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MacLean JE, Wertman JN, Prykhozhij SV, Chedrawe E, Langley S, Steele SL, Ban K, Blake K, Berman JN. phox2ba: The Potential Genetic Link behind the Overlap in the Symptomatology between CHARGE and Central Congenital Hypoventilation Syndromes. Genes (Basel) 2023; 14:genes14051086. [PMID: 37239446 DOI: 10.3390/genes14051086] [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: 10/12/2022] [Revised: 05/06/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023] Open
Abstract
CHARGE syndrome typically results from mutations in the gene encoding chromodomain helicase DNA-binding protein 7 (CHD7). CHD7 is involved in regulating neural crest development, which gives rise to tissues of the skull/face and the autonomic nervous system (ANS). Individuals with CHARGE syndrome are frequently born with anomalies requiring multiple surgeries and often experience adverse events post-anesthesia, including oxygen desaturations, decreased respiratory rates, and heart rate abnormalities. Central congenital hypoventilation syndrome (CCHS) affects ANS components that regulate breathing. Its hallmark feature is hypoventilation during sleep, clinically resembling observations in anesthetized CHARGE patients. Loss of PHOX2B (paired-like homeobox 2b) underlies CCHS. Employing a chd7-null zebrafish model, we investigated physiologic responses to anesthesia and compared these to loss of phox2b. Heart rates were lower in chd7 mutants compared to the wild-type. Exposure to tricaine, a zebrafish anesthetic/muscle relaxant, revealed that chd7 mutants took longer to become anesthetized, with higher respiratory rates during recovery. chd7 mutant larvae demonstrated unique phox2ba expression patterns. The knockdown of phox2ba reduced larval heart rates similar to chd7 mutants. chd7 mutant fish are a valuable preclinical model to investigate anesthesia in CHARGE syndrome and reveal a novel functional link between CHARGE syndrome and CCHS.
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Affiliation(s)
- Jessica E MacLean
- Department of Pediatrics, Dalhousie University, Halifax, NS B3K 6R8, Canada
| | - Jaime N Wertman
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Sergey V Prykhozhij
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
| | - Emily Chedrawe
- Department of Pediatrics, Dalhousie University, Halifax, NS B3K 6R8, Canada
| | - Stewart Langley
- Department of Pediatrics, Dalhousie University, Halifax, NS B3K 6R8, Canada
| | - Shelby L Steele
- Department of Pediatrics, Dalhousie University, Halifax, NS B3K 6R8, Canada
| | - Kevin Ban
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
| | - Kim Blake
- Department of Pediatrics, Dalhousie University, Halifax, NS B3K 6R8, Canada
| | - Jason N Berman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
- Departments of Pediatrics and Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada
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Molecular Organization and Patterning of the Medulla Oblongata in Health and Disease. Int J Mol Sci 2022; 23:ijms23169260. [PMID: 36012524 PMCID: PMC9409237 DOI: 10.3390/ijms23169260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
The medulla oblongata, located in the hindbrain between the pons and the spinal cord, is an important relay center for critical sensory, proprioceptive, and motoric information. It is an evolutionarily highly conserved brain region, both structural and functional, and consists of a multitude of nuclei all involved in different aspects of basic but vital functions. Understanding the functional anatomy and developmental program of this structure can help elucidate potential role(s) of the medulla in neurological disorders. Here, we have described the early molecular patterning of the medulla during murine development, from the fundamental units that structure the very early medullary region into 5 rhombomeres (r7–r11) and 13 different longitudinal progenitor domains, to the neuronal clusters derived from these progenitors that ultimately make-up the different medullary nuclei. By doing so, we developed a schematic overview that can be used to predict the cell-fate of a progenitor group, or pinpoint the progenitor domain of origin of medullary nuclei. This schematic overview can further be used to help in the explanation of medulla-related symptoms of neurodevelopmental disorders, e.g., congenital central hypoventilation syndrome, Wold–Hirschhorn syndrome, Rett syndrome, and Pitt–Hopkins syndrome. Based on the genetic defects seen in these syndromes, we can use our model to predict which medullary nuclei might be affected, which can be used to quickly direct the research into these diseases to the likely affected nuclei.
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Tovichien P, Rattananont K, Kulthamrongsri N, Chanvanichtrakool M, Yangthara B. Rare cause of neonatal apnea from congenital central hypoventilation syndrome. BMC Pediatr 2022; 22:105. [PMID: 35209861 PMCID: PMC8867765 DOI: 10.1186/s12887-022-03167-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 02/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Congenital central hypoventilation syndrome (CCHS) is a rare condition caused by mutations in the Paired-Like Homeobox 2B (PHOX2B) gene. It causes alveolar hypoventilation and autonomic dysregulation. This report aimed to raise awareness of this rare cause of neonatal apnea and hypoventilation as well as described the diagnostic work up to confirm the diagnosis in resource-limited setting where polysomnography for neonate is unavailable. CASE PRESENTATION A late preterm female newborn born from a non-consanguineous primigravida 31-year-old mother had desaturation soon after birth followed by apnea and bradycardia. After becoming clinically stable, she still had extubation failure from apnea without hypercapnic ventilatory response which worsened during non-rapid eye movement (NREM) sleep. After exclusion of other etiologies, we suspected congenital central hypoventilation syndrome and sent genetic testing. The result showed a PHOX2B gene mutation which confirmed the diagnosis of CCHS. We gave the patient's caregivers multidisciplinary home respiratory care training including tracheostomy care, basic life support, and simulation training for respiratory problem solving. Then, the patient was discharged and scheduled for follow-up surveillance for associated conditions. CONCLUSION Diagnosis of CCHS in neonates includes the main clue of the absence of hypercapnic ventilatory response which worsens during non-rapid eye movement (NREM) sleep after exclusion of other causes. Molecular testing for PHOX2B gene mutation was used to confirm the diagnosis.
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Affiliation(s)
- Prakarn Tovichien
- Division of Pulmonology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | | | | | - Mongkol Chanvanichtrakool
- Division of Neurology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Buranee Yangthara
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Chawla J, Edwards EA, Griffiths AL, Nixon GM, Suresh S, Twiss J, Vandeleur M, Waters KA, Wilson AC, Wilson S, Tai A. Ventilatory support at home for children: A joint position paper from the Thoracic Society of Australia and New Zealand/Australasian Sleep Association. Respirology 2021; 26:920-937. [PMID: 34387937 PMCID: PMC9291882 DOI: 10.1111/resp.14121] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 04/04/2021] [Accepted: 07/05/2021] [Indexed: 11/28/2022]
Abstract
The goal of this position paper on ventilatory support at home for children is to provide expert consensus from Australia and New Zealand on optimal care for children requiring ventilatory support at home, both non-invasive and invasive. It was compiled by members of the Thoracic Society of Australia and New Zealand (TSANZ) and the Australasian Sleep Association (ASA). This document provides recommendations to support the development of improved services for Australian and New Zealand children who require long-term ventilatory support. Issues relevant to providers of equipment and areas of research need are highlighted.
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Affiliation(s)
- Jasneek Chawla
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Elizabeth A Edwards
- New Zealand Respiratory & Sleep Institute, Starship Children's Hospital, Auckland, New Zealand
| | - Amanda L Griffiths
- Respiratory & Sleep Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Gillian M Nixon
- Melbourne Children's Sleep Centre, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Sadasivam Suresh
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Jacob Twiss
- New Zealand Respiratory & Sleep Institute, Starship Children's Hospital, Auckland, New Zealand
| | - Moya Vandeleur
- Respiratory & Sleep Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Karen A Waters
- Sleep Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Andrew C Wilson
- Respiratory & Sleep Medicine, Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - Susan Wilson
- Child Youth Mental Health Services, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Andrew Tai
- Respiratory & Sleep Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
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Porcaro F, Paglietti MG, Cherchi C, Schiavino A, Chiarini Testa MB, Cutrera R. How the Management of Children With Congenital Central Hypoventilation Syndrome Has Changed Over Time: Two Decades of Experience From an Italian Center. Front Pediatr 2021; 9:648927. [PMID: 33855005 PMCID: PMC8039127 DOI: 10.3389/fped.2021.648927] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 02/12/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Congenital central hypoventilation syndrome (CCHS) is a rare disorder whose clinical phenotype is closely related to genotype. Methods: A retrospective analysis has been conducted on 22 patients with CCHS, who were referred to the Pediatric Pulmonology and Respiratory Intermediate Care Unit of Bambino Gesù Children's Hospital (Italy) for a multidisciplinary follow-up program between 2000 and 2020. Results: Apnea and cyanosis were the most frequent symptoms at onset (91%). Overall, 59% of patients required tracheostomy and invasive mechanical ventilation (IMV) in the first months of life. Thirty-two percent of patients had Hirschsprung disease (HSCR) that was associated with longer polyalanine repetitions or non-polyalanine repeat expansion mutations (NPARMs). Polyalanine repeat expansion mutations (PARMs) were more frequent and two novel NPARMs (c.780dupT and C.225-256delCT) were described in 14% of patients. Focal epilepsy was first described in 14% of patients and neurocognitive and neuromotor impairment involved 27% and 23% of children, respectively. Symptoms due to autonomic nervous system dysfunction/dysregulation (ANSD)-including strabismus (27%), dysphagia (27%), abnormal heart rhythm (10%), breath-holding spells (9%), and recurrent seizures due to hypoglycemia (9%)-were associated with an increased number of polyalanine repetitions of exon 3 or NPARMs of PHOX2B gene. Overall, the number of patients with moderate to severe phenotype initially treated with non-invasive ventilation (NIV) increased over time, and the decannulation program was concluded with 3 patients who started with IMV. Conclusions: Our study confirms that more severe phenotypes of CCHS are related to the number of polyalanine repetitions or to NPARMs. Although invasive ventilation is often required by patients with severe genotype/phenotype, gradual acquisition of specific skills in the management of patients with CCHS and technological improvements in mechanical ventilation allowed us to improve our therapeutic approach in this population.
