BRIEF COMMUNICATION
€ ve-Wiedemann syndrome with complete
Unusual Stu
maternal chromosome 5 isodisomy
Mariarosa A. B. Melone1, Michael J. Pellegrino2, Maria Nolano3, Beth A. Habecker2,
Stefan Johansson4,5, Neil M. Nathanson6, Per M. Knappskog4,5, Angelika F. Hahn7 & Helge Boman4,5
1
Division of Neurology and InterUniversity Center for Research in Neuroscience, Department of Clinical and Experimental Medicine and Surgery,
Second University of Naples, Naples, Italy
2
Department of Physiology and Pharmacology, OHSU School of Medicine, Portland, Oregon
3
Neurology Division, ‘Salvatore Maugeri’ Foundation IRCCS, Medical Center of Telese Terme, Telese Terme, Benevento, Italy
4
Department of Clinical Science, University of Bergen, Bergen, Norway
5
Center of Medical Genetics and Molecular Medicine, Haukeland University Hospital, Bergen, Norway
6
Department of Pharmacology, University of Washington, Seattle, Washington
7
Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
Correspondence
Helge Boman, Center for Medical Genetics
and Molecular Medicine, Haukeland
University Hospital, N-5021 Bergen, Norway.
Tel: (+47) 55975475; Fax: (+47) 55975479;
E-mail: helge.boman@helse-bergen.no
Funding Information
The study was supported in part through
National Institutes of Health grant HL068231
to Professor Dr. Beth Habecker, PhD.
Received: 19 June 2014; Revised: 26 August
2014; Accepted: 27 August 2014
Abstract
A woman was isozygous for a novel mutation in the leukemia inhibitory factor
receptor gene (LIFR) (c.2170C>G; p.Pro724Ala) which disrupts LIFR downstream signaling and results in St€
uve-Wiedemann syndrome (STWS). She
inherited two identical chromosomes 5 from her mother, heterozygous for the
LIFR mutation. The presentation was typical for STWS, except there was no
long bone dysplasia. Prominent cold-induced sweating and heat intolerance lead
to an initial diagnosis of cold-induced sweating syndrome, excluded by exome
sequencing. Skin biopsies provide the first human evidence of failed postnatal
cholinergic differentiation of sympathetic neurons innervating sweat glands in
cold-induced sweating, and of a neuropathy.
Annals of Clinical and Translational
Neurology 2014; 1(11): 926–932
doi: 10.1002/acn3.126
The core clinical data were presented in
abstract form at the joint Congress of the
Italian Association of Neuropathology and
the Italian Association for Research on Brain
Aging. Genova, Italy, 19–21 May 2011.
Introduction
St€
uve-Wiedemann syndrome (STWS, MIM 601559), a
severe autosomal recessive disorder, is due to mutations
in the leukemia inhibitory factor receptor gene (LIFR) on
chromosome 5p13.1 Skeletal dysplasia, camptodactyly,
severe sucking/swallowing difficulties, episodes of respiratory distress, and hyperthermia are manifest from birth
and often result in early death. The few survivors to adolescence develop progressive scoliosis, joint contractures,
and thermoregulatory difficulties akin to cold-induced
926
sweating syndrome (CISS).2,3 Complete maternal chromosome 5 isodisomy is only reported once.4 We describe in
a 33-year-old woman a fully manifest STWS without long
bone dysplasia, caused by an isozygous LIFR mutation.
Subject and Methods
Blood was sampled from the patient, parents, and two
siblings. Electrophysiological studies (median, ulnar, peroneal, sural nerves) followed standard techniques. Quantitative sensory testing (QST): Cold, warm, cold- and heat
ª 2014 The Authors. Annals of Clinical and Translational Neurology published by Wiley Periodicals, Inc on behalf of American Neurological Association.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and
distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
M. A. B. Melone et al.
€ ve-Wiedemann Syndrome With Isochromosome 5
Stu
pain thresholds were tested (foot, hand, thigh, and leg)
using a thermal sensory analyzer (Medoc, Ramat Yishai,
Israel) and methods of limits. Tactile thresholds and
mechanical pain perception were evaluated using 18 calibrated Semmes–Weinstein monofilaments, and a calibrated monofilament with a bending force of 95 mN,
connected to a probe. Sudomotor function was assessed
by sympathetic skin responses (SSRs),5 thermoregulatory
sweat test (TST)6 and dynamic sweat test (DST).7 Autonomic cardiovascular reflexes were studied as described.2
Skin biopsy
Three millimeter punch biopsies were performed on four
body sites: upper arm (hyperhidrotic area) and thigh, leg,
and fingertip (anhidrotic areas). Samples were processed
using indirect immunofluorescence technique, according to
previously published procedures.8 Primary antibodies
(ABs) against protein gene product (PGP) 9.5 (pan-neuronal marker), myelin basic protein (MBP) (myelinated
fibers), dopamine beta hydroxylase (DbH) (noradrenergic
fibers), and vasoactive intestinal peptide (VIP) (cholinergic
fibers) were used to visualize nerve fiber populations. ABs
against Collagen IV (Col IV) and an endothelium-binding
agglutinin (Ulex europaeus; UEA-1) were used to visualize
Meissner corpuscle (MC) capsules and sweat glands (Col
IV) and blood vessels (UEA-1). Quantification of epidermal nerve fibers (ENFs), intrapapillary myelinated endings
(IMEs) and MCs was performed as previously described.9
Both monoclonal mouse and polyclonal rabbit ABs were
used in indirect immunofluorescence studies (see Table 1).
DNA analysis
First, single gene sequencing of cytokine receptor-like factor
1 (CRLF1), cardiotrophin-like factor 1 (CLCF1), interleukin
6 signal transducer (IL6ST) and LIFR was carried out.
Then genome-wide single-nucleotide polymorphism (SNP)
genotyping was performed with the Genome-Wide Human
SNP array 6.0 (Affymetrix, Santa Clara, CA) and analyzed
using PLINK v1.07.10 Whole-exome sequencing was performed at Hudson Alpha Institute for Biotechnology
(Huntsville, AL) using Roche-NimbleGen Sequence Capture EZ Exome v2 kit and paired-end 100nt sequencing
on the Illumina HiSeq.11 The reads were analyzed with
Casava v.1.8 (Illumina , San Diego, CA) and aligned to
hg19 reference genome using Burrows-Wheeler Alignment
tool.12 The chemical analysis was performed at Hudson
Alpha Institute for Biotechnology. The chromosome 5
aligned sequence data resulted in 137X mean coverage of
the target capture regions with more than 98% of target
bases covered at least 8X. Cytogenetic studies were performed with blood lymphocytes and fibroblasts from four
skin biopsies.
Cell culture and transfection,
immunoblotting, and glycosylation
Hep3B2.1-7 cells, which do not express LIFR, were
obtained from and cultured as recommended by American Type Culture Center (Manassas, VA). Cells were
transfected with 1.5 lg DNA per well using LipofectamineTM 2000 (Invitrogen, Carlsbad, CA) and transfection
efficiency was assessed by GFP expression. Immunoblotting of cell lysates was carried out using antibodies against
STAT3, tyrosine-phosphorylated STAT3 (Tyr705) (Cell
Signaling Technology, Danvers, MA) and LIFR (C-19;
Santa Cruz Biotechnology Inc, Santa Cruz, CA). Speciesspecific secondary antibodies conjugated to horseradish
peroxidase (Pierce, Rockford, IL) were used to visualize
bands with chemiluminescence.
Ethics
The research was performed according to the guidelines
of the Declaration of Helsinki. All participating subjects
provided informed consent.
Results
Clinical observations
Term delivery was uneventful (birth weight 2300 g). From
birth she had severe difficulties swallowing and feeding,
Table 1. Name, target, source, and dilution of primary antibodies.
