The first presentation of a case of nail-patella syndrome newly diagnosed at the onset of rheumatoid arthritis: a case report

BACKGROUND

Nail-patella syndrome (NPS) is a rare autosomal dominant disorder that is characterized by dysplasia of the nails, hypoplasia and/or dislocation of the patella and the presence of iliac horns. Using the CARE guidelines, we present the first reported case of NPS that was newly diagnosed at the onset of rheumatoid arthritis (RA).

CASE PRESENTATION

A 74-year-old man was admitted to our hospital due to an 8-month history of arthralgia in bilateral wrists, elbows and fingers. He had a past history of glaucoma and left patella dislocation that had been operatively recentered at the age of 15 years. Laboratory data showed elevated levels of serum C-reactive protein and rheumatoid factor and an elevated titer of anti-SS-A antibodies, while estimated glomerular filtration rate (eGFR), titers of other antibodies and the results of a urinary test were normal. An X-ray showed deformity of bilateral radial heads and the right elbow, and magnetic resonance imaging (MRI) of his hands showed synovitis and erosion in the multiple swollen joints of the wrists and fingers. In addition to these typical features of RA, he had bilateral thumb nail dysplasia with mild hypoplasia of bilateral patellae and iliac horns as shown by the X-ray. He was diagnosed as having autosomal dominant disorder NPS co-existing with RA and he was treated with methotrexate in combination with an oral Janus kinase (JAK) inhibitor, leading to induction of remission.

CONCLUSIONS

We have presented a rare case of NPS that was newly diagnosed at the onset of RA. Clinical and radiographic findings of NPS are highlighted in this case report for diagnosing NPS on the basis of typical manifestations.

Diagnosing nail-patella syndrome: can it be so simple?

We describe here an interesting case of a 7-day-old male infant brought with parental concerns of inability to extend both knees. Clinical evaluation revealed dysplastic fingernails, bilateral abnormal patellae, triangular lunules in conjunction with pathognomic iliac horns on pelvic radiographs suggesting the possibility of nail-patella syndrome (NPS). Other competing diagnoses with similar phenotypic features were considered and sequentially excluded. A definitive diagnosis was established by the identification of the principal mutation at the LMX1B gene locus of chromosome 9. NPS is seldom diagnosed in neonates due to the heterogeneity of clinical presentations as well as the subtlety of clinical clues in this population. NPS is a dominantly inherited disorder that is predominantly familial in origin and thus carries important implications for the prenatal diagnosis of future pregnancies as well as pre-emptive surveillance of nephropathy in the index child.

Unicompartmental Knee Arthroplasty in a Patient with Nail-Patella Syndrome: A Case Report

CASE

A 46-year-old woman with a medical history of nail-patella syndrome (NPS) presented with chronic right knee pain. Radiographic and physical examination revealed isolated medial tibiofemoral osteoarthritis and a hypoplastic laterally subluxed patella. The patient was successfully treated with a medial unicompartmental knee arthroplasty (UKA).

CONCLUSION

In patients with NPS and osteoarthritis limited to one tibiofemoral compartment, a UKA may be successfully performed.

A microdeletion of chromosome 9q33.3 encompasses the entire LMX1B gene in a Chinese family with nail patella syndrome

Nail patella syndrome (NPS) is an autosomal dominant disorder characterized by nail malformations, patellar apoplasia, or patellar hypoplasia. Mutations within the LMX1B gene are found in 85% of families with NPS; thus, this gene has been characterized as the causative gene of NPS. In this study, we identified a heterozygous microdeletion of the entire LMX1B gene using multiplex ligation-dependent probe amplification (MLPA) in a Chinese family with NPS. The determination of the deletion breakpoints by Illumina genome-wide DNA analysis beadchip showed that the deletion was located in chromosome 9q33.3 and spanned about 0.66 Mb in size. This heterozygous deletion provides strong evidence for haploinsufficiency as the pathogenic mechanism of NPS.

