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At a glance

An extremely rare genetic disorder characterized by severe insulin resistance and craniofacial anomalies, abnormalities of the teeth and nails, and acanthosis nigricans (hyperpigmentation and hyperkeratosis), particularly of the neck, groin, and underarms.

Synonym

Mendenhall Syndrome.

History

In 1956, S. M. Rabson and E. N. Mendenhall described this familial syndrome comprising insulin-resistant diabetes, pineal hyperplasia, and various somatic anomalies.

Incidence

Less than 1/1,000,000, usually consanguineous.

Genetic inheritance

Autosomal recessive.

Pathophysiology

The causative mutation(s) reside in the insulin receptor gene INSR, gene locus 19p13.2 with the defect between synthesis of the receptor precursor and insertion of it into the membrane. The severely impaired insulin-binding capacity results in highly insulin-resistant diabetes mellitus.

Diagnosis

Dental and skin abnormalities (acanthosis nigricans, truncal hypertrichosis, malpositioned teeth), short stature, coarse facial features with prognathism, abdominal distension, and phallic enlargement. It is highly insulin-resistant diabetes mellitus. The pineal body is hyperplastic. Studies of melatonin state show raised melatonin metabolite excretion in the urine, as might be expected with disordered pineal function.

Clinical aspects

Somatic anomalies present at birth. Diabetes manifests during childhood or adolescence and may result in ketoacidosis and intercurrent infections. Patients present with early dentition, a coarse, senile-appearing facies, and striking hirsutism. Mortality from ketoacidotic coma has been reported. Acanthosis usually decreases in intensity and extent over time. Hypophysectomy has been of short-term benefit, but the problems of insulin resistance persist.

Precautions before anesthesia

Optimization of blood sugar control via tight monitoring and institution of appropriate insulin therapy. An appropriate assessment and management of coexisting disease is mandatory. Investigations: blood sugar levels, electrolytes, CBC, ECG, chest radiograph. Other investigations will be necessary to evaluate various end-organ functions and should be ordered as directed by clinical findings.

Anesthetic considerations

Regional techniques, where appropriate, are preferable to general anesthesia, because they usually allow an earlier return to a normal feeding pattern. The stress response to surgery may also be partially obtunded.

Pharmacological implications

There are no known specific implications for this condition.

Other condition to be considered

  • Donohue Syndrome: Very rare autosomal recessive disorder associated with a fatal congenital form of dwarfism (Leprechaunism) with features of intrauterine and postnatal growth retardation, exaggerated hyperglycemia with hyperinsulinism, and dysmorphic abnormalities. Cardiac disease develops early in life, with progressive hypertrophic cardiomyopathy representing an increase of cardiovascular events during anesthesia.

References

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Hirsch  IB, McGill  JB, Cryer  PE  et al: Perioperative management of surgical patient with diabetes mellitus. Anesthesiology 74:346, 1991.  [PubMed: 1990909]
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Kirkwood ...

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