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Akbar A, Ahmad S, Creeden S, Huynh H. Infant with Loeys-Dietz syndrome treated for febrile status epilepticus with COVID-19 infection: first reported case of febrile status epilepticus and focal seizures in a patient with Loeys-Dietz syndrome and review of literature. BMJ Case Rep 2022; 15:15/11/e250587. [DOI: 10.1136/bcr-2022-250587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Loeys-Dietz syndrome (LDS) is a rare, autosomal dominant multisystem disorder that is caused by mutations of transforming growth factor-β receptors. Mutations inSMAD3andTGFB3have been recently reported.LDS is characterised by the triad of arterial tortuosity, hypertelorism and a bifid uvula or cleft palate among other cardiovascular, craniofacial and orthopaedic manifestations. Patients with LDS show clinical and genetic variability and there is a significant risk of reduced life expectancy due to widespread arterial involvement, aortic root dilation, aneurysms and an aggressive vascular course. Thus early genetic testing is warranted if clinical signs and history are suggestive of this potentially catastrophic disorder.LDS predisposes patients to aortic aneurysms and early death due to vascular malformations, but neurological emergencies, such as seizures and febrile status epilepticus, have not been reported.Febrile status epilepticus is the most common neurological emergency in childhood. Neurological manifestations of COVID-19 in the paediatric population are not as well described in medical literature.To the best of our knowledge, this is the first reported case of febrile status epilepticus with COVID-19 infection in an infant with LDS. Our patient had focal epileptiform activity emanating over the left posterior hemisphere, which evolved into an electrographic seizure on video EEG. Such patients have a heightened risk of epilepsy in the future, and this occurrence is consistent with a diagnosis of focal epilepsy. Neurological complications such as epilepsy and status epilepticus in a patient with LDS have never been reported before.A brief review of literature is also given here.
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Zaza P, Indrio F, Fracchiolla A, Rinaldi M, Meliota G, Salatto A, Bonacaro A, Maffei G. Cleft Palate and Aortic Dilatation as Clues for Loeys–Dietz Syndrome. CHILDREN 2022; 9:children9091290. [PMID: 36138598 PMCID: PMC9497579 DOI: 10.3390/children9091290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 11/16/2022]
Abstract
Loeys–Dietz syndrome (LDS) is a rare autosomal-dominant disorder of the connective tissue with some typical vascular findings, skeletal manifestations, craniofacial features, and cutaneous findings with a wide phenotypic spectrum. Six different genes are involved in LDS and the diagnosis is based on the identification of a heterozygous pathogenic variant in TGFBR1, TGFBR2, SMAD3, TGFB2, TGFB3, or SMAD2 in children with suggestive findings. These genes distinguish LDS into six classes (LDS1–LDS6, respectively). Delay in diagnosis of Loeys–Dietz syndrome may be associated with an adverse prognosis due to a very high augmented risk of early complications such as aortic or vascular rupture. The present report describes a case of an early diagnosis of LDS in a neonate with cleft soft palate and aortic root dilatation.
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Affiliation(s)
- Pierluigi Zaza
- Ospedali Riuniti Foggia Italy-U.O.C. Neonatologia e Terapia Intensiva Neonatale, 71100 Foggia, Italy
| | - Flavia Indrio
- Department of Medical and Surgical Science Pediatric Section, University of Foggia, 71100 Foggia, Italy
- Correspondence:
| | - Annalisa Fracchiolla
- Ospedali Riuniti Foggia Italy-U.O.C. Neonatologia e Terapia Intensiva Neonatale, 71100 Foggia, Italy
| | - Matteo Rinaldi
- Ospedali Riuniti Foggia Italy-U.O.C. Neonatologia e Terapia Intensiva Neonatale, 71100 Foggia, Italy
| | - Giovanni Meliota
- Ospedale Giovanni XXIII U.O. Cardiologia Pediatrica, 70124 Bari, Italy
| | - Alessia Salatto
- DAI Materno-Infantile, Azienda Ospedaliera-Universitaria Federico II di Napoli, 80100 Napoli, Italy
| | - Antonio Bonacaro
- School of Health and Sports Sciences, University of Suffolk, Ipswich IP4 1QJ, UK
| | - Gianfranco Maffei
- Ospedali Riuniti Foggia Italy-U.O.C. Neonatologia e Terapia Intensiva Neonatale, 71100 Foggia, Italy
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Neonatal presentation of Loeys-Dietz syndrome: two case reports and review of the literature. Ital J Pediatr 2022; 48:85. [PMID: 35668506 PMCID: PMC9169291 DOI: 10.1186/s13052-022-01281-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/13/2022] [Indexed: 01/24/2023] Open
Abstract
Background Loeys-Dietz syndrome (LDS) is a rare connective tissue disorder characterized by cardiovascular manifestations, especially aortic dilatations and arterial tortuosity, craniofacial and skeletal features, joint laxity or contractures, skin abnormalities, hypotonia and motor delay. Its diagnosis is established by the identification of a pathogenic variant in TGFBR1, TGFBR2, SMAD2, SMAD3, TGFB2 or TGFB3 genes. In newborns and toddlers, vascular complications such as aneurism rupture, aortic dissection, and intracerebral incidents, can occur already in the weeks of life. To avoid these events, it is crucial to precociously identify this condition and to start an apunderwent a surgical procedurepropriate treatment which, depending on the severity of the vascular involvement, might be medical or surgical. Case presentation We report two cases of Loeys-Dietz syndrome precociously diagnosed. The first describes a male, born at 38 + 1 weeks of gestation, with hypotonia, joint hypermobility, arachnodactyly, and fingers joint contractures, as well as senile appearance and facial dysmorphisms. In the suspect of a connective tissue disorder, an echocardiography was performed and revealed an aortic root dilatation of 13 mm (Z score + 3). A trio based Whole Exome Sequencing found a novel de novo variant in the TGFBR2 gene. Despite the onset of a low-dose angiotensin receptor blocker therapy, the aneurysm progressed. The second case describes a female, born at 41 + 3 weeks of gestation. During the neonatal examination a cleft palate was noticed, as well as minor dysmorphisms. Since the family history was suspicious for connective tissue disorders, a genetic panel was performed and identified a pathogenetic variant in TGFB3 gene. In this case, the echocardiography revealed no abnormalities. Conclusions In addition to our cases, we identified 14 subjects with neonatal LDS in the medical literature. All of them had aortic involvement. Skeletal and face abnormalities, including eyes and palate malformations, were also highly frequent. Overall, 10 subjects required medical therapy to avoid aneurysm progression, and 8 patients underwent surgical procedures. Benefits of an early diagnosis of LDS are various and imply a potential modification of the natural history of the disease with early interventions on its complications.
