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Observation |

A Novel Mutation in the PORCN Gene Underlying a Case of Almost Unilateral Focal Dermal Hypoplasia FREE

Diane Maalouf, MD; Hala M égarban é, MD; Eliane Chouery, PhD; Joanna Nasr, MD; Catherine Badens, MD; Caroline Lacoste, MS; Karl-Heinz Grzeschik, MD, PhD; Andr é M égarban é, MD, PhD
[+] Author Affiliations

Author Affiliations: Unit é de G én étique M édicale et Laboratoire Associ é Institut National de la Sant é et de la R écherche M édicale Unit é Mixte de R écherche en Sant é 910, Universit é Saint Joseph (Drs Maalouf, Chouery, and A. M égarban é), and Department of Dermatology, Saint George Hospital (Drs H. M égarban é and Nasr), Beirut, Lebanon; Laboratoire de G én étique Mol éculaire, H ôpital d ’Enfants de la Timone, Marseille (Dr Badens and Ms Lacoste), and Institut J ér ôme Lejeune, Paris (Dr A. M égarban é), France; and Department of Human Genetics, University of Marburg, Marburg, Germany (Dr Grzeschik).


Arch Dermatol. 2012;148(1):85-88. doi:10.1001/archdermatol.2011.343.
Text Size: A A A
Published online

ABSTRACT

Background Focal dermal hypoplasia (also known as Goltz syndrome) is an X-linked dominant syndrome characterized by patchy hypoplastic skin with soft-tissue, skeletal, dental, and ocular defects that are secondary to mutations in the PORCN gene. To our knowledge, only 5 cases of focal dermal hypoplasia with unilateral presentation have been reported, and molecular studies were not performed in any of the cases.

Observations A 17-year-old girl was seen with features of almost unilateral focal dermal hypoplasia. These included left cleft hand, dental dysplasia, left mammary hypoplasia, deviation of the sacral line, raspberrylike papillomas in the perianal region, syndactyly of the second and third digits of the left foot, and linear streaks of dermal hypoplasia and pigmented lesions on her left hemibody.

Conclusions Mutation analysis of PORCN revealed a novel heterozygous mutation in exon 10, c.854-855insACCTGAC; [p.T285fsX316], resulting in a premature stop signal. Analysis of the X-chromosome inactivation status was performed on blood and skin DNA samples, showing random inactivation in blood and unaffected skin and skewed inactivation in affected skin, highlighting the role of X-chromosome inactivation in X-linked disease expression.

Figures in this Article

Focal dermal hypoplasia (also known as Goltz syndrome) is an X-linked dominant genodermatosis characterized by developmental defects in ectodermal and mesodermal structures, leading primarily to patchy hypoplastic skin and pigmentary changes, often following Blaschko lines, with skeletal, ocular, and dental malformations.1,2 It is secondary to mutations in the PORCN gene (OMIM 300651) located on chromosome Xp11.23.3,4PORCN encodes an O-acyltransferase involved in the palmitoylation and secretion of Wnt signaling proteins that are required for embryonic tissue development, notably for fibroblast proliferation and osteogenesis.5,6 Among more than 100 patients with focal dermal hypoplasia described in the literature, only 5 had unilateral presentation, and molecular studies were not performed in any of the cases.711

In this case report, a Lebanese girl with almost unilateral focal dermal hypoplasia and a novel heterozygous mutation is described. X-chromosome inactivation status in blood and skin samples was examined to further delineate the lateralization pattern.

REPORT OF A CASE

CLINICAL FEATURES

The consultand was born at term to a healthy gravida 6, para 5 mother. The pregnancy and labor were uneventful. At birth, multiple skin and skeletal abnormalities were noted on the left side of the body. She was first seen by us at age 17 years. Her psychomotor development was normal, and her height was 154 cm. Clinical examination revealed hypopigmented atrophic macules and hyperpigmented lesions following Blaschko lines or showing a reticulate grouping involving the left side of the chest and left extremities. A few hyperpigmented and slightly atrophic lesions were noted on the right side of the back. She had soft yellow nodules on the left hand and raspberrylike papillomas in the perianal region. She also demonstrated oligodontia, left cleft hand, left mammary hypoplasia, deviation of the sacral line, malformed and irregularly spaced teeth, and syndactyly of the second and third toes of the left foot (Figure). There were no ocular signs or internal organ anomalies. Chromosomal analysis revealed a normal 46,XX karyotype.

