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AUTHOR QUERY SHEETAuthor(s): Gabriele Tonni, Alessandro Ventura Pierpaolo Pattacini,

MariaPaola Bonasoni, and Bruno Ferrari

Article title: Complex Cardiac Defect, Bowing of Lower Limbs and MultipleAnomalies in Trisomy 22. Ultrasound, Post-Mortem CT Findings withNecropsy Confirmation

Article no: 659409

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Fetal and Pediatric Pathology, 00:1–9, 2012Copyright C© Informa Healthcare USA, Inc.ISSN: 1551-3815 print / 1551-3823 onlineDOI: 10.3109/15513815.2012.659409

Complex Cardiac Defect, Bowing of Lower Limbsand Multiple Anomalies in Trisomy 22. Ultrasound,Post-Mortem CT Findings with NecropsyConfirmation

Gabriele Tonni, Alessandro Ventura, Pierpaolo Pattacini,5

MariaPaola Bonasoni, and Bruno Ferrari

Department of Obstetrics & Gynceology, AUSL Reggio Emilia, Guastalla, Italy; Departmentof Obstetrics & Gynecology, AUSL Reggio Emilia, Guastalla Civil Hospital, Guastalla, Italy;Arcispedale ”Santa Maria Nuova,” IRCCS, Reggio Emilia, Italy, Radiology Unit, Departmentof Diagnostic Imaging, Viale Risorgimento, Reggio Emilia, Italy; Arcispedale ”Santa Maria10Nuova,” Department of Pathology, Reggio Emilia, Italy; Department of Obstetrics &Gynecology, University of Parma, Parma, Italy

Trisomy 22 is commonly associated with severe intrauterine growth retardation and congenitalanomalies. The sonographic identification of a complex cardiac defect and bowing of the longbones associated with multiple structural anomalies add new clinical informations to our knowl-15edge about the prenatal phenotype of trisomy 22. These findings have not been reported previ-ously and are of critical importance as sonographic signs of trisomy 22 may overlap that of trisomy13–18 and will help clinicians in indicating fetal karyotyping. Prenatal diagnosis of trisomy 22 isessential as trisomy 22 is a lethal condition.

Keywords trisomy 22, prenatal diagnosis, congenital anomalies, 2D-3D ultrasound, MR imaging,20CT scan, necropsy

INTRODUCTION

Trisomy 22 is a very rare chromosomal abnormality with a life birth prevalence of 1in 30,000–50,000 [1]. It is commonly associated with severe intrauterine growth re-tardation and multiple congenital anomalies. Trisomy 22 is a common cause of first25trimester miscarriage [1, 2] and detection in the second trimester of pregnancy israre. Consequently, there is a paucity of information for counselling parents [1]. Tri-somy 22 may be complete [3] or due to familial duplication [4], familial translocationwith supernumerary derivative chromosome [5], and monocentric isochromosome[6]. Isochromosome 22 in trisomy mosaic has been diagnosed in a newborn with nu-30merous dysmorphic features [7]. Trisomy 22 may be also due to duplicated 22q13.1-qter or distal trisomy 22 as a result of paternal inversion (22)(p11q13.1) [8], as a result ofduplication and pericentric inversion [9] or due to a de-novo mutation due to an extra22Q-chromosome [10]. Sometimes trisomy 22 may be diagnosed during first trimesterscreening for Down syndrome, as it is associated with a decreased placental produc-35tion of free-β-hCG and PAPP-A [1, 11]. Trisomy 22 has been shown to be associated

Address correspondence to Dr. Gabriele Tonni, AUSL Reggio Emilia, Obstetrics & Gynceology, ViaDonatori Sangue, 2, Guastalla, 42016 Italy. E-mail: Tonni.Gabriele@ausl.re.it.

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with retrocervical septated cystic hygroma (SCHy) [12] and with multiple anomalies(growth deficiency, microcephaly, micrognathia, ear malformations, cleft palate, andcongenital heart defect) [13], abnormal face, ambiguous genitalia, and male pseudo-ermaphroditism and gonadal mosaicism [14], and congenital heart defects with short 40post-natal survival [6].

