Readings

Intro
- Not all genetic disorders manifest in infancy and childhood
- Heredity disorders: derived from ones parents, are transmitted by gametes through the generations and therefore familial
- Congenital: “present at birth”
o Some are not genetic

Nature of Genetic Abnormalities Contributing to Human Disease

- Several types of genetic abnormalities that affect the structure and function of proteins, disrupting cellular homeostasis and contributing
to disease

Mutations in Protein-Coding Genes

- Mutation: permanent changes in the DNA
o Those that affect germ cells are transmitted to the progeny and may give rise to inherited diseases
- Mutations in somatic cellsa re not transmitted to the progeny but are important in the causation of cancers in some congential
malformations
- Point mutations: result from substitution of a single nucleotide base by a diff base
o Results in the replacement of one amino acid by another in the protein product
o Ie., the mutation in the B-globin chain of hemoglobin giving rise to sickle cell anemia
o Aka missense mutations
o Certain point mutations may change an amino acid condon to a chain termination codon, or a stop codon
 Inerupt translation and in most cases RNAs are rapidly degraded (nonsense mediated decay)
 Results in little to no protin being formed
- Frameshift mutations: occur when insertion or deletion of one or two base pairs alters the reading frame of th DNA strand
- Trinucleotide repeat mutations: special bc these mutations are characterized by amplfcation of a sequence of three nucleotides
o Varies with diff disorders > but all share the nucleotides Guanine and Cytosine Three Major Categories of Genetic
o Ie., fragile X syndrome Disorders…
1. Mendelian Disorders
Alterations in Protein-Coding Genes Other than Mutations 2. Complex disorders
- Can also undergo structural variations (ie., copy number changes – deletions or 3. Diseases arising from
amplifications – or translocations chromosomal
- Result in aberrant gain or loss of protein function abnormalities
- May coccur in the germlie or be acquired in somatic tissues
- Cancers often contrain somatically acquired structural alterations
o Ie., the “Philadelphia chromosome” (translocation of 9 and 22
btwn the BCR and
ABL genes in chronic myeloid leukemia
- Alterations in Non-Coding RNAs
o Non-coding RNAs have important regulatory functions

Mendelian Disorders: Diseases Caused by Single-Gene Disorders

- Resulting from mutations in single genes that follow the well-nown
medenalian patterns of inheritance
- Show high penetrance, meaning that most indcs who inherit the
anomaly show phenotypic effects
- These disease are hereditary and familiar
- The include many uncommon conditions ie., storage disease and inborn
errors of metabolism
- Rare – account for approx. 1% of all adult admissions to hostpials and 6-
8% of all pedatric admissions
- Mutations involving single genes follow one of three patterns of
inheritance: autosomal dominanent, autosomoal recessive or X-linked
- May have many phenotypic effects (pleotropy)
- Mutations are several genetic loci may produce the same trait (genetic
heterogeneity)
o Ie., Marfan syndrome: basic defect in connective tissue with widespread effects involving the skeleton, eyes and CV system all
of which stem from a mutation in the gene encoding fibrillin (a component of CT)
- Several diff types of mutations can cause retinitis pigmentosa, an inherited disorder assocaiated with abnormal retinal pigmentation and
visual impairment
- Recognition of genetic heterogenetiy is important for counseling and the pathogenesis of common disorders ie., diabetes mellitus
- The phenotypic manifestations of mutations affecting a known single gene are influenced by other genetic loci (aka modifier gene)
Transmission Patterns of Single-Gene Disorders
- Disorders of autosomonal dominant inheritance
o Manifested in the heterozygous state – so at least one parentin a case usually is affected
o Both males and females can be affected
o Both sexed can transmit the condition
o When an affected person marries an unaffected one, each child has 50% of having the disease
o Features:
 Some patients do not have affected parents
 Owe disorder to new mutations involving either the egg or sperm from which they were derived – their
siblings are neither affected nor at an increased risk
 Clinical features can be modified by reduced penetrance and variable expressivity
 Some ppl inherit the mutant gene but are phenotypically normal (called reduced penetrance)
 Not fully understoof
 Variable expressivity: if a trait is consistently associated with a mutant gene but is expressed differently
among ppl carrying the gene
o Ie., neurofibromatosis 1 range from brownish spots on skin to tumors and skeletal deformities
 In many conditions, the age at onset is delayed and symptoms and signs do not appear until afultkhood
 Ie., huntingtons diseasae
 A 50% reduction in the normal gene product is associated with clinical signs and symptoms
 Bc 50% loss of enzyme activity can be compensated for, involved genes in autosomal dominant disorders
usually do not encode enzyme proteins and instead fall into 2 other categoeires of proteins
o Those involved in regulation of comlex metabolic pathways, often subject to feedback control
 Ie., familial hypercholesterolemia, which results from mutation in the low-density
lipoprotein (LDL) receptor gene
o Key structural proteins, ie., collagen and components of the red cell membrane skeleton
 Ie., spectrin, abnormalities of which result in heredity spherocytosis
- The biochem mechanisms by which 50% reduction in thelevels of such proteins results in an abnormal phenotype are not fully understoof

