Variant filtering, digenic variants, and other challenges in clinical sequencing: a lesson from fibrillinopathies

Genome-scale high-throughput sequencing enables the detection of unprecedented numbers of sequence variants. Variant filtering and interpretation are facilitated by mutation databases, in silico tools, and population-based reference datasets such as ExAC/gnomAD, while variants are classified using the ACMG/AMP guidelines. These methods, however, pose clinically relevant challenges. We queried the gnomAD dataset for (likely) pathogenic variants in genes causing autosomal-dominant disorders. Furthermore, focusing on the fibrillinopathies Marfan syndrome (MFS) and congenital contractural arachnodactyly (CCA), we screened 500 genomes of our patients for co-occurring variants in FBN1 and FBN2. In gnomAD, we detected 2653 (likely) pathogenic variants in 253 genes associated with autosomal-dominant disorders, enabling the estimation of variant-filtering thresholds and disease predisposition/prevalence rates. In our database, we discovered two families with hitherto unreported co-occurrence of FBN1/FBN2 variants causing phenotypes with mixed or modified MFS/CCA clinical features. We show that (likely) pathogenic gnomAD variants may be more frequent than expected and are challenging to classify according to the ACMG/AMP guidelines as well as that fibrillinopathies are likely underdiagnosed and may co-occur. Consequently, selection of appropriate frequency cutoffs, recognition of digenic variants, and variant classification represent considerable challenges in variant interpretation. Neglecting these challenges may lead to incomplete or missed diagnoses.

Restrictive Dermopathy: A Rare Disease with Unusual Radiographic Findings

The patient is a unique case presenting with presumed Restrictive Dermopathy (RD) and intracranial and adrenal calcifications, an association not previously described in the literature. This case postulates the possibility of additional radiographic features that can be included in the spectrum of RD or as secondary events from the underlying pathophysiology of RD.

Congenital gluteus maximus contracture syndrome--a case report with review of imaging findings

Although the clinical features of gluteus maximus contracture syndrome have been frequently described, imaging features have been seldom described. Most commonly reported cases are those following intramuscular injection in the gluteal region although congenital contracture is an uncommon but important occurrence. This condition has most often been reported in children of school going age. These patients often present with difficulty in squatting, limitation of hip motion or specific deformities and often require surgical correction. We describe the plain radiography, ultrasonography (USG) and magnetic resonance imaging (MRI) features of this condition in a patient with no previous known history of intramuscular injections.

A novel autosomal dominant inclusion body myopathy linked to 7q22.1-31.1

We describe a novel autosomal dominant hereditary inclusion body myopathy (HIBM) that clinically mimics limb girdle muscular dystrophy in a Chinese family. We performed a detailed clinical assessment of 36 individuals spanning four generations. The age of onset ranged from the 30s to the 50s. Hip girdle, neck flexion and axial muscle weakness were involved at an early stage. This disease progressed slowly, and a shoulder girdle weakness appeared later in the disease course. Muscle biopsies showed necrotic, regenerating, and rimmed vacuolated fibers as well as congophilic inclusions in some of the fibers. Electron micrograph revealed cytoplasmic inclusions of 15–21 nm filaments. A genomewide scan and haplotype analyses were performed using an Illumina Linkage-12 DNA Analysis Kit (average spacing 0.58 cM), which traced the disease to a new locus on chromosome 7q22.1–31.1 with a maximum multi-point LOD score of 3.65. The critical locus for this unique disorder, which is currently referred to as hereditary inclusion body myopathy 4 (HIBM4), spans 8.78 Mb and contains 65 genes. This localization raises the possibility that one of the genes clustered within this region may be involved in this disorder.