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Present case. A, Atrophic lesions and pigmentary changes on the left side of the back. B, Abnormally shaped and irregularly spaced teeth. C, Left cleft hand. D, Syndactyly of the second and third digits of the left foot.

DNA SEQUENCE ANALYSIS

Gene sequence analysis was performed on the PORCN gene. After informed consent was obtained, genomic DNA was extracted from peripheral leucocytes, and the 14 coding exons of PORCN were amplified. A novel heterozygous mutation was detected in exon 10, c.854-855insACCTGAC; [p.T285fsX316], resulting in a premature stop signal. This mutation was confirmed by single-strand confirmation polymorphism analysis and was not found in 100 unrelated control subjects.

X-CHROMOSOME INACTIVATION ANALYSIS

Analysis of the X-chromosome inactivation status pattern using the human androgen receptor methylation assay was performed on blood and skin DNA samples.12 The X-chromosome inactivation pattern in DNA isolated from blood identified random inactivation, with a ratio of 30:70. Using a kit (QIAGEN, Studio City, California), DNA was then extracted from small skin samples of affected and unaffected sites. The DNA from apparently healthy skin of the right arm showed random inactivation (45:55 ratio). On the affected (left) side, there was skewed inactivation in DNA extracted from an atrophic hyperpigmented lesion of the left arm (87:13 ratio) and borderline random inactivation in DNA extracted from apparently healthy skin of the left arm (75:25 ratio).

COMMENT

A female patient having focal dermal hypoplasia with classic features of the disease also had mammary hypoplasia and cleft hand, which are rare.3,13 Her skin lesions were predominantly on the left side of the body. Only 5 cases of focal dermal hypoplasia with unilateral presentation have been previously reported, 1 boy and 4 girls (Table). There was no preferential left-sided or right-sided unilateral involvement. Four patients had asymmetric skeletal defects, and 3 girls had ocular anomalies. Molecular studies were not performed in any of these cases. In the present case, a novel heterozygous frameshift mutation in exon 10 of PORCN, resulting in a premature stop signal, was encountered. Six cases with exon 10 mutations have been reported.3,1417 Clinical comparison showed no genotype-phenotype correlation, which can be secondary to lyonization or postzygotic mosaicism or various environmental and epigenetic factors.3,4

Table Graphic Jump LocationTable. Summary of Findings in Cases of Unilateral Focal Dermal Hypoplasia Reported in the Literature and in the Present Case

To better understand the lateralization pattern seen in our patient, we performed X-chromosome inactivation studies on blood and skin DNA samples from both sides of her body. X-chromosome inactivation has been previously studied using DNA derived from peripheral leukocytes of patients with focal dermal hypoplasia.3,4,1420 Patients with de novo point mutations usually demonstrated random inactivation, whereas patients with familial focal dermal hypoplasia and all patients with microdeletions encompassing PORCN and neighboring genes showed extreme skewing, possibly to allow the viability of individuals with such deleterious mutations. As expected in the present case, a random pattern of X-chromosome inactivation was identified in blood and in skin on the right side of the body. However, on the left side, there was consistent preferential bias to inactivate 1 of the 2 alleles, and skewed X-chromosome inactivation was found in DNA extracted from an atrophic skin lesion. It is probable that the bias observed on the affected side is due to an expansion of cells carrying the active mutated X, leading to the left-sided distribution of the disease features. Another explanation for this lateralization pattern is somatic mosaicism, resulting from an early somatic mutation in the precursor cells on the left side of the body. In this case, X-chromosome inactivation would be superimposed on the mosaicism and cause Blaschko lines.

