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Pollak RM, Mortillo M, Murphy MM, Mulle JG. Behavioral Phenotypes and Comorbidity in 3q29 Deletion Syndrome: Results from the 3q29 Registry. J Autism Dev Disord 2024:10.1007/s10803-023-06218-w. [PMID: 38216835 DOI: 10.1007/s10803-023-06218-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 01/14/2024]
Abstract
3q29 deletion syndrome (3q29del) is associated with a significantly increased risk for neurodevelopmental and neuropsychiatric disorders. However, the full spectrum of behavioral phenotypes associated with 3q29del is still evolving. Individuals with 3q29del (n = 96, 60.42% male) or their guardian completed the Achenbach Child or Adult Behavior Checklist (CBCL/ABCL) via the online 3q29 registry (3q29deletion.org). Typically developing controls (n = 57, 49.12% male) were ascertained as a comparison group. We analyzed mean performance on the CBCL/ABCL for individuals with 3q29del and controls across composite, DSM-keyed, and developmental scales; and the relationship between CBCL/ABCL performance and clinical and developmental phenotypes for individuals with 3q29del. Individuals with 3q29del showed significantly elevated behavioral and developmental impairment relative to controls across CBCL/ABCL domains. A substantial proportion of study participants with 3q29del scored in the Borderline or Clinical range for composite and DSM-keyed scales, indicating significant behavioral problems that may require clinical evaluation. We found that the preschool CBCL DSM-keyed autism spectrum problems scale is a potential screening tool for autism spectrum disorder (ASD) for individuals with 3q29del; CBCL/ABCL DSM-keyed scales were not accurate screeners for anxiety disorders or attention-deficit/hyperactivity disorder (ADHD) in our study sample. We identified a high degree of psychiatric comorbidity in individuals with 3q29del, with 60.42% (n = 58) of individuals with 3q29del scoring in the Borderline or Clinical range on two or more DSM-keyed CBCL/ABCL scales. Finally, we found that the degree of developmental delay in participants with 3q29del does not explain the increased behavioral problems observed on the CBCL/ABCL. The CBCL/ABCL can be used as screening tools in populations such as 3q29del, even in the presence of substantial psychiatric comorbidity. These results expand our understanding of the phenotypic spectrum of 3q29del and demonstrate an effective method for recruiting and phenotyping a large sample of individuals with a rare genetic disorder.
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Affiliation(s)
- Rebecca M Pollak
- Department of Psychiatry, Center for Advanced Biotechnology and Medicine, Robert Wood Johnson Medical School, Rutgers University, 679 Hoes Ln W, Piscataway, NJ, 08854, USA
| | - Michael Mortillo
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Melissa M Murphy
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, GA, USA
| | - Jennifer G Mulle
- Department of Psychiatry, Center for Advanced Biotechnology and Medicine, Robert Wood Johnson Medical School, Rutgers University, 679 Hoes Ln W, Piscataway, NJ, 08854, USA.
- Department of Psychiatry, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA.
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2
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Ong MS, Rider NL, Stein S, Maglione PJ, Galbraith A, DiGiacomo DV, Farmer JR. Racial and ethnic disparities in early mortality among patients with inborn errors of immunity. J Allergy Clin Immunol 2024; 153:335-340.e1. [PMID: 37802474 PMCID: PMC10872997 DOI: 10.1016/j.jaci.2023.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 09/08/2023] [Accepted: 09/28/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Racial and ethnic disparities in life expectancy in the United States have been widely documented. To date, there remains a paucity of similar data in patients with inborn errors of immunity (IEIs). OBJECTIVE Our aim was to examine racial and ethnic differences in mortality due to an IEI in the United States. METHODS We analyzed National Center for Health Statistics national mortality data from 2003 to 2018. We quantified age-adjusted death rate and age-specific death rate as a result of an IEI for each major racial and ethnic group in the United States and examined the association of race and ethnicity with death at a younger age. RESULTS From 2003 to 2018, IEIs were reported as the underlying or contributing cause of death in 14,970 individuals nationwide. The age-adjusted death rate was highest among Black patients (4.25 per 1,000,000 person years), compared with 2.01, 1.71, 1.50, and 0.92 per 1,000,000 person years for White, American Indian/Alaska Native, Hispanic, and Asian/Pacific Islander patients, respectively. The odds of death before age 65 years were greatest among Black patients (odds ratio [OR] = 5.15 [95% CI = 4.61-5.76]), followed by American Indian/Alaska Native patients (OR = 3.58 [95% CI = 2.30-5.82]), compared with White patients. The odds of death before age 24 years were greater among Hispanic patients than among non-Hispanic patients (OR = 3.60 [95% CI = 3.08-4.18]). CONCLUSION Our study highlights racial and ethnic disparities in mortality due to an IEI and the urgent need to further identify and systematically remove barriers in care for historically marginalized patients with IEIs.
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Affiliation(s)
- Mei-Sing Ong
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass.
| | - Nicholas L Rider
- Division of Clinical Informatics, Pediatrics, Allergy and Immunology, Liberty University College of Osteopathic Medicine and Collaborative Health Partners, Lynchburg, Va
| | - Sarah Stein
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Mass
| | - Paul J Maglione
- Pulmonary Center and Section of Pulmonary, Allergy, Sleep and Critical Care, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, Mass
| | - Alison Galbraith
- Department of Pediatrics, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, Mass
| | - Daniel V DiGiacomo
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Jocelyn R Farmer
- Beth Israel Lahey Health, Division of Allergy and Inflammation, Harvard Medical School, Boston, Mass
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3
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Bileckyj C, Blotz B, Cripps RM. Drosophila as a Model to Understand Second Heart Field Development. J Cardiovasc Dev Dis 2023; 10:494. [PMID: 38132661 PMCID: PMC10744189 DOI: 10.3390/jcdd10120494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/06/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023] Open
Abstract
The genetic model system Drosophila has contributed fundamentally to our understanding of mammalian heart specification, development, and congenital heart disease. The relatively simple Drosophila heart is a linear muscular tube that is specified and develops in the embryo and persists throughout the life of the animal. It functions at all stages to circulate hemolymph within the open circulatory system of the body. During Drosophila metamorphosis, the cardiac tube is remodeled, and a new layer of muscle fibers spreads over the ventral surface of the heart to form the ventral longitudinal muscles. The formation of these fibers depends critically upon genes known to be necessary for mammalian second heart field (SHF) formation. Here, we review the prior contributions of the Drosophila system to the understanding of heart development and disease, discuss the importance of the SHF to mammalian heart development and disease, and then discuss how the ventral longitudinal adult cardiac muscles can serve as a novel model for understanding SHF development and disease.
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Affiliation(s)
| | | | - Richard M. Cripps
- Department of Biology, San Diego State University, San Diego, CA 92182, USA
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4
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Kruszka P, Tekendo-Ngongang C. Application of facial analysis Technology in Clinical Genetics: Considerations for diverse populations. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2023; 193:e32059. [PMID: 37534870 DOI: 10.1002/ajmg.c.32059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 08/04/2023]
Abstract
Facial analysis technology in rare diseases has the potential to shorten the diagnostic odyssey by providing physicians with a valuable diagnostic tool. Given that most clinical genetic resources focus on populations of European descent, we compare craniofacial features in genetic syndromes across different populations and review how machine learning algorithms perform on diagnosing genetic syndromes in geographically and ethnically diverse populations. We also discuss the value of populations from ancestrally diverse backgrounds in the training set of machine learning algorithms. Finally, this review demonstrates that across diverse population groups, machine learning models have outstanding accuracy as supported by the area under the curve values greater than 0.9. Artificial intelligence is only in its infancy in the diagnosis of rare disease in diverse populations and will become more accurate as larger and more diverse training sets, including a wider spectrum of ages, particularly infants, are studied.
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5
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Méndez-Rosado LA, de León-Ojeda N, García A, Sheth F, Gaadi A, Bousfiha AA, Lehlimi M, Natiq A, Kurinnaia OS, Vorsanova SG, Iourov I, Huhle D, Liehr T. Clinical characterization of 72 patients with del(22)(q11.2q11.2) from different ethnic backgrounds. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2022. [DOI: 10.1186/s43042-022-00374-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Abstract
Background
DiGeorge syndrome (DGS), caused by a deletion del(22)(q11.2q11.2), is the most frequently observed microdeletion syndrome. There is a vast clinical heterogeneity in DGS, and several studies suggested also heterogeneity of clinical signs and phenotypic appearance to be related to ethnic differences. Here, clinical characteristics of 72 patients with molecular diagnosed deletion del(22)(q11.2q11.2) derived from different countries from Europe, America, Africa, and Asia are summarized and compared.
Results
Unless ethnic differences, the expected major clinical signs were present in all cases. Frequent clinical manifestations found in this study were congenital heart disease with 68% (49/72), followed by dysmorphic features found in 61% (44/72); neurodevelopmental disorders were present in 43% (31/72) and thymus hypoplasia/aplasia in 32% (23/72). However, clinical features of the patients appeared/were recognized at different times during their lives. Within the group, under 2 years predominated heart disease, dysmorphic features, and hypocalcemia and/or hypoparathyroidism. In the group older than 2 years, the following combination of clinical findings was most frequent: dysmorphic features, congenital heart disease, intellectual disability, and immunological disorders. In the eight cases detected prenatally, abnormal sonographic findings were the major clinical signs (cardiovascular malformations and renal malformations).
Conclusions
Despite the heterogeneous nature of the sample analyzed, a number of clinical findings could be highlighted to be useful for the clinical delineation of this DGS. Interestingly, diagnostic indicators may vary depending on the age at diagnosis. Finally, apparent differences in DGS patients from different regions seem to be rather due to applied test systems than to real differences in patients from different ethnicities.
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6
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Kotcher RE, Chait DB, Heckert JM, Crowley TB, Forde KA, Ahuja NK, Mascarenhas MR, Emanuel BS, Zackai EH, McDonald-McGinn DM, Reynolds JC. Gastrointestinal Features of 22q11.2 Deletion Syndrome Include Chronic Motility Problems From Childhood to Adulthood. J Pediatr Gastroenterol Nutr 2022; 75:e8-e14. [PMID: 35641891 PMCID: PMC9329196 DOI: 10.1097/mpg.0000000000003491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES 22q11.2 deletion syndrome (22q11.2DS) is the most common chromosomal microdeletion syndrome and has a multisystemic presentation including gastrointestinal features that have not yet been fully described. Our aim was to examine lifetime gastrointestinal problems in a large cohort of patients with 22q11.2DS. METHODS All patients followed in the 22q and You Center at the Children's Hospital of Philadelphia (n = 1421) were retrospectively screened for: 1) age ≥ 17 years, 2) documented chromosomal microdeletion within the 22q11.2 LCR22A-LCR22D region, and 3) sufficient clinical data to characterize the adult gastrointestinal phenotype. Gastrointestinal problems in childhood, adolescence, and adulthood were summarized. Statistical association testing of symptoms against other patient characteristics was performed. RESULTS Included patients (n = 206; 46% female; mean age, 27 years; median follow-up, 21 years) had similar clinical characteristics to the overall cohort. Genetic distribution was also similar, with 96% having deletions including the critical LCR22A-LCR22B segment (95% in the overall cohort). Most patients experienced chronic gastrointestinal symptoms in their lifetime (91%), but congenital gastrointestinal malformations (3.5%) and gastrointestinal autoimmune diseases (1.5%) were uncommon. Chronic symptoms without anatomic or pathologic abnormalities represented the vast burden of illness. Chronic symptoms in adulthood are associated with other chronic gastrointestinal symptoms and psychiatric comorbidities ( P < 0.01) but not with deletion size or physiologic comorbidities ( P > 0.05). One exception was increased nausea/vomiting in hypothyroidism ( P = 0.002). CONCLUSIONS Functional gastrointestinal disorders (FGIDs) are a common cause of ill health in children and adults with 22q11.2DS. Providers should consider screening for the deletion in patients presenting with FGIDs and associated comorbidities such as neuropsychiatric illness, congenital heart disease, and palatal abnormalities.
