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Beyltjens T, Boudin E, Revencu N, Boeckx N, Bertrand M, Schütz L, Haack TB, Weber A, Biliouri E, Vinkšel M, Zagožen A, Peterlin B, Pai S, Telegrafi A, Henderson LB, Ells C, Turner L, Wuyts W, Van Hul W, Hendrickx G, Mortier GR. Heterozygous pathogenic variants involving CBFB cause a new skeletal disorder resembling cleidocranial dysplasia. J Med Genet 2022; 60:498-504. [PMID: 36241386 PMCID: PMC10176335 DOI: 10.1136/jmg-2022-108739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/03/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Cleidocranial dysplasia (CCD) is a rare skeletal dysplasia with significant clinical variability. Patients with CCD typically present with delayed closure of fontanels and cranial sutures, dental anomalies, clavicular hypoplasia or aplasia and short stature. Runt-related transcription factor 2 (RUNX2) is currently the only known disease-causing gene for CCD, but several studies have suggested locus heterogeneity. METHODS The cohort consists of eight subjects from five unrelated families partially identified through GeneMatcher. Exome or genome sequencing was applied and in two subjects the effect of the variant was investigated at RNA level. RESULTS In each subject a heterozygous pathogenic variant in CBFB was detected, whereas no genomic alteration involving RUNX2 was found. Three CBFB variants (one splice site alteration, one nonsense variant, one 2 bp duplication) were shown to result in a premature stop codon. A large intragenic deletion was found to delete exon 4, without affecting CBFB expression. The effect of a second splice site variant could not be determined but most likely results in a shortened or absent protein. Affected individuals showed similarities with RUNX2-related CCD, including dental and clavicular abnormalities. Normal stature and neurocognitive problems were however distinguishing features. CBFB encodes the core-binding factor β subunit, which can interact with all RUNX proteins (RUNX1, RUNX2, RUNX3) to form heterodimeric transcription factors. This may explain the phenotypic differences between CBFB-related and RUNX2-related CCD. CONCLUSION We confirm the previously suggested locus heterogeneity for CCD by identifying five pathogenic variants in CBFB in a cohort of eight individuals with clinical and radiographic features reminiscent of CCD.
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Affiliation(s)
- Tessi Beyltjens
- Department of Medical Genetics, University of Antwerp, Antwerp, Belgium
| | - Eveline Boudin
- Department of Medical Genetics, University of Antwerp, Antwerp, Belgium
| | - Nicole Revencu
- Center for Human Genetics, Cliniques universitaires Saint-Luc and University of Louvain, Brussels, Belgium
| | - Nele Boeckx
- Department of Medical Genetics, University of Antwerp, Antwerp, Belgium
| | - Miriam Bertrand
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, Tübingen, Germany
| | - Leon Schütz
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, Tübingen, Germany
| | - Tobias B Haack
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, Tübingen, Germany
| | - Axel Weber
- Institute of Human Genetics, Justus Liebig University, Giessen, Germany
| | - Eleni Biliouri
- Institute of Human Genetics, Justus Liebig University, Giessen, Germany
| | - Mateja Vinkšel
- Clinical Institute of Genomic Medicine, University Medical Centre Ljubljana Division of Internal Medicine, Ljubljana, Slovenia
| | - Anja Zagožen
- Clinical Institute of Genomic Medicine, University Medical Centre Ljubljana Division of Internal Medicine, Ljubljana, Slovenia
| | - Borut Peterlin
- Clinical Institute of Genomic Medicine, University Medical Centre Ljubljana Division of Internal Medicine, Ljubljana, Slovenia
| | - Shashidhar Pai
- Children's Health, Division of Genetics, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | | | - Courtney Ells
- Provincial Medical Genetics Program, Eastern Health, St. John's, Newfoundland, Canada
| | - Lesley Turner
- Provincial Medical Genetics Program, Eastern Health, St. John's, Newfoundland, Canada.,Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - Wim Wuyts
- Department of Medical Genetics, University of Antwerp, Antwerp, Belgium
| | - Wim Van Hul
- Department of Medical Genetics, University of Antwerp, Antwerp, Belgium
| | - Gretl Hendrickx
- Department of Medical Genetics, University of Antwerp, Antwerp, Belgium .,Department of Human Genetics, KU Leuven, Leuven, Belgium
| | - Geert R Mortier
- Department of Medical Genetics, University of Antwerp, Antwerp, Belgium.,Department of Human Genetics, KU Leuven, Leuven, Belgium.,Center for Human Genetics, University Hospital Leuven, Leuven, Belgium
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Abstract
We present a 4-year-old girl with persistent anterior fontanelle and narrow sloping shoulders. The X-ray imaging revealed widely open anterior fontanelle, supernumerary teeth, and absence of clavicles. Therefore, the diagnosis was cleidocranial dysplasia, which is a rare autosomal dominant skeletal disease, caused by the mutation in the gene on 6p21 encoding transcription factor CBFA1 (runt-related transcription factor 2-RUNX2). The girl remains under close surveilance, her anterior fontanelle closed spontaneously at the age of 9 years.
