Wolfram syndrome, initially described in the first half of the 20th century, is a very rare genetic disorder that includes several clinical entities - juvenile-onset diabetes mellitus, diabetes insipidus, optic atrophy, and deafness, which is why the term DIDMOAD is sometimes used in the literature [1] [2] [3] [4] [5] [6] [7]. The onset of symptoms in Wolfram syndrome almost universally occurs in childhood and early adolescence [1] [3] [5]. Diabetes mellitus, with its typical symptoms of polyuria, polydipsia, weight loss, etc., is the first one to develop around 6 years of age, followed by atrophy of the optic nerve that presents with severe deficits in peripheral and color vision around 11 years of age [1] [2] [5]. Diabetes insipidus appears soon after, whereas a variable degree of sensorineural hearing deficit (from total hearing loss from birth to a delayed presentation of a milder impairment in adolescence that progressively worsens) has been observed [1] [2] [3]. Abnormalities of the urinary tract, such as atony of the bladder, ductal obstruction, and difficulties urinating affect up to 90% of patients and cause significant impairment in the quality of life [1] [2]. However, the main reason for a poor overall prognosis is the eventual occurrence of neurological deficits that presumably appear as a result of underlying genetic mutations - ataxia, myoclonus, dysphagia, poor autonomic system regulation (diarrhea, sweating, inability to control sphincters, etc.) reduced senses, psychiatric symptoms (mainly mood disorders), and atrophy of the brainstem that leads to respiratory insufficiency have all been documented [1] [2] [3]. Unfortunately, most patients die suffering from Wolfram syndrome at a median age of 30 years [1] [2] [3].

• Fatigue

  Chronic fatigue Depression Causes of Wolfram syndrome Wolfram syndrome is caused by a mutation in the WFS1 gene. [diabetes.co.uk]

  Chronic fatigue: People with Wolfram Syndrome have a progressively declining levels of physical stamina. As this condition progresses they will need increasingly greater amounts of sleep. [diabetes.org.uk]

• Weight Gain

  The problems an individual DIABETES MELLITUS may have can include: Frequent thirst and urination Slow healing Weight loss or lack of weight gain or growth with children Itching Constant hunger Dryness of skin The management of DIABETES MELLITUS in WS [syndrome.org]

  The complaints a person with DM may have may include: slow healing, frequent thirst and urination, weight loss, ( or lack of weight gain or growth in children) constant hunger, itching and/or dryness of the skin. [didmoad.org]

• Goiter

  In addition, two had goiter, two delayed puberty, one seizure and one mental retardation with depression attacks. Urinary tract dilatation was recorded in five patients. Four patients developed typical complications of DM. [ncbi.nlm.nih.gov]

• Polydipsia

  Although the Wolfram syndrome is rare, it should be considered in diabetic patients with unexplained optic atrophy and hearing loss or with polyuria and polydipsia in the presence of adequate blood sugar control. [ncbi.nlm.nih.gov]

  Diabetes mellitus, with its typical symptoms of polyuria, polydipsia, weight loss, etc., is the first one to develop around 6 years of age, followed by atrophy of the optic nerve that presents with severe deficits in peripheral and color vision around [symptoma.com]

  Causes of polydipsia Increased thirst is often the reaction to fluid loss during exercise, or to eating salty or spicy foods. [diabetes.co.uk]

• Microstomia

  microcephaly, microstomia, clinodactylyl, brachydactylyl, empty sella syndrome and severe hypoplasia of the right internal carotid vessels associated with mild narrowing of the left internal carotid artery which have not been previously described. [ncbi.nlm.nih.gov]

• Hearing Impairment

  We sought to study the audiometric data of genotyped Wolfram syndrome patients with sensorineural hearing impairment. [ncbi.nlm.nih.gov]

• Headache

  Urine culture is recommended for Wolfram patients with fever or other symptoms, such as headache. Inflammatory conditions associated with UTI may cause headache and other symptoms. [doi.org]

  If she sits even for half an hour at a stretch, her legs and hands swell, and she starts getting splitting headaches. [timesofindia.indiatimes.com]

