Continuing Education Activity

Cri du chat syndrome is a genetic disorder caused by a deletion of the short arm of chromosome 5. The name of the syndrome means the cry of the cat and describes the main clinical finding of a high-pitched, monochromatic cat-like cry. The clinical picture, severity, and progression of the disease vary depending on the region of the chromosome that is deleted. This disorder is often characterized by distinctive facial features, delayed development, and intellectual disability. This activity illustrates the presentation, evaluation, and management strategies for Cri du chat syndrome and highlights the interprofessional team's role in the care of affected patients.

Objectives:

• Describe the presentation of a patient with cri du chat syndrome.
• Identify the cause of cri du chat syndrome.
• Outline the treatment options for cri du chat syndrome.
• Summarize the importance of improving coordination amongst interprofessional team members to enhance outcomes for patients affected by cri du chat syndrome.

Introduction

Cri-du-chat is a genetic disorder that is caused by a deletion of the short arm of chromosome 5. The name of the syndrome, meaning cat cry, was coined after the main clinical finding of a high-pitched, monochromatic cat-like cry. The clinical picture, severity, and progression of the disease vary depending on the region of the chromosome deleted and whether it is terminal or interstitial. In other words, differences in phenotype are attributable to the differences in genotype. This disorder characteristically presents with distinctive facial features, delayed development, and intellectual disability.[1][2]

Etiology

Cri-du chat results from either a partial or complete deletion of chromosome 5p. Most of the deletions occur de novo. The deletions occur as random events during the formation of reproductive cells in early fetal development. Around 80% to 90% are paternal in origin, which can arise from a chromosomal breakage during gamete formation. The remaining 10% to 15% result from unbalanced parental translocation. Moreover, 80% to 90% of cases result from terminal deletions of chromosome 5, while 3% to 5% are due to an interstitial deletion. Mosaicism, inversions, and ring chromosomes are less common mechanisms.[2]

Epidemiology

Although Cri du chat is considered a rare disorder, it is one of the most common chromosomal anomalies. The incidence ranges from 1 in 15,000 to 1 in 50,000 liveborn infants. The incidence in females is slightly higher than in males. The exact incidence and prevalence worldwide and among races has not been established. Similarly, specific risk factors associated with prenatal events or parental age have are not clear. However, there are occasional reports of parental exposure to radiation, hyperemesis, anorexia, and toxemia.[3]

Pathophysiology

Patients demonstrate phenotypic and genotypic variability. Research has revealed that partial deletion of the short arm of chromosome 5 to be the cause of the characteristic phenotype. The phenotype being identifiable despite the fact that variations in deletion size have led to a theory that a critical region is responsible for the characteristic feature in hemizygosity. The region identified is 5p15.2, and individuals with a deletion of chromosome 5 that does not include this region do not show a typical phenotype and, in some cases, are even normal.

Cytogenetic studies have helped identify two regions, 5p15.3, which is responsible for the characteristic cry, and 5p15.2, which is responsible for the other significant clinical findings. Similarly, other areas have been identified for additional features such as speech retardation and dysmorphism. Therefore, clinical manifestations depend on the deletion of the critical area. Another crucial factor in the manifestation is the size as well as the type of deletion and whether it is interstitial or terminal.

The most characteristic feature of this disease is high-pitched crying, and the pathogenesis is attributable to the anatomical alteration of the laryngeal morphology, which may be a result of:

• A small, floppy epiglottis
• Hypoplasia of the larynx
• A narrow or diamond-shaped larynx
• Abnormal airspace in the posterior area during phonation

However, not all patients with abnormal crying have the above features. Therefore, there may be neurological changes as well.[3]

History and Physical

Neonatal Period

In the neonatal period, the most characteristic finding is a high-pitched, monotonous cry, which usually disappears within the first few months of life. The cry is not limited to this syndrome alone and is known to accompany a few other neurological disorders. Newborns also exhibit low birthweight and microcephaly as well as asphyxia, muscle hypotonia, and impaired suction. These lead to impaired growth and development during the first few years of life. Reports exist of recurrent respiratory and intestinal infections.[3]

General Characteristics

(a) Craniofacial Malformations

• Microcephaly
• Moon face
• Hypertelorism
• Prominent epicanthic folds
• Large nasal bridge
• Downturned corners of the mouth
• Short philtrum
• Premature gray hair
• Abnormal transverse flexion creases

 Uncommonly:

• Downward slanting palpebral fissures
• Low-set ears
• Narrow auditory ducts
• Preauricular tags
• Deafness
• Myopia and cataracts
• Hypersensitivity of pupils to methacholine
• Hypospadias and cryptorchidism

With increasing age, the following features change:

• Hypotonia in the neonatal period is replaced with hypertonia
• Prominent microcephaly
• Prominent supraorbital arch
• Dental malocclusions
• Moon face changes into a more narrow vertical face in adulthood

(b) Other Anomalies That Might Be Present

• Hypersensitivity to sound
• Cardiac disorders, including congenital heart defects
• Cutaneous hemangioma
• Renal pathology

(c) Orofacial Abnormalities

• High palate
• Mandibular microretrognathia
• Hypoplasia of the enamel
• Chronic periodontitis

