Wolcott-Rallison综合征一例报告及其EIF2AK3基因突变检测

目的 报道一例Wolcott-Rallison综合征患儿,研究患儿真核生物翻译起始因子-2α-激酶-3基因(eukaryoticinitiation factor 2α kinase 3,EIF2AK3)的突变情况,为该病的临床诊断、基因诊断与遗传咨询提供依据.方法 分析患儿的临床症状、体征、生化检查及骨骼X线检查并做出临床诊断;提取患儿及其父母的基因组DNA,针对EIF2AK3基因设计特异性引物,应用降落聚合酶链式反应(Touch-down PCR)扩增基因的全部外显子及外显子-内含子交界区,对扩增产物进行直接测序分析.结果 (1)9岁4个月男性患儿,身高108 cm,智力相当于6岁儿童发育水平;出生3个月时被诊断为1型糖尿病,正规胰岛素治疗后空腹血糖常高于11.0 mmol/L,最高达23.5 mmol/L;面容异常;肝脏于肋下5 cm,剑突下2 cm;骨骼畸形,X线提示多发性骨骺发育不良.(2)患儿EIF2AK3基因的外显子8中检测到c.1408_1409insT(p.S470FfsX7)杂合突变,外显子9中检测到c.1596T＞A(p.C532X)杂合突变,2个突变位点分别在患儿母亲和父亲的基因中得到验证.结论 Wolcott-Rallison综合征临床特点:新生儿或婴儿早期发生的1型糖尿病,多发性骨骺发育不良,体格和智力发育迟缓,多系统损伤;结合患者临床表现与生化、物理检查,对致病基因EIF2AK3进行突变检测是诊断Wolcott-Rallison 综合征的可靠方法.EIF2AK3基因c.1408_1409insT与c.1596T＞A是导致该患儿出现Wolcott-Rallison综合征表型的致病突变,患儿为EIF2AK3基因突变的遗传复合体,这2个突变在国内外均未见报道,属新突变.

Abstract：

Objective Wolcott-Rallison syndrome(WRS)is a rare autosomal recessive disorder characterized by the association of permanent neonatal or early-infancy insulin-dependent diabetes,multiple epiphyseal dysplasia and growth retardation,and other variable multisystem clinical manifestations.Here we describe a Chinese boy affected by WRS.Genetic testing of his EIF2AK3 gene was performed in order to elucidate molecular variations and subsequently to provide credible genetic counseling for prenatal diagnosis in his family. Method Based on analysis of a nine-year-old boy's clinical symptoms associated with biochemical examination and imaging,the diagnosis of WRS was therefore made.Genomic DNAs were extracted from peripheral blood leukocytes from the boy and his parents with their informed consent for genetic studies.All EIF2AK3 exons and intron-exon boundaries were amplified by Touch-down polymerase chain reaction(Touch-down PCR)and sequenced.Result Direct sequencing of PCR products revealed the presence of a heterozygous T insertion(c.1408_1409insT)in exon 8 of the EIF2AK3 gene leading to frameshifting and termination,and another heterozygous T to A exchange(c.1596T ＞ A)in exon 9 of the EIF2AK3 gene resulting in nonsense C532X mutation. Conclusion Combining mutation screening of EIF2AK3 gene with clinical manifestations and effective examination may provide a reliable diagnostic method for patients.In this research,two novel mutations identified in the Chinese boy locate in the catalytic domain of the EIF2AK3 gene,disrupting the ability of autophosphorylation,leading to the truncated proteins that are unable to phosphorylate the natural substrate,which are responsible for the phenotype of Wolcott-Rallison syndrome.     

AUTOPSY FINDINGS IN THE WOLCOTT-RALLISON SYNDROME

Wolcott-Rallison syndrome is a rare autosomal recessive condition characterized by diabetes mellitus arising in early infancy and multiple epiphyseal dysplasia. To date, nine cases have been described in the world literature. We report an affected girl who died at the age of 4 years and on whom a full autopsy was performed. In addition to neonatal diabetes mellitus and epiphyseal dysplasia, this child had mental retardation and recurrent episodes of self-limiting hepatic failure. Autopsy revealed severe pancreatic hypoplasia and markedly abnormal pancreatic histology, while histology of the bone was consistent with epiphyseal dysplasia. There was laryngeal stenosis and pulmonary hypoplasia. The heart was enlarged with mitral valve dysplasia and stenosis, left atrial dilatation, left ventricular hypertrophy, and endocardial fibroelastosis. Examination of the central nervous system showed arrhinencephaly and cerebellar cortical dysplasia. The liver showed minor histological abnormalities but no features were present to account for the recurrent hepatic failure. In addition to Wolcott-Rallison syndrome this child had a deletion at 15q11-12 in 65 of her cells.     

