille syndrome (ALGS) is a multisystem disease characterized by cholestasis and bile duct paucity on liver biopsy in addition to variable involvement of the heart, eyes, skeleton, face, kidneys, and vasculature. The identification of JAG1 and NOTCH2 as disease-causing genes has deepened our understanding of the molecular mechanisms underlying ALGS. However, the variable expressivity of the clinical phenotype and the lack of genotype-phenotype relationships creates significant diagnostic and therapeutic challenges. In this review, we provide a comprehensive overview of the clinical characteristics and management of ALGS, and the molecular basis of ALGS pathobiology. We further describe unique diagnostic considerations that pose challenges to clinicians and outline therapeutic concepts and treatment targets that may be available in the near future.
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Affiliation(s)
- Mohammed D. Ayoub
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada;
- Department of Pediatrics, Faculty of Medicine, Rabigh Branch, King Abdulaziz University, P.O. Box 80205, Jeddah 21589, Saudi Arabia
| | - Binita M. Kamath
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada;
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Intracranial Hypertension and Papilledema in a Large Cohort of Pediatric Patients With Alagille Syndrome. J Pediatr Gastroenterol Nutr 2020; 71:655-662. [PMID: 33093373 DOI: 10.1097/mpg.0000000000002883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
AIMS AND BACKGROUND Ophthalmic abnormalities are amongst the 5 major criteria required for a diagnosis of Alagille syndrome (ALGS), of which embryotoxon, pseudopapilledema, and hypopigmented retinopathy are the most common. Papilledema with or without intracranial hypertension (ICHT) is rarely described. We report 9 pediatric cases of ALGS with bilateral papilledema, 5 of which were diagnosed with ICHT. METHODS The ophthalmic data from 85 patients with clinically and/or genetically (n = 37) proven ALGS were reviewed. The study inclusion criteria were a positive diagnosis of ALGS and availability of ophthalmic follow-up data. Ophthalmic data from 40 patients after liver transplantation (LT) for other indications were also analyzed. RESULTS Nine (13.0%) of the 69 patients meeting the inclusion criteria had papilledema. The neurological and neuroimaging results in all 9 patients were normal. These 9 patients were categorized into 4 groups: a nontransplant group (n = 1), a group with pretransplant papilledema persistent after LT (n = 2), a group with papilledema occurring after LT with spontaneous resolution (n = 1), and a group with papilledema and signs of ICHT after LT (n = 5). The patients with ICHT were treated with steroids alone (n = 1) or with acetazolamide (n = 4). A ventriculoperitoneal shunt was placed in 2 of the 5 cases because of progressive visual loss. Pseudopapilledema was present in 10 additional patients (14.5%, 10/69). One (2.5%) of the 40 patients without ALGS developed papilledema after LT. CONCLUSIONS True ICHT may be underdiagnosed in patients with ALGS. Our findings underscore the need for close ophthalmic follow-up before and after LT in these patients.
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Vitiello L, De Bernardo M, Guercio Nuzio S, Mandato C, Rosa N, Vajro P. Pediatric liver diseases and ocular changes: What hepatologists and ophthalmologists should know and share with each other. Dig Liver Dis 2020; 52:1-8. [PMID: 31843253 DOI: 10.1016/j.dld.2019.11.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/29/2019] [Accepted: 11/17/2019] [Indexed: 12/11/2022]
Abstract
Several rare pediatric liver disorders are accompanied by ophthalmic signs whose awareness and early identification may be of value in confirming/accelerating their diagnosis. Many of these signs are asymptomatic and can only be detected with an ophthalmological examination. Corneal signs are described in patients with Wilson's disease, Alagille's syndrome and some liver storage diseases. Cataract plays an important role to diagnose galactosemia. Retinal involvement is seen in some peroxisomal disorders (e.g. Zellweger's syndrome), in mucopolysaccharidoses (pigmentary retinopathy), and in Niemann-Pick disease (macular cherry red spot). In mucopolysaccharidoses optic nerve can be involved as optic atrophy secondary to pigmentary retinopathy or to chronic papilledema. Children with neonatal cholestasis due to hypopituitarism may present septo-optic dysplasia. Several infectious agents have an ophthalmological/hepatic involvement in the fetal life and/or thereafter. Some mitochondrial liver diseases, such as Pearson's syndrome, present pigmentary retinopathy and a chronic progressive external ophthalmoplegia. Finally, some drugs while protecting the liver may damage the ocular system as seen with long-term glucocorticoids and Nitisinone administration. This review provides a synopsis of those conditions that hepatologists and ophthalmologists should share among themselves to better take care of patients. Synoptic tables are presented to facilitate the mutual understanding of the issues.
