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Chiari malformation Type I

After waiting for 4 months, Vera finally had an MRI scan done recently of her back, spine and head. Towards the summer of 2015, Vera had been making progress with walking with her walker and had started potty training. mri-kamerBut it turned out summer was her best moment. In August she started regressing again. She made it clear she was in pain more often (during the day, but also at night, despite sleep medication she would wake suddenly and cry loudly), she didn’t want to sit on the potty any more and was walking less and less. She went from walking from the garden gate to the square near our house to a few steps in the living room and sitting or laying down again, simply because she couldn’t do it. She often pointed to her leg or knee hurting and made the gesture for doctor. This was not only noticeable at home but at her therapeutic preschool as well.

So in September we prompted a call to action and requested an MRI after consultation. In the first place because we thought she might have tethered cord, where the spinal cord is abnormally attached to the base of the spine and the spinal cord can’t move freely. A common problem often associated with Costello syndrome. Most of her symptoms would fit this diagnosis. They looked at her head as well during the MRI because chiari is another known issue often associated with Costello syndrome.
To make the story complete: the scan for tethered cord was needed regardless, because the positioning of her feet was getting more and more off and her Achilles tendons appear to be too short. This can be solved by stretching, putting her feet in casts and stretching little by little. But this can only be done when tethered cord is ruled out, otherwise it will only make things worse. This option is still a possibility in the coming year to correct the positioning of her feet and to hopefully improve her walking.
In short: the MRI was part of a careful consideration in the correct order of tests based on her complaints.

But the results of the MRI, two weeks ago, were unexpected. There was no tethered cord. But the MRI did show a cavity in the medulla oblongata (located in the hindbrain) and a mild chiari malformation.

chiari malformation

A chiari malformation is, in short, the downward displacement of the bottom part of the brain through the opening at the base of the skull. In Vera’s case it’s the cerebellar tonsils and it’s mild (there are lots of people who have this but the condition can remain unknown because there are no symptoms). But, combined with the cavity (possibly a cyst) present in the medulla oblongata, this could very well be the cause of Vera’s symptoms. Because we don’t have an earlier MRI, there is no point of reference or comparison, which makes it impossible to pinpoint when this may have started to develop. The cavity in the medulla oblongata (syringomyelia) in particular can cause a lot of symptoms in vital functions such as waking/sleeping and loss of strength in the limbs. Problems with swallowing, pressure in the ears, headaches, painful bowel movements (due to pressure in the spine) and vision problems are also mentioned. These are all symptoms that Vera has, so there could be a correlation. We were quickly invited for a consultation with the paediatric neurosurgeon.

During a good conversation we quickly agreed to operate. Part of the cerebellar tonsils have slipped through the opening at the base of the skull into the spinal cavity. There is not enough space in the skull itself for the cerebellum and therefore more space has to be created in the skull bone. To speak with the words of the surgeon: the operation will be ‘bone only‘. Fortunately, the membranes and the brain itself will be left alone so there will be less risk.Nonetheless, we are about to embark on a very scary operation, possibly even before April.

I may be able to write this down in a technical and calm manner, but for us as parents (and big sister Mieke of course) these are scary and trying times. Making sure you are ‘reading’ your child correctly, having critical conversations as parents about what we are seeing and whether or not we should take action, the blurred overall picture because so many other medical issues are going on with Vera and could be causing similar symptoms, the difficulty in communicating with her to find out what is and what isn’t bothering her, the many phone calls and car trips to the hospital, conversations with doctors and the medical tests all drain our energy. Not to mention the emotional toll it has on a parent to watch your child cry many times a day because she is hurting somewhere inside her body. The past couple of months we have walked around with her and held her very often. Not counting a couple of hours of continuous sleep at night, we basically have had to comfort her hourly, holding her with her head on our shoulders or in our lap to get her comfortable again. Every day.
So oddly, we feel a sense of relief that, after the process of worrying, taking action, testing (while doubting all the while whether all this invasiveness is really necessary) and waiting for the results, we finally have a conversation with a possible course of action to solve the problem. ‘Cause in the end, that is what we want: to improve Vera’s quality of life. And in doing so, lighten the burden in daily life for us as parents as well.

