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Ouboukss F, Adadi N, Amasdl S, Smaili W, Laarabi FZ, Lyahyai J, Sefiani A, Ratbi I. High frequency of hotspot mutation in PTPN11 gene among Moroccan patients with Noonan syndrome. J Appl Genet 2024; 65:303-308. [PMID: 37987971 DOI: 10.1007/s13353-023-00803-6] [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: 07/03/2023] [Revised: 10/27/2023] [Accepted: 10/29/2023] [Indexed: 11/22/2023]
Abstract
Noonan syndrome (NS; OMIM 163950) is an autosomal dominant RASopathy with variable clinical expression and genetic heterogeneity. Clinical manifestations include characteristic facial features, short stature, and cardiac anomalies. Variants in protein-tyrosine phosphatase, non-receptor-type 11 (PTPN11), encoding SHP-2, account for about half of NS patients, SOS1 in approximately 13%, RAF1 in 10%, and RIT1 each in 9%. Other genes have been reported to cause NS in less than 5% of cases including SHOC2, RASA2, LZTR1, SPRED2, SOS2, CBL, KRAS, NRAS, MRAS, PRAS, BRAF, PPP1CB, A2ML1, MAP2K1, and CDC42. Several additional genes associated with a Noonan syndrome-like phenotype have been identified. Clinical presentation and variants in patients with Noonan syndrome are this study's objectives. We performed Sanger sequencing of PTPN11 hotspot (exons 3, 8, and 13). We report molecular analysis of 61 patients with NS phenotype belonging to 58 families. We screened for hotspot variants (exons 3, 8, and 13) in PTPN11 gene by Sanger sequencing. Twenty-seven patients were carrying heterozygous pathogenic variants of PTPN11 gene with a similar frequency (41.4%) compared to the literature. Our findings expand the variant spectrum of Moroccan patients with NS phenotype in whom the analysis of hotspot variants showed a high frequency of exons 3 and 8. This screening test allowed us to establish a molecular diagnosis in almost half of the patients with a good benefit-cost ratio, with appropriate management and genetic counseling.
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Affiliation(s)
- Fatima Ouboukss
- Research Team in Genomics and Molecular Epidemiology of Genetic Diseases, Genomics Center of Human Pathologies, Faculty of Medicine and Pharmacy, University Mohammed V in Rabat, Rabat, Morocco.
- Department of Medical Genetics, National Institute of Health in Rabat, BP 769 Agdal, 10 090, Rabat, Morocco.
| | - Najlae Adadi
- Research Team in Genomics and Molecular Epidemiology of Genetic Diseases, Genomics Center of Human Pathologies, Faculty of Medicine and Pharmacy, University Mohammed V in Rabat, Rabat, Morocco
- Department of Medical Genetics, National Institute of Health in Rabat, BP 769 Agdal, 10 090, Rabat, Morocco
| | - Saadia Amasdl
- Research Team in Genomics and Molecular Epidemiology of Genetic Diseases, Genomics Center of Human Pathologies, Faculty of Medicine and Pharmacy, University Mohammed V in Rabat, Rabat, Morocco
- Department of Medical Genetics, National Institute of Health in Rabat, BP 769 Agdal, 10 090, Rabat, Morocco
| | - Wiam Smaili
- Research Team in Genomics and Molecular Epidemiology of Genetic Diseases, Genomics Center of Human Pathologies, Faculty of Medicine and Pharmacy, University Mohammed V in Rabat, Rabat, Morocco
- Department of Medical Genetics, National Institute of Health in Rabat, BP 769 Agdal, 10 090, Rabat, Morocco
| | - Fatima Zahra Laarabi
- Department of Medical Genetics, National Institute of Health in Rabat, BP 769 Agdal, 10 090, Rabat, Morocco
| | - Jaber Lyahyai
- Research Team in Genomics and Molecular Epidemiology of Genetic Diseases, Genomics Center of Human Pathologies, Faculty of Medicine and Pharmacy, University Mohammed V in Rabat, Rabat, Morocco
| | - Abdelaziz Sefiani
- Research Team in Genomics and Molecular Epidemiology of Genetic Diseases, Genomics Center of Human Pathologies, Faculty of Medicine and Pharmacy, University Mohammed V in Rabat, Rabat, Morocco
- Department of Medical Genetics, National Institute of Health in Rabat, BP 769 Agdal, 10 090, Rabat, Morocco
| | - Ilham Ratbi
- Research Team in Genomics and Molecular Epidemiology of Genetic Diseases, Genomics Center of Human Pathologies, Faculty of Medicine and Pharmacy, University Mohammed V in Rabat, Rabat, Morocco
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Orlova A, Guseva D, Demina N, Polyakov A, Ryzhkova O. Spectrum of Mutations in PTPN11 in Russian Cohort. Genes (Basel) 2024; 15:345. [PMID: 38540404 PMCID: PMC10970286 DOI: 10.3390/genes15030345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 06/14/2024] Open
Abstract
Noonan syndrome is a group of diseases with a similar clinical picture, consisting of 16 diseases caused by mutations in 15 genes. According to the literature, approximately half of all cases are attributed to Noonan syndrome type 1, NSML, caused by mutations in the PTPN11 gene. We analyzed 456 unrelated probands using a gene panel NGS, and in 206 cases, the cause of the disease was identified. Approximately half of the cases (107) were caused by variants in the PTPN11 gene, including three previously undescribed variants, one of which was classified as VOUS, and the other two as LP causative complex alleles. Frequent variants of the PTPN11 gene characteristics for Russian patients were identified, accounting for more than 38% (c.922A>G p.Asn308Asp, c.417G>C p.Glu139Asp, c.1403C>T p.Thr468Met) of all cases with mutations in the PTPN11 gene. A comparative characterization of frequent variants of the PTPN11 gene in different populations is shown. The most common features of Noonan syndrome in the studied sample were facial dysmorphisms and cardiovascular system abnormalities. A lower representation of patients with growth delay was observed compared to previously described samples.
