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Bouman A, Geelen JM, Kummeling J, Schenck A, van der Zwan YG, Klein WM, Kleefstra T. Growth, body composition, and endocrine-metabolic profiles of individuals with Kleefstra syndrome provide directions for clinical management and translational studies. Am J Med Genet A 2024; 194:e63472. [PMID: 38155610 DOI: 10.1002/ajmg.a.63472] [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: 08/09/2023] [Revised: 10/17/2023] [Accepted: 10/27/2023] [Indexed: 12/30/2023]
Abstract
Mendelian neurodevelopmental disorders caused by variants in genes encoding chromatin modification can be categorized as Mendelian disorders of the epigenetic machinery (MDEMs). These disorders have significant overlap in molecular pathways and phenotypes including intellectual disability, short stature, and obesity. Among the MDEMs is Kleefstra syndrome (KLFS), which is caused by haploinsufficiency of EHMT1. Preclinical studies have identified metabolic dysregulation and obesity in KLFS models, but proper clinical translation lacks. In this study, we aim to delineate growth, body composition, and endocrine-metabolic characteristics in a total of 62 individuals with KLFS. Our results revealed a high prevalence of childhood-onset overweight/obesity (60%; 28/47) with disproportionately high body fat percentage, which aligns perfectly with previous preclinical studies. Short stature was common (33%), likely due to advanced skeletal maturation. Endocrine-metabolic investigations showed thyroid dysregulation (22%; 9/41), elevated triglycerides, and decreased blood ammonia levels. Moreover, hand radiographs identified decreased bone mineralization (57%; 8/14) and negative ulnar variance (71%; 10/14). Our findings indicate a high (cardio)metabolic risk in KLFS. Therefore, we recommend monitoring of weight and endocrine-metabolic profile. Supporting a healthy lifestyle and screening of bone mineralization is advised. Our comprehensive results support translational research and contribute to a better understanding of MDEM-associated phenotypes.
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Affiliation(s)
- Arianne Bouman
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joyce M Geelen
- Department of Pediatrics, Developmental and Genetic Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joost Kummeling
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Annette Schenck
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Yvonne G van der Zwan
- Department of Pediatrics, Pediatric Endocrinology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Willemijn M Klein
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tjitske Kleefstra
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
- Center of Excellence for Neuropsychiatry, Vincent van Gogh Institute for Psychiatry, Venray, The Netherlands
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2
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Niu M, Li Y, Zhan S, Sun B, Liu J, Wu Y. Tourette-like syndrome secondary to Kleefstra syndrome 1 with a de novo microdeletion in the EHMT1 gene. BMC Neurol 2023; 23:365. [PMID: 37817104 PMCID: PMC10563308 DOI: 10.1186/s12883-023-03417-x] [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: 05/14/2023] [Accepted: 10/01/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Gills de la Tourette syndrome (TS) is a childhood-onset neurodevelopmental disorder manifested by motor and vocal tics. Kleefstra syndrome 1 (KS1), a rare genetic disorder, is caused by haploinsufficiency of the EHMT1 gene and is characterized by intellectual disability (ID), childhood hypotonia, and distinctive facial features. Tourette-like syndrome in KS1 has rarely been reported. CASE PRESENTATION Here we describe a 7-year-old girl presenting involuntary motor and vocal tics, intellectual disability, childhood hypotonia, and dysmorphic craniofacial appearances, as well as comorbidities including attention deficit-hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), and self-injurious behavior (SIB). The patient's CNV-seq testing revealed a de novo 320-kb deletion in the 9q34.3 region encompassing the EHMT1 gene. CONCLUSIONS This is the first case reporting Tourette-like syndrome secondary to KS1 with a de novo microdeletion in the EHMT1 gene. Our case suggests TS with ID and facial anomalies indicate a genetic cause and broadens the phenotypic and genotypic spectrum of both TS and KS1.
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Affiliation(s)
- Mengyue Niu
- Department of Neurology, Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanjing Li
- Department of Neurology, Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shikun Zhan
- Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bomin Sun
- Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Liu
- Department of Neurology, Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiwen Wu
- Department of Neurology, Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Ng R, Kalinousky A, Fahrner JA, Bjornsson HT, Harris J. The social phenotype associated with Wiedemann-Steiner syndrome: Autistic traits juxtaposed with high social drive and prosociality. Am J Med Genet A 2023; 191:2591-2601. [PMID: 37470210 DOI: 10.1002/ajmg.a.63351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 06/13/2023] [Accepted: 06/28/2023] [Indexed: 07/21/2023]
Abstract
The aim of this study was to provide a descriptive overview of the social characteristics associated with Wiedemann-Steiner syndrome (WSS). A total of 24 parents of children/adults with WSS (11F, mean age = 12.94 years, SD = 8.00) completed the Social Responsiveness Scale 2nd Edition (SRS-2); Colorado Learning Difficulties Questionnaire (CLDQ) and Strengths and Difficulties Questionnaire (SDQ). Almost half our sample reported a diagnosis of autism spectrum disorder (ASD) and 70% had intellectual disability. On the SDQ, over 90% of participants were rated in borderline/clinical ranges in Peer Problems, yet the majority fell within normal limits in Prosocial Behaviors. Most fell in the moderate/severe difficulties ranges across SRS-2 Social Cognition, Communication, and Restricted/Repetitive Behaviors scales (all >70%); whereas substantially less participants met these ranges for deficits in Social Awareness (50%) and Social Motivation (33.33%). A pattern of relatively strong prosocial skills and social drive in the context of difficulties with inflexible behaviors, social cognition, and communication was observed, regardless of gender, ASD or intellectual disability diagnosis. The social phenotype associated with WSS is characterized by some autistic features paired with unusually high social motivation and prosocial tendencies.
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Affiliation(s)
- Rowena Ng
- Kennedy Krieger Institute, Baltimore, Maryland, USA
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Allison Kalinousky
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jill A Fahrner
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hans Tomas Bjornsson
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Landspitali University Hospital, Reykjavik, Iceland
| | - Jacqueline Harris
- Kennedy Krieger Institute, Baltimore, Maryland, USA
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Bloemendaal M, Vlaming P, de Boer A, Vermeulen-Kalk K, Bouman A, Kleefstra T, Arias Vasquez A. The role of the gut microbiota in patients with Kleefstra syndrome. Am J Med Genet B Neuropsychiatr Genet 2023; 192:124-138. [PMID: 36630271 DOI: 10.1002/ajmg.b.32926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 01/12/2023]
Abstract
Kleefstra Syndrome (KS) is a rare monogenetic syndrome, caused by haploinsufficiency of the euchromatic histone methyl transferase 1 (EHMT1) gene, an important regulator of neurodevelopment. The clinical features of KS include intellectual disability, autistic behavior and gastrointestinal problems. The gut microbiota, an important modifier of the gut-brain-axis, may constitute an unexplored mechanism underlying clinical KS variation. We investigated the gut microbiota composition of 23 individuals with KS (patients) and 40 of their family members, to test whether (1) variation in the gut microbiota associates with KS diagnosis and (2) variation within the gut microbiota relates with KS syndrome symptoms. Both alpha and beta diversity of patients were different from their family members. Genus Coprococcus 3 was lower in abundance in patients compared to family members. Moreover, abundance of genus Merdibacter was lower in patients versus family members, but only in participants reporting intestinal complaints. Within the patient group, behavioral problems explained 7% of beta diversity variance. Also, within this group, we detected higher levels of Atopobiaceae - uncultured and Ruminococcaceae Subdoligranulum associated with higher symptom severity. These significant signatures in the gut microbiota composition in patients with KS suggest that microbiota differences are part of the KS phenotype.