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Affiliation(s)
- Livio Vitiello
- Eye Clinic, Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Baronissi, Italy
| | - Maddalena De Bernardo
- Eye Clinic, Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Baronissi, Italy
| | - Salvatore Guercio Nuzio
- Pediatric Clinic, Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Baronissi, Italy
| | - Claudia Mandato
- Department of Pediatrics, Children's Hospital Santobono-Pausilipon, Naples, Italy
| | - Nicola Rosa
- Eye Clinic, Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Baronissi, Italy
| | - Pietro Vajro
- Pediatric Clinic, Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Baronissi, Italy.
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Pierpont ME, Brueckner M, Chung WK, Garg V, Lacro RV, McGuire AL, Mital S, Priest JR, Pu WT, Roberts A, Ware SM, Gelb BD, Russell MW. Genetic Basis for Congenital Heart Disease: Revisited: A Scientific Statement From the American Heart Association. Circulation 2019; 138:e653-e711. [PMID: 30571578 DOI: 10.1161/cir.0000000000000606] [Citation(s) in RCA: 331] [Impact Index Per Article: 66.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This review provides an updated summary of the state of our knowledge of the genetic contributions to the pathogenesis of congenital heart disease. Since 2007, when the initial American Heart Association scientific statement on the genetic basis of congenital heart disease was published, new genomic techniques have become widely available that have dramatically changed our understanding of the causes of congenital heart disease and, clinically, have allowed more accurate definition of the pathogeneses of congenital heart disease in patients of all ages and even prenatally. Information is presented on new molecular testing techniques and their application to congenital heart disease, both isolated and associated with other congenital anomalies or syndromes. Recent advances in the understanding of copy number variants, syndromes, RASopathies, and heterotaxy/ciliopathies are provided. Insights into new research with congenital heart disease models, including genetically manipulated animals such as mice, chicks, and zebrafish, as well as human induced pluripotent stem cell-based approaches are provided to allow an understanding of how future research breakthroughs for congenital heart disease are likely to happen. It is anticipated that this review will provide a large range of health care-related personnel, including pediatric cardiologists, pediatricians, adult cardiologists, thoracic surgeons, obstetricians, geneticists, genetic counselors, and other related clinicians, timely information on the genetic aspects of congenital heart disease. The objective is to provide a comprehensive basis for interdisciplinary care for those with congenital heart disease.
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25
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Fu H, Li Y, Bai G, Yin R, Yin C, Shi W, Zhang L, Li R, Zhao R. Persistent cholestasis resulting from duodenal papillary carcinoma in an adolescent male: A case report. Medicine (Baltimore) 2019; 98:e15708. [PMID: 31145285 PMCID: PMC6708834 DOI: 10.1097/md.0000000000015708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
RATIONALE Cholestasis in pediatric patients has diverse etiologies and can be broadly classified as intrahepatic or extrahepatic. The common causes of extrahepatic cholestasis are bile duct calculus, inflammation, or pancreatitis. Malignant tumor is a rare cause of bile ducts obstruction in adolescent. Here we report a 14-year-old male patient with cholestasis due to poorly differentiated adenocarcinoma. PATIENT CONCERNS A 14-year-old male patient with cholestasis was admitted because of jaundice, weakness, weight loss, and stomach pain for 2 months. The patient had been diagnosed with epilepsy 4 years previously and was being treated with sodium valproate and oxcarbazepine. On admission, laboratory studies showed elevated levels of aspartate aminotransferase (271 IU/L), alanine aminotransferase (224 IU/l), γ-glutamyltransferase (1668.9 IU/L), total bilirubin (66.4 μmol/L), and direct bilirubin (52.6 μmol/L). Additional laboratory tests eliminated common causes of cholestasis such as bacterial/viral infection, autoimmune liver disease, Wilson disease, Alagille syndrome, or progressive familial intrahepatic cholestasis type 3. The results of laboratory investigations showed no improvement after 10 days of treatment with ursodeoxycholic acid and vitamins A, D, and K1. Enhanced magnetic resonance imaging demonstrated a tumor of 22 mm diameter in the duodenal lumen and dilatation of the common bile duct. Endoscopic retrograde cholangiopancreatography detected a tumor in the duodenal lumen. DIAGNOSIS Considering the clinical features, imaging manifestation, endoscopic findings, and pathologic characteristic, the patient was diagnosed with poorly differentiated adenocarcinoma. INTERVENTIONS The patient underwent pancreaticoduodenectomy and chemotherapy. OUTCOME The patient recovered well. Elevated levels of tumor biomarkers or abnormal liver function tests have not occurred during the 2-year follow-up. CONCLUSION Cholestasis resulting from primary duodenal papillary carcinoma is rare in pediatric patients but should be considered in the differential diagnosis.