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Affiliation(s)
- Anna Orlova
- SRC «Genome», Research Centre for Medical Genetics, 115522 Moscow, Russia;
| | - Daria Guseva
- Counselling Unit, Research Centre for Medical Genetics, 115522 Moscow, Russia; (D.G.); (N.D.)
| | - Nina Demina
- Counselling Unit, Research Centre for Medical Genetics, 115522 Moscow, Russia; (D.G.); (N.D.)
| | - Aleksander Polyakov
- DNA-Diagnostics Laboratory, Research Centre for Medical Genetics, 115522 Moscow, Russia;
| | - Oksana Ryzhkova
- SRC «Genome», Research Centre for Medical Genetics, 115522 Moscow, Russia;
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Tabib A, Talebi T, Ghasemi S, Pourirahim M, Naderi N, Maleki M, Kalayinia S. A novel stop-gain pathogenic variant in FLT4 and a nonsynonymous pathogenic variant in PTPN11 associated with congenital heart defects. Eur J Med Res 2022; 27:286. [PMID: 36496429 PMCID: PMC9737984 DOI: 10.1186/s40001-022-00920-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Congenital heart defects (CHDs) are the most common congenital malformations, including structural malformations in the heart and great vessels. CHD complications such as low birth weight, prematurity, pregnancy termination, mortality, and morbidity depend on the type of defect. METHODS In the present research, genetic analyses via whole-exome sequencing (WES) was performed on 3 unrelated pedigrees with CHDs. The candidate variants were confirmed, segregated by PCR-based Sanger sequencing, and evaluated by bioinformatics analysis. RESULTS A novel stop-gain c.C244T:p.R82X variant in the FLT4 gene, as well as a nonsynonymous c.C1403T:p.T468M variant in the PTPN11 gene, was reported by WES. FLT4 encodes a receptor tyrosine kinase involved in lymphatic development and is known as vascular endothelial growth factor 3. CONCLUSIONS We are the first to report a novel c.C244T variant in the FLT4 gene associated with CHDs. Using WES, we also identified a nonsynonymous variant affecting protein-tyrosine phosphatase, the non-receptor type 11 (PTPN11) gene. The clinical implementation of WES can determine gene variants in diseases with high genetic and phenotypic heterogeneity like CHDs.
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Affiliation(s)
- Avisa Tabib
- grid.411746.10000 0004 4911 7066Heart Valve Diseases Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Taravat Talebi
- grid.411746.10000 0004 4911 7066Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Serwa Ghasemi
- grid.411463.50000 0001 0706 2472Department of Biology, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Maryam Pourirahim
- grid.411746.10000 0004 4911 7066Cardiogenetic Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Niloofar Naderi
- grid.411746.10000 0004 4911 7066Cardiogenetic Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Majid Maleki
- grid.411746.10000 0004 4911 7066Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Samira Kalayinia
- grid.411746.10000 0004 4911 7066Cardiogenetic Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Hübner CT, Amin AK, Dey D, Meyer R, Eggermann T. Mosaic Variegated Aneuploidy Syndrome and Noonan Syndrome in the Same Family. Mol Syndromol 2022; 13:402-408. [PMID: 36588761 PMCID: PMC9801314 DOI: 10.1159/000523877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/26/2022] [Indexed: 01/04/2023] Open
Abstract
Introduction Mosaic variegated aneuploidy syndrome 2 (MVA2) and Noonan syndrome (NS) are 2 genetic disorders with overlapping clinical features, including intrauterine growth retardation, dysmorphic features, and heart defects. Whereas NS is a well-known congenital entity, MVA2 is rare, and only a few cases have been reported in the literature. Case Presentation We report on the molecular findings in 3 patients with short stature phenotypes from the same family. By considering the clinical overlap between the patients, a common cause for the small stature was assumed in the beginning, but by whole exome analysis (WES) it turned out that the phenotypes were caused by different pathogenic variants in CEP57 and PTPN11, respectively. As a result, both MVA2 and NS occurred in the same family. Conclusion As our example shows, the parallel occurrence of pathogenic alterations in different genes in the same family constitutes a challenge for the interpretation of WES data and has to be considered. The diagnostic workup illustrates the need for a careful anamnesis and molecular documentation in affected and healthy family members. The knowledge on the different molecular causes underlying the features of the affected family members is the basis for personalised therapeutic managements and can avoid unnecessary burden and even contraindicated therapies; while in patients with NS carrying PTPN11 variants growth hormone treatment leads to height increase, patients with MVA2 carrying CEP57 probably do not benefit from it.