Wolcott–Rallison syndrome due to the same mutation (W522X) in EIF2AK3 in two unrelated families and review of the literature*

Ozbek MN, Senée V, Aydemir S, Kotan LD, Mungan NO, Yuksel B, Julier C, Topaloglu AK. Wolcott–Rallison syndrome due to the same mutation (W522X) in EIF2AK3 in two unrelated families and review of the literature. Wolcott‐Rallison syndrome (WRS) is a rare autosomal recessive disorder characterized by an early‐infancy‐onset diabetes mellitus associated with a variety of multisystemic clinical manifestations. Here, we present six patients with WRS, carrying the same homozygous mutation (EIF2AK3‐W522X), from two unrelated Turkish families. This is the largest series of patients with the same mutation for this rare syndrome. In this communication we compare clinical features of these six patients with the other 34 patients who have been reported to date, and review the clinical features of WRS. All WRS patients presented first with symptoms of insulin dependent diabetes mellitus, with a mean age at onset of 2 months. All patients had skeletal dysplasia or early signs of it, and growth retardation. Many of the patients with WRS have been reported to have developmental delay, mental retardation, and learning difficulties; in contrast, none of our patients showed abnormal development at age up to 30 months. Acute attacks of hepatic failure were reported in 23 cases out of 37 patients; in 15 of those 23 cases an acute attack of renal failure accompanied the liver failure. Exocrine pancreatic deficiency has been reported in only four cases other than our four patients. Central hypothyroidism was observed in six of 28 cases. We propose that central hypothyroidism is not a component of WRS, but rather a reflection of euthyroid sick syndrome. Four of our patients experienced severe neutropenia, compared to only five of the 27 other cases, suggesting that the W522X mutation may be specifically associated with neutropenia. Other than the consistent features of diabetes mellitus and epiphyseal dysplasia, WRS patients are otherwise characterized by extensive phenotypic variability that correlates poorly to genotype.     

真核翻译始动因子2-a激酶3基因突变致Wolcott-Rallison综合征1例

目的 对Wolcott - Rallison综合征的临床特征及遗传发病机制进行研究.方法 选取临床诊断为Wolcott - Rallison综合征的患儿及其父母为研究对象,运用PCR技术扩增患儿家系真核翻译始动因子2-α激酶3(EIF2AK3)基因的17个外显子区,用DNA直接测序技术,对患儿家系EIF2AK3基因的17个外显子进行基因突变分析.结果 在患儿及其父亲EIF2AK3基因的第9外显子区发现了1个杂合突变(1798A/T),氨基酸序列分析显示这个突变是一种无义突变,可导致EIF2AK3第532位C氨基酸残基形成终止密码子( C532STOP),形成1个532氨基酸残基组成的截短蛋白.患儿母亲EIF2AK3基因未发现相应突变(1798T/T).结论 在中国儿童中,EIF2AK3基因突变可导致Wolcott - Rallison综合征发生.     

Wolcott Rallison Syndrome: A Rare Inherited Diabetes Mellitus

A 9-y-old boy was referred to authors’ institute for the management of insulin dependent diabetes mellitus. He was the product of third degree consanguineous marriage and was delivered by full term vaginal delivery with a birth weight of 2.75 kg. At 3 mo of age, he had presented with diabetic ketoacidosis and was on insulin regimen. Patient had delayed milestones and short stature. On follow up, child developed limb deformity and was diagnosed to have skeletal dysplasia. At the age of 9 y, patient was diagnosed to have cirrhosis of liver. Genetic analysis revealed homozygous EIF2AK3 nonsense mutation. It confirmed the diagnosis of Wolcott-Rallison syndrome. Patient’s mother was heterozygous for the same mutation.     

EIF2AK3基因相关Wolcott-Rallison综合征1例并文献复习

患儿，女，1个月29 d。因抽搐6 d、发现血糖增高5 d入院。血糖波动于正常或增高，糖化血红蛋白因过高无法检测，尿糖+~++++，空腹C肽0.19 ng/mL，胰岛素11.68 μIU/mL。遗传性内分泌疾病基因Panel（检测基因412个，包含已知糖尿病相关基因49个）高通量测序发现患儿EIF2AK3基因存在新发c.2731_2732delAG和c.2980G > A复合杂合突变，均位于基因的激酶结构域。该婴儿被确诊为Wolcott-Rallison综合征（WRS）。WRS是一种罕见的常染色体隐性遗传疾病，以新生儿糖尿病、多发性骨骺发育不良和肝脏疾病为特征，新生儿糖尿病是WRS诊断的必备条件，EIF2AK3基因是WRS的致病基因。     