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Affiliation(s)
| | | | | | | | - Kimberly A. Forde
- Perelman School of Medicine, University of Pennsylvania
- Division of Gastroenterology, University of Pennsylvania
| | - Nitin K. Ahuja
- Perelman School of Medicine, University of Pennsylvania
- Division of Gastroenterology, University of Pennsylvania
| | - Maria R. Mascarenhas
- Perelman School of Medicine, University of Pennsylvania
- 22q and You Center, Children’s Hospital of Philadelphia
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia
| | - Beverly S. Emanuel
- Perelman School of Medicine, University of Pennsylvania
- 22q and You Center, Children’s Hospital of Philadelphia
- Division of Human Genetics, Children’s Hospital of Philadelphia
| | - Elaine H. Zackai
- Perelman School of Medicine, University of Pennsylvania
- 22q and You Center, Children’s Hospital of Philadelphia
- Division of Human Genetics, Children’s Hospital of Philadelphia
| | - Donna M. McDonald-McGinn
- Perelman School of Medicine, University of Pennsylvania
- 22q and You Center, Children’s Hospital of Philadelphia
- Division of Human Genetics, Children’s Hospital of Philadelphia
| | - James C. Reynolds
- Perelman School of Medicine, University of Pennsylvania
- Division of Gastroenterology, University of Pennsylvania
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7
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Urschel D, Hernandez-Trujillo VP. Spectrum of Genetic T-Cell Disorders from 22q11.2DS to CHARGE. Clin Rev Allergy Immunol 2022; 63:99-105. [PMID: 35133619 DOI: 10.1007/s12016-022-08927-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 01/12/2023]
Abstract
Improved genetic testing has led to recognition of a diverse group of disorders of inborn errors of immunity that present as primarily T-cell defects. These disorders present with variable degrees of immunodeficiency, autoimmunity, multiple organ system dysfunction, and neurocognitive defects. 22q11.2 deletion syndrome, commonly known as DiGeorge syndrome, represents the most common disorder on this spectrum. In most individuals, a 3 Mb deletion of 22q11 results in haploinsufficiency of 90 known genes and clinical complications of varying severity. These include cardiac, endocrine, gastrointestinal, renal, palatal, genitourinary, and neurocognitive anomalies. Multidisciplinary treatment also includes pediatrics/general practitioners, genetic counseling, surgery, interventional therapy, and psychology/psychiatry. Chromosome 10p deletion, TBX1 mutation, CHD7 mutation, Jacobsen syndrome, and FOXN1 deficiency manifest with similar overlapping clinical presentations and T-cell defects. Recognition of the underlying disorder and pathogenesis is essential for improved outcomes. Diagnosing and treating these heterogenous conditions are a challenge and rapidly improving with new diagnostic tools. Collectively, these disorders are an example of the complex penetrance and severity of genetic disorders, importance of translational diagnostics, and a guide for multidisciplinary treatment.
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Affiliation(s)
- Daniel Urschel
- Department of Medical Education, Nicklaus Children's Hospital, Miami, FL, USA. .,Division of Allergy and Immunology, Nicklaus Children's Hospital, Miami, FL, USA. .,Allergy and Immunology Care Center of South Florida, Miami Lakes, FL, USA.
| | - Vivian P Hernandez-Trujillo
- Department of Medical Education, Nicklaus Children's Hospital, Miami, FL, USA.,Division of Allergy and Immunology, Nicklaus Children's Hospital, Miami, FL, USA.,Allergy and Immunology Care Center of South Florida, Miami Lakes, FL, USA
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8
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Rojnueangit K, Khetkham T, Onsod P, Chareonsirisuthigul T. Clinical Features to Predict 22q11.2 Deletion Syndrome Proven by Molecular Genetic Testing. J Pediatr Genet 2020; 11:22-27. [PMID: 35186386 DOI: 10.1055/s-0040-1718386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 08/30/2020] [Indexed: 02/08/2023]
Abstract
The 22q11.2 deletion syndrome (22q11.2 DS) is the most common microdeletion syndrome with a wide variety of clinical features. However, as there are no clinical criteria for diagnosis, confirmation is solely done by genetic tests if clinicians recognize the syndrome. Therefore, we aimed to identify clinical features that may help clinicians recognize 22q11.2 DS. Participants with at least two anomalies were enrolled, complete patient history and physical examinations were performed, then multiplex ligation-dependent probe amplification (MLPA) analysis for 22q11.2 DS was utilized. We identified 11/48 (23%) cases with 22q11.2 DS. Palatal anomalies, hypocalcemia, and ≥3 affected body systems were highly significant presentations in the 22q11.2 DS group versus the group without deletion ( p < 0.05). Therefore, a comprehensive physical examination is crucial at identifying any subtle features which may lead to testing and a definite diagnosis.
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Affiliation(s)
- Kitiwan Rojnueangit
- Division of Genetics, Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Thanitchet Khetkham
- Divison of Forensic Medicine, Thammasat University Hospital, Pathumthai, Thailand
| | - Preyaporn Onsod
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Takol Chareonsirisuthigul
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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9
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Optical mapping of the 22q11.2DS region reveals complex repeat structures and preferred locations for non-allelic homologous recombination (NAHR). Sci Rep 2020; 10:12235. [PMID: 32699385 PMCID: PMC7376033 DOI: 10.1038/s41598-020-69134-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/03/2020] [Indexed: 12/27/2022] Open
Abstract
The most prevalent microdeletion in humans occurs at 22q11.2, a region rich in chromosome-specific low copy repeats (LCR22s). The structure of this region has defied elucidation due to its size, regional complexity, and haplotype diversity, and is not well represented in the human genome reference. Most individuals with 22q11.2 deletion syndrome (22q11.2DS) carry a de novo hemizygous deletion of ~ 3 Mbp occurring by non-allelic homologous recombination (NAHR) mediated by LCR22s. In this study, optical mapping has been used to elucidate LCR22 structure and variation in 88 individuals in thirty 22q11.2DS families to uncover potential risk factors for germline rearrangements leading to 22q11.2DS offspring. Families were optically mapped to characterize LCR22 structures, NAHR locations, and genomic signatures associated with the deletion. Bioinformatics analyses revealed clear delineations between LCR22 structures in normal and deletion-containing haplotypes. Despite no explicit whole-haplotype predisposing configurations being identified, all NAHR events contain a segmental duplication encompassing FAM230 gene members suggesting preferred recombination sequences. Analysis of deletion breakpoints indicates that preferred recombinations occur between FAM230 and specific segmental duplication orientations within LCR22A and LCR22D, ultimately leading to NAHR. This work represents the most comprehensive analysis of 22q11.2DS NAHR events demonstrating completely contiguous LCR22 structures surrounding and within deletion breakpoints.
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10
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A First Case Report of DiGeorge Syndrome from Ethiopia Highlights Challenges in Identifying and Treating Children with Primary T-Cell Deficiencies in Low Resource Settings. Case Reports Immunol 2020; 2020:8157212. [PMID: 32158567 PMCID: PMC7061102 DOI: 10.1155/2020/8157212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/31/2020] [Accepted: 02/08/2020] [Indexed: 11/17/2022] Open
Abstract
Background Cellular primary immunodeficiencies are rarely reported from Africa. DiGeorge syndrome is a commonly recognized form of a congenital T-cell deficiency. The disorder is characterized by hypoplastic or aplastic thymus, hypocalcemia, recurrent infections, and other associated congenital defects. Case Report. We report an eleven-month-old infant presenting with recurrent chest and diarrheal infections, failure to thrive, lymphopenia, hypocalcemia, and hypoplastic thymus on imaging. A diagnosis of DiGeorge syndrome was confirmed after determining very low CD3 and CD4 levels. Conclusions We describe the first case report of an Ethiopian child with a congenital T-cell immunodeficiency. We have outlined essentials for diagnosis and management of cellular primary immunodeficiency disorders in low resource settings.
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11
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Demaerel W, Mostovoy Y, Yilmaz F, Vervoort L, Pastor S, Hestand MS, Swillen A, Vergaelen E, Geiger EA, Coughlin CR, Chow SK, McDonald-McGinn D, Morrow B, Kwok PY, Xiao M, Emanuel BS, Shaikh TH, Vermeesch JR. The 22q11 low copy repeats are characterized by unprecedented size and structural variability. Genome Res 2020; 29:1389-1401. [PMID: 31481461 PMCID: PMC6724673 DOI: 10.1101/gr.248682.119] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 07/24/2019] [Indexed: 12/17/2022]
Abstract
Low copy repeats (LCRs) are recognized as a significant source of genomic instability, driving genome variability and evolution. The Chromosome 22 LCRs (LCR22s) mediate nonallelic homologous recombination (NAHR) leading to the 22q11 deletion syndrome (22q11DS). However, LCR22s are among the most complex regions in the genome, and their structure remains unresolved. The difficulty in generating accurate maps of LCR22s has also hindered localization of the deletion end points in 22q11DS patients. Using fiber FISH and Bionano optical mapping, we assembled LCR22 alleles in 187 cell lines. Our analysis uncovered an unprecedented level of variation in LCR22s, including LCR22A alleles ranging in size from 250 to 2000 kb. Further, the incidence of various LCR22 alleles varied within different populations. Additionally, the analysis of LCR22s in 22q11DS patients and their parents enabled further refinement of the rearrangement site within LCR22A and -D, which flank the 22q11 deletion. The NAHR site was localized to a 160-kb paralog shared between the LCR22A and -D in seven 22q11DS patients. Thus, we present the most comprehensive map of LCR22 variation to date. This will greatly facilitate the investigation of the role of LCR variation as a driver of 22q11 rearrangements and the phenotypic variability among 22q11DS patients.
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Affiliation(s)
| | - Yulia Mostovoy
- Cardiovascular Research Institute, UCSF School of Medicine, San Francisco, California 94158, USA
| | - Feyza Yilmaz
- Department of Integrative Biology, University of Colorado Denver, Denver, Colorado 80204, USA.,Department of Pediatrics, Section of Clinical Genetics and Metabolism, University of Colorado Denver, Aurora, Colorado 80045, USA
| | | | - Steven Pastor
- Division of Human Genetics, Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Matthew S Hestand
- Departement of Human Genetics, KU Leuven, Leuven, 3000 Belgium.,Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio 45221, USA
| | - Ann Swillen
- Departement of Human Genetics, KU Leuven, Leuven, 3000 Belgium
| | - Elfi Vergaelen
- Departement of Human Genetics, KU Leuven, Leuven, 3000 Belgium
| | - Elizabeth A Geiger
- Department of Pediatrics, Section of Clinical Genetics and Metabolism, University of Colorado Denver, Aurora, Colorado 80045, USA
| | - Curtis R Coughlin
- Department of Pediatrics, Section of Clinical Genetics and Metabolism, University of Colorado Denver, Aurora, Colorado 80045, USA
| | - Stephen K Chow
- Cardiovascular Research Institute, UCSF School of Medicine, San Francisco, California 94158, USA
| | - Donna McDonald-McGinn
- Division of Human Genetics, Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Bernice Morrow
- Department of Genetics, Albert Einstein College of Medicine, Bronx, New York 10461, USA
| | - Pui-Yan Kwok
- Cardiovascular Research Institute, UCSF School of Medicine, San Francisco, California 94158, USA
| | - Ming Xiao
- School of Biomedical Engineering, Drexel University, Philadelphia, Pennsylvania 19104, USA
| | - Beverly S Emanuel
- Division of Human Genetics, Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Tamim H Shaikh
- Department of Pediatrics, Section of Clinical Genetics and Metabolism, University of Colorado Denver, Aurora, Colorado 80045, USA
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12
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Mubungu G, Lumaka A, Mvuama N, Tshika D, Makay P, Tshilobo PL, Devriendt K. Morphological characterization of newborns in Kinshasa, DR Congo: Common variants, minor, and major anomalies. Am J Med Genet A 2020; 182:632-639. [DOI: 10.1002/ajmg.a.61477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/28/2019] [Accepted: 12/16/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Gerrye Mubungu
- Faculty of Medicine, Centre for Human GeneticsUniversity of Kinshasa Kinshasa DR Congo
- Faculty of Medicine, Department of PediatricsUniversity of Kinshasa Kinshasa DR Congo
- Centre for Human Genetics, University HospitalsUniversity of Leuven Leuven Belgium
| | - Aimé Lumaka
- Faculty of Medicine, Centre for Human GeneticsUniversity of Kinshasa Kinshasa DR Congo
- Faculty of Medicine, Department of PediatricsUniversity of Kinshasa Kinshasa DR Congo
- Département des Sciences Biomédicales et Précliniques, GIGA‐R, Laboratoire de Génétique HumaineUniversity of Liège Liège Belgium
- Institut National de Recherche Biomédicale Kinshasa DR Congo
| | - Nono Mvuama
- Department of Health EnvironmentKinshasa School of Public Health Kinshasa DR Congo
| | - Dahlie Tshika
- Faculty of Medicine, Centre for Human GeneticsUniversity of Kinshasa Kinshasa DR Congo
- Faculty of Medicine, Department of PediatricsUniversity of Kinshasa Kinshasa DR Congo
| | - Prince Makay
- Faculty of Medicine, Centre for Human GeneticsUniversity of Kinshasa Kinshasa DR Congo
- Faculty of Medicine, Department of PediatricsUniversity of Kinshasa Kinshasa DR Congo
| | - Prosper Lukusa Tshilobo
- Faculty of Medicine, Centre for Human GeneticsUniversity of Kinshasa Kinshasa DR Congo
- Faculty of Medicine, Department of PediatricsUniversity of Kinshasa Kinshasa DR Congo
- Centre for Human Genetics, University HospitalsUniversity of Leuven Leuven Belgium
- Institut National de Recherche Biomédicale Kinshasa DR Congo
| | - Koenraad Devriendt
- Centre for Human Genetics, University HospitalsUniversity of Leuven Leuven Belgium
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13
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Ale H, Beiro Z, Blouin W, Calderon J, Hernandez-Trujillo VP. Pediatric Hispanic versus non-Hispanic patients with partial DiGeorge syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:383-384. [PMID: 31253579 DOI: 10.1016/j.jaip.2019.05.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 05/21/2019] [Accepted: 05/23/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Hanadys Ale
- Division of Pediatric Immunology and Allergy, Joe DiMaggio Children's Hospital, Hollywood, Fla.