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Affiliation(s)
- Haiyan Fu
- Department of Infectious and Digestive Diseases, Children’ Hospital of Hebei Province
| | - Yingchao Li
- Department of Pediatric Surgery, The Second Hospital of Hebei Medical University
| | - Gelan Bai
- Department of Infectious and Digestive Diseases, Children’ Hospital of Hebei Province
| | - Runkai Yin
- Department of Infectious and Digestive Diseases, Children’ Hospital of Hebei Province
| | - Chunlan Yin
- Department of Infectious and Digestive Diseases, Children’ Hospital of Hebei Province
| | - Weina Shi
- Department of Infectious and Digestive Diseases, Children’ Hospital of Hebei Province
| | - Lili Zhang
- Department of Pathology, Children’ Hospital of Hebei Province
| | - Rongpin Li
- Department of Medical Imagine, Children’ Hospital of Hebei Province, Hebei Shijiazhuang, China
| | - Ruiqin Zhao
- Department of Infectious and Digestive Diseases, Children’ Hospital of Hebei Province
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Imam L, Haboubi HN. G-Eye: ocular manifestations of gastrointestinal disease. Frontline Gastroenterol 2019; 11:162-167. [PMID: 32133116 PMCID: PMC7043099 DOI: 10.1136/flgastro-2018-101083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/14/2019] [Accepted: 01/22/2019] [Indexed: 02/04/2023] Open
Abstract
Extraintestinal manifestations of gastrointestinal disease can form an important aspect of the diagnosis, monitoring and management in these diseases. Ocular manifestations in particular are often disregarded and can, albeit rarely, present as an emergency.
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Affiliation(s)
- Lema Imam
- Department of Medicine, Glangwili General Hospital, Carmarthen, UK
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27
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Delaney S, O'Connor G, Reardon W, Murphy SJX, Tierney S, Ryan BM, Delaney H, Doherty CP, Guiney M, Brennan P, Tobin WO, McCabe DJH. Extracranial and Intracranial Vasculopathy With "Moyamoya Phenomenon" in Association With Alagille Syndrome. Front Neurol 2019; 9:1194. [PMID: 30761079 PMCID: PMC6362309 DOI: 10.3389/fneur.2018.01194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 12/31/2018] [Indexed: 01/21/2023] Open
Abstract
Background: Alagille syndrome (AGS) is an autosomal-dominant, multisystem disorder caused by mutations in the JAG1 gene. Case Description: A 34-year-old man was referred to our service 10 years ago with focal seizures with impaired awareness and transient slurred speech. He had a 5-year history of intermittent left monocular low-flow retinopathy. He has a family history of AGS. General examination revealed mild hypertension, aortic regurgitation, and livedo reticularis. Neurological examination was normal. Investigations: He had mild hyperlipidaemia and persistently-positive lupus anticoagulant consistent with primary anti-phospholipid syndrome. Color Doppler ultrasound revealed low velocity flow in a narrowed extracranial left internal carotid artery (ICA). MR and CT angiography revealed a diffusely narrowed extracranial and intracranial left ICA. Formal cerebral angiography confirmed severe left ICA narrowing consistent with a left ICA “vasculopathy” and moyamoya phenomenon. Transthoracic echocardiogram revealed a bicuspid aortic valve and aortic incompetence. Molecular genetic analysis identified a missense mutation (A211P) in exon 4 of the JAG1 gene, consistent with AGS. Discussion: AGS should be considered in young adults with TIAs/stroke and unexplained extracranial or intracranial vascular abnormalities, and/or moyamoya phenomenon, even in the absence of other typical phenotypic features. Gene panels should include JAG1 gene testing in similar patients.
