Genetics Summary

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1. Methods of human genetic study. Pedigree construction: symbols, pedigree

drawing, assessment. Twin study.
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2. Methods of human genetic study. Molecular-genetic methods. Principles

and approaches for DNA analysis. Direct DNA analysis – principles, techniques
and application.
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3. Methods of human genetic study. Molecular-genetic methods. Principles

and approaches for DNA analysis. Indirect DNA analysis – principles,
techniques and application.
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4. Methods of genetic study. Cytogenetic methods – materials, steps in

cytogenetic preparation (banding staining techniques), clinical indication for
analysis.
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5. Chromosomal mutations – types (numerical and structural), mosaicism,

mechanism, clinical significance, recurrence risk.
→ Normal human cells contain total 46 chromosomes or 23 pairs of chromosomes
• 22 pairs of autosomes and one pair of sex chromosomes/ XX or XY
During the cell division we can identify chromosomes, mainly in metaphase of the cell division
Haploid → set of 23 chromosomes (the normal complement of reproductive cells/ gametes)
Diploid → normal number of 46 chromosomes (the normal complement of somatic cells)
Normal karyotype
Karyotype → a picture of the
chromosomes from a single cell,
ranked according to their size
and structure.
• 46, XX – Female karyotype
• 46, XY – Male karyotype
Chromosome structure
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Chromosomal disorders
→ pathological conditions or disorders due to numerical or structural (microscopically detectable) alteration is
human karyotype, associated with disturbance in the total amount of genetic material and leading to a wide
range of clinical manifestation.
Etiology
Chromosomal disorders are due to different type of chromosomal alterations/ mutations:
Classification of chromosomal abnormalities
• Numerical abnormalities
• Structural abnormalities
or
• Anomalies affecting autosomes (from 1st to 22nd chromosome)

• Anomalies affecting sex chromosomes/ gonosomes (x, y)
or
• Balanced chromosomes rearrangements – structural rearrangements with dislocation of

chromosomal regions without change in the total amount of genetic material
• unbalanced chromosome rearrangements – associated with loss or gain of genetic material
Types (numerical and structural), mosaicisms, mechanism
Numerical abnormalities
• Haploid: Set of 23 chromosomes (normal complement of gametes)
• Euploid: Any exact multiple of haploid complement (diploid and polyploid) n x 23
• Diploid: Normal number of 46 chromosomes (normal complement of somatic cells) 2n=46
• Polyploid: triploid 3n=69, tetraploid 4n=96
• Aneuploidy: Chromosome complement that is not an exact multiple of haploid 23, extra or
missing single chromosome
o Presence of an extra chromosome – trisomy (trisomy 21)
o Absence a single chromosome – monosomy (monosomy X)
▪ Mechanism:
– Nondisjunction (most common)
– Anaphase lag (loss of chromosome when it moves to the pole during
anaphase of cell division.
Polyploidy 3n, 4n
Triploidy (n=69) and tetraploidy (n=92) are usually lethal conditions most common seen in spontaneous
abortion and very rarely in newborns (with short survival).
▪ Mechanism: → Abnormal events prior or during fertilization.

o Triploidy is result from fertilization of a single haploid egg by two haploidsperms
o Tetraploidy is result of normal meiotic division but failure of cytoplasmic cleavage at 1st
division of the zygote.
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Aneuploidy
• Trisomy = presence of an extra chromosome

o Although autosomal and sex chromosome trisomers result in clinical abnormalities they
are more viable than monosomies (with exception of monosomy X)
o Nonmosaic trisomies are described for different chromosomes, e.g.: trisomy 21, 13, 18,
16, 15, 14, 12
o They are present mainly in spontaneous abortions, stillbirths and less common in live
born babies.
• Monosomy
o Monosomy of an entire chromosome is usually associated with lethal effect and
monosomies are not present in newborn
o The only compatible with life monosomy of an entire chromosome is monosomy X (45, X
– Turner syndrome)
o Moreover, fewer than 5% of 45, X conception actually survive to birth
▪ Mechanisms:
→ Non-disjunction – Usually is accidental error (de novo), leads to different
consequences depending on the type of cell division when occurred
- Meiosis – most of the aneuploidy are result of errors in maternal
meiosis I, less often meiosis II (association with maternal age)
- Mitosis – Increasing frequency of occurring is observed along with
increasing of maternal age, maternal hypothyroidism, as familial
predisposition
→ Meiotic error (de novo) – non-disjunction results in an aneuploidy gamete and

after fertilization, in aneuploidy zygote.
– Consequences – all of the somatic cells of the individual are with the
same specific chromosomal abnormality (e.g. 47, XX, +21)
Mosaicism
• Due to non-disjunction or error in mitotic division of the blastomeres (in the early embryonic
development before gastrulation) – give rise to 2 or more population of cells (cell lines) with
different chromosomal complement in same individual. All cells derived from a single zygote.
o 46, XX/ 47, XX, +21 – Mosaic Dawn syndrome
o 45, X/ 46, XX – Mosaic Turner syndrome
o 45, X/47, XXX
• Most frequently involved sex chromosome than autosomes
• Mosaicism is found in approximately 0.2% of foetuses prenatally
o 1% of Down syndrome patients
o 10% of Klinefelter syndrome patients
o Over 30% of Turner syndrome patients
• Clinical significance or features depends on the proportion and tissue distribution of the
aneuploidy cells
Clone of cells and malignancy
In contrast, this is an error in mitotic division occurring in a single somatic cell (of specific tissue) that gives rise
a clone of cells with aberrant karyotype. Cancer and clones.
Chimerism
In contrast, the different cell lines are derived from more than one zygote (twin pregnancy).
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→ Relative frequency of different abnormalities in chromosomally abnormal spontaneous abortion:
• Trisomy (52-60%)
• 45, X (18-20%)
• Triploidy (15-17%)
• Translocations (2-4%)
Structural abnormalities
• Unbalanced rearrangements – deletion, duplication
o Another result → only a structural reallocation, no loss or gain of essential chromosome
material, no genes are damaged by breakage and reunion process.
• Balanced rearrangements – inversion, translocation
→ Mechanism:
The structural abnormalities are result of chromosome breaks, followed of loss of the broken fragment in
the next cell division or reunion with the same/another chromosome
• This event can result in loss or gain of genetic material (with consequence – Partial trisomy or
monosomy for a specific chromosome segment).
Unbalanced rearrangements
• Deletions
o Loss of a portion of chromosome
o Type of deletions: interstitial or terminal
o If big enough to be visible a deletion must be removing many genes and will probably
give rise to a severe phenotype
o A well-known terminal deletion involves the loss of material at the end of the short arm
of chromosome 5. It causes “Cri di Chat” syndrome
• Ring chromosome
o A mutation event which removes both telomeres and the chromosome can be repaired
by sealing the ends together forming a ring chromosome
o This will be deleted for genes at both ends of the chromosome.
o The symptoms will depend on the extent of the deletion
• Isochromosome
o A chromosome can split “the wrong way” in mitosis (or meiosis II) so that both long arms
remain attached and move to one pole and both short arms do likewise moving to
another pole.
o The consequence is the formation of an isochromosome.
▪ One arm is lost, the other arm is reduplicated.
• These are simultaneously duplicated for the genes in the other.
o The prognosis is poor except for i(Xq) (isochromosome of the long arm of the X).
• Duplications
o Genetic material from on chromosome is duplicated
• Insertion
o Genetic material is added from one to another chromosome
o They are result of non-reciprocal translocation
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• Microdeletions
o Chromosome’s deletions affecting small parts of the chromosome usually under
resolution of the routine microscope analysis
o Detection by combination of high-resolution prometaphase banding technique and
molecular genetic methods – FISH (Fluorescent in situ hybridization)
o Microdeletions covers a group of adjacent genes/ arranged alternately this group of
disorders is known as contiguous gene syndrome
o They are:
▪ Williams-Beuren Syndrome (WBS) → del (7) (q11.23)
▪ DiGeorge → del (22) (q11.2)
▪ Miller-Dicker Syndrome → del (17) (p13)
▪ Prader-Willi Syndrome → del (15) (q11-12) pat
▪ Angelman Syndrome → del (15) (q11-12) mat
▪ Rubistein-Taybi Syndrome → del (16) (p13.3)
Balanced rearrangements
• Inversion
o Two breaks in chromosome, the fragment turns upside down (180° rotation) and re-
attaches
o Type of inversions
▪ Paracentric – Two breaks are in the same arm
▪ Pericentric – Includes centromere/ one break in each arm
o Usually there is no genetic misbalance → no clinical effect for heterozygous.
o Consequences for reproduction of the carrier and genetic risk
▪ Special features of meiosis when the chromosome with inversion and its normal
homologue should be paired
▪ Crossing over within the inversion stich can produce gametes with recombinant
chromosomes (gain or loss of material)
▪ Carriers of inversions has risk to produce gametes with chromosomal
misbalance
o Consequence – Due to the lethal effect of chromosomal abnormalities such pregnancies

end with early spontaneous abortion and rarely with newborn with malformations
• Translocations
o Reciprocal translocation
▪ Exchange of material between two chromosomes a segment from one
chromosome is transferred to another chromosome and vice versa.
▪ In a balanced translocation, there is no gain or loss of chromosomal material,
two chromosomes have been broken and re-joined in the wrong combinations
o Robertsonian translocations
▪ Involved acrocentric chromosomes
▪ Fusion (in centromere region) of the long arms of two acrocentric chromosomes
with loss of their short arm
▪ This is balanced rearrangement because the lost genetic material contains only
multiple copies of ribosomal genes (there is no loss of unique DNA sequences)
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Clinical significance of chromosomal abnormalities
• Contribute significantly to genetic pathology resulting in:

o Reproductive failure (abortion, infertility, stillbirths)
o Congenital anomalies in newborn
o Disorders of sex development (DSD)
o Mental retardation
o Pathogenesis of malignancy
• Specific chromosomal abnormalities (CA) have been associated with over 60 identifiable clinical
syndromes
Incidence of spontaneous abortions, stillbirths and newborns:
• 95% of chromosomally abnormal conceptus are aborted spontaneously

o CAs present in at least 50% of spontaneous abortion (mostly in 1 st trimester, most common
due to Triploidy, 45 X, trisomy 16)
o About 5 6% of stillbirths/fetal deaths
o About 0,5 0,6% of newborns /1: 500 live births
• About 5% of couples with 2 or more miscarriages
• In women aged 35 or over, chromosomal abnormalities are
• detected in about 2% of pregnancies.
Recurrence risk
• Families with unexplained infertility /due to the carrier of balanced translocation
• Multiple abortions ≥ 2
• Prior case of pregnancy or newborn baby with multiple malformations
o Suspicious for chromosomal abnormalities?
o Cytogenetic analysis of the parents is recommended
• Presence of congenital anomalies in newborns

• Major anomaly 1.5% of newborns
• Single minor anomalies 15%
• Presence of 3 or more minor anomalies is unusual 1% of newborns, but 90% of them have at least one
associated major anomaly
• Cases with 3 or more anomalies may represent chromosomal abnormalities (detected in about 25-36%
of these cases).
o Cytogenic genetic analysis of the baby is recommended
→ 80 90% of all chromosomal disorders are non-inherited (result of coincidental /de novo chromosomal
mutation)
→ They are representing sporadic cases in the families
→ Result of de novo mutation during gametogenesis of a parent with normal karyotype
→ No significant recurrent risk (for subsequent pregnancy)
→ Very low proportion 10 20% of chromosomal disorders are Inherited (in the offspring of a parent with
abnormal karyotype)
o Associated with different in magnitude risk for recurrence
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6. Chromosomal disorders – autosomal chromosomal abnormalities

(numerical and structural): incidence; general clinical characteristics,
mechanism, recurrence risk, cytogenetic variants, examples of chromosomal
syndromes.
Normal karyotype
and structure.
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Etiology
or

or

Autosomal chromosomal abnormalities (numerical and structural)

Main clinical characteristics:
• Nonspecific clinical features

• Multiple congenital malformations (available at birth) affecting several organs/ body systems
• General features:
o Prenatal hypotrophy – low weight at birth
o Postnatal growth deficiency
o Cranio-facial abnormalities
o Congenital anomalies of internal organs (heart, kidney), skeletal, genital
o Reduced survival, high mortality
o Reproduction failure
Down syndrome – trisomy 21
• Incidence – from 1 in 600 in 1000

• Over 60% of these conceptions aborted spontaneously
• 20% stillborn
• Incidence increases sharply with maternal age
o 1/1600 <25 years old
o 1/300 for 35 years old
o 1/80 >40 years old
o 1/22 for 45 years old
• As a woman gets older, her chance of having a baby with a chromosome abnormality increases
• A woman is born with all of her egg cells, but meiosis is not yet complete (egg development stops in
prophase I until the follicle matures to ovulation)
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Clinical features
• Characteristics facial appearance

o Small nose, flat face, epicanthal fold, protruding tongue
• Short, broad hands, clinodactyly V
• Single, palmar crease
• Hypotonia without weakness
• Congenital cardiac and GI defect
• Mental retardation (av. IQ <50) socially do better with good environment (happy children)
• Multiple complications
o Hyperthyroidism
o Leukaemia (10 to 20-fold increases risk)
o Epilepsy
o Alzheimer (up to 25% over 40 years old)
o Impotency in males, some fertility
Cytogenetic variants
• 95% have trisomy 21 (chromosome number 47) with extra chromosome from mother mostly (95%) =
meiotic nondisjunction
• 3 - 4% cases are translocation = extra chromosomal material derives from presence of Robertsonian
translocation of long arm of chromosome 21 to acrocentric chromosome
o Small part of these cases could be inherited from a parent – carrier of the translocation.
▪ Cytogenetic analysis of the parent is recommended
o Another part of these, will arise de novo
• 1 - 2% cases are mosaics = mitotic nondisjunction
Recurrence risk:
• Trisomy 21 → 1%
• Translocation
o De novo → 1 – 2%
o Inherited:
▪ 10% when inherited from the mother
▪ 2 – 5% when inherited from the father
• Mosaicism → depends on the incidence
Edward Syndrome – trisomy 18

• Incidence: 1/8000 births
• Clinical features:
o Severe intrauterine growth retardation
o Microcephaly, Small face with prominent occiput
o Micrognanthia (mandibular hypoplasia)
o Small sternum and pelvis
o Flexion deformity of the finger
o Rocket-bottom heels
o Congenital cardiac defects (VSD) horseshoe kidney
• Rarely survive beyond 1 year
• Recurrence risk → low, unless due to parental translocation.
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Patau Syndrome – trisomy 13
• Incidence: 1/20 000

o Severe intrauterine growth retardation
o Microcephaly, midline brain defect (holoprosencephaly)
o Cleft lip and palate
o Polydactyly
o Malformation ear
o Micropthalmos and coroboma
o Cardiac and renal defects
o Scalp defect
o 50% die in first month, rarely survive beyond 1 year
• Recurrence risk → low, unless due to parental translocation.
Microdeletions Syndromes
Williams-Beurre syndrome (WBS)
• Incidence: (1/ 20 000) of all populations
• Phenotype:
o Dysmorphic facies
o Growth and mental retardation
o Distinctive personality
o Transient hypercalcemia
o Arterial diseases
• 1.5 MB deletion – del (7) q11.23
• Region flanked by duplicated genes; non-homologous recombination
o 17 genes including ELN, which encodes tropoelastin (point mutation causes AD supravalvular
aortic stenosis).
Chromosome 22q11.2 deletion syndrome
• Small deletion of band q11.2 on long arm of chromosome 22

• Incidence: 1 in 4 000 births
• Included the cases of syndromes:
o Velo-cardio-facial/Shprintzen
o DiGeorge with the deletion 22q11.2
o Congenital heart defects
o Palatal abnormalities
o Facial dysmorphism
o Development delay
o T-cell immunodeficiency
o Hypokalemia
• High risk for schizophrenia disorder
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Prader – Willi syndrome (PWS)
• Incidence: 1/10 000

• Phenotype:
o Mild to moderate mental retardation/ MR
o Hypotonia, poor feeding in infancy
o Short stature, small hands and feet, small external genitalia
o Almond shaped blue eyes
o Polyphagia (compulsive overeating), obesity
• Del (15) (q11-13), paternal → 75% of cases
• Uniparental disomy – maternal
Angelman Syndrome
o Severe MR, absence of speech
o Inappropriate laughter – “Happy puppet syndrome”
o Decrease pigmentation of choroid or iris (pale blue eyes)
o Ataxia and jerky movement
o Large jaw
• Del (15) (q11-q13), maternal – 70%
• Uniparental disomy – paternal
Mechanisms of genomic imprinting

• Prader Willi and Angelman are syndromes with unusual pattern of inheritance that present specific
genetic mechanism of genomic imprinting
• Genomic imprinting – epigenetic phenomenon by which certain genes are expressed by different
manner depending of genomic imprinting
o If allele inherited from father is imprinted, it is thereby silenced and only the allele from
mother is expressed
o If allele from mother is imprinted → only allele from father is expressed
• Biochemical base of imprinting: differential DNA methylation/histone acetylation leads to inactivation

of gene/genes – silencing of gene
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7. Chromosomal disorders – sex chromosomal abnormalities: incidence;

general clinical characteristics, mechanism, recurrence risk, cytogenetic
variants, examples of chromosomal syndromes.
Normal karyotype
and structure.
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Etiology
or

or

Sex chromosomal abnormalities

Main characteristics:
• Because of X inactivation and paucity of genes of the Y chromosome, aneuploidies involving the sex
chromosomes are far more common than those involving autosomes
• Found most often in puberty of reproductive age
• No rough malformation (available at birth)
• Somatic features → mainly affecting stature
• Mental retardation is not obligatory in classical variants
• The most important clinical feature is reproductive failure (infertility)
Turner syndrome
• Monosomy of X chromosome – Complete or partial

• Hypogonadism in phenotypic females (ovarian, failure, infertility)
• Incidence: 1 in 2 000 live born females (fewer than 5% of 45, x conceptions actually survive to births).
• Cytogenetic variants:
o 57% of cases missing an entire X chromosome → 45, X
o 29% are mosaics
▪ 45 X/ 46, XX
▪ 45 X/ 46, XY
▪ 45 X/ 47, XXX
▪ 45 X/ 45, X, i(X), q(10)
o 14% have structural abnormalities of X chromosome
▪ Deletion of small arm-isochromosome of long arm → 46, X, i(X)(q10)
▪ Deletion of portion of both long and short arm-ring chromosome → 46, X, r, (X)
▪ Deletion of portion of short or long arm – 46, X, del(Xq)
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o Generally asymptomatic “till puberty”
o Female, primary amenorrhea, underdeveloped breast
o Short stature, low hair line, Webbed neck, Shield chest
o Heart disease (coarctation of the aorta), renal malformations, hypothyroidism
o Ovaries generally underdeveloped, sterile/ hormone replacement therapy helpful
o Normal IQ
o Neonatal: wide spaced nipple, lymphedema, shield chest, down slanting palpebral fissure
Klinefelter syndrome
• Male hypogonadism occurs when there are 2/ more X chromosome and one/ more y chromosome
• Incidence: 1 in 500-660 live male births
o Usually asymptomatic with the exception of sterility
o Small, atrophic testis, spermal impairment (azoospermia, olygospermia) – hormone therapy
improves symptoms
o Rarely classical phenotype: eunuchoid body habits, gynecomastia, elongated limbs
o IQ is 98 (normal) with mild decreases in verbal IQ
o Higher risks of breast cancer, extragonadal germ cell tumor, autoimmune diseases, type 2
diabetes
• Cytogenetic variants:
o 80-90% of cases – 47, XXY
o 10-20% of cases are mosaics
▪ 47, XXY/46, XY
▪ Rare variants – 48, XXXY; 49, XXXXY (severe mental retardation)
Other sex chromosomal disorders

47, XYY = Polysomy Y
• Incidence: 1/1000 live male births

• Formerly called “criminal chromosome”
o 99% asymptomatic, though high incidence in penal institutions for the mentally subnormal
(20/1000)
o Lower than average intelligence/IQ (learning disabilities)
o Above average height but normally proportioned
o Tendency to severe acne.
Triple X – 47, XXX = Polysomy X
• Incidence: 1/1000 live female births

o Generally asymptomatic female
o Usually fertile but they do not transmit the extra chromosome
o Some infertility (spontaneous abortion, secondary amenorrhea, early climax)
o 15-25% reduction of in IQ comparable to that of Klinefelter’s in males
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8. Chromosomal disorders – incidence (spontaneous abortions, stillbirths,

newborns), general clinical characteristics (autosomal and sex chromosomal);
role of chromosomal abnormalities for human infertility.
Chromosomal disorders – incidence (spontaneous abortions, stillbirths, newborns)
• Contribute significantly to genetic pathology resulting in:
o Reproductive failure (abortion, infertility, stillbirths)
o Congenital anomalies in newborn
o Disorders of sex development (DSD)
o Pathogenesis of malignancy
• Specific chromosomal abnormalities (CA) have been associated with over 60 identifiable clinical
syndromes
Incidence of spontaneous abortions, stillbirths and newborns:
• 95% of chromosomally abnormal conceptus are aborted spontaneously

o CAs present in at least 50% of spontaneous abortion (mostly in 1 st trimester, most common
due to Triploidy, 45 X, trisomy 16)
o About 5 6% of stillbirths/fetal deaths
o About 0,5 0,6% of newborns /1: 500 live births
• About 5% of couples with 2 or more miscarriages
• In women aged 35 or over, chromosomal abnormalities are
• detected in about 2% of pregnancies.
Recurrence risk
• Families with unexplained infertility /due to the carrier of balanced translocation
• Multiple abortions ≥ 2
• Prior case of pregnancy or newborn baby with multiple malformations
o Suspicious for chromosomal abnormalities?
o Cytogenetic analysis of the parents is recommended
• Presence of congenital anomalies in newborns

• Major anomaly 1.5% of newborns
• Single minor anomalies 15%
• Presence of 3 or more minor anomalies is unusual 1% of newborns, but 90% of them have at least one
associated major anomaly
• Cases with 3 or more anomalies may represent chromosomal abnormalities (detected in about 25-36%
of these cases).
o Cytogenic genetic analysis of the baby is recommended
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General clinical characteristics (autosomal and sex chromosomal).