Another VCP interactor: NF is enough

Inclusion body myopathy with Paget disease of the bone and frontotemporal dementia (IBMPFD) is a multisystem degenerative disorder caused by mutations in the valosin-containing protein (VCP) gene. How missense mutations in this abundant, ubiquitously expressed, multifunctional protein lead to the degeneration of disparate tissues is unclear. VCP participates in diverse cellular functions by associating with an expanding collection of substrates and cofactors that dictate its functionality. In this issue of the JCI, Wang and colleagues have further expanded the VCP interactome by identifying neurofibromin-1 (NF1) as a novel VCP interactor in the CNS. IBMPFD-associated mutations disrupt binding of VCP to NF1, resulting in reduced synaptogenesis. Thus, aberrant interactions between VCP and NF1 may explain the dementia phenotype and cognitive delay observed in patients with IBMPFD and neurofibromatosis type 1.

Panhypopituitary insufficiency in a patient with clinical diagnosis of Chitayat-Hall syndrome

We report an 8-year-old proband with severe motor and intellectual disability presenting a variety of dysmorphic features such as microcephaly, prominent glabella (ridged metopic suture) and congenital distal limb contractures. As well as panhypopituitary insufficiency, brain defects, e.g. agenesis of corpus callosum, colpocephaly, and pachygyria as well as strabismus and tracheo-laryngeal hypoplasia, were diagnosed. Genetic examination revealed a normal karyotype and excluded Wolf-Hirschhorn syndrome and subtelomeric deletions. Chitayat-Hall syndrome was diagnosed based on clinical traits.

Prenatal diagnosis of restrictive dermopathy

We report three cases of Restrictive dermopathy from unrelated families. All were small for gestational age with small eyes and open mouth. Taut, stretched skin caused restriction of movements. Clavicular hypoplasia was a consistent radiological feature. Molecular diagnosis in the parents facilitated prenatal diagnosis from chorionic villous sample (CVS) in the subsequent pregnancy.

Familial chilblain and late contractural arachnodactyly: a novel association?

We report an Italian family suffering from chilblain. Seven members over three generations affected, two of them presenting association with late contractural arachnodactyly. Inflammatory cutaneous lesions following exposure to cold or drop in temperature are called chilblain. Arachnodactyly is an hallmark of hereditary connective tissue disorders such as Marfan's syndrome and Beals' syndrome. The latter, showing joint congenital contractures, is called indeed congenital contractural arachnodactyly. We speculate that an underlying alteration in connective tissue could lead to the association between chilblain lesions and contractural arachnodactyly.

[Clinical diagnosis and surgical treatment of congenital contractural arachnodactyly: analysis of 6 cases]

OBJECTIVE

To discuss the clinical diagnosis and surgical treatment of congenital contractural arachnodactyly (CCA).

METHODS

The clinical data of 6 CCA patients, 1 male and 5 female, aged 7.5 (5-14) were analyzed. All cases had kyphoscoliosis, 2 in the thoracic segments and 4 in the thoracolumbar segments. The average scoliosis Cobb angle was 88.6 degrees (85 degrees-117 degrees). The average kyphosis Cobb angle was 93.6 degrees (75 degrees-123 degrees). All of the cases underwent internal fixation with pedicle screw and lamina hooks instrumentation, in which 4 cases underwent posterior Smith-Petersen osteotomy. The diagnosis was based on a constellation of clinical findings. The clinical manifestations included marfanoid habitus, flexion contractures of multiple joints (elbow, knee, hip, and finger), kyphoscoliosis, muscular hypoplasia, and abnormal pinnae ("crumpled" outer helices). Molecular genetic testing showed mutation in the fibrillin-2 (FBN2) gene encoding the extracellular matrix microfibril. Four cases were followed up for 6-9 months.

RESULTS

After operation the average Cobb angle of the scoliosis and kyphosis were 37.6 degrees (35 degrees-52 degrees) and 38.6 degrees (28 degrees-54 degrees) immediately, with 62.3% and 68.7% curve correction respectively. Three cases got excellent synostosis of posterior lamina, 1 case underwent revision with lamina hook because the distal screw was loose and hurt the nerve root, and the other 2 cases lost follow-up. The patients' body appearance and pulmonary function were obviously improved.