And, as is always the case with Vera, between all the bad moments, we keep being amazed at her infectious smile and endless enthusiasm to make the best of things and to do what she can do.

happy sisters

 

Gallery
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Experiences in Manchester

Report from the 2015 conference in Manchester: first part is generally (with some pictures), last part are details of the lectures (with some pictures of the presentations)

There was good atmosphere and it was educational, confrontational, busy and emotional…the Costello syndrome conference in Manchester was many things at once. First and foremost, it was once again special to meet other people with the syndrome. In The Netherlands we know 3 children besides Vera with Costello, being in the UK we could add 10 more with ages ranging between 2 and 30. All from different European countries. Because our children all look so similar and because we are dealing with such similar difficulties in our lives, these people quickly become family. We are able to have deep conversations quickly, where we share experiences and exchange tips. It instantly feels like we’ve known each other for much longer.

In some cases it gives us hope to see examples of what awaits Vera as she gets older and in other cases it can be quite confronting. Orthopaedic problems are fairly common, walking is possible for most people with the syndrome, but most use a wheelchair as well. Speech and language capabilities can vary greatly. And not everyone will be able to graduate from tube feedings. It became clear that, while the syndrome causes many similarities, every child or adult follows their own path with its own challenges, talents and limitations.
At this conference there were also about 20 families with children who have CFC, a syndrome that’s closely related to Costello. And again we had wonderful exchanges and saw many similarities, but also different challenges.

The days were planned so that there was time to spend time with the families, but also to attend lectures while there was a children’s program going on at the same time. Niels and I took turns attending lectures and spending time with the children. We’ve learned more about the increased chance of developing tumours, about autism and ADHD and the new knowledge about the decreased amount of growth hormones. We also heard about what was discussed during the American Costello conference in Seattle that took place earlier this year. We feel we moved up a notch again in our education about Vera and the Costello syndrome.

A direct effect of the information we gained during the conference is that we will look further into the shortage of growth hormones. Besides the fact that people with Costello syndrome tend to stay small, we now know that they have a shortage in growth hormones as well. This manifests itself not only in a completely different growth curve (Vera is now even deviating from the adapted CS growth curves), but also in impaired bone growth, less muscle mass, lack of energy and disrupted blood sugar levels.
We learned from two blood tests in the past that Vera’s levels of growth hormone are very low. Next week we will have a test to measure whether it truly is a shortage. If that is indeed the case, we are thinking of supplementing because it could improve her quality of life. This does mean she would need daily shots of growth hormone. We will wait for the test results and will consult with the endocrinologist to see what’s best for Vera.

And finally: a big thank you to our sponsors!
Thanks to you we were able to attend the European Costello conference in Manchester. We came back feeling enriched.
And with a suitcase full of fake spiders that have given me a fright on several occasions since then. (The spiders were from the Halloween party on the last night of the conference.)

 

 


= Details from the lectures for other parents, photos of presentations below =

De first lecture was a general introduction by Dr. Emma Burkitt-Wright. She talked about genetics, in particular about the RAS-MAPK pathway and the differences between CS and CFC (since it was a joint conference) and how common these syndromes are estimated to be at this moment.
Things that stood out for me (Niels):

  • a lot more attention is paid to low blood sugar levels in the US and the UK. (this has never been a big area of interest with Vera. Her blood sugar levels were checked recently but turned out not to be an issue for her. We have heard the same from other Dutch families).
  • It became clear that orthopaedic problems are of much greater concern with CS than with CFC.
  • The numbers associated with heart problems in people with CS (see photo of sheet) are impressively high, in particular the enlarged heart muscle (cardiomyopathy) in 60% of CS cases.
  • For further monitoring of the complications of CS it was recommended to have ultrasounds done 4 times a year to catch possible tumours at an early stage. This has been done with Vera as well. It was recommended to keep doing this at this frequency until the age of 7 after which the testing could be done less often.
  • A head MRI was also recommended, possibly to detect chiari malformation. We suspect Vera will get this MRI in the coming weeks.
  • And finally the importance of a support group for parents was emphasized (a lot of valuable information gets exchanged there, information doctors may not have direct access to or information about which nothing has been published yet), we can only confirm this!

