Supplementary Clinical Information

Transcription

1 Supplementary Clinical Information Patient 1 This female was born as the second child of a twin after a pregnancy duration of 32 weeks. The birth was otherwise uncomplicated and her twin brother was healthy. Possibly there was some asphyxia. The birth weight was grams. She had a respiratory syncytial virus infection complicated by a septic shock at the age of 3 months. Developmental delay was evident from the beginning with walking at 2 years and first words at 3 years of age. At physical examination at 5 years of age, her height was 106 cm (25 th centile), weight 20.6 kg (75 th centile) and head circumference 51.4 cm (>75 th centile). There were no facial dysmorphisms except for strabismus. Routine chromosome analysis, metabolic screening and analysis for Angelman syndrome were all normal. At the age of 13 years, she presents with severe intellectual disability with an IQ score of She is able to speak, but cannot read nor write. Since the age of 8 years her weight has increased. She often asks for food but there is no food seeking behavior. Her height is cm (50 th centile), weight is 89.6 kg (>97 th centile), BMI is 35.2kg/m 2 and head circumference is 57 cm (>97 th centile). The patient has some minor dysmorphisms including full round face, low insertion of the columella, broad nasal tip, short philtrum, and small hands (Figure 1a). 250k SNP array analysis showed a 2p25.3 loss (SNP_A >SNP_A )x1 ( Mb, hg19). Testing of the parents using the same array platform and FISH analysis using a subtelomeric probe did not reveal any copy number changes. Patient 2 This patient was born after an uncomplicated pregnancy at 40 weeks of gestation with a birth weight of grams. There is no history of hypotonia or feeding problems. Development was slow and normal education was not possible. In childhood she showed aggressive and destructive behavior and she was obese. She has always been healthy. Physical examination in adulthood revealed a height of 160 cm (between 10 th and 25 th centile), a weight of 81 kg (>90 th centile) and a head circumference of 61 cm (>97 th

2 centile). She can only speak a few words and is repeatedly handwringing. Upslanting of the palpebral fissures, low frontal hairline, high nasal bridge, a broad mouth, and full lips were noticed upon clinical examination (Figure 1b). MLPA analysis (P070 MRC Holland) revealed a terminal deletion of the short arm of chromosome 2 and a terminal duplication of the long arm of chromosome 14, the size of the aberrations was determined by microarray analysis: arr 2p25.3(17,019-2,692,574)x1, 14q32.31q32.33(103,004, ,287,505)x3dn. rsa 2p25.3(P070)x1, 14q32.3(P070)x3 (hg19). The parents showed a normal karyotype and FISH pattern: ish 2p25.3(VIJyRM2052x2), 14q32.3(D14S1420x2) (FISH probes by Abbott Vysis). Patient 3 This girl was originally referred for assessment at age 7 after her behavior had deteriorated and she had become very aggressive. She had been investigated for moderate to severe learning disability and had a 46,XX apparently normal female karyotype upon conventional chromosome analysis. Fragile X testing gave normal results. She was born at days gestation and weighed grams (90 th centile). She walked at 17 months and has delayed speech development. She attends a special school where her reading and writing is at a pre-school level. She has been diagnosed with autism. She has good health and has never had seizures. Obesity was apparent at age 7 when her occipital frontal circumference was +3 standard deviations, her height was on the 75 th centile and her weight was 10 kg above the 99.6 th centile. Menarche occurred at 11.5 years. At age 13, she still is obese with a Body Mass Index of 35.3 kg/m 2 (height 161.9cm (75 th centile), weight 92.6kg (17kg > 99.6 th centile)). She has hand stereotypies but does not have any dysmorphic features. Microarray analysis revealed a 2.64 Mb 2p25.3 submicroscopic deletion: arr 2p25.3(17,049-2,659,882)x1 dn (hg19).

