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Association of Mutations in FLNA with Craniosynostosis

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Association of Mutations in FLNA with Craniosynostosis European Journal of Human Genetics (2015) 23, 1684–1688 & 2015 Macmillan Publishers Limited All rights reserved 1018-4813/15 www.nature.com/ejhg ARTICLE Association of mutations in FLNA with craniosynostosis Nathalie Fennell1, Nicola Foulds2,3, Diana S Johnson4, Louise C Wilson5, Michelle Wyatt6, Stephen P Robertson7, David Johnson1, Steven A Wall1 and Andrew OM Wilkie*,1,8 Mutations of FLNA, an X-linked gene that encodes the cytoskeletal protein filamin A, cause diverse and distinct phenotypes including periventricular nodular heterotopia and otopalatodigital spectrum disorders (OPDS). Craniofacial abnormalities associated with OPDS include supraorbital hyperostosis, down-slanting palpebral fissures and micrognathia; craniosynostosis was previously described in association with FLNA mutations in two individual case reports. Here we present four further OPDS subjects who have pathological FLNA variants and craniosynostosis, supporting a causal link. Together with the previously reported patients, frontometaphyseal dysplasia was the most common clinical diagnosis (four of six cases overall); five patients had multiple suture synostosis with the sagittal suture being the most frequently involved (also five patients). No genotype– phenotype correlation was evident in the distribution of FLNA mutations. This report highlights the need to consider a filaminopathy in the differential diagnosis of craniosynostosis, especially in the presence of atypical cranial or skeletal features. European Journal of Human Genetics (2015) 23, 1684–1688; doi:10.1038/ejhg.2015.31; published online 15 April 2015 INTRODUCTION stenosis, and ureteric and urethral stenosis.9 Melnick–Needles syn- The phenotypic spectrum associated with mutations in FLNA is drome (MNS) is usually lethal in males; facial features in affected unusually diverse and correlates with the functional consequence for females include prominent supraorbital ridge, exorbitism, oligohypo- the filamin A protein. Loss-of-function mutations were originally dontia, and micrognathia, which are associated with multiple skeletal described in periventricular nodular heterotopia,1 a central nervous abnormalities that include late-closing fontanelles, skull base sclerosis, system migration defect; an extended phenotype is increasingly sinuous clavicles, irregular rib contour, bowed long bones, pelvic recognised in association with these mutations, which may include hypoplasia and elongated metacarpals.10 Terminal osseous dysplasia is intestinal pseudo-obstruction/congenital short bowel syndrome,2 lethal in males and manifests in female infancy with skeletal dysplasia cardiac valvulopathies,3 vascular dilatation, joint hypermobility, and particularly affecting the extremities, digital fibromata, abnormal facial various skin manifestations.4 and scalp skin pigmentation, and facial dysmorphism including By contrast, gain-of-function FLNA mutations are characteristic of hypertelorism, upslanting palpebral fissures, and epicanthic folds.11 the skeletal and connective tissue disorders collectively termed Although craniofacial abnormalities across the OPDS are often otopalatodigital spectrum disorders (OPDS), which manifest a broad adefining feature in clinical diagnosis, overt craniosynostosis range of clinical severity.5 The mildest phenotype is otopalatodigital (premature fusion of the cranial sutures) has only been reported in 9,10 syndrome type 1 (OPD1), which presents in affected males with cleft two separate mutation-proven cases. Here we present four further palate, hearing loss (which can be conductive, sensorineural, or subjects with craniosynostosis (two male and two female), who have FLNA mixed), and a characteristic craniofacial phenotype of downslanting documented variants. This novel association is important to palpebral fissures and micrognathia; skeletally there are overlapping recognise in the assessment of a patient with craniosynostosis. fingers and bowed long bones.6 These characteristics are also present in OPD type 2 (OPD2), a more severe phenotype associated with METHODS perinatal male lethality and additional midline defects such as DNA was extracted from peripheral blood of each patient and referred for diagnostic sequencing of the FLNA gene. Details of the primers used can be hypospadias and omphalocele.5,7,8 Females who are obligate carriers obtained from either of the two laboratories that undertook the testing of mutations causing both OPD1 and OPD2 have a variable, milder (Genetics Laboratories, Oxford, UK or Clinical Genetics Group, University of 7,8 expression of similar characteristics. Frontometaphyseal dysplasia