Clinical Description
Males and females are equally affected with no apparent parent-of-origin effect (Table 2).
Table 2.
Features of Phelan-McDermid Syndrome
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Prevalence | Features |
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>75% | Neonatal hypotonia Developmental delay Absent or severely delayed speech Normal growth Decreased perception of pain Mouthing /chewing / tooth grinding Autism / autistic-like behavior
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>50% |
|
>25% |
|
Hypotonia. Newborns with Phelan-McDermid syndrome have generalized hypotonia that may be associated with weak cry, poor head control, and feeding difficulties leading to slow growth.
Developmental delay. Most individuals with Phelan-McDermid syndrome are described as having "global developmental delay" or "moderate-to-profound intellectual disability." Although the severity of the delay tends to vary with deletion size [Sarasua et al 2011, Zwanenburg et al 2016], individuals with the same size deletion may be vastly different in their degree of disability [Dhar et al 2010]. Development assessment using the Developmental Profile II (DPII) and the Scales of Independent Behavior-Revised – Full Scale (SIB-R) demonstrated that while all participants in the study of Wilson et al [2003] had moderate to profound intellectual disability, compared to most children with this level of impairment, those with Phelan-McDermid syndrome had less frequent and less severe problematic behaviors. In an independent study based on the Bayley-II-NL scale of infant development, Zwanenburg and colleagues [2016] reported developmental delay with a maximum developmental age equivalent of 3 to 4.5 years and more pronounced delays in older individuals than in younger children, a trend referred as "growing into deficit."
Major milestones are delayed: the average age for rolling over is approximately eight months, for crawling approximately 16 months, and for walking approximately three years. Poor muscle tone, lack of balance, and decreased upper body strength contribute to the delay in walking. Gait is typically broad-based and unsteady. Individuals may walk on their toes to achieve balance.
Toilet training is difficult to achieve and requires extreme vigilance by parents and caregivers. Children may stay dry at night but become wet or soiled during the day because they are unable to communicate their needs.
Neurologic. Arachnoid cysts occur in approximately 15% of individuals with Phelan-McDermid syndrome compared to an estimated 1% in the general population. Other neurologic problems include reduced myelination, frontal lobe hypoplasia, agenesis of the corpus callosum, ventriculomegaly, focal cortical atrophy, and seizures [Tabolacci et al 2005].
Brain imaging studies on eight children with Phelan-McDermid syndrome revealed normal MRI in three children with the smallest deletion size; four of the remaining five had thinning of the corpus callosum; and one of the five had atypical morphology of the corpus callosum [Philippe et al 2008]. PET studies of the eight children demonstrated localized dysfunction of the left temporal polar lobe and significant hypoperfusion of the amygdala compared to 13 children with idiopathic intellectual disability.
Between 25% and 50% have seizures, many of which are febrile and do not require medication; however, grand mal seizures, focal seizures, and absence seizures have been described. No characteristic EEG findings are associated with Phelan-McDermid syndrome.
Neurologic and motor regression has been reported by a number of parents of individuals with Phelan-McDermid syndrome. Loss of speech is most frequently reported but loss of self-help skills, social interactions, purposeful hand movements, and walking have also been described. In a study of 42 individuals age four to 48 years, Reierson et al [2017] found that parents reported regression in 43% of individuals with onset around age six years. About 40% of individuals recovered skills; time to recovery ranged from one month to ten years. The ADI-R was used to characterize the regression and reported loss of:
Motor skills in 50% at mean age 4 years
Self-help skill in 50% at mean age 4 years
Language in 33% at mean age 3 years
Social engagement/responsiveness in 33% at mean age 5 years
Purposeful hand movement in 28% at mean age 7 years
Constructive/imaginative play in 22% at mean age 7 years
The regression in Phelan-McDermid syndrome is distinct from the regression seen in autism and Rett syndrome in that it occurs later in life and has a stronger impact on motor skills and self-help skills [Reierson et al 2017].
Behavior.
Philippe et al [2008] examined the neurobehavioral profiles of eight children with Phelan-McDermid syndrome who ranged in age from four years, three months to 11 years, four months. Behavior problems included hyperactivity, short attention span, restlessness, clumsiness, ignorance of the consequences, resistance to change, and repetitive activities.
Other abnormal behaviors described in Phelan-McDermid syndrome include habitual chewing or mouthing, tooth grinding, decreased perception of pain, and sleep disturbance. Although sleep apnea is not a problem, affected individuals may have difficulty falling asleep and staying asleep. Affected individuals may become agitated in unfamiliar, noisy, or crowded surroundings.
