Clinical Diagnosis

The clinical diagnosis of Shwachman-Diamond syndrome (SDS) relies on evidence of exocrine pancreatic dysfunction and bone marrow failure with single- or multi-lineage cytopenia [Rothbaum et al 2002].

Exocrine pancreatic dysfunction can be documented with any one of the following:

• An abnormal fecal fat balance study of a 72-hour stool collection (with exclusion of intestinal mucosal disease or cholestatic liver disease) plus abnormal exocrine pancreas on imaging
• Low serum concentrations of the digestive enzymes pancreatic isoamylase and cationic trypsinogen
• Deficiency in pancreatic enzyme secretion following quantitative pancreatic stimulation testing with intravenous cholecystokinin and secretin

Note: Exocrine pancreatic dysfunction may be difficult to detect because the production of individual pancreatic enzymes varies during childhood and because severe perturbations of enzyme levels are required to meet diagnostic criteria [Schibli et al 2006]:

• Serum pancreatic isoamylase concentration is not reliable in children younger than age three years [Ip et al 2002].
• Serum cationic trypsinogen concentration increases to pancreatic-sufficient levels during early childhood in approximately 50% of children with SDS [Durie & Rommens 2004].

Pancreatic histopathology reveals few acinar cells and extensive fatty infiltration. Pancreatic imaging studies with ultrasonography or CT reveal small size for age. In a series of persons with mutation-positive SDS, MRI revealed fatty infiltration with retained ductal and islet components [Toiviainen-Salo et al 2008].

Hematologic abnormalities caused by bone marrow dysfunction involve one or more of the following:

• Persistent or intermittent depression of at least one myeloid lineage:
  • Neutropenia (established with an absolute neutrophil count <1,500 neutrophils /mm³ for ≥3 measurements taken over a period of ≥3 months)
  • Thrombocytopenia (persistent, with platelet count <150,000 platelets/mm³)
  • Anemia (with hemoglobin concentration below the normal range for age)
• Pancytopenia (trilineage cytopenia with persistent neutropenia, thrombocytopenia, and anemia)

Bone marrow examination may reveal the following:

• Varying degrees of hypocellularity and fatty infiltration of the marrow compartments, indicating marrow failure and disordered hematopoiesis
• Maturation arrest or delay in single- or multiple-myeloid lineages
• Aplastic anemia and myelodysplasia with or without abnormal cytogenetic findings. When cytogenetic anomalies are present, they can be monosomy 7, isochromosome 7, or other chromosomal changes seen in bone marrow failure syndromes.

Studies in which patient and non-patient marrow cells are co-cultured indicate problems with both the stem cell and stromal microenvironment compartments [Dror & Freedman 1999]. These findings, together with the wide range of abnormalities seen in the bone marrow, are consistent with SDS being a bone marrow failure syndrome.

Other. Variation in severity and clinical manifestations complicate the ability to establish a definitive diagnosis of SDS. Other primary features used in support of the diagnosis:

• Short stature
• Skeletal abnormalities
• Hepatomegaly with or without elevation of serum aminotransferase levels

Molecular Genetic Testing

Gene. SBDS is the only gene presently known to be associated with SDS [Boocock et al 2003].

Evidence for locus heterogeneity. A limited number (<10%) of persons with clear clinical indications of SDS do not appear to have mutations in SBDS, suggesting that mutations in another gene(s) may be causative.

Testing

• Targeted mutation analysis. In more than 90% of individuals with SDS, at least one of the mutant SBDS alleles has resulted from a phenomenon known as gene conversion (see Molecular Genetics). The three most common gene conversion mutations account for more than 76% of disease alleles (Note: In >62% of affected individuals, the following mutations account for both disease-causing alleles):
  • c.183_184delinsCT
  • c.258+2T>C
  • c.[183_184delinsCT; 258+2T>C], in which both mutations occur on a single allele
• Sequence analysis. The common gene conversion mutations can be detected by direct sequencing of exon 2 [Boocock et al 2003], accounting for 76% of the SDS-causing alleles in more than 200 families [Author, unpublished]. Most of the other rare mutations, including splicing mutations, short insertions or deletions, and missense mutations, can be identified by direct sequencing of the five exons of SBDS.
• Unusual mutations that involve exon deletions [Costa et al 2007], extended conversions of exon 2 and flanking introns, or gene rearrangements involving exon 2 have been observed but may not be detected readily with routine sequencing [Author, unpublished]. In these cases, testing with methods that detect the number of copies of SBDS exons is necessary (e.g., quantitative PCR methods); however, their interpretations must consider the occurrence of the pseudogene. The extent of variation in the pseudogene is not known.

