Prevalence of Psychiatric Comorbidities in Patients With Neurofibromatosis

Objective: To assess the prevalence of psychiatric comorbidities in patients with neurofibromatosis.

Methods: In this cross-sectional study, we used the 2010-2014 National Inpatient Sample database. Patients ≥ 18 years of age with a primary or secondary diagnosis of neurofibromatosis and psychiatric comorbidities were queried.

Results: A total of 43,270 patients with a mean age of 48.7 years (female: 55.7%, White: 70.1%) were included in the study. Overall, psychiatric comorbidities were present in 46.5% of patients; mood disorders (22.1%) and anxiety disorders (12.2%) were the most prevalent comorbidities. Although previous studies report prevalence rates of attention-deficit/hyperactivity disorder in up to 50% of patients with neurofibromatosis, our study found that the rate was much lower at 1.10%. Female sex and non-White race were less associated with psychiatric comorbidities (odds ratio = 0.868 [P = .003] and 0.689 [P < .001], respectively). The moderate-to-extreme loss of function illness severity category was associated with 1.35-times higher odds of having psychiatric comorbidities compared to mild-to-moderate or no loss of function (P < .001). The total length of stay was similar in patients with and without psychiatric comorbidities (mean = 4.98 [95% CI, 4.72-5.24] vs mean = 4.83 [95% CI, 4.60-5.07], respectively; P = .34).

Conclusions: In adult patients with neurofibromatosis, 46.5% were found to have at least one psychiatric comorbid diagnosis. The most frequent psychiatric comorbid disorders were mood disorders and anxiety disorders. Female sex and non-White race predicted a lower likelihood of having a psychiatric disorder.

Prim Care Companion CNS Disord 2023;25(5):23m03514.

Author affiliations are listed at the end of this article.

COVID-19 in people with neurofibromatosis 1, neurofibromatosis 2, or schwannomatosis

PURPOSE

People with pre-existing conditions may be more susceptible to severe COVID-19 when infected by SARS-CoV-2. The relative risk and severity of SARS-CoV-2 infection in people with rare diseases such as neurofibromatosis type 1 (NF1), neurofibromatosis type 2 (NF2), or schwannomatosis (SWN) is unknown.

METHODS

We investigated the proportions of people with NF1, NF2, or SWN in the National COVID Cohort Collaborative (N3C) electronic health record data set who had a positive test result for SARS-CoV-2 or COVID-19.

RESULTS

The cohort sizes in N3C were 2501 (NF1), 665 (NF2), and 762 (SWN). We compared these with N3C cohorts of patients with other rare diseases (98-9844 individuals) and the general non-NF population of 5.6 million. The site- and age-adjusted proportion of people with NF1, NF2, or SWN who had a positive test result for SARS-CoV-2 or COVID-19 (collectively termed positive cases) was not significantly higher than in individuals without NF or other selected rare diseases. There were no severe outcomes reported in the NF2 or SWN cohorts. The proportion of patients experiencing severe outcomes was no greater for people with NF1 than in cohorts with other rare diseases or the general population.

CONCLUSION

Having NF1, NF2, or SWN does not appear to increase the risk of being SARS-CoV-2 positive or of being a patient with COVID-19 or of developing severe complications from SARS-CoV-2.

Neurofibromatosis Type 1 in a Pediatric Population: Ste-Justine's Experience

Background:

To date, few pediatric series of neurofibromatosis type 1 (NF-1) have been described in the literature even though it is the most frequently encountered phakomatosis.

Methods:

We reviewed 987 charts of pediatric patients with a presumptive diagnosis of NF-1 who were evaluated at Ste-Justine hospital from January 1, 1991 to July 31, 2002. Patients who presented with two or more cardinal criteria were diagnosed with NF-1. Clinical and laboratory data were retrospectively collected, including: demographics, neuroimaging and presence or absence of associated symptoms or signs of NF-1.