| | - Zaimat Beiro
- Department of Medical Education, Cleveland Clinic Florida, Weston, Fla
| | - William Blouin
- Division of Allergy & Immunology, Nicklaus Children's Hospital, Miami, Fla
| | - José Calderon
- Division of Allergy & Immunology, Nicklaus Children's Hospital, Miami, Fla
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14
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Farrera A, Villanueva M, Vizcaíno A, Medina-Bravo P, Balderrábano-Saucedo N, Rives M, Cruz D, Hernández-Carbajal E, Granados-Riveron J, Sánchez-Urbina R. Ontogeny of the facial phenotypic variability in Mexican patients with 22q11.2 deletion syndrome. Head Face Med 2019; 15:29. [PMID: 31829202 PMCID: PMC6905036 DOI: 10.1186/s13005-019-0213-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/14/2019] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
22q11.2 deletion syndrome is a medical condition that results from genomic loss at chromosome 22. Affected patients exhibit large variability that ranges from a severe condition to mild symptoms. In addition, the spectrum of clinical features differs among populations and even within family members. The facial features related to this syndrome are not an exception, and although part of its variation arises through development, few studies address this topic in order to understand the intra and inter-population heterogeneities. Here, we analyze the ontogenetic dynamics of facial morphology of Mexican patients with del22q11.2 syndrome.
Methods
Frontal facial photographs of 37 patients (mean age = 7.65 ± 4.21 SE) with del22q11.2DS and 200 control subjects (mean age = 7.69 ± 4.26 SE) were analyzed using geometric morphometric methods. Overall mean shape and size differences between patients and controls were analyzed, as well as differences in ontogenetic trajectories (i.e. development, growth, and allometry).
Results
We found that Mexican patients show typical traits that have been reported for the Caucasian population. Additionally, there were significant differences between groups in the facial shape and size when all the ontogenetic stages were considered together and, along ontogeny. The developmental and allometric trajectories of patients and controls were similar, but they differed in allometric scaling. Finally, patients and controls showed different growth trajectories.
Conclusion
The results suggest that the typical face of patients with del22q11.2DS is established prenatally; nonetheless, the postnatal ontogeny could influence the dysmorphology and its variability through size-related changes.
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15
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Abstract
PURPOSE OF REVIEW Dysmorphic features result from errors in morphogenesis frequently associated with genetic syndromes. Recognizing patterns of dysmorphic features is a critical step in the diagnosis and management of human congenital anomalies and genetic syndromes. This review presents recent developments in genetic syndromes and their related dysmorphology in diverse populations. RECENT FINDINGS Clinical findings in patients with genetic syndromes differ in their heterogeneity across different population groups. Some genetic syndromes have variable features in different ethnicities, in part due to specific background exam characteristics such as flat facial profiles or nasal differences; however, other genetic syndromes are similar across different ethnicities. Facial analysis technology is accurate in diagnosing genetic syndromes in populations around the world and is a powerful adjunct to conventional clinical examination. This accuracy also reinforces the concept that genetic syndromes can and should be diagnosed in any ethnicity. SUMMARY The increasing amount of data from studies on genetic syndromes in diverse populations is significantly improving our knowledge and approach to dysmorphic patients from various ethnic backgrounds. Optimal management of genetic syndromes requires early diagnosis, including in developing countries.
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Affiliation(s)
- Paul Kruszka
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
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16
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Cohen JL, Crowley TB, McGinn DE, McDougall C, Unolt M, Lambert MP, Emanuel BS, Zackai EH, McDonald-McGinn DM. 22q and two: 22q11.2 deletion syndrome and coexisting conditions. Am J Med Genet A 2018; 176:2203-2214. [PMID: 30244528 DOI: 10.1002/ajmg.a.40494] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/30/2018] [Accepted: 07/11/2018] [Indexed: 01/21/2023]
Abstract
22q11.2 deletion syndrome (DS) is the most frequent copy number variant (CNV) affecting ~1/1,000 fetuses and ~1/2,000-4,000 children, resulting in recognizable but variable findings across multiple organ systems. Patients with atypical features should prompt consideration of coexisting diagnoses due to additional genome-wide mutations, CNVs, or mutations/CNVs on the other allele, unmasking autosomal recessive conditions. Importantly, a dual diagnosis compounds symptoms and impacts management. We previously reported seven patients with 22q11.2DS and: SCID, Trisomy 8 mosaicism, Bernard-Soulier, and CEDNIK syndromes. Here we present six additional unreported patients with 22q11.2DS and concurrent diagnoses. Records on 1,422 patients with 22q11.2DS, identified via FISH, microarray, or MLPA, followed in our 22q and You Center at the Children's Hospital of Philadelphia (CHOP) were reviewed to identify a dual diagnosis. In addition to our seven previously reported cases, we identified an additional six with 22q11.2DS and another coexisting condition identified via: molecular/cytogenetic studies, newborn screening, coagulation factor studies, or enzyme testing; these include CHARGE syndrome (CHD7 mutation), cystic fibrosis, a maternally inherited 17q12 deletion, G6PD deficiency, von Willebrand disease, and 1q21.1 deletion, resulting in an incidence of dual diagnoses at our center of 0.9%. The range of dual diagnoses identified in our cohort is notable, medically actionable, and may alter long-term outcome and recurrence risk counseling. Thus, our findings may support testing patients with 22q11.2DS using a combination of microarray, mutational analysis of the other allele/WES, to ensure appropriate personalized care, as formulating medical management decisions hinges on establishing the correct diagnoses in their entirety.
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Affiliation(s)
- Jennifer L Cohen
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Daniel E McGinn
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Carey McDougall
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Marta Unolt
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics and Pediatric Neuropsychiatry, "Sapienza" University of Rome and Ospedale Bambino Gesu, Rome, Italy
| | - Michele P Lambert
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Beverly S Emanuel
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elaine H Zackai
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donna M McDonald-McGinn
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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17
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Lumaka A, Race V, Peeters H, Corveleyn A, Coban-Akdemir Z, Jhangiani SN, Song X, Mubungu G, Posey J, Lupski JR, Vermeesch JR, Lukusa P, Devriendt K. A comprehensive clinical and genetic study in 127 patients with ID in Kinshasa, DR Congo. Am J Med Genet A 2018; 176:1897-1909. [PMID: 30088852 DOI: 10.1002/ajmg.a.40382] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 06/06/2018] [Indexed: 12/21/2022]
Abstract
Pathogenic variants account for 4 to 41% of patients with intellectual disability (ID) or developmental delay (DD). In Sub-Saharan Africa, the prevalence of ID is thought to be higher, but data in Central Africa are limited to some case reports. In addition, clinical descriptions of some syndromes are not available for this population. This study aimed at providing an estimate for the fraction of ID/DD for which an underlying etiological genetic cause may be elucidated and provide insights into their clinical presentation in special institutions in a Central African country. A total of 127 patients (33 females and 94 males, mean age 10.03 ± 4.68 years), were recruited from six institutions across Kinshasa. A clinical diagnosis was achieved in 44 but molecular confirmation was achieved in 21 of the 22 patients with expected genetic defect (95% clinical sensitivity). Identified diseases included Down syndrome (15%), submicroscopic copy number variants (9%), aminoacylase deficiency (0.8%), Partington syndrome in one patient (0.8%) and his similarly affected brother, X-linked syndromic Mental Retardation type 33 (0.8%), and two conditions without clear underlying molecular genetic etiologies (Oculo-Auriculo-Vertebral and Amniotic Bands Sequence). We have shown that genetic etiologies, similar to those reported in Caucasian subjects, are a common etiologic cause of ID in African patients from Africa. We have confirmed the diagnostic utility of clinical characterization prior to genetic testing. Finally, our clinical descriptions provide insights into the presentation of these genetic diseases in African patients.
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Affiliation(s)
- Aimé Lumaka
- Centre for Human Genetics, Faculty of Medicine, University of Kinshasa, Kinshasa, DR, Congo.,Département des Sciences Biomédicales et Précliniques, GIGA-R, Laboratoire de Génétique Humaine, University of Liège, Liège, Belgium.,Institut National de Recherche Biomédicale, Kinshasa, DR, Congo.,Department of Pediatrics, Faculty of Medicine, University of Kinshasa, Kinshasa, DR, Congo
| | - Valerie Race
- Centre for Human Genetics, University Hospital, University of Leuven, Leuven, Belgium
| | - Hilde Peeters
- Centre for Human Genetics, University Hospital, University of Leuven, Leuven, Belgium
| | - Anniek Corveleyn
- Centre for Human Genetics, University Hospital, University of Leuven, Leuven, Belgium
| | - Zeynep Coban-Akdemir
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Shalini N Jhangiani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Xiaofei Song
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Gerrye Mubungu
- Centre for Human Genetics, Faculty of Medicine, University of Kinshasa, Kinshasa, DR, Congo.,Institut National de Recherche Biomédicale, Kinshasa, DR, Congo.,Department of Pediatrics, Faculty of Medicine, University of Kinshasa, Kinshasa, DR, Congo.,Centre for Human Genetics, University Hospital, University of Leuven, Leuven, Belgium
| | - Jennifer Posey
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas
| | - James R Lupski
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas.,Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Genetics Clinic service, Texas Children's Hospital, Houston, Texas
| | - Joris R Vermeesch
- Centre for Human Genetics, University Hospital, University of Leuven, Leuven, Belgium
| | - Prosper Lukusa
- Centre for Human Genetics, Faculty of Medicine, University of Kinshasa, Kinshasa, DR, Congo.,Département des Sciences Biomédicales et Précliniques, GIGA-R, Laboratoire de Génétique Humaine, University of Liège, Liège, Belgium.,Institut National de Recherche Biomédicale, Kinshasa, DR, Congo.,Centre for Human Genetics, University Hospital, University of Leuven, Leuven, Belgium
| | - Koenraad Devriendt
- Centre for Human Genetics, University Hospital, University of Leuven, Leuven, Belgium
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18
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Lumaka A, Lubala TK, Race V, Peeters H, Lukusa P, Devriendt K. Usefulness of fragile X checklist and CGG distribution in specialized institutions in Kinshasa, DR Congo. J Community Genet 2018; 10:153-159. [PMID: 29974402 DOI: 10.1007/s12687-018-0374-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/20/2018] [Indexed: 11/27/2022] Open
Abstract
Screening for fragile X syndrome (FXS) is essential in children with developmental delay or intellectual disability (ID). In addition, using clinical screening checklists remains of high interest in resource-limited settings. We aimed to gain insight into the prevalence of FXS and the distribution of CGG alleles and to evaluate the usefulness of three checklists in specialized institutions in Kinshasa, DR Congo. We recruited 80 males and 25 females from six specialized institutions in Kinshasa and administered a questionnaire comprising items from the following FXS checklists: Hagerman, Maes, and Guruju. FMR1 CGG repeats were assessed for every patient. About 37% of patients were referable for FX testing based on Hagerman's checklist, 35% for Maes', and 43.80% for Guruju's, but none of them was molecularly confirmed to have FXS. Thus, specificities were 62.86, 64.76, and 56.5%, respectively, for Hagerman, Maes, and Guruju, respectively. The mean CGG allele size was 28.55 ± 2.83 (ranges, 17-48). The 29 CGG was the most frequent allele (24.61%). Thus, existing checklists should not be automatically applied to Congolese patients without adjustments. The distribution of CGG repeats and the number of CGG alleles are similar to other African studies.
