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Original articles

Hirschsprung disease, microcephaly, mentalretardation, and characteristic facial features:delineation of a new syndrome and identificationof a locus at chromosome 2q22-q23

D R Mowat, G D H Croaker, D T Cass, B A Kerr, J Chaitow, L C Ades, N L Chia,M J Wilson

Department of ClinicalGenetics, RoyalAlexandra Hospital forChildren, Westmead,Sydney, NSW 2124,AustraliaD R MowatL C AdesM J Wilson

Department ofSurgery, RoyalAlexandra Hospital forChildren, Westmead,Sydney, NSW 2124,AustraliaG D H CroakerD T Cass

Department ofMedical Genetics, StMary's Hospital,Manchester M13 OJH,UKB A Kerr

Department ofMedicine, RoyalAlexandra Hospital forChildren, Westmead,Sydney, NSW 2124,AustraliaJ Chaitow

Department ofCytogenetics, RoyalAlexandra Hospital forChildren, Westmead,Sydney, NSW 2124,AustraliaN L Chia

Correspondence to:Dr Wilson.

Received 8 January 1997Revised version accepted forpublication 29 January 1998

AbstractWe have identified six children with a dis-tinctive facial phenotype in associationwith mental retardation (MR), micro-cephaly, and short stature, four of whompresented with Hirschsprung (HSCR) dis-ease in the neonatal period. HSCR wasdiagnosed in a further child at the age of 3years after investigation for severe chronicconstipation and another child, identifiedas sharing the same facial phenotype, hadchronic constipation, but did not haveHSCR. One of our patients has an inter-stitial deletion of chromosome 2,del(2)(q21q23). These children stronglyresemble the patient reported by Lurie etal with HSCR and dysmorphic featuresassociated with del(2) (q22q23). All pa-tients have been isolated cases, suggestinga contiguous gene syndrome or a domi-nant single gene disorder involving a locusfor HSCR located at 2q22-q23.Review of published reports suggests

that there is significant phenotypic andgenetic heterogeneity within the group ofpatients with HSCR, MR, and micro-cephaly. In particular, our patients appearto have a separate disorder fromGoldberg-Shprintzen syndrome, forwhich autosomal recessive inheritancehas been proposed because of sib recur-rence and consanguinity in some families.(JMed Genet 1998;35:617-623)

Keywords: Hirschsprung disease; mental retardation;microcephaly; chromosome 2

The association of Hirschsprung disease(HSCR), microcephaly, and mental retardationwas first described in a pair of sibs by Goldbergand Shprintzen in 1981.1 This association hasbeen reported with other features including cleftpalate,'3 iris coloboma,4 congenital heartdisease,2 5 6 and abnormal cranial imaging.'Autosomal recessive inheritance has been pro-posed in view of parental consanguinity4 and sibrecurrence in three families.' 2 7

We report six children with a distinctivefacial phenotype in association with HSCR,MR, and microcephaly, one of whom has aninterstitial deletion of chromosome 2q. Thefirst five patients are from New South Wales,Australia and the sixth from Manchester, UK.We reviewed the previous case reports ofHSCR, MR, and microcephaly, and of patientswith chromosome 2q deletions,'-" and com-pared the findings to those of our patients.Polymorphic microsatellite markers encom-passing the region of cytogenetic deletion weretyped in the first five families.

Case reportsPATIENT 1 (FIG 1)This boy is the fifth of six children ofnon-consanguineous parents. His birth weightwas 3700 g, length 50 cm, and head circumfer-ence 33 cm. He did not pass meconium, devel-oped bilious vomiting and abdominal disten-sion on day 5, and HSCR was diagnosed byrectal suction biopsy. Aganglionosis was foundto extend to the splenic flexure and he had aninitial defunctioning colostomy, followed by aDuhamel pull through procedure at the age of8 months. He had bilateral grade IV vesicouret-eric reflux and underwent bilateral reimplanta-tion of his ureters at 9 months of age.At 4 months he had hypotonia and poor head

growth; cerebral ultrasound suggested partialagenesis of the corpus callosum, but a cranialCT scan was normal. At 2 years of age he devel-oped recurrent seizures, which continued inter-mittently for another year, but by the age of 5were well controlled with sodium valproate andclonazepam. He required a Nissen fundoplica-tion for severe gastro-oesophageal reflux andfailure to thrive. At 51/2 years he vocalised buthad no recognisable words, was able to sit inde-pendently, crawl, pull to stand, and walked in awalker. His hearing and vision were normal andhe had a generally placid personality.On examination at the age of 41/2 years his

height was 96 cm (

Mowat, Croaker, Cass, et al

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Figure 1 (Top row) Patient I at 4½12 years of age. (Middle row) Patient 2 at 3 yearage. (Bottom row) Patient 3 at 3 years of age.