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Affiliation(s)
- Mirjam Bloemendaal
- Department of Human Genetics, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
- Department of Psychiatry, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Priscilla Vlaming
- Department of Human Genetics, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Anneke de Boer
- Karakter Child and Adolescent Psychiatry University Centre, Nijmegen, The Netherlands
| | - Karlijn Vermeulen-Kalk
- Department of Human Genetics, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
- Karakter Child and Adolescent Psychiatry University Centre, Nijmegen, The Netherlands
| | - Arianne Bouman
- Department of Human Genetics, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Tjitske Kleefstra
- Department of Human Genetics, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
- Department of Psychiatry, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
- Centre of Excellence for Neuropsychiatry, Vincent van Gogh Institute for Psychiatry, Venray, The Netherlands
| | - Alejandro Arias Vasquez
- Department of Human Genetics, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
- Department of Psychiatry, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
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Alonso A, Samanta A, van der Meij J, van den Brand L, Negwer M, Navarro Lobato I, Genzel L. Defensive and offensive behaviours in a Kleefstra syndrome mouse model. Anim Cogn 2023; 26:1131-1140. [PMID: 36877418 PMCID: PMC10345049 DOI: 10.1007/s10071-023-01757-2] [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: 08/16/2022] [Revised: 01/16/2023] [Accepted: 02/07/2023] [Indexed: 03/07/2023]
Abstract
Kleefstra syndrome in humans is characterized by a general delay in development, intellectual disability and autistic features. The mouse model of this disease (Ehmt1±) expresses anxiety, autistic-like traits, and aberrant social interactions with non-cagemates. To investigate how Ehmt1± mice behave with unfamiliar conspecifics, we allowed adult, male animals to freely interact for 10 min in a neutral, novel environment within a host-visitor setting. In trials where the Ehmt1± mice were hosts, there were defensive and offensive behaviors. Our key finding was that Ehmt1± mice displayed defensive postures, attacking and biting; in contrast, wild-type (WT) interacting with other WT did not enact such behaviors. Further, if there was a fight between an Ehmt1± and a WT mouse, the Ehmt1± animal was the most aggressive and always initiated these behaviors.
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Affiliation(s)
- Alejandra Alonso
- Department of Neuroinformatics, Faculty of Science, Donders Institute for Brain, Cognition and Behaviour, Radboud University, P.O. Box 9010, 6500 GL, Nijmegen, The Netherlands.
| | - Anumita Samanta
- Department of Neuroinformatics, Faculty of Science, Donders Institute for Brain, Cognition and Behaviour, Radboud University, P.O. Box 9010, 6500 GL, Nijmegen, The Netherlands
| | - Jacqueline van der Meij
- Department of Neuroinformatics, Faculty of Science, Donders Institute for Brain, Cognition and Behaviour, Radboud University, P.O. Box 9010, 6500 GL, Nijmegen, The Netherlands
| | - Liz van den Brand
- Department of Neuroinformatics, Faculty of Science, Donders Institute for Brain, Cognition and Behaviour, Radboud University, P.O. Box 9010, 6500 GL, Nijmegen, The Netherlands
| | - Moritz Negwer
- Donders Institute for Brain, Cognition and Behaviour, RadboudUMC, Nijmegen, The Netherlands
| | - Irene Navarro Lobato
- Department of Neuroinformatics, Faculty of Science, Donders Institute for Brain, Cognition and Behaviour, Radboud University, P.O. Box 9010, 6500 GL, Nijmegen, The Netherlands
| | - Lisa Genzel
- Department of Neuroinformatics, Faculty of Science, Donders Institute for Brain, Cognition and Behaviour, Radboud University, P.O. Box 9010, 6500 GL, Nijmegen, The Netherlands.
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6
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Psychosis and autism without functional regression in a patient with Kleefstra syndrome. Psychiatr Genet 2023; 33:34-36. [PMID: 36617745 DOI: 10.1097/ypg.0000000000000330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Kleefstra syndrome is a rare genetic disorder caused by haploinsufficiency of the euchromatic histone lysine methyltransferase 1 (EHMT1) gene. It is characterized by a variety of dysmorphic features, comorbid medical issues, and developmental delays/intellectual disability. Neuropsychiatric symptoms may also occur, including autistic features and psychosis, and are often accompanied by functional regression. However, the phenomenology of psychotic symptoms in this syndrome has not been well described in the literature. As such, in this brief report, we review the literature with respect to the occurrence of psychosis in Kleefstra syndrome and describe the symptom profile of a 35-year-old affected male with an intellectual disability, autism spectrum disorder, and schizophrenia (in association with manic features). This is the first report of psychotic symptoms fully remitting in response to zuclopenthixol therapy in an individual with Kleefstra syndrome. This case is also unique as it demonstrates that functional regression does not necessarily coincide with the development of schizophrenia-like presentations in affected individuals.
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Adaptive Behavior in Slovak Children with Intellectual Disability in Institutional Care. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121911. [PMID: 36553354 PMCID: PMC9777255 DOI: 10.3390/children9121911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/25/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
This study aimed to analyze the adaptive skills of children with intellectual disabilities in institutional care. We focused on communication, socialization, daily living skills and their relationship with risk factors, and institutional care. Our sample included 197 children aged 5−18 years (M = 12.8, SD = 2.97), 50% boys, with IQ < 85 placed in different types and lengths of stay in institutional care. There were 17% that presented with borderline intellectual functioning (IQ 84−87) and 83% that had intellect disabilities. Adaptive behavior (AB) was assessed by Vineland Adaptive Behavior Scale (VABS-3). The BIF and Mild ID groups did not differ in Socialization. The profile of adaptive behavior for BIF and Mild ID was Daily Living Skills > Communication > Socialization, and for Moderate and Severe ID, Socialization > Daily Living Skills > Communication. Longer institutional care was associated with lower competencies in AB. Gender differences were found, females overperformed males in Socialization, Daily Living Skills, and ABC score. Levels of ID, gender, length of stay in institutional care, and neonatal difficulties were significant predictors in the model which explain the 63% variance of AB. The practical implications of the results are discussed related to the assessment of ID, prevention, and care for institutionalized children.
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8
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Akhtar TN, McGibbon E. Blindspot in the evidence base: A systematic review of psychological interventions for children and adolescents with intellectual disabilities and co-occurring obesity. RESEARCH IN DEVELOPMENTAL DISABILITIES 2022; 126:104240. [PMID: 35500443 DOI: 10.1016/j.ridd.2022.104240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 02/25/2022] [Accepted: 04/18/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Children and adolescents with intellectual disabilities (C&A-ID) face many disadvantages in healthcare research and service delivery. Intellectual disabilities have been found to precipitate weight-related problems, and together, they may be indicators of rare genetic diseases (RGDs). C&A-ID may require support for health problems exacerbated by primary diagnoses. While it is generally agreed that C&A-ID have more complex needs than typically developing individuals, psychological services to address these needs are under-explored. AIMS This systematic review aimed to identify psychological interventions for weight management in C&A-ID. METHOD MEDLINE, PsycINFO, CINAHL, The Cochrane Library and SCOPUS were systematically searched. Data extraction and quality appraisal were performed for all eligible studies RESULTS: The search strategy yielded seven studies published in English between 2010 and 2022. All interventions addressed obesity through multi-disciplinary programmes and resulted in weight reductions, with most interventions theoretically influenced by principles of behaviourism. Quality appraisal revealed methodological weaknesses in six of seven studies, such as heterogeneity in samples, interventions, and outcome measures, disallowing meta-analyses and weakening the generalisability of interventions to diverse contexts and groups CONCLUSIONS AND IMPLICATIONS: A genuine disconnect between empirical evidence and services for C&A with complex needs was observed. This emphasises an urgency for increased inclusion in clinical and behavioural research and for robust enquiries to test/adapt psychological interventions for weight management for C&A-ID. The findings of this review hold clinical utility for clinicians working with C&A-ID, and with RGDs such as Bardet-Biedl, Prader-Willi and Down syndromes. Recommendations and a conceptual framework are provided herein for enhanced efficacy of interventions.