Interpretation of test results. To interpret the common gene conversion mutations identified by targeted mutation analysis, parents should be tested to determine whether the mutation(s) observed in their child are:

• Monoallelic (e.g., c.[183_184delinsCT; 258+2T>C] on one chromosome and a normal allele on the other chromosome)
  
  OR
  
• Biallelic (e.g., c.183_184delinsCT on one chromosome and c.258+2T>C on the other chromosome)

For issues to consider in interpretation of sequence analysis results, click here.

Testing Strategy

Confirmation of the diagnosis in a proband. If both exocrine pancreatic dysfunction and characteristic hematologic abnormalities are present, it is appropriate to proceed with molecular genetic testing of SBDS:

• Targeted mutation analysis for the three common mutations in exon 2 can detect at least one mutation in 90% of affected individuals.
• If no mutation or only one mutation is identified using targeted mutation analysis, sequence analysis of the whole coding region can be performed.

Carrier testing for at-risk relatives requires prior identification of the disease-causing mutations in the family.

Note: Carriers are heterozygotes for this autosomal recessive disorder and are not at risk of developing the disorder.

Prenatal diagnosis and preimplantation genetic diagnosis (PGD) for at-risk pregnancies require prior identification of the disease-causing mutations in the family.

Genetically Related (Allelic) Disorders

No other phenotypes are known to be associated with variations in SBDS.

Note: (1) Although a recent publication suggested that carriers with one normal and one disease-causing SBDS allele may be at higher-than-average risk for aplastic anemia [Calado et al 2007], methodic problems with this study may include the following:

• Background risk of being a SBDS carrier (1/139) did not appear to be considered.
• Criteria for performing sequence analysis on individuals with aplastic anemia were not clearly delineated.

(2) Aplastic anemia has not been observed in SBDS heterozygotes (i.e., carriers) of more than 200 families with SDS [Authors, personal observation].

(3) Sequence analysis of DNA obtained from bone marrow samples from 77 persons with acute myelogeneous leukemia (AML) did not reveal any SBDS mutations [Majeed et al 2005].

Natural History

The clinical spectrum of Shwachman-Diamond syndrome (SDS) is broad and varies among affected individuals, even sibs [Ginzberg et al 1999]. Despite this variability, both gastrointestinal and hematologic findings are observed in all affected individuals [Cipolli et al 1999, Ginzberg et al 1999].

Neonates generally do not show manifestations of SDS; however, early presentations have included acute life-threatening infections and asphyxiating thoracic dystrophy caused by rib cage restriction. Rare neonatal presentations have also included severe bone marrow failure and aplastic anemia [Kuijpers et al 2005] or severe spondylometaphyseal dysplasia [Nishimura et al 2007].

More commonly, SDS presents in infancy with failure to thrive and poor growth secondary to exocrine pancreatic dysfunction, and recurrent infections secondary to neutropenia and impaired neutrophil chemotaxis, which are likely the most critical contributors to frequent recurrent infections, especially in young children [Dror & Freedman 2002, Stepanovic et al 2004, Kuijpers et al 2005]. Persistent or intermittent neutropenia is recognized first in almost all affected children, often before the diagnosis is made; in one series of 88 children, neutropenia was a presenting finding in 98% [Ginzberg et al 1999]. Acute and deep-tissue infections can be life threatening, particularly in young children [Cipolli 2001, Grinspan & Pikora 2005].

The risk for leukemia, typically AML, may be 15%-25% or higher in individuals with SDS than in the general population [Dror & Freedman 2002]. Although information is limited to a few studies, a retrospective survey over 25 years revealed that seven of 21 individuals with SDS developed myelodysplastic syndrome; five of the seven developed AML [Smith et al 1996]. In a more recent study, eight of 71 persons with SDS developed MDS and/or leukemia over a ten-year period [Donadieu et al 2005].