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Affiliation(s)
- Stepan Kutilek
- Department of Pediatrics, Klatovy Hospital, Klatovy, Czech Republic.,Department of Pediatrics, Pardubice Hospital, Pardubice, Czech Republic
| | - Roman Machytka
- General Pediatrician-Practitioner, Holice, Czech Republic
| | - Petr Munzar
- Department of Pediatrics, Pardubice Hospital, Pardubice, Czech Republic
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3
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Pierpont ME, Brueckner M, Chung WK, Garg V, Lacro RV, McGuire AL, Mital S, Priest JR, Pu WT, Roberts A, Ware SM, Gelb BD, Russell MW. Genetic Basis for Congenital Heart Disease: Revisited: A Scientific Statement From the American Heart Association. Circulation 2018; 138:e653-e711. [PMID: 30571578 PMCID: PMC6555769 DOI: 10.1161/cir.0000000000000606] [Citation(s) in RCA: 349] [Impact Index Per Article: 58.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This review provides an updated summary of the state of our knowledge of the genetic contributions to the pathogenesis of congenital heart disease. Since 2007, when the initial American Heart Association scientific statement on the genetic basis of congenital heart disease was published, new genomic techniques have become widely available that have dramatically changed our understanding of the causes of congenital heart disease and, clinically, have allowed more accurate definition of the pathogeneses of congenital heart disease in patients of all ages and even prenatally. Information is presented on new molecular testing techniques and their application to congenital heart disease, both isolated and associated with other congenital anomalies or syndromes. Recent advances in the understanding of copy number variants, syndromes, RASopathies, and heterotaxy/ciliopathies are provided. Insights into new research with congenital heart disease models, including genetically manipulated animals such as mice, chicks, and zebrafish, as well as human induced pluripotent stem cell-based approaches are provided to allow an understanding of how future research breakthroughs for congenital heart disease are likely to happen. It is anticipated that this review will provide a large range of health care-related personnel, including pediatric cardiologists, pediatricians, adult cardiologists, thoracic surgeons, obstetricians, geneticists, genetic counselors, and other related clinicians, timely information on the genetic aspects of congenital heart disease. The objective is to provide a comprehensive basis for interdisciplinary care for those with congenital heart disease.
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4
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Wang J, Huang X, Lai C, Jiang K. Clinical spectrum of cleidocranial dysplasia in a family with twins. Pediatr Int 2013; 55:392-5. [PMID: 23782374 DOI: 10.1111/ped.12043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Revised: 08/07/2012] [Accepted: 10/10/2012] [Indexed: 11/27/2022]
Abstract
Cleidocranial dysplasia (CCD) is a rare congenital defect of autosomal dominant inheritance, primarily affecting bones that undergo intra-membranous ossification. Herein is reported the case of monozygotic male 13-year-old twins with typical features of this syndrome, such as large wide-open fontanels, abnormal clavicles with narrow, sloping shoulders that can be apposed at the midline, short stature, mid-face hypoplasia, multiple supernumerary teeth, and skeletal anomalies. Their physical appearance led to the diagnosis of CCD. Genetic analysis found a C-T exchange in exon 2 at cDNA position 568, which changes the codon CGG for arginine to TGG for tryptophan (R190W) of the runt-related transcription factor 2 RUNX2 gene. CCD should be suspected in patients with persistence of the widely open anterior fontanels and sutures, short stature, and poor clavicles, calvarium, or teeth. Timely recognition and hereditary tendency counseling is required and useful because of the possibility of covert transmissibility and sporadic genetic mutation.
