Noonan syndrome

Anesthesia risk

There have been few reports of patients with Noonan syndrome who have subsequently suffered from Malignant Hyperthermia (MH). However Noonan's syndrome is not associated with MH. Only King-Denborough syndrome and central core disease are associated with MH. King-Denborough syndrome has been linked to a mutation on chromosome 19 located near the gene that encodes the ryanodine receptor whereas Noonan syndrome is associated with a mutation on chromosome 12.

Some individuals with NS have been reported to develop respiratory depression from narcotics given during and after surgery, which has sometimes required cardiac resuscitation. Impaired anesthetic clearance in the 24–48 hours after surgery has also been reported.

Heart

Up to ~85% of people with NS have one of the following heart defects:

Pulmonary valvular stenosis (50–60%)

Septal defects: atrial (10–25%) or ventricular (5–20%)

Hypertrophic cardiomyopathy (12–35%)

Lungs

Restrictive lung function has been reported in some patients

Gastrointestinal system

Failure to thrive From infancy to puberty (75%)

Decreased appetite

Digestive problems

Frequent or forceful vomiting

Swallowing difficulties

Intestinal malrotation

Need for a feeding tube

Low gut motility

Gastroparesis (delayed gastric emptying)

Genito-urinary system

Cryptorchidism (undescended testicles)

Lymphatic system

Posterior cervical hygroma (webbed neck)

Lymphedema

Developmental

Clumsiness

Motor development delay/delayed milestones

Learning disabilities

Dysmaturity

Speech-language pathology

Autism, pervasive developmental disorder

Frequent illnesses, doctor appointments, pain, headaches and fatigue are a few things that can affect school attendance and performance.

Despite the various possible developmental/learning issues that can be seen in NS, there are Noonan Syndrome patients that have advanced degrees, including at least two that have become attorneys. Source Noonan Syndrome Foundation

Recommendations

Neuropsychological testing is recommended to find strengths and challenges to tailor support needed for school, career.

Educational customization such as an Individualized Education Program plan or a Section 504 plan is sometimes needed for school-aged children.

Speech therapy if there are speech and articulation issues

Physical therapy and occupational therapy for gross and fine motor delays

Hypotonia and motor difficulties often impact handwriting. Accommodations for lessening handwriting demands will improve performance and save long-term hand function.

Hematologic

Bleeding disorders

Easy bruising

Amegakaryocytic thrombocytopenia (low platelet count)

Blood clotting disorders

Von Willebrand disease

Prolonged activated partial thromboplastin time

Partial deficiency of Factor VIII:C

Partial deficiency of Factor XI:C

Partial deficiency of Factor XII:C

Platelet dysfunction

Combined coagulation defects

Imbalance of Plasminogen Activator Inhibitor Type-1 (PAI-1) and Tissue Plasminogen Activator (t-PA) Activity.

Musculoskeletal

Joint pain or muscle pain especially in adults, which can vary in severity

Undifferentiated Connective Tissue Disorders

Scoliosis

Prominence of breast bone (pectus carinatum)

Depression of breast bone (pectus excavatum)

Joint contractures (tightness)

Joint hypermobility (looseness)

Winging of the scapula

Hypotonia (low muscle tone)

Hypermobility syndrome

Lordosis (increased hollow in the back) due to poor stomach muscle tone

Neurological

Arnold-Chiari malformation (type 1), which can lead to hydrocephalus, has been noted in some patients

Seizures

Stature

Short stature Growth Hormone (GH) sometimes combined with IGF-1 (or as an alternative, IGF-1 as a stand-alone could be used as stated in cited paper) can be used to achieve an increased height/final height quicker

Head

Excess skin on the back of the neck

Low hairline at the nape of the neck

High hairline at the front of the head

Large head

Triangular face shape

Broad forehead

Short neck, webbed neck

Eyes

Hypertelorism (widely set eyes) (95%)

Epicanthal folds (extra fold of skin at the inner corner of the eye)

Ptosis (drooping of the eyelids)

Proptosis (bulging eyes)

Refractive visual errors

Strabismus (inward or outward turning of the eyes)

