Background
Cornelia de Lange syndrome (CdLS, OMIM#122470, 300,590, 610,759) is a rare congenital syndrome with an incidence of 0.6/100,000 birth according to data from USA [
1] and 1.6–2.2/100,000 birth according to data from Europe [
2]. According to reports from North America [
3‐
5], Europe [
6], and Asia [
7,
8], clinical features of CdLS are facial dysmorphism +/− other organ congenital malformations, growth and developmental delay, behavioral disorders. But there is no racial difference for CdLS, It was reported that less than one tenth of CdLS patients were diagnosed within the first 28 days of life [
4,
9]. The objective of this study is to report the clinical data and genetic analysis results of CdLS cases from China. This is an observational study.
Methods
Patient referring
Suspected patients with facial dysmorphism were referred to the Clinical Genetic Consultation Clinic of the National Key Laboratory of Medical Genetics of Central South University (for non-neonatal pediatric patients) or to Neonatal Department of the Third Xiangya Hospital of Central South University or Xuzhou Affiliated Hospital of East South University (for neonatal patients). Gene mutation tests were completed at the National Key Lab of Medical Genetics of Central South University. Pediatricians were responsible for the clinical management and treatment, genetic consultants were responsible for the family history collection and genetic laboratory examination of the patients. The patient referring and genetic testing were all under voluntary condition.
Clinical diagnostic criteria
Diagnostic criteria of CdLS in this study are [
3]: (a) Positive mutation on CdLS gene testing; or (b) Facial findings and criteria from two of the growth, development or behavior categories; or (c) Facial findings and criteria for three other categories, including one from growth, development or behavior, and two from the other categories.
Clinical data and genetic study
The family history, demographic data (gender, delivery pattern, birth weight, patient’s age at diagnosis, maternal age/health status), and clinical data (facial characteristics, other organ congenital malformations, hypoacusis, gastrointestinal complications, mental retardation and behaviour disorders) of each patient were collected. Chromosomal analysis was completed on peripheral blood lymphocytes of the probands according to conventional techniques and high resolution banding analysis. Mutational analysis of the NIPBL, SMC1A, and SMC3 genes were carried out by polymerase chain reaction (PCR), reverse transcription PCR direct sequencing in the probands, and SNP array to detect the genome-wide copy number variations. DNA from parents was sequenced in the corresponding region when a mutation was detected in affected child.
Ethical approval and consent
This study was conducted in accordance with the 1964 Helsinki Declaration or comparable standards, and got an ethical approval from the Institutional Review Board of The Third Xiangya Hospital of Central South University (No. 2011-S096). We obtained written consent from parents of all CdLS cases in this study for the publication of their information for research purpose.
Discussion
CdLS is a rare disease that occurs sporadically and is dominant paternal transmission [
11] with no racial differences. Clinically, CdLS is divided into two subtypes: classic type and mild type, both having specific facial dysmorphism [
12]. A population-based epidemiology study of the classic CdLS using the European Surveillance of Congenital Anomalies (EUROCAT) database established a prevalence for the classic form CdLS to be 1.24/100,000 births and the overall CdLS prevalence to be 1.6–2.2/100,000 births [
2]. The antenatal diagnosis of CdLS is not always possible. However, a decreased Pregnancy-Associated Plasma Protein level in the first trimester [
13] and second trimetster [
14] might suggest CdLS. Schrier et al. [
4] reviewed 426 CdLS cases published from 1965 to 2007 and found that only 30 (7%) were neonates. But in the present study, 9 out of 20 cases (45%) were neonates, which is much higher than that in USA. This difference of percentage of neonatal cases between China and USA is unknown. The diagnosis of 20 CdLS patients in the present study was based on the characteristic facial dysmorphisms as clinicians did in the other countries [
3,
6,
15]. Kline et al. reported that dysmorphisms of CdLS patients include, in sequence, thick and long eyelashes (99%), synophrys joining at the midline and extending down to the bridge of the nose with an arched appearance of the eyebrows (98%), long prominent philtrum with down-turned lip corners (94%), small hands and feet with thin tips (90%), short and flattened nose (85%), hirsute forehead (78%), and cutis marmorata (74%). Most of these findings were observed in the Chinese CdLS patients as well and almost in the same sequence. Feeding difficulties and gastrointestinal reflux, the most important diagnostic criteria of CdLS, was observed in the neonatal patients in this study. Feeding difficulty has also been reported in earlier studies [
3,
5,
11], mainly because of the refractory gastrointestinal regurgitation. A Canada study consisting of 120 CdLS children [
4] reported multiple eye problems, such as ptosis iridis (44%), epiphora (22%), nasolacrimal duct obstruction (16%), blepharitis (25%), and myopia (58%). Unfortunately, the ophthalmologic evaluations were unable to be obtained for the 20 CdLS patients from China.
The etiology of CdLS is gene mutation. About 25–60% cases of CdLS are caused by point mutations in one of four genes building the cohesin system, mainly in NIPBL, and less frequently in SMC1, SMC3 and HDAC8. The three genes recognized to cause CdLS include the NIPBL gene on chromosome 5 (approximately 50% of CdLS patients carry this gene mutation) [
15,
16], SMC1A gene on chromosome X (approximately 5% of CdLS patients) [
17], SMC3 gene on chromosome 10 (there has been only 1 case report of this gene mutation) [
18], and RAD21 and HDAC8 mutations as well [
19]. Both SMC1A and SMC3 gene mutations are associated with the mild type of CdLS [
15,
18]. In the Chinese cases described above, NIPBL gene mutations were also identified. Baynam et al. [
20] reported an 8p23.1 deletion resulting in features of CdLS and diaphragmatic hernia, and proposed that TANKYRASE 1, a gene involved with sister chromatin cohesion from within the deleted segment, might be a novel candidate gene causing CdLS. Hayashi et al. [
8] reported a 2-year-old Japanese girl with CdLS who had a balanced translocation of chromosome 12 and 13 and a 46, XX, t (5; 13) (p13.1; q12.1) karyotype. In their study, fluorescence in situ hybridization confirmed the breakpoint within NIPBL at 5p13.1, and array-based comparative genomic hybridization (array-CGH) demonstrated a cryptic 1-Mb deletion harboring six known genes at 1q25–q31.1. In the 20 Chinese cases described above, karyotyping was completed in 17 patients, but no abnormality was identified.
The intellectual disability in CdLS patients may be associated with altered gene expression as well [
19]. Schrier et al. [
4] reported that 63% of the CdLS patients in the United States had a birth weight less than 5th centile. In the present study, 90% of the Chinese CdLS patients were born with birth weight less than 10th centile and 70% were less than 3rd centile, and 55% of the Chinese CdLS patients had developmental retardation.
The limitations of the present study are the small number of diagnosed patients and the information of genetic study. In addition, the withdrawal of care due to the concerning of parents for the economical burden and the patients’ long-term developmental deficits is also a significant issue in China, as in China, it is the parents but not the doctors who have the legal power to decide whether a child will be taken to see a doctor and to receive medical examination or treatment. But we believe that with the development of medicine in China, more CdLS patients will be diagnosed and more genetic information will be collected in the coming future.