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Tsou PY, Tapia IE. Tracheostomy and inpatient outcomes among children with congenital central hypoventilation syndrome: A kids' inpatient database study. Pediatr Pulmonol 2024; 59:1932-1943. [PMID: 38629429 DOI: 10.1002/ppul.27015] [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: 03/05/2024] [Revised: 04/03/2024] [Accepted: 04/05/2024] [Indexed: 07/22/2024]
Abstract
STUDY OBJECTIVES Congenital central hypoventilation syndrome (CCHS) is a rare disease predisposing children to respiratory failure due to abnormal ventilatory drive. Variability in hypoventilation and respiratory support need have been reported. We aim to identify clinical variables associated with incident tracheostomy and common etiologies of hospitalization among children with CCHS. METHODS Hospital discharge records were obtained for children (<21 years) with CCHS hospitalized between 2006 and 2019 from the Kid's Inpatient Database. Primary diagnostic categories for hospitalizations with CCHS were summarized. Multivariable logistic regression models were used to explore risk factors associated with incident tracheostomy. RESULTS Among 2404 hospitalizations with CCHS, 133 (5.5%) had incident tracheostomy, 1230 (51.2%) had established tracheostomy, and 1041 (43.3%) had no tracheostomy. Compared with children without tracheostomy, those with incident tracheostomy were younger, had a history of prematurity, congenital heart disease, laryngeal, glottic, and subglottic stenosis (LGSS), congenital airway anomalies, neuromuscular weakness, gastroesophageal reflux disease. Children without tracheostomy had higher mortality than those with tracheostomy status (2.19% vs. 0.66%). Multivariable-adjusted analyses showed that incident tracheostomy was associated with infancy (0-1 years), neuromuscular weakness, and congenital heart disease. Most common diagnostic categories include (1) diseases of the respiratory system (30.23%), (2) injury and poisoning (9.35%), and (3) diseases of the nervous system and sense organs (6.71%). CONCLUSIONS Children with CCHS who received incident tracheostomy are more likely to be younger and with LGSS, neuromuscular weakness and congenital heart disease. Clinicians should be aware of these risk factors representing more severe CCHS with earlier manifestation needing tracheostomy. Higher mortality among nontracheostomy group highlights the need for considering tracheostomy in caring for children with CCHS.
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Affiliation(s)
- Po-Yang Tsou
- Boston Children's Hospital, Harvard Medical School, Division of Pulmonary Medicine, Boston, Massachusetts, USA
| | - Ignacio E Tapia
- Division of Pediatric Pulmonology, University of Miami Health System, Miami, Florida, USA
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2
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Amos L. Later Onset Congenital Central Hypoventilation Syndrome. Med Clin North Am 2024; 108:215-226. [PMID: 37951652 DOI: 10.1016/j.mcna.2023.05.021] [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] [Indexed: 11/14/2023]
Abstract
Congenital central hypoventilation syndrome (CCHS) is a rare disorder of the autonomic nervous system involving multiple organ systems, with the hallmark symptom of respiratory failure due to aberrant central control of breathing resulting in hypoxemia and hypercapnia. Later onset CCHS (LOCCHS) is defined as the diagnosis of CCHS in children older than 1 month. Molecular genetic testing for PHOX2B variants has led not only to increased diagnosis of neonates with CCHS but also the increased identification of older children, adolescents, and adults with LOCCHS who may have a milder clinical presentation of this multisystem disease.
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Affiliation(s)
- Louella Amos
- Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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3
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Sivan Y, Bezalel Y, Adato A, Levy N, Efrati O. Congenital Central Hypoventilation Syndrome in Israel-Novel Findings from a New National Center. J Clin Med 2023; 12:3971. [PMID: 37373665 DOI: 10.3390/jcm12123971] [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: 04/13/2023] [Revised: 06/05/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Congenital central hypoventilation syndrome (CCHS) is a rare autosomal-dominant disorder of the autonomic nervous system that results from mutations in the PHOX2B gene. A national CCHS center was founded in Israel in 2018. Unique new findings were observed. METHODS All 27 CCHS patients in Israel were contacted and followed. Novel findings were observed. RESULTS The prevalence of new CCHS cases was almost twice higher compared to other countries. The most common mutations in our cohort were polyalanine repeat mutations (PARM) 20/25, 20/26, 20/27 (combined = 85% of cases). Two patients showed unique recessive inheritance while their heterozygotes family members were asymptomatic. A right-sided cardio-neuromodulation was performed on an eight-year-old boy for recurrent asystoles by ablating the parasympathetic ganglionated plexi using radiofrequency (RF) energy. Over 36 months' follow-up with an implantable loop-recorder, no bradycardias/pauses events were observed. A cardiac pacemaker was avoided. CONCLUSIONS A significant benefit and new information arise from a nationwide expert CCHS center for both clinical and basic purposes. The incidence of CCHS in some populations may be increased. Asymptomatic NPARM mutations may be much more common in the general population, leading to an autosomal recessive presentation of CCHS. RF cardio-neuromodulation offers a novel approach to children avoiding the need for permanent pacemaker implantation.
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Affiliation(s)
- Yakov Sivan
- National CCHS Center & Department of Pediatric Pulmonology, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Aviv 5262000, Israel
- Adelson School of Medicine, Ariel University, Ariel 4070000, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Yael Bezalel
- National CCHS Center & Department of Pediatric Pulmonology, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Aviv 5262000, Israel
| | - Avital Adato
- Yad LaNeshima, The Israeli CCHS Patients' Foundation, Tel Aviv 6927728, Israel
- Department of Natural and Life Sciences, The Open University of Israel, Ra'anana 4353701, Israel
| | - Navit Levy
- National CCHS Center & Department of Pediatric Pulmonology, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Aviv 5262000, Israel
| | - Ori Efrati
- National CCHS Center & Department of Pediatric Pulmonology, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Aviv 5262000, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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4
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Ueda A, Osawa M, Naito H, Ochiai E, Kakimoto Y. Non-polyalanine repeat mutation in PHOX2B is detected in autopsy cases of sudden unexpected infant death. PLoS One 2022; 17:e0267751. [PMID: 35486589 PMCID: PMC9053812 DOI: 10.1371/journal.pone.0267751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 04/15/2022] [Indexed: 11/18/2022] Open
Abstract
Background Congenital central hypoventilation syndrome (CCHS), which is caused by PHOX2B with phenotypic variations, has a point of controversy: CCHS is putatively involved in autopsy cases of sudden unexpected infant death (SUID) including sudden infant death syndrome. Objective The relation of CCHS to SUID cases was investigated by extensive genotyping of PHOX2B. Methods We analyzed 93 DNA samples of less than one-year-old SUID cases that were autopsied in our department. Unrelated adult volunteers (n = 942) were used as the control. Results No polyalanine tract expansion was detected in the SUID cases. The allelic frequencies of repeat contractions and SNP (rs28647582) in intron 2 were not significantly different from that in those control group. Further extensive sequencing revealed a non-polyalanine repeat mutation (NPARM) of c.905A>C in a sudden death case of a one-month-old male infant. This missense mutation (p.Asn302Thr), registered as rs779068107, was annotated to ‘Affected status is unknown’, but it might be associated with the sudden death. Conclusion NPARM was more plausibly related to sudden unexpected death than expansions because of severe clinical complications. This finding indicates possible CCHS involvement in forensic autopsy cases without ante-mortem diagnosis.
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Affiliation(s)
- Atsushi Ueda
- Department of Forensic Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Motoki Osawa
- Department of Forensic Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
- * E-mail:
| | - Haruaki Naito
- Department of Forensic Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Eriko Ochiai
- Department of Forensic Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
- Department of Legal Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Yu Kakimoto
- Department of Forensic Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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5
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Adolescent Congenital Central Hypoventilation Syndrome: An Easily Overlooked Diagnosis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182413402. [PMID: 34949014 PMCID: PMC8703802 DOI: 10.3390/ijerph182413402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022]
Abstract
Congenital central hypoventilation syndrome (CCHS), also known as Ondine’s curse, is a rare, potentially fatal genetic disease, manifesting as a lack of respiratory drive. Most diagnoses are made in pediatric patients, however late-onset cases have been rarely reported. Due to the milder symptoms at presentation that might easily go overlooked, these late-onset cases can result in serious health consequences later in life. Here, we present a case report of late-onset CCHS in an adolescent female patient. In this review we summarize the current knowledge about symptoms, as well as clinical management of CCHS, and describe in detail the molecular mechanism responsible for this disorder.
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6
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Kasi AS, Li H, Jurgensen TJ, Guglani L, Keens TG, Perez IA. Variable phenotypes in congenital central hypoventilation syndrome with PHOX2B nonpolyalanine repeat mutations. JOURNAL OF CLINICAL SLEEP MEDICINE : JCSM : OFFICIAL PUBLICATION OF THE AMERICAN ACADEMY OF SLEEP MEDICINE 2021; 17:2049-2055. [PMID: 33983112 DOI: 10.5664/jcsm.9370] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Congenital central hypoventilation syndrome (CCHS) is a rare disorder affecting the autonomic nervous system that is caused by variants in the PHOX2B gene. About 10% of patients with CCHS have nonpolyalanine repeat mutations (NPARM) that are associated with severe phenotypes requiring continuous assisted ventilation, Hirschsprung's disease, and increased neural crest tumor risk. However, some patients with NPARMs have milder phenotypes. Our objective was to describe the phenotypes in patients with CCHS PHOX2B NPARM. METHODS Retrospective case series of patients with CCHS PHOX2B NPARM was conducted at two children's hospitals to evaluate their phenotypes. RESULTS We identified eight patients with CCHS PHOX2B NPARM aged 3-31 years. Seven patients were diagnosed in infancy and one patient at two years of age. All patients presented with respiratory depression in the first two months of life. Only one patient was identified with a severe phenotype requiring continuous assisted ventilation, Hirschsprung's disease, and a neural crest tumor, that was resected. Five patients required positive pressure ventilation via tracheostomy only during sleep and two patients required oxygen only during sleep. Four patients had Hirschsprung's disease and one patient had a cardiac pacemaker due to a bradyarrhythmia. None of the patients had echocardiographic abnormalities. CONCLUSIONS Patients with CCHS PHOX2B NPARM can have variable phenotypes emphasizing the importance of implementing a plan of care that is individualized for each patient. The type of NPARM and its respective location on the PHOX2B gene may play a critical role in the severity of phenotypes displayed by each patient.
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Affiliation(s)
- Ajay S Kasi
- Department of Pediatrics, Division of Pediatric Pulmonology, Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Hong Li
- Department of Human Genetics, Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Taryn J Jurgensen
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Lokesh Guglani
- Department of Pediatrics, Division of Pediatric Pulmonology, Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Thomas G Keens
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA.,Keck School of Medicine of the University of Southern California
| | - Iris A Perez
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA.,Keck School of Medicine of the University of Southern California
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7
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Adult-onset congenital central hypoventilation syndrome due to PHOX2B mutation. Acta Neurol Belg 2021; 121:23-35. [PMID: 32335870 DOI: 10.1007/s13760-020-01363-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/16/2020] [Indexed: 01/29/2023]
Abstract
Central hypoventilation in adult patients is a rare life-threatening condition characterised by the loss of automatic breathing, more pronounced during sleep. In most cases, it is secondary to a brainstem lesion or to a primary pulmonary, cardiac or neuromuscular disease. More rarely, it can be a manifestation of congenital central hypoventilation syndrome (CCHS). We here describe a 25-year-old woman with severe central hypoventilation triggered by analgesics. Genetic analysis confirmed the diagnosis of adult-onset CCHS caused by a heterozygous de novo poly-alanine repeat expansion of the PHOX2B gene. She was treated with nocturnal non-invasive ventilation. We reviewed the literature and found 21 genetically confirmed adult-onset CCHS cases. Because of the risk of deleterious respiratory complications, adult-onset CCHS is an important differential diagnosis in patients with central hypoventilation.
