CDH23 mutation and phenotype heterogeneity: a profile of 107 diverse families with Usher syndrome and nonsyndromic deafness

Usher syndrome type I is characterized by congenital hearing loss, retinitis pigmentosa (RP), and variable vestibular areflexia. Usher syndrome type ID, one of seven Usher syndrome type I genetic localizations, have been mapped to a chromosomal interval that overlaps with a nonsyndromic-deafness localization, DFNB12. Mutations in CDH23, a gene that encodes a putative cell-adhesion protein with multiple cadherin-like domains, are responsible for both Usher syndrome and DFNB12 nonsyndromic deafness. Specific CDH23 mutational defects have been identified that differentiate these two phenotypes. Only missense mutations of CDH23 have been observed in families with nonsyndromic deafness, whereas nonsense, frameshift, splice-site, and missense mutations have been identified in families with Usher syndrome. In the present study, a panel of 69 probands with Usher syndrome and 38 probands with recessive nonsyndromic deafness were screened for the presence of mutations in the entire coding region of CDH23, by heteroduplex, single-strand conformation polymorphism, and direct sequence analyses. A total of 36 different CDH23 mutations were detected in 45 families; 33 of these mutations were novel, including 18 missense, 3 nonsense, 5 splicing defects, 5 microdeletions, and 2 insertions. A total of seven mutations were common to more than one family. Numerous exonic and intronic polymorphisms also were detected. Results of ophthalmologic examinations of the patients with nonsyndromic deafness have found asymptomatic RP-like manifestations, indicating that missense mutations may have a subtle effect in the retina. Furthermore, patients with mutations in CDH23 display a wide range of hearing loss and RP phenotypes, differing in severity, age at onset, type, and the presence or absence of vestibular areflexia.

A new clinical classification for Usher's syndrome based on a new subtype of Usher's syndrome type I

OBJECTIVES

Usher's syndrome is an autosomal recessive disorder characterized by sensorineural hearing loss and progressive visual loss secondary to retinitis pigmentosa. Usher's syndrome is both clinically and genetically heterogeneous. Three clinical types are known today.

METHODS

We conducted a study on 74 patients with Usher's syndrome, performing complete audiological and neurotological examinations.

RESULTS

Twenty-six patients had total profound hearing loss and retinitis pigmentosa (Usher's syndrome type I), and 48 patients had moderate to severe sensorineural hearing loss and retinitis pigmentosa (Usher's syndrome type II). We identified 9 of the 26 Usher's syndrome patients with profound hearing loss who showed a normal response to bithermal vestibular testing.

CONCLUSIONS

The combination of profound hearing loss and normal response to bithermal vestibular testing has not been previously described in Usher's syndrome. Therefore we describe a new subtype of Usher's syndrome type I and suggest a modified clinical classification for Usher's syndrome.

[Utilization of a new night vision enhancement device (DAVIS)]

PATIENTS AND METHODS

Following complete ophthalmologic examination 37 patients with night blindness due to Retinitis Pigmentosa (sometimes Usher-Syndrome) and Choroideremia (n = 3) performed several tests with DAVIS during darkness. We evaluated the improvement of visual function on a special outside course in the city of Heidelberg (duration 1.5 to 4 hours).

RESULTS

Twenty six of the patients were able to better recognize obstacles, 28 could see objects which were not seen without DAVIS. Twenty two of the 37 patients would use the DAVIS. Patients needed a visual acuity of more than 0.1 and more than 6 degree of central visual field to experience improvement with DAVIS. However, in patients with only minimal changes of the visual field, the restriction due to the presence of the device was a drawback. Sudden occurrence of light sources leads to blinding and limits the indoor use.

CONCLUSION

DAVIS enhances contrast acuity especially during night and twilight. This leads to improvement of orientation due to better recognition of obstacles and allows rehabilitation of patients with night blindness for outdoor mobility. Individual test and adjustment of DAVIS is necessary to allow exact and adequate prescription.

