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Avagliano L, Castiglioni S, Lettieri A, Parodi C, Di Fede E, Taci E, Grazioli P, Colombo EA, Gervasini C, Massa V. Intrauterine growth in chromatinopathies: A long road for better understanding and for improving clinical management. Birth Defects Res 2024; 116:e2383. [PMID: 38984779 DOI: 10.1002/bdr2.2383] [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: 02/23/2024] [Revised: 06/12/2024] [Accepted: 06/25/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Chromatinopathies are a heterogeneous group of genetic disorders caused by pathogenic variants in genes coding for chromatin state balance proteins. Remarkably, many of these syndromes present unbalanced postnatal growth, both under- and over-, although little has been described in the literature. Fetal growth measurements are common practice in pregnancy management and values within normal ranges indicate proper intrauterine growth progression; on the contrary, abnormalities in intrauterine fetal growth open the discussion of possible pathogenesis affecting growth even in the postnatal period. METHODS Among the numerous chromatinopathies, we have selected six of the most documented in the literature offering evidence about two fetal overgrowth (Sotos and Weaver syndrome) and four fetal undergrowth syndromes (Bohring Opitz, Cornelia de Lange, Floating-Harbor, and Meier Gorlin syndrome), describing their molecular characteristics, maternal biochemical results and early pregnancy findings, prenatal ultrasound findings, and postnatal characteristics. RESULTS/CONCLUSION To date, the scarce data in the literature on prenatal findings are few and inconclusive, even though these parameters may contribute to a more rapid and accurate diagnosis, calling for a better and more detailed description of pregnancy findings.
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Affiliation(s)
| | - Silvia Castiglioni
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Antonella Lettieri
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Chiara Parodi
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Elisabetta Di Fede
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
- Aldo Ravelli Center for Neurotechnology and Experimental Brain Therapeutics, Università Degli Studi di Milano, Milan, Italy
| | - Esi Taci
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
- Aldo Ravelli Center for Neurotechnology and Experimental Brain Therapeutics, Università Degli Studi di Milano, Milan, Italy
| | - Paolo Grazioli
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Elisa Adele Colombo
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Cristina Gervasini
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
- Aldo Ravelli Center for Neurotechnology and Experimental Brain Therapeutics, Università Degli Studi di Milano, Milan, Italy
| | - Valentina Massa
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
- Aldo Ravelli Center for Neurotechnology and Experimental Brain Therapeutics, Università Degli Studi di Milano, Milan, Italy
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Klein SD, Nisbet A, Kalish JM. Overgrowth syndromes, diagnosis and management. Curr Opin Pediatr 2023; 35:620-630. [PMID: 37791807 PMCID: PMC10872759 DOI: 10.1097/mop.0000000000001298] [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] [Indexed: 10/05/2023]
Abstract
PURPOSE OF REVIEW This review will focus on the current knowledge of the diagnosis and management of overgrowth syndromes with specific focus on mosaic conditions and treatment strategies. RECENT FINDINGS With the implementation of massively parallel sequencing, the genetic etiology of many classically described overgrowth syndromes have been identified. More recently, the role of mosaic genetic changes has been well described in numerous syndromes. Furthermore, the role of imprinting and methylation, especially of the 11p15 region, has been shown to be instrumental for growth. Perhaps most importantly, many overgrowth syndromes carry an increased risk of neoplasm formation especially in the first 10 years of life and possibly beyond. The systematic approach to the child with overgrowth will aide in timely diagnosis and efficiently align them with appropriate screening strategies. In some cases, precision medical interventions are available to target the perturbed growth signaling pathways. SUMMARY The systematic approach to the child with overgrowth aids in the standardization of the diagnostic pathway for these young patients, thereby expediting the diagnostic timeline, enabling rigorous monitoring, and delivering tailored therapeutic interventions.