CASE REPORT

A 27-year-old primigravida underwent first trimester screening for Down syndromeaccording to the Fetal Medicine Foundation guidelines (www.fetalmedicine.com).The scan was carried out with LQ 7 and E6 (GE, General Electric Healthcare Medi- 45cal System, Milwaukee, WI, USA) ultrasound equipment using transabdominal 3.5–5probe (4C), and transabdominal RAB 4-8 MHz probes (E8C). The crown-rump lengthmeasurement was 67.2 mm (13.2 weeks) and transvaginal three-dimensional ultra-sound showed septated cystic hygroma, that persisted beyond the first trimester (Fig-ure 1). Free β-hCG and PAPP-A were 15 ng/ml and 0.5 mUI/ml, respectively. Due to 50anomalous ultrasound findings and maternal serum test, prenatal counselling wasperformed. The couple opted to undergo amniocentesis that was undertaken aftersigned informed consent at 16- week’s gestation and cytogenetic analysis demon-strated a complete 47,XX,22+ karyotype (Figure 2). STOPPED HERE Fluorescence insitu hybridization (FISH) was performed on uncultured amniocytes and confirmed 55the conventional QFQ banding. A thorough 2nd level scan performed at 19 weeks doc-umented the following sonographic features: persistent septated cystic hygroma withincreased nuchal fold (14.5 mm) associated with an asymmetric, moderate, borderlineleft ventriculomegaly (right lateral ventricle = 11.5 mm) (Figure 3). The fetal face wasinvestigated either by 2D and 3D volume rendering and showed micrognathia (Figure 604a, Figure 4b). Echocardiographic examination documented the following: pulmonaryatresia with severe cardiomegaly and right side enlargement associated with tricus-pid regurgitation at pulsed-color Doppler, severe tachycardia (206 beat per min), andpericardial-pleural effusion (Figure 5a, Figure 5b). The femur and the tibia were belowthe 5th centile for the gestational age and curved with the typical “French telephone” 65receiver appearance either on 2D and 3D scan (Figure 6).

FIGURE 1 Cytogenetic analysis using QFQ banding on amniotic fluid cells demonstrating a47,XX,22+ fetal karyotype.

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FIGURE 2 Transabdominal scan performed at 19 week’s gestation showing mild, asymmetric leftventriculomegaly.

Antenatal ultrafast magnetic resonance imaging (MRI) was arranged. The MRI

AQ2

equipment used was a 1.5 Tesla Sign Twin Speed (GE R©, General Electric HealthcareMedical System, Milwaukee, WI) single shot fast spin echo (SSFSE). The MRI equip-ment used an 8-element phased array surface coil. Standard single-shot fast spin echo70(SSFSE) imaging was performed in the fetal sagittal, coronal, and axial planes usingthe following parameters: repetition time (TR), single-shot, echo time (TE), 80 mil-lisec; TR/TE, Infinite/90; bandwidth, 32 kHz; field of view, 30 × 30 cm; matrix, 256× 192; gap, 1.5 mm; number of excitations, 0.5; refocusing pulse of less than 180 de-grees; slice thickness, 4 mm; and 0.6 sec per slice, echo-train length, 72; 1 signal ac-75quired. T2 weighted MRI confirmed the ultrasound based diagnosis of communicat-ing hydrocephalus (Figure 7) and cardiomegaly (Figure 8). Pregnancy termination wasachieved by vaginal administration of prostaglandin E at 22 weeks gestation. DNAwas extracted from skin fibroblasts and SOX9 mutation was sought to exclude an

FIGURE 3 (A) Transabdominal scan performed at 19-week’s gestation with invert volume contrastimaging (VCI) showing micrognathia (white arrow). (B) Three-dimensional volume rendering insurface minimum mode confirming the 2D ultrasound diagnosis of micrognathia (white arrow).

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FIGURE 4 Fetal echocardiogram showing severe cardiomegaly with right-sided enlargement andpleural effusion (∗). Abbreviations: ra = right atrium; rv = right ventricle.

