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__NOTOC__ | __NOTOC__ | ||
{{Noonan syndrome}} | {{Noonan syndrome}} | ||
{{CMG}}; {{AE}} Serge Korjian | {{CMG}}; {{AE}} [[User:Sergekorjian|Serge Korjian]], [[User:YazanDaaboul|Yazan Daaboul]] | ||
==Overview== | ==Overview== | ||
A careful physical exam at diagnosis would often reveal many of the manifestations of Noonan syndrome although variable presentations are typically seen. Findings may include a cardiac murmur, signs of heart failure, typical facial features, skin abnormalities, short stature, cryptorchidism, ans skeletal abnormalities among others. | |||
==Physical Examination== | ==Physical Examination== | ||
''The most important part of the diagnosis of Noonan syndrome is a careful physical exam. Although patients often do not manifest all the features of the disorder, certain physical exam findings can orient towards the diagnosis:'' | ''The most important part of the diagnosis of Noonan syndrome is a careful physical exam. Although patients often do not manifest all the features of the disorder, certain physical exam findings can orient towards the diagnosis:''<ref name="pmid22973420">{{cite journal| author=| title=Erratum. | journal=Therap Adv Gastroenterol | year= 2012 | volume= 5 | issue= 5 | pages= 371 | pmid=22973420 | doi=10.1177/1756283X10363751 | pmc=PMC3437532 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22973420 }} </ref><ref name="pmid3895929">{{cite journal| author=Mendez HM, Opitz JM| title=Noonan syndrome: a review. | journal=Am J Med Genet | year= 1985 | volume= 21 | issue= 3 | pages= 493-506 | pmid=3895929 | doi=10.1002/ajmg.1320210312 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3895929 }} </ref><ref name="doi10.1007/BF00441408">{{cite journal| author=Ranke MB, | ||
Heidemann P, Knupfer C, Enders H, Schmaltz AA, Bierich JA| title=Noonan syndrome: growth and clinical manifestations in 144 cases| journal=Eur J Ped | year= 1988 | volume= 148 | issue= 3 | pages= 220-7 | pmid= | doi=10.1007/BF00441408 | pmc= | url=http://link.springer.com/article/10.1007/BF00441408 }} </ref><ref name="pmid23312968">{{cite journal| author=Roberts AE, Allanson JE, Tartaglia M, Gelb BD| title=Noonan syndrome. | journal=Lancet | year= 2013 | volume= 381 | issue= 9863 | pages= 333-42 | pmid=23312968 | doi=10.1016/S0140-6736(12)61023-X | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23312968 }} </ref> | |||
* '''Cardiac auscultation''' can often detect signs of congenital or acquired heart disease in Noonan syndrome patients. The most common murmur is that of pulmonary stenosis, a harsh crescendo-decrescendo systolic ejection murmur hear best in the pulmonic area (the second intercostal space along the left sternal border). Significant splitting of S2 can also be heard that can be secondary to the RV outflow tract obstruction or and underlying ASD. Another possible finding is a systolic ejection murmur at the aortic site without radiation to the carotids that decreases with squatting or handgrip maneuvers signifying the possible presence of hypertrophic cardiomyopathy. | * '''Cardiac auscultation''' can often detect signs of congenital or acquired heart disease in Noonan syndrome patients. The most common murmur is that of pulmonary stenosis, a harsh crescendo-decrescendo systolic ejection murmur hear best in the pulmonic area (the second intercostal space along the left sternal border). Significant splitting of S2 can also be heard that can be secondary to the RV outflow tract obstruction or and underlying ASD. Another possible finding is a systolic ejection murmur at the aortic site without radiation to the carotids that decreases with squatting or handgrip maneuvers signifying the possible presence of hypertrophic cardiomyopathy. | ||
* Assessment of '''auditory acuity''' is important since some form of loss of hearing can be seen in some patients (10% have low frequency deficits, 25% have high frequency deficits) | |||
* '''Signs of heart failure''' including pulmonary congestion, increased JVD, and edema should be noted. | |||
* '''Facial features''' are notable for large head with tall and prominent forehead, hypertelorism, downslanting palpebral fissures, and wide and depressed nasal root. | |||
* '''Skin abnormalities''' including multiple pigmented nevi, café au lait spots, keratosis pilaris of upper arms and face and lentigines can be seen although not very common. | |||
* Signs of '''lymphatic obstruction''' are very common especially neck webbing with prominence of the trapezius. | |||
* '''Short stature''' is common in Noonan syndrome especially during puberty since pubertal growth is usually delayed. However, adult height can often be normal. | |||
* '''Delayed onset of puberty''' can be seen in some patients with at least one third entering pubertal age after 13. | |||
* Assessment for '''cryptorchidism''' is important since at least 80% of males have unilateral or bilateral cryptorchidism. | |||
* '''Signs of thrombocytopenia or coagulation defects''' can be seen in about half of the patients presenting with easy bruising or bleeding. | |||
* '''Peripheral lymphedema''' can be seen in 20% of patients. | |||
* '''Skeletal abnormalities''' are detectable in many patients with Noonan syndrome particularly spiny deformities and chest deformities like pectus carinatum and pectus excavatum usually also associated with widely spaced nipples. | |||
* '''Ocular findings''' are found in 95% of patients including ptosis, strabismus, amblyopia, nystagmus, refractive errors, and cataracts. | |||
==References== | ==References== | ||
Latest revision as of 02:17, 15 November 2013
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Serge Korjian, Yazan Daaboul
Overview
A careful physical exam at diagnosis would often reveal many of the manifestations of Noonan syndrome although variable presentations are typically seen. Findings may include a cardiac murmur, signs of heart failure, typical facial features, skin abnormalities, short stature, cryptorchidism, ans skeletal abnormalities among others.
