EFNB1 mutation at the ephrin ligand-receptor dimerization interface in a patient with craniofrontonasal syndrome

Craniofrontonasal syndrome (CFNS) is characterized by craniosynostosis, hypertelorism, a broad nasal tip and occasionally cleft lip and palate, and is caused by a mutation in the ephrin-B1 gene (EFNB1). The study of naturally occurring human EFNB1 mutations offers a unique opportunity to better define the critical portion within the ephrin domain that is essential for the function of EFNB1 protein in craniofacial development. Here, we report a CFNS patient with a novel EFNB1 missense mutation present at the interface between EFNB1 and its receptor proteins. The patient's facial features included hypertelorism, a broad nasal tip, brachycephaly, frontal bossing, facial asymmetry and esotropia. In addition, she had pectus carinatum, grooved nails on her thumb, an abnormal palmar crease pattern and a broad first toe. Her development was appropriate for her age. Direct sequencing of polymerase chain reaction products using an autosequencer revealed a heterozygous missense mutation, Ser118Ile. Ser118 is located in the G-H loop of the extracellular ephrin domain and is highly evolutionarily conserved among rodents, avians and fish. The mutation occurred de novo and was not present in 100 normal Japanese control subjects. Substitutions of the adjacent amino acid residue, Pro119, have been previously reported in three CFNS patients. Since the structure of EFNB1 is not yet available, the spatial locality of Ser118 was characterized using the protein structure of EFNB2. We deduced that Ser118 in EFNB1 resides at the major dimerization interface with Eph receptors and inferred that the Ser118Ile mutation may impede the protrusion of the G-H loop, thereby disturbing Eph-Ephrin signal transduction.

Malpuech syndrome: broadening the clinical spectrum and molecular analysis by array-CGH

We report on a patient with mental and growth retardation, bilateral cleft lip and palate, hypertelorism, ptosis, hearing loss and mild epispadias, suggestive of Malpuech syndrome. High-resolution karyotype and microarray-CGH using an oligonucleotide array with 75Kb oligo's were normal, excluding Wolf-Hirschhorn syndrome. Long-term follow-up revealed psychiatric manifestations starting at young age.

Neonatal teeth in X-linked Opitz (G/BBB) syndrome

Two male siblings are described with a clinical and molecular diagnosis of X-linked Opitz (G/BBB) syndrome and the previously unreported feature of neonatal mandibular incisors.

A longitudinal study on influence of primary facial deformities on maxillofacial growth in patients with cleft lip and palate

OBJECTIVE

The goal of this study was to use three-dimensional (3D) analysis to characterize the primary facial deformities in children with unilateral cleft lip and palate (UCLP) and then serially analyze the relationships between facial deformities and maxillofacial growth from infancy to adolescence.

PARTICIPANTS

Twenty-one Japanese subjects with unilateral cleft lip and alveolus (UCLA) and 20 with UCLP who had been operated on and then followed up for more than 15 years were enrolled in this study.

MAIN OUTCOME MEASURES

Facial cast models taken at cheiloplasty were scanned with a 3D laser scanner. Lateral cephalographs taken when subjects were 15 years of age or older were traced, and linear and angular measurements were calculated. The correlation between primary facial forms and maxillofacial morphology in adolescence was analyzed.

RESULTS

Three-dimensional analysis showed larger ocular hypertelorism, wider cleft, greater deviation of the columella base, and more severe retruded position of the affected nasal alar base in subjects with UCLP than those with UCLA. Total surface area of the upper lips in subjects with UCLP was significantly smaller than those with UCLA. Correlation analyses revealed that the width of cleft lip, deviation of the columella base, difference of the nose base width, and surface area of the upper lip were statistically correlated with the maxillary length, the anterior position of the maxillary alveolar base, the posterior facial height, and the high angle of the mandible.

CONCLUSION

The subjects who had less severe facial deformities and more tissue volume of the upper lips at cheiloplasty showed better maxillofacial growth.

Clinical variation of Aarskog syndrome in a large family with 2189delA in the FGD1 gene

The clinical diagnosis of ASS (Aarskog-Scott syndrome or Faciogenital Dysplasia) was made in seven individuals belonging to a large Arabic family, which was supported by molecular studies revealing a 2189delA mutation in exon 15 of the FDG1 gene. The affected individuals in this family demonstrated clinical variability particularly in their cognitive skills, raising the question whether other genetic factors might be involved in the phenotypic evolution of ASS.