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Affiliation(s)
- Aimé Lumaka
- Centre for Human Genetics, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo.,Laboratory of Human Genetics, GIGA-Institute, University of Liège, 4500, Liège, Belgium.,Department of Pediatrics, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo.,Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo
| | - Toni Kasole Lubala
- Division of Dysmorphology and Birth Defects, Department of Pediatrics, University of Lubumbashi, Lubumbashi, Congo
| | - Valérie Race
- Centre for Human Genetics, University Hospitals, University of Leuven, Herestraat 49, Bus 602, 3000, Leuven, Belgium
| | - Hilde Peeters
- Centre for Human Genetics, University Hospitals, University of Leuven, Herestraat 49, Bus 602, 3000, Leuven, Belgium
| | - Prosper Lukusa
- Centre for Human Genetics, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo.,Department of Pediatrics, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo.,Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo.,Centre for Human Genetics, University Hospitals, University of Leuven, Herestraat 49, Bus 602, 3000, Leuven, Belgium
| | - Koenraad Devriendt
- Centre for Human Genetics, University Hospitals, University of Leuven, Herestraat 49, Bus 602, 3000, Leuven, Belgium.
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19
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Homans JF, Tromp IN, Colo D, Schlösser TPC, Kruyt MC, Deeney VFX, Crowley TB, McDonald-McGinn DM, Castelein RM. Orthopaedic manifestations within the 22q11.2 Deletion syndrome: A systematic review. Am J Med Genet A 2017; 176:2104-2120. [DOI: 10.1002/ajmg.a.38545] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/07/2017] [Accepted: 10/27/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Jelle F. Homans
- Department of Orthopaedic Surgery; University Medical Center Utrecht; Utrecht The Netherlands
| | - Isabel N. Tromp
- Department of Orthopaedic Surgery; University Medical Center Utrecht; Utrecht The Netherlands
| | - Dino Colo
- Department of Orthopaedic Surgery; University Medical Center Utrecht; Utrecht The Netherlands
| | - Tom P. C. Schlösser
- Department of Orthopaedic Surgery; University Medical Center Utrecht; Utrecht The Netherlands
| | - Moyo C. Kruyt
- Department of Orthopaedic Surgery; University Medical Center Utrecht; Utrecht The Netherlands
| | - Vincent F. X. Deeney
- Department of Orthopaedic Surgery; The Children's Hospital of Philadelphia (CHOP) and The Perelman School of Medicine at the University of Pennsylvania; Philadelphia Pennsylvania
| | - Terrence B. Crowley
- Division of Human Genetics and 22q and You Center; The Children's Hospital of Philadelphia (CHOP); Philadelphia Pennsylvania
| | - Donna M. McDonald-McGinn
- Division of Human Genetics and 22q and You Center; The Children's Hospital of Philadelphia (CHOP); Philadelphia Pennsylvania
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia Pennsylvania
| | - René M. Castelein
- Department of Orthopaedic Surgery; University Medical Center Utrecht; Utrecht The Netherlands
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20
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Tang SX, Moore TM, Calkins ME, Yi JJ, Savitt A, Kohler CG, Souders MC, Zackai EH, McDonald-McGinn DM, Emanuel BS, Gur RC, Gur RE. The Psychosis Spectrum in 22q11.2 Deletion Syndrome Is Comparable to That of Nondeleted Youths. Biol Psychiatry 2017; 82:17-25. [PMID: 27832840 PMCID: PMC5342951 DOI: 10.1016/j.biopsych.2016.08.034] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 08/15/2016] [Accepted: 08/30/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Chromosome 22q11.2 deletion syndrome (22q11DS) is a promising model for studying psychosis risk. Direct comparisons of psychosis features between 22q11DS and nondeleted (ND) individuals are limited by inconsistency and small samples. In the largest study to date, we compare 22q11DS to ND in comorbidities, functioning, cognition, and psychosis features across the full range of overall severity. METHODS ND youths (n = 150) ages 9 to 24 years were matched to 22q11DS individuals (n = 150) on age and sex, stratifying for presence of psychosis spectrum disorder. Individuals were evaluated for psychosis using the Structured Interview for Prodromal Syndromes, and for attention-deficit/hyperactivity, substance-related, and mood disorders. Differential item functioning analysis addressed whether 22q11DS differs from ND in the probability of clinically significant ratings while holding constant the overall level of psychosis. RESULTS Onset of psychosis proneness was similar among 22q11DS (mean: 11.0 years) and ND (mean: 12.1 years) individuals. Accounting for higher overall psychosis symptoms, 22q11DS participants were still more likely to manifest impaired stress tolerance, avolition, and ideational richness; ND individuals were more likely to exhibit unusual thoughts, persecutory ideas, and bizarre thinking. Cognition was impaired in 22q11DS, but it did not correlate with symptoms except ideational richness. Comorbid anxiety disorders were more likely in psychosis spectrum 22q11DS; substance-related disorders were more likely in ND. Global assessment of function was similar in 22q11DS and ND individuals, except among those with low total Structured Interview for Prodromal Syndromes scores. CONCLUSIONS Individuals with 22q11DS share overarching similarities with ND individuals in psychosis symptoms and age of onset for psychosis proneness; this continues to support the 22q11DS model as a valuable window into mechanisms contributing to psychosis.
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Affiliation(s)
- Sunny X Tang
- Department of Psychiatry, Philadelphia, Pennsylvania.
| | - Tyler M Moore
- Department of Psychiatry, Philadelphia, Pennsylvania
| | | | - James J Yi
- Department of Psychiatry, Philadelphia, Pennsylvania; Department of Child and Adolescent Psychiatry, Philadelphia, Pennsylvania
| | - Adam Savitt
- Department of Psychiatry, Philadelphia, Pennsylvania
| | | | - Margaret C Souders
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elaine H Zackai
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Donna M McDonald-McGinn
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Beverly S Emanuel
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ruben C Gur
- Department of Psychiatry, Philadelphia, Pennsylvania
| | - Raquel E Gur
- Department of Psychiatry, Philadelphia, Pennsylvania; Department of Child and Adolescent Psychiatry, Philadelphia, Pennsylvania
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21
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Kruszka P, Addissie YA, McGinn DE, Porras AR, Biggs E, Share M, Crowley TB, Chung BHY, Mok GTK, Mak CCY, Muthukumarasamy P, Thong MK, Sirisena ND, Dissanayake VHW, Paththinige CS, Prabodha LBL, Mishra R, Shotelersuk V, Ekure EN, Sokunbi OJ, Kalu N, Ferreira CR, Duncan JM, Patil SJ, Jones KL, Kaplan JD, Abdul-Rahman OA, Uwineza A, Mutesa L, Moresco A, Obregon MG, Richieri-Costa A, Gil-da-Silva-Lopes VL, Adeyemo AA, Summar M, Zackai EH, McDonald-McGinn DM, Linguraru MG, Muenke M. 22q11.2 deletion syndrome in diverse populations. Am J Med Genet A 2017; 173:879-888. [PMID: 28328118 PMCID: PMC5363275 DOI: 10.1002/ajmg.a.38199] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/02/2017] [Accepted: 02/02/2017] [Indexed: 11/10/2022]
Abstract
22q11.2 deletion syndrome (22q11.2 DS) is the most common microdeletion syndrome and is underdiagnosed in diverse populations. This syndrome has a variable phenotype and affects multiple systems, making early recognition imperative. In this study, individuals from diverse populations with 22q11.2 DS were evaluated clinically and by facial analysis technology. Clinical information from 106 individuals and images from 101 were collected from individuals with 22q11.2 DS from 11 countries; average age was 11.7 and 47% were male. Individuals were grouped into categories of African descent (African), Asian, and Latin American. We found that the phenotype of 22q11.2 DS varied across population groups. Only two findings, congenital heart disease and learning problems, were found in greater than 50% of participants. When comparing the clinical features of 22q11.2 DS in each population, the proportion of individuals within each clinical category was statistically different except for learning problems and ear anomalies (P < 0.05). However, when Africans were removed from analysis, six additional clinical features were found to be independent of ethnicity (P ≥ 0.05). Using facial analysis technology, we compared 156 Caucasians, Africans, Asians, and Latin American individuals with 22q11.2 DS with 156 age and gender matched controls and found that sensitivity and specificity were greater than 96% for all populations. In summary, we present the varied findings from global populations with 22q11.2 DS and demonstrate how facial analysis technology can assist clinicians in making accurate 22q11.2 DS diagnoses. This work will assist in earlier detection and in increasing recognition of 22q11.2 DS throughout the world.
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MESH Headings
- Adolescent
- Adult
- Asian People
- Biometric Identification/methods
- Black People
- Child
- Child, Preschool
- Chromosomes, Human, Pair 22/chemistry
- DiGeorge Syndrome/diagnosis
- DiGeorge Syndrome/ethnology
- DiGeorge Syndrome/genetics
- DiGeorge Syndrome/pathology
- Facies
- Female
- Heart Defects, Congenital/diagnosis
- Heart Defects, Congenital/ethnology
- Heart Defects, Congenital/genetics
- Heart Defects, Congenital/pathology
- Hispanic or Latino
- Humans
- Image Interpretation, Computer-Assisted/methods
- In Situ Hybridization, Fluorescence
- Infant
- Infant, Newborn
- Learning Disabilities/diagnosis
- Learning Disabilities/ethnology
- Learning Disabilities/genetics
- Learning Disabilities/physiopathology
- Male
- Phenotype
- White People
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Affiliation(s)
- Paul Kruszka
- Medical Genetics Branch, National Human Genome Research Institute, The National Institutes of Health, Bethesda, Maryland
| | - Yonit A Addissie
- Medical Genetics Branch, National Human Genome Research Institute, The National Institutes of Health, Bethesda, Maryland
| | - Daniel E McGinn
- Division of Human Genetics, 22q and You Center, and Clinical Genetics Center, The Children's Hospital of Philadelphia and the Department of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Antonio R Porras
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, D.C
| | - Elijah Biggs
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, D.C
| | - Matthew Share
- Division of Human Genetics, 22q and You Center, and Clinical Genetics Center, The Children's Hospital of Philadelphia and the Department of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - T Blaine Crowley
- Division of Human Genetics, 22q and You Center, and Clinical Genetics Center, The Children's Hospital of Philadelphia and the Department of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian H Y Chung
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Gary T K Mok
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Christopher C Y Mak
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Premala Muthukumarasamy
- Faculty of Medicine, Department of Paediatrics, University of Malaya, Kuala Lumpur, Malaysia
| | - Meow-Keong Thong
- Faculty of Medicine, Department of Paediatrics, University of Malaya, Kuala Lumpur, Malaysia
| | - Nirmala D Sirisena
- Faculty of Medicine, Human Genetics Unit, University of Colombo, Sri Lanka
| | | | | | | | - Rupesh Mishra
- Faculty of Medicine, Human Genetics Unit, University of Colombo, Sri Lanka
| | - Vorasuk Shotelersuk
- Center of Excellence for Medical Genetics, Faculty of Medicine, Department of Pediatrics, Chulalongkorn University, Bangkok, Thailand
| | - Ekanem Nsikak Ekure
- Department of Paediatrics College of Medicine, University of Lagos, Lagos University Teaching, Lagos, Nigeria
| | | | - Nnenna Kalu
- Department of Paediatrics College of Medicine, University of Lagos, Lagos University Teaching, Lagos, Nigeria
| | - Carlos R Ferreira
- Division of Genetics and Metabolism, Children's National Health System, Washington, D.C
| | - Jordann-Mishael Duncan
- Medical Genetics Branch, National Human Genome Research Institute, The National Institutes of Health, Bethesda, Maryland
| | | | - Kelly L Jones
- Division of Medical Genetics, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Julie D Kaplan
- Division of Medical Genetics, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Omar A Abdul-Rahman
- Division of Medical Genetics, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Annette Uwineza
- Center of Human Genetics/School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Leon Mutesa
- Center of Human Genetics/School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Angélica Moresco
- Servicio de Genética, Hospital de Pediatría Garrahan, Buenos Aires, Argentina
| | | | - Antonio Richieri-Costa
- Hospital for the Rehabilitation of Craniofacial Anomalies, São Paulo University, Bauru, Brazil
| | | | - Adebowale A Adeyemo
- Center for Research on Genomics and Global Health, National Human Genome Research Institute, The National Institutes of Health, Bethesda, Maryland
| | - Marshall Summar
- Division of Genetics and Metabolism, Children's National Health System, Washington, D.C
| | - Elaine H Zackai
- Division of Human Genetics, 22q and You Center, and Clinical Genetics Center, The Children's Hospital of Philadelphia and the Department of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donna M McDonald-McGinn
- Division of Human Genetics, 22q and You Center, and Clinical Genetics Center, The Children's Hospital of Philadelphia and the Department of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marius George Linguraru
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, D.C
| | - Maximilian Muenke
- Medical Genetics Branch, National Human Genome Research Institute, The National Institutes of Health, Bethesda, Maryland
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22
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Wonkam A, Toko R, Chelo D, Tekendo-Ngongang C, Kingue S, Dahoun S. The 22q11.2 Deletion Syndrome in Congenital Heart Defects: Prevalence of Microdeletion Syndrome in Cameroon. Glob Heart 2017; 12:115-120. [PMID: 28302550 DOI: 10.1016/j.gheart.2017.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 01/05/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The 22q11.2 deletion syndrome is amongst the most common microdeletion syndrome in humans. Its prevalence remains unknown in sub-Saharan Africa, and its clinical features are under-reported for people of African descent. OBJECTIVE We have investigated the prevalence of the 22q11.2 deletion syndrome in patients with congenital heart defects in Cameroon. METHODS A total of 70 of 100 cases of congenital cardiac malformation with echocardiographic evidence were examined prospectively and tested for the 22q11.2 deletion, using multiplex ligation-dependent probe amplification and fluorescence in situ hybridization. RESULTS Two of 70 patients (2.8%) were found to have 22q11.2 deletion. Both cases had conotruncal heart defects and exhibited extracardiac features of the 22q11.2 deletion syndrome that were either classical (e.g., puffy upper eyelids, bulbous tip of the nose) or less identifiable (telecanthus, hooding of eyelids and prominent nasal bridge). CONCLUSIONS The report shows that the prevalence of the 22q11.2 deletion syndrome in patients with heart malformations in Cameroon (2.8%) is similar to that of various world populations. The clinical phenotypes will contribute to the Global Atlas for dysmorphology. "Omics" technologies offer much promise in genetic/genomic screening of severe global health problems.