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Prablek MA, LoPresti M, Bertot B, Morris SA, Bauer D, Lam S, Ravindra V. Evaluation of cervical spine pathology in children with Loeys-Dietz syndrome. Surg Neurol Int 2022; 13:96. [PMID: 35399906 PMCID: PMC8986760 DOI: 10.25259/sni_48_2022] [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: 01/12/2022] [Accepted: 02/25/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Loeys-Dietz syndrome (LDS) is a genetic connective tissue disorder associated with multiple musculoskeletal anomalies, including cervical spine instability. We sought to examine the nature of imaging for cervical spine instability in children with LDS due to likely pathogenic or pathogenic variants in TGFBR1, TGFBR2, TGFB2, SMAD3, or TGFB3. Methods: A retrospective chart review was conducted, examining relevant data for all children with LDS screened at our institution from 2004 through 2021. Cervical spine X-rays were used to assess cervical instability, cervical lordosis, and basilar impression. Results: A total of 39 patients were identified; 16 underwent cervical spine screening (56.25% male). Median age at initial screening was 7 years (Q1-Q3: 3.75–14, range: 0.1–19). Six of 16 patients evaluated (37.5%) had radiographical evidence of cervical instability. Mean angles of cervical lordosis were 20° (SD = 14.1°, range = 4°–33°) and 17.3° (SD = 16.4°, range = 2°–41°), respectively. Three patients demonstrated radiographical basilar impression. Radiographic progression of cervical instability was seen in one case. All but two were managed conservatively with observation, one patient underwent surgical fixation and fusion of C1-2, the other underwent complex cervical reconstruction anterior and posterior instrumentation. Conclusion: Cervical spine evaluation is important in this cohort; we identified 37.5% had evidence of cervical spine instability, and many had concurrent spinal pathology. From our experience, we agree with the recent advisement for screening at diagnosis and for those previously diagnosed that have not undergone screening. Future study may outline more specific screening practices.
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Affiliation(s)
| | - Melissa LoPresti
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas,
| | - Brandon Bertot
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,
| | | | - David Bauer
- Departments of Neurosurgery, Texas Children’s Hospital, Houston, Texas,
| | - Sandi Lam
- Department of Neurosurgery, Lurie Children’s Hospital, Chicago, Illinois,
| | - Vijay Ravindra
- Department of Neurosurgery, University of California San Diego, San Diego, California, United States
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Evaluating the monogenic contribution and genotype-phenotype correlation in patients with isolated thoracic aortic aneurysm. Eur J Hum Genet 2021; 29:1129-1138. [PMID: 33824467 DOI: 10.1038/s41431-021-00857-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 01/09/2023] Open
Abstract
Thoracic aortic aneurysm with or without dissection (TAAD) can be broadly categorized as syndromic TAAD (sTAAD) and isolated TAAD (iTAAD). sTAAD and is highly correlated with genetics. However, although the incidence of iTAAD is much higher, its monogenic contribution is not yet clear. Here, we sequenced 15 known TAAD genes for 578 iTAAD cases from four cardiac centers in China and found that 10.6% patients with a pathogenic/likely pathogenic (P/LP) variant. Other 7.27% of patients carried variants of uncertain significance in these target genes. We further investigated the correlations among genetics, clinical features, and long-term outcomes. Genetic patients showed younger onset ages (P = 1.31E-13) and larger aortic diameter (P = 1.00E-6), with the youngest age in patients with FBN1 P/LP variants. Monogenic variants were also associated with more aortic segments involved (P = 0.043) and complicated with initial dissection (P = 4.50E-5), especially for genetic patients with non-FBN1 P/LP variants. MACEs occurred in 14.9% patients during follow-up of median 55 months. Genetic status (P = 0.001) and initial dissection (P = 3.00E-6) were two major risk factors for poor prognosis. Early onset age was associated with MACEs in non-genetic cases without initial dissection (P = 0.005). Our study revealed the monogenic contribution in known TAAD genes to iTAAD patients. The genotype-phenotype correlations may complement the risk stratification of iTAAD patients and identification of higher risk subgroups, as well as assist the development of tailored precision medicine in iTAAD.
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Siddiqui S, Polanco A, DiLorenzo MP, Shah A, Snyder M, Dietz H, Bacha E, Farooqi KM. Massive ductal aneurysm in an asymptomatic child with Loeys-Dietz syndrome. Ann Pediatr Cardiol 2020; 14:113-115. [PMID: 33679075 PMCID: PMC7918009 DOI: 10.4103/apc.apc_85_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/20/2020] [Accepted: 08/04/2020] [Indexed: 11/04/2022] Open
Abstract
An asymptomatic 3-year-old with Loeys-Dietz Syndrome (LDS) followed for a small patent ductus arteriosus and dilated aorta was found to have a massive ductal aneurysm on routine surveillance cardiac magnetic resonance. The aneurysm was successfully resected. Serial advanced imaging tools are useful in surveillance, diagnosis, and management in patients with LDS.
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Affiliation(s)
- Saira Siddiqui
- Division of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, OH, USA
| | - Antonio Polanco
- Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Michael P DiLorenzo
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Amee Shah
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Michael Snyder
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Harry Dietz
- Mckusick-Nathans Department of Genetic Medicine, Howard Hughes Medical Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emile Bacha
- Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Kanwal Majeed Farooqi
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Irving Medical Center, New York, NY, USA
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Abstract
PURPOSE OF REVIEW To review the literature and provide a summary of management of syndromic and nonsyndromic aortopathies. RECENT FINDINGS The number of newly identified genetic causes for aortopathies have continued to increase over the past 10 years. The number of reported individuals with most hereditary aneurysm genes is small but increasing with more publications focusing describing the natural history caused by each gene. SUMMARY Aortopathy can present as an isolated finding or present as part of a larger genetic syndrome. Advances in genetic testing technology has shed light on the increasing importance of molecular diagnostics in the evaluation and management of patients with hereditary aortic disease. Molecular diagnostics and family phenotyping can aide in the diagnosis and management of pediatric patients with aortic disease.
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Affiliation(s)
| | - Rocio T Moran
- Division of Genetics and Genomics, The MetroHealth System, Cleveland, Ohio, USA
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Riise N, Lindberg BR, Kulseth MA, Fredwall SO, Lundby R, Estensen ME, Drolsum L, Merckoll E, Krohg-Sørensen K, Paus B. Clinical diagnosis of Larsen syndrome, Stickler syndrome and Loeys-Dietz syndrome in a 19-year old male: a case report. BMC MEDICAL GENETICS 2018; 19:155. [PMID: 30170566 PMCID: PMC6119281 DOI: 10.1186/s12881-018-0671-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 08/22/2018] [Indexed: 01/06/2023]
Abstract
Background Larsen syndrome is a hereditary disorder characterized by osteochondrodysplasia, congenital large-joint dislocations, and craniofacial abnormalities. The autosomal dominant type is caused by mutations in the gene that encodes the connective tissue protein, filamin B (FLNB). Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder characterized by arterial aneurysms, dissections and tortuosity, and skeletal, including craniofacial, manifestations. Mutations in five genes involved in the transforming growth factor beta (TGF-β) signaling pathway cause five types of LDS. Stickler syndrome is a genetically heterogeneous arthro-ophthalmopathy caused by defects in collagen, exhibiting a wide specter of manifestations in connective tissue. A rare case is reported that was diagnosed with all these three hereditary connective tissue disorders. Case presentation A 19 year-old, Norwegian male with a clinical diagnosis of Larsen syndrome and with healthy, non-consanguineous parents attended a reference center for rare connective tissue disorders. Findings at birth were hypotonia, joint hypermobility, hyperextended knees, adductovarus of the feet, cervical kyphosis, craniofacial abnormalities, and an umbilical hernia. From toddlerhood, he required a hearing aid due to combined conductive and sensorineural hearing loss. Eye examination revealed hyperopia, astigmatism, and exotropia. At 10 years of age, he underwent emergency surgery for rupture of an ascending aortic aneurysm. At 19 years of age, a diagnostic re-evaluation was prompted by the findings of more distal aortic dilation, tortuosity of precerebral arteries, and skeletal findings. High throughput sequencing of 34 genes for hereditary connective tissue disorders did not identify any mutation in FLNB, but did identify a de novo missense mutation in TGFBR2 and a nonsense mutation in COL2A1 that was also present in his unaffected father. The diagnosis was revised to LDS Type 2. The patient also fulfills the proposed criteria for Stickler syndrome with bifid uvula, hearing loss, and a known mutation in COL2A1. Conclusion LDS should be considered in patients with a clinical diagnosis of Larsen syndrome, in particular in the presence of arterial aneurysms or tortuosity. Due to genetic heterogeneity and extensive overlap of clinical manifestations, genetic high throughput sequencing analysis is particularly useful for the differential diagnosis of hereditary connective tissue disorders.
