Electroclinical Features of Epilepsy in Kleefstra Syndrome

BACKGROUND

Kleefstra syndrome (KS) or 9q34.3 microdeletion syndrome (OMIM #610253) is a rare genetic condition featuring intellectual disability, hypotonia, and dysmorphic facial features. Autism spectrum disorder, severe language impairment, and sleep disorders have also been described. The syndrome can be either caused by a microdeletion in 9q34.3 or by pathogenic variants in the euchromatin histone methyltransferase 1 gene (EHMT1, *607001). Although epilepsy has been reported in 20 to 30% of subjects, a detailed description of epileptic features and underlying etiology is still lacking. The purpose of this study is to investigate epilepsy features in a cohort of epileptic patients with KS.

METHODS

This multicenter study investigated eight patients with KS and epilepsy. Our findings were compared with literature data.

RESULTS

We included five patients with 9q or 9q34.33 deletions, a subject with a complex translocation involving EHMT1, and two with pathogenic EHMT1 variants. All patients presented with moderate to severe developmental delay, language impairment, microcephaly, and infantile hypotonia. Although the epileptic manifestations were heterogeneous, most patients experienced focal seizures. The seizure frequency differs according to the age of epilepsy onset, with patients with early-onset epilepsy (before 36 months of age) presenting more frequent seizures. An overtime reduction in seizure frequency, as well as in antiseizure drug number, was observed in all patients. Developmental delay degree did not correlate with seizure onset and frequency or drug resistance.

CONCLUSION

Epilepsy is a frequent finding in KS, but the underlying pathogenetic mechanism and specific features remain elusive.

Exome Analysis Reveals Novel Missense and Deletion Variants in the CC2D2A Gene as Causative of Joubert Syndrome

The CC2D2A gene is essential for primary cilia formation, and its disruption has been associated with Joubert Syndrome-9 (JBTS9), a ciliopathy with typical neurodevelopmental features. Here, we describe an Italian pediatric patient with typical features of Joubert Syndrome (JBTS): “Molar Tooth Sign”, global developmental delay, nystagmus, mild hypotonia, and oculomotor apraxia. Whole exome sequencing and segregation analysis identified in our infant patient a novel heterozygous germline missense variant c.3626C > T; p.(Pro1209Leu) inherited from the father and a novel 7.16 kb deletion inherited from the mother. To the best of our knowledge, this is the first report showing a novel missense and deletion variant involving exon 30 of the CC2D2A gene.

Quantitative MRI-Based Analysis Identifies Developmental Limbic Abnormalities in PCDH19 Encephalopathy

Protocadherin-19 (PCDH19) is a calcium dependent cell-adhesion molecule involved in neuronal circuit formation with prevalent expression in the limbic structures. PCDH19-gene mutations cause a developmental encephalopathy with prominent infantile onset focal seizures, variably associated with intellectual disability and autistic features. Diagnostic neuroimaging is usually unrevealing. We used quantitative MRI to investigate the cortex and white matter in a group of 20 PCDH19-mutated patients. By a statistical comparison between quantitative features in PCDH19 brains and in a group of age and sex matched controls, we found that patients exhibited bilateral reductions of local gyrification index (lGI) in limbic cortical areas, including the parahippocampal and entorhinal cortex and the fusiform and lingual gyri, and altered diffusivity features in the underlying white matter. In patients with an earlier onset of seizures, worse psychiatric manifestations and cognitive impairment, reductions of lGI and diffusivity abnormalities in the limbic areas were more pronounced. Developmental abnormalities involving the limbic structures likely represent a measurable anatomic counterpart of the reduced contribution of the PCDH19 protein to local cortical folding and white matter organization and are functionally reflected in the phenotypic features involving cognitive and communicative skills as well as local epileptogenesis.

