The Wolf-Hirschhorn syndrome (WHS) is the first example of a human chromosomal deletion syndrome, described as a pathogenetic syndrome. It is usually caused by the deletion of the sub-telomeric short arm of chromosome 4[1].
The spectrum and severity of WHS clinical features typically correlate with the deletion size[2,3,4,5].This report focuses on the DSD as particular features in genotype-phenotype correlation analysis of WHS patients on two Tunisian patients and proposes a candidate gene to this developmental disorder.
The main characteristic of WHS is the typical face, usually referred to as a ‘‘Greek warrior helmet face’’. Previous studies suggest a critical region that, when deleted, causes the recognizable syndrome. It has been narrowed to a 165 kb , about 1.9 Mb from the 4p telomere, and includes two purported regions, called WHSCR1 and WHSCR2[6,7]. So far, advanced molecular techniques such as FISH and CGH array provided the possibility of detecting smaller deletions with less evident phenotypes.
Our study focuses on variable features in two 4p deletions cases. Molecular and conventional cytogenetic analysis, showed a partial loss of 4p with different breakpoints and different size deletions[3].Both patients are clinically suspected to have WHS. Patient 1 has specific dysmorphic features, a severe psychomotor delay, failure to thrive and microcephaly. His clinical profile is suggestive of a mild form. However, patient 2 has a polymalformative syndrome including dysmorphic features: a microcephaly, a megalocornea, an hypertelorism, a microretrognatism and a growth delay. He presents a heart defect, a Palatine crack and a cryptorchidism, micropenis and hypospadias, all the three last features are suggestive of sex development disorder in atypical WHS case. Array-CGH exploration characterized the 4p loss of 3.4Mb in the first patient and of 4.8 Mb in the second. We suggest that different deletion sizes and the variability of the involved genes could play an important role in the complex phenotype of WHS in each patient (Table 1).
Table 1
Comparison of the phenotypic features in patients with 4p deletion.
Paper
|
Flipsen-ten Berg and al., [2007]
|
Chen and al., [2011]
|
Sifakis and al.,[2012]
|
Malvestiti and al., [2013]
|
Venegas-Vega and al., [2012]
|
Present Study
|
Patient reference
|
Patient 1
|
Patient 1
|
Patient 1
|
Patient 1
|
Patient 1
|
Patient 1
|
Patient 2
|
Size of deletion,Mb
|
8,3
|
6,5
|
14.7
|
6,29
|
6.48
|
3,4
|
4,8
|
Deleted region
|
4pter-p16.1
|
4p16.3-p16.1
|
4p15.33-pter
|
4p16.3
|
4p16.1-p16.3
|
4p16.3
|
4p15.3-16.2
|
Age at diagnosis, years
|
1 and 2 months
|
prenatal
|
prenatal
|
prenatal
|
9 and 9 months
|
1
|
2 days
|
Gender
|
M
|
M
|
M
|
M
|
M
|
M
|
M
|
Cranio-facial dismorphism
|
-
|
+
|
+
|
+
|
+
|
+
|
+
|
Growth retardation
|
+
|
+
|
+
|
+
|
NA
|
+
|
+
|
Microcephaly
|
+
|
NA
|
NA
|
NA
|
+
|
+
|
+
|
Neurological features
Hypotonia
|
+
|
+
|
NA
|
+
|
+
|
+
|
-
|
Hypertelorism
|
+
|
+
|
NA
|
NA
|
NA
|
-
|
+
|
Delayed mental development
|
+
|
+
|
NA
|
NA
|
+
|
-
|
-
|
Delayed motor development
|
+
|
NA
|
NA
|
NA
|
+
|
+
|
-
|
Hypospadias
|
+
|
+
|
NA
|
NA
|
NA
|
-
|
+
|
cryptorchidism
|
+
|
NA
|
NA
|
+
|
NA
|
-
|
+
|
|
+: present/-:absent/NA:not available
|
|
|
|
In order to understand the genotype-phenotype correlation in both cases, we focus on the uncommon deleted region. However, the common deleted region, in both cases, involves three important genes implicated in the development of the main features of WHS. These genes are WHSC1, FGFRL1, and LETM1.The Wolf–Hirschhorn syndrome candidate 1 gene (WHSC1), also known as NSD2 (nuclear receptor SET domain containing) and MMSET (multiple myeloma SET domain containing) is located in the WHSCR1 region and its loss is believed to be responsible for several features of the syndrome. It encodes a putative histone methyltransferase, and the resulting protein has several domains [8,9].
