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Somatic Mosaicism in Wiskott–Aldrich Syndrome Suggests in Vivo Reversion by a DNA Slippage Mechanism

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Somatic Mosaicism in Wiskott–Aldrich Syndrome Suggests in Vivo Reversion by a DNA Slippage Mechanism Somatic mosaicism in Wiskott–Aldrich syndrome suggests in vivo reversion by a DNA slippage mechanism Taizo Wada*, Shepherd H. Schurman*, Makoto Otsu*, Elizabeth K. Garabedian*, Hans D. Ochs†, David L. Nelson‡, and Fabio Candotti*§ *Disorders of Immunity Section, Genetics and Molecular Biology Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892; †Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195; and ‡Immunophysiology Section, Metabolism Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892 Communicated by Francis S. Collins, National Institutes of Health, Bethesda, MD, May 24, 2001 (received for review April 23, 2001) Somatic mosaicism caused by in vivo reversion of inherited muta- of whom showed a progressively mild clinical course because of tions has been described in several human genetic disorders. Back the selective growth advantage of the revertant lymphocytes. mutations resulting in restoration of wild-type sequences and The molecular mechanism leading to the reversion events has second-site mutations leading to compensatory changes have been remained unknown in most cases, except for the few cases where shown in mosaic individuals. In most cases, however, the precise crossing over or gene conversion has been shown in compound genetic mechanisms underlying the reversion events have re- heterozygous patients (11, 12). DNA polymerase slippage is the mained unclear, except for the few instances where crossing over most commonly invoked mechanism to explain triplet repeat or gene conversion have been demonstrated. Here, we report a expansion in human diseases (e.g., Huntington’s disease, fragile patient affected with Wiskott–Aldrich syndrome (WAS) caused by X syndrome, and Friedreich ataxia) (16). It is well accepted that a 6-bp insertion (ACGAGG) in the WAS protein gene, which abro- slippage-type events also can cause small insertion or deletion of gates protein expression. Somatic mosaicism was documented in tandem repeats (17), and it is therefore possible that in the this patient whose majority of T lymphocytes expressed nearly appropriate genomic context, this mechanism could lead to normal levels of WAS protein. These lymphocytes were found to reversion of a mutation to wild-type sequence (13). In this lack the deleterious mutation and showed a selective growth report, we describe a 43-year-old WAS patient carrying a advantage in vivo. Analysis of the sequence surrounding the spontaneous in vivo reversion likely caused by a DNA slippage mutation site showed that the 6-bp insertion followed a tandem mechanism. The mutation responsible for the disease in this repeat of the same six nucleotides. These findings strongly suggest patient’s family is a 6-bp insertion after a tandem microrepeat of that DNA polymerase slippage was the cause of the original the same six nucleotides. In contrast to those of other affected germ-line insertion mutation in this family and that the same family members, the majority of the proband’s T lymphocytes mechanism was responsible for its deletion in one of the propos- were demonstrated to express WASP and lack the deleterious itus T cell progenitors, thus leading to reversion mosaicism. mutation. In addition, we show evidence of selective advantage of the WASP-expressing (WASPϩ) T lymphocytes over the Ϫ he Wiskott–Aldrich syndrome (WAS) is an X-linked disor- WASP-negative (WASP ) ones, which explains the accumula- Tder characterized by thrombocytopenia with small-sized tion of the former cells. Finally, our patient has shown clinical platelets, eczema, and immune deficiency, leading to increased improvement over the years, which suggests the revertant T cells susceptibility to infection from all classes of pathogens (1, 2). having contributed to the modification of his previously severe Sepsis and severe intracerebral hemorrhage represent frequent clinical phenotype. causes of death in WAS boys, who also are subjected to malignancies with increased frequency. The disease gene was Materials and Methods discovered by positional cloning (3) and encodes the WAS Case Presentation. Fig. 1 shows a pedigree of the proband’s family protein (WASP), a 502-aa proline-rich protein, which is consti- whose history began at the age of 10 months with encephalitis. tutively expressed in cytoplasm of all nonerythroid hematopoi- Between the ages of 2 and 5 years, he had recurrent easy bruising, etic cells (4, 5). Although the definitive function of WASP eczema, and recurrent otitis media. At age 5, it was noted that remains to be determined, this protein has been demonstrated to his younger brother