Prolidase deficiency (PD) is an exceptionally rare autosomal recessive disorder characterized by impaired collagen degradation, leading to the accumulation of proline-containing dipeptides. We report a cluster case of three siblings aged 17, 19, and 20 years, comprising of two sisters and one brother, who presented with non-healing ulcers on their shins and feet along with facial features of hypertelorism, depressed nasal bridge, reduced intellectual function, and high-arched palate. History and clinical features were consistent with PD. Due to the rarity of the disease and low socioeconomic background of the patients, specialized investigations or treatments were either unavailable or inaccessible. Furthermore, surgical intervention was ill-advised. Despite these challenges, patients were treated using improvised tailored therapy using three different modalities and showed remarkable progress. The evaluation and management took place at the dermatology unit of Hayatabad Medical Complex in Peshawar, Pakistan.

BACKGROUND: Lateral facial clefts are atypical with a low incidence in the facial cleft spectrum. With the development of ultrasonography (US) prenatal screening, such facial malformations can be detected and diagnosed prenatally rather than at birth. Although three-dimensional US (3DUS) can render the fetus\' face via 3D reconstruction, the 3D images are displayed on two-dimensional screens without field depth, which impedes the understanding of untrained individuals. In contrast, a 3D-printed model of the fetus\' face helps both parents and doctors develop a more comprehensive understanding of the facial malformation by creating more interactive aspects. Herein, we present an isolated lateral facial cleft case that was diagnosed via US combined with a 3D-printed model.
METHODS: A 31-year-old G2P1 patient presented for routine prenatal screening at the 22nd wk of gestation. The coronal nostril-lip section of two-dimensional US (2DUS) demonstrated that the fetus\' bilateral oral commissures were asymmetrical, and left oral commissure was abnormally wide. The left oblique-coronal section showed a cleft at the left oral commissure which extended to the left cheek. The results of 3DUS confirmed the cleft. Furthermore, we created a model of the fetal face using 3D printing technology, which clearly presented facial malformations. The fetus was diagnosed with a left lateral facial cleft, which was categorized as a No. 7 facial cleft according to the Tessier facial cleft classification. The parents terminated the pregnancy at the 24th wk of gestation after parental counseling.
CONCLUSIONS: In the diagnostic course of the current case, in addition to the traditional application of 2D and 3DUS, we created a 3D-printed model of the fetus, which enhanced diagnostic evidence, benefited the education of junior doctors, improved parental counseling, and had the potential to guide surgical planning.