(d) Developmental and Behavioral Manifestations

• Hyperactivity
• Self-injurious behavior
• Repetitive movements
• Gentle personality
• Obsessive attachment to objects
• Comprehension of speech is better than their ability to express or communicate[2]

Evaluation

Antenatally 

Cri du chat is diagnosable via amniocentesis during the antenatal period, where the deletion of chromosome 5 will be visible. The structural abnormalities are observable sonographically. Also, fetuses who show mosaicism may display fetoplacental and feto-amniotic chromosomal abnormalities along with microcephaly and cerebellar hypoplasia.[3][4][5][6]

Postnatally

A diagnosis can be made based on clinical findings. The occurrence of specific characteristic findings such as microcephaly, low birth weight, moon face, muscle hypotonia, and a cat-like cry together should raise clinical suspicion of the condition. Sometimes this can be difficult because the features may not be obvious as patients show a cytogenetic variation leading to phenotypic variation. The clinical features, as well as the severity and prognosis, can be determined by the size and position of the deletion.

If clinical suspicion is present, one of the first tests that can confirm the diagnosis is a karyotype analysis. However, in cases where the clinical suspicion is high in the presence of a normal karyotype, further specific tests can be carried out, such as FISH, CGH (comparative genomic hybridization), or quantitative PCR (polymerase chain reaction).

FISH has led to an improvement in the diagnosis of genetic disorders caused by chromosome deletion and has provided a phenotypic map and the associated genome of an individual. Newer techniques, such as CGH, have opened up new doors by including the whole genome and the associated markers, which can identify genetic alterations.

There have been very few studies on the MRI findings. However, pontine hypoplasia seems to be the most common feature. This presentation is associated with other findings such as cerebellar hypoplasia and microcephaly, as well as corpus callosum anomalies. Supratentorial abnormalities also have been observed.[2][7]

Treatment / Management

There is no specific treatment for patients due to the early onset of cerebral damage during embryonal development. However, patients benefit from rehabilitation, especially with early intervention. This approach has demonstrated to improve prognosis as well as social adaptation.

During the neonatal period, physical therapy should be started in the first week of life to help with any difficulty in swallowing and suction. Breastfeeding is still possible, and intensive care is rarely necessary.[8][1][9]

Physical therapy, psychomotricity, and speech therapy are suggested interventions for psychomotor and speech retardation. Patients often have sensorineural deafness; therefore, audiometric examinations should take place in all children. Other helpful treatments include surgery, a special diet, and healthy routines.

Families should be involved in the care of the patient. They should receive information about the disease and available support groups.

Genetic counseling services should be offered for subsequent pregnancies.[3][10]

Differential Diagnosis

The differential diagnosis of cri du chat syndrome include the following:

• Multiple congenital anomalies
• Other autosomal monosomy or trisomy syndromes
• Mental retardation syndromes
• Patau syndrome
• Wolf-Hirschhorn syndrome

Prognosis

Morbidity and mortality rates decrease after the first few years of life. Reportedly 75% of deaths occur during the first month of life, and about 90% of deaths occur during the first year. It is important to note that the type, size, and location of the deletion(s) significantly influence the prognosis.

One of the most important factors in the prognosis of the disease is an early diagnosis. Early diagnosis allows for the implementation of therapeutic measures early on to improve the outcome of physical as well as psychomotor development and helps with social adaptation.[2]

Complications

Cri du chat syndrome is a chromosomal deletion caused by the partial deletion of the p arm of chromosome 5. Complicated may include the following:

• Heart or other organ defects
• Scoliosis
• Poor muscle tone
• Hearing or visual difficulties
• Intellectual disabilities

Deterrence and Patient Education

Apart from the patients, the families of affected individuals have to deal with increased stress due to the patient's maladaptive behavior. The patients and families require support from healthcare providers, other families, and friends. Families should be educated on the latest information regarding the syndrome and provided with the necessary resources.

Pearls and Other Issues

• Cri-du-chat is a rare genetic disorder caused by the deletion of the short arm of chromosome 5.
• Differences in phenotype are attributable to differences in genotype, which also plays a role in the severity and prognosis.
• The most characteristic finding is a high-pitched, monotonous cry. Other features include microcephaly, low birth weight, hypotonia, psychomotor retardation, and craniofacial malformations.
• A clinical diagnosis is possible. However, a karyotype analysis can confirm the diagnosis if clinical suspicion is high.
• In the presence of a normal karyotype, and if the clinical suspicion is high, more specific cytogenetic studies can be carried out, such as FISH or CGH.
• Management revolves around physical therapy and rehabilitation programs as early as possible that will improve prognosis and social adaptation.
• Morbidity and mortality are the highest in the first few years of life. Ninety percent of deaths occur in the first year.

Enhancing Healthcare Team Outcomes

Cri du chat is managed by an interprofessional team that includes nurses, therapists, social workers, and dietitians. There is no specific treatment for patients due to the early onset of cerebral damage during embryonal development. However, patients benefit from rehabilitation, but results are better the earlier it starts. This approach to treatment improves prognosis as well as social adaptation. During the neonatal period, physical therapy should be started in the first week of life to help with any difficulty in swallowing and suction. Breastfeeding is still possible, and intensive care is rarely necessary.[8][1][9]