CASE II

STEP 1

A 3-month-old baby is diagnosed with mosaicim Down Syndrome. The mother

wad 45 years old when she carried her baby.

STEP 2

1. Explain the cause of the syndrome and possible mechanism!

Mosaic Down Syndrome

Mosaic Down syndrome, or mosaicism, is a rare form of Down

syndrome. Down syndrome is a genetic disorder that results in an extra copy of
chromosome 21. People with mosaic Down syndrome have a mixture of cells.
Some have two copies of chromosome 21, and some have three. Mosaic Down
syndrome occurs in about 2 percent of all Down syndrome cases. People with
mosaic Down syndrome often, but not always, have fewer symptoms of Down
syndrome because some cells are normal.1

Down syndrome is a genetic disorder in which some, or all, of a person’s

cells have an extra chromosome. All normal human cells have 46 chromosomes,
except the egg and sperm, which normally have 23. These sex cells are formed
by division (called meiosis). When an egg is fertilized, these two cells join,
normally giving the embryo 23 chromosomes from each parent for a total of 46
chromosomes. Sometimes an error occurs in this process, causing the wrong
number of chromosomes to occur in the sperm or egg. A healthy baby has two
copies of chromosome 21 in each cell. People with Down syndrome have three.
Any cell replicated from the flawed cell will also have the wrong number of
chromosomes.1

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 Figure 1. Mosaic Cell Division1

People with mosaic Down syndrome have a mixture of cells. Some cells
have a normal pair of chromosome 21, and other cells contain three copies. This
usually happens because the division problem that causes the extra copy of
chromosome 21 happens after fertilization. Irregular chromosome copies change
the genetic makeup of a baby, ultimately affecting their mental and physical
development.2

People with Down syndrome typically have:2

 slower speech

 lower IQ

 a flattened face

 small ears

 shorter height

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  eyes that tend to slant up

 white spots on the iris of the eye

Sign and Symptoms

Down syndrome is sometimes accompanied by a number of other health

problems, including:2

 sleep apnea, a health condition that causes you to temporarily

stop breathing while you sleep
 ear infections
 immune disorders
 hearing loss
 heart defects
 visual impairments
 vitamin deficiencies

These symptoms are also common in people with mosaic Down

syndrome. However, they may have less of these symptoms. For example,
people with mosaic Down syndrome typically have a higher IQ than those with
other forms of Down syndrome. Doctors can perform tests to screen for Down
syndrome during pregnancy. These tests show the likelihood that the fetus will
have Down syndrome and can identify health problems early.

Screening tests

Screening tests for Down syndrome are offered as routine testing during
pregnancy. They’re usually provided during the first and second trimesters. These
screens measure hormone levels in the blood to detect abnormalities and use an
ultrasound to look for irregular fluid buildup in the baby’s neck. Screening tests only
provide the likelihood of a baby developing Down syndrome. It cannot diagnose Down
syndrome. They can determine, though, whether more tests are needed to confirm the
diagnosis.3

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 Diagnostic tests

Diagnostic tests can confirm if your baby has Down syndrome before
it’s born. The two most common diagnostic tests are chorionic villus sampling
and amniocentesis. Both tests take samples from the uterus to analyze
chromosomes. Chorionic villus sampling uses a sample of the placenta to do
this. This test can be completed in the first trimester. Amniocentesis analyzes an
amniotic fluid sample surrounding the growing fetus. This test is typically
performed in the second trimester. 3

Mosaic Down syndrome is typically described through a percentage. To

confirm mosaic Down syndrome, doctors will analyze chromosomes from 20
cells. If 5 cells have 46 chromosomes and 15 have 47 chromosomes, a baby has
a positive mosaic Down syndrome diagnosis. In this case, the baby would have
a 75 percent level of mosaicism.3

2. Explain the principal of various chromosom examination!

3. Discuss the advantages and disadvantages of using each of the technique for
diagnosis!

Karyotyping

Karyotyping is common chromosome analysis refers to alaysis of metaphase

chromosomes. The methapase chromosomes bended using typsin and added by giemsa,
leishmanns or a mixture of them. This mixture will creates unique banding of
chromosomes. It likely related to chromatin packing and replication timing.4

Slide preparation

Cells from blood, bone marrow, amniotic fluid, tumor, cord blood and tissues
(including skin, liver, chorionic villi, umbilical cord, and many other organs) first must
be cultured in order to increase their number. After that A mitotic inhibitor (colcemid,
colchicine) can be added into cultured cell. Micotic inhibitor will stops cell division at
mitosis which will make it easily for analysis. After that the cells centrifuged, media of

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cultured cell and mitotic inhibitor are removed, than replaced by a hypotonic solution,
the effect of that is lysis of the cell. After that Carnoy's fixative (3:1 methanol to glacial
acetic acid) is added, this reagent will hardens the nuclei and kills the cells. Remove any
debris of the cell, than drop the cell suspension into specimen slides. After aging the
slides in an oven or waiting a few days they are ready for banding and analysis.5

