1
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Shpargel KB, Quickstad G. SETting up the genome: KMT2D and KDM6A genomic function in the Kabuki syndrome craniofacial developmental disorder. Birth Defects Res 2023; 115:1885-1898. [PMID: 37800171 PMCID: PMC11190966 DOI: 10.1002/bdr2.2253] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/04/2023] [Accepted: 09/14/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Kabuki syndrome is a congenital developmental disorder that is characterized by distinctive facial gestalt and skeletal abnormalities. Although rare, the disorder shares clinical features with several related craniofacial syndromes that manifest from mutations in chromatin-modifying enzymes. Collectively, these clinical studies underscore the crucial, concerted functions of chromatin factors in shaping developmental genome structure and driving cellular transcriptional states. Kabuki syndrome predominantly results from mutations in KMT2D, a histone H3 lysine 4 methylase, or KDM6A, a histone H3 lysine 27 demethylase. AIMS In this review, we summarize the research efforts to model Kabuki syndrome in vivo to understand the cellular and molecular mechanisms that lead to the craniofacial and skeletal pathogenesis that defines the disorder. DISCUSSION As several studies have indicated the importance of KMT2D and KDM6A function through catalytic-independent mechanisms, we highlight noncanonical roles for these enzymes as recruitment centers for alternative chromatin and transcriptional machinery.
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Affiliation(s)
- Karl B. Shpargel
- Department of GeneticsUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Gabrielle Quickstad
- Department of GeneticsUniversity of North CarolinaChapel HillNorth CarolinaUSA
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2
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Chen JE, Chen YR, Wang HH, Niu DM, Cheng YF, Chen YJ. KMT2D-related disorder with a restricted spectrum distinct from Kabuki syndrome: A rare case report describing male twins in Taiwan and a literature review. Pediatr Neonatol 2023; 64:91-92. [PMID: 35973905 DOI: 10.1016/j.pedneo.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 04/14/2022] [Accepted: 06/29/2022] [Indexed: 01/18/2023] Open
Affiliation(s)
- Jing-Er Chen
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yun-Ru Chen
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsin-Hui Wang
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Pediatrics, Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Dau-Ming Niu
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Fu Cheng
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yann-Jang Chen
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Life Sciences and Institute of Genome Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Education and Research, Taipei City Hospital, Taipei, Taiwan.
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3
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Patel LR, Flemming BC, Savioli KA. Neonate with Respiratory Distress, Bilateral Microtia, Hypocalcemia, and Lymphopenia. Pediatr Rev 2022; 43:275-279. [PMID: 35490203 DOI: 10.1542/pir.2020-003749] [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: 11/24/2022]
Affiliation(s)
- Leela R Patel
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD
| | - Brittany C Flemming
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD
| | - Katrina A Savioli
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD
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4
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Thewjitcharoen Y, Wanothayaroj E, Nakasatien S, Krittiyawong S, Khurana I, El‐Osta A, Himathongkam T. Diabetes mellitus and insulin resistance associated with Kabuki syndrome—A case report and literature review. Clin Case Rep 2022; 10:e05736. [PMID: 35441024 PMCID: PMC9010955 DOI: 10.1002/ccr3.5736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/11/2022] [Accepted: 03/28/2022] [Indexed: 11/25/2022] Open
Abstract
Kabuki syndrome (KS) is a genetic disorder characterized by distinctive facies, intellectual disability, and multi‐organ anomalies. This case report highlights the importance of clinical recognizable phenotype in patients with diabetes. The development of diabetes should be considered an endocrine complication in KS patients.