had petechiae and thrombocytopenia. The be involved in signal transduction pathways of important cellular patient’s platelet count was then tested and found to be in the growth factors (e.g., Nck, Fyn, Itk, and Grb2) and in cytoskeleton range of 13,000 to 20,000͞mm3. A clinical diagnosis of WAS was reorganization events of hematopoietic cells, possibly in re- made, and the patient underwent an elective splenectomy, sponse to cellular activation (6). leading to correction of platelet numbers and size. Shortly after It has been recently recognized that somatic reversion of splenectomy, the patient suffered from pneumococcal meningi- inherited mutations occurs in human genetic disorders. Back tis, from which he recovered. Frequent upper respiratory and͞or mutations resulting in restoration of wild-type sequences (7–13) ear infections and continued eczema are described until the age and second-site mutations leading to compensatory changes (14, of 12, when the patient was hospitalized for vasculitic rash, 15) have been shown in mosaic individuals. If a reverse mutation thrombocytopenia, and an illness resembling rheumatoid arthri- occurs in a somatic cell during mitosis and the cell with the reverse mutation has a selective growth advantage in vivo, cells carrying the original mutation are expected to be replaced by Abbreviations: WAS, Wiskott–Aldrich syndrome; WASP, WAS protein; X-SCID, X-linked severe combined immunodeficiency; PBMC, peripheral blood mononuclear cells; TCR, T cell revertants that have regained wild-type phenotype. This rare receptor; CDR3, complementarity-determining region 3; FACS, fluorescence-activated cell event may modify the disease clinical phenotype, leading to sorter. atypical and unexpectedly mild presentations. In fact, sponta- §To whom reprint requests should be addressed. E-mail: [email protected]. neous in vivo reversion has been reported in one patient with The publication costs of this article were defrayed in part by page charge payment. This GENETICS adenosine deaminase deficiency (7) and one patient with X- article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. linked severe combined immunodeficiency (X-SCID) (8), both §1734 solely to indicate this fact. www.pnas.org͞cgi͞doi͞10.1073͞pnas.151260498 PNAS ͉ July 17, 2001 ͉ vol. 98 ͉ no. 15 ͉ 8697–8702 Downloaded by guest on September 29, 2021 was boiled, subjected to 8% SDS͞PAGE, and electrotransferred onto nylon membranes (Immobilon-P, Millipore). The detection of WASP was performed as described (19). Flow Cytometric Analysis of WASP. Three-color immunofluores- cence analysis was used to study cell-surface antigens and intracellular WASP expression simultaneously. Detection of WASP was performed as described with minor modifications (20). Briefly, PBMC were stained for cell-surface antigens before cell membrane permeabilization using the following mAbs: Cy-chrome-conjugated anti-CD3 (PharMingen); TRI- color labeled anti-CD8 and anti-CD56 (Caltag, South San Francisco, CA); FITC-conjugated anti-CD4 (Caltag); and FITC- conjugated anti-CD45RA, anti-CD45R0, and anti-CD20 (PharMingen). After washing, cells were treated with Cytofix͞ Cytoperm solution from CytoStain kit (PharMingen) at 4°C for 20 min. After washing twice, they were incubated with 1:200 diluted anti-WASP (3F3-A5) mAb (5) or purified mouse IgG1 (PharMingen) at 4°C for 20 min. Cells were then reacted with Fig. 1. Simplified pedigree of the proband’s family. Solid squares represent biotin-conjugated anti-mouse IgG1 at 4°C for 20 min, followed affected individuals; diagonal lines indicate deceased subjects. Carrier status by further incubation with phycoerythrin-conjugated streptavi- of female subjects is indicated by a dot. din (both from PharMingen). Stained cells were analyzed with a FACScan [fluorescence-activated cell sorter (FACS)] flow cytom- eter using CELLQUEST software (Becton Dickinson). WASP expres- tis with concurrent dysgammaglobulinemia and nephritis. The sion of monocytes was evaluated in CD3-negative cells among same year, he developed pneumococcal meningitis and sepsis, monocytic cells determined by a distribution pattern in the forward which were successfully treated. One month later, another and side scatter. Because anti-WASP mAb (3F3-A5) belongs to episode of pneumococcal meningitis occurred. At age 16, the the mouse IgG1 subclass, all antibodies for surface staining were patient developed a right mastoiditis. This clinical history is chosen from mouse IgG2 subclass to avoid crossreaction. consistent with severe WAS phenotype (score of 5) (18). Since his 20s, the patient has been relatively well, with complaints of Mutation Analysis. DNA was extracted from blood samples with sinusitis episodes responding to antibiotic treatment. The patient the QIAamp DNA blood mini kit and from a skin biopsy is now 43 years
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