Genomic diagnosis by whole genome sequencing in a Korean family with atypical progeroid syndrome

Clinical genomic diagnosis is unfamiliar to many dermatologists. Limited knowledge of bioinformatics has limited the use of the next generation sequencing method in dermatological clinics. We evaluated the usefulness of whole genome sequencing as a diagnostic approach to inherited dermatological disease. Here, we present our experience with two female siblings with atypical familial generalized lipodystrophy with diabetes mellitus and dyslipidemia. Whole genome sequencing was performed to diagnose the inherited disease. We compared control genomic databases using the Exome Aggregation Consortium, and filtered false‐positive calls with the segmental duplication, non‐flagged single nucleotide variants and COSMIC mutation databases, and applied the prediction tools of SIFT and PolyPhen2. The two siblings who presented with generalized lipodystrophy were diagnosed with an atypical progeroid syndrome with a p.D136H mutation in the LMNA gene (NM_005572). We diagnosed a familial atypical progeroid syndrome using whole genome sequencing. In this paper, we present our experience with whole genome sequencing and demonstrate that it can provide useful information for clinical genomic diagnosis of inherited diseases with atypical clinical features, such as atypical progeroid syndrome.     

A case of Werner syndrome with three primary lesions of malignant melanoma

Three primary lesions of malignant melanoma developed in a 44-year-old Japanese woman with Werner syndrome. One lesion was on the right large pudental lip and the others in distinct locations on her left sole. After the wide local excision of these tumors, the wound of the large pudental lip was sutured, and the defects on the sole were covered with skin grafts. After one course of chemotherapy consisting of dacarbazine, nimustine, vincristine sulfate and local injection of Interferon beta were performed, severe myelosupression occurred and continued for two months. Defective production of WRN protein was confirmed by Western blotting, although the three representative mutations in Japanese patients, mutations 1, 4 and 6, which include over 90% of the Japanese patients, were not detected. We also reviewed 26 cases of malignant melanoma associated with Werner syndrome (WS), including ours.     

伴神经性耳聋的Werner综合征1例国内首报

目的探讨Werner综合征的临床表现及诊断,提高对Werner综合征的认识。方法报告1例伴神经性耳聋的Werner综合征,并进行相关的文献复习,详细分析该病的组织起源、临床表现、鉴别诊断、治疗及预后等,完善患者各系统筛查和实验室检查。结果各系统筛查结果提示患者多组织发育不良或加速退行性变。其临床表现复杂,伴有神经性耳聋等,但无糖尿病及白内障,临床诊断为伴神经性耳聋Werner综合征。结论伴神经性耳聋的Werner综合征较为罕见,目前国内未见报道,该病极易误诊,应对Werner综合征相关基因进一步筛查研究。     

Diffuse,mottled hyperpigmentation and mutations in LMNA gene in a 5‐year‐old boy,his mother,and his grandmother: Atypical progeroid syndrome

We present a multigenerational family with a phenotypic spectrum of skin dyspigmentation, lipodystrophy, bony anomalies, and progeroid facies. All were found to be heterozygous for a c.11C>G (p.Pro4Arg) (P4R) mutation in the lamin A/C gene consistent with atypical progeroid syndrome. Various phenotypic associations have been reported with specific mutations in atypical progeroid syndrome, but the strength of each phenotype‐genotype relationship is unknown. This report adds to the literature of patients with atypical progeroid syndrome and highlights an unusual diagnosis that may present to dermatologists.     

Diagnosis of Werner syndrome by immunoblot analysis

Werner syndrome (WS) is caused by mutations in the gene encoding RecQ type DNA helicase (WRN). We report a 53-year-old Japanese male with WS who initially presented with skin ulcers on the feet and the left elbow. The patient had a high-pitched voice, hoarseness, a characteristic bird-like facial appearance with a beak-shaped nose, canities and juvenile cataracts. Immunoblot analysis using a monoclonal antibody directed against the WS gene product DNA helicase revealed that the patient's leucocytes lacked this particular molecule, confirming the diagnosis of WS. This new immunoblot system therefore enables the diagnosis of WS to be made without the need to undertake more complex mutational analysis.     

