Somatic GPR101 Duplication Causing X-Linked Acrogigantism (XLAG)-Diagnosis and Management

CONTEXT

Recent reports have proposed that sporadic or familial germline Xq26.3 microduplications involving the GPR101 gene are associated with early-onset X-linked acrogigantism (XLAG) with a female preponderance.

CASE DESCRIPTION

A 4-year-old boy presented with rapid growth over the previous 2 years. He complained of sporadic headaches and had coarse facial features. His height Z-score was +4.89, and weight Z-score was +5.57. Laboratory testing revealed elevated serum prolactin (185 μg/L; normal, <18 μg/L), IGF-1 (745 μg/L; normal, 64-369 μg/L), and fasting GH > 35.0 μg/L. Magnetic resonance imaging demonstrated a homogenous bulky pituitary gland (18 × 15 × 13 mm) without obvious adenoma. A pituitary biopsy showed hyperplastic pituitary tissue with enlarged cords of GH and prolactin cells. Germline PRKAR1A, MEN1, AIP, DICER1, CDKN1B, and somatic GNAS mutations were negative. Medical management was challenging until institution of continuous sc infusion of short-acting octreotide combined with sc pegvisomant and oral cabergoline. The patient remains well controlled with minimal side effects 7 years after presentation. His phenotype suggested XLAG, but his peripheral leukocyte-, saliva-, and buccal cell-derived DNA tested negative for microduplication in Xq26.3 or GPR101. However, DNA isolated from the pituitary tissue and forearm skin showed duplicated dosage of GPR101, suggesting that he is mosaic for this genetic abnormality.

CONCLUSIONS

Our patient is the first to be described with somatic microduplication leading to typical XLAG phenotype. This patient demonstrates that a negative test for Xq26.3 microduplication or GPR101 duplication on peripheral blood DNA does not exclude the diagnosis of XLAG because it can result from a mosaic mutation affecting the pituitary.

Macrodystrophia lipomatosa of foot involving great toe

Macrodystrophia lipomatosa is a rare form of congenital disorder in which there is localized gigantism characterized by progressive overgrowth of all mesenchymal elements with a disproportionate increase in the fibroadipose tissues. The adipose tissue infiltration involves subcutaneous tissue, periosteum, nerves and bone marrow. Most of the cases reported have hand or foot involvement. Patient seeks medical help for improving cosmesis or to get the size of the involved part reduced in order to reduce mechanical problems. We report a case of macrodystrophia lipomatosa involving medial side of foot with significant enlargement of great toe causing concern for cosmesis and inconvenience due to mechanical problems. The X-rays showed increased soft tissue with more of adipose tissue and increased size of involved digits with widening of ends. Since the patient's mother did not want any surgical intervention he was educated about foot care and proper footwear design was suggested.

Gigantism of the lower limb in Klippel-Trenaunay syndrome: anatomy of the lateral marginal vein

The Klippel-Trenaunay syndrome is a combination of venous and capillary malformations associated with soft tissue and/or bony limb hypertrophy, with or without lymphatic malformations. Although persistent foetal veins are rare, the persistence of the lateral marginal vein is a common association in this syndrome. It results in venous hypertension, which gives rise to venous varicosities, which are commonly seen in this syndrome. This is a case report of a 28-year-old man with Klippel-Trenaunay syndrome, with persistence of the lateral marginal vein, affecting his right lower limb. He was treated with an above-knee amputation. The amputated limb was dissected to demonstrate the anatomy of the lateral marginal vein. To the best of the authors' knowledge, the gross anatomy of the lateral marginal vein has not been previously reported.

Case study of a 15-year-old boy with McCune-Albright syndrome combined with pituitary gigantism: effect of octreotide-long acting release (LAR) and cabergoline therapy

The use of octreotide-LAR and cabergoline therapy has shown great promise in adults with acromegaly; however, the experience in pediatric patients has rarely been reported. We described a clinical course of a 15-year-old boy of McCune-Albright syndrome (MAS) with pituitary gigantism. At the age of 8 years, a growth hormone (GH) and prolactin (PRL) producing pituitary adenoma was diagnosed at our hospital. He also had multiple fibrous dysplasia, so that he was diagnosed as having MAS. The tumor was partially resected, and GNAS1 gene mutation (R201C) was identified in affected tissues. We introduced octreotide to suppress GH secretion (100 mug 2/day s.c). During therapy with octreotide, IGF-1 and GH levels could not be suppressed and the patient frequently complained of nausea from octreotide treatment. Therefore, the therapy was changed to monthly injections of octreotide-LAR at the age of 12.3 years and was partially effective. However, as defect of left visual field worsened due to progressive left optic canal stenosis, he underwent second neurological decompression of the left optic nerve at 13.4 years of age. After surgery, in addition to octreotide-LAR, cabergoline (0.25 mg twice a month) was started. This regimen normalized serum levels of GH and IGF-1; however, he showed impaired glucose tolerance and gallstones at 15.7 years of age. Therefore, the dose of octreotide-LAR was reduced to 10 mg and the dose of cabergoline increased. This case demonstrated the difficulty of treating pituitary gigantism due to MAS. The use of octreotide-LAR and cabergoline should be considered even in pediatric patients; however, adverse events due to octreotide-LAR must be carefully examined.

