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Year : 2009  |  Volume : 75  |  Issue : 1  |  Page : 100

Osler-Weber-Rendu syndrome: A case report with familial clustering

1 Department of Dermatology, Armed Forces Medical College and Command Hospital, Pune - 411 040, India
2 Department of Radiodiagnosis, Armed Forces Medical College and Command Hospital, Pune - 411 040, India
3 Department of Medicine, Armed Forces Medical College and Command Hospital, Pune - 411 040, India

Correspondence Address:
Sanjiv Grover
Department of Dermatology, Armed Forces Medical College, Pune - 411 040
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0378-6323.45242

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Osler-Weber-Rendu syndrome, also known as hereditary hemorrhagic telangiectasia, is a rare autosomal dominant disorder manifested by telangiectases of the skin and mucous membranes and arteriovenous malformations of various organ systems. We present a case of Osler-Weber-Rendu syndrome with 11 affected members in her family.

Keywords: Familial, Hereditary, Telangiectasia

How to cite this article:
Grover S, Grewal R S, Verma R, Sahni H, Muralidhar R, Sinha P. Osler-Weber-Rendu syndrome: A case report with familial clustering. Indian J Dermatol Venereol Leprol 2009;75:100

How to cite this URL:
Grover S, Grewal R S, Verma R, Sahni H, Muralidhar R, Sinha P. Osler-Weber-Rendu syndrome: A case report with familial clustering. Indian J Dermatol Venereol Leprol [serial online] 2009 [cited 2020 Jun 4];75:100. Available from: http://www.ijdvl.com/text.asp?2009/75/1/100/45242

  Introduction Top

Osler-Weber-Rendu syndrome, or hereditary hemorrhagic telangiectasia (HHT), is a rare genetically determined autosomal dominant disorder identified by the triad of telangiectasia, recurrent epistaxis, and a positive family history for the disorder. [1] Presenting at any age, the disease has a wide spectrum of presentations, varying from asymptomatic to multiple organ involvement. The major cause of morbidity and mortality lies in the presence of multiorgan arteriovenous malformations (AVMs) and the associated hemorrhage. We present a case of HHT with typical mucocutaneous and gastrointestinal (GI) AVMs and association in 11 other members of the patient's family.

  Case Report Top

A 45-year-old postmenopausal lady born to nonconsanguineous parents presented with multiple red raised lesions on the tongue and both hands of almost 25 years duration. She also had breathlessness on exertion and easy fatig ability since 15 years. She had a history of recurrent spontaneous severe bleeding from the lesions, especially from those on the tongue due to which she had to receive multiple blood transfusions in the past two decades, and multiple episodes of mild epistaxis, palpitations, and frequent blackouts. There was no history of bleeding gums, abdominal pain, bleeding rectum, headaches, seizures, visual disturbances, hemoptysis, menorrhagia, or bluish discoloration of fingertips or nose. There was history of similar lesions being present in 11 of her immediate family members [Figure 1]. Her three elder sisters died of severe bleeding from such lesions in the mouth and hands; also, her father suffered from hemiplegia.

Clinical examination revealed pallor and absence of organomegaly. Dermatologically, multiple erythematous macular blanchable lesions on both palms, multiple erythematous compressible nonpulsatile papulonodular lesions on the tongue, and multiple petechiae over the palate [Figure 2] were evident.

Investigations revealed microcytic hypochromic anemia, normal reticulocyte count, and normal coagulation profile. Serum for antinuclear antibody (ANA), urine for hemoglobinuria, and Sickling test were negative. Abdominal ultrasonogram, chest skiagram, and fundoscopy were unremarkable. Angiogram of carotids revealed multiple telangiectatic lesions in the tongue fed by bilateral lingual arteries, while those in the palate were fed by sphenopalatine branch of internal maxillary artery (IMA) [Figure 3]. The lesions showed early venous drainage with persistence of stain in the parenchymal phase. Upper GI endoscopy revealed multiple petechiae in the abdominal wall. Neither colonoscopy nor abdominal, pulmonary, and renal angiograms revealed any AVMs in other organ systems.

  Discussion Top

While Henri Rendu (1896), Sir William Osler (1901), and Frederick Parks Weber (1907) emphasized and published detailed observations of the syndrome which bears their names, it was Sutton (1864) who first described Osler-Weber-Rendu disease and Benjamin Guy Babington (1865) was the first to note its familial nature.

A number of variants of HHT have been described in literature. HHT type-1 and type-2 are due to defective endoglin ( ENG ) and activin like receptor kinase ( ALK1 ) genes, respectively. Mutations of ENG are located on the long arm of chromosome 9 (9q33-34), whereas ALK1 mutations are on the long arm of chromosome 12 (12q13). [2],[3] HHT type-3 involves mutations of the long arm of chromosome 5 (5q31.1-32) and type-4 maps to the short arm of chromosome 7 (7p14). [4],[5] A HHT-juvenile polyposis overlap syndrome due to mutations of SMAD4 has also been described. [6] Patients with the HHT type-1 genotype have higher prevalence of pulmonary and cerebral AVMs, and more severe GI bleeding than in those with the HHT type-2 genotype. Conversely, the prevalence of hepatic AVMs is higher in patients with HHT type-2 than in those with HHT type-1. [7] Although the precise mechanism remains poorly understood, bleeding tendency in HHT is attributed to localized vessel wall weakness.

