Iran J Pediatr Case Report Mar 2010; Vol 20 (No 1), Pp:101-106 Premature Loss of Permanent Teeth in Allgrove (4A) Syndrome in Two Related Families Zahra Razavi*1, MD; Mohammad­Mehdi Taghdiri¹, MD; Fatemeh Eghbalian¹, MD; Nooshin Bazzazi², MD 1. Department of Pediatrics, Hamadan University of Medical Sciences, IR Iran 2. Department of Ophthalmology, Hamadan University of Medical Sciences, IR Iran Received: Feb 07, 2009; Final Revision: Apr 27, 2009; Accepted: May 06, 2009 Abstract Background: Allgrove syndrome is a rare autosomal recessive condition characterized by adrenal insufficiency, achalasia, alacrima and occasionally autonomic disturbances. Mutations in the AAAS gene, on chromosome 12q13 have been implicated as a cause of this disorder. Case(s) Presentation: We present various manifestations of this syndrome in two related families each with two affected siblings in which several members had symptoms including reduced tear production, mild developmental delay, achalasia, neurological disturbances and also premature loss of permanent teeth in two of them, Conclusion: The importance of this report is dental involvement (loss of permanent teeth) in Allgrove syndrome that has not been reported in literature. Iranian Journal of Pediatrics, Volume 20 (Number 1), March 2010, Pages: 101­106 Key Words: Achalasia, Adrenocortical Insufficiency, Alacrimia (Allgrove, triple‐A) Protein, Human; AAAS Protein, Human; Teeth; Allgrove Syndrome; Triple A Syndrome Protein, Human Introduction autonomic disturbances associated with Allgrove syndrome leading one author to In 1978 Allgrove and colleagues described 2 recommend the name 4A syndrome (adreno‐ unrelated pairs of siblings with achalasia and cortical insufficiency, achalasia of cardia, ACTH insensivity, three had impaired alacrima and autonomic abnormalities)[2‐4]. lacrimation and one also had autonomic There is significant variability in the clinical dysfunction. This triad (achalasia, adrenal presentation [5]. insufficiency and alacrima) became known as Additional features included hyper‐reflexia, Ttriple A Syndrome [1]. muscle weakness and nasal speech. Incidence is During the following years several reports in the unknown and only few numbers of families and literature have focused on more global case reports exist in literature. Inheritance is * Corresponding Author; Address: Be’ssat Hospital, Hamadan, IR Iran E-mail: [email protected] © 2010 by Pediatrics Center of Excellence, Children’s Medical Center, Tehran University of Medical Sciences, All rights reserved. 102 Allgrove Syndrome in 2 Related Families; Z Razavi, et al autosomal recessive and most patients have poor school performance and learning consanguineous parents [6], but autosomal difficulties. There was loosening of permanent dominant forms with incomplete penetrance teeth when she was l0 years old, and became have also been reported [7,8]. Parental near totally edentulous by the age of 13 years. consanguinity and previously affected siblings She was also suffering from muscular wasting are the primary risk factors. and weakness. Her sister had achalasia and Mutations in the AAAS gene, which encodes hearing deficits. the product aladin, on chromosome 12q13 have On physical examination she was found to be been implicated as a cause of this disorder. This of short stature and delayed in response. Blood gene belongs to WD‐repeat regulatory protein pressure was normal without orthostatic family which exhibits wide functional diversity. hypotension, weight 25 kg (Z score ‐3 SD), height The encoded protein, aladin, may help regulate 132 cm (Z score ‐4 SD) according to NCHS nucleo‐cytoplasmic transport of other proteins. growth chart. Pubertal stage: breast SMR (sex High expression of this protein is seen in the maturity rating) 1 and pubic hair SMR 2 adrenal gland, brain and gastrointestinal tract, according to Tanner's staging system. the organs in which the main pathologic She had a distinct facial appearance consisting manifestations of disease occur[9‐14]. Some of narrow upper lip and down–turned mouth authors believed that the pathology of this with nasal speech. The patient was near totally condition may be due to a progressive loss of edentulous. There was distal wasting in the cholinergic function throughout the body [8,15]. arms, lower limb, and significant weakness of Age at onset of symptoms is variable but the legs. patients usually present during the first decade Her past hospital records ‐ before treatment of life with hypoglycemia, adrenal crisis or with prednisolone– showed normal thyroid dysphagia. Achalasia or alacrima may precede function tests and routine biochemical and adrenal insufficiency. Adult patients with 4A hematological tests. Serum glucose was low (30 syndrome may present