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Affiliation(s)
- Jiangping Wang
- Department of Rehabilitation, Zhejiang University School of Medicine, Hangzhou, China
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5
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Vij R, Batra P, Vij H. Cleidocranial dysplasia: complete clinical, radiological and histological profiles. BMJ Case Rep 2013; 2013:bcr-2013-009015. [PMID: 23519515 DOI: 10.1136/bcr-2013-009015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cleidocranial dysplasia is an autosomal-dominant condition characterised by widely patent calvarial sutures, clavicular hypoplasia, supernumerary teeth and short stature. Though it is not a very uncommon occurrence, its histopathological features are not frequently reported. This paper presents a similar case with complete clinical, radiological, histological and treatment profiles.
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Affiliation(s)
- Ruchieka Vij
- Department of Oral Pathology & Microbiology, Institute of Dental Studies and Technologies, Modinagar, Uttar Pradesh, India
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Shen Z, Zou CC, Yang RW, Zhao ZY. Cleidocranial dysplasia: report of 3 cases and literature review. Clin Pediatr (Phila) 2009; 48:194-8. [PMID: 18832541 DOI: 10.1177/0009922808323107] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cleidocranial dysplasia (CCD) is an autosomal-dominant skeletal dysplasia syndrome that is characterized by widely patent calvarial sutures, clavicular hypoplasia, supernumerary teeth, and short stature. It is caused by mutations of the transcription factor RUNX2, which is known as a major regulator of bone differentiation. OBJECTIVE To report on 3 Chinese pediatric cases of CCD with an emphasis on the clinical presentation and diagnostic modalities. CASE SUMMARY 3 Chinese children were admitted to our hospital because of short stature. All the children had hypoplastic clavicles, absent calvarium, open fontanel, and messy palmprint. Screening laboratory test results for bone mineral density, free thyroxine, and thyroid stimulating hormone were all normal. One child had mental retardation. Two were hereditary, and 1 was sporadic. CONCLUSION These results showed that CCD should be suspected in patients with short stature and poor clavicles, calvarium, or teeth. Timely recognition and hereditary tendency counseling is required and useful.
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Affiliation(s)
- Zheng Shen
- Department of Medicine, the Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
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7
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Purandare SM, Mendoza-Londono R, Yatsenko SA, Napierala D, Scott DA, Sibai T, Casas K, Wilson P, Lee J, Muneer R, Leonard JC, Ramji FG, Lachman R, Li S, Stankiewicz P, Lee B, Mulvihill JJ. De novo three-way chromosome translocation 46,XY,t(4;6;21)(p16;p21.1;q21) in a male with cleidocranial dysplasia. Am J Med Genet A 2008; 146A:453-8. [PMID: 18203189 PMCID: PMC2663417 DOI: 10.1002/ajmg.a.31750] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cleidocranial dysplasia (CCD) is an autosomal dominant skeletal dysplasia associated with cranial, clavicular, and dental anomalies. It is caused by mutations in the RUNX2 gene, which encodes an osteoblast-specific transcription factor and maps to chromosome 6p21. We report clinical and molecular cytogenetic studies in a patient with clinical features of CCD including wormian bones, delayed fontanel closure, hypoplastic clavicles and pubic rami, and supernumerary dentition. Additional abnormalities of bone growth and connective tissue, including easy bruisability, scarring, bleeding, joint hypermobility, and developmental delay were also observed. Molecular cytogenetic studies identified a de novo apparently balanced three-way translocation 46,XY,t(4;6;21)(p16;p21.1;q21). Further mapping revealed the breakpoint on 6p21 to be ∼50 kb upstream of exon 1 of the RUNX2 gene, with RUNX2 being intact on the derivative chromosome 6. We hypothesize that the proband's CCD has arisen from disruption of the developmentally regulated gene RUNX2 at the 6p21 breakpoint, due to a position effect mutation which may have altered the expression of the gene. Further studies might unravel a new regulatory element for RUNX2.
