Establishment and characterization of ZJUCHi003: an induced pluripotent stem cell line from a patient with Temple-Baraitser/Zimmermann-Laband syndrome carrying KCNH1 c.1070G > A (p.R357Q) variant

Pathogenic variants of the KCNH1 gene can cause dominant-inherited Temple-Baraitser/Zimmermann-Laband syndrome with severe mental retardation, seizure, gingival hyperplasia and nail hypoplasia. This study established an induced pluripotent stem cell (iPSC) line using urinary cells from a girl with KCNH1 recurrent/hotspot pathogenic variant c.1070G > A (p.R357Q). The cell identity, pluripotency, karyotypic integrity, absence of reprogramming virus and mycoplasma contamination, and differential potential to three germ layers of the iPSC line, named as ZJUCHi003, were characterized and confirmed. Furthermore, ZJUCHi003-derived neurons manifested slower action potential repolarization process and wider action potential half-width than the normal neurons. This cell line will be useful for investigating the pathogenic mechanisms of KCNH1 variants-associated symptoms, as well as for evaluating novel therapeutic approaches.

Potassium Channel KCNH1 Activating Variants Cause Altered Functional and Morphological Ciliogenesis

The primary cilium is a non-motile sensory organelle that extends from the surface of most vertebrate cells and transduces signals regulating proliferation, differentiation, and migration. Primary cilia dysfunctions have been observed in cancer and in a group of heterogeneous disorders called ciliopathies, characterized by renal and liver cysts, skeleton and limb abnormalities, retinal degeneration, intellectual disability, ataxia, and heart disease and, recently, in autism spectrum disorder, schizophrenia, and epilepsy. The potassium voltage-gated channel subfamily H member 1 (KCNH1) gene encodes a member of the EAG (ether-à-go-go) family, which controls potassium flux regulating resting membrane potential in both excitable and non-excitable cells and is involved in intracellular signaling, cell proliferation, and tumorigenesis. KCNH1 missense variants have been associated with syndromic neurodevelopmental disorders, including Zimmermann-Laband syndrome 1 (ZLS1, MIM #135500), Temple-Baraitser syndrome (TMBTS, MIM #611816), and, recently, with milder phenotypes as epilepsy. In this work, we provide evidence that KCNH1 localizes at the base of the cilium in pre-ciliary vesicles and ciliary pocket of human dermal fibroblasts and retinal pigment epithelial (hTERT RPE1) cells and that the pathogenic missense variants (L352V and R330Q; NP_002229.1) perturb cilia morphology, assembly/disassembly, and Sonic Hedgehog signaling, disclosing a multifaceted role of the protein. The study of KCNH1 localization, its functions related to primary cilia, and the alterations introduced by mutations in ciliogenesis, cell cycle coordination, cilium morphology, and cilia signaling pathways could help elucidate the molecular mechanisms underlying neurological phenotypes and neurodevelopmental disorders not considered as classical ciliopathies but for which a significant role of primary cilia is emerging.

Fibrodysplasia ossificans progressiva in a young adult with genetic mutation: Case report

RATIONALE

Fibrodysplasia ossificans progressiva (FOP) is a rare autosomal dominant disorder characterized by congenital skeletal deformities and soft tissue masses that progress into heterotopic ossification. Deformities of the great toes are distinctive and heterotrophic ossification usually begins in the first decade of the patient's life. Any invasive procedure could potentially trigger a flare and heterotopic calcification. The diagnosis is difficult and there is no effective treatment for FOP and the approximate life expectancy is 4 decades.

PATIENT CONCERNS

A 22-year-old male patient who had suffered from pain and movement limitations for 14 years. At the early stage of disease, the child underwent an operation on both thighs with a diagnosis of myophagism. He had serious stiffness and multiple bony masses with the characteristic bilateral hallux valgus deformity and microdactyly.