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Affiliation(s)
- Siobhan Delaney
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, Incorporating The National Children's Hospital (AMNCH)/Tallaght University Hospital, Dublin, Ireland.,Stroke Service, AMNCH/Tallaght University Hospital, Dublin, Ireland
| | - Ged O'Connor
- Department of Neurology, University Hospital Waterford, Waterford, Ireland
| | - William Reardon
- National Centre for Medical Genetics, Our Lady's Children's Hospital, Dublin, Ireland
| | - Stephen J X Murphy
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, Incorporating The National Children's Hospital (AMNCH)/Tallaght University Hospital, Dublin, Ireland.,Stroke Service, AMNCH/Tallaght University Hospital, Dublin, Ireland.,Vascular Neurology Research Foundation, C/O Department of Neurology, AMNCH/Tallaght University Hospital, Dublin, Ireland
| | - Sean Tierney
- Department of Vascular Surgery, AMNCH/Tallaght University Hospital, Dublin, Ireland
| | - Barbara M Ryan
- Department of Gastroenterology, AMNCH/Tallaght University Hospital, and Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - Holly Delaney
- Department of Radiology, AMNCH/Tallaght University Hospital, Dublin, Ireland
| | - Colin P Doherty
- Department of Neurology, St James's Hospital, Dublin, Ireland
| | - Michael Guiney
- Department of Radiology, St James's Hospital, Dublin, Ireland
| | - Paul Brennan
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - W Oliver Tobin
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, Incorporating The National Children's Hospital (AMNCH)/Tallaght University Hospital, Dublin, Ireland.,Stroke Service, AMNCH/Tallaght University Hospital, Dublin, Ireland.,Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Dominick J H McCabe
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, Incorporating The National Children's Hospital (AMNCH)/Tallaght University Hospital, Dublin, Ireland.,Stroke Service, AMNCH/Tallaght University Hospital, Dublin, Ireland.,Vascular Neurology Research Foundation, C/O Department of Neurology, AMNCH/Tallaght University Hospital, Dublin, Ireland.,Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, United Kingdom.,Irish Centre for Vascular Biology, Dublin, Ireland.,Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Dublin, Ireland
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Paucity of intrahepatic bile ducts in pediatric practice. PEDIATRU.RO 2019. [DOI: 10.26416/pedi.55.3.2019.2643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Bang SP, Lee DC, Lee SY. Asymmetric Lateral Rectus Muscle Insertion Presenting as Esotropia in a Child With Alagille Syndrome. J Pediatr Ophthalmol Strabismus 2018; 55:e36-e38. [PMID: 30388280 DOI: 10.3928/01913913-20181012-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 08/03/2018] [Indexed: 11/20/2022]
Abstract
A 2-year-old boy with Alagille syndrome who had esotropia underwent bilateral medial rectus recession. One month postoperatively, esotropia reoccurred and was aggravated thereafter. Right lateral rectus resection was unsuccessful because the insertion site could not be identified. Careful preoperative imaging may be necessary in patients with Alagille syndrome to detect any abnormal extraocular muscle insertion. [J Pediatr Ophthalmol. 2018;55:e36-e38.].
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Abstract
Alagille syndrome is a complex multisystem autosomal dominant disorder with a wide variability in penetrance of clinical features. A majority of patients have pathogenic mutations in either the JAG1 gene, encoding a Notch pathway ligand, or the receptor NOTCH2. No genotype-phenotype correlations have been found in any organ system. Liver disease is a major cause of morbidity in this population, whereas cardiac and vascular involvement accounts for most of the mortality. Current therapies are supportive, but the future is promising for the development of targeted interventions to augment Notch pathway signaling in involved tissues.
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Affiliation(s)
- Ellen Mitchell
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - Melissa Gilbert
- Division of Genomic Diagnostics, Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3615 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Kathleen M Loomes
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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31
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Phenotype–genotype correlations and emerging pathways in ocular anterior segment dysgenesis. Hum Genet 2018; 138:899-915. [DOI: 10.1007/s00439-018-1935-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 09/10/2018] [Indexed: 12/11/2022]
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Clinical and genetic characteristics of 251 consecutive patients with macular and cone/cone-rod dystrophy. Sci Rep 2018; 8:4824. [PMID: 29555955 PMCID: PMC5859282 DOI: 10.1038/s41598-018-22096-0] [Citation(s) in RCA: 145] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 02/16/2018] [Indexed: 12/14/2022] Open
Abstract
Macular and cone/cone-rod dystrophies (MD/CCRD) demonstrate a broad genetic and phenotypic heterogeneity, with retinal alterations solely or predominantly involving the central retina. Targeted next-generation sequencing (NGS) is an efficient diagnostic tool for identifying mutations in patient with retinitis pigmentosa, which shows similar genetic heterogeneity. To detect the genetic causes of disease in patients with MD/CCRD, we implemented a two-tier procedure consisting of Sanger sequencing and targeted NGS including genes associated with clinically overlapping conditions. Disease-causing mutations were identified in 74% of 251 consecutive MD/CCRD patients (33% of the variants were novel). Mutations in ABCA4, PRPH2 and BEST1 accounted for 57% of disease cases. Further mutations were identified in CDHR1, GUCY2D, PROM1, CRX, GUCA1A, CERKL, MT-TL1, KIF11, RP1L1, MERTK, RDH5, CDH3, C1QTNF5, CRB1, JAG1, DRAM2, POC1B, NPHP1 and RPGR. We provide detailed illustrations of rare phenotypes, including autofluorescence and optical coherence tomography imaging. Targeted NGS also identified six potential novel genotype-phenotype correlations for FAM161A, INPP5E, MERTK, FBLN5, SEMA4A and IMPDH1. Clinical reassessment of genetically unsolved patients revealed subgroups with similar retinal phenotype, indicating a common molecular disease cause in each subgroup.