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Affiliation(s)
- Christian T. Hübner
- Institute of Human Genetics, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Asmaa K. Amin
- Department of Human Genetics, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Daniela Dey
- Institute of Human Genetics, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Robert Meyer
- Institute of Human Genetics, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Thomas Eggermann
- Institute of Human Genetics, Medical Faculty, RWTH Aachen University, Aachen, Germany,*Thomas Eggermann,
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Porras AR, Summar M, Linguraru MG. Objective differential diagnosis of Noonan and Williams-Beuren syndromes in diverse populations using quantitative facial phenotyping. Mol Genet Genomic Med 2021; 9:e1636. [PMID: 33773094 PMCID: PMC8172204 DOI: 10.1002/mgg3.1636] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/10/2021] [Indexed: 01/07/2023] Open
Abstract
Introduction Patients with Noonan and Williams–Beuren syndrome present similar facial phenotypes modulated by their ethnic background. Although distinctive facial features have been reported, studies show a variable incidence of those characteristics in populations with diverse ancestry. Hence, a differential diagnosis based on reported facial features can be challenging. Although accurate diagnoses are possible with genetic testing, they are not available in developing and remote regions. Methods We used a facial analysis technology to identify the most discriminative facial metrics between 286 patients with Noonan and 161 with Williams‐Beuren syndrome with diverse ethnic background. We quantified the most discriminative metrics, and their ranges both globally and in different ethnic groups. We also created population‐based appearance images that are useful not only as clinical references but also for training purposes. Finally, we trained both global and ethnic‐specific machine learning models with previous metrics to distinguish between patients with Noonan and Williams–Beuren syndromes. Results We obtained a classification accuracy of 85.68% in the global population evaluated using cross‐validation, which improved to 90.38% when we adapted the facial metrics to the ethnicity of the patients (p = 0.024). Conclusion Our facial analysis provided for the first time quantitative reference facial metrics for the differential diagnosis Noonan and Williams–Beuren syndromes in diverse populations.
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Affiliation(s)
- Antonio R Porras
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, D.C., USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Marshal Summar
- Rare Disease Institute - Genetics and Metabolism, Children's National Hospital, Washington, D.C., USA
| | - Marius George Linguraru
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, D.C., USA.,School of Medicine and Health sciences, George Washington University, Washington, D.C., USA
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Orrego-González E, Martin-Restrepo C, Velez-Van-Meerbeke A. Noonan Syndrome with Multiple Lentigines and PTPN11 Mutation: A Case with Intracerebral Hemorrhage. Mol Syndromol 2021; 12:57-63. [PMID: 33776629 DOI: 10.1159/000512374] [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: 08/10/2020] [Accepted: 10/16/2020] [Indexed: 01/02/2023] Open
Abstract
Noonan syndrome with multiple lentigines (NSML), previously known as LEOPARD syndrome, is a rare autosomal dominant disorder with an unknown prevalence. Characteristics of this disease include cutaneous, neurologic, and cardiologic abnormalities. In this case report, we present a 12-year-old girl who was admitted to the emergency department for acute-onset left weakness, unsteady gait, nausea, and vomiting. Her physical exam notably showed left side upper motor neuron signs and dysmetria. CT scan revealed an acute hemorrhage of the right thalamus. Physical exam exhibited several craniofacial dysmorphisms and lentigines. The genetic test revealed a heterozygous missense mutation in the protein tyrosine phosphatase non-receptor type 11 (PTPN11) gene and a variant of unknown significance of the MYH11 gene. To the best of our knowledge, this is the first case of a patient with NSML presenting an intracerebral hemorrhage.
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Affiliation(s)
- Eduardo Orrego-González
- Research Group in Neurosciences (NEUROS), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Carlos Martin-Restrepo
- GENIUROS Research Group, Center for Research in Genetics and Genomics-CIGGUR, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Alberto Velez-Van-Meerbeke
- Research Group in Neurosciences (NEUROS), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
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Athota JP, Bhat M, Nampoothiri S, Gowrishankar K, Narayanachar SG, Puttamallesh V, Farooque MO, Shetty S. Molecular and clinical studies in 107 Noonan syndrome affected individuals with PTPN11 mutations. BMC MEDICAL GENETICS 2020; 21:50. [PMID: 32164556 PMCID: PMC7068896 DOI: 10.1186/s12881-020-0986-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 02/25/2020] [Indexed: 02/08/2023]
Abstract
Background Noonan syndrome (NS), an autosomal dominant developmental genetic disorder, is caused by germline mutations in genes associated with the RAS / mitogen-activated protein kinase (MAPK) pathway. In several studies PTPN11 is one of the genes with a significant number of pathogenic variants in NS-affected patients. Therefore, clinically diagnosed NS individuals are initially tested for pathogenic variants in PTPN11 gene to confirm the relationship before studying genotype–phenotype correlation. Methods Individuals (363) with clinically diagnosed NS from four hospitals in South India were recruited and the exons of PTPN11 gene were sequenced. Results Thirty-two previously described pathogenic variants in eight different exons in PTPN11 gene were detected in 107 patients, of whom 10 were familial cases. Exons 3, 8 and 13 had the highest number of pathogenic variants. The most commonly identified pathogenic variants in this series were in exon 8 (c.922A > G, c.923A > G), observed in 22 of the affected. Congenital cardiac anomalies were present in 84% of the mutation-positive cohort, the majority being defects in the right side of the heart. The most common facial features were downward-slanting palpebral fissures, hypertelorism and low-set posteriorly rotated ears. Other clinical features included short stature (40%), pectus excavatum (54%) and, in males, unilateral or bilateral cryptorchidism (44%). Conclusion The clinical features and mutational spectrum observed in our cohort are similar to those reported in other large studies done worldwide. This is the largest case series of NS-affected individuals with PTPN11 mutations described till date from India.