Physical Examination
The most important part of the diagnosis of Noonan syndrome is a careful physical exam. Although patients often do not manifest all the features of the disorder, certain physical exam findings can orient towards the diagnosis:[1][2][3][4]
- Cardiac auscultation can often detect signs of congenital or acquired heart disease in Noonan syndrome patients. The most common murmur is that of pulmonary stenosis, a harsh crescendo-decrescendo systolic ejection murmur hear best in the pulmonic area (the second intercostal space along the left sternal border). Significant splitting of S2 can also be heard that can be secondary to the RV outflow tract obstruction or and underlying ASD. Another possible finding is a systolic ejection murmur at the aortic site without radiation to the carotids that decreases with squatting or handgrip maneuvers signifying the possible presence of hypertrophic cardiomyopathy.
- Assessment of auditory acuity is important since some form of loss of hearing can be seen in some patients (10% have low frequency deficits, 25% have high frequency deficits)
- Signs of heart failure including pulmonary congestion, increased JVD, and edema should be noted.
- Facial features are notable for large head with tall and prominent forehead, hypertelorism, downslanting palpebral fissures, and wide and depressed nasal root.
- Skin abnormalities including multiple pigmented nevi, café au lait spots, keratosis pilaris of upper arms and face and lentigines can be seen although not very common.
- Signs of lymphatic obstruction are very common especially neck webbing with prominence of the trapezius.
- Short stature is common in Noonan syndrome especially during puberty since pubertal growth is usually delayed. However, adult height can often be normal.
- Delayed onset of puberty can be seen in some patients with at least one third entering pubertal age after 13.
- Assessment for cryptorchidism is important since at least 80% of males have unilateral or bilateral cryptorchidism.
- Signs of thrombocytopenia or coagulation defects can be seen in about half of the patients presenting with easy bruising or bleeding.
- Peripheral lymphedema can be seen in 20% of patients.
- Skeletal abnormalities are detectable in many patients with Noonan syndrome particularly spiny deformities and chest deformities like pectus carinatum and pectus excavatum usually also associated with widely spaced nipples.
- Ocular findings are found in 95% of patients including ptosis, strabismus, amblyopia, nystagmus, refractive errors, and cataracts.
References
- ↑ "Erratum". Therap Adv Gastroenterol. 5 (5): 371. 2012. doi:10.1177/1756283X10363751. PMC 3437532. PMID 22973420.
- ↑ Mendez HM, Opitz JM (1985). "Noonan syndrome: a review". Am J Med Genet. 21 (3): 493–506. doi:10.1002/ajmg.1320210312. PMID 3895929.
- ↑ Ranke MB,
Heidemann P, Knupfer C, Enders H, Schmaltz AA, Bierich JA (1988). "Noonan syndrome: growth and clinical manifestations in 144 cases". Eur J Ped. 148 (3): 220–7. doi:10.1007/BF00441408. line feed character in
|author=at position 10 (help) - ↑ Roberts AE, Allanson JE, Tartaglia M, Gelb BD (2013). "Noonan syndrome". Lancet. 381 (9863): 333–42. doi:10.1016/S0140-6736(12)61023-X. PMID 23312968.
Template:Phakomatoses and other congenital malformations not elsewhere classified