Metabolics/Genetics Flashcards
Classic presentation for galactosemia
- Jaundice, hepatomegaly
- FTT, poor feeding, emesis
- Sepsis (E. coli)
- Cataracts
Inheritance pattern for Marfan Syndrome
Autosomal dominant
Features of Noonan Syndrome
- Dysmorphic features = low posterior hairline, wide philtrum, hypertelorism, down slanting palpebral fissures, short nose with bulbous tip, cubitus valgus, nuchal skin fold, wide bi-temporal distance
- Cardiac = R sided lesions (PV stenosis, double outlet RV, HCM), lymphedema
- CNS = seizures, chiari I malformation, mild ID, eye issues
- Other = endo (short stature, hypothyroidism), MSK (scoliosis, club foot, pectus abnormality), GU (renal anomalies), heme (thrombocytopenia), onc (JMML)
Williams Syndrome - cardiac manifestations
Supravalvular AS + PS
Pulmonary valve stenosis
Hypertension
Sturge-Weber Syndrome - derm manifestations
Port wine stain V1/V2
What genetic syndrome do you think for hemihypertrophy?
BW
What neoplasm to look for for BW?
Hepatoblastoma
Wilm’s tumor
What oncology screening for BW?
Abdo US q3m
AFP q3m
Until age 8
Electrolyte disturbance in CAH?
Hypoglycaemia
Hyponatremia
Hyperkalemia
What neuro complication in achondroplasia?
Risk of foremen magnum narrowing/stenosis that can lead to hydrocephalus and OSA
SMA - genetic inheritance
Autosomal recessive
5 BM failure congenital syndromes
Fanconi anemia Schwachmann Diamond Dyskeratosis congenita Pearson syndromes Congenital amegakaryocytic thrombocytopenia
What BM failure syndrome is associated with VACTERL?
Fanconi anemia
What BM syndrome is associated with hair/skin findings?
Dyskeratosis congenita
Non-ketotic hypoglycaemia (x3 causes)
GDM/SGA/prep
Insulin mediated = hyperinsulinemia
Lipid disorders = beta oxidation, carnitine
VLCAD complications (x2)
Rhabo
Cardiomyopathy
Hemophilia A inheritance pattern
X-linked recessive
Most common chromosomal abnormality involved spontaneous first trimester miscarriages?
Trisomy 16
Turner Syndrome - karyotype
45 XO
Turner Syndrome - clinical presentation
- Dysmorphic ftrs: Low posterior hairline, cubitus valgus, nuchal skin fold, abnormal ears, shield chest with wide-spaced nipples, short 4th metacarpal, hyperconvex nails
- CVS: BAV, coarct, AS, HTN, lymphedema
- CNS: IQ normal, SNHL + CHL hearing loss, strabismus
- Endo: met syndrome, hypothyroid, short stature
- MSK/derm: pigment nevi, scoliosis, DDH, cystic hygroma
- Onc: neuroblastoma, gonadoblastoma
- Gyne: Ovarian failure
- GU: renal anomalies (horseshoe kidney, solitary kidney)
Friedrich Ataxia - inheritance pattern, pathophys of chromosomal abnormality, and x3 classical clinical features
- Auto recessive
- Chromo 9q13 = frataxin protein –> deficiency leads to accumulation of iron in mitochrondria = oxidative stress
- Features: ataxic gait, extensor plantar responses, loss of DTRs
Most likely finding on blood gas for urea cycle defect
Respiratory alkalosis
x3 top findings on labs for urea cycle defect
- resp alkalosis
- hyperammonemia
- little/no urea
Inheritance pattern for OTC deficiency
X-linked recessive
What IEM presents with more significant ketosis?
Organic acidemias
Important severe, complications from organic acidemias?
