Facio-auriculo-vertebral sequence in association with DiGeorge sequence, Rokitansky sequence, and Dandy-Walker malformation: case report

A Possible case of Facio-Auriculo-Vertebral sequence (FAVs) in an adult female from medieval Iceland (13th-16th Century)

OBJECTIVE

This paper presents a possible case of Facio-Auriculo-Vertebral sequence (FAVs) in an adult female from Haffjarðarey, Western Iceland (1200-1563 CE) and a brief review of associated terminology.

MATERIALS

The skeletal remains of a single adult female (HFE-A-34, 18-24 years old), excavated in 1945 by the National Museum of Iceland.

METHODS

We carried out macroscopic examination of the cranium and mandible in 2017.

RESULTS

Right side unilateral asymmetric craniofacial dysplasia was identified on the cranium and mandible of HFE-A-34.

CONCLUSIONS

This individual presents with anomalous craniofacial asymmetry consistent with a clinical diagnosis of FAVs.

SIGNIFICANCE

This paper offers a visually distinct case of an under-represented and under-documented congenital condition for future identification within paleopathology.

LIMITATIONS

Infra-cranial skeletal manifestations of FAVs would strengthen this possible diagnosis, but at this time it is not possible to definitively link the cranium and mandible of HFE-A-34 to any of the infra-cranial remains excavated from Haffjarðarey.

SUGGESTIONS FOR FURTHER RESEARCH

In addition to further clarifying the variable nature of FAVs in archaeological remains, a detailed discussion of disability and the perception of disabled individuals within the medieval North Atlantic is necessary in order to understand the lived experiences of affected individuals.

Etiologies of uterine malformations

Ranging from aplastic uterus (including Mayer-Rokitansky-Kuster-Hauser syndrome) to incomplete septate uterus, uterine malformations as a group are relatively frequent in the general population. Specific causes remain largely unknown. Although most occurrences ostensibly seem sporadic, familial recurrences have been observed, which strongly implicate genetic factors. Through the study of animal models, human syndromes, and structural chromosomal variation, several candidate genes have been proposed and subsequently tested with targeted methods in series of individuals with isolated, non-isolated, or syndromic uterine malformations. To date, a few genes have garnered strong evidence of causality, mainly in syndromic presentations (HNF1B, WNT4, WNT7A, HOXA13). Sequencing of candidate genes in series of individuals with isolated uterine abnormalities has been able to suggest an association for several genes, but confirmation of a strong causative effect is still lacking for the majority of them. We review the current state of knowledge about the developmental origins of uterine malformations, with a focus on the genetic variants that have been implicated or associated with these conditions in humans, and we discuss potential reasons for the high rate of negative results. The evidence for various environmental and epigenetic factors is also reviewed. © 2016 Wiley Periodicals, Inc.

Utero-vaginal aplasia (Mayer-Rokitansky-Küster-Hauser syndrome) associated with deletions in known DiGeorge or DiGeorge-like loci

Background

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is characterized by congenital aplasia of the uterus and the upper part of the vagina in women showing normal development of secondary sexual characteristics and a normal 46, XX karyotype. The uterovaginal aplasia is either isolated (type I) or more frequently associated with other malformations (type II or Müllerian Renal Cervico-thoracic Somite (MURCS) association), some of which belong to the malformation spectrum of DiGeorge phenotype (DGS). Its etiology remains poorly understood. Thus the phenotypic manifestations of MRKH and DGS overlap suggesting a possible genetic link. This would potentially have clinical consequences.

Methods

We searched DiGeorge critical chromosomal regions for chromosomal anomalies in a cohort of 57 subjects with uterovaginal aplasia (55 women and 2 aborted fetuses). For this candidate locus approach, we used a multiplex ligation-dependent probe amplification (MLPA) assay based on a kit designed for investigation of the chromosomal regions known to be involved in DGS.

The deletions detected were validated by Duplex PCR/liquid chromatography (DP/LC) and/or array-CGH analysis.

Results

We found deletions in four probands within the four chromosomal loci 4q34-qter, 8p23.1, 10p14 and 22q11.2 implicated in almost all cases of DGS syndrome.

Conclusion

Uterovaginal aplasia appears to be an additional feature of the broad spectrum of the DGS phenotype. The DiGeorge critical chromosomal regions may be candidate loci for a subset of MRKH syndrome (MURCS association) individuals. However, the genes mapping at the sites of these deletions involved in uterovaginal anomalies remain to be determined. These findings have consequences for clinical investigations, the care of patients and their relatives, and genetic counseling.

Recurrent aberrations identified by array-CGH in patients with Mayer-Rokitansky-Küster-Hauser syndrome

OBJECTIVE

To identify genetic causes of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome.

DESIGN

Prospective laboratory study.

SETTING

University hospital.

PATIENT(S)

Fifty-six patients with MRKH syndrome.