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8
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Di Lascio S, Benfante R, Cardani S, Fornasari D. Research Advances on Therapeutic Approaches to Congenital Central Hypoventilation Syndrome (CCHS). Front Neurosci 2021; 14:615666. [PMID: 33510615 PMCID: PMC7835644 DOI: 10.3389/fnins.2020.615666] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/17/2020] [Indexed: 12/11/2022] Open
Abstract
Congenital central hypoventilation syndrome (CCHS) is a genetic disorder of neurodevelopment, with an autosomal dominant transmission, caused by heterozygous mutations in the PHOX2B gene. CCHS is a rare disorder characterized by hypoventilation due to the failure of autonomic control of breathing. Until now no curative treatment has been found. PHOX2B is a transcription factor that plays a crucial role in the development (and maintenance) of the autonomic nervous system, and in particular the neuronal structures involved in respiratory reflexes. The underlying pathogenetic mechanism is still unclear, although studies in vivo and in CCHS patients indicate that some neuronal structures may be damaged. Moreover, in vitro experimental data suggest that transcriptional dysregulation and protein misfolding may be key pathogenic mechanisms. This review summarizes latest researches that improved the comprehension of the molecular pathogenetic mechanisms responsible for CCHS and discusses the search for therapeutic intervention in light of the current knowledge about PHOX2B function.
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Affiliation(s)
- Simona Di Lascio
- Department of Medical Biotechnology and Translational Medicine (BIOMETRA), Università degli Studi di Milano, Milan, Italy
| | - Roberta Benfante
- Department of Medical Biotechnology and Translational Medicine (BIOMETRA), Università degli Studi di Milano, Milan, Italy.,CNR-Institute of Neuroscience, Milan, Italy.,NeuroMi-Milan Center for Neuroscience, University of Milano Bicocca, Milan, Italy
| | - Silvia Cardani
- Department of Medical Biotechnology and Translational Medicine (BIOMETRA), Università degli Studi di Milano, Milan, Italy
| | - Diego Fornasari
- Department of Medical Biotechnology and Translational Medicine (BIOMETRA), Università degli Studi di Milano, Milan, Italy.,CNR-Institute of Neuroscience, Milan, Italy
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9
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Hino A, Terada J, Kasai H, Shojima H, Ohgino K, Sasaki A, Hayasaka K, Tatsumi K. Adult cases of late-onset congenital central hypoventilation syndrome and paired-like homeobox 2B-mutation carriers: an additional case report and pooled analysis. J Clin Sleep Med 2020; 16:1891-1900. [PMID: 32741443 DOI: 10.5664/jcsm.8732] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Congenital central hypoventilation syndrome (CCHS) is caused by the paired-like homeobox 2B (PHOX2B) mutation and predominantly diagnosed during the neonatal period. Although late-onset CCHS and PHOX2B mutation carriers have been reported, the features of these disease states in adults remain uncertain. This study aimed to identify the characteristics of adult-onset CCHS and PHOX2B-mutation carriers in adult. METHODS We mainly searched the PubMed/Medline and Cochrane Databases and classified our target patients into 2 groups: group A, symptomatically diagnosed with late-onset CCHS in adulthood; group B, adult PHOX2B-mutation carriers. Then, clinical characteristics, including the onset, treatment, long-term course, and pattern of the PHOX2B mutation in both groups were analyzed. Additionally, a new adult-case of late-onset CCHS was added to the analysis. RESULTS Group A was comprised of 12 patients. The onset triggers of illness included a history of respiratory compromise following general anesthesia and respiratory tract infections. All patients in group A had 20/25 polyalanine repeat mutations and required some chronic ventilatory support at least during sleep, including portable positive pressure ventilator via tracheostomy or noninvasive positive pressure ventilation. In these patients with ventilatory support during sleep, sudden death or poor prognosis was not reported. Group B was comprised of 33 adults from 24 families with PHOX2B mutations. Nine patients in group B were confirmed with the diagnosis of CCHS. Although polyalanine repeat mutations 20/25 represented the most common gene mutation, diverse mutations, including mosaicism, were observed. Hypoventilation of several cases in group B were underdiagnosed by overnight polysomnography without monitoring for CO₂. CONCLUSION Alveolar hypoventilation with unknown origin can be caused by the PHOX2B mutation even in adult cases. Both the identification of the PHOX2B mutation and the incorporation of capnography in polysomnography are important for adult cases with unexplained alveolar hypoventilation or asymptomatic mutation carriers.
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Affiliation(s)
- Aoi Hino
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Jiro Terada
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hajime Kasai
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | | | - Keiko Ohgino
- Department of Respiratory Medicine, Kawasaki Municipal Hospital, Kawasaki City, Japan
| | - Ayako Sasaki
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata City, Japan
| | - Kiyoshi Hayasaka
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata City, Japan.,Department of Pediatrics, Miyukikai Hospital, Kaminoyama, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
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10
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Chahal CAA, Salloum MN, Alahdab F, Gottwald JA, Tester DJ, Anwer LA, So EL, Murad MH, St Louis EK, Ackerman MJ, Somers VK. Systematic Review of the Genetics of Sudden Unexpected Death in Epilepsy: Potential Overlap With Sudden Cardiac Death and Arrhythmia-Related Genes. J Am Heart Assoc 2020; 9:e012264. [PMID: 31865891 PMCID: PMC6988156 DOI: 10.1161/jaha.119.012264] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 09/25/2019] [Indexed: 12/29/2022]
Abstract
Background Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy-related death. SUDEP shares many features with sudden cardiac death and sudden unexplained death in the young and may have a similar genetic contribution. We aim to systematically review the literature on the genetics of SUDEP. Methods and Results PubMed, MEDLINE Epub Ahead of Print, Ovid Medline In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Scopus were searched through April 4, 2017. English language human studies analyzing SUDEP for known sudden death, ion channel and arrhythmia-related pathogenic variants, novel variant discovery, and copy number variant analyses were included. Aggregate descriptive statistics were generated; data were insufficient for meta-analysis. A total of 8 studies with 161 unique individuals were included; mean was age 29.0 (±SD 14.2) years; 61% males; ECG data were reported in 7.5% of cases; 50.7% were found prone and 58% of deaths were nocturnal. Cause included all types of epilepsy. Antemortem diagnosis of Dravet syndrome and autism (with duplication of chromosome 15) was associated with 11% and 9% of cases. The most frequently detected known pathogenic variants at postmortem were in Na+ and K+ ion channel subunits, as were novel potentially pathogenic variants (11%). Overall, the majority of variants were of unknown significance. Analysis of copy number variant was insignificant. Conclusions SUDEP case adjudication and evaluation remains limited largely because of crucial missing data such as ECGs. The most frequent pathogenic/likely pathogenic variants identified by molecular autopsy are in ion channel or arrhythmia-related genes, with an ≈11% discovery rate. Comprehensive postmortem examination should include examination of the heart and brain by specialized pathologists and blood storage.
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Affiliation(s)
- C. Anwar A. Chahal
- Mayo Clinic College of MedicineMayo ClinicRochesterMN
- Mayo Clinic Graduate School of Biomedical SciencesMayo ClinicRochesterMN
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
| | - Mohammad N. Salloum
- Internal MedicineIcahn School of Medicine at Mount SinaiQueens Hospital CenterNew YorkNY
| | - Fares Alahdab
- Evidence‐Based Practice Research ProgramMayo ClinicRochesterMN
- Division of Preventive, Occupational and Aerospace MedicineMayo ClinicRochesterMN
| | | | - David J. Tester
- Mayo Clinic College of MedicineMayo ClinicRochesterMN
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
- Windland Smith Rice Sudden Death Genomics LaboratoryMayo ClinicRochesterMN
| | - Lucman A. Anwer
- Mayo Clinic College of MedicineMayo ClinicRochesterMN
- Department of Cardiovascular SurgeryMayo ClinicRochesterMN
- General SurgeryUIC/MGHChicagoIL
| | - Elson L. So
- Evidence‐Based Practice Research ProgramMayo ClinicRochesterMN
| | - Mohammad Hassan Murad
- Evidence‐Based Practice Research ProgramMayo ClinicRochesterMN
- Division of Preventive, Occupational and Aerospace MedicineMayo ClinicRochesterMN
| | - Erik K. St Louis
- Mayo Clinic College of MedicineMayo ClinicRochesterMN
- Department of NeurologyMayo ClinicRochesterMN
- Mayo Center for Sleep MedicineMayo ClinicRochesterMN
| | - Michael J. Ackerman
- Mayo Clinic College of MedicineMayo ClinicRochesterMN
- Mayo Clinic Graduate School of Biomedical SciencesMayo ClinicRochesterMN
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
- Windland Smith Rice Sudden Death Genomics LaboratoryMayo ClinicRochesterMN
- Department of PediatricsMayo ClinicRochesterMN
| | - Virend K. Somers
- Mayo Clinic College of MedicineMayo ClinicRochesterMN
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
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11
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Sasaki A, Kishikawa Y, Imaji R, Fukushima Y, Nakamura Y, Nishimura Y, Yamada M, Mino Y, Mitsui T, Hayasaka K. Novel PHOX2B mutations in congenital central hypoventilation syndrome. Pediatr Int 2019; 61:393-396. [PMID: 30786110 DOI: 10.1111/ped.13812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 12/17/2018] [Accepted: 02/15/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Congenital central hypoventilation syndrome (CCHS) is caused by mutation of paird-like homeobox 2B (PHOX2B). Approximately 90% of patients were found to carry polyalanine repeat expansion mutation (PARM), and the remaining 10% had non-PARM (NPARM). In PARM, the length of the polyalanine expansion correlates with clinical disease severity. Most patients with NPARM have hypoventilation symptoms in the neonatal period and complications of Hirschsprung disease, dysregulation of autonomic nervous system, and tumors of neural crest origin. Data on the genotype-phenotype association may contribute to the clinical management of the disease. METHODS We studied the genetic background of Japanese CCHS patients according to PHOX2B sequencing. RESULTS Of 133 Japanese CCHS patients we identified 12 patients carrying 11 different NPARM (approx. 9% of the patients) and described the clinical manifestations in seven of them with the following novel mutations: c.941-945del5, c.678_693dup16, c.609_616del8, c.620_633del14, c.663_711del 49, c.448C>G and c.944G>C. All patients had hypoventilation in the neonatal period and also had Hirschsprung disease, with the exception of two patients carrying c.620_633del14 and c.663_711del49 mutations. The patient carrying the c.609_616del8 mutation also had a benign mediastinal tumor. CONCLUSION Most patients carrying NPARM had severe symptoms with frequent complications, as in previous reports, and should be carefully monitored for various complications, including neural crest-derived tumor.