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Affiliation(s)
- N Riise
- TRS National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesoddtangen, N-1450, Oslo, Norway.
| | - B R Lindberg
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | - M A Kulseth
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - S O Fredwall
- TRS National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesoddtangen, N-1450, Oslo, Norway
| | - R Lundby
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - M-E Estensen
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - L Drolsum
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - E Merckoll
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - K Krohg-Sørensen
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - B Paus
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Yetman AT, Hammel J, Sanmann JN, Starr LJ. Valve-Sparing Root and Total Arch Replacement for Cutis Laxa Aortopathy. World J Pediatr Congenit Heart Surg 2017; 10:376-379. [PMID: 28673110 DOI: 10.1177/2150135117698458] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aortic aneurysms requiring surgery in early childhood are rare. Herein we describe the case of a three-year-old with massive aneurysmal aortic dilation secondary to the rare and often lethal genetic disorder, cutis laxa. Initial thoracic aortic aneurysm gene panel was negative. Parents of the child were not known to be consanguineous, but high-density SNP array revealed several regions of homozygosity. This prompted targeted sequence analysis that identified a novel homozygous missense mutation in the gene for cutis laxa, EFEMP2. The patient underwent aortic valve-sparing aortic root and ascending aorta replacement and total aortic arch replacement, with continuous, moderately hypothermic cardiopulmonary bypass, using a dual cannulation technique. He was discharged well on the third postoperative day and remains free of aneurysmal disease at two-year follow-up.
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Affiliation(s)
- Anji T Yetman
- 1 Cardiology, Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA
| | - James Hammel
- 2 Cardiovascular Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jennifer N Sanmann
- 3 Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center, Omaha, NE, USA
| | - Lois J Starr
- 4 Genetic Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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Aortic Root Replacement for Children With Loeys-Dietz Syndrome. Ann Thorac Surg 2017; 103:1513-1518. [DOI: 10.1016/j.athoracsur.2017.01.053] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 01/03/2017] [Accepted: 01/09/2017] [Indexed: 11/22/2022]
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Valenzuela I, Fernández-Alvarez P, Munell F, Sanchez-Montanez A, Giralt G, Vendrell T, Tizzano EF. Arthrogryposis as neonatal presentation of Loeys-Dietz syndrome due to a novel TGFBR2 mutation. Eur J Med Genet 2017; 60:303-307. [PMID: 28344185 DOI: 10.1016/j.ejmg.2017.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/10/2017] [Accepted: 03/22/2017] [Indexed: 11/30/2022]
Abstract
Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder characterized mainly by cardiovascular, craniofacial and skeletal features. We report on a patient with LDS, whose prenatal examination was compatible with the diagnosis of arthrogryposis multiplex congenita. Neonatal assessment showed craniofacial and cardiovascular findings suggestive of LDS whose diagnosis was confirmed by the detection of a novel mutation (HGVN: NM_003242.5 (TGFBR2): c.1381T > C (p.(Cys461Arg))) in the TGFBR2 gene. Few prenatal and neonatal cases of LDS have been reported in the literature. We reviewed all cases reported to date with perinatal onset to delineate the clinical manifestations that allow us to prompt diagnosis of this syndrome at an early stage to prevent fatal cardiovascular complications. Furthermore we discuss the multidisciplinary follow up required in these patients.
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Affiliation(s)
- Irene Valenzuela
- Department of Clinical and Molecular Genetics and Rare Disease Unit, University Hospital Vall d'Hebron, CIBERER, Barcelona, Spain
| | - Paula Fernández-Alvarez
- Department of Clinical and Molecular Genetics and Rare Disease Unit, University Hospital Vall d'Hebron, CIBERER, Barcelona, Spain
| | - Francina Munell
- Neuropediatrics Service, University Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Gemma Giralt
- Pediatric Cardiology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Teresa Vendrell
- Department of Clinical and Molecular Genetics and Rare Disease Unit, University Hospital Vall d'Hebron, CIBERER, Barcelona, Spain
| | - Eduardo F Tizzano
- Department of Clinical and Molecular Genetics and Rare Disease Unit, University Hospital Vall d'Hebron, CIBERER, Barcelona, Spain.
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Woolnough R, Dhawan A, Dow K, Walia JS. Are Patients With Loeys-Dietz Syndrome Misdiagnosed With Beals Syndrome? Pediatrics 2017; 139:peds.2016-1281. [PMID: 28209770 DOI: 10.1542/peds.2016-1281] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2016] [Indexed: 11/24/2022] Open
Abstract
Beals syndrome, also known as congenital contractural arachnodactyly (Online Mendelian Inheritance in Man: 121050), is an autosomal dominant disorder caused by a mutation in FBN2 that is typically characterized by congenital contractures and arachnodactyly. It shares a number of phenotypic features with Loeys-Dietz syndrome (Online Mendelian Inheritance in Man: 609192). Loeys-Dietz syndrome, initially described in 2005, is associated with mutations for the transforming growth factor β receptor and is characterized by findings of cerebral, thoracic, and abdominal arterial aneurysms. This report describes a 17-year-old male patient with a typical neonatal diagnosis of Beals syndrome. At age 15 years, an echocardiogram conducted in response to an aortic dissection in his father showed moderate aortic root dilation, prompting comprehensive testing for aortopathies, revealing a mutation in TGFBR1, thereby changing the diagnosis to Loeys-Dietz syndrome. Previously published reports have not implicated any mutation of the transforming growth factor β receptor genes in cases of Beals syndrome. This case underscores that due to significant phenotypic overlap, there is utility in a full panel of testing, including genes for hereditary connective tissue disorders with vascular involvement, as well as FBN2. Likewise, young patients who have tested negative for FBN2 should be tested for hereditary connective tissue disorders with vascular involvement.
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Affiliation(s)
| | - Andrew Dhawan
- School of Medicine, Queen's University, Kingston, Ontario, Canada
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Patel ND, Crawford T, Magruder JT, Alejo DE, Hibino N, Black J, Dietz HC, Vricella LA, Cameron DE. Cardiovascular operations for Loeys-Dietz syndrome: Intermediate-term results. J Thorac Cardiovasc Surg 2016; 153:406-412. [PMID: 27955909 DOI: 10.1016/j.jtcvs.2016.10.088] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 10/02/2016] [Accepted: 10/05/2016] [Indexed: 02/09/2023]
Abstract
OBJECTIVES Early experience with Loeys-Dietz syndrome (LDS) suggested an aggressive aortopathy with high risk of aneurysm dissection and rupture at young ages and at smaller aortic diameters than in other connective tissue disorders. We reviewed our experience with LDS to re-examine our indications and outcomes of surgical management. METHODS We reviewed all patients with a diagnosis of LDS who underwent cardiovascular surgery at our institution. The primary endpoint was mortality, and secondary endpoints included postoperative complications and need for reintervention. RESULTS Seventy-nine operated patients with LDS were identified. Mean age at first operation was 25 years, 39 (49%) were female, and 38 (48%) were children (age <18 years). Six (8%) patients presented with acute dissection. Five (6%) patients had a bicuspid aortic valve, and all presented with an ascending aortic aneurysm with a mean root diameter of 3.5cm. Twenty (25%) patients had a previous sternotomy. Sixty-five (82%) patients underwent aortic root replacement, of whom 52 underwent a valve-sparing operation and 4 had concomitant arch replacement. Mean aortic root diameter in this group was 4.2 cm. Nine (11%) patients underwent aortic arch replacement, 2 (3%) had isolated ascending aorta replacement, and 3 (4%) underwent open thoracoabdominal repair. There were 2 (3%) operative and 8 late deaths. Nineteen patients underwent subsequent operations for late aneurysm and/or dissection. Mean follow-up was 6 years (range 0-24 years). Kaplan-Meier survival was 88% at 10 years. CONCLUSIONS Growing experience with LDS has confirmed early impressions of its aggressive nature and proclivity toward aortic catastrophe. Surgical outcomes are favorable, but reintervention rates are high. Meticulous follow-up with cardiovascular surveillance imaging remain important for management, particularly as clinical LDS subtypes are characterized and more tailored treatment is developed.