Proteus syndrome: a rare cause of hemihypertrophy and macrodactyly on bone scanning

Proteus syndrome is a rare, sporadic genetic disorder characterized by overgrowth of multiple different tissues in a mosaic pattern. It is associated with connective tissue nevi, epidermal nevi, disproportionate overgrowth of multiple tissues, vascular malformations, characteristic tumors, and specific facial anomalies. Joseph Merrick, popularly known as the Elephant Man, is now believed to have suffered from Proteus syndrome. A case of Proteus syndrome and associated findings on bone scintigraphy are presented.

Congenital macrodactyly: a clinical study

Congenital macrodactyly is a rare congenital malformation characterised by progressive enlargement of all mesenchymal elements of a digit. The present study is an attempt to draw the attention towards the similarities and differences between macrodactyly of the hand and foot. Radiographical, operative findings and histopathological examination of five cases are included in the present study. Emphasis was given to know the possible basic lesion. Radiographic findings, which differentiate this entity from other forms of local gigantism, were also analysed. The most characteristic finding noted was excessive overgrowth of fibro-fatty tissue with unusually large fatty lobules, apparently fixed by a mesh of dense fibrous tissue. Hypertrophy and tortuosity of the digital nerve, a striking feature in macrodactyly of the hand, was notably absent in cases affecting the foot. None of the patients had any other associated congenital anomalies. Neither the patients nor any of their family members had any stigmata of neurofibromatosis. Chromosomal study was normal in all of them. We conclude that in macrodactyly of the foot, excessive proliferation and accumulation of adipose tissue was the basic lesion, whereas involvement of the nerve might be the fundamental lesion in gigantism of the hand. Furthermore, whatever be the basic lesion, the final pathway must be either the local deficiency of a growth inhibiting factor or local expression of a basic intrinsic factor, leading to excessive growth of all elements of the digit.

Surgical treatment of macrodactyly in older children and adults

PURPOSE

To introduce a surgical technique for the treatment of macrodactyly in older children and adults, to represent the degree of correction obtained by the procedure, and to give the functional results.

METHODS

Two thumbs and 5 fingers of 5 patients aged 12 to 32 years (mean, 17.5 years) with macrodactyly had surgery. The amount of tissue sufficient to reconstruct a normal-sized digit was left attached with the neurovascular bundle on the concave side of the macrodactylic digit and complete excision of whatever remained was performed. This requires usually arthrodesis of the distal interphalangeal joint with bone shortening. The large skin fold created during bone shortening and remaining angulations at the proximal phalanx were corrected during a second procedure. The patients were evaluated for 3 to 9 years (mean, 5.4 years) after the surgery. The length and circumferences of the involved digits and their opposites were measured before surgery and during the last follow-up examination to calculate the differences between the involved and the healthy digits, which were documented. The degree of reduction was quantified and noted. Two-point discrimination tests and active range of motion of the joints were recorded as well.

RESULTS

For the thumbs an average 37% of circumference and 15% of length were reduced and for the fingers an average 44% of circumference and 35% of length were reduced. Ranges of motion of the joints of the involved digits were the same or nearly the same as before surgery in all of the cases. Two-point discriminations at the pulp of the involved digits were found to be the same as presurgical values in all digits.

CONCLUSIONS

The technique is precise and simplifies the planning of the surgery. Although the macrodactylic digits with angulation deformities required a subsequent surgery for corrections patients with marked macrodactyly of the digit without a very wide proximal phalanx and metacarpal gained most from this technique.

Advanced imaging in renal osteodystrophy of the oral and maxillofacial region

Magnetic resonance imaging and computed tomography was performed in one and two patients, respectively, with renal osteodystrophy (ROD). Conventional radiographs clearly depicted the characteristics of ROD of the oral and maxillofacial region. CT and MRI did not add any more information.