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Affiliation(s)
- Federica Porcaro
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep, and Long-Term Ventilation Unit, Academic Department of Pediatrics and Genetic Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Maria Giovanna Paglietti
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep, and Long-Term Ventilation Unit, Academic Department of Pediatrics and Genetic Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Claudio Cherchi
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep, and Long-Term Ventilation Unit, Academic Department of Pediatrics and Genetic Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandra Schiavino
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep, and Long-Term Ventilation Unit, Academic Department of Pediatrics and Genetic Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Maria Beatrice Chiarini Testa
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep, and Long-Term Ventilation Unit, Academic Department of Pediatrics and Genetic Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Renato Cutrera
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep, and Long-Term Ventilation Unit, Academic Department of Pediatrics and Genetic Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Hino A, Terada J, Kasai H, Shojima H, Ohgino K, Sasaki A, Hayasaka K, Tatsumi K. Adult cases of late-onset congenital central hypoventilation syndrome and paired-like homeobox 2B-mutation carriers: an additional case report and pooled analysis. J Clin Sleep Med 2020; 16:1891-1900. [PMID: 32741443 DOI: 10.5664/jcsm.8732] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Congenital central hypoventilation syndrome (CCHS) is caused by the paired-like homeobox 2B (PHOX2B) mutation and predominantly diagnosed during the neonatal period. Although late-onset CCHS and PHOX2B mutation carriers have been reported, the features of these disease states in adults remain uncertain. This study aimed to identify the characteristics of adult-onset CCHS and PHOX2B-mutation carriers in adult. METHODS We mainly searched the PubMed/Medline and Cochrane Databases and classified our target patients into 2 groups: group A, symptomatically diagnosed with late-onset CCHS in adulthood; group B, adult PHOX2B-mutation carriers. Then, clinical characteristics, including the onset, treatment, long-term course, and pattern of the PHOX2B mutation in both groups were analyzed. Additionally, a new adult-case of late-onset CCHS was added to the analysis. RESULTS Group A was comprised of 12 patients. The onset triggers of illness included a history of respiratory compromise following general anesthesia and respiratory tract infections. All patients in group A had 20/25 polyalanine repeat mutations and required some chronic ventilatory support at least during sleep, including portable positive pressure ventilator via tracheostomy or noninvasive positive pressure ventilation. In these patients with ventilatory support during sleep, sudden death or poor prognosis was not reported. Group B was comprised of 33 adults from 24 families with PHOX2B mutations. Nine patients in group B were confirmed with the diagnosis of CCHS. Although polyalanine repeat mutations 20/25 represented the most common gene mutation, diverse mutations, including mosaicism, were observed. Hypoventilation of several cases in group B were underdiagnosed by overnight polysomnography without monitoring for CO₂. CONCLUSION Alveolar hypoventilation with unknown origin can be caused by the PHOX2B mutation even in adult cases. Both the identification of the PHOX2B mutation and the incorporation of capnography in polysomnography are important for adult cases with unexplained alveolar hypoventilation or asymptomatic mutation carriers.
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Affiliation(s)
- Aoi Hino
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Jiro Terada
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hajime Kasai
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | | | - Keiko Ohgino
- Department of Respiratory Medicine, Kawasaki Municipal Hospital, Kawasaki City, Japan
| | - Ayako Sasaki
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata City, Japan
| | - Kiyoshi Hayasaka
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata City, Japan.,Department of Pediatrics, Miyukikai Hospital, Kaminoyama, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Macdonald KT, Mosquera RA, Yadav A, Caldas-Vasquez MC, Emanuel H, Rennie K. Neurocognitive functioning in individuals with congenital central hypoventilation syndrome. BMC Pediatr 2020; 20:194. [PMID: 32375736 PMCID: PMC7203975 DOI: 10.1186/s12887-020-2006-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 02/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Congenital central hypoventilation syndrome (CCHS) is a rare disorder characterized by respiratory system abnormalities, including alveolar hypoventilation and autonomic nervous system dysregulation. CCHS is associated with compromised brain development and neurocognitive functioning. Studies that evaluate cognitive skills in CCHS are limited, and no study has considered cognitive abilities in conjunction with psychosocial and adaptive functioning. Moreover, the roles of pertinent medical variables such as genetic characteristics are also important to consider in the context of neurocognitive functioning. METHODS Seven participants with CCHS ranging in age from 1 to 20 years underwent neuropsychological evaluations in a clinic setting. RESULTS Neurocognitive testing indicated borderline impaired neurocognitive skills, on average, as well as relative weaknesses in working memory. Important strengths, including good coping skills and relatively strong social skills, may serve as protective factors in this population. CONCLUSION CCHS was associated with poor neurocognitive outcomes, especially with some polyalanine repeat expansion mutations (PARMS) genotype. These findings have important implications for individuals with CCHS as well as medical providers for this population.
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Affiliation(s)
| | - Ricardo A Mosquera
- Department of Pediatrics, 2Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA
| | - Aravind Yadav
- Department of Pediatrics, 2Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA
| | - Maria C Caldas-Vasquez
- Department of Pediatrics, 2Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA
| | - Hina Emanuel
- Department of Pediatrics, 2Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA
| | - Kimberly Rennie
- Department of Pediatrics, 2Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA.
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Screening Children with a Family History of Central Congenital Hypoventilation Syndrome. Case Rep Pediatr 2020; 2020:2713606. [PMID: 32274237 PMCID: PMC7136801 DOI: 10.1155/2020/2713606] [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: 10/04/2019] [Accepted: 02/25/2020] [Indexed: 11/21/2022] Open
Abstract
Congenital central hypoventilation syndrome (CCHS) is a rare genetic disorder of an autonomic nervous disorder that affects breathing. It is characterized by respiratory insufficiency secondary to insensitivity to hypoxemia and hypercarbia, particularly during sleep leading to persistent apnea. We report four individuals across two generations harboring heterozygous 25 polyalanine repeats mutations (PARMs) in PHOX2B with a varying degree of phenotypic clinical manifestations. Two family members who reported to be “asymptomatic” were subsequently diagnosed with CCHS, based on genetic testing, obtained because of their family history. Genetic studies in the family including a mother and three offsprings revealed in-frame five amino acid PARMs of PHOX2B consistent with CCHS in addition to full clinical assessment. All affected individuals had evidence of hypercapnia on blood gas analysis with PCO2 in the range of 32–70 (mean; 61). Nocturnal polysomnogram revealed evidence of hypoventilation in two individuals (1 offspring and mother) with the end-tidal CO2 median of 54. Magnetic resonance imaging of brain revealed no abnormalities in the brain stem. There was no evidence of cor pulmonale on echocardiograms in all individuals. Neuropsychological testing was conducted on all four patients; two patients (mother and 1 offspring) had normal results, while the other two offspring exhibited some impairments on neuropsychological testing. This case series emphasizes the importance of screening first-degree relatives of individuals with confirmed CCHS to minimize complications associated with long-term ventilatory impairment. It also suggests that some patients with CCHS should undergo neuropsychological evaluations to assess for cognitive weaknesses secondary to their CCHS.
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Woo HY, Oh C, Han JW, Kim HY, Jung SE. Clinical features of children with Haddad syndrome: A single-center experience. J Pediatr Surg 2020; 55:387-392. [PMID: 30850150 DOI: 10.1016/j.jpedsurg.2019.01.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND/PURPOSE Haddad syndrome (HS) is a very rare disease considered a form of neurocristopathy. It is characterized by a combination of congenital central hypoventilation syndrome (CCHS) and Hirschsprung's disease (HD). We report the clinical features and disease progression of HS to provide better care for HS patients by achieving an earlier diagnosis and optimal treatment. METHODS Medical records of patients diagnosed with HS from 2005 to 2016 were retrospectively reviewed. Demographic data including gestational age, birth weight and height, and paired-like homeobox 2b (PHOX2B) gene mutation were collected. RESULTS Seven males and three females were identified (mean gestational age 39.76 ± 1.49 weeks, mean birth weight 3117.5 ± 288.9 g). PHOX2B gene mutation was identified in all patients. Immediate ventilation care after birth was required in five patients due to poor respiration. The current median age of the children is 5.4 years (range, 1.8-10.1). Tracheostomy was performed in nine patients. Eight patients required sleep ventilation and two patients, 24-h continuous ventilation support. Six patients showed rectosigmoid aganglionosis and four patients exhibited total colonic aganglionosis, of these one had aganglionosis extended to the distal small bowel. Soiling was observed in seven patients (5 with laparoscopy-assisted transanal endorectal pull-through and 2 with Duhamel procedure) and one patient showed grade 2 constipation with Duhamel procedure. Six patients had developmental delay. All patients are alive. CONCLUSIONS HS may require lifelong medical care. This study could be helpful to understand the clinical features of HS including associated abnormalities and disease progression. By assisting to understand the clinical features, we could provide better care for HS patients by achieving an earlier diagnosis and appropriate treatment. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Hye Young Woo
- Department of Pediatric Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chaeyoun Oh
- Department of Pediatric Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ji-Won Han
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyun-Young Kim
- Department of Pediatric Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Sung-Eun Jung
- Department of Pediatric Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
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10
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Binmanee A, Alfadhel A, Alzamil N, ALBanyan S, Alammar M. Congenital Central Hypoventilation Syndrome Presenting with Seizures. Cureus 2020; 12:e6680. [PMID: 31976189 PMCID: PMC6968830 DOI: 10.7759/cureus.6680] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Congenital central hypoventilation syndrome (CCHS) is a critical and rare autosomal dominant disorder that was first described by Robert Mellins in 1970. CCHS is defined to be an autonomic nervous system (ANS) dysfunction that usually presents in the neonatal period with hypoventilation and dysregulated autonomic homeostasis on a multi-system level. Classically, CCHS presents with normal ventilation while awake, and hypoventilation with normal respiratory rate during sleep. CCHS has been causally linked to the paired-like homeobox 2B (PHOX2B) gene. We report the case of a full-term male infant diagnosed with CCHS at two months of age with repeated extubation failure secondary to CCHS. The patient was discharged at five months of age with a home ventilator.
