Andersen–Tawil syndrome

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Andersen–Tawil syndrome
SynonymsCardiodysrhythmic potassium-sensitive periodic paralysis, Long QT syndrome type 7
SinusRhythmLabels.svg
This condition affects the QT interval(in blue)
SpecialtyCardiology
SymptomsAbnormal heart rhythms, periodic paralysis, characteristic physical features
ComplicationsSudden death
Usual onsetBirth
DurationLifelong
TypesType 1 (KCNQ2 mutation positive), Type 2 (Genetic mutation not identified)
CausesGenetic
Diagnostic methodClinical, genetic testing
Differential diagnosisRomano-Ward syndrome, Jervell and Lange-Nielsen syndrome, Timothy syndrome
TreatmentMedication, implantable cardioverter-defibrillator
MedicationFlecainide, beta-blockers, acetazolamide
Frequency1:1,000,000

Andersen–Tawil syndrome, also called Andersen syndrome and Long QT syndrome 7, is a rare genetic disorder affecting several parts of the body. The condition is associated with a disturbance of the electrical function of the heart, characterised by a feature of an electrocardiogram known as a long QT interval. This abnormality increases the risk of experiencing abnormal heart rhythms. Unlike those with other forms of Long QT syndrome, those with Andersen-Tawil syndrome often have characteristic physical features including low-set ears and a small lower jaw, and may experience intermittent periods of muscle weakness known as hypokalaemic periodic paralysis.[1]

Andersen–Tawil syndrome is inherited in an autosomal dominant pattern. It is caused in most cases by a mutation in the KCNJ2 gene which encodes an ion channel that transports potassium out of cardiac muscle cells. The arrhythmias seen in the condition can be treated with flecainide or beta-blockers, but an implantable defibrillator may sometimes be required. Periodic paralysis can be treated with carbonic anhydrase inhibitors such as acetazolamide. The condition is very rare and is estimated to affect one person in every million. The triad of features seen in this condition were first described in 1971 by Ellen Andersen, and significant contributions to its understanding were made by Rabi Tawil.

Signs and symptoms[edit]

Andersen-Tawil Syndrome classically comprises three groups of features: abnormal electrical function of the heart, hypokalemic periodic paralysis, and characteristic physical features, although some of those affected will not exhibit all aspects of the condition.[2]

Anderson-Tawil syndrome affects the heart by prolonging the QT interval, a measure of how long it takes the heart to relax after each heart beat. This, as in other forms of long QT syndrome, can lead to abnormal heart rhythms such as ventricular ectopy or ventricular tachycardia causing palpitations. [2] The ventricular tachycardia seen in Anderson-Tawil syndrome often takes a form known as bidirectional ventricular tachycardia. The arrhythmias seen in association with the condition can cause sudden cardiac death, but the risk of this is lower than in other forms of Long QT syndrome. [1]

Clinodactyly - abnormal curvature of 5th finger towards 4th finger

The physical abnormalities associated with Andersen–Tawil syndrome typically affect the head, face, limbs and spine. Abnormalities of the head and face include an unusually small lower jaw (micrognathia), low-set ears, widely spaced eyes (hypertelorism), a broad forehead and nasal root, a high arched or cleft palate, and a long narrow head (scaphocelphaly).[3] Abnormalities of the limbs and spine include an abnormal curvature of the fingers, particularly the fifth finger (clinodactyly), fused fingers or toes (syndactyly), short stature, and a curved spine (scoliosis).[3]

The third key feature of Andersen–Tawil syndrome is intermittent muscle weakness. This can last from seconds to minutes, but in some cases may last for days at a time. Weakness often occurs at times when the levels of potassium in the blood are lower than normal (hypokalaemia), and is referred to as hypokalaemic periodic paralysis. This weakness can however occur at times when potassium levels are normal, triggered by other factors including exercise, cold, or even menstruation.[3]

Cause[edit]

Andersen–Tawil syndrome is a genetic disorder which in the majority of cases is caused by a mutation in the KCNJ2 gene. The condition is often inherited from a parent in an autosomal dominant manner, but may occur due to a new genetic mutation in the affected person.[3]

Genetics[edit]

