The CAG repeat at the Huntington disease gene in the Portuguese population: insights into its dynamics and to the origin of the mutation

Huntington disease (HD) is caused by an expansion of a CAG repeat. This repeat is a dynamic mutation that tends to undergo intergenerational instability. We report the analysis of the CAG repeat in a large population sample (2,000 chromosomes) covering all regions of Portugal, and a haplotype study of (CAG)_n and (CCG)_n repeats in 140 HD Portuguese families. Intermediate class 2 alleles represented 3.0% of the population; and two expanded alleles (36 and 40 repeats, 0.11%) were found. There was no evidence for geographical clustering of the intermediate or expanded alleles. The Portuguese families showed three different HD founder haplotypes associated with 7-, 9- or 10-CCG repeats, suggesting the possibility of different origins for the HD mutation among this population. The haplotype carrying the 7-CCG repeat was the most frequent, both in normal and in expanded alleles. In general, we propose that three mechanisms, occurring at different times, may lead to the evolution from normal CAGs to full expansion: first, a mutation bias towards larger alleles; then, a stepwise process that could explain the CAG distributions observed in the more recent haplotypes; and, finally, a pool of intermediate (class 2) alleles more prone to give rise to expanded HD alleles.     

Trinucleotide expansion within the MJD1 gene presents clinically as spinocerebellar ataxia and occurs most frequently in German SCA patients

Autosomal dominant spinocerebellar ataxia (SCA) is a clinicallyand genetically heterogeneous neurodegenerative disorder whichleads to progressive cerebellar ataxia. A gene responsible forSCA type 3 has been mapped to human chromosome 14q, close tothe Machado-Joseph disease (MJD) locus. The MJD1 gene has recentlybeen cloned and the disease causing mutation has been identifiedas an unstable and expanded (CAG)_n trinucleotide repeat. Assome clinical features of MJD overlap with those of SCA we investigatedthe MJD mutation in 38 German families with dominantly inheritedSCA. The MJD1 (CAG)_n expansion was identified in 19 families.In contrast, the trinucleotide expansion was not observed in21 ataxia patients without family history of the disease. Analysisof the (CAG)_n repeat length in 30 patients revealed an inversecorrelation with the age of onset. The (CAG)_n stretch of theaffected allele varied between 67 and 78 trinucleotide units,the normal alleles carried between 12 and 28 simple repeats.These results demonstrate that the MJD mutation causes the diseasephenotype of most SCA patients in Germany.     

DNA haplotype analysis of Huntington disease reveals clues to the origins and mechanisms of CAG expansion and reasons for geographic variations of prevalence

This study of allelic association using three Intra- and twoextragenlc markers within 150 kb of the Huntlngton disease (HD)mutation has provided evidence for linkage disequilibrium forfour of five markers. Haplotype analysis of 67 HD families usingmarkers in strong linkage disequilibrium with HD Identifiedtwo haplotypes underlying 77.6% of HD chromosomes. Normal chromosomeswith these two haplotypes had a mean number of CAG repeats significantlylarger than and an altered distribution of CAG repeats comparedwith other normal chromosomes. Furthermore, haplotype analysisof five new mutation families reveals that HD has arisen onthese same two chromosomal haplotypes. These findings suggestthat HD arises more frequently on chromosomes with specificDNA haplotypes and higher CAG repeat lengths. We then studiedCAG and CCG repeat lengths In the HD gene on 896 control chromosomesfrom different ancestries to determine whether the markedlyreduced frequency of HD in Finland, Japan, China and AfricanBlacks Is associated with an altered frequency of DNA haplotypesand subsequently lower CAG lengths on control chromosomes comparedto populations of Western European descent. The results showa highly significant positive correlation between CAG size onnormal chromosomes and the frequency of HD and a significantinverse relationship between CAG and CCG repeat lengths. Inpopulations with lowered prevalence rates of HD, CAG repeatlengths are smaller and the distribution of CCG alleles Is markedlydifferent from Western European populations. These findingssuggest that, in addition to European emigration, new mutationsmake a contribution to geographical variation of prevalencerates and is consistent with a multistep model of HD developingfrom normal chromosomes with higher CAG repeat lengths.     

