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Padhiyar J, Mahajan R, Panda M. RASopathies: Evolving Concepts in Pathogenetics, Clinical Features, and Management. Indian Dermatol Online J 2024; 15:392-404. [PMID: 38845651 PMCID: PMC11152490 DOI: 10.4103/idoj.idoj_594_23] [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: 08/03/2023] [Revised: 09/27/2023] [Accepted: 10/01/2023] [Indexed: 06/09/2024] Open
Abstract
RASopathies refers to the group of disorders which are caused by a mutation in various genes of the RAS/MAPK (RAT sarcoma virus/Mitogen activated protein kinase) pathway. It includes many genes with varied functions, which are responsible for cell cycle regulation. As the mutation in one gene affects the entire pathway, there are many overlapping features among the various syndromes which are included under an umbrella term "RASopathies." However, neuroectodermal involvement is a unifying feature among these syndromes, which are caused by germline mutations affecting genes along this pathway. Recently, many other RASopathies have been described to involve blood vessels, lymphatics, and immune system. Also, many cutaneous mosaic disorders have been found to have mutations in the concerned pathway. The purpose of this article is to briefly review the pathogenesis of RASopathies with cutaneous manifestations, and summarise the features that can be helpful as diagnostic clues to dermatologists. As we understand more about the pathogenesis of the pathway at the cellular level, the research on genotype-phenotype correlation and therapeutic options broadens. Targeted therapy is in the clinical and preclinical trial phase, which may brighten the future of many patients.
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Affiliation(s)
- Jigna Padhiyar
- Department of DVL, Gujarat Cancer Society Medical College, Hospital and Research Centre, Ahmedabad, Gujarat, India
| | - Rahul Mahajan
- Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Maitreyee Panda
- Department of Dermatology, IMS and SUM Hospital, Bhubaneshwar, Odisha, India
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Barg AA, Yeshayahu Y, Avishai E, Budnik I, Cohen O, Brutman-Barazani T, Dardik R, Raas-Rothschild A, Levy-Mendelovich S, Livnat T, Pinhas-Hamiel O, Kenet G. Bleeding phenotype and hemostatic evaluation by thrombin generation in children with Noonan syndrome: A prospective study. Pediatr Blood Cancer 2024; 71:e30761. [PMID: 37974388 DOI: 10.1002/pbc.30761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/04/2023] [Accepted: 10/27/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND This study aimed to evaluate the bleeding phenotype and to conduct a comprehensive hemostatic evaluation in individuals with Noonan syndrome (NS), a dominantly inherited disorder caused by pathogenic variants in genes associated with the Ras/MAPK signaling pathway. METHODS Children with a genetically confirmed diagnosis of NS underwent clinical evaluation, routine laboratory tests, platelet function testing, and thrombin generation (TG) assessment. RESULTS The study included 24 children. The most frequently reported bleeding symptoms were easy bruising and epistaxis, while bleeding complications were observed in 15% of surgical procedures. Various hemostatic abnormalities were identified, including platelet dysfunction, von Willebrand disease, and clotting factor deficiencies. Abnormal platelet function was observed in 50% of the patients, and significantly lower TG parameters were found compared to controls. However, no significant correlation was observed between bleeding symptoms and TG results. CONCLUSIONS The study suggests that the bleeding diathesis in NS is multifactorial, involving both platelet dysfunction and deficiencies of plasma coagulation factors. The potential role of TG assay as an ancillary tool for predicting bleeding tendencies in individuals with NS undergoing surgery warrants further investigation.
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Affiliation(s)
- Assaf A Barg
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ashdod, Israel
| | - Yonatan Yeshayahu
- Pediatrics Department, Samson Assuta Ashdod Hospital, Ashdod, Israel
- Noonan Multidisciplinary Clinic, Pediatric Endocrinology and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
- Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Ashdod, Israel
| | - Einat Avishai
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ashdod, Israel
| | - Ivan Budnik
- Department of Internal Medicine, Division of Hematology/Oncology, University of Iowa, Iowa City, Iowa, USA
| | - Omri Cohen
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ashdod, Israel
| | - Tami Brutman-Barazani
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ashdod, Israel
| | - Rima Dardik
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ashdod, Israel
| | - Annick Raas-Rothschild
- The Institute for Rare Diseases, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ashdod, Israel
| | - Sarina Levy-Mendelovich
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ashdod, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Tami Livnat
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ashdod, Israel
| | - Orit Pinhas-Hamiel
- Noonan Multidisciplinary Clinic, Pediatric Endocrinology and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Gili Kenet
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Ashdod, Israel
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Liu L, Hu C, Chen Z, Zhu S, Zhu L. Co-Occurring Thrombotic Thrombocytopenic Purpura and Autoimmune Hemolytic Anemia in a Child Carrying the Pathogenic SHOC2 c.4A>G (p.Ser2Gly) Variant. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e942377. [PMID: 38019730 PMCID: PMC10697549 DOI: 10.12659/ajcr.942377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/21/2023] [Accepted: 11/11/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND RASopathies involve mutations in genes that encode proteins participating in the RAS-mitogen-activated protein kinase pathway and are a collection of multisystem disorders that clinically overlap. Variants in the SHOC2 gene have been reported in Noonan-like syndrome, which include distinct facial features, short stature, congenital cardiac defects, developmental delays, bleeding disorders, and loose anagen hair. This report is of a 7-year-old girl with the c.4A>G (p.Ser2Gly) variant of the SHOC2 gene, consistent with Noonan-like syndrome, with loose anagen hair, presenting with thrombotic thrombocytopenic purpura and autoimmune hemolytic anemia. CASE REPORT The child had a medical history of 7 hospitalizations at our institution. At the age of 2 months, she underwent surgical correction for ventricular and atrial septal defects. At the age of 2 years, tonsil and adenoid removal surgery was performed, followed by surgery for otitis media at age 5 years. At 7 years, she was hospitalized for the simultaneous occurrence of thrombotic thrombocytopenic purpura and autoimmune hemolytic anemia. The patient displayed short stature and mild intellectual disability. Notable facial features included sparse hair, mild frontal bossing, and low-set ears. Antinuclear antibody levels demonstrated a significant gradual shift. Through trio whole-exome sequencing, a c.4A>G (p.Ser2Gly) variation in the SHOC2 gene was identified. CONCLUSIONS Given the clinical information and genetic testing results, the patient's condition appeared to closely be a type of RASopathy. This report has highlighted the importance of physical, developmental, and genetic testing in children presenting with dysmorphism, developmental delay, and hematological abnormalities.