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Affiliation(s)
- Tooba Nadeem Akhtar
- The Great Ormond Street Institute of Child Health, University College London, United Kingdom.
| | - Emma McGibbon
- Wolfson Neurodisability Service, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom.
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9
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Ojaimi MA, Banimortada BJ, Othman A, Riedhammer KM, Almannai M, El-Hattab AW. Disorders of histone methylation: molecular basis and clinical syndromes. Clin Genet 2022; 102:169-181. [PMID: 35713103 DOI: 10.1111/cge.14181] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/12/2022] [Accepted: 06/14/2022] [Indexed: 12/01/2022]
Abstract
Epigenetic modifications of DNA and histone tails are essential for gene expression regulation. They play an essential role in neurodevelopment as nervous system development is a complex process requiring a dynamic pattern of gene expression. Histone methylation is one of the vital epigenetic regulators and mostly occurs on lysine residues of histones H3 and H4. Histone methylation is catalyzed by two sets of enzymes: histone lysine methyltransferases (KMTs) and histone lysine demethylases (KDMs). KMT2 enzymes form a distinct multi-subunit complex known as COMPASS to enhance their catalytic activity and diversify their biologic functions. Several neurodevelopmental syndromes result from defects of histone methylation which can be caused by deficiencies in histone methyltransferases and demethylases, loss of the histone methyltransferase activator TASP1, or derangements in COMPASS formation. In this review article, the molecular mechanism of histone methylation is discussed followed by summarizing clinical syndromes caused by monogenic defects in histone methylation.
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Affiliation(s)
- Mode Al Ojaimi
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | | | - Amna Othman
- Genetics and Genomic Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Korbinian M Riedhammer
- Institute of Human Genetics, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany.,Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Mohammed Almannai
- Genetics and Precision Medicine Department, King Abdullah Specialized Children's Hospital, Riyadh, Saudi Arabia
| | - Ayman W El-Hattab
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates.,Pediatrics Department, University Hospital Sharjah, Sharjah, United Arab Emirates.,Genetics and Metabolic Department, KidsHeart Medical Center, Abu Dhabi, United Arab Emirates
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10
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Cunningham AC, Hall J, Einfeld S, Owen MJ, van den Bree MBM. Assessment of emotions and behaviour by the Developmental Behaviour Checklist in young people with neurodevelopmental CNVs. Psychol Med 2022; 52:574-586. [PMID: 32643597 PMCID: PMC7794095 DOI: 10.1017/s0033291720002330] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/19/2020] [Accepted: 06/08/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND A number of genomic conditions caused by copy number variants (CNVs) are associated with a high risk of neurodevelopmental and psychiatric disorders (ND-CNVs). Although these patients also tend to have cognitive impairments, few studies have investigated the range of emotion and behaviour problems in young people with ND-CNVs using measures that are suitable for those with learning difficulties. METHODS A total of 322 young people with 13 ND-CNVs across eight loci (mean age: 9.79 years, range: 6.02-17.91, 66.5% male) took part in the study. Primary carers completed the Developmental Behaviour Checklist (DBC). RESULTS Of the total, 69% of individuals with an ND-CNV screened positive for clinically significant difficulties. Young people from families with higher incomes (OR = 0.71, CI = 0.55-0.91, p = .008) were less likely to screen positive. The rate of difficulties differed depending on ND-CNV genotype (χ2 = 39.99, p < 0.001), with the lowest rate in young people with 22q11.2 deletion (45.7%) and the highest in those with 1q21.1 deletion (93.8%). Specific patterns of strengths and weaknesses were found for different ND-CNV genotypes. However, ND-CNV genotype explained no more than 9-16% of the variance, depending on DBC subdomain. CONCLUSIONS Emotion and behaviour problems are common in young people with ND-CNVs. The ND-CNV specific patterns we find can provide a basis for more tailored support. More research is needed to better understand the variation in emotion and behaviour problems not accounted for by genotype.
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Affiliation(s)
- Adam C. Cunningham
- Division of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University School of Medicine, Cardiff, UK
| | - Jeremy Hall
- Division of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University School of Medicine, Cardiff, UK
| | - Stewart Einfeld
- Faculty of Health Sciences, University of Sydney, Sydney, Australia
| | - Michael J. Owen
- Division of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University School of Medicine, Cardiff, UK
| | | | - Marianne B. M. van den Bree
- Division of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University School of Medicine, Cardiff, UK
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Nikam V, Mohammad NS. Tissue-specific DNase I footprint analysis confirms the association of GATAD2B Q470* variant with intellectual disability. J Genet 2021. [DOI: 10.1007/s12041-021-01308-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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12
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Blok LS, Goosen YM, van Haaften L, van Hulst K, Fisher SE, Brunner HG, Egger JIM, Kleefstra T. Speech-language profiles in the context of cognitive and adaptive functioning in SATB2-associated syndrome. GENES BRAIN AND BEHAVIOR 2021; 20:e12761. [PMID: 34241948 PMCID: PMC9285502 DOI: 10.1111/gbb.12761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 07/03/2021] [Accepted: 07/07/2021] [Indexed: 11/28/2022]
Abstract
SATB2‐associated syndrome (SAS) is a neurodevelopmental disorder caused by heterozygous pathogenic variants in the SATB2 gene, and is typically characterized by intellectual disability and severely impaired communication skills. The goal of this study was to contribute to the understanding of speech and language impairments in SAS, in the context of general developmental skills and cognitive and adaptive functioning. We performed detailed oral motor, speech and language profiling in combination with neuropsychological assessments in 23 individuals with a molecularly confirmed SAS diagnosis: 11 primarily verbal individuals and 12 primarily nonverbal individuals, independent of their ages. All individuals had severe receptive language delays. For all verbal individuals, we were able to define underlying speech conditions. While childhood apraxia of speech was most prevalent, oral motor problems appeared frequent as well and were more present in the nonverbal group than in the verbal group. For seven individuals, age‐appropriate Wechsler indices could be derived, showing that the level of intellectual functioning of these individuals varied from moderate–mild ID to mild ID‐borderline intellectual functioning. Assessments of adaptive functioning with the Vineland Screener showed relatively high scores on the domain “daily functioning” and relatively low scores on the domain “communication” in most individuals. Altogether, this study provides a detailed delineation of oral motor, speech and language skills and neuropsychological functioning in individuals with SAS, and can provide families and caregivers with information to guide diagnosis, management and treatment approaches.
