Whole exome sequencing in foetal akinesia expands the genotype–phenotype spectrum of GBE1 glycogen storage disease mutations

doi:10.1016/j.nmd.2012.11.005

Neuromuscular Disorders

Volume 23, Issue 2, February 2013, Pages 165-169

https://doi.org/10.1016/j.nmd.2012.11.005 Get rights and content

Abstract

The clinically and genetically heterogenous foetal akinesias have low rates of genetic diagnosis. Exome sequencing of two siblings with phenotypic lethal multiple pterygium syndrome identified compound heterozygozity for a known splice site mutation (c.691+2T>C) and a novel missense mutation (c.956A>G; p.His319Arg) in glycogen branching enzyme 1 (GBE1). GBE1 mutations cause glycogen storage disease IV (GSD IV), including a severe foetal akinesia sub-phenotype. Re-investigating the muscle pathology identified storage material, consistent with GSD IV, which was confirmed biochemically. This study highlights the power of exome sequencing in genetically heterogeneous diseases and adds multiple pterygium syndrome to the phenotypic spectrum of GBE1 mutation.

Introduction

The foetal akinesias are clinically and genetically diverse, with multiple clinical sub-types [1] and numerous disease genes showing autosomal dominant, autosomal recessive and X-linked inheritance [2]. The classic form, foetal akinesia deformation sequence (FADS) or Pena-Shokeir phenotype 1 (OMIM 208150) has a characteristic set of features including decreased foetal movements, intrauterine growth restriction, craniofacial anomalies, joint contractures and pulmonary hypoplasia. These features are common to any conditions characterised by reduced or absent foetal movement [1]. Other disease entities that may phenotypically overlap with FADS include lethal congenital contracture syndromes (LCCS 1-3; OMIM 253310, 607598, 611369); multiple pterygium syndromes (MPS) (both lethal (OMIM 253290) and non-lethal (OMIM 265000) variants) and arthrogryposis multiplex congenita (OMIM 108110). Earlier occurrence of akinesia/hypokinesia is more likely to cause the full FADS phenotype [1]. FADS results from onset of akinesia/hypokinesia in the latter portion of the second trimester, whereas onset in the third trimester results in arthrogryposis multiplex congenita, [1], [3]. Very early and profound akinesia causes joint webbing (pterygia) and foetal hydrops leading to lethal MPS [3]. Primary muscle disease accounts for ∼50% of FADS cases [4], with a growing number of genes implicated [2]. Despite this, the majority of foetal akinesia cases remain without a genetic diagnosis. The low rate of genetic diagnosis is due to the rarity of these disorders coupled with extensive genetic heterogeneity. This is frequently compounded by the poor quality of the foetal tissues at autopsy hampering diagnosis.

Section snippets

Case report

Written informed consent was obtained for participation in this study, which was approved by the Human Research Ethics Committee of the University of Western Australia.

Discussion

We describe a family with three foetuses (a singleton and monozygotic twins) presenting with foetal akinesia in the second trimester and with a diagnosis of lethal MPS. Whole exome sequencing of DNA from the singleton and one of the monozygotic twins revealed compound heterozygosity for a known splice-site mutation (c.691+2T>C) and a novel missense mutation (c.956A>G; p.His319Arg) in GBE1 (OMIM 607839). This molecular diagnosis resulted in re-examination of the pathology and a revised diagnosis

Acknowledgements

This research was supported by the National Health and Medical Research Council of Australia (Early Career Researcher Fellowship #1035955 to GR, Research Fellowship APP1002147 to NGL and Project Grant APP1022707); the Association Francaise contre les Myopathies (#15734) and a UWA Collaborative Research Award and the Western Australian Department of Health, Medical and Health Research Infrastructure Fund. ET and KSY are supported by University Postgraduate Awards.

