SAN FRANCISCO, CALIFORNIA. inner canthal distance 40 mm. The eyes protruded. valgus was present. Brachydactyly, broad

Transcription

1 VOL. ii6, No. 3 FAMILIAL ACROCEPHALOSYNDACTYLY (PFEIFFER SYNDROME)* By RONALD M. SALDINO, M.D.,f HOWARD L. STEINBACH, M.D.,t and CHARLES J. EPSTEIN, M.D. ACROCEPHALOSYNDACTYLY SAN FRANCISCO, CALIFORNIA (ACS) A I is a descriptive term applied to a group of closely related genetic diseases characterized by a premature fusion of the cranial sutures and a varied degree of syndactyly. In recent years, several distinct varieties of ACS have been separated from the classic type described by Apert in Although considerable phenotypic overlay exists, these syndromes are caused by distinct genes, and correct genetic counseling depends on an accurate clinical and roentgenographic diagnosis. This report describes the clinical and roentgenographic features in a mother and her children who had a dominantly inherited, familial variety of acrocephalosyndactyly as described by Pfeiffer.2 REPORT OF CASES CASE I. A 30 year old mother of 3 was born with a prominent forehead, broad thumbs and toes, and webbing between the second and third toes of both feet. She did not receive any specific treatment for these abnormalities, and physical and mental development was normal. At the age of 20 years, the patient delivered a child (Case II) that resembled the mother in several respects. A second child, born when the mother was 21 years of age, was normal. The third child (Case in) was born when the mother was 25 years old, and this child also had anomalies of the head and extremities similar to those of the mother. One year later, the mother experienced a single grand mal seizure. An electroencephalogram was said to have been abnormal and she was treated with Dilantin and Gemonil without recurrence of the seizures. The mother complained of pain in her hips, elbows, shoulders, and hands which was not associated with swelling or redness, but was aggravated by the cold. Neither the parents nor other members of the patient s family had similar malformations of the skull or extremities. On physical examination, the skull was decreased in anteroposterior diameter and the forehead was wide and prominent. The circumference of the head measured i cm. and the inner canthal distance 40 mm. The eyes protruded slightly, and the patient wore eyeglasses because of hyperopia (Fig. I, A and B). Hypoplasia of the maxillary region with a parrotbeaked nose was apparent. The palate was narrow and the alveolar ridges were wide. The teeth were irregularly placed and some of the anterior teeth were missing. Duplicated upper canines had been removed previously. Supination of the forearms was limited and cubitus valgus was present. Brachydactyly, broad thumbs, and radially deviated terminal phalanges were noted in the hands. A painful bony nodule was present on the distal phalanx of the right thumb and there was a moderate clinodactyly of the fifth fingers. Dermatoglyphics were normal. The great toes were broad, and there was a partial soft-tissue syndactyly that involved the second and third toes, bilaterally. In general, all the long bones of the arms and hands appeared short. Height of the patient was I 52 cm. Routine clinical laboratory values of the blood chemistry were unremarkable. Roentgenographic Findings (Fig. 2-5). The roentgenograms of the skull demonstrated the typical features of premature fusion of the cranial sutures, with increased height and flattening of the frontal and occipital bones, and shortened anterior and posterior diameters. Minimal increase in the convolutional markings of the skull, upward slanting of the lesser sphenoid wings, a deepened sella turcica, and a small posterior fossa were also shown. An apparent assimilation of the atlas at the base of the skull was noted. Maxillary hypoplasia was pronounced and resulted in prognathism. * From the Departments of Radiology,f and Pediatrics, University of california School of Medicine, San Francisco, California.#{149} Supported by USPHS grant AM02589 and a grant from the National Foundation March of Dimes. Currently Clinical Associate, Department of Radiology, National Institutes of Health, Bethesda, Maryland. Recipient of a Career Development Award from the National Institute of Child Health Development, USPHS.. 6o9