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Affiliation(s)
- L Snijders Blok
- Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands.,Language & Genetics Department, Max Planck Institute for Psycholinguistics, Nijmegen, the Netherlands.,Donders Institute for Brain, Cognition & Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Y M Goosen
- Centre of Excellence for Neuropsychiatry, Vincent van Gogh Institute for Psychiatry, Venray, the Netherlands
| | - L van Haaften
- Donders Institute for Brain, Cognition & Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Rehabilitation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - K van Hulst
- Donders Institute for Brain, Cognition & Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Rehabilitation, Radboud University Medical Center, Nijmegen, the Netherlands
| | - S E Fisher
- Language & Genetics Department, Max Planck Institute for Psycholinguistics, Nijmegen, the Netherlands.,Donders Institute for Brain, Cognition & Behaviour, Centre for Neuroscience, Radboud University, Nijmegen, the Netherlands
| | - H G Brunner
- Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands.,Donders Institute for Brain, Cognition & Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Clinical Genetics, MHeNS School of Neuroscience, and GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - J I M Egger
- Centre of Excellence for Neuropsychiatry, Vincent van Gogh Institute for Psychiatry, Venray, the Netherlands.,Stevig Specialized and Forensic Care for People with Intellectual Disabilities, Dichterbij, Oostrum, The Netherlands.,Donders Institute for Brain, Cognition & Behaviour, Centre for Cognition, Radboud University, Nijmegen, the Netherlands
| | - T Kleefstra
- Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands.,Donders Institute for Brain, Cognition & Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands.,Centre of Excellence for Neuropsychiatry, Vincent van Gogh Institute for Psychiatry, Venray, the Netherlands
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13
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De Taevernier C, Meunier-Cussac S, Madigand J. First episode of psychosis in Kleefstra syndrome: a case report. Neurocase 2021; 27:227-230. [PMID: 34010111 DOI: 10.1080/13554794.2021.1905851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Kleefstra syndrome (KS) is a genetic syndrome caused by a haploinsufficiency of the EHMT1 gene and characterized by intellectual disability, language disorders, childhood hypotonia and distinct facial features. Only a few cases of first episode of psychosis in KS have already been reported. We describe a young female patient with KS who presented a first episode of psychosis. In a context of an initial diagnosis wavering and a lack of recommendations, this clinical observation illustrates the importance of psychiatric comorbidities and their diagnostic and therapeutic complexity in KS; with a need for multidisciplinary management considering its specific aspects and vulnerabilities.
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14
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Mossink B, Negwer M, Schubert D, Nadif Kasri N. The emerging role of chromatin remodelers in neurodevelopmental disorders: a developmental perspective. Cell Mol Life Sci 2021; 78:2517-2563. [PMID: 33263776 PMCID: PMC8004494 DOI: 10.1007/s00018-020-03714-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/04/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022]
Abstract
Neurodevelopmental disorders (NDDs), including intellectual disability (ID) and autism spectrum disorders (ASD), are a large group of disorders in which early insults during brain development result in a wide and heterogeneous spectrum of clinical diagnoses. Mutations in genes coding for chromatin remodelers are overrepresented in NDD cohorts, pointing towards epigenetics as a convergent pathogenic pathway between these disorders. In this review we detail the role of NDD-associated chromatin remodelers during the developmental continuum of progenitor expansion, differentiation, cell-type specification, migration and maturation. We discuss how defects in chromatin remodelling during these early developmental time points compound over time and result in impaired brain circuit establishment. In particular, we focus on their role in the three largest cell populations: glutamatergic neurons, GABAergic neurons, and glia cells. An in-depth understanding of the spatiotemporal role of chromatin remodelers during neurodevelopment can contribute to the identification of molecular targets for treatment strategies.
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Affiliation(s)
- Britt Mossink
- Department of Human Genetics, Radboudumc, Donders Institute for Brain, Cognition and Behaviour, Geert Grooteplein 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
- Department of Cognitive Neuroscience, Radboudumc, Donders Institute for Brain, Cognition and Behaviour, 6500 HB, Nijmegen, The Netherlands
| | - Moritz Negwer
- Department of Human Genetics, Radboudumc, Donders Institute for Brain, Cognition and Behaviour, Geert Grooteplein 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
- Department of Cognitive Neuroscience, Radboudumc, Donders Institute for Brain, Cognition and Behaviour, 6500 HB, Nijmegen, The Netherlands
| | - Dirk Schubert
- Department of Cognitive Neuroscience, Radboudumc, Donders Institute for Brain, Cognition and Behaviour, 6500 HB, Nijmegen, The Netherlands
| | - Nael Nadif Kasri
- Department of Human Genetics, Radboudumc, Donders Institute for Brain, Cognition and Behaviour, Geert Grooteplein 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
- Department of Cognitive Neuroscience, Radboudumc, Donders Institute for Brain, Cognition and Behaviour, 6500 HB, Nijmegen, The Netherlands.
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15
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Negwer M, Piera K, Hesen R, Lütje L, Aarts L, Schubert D, Nadif Kasri N. EHMT1 regulates Parvalbumin-positive interneuron development and GABAergic input in sensory cortical areas. Brain Struct Funct 2020; 225:2701-2716. [PMID: 32975655 PMCID: PMC7674571 DOI: 10.1007/s00429-020-02149-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 09/10/2020] [Indexed: 02/08/2023]
Abstract
Mutations in the Euchromatic Histone Methyltransferase 1 (EHMT1) gene cause Kleefstra syndrome, a rare form of intellectual disability (ID) with strong autistic traits and sensory processing deficits. Proper development of inhibitory interneurons is crucial for sensory function. Here we report a timeline of Parvalbumin-positive (PV+) interneuron development in the three most important sensory cortical areas in the Ehmt1+/- mouse. We find a hitherto unreported delay of PV+ neuron maturation early in sensory development, with layer- and region-specific variability later in development. The delayed PV+ maturation is also reflected in a delayed maturation of GABAergic transmission in Ehmt1+/- auditory cortex, where we find a reduced GABA release probability specifically in putative PV+ synapses. Together with earlier reports of excitatory impairments in Ehmt1+/- neurons, we propose a shift in excitatory-inhibitory balance towards overexcitability in Ehmt1+/- sensory cortices as a consequence of early deficits in inhibitory maturation.
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Affiliation(s)
- Moritz Negwer
- Department of Human Genetics, Radboudumc, Donders Institute for Brain, Cognition, and Behaviour, 6500 HB, Nijmegen, The Netherlands
| | - Karol Piera
- Department of Human Genetics, Radboudumc, Donders Institute for Brain, Cognition, and Behaviour, 6500 HB, Nijmegen, The Netherlands
| | - Rick Hesen
- Department of Human Genetics, Radboudumc, Donders Institute for Brain, Cognition, and Behaviour, 6500 HB, Nijmegen, The Netherlands
| | - Lukas Lütje
- Department of Human Genetics, Radboudumc, Donders Institute for Brain, Cognition, and Behaviour, 6500 HB, Nijmegen, The Netherlands
| | - Lynn Aarts
- Department of Human Genetics, Radboudumc, Donders Institute for Brain, Cognition, and Behaviour, 6500 HB, Nijmegen, The Netherlands
| | - Dirk Schubert
- Department of Cognitive Neuroscience, Radboudumc, Donders Institute for Brain, Cognition and Behaviour, 6500 HB, Nijmegen, The Netherlands
| | - Nael Nadif Kasri
- Department of Human Genetics, Radboudumc, Donders Institute for Brain, Cognition, and Behaviour, 6500 HB, Nijmegen, The Netherlands.
- Department of Cognitive Neuroscience, Radboudumc, Donders Institute for Brain, Cognition and Behaviour, 6500 HB, Nijmegen, The Netherlands.
