VCFS presents with a myriad of anomalies and clinical features which occur in different combinations in patients. Some features may present later in life, while others present at birth.

Generally, the signs and symptoms which manifest in each patient are reflective of the anomalies present; cardiac defects such as tetralogy of fallot present with cyanosis, and abnormal interruptions in the aortic arch presents with poor feeding, lethargy, tachypnea, and cardiogenic shock. Poor feeding and failure to thrive may result secondary to severe cardiac anomalies and congestive cardiac failure.

Other common cardiac defects seen in VFCS include ventricular septal defects, pulmonary atresia, truncus arteriosus, absent pulmonary valve syndrome, aortic stenosis, and abnormalities of the pulmonary artery. Generally, the defects affect the cardiac outflow tract. Abnormalities in the aortic arch are almost a typical finding in VFCS and are strongly suggestive of the 22q11.2 microdeletion. Cardiac defects are seen in three of four cases of VFCS.

Submucous cleft palate causes nasal reflux of meals in infants, and velopharyngeal incompetence causes speech defects and hypernasal speech.

Sequel to the thymic underdevelopment, there may be immune dysfunction which make the patients prone to recurrent infections and development of autoimmune diseases.

The palatal abnormality predisposes to recurrent upper respiratory tract and ear infections which exacerbate the speech difficulty. Pierre robin syndrome is seen in 15-20% of cases and it comprises of micrognathia, glossoptosis, and cleft palate.

Delay in attaining developmental milestones is also commonly seen in infants, up to 55% of which develop attention deficit hyperactivity disorder (ADHD) in childhood.

Ophthalmic involvement occurs in up to 70% of patients with VFCS and may manifest as small optic disks, tortuous retinal vessels, bilateral cataracts and absence of the nasolacrimal ducts.

Over 10% of children go on to develop psychiatric disorders including schizophrenia with antisocial personality disorders. Hypocalcemia from the parathyroid defects may cause seizures during infancy. The hypocalcemia may resolve spontaneously.

About 30% of patients with VFCS have short stature, 25-50% of whom are below the second percentile with respect to all growth parameters for the respective age [14]. Common facial features in VFCS include micrognathia, malar flattening, and a bulb shaped tip of the nose.

• Short Stature

  Learning disabilities occur often; short stature, slender hyperextensible hands and digits, scoliosis, mental retardation, inguinal hernia, auricular abnormalities, and microcephaly occur less frequently. [medical-dictionary.thefreedictionary.com]

  The main manifestations of our patient were feeding difficulties, respiratory infections, short stature, peculiar face with hypertelorism, prominent nose, abnormal ears, microstomia and crowded teeth, short broad neck and shield chest with pectus deformity [ncbi.nlm.nih.gov]

  Height: short stature was detected in 7 of 73 (9.6%) of the total patients; the patients with short stature were all < 10 years old; the height was within the normal age in all adolescent patients. [nature.com]

  Less frequent features include short stature, small-than-normal head (microcephaly), mental retardation, minor ear anomalies, slender hands and digits, and inguinal hernia. [rxlist.com]

  Less frequent features include short stature, small-than-normal head ( microcephaly ), mental retardation, minor ear anomalies, slender hands and digits, and inguinal hernia. [medicinenet.com]

• Recurrent Infection

  Complications In the newborn period, patients may present with hypocalcemic tetany/seizures, manifestation of cardiac abnormality, nasal regurgitation, GERD, dysphagia, and recurrent infections. [unboundmedicine.com]

  While somatic symptoms include congenital cardiovascular and craniofacial abnormalities, recurrent infections and hypocalcemia1, the most prevalent group of symptoms are neuropsychiatric and include cognitive dysfunction with mild mental retardation, [clinicaltrials.gov]

  Sequel to the thymic underdevelopment, there may be immune dysfunction which make the patients prone to recurrent infections and development of autoimmune diseases. [symptoma.com]

  People with 22q11.2 deletion syndrome commonly have heart abnormalities that are often present from birth, recurrent infections caused by problems with the immune system, and distinctive facial features. [medlineplus.gov]

  People with 22q11.2 deletion syndrome often experience recurrent infections caused by problems with the immune system, and some develop autoimmune disorders such as rheumatoid arthritis and Graves disease in which the immune system attacks the body's [ghr.nlm.nih.gov]