Macrodystrophia lipomatosa: CT and MR findings

Macrodystrophia lipomatosa is a congenital macrodactyly characterized by proliferation of all mesenchymal components, particularly fibroadipose tissue. We report imaging features of two such patients. MR imaging and CT scanning demonstrated proliferation of fatty tissue in the territory of the median nerve in the hands and forearms, characteristic of macrodystrophia lipomatosa.

Progressive pedal macrodactyly surgical history with 15 year follow-up

Macrodactyly can affect the fingers and/or toes1. Histopathologic examination will distinguish macrodactylia fibrolipomatosis or neural fibrolipoma with macrodactyly, from macrodactylia as a part of neurofibromatosis. Surgical repair is aimed at decreasing the size of the affected foot so it is as near in size and shape to the normal foot as possible. Surgical approaches have included reconstructive surgery (usually staged debulking procedures), epiphyseal plate arrest and amputation. Repeated reconstructive surgical procedures, as illustrated in this report covering patient care over a 15 year period, are usually necessary due to recurring soft tissue and boney enlargement.

McCune-Albright syndrome: clinical and molecular evidence of mosaicism in an unusual giant patient

Molecular genetics recently uncovered the mystery of the protean picture of McCune-Albright syndrome by identification of the somatic gain of function mutations in the GNAS1 gene. Here we present an adult patient with fibrous dysplasia and an endocrinopathy resulting in unusual giant height. The clinical diagnosis in the patient could be confirmed by molecular investigations in tissues involved in the process of fibrous dysplasia.

Digital enlargement in tuberous sclerosis

A 23-year-old woman with a medical history significant for tuberous sclerosis presented with symptoms of postpartum endometritis. Focal gigantism of the third digit of her right hand was incidentally noted and is reported to be a rare manifestation of tuberous sclerosis.

Gigantism of the foot: our experience in seven cases

We report our experience in seven patients with congenital gigantism of the foot with the following diagnoses: neurofibromatosis (two), fibrolipomatosis (two), Proteus syndrome (two), and idiopathic localized gigantism (one). Our purpose is to introduce a new classification of foot gigantism, based on the concept of "neuroinduction." In our experience, intraoperative examination and subsequent histologic examination show consistently pathologic findings in the plantar nerve and its terminal branches in the foot affected by gigantism. Limited surgical treatment was used in five patients. To prevent forefoot enlargement and recurrence of deformity, we suggest complete ray resection. We evaluated our results using radiographs, functional status, and cosmetic considerations.

Macrodystrophia lipomatosa of the foot: a report of three cases and literature review

Macrodystrophia lipomatosa is a distinct clinical entity often misdiagnosed as other forms of macrodactyly. The most specific finding is an overabundance of fibrofatty tissue on the plantar aspect of the foot. Three cases, with the diagnoses made from tissue specimens, are presented in this article. The clinical, pathologic, and roentgenographic findings are discussed and a review of the literature is provided.

Macrodystrophia lipomatosa. A case report

Macrodystrophia lipomatosa, a rare form of localized gigantism of unknown cause, is characterized by a dramatic overgrowth of all the mesenchymal elements, particularly the fibroadipose tissue, of one or more digits of the foot or hand. Of the known forms, static and progressive (1), we report the case of an African patient, of Bantu origin, who had a progressive deformity of his left hand.

A case of nondiabetic macrosomia with Simpson-Golabi-Behmel syndrome: antenatal sonographic findings

The incidence of macrosomic infants weighing 5,000 g or more is rare. We experienced a case of nondiabetic macrosomia, in which the fetus weighed more than 5,000 g. The newborn was diagnosed as having Simpson-Golabi-Behmel syndrome. We discuss antenatal ultrasonographic findings in the case.

Metacarpophalangeal pattern profile analysis in Sotos and Marfan syndrome

Patients with Sotos and Marfan syndrome have unusually long metacarpals and phalanges which may make the differential diagnosis difficult in younger children. Using Q-scores, we compared metacarpophalangeal pattern profile (MCPP) analysis in these two syndromes and identified distinct and different pattern profiles. This illustrates that the MCPPs are specific in these syndromes, even at an early age, and not related solely to the unusually long metacarpals and phalanges. For this study we used data from 50 Sotos patients (34 from the United Kingdom and 16 from the Netherlands, with a total of 95 hand films) and 36 Marfan patients (from the Netherlands, with 98 hand films). Of all patients over age 3 years the bone length (including the epiphysis) was determined. The patients under 7 1/2 years (29 Sotos and 12 Marfan) were also measured without inclusion of the epiphysis. The patients measured without epiphysis had a relative short metacarpal 1 (MC1) and long distal phalanx 1 (DPh1) in Sotos syndrome, and a relative long MC1 and short DPh1 in Marfan syndrome. Between age 3 and 7 1/2 years more than 90% of the films could be classified correctly using these two variables. Of the roentgenograms measured with epiphyses, about 80% were classified correctly.