Strokes, myocarditis, pancreatitis
IEM cause for subdural hematoma and on ddx for maltreatment
Glutaric acidemia
IEM diagnosis on ddx for Marfan Syndrome
Homocysteinuria
x2 dx to think of for neonates with ketonuria
Organic acidemias and maple syrup urine disease
IEM presenting with liver failure, conjugated hyperbili, and RTA (type II)
Tyrosinemia
IEM with neutropenia
GSD 1
IEM to think of for rhabdo out of in keeping of mechanism
GSD-5 = McArdle
When can you get a false positive galactosemia screen?
G6PD
Medical based reason for soy based formula (x1)
Galactosemia
FAOD labs (x2)
- Hepatitis
- Non-ketotic hypoglycemia
Peroxismal disorder presenting in neonates
Zellweger
What is the dx that has developmental regression (starting within school aged), new spasticity, and adrenal failure?
Adrenoleukodystrophy
MELAS - what does that stand for?
Mitochondrial encephalomyopathy lactic acidosis, stroke like episodes
Sturge Weber - inheritance
Sporadic
Sturge Weber - derm and classic CNS sign
- Angioma involving leptomeninges - vascular lesion, tram track sign
- V1 and V2 port wine stain
Lesch Nyhan Syndrome - inheritance
X linked recessive
IEM with gout, kidney stones, dev delay, self injurious behav
Lesch Nyhan Syndrome
What x2 genotypes has the worst disease for alpha 1 antitrypsin?
SZ and ZZ
Incontinentia pigmenti - inheritance, derm manifestation, dental
- X linked dominant (males die in utero)
- Stages: 1 vesicles (linear/whorls), 2 ketatotic plaques, 3 hypopigmentation, 4 hyperpigmentation
- Peg teeth
What tumor is classic for Denys-Drash?
Wilm’s tumor
Triad of Denys Drasch
Nephropathy, ambiguous genitalia, Wilm’s tumor
IEM presenting with learning disabilities and behaviour problems that is often dx with ADHD
X linked leukodystrophy
Sacral agenesis - associated with?
IDM
Trinucleotide repeat disorders (4)
Fragile X, myotonic dystrophy, spinocerebellar ataxia, Huntington’s disease
PHACE Syndrome/association
- Posterior fossa abnormalities - dandy walker malformation
- hemangioma
- arterial/aortic abnormality
- cardiac
- eye abnormality
- sternal abnormalities
Supravalvular aortic stenosis
William Syndrome
CATCH-22
For DiGeorge Syndrome:
- Cardiac
- AbN facies
- Thymic hypoplasia
- Cleft lip+palate
- HypoCa
Inheritance pattern for DiGeorge
Autosomal dominant
What is the most common genetic condition associated with cutis aplasia?
T13
What is a clue on ECG for T21 that suggests AVSD?
Left axis deviation
What cardiac lesions are Turner syndrome patients at risk for?
Coarctation, BAV, long QTc
X2 heart lesions in Williams Syndrome
Supravalvular aortic stenosis
Pulmonary artery stenosis
Electrolyte abnormality in Williams Syndrome
HyperCa
What eye finding in Williams Syndrome?
Starburst eye pattern
What syndrome has aniridia?
WAGR
X3 syndromes with Persistent peripheral pulmonary stenosis
Alagille syndrome, noonan, William
When should PPS murmur go away?
3-6 months
What does Rhizomelic mean?
Proximal aspect of extremity is shorter - example femur
Why should we do a CT or MRI around 12 months of age for achondroplasia?
Narrowing of the foremen magnum
Differences in homocysteinuria compared to Marfan syndrome?
Higher risk of clotting and decreased cognition
Main cardiac abnormality for Noonan Syndrome
Pulmonary stenosis
What type of leukaemia for neurofibromatosis type 1?
Juvenile myelomonocytic leukaemia
Optho finding in Sturge Weber
Glaucoma
What MRI finding for children with Sturge Weber?
Ipsilateral leptomeningeal angioma
What neuro manifestation do you worry about for tuberous sclerosis?
Infantile spasms
What first line med for infantile spasm in tuberous sclerosis?
Vigabatrin
Cardiac rhabdomyosarcoma - what syndrome?