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Affiliation(s)
- Ayako Sasaki
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata City, Japan
| | - Yumiko Kishikawa
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata City, Japan
| | - Reisuke Imaji
- Department of Pediatric Surgery, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Yu Fukushima
- Division of Neonatology, Nagano Children's Hospital, Azumino, Nagano, Japan
| | | | - Yutaka Nishimura
- Division of Neonatology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Megumi Yamada
- Division of Neonatology, Saitama City Hospital, Saitama, Japan
| | - Yoichi Mino
- Division of Pediatrics and Perinatology, Tottori University Faculty of Medicine, Yonago, Tottori, Japan
| | - Tetsuo Mitsui
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata City, Japan
| | - Kiyoshi Hayasaka
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata City, Japan.,Department of Pediatrics, Miyukikai Hospital, Kaminoyama, Yamagata, Japan
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12
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Sivan Y, Zhou A, Jennings LJ, Berry-Kravis EM, Yu M, Zhou L, Rand CM, Weese-Mayer DE. Congenital central hypoventilation syndrome: Severe disease caused by co-occurrence of two PHOX2B variants inherited separately from asymptomatic family members. Am J Med Genet A 2019; 179:503-506. [PMID: 30672101 DOI: 10.1002/ajmg.a.61047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/20/2018] [Accepted: 12/24/2018] [Indexed: 11/12/2022]
Abstract
Congenital Central Hypoventilation Syndrome (CCHS) is a rare disease characterized by autonomic nervous system dysregulation. Central hypoventilation is the most prominent and clinically important presentation. CCHS is caused by mutations in paired-like homeobox 2b (PHOX2B) and is inherited in an autosomal dominant pattern. A co-occurrence of two asymptomatic PHOX2B variants with a classical CCHS presentation highlights the importance of clinical PHOX2B testing in parents and family members of all CCHS probands. Despite being an autosomal dominant disease, once a polyalanine repeat expansion mutation has been identified, sequencing of the other allele should also be considered.
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Affiliation(s)
- Yakov Sivan
- Department of Pediatric Pulmonology and Sleep, Safra Children's Hospital, Sheba Medical Center, Tel Aviv University, Sackler Faculty of Medicine, Tel Aviv-Yafo, Israel
| | - Amy Zhou
- Division of Pediatric Autonomic Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, Illinois
| | - Lawrence J Jennings
- Molecular Diagnostics Laboratory, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Elizabeth M Berry-Kravis
- Departments of Pediatrics, Neurological Sciences and Biochemistry, Rush University Medical Center, Chicago, Illinois
| | - Min Yu
- Molecular Diagnostics Laboratory, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Lili Zhou
- Departments of Pediatrics, Neurological Sciences and Biochemistry, Rush University Medical Center, Chicago, Illinois
| | - Casey M Rand
- Division of Pediatric Autonomic Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, Illinois
| | - Debra E Weese-Mayer
- Division of Pediatric Autonomic Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, Illinois.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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13
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Kasi AS, Kun SS, Keens TG, Perez IA. Adult With PHOX2B Mutation and Late-Onset Congenital Central Hypoventilation Syndrome. J Clin Sleep Med 2018; 14:2079-2081. [PMID: 30518452 DOI: 10.5664/jcsm.7542] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/29/2019] [Indexed: 11/13/2022]
Abstract
ABSTRACT PHOX2B 20/27 polyalanine repeat mutation (PARM) in patients with congenital central hypoventilation syndrome (CCHS) is generally associated with full-time ventilator dependence, Hirschsprung disease, and increased risk for cardiac asystole. We follow a 14-year-old boy with CCHS PHOX2B 20/27 PARM who is full-time ventilator dependent via tracheostomy and has Hirschsprung disease. His mother, age 52 years, has a history of prolonged recovery from anesthesia and an elevated serum bicarbonate level of 45 mEq/L discovered on routine blood chemistry. PHOX2B gene mutation analysis was performed and showed an identical 20/27 PARM, diagnostic of CCHS. Late-onset CCHS has been reported in those with 20/24, 20/25 PHOX2B PARM, and in nonpolyalanine repeat mutations. This is the first report of a patient with PHOX2B 20/27 PARM with a mild phenotype diagnosed during adulthood. This unusual presentation supports the screening for PHOX2B mutations in parents of children with CCHS.
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Affiliation(s)
- Ajay S Kasi
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Sheila S Kun
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Thomas G Keens
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Iris A Perez
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine of the University of Southern California, Los Angeles, California
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14
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Di Lascio S, Benfante R, Cardani S, Fornasari D. Advances in the molecular biology and pathogenesis of congenital central hypoventilation syndrome—implications for new therapeutic targets. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1540978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Simona Di Lascio
- Department of Medical Biotechnology and Translational Medicine (BIOMETRA), Università degli Studi di Milano, Milan, Italy
| | - Roberta Benfante
- Department of Medical Biotechnology and Translational Medicine (BIOMETRA), Università degli Studi di Milano, Milan, Italy
- CNR- Neuroscience Institute, Milan, Italy
| | - Silvia Cardani
- Department of Medical Biotechnology and Translational Medicine (BIOMETRA), Università degli Studi di Milano, Milan, Italy
| | - Diego Fornasari
- Department of Medical Biotechnology and Translational Medicine (BIOMETRA), Università degli Studi di Milano, Milan, Italy
- CNR- Neuroscience Institute, Milan, Italy
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15
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Cardani S, Di Lascio S, Belperio D, Di Biase E, Ceccherini I, Benfante R, Fornasari D. Desogestrel down-regulates PHOX2B and its target genes in progesterone responsive neuroblastoma cells. Exp Cell Res 2018; 370:671-679. [PMID: 30036539 DOI: 10.1016/j.yexcr.2018.07.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 07/18/2018] [Accepted: 07/19/2018] [Indexed: 10/28/2022]
Abstract
The paired-like homeobox 2B gene (PHOX2B) encodes a key transcription factor that plays a role in the development of the autonomic nervous system and the neural structures involved in controlling breathing. In humans, PHOX2B over-expression plays a role in the pathogenesis of tumours arising from the sympathetic nervous system such as neuroblastomas, and heterozygous PHOX2B mutations cause Congenital Central Hypoventilation Syndrome (CCHS), a life-threatening neurocristopathy characterised by the defective autonomic control of breathing and involving altered CO2/H+ chemosensitivity. The recovery of CO2/H+ chemosensitivity and increased ventilation have been observed in two CCHS patients using the potent contraceptive progestin desogestrel. Given the central role of PHOX2B in the pathogenesis of CCHS, and the progesterone-mediated effects observed in the disease, we generated progesterone-responsive neuroblastoma cells, and evaluated the effects of 3-Ketodesogestrel (3-KDG), the biologically active metabolite of desogestrel, on the expression of PHOX2B and its target genes. Our findings demonstrate that, through progesterone nuclear receptor PR-B, 3-KDG down-regulates PHOX2B gene expression, by a post-transcriptional mechanism, and its target genes and open up the possibility that this mechanism may contribute to the positive effects observed in some CCHS patients.
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Affiliation(s)
- Silvia Cardani
- Dept. of Medical Biotechnology and Translational Medicine (BIOMETRA), Università degli Studi di Milano, via Vanvitelli 32, 2019 Milan, Italy
| | - Simona Di Lascio
- Dept. of Medical Biotechnology and Translational Medicine (BIOMETRA), Università degli Studi di Milano, via Vanvitelli 32, 2019 Milan, Italy
| | - Debora Belperio
- Dept. of Medical Biotechnology and Translational Medicine (BIOMETRA), Università degli Studi di Milano, via Vanvitelli 32, 2019 Milan, Italy
| | - Erika Di Biase
- Dept. of Medical Biotechnology and Translational Medicine (BIOMETRA), Università degli Studi di Milano, via Vanvitelli 32, 2019 Milan, Italy
| | - Isabella Ceccherini
- Laboratorio di Genetica Molecolare, Istituto Giannina Gaslini, Largo G. Gaslini 5, 16148 Genoa, Italy
| | - Roberta Benfante
- Dept. of Medical Biotechnology and Translational Medicine (BIOMETRA), Università degli Studi di Milano, via Vanvitelli 32, 2019 Milan, Italy; CNR -Neuroscience Institute, via Vanvitelli 32, 20129 Milan, Italy.
| | - Diego Fornasari
- Dept. of Medical Biotechnology and Translational Medicine (BIOMETRA), Università degli Studi di Milano, via Vanvitelli 32, 2019 Milan, Italy; CNR -Neuroscience Institute, via Vanvitelli 32, 20129 Milan, Italy.
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16
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Byers HM, Chen M, Gelfand AS, Ong B, Jendras M, Glass IA. Expanding the phenotype of congenital central hypoventilation syndrome impacts management decisions. Am J Med Genet A 2018; 176:1398-1404. [PMID: 29696799 DOI: 10.1002/ajmg.a.38726] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 04/01/2018] [Accepted: 04/04/2018] [Indexed: 11/10/2022]
Abstract
Congenital central hypoventilation syndrome (CCHS) is a neurocristopathy caused by pathogenic heterozygous variants in the gene paired-like homeobox 2b (PHOX2B). It is characterized by severe infantile alveolar hypoventilation. Individuals may also have diffuse autonomic nervous system dysfunction, Hirschsprung disease and neural crest tumors. We report three individuals with CCHS due to an 8-base pair duplication in PHOX2B; c.691_698dupGGCCCGGG (p.Gly234Alafs*78) with a predominant enteral and neural crest phenotype and a relatively mild respiratory phenotype. The attenuated respiratory phenotype reported here and elsewhere suggests an emergent genotype:phenotype correlation which challenges the current paradigm of invoking mechanical ventilation for all infants diagnosed with CCHS. Best treatment requires careful clinical judgment and ideally the assistance of a care team with expertise in CCHS.
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Affiliation(s)
- Heather M Byers
- Division of Medical Genetics, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Maida Chen
- Department of Pediatrics, University of Washington, Seattle, Washington.,Division of Pulmonary Medicine, Seattle Children's Hospital, Seattle, Washington
| | | | - Bruce Ong
- Division of Pediatric Pulmonology, Tripler Army Medical Center, Honolulu, Hawaii
| | | | - Ian A Glass
- Department of Pediatrics, University of Washington, Seattle, Washington.,Division of Medical Genetics, Seattle Children's Hospital, Seattle, Washington
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17
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Maloney MA, Kun SS, Keens TG, Perez IA. Congenital central hypoventilation syndrome: diagnosis and management. Expert Rev Respir Med 2018; 12:283-292. [DOI: 10.1080/17476348.2018.1445970] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Melissa A. Maloney
- Children’s Hospital Los Angeles, Division of Pediatric Pulmonology and Sleep Medicine, Los Angeles, USA
| | - Sheila S. Kun
- Children’s Hospital Los Angeles, Division of Pediatric Pulmonology and Sleep Medicine, Los Angeles, USA
| | - Thomas G. Keens
- Children’s Hospital Los Angeles, Division of Pediatric Pulmonology and Sleep Medicine, Los Angeles, USA
- Physiology and Biophysics, Keck School of Medicine of the University of Southern California, Los Angeles, USA
| | - Iris A. Perez
- Children’s Hospital Los Angeles, Division of Pediatric Pulmonology and Sleep Medicine, Los Angeles, USA
- Physiology and Biophysics, Keck School of Medicine of the University of Southern California, Los Angeles, USA
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18
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Di Lascio S, Benfante R, Di Zanni E, Cardani S, Adamo A, Fornasari D, Ceccherini I, Bachetti T. Structural and functional differences in PHOX2B frameshift mutations underlie isolated or syndromic congenital central hypoventilation syndrome. Hum Mutat 2017; 39:219-236. [PMID: 29098737 PMCID: PMC5846889 DOI: 10.1002/humu.23365] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/24/2017] [Accepted: 10/29/2017] [Indexed: 12/13/2022]
Abstract
Heterozygous mutations in the PHOX2B gene are causative of congenital central hypoventilation syndrome (CCHS), a neurocristopathy characterized by defective autonomic control of breathing due to the impaired differentiation of neural crest cells. Among PHOX2B mutations, polyalanine (polyAla) expansions are almost exclusively associated with isolated CCHS, whereas frameshift variants, although less frequent, are often more severe than polyAla expansions and identified in syndromic CCHS. This article provides a complete review of all the frameshift mutations identified in cases of isolated and syndromic CCHS reported in the literature as well as those identified by us and not yet published. These were considered in terms of both their structure, whether the underlying indels induced frameshifts of either 1 or 2 steps ("frame 2" and "frame 3" mutations respectively), and clinical associations. Furthermore, we evaluated the structural and functional effects of one "frame 3" mutation identified in a patient with isolated CCHS, and one "frame 2" mutation identified in a patient with syndromic CCHS, also affected with Hirschsprung's disease and neuroblastoma. The data thus obtained confirm that the type of translational frame affects the severity of the transcriptional dysfunction and the predisposition to isolated or syndromic CCHS.
