Hutchinson-Gilford progeria syndrome is a rare disorder characterized by short stature, low body weight, early loss of hair, lipodystrophy, scleroderma, decreased joint mobility, osteolysis, and facial features that resemble aged persons. Cardiovascular compromise leads to early death. Cognitive ... Hutchinson-Gilford progeria syndrome is a rare disorder characterized by short stature, low body weight, early loss of hair, lipodystrophy, scleroderma, decreased joint mobility, osteolysis, and facial features that resemble aged persons. Cardiovascular compromise leads to early death. Cognitive development is normal. Onset is usually within the first year of life (review by Hennekam, 2006). The designation Hutchinson-Gilford progeria syndrome appears to have been first used by DeBusk (1972). A subset of patients with heterozygous mutations in the LMNA gene and a phenotype similar to HGPS have shown onset of the disorder in late childhood or in the early teenage years, and have longer survival than observed in classic HGPS (Chen et al., 2003; Hegele, 2003). Other disorders with a less severe, but overlapping phenotype include mandibuloacral dysplasia (MADA; 248370), an autosomal disorder caused by homozygous or compound heterozygous mutations in the LMNA gene, dilated cardiomyopathy with hypergonadotropic hypogonadism (212112), caused by heterozygous mutation in the LMNA gene, and Werner syndrome (277700), an autosomal recessive progeroid syndrome caused by homozygous or compound heterozygous mutations in the RECQL2 gene (604611).
Hastings Gilford (1904) gave the name progeria to this disorder in an article in which he also assigned the term ateleiosis to a pituitary growth hormone deficiency (262400). He provided no photographs of progeria and indicated that 'only ... Hastings Gilford (1904) gave the name progeria to this disorder in an article in which he also assigned the term ateleiosis to a pituitary growth hormone deficiency (262400). He provided no photographs of progeria and indicated that 'only two well-marked instances have so far been recorded.' Death from angina pectoris at age 18 years was noted. Jonathan Hutchinson (1886) had previously written about the disorder (McKusick, 1952). Hutchinson's report was accompanied by a photograph of his patient at the age of 15.5 years showing the stereotypic phenotype of this disorder. Hutchinson emphasized the lack of hair but the other features were evident: disproportionately large head, 'pinched' facial features, lipodystrophy, incomplete extension at the knees and elbows indicating stiffness of joints, and generally a senile appearance. Paterson (1922) recorded the cases of 2 possibly affected brothers whose parents were first cousins. Photographs were not published and the diagnosis is not completely certain. The full report was simply the following: 'A boy, aged 8 years. Condition has been present since birth... There are 4 children in the family; the girls are unaffected, both boys are affected. The senile condition of the skin and facies should be noted. The vessels show arteriosclerosis. (There is almost complete absence of subcutaneous fat.)' Ogihara et al. (1986) described a Japanese patient with progeria who survived to age 45, dying of myocardial infarction. Clinically, he seemed typical except for the unusually long survival. According to reviews of the literature, the age at death ranges from 7 to 27.5 years, with a median age of 13.4 years. Dyck et al. (1987) reported coronary artery bypass surgery and percutaneous transluminal angioplasty in a 14-year-old girl with this disorder. The 2 brothers reported as having progeria by Parkash et al. (1990) probably had mandibuloacral dysplasia (MADA; 248370). Fatunde et al. (1990) described a family in which 3 of 6 sibs had progeria. A seventh sib, who had died before the time of study, may have been affected. Rodriguez et al. (1999) reported a severe prenatal form of progeria in a female fetus at 35 weeks' gestation. The patient was born by cesarean section. Severe growth retardation and oligohydramnios had been detected at 32 weeks by ultrasonography. This was the first patient reported in the English literature; 3 cases of neonatal HGPS had been reported in France (De Martinville et al., 1980; Labeille et al., 1987). All 4 patients died early, 2 on the first day of life and the others at 6 and 20 months of age, respectively. Unlike classic HGPS, however, none of the 4 presented clinical signs of coronary occlusion. Faivre et al. (1999) concluded that the patient reported by Rodriguez et al. (1999) could not in fact have had Hutchinson-Gilford progeria syndrome. They also thought it unlikely that the infant had Wiedemann-Rautenstrauch syndrome, also known as neonatal progeroid syndrome (264090). Rodriguez and Perez-Alonso (1999) defended the 'diagnosis of progeria syndrome [as] the only one possible.' De Paula Rodrigues et al. (2002) reported details of the involvement of bones and joints in a seemingly typical example of progeria in an 8-year-old girl. Hennekam (2006) provided an exhaustive review of the phenotype of HGPS, based on data from 10 of his own cases and 132 cases from the literature. Merideth et al. (2008) comprehensively studied 15 children between 1 and 17 years of age, representing nearly half of the world's known patients with Hutchinson-Gilford progeria syndrome. The previously described features were documented. Previously unrecognized findings included prolonged prothrombin times, elevated platelet counts and serum phosphorus levels, low-frequency conductive hearing loss, and functional oral deficits. Growth impairment was not related to inadequate nutrition, insulin unresponsiveness, or growth hormone deficiency. Growth hormone treatment in a few patients increased height growth by 10% and weight growth by 50%. Cardiovascular studies revealed diminishing vascular function with age, including elevated blood pressure, reduced vascular compliance, decreased ankle-brachial indices, and adventitial thickening. The ankle-brachial index was used to measure the difference in blood pressure between the legs and arms in 11 children. The index was abnormal in 2 patients, indicating arterial disease in the legs. - Childhood-Onset HGPS Chen et al. (2003) found that 26 (20%) of 129 probands referred to their international registry for molecular diagnosis of the autosomal recessive progeroid disorder Werner syndrome (277700) did not have mutations in the RECQL2 gene (604611). Sequencing of the LMNA gene in these individuals found that 4 (15%) had heterozygous mutations: A57P (150330.0030), R133L (in 2 persons) (150330.0027), and L140R (150330.0031), all of which altered relatively conserved residues within lamin A/C. Fibroblasts from the patient with the L140R mutation had a substantially enhanced proportion of nuclei with altered morphology and mislocalized lamins. These individuals had a more severe phenotype than those with RECQL2-associated Werner syndrome. Although Chen et al. (2003) designated these patients as having 'atypical Werner syndrome,' Hegele (2003) suggested that the patients more likely had late-onset Hutchinson-Gilford progeria syndrome. Hegele (2003) reviewed the clinical features of the 4 patients with LMNA mutations reported by Chen et al. (2003), and stated that the designation of 'atypical Werner syndrome' appeared somewhat insecure. He noted that the comparatively young ages of onset in the patients with mutant LMNA would be just as consistent with late-onset HGPS as with early-onset Werner syndrome. These patients also expressed features of nonprogeroid laminopathies, including insulin resistance (FPLD2; 151660), dilated cardiomyopathy (115200), and phalangeal osteosclerosis (MADA; 248370). Hegele (2003) suggested that genomic DNA analysis can help draw a diagnostic line that clarifies potential overlap between older patients with Hutchinson-Gilford syndrome and younger patients with Werner syndrome, and that therapies may depend on precise molecular classification. McPherson et al. (2009) noted phenotypic similarities between the patient studied by Chen et al. (2003) with the A57P LMNA mutation and 2 unrelated patients with heterozygosity for an adjacent mutation in the LMNA gene, L59R (150330.0052). Features common to these 3 patients included premature ovarian failure, dilated cardiomyopathy, lipodystrophy, and progressive facial and skeletal changes involving micrognathia and sloping shoulders, but not acroosteolysis. Although the appearance of these patients was somewhat progeroid, none had severe growth failure, alopecia, or rapidly progressive atherosclerosis, and McPherson et al. (2009) suggested that the phenotype represents a distinct laminopathy (dilated cardiomyopathy and hypergonadotropic hypogonadism, 212112).
Moulson et al. (2007) reported 2 unrelated patients with extremely severe forms of HGPS associated with unusual mutations in the LMNA gene. (150330.0036 and 150330.0040, respectively). Both mutations resulted in increased use of the cryptic exon 11 donor ... Moulson et al. (2007) reported 2 unrelated patients with extremely severe forms of HGPS associated with unusual mutations in the LMNA gene. (150330.0036 and 150330.0040, respectively). Both mutations resulted in increased use of the cryptic exon 11 donor splice site observed with the common 1824C-T mutation (150330.0022). As a consequence, the ratios of mutant progerin mRNA and protein to wildtype were higher than in typical HGPS patients. The findings indicated that the level of progerin expression correlates to the severity of the disease.
