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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 1  |  Issue : 3  |  Page : 152-154

A severe and rapidly progressive case of proteus syndrome in a neonate who presented with unilateral hydrocephalus apart from other typical features of the proteus syndrome


Department of Pediatrics, Katihar Medical College, Katihar, Bihar, India

Date of Web Publication28-Sep-2012

Correspondence Address:
Rakesh Kumar
Department of Pediatrics, Katihar Medical College, Katihar, Bihar
India
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DOI: 10.4103/2249-4847.101702

PMID: 24027714

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  Abstract 

Proteus syndrome is a rare hamartomatous disorder affecting multiple tissues and manifesting itself in a variety of ways. The understanding of the complete spectrum of clinical features, the natural clinical course of the disease and the proper management of such a rare but highly variable syndrome depend heavily on experiences gathered by previously reported cases. We present an unusually severely affected and rapidly progressive case of proteus syndrome in a neonate who presented with craniofacial hemihypertrophy, subcutaneous masses, capillary hemangioma, varicose veins, epidermal nevi and macrodactyly. The cranial ultrasonogram revealed unilateral hydrocephalus with partial obstruction of the foramen of monro.

Keywords: Craniofacial hemihypertrophy, proteus syndrome, unilateral hydrocephalus


How to cite this article:
Kumar R, Bhagat P. A severe and rapidly progressive case of proteus syndrome in a neonate who presented with unilateral hydrocephalus apart from other typical features of the proteus syndrome. J Clin Neonatol 2012;1:152-4

How to cite this URL:
Kumar R, Bhagat P. A severe and rapidly progressive case of proteus syndrome in a neonate who presented with unilateral hydrocephalus apart from other typical features of the proteus syndrome. J Clin Neonatol [serial online] 2012 [cited 2014 Oct 1];1:152-4. Available from: http://www.jcnonweb.com/text.asp?2012/1/3/152/101702


  Introduction Top


First description of Proteus syndrome (PS) dates back to 1979 when Cohen and Hayden described two patients of this syndrome. [1] It was termed by Wiedemann et al in 1983 as PS after the Greek God Proteus who could change his shape at will to avoid capture, emphasizing the variability of clinical expression of the disease. [1] Several central nervous system malformations (CNS) have been described to be associated with PS in individual cases. The multiple, diverse, somatic manifestations of the syndrome evolve over time and the patients are usually asymptomatic or only partially affected in the neonatal period. The purpose of this article is two fold: (1) To present an unusually severely affected and rapidly progressive case of PS, who presented in the neonatal period with all the typical features of the syndrome (2) To report a new possible association of PS in the form of unilateral hydrocephalus.


  Case Report Top


A 5-day-old male baby presented with enlarging head size and multiple physical abnormalities. He was the first child of nonconsanguineous parents. The pregnancy had been uneventful. He was born by caesarean section with birth weight of 2600 gm (5 th centile), length 50 cm (50 th centile), and head circumference 38 cm (>90th centile). The baby was on breast feeds. There was no relevant family history.

On physical examination, the baby had marked right-sided hemihypertrophy involving face and cranium. The facial hemihypertrophy included enlarged palpebral fissure, cheek, ear, and lip [Figure 1]. There was marked wasting of subcutaneous tissue of arms and thighs on both sides. Capillary hemangioma large in size was present in both flanks. There was venous prominence over scalp and trunk. Multiple subcutaneous masses were palpable over both thighs clinically appearing to be lipomas. The second and third toes of the left foot were significantly enlarged [Figure 2]. The head circumference has increased to 39.2 cm (95 th centile).
Figure 1: Facial hemihypertrophy

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Figure 2: Macrodactyly of second and third toe

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A cranial ultrasonogram (USG) was carried out which revealed selective dilatation of the right ventricle with partial occlusion of the right foramen of monro [Figure 3]. The brain parenchyma, left lateral ventricle, corpus callosum and cerebellum were normal. The cranial USG finding together with rapidly increasing head circumference in our patient indicated toward right-sided unilateral hydrocephalus. Computed tomography of the head was advised to confirm the USG finding and to detect any other associated CNS anomalies. But the baby became lethargic on day 7 of life. He developed marked respiratory distress. Examination revealed a bluish discoloration over anterior trunk and a large venous prominence visible over left side of chest and abdomen originating from mid axillae with flow from upward to downward [Figure 4]. The platelet count was 30×10 3 /μl. Other parameters of hemogram and sepsis screen were normal. Duplex scan of chest and abdomen was advised but the baby died before the investigation. Parents refused to go for autopsy.
Figure 3: USG cranium showing dilatation of right ventricle and partial obstruction of foramen of monro

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Figure 4: Venous prominence over abdomen

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  Discussion Top


PS is a rare, sporadic, complex, congenital, sometimes lethal hamartomatous disorder characterized by a variety of malformations and disproportionate, asymmetric overgrowth of multiple tissues. [1],[2],[3] The typical clinical features include hemihypertrophy, macrodactyly, subcutaneous tumors, lipolymphohemangiomas and epidermal nevi. [1],[2],[3]

The patients of PS are usually asymptomatic with no any gross abnormality detectable at the time of birth. [1] As the child grows older, characteristic manifestations of the disease appear suggesting progressive nature of the disease. The presence of many characteristic features of the disease at the time of birth in our patient suggests that the clinical course of the disease can be progressive prenatally.

Most authors suggest that PS results from mosaicism for a mutation that is lethal in nonmosaic state. Recently, a somatic activating mutation in AKT1 has been found in cases of PS, proving the hypothesis of somatic mosaicism. [2] An early postzygotic mutation would be expected to present with more severe disease, because an early somatic cell carrying mutation would give rise to more abnormal cell lineages. [3] This could explain the severity and rapid progression of the disease in our case.