Two types of Andersen–Tawil syndrome have been described, distinguished by the genetic abnormality that is detected. Type 1 Andersen-Tawil, accounting for about 60% of cases, is caused by mutations in the KCNJ2 gene.[4] In type 2 Andersen–Tawil, accounting for about 40% of cases, a KCNJ2 mutation is not identified. Mutations in a related gene encoding a similar potassium ion channel, KCNJ5, have been identified in some of those with type 2 Andersen–Tawil, but in many cases a genetic variant is not found. [1]

Type OMIM Gene Notes
Type 1 ATS 170390 KCNJ2 Encodes inward rectifying potassium current Kir2.2 carrying the potassium current IK1. [1]
Type 2 ATS 600734 KCNJ5 Also known as GIRK4, encodes G protein-sensitive inwardly rectifying potassium channels (Kir3.4) which carry the potassium current IK(ACh). [1]

The protein made by the KCNJ2 gene forms an ion channel that transports potassium ions into muscle cells. This specific channel (the inward rectifier potassium channel Kir2.1) carries a potassium current known as IK1 which is responsible for setting the resting membrane potential of muscle cells and is therefore critical for maintaining the normal functions of skeletal and cardiac muscle.[3] Mutations in the KCNJ2 gene alter the usual structure and function of potassium channels or prevent the channels from being inserted correctly into the cell membrane. Many mutations prevent a molecule called PIP2 from binding to the channels and effectively regulating their activity. These changes disrupt the flow of potassium ions, leading to the periodic paralysis and abnormal heart rhythms characteristic of Andersen–Tawil syndrome.[4] It is not understood how mutations in the gene lead to the developmental or bone abnormalities.[4]

Diagnosis[edit]

Foot with partial syndactyly - fusion of two toes

Andersen–Tawil syndrome is generally diagnosed based on symptoms, the findings on examination, and the results of an electrocardiogram. [3] Clinical diagnostic criteria have been proposed which suggest that a diagnosis can be made if two of the following three criteria are met: (1) periodic paralysis; (2) ventricular arrhythmias (frequent ventricular ectopic beats or ventricular tachycardia), a prolonged QT interval when corrected for rate, and/or a prominent U wave; (3) at least two of the following dysmorphic features: low-set ears, wide-set eyes, a small mandible, fifth-digit clinodactyly, and syndactyly; and (4) a family member with confirmed Andersen–Tawil syndrome.[3]

Genetic testing can be used to identify the specific mutation in an affected person, which if found can assist with screening family members.[3] Other investigations that may be helpful in making a diagnosis include ambulatory ECG monitoring to assess for arrhythmias, measurement of blood potassium levels at baseline and during periods of weakness, and measurement of thyroid function. [5]

Differential diagnosis[edit]

The differential diagnosis for a prolonged QT interval includes other forms of Long QT syndrome such as Romano–Ward syndrome in which only the electrical activity of the heart is affected without involving any other organs; Jervell and Lange-Nielsen syndrome in which a prolonged QT interval is combined with congenital deafness; and Timothy syndrome in which a prolonged QT interval is combined with abnormalities in the structure of the heart, in addition to autism-spectrum disorder.[6] The frequent ventricular ectopy and bidirectional ventricular tachycardia seen in Andersen–Tawil syndrome can also occur in catecholaminergic polymorphic ventricular tachycardia. [2]

The intermittent weakness seen in Andersen–Tawil syndrome also occurs in other forms of periodic paralysis - hypokalaemic periodic paralysis, hyperkalaemic periodic paralysis, and paramyotonia congenita. [5]

Treatment[edit]

As a genetic condition, Andersen–Tawil syndrome cannot be cured.  However, many of symptoms of Andersen-Tawil such as blackouts due to abnormal heart rhythms or periodic paralysis can be successfully treated with medication or implantable devices.  The rarity of the condition means that many of these treatments are based on consensus opinion as there are too few patients to conduct adequately powered clinical trials.[3]

General measures[edit]

Medications should be avoided that further prolong the QT interval such as sotalol and amiodarone as these drugs can promote abnormal heart rhythms.[3] A list of these drugs can be found at the QTDrugs.org website.  Drugs which reduce blood levels of potassium such as diuretics like furosemide and bendroflumethiazide should also be avoided as these can worsen the tendency to periodic paralysis and arrhythmias. [3] Conversely, potassium-containing supplements to increase blood potassium levels may be helpful. [3] Very strenuous or competitive sport should be discouraged as increases the risk of arrhythmias, although gentle exercise should be encouraged.[6]

Arrhythmias[edit]

Labelled chest X-ray showing an implantable cardioverter defibrillator.