3 Patient 4 This patient s birth weight was grams (93 rd centile) at 40+7 weeks. Developmental delay was noted when she did not sit unsupported until 9 months and did not walk until 18 months. Her speech is also delayed and she receives speech and language therapy but she is able to hold a conversation. She has been diagnosed with autism and ADHD and attends a school with a Language and Communication resource where, at age 11, her abilities are equivalent to those of an average 6-year-old. She has been prescribed Melatonin because she has difficulty getting to sleep and wakes after 4-5 hours. She developed absence seizures aged 5 years and was treated with Ethosuxemide and sodium valproate. Recently she started refusing medication and her seizures have not recurred. Aged 9, her occipital frontal circumference and height were on the 50 th centile and her weight was on the 75 th centile. By age 11, she is still prepubertal and her height is on the 25 th centile while her weight is on the 50 th centile. She is not considered to have dysmorphic features. Microarray analysis revealed a 2.29 Mb microdeletion at chromosome band 2p25.3: arr 2p25.3(20,807-2,309,010)x1 (hg19). Patient 5 The patient has psychomotoric impairment. He does not really speak, laughs a lot and is generally a happy boy. He started walking at the age of 2 years. He has a short stature (height 156 cm (<3 rd centile)) and his weight is 70 kg (75 th centile). His head circumference is 57 cm (90 th centile). He has small palpebral fissures and has a clear sight. At the age of 8 years, developing cataract was detected in the right eye. The patient has a hiatal hernia and mild gastroesophageal reflux. He takes antipsychotics and antiepileptic drugs. He also has systolic heart murmurs and microorchidism. Extension of the elbows is limited to 170 degrees. Ultrasound of the abdomen detected a 4 cm cyst located in the right kidney and asymptomatic cholecystolithiasis.

4 Chromosome analysis showed a normal 46,XY karyotype. Molecular screening of the FMR1 gene was normal (30 CGG repeats). Microarray analysis revealed a 2p25.3 deletion [arr 2p25.3(234,263-4,149,074)x1; 3.91 Mb, hg19] which was confirmed with a subtelomeric 2pter FISH probe. The patient has one healthy sister en two healthy brothers. Patient 6 The proband was born after an uneventful pregnancy to healthy non-consanguineous parents. She has a delayed neuromotor development: sitting at age 13 months, independent gait at 3 years of age. At the age of 4 there is no active speech, and minimal understanding of simple words. There is some autistic behavior. Clinical examination at the age of 4 reveals a height of 101 cm (25 th centile), weight of 16.2 kg (30 th centile) and head circumference of 48.7 cm (25 th centile). Except for mild strabismus, no dysmorphic signs are noted (Figure 1d). She has a problem of intermittent but sometimes pronounced toe-walking. Array CGH analysis result showed a 1.02 Mb submicroscopic 2p25.3 deletion [arr 2p25.3(1,596,497-2,620,552)x1 dn; hg19]. Brain MRI at age 15 months showed mild bilateral T2 hyperintensities in the parietooccipital white matter, which could be due to delayed myelination. Patient 7 The patient arrived to our observation for cognitive delay. He is the first of two siblings born to unrelated and healthy parents. The pregnancy was characterized by threat of abortion during the first quarter, then it is continued without particular problems; ultrasound monitoring was reported to be normal. The child was born by natural delivery at 40 weeks of gestational age: his birth weight was grams and birth length 52 cm; occipital frontal circumference was not available.

