Search

In our study of sequence variation within the RPGR gene associated with X-linked retinitis pigmentosa, we and others have observed a high rate of new mutation within this gene, as all reported mutations are unique or uncommon. In this article we report the identification in a single family of a complex allele of 7 sequence variants in linkage disequilibrium, of which four result in amino-acid alterations (Arg425Lys, DGlu, Thr533Met and Gly566Glu). This complex allele was initially found in a family with XLRP. However, further study revealed an estimated prevalence of 4.3% (15/344 chromosomes) with this complex allele in the European population indicating the non-pathogenic nature of this allele and, along with previously reported polymorphisms, further supporting a high level of human protein diversity for RPGR. This common complex allele may have been established in the population as a founder effect. Complete gene sequencing identified a potential pathogenic sequence variant in the family described (IVS6+5G>A). This study emphasises the need to create a more complete picture of the allelic variation within a gene, suggests cautious interpretation of a phenotypic association with variant sequences, and highlights the potential problems associated with interpreting genetic studies for diagnostic purposes.

A young woman presented with renal failure and skin lesions of livedo reticularis (LR) due to primary oxalosis. Primary oxalosis is a rare autosomal-recessive error of metabolism characterized by accumulation of calcium-oxalate crystals in the kidneys, eyes, heart and skin. This unusual cause of intravascular obstruction resulting in livedo reticularis should be considered in patients with renal impairment. An approach to the diagnosis of LR is presented.

Piebaldism is a disorder in which the major clinical features are patchy hypopigmentation of the skin and a white forelock. The manifestations of piebaldism overlap with those of other genodermatoses, in particular the Waardenburg syndrome, and it is uncertain whether piebaldism is a distinct entity. We have documented a family in which seven affected members in three generations have gross piebaldism without any additional stigmata. The intrafamilial phenotypic consistency is suggestive that this autosomal dominant disorder has independent syndromic status. Linkage studies using conventional gene markers failed to identity the locus of the faulty gene.

Hearing impairment is a variable manifestation of several heritable conditions in which pigmentation of the skin or eyes is abnormal. Some of these disorders are well recognized although uncommon, while others are virtually private syndromes. Practical issues concerning the major conditions of this type are reviewed in this article on a basis of a survey of 4452 profoundly deaf children attending special schools in Southern Africa, together with investigations in affected families. The Waardenburg syndrome (WS), which is the most common deafness-depigmentation disorder, was present in 121 (2.7%) of the 4452 deaf scholars. Further studies in 7 multigeneration affected families confirmed phenotypic variability and indicated a need for internationally agreed diagnostic criteria. In 4 Cape Town families of mixed ancestry the WS-I gene was linked to the 2q37 locus, but in another large kindred no linkage could be demonstrated. Nonallelic heterogeneity is possible. There is uncertainty concerning possible interrelationship between WS and piebaldism. The phenotypic consistency of a South African family in which 7 persons in 3 generations had gross piebaldism in the absence of disturbance of hearing or involvement of the eyes and periorbital structures is suggestive that this disorder and WS are separate entities. Molecular investigations indicate that the gene for piebaldism in this kindred is not situated at the WS-I locus 2q37. Deafness and hyperpigmentation are present in neurofibromatosis type II (acoustic neuromata) and the multiple lentigines syndrome, while retinal pigmentation is a feature of the Usher syndrome. This latter entity is apparently much less common in Southern Africa than in other parts of the world.

Premature ovarian failure (POF) or premature menopause is a common disorder, defined by the occurrence of menopause under the age of 40 years and is characterised by amenorrhoea, hypoestrogenism and elevated gonadotrophins. Worldwide it affects 1% of all women and occurs in 0.1% before the age of 30 years. The major problems associated with POF are the loss of fertility at an early age and the psychological problems associated with this. In addition there are the physiological effects of reduced oestrogen, which include an increased risk of osteoporosis. POF is a heterogeneous disorder and the cause of most cases is unknown. A significant proportion (20-30%) of women with POF have a genetic predisposition. Our primary goal is to identify genes involved in POF. In most cases, the menopause is due to the loss of follicles, and it stands to reason that suitable candidate genes for POF development would be genes that regulate the rate of follicle loss. We have identified two common gene mutations, a 769G>A transition in the inhibin alpha gene in approximately 5% of POF patients associated with POF at a very early age, and mutations in FOXL2 in approximately 5% of patients. FOXL2 is thought to act downstream of inhibin which suggests that other candidate genes may arise from the analysis of the activin signalling pathway. Functional studies will help us to understand more about the molecular basis of POF. Each mutation has been associated with less than 10% of POF cases and POF is likely to be caused by mutations at many different loci. It is hoped that determining the molecular basis of POF will lead to the development of genetic tests to predict the development of POF, and eventually lead to treatment that will return fertility to these women.

