ChromosOmics - Database

Icon by Leon Liehr                   

                                                  CHROMOSOME #18 -                                                 
ABNORMAL


Cases without clinical findings
Similar imbalances – no sSMC
Cases with clinical findings
Similar imbalances – no sSMC
sSMC – not well characterized
Cases with isochromosome 18p
Cases without clear clinical correlation
Cases with discontinous sSMC
Cases with complex sSMC
Cases with UPD and sSMC
Cases with neocentromeres
Similar imbalances – no sSMC
Tumor
DISCLAIMER


References

In general 70% of sSMC carriers are clinically normal. The figures listed above

are based on the bias, that mainly clinically aberrant cases are studied and reported in literature!

UPD (uniparental disomy) cases: UPD(18)mat UPD(18)pat UPD(18)mat or pat

Cases with clinical findings (W)

case no.
gender/
age at diagnosis

studied
material

de novo/
inherited

GTG-banding result
grade of mosaicism

final result of the sSMC
test
methods

clinical symptoms
Reference
18-
W-

pter
see 18-U-10
18-
W-
p11.22/
1-1


°°°
male/
prenatal
AF n.a. 47,XY+mar[15]/
46,XY[5]
min(18)(:p11.22q11.1:)*
aCGH: 9.83-14.92 MB
aCGH AMA, cerebral malformation; DYS {160} case 18
***
18-
W-

p11.21/
1-1

n.a./
postnatal
PBL n.a. 47,+mar[68%]/
46[34%]
min(18)(:p11.21q11.2:)*
array: distal clone in 18p RP11-756J15 (13.17MB)
distal clone in 18q RP11-639E23 (19.34MB)
aCGH DD, DYS {91} case 11
{109} case 8
***
18-
W-

p11.21/
1-2

°°°
male/
2.5y
PBL de novo 47,XY+mar[41]/
46,XY[9]
mar(18)(:p11.21q11.2:)
array: 12.60-19.51 MB (hg19)
equals in hg18: 12.59-17.76 MB
aCGH (Illumina) speech delay, minor VSD, atopic eczema, anxiety {0} provided by Dr. Marie Trková, Praha, Czech Republic
18-
W-

p11.21/
2-1
male/
49y
PBL n.a. 47,XY,+i(18p)[15] idic(18)(:p11.21q10:) cenM;
subcenM;
MCB
severe MR, thin skin, hypogonadism, brachydactyly, long face, high palate, bilateral hearing loss; left hemiplagia (CVA 1992); DD - walking at 3 years; birth at term - 2800g {75} case 18-4
18-
W-

p11.21/
3-1

°°°
male/
30y
PBL/
BM
de novo 47,XY,+r[13]/
46,XY[42]
r(18)(::p11.21q10::)* all cep probes;
pericentric YAC clones as detailed in {66}
normal pregnancy and delivery; learning disabilities; multiple symptoms summarized as Klippel-Trenaunay syndrome {66}
18-
W-

p11.21/
4-1

male/
3y
PBL
de novo 47,XY,+r[35%]/
46,XY[65%]
r(18)(::p11.21q2.32::) aCGH see below {194} case 13
DD, VSD, AR, Bilateral SNHL, Facial dysmorphic features, Bilateral UDT, Speech delay, Malformed, Posteriorly rotated and low set ears, Simian crease, 5th toe clinodactyly, Umbilical hernia, Sacral mongolian spot, Right lower limb paresis, Joint contractures, Bilateral pachygyria
18-
W-

p11.1/
1-1
see 18-U-23
18-
O-

p11.1/
2-1

°°°
female/
1m
PBL de novo 47,XX,+mar[15] min(18)(:p11.1q11.2:)
FISH: BAC in 17.43MB present
cenM;
subcenM;
MCB
child without visible clinical signs; hyperbilirubinemia; artrial septal defect; open ductus botalli {75} case 18-2
18-
O-

p11.1/
2-2

°°°
male/
13y
PBL n.a. 47,XY,+mar[90%]/
46,XY[10%]
min(18)(:p11.1q11.2:)
FISH: BAC in 17.43MB present
array: 15.18-17.48
cenM;
subcenM;
midi; aCGH
child with 'abnormal behavior' (aggression and auto aggression) and small genitals. At birth head circumference at 3rd-10th, and weight at 3rd centile. At 13y OFC at 75-90 centile and obesity {158} case Sm-8
18-
W-