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Affiliation(s)
- Lijun Liu
- Department of Pediatric Intensive Care Unit, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, PR China
| | - Chanchan Hu
- Department of Pediatric Intensive Care Unit, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, PR China
| | - Zhenjie Chen
- Department of Pediatric Intensive Care Unit, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, PR China
| | - Shuzhen Zhu
- Department of Emergency, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, PR China
| | - Lvchang Zhu
- Department of Pediatric Intensive Care Unit, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, PR China
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Mehic D, Pabinger I, Gebhart J. Investigating patients for bleeding disorders when most of the "usual" ones have been ruled out. Res Pract Thromb Haemost 2023; 7:102242. [PMID: 38193045 PMCID: PMC10772891 DOI: 10.1016/j.rpth.2023.102242] [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: 08/30/2023] [Revised: 10/06/2023] [Accepted: 10/12/2023] [Indexed: 01/10/2024] Open
Abstract
A State of the Art lecture titled "Investigating Patients for Bleeding Disorders When Most of the Usual Ones Have Been Ruled Out" was presented at the International Society on Thrombosis and Haemostasis Congress in 2023. Mild to moderate bleeding disorders (MBDs) in patients in whom no diagnosis of an established disorder, such as platelet function defect, von Willebrand disease, or a coagulation factor deficiency, can be identified are classified as bleeding disorders of unknown cause (BDUCs). Prospective data from the Vienna Bleeding Biobank and other studies have revealed a high proportion of BDUCs of up to 70% among patients with MBD who have a similar bleeding phenotype as other MBDs. As BDUC is a diagnosis of exclusion, the accuracy of the diagnostic workup is essential. For example, repeated testing for von Willebrand disease should be considered if von Willebrand factor values are <80 IU/dL. Current evidence does not support the clinical use of global assays such as thromboelastography, platelet function analyzer, or thrombin generation potential. Rare and novel bleeding disorders due to genetic variants in fibrinolytic factors or natural anticoagulants are rare and should only be analyzed in patients with specific phenotypes and a clear family history. In BDUC, blood group O was identified as a risk factor for increased bleeding severity and bleeding risk after hemostatic challenges. Future studies should improve the phenotypical characterization and ideally identify novel risk factors in BDUC, as a multifactorial pathogenesis is suspected. Finally, we summarize relevant new data on this topic presented during the 2023 International Society on Thrombosis and Haemostasis Congress.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Tiemens DK, Kleimeier L, Leenders E, Wingbermühle E, Roelofs RL, Sibbles B, Oostwegel FSM, Vroonland E, van Leeuwen C, Niessen H, Sonnega P, Duursma A, Willemsen MAAP, Draaisma JMT, Pittens CACM. The most important problems and needs of rasopathy patients with a noonan syndrome spectrum disorder. Orphanet J Rare Dis 2023; 18:198. [PMID: 37480127 PMCID: PMC10362585 DOI: 10.1186/s13023-023-02818-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 07/08/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Noonan syndrome spectrum disorders (NSSDs) constitute a group within the Rasopathies, and are one of the largest groups of syndromes with impact on multi-organ involvement known. The extreme variability of the clinical phenotype is, among others, due to the numerous different genes that are involved, and the differences in clinical presentation over the life span. We have studied the needs of patients and their relatives aiming to develop, evaluate and choose focus in research, medical care and policy to better meet their perspectives. METHODS Using the participatory and interactive Dialogue method, 80 patients and relatives mentioned 53 different problems or needs (topics) that were categorized into eight themes. These themes and the topics within each theme, were subsequently prioritized by putting them in order of importance methodologically. RESULTS The four highest prioritized themes were: (1) Physical problems (non-musculoskeletal related); (2) Social, emotional and behavioral problems; (3) Cognitive functioning and information processing; and (4) Problems related to the musculoskeletal system. Nineteen out of the 53 topics were physical problems. According to the total group of respondents, the top 3 prioritized topics within theme 1 were coagulation problems, heart problems, and feeding problems. Also data stratified by age groups, phenotype (NS and other NSSDs) and gender showed some remarkable results. For instance, feeding problems were prioritized as the most important topic of the highest prioritized theme, according to patients aged 0-12 years. Also feeding problems show a significant difference in its prioritization according to female patients (2) compared to male patients (7). On the other hand, heart problems were not mentioned in the top three prioritized topics in the youngest age groups, although heart problems are generally considered most important for patients with NSSD. CONCLUSIONS With our results we underline the importance of methodologically inventorying the needs of NSSD patients, not only at the group level, but to also focus on specific needs according to e.g. age, phenotype and gender. For instance, it is remarkable that both the current Clinical Guidelines and the Noonan Syndrome diagnostic criteria give little to no attention to feeding problems, though our results indicate that, to the youngest patients, these problems have top priority. A similar situation appears to apply to the clinical management of e.g. coagulation, neuropsychological and musculoskeletal problems (like physiotherapy or occupational therapy) and to a need for (educational) tools to support patients at school or at work. Our study may help to shape targeted (clinical) management, research and policy inside and outside medical (research) institutes and shed light on the complex phenotypes of NSSDs, the families' and patients' perspectives on the everyday consequences of the many different problems, as well as their needs.
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Affiliation(s)
- Dagmar K Tiemens
- Department of Pediatrics, Radboud Institute for Health Sciences, Amalia Children's Hospital, Radboud university medical center, Nijmegen, The Netherlands
- Dutch Noonan Syndrome Foundation, Nijkerk, The Netherlands
| | - Lotte Kleimeier
- Department of Pediatrics, Radboud Institute for Health Sciences, Amalia Children's Hospital, Radboud university medical center, Nijmegen, The Netherlands
| | - Erika Leenders
- Department of Human Genetics, Radboud university medical center, Nijmegen, The Netherlands
| | - Ellen Wingbermühle
- Department of Human Genetics, Radboud university medical center, Nijmegen, The Netherlands
- Centre of Excellence for Neuropsychiatry, Vincent van Gogh Institute for Psychiatry, Venray, The Netherlands
- Donders Institute for Brain, Cognition and Behavior, Amalia Children's Hospital Nijmegen, Nijmegen, The Netherlands
| | - Renee L Roelofs
- Centre of Excellence for Neuropsychiatry, Vincent van Gogh Institute for Psychiatry, Venray, The Netherlands
- Donders Institute for Brain, Cognition and Behavior, Amalia Children's Hospital Nijmegen, Nijmegen, The Netherlands
| | - Barbara Sibbles
- Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Floor S M Oostwegel
- Faculty of Earth and Life Science, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, VU University, Amsterdam, The Netherlands
| | | | | | | | - Paul Sonnega
- Dutch Noonan Syndrome Foundation, Nijkerk, The Netherlands
| | - Anniek Duursma
- Dutch Noonan Syndrome Foundation, Nijkerk, The Netherlands
| | - Michel A A P Willemsen
- Department of Pediatrics, Radboud Institute for Health Sciences, Amalia Children's Hospital, Radboud university medical center, Nijmegen, The Netherlands
- Department of Pediatrics, Donders Institute for Brain, Cognition and Behavior, Amalia Children's Hospital Nijmegen, Nijmegen, The Netherlands
| | - Jos M T Draaisma
- Department of Pediatrics, Radboud Institute for Health Sciences, Amalia Children's Hospital, Radboud university medical center, Nijmegen, The Netherlands.
| | - Carina A C M Pittens
- Faculty of Earth and Life Science, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, VU University, Amsterdam, The Netherlands
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Neurosurgical aspects of Noonan syndrome. Childs Nerv Syst 2023; 39:849-856. [PMID: 36847963 DOI: 10.1007/s00381-023-05888-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 02/14/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE Noonan syndrome (NS) is a rare neurodevelopmental syndrome characterized by dysmorphic features, congenital heart defects, neurodevelopmental delay, and bleeding diathesis. Though rare, several neurosurgical manifestations have been associated with NS, such as Chiari malformation (CM-I), syringomyelia, brain tumors, moyamoya, and craniosynostosis. We describe our experience in treating children with NS and various neurosurgical conditions, and review the current literature on neurosurgical aspects of NS. METHODS Data were retrospectively collected from the medical records of children with NS who were operated at a tertiary pediatric neurosurgery department, between 2014 and 2021. Inclusion criteria were clinical or genetic diagnosis of NS, age < 18 years at treatment, and need for a neurosurgical intervention of any kind. RESULTS Five cases fulfilled the inclusion criteria. Two had tumors, one underwent surgical resection. Three had CM-I, syringomyelia, and hydrocephalus, of whom one also had craniosynostosis. Comorbidities included pulmonary stenosis in two patients and hypertrophic cardiomyopathy in one. Three patients had bleeding diathesis, two of them with abnormal coagulation tests. Four patients were treated preoperatively with tranexamic acid, and two with Von Willebrand factor or platelets (1 each). One patient with a clinical bleeding predisposition developed hematomyelia following a syringe-subarachnoid shunt revision. CONCLUSIONS NS is associated with a spectrum of central nervous system abnormalities, some of which with known etiology, while in others a pathophysiological mechanism has been suggested in the literature. When operating on a child with NS, a meticulous anesthetic, hematologic, and cardiac evaluation should be conducted. Neurosurgical interventions should then be planned accordingly.
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Bruno L, Lenberg J, Le D, Dimmock D, Thornburg CD, Briggs B. Novel Approach to Improve the Identification of the Bleeding Phenotype in Noonan Syndrome and Related RASopathies. J Pediatr 2023:S0022-3476(23)00019-7. [PMID: 36646249 DOI: 10.1016/j.jpeds.2022.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/10/2022] [Accepted: 12/01/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To characterize bleeding phenotype in Noonan Syndrome, to test the utility of following national guidelines in detecting this phenotype, to evaluate thromboelastography (TEG) as a diagnostic tool and to evaluate the cohort for genotype-phenotype correlations. STUDY DESIGN Participants with a clinical diagnosis NS or related RASopathy were enrolled in a cohort study. Study procedures included clinical bleeding assessment, coagulation testing per guidelines and hematology consultation. TEG was completed in a subset and genetic testing was conducted for those without a molecular diagnosis. International Society of Haemostasis and Thrombosis Bleeding Assessment Tool (ISTH-BAT) scores were calculated with hematology consultation. Bleeding phenotype was defined as abnormal bleeding score. RESULTS Twenty participants enrolled; 12completed clinical and laboratory evaluation, five of whom met the definition for bleeding phenotype. Four of the five participants with a bleeding phenotype had platelet aggregation defects and at least one additional coagulation defect. TEG was performed in nine participants, four with bleeding phenotype and five without, and results were normal in all cases. No genotype-phenotype correlation was found. CONCLUSION Five of 20 participants had a bleeding phenotype identified. Based on available data we do not recommend incorporating TEG into clinical practice for NS patients. Platelet aggregation defects were the most common abnormalities, which would not be detected on Tier 1 testing of current guidelines, therefore we propose a new algorithm.
