Evidence of Postzygotic Mosaicism in a Transmitted Form of Conradi-Hu¨ Nermann-Happle Syndrome Associated with a Novel EBP Mutation
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OBSERVATION Evidence of Postzygotic Mosaicism in a Transmitted Form of Conradi-Hu¨ nermann-Happle Syndrome Associated With a Novel EBP Mutation Fanny Morice-Picard, MD; Elise Kostrzewa, MD; Claude Wolf, MD; Pascale Benlian, MD, PhD; Alain Taı¨eb, MD, PhD; Didier Lacombe, MD, PhD Background: X-linked dominant chondrodysplasia novel heterozygous missense EBP mutation (c.199CϾT; punctata, also known as Conradi-Hu¨ nermann-Happle syn- p.Cys67Arg). The mutation was not detectable on ge- drome, is a rare skeletal dysplasia characterized by short nomic DNA extracted from blood lymphocytes in both stature, craniofacial defects, cataracts, ichthyosis, coarse parents. The mother presented with an erythematous and hair, and alopecia. Conradi-Hu¨ nermann-Happle syn- ichthyosiform skin lesion. EBP analysis of DNA ex- drome is caused by mutations in the gene EBP encoding tracted from a lesional skin biopsy revealed the pres- ⌬8 ⌬7 - sterol isomerase emopamil-binding protein. Ran- ence of p.Cys67Arg mutation. dom X-inactivation could account for the intrafamilial variability of the phenotype of X-linked dominant chon- Conclusion: To our knowledge, we report the first mo- drodysplasia punctata. lecular confirmation of postzygotic mosaicism on an ich- thyosiform skin lesion in the mother of a girl with X- Observations: We describe a girl with clinical fea- linked dominant chondrodysplasia punctata associated tures of X-linked dominant chondrodysplasia punctata. with a novel EBP mutation. Biochemical analysis showed an abnormal sterol profile consistent with a defect in ⌬8-⌬7 sterol isomerase. Mo- lecular studies confirmed the diagnosis by identifying a Arch Dermatol. 2011;147(9):1073-1076 -LINKED DOMINANT CHON- isomerase, which plays a major role in cho- drodysplasia punctata lesterol biosynthesis pathway. Mutations (CDPX2), also known as in this gene lead to increased levels of cho- Conradi-Hu¨ nermann- lesterol precursors cholesta-8-en-3-ol and Happle syndrome (OMIM 8(9)-dehydrocholesterol. CDPX2 arises al- X 302960), is a disorder char- most exclusively in girls, since it seems to acterized by punctate chondrodysplasia, be lethal early in boys. Phenotypic vari- asymmetric shortness of limbs, linear ich- ability and asymmetrical anomalies have thyosis, and cataracts. At birth, skin might been related to random X-inactivation and Author Affiliations: Service de be erythrodermic with a collodion baby to postzygotic mosaicism.2 To our knowl- Ge´ne´tique Me´dicale phenotype and hyperkeratosis along the edge, we report the first molecular con- (Drs Morice-Picard and Blaschko lines. These features lead to atro- firmation of postzygotic cutaneous mosa- Lacombe) and Service de phic hypopigmentary lesions and patchy icism in an otherwise asymptomatic Dermatologie et Dermatologie Pe´diatrique, Centre de mother of a girl affected with CDPX2. Re´fe´rence pour les Maladies For editorial comment Rares de la Peau METHODS (Drs Morice-Picard, Kostrzewa, see page 1094 and Taı¨eb), Universite´de Bordeaux 2, Centre Hoˆpitalier areas of alopecia. Osseous anomalies are PROFILING OF SERUM STEROLS Universitaire (CHU) de almost always present, often occurring Bordeaux, Bordeaux, France; with asymmetric shortness of limbs, ver- Gas chromatography–mass spectrometry analy- Faculte´deMe´decine Pierre et sis of circulating sterols was carried out as pre- tebral defects with scoliosis, and epiphy- viously indicated.3 Marie Curie (UPMC), seal stippling on radiographs. CDPX2 is Universite´ Paris 6, Paris, France caused by mutations in the EBP (emo- (Dr Wolf); and Unite´de DNA ANALYSIS Me´decine Mole´culaire du pamil-binding protein) gene (RefSeq, 1 Me´tabolisme Lipidique, Faculte´ NM_006579). This gene is located on Following informed consent for genetic test- de Me´decine, Universite´ Lille 2, chromosome Xp11.2-p11.23 and en- ing, genomic DNA was extracted from periph- Lille, France (Dr Benlian). codes a 3-hydroxysterol-⌬ 8 -⌬ 7 - eral blood leukocytes by a phase exchange ARCH DERMATOL/ VOL 147 (NO. 9), SEP 2011 WWW.ARCHDERMATOL.COM 1073 ©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 tation detection and estimation of the deleterious potential of A identified mutations against HUGO criteria and public ge- netic databases (http://www.phenosystems.com). In addition, several prediction algorithms (POLYPHEN [http://genetics .bwh.harvard.edu/pph], PMut [http://mmb2.pcb.ub.es:8080 /PMut/], SIFT [http://blocks.fhcrc.org/sift], and SNPs3D [http: //www.snps3d.org]) were used for computed estimation of the potential of a point mutation to induce functional changes on the protein, as previously