The molecular features of WHSC1 suggest functions as a chromatin-remodelling enzyme since its SET domains act as histone methylases. A deficiency could then deregulate multiple genes expression leading to a pleiotropic effect[10]. Recently, it has been proposed that deficiency in WHSC1 gene lead to defects in the DNA damage response as seen in WHS patients and the WHSC1 has been indeed localized at sites of DNA damage and replication stress and then is required for resistance to many DNA-damaging and replication stress-inducing agents[11,12].WHSC1’s role in the DNA damage and DNA replication stress response could then explain the developmental and neurological impairment in WHS. However, the hypothesis that typical WHS could be a single-gene disorder is unlikely. We think that the full WHS phenotype results from the haplo-insufficiency of several other candidate genes, especially these telomeric to WHSC1.The best possible interpretation of the currently available data, in patients 1 and 2 is that WHSC1, in combination with closely linked genes, are responsible for the core phenotypes.
Interestingly, the common deleted interval in both patients encompasses the Fibroblast growth factor like-1 gene (FGFRL1) considered as the most characterized gene in this region. Located on 4p16.3 outside and distal to the WHSCRs, the FGFRL1 gene encodes a member of the fibroblast growth factor receptor family[8]. Recent studies suggest that FGFRL1 represents a plausible second candidate gene for several WHS features. Mouse models targeting FGFRL1 present growth delay, craniofacial defects, skeletal anomalies and congenital heart defects features that are in complete accordance with WHS phenotype. mainly the craniofacial phenotype [6,13,14]. In the proximal side of WHSC1, additional genes contributing to the core phenotypes may act to complete the pleiotropic WHS phenotype. Leucine zipper/EF-hand-containing transmembrane gene (LETM1),an ubiquitous Ca2+ binding protein involved in Ca2+ homeostasis, located at 1.8 Mb from the telomere. This gene has been suggested to cause seizures[7,15]. LETM1 seems to be the most likely candidate gene for epilepsy in WHS patients since impaired Ca2+ homeostasis in nerve cells has been correlated with neurodegenerative disorders and seizures [16,17,18,19]. In the present study, while the LETM1 gene is deleted in both cases only the first patient presents epilepsy. Elsewhere, it has been previously reported a WHS patient suffering from seizures with a 1.4 Mb terminal 4p deletion preserving LETM1 gene[2].In another study, six of eight subjects with terminal 4p deletions preserving LETM1 had seizures, whereas seven of seven with small interstitial deletions including LETM1, did not[7].Taken together, it seems that LETM1 haploinsufficiency contributes to seizure genesis and epileptic phenotype genesis appears to be questionable and not fully elucidated and another gene or genes , could be incriminated. As advanced elsewhere C-Trminal-binding protein 1,a transcriptional co-repressor gene, could be a good candidate for seizures/ epilepsy in WHS[20,21].