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16
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Haseley A, Wallis K, DeBrosse S. Kleefstra syndrome: Impact on parents. Disabil Health J 2020; 14:101018. [PMID: 33189624 DOI: 10.1016/j.dhjo.2020.101018] [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: 03/21/2020] [Revised: 10/01/2020] [Accepted: 10/24/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Kleefstra syndrome (KS) is associated with developmental delay, autism, intellectual disability, psychosis, and regression. Research has not been conducted to assess the impact of KS on parents. OBJECTIVE/HYPOTHESIS A mixed-method study was conducted to assess the impact on parental well-being by evaluating parents' well-being, identifying factors of parental experience predicting well-being, and exploring the parental experience. METHODS Parents completed an online survey containing the PedsQL™ Family Impact Module (FIM) and a questionnaire created by the researchers. One-Way T-Test compared parents of children with KS to parents of children with Prader-Willi syndrome (PWS). Multiple linear regression used parents' total scale scores on PedsQL™ FIM to identify factors influencing parental well-being. Constant comparative analysis used open-ended responses to explore the parental experience of having a child with KS. RESULTS Parents of children with KS had statistically lower scores in daily activity and social functioning, but statistically higher scores in communication and emotional functioning compared to parents of children with PWS. However, the power was below 0.80, meaning additional research needs to be completed to confirm these findings. The linear multiple regression was not significant. Most importantly, the themes of establishing the diagnosis, importance of knowledge, sense of community, KS and relationships with others, how life changed, and what the future will hold, characterized the parental experience. CONCLUSIONS Knowledge and support were important to parents who had a child recently diagnosed with KS. Therefore, parents should be provided resources about KS and support groups at diagnosis.
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Affiliation(s)
- Alexandria Haseley
- Department of Genetics and Genome Sciences, Case Western Reserve University, Biomedical Research, 2109, Adelbert Rd Building, 6th FL, Cleveland, OH, USA.
| | - Kimberly Wallis
- Center for Human Genetics, University Hospitals Cleveland Medical Center, 11100 Euclid Ave #1500, Cleveland, OH, 44106, USA; Genetic Services, Akron Children's Hospital, 215 W Bowery St, Akron, OH, 44308, USA.
| | - Suzanne DeBrosse
- Department of Genetics and Genome Sciences, Case Western Reserve University, Biomedical Research, 2109, Adelbert Rd Building, 6th FL, Cleveland, OH, USA; Center for Human Genetics, University Hospitals Cleveland Medical Center, 11100 Euclid Ave #1500, Cleveland, OH, 44106, USA.
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17
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Clinical and molecular description of 19 patients with GATAD2B-Associated Neurodevelopmental Disorder (GAND). Eur J Med Genet 2020; 63:104004. [PMID: 32688057 DOI: 10.1016/j.ejmg.2020.104004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/07/2020] [Indexed: 12/16/2022]
Abstract
De novo pathogenic variants in the GATAD2B gene have been associated with a syndromic neurodevelopmental disorder (GAND) characterized by severe intellectual disability (ID), impaired speech, childhood hypotonia, and dysmorphic features. Since its first description in 2013, nine patients have been reported in case reports and a series of 50 patients was recently published, which is consistent with the relative frequency of GATAD2B pathogenic variants in public databases. We report the detailed phenotype of 19 patients from various ethnic backgrounds with confirmed pathogenic GATAD2B variants including intragenic deletions. All individuals presented developmental delay with a median age of 2.5 years for independent walking and of 3 years for first spoken words. GATAD2B variant carriers showed very little subsequent speech progress, two patients over 30 years of age remaining non-verbal. ID was mostly moderate to severe, with one profound and one mild case, which shows a wider spectrum of disease severity than previously reported. We confirm macrocephaly as a major feature in GAND (53%). Most common dysmorphic features included broad forehead, deeply set eyes, hypertelorism, wide nasal base, and pointed chin. Conversely, prenatal abnormalities, non-cerebral malformations, epilepsy, and autistic behavior were uncommon. Other features included feeding difficulties, behavioral abnormalities, and unspecific abnormalities on brain MRI. Improving our knowledge of the clinical phenotype is essential for correct interpretation of the molecular results and accurate patient management.
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18
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Kolevzon A, Delaby E, Berry-Kravis E, Buxbaum JD, Betancur C. Neuropsychiatric decompensation in adolescents and adults with Phelan-McDermid syndrome: a systematic review of the literature. Mol Autism 2019; 10:50. [PMID: 31879555 PMCID: PMC6930682 DOI: 10.1186/s13229-019-0291-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 10/09/2019] [Indexed: 12/22/2022] Open
Abstract
Phelan-McDermid syndrome (PMS) is caused by haploinsufficiency of the SHANK3 gene on chromosome 22q13.33 and is characterized by intellectual disability, hypotonia, severe speech impairments, and autism spectrum disorder. Emerging evidence indicates that there are changes over time in the phenotype observed in individuals with PMS, including severe neuropsychiatric symptoms and loss of skills occurring in adolescence and adulthood. To gain further insight into these phenomena and to better understand the long-term course of the disorder, we conducted a systematic literature review and identified 56 PMS cases showing signs of behavioral and neurologic decompensation in adolescence or adulthood (30 females, 25 males, 1 gender unknown). Clinical presentations included features of bipolar disorder, catatonia, psychosis, and loss of skills, occurring at a mean age of 20 years. There were no apparent sex differences in the rates of these disorders except for catatonia, which appeared to be more frequent in females (13 females, 3 males). Reports of individuals with point mutations in SHANK3 exhibiting neuropsychiatric decompensation and loss of skills demonstrate that loss of one copy of SHANK3 is sufficient to cause these manifestations. In the majority of cases, no apparent cause could be identified; in others, symptoms appeared after acute events, such as infections, prolonged or particularly intense seizures, or changes in the individual's environment. Several individuals had a progressive neurological deterioration, including one with juvenile onset metachromatic leukodystrophy, a severe demyelinating disorder caused by recessive mutations in the ARSA gene in 22q13.33. These reports provide insights into treatment options that have proven helpful in some cases, and are reviewed herein. Our survey highlights how little is currently known about neuropsychiatric presentations and loss of skills in PMS and underscores the importance of studying the natural history in individuals with PMS, including both cross-sectional and long-term longitudinal analyses. Clearer delineation of these neuropsychiatric symptoms will contribute to their recognition and prompt management and will also help uncover the underlying biological mechanisms, potentially leading to improved interventions.
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Affiliation(s)
- Alexander Kolevzon
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Elsa Delaby
- Sorbonne Université, INSERM, CNRS, Neuroscience Paris Seine, Institut de Biologie Paris Seine, Paris, France
| | - Elizabeth Berry-Kravis
- Department of Pediatrics, Neurological Sciences, Biochemistry, Rush University Medical Center, Chicago, Illinois USA
| | - Joseph D. Buxbaum
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Catalina Betancur
- Sorbonne Université, INSERM, CNRS, Neuroscience Paris Seine, Institut de Biologie Paris Seine, Paris, France
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19
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Trubnykova M, Bazalar Montoya J, La Serna-Infantes J, Vásquez Sotomayor F, Castro Mujica MDC, Abarca Barriga HH. GATAD2B Gene Microdeletion Causing Intellectual Disability Autosomal Dominant Type 18: Case Report and Review of the Literature. Mol Syndromol 2019; 10:186-194. [PMID: 31602190 DOI: 10.1159/000499209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2019] [Indexed: 12/15/2022] Open
Abstract
Pathogenic variants of the GATAD2B gene (1q21.3) are linked to intellectual disability autosomal dominant type 18 (MRD18; MIM 615074), characterized by dysmorphic features, psychomotor and language delay. We present an 11-year-old female patient with intellectual disability and typical clinical characteristics of MRD18. Chromosomal microarray analysis (CMA) revealed a novel CNV, approximately 200 kb in size and showed that the INTS3 and SLC27A3 genes are completely deleted along with the first 10 exons of the GATAD2B gene. INTS3 encodes the integrator complex subunit 3 and is part of the complex that maintains genome stability; SLC27A3 encodes a fatty acid transporter and has been associated with autism spectrum disorder. GATAD2B haploinsufficiency is associated with the phenotype. Furthermore, the girl had other clinical characteristics not previously described, such as emotional instability, calf hypotrophy, hypoplastic digit pads, tapered thumbs, and anterior earlobe crease. This study highlights the importance of the phenotype-genotype correlation using molecular diagnostic techniques, such as CMA, and its impact on precise diagnosis, treatment, prognosis, and genetic counseling for patients and their families.