Predictive testing for Huntington disease: interpretation and significance of intermediate alleles

Direct mutation analysis for Huntington disease (HD) became possible in 1993 with the identification of an expanded CAG trinucleotide repeat as the mutation underlying the disease. Expansion of CAG length beyond 35 repeats may be associated with the clinical presentation of HD. HD has never been seen in a person with a CAG size of <36 repeats. Intermediate alleles are defined as being below the affected CAG range but have the potential to expand to >35 CAG repeats within one generation. Thus, children of intermediate allele carriers have a low risk of developing HD. Currently, the intermediate allele range for HD is between 27 and 35 CAG repeats. In this study, we review the current knowledge on intermediate alleles for HD including the CAG repeat range, the intermediate allele frequency, and the clinical implications of an intermediate allele predictive test result. The factors influencing CAG repeat expansion, including the CAG size of the intermediate allele, the sex and age of the transmitting parent, the family history, and the HD gene sequence and haplotype, will also be reviewed.     

中国人亨廷顿病CAG三核苷酸重复的分子分析

为在分子水平了解中国人亨廷顿病的发病机理，为该病的基因诊断和遗传咨询提供科学依据，应用巢式ＰＣＲ、变性聚丙烯酰胺凝胶电泳以及ＤＮＡ测序等方法，对正常中国人及亨廷顿病（Ｈｕｎｔｉｎｇｔｏｎ＇ｓｄｉｓｅａｓｅ，ＨＤ）患者的ＩＴ１５基因（ＣＡＧ）ｎ重复序列的拷贝数进行了分析。４０例正常中国人以及１３个ＨＤ家系的研究结果表明：中国人正常ＩＴ１５基因（ＣＡＧ）ｎ重发序列的拷贝数为１３～２６，多数为１６；而所有被分析的ＨＤ患者都携带一个ＣＡＧ序列高度重复的ＩＴ１５基因，其（ＣＡＧ）ｎ的拷贝数为４０～９４；且ＣＡＧ重复序列的拷贝数与发病年龄呈现一定的相关性。正常和ＨＤ等位基因之间的（ＣＡＧ）ｎ拷贝数不相重叠，在１０３例高风险ＨＤ家庭成员的症状前诊断中，根据（ＣＡＧ）ｎ拷贝数的测定，发现了３５例ＨＤ基因携带者，结果表明，ＩＴ１５基因的不稳定突变是导致中国人亨廷顿病的遗传基础。     

Dynamic mutation in Dutch Huntington''s disease patients: increased paternal repeat instability extending to within the normal size range.

Analysis of the distribution of normal and expanded alleles of the polymorphic (CAG)n repeat in the IT15 gene in the Dutch population confirmed the presence of an expanded repeat on all Huntington's disease (HD) chromosomes. Our results show that the size distributions of normal and affected alleles overlap. Normal alleles range from 11 to 37 repeats and HD alleles contain 37 to 84 repeats. A clear correlation is found between age at onset and repeat length, but the spread of the age at onset in the major repeat range producing characteristic HD is too wide to be of diagnostic value. In the available parent-offspring pairs, maternal HD alleles show a moderate instability with a slight preponderance of size increase over size decrease. Paternal alleles have a bimodal distribution: the majority (69%) behave similarly to the maternal alleles, while the remainder (31%) show a dramatic expansion, the degree of which appears proportional to the initial size. This is shown in three out of four juvenile patients, who have repeats of 71, 74, and 84 copies, respectively, originating from expanded paternal HD alleles in the previous generation. Two sporadic cases are caused by expansion of 'large' normal paternal alleles of 32 and 34 repeats, respectively, to 46 copies. This not only confirms the diagnosis of HD in two de novo cases, but it also underlines the increased paternal instability. In addition paternal repeat instability was once detected within the normal range in two sibs who inherited 21 and 22 repeats, respectively, on the same paternal chromosome. In two Dutch HD families the segregation of the expanded (CAG)n repeat was found. Analysis of the (CAG)n repeat in our previously reported recombinants confirmed their disease status.     

Familial predisposition to recurrent mutations causing Huntington''s disease: genetic risk to sibs of sporadic cases.

Huntington's disease (HD) is associated with expansion of a CAG repeat in a new gene. We have recently defined a premutation in a paternal allele of 30 to 38 CAG repeats in the HD gene which is greater than that seen in the general population (< 30 repeats) but below the range seen in patients with HD (> 38). These intermediate alleles are unstable during transmission through the germline and in sporadic cases expand to the full mutation associated with the clinical phenotype of HD. Here we have analysed three new mutation families where, in each, the proband and at least one sib have CAG sizes in the HD range. In one of these families, two sibs with expanded CAG repeats are both clinically affected with HD, thus presenting a pseudorecessive pattern of inheritance. In all three families the parental intermediate allele has expanded in more than one offspring, thus showing a previously unrecognised risk of inheriting HD to sibs of sporadic cases of HD.     