Otago, New Zealand). (FMD) is described in both male and female subjects and presents with the cardinal features of prominent supraorbital ridges, hyperte- RESULTS lorism, down-slanting palpebral fissures, and a generalised skeletal Case reports dysplasia that manifests with thickening of the calvarium, agenesis of Patient 1. This female subject is the only child of unrelated parents; the frontal, ethmoidal and sphenoidal sinuses, and bowing and she was born at term via normal vaginal delivery after an uneventful undermodelling of the diaphyses and metaphyses of tubular bones. pregnancy. She was referred for clinical genetic assessment at an age of Other extra-skeletal manifestations include cardiac defects, laryngeal 11 years because of dysmorphic features, difficulty with concentration 1Craniofacial Unit, Department of Plastic and Reconstructive Surgery, John Radcliffe Hospital, Oxford, UK; 2Wessex Clinical Genetics Services, UHS NHS Foundation Trust, Princess Anne Hospital, Southampton, UK; 3Academic Unit of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK; 4Department of Clinical Genetics, Sheffield Children’s Hospital, Sheffield, UK; 5Department of Clinical Genetics, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; 6Department of Paediatric Otolaryngology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; 7Department of Women’s and Children’s Health, Dunedin School of Medicine, Dunedin, New Zealand; 8Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK *Correspondence: Professor AOM Wilkie, Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Headington, Oxford OX3 9DS, UK. Tel: +44 1865 222 619; Fax: +44 1865 222 500; E-mail: [email protected] Received 29 October 2014; revised 1 January 2015; accepted 27 January 2015; published online 15 April 2015 FLNA mutations and craniosynostosis N Fennell et al 1685 and bilateral moderate–severe mixed hearing loss. On examination she slender fingers and toes, absent flexion of the interphalangeal joint had an irregular retroclined forehead and a prominent supraorbital of the thumbs, flexion deformity at the elbow, genu valgum, and ridge; there was mild hypertelorism and micrognathia but no bilateral hallux valgum. Radiographs showed undermodelling of the substantial midface hypoplasia (Figure 1a and b). She had long short tubular bones of the hand, bowing of the proximal radii, valgus Figure 1 Clinical appearance of subjects with craniosynostosis and FLNA variants. (a, b, c) Patient 1 aged 11 years, FMD with pansynostosis showing down- slanting palpebral fissures (a), irregular retroclined forehead with prominent supraorbital rim (b) and 3D CT reconstruction showing prominent supraorbital rim (c). (d–f) Patient 2 aged 7 years, OPD2 carrier with sagittal synostosis showing prominent supraorbital rim and hypertelorism (d, e) and broad halluces (f). (g–j) Patient 3, FMD with sagittal and bilambdoid synostosis showing down-slanting palpebral fissures at the age of 10 months (g, h), and spatulate fingertips and 2–3 toe syndactyly at the age of 1.5 years (i, j). (k–m) Patient 4 aged 3 years, FMD with prominent supraorbital rim and elongated, saddle-shaped skull contour (k, l). 3D CT reconstruction and venogram (apical view) showing fusion of the metopic and sagittal sutures associated with metopic and supraorbital ridging (m). European Journal of Human Genetics 1686 European Journal of Human Genetics Table 1 Clinical features and molecular analysis of patients with FLNA variants and craniosynostosis Broad or prominent Broad/flattened/ FLNA Sutures forehead/ Micro/ Camptodactyly/ spatulateterminal Patient ID Sex Exona DNAb Protein Domain Inheritance Diagnosis affected brow ridge retrognathia arthrogryposis digits Other major clinical features or reference mutations and craniosynostosis M5c.759C4Gp.CHD2 Maternal FMD Bicoronal + + ++ Bifid uvula, axillary webbing, partial cutaneous Ref. 9 (Asp253Glu) in ABD syndactyly, distal phalangeal hypoplasia, bilateral cryptorchidism, umbilical hernia F5c.760G4Ap.CHD2 Likely OPD2 Sagittal + + Hypertelorism, cleft palate Patient 2 NFennell (Glu254Lys) in ABD de novo F22c.3394G4Tp.Repeat de novo FMD Pansynostosis + ± + Long slender digits, flexion deformity of elbows, Patient 1 (Gly1132Trp) 9 genu valgum, mixed hearing loss M 22 c.3467C4Tp.Repeat de novo FMD Sagittal + ++ + Deep set eyes, down-slanting palpebral fissures, Patient 3 et al (Pro1156Leu) 9 bilambdoid disorganised eyebrows, broad philtrum, small mouth, thin upper lip, tongue tie, poor shoulder girdle muscle development, glenoid hypoplasia, hand syn- dactyly 2,3, toe syndactyly 2,3, developmental delay, urethral stenosis, feeding aversion, develop- mental hip dysplasia F 28 c.4738_4755 - Repeat de novo MNS Bicoronal + ++ Hypertelorism, exorbitism, micrognathia, bowed long Ref.
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