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Affiliation(s)
| | | | | | | | - Ishant Khurana
- Epigenetics in Human Health and Disease Laboratory Department of Diabetes Central Clinical School Faculty of Medicine Nursing and Health Sciences Monash University Melbourne Australia
| | - Assam El‐Osta
- Epigenetics in Human Health and Disease Laboratory Department of Diabetes Central Clinical School Faculty of Medicine Nursing and Health Sciences Monash University Melbourne Australia
- Department of Medicine and Therapeutics The Chinese University of Hong Kong (CUHK) Hong Kong SAR
- Hong Kong Institute of Diabetes and Obesity Hong Kong SAR
- Li Ka Shing Institute of Health Sciences Hong Kong SAR
- School of Biomedical Sciences CUHK Hong Kong SAR
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5
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Tharreau M, Garde A, Marlin S, Morel G, Ernest S, Nambot S, Duffourd Y, Ternoy N, Duvillard C, Banka S, Philippe C, Thauvin‐Robinet C, Mau‐Them FT, Faivre L. Refining the clinical phenotype associated with missense variants in exons 38 and 39 of
KMT2D. Am J Med Genet A 2022; 188:1600-1606. [DOI: 10.1002/ajmg.a.62642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 11/22/2021] [Accepted: 12/11/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Mylène Tharreau
- UF Innovation en Diagnostic Génomique des Maladies Rares, Laboratoire de Génétique Chromosomique Moléculaire, FHU‐TRANSLAD Hospital Center University Dijon Bourgogne Dijon France
| | - Aurore Garde
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, FHU TRANSLAD Centre Hospitalier Universitaire Dijon Dijon France
- Genetics of Developmental Disorders Team INSERM ‐ Bourgogne Franche‐Comté University, UMR 1231 GAD Dijon France
| | - Sandrine Marlin
- Laboratory of Embryology and Genetics of Malformations, INSERM UMR 1163 Imagine Institute, Université de Paris Paris France
- Centre de Référence « Surdités Génétiques », Fédération de Génétique, Hôpital Necker‐Enfants Malades Assistance Publique Hôpitaux de Paris (AP‐HP) Paris France
| | - Godelieve Morel
- Laboratory of Embryology and Genetics of Malformations, INSERM UMR 1163 Imagine Institute, Université de Paris Paris France
| | - Sylvain Ernest
- Laboratory of Embryology and Genetics of Malformations, INSERM UMR 1163 Imagine Institute, Université de Paris Paris France
| | - Sophie Nambot
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, FHU TRANSLAD Centre Hospitalier Universitaire Dijon Dijon France
- Genetics of Developmental Disorders Team INSERM ‐ Bourgogne Franche‐Comté University, UMR 1231 GAD Dijon France
| | - Yannis Duffourd
- UF Innovation en Diagnostic Génomique des Maladies Rares, Laboratoire de Génétique Chromosomique Moléculaire, FHU‐TRANSLAD Hospital Center University Dijon Bourgogne Dijon France
- Genetics of Developmental Disorders Team INSERM ‐ Bourgogne Franche‐Comté University, UMR 1231 GAD Dijon France
| | - Ninon Ternoy
- Service de Néonatologie, Pédiatrie 2 Centre Hospitalier Universitaire Dijon France
| | | | - Siddharth Banka
- Manchester Centre for Genomics Medicine, St Mary's Hospital, Manchester University Hospital Foundation Trust Manchester UK
| | - Christophe Philippe
- UF Innovation en Diagnostic Génomique des Maladies Rares, Laboratoire de Génétique Chromosomique Moléculaire, FHU‐TRANSLAD Hospital Center University Dijon Bourgogne Dijon France
- Genetics of Developmental Disorders Team INSERM ‐ Bourgogne Franche‐Comté University, UMR 1231 GAD Dijon France
| | - Christel Thauvin‐Robinet
- UF Innovation en Diagnostic Génomique des Maladies Rares, Laboratoire de Génétique Chromosomique Moléculaire, FHU‐TRANSLAD Hospital Center University Dijon Bourgogne Dijon France
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, FHU TRANSLAD Centre Hospitalier Universitaire Dijon Dijon France
- Genetics of Developmental Disorders Team INSERM ‐ Bourgogne Franche‐Comté University, UMR 1231 GAD Dijon France
| | - Frederic Tran Mau‐Them
- UF Innovation en Diagnostic Génomique des Maladies Rares, Laboratoire de Génétique Chromosomique Moléculaire, FHU‐TRANSLAD Hospital Center University Dijon Bourgogne Dijon France
- Genetics of Developmental Disorders Team INSERM ‐ Bourgogne Franche‐Comté University, UMR 1231 GAD Dijon France
| | - Laurence Faivre
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, FHU TRANSLAD Centre Hospitalier Universitaire Dijon Dijon France
- Genetics of Developmental Disorders Team INSERM ‐ Bourgogne Franche‐Comté University, UMR 1231 GAD Dijon France
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6
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Stadelmaier RT, Kenna MA, Barrett D, Mullen TE, Bodamer O, Agrawal PB, Robson CD, Wojcik MH. Neuroimaging in Kabuki syndrome and another KMT2D-related disorder. Am J Med Genet A 2021; 185:3770-3783. [PMID: 34369642 DOI: 10.1002/ajmg.a.62450] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/03/2021] [Accepted: 07/08/2021] [Indexed: 11/09/2022]
Abstract
Recognition of distinct phenotypic features is an important component of genetic diagnosis. Although CHARGE syndrome, Kabuki syndrome, and a recently delineated KMT2D Ex 38/39 allelic disorder exhibit significant overlap, differences on neuroimaging may help distinguish these conditions and guide genetic testing and variant interpretation. We present an infant clinically diagnosed with CHARGE syndrome but subsequently found to have a de novo missense variant in exon 38 of KMT2D, the gene implicated in both Kabuki syndrome and a distinct KMT2D allelic disorder. We compare her brain and inner ear morphology to a retrospective cohort of 21 patients with classic Kabuki syndrome and to typical CHARGE syndrome findings described in the literature. Thirteen of the 21 Kabuki syndrome patients had temporal bone imaging (5/13 CT, 12/13 MRI) and/or brain MRI (12/13) which revealed findings distinct from both CHARGE syndrome and the KMT2D allelic disorder. Our findings further elucidate the spectrum of inner ear dysmorphology distinguishing Kabuki syndrome and the KMT2D allelic disorder from CHARGE syndrome, suggesting that these three disorders may be differentiated at least in part by their inner ear anomalies.