While Philippe et al [2008] concluded that behavior exhibited by children with Phelan-McDermid syndrome did not meet the DSM IV criteria for autism spectrum disorder (ASD), other investigators have described the behavior as autistic or autistic-like with poor eye contact, stereotypic movements, and self-stimulation. More recently, Soorya et al [2013] reported in a cohort of 32 individuals with Phelan-McDermid syndrome a high rate of individuals meeting criteria for autism spectrum disorder (84%) and for autistic disorder (75%). Oberman et al [2015] evaluated the behavioral profile of 40 children with Phelan-McDermid syndrome and noted that the majority of individuals displayed persistent deficits in social communication, but only half met diagnostic criteria under the restricted, repetitive patterns of behavior, interests, or activities domain. Furthermore, logistic regressions indicated that general developmental delay significantly contributed to the ASD diagnosis.
As a result of decreased perception of pain and lack of expressive communication skills, affected individuals may suffer cuts, scrapes, or even broken bones without indicating that they are in pain. They may suffer ear infections, gastroesophageal reflux, increased intracranial pressure, or other painful medical conditions without indicating discomfort.
Aggressive behavior including biting, hair pulling, or pinching is seen in approximately 25% of affected individuals. The behavior is typically displayed when individuals are frustrated and may indicate that they are in pain but cannot express themselves appropriately. The behavior is not self-injurious but is often directed at the parent or caregiver.
Speech delay. Infants typically babble at the appropriate age and children may acquire a limited vocabulary. However, by approximately age four years many children have lost the ability to speak. With intensive occupational, speech, and physical therapy they may regain speech and increase their vocabularies. Physical therapy strengthens muscle tone, improves coordination, and generally increases the individual's awareness of his/her surroundings. Although speech remains impaired throughout life, individuals can learn to communicate with the aid of aggressive therapy and communication training.
Receptive communication skills are more advanced than expressive language skills as evidenced by the ability of affected children to follow simple commands, demonstrate humor, and express emotions.
Hearing. Individuals with Phelan-McDermid syndrome have a delayed response to verbal cues. They also have difficulty discerning spoken words from background noise. These two factors, along with the frequent occurrence of ear infections, contribute to the perception that hearing may be impaired. In fact, more than 80% of affected individuals have normal hearing.
Vision. Most affected individuals have normal vision, although hyperopia and myopia are observed. Cortical visual impairment, characterized by extensive use of peripheral vision, difficulty in processing cluttered images, problems with depth perception, and the tendency to look away from objects before reaching for them, has been reported in approximately 6% of affected individuals. The quality of vision fluctuates. Blindness and optic nerve hypoplasia have been associated with cortical visual impairment [Phelan et al 2010].
Gastrointestinal. Gastroesophageal reflux is seen in approximately 30% and cyclic vomiting in approximately 25% of individuals. Constipation and diarrhea are also reported. Precautions must be taken to avoid dehydration.
Renal. The frequency of renal abnormalities has been reported as high as 38% [Soorya et al 2013]. These include cystic kidneys, renal agenesis or dysplastic kidneys, hydronephrosis, vesicoureteral reflux, horseshoe kidney, and pyelectasis. Frequent urinary tract infections are also reported.
Growth. Intrauterine growth in Phelan-McDermid syndrome is appropriate for gestational age; the mean gestational age is 38.2 weeks. Postnatal growth is normal. Height is often advanced for age but remains within two to three standard deviations from the mean. Weight is not increased so children appear tall and thin.
Whereas children may have increased height for age, adults tend to fall within the normal range for height. Most adults are also within the normal range for weight, although inactivity and overeating (possibly a manifestation of compulsive mouthing) result in increased weight gain in approximately 10% of individuals.
Head size is typically within normal range with microcephaly reported in about 11% of individuals [Rollins et al 2011].
Hypothyroidism occurs in 3%-6% of individuals with this disorder [Soorya et al 2013, Sarasua et al 2014b]. Symptoms include lethargy, loss of interest, weight gain, and decline in skills and are typically manifested in the teenager or young adult. A thyroid panel should be obtained to rule out hypothyroidism.
Dental. The most frequently encountered dental problems are malocclusion and crowding. Poor muscle tone, incessant chewing, tooth grinding, and tongue thrusting may contribute to malocclusion. Malocclusion may be accompanied by drooling and difficulty swallowing, and may contribute to difficulties in verbalization.