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Affiliation(s)
- Abdulaziz Binmanee
- Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, SAU
| | - Abdulrahman Alfadhel
- Emergency Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, SAU
| | - Naif Alzamil
- Internal Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, SAU
| | - Sara ALBanyan
- Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, SAU
| | - Mishal Alammar
- Urology, King Faisal Specialist Hospital and Research Center, Riyadh, SAU
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Paglietti MG, Porcaro F, Sovtic A, Cherchi C, Verrillo E, Pavone M, Bottero S, Cutrera R. Decannulation in children affected by congenital central hypoventilation syndrome: A proposal of an algorithm from two European centers. Pediatr Pulmonol 2019; 54:1663-1669. [PMID: 31313536 DOI: 10.1002/ppul.24448] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 06/16/2019] [Indexed: 11/08/2022]
Abstract
RATIONALE Long-life ventilatory assistance is necessary for survival in pediatric patients with congenital central hypoventilation syndrome (CCHS). Invasive mechanical ventilation (IMV) through tracheostomy is the most used method, especially in the first years of life when the central nervous system is maturing. Nevertheless, IMV via tracheostomy is not ideal because tracheostomy in children is associated with impaired speech and language development, also frequent infections of the lower airway tract occur. OBJECTIVE Only few reports describe the transition from IMV to the noninvasive method, ending with decannulation in CCHS affected patients. We aim to provide our experience regarding decannulation program in CCHS affected children and to describe a proposal of an algorithm concerning transition from invasive to noninvasive ventilation (NIV) in CCHS patients. METHODS The study has been conducted retrospectively. Four children from two European centers underwent tracheostomy removal and decannulation, upon request of patients and their families. RESULTS All children were trained to carry out tracheostomy capping before decannulation and underwent endoscopic assessment of upper and lower airway. Subsequently they started training to NIV at mean age of 106.25 months (±40.7 SD). Decannulation occurred 12 months after and no patients needed the reintroduction of tracheal cannula in either short or long term follow up. CONCLUSIONS our study shows that effective liberation from IMV, the transition to NIV and decannulation are possible in CCHS affected children and offers a proposal of an algorithm which can be applied in selected centers.
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Affiliation(s)
- Maria Giovanna Paglietti
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Federica Porcaro
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Aleksandar Sovtic
- Department of Pulmonology, Mother and Child Health Institute and School of Medicine University of Belgrade, Serbia
| | - Claudio Cherchi
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Elisabetta Verrillo
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Martino Pavone
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Sergio Bottero
- Airway Surgery Unit, Department Pediatric Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Renato Cutrera
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
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Congenital central hypoventilation syndrome and Hirschsprung disease: A retrospective review of the French National Registry Center on 33 cases. J Pediatr Surg 2019; 54:2325-2330. [PMID: 30879749 DOI: 10.1016/j.jpedsurg.2019.02.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/06/2019] [Accepted: 02/08/2019] [Indexed: 01/29/2023]
Abstract
AIM OF THE STUDY Congenital Central Hypoventilation Syndrome (CCHS) is a rare affection associated to Hirschsprung disease (HD) in 20% of the cases. Using the French CCHS registry, we described the population of patients suffering from both CCHS and HD reporting the outcome on these patients. METHODS Medical records were reviewed. Epidemiological, clinical, histological and genetic data were analyzed and extracted from the national French registry data. RESULTS 33 patients had CCHS and HD. Thirty percent had a severe form of CCHS (Death owing to CCHS or 24/24 ventilation beyond 1 year old). Fifty four percent required tracheotomy. HD's pathologic segment was classic (Rectosigmoid and left colic form) in 20% and long (Above the splenic flexure) in 80%. Twenty four percent were treated with daily irrigation, 21% had colostomy without undergoing pullthrough, and 55% underwent optimal treatment (pull through). We failed to demonstrate a correlation between severity of CCHS and HD's length. The rate of mortality was 57% and was higher in the long HD group (p = 0.0005). Fourteen patients were still alive, aged 1 to 31 years old. Ninety two percent were weaned off the 24/24 ventilation. Regarding the intestinal function, 38% presented with soiling and 30% with chronic diarrhea. Hundred percent had CCHS follow-up while only 35% had no surgical follow-up in regard to the HD. CONCLUSIONS This is the largest study regarding the CCHS / HD association and its long-term followup. Mortality is high demonstrating that a multidisciplinary follow-up on respiratory and intestinal function is necessary to improve outcome. Level III study.
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Rauf A, Gupta D, Sachdev A, Gupta N, Gupta S, Kumar P, Sabharwal R. Neurally Adjusted Ventilatory Assist: An Early Clue to Diagnosis of Congenital Central Hypoventilation Syndrome. Indian J Crit Care Med 2019; 23:536-537. [PMID: 31911748 PMCID: PMC6900881 DOI: 10.5005/jp-journals-10071-23286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Congenital central hypoventilation syndrome (CCHS) is characterized by shallow breathing during sleep due to negligible ventilatory sensitivity to hypercarbia and hypoxemia. It is diagnosed using a genetic test for PHOX2B mutation, which is not easily available. Neurally adjusted ventilatory assist (NAVA) is a spontaneous ventilatory mode that was designed basically for better adapting the ventilator to the patient by using electrical activity of diaphragm (EAdi) signals. We report a case of a 6-month-old infant who presented with recurrent apneas, where differential decrease in EAdi discharges during sleep using NAVA served as an early clue to the diagnosis of CCHS. Definitive diagnosis was later confirmed by genetic testing.
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Affiliation(s)
- Abdul Rauf
- Department of Pediatrics (Intensive Care), Sir Ganga Ram Hospital, New Delhi, India
| | - Dhiren Gupta
- Department of Pediatrics (Intensive Care), Sir Ganga Ram Hospital, New Delhi, India
- Dhiren Gupta, Department of Pediatrics, (Intensive Care), Sir Ganga Ram Hospital, New Delhi, India, Phone: +91 9910455753, e-mail:
| | - Anil Sachdev
- Department of Pediatrics (Intensive Care), Sir Ganga Ram Hospital, New Delhi, India
| | - Neeraj Gupta
- Department of Pediatrics (Intensive Care), Sir Ganga Ram Hospital, New Delhi, India
| | - Suresh Gupta
- Department of Pediatrics (Intensive Care), Sir Ganga Ram Hospital, New Delhi, India
| | - Praveen Kumar
- Department of Pediatrics (Neurology), Sir Ganga Ram Hospital, New Delhi, India
| | - Ramakant Sabharwal
- Department of Pediatrics (Neurology), Sir Ganga Ram Hospital, New Delhi, India
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Paglietti MG, Cherchi C, Porcaro F, Agolini E, Schiavino A, Petreschi F, Novelli A, Cutrera R. Two novel mutations in exon 3 of PHOX2B gene: think about congenital central hypoventilation syndrome in patients with Hirschsprung disease. Ital J Pediatr 2019; 45:49. [PMID: 30999961 PMCID: PMC6471850 DOI: 10.1186/s13052-019-0636-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 03/29/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Congenital central hypoventilation syndrome (CCHS) is characterized by alveolar hypoventilation increasing during sleep and affected patients are unable to perceive and respond to hypercarbia with increased ventilation and arousal during sleep. PHOX2B gene mutations are considered as responsible for CCHS. Most of patients with CCHS are heterozygous for polyalanine expansion mutations (PARMs) in exon 3, but 10% of patients with classic CCHS are heterozygous for non-polyalanine expansion mutations (NPARMs) of the PHOX2B gene. METHODS Data are collected on 3 patients affected by CCHS who referred to the Paediatric Pulmonology Unit of Bambino Gesù Children's Hospital (Rome, Italy) for a multidisciplinary follow-up program between 2000 and 2017. RESULTS We describe three cases of patients affected by CCHS for which two novel mutations on exon 3 of PHOX2B gene were detected. CONCLUSIONS The description of these novel mutations and related clinical phenotypes allows to expand the knowledge into NPARM spectrum. Since the presence of Hirschsprung disease is related to NPARMs and the number of alanine repeats, we suggest performing CCHS genetic investigation and periodical assessment also in patients without a clear history of CCHS but affected by Hirschsprung disease. TRIAL REGISTRATION Data are retrospectively collected.