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Affiliation(s)
- Nishant D Patel
- Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md
| | - Todd Crawford
- Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md
| | - J Trent Magruder
- Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md
| | - Diane E Alejo
- Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md
| | - Narutoshi Hibino
- Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md
| | - James Black
- Division of Vascular Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md
| | - Harry C Dietz
- Department of Medicine, The McKusick-Nathans Institute of Genetic Medicine, The Johns Hopkins Medical Institutions, Baltimore, Md
| | - Luca A Vricella
- Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md
| | - Duke E Cameron
- Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md.
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Attenhofer Jost CH, Greutmann M, Connolly HM, Weber R, Rohrbach M, Oxenius A, Kretschmar O, Luscher TF, Matyas G. Medical treatment of aortic aneurysms in Marfan syndrome and other heritable conditions. Curr Cardiol Rev 2015; 10:161-71. [PMID: 24527681 PMCID: PMC4021286 DOI: 10.2174/1573403x1002140506124902] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Revised: 12/22/2013] [Accepted: 02/06/2014] [Indexed: 01/15/2023] Open
Abstract
Thoracic aortic
aneurysms can be triggered by genetic disorders such as Marfan syndrome (MFS)
and related aortic diseases as well as by inflammatory disorders such as giant
cell arteritis or atherosclerosis. In all these conditions, cardiovascular risk
factors, such as systemic arterial hypertension, may contribute to faster rate
of aneurysm progression. Optimal medical management to prevent progressive
aortic dilatation and aortic dissection is unknown. β-blockers have been the
mainstay of medical treatment for many years despite limited evidence of
beneficial effects. Recently, losartan, an angiotensin II type I receptor
antagonist (ARB), has shown promising results in a mouse model of MFS and
subsequently in humans with MFS and hence is increasingly used. Several ongoing
trials comparing losartan to β-blockers and/or placebo will better define the
role of ARBs in the near future. In addition, other medications, such as statins
and tetracyclines have demonstrated potential benefit in experimental aortic
aneurysm studies. Given the advances in our understanding of molecular
mechanisms triggering aortic dilatation and dissection, individualized
management tailored to the underlying genetic defect may be on the horizon of
individualized medicine. We anticipate that ongoing research will address the
question whether such genotype/pathogenesis-driven
treatments can replace current phenotype/syndrome-driven strategies and whether
other forms of aortopathies should be treated similarly. In this work, we review
currently used and promising medical treatment options for patients with
heritable aortic aneurysmal disorders.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Gabor Matyas
- Cardiovascular Center Zurich, Klinik Im Park, Seestr. 220, CH-8027 Zurich, Switzerland.
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15
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Epelman M, Johnson C, Hellinger JC, Darge K, Newman B. Vascular Lesions—Congenital, Acquired, and Iatrogenic: Imaging in the Neonate. Semin Ultrasound CT MR 2015; 36:193-215. [DOI: 10.1053/j.sult.2015.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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16
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Pulmonary artery rupture after bilateral pulmonary artery banding in a neonate with Loeys-Dietz syndrome and an interrupted aortic arch complex: report of a case. Surg Today 2014; 45:495-7. [PMID: 24817126 PMCID: PMC4359291 DOI: 10.1007/s00595-014-0910-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 12/10/2013] [Indexed: 01/01/2023]
Abstract
Loeys–Dietz syndrome (LDS) is a recognized connective tissue disorder characterized by progressive aortic aneurysm and dissection. Patients are at high risk of aortic dissection or rupture at an early age, but to our knowledge, surgery on the great arteries has never been attempted in the neonatal period. We report a case of LDS with dilated pulmonary arteries and an interrupted aortic arch complex in a neonate. We performed bilateral pulmonary artery banding, but 12 days after the procedure, the infant died of rupture of the distal portion of the banding sites following massive dilatation.
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17
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MacCarrick G, Black JH, Bowdin S, El-Hamamsy I, Frischmeyer-Guerrerio PA, Guerrerio AL, Sponseller PD, Loeys B, Dietz HC. Loeys-Dietz syndrome: a primer for diagnosis and management. Genet Med 2014; 16:576-87. [PMID: 24577266 PMCID: PMC4131122 DOI: 10.1038/gim.2014.11] [Citation(s) in RCA: 306] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 01/13/2014] [Indexed: 12/20/2022] Open
Abstract
Loeys-Dietz syndrome is a connective tissue disorder predisposing individuals to aortic and arterial aneurysms. Presenting with a wide spectrum of multisystem involvement, medical management for some individuals is complex. This review of literature and expert opinion aims to provide medical guidelines for care of individuals with Loeys-Dietz syndrome.
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Affiliation(s)
- Gretchen MacCarrick
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sarah Bowdin
- Division of Clinical and Metabolic Genetics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | | | - Anthony L Guerrerio
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Bart Loeys
- Center for Medical Genetics, University of Antwerp, Antwerp, Belgium
| | - Harry C Dietz
- 1] McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA [2] Howard Hughes Institute, Chevy Chase, Maryland, USA
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18
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Chung BHY, Bradley T, Grosse-Wortmann L, Blaser S, Dirks P, Hinek A, Chitayat D. Hand and fibrillin-1 deposition abnormalities in Loeys-Dietz syndrome--expanding the clinical spectrum. Am J Med Genet A 2013; 164A:461-6. [PMID: 24194458 DOI: 10.1002/ajmg.a.36246] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 08/21/2013] [Indexed: 11/06/2022]
Abstract
Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder characterized by hypertelorism, bifid uvula, cleft palate and arterial tortuosity. We report on a patient with LDS, bearing mutation in the TGFβR2 gene, whose prenatal examination demonstrated clenched fists and club feet, suggesting arthrogryposis multiplex congenita. Postnatal assessment showed digital abnormalities, including brachydactyly, camptodactyly, partial syndactyly and absent distal phalanges. With the lack of fibrillin-1 microfibril deposition as well as impaired and inadequate elastic fiber assembly in our patient's fibroblasts, we speculate that the skeletal abnormalities seen in this patient with LDS are the result of lack of these components in embryonal perichondrium and in blood vessels. We suggest that LDS should be included in the differential diagnosis of joint contractures seen pre and postnatally. Prenatal diagnosis of LDS would be important in parental counseling and early post natal diagnosis could prompt treatment before the development of detrimental vascular complications.