p11.1/
2-3

°°°
female/
11m
PBL; fibroblasts n.a. 49,XX,+marx3[1]/ 48,XX,+marx2[2]/ 47,XX,+mar[25]/
46,XX[32]
no sSMC in skin fibroblasts
mar(18)(:p11.1q11.2:)
aCGH: size 3.4 MB
aCGH, cep 18 hydrops, renal impairment, talipes {148} case 7
18-
W-

p11.1/
3-1
see 18-Ud-1
18-
W-

p11.1/
4-1
male/
24y
PBL de novo 47,XY,+mar[4]/
46,XX[26]
r(18)(::p11.1q11.2:
:p11.1
q11.2:
:p11.1
q11.2::)
array: 16.1-21.12MB
subcenM
aCGH; UPD-test
see below {125}
uncomplicated pregnancy of 37 weeks, weight at birth of 2670 grams with a single umbilical artery; in first week diagnosed: anal atresia, dysplastic lumbar and sacral vertebrae, penoscrotal hypospadia, cryptorchism on both sides, bifid scrotum, ureteral flow abnormality (dilatation of the higher urinary tract caused by vesico ureteral reflux, trabeculated bladder), radial dysplasia and thumb hypoplasia on the right upper extremity and preaxial polydactyly of the left hand. The diagnosis VACTERL-association was made, although there were no abnormalities of heart, trachea and esophagus. The urinary flow problems resulted in frequent infections and some episodes of urosepsis, finally causing chronic renal insufficiency. In his teens he underwent cholecystectomy because of an abnormal gallbladder full of stones. A pancreas fissum was seen. Neurologic investigation showed no signs of tethered cord syndrome. School performances were normal, there were no reasons for IQ testing. As an adult his height was on the 3rd centile and his headcircumference was normal.
18-
W-

p11.1/
5-1

°°°
male/
23y
PBL mat
(10% sSMC instead of normal #18)
47,XY,+mar[75]/
46,XX[25]
r(18)(::p11.1q21::) FISH with locusspec. probes see below {140}
birth weight 2,250 g (<3rd centile), length 42 cm (<3rd centile). At 9 months hypotonia, motor retardation, microcephaly, (occipitofrontal circumference [OFC] 42 cm; <3rd centile), hypotelorism, depressed nasal bridge, underdeveloped alae nasi, very hypoplastic columella, smooth philtrum, deciduous single median maxillary central incisor, bilateral clinodactyly, cryptorchidism. length at the 10th centile (68 cm), weight at the 50th centile (8.5 kg). At 3 years developmental quotient of 70 and IQ 44 with autistic features at age 6 years. At 9 years add. short stature at 125 cm (<3rd centile), normal weight (21.5 kg; 10th centile), and microcephaly (OFC 49 cm; <3rd centile). He had a permanent single median maxillary central incisor, long cupped ears with large lobes, and short neck. Also small penis, cryptorchidism, flat feet, frontotemporal atrophy, and large cisterna magna, bifid pelvis on the left kidney; at age 17 years severe sleep apnea. At 23 years, he suffered from severe sleep apnea, obesity, and idiopathic leg edema treated with antidiuretics. Height 155 cm(<3rd centile) weight was 90 kg (>97th centile), cognitively impaired, but was well-mannered and very kooperative with a friendly attitude.
mother phenotypically normal except for a double ureter and bifid renal pelvis (as in son)
18-
W-

q12.2/
1-1
n.a./
postnatal
PBL n.a. 47, XN,+mar[100%] idic(18)(q12.2) aCGH DD {109} case 16

W-Cases with similar imbalances NOT caused by sSMC (W-IMB)

case no.
gender/
age at diagnosis

studied
material

de novo/
Inherited

GTG-banding and final FISH result test
methods

clinical symptoms
Reference
18-
W-

IMB-
p11.32/
1-1

°°°
male/
11y
PBL n.a. 46,XY,dup(18)(p11.21p11.32),
inv(20)(p13q11)
10.2MB
aCGH mild MR, growth retardation, mild DYS, behavioural problems, hernial inguinalis, ADHD {114} case 71
18-
W-

IMB-
q11.2/
1-1

°°°
n.a./
postnatal
PBL n.a. 46,dup(18)(q11.2) n.a. knee dislocation and hyperpigmentation {96}
18-
W-

