Signs & Symptoms 

The multiple symptoms of SIOD and the relative frequency of them are listed in the table. The symptoms are subsequently discussed according to the organ system affected.

Physical Traits
Most affected individuals have distinctive physical features. These include fine hair (60%), a thin upper lip, a broad, low nasal bridge (68%), a bulbous nasal tip (83%), and disproportionately short stature (98%). Additional features include excessive inward curvature of the lumbar spine (lumbar lordosis, 84%), a protruding abdomen, and hyperpigmented macules (85%) on the trunk and occasionally on the neck, face, arms and legs. Less common physical features include absent or small teeth and corneal opacities (19%).

Growth and Skeletal System
Growth failure, which is often the first obvious sign of SIOD, occurs despite normal growth hormone production and is not corrected with growth hormone supplementation. In most affected individuals, the growth failure begins prior to and continues after birth; however, some affected children do have normal birth lengths and weights and their growth failure is not noted until after birth (range: 0 to 13 years, mean: 2 years). The heights of those who survived to adulthood were 136-157 cm for men and 98.5-143 cm for women.

The short stature arises generally because of spondyloepiphyseal dysplasia (86%), a disorder of skeletal growth; it does not arise as a complication of their renal failure. The anthropometric characteristics of patients with SIOD differ markedly from those of patients with other forms of chronic kidney disease, especially with respect to median leg length and sitting height. The spinal column and hip joint are most severely affected. The radiological abnormalities include ovoid or mildly flattened vertebral bodies, small and laterally displaced femurs (thigh bone), and shallow abnormal acetabular fossae (hip sockets). Less frequent skeletal problems include lordosis, kyphosis and scoliosis (abnormal curvatures of the spine) as well as osteopenia (decreased bone mineral density) and degenerative hip disease. Many patients have required hip replacements.

Endocrine System
Approximately 42% of individuals with SIOD have reduced thyroid function. However, to date, the poor thyroid function has not caused clinical symptoms (subclinical hypothyroidism). Among those who have received thyroid hormone supplementation, the correction of thyroid hormone levels does not mitigate other symptoms of SIOD.

Renal System
All reported affected individuals have eventually developed renal dysfunction. The kidney disease is characterized by progressively worsening loss of protein in the urine and ultimately concludes with renal failure. The progressive renal disease is not responsive to immunosuppressant therapy. The diagnosis of renal dysfunction is usually made concurrent with or within the five years following the diagnosis of the growth failure. Renal failure requiring dialysis or kidney transplantation usually develops within the subsequent 11 years, although the rate of progression varies greatly. Because renal disease causes high blood pressure and high levels of blood cholesterol and lipids, the theory is that it accentuates the vascular disease of SIOD; however, renal transplantation does not prevent progression of the atherosclerosis. The incidence of a single kidney may be higher than in the unaffected population and this is associated with a more rapid onset of renal failure.

Cardiovascular system
Half of SIOD individuals develop clinical signs of atherosclerosis. The onset is often in early childhood and relentlessly progressive. The disease is not abrogated by renal or bone marrow transplantation nor by cholesterol lowering agents, although the cholesterol lowering agents and renal transplantation can slow the progression by mitigating factors such as high blood pressure and high blood lipid and cholesterol levels. Consistent with the atherosclerosis resulting from an intrinsic defect of SIOD tissue, the vascular disease does not recur in the transplanted kidneys. Besides atherosclerosis, splitting and fraying of the arterial internal elastic layer and thickening of the muscular layer of the arterial walls have been found on autopsy. The latter finding may be a complication of high blood pressure or an intrinsic defect in the blood vessels. A few patients have also developed subaortic stenosis, one patient showed severe bicuspid aortic stenosis and one patient had extensive fatty infiltration resembling that of arrhythmogenic right ventricular cardiomyopathy.

Central nervous system (CNS)
The central nervous system shows both multiple developmental and ischemic changes. The developmental defects include brain malformations suggestive of aberrant neuronal migration including heterotopia, irregular cortical thickness, incomplete gyral formation, poor definition of cortical layers, and hamartia. Additionally, adolescent and adult patients have very few neural progenitors (stem cells). Despite these malformations, most SIOD patients have normal social, language, motor, and cognitive development until the onset of symptoms from reduced brain blood supply (cerebral ischemia).

The cerebral ischemia can either temporarily or permanently disturb the blood supply of a given area of the brain and thereby cause temporary (47%, transient ischemic attacks) or permanent (44%, strokes) dysfunction. The cerebral ischemic attacks and strokes are often precipitated by acute changes in blood pressure, such as following the administration of high doses of steroids. Ischemic changes include loss of neurons and myelin, gliosis (scarring), brain atrophy, and degeneration of infarcted regions including atrophy of the cerebellum. Likely as a complication of the cerebral ischemia and atherosclerosis, a few of the patients have also manifest Moyamoya disease.

Another common neurological feature in SIOD patients is severe migraine-like headaches (60%). The cause of the headaches is still unknown but they tend to be more severe and refractory to anti-migraine medications that migraine-like headaches in the general population. In one patient a reversible cerebral vasoconstriction syndrome was suspected.

Pulmonary system
Several patients have died from pulmonary complications including pulmonary emboli, pulmonary hypertension, and lung disease. Lung abnormalities identified by autopsy include diffuse thickening (hyperplasia) of the airway (bronchial) smooth muscles, enlargement (emphysematous changes) of the gas exchange regions (alveoli), and diffuse hyperplasia of the pulmonary artery smooth muscles. The last finding could account for the pulmonary hypertension observed in some patients.

Hematopoietic and Immune Systems
Nearly all affected individuals have some blood cell deficiency. Deficiency of T lymphocytes, a subgroup of white blood cells that plays an important role in immunity, is most common (97%) and is usually present at birth. Reductions in both CD4 T cells, which regulate multiple aspects of the immune system and CD8 T lymphocytes, which are important in the control of viruses are typical. However, in addition to a deficit of T lymphocytes, the hematopoietic disturbance can include any or all other blood cell lineages. These hematopoietic cell deficiencies reflect reduced production of these cells by the bone marrow, and affected individuals are more prone than unaffected ones to developing decreased hematopoietic cell levels in the blood as a side effect of drug therapy. Affected individuals are also less responsive to the effects of G-CSF therapy to increase bone marrow production of neutrophils and erythropoietin therapy to increase the bone marrow production or red blood cell precursors.

Because of their immunodeficiency, affected individuals have an increased risk for opportunistic fungal, viral and bacterial infections. They also have an increased risk of more severe infections. The immunodeficiency is also associated with immune dysregulation disorders, such as autoimmune blood diseases.

Reproductive system
Few SIOD patients have reached sexual maturity and of the ones who have, no children were subsequently born. However, the patients who have survived to adulthood did develop with secondary sexual characteristics and the women have menstrual cycles. The autopsy of two affected males revealed that sperm production was affected in a varying degree. In one patient, the testes showed interstitial fibrosis and absence of sperm (azoospermia), whereas the other had less interstitial fibrosis individual and produced some sperm.

- National Organization for Rare Disorders

https://rarediseases.org/rare-diseases/schimke-immuno-osseous-dysplasia/