System based disorders II
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Cystic Fibrosis | respiratory, exocrine pancreas, intestesting, vas deferens, hepatobiliary and sweat glands
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Cystic fibrosis | 15-20% neonates meconium ileus
>95% males infertile
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Cystic fibrosis | dx: sweat Cl>60 mEq/L OR CFTR disease causing mutations
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Cystic fibrosis | deltaF508 (0.7 of ~1500 alleles)
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Cystic fibrosis | antibiotics, bronchodilators, mucolytic (pulmonzyme, mucomyst), chest PT; avoid smoking, resp viruses and dehydration
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Cystic fibrosis | mutation specific therapy (G551D) using Ivacaftor/Kalydeco
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Heritable Pulmonary Arterial Hypertension (HPAH) | dyspnea 60%, fatigue 19%, chest pain 7%, edema 3%; PA pressure <25 mmHg (rest)/ >30 (exercise) and other causes exclueded;
increased PA pressure causes right heart failure and death within 3 yrs of dx
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Heritable Pulmonary Arterial Hypertension (HPAH) | ~6% of cases familial: AD w/ 10% pen, variable age onset and ?anticipation;
2.4 females/males;
BMPR2 and ACVRL1, BMPR1B, CAV1,, ENG and SMAD8 rare
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Heritable Pulmonary Arterial Hypertenstion | treatment; sc/iv treprostinil,; po Bosentant, sildenafil; neb Iloprost and IV epoprostenol
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Idiopathic Pulmonary Fibrosis (IPF) | Bibasilar reticular anomalies/nodules on high res CT, abnl lung func (VC), usually 50-70 yrs; +/- lung Ca; 30-50% 5 yr survival
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Idiopathic Pulmonary Fibrosis (IPF) | TERT and TERC (short telomeres) or SFTPC in 8-15% multiplex or 3% simplex; all AD reduced penetrance;
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Pulmonary Fibrosis | occurs in Hermansky Pudlak (AR),
Dyskeratosis Congenita (AD, AR, XL)
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Idiopathic Pulmonary Fibrosis | treatment: supp O2, lung transplant, no smoking
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Adenosine Deaminase Def | SCID with FTT, opportunistic infections, marked lymphocytopenia, absent humoral and cellular, usually Dx <6/12
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Adenosine Deaminase Def | <1% ADA activity (purine metabolism) or 2 known ADA causing muts (AR)
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Adenosine Deaminase Def | antibiotic, antifungual, IV immunoglobulin (IVIg), Pneumocystis prophylaxis, bone marrow/stem cell transplant; PED ADA ERT
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Common Variable Immune Def (CVID) | humoral immune def after 24/12 (often young adults), sinopulmonary (Strep, H flu, Kleb pn), meningitis after bacterial infections, chronic diarrhea, malabsorption, +/- lymphoid hyperplasia, autoimmune, lymphomas
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Common Variable Immune Def (CVID) | IgG < 100 mg/dL to low, poor response to Pneumovax
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Common Variable Immune Def (CVID) | loss RAC1, CD19, BAFFER protein; TNFRSF13B (TAC1)10-15%, ICOS (<1%), muts (AD, AR)
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Common Variable Immune Def (CVID) | rx: immune globulin (IVIg), antibiotics, monitor lymphoma, thyroid function
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AD Hyper IgE syndrome | boils, cysts forming pneumonia and very high IgE; characteristic face, Chiari malform, +/- eczema, candiasis, osteopenia, fractures, scoliosis, arterial tortuosity and aneurysms
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AD Hyper IgE syndrome | IgE >2000 IU/mL (~15X)
STAT3 gene (AD)
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AD Hyper IgE syndrome | rx: antibiotics to prevent Staph absecess/pn
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X linked hyper IgM syndrome | 50% onset by 1 yr, >90% by 4yr; recurrent respiratory bacterial, recurrent diarrhea w/ FTT; neutro & thrombopenia, anemia; 10-15% CNS infections; liver, GI, pancreatic tumors; lymphoma (Hodgkins) and EBV
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X linked hyper IgM syndrome | CD40LG (aka TNFSF5/CD154) muts in 95% of affected males (XL)
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X linked hyper IgM syndrome | allogenic hematopoietic cell transplantation, recombinant granulocyte stim factor (G-CSF) for neutopenia, antibiotics
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IPEX syndrome | Immune dysregulation, Polyendocrinopathy, Enteropathy; watery diarrhea, eczema, diabetes, autoimmune thyroid, anemia, low polys and plts, tubular neuropathy
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IPEX syndrome | FOXP3 muts in ~25% affected males (XL)
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IPEX syndrome | rx: immunosuppression, steriods, granulocyte stim factor, bone marrow transplant
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XL SCID | severe combined cellular and humoral immunodef, present 1-3/12 w FTT, oral/diaper candidiasis, absent tonsils and lymph nodes, recurrent and presistent infections
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XL SCID | NBS in 10 states, IL2RG muts found in >99% of affected males (XL)
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XL SCID | rx: antibiotics (esp pneumocystis, IVIg, bone marrow transplant ASAP, gene therapy?