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Affiliation(s)
- Leah Bruno
- Department of Pediatrics, Division of Hematology and Oncology, University of California San Diego, La Jolla, California; Rady Children's Institute of Genomic Medicine, San Diego, California
| | - Jerica Lenberg
- Rady Children's Institute of Genomic Medicine, San Diego, California
| | - Dzung Le
- Department of Pathology, University of California San Diego, La Jolla, California
| | - David Dimmock
- Rady Children's Institute of Genomic Medicine, San Diego, California
| | - Courtney D Thornburg
- Department of Pediatrics, Division of Hematology and Oncology, University of California San Diego, La Jolla, California; Hemophilia and Thrombosis Treatment Center, Rady Children's Hospital San Diego, San Diego, California
| | - Benjamin Briggs
- Rady Children's Institute of Genomic Medicine, San Diego, California.
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Chakraborty A, Beasley G, Martinez H, Jesudas R, Anton-Martin P, Christakopoulos G, Kramer J. Selumetinib for Refractory Pulmonary and Gastrointestinal Bleeding in Noonan Syndrome. Pediatrics 2022; 150:189468. [PMID: 36082608 DOI: 10.1542/peds.2022-056336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/24/2022] Open
Abstract
A 15-year-old-boy with Noonan syndrome and status post orthoptic heart transplant developed mixed mitral valve disease and underwent mechanical mitral valve replacement 6 months before presentation with acute respiratory distress. He developed massive pulmonary hemorrhage that required veno-venous extracorporeal membrane oxygenation (ECMO) support. He had a prolonged anticoagulation free ECMO course of 4 weeks, with ongoing recurrent pulmonary hemorrhage and underwent several rounds of coil embolization of aortopulmonary collaterals. ECMO course was complicated by significant nasopharyngeal bleeding that required embolization of the sphenopalatine artery. Shortly after decannulation, he developed massive gastrointestinal and peritoneal hemorrhage that was treated by embolization of the left gastric artery and a branch of the internal iliac artery. His bleeding was attributed to neo-angiogenesis. Initial treatment with propranolol was unsuccessful. Subsequent treatment with interferon α 2b demonstrated efficacy, but severe neutropenia required cessation of therapy. Because functional alterations of the rat sarcoma virus-mitogen activated protein kinase signaling pathway and protein tyrosine phosphatase nonreceptor type (PTPN11) mutations in Noonan syndrome are known to be associated with neo-angiogenesis, we used the mitogen-activated protein kinase inhibitor selumetinib as a gene-targeted therapy with the hope of controlling bleeding and inhibiting neo-angiogenesis. After initiation of selumetinib, bleeding stopped and allowed the patient to be discharged from the hospital on dipyridamole as antiplatelet prophylaxis for his mechanical mitral valve. He had no further bleeding episodes through 1 year after hospital discharge.
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Affiliation(s)
- Abhishek Chakraborty
- Division of Pediatric Cardiology, University of Tennessee, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Gary Beasley
- Division of Pediatric Cardiology, University of Tennessee, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Hugo Martinez
- Division of Pediatric Cardiology, University of Tennessee, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Rohith Jesudas
- Department of Clinical Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Pilar Anton-Martin
- Division of Pediatric Cardiology, University of Tennessee, Le Bonheur Children's Hospital, Memphis, Tennessee
| | | | - Jennifer Kramer
- Division of Pediatric Cardiology, University of Tennessee, Le Bonheur Children's Hospital, Memphis, Tennessee
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Janas-Naze A, Malkiewicz K, Zhang W. Clinical Findings in Children with Noonan Syndrome—A 17-Year Retrospective Study in an Oral Surgery Center. CHILDREN 2022; 9:children9101486. [PMID: 36291422 PMCID: PMC9600410 DOI: 10.3390/children9101486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/19/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022]
Abstract
To date, only a limited number of publications have studied the specific oral and maxillofacial findings in patients diagnosed with Noonan syndrome (NS), which is an example of a genetically heterogeneous RASopathy. In this retrospective study, we aimed to ascertain the genotype–phenotype correlations between genetic mutations and certain diagnoses in the field of oral surgery. We collected surgical and genetic data from 42 children (median age, 12 years) who had a confirmed diagnosis of NS and underwent surgery in the Department of Oral Surgery, Medical University of Lodz, over a 17-year period, from 2004 to 2021. In total, 17 patients with mutations of the PTPN11 gene were diagnosed with over-retained deciduous teeth and supernumerary teeth. An amount of 7 patients with mutations of the SOS1 gene were diagnosed with mandibular compound odontomas. Finally, 12 patients with mutations of the LZTR1 gene were diagnosed with bilateral or unilateral central giant cell granulomas in the mandible. Although craniofacial features of many genetic disorders have been previously described in the literature, this study determined the genotype–phenotype correlations in the field of oral surgery.
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Affiliation(s)
- Anna Janas-Naze
- Department of Oral Surgery, Medical University of Lodz, 92-213 Lodz, Poland
- Correspondence: ; Tel.: +48-426757529
| | - Konrad Malkiewicz
- Department of Orthodontics, Medical University of Lodz, 92-213 Lodz, Poland
| | - Wei Zhang
- Shanxi Oral Disease Prevention and Treatment Center, Shanxi Provincial People’s Hospital, Taiyuan 030012, China
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Lan J, Zeng T, Liu S, Lan J, Qian L. Noonan syndrome with RAF1 gene mutations in a newborn with cerebral haemorrhage. Eur J Med Res 2022; 27:146. [PMID: 35953836 PMCID: PMC9367063 DOI: 10.1186/s40001-022-00772-2] [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: 05/10/2022] [Accepted: 07/26/2022] [Indexed: 11/29/2022] Open
Abstract
Background Noonan syndrome is an autosomal dominant genetic disorder that can occur in men and women and has a sporadic or family history. NS can lead to abnormal bleeding, but cerebral haemorrhage is rare. This is the first case of cerebral haemorrhage with a RAF1 gene mutation that originated in the neonatal period. Case presentation This case presents a newborn with a RAF1 gene mutation resulting in NS complicated with an abnormality of chromosome 46, X, del (Y) (q12). In the course of treatment, the baby's breathing suddenly increased. After an MRI examination of the skull, haemorrhaging was found in multiple parts of the brain. Conclusions After symptomatic treatment, the baby recovered well, but the main cause of cerebral haemorrhage was not found.
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Affiliation(s)
- Junwei Lan
- Neonatology Department, Research Group in Lishui Municipal Central Hospital of Zhejiang Province, Lishui Hospital of Zhejiang University, Lishui, 323000, China
| | - Tianbao Zeng
- Neonatology Department, Research Group in Lishui Municipal Central Hospital of Zhejiang Province, Lishui Hospital of Zhejiang University, Lishui, 323000, China
| | - Sheng Liu
- Neonatology Department, Research Group in Lishui Municipal Central Hospital of Zhejiang Province, Lishui Hospital of Zhejiang University, Lishui, 323000, China
| | - Juhong Lan
- Neonatology Department, Research Group in Lishui Municipal Central Hospital of Zhejiang Province, Lishui Hospital of Zhejiang University, Lishui, 323000, China
| | - Lijun Qian
- Neonatology Department, Research Group in Lishui Municipal Central Hospital of Zhejiang Province, Lishui Hospital of Zhejiang University, Lishui, 323000, China.
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Orthognathic surgery in patients with systemic diseases. Oral Maxillofac Surg 2022:10.1007/s10006-022-01054-1. [PMID: 35344096 DOI: 10.1007/s10006-022-01054-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/04/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE To review the experience with orthognathic surgery in patients with systemic diseases, syndromic conditions or an oncological history at a tertiary center. METHODS All patients who had undergone orthognathic surgery and all patients who were considered for orthognathic surgery between January 2013 and August 2020 at a tertiary center were retrospectively reviewed. Patients with cleft lip/palate and orthognathic patients requiring craniofacial surgery or reconstructive surgery were excluded. Patients with an underlying disorder were identified and divided into 3 categories: systemic disease, syndromic condition, or oncological disease treated with chemotherapy and/or radiation therapy of the head and neck. Data on intraoperative and postoperative complications until 3 months after surgery were collected for the patients who had undergone surgery. If orthognathic surgery was contraindicated, the reason was extracted from the patient's medical record. RESULTS Eighty out of 1049 orthognathic patients had an underlying disorder (7.6%), including 50 patients with at least one systemic disease, 25 patients with a syndromic condition, and 5 patients with an oncological disease. A complication was encountered in respectively 5 (10%), 9 (36%), and 0 (0%) patients. Three out of 1134 patients who consulted the multidisciplinary orthognathic-orthodontic consultation had a contraindication for orthognathic surgery because of an underlying disease (0.3%). CONCLUSION Based on our findings, intraoperative and short-term postoperative complications in patients with an underlying disorder are not frequent. Contraindications for orthognathic surgery because of a medical condition are very rare.