Analysis

Microscope is used to analysis the banded of the chromosomes, the number of

the chromosomes and the makro deletion and insertion can be analyze. The
chromosomes are photographed and rearranged into pairs for examination (a
karyogram).6

Adventages :

1. It Easy to use
2. It can view the entire genome.
3. It can visualize individual cells and individual chromosomes.
4. it only needed a low cost material

Disadventages :

1. Limited resolution (5 Mb)

2. An activaly growing source of cells is required
3. It cannot analyze micro deletion and micro insertion

FISH (Fluorescence in situ hybridization)

FISH (Fluorescence in situ hybridization) is a method that can detect how many
chromosomes of a certain type are present in each cell and to confirm rearrangements
that are suspected after microscope analysis. FISH also can detect small deletions and
duplications that can not be found by microscope analysis.7

FISH works only at the one specific area of a chromosome with exploiting the
ability of one DNA strand to hybridise specifically to another DNA strand. Probes (a
small DNA strands) have a fluorescent label attached to them, the probes are
complementary to specific parts of a chromosome. FISH usually used two of probes,

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they are The first probe (green) is a control probe used to identify both copies of the
chromosome under test. It hybridises to a sequence that is not part of the deletion, so a
signal is observed on each chromosome. The second probe (red) hybridises to the
sequence that may be deleted. A deletion is usually found in only one of the
chromosomes in a pair, therefore the probe can bind to the intact chromosome, but is
unable to bind to the deleted chromosome and only one signal is seen.7

When DNA is heated, the patient’s two DNA strands break apart, or denature,
and the probes are able to hybridise to their complementary sequence in the patient’s
DNA. If a small deletion is present in the region complementary to the probe, the probe
will not hybridise and only one bright spot can be seen of two. If a duplication is present,
more of the probe is able to hybridise so three bright spots can be seen.7

Advantages FISH :

- Diagnosis from FISH may prevent patients from many other tests
- FISH can detect many duplications, rearrangements, and deletion that can not
be seen with standard microscope analysis.
- FISH test can show specific genes are included in patient’s deletion or
duplication.
- Parents and other family members can be tested to see if they are carriers of
changes in their DNA, so they can reduce the risk having more children with a
chromosome abnormal.7

Disadvantages FISH :

- FISH testing not usually screen all the changes chromosomes. Most FISH probes
are specific for one particular deletion or duplication within one band of one
chromosome so it will only find what it is looking for
- FISH probes are only available for the most well characterised deletion and
duplication syndromes.
- FISH has limited ability to precisely define which genes and breakpoints are
involved in an imbalance.7

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Comparative Genomic Hybridisation

The CGH is a molecular cytogenetic analysis that particularly useful in solid

tumor to identify gained or losses of either whole or only sub part of cromosome by
comparing it with DNA reference. This technique was developed decade ago til today
this technique has improved by increased of the resolution, so we could se more detail
in cromosome. This tecnique use some dye (Cyanine 5,3) to give the DNA color (the
patient and the reference determined by color) and after that the special machine
(microarray) will scan the DNA thoroughly. After that the special software used to read
the result and we can analyze the result.8

The advantage of this technique, we didn’t need to do cell culture to analysis

more detail to cromosome than ordinary cytogenetic test, and also we can se the
abnormality of cromosome more detail such as loss or gaining little pice of cromosome
in particular place but, to do this technique its required a lot of tools, long preparation,
three days of analysis so the cost is high. maybe those can be considered as
disanvantage.8

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REFERENCES

1. National Down Syndrome Society. Down Syndrome. 2019 [cited 2019 Jan 23].
Available from: https://www.ndss.org/about-down-syndrome/down-
syndrome/.
2. Asim A, et al. Journal of Biomedical Science Down syndrome: an insight of the
disease. (2015) 22:41 DOI 10.1186/s12929-015-0138-y.
3. Kazemi1 M, Salehi M, Kheirollahi M. Down Syndrome: Current Status,
Challenges and Future Perspectives. IJMCM Review Article Summer 2016, Vol
5, No 3.
4. Lisa G. Shaffer and Niels Tommerup. 2005. ISCN 2005: An International System
for Human Cytogenetic Nomenclature. Switzerland: S. Karger AG. ISBN 978-
3-8055-8019-9.
5. Schröck E, du Manoir S, Veldman T, et al. 1996. Multicolor spectral karyotyping
of human chromosomes. Science. 273 (5274): 494–7.
Bibcode:1996Sci...273..494S. doi:10.1126/science.273.5274.494.
PMID 8662537.
6. Rooney E. 2001. Human Cytogenetics: constitutional analysis. 3e édition.
Oxford University Press
7. Edwards, A. A. (2000) ‘Fluorescence in situ hybridisation (FISH)’, Radiation
Protection Dosimetry, 88(1), pp. 5–6. doi: 10.1093/oxfordjournals.rpd.a033019.
8. Beheshti B, Park PC, Braude I, Squire JA. Microarray CGH. In: Y.-S. Fan (Ed.),
Molecular Cytogenetic: Protocols and Applications, Humana Press: 2002.