Tuberous sclerosis
Ectodermal dysplasia - dental finding
Conal dentition
Rett Syndrome - 3 clinical features
Writhing hands, dev regression, seizures
Inheritance for Rett Syndrome
MECP2 - X linked dominant
What syndrome is good at puzzles?
Prader Willi
Onc things to monitor for BW Syndrome?
Hepatoblastoma, Wilm’s tumor
Facial asymmetry - syndrome?
Goldenhar syndrome
Diagnosis of Cystic Fibrosis
- 1 or more typical features, OR history of CF in sibling, OR abnormal NMS
- PLUS lab evidence: +sweat Cl, x2 known disease causing mutations, abnormal nasal potential difference measurements
What syndrome is most likely with seizure disorder, ataxia, absent speech, and microcephaly?
Angelman Syndrome
What is the mother at risk for when carrying a baby with DMD?
Cardiomyopathy
Inheritance pattern for DMD
X-linked recessive
x2 confirmatory tests for DMD
- Muscle biopsy - absent dystrophin, muscle atrophy
- Genetics - dystrophin gene
What mode of inheritance is characterized by male to male transmission?
Autosomal dominant
What mode of inheritance is characterized by female only transmission?
X-linked recessive
What mode of inheritance is characterized by a horizontal appearance of disease phenotype?
Autosomal recessive
What x2 syndromes are associated with Pierre Robin sequence?
- 22q11
- Stickler Syndrome
What syndrome are brushfield spots found in?
T21
T21 - facial features?
- Brachycephaly/microcephaly
- Up slanting palpebral fissures
- Epicanthal folds
- Low set ears
- Hearing loss, recurrent AOM
- Flat nasal bridge
T21 - MSK features?
- Single palmar crease
- Short 5th digit with clindodactyly
- Short neck with redundant skin
- Wide gap between first two toes
- Hip dysplasia
- Dislocations
- Atlantoaxial instability
T21 - GI features?
- Hirschsprung
- Celiac disease
- Duodenal atresia
- TEF
- Imperforate anus
Prenatal screen lab findings for T21
- High hCG
- Low AFP
Clinical features of T18
- Rockerbottom feet
- Overlapping fingers
- Clenched fist
- IUGR, microcephaly
- Micrognathia
- Cleft lip/palate
- Hypertonia
- CVS: VSD
Clinical features of T13
- Midline defect
- Aplasia cutis congenital
- Microphthalmia, microcephaly
- Hypotonia
- Postaxial polydactyly
- CVS: PDA
What syndrome will you see a stellate iris?
William Syndrome
Clinical features of William’s Syndrome
- Long philtrum (Elfin facies)
- Broad mouth
- Short nose with bulbous tip
- Cocktail personality, anxiety
- Developmental delay
- Joint laxity
Classic facial feature of Wolf-Hirschhorn Syndrome?
Greek helmet face
BW syndrome malignancies x2
Hepatoblastoma
Wilms tumor
Triad of BW Syndrome
- Omphalocele
- Macroglossia
- Hypoglycemia
Ear findings in BW Syndrome
- Ear lobe creases
- Posterior auricular pits
Fragile X - genital feature for F and M
- F = premature ovarian failure
- M = macroorchidism
CVS finding of Fragile X
-MV prolpase
Fragile X - what is the trinucleotide repeat?
CGG
x2 CVS findings in Turner’s
- BAV
- Coarctation
Clinical features of Turner’s Syndrome
- Short stature
- Lymphedema
- Shield chest
- Cubitus valgus
- Low posterior hairline
- Posteriorly rotated ears
- Webbed neck
- Short 4th metacarpal bone
- Ovarian dysgenesis
- Horseshoe kidney
- Autoimmune/endo disorders
Differentiating clinical features for Turner vs Noonan Syndrome?
-Noonan: down slanting palpebral fissures, intellectual disability, pulmonary stenosis (vs BAV/coarct), normal karyotype
What is the most common cause of primary hypogonadism + infertility in males?