Results:

A total of 279 patients were diagnosed with NF-1. The mean age at diagnosis was 3.4 years. Ninety-nine percent of the patients had café au lait spots and 47% had a first degree relative with NF-1. Almost 60 percent (59.6%) of those seen by an ophthalmologist had Lisch nodules. Optic glioma was found in in 14.7%, cutaneous neurofibromas in 38.4%, plexiform neurofibromas in 24.7%, neurofibrosarcoma in 1.8%, learning disabilities in 39%, attention deficit disorder in 40.5%, osseous dysplasias in 7.2%, pseudoarthrosis in 3.6%, precocious puberty in 3.2% and short stature in 17.9%. Magnetic resonance, when performed, showed hyperintense T2 lesions in 87.1% of cases. The mean period of follow-up was 7.4 years.

Conclusion:

Neurofibromatosis type 1 is a multisystemic disorder associated with increased risk of malignancy. It can be diagnosed at a very young age and clinical follow-up is advised. To our knowledge, this is the largest single center study of NF-1 in a pediatric population.

Rasopathies - dysmorphic syndromes with short stature and risk of malignancy

OBJECTIVES

The term ´Rasopathies´ represents a group of five neurodevelopmental syndromes (Noonan, LEOPARD, Costello, Cardio-facio-cutaneous, and Neurofibromatose-Noonan syndrome) caused by germline mutation in genes encoding proteins involved in RAS/MAPK (rat sarcoma/mitogen-activated protein kinase) signaling pathway. The RAS/MAPK signaling pathway participates in regulation of cell determination, proliferation, differentiation, migration, and senescence and dysregulation of this pathway can lead to the risk of tumorigenesis. In this review, we aim to summarize the current clinical and molecular genetic knowledge on Rasopathies with special attention for the risk of cancer. We propose also clinical and therapeutic approach for patients with malignancy.

METHODS

We are reviewing the clinical and molecular basis of Rasopathies based on recent studies, clinical examination, and molecular diagnostics (mutation analysis of causal genes for Rasopathies) in Slovak pediatric patients.

RESULTS

Some clinical features, such as short stature, a specific facial dysmorphology and cardiac abnormalities are common to all of Rasopathy syndromes. However, there are unique signs by which the syndromes can differ from each other, especially multiple lentigo in LEOPARD syndrome, increased risk of malignancy in Costello syndrome, dry hyperkeratotic skin in patients with cardio-facio-cutaneous syndrome, and neurofibromas and cafe-au-lait spots in neurofibromatosis-Noonan syndrome.

CONCLUSION

Despite the overlapping clinical features, Rasopathy syndromes exhibit unique fenotypical features and the precise molecular diagnostics may lead to confirmation of each syndrome. The molecular diagnostics may allow the detection of pathogenic mutation associated with tumorigenesis.

[How to recognize neurofibromatosis?]

Neurofibromatosis 1 is a hereditary symptom predisposing to cancer, affecting some 1,500 Finnish people. This systemic disease is most commonly detected through cutaneous findings. Although the cutaneous symptoms are harmless, they impair the patients' quality of life. The disease is, however, insidious, as the complications often become manifested from unexpected organ systems. For example cancers originally from nervous systems and severe bone lesions require rapid diagnosis and treatment. The healthcare personnel should thus be aware of the diagnosis of NF syndrome, and the patients should have sufficient knowledge of their disease.

Neurofibromatoses

The studies of familial tumor predisposition syndromes have contributed immensely to our understanding of oncogenesis. Neurofibromatosis 1, neurofibromatosis 2 and schwannomatosis are inherited autosomal dominant neurocutaneous disorders with complete penetrance. They are clinically and genetically distinct and considerable knowledge has been gathered about their pathogenesis. In this chapter, the genetics, molecular mechanism of disease, as well as clinical features, diagnosis and treatment are discussed.

