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Xp11.3 microdeletion causing Norrie disease and X-linked Kabuki syndrome. Am J Ophthalmol Case Rep 2023; 29:101798. [PMID: 36703904 PMCID: PMC9871737 DOI: 10.1016/j.ajoc.2023.101798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 01/03/2023] [Accepted: 01/12/2023] [Indexed: 01/20/2023] Open
Abstract
Purpose To describe a novel case of Norrie disease and X-linked Kabuki syndrome caused by a microdeletion encompassing multiple genes on the X chromosome. Observations A 3-day-old boy born at full term had bilateral retrolental fibrovascular plaques. Surgery with lensectomy and vitrectomy revealed bilateral, closed funnel retinal detachments consistent with a clinical diagnosis of Norrie disease. In addition, the baby had congenital heart defects, hearing loss, and dysmorphic facies. His mother carried a clinical diagnosis of Kabuki syndrome. Genetic testing of the baby revealed an Xp11.3 microdeletion that included the NDP and KDM6A genes, confirming the baby had both Norrie disease and X-linked Kabuki syndrome. The mother was found via ultrawide-field fluorescein angiography to have asymptomatic peripheral retinal vascular anomalies, consistent with NDP-associated familial exudative vitreoretinopathy (FEVR). Conclusions and importance This is the first reported case of Norrie disease together with X-linked Kabuki syndrome. Contiguous gene deletions may explain some of the variable systemic involvement in Norrie disease.
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Rodríguez-Muñoz A, García-García G, Menor F, Millán JM, Tomás-Vila M, Jaijo T. The importance of biochemical and genetic findings in the diagnosis of atypical Norrie disease. Clin Chem Lab Med 2019; 56:229-235. [PMID: 28742514 DOI: 10.1515/cclm-2017-0226] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 06/25/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Norrie disease (ND) is a rare X-linked disorder characterized by bilateral congenital blindness. ND is caused by a mutation in the Norrie disease pseudoglioma (NDP) gene, which encodes a 133-amino acid protein called norrin. Intragenic deletions including NDP and adjacent genes have been identified in ND patients with a more severe neurologic phenotype. We report the biochemical, molecular, clinical and radiological features of two unrelated affected males with a deletion including NDP and MAO genes. METHODS Biochemical and genetic analyses were performed to understand the atypical phenotype and radiological findings. Biogenic amines in cerebrospinal fluid (CSF) were measured by high-performance liquid chromatography. The coding exons of NDP gene were amplified by polymerase chain reaction. Multiplex ligation-dependent probe amplification and chromosomal microarray were carried out on both affected males. Computed tomography and magnetic resonance imaging were performed on the two patients. RESULTS In one patient, the serotonin and catecholamine metabolite levels in CSF were virtually undetectable. In both patients, genetic studies revealed microdeletions in the Xp11.3 region, involving the NDP, MAOA and MAOB genes. Radiological examination demonstrated brain and cerebellar atrophy. CONCLUSIONS We suggest that alterations caused by MAO deficit may remain during the first years of life. Clinical phenotype, biochemical findings and neuroimaging can guide the genetic study in patients with atypical ND and help us to a better understanding of this disease.