Klinefelter Syndrome
Karyotype for Klinefelter
XXY
Clinical features for Klinefelter
- Gynecomastia
- Tall stature
- Small testes, micropenis
- Infertility
- Intellectual disability, behavioural problems
Most effective therapy for Klinefelter Syndrome
Testosterone replacement therapy
What x2 malignancies is Klinefelter at risk for?
Breast + testicular cancer
Clinical features of Angelman Syndrome
- Jerky ataxic movements (happy puppet)
- Inappropriate bouts of laughter
- Excitable with hand flapping
- Hypotonia
- Seizure
- Microcephaly
- Small/separated teeth
- Fair hair
- Severe intellectual disabilities
- Speech delay
Mode of inheritance for Angelman Syndrome
-Maternal UPD
What syndrome has almond-shaped eyes?
Prader Willi Syndrome
Clinical features of Prader Willi Syndrome?
- Infancy: hypotonia, FTT, feeding problems
- Hyperphagia, central obesity, short stature
- Hypogonadism
- Mild ID, behaviour disorder
- Almond-shaped eyes
Mode of inheritance for Prader Willi Syndrome
Paternal UPD
Classic finding of Alagille Syndrome
-Paucity of bile ducts
Syndrome with nephrogenic DI
Bardet-Biedl
Syndrome with LGA, excessive growth during first year of life, large head with frontal prominence, premature tooth eruption, and ventriculomegaly?
Sotos Syndrome
Syndrome with trident hands?
Achondroplasia
Syndrome with ice cream cone shaped femoral head?
Achondroplasia
x2 lab findings in OI
High ALP + hyperCa
Cardiac defect in Marfan Syndrome
- Mitral valve prolapse
- Aortic root dilatation
Major criteria for Marfan Syndrome
- Ectopia lentis
- Aortic dilation/dissection
- Family history
Clinical features of Treacher Collins Syndrome?
- Zygomatic/mandibular bone hypoplasia
- Eyelid colobomas
- Microretrognathia
- Choanal atresia
- Microtia
- Conductive hearing loss
- Cleft lip + palate
Syndrome with facial asymmetry, ear abnormalities, vertebral anomalies, and pathagnomnic limbal dermoid?
Goldenhar Syndrome
What clinical features are included in the Pierre Robin sequence?
- Mandibular hypoplasia
- Micrognathia
- Glossoptosis
- U shaped cleft palate
- Upper airway obstruction
What syndrome has a white forelock, heterochromia, and skin depigmentation?
Waardenburg Syndrome
What GI association is there is Waardenburg Syndrome?
Hirschsprung disease
Facial features of Cornelia de Lange?
- Long eyelashes
- Bushing/arched eyebrows
- Hirsutism
- Low hairline
- Down-ward turned mouth
- Thin upper lip
What are children with NF1 at risk for?
Malignancies
Diagnostic criteria for NF-1
- At least 2 of the following:
- At least 6 CALM (>5mm pre-pubertal; >15mm post-pubertal)
- At least 2 neurofibromas or 1 plexiform neurofibroma
- Axillary/inguinal freckling
- Optic glioma
- At least 2 Lisch nodules (iris hamartoma)
- Distinctive bony lesion: sphenoid dysplasia, tibial pseudoarthrosis, or cortical thickening of the long bone
- First degree relative with NF-1
Diagnostic criteria for NF-2
- 1 of the following:
- Bilateral vestibular schwannomas
- Unilateral vestibular schwannoma + first degree relative
- Unilateral vestibular schawannoma OR first degree relative AND any 2 of: meningioma, non-vestibular schwannoma, ependymoma, cataract
What is the most common neurological complication in Tuberous Sclerosis?