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12
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Post DS, van der Veer A, Schijns OEMG, Klinkenberg S, Rijkers K, Wagner GL, van Kranen-Mastenbroek VHJM, Willems PCPH, Verhezen PWM, Beckers EAM, Heubel-Moenen FCJI, Henskens YMC. Assessment of need for hemostatic evaluation in patients taking valproic acid: A retrospective cross-sectional study. PLoS One 2022; 17:e0264351. [PMID: 35213601 PMCID: PMC8880909 DOI: 10.1371/journal.pone.0264351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 02/08/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Valproic acid (VPA) is a frequently prescribed anti-epileptic drug. Since its introduction side effects on hemostasis are reported. However, studies show conflicting results, and the clinical relevance is questioned. We aimed to determine the coagulopathies induced by VPA in patients who undergo high-risk surgery. The study results warrant attention to this issue, which might contribute to reducing bleeding complications in future patients. METHODS Between January 2012 and August 2020, 73 consecutive patients using VPA were retrospectively included. Extensive laboratory hemostatic assessment (including platelet function tests) was performed before elective high-risk surgery. Patient characteristics, details of VPA treatment, and laboratory results were extracted from medical records. RESULTS 46.6% of the patients using VPA (n = 73) showed coagulopathy. Mainly, platelet function disorder was found (36.4%). Thrombocytopenia was seen in 9.6% of the patients. Data suggested that the incidence of coagulopathies was almost twice as high in children as compared to adults and hypofibrinogenemia was only demonstrated in children. No association was found between the incidence of coagulopathies and VPA dosage (mg/kg/day). CONCLUSION A considerable number of patients using VPA were diagnosed with coagulopathy, especially platelet function disorder. Further prospective studies are needed to confirm the need for comprehensive laboratory testing before elective high-risk surgery in these patients.
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Affiliation(s)
- Demi S. Post
- Department of Pediatric Hematology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Arian van der Veer
- Department of Pediatric Hematology, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Pediatric Hematology, Amalia children’s hospital, RadboudUMC, Nijmegen, The Netherlands
- * E-mail:
| | - Olaf E. M. G. Schijns
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Academic Center for Epileptology, Maastricht University Medical Center and Kempenhaeghe, Maastricht–Heeze, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (UM), Maastricht, The Netherlands
| | - Sylvia Klinkenberg
- Department of Pediatric Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Kim Rijkers
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Academic Center for Epileptology, Maastricht University Medical Center and Kempenhaeghe, Maastricht–Heeze, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (UM), Maastricht, The Netherlands
| | - G. Louis Wagner
- Academic Center for Epileptology, Maastricht University Medical Center and Kempenhaeghe, Maastricht–Heeze, The Netherlands
| | - Vivianne H. J. M. van Kranen-Mastenbroek
- Academic Center for Epileptology, Maastricht University Medical Center and Kempenhaeghe, Maastricht–Heeze, The Netherlands
- Department of Clinical Neurophysiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Paul C. P. H. Willems
- Department of Orthopedic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Paul W. M. Verhezen
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Erik A. M. Beckers
- Department of Hematology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Yvonne M. C. Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
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13
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Omori A, Katayama K, Saiki R, Masui S, Suzuki K, Kanii Y, Tsujimoto K, Nakamori S, Kurita T, Murata T, Inoue T, Dohi K. Disruption of the glomerular basement membrane associated with nutcracker syndrome and double inferior vena cava in Noonan syndrome: a case report. BMC Nephrol 2022; 23:65. [PMID: 35151252 PMCID: PMC8841073 DOI: 10.1186/s12882-022-02671-4] [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: 11/04/2021] [Accepted: 01/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background Nutcracker syndrome (NCS) is characterized by compression of the left renal vein (LRV) between the aorta and the superior mesenteric artery. While rare, NCS was reported to be accompanied by double inferior vena cava (IVC). We herein report a case of Noonan syndrome (NS) with double IVC who presented with macrohematuria and proteinuria. Case presentation The patient was a 23-year-old man, who had been diagnosed with NS due to RIT1 mutation, after showing foamy macrohematuria 3 weeks previously. A physical examination revealed low-set ears and a webbed neck. A urinalysis showed hematuria and proteinuria, and urinary sediments showed more than 100 isomorphic red blood cells per high-power field. His proteinuria and albuminuria concentrations were 7.1 and 4.5 g/g⋅Cr, respectively. Three-dimensional contrast-enhanced computed tomography (CT) showed double IVC and narrowing of the LRV after interflow of the left IVC. The aortomesenteric angle on a sagittal reconstruction of the CT image was 14.7°. Cystoscopy revealed a flow of macrohematuria from the left ureteral opening. On Doppler ultrasonography, there was scant evidence to raise the suspicion of the nutcracker phenomenon. Since severe albuminuria continued, a left kidney biopsy was performed. Light microscopy showed red blood cells in Bowman’s space and the tubular lumen. Electron microscopy revealed disruption of the glomerular basement membrane (GBM). Vulnerability of the GBM was suspected and a genetic analysis revealed a heterozygous mutation at c.4793 T > G (p.L1598R) in the COL4A3 gene. Screening for coagulation disorders revealed the factor VIII and von Willebrand factor (vWF) values were low, at 47.6 and 23%, respectively. A multimer analysis of vWF showed a normal multimer pattern and he was diagnosed with von Willebrand disease type 1. As the bleeding tendency was mild, replacement of factor VIII was not performed. His macrohematuria and proteinuria improved gradually without treatment, and his urinalysis results have been normal for more than 6 months. Conclusions The present case showed macrohematuria and proteinuria due to NCS in NS with double IVC and von Willebrand disease type 1. The macrohematuria and proteinuria originated from glomerular hemorrhage because of vulnerability of the GBM due to COL4A3 mutation. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02671-4.
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Falls CJ, Page PS, Greeneway GP, Resnick DK, Stadler JA. Management of failed Chiari decompression and intrasyringeal hemorrhage in Noonan syndrome: illustrative cases. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21625. [PMID: 36130568 PMCID: PMC9379712 DOI: 10.3171/case21625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Noonan syndrome (NS) is a rare genetic RASopathy with multisystem implications. The disorder is typically characterized by short stature, distinctive facial features, intellectual disability, developmental delay, chest deformity, and congenital heart disease. NS may be inherited or arise secondary to spontaneous mutations of genes in the Ras/mitogen activated protein kinase signaling pathways. OBSERVATIONS Numerous case reports exist detailing the association between NS and Chiari I malformation (CM-I), although this relationship has not been fully established. Patients with NS who present with CM-I requiring operation have shown high rates reoperation for failed decompression. The authors reported two patients with NS, CM-I, and syringomyelia who had prior posterior fossa decompressions without syrinx improvement. Both patients received reoperation with successful outcomes. LESSONS The authors highlighted the association between NS and CM-I and raised awareness that patients with these disorders may be at higher risk for failed posterior fossa decompression, necessitating reoperation.
