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Frey T, Ivanovski I, Bahr A, Zweier M, Laube J, Luchsinger I, Steindl K, Rauch A. A very mild phenotype in six individuals of a three-generation family with the novel HRAS variant c.176C > G p.(Ala59Gly): Emergence of a new HRAS-related RASopathy distinct from Costello syndrome. Am J Med Genet A 2023; 191:2074-2082. [PMID: 37194190 DOI: 10.1002/ajmg.a.63240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/26/2023] [Accepted: 04/29/2023] [Indexed: 05/18/2023]
Abstract
Costello syndrome is a clinically recognizable, severe neurodevelopmental disorder caused by heterozygous activating variants in HRAS. The vast majority of affected patients share recurring variants affecting HRAS codons 12 and 13 and a relatively uniform phenotype. Here, we report the unique and attenuated phenotype of six individuals of an extended family affected by the HRAS variant c.176C>T p.(Ala59Gly), which, to our knowledge, has never been reported as a germline variant in patients so far. HRAS Alanine 59 has been previously functionally investigated as an oncogenic hotspot and the p.Ala59Gly substitution was shown to impair intrinsic GTP hydrolysis. All six individuals we report share a phenotype of ectodermal anomalies and mild features suggestive of a RASopathy, reminiscent of patients with Noonan syndrome-like disorder with loose anagen hair. All six are of normal intelligence, none have a history of failure to thrive or malignancy, and they have no known cardiac or neurologic pathologies. Our report adds to the previous reports of patients with rare variants affecting amino acids located in the SWITCH II/G3 region of HRAS and suggests a consistent, attenuated phenotype distinct from classical Costello syndrome. We propose the definition of a new distinct HRAS-related RASopathy for patients carrying HRAS variants affecting codons 58, 59, 60.
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Affiliation(s)
- Tanja Frey
- Institute of Medical Genetics, University of Zurich, Zurich, Switzerland
| | - Ivan Ivanovski
- Institute of Medical Genetics, University of Zurich, Zurich, Switzerland
| | - Angela Bahr
- Institute of Medical Genetics, University of Zurich, Zurich, Switzerland
| | - Markus Zweier
- Institute of Medical Genetics, University of Zurich, Zurich, Switzerland
| | - Julia Laube
- Institute of Medical Genetics, University of Zurich, Zurich, Switzerland
| | - Isabelle Luchsinger
- Department of Dermatology, Pediatric Skin Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Katharina Steindl
- Institute of Medical Genetics, University of Zurich, Zurich, Switzerland
| | - Anita Rauch
- Institute of Medical Genetics, University of Zurich, Zurich, Switzerland
- University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich Research Priority Program ITINERARE: Innovative Therapies in Rare Diseases, Zurich, Switzerland
- University of Zurich Research Priority Program AdaBD: Adaptive Brain Circuits in Development and Learning, Zurich, Switzerland
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Lindsey-Temple S, Edwards M, Rickassel V, Nauth T, Rosenberger G. A novel HRAS c.466C>T p.(Phe156Leu) variant in two patients with attenuated features of Costello syndrome. Eur J Hum Genet 2022; 30:1088-1093. [PMID: 35764878 PMCID: PMC9437031 DOI: 10.1038/s41431-022-01139-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/19/2022] [Accepted: 06/13/2022] [Indexed: 12/29/2022] Open
Abstract
Costello syndrome (CS) is caused by heterozygous HRAS germline mutations. Most patients share the HRAS variant p.Gly12Ser that is associated with a typical, homogeneous phenotype. Rarer pathogenic HRAS variants (e.g., p.Thr56Ile) were identified in individuals with attenuated CS phenotypes. The obvious phenotypical variability reflects different dysfunctional consequences of distinct HRAS variants. We report on two boys with the novel de novo HRAS variant c.466 C > T p.(Phe156Leu). Both had severe feeding difficulties, airway obstruction and developmental delay, which are typical findings in CS. They showed subtle facial and dermatologic features consistent with attenuated CS. They significantly differed in their musculoskeletal, cardiovascular and endocrinologic manifestations underscoring the clinical variability of individuals with identical, in particular rarer pathogenic HRAS variants. Functional studies revealed enhanced effector-binding, increased downstream signaling activation and impaired growth factor-induced signaling dynamics in cells expressing HRASPhe156Leu. Our data further illustrate the molecular and phenotypic variability of CS.