New cases of Bohring–Opitz syndrome, update, and critical review of the literature

We report on four additional unrelated cases of Bohring-Opitz syndrome with the highly characteristic phenotype of facial anomalies including bulging forehead over the metopic suture, frontal nevus flammeus, exophthalmos, hypertelorism, upslanting palpebral fissures, and cleft lip and/or palate, as well as flexion deformities of the upper limbs, multiple other anomalies, and severe failure to thrive. We also update the clinical outcome of the patients reported in the original article by Bohring et al. [Am J Med Genet 85:438-446] and critically review the subsequently published cases considered to have Bohring-Opitz syndrome.

Terminal deletion of 6p results in a recognizable phenotype

With improved cytogenetic techniques, small deletions and duplications are being identified with increased frequency. We report four cases with terminal deletions involving the 6p24- and 6p25-pter chromosomal segment who exhibit a distinct, recognizable pattern of malformations including hypertelorism, downslanting palpebral fissures, flat nasal bridge, Dandy-Walker malformation/variant, congenital heart defects, anterior eye-chamber abnormalities, hearing loss, and developmental delay. We also compare the clinical aspects of these patients to those of previously reported cases in the literature with similar terminal deletions of chromosome 6p. Routine chromosome analysis can miss this deletion, therefore, high-resolution chromosome analysis is indicated for individuals who exhibit these distinct features. Furthermore, individuals with this deletion should have an ophthalmologic exam, cardiac evaluation, head imaging, renal ultrasound, and formal hearing evaluation.

Dysmorphology and the orbital region: a practical clinical approach

Dysmorphology is the field of medicine focusing on congenital developmental abnormalities due to exogenous teratogens, chromosomal anomalies, or to a defect in a single gene. Numerous syndromes have been reported and a growing number of genes or chromosomal anomalies are identified. The clinical observation of the face remains an essential part of the clinical evaluation of the patients. The orbital region, as other regions of the face, should be systematically evaluated. Orbital malformations can be isolated or part of a syndrome. In the diagnostic process, the orbital anomaly can be classified as a major feature (essential for the diagnosis), a moderate feature (important but not essential for the diagnosis), or a minor feature (contributing weakly to the diagnosis). The diagnoses of the main orbital anomalies in dysmorphology are reviewed and illustrated with relevant examples of syndromes that are presented as well as the usual landmarks used in clinical practice. Abnormal position of the eyes in syndromes such as hypertelorism, hypotelorism, primary or secondary telecanthus, asymmetry, and proptosis are discussed. Eyelid anomalies, such as cryptophthalmos, ablepharon, blepharophimosis, euryblepharon, or anomalies at the level of the eyelashes and eyebrows are described.

Michels syndrome, Carnevale syndrome, OSA syndrome, and Malpuech syndrome: Variable expression of a single disorder (3MC syndrome)?

We report on a 3-year-old girl with Michels syndrome, a rare condition characterized by craniosynostosis, blepharophimosis, ptosis, epicanthus inversus, cleft lip/palate, abnormal supra-umbilical abdominal wall, and mental deficiency. The phenotypic findings are compared with the six previously reported Michels cases, and with patients referred to as Carnevale, OSA, and Malpuech syndromes. Michels syndrome is characterized by cleft lip and palate, anterior chamber anomalies, blepharophimosis, epicanthus inversus, and craniosynostosis. Carnevale syndrome shows hypertelorism, downslanting palpebral fissures, ptosis, strabismus synophrys, large and fleshy ears, and lozenge-shaped diastasis around the umbilicus. OSA syndrome resembles Carnevale, with humeroradial synostoses, and spinal anomalies as extra features. Malpuech syndrome shows IUGR, hypertelorism, cleft lip and palate, micropenis, hypospadias, renal anomalies, and caudal appendage. All are autosomal recessive. Despite the presence of apparently distinctive key features, it appears that these four entities share multiple similarities in the facial Gestalt and the pattern of MCA. Those similarities lead us to postulate that they belong to the same spectrum, which could be referred to as "3MC syndrome" (Malpuech-Michels-Mingarelli-Carnevale syndrome).