The risks for transformation with dysplastic cytologic abnormalities and AML are considered to be lifelong; AML is generally associated with poor outcome [Donadieu et al 2005]. The risk for malignancies other than AML does not appear to be increased, but information to date is limited.

Characteristic skeletal changes appear to be present in all mutation-positive individuals [Mäkitie et al 2004]; however, skeletal manifestations vary among individuals and over time. In some individuals the skeletal findings may be sub-clinical.

Cross-sectional and longitudinal data from the study of Mäkitie et al [2004] revealed the following:

• Delayed appearance of secondary ossification centers, causing bone age to appear to be delayed
• Variable widening and irregularity of the metaphyses in early childhood (i.e., metaphyseal chondrodysplasia), followed by progressive thickening and irregularity of the growth plates
• Generalized osteopenia

Of note, the epiphyseal maturation defects tended to normalize with age and the metaphyseal changes tended to progress (worsen) with age [Mäkitie et al 2004].

Additional skeletal findings can include rib abnormalities and joint abnormalities, the latter of which can result from asymmetric growth and can be sufficiently severe to warrant surgical intervention.

Children with adequate nutrition and pancreatic enzyme supplementation have normal growth velocity and appropriate weight for height; however, approximately 50% of children with SDS are below the third percentile for height and weight [Durie & Rommens 2004].

Hepatomegaly and liver dysfunction with elevated serum aminotransferase concentration can be observed in young children, but tend to resolve by age five years. Mild histologic changes may also be evident in biopsies, and although they do not appear to be progressive, it has been noted that liver complications have occurred in older individuals following bone marrow transplantation [Ritchie et al 2002].

Other possible findings:

• Ichthyosis and eczematous lesions
• Oral disease including delayed dental development, increased dental caries in both primary and permanent teeth, and recurrent oral ulcerations [Ho et al 2007]
• Cognitive and/or behavioral problems [Cipolli et al 1999, Ginzberg et al 1999]; however, few studies have described their full extent and range [Kent et al 1990; E Kerr, personal communication].
• Immune dysfunction [Dror et al 2001]
• Kidney or urinary tract anomalies

Genotype-Phenotype Correlations

No genotype-phenotype correlations have been observed with SBDS mutations [Mäkitie et al 2004; Kawakami et al 2005; Kuijpers et al 2005; Author, unpublished]; this is consistent with the earlier observed phenotypic variability among affected sibs [Ginzberg et al 1999].

Nomenclature

SDS has previously been known as:

• Shwachman’s syndrome
• Congenital lipomatosis of the pancreas
• Shwachman-Bodian syndrome

Prevalence

It has been estimated that SDS occurs in one of 76,000 births based on the observation that it is approximately 1/20th as frequent as cystic fibrosis in North America [Goobie et al 2001].

SDS occurs in diverse populations including those with European, Indian, aboriginal (North America), Chinese, Japanese, and African ancestry.

Pancreatic Dysfunction

Cystic fibrosis, which often presents with both upper-respiratory infections and exocrine pancreatic dysfunction, can be distinguished from SDS by sweat chloride testing and absence of primary bone marrow failure.

Other conditions with exocrine pancreatic dysfunction:

• Johanson-Blizzard syndrome, which can be distinguished from SDS by the characteristic anomalies, severe developmental delays, and absence of hematologic abnormalities
• Pearson bone marrow-pancreas syndrome, a rare mitochondrial disorder with both exocrine pancreatic dysfunction and bone marrow dysfunction, which can be distinguished from SDS by bone marrow examination and molecular genetic testing

Exocrine pancreatic insufficiency can also result from severe malnutrition.

Other bone marrow failure syndromes that overlap in some respects with SDS include the following:

• Diamond-Blackfan anemia
• Fanconi anemia
• Dyskeratosis congenita

These conditions and aplastic anemia can often be excluded by clinical investigations and bone marrow examination. Primary exocrine pancreatic dysfunction is not known to occur is these related syndromes.

Neutropenia

Transient neutropenia can result from medications or infections.

Clinical findings, repeated assessments of hematologic findings, and molecular genetic testing reliably distinguish SDS from Kostmann congenital neutropenia and ELANE-related neutropenia.

