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Table of Contents 
CASE REPORT
Year : 2012  |  Volume : 57  |  Issue : 4  |  Page : 299-301
Cardiofaciocutaneous syndrome: A rare entity


1 Derma-care, Skin and Cosmetology Center, Mangalore, Karnataka, India
2 KS Hegde Medical College, Mangalore, Karnataka, India

Date of Web Publication29-Jun-2012

Correspondence Address:
S Pavithra
Derma-care, Trade Centre, Near Woodlands, Mangalore-575 003, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.97677

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   Abstract 

The cardiofaciocutaneous (CFC) syndrome is a condition of sporadic occurrence, with patients showing multiple congenital anomalies and mental retardation and characteristic dysmorphic features. We, thus, report a rare case of this syndrome in a 1-year-old child who presented with typical features of CFC syndrome.


Keywords: Anomalies, cardiofaciocutaneous syndrome, defects


How to cite this article:
Pavithra S, Mallya H, Pai G S. Cardiofaciocutaneous syndrome: A rare entity. Indian J Dermatol 2012;57:299-301

How to cite this URL:
Pavithra S, Mallya H, Pai G S. Cardiofaciocutaneous syndrome: A rare entity. Indian J Dermatol [serial online] 2012 [cited 2019 Jul 15];57:299-301. Available from: http://www.e-ijd.org/text.asp?2012/57/4/299/97677

What was known? The cardiofaciocutaneous (CFC) syndromeis a syndrome where patients have multiple congenital anomalies related to mentation, growth, cardiovascular system skin, eyes, gastrointestinal tract and central nervous system.



   Introduction Top


The cardiofaciocutaneous (CFC) syndrome (OMIM 115150) is a syndrome where patients have multiple congenital anomalies or mental retardation, failure to thrive, psychomotor delay, a characteristic face, congenital heart defects, and abnormalities of the skin, eyes, gastrointestinal tract and central nervous system. Occurrence is sporadic, with men and women equally affected. The syndrome was first described 20 years ago by Reynolds et al[1] in eight children. Additional reports soon followed and, according to a recent review, [2] about 59 patients have been reported, providing the basis for an accurate delineation of the phenotypic spectrum of the syndrome. Nevertheless, a question has lingered for many years whether CFC is a unique and separate condition, or a variant of the Noonan syndrome (OMIM 163950) [3],[4],[5],[6],[7],[8],[9] or of the Costello syndrome (OMIM 218040). [10] A useful diagnostic approach was provided with the creation of a CFC index based on 82 clinical traits and their frequencies in the population with the CFC syndrome. [11] However, matters changed radically only with the discovery of different genes whose mutations cause each one of these syndromes: the protein tyrosine phosphatase SHP-2 gene PTPN11 for Noonan syndrome, [12] HRAS for Costello syndrome, [13] and KRAS, BRAF, mitogen-activated protein/extracellular signal-regulated kinase MEK1 and MEK2 for CFC. [14],[15]


   Case Report Top


One-year-old Indian boy was referred to our center at 8 months of age with some dysmorphic features and developmental delay for evaluation. He was a product of a full-term normal delivery with a birth weight of 3.6 kg (more than the 95 th percentile). He had transient neonatal jaundice which needed phototherapy but without any complications. Developmental history showed a delay from the beginning with the child unable to crawl, sit or hold objects in hand or produce any sounds like the normal children. Family history revealed the child being the third sibling after two normal children and two early abortions. There was no history of consanguineous marriage. No similar condition existed in the family.

Clinically his weight was 10 kg (90 th percentile), height 73 cm (75 th percentile), and head circumference 44.5 cm (25 th percentile).