Clinical and genetic features of 20 Japanese patients with vascular‐type Ehlers–Danlos syndrome

Background Vascular‐type Ehlers–Danlos syndrome (vEDS) is a severe autosomal dominant inherited disorder resulting from mutations within the α1 type III collagen gene (COL3A1). The majority of published mutations are base changes leading to the substitution of single glycine residues within the triple‐helical domain of type III collagen. Although clinical characteristics and mutations in the COL3A1 gene have been analysed for some patients from Europe and America, similar analyses have not yet been performed for Japanese patients with vEDS. Objectives To analyse the genetic and phenotypic findings in Japanese patients with vEDS. Methods We analysed the clinical features of 20 unrelated individuals with vEDS. To quantify type III collagen production, the fibroblasts were cultured with ³H‐proline, and the radiolabelled collagenous proteins were analysed using sodium dodecyl sulphate–polyacrylamide gel electrophoresis and fluorography. Mutations in COL3A1 were detected by sequence analysis of cDNA from patients’ fibroblasts and subsequently by a genomic DNA sequence analysis. Results Thin and translucent skin with extensive bruising and hypermobility of the small joints were observed in about 90% of the patients, whereas the prevalence of serious clinical findings such as rupture/dissection/aneurysm of the arteries (30%) or rupture of the gastrointestinal tract (25%) was relatively low. Sequence analyses of the COL3A1 gene demonstrated heterozygous point mutations leading to glycine substitution in only nine patients (45%), while heterozygous splice‐site mutations at the junction of the triple‐helical exons were observed in the remaining 11 patients (55%). The average type III collagen production level in the cultured dermal fibroblasts was 14·6% of the normal value. The types of complication were not associated with specific mutations in COL3A1. Conclusion The analysis in the present series revealed a low frequency of patients presenting with serious clinical findings such as arterial rupture/arterial dissection/aneurysm and perforation or rupture of the gastrointestinal tract, and revealed a higher prevalence of splice‐site mutations at the junction of the triple‐helical exons than of glycine substitution mutations in COL3A1.     

Possible Werner syndrome. A unique association with spontaneous digital gangrene in infancy and decreased life span of cultured skin fibroblasts.

BACKGROUND--Werner syndrome is a hereditary disease characterized by several features generally associated with aging. However, the differences between Werner syndrome and the normal aging process are clear. Werner syndrome is usually diagnosed through the clinical signs and symptoms it presents. In recent years, however, the cultured skin fibroblasts of patients have grown slowly and patients have a short life span; these characteristics provide a useful diagnostic aid. OBSERVATIONS--We recently examined a 42-year-old single man who had short fingers, marked facial scars resulting from chilblain-like eruption in infancy, glaucoma caused by uveitis developed in his middle age, callosities on the soles, and immaturation of sexual glands. Repeated peripheral blood examinations showed a positive result for antinuclear factor, slight elevation of immunoglobulin levels, and a low leukocyte count. His family had repeated consanguineous marriages and his parents were cousins. We cultured skin fibroblasts from the patient's forearm and compared them with those of four normal control male subjects. The patient's skin fibroblasts showed a remarkably low population growth rate and a total replicative life span. CONCLUSION--The patients presented unique clinical features for Werner syndrome such as chilblain-like eruption in infancy and glaucoma caused by uveitis. Cell culture studies revealed cellular abnormalities compatible with Werner syndrome. We thus diagnosed the patients as possibly having Werner syndrome.     

A novel mutation of the WRN gene in a Chinese patient with Werner syndrome

Werner syndrome (WS) is an autosomal recessive inherited disease characterized by features of premature ageing. It is caused by mutations of the WRN gene encoding a protein with both exonuclease and helicase activities. The aim of this study was to identify gene mutations in a Chinese patient with WS. A 31-year-old Chinese man with typical features of WS was diagnosed as having probable WS. We performed PCR to scan 33 exons of the WRN gene of the patient, six members of his family, and 50 unrelated controls. Automated DNA sequencing identified the mutation in the patient as 3250delG. The proband's parents, son, younger brother and paternal grandmother were heterozygous. We did not find this heterozygous mutation in the proband's maternal grandmother or in any of 50 normal controls. The novel mutation in the WRN gene is responsible for the pathogenesis of WS and genetic detection is a useful method to confirm the diagnosis.     

