Smith-Lemli-Opitz syndrome is an autosomal recessive multiple congenital malformation and mental retardation syndrome. Although historically a clinical distinction was often made between a classic 'type I' disorder and a more severe 'type II' disorder, in reality the syndrome ... Smith-Lemli-Opitz syndrome is an autosomal recessive multiple congenital malformation and mental retardation syndrome. Although historically a clinical distinction was often made between a classic 'type I' disorder and a more severe 'type II' disorder, in reality the syndrome constitutes a clinical and biochemical continuum from mild to severe (Opitz et al., 1987; Cunniff et al., 1997; Kelley, 1998). The discovery of the deficiency of 7-dehydrocholesterol reductase as a causative factor of the SLO syndrome (Tint et al., 1994) made this syndrome the first true metabolic syndrome of multiple congenital malformations. A multidisciplinary National Institute of Child Health and Human Development (NICHD) conference of the SLO syndrome reviewed different implications of this discovery and proposed further studies in this field. A detailed report on this conference and abstracts of presentations were provided by Opitz and de la Cruz (1994). Observations presented at an NICHD RSH/SLOS conference in September 1995 were reviewed by Kelley (1997). Kelley (1998) referred to SLOS as a metabolic malformation syndrome, but suggested that this may be an exception. Most mutations that had been related to multiple congenital malformation syndromes, i.e., disturbances of the body plan, have not been disorders of intermediary metabolism but, instead, mutations of homeobox genes and other transcriptional regulators and signaling systems. Opitz et al. (1987) gave a presumedly complete bibliography of the SLO syndrome, which was updated by Opitz et al. (1994) and included almost 200 references. They concluded that lumping SLO syndrome with the Pallister-Hall hamartoblastoma syndrome (146510) is not justified. In a given severe case, differentiation from the Meckel syndrome (249000) may be a challenge. Herman (2003) reviewed the cholesterol biosynthetic pathway and the 6 disorders involving enzyme defects in post-squalene cholesterol biosynthesis: SLOS, desmosterolosis (602398), X-linked dominant chondrodysplasia punctata (CDPX2; 302960), CHILD syndrome (308050), lathosterolosis (607330), and hydrops-ectopic calcification-moth-eaten skeletal dysplasia (HEM; 215140).
In 2 adult brothers formerly described as having SLO syndrome (de Die-Smulders and Fryns, 1990), de Die-Smulders et al. (1996) reported confirmation of the diagnosis by the finding of low levels of cholesterol (15 to 27% of normal) ... In 2 adult brothers formerly described as having SLO syndrome (de Die-Smulders and Fryns, 1990), de Die-Smulders et al. (1996) reported confirmation of the diagnosis by the finding of low levels of cholesterol (15 to 27% of normal) and very high levels of 7-dehydrocholesterol. Guzzetta et al. (1996) collected 20 patients suspected of having SLOS by 11 Italian pediatric or clinical genetic centers. In 10 patients, the diagnosis was confirmed biochemically by gas chromatography/mass spectrometry (GC/MS) analysis of serum sterols; the serum sterol profiles in the other 10 patients were normal. A comparison of confirmed SLOS patients to biochemically negative subjects did not identify clinical signs specific for the syndrome. Ultraviolet spectrophotometry measurement of 7-dehydrocholesterol correlated well with GC/MS profiles, showing 100% sensitivity and specificity. Four of 5 patients studied had serum bile acid concentrations below the normal range of controls. Honda et al. (1997) described a new rapid method for determination of plasma 7-dehydrocholesterol by ultraviolet spectrometry. In addition, Honda et al. (1997) found that analysis of cultured skin fibroblasts that had been exposed to delipidated medium for 4 weeks allowed accurate diagnosis even in atypical cases of SLOS. - Prenatal Diagnosis Johnson et al. (1994) presented the first report of prenatal diagnosis of SLO syndrome, and described prenatal detection of multiple anomalies in a fetus in which the diagnosis of SLO syndrome was made postnatally. McGaughran