Eriksson et al. (2003) reported de novo point mutations in lamin A (150330) causing Hutchinson-Gilford progeria syndrome. The HGPS gene was initially localized to chromosome 1q by observing 2 cases of uniparental isodisomy of 1q, and 1 case ... Eriksson et al. (2003) reported de novo point mutations in lamin A (150330) causing Hutchinson-Gilford progeria syndrome. The HGPS gene was initially localized to chromosome 1q by observing 2 cases of uniparental isodisomy of 1q, and 1 case with a 6-Mb paternal interstitial deletion. Eighteen of 20 classic cases of HGPS harbored the identical de novo single-base substitution, a C-to-T transition resulting in a silent gly-to-gly change at codon 608 within exon 11 (G608G; 150330.0022). One additional case was identified with a different substitution within the same codon (150330.0023). Both of these mutations were shown to result in activation of a cryptic splice site within exon 11 of the lamin A gene, resulting in production of a protein product that deletes 50 amino acids near the C terminus. This prelamin A still retains the CAAX box but lacks the site for endoproteolytic cleavage. Immunofluorescence of HGPS fibroblasts with antibodies directed against lamin A revealed that many cells showed visible abnormalities of the nuclear membrane. Cao and Hegele (2003) studied cell lines from 7 HGPS probands. Five carried the common mutation within exon 11 of LMNA, which they termed 2036C-T (150330.0022). In 1 of 7 patients, they identified the G608S mutation (150330.0023). Cao and Hegele (2003) confirmed the findings of Eriksson et al. (2003) using the same cell lines. In 1 patient with an HGPS phenotype who was 28 years old at the time that DNA was obtained, Cao and Hegele (2003) identified compound heterozygosity for 2 missense mutations in the LMNA gene (150330.0025 and 150330.0026); this patient was later determined (Brown, 2004) to have mandibuloacral dysplasia. De Sandre-Giovannoli et al. (2003) identified the exon 11 cryptic splice site activation mutation (1824C-T+1819-1968del; 150330.0022) in 2 HGPS patients. Immunocytochemical analyses of lymphocytes from 1 patient using specific antibodies directed against lamin A/C, lamin A, and lamin B1 showed that most cells had strikingly altered nuclear sizes and shapes, with envelope interruptions accompanied by chromatin extrusion. Lamin A was detected in 10 to 20% of HGPS lymphocytes. Only lamin C was present in most cells, and lamin B1 was found in the nucleoplasm, suggesting that it had dissociated from the nuclear envelope due to the loss of lamin A. Western blot analysis showed 25% of normal lamin A levels, and no truncated form was detected. In 4 affected members of a consanguineous family from north India, Plasilova et al. (2004) with features of both MADA (248370) and HGPS resulting from a homozygous missense mutation in the LMNA gene (150330.0033). Plasilova et al. (2004) suggested that autosomal recessive HGPS and MADA may represent a single disorder with varying degrees of severity.
Hennekam (2006) stated that the incidence of HGPS was 1 per 8 million newborns in the US between 1915 and 1967 and 1 per 4 million newborns in the Netherlands between 1900 and 2005. Patients have been reported ... Hennekam (2006) stated that the incidence of HGPS was 1 per 8 million newborns in the US between 1915 and 1967 and 1 per 4 million newborns in the Netherlands between 1900 and 2005. Patients have been reported from all continents and all ethnic backgrounds.
The diagnosis of classic Hutchinson-Gilford progeria syndrome (HGPS, progeria) is based on recognition of common clinical features and detection of the classic c.1824C>T (p.Gly608Gly) heterozygous LMNA mutation; the diagnosis of atypical HGPS is made in individuals with more or less severe features or the non-classic LMNA mutations, for example, c.1822 G>A (p.Gly608Ser), c.1821G>A (p.Val607Val), or c.1968+1G>A....
DiagnosisClinical DiagnosisThe diagnosis of classic Hutchinson-Gilford progeria syndrome (HGPS, progeria) is based on recognition of common clinical features and detection of the classic c.1824C>T (p.Gly608Gly) heterozygous LMNA mutation; the diagnosis of atypical HGPS is made in individuals with more or less severe features or the non-classic LMNA mutations, for example, c.1822 G>A (p.Gly608Ser), c.1821G>A (p.Val607Val), or c.1968+1G>A.Individuals having the p.Gly608Gly LMNA silent mutation and most of the following features after age three years are considered to have the classic Hutchinson-Gilford progeria syndrome: Growth Short stature (<3rd percentile), lifelongWeight (<3rd percentile), lifelong Weight distinctly low for height Head disproportionately large for face Thin, high-pitched voice Body fat. Diminished subcutaneous fat globally, with the following sequellae:Prominent scalp veins Prominent veins over most of bodyIrregular small outpouchings of skin over lower abdomen and/or proximal thighsCircumoral cyanosisProminent eyesLack of ear lobes, in some but not all cases Skin/hair/nails Taut, dry skin that is variably pigmented (spotty) "Sclerodermatous" skin over lower abdomen and proximal thighsGeneralized alopecia with sparse downy hairs on the occiputLoss of eyebrows and sometimes eyelashes Dystrophic fingernails and toenails Lagophthalmos (the inability to fully close the eye) and, in a minority of cases, corneal ulcerationThin lips Teeth Delayed eruption of primary teethDelayed