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DOI: 10.1055/s-0043-1769494
PMM2-CDG T237M Mutation in a Patient with Cerebral Palsy-Like Phenotypes Reported from South India
Abstract
Congenital disorder of glycosylation (CDG) is an autosomal recessively inherited disorder. Hypotonia, stroke-like episodes, and peripheral neuropathy are also associated with the condition that typically develops during infancy. The patient, a 12-year-old girl born to healthy consanguineous parents, was diagnosed with cerebral palsy as a child. The affected patient has hypotonia, inadequate speech, strabismus, and developmental delay with mild mental retardation, which are key symptoms of CDG. Whole-exome sequencing (WES) identified the known missense pathogenic variant PMM2 c.710 C > T, p.T237M in the patient coding for the phosphomannomutase 2 (PMM2) confirming molecular testing of CDG. The patient's parents carried heterozygous PMM2 c.710 C > T variants. This study highlights the importance of WES in patients with a developmental disability or other neurological conditions, which is also useful in screening risk factors in couples with infertility or miscarriage issues.
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Introduction
Congenital disorder of glycosylation (CDG) type Ia (CDG-Ia) [MIM #212065] is an autosomal recessive disorder of protein N-glycosylation characterized by a phosphomannomutase (PMM) deficiency and mutations in the (PMM2) gene [MIM #601785] located on chromosome 16p13 that causes CDG (PMM2-CDG) type Ia.[1] [2] PMM2-CDG is characterized by central nervous system dysfunction and multiorgan failure.[3] PMM2 gene catalyzes the isomerization of mannose-6-phosphate to mannose-1-phosphate, which is a precursor to GDP-mannose necessary for the synthesis of dolichol-pyrophosphate-oligosaccharides in the early steps of N-glycan synthesis.[4] [5] About 130 pathological mutations have been described in the PMM2 gene according to the Human Gene Mutation Database (HGMD® professional 2021.3) affecting the oligosaccharide precursor transfer in the endoplasmic reticulum, and PMM2-CDG II affects the transfer in the Golgi apparatus.[6] [7]
Hypotonia, stroke-like episodes, and peripheral neuropathy are also associated with the condition that typically develops during infancy; young individuals with PMM2-CDG may have a moderate intellectual disability and unsteady or abnormal gait.[2] [8] The childhood mortality rate is approximately 15 to 30%, and permanent neurological disabilities develop in surviving patients.[9] This case study describes the clinical and molecular findings of a young girl from South India affected with cerebral palsy (CP) phenotypes carrying PMM2-CDG mutation.
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Clinical Report
A 12-year-old female from South India was born preterm to healthy consanguineous parents. Her birth weight was 2,500 g and presented with a delayed birth cry. Since birth, she presented generalized hypotonia. No history of neonatal jaundice or neonatal hypoxia was reported. The average tone of the muscle motor sensor, an inaccurate gait pattern, and a bilateral flexed knee was observed. No ataxia or cerebellar syndrome was observed. Since an early age, she presented inadequate speech and language, learning difficulties with mild mental retardation and dependence on several activities of daily life, psychomotor and developmental delay, and inability to walk. No history of hearing difficulties was reported. The ophthalmological analysis showed squint vision. After explaining the purposes of the study, informed consent was obtained from the parents to perform molecular diagnosis, and to publish the data on the patient. Blood samples were collected from the patient and her family members by a Phlebotomist. Genomic DNA was extracted from peripheral blood by using PureLink Genomic DNA Mini Kit (Thermo Fisher Scientific, United States) according to the manufacturer's instructions. Whole-exome sequencing (WES) was performed for the proband. The exome libraries were constructed using the Ion Ampliseq exome RDY kit (Thermo Fisher Scientific, United States) and sequenced on the Ion Proton sequencing platform (Life Technologies, United States). Variants were called using the Torrent Variant Caller plug-in using the software console of the Torrent server. Variants were annotated using Ion Reporter (Thermo Fisher Scientific, United States) using the human reference genome (hg19). Pathogenicity of candidate variants was evaluated using Genome Aggregation Database (https://gnomad.broadinstitute.org/), ClinVar (https://www.ncbi.nlm.nih.gov/clinvar/), and literature review. Sanger sequencing was performed for variant validation of the proband and the parents by amplifying the PMM2 region (rs80338708) using the primers (forward: 5′-ACAGATCTTCGCAAGAACATCGT-3′, reverse:5′- CACGTTAGGAGAACAGCAGTTCA-3′) for a total volume of 10 μL. An initial denaturation step at 95°C for 2 minutes was followed by 35 cycles of 98°C for 25 seconds, 67°C for 45 seconds for annealing, 72°C for 30 seconds for elongation, and final extension at 72°C for 7 minutes. The PCR products were evaluated using a 2% agarose gel electrophoresis. PCR products were labeled with BigDye Terminator v3.1 Cycle Sequencing Kit (Applied Biosystems, United States). The above-mentioned PCR primer (PMM2 Forward) was used as a sequencing primer and then analyzed by ABI 3500 Genetic Analyser (Applied Biosystems, United States). Sequence data were analyzed with Seqscape v3 software (Applied Biosystems, United States).
