Bloom's syndrome with growth hormone deficiency: a rare association.

We report a case of a 5-year-old boy presenting to us with short stature. He was born of consanguineous parentage and was small for gestational age. He had severe short stature, with height Z score of -6.2 SD Score, markedly delayed skeletal age, low level of insulin-like growth factor 1, unstimulated growth hormone and hypoplastic anterior pituitary gland on MRI. He was advised growth hormone (GH) replacement at 2 years of age, but he did not receive it . Later on, he developed photosensitive telangiectatic lesions over face and required multiple hospital admissions for recurrent systemic infections. Genetic analysis confirmed the diagnosis of Bloom's syndrome. The present case report illustrates the need for high vigilance for conditions like Bloom's syndrome in growth hormone deficiency (GHD), in whom GH treatment could potentially be harmful. Bloom's syndrome with GHD is an exceedingly rare association.

False-positive quadruple screen test for trisomy 18 in a patient with a fetus with Bloom's syndrome.

In the literature, conflicting reports on the significance of false-positive maternal serum multiple marker testing for trisomy 18 are encountered; however, the biology of this finding is discussed infrequently. We present such a case in association with Bloom's syndrome in the fetus. The fetus had intrauterine growth restriction, seen early in the second trimester, oligohydramnios, and was delivered at 34 weeks of gestation for impending fetal compromise. We propose that the adverse outcome of the pregnancy with false-positive serum analyte testing for trisomy 18 might result from a small-sized placenta and perhaps pathology at receptor level.

Evaluation of short stature, carbohydrate metabolism and other endocrinopathies in Bloom's syndrome.

AIMS: To obtain an understanding of the etiology of proportional dwarfism and endocrinopathies of Bloom's syndrome BS. METHODS: Admission for 5-day periods to an NIH-supported Clinical Research Center of a randomly selected population of persons with BS (n = 11; mean age 11.5 years, range 9 months to 28.5 years) for clinical and genetic history-taking, physical examination, and endocrinological, gastroenterological and immunological testing. RESULTS: An oral glucose tolerance test was performed in all participants. Impaired glucose tolerance was present in 4 individuals, insulin resistance was observed in 6 individuals, and previously unrecognized diabetes was found in 1. Growth hormone provocation was normal in the 10 individuals tested. Overnight frequent GH sampling was suggestive of neurosecretory dysfunction in 3. Compensated hypothyroidism was found in 2 participants. Lipid profile abnormalities were present in 5 of 10 individuals. Low immunoglobulin concentrations (IgG and/or IgM) were seen in all tested. Intestinal absorption by D-xylose and/or fecal fat measurement was normal in all individuals tested as well. CONCLUSION: Altered carbohydrate metabolism is very common in BS, and is present from childhood. BS dwarfism is not related to growth hormone deficiency or malabsorption. The basis for the growth restriction in BS remains to be elucidated.

Two Japanese siblings with Bloom syndrome gene mutation and B-cell lymphoma.

Bloom syndrome (BS) is a rare autosomal recessive genetic disorder characterized by lupus-like erythematous telangiectasia of the face, sun sensitivity, infertility and stunted growth. Upper respiratory tract and gastrointestinal infections are commonly associated with the decreased immunoglobulin levels found in BS patients. Chromosomal abnormalities are hallmarks of the disorder, and high frequencies of sister chromatid exchanges and quadriradial configurations in lymphocytes and fibroblasts are virtually diagnostic. Recently, the causative gene for BS (BLM) has been identified. We encountered and defined a family with a nonsense mutation in BLM. The brother and sister were homozygous for the mutation and both developed B-cell malignant lymphoma in their twenties. These findings indicate the importance of prenatal diagnosis and the detection of BS carriers based on molecular genetic analysis.

Effects of topoisomerase II inhibition in lymphoblasts from patients with progeroid and "chromosome instability" syndromes.

DNA topoisomerase II is involved in DNA topologic changes through the formation of a cleavable complex. This is stabilized by the antitumor drug VP16, which results in DNA breakage, aberrant recombination, and cell death. In this work, we compare the chromosomal damage induced by VP16 with that induced by bleomycin (BLM) in lymphoblasts from patients affected by the chromosome breakage syndromes ataxia telangiectasia (AT), xeroderma pigmentosum (XP), and Bloom syndrome (BS), and by the progeroid syndromes Werner (WS) and Cockayne (CS). Patients affected by AT, XP, BS, and WS have a greatly enhanced risk of developing cancer. The results show that AF and WS cells are hypersensitive to VP16, as revealed in the higher proportion of metaphases showing exchange figures and more than two breaks. All lines except AT and one CS line showed normal sensitivity to BLM. Our data on the sensitivity to VP16 of all these mutant cells underline the fact that VP16 damage is amplified only in cells that have abnormal illegitimate recombination (i.e., AT and WS).

Bloom syndrome: an analysis of consanguineous families assigns the locus mutated to chromosome band 15q26.1.

By the principle of identity by descent, parental consanguinity in individuals with rare recessively transmitted disorders dictates homozygosity not just at the mutated disease-associated locus but also at sequences that flank that locus closely. In 25 of 26 individuals with Bloom syndrome examined whose parents were related, a polymorphic tetranucleotide repeat in an intron of the protooncogene FES was homozygous, far more often than expected (P < 0.0001 by chi 2). Therefore, BLM, the gene that when mutated gives rise to Bloom syndrome, is tightly linked to FES, a gene whose chromosome position is known to be 15q26.1. This successful approach to the assignment of the Bloom syndrome locus to one short segment of the human genome simultaneously (i) demonstrates the power of homozygosity mapping and (ii) becomes the first step in a "reverse" genetics definition of the primary defect in Bloom syndrome.

