Having in mind the fact that about 145 cases have been described in the literature so far, Dubowitz syndrome is a rare clinical entity with an unknown etiology [1] [2] [3]. Certain authors hypothesize that a genetic background (DNA ligase IV and RNA methyltransferase mutations), an autosomal recessive pattern of inheritance, and various hormonal abnormalities are involved in the pathogenesis [4] [5] [6]. Fortunately, the clinical presentation has been well-demarcated by several authors, and is composed of the following [1] [2] [3] [4] [5] [6]:

• Facial changes - One of the cardinal features of Dubowitz syndrome is a narrow and triangular-shaped face with micrognathia, a sloping forehead, and thin and sparse eyebrows and hair [1] [4]. Other common findings are low-set ears, wide-set eyes with drooping upper eyelids, a broad and wide nasal bridge, and facial asymmetry [1] [2] [3] [4]. Telecanthus, visual deficits, a cleft palate and several other facial deformities are less commonly encountered [1] [2] [3] [4].
• Growth abnormalities - In addition to a distinct facial appearance, a markedly reduced growth rate starting during intrauterine life is one of the main characteristics of Dubowitz syndrome [1] [2] [4] [5]. Virtually all individuals suffer from microcephaly, a short stature and a low body weight for appropriate age, whereas hypotonia (stemming from the weakness of the skeletal muscles) is also a frequent finding [1]. Furthermore, scoliosis, fused vertebrae, impaired rib development, toe fusion and feet-related problems (club foot, inverted foot, flat-footedness, etc.) are seen in a significant number of cases [1] [7].
• Psychiatric symptoms - Hyperactivity, aggressiveness, bedwetting, difficulties with sleep, and frequent withdrawal from other individuals or crowd (although rare) are often reported in Dubowitz syndrome [1] [3] [4]. A variable degree of mental retardation and learning impairment is observed as well [1] [3].

Other notable features are a high-pitched voice, gastrointestinal irritation (presenting as diarrhea), the presence of eczema, genital disorders (cryptorchidism, hypospadias, and underdevelopment of either male or female genitalia), frequent infections (most commonly of the ears, GI system, the lungs, the urinary tract and the sinuses), and several congenital heart diseases (atrial and ventricular septal defects, as well as patent ductus arteriosus) [1] [2] [3] [4]. Rare reports have described malignant tumors (primarily of hematologic origin), aplastic anemia and immunological deficits (IgA deficiency) [1] [3].

• Recurrent Infection

  Eczema and recurrent infections require conservative treatment. Surgical intervention might be necessary for certain cardiovascular, urogenital, craniofacial or limb anomalies. Surveillance of hematological and malignant disorders is recommended. [orpha.net]

  She/he may be prone to recurrent infections, hypogammaglobulinemia, IgA deficiency, aplastic anemia, acute lymphatic leukemia, lymphoma, and/or neuroblastoma. contributor: Kelly A.Przylepa, revised 4/4/2003 creation date: John F. [dubowitzsyndrome.net]

• Poor Feeding

  Dubowitz syndrome is a rare hereditary disorder whose main features are intra-uterine and post-natal growth retardation, characteristic facies, microcephaly, mental retardation and poor feeding. [ncbi.nlm.nih.gov]

  Abdominal/Gastrointestinal characteristics can include poor feeding, frequent vomiting, chronic diarrhea, and/or gastroesophageal reflux. In boys, there can be hypospadias, inguinal hernia, or cryptorchidism. [dubowitzsyndrome.net]

  Associations have been made with hyperactivity (4G" variable clefts of the soft palate (10% to 15%), poor feeding and gastroesophageal reflux (33%), chronic diarrhea (35%), and mild eczema (65%)7. [healio.com]

• Turkish

  Here we describe a male Turkish patient who has typical and less common findings of DS with additionally persistently low serum lipid levels and an arachnoid cyst. The present patient is the second case of DS with persistently low cholesterol levels. [ncbi.nlm.nih.gov]

• High Pitched Voice

  Speech delays, an unusually soft, high-pitched voice, submucous cleft palate, and velopharyngeal insufficiency were noted in childhood. Mild mental retardation was present. [ncbi.nlm.nih.gov]