Dermatological evaluation showed a dysmorphic child with asymmetrical face, bitemporal narrowing and prominant metopic sutures, epicanthic fold, wide mouth, sparse hair, and absent eye brows [Figure 1]a-c. His skin was dry and mildly hyperkeratotic; eczematous lesions were found on his neck and extremities, keratosis pilaris on his arms [Figure 2], seborrheic dermatitis on his scalp, and miliaria on his back.
Figure 1a: Dysmorphic face with asymmetry, bitemporal narrowing and prominant metopic sutures, epicanthic fold, wide mouth, sparse hair and absent eye brows
Figure 1b: Close-up view of facial features
Figure 1c: Sparse scalp hair


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Figure 2: Dry and mildly hyperkeratotic skin. Eczematous lesions found on his neck and extremities, keratosis pilaris on his arms

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There was an evidence of a vascular hemangiomatous plaque measuring 5 cm×3.5 cm involving the medial aspect of right lower limb [Figure 3].
Figure 3: A vascular hemangiomatous plaque involving the right lower limb

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The results of routine hematological examination, blood biochemistry analysis, urinalysis, thyroid function tests, and serum zinc level assessment were within the normal ranges.

Echocardiography was suggestive of small secundum atrial septal defect and patent ductus arteriosus. Ultrasound of the abdomen showed mild hepatosplenomegaly. MRI scanning of the brain showed bifrontal subdural T2 hyperintense areas plus prominence of the frontotemporal subarachnoid space and corpus callosum hypoplasia. There was no evidence of hypoplasia.

Karyotype revealed 46 XY, involving 9p11q21.2 chromosome.


   Discussion Top


CFC syndrome is a sporadic developmental disorder involving characteristic craniofacial features, cardiac defects, ectodermal abnormalities, and developmental delay. [14]

The syndrome is caused by gain-of-function mutations in four different genes BRAF, KRAS, mitogen-activated protein/extracellular signal-regulated kinase MEK1 and MEK2, all belonging to the same RAS extracellular signal-regulated kinase (ERK) pathway that regulates cell differentiation, proliferation and apoptosis. [16]

The diagnosis of CFC syndrome is purely clinical. [11]

It is characterised by failure to thrive, relative macrocephaly, a distinctive face with prominent forehead, bitemporal constriction, absence of eyebrows, hypertelorism, downward-slanting palpebral fissures often with epicanthic folds, depressed nasal root and a bulbous tip of the nose. The cutaneous involvement consists of dry, hyperkeratotic, scaly skin, sparse and curly hair, and cavernous hemangiomata. Most patients have a congenital heart defect, most commonly pulmonic stenosis and hypertrophic cardiomyopathy. The developmental delay usually is moderate to severe. [16]

Neurological involvement in the CFC syndrome is extensive, and can involve functions of the cortex, brain stem and ventricular system. Mental retardation and global developmental delay are found in most (81%) cases. [17]

We established the diagnosis in our patient based on typical dysmorphic features concordant with CFC syndrome. Noonan syndrome and Costello syndrome, especially the former, can be phenotypically similar to CFC syndrome and should be excluded. [18] Noonan syndrome differs by less severe psychomotor delay bordering to normality, low posterior hairline with thick hair, cubitus valgus, neck abnormalities, ectodermal involvement characterized by nevi, café-au-lait spots, familial occurrence. [4] Costello syndrome differs by the presence of 'coarse' face, nasal and/or anal papillomata and a predisposition to child tumors such as neuroblastoma, redundant skin of hands and feet with deep palmar and plantar creases, elbow joint limitation. [18]

 
   References Top

1.Reynolds JF, Neri G, Herrmann JP, Blumberg B, Coldwell JG, Miles PV, et al. New multiple congenital anomalies/mental retardation syndrome with cardio-facio-cutaneous involvement-the CFC syndrome. Am J Med Genet 1986;28:413-27.  Back to cited text no. 1
    
