Factor VII deficiency and developmental abnormalities in a patient with partial monosomy of 13q and trisomy of 16p: case report and review of the literature

Background Unbalanced chromosomal translocations may present with a variety of clinical and laboratory findings and provide insight into the functions of genes on the involved chromosomal segments. Case Presentation A 9 year-old boy presented to our clinic with Factor VII deficiency, microcephaly, a seizure disorder, multiple midline abnormalities (agenesis of the corpus callosum, imperforate anus, bilateral optic nerve hypoplasia), developmental delay, hypopigmented macules, short 5th fingers, and sleep apnea due to enlarged tonsils. Cytogenetic and fluorescence in situ hybridization analyses revealed an unbalanced translocation involving the segment distal to 16p13 replacing the segment distal to 13q33 [46, XY, der(13)t(13;16)(q33;p13.3)]. Specific BAC-probes were used to confirm the extent of the 13q deletion. Conclusion This unique unbalanced chromosomal translocation may provide insights into genes important in midline development and underscores the previously-reported phenotype of Factor VII deficiency in 13q deletions.


Background
The identification of chromosomal breakpoints in association with variations in human phenotypes often leads to the discovery of novel genes or the characterization of the clinical importance of known genes. Patients who present with a known Mendelian disorder, but who also exhibit developmental delay or other, seemingly unrelated condi-tions, may harbor a chromosomal abnormality. We present the case of a child who presented with asymptomatic Factor VII deficiency at age 9 who was found to have an unbalanced 13;16 translocation associated with several other developmental abnormalities.
These photographs demonstrate the mild dysmorphic features of the patient, including microcephaly, a triangular and mildly asymmetric face, prominent forehead, slightly downslanting and almond-shaped palpebral fissures, mild ptosis, high nasal bridge and a small chin (panels A and B) Figure 1 These photographs demonstrate the mild dysmorphic features of the patient, including microcephaly, a triangular and mildly asymmetric face, prominent forehead, slightly downslanting and almond-shaped palpebral fissures, mild ptosis, high nasal bridge and a small chin (panels A and B). He had bilateral 5 th finger clinodactyly (panel C) and bilateral optic nerve hypoplasia (panel D). A 9 year-old male presented with Factor VII deficiency and multiple congenital abnormalities. Prior to her pregnancy with this child, his mother (currently 50 years old) had nine in vitro fertilization attempts that ended in miscarriage. One of these miscarriages was documented as trisomy 21 at 18 weeks gestation. This patient was one twin of a fraternal twin pregnancy conceived on the 10 th round of in vitro fertilization. His sister was born healthy and her cytogenetic evaluation has not been performed. This twin pregnancy was complicated by premature labor requiring 13 weeks of maternal bed rest prior to delivery via C-section at 36 weeks gestation. The patient's birth weight was 3 lbs, 14.5 oz and his Apgar scores were 9 and 9 at 1 and 5 minutes, respectively.

