Cornelia de Lange Syndrome

Cornelia de Lange Syndrome

National Organization for Rare Disorders, Inc.

Important

It is possible that the main title of the report Cornelia de Lange Syndrome is not the name you expected. Please check the synonyms listing to find the alternate name(s) and disorder subdivision(s) covered by this report.

Synonyms

  • BDLS
  • Brachmann-de Lange Syndrome
  • CdLS
  • de Lange Syndrome
  • Amsterdam syndrome

Disorder Subdivisions

  • None

General Discussion

Cornelia de Lange syndrome (CdLS) is a rare genetic disorder that is apparent at birth (congenital). Associated symptoms and findings typically include delays in physical development before and after birth (prenatal and postnatal growth retardation); characteristic abnormalities of the head and facial (craniofacial) area, resulting in a distinctive facial appearance; malformations of the hands and arms (upper limbs); and mild to severe mental retardation. Many infants and children with the disorder have an unusually small, short head (microbrachycephaly); an abnormally long vertical groove between the upper lip and nose (philtrum); a depressed nasal bridge; upturned nostrils (anteverted nares); and a protruding upper jaw (maxillary prognathism). Additional, characteristic facial abnormalities may include thin, downturned lips; low-set ears; arched, well-defined eyebrows that grow together across the base of the nose (synophrys); an unusually low hairline on the forehead and the back of the neck; and abnormally curly, long eyelashes. Affected individuals may also have distinctive malformations of the limbs, such as unusually small hands and feet, inward deviation (clinodactyly) of the fifth fingers, or webbing (syndactyly) of certain toes. Less commonly, there may be absence of the forearms, hands, and fingers. Infants with Cornelia de Lange syndrome may also have feeding and breathing difficulties; an increased susceptibility to respiratory infections; a low-pitched "growling" cry; heart defects; delayed skeletal maturation; hearing loss; or other physical abnormalities. The range and severity of associated symptoms and findings may be extremely variable from case to case.



Cornelia de Lange syndrome can be inherited as an autosomal dominant condition or an X-linked condition. The only genes that have been found to be associated with Cornelia de Lange syndrome are the NIPBL gene on chromosome 5 and the SMC1L1 gene on the X chromosome. Most affected individuals have an abnormal gene as a result of a new gene mutation and do not have an affected parent. Other genes may be found to be associated with Cornelia de Lange syndrome in the future.

Symptoms

Cornelia de Lange syndrome (CdLS) is a very rare disorder characterized by growth delays; distinctive facial features; malformations of the hands, feet, arms, and/or legs (limb anomalies); other physical abnormalities; mental retardation; and/or developmental delays. The range and severity of symptoms and physical characteristics may vary greatly from case to case.



Individuals with CdLS exhibit abnormal growth delays that affect both weight and linear growth before and after birth (prenatal and postnatal growth retardation). Most affected infants may have a low birth weight and may fail to gain weight or grow at the expected rate (failure to thrive). CdLS growth charts are available to compare growth to other affected individuals. Individuals may experience feeding, chewing, and swallowing difficulties during the first several months/years of life.



Many affected infants may frequently "spit up" food that has already been swallowed (regurgitation) and experience episodes of severe, forceful vomiting (projectile vomiting). Infants with CdLS may also demonstrate abnormally increased muscle tone (hypertonicity) and have an unusual, low-pitched, growling cry.



Individuals with Cornelia de Lange syndrome also have distinctive features of the head and facial (craniofacial) area including an abnormally small head (microcephaly) that may also be unusually short and wide (brachycephaly); a short, thick neck; a low hairline; a small, broad, upturned nose with nostrils that tilt forward (anteverted nares); neat, arched eyebrows that grow together (synophrys); long, curly eyelashes; and/or excessive hair growth on various areas of the body (hypertrichosis). Additional features may include thin, downturned lips; an abnormally long vertical gap between the upper lip (philtrum) and the nose; an abnormally small, underdeveloped jaw (micrognathia); late-erupting, widely-spaced, unusually small teeth; and low-set ears. In some cases, affected infants may also exhibit incomplete closure of the roof of the mouth (cleft palate) and/or a highly arched palate.



