Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 10  |  Issue : 5  |  Page : 473-475  

A seizuring alagille syndrome


Department of Paediatrics, Malankara Orthodox Syrian Church Medical College, Kolenchery, Kerala, India

Date of Submission12-Oct-2016
Date of Acceptance25-Jan-2017
Date of Web Publication14-Nov-2017

Correspondence Address:
Jomon Mathew John
Karimarathinal, 44/2398, Santhipuram Road, Palarivattom, Ernakulam - 682 025, Kerala
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJDRDYPU.MJDRDYPU_248_16

Rights and Permissions
  Abstract 


Alagille syndrome is a rare autosomal dominant inherited disorder with incidence of one in 100,000 live births. This syndrome with seizure as a presentation has been rarely reported in Indian studies. We present a 3-month-old infant who presented to us with seizures was found to have a dysmorphic face, jaundice, hepatomegaly, and soft systolic murmur. Infant was stabilized and remained seizure free. A detailed clinical evaluation of a common presentation may reveal a rare syndrome.

Keywords: Arteriohepatic dysplasia, conjugated hyperbilirubinemia, seizures


How to cite this article:
John JM. A seizuring alagille syndrome. Med J DY Patil Univ 2017;10:473-5

How to cite this URL:
John JM. A seizuring alagille syndrome. Med J DY Patil Univ [serial online] 2017 [cited 2019 Nov 19];10:473-5. Available from: http://www.mjdrdypu.org/text.asp?2017/10/5/473/218180




  Introduction Top


Alagille syndrome (AS) is an autosomal dominant disorder associated with abnormalities of the liver, heart, skeleton, eye, and kidneys and a characteristic facial appearance.[1] In 1973, Watson and Miller reported nine cases of neonatal liver disease with familial pulmonary valvular stenosis. Then in 1975, Alagille et al. described several patients with hypoplasia of the hepatic ducts with associated features.[2]

The incidence rate is approximately one case in every 100,000 live births.

Mutations in either jagged-1 (JAG1) or notch-2 (NOTCH2) have been reported in patients with AS. The syndrome has been mapped to the 20p12-jagged-1 locus, JAG1, which encodes a ligand critical to the notch gene–signaling cascade that is important in fetal development. Notch signaling has been found to regulate the formation of 3-dimensional intrahepatic biliary architecture in murine models.[3],[4]


  Case Report Top


Three-month-old boy baby born to a primi mother presented with excessive cry and reduced feeding for 2 days and generalized tonic–clonic seizures with uprolling of eyes lasting for 30 min associated with frothing and urinary incontinence. There was no history of fever, head trauma, no family history of seizures, developmentally normal, and immunized for age.

On examination, the child has dysmorphic face with severe pallor and icterus. Anterior fontanelle was bulged and tensed. No neurocutaneous markers. Anthropometric parameters were within the normal limits. There were no focal neurological deficits. The liver was palpable 4 cm below the right costal margin with round border, soft consistency, and smooth surface with total span of 6 cm. Spleen was not palpable. On auscultation, he had a grade 3 ejection systolic murmur over the pulmonary area. Respiratory system was normal.

Course in the hospital

The child was resuscitated and stabilized in casualty, shifted to the Pediatric Intensive Care Unit. The child was electively intubated. Routine investigation and liver function tests were done and showed anemia, conjugated hyperbilirubinemia. Total cholesterol was high.

Computed tomography imaging of the brain showed intraparenchmal hematoma in the left parietal region with midline shift [Figure 1].
Figure 1: Computed tomography head showing intracranial bleed

Click here to view


X-ray of the lumbar vertebra was done which showed butterfly vertebrae [Figure 2].
Figure 2: X-ray showing the butterfly vertebra

Click here to view


The ECG shows a right axis deviation with a rsR' pattern [Figure 3]. Subsequently an echocardiography was done which revealed moderate to severe right pulmonary artery stenosis with ostium secundum atrial septal defect.
Figure 3: Electrocardiogram changes

Click here to view


With the above features, the diagnosis of AS was made. Packed cell transfusion and intravenous antibiotic were empirically started along with antiepileptic drugs.

Gradually, the child improved on ventilator and was extubated after 10 days. He remained seizure free. He was discharged on vitamin supplementation (A, D, E, K) and syrup ursodecholic acid.


  Discussion Top


Children with AS often present with poor linear growth.

Commonly associated facial features include broadened forehead, pointed chin, and elongated nose with bulbous tip. Most frequent ophthalmologic finding is a posterior embryotoxon. Some of these patients may also have the  Axenfeld anomaly More Details. Other findings reported include retinitis pigmentosa, pupillary abnormalities, and anomalies of the optic disc. The most common cardiac lesions are stenoses within the pulmonary tree (peripheral pulmonic stenosis) with or without other structural lesions. Hemodynamically significant lesions include atrial septal defect, ventricular septal defect, tetralogy of Fallot, patent ductus arteriosus, and pulmonary atresia. Significant intracardiac lesions place patients with AS at increased mortality risk. Recent data have reported an association between Wolff–Parkinson–White syndrome in a subset of patients with AS.[5]

Vascular lesions include basilar artery aneurysms, internal carotid artery anomalies, middle cerebral artery aneurysm, Moyamoya disease and aortic aneurysms, coarctation of the aorta, and renal artery stenosis.

Abnormalities of the vertebrae, ribs, and hands are frequently associated with AS such as butterfly hemivertebrae and other isolated anomalies include rib anomalies and shortening of the radius, ulna, and phalanges.

As the differential diagnosis of cholestasis is extensive, early recognition is essential to ensure timely treatment and optimal prognosis. Developments in molecular genetic techniques have enabled the identification of causative genes, which has improved diagnostic accuracy for patients.[6],[7]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Krantz ID, Piccoli DA, Spinner NB. Alagille syndrome. J Med Genet 1997;34:152-7.  Back to cited text no. 1
[PUBMED]    
2.
Watson GH, Miller V. Arteriohepatic dysplasia: Familial pulmonary arterial stenosis with neonatal liver disease. Arch Dis Child 1973;48:459-66.  Back to cited text no. 2
[PUBMED]    
3.
Li L, Krantz ID, Deng Y, Genin A, Banta AB, Collins CC, et al. Alagille syndrome is caused by mutations in human jagged1, which encodes a ligand for notch1. Nat Genet 1997;16:243-51.  Back to cited text no. 3
[PUBMED]    
4.
Boyer-Di Ponio J, Wright-Crosnier C, Groyer-Picard MT, Driancourt C, Beau I, Hadchouel M, et al. Biological function of mutant forms of JAGGED1 proteins in Alagille syndrome: Inhibitory effect on notch signaling. Hum Mol Genet 2007;16:2683-92.  Back to cited text no. 4
[PUBMED]    
5.
Lalani SR, Thakuria JV, Cox GF, Wang X, Bi W, Bray MS, et al. 20p12.3 microdeletion predisposes to Wolff-Parkinson-White syndrome with variable neurocognitive deficits. J Med Genet 2009;46:168-75.  Back to cited text no. 5
[PUBMED]    
6.
Venigalla S, Gourley GR. Neonatal cholestasis. Semin Perinatol 2004;28:348-55.  Back to cited text no. 6
[PUBMED]    
7.
Hartley JL, Gissen P, Kelly DA. Alagille syndrome and other hereditary causes of cholestasis. Clin Liver Dis 2013;17:279-300.  Back to cited text no. 7
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
   
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Case Report
Discussion
References
Article Figures

 Article Access Statistics
    Viewed1179    
    Printed18    
    Emailed0    
    PDF Downloaded82    
    Comments [Add]    

Recommend this journal