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Affiliation(s)
- Maria Giovanna Paglietti
- Respiratory Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
| | - Claudio Cherchi
- Respiratory Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
| | - Federica Porcaro
- Respiratory Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
| | - Emanuele Agolini
- Laboratory of Medical Genetics, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Alessandra Schiavino
- Respiratory Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
| | - Francesca Petreschi
- Respiratory Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
| | - Antonio Novelli
- Laboratory of Medical Genetics, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Renato Cutrera
- Respiratory Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, Piazza di Sant’Onofrio 4, 00165 Rome, Italy
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15
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Bardanzellu F, Pintus MC, Fanos V, Marcialis MA. Neonatal Congenital Central Hypoventilation Syndrome: Why We Should not Sleep on it. Literature Review of Forty-two Neonatal Onset Cases. Curr Pediatr Rev 2019; 15:139-153. [PMID: 31223092 DOI: 10.2174/1573396315666190621103954] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/18/2019] [Accepted: 03/25/2019] [Indexed: 12/31/2022]
Abstract
Congenital Central Hypoventilation Syndrome (CCHS), also referred with the expression "Ondine's Curse", is a rare genetic life-long disease resulting from the mutation of PHOX2B gene on chromosome 4p12.3. CCHS represents an autonomic nervous system disorder; its more fearsome manifestation is central hypoventilation, due to a deficient response of chemoreceptors to hypercapnia and hypoxia. Several associated symptoms can occur, such as pupillary anomalies, arrhythmias, reduced heart rate variability, esophageal dysmotility, and structural comorbidities (Hirschsprung's Disease or neural crest tumours). CCHS typical onset is during the neonatal period, but cases of delayed diagnosis have been reported; moreover, both sporadic or familial cases can occur. In preterm newborns, asphyxia and typical prematurity-related findings may overlap CCHS clinical manifestations and make it harder to formulate a correct diagnosis. The early recognition of CCHS allows appropriate management, useful to reduce immediate and long- term consequences.
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Affiliation(s)
- Flaminia Bardanzellu
- Neonatal Intensive Care Unit, AOU and University of Cagliari, SS 554 km 4,500, 09042 Monserrato, Italy
| | - Maria Cristina Pintus
- Neonatal Intensive Care Unit, AOU and University of Cagliari, SS 554 km 4,500, 09042 Monserrato, Italy
| | - Vassilios Fanos
- Neonatal Intensive Care Unit, AOU and University of Cagliari, SS 554 km 4,500, 09042 Monserrato, Italy
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Bishara J, Keens TG, Perez IA. The genetics of congenital central hypoventilation syndrome: clinical implications. APPLICATION OF CLINICAL GENETICS 2018; 11:135-144. [PMID: 30532577 PMCID: PMC6241683 DOI: 10.2147/tacg.s140629] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Congenital central hypoventilation syndrome (CCHS) is a rare genetic disorder of the autonomic nervous system (ANS) and respiratory control. This disorder, formerly referred to as Ondine’s curse, is due to a mutation in the PHOX2B gene that affects the development of the neural crest cells. CCHS has an autosomal dominant pattern of inheritance. Majority of the patients have a polyalanine repeat mutation (PARM) of the PHOX2B, while a small group has non-PARM (NPARM). Knowledge of the patient’s PHOX2B gene mutation helps predict a patient’s clinical presentation and outcome and aids in anticipatory management of the respiratory and ANS dysfunction.
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Affiliation(s)
- John Bishara
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA,
| | - Thomas G Keens
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA, .,Department of Pediatrics, Keck School of Medicine of USC, Los Angeles, CA, USA,
| | - Iris A Perez
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA, .,Department of Pediatrics, Keck School of Medicine of USC, Los Angeles, CA, USA,
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17
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Hirooka K, Kamata K, Horisawa S, Nomura M, Taira T, Ozaki M. Conscious sedation with dexmedetomidine for implantation of a phrenic nerve stimulator in a pediatric case of late-onset congenital central hypoventilation syndrome. JA Clin Rep 2018; 3:46. [PMID: 29457090 PMCID: PMC5804643 DOI: 10.1186/s40981-017-0117-2] [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: 08/11/2017] [Accepted: 08/24/2017] [Indexed: 11/18/2022] Open
Abstract
Patients with congenital central hypoventilation syndrome (CCHS) develop alveolar hypoventilation resulting from a failure of central ventilatory control. Late-onset CCHS (LO-CCHS), which may be precipitated by severe respiratory infection or exposure to sedatives or general anesthesia, presents after the neonatal period. Since CCHS patients require lifelong mechanical-assisted ventilation, in western countries, diaphragm pacing is used to provide adequate alveolar ventilation and oxygenation during rest and daily activities. The main anesthesia-related concern regarding CCHS is postoperative respiratory failure or apnea, and anesthetic agents should be minimized to avoid further respiratory depression after surgery. A 5-year-old girl with LO-CCHS was referred to our hospital for implantation of a phrenic nerve stimulator for diaphragm pacing. Respiratory infection triggered the need for permanent nocturnal ventilator support at age 3 years and tracheotomy was performed at age 4 years. Repeated self-dislodgement of the ventilator tube led to hypoxic ischemic encephalopathy. The patient was thought to require mechanical ventilation under minimum sedation and pain management during the early postoperative period. The co-administration of dexmedetomidine and morphine provided effective conscious sedation with protection of the surgical site and without adverse events. She was discharged from the intensive care unit with a home ventilator at 3 days post-operation.
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Affiliation(s)
- Keiko Hirooka
- 1Department of Anesthesiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666 Japan
| | - Kotoe Kamata
- 1Department of Anesthesiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666 Japan
| | - Shiro Horisawa
- 2Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666 Japan
| | - Minoru Nomura
- 1Department of Anesthesiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666 Japan
| | - Takaomi Taira
- 2Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666 Japan
| | - Makoto Ozaki
- 1Department of Anesthesiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666 Japan
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Congenital central hypoventilation syndrome: a bedside-to-bench success story for advancing early diagnosis and treatment and improved survival and quality of life. Pediatr Res 2017; 81:192-201. [PMID: 27673423 DOI: 10.1038/pr.2016.196] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/15/2016] [Indexed: 01/13/2023]
Abstract
The "bedside-to-bench" Congenital Central Hypoventilation Syndrome (CCHS) research journey has led to increased phenotypic-genotypic knowledge regarding autonomic nervous system (ANS) regulation, and improved clinical outcomes. CCHS is a neurocristopathy characterized by hypoventilation and ANS dysregulation. Initially described in 1970, timely diagnosis and treatment remained problematic until the first large cohort report (1992), delineating clinical presentation and treatment options. A central role of ANS dysregulation (2001) emerged, precipitating evaluation of genes critical to ANS development, and subsequent 2003 identification of Paired-Like Homeobox 2B (PHOX2B) as the disease-defining gene for CCHS. This breakthrough engendered clinical genetic testing, making diagnosis exact and early tracheostomy/artificial ventilation feasible. PHOX2B genotype-CCHS phenotype relationships were elucidated, informing early recognition and timely treatment for phenotypic manifestations including Hirschsprung disease, prolonged sinus pauses, and neural crest tumors. Simultaneously, cellular models of CCHS-causing PHOX2B mutations were developed to delineate molecular mechanisms. In addition to new insights regarding genetics and neurobiology of autonomic control overall, new knowledge gained has enabled physicians to anticipate and delineate the full clinical CCHS phenotype and initiate timely effective management. In summary, from an initial guarantee of early mortality or severe neurologic morbidity in survivors, CCHS children can now be diagnosed early and managed effectively, achieving dramatically improved quality of life as adults.
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19
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Sandoval RL, Zaconeta CM, Margotto PR, de Oliveira Cardoso MT, França EMS, Medina CTN, Canó TM, de Faria AS. Congenital central hypoventilation syndrome associated with Hirschsprung's Disease: case report and literature review. REVISTA PAULISTA DE PEDIATRIA (ENGLISH EDITION) 2016. [PMID: 26838603 PMCID: PMC5178125 DOI: 10.1016/j.rppede.2015.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective: To report the case of a newborn with recurrent episodes of apnea, diagnosed with Congenital Central hypoventilation syndrome (CCHS) associated with Hirschsprung's disease (HD), configuring Haddad syndrome. Case description: Third child born at full-term to a non-consanguineous couple through normal delivery without complications, with appropriate weight and length for gestational age. Soon after birth he started to show bradypnea, bradycardia and cyanosis, being submitted to tracheal intubation and started empiric antibiotic therapy for suspected early neonatal sepsis. During hospitalization in the NICU, he showed difficulty to undergo extubation due to episodes of desaturation during sleep and wakefulness. He had recurrent episodes of hypoglycemia, hyperglycemia, metabolic acidosis, abdominal distension, leukocytosis, increase in C-reactive protein levels, with negative blood cultures and suspected inborn error of metabolism. At 2 months of age he was diagnosed with long-segment Hirschsprung's disease and was submitted to segment resection and colostomy through Hartmann's procedure. A genetic research was performed by polymerase chain reaction for CCHS screening, which showed the mutated allele of PHOX2B gene, confirming the diagnosis. Comments: This is a rare genetic, autosomal dominant disease, caused by mutation in PHOX2B gene, located in chromosome band 4p12, which results in autonomic nervous system dysfunction. CCHS can also occur with Hirschsprung's disease and tumors derived from the neural crest. There is a correlation between phenotype and genotype, as well as high intrafamilial phenotypic variability. In the neonatal period it can simulate cases of sepsis and inborn errors of metabolism.