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Affiliation(s)
| | - Meenakshi Bhat
- Molecular Genetics, Centre for Human Genetics, Bengaluru, 560100, India.,Pediatric Genetics, Indira Gandhi Institute of Child Health, Bengaluru, 560029, India
| | - Sheela Nampoothiri
- Pediatric Genetics, Amrita Institute of Medical Sciences & Research Centre (AIMS), Kochi, 682041, India
| | | | | | | | | | - Swathi Shetty
- Molecular Genetics, Centre for Human Genetics, Bengaluru, 560100, India.
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El Bouchikhi I, Bouguenouch L, Moufid FZ, Samri I, Abdouss F, Melhouf MA, Iraqui Houssaini M, Belhassan K, Atmani S, Ouldim K. Molecular and environmental characterization of Noonan syndrome in Morocco reveals a significant association with consanguinity and advanced parental age. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2020. [DOI: 10.1186/s43042-020-0047-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Abstract
Background
Noonan syndrome (NS) is one of the most common RASopathies, with an autosomal dominant inheritance. This disorder is caused by a range of genes belonging to the RAS-MAP kinase (rat sarcoma viral oncogene homolog/mitogen-activated protein kinases) pathway, with PTPN11 (protein-tyrosine phosphatase, non-receptor type 11) being the most involved genetic factor.
The aim of this study is to report PTPN11 mutations found in a cohort of Moroccans with Noonan syndrome, compare the mutation rate with various studies, and statistically assess involvement of prominent risk factors in manifestation of this disorder.
Thirty-one NS patients were screened for PTPN11 mutations using PCR-Sanger sequencing method. Pathogenic effect prediction, for detected variants, was carried out using PROVEAN, MutationTaster2, and HSF programs. Statistical tests were performed with R software. Chi-square and Fisher’s exact tests were used in percentage comparisons, while Student’s test was used in average comparisons.
Results
We detected five pathogenic mutations, one synonymous variant with a potential altering effect on splicing function, and three novel intronic duplications. PTPN11 mutation rate in our cohort is around 16.13%. Comparison of this rate with the corresponding rates in various populations shows notably significant differences across continents.
Conclusions
Besides genetic factors, the present study suggests involvement of additional environmental factors. Statistical assessment of clinical data confirms particularly the association of NS manifestation with consanguinity and advanced paternal age, and suggests an eventual implication of advanced maternal age as well.
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Tafazoli A, Eshraghi P, Pantaleoni F, Vakili R, Moghaddassian M, Ghahraman M, Muto V, Paolacci S, Golyan FF, Abbaszadegan MR. Novel mutations and their genotype-phenotype correlations in patients with Noonan syndrome, using next-generation sequencing. Adv Med Sci 2018; 63:87-93. [PMID: 28957739 DOI: 10.1016/j.advms.2017.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 06/29/2017] [Accepted: 07/07/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE Noonan Syndrome (NS) is an autosomal dominant disorder with many variable and heterogeneous conditions. The genetic basis for 20-30% of cases is still unknown. This study evaluates Iranian Noonan patients both clinically and genetically for the first time. MATERIALS/METHODS Mutational analysis of PTPN11 gene was performed in 15 Iranian patients, using PCR and Sanger sequencing at phase one. Then, as phase two, Next Generation Sequencing (NGS) in the form of targeted resequencing was utilized for analysis of exons from other related genes. Homology modelling for the novel founded mutations was performed as well. The genotype, phenotype correlation was done according to the molecular findings and clinical features. RESULTS Previously reported mutation (p.N308D) in some patients and a novel mutation (p.D155N) in one of the patients were identified in phase one. After applying NGS methods, known and new variants were found in four patients in other genes, including: CBL (p. V904I), KRAS (p. L53W), SOS1 (p. I1302V), and SOS1 (p. R552G). Structural studies of two deduced novel mutations in related genes revealed deficiencies in the mutated proteins. Following genotype, phenotype correlation, a new pattern of the presence of intellectual disability in two patients was registered. CONCLUSIONS NS shows strong variable expressivity along the high genetic heterogeneity especially in distinct populations and ethnic groups. Also possibly unknown other causative genes may be exist. Obviously, more comprehensive and new technologies like NGS methods are the best choice for detection of molecular defects in patients for genotype, phenotype correlation and disease management.