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AR SCID | SCID presents in 1st yr, recurrent bacterial, viral, and opportunistic infections, diarrhea, oral moniliasis, FTT, Pneumocystis, usually die by 2 yrs unless stem cell transplant
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AR SCID | due to abnl T cell receptor signaling; low CD3,4,8 T cells; ZAP70 muts (AR)
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AR SCID | IVIg, antibacterial,-fungal, -protozoal, allogenic HSCT within 3/12; avoid live viral vaccines
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GATA1 related XL cytopenia | thrombocytopenia +/- anemia w 1 or more of the following: plt dysfx, mild beta thal, neutropenia and congen erythropoietic porphyris in males
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GATA1 related XL cytopenia | rx: plt or rbc transfusions, avoid ASA, NSAIDs
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Hemophilia A | prolonged oozing after trauma, tooth extractions or surgery, age at dx relates to F8 activity, sever joint/deep muscle bleeds <2 yrs, 10% carriers bleed
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Hemophilia A | Low F8 clotting activity with nl von Willebrand factor level; F8 muts in 98% of affected males (XL), IVS 22 inversion in 48% severe cases and dels/dups in 6%
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Hemophilia A | hemophilia center, IV F8, DDAVP, avoid ASA, IM injections, impact sports and activities, and always rx before circumcision
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Hemophilia B | prolonged oozing after trauma, tooth extractions or surgery, age at dx relates to F9 activity, severe joint/deep muscle bleeds <2yrs, 10% carriers bleed
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Hemophilia B | low F9 clotting activity; F9 mut in 100% of affected males (XL), dels/dups 3%
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Hemophilia B | rx; hemophilia center, IV F9, avoid ASA, IM injections, impact sports and activities; always rx before circumcision
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Sickle Cell Disease | intermittent vaso-oclusive events and hemolytic anemia, dactylitis, splenic infarction and asplenia, cholelithiasis, PAH, leg ulcers
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Sickle cell Disease | HBB muts B(s) Glu6Val, B(c), B(punjab), B(arab) - all AR; SS and SC <3.6% and Sb(thal) >3.6% Hb A2
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Sickle Cell Disease | rx: hydration, transfusion, penicillin, hydroxyurea, rx PAH phosphodiesterase inhibs/nitric oxide
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Alpha Thalessemia | significant Hb Bart hydrops fetalis (Hb Bard Syn) and HbH disease w 90% vs 5% Hb Bart
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Alpha Thalessemia | Hb Bart syn, HbH, alpha thal trait, silent carrier and nl have deletion of 4,3,2,1,1 alpha globin genes; dels 90% and point 10% of mut, alpha thal moderates SS
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Alpha Thalessemia | rx: Hb Bart syn fatal, HbH transfuse prn; avoid excess FE rx and sulphonamides in HbH
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Hb Bart syndrome | 4 null alpha genes
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HbH | 3 null alpha genes
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alpha thal trait | 2 null alpha genes (in cis or trans)
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silent carrier | 1 null alpha gene
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Beta Thalessemia | reduced beta globin causes microcytic hypochromic anemia and dec HbA; Bthal major > severe anemia and hepatosplenomegaly <2 yrs, marrow expansion
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Beta Thalessemia | RBC indices, dec Hb A2 and inc Hb F >12 months; nucleated RBCs
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Beta Thalessemia | rx; regular transfusion, Fe chelation, bone marrow transplant, splenectomy?; monitor endo function; avoid EtOH & iron meds
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Thiamine Responsive Megaloblastic Anemia | triad of megaloblastic anemia, SNHL and DM; +/- optic atrophy, CHD, arrythmias, strokes
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Thiamine Responsive Megaloblastic Anemia | SLC19A2 muts in 100% (AR)
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Thiamine Responsive Megaloblastic Anemia | rx: anemia corrected by high dose Thiamine (B1), RBC remain macrocytic and SNHL irreversible
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XL Adrenal Hypoplasia Congenita (AHC) | acute adrenal insufficiency by 3 wks in ~60%; vomiting, hypoglycemia and salt wasting with hyper kalemia; +/- cryptochidism
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XL Adrenal Hypoplasia Congenita (AHC) | NROB1 (DAX1) dels in 100% with glycerol kinase def +/- DMD; but point muts in nearly all isolated AHC