The Wolf–Hirschhorn syndrome candidate 2 (WHSC2), encodes a subunit of the negative elongation factor complex, involved in mRNA processing and the cell cycle[22,23].This complex seems to induce promoter-proximal pause by inhibiting RNA polymerase II early progression during elongation, and consequently altering the expression of its target genes [24].Recently, WHSC2 has been implicated in the recruitment of Stem Loop Binding Protein (SLBP) to the 3′ ends of histone pre-mRNAs[22]. Taken into account that the SLBP gene is included in the patients1 and 2 deletions, we suppose that haploinsufficiency of SLBP and/or WHSC2 supply microcephaly, pre- and postnatal growth retardation, the core clinical features of WHS. Employing a unique panel of patient-derived cell lines with differently-sized 4p deletions, underlies novel cellular defects associated with WHS. It has been demonstrated that haploinsufficiency of SLBP and/or WHSC2 contributes to delayed cell-cycle progression impaired, DNA replication and altered chromatine structure.[25]. These results may explain the phenotype severity observed in our patients too suggesting a functional relationship between both genes SLBP and WHSC2 commonly haploinsufficient in WHS.
In addition, in the present study, we report on the deletion of Chromosome 4 open reading frame 48(C4ORF48), a gene located in a 191.5-kb region and associated to WHS patients presenting microcephaly and growth retardation. Interestingly, expression of C4Orf48 in different zones during cortical and cerebellar development, as well as in almost all cortical and subcortical regions of the adult mouse brain was proven [26]. This suggests a potential role of C4ORF48 in the development of human cerebral and cerebellar structures, and plasticity function in adult brain neurons and indicates that C4ORF48 hemizygosity might be partly involved in the WHS neurological aspects.
Otherwise, if we focus on the differential features and the non-overlapping region between the two patients 1 and 2 in the present report, we notice that the different genes involved may explain the presence of a sex development disorder in patient 2. A deep analysis of this region underlies a deletion of the MSX1 gene at 4.9 Mb from the telomere. As previously seen monosomy of MSX1 was linked to the oligodontia observed in some WHS patients suggesting that selective tooth agenesis is a common phenotype in Wolf-Hirschhorn syndrome[27,28].It could be considered then as an obvious candidate gene for the development of cranio facial structures and the anterior forebrain[29].MSX1 has been reported also as a transcriptional repressor of GnRH promoter activity that is expressed in the ventral side of the developing anterior pituitary. It is regulated by Bone Morphogenetic Protein(BMP), and implicated in gonadotropin neurons differentiation [30,31].
Interestingly, some other studies mapped the critical region for hypospadias in WHS syndrome between 3 Mb and 4.0 Mb [2,32]. Taken into account the deleted region of the second patient in the present report, it is possible that an haploinsufficiency of the MSX1 gene could explain hypospadias phenotype.
As known, proper sexual maturation depends upon the correct function of the hypothalamic-pituitary-gonadal axis, initiated by a critical population of GnRH neurons[33]and then, by binding to the consensus homeodomain repeats (ATTA) in the enhancer and promoter,MSX1 could repress GnRH promoter activity and consequently participate in the regulation of GnRH gene expression network[32].
Thus, it may deregulate the androgen synthesis; which may lead to hypospadias during an embryogenesis critical phase. Indeed, recently, MSX1 has been proposed as a candidate gene for hypogonadism based on its function in the gonadotropic axis[34].
Curiously, the MSX1 deletion in the second patient is associated with hypospadias without the expected oligodontia. Here we could explain these controversies by variable expressivity or incomplete penetrance. Several mutations in the homeodomain of MSX1 are associated to tooth agenesis or orofacial clefts[35].
But to the best of our knowledge, no reported MSX1 gene mutations have been associated to DSD. Here, again we underlie the acting network in a multiple genes deleted syndrome as WHS.
In summary, we suggest MSX1 gene as an intriguing candidate gene for contribution to the hypogonadal phenotype. Functional studies for MSX1 gene should be considered to more understand its implication in the development of oligodontia and hypospadias.
Here we emphasize the phenotype-genotype correlation studies, which are considered as the core, the beginning, and the end of gene analysis. The use of a combined approach conventional cytogenetic and, chromosomal array associated with a deep analysis of a molecular and functional gene studies are necessary. Besides, functional studies or more sophisticated technologies such as Hi-C technologies are highly recommended to better characterize the genetic interactions following 4p deletion. It is likely that more patients with WHS will present hypogonadism and therefore precise personal medical care is required.