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20
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Hager A, Koch W, Stenzel H, Hess J, Schöber J. Effects of movement and work load in patients with congenital central hypoventilation syndrome. ACTA ACUST UNITED AC 2016; 14:294-8. [PMID: 17446810 DOI: 10.1097/hjr.0b013e328033eb63] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with congenital central hypoventilation syndrome lack ventilatory chemosensitivity and depend at least in part on the ergoreceptor function during exercise. In these patients a substantial increase of ventilation has been reported for passive movement during sleep as well as active movement on a treadmill. OBJECTIVES The aim of the study was to investigate ventilatory response to an increasing work load with constant movement. METHODS AND RESULTS Eighteen patients and 17 healthy volunteers performed a cardiopulmonary exercise test on a bicycle pedaling at a constant rate of about 60 revolutions per minute throughout the entire test. The patients were able to exercise adequately and showed normal peak oxygen uptake. There was a steep rise in minute ventilation in both groups at the start of exercise, yet there was only a minor increase in both groups during the increase of workload up to the anaerobic threshold. After the anaerobic threshold, there was again an increase in ventilation in both groups, but the increase was less prominent in the patient group. CONCLUSIONS Ventilation in patients with congenital central hypoventilation syndrome is increased during exercise caused both by movement (mechanoreceptors) and by anaerobic workload. This facilitates a normal ventilatory drive up to the anaerobic threshold and a normal exercise capacity in these patients.
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Affiliation(s)
- Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany.
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21
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Significant phenotype variability of congenital central hypoventilation syndrome in a family with polyalanine expansion mutation of the PHOX2B gene. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2016; 160:495-498. [PMID: 27485184 DOI: 10.5507/bp.2016.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/13/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Congenital central hypoventilation syndrome (CCHS) is a rare genetic disorder resulting from mutations in the PHOX2B gene located on chromosome 4p12.3, characterized by hypoventilation secondary to missing responses to both hypercapnia and hypoxia. CASE REPORT Proband. A girl, hospitalised 5 times for respiratory failure from 6 weeks old, presented at 4 years of age severe cyanosis related to pneumonia. Tracheostomy was done, and she was discharged home using a portable positive pressure ventilator during sleep. Proband's father: The father was retrospectively found out to suffer from severe headache and excessive daytime sleepiness. Molecular genetic evaluation of PHOX2B gene was performed and casual polyalanine repeat expansion mutation c.741_755dup15 in exon 3 was found both in proband and her father in heterozygous form. The proband's grandmother died of respiratory failure after administration of benzodiazepine at the age of fifty years. Considering the grandmother's history, she is highly suspected of having had CCHS as well. CONCLUSION Repeated respiratory failure of girl was explained by PHOX2B mutation and Ondina curse. Proband´s father has incompletely penetrated PHOX2B heterozygous mutation as well and proband´s grandmother died probably from the consequences of drug interaction with PHOX2B mutated background as well. Both daughter and father currently require overnight mechanical ventilatory support. Although most PHOX2B mutations occur de novo, our case is a rare three generation family affected by autosomal dominant inheritance with incomplete penetrance manifested as the late-form of CCHS and proven PHOX2B mutation in two generations.
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Pansani AP, Xavier CH, de Castro CH, Scorza FA, Colugnati DB. Could the retrotrapezoid nucleus neurons tell us something about SUDEP? Epilepsy Behav 2016; 61:86-87. [PMID: 27337159 DOI: 10.1016/j.yebeh.2016.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Aline P Pansani
- Laboratório Integrado de Fisiopatologia Cardiovascular e Neurológica, Departamento de Ciências Fisiológicas, ICB, Universidade Federal de Goiás, GO, Brazil
| | - Carlos H Xavier
- Laboratório de Fisiologia e Terapêutica Cardiovascular, Departamento de Ciências Fisiológicas, ICB, Universidade Federal de Goiás, GO, Brazil
| | - Carlos Henrique de Castro
- Laboratório Integrado de Fisiopatologia Cardiovascular e Neurológica, Departamento de Ciências Fisiológicas, ICB, Universidade Federal de Goiás, GO, Brazil
| | - Fulvio A Scorza
- Disciplina de Neurociência, Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil
| | - Diego B Colugnati
- Laboratório Integrado de Fisiopatologia Cardiovascular e Neurológica, Departamento de Ciências Fisiológicas, ICB, Universidade Federal de Goiás, GO, Brazil
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23
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Hong SY, Hsin YL, Lee IC. An Infant with Congenital Central Hypoventilation Syndrome: Transient Burst Suppression Electroencephalogram. Pediatr Neonatol 2016; 57:357-8. [PMID: 26916541 DOI: 10.1016/j.pedneo.2015.11.003] [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: 06/30/2015] [Revised: 11/04/2015] [Accepted: 11/24/2015] [Indexed: 11/28/2022] Open
Affiliation(s)
- Syuan-Yu Hong
- Division of Pediatrics Neurology, Children's Hospital of China Medical University, Taichung, Taiwan
| | - Yue-Loong Hsin
- Department of Neurology, Chung Shan Medical University Hospital, Taichung, Taiwan; Institute of Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Inn-Chi Lee
- Division of Pediatric Neurology, Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan; Institute of Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan.
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Boka V, Lefkelidou A, Athanasiadou E. Dental treatment of a child with congenital central hypoventilation syndrome. Eur Arch Paediatr Dent 2016; 17:211-4. [DOI: 10.1007/s40368-015-0213-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 10/13/2015] [Indexed: 10/22/2022]
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Abstract
Congenital central hypoventilation syndrome (CCHS) causes predominantly sleep apnoea and is one of a growing number of inherited disorders characterised by autonomic nervous system dysfunction/dysregulation (ANSD). In association with Hirschsprung's disease (HSCR), it presents as Haddad's syndrome. We report a case of Haddad's syndrome complicated by sinus node dysfunction.
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Affiliation(s)
- Alexander Tsoutsinos
- Department of Paediatric Cardiology, Onassis Cardiac Surgery Centre, Athens, Greece
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26
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Sandoval RL, Zaconeta CM, Margotto PR, Cardoso MTDO, França EMS, Medina CTN, Canó TM, Faria ASD. Congenital central hypoventilation syndrome associated with Hirschsprung's Disease: case report and literature review. REVISTA PAULISTA DE PEDIATRIA 2016; 34:374-8. [PMID: 26838603 DOI: 10.1016/j.rpped.2015.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 09/18/2015] [Accepted: 10/04/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To report the case of a newborn with recurrent episodes of apnea, diagnosed with Congenital Central hypoventilation syndrome (CCHS) associated with Hirschsprung's disease (HD), configuring Haddad syndrome. CASE DESCRIPTION Third child born at full-term to a non-consanguineous couple through normal delivery without complications, with appropriate weight and length for gestational age. Soon after birth he started to show bradypnea, bradycardia and cyanosis, being submitted to tracheal intubation and started empiric antibiotic therapy for suspected early neonatal sepsis. During hospitalization in the NICU, he showed difficulty to undergo extubation due to episodes of desaturation during sleep and wakefulness. He had recurrent episodes of hypoglycemia, hyperglycemia, metabolic acidosis, abdominal distension, leukocytosis, increase in C-reactive protein levels, with negative blood cultures and suspected inborn error of metabolism. At 2 months of age he was diagnosed with long-segment Hirschsprung's disease and was submitted to segment resection and colostomy through Hartmann's procedure. A genetic research was performed by polymerase chain reaction for CCHS screening, which showed the mutated allele of PHOX2B gene, confirming the diagnosis. COMMENTS This is a rare genetic, autosomal dominant disease, caused by mutation in PHOX2B gene, located in chromosome band 4p12, which results in autonomic nervous system dysfunction. CCHS can also occur with Hirschsprung's disease and tumors derived from the neural crest. There is a correlation between phenotype and genotype, as well as high intrafamilial phenotypic variability. In the neonatal period it can simulate cases of sepsis and inborn errors of metabolism.
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Affiliation(s)
- Renata Lazari Sandoval
- Hospital de Base do Distrito Federal (HBDF), Brasília, DF, Brasil; Universidade de Brasília (UnB), Brasília, DF, Brasil.