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Discussion
We describe the case of a girl with CP phenotypes who had missense variations in the PMM2 gene that was identified by WES. The patient presented strong genotypic and phenotypic features of typical PMM2-CDG type 1a ([Table 1]). WES identified the pathogenic homozygous variant [NM_000303.3] c.710C > T p.T237M (rs80338708) in the patient and also identified heterozygous variants in the parents ([Fig. 1]). She exhibited age-inadequate speech and language skills; weakness in lower limbs was also observed in the patient. Spastic diplegia was observed that impairs the legs but does not usually affect the arms; but the patient in this study has weakness in the hands because of low muscle tone. Hip problems are also common in spastic diplegic patients. The spastic type of CP is more commonly associated with ocular abnormalities.[10] Strabismus was seen in the patient that is associated with neurodevelopmental disorders such as CP, Down's syndrome, intellectual disability, and white matter damage of prematurity.[11] [12] [13]
![](https://www.thieme-connect.de/media/10.1055-s-00046370/202302/thumbnails/10-1055-s-0043-1769494-i2300020-1.jpg)
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On chromosome 16p13.2, mutations in PMM2 gene that cause CDG-Ia were identified.[1] This work is the first to report the T237M variant of the PMM2 gene in a patient with CDG-Ia phenotypes (https://www.chop.edu/conditions-diseases/congenital-disorders-glycosylation-cdg) in a South Indian girl ([Table 1]). The parents carried the heterozygous recessive variant of PMM2 c.710 C > T that was expressed as the homozygous genotype in their child (patient; [Fig. 1]). Mutations of the PMM2 gene cause PMM2 deficiency, which is the most common autosomal recessive CDG.[14] Several missense mutations associated with a recessive disease are observed in PMM2.[15] Predetermined maternal factors such as heredity, malnutrition, and metabolism may lead to physical or mental problems, or even death.[16] Premature birth and low birth weight, which are linked with numerous health problems later in life, also can be influenced by birth defects. However, factors such as adolescent pregnancy (<19 years),[17] advanced maternal age (>35 years),[18] and poor access to medical care contribute as well.[19] Also, birth defects are a contributing factor to some miscarriages and stillbirths.[20] For that reason, some factors affect the prenatal developmental stage of fetal abnormalities. In this study the mother has a history of one miscarriage after the patient was born ([Fig. 1]). PMM2-CDG is not thoroughly diagnosed, since the phenotypes are similar to CP. Therefore, clinical awareness and molecular diagnosis should be performed to screen couples with infertility or miscarriage issues[21] and they should be appropriately counseled on the potential risk before subsequent pregnancies. In conclusion, we describe the first South Indian patient with autosomal recessive CDG-Ia with PMM2 c.710 C > T, T237M mutation inherited from carrier parents in accordance with the PMM2-CDG type Ia. This study emphasizes the importance of considering WES in patients with developmental disabilities or other neurological conditions.
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Conflict of Interest
None declared.
Acknowledgments
The authors thank the Director, All India Institute of Speech and Hearing, Mysore, and also acknowledge the patient and her parents for their participation.
Ethical Approval
The study was approved by the Ethics Committee of All India Institute of Speech and Hearing, Mysore, India.
Authors' Contributions
N Sreedevi was involved in conceptualization, supervision, and project administration. Swapna N contributed to conceptualization. Santosh Maruthy was involved in supervision and project administration. Meghavathi HS helped in molecular biology and original draft preparation. Charles Sylvester was involved in methodology and database analysis.