Primary hypothyroidism and nipple hypoplasia in a girl with Wolcott–Rallison syndrome

Wolcott–Rallison syndrome (WRS), caused by mutation in the EIF2AK3 gene encoding the PERK enzyme, is the most common cause of permanent neonatal diabetes mellitus (PNDM) in consanguineous families and isolated populations. Besides PNDM, it also includes skeletal abnormalities, liver and renal dysfunction, and other inconsistently present features. We present two siblings, who are WRS patients, and are Albanians from Kosovo born to unrelated parents. The older sister presented with PNDM, exocrine pancreatic insufficiency, short stature, microcephaly, normocytic anemia, delay in speech development, skeletal abnormalities, primary hypothyroidism, and hypoplastic nipples. Sequencing of the EIF2AK3 gene identified a homozygous mutation R902X in exon 13. The younger brother was diagnosed with PNDM and died from hepatic failure suggesting that he has been suffering from WRS as well. Including one previously reported patient from Kosovo carrying the same homozygous mutation, there are three WRS patients from this very small, ethnically homogenous region suggesting founder effect in this population. Conclusion: We postulate that thyroid hypoplasia with primary subclinical hypothyroidism already reported in two WRS patients and nipple hypoplasia could also be the phenotypic reflection of the mutation of pleiotropic EIF2AK3 gene in secretory cells.     

Thiamine-responsive megaloblastic anaemia syndrome: long-term follow-up and mutation analysis of seven families

Aim: Thiamine-responsive megaloblastic anaemia syndrome (TRMA) is the association of diabetes mellitus, anaemia and deafness, due to mutations in SLC19A2, encoding a thiamine transporter protein. This is a unique monogenic form of vitamin-dependent diabetes for which there is limited long-term data. We aimed to study genotype-phenotype relationships and long-term follow-up in our cohort. Methods: We have studied 13 patients from seven families and have follow-up data for a median of 9 y (2-30 y). Results: All patients originated from Kashmir or Punjab, and presented with non-immune, insulin-deficient diabetes mellitus, sensorineural deafness and a variable anaemia in the first 5 y of life, the anaemia progressing to megaloblastic and sideroblastic changes in the bone marrow. The anaemia and diabetes mellitus responded to oral thiamine hydrochloride 25 mg/d, but during puberty thiamine supplements became ineffective, and almost all patients require insulin therapy and regular blood transfusions in adulthood. All patients are homozygous for mutations in the SLC19A2 gene. We have identified a novel missense mutation (T158R) that was excluded in 100 control alleles.

Conclusion: Diabetes in this syndrome is due to an insulin insufficiency that initially responds to thiamine supplements; however, most patients become fully insulin dependent after puberty. A mutation screening strategy is feasible and likely to identify mutations in almost all cases.     

Wolcott-Rallison syndrome: Diabetes mellitus and spondyloepiphyseal dysplasia

In 1972, Wolcott and Rallison described three siblings with a combination of infancy-onset diabetes mellitus and multiple epiphyseal dysplasia. We have observed a brother and sister with the same disorder. The chondro-osseous lesions are those of a spondylo-epiphyseal dysplasia. The diabetes mellitus is relatively mild. Histologic and electron microscopic studies of chondro-osseous tissue show findings similar to those in other epiphyseal and spondylo-epiphyseal dysplasias. In addition, however, atypical collagen-like fibres are found inside and outside chondrocytes. Collagen production seems to be normal in cultured fibroblasts. From the available data it appears that the association of characteristic chondro-osseous and endocrine abnormalities is non-random and that the lesions are independent manifestations of a pleiotropic gene. We propose to call this disorder the Wolcott-Rallison Syndrome.Supported by a grant from the Stiftung Volkswagenwerk     

The Greek family system when a child has diabetes mellitus type 1

Aim: To depict the characteristic ways that families who have a child suffering from diabetes and face difficulties with metabolic control function. In addition, to reveal the ways that this functioning is related to metabolic control problems. Methods: Qualitative methods were used, including an in-depth interview and observation of 30 Greek families having one child suffering from diabetes mellitus type 1 and facing difficulties with metabolic control. An average of 10 meetings were conducted with each family, including separate meetings with each individual family member, the parental couple and the family as a whole. Methods were based on thematic categories provided by the model of the "psychosomatic family". Results: The presence of the disease and the requirements of the treatment regimen seemed to be associated with certain family characteristics: enmeshed relationships, ambiguous roles and rules, break down of hierarchy, coalition between mother and patient, absence of father's involvement and "infantilization" of the suffering child. Also in such families, healthy siblings are assigned parental roles and, finally, the families present signs of social exclusion.