| | - Carlos Moreno Zaconeta
- Universidade de Brasília (UnB), Brasília, DF, Brasil; Hospital Materno Infantil de Brasília (HMIB), Brasília, DF, Brasil
| | | | | | - Evely Mirella Santos França
- Hospital Materno Infantil de Brasília (HMIB), Brasília, DF, Brasil; Secretaria de Estado de Saúde do Distrito Federal, Brasília, DF, Brasil
| | | | - Talyta Matos Canó
- Secretaria de Estado de Saúde do Distrito Federal, Brasília, DF, Brasil
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Pathophysiology of central sleep apneas. Sleep Breath 2016; 20:467-82. [DOI: 10.1007/s11325-015-1290-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 11/10/2015] [Accepted: 11/23/2015] [Indexed: 11/26/2022]
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28
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Charnay AJ, Antisdel-Lomaglio JE, Zelko FA, Rand CM, Le M, Gordon SC, Vitez SF, Tse JW, Brogadir CD, Nelson MN, Berry-Kravis EM, Weese-Mayer DE. Congenital Central Hypoventilation Syndrome: Neurocognition Already Reduced in Preschool-Aged Children. Chest 2016; 149:809-15. [PMID: 26378991 DOI: 10.1378/chest.15-0402] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 07/01/2015] [Accepted: 07/27/2015] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Congenital Central Hypoventilation Syndrome (CCHS) is a rare neurocristopathy characterized by severe hypoventilation and autonomic dysregulation, with typical presentation in the neonatal period, and deficient cognitive skills in school-aged patients. We hypothesized that younger (preschool) children with CCHS would also show neurocognitive delay and that CCHS-related physiologic factors would impact neurocognitive test results. METHODS We studied developmental (Bayley) test results collected during routine clinical care in 31 children (mean age 25.0 ± 8.5 months; range, 6-40 months) with PHOX2B mutation-confirmed CCHS by comparing them with the normative reference mean from the Bayley standardization sample; we also examined associations between Bayley scores and CCHS disease-related factors. RESULTS Preschool patients with CCHS fell significantly below the normative mean of 100 on Bayley indices of mental (mean, 83.35 ± 24.75) and motor (mean, 73.33 ± 20.48) development (P < .001 for both). Significantly lower Bayley mental and motor scores were associated with severe breath-holding spells, prolonged sinus pauses, and need for 24 h/d artificial ventilation. Lower Bayley motor scores were also associated with seizures. Bayley scores differed among children with the three most common polyalanine repeat expansion mutation genotypes (mental, P = .001; motor, P = .006), being essentially normal in children with the 20/25 genotype but significantly lower in the other genotype groups (P < .05). CONCLUSIONS These results confirm neurodevelopmental impairment of CCHS preschoolers, with severity related to physiologic compromise and PHOX2B genotype. These findings suggest that adverse effects begin early in the disease process, supporting the need for neurodevelopmental monitoring and intervention from early infancy.
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Affiliation(s)
- Aaron J Charnay
- Center for Autonomic Medicine in Pediatrics, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and The Stanley Manne Children's Research Institute, Chicago, IL
| | - Jeanne E Antisdel-Lomaglio
- Department of Child and Adolescent Psychiatry, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Frank A Zelko
- Department of Child and Adolescent Psychiatry, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Casey M Rand
- Center for Autonomic Medicine in Pediatrics, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and The Stanley Manne Children's Research Institute, Chicago, IL
| | - Michele Le
- Center for Autonomic Medicine in Pediatrics, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and The Stanley Manne Children's Research Institute, Chicago, IL
| | - Samantha C Gordon
- Center for Autonomic Medicine in Pediatrics, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and The Stanley Manne Children's Research Institute, Chicago, IL
| | - Sally F Vitez
- Center for Autonomic Medicine in Pediatrics, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and The Stanley Manne Children's Research Institute, Chicago, IL
| | - Jennifer W Tse
- Center for Autonomic Medicine in Pediatrics, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and The Stanley Manne Children's Research Institute, Chicago, IL
| | - Cindy D Brogadir
- Center for Autonomic Medicine in Pediatrics, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and The Stanley Manne Children's Research Institute, Chicago, IL
| | - Michael N Nelson
- Departments of Pediatrics and Behavioral Sciences, Rush University Medical Center, Chicago, IL
| | - Elizabeth M Berry-Kravis
- Departments of Pediatrics, Neurological Sciences and Biochemistry, Rush University Medical Center, Chicago, IL
| | - Debra E Weese-Mayer
- Center for Autonomic Medicine in Pediatrics, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and The Stanley Manne Children's Research Institute, Chicago, IL; Northwestern University Feinberg School of Medicine, Chicago, IL
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Sivertsen W, Eriksen BH. Et nyfødt barn med apneer. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:1653-1655. [DOI: 10.4045/tidsskr.16.0109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Healy F, Marcus CL. Care of the Child with Congenital Central Hypoventilation Syndrome. Respir Med 2016. [DOI: 10.1007/978-1-4939-3749-3_17] [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: 11/30/2022]
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Harper RM, Kumar R, Macey PM, Harper RK, Ogren JA. Impaired neural structure and function contributing to autonomic symptoms in congenital central hypoventilation syndrome. Front Neurosci 2015; 9:415. [PMID: 26578872 PMCID: PMC4626648 DOI: 10.3389/fnins.2015.00415] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 10/15/2015] [Indexed: 12/30/2022] Open
Abstract
Congenital central hypoventilation syndrome (CCHS) patients show major autonomic alterations in addition to their better-known breathing deficiencies. The processes underlying CCHS, mutations in the PHOX2B gene, target autonomic neuronal development, with frame shift extent contributing to symptom severity. Many autonomic characteristics, such as impaired pupillary constriction and poor temperature regulation, reflect parasympathetic alterations, and can include disturbed alimentary processes, with malabsorption and intestinal motility dyscontrol. The sympathetic nervous system changes can exert life-threatening outcomes, with dysregulation of sympathetic outflow leading to high blood pressure, time-altered and dampened heart rate and breathing responses to challenges, cardiac arrhythmia, profuse sweating, and poor fluid regulation. The central mechanisms contributing to failed autonomic processes are readily apparent from structural and functional magnetic resonance imaging studies, which reveal substantial cortical thinning, tissue injury, and disrupted functional responses in hypothalamic, hippocampal, posterior thalamic, and basal ganglia sites and their descending projections, as well as insular, cingulate, and medial frontal cortices, which influence subcortical autonomic structures. Midbrain structures are also compromised, including the raphe system and its projections to cerebellar and medullary sites, the locus coeruleus, and medullary reflex integrating sites, including the dorsal and ventrolateral medullary nuclei. The damage to rostral autonomic sites overlaps metabolic, affective and cognitive regulatory regions, leading to hormonal disruption, anxiety, depression, behavioral control, and sudden death concerns. The injuries suggest that interventions for mitigating hypoxic exposure and nutrient loss may provide cellular protection, in the same fashion as interventions in other conditions with similar malabsorption, fluid turnover, or hypoxic exposure.
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Affiliation(s)
- Ronald M Harper
- Brain Research Institute, University of California, Los Angeles Los Angeles, CA, USA ; Department of Neurobiology, David Geffen School of Medicine, University of California, Los Angeles Los Angeles, CA, USA
| | - Rajesh Kumar
- Brain Research Institute, University of California, Los Angeles Los Angeles, CA, USA ; Department of Anesthesiology, David Geffen School of Medicine, University of California, Los Angeles Los Angeles, CA, USA ; Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles Los Angeles, CA, USA ; Department of Bioengineering, University of California, Los Angeles Los Angeles, CA, USA
| | - Paul M Macey
- Brain Research Institute, University of California, Los Angeles Los Angeles, CA, USA ; UCLA School of Nursing, University of California, Los Angeles Los Angeles, CA, USA
| | - Rebecca K Harper
- Department of Neurobiology, David Geffen School of Medicine, University of California, Los Angeles Los Angeles, CA, USA
| | - Jennifer A Ogren
- Department of Neurobiology, David Geffen School of Medicine, University of California, Los Angeles Los Angeles, CA, USA
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Health-related quality of life in young adults with congenital central hypoventilation syndrome due to PHOX2B mutations: a cross-sectional study. Respir Res 2015; 16:80. [PMID: 26122307 PMCID: PMC4487972 DOI: 10.1186/s12931-015-0241-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 06/21/2015] [Indexed: 11/10/2022] Open
Abstract
Background Congenital central hypoventilation syndrome (CCHS) is a rare genetic disease due to PHOX2B mutations. CCHS patients suffer from many autonomic disorders, dominated clinically by defective ventilatory automatisms. From birth, the life of CCHS patients depends on ventilatory support during sleep, involving a high burden of care. Whether or not this impairs the quality of life of these patients during adulthood remains unknown. Methods We applied the medical outcome study short form-36 (SF-36) to 12 CCHS patients aged 15–33 (9 women) at the time of their passage from pediatric to adult care. Scores for the SF-36 dimensions were compared to the age- and gender-matched French reference population after transformation into standardized Z-scores. The SF-36 physical component summary score (PCS) and mental component summary score (MCS) were compared to American reference values. Results Median Z-scores were significantly different from zero for PF (physical functioning, p = 0.020) and GH (general health perception, p = 0.0342) and for PCS (p = 0.020). The other physical dimensions (RP, role limitation due to physical function; BP, bodily pain) and the mental dimensions (VT, vitality; SF, social functioning; RE, role limitation due to emotional function; MH, mental health) and MCS were not altered. Conclusions We conclude that, despite the physical constraints imposed by CCHS and its anxiogenic nature, this disease is associated with an impairment of health-related quality of life in young adults that remains moderate. Whatever the underlying explanations, these results convey hope to parents with a child diagnosed with CCHS and for patients themselves.