The second lecture was given by Dr. Bronwyn Kerr, an authority in the field of CS research. She gave us an overview of what was discussed at the CS symposium in Seattle earlier this year. What we learned from the Seattle overview:

  • heart monitoring should be life long, the frequency can be lowered as the person gets older.
  • there are adapted growth curves for CS, if growth deviates from these curves, testing is recommended to determine growth hormone levels present in the blood. Supplementing with growth hormone is only beneficial if there is a shortage, which is then only supplemented until normal levels are reached.
  • the topic of hypoglycaemia when giving several tube feedings a day was brought up
  • she talked about nutrition and the lack of causal effect between vitamin C, fish oil, ginseng, co-enzyme Q etc. and improvement (more research was needed for further evidence, it can be hard to determine which factor contributed to improvement).
  • improvement of bone density with vitamin D: research has been started to determine the relationship, early outcomes have been varying.
  • hips: it was recommended to check the hips periodically (annually or twice a year through x-ray, during the first months it can still be done with ultrasound) in particular if tethered cord is present. Instability of the knee is a known fact and should also be checked by the paediatrician (being able to stretch the knee fully).
  • skin problems were discussed as well; this doesn’t apply to us yet, but useful tips on the sheets about the use of alcohol free products to make sure the skin doesn’t dry out further (in particular with shoes).
  • from family surveys in Seattle we learned that arrhythmia often improves after age 4 and speech improves after age 10.
  • anxiety disorder is present in many children, some benefit from the use of the medicine Prozac.
  • for behavioural problems the medication Clonidine is often used. Or medication that is often prescribed for ADHD.
  • sleep problems are a common issue that occur often in many and for long periods of time. Several types of medication are being used, the early years are the hardest. This is an issue that deserves more research as it has a huge impact on the lives of parents and children and is a heavy burden.
  • several studies are currently being done with a mouse with characteristics of CS and NF1 (important to test treatment and influence of signals in the cells), for Noonan syndrome there is a fruit fly model (a lot of information about treatment and how the cells react was gained from this, because it could be repeated quickly and often).
  • there are important developments in the HRAS splicing study (and removing exon2). I do not have sufficient DNA knowledge to expand on this.

The next lecture was by Dr. Peter Clayton about growth differences and treatment. In short (by Leonie): people who are affected by CFC and CS have small stature as a result of their genetic makeup. Decreased amounts of growth hormone can also be present. Dr. Clayton advocated to supplement with growth hormones, if this was the case, until normal levels are reached. Not necessarily to gain height, but to improve quality of life in the first place. Growth hormones regulate growth, blood sugar levels, bone growth and muscle mass. With CS there is often fear that growth hormones would also increase the chance of developing tumour cells (with an already increased chance of cancer). No evidence of this has been found. The thickening of the heart muscle does deserve special attention, however.

Dr. Shruti Garg did a study in the UK on behavioural problems in children with CFC and CS. The last lecture I attended was about this. Behavioural problems appear to be fairly common. The large majority shows signs of AD(H)D and autism. Dr. Garg stated that it could be very beneficial to seek a separate diagnosis. Often, the behaviour is grouped under the characteristics of the syndrome. If a separate diagnosis is attained, more concrete treatment can take place with behavioural therapy and/or medication.

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Interview voor KinderThuisZorg

costello-interviewIn het voorjaarsnummer van het magazine van de KinderThuisZorg is een artikel geschreven over Vera in ons gezin! De journalist heeft ons per telefoon geïnterviewd en ik heb zelf de foto’s gemaakt en aangeleverd. Dus de gezinsfoto is in de huiskamer gemaakt met 10 seconden zelfontspanner 🙂

Erg bijzonder om zo een persoonlijk verhaal te vertellen, dat vervolgens in een oplage van 5.000 stuks verspreid wordt. Ook in het ziekenhuis zagen we hem overal liggen en we zijn al een aantal keer aangesproken door andere ouders, met positieve reactie overigens.

Een van de redenen om hier aan mee te werken is bekendheid te krijgen voor het syndroom. Maar ook om andere ouders ons verhaal te laten meelezen hoe we dit ervaren.

Het artikel met ons verhaal is hier te downloaden als PDF

costello-artikel

Daarnaast is voor dit magazine onze vaste kinderarts uit het WKZ geïnterviewd over het Costello syndroom en wat dat is en medisch gezien betekent.

Het artikel waarin onze kinderarts uitleg geeft over het Costello syndroom is hier te downloaden als PDF

 

[this blog is not translated; the articles are in Dutch too, about our family and about the Costello syndrome in a Dutch magazine]