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Affiliation(s)
- Simona Di Lascio
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Milan, Italy
| | - Roberta Benfante
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Milan, Italy.,CNR- Neuroscience Institute, Milan, Italy
| | | | - Silvia Cardani
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Milan, Italy
| | - Annalisa Adamo
- UOC Genetica Medica, Istituto Giannina Gaslini, Genoa, Italy
| | - Diego Fornasari
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Milan, Italy.,CNR- Neuroscience Institute, Milan, Italy
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19
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Kasi AS, Jurgensen TJ, Yen S, Kun SS, Keens TG, Perez IA. Three-Generation Family With Congenital Central Hypoventilation Syndrome and Novel PHOX2B Gene Non-Polyalanine Repeat Mutation. J Clin Sleep Med 2017. [PMID: 28633714 DOI: 10.5664/jcsm.6670] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
ABSTRACT PHOX2B non-polyalanine repeat mutation (NPARM) in patients with congenital central hypoventilation syndrome (CCHS) is generally considered to be associated with full-time ventilator dependence and severe autonomic nervous system dysfunction. We report a three-generation family with four individuals possessing a novel PHOX2B NPARM (c.245C > T) with variable phenotypes. This mutation was inherited in an autosomal dominant pattern with variable penetrance. The affected family members with CCHS have a milder phenotype than is typically expected with a NPARM. Two family members are ventilator dependent only during sleep and do not have Hirschsprung disease or neural crest tumors. One family member was asymptomatic until systemic hypertension developed during adulthood and another family member remains asymptomatic as an adult. Our findings emphasize the importance of monitoring adults with a PHOX2B NPARM who are considered asymptomatic in childhood.
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Affiliation(s)
- Ajay S Kasi
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Taryn J Jurgensen
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Stephanie Yen
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Sheila S Kun
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Thomas G Keens
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Iris A Perez
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine of the University of Southern California, Los Angeles, California
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20
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Lombardo RC, Kramer E, Cnota JF, Sawnani H, Hopkin RJ. Variable phenotype in a novel mutation in PHOX2B. Am J Med Genet A 2017; 173:1705-1709. [PMID: 28422456 DOI: 10.1002/ajmg.a.38218] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 02/13/2017] [Accepted: 02/17/2017] [Indexed: 11/10/2022]
Abstract
We evaluated a family with three siblings, two of whom ages 2 years and 19 months, had long segment colonic agangliosis and anisocoria. The mother also had anisocoria. All three affected family members were mildly dysmorphic with a flat facial profile, square appearance to the face, depressed nasal bridge, and anteverted nares. Genetic testing identified a novel heterozygous mutation, c.234C>G, resulting in a premature stop codon in exon 1 of the PHOX2B gene. Screening for neural crest tumors was performed in the siblings and to date has been negative. This family supports a strong association between non polyalanine tract mutations, autonomic dysfunction, and Hirschsprung disease, but suggests mutation outside of the polyalanine tract may not dictate severe phenotype with significant respiratory compromise. A unique finding in this family is the association of congenital heart disease in two of the affected patients. These malformations may be a sporadic isolated finding or the result of environmental factors or a modifying allele. Given the association between congenital heart disease and aberrant neural crest cell development, however, findings are suggestive that congenital heart disease may be a rare feature of PHOX2B mutation which has not been previously reported.
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Affiliation(s)
- Rachel C Lombardo
- Division of Human Genetics, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | - Elizabeth Kramer
- Division of Pulmonary Medicine, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | - James F Cnota
- Division of Cardiology, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | - Hemant Sawnani
- Division of Pulmonary Medicine, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | - Robert J Hopkin
- Division of Human Genetics, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
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21
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Cain JT, Kim DI, Quast M, Shivega WG, Patrick RJ, Moser C, Reuter S, Perez M, Myers A, Weimer JM, Roux KJ, Landsverk M. Nonsense pathogenic variants in exon 1 of PHOX2B lead to translational reinitiation in congenital central hypoventilation syndrome. Am J Med Genet A 2017; 173:1200-1207. [PMID: 28371199 DOI: 10.1002/ajmg.a.38162] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 11/15/2016] [Accepted: 01/09/2017] [Indexed: 11/06/2022]
Abstract
Pathogenic variants in PHOX2B lead to congenital central hypoventilation syndrome (CCHS), a rare disorder of the nervous system characterized by autonomic dysregulation and hypoventilation typically presenting in the neonatal period, although a milder late-onset (LO) presentation has been reported. More than 90% of cases are caused by polyalanine repeat mutations (PARMs) in the C-terminus of the protein; however non-polyalanine repeat mutations (NPARMs) have been reported. Most NPARMs are located in exon 3 of PHOX2B and result in a more severe clinical presentation including Hirschsprung disease (HSCR) and/or peripheral neuroblastic tumors (PNTs). A previously reported nonsense pathogenic variant in exon 1 of a patient with LO-CCHS and no HSCR or PNTs leads to translational reinitiation at a downstream AUG codon producing an N-terminally truncated protein. Here we report additional individuals with nonsense pathogenic variants in exon 1 of PHOX2B. In vitro analyses were used to determine if these and other reported nonsense variants in PHOX2B exon 1 produced N-terminally truncated proteins. We found that all tested nonsense variants in PHOX2B exon 1 produced a truncated protein of the same size. This truncated protein localized to the nucleus and transactivated a target promoter. These data suggest that nonsense pathogenic variants in the first exon of PHOX2B likely escape nonsense mediated decay (NMD) and produce N-terminally truncated proteins functionally distinct from those produced by the more common PARMs.
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Affiliation(s)
- Jacob T Cain
- Children's Health Research Center, Sanford Research, Sioux Falls, South Dakota
| | - Dae I Kim
- Children's Health Research Center, Sanford Research, Sioux Falls, South Dakota
| | - Megan Quast
- Children's Health Research Center, Sanford Research, Sioux Falls, South Dakota
| | - Winnie G Shivega
- Children's Health Research Center, Sanford Research, Sioux Falls, South Dakota
| | - Ryan J Patrick
- Children's Health Research Center, Sanford Research, Sioux Falls, South Dakota
| | - Chuanpit Moser
- Section of Pediatric Pulmonology, Sanford School of Medicine at the University of South Dakota, Sioux Falls, South Dakota
| | - Suzanne Reuter
- Section of Neonatal-Perinatal Medicine, Sanford School of Medicine at the University of South Dakota, Sioux Falls, South Dakota
| | - Myrza Perez
- Department of Pediatric Pulmonology, Kaiser Permanente, Roseville, California
| | - Angela Myers
- Department of Pediatrics, Sanford School of Medicine at the University of South Dakota, Sioux Falls, South Dakota
| | - Jill M Weimer
- Children's Health Research Center, Sanford Research, Sioux Falls, South Dakota.,Department of Pediatrics, Sanford School of Medicine at the University of South Dakota, Sioux Falls, South Dakota
| | - Kyle J Roux
- Children's Health Research Center, Sanford Research, Sioux Falls, South Dakota.,Department of Pediatrics, Sanford School of Medicine at the University of South Dakota, Sioux Falls, South Dakota
| | - Megan Landsverk
- Children's Health Research Center, Sanford Research, Sioux Falls, South Dakota.,Department of Pediatrics, Sanford School of Medicine at the University of South Dakota, Sioux Falls, South Dakota
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22
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Congenital central hypoventilation syndrome: a bedside-to-bench success story for advancing early diagnosis and treatment and improved survival and quality of life. Pediatr Res 2017; 81:192-201. [PMID: 27673423 DOI: 10.1038/pr.2016.196] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/15/2016] [Indexed: 01/13/2023]
Abstract
The "bedside-to-bench" Congenital Central Hypoventilation Syndrome (CCHS) research journey has led to increased phenotypic-genotypic knowledge regarding autonomic nervous system (ANS) regulation, and improved clinical outcomes. CCHS is a neurocristopathy characterized by hypoventilation and ANS dysregulation. Initially described in 1970, timely diagnosis and treatment remained problematic until the first large cohort report (1992), delineating clinical presentation and treatment options. A central role of ANS dysregulation (2001) emerged, precipitating evaluation of genes critical to ANS development, and subsequent 2003 identification of Paired-Like Homeobox 2B (PHOX2B) as the disease-defining gene for CCHS. This breakthrough engendered clinical genetic testing, making diagnosis exact and early tracheostomy/artificial ventilation feasible. PHOX2B genotype-CCHS phenotype relationships were elucidated, informing early recognition and timely treatment for phenotypic manifestations including Hirschsprung disease, prolonged sinus pauses, and neural crest tumors. Simultaneously, cellular models of CCHS-causing PHOX2B mutations were developed to delineate molecular mechanisms. In addition to new insights regarding genetics and neurobiology of autonomic control overall, new knowledge gained has enabled physicians to anticipate and delineate the full clinical CCHS phenotype and initiate timely effective management. In summary, from an initial guarantee of early mortality or severe neurologic morbidity in survivors, CCHS children can now be diagnosed early and managed effectively, achieving dramatically improved quality of life as adults.