• Fatigue

  Boys with VCFS scored significantly lower than girls on school functioning (p < .05) and cognitive fatigue (p < .01). [ncbi.nlm.nih.gov]

  Learning disabilities and difficulties Significant feeding difficulties Hypocalcemia Conductive or sensorineural hearing loss Deficiencies in growth hormones Renal anomalies Seizures Psychiatric disorders Weariness or easy fatigue Failure to realize one [syndromepictures.com]

  However, the immunodeficiency can last into adult life, with an increased vulnerability to infections and fatigue, as well as increased risk of autoimmune diseases in which the immune system of the body attacks its own cells. [socialstyrelsen.se]

• Trisomy 21

  We at the Children's Hospital of Philadelphia, therefore, refer to all patients with a 22q11.2 deletion by their cytogenetic name, patients with a 22q11.2 deletion (as we do in other chromosomal disorders, i.e. 4p-, 18q+, trisomy 21, etc.) which allows [cbil.upenn.edu]

  Besides the previously mentioned Down syndrome and trisomy 21, many other nosologic variations exist. There is no specific system of taxonomy in the naming of syndromes. [ncbi.nlm.nih.gov]

• Pediatric Disease

  Autoimmune disease in 22q11.2DS is common. However, it does not correlate with severe T-cell dysfunction and it includes a range of pediatric diseases. [ncbi.nlm.nih.gov]

• Failure to Thrive

  When their symptoms began, in the 3 cases failure to thrive was noted and in 2, dimorphism related to abnormal facial features. In 1 case, cleft palate was recorded and, pie bott in another. [scielo.sa.cr]

  Poor feeding and failure to thrive may result secondary to severe cardiac anomalies and congestive cardiac failure. [symptoma.com]

  Congenital anomalies of any organ system, classically cardiac defects, particularly interrupted aortic arch type B, septal defects, tetralogy of Fallot ± pulmonary atresia, truncus arteriosus, and vascular ring Failure to thrive/dysphagia/gastroesophageal [unboundmedicine.com]

• Microstomia

  The main manifestations of our patient were feeding difficulties, respiratory infections, short stature, peculiar face with hypertelorism, prominent nose, abnormal ears, microstomia and crowded teeth, short broad neck and shield chest with pectus deformity [ncbi.nlm.nih.gov]

• Mitral Valve Prolapse

  Circulation (1987) [ Pubmed ] The determinants of onset of mitral valve prolapse in the systolic click-late systolic murmur syndrome. Mathey, D.G., Decoodt, P.R., Allen, H.N., Swan, H.J. [wikigenes.org]

• Almond-Shaped Eyes

  […] symptoms of this disease that is caused by the deletion of the 22q11.2 Symptoms include: cleft palate, usually of the soft palate (the roof of the mouth nearest the throat which is behind the bony palate); heart problems; similar faces (elongated face, almond-shaped [wiki.ggc.edu]

  Typical facial features include a long face, small almond shaped eyes, a wide bridged nose, and malformations of the ear. Learning disabilities, including delayed speech and developmental milestones, are present in 70-90% of individuals. [genedx.com]

  The list includes: cleft palate, usually of the soft palate (the roof of the mouth nearest the throat which is behind the bony palate); heart problems; similar faces (elongated face, almond-shaped eyes, wide nose, small ears); learning difficulties; eye [healthieryou.com]

  Symptoms include: cleft palate, usually of the soft palate (the roof of the mouth nearest the throat which is behind the bony palate); heart problems; similar faces (elongated face, almond-shaped eyes, wide nose, small ears); eye problems; feeding problems [genome.gov]

  […] problem that is of the conotruncal type such as the interrupted aortic arch, cases of truncus arteriosus and tetralogy of Fallot Palatal problems that predispose the child to difficulties of feeding and speech Similar facial features like having an almond-shaped [syndromespedia.com]

• Low Set Ears

  These may include small, low-set ears, short width of eye openings (palpebral fissures), hooded eyes, a relatively long face, an enlarged nose tip (bulbous), or a short or flattened groove in the upper lip. [mayoclinic.org]