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Affiliation(s)
- Ana Rodríguez-Muñoz
- Grupo de Investigación en Biomedicina Molecular, Celular y Genómica, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Gema García-García
- Grupo de Investigación en Biomedicina Molecular, Celular y Genómica, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Valencia, Spain
| | - Francisco Menor
- Radiología Infantil, Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | - José M Millán
- Grupo de Investigación en Biomedicina Molecular, Celular y Genómica, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Valencia, Spain
| | - Miguel Tomás-Vila
- Neuropediatría, Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | - Teresa Jaijo
- Grupo de Investigación en Biomedicina Molecular, Celular y Genómica, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Valencia, Spain.,Unidad de Genética y Diagnóstico Prenatal, Hospital Universitari i Politecnic La Fe, Valencia, Spain
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Cação G, Garrido C, Miranda V, Pinto-Basto J, Chaves J, Chorão R. Refractory epilepsy in Norrie disease. Neurol Sci 2018; 39:1631-1633. [DOI: 10.1007/s10072-018-3428-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 04/23/2018] [Indexed: 10/17/2022]
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Jia B, Huang L, Chen Y, Liu S, Chen C, Xiong K, Song L, Zhou Y, Yang X, Zhong M. A novel contiguous deletion involving NDP, MAOB and EFHC2 gene in a patient with familial Norrie disease: bilateral blindness and leucocoria without other deficits. J Genet 2018; 96:1015-1020. [PMID: 29321361 DOI: 10.1007/s12041-017-0869-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Contiguous microdeletions of the Norrie disease pseudoglioma (NDP) region on chromosome Xp11.3 have been widely confirmed as contributing to the typical clinical features of Norrie disease (ND). However, the precise relation between genotype and phenotype could vary. The contiguous deletion of NDP and its neighbouring genes, MAOA/B and EFHC2, reportedly leads to syndromic clinical features such as microcephaly, intellectual disability, and epilepsy. Herewe report a novel contiguous microdeletion of the NDP region containing the MAOB and EFHC2 genes,which causes eye defects but no cognitive disability.We detected a deletion of 494.6 kb atXp11.3 in both the proband and carrier mother. This deletionwas then used as the molecular marker in prenatal diagnosis for two subsequent pregnancies. The deletion was absent in one of the foetuses, who remain without any abnormalities at 2 years of age. The proband shows the typical ocular clinical features of ND including bilateral retinal detachment, microphthalmia, atrophic irides, corneal opacification, and cataracts, but no symptoms of microcephaly, intellectual disability, and epilepsy. This familial study demonstrates that a deficiency in one of two MAO genes may not lead to psychomotor delay, and deletion of EFHC2 may not cause epilepsy. Our observations provide new information on the genotype-phenotype relations of MAOA/B and EFHC2 genes involved in the contiguous deletions of ND.
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Affiliation(s)
- Bei Jia
- The Center for Prenatal and Hereditary DiseaseDiagnosis,Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, People's Republic of China.
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Okumura A, Arai E, Kitamura Y, Abe S, Ikeno M, Fujimaki T, Yamamoto T, Shimizu T. Epilepsy phenotypes in siblings with Norrie disease. Brain Dev 2015; 37:978-82. [PMID: 25944760 DOI: 10.1016/j.braindev.2015.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 04/01/2015] [Accepted: 04/03/2015] [Indexed: 10/23/2022]
Abstract
Norrie disease is an X-linked recessive disorder that is characterized by congenital blindness. Although epileptic seizures are observed in some patients with Norrie disease, little is known about this phenomenon. Here, we report the manifestation of epilepsy in siblings with Norrie disease to increase our knowledge of epilepsy in this condition. Three brothers with congenital blindness were diagnosed with Norrie disease after genetic analyses indicated the deletion of exon 2 of the NDP gene. The eldest brother had suffered from epileptic seizures since the age of 11years, and his seizures were resistant to antiepileptic drugs. Although the second brother had no epileptic seizures, the youngest sibling had experiences epileptic seizures since the age of 8years. His seizures were controlled using lamotrigine and levetiracetam. An electroencephalography (EEG) revealed epileptiform discharges in the occipital areas in all three brothers. A study of these patients will increase our knowledge of epilepsy in patients with Norrie disease.
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Affiliation(s)
- Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, Japan; Department of Pediatrics, Juntendo University, Faculty of Medicine, Japan.