[Neurofibromatosis--an inborn genetic disorder with susceptibility to neoplasia]

Among different subtypes of neurofibromatosis (Nf), type 1 (Nf-1) predominates in frequency (approximately 97% of Nfs' patients) with an incidence of approximately 1 in 3500 live births. Nf-2, comprises 2% of the Nf population and is a very rare disease (1:40,000). Both are autosomal dominant disorders with 100% penetration, variable expression and 50% rate of new (de novo) mutations. The protein products of both, NF1 andNF2 genes are best known and the genes serve as tumour suppressors. Mutations result in a predisposition to develop a variety of tumours of the central and peripheral nervous systems, as well as other malignancies. Nf-2 is a multisystem genetic disorder associated with bilateral vestibular schwannomas, spinal cord schwannomas, meningiomas, gliomas, and juvenile cataracts with a paucity of cutaneous features, which are seen more consistently in Nf-1. In contrast to Nf-1, Nf-2 is associated with significant morbidity and decreased life span and a higher incidence of CNS tumours. However, morbidity and mortality rates in Nf-1 are not negligible. The cardinal features of Nf-1 are cafe-au-lait spots, axillary and inguinal freckling, cutaneous neurofibromas, and iris hamartomas (Lisch nodules). Optic gliomas and both malignant and benign peripheral nerve sheet tumours are the most common malignancies arising in Nf-1 patients. Among neurological symptoms epilepsy, intellectual disability and learning difficulty are also observed. Bone dysplasia results in scoliosis. There is no known medical treatment beneficial to both groups of patients. The mainstay of care for Nf patients is anticipatory guidance, and early detection and symptomatic treatment of disease complications.

Vitamin D deficiency associated with number of neurofibromas in neurofibromatosis 1

Neurofibromatosis 1 (NF1) is a tumour suppressor gene syndrome characterized by multiple cutaneous and plexiform neurofibromas. Focal osseous abnormalities, short stature, and decreased bone mineral density are also frequent in people with NF1. We measured serum 25-hydroxyvitamin D concentrations in 55 patients with NF1 and 58 healthy controls, and correlated the findings in the patients with NF1 with their estimated number of dermal neurofibromas. Geometric mean (SD) serum 25-hydroxyvitamin D concentration was 14.0 (1.6) ng/mL among the patients with NF1 compared with 31.4 (1.7) ng/mL among healthy controls (p<<0.0001). The serum vitamin D concentration and number of dermal neurofibromas reported by patients with NF1 were inversely correlated (Spearman's rho = -0.572, p<0.00001). The occurrence of low serum vitamin D concentrations in people with NF1, especially those with many dermal neurofibromas, may provide new pathogenic insights and have important therapeutic implications.

Clinical phenotype of South African children with neurofibromatosis 1

Forty-eight children with neurofibromatosis 1 presenting between 2000 and 2004 were reviewed for their clinical phenotype, and data were compared with published reports. The median age at presentation was 4 years (range 10 days to 12 years). The male to female ratio was similar (22 male:26 female). There were frequencies of café au lait spots, axillary freckling, Lisch nodules, and new mutations comparable to those cited in the literature. Fewer patients had neurofibromas (4%), but more patients had plexiform neurofibromas of the head and neck (16%). Three patients of the 22 who had neuroimaging had optic gliomas (14%). The most consistent disability, with maximum impact, related to the patient's cognitive level of functioning. School problems, defined as learning and behavioral problems observed in the classroom, were reported in 70% of school-aged children (n = 21), compared with international figures of 29.8% to 45%. This high prevalence has reinforced the clinic service policy of formal neuropsychology assessments in all children with reported school problems. In addition, earlier referral of children to the service (preschool n = 18) has enabled formal developmental assessments and planning of specific educational placement to optimize learning. This is the first description of the neurofibromatosis 1 phenotype from the African continent. The multidisciplinary approach to management has proved beneficial in the South African context. The combined clinic has resulted in a holistic approach to patient care, early detection of pathology, consistent therapies across the specialties, and better patient attendance and compliance. (J Child Neurol 2006;21:63-70).

Neurofibromatoses et sclérose tubéreuse de bourneville

Neurofibromatoses and tuberous sclerosis have specific genetic epidemiology, diagnostic criteria and management. These diseases are autosomal dominant disorders linked to mutations on tumour suppressor genes. Their management is mainly clinically oriented and aimed at managing potential complications.

