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Overview of Rett Syndrome First described by Dr. Andreas Rett in 1964 but did not receive worldwide recognition until the first English language publication by Dr. Bengt Hagberg in 1983 Neurodevelopmental disorder (not a degenerative disorder) Onset in early infancy Occurs in 1:10,000 to 1:23,000 female births Primarily affects girls Child appears to be born healthy Development appears normal until 6-18 months old Often misdiagnosed as autism, cerebral palsy or non-specified developmental delay Occurs in a variety of racial and ethnic groups worldwide Several Stages have been identified Course and Stages of Rett Syndrome STAGE I: Early Onset Age: 6 months to 1½ years Duration: months Stage usually overlooked Symptoms just emerging and somewhat vague May be reduced interest in toys and play activity May be decreased eye contact Often described as a "good" baby, calm and placid May be delays in gross motor milestones Non-specific hand wringing May be decelerating head growth STAGE II: Rapid Destructive Age: 1 to 4 years Duration: weeks to months Rapid onset or more gradual Purposeful hand skills and spoken language are lost Stereotyped hand movements emerge o Hand-to-mouth movements as the first expression o Most often midline hand wringing or hand washing o Persist while awake but disappear during sleep o Hand clapping or tapping o Hands are sometimes clasped behind the back or held at the sides in a specific pose, with random touching, grasping and releasing. Breathing irregularities may emerge o Breath holding and hyperventilation associated with vacant spells o Breathing is usually normal during sleep Some girls appear autistic-like o Loss of social interaction and communication General irritability and sleep irregularity may be seen Periods of tremulousness, especially when excited Unsteady gait patterns Page 1 Difficulty initiating motor movements Slowing of head growth is usually noticed from 3 months - 4 years STAGE III: Plateau Age: Pre-school to school years (2-10 years) Duration: years More prominent o Apraxia The inability to perform motor functions Perhaps the most severely disabling feature Interfering with every body movement, including eye gaze and speech. o Motor problems o Severe seizures Mental Retardation Bruxism (teeth grinding), Improvement in behavior o Less irritability and crying o Less autistic features o Show greater interest in surroundings o Alertness, attention span and communication skills improve Many girls with RS remain in Stage III for most of their lifetime STAGE IV A (Previously ambulant): Late Motor Deterioration STAGE IV B (Never ambulant): Late Motor Deterioration Age: When stage III ceases, 5-15-25-? years Duration: up to decades Usually begins after age 10 Characterized by reduced mobility o Some stop walking, others have never walked. o Scoliosis is a prominent feature o Muscle Wasting o Rigidity (stiffness) o Dystonia (increased muscle tone with abnormal extremity or trunk positions) no decline in cognition, communication or hand skills Repetitive hand movements may decrease. Eye gaze/contact usually improves Puberty begins at the expected age in most girls Page 2 DSM-IV: Pervasive Developmental Disorder: 299.80 Rett’s Disorder A. All of the following: (1) Apparently normal prenatal and perinatal development (2) Apparently normal psychomotor development through the first 5 months after birth (3) Normal head circumference at birth B. Onset of all of the following after the period of normal development: (1) Decelaration of head growth between ages 5 and 48 months (2) Loss of previously acquired purposeful hand skills between ages 5 and 30 months with the subsequent development of stereotyped hand movements (e.g., hand-wringing or hand washing) (3) Loss of social engagement early in the course (although often social interaction develops later) (4) Appearance of poorly coordinated gait or trunk movements (5) Severely impaired expressive and receptive language development with severe psychomotor retardation Recent Revised diagnostic criteria for Rett Syndrome Hagberg B, Hanefeld F, Percy A, Skjeldal O. An update on clinically applicable diagnostic criteria in Rett syndrome. European J of Paediatric Neurology 2002; 6: 293297 IRSA convened a panel of international experts as part of the European Pediatric Neurology Society. Based on the correlation between genotypes (gene mutations) and phenotypes (symptoms). Includes information on atypical or borderline variants of RS. The diagnosis of RS remains a clinical one and is not made solely on the basis of MECP2 mutations. This means that RS can occur with or without mutations in MECP2, and MECP2 mutations can occur without the diagnosis of RS. Diagnostic Criteria: Typical A. Necessary criteria 1.apparently normal prenatal and perinatal history 2.psychomotor development largely normal through the first six months or may be delayed from birth 3.normal head circumference at birth 