Child Syndrome


Article Author:
Kamleshun Ramphul
Vasudha Kota


Article Editor:
Stephanie Mejias


Editors In Chief:
Shivajee Nallamothu
Matthew Varacallo
Joshua Tuck


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
6/4/2019 7:18:31 PM

Introduction

Congenital hemidysplasia with ichthyosiform erythroderma and limb defects syndrome, also known as CHILD syndrome, is a rare condition that affects different parts of the body. In 1903, Dr. Otto Sachs first described this disease in when he summarized his examination of an 8-year-old girl. Since then, many case reports have been published. In 1980, Happle et al. proposed the acronym of the CHILD syndrome for congenital hemidysplasia, ichthyosiform erythroderma, and limb defects.[1][2] It has been described as an X-linked, dominant condition with a male-lethal trait with most surviving patients being females. It is related to mutations in the NSDHL gene. This condition should be suspected at birth if a child presents with a unilateral epidermal nevus. Other commonly seen features include unilateral limb and skin, unilateral ichthyosiform erythroderma, inflammatory variable epidermal nevus, and congenital heart disease.[3][4]

Etiology

CHILD syndrome is a disorder with an X-linked dominant mode of inheritance. It involves a mutation in the NAD[P]H steroid, dehydrogenase-like protein gene which is also known as the NSDHL gene. The NSDHL gene is located on the long arm of the X chromosome at position 28, Xq28. It encodes for the enzyme 3beta-hydroxy sterol dehydrogenase that is involved in cholesterol pathways. Several types of mutations have been reported in the NSDHL gene such as nonsense mutations and missense mutations, and the net effect is a loss of function of the gene.[5][6] Some studies have suggested that the unilateral findings of the symptoms of CHILD syndrome can be related to an abnormal sonic hedgehog signaling during embryogenesis that results from impaired cholesterol processing.[7] The EBP gene has also been reported as a cause of CHILD syndrome in some patients.[8]

Epidemiology

There are about 60 reported cases in literature making CHILD syndrome a very rare condition. This disorder is lethal to males, who die in utero; however, almost all patients presenting with this conditions are females. Nevertheless, there have been 2 reported cases involving living, male patients. One of them had a normal 46 XY karyotype, and Happle et al. explained this finding as a possible early somatic mutation.[2] Features of the condition are visible at birth and persist throughout the lifetime.  Stephanie Jallen, who is a Paralympic skier and medalist, is one of the people afflicted by this condition.

Pathophysiology

Congenital hemidysplasia with ichthyosiform erythroderma and limb defects syndrome is a congenital condition that is inherited in an X-linked dominant fashion. NAD[P]H steroid dehydrogenase-like protein gene which is responsible for the enzyme 3beta-hydroxy sterol dehydrogenase is mutated. This enzyme is vital for the synthesis of cholesterol. A deficiency of this enzyme leads to the accumulation of metabolic products from cholesterol biosynthetic pathway. Cholesterol is also essential for the proper formation of membranes and myelin that protects nerve fibers.[5] Most of the clinical and histologic abnormalities seen in CHILD syndrome result from defects in the cholesterol pathway. The most common types of mutations that have been reported in the literature include missense, nonsense, and stop mutations. They lead to a loss of function in the NSDHL gene that eventually affects the cholesterol pathway.[6][9][10]

Histopathology

Skin lesions of patients with CHILD syndrome usually reveal a psoriasiform epidermis with hyperkeratosis and parakeratosis. The papillary dermis usually also has foam cells that express surface markers such as CD68 and CD163 which are specific for macrophages. They do not express pan-cytokeratin markers AE1/AE3 and S100 proteins. Under electron microscopy, numerous lipid droplets and vacuoles are usually seen in the foam cells found in the upper dermis. These cells are made by ingestion of lipids by macrophages. When affected cells and unaffected cells from a CHILD syndrome patient is compared, there are significant differences in the markers of the keratinocytes. This strongly suggests that the difference in the affected skin originates in the keratinocytes and not from external factors or mutant cells. Mi et al. also confirmed these previous findings in their work published in 2015 where their patient with CHILD syndrome had macrophage-derived foam cells.[5]

History and Physical

This condition will present with ipsilateral symptoms affecting multiple systems and organs. All patients with CHILD syndrome will have a congenital ichthyosiform erythroderma. The right side of the body is twice as likely to be affected than the left side. It presents as a unilateral erythematous skin plaque with a midline demarcation usually present at birth. The patient’s face is often spared. Multiple other dermatologic findings are also common such as unilateral ptychotropism, verruciform xanthomas, and scaling alopecia.[11] Hyperkeratosis is also a very common finding seen in 30% to 79% of patients.