5 At birth hypotonia was detected. From the age of 6-7 months, the parents noticed stereotypic hand movements. He reached the sitting position at 11 months of age and walked independently at 30 months. Electroencephalography did not reveal any epileptic anomalies. Magnetic resonance imaging showed that central nervous system morphology was normal, and fragile mental retardation 1 gene molecular analysis gave normal results. Presently, at the age of 4 years and 6 months speech delay is evident since he says only a few words. Psychomotor development is clearly delayed (IQ 53, verbal IQ 65, performance IQ 50) and a diagnosis of attention-deficit hyperactivity disorder was made. At this time his weight was 22.1 kg (95 th centile), height cm (90 th centile) and occipital frontal circumference 51.5 cm (75 th centile). He presents a sloping forehead, mild deep-set eyes, hyperplastic ear lobes and large ears, broad nasal bridge, and short philtrum (Figure 1e). Microarray analysis revealed a de novo 1.65 Mb deletion: arr 2p25.3(1,741,993-3,394,993)x1 dn (hg19). Patient 8 This boy was born at term after a normal pregnancy with a birth weight of grams. He had a delayed development, especially in speech and language. His motor development was mildly delayed (independent walking at the age of 20 months). He had a discrepancy in IQ measurements (verbal IQ 70 and performance IQ 58 at age 7). Examination at the age of 7 showed that his height was 122 cm (25 th centile), weight was 23.5 kg (25 th centile) and head circumference 50.5 cm (3 rd centile). From the age of 7 he was put on psychiatric medication (aripiprazol) because of severe mood disturbances. Along with this medication, his weight gradually increased, though remained within normal BMI range. He was last examined at the age of 13 years, when his height was 162 cm (50 th centile), weight 59 kg (>75 th centile)and occipital frontal circumference was 53.5 cm (25 th centile). His face showed mild dysmorphisms: broad nosebridge, anteverted nares, simple ear helices and short fingers (Figure 1f). At the age of 7, a cerebral brain MRI was normal. DNA analysis of Fragile X and a metabolic screen revealed no abnormalities. A SNP array revealed a de novo 750 kb 2p25.3 deletion: arr 2p25.3(1,742,952 2,495,732)x1 dn (hg 19).

6 Patient 9 The proband is a 4-1/2-year-old boy with developmental delay. He was born to nonconsanguineous parents and has a normal, healthy male fraternal twin and an older brother. A 3-generation family history was non-contributory. The pregnancy was normal and uncomplicated; there were no exposures to medications, drugs, ethanol or cigarettes and no infections. The twins were delivered by spontaneous vaginal vertex delivery at 38 weeks of gestation and there were no newborn complications. His gross motor milestones were delayed in that he was sitting at 10 months and walking at 18 months; he did not have any words until 2-1/2 years of age. He currently has several words, but is only understood by his family. He is otherwise healthy, and has had neither hospitalizations nor surgeries. He is allergic to Sulfa drugs. He is currently in junior kindergarten and behind many of the other children, but doing well socially. On physical examination, he was a tall and overweight boy in no apparent distress. His weight was 27 kg, well above the 97 th centile; his height was cm, at about the 97 th centile; and his head circumference was 53.5 cm, well above the 98 th centile. According to his parents, he was clearly much larger than his twin brother. He had a very round face, horizontal palpebral fissures, strabismus, thin upper and lower vermillion borders and flatish philtrum. He had large and fleshy lobules. He had a single palmar crease on the left and a bridge palmar crease on the right. His feet measured 6.3 and 6.5 cm, which is about the 50 th centile bilaterally; his hand measured at the 75 th centile at 12.8 cm bilaterally, but his fingers were long at 8 cm which is well above the 97 th centile. The remainder of the general physical examination was within normal limits. The arraycgh result was arr 2p25.3(1,777,285-2,659,882)x1 dn (hg19). FISH analysis confirmed the deletion in the patient and was normal for both parents [ish del(2)(p25.3p25.3)(rp11-352j11-)dn] Patient 10 This female was born after a normal pregnancy and delivery. Exact birth figures are unknown. From the age of 6 months, developmental delay was noted while she made poorly contact and was hypertonic. Both language and motor development were