2 6io R. \l. Saldino, H. L. Steinbach and C. J. Epstein NOVEMBER, i972 1 ic;. i. Case 1. (4 and B) Views of face and head showing maxillary hypoplasia, prominence of the eves, wide forehead, and increased inner canthal distance. The roentgenograms of the hands showed a generalized brachydactyly. The greatest degree of shortening was in the middle phalanges. especially those of the index and little fingers, Complete fusion of the proximal and distal phalanx of the left thumb and partial fusion of the interphalangeal joint of the right thumb were noted. The thumbs were broad and deviated radially. The articular cartilage of all the interphalangeal and metacarpophalangeal join ts was narrowed. No fusion of the carpal bones was demonstrated. A bone island was present in the distal left ulna. Significantly, no osseous syndactyly was demonstrated. The roentgen findings in the feet were a generalized brachyphalangia with absence of the middle phalanges of all the toes and partial fusion of the proximal and distal phalanges of the great toes. The first metatarsal was greatly shortened and extremely broad. Multiple tarsal.. coalitions were noted, with calcaneocuboid fu- FIG. 2. Case I. Lateral view of the skull showing typical changes of acrocephaly. The size of the skull is increased and the frontal and occipital increased. Pronounced maxillary hypoplasia is bones are flat. The depth of the sella turcica is present.

3 \OL. ii#{243}, No. j Familial Acrocephalosyndactyly (Pfeiffer Syndrome) 611

4 612 R. M. Saldino, H. L. Steinbach and C. J. Epstein NOVEMBER, 1972 l 1G. 4. Case I. (A and B) Frontal, and (C) oblique projections of the feet. The first metatarsals are markedly broadened and deformed, especially on the right. The interphalangeal joints of the broadened and shortened great toe are fused. The middle phalanges are absent bilaterally, and multiple tarsal bones have fused. word at 7 months, she did not walk until 2 years of age. At 3 years she required glasses because of severe hyperopi a. Thereafter development appeared normal and she progressed well in school. At years of age, petit mal and grand mal seizures began ; these were treated with phenobarbital and Gemonil. Also at 9 years, strabismus was corrected surgically. On physical examination, the patient s resemblance to her mother was striking. The conformation of the skull was similar and the circumference of the head was 52.8 cm. The inner canthal distance was 37 mm. and there was marked antimongoloid slant to the eyes. Pronounced maxillary hypoplasia was noted and the mouth was held open. The alveolar ridges were wide and the palate was narrow but high (Fig. 6). The teeth were crowded and orthodontic procedures had been performed to correct malalignment. The ears were low-set but normal in conformation. External rotation of the elbows was limited markedly. Shortening of all fingers, abnormally wide thumbs, and slight clinodactyly of both fifth fingers were observed. Dermatoglyphics were normal. The great toes were broad and a soft-tissue syn dactyly of both second toes extended as far distally as the nails (Fig. 7). The patient s height was 137 cm. Although formal testing was not done, mentation appeared somewhat slow. However, her teacher stated that the child s school work was above average. Roentgenographic Findings (Fig. 8-13). Skull roentgenograms were obtained at 8 and 10 years of age. Previous craniectomy defects were noted along the coronal and lambdoid sutures bilaterally. Metallic clips about the foramen magnum had been placed during the previous surgical procedures because of premature cranial synostosis and Arnold-Chiari malformation. The frontal bone was increased in height and was flat, and the coronal diameter of the skull was increased. The lesser sphenoid wings slanted upward and were unusually dense. A shallow

5 VOL. ii6, No. 3 Familial Acrocephalosyndactyly (Pfeiffer Syndrome) 613 FIG. 6. Case II. High narrow palate with wide alveolar ridges. The lateral incisors have been removed because of crowding of the teeth. lanx of the thumb showed a partially assimilated anomalous ossification center in the distal portion. No fusion ofthe carpal bones was noted or bony fusion of the pilalanges. The thumbs were abnormally broad. At the age of 8 years, the roentgenograms of the feet demonstrated hypoplasia of the middle phalanges and absence of the epiphyses of the distal and middle pha- FIG. 7. Case II. Broad great toes with extensive soft-tissue syndactyly of the second and third toes bilaterally.

