CASE
A
2
months and 28 days old male, Han Nationality from the Jianshui County of
Yunnan Province, was born full term at 38.5 weeks gestation with a birth
weight of 3,200 g and a birth length 47 cm, who was not the product of a
consanguineous marriage. He presented skin yellowing, mild anemia and
feeding difficulty for 2 months. Physical examination revealed a body
weight of 6.5 kg, height 58 cm and head circumference 41.5 cm. Obvious
jaundice was observed in the skin and sclera. No stridor, crackles or
crepitus was heard in the two lungs. There was no abdominal distention,
liver was palpable under the right costal margin (2.0 cm), spleen was
non-palpable. Echocardiography showed patent foramen ovale (PFO).
Laboratory test revealed that the serum levels of total bilirubin
(TBIL), direct bilirubin (DBIL), indirect bilirubin (IBIL), total bile
acids (TBA), aspartate transaminase (AST) and alanine transaminase
(ALT), thyroid stimulating hormone (TSH), and alkaline phosphatase (ALP)
were all elevated; 25-hydroxy vitamin D (VD) was decreased (Table 1).
Blood routine examination revealed that the mean corpuscular volume
(MCV), corpuscular hemoglobin (MCH) and hemoglobin (HB) were decreased
(Table 1). The baby was diagnosed to have hypercholesterolemia,
hyperbilirubinemia, mild anemia, abnormal liver and thyroid function,
and high suspicion of NTCPD. Sanger sequencing revealed that the patient
was a compound heterozygous for the c.800C>T (p.Ser267Phe)
and c.263T>C (p.lle88Thr) SLC10A1 mutations, which was
inherited from the mother and father, respectively (Figures 1A-F);
moreover, the patient and his mother were both heterozygous missense
mutation of c.2698G>A (p.Ala900Thr) in AT-rich interaction
domain 1A (ARID1A) gene (Figure 1G and H), and heterozygous deletion
type α- Thalassemia (–SEA/αα), while his father was
normal (Figure 1I). A diagnosis of NTCPD with heterozygous missense
mutations in c.800C>T and c.263T>C,
ARID1A
gene with a heterozygous missense mutation in c.2698G>A,
and heterozygous deletion type α- Thalassemia
(–SEA/αα) was confirmed. Considering that the
genotype of ARID1A is related to the phenotype of CSS, we did a detailed
physical examination for the child again. However, except for feeding
difficulties and PFO, we did not find any typical characteristics of
CSS, such as developmental delay (DD), mental retardation, hypo/aplasia
of the fifth digit phalanges/nails, coarse facial features, or body
hypertrichosis and so on, which may be due to the baby was too young.
The baby was started on symptomatic and supportive treatment including
phototherapy for neonatal indirect hyperbilirubinemia, intravenous
ademetionine1,4-butanedisulfonate, oral ursodeoxycholic acid capsules,
fat-solublevitamin D and clostridium butyricum powder. His transaminase,
bilirubin, TSH, ALP, VD and foramen ovale gradually returned to normal,
but the levels of TBA remained high, and mild anemia, which could only
be continuously observed. After two years of close clinic follow-up, the
baby grew well and had no other special clinical signs except mild
hyperbilirubinemia and anemia (Table1, Figure 1J). We will continue to
follow up and observe the patient. Written informed consent was obtained
from the child’s parents.