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Advances in Genetics 346 Archives ofDisease in Childhood 1996;75:346-350 RECENT ADVANCES Arch Dis Child: first published as 10.1136/adc.75.4.346 on 1 October 1996. Downloaded from Advances in genetics Melissa M Lees, Robin M Winter The contribution of genetics to the under- ment and human disease have been gained in standing of paediatric disease has increased this way. An example of this is the homology of dramatically over recent years. The identifica- DNA repair mechanisms between yeast and tion of disease genes and the understanding of humans."' disease processes at the molecular level have implications for screening, diagnosis, and Mutation detection therapeutic manipulation. Inevitably, complex Once a gene has been isolated, the mutation in ethical issues have arisen from such a rapid rate the gene resulting in the clinical phenotype in of scientific progress, and many ask whether an individual or a family can be sought. Muta- society is prepared for the consequences of tion detection remains an expensive and time such advances. consuming activity in the majority of cases, but This review aims to cover areas of progress it is one that can confirm a clinical diagnosis, within the field of clinical genetics over recent enable prenatal and presymptomatic diagnosis years, and also to discuss future prospects, of an individual in an affected family, and pro- possibilities, and perceived difficulties. vide carrier testing. In some cases a specific test can be used to detect a known common muta- Human Genome Mapping Project tion, such as in Apert's syndrome, achondro- The Human Genome Mapping Project plasia, and cystic fibrosis. In cystic fibrosis four (HGMP), an international project whose known mutations account for 87% of muta- ultimate aim is to sequence the entire human tions in the northern European population. genome, will lead to understanding about Detection of these mutations is efficient and chromosomal structure, the organisation of the inexpensive to perform, and can be carried out http://adc.bmj.com/ genome, regulation of genes, disease suscepti- on a routine service basis. Other disorders bility, and normal and abnormal human devel- amenable to routine testing include those due opment. The projected completion date is to a common mutational mechanism, such as between 2001 and 2005. The human haploid deletions in Duchenne muscular dystrophy, genome consists of around three billion base and duplications in Charcot-Marie-Tooth dis- pairs of DNA, encoding approximately 50 000 ease. However, in many diseases the causative to 100 000 genes. One major goal of the mutations are unique to each family, and HGMP is to produce a map of the human mutation detection techniques have to be used on September 27, 2021 by guest. Protected copyright. genome, containing 30 000 ordered markers, for each new case. If the gene involved is large, spaced approximately 100 000 base pairs and mutations occur anywhere on that gene, apart.' Expressed sequence tags, which are then localising the mutation may be time con- complementary to the 3' untranslated region of suming. The gene for Marfan's syndrome, mRNA, are also being developed as markers fibrillin-1 (FBN1), is located on chromosome for individual genes.2 These resources will aid 1 5q21 and spans approximately 1 10 kb. Muta- positional cloning, where a gene is cloned tions in FBN1 were first detected in patients in using information as to its location on the 1991, and over 50 distinct mutations have chromosome, as well as being a foundation for since been reported,89 each generally unique to the sequencing of the entire genome.3 Other individual families. Identification of an FBN1 projects involve the sequencing of model mutation in a new case is therefore difficult, organisms such as bacteria, yeast, nematodes, and this technique cannot be used as a and mice. DNA sequences that share a diagnostic test. A further example where structural similarity between different species individual mutation detection in a known gene Mothercare Unit of suggest a common ancestral origin. The has proved difficult is provided by the neurofi- Clinical Genetics and of human genes with the genes of bromin in neurofibromatosis type 1 Fetal Medicine, comparison gene Institute of Child simpler model organisms gives insight into (NFl), which spans over 350 kb of genomic Health, 30 Guilford genome structure, and provides valuable ho- DNA in chromosomal region 17ql1.2. Over Street, London WC1N mology data. Having identified a mutant gene 100 disease causing mutations have been iden- 1EH in a 'simple' organism such as the fruit fly dro- tified so far,1' but collectively these are only MM Lees sophila, a short cut to finding human genes responsible for approximately 40% of patients RM Winter exists by searching for sequence similarities with NFl." Correspondence to: through computer databases such as FlyBase.4 Conditions may show genetic heterogeneity, Dr Lees. Surprising insights into mammalian