Neurofibromatosis and Caroli's disease: an extremely rare association

Neurofibromatosis type-1 (NF-1) is a rare genetic disorder with an extremely variable phenotype. A broad spectrum of associations have also been reported with it. We present a florid case of NF, presenting with unusual symptoms, which was found to have an associated Caroli's disease, a rare congenital disorder of the intrahepatic bile ducts. The case is reported along with a brief review of both the disorders.

Pediatric neurofibrosarcoma

BACKGROUND/PURPOSE

Neurofibrosarcoma is rare in children, and the natural history and prognostic factors are not well described. The authors present a 57-year review of their experience.

METHODS

The charts of children with neurofibrosarcoma were reviewed retrospectively. Statistical analysis was performed using the Chi2 and unpaired t tests.

RESULTS

From 1944 to 2001, 38 patients under the age of 21 were diagnosed with neurofibrosarcoma. Twenty-two were boys. The average age at diagnosis was 13.8 years (range, 3 to 19.9 years). Nineteen patients (50%) had neurofibromatosis. The tumor site was as follows: extremity, 19 patients; trunk, 9 patients; head and neck, 7 patients; and retroperitoneum, 3 patients. The average tumor size was 10 cm. The margins after resection were as follows: grossly positive, 9; microscopically positive, 5; negative, 21; and unknown, 3. Patients with positive margins had a 22% survival rate, whereas those with negative or unknown margins had a 34% survival rate. Thirty-two patients achieved a complete response, 2 a partial response, and 4 progressed while on therapy. Twenty-six patients relapsed after a complete response (11 local, 10 distant, 5 both). Of the 15 patients with a distant relapse, 73% (11) relapsed in the lung. Twelve (32%) patients survived with an average follow-up of 14 years (range, 0.3 to 28 years). Nine patients were treated with chemotherapy, 9 with radiation, and 9 with both chemotherapy and radiation. Outcome was not significantly affected by gender, presence of neurofibromatosis, site, margin, or use of adjuvant therapy.

CONCLUSION

Neurofibrosarcoma remains a rare disease in children with insufficient contemporary numbers to assess efficacy of therapy. Prognosis remains poor with a high incidence of relapse, particularly in the lungs, suggesting that more aggressive therapies to control both local and distant relapses are needed.

[Electrooculographic findings in patients with neurofibromatosis]

Neurofibromatosis are frequent genetic syndromes, with the electrooculographic examination (EOG) as an useful tool in their evaluation. We present the EOG findings of 16 patients with this entity which were seen at our Department between 1969 and 1991. Mean of age was 31 years. Nine patients were female (56%). The most frequent pathologic findings were: spontaneous nystagmus (37.5%) and abnormalities in the pursuit tracking test (31.2%). These results are discussed and the main literature concerning this matter is reviewed.

Autism and associated medical disorders in a French epidemiological survey

OBJECTIVE

To estimate the prevalence of autism, to assess the strength of its association with specific medical disorders, and to test for a secular increase in its incidence.

METHOD

An epidemiological survey was conducted among 325,347 French children born between 1976 and 1985 and living in three different French départements. Diagnosis, educational level, and associated medical conditions were abstracted from the records of children known to local educational authorities. Data were also pooled with those from another similar survey.

RESULTS

One hundred seventy-four children (mean age: 11.6 years) with autism were identified. The prevalence rate was 5.35/10,000 (16.3/10,000 if other pervasive developmental disorders are included), with no difference according to geographical area or social class. Rates of medical conditions were as follows: 1.1% for tuberous sclerosis, 2.9% for chromosomal abnormalities including fragile X, 2.9% for cerebral palsy, 4.6% for sensory impairments, 0.6% for neurofibromatosis, 0.6% for congenital rubella, and 1.7% for Down syndrome. In the combined sample of 328 children with autism, the level and pattern of medical correlates were comparable, with tuberous sclerosis having a consistently strong association with autism. Prevalence rates were similar in successive birth cohorts.

