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Genetic Factors Contributing to Autism Spectrum Disorder in Williams Cognitive and behavioural genetics J Med Genet: first published as 10.1136/jmedgenet-2019-106080 on 14 August 2019. Downloaded from ORIGINAL ARTICLE Genetic factors contributing to autism spectrum disorder in Williams-Beuren syndrome Marta Codina-Sola,1,2 Mar Costa-Roger,1 Debora Pérez-García,1 Raquel Flores,1 Maria Gabriela Palacios-Verdú,1,3 Ivon Cusco, 1,2 Luis Alberto Pérez-Jurado 1,4 ► Additional material is ABSTRACT remaining 3% of patients with WBS show atypical 3 4 published online only. To view, Background The hallmark of the neurobehavioural deletions mediated by other mechanisms. The please visit the journal online (http:// dx. doi. org/ 10. 1136/ phenotype of Williams-Beuren syndrome (WBS) is WBS multisystemic phenotype is characterised by jmedgenet- 2019- 106080). increased sociability and relatively preserved language cardiovascular disease, distinctive facies, connec- skills, often described as opposite to autism spectrum tive tissue abnormalities and growth and endocrine For numbered affiliations see disorders (ASD). However, the prevalence of ASD in WBS alterations, among others.2 5 The main neurobe- end of article. is 6–10 times higher than in the general population. havioural hallmarks are mild to moderate intellec- We have investigated the genetic factors that could tual disability (ID), hypersociability and relative Correspondence to 6 Dr Ivon Cusco, Clinical and contribute to the ASD phenotype in individuals with WBS. language preservation. Interestingly, the reciprocal Molecular Genetics Area, Vall Methods We studied four males and four females with duplication of 7q11.23 (OMIM#609757) results Hebrón Hospital Research WBS and a confirmed diagnosis ofA SD by the Autism in a phenotype with speech delay, language impair- Institute (VHIR), Hospital de Diagnostic Interview-Revised. We performed a detailed ment, milder learning problems and clear social la Vall d’Hebron, Hospital Vall molecular characterisation of the deletion and searched d’Hebron, Barcelona 08035, interaction deficits often associated with autism 6 7 Spain; icusco@ vhebron. net for genomic variants using exome sequencing. spectrum disorder (ASD). Results A de novo deletion of 1.55 Mb (6 cases) or Due to their associated behavioural manifes- MC-S and MC-R are joint first 1.83 Mb (2 cases) at 7q11.23 was detected, being in tations, ASD and WBS have often been described authors. 7/8 patients of paternal origin. No common breakpoint, as diametric opposite disorders, although this Received 13 February 2019 deletion mechanism or size was found. Two cases consideration is an oversimplification of both Revised 11 July 2019 were hemizygous for the rare T allele at rs12539160 phenotypes.8 9 Moreover, several cases of WBS Accepted 16 July 2019 in MLXIPL, previously associated with ASD. Inherited with comorbid ASD have been reported and some rare variants in ASD-related or functionally constrained authors have suggested that ASD features should genes and a de novo nonsense mutation in the UBR5 be considered as part of the WBS phenotype.7–18 gene were identified in six cases, with higher burden in A recent meta-analysis of the comorbidity of ASD females compared with males (p=0.016). features in several well-defined genetic syndromes Conclusions The increased susceptibility to ASD in concluded that the prevalence of ASD features patients with WBS might be due to additive effects of among WBS individuals is as high as 12%.19 There- http://jmg.bmj.com/ the common WBS deletion, inherited and de novo rare fore, the frequency of ASD is 6–10 times higher in sequence variants in ASD-related genes elsewhere in the individuals with WBS than in the general popula- genome, with higher burden of deleterious mutations tion, a striking finding considering the typical WBS required for females, and possible hypomorphic variants neurocognitive profile. in the hemizygous allele or cis-acting mechanisms on Potential modifiers of the common neurobe- imprinting. havioural phenotype of WBS include: (1) cis-acting on September 25, 2021 by guest. Protected copyright. mechanisms due to variable breakpoints altering flanking genes, although most patients described 3 17 INTRODUCTION present common deletions of identical size ; Williams-Beuren syndrome (WBS, OMIM#194050) (2) trans-acting factors present in the non-deleted is a rare neurodevelopmental disorder resulting hemizygous allele; (3) genetic mutations and/or from an heterozygous deletion of 25–27 genes at structural variants elsewhere in the genome; (4) chromosome 7q11.23, estimated to affect approx- environmental events with or without epigenetic imately 1 in 7500 individuals.1 The WBS locus has effects, including medical complications during development and early life. All these