Normal values of medial and lateral canthal distances in 3 to 18 year-old Nigerians

BACKGROUND

This study was carried out on male and female Nigerians whose age ranged from 3 to 18 years in order to provide a database of canthal measurements for a predominantly black population and compare them with Caucasians.

STUDY DESIGN

All the healthy pupils and students were randomly selected. The ages of the children, adolescents and young adults were approximated to their nearest birthdays. Two different researchers measured each parameter and the mean values were recorded.

SETTING

Nursery, primary, secondary schools and the University of Benin, in Benin City, Nigeria.

RESULTS

Four hundred and sixty eight males (53.4%) and 408 (46.6%) females making up a total of 876 subjects were studied. The mean values for medial canthal distance for male Nigerians are slightly higher than those established for male Caucasians and these differences are significant (p>0.05). There was no significant difference in the lateral canthal distance between the two groups (p<0.05). Nigerian and Caucasian females have significant difference (p>0.05) in mean values for medial canthal distances but not in lateral canthal distance (p<0.05). The difference in these distances between Nigerian males and females are not significant. Weight and lateral canthal distance showed a covariance of 6.980 while age and lateral canthal distance, age and medial canthal distance showed a covariance of 2.970 and 1.140 respectively. There was no correlation between age, height, weight and the distances measured.

CONCLUSION

Medial canthal distances between male and female Nigerians compared to males and female Caucasians show significant variations but not in the lateral canthal distances.

Segregation of a t(1;3) translocation in multiple affected family members with both types of adjacent-1 segregants

A subtle balanced translocation involving the terminal regions of 1q and 3p was identified in a large family by high-resolution karyotype analysis and confirmed by fluorescence in situ hybridization (FISH) analysis. In this family, segregation of a balanced t(1:3)(q42.3;p25) chromosome translocation led to two types of viable unbalanced complements. The proband inherited the derivative chromosome 3, resulting in partial trisomy of 1q and partial monosomy of 3p. A paternal uncle and cousin had the reciprocal rearrangement with a derivative of chromosome 1, resulting in partial monosomy for 1q and partial trisomy for 3p. While profound mental and physical retardation and congenital heart defects were characteristics for both rearrangements, facial dysmorphism was quite distinct for each imbalance. Individuals who had the derivative chromosome 3 had a long face, wide eyebrows, small palpebral fissures, hypertelorism, prominent glabella, a large tip of the nose, long philtrum with thin upper lip, and low set-ears. In contrast, family members with the derivative of chromosome 1 had a tall forehead with bifrontal narrowing, full and large cheeks, and large simple ears. Since the translocated segments are small and approximately equal in size in this family, it is not surprising that viability was seen in individuals with both types of adjacent-1 segregation. In this kindred, the ratio of normal to abnormal individuals born to balanced carriers is believed to be about 1:1.5. This suggests that the recurrence risk for carriers is 50%.

A newly recognized syndrome with double upper and lower lip, hypertelorism, eyelid ptosis, blepharophimosis, and third finger clinodactyly

Congenital double lip is an uncommon developmental abnormality usually affecting the upper lip. We report a 21-year-old male with double upper and lower lip, hypertelorism, unilateral ptosis, blepharophimosis, and broad nose with broad nasal tip, highly arched palate, and bilateral third finger clinodactyly. The disorder differs from Ascher syndrome and appears to represent a newly recognized syndrome.

Clinical and molecular delineation of the Greig cephalopolysyndactyly contiguous gene deletion syndrome and its distinction from acrocallosal syndrome

Greig cephalopolysyndactyly syndrome (GCPS) is caused by haploinsufficiency of GLI3 on 7p13. Features of GCPS include polydactyly, macrocephaly, and hypertelorism, and may be associated with cognitive deficits and abnormalities of the corpus callosum. GLI3 mutations in GCPS patients include point, frameshift, translocation, and gross deletion mutations. FISH and STRP analyses were applied to 34 patients with characteristics of GCPS. Deletions were identified in 11 patients and the extent of their deletion was determined. Nine patients with deletions had mental retardation (MR) or developmental delay (DD) and were classified as severe GCPS. These severe GCPS patients have manifestations that overlap with the acrocallosal syndrome (ACLS). The deletion breakpoints were analyzed in six patients whose deletions ranged in size from 151 kb to 10.6 Mb. Junction fragments were found to be distinct with no common sequences flanking the breakpoints. We conclude that patients with GCPS caused by large deletions that include GLI3 are likely to have cognitive deficits, and we hypothesize that this severe GCPS phenotype is caused by deletion of contiguous genes.