Antigen (abbreviation)
Target
Manufacturer
Dilution
Rabbit protein gene product 9.5 (rPGP)
Mouse protein gene product 9.5 (mPGP)
Rabbit vasoactive intestinal peptide (rVIP)
Mouse vasoactive intestinal peptide (mVIP)
Mouse collagen IV (mCOLIV)
Mouse myelin basic protein (mMBP)
Rabbit dopamine beta hydroxylase (rDbH)
Pan-neuronal marker
Pan-neuronal marker
Cholinergic nerve fibers
Cholinergic nerve fibers
Basement membrane and vessels
Myelinated nerve fibers
Noradrenergic nerve fibers
Biogenesis (Poole, UK)
AbD Serotec (Kidlington, UK)
Immunostar (Hudson WI, US)
Santa Cruz Biotechnology (Heidelberg, Germany)
Chemicon (Billerica, MA, USA)
Santa Cruz Biotechnology (Heidelberg, Germany)
Chemicon (Billerica, MA, USA)
1:400
1:800
1:1000
1:300
1:800
1:800
1:1000
ª 2014 The Authors. Annals of Clinical and Translational Neurology published by Wiley Periodicals, Inc on behalf of American Neurological Association.
927
€ ve-Wiedemann Syndrome With Isochromosome 5
Stu
which caused developmental and growth delay. During
the first 2 years she suffered bouts of respiratory distress,
pneumonia, and unexplained high fevers. She was noted
to sweat very little in hot weather since age four, and still
becomes easily overheated. Paradoxically, she sweats profusely on the face, arms, and upper trunk when exposed
to cold temperatures or when stressed. At 18 months, she
underwent talipes equino-varus correction and Achilles
tendon lengthening. At 12 years, a severe and rapidly progressive thoracolumbar scoliosis was treated with spinal
instrumentation. Despite early surgical intervention, she
developed a moderate spastic paraparesis, diagnosed as
spondylogenic cervical myelopathy.
Cognitive function and intellect were normal. She displayed typical dysmorphic features: narrow face, high
arched palate, mild lower facial weakness and horizontal
smile, low set ears, short stature, cubitus valgus and flexion contractures at the elbows, small hands with clinodactyly, thoracolumbar scoliosis and lumbar lordosis, a
deformed left foot and misshaped toes. A plantar trophic
ulcer required repeat debridement. At age 24, a mild axonal sensory-motor neuropathy was confirmed by electrophysiological studies. She remains ambulatory and leads a
fairly normal life. Paradoxical sweating is adequately controlled with oral clonidine 0.1 mg twice daily and amitriptyline 10 mg once daily. She is now married and
pregnant.
Investigations
Blood work was normal including hematologic parameters; blood sugar; liver, renal, and thyroid function;
plasma-luteinizing and follicular-stimulating hormone,
testosterone; resting plasma adrenaline, noradrenaline,
dopamine, renin, and vasopressin. A skeletal survey was
normal, aside from congenitally contracted elbow and
ankle joints, and a severe rotatory thoracolumbar scoliosis. There was no bowing of long bones, nor internal cortical thickening, osteopenia, or signs of previous fractures
(Fig. 1A and B). Although she had no sensory complaints,
QST indicated distal sensory impairment for touch,
warm, cold, noxious heat and cold pain, and mechanical
pain evoked by pinprick. Electrophysiological studies were
consistent with a length-dependent axonal neuropathy.
M. A. B. Melone et al.
demonstrated in areas of hyperhidrosis (forearm) a pattern of pilocarpine-induced sweating that was similar to
that induced by cold ambient temperatures with regard
to sweat gland density and sweat volume (Fig. 1C). In
areas of anhidrosis (leg) few sweat glands became activated by pilocarpine and with low sweat output
(Fig. 1D). SSRs were of low amplitude on recording from
the palm and were not recordable from the sole (data
not shown).