CONCLUSION

The characteristic clinical manifestation include severe and stiff kyphoscoliosis, difficult to correct , and enhanced Cobb angle, and pedicle dysplasia of vertebral pedicle leading to difficulty in installing screws. Smith-Petersen osteotomy is often necessary. CCA should be differentiated with Marfan syndrome (MFS), Stickler syndrome, Homocystinuria, and distal arthrogryposis, especially MFS.

A rare case of progressive bilateral congenital abduction contracture with shoulder dislocations treated with proximal deltoid release

The contracture of the deltoid muscle is an uncommon disorder. Amongst the various causes reported, post intramuscular injection and trauma leading to the fibrosis of the muscle are common. However, congenital cases are extremely rare. We report a case of congenital progressive bilateral abduction contracture left untreated for a long time leading to anteroinferior subluxation. A proximal release was performed with satisfactory outcome on both sides.

A new lethal case of joint contractures, facial abnormalities, pachygyria plus early-onset encephalopathy with a suppression-burst EEG pattern

Pachygyria, joint contractures and facial abnormalities have been reported in the literature very rarely. These features constitute a new lethal syndrome. We describe a male infant who represents an additional case of the same lethal syndrome first described in 1989. The patient also presented an early-onset epileptic encephalopathy with a suppression-burst EEG pattern.

Mutations in cytokine receptor-like factor 1 (CRLF1) account for both Crisponi and cold-induced sweating syndromes

Crisponi syndrome is a rare autosomal recessive disorder characterized by congenital muscular contractions of facial muscles, with trismus in response to stimuli, dysmorphic features, bilateral camptodactyly, major feeding and respiratory difficulties, and access of hyperthermia leading to death in the first months of life. The overlap with Stuve-Wiedemann syndrome (SWS) is striking, but the two conditions differ in that congenital lower limb bowing is absent in Crisponi syndrome, whereas it is a cardinal feature of SWS. We report here the exclusion of the leukemia inhibitory factor receptor gene in Crisponi syndrome and the identification of homozygote or compound heterozygote cytokine receptor-like factor 1 (CRLF1) mutations in four children from three unrelated families. The four mutations were located in the immunoglobulin-like and type III fibronectin domains, and three of them predicted premature termination of translation. Using real-time quantitative polymerase chain reaction, we found a significant decrease in CRLF1 mRNA expression in patient fibroblasts, which is suggestive of a mutation-mediated decay of the abnormal transcript. CRLF1 forms a heterodimer complex with cardiotrophin-like cytokine factor 1, and this heterodimer competes with ciliary neurotrophic factor for binding to the ciliary neurotrophic factor receptor (CNTFR) complex. The identification of CRLF1 mutations in Crisponi syndrome supports the key role of the CNTFR pathway in the function of the autonomic nervous system.

Congenital shortening of the flexor digitorum profundus muscle

An 8-year-old boy with a history of the inability to extend the middle finger at the proximal interphalangeal and distal interphalangeal joints with the wrist and metacarpophalangeal joints in the neutral position since the age of 5 months had surgery. The flexor digitorum profundus muscle of the middle finger had a short muscle belly and was replaced in part with mature fat tissue. Histologic examination of the resected tissue showed replacement of a part of the muscle with mature fat tissue. It was speculated that some myosatellite cells, which typically differentiate into skeletal muscle cells, may have erroneously differentiated into adipocytes in the first postnatal year, during which complete development of skeletal muscles occurs.

Distal joint contractures, mental retardation, characteristic face and growth retardation: Chitayat syndrome revisited

We report on a patient with congenital distal limb contractures, characteristic face, prominent metopic sutures, narrow forehead, severe psychomotor and growth retardation, white matter lesions and failure to thrive. The child has many overlapping features with those reported previously by Chitayat. We suggest that the central nervous anomalies are responsible for the congenital contractures in Chitayat syndrome.

Congenital contracture of the quadriceps muscle: confirming the diagnosis with magnetic resonance imaging

Congenital contracture of the quadriceps muscle can be defined as progressive loss of knee flexion due to fibrosis within the muscle without a history of trauma or intramuscular injection into the thighs. In the course of time, secondary changes might develop and vitiate the end result so this rare childhood disease needs particular attention for early diagnosis and treatment. Herein, we report a 14-year-old girl presented with inability to bend her knees completely. The clinical and radiological assessment was detailed with magnetic resonance imaging findings.