Clinical presentation
At birth, the patient was noted to have an imperforate anus that was repaired with a colostomy at 15 days of life. An ultrasound of the brain showed agenesis of the corpus callosum, which was later confirmed on MRI. Both an echocardiogram and a renal ultrasound were normal.
For the first year of life, the patient failed to thrive. He underwent two successful operations for his imperforate anus at ages 9 and 11 months, after which he began to gain weight appropriately. Development was delayed; he sat at 9 months, pulled up at 11 months, walked at 22 months, and spoke single words at 15 months. His pediatricians noted "borderline microcephaly" and low muscle tone. He has been receiving speech therapy and physical therapy since age 1. At age 6 years, he developed grand mal seizures which have been successfully managed with medication. He had repeated upper respiratory infections and was noted to have enlarged tonsils that may have contributed to sleep apnea. As part of his pre-operative work-up for tonsillectomy, he was discovered to have elevated prothrombin and partial thromboplastin times of 21.3 seconds and 36.8 seconds, respectively. Factor VII deficiency (17% of normal) was subsequently diagnosed; Factor X levels were 54% of normal. The patient, however, has never had a severe bleeding disorder. It was the combination of Factor VII deficiency and multiple congenital malformations that prompted the genetics work-up, including karyotype. He had abnormal tooth eruption and required dental surgery and frenulectomy. Neither surgery required coagulation assistance.
The patient's parents are healthy, as is his fraternal twin sister and a younger brother, age 7. Review of systems was notable for chronic constipation requiring daily enemas. He is currently on Depakote 325 mg bid and has no known drug allergies.
On physical examination (Figure 1), the patient's height is 51 inches (10 th centile), his weight is 42 pounds (3 rd centile) and his head circumference is 49.5 cm (<3 rd centile, the 50 th centile for a 2 year-old). His inner and outer canthal distances are at 97 th centile. He has thick, curly hair with one hair whorl and a normal posterior hairline. His forehead is prominent and his face is triangular. His palpebral fissures are somewhat almond-shaped and upslanting. He has mild ptosis. He has a high nasal root, hypoplastic alae nasi with prominent columella, a thin upper lip, downturned corners of the mouth, and a small, pointed chin. He has some mild facial asymmetry. His ears are normally placed and rotated without tags or pits; however, there is a slightly flattened appearance to both auricles. His palate is high arched and he has a small notch in his uvula. He has several dental caps and his lower front teeth are abnormally rotated. His chest is normally shaped without pectus deformity. His chest circumference and inter-nipple distance were 50 th and 75 th centiles, respectively. He has multiple hypopigmented macules on his torso and one café-au-lait spot on his left shoulder measuring approximately 3 cm × 2 cm. He has approximately 10 degrees of scoliosis, mild lordosis and a small sacral dimple. There are surgical scars from his colostomy and anal repair. He has normal male genitalia, Tanner Stage 1. He has decreased elbow and shoulder extension. His distal extensibility is normal. His 5 th fingers are slightly short relative to the 4 th distal inter-phalangeal crease and show clinodactyly. His palmar creases are normal. Heart, lung, and abdominal examinations were normal. His knees were normal and he has pes planus.
Endocrine studies, including a thyroid panel, a random cortisol, prolactin, and follicle-stimulating were within normal limits. The patient's bone age is at the upper limits of normal by Pyles and Greulich critreria.

Cytogenetic analysis
Routine karyotyping showed a translocation of material of unknown origin onto 13q33 ( Figure 2). FISH probes for all telomeres were used to confirm the presence of an unbalanced translocation with distal 16p (16p13.3 → ptelomere) translocated to 13q33. Thus, the patient is monosomic for genes at 13q33 and distal, as well as trisomic for genes at 16p13.3. The nomenclature for this karyotype is 46, XY, der(13)t(13;16)(q33;p13.3). Because Routine cytogenetics identified a translocation of material of unknown origin onto 13q33 (panel A) Figure 2 Routine cytogenetics identified a translocation of material of unknown origin onto 13q33 (panel A). Using probes specific for subtelomeric sequences, a translocation was identified from 16p (green) onto 13q (panel B, red probe is for 16q). Similarly, two probes for distal 13q (red and green probes, panel C) were absent from one chromosome 13 identified using an aqualabeled proximal 13q probe. A FISH BAC probe specific for the ZIC2 gene on 13q (panel D, green probe) confirms that it is not deleted in this patient.
Ideogram of chromosomes 16 with the trisomic region highlighted  A the transcription factor gene, ZIC2, lies close to the breakpoint and because mutations in ZIC2 are known to cause holoprosencephaly (a midline defect), we confirmed the breakpoints by performing FISH analysis using ZIC2 specific bacterial artificial chromosome (BAC) probes, RPCI 11 12-G12 selected from NCBI and Ensembl databases (BACPAC Resources, Children's Hospital Oakland Research Institute, Oakland, CA). These FISH studies confirmed that ZIC2 was present on both chromosome 13's and that the breakpoint was distal to 13q32, consistent with our impression that the breakpoint is at 13q33. Cytogenetic analysis of both parents was recommended given the history of previous miscarriages, but has not yet been pursued by the family.

