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1.  What can rare variant genetics tell us about cognition and intellectual difficulties? 
Journal of Neurology  2016;263(12):2565-2566.
doi:10.1007/s00415-016-8326-6
PMCID: PMC5110588  PMID: 27822598
2.  The consequences of valproate exposure in utero 
Journal of Neurology  2016;263(9):1887-1889.
doi:10.1007/s00415-016-8269-y
PMCID: PMC5010822  PMID: 27565477
3.  Pathogenic copy number variants and SCN1A mutations in patients with intellectual disability and childhood-onset epilepsy 
BMC Medical Genetics  2016;17:34.
Background
Copy number variants (CNVs) have been linked to neurodevelopmental disorders such as intellectual disability (ID), autism, epilepsy and psychiatric disease. There are few studies of CNVs in patients with both ID and epilepsy.
Methods
We evaluated the range of rare CNVs found in 80 Welsh patients with ID or developmental delay (DD), and childhood-onset epilepsy. We performed molecular cytogenetic testing by single nucleotide polymorphism array or microarray-based comparative genome hybridisation.
Results
8.8 % (7/80) of the patients had at least one rare CNVs that was considered to be pathogenic or likely pathogenic. The CNVs involved known disease genes (EHMT1, MBD5 and SCN1A) and imbalances in genomic regions associated with neurodevelopmental disorders (16p11.2, 16p13.11 and 2q13). Prompted by the observation of two deletions disrupting SCN1A we undertook further testing of this gene in selected patients. This led to the identification of four pathogenic SCN1A mutations in our cohort.
Conclusions
We identified five rare de novo deletions and confirmed the clinical utility of array analysis in patients with ID/DD and childhood-onset epilepsy. This report adds to our clinical understanding of these rare genomic disorders and highlights SCN1A mutations as a cause of ID and epilepsy, which can easily be overlooked in adults.
Electronic supplementary material
The online version of this article (doi:10.1186/s12881-016-0294-2) contains supplementary material, which is available to authorized users.
doi:10.1186/s12881-016-0294-2
PMCID: PMC4845474  PMID: 27113213
Array comparative genomic hybridization; Intellectual disability; Epilepsy; Copy number variation; SCN1A
4.  CHD2 myoclonic encephalopathy is frequently associated with self-induced seizures 
Neurology  2015;84(9):951-958.
Objective:
To delineate the phenotype of early childhood epileptic encephalopathy due to de novo mutations of CHD2, which encodes the chromodomain helicase DNA binding protein 2.
Methods:
We analyzed the medical history, MRI, and video-EEG recordings of 9 individuals with de novo CHD2 mutations and one with a de novo 15q26 deletion encompassing CHD2.
Results:
Seizures began at a mean of 26 months (12–42) with myoclonic seizures in all 10 cases. Seven exhibited exquisite clinical photosensitivity; 6 self-induced with the television. Absence seizures occurred in 9 patients including typical (4), atypical (2), and absence seizures with eyelid myoclonias (4). Generalized tonic-clonic seizures occurred in 9 of 10 cases with a mean onset of 5.8 years. Convulsive and nonconvulsive status epilepticus were later features (6/10, mean onset 9 years). Tonic (40%) and atonic (30%) seizures also occurred. In 3 cases, an unusual seizure type, the atonic-myoclonic-absence was captured on video. A phenotypic spectrum was identified with 7 cases having moderate to severe intellectual disability and refractory seizures including tonic attacks. Their mean age at onset was 23 months. Three cases had a later age at onset (34 months) with relative preservation of intellect and an initial response to antiepileptic medication.
Conclusion:
The phenotypic spectrum of CHD2 encephalopathy has distinctive features of myoclonic epilepsy, marked clinical photosensitivity, atonic-myoclonic-absence, and intellectual disability ranging from mild to severe. Recognition of this genetic entity will permit earlier diagnosis and enable the development of targeted therapies.
doi:10.1212/WNL.0000000000001305
PMCID: PMC4351660  PMID: 25672921
5.  Genome-wide Polygenic Burden of Rare Deleterious Variants in Sudden Unexpected Death in Epilepsy 
EBioMedicine  2015;2(9):1063-1070.