Nystagmus (jerking movement of the eyes)

Nose

Small, upturned nose

Ears and hearing

Low-set ears (in over 90%)

Backward-rotated ears (over 90%)

Thick helix (outer rim) of ear(over 90%)

Incomplete folding of ears

Chronic otitis media (ear infections)

Hearing loss

Mouth and speech

Deeply grooved philtrum (top lip line) (over 90%)

Micrognathia (undersized lower jaw)

High arched palate

Dental problems

Articulation difficulties

Poor tongue control

Limbs/extremities

Bluntly ended fingers

Extra padding on fingers and toes

Edema of the back of hands and tops of feet

Cubitus valgus (Wide carrying angle of the elbows)

Skin

Lymphedema (lymph swelling of the extremities)

Keloid formation, excessive scar formation

Hyperkeratosis (overdevelopment of outer skin layer)

Pigmented nevi (darkly pigmented skin spots)

Connective tissue disease

Causes

Recurrence in siblings and apparent transmission from parent to child has long suggested a genetic defect with autosomal dominant inheritance and variable expression. Mutations in the Ras/mitogen activated protein kinase signaling pathways are known to be responsible for ~70% of NS cases.

A person with NS has up to a 50% chance of transmitting it to their offspring. The fact that an affected parent is not always identified for children with NS suggests several possibilities:

1. Manifestations could be so subtle as to go unrecognized (variable expressivity)
2. NS is heterogeneous, comprising more than one similar condition of differing causes, and some of these may not be inherited.
3. A high proportion of cases may represent new, sporadic mutations.

Heterozygous mutations in NRAS, HRAS, BRAF, SHOC2, MAP2K1, MAP2K2, and CBL have also been associated with a smaller percentage of NS and related phenotypes.

A condition known as "neurofibromatosis-Noonan syndrome" is associated with neurofibromin.

Diagnosis

NS can be confirmed genetically by the presence of any of the known mutations listed above. However, despite identification of fourteen causative genes, the absence of a known mutation will not exclude the diagnosis, as there are more, as-yet-undiscovered genes that cause NS. Thus, the diagnosis of NS is still based on clinical features. In other words, it is made when a physician feels that a patient has enough of the features to warrant the label. The principal values of making a genetic diagnosis are that it guides additional medical and developmental evaluations, it excludes other possible explanations for the features, and it allows more accurate recurrence risk estimates. With more genotype-phenotype correlation studies being performed, a positive genetic diagnosis will help the clinician to be aware of possible anomalies specific to that certain gene mutation. For example, there is an increase in hypertrophic cardiomyopathy in patients with a mutation of KRAS and an increased risk of juvenile myelomonocytic leukemia for a mutation of PTPN11. In the future, studies may lead to a targeted management of NS symptoms that depends on what genetic mutation a patient has.

Prognosis

A 2007 study followed 112 individuals for a mean of 12 years (mean age 25.3, range 12-71). No patient died during follow-up, but several required medical interventions. The mean final heights were 167 and 153 cm for men and women, respectively, which is approximately 2 standard deviations below normal.

History

Jacqueline Noonan was practicing as a pediatric cardiologist at the University of Iowa when she noticed that children with a rare type of heart defect, valvular pulmonary stenosis, often had a characteristic physical appearance, with short stature, webbed neck, wide spaced eyes, and low-set ears. Both boys and girls were affected. These characteristics were sometimes seen running in families but were not associated with gross chromosomal abnormalities. She studied 833 patients at the congenital heart disease clinic, looking for other congenital abnormalities, and in 1963 presented a paper: "Associated non-cardiac malformations in children with congenital heart disease". This described 9 children who in addition to congenital heart disease had characteristic facial features, chest deformities and short stature.

Dr. John Opitz, a former student of Dr. Noonan, first began to call the condition "Noonan syndrome" when he saw children who looked like those whom Dr. Noonan had described. Dr. Noonan produced a paper entitled "Hypertelorism with Turner Phenotype" in 1968, and in 1971 at the Symposium of Cardiovascular defects, the name 'Noonan syndrome' became officially recognized.