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23
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Sandoval RL, Zaconeta CM, Margotto PR, de Oliveira Cardoso MT, França EMS, Medina CTN, Canó TM, de Faria AS. Congenital central hypoventilation syndrome associated with Hirschsprung's Disease: case report and literature review. REVISTA PAULISTA DE PEDIATRIA (ENGLISH EDITION) 2016. [PMID: 26838603 PMCID: PMC5178125 DOI: 10.1016/j.rppede.2015.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective: To report the case of a newborn with recurrent episodes of apnea, diagnosed with Congenital Central hypoventilation syndrome (CCHS) associated with Hirschsprung's disease (HD), configuring Haddad syndrome. Case description: Third child born at full-term to a non-consanguineous couple through normal delivery without complications, with appropriate weight and length for gestational age. Soon after birth he started to show bradypnea, bradycardia and cyanosis, being submitted to tracheal intubation and started empiric antibiotic therapy for suspected early neonatal sepsis. During hospitalization in the NICU, he showed difficulty to undergo extubation due to episodes of desaturation during sleep and wakefulness. He had recurrent episodes of hypoglycemia, hyperglycemia, metabolic acidosis, abdominal distension, leukocytosis, increase in C-reactive protein levels, with negative blood cultures and suspected inborn error of metabolism. At 2 months of age he was diagnosed with long-segment Hirschsprung's disease and was submitted to segment resection and colostomy through Hartmann's procedure. A genetic research was performed by polymerase chain reaction for CCHS screening, which showed the mutated allele of PHOX2B gene, confirming the diagnosis. Comments: This is a rare genetic, autosomal dominant disease, caused by mutation in PHOX2B gene, located in chromosome band 4p12, which results in autonomic nervous system dysfunction. CCHS can also occur with Hirschsprung's disease and tumors derived from the neural crest. There is a correlation between phenotype and genotype, as well as high intrafamilial phenotypic variability. In the neonatal period it can simulate cases of sepsis and inborn errors of metabolism.
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24
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Significant phenotype variability of congenital central hypoventilation syndrome in a family with polyalanine expansion mutation of the PHOX2B gene. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2016; 160:495-498. [PMID: 27485184 DOI: 10.5507/bp.2016.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/13/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Congenital central hypoventilation syndrome (CCHS) is a rare genetic disorder resulting from mutations in the PHOX2B gene located on chromosome 4p12.3, characterized by hypoventilation secondary to missing responses to both hypercapnia and hypoxia. CASE REPORT Proband. A girl, hospitalised 5 times for respiratory failure from 6 weeks old, presented at 4 years of age severe cyanosis related to pneumonia. Tracheostomy was done, and she was discharged home using a portable positive pressure ventilator during sleep. Proband's father: The father was retrospectively found out to suffer from severe headache and excessive daytime sleepiness. Molecular genetic evaluation of PHOX2B gene was performed and casual polyalanine repeat expansion mutation c.741_755dup15 in exon 3 was found both in proband and her father in heterozygous form. The proband's grandmother died of respiratory failure after administration of benzodiazepine at the age of fifty years. Considering the grandmother's history, she is highly suspected of having had CCHS as well. CONCLUSION Repeated respiratory failure of girl was explained by PHOX2B mutation and Ondina curse. Proband´s father has incompletely penetrated PHOX2B heterozygous mutation as well and proband´s grandmother died probably from the consequences of drug interaction with PHOX2B mutated background as well. Both daughter and father currently require overnight mechanical ventilatory support. Although most PHOX2B mutations occur de novo, our case is a rare three generation family affected by autosomal dominant inheritance with incomplete penetrance manifested as the late-form of CCHS and proven PHOX2B mutation in two generations.
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25
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Moreira TS, Takakura AC, Czeisler C, Otero JJ. Respiratory and autonomic dysfunction in congenital central hypoventilation syndrome. J Neurophysiol 2016; 116:742-52. [PMID: 27226447 PMCID: PMC6208311 DOI: 10.1152/jn.00026.2016] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 05/25/2016] [Indexed: 12/22/2022] Open
Abstract
The developmental lineage of the PHOX2B-expressing neurons in the retrotrapezoid nucleus (RTN) has been extensively studied. These cells are thought to function as central respiratory chemoreceptors, i.e., the mechanism by which brain Pco2 regulates breathing. The molecular and cellular basis of central respiratory chemoreception is based on the detection of CO2 via intrinsic proton receptors (TASK-2, GPR4) as well as synaptic input from peripheral chemoreceptors and other brain regions. Murine models of congenital central hypoventilation syndrome designed with PHOX2B mutations have suggested RTN neuron agenesis. In this review, we examine, through human and experimental animal models, how a restricted number of neurons that express the transcription factor PHOX2B play a crucial role in the control of breathing and autonomic regulation.
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Affiliation(s)
- Thiago S Moreira
- Department of Physiology and Biophysics, Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo, Brazil;
| | - Ana C Takakura
- Department of Pharmacology, Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo, Brazil; and
| | - Catherine Czeisler
- The Ohio State University, College of Medicine, Department of Pathology, Division of Neuropathology, Columbus, Ohio
| | - Jose J Otero
- The Ohio State University, College of Medicine, Department of Pathology, Division of Neuropathology, Columbus, Ohio
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26
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Sandoval RL, Zaconeta CM, Margotto PR, Cardoso MTDO, França EMS, Medina CTN, Canó TM, Faria ASD. Congenital central hypoventilation syndrome associated with Hirschsprung's Disease: case report and literature review. REVISTA PAULISTA DE PEDIATRIA 2016; 34:374-8. [PMID: 26838603 DOI: 10.1016/j.rpped.2015.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 09/18/2015] [Accepted: 10/04/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To report the case of a newborn with recurrent episodes of apnea, diagnosed with Congenital Central hypoventilation syndrome (CCHS) associated with Hirschsprung's disease (HD), configuring Haddad syndrome. CASE DESCRIPTION Third child born at full-term to a non-consanguineous couple through normal delivery without complications, with appropriate weight and length for gestational age. Soon after birth he started to show bradypnea, bradycardia and cyanosis, being submitted to tracheal intubation and started empiric antibiotic therapy for suspected early neonatal sepsis. During hospitalization in the NICU, he showed difficulty to undergo extubation due to episodes of desaturation during sleep and wakefulness. He had recurrent episodes of hypoglycemia, hyperglycemia, metabolic acidosis, abdominal distension, leukocytosis, increase in C-reactive protein levels, with negative blood cultures and suspected inborn error of metabolism. At 2 months of age he was diagnosed with long-segment Hirschsprung's disease and was submitted to segment resection and colostomy through Hartmann's procedure. A genetic research was performed by polymerase chain reaction for CCHS screening, which showed the mutated allele of PHOX2B gene, confirming the diagnosis. COMMENTS This is a rare genetic, autosomal dominant disease, caused by mutation in PHOX2B gene, located in chromosome band 4p12, which results in autonomic nervous system dysfunction. CCHS can also occur with Hirschsprung's disease and tumors derived from the neural crest. There is a correlation between phenotype and genotype, as well as high intrafamilial phenotypic variability. In the neonatal period it can simulate cases of sepsis and inborn errors of metabolism.
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Affiliation(s)
- Renata Lazari Sandoval
- Hospital de Base do Distrito Federal (HBDF), Brasília, DF, Brasil; Universidade de Brasília (UnB), Brasília, DF, Brasil.
| | - Carlos Moreno Zaconeta
- Universidade de Brasília (UnB), Brasília, DF, Brasil; Hospital Materno Infantil de Brasília (HMIB), Brasília, DF, Brasil
| | | | | | - Evely Mirella Santos França
- Hospital Materno Infantil de Brasília (HMIB), Brasília, DF, Brasil; Secretaria de Estado de Saúde do Distrito Federal, Brasília, DF, Brasil
| | | | - Talyta Matos Canó
- Secretaria de Estado de Saúde do Distrito Federal, Brasília, DF, Brasil
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Heide S, Masliah-Planchon J, Isidor B, Guimier A, Bodet D, Coze C, Deville A, Thebault E, Pasquier CJ, Cassagnau E, Pierron G, Clément N, Schleiermacher G, Amiel J, Delattre O, Peuchmaur M, Bourdeaut F. Oncologic Phenotype of Peripheral Neuroblastic Tumors Associated With PHOX2B Non-Polyalanine Repeat Expansion Mutations. Pediatr Blood Cancer 2016; 63:71-7. [PMID: 26375764 DOI: 10.1002/pbc.25723] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 08/03/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Germline non-polyalanine repeat expansion mutations in PHOX2B (PHOX2B NPARM) predispose to peripheral neuroblastic tumors (PNT), frequently in association with other neurocristopathies: Hirschsprung disease (HSCR) or congenital central hypoventilation syndrome (CCHS). Although PHOX2B polyalanine repeat expansions predispose to a low incidence of benign PNTs, the oncologic phenotype associated with PHOX2B NPARM is still not known in detail. METHODS We analyzed prognostic factors, treatment toxicity, and outcome of patients with PNT and PHOX2B NPARM. RESULTS Thirteen patients were identified, six of whom also had CCHS and/or HSCR, one also had late-onset hypoventilation with hypothalamic dysfunction (LO-CHS/HD), and six had no other neurocristopathy. Four tumours were "poorly differentiated," and nine were differentiated, including five ganglioneuromas, three ganglioneuroblastomas, and one differentiating neuroblastoma, hence illustrating that PHOX2B NPARM are predominantly associated with differentiating tumors. Nevertheless, three patients had stage 4 and one patient had stage 3 disease. Segmental chromosomal alterations, correlating with poor prognosis, were found in all the six tumors analyzed by array-comparative genomic hybridization. One patient died of tumor progression, one is on palliative care, one died of hypoventilation, and 10 patients are still alive, with median follow-up of 5 years. CONCLUSIONS Based on histological phenotype, our series suggests that heterozygous PHOX2B NPARM do not fully preclude ganglion cell differentiation in tumors. However, this tumor predisposition syndrome may also be associated with poorly differentiated tumors with unfavorable genomic profiles and clinically aggressive behaviors. The intrafamilial variability and the unpredictable tumor prognosis should be considered in genetic counseling.
