The Woodhouse–Sakati Syndrome (WSS; OMIM: #241080) is a rare multisystem autosomal recessive disorder that was first described by Woodhouse and Sakati (1983). Since that time more than 58 patients from 26 families have been reported to have WSS. Most of the reported families are from the Middle Eastern countries, India, and Pakistan, although Caucasian patients have been described rarely (Schneider and Bhatia, 2008).
Hypogonadism, with low estradiol or testosterone levels, and alopecia are the hallmarks of the syndrome (Woodhouse and Sakati, 1983). Other systemic manifestations such as deafness, diabetes mellitus, and mild-to-severe mental retardation are present in most Arab patients (Al-Semari and Bohlega, 2007). The molecular pathology of the syndrome was found to be due to mutations in the DCAF17 (C2orf37) gene, a previously unknown gene that encodes a poorly characterized nucleolar protein (Alazami et al., 2008). Alazami et al. (2010) reported that ‘A founder mutation, confirmed by haplotype analysis, was present in all affected individuals from eight unrelated Saudi families, while other ethnicities exhibited their own private mutations’.
In this study, we report on an additional six Kuwaiti families with 17 affected individuals of different age groups. Some of these affected individuals present the full picture of the syndrome, which was first reported by Woodhouse and Sakati (1983) and confirmed by others (Al-Semari and Bohlega, 2007; Koshy et al., 2008; Ben-Omran et al., 2011).
Patients and methods
The study included 17 patients (seven male patients and 10 female patients) from six consanguineous Kuwaiti families. They were referred to the Kuwait Medical Genetic Centre for a combination of hypogonadism, alopecia, and mental subnormalities. All patients were subjected to thorough clinical examination.
Blood was collected from all probands for biochemical and molecular genetic investigations. Parents of the probands with positive molecular testing were tested to confirm their carrier state.
All guardians provided written informed consent and the study was approved by the Kuwait Medical Genetic Ethical Committee in accordance with the Declaration of Helsinki.
Mutation analysis of the DCAF17 (C2orf37) gene was carried out as follow:
Polymerase chain reaction and direct sequencing of the DCAF17 (C2orf37) gene
DNA was extracted from peripheral venous blood samples using the Maxwell 16 blood DNA purification kit and the Maxwell 16 instrument (Promega Corp., Madison, Wisconsin, USA). PCR and direct sequencing of all coding exons and flanking exon/intron boundaries of the DCAF17 (C2orf37) gene were performed using the Big Dye Terminator Cycle sequencing kit v3.1 and the AB1 3130 genetic analyzer (Applied Biosystems, Grand Island, New York, USA). PCR primer sequences of the DCAF17 (C2orf37) gene were kindly supplied by Dr Fowzan S. AlKuraya (Alazami et al., 2008).
Screening for c.436 delC; p.Ala147HisfsX9 in exon 4 using the amplification refractory mutation system technique
To screen for the common Arab mutation c.436 delC, we designed an amplification refractory mutation system primer to amplify either the wild type or mutant exon 4 of the DCAF17 gene. Two uniplex PCR reactions were set for each DNA sample using a common primer and either a wild or mutant primer. PCR amplification products were resolved on a 2% agarose gel in 1× TBE buffer alongside a 100 bp DNA ladder. Normal controls will only show amplifications with the wild type primer. Homozygous mutant samples will only show amplifications with mutant primers, whereas heterozygous samples will show amplifications with both wild type and mutant primers. The primer sequence and PCR conditions are available from the author upon request. All samples with negative screening results were subjected to direct sequencing of all DCAF17 gene coding exons and exon/intron boundaries as above.
Summary of clinical and laboratory findings in patients with WSS is shown in Tables 1–3. Table 4 shows a comparison of the descriptive statistics in clinical characteristic between our cases and previous reported cases.
The apparently healthy mother and father are far relatives from the same tribe. They have eight children (six female and two male); four (three female and one male) of them were affected (Fig. 1; pedigree no. 1).