Teebi hypertelorism syndrome

Teebi (1987) described an autosomal dominant syndrome with resemblance to craniofrontonasal dysplasia. Here we present a 2 year 5 month old girl with Teebi syndrome showing a prominent forehead, hypertelorism, mild exophthalmos, downslanting palpebral fissures, a depressed nasal bridge, a broad nasal tip, a long philtrum, natal teeth, a thin upper lip, an everted lower lip, a small chin, low-set ears, preauricular fistulas, a short neck, mild pectus excavatum, an umbilical hernia, clinodactyly of the 5th fingers with mild radial deviation of the distal phalanges of the middle fingers, mild pes adductus, an ectopic kidney, and normal psychomotor development. Her mother and her grandmother had similar features.

Is it a new syndrome or a clinical variability in cerebro-oculo-nasal syndrome?

We present a male infant 2.5-months old with asymmetric skull, anophthalmia, apparent hypertelorism, abnormal nares, unilateral cleft lip and palate, and structural abnormalities of the central nervous system. These findings are similar to cerebro-oculo-nasal syndrome except for the appearance of nose. This case is either a clinical variability in cerebro-oculo-nasal syndrome or a new entity.

X-linked Opitz syndrome: novel mutations in the MID1 gene and redefinition of the clinical spectrum

Opitz (or G/BBB) syndrome is a pleiotropic genetic disorder characterized by hypertelorism, hypospadias, and additional midline defects. This syndrome is heterogeneous with an X-linked (XLOS) and an autosomal dominant (ADOS) form. The gene implicated in the XLOS form, MID1, encodes a protein containing a RING-Bbox-Coiled-coil motif belonging to the tripartite motif (TRIM) family. To further clarify the molecular basis of XLOS, we have undertaken mutation analysis of the MID1 gene in patients with Opitz syndrome (OS). We found novel mutations in 11 of 63 male individuals referred to us as sporadic or familial X-linked OS cases. The mutations are scattered throughout the gene, although more are represented in the 3' region. By reviewing all the MID1-mutated OS patients so far described, we confirmed that hypertelorism and hypospadias are the most frequent manifestations, being present in almost every XLOS individual. However, it is clear that laryngo-tracheo-esophageal (LTE) defects are also common anomalies, being manifested by all MID1-mutated male patients. Congenital heart and anal abnormalities are less frequent than reported in literature. In addition, we can include limb defects in the OS clinical synopsis as we found a MID1-mutated patient showing syndactyly. The low frequency of mutations in MID1 and the high variability of the phenotype suggest the involvement of other genes in the OS phenotype.

Teebi hypertelorism syndrome: additional cases

We report on two unrelated Brazilian boys who have craniofacial and digital anomalies resembling those reported with Teebi hypertelorism syndrome. Additional features such as cleft lip and palate, large uvula, atypical chin and abnormal scapulae were observed.

Guadalajara camptodactyly type III: a new probably autosomal dominant syndrome

A Mexican family is presented with the main clinical features of camptodactyly, a distinctive facial appearance because of ocular hypertelorism, telecanthus, symblepharon and spinal defects. Other clinical manifestations included: multiple nevi, simplified ears, retrognathia, congenital shortness of the sternocleidomastoid muscle, thin hands and feet, a small penis and mild mental retardation. Radiographic studies revealed spina bifida occulta at cervical and dorso-lumbar levels, increased bone trabeculae, cortical thickening and delayed bone age. The presence of five affected members through four generations suggests autosomal dominant inheritance although no male-to-male transmission was documented. The authors propose this as a new entity, and have designated it Guadalajara camptodactyly type III.

Food aversion and facial dysmorphism--a newly described syndrome?

We report three children with food aversion and characteristic facial dysmorphism, long digits and genitourinary abnormality. Interrogation of the London Dysmorphology Database suggests that this is a previously unreported syndrome.

Association of external auditory canal atresia, vertical talus, and hypertelorism: confirmation of Rasmussen syndrome

In 1979, Rasmussen et al. reported six members of a family with congenital, bilateral, symmetrical, and isolated subtotal atresia of the external auditory canal, bilateral foot abnormalities, and increased interocular distance. The family history suggested autosomal dominant inheritance of the syndrome. We report a 3-year-old girl whose symptoms are compatible with this diagnosis. Therefore, we suggest confirmation of the description by Rasmussen et al. as a distinct entity and suggest the term Rasmussen syndrome for this condition.