Disorders of Autosomal Recesive Inheritance

- Are manifestedin the homozygous state
- They occur when both of the alleles at a given gene locus are mutants > thus such disorders are characterized by:
o The trait does not usually affect the parents who are carriers of one diseased allele, but multiple sbling may show the disease
o Siblings have 25% chance (for each birth) of being affected
o If the mutant gene occurs with a low frequency in the popn, there is a strong likelihood that the affected patient is the product
of a consanguineous marriage
- Features:
o The expresson of the defect tends to be more uniform
than in autosomal dominant disorders
o Complete penetrance is common
o Onset is frequently early in life
o They are rarely detected clinically
 Bc the affecter person is an asympticatic
heterozygote, several generations may pass
before the descendants produce affected
offspring
o In many cases, enzymes are affected by the mutation
  In heterozygotes, equal amounts of normal and defective enzyme are synthesized

X-Linked Disorders
- Y chromosome is home to testes-determining gene SRY
- Most are recessive and characertized by:
o Heterozygous female carriers transmite them only to sons, who are hemizygous for the X chromosome
o Heterozygous females rarely express the full phenotypic
change bc thy have the paired normal allele
 Although one X in the females is inactivated, this
process is random
o An affectd male does not transmit the disorder to sons, but all
daughters are carriers
 Sons of heterozygous women have 50% change of
receiving the mutant gene

Diseases Caused by Mutations in Genes Encoding Structural Proteins

- Marfan Syndrome
o Autosomal dominant disorder of CT
o Manifested by changes in the skeleton, eyes and CV system
o Caused by an inhterited defect in the extracellular
glycoprotein called fibrillin-1
 Fribroblasts secret Fibrillin-1 > which is a major
component of microfibrils found in the
extracellular matrix
 Microfibrils serve as scaffolding for deposition of
tropoelastin (an integral component of elastic
fibers)
 These microfibrils are everywehere but abundant in
the aorate, ligraments and ciliary zonules that
support the ocular lens (all tissues that are
prominently affected in the syndrome)
o Fibrillin is encoded by the FBN1 gene > mutations in FBN1
are found in all patients with Marfan syndrome
 Over 1800 causative mutations have been found
o Prevalence is estimated to be 1 in 5000
o Approx. 70-85% of cases are familial
 Rest are sporadic, arising from de novo FBN1 mutations in the germ cells of parents
o Angiotensin receptor blockers imporove aortic and cardiac function in mice
o Prevention of CV disease entails use of beta-aderenergic blocking agens, which lower BP
 As well as angiotensin receptor inhibitors, which not only lower BP but also interfere with TGF-B activity

