A case of Kartagener's syndrome: Importance of early diagnosis and treatment

Kartagener''s syndrome is a very rare congenital malformation comprising of a classic triad of sinusitis, situs inversus and bronchiectasis. Primary ciliary dyskinesia is a genetic disorder with manifestations present from early life and this distinguishes it from acquired mucociliary disorders. Approximately one half of patients with primary ciliary dyskinesia have situs inversus and, thus are having Kartagener syndrome. We present a case of 12 year old boy with sinusitis, situs inversus and bronchiectasis. The correct diagnosis of this rare congenital autosomal recessive disorder in early life is important in the overall prognosis of the syndrome, as many of the complications can be prevented if timely management is instituted, as was done in this in this case.     

A case of Kartagener’s syndrome: Importance of early diagnosis and treatment

Kartagener’s syndrome is a very rare congenital malformation comprising of a classic triad of sinusitis, situs inversus and bronchiectasis. Primary ciliary dyskinesia is a genetic disorder with manifestations present from early life and this distinguishes it from acquired mucociliary disorders. Approximately one half of patients with primary ciliary dyskinesia have situs inversus and, thus are having Kartagener syndrome. We present a case of 12 year old boy with sinusitis, situs inversus and bronchiectasis. The correct diagnosis of this rare congenital autosomal recessive disorder in early life is important in the overall prognosis of the syndrome, as many of the complications can be prevented if timely management is instituted, as was done in this in this case.     

Handedness and situs inversus in primary ciliary dyskinesia

...The limbs on the right side are stronger. [The] cause may be ... [that] ... motion, and abilities of moving, are somewhat holpen from the liver, which lieth on the right side. (Sir Francis Bacon, Sylva sylvarum (1627).)Fifty per cent of people with primary ciliary dyskinesia (PCD) (also known as immotile cilia syndrome or Siewert-Kartagener syndrome) have situs inversus, which is thought to result from absent nodal ciliary rotation and failure of normal symmetry breaking. In a study of 88 people with PCD, only 15.2% of 46 individuals with situs inversus, and 14.3% of 42 individuals with situs solitus, were left handed. Because cerebral lateralization is therefore still present, the nodal cilia cannot be the primary mechanism responsible for symmetry breaking in the vertebrate body. Intriguingly, one behavioural lateralization, wearing a wrist-watch on the right wrist, did correlate with situs inversus.     

Kartagener's syndrome and the syndrome of immotile cilia

Summary Kartagener's syndrome (KS) is a hereditary disease with typical symptoms of situs inversus, bronchiectasis, and chronic infections of the nasal mucosa. Autosomal recessive inheritance cannot be doubted on account of repeated observations of affected sibs and parental cansanguinity. The bronchopulmonary symptoms in sibs, however, cannot be explained by this mode of inheritance.Recent clinical findings and electron microscope investigations suggest that KS is a special form of manifestation within the immotile cilia syndrome. This disease combines the typical bronchial and nasal symptoms of KS with sterility in the male due to immotile sperm tails and, as a facultative symptom, situs inversus. Thus, sibs with bronchiectasis but without situs inversus are also classified under this syndrome. The symptoms mentioned are caused by an abnormal morphology of bronchial cilia and sperm tails, which can be demonstrated by electron microscopy. The dynein arms normally attached to the nine microtubular doublets and providing a normal ciliary movement are lacking.It is assumed that during early embryonic life ciliary beats in the growing embryo determine the type of laterality. When ciliary movements are absent laterality may develop fortuitously, thus effecting a situs inversus in about half the affected cases. The numerical evaluation of pedigrees from the literature supports this assumption.     

Congenital heart disease and the specification of left-right asymmetry

Complex congenital heart disease (CHD) is often seen in conjunction with heterotaxy, the randomization of left-right visceral organ situs. However, the link between cardiovascular morphogenesis and left-right patterning is not well understood. To elucidate the role of left-right patterning in cardiovascular development, we examined situs anomalies and CHD in mice with a loss of function allele of Dnaic1, a dynein protein required for motile cilia function and left-right patterning. Dnaic1 mutants were found to have nodal cilia required for left-right patterning, but they were immotile. Half the mutants had concordant organ situs comprising situs solitus or mirror symmetric situs inversus. The remaining half had randomized organ situs or heterotaxy. Looping of the heart tube, the first anatomical lateralization, showed abnormal L-loop bias rather than the expected D-loop orientation in heterotaxy and nonheterotaxy mutants. Situs solitus/inversus mutants were viable with mild or no defects consisting of azygos continuation and/or ventricular septal defects, whereas all heterotaxy mutants had complex CHD. In heterotaxy mutants, but not situs solitus/inversus mutants, the morphological left ventricle was thin and often associated with a hypoplastic transverse aortic arch. Thus, in conclusion, Dnaic1 mutants can achieve situs solitus or inversus even with immotile nodal cilia. However, the finding of abnormal L-loop bias in heterotaxy and nonheterotaxy mutants would suggest motile cilia are required for normal heart looping. Based on these findings, we propose motile nodal cilia patterns heart looping but heart and visceral organ lateralization is driven by signaling not requiring nodal cilia motility.     