loss of erupted primary teethPartial secondary tooth eruptionDental crowding as a result of small mouth, lack of primary tooth loss, and secondary tooth eruption behind primary teethSkeletal system/joints Narrow nasal bridge, pointed nasal tip Osteolysis of the distal phalanges Delayed closure of the anterior fontanelle Pear-shaped thorax Retrognathia and micrognathia Short, dystrophic clavicles Osteoarthritis"Horse-riding" stance and wide-based, shuffling gait Coxa valga Low bone densityThin limbs Tightened joint ligaments globally but variable in severityCardiovascular/neurovascularSevere progressive atherosclerosis with variable age of clinical manifestation resulting in: Cardiac manifestations: angina, congestive heart failure, myocardial infarction Stroke, including transient ischemic attacks and silent strokes that are seen on MRI or CT of the head but do not manifest as clinical deficits Raynaud phenomenon in fingers of some but not all individualsAudiologic. Low-frequency conductive hearing lossEndocrineFailure to complete secondary sexual development Low serum leptin concentrationInsulin resistance in up to 50% of individuals. Note that frank diabetes mellitus is unusual. Molecular Genetic TestingGene. LMNA is the only gene in which mutation is known to be causative for HGPS. As per the definition of HGPS used in this GeneReview, only four causative heterozygous mutations in LMNA are recognized:Classic HGPS. c.1824C>T transition in exon 11 results in a silent Gly-to-Gly change at codon 608 (p.Gly608Gly). This silent change results in increased usage of an internal cryptic spice site resulting in an in-frame deletion of 150 nucleotides and 50 amino acids from the lamin A protein. Atypical HGPS. c.1822G>A (p.Gly608Ser), c.1821G>A (p.Val607Val), or c.1968+1G>A Clinical testingTargeted mutation analysis can be used to identify the pathologic variant c.1824C>T, the common recurrent de novo LMNA mutation in exon 11 that defines classic HGPS [Cao & Hegele 2003, De Sandre-Giovannoli et al 2003, Eriksson et al 2003]. Sequence analysis of the entire coding region and associated splice junctions identifies:c.1824C>T, the common mutation that defines classic HGPS; c.1822G>A, c.1821G>A, and c.1968+1G>A, the other three mutations that define atypical HGPS; Other sequence variants in the gene that may be associated with other progeroid syndromes [Moulson et al 2007]. Table 1. Summary of Molecular Genetic Testing Used in Hutchinson-Gilford Progeria SyndromeView in own windowGene SymbolTest MethodMutations DetectedMutation Detection Frequency 1Test AvailabilityLMNATargeted mutation analysisc.1824C>T100% 2ClinicalSequence analysis of the coding and intronic regionsSequence variants 3 throughout the gene, including c.1824C>T, c.1822 G>A, c.1821G>A, and c.1968+1G>ASee footnote 4Deletion/duplication analysisGene deletionNot relevant to HGPS 51. The ability of the test method used to detect a mutation that is present in the indicated gene2. Classic Hutchinson-Gilford progeria syndrome (HGPS, progeria) is defined by the presence of LMNA mutation c.1824C>T. 3. Examples of mutations detected by sequence analysis may include small intragenic deletions/insertions and missense, nonsense, and splice site mutations.4. Detects the common mutations that define atypical HGPS and also detects other sequence variants. 5. One rare case of a progeroid syndrome other than HGPS. See Molecular Basis of Disease for an explanation.Interpretation of test results. For issues to consider in interpretation of sequence analysis results, click here.Testing StrategyTo confirm the diagnosis in a probandEstablish the clinical diagnosis based on age-related findings (see Clinical Diagnosis). Molecular genetic testing of LMNA confirms the diagnosis; either: Targeted mutation analysis for the mutation associated with classic HGPS or Sequence analysis of the entire coding region and associated splice junctions to identify the one mutation associated with classic HGPS and the three mutations associated with atypical HGPS.Note: Urinary hyaluronic acid is not a valid test for the diagnosis of HGPS. Although urinary hyaluronic acid has been reported to be increased in children with HGPS, the measurement is now regarded as unreliable [Gordon et al 2003]. Prenatal diagnosis and preimplantation genetic diagnosis (PGD) for at-risk pregnancies require prior identification of the disease-causing mutation in the family. Of note, recurrence within a family is rare given that most mutations are de novo and germline mosaicism is rare.Genetically Related (Allelic) DisordersMore than ten other diseases and conditions with mutations or variations in LMNA have been identified. See OMIM 150330.Progeroid laminopathy. The term "progeroid laminopathy" can be used to describe phenotypes that resemble HGPS in which an LMNA mutation other than c.1824C>T, c.1822 G>A, c.1821G>A, or c.1968+1G>A has been identified. To date 18 referenced mutations causing progeroid laminopathies have been identified (see www.umd.be/LMNA). Uniparental isodisomy (UPD) of chromosome 1 (including LMNA) was identified in cultured cells of an individual with progeroid phenotype. This was a mosaic rearrangement of chromosome 1 and a deletion involving the LMNA locus [Eriksson et al 2003]. A child with the mutation NM_170707.2: c.433G>A (p.Glu145Lys) in exon 2 had atypical progeroid features including persistence of coarse hair