Lethal congenital contracture syndrome (LCCS) and other lethal arthrogryposes in Finland—An epidemiological study

Arthrogryposis multiplex congenita is a heterogeneous group of disorders characterized by multiple contractures with an estimated frequency of 1 in 3,000 births. With improving diagnostic methods, increasing numbers of fetuses with arthrogryposis are found. The pathogenetic mechanisms are relatively well known but the epidemiology and genetics of the prenatally lethal forms of arthrogryposis are less well known. In this study we collected all cases of a multiple contractures diagnosed in Finland during 1987-2002 including live born infants, stillbirths, and terminated pregnancies. Ninety-two cases of 214 suffered intrauterine demise (68 selective pregnancy terminations and 24 stillbirths) and 58 died in infancy. In 141 out of these cases the diagnosis could be included within lethal arthrogryposes, with a prevalence of 1 in 6,985 (1.43/10,000) births. Of these, 59 had spinal cord pathology at autopsy and thus were of neurogenic origin. Thirty-nine cases had lethal congenital contracture syndrome (LCCS) clinically characterized by total immobility of the fetus at all ultrasound examinations (12 weeks or later), multiple joint contractures in both upper and lower limbs, hydrops, and fetal death before the 32nd week of pregnancy. LCCS is noted as a unique Finnish disorder with a prevalence of 1 in 25,250 (0.40/10,000) births and is a major cause of lethal arthrogryposis in Finland.

Intracranial hemorrhage as the initial manifestation of a congenital disorder of glycosylation

Intracranial hemorrhage in a term neonate is a rare event in the absence of an identifiable precipitating factor such as severe thrombocytopenia, mechanical trauma, asphyxia, infections, or congenital vascular malformations. Congenital disorders of glycosylation are a genetically and clinically heterogeneous group of multisystem disorders characterized by the abnormal glycosylation of a number of glycoproteins. Although bleeding caused by abnormal glycosylation of various coagulation factors is a well-known clinical complication of several types of congenital disorders of glycosylation, intracranial hemorrhage has not been reported as an initial manifestation of this entity. Here we report the detailed history of a family with 2 consecutive male infants, both born at term with intracranial hemorrhage diagnosed within the first 24 hours of life. The diagnosis of a congenital disorder of glycosylation was established in the second infant by an abnormal glycosylation of serum transferrin detected by electrospray-ionization mass spectrometry. Both infants showed significant neurologic deterioration during the first month of life, and both died at 5 months of age. Intracranial hemorrhage in a term neonate without a potential precipitating factor represents yet another clinical feature that should raise the suspicion for a congenital disorder of glycosylation.

Congenital contractural arachnodactyly (Beals syndrome)

Congenital contractural arachnodactyly (Beals syndrome) is an autosomal dominantly inherited connective tissue disorder characterized by multiple flexion contractures, arachnodactyly, severe kyphoscoliosis, abnormal pinnae and muscular hypoplasia. It is caused by a mutation in FBN2 gene on chromosome 5q23. Although the clinical features can be similar to Marfan syndrome (MFS), multiple joint contractures (especially elbow, knee and finger joints), and crumpled ears in the absence of significant aortic root dilatation are characteristic of Beals syndrome and rarely found in Marfan syndrome. The incidence of CCA is unknown and its prevalence is difficult to estimate considering the overlap in phenotype with MFS; the number of patients reported has increased following the identification of FBN2 mutation. Molecular prenatal diagnosis is possible. Ultrasound imaging may be used to demonstrate joint contractures and hypokinesia in suspected cases. Management of children with CCA is symptomatic. Spontaneous improvement in camptodactyly and contractures is observed but residual camptodactyly always remains. Early intervention for scoliosis can prevent morbidity later in life. Cardiac evaluation and ophthalmologic evaluations are recommended.

