Dear Sir,
Pfeiffer syndrome is a rare syndrome of primary craniosynostosis presenting usually
with microcephaly, turricephaly, brachycephaly, medially deviated big toes and partial
syndactyly of hands and feet.[1
2] The condition results from mutations in fibroblast growth factor receptor gene
(FGFR1 or FGFR2).[1
2] We report a case of a 7-year-old child who was diagnosed as having Pfeiffer syndrome
based on the clinical features and neuro imaging.
A 7-year-old male child born of second degree consanguineous marriage presented with
acute gastroenteritis to the pediatric ward of a tertiary care teaching hospital.
On examination child was found to have microcephaly, abnormal shaped skull (cone shape),
proptosis of both eyes, brachycephaly, and maxillary hypoplasia [Figure 1]. In addition
to that, child also had medially deviated big toe of both feet and partial soft tissue
syndactyly of 2nd and 3rd toe [Figure 2]. Child's school performance and development
was normal. Other anthropometric features were appropriate for age and sex of the
child. A computed tomography scan of the brain was advised, which was suggestive of
primary craniosynostosis with no hydrocephalus. Detail family history of child suggested
that all members of family from the paternal side (grandfather, father, one uncle)
had partial syndactyly of 2nd and 3rd toe of both feet. However, in no family members
microcephaly, proptosis or any skull deformity was noted.
Figure 1
Ocular proptosis, turricephaly, maxillary hypoplasia in Pfeiffer syndrome
Figure 2
Hallux valgus (medially deviated big toe) and partial syndactyly of 2nd and 3rd toe
in Pfeiffer syndrome
Based on this clinical features and investigation, child was diagnosed as Pfeiffer
syndrome type 1. Neurosurgical opinion was taken; parents and the whole family were
advised for genetic counseling and further testing. Child was discharged after child
improved from presenting complains of acute gastroenteritis.
Pfeiffer syndrome is a rare syndrome of primary craniosynostosis, hallux valgus and
partial syndactyly of hands and feet. Other features may be found such as hydrocephalus,
ocular proptosis, other skeletal deformities of hand and feet and slow development.[1
2] Cohen has described three subtype of Pfieffer syndrome on the basis of clinical
features and severity.[1] Type 1 or classic Pfeiffer syndrome patient has mild manifestations
such as brachycephaly, midface hypoplasia, finger, and toe abnormalities. It is associated
with normal intelligence and generally good prognosis. Type 2 Pfeiffer syndrome patients
have cloverleaf skull, extreme proptosis and major finger and toe abnormalities, developmental
delay and neurological complications. Type 3 Pfeiffer syndrome is like type 2, but
without cloverleaf skull. In Pfeiffer types 2 and 3, there may be choanal anomalies,
laryngotracheal abnormalities, hydrocephalus, seizures, sacrococcygeal anomalies,
and increased risk of death.[1
2]
Pfeiffer syndrome affects about 1 in 100,000 population.[2] Only three cases have
been reported from India so far.[3
4
5] The syndrome is a result of mutations in the FGFR1 or FGFR2 genes.[2] Antenatal
diagnosis of Pfeiffer syndrome can be offered on antenatal sonographic findings like
craniosynostosis, proptosis, and broad thumb. If the mutation is diagnosed in the
index case, molecular diagnosis can be offered for identifying recurrence. Molecular
genetic testing is important to confirm the diagnosis. Management includes craniotomy
for craniosynostosis. Moreover, surgery can be performed to reduce the exophthalmos
and maxillary hypoplasia in very severe cases.[2]