2.Weiss G, Confino Y, Shemer A, Trau H. Cutaneous manifestations in the cardiofaciocutaneous syndrome: A variant of the classical Noonan syndrome: Report of a case and review of the literature. J Eur Acad Derm Venerol 2004;18:324-7.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Fryer AE, Holt PJ, Hughes HE. The cardio-facio-cutaneous syndrome and Noonan syndrome: Are they the same? Am J Med Genet 1991;38:548-51.  Back to cited text no. 3
[PUBMED]    
4.Neri G, Zollino M, Reynolds JF. The Noonan-CFC controversy. Am J Med Genet 1991;39:367-70.  Back to cited text no. 4
[PUBMED]    
5.Ward KA, Moss C, McKeown C. The cardio-facio-cutaneous syndrome: A manifestation of the Noonan syndrome? Br J Dermatol 1994;131:270-4.  Back to cited text no. 5
[PUBMED]    
6.Leichtman LG. Are cardio-facio-cutaneous syndrome and Noonan syndrome distinct? A case of CFC offspring of a mother with Noonan syndrome. Clin Dysmorph 1996;5:61-4.  Back to cited text no. 6
[PUBMED]    
7.Lorenzetti ME, Fryns JP. Retinitis pigmentosa in a young man with Noonan syndrome: Further evidence that Noonan syndrome (NS) and the cardio-facio-cutaneous syndrome (CFC) are variable manifestations of the same entity? Am J Med Genet 1996;65:97-9.  Back to cited text no. 7
[PUBMED]    
8.Neri G, Zollino M. More on the Noonan-CFC controversy. Am J Med Genet 1996;65:100.  Back to cited text no. 8
[PUBMED]    
9.Legius E, Schollen E, Matthijs G, Fryns JP. Fine mapping of Noonan/cardio-facio cutaneous syndrome in a large family. Eur J Hum Genet 1998;6:32-7.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  
10.Wieczorek D, Majewski F, Gillessen-Kaesbach G. Cardio-facio-cutaneous (CFC) syndrome: A distinct entity? Report of three patients demonstrating the diagnostic difficulties in delineation of CFC syndrome. Clin Genet 1997;52:37-46.  Back to cited text no. 10
[PUBMED]    
11.Kavamura MI, Peres CA, Alchorne MM, Brunoni D. CFC index for the diagnosis of cardiofaciocutaneous syndrome. Am J Med Genet 2002;112:12-6.  Back to cited text no. 11
[PUBMED]  [FULLTEXT]  
12.Tartaglia M, Mehler EL, Goldberg R, Zampino G, Brunner HG, Kremer H, et al. Mutations in PTPN11, encoding the protein tyrosine phosphatase SHP-2, cause Noonan syndrome. Nat Genet 2001;29:465-8.  Back to cited text no. 12
[PUBMED]  [FULLTEXT]  
13.Aoki Y, Niihori T, Kawame H, Kurosawa K, Ohashi G, Tanaka Y, et al. Germline mutations in HRAS proto-oncogene cause Costello syndrome. Nat Genet 2005;37:1038-40.  Back to cited text no. 13
    
14.Rodriguez-Viciana P, Tetsu O, Tidyman WE, Estep AL, Conger BA, Santa Cruz M, et al. Germline mutations in genes within the MAPK pathway cause cardio-facio-cutaneous syndrome. Science 2006;311:1287-90.  Back to cited text no. 14
    
15.Niihori T, Aoki Y, Narumi Y, Neri G, Cave H, Verloes A, et al. Germline KRAS and BRAF mutations in cardio-facio-cutaneous syndrome. Nat Genet 2006;38:294-6.  Back to cited text no. 15
    
16.Roberts A, Allason J, Jadico SK, Kavamura MI, Noonan J, Opitz JM, et al. The cardiofaciocutaneous syndrome. J Med Genet 2006;43:833-42.  Back to cited text no. 16
    
17.Somer M, Peippo M, Aalto-Korte K, Ritvanen A, Niemi KM. Cardio-facio-cutaneous syndrome: Three additional cases and review of the literature. Am J Med Genet 1992;44:691-5.  Back to cited text no. 17
[PUBMED]    
18.Neri G, Kavamura MI, Zollino M, Opitz JM. CFC syndrome. Am J Med Genet A 2003;116A:410.  Back to cited text no. 18
[PUBMED]  [FULLTEXT]  

What is new? Combination of classical clinical features should raise the suspicion of rare entity like this one.


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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