In most infants with Cornelia de Lange syndrome, the hands and feet are small for their size. In addition, affected individuals may have short fingers that become smaller and thinner toward the ends (tapered fingers), fifth fingers that are permanently curved toward the ring finger (clinodactyly), and/or, in some cases, absence of one or more fingers (oligodactyly). The thumbs may be abnormally positioned (i.e., proximally placed) and the arms may be permanently bent or flexed at the elbows due to bone fusions. In addition, in many cases, affected individuals may demonstrate underdevelopment (hypoplasia) of some of the bones of the fingers and toes, and the second and third toes are often abnormally fused or webbed (syndactyly). Some affected infants may also have abnormally small or short bones in the arms and/or legs (micromelia) or, in rare cases, fingers, hands, and forearms may be missing. In individuals with CdLS, upper limb abnormalities may involve one side (unilateral) or both sides (bilateral) of the body. If bilateral limb malformations are present, the abnormalities on one side of the body may be completely different from those on the other side (asymmetrical). Although the feet are small, only in extremely rare cases are there absent bones in the feet or lower legs.



Individuals with Cornelia de Lange syndrome also demonstrate delayed bone age (retarded osseous maturation). In addition, affected individuals may remain low in weight and exhibit abnormally short stature (prenatal and postnatal growth retardation), failure to thrive during infancy, delayed bone age, and/or other abnormalities. Many individuals with CdLS also exhibit additional skeletal abnormalities. These may include a deformity of the hip (coxa valga), a short breastbone (sternum), and/or abnormally thin ribs.



Many infants and children with CdLS may exhibit delays in the acquisition of skills requiring the coordination of mental and muscular activity (psychomotor retardation), have mild to severe mental retardation, and/or demonstrate behavioral problems (e.g., episodes of biting, screaming, hitting, etc.). In addition, although affected children often lack facial expression based on emotion, they appear to respond positively to certain stimuli (e.g., fast movements). A CdLS developmental chart is available to compare milestones.



In many cases, children with Cornelia de Lange syndrome also demonstrate hearing impairment as well as abnormal speech development. Middle ear infections (otitis media), which sometimes occur chronically with an accumulation of sticky fluid (otitis media with effusion or glue ear), are common. Younger children may have difficulty speaking (dysphonia), while older children may have abnormally hoarse speech.



Many individuals with CdLS also exhibit additional physicial abnormalities. In many cases, the skin may appear "marbled" (cutis marmorata), and the skin above the eyes, mouth, and nose may have an unusual bluish tone. In addition, many affected individuals demonstrate irregularities in the skin ridge patterns on the palms of the hands (dermatoglyphics). As mentioned earlier, most affected individuals may exhibit excessive hair growth (hypertrichosis) on various areas of the body including the ears. Hair may also tend to appear on the lower back, limbs, and/or other areas of the body.



Many individuals with Cornelia de Lange syndrome may also have various abnormalities of the gastrointestinal system including gastroesophageal reflux, a condition in which the acidic contents of the stomach flow upward into the lower esophagus; inflammation of the lining of the esophagus (esophagitis); and/or narrowing of the esophagus (esophageal stenosis). (For more information on this condition, choose "Gastroesophageal Reflux" as your search term in the Rare Disease Database.) In addition, affected individuals may demonstrate abnormal twisting (malrotation) of the intestines, potentially causing intestinal obstruction (volvulus). In some cases, the bands of muscle fibers (pyloric sphincter) at the junction between the stomach and small intestine (pyloric stenosis) may become abnormally narrowed (stenosis), resulting in obstruction of the normal flow of stomach contents into the small intestine. In addition, some individuals with CdLS may also exhibit protrusion of portions of the large intestine through an abnormal opening in musculature lining the abdominal cavity in the area of the groin (inguinal hernia) and/or part of the stomach through an abnormal opening where the esophagus passes through the diaphragm (hiatal hernia). In some individuals with CdLS, certain gastrointestinal abnormalities may lead to intestinal obstruction, potentially causing serious or life-threatening complications if left untreated.