Immunoglobulin G4-positive multi-organ lymphoproliferative syndrome with antiphospholipid antibody syndrome

We report immunoglobulin (Ig)G4-positive multi-organ lymphoproliferative syndrome (IgG4(+) -MOLPS) with antiphospholipid antibody syndrome (APS) in a 56-year-old Japanese man presenting with purpuric patches on his legs. Skin biopsy revealed leukocytoclastic vasculitis. Laboratory tests demonstrated high levels of serum IgG and IgG4, hypocomplementemia and anticardiolipin antibody. Echography of the lower limbs and pulmonary scintigraphy showed a thrombus in the left soleal vein and multiple emboli in the basal part of both inferior pulmonary arteries. Computed tomography revealed systemic lymphadenopathy. Histologically, there was reactive paracortical hyperplasia with proliferation of histiocytes and infiltration of IgG4-positive plasma cells. We made a diagnosis of IgG4(+) -MOLPS with APS. To our knowledge, this complication has not been reported previously.     

抗磷脂综合征的皮肤表现

抗磷脂综合征是一种以反复动静脉形成、流产、血小板减少及血抗磷脂抗体持续阳性为特征的系统性自身免疫性疾病。该综合征可以累及包括皮肤在内的全身任何器官。临床上皮肤表现可作为其首要症状,多见于网状青斑、Sneddon综合征、白色萎缩、皮肤溃疡坏死、斑状萎缩和Degos病等。掌握抗磷脂综合征的皮肤表现对其早期诊断、及时治疗极为关键。     

Waardenburg综合征的分子遗传学进展

Waardenburg综合征是一种少见的遗传性听力一色素异常综合征.具有皮肤脱色素改变、额部白发或早年白发、眼虹膜及眼底色素异常、先天性感音神经性耳聋等临床特征.该病具有临床表型差异性和遗传异质性,依据不同的表现和伴发异常,Waardenburg综合征可分为4型.研究证实.配对盒3、小眼畸形相关转录因子、性别决定区域相关转录因子10、Snail相关锌指蛋白转录因子、内皮素3和内皮素受体B基因突变可引起神经嵴细胞迁徙和黑素细胞增殖等过程的异常,从而发生Waardenburg综合征.     

Three years dermoscopic follow‐up of atypical nevi

Atypical nevi are dynamic lesions and may progressively transform into more or less atypical lesions. We aimed to investigate the dermoscopic features of atypical nevi and dynamic changes in these lesions over a period of 3‐years. Patients with 3‐year dermoscopic follow‐up records were enrolled in the study. We compared the dermatoscopic features of the nevus recorded in the first dermoscopic examination and at the end of the third year. Changes in size (mm), pattern, and color were investigated. The most common dermoscopic patterns were reticular (18 patients; 34%), reticular‐homogeneous (17 patients; 32.1%), and reticular‐globular (7 patients; 13.2%). The most common pigmentation patterns were central hyperpigmentation (28 patients; 52.8%), regular pigmentation (nine patients; 17.0%), and multifocal hypo/hyperpigmentation (eight patients; 15.1%). Twenty‐one (39.6%) patients showed changes in pattern. The transformation from reticular‐homogeneous pattern to the homogeneous pattern was the most frequent change in pattern (7 of 21 patients; 33.3%). The transformation from reticular pattern to reticular‐homogeneous pattern was the second most common change in pattern (5 of 21 patients; 23.8%). Fourteen (26.4%) patients experienced symmetrical enlargement. Symmetrical enlargement was statistically more frequent in patients who showed dermoscopic changes in pattern than in those who did not show any changes in the pattern (p: .038). In this study, we did not observe any new dermoscopic clues for the diagnosis of melanoma during the follow‐up. The nevi tended to turn into a homogeneous (structureless) pattern. We observed that the most common dermoscopic change in pattern was the transformation from reticular‐homogeneous pattern to homogeneous pattern, and the lesions had symmetrical enlargement during this transformation. In conclusion, despite the known association between atypical nevi and the risk of developing melanoma, most atypical nevi do not transform into melanoma. Therefore, our study suggests that the excision of atypical nevi is not necessary and dermatoscopic follow‐up can reduce the number of unnecessary excisions.     