factors can © Author(s) (or their a complex genomic architecture with a single copy employer(s)) 2019. Re-use region flanked by three large segmental duplica- have additive effects acting on a sensitised back- permitted under CC BY-NC. No tions, each composed of three major blocks (A, B ground caused by haploinsufficiency at the WBS 10 17 commercial re-use. See rights and C), located in the centromeric (c), medial (m) locus. Two individuals with WBS and co-occur- and permissions. Published 2 ring ASD previously reported presented hyperse- by BMJ. and telomeric (t) sides. Two types of recurrent rearrangements promoted by non-allelic homol- rotonaemia and were homozygous for the short (s) To cite: Codina-Sola M, ogous recombination (NAHR) can result in WBS allele in the promoter of the serotonin transporter Costa-Roger M, syndrome. The most frequent is a 1.55 Mb deletion SLC6A4 (5-HTTLPR), suggesting a possible modi- Pérez-García D, et al. 14 17 J Med Genet Epub ahead of occurring between the medial and centromeric B fier role of this locus. print: [please include Day blocks in 87% of cases. Around 10% of patients In the present work, we have investigated the Month Year]. doi:10.1136/ present a larger 1.83 Mb deletion due to a crossing genetic factors that could contribute to the ASD jmedgenet-2019-106080 over between centromeric and medial A blocks. The phenotype of eight individuals with WBS and Codina-Sola M, et al. J Med Genet 2019;0:1–8. doi:10.1136/jmedgenet-2019-106080 1 Cognitive and behavioural genetics J Med Genet: first published as 10.1136/jmedgenet-2019-106080 on 14 August 2019. Downloaded from controls. The nature of the changes was assessed by PolyPhen and Condel (http:// bg. upf. edu/ fannsdb/) protein effect predic- tion algorithms. For CNV detection, we applied ExomeDepth and compared our samples with a matched aggregate reference set of 248 in-house exomes captured and sequenced using the same protocol. CNVs were filtered based on their overlap with vari- ants previously described in the Database of Genomic Variants and DECIPHER.20 Rare variant analysis and validation We selected exonic variants with a minor allele frequency (MAF) lower than 0.002 according to several databases (previously Figure 1 Strategy followed for the identification of second-hit genetic mentioned) for heterozygous variants following a dominant factors. DGV, Database of Genomic Variants; LoF, loss of function; MAF, inheritance model. For homozygous or compound heterozy- minor allele frequency; SNV, single nucleotide variant. gous variants, under a recessive inheritance model, we selected a MAF ≤0.01. Since second-hit variants would act in the presence of a major hit and would not be expected to solely cause ASD, comorbid ASD. We completed a detailed molecular character- they might be present in the general population and inherited isation of the deletion, genotyped the reported polymorphism from unaffected progenitors. Moreover, given the high degree at SLC6A4 and performed a genome-wide unbiased search of of genetic heterogeneity of ASD, they could affect hundreds of second-hits by exome sequencing following the strategy depicted genes. Taking into account the prevalence of ASD in individuals in figure 1. with WBS and the large number of genes involved, we reasoned that the frequency of each individual variant should be relatively METHODS rare and, consequently, set our MAF threshold for homozygous Patient selection or compound heterozygous variants at ≤0.01. From a cohort of 122 individuals with a diagnosis of WBS To validate variants and perform segregation studies in and confirmed 7q11.23 deletion by molecular techniques, we parental samples, we used Sanger sequencing by capillary elec- selected four males and four females aged 6–31 years with an trophoresis (ABI PRISM 7900HT, Applied Biosystems, Foster associated diagnosis of ASD. The diagnosis was based on the City, California, USA). Primers were designed with the PRIMER3 direct observation by a trained psychologist and clinicians and program (http:// www. bioinformatics. nl/ cgi- bin/ primer3plus/ confirmed in all of them using the Autism Diagnostic Inter- primer3plus.​​cgi/ ) and PCR reactions were carried following view-Revised (ADI-R). Written informed consent was obtained standard conditions. from all parents or legal caregivers. Epistatic effects of rare variants 7q11.23 deletion characterisation To study the putative contribution of epistatic effects of rare Blood samples from probands and parents were obtained and SNVs on gene expression deregulation in WBS, we compiled a http://jmg.bmj.com/ genomic DNA was extracted using the Puregene DNA Purifica- list of genes previously altered in WBS by various mechanisms, tion Kit (Gentra Systems, Big Lake, Minnesota, USA). The size including transcriptional
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