Some individuals with Cornelia de Lange syndrome may also have malformations of the genitourinary tract. In affected males, such abnormalities may include underdevelopment (hypoplasia) of the genitals, failure of one or both of the testes to descend into the scrotum (cryptorchidism), and/or abnormal placement of the urinary opening (urinary meatus) on the underside of the penis (hypospadias). Affected females may demonstrate abnormal development of the uterus (e.g., bicornate or septate uterus), and menstruation may be irregular.



In many cases, individuals with CdLS may have additional physical abnormalities. Some affected infants and children may have various heart (cardiac) abnormalities, and many may demonstrate an increased suspectibility to repeated respiratory infections. In some cases, affected individuals may also have eye abnormalities such as nearsightedness (myopia), rapid, involuntary eye movements (nystagmus), and/or abnormal drooping of the upper eyelid(s) (ptosis). Some infants and children with CdLS may also experience episodes of uncontrolled electrical disturbances in the brain (seizures); and/or exhibit additional physical abnormalities.

Causes

Cornelia de Lange syndrome can be inherited as an autosomal dominant condition or an X-linked condition, but most affected individuals have an abnormal gene as a result of a new gene mutation. The only genes that have been found to be associated with Cornelia de Lange syndrome are the NIPBL gene on chromosome 5 and the SMC1L1 gene on the X chromosome. Approximately 50% of those affected have a NIPBL gene mutation and a small percentage have a SMC1L1 gene mutation. Other genes may be found to be associated with Cornelia de Lange syndrome in the future.



Dominant genetic disorders occur when only a single copy of an abnormal gene is necessary to cause a particular disease. The abnormal gene can be inherited from either parent or can be the result of a new mutation (gene change) in the affected individual. The risk of passing the abnormal gene from affected parent to offspring is 50% for each pregnancy. The risk is the same for males and females.



X-linked genetic disorders are conditions caused by an abnormal gene on the X chromosome and occur mostly in males. Females that have a disease gene present on one of their X chromosomes are carriers for that disorder. Carrier females usually do not display symptoms because females have two X chromosomes and one is inactivated so that the genes on that chromosome are nonfunctioning. It is usually the X chromosome with the abnormal gene that is inactivated. Males have one X chromosome that is inherited from their mother and if a male inherits an X chromosome that contains a disease gene he will develop the disease. Female carriers of an X-linked disorder have a 25% chance with each pregnancy to have a carrier daughter like themselves, a 25% chance to have a non-carrier daughter, a 25% chance to have a son affected with the disease and a 25% chance to have an unaffected son.



Males with X-linked disorders pass the disease gene to all of their daughters who will be carriers. A male cannot pass an X-linked gene to his sons because males always pass their Y chromosome instead of their X chromosome to male offspring.

Affected Populations

Cornelia de Lange syndrome is a very rare disorder that is apparent at birth (congenital). Males and females appear to be affected in equal numbers. It has been estimated that Cornelia de Lange syndrome occurs in approximately one in every 10,000 live births in the United States. More than 400 cases have been reported in the medical literature, including affected individuals within several families (kindreds). In some reported cases, affected family members have been siblings. It is estimated that there is a one to two percent rate of recurrence within affected families.

Standard Therapies

Diagnosis

In some cases, a diagnosis of Cornelia de Lange syndrome (CdLS) may be suspected before birth (prenatally) through the use of ultrasound imaging. During such testing, reflected sound waves create an image of the fetus that may reveal certain abnormalities characteristic of CdLS such as retarded growth, limb abnormalities, facial anomalies and/or organ malformations.