DIAGNOSES

The patient was diagnosed with FOP by the help of characteristic great toe malformations and widespread heterotopic ossification throughout the body. Deoxyribonucleic acid sequencing demonstrated that the patient had a de novo heterozygous mutation (c.617G>A; p.R206H) in activin A receptor/activin-like kinase 2.

INTERVENTIONS

We administered a co-therapy of glucocorticoids, NSAIDs to relieve pain, and montelukast for 2 months. Bisphosphonate (5 mg, intravenous) was used once.

OUTCOMES

At the follow-up 12 months later, the patient still felt low back pain sometimes and need take NSAIDs three times a week.

LESSONS

Clinicians and radiologists should realize the characteristic features of FOP and early diagnosis can prevent additional invasive harm to the patient.

Temple-Baraitser syndrome with KCNH1 Asn510Thr: a new case report

Temple-Baraitser syndrome (TMBTS; OMIM: 611816) is a rare developmental disorder characterized by severe mental retardation and anomalies of thumb and great toe with absence/hypoplasia of the nails. Here, we report an additional patient with TMBTS, review clinical and radiological features of previously reported cases and discuss mode of inheritance. The patient exhibited a pattern of anomalies: mild dysmorphic facial features with a wide open mouth, a thick vermilion border of the upper lip and downturned corners of the mouth; nails were absent on both great toes and thumb. Electroencephalogram showed a diffusely slow background. Whole genome sequencing identified one pathogenic missense mutation in KCNH1 (c. 1529 A > C; Asn510Thr) in this TMBTS patient. The mutation was also validated by Sanger sequencing.

Early Recognition of Fibrodysplasia Ossificans Progressiva-Important For the Clinician

Fibrodysplasia ossificans progressiva is a rare disorder of heterotopic ossification. Procedures like biopsy and surgery are known to be aggravating factors in promoting heterotopic ossification Clues to clinical diagnosis may therefore be a great advantage to treating orthopedician. Valgus deformity of great toe is an important diagnostic clue for treating physicians and thus aids in preventing the clinicians from subjecting the patients to unnecessary invasive and traumatic procedures. Hence clinical clues to early diagnosis are important in establishing the correct diagnosis and directing future management.

Two cases of Temple-Baraitser syndrome: natural history and further delineation of the clinical and radiologic phenotypes

This study reports on two individuals with Temple-Baraitser syndrome, manifesting typical hallux and pollex findings, global developmental delay, and seizures. In the five previous cases identified to date, consistent craniofacial and osseous characteristics have been observed. The children described herein exhibit minor differences within this phenotype and are older, highlighting the phenotypic variability and natural history of the clinical and radiographic findings.

Fibrodysplasia ossificans progressiva

Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disorder of the connective tissue characterized by progressive disability as a result of extensive extra skeletal enchondral bone formation and malformed big toes which are often monophalangic. Occasional features include short thumbs, fifth finger clinodactyly, malformed cervical vertebrae and mild mental retardation. Beginning during childhood, FOP progressively immobilizes all the joints through adult life, rendering movement impossible. Currently, there is no effective prevention or cure for this debilitating disease. Since it has an autosomal dominant inheritance, our concern is to highlight prompt genetic counseling in the concerned families although many sporadic cases have also been identified.

Scalp nodules as a presenting sign of fibrodysplasia ossificans progressiva: a register-based study

BACKGROUND

Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disorder characterized by progressive ossification of soft tissues. Clinical diagnosis is important because trauma from lesional biopsies can exacerbate the disease.

OBJECTIVE

We sought to evaluate the frequency of scalp nodules as the presenting manifestation of FOP.

METHODS

We describe 3 infants with FOP who presented with multiple neonatal scalp nodules. We reviewed all 43 cases of this disorder in the French FOP registry.

RESULTS

Scalp nodules were found in 40% of cases and usually represented the first manifestation of the disease. All 43 patients had characteristic skeletal malformations involving the great toes (n = 43), fingers (n = 12), and vertebrae (n = 3). Other abnormalities were cerebral malformations (n = 1) and alopecia (n = 2). Histopathologic analysis did not contribute to the differential diagnosis and was interpreted as cranial fasciitis in two patients.