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XL Adrenal Hypoplasia Congenita (AHC) | rx: IV glucose, NaCl; glucocorticoids, mineralocorticoids and NaCl
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Antley Bixler (cyto p450 oxidooreductase def) | steroidogenic defect ranging from cortisol deficiency to Antly Bixler syndrome with ambiguous genitalia, craniosynostosis, choanal atresia,radiohumeral synostosis
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Antley Bixler (cyto p450 oxidooreductase def) | sterol/steriod abnormalities, POR muts (AR)
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Antley Bixler (cyto p450 oxidooreductase def) | rx: tracheostomy, cortisol, surgery for craniosynostosis and hypospadias
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Congenital Adrenal Hyperplasia | >90% CYP21OHD, impaired cortisol synthesis by adrenal cortex, simple virilizing (25%) and salt wasting (low cortisol and inadequate aldosterone) (75%), NBS of neonates lowers risk for initial fatal salt wasting crisis
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Congenital Adrenal Hyperplasia | CYP21A2 panel of 9 seq or del/dups detect 80-98% (AR)
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Congenital Adrenal Hyperplasia | rx: glucocorticoid (increase w stress), salt wasting add mineralocorticoid and NaCl
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Congenital Adrenal Hyperplasia | ACTH causes adrenal hyperplasia and overproduction og 17OHP and hormones
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Familial Hyperinsulinism | Hypoglycemia (ranges from severe neonatal to mild childhood onset)
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Familial Hyperinsulinism | ~45% ABCC8 and 5% KCNJ11 (AR), ~5% GLUD1 and 5% HNF4A (AD w anticipation)
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Familial Hyperinsulinism | rx: IV glucose, diazoxide, etc, diet, pancreatic resection, avoid fasting
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Isolated Gonadotropin Releasing Hormone (GnRH) Def | low LH and FSH w hypogonadism, +/- micropenis/cryptochidism, small testes, absent puberty, 60% anosmia (aka Kallmann), bimanual synkinesis
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Isolated Gonadtropin Releasing Hormone (GnRH) def | FGFR1, PROKR2, PROK2, CHD7, FGF8 muts ~25% (AD), KAL1 ~10% (XL) muts/del
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Isolated Gonadtropin Releasing Hormone (GnRH) deff | Testosterone, hCG in males and estrogen, progestins in females
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PROP1 related combined pituitary hormone def | combined pituatary hormone def (CPHD) w GH, TSH, LH, FSH, and PrL +/- ACTH deficiencies, short stature, FTT in childhood
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PROP1 related combined pituatary hormone def | PROP1 muts >98% (AR)
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PROP1 related combined pituatary hormone def | rx: GH, L thyroxine, +/- testosterone or estrogens, +/- hyrocortisone
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Achondoplasia and Hypochondroplasia | Rhizomelic short stature, macrocephaly/inc ICP; kyphosis, lordosis, narrowing interpedicular distance, trident hand, genu varum, cranio-cervial compression and spinal stenosis
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Achondroplasia and Hypochondroplasia | dx: signs and x-rays;
FGFR3: Achondroplasia 98% G>A transition due to CpG results in Gly380Arg; Hypochondroplasia Asn650Lys C>A and 21% C>G
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Achondroplasia and Hypochondroplasia | rx: cns shunt for ICP, sleep and cc apnea; otitis; orthopedics for gibbus, genu varum and spinal stenosis
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Osteogenesis Imperfecta | Fx fater min trauma, +/- dentinogenesis imperfect (gray/brown) and HL (adults
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OI type 1 | non-deforming with blue sclerae
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OI type 2 | perinatal lethal
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OI type 3 | progressively deforming
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OI type 4 | variable OI with nl sclerae
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Osteogenesis imperfecta | dx: FHx (fx/signs), X rays (fx, wormian, codfish vertebrae and oseopenia);
COL1A1/2 molecular test and/or biochemical analysis of type 1 collagen
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COL1A1/2 ratio | 2:1
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Osteogenesis Imperfecta | Molecular testing COL1A/2 detects 90% of OI types 1-4 (AD, >95% seq changes and 2% del/dup); biochemical detects 90,98,84,84% of OI types 1-4
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Ostoeogenesis imperfecta | rx: orthopedic and otolaryngology management, periodic dental and hearing eval; bisphosphonates, oral alendronate or risedronate and GH may reduce fx, increase bone density and improve growth