In most cases, CdLS is diagnosed and/or confirmed after birth based upon a thorough clinical evaluation and identification of characteristic physical findings. According to the medical literature, a diagnosis of Cornelia de Lange syndrome should be considered if affected individuals exhibit certain distinctive facial features in association with limb anomalies, prenatal and postnatal growth retardation, and mental retardation. Diagnosis may be more difficult if symptoms and physical characteristics associated with the disorder are very mild. Molecular genetic testing for the NIPBL and SMC1L1 gene mutations associated with CdLS is available to confirm the diagnosis and is particularly helpful when the physical features are mild or unusual. Prenatal diagnosis is available if a specific NIPBL or SMC1L1 gene mutation has been identified.



Molecular genetic testing for the NIPBL and SMC1L1 gene mutations associated with CdLS is available to confirm the diagnosis and is particularly helpful when the physical features are mild or unusual. Prenatal diagnosis is available if a specific NIPBL or SMC1L1 gene mutation has been identified.



Treatment

The treatment of Cornelia de Lange syndrome is directed toward the specific symptoms that are apparent in each individual. Treatment may require the efforts of a team of specialists who will work together to systematically and comprehensively plan an affected child's treatment. Such specialists may include pediatricians; geneticists; surgeons; specialists who diagnose and treat skeletal disorders (orthopedists); plastic surgeons; orthopedic surgeons; specialists who diagnose and treat abnormalities of the digestive system (gastroenterologists), disorders of the urinary tract (urologists), and abnormalities of the ears, nose, and throat (otolaryngologists); pediatric heart specialists (cardiologists); dental specialists; speech pathologists; specialists who assess and treat hearing problems (audiologists); eye specialists; physical and occupational therapists; and/or other health care professionals.



Affected infants and children may be closely monitored for certain abnormalities potentially associated with Cornelia de Lange syndrome (e.g., potential intestinal obstruction due to gastrointestinal abnormalities, cardiac defects, gastroesophageal reflux, glue ear, and/or susceptibility to respiratory infections) to ensure early detection and prompt treatment.



Specific therapies for the treatment of Cornelia de Lange syndrome are symptomatic and supportive. In some cases, surgery may be performed to help correct certain cleft palate. Plastic surgery may be helpful in reducing excessive hair. In some cases, other abnormalities potentially associated with CdLS (e.g., gastrointestinal, genitourinary, and/or cardiac malformations) may be treated with certain medications, surgical intervention, and/or other techniques. In such cases, the surgical procedures performed will depend upon the location and severity of the anatomical abnormalities and their associated symptoms. Respiratory infections may be treated with antibiotic drug therapy and/or other medications that may help fight infection.



In some individuals with Cornelia de Lange syndrome, various orthopedic techniques may be used to help treat limb deformities. In affected individuals with hearing impairment, hearing aids may be beneficial in some cases. In addition, for individuals with CdLS who experience seizure episodes, treatment with anticonvulsant medications may help prevent, reduce, or control seizures in some cases.



Early intervention is important in ensuring that children with Cornelia de Lange Syndrome reach their highest potential. Services that may be beneficial may include special remedial education, vocational training, speech therapy, and/or other medical and/or social services.



Genetic counseling is recommended for affected individuals and their families. Other treatment is symptomatic and supportive.

Investigational Therapies

Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this web site.



For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:



Tollfree: (800) 411-1222

TTY: (866) 411-1010

Email: prpl@cc.nih.gov



For information about clinical trials sponsored by private sources, contact: www.centerwatch.com.



The identification in May 2004 of the gene involved in Cornelia de Lange syndrome offers the opportunity to learn more about the disorder, perhaps ultimately leading to new ways of treating or caring for those affected. It is hoped that this discovery will speed the development of a prenatal genetic test for the syndrome. The discovery is also expected to be helpful in confirming the diagnosis in young children suspected of having the disorder.

References

TEXTBOOKS

Jones KL. Smith's Recognizable Patterns of Human Malformation. 5th ed. Philadelphia, PA; W.B. Saunders Company; 1997:88-89.



Adams RD, et al., eds. Principles of Neurology. 6th ed. New York, NY; McGraw-Hill Companies, Inc.; 1997:1001.



