Mental retardation and psychosis in VCFS From the 22q11 deletion ...

!Mental retardation and psychosis in VCFSFrom the 22q11 deletion to hyperprolinemiaAudrey GUILMATREDr Dominique CampionInserm U614, Faculty of Medicine, Rouen, FranceLaboratory director : Pr Thierry Frébourg

THE 22Q11 DELETION SYNDROME- Facial dysmorphism- Cardiac defects- Thymus hypoplasia- Palatal cleftPsychosis in 10-30% ofVCFS patientsPolymalformative SyndromeVCF syndrome(22q11DS) : the mostfrequent microdeletion in the population(1/4000)Detection of the 22q11deletion by FISHMild to moderate mentalretardation in 50% ofVCFS patients

14,5715,515,615,815,9616,0316,2616,3116,3516,5916,6516,716,8416,871717,3117,6317,7818,519,1520,143 Mb deletionCECR1TUBA8USP18PRODHDGCR5DGCR2GSCLHIRANLVCFUFD1LPNUTL1TBX1GNB1LCOMTARVCFRANBP1ZNF74PIK4CASNAP29UBE2L3VPREB1BCR______________________THE 22q11 REGION

PRODH AND HYPERPROLINEMIAL - prolinePROLINEDEHYDROGENASEΔ -1- pyrroline - 5 – carboxylate (P5C)Type 1 Hyperprolinemia(MIM 239500)NAD +NADH + H +P5CDEHYDROGENASEType II Hyperprolinemia(MIM 239510)GlutamateCO 2γ aminobutyric acid (GABA)

MISSENSE MUTATIONS IN THE PRODH GENEQ19PR185WT275N ?L289M23 4 5 6 7 89A58T ?R431H R453C T466M Q521E10 11121314 15P406LL441P A455S A472T

GENE DOSAGE VARIATION: DELETION OF 350 kbAT THE PRODH LOCUSUSP18DGCR6 PRODHLOC200301 DGS-A DGCR2PRODH-P DGCR6 LCENLCR22TEL234 kb16 kb1180 kbFrequency:1/250 in thegeneralpopulationDeletion of350 kbUSP18 DGCR2 PRODH-P DGCR6 LCENTEL

MOLECULAR BASIS OF TYPE IHYPERPROLINEMIAPhenotype : severe hyperprolinemia is associated with mentalretardation and epilepsyPlasma Proline : 800 µmol/LPlasma Proline : 1255 µmol/LL441P/L441PPlasma Proline : 2246 µmol/LPRODH Del/DelJacquet et al. 2003, Hum Mol Genet.

TYPE 1 HYPERPROLINEMIA : GENOTYPE/PHENOTYPE CORRELATIONSPatient Age PhenotypePlasmaproline(µmol/l)PRODHgenotypePredictedresidualenzymaticactivityDum 2 Autistic features, epilepsy1515-2186del/del0%Sal5 MR, autism, epilepsy 422-1883 del/V427M+R453C0%Gal 4 MR1003L441P/Stop c550%Elk3 MR, epilepsy418-814T466M+R453C/Q19P25%Chin 3 MR, epilepsy 750-816 P406L+R431H /R431HDir 12 epilepsy 604-862 V427M+R453C/Q19PChoFon3 Autism 256 T466M+R453C/R185W30 PDD-NOS339 T466M+R453C/R431H25%25%25%25%

CORRELATION BETWEEN HYPERPROLINEMIAAND COGNITIVE/PSYCHIATRIC SYMPTOMS INTHE VCF SYNDROMEMental retardation in 40 -50% of VCFS subjectsPsychosis in 10 - 30% of VCFS subjectsHyperprolinemia in 40 - 50% of VCFS subjectsAre cognitive impairment and/or psychosisassociated with hyperprolinemia?Collaborative Study (PHRC 2003) :Paris, Leuven, Amsterdam, Marseille, Strasbourg,Montpellier, Bordeaux, Lille, Rouen

VCFS SAMPLE Inclusion : 92 subjects. Mean age 25 ± 10 years (range: 15 - 58 years) Psychiatry (SADS-LA): schizotypal personality (n=4) atypical psychosis (n=6) schizophreniform disorder (n=3) schizophrenia (n=18)36% of subjects (n=33) autism (n=2) Cognition (WAIS III): Mental retardation (IQ < 70) in 69% of subjects VIQ (66.7 ± 16.6) > PIQ (64 ± 13.5)

VCFS SUBJECTS WITH SEVERE HYPERPROLINEMIAPatient Proline age IQ Psychiatry Other001 1275 34 53 Psychosis -002 1268 42 62 SZ epilepsy002 1120 48 60 SZ epilepsy004 962 24 48 - -005 739 47 45 SZ -006 718 25 45 Autism epilepsy007 707 19 45 SZ.T epilepsy

TREND FOR ASSOCIATION BETWEENHYPERPROLINEMIA AND PSYCHOSIS IN VCFSProlinemia >300µm/L(hyperprolinemia)Prolinemia < 300µm/L(normal values)Psychosis(n=33)Other patients(n=59)16 (48%)18 (31%)1741Chi-2, 1ddl = 2,93 p=0.08

SEVERE HYPERPROLINEMIA IS ASSOCIATED WITHMORE SEVERE MENTAL RETARDATIONHyperprolinemia > 600 µm/L(n=7)Prolinemia< 600 µm/L(n=85)QIG = 50,6 ± 7 QIG = 65,2 ± 14Significant difference: p=0.007Inverse correlation Prolinemia / IQ.r = -0.24, p = 0.02,Spearman’s test