• Non-inherited – result of coincidental (de novo) chromosomal mutation
o In a single gamete during gametogenesis (meiosis) of a parent with normal karyotypes
o In early mitotic of a normal zygote (mosaic)
• Inherited – in the offspring of a parent with aberrant karyotype, with chromosomal abnormalities
representing
o Most common balanced rearrangement
o Very rarely non-balance
o Rarely in mosaic variant
→ 80-90% of all chromosomal disorders are non-inherited (result of coincidental/ de novo chromosomal
mutation)
→ They represent sporadic cases in the families
→ Result of de novo mutation during gametogenesis of a parent with normal karyotype
→ No significant recurrent risk (for subsequent pregnancy)
→ Very low proportion 10-20% of chromosomal disorders are inherited (in the offspring of a parent with
abnormal karyotype)
o Associated with different in magnitude risk for recurrence
Chromosomal disorders affecting autosomes

Main clinical characteristics:
• Nonspecific clinical features

• Multiple congenital malformations (available at birth) affecting several organs/ body systems
• General features
o Prenatal hypotrophy – low weight at birth
o Postnatal growth deficiency
o Cranio-facial abnormalities
o Congenital anomalies of internal organs (heart, kidney), skeletal, genital
o Reduced survival, high mortality
o Reproduction failure
Chromosomal disorder affecting sex chromosomes

Main characteristics:
• Because of X inactivation and paucity of genes of the Y chromosome, aneuploidies involving the sex
chromosomes are far more common than those involving autosomes
• Found most often in puberty of reproductive age
• General features:
o No rough malformation (available at birth)
o Somatic features → mainly affecting stature
o Mental retardation is not obligatory in classical variants
o The most important clinical feature is reproductive failure (infertility)
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Role of chromosomal abnormalities for human infertility.

• Reproductive problems are due to:
o Sex chromosomal disorders (e.g.: X, XXY)
o Structural chromosomal disorders (mainly translocations/inversions) = balanced
chromosomal rearrangements
o Numerical chromosomal disorders = Microdeletion of Y chromosome
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9. Pattern of inheritance – autosomal dominant: characteristics of pedigree,

role of the specific factors, genetic risks, clinical features, examples -
Huntington disease, Myotonic dystrophy, Neurofibromatosis and etc.
Single gene mutations
→ An important reason for studying the pattern of inheritance of disorders with families is to enable advice
to be given to members of a family regarding the likelihood of their developing it or passing it on to their
children, i.e. genetic counselling.
→ Any gene-determined characteristic is called a trait (any detectable phenotypic property or character).
→ Over 800 traits or disorders in humans exhibit single gene unifactorial or Mendelian inheritance.
• If a trait is expressed in the heterozygote, then the trait is dominant, whereas if only expressed in the
homozygote it is recessive.
• In some instances, the effects of both alleles may be seen in the heterozygote and these are called
codominant traits.
• A trait or disorder which is determined by a gene on an autosome is said to show autosomal
inheritance, whereas a trait or disorder determined by a gene on one of the sex chromosomes is said
to show sex-linked inheritance.
Autosomal dominant inheritance

→ An autosomal dominant trait is one, which manifests in the heterozygous state, i.e. in a person possessing
both the abnormal (mutant) allele and the normal allele.
Characteristics of pedigree
• Because having only a single aberrant copy of the gene is sufficient to develop a recognizable clinical
phenotype, the transmission pattern is very characteristic.
• Each gamete from an individual with a dominant trait or disorder will contain either the normal allele
or the mutant allele.
• If we represent the dominant mutant allele as “A” and the recessive normal allele as “a”, then the
various possible combinations of the gametes can be represented in a Punnett’s square.
• Any child born to a person affected with a dominant trait or disorder has 1 in 2 (50%) chance of
inheriting it and being similarly affected.
• It is expected that an average of one-half of the offspring of an affected individual also will be
affected.
• It is often possible to trace a dominantly inherited trait or disorder through many generations of a
family.
o This pattern of inheritance is sometimes referred to as “vertical” transmission.
• The sexes are involved equally, because there is no sex limitation for manifesting the aberrant gene.
o Males can transmit the condition to males or females and vice versa.
• An affected person will usually have an affected parent.
o The trait is transmitted from one generation to the next.
• Unaffected persons do not transmit the condition.
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Role of the specific factors
• Pleiotropy → the multiple effects of a gene.

o Autosomal dominant traits can involve only one organ or part of the body. A common
example is polydactyly.
o Many autosomal dominant disorders in humans can manifest in a number of different
systems of the body in a variety of ways, so-called pleiotropy.
o With improved biochemical and physiologic understanding such effect is found to be
consistent with the biology of change.
▪ An example is tuberous sclerosis, in which affected individuals can present with
learning difficulties, epilepsy and facial rash known as adenoma sebaceous which,
although it can be confused with acne, is histologically composed of blood vessels
and fibrous tissue or what is known as an angiokeratoma(ta).
• Variable expressivity → variation in the severity of the phenotypic features of a particular gene.
o The clinical features in autosomal dominant disorders can show striking variation from person
to person.
o This difference in involvement between individuals is referred to as variable expressivity.
o The variable expression is typical of an autosomal dominant trait but its basis is unclear.
o Although each affected individual has the same mutant gene, there is variation in the time of
onset and severity of xanthomata and vascular disease in familial hypercholesterolemia.
• Reduced penetrance → the proportion of heterozygotes for a dominant gene who express a trait,
even if mildly.
o In some heterozygous individuals for certain autosomal disorders, the presence of the
mutation can be undetected clinically, representing so-called reduced penetrance or in lay
terms the disorder “skipping a generation”.
o Reduced penetrance is thought to be the result of the modifying effects of other genes, as
well as being due to interactions with environmental factors.
o In some dominant traits, for example inherited colon cancer, inherited breast cancer, an
individual may have the mutant gene and yet have normal phenotype.
▪ An individual who is heterozygous for a dominant mutation but has no features of
the disorder is said to represent non-penetrance.
• It is an important exception to the rule that unaffected persons do not
transmit an autosomal dominant trait.
• These individuals can pass the condition to descendants and so produce a
skipped generation.
o In some dominant traits (for example Huntington disease) there is age-dependent non-
penetrance.
▪ The onset of symptoms (and hence the penetrance) is age-related and reassurance
of family members at risk on the basis of clinical examination is not possible until
they reach an advanced age.
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• New mutations → the occurrence of a change in a gene arising as a new event.

o In autosomal dominant disorders an affected person will usually have an affected parent.
Sometimes, however, a trait can appear in an individual in one generation when no one else
in previous generations has been affected.
▪ An example is achondroplasia, a form of short-limbed dwarfism in which the parents
are usually of normal stature.
o The sudden unexpected appearance of a condition arising as a result of a mistake occurring in
the transmission of a gene is called a new mutation.
o Subsequent transmission will follow the predictable pattern with a 50% chance of
transmitting the trait.
o The recurrence risk for the clinically normal parents of an affected child (when a condition
shows full penetrance) is low but not negligible because of gonadal mosaicism.
▪ Such mutations confined to the gonad carry a high recurrence risk and can only be
proven when unaffected parents have a second affected child.
o New dominant mutations, in certain instances, have been associated with an increased age of
the father: Marfan syndrome, achondroplasia, retinoblastoma and neurofibromatosis.
▪ It is believed that this is due to the large number of meiotic divisions which male
gamete stem cells undergo during a reproductive lifetime.
• Triplet repeat disorders → unstable mutations, expansion of triplet repeats.

o Dominant transmission includes the mechanism of so-called triplet repeat disorders.
o This relatively new recognized phenomenon has added particularly valuable insight into
certain neurologic disorders and what have been considered anomalous aspects of their
transmission.
o Myotonic dystrophy is a common adult-onset form of muscular dystrophy which is due to
unstable length mutation. Small length mutations may produce few or no symptoms but
amplification (lengthening particular gene repeats) in generations can result in increasing
disease severity – anticipation.
Genetic risks and clinical features (clinical phenotype)
→ In general, the autosomal dominant traits tend to be less severe than recessive traits.
→ Because dominant conditions are detectable in the presence of the normal allele of the responsible
gene (of the unaffected chromosome) their physiologic bases often are related to aberrant structural
(developmental) or receptor protein problems.
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Examples - Huntington Disease, Myotonic Dystrophy,

Neurofibromatosis and etc.
Huntington disease (AD)
→ It is an autosomal dominant disorder, typically without anticipation.
• Occasional juvenile onset → always by paternal transmission

• Clinical findings include:
o Progressive involuntary movements → leading to complete
debilitation
o Cognitive loss → leading to complete debilitation
o Psychiatric problems (depression) → common
Myotonic dystrophy (AD)

→ It is an autosomal dominant disease showing anticipation.
• Unstable CTG repeat in the MT-PK gene

• Congenital form with maternal transmission only.
o Myotonia
o Cataracts
o Cardiac arrhythmias
o Temporal bleeding
o Endocrinopathies
Neurofibromatosis (AD)
→ It is an autosomal dominant disease showing anticipation.
• Mutation of the NF1/NF2 gene

o Flat, light brown spots on the skin (cafe au lait spots)
o Freckling in the armpits or groin area
o Tiny bumps on the iris of the eye (Lisch nodules).
o Soft, pea-sized bumps on or under the skin
(neurofibromas).
o Bone deformities.
o Tumour on the optic nerve (optic glioma).
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10. Pattern of inheritance – autosomal recessive: characteristics of pedigree,

role of the specific factors, genetic risks, clinical features, examples - Cystic
fibrosis, β-Thalassaemia, Spinal muscular atrophy and etc.
codominant traits.
Autosomal recessive inheritance

→ Recessive traits and disorders are only manifest when the mutant allele is present in a double dose, i.e.
homozygosity.
• Individuals heterozygous for a recessive mutant allele show no features of the disorder and are
healthy, i.e. they are carriers.
• If we represent the normal dominant allele as “A” and the recessive mutant allele as “a”, then each
parental gamete carries either the mutant or the normal allele.
• The various possible combinations of gametes mean that the offspring of two heterozygotes have:
o A 1 in 4 (25%) chance of being homozygous affected
o A 1 in 2 (50%) chance of being heterozygous unaffected
o A 1 in 4 (25%) chance of being homozygous unaffected.
• It is not possible to trace an autosomal recessive trait or disorder through the family, i.e. all the
affected individuals in a family are usually in a single sibship, that is, they are brothers and sisters; it
does not occur in previous and subsequent generations.
o This is sometimes referred to as “horizontal” transmission.
• An individual manifesting a recessive disorder usually has heterozygous parents.
• Thus, the appearance of an affected person is often unprecedented in the family.
• The disorder affects males and females in equal proportions.
• Two-thirds of the unaffected siblings of an individual with AR disorder are likely to be heterozygotes.
o They can disseminate the abnormal allele, preserving the chance for homozygotes to appear
again.
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Role of the specific factors
• Consanguinity
o Enquiry into the family history of individuals affected with rare recessive traits or disorders
can reveal that their parents are related, i.e. consanguineous.
o Consanguinity can lead to an increased likelihood of mattings between heterozygotes.
o Because of inbreeding consanguineous populations demonstrate a “founder effect”.
▪ Such groups may be relatively small and concentrated such as the Parsis in India and
the Old Order Amish.
▪ On the other hand, they may be less concentrated but still tend toward marriages
within the community, either overtly or because of geographic limitations, religious
communities and islanders.
▪ The high frequency of sickle cell disease is due to selective advantage of the carriers
with regard to malarial infection.
▪ Ethnic associations may also arise from the founder effect in genetically isolated
populations.
• Hence the ethnic origin of a patient may be an important clue to an AR trait.
o Generally speaking, the rarer a recessive trait or disorder, the greater the frequency of
consanguinity among the parents of affected individuals.
▪ In cystic fibrosis, the commonest autosomal recessive disorder in persons of
European origin, the frequency of parental consanguinity is only slightly greater than
that seen in the general population.
▪ In oculocutaneous albinism which is rarer, roughly 1 in 20 parents of affected
children are first cousins.
▪ In alkaptonuria, one of the original inborn errors of metabolism, which is an
exceedingly rare recessive disorder, Bateson and Garrod observed that a quarter or
more of the parents were first cousins.
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• Metabolic abnormalities are common in recessive disorders. Many of these can be considered “inborn
errors of metabolism” and present constant expressivity in a family.
• With no normal copies of the responsible gene, recessive metabolic diseases may be severe; in fact,
they may be lethal.
o Homozygotes for many recessive conditions often die early (sometimes in infancy) and others
may not be able to reproduce.
• Many recessive disorders have been studied in detail from both biochemical and molecular genetic
perspectives; these often are detectable prenatally and/or presymptomatically.
• The fact that several thousand recessive disorders have been identified, immediately indicate that any
given individual is a carrier for several mutant alleles.
o As noted, the clinical status of heterozygotes is usually normal.
o Nevertheless, it is not known what the effect of heterozygosity for mutant alleles of multiple
genes might be.
o The potential for heterozygosity in thousands of individual gene establishes a formidable base
of genetic and clinical variation.
Examples - Cystic Fibrosis, β-thalassaemia, Spinal Muscular Atrophy and etc.

Cystic fibrosis
→ inherited as an autosomal recessive trait and is caused by a variety

(over 500) of mutations in the cystic fibrosis transmembrane
conductance regulator gene (CFTR).
• A 3bp deletion at position 508 (DF508) accounts for 70 – 80% of

mutant alleles in northern Europe and the USA but is less
common in southern Europe (45 – 55%, US Blacks (37%) and
Ashkenazi Jews (30%).
o The protein in patients with DF508 is abnormally
processed after translation and is degraded before it
reaches its site of function.
• Of the remaining mutations, most are missense (40%),
frameshift (30%), nonsense (20%) or splicing mutation (10%) –
large length mutations are rare.
o Most of these other mutations are individually uncommon.
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β-thalassemia
→ Underproduction of β-globin chains
• Most commonly in persons from Mediterranean area, Indian subcontinent

o It is the commonest haemoglobinopathy in Bulgaria
Genetics:
o Mutations:
▪ Different point mutations in b-gene
• Usually in the regulatory non-coding gene
regions (introns)
• Affected transcription, translation or RNA
splicing → reduced synthesis of b-globin
chains.
▪ Allelic heterogeneity → variety (over 120) of
mutations in the b-globin gene
• Most affected patients are not
“homozygous” in the strict sense → they are
“compound heterozygotes” = have different
disease’s mutations on each copy of b-globin
gene
Spinal Muscular Atrophy (AR)

→ inherited as an autosomal recessive trait and is caused by mutations in the SMN1 and SMA2 genes on
chromosome 5 at chromosomal locus 5q11-q13
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11. Pattern of inheritance – X-linked (dominant and recessive): characteristics

of pedigree, role of the specific factors, genetic risks, clinical features,
examples - Duchenne muscular dystrophy, Haemophilia – A and B, Fragile X
syndrome, Familial hypophosphatemia /Vitamin D-resistant rickets.
codominant traits.
Sex linked inheritance (X-linked inheritance)

→ refers to the pattern of inheritance shown by genes, which are located on either of the sex chromosomes.
• Genes carrier on the X chromosome are referred to as being X-linked, while genes carried on the Y
chromosome are referred to as Y-linked inheritance.
• A male has only one X chromosome and hence only one copy of each X-linked gene.
• In contrast, a female has two X chromosomes; one of paternal and one of maternal origin.
• However, with the exception of several genes, one of these X-chromosomes is inactivated in each
somatic cell (Lyonization phenomenon).
o Thus, the female is really a natural mosaic with a percentage of cells having the paternal X
active, and the maternal X active in the remainder.
• This mosaicism means that the effect of a mutant allele on a single X chromosome may be minimally
detectable, not apparent at all, or obvious, depending on whether the X chromosome carrying the
mutant allele has been inactivated in the organ/system in which that gene is normally expressed.
X-linked recessive inheritance.

→ determined by a gene carried on the X chromosome and usually only manifests in males.
• A male with a mutant allele on his single X chromosome is said to be hemizygous for that allele.
• The X chromosome remains active in every somatic cell, and so any mutant X alleles will always be
expressed in a male.
• Diseases inherited in an X-linked manner are transmitted by healthy heterozygous female carriers to
affected males, as well as by affected males to their obligate carrier daughters with a consequent risk
to male grandchildren through these daughters (hence fathers cannot transmit X-linked genes to their
sons).
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• For a carrier female of an X-linked recessive disorder having children with a normal male:
o Each son has a 1 in 2 (50%) chance of being a carrier and so affected
o Each daughter has a 1 in 2 risk of being a carrier unaffected
• This type of pedigree is sometimes said to show “diagonal” or a “knight’s move” pattern of
transmission.
• If an affected male has children with a normal female, then all his daughters (100%) will be obligate
carriers and none of his sons will be affected.
• An affected male cannot transmit the trait to his sons
o A male transmits his X chromosome to each of his daughters and his Y chromosome to each
of his sons.
• Very rarely a woman can exhibit an X-linked recessive trait.
o The red-green color blindness is the inability to distinguish between the color red and green.
▪ Homozygosity in a woman for such a trait is present if her mother was a carrier and
her father was affected.
o Another explanation for affected females with X-linked recessive disorder is the skewed X
inactivation – by chance in an occasional heterozygous carrier female the active X
chromosome in most of her cells could be the one bearing the mutant allele.
▪ If this happens, she would exhibit some of the symptoms and signs of the disease
(e.g. haemophilia) and be so-called manifesting heterozygote.
• So far, 412 X-linked recessive traits are known in humans.

• The frequencies vary in different ethnic groups, for example red-green color blindness is rare in
Eskimos and frequent in UK.
• Some X-linked disorders are not compatible with survival to the reproductive age and are not,
therefore, transmitted by affected males.
o Duchenne muscular dystrophy is the most common form of muscular dystrophy and is a
severe disease.
▪ The first signs in an affected male are a waddling gait, difficulty in climbing stairs
unaided and a tendency to fall over easily.
▪ The muscle weakness gradually progresses and affected males ultimately become
confined to bed and will often die before reaching the age of 20 years.
▪ Since affected boys do not usually survive to reproduce, the disease is transmitted
almost entirely by healthy female carriers.
o A milder X-linked form of muscular dystrophy → Becker muscular dystrophy.
• These conditions are due to different mutant alleles in the gene for the protein dystrophin.
• Before counselling a family with muscular dystrophy, it is important to establish the precise type, as in
addition to these X-linked forms, autosomal dominant and recessive forms of muscular dystrophy are
known (genetic heterogeneity).
• The fragile X syndrome provides an important exception to the principle of consistent male severity
within the family for an X-linked recessive trait.
• It is caused by an unstable mutation; small length mutations may produce few or no symptoms in
males or females but subsequent amplification to a larger length mutation results in mentally
handicapped offspring (anticipation).
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X-linked dominant inheritance.
• Although uncommon, there are X-linked dominant traits, which are manifest in the heterozygous
female as well as in the male who has the mutant allele on this single X chromosome.
• X-linked dominant inheritance superficially resembles that of an autosomal dominant trait.
• Both daughters and sons of an affected female have a 1 in 2 (50%) chance of being affected.
• The pedigree resembles that of an autosomal dominant trait tough, in families with an
• X-linked dominant disorder there is an excess of affected females.
• The key difference, however, is the lack of male-to-male transmission with an X-linked dominant trait.
• Homozygous males are more severely affected than heterozygous females
• Example of X-linked dominant traits are:

o X-linked ichthyosis
o Vitamin-D-resistant rickets.
▪ Rickets can be due to a dietary deficiency of vitamin D, but in vitamin-Dresistant
rickets the disorder occurs even when there is an adequate dietary intake of vitamin
D.
▪ In the X-linked dominant form of vitamin-D-resistant rickets, both males and females
are affected.
• However, whereas in males the condition is uniformly severe, the female
heterozygote is more variably affected because of Lyonization.
o The few other conditions which are inherited in this fashion are rare:
▪ Incontinentia pigmenti and Rett syndrome deserve further mention as the affected
males are believed to be so severely affected that spontaneous abortion is usual and
hence only affected females are seen.
Y-linked or holandric inheritance.
→ implies that only males are affected.
• An affected male transmits Y-linked traits to all his sons but to none of his daughters.
• In the past, it has been suggested that bizarre-sounding conditions such as porcupine skin, hairy ears
and webbed toes are Y-linked traits.
o With the possible exception of hairy ears, these claims of holandric inheritance have not
stood up to more careful study.
• Recent evidence clearly indicates, however, that genes involved in spermatogenesis (TDF) and the H-Y
histocompatibility antigen are carried on the Y chromosome and therefore manifest holandric
inheritance.
• The family surname also shows this pattern of inheritance
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12. The inborn errors of metabolism (IEM) – prevalence, inheritance,

biochemical basis of IEM, common clinical features, examples.
The Inborn Errors of Metabolism (IEM)

→ Inherited disorders that are caused by a defect in a single gene, and where the gene product is an enzyme.
Prevalence
• IEM as a group are not rare → 1/5000 births

o More than 400 different inborn errors of metabolism have been described to date, and most
of these are rare.
• Taken together → substantial percentage of the morbidity and mortality directly attributable to
genetic disease.
• Often treatable if diagnosed earlier.
Inheritance
• A block in a metabolic pathway results in the accumulation of metabolic intermediates and/or a

deficiency of the end-product of the particular metabolic pathway concerned, a so-called inborn error
of metabolism.
o The majority of inborn errors of metabolism are inherited as autosomal recessive or X-linked
recessive traits.
o A few are inherited as autosomal dominant disorders involving rate-limiting enzymes, cell
surface receptors or multimeric enzymes.
Classification and Examples

From a clinical, pathophysiological and therapeutic perspective, metabolic disorders can be divided into 3
groups:
• Disorders that give rise to intoxication

• Disorders involving energy metabolism
• Disorders involving complex molecules
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Disorders that give rise to intoxication:
• This group includes IEM that lead to an acute or progressive intoxication because of the accumulation
of toxic substrate or compounds proximal to the metabolic block.
• They do not interfere with the embryo-fetal development!
o Examples:
▪ Amionoacidopathies (PKU, Maple syrup urine disease)
▪ Organic acidurias (methylmalonic, propionic)
▪ Congenital urea cycle defects (hyperammonemia)
▪ Sugar intolerance (galactosemia, fructosemia)
Disorders involving energy metabolism:
• IEM with symptoms caused, at least partly, by the deficiency of energy production or utilization.
• Some can interfere with embryo-fetal development!
• Examples:
• Mitochondrial (energy defects) → lactic acidemias, mitochondrial respiratory chain disorders, fatty
acid oxidation defects…
• Cytoplasmic: glycogenesis, glycolysis, gluconeogenesis…
Disorders involving complex molecules:
• This group involves cellular organelles and includes diseases that disturb the synthesis or the
catabolism of complex molecules.
• They interfere with embryo-fetal development
• Symptoms are permanent, progressive, independent of undercurrent events and unrelated to the
food intake.
• Examples:
• Lysosomal storage disorders → Mucopolysaccharidoses, sphingolipidoses, oligosaccharidosis,
mucolipidoses…
• Peroxisomal disorders → Zwellweger-Refsum syndrome, adrenoleukodystrophy…
• Disorders of intracellular trafficking and processing → congenital disorders of glycosylation = CDGs
Biochemical basis of IEM

The defective protein in most inborn errors is an enzyme which is diffusible and there is usually sufficient
residual activity in the heterozygous state for the enzyme to function normally in most situations.’
Common clinical features