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Affiliation(s)
- Rachel T Stadelmaier
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Margaret A Kenna
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Devon Barrett
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Thomas E Mullen
- Center for Mendelian Genomics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Olaf Bodamer
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Pankaj B Agrawal
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Genetics and Genomics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Caroline D Robson
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Monica H Wojcik
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Division of Genetics and Genomics, Boston Children's Hospital, Boston, Massachusetts, USA
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7
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Schwenty-Lara J, Pauli S, Borchers A. Using Xenopus to analyze neurocristopathies like Kabuki syndrome. Genesis 2020; 59:e23404. [PMID: 33351273 DOI: 10.1002/dvg.23404] [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: 10/23/2020] [Revised: 12/09/2020] [Accepted: 12/09/2020] [Indexed: 11/08/2022]
Abstract
Neurocristopathies are human congenital syndromes that arise from defects in neural crest (NC) development and are typically associated with malformations of the craniofacial skeleton. Genetic analyses have been very successful in identifying pathogenic mutations, however, model organisms are required to characterize how these mutations affect embryonic development thereby leading to complex clinical conditions. The African clawed frog Xenopus laevis provides a broad range of in vivo and in vitro tools allowing for a detailed characterization of NC development. Due to the conserved nature of craniofacial morphogenesis in vertebrates, Xenopus is an efficient and versatile system to dissect the morphological and cellular phenotypes as well as the signaling events leading to NC defects. Here, we review a set of techniques and resources how Xenopus can be used as a disease model to investigate the pathogenesis of Kabuki syndrome and neurocristopathies in a wider sense.
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Affiliation(s)
- Janina Schwenty-Lara
- Department of Biology, Molecular Embryology, Philipps-University Marburg, Marburg, Germany
| | - Silke Pauli
- Institute of Human Genetics, University Medical Center Göttingen, Göttingen, Germany
| | - Annette Borchers
- Department of Biology, Molecular Embryology, Philipps-University Marburg, Marburg, Germany.,DFG Research Training Group, Membrane Plasticity in Tissue Development and Remodeling, GRK 2213, Philipps-University Marburg, Marburg, Germany
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8
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Shpargel KB, Mangini CL, Xie G, Ge K, Magnuson T. The KMT2D Kabuki syndrome histone methylase controls neural crest cell differentiation and facial morphology. Development 2020; 147:dev.187997. [PMID: 32541010 DOI: 10.1242/dev.187997] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 06/02/2020] [Indexed: 12/13/2022]
Abstract
Kabuki syndrome (KS) is a congenital craniofacial disorder resulting from mutations in the KMT2D histone methylase (KS1) or the UTX histone demethylase (KS2). With small cohorts of KS2 patients, it is not clear whether differences exist in clinical manifestations relative to KS1. We mutated KMT2D in neural crest cells (NCCs) to study cellular and molecular functions in craniofacial development with respect to UTX. Similar to UTX, KMT2D NCC knockout mice demonstrate hypoplasia with reductions in frontonasal bone lengths. We have traced the onset of KMT2D and UTX mutant NCC frontal dysfunction to a stage of altered osteochondral progenitor differentiation. KMT2D NCC loss-of-function does exhibit unique phenotypes distinct from UTX mutation, including fully penetrant cleft palate, mandible hypoplasia and deficits in cranial base ossification. KMT2D mutant NCCs lead to defective secondary palatal shelf elevation with reduced expression of extracellular matrix components. KMT2D mutant chondrocytes in the cranial base fail to properly differentiate, leading to defective endochondral ossification. We conclude that KMT2D is required for appropriate cranial NCC differentiation and KMT2D-specific phenotypes may underlie differences between Kabuki syndrome subtypes.