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Affiliation(s)
- Suzanna Lindsey-Temple
- Department of Clinical Genetics, Liverpool Hospital, Sydney, NSW, Australia.,School of Women's and Children's Health, Faculty of Medicine and Health, UNSW, Sydney, NSW, Australia
| | - Matt Edwards
- Paediatrics, School of Medicine, Western Sydney University, Hunter Genetics, Newcastle, NSW, Australia
| | - Verena Rickassel
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Theresa Nauth
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Georg Rosenberger
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Leoni C, Viscogliosi G, Tartaglia M, Aoki Y, Zampino G. Multidisciplinary Management of Costello Syndrome: Current Perspectives. J Multidiscip Healthc 2022; 15:1277-1296. [PMID: 35677617 PMCID: PMC9169840 DOI: 10.2147/jmdh.s291757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 05/10/2022] [Indexed: 01/09/2023] Open
Abstract
Costello syndrome (CS) is a rare neurodevelopmental disorder caused by germline mutations in HRAS. It belongs among the RASopathies, a group of syndromes characterized by alterations in components of the RAS/MAPK signaling pathway and sharing overlapping phenotypes. Its typical features include a distinctive facial appearance, growth delay, intellectual disability, ectodermal, cardiac, and musculoskeletal abnormalities, and cancer predisposition. Due to the several comorbidities having a strong impact on the quality of life, a multidisciplinary team is essential in the management of such a condition from infancy to adult age, to promptly address any detected issue and to develop appropriate personalized follow-up protocols and treatment strategies. With the present paper we aim to highlight the core and ancillary medical disciplines involved in managing the health challenges characterizing CS from pediatric to adult age, according to literature and to our large clinical experience.
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Affiliation(s)
- Chiara Leoni
- Center for Rare Diseases and Birth Defects, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Germana Viscogliosi
- Center for Rare Diseases and Birth Defects, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Marco Tartaglia
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Yoko Aoki
- Department of Medical Genetics, Tohoku University School of Medicine, Sendai, Japan
| | - Giuseppe Zampino
- Center for Rare Diseases and Birth Defects, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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Ríos-González BE, Rodríguez-Ortiz JF, Castro-Martínez AG, Magaña-Torres MT, Barros-Núñez P. Clinical and molecular characterization of Costello syndrome in unrelated Mexican patients. Clin Dysmorphol 2022; 31:55-58. [PMID: 34845155 DOI: 10.1097/mcd.0000000000000405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study intends to describe for the first time a cohort of Mexican patients with Costello syndrome. The five exons of the HRAS gene were amplified in DNA samples from 13 patients with a clinical suspicion of Costello syndrome. PCR products were sequenced using the Ready Reaction Big Dye Terminator v.3.0 Kit and an ABI PRISM 310 sequencer. Only five patients (38%) showed causal variant in codon 12 of the HRAS gene (four with the p.Gly12Ser and one with the p.Gly12Ala variant). Three patients showed silent polymorphic variants (p.His27His and p.Leu159Leu). Clinical features in patients carrying the causal variant were variable. The alternative diagnosis of cardio-facio-cutaneous syndrome was considered in patients who did not have a causative variant in HRAS.