Skeletal Dysplasia

Cartilage-hair hypoplasia (CHH) syndrome has gastrointestinal, skeletal, hematologic, and immunologic features. However, the skeletal anomalies of CHH can be distinguished from those of SDS, and the gastrointestinal features of CHH are secondary to complications of infections rather than to exocrine pancreatic insufficiency.

Evaluations Following Initial Diagnosis

To establish the extent of disease following the initial diagnosis of Shwachman-Diamond syndrome (SDS), the following evaluations to assess the status of the pancreas, liver, bone marrow, and skeleton are recommended:

• Assessment of growth: height, weight in relation to age
• Assessment of developmental milestones (including pubertal development)
• Assessment of nutritional status to determine if supplementation with pancreatic enzymes is necessary and/or effective:
  • Measurement of fat-soluble vitamins (vitamin A, 25-OH-vitamin D, and vitamin E) or their related metabolites
  • Measurement of prothrombin time (to detect vitamin K deficiency)
• Assessment of serum concentration of the digestive enzyme cationic trypsinogen and, if sufficiency is observed, followed by confirmation with 72-hour fecal fat balance study (with discontinuation of enzyme supplementation for at least a 24-hour period)
• Assessment of serum aminotransferase levels
• Complete blood count with white cell differential and platelet count at six-month intervals (or more often as clinically indicated)
• Bone marrow examination with biopsy and cytogenetic studies at initial assessment
  
  Note: Current practice typically involves these studies; discussions to develop uniform recommendations are ongoing.
• Skeletal survey with radiographs of at least the hips and lower limbs

Treatment of Manifestations

A multidisciplinary team that includes specialists from the following fields is recommended: hematology, gastroenterology, medical genetics, orthopedics, endocrinology, immunology, dentistry, child development, psychology, and social work as needed [Dror & Freedman 2002, Rothbaum et al 2002, Durie & Rommens 2004].

Exocrine pancreatic insufficiency can be treated with the same oral pancreatic enzymes commonly used in treatment of cystic fibrosis; dose should be based on results of routine assessment of pancreatic function and nutritional status. Steatorrhea often resolves in early childhood, but pancreatic enzyme levels can remain low; routine monitoring (see Surveillance) is recommended.

Supplementation with fat-soluble vitamins (A, D, E, and K) is recommended.

Blood and/or platelet transfusions may be considered for anemia and bi- or trilineage cytopenia.

If recurrent infections are severe and absolute neutrophil counts are persistently 500/mm³ or less, treatment with prophylactic antibiotics and granulocyte-colony stimulation factor (G-CSF) can be considered.

Hematopoietic stem cell transplantation (HSCT) can be considered for treatment of severe pancytopenia, bone marrow transformation to myelodysplastic syndrome, or AML. Cells from both bone marrow and cord blood have been used. Although earlier reports indicate that survival is fair, cautious myeloablation and newer regimens show promise for improving outcomes [Cesaro et al 2005; Vibhakar et al 2005; Sauer et al 2007; R Harris, personal communication].

Note: Bone marrow abnormalities, per se, are not treated unless severe aplasia, myelodysplastic fluxes, or leukemic transformation are present.

Children with poor growth and delayed puberty benefit from ongoing consultation with an endocrinologist, who may also consult with orthopedists regarding possible surgical management of asymmetric growth and joint deformities.

Although cognitive, learning, and behavioral features of SDS have been less well investigated than other aspects, remedial interventions are considered beneficial [E Kerr, personal communication].

For pregnancies in women with SDS, high-risk pregnancy care including consultation with a hematologist is recommended.

Prevention of Secondary Complications

Frequent dental visits to monitor tooth development and oral health are recommended to reduce the incidence of mouth ulcers and gingivitis. Home care should include aggressive dental hygiene with topical fluoride treatments to help prevent dental decay [M Glogauer, personal communication].

Prophylactic antibiotics and G-CSF may be especially helpful when interventions such as complex dental procedures or orthopedic surgery are being considered.

Surveillance

The following is recommended given the intermittent nature of some features of SDS and the evolution of the phenotype over time [Rothbaum et al 2002]:

• Developmental and growth assessment every six months
• Assessment of nutritional status every six months and measurement of serum concentration of vitamins to evaluate effectiveness of or need for pancreatic enzyme therapy
• Complete blood counts with white blood cell differential and platelet counts at least every six months, or more frequently if infections are recurrent and debilitating
• Current practice is to repeat bone marrow examinations every one to three years following the baseline examination. These should be more frequent if changes in bone marrow function or cellularity are observed.
  