Conclusion
We report on the clinical and cytogenetics findings in a male with a novel, unbalanced 13;16 chromosomal translocation that resulted in monosomy for genes from 13q33 to the q terminus and trisomy for 16p13.3 genes, the most distal band on the short arm of chromosome 16. Examples of genes that map to these segments are given in Figure 3 and 4. Because chromosome 16 may include imprinted loci, it is possible that the phenotype of this patient could be affected by parent-of-origin effects and/ or uniparental disomy for 16p13.3. The presence of several midline abnormalities (e.g., absent corpus callosum, optic nerve hypoplasia, small cleft in the uvula, and anal atresia) suggest a midline field abnormality around the time of gastrulation. [1] While 13q deletion syndromes are well-recognized, [2] we present a novel translocation associated with 13q deletion and a complex clinical phenotype. The variability in reported phenotypes depends, in part, on the portions of 13q that are deleted and whether other chromosomal abnormalities are involved. Table 1 summarizes pub-lished reports of very distal 13q deletions similar to ours. Findings in our patient consistent with 13q deletion include growth and psychomotor retardation, microcephaly, deficiency of coagulation factors VII and X, and mild facial dysmorphisms and asymmetry. His sacral dimple is a finding consistent with the proposal of Luo et al that this region may include genes important in neural tube closure. [3] Similarly, his imperforate anus, muscular hypotonia, microcephaly and dysmorphic features are consistent with the three patients described by Kuhnle et al with sub-telomeric deletions of 13q, although this case is complicated by mosaicism for monosomy 13 and is therefore not included in table 1. [4] Stoll and Alembik describe a patient with 13q33.3→qter with only mild mental retardation, microcephaly, growth delay, a small chin, hypotonia, and a broad forehead [5] and Rivera et al. review six cases with many similar findings, despite a larger 13q deletion. [6] Submicroscopic deletions and/or rearrangements of 13qter have also been reported to lead to "idiopathic" mental retardation. [7] Less has been reported on trisomy 16p, perhaps because it is less susceptible than other chromosomal regions to translocation [8] and because complete trisomy 16 -the most frequent autosomal anomaly found in miscarriages -is frequently lethal. [9] Again, there is significant phenotypic heterogeneity reported, in part because most patients described have unbalanced translocations and are trisomic for variable portions of 16p. [10][11][12][13][14][15][16][17][18][19] Findings consistent with this anomaly in our patient include microcephaly, a broad nasal bridge, developmental delay, and seizures. [16,20] Cases involving only trisomy of 16p13 are summarized in Table 2. An insertion of 16p13.1→p13.3 into chromosome 1 resulted in mental retardation, short stature, microcephaly, seizures, and multiple dysmorphic features. [21] A 14 year-old male with 46, XY, dup(16)(p13.1→pter) karyotype presented Factor VII is a vitamin-K dependent clotting factor in the extrinsic pathway that -when deficient -is inherited as an autosomal recessive trait and produces an elevated partial thromboplastin time (PTT) in the face of a normal activated prothrombin time (PT); hemarthrosis; intracranial hemorrhage; hematuria; spontaneous epistaxis and bruis-Ideogram of chromosome 13 with the monosomic region highlighted  Our patient would be predicted to be monosomic for 13q34. The fact that he exhibits less than 50% activity may be related to a polymorphism on his remaining allele causing slightly reduced activity or reduced levels of protein expression. Factor VII activity was not assayed in his parents.
Bilateral optic nerve hypoplasia is sometimes accompanied by midline anomalies of the central nervous system, such as absent corpus callosum, absent septum pellicidum, and pituitary insufficiency. [30] None of the three genes known to produce this phenotype in animal models -namely netrin (17p13-p12), Hesx1 (3p21), [31] and DCC (18q21.3)[32] -map to either chromosome 13 or 16, suggesting an uncharacterized regulatory gene for midline CNS development in the abnormal regions. Of note, netrin-2 -like gene is located on 16p13. [33] Several other zinc-finger containing proteins of unknown function also map to this region. A three-generation family with dominant congenital cataract and microphthalmia co-segregates with a t(2;16)(p22.3;p13.3) translocation in four balanced carriers and three with monosomy of 16p13.3, suggesting that an important eye developmental gene resides at or near this breakpoint. [34] List of abbreviations