CT of the "Tegernsee Giant": juvenile gigantism and polyostotic fibrous dysplasia

We report the radiological findings in the unusual case of the Bavarian "Tegernsee Giant." With conventional radiography, CT, and histologic examination, we succeeded in diagnosing two disorders: The Tegernsee Giant suffered from (a) juvenile gigantism caused by a growth hormone-secreting tumor of the pituitary gland and (b) a polyostotic form of fibrous dysplasia of the skull and multiple bones particularly on the left side of the body.

Radiologic case study. Macrodystrophia lipomatosa

Macrodystrophia lipomatosa is a rare form of gigantism involving an extremity consisting of predominately fibroadipose tissue. Radiographically, it appears as hypertrophy of soft tissues and bone. CT and MR scanning delineate the tissues involved and are virtually diagnostic, demonstrating the predominantly adipose component as well as the overgrowth of the bones, nerves, and vessels also involved.

[Rare forms of partial gigantism due to vascular hypoplasia]

On the basis of findings of angiographic studies performed in 35 patients with partial gigantism of the upper and lower extremities, the two types of developmental anomaly of the vessels have been distinguished.

[Clinical aspects, morphology and therapy of an unusual case of bilateral macrodactyly]

Macrodactyly, originally described by von Klein in 1824, is one of the rarest congenital anomalies of the hand. It displays a wide variety of manifestations, and its association with other congenital defects and syndromes has been discussed by many authors. A rare case involving an adult with bilateral, hyperostotic macrodactyly of the hands is presented. The hands were not treated in childhood. Clinical findings, pathology, and treatment are discussed.

CT diagnosis of macrodystrophia lipomatosa. A case report

Radiographs and CT scans of a 45-year-old male with progressive enlargement of his right upper limb and shoulder are presented. Extensive soft-tissue hypertrophy with linear radiolucent bands (fat) limited to the lateral aspect of the limb were seen. Exostoses-like bony overgrowth were also seen along interphalangeal joints. At CT, hypertrophic adipose tissue intermingling with muscle fibers was demonstrated, a diagnostic finding distinguishing the lesion from plexiform neurofibrolipomatosis, Klippel-Trenaunay syndrome and other angiomatous lesions.

Macrodystrophia lipomatosa: radiographic observations

23 cases of macrodystrophia lipomatosa (MDL) are reported showing a wide spectrum of radiographic findings. Typical findings were hypertrophy of all the mesodermal tissues of the affected digits with dramatic overgrowth of fat. Phalanges were enlarged both in length and transverse diameter, but the trabecular pattern was maintained. In one patient, the phalanges and metatarsals were elongated but thinned. In another case, all the phalanges and metatarsals of the great toe were small. The little toe was also involved in two cases. Articular surfaces were slanting. There was a high incidence of palmar and plantar involvement. In a few cases the forearm and leg were also involved. Other uncommon features observed were early maturation of epiphyseal centres of ossification of phalanges and metatarsals, syndactyly, polydactyly, brachydactyly and symphalangism. Angiography was uncharacteristic.

Paraxial macrodystrophia lipomatosa of the medial right lower limb

We report the orthopaedic management of a child with macrodystrophia lipomatosa of the medial aspect of the right lower limb. Bony and soft tissue overgrowth of the medial aspect of the lower limb resulted in valgus deformities at the subtalar joint, ankle, knee, and hip. The paraxial distribution, which has not been previously reported, suggests that the condition may be caused by alteration of somatic cells during limb bud development.

Sotos syndrome presenting with epilepsy

A fourteen and a half year-old boy of tall stature presenting with epilepsy was diagnosed as having Sotos syndrome (cerebral gigantism) at the Hacettepe University Children's Hospital. Since EEG abnormalities are known manifestations in this syndrome, a case presenting with epilepsy is very rare. We believe that a presumed cerebral defect could create convulsions and would thus be the cause of cerebral gigantism whose etiology is still unclear. Thus patients with this syndrome should be followed up for the risk of epilepsy.

Computed tomography diagnosis of macrodystrophia lipomatosa

Isolated congenital macrodactyly, termed macrodystrophia lipomatosa, is a rare entity. It may be confused with plexiform neurofibroma, hemangioma, or lymphangioma. Computed tomography provides an ideal methodology to verify the fatty proliferation of soft tissue that accompanies bone overgrowth and distinguishes this lesion from the others in the differential list.