IMB-
q11.2/
1-2

°°°
n.a./
postnatal
PBL n.a. 46,dup(18)(q11.2) n.a. knee dislocation and hyperpigmentation {105}

W-cases with unclear/insufficient characterization of the sSMC (CW)

case no.
gender/
age at diagnosis

studied
material

de novo/
inherited

GTG-banding result
grade of mosaicism

final result of the sSMC
test
methods

clinical symptoms
Reference
18-
CW-
1
male/
23y
PBL n.a. 47,XY,+mar r(18) SKY Klippel-Trenaunay-Weber syndrome {14} case 6
18-
CW-
2
see 18-Uc-1
18-
CW-
3
male/
prenatal
AF de novo 47,XY,+r[28%]/
46,XY[72%]
r(18) FISH with all available centromeric probes TOP; autopsy showed 2 vessels in umbilical cord; abnormal left kidney. {12} case 10
18-
CW-
4
female/
postnatal
PBL n.a. 47,XX,+mar[mosaic status unclear] dic(18) primed in situ hybridization (PRINS) DYS like brachycephaly, short upper jaw, missing ear-lobe, micrognathia {16}
18-
CW-
5
female/
1d
fibroblasts de novo 47,XX,+mar[15%]/
46,XX[85%]
mar(18) FISH with all available centromeric probes Baby was delivered at term but died one day after birth; abnormal facial appearance, abnormal position of the limbs, ventricular septal defect, non-mmunological hydrops fetalis {22} case 33
18-
CW-
6
n.a./
n.a.
n.a. n.a. 47,+mar[?%] mar(18) FISH with ? developmental abnormal {73} 1 case
18-
CW-
7

female/
8m
PBL de novo 47,XX,+mar[30%]/
46,XX[70%]
mar(18) PRINS see below {73} case 3
DD, weight at 5th centile, lenght at 10. centile, OFC at 5th centile at 8m. mild hypotonia, flat nasal bridge, high arched palate, protruding tongue, capillary hemangiomas on the left upper eyelid, lower lip, right side of the back, right upper chest, right second finger, and left fifth finger; patent ductus arteriosus.
18-
CW-
8
male/
newborn
PBL de novo 47,XY+del(18)(q11)[100%]
mar looks like an i(18p!!)
n.a. no FISH developmental abnormal {92}
18-
CW-
9
male/
newborn
PBL de novo 47,XY,+del(18)(q11)[100%] n.a. no FISH developmental abnormal {93}
18-
CW-
10
n.a./
prenatal
AF de novo 47,+mar[17%]/
46[83%]
mar(18) wcp18; cep18 Abnormal triple test, sonographic malformations (facial dysmorphism), TOP; Fetopathology low set ears, retrognathism {119} case 8

Cases with isochromosome 18p (Wi)

According to {32} i(18p) commonly form through meiosis II non-disjunction immediately followed by meiotic or early post-meiotic mitotic miss-division at the centromere; the i(18p) are preferentially of maternal origin. Exceptions are familial forms like described in {35, 37, 39, 43}.
Here some guidelines how to deal best with tretasomy 18 patients from "The Chromosome 18 Registry & Research Society"

case no.
Reference
18-
Wi-
1
{3} case 3; {32} case 6
18-
Wi-
2 to 3
{4} cases 22, 24; {5} cases 10-11
18-
Wi-
4
{6}; {5} case 8; {58} case 9
18-
Wi-
5 to 13
{7}; {8} case 11
18-
Wi-
14 to 15
{13} case 12-13
18-
Wi-
16
{17}
118-
Wi-
17
{11} case 1
18-
Wi-
18
{18} case 2
18-
Wi-
19
{19}
18-
Wi-
20 to 21
{20-21} cases 14-15
18-
Wi-
22
{20} case 16
18-
Wi-
23 to 24
{5} cases 9, 12; case 12 = {58} case 8
18-
Wi-
25
{24} case 2
18-
Wi-
26
{25} case 4
18-
Wi-
27
{28} case B
18-
Wi-
28 to 29
{30} cases 1-2
18-
Wi-
30
{31} case VII
18-
Wi-
31 to 39
{32} cases 1-5; 7-9
18-
Wi-
40
{34} i(18p) in grandmother and two daughters in low level mosaic; then affected child born
18-
Wi-
41
{35} i(18p) maternal in origin (mother normal with 2/50 metaphases in blood with sSMC)
18-
Wi-
42
{36} mosaic: 47,XY,+i(18p)/46,XY
18-
Wi-
43
{37} - 47,XX,del(18)(p11.21),+i(18p)
18-
Wi-
44
{38}
18-
Wi-
45
{39} - 47,XX,del(18)(p11),+i(18p)
18-
Wi-
46
{40}
18-
Wi-
47

