The signs were so subtle that many doctors over several months had missed them: a slight thickening of the fingertips and toe pads, one ear that was sticking out a little more than the other, almond-shaped eyes, arched eyebrows, a high palate. Elaine Zackai, MD, a clinical geneticist at CHOP, needed to spend only a few minutes examining then 4-month-old Rosalie August, pulling out her trusty jewelers’ loupe for close inspection, before pronouncing, “We should test for Kabuki syndrome. I’m 100% sure she has it.”

 

Kabuki syndrome, so named because children with it tend to have facial characteristics similar to a Japanese Kabuki mask, is a rare genetic condition affecting multiple body systems. Its presentation varies greatly across the population, both in symptoms and severity. And some issues don’t present until the child gets older. 

 

Genetic tests through the Roberts Individualized Medical Genetics Center confirmed Zackai’s opinion, built on decades of experience, and everything fell into place. The elusive diagnosis helped explain not only the visible signs, but the many medical difficulties Rosalie was experiencing.  “As Dr. Zackai was leaving she told me, ‘Don’t Google it,’ but I did,” says Rosalie’s mother, Dara. “At first I thought, ‘No way.’”

Because Rosalie’s father is half Japanese, Dara had another explanation for Rosalie’s eyes. But the more Dara read about the full range of symptoms, the more she believed.

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Rosie was born at a local hospital and spent a month  in the newborn intensive care until she came home on  a nasogastric tube because she had trouble getting enough nutrition by mouth. When Dara pointed out other troublesome features to the doctors there, like her fingertip pads and misshaped ear, “they made me think  I was crazy,” she says “But Rosie is my second child. I knew something was off.” 

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Rosalie was in and out of the hospital a few times over the next three months before she was admitted to CHOP with low blood sugar. Dara had to keep startling Rosalie to keep her awake when she tried to give her a bottle. “She’d take a couple sucks then dose off,” Dara says. “I knew that wasn’t normal.”

 

Once at CHOP, the diagnoses kept coming, and most — in retrospect — were related to Kabuki syndrome.

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Rosalie’s low blood sugar was the result of congenital hyperinsulinism (HI), which is common in children with Kabuki syndrome. Since she didn’t respond to  the two front-line medications, she was started on continuous dextrose (sugar water) to boost her sugar  to the safe range. As she has grown, she’s needed less dextrose and now, at 31/2 years old, may be able to get  off dextrose all together, according to her team in CHOP’s Congenital Hyperinsulinism Center.

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Cardiologists found three small holes in her heart  chambers, two ventricular septal defects and one  atrial septal defect, that allowed oxygenated and deoxygenated blood to mix in the heart, which can sap energy and delay growth. Two of the holes have closed on their own, and the third is smaller. Rosalie has had surgery to correct misaligned eyes (strabismus). She sees specialists in Orthopaedics for hip dysplasia (loose hip joints) and Gastroenterology for chronic constipation. Some conditions are connected to the tendency for children with Kabuki syndrome to have diminished muscle tone (hypotonia). 

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“It seems like every time we come to CHOP, they find something new,” Dara says.

Also on Rosalie’s list of specialists: Neurology, Urology, Otolaryngology, Immunology, the Sleep Center, the Autism Integrated Care Program, Nutrition and the Feeding Clinic. She has been an inpatient numerous times, often for infections; frequent infections are another characteristic of Kabuki syndrome. One consistent trait Dara sees no matter where within CHOP she and Rosalie visit: a family-first approach.

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“Doctors need to be willing to listen to parents,” Dara says. “Together, we need to brainstorm different solutions. CHOP is wonderful. Doctors don’t dismiss what I say. They listen and think outside the box. If it wasn’t for CHOP, my daughter would not be alive.”

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The Rare Disease Program within the Roberts IMGC recognizes that children with Kabuki syndrome need a team of specialists that understands the multifaceted and evolving nature of the syndrome to guide families. 

To better serve these families, the RIMGC is launching  a special multidisciplinary clinic just for them. In  

one appointment, they will meet with a clinical  geneticist, genetic counselor, endocrinologist,  gastroenterologist, immunologist and nutritionist. Additional pediatric specialists join the team as needed by a particular patient. Together, they’ll map out a care plan tailored for each child. “I’m thrilled,” Dara says. “It will be a significant help for those of us in the Kabuki community. When we get this diagnosis, we’re blindsided. It’s overwhelming.

“The Kabuki Syndrome Clinic will help families answer the question we all have: What do I do now?”

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While CHOP is helping the family figure out the medical side, Rosalie is a busy 3-year-old who loves music, dancing and her baby dolls. “She loves to rock her dolls and give them kisses,” Dara says. She receives occupational and physical therapy at home, which is helping build up her endurance. While she isn’t speaking much yet, she understands what she hears.  “Rosie is high functioning,” her mother says. “She’ll follow easy instructions.” Some of Rosalie’s other favorite activities are slipping some of her food to the family dog, sitting in a shopping cart and going on short walks.  “We don’t know what the future will bring,” says Dara. “Kabuki syndrome is so odd in that it is different in every child. That’s why I’m so excited CHOP is having a special clinic for our kids. It’s a phenomenal hospital.”