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Shimokaze T, Sasaki A, Meguro T, Hasegawa H, Hiraku Y, Yoshikawa T, Kishikawa Y, Hayasaka K. Genotype-phenotype relationship in Japanese patients with congenital central hypoventilation syndrome. J Hum Genet 2015; 60:473-7. [PMID: 26063465 DOI: 10.1038/jhg.2015.65] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 05/07/2015] [Accepted: 05/12/2015] [Indexed: 11/09/2022]
Abstract
Examine the genotype-phenotype relationship in Japanese congenital central hypoventilation syndrome (CCHS) patients and estimate the incidence of CCHS in Japan. Subjects were 92 Japanese patients with PHOX2B mutations; 19 cases carried 25 polyalanine repeat expansion mutations (PARMs); 67 cases carried 26 or more PARMs; and 6 had non-PARMs (NPARMs). We collected clinical data in all patients and estimated the development or intelligent quotients only in the patients carrying 25 PARM. The estimated incidence of CCHS was greater than one case per 148 000 births. Polyhydramnios was observed in three cases. Twelve infants exhibited depressed respiration at birth. In 19 cases carrying 25 PARM, the male-to-female ratio was ~3, no cases had Hirschsprung disease; 7 cases (37%) developed hypoventilation after the neonatal period, and 8 cases (42%) had mental retardation. In other 73 cases carrying 26 or more PARMs or NPARMs, male-to-female ratio was equal; patients frequently complicated with Hirschsprung disease and constipation, and all patients presented with hypoventilation in the neonatal period. Clinical symptoms were severe in most patients carrying long PARMs and NPARMs. In 25 PARM, additional genetic and/or epigenetic factors were required for CCHS development and male sex is likely a predisposing factor. The patients carrying 25 PARM frequently had mental retardation likely because they were not able to receive appropriate ventilation support following a definitive diagnosis owing to subtle and or irregular hypoventilation. Molecular diagnosis provides a definitive diagnosis and enables to receive appropriate ventilator support.
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Affiliation(s)
- Tomoyuki Shimokaze
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata, Japan
| | - Ayako Sasaki
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata, Japan
| | - Toru Meguro
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata, Japan
| | - Hisaya Hasegawa
- Division of Neonatal Intensive Care, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Yuka Hiraku
- Department of Obstetrics and Gynecology, Gifu Municipal Hospital, Gifu, Japan
| | - Tetsushi Yoshikawa
- Departments of Pediatrics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Yumiko Kishikawa
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata, Japan
| | - Kiyoshi Hayasaka
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata, Japan.,Department of Pediatrics, Miyukikai Hospital, Kaminoyama, Japan
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Diep B, Wang A, Kun S, McComb JG, Shaul DB, Shin CE, Keens TG, Perez IA. Diaphragm Pacing without Tracheostomy in Congenital Central Hypoventilation Syndrome Patients. Respiration 2015; 89:534-8. [DOI: 10.1159/000381401] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 03/03/2015] [Indexed: 11/19/2022] Open
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Karimzadeh P. Psycho-cognitive behavioral problems in sleep disordered children. Neural Regen Res 2015; 7:635-9. [PMID: 25745456 PMCID: PMC4346990 DOI: 10.3969/j.issn.1673-5374.2012.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 01/22/2012] [Indexed: 12/21/2022] Open
Abstract
Sleep disturbances are common in childhood and adolescence. Sleep problems in early infants tend to be persistent and prominent in preschool and school-aged children. Chronic sleep disorders, especially in young children may lead to neurobehavioral problems and psycho-cognitive impairment. Sleep difficulties may be the result of underlying medical conditions, (breathing disorders) or psychological problems. Research studies have shown the association between sleep disorders and day time cognitive impairment, behavioral problems, poor school performance and inattention in children. Appropriate diagnosis and early management of sleep disorders in children lead to improvement of neurocognitive function and behavioral problems in these children.
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Affiliation(s)
- Parvaneh Karimzadeh
- Research Center of Pediatric Neurology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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36
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Trang H, Brunet JF, Rohrer H, Gallego J, Amiel J, Bachetti T, Fischbeck KH, Similowski T, Straus C, Ceccherini I, Weese-Mayer DE, Frerick M, Bieganowska K, Middleton L, Morandi F, Ottonello G. Proceedings of the fourth international conference on central hypoventilation. Orphanet J Rare Dis 2014; 9:194. [PMID: 25928806 PMCID: PMC4268904 DOI: 10.1186/s13023-014-0194-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 11/14/2014] [Indexed: 02/07/2023] Open
Abstract
Central hypoventilation syndromes (CHS) are rare diseases of central autonomic respiratory control associated with autonomous nervous dysfunction. Severe central hypoventilation is the hallmark and the most life-threatening feature. CHS is a group of not-fully defined disorders. Congenital CHS (CCHS) (ORPHA661) is clinically and genetically well-characterized, with the disease-causing gene identified in 2003. CCHS presents at birth in most cases, and associated with Hirschsprung's disease (ORPHA99803) and neural crest tumours in 20% and 5% of cases, respectively. The incidence of CCHS is estimated to be 1 of 200,000 live births in France, yet remains unknown for the rest of the world. In contrast, late-onset CHS includes a group of not yet fully delineated diseases. Overlap with CCHS is likely, as a subset of patients harbours PHOX2B mutations. Another subset of patients present with associated hypothalamic dysfunction. The number of these patients is unknown (less than 60 cases reported worldwide). Treatment of CHS is palliative using advanced techniques of ventilation support during lifetime. Research is ongoing to better understand physiopathological mechanisms and identify potential treatment pathways.The Fourth International Conference on Central Hypoventilation was organised in Warsaw, Poland, April 13-15, 2012, under the patronage of the European Agency for Health and Consumers and Public Health European Agency of European Community. The conference provided a state-of-the-art update of knowledge on all the genetic, molecular, cellular, and clinical aspects of these rare diseases.
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Affiliation(s)
- Ha Trang
- French Centre of Reference for Central Hypoventilation, Robert Debré University Hospital, EA 7334 REMES Paris-Diderot University, 48 boulevard Serurier, 75019, Paris, France.
| | | | - Hermann Rohrer
- Research Group Developmental Neurobiology, Department of Neurochemistry, Max Planck Institute for Brain Research, Frankfurt am Main, Germany.
| | - Jorge Gallego
- Inserm U676, Robert Debré University Hospital, Paris, France.
| | - Jeanne Amiel
- French Centre of Reference for Central Hypoventilation, Necker-Enfants Malades University Hospital, Paris, France.
| | | | - Kenneth H Fischbeck
- Neurogenetics Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Missouri, USA.
| | - Thomas Similowski
- French Centre of Reference for Central Hypoventilation, La Pitié Salpêtrière University Hospital, Pierre et Maris Curie University, Paris, France.
| | - Christian Straus
- French Centre of Reference for Central Hypoventilation, La Pitié Salpêtrière University Hospital, Pierre et Maris Curie University, Paris, France.
| | - Isabella Ceccherini
- Laboratorio di Genetica Molecolare, Istituto Giannina Gaslini, Genova, Italy.
| | - Debra E Weese-Mayer
- Autonomic Medicine in Paediatrics (CAMP), Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Rand CM, Carroll MS, Weese-Mayer DE. Congenital Central Hypoventilation Syndrome. Clin Chest Med 2014; 35:535-45. [DOI: 10.1016/j.ccm.2014.06.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Saiyed R, Rand CM, Carroll MS, Weese-Mayer DE. Hypoventilation Syndromes of Infancy, Childhood, and Adulthood. Sleep Med Clin 2014. [DOI: 10.1016/j.jsmc.2014.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Schönhofer B. [Noninvasive ventilation in patients with persistent hypercapnia]. Med Klin Intensivmed Notfmed 2014; 110:182-7. [PMID: 24938398 DOI: 10.1007/s00063-014-0373-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 03/12/2014] [Accepted: 04/06/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic respiratory failure is caused by insufficiency of the inspiratory muscles, i.e. mainly the diaphragm, which represents the so-called "respiratory pump". Insufficiency of the respiratory pump causes hypercapnia. THERAPEUTIC INTERVENTION Diseases with chronic hypercapnia are characterized by reduced survival. Mechanical ventilation-mostly applied as noninvasive mechanical ventilation (NIV)-improves ventilation and unloads the inspiratory muscles. INDICATION Strong evidence supports the use of domiciliary NIV already in mild degrees of chronic respiratory failure caused by neuromuscular diseases, thoracic restrictions and obesity hypoventilation. In these diseases long-term NIV improves both physiological parameters (such as blood gases) and clinical outcome, e.g. exercise capacity, right heart dysfunction, sleep quality, disease-specific aspects of health-related quality of life (HRQL) and survival rate. In contrast, its influence on long-term survival in chronic obstructive pulmonary disease (COPD) patients is not clearly proven. Prescription of home NIV in COPD should therefore be restricted to severe degrees of chronic respiratory failure. Finally, there is an indication for domiciliary NIV in patients after prolonged weaning from mechanical ventilation. This paper elaborates underlying pathophysiology, diseases and how NIV works in chronic hypercapnic respiratory failure.
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Affiliation(s)
- B Schönhofer
- Abteilung für Pneumologie, Internistische Intensivmedizin und Schlafmedizin, Krankenhaus Oststadt-Heidehaus, Klinikum Region Hannover, Podbielskistr. 380, 30659, Hannover, Deutschland,
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Chen ML, Tablizo MA, Kun S, Keens TG. Diaphragm pacers as a treatment for congenital central hypoventilation syndrome. Expert Rev Med Devices 2014; 2:577-85. [PMID: 16293069 DOI: 10.1586/17434440.2.5.577] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Congenital central hypoventilation syndrome is a rare syndrome present from birth, and is defined as the failure of automatic control of breathing. All patients with congenital central hypoventilation syndrome require life-long ventilatory support during sleep, although approximately a third of patients require ventilatory support 24 h per day. Diaphragm pacers offer a modality of ventilatory support that affords congenital central hypoventilation syndrome patients with maximal mobility for full-time ventilatory patients, and they may allow for a more normal lifestyle in the appropriate patient. They may permit tracheostomy decannulation in those requiring only support during sleep. Diaphragm pacing entails surgical placement of an electrode onto the phrenic nerve, connected to a subcutaneous receiver. There is an external battery-operated transmitter and antenna placed on the skin over the receiver. The transmitter emits energy, similar to radio transmission, which is converted into an electrical current by the receiver. This stimulates the phrenic nerve resulting in a diaphragmatic contraction. Settings on the transmitter include respiratory rate and electrical voltage, and are adjusted to give enough tidal volume to allow for adequate oxygenation and ventilation. Therefore, diaphragm pacing is an attractive alternative mode of mechanically assisted ventilation for many patients with congenital central hypoventilation syndrome.