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Affiliation(s)
- Alireza Tafazoli
- Medical Genetics Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Peyman Eshraghi
- Department of Pediatrics, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Francesca Pantaleoni
- Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy; Research Center, Genetic and Rare Diseases, Ospedale Pediatrico Bambino Gesù, IRCSS, Rome, Italy
| | - Rahim Vakili
- Department of Pediatrics, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Morteza Moghaddassian
- The Edward S. Rogers Sr. Department of Electrical and Computer Engineering, Faculty of Applied Science and Engineering, University of Toronto, ON, Canada
| | - Martha Ghahraman
- Medical Genetics Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; Razavi Cancer Research Center, Razavi Hospital, Imam Reza International University, Mashhad, Iran
| | - Valentina Muto
- Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
| | - Stefano Paolacci
- Department of Hematology, Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
| | - Fatemeh Fardi Golyan
- Medical Genetics Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Kruszka P, Porras AR, Addissie YA, Moresco A, Medrano S, Mok GTK, Leung GKC, Tekendo-Ngongang C, Uwineza A, Thong MK, Muthukumarasamy P, Honey E, Ekure EN, Sokunbi OJ, Kalu N, Jones KL, Kaplan JD, Abdul-Rahman OA, Vincent LM, Love A, Belhassan K, Ouldim K, El Bouchikhi I, Shukla A, Girisha KM, Patil SJ, Sirisena ND, Dissanayake VHW, Paththinige CS, Mishra R, Klein-Zighelboim E, Gallardo Jugo BE, Chávez Pastor M, Abarca-Barriga HH, Skinner SA, Prijoles EJ, Badoe E, Gill AD, Shotelersuk V, Smpokou P, Kisling MS, Ferreira CR, Mutesa L, Megarbane A, Kline AD, Kimball A, Okello E, Lwabi P, Aliku T, Tenywa E, Boonchooduang N, Tanpaiboon P, Richieri-Costa A, Wonkam A, Chung BHY, Stevenson RE, Summar M, Mandal K, Phadke SR, Obregon MG, Linguraru MG, Muenke M. Noonan syndrome in diverse populations. Am J Med Genet A 2017; 173:2323-2334. [PMID: 28748642 DOI: 10.1002/ajmg.a.38362] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 06/24/2017] [Indexed: 12/21/2022]
Abstract
Noonan syndrome (NS) is a common genetic syndrome associated with gain of function variants in genes in the Ras/MAPK pathway. The phenotype of NS has been well characterized in populations of European descent with less attention given to other groups. In this study, individuals from diverse populations with NS were evaluated clinically and by facial analysis technology. Clinical data and images from 125 individuals with NS were obtained from 20 countries with an average age of 8 years and female composition of 46%. Individuals were grouped into categories of African descent (African), Asian, Latin American, and additional/other. Across these different population groups, NS was phenotypically similar with only 2 of 21 clinical elements showing a statistically significant difference. The most common clinical characteristics found in all population groups included widely spaced eyes and low-set ears in 80% or greater of participants, short stature in more than 70%, and pulmonary stenosis in roughly half of study individuals. Using facial analysis technology, we compared 161 Caucasian, African, Asian, and Latin American individuals with NS with 161 gender and age matched controls and found that sensitivity was equal to or greater than 94% for all groups, and specificity was equal to or greater than 90%. In summary, we present consistent clinical findings from global populations with NS and additionally demonstrate how facial analysis technology can support clinicians in making accurate NS diagnoses. This work will assist in earlier detection and in increasing recognition of NS throughout the world.
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Affiliation(s)
- Paul Kruszka
- Medical Genetics Branch, National Human Genome Research Institute, The National Institutes of Health, Bethesda, Maryland
| | - Antonio R Porras
- Children's National Health System, Sheikh Zayed Institute for Pediatric Surgical Innovation, Washington, District of Columbia
| | - Yonit A Addissie
- Medical Genetics Branch, National Human Genome Research Institute, The National Institutes of Health, Bethesda, Maryland
| | - Angélica Moresco
- Servicio de Genética, Hospital de Pediatría Garrahan, Buenos Aires, Argentina
| | - Sofia Medrano
- Servicio de Genética, Hospital de Pediatría Garrahan, Buenos Aires, Argentina
| | - Gary T K Mok
- LKS Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Gordon K C Leung
- LKS Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | | | - Annette Uwineza
- Center of Human Genetics, School of Medicine and Pharmacy, College of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
| | - Meow-Keong Thong
- Faculty of Medicine,Department of Paediatrics, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Engela Honey
- Department of Genetics, University of Pretoria, Pretoria, South Africa
| | - Ekanem N Ekure
- Department of Paediatrics College of Medicine, University of Lagos, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Ogochukwu J Sokunbi
- Department of Paediatrics College of Medicine, University of Lagos, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Nnenna Kalu
- Department of Paediatrics College of Medicine, University of Lagos, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Kelly L Jones
- Division of Medical Genetics, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Julie D Kaplan
- Division of Medical Genetics, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Omar A Abdul-Rahman
- Division of Medical Genetics, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | | | | | - Khadija Belhassan
- Medical Genetics Branch, National Human Genome Research Institute, The National Institutes of Health, Bethesda, Maryland.,Medical Genetics and Oncogenetics Unit, Hassan II University Hospital, Fez, Morocco
| | - Karim Ouldim
- Medical Genetics and Oncogenetics Unit, Hassan II University Hospital, Fez, Morocco
| | - Ihssane El Bouchikhi
- Medical Genetics and Oncogenetics Unit, Hassan II University Hospital, Fez, Morocco.,Faculty of Sciences and Techniques,Laboratory of Microbial Biotechnology, University of Sidi Mohammed Ben Abdellah, Fez, Morocco
| | - Anju Shukla
- Department of Medical Genetics, Kasturba Medical College, Manipal University, Manipal, India