In conclusion, more case reports and further molecular studies of patients with unilateral focal dermal hypoplasia are warranted. Examination of differential X-chromosome expression in involved tissues will better correlate the X-chromosome inactivation pattern and the observed phenotype.

ARTICLE INFORMATION

Correspondence: Andr é M égarban é, MD, PhD, Unit é de G én étique M édicale, Universit é Saint Joseph, 42 Rue de Grenelle, 75007 Paris, France (megarbane@usj.edu.lb).

Accepted for Publication: August 24, 2011.

Author Contributions: All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: H. M égarban é and A. M égarban é. Acquisition of data: Maalouf, H. M égarban é, and Nasr. Analysis and interpretation of data: Maalouf, H. M égarban é, Badens, and Grzeschik. Drafting of the manuscript: Maalouf and A. M égarban é. Critical revision of the manuscript for important intellectual content: Badens, Grzeschik, and A. M égarban é. Administrative, technical, or material support: Chouery, Badens, and Lacoste. Study supervision: A. M égarban é.

Financial Disclosure: None reported.

Funding/Support: This study was supported by Universit é Saint Joseph.

REFERENCES

Goltz RW, Peterson WC, Gorlin RJ, Ravits HG. Focal dermal hypoplasia.  Arch Dermatol. 1962;86:708-717
PubMed   |  Link to Article
Goltz RW. Focal dermal hypoplasia syndrome: an update.  Arch Dermatol. 1992;128(8):1108-1111
PubMed   |  Link to Article
Grzeschik KH, Bornholdt D, Oeffner F,  et al.  Deficiency of PORCN, a regulator of Wnt signaling, is associated with focal dermal hypoplasia.  Nat Genet. 2007;39(7):833-835
PubMed   |  Link to Article
Wang X, Reid Sutton V, Omar Peraza-Llanes J,  et al.  Mutations in X-linked PORCN, a putative regulator of Wnt signaling, cause focal dermal hypoplasia.  Nat Genet. 2007;39(7):836-838
PubMed   |  Link to Article
Grigoryan T, Wend P, Klaus A, Birchmeier W. Deciphering the function of canonical Wnt signals in development and disease: conditional loss- and gain-of-function mutations of β-catenin in mice.  Genes Dev. 2008;22(17):2308-2341
PubMed   |  Link to Article
Adaimy L, Chouery E, M égarban é H,  et al.  Mutation in WNT10A is associated with an autosomal recessive ectodermal dysplasia: the odonto-onycho-dermal dysplasia.  Am J Hum Genet. 2007;81(4):821-828
PubMed   |  Link to Article
Stalder JF, Delaire J, David A, Cohen JY, Le Pape A. Unilateral Goltz syndrome in a boy.  Ann Dermatol Venereol. 1984;111(9):829-830
PubMed
Denis-Thely L, Cordier MP, Cambazard F, Misery L. Unilateral focal dermal hypoplasia [abstract].  Ann Dermatol Venereol. 2002;129(10, pt 1):s1161
Aoyama M, Sawada H, Shintani Y, Isomura I, Morita A. Case of unilateral focal dermal hypoplasia (Goltz syndrome).  J Dermatol. 2008;35(1):33-35