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Affiliation(s)
- Karl B Shpargel
- Department of Genetics and Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599-7264, USA
| | - Cassidy L Mangini
- Department of Genetics and Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599-7264, USA
| | - Guojia Xie
- Laboratory of Endocrinology and Receptor Biology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Kai Ge
- Laboratory of Endocrinology and Receptor Biology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Terry Magnuson
- Department of Genetics and Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599-7264, USA
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9
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Baldridge D, Spillmann RC, Wegner DJ, Wambach JA, White FV, Sisco K, Toler TL, Dickson PI, Cole FS, Shashi V, Grange DK. Phenotypic expansion of KMT2D-related disorder: Beyond Kabuki syndrome. Am J Med Genet A 2020; 182:1053-1065. [PMID: 32083401 DOI: 10.1002/ajmg.a.61518] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/29/2020] [Accepted: 01/29/2020] [Indexed: 12/13/2022]
Abstract
Pathogenic variants in KMT2D, which encodes lysine specific methyltransferase 2D, cause autosomal dominant Kabuki syndrome, associated with distinctive dysmorphic features including arched eyebrows, long palpebral fissures with eversion of the lower lid, large protuberant ears, and fetal finger pads. Most disease-causing variants identified to date are putative loss-of-function alleles, although 15-20% of cases are attributed to missense variants. We describe here four patients (including one previously published patient) with de novo KMT2D missense variants and with shared but unusual clinical findings not typically seen in Kabuki syndrome, including athelia (absent nipples), choanal atresia, hypoparathyroidism, delayed or absent pubertal development, and extreme short stature. These individuals also lack the typical dysmorphic facial features found in Kabuki syndrome. Two of the four patients had severe interstitial lung disease. All of these variants cluster within a 40-amino-acid region of the protein that is located just N-terminal of an annotated coiled coil domain. These findings significantly expand the phenotypic spectrum of features associated with variants in KMT2D beyond those seen in Kabuki syndrome and suggest a possible new underlying disease mechanism for these patients.
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Affiliation(s)
- Dustin Baldridge
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Rebecca C Spillmann
- Department of Pediatrics, Division of Medical Genetics, Duke University Medical Center, Durham, North Carolina, USA
| | - Daniel J Wegner
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jennifer A Wambach
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Frances V White
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kathleen Sisco
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Tomi L Toler
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Patricia I Dickson
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - F Sessions Cole
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Vandana Shashi
- Department of Pediatrics, Division of Medical Genetics, Duke University Medical Center, Durham, North Carolina, USA
| | - Dorothy K Grange
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
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10
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Cuvertino S, Hartill V, Colyer A, Garner T, Nair N, Al-Gazali L, Canham N, Faundes V, Flinter F, Hertecant J, Holder-Espinasse M, Jackson B, Lynch SA, Nadat F, Narasimhan VM, Peckham M, Sellers R, Seri M, Montanari F, Southgate L, Squeo GM, Trembath R, van Heel D, Venuto S, Weisberg D, Stals K, Ellard S, Barton A, Kimber SJ, Sheridan E, Merla G, Stevens A, Johnson CA, Banka S. A restricted spectrum of missense KMT2D variants cause a multiple malformations disorder distinct from Kabuki syndrome. Genet Med 2020; 22:867-877. [PMID: 31949313 PMCID: PMC7200597 DOI: 10.1038/s41436-019-0743-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/24/2019] [Indexed: 12/19/2022] Open
Abstract
Purpose To investigate if specific exon 38 or 39 KMT2D missense variants (MVs) cause a condition distinct from
Kabuki syndrome type 1 (KS1). Methods Multiple individuals, with MVs in exons 38 or 39 of KMT2D that encode a highly conserved region of 54
amino acids flanked by Val3527 and Lys3583, were identified and phenotyped.
Functional tests were performed to study their pathogenicity and understand the
disease mechanism. Results The consistent clinical features of the affected individuals, from
seven unrelated families, included choanal atresia, athelia or hypoplastic
nipples, branchial sinus abnormalities, neck pits, lacrimal duct anomalies,
hearing loss, external ear malformations, and thyroid abnormalities. None of the
individuals had intellectual disability. The frequency of clinical features,
objective software-based facial analysis metrics, and genome-wide peripheral
blood DNA methylation patterns in these patients were significantly different
from that of KS1. Circular dichroism spectroscopy indicated that these MVs
perturb KMT2D secondary structure through an increased disordered to ɑ-helical
transition. Conclusion KMT2D MVs located in a specific
region spanning exons 38 and 39 and affecting highly conserved residues cause a
novel multiple malformations syndrome distinct from KS1. Unlike KMT2D haploinsufficiency in KS1, these MVs likely
result in disease through a dominant negative mechanism.