6 614 R. M. Saldino, H. L. Steinbach and C. J. Epstein NoVEMBER, G. 8. Case II. (A) Lateral and (B) frontal projections of the skull. The postoperative defects are the result of craniectomy performed because of Arnold-Chiari malformation and premature sutural synostosis. Severe maxillary hypoplasia, crowding of the teeth, and narrowing of the palate are present. langes. An anomalous ossification center was present in the proximal phalanx of the great toe which was abnormally wide and considerably shortened. The first metatarsal was also extremely broad and short, especially on the left side. The epiphysis of the left first metatarsal was deformed and medially placed. Early fusion was seen of the deformed medial cuneiform with the first metatarsal and navicular bones. The navicular and middle cuneiform were fused Oil the right side. Solid calcaneocuboid fusion was present bilaterally. Roentgenograms at the age of 10 years demonstrated a progressive synostosis of the previously described early fusions with the calcaneocuboid fusion forming one solid mass, and multiple coalitions between the cuneiforms, navicular, and first 3 metatarsals. The middle and distal phalanges had not yet fused. In the roentgenogram ofthe elbowjoint, considerable hypoplasia of all the bones was seen. The normal anterior angulation of the distal humeral condyles was absent and the radial head was hypoplastic. The epiphysis of the proximal radius was extremely small and flat. In the lumbar spine, the intervertebral disk between the fourth and fifth lumbar vertebrae was narrow and the posterior elements were fused. The right twelfth rib was hypoplastic. Coxa valga, abnormal widening of the symphysis, and hypoplasia of the greater trochanters were seen in roentgenograms of the pelvis. No significant roentgen abnormalities could be detected in the chest, knees, lower extremities, forearms, humeri, or femora. The acromial process of the scapula appeared unusually large. CASE III. This patient, the 5 year old daughter ofcase I, had malformations similar to those of her sister and mother. During the first year of life, premature fusion of the coronal suture was noted and craniectomies were performed. Early development was slightly delayed and the child did not walk until 17 months. Mental development, however, was considered normal thereafter. On physical examination, the patient s face resembled that of her mother and sister (Fig. 14, A and B). The forehead was bulging and a surgical bony defect was noticeable. The head measured 45.4 cm. in circumference and the inner canthal distance was 30 mm. The right ear was slightly low-set. The alveolar ridges were wide and the palate was deep. Only the right upper incisor, which had been capped, remained in the jaw. The lower teeth were placed irregularly. External rotation of the forearm was moderately limited and full extension of the elbow could not be attained. The thumbs were

7

8 616 R. M. Saldino, H. L. Steinbach and C. J. Epstein NOVEMBER, G. 10. Case II. (A and B) Anteroposterior and (C and D) oblique projections of the feet. The first metatarsals are severely deformed and an unusual epiphysis of the proximal phalanx of the great toe is present. The epiphyses of the distal and middle phalanges are absent, probably prior to their fusion. The calcaneocuboid and multiple other tarsal and metatarsal bones are fused. I I fusion of the distal phalanges with complete syndactyly, and usually a single nail ( synorchia). Hoover et al. 3 have described in detail the malformations in o cases of Apert ACS. In these, severe premature synostosis of the cranial sutures resulted in the classic tower skull. Other associated anomalies, such as mental retardation, maxillary hypoplasia, limited motion of the elbows, and visual difficulties were often present. Other causes of secondary craniosynostosis have been reviewed by Duggan and co-workers.1#{176} All of the other variations of acrocephalosyndactyly were called atypical ACS. In none of these variants was the severe interdigital osseous fusion seen that is char G. II. Case II. Lateral view of the cervical spine. Hypoplasia of the posterior elements of the first cervical vertebra is noted; patient had Arnold- Chiari malformation. Complete fusion of the posterior elements of the fifth and sixth cervical vertebrae and partial fusion of the anterior intervertebral body are noted. k A

9 VOL. ii6, No. 3 Familial Acrocephalosyndactyly (Pfeiffer Syndrome) 617 a,

10 6i R. M. Saldino, H. L. Steinbach and C. J. Epstein NOVEMBER, G. 14. Case III. (A and B) Views of face and head showing maxillary hypoplasia, wide forehead, and increased inner canthal distance. cilaracteristic of the Pfeiffer syndrome indude I flat nasal bridge, hypertelorism, antimongoloid slant of the palpebral fissures, high-arched palate, varus deformities of the great toes, brachmesophalangia, trapezoidal shape of the proximal phalanx of the thumb, and a deformed, wide first metatarsal. The mother and affected siblings of this report had all these features. Additional roentgenographic features found in this family, not reported previously in cases of the Pfeiffer syndrome included: Arnold-Chiari malformation (Case ii), congenital fusions of the cervical spine (Cases II and III) and of the lumbar spine (Cases i and ii), coxa valga (Cases i, II, and III), and widening of the svmphvsis pubis FIG. 15. Case III. A broad thumb, markedly shortened second and fifth middle phalanges, and abnormal distal end of the proximal phalanx of the thumb are seen in the hand.