  Some of them include: Long face with prominent upper jaw Low set ears Down slanting mouth Cleft palate Rheumatoid arthritis Heart, immune, endocrine system and nervous system abnormalities Feeding difficulties Hearing loss Developmental delays with learning [nicklauschildrens.org]

  Some of the signs of velocardiofacial syndrome are as follows: Abnormalities of the palate like cleft palate Characteristic facial features like a narrow groove of the upper lip, wide-set eyes, hypertelorism or low-set ears. [syndromepictures.com]

  Long face with prominent upper jaw Underdeveloped lower jaw Low set ears Prominent nose with narrow nasal passages Thin upper lip with a down-slanted mouth Multiple abnormalities of the heart including ventricular septal defect (VSD), pulmonary atresia [cincinnatichildrens.org]

• Hearing Impairment

  A large number of medical conditions may be associated with 22q11.2 deletion syndrome, such as hearing impairment, poor vision, breathing problems, poor kidney function and relatively short stature for one's family. [mayoclinic.org]

  Lundin J, Söderhäll C, Lundén L, Hammarsjö A, White I, et al. (2010) 22q11.2 microduplication in two patients with bladder exstrophy and hearing impairment. Eur J Med Genet 53: 61–65. View Article Google Scholar 26. [journals.plos.org]

  Many of these children have slightly impaired hearing, and a small number have more severe hearing deficiencies. Other malformations and abnormalities may also be seen, but less frequently. [socialstyrelsen.se]

• Small Head

  Distinct physical features sometimes associated with the syndrome include loss of muscle tone (hypotonia), small slender stature, tapered hands and fingers, small head circumference (microcephaly), recessed jaw (retrognathia), tubular nose, flat cheeks [rarediseases.org]

  Additional common traits include feeding problems, developmental delay, microcephaly (small head size) and psychiatric disorders (such as bipolar disorder and schizophrenia). [kidsplasticsurgery.org]

  What follows are the most common features of Velo-Cardio-Facial syndrome: Feeding Difficulties Microcephaly, or a small head Hearing loss, or abnormal ear exams Hypocalcemia, or low blood calcium levels IQ levels that are usually in the 70 to 90 range [disabled-world.com]

• Psychomotor Retardation

  Other common clinical features include cardiovascular disorders (conotruncal), short stature, psychomotor retardation, mental retardation, psychiatric disorders and learning disabilities. [medigraphic.com]

• Bulbous Nose

  nose, and pointed chin. [rarediseases.org]

• Phenylketonuria

  Besides 22q11 deletion syndrome, there is trisomy 13, trisomy 18, amnion rupture sequence, fetal alcohol syndrome, retinoic acid embryopathy, homocystinuria, and phenylketonuria. [ncbi.nlm.nih.gov]

• Seizure

  In each patient, sporadic rolandic or occipital partial-onset seizures with the clinical and electroencephalographic features of benign idiopathic childhood epilepsy manifested at age 3 and 5 years, respectively. [ncbi.nlm.nih.gov]

  Hypocalcemia from the parathyroid defects may cause seizures during infancy. The hypocalcemia may resolve spontaneously. [symptoma.com]

• Nasal Speech

  Speech and feeding problems Severe oral motor planning Hyper nasal speech Disorganized or dysfunctional feeding patterns 6. [speechsolutionshawaii.com]

  A nasal speech tone is observed in the vast majority of individuals with VCFS as well as difficulties with articulation whose origin is assumed to be the cleft palate and pharyngal hypotonia. [cibsr.stanford.edu]

  Later in life, VPI leads to slurred pronunciation and often to very open, nasal speech owing to leakage of air up into the nose. Feeding difficulties are frequent. [socialstyrelsen.se]

  A prominent nasal root, bulbous nasal tip, hypoplastic alae nasae, and a nasal dimple/bifid nasal tip are common [ Gripp et al 1997 ]. [ncbi.nlm.nih.gov]

• Delayed Milestone

  Many infants present with generalized hypotonia and delayed milestones. There are psychological consequences with the reduction of full-scale intelligence quotient. [clinicaladvisor.com]

• Global Developmental Delay

  […] or absence of expressive speech, global developmental delay, normal to accelerated growth and mild dysmorphic features 12,13. [cytocell.com]

To evaluate DiGeorge syndrome, some of the laboratory studies carried out include multiplex ligation-dependent probe amplification (MLPA), TBX1 gene sequencing or TBX1 deletion/duplication analysis, fluorescent in situ hybridization (FISH) and array comparative genomic hybridization (aCGH) [8].