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References
- 1 Matthijs G, Schollen E, Bjursell C. et al. Mutations in PMM2 that cause congenital disorders of glycosylation, type Ia (CDG-Ia). Hum Mutat 2000; 16 (05) 386-394
- 2 Barone R, Carrozzi M, Parini R. et al. A nationwide survey of PMM2-CDG in Italy: high frequency of a mild neurological variant associated with the L32R mutation. J Neurol 2015; 262 (01) 154-164
- 3 Ganetzky R, Reynoso FJ, He M. Congenital disorders of glycosylation. In: Uttam Garg, Laurie D. Smith, Eds. Clinical Aspects and Laboratory Determination. 2017. Chapter 15; pp. 343-360
- 4 Monin ML, Mignot C, De Lonlay P. et al. 29 French adult patients with PMM2-congenital disorder of glycosylation: outcome of the classical pediatric phenotype and depiction of a late-onset phenotype. Orphanet J Rare Dis 2014; 9 (01) 207
- 5 Lebredonchel E, Riquet A, Neut D. et al. A PMM2-CDG caused by an A108V mutation associated with a heterozygous 70 kilobases deletion case report. Ital J Pediatr 2022; 48 (01) 178
- 6 Goreta SS, Dabelic S, Dumic J. Insights into complexity of congenital disorders of glycosylation. Biochem Med (Zagreb) 2012; 22 (02) 156-170
- 7 Chang IJ, He M, Lam CT. Congenital disorders of glycosylation. Ann Transl Med 2018; 6 (24) 477
- 8 Sparks SE, Krasnewich DM. Congenital disorders of N-linked glycosylation and multiple pathway overview. GeneReviews®[Internet] 2017
- 9 Altassan R, Péanne R, Jaeken J. et al. International clinical guidelines for the management of phosphomannomutase 2-congenital disorders of glycosylation: diagnosis, treatment and follow up. J Inherit Metab Dis 2019; 42 (01) 5-28
- 10 Park MJ, Yoo YJ, Chung CY, Hwang JM. Ocular findings in patients with spastic type cerebral palsy. BMC Ophthalmol 2016; 16 (01) 195
- 11 Pennefather PM, Tin W. Ocular abnormalities associated with cerebral palsy after preterm birth. Eye (Lond) 2000; 14 (Pt 1): 78-81
- 12 Yurdakul NS, Ugurlu S, Maden A. Strabismus in Down syndrome. J Pediatr Ophthalmol Strabismus 2006; 43 (01) 27-30
- 13 Jeon H, Jung J, Kim H, Yeom JA, Choi H. Strabismus in children with white matter damage of immaturity: MRI correlation. Br J Ophthalmol 2017; 101 (04) 467-471
- 14 Schiff M, Roda C, Monin ML. et al. Clinical, laboratory and molecular findings and long-term follow-up data in 96 French patients with PMM2-CDG (phosphomannomutase 2-congenital disorder of glycosylation) and review of the literature. J Med Genet 2017; 54 (12) 843-851
- 15 Citro V, Cimmaruta C, Monticelli M. et al. The analysis of variants in the general population reveals that PMM2 is extremely tolerant to missense mutations and that diagnosis of PMM2-CDG can benefit from the identification of modifiers. Int J Mol Sci 2018; 19 (08) 2218
- 16 Morgese MG, Trabace L. Maternal malnutrition in the etiopathogenesis of psychiatric diseases: role of polyunsaturated fatty acids. Brain Sci 2016; 6 (03) 24
- 17 Sully EA, Biddlecom A, Darroch JE. et al. Adding It Up: Investing in Sexual and Reproductive Health 2019. 2020. New York: Guttmacher Institute; Accessed May 2, 2023 at: https://www.guttmacher.org/report/adding-it-up-investing-in-sexual-reproductive-health-2019
- 18 Rademaker D, Hukkelhoven CWPM, van Pampus MG. Adverse maternal and perinatal pregnancy outcomes related to very advanced maternal age in primigravida and multigravida in the Netherlands: a population-based cohort. Acta Obstet Gynecol Scand 2021; 100 (05) 941-948
- 19 Weinhold B. Environmental factors in birth defects: what we need to know. Environ Health Perspect 2009; 117 (10) A440-A447
- 20 Heinke D, Nestoridi E, Hernandez-Diaz S. et al; National Birth Defects Prevention Study. Risk of stillbirth for fetuses with specific birth defects. Obstet Gynecol 2020; 135 (01) 133-140
- 21 González-Domínguez CA, Raya-Trigueros A, Manrique-Hernández S. et al. Identification through exome sequencing of the first PMM2-CDG individual of Mexican mestizo origin. Mol Genet Metab Rep 2020; 25: 100637
Address for correspondence
Publication History
Article published online:
01 June 2023
© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
Georg Thieme Verlag KG
Stuttgart · New York