-Infantile spasms
Diagnostic criteria for Tuberous Sclerosis
- MAJOR*
- At least 3 hypomelanotic spots (ash leaf)
- At least 3 angiofibromas
- At least 2 ungual fibromas
- Shagreen patch
- Cortical dysplasia
- Subependymal nodules
- Subependymal giant cell astrocytoma
- Cardiac rhabdomyoma
- Lymhangioleiomyomatosis
- Angiomyolipomas
- MINOR*
- Confetti skin lesions
- Dental enamel pits
- Intra-oral fibromas
- Multiple renal cysts
- Non-renal hamartomas
*Need 2 major OR 1 major/2 minor
Classic triad for McCune-Albright Syndrome
- Precocious puberty
- CALM
- Polyostotic fibrous dysplasia
Most common presenting sign for precocious puberty in McCune-Albright?
-Vaginal bleeding
Most common endo association with McCune-Albright Syndrome?
Hyperthyroidism
Major criteria for CHARGE Syndrome (x4)
- Ocular colobomas
- Choanal atresia
- CN dysfunction
- Ear anomalies
What syndrome to think about if there is a single umbilical artery?
VACTERL association
Clinical features of VACTERL association
- Vertebral defect
- Anal atresia
- CHD (VSD)
- TEF
- Esophageal atresia
- Renal anomalies
- Limb hypoplasia
Three categories of protein disorders
- Amino acid disorders
- Organic acid disorders
- Urea cycle disorders
Typical presentation for PKU
- No acute signs/symptoms
- Gradual progression of developmental delay resulting in irreversible profound delays
Main method of management for PKU patients
Dietary restriction of phenylalanine
Classic presentation of amino acid disorders
- Acute sepsis-like decompensation, liver failure, and/or chronic neurological injury
- Acute symptoms typically occur in a catabolic state that predisposes to protein breakdown (e.g., infection, puberty, procedures)
Typical presentation of organic acid disorders in infancy (including symptoms + their cause)
- Feeding intolerance, emesis
- Lethargy
- Non-specific, sepsis-like presentation
- Progression to coma
- Toxin accumulation = metabolic acidosis + hyperammonemia
- Substrate deficiency = production of ketones/lactic acid
Acute + chronic management of organic acid disorders
- Acute: stop protein, provide calories, reduce ammonia, IV carnitine
- Chronic: protein restriction + carnitine
What is the role of carnitine in organic acid disorders?
- Binds to organic acid + helps to facilitate their excretion
- Leads to carnitine deficiency
What acid-base disturbance do organic acid disorders vs urea cycle disorders?
- Organic acid: metabolic acidosis (secondary to build up of acids)
- UCD: respiratory alkalosis (secondary to high ammonia)
Typical presentation of urea cycle disorders
- Feeding intolerance, emesis
- Lethargy
- Non-specific, sepsis-like presentation
- Progression to coma
Acute + chronic management of urea cycle disorders
- Acute: decrease ammonia, stop protein, give calories
- Chronic: restrict protein
When do FAOD typically present?
- Once body starts to rely on fats for energy or prolonged fasting
- Neonates = >3-4 hours
- Adults = >10-12 hours
Classic 3 presentations for FAOD (not necessarily at diagnosis)
- Hypoglycemia
- Cardiomyopathy/arrhythmia
- Rhabdo
Acute + chronic management for FAOD
- Acute: stop dietary LC fat intake, given calories (dextrose)
- Chronic: LCHAD + VLCAD (fat restriction, avoidance of fasting), MCAD (avoidance of fasting)
Three categories of carbohydrate metabolism disorders (including main source of that particular sugar + main examples of disorders)
- Galactose (main source: lactose) = galactosemia
- Fructose (main source: sucrose) = hereditary fructose intolerance
- Glucose = glycogen storage disorders, gluconeogenic disorders
What IEM to think about if hypoglycemia + hepatomegaly?