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Affiliation(s)
- Brian H Y Chung
- Department of Paediatrics and Adolescent Medicine, Centre for Reproduction, Growth and Development, The University of Hong Kong, Hong Kong, Hong Kong
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19
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Chan AK, Teoh D, Matthews P, Fresco L. A patient with Loeys-Dietz syndrome treated with chemoradiotherapy for an oropharyngeal carcinoma. BMJ Case Rep 2013; 2013:bcr-2013-201024. [PMID: 24045763 DOI: 10.1136/bcr-2013-201024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present the first published case of a patient with Loeys-Dietz syndrome (LDS) who was treated with radical chemoradiotherapy for an oropharyngeal carcinoma. In view of this newly recognised connective tissue disease, the uncertainty of severe toxicity from chemoradiotherapy to treat a potentially curative cancer posed a management challenge. The patient was treated with chemoradiotherapy and remains well with no evidence of recurrence at 3 years. Furthermore, we have observed minimal late effects secondary to chemoradiotherapy at 3 years following the completion of treatment suggesting that the underlying pathogenesis of LDS may provide an interesting human model to further elucidate the complex interactions of transforming growth factor β1 (TGF-β1) and tissue fibrosis secondary to chemoradiotherapy. A review of LDS as well as the association of TGF-β1 expression and tissue fibrosis is presented.
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Affiliation(s)
- Andrew K Chan
- Arden Cancer Centre, University Hospitals Coventry & Warwickshire, Coventry, UK
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20
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Jacques F, Grosse-Wortmann L, Hickey EJ, Chitayat D, Van Arsdell GS, Bradley TJ. Unexpected Contained Rupture of a Ductus Arteriosus Aneurysm Found at Surgical Repair in an Infant With Loeys-Dietz Syndrome. Ann Thorac Surg 2013; 95:710-1. [DOI: 10.1016/j.athoracsur.2012.06.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 06/11/2012] [Accepted: 06/21/2012] [Indexed: 10/27/2022]
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21
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Morgan GJ, Yim DLS, Hayes AM, Martin RP, Hamilton MCK, Stuart G. Imaging and percutaneous occlusion of a large aneurysm of the ductus arteriosus in an infant with Loeys-Dietz syndrome. CONGENIT HEART DIS 2013; 8:E192-5. [PMID: 23350955 DOI: 10.1111/chd.12041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2012] [Indexed: 11/28/2022]
Abstract
Loeys-Dietz is a multisystem congenital syndrome that comprises craniofacial and cutaneous abnormalities as well as structural cardiac defects. One of its key pathological features is an aggressive widespread vasculopathy that can manifest as aortic or cerebral aneurysms, which is prone to dissection and rupture. We report a case of a large aneurysm of the ductus arteriosus in a patient with Loeys-Dietz syndrome, successfully occluded by interventional catheterization.
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Affiliation(s)
- Gareth J Morgan
- Department of Cardiology, Bristol Royal Hospital for Children, Bristol, United Kingdom
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22
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Natarajan G, Shankaran S, McDonald SA, Das A, Ehrenkranz RA, Goldberg RN, Stoll BJ, Tyson JE, Higgins RD, Schendel D, Hougaard DM, Skogstrand K, Thorsen P, Carlo WA. Association between blood spot transforming growth factor-β and patent ductus arteriosus in extremely low-birth weight infants. Pediatr Cardiol 2013; 34:149-54. [PMID: 22684193 PMCID: PMC3704212 DOI: 10.1007/s00246-012-0404-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 05/17/2012] [Indexed: 11/24/2022]
Abstract
Permanent ductal closure involves anatomic remodeling, in which transforming growth factor (TGF)-β appears to play a role. Our objective was to evaluate the relationship, if any, between blood spot TGF-β on day 3 and day 7 of life and patent ductus arteriosus (PDA) in extremely low birth weight (ELBW) infants. Prospective observational study involving ELBW infants (n = 968) in the National Institute of Child Health and Human Development Neonatal Research Network who had TGF-β measured on filter paper spot blood samples using a Luminex assay. Infants with a PDA (n = 493) were significantly more immature, had lower birth weights, and had higher rates of respiratory distress syndrome than those without PDA (n = 475). TGF-β on days 3 and 7 of life, respectively, were significantly lower among neonates with PDA (median 1,177 pg/ml [range 642-1,896]; median 1,386 pg/ml [range 868-1,913]) compared with others without PDA (median 1,334 pg/ml [range 760-2,064]; median 1,712 pg/ml [range 1,014-2,518 pg/ml]). The significant difference persisted when death or PDA was considered a composite outcome. TGF-β levels were not significantly different among subgroups of infants with PDA who were not treated (n = 51) versus those who were treated medically (n = 283) or by surgical ligation (n = 159). TGF-β was not a significant predictor of death or PDA (day 3 odds ratio [OR] 0.99, 95 % confidence interval [CI] 0.83-1.17; day 7 OR 0.88, 95 % CI 0.74-1.04) on adjusted analyses. Our results suggest that blood spot TGF-β alone is unlikely to be a reliable biomarker of a clinically significant PDA or its responsiveness to treatment.
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Affiliation(s)
- Girija Natarajan
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI 48201, USA.
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23
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Buckvold S, Yetman AT. The 2010 AHA/ACC/AATS Guidelines on the Management of Thoracic Aortic Disease: What they say and why. PROGRESS IN PEDIATRIC CARDIOLOGY 2012. [DOI: 10.1016/j.ppedcard.2012.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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24
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Iwata JI, Hacia JG, Suzuki A, Sanchez-Lara PA, Urata M, Chai Y. Modulation of noncanonical TGF-β signaling prevents cleft palate in Tgfbr2 mutant mice. J Clin Invest 2012; 122:873-85. [PMID: 22326956 DOI: 10.1172/jci61498] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 01/04/2012] [Indexed: 11/17/2022] Open
Abstract
Patients with mutations in either TGF-β receptor type I (TGFBR1) or TGF-β receptor type II (TGFBR2), such as those with Loeys-Dietz syndrome, have craniofacial defects and signs of elevated TGF-β signaling. Similarly, mutations in TGF-β receptor gene family members cause craniofacial deformities, such as cleft palate, in mice. However, it is unknown whether TGF-β ligands are able to elicit signals in Tgfbr2 mutant mice. Here, we show that loss of Tgfbr2 in mouse cranial neural crest cells results in elevated expression of TGF-β2 and TGF-β receptor type III (TβRIII); activation of a TβRI/TβRIII-mediated, SMAD-independent, TRAF6/TAK1/p38 signaling pathway; and defective cell proliferation in the palatal mesenchyme. Strikingly, Tgfb2, Tgfbr1 (also known as Alk5), or Tak1 haploinsufficiency disrupted TβRI/TβRIII-mediated signaling and rescued craniofacial deformities in Tgfbr2 mutant mice, indicating that activation of this noncanonical TGF-β signaling pathway was responsible for craniofacial malformations in Tgfbr2 mutant mice. Thus, modulation of TGF-β signaling may be beneficial for the prevention of congenital craniofacial birth defects.