with multisystem mg/dL). Serum cortisol was 1.5 µg/dL (normal neurological disease [4]. range 5‐20) before, 3 µg/dL 30 minutes and 2 This article reports two pairs of siblings in µg/dL 4 hours after intramuscular injection of two related families with broad clinical features 250 µg long acting ACTH. (Normal response: of the syndrome with particular attention to peak plasma cortisol level greater than 19 premature loss of permanent teeth in two µg/dL). siblings. Ophthalmologic evaluation and Schirmer test revealed alacrima. Barium esophago‐gram did not demonstrate achalasia. The clinical finding was typical for Allgrove syndrome. Case(s) Presentation Case 2: This 15‐year‐old girl was second sibling Family 1 of case 1 who was born of consanguineous Case 1: A 13 year‐old girl with unremarkable parents. She first presented with vomiting and birth history was referred to our endocrinology difficulty in swallowing at age 5 and clinic for further follow up. She was diagnosed subsequently underwent esophageal dilatations with familial gluococorticoid insufficiency at age for achalasia. 4 after a hypoglycemic seizure with low cortisol She lost her teeth prematurely one by one at and elevated ACTH level and was discharged on age 13. She also was noted to have learning oral prednisolone. Her parents were cousins and difficulties, poor school performance and she was born at term. hearing deficit. Review of systems was positive for crying On examination she was mentally disabled without tears from early infancy and darkening and had dysmorphic facial features with nasal of skin at age 4. By age 7 she was felt to have speech. She was partially edentulous. Blood Iran J Pediatr, Vol 20 (No 1); Mar 2010 103 pressure, weight and height were normal. Breast Based on these findings, Allgrove syndrome and pubic hair were in SMR 2. Additional diagnosis was established. findings were muscular wasting, weakness and alacrima. Case 4: This 10‐year‐old patient is older sister Bilateral hearing loss was confirmed by of case 3 and was born with unremarkable birth hearing evaluation. Routine biochemical, history. She was evaluated because of reduced hematological and serum cortisol level before tear production and positive history of Allgrove and after ACTH stimulation test were normal. syndrome in her brother. At age 2 she was noted Neither of the two patients had significant to have prominent neuro‐developmental delay dental caries or periodontal disease, we did not (delay in sitting, walking and speech). She had find abnormal results in clinical and laboratory not attended school normally because of investigations for their teeth loss. learning difficulties. Achalasia and alacrima were valuable clues to On examination she was normal for weight, speculate that she had Allgrove syndrome. height and blood pressure without orthostatic changes. Clinical findings included distinct facial Family 2 appearance characteristic of Allgrove syndrome, Case 3: A 6‐year old boy born to consanguineous nasal voice, dysarthria, mental retardation, parents (cousin to cases 1 and 2) was referred to ataxia (tandem gait and finger‐to‐nose testing our clinic with darkening of skin, developmental was disturbed). Slit lamp examination and delay and photophobia. Hyperpigmentation over ophtalmoscopy were normal, but Schirmer's test the knuckles of the hands and feet had typically showed alacrima. Barium developed gradually over the last 12 months. esophagogram did not show dilated esophagus. The patient's past medical history was Biochemical, hormonal and hematological significant for esophageal surgery and screening were negative except for low cortisol cardiomyotomy for achalasia manifested by and blood sugar and high ACTH (serum glucose recurrent vomiting. 40 mg/dL, serum cortisol 3.4 µg/dL, 4 µg/dL, On physical examination long thin face with and 2.4 µg/dL, immediately before, 30 minutes long philtrum, narrow upper lip characteristic of and 4 hours after intramuscular injection of 250 Allgrove syndrome was observed. He was µg long acting ACTH, respectively). ACTH level mentally disabled. The weight was 16.5 kg (Z was 60 pg/ml. In the light of these findings a score ‐2.5 standard deviation) and the height diagnosis of Allgrove syndrome was considered. was 103 cm (Z score ‐3 standard deviation). Clinical findings in patients are summarized in Neurologic findings consisted of dysarthria, and table 1. mild gait disturbance. Heart rate was 90/min and blood pressure 100/60 mmHg in supine position, but he had marked postural fall in both. (60/min and 70/40 in upright position, respectively). Schirmer's test revealed right eye Discussion 4 mm and left eye 2 mm of wetting (alacrima was confirmed). When adrenal insufficiency is seen in Serum Na, K, aldosterone, renin,