Novel LMX1B mutation in familial nail-patella syndrome with variable expression of open angle glaucoma

PURPOSE

To describe the genetic and clinical findings in a large Spanish pedigree with nail-patella syndrome (NPS) and to investigate the expressivity of open angle glaucoma (OAG) in the family members.

METHODS

All individuals underwent a complete ophthalmologic examination, including optical coherence tomography (OCT) of the optic disc and peripapillary region and ultrasound pachymetry. Screening for mutations in the LMX1B gene was performed by denaturing gradient gel electrophoresis and direct genomic sequencing analysis.

RESULTS

Ten family members had NPS, seven with varying degrees of ocular hypertension (OHT). Only one of these had advanced OAG. The others showed high pachymetry values and OCT retinal nerve fiber layer (RNFL) thickness above the normal values. Screening for mutations in the exonic and flanking sequences of the LMX1B gene showed a deletion of one G (289delG) within the coding sequence of exon 3 at codon 97, resulting in a frame shift that creates a premature stop at codon 105 (E97fsX105), predicting a truncated protein. This mutation was present in all NPS patients and absent in the unaffected family members.

CONCLUSIONS

A novel mutation in the homeobox transcription factor LMX1B causes NPS in a family with variable expressivity of the syndrome, including OAG. The pathogenic mechanism resulting from the mutation is presumably haploinsufficiency rather than a dominant negative effect, which would explain the clinical variability in this family. All NPS OHT patients had considerably thick corneas and RNFL.

[The nail-patella syndrome: rare genetically determined cause of proteinuria]

Nail-patella syndrome (NPS) is rare genetic disorder with autosomal mode of inheritance resulting from mutations in the LMX1B gene mapped on the long arm of chromosome 9 (9q34), encoding transcription factor, also named LMX1B. This syndrome is characterized by a skeletal malformations, such as dysplasia of the knees (with typical patellar hypoplasia or aplasia), elbows and nails as well as characteristic protuberaces of ilium named ,,iliac homes". Chronic nephropathy and nails dysplasia are most common extraosseal signs of NPS. Familial, genetic proved (missense mutation -G599A (R200Q) case of NPS in the mother and her son was presented. Clinical features characteristic for this syndrome and observed in both our patients were compared to the data published previously.

[Clinical picture and molecular analysis in a familial case of Nail-Patella Syndrome--identification of a new mutation in LMX1B gene]

The Nail-Patella Syndrome (NPS) (OMIM: 161200) is an autosomal dominant disorder characterized by skeletal malformations, such as: patellar aplasia/ hypoplasia, iliac horns on X-ray as well as nail dysplasia, renal and ocular abnormalities. Mutations in the gene encoding transcription factor LMX1B, mapped on the long arm of chromosome 9 (9q34), are responsible for the clinical phenotype of NPS. A familial case (in the mother and her son) of Nail-Patella Syndrome is presented here. DNA analysis has shown a new missense mutation in exon 5 of LMX1B gene (745C-G) leading to a change of glutamine into glutamic acid (Q245E) in the coded protein. Characteristic clinical features, seen in both patients, are discussed within the context of molecular analysis results.

[Familial nail patella-syndrome]

Nail patella-syndrome is a rare hereditary (autosomal dominant) disorder resulting from a heterogenous loss of function in the LMXB1 gene on chromosome 9q34. It is associated with multiple deformities. Patients have a characteristic tetrad of pathologic symptoms including fingernail dysplasia, hypoplastic or absence patella, radial head dislocation, iliac horns and in some cases nephropathy and ophtalmo-logical findings (glaucoma). In this study four affected members in one family are presented. All of the familly members presented absence or hypoplastic patella and fingernails dysplasia. There were not indications for surgical treatment dislocated radial heads or subluxated dysplastic patella. Genetic counseling is recomended because nail patella syndrome is an autosomal dominant disease.