Diagnosis is based on the four components of the Curaηao criteria, established by the Scientific Advisory Board of the HHT Foundation International, Inc., viz. (1) epistaxis: spontaneous and recurrent; (2) telangiectasias: multiple, at characteristic sites, including lips, oral cavity, fingers, and nose; (3) presence of internal lesions: GI telangiectasia, pulmonary, hepatic, cerebral, and spinal AVMs; and (4) family history: first-degree relative with HHT according to these criteria. The diagnosis is considered definite if any three of the above mentioned criteria are present and possible if any two of the criteria are present. The diagnosis is unlikely if less than two criteria are present. [8] Our case was unique with the presence of all four criteria confirming the diagnosis. In the absence of pulmonary AVMs, her symptomatology is attributed to anemia resulting from frequent bleeding from her vascular lesions.

The varied treatment modalities include estrogen, Î-amino-caproic acid, cryotherapy, cautery, infrared coagulation, radiofrequency, pulse dye laser, Nd-YAG laser, and surgical ablation - all of which may be fraught with risks. [9],[10],[11],[12],[13]

Asymptomatic pulmonary and CNS AVMs and their hemorrhagic or embolic complications, viz. brain abscess and stroke are responsible for most of HHT's 10% mortality rate. It is crucial that a long-term follow-up for identification of potential complications is maintained and patients are counseled regarding the autosomal dominant nature of the condition.

Though cases have been reported with digital and mucocutaneous telangiectasias, [14] our case is particularly unique as it had all the four criteria for diagnosis and that 12 members of the same family could be identified with this disease.

  References Top

1.Guttmacher AE, Marchuk DA, White RI Jr. Hereditary hemorrhagic telangiectasia. N Eng J Med 1995;333:918-24.  Back to cited text no. 1    
2.Gu Y, Jin P, Zhang L, Zhao X, Gao X, Ning Y, et al . Functional analysis of mutations in the kinase domain of the TGF-beta receptor ALK1 reveals different mechanisms for induction of hereditary hemorrhagic telangiectasia. Blood 2006;107:1951-4.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Shovlin CL, Hughes JM, Scott J, Seidman CE, Seidman JG. Characterization of endoglin and identification of novel mutations in hereditary hemorrhagic telangiectasia. Am J Hum Genet 1997;61:68-79.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Cole SG, Begbie ME, Wallace GM, Shovlin CL. A new locus for hereditary haemorrhagic telangiectasia (HHT3) maps to chromosome 5. J Med Genet 2005;42:577-82.   Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Bayrak-Toydemir P, McDonald J, Akarsu N, Toydemir RM, Calderon F, Tuncali T, et al . A fourth locus for hereditary hemorrhagic telangiectasia maps to chromosome 7. Am J Med Genet 2006;140:2155-62.  Back to cited text no. 5    
6.Gallione CJ, Repetto GM, Legius E, Rustgi AK, Schelley SL, Tejpar S, et al . A combined syndrome of juvenile polyposis and hereditary haemorrhagic telangiectasia associated with mutations in MADH4 (SMAD4). Lancet 2004;363:852-9.   Back to cited text no. 6    
7.Johnson DW, Berg JN, Baldwin MA, Gallione CJ, Marondel I, Yoon SJ, et al . Mutations in the activin receptor like kinase 1 gene in hereditary hemorrhagic telangiectasia type 2. Nat Genet 1996;13:189-95.   Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Shovlin CL, Guttmacher AE, Buscarini E, Faughnan ME, Hyland RH, Westermann CJ, et al . Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Am J Med Genet 2000;91:66-7.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Saba HI, Morelli GA, Logrono LA. Brief report: Treatment of bleeding in hereditary hemorrhagic telangiectasia with aminocaproic acid. N Eng J Med 1994;330:1789-90.  Back to cited text no. 9    
10.Colver GB, Davies S, Bullock J. Infra red coagulation for bleeding mucosal telangiectasia. J Laryngol Otol 1992;106:992-3.  Back to cited text no. 10  [PUBMED]  
11.Galletta A, Amoto G. Hereditary hemorrhagic telangiectasia (Osler-Rendu-Weber disease): Management of epistaxis and oral hemorrhage by Nd-YAG laser. Minerva Stomatol 1998;47:283-6.   Back to cited text no. 11    
12.Harries PG, Brockbank MJ, Shakespeare PG, Carruth JA. Treatment of hereditary haemorrhagic telangiectasia by the pulsed dye laser. J Laryngol Otol 1997;111: 1038-41.  Back to cited text no. 12  [PUBMED]  
13.Maarouf M, Runge M, Kocher M, Zδhringer M, Treuer H, Sturm V. Radiosurgery for cerebral arteriovenous malformations in hereditary hemorrhagic telangiectasia. Neurology 2004;63:367-9.  Back to cited text no. 13    
14.Thappa DM, Laxmisha C. Recurrent bleeding from the tip of index finger and mucocutaneous telangiectases: Osler-Weber-Rendu syndrome. J Postgrad Med 2002;48:274-87.  Back to cited text no. 14  [PUBMED]  


  [Figure 1], [Figure 2], [Figure 3]

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