Genetical and ultrastructural aspects of the immotile-cilia syndrome.

The immotile-cilia syndrome is a congenital disorder characterized by all cilia in the body being either immotile or showing an ineffective beating pattern. Most symptoms, not unexpectedly, come from the ciliated epithelia, but two further symptoms are: (1) male sterility caused by the spermatozoa being unable to swim progressively (the sperm tail has the same structure as a cilium), and (2) situs inversus in 50% of the cases possible caused by an inability of embryonic cilia to shift the heart to the left side. By electron microscopy, one can see directly which of the many ciliary components is the missing one. The molecular basis of this congenital defect can then be detected, and it has been found to be a heterogeneous disease. There are many genes that, when mutated, will cause the cilia to be dysfunctional or totally immotile. The fact that many genes may be responsible for the syndrome will also explain why it has a relatively high prevalence and why previous investigators have been unable to locate the (assumed single) gene by linkage analysis. The trait, situs inversus, is of particular interest as it occurs in only 50% of the assumed homozygotes. I conclude that the wild-type genes code for a control of the proper body asymmetry and the mutated ones for a lack of control, and, hence, to a random situs determination.     

Axonemal dynein intermediate-chain gene (DNAI1) mutations result in situs inversus and primary ciliary dyskinesia (Kartagener syndrome)

Kartagener syndrome (KS) is a trilogy of symptoms (nasal polyps, bronchiectasis, and situs inversus totalis) that is associated with ultrastructural anomalies of cilia of epithelial cells covering the upper and lower respiratory tracts and spermatozoa flagellae. The axonemal dynein intermediate-chain gene 1 (DNAI1), which has been demonstrated to be responsible for a case of primary ciliary dyskinesia (PCD) without situs inversus, was screened for mutation in a series of 34 patients with KS. We identified compound heterozygous DNAI1 gene defects in three independent patients and in two of their siblings who presented with PCD and situs solitus (i.e., normal position of inner organs). Strikingly, these five patients share one mutant allele (splice defect), which is identical to one of the mutant DNAI1 alleles found in the patient with PCD, reported elsewhere. Finally, this study demonstrates a link between ciliary function and situs determination, since compound mutation heterozygosity in DNAI1 results in PCD with situs solitus or situs inversus (KS).     

Adrenergic neurotransmitters and calcium ionophore-induced situs inversus viscerum in Xenopus laevis embryos

Xenopus laevis embryos at the blastula–early tail bud stage were exposed to norepinephrine or octopamine dissolved in culture saline until they reached the larval stage. The left–right asymmetry of the heart and gut was then examined. We found that these adrenergic neurotransmitters induced situs inversus in the heart and/or gut in up to 35% of tested neurula embryos. Norepinephrine-induced situs inversus was blocked by the α-1 adrenergic antagonist prazosin. Furthermore, A23187, a calcium ionophore, also increased the incidence of situs inversus up to 54% when late-neurula embryos were exposed to the solution. A23187 treatment initiated before neural groove formation was less effective. The incidence of situs inversus induced by these reagents decreased towards the control level (2.2%, 25 untreated embryos out of 1127 embryos in total) in embryos past the stage of neural tube closure. In the present experiments we obtained 22 gut-only situs inversus embryos having an inverted gut and a normal heart. In contrast, such embryos were not observed among the 1127 untreated embryos. An adrenergic signal mediated by an increase in intracellular free calcium may be involved in the asymmetrical visceral morphogenesis of Xenopus embryos.     