McCune-Albright syndrome with gigantism and hyperprolactinemia

We describe the case of a 38-year-old man with typical Mc Cune-Albright syndrome and the unusual combination of both growth-hormone and prolactin hypersecretion. The patient was extremely tall, which is unusual in Mc Cune-Albright syndrome, suggesting that he did not have precocious fusion of the epiphysis, a common finding in this syndrome. Unfortunately the patient refused any treatment for his disease. A similar case has been previously described only in a 14-year-old boy.

Cerebral gigantism with hydronephrosis: a case report

A case of cerebral gigantism with hydronephrosis in a 20-month-old boy is described. Hydronephrosis is believed to be an additional association of the syndrome not hitherto reported.

Gigantism associated with McCune-Albright's syndrome

The case of a 16 year-old boy with McCune-Albright's syndrome which is rarely accompanied by gigantism was studied endocrinologically. The stimulation of growth hormone (GH) release by hypoglycemia, the decline of elevated GH by hyperglycemia and a little lower somatostatin like immunoreactivity (SLI) may support abnormalities of hypothalamic function, but the existence of pituitary microadenoma cannot be ruled out because of the paradoxical suppression of GH release by oral administration of bromocriptine (CB-154) and L-DOPA and the stimulation of GH release by intravenous administration of TRH.

Metacarpophalangeal pattern profile analysis in Sotos syndrome

The metacarpophalangeal pattern profile (MCPP) was analyzed on 16 Sotos syndrome patients. A mean Sotos syndrome profile was produced. Correlation studies confirm clinical homogeneity of Sotos syndrome individuals. Discriminant analysis of Sotos syndrome patients and normal individuals produces a function of two MCPP variables and age, which may provide a useful tool for diagnosis.

Cerebral gigantism associated with Wilms' tumor

Two children had cerebral gigantism in unique association with Wilms' tumor. An increased incidence of neoplasms has been reported in cerebral gigantism, as well as in Beckwith-Wiedemann syndrome. We report similarities and differences between these disorders.

Unilateral delayed opercularization in a case of Sotos' syndrome (Cerebral Gigantism)

A case of Sotos' syndrome (cerebral gigantism) is described. Pneumencephalography, performed at the age of 15 days, revealed abnormal separation of the opercula on the right. By comparing the contours with developmental anatomical features of this area it agreed with a foetal development of 24 weeks gestational age. Bilateral carotid angiography was normal. CT showed normal development of the Sylvian area at the age of 27 months.

Roentgen cephalometric studies on skull development in rats. III. Gigantism versus acromegaly: age differences in response to prolonged growth hormone administration

Experimental conditions simulating the induction of clinical pituitary gigantism and acromegaly were established by prolonged administration of growth hormone in high dosage to adult male rats starting at two different ages: 6 months (growth still active) and 14 1/2 months (growth virtually arrested). Treatment continued for 14 1/2 months, control receiving saline injections. Each group numbered eight at onset. Standardized x-rays of skull were made in ventro-dorsal and lateral planes, at onset, mid-period, and end of the study. Representative dimensions of cranial and facial segments were measured, including lengths, widths, palate dimensions, gnathic and interzygomatic angles, and incisor curvature. Some related indices were calculated. Means and standard errors were computed, usually on five to eight rats (oldest controls: three only). The response pattern of overall skull length was most illustrative. Younger adult controls grew actively until 14 months of age (5%) while injected rats grew still faster (8%); thereafter, controls grew negligibly (1%) and injected rats only slightly (2%). Older controls showed negligible skull elongation from 14 1/2 to 29 months of age, and growth hormone stimulated no gain. In the younger group, skull length gains were almost entirely in the facial region; cranium gained no length and widened only slightly. Cranial index increased slightly with the hormone. Facial (bizygomatic) width increased in both injected groups--proportionately in younger rats(to giganntism) and disproportionately in older rats. Palatal and dental growth followed facial patterns in both groups. Cranial vault bones thickened and, in older rats, developed surface irregularities, giving them a more massive, acromegaloid structure.

Macrodystrophia lipomatosa: radiographic diagnosis

Macrodystrophia lipomatosa is a rare form of localized gigantism characterized by progressive overgrowth of all the mesenchymal elements with a disaproportionate increase in the fibroadipose tissues. This congenital abnormality occurs most frequently in the distribution of the median nerve in the upper extremity and in the distribution of the planter nerves in the lower extremity. It is usually recognized at birth or in the neonatal period. As the patient grows, the deformity begins to mechanically interfere with joint function, vascular supply, and innervation. Six cases are described with emphasis on the radiographic findings which differentiate this entity from other forms of local gigantism. These findings include a predominately distal involvement, enlargement of the phalanges and soft tissue elements of the digit, and lucencies within the soft tissues.