Nail-patella syndrome: long term evolution

Nail-patella syndrome is a rare dysplasia characterized by a typical tetrad: hypoplasic nails, hypoplasic or absent patella, radial head dislocation and iliac horns. We review eight patients, four men and four women, aged from 20 to 70 years. The main complaint at consultation was with their knees due to patellar instability and pain. Five of them required surgical treatment due to patellar dislocation and three patients were not treated. The Krogius-Lecène procedure was performed in four patients with a good result following the Insall classification of pain and instability and with an average follow-up of 24 years (range, 18-28 years). Patellectomy was performed in the eldest patient due to femoropatellar arthritis present at first consultation. No patients presented with elbow or nail disorders or with iliac horns.

Nail patella syndrome. A 55-year follow-up of the original description

The long-term skeletal changes and the lack of significant clinical complaints in a 77-year-old woman with nail patella syndrome are described. Fifty-five years previously she was one of the first reported patients. These early patients came from two families with involvement of multiple individuals with the variable constellation of deformities. We reviewed her skeletal natural history and her family history as it related to nail patella syndrome involvement and treatment, and correlated the original premolecular biology description and subsequent long-term follow-up with the current molecular and genetic concepts of the cause of the variable expression of nail patella syndrome.

Bilateral accessory iliac horns: pathognomonic findings in Nail-patella syndrome. Scintigraphic evidence on bone scan

Nail-patella syndrome is a rare hereditary (autosomal dominant) disorder, also called hereditary osteo-onychodysplasia and Fong's syndrome. Its incidence is 4.5 per million population in the United States. Patients have a characteristic tetrad of pathologic symptoms including fingernail dysplasia, hypoplastic or absent patellas, radial head dislocation, and iliac horns. Soft-tissue changes and renal dysplasia have also been associated with the syndrome. Iliac horns are bilateral accessory outgrowths consisting of cortex and medulla continuous with the iliac bone. They are located at the site of attachment of the gluteus medius muscles and project posterolaterally. These smooth bony outgrowths are asymptomatic, frequently palpable, and, because they have no effect on gait, they need not be treated. Iliac horns are the pathognomonic feature of Nail-patella syndrome; that is, they occur in approximately 80% of cases and are observed only in this condition. Four patients (two female, two male) with Nail-patella syndrome have been examined in the authors' department: three family members, including a 37-year-old woman, her 18-year-old son, and her 15-year-old daughter, and an unrelated 26-year-old man. All patients, regardless of age or sex, had similar pelvic findings on their bone scans. Although whole-body scans were obtained in all patients, significant scintigraphic findings were observed only in the pelvis in all the patients examined. This is most likely the result of the mild nature of the related deformities, which do not yield scintigraphically detectable osteoblastic changes. A representative image showing these independent ossification on a Tc-99m MDP bone scan is presented. A conventional pelvic radiographic image of the same patient's pelvis is presented for comparison.

Nail-patella syndrome: an incidental finding from abdominal discomfort

An otherwise healthy 18-year-old woman had abdominal discomfort. Physical examination and laboratory studies were unremarkable, with the exception of nail dystrophy of the ulnar digits. An abdominal plain film revealed bilateral posterior iliac horns, pathognomonic of nail-patella syndrome. Additional radiographs showed hypoplastic patellas bilaterally. While glomerulonephritis occurs in 30% of patients with nail-patella syndrome, there was no evidence of renal involvement.

Sonography of patellar abnormalities in children

OBJECTIVE

We describe our experience using sonography to evaluate the patella and patellofemoral joint in three children with congenital abnormalities of the extensor mechanism of the lower extremity.

CONCLUSION

Sonography can be used to evaluate the extensor mechanism and unossified patella in young children. Advantages of sonography over MR imaging are no need for sedation, speed of examination and ability to compare with the contralateral knee, low cost, and the sonographer's ability to dynamically evaluate the extensor mechanism.