The immotile-cilia syndrome: a microtubule-associated defect

The immotile-cilia syndrome is a congenital disorder characterized by all the cilia in the body being either immotile or showing an abnormal and inefficient beating pattern. Most symptoms come from the ciliated airways (nose, paranasal sinuses, and bronchs) and from the middle ear. Two further symptoms are situs inversus and male sterility. Situs inversus occurs in 50% of the cases and this subgroup is termed the Kartagener's syndrome; it might be due to an inability of the embryonic cilia to shift the heart to the left side and situs laterality seems to be a random process in the immotile-cilia syndrome. Male sterility is caused by the spermatozoa being unable to swim progressively; the sperm tail has the same structure as a cilium. In a few cases only the sperm tail or only the cilia of the body are affected. Female patients have a decreased fertility; most are involuntarily childless. The immotile-cilia syndrome is a heterogeneous disorder in that one out of many different genes may be involved. The different subtypes can be distinguished by an electron microscopic examination which will show defects in either one of a number of the ciliary components.     

Paternal age and the occurrence of birth defects

The association between paternal age and the occurrence of birth defects was studied using data collected in Metropolitan Atlanta. Paternal-age information for babies born with defects was obtained from birth certificates, hospital records, and interviews with mothers; for babies born without defects, the information was obtained from birth certificates. Several statistical techniques were used to evaluate the paternal-age-birth-defects associations for 86 groups of defects. Logistic regression analysis that controlled for maternal age and race indicated that older fathers had a somewhat higher risk for having babies with defects, when all types of defects were combined; an equivalent association for older mothers was not found. Logistic regression analyses also indicated modestly higher risks for older fathers for having babies with ventricular septal defects and atrial septal defects and substantially higher risks for having babies with defects classified in the category chondrodystrophy (largely sporadic achondroplasia) and babies with situs inversus. An association between elevated paternal age and situs inversus has not been reported before; the magnitude of the estimated increased risk for situs inversus was about the same as that found in this study for chondrodystrophy.     

Primary ciliary dyskinesia: genes, candidate genes and chromosomal regions

Primary ciliary dyskinesia (PCD) is a multisystem disease characterized by recurrent respiratory tract infections, sinusitis, bronchiectasis and male subfertility, associated in about 50% patients with situs inversus totalis (the Kartagener syndrome). The disease phenotype is caused by ultrastructural defects of respiratory cilia and sperm tails. PCD is a heterogenetic disorder, usually inherited as an autosomal recessive trait. So far, mutations in two human genes have been proved to cause the disease. However, the pathogenetics of most PCD cases remains unsolved. In this review, the disease pathomechanism is discussed along with the genes that are or may be involved in the pathogenesis of primary ciliary dyskinesia and the Kartagener syndrome.     

Implantation of a Bi-Ventricular Pacing System in the Setting of Dextrocardia with Situs Inversus Totalis

Dextrocardia with situs inversus totalis is a rare disorder but is frequently associated with anomalous venous return. Pacemaker/Internal Cardioverter Defibrillator implantation in this population can be difficult given the difficult venous anatomy. This case illustrates how beforehand knowledge of the venous anatomy by cardiac MRI can facilitate device implantation.     

A case of otocephaly with anencephaly and meningomyelocele

A case of otocephaly with anencephaly and meningomyelocele: Otocephaly is a rare lethal syndrome with microstomia, aglossia, agnathia, and synotia as major clinical features due to arrest in development of the first branchial arch. Some associated anomalies may be present as cyclopia, holoprosencephaly, cerebellar hypoplasia, situs inversus, and other visceral anomalies. We describe a case of fetus, spontaneously aborted in the 14th week of gestation with otocephaly complex (agnathia, synotia, microstomia) and associated anencephaly and meningomyelocele.     

Ultrastructural abnormalities of respiratory cilia

Ultrastructural abnormalities of human respiratory tract cilia have been studied in 33 patients: 21 were adults, 18 with chronic bronchitis, and 12 were children, two with situs inversus. Abnormalities, such as the lack of a few dynein arms or the loss of a peripheral doublet were observed quite frequently in both children and adults. However, congenital abnormalities associated with the "immotile cilia syndrome" were rare and were observed in only three of the children and none of the adults.     

The development of asymmetry: the sidedness of drug-induced limb abnormalities is reversed in situs inversus mice

We are studying the development of handedness, in particular the relationships between handed structures with bilateral symmetry, for example the limbs, and those with lateral asymmetry, such as the heart, lungs and gut. Asymmetric (unilateral) developmental limb abnormalities can be induced by chemical treatment of mouse embryos, either in utero by acetazolamide, or in culture by misonidazole. We have examined these effects in mice homozygous for the iv gene. The development of bilateral symmetry in iv/iv mice is normal, but the control of asymmetry appears to be random, that is 50% develop normally (situs solitus), 50% with laterally inverted viscera (situs inversus). We find that the handedness of induced asymmetric limb defects is highly correlated with embryonic visceral situs. Right limb defects are induced in situs solitus embryos, left-sided defects in situs inversus. This suggests that the mechanism of induction of asymmetric defects is not related to any intrinsic difference between the development of left and right limbs, but is connected to visceral asymmetry. In addition, the high correlation of limb defects with situs was observed in culture as well as in utero suggesting that the maternal environment plays no role in the development of asymmetry.     