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Affiliation(s)
- Ambroise Wonkam
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Ricardo Toko
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - David Chelo
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - Cedrik Tekendo-Ngongang
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Samuel Kingue
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - Sophie Dahoun
- Service of Genetic Medicine, Geneva University Hospitals, Geneva, Switzerland
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Lumaka A, Cosemans N, Lulebo Mampasi A, Mubungu G, Mvuama N, Lubala T, Mbuyi-Musanzayi S, Breckpot J, Holvoet M, de Ravel T, Van Buggenhout G, Peeters H, Donnai D, Mutesa L, Verloes A, Lukusa Tshilobo P, Devriendt K. Facial dysmorphism is influenced by ethnic background of the patient and of the evaluator. Clin Genet 2017; 92:166-171. [PMID: 27925162 DOI: 10.1111/cge.12948] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 11/26/2016] [Accepted: 11/28/2016] [Indexed: 11/29/2022]
Abstract
The evaluation of facial dysmorphism is a critical step toward reaching a diagnostic. The aim of the present study was to evaluate the ability to interpret facial morphology in African children with intellectual disability (ID). First, 10 experienced clinicians (five from Africa and five from Europe) rated gestalt in 127 African non-Down Syndrome (non-DS) patients using either the score 2 for 'clearly dysmorphic', 0 for 'clearly non dysmorphic' or 1 for 'uncertain'. The inter-rater agreement was determined using kappa coefficient. There was only fair agreement between African and European raters (kappa-coefficient = 0.29). Second, we applied the FDNA Face2Gene solution to assess Down Syndrome (DS) faces. Initially, Face2Gene showed a better recognition rate for DS in Caucasian (80%) compared to African (36.8%). We trained the Face2Gene with a set of African DS and non-DS photographs. Interestingly, the recognition in African increased to 94.7%. Thus, training improved the sensitivity of Face2Gene. Our data suggest that human based evaluation is influenced by ethnic background of the evaluator. In addition, computer based evaluation indicates that the ethnic of the patient also influences the evaluation and that training may increase the detection specificity for a particular ethnic.
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Affiliation(s)
- A Lumaka
- Center for Human Genetics, University Hospitals Leuven, Leuven, Belgium.,Center for Human Genetics, Faculty of Medicine, University of Kinshasa, Kinshasa, DR Congo.,Department of Paediatrics, Faculty of Medicine, University of Kinshasa, Kinshasa, DR Congo.,Institut National de Recherche Biomédicale, Kinshasa, DR Congo
| | - N Cosemans
- Center for Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - A Lulebo Mampasi
- School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, DR Congo
| | - G Mubungu
- Center for Human Genetics, Faculty of Medicine, University of Kinshasa, Kinshasa, DR Congo.,Department of Paediatrics, Faculty of Medicine, University of Kinshasa, Kinshasa, DR Congo
| | - N Mvuama
- School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, DR Congo
| | - T Lubala
- Sendwe University Hospitals, University of Lubumbashi, Lubumbashi, DR Congo
| | - S Mbuyi-Musanzayi
- Sendwe University Hospitals, University of Lubumbashi, Lubumbashi, DR Congo
| | - J Breckpot
- Center for Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - M Holvoet
- Center for Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - T de Ravel
- Center for Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - G Van Buggenhout
- Center for Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - H Peeters
- Center for Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - D Donnai
- Manchester Centre for Genomic Medicine, Saint Mary's Hospital, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - L Mutesa
- Center for Human Genetics, College of Medicine and Health Sciences, University of Rwanda, Butare, Rwanda
| | - A Verloes
- Département de Génétique, CHU Paris - Hôpital Robert Debré, Paris, France
| | - P Lukusa Tshilobo
- Center for Human Genetics, University Hospitals Leuven, Leuven, Belgium.,Center for Human Genetics, Faculty of Medicine, University of Kinshasa, Kinshasa, DR Congo.,Department of Paediatrics, Faculty of Medicine, University of Kinshasa, Kinshasa, DR Congo.,Institut National de Recherche Biomédicale, Kinshasa, DR Congo
| | - K Devriendt
- Center for Human Genetics, University Hospitals Leuven, Leuven, Belgium
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24
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Franconi CP, McDonald-McGinn D, H.Zackai E, McNamara MA, Salmons H, Moss E, Gur RE, Devoto M, Emanuel BS. IQ and hemizygosity for the Val 158 Met functional polymorphism of COMT in 22q11DS. Am J Med Genet B Neuropsychiatr Genet 2016; 171:1112-1115. [PMID: 27619075 PMCID: PMC6733517 DOI: 10.1002/ajmg.b.32492] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 08/15/2016] [Indexed: 11/12/2022]
Abstract
22q11.2 Deletion Syndrome (22q11DS) is a multisystem disorder caused by a hemizygous deletion within 22q11.2. Patients with the deletion display a wide range of cognitive deficits. The gene catechol-O-methyl-transferase (COMT) resides in the typically deleted region of 22q11.2 and is rendered hemizygous in individuals affected by the 22q11DS. COMT is a critical enzyme in the degradation of catecholamine neurotransmitters in the brain. A functional polymorphism, Val158 Met, has been associated with a variety of neurocognitive outcomes. In this study, 159 patients with 22q11DS were analyzed for a potential association between intelligence quotient (IQ) and COMT genotype. We performed a univariate analysis for overall influence and modified our analysis to focus on possible differences between average, borderline, and intellectually impaired patients. No correlation between COMT genotype and IQ performance was found. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Colleen P. Franconi
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Donna McDonald-McGinn
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elaine H.Zackai
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Meghan A. McNamara
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Harold Salmons
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Raquel E. Gur
- Department of Psychiatry, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marcella Devoto
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Biostatistics and Epidemiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Molecular Medicine, University La Sapienza, Roma, Italy
| | - Beverly S. Emanuel
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Correspondence to: Beverly S. Emanuel, Ph.D., Division of Human Genetics, The Children's Hospital of Philadelphia, 3615 Civic Center Blvd. Philadelphia, PA 19104; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104.
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25
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Giovani ÉM, Marinho KCT, Andia-Merlin R. Dental treatment of a patient with Opitz G/BBB syndrome. SPECIAL CARE IN DENTISTRY 2016; 37:102-106. [PMID: 27642052 DOI: 10.1111/scd.12200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Opitz G/BBB syndrome is a genetic condition characterized by several abnormalities along the midline of the body, such as hypertelorism, craniofacial deformities, and dysphagia. This study reports the clinical features of Optiz syndrome and its importance in the knowledge of patients who are developmentally challenged as a whole, in order to establish adequate dental treatment for a certain clinical case. A 19-year-old patient visited the Paulista University for a dental treatment. The extraoral examination revealed ocular hypertelorism (wide-spaced eyes), oblique eyelids, epicanthus, low-set cart, and intellectual disability. During the intraoral examination, large caries lesions were observed surrounding the braces of the fixed orthodontic appliance and poor oral hygiene. Preventive and restorative treatments were carried out. It was concluded that the knowledge of patients with special needs as a whole is mandatory for an adequate dental treatment. This is a case report that highlights the importance of dentist and interdisciplinary care attendance for all patient systems, the examination and analyses should not be restricted to the oral cavity.
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Affiliation(s)
- Élcio Magdalena Giovani
- Chairman, Professor, Integrated Clinic Discipline, Coordinator of Center for Studies and Special Service for Patients, Professor, Postgraduate Dentistry Courses, UNIP, São Paulo, SP, Brazil
| | | | - Ruth Andia-Merlin
- Associate Professor, Integrated Clinic and Center for Studies and Special Service for Patients, UNIP, São Paulo, SP, Brazil
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26
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Dugoff L, Mennuti MT, McDonald-McGinn DM. The benefits and limitations of cell-free DNA screening for 22q11.2 deletion syndrome. Prenat Diagn 2016; 37:53-60. [DOI: 10.1002/pd.4864] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 06/14/2016] [Accepted: 06/16/2016] [Indexed: 12/24/2022]
Affiliation(s)
- Lorraine Dugoff
- Department of OB/GYN, Divisions of Reproductive Genetics and Maternal Fetal Medicine; University of Pennsylvania; Philadelphia PA USA
| | - Michael T. Mennuti
- Department of OB/GYN, Divisions of Reproductive Genetics and Maternal Fetal Medicine; University of Pennsylvania; Philadelphia PA USA
| | - Donna M. McDonald-McGinn
- Division of Human Genetics, 22q and You Center and Clinical Genetics Center, The Children's Hospital of Philadelphia, and the Department of Pediatrics; The Perelman School of Medicine of the University of Pennsylvania; Philadelphia PA USA
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27
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Abstract
22q11.2 deletion syndrome (22q11.2DS) is the most common chromosomal microdeletion disorder, estimated to result mainly from de novo non-homologous meiotic recombination events occurring in approximately 1 in every 1,000 fetuses. The first description in the English language of the constellation of findings now known to be due to this chromosomal difference was made in the 1960s in children with DiGeorge syndrome, who presented with the clinical triad of immunodeficiency, hypoparathyroidism and congenital heart disease. The syndrome is now known to have a heterogeneous presentation that includes multiple additional congenital anomalies and later-onset conditions, such as palatal, gastrointestinal and renal abnormalities, autoimmune disease, variable cognitive delays, behavioural phenotypes and psychiatric illness - all far extending the original description of DiGeorge syndrome. Management requires a multidisciplinary approach involving paediatrics, general medicine, surgery, psychiatry, psychology, interventional therapies (physical, occupational, speech, language and behavioural) and genetic counselling. Although common, lack of recognition of the condition and/or lack of familiarity with genetic testing methods, together with the wide variability of clinical presentation, delays diagnosis. Early diagnosis, preferably prenatally or neonatally, could improve outcomes, thus stressing the importance of universal screening. Equally important, 22q11.2DS has become a model for understanding rare and frequent congenital anomalies, medical conditions, psychiatric and developmental disorders, and may provide a platform to better understand these disorders while affording opportunities for translational strategies across the lifespan for both patients with 22q11.2DS and those with these associated features in the general population.