- Ehlers-Danlos Syndromes
o A group of disease characterized by defects in collagen synthesis or structure
 All are single-gene disorders, but the mode of inheritance encompasses both autosomal dominant and recessive
patterns
o Approx. 30 types of collagen, al have characteristic tissue distributions and are products of diff genes
o At least 6 clincial and gentic variants of EDS ar recognized:
 Tissues rich in collagen (ie,, skin, ligaments and joints) are frequently affected in most variants of EDS
 Bc the abnormal collagen fibers lack adequate tensile strength, joints are hypermobile
o Permit grotesque contortions (ie., bending the knee upward)
 Results in predisposition to joint dislocation
 Skin fragility – minor injuries produce gaping defects and surgical repair or intervention is accomplished only with
great difficulty bc of the lack of normal tensile strength
 Structural failure of organ or tissues – the structural dfet in CT may leads to serious internal complications (ie.,
rupture of the colon and large arteris (vascular EDS), ocular fragility, retinal detachment (kyphoscoliotic EDS),
diaphgramatic hernias (classical EDS))
o Molecular bases for 3 of the more common variants are:
  Deficient synthesis of type 3 collagen resulting from mutatiojns affecting the COL3A1 gene
 Vascular EDS
 Inherited as an autosomal dominant disorder
 Characterize dby weekness of tissue rich in type 3 collagen (ie., blood vessels, bowel wall), presdisposing
them to rupture
 Deficiency of the enzyme lysyl hydroxylase
 Kyphoscoliotic EDS
 Inherited as an autosomal recessive disorder
 Decreased hydroxylation of lysyl residures in types 1 and 3 collagen intereferes with the formation of
crosslinks among collagen mols
 Patients typrically manifest with congential scoliosis and ocular fragility
 Deficient synthesis of type 5 collagen
resulting from mutations in COL5A1 and
COL5A2
 Inherited as an autosomal
dominant disorder
 Results in classical EDS