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Affiliation(s)
- Sara Cuvertino
- Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, UK.,Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, UK
| | - Verity Hartill
- Leeds Institute of Medical Research, Faculty of Medicine and Health, The University of Leeds, Leeds, UK.,Department of Clinical Genetics, Chapel Allerton Hospital, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Alice Colyer
- Astbury Centre for Structural Molecular Biology, Faculty of Biological Sciences, The University of Leeds, Leeds, UK
| | - Terence Garner
- Division of Developmental Biology & Medicine, School of Biological Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, UK
| | - Nisha Nair
- Centre of Genetics & Genomics Versus Arthritis, Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | - Lihadh Al-Gazali
- Department of Paediatrics, College of Medicine & Health Sciences, United Arab University, Al-Ain, UAE
| | - Natalie Canham
- Liverpool Centre for Genomic Medicine, Liverpool Women's NHS Foundation Trust, Liverpool, UK.,North West Thames Regional Genetics Service, Northwick Park Hospital, Harrow, UK
| | - Victor Faundes
- Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, UK.,Laboratorio de Genética y Enfermedades Metabólicas, Instituto de Nutrición y Tecnología de los Alimentos, Universidad de Chile, Santiago, Chile
| | - Frances Flinter
- Department of Clinical Genetics, Guy's & St Thomas NHS Foundation Trust, London, UK
| | | | | | - Brian Jackson
- Astbury Centre for Structural Molecular Biology, Faculty of Biological Sciences, The University of Leeds, Leeds, UK
| | - Sally Ann Lynch
- Temple street Children's University Hospital, Dublin, Ireland
| | - Fatima Nadat
- Astbury Centre for Structural Molecular Biology, Faculty of Biological Sciences, The University of Leeds, Leeds, UK
| | | | - Michelle Peckham
- Astbury Centre for Structural Molecular Biology, Faculty of Biological Sciences, The University of Leeds, Leeds, UK
| | - Robert Sellers
- Division of Developmental Biology & Medicine, School of Biological Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, UK
| | - Marco Seri
- Medical Genetics Unit, St. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Francesca Montanari
- Medical Genetics Unit, St. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Laura Southgate
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.,Department of Medical & Molecular Genetics, King's College London, London, UK
| | - Gabriella Maria Squeo
- Division of Medical Genetics, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Richard Trembath
- Department of Medical & Molecular Genetics, King's College London, London, UK
| | | | - Santina Venuto
- Division of Medical Genetics, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Daniel Weisberg
- Clinical Psychology Department, Royal Manchester Children's Hospital, Manchester University Foundation NHS Trust, Health Innovation Manchester, Manchester, UK
| | - Karen Stals
- Molecular Genetics Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Sian Ellard
- Molecular Genetics Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.,Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | | | - Anne Barton
- Centre of Genetics & Genomics Versus Arthritis, Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | - Susan J Kimber
- Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, UK
| | - Eamonn Sheridan
- Leeds Institute of Medical Research, Faculty of Medicine and Health, The University of Leeds, Leeds, UK.,Department of Clinical Genetics, Chapel Allerton Hospital, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Giuseppe Merla
- Division of Medical Genetics, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Adam Stevens
- Division of Developmental Biology & Medicine, School of Biological Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, UK
| | - Colin A Johnson
- Leeds Institute of Medical Research, Faculty of Medicine and Health, The University of Leeds, Leeds, UK
| | - Siddharth Banka
- Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, UK. .,Manchester Centre for Genomic Medicine, St. Mary's Hospital, Manchester University Foundation NHS Trust, Health Innovation Manchester, Manchester, UK.
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11
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Schwenty-Lara J, Nehl D, Borchers A. The histone methyltransferase KMT2D, mutated in Kabuki syndrome patients, is required for neural crest cell formation and migration. Hum Mol Genet 2020; 29:305-319. [PMID: 31813957 PMCID: PMC7003132 DOI: 10.1093/hmg/ddz284] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 12/30/2022] Open
Abstract
Kabuki syndrome is an autosomal dominant developmental disorder with high similarities to CHARGE syndrome. It is characterized by a typical facial gestalt in combination with short stature, intellectual disability, skeletal findings and additional features like cardiac and urogenital malformations, cleft palate, hearing loss and ophthalmological anomalies. The major cause of Kabuki syndrome are mutations in KMT2D, a gene encoding a histone H3 lysine 4 (H3K4) methyltransferase belonging to the group of chromatin modifiers. Here we provide evidence that Kabuki syndrome is a neurocrestopathy, by showing that Kmt2d loss-of-function inhibits specific steps of neural crest (NC) development. Using the Xenopus model system, we find that Kmt2d loss-of-function recapitulates major features of Kabuki syndrome including severe craniofacial malformations. A detailed marker analysis revealed defects in NC formation as well as migration. Transplantation experiments confirm that Kmt2d function is required in NC cells. Furthermore, analyzing in vivo and in vitro NC migration behavior demonstrates that Kmt2d is necessary for cell dispersion but not protrusion formation of migrating NC cells. Importantly, Kmt2d knockdown correlates with a decrease in H3K4 monomethylation and H3K27 acetylation supporting a role of Kmt2d in the transcriptional activation of target genes. Consistently, using a candidate approach, we find that Kmt2d loss-of-function inhibits Xenopus Sema3F expression, and overexpression of Sema3F can partially rescue Kmt2d loss-of-function defects. Taken together, our data reveal novel functions of Kmt2d in multiple steps of NC development and support the hypothesis that major features of Kabuki syndrome are caused by defects in NC development.