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28
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Swillen A, McDonald-McGinn D. Developmental trajectories in 22q11.2 deletion. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2015; 169:172-81. [PMID: 25989227 DOI: 10.1002/ajmg.c.31435] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chromosome 22q11.2 deletion syndrome (22q11.2DS), a neurogenetic condition, is the most common microdeletion syndrome affecting 1 in 2,000-4,000 live births and involving haploinsufficiency of ∼50 genes resulting in a multisystem disorder. Phenotypic expression is highly variable and ranges from severe life-threatening conditions to only a few associated features. Most common medical problems include: congenital heart disease, in particular conotruncal anomalies; palatal abnormalities, most frequently velopharyngeal incompetence (VPI); immunodeficiency; hypocalcemia due to hypoparathyroidism; genitourinary anomalies; severe feeding/gastrointestinal differences; and subtle dysmorphic facial features. The neurocognitive profile is also highly variable, both between individuals and during the course of development. From infancy onward, motor delays (often with hypotonia) and speech/language deficits are commonly observed. During the preschool and primary school ages, learning difficulties are very common. The majority of patients with 22q11.2DS have an intellectual level that falls in the borderline range (IQ 70-84), and about one-third have mild to moderate intellectual disability. More severe levels of intellectual disability are uncommon in children and adolescents but are more frequent in adults. Individuals with 22q11.2DS are at an increased risk for developing several psychiatric disorders including attention deficit with hyperactivity disorder (ADHD), autism spectrum disorder (ASD), anxiety and mood disorders, and psychotic disorders and schizophrenia. In this review, we will focus on the developmental phenotypic transitions regarding cognitive development in 22q11.2DS from early preschool to adulthood, and on the changing behavioral/psychiatric phenotype across age, on a background of frequently complex medical conditions.
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29
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Walong E, Rogena E, Sabai D. Primary immunodeficiency diagnosed at autopsy: a case report. BMC Res Notes 2014; 7:425. [PMID: 24996427 PMCID: PMC4094674 DOI: 10.1186/1756-0500-7-425] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 06/23/2014] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND DiGeorge syndrome may manifest as severe immunodeficiency diagnosed at infancy. The diagnosis of primary immunodeficiency is based on characteristic clinical features, immunophenotyping by flow cytometry, molecular diagnostics and functional lymphocyte evaluation. At autopsy, gross evaluation, conventional histology and immunohistochemistry may be useful for the diagnosis of primary immunodeficiency. This case report illustrates the application of autopsy and immunohistochemistry in the diagnosis of DiGeorge syndrome. CASE PRESENTATION A four-month-old African female infant died while undergoing treatment at Kenyatta National Hospital, a Referral and Teaching Hospital in Nairobi, Kenya. She presented with a month's history of recurrent respiratory infections, a subsequent decline in the level of consciousness and succumbed to her illness within four days. Her two older siblings died following similar circumstances at ages 3 and 5 months respectively. Autopsy revealed thymic aplasia, bronchopneumonia and invasive brain infection by Aspergillus species. Microbial cultures of cerebrospinal fluid, jejunal contents, spleen and lung tissue revealed multi drug resistant Klebsiella spp, Pseudomonas spp, Serratia spp and Escherichia coli. Immunohistochemistry of splenic tissue obtained from autopsy confirmed reduction of T lymphocytes. CONCLUSION Use of immunohistochemistry on histological sections of tissues derived from autopsy is a useful adjunct for post mortem diagnosis of DiGeorge syndrome.
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Affiliation(s)
- Edwin Walong
- Anatomic Pathology Unit, Department of Human Pathology, School of Medicine, University of Nairobi, PO Box 19676, Nairobi, Kenya
| | - Emily Rogena
- Anatomic Pathology Unit, Department of Human Pathology, School of Medicine, University of Nairobi, PO Box 19676, Nairobi, Kenya
| | - David Sabai
- Anatomic Pathology Unit, Department of Human Pathology, School of Medicine, University of Nairobi, PO Box 19676, Nairobi, Kenya
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30
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Liu APY, Chow PC, Lee PPW, Mok GTK, Tang WF, Lau ET, Lam STS, Chan KY, Kan ASY, Chau AKT, Cheung YF, Lau YL, Chung BHY. Under-recognition of 22q11.2 deletion in adult Chinese patients with conotruncal anomalies: implications in transitional care. Eur J Med Genet 2014; 57:306-11. [PMID: 24721633 DOI: 10.1016/j.ejmg.2014.03.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 03/19/2014] [Accepted: 03/22/2014] [Indexed: 11/17/2022]
Abstract
22q11.2 deletion syndrome (22q11.2DS) is a multi-systemic disorder with high phenotypic variability. Under-diagnosis in adults is common and recognition of facial dysmorphic features can be affected by age and ethnicity. This study aims to determine the prevalence of undiagnosed 22q11.2DS in adult Chinese patients with conotruncal anomalies and to delineate their facial dysmorphisms and extra-cardiac manifestations. We recruited consecutively 156 patients with conotruncal anomalies in an adult congenital heart disease (CHD) clinic in Hong Kong and screened for 22q11.2DS using fluorescence-PCR and fluorescence in-situ hybridization. Assessment for dysmorphic features was performed by a cardiologist at initial screening and then by a clinical geneticist upon result disclosure. Clinical photographs were taken and childhood photographs collected. Eighteen patients (11.5%) were diagnosed with 22q11.2DS, translating into 1 previously unrecognized diagnosis of 22q11.2DS in every 10 adult patients with conotruncal anomalies. While dysmorphic features were detected by our clinical geneticist in all patients, only two-thirds were considered dysmorphic by our cardiologist upon first assessment. Evolution of facial dysmorphic features was noted with age. Extra-cardiac manifestations included velopharyngeal incompetence or cleft palate (44%), hypocalcemia (39%), neurodevelopmental anomalies (33%), thrombocytopenia (28%), psychiatric disorders (17%), epilepsy (17%) and hearing loss (17%). We conclude that under-diagnosis of 22q11.2DS in Chinese adults with conotruncal defects is common and facial dysmorphic features may not be reliably recognized in the setting of adult CHD clinic, referral for genetic evaluation and molecular testing for 22q11.2DS should be offered to patients with conotruncal defects.
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Affiliation(s)
- Anthony P Y Liu
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Pak-Cheong Chow
- Department of Paediatric Cardiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Pamela P W Lee
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Gary T K Mok
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Wing-Fai Tang
- Department of Obstetrics & Gynaecology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Elizabeth T Lau
- Department of Obstetrics & Gynaecology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Department of Obstetrics & Gynaecology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Stephen T S Lam
- Clinical Genetic Service, Department of Health, Hong Kong SAR, China
| | - Kelvin Y Chan
- Department of Obstetrics & Gynaecology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Department of Obstetrics & Gynaecology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Anita S Y Kan
- Department of Obstetrics & Gynaecology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Department of Obstetrics & Gynaecology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Adolphus K T Chau
- Department of Paediatric Cardiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Yiu-Fai Cheung
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Yu-Lung Lau
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Brian H Y Chung
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Department of Obstetrics & Gynaecology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.
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31
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Tang SX, Yi JJ, Calkins ME, Whinna DA, Kohler CG, Souders MC, McDonald-McGinn DM, Zackai EH, Emanuel BS, Gur RC, Gur RE. Psychiatric disorders in 22q11.2 deletion syndrome are prevalent but undertreated. Psychol Med 2014; 44:1267-1277. [PMID: 24016317 PMCID: PMC4461220 DOI: 10.1017/s0033291713001669] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Chromosome 22q11.2 deletion syndrome (22q11DS) is a common genetic disorder with high rates of psychosis and other psychopathologies, but few studies discuss treatment. Our aim was to characterize the prevalence and treatment of major psychiatric illnesses in a well-characterized sample of individuals with 22q11DS. METHOD This was a cross-sectional study of 112 individuals aged 8 to 45 years with a confirmed diagnosis of 22q11DS. Each participant was administered a modified Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) and the Structured Interview for Prodromal Syndromes (SIPS). Phenotypes assessed were threshold and subthreshold psychosis, depression, mania, generalized and separation anxiety, obsessions/compulsions, inattention/hyperactivity and substance use. Histories of mental health care and current psychotropic treatment were obtained. RESULTS Psychopathology was common, with 79% of individuals meeting diagnostic criteria for a disorder at the time of assessment. Diagnoses of psychosis were made in 11% of cases, attenuated positive symptom syndrome (APS) in 21%, and 47% experienced significant subthreshold symptoms. Peak occurrence of psychosis risk was during adolescence (62% of those aged 12-17 years). Criteria for a mood disorder were met by 14%, for anxiety disorder 34% and for attention deficit hyperactivity disorder (ADHD) 31%. Mental health care had been received by 63% of individuals in their lifetime, but only 40% continued therapy and 39% used psychotropics. Antipsychotics were used by 42% of participants with psychosis and none of the participants with APS. Half of those at risk for psychosis were receiving no mental health care. CONCLUSIONS Psychopathology is common in 22q11DS but is not adequately treated or clinically followed. Particular attention should be paid to subthreshold psychotic symptoms, especially in adolescents.
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Affiliation(s)
- S. X. Tang
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - J. J. Yi
- Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - M. E. Calkins
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - D. A. Whinna
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - C. G. Kohler
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - M. C. Souders
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - D. M. McDonald-McGinn
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - E. H. Zackai
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - B. S. Emanuel
- Division of Human Genetics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - R. C. Gur
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - R. E. Gur
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Pasick C, McDonald-McGinn DM, Simbolon C, Low D, Zackai E, Jackson O. Asymmetric crying facies in the 22q11.2 deletion syndrome: implications for future screening. Clin Pediatr (Phila) 2013; 52:1144-8. [PMID: 24137031 DOI: 10.1177/0009922813506606] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Asymmetric crying facies (ACF) is congenital hypoplasia of the depressor anguli oris muscle characterized by asymmetry of lower lip depression during crying. This has an overall incidence of 0.6%. This study determines the incidence of ACF in a large population of patients with 22q11.2 deletion. PATIENTS AND METHODS A retrospective review of medical records on patients with a confirmed 22q11.2 deletion was undertaken. RESULTS A total of 836 records were reviewed. Of these, 117 (14%) were noted to have ACF on physical examination. Within this latter group, palatal anomalies were common (77%), as was congenital heart disease (78%); however, these numbers did not differ significantly from their known prevalence in the 22q11.2 population. CONCLUSIONS We report a 14% incidence of ACF in patients with a 22q11.2 deletion, significantly higher than in the general population. We suggest, therefore, that newborns with ACF be referred for further screening for the 22q11.2 deletion syndrome.
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Ohi K, Hashimoto R, Yamamori H, Yasuda Y, Fujimoto M, Nakatani N, Kamino K, Takeda M. How to diagnose the 22q11.2 deletion syndrome in patients with schizophrenia: a case report. Ann Gen Psychiatry 2013; 12:29. [PMID: 24063534 PMCID: PMC3849181 DOI: 10.1186/1744-859x-12-29] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 09/18/2013] [Indexed: 12/02/2022] Open
Abstract
The 22q11.2 deletion syndrome is caused by a microdeletion of chromosome 22. One third of all patients with 22q11.2 deletion develop schizophrenia-like symptoms. In general, the prevalence of 22q11.2 deletion in patients with schizophrenia is 1%-2%. The 22q11.2 deletion is one of the major known genetic risk factors for schizophrenia. However, clinical differences in the phenotypes between patients with schizophrenia who are 22q11.2 deletion carriers and those who are not are still unknown. Therefore, it may be difficult to diagnose 22q11.2 deletion in patients with schizophrenia on the basis of clinical symptoms. To date, only two Japanese patients with the deletion have been identified through microdeletion studies of patients with schizophrenia in the Japanese population. Herein, we report the case study of a 48-year-old Japanese woman with 22q11.2 deletion who had a 30-year history of schizophrenia. Based on craniofacial anomalies, unpredictable agitation, hypocalcemia, and brain imaging finding, we suspected the 22q11.2 deletion in clinical populations and diagnosed the deletion using fluorescence in situ hybridization analysis. To find common phenotypes in Japanese patients with the deletion who have schizophrenia-like symptoms, we compared phenotypes among three Japanese cases. The common phenotypes were an absence of congenital cardiovascular anomalies and the presence of current findings of low intellectual ability, agitation, and hypocalcemia. We propose that hypocalcemia and agitation in patients with schizophrenia may derive from the 22q11.2 deletion, particularly when these phenotypes are coupled with schizophrenia-like symptoms.