Long-term survival in a child with severe congenital contractural arachnodactyly, autism and severe intellectual disability

The severe form of congenital contractural arachnodactyly is usually associated with early mortality due to multisystem complications. Here, we report a 9-year-old male child with severe skeletal manifestations of congenital contractural arachnodactyly. He had none of the cardiovascular or gastrointestinal features that have been described in severe congenital contractural arachnodactyly. He had profound intellectual disability with autism. All exons of FBN2, the gene associated with congenital contractural arachnodactyly, were sequenced and no disease-causing mutation was found. When severe congenital contractural arachnodactyly is diagnosed in the newborn period, parents need to be aware that long-term survival is possible, particularly if no significant extraskeletal complications are present, and that significant neurodevelopmental delay may occur.

An unusual complication of mandibular distraction

BACKGROUND

The authors present an unusual complication of mandibular distraction in a child with the curious condition of multiple pterygium syndrome is presented.

CASE REPORT

The patient was a Caucasian male with severe pterygia in his neck. As a result of his limited mouth opening and restricted upper airway leading to obstruction, he underwent lengthening of his mandible by distraction, which significantly improved his breathing. During his follow-up, it was observed that an unusually elongated permanent molar was present in an abnormal position.

CONCLUSION

This case highlights the need to carefully plan the sites for osteotomy and the potential for damage to the developing permanent dentition in young children.

Transient Cardiomyopathy in a Patient with Congenital Contractural Arachnodactyly (Beals Syndrome)

We report on an infant with Beals syndrome (congenital contractural arachnodactyly [CCA], MIM 121050) with transient cardiomyopathy showing ballon-like dilatation of the left ventricle that was similar to noncompaction. The patients father and two of his brothers were also found to have CCA without cardiovascular complications. CCA, which is caused by a mutation of the gene for fibrillin 2 protein is similar to Marfan syndrome (MIM 154700), which is caused by a mutation of fibrillin 1 but produces a life-threatening cardiovascular complications. This is the first report of CCA with transient cardiomyopathy. We discuss the mechanism of the spontaneous improvement of cardiomyopathy in this case on the basis of expression of the responsible gene.

van den Ende-Gupta syndrome of blepharophimosis, arachnodactyly, and congenital contractures

Here, we report on a Venezuelan child with manifestations of van den Ende-Gupta syndrome, including blepharophimosis, arachnodactyly, and congenital contractures. We also review cases from the literature.

Assoziation von Kongenitaler kontraktureller Arachnodaktylie (Beals-Hecht-Syndrom) und Brown-Syndrom

BACKGROUND

We report what is probably the first report of an association between congenital contractural arachnodactyly (CCA) and Brown's syndrome.

CASE REPORT

A 7 (1/2)-year-old boy exhibited characteristic signs of CCA: multiple flexion contractures, marfanoid habitus and "crumpled" ears. In addition, the boy had Brown's syndrome. He had an up-gaze deficit and a slight down-shoot of the left eye in adduction. He held his head tilted to the left shoulder. As the cause, computed tomography revealed a thickening of the superior oblique muscle tendon near the trochlea. A molecular genetic examination revealed a mutation of Fibrillin-2 (FBN2 - 5 q 23 - q 31).

CONCLUSIONS

The association of the CCA and Brown's syndrome seems to be very rare. A specific link between the two mesenchymal disorders was not found. Probably the combination was coincidental.

Orofacial manifestations of congenital fibrillin deficiency: pathogenesis and clinical diagnostics

Mutations in the genes encoding fibrillin, an extracellular matrix protein involved in providing elastic properties to the connective tissues, may result in specific craniofacial and oral anomalies. A number of craniofacial (retrognathia, dolichocephaly, high palate) and dental (root deformity, pulp calcification) manifestations are considered pathognomic for the Marfan syndrome (MFS), a condition caused by congenital fibrillin-1 deficiency. Reports on similar features in congenital contractural arachnodactyly (CCA), caused by fibrillin-2 deficiency, support the hypothesis that fibrillin deficiency might result in a number of morphological anomalies by influencing tissue interaction during growth and development. Hence, clinical manifestations can be related to specific aspects of fibrillin deficiency pathogenesis, and may be adopted as diagnostic tools in the outlook for affected individuals.