A 75‐year‐old woman with primary antiphospholipid syndrome presenting with livedoid vasculopathy

The clinical presentation of primary antiphospholipid syndrome (PAPS) can vary, often mimicking many other medical conditions. Therefore, it is difficult to diagnose at the first presentation because of the absence of classical symptoms. We described an unusual presentation of PAPS mimicking livedoid vasculopathy (LV), where the only diagnostic clue at the initial presentation was skin lesions in both lower legs. A 75‐year‐old Han Chinese woman presented with features mimicking LV, without clinically significant antiphospholipid syndrome (APS). After many relevant laboratory examinations and histopathological examination, the patient was finally diagnosed as having PAPS. LV should not be treated as an independent disease, but as a skin manifestation. A high degree of suspicion of APS is needed in patients presenting or diagnosed with LV. Early interventions are necessary to prevent and reduce the risk of thrombosis. This case presents a rare clinical manifestation and provides significant information on PAPS.     

Genetic analyses of two cases of Werner's syndrome

We report two cases of Werner's syndrome (WS). First, a 42-year-old Japanese man was referred on suspicion of systemic sclerosis (SSc) because of scleroderma-like skin atrophy and foot ulcers. Second, a 51-year-old woman with malignant fibrous histiocytoma was referred on suspicion of premature aging syndrome. Because both patients had many typical manifestations compatible with WS, we made a clinical diagnosis of WS. Genetic analyses revealed a homozygous mutation, an A deletion at nucleotide 3677 of WS gene (WRN) in the first case and a homozygous mutation, a G to C substitution at one base upstream of exon 26 of WRN in the second case. Both mutations were consistent with those previously reported in Japanese WS patients.     

1例伴神经性耳聋的Werner综合征患者WRN基因突变研究

目的:检测1例伴神经性耳聋Werner综合征患者的WRN基因突变情况。方法:收集1例伴神经性耳聋Werner综合征患者及其亲属的外周血标本,提取其外周血总RNA进行RT-PCR,将cDNA产物测序;提取患者外周血基因组DNA进行PCR,将DNA产物测序验证突变,以同样方法检测其1例亲属及30例健康对照。结果:患者WRN基因发现4处碱基改变:内含子2967+237 A>G和3309+26C>T、同义突变c.2361 G>T和c.3237 G>A。结论:该例伴神经性耳聋Werner综合征患者存在WRN基因2个内含子SNP和2个已报道cSNPs。     

Recurrent skin ulcer cross-repair and sensory reconstruction in a WRN gene mutational patient

A 37-year-old man complained of a refractory posterior malleolar ulceration on his left ankle. He was diagnosed with Werner syndrome according to the progeroid clinical features and genetic testing. To approach the ulceration, a free flow-through right anterolateral thigh perforator flap with anterolateral thigh cutaneous nerve was harvested. One year later, he was readmitted due to a new ulceration on his right ankle. We harvested the left anterolateral thigh perforator flap with anterolateral thigh cutaneous nerve to reconstruct the defect. After one more year of follow-up, there was no recurrence of ulcers, and the sensation of the flap recovered partially after 6 months. We conclude that free flow-through anterolateral thigh perforator flap is a feasible choice for the repair of foot ulcers in Werner syndrome.     

Cellular aging in Werner's syndrome: a unique phenotype?

Werner's syndrome is commonly regarded as a model for the study of premature aging. There are, however, a variety of clinical and pathologic anatomical features that clearly distinguish it from aging in normal individuals. In this paper we report on in vitro cytogenetic and cell fusion studies that indicate cultured fibroblast-like cells derived from Werner patients differ from cells of normal donors. Despite these discordances with "natural" aging, however, Werner's syndrome, like several other "segmental progeroid syndromes," may prove useful for the investigation of selected aspects of the aging process and of age-related diseases.