# Smith-Kingsmore syndrome with nystagmus as the initial symptom

## TL;DR

A 5-month-old girl with nystagmus and developmental delays was diagnosed with Smith-Kingsmore syndrome, expanding the known symptoms of this rare genetic disorder.

## Contribution

This case expands the phenotypic spectrum of Smith-Kingsmore syndrome and highlights nystagmus as an initial symptom.

## Key findings

- Nystagmus was identified as an initial symptom in a patient with Smith-Kingsmore syndrome.
- The patient exhibited macrocephaly, facial deformity, and seizures, typical of SKS, along with new features like pigmentation abnormalities.
- Treatment with multiple antiseizure medications reduced seizure amplitude but did not eliminate drug resistance.

## Abstract

Smith-Kingsmore syndrome (SKS) is a rare autosomal dominant disorder caused by de novo mutations of gene MTOR in most cases and germline mosaicism in a few cases. The first case of SKS was reported in 2013. The incidence of SKS remains unknown. The clinical manifestations of SKS are diverse, and common features are macrocephaly, intellectual disability, and seizures. Some patients with SKS have special facial features.

The case was a 5-month-old baby girl, who was admitted to the hospital for nystagmus, delayed development for 2 months, and intermittent convulsions for 2 days. The patient had a head circumference of 42 cm (+ 2SD), and showed facial deformity, low limb muscle tension, large areas of pigmentation, as well as mosaic patchy and strip-like pigment loss in her trunk and limbs. Meanwhile, her development was lagging behind peers. Physical examination did not reveal other abnormalities. She was diagnosed with SKS based on whole-exome sequencing combined with clinical symptoms and signs. She successively received treatment with adrenocorticotropic hormone, methylprednisolone sodium succinate, topiramate, levetiracetam, and zonisamide to reduce the number of convulsions in a short time, but drug resistance appeared thereafter. After combined treatment with multiple antiseizure medications, the patient still had seizures, but the amplitude of limb movement during the seizures was reduced compared to that before treatment.

This case expanded the phenotypic spectrum of SKS for diagnosis. We also review the related literature to promote the awareness, diagnosis, clinical management, and follow-up of SKS patients with MTOR mutations.