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Affiliation(s)
- Cody J. Falls
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; and
| | - Paul S. Page
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Garret P. Greeneway
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Daniel K. Resnick
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - James A. Stadler
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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15
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Sasaki H, Mizuta K. Severe Bleeding During Orthognathic Surgery for a Noonan Syndrome Patient. Anesth Prog 2022; 69:22-25. [PMID: 36534772 PMCID: PMC9773416 DOI: 10.2344/anpr-69-02-02] [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: 07/14/2021] [Accepted: 02/04/2022] [Indexed: 12/23/2022] Open
Abstract
Noonan syndrome (NS) is a genetic disorder characterized by craniofacial dysmorphism, chest deformities, congenital heart defects, and bleeding disorders. Although patients with NS have a high prevalence of orofacial deformity, few reports are available on their anesthetic management during orthognathic surgery. This case report describes a 31-year-old female with NS, anemia, hypertrophic cardiomyopathy, and mild mitral valve regurgitation who experienced severe bleeding during orthognathic surgery. After treating her anemia with oral iron therapy and subcutaneous epoetin β, 4 units of autologous blood was deposited prior to surgery. General anesthesia was induced with remifentanil and propofol and maintained with sevoflurane, remifentanil, and fentanyl. Despite mild hypotensive anesthesia (targeted mean arterial pressure of 65 mm Hg) with nitroglycerine and intravenous tranexamic acid for bleeding, adequate hemostasis was difficult to achieve and led to severe blood loss (1442 mL). Therefore, the 4 units of autologous blood and 2 units of packed red blood cells were transfused. Her postoperative course proceeded uneventfully without abnormal postoperative bleeding. Because patients with NS can have difficulty with hemostasis, vascular malformations, and fragile blood vessels, extensive hematologic evaluation and thorough preparation for unexpected bleeding are crucial to accomplish orthognathic surgery.
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Affiliation(s)
- Haruka Sasaki
- Division of Dento-oral Anesthesiology, Tohoku University Graduate School of Dentistry, Sendai, Japan
| | - Kentaro Mizuta
- Division of Dento-oral Anesthesiology, Tohoku University Graduate School of Dentistry, Sendai, Japan
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16
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Palit A, Inamadar AC. RASopathies: Dermatologists’ viewpoints. Indian J Dermatol Venereol Leprol 2021; 88:452-463. [DOI: 10.25259/ijdvl_799_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 04/01/2021] [Indexed: 11/04/2022]
Abstract
Ras/mitogen-activated protein kinase pathway dysregulation results in a group of disorders, collectively termed as RASopathies. Neurofibromatosis type 1, Noonan syndrome, Noonan syndrome with multiple lentigines, Noonan syndrome/loose anagen hair, Legius syndrome, Costello syndrome, cardio-facio-cutaneous syndrome and capillary malformation-arteriovenous malformation are the well-recognized RASopathies. These are characterized by multi-organ tumours and hamartomas. Some other features in common are facial dysmorphism, skeletal abnormalities, congenital heart disease, neurocognitive abnormalities and risk of various solid-organ and haematological malignancies. Some of the RASopathies are heterogeneous, caused by several gene mutations resulting in variations in phenotypes and severity ranging from mild to fatal. Significant phenotypic overlaps among different disorders, often makes it difficult to pinpoint a clinical diagnosis. Specific cutaneous manifestations are present in some of the RASopathies and are often the earliest clinical signs/symptoms. Hence, dermatologists contribute significantly as primary care physicians by identifying disorder-specific cutaneous lesions. However, diagnostic work-up and management of these disorders are often multidisciplinary. Confirmation of diagnosis is possible only by genetic mapping in each case. Genetic counseling of the patients and the affected families is an important component of the management. The aim of this review is description of cutaneous manifestations of RASopathies in the background of multi-system involvement to enable dermatologists a comprehensive and logical approach to work up and diagnose such patients in the absence of facility for specific molecular testing.
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Affiliation(s)
| | - Arun C. Inamadar
- Department of Dermatology, Venereology and Leprosy, Shri B. M. Patil Medical College, Hospital and Research Center, BLDE University, Vijayapur, Karnataka, India
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17
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Carter R, Niemi AK. Severe thrombocytopenia and intracranial hemorrhage in a newborn with Noonan syndrome and neonatal alloimmune thrombocytopenia. Platelets 2021; 33:649-651. [PMID: 34904514 DOI: 10.1080/09537104.2021.1981845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Noonan syndrome (NS) is a genetic disorder with distinctive physical features and often multiple organ involvement. Bleeding disorders are reported in over half of patients with NS, including thrombocytopenia and platelet dysfunction. Neonatal alloimmune thrombocytopenia (NAIT) is an alloantigenic thrombocytopenia that can present with severe bleeding. Here, we present a case of intracranial hemorrhage and severe thrombocytopenia in a neonate found to have both NAIT and a de novo heterozygous pathogenic variant in PTPN11, consistent with Noonan syndrome.
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Affiliation(s)
- Rebecca Carter
- Division of Neonatology, Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | - Anna-Kaisa Niemi
- Division of Neonatology, Department of Pediatrics, University of California San Diego, La Jolla, CA, USA.,Division of Neonatology, Rady Children's Hospital San Diego, University of California San Diego, San Diego, CA, USA
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18
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Di Candia F, Marchetti V, Cirillo F, Di Minno A, Rosano C, Pagano S, Siano MA, Falco M, Assunto A, Boccia G, Magliacane G, Pinna V, De Luca A, Tartaglia M, Di Minno G, Strisciuglio P, Melis D. RASopathies and hemostatic abnormalities: key role of platelet dysfunction. Orphanet J Rare Dis 2021; 16:499. [PMID: 34857025 PMCID: PMC8638204 DOI: 10.1186/s13023-021-02122-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 11/06/2021] [Indexed: 11/23/2022] Open
Abstract
Background Bleeding anomalies have been reported in patients affected by Noonan syndrome. No study has been performed in patients with molecularly confirmed RASopathy. We aimed to characterize the frequency and types of bleeding disorders in patients with RASopathies and evaluate any significant association with laboratory findings. Patients and methods Forty-nine individuals (PTPN11, n = 27; SOS1, n = 7; RIT1, n = 3; SPRED1, n = 1; LZTR1, N = 3; RAF1, n = 2; BRAF, n = 4; MEK1, n = 1; MEK2, n = 1), and 49 age- and sex-matched controls were enrolled. The “Paediatric Bleeding Questionnaire Scoring Key” was administered to patients and families. Laboratory screening tests including clotting factors dosing, platelet count, Prothrombin Time and Partial Thromboplastin Time, were employed both in patients and controls to characterize the bleeding diathesis. A subgroup of 29/49 patients and 29/49 controls was also tested for platelet function. Results Regardless of the gene involved, pathological paediatric bleeding scores were recorded in 14/49 (28.5%) patients. Indeed, 7 were mutated in PTPN11, 3 in SOS1, 2 in RIT1, 1 in BRAF, and 1 in MEK1. Compared to patients with normal bleeding scores, those with pathologic bleeding score showed higher prevalence of splenomegaly (p = 0.006), prolonged aPTT (p = 0.04), lower levels of coagulation factor V (FV, p = 0.001), FVII (p = 0.003), FX (p = 0.0008) and FXIII (p = 0.002), higher vWAg (p = 0.04), and lower platelet sensitivity to Ristocetin (p = 0.001), arachidonic acid (AA) (p = 0.009) and collagen (p = 0.01). The presence of hematomas inversely correlated with factor V (p = 0.002), factor VII (p = 0.003), factor X (p = 0.002) and factor XIII (p = 0.004) levels, and directly correlated with platelet response to collagen (p = 0.02) and AA (p = 0.01). The presence of splenomegaly directly correlated with the presence of hematoma (p = 0.006), platelet response to Ristocetin (p = 0.04) and AA (p = 0.04), and inversely correlated with factor V levels (p = 0.03). Conclusions Patients with RASopathies and a bleeding tendency exhibit multiple laboratory abnormalities, including platelet-related disorders. Splenomegaly is frequently detected and might be a suggestive sign for qualitative platelet dysfunction. A comprehensive clinical assessment should be carried out at diagnosis, during the follow-up and before any surgical procedures. Since there is currently no consensus on management of bleeding complications, it is important that physicians closely monitor these patients.
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Affiliation(s)
- Francesca Di Candia
- Dipartimento di Scienze Mediche Traslazionali, Università degli studi di Napoli Federico II, Naples, Italy
| | - Valeria Marchetti
- Dipartimento di Scienze Mediche Traslazionali, Università degli studi di Napoli Federico II, Naples, Italy
| | - Ferdinando Cirillo
- Regional Reference Centre for Coagulation Disorders, Department of Clinical and Experimental Medicine, Federico II University of Naples, Naples, Italy
| | - Alessandro Di Minno
- Regional Reference Centre for Coagulation Disorders, Department of Clinical and Experimental Medicine, Federico II University of Naples, Naples, Italy
| | - Carmen Rosano
- Dipartimento di Scienze Mediche Traslazionali, Università degli studi di Napoli Federico II, Naples, Italy
| | - Stefano Pagano
- Dipartimento di Scienze Mediche Traslazionali, Università degli studi di Napoli Federico II, Naples, Italy
| | - Maria Anna Siano
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy.,Pediatric Unit, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy
| | - Mariateresa Falco
- Pediatric Unit, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy
| | - Antonia Assunto
- Dipartimento di Scienze Mediche Traslazionali, Università degli studi di Napoli Federico II, Naples, Italy
| | - Giovanni Boccia
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Gerardo Magliacane
- Clinic Pathology, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy
| | - Valentina Pinna
- Medical Genetics Division, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Alessandro De Luca
- Medical Genetics Division, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Marco Tartaglia
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Giovanni Di Minno
- Regional Reference Centre for Coagulation Disorders, Department of Clinical and Experimental Medicine, Federico II University of Naples, Naples, Italy
| | - Pietro Strisciuglio
- Dipartimento di Scienze Mediche Traslazionali, Università degli studi di Napoli Federico II, Naples, Italy
| | - Daniela Melis
- Dipartimento di Scienze Mediche Traslazionali, Università degli studi di Napoli Federico II, Naples, Italy. .,Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy. .,Pediatric Unit, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy.