GENOTYPE/PHENOTYPE CORRELATIONSEnzymatic activity Proline Phenotype>50% Normal Normal

THE OPPOSITE STRATEGY: SEARCH FORPRODH DELETIONS IN PATIENTS WITHPSYCHIATRIC DISORDERSGuilmatre et al, Archives of General Psychiatry, 2009 in press

CNVs IN PSYCHIATRIC DISORDERS Recently, wide use of array-CGH in neurological andpsychiatric disorders Recurrent rare CNVs in MR, ASD and schizophreniaMental RetardationFriedman et al, 2006, Am JHum GenetFroyen et al, 2007, HumMutatMenten et al, 2006, J MedGenetAutism SpectrumDisordersMarshall et al, 2008, Am JHum GenetSebat et al, 2007, ScienceChristian et al, 2008, BiolPsychiatrySzatmari et al, 2007, NatGenetSchizophreniaWalsh et al, 2008, ScienceConsortium IS, 2008,NatureKirov et al, 2008, Hum MolGenetXu et al, 2008, Nat GenetStefansson et al, 2008,NatureMefford et al, 2008, N EnglJ MedKirov et al, 2009, Hum MolGenet

TARGETED ANALYSIS28 candidate loci previously identifiedin rare cases of MR, ASD or SZ by array-CGH studiesNeuronalmigration andgrowth(PTK2,TSPAN7)28 genesOthers(ST7, MECP2,MAPT, IL1RAPL1)Synapse formationand maintenance(NRXN1, NLGN1,NLGN4, SHANK3,CASK, ERBB4,NRG1, DLG2,CNTN4, CNTNAP2)Neuromodulation(PRODH)Neurotransmission(DOC2A, GRIA3, GRM7,GABRA5, GABRG1,GRIP1, APBA2, SLC1A3,DPP10, DLGAP2,CHRNA7)

AIM OF THE STUDY To provide an estimate of the collective frequency of aset of recurrent/overlapping CNVs in three differentgroups of patients (autism, schizophrenia and mentalretardation) as compared with healthy controls To assess whether each CNV is present in more thanone clinical category

SUBJECTS 247 patients with mental retardation, without anyestablished syndrome 260 patients with autism 236 patients with schizophrenia or schizoaffectivedisorder 236 healthy controls

DISEASES ASSOCIATED CNVs (11/28)Patients with autism16/2606.1%Patients with MR13/2475.3%Patients with SZ10/2364.2%Significant excess of these CNVs in each disease groupas compared with controls(p value < 0.001, p=0.001 and p= 0.01 respectively, Fisher exact test)Individual significance for association between the 350kb PRODHdeletion and autism ( p=0.02)

DISEASES ASSOCIATED CNVs: AUTISMID ChromosomallocationSize Genes involved Type TransmissionT35 2p16.3

PRODH DELETION: GENOTYPE/PHENOTYPECORRELATION9/12 tested patients have hyperprolinemiaAll but one patients have mutations on the remaining allele resulting ina predicted PRODH residual activity below 30%ID diagnosis144.1144.21245212746138994473745435458564626147766si301236311780968014684SZAFFSZAutismHFAAutismAutismAutismAutismAutismAutismAutismMRMRMRMRPlasma proline(µmol/l)538338287214312329487ND243-283ND422-1883512ND299238genotypedel/R453C+R185Wdel/Q19Pdel/R185Wdel/Q19P+A58Tdel/Q19Pdel/T275N+V427Mdel/R185W+Q19Pdel/Q19P+P30Sdel/R185W+Q19Pdel/WTdel/R453C+Q19P+A58T+V427Mdel/R185Wdel/R185W+Q19Pdel/Q19P+P30Sdel/R185W+Q19PPredicted PRODHresidual activity2%30%25%≤30%≤25%≤20%≤25%≤30%≤25%50%≤2%25%≤25%≤30%≤25%

CONCLUSION• Type I hyperprolinemia is a rare recessive disorder, resulting fromPRODH loss of function• Type I hyperprolinemia is associated with MR, epilepsy andpsychosis• Trend for association between hyperprolinemia and psychosis in22q11 DS• Inverse correlation between IQ and prolinemia in 22q11 DS• Individual significance reached for association between the 350kb22q11 deletion spanning the PRODH gene and autism in a casecontrolstudyPRODH deletion leading to hyperprolinemia isinvolved in the cognitive and psychotic symptoms inVCFS

Inserm U614Department of Genetics, University Hospital,Rouen, FranceSolenn LegallicValérie Drouin-GarraudAlice GoldenbergGéraldine Joly-HelasPascale Saugier-VeberDominique CampionThierry FrébourgACKNOWLEDGEMENTSUMR 6061 CNRS, University of Rennes I,Rennes, FranceChristèle DubourgVéronique DavidClaude BendavidSylvie OdentDepartment of Genetics, UniversityHospital, Dijon, FranceAnne-Laure MoscaLaurence FaivreInserm U619, Tours, FranceChristian AndresUniversity of Messina, SicilyGabriella Di RosaGaetano TortorellaCaterina ImpallomeniEva GermanoInserm U930, University Hospital,Tours, FranceFrédérique Bonnet-BrilhaultFrédéric LaumonnierCatherine BarthélémyDepartment of Genetics, Hospital,Le Havre, FranceValérie LayetDepartment of Research, CHSR,Rouen, FranceGaël Le VaconCentres de Ressources Autisme deHaute-Normandie (A. Rosier), deBourgogne (JM Pinoit, C. Henry)CHU De MontpellierPierre Sarda