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Affiliation(s)
- Milana Trubnykova
- Servicio de Genética & Errores Innatos del Metabolismo (EIM), Instituto Nacional de Salud del Niño-Breña
| | - Jeny Bazalar Montoya
- Unidad de Genética & Biología Molecular, Instituto Nacional de Enfermedades Neoplásicas
| | | | - Flor Vásquez Sotomayor
- Servicio de Genética & Errores Innatos del Metabolismo (EIM), Instituto Nacional de Salud del Niño-Breña
| | | | - Hugo Hernán Abarca Barriga
- Servicio de Genética & Errores Innatos del Metabolismo (EIM), Instituto Nacional de Salud del Niño-Breña.,Facultad de Medicina Humana, Universidad Ricardo Palma.,Facultad de Odontología, Universidad Científica del Sur, Lima, Peru
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20
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Iacono G, Dubos A, Méziane H, Benevento M, Habibi E, Mandoli A, Riet F, Selloum M, Feil R, Zhou H, Kleefstra T, Kasri NN, van Bokhoven H, Herault Y, Stunnenberg HG. Increased H3K9 methylation and impaired expression of Protocadherins are associated with the cognitive dysfunctions of the Kleefstra syndrome. Nucleic Acids Res 2019; 46:4950-4965. [PMID: 29554304 PMCID: PMC6007260 DOI: 10.1093/nar/gky196] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 03/09/2018] [Indexed: 12/13/2022] Open
Abstract
Kleefstra syndrome, a disease with intellectual disability, autism spectrum disorders and other developmental defects is caused in humans by haploinsufficiency of EHMT1. Although EHMT1 and its paralog EHMT2 were shown to be histone methyltransferases responsible for deposition of the di-methylated H3K9 (H3K9me2), the exact nature of epigenetic dysfunctions in Kleefstra syndrome remains unknown. Here, we found that the epigenome of Ehmt1+/- adult mouse brain displays a marked increase of H3K9me2/3 which correlates with impaired expression of protocadherins, master regulators of neuronal diversity. Increased H3K9me3 was present already at birth, indicating that aberrant methylation patterns are established during embryogenesis. Interestingly, we found that Ehmt2+/- mice do not present neither the marked increase of H3K9me2/3 nor the cognitive deficits found in Ehmt1+/- mice, indicating an evolutionary diversification of functions. Our finding of increased H3K9me3 in Ehmt1+/- mice is the first one supporting the notion that EHMT1 can quench the deposition of tri-methylation by other Histone methyltransferases, ultimately leading to impaired neurocognitive functioning. Our insights into the epigenetic pathophysiology of Kleefstra syndrome may offer guidance for future developments of therapeutic strategies for this disease.
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Affiliation(s)
- Giovanni Iacono
- Radboud University, Department of Molecular Biology, Faculty of Science, 6500 HB Nijmegen, the Netherlands
- To whom correspondence should be addressed. Tel: +31 24 3610524; . Correspondence may also be addressed to Giovanni Iacono.
| | - Aline Dubos
- CELPHEDIA, PHENOMIN, Institut Clinique de la Souris, 1 rue Laurent Fries, 67404 Illkirch, France
- Institut de Génétique et de Biologie Moléculaire et Cellulaire, Université de Strasbourg, Illkirch, France
- Centre National de la Recherche Scientifique, UMR7104, Illkirch, France
- Institut National de la Santé et de la Recherche Médicale, U964, Illkirch, France
| | - Hamid Méziane
- CELPHEDIA, PHENOMIN, Institut Clinique de la Souris, 1 rue Laurent Fries, 67404 Illkirch, France
| | - Marco Benevento
- Department of Cognitive Neuroscience, Radboudumc, 6500 HB Nijmegen, the Netherlands
- Department of Human Genetics, Radboudumc, 6500 HB Nijmegen, the Netherlands
- Donders Institute for Brain, Cognition, and Behaviour, Centre for Neuroscience, 6525 AJ Nijmegen, the Netherlands
| | - Ehsan Habibi
- Radboud University, Department of Molecular Biology, Faculty of Science, 6500 HB Nijmegen, the Netherlands
| | - Amit Mandoli
- Radboud University, Department of Molecular Biology, Faculty of Science, 6500 HB Nijmegen, the Netherlands
| | - Fabrice Riet
- CELPHEDIA, PHENOMIN, Institut Clinique de la Souris, 1 rue Laurent Fries, 67404 Illkirch, France
| | - Mohammed Selloum
- CELPHEDIA, PHENOMIN, Institut Clinique de la Souris, 1 rue Laurent Fries, 67404 Illkirch, France
| | - Robert Feil
- Institute of Molecular Genetics (IGMM), UMR5535, Centre National de Recherche Scientifique (CNRS), 1919 Route de Mende, 34293 Montpellier, France
- The University of Montpellier, 163 rue Auguste Broussonnet, 34090 Montpellier, France
| | - Huiqing Zhou
- Radboud University, Department of Molecular Biology, Faculty of Science, 6500 HB Nijmegen, the Netherlands
- Department of Human Genetics, Radboudumc, 6500 HB Nijmegen, the Netherlands
| | - Tjitske Kleefstra
- Department of Human Genetics, Radboudumc, 6500 HB Nijmegen, the Netherlands
- Donders Institute for Brain, Cognition, and Behaviour, Centre for Neuroscience, 6525 AJ Nijmegen, the Netherlands
| | - Nael Nadif Kasri
- Department of Cognitive Neuroscience, Radboudumc, 6500 HB Nijmegen, the Netherlands
- Department of Human Genetics, Radboudumc, 6500 HB Nijmegen, the Netherlands
- Donders Institute for Brain, Cognition, and Behaviour, Centre for Neuroscience, 6525 AJ Nijmegen, the Netherlands
| | - Hans van Bokhoven
- Department of Cognitive Neuroscience, Radboudumc, 6500 HB Nijmegen, the Netherlands
- Department of Human Genetics, Radboudumc, 6500 HB Nijmegen, the Netherlands
- Donders Institute for Brain, Cognition, and Behaviour, Centre for Neuroscience, 6525 AJ Nijmegen, the Netherlands
| | - Yann Herault
- CELPHEDIA, PHENOMIN, Institut Clinique de la Souris, 1 rue Laurent Fries, 67404 Illkirch, France
- Institut de Génétique et de Biologie Moléculaire et Cellulaire, Université de Strasbourg, Illkirch, France
- Centre National de la Recherche Scientifique, UMR7104, Illkirch, France
- Institut National de la Santé et de la Recherche Médicale, U964, Illkirch, France
| | - Hendrik G Stunnenberg
- Radboud University, Department of Molecular Biology, Faculty of Science, 6500 HB Nijmegen, the Netherlands
- To whom correspondence should be addressed. Tel: +31 24 3610524; . Correspondence may also be addressed to Giovanni Iacono.