• A number of IEM can be screened for in the newborn period and successfully treated by dietary
restriction or supplementation.
• Prenatal diagnosis of many of the inborn errors of metabolism is possible.
o Until recently this has been by biochemical analysis of cultured amniocytes obtained at mid-
trimester amniocentesis or direct/cultured chorionic villi, allowing first-trimester diagnosis.
o In many instances, this traditional biochemical approach is being replaced by the use of linked
DNA sequence variants of identification of specific mutations when biochemical basis has not
yet been identified or the enzyme is not expressed in amniocytes or chorionic villi.
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Data from Family history and Clinical features indicating IEM in the neonatal period:
Family history
• Neonatal deaths of sepsis, SID, heart failure, Mentally retarded children

• Children with cerebral palsy, cirrhosis, cataracts
• Normal pregnancy, Normal delivery
General clinical features
• Poor feeding, vomiting, diarrhea, failure to thrive

• Floppiness, lethargy, general hypotonia
• Jaundice, heart failure, hypoglycaemia with fast heart rate
• Neurological abnormalities (convulsions, tremor, fits), muscle cramps and weakness
• Progressive deterioration and developmental regression
• Dysmorphic features – uncommon
• Specific urine odor
• Normal results: X-ray of lungs, CSF, bacterial blood test, brain ultrasound
Biochemical diagnosis in metabolic screening
• Urine → 10 – 20 ml collected from 24h period or two portions at least

• Blood → 5 ml in EDTA tube
• PKU blank with 6 dry blood spots
Phenylketonuria
• Diagnosis → elevated blood and urine phenylalanine
• Prognosis
o Normal development and lifespan with a diet low in phenylalanine and
supplemented with tyrosine.
▪ A low phenylalanine diet is extremely effective in preventing mental retardation,
and, although it is not particularly palatable. Most affected children can be
persuaded to adhere to it until early adult life when it can be relaxed.
o Mental handicap if untreated
o Risk of mentally handicapped and malformed offspring for treated female unless diet is
reintroduced prior to pregnancy to keep the maternal blood phenylalanine at 120 – 480
μmol/l
▪ Any woman with phenylketonuria who is contemplating pregnancy should adhere to
a strict low phenylalanine diet both before and during pregnancy to minimize the
risk of brain damage (primary microencephaly) to her unborn child.
• Genetics
o Autosomal recessive trait due to a variety of
mutations in phenylalanine hydroxylase.
o Pattern of predominant mutations shows
ethnic variation.
o Within affected families, carrier detection
and prenatal diagnosis are possible by DNA
analysis.
o Frequency 1 in 10 000 in Europe
(except for Turkey 1 in 3 000 and Bulgaria 1
in 35 000).
o Rare in Afro-Caribbeans and Indians
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Galactosemia
• Diagnosis
o Newborn infants with galactosemia present with: vomiting, lethargy, failure to thrive (weight
loss) and jaundice in the second week of life.
▪ If untreated, they go on to develop complications which include: mental retardation,
cataracts, hepatomegaly, cirrhosis of the liver, and susceptibility to infection.
o Reducing substance (galactose) in the urine
o Absent red cell galactose-1-phosphate uridyl transferase (GALT).
• Prognosis
o Exclusion of milk and milk products from the diets:
▪ Lifespan is normal but developmental delay will occur
▪ Speech abnormalities – frequent
▪ Ovarian dysfunction - frequent
o Mental handicap is invariable if therapy is delayed until after 1 month → hence the value of
neonatal screening.
• Genetics
o Autosomal recessive trait due to a variety of
mutations in GALT
o Carrier detection – possible (assay red cell GALT or
DNA analysis)
o Prenatal diagnosis – possible (assay of GALT in
amniocytes or chorionic villi, assay of galactitol in
amniotic fluid or DNA analysis)
o Incidence of galactosemia is of 1 in 50 000 in Europe
(but 1 in 120 000 in Bulgaria).
Mucopolysaccharidosis
• Diagnosis – four main types (although seven types are known):

o Type I (Hurler syndrome) → deficiency of alpha-1-iduronidase
o Type II (Hunter syndrome) → deficiency of iduronate-2-sulphatase
o Type III (Sanfilippo syndrome) → deficiency of heparin sulphate sulphatase or
Nacetyl-alpha-d-glucosaminidase
o Type IV (Morquio disease) → deficiency of fibroblast 6-sulpho-
Nacetylhexosaminido-sulphatase
• Prognosis
o Type I constituent features include:
▪ Coarse facies in infancy
▪ Corneal clouding
▪ Umbilical hernia
▪ Short stature
▪ Progressive mental handicap to death in second decade
o Type II → as type I but later onset and clear cornea + death in third decade
o Type III
▪ Progressive mental handicap in early childhood
▪ Normal facies, stature and cornea
▪ Death in second decade
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o Type IV
▪ Short stature with scoliosis
▪ Normal intelligence, facies and cornea
▪ Atlantoaxial subluxation
▪ Death in third decade
• Genetics
o All are inherited as autosomal recessive traits with
exception of type II which is an X-linked recessive trait.
o Combined frequency 1 in 20 000 with type III most
common.
o Prenatal diagnosis – possible by analysis of
glycosaminoglycans in amniotic fluid and by enzyme
assay in cultured amniocytes or chorionic villi.
o Carrier detection by DNA analysis – possible in females
at risk for type II (X-linked recessive).
Familial Hypercholesterolemia (Hyperlipidaemia II)
• Diagnosis
o Onset in third or fourth decade with xanthomata (subcutaneous deposition of lipid), corneal
arcus and evidence of ischemic heart disease.
o Markedly increased fasting LDL (including cholesterol) due to reduced clearance by defective
LDL receptors.
o Routine laboratory distinction from polygenic hypercholesterolemia (5% of the population) is
impossible.
o Identification of heterozygotes by measurement of total cholesterol or LDL cholesterol is not
reliable, especially in children.
• Prognosis
o Premature death from ischemic heart disease with 50% of affected males, dead by 60 years
of age unless treated.
o Dietary restriction of cholesterol intake and drug treatment with agents, which sequester
cholesterol from the enterohepatic circulation or inhibit the secondary endogenous synthesis
of cholesterol, can lower cholesterol levels and
reduce the risk of coronary artery disease.
• Genetics
o Autosomal dominant trait due to a variety of
mutations in the low-density lipoprotein
receptor (LDLR)
o Prenatal and presymptomatic diagnosis –
possible by direct or indirect DNA analysis
19p13.2 – p13.1
o General population frequency of familial
hypercholesterolemia is 1 in 500
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Cystic Fibrosis
→ It is a biochemical disease that does not alter enzymatic activity, but a transmembrane protein.
• Diagnosis
o Sodium exceeds 60 mmol/l and chloride exceeds 70 mmol/l in a sample (≥ 100 mg) of sweat
induced by pilocarpine iontophoresis.
o Absent trypsin in pancreatic juice.
▪ Serum immunoreactive trypsin levels in newborn permit neonatal screening.
• Prognosis
o Pancreatic insufficiency (85 – 90%)
o Chronic lung disease secondary to recurrent infection
o Rectal prolapse (5 – 10%)
o Male infertility (98%)
o Meconium ileus (5 – 10%)
o Cirrhosis of the liver (1 – 5%)
o Median survival of 25 years, variable clinical severity.
• Genetics
o Cystic fibrosis is inherited as an autosomal recessive trait and is caused by a variety (over 500)
of mutations in the cystic fibrosis transmembrane conductance regulator gene (CFTR).
▪ A 3bp deletion at position 508 (DF508) accounts for 70 – 80% of mutant alleles in
northern Europe and the USA but is less common in southern Europe (45 – 55%, US
Blacks (37%) and Ashkenazi Jews (30%).
• The protein in patients with DF508 is abnormally processed after translation
and is degraded before it reaches its site of function.
▪ Of the remaining mutations, most are missence (40%), frameshift (30%), nonsense
(20%) or splicing mutation (10%) – large length mutations are rare.
• Most of these other mutations are individually uncommon.
o Homozygosity of DF508 or other mutations with no residual function are associated with
pancreatic insufficiency but the genotype (even within a family) is not predictive of the
severity of pulmonary involvement which is the main prognostic factor.
o Homozygotes and compound heterozygotes for certain mutations where there is residual
function retain pancreatic function, and in some, the only symptoms are chronic sinusitis or
male infertility due to congenital bilateral absence of vas deferens (CVAVD), where it
accounts for 6% of all male infertility.
o Carrier detection and prenatal diagnosis – possible by direct or indirect DNA analysis.
o The frequency of affected homozygotes is 1 in 2 500 in Europe (1 In 3 600 in Bulgaria) with a
carrier frequency of 1 in 25-33 and it is less common in Blacks and Orientals.
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13. The inborn errors of metabolism. Newborn screening program - Mass and
selective newborn screening (criteria, requirements, study methods,
indications)
IEM → inherited disorders that are caused by a defect in a single gene, and where
the gene product is an enzyme.
Population screening involves the offer of genetic testing on an equitable basis to all individuals in a defined
population.
• Its primary objective is to enhance autonomy by enabling individuals to be better informed about
genetic risk and reproductive options.
• A secondary goal is the prevention of morbidity due to genetic disease and alleviation of the suffering
that this would impose.
• The criteria for screening program can be considered under the headings of the disease, the test and
the practical aspects of the program:
The Disease
• It should be relatively common and have potentially serious effects which are amenable to prevention
or amelioration.
• This can involve the early introduction of treatment, as in the case of neonatally diagnosed
phenylketonuria, or the offer of termination of pregnancy for disorders which cannot be treated
effectively and which convey a high likelihood of serious morbidity and/or mortality.
The Test
• It should be accurate and reliable with high sensitivity and specificity.

o Sensitivity – ability to correctly identify those with the disease.
▪ It refers to the proportion of cases which are true positive detected.
▪ A measure of sensitivity can be made by determining the proportion of false-
negative results, i.e. how many cases are missed.
o Specificity – ability to correctly identify those without the disease.
▪ If unaffected persons test positive, these are referred to as false-positives.
• Screening tests are seldom, if ever, 100% sensitive and 100% specific.
o This is because the range of test values in the disease population overlaps that of the
unaffected population.
o Thus, a screening test, as opposed to the definitive follow-up diagnostic test, will diagnose
some members of the population incorrectly.
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The Program
• It should be offered in a fair and equitable manner and should be widely available.
• It must also be morally acceptable to a substantial proportion of the population to which it is offered.
• Participation must be entirely voluntary.
• Easily understood information and well-informed counselling should both be available.
Newborn screening program.

Since many of the genes encoding disease-related enzymes have been cloned and their mutations
characterized, carrier testing and prenatal diagnosis for many disorders is available.
• However, testing samples of dried blood for elevated levels of metabolites in the newborn period
(e.g.: for PKU and Galactosemia) remains the most commonly used population-based screening test
for metabolic disorders.
• Unfortunately, most deaths caused by inborn errors of metabolism are due to enzyme variants that
are not included in newborn screening programs.
→ Newborn screening programs represent an ideal opportunity for presymptomatic detection and
prevention of genetic disease.
→ Newborn screening is an effective public health strategy for treatable disorders such as PKU,
hypothyroidism, galactosemia…
Selective newborn screening (criteria, requirements, study methods, indications).

Characteristics of Selected Newborn Screening Programs
*The Guthrie test is based on reversal of bacterial growth inhibition by a high level of phenylalanine.
Phenylketonuria
→ Early diagnosis and therapy of phenylketonuria are mandatory if normal development is to occur.
• However, few if any physical signs are present in the neonate.

• The presence of an increased level of blood phenylalanine in the dried blood spot is detected by the
Guthrie bacterial inhibition assay.
o The test is carried out on a small sample of blood obtained by heel-prick at age 3 – 5 days.
• An abnormal test result is further investigated by repeat analysis of phenylalanine levels in a venous
blood sample.
o Mild elevations of phenylalanine due to prematurity or delayed enzyme maturation are not
uncommon and these can be excluded by repeat testing.
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Congenital hypothyroidism
→ Early diagnosis and therapy will permit normal development, yet few physical signs are present in the
newborn (prolonged jaundice, open fontanelles, poor feeding, large tongue, umbilical hernia).
• This disorder is particularly suitable for screening as it is relatively common with an incidence of
approximately 1 in 3.000-4.000 in the UK (as compared with 1 in 900 in Asians) and treatment with
life-long thyroxine replacement is extremely effective in preventing the severe developmental
problems associated with the classical picture of “cretinism”.
• Test is based on assay of either thyroxine or TSH measured on the dried blood spot.
o Neonates with primary hypothyroidism have elevated levels of TSH.
• Although occasional cases are recessive enzyme defects (there is usually a goiter) the most common
cause of congenital hypothyroidism is sporadic absence of the thyroid glands usually not caused by
genetic factors with a low recurrence risk.
Other miscellaneous conditions (not inborn errors of metabolism) for which neonatal screening can be
undertaken.
• In recent years, some nations have instituted screening programs to identify neonates with
hemoglobin disorders (e.g.: sickle cell disease).
o These programs are justified by the fact that up to 15% of children with sickle cell disease will
die from infections before age 5.
o Newborn screening based on hemoglobin electrophoresis or DNA analysis is undertaken in
many countries with a significant Afro-Caribbean community (prevalence of the disease =
1/400-1/600).
• Newborn screening for cystic fibrosis has been introduced in several countries with a significant
population of northern European origin.
o Based on the detection of an elevated blood level of immunoreactive trypsin → consequence
of blockage of pancreatic ducts in utero, supplemented by DNA analysis.
o The rationale for screening is that early treatment with physiotherapy and antibiotics are
thought to improve the long-term prognosis.
• Some communities have begun screening for Duchenne muscular dystrophy (DMD) by measuring
creatine kinase levels in newborns.
o The objective is not presymptomatic treatment, rather it is identification of families who
should receive genetic counseling.
Additional info from books

Newborn Screening
• Nonselective screening – screening all newborns for a limited number of common inborn errors.
• Selective screening – testing of an individual known to be at increased risk (e.g.: sibling).
• Tandem mass spectroscopy – allows clinicians to screen for > 30 disorders.
Clinical Examination
• A competent and thorough clinical examination of the newborn infant within 2–3 days of birth is a
fundamental screening episode and should be performed by a trained clinician or health visitor who is
familiar with the normal range.
o To miss developmental dysplasia of the hip at this stage and not embark on treatment, for
example, may have lifelong disabling consequences.
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• Follow-up examinations are usually performed by health visitors, who refer to a pediatrician if they
have concerns about developmental progress or hearing, vision, and vocalization/speech.
Newborn Bloodspot Screening
• Using a bacterial inhibition assay he developed a

method that could detect high levels of
phenylalanine in blood shortly after a baby was
born, which he pioneered from 1961.
• For this he introduced the filter paper on which
blood spots could be easily collected and
transported—still used today—and overcame
commercial pressures to see his methods
introduced at low cost.
• NBS programs have been extended significantly
after being limited to phenylketonuria,
galactosemia, and congenital hypothyroidism for
many years, and the analytical methods vary, with
tandem mass spectrometry greatly extending the
range.
Newborn Hearing Screening
• The acquisition of language skills is an early

developmental process in postnatal life and
crucially dependent on adequate hearing sense.
Although individuals, and their community, with
hearing impairment make the best of life
opportunities, and should not be subject to
discrimination, most would concur that good
communication skills are very important through
life. If hearing impairment is identified early then
aids can be fitted. The assessment should be
performed in the first month of life and consists of
the automated otoacoustic emission (AOAE) test
for well babies followed by the automated auditory
brain- stem response test where there is no clear
AOAE response.
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14. Multifactorial inheritance. The liability / threshold model. Recurrence risk

in multifactorial disorders. Increasing risk factors. Genetic counselling.
Contribution of genetics and environment
• Human diseases are caused by a multitude of genetic and environmental factors acting together.
• Most chronic non-communicable conditions such as schizophrenia and diabetes as well as certain
congenital malformations are caused by an interaction of both genetic and environmental factors.
Multifactorial Disorders
• More common than single-gene disorders and chromosomal abnormalities.
• Caused by the interaction of many genes with environmental factors
• They make a major contribution to human morbidity and mortality
o Optimum prevention relies on avoidance of the bad environmental factors.
• They can be explained through genetic counselling (periconception and chronic-noncommunicable
diseases counselling)
• Most congenital malformations and many common adult diseases demonstrate a definite familial
tendency, but are not caused by single genes or chromosome defects → do not follow any Mendelian
pattern of inheritance
• They show multifactorial inheritance
• If only the genetic factors are considered → polygenic inheritance
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Multifactorial → both environment and genetics (usually more than one gene) contribute to the phenotype
Polygenic → more than one gene
→ Each gene, separately, follows Mendel’s laws, but the trait overall does not
Polygenic Inheritance
• This involves the inheritance and expression of a phenotype being determined by many (2 or more)
genes at different loci, with each gene exerting a small additive effect.
o Additive → implies that the effects of the genes are cumulative, i.e.: no one gene is dominant
or recessive to another
• Several normal human characteristics, which can be measured
= quantitative traits (height, weight, intelligence, blood
pressure, skin colour) show a continuous distribution in the
general population, which closely resembles a normal
(Gaussian) distribution.
o This takes the form a symmetrical bell-shaped curve
distributed-evenly about mean.
o A normal distribution is generated by polygenes → in
an additive fashion
→ In general, quantitative traits exhibit continuous variability → they

can assume an unlimited number of intermediate values between
extremes.
• This contrasts with qualitative traits → either present or absent (NTD, cleft palate…)
Multifactorial Inheritance
• Environmental factors interact with many genes at different loci to generate a normally distributed
susceptibility.
• The genetic predisposition to multifactorial traits is usually inherited from both parents.
• The genes and environmental factors affecting a given multifactorial trait can vary among different
individuals.
• Disorders showing multifactorial inheritance:
o Isolated congenital malformations
▪ Cleft lip/palate
▪ Congenital heart defects
▪ Congenital dislocation of the hip
▪ Neural tube defects: Anencephaly, Spina Bifida
▪ Pyloric stenosis
▪ Talipes
o Common adult disorders

▪ Autism, Manic depression, Schizophrenia, Epilepsy
▪ Coronary heart disease, Hypertension, Asthma
▪ Crohn disease
▪ Diabetes mellitus, Rheumatoid arthritis,
▪ Glaucoma
▪ Multiple sclerosis, Parkinson disease
▪ Psoriasis
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The Liability / Threshold Model.

• According to the liability/threshold model, all of the factors that influence the development of a
multifactorial disorder (whether genetic or environmental) can be considered as a single entity =
liability (susceptibility)
• The liabilities of all individuals in a population can be represented as a normal (Gaussian) curve in both
the general population and in relatives of affected individuals.
• However, the curves for these relatives will be shifted to the right.
• A threshold exists above which the abnormal phenotype is expressed.
o The disorder is manifested in an individual, when a certain
threshold of liability is exceeded.
o The liability of the majority of the population lies below the
threshold level.
• It is important to emphasize, that exceeding the liability includes all
factors that contribute to the cause of the condition.
• The liability/threshold model should be viewed as an attractive
hypothesis, rather than as a proven scientific fact.
• It provides a simple explanation for the observed patterns of familial
risk in many multifactorial disorders, mainly isolated congenital
malformations.
Recurrence Risk in Multifactorial Disorders.

• Multifactorial disorders result when environmental and genetic risk factors
combine to bring the susceptibility of an individual to the disease above a
threshold value = the liability that can be attributed.
• Recurrence risks are empiric risks derived from population studies. So, they are
observational and do not depend on theory as the Mendelian characters.
• The recurrence risk for multifactorial disorders within a family:
o Is generally low = 2 – 4% instead of the much higher figures seen in single
gene disorders (20%)
o It mainly affects first degree relatives (siblings and offspring)
o Is an empirical risk (based on direct observation of data), because the no.
of genes contributing to the disease and the allelic contribution of the
parents are not known.
▪ In contrast, the recurrence risk for monogenic disorders is
theoretical and constant for each following offspring (25% for
AR, 50% for AD…)
o Is specific to a given population and for each disorder (risk factors vary
among diseases).
Increasing Risk Factors.

• Factors increasing probability of recurrence in a particular family
o High heritability of disorder
o Close relationship to proband
o Multiple family members affected
o Severe or early onset disease
o Proband of more rarely affected sex
→ All these suggest that family has a higher liability to the disorder → have genes of higher effect or more
adverse environmental influences.
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1. The recurrence risk for the disorder is greater among close relatives and decreases rapidly in more
remotely related relatives (more distant relatives):
o e.g.: Spina bifida

▪ First-degree relatives → 4%
▪ Second-degree relatives → 1%
▪ Third-degree relatives → < 0.5%
2. The recurrence risk is higher if more than one close relative is affected
o This means that the parents with two affected children are probably located higher on the
liability curve than a family with only one affected child → they have more risk factors
(genetic and/or environmental) and are more likely to produce an affected child.
o This is different from monogenic inheritance → recurrence risk is independent on the number
of previously affected children.
▪ e.g.: Spina bifida
• One sibling/offspring affected → 4%
• Two siblings/offspring affected → 10%
3. If the disorder in the proband (affected child) is more severe, the recurrence risk is higher
o A more severe expression indicates that the affected individual is at the extreme tail of the
liability curve → his/her relatives (siblings and offspring) are at higher risk to inherit disease
genes.
o This is very different from monogenic and chromosome disorders → severity does not
influence the recurrence risk
▪ e.g.: Cleft lip/palate
• Bilateral → higher recurrence risk = 6%
• Unilateral → lower recurrence risk = 2%
▪ e.g.: Neural tube defect
• Spina bifida aperta → lower recurrence risk = 4 – 5%
• Anencephaly → higher recurrence risk = 8 – 9%
4. Multifactorial disorders tend to occur more frequently in one sex than in the other → the recurrence
risk is higher if the proband is of the less commonly affected sex.
o This is because an affected individual of the less susceptible sex is usually at a more extreme
position on the liability curve and has higher liability threshold.
o e.g.: Pyloric stenosis → male/female ratio = 5/1 → males have a lower threshold and females
have a higher one → they must be exposed to more disease-causing factors than males in
order to develop the disease.
▪ The recurrence risk is higher in females
▪ Relatives of an affected female must have more genetic and environmental factors
→ produces a higher risk for future offspring
▪ Recurrence risk for the offspring of an affected male:
• Sons = 6.4%
• Daughters = 2.5%
▪ Recurrence risk for the offspring of an affected female:
• Sons = 22.9%
• Daughters = 11.4%
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Genetic Counselling.
It is not possible to assess an individual’s liability for a particular disorder, but it is possible to estimate what
proportion of the etiology can be ascribed to genetic factors as opposed to environmental factors = heritability.
Heritability → degree from which a disease is developed form genetic factors
• Disorders with a greater genetic contribution have higher heritability, and hence, higher risk of
recurrence.
o Schizophrenia = 85%
o Asthma = 80%
o Cleft lip/palate = 76%
o Pyloric stenosis = 75%
o Coronary artery disease = 65%
o Essential hypertension = 60%
o Neural tube defects = 60%
o Diabetes mellitus = 40%
o Congenital heart defects = 35%
→ How can the probability of recurrence be determined for multifactorial disorders?
• The recurrence risk multifactorial disorders, is determined through family studies

o Observe the number of affected siblings in many families → determine empiric risk (known
incidence of trait in particular population)
→ How evidence is gathered for genetic factors in complex diseases?
• Familial risks → What is the incidence of a disorder in relatives compared with the incidence in the
general population?
• Twin studies → What is the incidence in monozygotic compared with dizygotic twins?
• Concordance → Percentage of twin pairs in which both twins show the particular phenotype
(concordant or discordant pair)
• Adoption studies → What is the incidence in adopted children of the disorders which their parent
had?
• Population and migration studies → What is the incidence in people from a particular ancestry group
when they move to a different geographical area?
Evidence from these types of studies can estimate the heritability of a condition – the proportion of the
etiology ascribed to genetic factors rather than environmental factors.
→ Heritability is usually calculated using data on the Twin and Adoption studies.
• These two research strategies are often used to estimate the relative influence of genes and
environment.
• They do not provide definitive measures of the role of genes in multifactorial disorders, nor can they
identify specific genes responsible for the disease.
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Twin studies
• Consist of comparison between monozygotic (MZ or “identical”) and dizygotic (DZ or “fraternal”)
twins.
o If both members of a twin pair share a trait (e.g. a cleft lip) = concordant
o If they do not share the trait = discordant
→ For a trait determined totally by genes, MZ should be always concordant, while DZ twins should be
concordant less often, since they, like siblings, share only 50% of their genes.
• MZ → share 100% genes and environment

• DZ → share 50% genes and environment
→ Comparisons of correlation and concordance rates in MZ and DZ twins allow the

estimation of heritability, a measure of the proportion of the population variation
in a disease that can be attributed to genes.
• It is expressed either as a proportion of 1 or as a percentage, and is depicted using the symbol H.

o If expressed as a percentage (with higher values) → denotes that the genetic contribution is
more important.
• Both genetic and environmental factors are important.

o The greater the difference in concordance between MZ and DZ, the greater is the proportion
of genetics in etiology of the disorder.
Adoption studies
• Consist of comparing the disease rates among the adopted offspring of affected parents with the rates
among adopted offspring of unaffected parents.
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15. Multifactorial inheritance. Genetic susceptibility to common disorders.