Diseases Caused by Mutations in Genes Encoding Receptor Proteins or

Channels
- Familial Hypercholesterolemia
o Autuosomal dominant disease
 Heterozygotes have twofold- to threefold- elevation of plasma cholesterol levels
 More than 900 diff mutations have been found
 Class 1: are uncommon; associated
with complete loss of receptor
synthesis
 Class 2: the most prevalent type;
the receptor protein is
synthesized, but its transport from
the endoplasmic reticulum to the
Golgi apparatus is impaired bc of
defects in protein folding
 Class 3: produce receptors that are
transported to the cell surface but
fail to bind LDL normally
 Calss 4: receptors fail to internalize
within clathrin pits ater binding to
LDL
 Class 5: encode receptors that can
bind LDL; are internalized but are
trapped I endosomes bc
dissoaciton of receptor and bound LDL does not occur
 Homozygotes may have an excess of a fivefold elevation
o Although cholesterol levels are elevated from birth, hetero remain asymptomatic until adult life, when they develop colesteral
deposits (xanthomas) along tendon sheaths and premature altherosclerosis resulting in coronary artery disease
 Homozygotes are much more severely affected, developing cutaneous infarction before the age of 20 yrs
o Is a “receptor disease” caused by loss-of-function mutations in the gene encoding the LDL receptor, which is involved in the
transport and metabolism of cholesterol
o As a conosequence of receptor abnormalities there is a loss of feedback control that normally hols cholesteral synthesis in
check
o Results in elevated levels of cholesterol which can induce premature altherosclerosis and grealy increase th risk of MI
o Among the most common of mendelian disorders
o The frequency of the heterozygous codition is 1 in 500 in the gernal popn
o Approx. 7% of the bodys cholesteral circulates in the
palsma, predominantly in the form of LDL
 The amount of plasma cholesteral is influenced by
its synthesis and catabolism
o Pathogenesis
 Mutations in the LDL receptor protein impair the
intracellular transport and catabolism of LDL,
resulting in accumulation of LDL cholesterol in the
plasma
 o Patients with the disease develop excessive levels of serum cholesterol as a result of the combined effects of reduced
catabolism and excessive biosynthesis
 Leads to increase of cholesterol uptake
o With fewer LDL receptors on the cell surface, there is reduced uptake of plasma LDL, leading to hypercholesterolemia
o Statin family drugs are now used to lower plasma cholesterol
 They promote greater synthesis of LDL receptors
- Cystic Fibrosis
o A disorder of epithelial ion transport affecting fluid secretion in exocrine glands and the epithelial linings of the resp, GI and
repro tracts
o The ion transport defects lead to abnormally viscid mucous secretions that block the airways and the pancreatic ducts
 In turn, are responsible for the two most important clinical manifestations:
 Recurrent and chronic pulmonary infections
 Pancreatic insufficiency
o Although the exocrine sweat glands are structurally normal, a high level of sodium chloride in the sweat is a consistent and
characteristic biochem abnormality in CF
o The variation in phenotype results from diverse mutations in the CF-associated gene, tissue-specific effects of loss of the CF
gene’s function and the influence of disease modifier genes
o Incidence of 1 in 2500 live births
o Most common lethal genetic disease that affects white popns
o Autosomal recessive transmission
 Although even heterozygous carriers have a predisposition toward pulmonary and pancreatic disease at higher rates
than the general popn
o Pathogenesis
 The primary defect in CF is reduced production, or
abnormal function, of an epithelial chloride channel protein
encoded by the CF transmembrane conductance regulator
(CTFR) gene
 Disruptive mutations in CTFR render the epithelial
membranes relatively impermeable to chloride ions
 The impact of this defect on transport function is tissue
specific
 The major function of the CTFR protein in the sweat glad
ducts is to reabsorb luminal chloride ions and augment
sodium reabsorption through the epithelial sodium channel
(ENaC)
 Therefore, in the sweat ducts, loss of CTFR function leads to
decreased reabsorption of sodium chloride and production of hypertonic (salty) sweat
 CTFR in the resp and intestinal epithelium is one of the most important avenues for active secretion of chloride
 At these sites, CTFR mutations result in loss or reduction of chloride
secretion into the lumen
o Resp and intestinal complications in CF seem to stem from dehydration of surface
fluid layer
o In the lungs this dehydration leads to defective muscociliary action and the
accumulation of concentrated, viscid secretions that obstruct the air passages
and predispose to recurrent pulmonary infections
o In addition to chloride, CTFR also regulates secretion of bicarbonate ions
 Pancreatic insufficiency, a feature of classic CF, is virtually always present in
patients who carry CTFR mutations with abnormal bicarbonate
conductance
o More 1800 disease-causing mutations have been ID
 They may result in reduced quantity of functional CTFR that reaches
the cell surface or reduced function of CTFR that reaches the cell surface
 These diffs impact on the development of tx strategies
 That can also be classified as severe or mild
o The most common sever CTFR mutation is a deletion of 3 nucleotides coding for
phenylalanine at amino acid position 508 > causes total loss of CTFR, found in approx. 70% of patients with CF
o Since CF is an autosomal recessive disease, affected ppl harbor mutations on both alleles
Clinical Course: CF
- Approx. 5-10% of the cases come to clinical attention at birth or soon after bc of an attack on meconium ileus
- Exocrine pancreatic insufficiency occurs in a majority (85-90%) of patients and is
associated with “severe” CTFR mutations
o 10-15% of patients who have 1 “severe” and 1 “mild” CTFR mutation, or
two “mild”, retain sufficicnet pancreatic exocrine function
- Pancreatic insufficiency is assocaited with malabsorption or protein and fat and
increased fecal loss
- Manifestations of malabsorption (ie., large, foul-smelling stools, abdominal
distention, poor weight gain) appear during the first year of life
- The faulty fat absorption may induce deficiency states of fat-soluble vitamins,
resulting in manifestations of avitaminosis, A, D, or K
- Hypoproteinemia may be severe enough to cause generalized edema
- Persistent diarrhea may result in rectal prolapse in 10% of kids with CF
- The pancrease-sufficient phenotype usually is not associated with other GI
complications > these patients experience excellent growth and development
- Endocrine insufficiency (ie., diabete) is uncommon in CF and occurs ate in the course
of the diease, esp with improved survival of patietns with CF
- Cardioresp complications (ie., chronic cough, persistent lung infections, obstructive
pulmonary disease, and cor pulmonale) constitute most of the common cause of
death
- Management of acute and chronic complications of CF – anti-microbial therapies, pancreatic enzyme replacement and bilateral lung
transplantation

Diseases Caused by Mutations In Genes Encoding Enzyme Proteins

- Phenylketonuria (PKU)
o Results from mutations that causea severe lack of enzyme phenylalanine hydroxylase (PAH)
o Affect 1 in 10,000 live-born white infants
o Several variants of this disease – most common in Scandinavian descent referred to as classic phenylketonuria
o Homozygotes with this autosomal recessive disorder classically have a severe lack of PAH, leading to hyperphenylalaninemia
and PKU
o Affected infants are normal at birth but within a few weeks exhibit a rising plasma phenylalanine level, which impairs brain
development
o Usually at 6mo of life, severe mental retardation becomes all too evident
o Hyperphenylalaninemia and resultant mental retardation can be avoided by restricting phenylalanine intake early in life
o Many female patients with PKY who receive dietary tx beginning in early life reach childbearing age and are clinically normal
o Btwn 75-90% of children born to such women are mentally retarded and microcephalic and 15% have congential heart disease
even thoigh the infants are heterozygotes – termed “Maternal PKU”
 Results from teratogenic effects of phenylalanine or its metabolites that cross the placenta and affect specific fetal
organs during development
 Imperative to restrict phenylalanine in maternal diet before conception and throughout pregnancy
o The biocheme abnormality in PKU is an inability to convert phenylalanine into tyrosine
 In normal kids, less than 50% of the dietary intake of phenylalaine is necessary