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Alagille Syndrome: Clinical and Ocular Pathognomonic Features. Eur J Ophthalmol 2018; 21:199-206. [PMID: 20677167 DOI: 10.5301/ejo.2010.5675] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2010] [Indexed: 11/20/2022]
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An unusual case of bilateral pigmented maculopathy and anterior segment dysgenesis. Eur J Ophthalmol 2017; 28:253-255. [PMID: 29148029 DOI: 10.5301/ejo.5001073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE Pigmentary maculopathy can occur in the context of various inherited and acquired diseases. Anterior segment dysgenesis arises due to developmental anomalies and may be associated with systemic disease, as in Rieger syndrome. CASE REPORT A 49-year-old woman presented with longstanding reduction in vision, evidence of anterior segment dysgenesis, and multiple discrete pigmented lesions throughout the macula bilaterally. Electroretinographic findings were consistent with severe macular dysfunction. Gene array analysis did not reveal any chromosomal imbalances or other specific abnormalities. CONCLUSIONS This is a unique case of bilateral pigmentary maculopathy and anterior segment dysgenesis, with clinical findings that are not characteristic of previously reported disease.
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Abstract
PURPOSE Although posterior embryotoxon (PE) has a high incidence in the general population, clinicians should exclude any sign of glaucoma in its presence. This anatomic abnormality is often referred to as "isolated" when the intraocular pressure is normal. Nevertheless, it may be the only sign of Alagille syndrome (AS) that can be clinically heterogenous, as presented here. This possibility must be known, to look for involvement of other organs, and in case of suspicion, mutation of the JAG1 gene must be considered. METHODS In this case series, we present the observation of a family with 3 individuals from 3 generations, in whom PE was a marker of AS. RESULTS PE were observed in these 3 patients and considered as "isolated" as the intraocular pressure was normal. The 2 elder patients were also followed for atypical retinal dystrophy with speckling of the retinal pigment and optic disc drusen. AS syndrome was suspected when mild liver dysfunction was detected in the youngest girl. The detection of JAG1 mutation confirmed this diagnosis. CONCLUSIONS As AS can be clinically heterogenous, it must be considered in case of isolated PE. Involvement of other organs must be looked for to search for mutation of the JAG1 gene in relevant cases.
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Kuony A, Michon F. Epithelial Markers aSMA, Krt14, and Krt19 Unveil Elements of Murine Lacrimal Gland Morphogenesis and Maturation. Front Physiol 2017; 8:739. [PMID: 29033846 PMCID: PMC5627580 DOI: 10.3389/fphys.2017.00739] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 09/11/2017] [Indexed: 12/21/2022] Open
Abstract
As an element of the lacrimal apparatus, the lacrimal gland (LG) produces the aqueous part of the tear film, which protects the eye surface. Therefore, a defective LG can lead to serious eyesight impairment. Up to now, little is known about LG morphogenesis and subsequent maturation. In this study, we delineated elements of the cellular and molecular events involved in LG formation by using three epithelial markers, namely aSMA, Krt14, and Krt19. While aSMA marked a restricted epithelial population of the terminal end buds (TEBs) in the forming LG, Krt14 was found in the whole embryonic LG epithelial basal cell layer. Interestingly, Krt19 specifically labeled the presumptive ductal domain and subsequently, the luminal cell layer. By combining these markers, the Fucci reporter mouse strain and genetic fate mapping of the Krt14+ population, we demonstrated that LG epithelium expansion is fuelled by a patterned cell proliferation, and to a lesser extent by epithelial reorganization and possible mesenchymal-to-epithelial transition. We pointed out that this epithelial reorganization, which is associated with apoptosis, regulated the lumen formation. Finally, we showed that the inhibition of Notch signaling prevented the ductal identity from setting, and led to a LG covered by ectopic TEBs. Taken together our results bring a deeper understanding on LG morphogenesis, epithelial domain identity, and organ expansion.