  Note: Discussions to develop uniform recommendations are ongoing.
• Monitoring for orthopedic complications resulting from growth during childhood with bone density measurements and x-rays of hips and knees during the most rapid growth stages

Agents/Circumstances to Avoid

Prolonged use of cytokine and hematopoietic growth factors such as G-CSF is cautioned against in view of the potential for contribution to leukemic transformation [Rosenberg et al 2006].

Some drugs, such as cyclophosphamide or cyclophosphamide and busulfan, typically used in standard preconditioning or preparative regimens for bone marrow transplantation may not be suitable because of possible cardiac toxicity [Mitsui et al 2004, Cesaro et al 2005, Vibhakar et al 2005, Sauer et al 2007].

Evaluation of Relatives at Risk

See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.

Therapies Under Investigation

Search ClinicalTrials.gov for access to information on clinical studies for a wide range of diseases and conditions. Note: There may not be clinical trials for this disorder.

Mode of Inheritance

Shwachman-Diamond syndrome (SDS) is inherited in an autosomal recessive manner. The mode of inheritance of SDS in individuals without identified SBDS mutations is unknown.

Risk to Family Members

Parents of a proband

• The parents of an affected child are usually heterozygotes (i.e., carriers of one mutant allele).
• Occasionally, only one parent is a carrier as the affected child has one inherited and one de novo SBDS allele.
• Heterozygotes are asymptomatic. See Genetically Related Disorders.

Sibs of a proband

• When both parents are known to be carriers
  • At conception, each sib of an affected individual has a 25% chance of being affected, a 50% chance of being an asymptomatic carrier, and a 25% chance of being unaffected and not a carrier.
  • Once an at-risk sib is known to be unaffected, the risk of his/her being a carrier is 2/3.
• When the proband has one inherited and one de novo mutation. At conception, each sib of an affected individual has a 50% chance of being an asymptomatic carrier and a 50% chance of being unaffected and not a carrier.
• Heterozygotes (carriers) are asymptomatic. See Genetically Related Disorders.

Offspring of a proband. The offspring of an individual with SDS are obligate heterozygotes (carriers) for a disease-causing mutation. In the rare event that the reproductive partner of the proband is a carrier, the offspring are at a 50% risk of being affected and a 50% risk of being carriers.

Other family members of a proband. Each sib of the proband’s parents is at a 50% risk of being a carrier.

Carrier Detection

Carrier testing for at-risk family members is possible once the mutations have been identified in the family.

Related Genetic Counseling Issues

Family planning

• The optimal time for determination of genetic risk, clarification of carrier status, and discussion of the availability of prenatal testing is before pregnancy.
• It is appropriate to offer genetic counseling (including discussion of potential risks to offspring and reproductive options) to young adults who are affected or at risk of being carriers.

DNA banking is the storage of DNA (typically extracted from white blood cells) for possible future use. Because it is likely that testing methodology and our understanding of genes, mutations, and diseases will improve in the future, consideration should be given to banking DNA of affected individuals.

Prenatal Testing

If the disease-causing mutations have been identified in the family, prenatal diagnosis for pregnancies at increased risk is possible by analysis of DNA extracted from fetal cells obtained by amniocentesis (usually performed at ~15-18 weeks’ gestation) or chorionic villus sampling (usually performed at ~10-12 weeks’ gestation).

Note: Gestational age is expressed as menstrual weeks calculated either from the first day of the last normal menstrual period or by ultrasound measurements.

Preimplantation genetic diagnosis (PGD) may be an option for some families in which the disease-causing mutations have been identified.

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Suggested Reading

1. Dokal I, Vulliamy T. Inherited aplastic anaemias/bone marrow failure syndromes. Blood Rev. 2008;22:141–53. [PubMed: 18164793]

Acknowledgments

We thank individuals with Shwachman-Diamond syndrome and their families and care givers for their cooperation.

Revision History

• 17 July 2008 (me) Review posted live
• 7 January 2008 (jr) Original submission