Complex Multigenic Disorders

- Involves multiple genes as well as environ influences
- Aka multifactorial disorders
- Include some of the most common disorders ie., hypertension, diabetes, allergic and autoimmune
diseases
Cytogenetic Disorders
- Ie., changes in the number or structure of chromosomes
-

Lecture

Introduction to Clinical Genetics

Fields Within Medical Genetics

- Cytogenetics
- Molecular Genetics
- Biochemical Genetics
- Clinical Genetics
o Canadian College of Medical Geneticists (FCCMG)
o Royal College of Physicians and Surgeons (FRCPC)
o Diagnosis, genetic counselling, and care of patients with genetic disorders
o Prenatal diagnosis
o Cancer genetics
o Newborn screening
o Metabolic genetics
o Popn screening and preventative medicine

The Load of Genetic Disease

- Miscarriages
o Half of all miscarriages have a chromosome abnormality
o 15%
- Congenital Anomaly at birth
o 3%
- Chromosome Anomaly at birth
o 0.6%
- Pediatric admissions
o 10%

Genotype vs. Phenotype

- Phenotype: observable characteristics of an indv
resulting from the interaction of its
genotype with the environ
- Genotype: the genetic constitution of an indv
organism

What should you consider a possible genetic disorder?

- Developmental delay, dysmorphic features, or congenital malformations
- A positive family history of a genetic disorder
- Recurrent miscarriages/stillbirths
o May be a balanced translocation
- Consanguinity: the fact of being descended from the same ancestor (inbredding)
- Ethnic background
 o Some disorders become more common due to founder effect/consanguinity
 Ashkenazi jewish – Tay-Sachs, BRCA1
 Mediterranean – beta-thalassemia
 Southeast Asian – alpha-thalassemia
 Amish/Mennonite and Arab – various rare disorders
 African – sickle cell anemia
 Caucasian – cystic fibrosis

Introduction to Mendelian Disorders

George Mendel: Father of Genetics

- Was a scientist and a friar
- Born in a German-speaking family in Austrian Empire
- Worked with 7 characteristics of pea plants: plant height, pod
shape and colour, seed shape and colour and flower position and
colour
- Designed Punnet Squares and concept of alleles
o Two copies of everything, depending on alleles we have, can
produce diff outcomes

Autosomal Dominant Inheritance

- Run in families
- Patterns of Inheritance
o Ppl with the condition in each generation
o Males and females affected in roughly equal proportions
o All forms of transmission present
 Male to female, male to male, female to male,
female to female
- Genes outside of our sex chromosomes
- Chances of recurrence is high – 50% of passing on
gene
- All you need is the one copy to be transferred to
offspring for that child to be affected as well
o The back-up copy that doesn’t have the
gene doesn’t matter, bc of the dominance of
the other gene

Polycystic Kidney Disease

- Autosomal Dominant
- Bilateral renal cysts
- Liver cysts
- An increased risk of intracranial aneurysms
- Mutations in PKD1, PKD2 (GANAB, or DNAJB11)

Autosomal Recessive Inheritance

- Patterns of inheritance
o Males and females have the condition in roughly equal proportions
 o Ppl with the conditions are usually in one sibship in one generation
 Doesn’t necessarily happen in all
generations
o Consanguinity increases the number of
indvs affected – when the two copies
that are affected are passed down =
child is affected
- Carrier is healthy (don’t show signs of
condition)
o When two carriers meet, their backup
copy compensates for the bad gene
o Its only when that back up is lost in offspring that condition may appear

Cystic Fibrosis
- High carrier frequency in European popn
- Mutations in the CTFR gene
- Starts to affect mucus and motility of the cilia
- Some symptoms include sinus/lung disease, gut involvement, pancreas dysfunction