7 delayed; she could walk independently at the age of 3 years. Until the age of 12 months, she had a normal weight, but thereafter, this gradually increased. At the age of 14 years, her height was cm (50 th centile), her weight was 80 kg (97 th centile), hand and feet length were small, at the 3 rd centile. Weight has gained to 98 kg in her twenties, but with disciplinary diet this decreased to 87 kg at the age of last examination (32 years). Her menarche was at the age of 10 years. She had behavioral problems that were categorized as limitations in adaptation of emotions and behavior fitting in autistic spectrum disorders, for which she received psychiatric medication from the age of 10 years (pipamperon). In addition, because of sleep disturbances, she also received sleep medication. Routine chromosomal studies, DNA studies of Fragile X and Prader Willi syndrome as well as a metabolic screen at the age of 14 years revealed no abnormalities. A SNP array at the age of 32 years revealed a de novo 120 kb intragenic MYT1L deletion arr 2p25.3(1,876,135-1,997,673)x1 (hg 19). Patient 11 Born at 40 weeks +5; birth weight: grams; birth length: 53 cm; occipital frontal circumference: 34/32 cm Notes at age 3 years and 3 months: Height was 93 cm (between 10 th and 25 th centile), weight 14.8 kg (25 th centile) and occipital frontal circumference 49.5 cm (<3 rd centile). He crawled when he was 8 months old and sat with support at the age of 1 year. He walked alone at 22 months. He has some very few indistinct words. A speech test showed that his language understanding was only ½ year behind, but his speech was more affected. The patient has intellectual disability, but no obvious dysmorphic signs. He does not have eating disturbances, but the parents have noted that he always wants to eat. He is hypermobile, as is his father. Reflexes could not be tested, but is likely to have slight foot clonus, without suspicion of cerebral palsy. MR scanning of the brain at 4 years and 7 months is normal. Notes at age 5 years 5 months: The speech specialist evaluates his impressive language as ½ year delayed. It is difficult to evaluate whether he has intellectual disability due to his language delay. His physical growth is normal and follows the growth chart. Notes at age 7 years 6 months: He has been diagnosed with infantile autism, but has some attitudes which do not fit into the classical diagnosis. He is very empathic and is

8 good in reading faces and sounds. He cannot cope with angry people. He is very sensitive to sound. He has a tendency to squeeze his right eye, or close with his hand while reading. He has slight strabismus and tendency to quick esotropia. At this age, his height is 120 cm (25 th centile) and his weight 25 kg (75 th centile). Microarray analysis showed a 170 kb duplication: arr 2p25.3(1,896,431-2,062,854)x3 dn (hg19). Patient 12 The pregnancy was uncomplicated and the proband was born at term with a normal birth weight. There were no early feeding difficulties although the parents report an absent sense of satiation. The girl was operated at the age of 9 months for an inguinal hernia. Formal evaluation at the age of 1.5 years revealed autistic features. Walking was achieved at the age of 2 years. Speech was equally delayed with the first words appearing at about 2 years. The excessive appetite led to marked central obesity, already apparent in the first years of life. The proband was reported to have a significant behavioral regression at the age of 15 years, when she developed aggressive as well as self-injurious behaviors, resistant to neuroleptics. Clinical evaluation at the age of 26 years revealed a weight of 110 kg (>90 th centile), height of 153 cm (3 rd to 10 th centile) and an occipital frontal circumference of 56 cm (75 th centile). She presented with dysmorphic features, including strabismus, thick lips with everted lower one, high arched palate, relatively small hands and genu valgum deformity at the lower limbs. Speech was limited to single words and rare simple phrases. Sleep was reported to have significantly improved after introduction of melatonine treatment. Array CGH resulted in a 341 kb microduplication involving 2p25.3: arr 2p25.3(1,944,993-2,285,993)x3 dn (hg19). Comprehensive neurologic evaluation was performed at the age of 33 years in the context of tonico-clinic seizures. Cerebral MRI

9 revealed a lesion compatible with the diagnosis of a glioma, particularly of a low-grade astrocytoma. Repeat MRI has been scheduled for re-evaluation of the cerebral images. Patient 13 This patient was the first child of healthy non-consanguineous parents. He has a healthy brother. Pregnancy was normal and delivery was provoked after 38 weeks of gestation. The birth weight was grams (3 rd -10 th centile), birth length was 46.5 cm (3 rd centile) and occipital frontal circumference was 32 cm (3 rd centile). Apgar was 10/10. The neonatal period was without concern. A progressive microcephaly was evidenced. Growth parameter at 3 years and 9 months were: height 96 cm (10 th pentile), weight 12.5 kg (3 rd centile) and occipital frontal circumference 45.5 cm (<3 rd centile). Psychomotor acquisitions were slow and walking was acquired at 21 months of age. Speech was delayed with only 3 words at 3 years and 9 months. He could not repeat simple words. He is not toilet trained. He had frequent swallowing. His walk remained instable. The major concerns were behavioral troubles with attention deficit, impulsivity further diagnosed as ADHD. Aggressiveness and sleep disorders were also mentioned. Scholarship was not started due to his difficulties. Facial dysmorphy: microcephaly, epicanthus, projected philtrum, thick and everted lower lip, full cheeks, laterally rare eyebrows, micrognathia, fifth finger clinodactyly (Figure 1g). Normal ophtalmological and auditive examination, normal paraclinical investigations with brain MRI, CDG, chromatography, ammonemia, AICAR-SAICAR. Molecular cytogenetic analysis (array CGH 180k, Agilent) diagnosed a de novo 370 kb duplication at 2p25.3 locus: arr 2p25.3(2,167,643-2,538,140)x3 dn (hg19), confirmed by qpcr. Patient 14 This female was born after a normal pregnancy and delivery with a high birth weight (4 750 grams, >97 th centile). She had neonatal hypotonia and feeding difficulties. Parents had noticed a developmental delay since the age of 6 months. She could walk without support at the age of 28 months and started to speak her first single words at the age of 3.5 years. She made stereotypic movements. At the age of 12 years she had an IQ of