| | - Eisuke Arai
- Department of Ophthalmology, Juntendo University, Faculty of Medicine, Japan
| | - Yuri Kitamura
- Department of Pediatrics, Juntendo University, Faculty of Medicine, Japan
| | - Shinpei Abe
- Department of Pediatrics, Juntendo University, Faculty of Medicine, Japan
| | - Mitsuru Ikeno
- Department of Pediatrics, Juntendo University, Faculty of Medicine, Japan
| | - Takuro Fujimaki
- Department of Ophthalmology, Juntendo University, Faculty of Medicine, Japan
| | - Toshiyuki Yamamoto
- Tokyo Women's Medical University, Institute for Integrated Medical Sciences, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Juntendo University, Faculty of Medicine, Japan
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Saito M, Yamagata T, Matsumoto A, Shiba Y, Nagashima M, Taniguchi S, Jimbo E, Momoi MY. MAOA/B deletion syndrome in male siblings with severe developmental delay and sudden loss of muscle tonus. Brain Dev 2014; 36:64-9. [PMID: 23414621 DOI: 10.1016/j.braindev.2013.01.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 12/25/2012] [Accepted: 01/12/2013] [Indexed: 12/01/2022]
Abstract
Deletion of the monoamine oxidase (MAO)-A and MAO-B was detected in two male siblings and in their mother. The approximately 800-kb deletion, extending from about 43.0MB to 43.8MB, was detected by array comparative genomic hybridization analysis. The MAOA and MAOB genes were included in the deletion, but the adjacent Norrie disease gene, NDP, was not deleted. The boys had short stature, hypotonia, severe developmental delays, episodes of sudden loss of muscle tone, exiting behavior, lip-smacking and autistic features. The serotonin levels in their cerebrospinal fluid were extremely elevated. Another set of siblings with this deletion was reported previously. We propose recognition of MAOA/B deletion syndrome as a distinct disorder.
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Affiliation(s)
- Mari Saito
- Department of Pediatrics, Jichi Medical Univiversity, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
| | - Takanori Yamagata
- Department of Pediatrics, Jichi Medical Univiversity, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan.
| | - Ayumi Matsumoto
- Department of Pediatrics, Jichi Medical Univiversity, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
| | - Yusuke Shiba
- Department of Pediatrics, Jichi Medical Univiversity, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
| | - Masako Nagashima
- Department of Pediatrics, Jichi Medical Univiversity, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
| | - Shuhei Taniguchi
- Department of Pediatrics, Jichi Medical Univiversity, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
| | - Eriko Jimbo
- Department of Pediatrics, Jichi Medical Univiversity, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
| | - Mariko Y Momoi
- Department of Pediatrics, Jichi Medical Univiversity, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
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Wang CC, Billett E, Borchert A, Kuhn H, Ufer C. Monoamine oxidases in development. Cell Mol Life Sci 2013; 70:599-630. [PMID: 22782111 PMCID: PMC11113580 DOI: 10.1007/s00018-012-1065-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 06/13/2012] [Accepted: 06/19/2012] [Indexed: 12/29/2022]
Abstract
Monoamine oxidases (MAOs) are flavoproteins of the outer mitochondrial membrane that catalyze the oxidative deamination of biogenic and xenobiotic amines. In mammals there are two isoforms (MAO-A and MAO-B) that can be distinguished on the basis of their substrate specificity and their sensitivity towards specific inhibitors. Both isoforms are expressed in most tissues, but their expression in the central nervous system and their ability to metabolize monoaminergic neurotransmitters have focused MAO research on the functionality of the mature brain. MAO activities have been related to neurodegenerative diseases as well as to neurological and psychiatric disorders. More recently evidence has been accumulating indicating that MAO isoforms are expressed not only in adult mammals, but also before birth, and that defective MAO expression induces developmental abnormalities in particular of the brain. This review is aimed at summarizing and critically evaluating the new findings on the developmental functions of MAO isoforms during embryogenesis.