Heritability and recurrence risk. Common multifactorial disorders in adult,
examples.
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16. Multifactorial inheritance. Genetic susceptibility to common disorders.

Heritability and recurrence risk. Common multifactorial congenital anomalies
in newborn babies.
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17. Dysmorphology. Genetics and congenital anomalies – malformation,

deformation and disruption. Definition and examples. Etiology, incidence and
clinical significance.
Dysmorphology
→ Study of human congenital malformations (birth defects), particularly those affecting the morphology of
the individual
• It implies study of human congenital defects and abnormalities of body structure that originate before
birth.
• The term “dysmorphic” is used to describe individuals whose physical features are not usually found in
other individuals with the same age or ethnic background.
• Anthropometry → science of measuring the human body; techniques for assessing the size,
proportion and composition of the human body.
o Helps the field of dysmorphology
o Its measurements should be used whenever possible to quantitatively identify abnormalities.
Congenital Anomalies
→ Any abnormal deviation from the expected type in structure, form or function.
• From an error in morphogenesis

• Many CAs (internal or functional) are not apparent at birth although by definition present.
Types of congenital anomalies
• According to the causal factor, time of origin and mechanism of action there are 4 main types of CAs =
single/isolated congenital anomalies:
o Malformation
o Deformation
o Disruption
o Dysplasia
• Dysmorphic complex = Multiple congenital anomalies → Recognizable pattern

of congenital anomalies:
o Association
o Sequence
o Malformation syndrome
Malformation, Deformation and Disruption

Malformation
→ Morphologic defect of an organ or bogy region due to an endogenously (intrinsically) abnormal
developmental process
o e.g.: hypoplasia of an organ or structure (microphthalmia), incomplete closure (NTDs, cleft

palate), incomplete separation (syndactaly)
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A primary defect in morphogenesis:
o Occur during formation of structures → complete or partial absence

o Alterations of its normal configuration
o Usually occurring before 10 weeks of gestation (embryonic period)
Types:
• Incomplete morphogenesis
o Aplasia / hypoplasia (anophthalmia / microphthalmia)
o Incomplete separation (syndactyly)
o Incomplete closure (cleft palate, Spina bifida aperta)
o Incomplete obstruction (ventricular septal defect)
• Excessive morphogenesis (polydactyly)
• Aberrant morphogenesis (unusual place)
Mechanism:
• The exact mechanism is mostly unknown

• Might be an error in embryonic cell proliferation, differentiation, migration, programmed death and
cell to cell communication.
Cause/Etiology:
• Genetic factors (chromosome, single gene defects)

• Environmental factors (teratogenic agents)
Examples: cleft palate, anencephaly, agenesis of limb or part of a limb
Embryonic developmental process – critical stages:
• 16th day – implantation

• 19th day – formation of the neural plate
• 21-27th day – neural tube closure
• 30th day – formation of limb buds
• 5-7 week – formation of heart and kidneys 7-10 week – sex
differentiation
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Types of malformations
• Major malformations
→ Those that have medical & /or social implications. Often require surgical repair.
o When the major malformations are isolated most commonly, they have polygenic/
multifactorial etiology (e.g.: congenital pyloric stenosis, cleft palate, Spina bifida aperta,
congenital heart defects).
o When the major malformations are into a pattern of multiple anomalies, they might be due
to chromosomal abnormalities, single gene defects or teratogenic exposure.
• Minor malformations
→ Minor morphologic features with negligible or no
known medical significance
o Have mostly cosmetic significance.
o Also named “dysmorphic features”
o They are found in less than 2-4% of population
o Clinical significance – when one minor
malformation is associated with one major
malformation or when there are 3 or more
minor malformations
▪ (in 90% of newborn babies with 3 or
more minor malformations is found and
one major malformation)
o Examples: Simian crease, Clinodactyly
• Normal variants → common features with familial characteristic:

o “Normal” morphological features representing variation of morphology, without medical
significance mainly with cosmetic effect.
o Found in more than 4% of population
o More common these features are familial characteristics with polygenic /multifactorial
pattern of inheritance
o “Normal” spectrum of human variation of morphological features with absolutely no medical
significance (e.g.: epicanthal folds, hypertelorism, ‘attached’ vs. ‘unattached ear lobes’)
Deformation
→ Abnormal form or position of a body region caused by mechanical (non-disruptive) forces
• A secondary arising defect in morphogenesis:

o Usually occurring latter after 10th weeks of gestation (fetal period)
o Ability for spontaneous or orthopaedic correction
Causes/Etiology and examples:
• Mechanical forces on an otherwise normally developing structure.

o This could be due to uterine malformation,
o Twins
o Oligohydramnios
o e.g.: clubfoot/talipes deformity, congenital hip dislocation, craniofacial asymmetry, over
folded ear…
• Functional
o E.g.: contractures of limbs in baby with congenital myotonic dystrophy
• Following a malformation
o Pes varus in baby with spina bifida aperta
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Disruption
→ Morphologic defect of an organ or region resulting from a destructive breakdown of, or interference with,
an originally normally developing structure, resulting in death of cells or tissue destruction.
• Secondary defect due to:

o Mechanical forces
o Infections
o Vascular events
• Examples:
o Loss of digit due to amniotic band constriction
o Lack of normal limb development or defects of abdominal wall (omphalocelle, gastroschisis)
due to intrauterine vascular accident
Dysplasia
→ Error of morphogenesis due to the abnormal cellular organization or function in a specific type of tissue
most often due to single gene defects.
• Examples:
o Ectodermal dysplasia
o Osteogenesis imperfecta
o Achondroplasia
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Incidence
Incidence according to birth outcome:
• Livebirths – 3-4%
• Stillbirths – 10-20%
• Cause of the perinatal death – 25-30%
• Spontaneous abortions – 25-80%
o 1st trimester – 85%
o 2nd trimester – 25-30%
Incidence according to etiology of congenital anomalies (proportion):
• Multifactorial: 20 - 40%
• Single gene: 8 - 14%
• Chromosomal: 6 - 8%
• Environmental (teratogenic) – 7 - 10%
• Unknown – 31 - 50%
Prevalence according to etiology:
• Chromosomal: 5-7 per 1000

• Single gene: 10-14 per 1000
• Multifactorial: 10-20 per 1000
• Non-genetic (environmental & unknown): 10 - 20 per 1000
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18. Dysmorphology. Genetics and congenital anomalies – syndrome,

association, sequence. Definition and examples. Etiology, incidence and
clinical significance.
Dysmorphology
the individual
birth.

o Malformation
o Deformation
o Disruption
o Dysplasia

o Association
o Sequence
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Syndrome, association, sequence

Sequence
→ Multiple defects derived from a cascade of effects related to a single known, or presumed, structural defect
Types of sequence:
• Malformation, deformation, disruption (depends on the primary structural defect.
Examples:
o Potter sequence
▪ Renal dysplasia, pulmonary hypoplasia, facial dysmorphisms, limb deformity
o Mandibular hypoplasia (Robin sequence)

▪ Glossoptosis, high/cleft palate
o Meningomyelocele/Spina bifida aperta

▪ Club foot, hip dislocation, hydrocephalus
Association
→ Non-random occurrence of a combination of several anomalies not yet identified as a specific sequence or
syndrome that occur more often together than by chance alone.
• In different cases some defects of the malformation complex might be absent
Examples:
• VATER
o Vertebral anomalies
o Anal atresia
o Tracheoeosophageal fistula
o Esophageal atresia
o Radial defect, renal defects
• CHARGE
o Coloboma
o Heart defects
o Atresia choanae
o Retarded growth
o Genital anomalies
o Ear anomalies
Syndrome
→ Multiple anomalies in one or more tissues or structures thought to be pathologically related due to a
specific etiologic mechanism (chromosome disorder, single gene defect, environmental agent, or unknown
factor), not representing a sequence.
• From Greek meaning – “running together”
In order to consider a syndrome, it is necessary:
• Multiple anomalies
o More than 3 minor anomalies
• One or more major anomaly
• One major anomaly and a few minor anomalies
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Causes/Etiology and examples:
• Chromosomal
o Patau syndrome/ trisomy 13 (microcephaly, facial cleft, polydactyly, holoprosencephaly)
• Single gene defects

o Meckel-Gruber syndrome (encephalocele, cleft palate, polydactyly, cystic dysplasia of kidneys
and liver)
• Teratogenic
o Fetal rubella syndrome (deafness, cataract, congenital heart defect, mental retardation)
• Unknown
Incidence
Incidence according to birth outcome:
• Livebirths – 3-4%
• Stillbirths – 10-20%
• Cause of the perinatal death – 25-30%
• Spontaneous abortions – 25-80%
o 1st trimester – 85%
o 2nd trimester – 25-30%
Incidence according to etiology of congenital anomalies (proportion):
• Multifactorial: 20 - 40%
• Single gene: 8 - 14%
• Chromosomal: 6 - 8%
• Environmental (teratogenic) – 7 - 10%
• Unknown – 31 - 50%
Prevalence according to etiology:
• Chromosomal: 5-7 per 1000

• Single gene: 10-14 per 1000
• Multifactorial: 10-20 per 1000
• Non-genetic (environmental & unknown): 10 - 20 per 1000
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19. Dysmorphology and teratogenesis. Major steps of syndrome identification

process. Environmental teratogens - examples.
Dysmorphology
the individual
birth.

o Malformation
o Deformation
o Disruption
o Dysplasia

o Association
o Sequence
Major steps of syndrome identification process

→ Multiple anomalies in one or more tissues or structures thought to be pathologically related due to a
specific etiologic mechanism (chromosome disorder, single gene defect, environmental agent, or unknown
factor), not representing a sequence.
In order to consider a syndrome, it is necessary:
• Multiple anomalies
o More than 3 minor anomalies
• One or more major anomaly
• One major anomaly and a few minor anomalies
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Examples of genetic syndromes include:
• Down syndrome → trisomy 21

• Fetal alcohol syndrome → maternal alcohol abuse during pregnancy
• Marfan syndrome → dominantly inherited mutation of the fibrillin gene.
The major steps of syndrome identification process are:
• The assessment of children with congenital malformation requires for this reason careful thinking of:
• History → possible exposure to teratogens, perinatal problems…
• Physical examination → detailed documentation with accurate clinical measurement and photographic
records
• Chromosomal analysis and Biochemical or Radiological studies
• A chromosomal or mendelian etiology has been identified for many multiple congenital malformation
syndromes.
• When the etiology of a recognized multiple MCA syndrome is not known → empirical risks of recurrence
are used (usually are low)
• Literature review (published case reports, specialized texts and available computer programs) → to
assist in differential diagnosis
Environmental teratogens – examples

Teratogens → Mutagens (agents that cause alterations in genetic material – DNA, chromosomes) which can
cause a birth defect by interfering with normal embryonic or fetal development (they act via exposure of the
mother).
• Teratogens accounts for 7-10% of all

congenital abnormalities.
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20. Classification of genetic diseases. Main groups of genetic disorders:

characteristics, incidence and significance for human pathology.
Medical genetics is a branch of medicine that deals in the causes, inheritance, diagnosis and
treatment of diseases caused by single gene mutations, chromosome abnormalities, and genetic
predisposition.
Genetic counselling, screening of genetic disorders and prenatal (before birth) diagnosis are also a
part of Medical genetics.
Classification of genetic diseases

Each individual is estimated to have approximately 30 000 different genes.
• Alterations in these genes, or in combinations of them → genetic disorders

• They are classified into several major groups, according to the kind of causing mutation:
1. Chromosome disorders (abnormalities)
2. Single gene disorders
a. Autosomal dominant
b. Autosomal recessive
c. X-linked
3. Multifactorial disorders
4. Mitochondrial disorders
5. Disorders due to somatic cell mutations
1. Chromosome Disorders → “Entire chromosomes, or large segment of them, are missing, duplicated, or
otherwise altered” or “Deviations from the normal chromosome number or structure”
o Down syndrome, Edwards syndrome, Turner syndrome, Klinefelter syndrome, etc.
2. Single Gene Disorder → Single genes are altered by gene mutations (also Monogenic/Mendelian conditions)
o Cystic fibrosis, Marfan syndrome, Sickle cell disease, etc.
• According to the way in which they are inherited in families they can be:
o Autosomal dominant (AD)
o Autosomal recessive (AR)
o X-linked (XL)
3. Multifactorial Disorders → they are due to a combination of multiple genetic (polygenic) as well as
environmental causes.
o Many birth defects: cleft lip/palate, neural tube defects, congenital heart defects, etc.
o Many common adult disorders: diabetes mellitus, schizophrenia, hypertension, etc.
4. Mitochondrial Disorders → caused by mutations in the small cytoplasmic mitochondrial DNA.
o LHON – Leber’s Hereditary Optic Neuropathy

o MERRF – Myoclonic Epilepsy
o Ragged-Res fibres myopathy
o KSS – Kearns-Sayre Syndrome
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5. Disorders due to Somatic Cell Mutations → Not all genetic errors are present from conception. Many
billions of cell mitoses occur in the course of an average human lifetime, and there is an opportunity for the
occurrence of somatic mutations
o Large proportion of malignancy and other diseases
The impact of genetic disease

• In embryonic, fetal life:
o At least 50% of all recognized first-trimester pregnancy loss (spontaneous miscarriages) are due to
chromosomal abnormalities.
• In newborn infants:
o 2 – 4% of all neonates have at least one major congenital abnormality (often caused by genetic
factors).
o 2% of all neonates have a chromosome abnormality or a single-gene disorder.
• In childhood genetic and congenital disorders account for:

o 40 – 50% of all childhood death
o 30% of all childhood hospital admissions
o 50% of all childhood blindness
o 50% of all childhood deafness
o 50% of all cases of severe mental retardation
• In adult life:
o 1% of all malignancy → directly due to genetic factors
o 10% of common cancers (breast, colon, ovary cancers) → have a strong genetic component
o By the age of 25, about 8% of the population → have a disorder in which genetic factors play an
important role.
“What proportion of individuals in the population will be diagnosed with a genetic disorder?”
A variety of factors can influence the answer:
• Some diseases are more frequent in certain ethnic groups (Cystic fibrosis in Europe, Sickle cell disease
in Central Africa…)
• Some diseases are more common in older individuals (Huntington disease, familial
hypercholesterolemia…)
• Variations in diagnostic and recording practices
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21. Organization of human genome. Chromosomes and genes - structure and

function. Mutations as a molecular base of genetic disorders.
Organization of human genome.

Human genome
• All the genes carried by a cell or the total DNA content of the haploid chromosome set
Human body → 100 trillion cells (d <0,1 mm) → nucleus → 46 chromosomes (diploid set) → 23 chromosomes
(haploid set) → 23 DNA molecules → 3x109 (3 billion) base pairs
Organization of human genome at molecular level

Types of DNA sequences:
1. Nuclear DNA:
a. Single copy (unique DNA): Structural genes; 60-70% of all human genome → they can be
transcribed)
i. Protein coding sequences (< than 10% of our DNA):
- The smaller proportion (exons of the structural genes)
ii. Non-coding sequences:
- The bigger proportion (introns + regulation sequences of the structural
genes)
b. Low copy number (multi-gene families): 1-2%
c. Repetitive (30-40%; non-coding sequences):

i. Tandem repeats (mutations are named polymorphisms – very useful as genetic
markers)
- Satellite
- Mini-satellite
- Micro-satellite
d. Interspersed repeats: mutations cause GD
i. Short interspersed nuclear elements (SINE)
ii. Long interspersed nuclear elements (LINE)
2. Mitochondrial DNA
Chromosomes and genes – structure and function.

Types of chromatin
• Euchromatin → genetically alive

• Heterochromatin → genetically inactive
o Constitutive chromatin → permanently
condensed regions
o Facultative heterochromatin → regions that
were previously euchromatic
▪ Barr body, which contains the
inactive X chromosome
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Gene structure
Gene – A part of DNA molecule of a chromosome, which directs the synthesis of a specific polypeptide chain
• Number: Approximately 25 – 30.000

• Size – varies:
o 1.500 bp (beta-globin gene)
o 2.400.000 bp (dystrophin gene) – only 0.6% of it is coding DNA
Details of the gene structure:
• Exons → functional portions of gene that code for proteins

• Introns → non-coding DNA, that separate exons
o The number and size of introns vary different genes
o The size of a gene depends on specific number of introns
• GT and AG splice sites – not transcribed, important for splicing
o 5’GT – donor site
o 3’AG – acceptor site
• 5’ - promoting region: ATG – translation initiation codon + TATA and CAAT boxes (regulatory function)
• 3’ – TAA – translation termination codon + poly-A addition site
Regulation of gene expression

• All cells have a DNA available to code for every cellular function.
• Some genes (house-keeping genes) are transcribed in all cells of the body (a small portion that encode
protein which are required for the cell’s life)
• Most genes are transcribed only in specific tissues at specific point of time
• This differential control of gene expression can occur at a variety of levels.
Levels of differential control of gene expression:
The regulation of gene

expression can be disrupted by
gene mutations in each of the
levels of control that can result
in different genetic disorder
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Epigenetic control of gene expression

→ Epigenetic factors affect only expression of genes without altering DNA
Examples: X-inactivation and Genomic imprinting (involved in pathogenesis of some diseases)
• X-chromosome inactivation
o Dosage compensation:
▪ Females have double doses of most X-linked genes, but the amount of X-linked gene
products is usually about the same in males and females.
▪ If a female somatic cell contains more than one X-chromosome, all but one is inactivated.
o X-inactivation:
▪ Occurs early in embryogenesis
▪ Is random in any single cell (either the X-mat or the X-pat can be inactivated with equal
likelihood; females are mosaics)
▪ Involves most but not all genes on the X-chromosome
▪ Methylation appears to be one of the molecular mechanisms
• Genomic imprinting = differential expression of a gene, depending on whether it was inherited from the
mother or from the father or patent of origin effect
o Imprinting is a functional change in a gene. The DNA sequence is not altered, but expression of an
affected gene is modified.
o Imprinting affects only a minority of genes
o Imprinting occurs soon after conception and once established, is usually transmitted to all the
descendants of an imprinted cell
o A gene’s imprinting is reversed or removed during gametogenesis. The effect depends on whether
oogenesis or spermatogenesis is occurred.
o Imprinted genes are usually methylated
o Clinical consequences of genomic imprinting are very important for several Monogenic disorders
(HD; MD) and syndromes (Prader-Willi and Angelman)
Mutations as a molecular base of genetic disorders.