Huntingtin gene CAG repeat size affects autism risk: Family‐based and case–control association study

The Huntingtin (HTT) gene contains a CAG repeat in exon 1, whose expansion beyond 39 repeats consistently leads to Huntington's disease (HD), whereas normal‐to‐intermediate alleles seemingly modulate brain structure, function and behavior. The role of the CAG repeat in Autism Spectrum Disorder (ASD) was investigated applying both family‐based and case–control association designs, with the SCA3 repeat as a negative control. Significant overtransmission of “long” CAG alleles (≥17 repeats) to autistic children and of “short” alleles (≤16 repeats) to their unaffected siblings (all p < 10^?5) was observed in 612 ASD families (548 simplex and 64 multiplex). Surprisingly, both 193 population controls and 1,188 neurological non‐HD controls have significantly lower frequencies of “short” CAG alleles compared to 185 unaffected siblings and higher rates of “long” alleles compared to 548 ASD patients from the same families (p < .05–.001). The SCA3 CAG repeat displays no association. “Short” HTT alleles seemingly exert a protective effect from clinically overt autism in families carrying a genetic predisposition for ASD, while “long” alleles may enhance autism risk. Differential penetrance of autism‐inducing genetic/epigenetic variants may imply atypical developmental trajectories linked to HTT functions, including excitation/inhibition imbalance, cortical neurogenesis and apoptosis, neuronal migration, synapse formation, connectivity and homeostasis.     

Single sperm analysis of the trinucleotide repeats in the Huntington's disease gene: quantification of the mutation frequency spectrum

The CAG triplet repeat region of the Huntington's disease genewas amplified in 923 single sperm from three affected and twonormal individuals. Average-size alleles (15–18 repeats)showed only three contraction mutations among 475 sperm (0.6%).A 30 repeat normal allele showed an 11% mutation frequency.The mutation frequency of a 36 repeat intermediate allele was53% with 8% of all gametes having expansions which brought theallele size into the HD disease range (38 repeats). Diseasealleles (38–51 repeats) showed a very high mutation frequency(92–99%). As repeat number increased there was a markedelevation in the frequency of expansions, in the mean numberof repeats added per expansion and the size of the largest observedexpansion. Contraction frequencies also appeared to increasewith allele size but decreased as repeat number exceeded 36.Our sperm typing data are of a discrete nature rather than consistingof smears of PCR product from pooled sperm. This allowed theobserved mutation frequency spectra to be compared to the distributioncalculated using discrete stochastic models based on currentmolecular ideas of the expansion process. An excellent fit wasfound when the model specified that a random number of repeatsare added during the progression of the polymerase through therepeated region.     

Analysis of the (CAG)n repeat causing Huntington's disease in a Mexican population

We investigated the allele distribution of the polymorphic (CAG)n repeat in the IT15 gene in 96 normal subjects from the Mexican population and 83 unrelated patients with Huntington's disease. Our results show that the size distributions of normal and affected alleles do not overlap. Normal alleles range from 13 to 32 triplets, with 18 being the most frequent allele, while HD alleles contain 37 to 76 repeats with 42 being the most frequent. One allele in the range of intermediate alleles was found (32 repeats) in a normal subject. The juvenile onset cases in this study are associated with an expansion greater than 49 repeats. In the available parent-offspring pairs, paternal alleles show instability with an expansion of 28 repeats in one case.     

Reduced penetrance of the Huntington's disease mutation

Controversy persists concerning the significance of Huntington disease (HD) alleles in the 36-39 repeat range. Although some clinically affected persons have been documented with repeats in this range, elderly unaffected individuals have also been reported. We examined 10 paternal transmissions of HD alleles of 37-39 repeats in collateral branches of families with de novo HD. All 10 descendants, including many who are elderly, are without symptoms of HD. Forty percent of the transmissions were unstable, although none varied by more than one repeat. The observation that individuals with alleles of 37-39 repeats may survive unaffected beyond common life expectancy supports the presence of reduced penetrance for HD among some persons with repeat sizes which overlap the clinical range. Non-penetrance may be increased in the collateral branches of de novo mutation families when compared to penetrance estimates from patient series. There was no CAA-->CAG mutation for the penultimate glutamine in either a de novo expanded 42 repeat allele or the corresponding non-penetrant 38 repeat allele in a family with fresh mutation to HD.      