| | - Katta M Girisha
- Department of Medical Genetics, Kasturba Medical College, Manipal University, Manipal, India
| | | | - Nirmala D Sirisena
- Faculty of Medicine, Human Genetics Unit, University of Colombo, Colombo, Sri Lanka
| | | | | | - Rupesh Mishra
- Faculty of Medicine, Human Genetics Unit, University of Colombo, Colombo, Sri Lanka
| | | | | | | | | | | | | | - Eben Badoe
- School of Medicine and Dentistry,Department of Child Health, College of Health Sciences, Accra, Ghana
| | - Ashleigh D Gill
- Medical Genetics Branch, National Human Genome Research Institute, The National Institutes of Health, Bethesda, Maryland
| | - Vorasuk Shotelersuk
- Faculty of Medicine,Center of Excellence for Medical Genetics, Department of Pediatrics, Chulalongkorn University, Bangkok, Thailand
| | - Patroula Smpokou
- Division of Genetics and Metabolism, Children's National Health System, Washington, District of Columbia
| | - Monisha S Kisling
- Division of Genetics and Metabolism, Children's National Health System, Washington, District of Columbia
| | - Carlos R Ferreira
- Division of Genetics and Metabolism, Children's National Health System, Washington, District of Columbia
| | - Leon Mutesa
- Center of Human Genetics, School of Medicine and Pharmacy, College of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
| | | | - Antonie D Kline
- Harvey Institute for Human Genetics, Greater Baltimore Medical Center, Baltimore, Maryland
| | - Amy Kimball
- Harvey Institute for Human Genetics, Greater Baltimore Medical Center, Baltimore, Maryland
| | | | | | | | - Emmanuel Tenywa
- Uganda Heart Institute, Kampala, Uganda.,Jinja Regional Referral Hospital, Jinja, Uganda
| | - Nonglak Boonchooduang
- Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Chiangmai University, Chiang Mai, Thailand
| | - Pranoot Tanpaiboon
- Division of Genetics and Metabolism, Children's National Health System, Washington, District of Columbia
| | - Antonio Richieri-Costa
- Hospital for the Rehabilitation of Craniofacial Anomalies, São Paulo University, Bauru, Brazil
| | - Ambroise Wonkam
- Division of Human Genetics, University of Cape Town, Cape Town, South Africa
| | - Brian H Y Chung
- LKS Faculty of Medicine, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | | | - Marshall Summar
- Division of Genetics and Metabolism, Children's National Health System, Washington, District of Columbia
| | - Kausik Mandal
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Shubha R Phadke
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - María G Obregon
- Servicio de Genética, Hospital de Pediatría Garrahan, Buenos Aires, Argentina
| | - Marius G Linguraru
- Children's National Health System, Sheikh Zayed Institute for Pediatric Surgical Innovation, Washington, District of Columbia
| | - Maximilian Muenke
- Medical Genetics Branch, National Human Genome Research Institute, The National Institutes of Health, Bethesda, Maryland
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11
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Ebrahimi-Fakhari D, Freiman E, Wojcik MH, Krone K, Casey A, Winn AS, Roberts AE, Harper BD. Congenital Chylothorax as the Initial Presentation of PTPN11-Associated Noonan Syndrome. J Pediatr 2017; 185:248-248.e1. [PMID: 28363362 PMCID: PMC5529256 DOI: 10.1016/j.jpeds.2017.02.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 02/15/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Darius Ebrahimi-Fakhari
- Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA,Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA,Corresponding Author: Dr. Darius Ebrahimi-Fakhari, Department of Medicine & Department of Neurology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA, Phone: 617-919-4377; Fax: 617-738-7066;
| | - Eli Freiman
- Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Monica H. Wojcik
- Division of Genetics and Genomics, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA,Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Katie Krone
- Division of Pulmonary and Respiratory Diseases, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Alicia Casey
- Division of Pulmonary and Respiratory Diseases, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ariel S. Winn
- Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy E. Roberts
- Division of Genetics and Genomics, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA,Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Beth D. Harper
- Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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12
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El Bouchikhi I, Belhassan K, Moufid FZ, Iraqui Houssaini M, Bouguenouch L, Samri I, Atmani S, Ouldim K. Noonan syndrome-causing genes: Molecular update and an assessment of the mutation rate. Int J Pediatr Adolesc Med 2016; 3:133-142. [PMID: 30805484 PMCID: PMC6372459 DOI: 10.1016/j.ijpam.2016.06.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 06/14/2016] [Indexed: 12/16/2022]
Abstract
Noonan syndrome is a common autosomal dominant disorder characterized by short stature, congenital heart disease and facial dysmorphia with an incidence of 1/1000 to 2500 live births. Up to now, several genes have been proven to be involved in the disturbance of the transduction signal through the RAS-MAP Kinase pathway and the manifestation of Noonan syndrome. The first gene described was PTPN11, followed by SOS1, RAF1, KRAS, BRAF, NRAS, MAP2K1, and RIT1, and recently SOS2, LZTR1, and A2ML1, among others. Progressively, the physiopathology and molecular etiology of most signs of Noonan syndrome have been demonstrated, and inheritance patterns as well as genetic counseling have been established. In this review, we summarize the data concerning clinical features frequently observed in Noonan syndrome, and then, we describe the molecular etiology as well as the physiopathology of most Noonan syndrome-causing genes. In the second part of this review, we assess the mutational rate of Noonan syndrome-causing genes reported up to now in most screening studies. This review should give clinicians as well as geneticists a full view of the molecular aspects of Noonan syndrome and the authentic prevalence of the mutational events of its causing-genes. It will also facilitate laying the groundwork for future molecular diagnosis research, and the development of novel treatment strategies.