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Affiliation(s)
| | | | - Anna G Castro-Martínez
- Genetic Department, Institute of Biological Sciences, Universidad Autónoma de Guadalajara
| | | | - Patricio Barros-Núñez
- Western Biomedical Research Center, IMSS
- Research Unit, Follow-up Metabolic Diseases, Pediatric UMAE, IMSS, Guadalajara, Mexico
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Vuralli D, Kosukcu C, Taskiran E, Simsek-Kiper PO, Utine GE, Boduroglu K, Alikasifoglu A, Alikasifoglu M. Hyperinsulinemic Hypoglycemia in a Patient with Costello Syndrome: An Etiology to Consider in Hypoglycemia. Mol Syndromol 2020; 11:207-216. [PMID: 33224014 DOI: 10.1159/000510171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 07/03/2020] [Indexed: 11/19/2022] Open
Abstract
Several endocrine disorders have been defined in patients with Costello syndrome (CS). In this report, we describe a patient with CS accompanied by a clinical picture of hyperinsulinemic hypoglycemia responsive to diazoxide treatment. A 41-day-old female patient with a birth weight of 3,600 g was referred for atypical facial features and swallowing dysfunction. She had a weight of 4,000 g (-0.8 SDS), a length of 50 cm (-2.4 SDS), and a head circumference of 38 cm (0.2 SDS). The clinical findings were suggestive of a genetic syndrome, mainly a RASopathy or Beckwith-Wiedemann syndrome. Whole exome sequencing revealed a de novo heterozygous missense variant in the HRAS (NM_001130442) gene in exon 2: c.35G>C; p.(Gly12Ala), establishing the molecular diagnosis of CS. The patient developed symptomatic hypoglycemia (jitteriness and sweating) at the age of 13 months. The patient's serum glucose was 38 mg/dL with simultaneous serum insulin and C-peptide levels, 2.8 μIU/mL and 1.8 ng/mL, respectively. Hyperinsulinism was suspected, and an exaggerated glucose response was detected in a glucagon test. Blood glucose monitoring indicated episodes of fasting hypoglycemia and postprandial hyperglycemia. Diazoxide of 10 mg/kg/day was initiated in 3 doses for hyperinsulinemic hypoglycemia, which resolved without new episodes of postprandial hyperglycemia. The patient deceased at the age of 17 months due to cardiorespiratory failure in the course of severe pneumonia complicated with pulmonary hypertension and hypertrophic cardiomyopathy. Several genetic syndromes including CS are associated with endocrinologic manifestations including abnormal glucose homeostasis. Although the frequency and underlying mechanisms leading to hyperinsulinemic hypoglycemia are yet unknown, hypoglycemia in CS responds well to diazoxide.
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Affiliation(s)
- Dogus Vuralli
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Medical School, Ankara, Turkey
| | - Can Kosukcu
- Department of Medical Genetics, Hacettepe University Medical School, Ankara, Turkey
| | - Ekim Taskiran
- Department of Medical Genetics, Hacettepe University Medical School, Ankara, Turkey
| | - Pelin Ozlem Simsek-Kiper
- Division of Pediatric Genetics, Department of Pediatrics, Hacettepe University Medical School, Ankara, Turkey
| | - Gulen Eda Utine
- Division of Pediatric Genetics, Department of Pediatrics, Hacettepe University Medical School, Ankara, Turkey
| | - Koray Boduroglu
- Division of Pediatric Genetics, Department of Pediatrics, Hacettepe University Medical School, Ankara, Turkey
| | - Ayfer Alikasifoglu
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University Medical School, Ankara, Turkey
| | - Mehmet Alikasifoglu
- Department of Medical Genetics, Hacettepe University Medical School, Ankara, Turkey.,Division of Pediatric Genetics, Department of Pediatrics, Hacettepe University Medical School, Ankara, Turkey
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The novel duplication HRAS c.186_206dup p.(Glu62_Arg68dup): clinical and functional aspects. Eur J Hum Genet 2020; 28:1548-1554. [PMID: 32499600 DOI: 10.1038/s41431-020-0662-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/07/2020] [Accepted: 05/19/2020] [Indexed: 11/08/2022] Open
Abstract
Specific activating missense HRAS variants cause Costello syndrome (CS), a RASopathy with recognizable facial features. The majority of these dominant disease causing variants affect the glycine residues in position 12 or 13. A clinically suspected CS diagnosis can be confirmed through identification of a dominant pathogenic HRAS variant. A novel HRAS variant predicting p.(Glu62_Arg68dup) was identified in an individual with hypertrophic cardiomyopathy, Chiari 1 malformation and ectodermal findings consistent with a RASopathy. Functional studies showed that the p.Glu62_Arg68dup alteration affects HRAS interaction with effector protein PIK3CA (catalytic subunit of phosphoinositide 3-kinase) and the regulator neurofibromin 1 (NF1) GTPase-activating protein (GAP). HRASGlu62_Arg68dup binding with effectors rapidly accelerated fibrosarcoma (RAF1), RAL guanine nucleotide dissociation stimulator (RALGDS) and phospholipase C1 (PLCE1) was enhanced. Accordingly, p.Glu62_Arg68dup increased steady-state phosphorylation of MEK1/2 and ERK1/2 downstream of RAF1, whereas AKT phosphorylation downstream of PI3K was not significantly affected. Growth factor stimulation revealed that expression of HRASGlu62_Arg68dup abolished the HRAS' capacity to modulate downstream signaling. Our data underscore that different qualities of dysregulated HRAS-dependent signaling dynamics determine the clinical severity in CS.
