MPS VII - Extending the classical phenotype

Mucopolysaccharidosis VII (or Sly syndrome) is an autosomal recessive disorder characterised by a deficiency in the enzyme Beta-glucuronidase (GUSB). Partial degradation of glycosaminoglycans (GAGs); chondroitin sulfate (CS), dermatan sulfate (DS) and heparan sulfate (HS) results in the accumulation of these fragments in the lysosomes of many tissues, eventually leading to multisystem damage. In some cases, early diagnosis on clinical grounds alone can be difficult due to the extreme variability of the clinical presentation and disease progression. We present a case report of a 31-year-old male patient diagnosed with MPS VII at the age of 28, who multiple specialists saw without suspecting the diagnosis due to the unusual presentation. The patient presented with a history of developmental delay, scoliosis, kyphosis, corneal clouding, abnormal gait, short stature, hearing impairment, slightly coarse facial features and progressive deterioration of fine motor skills since childhood. The patient had inguinal hernia repair at around 12 months, bilateral hearing impairment with a left bone-anchored hearing aid, and spinal surgery. During spinal surveillance MPS VII was suspected by a spinal surgeon with interest in MPS, and the diagnosis confirmed with a deficiency in beta-glucuronidase in leucocytes and marginally elevated urinary GAGs. Next-generation sequencing identified two mutations in the GUSB gene (OMIM 611499), c.526C > T p.(Leu176Phe) and c.1820G > C p.(Gly607Ala). Although the patient exhibited features of the severe form of non-classical manifestations, his metabolic condition has remained reasonably stable, surviving into adulthood with only symptomatic treatment. We present the ever-expanding phenotypic spectrum of this ultra-rare disease.

Successful treatment of sinusitis caused by Cunninghamella bertholletiae

Seventeen cases of infections due to Cunninghamella species have been reported worldwide in humans, and there have been only three survivors. We report a case of paranasal sinusitis due to Cunninghamella bertholletiae in an elderly patient who had diabetes mellitus and myelodysplasia. After receiving 7 weeks of therapy with deoxycholate amphotericin B (44 mg/kg or a total of 3 g) and rifampin, the patient was cured and did not have to undergo radical surgery.

Airway compression by vascular anomalies in infants and neonates

Despite the tremendous health-care advances in recent years, external compression of the tracheobronchial tree by cardiovascular anomalies still remains a significant cause of morbidity and potential mortality in neonates and infants. As the initial presenting symptoms can be deceivingly mild, the diagnosis is easily missed without a high index of suspicion by the investigating clinician utilising the appropriate investigations. Four case studies are presented, (i) illustrating the importance of tracheobronchoscopy in assessing any neonate or infant with suspected airway obstruction; (ii) reviewing the current literature, and (iii) suggesting a comprehensive diagnostic approach by way of relevant investigations.

Cardiopulmonary bypass for resection of low tracheal haemangioma

A 3 month old girl, weighing 4000 g, presented with a capillary haemangioma obstructing the lower trachea and left main bronchus; it was not responsive to steroids. Using cardiopulmonary bypass to maintain oxygenation the tumour was excised. We are not aware that this technique has been used before for the resection of such an obstructive haemangioma.

Evaluation of patients for cochlear implant by promontory stimulation. Psychophysical responses and electrically evoked brainstem potentials

The protocol for assessing patients for cochlear implantation at University College Hospital and the Royal National Institute for the Deaf, London, includes a session of electrophysiological tests and electrical stimulation of the cochlea. Electrocochleography is performed with the object of excluding non-organic hearing loss and of clarifying the site of deafness. Using the same transtympanic needle, AC and DC electrical stimulation is performed to establish whether patients perceive a sensation of sound, dynamic range and ability to detect frequency shifts. Tinnitus suppression was produced by AC and DC stimulation. It is likely that AC suppression of tinnitus occurs by a masking effect. Electrically evoked auditory brainstem potentials were recorded in one patient.