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References
- 1 Matthijs G, Schollen E, Bjursell C. et al. Mutations in PMM2 that cause congenital disorders of glycosylation, type Ia (CDG-Ia). Hum Mutat 2000; 16 (05) 386-394
- 2 Barone R, Carrozzi M, Parini R. et al. A nationwide survey of PMM2-CDG in Italy: high frequency of a mild neurological variant associated with the L32R mutation. J Neurol 2015; 262 (01) 154-164
- 3 Ganetzky R, Reynoso FJ, He M. Congenital disorders of glycosylation. In: Uttam Garg, Laurie D. Smith, Eds. Clinical Aspects and Laboratory Determination. 2017. Chapter 15; pp. 343-360
- 4 Monin ML, Mignot C, De Lonlay P. et al. 29 French adult patients with PMM2-congenital disorder of glycosylation: outcome of the classical pediatric phenotype and depiction of a late-onset phenotype. Orphanet J Rare Dis 2014; 9 (01) 207
- 5 Lebredonchel E, Riquet A, Neut D. et al. A PMM2-CDG caused by an A108V mutation associated with a heterozygous 70 kilobases deletion case report. Ital J Pediatr 2022; 48 (01) 178
- 6 Goreta SS, Dabelic S, Dumic J. Insights into complexity of congenital disorders of glycosylation. Biochem Med (Zagreb) 2012; 22 (02) 156-170
- 7 Chang IJ, He M, Lam CT. Congenital disorders of glycosylation. Ann Transl Med 2018; 6 (24) 477
- 8 Sparks SE, Krasnewich DM. Congenital disorders of N-linked glycosylation and multiple pathway overview. GeneReviews®[Internet] 2017
- 9 Altassan R, Péanne R, Jaeken J. et al. International clinical guidelines for the management of phosphomannomutase 2-congenital disorders of glycosylation: diagnosis, treatment and follow up. J Inherit Metab Dis 2019; 42 (01) 5-28
- 10 Park MJ, Yoo YJ, Chung CY, Hwang JM. Ocular findings in patients with spastic type cerebral palsy. BMC Ophthalmol 2016; 16 (01) 195
- 11 Pennefather PM, Tin W. Ocular abnormalities associated with cerebral palsy after preterm birth. Eye (Lond) 2000; 14 (Pt 1): 78-81
- 12 Yurdakul NS, Ugurlu S, Maden A. Strabismus in Down syndrome. J Pediatr Ophthalmol Strabismus 2006; 43 (01) 27-30
- 13 Jeon H, Jung J, Kim H, Yeom JA, Choi H. Strabismus in children with white matter damage of immaturity: MRI correlation. Br J Ophthalmol 2017; 101 (04) 467-471
- 14 Schiff M, Roda C, Monin ML. et al. Clinical, laboratory and molecular findings and long-term follow-up data in 96 French patients with PMM2-CDG (phosphomannomutase 2-congenital disorder of glycosylation) and review of the literature. J Med Genet 2017; 54 (12) 843-851
- 15 Citro V, Cimmaruta C, Monticelli M. et al. The analysis of variants in the general population reveals that PMM2 is extremely tolerant to missense mutations and that diagnosis of PMM2-CDG can benefit from the identification of modifiers. Int J Mol Sci 2018; 19 (08) 2218
- 16 Morgese MG, Trabace L. Maternal malnutrition in the etiopathogenesis of psychiatric diseases: role of polyunsaturated fatty acids. Brain Sci 2016; 6 (03) 24
- 17 Sully EA, Biddlecom A, Darroch JE. et al. Adding It Up: Investing in Sexual and Reproductive Health 2019. 2020. New York: Guttmacher Institute; Accessed May 2, 2023 at: https://www.guttmacher.org/report/adding-it-up-investing-in-sexual-reproductive-health-2019
- 18 Rademaker D, Hukkelhoven CWPM, van Pampus MG. Adverse maternal and perinatal pregnancy outcomes related to very advanced maternal age in primigravida and multigravida in the Netherlands: a population-based cohort. Acta Obstet Gynecol Scand 2021; 100 (05) 941-948
- 19 Weinhold B. Environmental factors in birth defects: what we need to know. Environ Health Perspect 2009; 117 (10) A440-A447
- 20 Heinke D, Nestoridi E, Hernandez-Diaz S. et al; National Birth Defects Prevention Study. Risk of stillbirth for fetuses with specific birth defects. Obstet Gynecol 2020; 135 (01) 133-140
- 21 González-Domínguez CA, Raya-Trigueros A, Manrique-Hernández S. et al. Identification through exome sequencing of the first PMM2-CDG individual of Mexican mestizo origin. Mol Genet Metab Rep 2020; 25: 100637
![](https://www.thieme-connect.de/media/10.1055-s-00046370/202302/thumbnails/10-1055-s-0043-1769494-i2300020-1.jpg)
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