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19
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Billar RJ, Manoubi W, Kant SG, Wijnen RMH, Demirdas S, Schnater JM. Association between pectus excavatum and congenital genetic disorders: A systematic review and practical guide for the treating physician. J Pediatr Surg 2021; 56:2239-2252. [PMID: 34039477 DOI: 10.1016/j.jpedsurg.2021.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/13/2021] [Accepted: 04/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pectus excavatum (PE) could be part of a genetic disorder, which then has implications regarding comorbidity, the surgical correction of PE, and reproductive choices. However, referral of a patient presenting with PE for genetic analysis is often delayed because additional crucial clinical signs may be subtle or even missed in syndromic patients. We reviewed the literature to inventory known genetic disorders associated with PE and create a standardized protocol for clinical evaluation. METHODS A systematic literature search was performed in electronic databases. Genetic disorders were considered associated with PE if studies reported at least five cases with PE. Characteristics of each genetic disorder were extracted from the literature and the OMIM database in order to create a practical guide for the clinician. RESULTS After removal of duplicates from the initial search, 1632 citations remained. Eventually, we included 119 full text articles, representing 20 different genetic disorders. Relevant characteristics and important clinical signs of each genetic disorder were summarized providing a standardized protocol in the form of a scoring list. The most important clinical sign was a positive family history for PE and/or congenital heart defect. CONCLUSIONS Twenty unique genetic disorders have been found associated with PE. We have created a scoring list for the clinician that systematically evaluates crucial clinical signs, thereby facilitating decision making for referral to a clinical geneticist.
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Affiliation(s)
- Ryan J Billar
- Erasmus University Medical Center - Sophia Children's Hospital, department of Paediatric Surgery Rotterdam, Netherlands
| | - Wiem Manoubi
- Erasmus University Medical Centre, department of Neuroscience, Rotterdam, Netherlands
| | - Sarina G Kant
- Erasmus University Medical Centre, department of Clinical Genetics, Rotterdam, Netherlands
| | - René M H Wijnen
- Erasmus University Medical Center - Sophia Children's Hospital, department of Paediatric Surgery Rotterdam, Netherlands
| | - Serwet Demirdas
- Erasmus University Medical Centre, department of Clinical Genetics, Rotterdam, Netherlands
| | - Johannes M Schnater
- Erasmus University Medical Center - Sophia Children's Hospital, department of Paediatric Surgery Rotterdam, Netherlands.
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20
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Ison HE, Griffin EL, Parrott A, Shikany AR, Meyers L, Thomas MJ, Syverson E, Demo EM, Fitzgerald KK, Fitzgerald-Butt S, Ziegler KL, Schartman AF, Stone KM, Helm BM. Genetic counseling for congenital heart disease - Practice resource of the national society of genetic counselors. J Genet Couns 2021; 31:9-33. [PMID: 34510635 DOI: 10.1002/jgc4.1498] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 12/11/2022]
Abstract
Congenital heart disease (CHD) is an indication which spans multiple specialties across various genetic counseling practices. This practice resource aims to provide guidance on key considerations when approaching counseling for this particular indication while recognizing the rapidly changing landscape of knowledge within this domain. This resource was developed with consensus from a diverse group of certified genetic counselors utilizing literature relevant for CHD genetic counseling practice and is aimed at supporting genetic counselors who encounter this indication in their practice both pre- and postnatally.
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Affiliation(s)
- Hannah E Ison
- Stanford Center for Inherited Cardiovascular Disease, Stanford Health Care, Stanford, California, USA
| | - Emily L Griffin
- Department of Pediatrics, Columbia University Medical Center, New York, New York, USA
| | | | - Amy R Shikany
- Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, Ohio, USA
| | | | - Matthew J Thomas
- Department of Pediatrics, Division of Genetics, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Erin Syverson
- Department of Pediatrics, Division of Genetics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Erin M Demo
- Sibley Heart Center Cardiology at Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kristi K Fitzgerald
- Nemours Cardiac Center, Alfred I. DuPont Hospital for Children, Wilmington, Delaware, USA
| | - Sara Fitzgerald-Butt
- Department of Medical & Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Allison F Schartman
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, Indiana University Health, Indianapolis, Indiana, USA
| | - Kristyne M Stone
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, Indiana University Health, Indianapolis, Indiana, USA
| | - Benjamin M Helm
- Department of Medical & Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Epidemiology, Indiana University Fairbanks School of Public Health, Indianapolis, Indiana, USA
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21
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Atypical late diagnosis of Noonan syndrome revealed by bleedings due to platelet dysfunction. J Thromb Thrombolysis 2021; 53:557-560. [PMID: 34368936 DOI: 10.1007/s11239-021-02547-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2021] [Indexed: 10/20/2022]
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22
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Liver Transplantation From a Donor With Noonan Syndrome: Caveat Emptor. Transplantation 2021; 105:e50-e51. [PMID: 33760797 DOI: 10.1097/tp.0000000000003626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Bell JM, Considine EM, McCallen LM, Chatfield KC. The Prevalence of Noonan Spectrum Disorders in Pediatric Patients with Pulmonary Valve Stenosis. J Pediatr 2021; 234:134-141.e5. [PMID: 33794220 DOI: 10.1016/j.jpeds.2021.03.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/23/2021] [Accepted: 03/25/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To investigate the prevalence of Noonan spectrum disorders in a pediatric population with pulmonary valve stenosis (PVS) and explore other characteristics of Noonan spectrum disorders associated with PVS. STUDY DESIGN A retrospective medical record review was completed for patients with a diagnosis of PVS seen at the Children's Hospital Colorado Cardiology clinic between 2009 and 2019. Syndromic diagnoses, genotypes, cardiac characteristics, and extracardiac characteristics associated with Noonan spectrum disorders were recorded; statistical analysis was conducted using R. RESULTS Syndromic diagnoses were made in 16% of 686 pediatric patients with PVS, with Noonan spectrum disorders accounting for 9% of the total diagnoses. Individuals with Noonan spectrum disorders were significantly more likely to have an atrial septal defect and/or hypertrophic cardiomyopathy than the non-Noonan spectrum disorder individuals. Supravalvar pulmonary stenosis was also correlated significantly with Noonan spectrum disorders. Extracardiac clinical features presenting with PVS that were significantly associated with Noonan spectrum disorders included feeding issues, failure to thrive, developmental delay, short stature, and ocular findings. The strongest predictors of a Noonan spectrum disorder diagnosis were cryptorchidism (70%), pectus abnormalities (66%), and ocular findings (48%). The presence of a second characteristic further increased this likelihood, with the highest probability occurring with cryptorchidism combined with ocular findings (92%). CONCLUSIONS The 9% prevalence of Noonan spectrum disorder in patients with PVS should alert clinicians to consider Noonan spectrum disorders when encountering a pediatric patient with PVS. The presence of PVS with 1 or more Noonan spectrum disorder-related features should prompt a genetic evaluation and genetic testing for RAS pathway defects. Noonan spectrum disorders should also be included in the differential when a patient presents with supravalvar pulmonary stenosis.
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Affiliation(s)
- Janet M Bell
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Ellen M Considine
- Department of Applied Mathematics, University of Colorado College of Engineering & Applied Science, Laboratory for Interdisciplinary Statistical Analysis (LISA), Boulder, CO
| | - Leslie M McCallen
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Kathryn C Chatfield
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO.