The proband was a girl referred to us at the age of 12 years because of difficulties at school. On examination, she had loss of scalp hair and absence of secondary sexual characteristics. Investigation of other family members revealed two affected sisters and one affected brother. All affected individuals had similar facial features, hypogonadism, delayed onset of secondary sexual characteristics, and alopecia. Further, they had neurological problems in the form of dystonia, dysarthria and fasciculation of the tongue. These neurological problems were acquired above the age of 12 years. A summary of main clinical features and laboratory investigations is provided in Table 1.
The proband, an affected boy, was referred to us at the age of 15 years for poor performance at school. Parents are first cousins with six sibs: four female and two male. On examination, he had scanty hair in the temporal region, scanty eyebrows and frontal bossing. Investigation of other family members revealed two affected sisters (Fig. 1; pedigree no. 2).
Seven years later, the proband’s sister was referred to us, at the age of 16 years, for primary amenorrhea. On examination, she had alopecia, scanty pubic and axillary hair, scanty eyebrows, and undeveloped secondary sexual characteristics.
The third affected member was a 13-year-old girl with a history of excessive hair loss and mental subnormality. A summary of the main clinical features and laboratory investigations is provided in Table 1.
The proband, an affected girl, was referred to us at the age of 15 years because of delayed menarche. The parents are first cousins with eight sibs: four female and four male. She had some facial dysmorphism with scanty scalp hair, scanty eyebrows, and underdevelopment of the secondary sexual characteristics. Chromosomal study revealed a normal female karyotype. She did not attend the clinic after her initial visit. She was referred to us for the second time at the age of 31 years with alopecia, diabetes mellitus, and dystonia with primary amenorrhea. Parents reported that they had another affected daughter and an affected son (Fig. 1; pedigree no. 3). A summary of the clinical and laboratory investigations is shown in Table 1.
The proband was referred to our Genetics Center at the age of 16 years for primary amenorrhea. The parents are second cousins with four sibs (three male and one female), among whom one male and one female were affected (Fig. 1; pedigree no. 4). On examination, the proband had scanty scalp hair, sparse eyebrows and eyelashes, and no secondary sexual characteristics. Her older affected brother showed the same clinical picture and dysmorphic features in addition to the extrapyramidal manifestations. A summary of the clinical and laboratory investigations is shown in Table 1.
The proband was referred to us at the age of nine years because she was a slow learner. At the age of 13 years, she was referred to our center for the second time because of absent menarche. The parents are second cousins with seven sibs: five female and two male (Fig. 1; pedigree no. 5). On examination, the proband had dry brittle hair and sparse eyebrows. Other sibs are apparently normal. Clinical and laboratory investigations are summarized in Table 1.
The proband was referred to us at the age of 12 years with a case of mild mental retardation. The parents are from the same tribe with 10 sibs: five female and five male. On examination, he had scanty scalp hair and sparse eyebrows and eyelashes. Examination of other family members revealed two similarly affected sisters and one affected brother (Fig. 1; pedigree no. 6). Clinical and laboratory investigations are summarized in Table 1.
Molecular genetic analysis of the DCAF17 gene
In families 1–5, all clinically affected members were homozygous for the common Arab mutation c.436 delC; p.Ala147HisfsX9 in exon 4 of the DCAF17 gene. Parents of the probands were heterozygous for the same mutation. No mutation could be detected in the affected members from family 6.
We report on 17 patients from six consanguineous Kuwaiti families with WSS. These patients had symptoms compatible with features described in the first original paper by Woodhouse and Sakati (1983) and the literature review by Schneider and Bhatia (2008). Phenotypic variability within families was present in some of our families as the extrapyramidal symptoms were obvious in some of the older patients but were not manifested in the younger patients as these symptoms did not appear until adulthood (Alazami et al., 2010).
Alopecia totalis or partial alopecia, which was a hallmark feature of WSS, present in all patients in the study by Schneider and Bhatia (2008), was reported in all our study patients (100%). There was intrafamilial variability as some of the patients showed alopecia totalis and others showed frontal alopecia or only partial alopecia. Such intrafamilial and interfamilial variabilities were reported by different investigators (Al-Semari and Bohlega, 2007; Koshy et al., 2008; Alazami et al., 2010; Ben-Omran et al., 2011).