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Affiliation(s)
- Alison Kuony
- Developmental Biology Program, Institute of Biotechnology, University of HelsinkiHelsinki, Finland
| | - Frederic Michon
- Developmental Biology Program, Institute of Biotechnology, University of HelsinkiHelsinki, Finland
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Magyar MA, Metropulos D, Antoon JW. Direct Hyperbilirubinemia in an Infant. Clin Pediatr (Phila) 2017; 56:696-699. [PMID: 27550871 DOI: 10.1177/0009922816664166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Matthew A Magyar
- 1 University of Illinois Hospital & Health Sciences System, Chicago, IL, USA
| | | | - James W Antoon
- 1 University of Illinois Hospital & Health Sciences System, Chicago, IL, USA
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El-Karaksy H, Hamed D, Fouad H, Mogahed E, Helmy H, Hasanain F. Ocular findings in patients with cholestatic disorders of infancy: A single-centre experience. Arab J Gastroenterol 2017; 18:108-113. [PMID: 28583322 DOI: 10.1016/j.ajg.2017.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 04/22/2017] [Accepted: 05/07/2017] [Indexed: 11/29/2022]
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Carroll WJ, Peck T, Jenkins TL, Karcioglu ZA. Periocular, periorbital, and orbital pathology in liver disease. Surv Ophthalmol 2017; 62:134-149. [DOI: 10.1016/j.survophthal.2016.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 11/01/2016] [Accepted: 11/04/2016] [Indexed: 12/24/2022]
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Sato A, Makino S, Tampo H. Sleep Mask-like Chorioretinal Atrophy in a Patient With Alagille Syndrome. J Pediatr Ophthalmol Strabismus 2016; 53:384. [PMID: 27858950 DOI: 10.3928/01913913-20160803-03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Ho DK, Levin AV, Anninger WV, Piccoli DA, Eagle RC. Anterior Chamber Pathology in Alagille Syndrome. Ocul Oncol Pathol 2016; 2:270-275. [PMID: 27843908 DOI: 10.1159/000446804] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/13/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Alagille syndrome is an autosomal dominant disorder characterized by neonatal cholestasis, characteristic facies, and cardiac abnormalities. Ocular abnormalities include posterior embryotoxon, mosaic pattern of iris stromal hypoplasia, microcornea, optic disc drusen, and pigmentary retinopathy. We present the second report of ocular pathology in two cases of Alagille syndrome. METHODS Gross and histologic preparations of four eyes of two patients. RESULTS Posterior embryotoxon is seen in both cases, with iris processes extending to the embryotoxon in case 1. Case 1 exhibited distinctly abnormal iris stroma with a prominent cleft separating the anterior and posterior stroma. Lacy vacuolization of the iris pigment epithelium was seen in case 2. CONCLUSIONS Alagille syndrome is primarily a hepatic disorder but presents with several distinct ocular pathologic features, most specifically posterior embryotoxon. This and the unusual iris stroma may be caused by improper migration of neural crest cells due to mutation in the Jagged 1 gene that causes Alagille syndrome. Patients with Alagille syndrome rarely present to ocular autopsy. Pathology findings may help us better understand the pathophysiology of the ocular abnormalities in this disorder.
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Affiliation(s)
- Derek K Ho
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pa., USA
| | - Alex V Levin
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pa., USA; Wills Eye Hospital, Philadelphia, Pa., USA
| | | | | | - Ralph C Eagle
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pa., USA; Wills Eye Hospital, Philadelphia, Pa., USA
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Saleh M, Kamath BM, Chitayat D. Alagille syndrome: clinical perspectives. APPLICATION OF CLINICAL GENETICS 2016; 9:75-82. [PMID: 27418850 PMCID: PMC4935120 DOI: 10.2147/tacg.s86420] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Alagille syndrome is an autosomal dominant, complex multisystem disorder characterized by the presence of three out of five major clinical criteria: cholestasis with bile duct paucity on liver biopsy, congenital cardiac defects (with particular involvement of the pulmonary arteries), posterior embryotoxon in the eye, characteristic facial features, and butterfly vertebrae. Renal and vascular abnormalities can also occur. Inter- and intrafamilial variabilities in the clinical manifestations are common. We reviewed the clinical features and management as well as the molecular basis of Alagille syndrome.
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Affiliation(s)
- Maha Saleh
- Division of Clinical and Metabolic Genetics
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Hospital for Sick Children
| | - David Chitayat
- Division of Clinical and Metabolic Genetics; Department of Obstetrics and Gynecology, Prenatal Diagnosis and Medical Genetics Program, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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Tooley AA, Sweetser S. Clinical examination: Eyes. Clin Liver Dis (Hoboken) 2016; 7:154-157. [PMID: 31041052 PMCID: PMC6490280 DOI: 10.1002/cld.561] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 04/24/2016] [Accepted: 05/06/2016] [Indexed: 02/04/2023] Open
Affiliation(s)
- Andrea A. Tooley
- Department of OphthalmologyMayo Clinic College of MedicineRochesterMN
| | - Seth Sweetser
- Division of Gastroenterology and HepatologyMayo Clinic College of MedicineRochesterMN
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Cho HH, Kim WS, Choi YH, Cheon JE, Lee SM, Kim IO, Shin SM, Ko JS, Moon JS. Ultrasonography evaluation of infants with Alagille syndrome: In comparison with biliary atresia and neonatal hepatitis. Eur J Radiol 2016; 85:1045-52. [PMID: 27161050 DOI: 10.1016/j.ejrad.2016.03.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 03/01/2016] [Accepted: 03/21/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the ultrasonography (US) features of Alagille syndrome (ALGS), as compared with biliary atresia (BA) or neonatal hepatitis (NH). METHODS Our study included 23 ALGS, 75 BA and 70 NH patients. The initial US images were retrospectively reviewed for gallbladder (GB) morphology with systemic classification, GB length and luminal area, presence of triangular-cord (TC) sign and hypertrophied hepatic-artery. The presence of anomalies associated with ALGS was evaluated. The diagnostic values of each finding and their combinations were evaluated. RESULTS Both ALGS (57%) and BA (79%) were more frequently associated with abnormal GB shapes than NH (19%, all P<0.001). The short and small GBs were more frequently observed in ALGS and BA than in NH (all P<0.001). None in the ALGS and NH showed TC sign, while 41% in the BA did (all P<0.001). Hypertrophied hepatic-artery was noted less frequently in both ALGS (13%) and NH (14%) than in BA (83%, all P<0.001). The combination of US criteria with associated anomalies increased the positive-predictive-value for ALGS. CONCLUSION Abnormal shaped GB with absence of the TC sign and hypertrophied hepatic-artery and presence of associated anomalies can be a differential point of ALGS.