Gene mutation → Any permanent change in the DNA of an organism, which can be
• Very few are helpful

• Some are lethal
• Many are harmful – molecular causes of the genetic disorders
Main types:
1. Germ mutations → occur in gonads or gametes, can be transmitted to offspring

2. Somatic mutations → occur in body cells, cannot be transmitted to offspring
3. Spontaneous mutations → arise by errors in DNA repair
4. Induced mutations → arise by exposure to mutagens
5. Fixed (stable) mutations → They are transmitted to offspring
6. Dynamic (unstable) mutations or triplet repeat expansion
a. undergo further alterations as they are transmitted in families
b. explain unusual phenomena and pattern of inheritance within families
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Fixed stable mutations
• According to the specific molecular findings at DNA levels

o Point mutations
o Deletions
o Insertions
o Frameshift mutations
• According to structural effect on protein
o Silent proteins
o Missense mutations
o Nonsense mutations
• According to the functional effects of mutations
o Loss of function mutations → results in absent activity of the gene. Seen in recessive diseases
o Gain of function mutations → results in increased activity of a gene usually in dominant
diseases
• According to the occurring region of the gen
o In coding DNA sequences of structural genes (exons) → usually lead to synthesis of an
abnormal gene products
o In non-coding DNA sequences of structural genes (introns; regulatory regions or splice sites of
the gens) → usually lead to reduced output of gene product
Point mutations (substitutions):
→ The replacement of a single nucleotide by another
• Missense mutations
o In coding DNA
o Different amino acid is formed
o Affected protein function
▪ Sickle cell anemia (AR)
▪ Cystic fibrosis (AR)
▪ Tay-Sachs disease (AR)
▪ Phenylketonuria (AR)
• Nonsense mutations
o In coding DNA
o Stop codon is generated
o Degradation of mRNA
o No amino acid and is produced so protein is impaired
Deletions:
→ Less of one or more nucleotides
• Frameshift deletion
o Deletion of any no. of nucleotides except for
those which can’t be divided by 3 (1,2,4,7…)
o Lead to disruption of reading frame and
changed triplet code for all followed codons
o Completely altered amino acids sequence in protein
→ Loss of function
▪ Duchene muscular dystrophy (DMD) – (XR)
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• Large partial gene deletions

o Result in termination with loss of gene function or expression
▪ Familial hypercholesteremia (FH) – (AD)
• Whole genetic deletions

o Loss of gene expression
▪ Alfa Thalassemia (AR): reduced Alfa-globin chains and HB A
Insertions:
→ Addition of one or more nucleotides; rare causes of mutations in human genome
• Frame-shift insertion
o Not multiple of 3 is inserted
o Change of the reading frame, changed triplet code for all followed codons
o Completely altered amino acids sequence in protein → Loss of function
o Transposition of DNA can disrupt a gene and its expression
▪ LINE (long interspersed repetitive sequences), factor VIII gene = haemophilia A (XR)
▪ SINE (Short interspersed repetitive sequences) in the Neurofibromatosis gene (AR)
Dynamic (unstable) mutations or genetic amplifications or

triplet repeat expansion
→ Expansion of a trinucleotide repeat sequence in novel genes

(new mechanism of human mutation)
•
•
• Number of single gene disorders are due to different
triplet repeated expansions, in their genes
o Fragile X syndrome [CGG]
o Huntington’s disease [CAG]
o Friedreich’s syndrome [GAA]
o Myotonic dystrophy [CTG]
• Mechanism:
o Normally triplet repeat sequences (amplifications) are stable during meiosis and mitosis →
Sequence copy number is transmitted as a polymorphism from parent to child
o Triplet repeats below a certain length for each disorder are faithfully transmitted in meiosis
and mitosis and do not lead to disease
o Above certain repeat number for each disorder, they are unstable and will be transmitted
with an increase in triplet repeat number and when it passes a certain specific number of
repeats, it will cause disease
• These are called dynamic mutations because the repeat sequence becomes more unstable as it
expands in size
• It causes anticipation (unusual pattern of inheritance)
o Anticipation is a when a genetic disease comes with grater severity or occurrence in earlier
age in more recent generations compared to older ones
o Anticipation results from the enlargement of the trinucleotide repeated region as the
dynamic mutation passes through meiosis
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22. Haemoglobinopathies. Disorders of haemoglobin structure – types of

mutations, general clinical features. Examples - Sickle cell disease.
Haemoglobinopathies
→ single gene (monogenetic) disorder of the structure and synthesis of human hemoglobin (Hb)
• more than 1/4 of million persons are born in the world each year with one of them
• they have the greatest impact on morbidity and mortality of any disorders at protein and DNA level
• they are molecular inherited diseases
• they serve as an illustration of the clinical consequences of gene mutations, because:
o all types of gene mutations have been observed in the Hb-disorders at
protein and DNA level
Structure and developmental expression of Hb
• There are large quantities of Hb in blood → easy to analyse by biochemical and

DNA techniques
• the Hb molecule is a tetramer of four polypeptide (protein) chains
• each of them is associated with a heme group with iron atom
• there are two groups of globin chains: α-like and β-like
• the amino acid sequence of the various globin polypeptides is known
Structure of the normal human Hb’s over time
Globin gene structure
• globin genes constitute a multi-gene family

• similar function and are physically close together
in two clusters on chromosome 16 and 11
• The whole of these clusters has been cloned and
the nucleotide sequence of each of the various
globin structural genes is known
• Locus control region (lcr) → is involving in timing
and tissue specificity of expression
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Disorders of haemoglobin structure – types of mutations, general clinical features

Hemoglobinopathies
• Two main groups:

1. Structural disorders of Hb (structural variants of the globin chains) → Sickle cell anaemia – HbS, …
2. Disorders of synthesis of the globin chains (reduced output of the globin chains) → a-Thalassemia,
b-Thalassemia, …
1. Structural disorders of haemoglobin

They are due to different gene mutations in
coding DNA sequences (exons) of the Hb-genes
→ leading to synthesis of abnormal globin
chains
Structural variants of the haemoglobin: →
Clinical aspects of the Hb structural variants
• Many are harmless, some are associated with

disease
Functional abnormalities of structural variants: →
Example – sickle cell disease/anemia (AR)
• Most common haemoglobinopathy

• Affects 1/40 African blacks
• Carrier frequency = 1/3 → selective advantage with regard to malarial
infection
• Most important disease of structural Hb variants
• Genetics:
o Point mutation → in triplet coding for glutamic acid (GAG to
GTG)
o Leads to missense mutation (substitution of valine for glutamic
acid in position 6 of the beta globin) → abnormal gene product
(Hb S)
o Pattern of inheritance = AR
o Pleiotropic effect of the gene + Allelic heterogeneity
▪ Pleiotropy describes the genetic effect of a single gene
on multiple phenotypic traits
▪ Allelic heterogeneity is the phenomenon in which
different mutations at the same locus lead to the same
or very similar phenotypes
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Clinical aspects and prognosis:
• Heterozygotes (Aa) → no significant risk to health

• Homozygotes (aa):
o Severe chronic hemolytic anemia
(weakness, lassitude, icterus)
o Recurrent episodes of infarction of lung,
spleen, bones (chest, back or limb pains)
o Prone to infections (pneumococcal or
salmonella osteomyelitis)
o Lifespan is shortened (despite supportive
care)
Diagnosis:
1. Blood film
a. Sickle shaped erythrocytes
i. Hb S
- Less soluble
- Tends to crystalize
ii. Er
- Less stable
- Shorter survival time
b. Hemolytic anemia
- Increased viscosity and clumping of cells
- Thrombosis, Infarctions
2. Hb electrophoresis
- Mainly Hb S with some Hb A2
- Some Hb F (5 – 15%)
3. Carrier detection is possible by

- Hematological analysis
- Hb electrophoresis
- DNA analysis
4. Prenatal diagnosis is possible by:

- DNA analysis (direct detection of the mutation)
- Hb electrophoresis (in the 2nd trimester)
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23. Haemoglobinopathies. Disorders of haemoglobin synthesis – types of

mutations, general clinical features. Examples α- and β -Thalassaemia.
Haemoglobinopathies
→ single gene (monogenetic) disorder of the structure and synthesis of human hemoglobin (Hb)
• more than 1/4 of million persons are born in the world each year with one of them
• they have the greatest impact on morbidity and mortality of any disorders at protein and DNA level
• they are molecular inherited diseases
• they serve as an illustration of the clinical consequences of gene mutations, because:
o all types of gene mutations have been observed in the Hb-disorders at
protein and DNA level
Structure and developmental expression of Hb
• There are large quantities of Hb in blood → easy to analyse by biochemical and

DNA techniques
• the Hb molecule is a tetramer of four polypeptide (protein) chains
• each of them is associated with a heme group with iron atom
• there are two groups of globin chains: α-like and β-like
• the amino acid sequence of the various globin polypeptides is known
Structure of the normal human Hb’s over time
Globin gene structure
• globin genes constitute a multi-gene family

• similar function and are physically close together
in two clusters on chromosome 16 and 11
• The whole of these clusters has been cloned and
the nucleotide sequence of each of the various
globin structural genes is known
• Locus control region (lcr) → is involving in timing
and tissue specificity of expression
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Disorders of haemoglobin structure – types of mutations, general clinical features

Hemoglobinopathies
• Two main groups:

1. Structural disorders of Hb (structural variants of the globin chains) → Sickle cell anaemia – HbS, …
2. Disorders of synthesis of the globin chains (reduced output of the globin chains) → a-Thalassemia,
b-Thalassemia, …
2. Disorders of Hb synthesis (Thalassemias – AR)
• The commonest single group of inherited disorders in humans

• Mainly in persons from:
o Mediterranean area
o Indian subcontinent
o South-East Asia
• Two major groups → depending on the globin chain that is reduced in quantity:
o α-thalassemia
o β-thalassemia
α-Thalassemia
• Underproduction of α-globin chains

• Most commonly in persons from South-East Asia
Genetics:
• Mutations → usually deletions of one or more a gene

• Mechanism → mispairing and unequal crossing over during meiosis
• Normally → two functional α-globin genes on each copy of

chromosome 16 (aa/aa)
• α-thalassemia-heterozygotes:
o two (-a/-a) or (--/aa) functional α-globin genes
o three (-a/aa) functional α-globin genes
• Patients with HbH (β4) disease → a single functional α-gene (--/-a)
o α-globin synthesis is reduced
o Chronic hemolytic anaemia (moderately severe)
• α-thalassemia homozygotes → not functional α-globin genes (--/--)
o α-globin synthesis absent
o foetuses have Hb Bart’s (γ4)
o Profound anaemia still in utero → hydrops fetalis (massive build-up of fluid)
→ Intrauterine death
Diagnosis:
• Electrophoresis (postnatal diagnosis):

o Homozygotes for α-thalassemia have:
▪ 80% Hb Bart’s (γ4)
▪ Persistence of embryonic Hb
o Patients with Hb H disease have:
▪ 5 – 30% Hb H (β4)
▪ Some Hb Bart’s (γ4)
• DNA analysis (prenatal diagnosis is possible):
o For couples at risk of α-thalassemia-homozygotes
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β-Thalassemia
• Underproduction of β-globin chains

• Most commonly in persons from Mediterranean area,
Indian subcontinent
• It is the commonest haemoglobinopathy in Bulgaria
Genetics:
• Mutations:
o Different point mutations in β-gene
o Usually in the regulatory non-coding gene regions
(introns)
o Affected transcription, translation or RNA splicing
→ reduced synthesis of β-globin chains.
• Allelic heterogeneity → variety (over 120) of mutations in

the β-globin gene
o Most affected patients are not “homozygous” in the strict sense → they are compound
heterozygotes = have different disease’s mutations on each copy of
β-globin gene
• Heterozygotes (Aa) → β-thalassemia minor

o Usually without symptoms
• Homozygotes (aa) → β-thalassemia major (Cooley’s anaemia)

o Severe transfusion-dependent anaemia:
o Pallor
o Unusually-shaped face = frontal bossing → due to bone marrow compensatory proliferation
o Hepatosplenomegaly → due to extramedullary haematopoiesis and infections
o Physical and sexual retardation
o Clinical severity depends on the nature of responsible mutation.
o Complications → due to iron overload from repeated transfusions
o Treatment → bone marrow transplantation (only effective one)
Diagnosis:
1. Postnatal (affected and carriers):

a. Haematological analysis → Microcytosis
b. Hb-electrophoresis:
i. Increased Hb F (and Hb A2)
ii. Decreased Hb A (reduced β-globin chains)
2. Prenatal
a. DNA analysis → on chorionic villus samples (9 – 11 w.g.)
b. Haematological analysis → on fetal blood samples (> 20 w.g.)
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24. Inherited immunodeficiency disorders. Primary (defects at specific stages

of differentiation of stem cells) immunodeficiency – examples.
Immune system
• The immunes system must be able to distinguish “self” from “non-self”
with a high degree of accuracy
• The genetic basis of the immune system is complex
• The study of the genetics of the immune system is known as
immunogenetics.
• During development, a lymphoid stem cell takes one of two pathways:

o Cellular immunity
▪ Includes → differentiation of lymphocyte stem cells
into T-lymphocytes
▪ Occurs → thymus gland, spleen and lymph nodes
o Humoral immunity
▪ Includes → differentiation of lymphocytes into B-cells
(→ produce immunoglobulins = antibodies)
▪ Occurs → bone marrow, bursa of Fabrius
(equivalents), fetal liver
Differentiation of stem cells into T and B lymphocytes and the sites

of hypothetical blocks in certain immunological deficiency diseases
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IMMUNOGLOBULIN STRUCTURE
• Light (L) chain

o Two classes
▪ κ
▪ λ
o Three regions
▪ Variable (V)
▪ Junctional (J)
▪ Constant (C)
• Heavy (H) chain

o Five classes:
▪ γ (IgG)
▪ μ (IgM)
▪ α (IgA)
▪ δ (IgD)
▪ ε (IgE)
o Four regions
▪ Variable (V)
▪ Diversity (D)
▪ Junctional (J)
▪ Constant (C)
Multi-gene family of immunoglobulin’s genes
• The gene for 𝜅 and 𝜆 light chain and the heavy chains in humans are located on chromosome 2, 22, and 14
respectively
• Each plasma cell produces only one VJC light chain combination and produces either kappa 𝜅 or lambda 𝜆
chains, but not both.
The generation of antibody diversity:

1. Multiple germline immunoglobulin genes – gene
family
2. Somatic recombination (VDJ recombination) in
DNA
3. Junctional diversity – in RNA processing
4. Somatic mutation – after stimulation by a foreign
antigen
5. Multiple combination of H and L chains
6. Immunoglobulin heavy (H) chain genes and the
creation of different antibody sequences by
somatic recombination and class switching:
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T-cell receptor structure:
• The T cell receptor of most cells is very similar in

structure to the immunoglobulins and consist of two
chains, α and β
• Each has a structure analogous to the Ig-gene clusters
with V and J genes (for the α chain) and V, D and J gene
(for the β chain).
• The diversity is created by the same mechanism that
produce Ig-diversity with the exception of somatic
mutation.
Inherited immunodeficiency disorders.

• They are:
o Uncommon
o Associated with severe morbidity and mortality
• They may occur in either or both components of the immune system.
• They in general show:
o Early onset
o Death infancy
o Increased susceptibility:
▪ Virus infection (abnormal cellular immunity), approximately 5%
▪ Bacterial infection (deficient Ig synthesis), approximately 50-70%
▪ Virus + bacterial (combined) infection, approximately 25%
o Genetic heterogeneity
• They can occur as:

1. Primary isolated abnormality
2. Secondary or associated findings
1. Primary (defects at specific stages of differentiation of stem cells) immunodeficiency
• Primary isolated immunodeficiency defects occur at specific developmental stages of the immune system:
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Severe combined immunodeficiency (SCID): (AR), (XL)

Diagnosis:
• Onset is the few months of life

• SCID shows recurrent infections (viral, fungal, and bacteria) because of profoundly abnormal cellular and
humoral immunity (reduced lymphocytes count and marked reduction in immunoglobulin).
Prognosis:
• Death occurs in infancy unless bone marrow transplantation is performed
Genetics:
• heterogeneous; can be inherited either as an X-linked (at least 2 types) or autosomal recessive disorder (at
least 4 types)
o XL forms are caused by mutation in the gene encoding the 𝛾-chain of the interleukin (IL)-2
receptor.
o AR forms are inborn errors in metabolism which affect the immune system. 25% of SCID cases are
caused by ADA (adenosine deaminase deficiency)
Reticular dysgenesis (AR)
• It is an autosomal recessive form of SCID and patients have abnormal cellular and humoral immunity and
deficiency of granulocytes
• They die early in the first year unless offered a bone marrow transplant
• The molecule basis has not yet been identified
Bruton-type agammaglobinaemia (XL)
• Caused by mutations in the gene (BTK), that encodes a B-cell tyrosinekinase, necessary for normal B-cell
maturation.
• Male children with the disorder:
o Develop multiple recurrent bacterial infections of the respiratory tract and skin after the first few
months of life
o Can still die from respiratory failure
o Have immunoglobulins deficiency and absence of B-lymphocytes
o Treatment with antibiotics and use of intravenous immunoglobulins improves survival prospects
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25. Inherited immunodeficiency disorders. Secondary (associated)

immunodeficiency disorders – examples.
Immune system
• The immunes system must be able to distinguish “self” from “non-self”

with a high degree of accuracy
• The genetic basis of the immune system is complex
• The study of the genetics of the immune system is known as
immunogenetics.
• During development, a lymphoid stem cell takes one of two pathways:

o Cellular immunity
▪ Includes → differentiation of lymphocyte stem cells
into T-lymphocytes
▪ Occurs → thymus gland, spleen and lymph nodes
o Humoral immunity
▪ Includes → differentiation of lymphocytes into B-cells
(→ produce immunoglobulins = antibodies)
▪ Occurs → bone marrow, bursa of Fabrius
(equivalents), fetal liver
Differentiation of stem cells into T and B lymphocytes and the sites

of hypothetical blocks in certain immunological deficiency diseases
Rodi Jelebi
IMMUNOGLOBULIN STRUCTURE
• Light (L) chain

o Two classes
▪ κ
▪ λ
o Three regions
▪ Variable (V)
▪ Junctional (J)
▪ Constant (C)
• Heavy (H) chain

o Five classes:
▪ γ (IgG)
▪ μ (IgM)
▪ α (IgA)
▪ δ (IgD)
▪ ε (IgE)
o Four regions
▪ Variable (V)
▪ Diversity (D)
▪ Junctional (J)
▪ Constant (C)
Multi-gene family of immunoglobulin’s genes
• The gene for 𝜅 and 𝜆 light chain and the heavy chains in humans are located on chromosome 2, 22, and 14
respectively
• Each plasma cell produces only one VJC light chain combination and produces either kappa 𝜅 or lambda 𝜆
chains, but not both.
The generation of antibody diversity:

7. Multiple germline immunoglobulin genes – gene
family
8. Somatic recombination (VDJ recombination) in
DNA
9. Junctional diversity – in RNA processing
10. Somatic mutation – after stimulation by a foreign
antigen
11. Multiple combination of H and L chains
12. Immunoglobulin heavy (H) chain genes and the
creation of different antibody sequences by
somatic recombination and class switching:
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T-cell receptor structure:
• The T cell receptor of most cells is very similar in

structure to the immunoglobulins and consist of two
chains, α and β
• Each has a structure analogous to the Ig-gene clusters
with V and J genes (for the α chain) and V, D and J gene
(for the β chain).
• The diversity is created by the same mechanism that
produce Ig-diversity with the exception of somatic
mutation.
Inherited immunodeficiency disorders.

• They are:
o Uncommon
o Associated with severe morbidity and mortality
• They may occur in either or both components of the immune system.
• They in general show:
o Early onset
o Death infancy
o Increased susceptibility:
▪ Virus infection (abnormal cellular immunity), approximately 5%
▪ Bacterial infection (deficient Ig synthesis), approximately 50-70%
▪ Virus + bacterial (combined) infection, approximately 25%
o Genetic heterogeneity
• They can occur as:

1. Primary isolated abnormality
2. Secondary or associated findings
2. Secondary (associated) immunodeficiency disorders.

• There are a number of hereditary disorders in which immunoglobulins abnormalities occur as one of a
number of associated features as part of a syndrome
o Di George syndrome
o Ataxia telangiectasia
o Wilkott-Aldrich syndrome
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DiGeorge syndrome (microdeletion syndrome – 22q 11)
• Children with this syndrome:

o Develop recurrent viral infections
o Have abnormal cellular immunity (severely reduced or absent
T-lymphocytes, associated with absence of the thymus gland)
o Have congenital abnormalities:
▪ Congenital heart diseases
▪ Absence of the parathyroid glands (can result with
tetany due to low calcium levels secondary to low
parathyroid hormone levels).
▪ Cleft palate, characteristic facies and other
abnormalities
Ataxia telangiectasia (Louis – Bar syndrome) – (AR)
• Children with this disorder develop in early childhood:

o Ataxia (difficulty in control of movement and balance)
o Oculo-cutaneous telangiectasia
o Low or absent serum IgA, IgG and Hypoplastic thymus
o Chromosome instability (increased incidence of chromosome beaks)
o Increased risk or leukaemia or lymphoid malignancies
Wilkott-Aldrich syndrome – (XL)

• Male children with this disorder:
o Eczema
o Diarrhea
o Recurrent infections
o Thrombocytopenia (a low platelet count)
o Low syndrome serum IgM levels
o Increased risk of B cell malignancies
→ Until the advent of bone marrow transplantation, the affected boys die by mid-adolescence usually from haemorrhage
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26. Unusual pattern of inheritance. Genomic imprinting and uniparental

disomy. Examples: Prader – Willi syndrome, Angelman syndrome
Unusual pattern of inheritance of single gene disorders

The reason for studying pattern of inheritance of disorders within families is their adequate genetic counselling
(correct clinical diagnosis and recurrence risk on the base of pattern of inheritance).
For many single gene disorders, gene characterization has revealed atypical, unusual inheritance mechanisms,
that are outside the scope of Mendel’s experiments.
• Unusual pattern of inheritance can be explained by genetic phenomena such as:

o Genomic imprinting
o Uniparental disomy
o Somatic or germ-line mosaicism
o Triplet repeat expansion
o Mitochondrial inheritance
Genomic imprinting (“Parent of origin”)

→ different expression of a gene, depending on the sex of the parent who transmits it.
• Imprinting affects only a minority of genes

• Functional (epigenetic) change in a gene (a form of silencing or temporary gene inactivation)
• DNA sequence is not altered (there is no mutation) but expression of affected gene is modified.
• A gene’s imprint is reversed or removed when a cell passes through opposite gametogenesis.
o Paternally imprinted gene → is not expressed when is inherited from father
o Maternally imprinted gene → is not expressed when is inherited form mother
Mechanism of imprinting:
• DNA methylation
o Must occur before fertilization
o Must be able to confer transcriptional silencing
o Must be stably transmitted through mitosis in somatic cells
o Must be reversible on passage through the opposite parental germline (e.g.: if an allele is
maternally imprinted, this must be removed in the gametes of a male offspring).
Uniparental disomy
→ presence of two homologous chromosomes inherited form only one parent.
• Isodisomy → parent passes on two copies of the same chromosome (nondisjunction meiosis II).
• Heterodisomy → parent passes on one copy of each homolog (non-disjunction in meiosis I).
• Clinically significant when it involves chromosomes with imprinted genes!
• Likely to play a role in etiology of pregnancy loss and unexplained IUGR.
• Known clinical phenotypes exist with:
o Paternal UPD 6, 7, 14, 15
o Maternal UPD 7, 14, 15, 16
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Clinical consequences of Genomic imprinting (GI) + Uniparental disomy (UPD)
• In many single gene disorders, there is the “parent of origin” effect.

o Huntington disease (AD)
▪ increased risk of an earlier and more severe form of the disease when the gene is
transmitted by the father
o Myotonic dystrophy (AD)

▪ increased risk of a severe neonatal form of the disease when the gene is transmitted by
the mother
• Microdeletion syndromes can be also illustration of UPD and GI.

1. Prader-Willi syndrome (PWS)
a. Clinical
▪ Mental retardation
▪ Obesity
▪ Short stature
▪ Hypogonadism
▪ Small hands and feet
▪ Skin lesions
b. Genetics
▪ 75% → microdeletion – 15 (q 11-12) → inherited from the father
o 46, XX/XY, del 15 (q 11-12) pat.
▪ 25% → UDP maternal - (both 15 chromosomes are from the mother)
▪ 2 – 3% → mutation in gene controlling imprinting = Imprinting defect (ID)
2. Angelman syndrome (AS)

a. Clinical
▪ Severe mental retardation
▪ Inappropriate laughter
▪ Epilepsy (convulsions)
▪ Ataxia (poor coordination)
b. Genetics
▪ 70% → microdeletion – 15 (q 11-12) → inherited from the
mother
▪ 2% → UDP paternal – (both 15 chromosomes are from the father)
▪ 2 – 3% → mutation in gene controlling imprinting = Imprinting defect (ID)
▪ 25% → maternal gonadal mosaicism or mutation in AS gene
→ Critical region 15 (q 11-12):
• It is deleted in PWS and in AS

• It includes the gene controlling imprinting
• It includes different specific genes (for PWS and for AS) that are opposite imprinted
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1. The gene for PWS is dominant and is expressed (active) only on chromosome inherited from the father.
o If single active copy of this paternal gene is lost by:

▪ Paternal chromosome deletion or maternal UPD 15
→ PWS results because no active paternal genes are present.
2. The gene for AS is dominant and is expressed (active) only on chromosome inherited from the mother.
o If single active copy of this paternal gene is lost by:

▪ Maternal chromosome deletion or paternal UPD 15
→ AS results because no active maternal genes are present
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27. Unusual pattern of inheritance. Anticipation and triplet repeat expansion.