Radiography and MRI, CT scanning, Echocardiography and Angiography are some of the imaging studies carried out.

Diagnosis of VFCS can be made by physical examination of infants and older children on outpatient basis. Neonates may be examined after delivery for features typical of this syndrome.

Once a diagnosis is made, investigations for serious anomalies such as cardiac defects should be commenced. Heart failure, immune deficiency, feeding difficulties, and failure to thrive can all be addressed with medical care.

Generally, VFCS requires a long-term multidisciplinary management approach involving a team comprising clinical psychologist, geneticist, genetic counsellor, physical therapist, plastic surgeon, pediatric immunologist, otorhinolaryngologist, and cardiac surgeon.

Management for infants and preschoolers is usually centered on correcting feeding difficulties and developmental delays, however, in children of school age, treatment is centered on cognitive and behavioral improvement. Common cognitive impairments associated with VFCS include diminished mathematical skills, visuospatial and executive impairments.

About 10% of children with VFCS develop severe personality and psychiatric disorders [15].

VCFS may cause significant impairment in the quality of life of the patient because of the plethora of anomalies present. Hearing defects, speech difficulties, learning disabilities, feeding difficulties, spinal deformities, and immune compromise play significant roles in reducing the quality of life of the patient. Other factors which could worsen the prognosis of this syndrome are the secondary ophthalmic, renal, cardiac, and psychiatric problems.

The most cases of velocardiofacial syndrome occur as a result of a microdeletion at the locus q11.2 of the short arm of chromosome 22, caused by mainly due to imbalance during the translocation between the pair of chromosome 22.

In approximately 10% of the patients, this deletion is inherited from a parent while in the other 90% cases it is acquired by mutation spontaneously. This microdeletion is detectable in 95% of patients with VFCS. 

Velocardiofacial Syndrome is the most prevalent syndrome found associated with cleft palate. It is also the commonest syndrome caused by microdeletions and the second most prevalent syndrome found associated with congenital cardiac defects.

VCFS is seen in approximately 1 child out of 2,000 - 5,000 live births. However, there are varying statistics which vary according to the mode of data collection and method of verification of the diagnosis. In most studies, the reports of the diagnosis depended on birth records, neonatal examinations, or other unverified sources [7] [8].

There is a possibility of under-diagnosis of this condition since many features become apparent much later in life or even might go undetected. Severe complications include cardiac malformations which may occur in about 70% of VCFS cases.

VCFS is caused by a microdeletion at the 11.2 band or locus of the short arm of chromosome 22. This in turn impairs the development and migration of neural crest cells, and development of the bronchial arches.

In about 90% of cases, the microdeletion is a new deletion occurring as a de-novo deletion or translocation involving 3-megabase in a region that contains at least 40 genes [9]. Because these genes are involved in the development of the heart and structures in the central nervous system, a number of coronary artery defects occur in this syndrome [10].

In the other 10% of cases, the mutation is inherited in an autosomal dominant pattern from a parent. Inheritance of this genetic mutation occurs in 50% of cases.

This genetic mutation is commonly associated with aortic arch, aortic branch, or pulmonary vessel defects, therefore, necessitating genetic testing in these patients [3]. However in this syndrome, there is a wide spectrum of features which may present in different combinations among patients, even of the same families [11] [12] [13].

There are no guidelines for prevention of DiGeorge syndrome.

Velocardiofacial syndrome (VCFS) is a genetic disorder involving microdeletion of the 11.2 band of the short arm of chromosome 22. VCFS was first described by Shprintzen and his colleagues in 1978 [1].

The disorder presents with an array of congenital malformations affecting virtually every organ system in the body. It includes over 180 clinical features which may not be similar in all patients: typical abnormalities include cleft palate, cardiac defects, and a characteristic facies. Patients are often affected by speech defects, cognitive and developmental impairments, and psychiatric disorders [2].