over the head, ample subcutaneous tissue over the arms and legs, and severe strokes beginning at age four years [Eriksson et al 2003]. One individual with the NM_170707.2: c.1867A>T (p.Thr623Ser) mutation (leading to a cryptic splice site in exon 11 and producing an LMNA allele missing 35 amino acids) was normal at birth and developed a large head at age one year, growth failure at 12 years, and alopecia in later childhood [Fukuchi et al 2004]. He died of a myocardial infarction at age 45 years, having developed a progeroid phenotype. Restrictive dermopathy (OMIM 275210) has been associated with NM_170707.2: c.1699_1968del (p.Gly567_Gln656del) and a severe progeroid phenotype [Navarro et al 2004]. Other laminopathies Autosomal dominant Emery-Dreifuss muscular dystrophy (AD-EDMD)Autosomal recessive Emery-Dreifuss muscular dystrophy (AR-EDMD) Autosomal dominant familial dilated cardiomyopathy and conduction system defects (CMD1A) (see Dilated Cardiomyopathy)Autosomal dominant Dunnigan-type familial partial lipodystrophy (FPLD) Autosomal dominant limb-girdle muscular dystrophy 1B (LGMD1B) (see Limb-Girdle Muscular Dystrophy)A normal variant in LMNA (NM_170707.2:c.1908C>T) associated with obesity-related traits in Canadian Oji-Cree Autosomal recessive axonal neuropathy Charcot-Marie-Tooth disease 2B1 (CMT2B1) (see Charcot-Marie-Tooth disease type 2)Autosomal recessive mandibuloacral dysplasia (MAD). A compound heterozygous mutation (NP_733821.1:p.[Arg471Cys]+ [Arg527Cys] in exon 8 and exon 9 respectively) in a 28-year-old woman with mandibuloacral dysplasia, previously diagnosed as "atypical progeria," was reported [Cao & Hegele 2003]. A family with four affected sibs with a homozygous mutation NM_170707.2:c.1626G>C (p.Lys542Asn) with many features of MAD, but some features of progeria as well [Plasilova et al 2004].Atypical Werner syndrome [Chen et al 2003] A single case report of a male heterozygous for the NM_170707.2:c.398G>T (p.Arg133Leu) mutation with lipoatrophy, disseminated white skin papules, hypertrophic cardiomyopathy, hepatic steatosis, and insulin resistance [Caux et al 2003] A single case report of a female heterozygous for the mutation NM_170707.2:c.428C>T (p.Ser143Phe) with myopathy, hypotonia, loss of subcutaneous tissue, osteopenia, and progressive spinal rigidity [Kirschner et al 2005]
Hutchinson-Gilford progeria syndrome (HGPS) is characterized by clinical features that develop in childhood and resemble some features of accelerated aging. ...
Natural HistoryHutchinson-Gilford progeria syndrome (HGPS) is characterized by clinical features that develop in childhood and resemble some features of accelerated aging. Children with progeria usually appear normal at birth and in early infancy. Early findings such as midfacial cyanosis, "sculpted nose," and "sclerema" (or "sclerodermatous skin") may suggest HGPS at or shortly after birth. Profound failure to thrive usually occurs during the first year. Characteristic facies, partial alopecia progressing to total alopecia, loss of subcutaneous fat, stiffness of joints, bone changes, and abnormal tightness of the skin over the abdomen and upper thighs usually become apparent during the second to third year. Children are particularly susceptible to hip dislocation because of the progressive coxa valga malformation.Delayed loss of primary teeth is common. Motor and mental development is normal. As a result of severe failure to thrive, affected individuals do not become sexually mature and do not reproduce.Insulin resistance occurs about 50% of the time, without overt development of diabetes mellitus. Tumor rate is not increased over that of the general population. One individual died of a chondrosarcoma of the chest wall at age 13 years. Other changes associated with normal aging such as near-sightedness or far-sightedness, arcus senilis, senile personality changes, or Alzheimer disease have not been documented. Children with HGPS appear to have a normal immune system; they respond as well as the general population when subjected to various infections. Wound healing is normal.Individuals with progeria develop severe atherosclerosis, usually without obvious abnormalities in lipid profiles [Gordon et al 2005]. In general, serum cholesterol and triglyceride concentrations are not elevated and HDL concentrations may decrease with age. Early cardiac changes can manifest in years five through eight, but usually begin to occur after age eight years. Typical manifestations of cardiovascular decline include heart valve and chamber decline as a result of increased afterload, angina, and late findings including dyspnea on exertion. Hypertension is usually a later sign of vascular disease. Transient ischemic attacks or symptomatic strokes have occurred as early as age four years. Strokes can occur at any brain site and, therefore, can lead to a variety of physical limitations and/or cognitive decline. Partial and complete carotid artery blockages can occur from plaque formation. Despite underlying vascular disease some children do not have clinically identified strokes. Death occurs as a result of complications of cardiac or cerebrovascular disease (heart attack or stroke) generally between ages six and 20 years, with an average life span of approximately 13 years.
Individuals with the HGPS-causing common c.1824C>T mutation appear remarkably similar in phenotype [Eriksson et al 2003]. ...