Sudden unexpected death in epilepsy (SUDEP) represents the most severe degree of the spectrum of epilepsy severity and is the commonest cause of epilepsy-related premature mortality. The precise pathophysiology and the genetic architecture of SUDEP remain elusive. Aiming to elucidate the genetic basis of SUDEP, we analysed rare, protein-changing variants from whole-exome sequences of 18 people who died of SUDEP, 87 living people with epilepsy and 1479 non-epilepsy disease controls. Association analysis revealed a significantly increased genome-wide polygenic burden per individual in the SUDEP cohort when compared to epilepsy (P = 5.7 × 10− 3) and non-epilepsy disease controls (P = 1.2 × 10− 3). The polygenic burden was driven both by the number of variants per individual, and over-representation of variants likely to be deleterious in the SUDEP cohort. As determined by this study, more than a thousand genes contribute to the observed polygenic burden within the framework of this study. Subsequent gene-based association analysis revealed five possible candidate genes significantly associated with SUDEP or epilepsy, but no one single gene emerges as common to the SUDEP cases. Our findings provide further evidence for a genetic susceptibility to SUDEP, and suggest an extensive polygenic contribution to SUDEP causation. Thus, an overall increased burden of deleterious variants in a highly polygenic background might be important in rendering a given individual more susceptible to SUDEP. Our findings suggest that exome sequencing in people with epilepsy might eventually contribute to generating SUDEP risk estimates, promoting stratified medicine in epilepsy, with the eventual aim of reducing an individual patient's risk of SUDEP.
Highlights
•Increased genome-wide polygenic burden of deleterious genetic variants in people who died of SUDEP•Some possible candidate genes may carry some of the increased burden of deleterious variants•If validated, exome sequence analysis may be a tool to estimate genetic susceptibility to SUDEP
doi:10.1016/j.ebiom.2015.07.005
PMCID: PMC4588398  PMID: 26501104
AED, anti-epileptic drug; MAF, minor allele frequency; n, number; QC, quality control; SUDEP, sudden unexpected death in epilepsy; WES, whole-exome sequencing; Epilepsy; Death; Mortality; Severity; Association; Burden
6.  A Novel GABRG2 Mutation, p.R136*, in a family with GEFS+ and extended phenotypes 
Neurobiology of disease  2014;64:131-141.
Genetic mutations in voltage-gated and ligand-gated ion channel genes have been identified in a small number of Mendelian families with genetic generalised epilepsies (GGEs). They are commonly associated with febrile seizures (FS), childhood absence epilepsy (CAE) and particularly with generalised or genetic epilepsy with febrile seizures plus (GEFS+). In clinical practice, despite efforts to categorise epilepsy and epilepsy families into syndromic diagnoses, many generalised epilepsies remain unclassified with a presumed genetic basis. During the systematic collection of epilepsy families, we assembled a cohort of families with evidence of GEFS+ and screened for variations in the γ2 subunit of the γ-aminobutyric acid (GABA) type A receptor gene (GABRG2). We detected a novel GABRG2(p.R136*) premature translation termination codon in one index-case from a two-generation nuclear family, presenting with an unclassified GGE, a borderline GEFS+ phenotype with learning difficulties and autism spectrum disorder (ASD). The GABRG2(p.R136*) mutation segregates with the febrile seizure component of this family's GGE and is absent in 190 healthy control samples. In vitro expression assays demonstrated that γ2(p.R136*) subunits were produced, but had reduced cell-surface and total expression. When γ2(p.R136*) subunits were co-expressed with α1 and β2 subunits in HEK 293T cells, GABA–evoked currents were reduced. Furthermore, γ2(p.R136*) subunits were highly-expressed in intracellular aggregations surrounding the nucleus and endoplasmic reticulum (ER), suggesting compromised receptor trafficking. A novel GABRG2(p.R136*) mutation extends the spectrum of GABRG2 mutations identified in GEFS+ and GGE phenotypes, causes GABAA receptor dysfunction, and represents a putative epilepsy mechanism.
doi:10.1016/j.nbd.2013.12.013
PMCID: PMC4222744  PMID: 24407264
GABAA receptors; epilepsy; protein truncating mutations; autism spectrum disorder
7.  A neurological presentation of intravascular B-cell lymphoma 
BMJ Case Reports  2012;2012:bcr2012006439.
Intravascular B-cell lymphoma is a rare, aggressive subtype of diffuse large B-cell lymphoma that presents insidiously with symptoms relating to organ involvement. We present the case of a male in his late 40s who presented with fluctuating neurological symptoms including episodes of altered upper-limb sensation, seizures and psychotic phenomena. These symptoms and signs were associated with fleeting brain lesions on neuroimaging. A brain biopsy confirmed the diagnosis of intravascular B-cell lymphoma and he was treated with CHOP chemotherapy (cyclophosphamide, hydroxydaunorubicin, vincristine and prednisolone). Two years later, he remains well. Timely diagnosis and aggressive treatment provides an optimal chance of long-term survival so it is essential to recognise early disease characteristics.
doi:10.1136/bcr-2012-006439
PMCID: PMC4544438  PMID: 22865806
8.  Epilepsy is different 
doi:10.1258/jrsm.2011.100412
PMCID: PMC3078616  PMID: 21502208
9.  Novel missense mutations in the glycine receptor β subunit gene (GLRB) in startle disease 
Neurobiology of Disease  2013;52:137-149.
