PHOENIX NEST BIOTECH

Jonah was born in 2008, we did not notice anything amiss. He was meeting his milestones on time.  At Jonah’s one year well visit we saw a new pediatrician. Our pediatrician remarked that Jonah’s head circumference was well above average. He referred back to the charts of Jonah’s first year of life and noted that Jonah’s head circumference was above average at birth and continued to grow. He recommended an MRI so we could rule out hydrocephaly. He sent us to a neurologist who agreed. What we didn’t know was that both of these doctors had a gut feeling that something else might be the cause of Jonah’s large head. They saw his coarse facial features, which my husband and I did not pick up on.  I want to point out that the hallmark features of a Lysosomal Storage Disease (LSD) even with the mildest somatic features can be detected at birth. 

 

The MRI was performed at NYU Langone. The MRI showed findings of: Frontal bossing, a bone deformity consistent with the MPS’s, innumerable prominent dilated perivascular spaces in the cerebral hemispheric white matter, including several lesions in the corpus callosum and J-shaped sella. These findings were all consistent with the group of diseases called mucopolysaccharidosis (MPS). 

 

Langone physicians recommended testing for all of the MPS’s. Our geneticist did this through Greenwood Genetics lab, it came back with elevated levels of Heparan Sulfate, which pointed towards MPS III, more commonly known as Sanfilippo syndrome.  We next did an enzymatic test to find out which subtype, that came back MPS IIIC.  Jonah was 22months at the time of diagnosis and to my knowledge is one of just a couple of babies diagnosed asymptomatic, without an older brother or sister diagnosed first. From my experience I would guestimate the average age of diagnosis for MPS IIIC, to be ~8. In the literature subtypes C and D are considered less severe than A and B. They are also noted as being rarer. I would agree on both of these statements. However, Sanfilippo syndrome is heterogeneous. Even between subtypes, a type C child can be just as severe as a type A child. I have also noticed a difference between severity of type C children from different geographical locations.

 

We were asked to take Jonah to numerous medical appointments: ENT, GI, MRI of the spine, head to toe X-rays, sleep study, cardiologist, allergist and ophthalmologist.

 

Jonah’s ear canals were filled with fluid, he had grommets placed for drainage. His adenoids were removed as well. The cervical spine MRI showed that the odontoid process as being small and sclerosed, meaning his top vertebrae was not formed properly. The echogram of his abdomen showed that he had hepatosplenomegaly, his liver and spleen were enlarged. The X-rays showed a couple of minor bone deformities, flared ribs and a raised sternum. A physical examination determined that he had ankle clonus.  

 

Between the ages of 1-4 Jonah suffered from numerous sinus infections, the worst being at 1 year of age. His ear infections are still frequent but have subsided some over the years. His nose no longer runs constantly. Jonah’s mucus is quite thick and sticky which is MPS related. Jonah developed seasonal allergies, that must be treated.  At the age of 2 Jonah started having bouts of non food or parasite related diarrhea.

 

As a toddler Jonah was extremely active, he was a runner and fearless.  He was very curios, he got into everything. He also threw the world’s most epic temper-tantrums. Throwing himself down on the ground kicking and screaming, he’d do it anywhere. He did this when he wanted to do something and was told he couldn’t. He has oppositional defiance disorder, which started to subside at the age of 7 but picked back up at 10, possibly due to puberty and then subsided again at age 13. We took him to an ABA therapist who helped my husband and I by teaching us how to manage the behaviors. We were able to break him from the temper-tantrums. Mood altering drugs had some affect when he was a toddler but stopped helping by elementary school. When not exhibiting difficult behaviors, Sanfilippo children are loving, affectionate, and sociable.

​

Jonah’s hair was fine and silky for the first three years of life, it quickly became thick and coarse. His lower half is abnormally hairy. Physicians and even hairdressers should take note of this change. A hairdresser once commented that Jonah must live in a swimming pool.  