Anesthetic management of a patient with Freeman-Sheldon syndrome

The Freeman-Sheldon syndrome (FSS) is rare congenital myopathy and dysplasia. The musculoskeletal and soft-tissue manifestations of FSS often require orthopedic and plastic reconstructive surgery. We report a case of 19-month-old girl with FSS.

Congenital contracture of the quadriceps muscle: a case report with magnetic resonance imaging

INTRODUCTION

Case report of a rare form of congenital contracture of the quadriceps muscle. Congenital contracture of the quadriceps muscle is encountered very rarely in daily orthopaedic practice. A few cases have been reported, but unfortunately these did not detail the MRI findings of congenital contracture.

MATERIALS AND METHODS

A 34-year-old woman presented with difficulty in sitting with full flexion of the bilateral knee joints. She had no history of intramuscular injection, and her brother had a similar abnormality. A physical and radiographical review of the case was conducted.

RESULTS

A palpable corded induration was detected in the quadriceps muscle which prevented further flexion of the bilateral knee joints. Magnetic resonance imaging of both thighs demonstrated marked atrophy of the rectus femoris muscle and dark signal intensity of the muscle on both T1-weighted and T2-weighted images. It was suggested that the muscles had been replaced by fibrosis.

CONCLUSION

This appears to be the first report to include MRI findings of congenital contracture. Clinical awareness of congenital contracture with unique clinical symptoms and radiographic findings may aid the correct diagnosis.

Die kongenitale unilaterale Muskelhyperplasie der Hand - eine seltene Fehlbildung

This is a report on eight cases of a rare congenital malformation in the upper extremity, consisting of a unilateral muscular hyperplasia. In addition to the hand, all segments of the upper extremity may be affected. The hyperplasia is always unilateral, preferably on the right hand side, in combination with accessory muscles. Hereditary dependence or association with other malformations has not been observed. Six of eight patients were male. Shoulder and arm function were normal in all cases. Ulnar drift of the fingers in the metacarpophalangeal joints (six of eight patients), flexion contractures of the metacarpophalangeal joints (six of eight patients) and extension contractures of the wrist (three of eight patients) to various degrees were seen. A prominence of the second and third metacarpal head with an enlarged space between them gave the affected hands a very typical appearance (six of eight patients). Deformities and functional limitations requiring surgical treatment were present in six patients. In all cases, accessory muscles were found intraoperatively and resected. The macroscopic and microscopic appearance of the muscle specimen did not differ from normal muscular tissue. In all cases, additional procedures were necessary to improve the overall function. Nevertheless, the reconstructive efforts did not lead to an entirely normal hand function or appearance. The malformation we describe can clearly be distinguished from other malformations such as arthrogryposis multiplex congenita, Freeman-Sheldon syndrome or macrodactyly. Up to now, only two other reports were found in the literature showing characteristics similar to those in our own cases. Four similar cases were observed by Benatar. From a pathomechanical point of view, a disturbance in the muscular balance seems to cause the deformities and functional limitations. This imbalance could be related to accessory muscles which are not opposed by defined antagonists or to an unbalanced hyperplasia of normally developed musculature. Surgical intervention should begin early to prevent joint stiffness. Splinting and hand therapy should precede surgical intervention. Surgical treatment should aim to restore the muscular balance by resection of accessory and hyperplastic musculature. In some cases, muscle transpositions and joint releases may have to be performed. Postoperative splinting and intensive hand therapy are mandatory to preserve the results.