Increased rate of spontaneous mitotic recombination in T lymphocytes from a Bloom's syndrome patient using a flow-cytometric assay at HLA-A locus.

Bloom's syndrome (BS) is an autosomal recessive disorder conferring high propensity for cancer and displaying a high degree of genetic instability; the frequency of sister chromatid exchange is characteristically 10 times above background. The symmetrical four-armed chromatid interchanges are much more readily detected in peripheral blood lymphocytes of BS patients, suggesting that the frequency of somatic recombination is also increased. In the present study, the rate of spontaneous loss of HLA-A allele expression was estimated following fluctuation analysis in cultured T lymphocytes using a flow-cytometric assay. It was found to be 10 times or more higher than normal in lymphocytes from a BS patient. Molecular and chromosome analyses showed that all 13 independent variants from the patient were most likely derived from somatic recombinations. Further tests for loss of heterozygosity at a closely linked proximal locus, HLA-DQA1, showed that as many as half of the recombinants retained heterozygosity irrespective of the donor. The results suggest that the HLA region is hyperrecombinogenic in somatic cells and that the elevated recombination rate in BS cells results from the general increase at ordinary sites and not from random creation of unusual sites for recombination.

Transition of phenotypic dimorphism with regard to spontaneous sister chromatid exchange in Epstein-Barr virus-transformed Bloom's syndrome lymphoblastoid cell lines.

We recently established four lymphoblastoid cell lines (LCLs) by infecting the peripheral blood of four Japanese patients suffering from Bloom's syndrome (BS) with Epstein-Barr virus (EBV). During the course of propagating these cell lines, two of them exhibited dimorphism regarding spontaneous sister chromatid exchange (SCE), i.e., a mixed population consisted of cells with extremely high SCE levels characteristic of BS and cells with low SCE levels indistinguishable from that of normal control cells. On the other hand, the other two cell lines maintained a monomorphic population with high SCE levels at least until 30 weeks after EBV infection. The proportion of the cells with high SCE levels in the cell lines with dual phenotype declined as the population doubling numbers (PDN) increased with time and they became ultimately undetectable. The proportion of cells with low SCE levels at the time of EBV infection was estimated in one of these LCLs as 0.075% by extrapolating the linear regression of the logit for the proportion plotted against PDN. In view of the well-known stability of the monomorphic phenotype in representative BS LCLs during extended cultivation, together with the present observations on the dual phenotype, we conclude that the frequent establishment of BS LCLs exclusively with low spontaneous SCE levels is attributable to the various proportions of low-SCE cells existing in vivo in the B-lymphocytes pool of BS individuals and to the selective pressure against the high-SCE cells in in vitro cultures.

Frequency of variant erythrocytes at the glycophorin-A locus in two Bloom's syndrome patients.

Blood type MN is determined by a glycoprotein termed glycophorin A (GPA) which exists on the surface of erythrocytes, and the difference between the M and N types is derived from the presence of 2 different amino acids in the amino-terminal portion (Furthmayer, 1978). Using a pair of fluorescence-labeled monoclonal antibodies specific to each GPA, somatic mutations in erythrocytes of MN heterozygotes at the GPA-M and -N alleles can be quantitatively determined using a flow sorter (Langlois et al., 1986). Our results for 2 Bloom's syndrome (BS) patients showed that variants either lost expression of one allele (simple gene inactivation or loss) or expressed only one allele at twice the normal level (most probably somatic recombination) occurring at a frequency of about 1-3 per 10(3) erythrocytes. The flow cytometric patterns of erythrocytes from the BS patients showed a typical smear of variants bearing intermediate levels of expression of one GPA allele, indicating that the real variant frequency is even greater than that measured. On the other hand, the parents heterozygous for the BS gene showed variant frequencies (1-8 x 10(-5)) within the normal range. These data strongly support the hypothesis that the cancer proneness of BS patients is due to their increased frequency of spontaneous mutations and somatic recombination.

Evidence for increased in vivo mutation and somatic recombination in Bloom's syndrome.

The glycophorin A assay was used to estimate the frequency of mutations that accumulate in vivo in somatic cells of persons with Bloom's syndrome (BS). This assay measures the frequency in persons of blood type MN of variant erythrocytes that lack the expression of one allelic form of glycophorin A, presumably due to mutational or recombinational events in erythroid precursor cells. Samples of blood from persons with BS showed dramatic 50- to 100-fold increases in the frequency of variants of three types, those with a hemizygous phenotype, those with a homozygous phenotype, and those with what appears to be partial loss of the expression of one locus. The high frequency of homozygous variants, genetic evidence for altered allelic segregation of a specific biochemical locus, provides evidence for increased somatic crossing-over in vivo in BS. An increased generation of functional hemizygosity and homozygosity in their somatic cells may play an important role in the extreme cancer risk of persons with BS.

Cytogenetic toxicity of D2O in human lymphocyte cultures. Increased sensitivity in Fanconi's anemia.

Chromosomal aberrations were scored in lymphocyte cultures from healthy individuals, patients with Bloom syndrome, and patients with Fanconi's anemia, after 4-5 h exposure to culture medium containing 90% heavy water (D2O). D2O treatment resulted in occasional pulverization of metaphases, and increased frequencies of chromosomal breakage. Patients with Fanconi's anemia were particularly sensitive to the chromosome breaking effect of D2O.