Ultrasound prenatal diagnosis of the Nail-Patella syndrome

The Nail-Patella syndrome (NPS) is an autosomal dominant connective-tissue disorder characterized by the absence or hypoplasia of the nails and patella, posterior illiac horns, elbow deformities, congenital nephropathy cervical ribs and eye problems. The presence of the posterior iliac horns is pathognomonic and have been observed in more than 80 per cent of cases. In this report, we present the first case of prenatal diagnosis of NPS by ultrasound. The possible kidney involvement, combined with other, milder, complications make the prenatal diagnosis of this syndrome worthwhile.

Treatment of antecubital pterygium in the nail-patella syndrome

Antecubital pterygium is rare in the nail-patella syndrome but common in the multiple pterygium syndrome and aplasia of the trochlea. It is known that there is the rebound phenomenon after treatment of congenital joint contracture. We describe the poor functional results due to rapid recurrence of the flexion contracture treated with the Ilizarov method for an antecubital pterygium in the nail-patella syndrome.

[Skeletal anomalies in nail-patella syndrome. Case report and overview]

The nail-patella syndrome (NPS), also known as hereditary onychoosteodysplasia (HOOD), is a hereditary disorder with an autosomal dominant mode of inheritance involving nails, bones and other tissues. It is characterized by onchodysplasia of the finger nails (most prominent on the thumb and index finger) and V-shaped lunulae. Extraosseous manifestations include ocular (glaucoma, microcornea) and renal involvement (proteinuria, nephrotic syndrome). A variety of skeletal anomalies can be observed. We report a 59 year old male with NPS. In addition to dysplastic patellae and elbow joints and the pathognomonic posterior iliacal horns, he had involvement of humerus, radius, ulna. and finger bones, leading to early and painful degenerative changes. Furthermore, microproteinuria was noted. Early diagnosis of NPS is important to prevent early secondary arthrosis and severe renal damage.

[Nail-patella syndrome]

The nail-patella syndrome is an autosomal dominant trait characterized by abnormalities of the nails, patella and radial head, iliac crest and, in some cases, nephropathy. The genetic defect is localized on chromosome 9q34.1. The clinical features in affected individuals vary greatly. The nephropathy may progress to end-stage renal failure, leading to decreased life expectancy. We report a woman with bilateral hypoplastic thumbnails, who also had aplasia of both patellae and subluxation of the left elbow joint with hypoplasia of the radial head. The mother and the sister of the patient had similar changes and also suffered from nephropathy.

Renal failure with skeletal abnormalities

Images

Imaging of "iliac horns" in nail-patella syndrome

Hereditary osteo-onychodysplasia, also known as the nail-patella syndrome (NPS), consists of a clinical tetrad of nail dysplasia, hypoplastic or absent patella, radial head dislocation, and iliac horns. Bilateral posterior iliac horns are observed only in NPS and present in >80% of patients. We describe the appearance, location, and structure of iliac horns by CT, MRI, and 3-dimensional CT reconstruction.

Clavicular horn: another bony projection in nail-patella syndrome

Nail-patella syndrome is an uncommon inherited disorder characterized by nail dysplasia, iliac horns, and knee and elbow abnormalities. We report a patient with nail-patella syndrome in whom calvicular horn, shoulder girdle dysplasias, and pelvic abnormalities were demonstrated, along with the classical tetrad.

Hereditary osteo-onycho-renal dysplasia with excess urinary pyridinoline cross-links and abnormal kidney collagen cross-linking

HOOD syndrome is a rare genetic disorder also known as nail patella syndrome. Biochemical and molecular biological data are rare and not conclusive. Preliminary data suggest the involvement of collagen type IV. This would, however, not be enough to explain nail or bone involvement. As kidney pathology would be consistent with a cross-linking disorder, we tested collagen IV and kidney collagen cross-linking on SDS-PAGE. This method showed a remarkable reduction in high-molecular-weight collagen polymers. The patient's and his mother's urinary pyridinoline cross-link excretion was manifold increased. Disturbed cross-linking of connective tissue proteins would help to explain the multiorgan involvement.