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Affiliation(s)
- Steven D. Klein
- Division of Human Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Alex Nisbet
- Division of Human Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Jennifer M. Kalish
- Division of Human Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, Philadelphia, PA 19104, USA
- Center for Childhood Cancer Research, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Genetics, Perelman School of Medicine, Philadelphia, PA 19104, USA
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Liu X, Chen C, Wan L, Zhu G, Zhao Y, Hu L, Liang Y, Gao J, Wang J, Yang G. A novel nonsense variant in NSD1 gene in a female child with Sotos syndrome: A case report and literature review. Brain Behav 2023; 13:e3290. [PMID: 37908045 PMCID: PMC10726859 DOI: 10.1002/brb3.3290] [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: 02/08/2023] [Revised: 09/13/2023] [Accepted: 10/10/2023] [Indexed: 11/02/2023] Open
Abstract
INTRODUCTION Sotos syndrome (SS) is an overgrowth disease characterized by distinctive facial features, advanced bone age, macrocephaly, and developmental delay is associated with alterations in the NSD1 gene. Here, we report a case of a 4-year-old female child with SS caused by NSD1 gene nonsense mutation. METHODS Whole-exome sequencing (WES) was applied for probands and her parents. Sanger sequencing was used to confirm the mutation. We performed the literature review using PubMed and found 12 articles and 14 patients who presented with SS. RESULTS The patient showed typical facial features of SS, hand deformities, and seizure. WES revealed de novo heterozygous variant: NSD1 (NM_022455.5), c.6095G > A, p.TRP2032*. We also reviewed the phenotype spectrum of 14 patients with SS, who exhibited a variety of clinical phenotypes, including developmental delay, seizures, scoliosis, hearing loss, cardiac and urinary system abnormalities, and so on. DISCUSSION The lack of correlation between mutation sites or types and phenotypes was summarized by literature reviewing. The NSD1 protein contains 14 functional domains and this nonsense mutation was located in SET domain. Early appearance of the termination codon leads to protein truncation. Haploinsufficiency of the NSD1 gene causes the overgrowth disorders.
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Affiliation(s)
- Xinting Liu
- Senior Department of Pediatricsthe Seventh Medical Center of PLA General HospitalBeijingChina
- Department of Pediatrics, the First Medical CenterChinese PLA General HospitalBeijingChina
- Medical School of Chinese PLABeijingChina
| | - Chen Chen
- Senior Department of Pediatricsthe Seventh Medical Center of PLA General HospitalBeijingChina
- Department of Pediatrics, the First Medical CenterChinese PLA General HospitalBeijingChina
| | - Lin Wan
- Senior Department of Pediatricsthe Seventh Medical Center of PLA General HospitalBeijingChina
- Department of Pediatrics, the First Medical CenterChinese PLA General HospitalBeijingChina
- Medical School of Chinese PLABeijingChina
| | - Gang Zhu
- Senior Department of Pediatricsthe Seventh Medical Center of PLA General HospitalBeijingChina
- Department of Pediatrics, the First Medical CenterChinese PLA General HospitalBeijingChina
- Medical School of Chinese PLABeijingChina
| | - Yan Zhao
- Senior Department of Pediatricsthe Seventh Medical Center of PLA General HospitalBeijingChina
- Department of Pediatrics, the First Medical CenterChinese PLA General HospitalBeijingChina
| | - Lizhu Hu
- Senior Department of Pediatricsthe Seventh Medical Center of PLA General HospitalBeijingChina
- Department of Pediatrics, the First Medical CenterChinese PLA General HospitalBeijingChina
- Medical School of Chinese PLABeijingChina
| | - Yan Liang
- Senior Department of Pediatricsthe Seventh Medical Center of PLA General HospitalBeijingChina
- Department of Pediatrics, the First Medical CenterChinese PLA General HospitalBeijingChina
- Medical School of Chinese PLABeijingChina
| | - Jing Gao
- Senior Department of Pediatricsthe Seventh Medical Center of PLA General HospitalBeijingChina
- Department of Pediatrics, the First Medical CenterChinese PLA General HospitalBeijingChina
| | - Jing Wang
- Senior Department of Pediatricsthe Seventh Medical Center of PLA General HospitalBeijingChina
- Department of Pediatrics, the First Medical CenterChinese PLA General HospitalBeijingChina
| | - Guang Yang
- Senior Department of Pediatricsthe Seventh Medical Center of PLA General HospitalBeijingChina
- Department of Pediatrics, the First Medical CenterChinese PLA General HospitalBeijingChina
- The Second School of Clinical MedicineSouthern Medical UniversityGuangzhouChina
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Zenker M, Mohnike K, Palm K. Syndromic forms of congenital hyperinsulinism. Front Endocrinol (Lausanne) 2023; 14:1013874. [PMID: 37065762 PMCID: PMC10098214 DOI: 10.3389/fendo.2023.1013874] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 03/07/2023] [Indexed: 04/18/2023] Open
Abstract
Congenital hyperinsulinism (CHI), also called hyperinsulinemic hypoglycemia (HH), is a very heterogeneous condition and represents the most common cause of severe and persistent hypoglycemia in infancy and childhood. The majority of cases in which a genetic cause can be identified have monogenic defects affecting pancreatic β-cells and their glucose-sensing system that regulates insulin secretion. However, CHI/HH has also been observed in a variety of syndromic disorders. The major categories of syndromes that have been found to be associated with CHI include overgrowth syndromes (e.g. Beckwith-Wiedemann and Sotos syndromes), chromosomal and monogenic developmental syndromes with postnatal growth failure (e.g. Turner, Kabuki, and Costello syndromes), congenital disorders of glycosylation, and syndromic channelopathies (e.g. Timothy syndrome). This article reviews syndromic conditions that have been asserted by the literature to be associated with CHI. We assess the evidence of the association, as well as the prevalence of CHI, its possible pathophysiology and its natural course in the respective conditions. In many of the CHI-associated syndromic conditions, the mechanism of dysregulation of glucose-sensing and insulin secretion is not completely understood and not directly related to known CHI genes. Moreover, in most of those syndromes the association seems to be inconsistent and the metabolic disturbance is transient. However, since neonatal hypoglycemia is an early sign of possible compromise in the newborn, which requires immediate diagnostic efforts and intervention, this symptom may be the first to bring a patient to medical attention. As a consequence, HH in a newborn or infant with associated congenital anomalies or additional medical issues remains a differential diagnostic challenge and may require a broad genetic workup.