Morphology of autonomic and sensory
innervation of skin
Immunohistochemical studies of skin biopsies from
hyperhidrotic and anhidrotic regions revealed an unusual
pattern of autonomic and somatic cutaneous innervation
(Fig. 1E–P). Areas of hyperhidrosis (upper arm) showed
preserved epidermal and dermal innervation including
sudomotor nerves, yet there was an abnormal expression
of noradrenergic (DbH-ir) sudomotor fibers in place of
the normal rich cholinergic (VIP-ir) innervation
(Fig. 1G, K, and O). Biopsies from anhidrotic hairy and
glabrous skin (the leg and fingertip, respectively)
revealed severe cutaneous denervation with loss of sensory receptors and unmyelinated and myelinated somatic
nerve fibers (Fig. 1H compared to G, and E compared
to F, respectively and indicated by arrows), and with
abnormalities of the surviving nerves, in particular the
shortening of internodal lengths (Fig. 1I compared to J).
In the anhidrotic hairy skin of the leg there was also
evidence of autonomic denervation involving all skin
adnexa – sweat glands (Fig. 1L compared to K), arteriovenous anastomoses (Fig. 1M compared to N), and piloerector muscles (Fig. 1P compared to O) – with a
complete absence of cholinergic (VIP-ir) nerves (Fig. 1L,
M, and P) and with few residual noradrenergic (DbHir) fibers (Fig. 1L and P). Together, the findings indicate
a severe, possibly developmental derangement of somatic
and autonomic innervation, with the most striking feature being the persistence of noradrenergic sudomotor
fibers in the hyperhidrotic skin (indicated by arrows in
Fig. 1K), which suggests a failed switch in noradrenergic
to cholinergic phenotype. Developmental derangement
may also have affected cutaneous nerve survival in most
of the lower body.
Autonomic assessment
Autonomic assessment demonstrated selective impairment
of sudomotor function. TST revealed no sweat responses
on raising her core temperature 1°C. In contrast, she
sweated profusely on her face, neck, shoulders, arms, and
upper trunk with ambient temperatures of 22°C or less,
while fingers and the lower body remained dry. DST
928
Genetic testing revealed complete maternal
isodisomy for chromosome 5 and a novel LIFR
variant
The patient’s karyotype was 46,XX. DNA sequencing
identified homozygosity for a novel missense variant
c.2170C>G in LIFR (Fig. S1) on 5p13 (NM_002310.5),
ª 2014 The Authors. Annals of Clinical and Translational Neurology published by Wiley Periodicals, Inc on behalf of American Neurological Association.
M. A. B. Melone et al.
€ ve-Wiedemann Syndrome With Isochromosome 5
Stu
Figure 1. Radiographs, taken at age 32 years, of both the tibia and fibula (A) and of the femurs (B) show neither bowing, nor cortical
thickening, or osteopenia. Evaluation of sweating by dynamic sweat test (DST) was carried out on the forearm (hyperhidrotic area, C) and the
lower leg (anhidrotic area, D). The sweat imprints of the forearm illustrate a high density of sweat glands (123/cm2; 5% cut-off 100/cm2) with
high sweat output (7.6 nL/min per gland; 5% cut-off 5.4 nL/min per gland) (C), while in the anhidrotic skin of the leg few sweat glands (15/cm2;
5% cut-off 64/cm2) became activated by pilocarpine and with low sweat output (3.0 nL/min per gland; 5% cut-off 5.6 nL/min per gland) (D). The
cutaneous innervation of hairy and glabrous skin is illustrated in triple–immunostained confocal images (E–P). The skin biopsy from the upper arm
(hyperhidrotic area; G, K, and O) shows a relatively preserved epidermal innervation (G, arrows) (19.0 ENF/mm; 5% cut-off 20.2 ENF/mm), but an
abnormal expression of noradrenergic (DbH-ir) sudomotor fibers (K, highlighted by arrows) in place of the usually rich cholinergic (VIP-ir)
innervation of sweat glands (note the complete absence of VIP staining); piloerector muscles present a normal noradrenergic innervation (O,
arrows) but lack cholinergic fibers (absence of VIP staining). In the anhidrotic skin from the leg (H, L, and P) there is a severe epidermal (6.3 ENF/
mm; 5% cut-off 12.7 ENF/mm) and dermal denervation (H, indicated by arrows) with lack of the normal cholinergic nerves and show only few
scattered noradrenergic fibers around sweat glands (L, arrows) and along piloerector muscles (P, arrows). In the glabrous skin from the fingertip
(E, I, M, control F, J, N), Meissner corpuscles are almost absent (E, arrows) (2.7 MC/mm2, 5% cut-off 21.2 MC/mm2) and there is a severe
epidermal and dermal denervation, with the subepidermal neural plexus being completely deranged (compare E to F). The few myelinated fibers
present in the patient’s dermis have shortened internodes (58.1 16.5 lm vs. 79.1 13.8 lm) and are thinner than normal (compare I to J).