11 \OL. ii6, \o. 3 Familial Acroceplialosvndactylv (Pfeiffer Syndrome) 619 (Cases I, II, and iii). All these features except the Arnold-Chiari malformation have been described previously in tile typical Apert syndrome Another prominent feature in the 3 members of this family was the severe coalition of the tarsal bones. Fusions of the tarsal bones were described in previousl reported cases of the Pfeiffer syndrome, but not emphasized Schauerte and St- Aubin25 stressed the progressive nature of 11G. i6. Case III. (A) Anteroposterior and (B) lateral views of the foot showing absence of the epiphyses of the distal and middle phalanges before fusion has taken place. The first metatarsal is short and broad, and the shortened great toes are greatly widened. 1)evelopmental anomalies of the tarsal bones that lead to fusion are present. The calcaneus and cuhoid are fused solidi v. 11G. 17. Case iii. Fusion of the posterior elements of the third and fourth cervical vertebrae. the svnosteoses ill tile classic.apert syndrome and presented examples of this condition in the feet, hands, and cervical spine. Points of roentgenographic interest besides the fusion of tarsal bones and vertebrae include hvpoplasia of the elbow and shoulder joint, fusion of the interphalangeal joints of the thumbs, and selective shortening of the middle phalanges of the index and little fingers. Except for one report,25 all of the types of ACS are inherited in an autosomal dominant manner When PolYdactyly accompanies ACS, then the inheritance may be autosomal recessive or dominant (Carpenter s5 and Noack s18 syndrome, respectively).31 Nearly all of the earlier reports of ACS were those of sporadie new mutations. The cases described by Weech,36 van den Bosch33 (typical ACS) and Waardenburg et al.3 (atypical ACS) presented familial examples. In 1964 Pfeiffer2 presented a familial example of atypical ACS, and further reports by Zippel and Sch#{252}ler,38 Martsolf et al.,17 and others, have established the entitv as a genetically distinct form of atypical ACS. Recognition of a familial form of ACS in the oung infant is of

12 620 R. i\l.saldino, H. L. Steinbach and C. J. Epstein NOVEMBER, 1972 FIG. i8. Case III. Widening of the symphysis pubis and bilateral coxa valga. obvious value in the prompt, correct genetic counseling of parents. The risk of occurrence in offspring of affected individuals is 50 per cent and there is no evidence for incomplete penetrance (unaffected individuals who carry the gene). The etiology of acrocephalos ndactyly is not known. Blank4 and Frerichs implicated an increased paternal age-a known phenomenon in new mutant cases of achondroplasia. Recently, Dodson et al.9 described a typical case of the Apert svndrome which was associated with a Group A chromosomal aberration. In their review of chromosomal analysis in patients with ACS, 3 abnormal chromosomes were discovered among 20 patients examined. All of these were in the typical form of ACS (Apert syndrome). Although all of the aberrations in ACS involved the Group A chromosome, the described abnormalities in each patient were different, and a specific chromosomal abnormality cannot be correlated with the Apert syndrome. In the family with Pfeiffer syndrome herein reported, ho dl romosom e abnorm ali ties were detected. In other instances of this syndrome, Pfeiffer,21 22 and Zippel and Sch#{252}ler8 reported that their analysis also disclosed norm al ch romosomes. Other causes of the Apert syndrome have been suggested. Pilosebaceous abnormalities of the forearms (acne vulgaris) in 7 postpubertal patients with the Apert syndrome were reported by Solomon et al.27 Since forearm acne is rare, the authors considered abnormal androgen metabolism as a possible etiologic factor in the Apert svndrome. Other syndromes that frequently manifest broad thumbs and broad great toes are distinguished easily from the Pfeiffer syndrome by the lack of acrocephaly. The malformations of the thumb and great toe in the Ru binstei n-taybi syndrome #{176} may be similar to those of the Pfeiffer syndrome. The frontodigital syndrome, 6 the oto-palato-digital syndrome,15 Len s pleonosteosis, and Type B brachydactyly32 also ma\ include similar digital abnormali ties. The acrocephalopolysyndactyly FIG. 19. Case III. Lateral view of the elbow demonstrates generalized hypoplasia of the bones of the elbow.