Conclusion: The study provides important findings concerning the psychological characteristics of the families under study. The present ways of functioning are associated with the difficulties families face when coping with the treatment regimen.     

Selectin polymorphisms and perinatal morbidity in low-birthweight infants

Background: Studies have shown an association between altered expression of selectins and premature birth, early sepsis and bronchopulmonary dysplasia.

Aim: To investigate the possible link between functional polymorphisms of the E-, P- and L-selectin genes and perinatal morbidity.

Methods: We compared the genotype distribution of the E-selectin Ser128Arg, P-selectin Thr715Pro and L-selectin Pro213Ser polymorphisms in 125 low-birthweight singleton infants with those of 156 healthy term neonates. We also analysed the association of genotype with risk of sepsis and bronchopulmonary dysplasia.

Results: We found no association between E-selectin or P-selectin polymorphisms and premature birth, nor did we find any association between E-selectin or P-selectin and early postnatal sepsis or bronchopulmonary dysplasia. Carriers of the 213Ser L-selectin allele were found to be more prevalent in low-birthweight infants, particularly in those with bronchopulmonary dysplasia. We found no association between the L-selectin polymorphism and early postnatal sepsis.

Conclusion: Our results underline the importance of L-selectin in perinatal pathology, but further studies are needed to evaluate the alteration of L-selectin levels in carriers of the 213Ser allele and their possible contribution to premature birth and bronchopulmonary dysplasia.     

EIF2S3基因变异致MEHMO综合征2例报告并文献复习

目的 探讨MEHMO综合征的临床特征与遗传学特点.方法 回顾分析2例确诊MEHMO综合征患儿的临床资料,并复习相关文献.结果 两例患儿均为男性.例1于2岁3个月就诊,表现为癫痫发作、智力低下、进行性痉挛性四肢瘫、小头畸形、面部畸形、身材矮小和隐睾等.例2于3月龄就诊,4个月15天龄死亡,表现为反复低血糖、小头畸形和小阴...     

Short stature in child with early-onset diabetes

We present a girl who initially presented at 12 weeks of age with antibody negative diabetes. Genetic screening for common mutations of monogenic diabetes was negative. She was noted to have short stature at 8 years of age (height <0.4 centile), as well as overlapping toes and distal abnormalities of her fingers. On reevaluation, further investigation revealed an EIF2AK3 mutation, and a diagnosis of Wolcott Rallison syndrome was made. This case highlights the importance of close follow up of patients with neonatal diabetes for the development of syndromic features that may lead to a unifying diagnosis.     

An unusual form of spondyloepiphyseal dysplasia, with advanced carpal and spinal end-plate ossification mimicking COMP-mutation-like multiple epiphyseal dysplasia

We present a child with irregular ossification of tubular bone epiphyses, short bones, and spine. The radiographic evolution of bones undergoing endochondral ossification was followed from the age of 1 year 9 months to 6 years. The unusual features demonstrated in this child made classification difficult: pseudoachondroplasia was excluded because no mutations of the COMP gene were found. Considering the evolution of the radiographic appearances, the most likely diagnosis would seem to be an unusual form of spondyloepiphyseal dysplasia, mimicking some aspects of multiple epiphyseal dysplasia. Endochondral ossification was diffusely altered with a mixture of epiphyseal ossification delay associated with acceleration and early fusion. This case was a unique presentation within the family, suggesting a mutation in the affected child.     

Congenital staphylococcal scalded skin syndrome in a premature infant

A case of congenital staphylococcal scalded skin syndrome (SSSS) with fatal outcome in a premature infant is reported. An intrauterine infection with Staphylococcus aureus was probably the cause for the fulminant course of the disease. Despite adequate antibiotic treatment, the infant died within 24 h after birth because of respiratory failure.

Conclusion: Although rare, infection may occur in the perinatal period and SSSS may present within the first 24 h of life. In this situation, early administering of appropriate antibiotics is essential.     