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Aynalem M, Shiferaw E, Gelaw Y, Enawgaw B. Coagulopathy and its associated factors among patients with a bleeding diathesis at the University of Gondar Specialized Referral Hospital, Northwest Ethiopia. Thromb J 2021; 19:36. [PMID: 34074308 PMCID: PMC8170961 DOI: 10.1186/s12959-021-00287-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 05/14/2021] [Indexed: 12/03/2022] Open
Abstract
Background Coagulopathy is the major cause of mortality and morbidity throughout the world. Globally, about 26–45% of healthy people have a history of bleeding symptoms, which may be a result of thrombocytopenia, factor deficiency, or pathological inhibitory. Objective To assess coagulopathy and its associated factors among patients with bleeding diathesis at the University of Gondar Specialized Referral Hospital from January to May 2020. Method A cross-sectional study was conducted on 384 study participants with bleeding diathesis recruited by using a convenient sampling technique. Socio-demographic and clinical characteristics were collected by using questioners. Then 6 ml venous blood was collected with a needle and syringe method. About 3 ml blood was transferred to EDTA test tube for platelet count and 2.7 ml blood was transferred to a test tube containing 0.3 ml of 3.2% sodium citrated anticoagulant for coagulation test. For those study participants with prolonged coagulation tests, a mixing test was done. Blood film and stool examination were also done for malaria and intestinal parasite identification, respectively. The data were entered into EPI-Info version 3.5.3 and then transferred to SPSS version-20 for analysis. Descriptive statistics were summarized as percentages, means, and standard deviations. Bivariate and multivariate logistic regression was used to identify the associated factors, and a P-value less than 0.05 was considered statistically significant. Results In this study, the prevalence of coagulopathy was 253/384 (65.9%; 95% CI: 61.16, 70.64). From them, 21.3% (54/253), 51.4% (130/253), and 27.3% (69/253) had only thrombocytopenia, only prolonged coagulation test, and mixed abnormality, respectively. Among participants with prolonged coagulation time, the prevalence of factor deficiency was 21.1% (42/199). Cardiac disease (AOR = 4.80; 95% CI: 2.65, 23.1), and other chronic diseases (AOR = 8.1; 95% CI: 1.84, 35.58) were significantly associated with coagulopathy. Conclusion In this study, coagulopathy due to inhibitory was a public health problem. The participants with cardiac and other chronic diseases were at high risk for coagulopathy. Therefore, mixing tests could be done for all prolonged coagulation tests and it could be considered as a routine laboratory test.
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Affiliation(s)
- Melak Aynalem
- Department of Hematology and Immunohematology, School of Medical Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, P.O. Box 196, Gondar, Ethiopia.
| | - Elias Shiferaw
- Department of Hematology and Immunohematology, School of Medical Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, P.O. Box 196, Gondar, Ethiopia
| | - Yemataw Gelaw
- Department of Hematology and Immunohematology, School of Medical Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, P.O. Box 196, Gondar, Ethiopia
| | - Bamlaku Enawgaw
- Department of Hematology and Immunohematology, School of Medical Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, P.O. Box 196, Gondar, Ethiopia
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25
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Kharel Z, Katel A, Neupane A, Panday P, Aryal M. Factor XIII Deficiency Associated With Noonan Syndrome. Cureus 2021; 13:e14150. [PMID: 33927952 PMCID: PMC8076579 DOI: 10.7759/cureus.14150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Noonan syndrome (NS) is an autosomal dominant disorder with multisystem involvement. NS can be associated with bleeding disorders due to defects in platelet function or coagulation factors and diagnosis can be challenging. Factor XIII (FXIII) deficiency is uncommon in patients with NS. We present a case of NS who presented with bleeding in both thighs and was diagnosed to have deficiency in FXIII.
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Affiliation(s)
- Zeni Kharel
- Internal Medicine, Rochester General Hospital, Rochester, USA
| | - Anjan Katel
- Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, NPL
| | - Arun Neupane
- Nursing and Critical Care, Alta Bates Summit Medical Center, California, USA
| | - Pradumna Panday
- Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, NPL
| | - Madan Aryal
- Medicine, Enloe Medical Center, Enloe Regional Cancer Center, California, USA
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26
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Mutation and Phenotypic Spectrum of Patients With RASopathies. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2092-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
PURPOSE OF REVIEW This article reviews the current understanding and limitations in knowledge of the effect genetics and genetic diagnoses have on perioperative and postoperative surgical outcomes in patients with congenital heart disease (CHD). RECENT FINDINGS Presence of a known genetic diagnosis seems to effect multiple significant outcome metrics in CHD surgery including length of stay, need for extracorporeal membrane oxygenation, mortality, bleeding, and heart failure. Data regarding the effects of genetics in CHD is complicated by lack of standard genetic assessment resulting in inaccurate risk stratification of patients when analyzing data. Only 30% of variation in CHD surgical outcomes are explained by currently measured variables, with 2.5% being attributed to diagnosed genetic disorders, it is thought a significant amount of the remaining outcome variation is because of unmeasured genetic factors. SUMMARY Genetic diagnoses clearly have a significant effect on surgical outcomes in patients with CHD. Our current understanding is limited by lack of consistent genetic evaluation and assessment as well as evolving knowledge and discovery regarding the genetics of CHD. Standardizing genetic assessment of patients with CHD will allow for the best risk stratification and ultimate understanding of these effects.
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Bertola DR, Castro MAA, Yamamoto GL, Honjo RS, Ceroni JR, Buscarilli MM, Freitas AB, Malaquias AC, Pereira AC, Jorge AAL, Passos‐Bueno MR, Kim CA. Phenotype–genotype analysis of 242 individuals with
RASopathies
: 18‐year experience of a tertiary center in Brazil. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2020; 184:896-911. [DOI: 10.1002/ajmg.c.31851] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/15/2020] [Accepted: 10/20/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Débora R. Bertola
- Unidade de Genética Instituto da Criança do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
- Instituto de Biociências Universidade de São Paulo São Paulo Brazil
| | - Matheus A. A. Castro
- Unidade de Genética Instituto da Criança do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
| | - Guilherme L. Yamamoto
- Unidade de Genética Instituto da Criança do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
| | - Rachel S. Honjo
- Unidade de Genética Instituto da Criança do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
| | - José Ricardo Ceroni
- Unidade de Genética Instituto da Criança do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
| | - Michele M. Buscarilli
- Unidade de Genética Instituto da Criança do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
| | - Amanda B. Freitas
- Unidade de Genética Instituto da Criança do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
| | - Alexsandra C. Malaquias
- Unidade de Endocrinologia‐Genetica LIM 25, Disciplina de Endocrinologia da Faculdade de Medicina da Universidade de Sao Paulo São Paulo Brazil
| | - Alexandre C. Pereira
- Laboratório de Genética e Cardiologia Molecular Instituto do Coração, do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
| | - Alexander A. L. Jorge
- Unidade de Endocrinologia‐Genetica LIM 25, Disciplina de Endocrinologia da Faculdade de Medicina da Universidade de Sao Paulo São Paulo Brazil
| | | | - Chong A. Kim
- Unidade de Genética Instituto da Criança do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
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Siegrist KK, Deegan RJ, Dumas SD, Eagle SS. Severe Cardiopulmonary Disease in a Parturient With Noonan Syndrome. Semin Cardiothorac Vasc Anesth 2020; 24:364-368. [PMID: 32746732 DOI: 10.1177/1089253220945918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Noonan syndrome is a relatively common genetic disorder and the second most common cause of congenital heart disease after trisomy 21. The spectrum of cardiac anomalies in Noonan syndrome typically involves pulmonary valve stenosis occasionally in conjunction with hypertrophic cardiomyopathy. Mitral valve involvement is a rare finding in Noonan syndrome and is most commonly associated with either mitral valve prolapse or abnormal valvular insertion causing left ventricular outflow tract obstruction. Patients with Noonan syndrome typically have preserved fertility and, given the success of cardiac surgery and medical management of heart failure in this population, are beginning to present more commonly as parturients in adulthood. Maternal physiologic changes during pregnancy introduce an added complexity to hemodynamic management and anesthetic considerations during labor and delivery. In this article, we present a case of a patient with Noonan syndrome with severe mitral stenosis, pulmonary valve insufficiency, and severe restrictive and obstructive pulmonary disease who presented preterm for delivery due to increased dyspnea at rest. Here we review the pathophysiology behind Noonan syndrome and peripartum management strategies in a patient with severe combined cardiac and pulmonary disease.