Genotype-Phenotype CorrelationsIndividuals with the HGPS-causing common c.1824C>T mutation appear remarkably similar in phenotype [Eriksson et al 2003]. The child with the c.1822 G>A mutation and a more severe progeroid laminopathy had more growth retardation and subcutaneous calcification on the hands, and died at age eight years. The child with the c.1968+1G>A mutation and a more severe progeroid laminopathy had more growth retardation and tighter skin, and died at age 3.5 years during an episode of gastroenteritis and pneumonia. Individuals whose cultured cells manifest uniparental isodisomy appear to have classic HGPS. Although it is thought that the uniparental isodisomy may be a somatic event that eliminates the mutant allele and "rescues" the phenotype, this may be an in vitro artifact as it has yet to be seen in vivo.
In one report, a heterozygous mutation (NM_170707.2:1960C>T (p.Arg654*) in LMNA and homozygous mutation in ZMPSTE24 (NM_005857.3), which encodes a post-translational prelamin A processing protein, resulted in a phenotype similar to progeroid laminopathy (see Genetically Related Disorders) [Denecke et al 2006]....
Differential DiagnosisIn one report, a heterozygous mutation (NM_170707.2:1960C>T (p.Arg654*) in LMNA and homozygous mutation in ZMPSTE24 (NM_005857.3), which encodes a post-translational prelamin A processing protein, resulted in a phenotype similar to progeroid laminopathy (see Genetically Related Disorders) [Denecke et al 2006].The following are other syndromes that include some features of premature aging:Neonatal progeroid syndrome (Weidemann-Rautenstrauch syndrome) Acrogeria Cockayne syndrome Hallermann-Streif syndrome Gerodermia osteodysplastica Berardinelli-Seip congenital lipodystrophy (congenital generalized lipodystrophy) Petty-Laxova-Weidemann progeroid syndrome Ehlers-Danlos syndrome, progeroid form Werner syndrome, atypical formMandibuloacral dysplasia (See Genetically Related Disorders)Note to clinicians: For a patient-specific ‘simultaneous consult’ related to this disorder, go to , an interactive diagnostic decision support software tool that provides differential diagnoses based on patient findings (registration or institutional access required).
To establish the extent of disease in an individual diagnosed with Hutchinson-Gilford progeria syndrome (HGPS), the following evaluations are recommended:...
ManagementEvaluations Following Initial DiagnosisTo establish the extent of disease in an individual diagnosed with Hutchinson-Gilford progeria syndrome (HGPS), the following evaluations are recommended:Weight and height plotted on standard growth charts to evaluate growth over timeBaseline electrocardiogram (ECG) and echocardiogramBaseline carotid artery duplex scans to evaluate size of the lumen and intimal thickness in order to establish baseline vascular statusBaseline MRI/MRA of the brain and neckSkeletal x-ray to evaluate for characteristic findings: acroosteolysis, clavicular resorption, and coxa valga Dual-energy x-ray absorptiometry (DEXA) to assess bone mineral densityStandard goniometry to assess joint mobility; physical therapy and occupational therapy assessmentsNutritional assessment Audiologic, ophthalmologic, and dental examinations Treatment of ManifestationsA complete, system-based management guide is available from the Progeria Research Foundation or at www.progeriaresearch.org/patient_care.html.No evidence that a low-cholesterol, low-fat, or other special diet influences the course of progeria exists. Thus, a regular diet is indicated unless the lipid profile becomes abnormal, at which point appropriate treatment includes exercise, diet modification, and medication as warranted. Frequent small meals tend to maximize caloric intake. Because the stiffened peripheral vasculature may be less tolerant to dehydration, maintaining optimal hydration orally is recommended.Shoe pads are recommended, as lack of body fat leads to foot discomfort. Use of sunscreen on all exposed areas of skin, including the head, is recommended for outdoor activities.Prior to decline in cardiovascular or neurologic status (resulting from strokes, angina, or heart attacks), children should be encouraged to be as physically active as possible, taking into account possible limitations related to restricted range of motion of joints and hip problems including osteoarthritis and hip dislocation. Because intellect and maturity are normal, age-appropriate schooling is usually indicated.Infections are generally handled as for unaffected children. Medications. Dosages should be based on body weight or body surface area and not on age. Anesthetics should be used with particular caution. Nitroglycerin is frequently of benefit if angina develops.Routine anticongestive therapy is appropriate if congestive heart failure is present.Statins are recommended for their putative effect on farnesylation inhibition.Anticoagulation is warranted if vascular blockage, transient ischemic attacks, stroke, angina, or myocardial infarction occur. Injuries. Wound healing is normal. Fracture rate is equivalent to the general pediatric population. When children do fracture, treatment and healing are routine. Hips. Conservative management of hip dislocation with physical therapy and body bracing and avoidance of surgical procedures on bones are recommended when possible. Teeth. Extraction of primary teeth may be required to avoid crowding and development of two rows of teeth. Since secondary teeth