LIMITATIONS

Our study was retrospective, and the presence or absence of scalp nodules was not always recorded.

CONCLUSION

Neonatal scalp nodules associated with a characteristic malformation of the great toes are a common presentation of FOP. Physicians should be aware that lesional biopsies can exacerbate the disease and must therefore be avoided. A diagnosis of classic FOP can be confirmed by molecular genetic studies.

Incomplete development of the nail of the hallux in the newborn

Between March and October 2008, the nails of 541 (252 females, 289 males) consecutively born neonates with an average age of 3.2 days were examined in the Neonatology Unit. Of these newborns with nail disorders, 36 were re-examined after a period that ranged from seven days to six months. The most frequent nail alteration was the incomplete development of the hallux nail, which was triangular - sometimes trapezoidal - shaped. This alteration, which had been previously reported in the literature as congenital hypertrophy of the lateral folds of the hallux, spontaneously regressed within one to three months in the infants re-examined. There was no associated inflammation or onychocryptosis at any time. The apparent hypertrophy of the nail folds seemed to be secondary to the lack of pressure of the nail lamina.

Prenatal diagnosis of a case probably with Oral-Facial-Digital Syndrome--Gabrielli type

We report here a case with microcephaly, preauricular pits, cleft lip-palate, hypertelorism, multiple frenula and preaxial polydactyly. The clinical picture overlaps with many syndromes, but it is mostly consistent with oral-facial-digital syndrome, Gabrielli type. There are no previously reported cases of this syndrome presenting also with microcephaly. On the other hand, it is hard to differentiate this clinical picture from Goldenhar syndrome (Oculo-auriculo-vertebral spectrum), and oculo-auriculo-fronto-nasal syndrome because of many overlapping features.

Short humerus: an additional antenatal sonographic feature of OFDS type II

The prevalence of skeletal dysplasia in the neonatal period is 2.4/10,000 births; it accounts for 1-2% of perinatal deaths, mainly stillbirths. A long bone measurement of less than -4 standard deviations is a definitive indication of skeletal dysplasia, whereas measurement between -2 and -4 standard deviations warrants detailed sonographic examination for other associated anomalies to arrive at a diagnosis. We report a case of oral-facial-digital syndrome type II that presented antenatally with polyhydramnios, short humerus, polydactyly, and duplicated thumb.

Correction of clawed hallux deformity: comparison of the Jones procedure and FHL transfer in a cadaver model

BACKGROUND

A clawed hallux is defined as extension of the first metatarsophalangeal (MTP) joint combined with flexion of the interphalangeal (IP) joint. Two operative procedures, the modified Jones procedure and flexor hallucis longus (FHL) transfer, are indicated for correction. The purpose of this study were to evaluate the overall effectiveness of these two procedures in correcting both the clawed hallux deformity and its mechanical consequences and to compare their effect on postoperative plantar pressures.

METHODS

The modified Jones procedure and FHL transfer were done on cadaver specimens that were tested before and after surgery in a specialized foot-loading frame. We quantified the angular correction of the MTP and the IP joints, as well as the plantar pressures under the head of the first metatarsal and the hallux.

RESULTS

Both surgeries were equally effective in correcting the angular deformity at the MTP and IP joints (p = 0.037 and 0.0020, respectively). A significant reduction in the plantar pressure (p = 0.015) beneath the first metatarsal was observed with both the modified Jones procedure and the FHL transfer. Overall, there was no significant difference between preoperative and postoperative pressures beneath the hallux (p = 0.5); however, for the FHL overpull group there was significantly less pressure beneath the hallux after surgery (p = 0.014).

CONCLUSIONS

The two surgeries produced similar results, but the FHL transfer does not require fusion of the hallux, which is considered an undesirable co-morbidity of the modified Jones procedure.