et al. (1994) used biochemical testing for successful prenatal diagnosis of severe SLO syndrome. The first child of the couple requesting prenatal diagnosis had this disorder with multiple external and internal anomalies and died in the neonatal period. Despite apparently normal results of detailed ultrasound scanning in the second pregnancy, that child was also affected and died a few days after birth. Apart from the distinctive facial appearance and body shape, a postmortem examination showed only a cleft of the soft palate and unilobar lungs. During the index pregnancy an amniocentesis was performed at 15 weeks' gestation. Analysis by gas chromatography-mass spectrometry demonstrated an amniotic fluid cholesterol concentration that was low and a 7-dehydrocholesterol concentration that was markedly elevated. The ratio of 7-dehydrocholesterol to cholesterol in plasma from children with this disorder was similar to the ratio in the amniotic fluid of the fetus but much higher than that in plasma from both parents. However, the ratio in plasma from both parents was twice that in plasma from adult controls. Both detailed prenatal scanning and examination of the fetus after termination of the pregnancy demonstrated female external genitalia, a feature of affected male fetuses. The elevated ratio of 7-dehydrocholesterol to cholesterol in the parents suggests the possibility of identifying heterozygotes by this means. Hyett et al. (1995) found increased nuchal translucency at 11 weeks of gestation, indicating accumulation of fluid in the neck area in a fetus subsequently shown to have SLO syndrome. Because of the association of this defect with chromosomal abnormalities, fetal karyotyping was performed by chorion villus sampling and found to show a normal 46,XY karyotype. Subsequent ultrasound examinations showed resolution of the nuchal fluid, but at 20 weeks the fetal genitalia appeared to be female, an impression confirmed by fetoscopy. Fetal blood sampling confirmed a normal male karyotype. The terminated pregnancy produced a fetus with hypertelorism and hypertrichosis, postaxial polydactyly in one hand, and syndactyly of the second and third toes. A finding of increased levels of 7-dehydrocholesterol in cultured skin fibroblasts confirmed the diagnosis of SLO syndrome. Dallaire et al. (1995) presented retrospective analyses of amniotic fluid indicating that the prenatal diagnosis of SLO syndrome is possible on the basis of measurements of 7-dehydrocholesterol in amniotic fluid. Amniocentesis had been performed at 17.3 weeks in a pregnancy with severe intrauterine growth retardation (IUGR). The diagnosis of SLO syndrome was suspected in the neonatal period and confirmed by the presence of 7-DHC in the plasma associated with a low total cholesterol concentration. Retrospective analysis of the amniotic fluid sample revealed an elevated level of 7-DHC. Irons and Tint (1998) concluded that the presence of abnormally elevated levels of 7-DHC in chorionic villus samples and in amniotic fluid is an almost infallible indicator of SLOS. Sterol analysis by gas chromatography/MASS spectroscopy technology was the method used. Kratz and Kelley (1999) tested 7-dehydrocholesterol levels in 76 amniotic fluid specimens and 9 chorionic villus samples. Of 39 fetuses at 25% risk, 10 (25.6%) were affected. Twenty-nine pregnancies not known to be at risk for SLOS were studied either because of fetal abnormality characteristic of SLOS (polydactyly, ambiguous genitalia, or both) detected by ultrasound, a low maternal serum uE3 (MSuE3), or both. None of the pregnancies with isolated low MSuE3 was affected; 3 of 4 pregnancies with both fetal abnormality and low MSuE3 were affected; 2 additional pregnancies with unavailable MSuE3 and fetal abnormalities were affected. There was an inverse correlation between clinical severity and both amniotic fluid 7-dehydrocholesterol and MSuE3 concentrations. Shackleton et al. (1999) reported that the equine-type estriols 1,3,5(10),7-estratetraene-3,16-alpha,17-beta-triol (16-alpha-hydroxy-17-beta-dihydroequilin) and 1,3,5(10),6,8-estrapentaene-3,16-alpha,17-beta-triol (16-alpha-hydroxy-17-beta-dihydroequilenin) constituted over half of the