Single sperm analysis of the CAG repeats in the gene for Machado-Joseph disease (MJD1): evidence for non-Mendelian transmission of the MJD1 gene and for the effect of the intragenic CGG/GGG polymorphism on the intergenerational instability

To investigate the mechanism of the meiotic instability of expanded CAG repeats in the gene for Machado-Joseph disease (MJD1), we analyzed the CAG repeat sizes of 1036 single sperm from six individuals with Machado- Joseph disease (MJD). The segregation ratio between single sperm with an expanded allele and those with a normal allele is significantly different (P <0.0001) from the expected 1:1 segregation ratio, which demonstrates segregation distortion of expanded alleles in male meiosis. In single sperm from individuals with the [expanded (CAG)n- CGG]/[normal (CAG)n-GGG] genotype, significantly greater instability of the CAG repeat was observed compared with single sperm from individuals with the [expanded (CAG)n-CGG]/[normal (CAG)n-CGG] genotype (F-test, P <0.001). These findings in single sperm confirm non-Mendelian transmission of the MJD1 gene and the effect of the intragenic CGG/GGG polymorphism on the intergenerational instability of the CAG repeats in the MJD1 gene, which have been observed in clinical and genetic studies. Our results indicate similarities and dissimilarities between MJD and Huntington's disease or myotonic dystrophy in terms of the inter-allelic interaction, segregation distortions and size distribution of trinucleotide repeats in mutant alleles. Further study is required to determine whether there is a common mechanism underlying the instability of the triplet repeats in 'triplet repeat diseases'.      

Instability of CAG repeats in Huntington''s disease: relation to parental transmission and age of onset.

Huntington's disease (HD) has recently been found to be caused by expansion of a trinucleotide (CAG) repeat within the putative coding region of a gene with an unknown function. We report here an analysis of HD mutation and the characteristics of its transmission in 36 HD families. CAG repeats on HD chromosomes were unstable when transmitted from parent to offspring. Instability appeared more frequent and stronger upon transmission from a male than from a female, with a clear tendency towards increased size. We have also found a significant inverse correlation (p = 0.0001) between the age of onset and the CAG repeat length. The observed scatter would, however, not allow an accurate individual prediction of age of onset. Three juvenile onset cases analysed had an HD mutation of paternal origin. In at least two of these cases a large expansion of the HD allele upon paternal transmission may explain the major anticipation observed. Our results suggest that several features of the expansion mutation in HD are similar to those previously observed for mutations of similar size in spinobulbar muscular atrophy and in myotonic dystrophy, and to those observed more recently in spinocerebellar ataxia type 1 and in dentatorubropallidoluysian atrophy, four diseases also caused by expansion of CAG repeats.     

Presymptomatic analysis of spinocerebellar ataxia type 1 (SCA1) via the expansion of the SCA1 CAG-repeat in a large pedigree displaying anticipation and parental male bias

Autosomal dominant cerebellar ataxia type 1 (ADCA1) is a clinicaland genetic heterogeneous neurodegenerative disorder which leadsto progressive cerebellar ataxia. One defective gene responsiblefor the disease was first localised to 6p (SCA1, splnocerebellarataxia type 1) and the mutation has been more recently characterised.We have analysed the CAG-repeat mutation responsible for theSCA1 phenotype in a large Spanish kindred with 41 affected members,in which positive linkage with D6S89 was previously shown. All(10) clinically affected members analysed were heterozygouswith one disease allele being between 41 to 57 CAG repeats,and the other in the normal range, from 6 to 39 repeats. Nineclinically unaffected individuals who were between the agesof 18 and 40, were found to have expansions of the CAG repeat(41 to 59), and 22 other ‘at risk’ individuals werefound to have inherited the SCA1 gene with copies of the CAGrepeat in the normal range. We have also observed that affectedfathers passed on the mutated SCA1 gene with larger increasesin the number of CAG repeats than affected mothers did. In onecase a decrease in the number of CAG repeats (51 to 50) wasdetected in the transmission from the affected mother, and intwo cases no change was observed in the transmission of a 41allele repeat by a mother. As in the other disorders in whichknowledge of the mutation has been obtained, analysis of therepeat expansion dramatically changes diagnosis of SCA1.     