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Affiliation(s)
- Hyun-Hae Cho
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Woo Sun Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; Institute of Radiation Medicine, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea.
| | - Young Hun Choi
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Jung-Eun Cheon
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; Institute of Radiation Medicine, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - So Mi Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - In-One Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; Institute of Radiation Medicine, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Su-Mi Shin
- Department of Radiology, SMG-SNU Boramae Medical Center, Seoul 07061, Republic of Korea
| | - Jae Sung Ko
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Republic of Korea
| | - Jin Soo Moon
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Republic of Korea
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Tilib Shamoun S, Le Friec G, Spinner N, Kemper C, Baker AJ. Immune dysregulation in Alagille syndrome: A new feature of the evolving phenotype. Clin Res Hepatol Gastroenterol 2015; 39:566-9. [PMID: 26026399 DOI: 10.1016/j.clinre.2015.02.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 01/20/2015] [Accepted: 02/01/2015] [Indexed: 02/04/2023]
Abstract
Alagille syndrome (ALGS) is a rare autosomal dominant, multi-system disease caused by mutations in one of two NOTCH signaling pathway genes. Mutations in JAG1 are found in more than 94% of patients, with associated Jagged1 defects. We previously showed that CD46, which is a complement and immune regulator, regulates NOTCH expression during T cell activation after binding to C3b/C4b. We have identified 25% of our ALGS cohort with frequent infections and studied a subgroup of 4 in detail who were not showing current features of infections in order to show if Jagged1 abnormalities could affect immune function. We used cytometric bead arrays and FACS to measure cytokines and cell membrane expression. Resting and activated T cells were studied in both low and high IL-2 concentration to assess the TH1 ability to shift from INFγ to IL-10 production. In vitro initial PBMC cell population and subpopulation assessment were normal but further assessment of the lymphocytes revealed that while NOTCH1 expression and regulation was normal on resting TH1, Jagged1 expression was exaggerated. Resting TH1 cells from some patients exhibited high CD132 levels. Upon activating T cells, TH1 cells managed to produce TNF but failed to produce sufficient IFNγ levels (in two patients TH1 produced no IFNγ). TH2 exhibited exaggerated response with high IL-4 and IL-5 levels. TH1 were unable to down-regulate CD127, resulting in prolonged immune activation, and failed to shift from IFNγ to IL-10 production maintaining high IL-2 levels suggesting an impaired T cell response. Disturbed CD46-Jagged1 interaction may explain recurrent infections among ALGS patients, and could predispose to Th2-driven conditions such as asthma, eczema, food allergies and airway atopy and otitis media. The ALGS description could now be extended to include immune dysregulation.
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Affiliation(s)
- S Tilib Shamoun
- King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
| | - G Le Friec
- MRC Center for Transplantation, Guys' Hospital, King's College London, 5th Floor Tower Wing, London SE1 9RT, United Kingdom
| | - N Spinner
- Abramson Research Center, The Children's Hospital of Philadelphia, 3615, Civic Center Boulevard, Philadelphia 19104-4318, PA, United States
| | - C Kemper
- MRC Center for Transplantation, Guys' Hospital, King's College London, 5th Floor Tower Wing, London SE1 9RT, United Kingdom
| | - A J Baker
- King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom.