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Affiliation(s)
- Maida Lynn Chen
- University of Southern California, Division of Pediatric Pulmonology, Childrens Hospital Los Angeles, Keck School of Medicine, Los Angeles, CA 90027, USA
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Gallego J. Genetic diseases: congenital central hypoventilation, Rett, and Prader-Willi syndromes. Compr Physiol 2013; 2:2255-79. [PMID: 23723037 DOI: 10.1002/cphy.c100037] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The present review summarizes current knowledge on three rare genetic disorders of respiratory control, congenital central hypoventilation syndrome (CCHS), Rett syndrome (RTT), and Prader-Willi syndrome (PWS). CCHS is characterized by lack of ventilatory chemosensitivity caused by PHOX2B gene abnormalities consisting mainly of alanine expansions. RTT is associated with episodes of tachypneic and irregular breathing intermixed with breathholds and apneas and is caused by mutations in the X-linked MECP2 gene encoding methyl-CpG-binding protein. PWS manifests as sleep-disordered breathing with apneas and episodes of hypoventilation and is caused by the loss of a group of paternally inherited genes on chromosome 15. CCHS is the most specific disorder of respiratory control, whereas the breathing disorders in RTT and PWS are components of a more general developmental disorder. The main clinical features of these three disorders are reviewed with special emphasis on the associated brain abnormalities. In all three syndromes, disease-causing genetic defects have been identified, allowing the development of genetically engineered mouse models. New directions for future therapies based on these models or, in some cases, on clinical experience are delineated. Studies of CCHS, RTT, and PWS extend our knowledge of the molecular and cellular aspects of respiratory rhythm generation and suggest possible pharmacological approaches to respiratory control disorders. This knowledge is relevant for the clinical management of many respiratory disorders that are far more prevalent than the rare diseases discussed here.
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Affiliation(s)
- Jorge Gallego
- Inserm U676 and University of Paris Diderot, Paris, France.
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Nirupam N, Sharma R, Chhapola V, Kanwal SK, Berry-Kravis EM, Kumar V. Congenital central hypoventilation syndrome with PHOX2B gene mutation: are we missing the diagnosis? Indian J Pediatr 2013; 80:688-90. [PMID: 22829249 DOI: 10.1007/s12098-012-0837-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 06/20/2012] [Indexed: 11/25/2022]
Abstract
Congenital Central Hypoventilation Syndrome is a rare disorder of autonomic and central nervous system dysfunction with impaired control of breathing. The authors report a 37- d-old girl infant with recurrent apnea requiring repeated mechanical ventilation with no evidence of neuromuscular, cardiac or lung disease. A mutation analysis of PHOX2B gene revealed 25 polyalanine repeat expansion mutation on chromosome 4p12. This article aims at raising awareness among pediatricians about molecular basis and availability of confirmatory genetic testing for diagnosis and to help with prognosis in this disorder.
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Affiliation(s)
- Nilay Nirupam
- Department of Pediatrics, Division of Pediatric Intensive Care, Lady Hardinge Medical College and associated Kalawati Saran Children's Hospital, New Delhi 110001, India
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Weese-Mayer DE, Berry-Kravis EM, Ceccherini I, Keens TG, Loghmanee DA, Trang H. [ATS clinical policy statement: congenital central hypoventilation syndrome. Genetic basis, diagnosis and management]. Rev Mal Respir 2013; 30:706-33. [PMID: 24182656 DOI: 10.1016/j.rmr.2013.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Obstructive sleep apnea syndrome (OSAS) in children with Class III malocclusion: involvement of the PHOX2B gene. Sleep Breath 2013; 17:1275-80. [PMID: 23536260 DOI: 10.1007/s11325-013-0833-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 03/12/2013] [Accepted: 03/13/2013] [Indexed: 12/31/2022]
Abstract
PURPOSE The aim of this study is to provide new molecular approaches to the children with obstructive sleep apnea syndrome by evaluating the possible involvement of the PHOX2B gene, notoriously associated to congenital central hypoventilation syndrome (CCHS), in Class III malocclusion. METHODS Fifty subjects with Class III malocclusion, aged from 8 to 14 years, and with history of sleep apneic episodes, and 20 age-matched controls were submitted to genomic DNA examination from oral cells to specifically analyze the PHOX2B genotype. RESULTS Point "silent" mutations affecting different nucleotides of the PHOX2B gene were observed in 32 % of patients with Class III malocclusion and never in controls (0 %). CONCLUSION The genetic data obtained in this study in children with Class III malocclusion and sleep-related breathing disorders provide new information useful to the genetic characterization of this pathology. The PHOX2B gene silent mutations can lead to structural and functional modification of their product providing to a group of children with Class III malocclusion similar features to those of CCHS (sleep apnea episodes and craniofacial malformations).
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Rand CM, Patwari PP, Carroll MS, Weese-Mayer DE. Congenital central hypoventilation syndrome and sudden infant death syndrome: disorders of autonomic regulation. Semin Pediatr Neurol 2013; 20:44-55. [PMID: 23465774 DOI: 10.1016/j.spen.2013.01.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Long considered a rare and unique disorder of respiratory control, congenital central hypoventilation syndrome has recently been further distinguished as a disorder of autonomic regulation. Similarly, more recent evidence suggests that sudden infant death syndrome is also a disorder of autonomic regulation. Congenital central hypoventilation syndrome typically presents in the newborn period with alveolar hypoventilation, symptoms of autonomic dysregulation and, in a subset of cases, Hirschsprung disease or tumors of neural crest origin or both. Genetic investigation identified PHOX2B, a crucial gene during early autonomic development, as disease defining for congenital central hypoventilation syndrome. Although sudden infant death syndrome is most likely defined by complex multifactorial genetic and environmental interactions, it is also thought to result from central deficits in the control of breathing and autonomic regulation. The purpose of this article is to review the current understanding of these autonomic disorders and discuss the influence of this information on clinical practice and future research directions.
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Affiliation(s)
- Casey M Rand
- Center for Autonomic Medicine in Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Edwards EA, Nixon GM. Paediatric home ventilatory support: changing milieu, proactive solutions. J Paediatr Child Health 2013; 49:13-8. [PMID: 23252372 DOI: 10.1111/jpc.12040] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2012] [Indexed: 11/29/2022]
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Presentation and treatment of monozygotic twins with congenital central hypoventilation syndrome. Can Respir J 2012; 18:87-9. [PMID: 21499593 DOI: 10.1155/2011/989741] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Congenital central hypoventilation syndrome is a rare genetic disorder characterized by hypoventilation during sleep secondary to a blunted response to hypercapnia and hypoxia. The current case report describes developmentally normal four-year-old monozygotic twin boys who presented in infancy with variable presentations and clinical severity of congenital central hypoventilation syndrome. Both were managed with noninvasive positive pressure ventilation.
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Congenital central hypoventilation syndrome with PHOX2B gene mutation. Indian J Pediatr 2012; 79:1526-8. [PMID: 22674249 DOI: 10.1007/s12098-012-0789-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Accepted: 05/21/2012] [Indexed: 10/28/2022]
Abstract
A term baby developed hypoventilation on day 1 of life requiring mechanical ventilation and had subsequent difficulty in weaning. Diagnostic workup for pulmonary, cardiac, metabolic, sepsis and structural CNS diseases were negative. In view of persistent hypoventilation despite raised pCO(2) levels in absence of any sedation, the diagnosis of Idiopathic. Congenital Central Hypoventilation Syndrome (CCHS) was considered. The baby was tested for Paired-like Homeobox 2B (PHOX2B) gene mutation and was found to have expanded alleles containing 10 polyalanine repeats producing genotype of 20/30 on chromosome 4p12 (The normal being 20/20). This is the first report of a neonate from India with genetically confirmed CCHS.
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[Late onset Ondine syndrome: literature review on a case report]. Arch Pediatr 2012; 19:1205-7. [PMID: 23037578 DOI: 10.1016/j.arcped.2012.08.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 06/09/2012] [Accepted: 08/22/2012] [Indexed: 11/23/2022]
Abstract
Ondine syndrome is the central congenital hypoventilation syndrome (CCHS) caused by the mutation of the PHOX2B gene. In late onset cases, the symptomatology often appears after an acute event (infection, general anesthesia, drug intake), increasing hypoventilation. We report a case of late onset Ondine curse in a 9-year-old girl. The diagnosis was made based on a hypercapnic coma complicating a respiratory infection caused by Mycoplasma pneumoniae and was confirmed by genetic testing. In the patient's history we found symptoms that had not been noted (e.g., enuresis, morning headache, adynamia), attesting to chronic hypoventilation. Through this observation, we review the literature on CCHS, notably late onset cases, which are rare and insidious, emphasizing the pre-existing hypoventilation symptoms in this child. This case underlines the need for all practitioners not to trivialize these symptoms so as to decrease the current delay in diagnosis for late onset CCHS and to introduce optimal care as soon as possible.
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