The Windblown Hand - Diagnosis, Clinical Picture and Pathogenesis

The syndrome of the windblown hand deformity is a complex constellation of malformations affecting not only the head and the feet but also the hands in a quite distinct manner. In the hand, it involves congenital bilateral flexion contracture with ulnar deviation of the metacarpophalangeal joints. The thumb is characteristically adducted (reaching the palm; "thumb-in-palm deformity") with flexion of the MP joint and hyperextension of the IP joint. The etiology is basically unknown. We present two theories based on knowledge derived from the disciplines of evolution biology and embryology. We believe that the atavistic appearance of phylogenetically primitive muscle groups in conjunction with an impaired rotation of the extremities during embryological development account for this malformation syndrome.

Kirner's Deformity Treated by Distal Detachment of the Flexor Digitorum Profundus Tendon

Kirner's deformity may be due to a very distal insertion of the flexor digitorum profundus tendon along the palmar surface of the distal phalanx of the small finger. Distal detachment of the flexor digitorum profundus tendon has already led to encouraging results. Intraoperative findings, surgical technique and results are shown.

Homozygosity mapping of lethal congenital contractural syndrome type 2 (LCCS2) to a 6 cM interval on chromosome 12q13

We have recently described a novel autosomal recessive disorder, lethal congenital contractural syndrome type 2 (LCCS2) (OMIM 607598), in a large Israeli Bedouin kindred. The phenotype, which is lethal in the neonatal period, is distinguished by the presence of a markedly distended urinary bladder. Association of LCCS2 to the known loci associated with arthogryposis was excluded. In the present study, we set out to determine the genetic locus harboring the gene defective in this disease. We performed genome-wide linkage analysis, demonstrating linkage to a approximately 6 cM (corresponding to approximately 7.2 Mb) homozygosity region on chromosome 12q13 between markers D12S1604 and D12S83. Based on recombination events, the interval harboring the disease-associated locus was further narrowed to a region spanning approximately 6 cM ( approximately 6.4 Mb) between D12S325 and D12S1072. Linkage of LCCS2 to that locus was established, with two significant maximum peaks at markers D12S1604 (Z(max) = 10.56 at theta = 0.01) and D12S1700 (Z(max) = 9.23 at theta = 0.00).

Congenital flexion deformity of the wrist owing to an anomalous insertion of the flexor carpi ulnaris: a case report

A case of congenital flexion deformity of the wrist is described. The cause was an anomalous insertion of the flexor carpi ulnaris into skin and palmar aponeurosis.

Novel dental anomalies associated with congenital contractural arachnodactyly: a case report

Congenital contractural arachnodactyly (CCA) is an inherited disorder of connective tissue similar to Marfan's syndrome. The craniofacial and oral features of a young girl with CCA are described. The patient has the typical features of CCA as well as some additional dental anomalies which have not previously been reported with this syndrome. These include banded pitted enamel hypoplasia and hypomineralization, long, spindly tapered roots, and pulp canal obliteration with multiple pulp stones. Dentists must be aware of the clinical features of a patient's syndrome to determine whether there are implications for dental treatment such as a need for antibiotic prophylaxis. It is important to exclude Marfan's syndrome as a differential diagnosis for CCA because the former has more associated complications and a less favorable prognosis.

A new autosomal recessive congenital contractural syndrome in an Israeli Bedouin kindred

We describe 23 cases with a syndrome of congenital contractures belonging to a large, inbred Israeli-Bedouin kindred. The phenotype described is similar to the Finnish type lethal congenital contracture syndrome yet differs in the following ways: by some additional craniofacial/ocular findings, by the lack of hydrops, multiple pterygia, and fractures, and by the normal duration of pregnancy. The major unique and previously undescribed clinical feature in our patients is a markedly distended urinary bladder as well as other urinary abnormalities. The vast majority of the cases died shortly after birth. Sonographic prenatal diagnosis was possible as early as 15 weeks gestation by demonstrating fetal akinesia, limb contractures, hydramnios, and distended urinary bladder. Linkage to 5q and 9q34 loci has been excluded.