{41}
18-
Wi-
48
{42} case 2
18-
Wi-
49
{43}
18-
Wi-
50
{44}
18-
Wi-
51 to 52
{45 cases 9-10, {78}
18-
Wi-
53
{46}
18-
Wi-
54 to 55
{47}
18-
Wi-
56
{48}
18-
Wi-
57
{49}
18-
Wi-
58
{50}
18-
Wi-
59
{51}
18-
Wi-

60 to 61
{52}
18-
Wi-
62
{53}
18-
Wi-
63
{54} = {58} case 4
18-
Wi-
64
{55}
18-
Wi-
65
{56}
18-
Wi-
66 to 77
{19} 12 cases reviewed but not detailed here with original citation
18-
Wi-
78
{57}
18-
Wi-
79 to 80
{58} cases 1 and 3 = {59} cases 4 and 2
18-
Wi-
81 to 84
{58} cases 2, 5, 6, 7
18-
Wi-
85
{60}
18-
Wi-
86 to 87
{61}
18-
Wi-
88
{62} mosaic karyotype with loss of one X-chromosome in a certain percentage of the cells
18-
Wi-
89
{63}
18-
Wi-
90
{64}
18-
Wi-
91 to 92
{65} cases 12-13
18-
Wi-
93
{67}
18-
Wi-
94
{69} case 4; inv dup 18p and inv dup 18q and normal 18
18-
Wi-
95
{71}
18-
Wi-
96 to 97
{72} 2 cases
18-
Wi-
98 to 99
{74} cases 19 and 23, {90} cases 24 and 29
18-
Wi-
100
{0} case provided by Dr. Küpferling, Cottbus, Germany
18-
Wi-
101

{76} 1 case of 15109 CVS cases
18-
Wi-
102
{128} case 9
18-
Wi-
103
{111} postnatal - case 26
18-
Wi-
104
{0} provided by Dr. Ivan Iourov, Moscow, Russian Federation
18-
Wi-
105
{79}
18-
Wi-
106
{80} 1 case
18-
Wi-
107 to 117
{81} 11 cases
18-
Wi-
118
{82} case 2
18-
Wi-
119 to 123
{83} cases 12-16
18-
Wi-
124 to 128
{84} cases 17-21
18-
Wi-
129
{0} provided by Jasen Andersen, Brisbane, Australia
18-
Wi-
130
{0} provided by Dr. Deutinger, Vienna, Austria
18-
Wi-
131
{0} provided by Dr. Decker, Mainz, Germany
18-
Wi-
132
{156} case 19
18-
Wi-
133
{85}
18-
Wi-
134 to 137
{86} cases 67-68; 72-73
18-
Wi-
138
{87} PBL
(EKF-
cellbank)
18-
Wi-
139
{158} case Si-3 (PBL
(EKF-cellbank) array: pter-0.36MB of q-arm
18-
Wi-
140
{89} case 3
18-
Wi-
141
{0} provided by Dr. Tittelbach, Nürnberg, Germany
18-
Wi-
142
{111} postnatal - case 28
18-
Wi-
143
{156} case 18
18-
Wi-
144
{111} postnatal - case 27
18-
Wi-
145 to 146
{0} cases provided by Dr. Dilek Aktas, Ankara, Turkey
18-
Wi-
147
{111} postnatal - case 29
18-
Wi-
148 to 149
{113} postnatal - 2 cases
18-
Wi-
150
{128} case 10
18-
Wi-
151 to 153
{116} postnatal - 3 cases; mosaicism in buccal mucosa with normal cells
18-
Wi-
154
{117} prenatal - mosaicism
18-
Wi-
155
{119} case 3, prenatal
18-
Wi-
156
{124} postnatal; {139} case P-9
18-
Wi-
157
{120} postnatal - mos 47,XY,+i(18)/45,X
18-
Wi-
158
{121, 161, 198} prenatal i(18p) present in 35% of the cells; postnatal no i(18p) detectable - normal child
18-
Wi-
158a
{198} normal 27y old male - i(18p) in 100% of peripheral blood cells
18-
Wi-
158b
{186, 198} prenatal; no sonographic signs; TOP; autopsy also phenotypically normal
18-
Wi-
158c
{190, 198} - mosaic +i(18p) in amnion probe 1 (8/39); in 2. probe 3 weeks later in 2/14; after birth no #(18p) in PBL and normal child at 8m; {206} case 3
18-
Wi-
159
{122} postnatal - cases 5, {206} case 1
18-
Wi-
160
{122} postnatal - cases 6
18-
Wi-
161 to 163
{123} prenatal - 3 cases
18-
Wi-
164
{0} prenatal case provided by Dr. Junge, Dresden [47,XY,+mar[23]/46,XY[35]]
18-
Wi-
165
{0} prenatal case provided by Dr. Michael Petersen, Athens, Greece
18-
Wi-
166
{126} postnatal case
18-
Wi-
167
{127} postnatal case
18-
Wi-
168
{129; 182} 1/42 postnatal cases with mosaic (19% sSMC in blood, 68% in fibroblasts abdomen; 94% in fibroblasts forehead) {146}
18-
Wi-
169 to 209
{129; 182} 41/42 postnatal cases without mosaic {146}
18-
Wi-
210
{132} prenatal; mosaic with normal cell line
18-
Wi-
211