As in many forms of long QT syndrome which predispose those affected to dangerous heart rhythm disturbances, the risk of arrhythmias can be reduced by taking beta blockers such as propranolol that block the effects of adrenaline on the heart. [3] Other antiarrhythmic drugs such as flecainide and verapamil may also be helpful. [3] Those at highest risk of recurrent arrhythmias such as those who have already suffered a cardiac arrest may benefit from an implantable cardioverter defibrillator - a small device implanted under the skin which can detect dangerous arrhythmias and automatically treat them with a small electric shock.[3]

Periodic paralysis[edit]

Periodic paralysis may be improved by taking carbonic anhydrase inhibitors such as acetazolamide.[3]

Epidemiology[edit]

Andersen–Tawil syndrome is very rare, and as of 2013 approximately 200 cases had been described in the medical literature.[3] The condition is estimated to affect one person in every 1,000,000.[3]

History[edit]

Although a description of the condition had probably been made by Klein in 1963,[3] Andersen–Tawil syndrome is named after Ellen Andersen who described the triad of symptoms in 1971,[7] and Rabi Tawil who made significant contributions to the understanding of the condition in 1994.[8][9]

See also[edit]

References[edit]

  1. ^ a b c d e Veerapandiyan A, Statland JM, Tawil R (2015). "Andersen-Tawil Syndrome". In Adam MP, Ardinger HH, Pagon RA, Wallace SE, Bean LJ, Stephens K, Amemiya A. GeneReviews. Seattle (WA): University of Washington. PMID 20301441.
  2. ^ a b c Tristani-Firouzi M, Etheridge SP (2013). "Chapter 32 - Andersen-Tawil and Timothy Syndromes". In Gussak I, Antzelevitch C. Electrical diseases of the heart. Volume 1, Basic foundations and primary electrical diseases (2nd ed.). London: Springer. ISBN 978-1-4471-4881-4. OCLC 841465583.
  3. ^ a b c d e f g h i j k l m n o p q r s Nguyen HL, Pieper GH, Wilders R (December 2013). "Andersen-Tawil syndrome: clinical and molecular aspects". International Journal of Cardiology. 170 (1): 1–16. PMID 24383070.
  4. ^ a b c Donaldson MR, Yoon G, Fu YH, Ptacek LJ (2004). "Andersen-Tawil syndrome: a model of clinical variability, pleiotropy, and genetic heterogeneity". Annals of Medicine. 36 (Suppl 1): 92–7. PMID 15176430.
  5. ^ a b Statland JM, Fontaine B, Hanna MG, Johnson NE, Kissel JT, Sansone VA, et al. (April 2018). "Review of the Diagnosis and Treatment of Periodic Paralysis". Muscle & Nerve. 57 (4): 522–530. doi:10.1002/mus.26009. PMC 5867231. PMID 29125635.
  6. ^ a b Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, et al. (November 2015). "2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC)Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC)". Europace. 17 (11): 1601–87. doi:10.1093/europace/euv319. PMID 26318695.
  7. ^ Andersen ED, Krasilnikoff PA, Overvad H (September 1971). "Intermittent muscular weakness, extrasystoles, and multiple developmental anomalies. A new syndrome?". Acta Paediatrica Scandinavica. 60 (5): 559–64. doi:10.1111/j.1651-2227.1971.tb06990.x. PMID 4106724.
  8. ^ Tawil R, Ptacek LJ, Pavlakis SG, DeVivo DC, Penn AS, Ozdemir C, Griggs RC (March 1994). "Andersen's syndrome: potassium-sensitive periodic paralysis, ventricular ectopy, and dysmorphic features". Annals of Neurology. 35 (3): 326–30. doi:10.1002/ana.410350313. PMID 8080508.
  9. ^ synd/3410 at Who Named It?

External links[edit]

Classification
External resources
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