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Affiliation(s)
- Martin Zenker
- Institute of Human Genetics, University Hospital, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- *Correspondence: Martin Zenker,
| | - Klaus Mohnike
- Department of Pediatrics, University Hospital, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Katja Palm
- Department of Pediatrics, University Hospital, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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Boodhansingh KE, Rosenfeld E, Lord K, Adzick NS, Bhatti T, Ganguly A, De Leon DD, Stanley CA. Mosaic GLUD1 Mutations Associated with Hyperinsulinism Hyperammonemia Syndrome. Horm Res Paediatr 2022; 95:492-498. [PMID: 35952631 PMCID: PMC9671865 DOI: 10.1159/000526203] [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] [Received: 06/29/2022] [Accepted: 07/20/2022] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION The hyperinsulinemia-hyperammonemia syndrome (HIHA) is the second most common cause of congenital hyperinsulinism and is caused by activating heterozygous missense mutations in GLUD1. In the majority of HIHA cases, the GLUD1 mutation is found to be de novo. We have identified 3 patients in whom clinical evaluation was suggestive of HIHA but with negative mutation analysis in peripheral blood DNA for GLUD1 as well as other known HI genes. METHODS We performed next-generation sequencing (NGS) on peripheral blood DNA from two children with clinical features of HIHA in order to look for mosaic mutations in GLUD1. Pancreas tissue was also available in one of these cases for NGS. In addition, NGS was performed on peripheral blood DNA from a woman with a history of HI in infancy whose child had HIHA due to a presumed de novo GLUD1 mutation. RESULTS Mosaic GLUD1 mutations were identified in these 3 cases at percent mosaicism ranging from 2.7% to 10.4% in peripheral blood. In one case with pancreas tissue available, the mosaic GLUD1 mutation was present at 17.9% and 28.9% in different sections of the pancreas. Two unique GLUD1 mutations were identified in these cases, both of which have been previously reported (c.1493c>t/p.Ser445Leu and c.820c>t/p.Arg221Cys). CONCLUSION The results suggest that low-level mosaic mutations in known HI genes may be the underlying molecular mechanism in some children with HI who have negative genetic testing in peripheral blood DNA.
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Affiliation(s)
- Kara E. Boodhansingh
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth Rosenfeld
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katherine Lord
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - N. Scott Adzick
- Department of Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tricia Bhatti
- Department of Pathology, The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arupa Ganguly
- Department of Genetics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Diva D. De Leon
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charles A. Stanley
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Hewat TI, Johnson MB, Flanagan SE. Congenital Hyperinsulinism: Current Laboratory-Based Approaches to the Genetic Diagnosis of a Heterogeneous Disease. Front Endocrinol (Lausanne) 2022; 13:873254. [PMID: 35872984 PMCID: PMC9302115 DOI: 10.3389/fendo.2022.873254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/14/2022] [Indexed: 11/17/2022] Open
Abstract
Congenital hyperinsulinism is characterised by the inappropriate release of insulin during hypoglycaemia. This potentially life-threatening disorder can occur in isolation, or present as a feature of syndromic disease. Establishing the underlying aetiology of the hyperinsulinism is critical for guiding medical management of this condition especially in children with diazoxide-unresponsive hyperinsulinism where the underlying genetics determines whether focal or diffuse pancreatic disease is present. Disease-causing single nucleotide variants affecting over 30 genes are known to cause persistent hyperinsulinism with mutations in the KATP channel genes (ABCC8 and KCNJ11) most commonly identified in children with severe persistent disease. Defects in methylation, changes in chromosome number, and large deletions and duplications disrupting multiple genes are also well described in congenital hyperinsulinism, further highlighting the genetic heterogeneity of this condition. Next-generation sequencing has revolutionised the approach to genetic testing for congenital hyperinsulinism with targeted gene panels, exome, and genome sequencing being highly sensitive methods for the analysis of multiple disease genes in a single reaction. It should though be recognised that limitations remain with next-generation sequencing with no single application able to detect all reported forms of genetic variation. This is an important consideration for hyperinsulinism genetic testing as comprehensive screening may require multiple investigations.