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Abstract
PURPOSE To describe multimodal imaging findings in a patient with Alagille syndrome and associated chorioretinopathy. METHODS In this case report, clinical examination and multimodal imaging, including fundus photography, spectral domain optical coherence tomography, and fundus autofluorescence (AF) and wide-field AF, are presented. RESULTS An 18-year-old Iranian-American girl with known history of Alagille syndrome reported diminished vision in both eyes. Color photographs depicted diffuse hypopigmentation of the fundus and atrophy of the macular retinal pigment epithelium with foveal sparing. Spectral domain optical coherence tomography revealed attenuation of the retinal pigment epithelium and overlying ellipsoid band. Fundus AF imaging of the macula revealed a geographic area of decreased AF that extended to the peripapillary region and inferotemporal arcade and contained discernable ovoid areas of deep AF loss in the nasal macula. Wide-field AF revealed a continuous and circumferential area of well-delineated decreased AF in the retinal periphery of both eyes. CONCLUSION This case represents a severe manifestation of posterior and peripheral chorioretinopathy in a patient with Alagille syndrome. This is the first documentation of significant peripheral chorioretinal atrophy as assessed by wide-field AF imaging in this condition.
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Affiliation(s)
- Daniel D Esmaili
- Retina Vitreous Associates Medical Group, Los Angeles, California
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Sakhuja P, Whyte H, Kamath B, Martin N, Chitayat D. Williams syndrome presenting with findings consistent with Alagille syndrome. Clin Case Rep 2014; 3:24-8. [PMID: 25678968 PMCID: PMC4317206 DOI: 10.1002/ccr3.138] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 05/23/2014] [Accepted: 08/02/2014] [Indexed: 11/10/2022] Open
Abstract
Conjugated hyperbilirubinemia, posterior embryotoxon, and vertebral anomalies are not features of William syndrome (WS). We herein report a preterm infant who presented with features suggestive of Alagille syndrome, but microarray showed findings consistent with WS. This further extends the phenotype of WS and emphasizes the need for microarray analysis.
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Affiliation(s)
- Pankaj Sakhuja
- Division of Neonatology, The Hospital for Sick Children, University of Toronto Toronto, Ontario, Canada
| | - Hilary Whyte
- Division of Neonatology, The Hospital for Sick Children, University of Toronto Toronto, Ontario, Canada
| | - Binita Kamath
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto Toronto, Ontario, Canada
| | - Nicole Martin
- The Prenatal Diagnosis and Medical Genetics Program, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto Toronto, Ontario, Canada
| | - David Chitayat
- The Prenatal Diagnosis and Medical Genetics Program, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto Toronto, Ontario, Canada ; Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, University of Toronto Toronto, Ontario, Canada
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Shenoy BH, Gupta A, Sachdeva V, Kekunnaya R. Cornelia de Lange syndrome with optic disk pit: Novel association and review of literature. Oman J Ophthalmol 2014; 7:69-71. [PMID: 25136230 PMCID: PMC4134549 DOI: 10.4103/0974-620x.137149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cornelia de Lange syndrome (CdLS), also called Brachmann-de Lange syndrome, is a multiple congenital anomaly syndrome characterized by a distinctive facial appearance, ophthalmological abnormalities, prenatal and postnatal growth deficiency, psychomotor delay, behavioral problems, and malformations of the upper extremities. Most common and consistent ophthalmic features reported are nasolacrimal duct obstruction, long and curly eyelashes, blepharitis, ptosis, synophrys, telecanthus, hypertelorism, microcornea, peripapillary pigment ring, and myopia. In this report we report a case of a 5-year old boy who presented to our institution with complaint of blurring of vision in the right eye since birth. A diagnosis of Cornelia de Lange syndrome was arrived at based on the characteristic external and ophthalmic examination. He was found to have a rare association of optic nerve head coloboma in the right eye and a novel finding of an optic disk pit in the left eye. The association of optic disk pit with CdLS has never been reported earlier. We aim to provide a thorough review of literature of this not so uncommon syndrome.
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Affiliation(s)
| | - Amit Gupta
- Jasti V Ramanamma Children's Eye Care Center, Hyderabad, India
| | - Virender Sachdeva
- Nimmagadda Prasad Children's Eye Care Center, LV Prasad Eye Institute, Vishakhapatnam, Andhra Pradesh, India
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Wax JR, Chard R, Pinette MG, Cartin A. Two- and three-dimensional prenatal sonographic diagnosis of Alagille syndrome. JOURNAL OF CLINICAL ULTRASOUND : JCU 2014; 42:293-296. [PMID: 24420446 DOI: 10.1002/jcu.22125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 08/27/2013] [Accepted: 11/20/2013] [Indexed: 06/03/2023]
Abstract
We describe a case of Alagille syndrome diagnosed by second-trimester ultrasound. Features included the characteristic prominent chin, single umbilical artery, and hemivertebrae. Three-dimensional imaging demonstrated classic butterfly vertebrae, which were not otherwise appreciable. Alagille syndrome may be detected by second-trimester ultrasound in the at-risk fetus.
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Affiliation(s)
- Joseph R Wax
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maine Medical Center, Portland, ME, 04102
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