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Affiliation(s)
- Kazutaka Ohi
- Department of Psychiatry, Graduate School of Medicine, Osaka University, Osaka, 565-0871, Japan.
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Wu D, Chen Y, Xu C, Wang K, Wang H, Zheng F, Ma D, Wang G. Characteristic face: a key indicator for direct diagnosis of 22q11.2 deletions in Chinese velocardiofacial syndrome patients. PLoS One 2013; 8:e54404. [PMID: 23342150 PMCID: PMC3547028 DOI: 10.1371/journal.pone.0054404] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Accepted: 12/11/2012] [Indexed: 11/22/2022] Open
Abstract
Velocardiofacial syndrome (VCFS) is a disease in human with an expansive phenotypic spectrum and diverse genetic mechanisms mainly associated with copy number variations (CNVs) on 22q11.2 or other chromosomes. However, the correlations between CNVs and phenotypes remain ambiguous. This study aims to analyze the types and sizes of CNVs in VCFS patients, to define whether correlations exist between CNVs and clinical manifestations in Chinese VCFS patients. In total, 55 clinically suspected Chinese VCFS patients and 100 normal controls were detected by multiplex ligation-dependent probe amplification (MLPA). The data from MLPA and all the detailed clinical features of the objects were documented and analyzed. A total of 44 patients (80.0%) were diagnosed with CNVs on 22q11.2. Among them, 43 (78.2%) presented with 22q11.2 heterozygous deletions, of whom 40 (93.0%) had typical 3-Mb deletion, and 3 (7.0%) exhibited proximal 1.5-Mb deletion; no patient was found with atypical deletion on 22q11.2. One patient (1.8%) presented with a 3-Mb duplication mapping to the typical 3-Mb region on 22q11.2, while none of the chromosomal abnormalities in the MLPA kit were found in the other 11 patients and 100 normal controls. All the 43 patients with 22q11.2 deletions displayed characteristic face and palatal anomalies; 37 of them (86.0%) had cognitive or behavioral disorders, and 23 (53.5%) suffered from immune deficiencies; 10 patients (23.3%) manifested congenital heart diseases. Interestingly, all patients with the characteristic face had 22q11.2 heterozygous deletions, but no difference in phenotypic spectrum was observed between 3-Mb and 1.5-Mb deletions. Our data suggest that the characteristic face can be used as a key indicator for direct diagnosis of 22q11.2 deletions in Chinese VCFS patients.
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Affiliation(s)
- Dandan Wu
- Department of Oral & Cranio-maxillofacial Science, Shanghai 9th People’s Hospital, College of Stomatology, School of Medicine, Shanghai Jiao Tong University, Shanghai Key Laboratory of Stomatology, Shanghai, P. R. China
| | - Yang Chen
- Department of Oral & Cranio-maxillofacial Science, Shanghai 9th People’s Hospital, College of Stomatology, School of Medicine, Shanghai Jiao Tong University, Shanghai Key Laboratory of Stomatology, Shanghai, P. R. China
| | - Chen Xu
- Department of Oral & Cranio-maxillofacial Science, Shanghai 9th People’s Hospital, College of Stomatology, School of Medicine, Shanghai Jiao Tong University, Shanghai Key Laboratory of Stomatology, Shanghai, P. R. China
| | - Ke Wang
- Department of Oral and Maxillofacial Surgery, The Affiliated Hospital, Medical School, Qingdao University, Qingdao, P. R. China
| | - Huijun Wang
- Children’s Hospital, Fudan University, Shanghai, P. R. China
| | - Fengyun Zheng
- Key Laboratory of Molecular Medicine, Ministry of Education, Department of Biochemistry and Molecular Biology, Institute of Medical Sciences, Shanghai Medical College, Fudan University, Shanghai, P. R. China
| | - Duan Ma
- Children’s Hospital, Fudan University, Shanghai, P. R. China
- Key Laboratory of Molecular Medicine, Ministry of Education, Department of Biochemistry and Molecular Biology, Institute of Medical Sciences, Shanghai Medical College, Fudan University, Shanghai, P. R. China
- * E-mail: (GW); (DM)
| | - Guomin Wang
- Department of Oral & Cranio-maxillofacial Science, Shanghai 9th People’s Hospital, College of Stomatology, School of Medicine, Shanghai Jiao Tong University, Shanghai Key Laboratory of Stomatology, Shanghai, P. R. China
- * E-mail: (GW); (DM)
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Chinthapalli K, Bartolini E, Novy J, Suttie M, Marini C, Falchi M, Fox Z, Clayton LMS, Sander JW, Guerrini R, Depondt C, Hennekam R, Hammond P, Sisodiya SM. Atypical face shape and genomic structural variants in epilepsy. ACTA ACUST UNITED AC 2012; 135:3101-14. [PMID: 22975390 PMCID: PMC3470710 DOI: 10.1093/brain/aws232] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Many pathogenic structural variants of the human genome are known to cause facial dysmorphism. During the past decade, pathogenic structural variants have also been found to be an important class of genetic risk factor for epilepsy. In other fields, face shape has been assessed objectively using 3D stereophotogrammetry and dense surface models. We hypothesized that computer-based analysis of 3D face images would detect subtle facial abnormality in people with epilepsy who carry pathogenic structural variants as determined by chromosome microarray. In 118 children and adults attending three European epilepsy clinics, we used an objective measure called Face Shape Difference to show that those with pathogenic structural variants have a significantly more atypical face shape than those without such variants. This is true when analysing the whole face, or the periorbital region or the perinasal region alone. We then tested the predictive accuracy of our measure in a second group of 63 patients. Using a minimum threshold to detect face shape abnormalities with pathogenic structural variants, we found high sensitivity (4/5, 80% for whole face; 3/5, 60% for periorbital and perinasal regions) and specificity (45/58, 78% for whole face and perinasal regions; 40/58, 69% for periorbital region). We show that the results do not seem to be affected by facial injury, facial expression, intellectual disability, drug history or demographic differences. Finally, we use bioinformatics tools to explore relationships between facial shape and gene expression within the developing forebrain. Stereophotogrammetry and dense surface models are powerful, objective, non-contact methods of detecting relevant face shape abnormalities. We demonstrate that they are useful in identifying atypical face shape in adults or children with structural variants, and they may give insights into the molecular genetics of facial development.
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Affiliation(s)
- Krishna Chinthapalli
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
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Clelland CL, Read LL, Baraldi AN, Bart CP, Pappas CA, Panek LJ, Nadrich RH, Clelland JD. Evidence for association of hyperprolinemia with schizophrenia and a measure of clinical outcome. Schizophr Res 2011; 131:139-45. [PMID: 21645996 PMCID: PMC3161723 DOI: 10.1016/j.schres.2011.05.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Revised: 05/05/2011] [Accepted: 05/09/2011] [Indexed: 10/18/2022]
Abstract
There are multiple genetic links between schizophrenia and a deficit of proline dehydrogenase (PRODH) enzyme activity. However, reports testing for an association of schizophrenia with the resulting proline elevation have been conflicting. The objectives of this study were to investigate whether hyperprolinemia is associated with schizophrenia, and to measure the relationship between plasma proline, and clinical features and symptoms of schizophrenia. We performed a cross-sectional case-control study, comparing fasting plasma proline in 90 control subjects and 64 schizophrenic patients and testing for association of mild to moderate hyperprolinemia with schizophrenia. As secondary analyses, the relationship between hyperprolinemia and five measures of clinical onset, symptoms and outcome were investigated. Patients had significantly higher plasma proline than matched controls (p<0.0001), and categorical analysis of gender adjusted hyperprolinemia showed a significant association with schizophrenia (OR 6.15, p=0.0003). Hyperprolinemic patients were significantly older at their first hospitalization (p=0.015 following correction for multiple testing). While plasma proline level was not related to total, positive or negative symptoms, hyperprolinemic status had a significant effect on length of hospital stay (p=0.005), following adjustment for race, BPRS score, and cross-sectional time from admission to proline measurement. Mild to moderate hyperprolinemia is a significant risk factor for schizophrenia, and may represent an intermediate phenotype in the disease. Hyperprolinemic patients have a significantly later age of first psychiatric hospitalization, suggestive of later onset, and hospital stays 46% longer than non-hyperprolinemic subjects. These findings have implications in the etiology of schizophrenia, and for the clinical management of these patients.
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Affiliation(s)
- Catherine L. Clelland
- Department of Pathology and Cell Biology, and Taub Institute for Research on Alzheimer’s Disease and the Aging Brain. Columbia University Medical Center. 630 West 168th Street. New York.
| | - Laura L. Read
- Department of Psychiatry, New York University Langone Medical Center, 550 First Avenue. New York, NY.
,Movement Disorders and Molecular Psychiatry. The Nathan Kline Institute for Psychiatric Research. 140 Old Orangeburg Road. Orangeburg. NY.
| | - Amanda N. Baraldi
- Movement Disorders and Molecular Psychiatry. The Nathan Kline Institute for Psychiatric Research. 140 Old Orangeburg Road. Orangeburg. NY.
| | - Corinne P. Bart
- Movement Disorders and Molecular Psychiatry. The Nathan Kline Institute for Psychiatric Research. 140 Old Orangeburg Road. Orangeburg. NY.
| | - Carrie A. Pappas
- Movement Disorders and Molecular Psychiatry. The Nathan Kline Institute for Psychiatric Research. 140 Old Orangeburg Road. Orangeburg. NY.
| | - Laura J. Panek
- Movement Disorders and Molecular Psychiatry. The Nathan Kline Institute for Psychiatric Research. 140 Old Orangeburg Road. Orangeburg. NY.
| | - Robert H. Nadrich
- Department of Psychiatry, New York University Langone Medical Center, 550 First Avenue. New York, NY.
,Bellevue Hospital Center, 462 First Avenue, New York, NY.
| | - James D. Clelland
- Department of Psychiatry, New York University Langone Medical Center, 550 First Avenue. New York, NY.
,Movement Disorders and Molecular Psychiatry. The Nathan Kline Institute for Psychiatric Research. 140 Old Orangeburg Road. Orangeburg. NY.
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Veerapandiyan A, Abdul-Rahman OA, Adam MP, Lyons MJ, Manning M, Coleman K, Kobrynski L, Taneja D, Schoch K, Zimmerman HH, Shashi V. Chromosome 22q11.2 deletion syndrome in African-American patients: a diagnostic challenge. Am J Med Genet A 2011; 155A:2186-95. [PMID: 21834039 DOI: 10.1002/ajmg.a.34226] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 06/09/2011] [Indexed: 11/08/2022]
Abstract
Chromosome 22q11.2 deletion syndrome (22q11DS) is associated with numerous and variable clinical manifestations including conotruncal heart abnormalities, palatal anomalies, hypoparathyroidism, immune deficiency, and cognitive deficits. The clinical suspicion of this syndrome is often heightened by the presence of characteristic facial features. A previous report highlighted the under-diagnosis of this condition in African Americans, thought to be related to a paucity of typical facial features. We ascertained the largest cohort (n = 50) of African-American individuals with 22q11DS reported thus far, across five genetics centers in the United States and report on their facial and other phenotypic features. About 3/4 of our cohort has at least one dysmorphic facial feature. Auricular abnormalities, especially small ears, are the most common dysmorphic facial feature followed by nasal and ocular abnormalities. Skeletal findings are seen in about 2/3 of our cohort, higher than the typical frequency reported in 22q11DS. Cardiac anomalies, developmental delay, and palatal abnormalities are seen at a lower frequency in our cohort. Thus, it is evident that the features traditionally associated with 22q11DS are difficult to recognize in African-American individuals with this syndrome, due to both altered frequencies of major anomalies and a non-classic facial appearance. Therefore, a high index of suspicion is needed to recognize 22q11DS in African-American individuals.
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Affiliation(s)
- Aravindhan Veerapandiyan
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina 27710, USA
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Abstract
The highly variable 22q11 deletion syndrome has been proposed for addition to newborn screening panels. A literature review investigated the incidence and prevalence, clinical features, and prognosis of 22q11 deletion syndrome and other issues related to newborn screening. Severe complications that could potentially be helped by screening include cardiac defects in 80% (with 20% having no outward signs to aid detection), hypocalcemia that can lead to seizures in 20% (though hypocalcemia is routinely investigated in sick newborns), and severe immune deficiency in <1% (which would be identified by some states' severe combined immunodeficiency screens). Other benefits that do not fit traditional goals of newborn screening include treatment for complications such as failure to thrive and developmental delay or preventing a "diagnostic odyssey." Although universal screening may prove the incidence to be >1:5000, undetected life-threatening effects occur in a minority of 22q11 deletion syndrome patients. Concerns include an untested screening technique, difficulty obtaining results in time for cardiac intervention, the chance of "vulnerable child syndrome" in mild cases, and possibly detecting congenital heart disease more efficiently by other means. Because addition of tests for highly variable conditions such as 22q11 deletion syndrome is likely to set a precedent for other syndromes, reevaluation of newborn screening criteria should be considered.
