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At a glance

Genetically transmitted polymalformative syndrome characterized by the association of ocular problems with renal dysfunction and mental retardation.

Synonyms

Lowe Oculocerebrorenal Syndrome; Oculocerebrorenal Syndrome; Lowe-Terrey-MacLachlan Syndrome; OCRL I.

Incidence

The prevalence is estimated between 1 and 10 males per 1,000,000 people. This condition has been reported in North and South America, Europe, Japan, and India. It occurs almost exclusively in males.

Genetic inheritance

X-linked disorder (Xq26.1). However, a few cases have been reported in females.

Pathophysiology

Lack of the enzyme phosphatidylinositol 4,5-biphosphate 5-phosphatase, which is located in the Golgi apparatus and controls the intracellular level of phosphatidylinositol 4,5-biphosphate. This enzyme deficiency may impair normal intracellular protein sorting (including second messengers), especially within polarized cells, and could be responsible for the observed ocular, renal, and cerebral abnormalities.

Diagnosis

Cataracts associated with renal tubular acidosis. In the blood, hypophosphatemia and elevated α2-globulin help confirm the diagnosis. Creatine kinase is sometimes increased. A deficiency in Phosphatidylinositol 4,5-Bisphosphate 5-Phosphatase is reported.

Clinical aspects

There are three different clinical presentations based on the age of onset of the disease:

  • Infancy: Neonatal cataracts (100%), glaucoma, megacornea, enophthalmos, and nystagmus caused by poor vision. The problems caused by renal tubular acidosis appear during the first year. Approximately 50% of patients experience seizures.

  • Childhood: Renal tubular acidosis, aminoaciduria, proteinuria (Fanconi Syndrome); failure to thrive; vitamin D-resistant rickets; corneal scarring.

  • Late Childhood: Progressive renal failure.

Patients have typical facies characterized by large forehead sunken eyes, large, poorly shaped ears, and sometimes retrognathism. They have mild-to-moderate mental retardation with major hypotonia and behavioral problems (stereotypical behavior); cryptorchidism is common.

Precautions before anesthesia

Check serum electrolytes, acid-base status, calcium and phosphate levels, and renal function. Some patients receive chronic oral bicarbonate therapy; treatment for glaucoma usually involves eye drops of a beta-blocking agent. Check intraocular pressure and presence of retrognathism.

Anesthetic considerations

Retrognathism may make direct laryngoscopy and tracheal intubation difficult. Careful titration of perioperative IV fluids must be used to prevent hyperhydration or dehydration. Ophthalmic beta blockade may lead to some systemic effects following local resorption.

Pharmacological implications

Related to the medical treatment of glaucoma (topical beta blockers) and to the extent of renal insufficiency or failure. Avoid succinylcholine in the presence of glaucoma.

Other condition to be considered

  • Congenital Cataracts and Fanconi Syndrome: Characterized by alteration of renal tubular function resulting in severe rickets, hypokalemia, acidosis, and severe growth failure; several diseases (usually autosomal recessive) are associated with Fanconi Syndrome, including cystinosis, glycogenosis, galactosemia, and tyrosinemia.

References

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