slanting palpebral fissures, broad nasal bbulbous nasal tip, prominent columella, tri.lar jaw, prognathism, open mouthedexpression, low set, posteriorly rotated earsuplifted lobes, tapered fingers, and bilateragle transverse palmar creases. Neurol4examination showed reduced lower limband generalised hyperreflexia. Investig,

including skeletal survey, urinary amino andorganic acids, and karyotype at 550 bandresolution were normal.

PATIENT 2 (FIG 1)This girl is the third of four children ofnon-consanguineous parents; her birth weightwas 4820 g, length 52 cm, and head circumfer-

ence 34 cm. Short segment HSCR wasdiagnosed at 6 weeks of age after she presentedwith vomiting and failure to thrive. Right uppertransverse colostomy was performed at the ageof 7 weeks, followed by Duhamel rectosigmoid-

d ectomy at the age of 8 months. She had hypo-K tonia and global developmental delay. She

started to crawl, sat unsupported, and startedto babble at 2 years of age. Seizures started at18 months and initially responded to anticon-vulsants, but she has gradually developed aresistant seizure disorder with episodes ofstatus epilepticus. She wears glasses for hyper-metropia and her hearing is normal. At 3 yearsof age she was able to stand and cruise, had nospeech, but smiled frequently and had a happy,affectionate personality.On examination her height was 89 cm (

Hirschsprung disease, microcephaly, mental retardation, and characteristic facialfeatures

... .1.

.....~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

aZ la -!Figure 2 (Top row) Patient 4 at 2'/2years of age. (Middle row) Patient 5 at 2 years 10months of age. (Bottom row) Patient 6 at 2 years 6 months of age.

(3rd centile), and head circumference 46.5 cm(


Table 1 Summary of reported patients with HSCR, MR, and microcephaly

Goldberg and Kumasaka andShprintzen' Clarren2 Halal Yonzo et aP Hurst et alJ

Brunoni andClinical manifestationis Sib 1 Sib 2 et al' Sib 1 Sib 2 Morel' Sib I Sib 2 Pt 1 Pt 2 Pt 3

Sex M F M M M M M F M M FConsanguinity - - - - - - - - + +

Core featuresMental retardation + + + + + + + + + + +Microcephaly + + + + + + + + + + +HSCR + + + + - + + + + + +Short stature + + - + + + + + - + +

Facial featuresTypical - - - ? ? - - - - - +Sparse hair + + - - - - + + - - +Eyebrow abn + + + ? ? - + + - - +Coloboma - - - - - - - - + - +Ptosis - - - - - - + + - - +Cleft palate/lip Sub Sub + Sub +

OtherfeaturesSeizures - - - - - - - - - - -Congenital heart disease - - - PS - ASD

Renal - - - ?- - - - VUR

InivestigationsAbn cranial CT/MRI/US + + ? ? ? + + + + +

Chromosomes N ND N ? ? N N N N ND N

+=present; -=absent; N=normal; ?/ND=unknown/not done; ASD=atrial septal defect; Hydro=hydronephrosis; PDA=patent duc-tus arteriosus; PS=pulmonary stenosis; Dup=duplex kidney; COARC=coarctation of the aorta; PA=pulmonary atresia;ACC=agenesis corpus callosum; TOF=tetralogy of Fallot; Sub=submucous cleft palate; *=constipation; PPS=peripheral pulmonarystenosis.

words, cruised around furniture, and took anoccasional single step. Her personality wasgenerally happy and sociable. She has had noseizures.On examination her height was 77.9 cm