X-linked ocular albinism with late-onset sensorineural deafness (OASD) is an autonomous disorder that poses significant clinical problems, causing affected individuals to be blind and deaf by early middle age. Classical X-linked ocular albinism (without deafness; OA1) has recently been linked to markers in the Xp22.2-Xp22.3 region of the human genome. In the present report, a large South African family with OASD was investigated at the molecular level and tight linkage was found to the DXS452 locus at Xp22.3 using 25 informative meioses, with a maximum lod score of 7.1 at a recombination fraction of 0.00. These findings suggest that OA1 and OASD are allelic variants or that they may be due to contiguous gene defects.

We report on a girl with anal atresia, renal aplasia, vertebral and rib anomalies, amelia and hemifacial microsomia. The patient demonstrates the overlap between the VACTERL association and the oculoauriculovertebral dysplasia. We propose that amelia is a severe manifestation of the limb defects which occur in these developmental dysplasias.

We report an infant with the principal features of bilateral radial defects, club foot deformity, micrognathia and cleft palate. Other dysmorphic manifestations include the presence of bilateral clinodactyly, medial displacement of the thumb, low set ears and an unusually long 2nd toe. This constellation of signs has not been previously reported and may constitute a new syndrome.

The heritable disorders of connective tissue have proven to be very heterogeneous and problems have arisen concerning syndromic boundaries, nomenclature, and classification. In an attempt to resolve these dilemmas, a group of experts participated in a Workshop held during the 7th International Congress of Human Genetics, Berlin, in September, 1986. At the Workshop, overviews were given of the uses and limitations of nosology (McKusick), diagnostic criteria (Pyeritz), and practical issues in biochemical and molecular diagnosis (Hollister). Invited speakers then gave brief comments on the current status of the nosology of specific categories of inherited connective tissue disorders and made recommendations for possible modification. The Workshop was followed by two closed committee meetings at which the participants attempted to reach agreement on syndromic definition and a standardized nomenclature. The final proposals, with brief comment where relevant, form the subject of this communication.

We have identified a novel gene, transducin (beta)-like 1 (TBL1), in the Xp22.3 genomic region, that shows high homology with members of the WD-40-repeat protein family. The gene contains 18 exons spanning approximately 150 kb of the genomic region adjacent to the ocular albinism gene (OA1) on the telomeric side. However, unlike OA1, TBL1 is transcribed from telomere to centromere. Northern analysis indicates that TBL1 is ubiquitously expressed, with two transcripts of approximately 2.1 kb and 6.0 kb. The open reading frame encodes a 526-amino acid protein, which shows the presence of six beta-transducin repeats (WD-40 motif) in the C-terminal domain. The homology with known beta-subunits of G proteins and other WD-40-repeat containing proteins is restricted to the WD-40 motif. Genomic analysis revealed that the gene is either partly or entirely deleted in patients carrying Xp22.3 terminal deletions. The complexity of the contiguous gene-syndrome phenotype shared by these patients depends on the number of known disease genes involved in the deletions. Interestingly, one patient carrying a microinterstitial deletion involving the 3' portion of both TBL1 and OA1 shows the OA1 phenotype associated with X-linked late-onset sensorineural deafness. We postulate an involvement of TBL1 in the pathogenesis of the ocular albinism with late-onset sensorineural deafness phenotype.

We have investigated a large Afrikaner kindred in which seven males had ocular albinism and late-onset sensorineural deafness (OASD). The pattern of inheritance of OASD is X-linked recessive. To the best of our knowledge, this association has not previously been reported and in order to establish syndromic identity we describe and discuss the condition in this article.

The question of genetic heterogeneity in tuberous sclerosis (TSC) was addressed by genetic linkage studies in eight affected families using nine polymorphic markers (EFD126.3, MCT136, ABO, ABL, AK1, and MCOA12 from distal 9q, and PBGD, MCT128.1, and 1CJ52.208M from distal 11q). The data as a whole supported a TSC locus on distal 9q, the peak lod score on multipoint analysis being 3.77 at 6 cM proximal to the Abelson oncogene locus (ABL). However, analysis of two point lod scores using the HOMOG programs showed significant evidence for genetic heterogeneity (p = 0.01), linkage to ABL being unlikely in one family. After exclusion of the unlinked family, multipoint analysis gave a peak lod score of 6.1 in the vicinity of ABL. The family unlinked to ABL showed no recombinants with two chromosome 11 probes, but was too small to provide significant evidence for linkage. Genetic heterogeneity in TSC will complicate efforts to clone the causative genes and severely limit the use of linked probes for carrier detection and prenatal diagnosis.

There is increasing evidence for genetic heterogeneity in tuberous sclerosis (TSC) on the basis of linkage analysis in affected kindreds. We have performed a detailed assessment of an affected South African family in which there is no evidence of linkage to chromosome 9 markers. The affected persons have atypical clinical features, namely prominent nuchal skin tags, a confetti pattern of hypopigmentation of the skin of the lower legs, and absence of ungual fibromata. Further investigation of these unusual phenotypic features is warranted in order to determine whether these lesions are consistently present in families in whom the gene for TSC is not on 9q34. We conclude that confetti depigmentation and nuchal skin tags may be clinical pointers to an alternative locus for TSC.