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Affiliation(s)
- Jun-ichi Iwata
- Center for Craniofacial Molecular Biology, Ostrow School of Dentistry, University of Southern California, Los Angeles, California 90033, USA
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25
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Zhang L, Gao LG, Zhang M, Zhou XL. Genotype-phenotype analysis of F-helix mutations at the kinase domain of TGFBR2, including a type 2 Marfan syndrome familial study. Mol Vis 2012; 18:55-63. [PMID: 22259224 PMCID: PMC3258522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2011] [Accepted: 01/05/2012] [Indexed: 12/02/2022] Open
Abstract
PURPOSE Transforming growth factor beta receptor II (TGFBR2) gene mutations are associated with Marfan syndrome; however, the relationship between the mutations and clinical phenotypes are not clear. METHODS Genomic DNA from peripheral blood leukocytes of a Chinese proband with Marfan syndrome, five of the proband's relatives, and 100 unrelated Chinese control subjects were isolated and screened for fibrillin-1 (FBN1) and TGFBR2 gene mutations by direct sequencing, and a genotype-phenotype study was performed following a review of the literature on TGFBR2 mutations in the search area. Also, the structure of TGFBR2 protein before and after gene mutation was analyzed. RESULTS The results identified a novel missense TGFBR2 mutation p.V453E (c.1358T>A) in the proband and two relatives that was located in the F-helix in the kinase domain of TGFBR2. No such genetic change was observed in the unrelated controls. No FBN1 mutation was detected in any of the subjects. Genotype-phenotype analyses indicated that F-helix mutations are related to type 2 Marfan syndrome and Loeys-Dietz syndrome, and these mutations can lead to severe cardiovascular (93.8%) and skeletal (81.3%) lesions and minor ocular lesions (25%). Losartan treatment can slow-down the progression of aortic lesions. CONCLUSIONS The findings extend the mutation spectrum of Marfan syndrome, and that mutations at the F-helix in the kinase domain of TGFBR2 may be associated with the development of severe cardiovascular and skeletal lesions and minor ocular lesions. These findings have implications for genetic testing, diagnosis, and treatment in individuals with transforming growth factor beta (TGF-β) signaling-related disorders.
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Affiliation(s)
- Lin Zhang
- Department of Cardiology, FuWai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ling-Gen Gao
- Department of Geriatric Cardiology, General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Ming Zhang
- Beijing Institute of Heart, Lung and blood vessel disease, AnZhen hospital, Beijing, China
| | - Xian-Liang Zhou
- Department of Cardiology, FuWai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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26
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Likes ML, Johnston TA. Gastric pseudoaneurysm in the setting of Loey's Dietz Syndrome. IMAGES IN PAEDIATRIC CARDIOLOGY 2012; 14:1-5. [PMID: 23720690 PMCID: PMC3663156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- ML Likes
- University of Washington, Pediatrics, Seattle Children's Hospital, Pediatric Cardiology,
Maggie L. Likes 4800 Sand Point Way NE M/S G-0035 PO Box 5371 Seattle, WA 98145
| | - TA Johnston
- University of Washington, Pediatrics, Seattle Children's Hospital, Pediatric Cardiology
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27
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Kalra VB, Gilbert JW, Malhotra A. Loeys-Dietz syndrome: cardiovascular, neuroradiological and musculoskeletal imaging findings. Pediatr Radiol 2011; 41:1495-504; quiz 1616. [PMID: 21785848 DOI: 10.1007/s00247-011-2195-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2011] [Revised: 06/04/2011] [Accepted: 06/10/2011] [Indexed: 11/29/2022]
Abstract
Loeys-Dietz syndrome (LDS) is an increasingly recognized autosomal-dominant connective tissue disorder with distinctive radiological manifestations, including arterial tortuosity/aneurysms, craniofacial malformations and skeletal abnormalities. LDS exhibits a more aggressive course than similar disorders, such as Marfan or the vascular subtype of Ehlers-Danlos syndrome, with morbidity and mortality typically resulting from complications of aortic/arterial dissections. Early diagnosis, short-interval follow-up imaging and prophylactic surgical intervention are essential in preventing catastrophic cardiovascular complications. This review focuses on the cardiovascular, neuroradiological and musculoskeletal imaging findings in this disorder and recommendations for follow-up imaging.
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Affiliation(s)
- Vivek B Kalra
- Department of Diagnostic Radiology, Yale-New Haven Medical Center, Box 208042, Tompkins East 2, 333 Cedar St., New Haven, CT 06520-8042, USA
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28
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Diedrich KT, Roberts JA, Schmidt RH, Albright LAC, Yetman AT, Parker DL. Medical record and imaging evaluation to identify arterial tortuosity phenotype in populations at risk for intracranial aneurysms. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2011; 2011:295-304. [PMID: 22195081 PMCID: PMC3243263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
High arterial tortuosity may signify early arterial pathology which may precede development of intracranial aneurysms. We measured arterial tortuosity of intracranial vessels and reviewed the medical records of three groups of patients: with intracranial aneurysms, without aneurysms but at increased clinical risk, and controls without aneurysms or associated risk factors. There was significant but inconsistent evidence of increased arterial tortuosity in aneurysm cases and high-risk cases across different arteries. Medical records review identified that a subset of aneurysm cases carried a diagnosis of Loeys-Dietz syndrome that is often misdiagnosed as Marfan syndrome. We found increased arterial tortuosity in the Loeys-Dietz syndrome cases. A combination of medical record screening for Marfan syndrome or Loeys-Dietz symptoms such as aneurysms and evaluation of arterial tortuosity by a curve of scores from medical images may identify previously undiagnosed cases of Loeys-Dietz syndrome.
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Affiliation(s)
- Karl T Diedrich
- Utah Center for Advanced Imaging Research, Department of Radiology, University of Utah, 729 Arapeen Drive, Salt Lake City, UT 84108, USA.
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29
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Vida VL, Padalino MA, Motta R, Micciolo M, Cerutti A, Milanesi O, Stellin G. Traumatic Aortic Dissection in a Boy With Loeys-Dietz Syndrome. Ann Thorac Surg 2011; 92:1520-2. [DOI: 10.1016/j.athoracsur.2011.03.140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 03/14/2011] [Accepted: 03/25/2011] [Indexed: 10/17/2022]
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30
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Schoenhoff FS, Cameron DE, Matyas G, Carrel TP. Cardiovascular surgery in Marfan syndrome: implications of new molecular concepts in thoracic aortic disease. Future Cardiol 2011; 7:557-69. [DOI: 10.2217/fca.11.37] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Acute dissection and rupture of aortic aneurysms comprise for 1–2% of all deaths in industrialized countries. Dilation of the aorta is caused by a multitude of mechanisms including inherited connective tissue disorders such as Marfan syndrome (MFS). MFS is one of the most common inherited connective tissue disorders affecting 1 in 5000 individuals. Although the phenotype of MFS can be quite variable, aneurysmal dilation of the aortic root and consecutive acute aortic dissection is the leading cause of death in this patient population. Over the past years it has been shown that a comprehensive understanding of this disorder provides greater understanding of vascular wall biology and identifies pathways relevant to aortic aneurysms and dissection in general. The current review discusses the surgical management of patients with MFS with a special emphasis on indications for surgery in this complex group of patients.
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Affiliation(s)
- Florian S Schoenhoff
- Department of Cardiovascular Surgery, University Hospital Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Duke E Cameron
- Divison of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Gabor Matyas
- Institute of Medical Molecular Genetics, University of Zurich, Zurich, Switzerland
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31
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Campbell IM, Kolodziejska KE, Quach MM, Wolf VL, Cheung SW, Lalani SR, Ramocki MB, Stankiewicz P. TGFBR2 deletion in a 20-month-old female with developmental delay and microcephaly. Am J Med Genet A 2011; 155A:1442-7. [PMID: 21567932 DOI: 10.1002/ajmg.a.34015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 03/07/2011] [Indexed: 11/07/2022]
Abstract
To date, over 70 mutations in the TGFBR2 gene have been reported in patients with Loeys-Dietz syndrome (LDS), Marfan syndrome type 2 (MFS2), or other hereditary thoracic aortic aneurysms and dissections. Whereas almost all of mutations analyzed thus far are predicted to disrupt the constitutively active C-terminal serine/threonine kinase domain of TGFBR2, mounting evidence suggests that the molecular mechanism underlying these diseases is more complex than simple haploinsufficiency. Using exon-targeted oligonucleotide array comparative genomic hybridization, we identified an ∼896 kb deletion of TGFBR2 in a 20-month-old female with microcephaly and global developmental delay, but no stigmata of LDS. FISH analysis showed no evidence of this deletion in the parental peripheral blood samples; however, somatic mosaicism was detected using PCR in the paternal DNA from peripheral blood lymphocytes and lymphoblasts. Our data suggest that TGFBR2 haploinsufficiency may cause a phenotype, which is distinct from LDS. Moreover, we propose that somatic mosaicism below the detection threshold of FISH analysis in asymptomatic parents of children with genomic disorders may be more common than previously recognized.