INTERVENTION(S)

Identification of microdeletions and -duplications in a group of 48 MRKH patients by array-CGH. Results obtained by array-CGH were confirmed by RT-qPCR. Sequential analysis of two candidate genes LHX1 and HNF1B in a group of 56 MRKH patients.

MAIN OUTCOME MEASURE(S)

Identification of chromosomal regions and genes (recurrent and private) associated with MRKH syndrome.

RESULT(S)

We could delineate three definitively relevant regions (1q21.1, 17q12, and 22q11.21) and suggest that LHX1 und HNF1B are candidate genes for MRKH syndrome, because we identified recurrent deletions affecting these genes and a possible causative missense mutation in LHX1.

CONCLUSION(S)

Our findings suggest that different chromosomal regions are associated with MRKH syndrome.

[The Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome: clinical description and genetics]

The Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is characterized by congenital aplasia of the uterus and the upper part (two-third) of the vagina. It may be isolated (type I) or associated with other malformations (type II or MURCS association). These latter involve the upper urinary tract, the skeleton and, to a lesser extent, the otologic sphere or the heart. The incidence of MRKH syndrome has been estimated as 1 in 4500 women. The prime feature is a primary amenorrhea in women presenting otherwise with normal development of secondary sexual characteristics and normal external genitalia. However, the vagina is reduced to a vaginal dimple with variable depth. The ovaries are normal and functional as well as the endocrine status. Karyotype is 46,XX, with no visible chromosome modification. The phenotypic manifestations of MRKH syndrome overlap with various other syndromes or malformations and thus require accurate delineation as well as differential diagnosis. For a long time, the syndrome has been considered as a sporadic anomaly, but increasing familial cases now support the hypothesis of a genetic cause currently under investigation. The syndrome appears to be transmitted as an autosomal dominant trait with incomplete penetrance and variable expressivity.

Bilateral macrostomia associated with aqueductal stenosis and glial heterotopias

We report on an Italian boy, born to normal and nonconsanguineous parents with a prenatal diagnosis of ventriculomegaly and subependymal glial heterotopias. At birth bilateral macrostomia was diagnosed without other evident facial anomalies. Magnetic resonance imaging (MRI) showed triventricular hydrocephalus and aqueductal stenosis and confirmed the nodules of glial heterotopia. The bilateral macrostomia was surgically corrected with the vermilion square flap method and W-plasty technique and follow up MRI at 6 months showed mild increase of ventricular dilatation without signs of active hydrocephalus. The association between macrostomia and hydrocephalus has been reported only in rare cases of complex malformative syndromes but never with isolated macrostomia.

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome

The Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is characterized by congenital aplasia of the uterus and the upper part (2/3) of the vagina in women showing normal development of secondary sexual characteristics and a normal 46, XX karyotype. It affects at least 1 out of 4500 women. MRKH may be isolated (type I) but it is more frequently associated with renal, vertebral, and, to a lesser extent, auditory and cardiac defects (MRKH type II or MURCS association). The first sign of MRKH syndrome is a primary amenorrhea in young women presenting otherwise with normal development of secondary sexual characteristics and normal external genitalia, with normal and functional ovaries, and karyotype 46, XX without visible chromosomal anomaly. The phenotypic manifestations of MRKH syndrome overlap with various other syndromes or associations and thus require accurate delineation. For a long time the syndrome has been considered as a sporadic anomaly, but increasing number of familial cases now support the hypothesis of a genetic cause. In familial cases, the syndrome appears to be transmitted as an autosomal dominant trait with incomplete penetrance and variable expressivity. This suggests the involvement of either mutations in a major developmental gene or a limited chromosomal imbalance. However, the etiology of MRKH syndrome still remains unclear. Treatment of vaginal aplasia, which consists in creation of a neovagina, can be offered to allow sexual intercourse. As psychological distress is very important in young women with MRKH, it is essential for the patients and their families to attend counseling before and throughout treatment.

The clinical, immunological, and molecular spectrum of chromosome 22q11.2 deletion syndrome and DiGeorge syndrome

PURPOSE OF REVIEW

New findings regarding the clinical manifestations and care of patients with DiGeorge syndrome or chromosome 22q11.2 deletion syndrome will be reviewed. Immunologists and primary care providers often are in a position to coordinate the complex care needs of these patients and an awareness of the clinical features is essential.

RECENT FINDINGS

DiGeorge syndrome typically occurs in association with a hemizygous deletion of chromosome 22q11.2. Approximately 5-10% of patients with the clinical entity of DiGeorge syndrome do not have the deletion. Recent evidence indicates that the T cell compartment in both patients with the deletion and patients with clinical DiGeorge syndrome without the deletion is less robust than is often indicated by standard T cell enumeration.

SUMMARY

This past year has seen a dramatic increase in our understanding of the clinical features of patients with the deletion. Advances in our understanding of the immunodeficiency have been particularly exciting and clinicians should be aware of the characteristics of the immunodeficiency and its changes with age.