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Affiliation(s)
- Chi Chiu Wang
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong
- Li Ka Shing Institute of Health Sciences, Shatin, Hong Kong
- School of Biomedical Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Ellen Billett
- School of Science and Technology, Nottingham Trent University, Clifton Lane, Nottingham, NG11 8NS UK
| | - Astrid Borchert
- Institute of Biochemistry, University Medicine Berlin-Charité, Oudenarder Str. 16, 13347 Berlin, Germany
| | - Hartmut Kuhn
- Institute of Biochemistry, University Medicine Berlin-Charité, Oudenarder Str. 16, 13347 Berlin, Germany
| | - Christoph Ufer
- Institute of Biochemistry, University Medicine Berlin-Charité, Oudenarder Str. 16, 13347 Berlin, Germany
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Smith SE, Mullen TE, Graham D, Sims KB, Rehm HL. Norrie disease: Extraocular clinical manifestations in 56 patients. Am J Med Genet A 2012; 158A:1909-17. [DOI: 10.1002/ajmg.a.35469] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 04/16/2012] [Indexed: 11/06/2022]
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Wang CC, Borchert A, Ugun-Klusek A, Tang LY, Lui WT, Chu CY, Billett E, Kuhn H, Ufer C. Monoamine oxidase a expression is vital for embryonic brain development by modulating developmental apoptosis. J Biol Chem 2011; 286:28322-30. [PMID: 21697081 DOI: 10.1074/jbc.m111.241422] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Monoamine oxidases (MAO-A, MAO-B) metabolize biogenic amines and have been implicated in neuronal apoptosis. Although apoptosis is an important process in embryo development, the role of MAO isoenzymes has not been investigated in detail. We found that expression of MAO-A and MAO-B can be detected early on during embryo development. Expression levels remained constant until around midgestation but then dropped to almost undetectable levels toward birth. Similar expression kinetics were observed in the brain. Isoform-specific expression silencing of MAO-A mediated by siRNA during in vitro embryogenesis induced developmental defects, as indicated by a reduction of the crown rump length and impaired cerebral development. These alterations were paralleled by elevated serotonin levels. Similar abnormalities were observed when embryos were cultured in the presence of the MAO-A inhibitor clorgyline or when the transcriptional inhibitor of MAO-A expression R1 was overexpressed. In contrast, no such alterations were detected when expression of MAO-B was knocked down. To explore the underlying mechanisms for the developmental abnormalities in MAO-A knockdown embryos, we quantified the degree of developmental apoptosis in the developing brain. MAO-A knockdown reduced the number of apoptotic cells in the neuroepithelium, which coincided with impaired activation of caspases 3 and 9. Moreover, we observed reduced cyclin D1 levels as an indicator of impaired cell proliferation in MAO-A knockdown embryos. This data highlights MAO-A as a vital regulator of embryonic brain development.
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Affiliation(s)
- Chi Chiu Wang
- Institute of Biochemistry, University Medicine Berlin-Charité, Oudenarder Strasse 16, 13347 Berlin, Germany
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Rodriguez-Revenga L, Madrigal I, Alkhalidi LS, Armengol L, González E, Badenas C, Estivill X, Milà M. Contiguous deletion of theNDP,MAOA,MAOB, andEFHC2 genes in a patient with Norrie disease, severe psychomotor retardation and myoclonic epilepsy. Am J Med Genet A 2007; 143A:916-20. [PMID: 17431911 DOI: 10.1002/ajmg.a.31521] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Norrie disease (ND) is an X-linked disorder, inherited as a recessive trait that, therefore, mostly affects males. The gene responsible for ND, called NDP, maps to the short arm of chromosome X (Xp11.4-p11.3). We report here an atypical case of ND, consisting of a patient harboring a large submicroscopic deletion affecting not only the NDP gene but also the MAOA, MAOB, and EFHC2 genes. Microarray comparative genomic hybridization (CGH) analysis showed that 11 consecutive bacterial artificial chromosome (BAC) clones, mapping around the NDP gene, were deleted. These clones span a region of about 1 Mb on Xp11.3. The deletion was ascertained by fluorescent in situ hybridization (FISH) analysis with different BAC clones located within the region. Clinical features of the proband include bilateral retinal detachment, microcephaly, severe psychomotor retardation without verbal language skills acquired, and epilepsy. The identification and molecular characterization of this case reinforces the idea of a new contiguous gene syndrome that would explain the complex phenotype shared by atypical ND patients.