[Nail-patella syndrome. A 4-generation family study]

Five cases of hereditary onycho-osteodysplasie are reported. All of the family members presented dysplastic nails. Hypoplastic patella, elbow dysplasia or iliac horns were shown in variable expression. We've seen no other anomalies especially nephropathy did not occur.

Nail patella syndrome: a review of 44 orthopaedic patients

Nail patella syndrome is a rare dysplasia with characteristic findings of finger nail abnormalities, hypoplastic patellas, radial head dislocations, and iliac horns. We reviewed the problems and treatment of 44 patients with this syndrome from 13 Shriners Hospital units. The inheritance pattern is autosomal dominant, with foot abnormalities as the chief presenting complaint. All patients were ambulatory. Twenty of the patients underwent knee operations, and 24 underwent operations to correct foot and ankle deformities. Knee extensor realignments and foot posteromedial releases had overall good results. Knee flexion contractures required full posterior capsular releases. Elbow reconstructive procedures were rarely indicated.

Nail-patella syndrome with some unusual features

Nail-patella syndrome is a rare hereditary disease. We report a patient who was the lone member affected in the family. The patient additionally had a bony defect of the skull which has not been reported so far in the literature.

[Nail-patella syndrome. A case report and review of the literature]

We report on the case of a 36 year-old woman with nail-patella syndrome that was detected following a plain roentgenogram of the abdomen showing iliac horns. The nail-patella syndrome (NPS) is a hereditary disorder of tissues of ectodermal and mesodermal origin transmitted as an autosomal-dominant trait. Complete NPS is characterised by a series of skeletal disorders and specific nephropathy; in the recent years some other diseases associated with NPS were described, whereas many patients exist with incomplete NPS.

[The patella-nail syndrome. Study of 2 families]

The radiological and clinical features of two families with a nail-patella syndrome are described. Our findings emphasize the varying expressivity of the syndrome, which has an autosomal dominant mode of inheritance and a penetrance of 100%. It is important for the radiologist to be aware of the syndrome's stigmata so that renal failure can be detected as early as possible after the diagnosis of skeletal dysplasia.

[Hereditary onycho-osteodysplasia (HOOD)]

Hereditary onycho-osteodysplasia (HOOD) is an autosomal dominant condition, characterized by dysplasia of the nails and joints and extra bone formation at the os ilium. Nephropathy occurs in some families with HOOD. We discuss a patient's history and the results of the study of her family. The incidence of all important features of this syndrome is given. Finally, some methods of treatment and genetic counseling are discussed.

The horn: a pathognomonic feature of paediatric bone dysplasias

In conclusion, this brief communication has summarized two fascinating systemic syndromes with the unusual common feature of a pathognomonic radiographic sign. In osteo-onychodysostosis, characteristic osseous horns arise from the posterior iliac wings, whereas in Type IX Ehlers-Danlos syndrome, similar protuberances extend inferiorly from the occiput. Although both conditions are uncommon, an awareness of these horns as specific earmarks of each is important, since early diagnosis may allow preventive intervention for their serious potential complications later in life.

Foot deformity in hereditary onycho-osteodysplasia

A 30-year-old woman with hereditary onycho-osteodysplasia was examined. In addition to the classic tetrad of fingernail and toenail dysplasia, patellar aplasia, iliac horns, and radial head hypoplasia and dislocation, she also had scoliosis, proteinuria, and distinctive bilateral foot anomalies. The foot deformity consisted of a ball-and-socket ankle joint, valgus ankle, forefoot supination, and lateral subluxation at the tarsal-metatarsal joints. The literature showed that the radiographic findings of foot deformity in this dysplasia have never been reported in detail before. Evidence suggests that this distinctive pattern of deformity may be more common than previously appreciated.