Beals-Hecht syndrome

Beals-Hecht syndrome, also known as congenital contractural arachnodactyly, is caused by a defect in fibrillin as in Marfan syndrome. This syndrome is characterized by a multitude of clinical findings including arachnodactyly, narrow body habitus, scoliosis, congenital contractures, and external ear deformities. Restrictive lung disease may be associated with the severe scoliosis and thoracic cage abnormalities in this syndrome. We describe a child with Beals-Hecht syndrome and review the literature.

[Ultrasound in the early diagnosis of congenital dislocation of the patella]

INTRODUCTION

Congenital dislocation of the patella is defined as lateral dislocation of the patella present at birth, impossibility of closed reduction and diagnosis before the age of 10 years. We report about a rare case of a bilateral congenital dislocation of the patella.

CASE REPORT

Physical examination of an eight-month- old boy showed bilateral knee flexion contractures associated with moderate genu varum. On both sides the patella could not be palpated easily. Radiographic diagnosis could not show the patella as the patella normally ossifies later. Ultrasound examination located the patella lateral to the lateral femoral condyle on both sides. Closed reduction was impossible. An open reduction with division of the lateral soft tissues, lateral release, and derotation of the quadriceps femoris and refining of the medial structures was performed. After cast removal the patellae were both located in the intercondylar grooves as confirmed by clinical and ultrasound examinations of both knees. Active and passive exercises were started.

CONCLUSION

Failure of internal rotation of the myotome which contains the quadriceps femoris and the patella is the etiology of congenital dislocation of the patella. The quadriceps acts as flexor, exerting a valgus stress on the knee, causing external rotation of the tibia. Diagnosis is often delayed because of the lack of pathological findings on plain radiographs. Early diagnosis is enabled by ultrasonography. Surgical treatment is necessary and results are good, as long as there are no secondary changes.

Congenital contractures, short stature, abnormal face, microcephaly, scoliosis, hip dislocation, and severe psychomotor retardation in two unrelated girls. a new MCA/MR syndrome?

Severe mental retardation, congenital contractures, short stature, microcephaly, ptosis, myopia, beaked nose, abnormal teeth, hip dislocation, and severe scoliosis, are described in a 16-year-old and an unrelated 24-year-old females. Results of all laboratory investigations were normal. Review of the literature, of the London Dysmorphology Data Base and POSSUM did not yield to any diagnosis. Whether these patients present a new MCA/MR syndrome is discussed.

Multiple congenital contractures: birth prevalence, etiology, and outcome

OBJECTIVES

We wanted to estimate the birth prevalence of multiple congenital contractures (MCC), determine the cause of the MCC according to the primary level of involvement of the developing motor system, and compare the different groups in terms of inheritance, mortality, and morbidity.

STUDY DESIGN

A retrospective epidemiologic study through the screening of registers, reviews of medical records, and clinical re-examinations was performed in western Sweden to identify all the children with MCC born between 1979 and 1994.

RESULTS

The birth prevalence of MCC on the basis of 68 cases was 1 in 5100 live births. The majority of cases with cerebral involvement (n = 23), spinal involvement (n = 16), or mechanical restriction (n = 3) were sporadic, whereas most cases with neuromuscular (n = 12) or connective tissue involvement (n = 9) were inherited. The cerebral group was more severely affected compared with the other groups in terms of mortality, joint contractures at birth, feeding difficulties during infancy, and independent walking at follow-up. In 8 cases with myopathy, the joint contractures were normalized on follow-up.

CONCLUSION

A search for a specific etiology in each case is important for genetic counseling, prognosis, and therapy because inheritance, mortality, and morbidity differ between the groups.

D-bifunctional protein deficiency with fetal ascites, polyhydramnios, and contractures of hands and toes

Fetal abnormalities including chylous ascites, polyhydramnios, claw hands, and hammer toes were identified in an infant who had a missense mutation R106P and a 52bp deletion in the gene for a peroxisomal beta-oxidation enzyme, D-3-hydroxyacyl-CoA dehydratase/D-3-hydroxyacyl-CoA dehydrogenase, D-bifunctional protein. The patient had psychomotor retardation and craniofacial dysmorphism and died at 7 months of age. The patient had atypical fetal manifestations of this enzyme deficiency.