estrogens excreted by a woman carrying a fetus with SLOS. Identification of these equine estrogens showed that an estrogen biosynthetic pathway parallel to normal is functional in the fetoplacental unit and uses 7-DHC as precursor, and therefore P450scc (118485), P450c17 (609300), 3-beta-HSD (613890), and P450(arom) (107910) are all active on 7-dehydrometabolites. Women pregnant with affected fetuses have low plasma estriol values (probably due to deficient production of the cholesterol precursor), and this is often a warning sign which instigates further evaluation for SLOS. These findings suggest the potential value of dehydroestriol measurement for noninvasive diagnosis of SLOS at midgestation, in addition to diagnosis that relies on imaging and measurement of 7-DHC levels in amniotic fluid and chorionic villus tissue. To investigate the antenatal expression of SLO syndrome, Goldenberg et al. (2004) reviewed a series of 30 cases. They found intrauterine growth retardation to be the most frequently detected trait (20/30), either in isolation (9/20) or in association with at least 1 other anomaly (11/20). Goldenberg et al. (2004) concluded that the combination of IUGR with another malformation, including nuchal edema, polydactyly, or a renal, cardiac, or genital malformation, should prompt consideration of the diagnosis of SLO syndrome. Jezela-Stanek et al. (2006) concluded that steroid measurements in maternal urine are a reliable basis for prenatal diagnosis of SLOS. Ten pregnancies at 25% risk of SLOS underwent prenatal testing.
Smith et al. (1964) reported 3 unrelated males with a strikingly similar combination of congenital anomalies: microcephaly, mental retardation, hypotonia, incomplete development of the male genitalia, short nose with anteverted nostrils, and, in 2, pyloric stenosis. A deceased ... Smith et al. (1964) reported 3 unrelated males with a strikingly similar combination of congenital anomalies: microcephaly, mental retardation, hypotonia, incomplete development of the male genitalia, short nose with anteverted nostrils, and, in 2, pyloric stenosis. A deceased male sib of one of these was probably affected. No parental consanguinity was discovered. Pauli et al. (1997) reassessed 1 of the patients reported by Smith et al. (1964) at age 34 years and described his physical, developmental, and behavioral manifestations. He was indeed found to have a cholesterol biosynthetic defect. A high cholesterol diet had been instituted and appeared to have had a beneficial effect on his behavior. Pinsky and DiGeorge (1965) reported affected brother and sister. Blair and Martin (1966) also described the condition in brother and sister. The male had hypospadias. Dallaire and Fraser (1966) described affected brothers and noted that blepharoptosis has been a feature of many cases. Lowry et al. (1968) described the combination of micrognathia, polydactyly, and cleft palate, resembling the syndrome known in the German literature as 'Typus Rostockiensis' or 'Ullrich-Feichtiger syndrome' but suggesting the Smith-Lemli-Opitz syndrome with respect to dermatoglyphics. Hoefnagel et al. (1969) and Fried and Fraser (1972) reported cases in adults. Syndactyly of toes 2 and 3 was said to be a frequent finding (Cowell, 1978). In 3 infants, including a brother and sister, Rutledge et al. (1984) described what they considered to be a 'new' lethal malformation syndrome. External features were mesomelic dwarfism, micrognathia, V-shaped upper lip, microglossia, thick alveolar ridges, ambiguous genitalia, webbed neck, highly arched palate, clubfeet, fused fontanels, inclusion cysts of the tongue, widely spaced nipples, and digital anomalies. Internal findings included oligopapillary renal hypoplasia, severe congenital heart defect, cerebellar hypoplasia, and pulmonary, laryngeal, and gallbladder hypoplasia. Both affected sibs showed polydactyly. Donnai et al. (1986) reported 3 unrelated infants with moderate limb shortening, joint contractures, and polydactyly. Two with an XY karyotype showed female external genitalia. Internal anomalies included unilobar lungs, hypoplasia of the anterior part of the tongue, and renal hypoplasia. Donnai et al. (1986) suggested that the disorder