GSD
Typical presentation of galactosemia
- Typically in the first 10 days of life with jaundice + feeding intolerance
- Progression to conjugated hyperbili, coagulopathy, liver failure
x4 long term complications of galactosemia
- Cataracts
- Speech apraxia
- Ataxia
- Premature ovarian failure
Management of galactosemia
Remove dairy products
Main x2 clinical findings to think about in GSD
Hypoglycemia + hepatomegaly
Management of hyperammonemia
- Stop protein intake
- Promote anabolism with D10W with Na/K at 1.5x maintenance, IV lipids
- Remove ammonia
- Provide deficient subtrates
What are the two main IEM to think about with hyperammonemia and how to differentiate them?
- Organic acid disorders = metabolic acidosis
- Urea cycle disorders = respiratory alkalosis
What IEM would be revealed when testing plasma amino acids?
- Amino acid disorders
- Urea cycle disorders
What IEM would be revealed when testing urine organic acids?
- Organic acid disorders
- FAOD
What IEM would be revealed when testing plasma acylcarnitine?
- Organic acid disorders
- FAOD
What will the results of uric acid and triglycerides be in GSD?
- Hyperuricemia
- Hypertriglyceridemia
Acute + chronic management for GSD
- Acute: PO/IV glucose
- Chronic: Avoid fasting, cornstarch
What IEM is at risk for liver adenomas?
GSD
What systems are typically involved in mitochondrial disease?
Brain, eyes, heart, muscle + endocrine
What is MELAS?
Mitochondrial encephalopathy, lactic acidosis, stroke-like episodes
Classic three features of lysosomal storage disorders?
- Coarse facial features
- Hepatosplenomegaly
- Hypertrophic cardiomyopathy
What eye finding is classic for lysosomal storage diseases?
Cherry red spot
36 month old boy with developmental delay, gout, kidney stones, self mutilation with head banging and finger biting. Inheritance pattern?
X-linked recessive = Lesch-Nyhan Syndrome
When to do cervical XR’s for child with T21?
- No routine screening
- Done when clinical concerns for atlantooccipital instability
What is (a) the normal and (b) the most severe phenotypes for alpha-1 antitrypsin?
(a) MM is the normal phenotype
- MS, SS and MZ are associated with mild to moderate deficiency
(b) ZZ and SZ are associated with severe deficiency
Inheritance pattern for incontinentia pigmenti?
X-linked dominant (lethal in boys)
x2 trinucleotide repeat disorders
- Fragile X
- Myotonic dystrophy
Inheritance pattern for VACTERL
Multifactorial
Inheritance pattern for SMA
Autosomal recessive
Congenital inherited bone marrow failure syndromes - x5
Fanconi Anemia Schwachman-Diamond syndrome Dyskeratosis congenita Pearson syndrome Congenital Amegakaryocytic thrombocytopenia
x4 classic findings for Schwachman-Diamond Syndrome
- Steatorrhea
- FTT
- Skeletal abnormalities
- Hepatomegaly
What syndrome/association is choanal atresia most closely associated with?
CHARGE
What eye finding is most likely associated with choanal atresia?
Coloboma = key hole pupil
What does CHARGE stand for>
- Coloboma
- Heart
- Atresia (of nose)
- Retardation of growth/development
- GU/genital abnormalities
- Ear abnormalities
What syndrome is associated with abnormality with the PHOX2 gene?
Congenital hypoventilation Syndrome
In addition to respiratory complications, what other group of symptoms will children with congenital hypoventilation syndrome have?
Autonomic dysfunction
What test should we do annually for children with congenital hypoventilation syndrome?
Holter - at risk for cardiac asystole
x2 other associations with congenital hypoventilation syndrome?
- Neural crest cell tumors (neuroblastoma)
- Hirschsprung’s
Dysmorphic child with pedal edema, webbed neck, hypertrophic cardiomyopathy
Noonan’s syndrome
Criteria for NF1
• At least 2 of:
○ 6 or more of café-au-lait macules > 5mm in prepubertal and >15mm in postpubertal
○ 2 or more neurofibromas of any type or one plexiform
○ Freckling in the axillary or inguinal regions
○ Optic glioma
○ 2 or more Lisch nodules
○ Distinctive bony lesion
First degree relative with NF1