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Affiliation(s)
- Ian M Campbell
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas 77030, USA
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32
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Rahme RJ, Adel JG, Bendok BR, Bebawy JF, Gupta DK, Batjer HH. Association of Intracranial Aneurysm and Loeys-Dietz Syndrome: Case Illustration, Management, and Literature Review. Neurosurgery 2011; 69:E488-92; discussion E492-3. [DOI: 10.1227/neu.0b013e318218cf55] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE:
Loeys-Dietz syndrome (LDS) is a newly described connective tissue disease associated with aortic aneurysms. A strong association between LDS and intracranial aneurysms has not yet been documented in the literature. We present the first detailed report of an intracranial aneurysm finding in an LDS patient.
CLINICAL PRESENTATION:
The patient is a 20-year-old female recently diagnosed with LDS and found to harbor 2 incidental intracranial aneurysms on a screening magnetic resonance angiography: a 3-mm right carotid ophthalmic aneurysm and an 8-mm partially fusiform paraclinoid carotid artery aneurysm. A standard left pterional craniotomy was performed. Intraoperative adenosine was used instead of temporary clipping because her vessels were extremely friable. After reconstruction, an intraoperative indocyanine green angiogram was obtained, confirming complete aneurysmal obliteration and internal carotid artery patency.
CONCLUSION:
This is the first detailed report of a clear association between intracranial aneurysms and LDS. An association between LDS and intracranial aneurysms, if substantiated in a larger study, has implications for aneurysm screening in this population. Such an association may shed light on mechanisms of aneurysm formation, growth, and rupture.
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Affiliation(s)
- Rudy J. Rahme
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joseph G. Adel
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Bernard R. Bendok
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John F. Bebawy
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dhanesh K. Gupta
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - H. Hunt Batjer
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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33
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Suarez B, Caldera A, Castillo M. Imaging and clinical features in a child with Loeys-Dietz syndrome. A case report. Interv Neuroradiol 2011; 17:9-11. [PMID: 21561552 PMCID: PMC3278033 DOI: 10.1177/159101991101700102] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 02/13/2011] [Indexed: 11/17/2022] Open
Abstract
We describe a boy with Loeys-Dietz syndrome (LDS) a genetic and recently described condition that affects connective tissues belonging to a group of Marfan-related disorders. Since there are only a few cases reported misdiagnosis may not be uncommon. Radiological findings in our patient include pectus excavatum, aortic root dilatation, diffuse dilatation of the intracerebral vessels and a Chiari I malformation. We describe the imaging findings, clinical presentation and diagnosis criteria of this entity.
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Affiliation(s)
- B Suarez
- Department of Neuroradiology, University of North Carolina, Chapel Hill, North Carolina 27599-7510, USA.
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34
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Kuisle AM, Gauguet S, Karlin LI, Dauber A, McCann ME. Postoperative adrenal crisis in an adolescent with Loeys-Dietz syndrome and undiagnosed adrenoleukodystrophy. Can J Anaesth 2011; 58:392-5. [PMID: 21225386 DOI: 10.1007/s12630-010-9451-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Accepted: 12/20/2010] [Indexed: 11/25/2022] Open
Abstract
PURPOSE We present an unusual case involving an adolescent who experienced cardiovascular collapse postoperatively. He had more than one rare life-threatening genetic disorder, and herein we review the anesthetic management of a patient with Loeys-Dietz syndrome (LDS) and adrenoleukodystrophy. CLINICAL FEATURES A 12-yr-old male (41.5 kg, American Society of Anesthesiologists' physical status III) with LDS, a connective tissue disorder, underwent posterior spinal fusion for spondylolisthesis. This patient demonstrated many signs of LDS: bifid uvula, retrognathia, dilated aortic root, aortic arch aneurysm, inguinal hernias and vertebral subluxations, and multiple areas of tortuous intracranial vessels. A fibreoptic intubation was performed and a balanced anesthetic was administered, consisting of opioids and a low-dose volatile agent. The patient was stable throughout surgery, and at the end of the procedure, his trachea was extubated and he was admitted to the intensive care unit. During the postoperative period, the patient became acutely hemodynamically unstable. Initially, the intensive care team considered the differential diagnoses of postoperative hemorrhage, postoperative sepsis, and cardiac failure secondary to aortic dissection. Supportive care was instituted, and these diagnoses were systematically ruled out. The differential diagnosis was expanded, and the patient was treated with corticosteroids after baseline cortisol levels were drawn. Later he was found to have primary adrenal failure, and it was determined by biochemical and genetic blood analysis that he also had adrenoleukodystrophy. CONCLUSIONS Although Occam's razor states that physicians should exercise diagnostic parsimony when treating patients, it is possible for a patient to have two or more life-threatening unrelated genetic disorders. Consequently, diagnosticians must always develop and test new hypotheses when treating patients.