PubMed   |  Link to Article
Fern ández-Torres R, Del Pozo J, Garc ía-Silva J, Fonseca E. Unilateral focal dermal hypoplasia.  Actas Dermosifiliogr. 2010;101(1):96-98
PubMed   |  Link to Article
Tenkir A, Teshome S. Goltz syndrome (focal dermal hypoplasia) with unilateral ocular, cutaneous and skeletal features: case report.  BMC Ophthalmol. 2010;10:e28http://www.biomedcentral.com/1471-2415/10/28. Accessed September 18, 2011
PubMed   |  Link to Article
Lossi AM, Mill án JM, Villard L,  et al.  Mutation of the XNP/ATR-X gene in a family with severe mental retardation, spastic paraplegia and skewed pattern of X inactivation: demonstration that the mutation is involved in the inactivation bias.  Am J Hum Genet. 1999;65(2):558-562
PubMed   |  Link to Article
Kilmer SL, Grix AW Jr, Isseroff RR. Focal dermal hypoplasia: four cases with widely varying presentations.  J Am Acad Dermatol. 1993;28(5, pt 2):839-843
PubMed   |  Link to Article
Clements SE, Mellerio JE, Holden ST, McCauley J, McGrath JA. PORCN gene mutations and the protean nature of focal dermal hypoplasia.  Br J Dermatol. 2009;160(5):1103-1109
PubMed   |  Link to Article
Bornholdt D, Oeffner F, K önig A,  et al.  PORCN mutations in focal dermal hypoplasia: coping with lethality [published correction appears in Hum Mutat. 2009;30(10):1472-1473].  Hum Mutat. 2009;30(5):E618-E628http://onlinelibrary.wiley.com/doi/10.1002/humu.20992/pdf. Accessed September 18, 2011
PubMed   |  Link to Article
Maas SM, Lombardi MP, van Essen AJ,  et al.  Phenotype and genotype in 17 patients with Goltz-Gorlin syndrome.  J Med Genet. 2009;46(10):716-720
PubMed   |  Link to Article
Clements SE, Wessagowit V, Lai-Cheong JE, Arita K, McGrath JA. Focal dermal hypoplasia resulting from a new nonsense mutation, p.E300X, in the PORCN gene.  J Dermatol Sci. 2008;49(1):39-42
PubMed   |  Link to Article
Leoyklang P, Suphapeetiporn K, Wananukul S, Shotelersuk V. Three novel mutations in the PORCN gene underlying focal dermal hypoplasia.  Clin Genet. 2008;73(4):373-379
PubMed   |  Link to Article
Harmsen MB, Azzarello-Burri S, Garc ía Gonz ález MM,  et al.  Goltz-Gorlin (focal dermal hypoplasia) and the microphthalmia with linear skin defects (MLS) syndrome: no evidence of genetic overlap.  Eur J Hum Genet. 2009;17(10):1207-1215
PubMed   |  Link to Article
Froyen G, Govaerts K, Van Esch H,  et al.  Novel PORCN mutations in focal dermal hypoplasia.  Clin Genet. 2009;76(6):535-543
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Present case. A, Atrophic lesions and pigmentary changes on the left side of the back. B, Abnormally shaped and irregularly spaced teeth. C, Left cleft hand. D, Syndactyly of the second and third digits of the left foot.