CONCLUSION

Medical disorders (excluding epilepsy and sensory impairments) accounted for fewer than 10% of the cases of autism. No secular increase in the prevalence of autism was found.

[Neurofibromatosis (von Recklinghausen disease) and carcinoid tumor in Vater's ampulla]

The localization of the carcinoid tumors of the gastrointestinal tract--as a part of the APUD system--is extremely seldom at the region of ampulla of Vater. A case of congenital neurofibromatosis is reported in a 49-year-old male patient, with a carcinoid tumor of the ampulla of Vater in the background of long-standing, atypical biliary complaints. Periampullary neoplasm of neural-crest origin are very rare, up to this time 73 cases of Vater papilla carcinoid tumors were described. Regarding the development of VP carcinoid in neurofibromatosis, our patient is the 21st reported case in the world literature, and the first one in Hungary. The authors review the literature, giving special attention to the risk of periampullary neoplasms in von Recklinghausen's disease, the need of accurate diagnosis and the correctly selected operative intervention.

Epidemiology of infantile spasms in Sweden

We performed a retrospective study of infantile spasms (IS) in 57 children (19 girls and 38 boys) from the east-central region of Sweden for the period 1987-1991. The incidence was 0.45/1,000 newborns a year, with a spread of 0.17-0.76 between the seven counties included. Forty-three cases (75%) were symptomatic and 14 (25%) were idiopathic. Cerebral malformations were diagnosed in 8 children, and chromosomal aberrations were diagnosed in 5. In addition, 2 children each were diagnosed as having tuberous sclerosis and neurofibromatosis. At follow-up, 57% in the idiopathic group had normal development, whereas 91% in the symptomatic group had died or developed a multihandicap. The value of modern neuroradiological techniques for etiological diagnosis is stressed.

Deterioration of operative correction in dystrophic spinal neurofibromatosis

STUDY DESIGN

Of 28 patients with dystrophic spinal deformity resulting from neurofibromatosis who were treated surgically since 1968, 25 were studied regarding the outcome of spinal deformity at a mean follow-up of 9.7 years after surgery (mean age at follow-up, 21.5 years).

OBJECTIVES

This study sought factors that contribute to curve deterioration despite successful spinal fusion for dystrophic spinal deformity in patients with neurofibromatosis. SUMMARY OF BACKGROUND DATA/METHODS: All patients had the following radiographs: standing anteroposterior and lateral, lateral bending, flexion and extension views of the spine, and radiographs of both tibiae. Patients who had large peripheral neurofibromata or evidence of long-bone deformity at other sites had radiographs of these anatomic regions. Spinal radiographs obtained pre-operatively, 6-12 months post-operatively, and at final follow-up were measured for spinal curvatures, vertebral height, and vertebral and disc wedging.

RESULTS

For analysis, the patients were divided into three groups according to deformity: 1) scoliosis, 2) ky-phoscoliosis (with kyphosis > 50 degrees) and 3) hyperkyphosis (with kyphosis > 50 degrees and sharply angulated over three vertebrae). Mean deterioration was: scoliotic group, 12 degrees (range, 0 degree-52 degrees); kyphoscoliotic group, 7 degrees (range, 0 degree-35 degrees); hyperkyphosis group, 38 degrees (range, 20 degrees-60 degrees). All patients in the latter group had anterior and posterior spinal fusion.

CONCLUSION

Spinal deformity in these patients tended to progress despite the achievement of spine arthrodesis in those with hyperkyphosis and short curves. The study shows that vertebral subluxation, disc wedging, and peripheral skeletal dystrophy are additional prognostic features that predict the progression of deformity after arthrodesis of the spine.