{133} postnatal
18-
Wi-
212 to 220
{134} postnatal - 9 cases
18-
Wi-
221
{135} postnatal
18-
Wi-
222
{136} postnatal
18-
Wi-
223
{137} postnatal
18-
Wi-
224
{138} postnatal
18-
Wi-
225
{142} postnatal
18-
Wi-
226
{143; 150} postnatal
18-
Wi-
227 to 228
{157} postnatal, provided by Dr.Maria Isabel Melaragno, Sao Paolo, Brazil
1 case asymmetric -
array: 2x on sSMC: pter to 15.39; 1x on sSMC: 15.39 to 17.36
18-
Wi-
229 to 230
{0} provided by Dr. Iourov, Moscow, Russia; postnatal
18-
Wi-
231
{0} provided by Dr. Melaragno, Sao Paulo, Brasil; postnatal
18-
Wi-
232
{0} provided by Dr. Melaragno, Sao Paulo, Brasil; postnatal; break in 18q11.2; pos: 17.48 MB
18-
Wi-
233
{0} provided by Dr. Sheth , Ahmedahad , India; postnatal
18-
Wi-
234
{0} provided by Dr. Mulhatino, Rio de Janeiro, Brasil
18-
Wi-
235 to 250
{152} 16 cases
18-
Wi-
251
{153} postnatal
18-
Wi-
252
{155} postnatal
18-
Wi-
253
{0} prenatal; provided by Dr. Reiber, Jena, i(18)(q11.2); TOP
18-
Wi-
254
{0} 47,XY,+i(18)(q11.1)[4]/47,XY,+min(18)(:p11.1-[gt]q11.1:)15]/46,XY[21]; postnatal, provided by Dr. T. Martin, Homburg, Germany
18-
Wi-
255
{0} prenatal; provided by Agnieszka Gnys-Wiercioch, Ruda Slaska, Poland
18-
Wi-
256
{159} prenatal, mosaic
18-
Wi-
257 to 258
{160} cases 17 and 19 - prenatal, mosaic - aCGH
18-
Wi-
259
{162; 170} postnatal
18-
Wi-
260 to 263
{163} 4 cases
18-
Wi-
264
{163} complex case postnatal: 47,XY,+i(18)(p10)/47,XY,+der(18)t(18;21)(q21.1;q11.2)
18-
Wi-
265
{164} prenatal mosaic
18-
Wi-
266
{165} besides i(18p) also i(21p)
18-
Wi-
267
{0} postnatal; provided by Dr. F. Sheth, Ahmedabhad, India
18-
Wi-
268
{167}
18-
Wi-
269
{168} case 1
18-
Wi-
270
{0} postnatal; provided by Dr. Midyan, Yerevan, Armenia
18-
Wi-
271
{0} prenatal; provided by Dr. Kania, Ruda Slaska, Poland
18-
Wi-
272
{198} postnatal; mar only in 11%!!; slight DD
18-
Wi-
273
{0} postnatal; provided by Dr. Baltaci, Ankara, Turkey
18-
Wi-
274
{172} prenatal, {206} case 2
18-
Wi-
275
{173} postnatal
18-
Wi-
276
{174} postnatal; also del(2)(q12q13)
18-
Wi-
276a
{192} postnatal; also del(2)(q12q13)
18-
Wi-
277 to 290
{176} 14 cases
18-
Wi-
291
{0} postnatal, provided by Dr. Weimer, Kiel, Germany
18-
Wi-
292
{0} postnatal, provided by Dr. Natiq, Rabat, Maroc
18-
Wi-
293
{177} 1 prenatal mosaic case by NIPT
18-
Wi-
294
{178} 1 prenatal case (SNP-array) case 3
18-
Wi-
295 to 296
{178} 1 pre- and 1 postnatal case
18-
Wi-
297
{180} 1 case prenatal, mosaic 30%
18-
Wi-
298
{0} postnatal, provided by Dr. Ruml, Serbia
18-
Wi-
299
{0} postnatal; provided by Dr. Ilic, Belgrade, Serbia
18-
Wi-
300
{181} postnatal
18-
Wi-
301 to 306
{182} postnatal 6 cases
18-
Wi-
307
{183} prenatal
18-
Wi-
308 to 309
{184} prenatal (twins)
18-
Wi-
310
{0} prenatal; provided from Greece
18-
Wi-
311
{185} prenatal
18-
Wi-
312
{188} ? postnatal
18-
Wi-
313
{189} postnatal
18-
Wi-
314 to 315
{191} 2 cases, postnatal
18-
Wi-
316 to 317
{191} 2 cases, postnatal; provided from Armenia
18-
Wi-
318