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Affiliation(s)
| | | | - Susan D Dumas
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan S Eagle
- Vanderbilt University Medical Center, Nashville, TN, USA
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Sewduth R, Pandolfi S, Steklov M, Sheryazdanova A, Zhao P, Criem N, Baietti M, Lechat B, Quarck R, Impens F, Sablina A. The Noonan Syndrome Gene Lztr1 Controls Cardiovascular Function by Regulating Vesicular Trafficking. Circ Res 2020; 126:1379-1393. [PMID: 32175818 PMCID: PMC8575076 DOI: 10.1161/circresaha.119.315730] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
RATIONALE Noonan syndrome (NS) is one of the most frequent genetic disorders. Bleeding problems are among the most common, yet poorly defined complications associated with NS. A lack of consensus on the management of bleeding complications in patients with NS indicates an urgent need for new therapeutic approaches. OBJECTIVE Bleeding disorders have recently been described in patients with NS harboring mutations of LZTR1 (leucine zipper-like transcription regulator 1), an adaptor for CUL3 (CULLIN3) ubiquitin ligase complex. Here, we assessed the pathobiology of LZTR1-mediated bleeding disorders. METHODS AND RESULTS Whole-body and vascular specific knockout of Lztr1 results in perinatal lethality due to cardiovascular dysfunction. Lztr1 deletion in blood vessels of adult mice leads to abnormal vascular leakage. We found that defective adherent and tight junctions in Lztr1-depleted endothelial cells are caused by dysregulation of vesicular trafficking. LZTR1 affects the dynamics of fusion and fission of recycling endosomes by controlling ubiquitination of the ESCRT-III (endosomal sorting complex required for transport III) component CHMP1B (charged multivesicular protein 1B), whereas NS-associated LZTR1 mutations diminish CHMP1B ubiquitination. LZTR1-mediated dysregulation of CHMP1B ubiquitination triggers endosomal accumulation and subsequent activation of VEGFR2 (vascular endothelial growth factor receptor 2) and decreases blood levels of soluble VEGFR2 in Lztr1 haploinsufficient mice. Inhibition of VEGFR2 activity by cediranib rescues vascular abnormalities observed in Lztr1 knockout mice Conclusions: Lztr1 deletion phenotypically overlaps with bleeding diathesis observed in patients with NS. ELISA screening of soluble VEGFR2 in the blood of LZTR1-mutated patients with NS may predict both the severity of NS phenotypes and potential responders to anti-VEGF therapy. VEGFR inhibitors could be beneficial for the treatment of bleeding disorders in patients with NS.
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Affiliation(s)
- R. Sewduth
- VIB-KU Leuven Center for Cancer Biology, VIB, Herestraat 49, 3000 Leuven, Belgium
- Department of Oncology, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - S. Pandolfi
- VIB-KU Leuven Center for Cancer Biology, VIB, Herestraat 49, 3000 Leuven, Belgium
- Department of Oncology, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - M. Steklov
- VIB-KU Leuven Center for Cancer Biology, VIB, Herestraat 49, 3000 Leuven, Belgium
- Department of Oncology, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - A. Sheryazdanova
- VIB-KU Leuven Center for Cancer Biology, VIB, Herestraat 49, 3000 Leuven, Belgium
- Department of Oncology, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - P. Zhao
- VIB-KU Leuven Center for Cancer Biology, VIB, Herestraat 49, 3000 Leuven, Belgium
- Department of Oncology, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - N. Criem
- VIB-KU Leuven Center for Cancer Biology, VIB, Herestraat 49, 3000 Leuven, Belgium
- Department of Oncology, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - M.F. Baietti
- VIB-KU Leuven Center for Cancer Biology, VIB, Herestraat 49, 3000 Leuven, Belgium
- Department of Oncology, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - B. Lechat
- VIB-KU Leuven Center for Cancer Biology, VIB, Herestraat 49, 3000 Leuven, Belgium
- Department of Oncology, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - R. Quarck
- University Hospitals and Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - F. Impens
- Department of Biomolecular Medicine, Ghent University, B-9000 Ghent, Belgium
- VIB Center for Medical Biotechnology, B-9000 Ghent, Belgium
- VIB Proteomics Core, Albert Baertsoenkaai 3, 9000 Ghent, Belgium
| | - A.A. Sablina
- VIB-KU Leuven Center for Cancer Biology, VIB, Herestraat 49, 3000 Leuven, Belgium
- Department of Oncology, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
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Briggs B, Savla D, Ramchandar N, Dimmock D, Le D, Thornburg CD. The Evaluation of Hematologic Screening and Perioperative Management in Patients with Noonan Syndrome: A Retrospective Chart Review. J Pediatr 2020; 220:154-158.e6. [PMID: 32111381 DOI: 10.1016/j.jpeds.2020.01.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/02/2020] [Accepted: 01/21/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To assess the potential impact of using screening recommendations for bleeding disorders in patients with Noonan syndrome on perioperative bleeding complications. STUDY DESIGN We performed a retrospective, single-site cohort study; patients were identified by query of the electronic medical record. All patients with a clinical diagnosis of Noonan syndrome over a 10-year period were included. Data on surgeries, hematologic evaluation, bleeding symptoms, and bleeding complications were extracted. Surgeries were graded as major or minor. RESULTS We identified 101 patients with Noonan syndrome, 70 of whom required surgery for a total of 164 procedures. Nine patients (9/70; 12.8%) had bleeding complications, occurring in those without comprehensive testing or perioperative intervention and undergoing major or dental surgery. Based on these findings, the risk of a bleeding complication for patients with Noonan syndrome who did not have comprehensive testing or perioperative intervention was 6.2% (95% CI 2.3%-10.1%), indicating the number needed to treat or screen would be 16 to prevent 1 bleeding complication (95% CI 9.9-43.9). The majority of patients had either no or incomplete evaluation (59 of 101; 58.4%). CONCLUSIONS With proper evaluation and management, the bleeding risk in patients with Noonan syndrome can be minimized. Efforts are needed to address the knowledge and implementation gap in this evaluation.
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Affiliation(s)
- Benjamin Briggs
- Department of Pediatrics, University of California San Diego, La Jolla, CA; Division of Hematology and Oncology, University of California San Diego, La Jolla, CA; Rady Children's Institute of Genomic Medicine, San Diego, CA.
| | - Dipal Savla
- Department of Pediatrics, University of California San Diego, La Jolla, CA
| | - Nanda Ramchandar
- Department of Pediatrics, University of California San Diego, La Jolla, CA; Rady Children's Institute of Genomic Medicine, San Diego, CA; Division of Infectious Disease, University of California San Diego, La Jolla, CA
| | - David Dimmock
- Rady Children's Institute of Genomic Medicine, San Diego, CA
| | - Dzung Le
- Department of Pathology, University of California San Diego, La Jolla, CA
| | - Courtney D Thornburg
- Department of Pediatrics, University of California San Diego, La Jolla, CA; Division of Hematology and Oncology, University of California San Diego, La Jolla, CA; Hemophilia and Thrombosis Treatment Center, Rady Children's Hospital San Diego, San Diego, CA
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Catalytic dysregulation of SHP2 leading to Noonan syndromes affects platelet signaling and functions. Blood 2020; 134:2304-2317. [PMID: 31562133 DOI: 10.1182/blood.2019001543] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 09/16/2019] [Indexed: 12/20/2022] Open
Abstract
Src homology 2 domain-containing phosphatase 2 (SHP2), encoded by the PTPN11 gene, is a ubiquitous protein tyrosine phosphatase that is a critical regulator of signal transduction. Germ line mutations in the PTPN11 gene responsible for catalytic gain or loss of function of SHP2 cause 2 disorders with multiple organ defects: Noonan syndrome (NS) and NS with multiple lentigines (NSML), respectively. Bleeding anomalies have been frequently reported in NS, but causes remain unclear. This study investigates platelet activation in patients with NS and NSML and in 2 mouse models carrying PTPN11 mutations responsible for these 2 syndromes. Platelets from NS mice and patients displayed a significant reduction in aggregation induced by low concentrations of GPVI and CLEC-2 agonists and a decrease in thrombus growth on a collagen surface under arterial shear stress. This was associated with deficiencies in GPVI and αIIbβ3 integrin signaling, platelet secretion, and thromboxane A2 generation. Similarly, arterial thrombus formation was significantly reduced in response to a local carotid injury in NS mice, associated with a significant increase in tail bleeding time. In contrast, NSML mouse platelets exhibited increased platelet activation after GPVI and CLEC-2 stimulation and enhanced platelet thrombotic phenotype on collagen matrix under shear stress. Blood samples from NSML patients also showed a shear stress-dependent elevation of platelet responses on collagen matrix. This study brings new insights into the understanding of SHP2 function in platelets, points to new thrombopathies linked to platelet signaling defects, and provides important information for the medical care of patients with NS in situations involving risk of bleeding.
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