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Glycogen storage disease type IV (GSD IV) is caused by mutations in the glycogen branching enzyme 1 (GBE1) gene and is characterized by accumulation of polyglucosan bodies in liver, muscle and other tissues. We report three cases with neuromuscular forms of GSD IV, none of whom had polyglucosan bodies on muscle biopsy. The first case had no neonatal problems and presented with delayed walking. The other cases presented at birth: one with arthrogryposis, hypotonia, and respiratory distress, the other with talipes and feeding problems. All developed a similar pattern of axial weakness, proximal upper limb weakness and scapular winging, and much milder proximal lower limb weakness. Our cases expand the phenotypic spectrum of neuromuscular GSD IV, highlight that congenital myopathy and limb girdle weakness can be caused by mutations in GBE1, and emphasize that GSD IV should be considered even in the absence of characteristic polyglucosan bodies on muscle biopsy.
Analysis of GBE1 mutations via protein expression studies in glycogen storage disease type IV: A report on a non-progressive form with a literature review
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Citation Excerpt :
In addition, a neuromuscular form has been reported, which is further sub-divided in accordance with the age at onset (perinatal, neonatal, juvenile, or adult). Patients with the perinatal form present in utero fetal akinesia deformation sequence, polyhydramnios, fetal hydrops, arthrogryposis, and perinatal death [5,10–19]. Those with the neonatal form present hypotonia, muscular atrophy, and cardiomyopathy immediately postpartum, and usually die in the neonatal period [4–6,16,18,20–24].
Glycogen storage disease type IV (GSD IV), caused by GBE1 mutations, has a quite wide phenotypic variation. While the classic hepatic form and the perinatal/neonatal neuromuscular forms result in early mortality, milder manifestations include non-progressive form (NP-GSD IV) and adult polyglucosan body disease (APBD). Thus far, only one clinical case of a patient with compound heterozygous mutations has been reported for the molecular analysis of NP-GSD IV. This study aimed to elucidate the molecular basis in a NP-GSD IV patient via protein expression analysis and to obtain a clearer genotype-phenotype relationship in GSD IV.
A Japanese boy presented hepatosplenomegaly at 2 years of age. Developmental delay, neurological symptoms, and cardiac dysfunction were not apparent. Observation of hepatocytes with periodic acid-Schiff-positive materials resistant to diastase, coupled with resolution of hepatosplenomegaly at 8 years of age, yielded a diagnosis of NP-GSD IV. Glycogen branching enzyme activity was decreased in erythrocytes. At 13 years of age, he developed epilepsy, which was successfully controlled by carbamazepine.
In this study, we identified compound heterozygous GBE1 mutations (p.Gln46Pro and p.Glu609Lys). The branching activities of the mutant proteins expressed using E. coli were examined in a reaction with starch. The result showed that both mutants had approximately 50% activity of the wild type protein.
This is the second clinical report of a NP-GSD IV patient with a definite molecular elucidation. Based on the clinical and genotypic overlapping between NP-GSD IV and APBD, we suggest both are in a continuum.
Lethal multiple pterygium syndrome: A severe phenotype associated with a novel mutation in the nebulin gene
2017, Neuromuscular Disorders
Fetal akinesia deformation sequence is a clinically and genetically heterogeneous disorder characterized by a variable combination of fetal akinesia, intrauterine growth restriction, developmental abnormalities such as cystic hygroma, hydrops fetalis, pulmonary hypoplasia, occasional arthrogryposis, and pterygia. The pathogenetic mechanisms of fetal akinesia deformation sequence include neuropathy, muscular disorders, neuromuscular junction disorders, maternal myasthenia gravis, restrictive dermopathy and others. We here report an Egyptian family presenting with recurrent lethal multiple pterygium syndrome. The diagnosis was based on antenatal sonographic demonstration of complete fetal akinesia and a large cystic hygroma with severe limb contractures evident on postmortem examination. Next generation sequencing performed on the second affected fetus identified a novel homozygous essential splice-site variant in the nebulin gene. In conclusion, our report adds further evidence for the involvement of the nebulin gene in the etiology of fetal akinesia deformation sequence/lethal multiple pterygium syndrome.
New era in genetics of early-onset muscle disease: Breakthroughs and challenges
2017, Seminars in Cell and Developmental Biology
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As stated, molecular diagnosis clarifies the precise genetic cause of the disease in a patient. This may include modifying the original clinical diagnosis of a patient [9,117] through sequencing in what has been called − “diagnosis by sequencing” [118]. Diagnosis by sequencing is facilitated by next generation sequencing diagnostics, since a large number of genes outside the clinical diagnosis of the patient are analysed in an unbiased manner.
Early-onset muscle disease includes three major entities that present generally at or before birth: congenital myopathies, congenital muscular dystrophies and congenital myasthenic syndromes. Almost exclusively there is weakness and hypotonia, although cases manifesting hypertonia are increasingly being recognised. These diseases display a wide phenotypic and genetic heterogeneity, with the uptake of next generation sequencing resulting in an unparalleled extension of the phenotype-genotype correlations and “diagnosis by sequencing” due to unbiased sequencing. Perhaps now more than ever, detailed clinical evaluations are necessary to guide the genetic diagnosis; with arrival at a molecular diagnosis frequently occurring following dialogue between the molecular geneticist, the referring clinician and the pathologist. There is an ever-increasing blurring of the boundaries between the congenital myopathies, dystrophies and myasthenic syndromes. In addition, many novel disease genes have been described and new insights have been gained into skeletal muscle development and function. Despite the advances made, a significant percentage of patients remain without a molecular diagnosis, suggesting that there are many more human disease genes and mechanisms to identify.