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Affiliation(s)
- Smita M Purandare
- Section of Genetics, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73104, USA
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McBrien H, Turk J, Letch N. The management of ADHD and associated problems in a young person with cleidocranial dysostosis (CCD) and mild intellectual disability. Clin Child Psychol Psychiatry 2006; 11:445-56. [PMID: 17080780 DOI: 10.1177/1359104506059127] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
It is increasingly recognized that comorbidity is common in all fields of psychiatry, and furthermore, it is acknowledged that a large number of individuals with genetically determined conditions have associated behavioural phenotypes, and are more susceptible to particular psychiatric and psychological comorbidities than others. It is also recognized that the identification of such phenotypes enables clinicians to be more aware of the potential difficulties an individual may experience, and hence, facilitate early diagnosis, effective management and prevention, appropriate allocation of resources and psychoeducation for the individual and their family. We describe the case report of a girl with cleidocranial dysostosis (CCD), and comorbid intellectual disability and attention deficit hyperactivity disorder (ADHD), and suggest the possible existence of a behavioural phenotype. We also highlight the lack of an evidence base for the management of ADHD within the learning-disability population, and describe successful management utilizing the current evidence base, which exists for those of average intellectual ability.
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González López BS, Ortiz Solalinde C, Kubodera Ito T, Lara Carrillo E, Ortiz Solalinde E. Cleido cranial dysplasia: report of a family. J Oral Sci 2005; 46:259-66. [PMID: 15901072 DOI: 10.2334/josnusd.46.259] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
A family case of Cleidocranial Dysplasia is presented. A mother and two adolescent girls were examined. In all three cases, a radiological series was performed over the entire body. Generalized dysplasia in bones, prolonged retention of primary teeth, and delayed eruption of permanent, as well as supernumerary teeth was diagnosed. The citogenetic study with GTG band showed normal 46, XX. Bilateral audiometry in the mother demonstrated a mild to moderate hypoacustic condition. Radiological findings are presented and the importance of early diagnosis is discussed.
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10
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Otto F, Kanegane H, Mundlos S. Mutations in the RUNX2 gene in patients with cleidocranial dysplasia. Hum Mutat 2002; 19:209-16. [PMID: 11857736 DOI: 10.1002/humu.10043] [Citation(s) in RCA: 202] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Cleidocranial dysplasia (CCD) is a autosomal dominant disorder characterized by skeletal anomalies such as patent fontanels, late closure of cranial sutures with Wormian bones, late erupting secondary dentition, rudimentary clavicles, and short stature. The locus for this disease was mapped to chromosome 6p21. RUNX2 is a member of the runt family of transcription factors and its expression is restricted to developing osteoblasts and a subset of chondrocytes. Mutations in the RUNX2 gene have been shown to cause CCD. Chromosomal translocations, deletions, insertions, nonsense and splice-site mutations, as well as missense mutations of the RUNX2 gene have been described in CCD patients. Although there is a wide spectrum in phenotypic variability ranging from primary dental anomalies to all CCD features plus osteoporosis, no clear phenotype-genotype correlation has been established. However analysis of the three-dimensional structure of the DNA binding runt domain of the RUNX proteins and its interaction with DNA, as well as the cofactor CBFB, start to provide an insight into how missense mutations affect RUNX2 function.
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Affiliation(s)
- Florian Otto
- Department of Hematology/Oncology, University of Freiburg Medical Center, Freiburg, Germany.
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11
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Ponzio GM, Cunningham ML. Clavicular hypoplasia, zygomatic arch hypoplasia, and micrognathia: a newly defined syndrome. AMERICAN JOURNAL OF MEDICAL GENETICS 2000; 92:200-5. [PMID: 10817655 DOI: 10.1002/(sici)1096-8628(20000529)92:3<200::aid-ajmg8>3.0.co;2-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We report on a 6-year-old boy with a previously undefined syndrome of clavicular hypoplasia, frontonasal malformation, zygomatic arch hypoplasia, micrognathia, and normal intelligence. His condition differs from similar syndromes on the basis of unique facial findings such as microcornea, stellate irises, and a midline maxillary cleft. We present his case, a review of the literature, and propose the acronym CHZAM, for clavicular hypoplasia, zygomatic arch, and micrognathia, to represent this syndrome.
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Affiliation(s)
- G M Ponzio
- University of Vermont College of Medicine, Burlington, USA
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Mundlos S, Otto F, Mundlos C, Mulliken JB, Aylsworth AS, Albright S, Lindhout D, Cole WG, Henn W, Knoll JH, Owen MJ, Mertelsmann R, Zabel BU, Olsen BR. Mutations involving the transcription factor CBFA1 cause cleidocranial dysplasia. Cell 1997; 89:773-9. [PMID: 9182765 DOI: 10.1016/s0092-8674(00)80260-3] [Citation(s) in RCA: 1088] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Cleidocranial dysplasia (CCD) is an autosomal-dominant condition characterized by hypoplasia/aplasia of clavicles, patent fontanelles, supernumerary teeth, short stature, and other changes in skeletal patterning and growth. In some families, the phenotype segregates with deletions resulting in heterozygous loss of CBFA1, a member of the runt family of transcription factors. In other families, insertion, deletion, and missense mutations lead to translational stop codons in the DNA binding domain or in the C-terminal transactivating region. In-frame expansion of a polyalanine stretch segregates in an affected family with brachydactyly and minor clinical findings of CCD. We conclude that CBFA1 mutations cause CCD and that heterozygous loss of function is sufficient to produce the disorder.