(


Table 1 continued

Ourpatients

Tanaka etat' Lurie et al7 Pt Pt 2 Pt 3 Pt 4 Pt 5 Pt 6

F M M F M M F M

+ + + + + + + ++ + + + + + + ++ + + + + + -* ++ + + + + -+ +

+ + + + + + + +? ? - ~~~~~ ~~~++ + - +

+ ?+ + + + _ +

_ _ - - Sub - - -

+ + + + + +_

PDA/ASD PDA/ASD - - PA - TOF PDA/COARC PPS

- - VUR - - Dup - Hydro+ ? N CT NMRI N CT ACC MRI NUS ACC

MRIN del 2q22-q23 N N N del N N

2q2 1-q23

laughing were reported. He could drink from abottle and took pureed foods. Absent visualresponses had been noted by 4-5 months of agewith only transient fixing and following, despitestructurally normal eyes. Audiological assess-ment had shown partial responses at both highand low frequencies, excluding a major degreeof hearing loss. He had always been a happy,contented baby. His head circumference was44 cm (3rd centile) and weight 8 kg (3rd-i Othcentile). The clinical features seen in theneonatal period were confirmed. He had sparsehair, laterally sparse eyebrows, deep set eyes,and an open mouthed expression. There wasmarked generalised hypertonia and hyper-reflexia with crossed adductor responses. Cer-ebral MRI at 15 months confirmed absence ofthe corpus callosum, with moderate dilatationof the posterior and temporal horns of the lat-eral ventricles. The myelination pattern wasdelayed, and there was some periventricularhigh signal seen around the occipital lobes,possibly representing dysmyelination. Echocar-diography at the same age confirmed thepersistence of a tiny patent ductus arteriosuswith a mild branch pulmonary stenosis. He wasrecognised to have the same syndrome as theprevious patients following discussion andcomparison of clinical photographs by two ofthe authors.

Molecular investigations and resultsTen highly polymorphic microsatellite markers(D2S2215, D2S 114, D2S 127, D2S 122,D2S151, D2S2301, D2S356, D2S2241,D2S2299, D2S2370), listed in assumed orderfrom centromere to telomere, spanning adistance of 23 cM'6 on chromosome 2q, weretyped for patients 1 to 5 and their parents. Afurther two markers (D2S333 and D2S326),

11 and 13 cM respectively towards thetelomere from D2S2370, were also typed.Markers D2S114, D2S127, and D2S122showed loss ofheterozygosity (LOH) in patient4, consistent with the observed cytogeneticdeletion. The telomeric boundary for this dele-tion was established as between markersD2S 122 and D2S 151, and the centromericboundary between D2S114 and D2S2215.Patient 2 was uninformative for the markersD2S 114, D2S 127, and D2S 122 and thereforeloss of heterozygosity could not be ruled out atthese loci. Patients 1, 3, and 5 showed noevidence ofLOH at these markers.

DiscussionThe children we report here share strikinglysimilar facial features, including deep set, largeeyes (blue in four patients), broad nasal bridge,rounded nasal tip, prominent columella, openmouthed expression, triangular jaw, prominentchin, and large uplifted ear lobes, in associationwith MR and microcephaly. Five have provenHSCR (four with short segment) and one haschronic constipation but a normal rectalbiopsy. They share musculoskeletal features,including postnatal short stature, slender,tapered fingers, and bilateral calcaneovalgus.Three of our patients have congenital heartdisease and three have renal structural abnor-malities. All have severe developmental delaywith absent or minimal speech and delayedgross motor skills, but a generally happy, smil-ing affect, and four have developed epilepsy,which has become resistant to treatment intwo. In four patients, cerebral ultrasound inearly infancy suggested complete or partialagenesis of the corpus callosum (ACC); latercerebral CT was normal in two with suggestedpartial ACC on ultrasound, while MRI con-firmed complete ACC in the other twopatients. One patient had a normal cerebralultrasound and one a normal cerebral CT ininfancy.

Table 1 lists the features of our patients andcompares these with the 13 previously reportedchildren with the association of HSCR, MR,microcephaly, and dysmorphic facial features.On review of these reports, we considered thatthree other patients definitely had the samefacial phenotype.4(case 3)6 8 All of these wereisolated cases. The patient reported by Lurie etat had a deletion of 2q22-q23 and our patient4 had a deletion of2q21-q23 (fig 3). Lurie et atcompared the phenotypic features of eightpatients with interstitial deletions including2q22-23, and concluded the observed spec-trum ofanomalies did not allow the delineationof a consistent clinical syndrome. Six patientshad congenital heart disease, four had cleftpalate, and two had ocular colobomata. Onlyone had diagnosed HSCR, and the publishedphotograph showed a strong facial resemblanceto our patients. Of the remainder, none of theavailable photographs in the originalreferences9 1012 13 enabled us to identify a simi-lar facial phenotype, and some were onlyreported as neonates, so the subsequent clinicalcourse, particularly with regard to milder formsof HSCR, was not known. Three of these