FIGURE 5 Detail of three-dimensional volume reconstruction in surface maximum mode showingbowing of both lower limbs. Note the typical “French telephone” receiver appearance, especiallyinvolving the tibia.

FIGURE 6 Antenatal T2-weighted single shot fast spin echo (SSFSE) MR imaging showing fetalcommunicating hydrocephalus.

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FIGURE 7 Antenatal T2-weighted single shot fast spin echo (SSFSE) MR imaging confirming thesevere cardiomegaly.

associated campomelic dysplasia. Cytogenetic analysis performed on skin fibroblasts80culture confirmed the cytogenetic diagnosis and necropsy confirmed the anomaliesdetected prenatally, with special focus on the congenital heart disease that revealed acomplex congenital cardiac malformations (Figure 9a, Figure 9b). Cardiomegaly (lon-gitudinal and transverse diameter of 6.5 and 3.5 cm, respectively) with the coronaricsinus ending into the ductus venosus. Pulmonary atresia with a membrane at ostium85level, hypoplastic pulmonary trunk with right and left pulmonary arteries and absentof the ductus arteriosus; dysplastic tricuspid valve and anomalous venous return ofthe left lung via azygos vein. There was an associated supravalvular sub-stenosis ofthe ascending aorta and histologically a fragmented and thickened vascular wall. Thecoronary arteries were occluded as were the head and neck vessels.90

DISCUSSION

Trisomy 22 has been reported as detected prenatally in only few cases [4, 5, 15] andthere are no specific ultrasound diagnostic clusters of the aneuploidy. The report of

FIGURE 8 (A) Necropsy specimen confirming the severe cardiomegaly (longitudinal and trans-verse diameter of 6.5 and 3.5 cm, respectively). The fetal heart weght was 26.2 g compared with 3.5g (+/- 0.6) as expected per gestational age. (B) Pulmonary atresia: the cups are fused (green arrow)like a membrane and the pulmonary trunk (white arrow) is severely hypoplastic.

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FIGURE 9 Post-mortem, three-dimensional CT confirming the bowing of the femur and tibia, withthe typical “French telephone” receiver appearance.

new ultrasound detectable congenital malformations associated with the conditionwill enhance our knowledge about prenatal phenotype and indicate mandatory pre- 95natal karyotyping.

Chen et al. [5] was the first to report a prenatally diagnosed Dandy-Walker malfor-mation with the karyotype of partial trisomy 11 and 22 due to familial translocationt(11;22)(q23;q11) inherited in three generations. Seoud et al. [16] in a study regarding46 fetuses with autosomal trisomies, namely trisomy 13, 18, 21 and 22, demonstrated 100that such fetuses, compared with 50 chromosomally normal fetuses, had short longbones, especially femurs, as well as high biparietal diameter/femur length ratios. In-creased nuchal thickness and abnormal heart anatomy, slight pyelectasis, increasedbowel echogenicity and/or abnormal flexion of the hands were also sonographic as-sociated findings. Stressig et al. [17] observed that nuchal thickening, cerebellar de- 105fects, IUGR, oligohydramnios and hypoplastic femur were the most frequent observedanomalies at prenatal ultrasound examination in five fetuses with complete trisomy22.

Cardiac defects namely atrioventricular septal defect, interventricular septal de-fect, severe left pleural effusion with marked mediastinal shift and other congenital 110anomalies has been reported by Sepulveda et al. [18] in three fetuses with trisomy 22.Besides sonographic observation of multiple congenital anomalies already describedin the medical literature, the present case is the first to report trisomy 22 associatedwith complex congenital cardiac defect and bowing of the lower limbs. Pulmonaryvalve atresia with intact ventricular septum is uncommon, accounting for only 1.7% 115of structural heart defects and is associated with variable degree of right ventricularand tricuspid valve hypoplasia.