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Affiliation(s)
- L Rodriguez-Revenga
- Biochemistry and Molecular Genetics Department, Hospital Clínic, Barcelona, Spain
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Dickinson JL, Sale MM, Passmore A, FitzGerald LM, Wheatley CM, Burdon KP, Craig JE, Tengtrisorn S, Carden SM, Maclean H, Mackey DA. Mutations in the NDP gene: contribution to Norrie disease, familial exudative vitreoretinopathy and retinopathy of prematurity. Clin Exp Ophthalmol 2006; 34:682-8. [PMID: 16970763 DOI: 10.1111/j.1442-9071.2006.01314.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND To examine the contribution of mutations within the Norrie disease (NDP) gene to the clinically similar retinal diseases Norrie disease, X-linked familial exudative vitreoretinopathy (FEVR), Coat's disease and retinopathy of prematurity (ROP). METHODS A dataset comprising 13 Norrie-FEVR, one Coat's disease, 31 ROP patients and 90 ex-premature babies of <32 weeks' gestation underwent an ophthalmologic examination and were screened for mutations within the NDP gene by direct DNA sequencing, denaturing high-performance liquid chromatography or gel electrophoresis. Controls were only screened using denaturing high-performance liquid chromatography and gel electrophoresis. Confirmation of mutations identified was obtained by DNA sequencing. RESULTS Evidence for two novel mutations in the NDP gene was presented: Leu103Val in one FEVR patient and His43Arg in monozygotic twin Norrie disease patients. Furthermore, a previously described 14-bp deletion located in the 5' unstranslated region of the NDP gene was detected in three cases of regressed ROP. A second heterozygotic 14-bp deletion was detected in an unaffected ex-premature girl. Only two of the 13 Norrie-FEVR index cases had the full features of Norrie disease with deafness and mental retardation. CONCLUSION Two novel mutations within the coding region of the NDP gene were found, one associated with a severe disease phenotypes of Norrie disease and the other with FEVR. A deletion within the non-coding region was associated with only mild-regressed ROP, despite the presence of low birthweight, prematurity and exposure to oxygen. In full-term children with retinal detachment only 15% appear to have the full features of Norrie disease and this is important for counselling parents on the possible long-term outcome.
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Good CD, Lawrence K, Thomas NS, Price CJ, Ashburner J, Friston KJ, Frackowiak RSJ, Oreland L, Skuse DH. Dosage-sensitive X-linked locus influences the development of amygdala and orbitofrontal cortex, and fear recognition in humans. Brain 2003; 126:2431-46. [PMID: 12958079 DOI: 10.1093/brain/awg242] [Citation(s) in RCA: 150] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The amygdala, which plays a critical role in emotional learning and social cognition, is structurally and functionally sexually dimorphic in humans. We used magnetic neuroimaging and molecular genetic analyses with healthy subjects and patients possessing X-chromosome anomalies to find dosage-sensitive genes that might influence amygdala development. If such X-linked genes lacked a homologue on the Y-chromosome they would be expressed in one copy in normal 46,XY males and two copies in normal 46,XX females. We showed by means of magnetic neuroimaging that 46,XY males possess significantly increased amygdala volumes relative to normal 46,XX females. However, females with Turner syndrome (45,X) have even larger amygdalae than 46,XY males. This finding implies that haploinsufficiency for one or more X-linked genes influences amygdala development irrespective of a direct or indirect (endocrinological) mechanism involving the Y-chromosome. 45,X females also have increased grey matter volume in the orbitofrontal cortex bilaterally, close to a region implicated in emotional learning. They are as poor as patients with bilateral amygdalectomies in the recognition of fear from facial expressions. We attempted to localize the gene(s) responsible for these deficits in X-monosomy by means of a deletion mapping strategy. We studied female patients possessing structural X-anomalies of the short arm. A genetic locus (no greater than 4.96 Mb in size) at Xp11.3 appears to play a key role in amygdala and orbitofrontal structural and (by implication) functional development. Females with partial X-chromosome deletions, in whom this critical locus is deleted, have normal intelligence. Their fear recognition is as poor as that of 45,X females and their amygdalae are correspondingly enlarged. This 4.96 Mb region contains, among others, the genes for monoamine oxidase A (MAOA) and B (MAOB), which are involved in the oxidative deamination of several neurotransmitters, including dopamine and serotonin. Abnormal activity of these neurotransmitters has been implicated in the aetiology of several neurodevelopmental disorders in which social cognitive deficits are prominent. These associated deficits include a specific lack of fear recognition from facial expressions. We show that the thrombocytic activity of MAOB is proportionate to the number of X-chromosomes, and hypothesize that haploinsufficiency of this enzyme in 45,X females predisposes to their deficits in social cognition.
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Affiliation(s)
- Catriona D Good
- Wellcome Department of Imaging Neuroscience, Institute of Neurology, Institute of Child Health, London, UK
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