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Affiliation(s)
- Solveig Heide
- Service de Pathologie, Hôpital Robert Debré, APHP, Paris, France
| | - Julien Masliah-Planchon
- INSERM U830, Génétique et Biologie des Cancers, Institut Curie, Paris, France.,Institut Curie, Unité de Génétique Somatique, Institut Curie, Paris, France
| | - Bertrand Isidor
- Service de Génétique Clinique, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Anne Guimier
- INSERM UMR 1163, Institut Imagine, Paris, France
| | - Damien Bodet
- Unité d'Onco-Hématologie, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Carole Coze
- Service d'Oncologie Pédiatrique, Hôpital de la Timone, Centre Hospitalier Universitaire de Marseille, Marseille, France
| | - Anne Deville
- Service d'Onco-Hématologie Pédiatrique, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Estelle Thebault
- Service d'Onco-Hématologie Pédiatrique, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | | | - Elisabeth Cassagnau
- Service d'Anatomie Et Cytologie Pathologiques, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Gaelle Pierron
- Institut Curie, Unité de Génétique Somatique, Institut Curie, Paris, France
| | - Nathalie Clément
- Institut Curie, Unité de Génétique Somatique, Institut Curie, Paris, France
| | - Gudrun Schleiermacher
- INSERM U830, Génétique et Biologie des Cancers, Institut Curie, Paris, France.,Institut Curie, Unité de Génétique Somatique, Institut Curie, Paris, France
| | - Jeanne Amiel
- INSERM UMR 1163, Institut Imagine, Paris, France.,Sorbonne Paris Cite, Université Paris Descartes, Paris, France.,Service de Génétique, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Olivier Delattre
- INSERM U830, Génétique et Biologie des Cancers, Institut Curie, Paris, France.,Institut Curie, Unité de Génétique Somatique, Institut Curie, Paris, France
| | - Michel Peuchmaur
- Service de Pathologie, Hôpital Robert Debré, APHP, Paris, France.,Sorbonne Paris Cite, Université Paris Diderot, Paris, France
| | - Franck Bourdeaut
- INSERM U830, Génétique et Biologie des Cancers, Institut Curie, Paris, France.,Institut Curie, Département de pédiatrie-adolescent-jeunes adultes, Institut Curie, Paris, France.,Site de Recherche Intégrée en Cancérologie, Recherche Translationnelle en Oncologie Pédiatrique, Institut Curie, Paris, France
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28
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Healy F, Marcus CL. Care of the Child with Congenital Central Hypoventilation Syndrome. Respir Med 2016. [DOI: 10.1007/978-1-4939-3749-3_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Szymońska I, Borgenvik TL, Karlsvik TM, Halsen A, Malecki BK, Saetre SE, Jagła M, Kruczek P, Talowska AM, Drabik G, Zasada M, Malecki M. Novel mutation-deletion in the PHOX2B gene of the patient diagnosed with Neuroblastoma, Hirschsprung's Disease, and Congenital Central Hypoventilation Syndrome (NB-HSCR-CCHS) Cluster. ACTA ACUST UNITED AC 2015; 6. [PMID: 26798564 DOI: 10.4172/2157-7412.1000269] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Neuroblastoma (NB), Hirschsprung disease (HSCR), Congenital Central Hypoventilation Syndrome (CCHS), clinically referred as the NB-HSCR-CCHS cluster, are genetic disorders linked to mutations in the PHOX2B gene on chromosome 4p12. SPECIFIC AIM The specific aim of this project is to define the PHOX2B gene mutations as the genomic basis for the clinical manifestations of the NB-HSCR-CCHS cluster. PATIENT A one day old male patient presented to the Jagiellonian University Medical College (JUMC), American Children Hospital, neonatal Intensive Care Unit (ICU) due to abdominal distention, vomiting, and severe apneic episodes. With the preliminary diagnosis of the NB-HSCR-CCHS, the blood and tissue samples were acquired from the child, as well as from the child's parents. All procedures were pursued in accordance with the Declaration of Helsinki, with the patient's Guardian Informed Consent and the approval from the Institutional Review Board. GENETIC/GENOMIC METHODS Karyotyping was analyzed based upon Giemsa banding. The patient's genomic DNA was extracted from peripheral blood and amplified by polymerase chain reaction. Direct microfluidic Sanger sequencing was performed on the genomic DNA amplicons. These procedures were pursued in addition to the routine clinical examinations and tests. RESULTS G-banding showed the normal 46 XY karyotype. However, genomic sequencing revealed a novel, heterozygous deletion (8 nucleotides: c.699-706, del8) in exon 3 of the PHOX2B gene on chromosome 4. This led to the frame-shift mutation and malfunctioning gene expression product. CONCLUSION Herein, we report a novel PHOX2B gene mutation in the patient diagnosed with the NB-HSCR-CCHS cluster. The resulting gene expression product may be a contributor to the clinical manifestations of these genetic disorders. It adds to the library of the mutations linked to this syndrome. Consequently, we suggest that screening for the PHOX2B mutations becomes an integral part of genetic counseling, genomic sequencing of fetal circulating nucleic acids and / or genomes of circulating fetal cells prenatally, while preparing supportive therapy upon delivery, as well as on neonates' genomes of intubated infants, when breathing difficulties occur upon extubation. Further, we hypothesize that PHOX2B may be considered as a potential target for gene therapy.
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Affiliation(s)
- Izabela Szymońska
- Department of Pediatrics, Jagiellonian University Medical College, Krakow, Poland, EU
| | | | | | - Anders Halsen
- Jagiellonian University Medical College, Krakow, Poland, EU
| | - Bianka Kathryn Malecki
- Jagiellonian University Medical College, Krakow, Poland, EU; Phoenix Biomolecular Engineering Foundation, San Francisco, CA, USA
| | | | - Mateusz Jagła
- Department of Pediatrics, Jagiellonian University Medical College, Krakow, Poland, EU
| | - Piotr Kruczek
- Department of Pediatrics, Jagiellonian University Medical College, Krakow, Poland, EU
| | - Anna Madetko Talowska
- Department of Clinical Genetics, Jagiellonian University Medical College, Krakow, Poland, EU
| | - Grażyna Drabik
- Department of Pathology, Children's University Hospital, Kraków, Poland, EU
| | - Magdalena Zasada
- Department of Pediatrics, Jagiellonian University Medical College, Krakow, Poland, EU
| | - Marek Malecki
- Phoenix Biomolecular Engineering Foundation, San Francisco, CA, USA; NMRFM, National Institutes of Health, Madison, WI, USA; University of Wisconsin, Madison, WI, USA
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Herrera-Flores EH, Rodríguez-Tejada A, Reyes-Zúñiga MM, Torres-Fraga MG, Castorena-Maldonado A, Carrillo-Alduenda JL. [Congenital central alveolar hypoventilation syndrome]. BOLETIN MEDICO DEL HOSPITAL INFANTIL DE MEXICO 2015; 72:262-270. [PMID: 29421146 DOI: 10.1016/j.bmhimx.2015.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/25/2015] [Accepted: 07/02/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Congenital central alveolar hypoventilation syndrome (CCAHS) is a rare sleep-related breathing disorder. Although increasingly frequently diagnosed in sleep clinics and pediatric pulmonology services, its epidemiology is not known. There are about 300 reported cases reported in the literature with an incidence of 1 case per 200,000 live births. CCAHS is characterized by alveolar hypoventilation that occurs or worsens during sleep and is secondary to a reduction/absence of the ventilatory response to hypercapnia and/or hypoxemia. In 90% of the cases it is due to a PARM-type mutation of the PHOX2B gene. Treatment includes mechanical ventilation and diaphragmatic pacemaker. If therapy is not initiated promptly the patient can evolve to chronic respiratory failure, pulmonary hypertension, cor pulmonale and death. CASE REPORTS In this paper we present three cases of CCAHS diagnosed, treated and followed up at the Sleep Disorders Clinic of the National Institute of Respiratory Diseases in Mexico. CONCLUSIONS Early diagnosis is important to initiate ventilatory support so as to prevent any complications and to reduce mortality.
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Affiliation(s)
- Edwin Hernando Herrera-Flores
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México
| | - Alfredo Rodríguez-Tejada
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México
| | - Martha Margarita Reyes-Zúñiga
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México
| | - Martha Guadalupe Torres-Fraga
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México
| | - Armando Castorena-Maldonado
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México
| | - José Luis Carrillo-Alduenda
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México.
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31
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Shimokaze T, Sasaki A, Meguro T, Hasegawa H, Hiraku Y, Yoshikawa T, Kishikawa Y, Hayasaka K. Genotype-phenotype relationship in Japanese patients with congenital central hypoventilation syndrome. J Hum Genet 2015; 60:473-7. [PMID: 26063465 DOI: 10.1038/jhg.2015.65] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 05/07/2015] [Accepted: 05/12/2015] [Indexed: 11/09/2022]
Abstract
Examine the genotype-phenotype relationship in Japanese congenital central hypoventilation syndrome (CCHS) patients and estimate the incidence of CCHS in Japan. Subjects were 92 Japanese patients with PHOX2B mutations; 19 cases carried 25 polyalanine repeat expansion mutations (PARMs); 67 cases carried 26 or more PARMs; and 6 had non-PARMs (NPARMs). We collected clinical data in all patients and estimated the development or intelligent quotients only in the patients carrying 25 PARM. The estimated incidence of CCHS was greater than one case per 148 000 births. Polyhydramnios was observed in three cases. Twelve infants exhibited depressed respiration at birth. In 19 cases carrying 25 PARM, the male-to-female ratio was ~3, no cases had Hirschsprung disease; 7 cases (37%) developed hypoventilation after the neonatal period, and 8 cases (42%) had mental retardation. In other 73 cases carrying 26 or more PARMs or NPARMs, male-to-female ratio was equal; patients frequently complicated with Hirschsprung disease and constipation, and all patients presented with hypoventilation in the neonatal period. Clinical symptoms were severe in most patients carrying long PARMs and NPARMs. In 25 PARM, additional genetic and/or epigenetic factors were required for CCHS development and male sex is likely a predisposing factor. The patients carrying 25 PARM frequently had mental retardation likely because they were not able to receive appropriate ventilation support following a definitive diagnosis owing to subtle and or irregular hypoventilation. Molecular diagnosis provides a definitive diagnosis and enables to receive appropriate ventilator support.
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Affiliation(s)
- Tomoyuki Shimokaze
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata, Japan
| | - Ayako Sasaki
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata, Japan
| | - Toru Meguro
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata, Japan
| | - Hisaya Hasegawa
- Division of Neonatal Intensive Care, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Yuka Hiraku
- Department of Obstetrics and Gynecology, Gifu Municipal Hospital, Gifu, Japan
| | - Tetsushi Yoshikawa
- Departments of Pediatrics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Yumiko Kishikawa
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata, Japan
| | - Kiyoshi Hayasaka
- Department of Pediatrics, Yamagata University School of Medicine, Yamagata, Japan.,Department of Pediatrics, Miyukikai Hospital, Kaminoyama, Japan
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32
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De Montpellier S, Sznajer Y, Amiel J, Francois G, Nassogne MC, Debauche C, Scheers I. An unusual cause of fetal hypomobility:congenital central hypoventilation syndrome associated with hirschsprung disease. Eur J Pediatr 2014; 173:1607-9. [PMID: 24135798 DOI: 10.1007/s00431-013-2171-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 09/30/2013] [Indexed: 11/29/2022]
Abstract
Co-occurrence of congenital central hypoventilation syndrome and Hirschsprung disease is known as Haddad syndrome. Affected patients develop with variable expressivity a dysfunction of the autonomic nervous system. We report the natural history of a full-term newborn infant presenting multiple features of autonomic system dysfunction that were already noted antenatally. The presence of a nonpolyalanine repeat expansion mutation in the PHOX2B gene confirmed postnatally the diagnosis of Haddad syndrome. This case suggests that patients presenting with autonomic system dysfunction may already present signs of the disease during the fetal period. Furthermore, antenatal presentations may correlate with a more severe presentation of the disease. In conclusion, antenatal signs of dysautonomy should stimulate multidisciplinary prenatal approach to orientate proper postnatal intervention and facilitate treatment strategies.