  Symptoms vary among patients, but other characteristics include a soft, high-pitched voice, partial webbing of the fingers and toes, palate deformations, genital abnormalities, language difficulties, and an aversion to crowds. ". Arch. Fr. Pediatr. [en.wikipedia.org]

• Failure to Thrive

  Afterwards, the child is sometimes labeled as failure to thrive. The head is usually microcephalic and face is small with some elongation with age. [dubowitzsyndrome.net]

  Failure to Thrive : growth failure, or failure to thrive (FTT), is a descriptive term and not a specific diagnosis. Although definitions vary, most use this term only when growth has been noted to be low or to have decreased over time. [ric.edu]

  On the other hand, lack of eating has been associated with failure to thrive or anorexic-like tendencies [ 12, 21, 29 ]. Failure to thrive is associated with a child’s inability to gain weight, grow or feed normally [ 29 ]. [ncbi.nlm.nih.gov]

• Alopecia

  McPherson Clemens syndrome Malignant hyperthermia susceptibility type 3 Oslam syndrome L-arginine:glycine amidinotransferase deficiency Lin-Gettig syndrome Alopecia-intellectual disability syndrome Tabatznik syndrome Persistent Mullerian duct syndrome [checkrare.com]

• Short Attention Span

  Behavioral characteristics may include hyperactivity with short attention span, impulsivity and shyness. [orpha.net]

  Also described is a tendency to be hyperactive or to have a short attention span. Speech delay is also common, as is a high pitched or nasal-y voice. The child's biggest issues seem to be with the immune system. [dubowitzsyndrome.net]

  attention span Shyness Mental retardation mild to severe Stubbornness Short attention span Reduced muscle tone Small face Supraorbital ridge is swallow Head that is small Short palpebral fissures Tip of nose broad Flat nasal bridge Lateral telecanthus [syndrome.org]

  Behavioral characteristics include hyperactivity, short attention span, and aggressiveness. Behavior problems include difficulty feeding, sleep disturbance, and bedwetting. [cornerstone.lib.mnsu.edu]

• Impulsivity

  Behavioral characteristics may include hyperactivity with short attention span, impulsivity and shyness. [orpha.net]

  Hyperactivity can exacerbate impulsiveness, problem behaviors, and learning deficits. Frequent outbursts are not uncommon in these children [ 5 ]. [ncbi.nlm.nih.gov]

• Small Face

  For example, many people affected by the disease have a small face and head. Sometimes they have a high forehead that slopes as well. In many cases, the eyelids droop and the nose is wide and flat. [wisegeek.net]

  Affected individuals have small face which is often triangular in shape with a pointed, receding chin. They also have broad wide-tipped nose, broad and sloping forehead, and wide-set eyes with drooping eyelids. [brighthub.com]

  face Supraorbital ridge is swallow Head that is small Short palpebral fissures Tip of nose broad Flat nasal bridge Lateral telecanthus Drooping upper eyelid Eyes are wide-set Blepharophimosis Prominent ears Epicanthal folds Dysplastic ears that is mild [syndrome.org]

  face Short and narrow face Small facies [ more ] 0000274 Syndactyly Webbed fingers or toes 0001159 Velopharyngeal insufficiency Velopharyngeal incompetence 0000220 Wide nasal bridge Broad nasal bridge Broad nasal root Broadened nasal bridge Increased [rarediseases.info.nih.gov]

  face Tapetoretinal degeneration Velopharyngeal insufficiency Wide nasal bridge Based on the frequency of symptoms observed, the following information may be noted: Very frequently present symptoms in 80-99% of the cases: Aplasia/hypoplasia of the thumb [dovemed.com]

• High Sloping Forehead

  Dubowitz syndrome (DS) (MIM#223370) (4) is a very rare genetic and developmental disorder involving multiple congenital anomalies including: 1) growth failure/short stature; 2) unusual but characteristic facial features; small triangular face, high sloping [ncbi.nlm.nih.gov]