Roberts syndrome, normal cell division, and normal intelligence

Roberts-SC phocomelia syndrome (RS) is an autosomal recessive disorder of symmetric limb defects, craniofacial abnormalities, pre- and postnatal growth retardation, and mental retardation. Patients with RS have been reported to have premature separation of heterochromatin of many chromosomes and abnormalities in the cell-division cycle. No case has been reported who had normal intelligence and normal cell division with typical clinical features of the RS. We report a case of a six-year-old male of clinical and radiologic findings of typical RS with normal cell division and normal intelligence. Although he showed growth retardation, his intelligence was normal. Van Den Berg and Francke later reported that 79 out of 100 cases of Roberts syndrome had premature cell separation (PCS). We think that this case may demonstrate severe expression of the Roberts syndrome even though PCS is not exhibited. The limb involvement of this case was symmetrical, and he showed phocomelia of upper limbs, equinus valgus deformity of ankle, aplasia of fibula, and shortness of fifth toes while his hands and feet were normal with 5 rays each. Craniofacial abnormalities of this case were typical; he showed scaphocephaly, mild hypertelorism, mandibular hypoplasia, dysplastic helix of ear, narrowing of external auditory canal, and cleft palate with wide gap. This report supports the theory that normal intelligence can make social-personal adjustment possible even if all of the stigmata of Roberts syndrome is present.

Schinzel-Giedion syndrome: interesting facial and orodental features, and dental management

Schinzel-Giedion syndrome comprises multiple congenital anomalies. The orofacial features include coarse facies, frontal bossing, ocular hypertelorism, anterior open bite and macrodontia. Two cases are presented in which the presence of specific craniofacial anomalies with bilateral hydronephrosis confirmed the diagnosis. In one patient, bottle-feeding was associated with caries in maxillary central and lateral incisors, but the second patient was permanently tube fed and did not experience any dental caries. Clinical management of these patients requires a coordinated approach from a team of medical and dental specialists.

Interpupillary index: a new parameter for hypo-hypertelorism

AIM

To establish a new clinical index to evaluate the presence of hypo-hypertelorism with greater accuracy.

MATERIAL AND METHODS

After screening a wide range of population, 310 elementary school children (185 boys, 125 girls) aged 7-15 years were included in this study. For this cross-sectional study, a millimetre ruler was used. The anatomical interpupillary distance was measured by a modified Viktorin's method. In addition, inner and outer intercanthal distances were obtained. The data were analyzed by Student's t-test for two independent samples using SPSS for Windows. There were children with clinical hypertelorism (n = 92, group 1), children with large fronto-occipital circumference (FOC) (n = 101, group 2), and age- and sex-matched normal controls (n = 117, group 3). Due to variations in FOC among healthy subjects, we introduced a new practical concept for evaluation of interpupillary distance, namely the interpupillary index, the simple product obtained by dividing the interpupillary distance by the FOC, multiplied by 100.

RESULTS

The overall idiopathic benign macrocephalic children (group 2) had significantly (p < 0.001) larger interpupillary distances (6.13 +/- 0.36 cm) and FOCs (56.99 +/- 1.46 cm) than those of normal controls (5.70 +/- 0.26cm and 52.82 +/- 1.22 cm, respectively). But, the difference between the combined product of interpupillary distance and FOC, the interpupillary index, was not significant (10.76 +/- 0.50 and 10.79 +/- 0.35, respectively) (p > 0.05). On the other hand, the children with hypertelorism had significantly (p < 0.001) larger interpupillary distances (6.47 +/- 0.29cm) and FOCs (54.90 +/- 2.18cm) when compared with the controls. In addition, the interpupillary index was significantly (p < 0.001) higher (11.80 +/- 0.45) than both macrocephalic children (10.76 +/- 0.50) and controls (10.79 +/- 0.35). Intercanthal distances and intercanthal index of hyperteloric children were also significantly (p<0.001) larger than both macrocephalic children and controls.

CONCLUSION

This new index offers a new concept for more accurate evaluation of the presence of ocular hypo-hypertelorism.