The CNS malformations described to be associated with PS include hemimegalencephaly, hydrocephalus, corpus callosal abnormalities, Dandy Walker malformation, periventricular heterotopias, cysts, and neoplasm like meningioma and pineoblastoma. [1],[4]

The disproportionate asymmetric overgrowth characteristic of PS can involve one half of the body (hemihypertrophy) or a limb or a digit (macrodactyly). Hemihypertrophy can be partial or complete. The partial hemihypertrophy involving the skull and face present as craniofacial asymmetry. The craniofacial asymmetry was present in previously reported cases and it was seen to be associated with hyperostosis of facial bones and calvaria, hemimegalencephaly and craniosynostosis. [1] In our case, it was associated with unilateral hydrocephalus.

Unilateral hydrocephalus, a rare entity in itself, has been defined as the progressive dilatation of one lateral ventricle due to abnormal circulation of cerebrospinal fluid. The obstruction of foramen of monro is the most common cause. The foramen of monro can be obstructed by congenital atresia or stenosis, or morphological obstruction due to hemorrhage, neoplasm, gliomatous or vascular anomalies or intrauterine infections like mumps. [5] Various neoplasm and cerebrovascular malformations has been described in previously reported cases of PS. [4],[6] On the basis of extensive vascular malformations present in our case, we think antenatal hemorrhage could be the most probable cause of obstruction of the foramen of monro, though hemorrhagic cast was not present in the ventricles in cranial USG.

Diagnosis of PS is primarily clinical. Because of the varied morphology of the patients, diagnostic criteria have been laid down. [1] The closest differential diagnosis of this case is CLOVE syndrome, a newly delineated syndrome characterized by congenital lipomatous overgrowth, vascular malformations and epidermal nevi. [7] The overgrowth in CLOVE Syndrome is congenital, as in our case. But the overgrowth in CLOVE Syndrome is of ballooning nature, proportionate and symmetrical, unlike PS where it is characteristically disproportionate and asymmetrical, as in the present case. [7] Other differential diagnosis particularly in cases associated with craniofacial hemihypertrophy includes Haberlund Encephalocraniocutaneous Lipomatosis, Beckwith- Wiedemann syndrome, Hemifacial hypertrophy of Rowe, Bannayan syndrome, Klippel-Trenaunay- Weber syndrome More Details and Mafucci syndrome. [8]

Sudden death, as in our case, but in older age group has been reported previously and the usual cause was pulmonary thromboembolism, which is a recognized complication of PS. [9] Functional ability and longevity in cases of PS vary with the severity of cutaneous and CNS abnormality. [3],[8] The full-blown picture of PS present in our patient since birth and his early death, suggest that children with normal infancy or fewer findings in early life may have an improved prolong survival. Limb anomaly like macrodactyly and cranial anomaly like unilateral hydrocephalus or hemihypertrophy can be diagnosed in antenatal period itself by an obstetric USG and if found together in a patient may be highly suggestive of PS. [5],[10] The prenatal diagnosis of PS in severe cases by antenatal USG will lead to early diagnosis and proper management of this syndrome and its complications, and this may result in favorable clinical outcome.

 
  References Top

1.Cohen MM Jr. Proteus syndrome: An Update. Am J Med Genet Part C Semin Med Genet 2005;137:38-52.  Back to cited text no. 1
    
2.Lindhurst MJ, Sapp JC, Teer JK, Johnston JJ, Finn EM, Peters K, et al. A mosaic Activating Mutation in AKT1 Associated with the Proteus Syndrome. N Eng J Med. 2011 ;365:611-9.   Back to cited text no. 2
[PUBMED]    
3.Nguyen D, Turner JT, Olsen C, Biesecker LG, Darling TN. Cutaneous manifestations of Proteus syndrome. Correlation with general clinical severity. Arch Dermatol 2004;140:947-3.  Back to cited text no. 3
[PUBMED]    
4.Dietrich RB, Glidden DE, Roth GM, Martin RA, Demo DS. The Proteus Syndrome: CNS manifestations. AJNR Am J Neuroradiol 1998;19:987-0.  Back to cited text no. 4
[PUBMED]    
5.Kim JH, Chung YG, Lee NJ, Kim SH, Lee HK, Lee KC, et al. Unilateral Hydrocephalus in Congenital atresia of foramen of monro. J Korean Neurosurg Soc 2000;29:434-7.  Back to cited text no. 5
    
6.Badia MC, Chamarro R, Lainez JM. Proteus syndrome with cerebral vascular malformations. Neurologia 2006;21:88-91.  Back to cited text no. 6
    
7.Gucev ZS, Tasic V, Jancerska A, Konstantinova MK, Jordanova NP, Trajkorski Z, et al. CLOVE Syndrome (Congenital Lipomatous Overgrowth, Vascular Malformations, and Epidermal Nevi): CNS Malformations and seizures may be a component of this disorder. Am J Med Genet A. 2008 ;146A:2688-90.  Back to cited text no. 7
    
8.Dean JCS, Cole GF, Appleton RE, Burn J, Roberts SA, Donnai D. Cranial hemihypertrophy and neurodevelopmental prognosis. J Med Genet 1990;27:160-4.  Back to cited text no. 8
    
9.Slavotinek AM, Vacha SJ, Peters KF, Biesecker LG. Sudden death caused by pulmonary thromboembolism in Proteus syndrome. Clin Genet 2001;58:386-9.  Back to cited text no. 9
    
10.Rypens F, Dubois J, Garel L, Fournet JC, Michand JL, Grignon A. Obstetric US: Watch the fetal hands. Radiographics 2006;26:811-829.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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