Abnormal first trimester screen in partial deletion of chromosome 6p21: a case-report

In this case-report we describe a 21-year-old primigravida with an abnormal first trimester screen: combined risk for Downs Syndrome was 1:90. Karyotype revealed 46,XX,del(6)(p21). Termination with Cytotec was offered because of the risk of congenital malformations and subsequent abnormalities associated with deletions in chromosome 6p. As to our knowledge no report has been written about the prenatal diagnosis of deletions on the short arm of chromosome six based on the first trimester screen. By publishing our experience we want to create awareness. This case-report shows the importance of combining prenatal screening with the biochemical tests, instead of only measuring nuchal translucency. It also shows the need for full karyotyping when invasive prenatal testing is done.

Difficulty in recognizing multiple sulfatase deficiency in an infant

We describe the difficulty in recognizing multiple sulfatase deficiency (MSD; Online Mendelian Inheritance in Man [OMIM] database No. 272200) in an infant. MSD is a rare autosomal recessive disorder that affects the posttranslational activation of various sulfatase enzymes. It is both biochemically and clinically variable. Currently, there are 12 known sulfatases in humans, and the clinical presentation of MSD is a unique composite of those individual enzyme defects. Here we report a black girl who presented with bilateral broad thumbs and great toes, both with angulation deformities at birth. Rubinstein-Taybi syndrome (OMIM No. 180849) was considered initially. The detection of inclusion bodies in her white blood cells at 37 months of age led to the appropriate diagnostic workups for lysosomal storage diseases. Elevation of urine mucopolysaccharides provided additional clues, and the fibroblast enzyme assays finally established the diagnosis. Broad thumbs and great toes are rare features of MSD, and to the best of our knowledge such a bilateral congenital anomaly with angulation deformities has never been reported before to be associated with MSD.

Pathomorphology and treatment of congenital anterolateral bowing of the tibia associated with duplication of the hallux

Congenital unilateral anterolateral tibial bowing in combination with a bifid ipsilateral great toe is a very rare deformity which resembles the anterolateral tibial bowing that occurs in association with congenital pseudarthrosis of the tibia. However, spontaneous resolution of the deformity without operative treatment and with a continuously straight fibula has been described in all previously reported cases. We report three additional cases and discuss the options for treatment. We suggest that this is a specific entity within the field of anterolateral bowing of the tibia and conclude that it has a much better prognosis than congenital pseudarthrosis of the tibia, although conservative treatment alone may not be sufficient.

Fibrodysplasia ossificans progressiva

A 2-year-old boy presented with low-grade fever and multiple progressive painful swellings over upper dorsal trunk and supraclavicular region with progressive stiffening of skin for the last 2 months. Examination revealed dysmorphic face, proximally placed thumb and bilateral hallux valgus. Hence, a diagnosis of Fibrodysplasia Ossificans Progressiva was entertained.

Island nail transfer in the treatment of macrodactyly of the great toe: a case report

Macrodactyly involving the great toe is difficult to treat when both the functional and cosmetic problems are addressed simultaneously. Partial resection of the distal phalanx is an easy way to reduce the length of the involved toe. However, there are cosmetic concerns with loss of the toenail. The authors report on a clinical case in which shortening and debulking of the toe was performed while preserving the hallux nail. The nail complex was transferred as an island flap to the dorsal aspect of the proximal phalanx. At the 1-year follow-up, the length of the reconstructed toe was significantly decreased, with a normal-looking nail.