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Affiliation(s)
- S Mundlos
- Kinderklinik, Klinikum der Johannes-Gutenberg-Universität, Mainz, Germany
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Ramesar RS, Greenberg J, Martin R, Goliath R, Bardien S, Mundlos S, Beighton P. Mapping of the gene for cleidocranial dysplasia in the historical Cape Town (Arnold) kindred and evidence for locus homogeneity. J Med Genet 1996; 33:511-4. [PMID: 8782054 PMCID: PMC1050640 DOI: 10.1136/jmg.33.6.511] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Cleidocranial dysplasia (CCD) is an autosomal dominant disorder, features of which include a patient anterior fontanelle, a bulging calvarium, hypoplasia or aplasia of the clavicles, a wide public symphysis, dental anomalies, vertebral malformation, and short stature. The Cape Town kindred which is under our genetic management was originally described more than four decades ago and now consists of more than 1000 people. Following reports of rearrangements on chromosomes 6 and 8 in people with CCD, we have carried out linkage analyses between highly information microsatellite dinucleotide repeat markers in the rearranged regions and the disorder in a branch of this South African CCD kindred, consisting of 38 subjects, 18 of whom are affected. Maximum lod scores (at theta = 0.00) of 7.14 (for marker D6S459), 4.32 (TCTE), 4.99 (D6S452), 5.97 (D6S269), and 3.95 (D6S465) confirm linkage of the disorder to the short arm of chromosome 6. Our data indicate that the CCD gene is located within a minimal region of approximately 10 cM flanked by the marker D6S451 distally and D6S466 proximally. This information is vital towards isolating and characterising the gene for CCD, and is being used to construct a physical map of 6p21.1-6p21.3. More importantly, mapping of the locus in the South African kindred of mixed ancestry, in which the "founder" of the disorder was of Chinese origin, suggests that a single locus is responsible for classic CCD.
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Affiliation(s)
- R S Ramesar
- MRC Research Unit for Medical Genetics, Department of Human Genetics, University of Cape Town, Medical School, Observatory, South Africa
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Gelb BD, Cooper E, Shevell M, Desnick RJ. Genetic mapping of the cleidocranial dysplasia (CCD) locus on chromosome band 6p21 to include a microdeletion. AMERICAN JOURNAL OF MEDICAL GENETICS 1995; 58:200-5. [PMID: 8533817 DOI: 10.1002/ajmg.1320580222] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Cleidocranial dysplasia (CCD) is a generalized skeletal dysplasia with autosomal dominant inheritance. Recently, the CCD disease locus was localized to 23 [Mundlos et al., 1995] and 17 cM regions [Feldman et al., 1995], of chromosome band 6p21 by linkage studies of seven affected families. Of note, the 23 cM region contained a microdeletion detected in one family at D6S459, an interval that was excluded in the 17 cM overlapping region. Here, linkage of CCD to 6p21 was independently confirmed with a maximal two-point LOD score of Z = 5.12 with marker D6S452 at theta = 0.00. Recombinant events in two affected individuals defined a CCD region of 7 cM from D6S465 to D6S282, which overlapped with the CCD region containing the microdeletion but did not overlap with the 17 cM critical region from D6S282 to D6S291. These results suggest the refined localization of the CCD region to 6 cM spanning markers D6S438 to D6S282, thereby reviving the possibility that the CCD gene lies within the microdeletion at D6S459.
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Affiliation(s)
- B D Gelb
- Department of Human Genetics, Mount Sinai School of Medicine, New York 10029, USA
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Narahara K, Tsuji K, Yokoyama Y, Seino Y. Cleidocranial dysplasia associated with a t(6;18)(p12;q24) translocation. AMERICAN JOURNAL OF MEDICAL GENETICS 1995; 56:119-20. [PMID: 7747775 DOI: 10.1002/ajmg.1320560128] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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