Startle disease is a rare, potentially fatal neuromotor disorder characterized by exaggerated startle reflexes and hypertonia in response to sudden unexpected auditory, visual or tactile stimuli. Mutations in the GlyR α1 subunit gene (GLRA1) are the major cause of this disorder, since remarkably few individuals with mutations in the GlyR β subunit gene (GLRB) have been found to date. Systematic DNA sequencing of GLRB in individuals with hyperekplexia revealed new missense mutations in GLRB, resulting in M177R, L285R and W310C substitutions. The recessive mutation M177R results in the insertion of a positively-charged residue into a hydrophobic pocket in the extracellular domain, resulting in an increased EC50 and decreased maximal responses of α1β GlyRs. The de novo mutation L285R results in the insertion of a positively-charged side chain into the pore-lining 9′ position. Mutations at this site are known to destabilize the channel closed state and produce spontaneously active channels. Consistent with this, we identified a leak conductance associated with spontaneous GlyR activity in cells expressing α1βL285R GlyRs. Peak currents were also reduced for α1βL285R GlyRs although glycine sensitivity was normal. W310C was predicted to interfere with hydrophobic side-chain stacking between M1, M2 and M3. We found that W310C had no effect on glycine sensitivity, but reduced maximal currents in α1β GlyRs in both homozygous (α1βW310C) and heterozygous (α1ββW310C) stoichiometries. Since mild startle symptoms were reported in W310C carriers, this may represent an example of incomplete dominance in startle disease, providing a potential genetic explanation for the ‘minor’ form of hyperekplexia.
Highlights
► We report novel missense mutations in the GlyR β subunit gene causing startle disease. ► Mutation M177R in the extracellular domain decreases GlyR agonist affinity. ► Mutation L285R in TM2 produces spontaneously active channels. ► Mutation W310C in TM3 affects hydrophobic stacking and shows incomplete dominance. ► Mutations in GLRB have unique pathogenic mechanisms and modes of inheritance.
doi:10.1016/j.nbd.2012.12.001
PMCID: PMC3581774  PMID: 23238346
GLRA1; GLRB; Glycine receptor; Hyperekplexia; Startle disease
10.  Careers advice 
BMJ : British Medical Journal  2007;334(7584):58.
doi:10.1136/bmj.39086.919051.1F
PMCID: PMC1767246  PMID: 17218676
11.  The Glycinergic System in Human Startle Disease: A Genetic Screening Approach 
Human startle disease, also known as hyperekplexia (OMIM 149400), is a paroxysmal neurological disorder caused by defects in glycinergic neurotransmission. Hyperekplexia is characterised by an exaggerated startle reflex in response to tactile or acoustic stimuli which first presents as neonatal hypertonia, followed in some with episodes of life-threatening infantile apnoea. Genetic screening studies have demonstrated that hyperekplexia is genetically heterogeneous with several missense and nonsense mutations in the postsynaptic glycine receptor (GlyR) α1 subunit gene (GLRA1) as the primary cause. More recently, missense, nonsense and frameshift mutations have also been identified in the glycine transporter GlyT2 gene, SLC6A5, demonstrating a presynaptic component to this disease. Further mutations, albeit rare, have been identified in the genes encoding the GlyR β subunit (GLRB), collybistin (ARHGEF9) and gephyrin (GPHN) – all of which are postsynaptic proteins involved in orchestrating glycinergic neurotransmission. In this review, we describe the clinical ascertainment aspects, phenotypic considerations and the downstream molecular genetic tools utilised to analyse both presynaptic and postsynaptic components of this heterogeneous human neurological disorder. Moreover, we will describe how the ancient startle response is the preserve of glycinergic neurotransmission and how animal models and human hyperekplexia patients have provided synergistic evidence that implicates this inhibitory system in the control of startle reflexes.
doi:10.3389/fnmol.2010.00008
PMCID: PMC2854534  PMID: 20407582
glycine; hyperekplexia; receptor; transporter; mutation
12.  Miracle hiccough cure gets the attention it deserves 
BMJ : British Medical Journal  2006;333(7580):1222.
doi:10.1136/bmj.39051.721632.3A
PMCID: PMC1693610  PMID: 17158401

Results 1-12 (12)