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21
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Coll-Tané M, Krebbers A, Castells-Nobau A, Zweier C, Schenck A. Intellectual disability and autism spectrum disorders 'on the fly': insights from Drosophila. Dis Model Mech 2019; 12:dmm039180. [PMID: 31088981 PMCID: PMC6550041 DOI: 10.1242/dmm.039180] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Intellectual disability (ID) and autism spectrum disorders (ASD) are frequently co-occurring neurodevelopmental disorders and affect 2-3% of the population. Rapid advances in exome and genome sequencing have increased the number of known implicated genes by threefold, to more than a thousand. The main challenges in the field are now to understand the various pathomechanisms associated with this bewildering number of genetic disorders, to identify new genes and to establish causality of variants in still-undiagnosed cases, and to work towards causal treatment options that so far are available only for a few metabolic conditions. To meet these challenges, the research community needs highly efficient model systems. With an increasing number of relevant assays and rapidly developing novel methodologies, the fruit fly Drosophila melanogaster is ideally positioned to change gear in ID and ASD research. The aim of this Review is to summarize some of the exciting work that already has drawn attention to Drosophila as a model for these disorders. We highlight well-established ID- and ASD-relevant fly phenotypes at the (sub)cellular, brain and behavioral levels, and discuss strategies of how this extraordinarily efficient and versatile model can contribute to 'next generation' medical genomics and to a better understanding of these disorders.
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Affiliation(s)
- Mireia Coll-Tané
- Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Alina Krebbers
- Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Anna Castells-Nobau
- Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Christiane Zweier
- Institute of Human Genetics, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Annette Schenck
- Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
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22
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The histone methyltransferase G9a regulates tolerance to oxidative stress-induced energy consumption. PLoS Biol 2019; 17:e2006146. [PMID: 30860988 PMCID: PMC6413895 DOI: 10.1371/journal.pbio.2006146] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
Stress responses are crucial processes that require activation of genetic programs that protect from the stressor. Stress responses are also energy consuming and can thus be deleterious to the organism. The mechanisms coordinating energy consumption during stress response in multicellular organisms are not well understood. Here, we show that loss of the epigenetic regulator G9a in Drosophila causes a shift in the transcriptional and metabolic responses to oxidative stress (OS) that leads to decreased survival time upon feeding the xenobiotic paraquat. During OS exposure, G9a mutants show overactivation of stress response genes, rapid depletion of glycogen, and inability to access lipid energy stores. The OS survival deficiency of G9a mutants can be rescued by a high-sugar diet. Control flies also show improved OS survival when fed a high-sugar diet, suggesting that energy availability is generally a limiting factor for OS tolerance. Directly limiting access to glycogen stores by knocking down glycogen phosphorylase recapitulates the OS-induced survival defects of G9a mutants. We propose that G9a mutants are sensitive to stress because they experience a net reduction in available energy due to (1) rapid glycogen use, (2) an inability to access lipid energy stores, and (3) an overinduced transcriptional response to stress that further exacerbates energy demands. This suggests that G9a acts as a critical regulatory hub between the transcriptional and metabolic responses to OS. Our findings, together with recent studies that established a role for G9a in hypoxia resistance in cancer cell lines, suggest that G9a is of wide importance in controlling the cellular and organismal response to multiple types of stress. Stress responses require proper activation of genetic programs to protect the organism from the stressor. However, the mechanisms controlling energy consumption during stress responses are not well understood. Here, we investigate the role of epigenetic modifier G9a in regulating metabolism and gene transcription during oxidative stress responses in Drosophila. Flies lacking G9a show a shift in the metabolic and transcriptional responses to oxidative stress, leading to decreased stress tolerance despite intact oxidative stress defense mechanisms. During oxidative stress exposure, G9a mutants show overactivation of stress response and many other genes, rapid depletion of glycogen energy stores, and an inability to access lipid energy stores. The increased susceptibility of G9a mutant flies to oxidative stress can be rescued simply by providing extra sugar. This suggests that G9a mutants are sensitive to stress because of reduced access to immediately available energy. Wild-type flies also become more tolerant to oxidative stress when they are fed extra sugar, whereas blocking energy access by genetically reducing a key metabolic enzyme leads to oxidative stress sensitivity. Though the genetic response to oxidative stress has long been appreciated, our study emphasizes the importance of energy metabolism for stress tolerance and identifies the histone methyltransferase G9a as an important player regulating both.
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Ueda K, Yanagi K, Kaname T, Okamoto N. A novel mutation in the GATAD2B gene associated with severe intellectual disability. Brain Dev 2019; 41:276-279. [PMID: 30482549 DOI: 10.1016/j.braindev.2018.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/09/2018] [Accepted: 10/16/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND The human GATA zinc finger domain containing 2B (GATAD2B) encodes a subunit of the MeCP1-Mi-2/nucleosome remodeling and deacetylase complex, which is involved in chromatin modification and transcription. Recently, patients with severe intellectual disabilities and characteristic features associated with GATAD2B mutations have been identified. CASE REPORT The patient was a 4-year-old male with dysmorphic features, including frontal bossing, hypertelorism, epicanthal folds, down-slanting palpebral fissures, a flat nasal bridge, a high arched palate, and micrognathia. He spoke no meaningful words and exhibited severe intellectual disability. Hypermetropic astigmatism and mild spasticity of the lower extremities were noted. Whole-exome sequencing revealed a de novo missense mutation in GATAD2B (NM_020699:exon4:c.502C>T; p.(Glu168∗)). CONCLUSION We report a novel GATAD2B mutation in a boy exhibiting bilateral leg spasticity and white matter abnormalities on brain magnetic resonance imaging.
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Affiliation(s)
- Kimiko Ueda
- Department of Medical Genetics, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan.
| | - Kumiko Yanagi
- Department of Genome Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Tadashi Kaname
- Department of Genome Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Nobuhiko Okamoto
- Department of Medical Genetics, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
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24
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de Boer A, Vermeulen K, Egger JIM, Janzing JGE, de Leeuw N, Veenstra-Knol HE, den Hollander NS, van Bokhoven H, Staal W, Kleefstra T. EHMT1 mosaicism in apparently unaffected parents is associated with autism spectrum disorder and neurocognitive dysfunction. Mol Autism 2018; 9:5. [PMID: 29416845 PMCID: PMC5784506 DOI: 10.1186/s13229-018-0193-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 01/16/2018] [Indexed: 02/06/2023] Open
Abstract
Background Genetic mosaicism is only detected occasionally when there are no obvious health or developmental issues. Most cases concern healthy parents in whom mosaicism is identified upon targeted testing of a genetic defect that was initially detected in their children. A germline genetic defect affecting the euchromatin histone methyltransferase 1 (EHMT1) gene causes Kleefstra syndrome, which is associated with the typical triad of distinct facial appearance, (childhood) hypotonia, and intellectual disability. A high degree of psychopathology is associated with this syndrome. A few parents with a mosaic EHMT1 mutation have been detected upon testing after a child was diagnosed with a germline EHMT1 defect. At first glance, carriers of a mosaic EHMT1 mutation appeared to function normally. However, recent studies have shown that de novo, postzygotic mutations in important developmental genes significantly contribute to autism spectrum disorder (ASD). Therefore, we hypothesized that EHMT1 mosaicism could cause neuropsychiatric defects. To investigate this, we performed a detailed investigation of cognitive neuropsychiatric parameters in parents identified with EHMT1 mosaicism. Methods Three adults (two males, one female) with a genetically confirmed diagnosis of EHMT1 mosaicism were examined by means of a battery of tests and observational instruments covering both neurocognitive and psychiatric features. The battery included the following instruments: the Autism Diagnostic Observation Schedule (ADOS), the mini Psychiatric Assessment Schedules for Adults with Developmental Disabilities (mini PAS-ADD), the Vineland Adaptive Behavior Scales (VABS), and the Cambridge Neuropsychological Test Automated Battery (CANTAB). These measures were compared with our previously reported data from Kleefstra syndrome patients with confirmed (germline) EHMT1 defects. Results All three subjects achieved maximum total scores on the VABS, indicative of adequate (adaptive) functioning. In all, scores above cutoff were found on the ADOS for ASD and on the mini PAS-ADD for major depressive disorder (lifetime). Finally, results on the CANTAB showed impaired cognitive flexibility in all subjects. Conclusion Individuals with EHMT1 mosaicism seem to have increased vulnerability for developing severe psychopathology, especially ASD and mood disorders. Although at first glance they appear to be well-adapted in their daily functioning, they may experience significant psychiatric symptoms and show reduced cognitive flexibility in comparison to the general population.