{144} postnatal
18-
Wi-
319
{145} postnatal
18-
Wi-
320
{193} postnatal after NIPT with trisomy 18
18-
Wi-
321 to 341
{195} 21 cases, postnatal
18-
Wi-
342 to 348
{196} 9 cases, postnatal
18-
Wi-
349
{196} normal but low mosaic and mother of case 3 
18-
Wi-
350
{0} prenatal; provided from Recklinghausen, Germany
18-
Wi-
351

{0} prenatal
18-
Wi-
352
{0} prenatal; provided from Moroc
18-
Wi-
353
{201} prenatal; case 8
18-
Wi-
354 to 356

{202} 1 prenatal, 1 postnatal; cases 61259 and 172168
18-
Wi-
357
{203} 1 prenatal
18-
Wi-
358 to 359
{204} case P12 and P13, postnatal
18-
Wi-
360
{0} fibro
(EKF-
cellbank)
18-
Wi-
361
{0} prenatal. provided from Essen
18-
Wi-
362
{205} same case listed as mult 2-53, as maternally inherited heterochr. sSMC also present
18-
Wi-
363
{207} 1 case
18-
Wi-
364
{208}
18-
Wi-
365
{209}  in amnion 47,XY,+i(18p). Postnatally, peripheral in blood 46,XY,+i(18q), and in fibroblasts 47,XY,+i(18p).
18-
Wi-
366
{209}
18-
Wi-
367 to 368
{59} case 1 and 3
18-
Wi-
369
{210}
18-
Wi-
370
{211}
18-
Wi-
371
{212}
18-
Wi-
372
{213}
18-
Wi-
373
{214}
18-
Wi-
374
{215}
18-
Wi-
375
{216}
18-
Wi-
376
{217} one case with 47,XX,+i(18)(p10)[47]/47,XX,+18[9] /46,XX[4]
18-
Wi-
377
{218}
18-
Wi-
378
{219}
18-
Wi-
379
{221}
18-
Wi-
380
{222}
18-
Wi-
381
{0} provided from Moroc
18-
Wi-
382
{223}
18-
Wi-
383 
{224} normal but low mosaic and monocygote twin with 100% +i(18p) 
18-
Wi-
384
{225} one affected in dizygote twins
18-
Wi-
385
{226}
18-
Wi-
386 to 387
{227} 2 cases
18-
Wi-
388
{228} diagnoses in a >40 year old patient
18-
Wi-
389
{229} case 13
18-
Wi-
390
{230} case 24