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Affiliation(s)
- Sybille De Montpellier
- General Pediatrics and Sleep Disorders Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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33
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Low KJ, Turnbull AR, Smith KR, Hilliard TN, Hole LJ, Meecham Jones DJ, Williams MM, Donaldson A. A case of congenital central hypoventilation syndrome in a three-generation family with non-polyalanine repeat PHOX2B mutation. Pediatr Pulmonol 2014; 49:E140-3. [PMID: 24799442 DOI: 10.1002/ppul.23051] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Accepted: 03/27/2014] [Indexed: 11/06/2022]
Abstract
We describe a three generation family in whom multiple individuals are variably affected due to a PHOX2B non-polyalanine repeat mutation. This family demonstrates extreme phenotypic variability and autosomal dominant transmission over three generations not previously reported in the wider literature. Novel findings also inclue a history of recurrent second trimester miscarriage. Pediatr Pulmonol. 2014; 49:E140-E143. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
- K J Low
- Department of Clinical Genetics, UHBristol NHS Trust, St Michaels Hospital, Bristol, UK
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34
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Rand CM, Carroll MS, Weese-Mayer DE. Congenital Central Hypoventilation Syndrome. Clin Chest Med 2014; 35:535-45. [DOI: 10.1016/j.ccm.2014.06.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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35
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Magalhães J, Madureira N, Medeiros R, Fernandes PC, Oufadem M, Amiel J, Estêvão MH, Reis MG. Late-onset congenital central hypoventilation syndrome and a rare PHOX2B gene mutation. Sleep Breath 2014; 19:55-60. [DOI: 10.1007/s11325-014-0996-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 04/19/2014] [Accepted: 04/28/2014] [Indexed: 10/25/2022]
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36
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Bachetti T, Di Duca M, Della Monica M, Grappone L, Scarano G, Ceccherini I. Recurrence of CCHS associated PHOX2B poly-alanine expansion mutation due to maternal mosaicism. Pediatr Pulmonol 2014; 49:E45-7. [PMID: 23460545 DOI: 10.1002/ppul.22790] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 01/20/2013] [Indexed: 11/12/2022]
Abstract
Heterozygous in frame trinucleotide duplications within the PHOX2B gene, leading to poly-alanine expansions, cause Congenital Central Hypoventilation Syndrome. Here we report about a CCHS patient, carrying a +13Ala PHOX2B expansion, whose asymptomatic mother resulted with a low level of mosaicism for the same mutation in peripheral blood cells. Her second pregnancy ended with the spontaneous miscarriage of a fetus who had inherited the PHOX2B mutation, thus confirming germline mosaicism in the mother and the need of proper genetic counseling to CCHS families.
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Affiliation(s)
- Tiziana Bachetti
- U.O.C. Medical Genetics, Institute Giannina Gaslini, Genova, Italy
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37
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Benditt JO, Boitano LJ. Pulmonary issues in patients with chronic neuromuscular disease. Am J Respir Crit Care Med 2013; 187:1046-55. [PMID: 23590262 DOI: 10.1164/rccm.201210-1804ci] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Patients with chronic neuromuscular diseases such as spinal cord injury, amyotrophic lateral sclerosis, and muscular dystrophies experience respiratory complications that are cared for by the respiratory practitioner. An organized anatomical approach for evaluation and treatment is helpful to provide appropriate clinical care. Effective noninvasive strategies for management of hypoventilation, sleep-disordered breathing, and cough insufficiency are available for these patients.
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38
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Distinct neuroblastoma-associated alterations of PHOX2B impair sympathetic neuronal differentiation in zebrafish models. PLoS Genet 2013; 9:e1003533. [PMID: 23754957 PMCID: PMC3675015 DOI: 10.1371/journal.pgen.1003533] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 04/14/2013] [Indexed: 11/19/2022] Open
Abstract
Heterozygous germline mutations and deletions in PHOX2B, a key regulator of autonomic neuron development, predispose to neuroblastoma, a tumor of the peripheral sympathetic nervous system. To gain insight into the oncogenic mechanisms engaged by these changes, we used zebrafish models to study the functional consequences of aberrant PHOX2B expression in the cells of the developing sympathetic nervous system. Allelic deficiency, modeled by phox2b morpholino knockdown, led to a decrease in the terminal differentiation markers th and dbh in sympathetic ganglion cells. The same effect was seen on overexpression of two distinct neuroblastoma-associated frameshift mutations, 676delG and K155X - but not the R100L missense mutation - in the presence of endogenous Phox2b, pointing to their dominant-negative effects. We demonstrate that Phox2b is capable of regulating itself as well as ascl1, and that phox2b deficiency uncouples this autoregulatory mechanism, leading to inhibition of sympathetic neuron differentiation. This effect on terminal differentiation is associated with an increased number of phox2b+, ascl1+, elavl3− cells that respond poorly to retinoic acid. These findings suggest that a reduced dosage of PHOX2B during development, through either a heterozygous deletion or dominant-negative mutation, imposes a block in the differentiation of sympathetic neuronal precursors, resulting in a cell population that is likely to be susceptible to secondary transforming events. Neuroblastoma, a tumor of the peripheral sympathetic nervous system, is the most common cancer diagnosed in infancy. Although most cases arise sporadically, familial predisposition also occurs in association with mutations in a single copy of the PHOX2B gene, a “master regulator” of sympathetic neuronal development. The exact mechanisms by which these mutations increase susceptibility to neuroblastoma are unclear, primarily because of the paucity of optimal models in which to study very early development of the sympathetic nervous system. We took advantage of the ex vivo development and transparent nature of zebrafish embryos to study the roles of both normal and mutated PHOX2B in development of the sympathetic nervous system. We present data indicating that aberrant PHOX2B expression causes an arrest in the normal maturation of sympathetic neurons, leading to immature cells that are resistant to drug-induced differentiation. Indeed, we demonstrate that phox2b gene “dosage” is important for normal differentiation of sympathetic neurons in the zebrafish and suggest that the population of immature cells resulting from a decreased dosage of this pivotal factor may be susceptible to secondary mutations that could ultimately lead to neuroblastoma.
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Weese-Mayer DE, Berry-Kravis EM, Ceccherini I, Keens TG, Loghmanee DA, Trang H. [ATS clinical policy statement: congenital central hypoventilation syndrome. Genetic basis, diagnosis and management]. Rev Mal Respir 2013; 30:706-33. [PMID: 24182656 DOI: 10.1016/j.rmr.2013.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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40
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Bygarski E, Paterson M, Lemire EG. Extreme intra-familial variability of congenital central hypoventilation syndrome: a case series. J Med Case Rep 2013; 7:117. [PMID: 23622117 PMCID: PMC3651317 DOI: 10.1186/1752-1947-7-117] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Accepted: 04/05/2013] [Indexed: 11/15/2022] Open
Abstract
Introduction Congenital central hypoventilation syndrome is an autosomal dominant disorder that classically presents as sudden death in infancy secondary to central hypoventilation. Most cases are caused by polyalanine repeat mutations in the paired-like homeobox 2B gene, PHOX2B. More severe disease is typically associated with nonpolyalanine repeat mutations. We report the case of a family with nonpolyalanine repeat mutations that uncharacteristically has many individuals who were mildly symptomatic and only diagnosed after genetic testing. We highlight the highly variable clinical presentation of this condition and the need for clinicians to remain vigilant. Case presentation We identified 10 individuals in a large extended Caucasian family of German and Austrian background with congenital central hypoventilation syndrome. Case 1: A 16-year old male proband presented for reproductive counseling. He had a previous history of apneic spells and Hirschsprung disease in the neonatal period. A PHOX2B nonpolyalanine repeat mutation was identified in the proband and used to screen his extended family. Cases 2 to 10: Several mildly symptomatic family members (males aged 5, 13, 42 and 80 years; females aged 28, 44, 46 and 48 years) spanning four generations were identified after genetic screening. A newborn boy from this family was also recently diagnosed with Hirschsprung disease and went on to have an abnormal sleep study. Conclusions In this report, we highlight the significant phenotypic variability of congenital central hypoventilation syndrome, previously thought to be a rare genetic condition. Given the extreme clinical variability, it is possible that the prevalence of congenital central hypoventilation syndrome in the general population is much higher than previous estimates. This is of major importance to all clinicians who will need to maintain a high index of suspicion for this not so rare and highly clinically variable genetic condition that spans all ages. As the familial mutation has been identified, presymptomatic and prenatal diagnostic testing are available options for family members.
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Affiliation(s)
- Elizabeth Bygarski
- Division of Medical Genetics, Royal University Hospital, 103 Hospital Drive, Saskatoon, SK S7N 0W8, Canada.
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[Late onset Ondine syndrome: literature review on a case report]. Arch Pediatr 2012; 19:1205-7. [PMID: 23037578 DOI: 10.1016/j.arcped.2012.08.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 06/09/2012] [Accepted: 08/22/2012] [Indexed: 11/23/2022]
Abstract
Ondine syndrome is the central congenital hypoventilation syndrome (CCHS) caused by the mutation of the PHOX2B gene. In late onset cases, the symptomatology often appears after an acute event (infection, general anesthesia, drug intake), increasing hypoventilation. We report a case of late onset Ondine curse in a 9-year-old girl. The diagnosis was made based on a hypercapnic coma complicating a respiratory infection caused by Mycoplasma pneumoniae and was confirmed by genetic testing. In the patient's history we found symptoms that had not been noted (e.g., enuresis, morning headache, adynamia), attesting to chronic hypoventilation. Through this observation, we review the literature on CCHS, notably late onset cases, which are rare and insidious, emphasizing the pre-existing hypoventilation symptoms in this child. This case underlines the need for all practitioners not to trivialize these symptoms so as to decrease the current delay in diagnosis for late onset CCHS and to introduce optimal care as soon as possible.
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Rand CM, Yu M, Jennings LJ, Panesar K, Berry-Kravis EM, Zhou L, Weese-Mayer DE. Germline mosaicism of PHOX2B mutation accounts for familial recurrence of congenital central hypoventilation syndrome (CCHS). Am J Med Genet A 2012; 158A:2297-301. [PMID: 22821709 DOI: 10.1002/ajmg.a.35499] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 05/06/2012] [Indexed: 11/09/2022]
Abstract
Congenital central hypoventilation syndrome (CCHS), a rare disorder characterized by alveolar hypoventilation and autonomic dysregulation, is caused by mutations in the PHOX2B gene. Most mutations occur de novo, but recent evidence suggests that up to 25% are inherited from asymptomatic parents with somatic mosaicism for these mutations. However, to date, germline mosaicism has not been reported. This report describes a family with recurrence of PHOX2B mutation-confirmed CCHS due to germline mosaicism. The first occurrence was a baby girl, noted on day 2 of life to have multiple episodes of apnea, bradycardia, and cyanosis while breathing room air. PHOX2B gene testing confirmed the diagnosis of CCHS with a heterozygous polyalanine repeat expansion mutation (PARM); genotype 20/27 (normal 20/20). Both parents tested negative for this mutation using fragment analysis (limit of detection<1%). Upon subsequent pregnancy [paternity confirmed using short tandem repeat (STR) analysis], amniocentesis testing identified the PHOX2B 20/27 genotype, confirmed with repeat testing. Elective abortion was performed at 21.5 weeks gestation. Testing of abortus tissue confirmed amniocentesis testing. The PHOX2B 20/27 expansion was not observed in a paternal sperm sample. This case represents the first reported family with recurrence of PHOX2B mutation-confirmed CCHS without detection of a parental carrier state or mosaicism, confirming the previously hypothesized possibility of germline mosaicism for PHOX2B mutations. This is an important finding for genetic counseling of CCHS families, suggesting that even if somatic mosaicism is not detected in parental samples, there is still reason for careful genetic counseling and consideration of prenatal testing during subsequent pregnancies.
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Affiliation(s)
- Casey M Rand
- Center for Autonomic Medicine in Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA
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Meguro T, Yoshida Y, Hayashi M, Toyota K, Otagiri T, Mochizuki N, Kishikawa Y, Sasaki A, Hayasaka K. Inheritance of polyalanine expansion mutation of PHOX2B in congenital central hypoventilation syndrome. J Hum Genet 2012; 57:335-7. [PMID: 22437207 DOI: 10.1038/jhg.2012.27] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Congenital central hypoventilation syndrome (CCHS; MIM 209880) is caused mostly by dominant alanine expansion (most prevalent is 7-alanine expansion) mutations in PHOX2B. More than 90% of the alanine expansion mutations had been considered to be de novo due to unequal crossover during gametogenesis. However, a recent report stated that 25% of patients inherited the alanine-expanded allele from their parents with somatic mosaicism or constitutive mutation. We studied inheritance in 45 unrelated families, and found that one patient (2%) inherited 5-alanine expansion mutation from a parent with late-onset central hypoventilation syndrome and nine patients (20%) inherited 5- to 7-alanine expansion mutation from apparently asymptomatic parents with somatic mosaicism. Analysis using a sensitive method would be recommended to all parents of CCHS proband due to high incidence of somatic mosaicism. The absence of an alanine-contracted allele (expected counterpart allele in unequal crossover) and the highest prevalence of 6-alanine expansion mutation in somatic mosaicism suggest that the somatic mosaicism is likely caused by a mechanism other than an unequal crossover, such as a replication mechanism.