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OI V-VII | Fx, no dentinogenesis (D) or hearing loss; abnl vertebrae and hyperplastic callous
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OI V | IFITM5 (AD)
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OI VI | SERPINF1 (AR)
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OI VII | CRTAP (AR)
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OI VIII | Fx, no dentinogenesis or HL; short limb dwarfism, gracile long bones
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OI VIII | LEPRE1 (AR)
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OI IX | Fx, white to gray sclerae, short limb dwarfism, bowed limbs
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OI IX | PPIB (AR)
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Type II Collagenopathies | Achondrogenesis 2;
Kniest,
SED,
Stickler
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Achondrogenesis Type 2 (Langer Saldino) | micromelic dwarfism, CP, short ribs and abnl vert; stillborn/neonatal death;
COL2A1 (AD)
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Kniest | short stature and trunk (platysopondyly); hearing loss; myopia and retinal detach (MRD and cataract;
COL2A1 (AD)
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Spondyloepiphyseal Dysplasia (SEDC) | flat face/CP, MRD, abnl vert, cervical myelopathy;
COL2A1 (AD)
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Stickler | flat face, MRD and cataract, HL, CP +/- Robin;
COL2A1 (85%) and COL11A1 (10-15%)
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Diastrophic dysplasia | short limbs, nl skull, hitchhikers thumbs, spine (scoliosis, lordosis, kyphosis), joint contractures and osteoarthritis, CP 1/3, cystic ears 2/3, club feet
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Diastrophic dysplasia | clinical and radiologic confirmed by SLC26A2 >90% have seq variants
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Diastrophic dysplasia | rx: PT, casting, ortho surgery with caution as deformities tend to recur, watch C spine for cord compression
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Ehlers Danlos | 5 types:
1.classic (i and ii) 2. hypermobility (III) 3.kyphoscoliotic (vi) 4. vascular(iv)
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Classic EDS (i and ii) | skin hyperextensible, abnl wound healing and joint hypermobility
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Hypermobility EDS (iii) | soft skin, dislocation, pain +/- aortic dilation
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Kyphoscoliotic EDS (vi) | friable, hyperextensible skin; scars, bruising, hypotonia, progressive scoliosis and fragile sclerea
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Vascular EDS (iv) | thin, translucent skin; bruising, vascular rupture (12% death secondary to arterial or uterine rupture in pregnancy); GI perforation
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Classic EDS (i and ii) | ~50% have COL5A1/2 seq, del/dup (AD)
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Hypermobility EDS (iii) | TNXB haploinsufficiency; very rare (AD)
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Kyphoscoliotic EDS (vi) | increase deoxypyrimidine/pyrimidine ration in urine (HPLC) due to def lysyl hydroxylase (PLOD1) activity (fibroblast); PLOD1 seq?; del/dups ~18% (AR)
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Vascular EDS (iv) | COL3A1 seq >95%, del/dup 2% (AD)
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Classic EDS (i and ii) | rx: care with sutures, ascorbic acid? avoid ASA and contact sports
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Hypermobility EDS (iii) | rx: watch aorta and avoid cs/joint hyperextension
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Kyphoscoliotic EDS (vi) | rx: ortho, opthal, pregnancy risk and avoid cs
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Vascular EDS (iv) | avoid contact sports and arteriography
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Marfan syndrome | ocular (myopia, ectopia lentis); skeletal (dolichosternomelia, pectus, scoliosis); aoritc dilation/tear/rupture/MV prolapse
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Marfan syndrome | dx: FHx, exam (esp ectopia lentis and aneurysm); FBN1 seq 70-93%, dels/dups? (AD), 25% de novo
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Marfan syndrome | rx: lens surgery, beta blockers/losartan for aortic dilation, surgery 5 cm or if 1 cm/yr; yearly opthal & ECHO; avoid contact sports, isometric; CV stimulants and LASIK; inc CV risk with pregnancy
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Loeys Dietz syndrome | vascular (CNS, thoracic and abdominal arterial aneurysms/dissections) and skeletal (pectus excav/carin, scoliosis, lax joints, arachnodactyly and clubfeet).