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Kostopoulou E, Dastamani A, Güemes M, Clement E, Caiulo S, Shanmugananda P, Dattani M, Gilbert C, Hurst JA, Shah P. Syndromic Forms of Hyperinsulinaemic Hypoglycaemia-A 15-year follow-up Study. Clin Endocrinol (Oxf) 2021; 94:399-412. [PMID: 33345357 DOI: 10.1111/cen.14393] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/18/2020] [Accepted: 11/24/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Hyperinsulinaemic hypoglycaemia (HH) is one of the commonest causes of hypoglycaemia in children. The molecular basis includes defects in pathways that regulate insulin release. Syndromic conditions like Beckwith-Wiedemann (BWS), Kabuki (KS) and Turner (TS) are known to be associated with a higher risk for HH. This systematic review of children with HH referred to a tertiary centre aims at estimating the frequency of a syndromic/multisystem condition to help address stratification of genetic analysis in infants with HH. METHODS We performed a retrospective study of 69 patients with syndromic features and hypoglycaemia in a specialist centre from 2004 to 2018. RESULTS Biochemical investigations confirmed HH in all the cases and several genetic diagnoses were established. Responsiveness to medications and the final outcome following medical treatment or surgery were studied. CONCLUSIONS This study highlights the association of HH with a wide spectrum of syndromic diagnoses and that children with features suggestive of HH-associated syndromes should be monitored for hypoglycaemia. If hypoglycaemia is documented, they should also be screened for possible HH. Our data indicate that most syndromic forms of HH are diazoxide-responsive and that HH resolves over time; however, a significant percentage continues to require medications years after the onset of the disease. Early diagnosis of hyperinsulinism and initiation of treatment is important for preventing hypoglycaemic brain injury and intellectual disability.
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Affiliation(s)
- Eirini Kostopoulou
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Antonia Dastamani
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Maria Güemes
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
- Genetics and Genomic Medicine Program, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Emma Clement
- Department of Genetics, Great Ormond Street Hospital for Children, London, UK
| | - Silvana Caiulo
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Prateek Shanmugananda
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Mehul Dattani
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
- Genetics and Genomic Medicine Program, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Clare Gilbert
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Jane A Hurst
- Department of Genetics, Great Ormond Street Hospital for Children, London, UK
| | - Pratik Shah
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
- Genetics and Genomic Medicine Program, UCL Great Ormond Street Institute of Child Health, London, UK
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Panigrahi I, Chaudhry C. Sotos syndrome in two children from India. Am J Med Genet A 2020; 182:2181-2183. [PMID: 32677741 DOI: 10.1002/ajmg.a.61751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 05/24/2020] [Accepted: 06/05/2020] [Indexed: 11/07/2022]
Abstract
Sotos syndrome is one of the overgrowth syndromes, and can present with intellectual disability, behavioral problems and tall stature. In some cases, seizures, pectus deformity, cardiac and renal anomalies may be identified. Here we report two Indian children with Sotos syndrome whose initial presentation was macrocephaly and behavioral problems, respectively. The pathogenic variants in NSD1 gene were confirmed by next generation sequencing. The gene variants in the two children, one male and one female; were NSD1: c.2362C>T and NSD1: c.5474dup, respectively, leading to premature termination of protein formation.
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Affiliation(s)
- Inusha Panigrahi
- Genetic Metabolic Unit, Department of Pediatrics, APC, PGIMER, Chandigarh, India
| | - Chakshu Chaudhry
- Genetic Metabolic Unit, Department of Pediatrics, APC, PGIMER, Chandigarh, India
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Rosenfeld E, Ganguly A, De León DD. Congenital hyperinsulinism disorders: Genetic and clinical characteristics. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2019; 181:682-692. [PMID: 31414570 PMCID: PMC7229866 DOI: 10.1002/ajmg.c.31737] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 07/13/2019] [Accepted: 07/29/2019] [Indexed: 12/11/2022]
Abstract
Congenital hyperinsulinism (HI) is the most frequent cause of persistent hypoglycemia in infants and children. Delays in diagnosis and initiation of appropriate treatment contribute to a high risk of neurocognitive impairment. HI represents a heterogeneous group of disorders characterized by dysregulated insulin secretion by the pancreatic beta cells, which in utero, may result in somatic overgrowth. There are at least nine known monogenic forms of HI as well as several syndromic forms. Molecular diagnosis allows for prediction of responsiveness to medical treatment and likelihood of surgically-curable focal hyperinsulinism. Timely genetic mutation analysis has thus become standard of care. However, despite significant advances in our understanding of the molecular basis of this disorder, the number of patients without an identified genetic diagnosis remains high, suggesting that there are likely additional genetic loci that have yet to be discovered.
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Affiliation(s)
- Elizabeth Rosenfeld
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Arupa Ganguly
- Department of Genetics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Diva D. De León
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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