 

Sanfilippo children are almost always diagnosed with Autism before receiving a Sanfilippo diagnosis. Physicians, if your autistic patient has frontal bossing, coarse hair and is overly hyper active, please test for MPS III. ​

 

Jonah has never had any seizures, nor does he have sleep issues. He did have infrequent night terrors until he was about 5. Jonah has also never had the disturbing episodes of inconsolable laughing or crying. These episodes fit into the description of Pseudobulbar Affect (PBA), but the underlying cause is not known. Parents search relentlessly for a medical explanation, sadly their physicians don’t usually come up with a definitive diagnosis. The frequency of these episodes is unpredictable, it may happen once and never again.

 

There are a few papers published that discuss retinitis pigmentosa in Sanfilippo children and non-syndromic adults. Out of curiosity I requested that Jonah have an ERG and OCT, these are not easily performed on Sanfilippo children who have a hard time sitting still. We did get a couple of good images of his retina; he has cystoid macular edema. 

 

When Jonah received his diagnosis he qualified for early intervention, we had in home speech therapy and physical therapy.  I wish we would have had OT from the start, Jonah has a hard time with motor planning. He had his first set of grommets placed in his ears at 2 years of age. We didn’t know that he could not hear well, his ENT said that Jonah’s hearing was as bad as someone trying to hear underwater. At that time Jonah was meeting his milestones and had several words. When the grommets were placed, we noticed an immediate improvement. He started pointing noises out, a plane, a motorcycle, baby crying, noises that he had not asked about before. After 2 sets of grommets, he had T-tubes, those were removed when he was 10 and he started wearing hearing aids.

 

Jonah began pre-school at 3 years of age, he received speech therapy 5 days a week! He also had OT and PT.  His motor planning and sense of self-awareness while he walks has never been normal. He’s now a bit knock-kneed and his gait is off. Jonah stopped with the fearless running by the time he was 6. He is aware of traffic and stops at crosswalks. 

 

He has irrational fears, he is uncomfortable around dogs. He does not like Halloween, he is wary of the costumes. I mention this minor hallmark because some kids have profound irrational fears. Running into the street to avoid walking by a dog. The literature always describes Sanfilippo children as fearless, there is a difference. 

 

Some kids have sensory seeking needs. Sucking on their shirts or a toy. Jonah excessively picks his fingers, toes and nose. Another child might like tearing shreds of paper, another the feel of someone else’s hair. Jonah used to lick anything from a subway mural to a stranger’s arm. It has gotten a lot better, but he still has compulsions. I recently caught him licking the bottom of his shoe. Germs are nerve wracking for Sanfilippo parents, upper respiratory infections easily lead to pneumonia. Older children don’t always survive pneumonia. Other times children don’t bounce back from an acute infection. Aspiration pneumonia is also common, swallowing issues should be watched for.

 

Physicians, I’d like one of your takeaways to be on the importance of early diagnosis. Because of Jonah’s early diagnosis we were able to save his hearing, at 14 Jonah’s language is well above average. He can speak full sentences and he can read at a first-grade level. If he had not been diagnosed at 2, he would not have received immediate early intervention therapies, he would not have qualified to attend a private pre-school at no cost. Emotionally and financially my husband and I are in a much better place than we would have been if Jonah had received his dx at 8. We were able to make major life decisions for our family, we could have had three affected children. We chose our home and made career choices that accommodated Jonah’s health and educational needs. I have noticed that physicians don’t always think along these lines, not wanting to tell a parent of a newborn that their child has an untreatable terminal illness. Assuming instead that ignorance is bliss.  It isn’t blissful to wonder why your child is not like their siblings or the other kids at the playground. Feeling like a bad parent because their child runs down the grocery store isle knocking food off the shelves. Getting kicked out of schools. Physicians, please don’t try to spare a parent’s feelings, we’re going to find out eventually, might as well be before it’s too late. 

 

The Cure Sanfilippo Foundation and the MPS Society are also of particular help. An extensive list of literature on Sanfilippo syndrome can be found on the Cure Sanfilippo Foundation site.

 

Sincerely,

Jill Wood (Jonah’s proud Mother)

​

​