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LDS type I | 75%
hypertelorism, bifid uvula/CP and craniosynostosis
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LDS type II | 25%
velvety/translucent skin; atrophic scars
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Loeys Dietz | TGFBR1/2 in 95% (AD), 3/4 de novo
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Leoys Dietz | rx: aortic dissection at smaller diameters than MFS, beta blockers, C spine instability, avoid contact sports and CV stimulants
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Multiple Epiphyseal Dysplasia | joint pain (hips and knees), malformations (hands, feet and knees) and scoliosis;
50% had clubfoot, clinodactyly or CP at birth; adult Ht 150-180 cm
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Multiple Epiphyseal Dysplasia | dx: clin and x-ray; SLC26A2 seq variants in ~100% (AR)
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Multiple Epiphyseal Dysplasia | rx: orthopedic, avoid sports involving joint overload and caution with NSAIDs
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Pseudoxanthoma Elasticum | affects elastic tissue skin, eye, CV and GI systems; skin (papules); retina (streaks and hemorrhage); GI bleeds, angina/claudication
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Pseudoxanthoma Elasticum | dx: skin and eye findings and skin biopsy; ABCC6 seq ~90% both alleles w dels in 5-30% (AR)
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Pseudoxanthoma Elasticum | rx: intraocular injections for macular degeneration; avoid contact sports, ASA, NSAIDs, retinal exams in pregnancy
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Branchiootorenal Spectrum Disorders | ear pits, tags, anomalies causing deafness >90%; branchial fistulae/cysts and renal hypoplasia, dysplasia or agenesis
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Branchiootic Syn (BOS) | BOR w/out renal anomalies
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Branchiootorenal disorders | EYA1, SIX5, SIX1 seq, dups/dels in 40% (AD) with 10% de novo
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Branchiootorenal disorders | rx: excision fistulae/cysts, ear surgery, aids, cochlear implants
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Lowe syndrome | eyes: cataracts, glaucoma and poor vision; CNS: hypotonia, absent DTRs and 75-90% mild to severe delay; Renal: Fanconi, RTA, renal
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Lowe syndrome | OCRL seq variant in 95% affected males and carriers (XL); enzyme in fibroblasts
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Lowe syndrome | rx: remove cataracts, GERD; oral Na/KHCO3, PO4 and calcitriol; avoid contact lens
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Polycystic kidney disease (AD) | late onset, bilateral renal cysts; liver and pancreatic cysts; CNS/aortic aneurysms and MVP; renal pain, hypertension, renal failure by 60 yrs
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Polycystic kidney disease (AD) | dx: renal imaging; 85% PKD1 and 15% PKD2 most seq but few del/dups (AD); contiguous PKD1 and TSC2 del > PKD in utero and Tuberous Sclerosis; rare early onset PKD with neg FHx due to hypo morph PKD1 in trans
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Polycystic kidney disease (AD) | rx: hypertension, pain, cyst decompression, nephrolithiasis, clip small and aortic replacement for large aneurysms; avoid nephrotoxic, caffeine and smoking
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Polycystic kidney disease (AR) | neonates with enlarged echogenic kidneys: ~45% hepatomegaly, dilated bile ducts and echogenicity; pulmonary hypoplasia w 30% dying by 1 yr of resp insuff and >50% have renal failure in first decade
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Polycystic kidney disease (AR) | dx: clin findings in absence of renal cysts in parents; ~80% PKHD1 seq variants, dups/dels seen
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Polycystic kidney disease (AR) | rx: resp failure, hypertension, avoid NSAIDS, aminoglycosides and caffeine
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UMOD associated kidney disease | hyperuricemia and goat from dec renal excretion uric acid; increase creatinine 5-40 yrs and renal failure >40 yrs; isosthenuria may exacerbate bouts of dehydration
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UMOD associated kidney disease | UMOD (aka uromodulin/Tamm Horsfall protein) seq variants in >95% (AD)
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UMOD associated kidney disease | rx: allopurinol/probenecid for gout; nepherology management, peritoneal dialysis, renal transplant; avoid nephrotoxic meds, dehydration and meats
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