The musculoskeletal system can also be affected. Patients present with unilateral limb defects that can range from hypoplasia to agenesis.[2] Such musculocutaneous defects can cause scoliosis in the patients. Epiphyseal stippling on radiographs has been reported in 80% to 99% of cases of CHILD syndrome.

Multiple organ abnormalities such as cardiovascular malformations have also been accounted for and are usually the most common cause of death.

Evaluation

Sterol analysis usually shows elevated levels of C4-methylated and C4-carboxy sterol intermediates due to the defect in the NAD[P]H steroid dehydrogenase-like protein gene. It is vital to detect any skeletal and visceral abnormalities early to provide appropriate care. Radiologic examination such as x-ray, CT, MRI should be performed. Confirmatory diagnosis is possible with DNA sequence analysis to detect any mutation in the NSDHL gene. Skin biopsies can also be performed for the dermatologic lesions.

Treatment / Management

The treatment plans vary according to the severity of the condition. Skin lesions can be treated with topic retinoids and keratolytics. Proper follow-ups should be done with dermatologists, orthopedic specialists, and cardiologists.

Differential Diagnosis

Multiple conditions can occur with similar findings ultimately requiring proper history and tests to be carried out to rule out epidermal nevus syndrome, sebaceous nevus syndrome, inflammatory linear verrucous epidermal nevus, phacomatosis pigmentokeratotica, and X-linked dominant chondrodysplasia puncta.[4]

Prognosis

Patients with a left-sided presentation of symptoms tend to have a less positive prognosis. The most common cause of death in CHILD syndrome is cardiovascular complications.

Complications

Since this condition is X-linked dominant, proper genetic counseling should be encouraged.

Postoperative and Rehabilitation Care

Multiple musculoskeletal deformities can be associated with CHILD syndrome. An early assessment by a pediatric orthopedic surgeon is important. Parents and the patients should be encouraged to follow proper rehabilitation plans.

Consultations

The consultations vary depending on the systems and organs affected. There should be proper follow-ups with a dermatologist for the skin lesions and a pediatric orthopedic surgeon to provide adequate help and treatment for any musculoskeletal abnormalities. Any organ abnormalities such as the heart or the central nervous system should have regular and appropriate follow-ups with a cardiologist and neurologist.

Deterrence and Patient Education

Early genetic counseling and education about the condition before pregnancy can be helpful for the parents.

Pearls and Other Issues

  • CHILD syndrome stands for Congenital hemidysplasia with ichthyosiform erythroderma and limb defects syndrome.
  • It is an X-linked, dominant condition with a male-lethal trait with most surviving patients being females.
  • It is related to mutations in the NSDHL gene.
  • Cardiovascular malformations are usually the most common cause of death.
  • This condition will present with ipsilateral symptoms affecting multiple systems and organs. All patients have a congenital ichthyosiform erythroderma.
  • Multiple other dermatologic findings are also common such as unilateral ptychotropism, verruciform xanthomas, and scaling alopecia.
  • The musculoskeletal system can also be affected. Patients present with unilateral limb defects that can range from hypoplasia to agenesis. Such musculocutaneous defects can cause scoliosis in the patients.
  • Epiphyseal stippling on radiographs has been reported in 80% to 99% of cases of CHILD syndrome.

Enhancing Healthcare Team Outcomes

Child syndrome is best treated with an interprofessional team of a dermatology specialist nurse and a dermatology clinician. The orthopedic surgeon and orthopedic nurse should assist with treatment for any musculoskeletal abnormalities. Organ abnormalities of the heart or the central nervous system require a cardiologist and neurologist. Genetic counseling and education about the condition before pregnancy from a nurse or clinician geneticist can be helpful for the parents. A multidisciplinary team approach to the care of this complex disease will provide the best results. [Level V]


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Child Syndrome - Questions

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What is the acronym represented by CHILD syndrome?



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What is the mode of inheritance of CHILD syndrome?



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What gene is affected in CHILD syndrome?



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What do skin lesion biopsies in CHILD syndrome usually reveal?



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What is a common radiographic finding of CHILD syndrome?