[A rare shortening of the first metatarsus of the foot and its treatment with distraction arthrodesis]

Multiple toes may develop on the medial or lateral side of the forefoot or in its middle. This may involve duplication of only the distal phalanx or the whole hallux including the metatarsal. In a duplicated big toe, the phalanx to be maintained, because short muscles of the leg are attached to it, is usually localized medially. A rare case of dysplasia of the first metatarsus, following a resection indicated in childhood for a hallux triples, is described in a 20-year-old girl. In order to remove hallux insufficiency and an overloading of the middle metatarsals, the authors decided to carry out a one-stage prolongation of the first metatarsal, using an autologous tricorticcal graft collected from the pelvis and a dynamic compression plate. No surgical treatment of the middle metatarsals was indicated because a disproportionate, short foot would result. Both the subjective and objective status of the patient at 6 months after the operation showed that the non-standard prolongation procedure was correctly indicated and allowed for physiological loading of the foot and restoration of normal walking.

Variations in the insertion of the extensor hallucis longus muscle

Reports that describe abnormalities of the muscles and tendons of the leg and foot are important with regard to understanding the function of the lower limb and correlating these abnormalities with the clinical aspects. Variations in the insertion of the extensor hallucis longus muscle were studied in 60 adult human cadavers. Three different patterns of insertion were noticed. Pattern I (65%): the extensor hallucis longus muscle had a single tendinous insertion on the dorsal aspect of the base of the distal phalanx of the big toe. Pattern II (26.67%): the muscle terminated in two tendons. Pattern III (8.33%): the muscle terminated in three tendinous slips. Various sites of insertion of the extensor hallucis longus muscle were recorded other than the dorsal aspect of the base of the distal phalanx of the big toe. These were the dorsal aspect of the base of the proximal phalanx of the big toe and the capsule of the first metatarso-phalangeal joint or a connection with the tendon of the extensor hallucis brevis. The frequency of occurrence of lateral deviation of the big toe at the metatarso-phalangeal joint (hallux valgus) was recorded. It is suggested that the presence of these variations in the insertion of the extensor hallucis longus muscle may have a role in explaining its association with hallux valgus.

Broad thumbs and halluces with deafness: a patient with Keipert syndrome

Clinical, radiological, and audiological features are described in a boy whose condition closely parallels the profile of patients previously described with Keipert syndrome. This case represents the fourth report of this rare disorder.

Diagnosing acrocallosal syndrome

A 3-month-old male child presented with typical features of acrocallosal syndrome. He satisfies Courten's diagnostic criteria for acrocallosal syndrome.

[Lengthening of the IV metatarsal in the treatment of the shortened toe of the foot]

The author presents the results of surgical treatment of congenital shortening of the IV metatarsal in 3 girls. In 2 cases the defect was bilateral. A total of 5 feet were operated on the age of the patients at time of operation ranged from 10 years and 1 months to 16 years and 11 months. A one-stage procedure with the use of a Pumed mini-distraction device was performed. The fissure between the bone fragments was augmented with a bone graft from the fibula. It was harvested in such a way as to maintain internal cortical integrity. K-wire fixation of the bony fragments was applied for 7 weeks. Immobilization by means of a plaster cast was applied for 6 to 8 weeks. Follow-up ranged from 7 months to 3 years. In all cases an improvement of the finger shape and it's lengthening was noted, although in 2 cases lengthening wasn't complete. In one case it resulted from an axial deformity of the IV metatarsal, a sequel of early (5 weeks) removal of the K-wire.

Oral-facial-digital syndrome type II (Mohr syndrome): clinical and genetic manifestations

The oral-facial-digital syndromes (OFDS) represent a heterogenous group of disorders characterized by oral malformation, facial anomalies, and digital anomalies. Type II OFDS was reported by Mohr in 1941. Mohr syndrome is an autosomal recessive inherited disease characterized by median cleft lip, poly lobed tongue, absence of medial incisors, and polydactyly of hands and feet. Some other different expressive types of OFDS cases have been reported, and identified with 11 different clinical entities up to the present. Until now, only three cases of OFDS II in Japanese patients have been detected except for our patient. At this time, we observed a Japanese patient of Mohr syndrome with median cleft lip and tongue, hypertrophied frenula, absence of left medial incisor, and bilateral bifidity of great toe. Lip and tongue plasty was performed at 7 months after birth and toe plasty was done at 11 months with good results.