There is a complete loss of cholinergic (VIP-ir) fibers in arteriovenous anastomoses (compare M to N). PGP, protein gene product 9.5; MBP, myelin
basic protein; DbH, dopamine beta hydroxylase; VIP, vasoactive intestinal peptide; NF, pan-neurofascin; COLIV, collagen IV; ULEX, endothelium
binding agglutinin; ENF, epidermal nerve fiber. Scale bar = 100 lm in E–H, K–N; 50 lm in I, J, O, P.
predicted to result in altered protein p.Pro724Ala.
Genome-wide SNP arrays, including parental samples,
revealed a complete maternal isodisomy for chromosome
5 with one crossing-over (Fig. 2). Mother carried the
Pro724Ala variant in heterozygosity. No trace of paternal
chromosome 5 was found in blood or cultured fibroblasts
derived from four skin biopsies. Whole-exome sequencing confirmed the subject’s isozygosity for the LIFR
variant and ten rare variants (Table S1). DNA analysis
revealed no sequence variants in CRLF1, CLCF1, IL6ST
(encoding gp130), OSMR (encoding oncostatin M receptor), and FAM134B.
ª 2014 The Authors. Annals of Clinical and Translational Neurology published by Wiley Periodicals, Inc on behalf of American Neurological Association.
929
€ ve-Wiedemann Syndrome With Isochromosome 5
Stu
M. A. B. Melone et al.
Figure 2. This figure illustrates uniparental isodisomy (UPD)
chromosome 5. The patient (black symbol) is shown to have two
completely identical chromosomes 5 from the mother by Affymetrix
Genome-Wide Human single-nucleotide polymorphism (SNP) array
6.0. The three siblings have the same SNPs at the start of the
chromosome. The SNP where the crossing-over occurred is given on
the far right. The patient has only one crossing-over. The leukemia
inhibitory factor receptor (LIFR) mutation (c.2170C>G; p.Pro724Ala) is
indicated. The paternal contribution to the two siblings is omitted.
The LIFR p.Pro724Ala mutation alters LIFR
function and glycosylation
Transfection of wild-type (WT) LIFR into Hep3B cells
generated LIFR protein of three different molecular
weights, while cells transfected with the Pro724Ala mutant
(LIFRP724A) contained only the smaller two forms of LIFR
(Fig. 3A, asterisks). Glycosidase treatment with PNGaseF
caused a downward shift in the higher molecular weight
forms of both the WT and LIFR mutant to similar sizes
(Fig. 3B), demonstrating that receptor glycosylation was
altered in the Pro724Ala mutant. To determine if the
mutant altered LIFR function, cells were treated with leukemia inhibitory factor (LIF) to stimulate downstream
STAT3 phosphorylation. LIF stimulated robust STAT3
phosphorylation in WT LIFR-transfected cells (Fig. 3C),
but little STAT3 phosphorylation in LIFRP724A transfected
cells. The presence of STAT3 (Fig. 3C) and LIFR
(Fig. 3D) protein was confirmed by western blot.