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Affiliation(s)
- Janina Schwenty-Lara
- Department of Biology, Molecular Embryology, Philipps-Universität Marburg, Marburg 35043, Germany
| | - Denise Nehl
- Department of Biology, Molecular Embryology, Philipps-Universität Marburg, Marburg 35043, Germany
| | - Annette Borchers
- Department of Biology, Molecular Embryology, Philipps-Universität Marburg, Marburg 35043, Germany
- DFG Research Training Group, Membrane Plasticity in Tissue Development and Remodeling, GRK 2213, Philipps-Universität Marburg, Marburg 35043, Germany
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12
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Meisner JK, Martin DM. Congenital heart defects in CHARGE: The molecular role of CHD7 and effects on cardiac phenotype and clinical outcomes. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2019; 184:81-89. [PMID: 31833191 DOI: 10.1002/ajmg.c.31761] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 12/02/2019] [Indexed: 02/06/2023]
Abstract
CHARGE syndrome is characterized by a pattern of congenital anomalies (Coloboma of the eye, Heart defects, Atresia of the choanae, Retardation of growth, Genital abnormalities, and Ear abnormalities). De novo mutations of chromodomain helicase DNA binding protein 7 (CHD7) are the primary cause of CHARGE syndrome. The clinical phenotype is highly variable including a wide spectrum of congenital heart defects. Here, we review the range of congenital heart defects and the molecular effects of CHD7 on cardiovascular development that lead to an over-representation of atrioventricular septal, conotruncal, and aortic arch defects in CHARGE syndrome. Further, we review the overlap of cardiovascular and noncardiovascular comorbidities present in CHARGE and their impact on the peri-operative morbidity and mortality in individuals with CHARGE syndrome.
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Affiliation(s)
- Joshua K Meisner
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Donna M Martin
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.,Department of Human Genetics, University of Michigan, Ann Arbor, Michigan
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13
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Serrano MDLA, Demarest BL, Tone-Pah-Hote T, Tristani-Firouzi M, Yost HJ. Inhibition of Notch signaling rescues cardiovascular development in Kabuki Syndrome. PLoS Biol 2019; 17:e3000087. [PMID: 31479440 PMCID: PMC6743796 DOI: 10.1371/journal.pbio.3000087] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 09/13/2019] [Accepted: 08/08/2019] [Indexed: 01/05/2023] Open
Abstract
Kabuki Syndrome patients have a spectrum of congenital disorders, including congenital heart defects, the primary determinant of mortality. Seventy percent of Kabuki Syndrome patients have mutations in the histone methyl-transferase KMT2D. However, the underlying mechanisms that drive these congenital disorders are unknown. Here, we generated and characterized zebrafish kmt2d null mutants that recapitulate the cardinal phenotypic features of Kabuki Syndrome, including microcephaly, palate defects, abnormal ear development, and cardiac defects. The cardiac phenotype consists of a previously unknown vasculogenesis defect that affects endocardium patterning and, consequently, heart ventricle lumen formation. Additionally, zebrafish kmt2d null mutants have angiogenesis defects depicted by abnormal aortic arch development, hyperactive ectopic blood vessel sprouting, and aberrant patterning of the brain vascular plexus. We demonstrate that zebrafish kmt2d null mutants have robust Notch signaling hyperactivation in endocardial and endothelial cells, including increased protein levels of the Notch transcription factor Rbpj. Our zebrafish Kabuki Syndrome model reveals a regulatory link between the Notch pathway and Kmt2d during endothelium and endocardium patterning and shows that pharmacological inhibition of Notch signaling rebalances Rbpj protein levels and rescues the cardiovascular phenotype by enhancing endothelial and endocardial cell proliferation and stabilizing endocardial patterning. Taken together, these findings demonstrate that Kmt2d regulates vasculogenesis and angiogenesis, provide evidence for interactions between Kmt2d and Notch signaling in Kabuki Syndrome, and suggest future directions for clinical research.