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The right ventricle is not hypoplastic but can be enlarged and dysfunctional, usu-ally with dilatation of a normal tricuspid valve that is severly incompetent, as it wasin our reported case. This form is difficult to distinguish from Ebstein’ anomaly or120other primary valve abnormalities. Even if the right ventricle and tricuspid valve arehypoplastic, significant tricuspid valve regurgitation may be causing severe right atrialenlargement. In these cases the heart can be significantly enlarged, predisposing thesefetuses to lung hypoplasia [19, 20]. Severe tricuspid regurgitation can progressivelydetermine thinning of the right ventricle and subsequently aneurismatic dilatation.125The severe enlargement of the right atrium and ventricle can led to the complicationknown as “wall-to-wall” heart, in which the heart occupies most of the thorax space,compressing the lungs and overall these patients have a poor prognosis [21]. Whenthe coronary arteries appear stenotic and/or occluded the coronary flow is from thehigh-pressure right ventricle and not the aorta. The histologic alterations observed in130our case at the level of the ascending aorta resemble those seen in the isolated form ofsupravalvular aortic stenosis (SVAS) or in that associated with Williams Beuren syn-drome (chromosome 7q11.23 deletion characterized by SVAS, “elfin face” and mentalretardation). Color Doppler imaging to demonstrate reduced or absent flow across thetricuspid valve and reverse flow in the ductus arteriosus/pulmonary artery are useful135ultrasound diagnostic clusters of the cardiac defect [22].

Trisomy 22 is also associated with skeleton and limb defects and a small supernu-merary NOR-positive marker derived from paternal chromosome 22 and identified asdel[22](q11.2) has been diagnosed in a newborn female presenting with costoverteb-tal dysplasia (CVD), subtle facial anomalies, and neonatal respiratory distress. These140findings suggests that a pericentric gene family, distributed on one or more acrocentricchromosomes, may have played a role in the development of the human axial skeleton[23]. Terminal transverse limb reduction defect, congenital cardiac defect and facialdysmorphism [24] have been reported in mosaic trisomy 22 as well as left ventricularnon-compaction cardiomyopathy [25]. Unexplained symmetrical IUGR (intrauterine145growth retadrdation) and ventricular septal defect (VSD) have been seen associatedwith trisomy 22 fetus due to maternal uniparental disomy for chromosome 22 [26].When trisomy 22 mosaicism is found in amniotic fluid it might not be confirmed onfetal blood sampling and thus fetal skin biopsy should be considered in the diagnos-tic work-up [27]. Interestingly, investigation of the placenta using FISH showed a low150presence of trisomy 22 cells in only one out of 14 biopses while in cultured fibroblastsof skin tissue, a mosaic 47,XX,+22[7]/46,XX[25] was observed [26]. Rarely trisomy 22can be confined to the placenta and be associated with abnormal Doppler velocimetry[28] and/or coexisting with agenesis of the ductus venosus [29]. Moreover, a trisomy22 has been detected in a 32-week-old fetus with phenotypic manifestaitions of Fryns155syndrome (diaphragmatic hernia, facial defects, nail hypoplasia with short distal fifthphalanges)[30, 31], renal agenesis [32], Goldenhar sequence (facioauriculo-vertebraldysplasia), and hypertelorism [33–35].

In conclusion, from analysis of the present case and that of the medical literature,few clinical considerations can be made: 1) trisomy 22 is a rare chromosomal abnor-160mality with a probable incidence of 1:30,000–1:50,000; 2) sonographic identification offetuses with trisomy 22 may be difficult during first trimester scan and missed at sec-ond trimester routine scan;3) sonographic signs of trisomy 22 may overlap that of tri-somy 13–18 and modern ultra-fast MRI may aid the prenatal diagnosis; 4) sonographicfeatures of trisomy 22 may include central nervous system anomalies, facial dysmor-165phisms, cardiac defects, as well as uro-genital; 5) prenatal karyotype may pose cytoge-netic interpretations and confirmation on skin fibroblast culture and/or fetal tissuesis mandatory in such cases; 6) early prenatal diagnosis of trisomy 22 is essential in the

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parental decision-making process regarding the outcome of the pregnancy as trisomy22 is a lethal condition. 170

Declaration of InterestAQ3

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