假性软骨发育不全一家系临床特征和COMP基因突变分析

假性软骨发育不全（pseudoachondroplasia, PSACH）是较罕见的常染色体显性遗传性脊柱骨骺发育不良疾病。该文分析总结一个5岁2月龄PSACH患儿及其父母的临床资料,对COMP基因的所有19个外显子及其侧翼序列进行PCR扩增和直接测序,并对外显子10进行分子克隆明确突变性质。患儿有手指粗短、弓形腿、短肢侏儒、长骨干骺端增宽和脊柱椎体前突等临床及影像学表现,其COMP基因外显子10检出突变c.1048_1116del（p.Asn350_Asp372del）。患儿父亲外显子10携带同样突变,但缺乏临床表现。结合临床和影像学特征,通过COMP突变分析明确了PSACH诊断。该文报道的COMP基因突变在PSACH中的不穿透现象属于首次报道。     

Fetal growth and postnatal growth failure in very-low-birthweight infants

Aim: To determine in a cohort of very-low-birthweight (VLBW) infants the incidence of postnatal growth failure and the influence of intrauterine growth and neonatal morbidities on the risk for severe postnatal growth failure (PNGF). Methods: The study was based on analysis of data from the Israel Neonatal Network database on VLBW infants born between 1995 and 2001. Z-score was determined for weight at birth and discharge, and severe PNGF was defined as a decline in z-score of greater than 2. Univariate analysis and multi-linear regression determined the effect of fetal growth and neonatal morbidities on the risk for severe PNGF. Results: Severe PNGF occurred in 10.6% of the cohort. The mean±SD birthweight (BW) z-score was -0.59±0.74, decreasing to -1.67±0.77 at discharge. The incidence of severe PNGF increased significantly with decreasing BW and gestational age. Each 1-unit increase in z-score BW was associated with a 2.37-fold increased risk for severe PNGF. Severe respiratory distress syndrome, patent ductus arteriosus, sepsis, necrotizing enterocolitis, and bronchopulmonary dysplasia were associated with severe PNGF.

Conclusion: Severe PNGF among VLBW infants was markedly influenced by intrauterine growth as well as major morbidities. In the assessment of postnatal growth among VLBW infants, growth status at birth should be considered.     

Jarcho-Levin syndrome: a case study

Jarcho-Levin syndrome is a rare genetic disorder characterized by multiple vertebral and rib anomalies. There are two types of Jarcho-Levin syndrome, spondylothoracic dysplasia and spondylocostal dysostosis. Spondylothoracic dysplasia has a grimmer prognosis than spondylocostal dysostosis. Many of the infants born with this disorder succumb to respiratory failure. With new advances in medical care, even the more severely affected children have an improved chance of survival. This is a case presentation of one child with spondylothoracic dysplasia and a brief history of the disease process.     

The rare syndromic forms of monogenic diabetes in childhood

The most frequent form of diabetes in the childhood is type 1 diabetes. Moreover, the rare forms of diabetes have been also identified in children. Besides of neonatal diabetes caused by the mutations in KCNJ11, SUR1 and GCK genes, other forms of monogenic diabetes are associated with different chronic disorders. These rare forms of syndromic diabetes are related to mutations in genes which lead to Wolfram syndrome, Alstr?m syndrome, Wolcott-Rallison syndrome or Roger's/TRMA syndrome. In this paper we discuss the clinical features of rare syndromic forms of monogenic diabetes, which gave suggestions on pathogenic mechanism of the diagnosed diabetes in childhood. This may be helpful for appropriate classification of the epidemiological, clinical and genetic data. It may be useful in the future to the form of the Polish National Survey of rare syndromic forms of monogenic diabetes in childhood.     

Exome capture and massively parallel sequencing identifies a novel HPSE2 mutation in a Saudi Arabian child with Ochoa (urofacial) syndrome

We describe a child of Middle Eastern descent by first-cousin coupling with idiopathic neurogenic bladder and high-grade vesicoureteral reflux at 1 year of age, whose characteristic facial grimace led to the diagnosis of Ochoa (urofacial) syndrome at age 5 years. We used homozygosity mapping, exome capture and paired-end sequencing to identify the disease causing mutation in the proband. We reviewed the literature with respect to the urologic manifestations of Ochoa syndrome. A large region of marker homozygosity was observed at 10q24, consistent with known autosomal recessive inheritance, family consanguinity and previous genetic mapping in other families with Ochoa syndrome. A homozygous mutation was identified in the proband in HPSE2: c.1374_1378delTGTGC, a deletion of 5 nucleotides in exon 10 that is predicted to lead to a frameshift followed by replacement of 132 C-terminal amino acids with 153 novel amino acids (p.Ala458Alafsdel132ins153). This mutation is novel relative to very recently published mutations in HPSE2 in other families. Early intervention and recognition of Ochoa syndrome with control of risk factors and close surveillance will decrease complications and renal failure.