Discussion
STWS was diagnosed in a 33-year-old female, isozygous
for a LIFR mutation (c.2170C>G, p.Pro724Ala) and the
entire chromosome 5. DNA analysis ruled out mutations
in CRLF1 and CLCF1, which can yield a similar neonatal
phenotype associated with high mortality in infancy or
early childhood.3,13 Few STWS patients survive to adoles-
930
Figure 3. Leukemia inhibitory factor receptor (LIFR) P724A mutant
has altered glycosylation and impaired signaling. LIFR-negative Hep3B
cells were transfected in duplicate with pcDNA3 (Vector, lanes 1–2),
wild-type LIFR (wild-type, lanes 3–4), or the LIFR mutant (P724A, lanes
5–6), and blotted for LIFR. Molecular weight standards are marked on
the left (kD). (A) Asterisks denote LIFR bands. The P724A mutant
lacks the highest molecular weight band. (B) Cell lysates were
combined with 5% SDS, 0.4 M DTT and denatured at 100°C for
10 min prior to incubation with 0.5 M sodium phosphate, pH 7.5,
1% NP40, and with (+) or without ( ) PNGaseF (Peptide -NGlycosidase F) for 1 hr at 37°C to remove glycosylation, and blotted
for LIFR. Wild-type and P724A-transfected cells had LIFR of similar size
after PNGaseF treatment, suggesting altered glycosylation of P724Amutant receptor. (C) Transfected cells were treated with LIF to
stimulate downstream signaling through LIFR-gp130 complex. Cells
expressing wild-type LIFR exhibited strong STAT3 phosphorylation
(Y705), but cells expressing vector alone or the P724A mutant did
not. Total STAT3 (STAT3) was readily detectable in all cells. (D) LIFR
protein was abundant in P724A transfected cells, despite the lack of
STAT3 phosphorylation. All blots are representative of at least three
independent experiments.
cence and none has been reported pregnant.3,14 Thus, our
patient is exceptional.
She presented most neonatal STWS characteristics, yet
lacked the congenital dysplasia of long bones, considered
a hallmark of STWS.1,3 Radiographs, taken in adulthood,
ª 2014 The Authors. Annals of Clinical and Translational Neurology published by Wiley Periodicals, Inc on behalf of American Neurological Association.
M. A. B. Melone et al.
were normal, aside from congenital contractures at the
elbows and ankles and a severe, partially corrected thoracolumbar scoliosis. Spinal deformities are reported in
STWS long-term survivors and are invariably seen in
juvenile CISS patients.14,15 The two conditions also exhibit cold-induced hyperhidrosis on the face and upper
body, and heat-induced hypohidrosis restricted to the
lower body.2,3 Paradoxical sweating and heat intolerance
was observed starting at age four. The early symptom
onset would be most consistent with a developmental
anomaly of autonomic sudomotor function, a postulate
supported by abnormal sweat gland innervation. Biopsies
from areas of cold-induced hyperhidrosis showed relatively preserved epidermal and dermal sensory innervation, yet sweat glands lacked the normally rich cholinergic
innervation8 and retained instead an ample supply of noradrenergic sympathetic fibers. This was also true for other
sympathetically innervated dermal adnexa – arteriovenous
anastomoses and piloerector muscles. Similar findings had
been documented in a CISS patient with compound heterozygocity of two CRLF1 mutations.16 These observations provide the first human evidence of a failed switch
of adrenergic to cholinergic sympathetic innervation of
sweat glands, causing paradoxical sweating. The LIFR
mutant does not stimulate STAT3 phosphorylation.
Impaired signaling through the CNTF/LIFR/gp130 tripartite complex accounts for the absence of cholinergic differentiation in sympathetic neurons innervating sweat
glands.17,18
Skin biopsies from the leg showed a length-dependent
dermal sensory and autonomic denervation. In the
anhidrotic skin of the leg, few residual sweat glands were
surrounded by scattered noradrenergic nerve fibers and
ENF counts were reduced. Moreover, biopsies of
glabrous skin from the fingertip, revealed denervation of
the epidermis and dermis, including loss of MC’s and
their afferent myelinated fibers. These morphological
findings correlate with the reduced tactile and nociceptive perception detected on QST. Abnormal sensation
has not yet been documented in STWS and our patient
had not voiced sensory complaints. A few clinical reports
hinted at possible insensitivity to pain in CISS and
STWS, as some children show little pain with recurring
fractures.13,19 These observations require future study.
