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Tuberous Sclerosis

By Margaret C. McBride, MD, Professor of Pediatrics;Pediatric Neurologist, NeuroDevelopmental Science Center, Northeast Ohio Medical University;Akron Children’s Hospital ; M. Cristina Victorio, MD, Assistant Professor in Pediatrics;Director, Headache Program; Pediatric Neurologist, Northeast Ohio Medical University;Akron Children's Hospital

Tuberous sclerosis is a hereditary disorder that causes abnormal growths in the brain, changes in the skin, and sometimes tumors in vital organs, such as the heart, kidneys, and lungs.

  • Children may have abnormal skin growths, seizures, delayed development, learning disorders, or behavioral problems and may be intellectually impaired or autistic.

  • Life expectancy is usually unaffected.

  • Because the disorder is lifelong and new problems can develop, people must be monitored for their entire life.

  • Doctors suspect the disorder based on symptoms, do imaging tests to check for tumors, and sometimes do genetic tests.

  • Treatment focuses on relieving symptoms.

Tumors or other abnormal growths develop in several organs, such as the brain, heart, lungs, kidneys, eyes, and skin. The tumors are usually noncancerous (benign). The disorder is named for the typical long and narrow tumors in the brain, which resemble roots or tubers.

Tuberous sclerosis is usually present at birth, but symptoms may be subtle or take time to develop, making the disorder difficult to recognize early.

In most cases, the disorder results from mutations in one of two genes. If either parent has the disorder, children have a 50% chance of having it. However, tuberous sclerosis often results from spontaneous—new (not inherited)—mutations in the gene, rather than an inherited abnormal gene. This disorder occurs in 1 of 6,000 children.

Symptoms

Symptoms of tuberous sclerosis vary greatly in severity.

Tuberous sclerosis may cause seizures, intellectual disability, autism, delayed development of motor or language skills, learning disorders, and behavioral problems (such as hyperactivity and aggression).

The first symptom of tuberous sclerosis may be infantile spasms, a type of seizure.

The skin is often affected, sometimes causing disfigurement:

  • Light-colored, ash-leaf–shaped patches may appear on the skin during infancy or early childhood.

  • Rough, raised patches resembling orange peel, usually on the back, may be present at birth or develop later.

  • Medium-brown, flat spots that are the color of coffee with milk (café-au-lait spots) may also develop.

  • Red lumps consisting of blood vessels and fibrous tissue (angiofibromas) may appear on the face later during childhood (called adenoma sebaceum).

  • Small fleshy bumps (fibromas) may grow around and under the toenails and fingernails at any time during childhood or early adulthood.

Before birth, benign heart tumors called myomas may develop. These tumors typically disappear over time and do not cause symptoms later in childhood or in adulthood.

In many children, permanent teeth are pitted.

Patches may develop on the retina, located at the back of the eye. If the patches are located near the center of the retina, vision may be affected.

Tubers in the brain may cause delays in development of motor or language skills. Affected children may be intellectually impaired and have seizures, autism, learning disorders, and behavioral problems (such as hyperactivity and aggression). These tubers may become tumors, which sometimes become cancerous, and enlarge, causing headaches or making other symptoms worse.

During adolescence and adulthood, kidney tumors may develop. They may cause high blood pressure, abdominal pain, and blood in the urine.

Nodules may develop in the lungs, particularly in adolescent girls. This condition is called lymphangioleiomyomatosis.

How well affected people do depends on how severe the symptoms are. If symptoms are mild, infants generally do well and grow up to live long, productive lives. If symptoms are severe, infants may have serious disabilities. Nonetheless, most children continue to develop, and life expectancy is usually unaffected.

Diagnosis

  • A doctor's evaluation

  • Magnetic resonance imaging or ultrasonography

Doctors may suspect tuberous sclerosis based on symptoms, such as seizures, delayed development, or typical skin changes. Sometimes tuberous sclerosis is suspected when routine prenatal ultrasonography detects a tumor in the heart or brain.

An eye examination (with ophthalmoscopy) is done to check for eye abnormalities. Magnetic resonance imaging (MRI) or ultrasonography is done to check for tumors in various organs.

Genetic testing may be done for the following reasons:

  • To confirm the diagnosis when symptoms suggest it

  • To determine whether people who have a family history of the disorder but who do not have symptoms have the abnormal gene

  • To check for the disorder before birth (prenatal diagnosis) if the family history includes the disorder

Treatment

  • Treatment of symptoms

Treatment of tuberous sclerosis focuses on relieving symptoms:

  • For seizures: Anticonvulsants may be used. Sometimes if drugs are ineffective, surgery is done to remove a tumor or to remove a small part of the brain that is involved in causing the seizures.

  • For high blood pressure: Antihypertensive drugs may be used, or surgery may be done to remove kidney tumors.

  • For behavioral problems: Behavior management techniques (including time-outs and consistent use of appropriate consequences and praise) may help. Sometimes drugs are needed.

  • For developmental delays: Special schooling or physical, occupational, or speech therapy may be recommended.

  • For skin growths: They may be removed with dermabrasion (rubbing the skin with an abrasive metal instrument to remove the top layer) or lasers.

  • For cancerous tumors and some noncancerous tumors: Everolimus can be used to shrink the tumors, including myomas in newborns.

Sirolimus and everolimus are being studied to determine whether they can effectively treat or even prevent some of the complications of tuberous sclerosis, such as skin growths, seizures, and intellectual disability. These drugs are currently used to treat certain cancers and to prevent rejection of transplanted organs.

Genetic counseling is recommended for affected people and family members when they are considering having children.

Screening for new problems

Because tuberous sclerosis is a lifelong disorder and new problems can develop, affected people must be closely monitored for the rest of their life.

Monitoring typically includes the following:

  • MRI of the head

  • Ultrasonography to check for kidney tumors

  • Chest x-ray for girls in their late teens

  • Detailed testing of mental function (neuropsychologic testing) for children to help plan for support at school

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  • AFINITOR

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