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Affiliation(s)
- Anneke de Boer
- 1Karakter Child and Adolescent Psychiatry University Centre, Nijmegen, the Netherlands.,3Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Karlijn Vermeulen
- 1Karakter Child and Adolescent Psychiatry University Centre, Nijmegen, the Netherlands.,2Donders Institute for Brain, Cognition and Behavior, Centre for Neuroscience, Radboud University, Nijmegen, the Netherlands.,3Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jos I M Egger
- 4Centre of Excellence for Neuropsychiatry, Vincent van Gogh Institute for Psychiatry, Venray, the Netherlands.,5Behavioural Science Institute, Radboud University, Nijmegen, the Netherlands.,6Donders Institute for Brain, Cognition and Behaviour, Centre for Cognition, Radboud University, Nijmegen, the Netherlands
| | - Joost G E Janzing
- 3Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Nicole de Leeuw
- 7Department of Human Genetics, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Hermine E Veenstra-Knol
- 8Department of Genetics, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Hans van Bokhoven
- 2Donders Institute for Brain, Cognition and Behavior, Centre for Neuroscience, Radboud University, Nijmegen, the Netherlands.,7Department of Human Genetics, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Wouter Staal
- 1Karakter Child and Adolescent Psychiatry University Centre, Nijmegen, the Netherlands.,2Donders Institute for Brain, Cognition and Behavior, Centre for Neuroscience, Radboud University, Nijmegen, the Netherlands.,3Department of Psychiatry, Radboud University Medical Center, Nijmegen, the Netherlands.,10Faculty of Social Sciences, Leiden University, Leiden, the Netherlands.,11Leiden Institute for Brain and Cognition, Leiden University, Leiden, the Netherlands
| | - Tjitske Kleefstra
- 2Donders Institute for Brain, Cognition and Behavior, Centre for Neuroscience, Radboud University, Nijmegen, the Netherlands.,7Department of Human Genetics, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands
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Nagy J, Kobolák J, Berzsenyi S, Ábrahám Z, Avci HX, Bock I, Bekes Z, Hodoscsek B, Chandrasekaran A, Téglási A, Dezső P, Koványi B, Vörös ET, Fodor L, Szél T, Németh K, Balázs A, Dinnyés A, Lendvai B, Lévay G, Román V. Altered neurite morphology and cholinergic function of induced pluripotent stem cell-derived neurons from a patient with Kleefstra syndrome and autism. Transl Psychiatry 2017; 7:e1179. [PMID: 28742076 PMCID: PMC5538124 DOI: 10.1038/tp.2017.144] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 04/28/2017] [Indexed: 01/05/2023] Open
Abstract
The aim of the present study was to establish an in vitro Kleefstra syndrome (KS) disease model using the human induced pluripotent stem cell (hiPSC) technology. Previously, an autism spectrum disorder (ASD) patient with Kleefstra syndrome (KS-ASD) carrying a deleterious premature termination codon mutation in the EHMT1 gene was identified. Patient specific hiPSCs generated from peripheral blood mononuclear cells of the KS-ASD patient were differentiated into post-mitotic cortical neurons. Lower levels of EHMT1 mRNA as well as protein expression were confirmed in these cells. Morphological analysis on neuronal cells differentiated from the KS-ASD patient-derived hiPSC clones showed significantly shorter neurites and reduced arborization compared to cells generated from healthy controls. Moreover, density of dendritic protrusions of neuronal cells derived from KS-ASD hiPSCs was lower than that of control cells. Synaptic connections and spontaneous neuronal activity measured by live cell calcium imaging could be detected after 5 weeks of differentiation, when KS-ASD cells exhibited higher sensitivity of calcium responses to acetylcholine stimulation indicating a lower nicotinic cholinergic tone at baseline condition in KS-ASD cells. In addition, gene expression profiling of differentiated neuronal cells from the KS-ASD patient revealed higher expression of proliferation-related genes and lower mRNA levels of genes involved in neuronal maturation and migration. Our data demonstrate anomalous neuronal morphology, functional activity and gene expression in KS-ASD patient-specific hiPSC-derived neuronal cultures, which offers an in vitro system that contributes to a better understanding of KS and potentially other neurodevelopmental disorders including ASD.
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Affiliation(s)
- J Nagy
- Pharmacology and Drug Safety Research, Gedeon Richter Plc., Budapest, Hungary,Laboratory of Molecular Cell Biology, Gedeon Richter Plc. Gyömrői út 19-21., Budapest 1103, Hungary. E-mail:
| | | | - S Berzsenyi
- Pharmacology and Drug Safety Research, Gedeon Richter Plc., Budapest, Hungary
| | - Z Ábrahám
- Pharmacology and Drug Safety Research, Gedeon Richter Plc., Budapest, Hungary
| | - H X Avci
- BioTalentum Ltd., Gödöllő, Hungary
| | - I Bock
- BioTalentum Ltd., Gödöllő, Hungary
| | - Z Bekes
- Pharmacology and Drug Safety Research, Gedeon Richter Plc., Budapest, Hungary
| | - B Hodoscsek
- Pharmacology and Drug Safety Research, Gedeon Richter Plc., Budapest, Hungary
| | | | | | - P Dezső
- Pharmacology and Drug Safety Research, Gedeon Richter Plc., Budapest, Hungary
| | - B Koványi
- Pharmacology and Drug Safety Research, Gedeon Richter Plc., Budapest, Hungary
| | - E T Vörös
- Pharmacology and Drug Safety Research, Gedeon Richter Plc., Budapest, Hungary
| | - L Fodor
- Pharmacology and Drug Safety Research, Gedeon Richter Plc., Budapest, Hungary
| | - T Szél
- Pharmacology and Drug Safety Research, Gedeon Richter Plc., Budapest, Hungary
| | - K Németh
- Autism Foundation, Budapest, Hungary
| | - A Balázs
- Autism Foundation, Budapest, Hungary
| | | | - B Lendvai
- Pharmacology and Drug Safety Research, Gedeon Richter Plc., Budapest, Hungary
| | - G Lévay
- Pharmacology and Drug Safety Research, Gedeon Richter Plc., Budapest, Hungary
| | - V Román
- Pharmacology and Drug Safety Research, Gedeon Richter Plc., Budapest, Hungary
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