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Affiliation(s)
- Maria de los Angeles Serrano
- Molecular Medicine Program—Neurobiology and Anatomy Department, University of Utah, Salt Lake City, Utah, United States of America
| | - Bradley L. Demarest
- Molecular Medicine Program—Neurobiology and Anatomy Department, University of Utah, Salt Lake City, Utah, United States of America
| | | | - Martin Tristani-Firouzi
- Nora Eccles Harrison Cardiovascular Research and Training Institute and Division of Pediatric Cardiology, University of Utah, Salt Lake City, Utah, United States of America
| | - H. Joseph Yost
- Molecular Medicine Program—Neurobiology and Anatomy Department, University of Utah, Salt Lake City, Utah, United States of America
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14
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Siavrienė E, Petraitytė G, Mikštienė V, Rančelis T, Maldžienė Ž, Morkūnienė A, Byčkova J, Utkus A, Kučinskas V, Preikšaitienė E. A novel CHD7 variant disrupting acceptor splice site in a patient with mild features of CHARGE syndrome: a case report. BMC MEDICAL GENETICS 2019; 20:127. [PMID: 31315586 PMCID: PMC6637606 DOI: 10.1186/s12881-019-0859-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/11/2019] [Indexed: 12/16/2022]
Abstract
Background CHARGE syndrome (MIM# 214800)—which is characterised by a number of congenital anomalies including coloboma, ear anomalies, deafness, facial anomalies, heart defects, atresia choanae, genital hypoplasia, growth retardation, and developmental delay—is caused by a heterozygous variant in the CHD7 (MIM# 608892) gene located on chromosome 8q12. We report the identification of a novel c.5535-1G > A variant in CHD7 and provide the evaluation of its effect on pre-mRNA splicing. Case presentation In this study, we report on a female presenting features of CHARGE syndrome. A novel heterozygous CHD7 variant c.5535-1G > A located in the acceptor splice site of intron 26 was identified in the proband’s DNA sample after analysis of whole exome sequencing data. In silico predictions indicating that the variant is probably pathogenic by affecting pre-mRNA splicing were verified by genetic analysis based on reverse transcription of the patient’s RNA followed by PCR amplifications performed on synthesised cDNA and Sanger sequencing. Sanger sequencing of cDNA revealed that the c.5535-1G > A variant disrupts the original acceptor splice site and activates a cryptic splice site only one nucleotide downstream of the pathogenic variant site. This change causes the omission of the first nucleotide of exon 27, leading to a frameshift in the mRNA of the CHD7 gene. Our results suggest that the alteration induces the premature truncation of the CHD7 protein (UniProtKB: Q9P2D1), thus resulting in CHARGE syndrome. Conclusion Genetic analysis of novel splice site variant underlines its importance for studying the pathogenic splicing mechanism as well as for confirming a diagnosis. Electronic supplementary material The online version of this article (10.1186/s12881-019-0859-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Evelina Siavrienė
- Department of Human and Medical Genetics, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania.
| | - Gunda Petraitytė
- Department of Human and Medical Genetics, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania
| | - Violeta Mikštienė
- Department of Human and Medical Genetics, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania
| | - Tautvydas Rančelis
- Department of Human and Medical Genetics, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania
| | - Živilė Maldžienė
- Department of Human and Medical Genetics, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania
| | - Aušra Morkūnienė
- Department of Human and Medical Genetics, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania
| | - Jekaterina Byčkova
- Center of Ear, Nose and Throat Diseases, Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania
| | - Algirdas Utkus
- Department of Human and Medical Genetics, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania
| | - Vaidutis Kučinskas
- Department of Human and Medical Genetics, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania
| | - Eglė Preikšaitienė
- Department of Human and Medical Genetics, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania
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15
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Geers NC, Thio HB, de Kort WJ. Capillary malformations in a child with Kabuki syndrome: A case report. JAAD Case Rep 2019; 5:560-562. [PMID: 31245521 PMCID: PMC6581967 DOI: 10.1016/j.jdcr.2019.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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16
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Adam MP, Banka S, Bjornsson HT, Bodamer O, Chudley AE, Harris J, Kawame H, Lanpher BC, Lindsley AW, Merla G, Miyake N, Okamoto N, Stumpel CT, Niikawa N. Kabuki syndrome: international consensus diagnostic criteria. J Med Genet 2018; 56:89-95. [PMID: 30514738 DOI: 10.1136/jmedgenet-2018-105625] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/09/2018] [Accepted: 11/15/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Kabuki syndrome (KS) is a clinically recognisable syndrome in which 70% of patients have a pathogenic variant in KMT2D or KDM6A. Understanding the function of these genes opens the door to targeted therapies. The purpose of this report is to propose diagnostic criteria for KS, particularly when molecular genetic testing is equivocal. METHODS An international group of experts created consensus diagnostic criteria for KS. Systematic PubMed searches returned 70 peer-reviewed publications in which at least one individual with molecularly confirmed KS was reported. The clinical features of individuals with known mutations were reviewed. RESULTS The authors propose that a definitive diagnosis can be made in an individual of any age with a history of infantile hypotonia, developmental delay and/or intellectual disability, and one or both of the following major criteria: (1) a pathogenic or likely pathogenic variant in KMT2D or KDM6A; and (2) typical dysmorphic features (defined below) at some point of life. Typical dysmorphic features include long palpebral fissures with eversion of the lateral third of the lower eyelid and two or more of the following: (1) arched and broad eyebrows with the lateral third displaying notching or sparseness; (2) short columella with depressed nasal tip; (3) large, prominent or cupped ears; and (4) persistent fingertip pads. Further criteria for a probable and possible diagnosis, including a table of suggestive clinical features, are presented. CONCLUSION As targeted therapies for KS are being developed, it is important to be able to make the correct diagnosis, either with or without molecular genetic confirmation.