It is now technically- and clinically-feasible to perform next generation sequencing for severe diseases on a population-wide scale, such that preconception-carrier screening can occur. Newborn screening for selected early-onset muscle diseases is also technically and ethically-achievable, with benefits to the patient and family from early management of these diseases and should also be implemented.
The need for world-wide Reference Centres to meticulously curate polymorphisms and mutations within a particular gene is becoming increasingly apparent, particularly for interpretation of variants in the large genes which cause early-onset myopathies: NEB, RYR1 and TTN. Functional validation of candidate disease variants is crucial for accurate interpretation of next generation sequencing and appropriate genetic counseling. Many published “pathogenic” variants are too frequent in control populations and are thus likely rare polymorphisms. Mechanisms need to be put in place to systematically update the classification of variants such that accurate interpretation of variants occurs.
In this review, we highlight the recent advances made and the challenges ahead for the molecular diagnosis of early-onset muscle diseases.
A novel neuromuscular form of glycogen storage disease type IV with arthrogryposis, spinal stiffness and rare polyglucosan bodies in muscle
2016, Neuromuscular Disorders
Citation Excerpt :
Three clinical forms based on age at onset can be identified. The first is characterized by antenatal onset, polyhydramnios, decreased fetal movements, fetal akinesia deformation sequence (FADS), arthrogryposis multiplex congenita (AMC), hydrops fetalis, and perinatal death [8–14]. The second one presents with severe/lethal congenital myopathy, often simulating Werdnig–Hoffmann disease [15–19].
Glycogen storage disease type IV (GSD IV) is an autosomal recessive disorder causing polyglucosan storage in various tissues. Neuromuscular forms present with fetal akinesia deformation sequence, lethal myopathy, or mild hypotonia and weakness. A 3-year-old boy presented with arthrogryposis, motor developmental delay, weakness, and rigid spine. Whole body MRI revealed fibroadipose muscle replacement but sparing of the sartorius, gracilis, adductor longus and vastus intermedialis muscles. Polyglucosan bodies were identified in muscle, and GBE1 gene analysis revealed two pathogenic variants. We describe a novel neuromuscular GSD IV phenotype and confirm the importance of muscle morphological studies in early onset neuromuscular disorders.
CAV3 mutations causing exercise intolerance, myalgia and rhabdomyolysis: Expanding the phenotypic spectrum of caveolinopathies
2016, Neuromuscular Disorders
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Patient 7 was evaluated by bi-directional sequence analysis for mutations in CAV3 and Patient 8 by whole exome sequencing (SOLiD™). Whole exome sequencing was performed as outlined previously [4]. Three µg of DNA was fragmented by sonication and ligated to SOLiD™ system sequencing adaptors.
Rhabdomyolysis is often due to a combination of environmental trigger(s) and genetic predisposition; however, the underlying genetic cause remains elusive in many cases. Mutations in CAV3 lead to various neuromuscular phenotypes with partial overlap, including limb girdle muscular dystrophy type 1C (LGMD1C), rippling muscle disease, distal myopathy and isolated hyperCKemia. Here we present a series of eight patients from seven families presenting with exercise intolerance and rhabdomyolysis caused by mutations in CAV3 diagnosed by next generation sequencing (NGS) (n = 6). Symptoms included myalgia (n = 7), exercise intolerance (n = 7) and episodes of rhabdomyolysis (n = 2). Percussion-induced rapid muscle contractions (PIRCs) were seen in five out of six patients examined. A previously reported heterozygous mutation in CAV3 (p.T78M) and three novel variants (p.V14I, p.F41S, p.F54V) were identified. Caveolin-3 immunolabeling in muscle was normal in 3/4 patients; however, immunoblotting showed more than 50% reduction of caveolin-3 in five patients compared with controls. This case series demonstrates that exercise intolerance, myalgia and rhabdomyolysis may be caused by CAV3 mutations and broadens the phenotypic spectrum of caveolinopathies. In our series, immunoblotting was a more sensitive method to detect reduced caveolin-3 levels than immunohistochemistry in skeletal muscle. Patients presenting with muscle pain, exercise intolerance and rhabdomyolysis should be routinely tested for PIRCs as this may be an important clinical clue for caveolinopathies, even in the absence of other “typical” features. The use of NGS may expand current knowledge concerning inherited diseases, and unexpected/atypical phenotypes may be attributed to well-known human disease genes.

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Case reportWhole exome sequencing in foetal akinesia expands the genotype–phenotype spectrum of GBE1 glycogen storage disease mutations

Abstract

Introduction

Section snippets

Case report

Discussion

Acknowledgements

Semin Pediatr Neurol

Neuromuscul Disord

Neuromuscul Disord

Biochem Biophys Res Commun

Pena-Shokeir phenotype (fetal akinesia deformation sequence) revisited

Birth Defects Res A Clin Mol Teratol

Fetal akinesia: review of the genetics of the neuromuscular causes

J Med Genet

Early-onset fetal hydrops and muscle degeneration in siblings due to a novel variant of type IV glycogenosis

Pediatr Dev Pathol

Lethal arthrogryposis multiplex congenita: a pathological study of 21 cases

Histopathology

Merlin—rapid analysis of dense genetic maps using sparse gene flow trees

Nat Genet

ANNOVAR: functional annotation of genetic variants from high-throughput sequencing data

Nucleic Acids Res

GENCODE: producing a reference annotation for ENCODE

Genome Biol

Case report
Whole exome sequencing in foetal akinesia expands the genotype–phenotype spectrum of GBE1 glycogen storage disease mutations