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Open Access Highly Accessed Case report

LEOPARD syndrome: clinical dilemmas in differential diagnosis of RASopathies

Claudia Santoro13, Giuseppe Pacileo2, Giuseppe Limongelli2, Saverio Scianguetta1, Teresa Giugliano3, Giulio Piluso3, Fulvio Della Ragione3, Mario Cirillo4, Giuseppe Mirone5 and Silverio Perrotta1*

Author Affiliations

1 Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Second University of Naples, Via Luigi De Crecchio, 4, Naples 80138, Italy

2 Division of Cardiology, Second University of Naples, Monaldi Hospital, Naples, Italy

3 Department of Biochemistry, Biophysics and General Pathology, Second University of Naples, Naples, Italy

4 Dipartimento di Scienze Mediche, Chirurgiche, Neurologiche, Metaboliche e dell’ Invecchiamento, Second University of Naples, Naples, Italy

5 Department of Pediatric Neurosurgery, Santobono Children’s Hospital, Naples, Italy

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BMC Medical Genetics 2014, 15:44  doi:10.1186/1471-2350-15-44

Published: 26 April 2014

Abstract

Background

Diagnosis within RASopathies still represents a challenge. Nevertheless, many efforts have been made by clinicians to identify specific clinical features which might help in differentiating one disorder from another. Here, we describe a child initially diagnosed with Neurofibromatosis-Noonan syndrome. The follow-up of the proband, the clinical evaluation of his father together with a gene-by-gene testing approach led us to the proper diagnosis.

Case presentation

We report a 8-year-old male with multiple café-au-lait macules, several lentigines and dysmorphic features that suggest Noonan syndrome initially diagnosed with Neurofibromatosis-Noonan syndrome. However, after a few years of clinical and ophthalmological follow-up, the absence of typical features of Neurofibromatosis type 1 and the lack of NF1 mutation led us to reconsider the original diagnosis. A new examination of the patient and his similarly affected father, who was initially referred as healthy, led us to suspect LEOPARD syndrome, The diagnosis was then confirmed by the occurrence in both patients of a heterozygous mutation c.1403 C > T, p.(Thr468Met), of PTPN11. Subsequently, the proband was also found to have type-1 Arnold-Chiari malformation in association with syringomyelia.

Conclusion

Our experience suggests that differential clinical diagnosis among RASopathies remains ambiguous and raises doubts on the current diagnostic clinical criteria. In some cases, genetic tests represent the only conclusive proof for a correct diagnosis and, consequently, for establishing individual prognosis and providing adequate follow-up. Thus, molecular testing represents an essential tool in differential diagnosis of RASophaties. This view is further strengthened by the increasing accessibility of new sequencing techniques.

Finally, to our knowledge, the described case represents the third report of the occurrence of Arnold Chiari malformation and the second description of syringomyelia with LEOPARD syndrome.

Keywords:
LEOPARD syndrome; Neurofibromatosis type 1; RASopathy; PTPN11