Stickler Syndrome is a rare clinically and genetically heterozygous connective tissue disorder with variable clinical presentation including serious vision (eg, myopia, cataract, and retinal detachment), hearing loss (eg, sensorineural, mixed and/or conductive), craniofacial abnormalities (midface underdevelopment and cleft palate) and joint problems (eg, precocious arthritis, spondyloepiphyseal dysplasia). Stickler syndrome is associated with pathogenic variants in the COL2A1, COL11A1, COL11A2, COL9A1, COL9A2 and COL9A3 genes are present. This syndrome is mainly inherited as an autosomal dominant pathology. We are presenting the case of a 15-year-old female who was referred to genetics by cardiology due to hypoglycemia, tachycardia and to rule out Marfan syndrome due to Marfanoid habitus. Upon physical examination there was evidence of joint hyperlaxity and decreased muscle tone. She also presented mild thoracolumbar dextroscoliosis of 25 degrees in curvature documented by spine X-rays. A connective tissue disorder gene panel was requested. The results indicate that the patient is heterozygous for variants in three genes: COL11A1, COL9A2 and NEPRO. The COL11A1 gene is responsible for providing the blueprint to synthesize a component of type XI collagen, which is commonly located in cartilage. Type XI collagen can also be found in the inner ear, the vitreous and in the nucleus pulposus. A sequence variant c.4718C>T in the COL11A1 gene was identified in this patient. This change is expected to cause an amino acid substitution p.Ser1573Leu, which has not been reported in the literature. Pathogenic variants in COL11A1 have been associated with autosomal dominant Stickler syndrome type II, autosomal dominant Marshall syndrome, autosomal dominant deafness 37 as well as autosomal recessive fibrochondrogenesis 1. COL9A2 gene provides the blueprint for synthesizing a part of a large molecule called type IX collagen, which is more flexible than other types of collagen. A sequence variant designated as c.1553G>T was documented in this gene and is expected to result in an amino acid substitution designated as p.Arg518Leu. Pathogenic variants in COL9A2 have been linked with autosomal recessive Stickler syndrome type V and autosomal multiple epiphyseal dysplasia 2. This variant has not been reported in the literature. The NERPRO (Nucleolus and neural progenitor protein) gene could be involved in cortex development as part of the Notch signaling pathway and it may also be involved in preimplantation embryo development. A NEPRO gene sequence variant designated as c.871G>A was documented as well. This sequence variant is expected to result in an amino acid substitution p.Val291Met. This variant has not been reported in the literature. Fifteen years old female with genetic variants on COL11A1, COL9A2 and NEPRO genes. The patient presents scoliosis, myopia, and amblyopia, micrognathia, hyperlaxed joints and hypotonia. The COL11A1 and the COL9A2 genes has been associated with autosomal dominant and autosomal recessive Stickler syndrome phenotypes respectively. Stickler syndrome is a connective tissue disorder that can include ocular findings of myopia, cataract, and retinal detachment; hearing loss that is both conductive and sensorineural; midfacial underdevelopment and cleft palate (either alone or as part of the Robin sequence). The COL11A1 variant has not been reported in the medical literature associate to the disease however predictive algorithms suggest the possibility of a deleterious effect on the protein. The patient also has a genetic variant on the COL9A2 gene that has not been associate to the disease but haploinsufficiency mechanisms may also be playing a role in this patient phenotype.
Read full abstract