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Repetto GM, Guzmán ML, Puga A, Calderón JF, Astete CP, Aracena M, Arriaza M, Aravena T, Sanz P. Clinical features of chromosome 22q11.2 microdeletion syndrome in 208 Chilean patients. Clin Genet 2009; 76:465-70. [DOI: 10.1111/j.1399-0004.2009.01234.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rosa RFM, Zen PRG, Roman T, Graziadio C, Paskulin GA. Síndrome de deleção 22q11.2: compreendendo o CATCH22. REVISTA PAULISTA DE PEDIATRIA 2009. [DOI: 10.1590/s0103-05822009000200015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJETIVO:Realizar uma revisão dos aspectos históricos, epidemiológicos, clínicos, etiológicos e laboratoriais da síndrome de deleção 22q11.2, salientando-se a importância e as dificuldades do seu diagnóstico. FONTES DE DADOS: Pesquisa nas bases de dados Medline, Lilacs e SciELO, além da Internet e capítulos de livros em inglês, acerca de publicações feitas entre 1980 e 2008. Para isso, utilizaram-se os descritores "22q11", "DiGeorge", "Velocardiofacial" e "CATCH22". SÍNTESE DOS DADOS: A síndrome de deleção 22q11.2, também conhecida como síndrome de DiGeorge ou velocardiofacial, foi identificada no começo da década de 1990. A microdeleção 22q11.2 é considerada uma das síndromes de microdeleção genética mais frequentes em seres humanos. Caracteriza-se por um espectro fenotípico bastante amplo, com mais de 180 achados clínicos já descritos do ponto de vista físico e comportamental. Contudo, nenhum achado é patognomônico ou mesmo obrigatório. A maioria dos pacientes apresenta uma deleção pequena, detectada somente por técnicas de genética molecular, como a hibridização in situ fluorescente. Apresenta padrão de herança autossômico dominante, ou seja, indivíduos acometidos apresentam um risco de 50% de transmiti-la a seus filhos. CONCLUSÕES: Pacientes com a síndrome de deleção 22q11.2 frequentemente necessitam, ao longo de suas vidas, de um grande número de intervenções médicas e hospitalizações. O diagnóstico precoce é fundamental para a adequada avaliação e manejo clínico dos indivíduos e seus familiares.
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Butts SC. The facial phenotype of the velo-cardio-facial syndrome. Int J Pediatr Otorhinolaryngol 2009; 73:343-50. [PMID: 19062108 DOI: 10.1016/j.ijporl.2008.10.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Revised: 10/03/2008] [Accepted: 10/07/2008] [Indexed: 11/19/2022]
Abstract
Velo-cardio-facial syndrome (VCFS) is a genetic disorder that is common but often variable in its expression. Several key organ systems are most often affected, including the craniofacial skeleton and soft tissues. Identification of the associated facial features will aid in the improved detection of patients. This review aims to highlight the approaches to facial analysis that are essential to the detection of the facial dysmorphisms in velo-cardio-facial syndrome, many of which may be subtle.
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Affiliation(s)
- Sydney C Butts
- Department of Otolaryngology and Communication Sciences, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA.
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McDonald-McGinn DM, Zackai EH. Genetic counseling for the 22q11.2 deletion. ACTA ACUST UNITED AC 2008; 14:69-74. [PMID: 18636638 DOI: 10.1002/ddrr.10] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Because of advances in palliative medical care, children with the 22q11.2 deletion syndrome are surviving into adulthood. An increase in reproductive fitness will likely follow necessitating enhanced access to genetic counseling for these patients and their families. Primary care physicians/obstetric practitioners are in a unique position to identify previously undiagnosed patients as they reach reproductive age and to refer them for genetic counseling. To date, most deletions are de novo, secondary to homologous recombination between low-copy repeat sequences located within 22q11.2. Nonetheless, both somatic and germ line mosaicism has been observed giving unaffected parents a small risk of recurrence. Once present though there is a 50% chance for a person with this contiguous deletion to have an affected child. With this in mind, a variety of prenatal monitoring techniques, as well as, preimplantation genetic diagnosis are available depending on the specific level of risk.
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Affiliation(s)
- Donna M McDonald-McGinn
- Division of Human Genetics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Abstract
PURPOSE 22q11 deletion syndrome (22q11DS) is a very common, but commonly overlooked, disorder that has many variable features, such as serious heart defects, speech and articulation problems, immune compromise, learning problems, pervasive developmental disorders, and a late appearing phenotype of this condition--mental illness. CONCLUSION Persons with 22q11DS are likely to be medically complex patients with pervasive developmental disorders and late appearing mental problems. PRACTICE IMPLICATIONS Establishing this diagnosis is useful to families and healthcare providers to anticipate and address immediate and future issues surrounding health promotion, disease prevention, and health maintenance.
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Affiliation(s)
- Mary Grace Umlauf
- Capstone College of Nursing, University of Alabama, Tuscaloosa, AL, USA.
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Binenbaum G, McDonald-McGinn DM, Zackai EH, Walker BM, Coleman K, Mach AM, Adam M, Manning M, Alcorn DM, Zabel C, Anderson DR, Forbes BJ. Sclerocornea associated with the chromosome 22q11.2 deletion syndrome. Am J Med Genet A 2008; 146A:904-9. [PMID: 18324686 PMCID: PMC2831198 DOI: 10.1002/ajmg.a.32156] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Reported ocular findings in the 22q11.2 deletion syndrome (which encompasses the phenotypes of DiGeorge, velocardiofacial, and Takao (conotruncal-anomaly-face) syndromes) have included posterior embryotoxon (prominent, anteriorly displaced Schwalbe's line at the corneal limbus or edge), retinal vascular tortuosity, eyelid hooding, strabismus, and astigmatism. We present seven 22q11.2 patients from multiple centers with sclerocornea, an eye finding previously unreported in the literature. Four boys and three girls were identified with sclerocornea, systemic DGS/VCFS findings, and fluorescence in situ hybridization (FISH)-confirmed microdeletion at chromosome 22q11.2. FISH diagnosis was perinatal in six patients but at 2 years of age in one child. Sclerocornea was bilateral in five patients. Findings included descemetocele (five eyes), microophthalmos (one eye), iridocorneal adhesions (one bilateral case), and severe anterior segment dysgenesis (one eye). Two patients underwent bilateral corneal transplantation; another two were scheduled for possible unilateral transplant. Sclerocornea is a static congenital condition in which the cornea is opaque and vascularized and resembles the sclera. The novel finding of sclerocornea suggests that a genetic locus at 22q11.2 may be involved in anterior segment embryogenesis. In most of our patients, the diagnostic process was underway, but in one patient 22q11.2 deletion was not suspected until after the child had already been undergoing treatment for sclerocornea for 2 years. Sclerocornea should be added to the clinical manifestations of the 22q11.2 deletion syndrome. Ophthalmologists diagnosing sclerocornea in children with systemic findings suggestive of 22q11.2 deletion should ensure appropriate genetic referral.
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Affiliation(s)
- Gil Binenbaum
- Department of Pediatric Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Scheie Eye Institute, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donna M. McDonald-McGinn
- Department of Pediatric Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elaine H. Zackai
- Department of Pediatric Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - B. Michael Walker
- Wilmer Ophthalmological Institute, Johns Hopkins University, Baltimore, Maryland
| | - Karlene Coleman
- Children’s Healthcare of Atlanta at Egleston, Atlanta, Georgia
| | | | | | - Melanie Manning
- Lucile Salter Packard Children’s Hospital, Palo Alto, California
| | | | - Carrie Zabel
- Marshfield Clinic, Saint Joseph’s Hospital, Marshfield, Wisconsin
| | | | - Brian J. Forbes
- Department of Pediatric Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Scheie Eye Institute, University of Pennsylvania, Philadelphia, Pennsylvania
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Ocular findings in the chromosome 22q11.2 deletion syndrome. J AAPOS 2007; 11:179-82. [PMID: 17140829 DOI: 10.1016/j.jaapos.2006.08.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2004] [Revised: 08/01/2006] [Accepted: 04/24/2006] [Indexed: 11/27/2022]
Abstract
PURPOSE To identify the ocular features of the chromosome 22q11.2 deletion syndrome and to provide ophthalmologic examination recommendations for affected patients. METHODS Ocular abnormalities were evaluated prospectively in patients with 22q11.2 deletion at the Children's Hospital of Philadelphia between 1997 and 1999. RESULTS Ninety patients with confirmed 22q11.2 deletion were examined. Posterior embryotoxon was found in 49%, tortuous retinal vessels in 34%, eyelid hooding in 20%, strabismus in 18%, ptosis in 4%, amblyopia in 4%, and tilted optic nerves in 1%. CONCLUSIONS The high incidence of ocular conditions that can potentially affect visual development suggest that children with 22q11.2 deletion should undergo a comprehensive eye examination upon diagnosis of the condition with follow-up as indicated by the findings in each case. In addition, knowledge of the ocular findings, in conjunction with certain cardiac, otolaryngologic, immunologic, and other systemic findings, may alert physicians to the possibility of a chromosome 22q11.2 deletion.
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Schaan BD, Huber J, Leite JCL, Kiss A. Cardiac surgery unmasks latent hypoparathyroidism in a child with the 22q11.2 deletion syndrome. J Pediatr Endocrinol Metab 2006; 19:943-6. [PMID: 16995575 DOI: 10.1515/jpem.2006.19.7.943] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The 22q11.2 deletion syndrome is a developmental field defect of the third and fourth pharyngeal pouches characterized by a spectrum of thymic and parathyroid gland abnormalities and conotruncal cardiac defects. Latent hypoparathyroidism, defined as normocalcaemia at rest but reduced ability to secrete parathyroid hormone (PTH) in response to pharmacologically evoked hypocalcaemia, is found in 30-50% of people with this syndrome. Its natural history is unknown. We describe a 1.5 year-old girl with tetralogy of Fallot, normal calcium metabolism and few facial dysmorphic features who developed transient hypoparathyroidism in the postoperative period, which lasted months and waxed and waned during this observation period. The clinical picture led us to the diagnosis of 22q11.2 deletion syndrome.
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Affiliation(s)
- Beatriz D'Agord Schaan
- Institute of Cardiology of Rio Grande do Sul/University Foundation of Cardiology, Brazil.
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Butts SC, Tatum SA, Mortelliti AJ, Shprintzen RJ. Velo-cardio-facial syndrome: the pediatric otolaryngologist's perspective. Curr Opin Otolaryngol Head Neck Surg 2006; 13:371-5. [PMID: 16282767 DOI: 10.1097/01.moo.0000186203.53214.ac] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The understanding of velo-cardio-facial syndrome has grown markedly since the initial descriptions of this common genetic disorder nearly 30 years ago. Our knowledge of the syndrome has advanced in part from opportunities to monitor many patients into adulthood because of advances in the fields of cardiothoracic surgery and immunology. Longitudinal study has brought to light psychiatric and behavioral features of the syndrome that are often not apparent until late adolescence or the early adult years. Certain endocrine and immunologic features of the syndrome thought to be resolved in childhood are now witnessed in older patients. Variable expression and lack of disease awareness are two major factors that contribute to the delays in diagnosis in many cases. To address this, there has been a call to delineate screening parameters for patients at risk of carrying the deletion. RECENT FINDINGS Several areas are highlighted in this review, reflecting the focus of scholarly work on velo-cardio-facial syndrome in the past year. Molecular genetics has shown smaller deletions in many families with the syndrome. The gene TBX1 has been found to be important to the phenotype. Surgical outcomes data reveal the greater challenges involved in correcting velopharyngeal insufficiency. SUMMARY Defining the genetic basis of velo-cardio-facial syndrome will allow clinicians and basic scientists to make further inroads into understanding the variable expressivity of this syndrome. It is also important to be aware of the continued diagnostic challenges encountered by clinicians in attempts to improve the detection of patients with this syndrome.
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Affiliation(s)
- Sydney C Butts
- Department of Otolaryngology and Communication Sciences, Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA.
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