develop- where mutations at a number of different loci Advances in genetics 347 result in the same phenotype. Two loci for chromosome 7 has been reported to be associ- adult onset polycystic kidney disease have been ated with short stature,24 and has also been mapped: polycystic kidney disease 1 gene identified in a number ofpatients with Russell- Arch Dis Child: first published as 10.1136/adc.75.4.346 on 1 October 1996. Downloaded from (PKD 1) on chromosome 16 accounting for Silver syndrome.25 around 85% of cases, and PKD2 on chromo- Mutations in mitochondrial DNA (mtDNA) some 4, 12 accounting for the majority of the can be pathogenic in man.26 27 One example of remaining cases. Two genetic loci have also a disease caused by mtDNA mutations is Leb- been confirmed for tuberous sclerosis, with er's hereditary optic neuropathy (LHON), approximately 50% of familial cases being which is transmitted maternally. Difficulties linked to a locus on chromosome 9q34 arise, however, in the genetic counselling of (TSC 1), and other cases linked to a locus on this disorder due to the incomplete penetrance, 16pl3.3 (TSC2), closely linked to the PKD1 variable age of onset, and preferential occur- gene. The PKD 1 and TSC1 genes have rence in males. A number of LHON pedigrees been isolated but both are very large. There- are heteroplasmic for the pathogenic mtDNA fore, in isolated cases with either of these disor- mutation, where the mutant allele coexists with ders, one cannot be certain that one is search- the normal allele in an individual.28 The ing the correct gene for the responsible mutant allele frequency varies between indi- mutation. viduals within a family, giving rise to further counselling difficulties. It has been suggested Unusual inheritance patterns that >70% mutant allele frequency is required A number of diseases have been found to result for a significant risk of visual loss.29 Autosomal from an unstable expansion of a triplet ofbases DNA mutations can give rise to mtDNA rear- within or around a gene, so-called trinucleotide rangements, such as in autosomal dominant repeats. The normal number of repeats is poly- progressive external ophthalmoplegia, a disor- morphic (meaning the existence of two or der with ptosis, weakness of the eye muscles, more alleles with different repeat lengths at and generalised muscle weakness. Affected significant frequency in the population), but a individuals have multiple mtDNA mutations, repeat number above a certain threshold with a pattern of inheritance indicating a results in the clinical phenotype. Fragile X syn- nuclear gene defect.30 drome, Huntington's chorea, and myotonic dystrophy all result from such an expansion.15 16 Friedreich's ataxia, an autosomal recessive Fluorescent in situ hybridisation (FISH) condition, has also recently been found to be FISH is a cytogenetic technique that detects caused by a trinucleotide repeat expansion.'7 In specific DNA sequences, chromosomal sub- this disease, a GAA repeat number of between regions or entire chromosomes during met- 200 and 900 within the frataxin gene on chro- aphase or interphase of cells, by the use of mosome 9 is seen in 95% of affected individu- fluorescently labelled complementary DNA als, while the normal copy number is between sequences.3' The technique has been enhanced 10 and 21. These diseases are all amenable to by the introduction of multicolour probes http://adc.bmj.com/ direct molecular diagnostic testing by assess- allowing simultaneous examination of a ment of the expansion size. number of sites, and chromosome painting- A number of conditions result from unipa- where consecutive probes spanning an entire rental disomy of an imprinted gene. An chromosome are used. The technique is being imprinted gene is one which is only expressed explored for the rapid prenatal diagnosis of from either the maternal or the paternal copy, aneuploidies, by analysis during interphase, that is the gene expression is monoallelic. Uni- giving a result within 48 hours. Some clinical on September 27, 2021 by guest. Protected copyright. parental disomy occurs where both alleles phenotypes result from the microdeletion of a originate from the same parent. Prader-Willi chromosome, resulting in the loss of a number syndrome results from maternal disomy of of genes that are located consecutively on the chromosome 15q11.13 in 20-25% of cases, chromosome. The phenotype in these 'con- and deletion of the same region of the paternal tiguous gene syndromes' varies depending on chromosome 15 in the other cases. Paternal the extent of the deletion, and therefore which disomy of this region results in Angelman syn- genes are missing. FISH techniques are drome in a small number of cases (<5%), but commonly used to determine the presence of more commonly Angelman syndrome arises microdeletions, which are not visible by from the deletion ofpart ofthe maternal 1 5ql 1 conventional cytogenetic means. Examples band (60-75% of cases).
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