Journal Information
Vol. 43. Issue. 2.March - April 2023
Pages 161-268
Vol. 43. Issue. 2.March - April 2023
Pages 161-268
Letter to the Editor
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Oral-facio-digital syndrome type I: In the differential diagnosis of autosomic dominant polycystic kidney disease, about three cases
Síndrome orofaciodigital tipo i: en el diagnóstico diferencial de la poliquistosis renal autosómica dominante, a próposito de 3 casos
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Víctor Martínez Jiméneza,
Corresponding author
victormj80@gmail.com

Corresponding author.
, Pedro Pablo Ortuño Lópeza, Susana Roca Meroñob, Lidia Rodríguez Peñac, Isabel Galán Carrillod, Liliana Galbis Martíneze, Fernanda Ramos Carrascod, Juan Alberto Piñero Hernándezf, Juan David González Rodríguezg, Encarnación Guillén Navarroc,h, Unidad Multidisciplinar de Enfermedades Renales Hereditarias de la Región de Murcia (UMERH-RM)
a Servicio de Nefrología, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
b Servicio de Nefrología, Hospital Universitario Santa Lucía, Cartagena, Spain
c Sección de Genética Médica, Servicio de Pediatría, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
d Servicio de Nefrología, Hospital Universitario Reina Sofía, Murcia, Spain
e Centro de Bioquímica y Genética Clínica, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
f Sección Nefropediatría, Servicio de Pediatría, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
g Sección Nefropediatría, Servicio de Pediatría, Hospital Universitario Santa Lucía, Cartagena, Spain
h Instituto Murciano de Investigación Biosanitaria-IMIB, Universidad de Murcia (Murcia), CIBERER-ISCIII, Madrid, Spain
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Table 1. Main clinical characteristics and follow-up.
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Dear Editor,

We present three patients with a clinical suspicion of autosomal dominant polycystic kidney disease (ADPKD),1 but with collaboration from the UMERH-RM group, the correct diagnosis of oral-facial-digital syndrome type I (OFDSI) was obtained.Case 1

Twenty-five-year-old woman with a personal history of cognitive deficit and surgical procedures for prognathism, anterior open bite malocclusion with extraction of two supernumerary canines and other teeth, fibromas, and tongue frenulae. She was referred to nephrology due to hypertension, glomerular filtration rate (GFR) of 61ml/min and kidney ultrasound: right kidney 11cm and left 12.4cm, multiple corticomedullary cysts and liver with small cysts, compatible with ADPKD. There were no kidney cysts on an ultrasound performed five years prior and the kidneys measured 10.3 and 10.8cm.

Physical examination: milia, slanted palpebral fissures, hypoplasia of the nasal wings, dental crowding, prognathism, clinodactyly and brachydactyly in hands and feet, and hallux valgus.

The head MRI identified agenesis of the corpus callosum and hypoplasia of the cerebellar vermis.

Genetic testing found a de novo pathogenic variant with deletion in exon 12: c.1193_1196delAATC (p.Q398LfsX1) on the OFD1 gene, giving rise to a truncated protein, previously reported as associated with OFDSI.Case 2

Thirty-two-year-old woman with chronic kidney disease and GFR of 47ml/min, in the context of non-steroidal anti-inflammatory drug abuse due to herniated disc. Treated surgically in childhood for accessory gingival frenulae and extraction of supernumerary teeth due to malocclusion.

After being referred to nephrology in 2015, polycystic kidneys were observed on ultrasound: right kidney 13cm and left 13.4, with no changes in the liver, spleen, or pancreas.

Family history: mother with kidney transplant due to chronic consumption of non-steroidal anti-inflammatory drugs due to rheumatoid arthritis. The rest of the family (father, sister, son and daughter) have normal kidney function. All underwent ultrasound with kidneys normal in size with no cysts.

On physical examination: fissure of the upper lip, micrognathia, narrow palate and lobulated tongue, and brachydactyly-clinodactyly with marked difference in size between both hands.

During follow-up, onset of hypertension and rapid deterioration of GFR: 37ml/min at six months and GFR: 30ml/min at one year. On a new ultrasound, increase in kidney size (right 14.7 and left 15.1cm). Clinically diagnosed with de novo rapidly progressing ADPKD and a candidate for tolvaptan. Head and face MRI ordered due to vertigo and headaches, with no abnormalities found. Currently 37 years old and GFR: 14ml/min.

