Fig. 1. Serial photographs of the patient. (A) Mild facial coarseness was noted at the age of 4 years. Facial dysmorphism, including coarse facial features, a depressed nasal bridge, prominent eyebrows, and malocclusion, was apparent at ages 13 (B) and 18 years (C). (D) He was bedridden and malnourished at the age of 21 years.