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Affiliation(s)
- Margaret P Adam
- Division of Genetic Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Siddharth Banka
- Manchester Centre for Genomic Medicine, Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Health Innovation Manchester, Manchester, UK
| | - Hans T Bjornsson
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Genetics and Molecular Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Olaf Bodamer
- Division of Genetics and Genomics, Department of Medicine, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts, USA.,Division of Genetics and Genomics, Broad Institute of MIT and Harvard University, Cambridge, Massachusetts, USA
| | - Albert E Chudley
- Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Biochemistry and Medical Genetics, Max Rady College of Medicine, Rady Faculty Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jaqueline Harris
- Departments of Neurology and Pediatrics, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Hiroshi Kawame
- Department of Education and Training, Tohoku University School of Medicine, Sendai, Japan
| | - Brendan C Lanpher
- Center for Individualized Medicine, Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA.,Department of Clinical Genomics, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew W Lindsley
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Giuseppe Merla
- Division of Medical Genetics, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - Noriko Miyake
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Nobuhiko Okamoto
- Department of Medical Genetics, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Constanze T Stumpel
- Department of Clinical Genetics and GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Norio Niikawa
- President, the Research Institute of Personalized Health Sciences, Health Sciences University of Hokkaido, Hokkaido, Japan
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Struzik M, Gawlik M. The role of the nursing team in the care of patients with Kabuki syndrome. MEDICAL SCIENCE PULSE 2018. [DOI: 10.5604/01.3001.0012.5180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Kabuki syndrome is a rare genetic condition characterised by pathological changes within all the systems of the body, but with variable gene expression. All the patients described in the literature so far have specific facial features resembling the masks of actors from the Japanese Kabuki Theatre and mild to moderate mental impairment. Diagnosis is made based by genetic testing for mutations of the KMT2D and KDM6A genes. Therapy is mainly based on symptomatic alleviation of the effects of mutation, rehabilitation and improvement of the quality of patients’ life. Then prognosis of patients with Kabuki syndrome is closely related to the severity of symptoms, which is very variable. Aim of the study: The purpose of the study is to present the nursing problems based on the case report and to present complications caused by the disease entity. Material and methods: The criterion for including the patient in the study was the legal guardian’s (parent’s) consent for the child to participate in the study. Qualitative research was conducted using analysis of medical records, interview with the child and the child’s legal guardian, direct and indirect observation of the child for psycho-social changes related to the disease and interpretation of the data in the context of the theoretical knowledge and our own observations. Case report: The report is based on the case of a 16-year-old girl, diagnosed (at the age of fourteen) with rare genetic disorder – Kabuki syndrome. The patient experiences some characteristic symptoms – big, red lips, lowset and sticky-out ears, drooping eyelids and short fingers and toes. One of the first symptoms suggesting Kabuki syndrome were: spitting up during breastfeeding, problems with swallowing, motor clumsiness and epilepsy. The role of the nursing team during hospitalization was to take care because of habitual dislocation of patella, and to provide psychological suport. At present time the girl uses a wheelchair or she moves on her knees Results: The manifestations of chronic disease contribute to the feeling of excessive stress, regardless of the patient’s age. An adequate diet enriched with proteins contributes to the prevention of bedsores among individuals with Kabuki syndrome, immobilised to various degrees. Regular consultations with specialists, such as cardiologist, neurologist, gastroenterologist, orthopaedist, ophthalmologist, psychologist, orthodontist, speech therapist, immunologist, endocrinologist and dietician reduce the risk of complications associated with the disease in the patient with Kabuki syndrome. Early implementation of rehabilitation, focused to increase muscle tension, contributes to maintaining autonomy and self-care in patients with Kabuki syndrome.
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