Given the complete chromosome 5 isodisomy, we considered and excluded, among others, the association of
STWS and recessive sensory and autonomic neuropathy
type 2 (HSAN II).20
The absence of long bone dysplasia remains
unexplained, but may relate to the mutation.21 The LIFR
variant (c.2170C>G; p.Pro724Ala) is located to the first
amino acid in the third fibronectin III motif, the proline
being conserved throughout evolution. Our in vitro
€ ve-Wiedemann Syndrome With Isochromosome 5
Stu
studies clearly indicate that the LIFR mutation alters the
gene product and disturbs LIFR function. Thus, there is
little doubt that the mutation is deleterious, causing
STWS. Genome-wide SNP arrays revealed complete
maternal isodisomy for chromosome 5. Cytogenetic studies yielded no paternal chromosome 5 material in blood
cells or fibroblasts; cells were exclusively maternal. Thus,
we conclude that the patient was the product of a paternal nullisomic rescue or, less likely, of an initial trisomy
with subsequent loss of the paternal contribution.22 This
case exemplifies uniparental isodisomy as a possible, albeit
rare, cause of autosomal recessive disorders.
Acknowledgments
The authors gratefully acknowledge the contribution of
the following participating investigators: Francesca Califano, M.D. and Carla Schettino, M.D. who provided and
cared for the study patient; Vincenzo Provitera, M.D. and
Giuseppe Caporaso BS who participated in the autonomic
testing and the morphological studies. Sigrid Erdal, Trude
Høysæter, and Jorunn S. Bringsli provided expert technical assistance. Cell transfection experiments and functional studies of the LIFR mutant were supported by the
National Institutes of Health grant HL068231 to Professor
Beth Habecker, Ph.D.
Author Contributions
All authors contributed equally to the conception and
execution of the various aspects of the work and to the
study as a whole. They collectively vouch for the accuracy and integrity of the data. Dr. H. Boman assumed
the leadership role in coordinating the contributions
from three areas of expertise: Drs. M. A. B. Melone,
M. Nolano, and A. F. Hahn were involved in the
acquisition and interpretation of the clinical and neuropathological data. Drs. H. Boman, S. Johansson, and P.
M. Knappskog directed the acquisition, analysis, and
interpretation of the genetic data. Drs. M. J. Pellegrino,
B. A. Habecker, and N. M. Nathanson carried out the
cell transfection and functional studies. Drs. M. A. B.
Melone, A. F. Hahn, H. Boman, M. Nolano, and N.
M. Nathanson drafted the manuscript, which was circulated, amended, and approved by all authors.
Conflict of Interest
None declared.
References
1. Dagoneau N, Scheffer D, Huber C, et al. Null leukemia
inhibitory factor receptor (LIFR) mutations in
ª 2014 The Authors. Annals of Clinical and Translational Neurology published by Wiley Periodicals, Inc on behalf of American Neurological Association.
931
€ ve-Wiedemann Syndrome With Isochromosome 5
Stu
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
932
St€
uve-Wiedemann/Schwartz-Jampel type 2 syndrome. Am
J Hum Genet 2004;74:298–305.
Hahn AF, Jones DL, Knappskog PM, et al. Cold-induced
sweating syndrome. A report of two cases and
demonstration of genetic heterogeneity. J Neurol Sci
2006;250:62–70.
Akawi NA, Ali BR, Al-Gazali L. St€
uve-Wiedemann
syndrome and related bent bone dysplasias. Clin Genet
2012;82:12–21.
Numata S, Hamada T, Teye K, et al. Complete maternal
isodisomy of chromosome 5 in a Japanese patient
with Netherton syndrome. J Invest Dermatol
2014;134:840–852.
Shahani BT, Halperin JJ, Boulu P, Cohen J. Sympathetic
skin response- a method of assessing unmyelinated axon
dysfunction in peripheral neuropathies. J Neurol
Neurosurg Psychiatry 1984;47:536–542.