4.postnatal deceleration of head growth in the majority 5.loss of achieved purposeful hand skill between ages ½ - 2½ years 6.stereotypic hand movements such as hand wringing/squeezing, clapping/tapping, mouthing and washing/rubbing automatisms 7.emerging social withdrawal, communication dysfunction, loss of learned words, and cognitive impairment 8.impaired (dyspraxic) or failing locomotion Page 3 B. Supportive criteria 1.awake disturbances of breathing (hyperventilation, breath-holding, forced expulsion of air or saliva, air swallowing 2.bruxism 3.impaired sleep pattern from early infancy 4.abnormal muscle tone successively associated with muscle wasting and dystonia 5.peripheral vasomotor disturbances 6.scoliosis/kyphosis progressing through childhood 7.growth retardation 8.hypotrophic small and cold feet; small, thin hands C. Exclusion criteria 1.organomegaly or other signs of storage disease 2.retinopathy, optic atrophy, or cataract 3.evidence of perinatal or postnatal brain damage 4.existence of identifiable metabolic or other progressive neurological disorder 5.acquired neurological disorder resulting from severe infections or head trauma Revised delineation of variant phenotypes: Atypical or Borderline -15% of total number of diagnosed cases A. Inclusion criteria 1.meet at least 3 of 6 main criteria 2.meet at least 5 of 11 supportive criteria B. Six main criteria 1.absence or reduction of hand skills 2.reduction or loss of babble speech 3.monotonous pattern to hand stereotypies 4.reduction or loss of communication skills 5.deceleraton of head growth from first years of life 6.RS disease profile: a regression stage followed by a recovery of interaction contrasting with slow neuromotor regression C. Eleven supportive criteria 1.breathing irregularities 2.bloating/air swallowing 3.teeth grinding, harsh sounding type 4.abnormal locomotion 5.scoliosis/kyphosis 6.lower limb amyotrophy 7.cold, purplish feet, usually growth impaired 8.sleep disturbances including night screaming outbursts 9.laughing/screaming spells 10.diminished response to pain Page 4 11.intense eye contact/eye pointing Pathogenesis Genetic Disorder o Caused by a mutations or a defective regulatory MECP2 gene o X chromosome o Usually Sporadic Mutation, (most often on father’s sperm) Not inherited: less than 1 percent of recorded cases are inherited or passed from one generation to the next. o MECP2 is believed to control the functions of several other genes contains instructions for the synthesis of a protein called methyl cytosine binding protein 2 (MeCP2), which acts as one of the many biochemical switches that tell other genes when to turn off and stop producing their own unique proteins. In RS, insufficient amounts of the protein are formed. The absence of the protein causes other genes to be switched on and stay on at inappropriate stages, forming excessive amounts of proteins, causing the neurodevelopmental problems that are characteristic of the disorder. o Not all children with Rett’s have mutations of the MECP2 gene 70-90% with “classical” RS 0-30% with atypical RS Why Rett’s is seen almost exclusively in females o Since males have an X and a Y chromosome, they lack a "backup" copy of the X chromosome that can compensate for a defective one o mutations in MECP2 are typically lethal to the male fetus Central Nervous System Reduced Brain Weight Reductions in Volume o Frontal Cortex: Most Vulnerable o Caudate Nucleus Reduced Melanin in Substantia Nigra Smaller Neurons Treatment No cure for Rett syndrome Treatment is symptomatic — focusing on the management of symptoms Medication may be needed for breathing irregularities and motor difficulties, and antiepileptic drugs may be used to control seizures. There should be regular monitoring for scoliosis and possible heart abnormalities Occupational therapy Physiotherapy Hydrotherapy may prolong mobility Nutritionists to help them maintain adequate Special academic, social, vocational, and support services Page 5 Future: Stem Cell and Gene Therapy Long-Term Prognosis Little is known Females have a 95% chance of surviving to 25 years old Morbidity often related to seizure disorder or swallowing difficulties More information International Rett Syndrome Association (IRSA) 9121 Piscataway Road Suite 2B Clinton, MD 20735 [email protected] http://www.rettsyndrome.org Tel: 301-856-3334 800-818-RETT (7388) Fax: 301-856-3336 Rett Syndrome Research Foundation (RSRF) 4600 Devitt Drive Cincinnati, OH 45246 [email protected] http://www.rsrf.org Tel: 513-874-3020 Fax: 513-874-2520 Easter Seals 230 West Monroe Street Suite 1800 Chicago, IL 60606-4802 [email protected] http://www.easter-seals.org Tel: 312-726-6200 800-221-6827 Fax: 312-726-1494 National Institute of Child Health and Human Development (NICHD) National Institutes of Health Bldg. 31, Rm. 2A32 Bethesda, MD 20892-2425 [email protected] http://www.nichd.nih.gov Tel: 301-496-5133 800-370-2943 http://www.ninds.nih.gov/health_and_medical/pubs/rett.htm Page 6