Interaction of normal and expanded CAG repeat sizes influences age at onset of Huntington disease

Huntington disease (HD) is a neurodegenerative disorder caused by the abnormal expansion of CAG repeats in the HD gene on chromosome 4p16.3. Past studies have shown that the size of expanded CAG repeat is inversely associated with age at onset (AO) of HD. It is not known whether the normal Huntington allele size influences the relation between the expanded repeat and AO of HD. Data collected from two independent cohorts were used to test the hypothesis that the unexpanded CAG repeat interacts with the expanded CAG repeat to influence AO of HD. In the New England Huntington Disease Center Without Walls (NEHD) cohort of 221 HD affected persons and in the HD-MAPS cohort of 533 HD affected persons, we found evidence supporting an interaction between the expanded and unexpanded CAG repeat sizes which influences AO of HD (P = 0.08 and 0.07, respectively). The association was statistically significant when both cohorts were combined (P = 0.012). The estimated heritability of the AO residual was 0.56 after adjustment for normal and expanded repeats and their interaction. An analysis of tertiles of repeats sizes revealed that the effect of the normal allele is seen among persons with large HD repeat sizes (47-83). These findings suggest that an increase in the size of the normal repeat may mitigate the expression of the disease among HD affected persons with large expanded CAG repeats.     

Analysis of triplet repeats in the huntingtin gene in Japanese families affected with Huntington''s disease.

Huntington's disease (HD) is associated with the expansion of a CAG repeat in the huntingtin gene. Molecular analysis of the repeat in Japanese HD patients and normal controls was performed. The size of the CAG repeat ranged from 37 to 95 repeats in affected subjects and from seven to 29 in normal controls. A significant correlation was found between the age of onset and the CAG expansion. The length of the expanded repeat is unstable in meiotic transmission and large increases occur in paternal transmission. At the same time the CCG repeat polymorphism adjacent to the CAG repeat was analysed and haplotypes of HD chromosomes were identified. Strong linkage disequilibrium was found between the CAG repeat expansion and an allele of (CCG)10 in Japanese HD chromosomes. It is distinct from that described previously in western populations. Western HD chromosomes strongly associate with an allele of (CCG)7. Possible mechanisms underlying the disequilibrium in Japan are discussed.     

Study of the Huntington''s disease (HD) gene CAG repeats in schizophrenic patients shows overlap of the normal and HD affected ranges but absence of correlation with schizophrenia.

The CAG repeats in the Huntington's disease gene were investigated in chromosomes from 71 unrelated schizophrenic persons and 18 patients with schizoaffective disorder in order to determine if any of these patients had abnormal expansions. All of the probands had repeat sizes in the normal range (< 35 repeats) and there was no significant difference between the allele distributions of these patients and the normal controls. The families of two patients with 32 repeats and one patient with 34 repeats were investigated further and showed no uniform segregation of the disease with the large repeat alleles. The proband with 34 repeats inherited a chromosome that originally had 36 repeats in her father. The presence of 36 CAG repeats in members of her family and in HD patients suggests that there is an overlap between the normal and Huntington's disease CAG repeat size ranges. The more recently described CCG polymorphism in this gene was also examined in the schizophrenic and schizoaffective persons. All patients had alleles in the normal range.     

Molecular and clinical correlations in autosomal dominant cerebellar ataxia with progressive macular dystrophy (SCA7)

Spinocerebellar ataxia 7 (SCA7) is caused by the expansion of an unstable CAG repeat in the first exon of the SCA7 gene. We have analyzed the SCA7 mutation in 19 families and one isolated case of various geographical origins, presenting with autosomal dominant cerebellar ataxia with progressive macular dystrophy. The SCA7 CAG repeat was expanded in 77 patients and in 11 at-risk individuals, with alleles containing from 37 to 130 repeats, demonstrating that SCA7 is genetically homogeneous. Repeats on normal alleles contained from 7 to 35 CAGs. There was a strong negative correlation (r = -0.84) between the age at onset and the size of the CAG repeat expansion in SCA7 patients. Larger expansions were associated with earlier onset, a more severe and rapid clinical course, and a higher frequency of decreased vision, ophthalmoplegia, extensor plantar response and scoliosis. The frequency of other clinical signs such as dysphagia and sphincter disturbances increased with disease duration. The mutation was highly unstable during transmission, with a mean increase of 10 +/- 16 CAG repeats, which was significantly greater in paternal (15 +/- 20) than in maternal (5 +/- 5) transmissions. This correlated well with the marked anticipation (19 +/- 13 years) observed in the families. Gonadal mosaicism, observed in the sperm of a patient, was particularly important, with expanded alleles ranging from 42 to >155 CAG repeats. The degree of instability during transmission, resulting mostly in expansions, is greater than in the seven other neurodegenerative disorders caused by polyglutamine expansions.