13 \OL. ii6, No. 3 Familial Acrocephalosvndactvl\? (Pfeiffer Syndrome) 621 syndromes described by Carpenter5 and by Noack included cranial and digital abnormalities, but these syndromes are recognizable by the presence of preaxial polydactyly. The delta phalanx described by J ones is closely related to the deformities in the great toe ofour patients. Although the malformations of acrocephalosvndactvly are predominantly of the head and distal extremities, a generalized skeletal dysplasia is clearly present. Deformities may be present in the shoulder, elbow, pelvis, hips, and spine, as in this family with the Pfeiffer syndrome. Actually, a generalized mesodermal defect is present in the Apert syndrome, with abnormal viscera, cleft palate, chamberangle abnormalities, other ocular problems, and bifid uvula The clinical and roentgenographic features of congenital ring constrictions of the digits, secondary to mechanical and amnio. tic bands, are superficially similar to deformities in the Apert syndrome, but they can and should be differentiated.2 35 SUMMARY A family with acrocephalosyndactyly, which differs from classic Apert s syndrome, has been described. The autosomal dominant manner of inheritance and the lack of interdigital osseous fusion clearly differentiates it from Apert s syndrome. Other characteristic features include broad thumbs and great toes, normal intelligence, and only mild soft-tissue syndactyly. Additional roentgen findings are presented and a differential diagnosis is discussed. Howard L. Steinbach, M.D. Department of Radiology University of California San Francisco San Francisco, California REFERENCES I. APERT, E. De l acroc#{233}phalosyndactylie. Bull. et m#{233}m. d. hop. Paris, 1906, 23, BAKER, C. J., and RUDOLPH, A. J. Congenital ring constrictions and intrauterine amputations. A.M.A. Am. 7. Dis. (Jhild., 1971, 12!, ,1. BARTSOCAS, C. S., WEBER, A. L., and CRAW- FORD, J. I). Acrocephalosyndactyly type : Chotzen s syndrome. 7. Pediat., 1970, 77, BLANK, C. E. Aperts syndrome type of acrocephalosyndactyly-observa tions on British series of thirty-nine cases. Ann. Human Genet., 1960,24, CARPENTER, G. Two sisters showing malformations of skull and other congenital abnormalities. Rep. Soc. Study Dis. Child, ioi, 1, I I 0-1 I COHN, B. N. True oxycephaly with syndactylism: case report. Am. 7. Surg., 1945, 68, 7 COOPER, R. Acrocephalosyndactyly with report of case. Brit. 7. Radiol., 1953, 26, CROME, L. Critique of current views on acrocephaly and related conditions. 7. Ment. Sc., 1961, 107, l)odsox, W. E., Mu5ELE5, M., KENNEDY, J. L., JR., and AL-AISH, M. Acrocephalosyndactylia associated with chromosomal translocation. A.M.A. Am. 7. Dii. Child., iyo, 120, DUGGAN, C. A., KEENER, E. B., and GAY, B. B., J R. Secondary craniosynostosis. AM. J. ROENT- GENOL., RAD. THERAPY & NUCLEAR MED., 1970, 109, I 1. FRERICHS, C. T. Apert s syndrome. Nebraska M. 7., 1967,52, GORLIN, R. J., and SEDANO, H. Acrocephalosyndactyly (Apert s syndrome). Mod. Med., 1969, 37, HOOVER, G. H., FLATT, A. E., and WEIss, M. W. Hand and Apert s syndrome. 7. Bone & Joint Surg., 1970, 52-A, JONES, G. B. Delta phalanx. 7. Bone & Joint Surg., 1964, 46-B, I 5. LANGER, L. 0., JR. Roentgenographic features of oto-palato-digital (OPD) syndrome. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1967, 100, i6. MARSHALL, R. E., and SMITH, D. W. Frontodigital syndrome: dominantly inherited disorder with normal intelligence. 7. Pediat., 1970,77, MARTSOLF, J. T., CRACCO, J. B., CARPENTER, G. G., and O HAitA, A. E. Pfeiffer syndrome: unusual type of acrocephalosyndactyly with broad thumbs and great toes. A.M.A. Am. 7. Dis. Child., 1971, 12!, i8. NOACK, M. Em Beitrag zum Krankheitsbild der Akrozephalosyndaktylie (Apert). Arch. Kinderheilk, 1959, 160, PALACIOS, E., and SCHIMKE, R. N. Craniosynostosis_syndactylism. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1969, zo#{243},