Developmental morphology of vascular and lymphatic capillaries in the working myocardium and Purkinje bundle of the sheep septomarginal band

The normal development of vascular and lymphatic capillaries in the right ventricular septomarginal band of the sheep heart was studied in 9 fetuses aged 60-143 days (term = 147 days), 14 lambs aged 1 day to 16 weeks, and 3 adults. Tissue was fixed by perfusion and examined with light and transmission electron microscopy. The septomarginal band is composed of working myocardium and a well-defined peripheral bundle of Purkinje cells. Vascular capillaries of the working myocardium were closely apposed to myocardial cells. By contrast, vascular capillaries of the Purkinje bundle were situated within the connective tissue sheath and septa, at variable distances from the Purkinje cells. After birth, the capillaries of the Purkinje bundle were also found in grooves and tunnels within the Purkinje strands. The ultrastructure of fetal vascular capillaries associated with myocardial and Purkinje cells was initially similar, and characterized by an abundance of synthetic organelles in endothelial cells and pericytes. However, after 115 days in utero, capillary endothelium with diaphragmed fenestrae, 40-60 nm in width, were observed within the Purkinje bundle. The fenestrae attained an average frequency of 1 per 11 capillary cross sections just before term, and this was maintained in lambs and adults. The ultrastructure of lymphatic capillaries, which were not observed in the septomarginal band until just before term, changed little during development.

Differentiation and innervation of the atrioventricular bundle and ventricular Purkinje system in sheep heart

The development of the atrioventricular bundle (AVB) and ventricular Purkinje system and their innervation have been studied in fetal sheep from 27 to 140 days gestation (term is 147 days). The AVB initially consisted of a primordium, which lacked innervation and was composed of small, relatively undifferentiated myocytes. Differentiation of Purkinje-like cells within the AVB began near its distal end and extended towards the atrioventricular node (AVN). Differentiation of the ventricular Purkinje system extended distally from the region of bifurcation of the AVB from cells that were indistinguishable from the working myocardium and continuous with the AVB primordium. Differentiation of Purkinje-like AVB cells was complete by 46 days gestation but Purkinje fibres were still differentiating within the ventricular wall at 60 days gestation. The main morphological changes included a large increase in cell size and organization into strands, development of characteristic glycogen-filled regions containing many intermediate filaments and early development of myofibrillar M lines compared to the working myocardium. The differentiation of AVB cells and the ventricular Purkinje system preceded their innervation. The AVB became innervated earlier than ventricular Purkinje fibres, intimate contacts between proximal AVB cells and nerve axons being present at 60 days gestation. Nerve fibres were present in the septomarginal band at this time, however, en passant associations with ventricular Purkinje fibres were rarely observed until 140 days gestation and intimate contacts were not present at any stage. Although the AVB and ventricular Purkinje system of adult sheep are composed of morphologically similar cells, the present study demonstrates that they differ in origin and their mode of differentiation as well as timing and intimacy of innervation. Innervation is not part of the developmental mechanism leading to the differentiation of Purkinje fibres. No primordium of the ventricular Purkinje system could be identified, suggesting that the mechanism of differentiation of ventricular Purkinje fibres involves recruitment from early working myocardium.

Autoradiographic localization of beta-1 and beta-2 adrenoceptors in guinea pig atrium and regions of the conducting system

[125I]Cyanopindolol binding to slide mounted guinea pig atrial sections was time-dependent (Ki = 2.4 X 10(8) M-1 min-1, K-1 = 1.2 X 10(-3) min-1) saturable (24-32 pM) and stereoselective with respect to the isomers of propranolol. Competition binding curves with the beta-1 selective antagonist CGP 20712A and beta-2 selective antagonist ICI 118,551 revealed the presence of beta-1 and beta-2 adrenoceptors in the proportions of 85 to 15%. X-ray film exposed to sections of guinea pig heart incubated previously with [125I]cyanopindolol with or without ICI 118,551 (70 nM) or CGP 20712A (100 nM) or (-)-propranolol (1 microM) showed a high density and even distribution of beta-1 adrenoceptors and a lower density and even distribution of beta-2 adrenoceptors over the myocardium. Beta-2 adrenoceptors also were located in the epicardium, the adventitia of the pulmonary artery, aorta, superior and inferior vena cava and the endothelium of the superior and inferior vena cava. Development of nuclear emulsion-coated coverslips confirmed these observations and, in addition, localized beta-2 adrenoceptors to nerve tissue and the aortic valve. In the papillary muscle and surrounding Purkinje cells there was a high density and even distribution of beta-1 and a much lower density of beta-2 adrenoceptors. The atrioventricular node, atrioventricular bundle and ventricular Purkinje system also contained both beta-1 and beta-2 adrenoceptors and in comparison with the surrounding myocardium, these tissues had a slightly greater density of beta-2 adrenoceptors.