X-Linked Inheritance
- Males affected almost exclusively
- The gene alteration can be transmitted from female carriers
(asymptomatic) to sons
- Affected males cannot transmit the condition to their sons (no male-to-
male transmission bc of Y chromosomes)
- Carrier females may be mildly affected or fully
affected due to skewed X inactivation
o Depends on how much of the good/bad x they
have
- Outcomes:
o Mom to pass on the change if X
chromosome is passed onto son, to be
affected
o Daughter will be a carrier like mom

Why are males affected by X-linked disorders?

- Only 1 X chromosome, don’t have a backup X – only takes mutation in the one X to have condition
- Must express all X-linked genes
- Hemizygous
Most carrier (heterozygous) females are not affected by X-linked disorders
- The normal gene usually produces enough gene product to prevent symptoms

X-inactivation
- Sometimes women can be affected/mildly symptomatic
- Happens bc of inactivation
- Process is random
o We have two X’s
o Body requires just one X to be active
o The other X will be switched off
o Depending on which X is switched off, may or may not have
symptoms

Duchenne Muscular Dystrophy

- Affected males die in their 20’s, cannot reproduce
- Mutation may be inherited from mother or de novo (new)
- High spontaneous mutation rate (1/3 cases)
- Normal vs. DMD muscle
o Breakdown of the muscle

Mitochondrial DNA Disorders

- All mitochondria are inherited from the mother through the
egg
- Mitochondria have their own circular DNA
- Maternal Inheritance

- Mom may have no-to-mild symptoms, but all

children will be affected
 o Bc the eggs will all have mtDNA
- Mitochondrial Multisystemic Disorders
o Affects many systems

Introduction to Chromosomal Disorders

DNA
- Chromosome made of DNA
- 23 pairs of chromosomes and 25,000 pairs of genes

G (Giemsa)-banded Chromosomes
- Look at G-band under microscope
- 23rd pair is sex chromosome
- Euploid
o Chromosome
o Karyotype

Chromosomal Disorders
- Numerical chromosome anomaly
o Error of meiosis (1 or 2) – results in aneuploidy
(monosomy or trisomy) or triploidy
- Structural anomaly
o Error of recombination
How do numerical chromosome abnormalities (aneuploidy) arise?
- Normal meiosis

- Nondisjunction during Meiosis 1 is the most common cause of trisomy 21

o 47, XY, +21

 3 separate #21 chromosomes
o Happens in moms of older age
 Bc chromosomes in older eggs are sticky

Down Syndrome
- Extra chromosome 21
 - Distinct facial features
- Developmental delay
- Heart defects
- On a spectrum of presentation

Trisomy 21
- Nondisjunction 93%
- Translocation. 5%
o Extra chromosome 21 on chromosome ie., 14
- Mosaic 2%
*** diff etiologies have different risk and potentially diff prognosis

Structural Chromosome Anomalies

- Caused by error of recombination
- May be balanced
o Translocation (reciprocal or Robertsonian)
o Inversion
- May be unbalanced
o Deletion
o Duplication
o Translocation
o Inversion

Balanced Reciprocal Translocation

- No clinical effects for carrier, but risk for carrier to have stillbirths or miscarriages

- Outcomes for offspring of Balanced Translocation Carriers

o Embryo’s that have a balance or imbalance

Chromosome Disorders to Know

- Trisomy 13: Patau Syndrome
o Midline defects common
o Cleft palate
o Extra fingers
o 80-90% die in first year
o Severe developmental delay
- Trisomy 18: Edward Syndrome
o Most are females (5:1)
o Frequent cardiac defects
o 80-90% die in first year
 o Marked developmental delay
- Turner Syndrome (45X, born with just 1 X) Figure 1: Edward Syndrome
o Only survivable loss of chromosome
o Puffy hands and feet at birth
o Webbed neck
o Coarctation of aorta
o Short stature
o Primary amenorrhea and infertility (streak ovaries)
o Normal intelligence
- Klinefelter Syndrome (47, XXY)
o Tall stature
o Excess breast development (gynecomastia)
o Small testes
o Infertility
o May have learning disability
o Normal appearance Figure 2: Klinefelter Syndrome