241 TZOUNTZOURIS et al. reported on apparent FMR1 allele instability of 9 developmentally delayed individuals with normal-sized alleles. This raises interesting questions and possible concerns regarding laboratory genetic testing of mutated Fragile X genes. The FMR1 CGG repeat is polymorphic ( , 10–55 repeats) in the normal population, with 30 repeats being the most common size (Brown et al., 1993). These normal alleles are generally considered to be very stable. However, their findings suggest that even normal sized alleles may, on occasion, have instability. Their documentation of this observation suggests laboratories doing such testing should be aware of the potential for this confusing finding to appear in their samples. Analysis of the repeat in normal males reveals AGG triplets embedded at regular intervals, most commonly at repeat positions of about 10 and 20 (Eichler et al., 1994; Kunst et al., 1994; Zhong et al., 1995). The alleles in Fragile X families differ in several ways. They have long repeats that are unstably transmitted from one generation to the next. Repeat expansions are gender-specific, with expansion to full-mutation alleles occurring only through females. In premutation females, the expansions are a function of repeat size, with larger repeats having a greater risk of expansion than smaller ones (Nolin et al., 1996, 1999). Analysis of premutation males indicates that Fragile X alleles usually have one or no AGG interruptions within the repeat and long stretches of pure CGG repeats in the 39 end. Despite intense interest in trinucleotide disorders, the mechanism of repeat expansion is poorly understood. For Fragile X, the expansion process is especially puzzling because the repeat may expand, for example, from 75 to more than 1,000 in one generation. The presence of long, uninterrupted CGG tracts in Fragile X families clearly distinguishes them from other families. The current favored model for large repeat expansions is slippage of Okazaki fragments during DNA replication of repeat regions (Brown et al., 1993; Richards and Sutherland, 1994). Expansions in Fragile X and the other trinucleotide disorders are not likely to be the result of defective DNA replication/repair proteins because the instability is limited to a single expanded repeat, and global microsatellite instability is not observed. Recent studies suggest that repeat instability is a consequence of abnormal localized DNA secondary structure (McMurray, 1999). Biochemical studies have demonstrated the ability of CGG tracts to form alternative DNA structures. Strand displacement of the repeat regions in Okazaki fragments may allow the formation of intramolecular hairpin and tetrahelical structures. These structures may defeat the DNA replication/repair machinery within a cell. Several DNA repair-related enzymes have been recently implicated in trinucleotide repeat instability. The FEN-1 enzyme is both an endonuclease and exonuclease involved in DNA replication and repair. One preferred substrate is branched DNA structures with a single-stranded 59 flap, such as Okazaki fragments generated from the lagging strand. In contrast, secondary structures such as loops and hairpins are resistant to cleavage by FEN-1. Impaired FEN-1 function due to inefficient cleavage of secondary structures in Okazaki fragments with long stretches of triplet repeats may lead to repeat expansion, whereas structures formed in the lagging strand during replication of CGG repeats can cause replication stalling (Goredin et al., 1997). The WRN gene is a DNA helicase responsible for Werner syndrome, an autosomal recessive disease characterized as a premature aging condition. It appears to be involved in DNA replication, both as a helicase and as a 39 to 59 exonuclease. The WRN helicase has been shown to unwind CGG/AGG oligomers more rapidly than uninterrupted CGG oligomers, suggesting that it is involved in repairing abnormal DNA structures such as DNA tetrahelices (Weisman-Shomer et al., 2000). Fragile X syndrome is a complex disorder that is poorly understood. Although the mutation is known to be an expansion of a CGG repeat, the factors leading to repeat expansion remain obscure. The findings in the current report (Tzountzouris et al., this issue) raise interesting questions regarding the mechanisms of normal allele length instability and imply that laboratories need to be on the look-out for their estimated 1% of cases that can lead to diagnostic confusion.
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