Familial dysautonomia (FD) is a rare inherited disorder in which affected individuals experience multiple malfunctions of the autonomic nervous system (the part of the nervous system that regulates heart muscle, smooth muscle, and glands) as well as the sensory, motor, and central components of the nervous system. The disorder is progressive with a continual loss of nerve cells of the sensory and autonomic nervous systems.
Familial dysautonomia is an inherited disorder that occurs almost exclusively in people of Eastern European (Ashkenazi) Jewish descent. FD is one of a larger group of at least five hereditary sensory and autonomic neuropathies (HSANs), meaning conditions that stem from abnormalities of the nervous system. FD was first described in 1949 by pediatricians Conrad Riley and Richard Day. They reported five children, all Jewish, who had an unusual set of reactions to mild anxiety, attributed to a disturbance of the autonomic nervous system. FD is also known as HSAN type III or Riley-Day syndrome. Decades of studies have determined the cause to be a genetic abnormality that causes poor development of nerve cells in the fetus, leading to a progressive loss of nerve cells of the autonomic and sensory nervous systems. The depletion of nerve cells in the autonomic system causes problems with unstable heart rate, blood pressure, and body temperature, as well as gastrointestinal dysfunction, poor motor coordination, and emotional instability. Abnormal development of the sensory nervous system results in poor perception of pain, heat, and cold. This causes affected individuals to injure themselves without being aware of it. This deterioration of the nervous system worsens throughout life and causes multiple health problems that lead to the death of 50% of those affected by adulthood.
FD is caused by mutations (genetic errors) in the IKBKAP gene that is found on human chromosome 9, specifically located at region 9q31. The disease is inherited as an autosomal recessive trait. This means that both parents have one copy of the mutant gene but do not have the disease. For these parents, there is a 25% chance with each pregnancy that the child will have the disease.
The IKBKAP gene has two known mutations, which together account for 100% of the Ashkenazi Jewish (AJ) cases of FD. There is also a third mutation causing FD that is rarely seen in the non-AJ population. This mutation's gene location has not yet been determined.
The abnormal gene causing FD is rare in the general population but has a fairly high incidence in the Ashkenazi Jewish population, originating from Eastern Europe. Both males and females are affected. In the at-risk group, one in 30 people is thought to be a carrier of the abnormal gene, with a disease frequency of one in 3,600 live births. Rare non-Jewish individuals affected with FD have been reported.
Signs and symptoms
Sensory and autonomic nervous systems fail to develop properly in the fetus. Newborn babies with FD have poor or decreased muscle tone and have poor sucking and swallowing reflexes that make feeding difficult. Affected babies are prone to periods of abnormally low body temperature and are unable to produce adequate tears when crying.
Although symptoms vary markedly, by adolescence affected children have a 90% likelihood of spinal curvature and experience weakness and leg cramping. They have difficulty concentrating and undergo personality changes including negativism, depression , irritability, and insomnia. Forty percent of affected people have regular vomiting crises in response to either emotional or physical stress. A crisis typically involves one to three days of compulsive vomiting, rapid heart rate, high blood pressure, profuse sweating, and red, blotchy skin.
Between crises, affected individuals may experience low blood pressure when rising to a standing position. They often have unexplained fevers and may have convulsions in response to even mild infections. Uncoordinated swallowing, reflux of stomach contents, and a poor gag reflex result in food or fluids being misdirected into the trachea and lungs. Aspiration pneumonia (lung infections) often follows. Kidney function may deteriorate with age. Affected people have an abnormal response to low oxygen or high carbon dioxide in their blood. They do not experience the expected "air hunger," or urge to breathe, and may faint or have a seizure. Lack of tears, decreased blink frequency, and insensitivity of the eye to pain from foreign objects can cause inflammation and ulcers of the cornea.
A characteristic sign in those affected with familial dysautonomia is a lack of the sense of taste. This is due to the absence of taste buds on the tongue. Other sensory problems include an inability to feel pain or distinguish between hot and cold temperatures; sensory loss increases with age. Deep tendon reflexes in affected individuals are decreased. Poor speech and motor coordination result in abnormal gait, unsteadiness, tongue thrusting, and abnormal rhythmic facial movements. Growth is stunted, with an average adult height of 5 ft (1.5 m). Puberty is delayed in both sexes. However, fertility and offspring of affected individuals are normal.
The presentation of FD varies between affected people. However, of the many manifestations of the disease, five signs are key to the diagnosis:
- flat, smooth tongue due to lack of taste buds,
- lack of red flare following histamine injection under the skin,
- decreased or absent deep tendon reflexes,
- absence of overflow tears with emotional crying,
- parents of Ashkenazi Jewish background.
Other frequent signs are decreased response to pain and temperature, decreased corneal reflexes, unstable blood pressure, low blood pressure when standing erect, red blotching of the skin, and increased sweating. Further supportive evidence of the FD diagnosis are feeding difficulties, repeated aspiration pneumonia, episodes of low body temperature, breath holding spells, poor muscle tone, delayed motor development, repeated vomiting, spinal curvature, and poor growth. Prenatal diagnosis, screenings for carrier status, and genetic counseling are available.
Treatment and management
The identification of the FD gene as IKBKAP was reported in March 2001, and is expected to lead to new treatment approaches as the function of the gene is better understood. Until that time, treatment is preventive and supportive. Management of vomiting crises is attempted with drugs, replacement of body fluids, prevention of aspiration of stomach contents into lungs, control of blood pressure, and promotion of sleep. Care of the eyes includes artificial tears, eyewashes, and topical antibiotics to avoid ulcers of the cornea. Early and adequate treatment of even mild infections is important to avoid triggering vomiting crises. Children should be protected from injury and watched for any unusual swellings or skin discolorations as a way of coping with decreased pain and temperature perception.
Physical and occupational therapy, braces, and other orthopedic aids are used for spinal curvature and poor motor coordination. Speech therapy, special feeding techniques, and respiratory care enhance quality of life. It is important to maintain adequate fluid intake and avoid situations such as high elevations, air travel, and diving underwater where oxygen concentration is decreased. Psychological intervention is helpful to alleviate emotional instability and mood swings in children and depression, anxiety, and phobias in adults.
The disease process of familial dysautonomia can not be prevented at present but 80% of affected individuals survive beyond childhood and 50% reach age 30. With the 2001 determination of the exact location of the gene abnormality, prospects for new treatments and possible gene therapy are on the horizon.
Gilbert, Patricia. Riley-Day Syndrome. The A-Z Reference Book of Syndromes and Inherited Disorders. 2nd ed. San Diego: Singular Publishing Group, Inc., 1996.
Axelrod, Felicia B. "Familial Dysautonomia: A 47-year Perspective." Journal of Pediatrics 132, no.3 (March 1998): S2-5.
Gelbart, Marsh. "In Our Parents' Shadow. Riley-Day Syndrome." Nursing Times 95, no. 6 (February 10-16, 1999): 33.
Dysautonomia Foundation, Inc. 633 Third Ave., 12th Floor, New York, NY 10017-6706. (212) 949-6644. <www.med.nyu.edu/fd/fdcenter.html>.
Marianne O'Connor, MT (ASCP), MPH