A Homozygous Missense Variant in Hedgehog Acyltransferase (HHAT) Gene Associated with 46,XY Gonadal Dysgenesis

Diverse genetic causes of amenorrhea in an ethnically homogeneous cohort and an evolving approach to diagnosis

RESEARCH QUESTION

Premature ovarian insufficiency (POI) is characterised by amenorrhea associated with elevated follicle stimulating hormone (FSH) under the age of 40 years and affects 1-3.7% women. Genetic factors explain 20-30% of POI cases, but most causes remain unknown despite genomic advancements.

DESIGN

We used whole exome sequencing (WES) in four Iranian families, validated variants via Sanger sequencing, and conducted the Acyl-cLIP assay to measure HHAT enzyme activity.

RESULTS

Despite ethnic homogeneity, WES revealed diverse genetic causes, including a novel homozygous nonsense variant in SYCP2L, impacting synaptonemal complex (SC) assembly, in the first family. Interestingly, the second family had two independent causes for amenorrhea - the mother had POI due to a novel homozygous loss-of-function variant in FANCM (required for chromosomal stability) and her daughter had primary amenorrhea due to a novel homozygous GNRHR (required for gonadotropic signalling) frameshift variant. WES analysis also provided cytogenetic insights. WES revealed one individual was in fact 46, XY and had a novel homozygous missense variant of uncertain significance in HHAT, potentially responsible for complete sex reversal although functional assays did not support impaired HHAT activity. In the remaining individual, WES indicated likely mosaic Turners with the majority of X chromosome variants having an allelic balance of ∼85% or ∼15%. Microarray validated the individual had 90% 45,XO.

CONCLUSIONS

This study demonstrates the diverse causes of amenorrhea in a small, isolated ethnic cohort highlighting how a genetic cause in one individual may not clarify familial cases. We propose that, in time, genomic sequencing may become a single universal test required for the diagnosis of infertility conditions such as POI.

Genetic control of typical and atypical sex development

Sex development relies on the sex-specific action of gene networks to differentiate the bipotential gonads of the growing fetus into testis or ovaries, followed by the differentiation of internal and external genitalia depending on the presence or absence of hormones. Differences in sex development (DSD) arise from congenital alterations during any of these processes, and are classified depending on sex chromosomal constitution as sex chromosome DSD, 46,XY DSD or 46,XX DSD. Understanding the genetics and embryology of typical and atypical sex development is essential for diagnosing, treating and managing DSD. Advances have been made in understanding the genetic causes of DSD over the past 10 years, especially for 46,XY DSD. Additional information is required to better understand ovarian and female development and to identify further genetic causes of 46,XX DSD, besides congenital adrenal hyperplasia. Ongoing research is focused on the discovery of further genes related to typical and atypical sex development and, therefore, on improving diagnosis of DSD.

Muscle spasms as presenting feature of Nivelon-Nivelon-Mabile syndrome

Hedgehog acyltransferase gene (HHAT)-associated Nivelon-Nivelon-Mabile syndrome (NNMS) is a rare genetic disorder of multiple system involvement with microcephaly, central nervous system malformations, skeletal dysplasia, and 46,XY sex reversal. Other variable and inconsistent features reported in this disorder are muscle spasms, facial dysmorphism, prenatal onset growth restriction, microphthalmia, and holoprosencephaly. This is the sixth postnatal reported patient with biallelic variants in HHAT gene, who presented with microcephaly, short stature, muscle hypertrophy, muscle spasms, and facial dysmorphism. The most prominent and presenting finding in this patient were muscle hypertrophy and muscle spasms which had a clinical response to phenytoin and acetazolamide treatment. Our report emphasizes the phenotypic variability of NNMS and further reiterates muscle spasms as an important clinical manifestation of this extremely rare condition.

Cloning, tissue distribution of desert hedgehog (dhh) gene and expression profiling during different developmental stages of Pseudopleuronectes yokohamae

As a crucial member of the Hedgehog (Hh) protein family, desert hedgehog (dhh) plays a vital role in multiple developmental processes, cell differentiation and tissue homeostasis. However, it is unclear how it regulates development in fish. In this study, we cloned and characterized the dhh gene from Pseudopleuronectes yokohamae. The full-length cDNA of Pydhh comprises 3194 bp, with a 1386 bp open reading frame (ORF) that encodes a polypeptide of 461 amino acids with a typical HH-signal domain, Hint-N and Hint-C domains. Multiple sequence alignment revealed that the putative PyDHH protein sequence was highly conserved across species, especially in the typical domains. Phylogenetic analysis showed that the PyDHH clustered within the Pleuronectiformes. Real-time quantitative PCR showed that Pydhh was detected in fourteen different tissues in adult-female and adult-male marbled flounder, and nine different tissues in juvenile fish. During early embryonic development stages, the expression of Pydhh was revealed high levels at hatching stage of embryo development. Moreover, the relative expression of Pydhh was significantly higher in the juvenile liver than adults', and higher in the female skin than the male skin. To further investigate its location, the in situ hybridization (ISH) assay was performed, the results showed that the hybridization signal was obviously expressed in the immune organs of Pseudopleuronectes yokohamae, with weak signal expression in the other tissues. Our results suggested that Pydhh is highly conserved among species and plays a vital role in embryonic development and formation of immune related organs.

Atypical Swyer Syndrome Presenting with Spontaneous Breast Development and Secondary Amenorrhea

46, XY pure gonadal dysgenesis (Swyer syndrome) is usually presented as sexual infantilism with delayed puberty and primary amenorrhea. Rarely, patients can present with spontaneous breast development and/or menstruation. A 32-year-old woman complained of secondary amenorrhea lasting 1 year. Her menarche occurred at the age of 15. On physical examination, her external genitals were completely feminine. Breast development and pubic hair were compatible with Tanner stage V. Pelvic ultrasound showed a small-sized uterus and gonads. Laboratory investigations revealed follicle-stimulating hormone (FSH) 75.86 mIU/mL, estradiol 28.67 pg/mL, testosterone 0.27 ng/mL, dehydroepiandrosterone sulfate (DHEAS) 260.55 ug/dL and anti-Müllerian hormone (AMH) < 0.02 ng/mL. Chromosomal analysis indicated a 46, XY karyotype. She underwent laparoscopic gonadectomy, and pathology revealed dysgenetic gonads without germ cell tumors. Only a few cases of Swyer syndrome, spontaneous breast development or spontaneous vaginal bleeding related with germ cell tumor have been reported in the literature. To my knowledge, this is the first report of Swyer syndrome with unexplained spontaneous breast development and menstruation, despite the absence of hormone-producing gonadal neoplasm.