The Next Generation Sequencing (NGS) massive sequencing testing for cystic kidney diseases identified a pathogenic variant on exon 2 of the OFD1 gene: c.71dup, (p.Try24*), not previously reported, giving rise to a truncated protein changing the diagnosis from ADPKD to OFDSI. Family testing confirmed the same variant in her daughter, ruling it out in the rest of the family members.Case 3

Twelve-year-old girl, daughter of case 2. With no history of interest, except the extraction of a supernumerary canine at six years old. On physical examination: accessory frenula and hands with brachydactyly and clinodactyly (like her mother, although affected to a lesser degree) (Fig. 1). On ultrasound, the kidneys were normal in size with no cysts.

Figure 1.

Comparison of hands between case 2 (mother) and case 3 (daughter). In the mother (left), we observe brachydactyly and clinodactyly, while in the daughter (right), they are present to a lesser extent.

(0.06MB).

OFDSI (OMIN #311200; ORPHA 2750) is a ciliopathy,2 with a prevalence: 1/50,000–1/250,000 in live newborns.

In 1998, De Conciliis3 identified the cause as the OFD1 gene on the X chromosome, which codes for a protein with 1,011 amino acids, expressed in the centrosome and basal body of the primary cilia.4 In the OFDSI, the embryogenesis process is altered, causing dysmorphias and kidney cysts. There are up to 18 types of oral-facial-digital syndrome, but type I is the most common.5

Up to 75% of the pathogenic variants of the OFD1 gene are sporadic or de novo. In family cases, the inheritance pattern is X-linked dominant, being lethal in males affected during gestation,6 therefore it would be transmitted from mothers to daughters.

The clinical diagnosis for suspected OFDSI is established after birth via orofacial and digital dysmorphias; or in adults by being associated with polycystic kidneys (Table 1).7 Annual blood pressure and kidney function checks and abdominal ultrasound are recommended because polycystic kidneys occur8 in 50%, or even the majority of women according to other authors,6 and may be the only manifestation.

Table 1.

Main clinical characteristics and follow-up.

  Most common symptom  Follow-up 
Facial featuresTelecanthus (eyes widely spaced)  Detailed physical examinationReconstruction of facial dysmorphias by maxillofacial surgery
Micrognathia 
Slanted palpebral fissures 
Hypoplasia of the nasal wings 
Median cleft lip 
Oral cavityClefts in the soft and hard palate  Detailed physical examinationIn children with palate alteration, annually:
Lobulated tongue 
Lingual nodules 
Ankyloglossia (due to short lingual frenula) 
  • -

    Hearing test

  • -

    Speech exam

  • -

    Odontologic follow-up (tooth extraction and orthodontia)

Accessory gingival frenulae 
Excess or Lack of teeth 
Dental malocclusion 
Digital alterationsBrachydactyly  Detailed physical examination
Syndactyly 
Clinodactyly of the fifth finger 
Thumb duplication (hallux) 
  • -

    Hand X-ray: rule out irregular mineralisation (fine reticular radiotransparencies and spicules on phalanges)

Preaxial or postaxial polydactyly 
RenalPolycystic kidney disease  In those over 10 years, annually:
Chronic kidney disease 
Arterial hypertension 
  • -

    Blood test with GFR

  • -

    Blood pressure check

  • -

    Abdominal ultrasound

 
Central nervous systemIntellectual disability (usually associated with brain abnormalities)  Measure intellectual ability 
Intracerebral cysts  Developmental and behavioural assessment 
Agenesis of the corpus callosum with or without Dandy-Walker malformation  Head MRI 
Agenesis of the cerebellum  Follow-up with neurology for seizures if they occur 
OtherMilia on head and hands  Assessment by dermatology (topical tretinoin for acne) 
Hypoacusis due to repeated otitis  Audiometry and speech therapy 
Cysts in liver, pancreas, ovaries (only in case of polycystic kidney disease)  Annual abdominal ultrasound (along with search for kidney cysts) 
GeneticsInheritance: X-link dominant  If index case with pathogenic mutation: 
Lethal for males in gestation 
  • -

    Genetic testing for all female relatives (including asymptomatic)

 

Due to its great phenotype variability, genetic confirmation is required. NGS panels for cystic kidney disease, which identify the molecular cause in 80%, are the test of choice.9

In conclusion, all women with OFDSI must receive annual follow-up by nephrology, because they may develop polycystic kidneys and progressive chronic kidney disease, which determines their prognosis.10 OFDSI brings up the differential diagnosis with ADPKD, with the search for orofacial and digital dysmorphias being key during the physical examination.

Conflicts of interest

The authors declare that there were no conflicts of interest.

References
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Spanish guidelines for the management of autosomal dominant polycystic kidney disease.
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Centrosomes and cilia in human disease.
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Novel mutations including deletions of the entire OFD1 gene in 30 families with type 1 orofaciodigital syndrome: a study of the extensive clinical variability.
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Hum Mutat, 30 (2009), pp. E320-9
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