10 about 45 and showed autistic features. Upon physical examination at the age of 12 years and 8 months she had normal growth parameters and mild facial dysmorphism, including a broad base and bridge of the nose and a large mouth (Figure 1h). SNP array, Angelman syndrome tests (UBE3A and methylation), and a metabolic screen revealed no abnormalities. Exome analysis revealed a de novo loss-of-function mutation in MYT1L: c g>a (NM_ ). Patient 15 This boy was born at term after a normal pregnancy with birth parameters within normal range, exact figures unknown. He had a delayed development, especially in speech and language development. His motor development was mildly delayed (independent sitting at the age of 13 months and walking at the age of 18 months). His IQ was around 50, tested at the age of 9 years. At that age also autism spectrum disorder was noted. Examination at the age of 13 years and 6 months showed that his height was 162 cm (50 th centile), his weight was 63.6 kg (90 th centile) and his occipital frontal circumference 54 cm (25 th centile). He had a brachycephaly and his face showed mild dysmorphisms: upward slant, narrow eyes (Figure 1i). DNA analysis of Fragile X and a metabolic screen revealed no abnormalities. By a largescale re-sequencing study of candidate intellectual disability genes, a de novo MYT1L mutation was identified (NM_ : c.1917t>g ; p.(tyr639*)). Family 1: Patients 16, 17, 18, 19 Patient 16 has moderate intellectual disability, speech impairment/delay and epilepsy. He also has minor craniofacial abnormalities such as an ogival shaped palate, open mouth, malposition of teeth, microretrognathia, short philtrum and mild trigonocephaly. Furthermore, he has cryptorchidism, mild scoliosis and pedes plani. There is tendon areflexia, but the muscle strength is normal. At birth, his length was 52 cm and his weight was grams. At adult age, he is 150 cm (<3 rd centile) and obese, his head circumference is 53 cm (3 rd centile). He is less social.

11 Array CGH analysis revealed a 2p25.3p25.1 deletion (RP11-327H5->RP11-16D24)x1 (6.07 Mb). FISH analysis of both parents indicates that the father carries the deletion too. His mother is normal for this locus. The father (patient 19) has mild intellectual disability and suffered from epilepsy until puberty. One sister (patient 17) and one brother (patient 18) of patient 16 also carry the same deletion. Patient 17 has moderate intellectual disability, speech impairment, nasal speech and the most severe teeth abnormalities of the three children. She is less social. Her birth weight was grams and length was 53 cm. Her head circumference was 35 cm. The three affected children have a short stature, a small forehead, almond shaped eyes and short upper lip. The neurologic screen was normal. They have two healthy brothers who do not carry the deletion. Family 2: Patients 20, 21, 22 In this family the father (patient 20), his son (patient 21) and his daughter (patient 22) have a 377 kb interstitial duplication in the 2p25.3 region detected by array comparative genomic hybridization and confirmed by quantitative PCR (arr 2p25.3(2,169,253-2,546,048)x1). The phenotype includes (Figures 1j-l): slight facial features including bulbous nasal tip, wide mouth, overfolded helix, strabismus, moderate intellectual disability with speech impediment, hypotonia, hyperactivity, mood disorder with aggressive behavior, neonatal feeding difficulties followed by a tendency to hyperphagia with overweight and a prominent abdomen with thick panniculus adiposus.