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Gripp KW, Morse LA, Axelrad M, Chatfield KC, Chidekel A, Dobyns W, Doyle D, Kerr B, Lin AE, Schwartz DD, Sibbles BJ, Siegel D, Shankar SP, Stevenson DA, Thacker MM, Weaver KN, White SM, Rauen KA. Costello syndrome: Clinical phenotype, genotype, and management guidelines. Am J Med Genet A 2019; 179:1725-1744. [PMID: 31222966 PMCID: PMC8238015 DOI: 10.1002/ajmg.a.61270] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/22/2019] [Accepted: 06/01/2019] [Indexed: 12/16/2022]
Abstract
Costello syndrome (CS) is a RASopathy caused by activating germline mutations in HRAS. Due to ubiquitous HRAS gene expression, CS affects multiple organ systems and individuals are predisposed to cancer. Individuals with CS may have distinctive craniofacial features, cardiac anomalies, growth and developmental delays, as well as dermatological, orthopedic, ocular, and neurological issues; however, considerable overlap with other RASopathies exists. Medical evaluation requires an understanding of the multifaceted phenotype. Subspecialists may have limited experience in caring for these individuals because of the rarity of CS. Furthermore, the phenotypic presentation may vary with the underlying genotype. These guidelines were developed by an interdisciplinary team of experts in order to encourage timely health care practices and provide medical management guidelines for the primary and specialty care provider, as well as for the families and affected individuals across their lifespan. These guidelines are based on expert opinion and do not represent evidence-based guidelines due to the lack of data for this rare condition.
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Affiliation(s)
- Karen W. Gripp
- Division of Medical Genetics, Department of Pediatrics, A.I. duPont Hospital for Children, Wilmington, Delaware
| | | | - Marni Axelrad
- Psychology Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Kathryn C. Chatfield
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Aaron Chidekel
- Division of Pulmonology, Department of Pediatrics, A.I. duPont Hospital for Children, Wilmington, Delaware
| | - William Dobyns
- Division of Medical Genetics, Seattle Children’s Hospital, Seattle, Washington
| | - Daniel Doyle
- Division of Endocrinology, A.I. duPont Hospital for Children, Wilmington, Delaware
| | - Bronwyn Kerr
- Manchester Center for Genomic Medicine, University of Manchester, Manchester, UK
| | - Angela E. Lin
- Medical Genetics Unit, Department of Pediatrics, MassGeneral Hospital for Children, Boston, Massachusetts
| | - David D. Schwartz
- Psychology Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Barbara J. Sibbles
- Division of Pediatrics, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Dawn Siegel
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Suma P. Shankar
- Division of Genomic Medicine, Department of Pediatrics, University of California Davis, Sacramento, California
| | - David A. Stevenson
- Division of Medical Genetic, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Mihir M. Thacker
- Department of Orthopedic Surgery, Nemoirs-Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - K. Nicole Weaver
- Division of Human Genetics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Sue M. White
- Victorian Clinical Genetics Services, Royal Children’s Hospital, Victoria, Australia
| | - Katherine A. Rauen
- Division of Genomic Medicine, Department of Pediatrics, University of California Davis, Sacramento, California
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