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Affiliation(s)
- Toru Meguro
- Department of Pediatrics, Yamagata University School of Medicine, 2-2-2 Iida-nishi, Yamagata, Japan
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Al Saadi MM. Congenital central hypoventilation syndrome due to PHOX2B mutation in a Saudi child: a case report. Sleep Breath 2011; 15:875-8. [PMID: 21088916 DOI: 10.1007/s11325-010-0438-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 09/01/2010] [Accepted: 10/27/2010] [Indexed: 11/30/2022]
Affiliation(s)
- Muslim Mohammed Al Saadi
- University Sleep Disorders Center, Department of Pediatrics, College of Medicine, King Saud University, Riyadh 11461, Saudi Arabia.
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Abstract
Congenital central hypoventilation syndrome (CCHS) is a rare, lifelong condition wherein control of breathing is abnormal and patients present with symptoms of alveolar hypoventilation. The severity of hypoventilation varies and although most patients present in the neonatal period, late onset cases have been reported. In 2003, it was discovered that mutations in the PHOX2B gene were responsible for CCHS. This gene also plays a role in neural crest cell migration, and many patients present with symptoms of autonomic dysfunction in addition to hypoventilation. The pathophysiology responsible for hypoventilation remains unclear although a unifying hypothesis is that the abnormality is located in areas of the brain involved in integration of chemoreceptor afferent pathways for ventilation. The goal of treatment for CCHS is to ensure adequate ventilation during wakefulness and sleep. A variety of ventilation modalities are available including positive pressure ventilation via tracheostomy, non-invasive ventilation via nasal mask, and diaphragmatic pacing. With close monitoring and support, children with CCHS can be expected to function well in society and have a good quality of life.
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Affiliation(s)
- F Healy
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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Kritzinger FE, Al-Saleh S, Narang I. Descriptive analysis of central sleep apnea in childhood at a single center. Pediatr Pulmonol 2011; 46:1023-30. [PMID: 21520440 DOI: 10.1002/ppul.21469] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2010] [Revised: 02/27/2011] [Accepted: 02/27/2011] [Indexed: 12/21/2022]
Abstract
UNLABELLED Data on central sleep apnea (CSA) and its significance in children are limited. Our objectives were to describe the polysomnogram (PSG) characteristics and clinical features of children with significant CSA at a single pediatric sleep center. STUDY DESIGN AND METHODS A retrospective chart review of children diagnosed with CSA on a PSG, from January 2007 to December 2008, was performed. All the PSG's were performed in the pediatric sleep laboratory at The Hospital for Sick Children in Toronto, Canada. All children diagnosed with significant CSA with a PSG was eligible for inclusion. Each PSG was conducted and scored according to the American Academy of Sleep Medicine standard. Significant CSA was defined as a central apnea index (CAI) of >5 events/hr. Outcome for each patient was defined by the percentage change in the CAI at follow up. RESULTS 52/969 (5.4%) patients had a CAI > 5/hr on a baseline PSG. Of the 25/52 (13 males) patients who met inclusion criteria, the median age was 19 months (range 3-156 months) and their median BMI z score was +0.27 (range -2.95 to 3.02). The median CAI was 11 events/hr (range 6-198/hr). The mean oxygen saturations ranged from 92.8% to 98.5%, with a median of 97%. Six (24%) patients had associated sleep-related hypoventilation and none of the patients had periodic breathing. The commonest identifiable risk factor for CSA in the study population was a neurological disorder. CONCLUSIONS This study confirms that CSA is an important finding in a significant number of young children referred for an evaluation for suspected sleep related disordered breathing. Any child diagnosed with CSA warrants full clinical assessment, including neuro-imaging. Future research should aim to evaluate the long term outcome of significant CSA.
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Affiliation(s)
- Fiona E Kritzinger
- Division of Pediatric Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.
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McKim DA, Road J, Avendano M, Abdool S, Côté F, Duguid N, Fraser J, Maltais F, Morrison DL, O’Connell C, Petrof BJ, Rimmer K, Skomro R. Home mechanical ventilation: a Canadian Thoracic Society clinical practice guideline. Can Respir J 2011; 18:197-215. [PMID: 22059178 PMCID: PMC3205101 DOI: 10.1155/2011/139769] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Increasing numbers of patients are surviving episodes of prolonged mechanical ventilation or benefitting from the recent availability of userfriendly noninvasive ventilators. Although many publications pertaining to specific aspects of home mechanical ventilation (HMV) exist, very few comprehensive guidelines that bring together all of the current literature on patients at risk for or using mechanical ventilatory support are available. The Canadian Thoracic Society HMV Guideline Committee has reviewed the available English literature on topics related to HMV in adults, and completed a detailed guideline that will help standardize and improve the assessment and management of individuals requiring noninvasive or invasive HMV. The guideline provides a disease-specific review of illnesses including amyotrophic lateral sclerosis, spinal cord injury, muscular dystrophies, myotonic dystrophy, kyphoscoliosis, post-polio syndrome, central hypoventilation syndrome, obesity hypoventilation syndrome, and chronic obstructive pulmonary disease as well as important common themes such as airway clearance and the process of transition to home. The guidelines have been extensively reviewed by international experts, allied health professionals and target audiences. They will be updated on a regular basis to incorporate any new information.
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Affiliation(s)
- Douglas A McKim
- Division of Respirology, University of Ottawa, and Respiratory Rehabilitation Services, Ottawa Hospital Sleep Centre, Ottawa, Ontario
| | - Jeremy Road
- Division of Respiratory Medicine and The Lung Centre, University of British Columbia, Provincial Respiratory Outreach Program, Vancouver, British Columbia
| | - Monica Avendano
- Respiratory Medicine, West Park Healthcare Centre, University of Toronto
| | - Steve Abdool
- Respiratory Medicine, West Park Healthcare Centre, University of Toronto
- Centre for Clinical Ethics at St Michael’s Hospital, West Park Healthcare Centre, and University of Toronto, Toronto, Ontario
| | | | - Nigel Duguid
- Eastern Health, Memorial University, St John’s, Newfoundland and Labrador
| | - Janet Fraser
- Respiratory Therapy Services, West Park Healthcare Centre, Toronto, Ontario
| | - François Maltais
- Research Centre, University Institute of Cardiology and Lung Health for Québec, Laval University, Québec, Québec
| | - Debra L Morrison
- Sleep Clinic and Laboratory, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia
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Wise MS, Nichols CD, Grigg-Damberger MM, Marcus CL, Witmans MB, Kirk VG, D'Andrea LA, Hoban TF. Executive summary of respiratory indications for polysomnography in children: an evidence-based review. Sleep 2011; 34:389-98AW. [PMID: 21359088 PMCID: PMC3041716 DOI: 10.1093/sleep/34.3.389] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE This comprehensive, evidence-based review provides a systematic analysis of the literature regarding the validity, reliability, and clinical utility of polysomnography for characterizing breathing during sleep in children. Findings serve as the foundation of practice parameters regarding respiratory indications for polysomnography in children. METHODS A task force of content experts performed a systematic review of the relevant literature and graded the evidence using a standardized grading system. Two hundred forty-three evidentiary papers were reviewed, summarized, and graded. The analysis addressed the operating characteristics of polysomnography as a diagnostic procedure in children and identified strengths and limitations of polysomnography for evaluation of respiratory function during sleep. RESULTS The analysis documents strong face validity and content validity, moderately strong convergent validity when comparing respiratory findings with a variety of relevant independent measures, moderate-to-strong test-retest validity, and limited data supporting discriminant validity for characterizing breathing during sleep in children. The analysis documents moderate-to-strong test-retest reliability and interscorer reliability based on limited data. The data indicate particularly strong clinical utility in children with suspected sleep related breathing disorders and obesity, evolving metabolic syndrome, neurological, neurodevelopmental, or genetic disorders, and children with craniofacial syndromes. Specific consideration was given to clinical utility of polysomnography prior to adenotonsillectomy (AT) for confirmation of obstructive sleep apnea syndrome. The most relevant findings include: (1) recognition that clinical history and examination are often poor predictors of respiratory polygraphic findings, (2) preoperative polysomnography is helpful in predicting risk for perioperative complications, and (3) preoperative polysomnography is often helpful in predicting persistence of obstructive sleep apnea syndrome in patients after AT. No prospective studies were identified that address whether clinical outcome following AT for treatment of obstructive sleep apnea is improved in association with routine performance of polysomnography before surgery in otherwise healthy children. A small group of papers confirm the clinical utility of polysomnography for initiation and titration of positive airway pressure support. CONCLUSIONS Pediatric polysomnography shows validity, reliability, and clinical utility that is commensurate with most other routinely employed diagnostic clinical tools or procedures. Findings indicate that the "gold standard" for diagnosis of sleep related breathing disorders in children is not polysomnography alone, but rather the skillful integration of clinical and polygraphic findings by a knowledgeable sleep specialist. Future developments will provide more sophisticated methods for data collection and analysis, but integration of polysomnographic findings with the clinical evaluation will represent the fundamental diagnostic challenge for the sleep specialist.
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Affiliation(s)
- Merrill S Wise
- Methodist Healthcare Sleep Disorders Center, Memphis, TN, USA
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Chew HB, Ngu LH, Keng WT. Rapid-onset obesity with hypothalamic dysfunction, hypoventilation and autonomic dysregulation (ROHHAD): a case with additional features and review of the literature. BMJ Case Rep 2011; 2011:2011/jan20_1/bcr0220102706. [PMID: 22715259 DOI: 10.1136/bcr.02.2010.2706] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A rare syndrome of rapid-onset obesity with hypothalamic dysfunction, hypoventilation and autonomic dysregulation (ROHHAD) has been recently described. We report the first patient with this syndrome in Southeast Asia and review reported cases to date. Our patient was good health with normal development until the age of 2. He then developed hyperphagic obesity, hypersomnolence, seizures, alveolar hypoventilation, central hypothyroidism, sodium and water dysregulation, gastrointestinal dysmotility, strabismus, disordered temperature and irregular heart rate, altered sweating, delayed puberty, mental retardation and recurrent respiratory tract infections. The cardiomyopathy with heart failure and abnormal cerebral spinal fluid (CSF) neurotransmitter analysis present in our patient have not been reported previously. Tumours of the sympathetic nervous system are known to be associated with this syndrome but had not been found in our patient at the time of reporting. We highlight the difficulty of achieving the diagnosis of ROHHAD syndrome and its overlap with other well-established disease entities. The mortality and morbidity resulting from the high incidence of cardiorespiratory arrest may be prevented by early ventilatory support.
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Affiliation(s)
- H B Chew
- Department of Paediatrics, University of Malaya Medical Centre, Kuala Lumpur, Malaysia.
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