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An 8-year-old girl presents to the outpatient clinic with symptoms of red and inflamed skin covered with plaques on her right hand. On physical examination, her right-hand fingers are underdeveloped, and there is evidence of scoliosis. There is a history of similar complaints in her uncle as well. She also reports to have been told about a problem with cholesterol metabolism by her family physician, and her mother forgot the name of the disorder. Which of the following best describes the mode of inheritance of this disorder?



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A 10-year-old boy is brought to the clinic for a well-child examination. His mother complains that his skin becomes rough and covered with plaques and so she applies a lot of moisturizing creams. His previous medical records show birth defects such as scoliosis, congenital nevus, and hypoplastic fingers of the right hand. His records also indicate a mutation of the NSDHL gene along with foam cells on histopathological examination of the papillary dermis. What are the radiographic findings expected in this patient?



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A 7-year-old girl presents with symptoms of extensive skin plaques on his left hand along with scoliosis and left upper limb hypoplasia. She has documented mutations of the NSDHL gene. Her previous upper limb radiographs show evidence of epiphyseal stippling. Histopathological examination of the papillary dermis shows foamy macrophages. What is the underlying cause of this child's disorder?



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A 12-year-old boy is brought for a well- child visit. His previous records indicate a history of excessively dry skin covered with plaques. His previous x-ray of the lower limb is shown. Physical examination is normal except for previously diagnosed scoliosis and underdeveloped fingers. Which of the following genetic mutations is most likely to be seen in this patient?

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  • Image 10004 Not availableImage 10004 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD



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Child Syndrome - References

References

CHILD syndrome avant la lettre., Bittar M,Happle R,, Journal of the American Academy of Dermatology, 2004 Feb     [PubMed]
The CHILD syndrome. Congenital hemidysplasia with ichthyosiform erythroderma and limb defects., Happle R,Koch H,Lenz W,, European journal of pediatrics, 1980 Jun     [PubMed]
CHILD Syndrome: Case Report of a Chinese Patient and Literature Review of the NAD[P]H Steroid Dehydrogenase-Like Protein Gene Mutation., Mi XB,Luo MX,Guo LL,Zhang TD,Qiu XW,, Pediatric dermatology, 2015 Nov-Dec     [PubMed]
Large deletions in the NSDHL gene in two patients with CHILD syndrome., Yang Z,Hartmann B,Xu Z,Ma L,Happle R,Schlipf N,Zhang LX,Xu ZG,Wang ZY,Fischer J,, Acta dermato-venereologica, 2015 Nov     [PubMed]
A novel missense mutation in the NSDHL gene identified in a Lithuanian family by targeted next-generation sequencing causes CK syndrome., Preiksaitiene E,Caro A,Benušienė E,Oltra S,Orellana C,Morkūnienė A,Roselló MP,Kasnauskiene J,Monfort S,Kučinskas V,Mayo S,Martinez F,, American journal of medical genetics. Part A, 2015 Jun     [PubMed]
Systematized inflammatory epidermal nevus with symmetrical involvement: an unusual case of CHILD syndrome?, Fink-Puches R,Soyer HP,Pierer G,Kerl H,Happle R,, Journal of the American Academy of Dermatology, 1997 May     [PubMed]
Ptychotropism as a cutaneous feature of the CHILD syndrome., Happle R,, Journal of the American Academy of Dermatology, 1990 Oct     [PubMed]
Mutational spectrum of NSDHL in CHILD syndrome., Bornholdt D,König A,Happle R,Leveleki L,Bittar M,Danarti R,Vahlquist A,Tilgen W,Reinhold U,Poiares Baptista A,Grosshans E,Vabres P,Niiyama S,Sasaoka K,Tanaka T,Meiss AL,Treadwell PA,Lambert D,Camacho F,Grzeschik KH,, Journal of medical genetics, 2005 Feb     [PubMed]
New players and puzzles in the Hedgehog signaling pathway., Johnson RL,Scott MP,, Current opinion in genetics & development, 1998 Aug     [PubMed]
Has C,Bruckner-Tuderman L,Müller D,Floeth M,Folkers E,Donnai D,Traupe H, The Conradi-Hünermann-Happle syndrome (CDPX2) and emopamil binding protein: novel mutations, and somatic and gonadal mosaicism. Human molecular genetics. 2000 Aug 12;     [PubMed]
Estapé A,Josifova D,Rampling D,Glover M,Kinsler VA, Congenital hemidysplasia with ichthyosiform naevus and limb defects (CHILD) syndrome without hemidysplasia. The British journal of dermatology. 2015 Jul;     [PubMed]

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