Case report Alagille syndrome Alagille syndrome is a highly variable, autosomal dominant multisystem disease • •Alagille syndrome 1, ALGS1 (MIM # 118450), which is caused by a mutation in the JAG1 gene on chromosome 20p12, with an incidence of 1:30,000 live births, 98% of patients with ALGS • •Alagille syndrome 2, ALGS2 (MIM # 610205), which is associated with a mutation in the NOTCH2 gene on chromosome 1p12 and represents a rarer form of disability (1: 70,000 live births), 1-2% of patients with ALGS The basic symptom of the syndrome is a reduction of intrahepatic bile ducts in combination with 5 diagnostic features: •Cholestasis (jaundice with conjugated hyperbilirubinemia, ↑ GGT, ↑ Chol, ↑ TGL, 10-20% of patients with rapid progression of liver disease) • •Congenital heart disease (most often peripheral pulmonary stenosis, Fallot's tetralogy, pulmonary atresia, atrial or ventricular septal defect) • •Skeletal abnormalities (most often butterfly vertebrae, vertebral fusion, spina bifida occulta, hemivertebra, 12th rib anomalies) • •Eye disorders (most often posterior embryotoxon - prominence of the Schwalbe´s ring at the interface of the iris and cornea) • •Characteristic appearance of a triangular face with a wide forehead, deep set eyes, hypertelorism, lower set ears and a longer onion-shaped nose •3 of these 5 major characters must be present to confirm the diagnosis • patient with ALGS, typical face D:\Dokumenty\ala3.JPG D:\Dokumenty\ala2.JPG • posterior embryotoxon • •butterfly vertebrae • •bile duct paucity • • • • • • • • •butterfly vertebrae •About 39% of patients suffer from kidney problems, most often renal dysplasia • •Growth retardation • •Pancreatic insufficiency (40%) • •Hypothyroidism • •Recurrent infections • •Mental retardation and learning disabilities usually in patients with deletion 20p12 • •Alagille syndrome is a genetically heterogeneous disorder • • • •We present phenotype of 4 probands with ALGS1, whose involvement was confirmed by molecular genetic examination • • • • •Method: next generation sequencing technique (MiSeq, Illumina) followed by direct sequencing of PCR products on a genetic analyzer. At the genomic DNA level, the coding region of the JAG1 gene, including exon / intron boundaries, was sequenced. The obtained sequences were compared with the reference sequences of the JAG1 gene NG_007496.1 and NM_000214.2. The analysis of the found variants was performed on the basis of the reference database (http://www.ncbi.nlm.nih.gov/projects/SNP). Phenotype of patients with ALGS1 Table 1 Clinical features present in carriers of JAG1 mutations Pacient Diagnosis Peculiar face Cholestasis Liver biopsy Heart disease Ocular Skeletal Renal Others Age anomalies anomalies anomalies 1 16 month yes yes intrahepatic bile duct peripheral pulmonary no butterfly no learning disability paucity artery stenosis vertebrae 2 6 years yes yes intrahepatic bile duct peripheral pulmonary no no no paucity artery stenosis 3 7month yes yes intrahepatic bile duct peripheral pulmonary no no ren behavioral disorders paucity artery stenosis arcuatus 4 3 month yes yes intrahepatic bile duct peripheral pulmonary embryotoxon rib cystic hypothyroidism paucity artery stenosis posterior anomalies disease growth retardation Results of molecular genetic testing of the JAG1 gene Table 2 Mutations in JAG1 found in patients with Alagille syndrome Pacient identified sequence variants Mutation Exon cDNA Protein Mutation origin type 1 gene JAG1 (NM_000214.2):c.3189dupG in heterozygous state not 25 c.3189dupG p.Asn1064Glufs*45 frameshift novel mutation, duplication investigated 2 gene JAG1(NM_000214.2): c.2039delG in heterozygous state mother 16 c.2039delG p.Gly680Alafs*63 frameshift novel mutation, deletion 3 gene JAG1 (NM_000214.2):c.1913delG in heterozygous state father 15 c.1913delG p.Cys638Leufs*105 frameshift novel mutation, deletion 4 gene JAG1 (NM_000214.2):c.2230C>T p.(Arg744Ter) in heterozygous state de novo 18 c.2230C>T p.Arg744Ter nonsense substitution the c. nomenclature is based on the cDNA sequence NM_000214.2 Family screening • •The mother of proband No. 2 was monitored at the Department of Gastroenterology for unexplained hepatitis • •Molecular - genetic examination also confirmed ALGS1 • •Cardiac examination revealed aortic valve insufficiency • •Another sibling - molecular-genetically ALGS1 excluded • •Importance: diagnosis and genetic counseling in the family •The care of these patients is multidisciplinary • •It includes a pediatrician, hepatologist, cardiologist, ophthalmologist, nephrologist, endocrinologist, nutritional therapist, radiologist, geneticist and, in some cases, a transplant team. • •Molecular-genetic examination x classical scoring system • •Genetic testing in unclear cases