may erupt slowly or not at all, pulling primary teeth to make room for secondary teeth should be performed after secondary teeth have fully or almost fully or almost fully descended. Once the primary tooth has been extracted, the secondary tooth often moves into the appropriate position with time.Physical therapy. Routine physical and occupational therapy is recommended to help maintain range of motion in large and small (i.e., finger) joints (see Physical Therapy and Occupational Therapy in Progeria; pdf). Active stretching and strengthening, along with hydrotherapy, are recommended. Podiatric evaluation is indicated to determine if shoe inserts are needed Eye care. Corneal dryness, clouding or ulceration should be fully evaluated by an ophthalmologist. Usually, in HGPS this is exposure keratitis and during daytime can be treated with moisturizing solution, and during sleep with moisturizing ointment or by closing eyelids with skin tape.Prevention of Secondary ComplicationsAspirin. Based on the evidence from adult studies that low doses of aspirin help delay heart attacks and strokes, it is probably appropriate to give children with HGPS low-dose aspirin treatment, at doses of 2-3 mg/kg body weight per day. Note: If chicken pox or influenza is prevalent in the community, it may be advisable to discontinue the aspirin during that time because of the increased risk of Reye syndrome. Vitamin supplementation. Standard amounts of ordinary multiple vitamin tablets are appropriate. Fluoride supplements are recommended in areas where needed. Immunizations. The routine doses and administration schedule for all immunizations are recommended. Immunizations are generally handled as for unaffected children.SurveillanceThe following are appropriate:ECG, measurement of blood pressure, echocardiogram, and carotid duplex scans annually or semi-annually to monitor for cardiovascular disease. Note: Children may experience severe carotid artery atherosclerotic blockage prior to any significant ECG changes. Annually:Neurologic assessmentMRI/MRA of head and neck to assess for vascular changes and silent strokes, which are true strokes that do not result in any clinical symptoms Lipid profiles Dental examination, x-ray, and cleaningHip x-rays to evaluate for avascular necrosis and progressing coxa valga Dual x-ray absorptiometry (DXA) scan of spine, hips, and total body to assess bone density and body fat compositionPhysical therapy and occupational therapy assessment for joint contractures and activities of daily livingComplete audiologic assessment with special attention to possible low-frequency conductive hearing lossComplete ophthalmologic examination with special attention to possible exposure to keratopathyAgents/Circumstances to AvoidChildren should avoid being in the midst of large crowds with much taller and larger peers because of the increased risk of injury.Evaluation of Relatives at RiskSee Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.Therapies Under InvestigationSearch HGPS or progeria within ClinicalTrials.gov for access to information on clinical trials for HGPS. The three therapies currently under investigation for HGPS include: lonafarnib, pravastatin, and zoledronate. For each of these drugs, the target action in HGPS is to inhibit post-translational farnesylation of progerin, the active disease-causing protein in HGPS (see Figure 1). FigureFigure 1. Medications that inhibit the farnesylation of progerin Lonafarnib is an investigational farnesyltransferase inhibitor. Pravastatin inhibits HMG-CoA reductase. Zoledronate is a bisphosphonate that inhibits farnesyl pyrophosphate synthase.
Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED....
Molecular GeneticsInformation in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED.Table A. Hutchinson-Gilford Progeria Syndrome: Genes and DatabasesView in own windowGene SymbolChromosomal LocusProtein NameLocus SpecificHGMDLMNA1q22Prelamin-A/CHuman Intermediate Filament Database LMNA (lamin C1) Human Intermediate Filament Database LMNA (lamin A) Human Intermediate Filament Database LMNA (lamin C2) IPN Mutations, LMNA LMNA homepage - Leiden Muscular Dystrophy pagesLMNAData are compiled from the following standard references: gene symbol from HGNC; chromosomal locus, locus name, critical region, complementation group from OMIM; protein name from UniProt. For a description of databases (Locus Specific, HGMD) to which links are provided, click here.Table B. OMIM Entries for Hutchinson-Gilford Progeria Syndrome (View All in OMIM) View in own window 150330LAMIN A/C; LMNA 176670HUTCHINSON-GILFORD PROGERIA SYNDROME; HGPSMolecular Basis of DiseaseLamin A is an inner nuclear membrane protein with both structural and cell signaling effects. The single C to T transition at nucleotide 1824 of LMNA does not change the translated amino acid (Gly608Gly), but activates a cryptic splice site, resulting in the deletion of 150 base pairs in the 3’ portion of exon 11. Translation followed by post-translational processing of this altered mRNA produces a shortened abnormal prelamin A protein with a 50 amino-acid deletion near its C-terminal end, henceforth called “progerin”. The 50 amino-acid deletion removes the recognition site that leads to proteolytic cleavage of the terminal 18 amino acids of prelamin A, along with the phosphorylation site(s) involved in the dissociation and reassociation of the nuclear membrane at each cell division.A key to disease in HGPS is the