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Key Words
- CDC25, cell division cycle 25
- CHD, congenital heart defects
- CR, conserved region
- CRD, cysteine-rich domain
- GAP, GTPase activating protein
- GDP, guanosine-DiPhosphate
- GEF, guanine exchange factor
- GH, growth hormone
- GTP, guanosine-TriPhosphate
- HCM, hypertrophic cardiomyopathy
- IGF-1, insulin-like growth factor I
- MAP kinase signaling pathways
- Molecular etiology
- Mutation rate
- Noonan syndrome
- PTPN11
- RAS family
- RBD, RAS binding domain
- REM, RAS exchange motif
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Affiliation(s)
- Ihssane El Bouchikhi
- Medical Genetics and Oncogenetics Laboratory, HASSAN II University Hospital, BP 1835, Atlas, Fez 30000, Morocco.,Laboratory of Microbial Biotechnology, Faculty of Sciences and Techniques, University of Sidi Mohammed Ben Abdellah, B.P. 2202, Route d'Imouzzer, Fez 30000, Morocco
| | - Khadija Belhassan
- Medical Genetics and Oncogenetics Laboratory, HASSAN II University Hospital, BP 1835, Atlas, Fez 30000, Morocco
| | - Fatima Zohra Moufid
- Medical Genetics and Oncogenetics Laboratory, HASSAN II University Hospital, BP 1835, Atlas, Fez 30000, Morocco.,Laboratory of Microbial Biotechnology, Faculty of Sciences and Techniques, University of Sidi Mohammed Ben Abdellah, B.P. 2202, Route d'Imouzzer, Fez 30000, Morocco
| | - Mohammed Iraqui Houssaini
- Laboratory of Microbial Biotechnology, Faculty of Sciences and Techniques, University of Sidi Mohammed Ben Abdellah, B.P. 2202, Route d'Imouzzer, Fez 30000, Morocco
| | - Laila Bouguenouch
- Medical Genetics and Oncogenetics Laboratory, HASSAN II University Hospital, BP 1835, Atlas, Fez 30000, Morocco
| | - Imane Samri
- Medical Genetics and Oncogenetics Laboratory, HASSAN II University Hospital, BP 1835, Atlas, Fez 30000, Morocco
| | - Samir Atmani
- Medico-Surgical Unit of Cardio-pediatrics, Department of Pediatrics, HASSAN II University Hospital, BP 1835, Atlas, Fez 30000, Morocco
| | - Karim Ouldim
- Medical Genetics and Oncogenetics Laboratory, HASSAN II University Hospital, BP 1835, Atlas, Fez 30000, Morocco
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13
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Edwards JJ, Martinelli S, Pannone L, Lo IFM, Shi L, Edelmann L, Tartaglia M, Luk HM, Gelb BD. A PTPN11 allele encoding a catalytically impaired SHP2 protein in a patient with a Noonan syndrome phenotype. Am J Med Genet A 2014; 164A:2351-5. [PMID: 24891296 DOI: 10.1002/ajmg.a.36620] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 05/04/2014] [Indexed: 11/10/2022]
Abstract
The RASopathies are a relatively common group of phenotypically similar and genetically related autosomal dominant genetic syndromes caused by missense mutations affecting genes participating in the RAS/mitogen-activated protein kinase (MAPK) pathway that include Noonan syndrome (NS) and Noonan syndrome with multiple lentigines (NSML, formerly LEOPARD syndrome). NS and NSML can be difficult to differentiate during infancy, but the presence of multiple lentigines, café au lait spots, and specific cardiac defects facilitate the diagnosis. Furthermore, individual PTPN11 missense mutations are highly specific to each syndrome and engender opposite biochemical alterations on the function of SHP-2, the protein product of that gene. Here, we report on a 5-year-old male with two de novo PTPN11 mutations in cis, c.1471C>T (p.Pro491Ser), and c.1492C>T (p.Arg498Trp), which are associated with NS and NSML, respectively. This boy's phenotype is intermediate between NS and NSML with facial dysmorphism, short stature, mild global developmental delay, pulmonic stenosis, and deafness but absence of café au lait spots or lentigines. The double-mutant SHP-2 was found to be catalytically impaired. This raises the question of whether clinical differences between NS and NSML can be ascribed solely to the relative SHP-2 catalytic activity.