Fealey RD, Low PA, Thomas JE. Thermoregulatory
sweating abnormalities in diabetes mellitus. Mayo Clin
Proc 1989;64:617–628.
Provitera V, Nolano M, Caporaso BS, et al. Evaluation of
sudomotor function in diabetes using the dynamic sweat
test. Neurology 2010;74:50–56.
Nolano M, Provitera V, Perretti A, et al. Ross syndrome: a
rare or misknown disorder of thermoregulation? A skin
innervation study on 12 subjects. Brain 2006;129:2119–
2131.
Nolano M, Provitera V, Crisci C, et al. Quantification of
myelinated endings and mechanoreceptors in human
digital skin. Ann Neurol 2003;54:197–205.
Purcell S, Neale B, Todd-Brown K, et al. PLINK: a tool set
for whole-genome association and population-based
linkage analysis. Am J Hum Genet 2007;81:559–575.
Haugarvoll K, Johansson S, Tzoulis C, et al. MRI
characterization of adult onset alpha-methylacyl-coA
racemase deficiency diagnosed by exome sequencing.
Orphanet J Rare Dis 2013;8:1–11.
Li H, Durbin R. Fast and accurate short read alignment
with Burrow-Wheeler transform. Bioinformatics
2009;25:1754–1760.
Crisponi G. Autosomal recessive disorder with muscle
contractions resembling neonatal tetanus,
characteristic face, camptodactyly, hyperthermia, and
sudden death: a new syndrome. Am J Med Genet
1996;62:365–371.
M. A. B. Melone et al.
14. Jung C, Dagoneau N, Baujat G, et al. St€
uve-Wiedemann
syndrome: long-term follow-up and genetic heterogeneity.
Clin Genet 2010;77:266–272.
15. Knappskog PM, Majewski J, Livneh A, et al. Cold-induced
sweating syndrome is caused by mutations in the CRLF1
gene. Am J Hum Genet 2003;72:375–383.
16. Di Leo R, Nolano M, Boman H, et al. Central and
peripheral autonomic failure in cold-induced sweating
syndrome type 1. Neurology 2010;75:1567–1569.
17. Stanke M, Duong CV, Pape M, et al. Target-dependent
specification of the neurotransmitter phenotype:
cholinergic differentiation of sympathetic neurons is
mediated in vivo by gp130 signaling. Development
2006;133:141–150.
18. Rousseau F, Gauchat J-F, McLeod JG, et al. Inactivation of
cardiotrophin-like cytokine, a second ligand for CNTF
receptor, leads to cold induced sweating syndrome in a
patient. PNAS 2006;103:10068–10073.
19. Yesßil G, Lebre AS, Santos SD, et al. St€
uve-Wiedemann
syndrome: is it underrecognized? Am J Med Genet A
2014;164:2200–2205.
20. Kurth I, Pamminger T, Hennings JC, et al. Mutations in
FAM134B, encoding a newly identified Golgi protein,
cause severe sensory and autonomic neuropathy. Nat
Genet 2009;41:1179–1181.
21. Sims NA, Johnson RW. Leukemia inhibitory factor: a
paracrine mediator of bone metabolism. Growth Factors
2012;30:76–87.
22. Robinson WP. Mechanisms leading to uniparental disomy
and their clinical consequences. Bioessays 2000;22:452–459.
Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Figure S1. DNA sequences of the region containing the
LIFR c.2170C>G variant are illustrated. The father is normal (p.Pro724, CCC), whereas his daughter (patient) is
homozygous (p.Pro724Ala, GCC) and the mother is heterozygous for the mutation.
Table S1. The table lists all unusual genetic findings on
the patient´s chromosome 5. The list shows the ten variants with a frequency of less than 0.01 in the 1000Genomes database, plus the LIFR variant.
ª 2014 The Authors. Annals of Clinical and Translational Neurology published by Wiley Periodicals, Inc on behalf of American Neurological Association.