  Raquel struggles with severe diabetes, bladder issues and unbearable headaches, apart from blindness and hearing loss. This disease is slowly stripping my child of her independence and her ability to enjoy life like most children her age. [thesnowfoundation.org]

  There was no history of fever, headache, convulsions, trauma, or any other contributing factors. Neither did we record a history of polyuria, visual deficit nor hearing loss. [cjhr.org]

• Babinski Sign

  These correlated with anosmia, loss of vision, loss of hearing, cerebellar symptoms and signs, Babinski sign, and clonus, respectively, clinically observed in this patient. [ncbi.nlm.nih.gov]

• Polyuria

  Although the Wolfram syndrome is rare, it should be considered in diabetic patients with unexplained optic atrophy and hearing loss or with polyuria and polydipsia in the presence of adequate blood sugar control. [ncbi.nlm.nih.gov]

  Diabetes mellitus, with its typical symptoms of polyuria, polydipsia, weight loss, etc., is the first one to develop around 6 years of age, followed by atrophy of the optic nerve that presents with severe deficits in peripheral and color vision around [symptoma.com]

The diagnosis of Wolfram syndrome might be difficult to attain given the rare occurrence of this genetic disease, as studies estimate a prevalence rate of 1 in 160,000 to 770,000 individuals [1] [2]. For this reason, physicians must perform a detailed clinical examination and obtain a thorough patient history [1]. Because the autosomal recessive pattern of inheritance is established as the mode of transmission, a detailed family history might be of crucial importance for identifying similar symptoms in parents or other close relatives. Some authors claim that in all children under 16 years of age who present with diabetes mellitus and visual deficits, Wolfram syndrome must be included in the differential diagnosis [1] [5]. During the physical examination, which should include a comprehensive neurological assessment, as well as vision and hearing testing, key pieces of the clinical presentation can be revealed. To confirm the diagnosis, however, genetic testing for Wolfram syndrome 1 (WFS1) gene, located on chromosome 4, must be carried out [1] [3] [4]. The exact pathogenesis model remains unknown, but WFS1 is assumed to play a key role in the functioning of cells of both endocrine and neuronal origin [5]. In addition to WFS1 mutations, some studies have identified additional mutations that have shown autosomal dominant properties [4].

• Gliosis

  Mild neuron loss and gliosis in the preoptic and paraventricular area of the hypothalamus and mild motor neuron loss in the spinal cord did not reach thresholds of impaired function, although loss of neurons in discrete bulbar nuclei might have accounted [ncbi.nlm.nih.gov]

• HLA-DR2

  Two of three patients with Wolfram syndrome had the HLA-DR2 antigen. Combining our cases with those described in the literature, 7 of 11 patients have the HLA-DR2 antigen. [ncbi.nlm.nih.gov]

1. Urano F. Wolfram Syndrome: Diagnosis, Management, and Treatment. Curr Diab Rep. 2016;16:6.
2. Barrett TG, Bundey SE, Macleod AF. Neurodegeneration and diabetes: UK nationwide study of Wolfram (DIDMOAD) syndrome. Lancet. 1995;346(8988):1458–1463.
3. Barrett TG, Bundey SE. Wolfram (DIDMOAD) syndrome. J Med Genet. 1997;34(10):838–841.
4. Hansen L, Eiberg H, Barrett T, et al. Mutation analysis of the WFS1 gene in seven Danish Wolfram syndrome families; four new mutations identified. Eur J Hum Genet. 2005;13(12):1275–84.
5. Naderian G, Ashtari F, Nouri-Mahdavi K, Sajjadi V. A Case of Wolfram Syndrome. J Ophthalmic Vis Res. 2010;5(1):53-56.
6. Medlej R, Wasson J, Baz P, et al. Diabetes mellitus and optic atrophy: a study of Wolfram syndrome in the Lebanese population. J Clin Endocrinol Metab. 2004;89(4):1656-1661.
7. Rohayem J, Ehlers C, Wiedemann B, et al. Diabetes and Neurodegeneration in Wolfram Syndrome: A multicenter study of phenotype and genotype. Diabetes Care. 2011;34(7):1503-1510.