described.5 Any newly identified amino acid substitution was considered as deleterious if at least 3 al- gorithms provided consistent predictions. DNA was extracted from blood leukocytes of 150 French healthy volunteer blood donors randomly selected over a pe- riod overlapping that of patient and family investigation. Ge- nomic DNA was extracted and the EBP gene was analyzed ac- cording to the same procedures as described in the preceding paragraph. Results were used as control sequences from the re- ferral population. RESULTS CLINICAL FINDINGS We describe a 10-year-old girl born at term after an un- eventful pregnancy. She was the first child of unrelated parents. Family history was uninformative. The mother had had 2 spontaneous abortions. The child was first as- sessed at birth owing to ichthyosis along the lines of Blaschko on the limbs and back associated with patchy B alopecia. Radiographs showed epiphyseal punctate cal- cifications and a mild scoliosis. These findings led to the diagnosis of CDPX2 syndrome. Subsequent evaluation at 10 years showed growth delay (−2 SD), scoliosis, patchy alopecia, linear atrophic scars, and a moderate conduc- tive bilateral deafness (Figure 1A). Ophthalmologic ex- amination revealed lens opacities. Parents were asymptomatic; however, careful exami- nation of the skin of the mother showed an erythema- tous ichthyotic lesion on the right knee (Figure 1B). Find- ings from her ophthalmologic examination were normal. Two skin biopsies, one in lesional skin and the other in healthy skin, were performed. PROFILING OF SERUM STEROLS Figure 1. A, Short humerus, scoliosis, and patchy alopecia at age 10 years; B, erythematous and ichthyosiform lesion on the mother’s right knee Gas chromatography–mass spectrometry analysis of cir- (arrow). culating sterols was carried out in the proband and re- vealed elevated levels of 8-dehydrocholesterol and cho- method (Puregene; Qiagen Inc, Valencia, California). DNA was  extracted from mother’s skin using an ion exchange column lesta-8(9)-en-3 -ol (0.009 g/L and 0.039 g/L, respectively). method, applying appropriate reagents for hard tissue DNA ex- traction (QIAamp DNA Mini Kit, Qiagen Inc). The coding se- MUTATION ANALYSIS quence and flanking intronic sequences of the EBP gene were amplified by polymerase chain reaction (PCR) using the fol- Genomic DNA from peripheral blood leukocytes from lowing primers: Ex2F CTT-CCT-GCC-TAT-ACA-CAC-GC, the propositus and both parents was analyzed at the EBP Ex2-R AGC-AAA-TCC-CAT-CCC-ACA-GC; Ex3-4F GTG- locus. In the proband, a novel heterozygous missense mu- TGT-GTT-CCT-TTC-ACT-GC, Ex3-4R CAT-CTG-TGT-CTG- tation was identified in exon 2 (c.119TϾC; p.Cys67Arg). TGG-ATC-CC; Ex5F AAG-GTG-TGA-GCT-CTC-CTG-AG, The mutation was not found in DNA extracted from pe- Ex5R GAC-TAG-ACT-CTT-CTG-GCA-GG. Exonic and periex- ripheral blood from both parents (Figure 2). Molecu- onic regions were sequenced from PCR products, on forward and reverse strands, by the Big-Dye terminator cycle- lar analyses of genomic DNA extracted from skin bi- sequencing protocol on a 16-capillary DNA sequencer (ABI 3130; opsy specimens revealed the presence of a minor signal Applied Biosystems, Villebon Sur Yvette, France) as previ- indicative of the presence of the mutation as found in the ously described.4 The GenSearch software (http://www daughter with CDPX2 syndrome and in lesional skin from .gensource.com) was used to analyze raw sequence data for mu- the mother, whereas there was no detectable mutation ARCH DERMATOL/ VOL 147 (NO. 9), SEP 2011 WWW.ARCHDERMATOL.COM 1074 ©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 in healthy skin. This confirmed the presence of postzy- gotic cutaneous and, almost certainly, gonadal mosa- A Child With CDPX2 Syndrome icism of the disorder in the mother. COMMENT Leukocytes G C G G C G A C T G T C C C T G C G C T G G T T T G C A G T G T G CDPX2 is caused by mutations in the EBP gene located T at Xp11.22-p11.23 and encoding for a ⌬8-⌬7 sterol isom- G C G G C G A C T G T C C C T G T G C T G G T T T G C A G T G T G > ∗ erase emopamil-binding protein,6 a central component c.199T C; p.Cys67Arg of cholesterol biosynthesis that catalyzes the conver- Father sion of 8(9)-cholestanol into lathosterol (5-a-cholest-7- B en-3-b-ol to 5-a-cholest-8-en-3-b-ol). More than 60 del- eterious mutations7-9 have been described in this EBP gene. Functional defect of the mutated protein leads to accu- Leukocytes mulation of 8-dehydrocholesterol and 8(9)-cholestanol G C G G C G A C T G T C C C T G T G C T G G T T T G C A G T G T G in plasma and tissues of the patients. Indeed, the pro- G C G G C G A C T G T C C C T G T G C T G G T T T G C A G T G T G band described herein had elevated plasma levels of both these cholesterol precursors.