Landmarks in the first hundred years of primary (9+0) cilium research

Primary cilia have had a long research history since 1898, but only in the last few years have investigations become intense. Only a few people took an interest in them until recently, when the consequences of their agenesis or dysfunction suddenly became apparent to all. Their function changed overnight from being speculative to being fully "acknowledged" as sensory, and the consequence of their lacking sensory function(s) led to a bonanza for cell and molecular biologists interested in the impact on clinical disease and disorder. Furthermore, once the medical profession had insight not just into the etiology of an extremely rare syndrome (situs inversus), but into one as prevalent as polycystic kidney disease, furious research activity sprang up in numerous centres, symposium were convened, special sessions arranged, and topical reviews written in all sorts of journals. Without an understanding of the history of research about this organelle, many reviews gave little credit to those who had persevered earlier to make key advances in primary cilium research, and most ignore the wealth of information on them that has relevance to fundamental (cell) biology as well as to medicine. Some of the "landmarks" presented here will hopefully provide a little guidance and a better perspective.     

Three-dimensional electroanatomical mapping for non-pulmonary vein foci in a patient with complete situs inversus and dextrocardia

In patients with atrial fibrillation (AF) having congenital anatomical abnormalities, such as complete situs inversus and dextrocardia, pulmonary vein isolation (PVI) ablation can be performed safety using a three-dimensional electroanatomical mapping system. However, it is not clear whether a three-dimensional electroanatomical mapping system can be used to detect non-PV ectopic beats initiating AF in patients with complete situs inversus and dextrocardia. Here, we report a 21-year-old man with complete situs inversus and dextrocardia, who showed AF caused by non-PV ectopic beats. We successfully detected the origin of the triggered activity from the non-PV foci using three-dimensional electroanatomical mapping.     

Visceroatrial heterotaxy syndrome in the NOD mouse with special reference to atrial situs

Following the onset of diabetes mellitus (DM) in the NOD mouse, diabetic dams have many offspring with severe anomalies, especially with visceroatrial heterotaxy syndrome. The purpose of the present study is to analyze this syndrome with special reference to atrial situs. The fetuses from a colony of NOD mice in our laboratory were divided into two study groups: Group A included fetuses from dams before the onset of DM and group B included fetuses from dams with overt DM before day 8 of pregnancy. The fetuses which had cardiac anomalies with viscero-atrial heterotaxy were classified into four subtypes according to the atrial morphology, i.e., "incomplete situs solitus" (or solitus-like), "incomplete situs inversus" (inversus-like), right isomerism, and left isomerism. Group A (671 fetuses) included only one case with right isomerism (0.15%) and four cases with left isomerism (0.6%). Group B (158 fetuses) had 57 fetuses with heterotaxy syndrome (36.1%), including 20 cases with solitus-like, 6 with inversus-like, 30 with right isomerism, and one with left isomerism. A tendency for right isomerism to occur was found in fetuses with solitus-like and inversus-like anomalies. These results show that the maternal DM in this mouse had an influence upon the morphological mechanism determining right isomerism of visceroatrial heterotaxy syndrome. Thus this syndrome in the NOD mouse is equivalent to asplenia in humans, and it may be useful in elucidating the mechanism of the human syndrome.     

Dextrocardia with situs inversus totalis: Cardiovascular surgery in three patients with concomitant coronary artery disease

Three patients with situs inversus totalis (mirror-image dextrocardia) and concomitant coronary artery disease were admitted to our institution for evaluation. In all cases, aortocoronary bypass grafting was successful. Patients with situs inversus and mirror-image dextrocardia are believed to have normal longevity, and, as these studies suggest, they have the same long-term prognosis after coronary bypass grafting as patients with situs solitus.     

Random determination of a developmental process: reversal of normal visceral asymmetry in the mouse.

Situs inversus viscerum in the mouse has been shown to be inherited as an autosomal recessive trait (gene symbol iv) with reduced penetrance. It is hypothesized that the normal allele at the iv locus exhibits complete dominance and controls normal visceral asymmetry. Absence of this control allows the situs of visceral asymmetry to be determined in a random fashion. This hypothesis also appears to apply to the inheritance of situs inversus in man and to the experimental production of situs inversus.