Pretzel Syndrome

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Kalsang Dolma, M.B.B.S.[2]

Overview

Pretzel syndrome is a rare disorder characterized by skeletal deformity, malformation of the brain (with accompanying seizures), electrolyte imbalances, and variable malformations of the heart and other organs.

Historical Perspective

Pretzel syndrome, is named so by the families for the characteristic body posture adopted by many affected children.

Pathophysiology

Genetics

It is a single gene disorder but it is complex in its mechanics.The defective gene is called LYK5. It has a complicated function that is only partly understood. The LYK5 gene product is part of a chemical “relay” or “messaging” system that controls the growth and function of many cells in the body.

In Pretzel syndrome, part of the LYK5 gene is missing, which leads to a complete loss of this signaling function. The LYK5 gene has an important role in normal organ development. Defective organ development that begins during the earliest stages of pregnancy is not treatable and leads to a variety of medical problems throughout life.

Diagnosis

Symptoms

• In affected children studied, the first signs of Pretzel syndrome began during gestation: 80% of mothers had polyhydramnios, extra amniotic fluid around the affected baby.
• All mothers also had preterm labor starting anywhere from 25-38 weeks gestation. The brain was large and malformed in all affected children.
• The nerve cells were not positioned properly and probably did not make normal connections with other nerve cells. As a result,seizures began early in life and were often difficult to treat.
• Mental development was severely delayed.
• In 20-30% of affected children, there was a buildup of calcium deposits in the kidneys, which then lost the ability to conserve water for the body. This condition, called diabetes insipidus, causes children to urinate frequently.

Physical Examination

Eyes

• Like other muscles of the body, those that controlled the eyes were also weak, and about 40% of affected children had strabismus or “lazy eye.”

Heart

Anatomical defect in heart typically does not cause symptoms of heart failure early in life, but can become problematic later in childhood.

Extremities

• The muscles were thin and weaker than normal. The combination of low muscle tone and abnormal connective tissue resulted in very flexible joints and allowed children to twist themselves into unusual “pretzel-like” postures.

MRI

• MRI studies showed extra fluid around the brain, or “hydrocephalus.”

Treatment

Although the organ defects caused by LYK5 deficiency can not be prevented or reversed, Pretzel syndrome can nonetheless be treated by recognizing problems such as seizures, strabismus, diabetes insipidus, and heart defects, and treating these problems appropriately to optimize the health and well-being of the child.

• Children with strabismus should be treated by a pediatric eye doctor to prevent permanent loss of vision.
• Children with diabetes insipidus should be allowed to drink freely to prevent severe dehydration.

See Also

• Single gene disorders
• List of genetic disorders
• medical genetics