Examples: Huntington's disease, Myotonic dystrophy, Fragile X syndrome.


o Somatic or germ-line mosaicism
Dynamic mutations or genetic amplification

• Triplet expansion (Genetic amplification) causes anticipation → one of the unusual patterns of inheritance.
• A number of single gene disorders (repeat expansion disorders) are due to different triplet repeated
expansions (amplifications) in their own genes.
• Triplet repeats (amplifications) can be present in 5’ or 3’ untranslated region of the particular gene or in its
coding region.
3‘
• Triplet repeats below a certain length for each 5'
disorder → are faithfully transmitted in meiosis
and mitosis and do not lead to disease.
• Above a certain repeat number for each

disorder → they are unstable and will be
transmitted with an increase in triplet repeat
number and usually lead to disease expressing
anticipation in following generations.
• There is a direct relationship between severity of phenotype and repeat copy number.
• Amplifications (triplet repeats) are named dynamic mutations because the repeat sequence becomes more
unstable as it expands in size.
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Huntington disease (AD)
• Chromosome → 4p 16.3
• Repeat triplet → CAG
• Repeat location → coding
o Normal range (repeats) → < 35
o Mutant range (repeats) → 40 – 70
• Autosomal dominant disorder, typically without anticipation.
• Occasional juvenile onset → always by paternal transmission
o Progressive involuntary movements → leading to complete debilitation
o Cognitive loss → leading to complete debilitation
o Psychiatric problems (depression) → common
Myotonic dystrophy (AD)
• Chromosome → 14q 13.2

• Repeat triplet → CTG
• Repeat location → 3’ UTR
o Premutation (repeats) → 35 – 50
o Mutant range (repeats) → 50 – 4000
• Autosomal dominant disease showing anticipation.
• Unstable CTG repeat in the MT-PK gene
• Congenital form with maternal transmission only.
o Myotonia
o Cataracts
o Cardiac arrhythmias
o Temporal bleeding
o Endocrinopathies
Fragile-X syndrome (Atypical XL)
• Chromosome → Xq27.3
• Repeat triplet → CGG
• Repeat location → 5’ UTR
o Premutation (repeats) → 50 – 200
o Mutant range (repeats) → > 200
• The mutation consists of an increase in size of a long CGG in the 5’
UTR of the FMR-1 gene (Xq 27.3), that causes methylation and
decreased gene expression → shows anticipation.
• Most common inherited form of mental retardation (1/1000 males)
• Clinical findings are divided in males and females:
o Affected males (full mutation) have:
▪ Mental retardation, Speech delay or acoustic features
▪ High forehead, large ears, long face
▪ Hypermobile joints
▪ Macroorchidism → important characteristic feature! → it develops during puberty!
o 50% of affected females (full mutation) have:
▪ Mental retardation, Educational difficulties
• Males and females with pre-mutation are unaffected
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28. Unusual pattern of inheritance. Mosaicism. Cytoplasmic (mitochondrial)

inheritance. Examples.


o Somatic or Germ-line mosaicism
Mosaicism
→ presence of more than one cell line in an individual.
• Somatic mosaicism → usually caused by a post-

zygotic mutation which affects a certain
percentage of cells in an individual
o the possibility of somatic mosaicism is
suggested by:
1. features of a single gene disorder
being less severe
2. being confined to a particular
part of the body in a segmental
distribution
o Examples:
▪ Mosaic down syndrome
▪ Segmental Neurofibromatosis-1
• distinctive café-au-lait spots and neurofibroma tumours may occur in one limb
or one body region
• if a patient is mosaic for disease allele because of post-zygotic mutation →
he/she may appear clinically unaffected
▪ McCune-Albright syndrome
• Gonadal mosaicism → presence of more than one cell line in the gonads but not in the rest of the body
(somatic cells)
o Mutation occurred in a precursor sperm or egg cell and is passed on to all derivatives of that cell
o The reminder germ and somatic cells in the body do not carry the mutation
o the characteristic of germ-line mosaicism is multiple affected offspring with normal parents
(resembles AR), but only for:
▪ AD diseases → Achondroplasia, Osteogenesis Imperfecta (OI)
▪ XL diseases → Duchene Muscular Dystrophy, Haemophilia
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Proven by DNA analysis example:
• OI demonstration of a mutation in the collagen gene responsible for oi

in a proportion of individual sperm from a clinically normal father who
had two affected infants with different partners:
o So, gonadal mosaicism is detected when 2 or more offspring
present with an autosomal dominant disorder in the face of a
negative family history.
o Neither parent has the disorder, although one has gonadal
mosaicism for the mutation.
o It is not possible to test individual sperm/eggs → so, we must use empiric recurrence
o Risks and offer prenatal diagnosis in all subsequent pregnancies .
Cytoplasmic (mitochondrial) inheritance

• Mitochondria have their own DNA from maternal origin only
• 16.5kb circular dsDNA containing 37 genes
• 2 rRNAs, 22 tRNAs, 13 ox. phos. subunits
• Each cell contains hundreds of copies of mtDNA
o Heteroplasmy → mixture of normal and abnormal mtDNA
▪ Normal phenotype → mutant < normal
▪ Disease phenotype → mutant > normal
▪ Disease phenotype will occur if there are more mutant
mitochondria than normal
o Homoplasmy → all mtDNA are the same (either normal or abnormal)
• With cell division, the many copies of mtDNA segregate randomly into the 2 daughter cells
• Different eggs can vary from: mostly normal mtDNA to mostly abnormal
• Clinical phenotype will vary according to the % of abnormal DNA
• % of abnormal DNA can change over time due to random drift as cells divide, or to a possible replicative
advantage of one type of mtDNA over another
• Tissues with high energy requirements are most likely to be affected (brain, muscle)
• Symptoms typically progress with age
• Often need muscle biopsy to confirm diagnosis
• Prenatal diagnosis is possible → prognosis is
difficult to predict due to Heteroplasm
• Examples
o Leber’s hereditary optic atrophy
(LHON)
o Mitochondrial encephalomyopathy
with ragged-red muscle fibres (MERRF)
o Kearns-Sayre syndrome
o Mitochondrial encephalomyopathy
and stroke-like episodes (MELAS)
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29. Genetic heterogeneity. Allelic and locus heterogeneity. Examples.
Factors that cause clinically heterogeneity (or variable expression and reduced penetrance) of single gene
disorders):
• Genetic heterogeneity (allelic and locus)

• Pleiotropy
• Environmental factors
• The interaction of other genes (modifier genes)
• The expansion of unstable triplet repeats
• The genomic imprinting
• The X-chromosome inactivation
• The mosaicism (somatic gem-line)
GENETIC HETEROGENEITY.
→ phenomenon that a disorder can be caused by different allelic or non-allelic mutations
• Types:
1. Allelic heterogeneity
2. Locus heterogeneity
1. Allelic heterogeneity (molecular heterogeneity)

→ different mutations (multiples alleles) in the same gene at the same chromosomal locus that cause a
particular phenotype.
• Multiple alleles → result of a normal gene having mutated to produce different alleles in the population
• An individual can possess any two of these alleles and transmits only one allele for a certain trait to any
particular offspring.
• Single-gene normal traits and multiple alleles:

o The ABO-blood system (at least 4 alleles -A1, A2, B and O)
o The HLA system
o The MN and Rh-blood groups
o Alfa-antitrypsin system
• Single-gene disorders and multiples

alleles:
o Cystic fibrosis (more than 1000
mutations)
o Phenylketonuria (>400
mutations)
o Marfan syndrome (>200
mutations)
o Duchene-Becker muscular
dystrophy
o Haemophilia A and B etc.
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• Allelic heterogeneity may cause compound heterozygote:

→ “an individual who is affected with an autosomal recessive disorder having two different mutations in
homologous genes (instead of two identical)”
o Cystic fibrosis
o Phenylketonuria
o Beta thalassemia
o Duchenne muscular dystrophy (DMD)
• Allelic heterogeneity also may cause two distinct phenotypes (disease):

o The beta-globin gene mutations can cause sickle-cell disease or various β-thalassemia
o The dystrophin gene mutations can cause Duchene or Becker muscular dystrophy
2. Locus heterogeneity
→ The situation in which mutations in gees at different chromosomal loci
cause the same phenotype in different affected families.
• “Genocopies” are genetic disorders with the same phenotype due to

mutations at distinct genetic loci, sometimes with different models of
inheritance (AD, AR, XL).
o Haemophilia
▪ Haemophilia A → a defect in clotting factor VIII
▪ Haemophilia B → with a similar phenotype – a defect in clotting factor IX
o Retinitis pigmentosa (RP) = progressive retinopathy and loss of vision RP is a type of hereditary
blindness caused by degeneration of photoreceptors (rods and cones) in retina
▪ Pattern of inheritance can be AD, AR, or XL, with only one locus involved in any particular
family. Mucopolysaccharidoses → Hurler s-me (AR) and Hunter s-me (XR)
o Albinism → AR and XR forms
o Osteogenesis imperfecta (OI) → AD, AR
▪ Clinical features
• Fractures
• Hyperextensible joints
• Hypoplasia of dentin
• Thin skin
• Blue appearance sclerae
▪ Mutations in genes on either chromosome 17 or chromosome 7
▪ OI is a good example for phenomena such as pleiotropy, locus and allelic heterogeneity (together)
• “Phenocopy” means that a phenotype (a disorder) resembles the phenotype of genetic disorder but is due
to different non-genetic factors.
The genetic counselling can be extremely difficult if the locus heterogeneity extends to different models of
inheritance.
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30. Genetic heterogeneity. Pleiotropy. Variable expression and reduced

penetrance. Examples.
Factors that cause clinically heterogeneity (or variable expression and reduced penetrance) of single gene
disorders):
• Genetic heterogeneity (allelic and locus)

• Pleiotropy
• The interaction of other genes (modifier genes)
• The expansion of unstable triplet repeats
• The genomic imprinting
• The X-chromosome inactivation
• The mosaicism (somatic gem-line)
Pleiotropy
→ Multiple phenotypic effects of a gene or Multiple traits determined by single
mutation”.
• Pleiotropy is a common feature of human genes and is the rule rather than
exception in the single gene disorder.
• Pleiotropy is a pathogenetic phenomenon → one gene product can be involved
in many biochemical processes affecting different pathways or growth and
maturation of different organs/ systems.
• Many Mendelian disorders can be manifested in a number of different systems of the body in a variety of
ways.
• Sometimes the disorder can involve only on organ or system.
• Usually only or two symptoms of a syndrome (AD) are present in the proband, but a family study can show
other relatives of the patient having one or more of the remaindered symptoms of the syndrome
(dispersed in family symptoms)
o Marfan’s syndrome (AD)
o Waardenburg syndrome (AD)
o Osteogenesis imperfecta (AD)
o Cystic fibrosis (AR)
Marfan syndrome (AD)
• More than 200 different fibrillin mutation are identified in Marfan patients (allelic heterogeneity)
• The gene encoding fibrillin (connective tissue protein) is mapped to 15q.
• Fibrillin is found in the aorta, the ligaments of the lens and the skeleton
• ‼ The location of the gene product (fibrillin) and its role as component of connective tissue explain the
pleiotropic effects → in the eye, the skeleton and the cardiovascular system
• Usually only one symptom of Marfan s-me is present in the proband, but taking a family history (dispersed
remaindered symptoms in other relatives) can itself provide a diagnosis
• Clinical phenotypes → defects involve connective tissue of three major systems
o The ocular
▪ Myopia (present in most patients)
▪ Detached lens/ectopia lentis (in approximately 50%)
o The skeletal
▪ Long, slender limbs with arachnodactyly = “spider fingers”
▪ Scoliosis and joint hypermobility
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o The cardiovascular
▪ Dilation of the aorta (in 90% cases
Waardenburg syndrome (AD)
• Hypopigmentation (white-forlock, heterochromatic iridis)

• Hearing impairment (bilateral deafness)
Osteogenesis Imperfecta (AD/AR)
• Fracture of bones: Blue scleral, hypoplasia of dentin…
Variable expression and reduced penetrance

Variable Expressivity
→ Differences in the degree of severity of a clinical phenotype or Variation in clinical
manifestations between individuals
• In real organism, many genes influence any trait and by gene influences many
traits
• Not possible to pinpoint specific modifying genes and nearly all mutant
phenotypes can be show to vary from one affected person to another.
• Variable expressivity is a characteristic of AD – disorders
• Mutant genes with pleiotropic effects frequently show variable expressivity
• The variation in clinical manifestations between affected individuals can give rise to considerable problems
in genetic counselling:
o A parent with mild expression of the disease (so mild that she/ he is not aware of it) may
transmit the gene to a child who can have severe expression.
• However, minimally the gene may be expressed clinically, any individual carrying the gene has 50% risk to
transmit the gene to any offspring
• Unfortunately, there is no way of predicting how severely any offspring might be affected.
o Almost all AD disorders with pleiotropic effects:
▪ Marfan syndrome
▪ Waardenburg syndrome
▪ Osteogenesis Imperfecta
▪ Achondroplasia
▪ Tuberous sclerosis
▪ … etc.
→ An individual may have only one, two or more symptoms of the syndrome and the severity of the s-me may
vary widely.
o Variable age of onset is another aspect of variable expressivity → many AD disorders appear
at a later age:
▪ Huntington disease (HD)
• Approximately 60% of cases are diagnosed between the age of 35 and 50
• Age of onset of HD is highly correlated with number of GAG repeats
o Phenylketonuria (PKU)
▪ Even though the metabolic error in it can diagnosed at birth, there are no overt
clinically abnormalities for a few months.
o Myotonic dystrophy (MD)
o Adult polycystic kidney disease
o Familial hypercholesterolemia
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Reduced Penetrance (RP)

→ a dominant gene which does not manifest itself in a proportion of heterozygotes
• RP is another important characteristic of many AD-disorders

• RP is an all-or-non-phenomenon → either a particular genotype is expressed or it is not expressed
• RP is an exception to a rule that unaffected persons do not transmit and AD-trait.
• Delay in age of onset complicate the interpretation of inheritance pattern in families and can cause age-
dependent non-penetrance
• Penetrance rates are estimated by examining a large number of families and determining what proportion
of the obligate carriers develop the disease (it is used in genetic counselling to individual at risk for AD
disorders).
The possibility of reduced penetrance, variable expressivity and pleiotropic effects of a mutant gene need to
be taken into account during genetic counselling for single gene disorders!
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31. Prevention of genetic disorders – main approaches and levels of

organization (primary or secondary).
The main approaches for prevention of genetic disorders (congenital anomalies and genetic diseases) are
classified into the following levels:
1. Primary prevention → avoiding of known or presumed causes of Congenital Anomalies (CA).

o Rubella immunization
o Peri-conceptional folic acid supplementation → for protection, the folate intake should be about
0,4 mg/day starting at least 2 months before conception.
o Optimizing the management of women with diabetes or epilepsy to minimize the risk for fetal
anomalies
• It relies on the programs for education of the population concerning possible risks (before conception or
antenatal) for the occurrence of anomalies.
• A kind of prevention, based on the reproductive behaviour and election, including an access to information
concerning possible teratogenic causes and the potential of prenatal screening for CA.
2. Secondary prevention
1. Early detection of CA, before birth or in neonatal period (based on the screening of all births and including in
programs for registration of CA).
2. Detection of CA during the pregnancy (includes antenatal screening and prenatal diagnosis of CA).
• Gives opportunities for:

o Therapy of the foetus prenatally or immediately after birth (in neonatal period) that provides
opportunities for a completely or satisfactory recovering (without invalidation).
o Family election to terminate the pregnancy (selective or therapeutic abortion) in cases of prenatal
diagnosis of severe anomalies with poor prognosis.
3. Genetic counselling of families with CA → families with family history of CA or genetic disorders.
o Genetic information about possible risk of recurrence

o Family support to make an informed decision
o Planning their future pregnancies
4. Prevention of risk pregnancies in families with CA or genetic disorders
o Previous pregnancy/child or other relatives with CA or genetic disease.

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32. Approaches for prevention of genetic disorders. Genetic screening (types).

Maternal serum screening.
Approaches for prevention of genetic disorders.

• Genetic screening/screening programs
• Genetic counselling
• Prenatal diagnosis/selective abortion
• Preimplantation genetic diagnosis (PGD)
• Treatment, surgical correction
• Education of family, public
Genetic screening (types).

In aspect of the organization, the prevention of congenital anomalies and genetic disorders might be carried
out as:
1. Prenatal screening programs → appropriate for populations with a low preliminary risk for CA.
o Maternal serum screening (MSS)
▪ MSS in the 2nd trimester (15 – 19 wg)
▪ Early MSS in the 1st semester (11 – 14wg)
o Ultrasound (US) screening for structural defects of the foetus
▪ Fetal morphology in 15 – 23 wg
▪ Early US screening → using some markers (nuchal translucence, nose bones hypoplasia)
in 11 – 14 wg
2. Prenatal diagnosis → appropriate for populations with a high preliminary risk for CA. These are risk
pregnancies in families with family history:
o Previous child with CA
o Other relatives with CA
o Parent with CA or carrier of genetic alterations with risk for transmission in offspring (single gene
defect, chromosomal carrier-ship)
• In these cases, the prevention is based on the applying of higher specific and accurate invasive methods of
prenatal diagnosis.
1. Prenatal screening program

Maternal serum screening.
• Not diagnosis, but an assessment of the risk for these conditions by measuring 3,4 proteins made by baby
and placenta for risk factor
• The signs suggestive of these defects cannot always be seen on ultrasound.
• Usually not inherited and are usually not present in a person’s family.
→ identify pregnant women who may be at increased risk for having a baby with either:
o Chromosomal aneuploidy (Down Syndrome, trisomy 18, trisomy 13, monosomy X…)
o Open neural tube defect (NTD)
o Open abdominal wall defect (AWD)
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• If the maternal serum screening test results are abnormal → the doctor may recommend one or more of
the following:
o Detailed ultrasound examination → this ultrasound can help to properly date the
pregnancy and/or carefully examine the physical features of the baby.
o Genetic counselling → a genetic counselor can thoroughly explain the test results and
discuss with woman further testing options.
o Amniocentesis → if the ultrasound does not provide an explanation for the MSS test
results, amniocentesis can be performed to examine the baby’s chromosomes.
General concepts
• Voluntary
• Used to adjust risk for Down Syndrome based on maternal age
• Screening tests are not diagnostic tests and cannot detect all chromosome abnormalities or other
congenital anomalies
o Sensitivity or detection rate → < 100%
• 5% positive screen rate → considered acceptable
• Advantages
o Avoids an invasive test
o Avoids potential for fetal loss
o Identifies a foetus at risk
• Disadvantages
o Anxiety
o False positive results → require unnecessary amniocentesis
o False negative results → missed anomalies
• Limitations
o Provides a revised risk assessment, not a diagnosis
o Sensitivity < 100%
o Miss other chromosome abnormalities (different from tri21, tri13, tri18, Monosomy X)
1. First trimester maternal serum screening
• Informative for aneuploidy: Trisomy 21, 13, 18, Monosomy X, Triploidy

• Gestational age → performed at 11 – 13 wg + 6 days
• Singleton or Twin Gestation
• US (ultrasound) marker → nuchal translucency (NT)
• Serum substance (values):
o PAPP-A (pregnancy associated plasma protein A)
▪ Glycoprotein of unknown function
▪ Only reliable for detection of Down Syndrome (DS) between 10 – 13weeks
▪ Levels are 60% lower in DS
▪ Highest detection rate of any marker (42%)
o Free β-hCG (human Chorionic Gonadotropin)

▪ Serum levels in DS often > 2.5 MoM
▪ hCG or free b-hCG are used
▪ Elevated levels → found in mola hydatidosa pregnancies = partial molar
pregnancies associated with triploidy
• Individual risk is based on: PAPP-A + Free b-hCG + NT + age-depending risk
• False positive (+) results = FPR 5%
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• Advantages
o Sensitivity higher than in MSS second trimester.
o Level of detection:
▪ 90 – 95% for DS
▪ 80 – 90% for other chromosomal abnormalities
o Performed earlier
o If positive → option of Chorionic villus sampling (CVS) or amniocentesis (AC)
o Option of earlier therapeutic abortion (TAB) if fetus is affected
o Increased privacy
• Disadvantages
o Does not test for NTDs (neural tube defects)
2. Second trimester maternal serum screening
• Informative for:
o Aneuploidy → trisomy 21, trisomy 18
o Neural tube defects (NTDs) → spina bifida, anencephaly and others
o Abdominal wall defects (AWDs)
▪ Exomphalos or omphalocele → gastrointestinal abnormality in which the
contents of the abdomen herniate into the umbilical cord through the umbilical
ring. The viscera, which often includes the liver, is covered by a thin membrane
consisting of peritoneum and amnion.
▪ Gastroschisis = “stomach cleft” → congenital defect of the abdominal wall,
usually to the right of the umbilical cord insertion. Abdomina contents herniate
into the amniotic sac, usually just involving the small intestine, but sometimes
also the stomach, colon and ovaries.
• Unlike exomphalos, there is no covering membrane.
• Second trimester maternal screening for aneuploidy → conditions for applying:

o Performed at 14 wg + 4 days – 19 wg + 3 days
o Singleton gestation
o Adjusts age risk based on levels of: hCG, AFP, uE3, Inhibin-A →
▪ hCG
▪ AFP (Alpha-fetoprotein) → glycoprotein of unknown function

• Used to screen for open NTDs
▪ At 15 – 22 wg
▪ Detection rate → 80 – 85%
▪ High levels → > 2.5 MoM
• Used to screen for trisomy 21
▪ At 15 – 22 wg
▪ Detection rate → 20 – 25%
▪ Low levels → < 0.5 MoM
▪ Unconjugated Estriol (uE3) → synthesized from DHEAS, converted to

16αOHDHEAS in fetal liver and then to uE3 by placenta
• Low levels associated with:
o Trisomy 21, § Trisomy 18, § Triploidy
o Smith Lemil Opitz
o Steroid sulfatase deficiency
o Fetal death
o Congenital adrenal hypoplasia
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▪ Inhibin-A → polypeptide hormone that is secreted by granulosa & Sertoli cells

o In pregnancy, it is secreted by fetoplacental unit
o Peaks at 8 – 10 weeks → then declines until 20 → and rises
gradually until term
• Detection rate in women:

o For trisomy 21 (DS)
▪ < 35 → 60 – 75% for DS
▪ > 35 → 75 – 80% or more
o For trisomy 18 → > 60 – 80%
• Positive screening rate = 5%
Sequential Screening for DS