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Affiliation(s)
- Ami M Kuisle
- Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA
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Erkula G, Sponseller PD, Paulsen LC, Oswald GL, Loeys BL, Dietz HC. Musculoskeletal findings of Loeys-Dietz syndrome. J Bone Joint Surg Am 2010; 92:1876-83. [PMID: 20686062 DOI: 10.2106/jbjs.i.01140] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Loeys-Dietz syndrome is a recently recognized multisystemic disorder caused by mutations in the genes encoding the transforming growth factor-beta receptor. It is characterized by aggressive aneurysm formation and vascular tortuosity. We report the musculoskeletal demographic, clinical, and imaging findings of this syndrome to aid in its diagnosis and treatment. METHODS We retrospectively analyzed the demographic, clinical, and imaging data of sixty-five patients with Loeys-Dietz syndrome seen at one institution from May 2007 through December 2008. RESULTS The patients had a mean age of twenty-one years, and thirty-six of the sixty-five patients were less than eighteen years old. Previous diagnoses for these patients included Marfan syndrome (sixteen patients) and Ehlers-Danlos syndrome (two patients). Spinal and foot abnormalities were the most clinically important skeletal findings. Eleven patients had talipes equinovarus, and nineteen patients had cervical anomalies and instability. Thirty patients had scoliosis (mean Cobb angle [and standard deviation], 30 degrees +/- 18 degrees ). Two patients had spondylolisthesis, and twenty-two of thirty-three who had computed tomography scans had dural ectasia. Thirty-five patients had pectus excavatum, and eight had pectus carinatum. Combined thumb and wrist signs were present in approximately one-fourth of the patients. Acetabular protrusion was present in approximately one-third of the patients and was usually mild. Fourteen patients had previous orthopaedic procedures, including scoliosis surgery, cervical stabilization, clubfoot correction, and hip arthroplasty. Features of Loeys-Dietz syndrome that are important clues to aid in making this diagnosis include bifid broad uvulas, hypertelorism, substantial joint laxity, and translucent skin. CONCLUSIONS Patients with Loeys-Dietz syndrome commonly present to the orthopaedic surgeon with cervical malformations, spinal and foot deformities, and findings in the craniofacial and cutaneous systems. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gurkan Erkula
- Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224-2780, USA
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Augmentation index and the evolution of aortic disease in marfan-like syndromes. Am J Hypertens 2010; 23:716-24. [PMID: 20395939 DOI: 10.1038/ajh.2010.78] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The augmentation index at a heart rate of 75 beats/min (AIx@HR75) and central pulse pressure (CPP) can be measured noninvasively with applanation tonometry (APT). In this observational study, we investigated the relationship between AIx@HR75, CPP and aortic disease in patients with Marfan-like syndromes. METHODS We performed APT in 78 consecutive patients in whom classic Marfan syndrome (MFS) had been excluded (46 men and 32 women aged 34 +/- 13 years). These patients comprised 9 persons with MFS-like habitus, 6 with a bicuspid aortic valve (BAV), 5 with MASS phenotype, 3 with vascular type of Ehlers-Danlos syndrome (EDS), 3 with familial thoracic aortic aneurysm, 2 with Loeys-Dietz syndrome (LDS), 1 with mitral valve prolapse syndrome, 1 with familial ectopia lentis, and 48 persons with Marfan-like features but no defined syndrome. During 20 +/- 18 months after APT, we observed progression of aortic diameters in 15 patients, and aortic surgery or aortic dissection in 3 individuals. RESULTS All 11 patients with Marfan-like syndromes and progression of aortic disease exhibited AIx@HR75 > or =11%, including 8 individuals with aortic diameters < or =95th percentile of normal at baseline. Similarly, all 7 individuals without any defined syndrome but progression of aortic diameters exhibited AIx@HR75 >11%, including 6 individuals with aortic diameters < or =95th percentile at the time of APT. Aortic disease did not evolve at AIx@HR75 <11%. CPP is also related to aortic disease progression. CONCLUSIONS Aortic disease evolution relates to AIx@HR75 and CPP in Marfan like syndromes. Larger studies with comprehensive clinical and echocardiographic follow-up over long time intervals will be required to establish APT for prediction of aortic disease evolution in Marfan-like syndromes.
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Muramatsu Y, Kosho T, Magota M, Yokotsuka T, Ito M, Yasuda A, Kito O, Suzuki C, Nagata Y, Kawai S, Ikoma M, Hatano T, Nakayama M, Kawamura R, Wakui K, Morisaki H, Morisaki T, Fukushima Y. Progressive aortic root and pulmonary artery aneurysms in a neonate with Loeys-Dietz syndrome type 1B. Am J Med Genet A 2010; 152A:417-21. [PMID: 20101701 DOI: 10.1002/ajmg.a.33263] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Loeys-Dietz Syndrome (LDS) is an autosomal dominant aortic aneurysm syndrome with multisystem involvement, caused by heterozygous mutations of transforming growth factor beta receptor type 1 (TGFBR1) or type 2 (TGFBR2) genes. We report on a neonate with the disorder caused by a known TGFBR2 mutation, who developed neonatal-onset progressive dilation of the aortic valve and aneurysms of the aortic root and main pulmonary artery (PA) associated with a large left-to-right shunt via a ventricular septal defect (VSD) and an atrial septal defect. He also had skeletal features (flexion contractures of the fingers, talipes equinovarus, a cleft palate, and joint laxity), mild facial dysmorphisms, and developmental delay. The dilation and aneurysms progressed after PA banding at age 12 days; and the patient received an intracardiac repair of the defects and PA plasty at age 42 days, followed by no further progression of the dilation and the aneurysms. Neonates with generalized hypotonia, a cleft palate, inguinal herniae, musculoskeletal features such as camptodactyly and talipes equinovarus, and a cardiac murmur should be suspected to have LDS, and extensive cardiovascular evaluation and testing of TGFBR1 and TGFBR2 are recommended. LDS patients with cardiac defects that lead to a large left-to-right shunt and congestive heart failure such as VSD should be considered for intracardiac repair even in early infancy.
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Affiliation(s)
- Yukako Muramatsu
- Department of Neonatology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
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A new sporadic case of early-onset Loeys-Dietz syndrome due to the recurrent mutation p.R528C in the TGFBR2 gene substantiates interindividual clinical variability. J Appl Genet 2010; 50:405-10. [PMID: 19875893 DOI: 10.1007/bf03195701] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We report on a 2-year-old Polish girl with typical manifestations of Loeys-Dietz syndrome (LDS), a rare genetic condition belonging to the group of Marfan-related disorders. The characteristic LDS symptoms observed in the girl included craniofacial dysmorphism (craniosynostosis, cleft palate, hypertelorism), arachnodactyly, camptodactyly, scoliosis, joint laxity, talipes equinovarus, translucent and hyperelastic skin, and umbilical hernia. Mild dilatation of the ascending aorta and tortuous course of the left internal carotid artery were recognized during her second year of life. Molecular genetic testing revealed a heterozygous missense mutation (c.1582C>T, p.R528C) in the transforming growth factor beta receptor II gene (TGFBR2). This mutation has been previously associated with LDS in 5 unrelated cases, and was never reported in patients with other Marfan-related disorders. Comparison of the phenotypes of our patient and these 5 individuals with c.1582C>T showed that only the hallmark triad of the syndrome - consisting of hypertelorism, aortic root dilatation/aneurysm, and cleft palate or bifid uvula - was present in all 6 cases. Interestingly, none of the 5 individuals who underwent psychological evaluation showed developmental delay. The pattern of all other LDS features showed interindividual variability. Our data support the recently reported observation that symptoms of LDS can develop at a very young age, making early diagnosis and management essential for these patients. This is the first report on a Polish infant with typical LDS symptoms caused by a TGFBR2 mutation.
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Augoustides JG, Andritsos M. Innovations in Aortic Disease: The Ascending Aorta and Aortic Arch. J Cardiothorac Vasc Anesth 2010; 24:198-207. [DOI: 10.1053/j.jvca.2009.09.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Indexed: 11/11/2022]
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Abstract
Loeys-Dietz syndrome is a newly recognized constellation that presents with aortic aneurysm or dissection similar to Marfan's syndrome. We describe successful surgical treatment in a 2-year-old with the syndrome in whom we performed a valve-sparing replacement of the aortic root because of significant dilation of the aortic root and the ascending aorta.
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Buddingh KT, Zeebregts CJ, Tilanus MEC, Roofthooft MTR, Broens PMA. Large neonatal thoracoabdominal aneurysm: case report and review of the literature. J Pediatr Surg 2008; 43:1361-4. [PMID: 18639697 DOI: 10.1016/j.jpedsurg.2008.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2007] [Revised: 01/31/2008] [Accepted: 02/05/2008] [Indexed: 11/19/2022]
Abstract
We present a neonate with a large saccular aneurysm of the thoracoabdominal aorta, extending from the intrathoracic aorta to the left common iliac artery. No underlying cause could be identified. Despite an early diagnosis, the aneurysm was deemed inoperable because of the lengthy involvement and the frail aspect of all visceral arteries. A review of the literature on congenital abdominal aortic aneurysm in infants was conducted. Eleven cases of live-born infants with a congenital abdominal aortic aneurysm have previously been published. None of them involved as large a part of the thoracic and abdominal aorta as the case presented here.
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Affiliation(s)
- K Tim Buddingh
- Division of Paediatric Surgery, Department of Surgery, University Medical Center Groningen, 9700 RB Groningen, The Netherlands
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