Hypogonadism in the form of amenorrhea, high follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels with an infantile uterus, and absence of secondary sexual characteristics was evident in all evaluated female patients. In all studied male patients, there was an absence of secondary sexual characteristics with cryptorchidism. Abnormal hormonal levels in the form of low testosterone levels were observed in only three of seven (43%) of our male patients. Levels of LH and FSH were variable, low, normal, and high. This may be explained by the fact that some of our male patients had started hormone replacement therapy and their basic hormonal levels were not available. Habib et al. (2011) reported lower testosterone, FSH, and LH levels in two of three male patients with WSS. Hypogonadism is well known by all investigators as a cardinal feature of the syndrome (Woodhouse and Sakati, 1983; Devriendt et al., 1996; Al-Semari and Bohlega, 2007; Ben-Omran et al., 2011).
Deafness, one of the main criteria of the syndrome, first reported by Woodhouse and Sakati (1983), was observed in only 5/17 (31%) patients and diabetes mellitus was reported in 13/17 (76%) patients in our study. Extrapyramidal disorder in the form of dystonia was observed in 8/17 (47%) patients. This may be because certain clinical presentations of WSS do not appear until a later age. Ben-Omran et al. (2011) did not report diabetes mellitus in any of his study patients. However, he reported deafness in 4/7 (57%) patients. Schneider and Bhatia (2008) found extrapyramidal manifestations in 50% of their WSS patients. Diabetes mellitus and extrapyramidal symptoms usually manifest later, during late teens or early adulthood. Interfamilial and intrafamilial variabilities in the clinical presentations were reported by many investigators, which strongly suggest a an important role of modifiers in the pathogenesis of WSS (Al-Semari and Bohlega, 2007; Alazami et al., 2008; 2010).
In our study, polyneuropathy was present in 9/17 (53%) patients. Neuropsychological evaluation revealed mild-to-severe cognitive decline in 11/16 (65%) patients; in some of the patients this was the main cause for referral. Our data are in accordance with previously reported data on WSS (Woodhouse and Sakati, 1983; Al-Semari and Bohlega, 2007; Schneider and Bhatia, 2008; Alazami et al., 2010).
In our study, we reported a homozygous single-base deletion c.436 delC; p.A147HfsX9 in exon 4 of the DCAF17 gene in all affected members from five Kuwaiti families. This mutation was previously reported in all Arab patients with WSS (Alazami et al., 2008; 2010; Ben-Omran et al., 2011; Rachmiel et al., 2011). Alazami et al. (2008), using single nucleotide polymorphism-based haplotype analysis, confirmed that this is a founder mutation that arose ∼55 generations ago. So far, few mutations have been reported in different ethnicities, all in the DCAF17 gene (Alazami et al., 2008; 2010; Habib et al., 2011). The function of this gene is still not known. Immunohistochemical analysis revealed nearly ubiquitous nucleolar expression in mouse embryos, with low levels of expression in brain, liver, and skin tissues and nearly no expression in pancreatic islet cells (Alazami et al., 2008).
Affected members (three male and one female) of family number 6 did not show mutations in any of the exons and exon–intron boundaries of the DCAF17 gene. All affected members of this family showed the common features of WSS, for example, alopecia, hypogonadism, cognitive impairment, and facial dysmorphia. One of them (28-year-old man) had diabetes mellitus and deafness. The possibility of a mutation in the upstream or downstream regulatory elements of the DCAF17 gene or in areas other than those sequenced in our laboratory could not be excluded. Moreover, there may be a possibility of locus heterogeneity. Real-time PCR to rule out deep intronic and regulatory element mutations in the DCAF17 gene and, if negative, homozygosity analysis and next-generation sequencing may solve this problem.
We report here six Kuwaiti consanguineous families with WSS. All affected members from five of these families carried a homozygous 1 bp deletion in the DCAF17 (c2orf37) gene. No DCAF17 gene mutation could be detected in the sixth family. The clinical pictures of all affected members were compared with those reported previously and showed some variability in the clinical presentation.
Conflicts of interest
There are no conflicts of interest.
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