An improved perfusion technique for fixation of sheep myocardium

Although sheep have been widely used as models in the study of cardiac physiology, corresponding morphologic and morphometric data are scanty. For meaningful correlation of morphometric data with physiological information, it is desirable that fixation of the heart occur under controlled conditions. This paper describes a technique for in situ, retrograde aortic perfusion fixation of sheep myocardium under conditions of controlled pressure and minimal wastage of fixative. This is achieved by the application of snares around the brachiocephalic trunk and aortic arch, which are tightened at the start of the perfusion. These isolate the ascending aorta and the coronary vasculature from the remainder of the circulation and allow fixation of the whole heart at a controlled pressure. The method produces good fixation and contrast for transmission electron microscopy and is applicable to late-gestation fetuses, lambs, and adult sheep.

Sheep cardiac Purkinje fibers: configurational changes during the cardiac cycle

Previous attempts to study the cytoarchitecture of cardiac Purkinje fibers with the scanning electron microscope (SEM) have been limited by the surrounding dense connective tissue. In this study the connective tissue was removed by treatment with 8N HCl, after adult sheep hearts were fixed in diastole or systole and tissue taken for SEM and transmission electron microscopy (TEM). In SEM, Purkinje fibers freely anastomosed in false tendons and formed a subendocardial plexus. In systole, medium and small-sized Purkinje fibers formed deep clefts not observed in diastole. The clefts are thought to be due to sarcolemmal folding and fiber buckling and may therefore affect conduction. The myofibrils beneath the laterally apposed sarcolemmas of adjacent Purkinje cells when fixed in systole were often observed as tightly curved arches in series. Similar configurations with expanded arches were observed in diastole. The formation of arches by myofibrils is unique to Purkinje fibers and is interpreted as the mechanism responsible for their compliance to stretch. The significance of contraction in producing the observed geometric changes in Purkinje fibers and the implications of their cytoarchitecture with respect to conduction are discussed.

Cardiac Purkinje cells in culture

Purkinje cells from false tendons of young rabbits, pigs and fetal lambs were dispersed by the action of collagenase and elastase and grown in culture for up to 14 days. Immunofluorescent staining with fluorescein-labelled antibodies to cardiac myosin and tropomyosin demonstrated cross-banding and/or a diffuse positive stain in Purkinje cells between 3 and 7 days in culture. Electron microscopy of cultured Purkinje cells at 3 days and 7 days revealed some disorganization of the myofilament system, in particular loss of Z-band material, as well as many thickened Z-bands, 120 nm to 240 nm in width. Gap junctions remained but desmosomes and fasciae adherentes were fewer in number. Organelles such as ribosomes, glycogen and mitochondria did not alter. Some Purkinje cells were spontaneously contractile in culture for up to seven days. Dominguez and Fozzard [7] propose that buckling of the Purkinje fibre and the production of sarcolemmal folds on the cell surface affect conduction of electrical impulses. We suggest that Purkinje cell contraction may play a major part in producing these geometric changes affecting conduction.

The demonstration of close nerve-Purkinje fibre contacts in false tendons of sheep heart

An observation of intimate nerve-Purkinje fibre associations in false tendons of sheep heart is reported. Nerve bundles were observed in deep clefts of Purkinje fibres, in channels running between coupled Purkinje cells and embedded within Purkinje cells, as well as in the outer connective tissue sheath. Most nerve terminals in these areas were filled with small clear vesicles and a few large dense-cored vesicles. Only a few axons with many small dense-cored vesicles were observed. Intimate associations (separation, 60 to 90 nm) between the Purkinje cell and nerve varicosity were observed in the deep clefts. Similar close appositions were also present where nerves were embedded in Purkinje cells. In these cases the Purkinje cell enclosing the nerve bundle formed intercellular junctions with its own sarcolemma. Elaborate sarcolemmal folds with multi-vesicular bodies were also frequently observed near nerve bundles and varicosities. The identity of the transmitter is unknown although the nerves forming intimate associations with Purkinje cells have a morphology typical of cholinergic nerves.