Buyse ML. Birth Defects Encyclopedia. Dover, MA; Blackwell Scientific Publications, Inc.; 1990:333-334, 486-487.



Gorlin RJ, et al., eds. Syndromes of the Head and Neck. 3rd ed. New York, NY; Oxford University Press; 1990:300-304.



REVIEW ARTICLE

Russell KL, Ming JE, Patel K, et al. Dominant paternal transmission of Cornelia de Lange syndrome: a new case and review of 25 previously reported familial recurrences. Am J Med Genet. 2001;104:267-76.



JOURNAL ARTICLES

Krantz I, et al. Cornelia de Lange syndrome is caused by mutations in NIPBL, the human homolog of Drosophila melanogaster nipped-B. Nature Genet. 2004;



Hyman P, Oliver C, Hall S. Self-injurious behavior, self restraint and compulsive behaviors Am J Ment Retard. 2002;107:146-54.



Krantz ID, Tonkin E, Smith M, et al. Exclusion of linkage to the CDL 1 gene region on chromosome 3q26.3 in some familial cases of Cornelia de Lange syndrome. AM J Med Genet. 2001;101:120-29.



Fryns JP. Partial trisomy 4p and Brachmann-de Lange syndrome. Am J Med Genet. 2000;95:406.



Sekimoto H, Osada H, Kimura H, et al. Prenatal findings in Brachmann-de Lange syndrome. Arch Gynecol Obstet. 2000;263:182-84.



Dyken P. De Lange's syndrome: facial features of pediatric neurological syndromes. J Child Neurol. 2000;15:84.



Ranzini AC, Day-Salvatore D, Farren-Chavez D, et al. Prenatal diagnosis of de Lange syndrome. J Ultrasound Med. 1997;16.



Allanson JE, Hennekam RC, Ireland M. De Lange Syndrome: subjective and objective comparison of the classical and mild phenotypes. J Med Genet. 1997;34:645-50.



Ackerman J, Gilbert-Barness E. Brachmann-de Lange syndrome. Am J Med Genet. 1997;68:367-68.



Manouvrier S, Espinasse M, Vaast P, et al. Brachmann-de Lange syndrome: pre- and postnatal findings. Am J Med Genet. 1996;62:268-73.



Jackson L, Kline AD, Barr MA, et al. de Lane syndrome: a clinical review of 310 persons. Am J Med Genet. 1993;47:940-46.



Kline AD, Barr M, Jackson LG. Growth manifestations in the Brachmann-de Lange syndrome. Am J Med Genet. 1993;47:1042-49.



Kline AD, Stanley C, Belevich J, et al. Developmental data on individuals with the Brachmann-de Lange syndrome. Am J Med Genet. 1993;47:1053-58.



Tonkin ET, Wang TJ, Lisgo S, et al. NIPBL, encoding a homolog of fungal Scc2-type sister chromatid cohesion proteins and fly Nipped-B, is mutated in Cornelia de Lange syndrome. Nat Genet 2004: 36:636-41.



Musio A, Selicorni A, Focarelli ML, et al. X-linked Cornelia de Lange syndrome owing to SMC1L1 mutations Nat Genet 2006:38:528-30.



FROM THE INTERNET

McCusick VA, ed. Online Mendelian Inheritance in Man, (OMIM). John Hopkins University, Baltimore, MD. Entry Number; 122470; Latest Edit; 1/3/02.



Cornelia de Lange syndrome-Genetics Home Reference

http://ghr.nlm.nih.gov/condition=corlenaidelangesyndrome/show/print



eMedicine-Cornelai de Lange Syndrome: Article by Mustafa Tekin, MD

http://www.emedicne.com/ped/topic482.htm



Deardorff MA, Yaeger DM and Krantz ID. (Updated 8/14/06) Cornelia de Lange Syndrome. In: GeneReviews at Genetests: Medical Genetics Information Resource (database online). Copyright, Universiity of Washington, Seattle. 1997-2008. Available at http://www.genetests.org. Accessed 1/08.

Resources

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