Many red cell polymorphisms are a result of selective pressure by the malarial parasite. Here we add another red cell disease to the panoply of erythrocytic changes that give rise to resistance to malaria. Erythrocytes from individuals with erythropoietic protoporphyria (EPP) have low levels of the final enzyme in the heme biosynthetic pathway, ferrochelatase. Cells from these patients are resistant to the growth of the human malarial parasite, Plasmodium falciparum. We first compared the growth and replication rates of P. falciparum cultured in red cells from EPP patients (n=4) and normal erythrocytes. There was a two to three-fold reduction in parasite growth in the patient cells. Next we sought to exclude the possible negative effects on the parasite due to elevated porphyrins and reduced cell hemoglobin. To do this we employed the EPP phenocopy, X-linked dominant protoporphyria (XLDPP), which has normal ferrochelatase activity. Cells from three individuals with XLDPP supported completely normal rates of parasite growth, proving that the EPP resistance phenomenon was due to the absence of ferrochelatase. We also tested the requirement of host ferrochelatase during malarial infection by using mice with a hypomorphic mutation in the murine ferrochelatase gene and the rodent malarial species, P. chabaudi. Mice homozygous for the mutation, Fechm1Pas, have 5% residual ferrochelatase activity compared to wild-type littermates 1. Following infection, we observed an almost two fold reduction in peak parasitemia levels and two to three times greater rates of survival in the homozygous mice. Host ferrochelatase is therefore also necessary to sustain a normal malarial infection in mice. To determine the requirement of parasite-expressed ferrochelase, we produced a P. berghei parasite line carrying a complete deletion of the ferrochelatase gene. This strain grew normally in wild-type mouse erythrocytes, indicating that parasite ferrochelatase is dispensable during the erythrocytic stage of infection. A complete absence of ferrochelatase in humans (and mice) is not compatible with life, and therefore testing parasite growth in complete knockout cells was not possible. Instead, we used a specific competitive inhibitor of the enzyme, N-methylprotoporphyrin (NMPP) to eliminate all ferrochelatase activity from the parasite and red cell. Treatment of P. falciparum cultures with NMPP resulted in potent cytocidal and growth inhibition effects against both antimalarial drug-sensitive and drug-resistant parasite lines. The activity of NMPP could be competitively removed by titration of the ferrochelatase substrate, protoporphyrin IX, proving that the effects of NMPP were due to specific enzyme inhibition and not off-target effects. Therefore ferrochelatase activity is also essential for the Plasmodium parasite. We conclude that the refractoriness of ferrochelatse-deficient red cells to Plasmodium is due to the parasite’s reliance on the host enzyme. Host ferrochelatase is probably utilized by the parasite for the biosynthesis of heme. In support of this hypothesis, others have observed that red cell ferrochelatase is imported by intraerythrocytic Plasmodium and enzymatic is retained 2,3. Finally, based on this collective data, we propose human ferrochelatase is a valid and novel “host-directed” target for an antimalarial therapy. Lyoumi S, Abitbol M, Andrieu V, et al. Increased plasma transferrin, altered body iron distribution, and microcytic hypochromic anemia in ferrochelatase-deficient mice. Blood. 2007;109(2):811-818.Bonday ZQ, Dhanasekaran S, Rangarajan PN, Padmanaban G. Import of host delta-aminolevulinate dehydratase into the malarial parasite: identification of a new drug target. Nat Med. 2000;6(8):898-903.Varadharajan S, Sagar BK, Rangarajan PN, Padmanaban G. Localization of ferrochelatase in Plasmodium falciparum. Biochem J. 2004;384(Pt 2):429-436. Disclosures No relevant conflicts of interest to declare.

The term 'epidermolysis bullosa hereditaria' is applied to a heterogeneous group of mechanobullous diseases of which at least 19 different forms have been reported. Classification of these separate genetic entities into various subtypes is possible on clinical, genetic, biochemical and histopathological bases. Some forms are potentially lethal, while others are benign. Many of the subgroups are represented in South Africa, although little has been published locally on these conditions. On the basis of a wide-scale study in the RSA, the condition is reviewed in order to present current concepts and future developments of this rare but significant genodermatosis.

Nine cases of Kabuki syndrome have been identified in Auckland and surrounding regions in the North Island, New Zealand since 1995. All have the characteristic facial dysmorphism and many of the well-described associated anomalies. Some of the abnormalities were unusual including a case with severe congenital mitral stenosis, two cases of eventration of the diaphragm, idiopathic thrombocytopaenic purpura and vitiligo. One child had an Arnold Chiari type 1 malformation and another had epibulbar dermoids, neither of which has previously been reported in this syndrome. There was a wide diversity of ethnic origin, with the syndrome being described in patients from the Pacific Islands for the first time. The cases described emphasize the broad range of associated anomalies found in Kabuki syndrome and further illustrate its presence in all ethnic groups.