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Affiliation(s)
- Jonathan J Edwards
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York; Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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14
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Mutational analysis of the PTPN11 gene in Egyptian patients with Noonan syndrome. J Formos Med Assoc 2013; 112:707-12. [DOI: 10.1016/j.jfma.2012.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2011] [Revised: 05/09/2012] [Accepted: 06/19/2012] [Indexed: 11/21/2022] Open
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15
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Romano AA, Allanson JE, Dahlgren J, Gelb BD, Hall B, Pierpont ME, Roberts AE, Robinson W, Takemoto CM, Noonan JA. Noonan syndrome: clinical features, diagnosis, and management guidelines. Pediatrics 2010; 126:746-59. [PMID: 20876176 DOI: 10.1542/peds.2009-3207] [Citation(s) in RCA: 371] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Noonan syndrome (NS) is a common, clinically and genetically heterogeneous condition characterized by distinctive facial features, short stature, chest deformity, congenital heart disease, and other comorbidities. Gene mutations identified in individuals with the NS phenotype are involved in the Ras/MAPK (mitogen-activated protein kinase) signal transduction pathway and currently explain ∼61% of NS cases. Thus, NS frequently remains a clinical diagnosis. Because of the variability in presentation and the need for multidisciplinary care, it is essential that the condition be identified and managed comprehensively. The Noonan Syndrome Support Group (NSSG) is a nonprofit organization committed to providing support, current information, and understanding to those affected by NS. The NSSG convened a conference of health care providers, all involved in various aspects of NS, to develop these guidelines for use by pediatricians in the diagnosis and management of individuals with NS and to provide updated genetic findings.
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Affiliation(s)
- Alicia A Romano
- Department of Pediatrics, Munger Pavilion, Room 123, New York Medical College, Valhalla, NY 10595, USA.
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16
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Lo FS, Luo JD, Lee YJ, Shu SG, Kuo MT, Chiou CC. High resolution melting analysis for mutation detection for PTPN11 gene: applications of this method for diagnosis of Noonan syndrome. Clin Chim Acta 2009; 409:75-7. [PMID: 19737548 DOI: 10.1016/j.cca.2009.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2009] [Revised: 08/28/2009] [Accepted: 08/28/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Noonan syndrome (NS, OMIM 163950) is a relatively common autosomal dominant disorder and has significant phenotypic overlap with Costello Syndrome and cardio-facio-cutaneous syndrome. Molecular diagnosis is useful for differential diagnosis. PTPN11 gene mutation is the most common mutation associated with NS and hence is a suitable target for molecular diagnostics. METHODS High resolution melting (HRM) analysis was used for screening of PTPN11 mutations. Eleven DNA samples with 10 known PTPN11 mutations were used for HRM calibration. Said calibrations were then applied to mutation screening of a panel of 50 additional NS patients. RESULTS HRM analysis differentiated all of the 10 known mutations and identified 9 additional mutations from 10 patients in the blind study, which is in line with results obtained by sequencing. CONCLUSIONS HRM analysis is a rapid, reliable, and low-cost tool for detection of PTPN11 genetic variants.
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Affiliation(s)
- Fu-Sung Lo
- Division of Pediatric Endocrinology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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17
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Lo FS, Lin JL, Kuo MT, Chiu PC, Shu SG, Chao MC, Lee YJ, Lin SP. Noonan syndrome caused by germline KRAS mutation in Taiwan: report of two patients and a review of the literature. Eur J Pediatr 2009; 168:919-23. [PMID: 18958496 DOI: 10.1007/s00431-008-0858-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Accepted: 10/09/2008] [Indexed: 11/30/2022]
Abstract
Noonan syndrome is a highly variable disorder that has significant phenotypic overlap with Costello syndrome and cardio-facio-cutaneous syndrome. KRAS mutation was the second reported gene for Noonan syndrome. This study screened for mutation of the KRAS gene in 57 unrelated ethnic Chinese children suffering from Noonan syndrome without PTPN11 gene mutation in Taiwan. This work only identified two patients with different missense mutations (c.40G>A, p.Val14Ile; c.108A>G, p.Ile36Met) in the exon 1 of KRAS gene. This study also analyzed the characteristics of 34 reported cases involving KRAS mutations in the literature. All these patients presented with variable phenotypes, including Noonan syndrome (n = 19), cardio-facio-cutaneous syndrome (n = 7), Costello syndrome (n = 6), and Noonan/cardio-facio-cutaneous syndrome (n = 1). The phenotype of KRAS mutations was generally severe, including short stature, mental retardation, heart defects, etc. In conclusion, this investigation demonstrates that KRAS mutations are the cause in a minority of cases of Chinese patients with Noonan syndrome in Taiwan.
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Affiliation(s)
- Fu-Sung Lo
- Department of Pediatrics, Division of Pediatric Endocrinology, Chang Gung Memorial Hospital, Chung Gung University College of Medicine, Kweishan, Taoyuan, Taiwan.
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18
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Hodgkin’s lymphoma in a patient with Noonan syndrome with germ-line PTPN11 mutations. Int J Hematol 2008; 88:287-290. [DOI: 10.1007/s12185-008-0157-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Accepted: 07/20/2008] [Indexed: 10/21/2022]
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