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Screening for neural tube defects
• Maternal serum alpha-fetoprotein (MSAFP)

• Ultrasonography
• Amniocentesis
o AFP (only in foetus)
o Acetylcholinesterase
It is recommended if the following are present:

o Ultrasound findings indicate NTDs
o A child with NTDs is already in the family
o A family history of NTDs exists, especially a mother with NTDs
o The mother has type 1 diabetes mellitus during pregnancy
o Maternal exposure to drugs → valproic acid (associated with NTDs)
o Elevated level of MSAFP (maternal screening alpha-fetoprotein) is present
Prevention of NTD
• Recurrence (presence of a child with NTD in the family) → intake folate 4 mg/day (3 months prior to
conception and through 1st trimester)
• Occurrence (primary prevention) → Intake of folate or multivitamin with folate – 4 mg/day (1 – 2 months
prior to conception and through 1st trimester)
Screening for Aneuploidy
• Sonographic screening, performed at 18 – 20 wg

• Look for major malformations often seen in foetus with aneuploidy (trisomy 21, 18, 13)
• Risk for aneuploidy increases with finding of major anomaly or 2 or more minor abnormalities
• US detection rate for trisomy 21 → 60 – 75%
• FPR = 4 – 15%
• Sonographic findings in trisomy 21:

o Cardiac defect
o Duodenal atresia
o Thick nuchal fold
o Renal pyelectasis
o Echogenic bowel
o Echogenic intracardiac focus
o Sandal gap
o CP cyst
o Short mid-phalanx 5th finger
o Short femur/humerus
o Flat facies with maxillary hypoplasia
o Macroglossia
Screening for fetal Down Syndrome
• Measuring maternal serum alpha-fetoprotein

o In cases where a low level of MSAFP is reported → indicates the condition of
o DS or other chromosomal aneuploidy and failing pregnancies.
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• Measuring maternal unconjugated estriol

o The amount of estriol in maternal serum depends upon viable foetus, a properly functioning
placenta, and on maternal well-being.
o Fetal adrenal glands produce dehydroepiandrosterone (DHEA) that gets metabolized to estriol in
the placenta that gets metabolized to estriol in the placenta.
o Estriol crosses to maternal circulation and is excreted either by maternal kidney in urine or by
maternal liver in the bile.
o In the 3rd trimester → level of estriol gives an indication for the well-being of the foetus.
▪ A low level → indication of DS and adrenal hyperplasia
• Measuring maternal serum b-human chorionic gonadotropin

o Following conception and implantation of the developing embryo into the uterus, the
trophoblasts produce enough β-hCG, which is an indicator for pregnancy.
o In the middle to late 2nd trimester → level of β-hCG also can be used in conjunction with the
MSAFP level to screen for chromosomal abnormalities.
▪ An increased b-hCG + decreased MSAFP → suggests DS
Nuchal Translucency
• NT is an US marker for chromosomal aneuploidy.
o The enlarged nuchal translucency (> 2.5 – 3 mm) is a highly informative US marker → used as an
independent predicting criterion in the screening of aneuploidy (mainly trisomy 21 or DS)
• At 11 – 14 wg → detection rate:
o > 85% for DS (FPR 5%)
o ~ 70 – 80% of overall chromosomal abnormalities
• Higher sensitivity for women > 35 years of age.
• The measurement of NT (11 – 14 wg) in combination with two serum markers (free β-hCG and PAPP-A) →
base of calculation of the individual risk in 1st trimester MSS for aneuploidy.
• Nasal bone
• Sonographic marker, used in the screening for DS → detects hypoplasia/aplasia of nasal bones.
• This marker can be used in the assessment of the risk for DS:
o At the 1st trimester maternal screening (in combination with serum markers)
o At the 2nd trimester US screening as independent predicting marker.
• The absence of nasal bones seems to be a better predicting marker for DS in comparison with enlarged
nuchal fold in 2nd trimester US.
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33. Approaches for prevention of genetic disorders. Genetic counselling –

definition, aims, main steps, indications.
Approaches for prevention of genetic disorders.

• Genetic screening/screening programs
• Genetic counselling
• Prenatal diagnosis/selective abortion
• Preimplantation genetic diagnosis (PGD)
• Treatment, surgical correction
• Education of family, public
Genetic counselling – definition, aims, main steps, indications.

Definition
→ Genetic counselling is a communication process, between a healthcare professional trained in genetics and
an individual or family affected by or at risk for an inherited disorder, in which they are advised of:
o The nature and consequences of the disorder
o The probability of developing or transmitting it in the offspring
o The options open to them in management
o Family planning in order to prevent or avoid it
→ By the national society of genetic counsellors: It is the process of helping people understand and adapt to
the medical, psychological and familial implications of genetic contribution to disease.
o Collection and interpretation of family and medical histories to assess the chance of disease
occurrence and recurrence
o Education about inheritance, testing, management, prevention, resources and research
o Counselling to promote informed choices and adaptation to the risk or condition
Communication process which deals with problems associated with the occurrence or risk of recurrence of a
birth defect or a genetic disease in a family
• Address individual concerns relating to development/transmission of hereditary disorders

o Consultant/s → individual/s seeking GC
o Genetic counsellor → specialist doctor/geneticist trained to doing GC
• Strong communicative and supportive element so that those who seek information are able to reach their
own fully informed decisions without undue pressure or stress
Types of Genetic Counselling (GC)
• Prospective (before reproduction) – most effectively

• Retrospective (after reproduction, already born child with inherited disorder, birth defects)
• GC in different medical fields:
o Paediatrics (child with inherited disorder)
o Prenatal Clinics (prenatal screening/diagnosis)
o Reproductive Genetics (reproductive technology and testing)
o Adult Specialty Clinics (Neurology, Psychiatry, Cardiology)
o Oncology/Oncogenetics (family cancer, discuss testing and screening option)
• GC in cases of genetic testing:

o Before specific genetic testing (to appoint test)
o On the final result of genetic testing
o Screening tests – newborn, prenatal, carrier
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Aims
• Provide Information
o Importance of the disorder for family → medical diagnosis, disease development, prognosis
o Pattern of inheritance of disorder and the risk of developing and transmitting it
o Options available for modification of disease/ influence on its development; management
o Choices or options available for dealing with the risks/ reproductive decision
• Promoting informed decisions by involved family members
• Clarifying the family’s options available, treatment and prognosis
• Explaining alternatives to reduce the risk of genetic disorders
• Decreasing the incidence of genetic disorders
• Reducing the impact of the genetic disorders
• Providing psychosocial support
Main steps in genetic counselling
1. Diagnosis → most critical step in any genetic counselling
• If incorrect → totally misleading information could be given with tragic consequences for the family
o Clinical diagnosis = determining nosology → Assignment to a particular nosological category
(disease, syndrome)
o Genetic diagnosis = determining etiology → determining the genetic/molecular defect
→ Therefore, it is a clinico-genetic diagnosis
• Sub-steps of diagnosis:
o Gathering information
▪ Anamnesis/case history
▪ Pedigree/Genealogy
o Physical examination, dysmorphological assessment → in cases with congenital anomalies
o Appropriate investigations
▪ Routine investigations → laboratory, instrumental
▪ Specialized genetic testing (Cytogenetic, biochemical/enzyme analysis, molecular/DNA
analysis)
▪ Consultations with appropriate clinical specialists
o Syndromological/dysmorphological search → in cases with congenital anomalies
• Problems in diagnosis:
o Etiologic heterogeneity (behind the same disorder may be a different etiology/reason)
▪ e.g.: deafness or non-specific mental retardation → may be due to genetic or non-
genetic/environmental causal factors
o Genetic heterogeneity → locus (the same disorder may result from mutations in different genes)
or allelic (different gene defects/allele in the same gene)
▪ Deafness – in different genetic disorders → Ehlers-Danlos - AD, АR, ХR;
▪ Retinitis Pigmentosa - AD, АR, ХR
▪ Variable expression
o Reduce penetrance
o Late onset of disorder
o Genomic imprinting, uniparental disomy
o Mosaicism → germline, somatic
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2. Risk assessment → different types of risk can be used:
• Mendelian risk → in cases of single gene/Mendelian disorders → a theoretical risk is determined, based on
the:
o Genotype of the parents
o Pattern of inheritance of the disorder
• Modified risk → in cases of single gene disorders → in addition to Mendelian risk, some factors or
characteristics in the course of the disease are taken into account:
o Late onset of the disease
o Reduce penetrance
o In cases of chromosomal disorders → additional factors are taken into account
o Lethal effect of chromosomal anomalies: gametal lethal effect /infertility, embryos spontaneous
abortions
• Empiric risk → in cases of non-Mendelian, polygenic disorders or diseases with unknown etiology
o The risk is based on the empiric data: the prevalence of the disorder among 1st degree relatives of
the proband (sibling, children)
• Magnitude of the risk:

o < 1% → negligible risk
o 1%-5% → low risk
o 5%-10% → moderate risk
o 10%-20% → high risk
o > 20% - Very high risk
3. Communication with the family and discussion of options available for dealing with the disorder
and risk of recurrence
• Communication with the family to inform about the disorder:

o Counsellor provides genetic information
▪ Medical diagnosis
▪ Nature, causes
▪ Course of the disease, prognosis
▪ Recurrence risk
o Information → has to be presented in clear, sympathetic and appropriate manner
• Discussing of options available for dealing with the disorder and risk
o Provide consultants with all information needed to arrive at their own informed decision:
o Management, treatment, surgery
o Dealing with the risk
o Potential for prevention of subsequent pregnancy
o Applying of alternative approaches to conception /IUI or IVF, donor ova/sperms/, adoption
o Review of techniques, limitations and risk associated with methods available for prenatal
diagnosis
• Support – helping family members to make informed decisions about their future behaviour
o Individual or couple could be extremely upset when first made aware of a genetic disorder
o Complex psychological and emotional factors can influence counselling dialog
o Setting → agreeable, private and quiet with ample time for discussion and questions
o Written letter summarizing the topics discussed at counseling session is provided to family
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4. Long-term support and follow-up
• Long-term support and follow-up by home visit or clinical appointment to clarify any confusing issues
• Genetic counselling and testing of other relatives at risk for disease or carrier
• Prevention of subsequent risk pregnancies in particular family or other relatives
• Building Genetic family registry including families with inherited disorders and congenital anomalies
Indications for genetic counselling
• Previous child, parent or relative with:

o Inherited disease /heart, kidney, skin, endocrine etc.
o Mental Retardation with/without other congenital anomalies
o Congenital anomalies – isolated /heart, NTD/ or multiple
o Impairment of vision, hearing
o Growth retardation, sexual impairment
o Neural – muscle and mental diseases
• Indications connecting with pregnancy:

o Advanced maternal age
o Contact with teratogenic and mutagenic factors
o Detected prenatally alterations in US and biochemical serum markers
• Reproductive failures: infertility, spontaneous abortions, stillbirths

• Consanguinity
• Family history of Cancer disease (particularly with early onset)
Genetic counselling ethics
• Respect of human right

• Keep privacy of individual and family
• Psychological support
• To relieve the sense of guilt in individuals who have a genetic defect or transmitted disease
• To create confidence in the genetic counsellor and opportunity to support the family /through repeated
visits
• Non-Directive → don’t give the patient any direction for a decision = self-determination of patients will
• Non-Judgmental
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34. Genetic counselling in different type of genetic disorders – chromosomal,

single gene, polygenic/multifactorial.
2. Risk assessment → different types of risk can be used:
• Mendelian risk → in cases of single gene/Mendelian disorders → a theoretical risk is determined, based on
the:
o Genotype of the parents
o Pattern of inheritance of the disorder
• Modified risk → in cases of single gene disorders → in addition to Mendelian risk, some factors or
characteristics in the course of the disease are taken into account:
o Late onset of the disease
o Reduce penetrance
o In cases of chromosomal disorders → additional factors are taken into account
o Lethal effect of chromosomal anomalies: gametal lethal effect /infertility, embryos spontaneous
abortions
• Empiric risk → in cases of non-Mendelian, polygenic disorders or diseases with unknown etiology
o The risk is based on the empiric data: the prevalence of the disorder among 1 st degree relatives of
the proband (sibling, children)
• Magnitude of the risk:

o < 1% → negligible risk
o 1%-5% → low risk
o 5%-10% → moderate risk
o 10%-20% → high risk
o > 20% - Very high risk
Risk in single gene/mendelian disorders
• Characteristics of the risk:

o Theoretical risk → calculation is based on particular regularities
o Permanent for each pregnancy → “risk has no memory”
o High magnitude: 25% - 75%
• Pattern of inheritance:
o AD pattern of inheritance
▪ Sporadic /result of de novo mutations → the risk is equal to the population risk of
the disease
▪ Inherited disease/familial cases
o AR disorders
o Х-linked
Risk assessment features:
• Mendelian risk → in cases of diseases with full penetrance. The risk is calculated, based on the:
o Genotype of the parents → first to establish the genetic defect in the proband
o Specific information from the pedigree → suspected carriers
o Pattern of inheritance based on the literature data → AD, AR, XR, XD
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• Modified risk → in cases of diseases, in which additional factors and disease characteristics should be
taken into account:
o Late onset of the disease → age-depended penetrance
o Reduce penetrance → coefficient of penetrance
o Dynamic mutations → number of repeats should be taken into account
o Genomic imprinting → predominantly transmitting parental sex
• In certain carrier status or parents, carriers of the genetic defect, clear genotypes of the parents →
• appropriate Mendelian risk is used
Risk in chromosomal disorders/ syndromes

Characteristics of the risk:
• Impossible calculation of accurate theoretical risk

• Determination of risk depends on the following factors:
o Type of chromosomal abnormality /CA

• Numerical
• Structural
o Predictable mechanism of occurrence
• De novo
• Inherited origin
o Karyotype of the parents
Depending on the type of chromosomal abnormality:

o Numerical → usually de novo, non-inherited
▪ Risk = population risk for the certain mutation
o Structural → the parents karyotype has to be investigated

▪ Normal → de novo, non-inherited
• Risk = population
▪ Abnormal → inherited origin
• Risk with different magnitude

• Main rule → risk determination is based on the karyotype of parents
o Normal karyotypes ® non-inherited CA
▪ The risk is negligible, empiric risks are used
• e.g.: a child with trisomy 21 ® risk for subsequent pregnancy is < 1-2%
(age of mother less than 35 years)
o Abnormal karyotype of a parent ® inherited CA
▪ Genetic risk with different magnitude
• e.g.: child with translocation form of tri 21 and a parent carrier of balanced
Robertsonian translocation
o Theoretical risk 33%
o Real risk depends on the sex of parent-carrier of translocation:
▪ Mother-carrier risk is about 10-20%
▪ Father-carrier risk is about 2-3%
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Risk in polygenic/multifactorial disorders

Characteristics of the risk:
• Impossible calculation of accurate theoretical risk

• Empiric and modified risks are used
• Low magnitude of the risk → usually 1%-5% (rarely 5%-10%)
• Empiric risk → based on the investigation on the prevalence of the disease among 1 st degree relatives
of the proband (sibling, children)
o e.g.: 1st child with Sp. Bifida aperta → risk for subsequent pregnancy is 4-5%
• Modified risk → take into account some additional factors that may influence the risk assessment:
o The severity of the disease/congenital anomaly in proband (Example, Sp. Bifida ap. 4-5%;
Anencephaly 8-9%)
o Sex of the proband (higher risk in proband of less affected sex)
o Degree of relationship with proband (highest risk for 1st degree relatives)
o More affected relatives in the family
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35. Prenatal diagnosis – main techniques (invasive and non-invasive),

diagnostic methods, optimal time in gestation, associated risk. Indications for
prenatal diagnosis.
Prenatal diagnosis (PD)

All procedures of PD are usually based on the preliminary established risk for a certain defect of the fetus in a
particular pregnancy, so PD is preceded of accurate diagnosis of the defect in previous pregnancy or child in the
family.
Benefits of prenatal diagnosis
• PD determines the outcome of the pregnancy

• It is helpful for couples to decide whether to continue the pregnancy
• It indicates possible complications that can arise at birth process
• It is helpful for the management of remaining weeks of pregnancy
• It prepares the couple for the birth of a child with an abnormality
• It can be helpful for the improvement of the outcome of pregnancy using fetal treatment
Indications for prenatal diagnosis.
Prenatal diagnosis is recommended in a family with:
o Advanced maternal age ≥ 35

o A previous child/pregnancy with a chromosomal abnormality
o A previous child or pregnancy with multiple congenital malformations (without cytogenetic study
of affected child)
o Carrier status for a chromosomal rearrangement in a parent (cytogenetically proved)
o A previous child or pregnancy with NTDs or others isolated congenital anomalies
o Abnormal ultrasound findings
o Teratogenic exposure during the pregnancy
o Known or suspected family history of genetic disease or multifactorial disorder
o Risk pregnancy for single gene defects → a sick child or relative, mother carrier of X
o Linked genetic defect, a parent carrier of single gene defect (genetically established)
→ In practical aspects: represents a complex of methods and techniques that allow to be established different
alterations (morphological or functional) in normal phenotype or genotype of the fetus (disorders), during
intrauterine development.
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Main techniques (invasive and non-invasive) diagnostic methods, optimal time in

gestation, associated risk.
→ According to the aims of PD and the risks characteristic of the studied pregnancies, different obstetrical
techniques and analytical methods can be applied (on different kind of biological material)
Main techniques
1. Non-invasive techniques
• Fetal visualization
o Ultrasound (US) → 16 – 20 wg
o Fetal echocardiography (FEC) → 20 – 22 wg (> 18 wg)
o Magnetic resonance angiogram (MRA)
• Maternal serum screening (Down and other aneuploidies, NTD…) → 15 – 22 wg.
• Separation of fetal cells from the mother’s blood → after 10 wg – up to 24 wg
2. Invasive techniques
• Fetal visualization
o Embryoscopy → < 12 wg
o Fetoscopy → 17 – 20 wg
• Fetal tissue sampling

o Chorionic villus sampling (CVS) → 9 – 12 wg
o Amniocentesis - Early → 12 – 14 wg; Late → 16 – 20 wg
o Cordocentesis (percutaneous umbilical blood sampling) → 20 – 24 wg (> 16 wg)
o Percutaneous skin biopsy → 17 – 20 wg
o Preimplantation biopsy of blastocysts obtained by in vitro fertilization (IVF) → in embryo ( of
6 – 8 days)
Each of these techniques is characterized with:
o A suitable period of gestation for applying

o Opportunity for detection of specific type of anomalies or genetic disorders
o A certain sensibility for detection of specific type of anomalies
o Risk connecting with the procedure
Diagnostic methods
Genetic or other methods for analysis in PD:
• Cytogenetic analysis
• Fluorescent in situ hybridization (FISH)
o Technique used for diagnosis of aneuploidy (trisomy or monosomy X)
• Molecular genetic techniques
o Linkage analysis using microsatellite markers
o Restriction fragment length polymorphisms (RFLPs)
o Single nucleotide polymorphisms (SNPs)
▪ DNA chip
▪ Dynamic allele-specific hybridization (DASH)
• Biochemical/enzyme analysis
• Microbiological analysis → infections like rubella, cytomegalovirus, toxoplasmosis, IgM or viral DNA
• Laboratory analysis of haematological or other parameters in fetal blood → infections like rubella,
cytomegalovirus, toxoplasmosis, IgM or viral DNA.
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36. Prenatal diagnosis. Non-invasive techniques - optimal time in gestation,

diagnostic methods, associated risk, indications.
Non-invasive techniques
Fetal visualization
• Ultrasound
o Is done routinely anyway as preventive measure in 15-20 wg
o For imaging fetal anatomy in 15-23 wg
o Harmless to both the foetus and the mother.
o Ultrasound can evaluate:
▪ Gestational age
▪ Twins’ identification
▪ Fetal position
▪ Placental location
▪ Fetal growth, development and movement
▪ Any structural birth defects
▪ Amniotic fluid volume
o Gives the opportunity for detection of different kind of congenital structural defects of the
foetus → usually at 16 – 20 wg
▪ The routine US, applying in pregnancies without a preliminary risk, gives
opportunities to detect about 50% of all major anomalies of the foetus.
▪ In high-risk pregnancies, the detection rate of US could nearly reach to 90%
o Many fetal organ systems and anatomical lesions can be visualized by US:
▪ Genitourinary abnormalities
▪ Gastrointestinal abnormalities
▪ Skeletal abnormalities
▪ CNS abnormalities
▪ Congenital cardiopathies
o Diagnostic methods → ultrasound (US) screening for structural defects of the foetus:
▪ Fetal morphology/anatomy can be seen in 15 – 23 wg
▪ Early US screening → using some markers (nuchal translucency, nasal bones
hyperplasia) → 11 – 14 wg
- Opportunities for early detection of CAs
- Applying in US centers with experience of early diagnosis of CAs
- Opportunities of prenatal diagnosis of structural defects, affecting part of
the body and organs that are already defined in these early stages of
intrauterine development.
- Applying of early US screening to some extent is limited (requires high
qualification of the sonographist).
- The average overall detection rate of CAs in 11 – 14 wg is about 44%, in
comparison with 74% of the screening in 15 – 20 wg.
- Major anomalies → will be detected in early stage of 10 – 11 wg.
o Head defects
o Abdominal wall defects
o Umbilical cord defects
o Placental defects
- Other anomalies like: spina bifida, diaphragmatic hernia or heart defect →
limited before 13 wg
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▪ Routine US screening (15 – 20 wg)

- The detection rate of CAs shows variations (among different US centers and
specialists)
- The detection rate of CAs increases along with increasing:
o Experience of the sonographist
o Resolution of the using technique
→ There is a difference between US screening programs of different countries with a variation: from absence
of the routine US screening to 3D ultrasound scans of the foetus for CA.
• Fetal echocardiography (FEC)

o It is a highly-specialized US investigation that allows prenatal detection of congenital heart
anomalies (CHA).
▪ Requires the use of special equipment → colour flow Doppler
▪ High-efficiency can be achieved when is conducted by a trained sonographist
(cardiologist or paediatrician-cardiologist)
▪ In gestational age ³ 18 wg (usually 20 – 22 wg)
o The contemporary opportunities of FEC in the 1st trimester, allows early diagnosis of CHA in
11 – 14 wg
▪ Detection rate → 85%
- Higher in cases with enlarged NT > 2.5 MoM → approved association
between chromosomal abnormalities, enlarged NT and CHA
o Indications:
▪ Family history of congenital heart defect, particularly in a parent or sibling
▪ Identification of major extra-cardiac malformation on routine ultrasound
▪ Suspected genetic disease or fetal chromosome abnormality associated with heart
defects
▪ Exposure to potentially teratogenic agents → alcohol, drugs, infections (rubella)
▪ Maternal diseases (diabetes, lupus or autoimmune diseases), associated with risk for
fetal congenital heart defects
• Maternal serum screening

o Purpose of the test → to identify pregnant women who may be at increased risk for having a
baby with either:
▪ Chromosomal aneuploidy (Down Syndrome, trisomy 18, trisomy 13, monosomy X…)
▪ Open neural tube defect (NTD)
▪ Open abdominal wall defect (AWD)
→ The MSAFP test has the greatest sensitivity between 16 – 18 wg, but it can also be performed between
15 – 22 wg.
• Separation of fetal cells from the mother’s blood

o Types of cells:
▪ Placental cells
▪ White blood cells
▪ Immature red blood cells with nuclei
→ These cells enter the bloodstream (at around 6 – 12 wg)