MIG is a dominant lymphocyte-attractant chemokine in lichen planus lesions

Dense accumulation of mononuclear cells (lymphocytes >> macrophages) in the dermal-epidermal interface and a T cell-mediated cytotoxic reaction against basal keratinocytes are hallmarks of lichen planus lesions. In this study, we focused on the chemotactic signals responsible for the selective recruitment of these cells. Using in situ hybridization and immunohistochemistry, the expression and localization of the lymphocyte-and/or monocyte/macrophage-attractant CC chemokines macrophage chemoattractant protein-1 (MCP-1), regulated on activation, normal T cell expressed, and secreted (RANTES), macrophage inflammatory protein-1alpha and -1alpha (MIP-1alpha/beta), I-309 and the CXC chemokines monokine induced by interferon-gamma (MIG), interferon-gamma-inducible protein-10 (IP-10), interleukin-8 (IL-8), epithelial-derived neutrophil attractant-78, and growth-related oncogene-alpha were investigated. Strong mRNA expression of MIG, IP-10, and MCP-1 and moderate mRNA expression of RANTES and MIP-1alpha were detected exclusively within foci characterized by strong infiltration with CD3+ lymphocytes (CD4+ cells > CD8+ cells) and CD68+ macrophages. All other chemokines investigated were minimally expressed or absent. With more than 11% of total cells strongly expressing MIG transcripts, this selectively lymphotactic chemokine was by far the dominant chemokine and thus may significantly contribute to the inflammatory reaction in lichen planus lesions. According to the mRNA expression profiles, MIG, IP-10, and MCP-1 were expressed by both basal keratinocytes above and mononuclear cells within the inflammatory foci. Our findings indicate that a set of chemokines composed of IP-10, MCP-1, RANTES, MIP-1alpha, and especially MIG contributes to the cytokine network and preferential trafficking of mononuclear cells to the interface region of lichen planus lesions.

The C-X-C chemokine Mig is highly expressed in the papillae of psoriatic lesions

A prominent feature within the histopathological changes of psoriatic lesions is the particular spatial distribution of neutrophils, macrophages, and T-cell which are considered to participate in the pathogenesis of psoriasis. In this study, an attempt has been made to examine the microanatomical localization and magnitude of expression of the T-cell-attractant and -stimulating C-X-C and C-C chemokines Mig, interferon-inducible protein-10 (IP-10), macrophage inflammatory protein-1 alpha and 1 beta (MIP-a alpha and 1 beta), and regulated on activation, normal T-cell expressed and secreted (RANTES). Employing in situ hybridization, Mig message was strongly and selectively expressed in the upper lesional dermis with pronounced clustering in the tips of the papillae, whereas expression in normal or uninvolved skin was quiescent. In contrast, message for all the other chemokines investigated was much weaker or lacking. Expression of Mig transcripts in cell clusters of the papillae was paralleled by Mig immunoreactivity on endothelial and mononuclear cells. The expression profile, with high levels of Migs virtually limited to those lesional papillae with a pronounced infiltration of mononuclear leukocytes, strongly suggests that Mig is produced by a local population of highly activated macrophages and dermal microvascular endothelial cells. Considering the T-cell-attracting and -stimulating capacity of Mig and the importance of T-cells in the pathogenesis of psoriasis, this study indicates that this novel C-X-C chemokine plays an important role as a mediator of T-cell recruitment and activation in the papillae and thus contributes significantly to the cytokine network of inflammation in psoriasis.

Differential expression of GRO-alpha and IL-8 mRNA in psoriasis: a model for neutrophil migration and accumulation in vivo

Dense focal accumulation of neutrophils in the upper epidermis is a hallmark of psoriasis. Because the signals for neutrophil diapedesis and migration in vivo are not fully understood, psoriatic lesions with pronounced migration of neutrophils may serve as an important model for studying neutrophil chemotaxis. In this study, we present evidence for differential expression of the neutrophil chemotactic cytokines growth-related oncogene alpha, interleukin-8, and ENA-78 (epithelial cell derived and neutrophil-activating properties, 78 amino acids) in psoriatic lesions. In situ hybridization and immunohistochemistry of serial sections were employed to identify and microanatomically localize the cells producing these chemokines. High levels of focal interleukin-8 message were found to be expressed in the upper epidermis by keratinocytes and, most importantly, neutrophils themselves. Growth-related oncogene alpha transcripts were detected in clusters of keratinocytes of the upper epidermis at the same sites where interleukin-8 mRNA was abundant. In contrast to interleukin-8, growth-related oncogene alpha was also detected in the papillary dermis produced by vessel-associated cells. Sites of interleukin-8 and growth-related oncogene alpha mRNA expression were associated with infiltration of neutrophils. Interestingly, mRNA expression of the highly homologous chemokine ENA-78 was quiescent. In conclusion, our data indicate that growth-related oncogene alpha is an important chemoattractant for neutrophil diapedesis in vivo, whereas further migration of neutrophils and formation of micropustules appears to be influenced by the cooperative action of both growth-related oncogene alpha and interleukin-8.