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patients had more extensive deletions incorpo-rating 2q22-23, and two more had deletionbreakpoints at either 2q22 or 2q23. It is possi-ble that the clinical differences, particularly inthose with deletions also involving 2q24, couldbe caused by an overriding phenotype. Five ofthe six patients we report did not have cytoge-netically detectable deletions, at 450 to 650band resolution, nor could we confirm thepresence of a molecular deletion in any of thesepatients with the markers tested. So far, wehave not been able to delineate the criticalregion for the observed phenotype, whichcould be caused by a contiguous gene syn-drome, or a single gene disorder, or disruptionof a critical region within 2q22-23. It is alsopossible that there is genetic heterogeneity andthat other genetic loci could give rise to thesame phenotype.A number of genes for HSCR have been

identified including the RET proto-oncogene(lOql 1.2),17 18 EDNRB (13q22),19 20 EDN3(20q13.2-q13.3)2' 22 and the RET ligand, andglial cell line derived neurotropic factor(GDNF) (5p 13. 1).23 24 No previous loci havebeen identified on chromosome 2q. Mutationalanalysis has shown that HSCR can be associ-ated with different genetic mechanisms includ-ing autosomal dominant and recessiveinheritance.17-24 In familial HSCR caused by apostulated loss of function mutation in theRET proto-oncogene, variable intrafamilialexpressivity (short segment and long segmentdisease) and non-penetrance (29% in malesand 50% in females) have been described.25 26A similar mechanism, possibly secondary toother HSCR gene polymorphisms,24 could beoperating to explain both the variable expres-sivity and penetrance of HSCR in our patientsand the apparent low frequency of HSCR inthe previously reported patients with deletionsincorporating 2q22-23.We could not confirm the facial phenotype

exhibited by our patients on review of pub-lished photographs of the two sibs reported byGoldberg and Shprintzen' and eight otherpatients subsequently reported as possibleGoldberg-Shprintzen syndrome.2 5 Eight ofthese 10 cases involved sib recurrence orparental consanguinity. There were a numberof congenital anomalies shared with some ofour patients, including congenital heart dis-ease, submucous cleft palate, and structuralcerebral abnormalities, in particular completeor partial agenesis of the corpus callosum.These anomalies are frequently documented innumerous other syndromes involving HSCR,which may not have either MR or micro-cephaly, so are likely to result from disruptionof normal neural crest cell migration by a vari-ety of different mechanisms. This suggests thatthere is genetic heterogeneity within the groupof patients presenting with HSCR, MR, andmicrocephaly, some of whom, including ourpatients, could have a contiguous gene syn-drome or new dominant mutation, whileothers, such as those reported by Goldberg andShprintzen,' could have separate autosomalrecessive disorders.

Following the recognition of a similarphenotype in our first two cases, the next threewere identified within the next six months, andwe suspect this could be a relatively commonsyndrome in children with syndromic HSCR.Recognition of the syndrome has importantimplications in regard to clinical managementand genetic counselling. Affected patients mayhave chronic abdominal discomfort or consti-pation secondary to unrecognised short seg-ment HSCR. These symptoms are common inhypotonic, delayed children, but identificationof the characteristic facies in a child withmicrocephaly and developmental delay, inassociation with chronic abdominal symptoms,should prompt consideration of rectal biopsy,high resolution analysis of chromosome 2q,and molecular studies with probes localised to2q22-23. Genetic counselling would also beaided by recognition of this disorder. All of ourpatients, and those previously published pa-tients whom we consider have the samesyndrome, have been isolated cases, some fromlarge sibships, and two have de novo deletionsinvolving chromosome 2q. This suggests a lowrecurrence risk should apply to most families,although at present sib recurrence secondary toparental germline mosaicism cannot be ex-cluded. This is in comparison to the 25%recurrence risk which applies to families withautosomal recessive syndromes ofHSCR, MR,and microcephaly.

We should like to thank the families of these children for theircooperation.

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