presumably persistent farnesylation of progerin, which renders it permanently intercalated into the inner nuclear membrane where it can accumulate and exert progressively more damage to cells as they age. That the failure to remove the farnesyl group is at least in part responsible for the phenotypes observed in HGPS is strongly supported by studies on both cell and mouse models which have either been engineered to produce a non-farnesylated progerin product or treated with a drug that inhibits farnesylation, rendering a non-farnesylated progerin product. Normal allelic variants. The coding region of the lamin A/C gene spans approximately 24 kb and contains 12 exons. Pathologic allelic variants. A recurrent de novo point mutation of a single-base substitution, a c.1824C>T transition that is a silent mutation that does not change the glycine amino acid at codon 608 within exon 11 in lamin A, was found in 18 of 23 individuals with a clinical diagnosis of HGPS [Eriksson et al 2003] and independently in two of two individuals studied by De Sandre-Giovannoli et al [2003]. One of 25 individuals had a c.1822G>A change at codon 608 (p.Gly608Ser) also leading to the same cryptic splice effect [Eriksson et al 2003]. Two individuals with a heterozygous transition mutation c. 1961+1G>A have been reported; one who died at age 3.5 years of gastroenteritis and pneumonia [Moulson et al 2007] and one who died at age six months [Navarro et al 2004]. This mutation creates a cryptic splice donor sequence that produces an estimated 4.5-fold increase in progerin production versus classic HGPS [Moulson et al 2007].One individual with a heterozygous transition mutation c.1821G>A (p.Val607Val) has been reported. The individual had a more severe progeroid phenotype than classic HGPS, and died at age 26 days of unspecified genodermatosis with interstitial pneumonia [Moulson et al 2007]. This mutation creates a cryptic splice donor sequence that produces an estimated twofold increase in progerin production vs. classic HGPS [Moulson et al 2007]A 6-Mb deletion spanning LMNA was reported in an affected individual [Eriksson et al 2003]. Of note, the 6-Mb deletion is not in itself considered pathologic. It was hypothesized that the individual was originally heterozygous for a codon 608 LMNA mutation, but this allele later underwent a deletion removing the codon 608 mutation. This phenomenon was referred to as a “somatic rescue” event. Table 2. LMNA Pathologic Allelic Variants in Hutchinson-Gilford Progeria SyndromeView in own windowDNA Nucleotide ChangeProtein Amino Acid Change Reference Sequencesc.1821G>Ap.Val607ValNM_170707.2 NP_733821.1c.1822G>A p.Gly608Ser c.1824C>T 1p.Gly608Gly c.1968+1G>A(Splice donor site mutaton)See Quick Reference for an explanation of nomenclature. GeneReviews follows the standard naming conventions of the Human Genome Variation Society (www.hgvs.org).1. In-frame, exon 11 cryptic splice site activation mutationNormal gene product. The nuclear lamina is a protein-containing layer attached to the inner nuclear membrane. In mammals, it is composed of a family of polypeptides, with the major components being the lamins A, B1, B2, and C, with molecular weights ranging from 60,000 to 78,000. Lamins A and C are formed by alternative splicing of the LMNA/C gene transcript. Splicing within exon 10 gives rise to lamin C, whereas transcription of all 12 exons gives rise to lamin A. Lamins B1 and B2 are encoded by separate genes and there are no known progeroid mutations within lamins B1 and B2.Lamin A is normally synthesized as a precursor molecule (prelamin A), and undergoes a four major post-translational processing steps. First, because prelamin A contains a CAAX (cysteine / aliphatic / aliphatic / any amino acid) box at its carboxyl terminus, it is modified by farnesylation. Following farnesylation, cleavage of the last three amino acids, methylation of the C-terminus, and internal proteolytic cleavage occur. Removal of the last 15 coding amino acids along with the CAAX box and farnesyl group generates mature lamin A with 646 amino acids. Abnormal gene product. The HGPS-causing mutations in codon 608 of LMNA leads to activation of a cryptic splice site within exon 11, resulting in production of a prelamin A that lacks 50 amino acids near the C terminus [Eriksson et al 2003]. The c.1824C>T mutation and consequent abnormal splicing produces a prelamin A that still retains the CAAX box and is therefore farnesylated, but is missing the site for endoproteolytic cleavage of the final 16 amino acids along with the farnesyl moiety that normally occurs during the final step in post-translational processing. The resulting protein, named progerin, is shortened and farnesylated. Since the lipophilic farnesyl moiety is utilized to anchor prelamin (and hence progerin) into the inner nuclear membrane, the lack of farnesyl cleavage likely results in permanent progerin intercalation within the nuclear membrane.The inability to release progerin from the nuclear membrane results in structural stress on the nucleus. Immunofluorescence of HGPS fibroblasts with antibodies directed against lamin A reveals a visible abnormality, an irregular shape of the nuclear envelope, in 40%-50% of cells [Eriksson et al 2003]. It is hypothesized that this permanently farnesylated mutant form of prelamin A (progerin) acts in a dominant-negative fashion and leads to the progressive defects in nuclear architecture that are seen in HGPS [Goldman et al 2004].