Lymphedema. Both lymphedema and recurrent cellulitis have been observed in approximately 10% of individuals, typically becoming problematic during the teen and adult years. Progressive lymphedema leading to pleural effusions has been reported in a female with Phelan-McDermid syndrome resulting from a ring chromosome r(22)(p11.2q12.3) [McGaughran et al 2010].
Craniofacial. Among the most common and striking craniofacial features are dolichocephaly, large or prominent ears, epicanthal folds, long eyelashes, supraorbital fullness, full cheeks, and short or bulbous nose. More subtle features are deep-set eyes, flat midface, full brow, and wide nasal bridge. The features may change over time, particularly if the individual is on anticonvulsants that tend to coarsen the features. Adults have a more prominent, square jaw and less bulbous-appearing nose.
Cardiac. Various congenital heart defects have been reported, including aortic regurgitation, patent ductus arteriosus, total anomalous venous return, atrial septal defect, and tricuspid valve regurgitation; estimates of the incidence of congenital heart defects range from 3% to 25% [Phelan & McDermid 2012, Soorya et al 2013, Kolevzon et al 2014a]. Kolevzon et al [2014a] recommend that the initial workup of an individual with Phelan-McDermid syndrome include a standard cardiac evaluation with echocardiograph and electrocardiography to detect defects requiring medical and/or surgical intervention.
Other
The hands appear large and fleshy.
Toenails are often dysplastic, thin, and flaky and tend to become ingrown. Fingernails are usually normal.
Adulthood. Longitudinal data are insufficient to determine life expectancy. However, life-threatening or life-shortening cardiac, pulmonary, or other organ system defects are not common. The paucity of older adults with Phelan-McDermid syndrome reflects the difficulty in establishing the diagnosis prior to the advent of high-resolution chromosome analysis, FISH, and CMA.
In older individuals, behavioral problems tend to subside, developmental abilities improve, and some features such as large or fleshy hands, full or puffy eyelids, hypotonia, lax ligaments, and hyperextensible joints are reported as less frequent [Sarasua et al 2014b]. Late-onset seizures, unexplained weight loss, and loss of motor skills may occur in older individuals, adversely affecting quality of life.
Ring chromosome 22. Individuals with Phelan-McDermid syndrome as a result of ring chromosome 22 have a specific risk of developing neurofibromatosis type 2 (NF2).
NF2 (pathogenic variants in which cause NF2) is at 22q12.2 adjacent to the Phelan-McDermid syndrome deletion region. The risk for NF2 is due to the instability of ring chromosomes during mitosis and follows a two-hit model. The first hit is the loss of the ring chromosome 22 during mitosis, making a cell hemizygous for chromosome 22. The second hit is a somatic mutation of the remaining NF2 allele [Zirn et al 2012].
Children with ring chromosome 22 should be monitored for NF2 in the same manner as if they had an affected parent. This includes baseline and annual ocular, dermal, and neurologic examinations between ages two and ten years with annual audiology screening and brain MRI every two years after age ten years [Lyons-Warren et al 2017].
Mosaic 22q13.3 deletion. Mosaic 22q13.3 deletion has been reported on occasion. The level of mosaicism for 22q13.3 deletion varies among affected individuals. Note: Because most testing is performed on blood samples, because the level of mosaicism in blood can change over time, and because the level of mosaicism in the blood is not representative of the level of mosaicism in the brain and other tissues, the level of mosaicism that is sufficient for expression of the major features of Phelan-McDermid syndrome is unknown.
Mosaicism is particularly common in 22q13 deletion associated with ring chromosomes because of the instability of the ring structure during cell division.
In at least three instances mosaicism in asymptomatic mothers resulted in Phelan-McDermid syndrome in their offspring:
Two brothers with features suggestive of Clark-Baraitser syndrome (see
Differential Diagnosis) were found to have
deletion of approximately 3.5 Mb at 22q13. It was inferred that the deletion had been inherited from the mother because the brothers had not inherited the same paternal
chromosome 22 [
Tabolacci et al 2005].
A phenotypically normal mother of two affected children was mosaic for
deletion 22q13.3, resulting from an unbalanced
translocation with the satellite region of an unidentified acrocentric
chromosome. The derivative chromosome 22 was observed in 6% of cells from maternal peripheral blood [Phelan, unpublished data].
The mother of a child with non-mosaic ring
chromosome 22 had ring chromosome 22 in fewer than 2% of peripheral blood cells [Phelan, unpublished data].