  Other facial characteristics can include a shallow supraorbital ridge, asymmetry, micrognathia, dysmorphic features, and a high, sloping forehead. [dubowitzsyndrome.net]

  sloping forehead, drooping eyelid, short distance between the inner and outer corner of the eye, broad and flat nasal bridge), microcephaly, intellectual disability, and eczema. [dovemed.com]

• Hyperactivity

  This autosomal recessive disorder is characterized by variable degrees of intrauterine and postnatal growth retardation, microcephaly, mild mental retardation, hyperactivity, "eczema", characteristic facial appearance and combination of minor abnormalities [ncbi.nlm.nih.gov]

  […] disorder Attention deficit Attention deficit disorder Attention deficit-hyperactivity disorder Attention deficits Childhood attention deficit/hyperactivity disorder [ more ] 0007018 Blepharophimosis Narrow opening between the eyelids 0000581 Clinodactyly [rarediseases.info.nih.gov]

In the absence of clear diagnostic criteria for Dubowitz syndrome and the striking similarity to several other disorders (including Fanconi anemia, fetal alcohol syndrome, Bloom's syndrome, Nijmegen breakage syndrome), the diagnosis might be difficult to make. With a properly obtained patient history and a meticulous physical examination, a presumptive diagnosis can be made [1] [4]. Exposure to significant amounts of alcohol during intrauterine life should be addressed during history taking, whereas a familial occurrence of the syndrome has been reported in a small number of cases, suggesting that a complete family history might also be of benefit [1] [2] [4]. The physical examination is, however, the pivotal step in the diagnostic workup, as the diagnosis relies on recognition of clinical features [3]. A comprehensive assessment of facial changes and growth rate, evaluation of cognitive skills, and determination of additional defects is crucial [1] [4]. Depending on the presence of additional signs and symptoms, appropriate diagnostic procedures should be employed. For example, echocardiography is needed in the setting of congenital heart diseases (CHDs), whereas a complete laboratory workup with an immunological profile in case frequent infections is noted, or if there is valid clinical suspicion toward a malignant disease.

• Delayed Bone Age

  Analysis of approximately 30 cases reveals prevalence of growth failure and delayed bone age, mild microcephaly, broad forehead with sparse frontal hair, telecanthus, blepharophimosis, abnormal pinnae, broad nose, and micrognathia. [ncbi.nlm.nih.gov]

  Skeletal issues can be delayed bone age, fifth finger clinodactyly, two/three toe syndactyly, and pes planus. Some are very prone to eczema or have severe allergies. There also can be sacral dimple (s), sparse scalp hair, and some hypotonia. [dubowitzsyndrome.net]

  bone age. head: microcephaly; high forehead; sparse hair; broad nose; epicanthus; hypertelorism; blepharophimosis; microretrognathia. skin: eczema, a classical sign, may be absent. congenital heart defects in 10%; other malformations: ocular, dental, [atlasgeneticsoncology.org]

1. Huber RS, Houlihan D, Filter K. Dubowitz Syndrome: A Review and Implications for Cognitive, Behavioral, and Psychological Features. J Clin Med Res. 2011;3(4):147-155.
2. Lee MK, Lee YS. Anesthesia of a patient with Dubowitz syndrome -A case report-. Korean J Anesthesiol. 2010;58(5):495-499.
3. Turkbeyler IH, Pehlivan Y, Comez G, et al. Esophagus cancer and IgA deficiency in a patient with Dubowitz syndrome: a case report. Tokai J Exp Clin Med. 2011;36(2):29-30.
4. Chehade C, Awwad J, Yazbeck N, et al. Dubowitz syndrome: common findings and peculiar urine odor. Appl Clin Genet. 2013;6:87-90.
5. Yue J, Lu H, Lan S, et al. Identification of the DNA Repair Defects in a Case of Dubowitz Syndrome. Borgmann K, ed. PLoS One. 2013;8(1):e54389.
6. Martinez F, Lee JH, Lee JE, et al. Whole Exome Sequencing identifies a splicing mutation in NSUN2 as a cause of a Dubowitz-like syndrome. J Med Genet. 2012;49(6):380-385.
7. Ballini A, Cantore S, Tullo D, Desiate A. Dental and craniofacial characteristics in a patient with Dubowitz syndrome: a case report. J Med Case Reports. 2011;5:38.