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o The fetal cells can be isolated after 10 wg (up to 24 wg)

▪ They are only 1/100.000 in mother’s blood
▪ They can be sorted and analysed by different techniques
o Diagnostic methods:
▪ Karyotyping (FISH)
▪ Biochemical analysis
▪ DNA techniques
- They can be analysed for diagnosis of genetic disorders using molecular
genetic techniques by isolating DNA and amplifying it by PCR
o Fetal cells separated from a mother’s blood can be successfully used in the diagnose of: cystic
fibrosis, sickle cell anaemia, and thalassemia in foetus.
o By now, the technique is implemented in a limited number of European laboratories
o (Germany), mainly for diagnosis of aneuploidy (trisomy 21, 13, 18 and monosomy X)
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37. Prenatal diagnosis. Invasive techniques - optimal time in gestation,

diagnostic methods, associated risk, indications.
Invasive techniques
Fetal visualization
• Embryoscopy
o Optimal time in gestation → in the 1st trimester (up to 12 wg)
o Principle → a rigid endoscope is inserted via the cervix in the space between the amnion and
the chorion, under sterile conditions and ultrasound guidance, to visualize the embryo for the
diagnosis of structural malformations.
o Limited application → high risk for pregnancy (miscarriage)
• Fetoscopy
o Optical time in gestation → during the 2nd trimester, after 16 wg (usually 17 - 20 wg)
o Principle → a fine-caliber endoscope is inserted into the amniotic cavity through a small
maternal abdominal incision, under sterile conditions and ultrasound guidance, for the
visualization of the fetus to detect the presence of subtle structural abnormalities.
o It is also used for fetal blood and tissue sampling.
o Associated with a 3 – 5% risk of miscarriage → it is superseded by detailed ultrasound
scanning.
Fetal tissue sampling
• Amniocentesis (AC)
o Invasive, well-established, safe, reliable and accurate procedure performed
between 14 – 20 wg.
▪ Early amniocentesis (12 – 14 wg) → procedure that is not applying recently due to
the high risk for reduction defects of the fetal limbs.
▪ Preferable procedure → late amniocentesis (16 – 20 wg).
o Amniocentesis is advised for → pregnant women at 35 years or older for detection of
chromosomal abnormalities in the foetus.
o Genetic diagnosis of > 150 disorders, cells analyzed for chromosomal and single gene
biochemical disorders.
o Procedure:
▪ It is performed under ultrasound guidance.
▪ A 22-gauge needle is passed through the mother’s lower abdomen into the amniotic
cavity inside the uterus, and 10 – 20 ml of amniotic fluid are collected. Amniotic fluid
contains cells from:
o Amnion
o Fetal skin
o Fetal lungs
o Urinary tract epithelium
▪ These cells are grown in culture for chromosomal, biochemical, and molecular
genetic analysis.
o Supernatant amniotic fluid is used for the measurement of substances, such as AFP,
hormones and enzymes.
▪ The results of the cytogenetic and biochemical studies on amniotic cell cultures are
more than 90% accurate.
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o In the 3rd trimester of pregnancy, the amniotic fluid can be analysed for determination of
lung maturity.
o Risks with amniocentesis are rare, but include:
▪ 0.5 – 1% fetal loss/abortion
▪ Infection
▪ Maternal Rh sensitization
• Chorionic villus sampling (CVS)

o Optimal time in gestation → between 9 – 12 wg (usually 10 wg)
▪ Cytogenetic analysis
▪ Biochemical analysis
▪ Molecular-genetic analysis
o Indication → similar reasons as amniocentesis
o Risks:
▪ 2 – 3% of abortion
▪ Limb defects of the fetus → rarely
o A higher rate of maternal cell contamination and confined placental mosaicism with CVS may
result in diagnostic ambiguity → need for additional invasive diagnostic tests.
→ Complications associated with invasive prenatal diagnostic tests (AC or CVS)
o Pregnancy loss/abortion → up to 6 weeks after procedure/up to 20 wg → from 0.5 – 2

o 3%
o Premature rupture of the amnion
o Vaginal bleeding
o Alloimmunization (Rh sensitization)
o Infection
o Placental mosaicism
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• Cordocentesis (percutaneous umbilical blood sampling)

o Performed after 16 wg (usually 20 – 24 wg)
o Procedure → a needle is inserted into the umbilical cord under ultrasound guidance, and fetal
blood is collected from the umbilical vein for chromosome analysis and genetic diagnosis.
o Advantages:
▪ Technique for collection of whole fetal blood sample
▪ Rapid rate at which lymphocytes grow → prompt genetic diagnosis
▪ Useful for evaluating fetal metabolism and hematologic abnormalities
o Disadvantages.
▪ Later period for TAB in case of a pathological result
▪ Risk for pregnancy loss → 1 – 3%
• Percutaneous skin biopsy

o Procedure → taken under ultrasonic guidance between 17 – 20 wg
o Applying for prenatal diagnosis of a number of serious skin disorders such as:
▪ Anhidrotic ectodermal dysplasia
▪ Epidermolysis bullosa letalis, epidermolysis bullosa dystrophica
▪ Hypohidrotic ectodermal dysplasia
▪ Oculocutaneous albinism
▪ Genetic forms of ichthyosis
• Preimplantation biopsy of blastocysts obtained by in vitro fertilization

o Techniques are being developed to test cells obtained from biopsy of early cleavage stages or
blastocysts of pregnancies conceived through in vitro fertilization.
o These techniques will be helpful for selective transfer and implantation of those pregnancies
into the uterus that are not affected by a specific disorder.
o The approach is suitable for couples with family history for genetic disorders (chromosomal,
single gene).
• Preimplantation genetic diagnosis (PGD):

1. Eggs collected, fertilized, allowed to develop
2. ~ 3rd day of fertilization → embryo has 6 – 8 cells
3. For PGD → one cell (blastomere) is removed
4. Analysis:
a. Cytogenetic or FISH
b. DNA extracted and tested by DNA analysis
5. Genetic selection → embryos without genetic disorder are implanted into the mother
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38. Cancer genetics. Tumour suppressor genes (Retinoblastoma, Wilms'

tumour).
Cancer → group of disorders that causes cells to grow out-of-control and invade other tissues.
Cells may become cancerous due to the accumulation of defects, or mutations, in their DNA:
• Inherited genetic defects (for example, BRCA1 and BRCA2 mutations) and infections can increase the
risk of cancer.
• Environmental factors (for example, air pollution) and poor lifestyle choices (such as smoking and
heavy alcohol use) can also damage DNA and lead to cancer.
Cells are able to detect and repair DNA damage (most of the time).
• If a cell is severely damaged and cannot repair itself → apoptosis.

• Cancer occurs when damaged cells grow, divide, and spread abnormally avoiding self-destruction
(apoptosis).
Cancer may affect people at all ages, even fetuses but risk for the more common varieties tends to increase
with age.
Early diagnosis and early treatment are vital, and identification of persons at increased risk of cancer before its
development is an important objective of cancer research.
Mechanisms for controlling progress through the cell cycle:

1. Checkpoints
2. Length of Telomeres
3. Chemical signals from within and outside the cell
1. Checkpoints:
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2. Length of telomerases:
• Telomeres are structures at the ends of chromosomes that shorten with each cell division.
• After 50 divisions, the shortened length of telomeres causes mitosis to stop.
3. Chemical signals that control the cell cycle:
• Cyclin and Kinase

o Proteins that initiate mitosis
o Requires build-up of cyclin to pair with kinase.
• Hormones
o Chemical signals from specialized glands that stimulate mitosis
• Growth Factors
o Chemical factors produced locally that stimulate mitosis
Etiology of cancer
• The etiology of cancer is multifactorial, results from the interaction of:

o Genetic factors
▪ Most cancer is caused by genetic mutations often, by a series of mutations.
▪ Cancer is caused by the accumulation of genetic mutations and epigenetic factors in
genes that normally play role in the regulation of cell proliferation, thus leading to
uncontrolled cell growth
▪ Cells acquire mutations in this gene as a result of spontaneous and environmentally-
induced DNA damage
▪ Cells with mutations that promote a growth and survival advantage over normal
cells are selected, leading to the evolution of a tumour
o Old age
o Unhealthy lifestyle (Western lifestyle): poor diet, lack of physical activity, or being
overweight.
o Lifestyle: tobacco use, diet, sunlight and infectious diseases.
o Occupational carcinogens
o Radiation, Chemicals and other substance
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Pathogenesis of cancer
• To become cancerous, a cell must:

o Control genes fail via mutation (de novo or inherited)
o Go-ahead signal stuck in the “on” position
o Develop expression of telomerase (enzyme that elongates telomeres) not in a stem cell
o Cancer cells have a failure on mutation repair → this begins to prompt many, many mutations
o Failure to stop at Cell Cycle Checkpoints:
▪ Mutation in a gene that usually slows the cell cycle → rate of cell division is
accelerated
▪ Failure to pause for DNA repair → faulty DNA leads to unregulated cell growth
▪ Loss of control over telomere length → cancer cells have telomerase (enzyme that
elongates telomeres), thus, cells continue to divide after 50 mitoses.
Cancer genetics.
Genes involved in cancerogenesis
• Functions:
o Directly regulate cell proliferation (either promoting or inhibiting)
o Control programmed cell death or apoptosis
o Involved in the repair of damaged DNA
Types → depend on how they affect each process:

o Proto oncogenes (growth promoters, gatekeepers)
o Tumour suppressor genes (growth inhibitory)
▪ Usually expressed as gatekeepers (e.g., p53, BRCA1, 2)
▪ Caretakers, genes that regulate DNA repair and chromosome segregation in mitosis
• DNA repair genes, whose mutations lead to genetic instability (more
mutations)
• Genes that regulate chromosome segregation, whose mutations lead to
abnormal chromosome content, or chromosomal instability.
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Tumour suppressor genes (Retinoblastomas, Wilms’ tumour)

→ Proteins, which inhibit cell cycle progression or promote apoptosis
• Types:
o Cytoplasmic Proteins
o APC (colon and stomach cancers),
o NF-1 inhibits a stimulatory (Ras) protein (brain, nerve, and
leukaemia),
o NF-2 (brain and nerve cancers)
• Nuclear Proteins
o RB codes for pRB protein, master brake on cell cycle
(retinoblastoma, bone, bladder, lung, and breast cancer)
o p53 codes for p53 protein, halts cell cycle in G1 and induces
cell suicide (many cancers)
o p16 inhibits cyclin D-dependent kinase activity
o WT1 (Wilms tumour of the kidney)
o BRCA1 functions in repair of damage to DNA (breast and
ovarian cancers)
o BRCA2 functions in repair of damage to DNA (breast cancer)
• Mechanisms of inhibiting tumour suppressor genes:

o Mutations
▪ Loss-of-function (mutation inhibits the normal function)
▪ Mutant allele behaves as a recessive (mutations in both alleles are required to inhibit
the tumour suppression)
▪ Somatic vs Germline mutation in tumour suppressor genes:
• Somatic mutations
o Arise in the somatic cells
o Acquired spontaneously during the individual life
• Germline mutations
o Pass through germ line
o Cause hereditary predisposition (risk for cancer) → susceptibility
genes
o Insufficient alone to cause cancer
o ~10% of all cancers have hereditary component
• Loss of heterozygosity (LOH)

o Deletion of:
▪ the normal allele
▪ the chromosome arm containing the normal allele
▪ the entire chromosome containing the normal allele → aneuploidy
o Duplication of the chromosome containing the mutated allele.
o Mitotic recombination = crossing over (with genetic recombination) occasionally occurs in
mitosis (as it always does in meiosis).
• Methylation (mechanism of parental imprinting)

o Imprinting starts in the gametes → allele will be inactive ("marked“) in the new embryo.
o The mark appears to be methylation of the DNA in the promoter(s) of the gene.
o Methyl groups are added to cytosines (Cs) in the DNA.
o Occurs at stretches of alternating Cs and Gs called CpG islands.
o Methylation of promoters prevents binding of transcription factors to the promoter thus
shutting down expression of the gene.
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Retinoblastoma
→ Cancerous tumour of retina
• Tumor suppressor gene = Rb1 gene

• The tumor is results of 2 hits = 2 hit hypotheses of cancer
o 1 hit → mutation (germline or somatic) in the first allele
o 2 hit → mutation (somatic) in the second allele
→ Both alleles are inactive in the cases with retinoblastoma
Wilm’s tumor (Nephroblastoma)

• Tumor suppressor genes → WT1 or WT2 genes (chromosome 11p13)
• Wilms tumors are either sporadic or familial (1-2%)
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39. Cancer genetics. Oncogenes (Examples).
risk of cancer.

(apoptosis).
with age.

4. Checkpoints
1. Checkpoints:
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• Hormones
• Growth Factors
Etiology of cancer

o Genetic factors
induced DNA damage
o Old age
overweight.
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accelerated
Cancer genetics.
• Functions:

mutations)
Oncogenes (examples)
→ Mutated forms of proto-oncogenes
• Involved in positive control of cell growth and

division (>100)
• Gene overproduction or over activity is associated
with cancer.
o Gain-of-function
o Behave as dominants → one mutant, or
overly-active allele can predispose the
cell to tumour formation
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Oncogene products:
• Growth Factors or Receptors for Growth Factors

o PDGF → Platelet Derived Growth Factor (brain and breast cancer)
o erb-B → receptor for epidermal growth factor (brain and breast cancer)
o erb-B2 → receptor for growth factor (breast, salivary, and ovarian cancers)
• Cytoplasmic Relays in Stimulatory Signalling Pathways

o Ki-ras → activated by active growth factor receptor proteins (lung, ovarian, colon and
pancreatic cancer)
o N-ras → activated by active growth factor receptor proteins (leukaemias)
• Transcription Factors that Activate Growth Promoting Genes

o C-myc → activates transcription of growth stimulation genes (leukaemia, breast, stomach,
and lung cancer)
o N-myc → (nerve and brain cancer)
• Other types of molecules

o Bcl-2 → normal protein blocks cell suicide (lymphoma)
o Bcl-1 → codes for cyclin D1, stimulatory protein of the cell cycle (breast, neck, head cancers)
Mechanisms of oncogene activation:
• Mutation
o Leading to structural alterations in the proteins
o In regulatory regions or catalytic domain, (lead to the uncontrolled, continuous activity of the
mutated protein) → e.g.: RAS
▪ Ras protein → involved in kinase signalling pathways (control the transcription of
genes, regulate cell growth and differentiation.
o Oncogene → through a point mutation → pathway is stuck in the "on" position
o Anti-cancer drugs target RAS dependent pathways
o Identified in cancers including: pancreas (90%), colon (50%), lung (30%), thyroid (50%),
bladder (6%), ovarian (15%), breast, skin, liver, kidney, and some leukaemia’s.
• Gene amplification
o Could be amplified 100-fold
o Resulting in an excess of normal protein Erb-B2 Receptor Tyrosine Kinase 2/HER 2
• Chromosomal rearrangements = (translocation and inversion)

o Gene is now regulated by novel regulatory sequences of another gene
o Generate fusion transcripts resulting in chimeric oncogenic proteins Philadelphia-
chromosome t(9;22) (q34;q11)
Chronic myelogenous leukaemia
• Often caused by a particular translocation “Philadelphia Chromosome”

• The exact point of translocation creates a hybrid gene → combination of C-ABL and BCR genes
o They produce a single protein that contains properties of both
▪ C-ABL is for signal transduction
▪ BCR activates and deactivates proteins
o The hybrid protein signals white blood cells to constantly multiply
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40. Cancer genetics. Mendelian disorders with strong predisposition to

cancer. Common cancers: breast and colon cancers.
risk of cancer.

(apoptosis).
with age.

7. Checkpoints
1. Checkpoints:
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• Hormones
• Growth Factors
Etiology of cancer

o Genetic factors
induced DNA damage
o Old age
overweight.
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accelerated
Cancer genetics.
• Functions:

mutations)
Mendelian disorders with strong predisposition to cancer

Types of cancer:
1. Sporadic
• Occurs in people without such predisposition

• Results from an accumulation of acquired and
uncontrolled mutations in somatic cells.
2. Hereditary
• Occurs in people with an alteration in susceptibility

genes which has been inherited through the germline
cells
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Common cancers: breast and colon cancers.

Breast cancer
• Hereditary → occurs in women with an alteration in a breast
cancer (BC) susceptibility gene which has been inherited through
the germline cells.
• Sporadic → occurs in women without such predisposition Results
from an accumulation of acquired and uncontrolled mutations in
somatic cells.
• Familial →occurs in a woman with at least one relative with BC
Features that indicate hereditary breast cancer:
• Multiple cases of early onset BC

• Bilateral BC
• Male BC
• Breast and ovarian cancer in the same woman
• Multiple cases with family history of BC and/or ovarian, Fallopian tube, pancreatic, prostate,
gastric and other associated cancers
Genetic counselling:
• Should be referred to:

o Affected individuals:
▪ Genetic testing
▪ Decision-making about BC surgery
o Unaffected individuals with a family history of BC (high risk woman)
▪ To take some prophylactic measures such as: breast self-examinations and
mammography
▪ Genetic testing
→ it influences in:
o Personal risk for woman with BC
▪ Confirmed BRCA mutation status → decision
between selection of a breast conserving approach
or a therapeutic mastectomy with or without
contralateral risk-reducing mastectomy.
o Risk for unaffected blood relatives
▪ Confirmed BRCA mutation status → could be
referred some prophylactic measurement such as
chemoprevention and risk-reducing mastectomy.
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Colorectal cancer
• 11% of cancer-related deaths
• Tumor progression may take 10-35 years
• Adenomatous polyp develops into carcinoma
Risk factors for colon cancer:
• Aging
• Personal history of CRC or adenomas
• High-fat intake
• Low-fiber diet
• Inflammatory bowel disease
• Family history of CRC
• Hereditary colon cancer syndromes
Types of genes:
• Oncogenes
• Tumor suppressor genes
• DNA repair genes
Genetics and progression of colorectal cancer (CRC):

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Types of colorectal cancer:
• 75% = sporadic → occur in people without genetic

predisposition or family history of CRC
• 15-20% = familial
o Family history of CRC
o Age at onset typical of sporadic CRC
o Multiple causes
o Few or no adenomas
• 5-8% = hereditary
o Familial adenomatous polyposis (chromosomal
instability) or FAP
o Hereditary nonpolyposis colon cancer (failure to repair
DNA) or HNPCC
• Familial adenomatous polyposis

o Mutation in APC gene
o Autosomal dominant (AD)
o Nearly 100% penetrant
o 20-25% new mutation
o Patients develop 100–1000 of colon polyps, some of which become malignant
• Hereditary nonpolyposis colon cancer

o HNPCC is caused by failed DNA repair enzymes that work during mitosis
o Even without polyps, mutation rate in colon is increased and cancer risk increases

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Rodi Jelebi

1. Methods of human genetic study. Pedigree construction: symbols, pedigree

2. Methods of human genetic study. Molecular-genetic methods. Principles

3. Methods of human genetic study. Molecular-genetic methods. Principles

4. Methods of genetic study. Cytogenetic methods – materials, steps in

5. Chromosomal mutations – types (numerical and structural), mosaicism,

→ Normal human cells contain total 46 chromosomes or 23 pairs of chromosomes

• 22 pairs of autosomes and one pair of sex chromosomes/ XX or XY

Haploid → set of 23 chromosomes (the normal complement of reproductive cells/ gametes)

Diploid → normal number of 46 chromosomes (the normal complement of somatic cells)

• 46, XX – Female karyotype

• 46, XY – Male karyotype

Chromosomal disorders are due to different type of chromosomal alterations/ mutations:

Classification of chromosomal abnormalities

• Anomalies affecting autosomes (from 1st to 22nd chromosome)

• Balanced chromosomes rearrangements – structural rearrangements with dislocation of

Types (numerical and structural), mosaicisms, mechanism

▪ Mechanism: → Abnormal events prior or during fertilization.

• Trisomy = presence of an extra chromosome

→ Meiotic error (de novo) – non-disjunction results in an aneuploidy gamete and

Clone of cells and malignancy

→ Relative frequency of different abnormalities in chromosomally abnormal spontaneous abortion:

o Consequence – Due to the lethal effect of chromosomal abnormalities such pregnancies

Clinical significance of chromosomal abnormalities

• Contribute significantly to genetic pathology resulting in:

Incidence of spontaneous abortions, stillbirths and newborns:

• 95% of chromosomally abnormal conceptus are aborted spontaneously

• Presence of congenital anomalies in newborns

6. Chromosomal disorders – autosomal chromosomal abnormalities

• 22 pairs of autosomes and one pair of sex chromosomes/ XX or XY

Haploid → set of 23 chromosomes (the normal complement of reproductive cells/ gametes)

Diploid → normal number of 46 chromosomes (the normal complement of somatic cells)

• 46, XX – Female karyotype

• 46, XY – Male karyotype

Chromosomal disorders are due to different type of chromosomal alterations/ mutations:

Classification of chromosomal abnormalities

• Anomalies affecting autosomes (from 1st to 22nd chromosome)

• Balanced chromosomes rearrangements – structural rearrangements with dislocation of

Autosomal chromosomal abnormalities (numerical and structural)

• Nonspecific clinical features

Down syndrome – trisomy 21

• Incidence – from 1 in 600 in 1000

• Characteristics facial appearance

• 1 - 2% cases are mosaics = mitotic nondisjunction

Edward Syndrome – trisomy 18

Patau Syndrome – trisomy 13

• Incidence: 1/20 000

Chromosome 22q11.2 deletion syndrome

• Small deletion of band q11.2 on long arm of chromosome 22

Prader – Willi syndrome (PWS)

• Incidence: 1/10 000

Mechanisms of genomic imprinting

• Biochemical base of imprinting: differential DNA methylation/histone acetylation leads to inactivation

7. Chromosomal disorders – sex chromosomal abnormalities: incidence;

→ Normal human cells contain total 46 chromosomes or 23 pairs of chromosomes

• 22 pairs of autosomes and one pair of sex chromosomes/ XX or XY

Haploid → set of 23 chromosomes (the normal complement of reproductive cells/ gametes)

Diploid → normal number of 46 chromosomes (the normal complement of somatic cells)

• 46, XX – Female karyotype

• 46, XY – Male karyotype

Chromosomal disorders are due to different type of chromosomal alterations/ mutations:

Classification of chromosomal abnormalities

• Anomalies affecting autosomes (from 1st to 22nd chromosome)

• Balanced chromosomes rearrangements – structural rearrangements with dislocation of