Cardiac defects are found in approximately 75% of cases of VFCS and mainly involve the outflow portion of developing heart. The commonest cardiac defects in VFCS are interrupted aortic arch seen in up to 50% of cases, involvement of truncus arteriosus, and tetralogy of fallot. Other common defects include aortic stenosis and pulmonary artery abnormalities [3].

Immune defects found are secondary to thymic abnormality. The resulting immune deficiencies may worsen or improve over time [4] [5]. 

Eye deformities are also found in up to 70% of cases and are presented with cataracts and absence of the nasolacrimal ducts [6].

Diagnosis of VFCS involves genetic testing and investigations to determine the presence of major complications such as heart defects and immunosuppression.

Treatment of VFCS involves a multidisciplinary approach involving geneticists, genetic counsellors, pediatric cardiologists and cardiac surgeons, pediatric immunologists, plastic surgeons, and speech therapists.

Genetic counselling is vital so that parents will be fully aware of the recurrence risk of DiGeorge syndrome.

The families of individuals with significant immunodeficiency equally have to be educated on the potential complications that can arise due to exposure to poliovirus vaccine, MMR vaccine, and chicken pox vaccine that is live attenuated [10].

1. Shprintzen RJ, Goldberg RB, Lewin ML, et al. A new syndrome involving cleft palate, cardiac anomalies, typical facies, and learning disabilities: velo-cardio-facial syndrome. Cleft Palate J. 1978;15(1):56-62.
2. Ryan AK, Goodship JA, Wilson DI, et al. Spectrum of clinical features associated with interstitial chromosome 22q11 deletions: a European collaborative study. J Med Genet. 1997; 34 (10):798-804.
3. Goldmuntz E, Clark BJ, Mitchell LE, et al. Frequency of 22q11 deletions in patients with conotruncal defects. J Am Coll Cardiol. 1998; 32(2):492-8.
4. Zemble R, Luning Prak E, McDonald K, McDonald-McGinn D, Zackai E, Sullivan K. Secondary immunologic consequences in chromosome 22q11.2 deletion syndrome (DiGeorge syndrome/velocardiofacial syndrome). Clin Immunol. 2010; 136(3):409-18.
5. Gennery AR. Immunological aspects of 22q11.2 deletion syndrome. Cell Mol Life Sci. 2012; 69(1):17-27.
6. Prabhakaran VC, Davis G, Wormald PJ, Selva D. Congenital absence of the nasolacrimal duct in velocardiofacial syndrome. J AAPOS. 2008;12(1):85-6
7. Ryan AK, Goodship JA, Wilson DI, et al. Velo-cardio-facial syndrome associated with chromosome 22 deletions encompassing the DiGeorge locus. Lancet; 1992;339:1138–1139.
8. Óskarsdóttir S, Vujic M, Fasth A. Incidence and Prevalence of the 22q11 Deletion Syndrome: A Population-based Study in Western Sweden. Arch Dis Child. 2004; 89:148–51.
9. Shprintzen RJ. Velo-cardio-facial syndrome: 30 Years of study. Dev Disabil Res Rev. 2008;14(1):3-10.
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11. Cuneo BF. 22q11.2 deletion syndrome: DiGeorge, velocardiofacial, and conotruncal anomaly face syndromes. Curr Opin Pediatr. 2001;13(5):465-72.
12. McLean-Tooke A, Spickett GP, Gennery AR. Immunodeficiency and autoimmunity in 22q11.2 deletion syndrome. Scand J Immunol. 2007; 66(1):1-7.
13. Leopold C, De Barros A, Cellier C, et al. Laryngeal abnormalities are frequent in the 22q11 deletion syndrome. Int J Pediatr Otorhinolaryngol. 2012; 76(1):36-40.
14. Tarquinio DC, Jones MC, Jones KL, Bird LM. Growth charts for 22q11 deletion syndrome. Am J Med Genet A. 2012; 158 A (11):2672-81.
15. Antshel KM, Fremont W, Kates WR. The neurocognitive phenotype in velo-cardio-facial syndrome: a developmental perspective. Dev Disabil Res Rev. 2008;14(1):43-51. 
16. McDonald-McGinn DM, Zackai EH. Genetic counseling for the 22q11.2 deletion. Dev Disabil Res Rev. 2008; 14(1):69-74.