Tables

Table Graphic Jump LocationTable. Summary of Findings in Cases of Unilateral Focal Dermal Hypoplasia Reported in the Literature and in the Present Case

References

Goltz RW, Peterson WC, Gorlin RJ, Ravits HG. Focal dermal hypoplasia.  Arch Dermatol. 1962;86:708-717
PubMed   |  Link to Article
Goltz RW. Focal dermal hypoplasia syndrome: an update.  Arch Dermatol. 1992;128(8):1108-1111
PubMed   |  Link to Article
Grzeschik KH, Bornholdt D, Oeffner F,  et al.  Deficiency of PORCN, a regulator of Wnt signaling, is associated with focal dermal hypoplasia.  Nat Genet. 2007;39(7):833-835
PubMed   |  Link to Article
Wang X, Reid Sutton V, Omar Peraza-Llanes J,  et al.  Mutations in X-linked PORCN, a putative regulator of Wnt signaling, cause focal dermal hypoplasia.  Nat Genet. 2007;39(7):836-838
PubMed   |  Link to Article
Grigoryan T, Wend P, Klaus A, Birchmeier W. Deciphering the function of canonical Wnt signals in development and disease: conditional loss- and gain-of-function mutations of β-catenin in mice.  Genes Dev. 2008;22(17):2308-2341
PubMed   |  Link to Article
Adaimy L, Chouery E, M égarban é H,  et al.  Mutation in WNT10A is associated with an autosomal recessive ectodermal dysplasia: the odonto-onycho-dermal dysplasia.  Am J Hum Genet. 2007;81(4):821-828
PubMed   |  Link to Article
Stalder JF, Delaire J, David A, Cohen JY, Le Pape A. Unilateral Goltz syndrome in a boy.  Ann Dermatol Venereol. 1984;111(9):829-830
PubMed
Denis-Thely L, Cordier MP, Cambazard F, Misery L. Unilateral focal dermal hypoplasia [abstract].  Ann Dermatol Venereol. 2002;129(10, pt 1):s1161
Aoyama M, Sawada H, Shintani Y, Isomura I, Morita A. Case of unilateral focal dermal hypoplasia (Goltz syndrome).  J Dermatol. 2008;35(1):33-35
PubMed   |  Link to Article
Fern ández-Torres R, Del Pozo J, Garc ía-Silva J, Fonseca E. Unilateral focal dermal hypoplasia.  Actas Dermosifiliogr. 2010;101(1):96-98
PubMed   |  Link to Article
Tenkir A, Teshome S. Goltz syndrome (focal dermal hypoplasia) with unilateral ocular, cutaneous and skeletal features: case report.  BMC Ophthalmol. 2010;10:e28http://www.biomedcentral.com/1471-2415/10/28. Accessed September 18, 2011
PubMed   |  Link to Article
Lossi AM, Mill án JM, Villard L,  et al.  Mutation of the XNP/ATR-X gene in a family with severe mental retardation, spastic paraplegia and skewed pattern of X inactivation: demonstration that the mutation is involved in the inactivation bias.  Am J Hum Genet. 1999;65(2):558-562
PubMed   |  Link to Article
Kilmer SL, Grix AW Jr, Isseroff RR. Focal dermal hypoplasia: four cases with widely varying presentations.  J Am Acad Dermatol. 1993;28(5, pt 2):839-843
PubMed   |  Link to Article
Clements SE, Mellerio JE, Holden ST, McCauley J, McGrath JA. PORCN gene mutations and the protean nature of focal dermal hypoplasia.  Br J Dermatol. 2009;160(5):1103-1109
PubMed   |  Link to Article
Bornholdt D, Oeffner F, K önig A,  et al.  PORCN mutations in focal dermal hypoplasia: coping with lethality [published correction appears in Hum Mutat. 2009;30(10):1472-1473].  Hum Mutat. 2009;30(5):E618-E628http://onlinelibrary.wiley.com/doi/10.1002/humu.20992/pdf. Accessed September 18, 2011
PubMed   |  Link to Article
Maas SM, Lombardi MP, van Essen AJ,  et al.  Phenotype and genotype in 17 patients with Goltz-Gorlin syndrome.  J Med Genet. 2009;46(10):716-720
PubMed   |  Link to Article
Clements SE, Wessagowit V, Lai-Cheong JE, Arita K, McGrath JA. Focal dermal hypoplasia resulting from a new nonsense mutation, p.E300X, in the PORCN gene.  J Dermatol Sci. 2008;49(1):39-42
PubMed   |  Link to Article
Leoyklang P, Suphapeetiporn K, Wananukul S, Shotelersuk V. Three novel mutations in the PORCN gene underlying focal dermal hypoplasia.  Clin Genet. 2008;73(4):373-379
PubMed   |  Link to Article
Harmsen MB, Azzarello-Burri S, Garc ía Gonz ález MM,  et al.  Goltz-Gorlin (focal dermal hypoplasia) and the microphthalmia with linear skin defects (MLS) syndrome: no evidence of genetic overlap.  Eur J Hum Genet. 2009;17(10):1207-1215
PubMed   |  Link to Article
Froyen G, Govaerts K, Van Esch H,  et al.  Novel PORCN mutations in focal dermal hypoplasia.  Clin Genet. 2009;76(6):535-543
PubMed   |  Link to Article

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