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CASE REPORT
Year : 2017  |  Volume : 7  |  Issue : 1  |  Page : 32-33

Very severe spinal muscular atrophy (Type 0)


Department Neonatal Unit, Leeds Teaching Hospitals NHS Trust, Children's Hospital, United Kingdom

Date of Web Publication4-Jan-2017

Correspondence Address:
Suleiman Al Dakhoul
Flat 1, 39 Yateholm Drive, Bradford, BD6 3WU
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-0770.197512

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   Abstract 

This case report describes a rare phenotype of very severe spinal muscular atrophy (SMA) in a newborn who presented with reduced fetal movements in utero and significant respiratory distress at birth. The patient was homozygously deleted for exon 7 and exon 8 of the survival motor neuron gene 1. Very severe SMA should be considered in the differential diagnosis of respiratory distress at birth, and more research should be dedicated to investigate the genetic determinants of its widely variable phenotypes.

Keywords: Exon, neurodegenerative, newborn, severe, spinal muscular atrophy


How to cite this article:
Al Dakhoul S. Very severe spinal muscular atrophy (Type 0). Avicenna J Med 2017;7:32-3

How to cite this URL:
Al Dakhoul S. Very severe spinal muscular atrophy (Type 0). Avicenna J Med [serial online] 2017 [cited 2017 May 25];7:32-3. Available from: http://www.avicennajmed.com/text.asp?2017/7/1/32/197512


   Introduction Top


Spinal muscular atrophy (SMA) is an autosomal recessive neurodegenerative disease characterized by progressive symmetrical muscle weakness resulting from the degeneration and loss of anterior horn cells in the spinal cord and brain stem nuclei. It is the most common genetic cause of infant mortality, affecting approximately 1 in 10,000 live births. [1]

The disease is conventionally classified into four phenotypes [Table 1]. [2]
Table 1: Phenotypes of spinal muscular atrophy


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In 1999, MacLeod et al. have described five cases of very severe SMA Type 1, all of whom presented with reduced fetal movements in utero, severe weakness at birth, and short survival time. [3]


   Case Report Top


This male newborn was the second child of unrelated parents. He was born by spontaneous vaginal delivery at 38 + 0 weeks of gestation weighing 2620 g.

Antenatally, the mother, noticed reduced fetal movements in the last 2 weeks of gestation, and there was polyhydramnios on antenatal scans. She is a nonsmoker and denies any alcohol or drugs consumption.

Around delivery, a mixture of nitrous oxide and oxygen (Entonox®) was used for pain relief during labor. The baby was born cyanotic, floppy with no respiratory effort and no chest wall movement. After two cycles of assisted breaths, the patient remained bradycardic with heart rate <20/min and therefore, chest compressions were initiated. The patient was intubated with size - 3.5 tube which resulted in an improvement in his oxygenation and circulatory response.

On day 9 of age, examination by neurologist revealed a generalized hypotonia with absent gag and suck reflexes. Contractures of the shoulders, elbows, hips, and knees were noted. Deep tendon reflexes and jaw jerk were absent.

A chest X-ray showed a right upper lobe consolidation, likely to be due to aspiration. Baby was covered with broad spectrum antibiotics: Benzylpenicillin (50 mg/kg twice daily) and gentamicin (5 mg/kg every 36 h) then vancomycin (15 mg/kg every 8 h) and ceftazidime (25 mg/kg twice daily). Cranial ultrasound showed the normal appearance of brain and ventricles with no signs of hemorrhage. A metabolic screen of amino acids and acylcarnitine was unremarkable.

In genetic studies, myotonic dystrophy Type 1 was negative but the baby was homozygously deleted for exon 7 and exon 8 of survival motor neuron gene 1 (SMN1).

The diagnosis was fully explained to parents and on day 12 of life, the baby was discharged to the local hospice for compassionate extubation after which he passed away.


   Discussion Top


SMA is caused by homozygous deletions or mutations in the SMN1 gene on chromosome 5 q13. [4] SMN1 exon 7 is homozygously absent in approximately 94% of patients with clinically typical SMA. [5] There is a marked correlation between SMN-encoded protein levels and disease severity in SMA. [6] In all SMA Type 0 cases reported by MacLeod and her team, centromeric SMN gene was present but in reduced copy number compared with a control group of children with the less severe Type 1 SMA. [3]

Although in this case, SMA has been confirmed, polyhydramnios, to some extent, might have contributed to the clinical features and presentation. Cessation of fetal movements associated with polyhydramnios has been reported in the medical literature. [7] A review showed that, in polyhydramnios, there is a 2-5-fold increase in the risk of perinatal mortality. [8]

Patients with SMA and their families or carers should be routinely offered genetic counseling. Being an autosomal recessive disease indicates that there is a 25% chance to have an affected child if both parents were found to be carriers. In an American study, Caucasians have the highest carrier's frequency and detection rate whereas African Americans had the lowest. [9]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Prior TW, Nagan N. Spinal muscular atrophy: Overview of molecular diagnostic approaches. Curr Protoc Hum Genet 2016;88:9.27.1-9.27.13. doi: 10.1002/0471142905.hg0927s88.  Back to cited text no. 1
    
2.
Mercuri E, Bertini E, Iannaccone ST. Childhood spinal muscular atrophy: Controversies and challenges. Lancet Neurol 2012;11:443-52.  Back to cited text no. 2
    
3.
MacLeod MJ, Taylor JE, Lunt PW, Mathew CG, Robb SA. Prenatal onset spinal muscular atrophy. Eur J Paediatr Neurol 1999;3:65-72.  Back to cited text no. 3
    
4.
Schmalbruch H, Haase G. Spinal muscular atrophy: Present state. Brain Pathol 2001;11:231-47.  Back to cited text no. 4
    
5.
Ogino S, Wilson RB. Genetic testing and risk assessment for spinal muscular atrophy (SMA). Hum Genet 2002;111:477-500.  Back to cited text no. 5
    
6.
Lefebvre S, Burlet P, Liu Q, Bertrandy S, Clermont O, Munnich A, et al. Correlation between severity and SMN protein level in spinal muscular atrophy. Nat Genet 1997;16:265-9.  Back to cited text no. 6
    
7.
Sadovsky E, Perlman M. Decreased fetal movements and polyhydramnios. Acta Obstet Gynecol Scand 1978;57:177-8.  Back to cited text no. 7
    
8.
Magann EF, Chauhan SP, Doherty DA, Lutgendorf MA, Magann MI, Morrison JC. A review of idiopathic hydramnios and pregnancy outcomes. Obstet Gynecol Surv 2007;62:795-802.  Back to cited text no. 8
    
9.
Sugarman EA, Nagan N, Zhu H, Akmaev VR, Zhou Z, Rohlfs EM, et al. Pan-ethnic carrier screening and prenatal diagnosis for spinal muscular atrophy: Clinical laboratory analysis of >72,400 specimens. Eur J Hum Genet 2012;20:27-32.  Back to cited text no. 9
    



 
 
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