Immune dysfunction in experimental versus naturally occurring neurofibromatosis in damselfish

Damselfish neurofibromatosis [DNF], a neoplastic disease characterized by multiple, neurofibromas and malignant schwannomas, is currently the only naturally occurring animal model of human neurofibromatosis type-1. Previous studies of immune function in DNF affected fish indicated the potential for significant immunosuppression in advanced stages of the disease. The current study compares healthy animals with fish captured in the wild bearing spontaneous tumors and with animals bearing experimental tumors transmitted in the laboratory. In order to determine the effects of tumor burden on the immune capabilities of these animals, proliferative responses to mitogens and toward allogeneic cells were tested. The data presented here indicate that animals bearing advanced tumors of experimental origin are profoundly immunocompromised. Similarly, some spontaneous tumor-bearing animals are deficient in proliferative immune responses, and splenocytes from most animals fail to respond to mitogens. However, a proportion of animals with stage 5 spontaneous tumors retain immune reactivity, and are capable of alloreactions comparable to those of normal individuals when stimulated with cells from healthy [4/10, 40%] or other tumor-bearing [4/8, 50%] animals. The contributions of tumor size, distribution and cytokine production to the differential immune impairment are discussed.

Management and outcome of low-grade astrocytomas of the midline in children: a retrospective review

Low-grade astrocytomas of the midline of the brain can be difficult to manage because of their location. To evaluate treatment and outcome, we performed a retrospective study of children with midline low-grade astrocytomas admitted to The Hospital for Sick Children between 1976 and 1991. Eighty-eight children with biopsy-proven low-grade astrocytomas were identified. Forty-three tumors occurred in the optic pathways or hypothalamus, 13 in the thalamus, 7 in the pineal region, 14 in the midbrain, and 11 in the medulla. Patient follow-up ranged from 6 months to 15 years, with a mean of 4 years, 9 months. Overall outcome was related to the extent of resection, histological type, and location. Partial resections were often associated with involution of the tumor. Response to radiation was variable, and serious sequelae were observed. Thirty-three patients experienced recurrence, often with a good response to subsequent surgery; however, 12 of these patients died. The probability of survival was calculated to be 96% at 1 year, 91% at 5, and 80% at 10 years. Our study suggests that resection should be considered in all patients, both at presentation and recurrence.

Neurofibromatosis type 1: review of the first 200 patients in an Australian clinic

Neurofibromatosis type 1 is a common multisystem disorder, best managed in a multidisciplinary clinic. In 1991, the first Australian neurofibromatosis clinic was established at the Children's Hospital, Camperdown, and the clinical characteristics of the first 150 families are reviewed. Two hundred individuals were assessed; there was an equal sex distribution, and 55% of cases were sporadic. Advanced paternal age appeared to predispose to new mutations in the neurofibromatosis gene. Café-au-lait spots and axillary freckling were important to the diagnosis of neurofibromatosis type 1 during childhood, and neurofibromas and Lisch nodules, although often not appearing until after puberty, were present in almost all patients over 30 years of age. Short stature (27%), macrocephaly (43%), scoliosis (20.5%), and learning disabilities (45%) were common associated features. The prevalence of disease complications was similar to the major US and European studies.

Neurofibromatosis and malignant schwannomas in Tanzania

In a five-year-period, twenty three cases of peripheral nerve tumours were seen at the pathology department of Muhimbili Medical Centre. Nine of these had von-Recklinghausen's disease (neurofibromatosis). One of these patients developed malignant schwannomas at two different sites simultaneously. Patients with malignant disease in Tanzania as in other sub-Saharan African countries usually get to the large referral hospitals late in the course of their disease. Despite this delay and the advanced nature of their illness, attempts should be made to achieve satisfactory palliative results.

Orbitotemporal neurofibromatosis: classification and treatment

In localized orbitotemporal neurofibromatosis, the treatment depends very much on the type and severity of the orbital involvement and on the functional state of the eye. The condition can be conveniently divided into three groups, each requiring different treatment: (1) orbital soft-tissue involvement with a seeing eye, (2) orbital soft-tissue and significant bony involvement with a seeing eye, and (3) orbital soft-tissue and significant bony involvement with a blind or absent eye. A total of 24 patients with a maximum of 12 years recurrence-free follow-up are presented.