14 622 R. M. Saldino, H. L. Steinbach and C. J. Epstein NOVEMBER, PARK, F. A., and POWERS, G. F. Acrocephaly and scaphocephaly with symmetrically distributed malformations of extremities: study of so-called acrocephalosyndactylism. Am. 7. Dis. Child., I 920, 20, I PFE1FFER, R. A. I)ominant erbliche Akrozephalosyndaktvlie. X. Kinderhei/k., i 964, 90, PFEIFFER, R. A. Associated deformities of head and hands. Birth Defects Original Article Series, 1969, 5, No.,, pp PILLAY, V. K. Acrocephalosyndactyly in Singapore: study of five Chinese males. 7. Bone & Joint Surg., 1964, 46-B, RUBINSTEIN, J. H. Broad thumbs syndromeprogress report Birth Defects Original Article Series, 1969, 5, No. 2, pp SCHAUERTE, E. W., and ST-AUBIN, P. M. Progressive synosteosis in Apert s syndrome (acrocephalosyndactyly) : with description of roentgenographic changes in feet. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1966, 97, 67-7,. 26. SEELENFREUND, M., and GARTNER, S. Acrocephalosyndactyly (Apert s syndrome). A.M.A. Arch. Ophth., 1967, 78, 8-u. 27. SOLOMON, L. M., I RETZIN, D., and PRUZANSKY, S. Pilosebaceous abnormalities in Apert s syncirome. A.M.A. Arc/i. Dermat., 1970, 102, SUMMITT, R. F. Recessive acrocephalosynulactylv with normal intelligence. Birth Defects Original Article Series, 1969,, No. 3, pp TAUSANOV, M., DUMA, H., and GRIYCEVA, N. Unusual form of acrocephalo-syndactyly resembling syndrome of Rubinstein and Taybi. God. Zborn Med. Fak. Skopje, u 968, z, :i#{176}tavbi, H., and RUBINSTEIN, J. H. Broad thumbs and toes, and unusual facial features: probable mental retardation syndrome. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1965, 93, TEMTAMY, S. A. Carpenter s syndrome: acrocephalopolysyndactyly : autosomal recessive syndrome. 7. Pediat., I 966, 69, I I I- I TEMTAMY, S. A. Genetic factors in hand malformations. Thesis, Johns Hopkins University, Baltimore, VAN DEN BOSCH, J. Cited by Zippel and Sch#{252}ler WAARDENBURG, P. J., IRANCE5CHETTI, A., and KLEIN, D. Genetics and Ophthalmology. Charles C Thomas, Publisher, Springfield, Ill., 1961, pp WALSH, R. J. Acrosyndactyly: study of twentyseven patients. C/in. Orthop., 1970, 7!, 99-I II.,6. WEECH, A. A. Combined acrocephaly and syndactylism occurring in mother and daughter: case report. Bull. Johns Hopkins Hosp., 1927, 40, WIGERT, V. Die Akrozephalosyndaktylie; Weiteres #{252}ber die aligemeinen Skelettver- #{227}nderungen. Ada p.cvchial. neurol., 1932, 7, ZIPPEL, H., and SCHULER, K. H. Dominant vererbte Akrozephalosyndaktylie ACS. Fortschr. a. d. Ge/i. d. Rontgenstrah/en u. d. Nuk/earmedizin, 1969, 110,