in their patients and in those reported by Lowry et al. (1968) and Kohler (1983) was not Smith-Lemli-Opitz syndrome, but a distinct disorder for which they suggested the designation Lowry-Miller-MacLean syndrome. Curry et al. (1987) gave an extensive review of 19 previously unreported patients with the disorder for which they suggested the designation Smith-Lemli-Opitz syndrome type II. Eighteen of their 19 patients had postaxial hexadactyly, 16 had congenital heart defects, 13 had cleft palate, and 10 had cataracts. Unusual findings at autopsy included Hirschsprung disease in 5, unilobar lungs in 6, large adrenals in 4, and pancreatic islet cell hyperplasia in 3. Early lethality was common. They found reports of 19 similar cases in the literature. Their report supported autosomal recessive inheritance by occurrence in 1 pair of sibs in their study and the report of recurrence in 3 of the reported families. Belmont et al. (1987) reported 2 cases of severe lethal SLOS. Eight cases of the same condition were described by Le Merrer et al. (1988), who suggested the designation of 'lethal acrodysgenital dwarfism.' Patients had failure to thrive, facial dysmorphism, ambiguous genitalia, syndactyly, postaxial polydactyly, and internal developmental anomalies such as Hirschsprung disease and cardiac and renal malformations. One of their cases showed parental consanguinity, and in another family 2 sibs were affected. Failure of masculinization in the SLO syndrome was emphasized by Patterson et al. (1983) and by Greene et al. (1984). Ambiguity of the external genitalia is a frequent feature of males. As shown by the case reported by Scarbrough et al. (1986) and 4 previously reported cases, in extreme instances there is complete failure of development of male external genitalia despite normal XY karyotype. This situation is similar to that in camptomelic dysplasia (114290). In a study of cases from the institution at which SLO syndrome was first described, Joseph et al. (1987) reviewed the genitourinary findings and reported upper urinary tract abnormalities in 57% and genital abnormalities in 71%. Bialer et al. (1987) reported a 46,XY infant with SLO syndrome with female external genitalia, intraabdominal testes with epididymides and deferent ducts, and a normally shaped uterus and vagina, polydactyly, cleft palate, and abnormalities of the kidneys, liver, and lungs. They reviewed 121 cases of SLO syndrome from the literature using a scoring system for severity. In 19 multiplex families, the affected sibs were generally similar in their SLOS scores. Overall degree of severity was positively correlated with genital abnormalities in males, polydactyly, and cleft palate. On the basis of studies of 2 cases of SLOS, McKeever and Young (1990) raised the question of a primary defect in the fetal adrenals resulting in a combination of low maternal estriol levels, sex reversal, and large adrenal glands in the fetus. Complete absence of lipid was observed in the adrenal cortex of 1 case. They suggested that the apparent suppression of maternal adrenal function in late pregnancy might, however, be secondary to fetomaternal transfer of an adrenal steroid that could not be processed normally by the fetal adrenals. Lachman et al. (1991) described a phenotypic female with SLOS and a 46,XY karyotype. The child also had clinical hypoglycemia with nesidioblastosis of the pancreas and died on the fifth day of life. An unusually high serum testosterone level suggested a possible defect in testosterone conversion to dihydrotestosterone or a deficiency of end-organ receptors for dihydrotestosterone. In an infant with SLO syndrome and 46,XY karyotype but normal internal and external genitalia of the female type, Fukazawa et al. (1992) found all normal sequences on the Y chromosome, using probes for 26 'loci' including SRY, the presumed gene for testis-determining factor (480000). Cunniff et al. (1997) reported the clinical and biochemical spectra of 80 patients (68 index cases and 12 family members) with abnormally increased levels of 7-dehydrocholesterol. The phenotypic spectrum ranged from isolated syndactyly of toes 2 and 3 to holoprosencephaly and multiple visceral anomalies resulting in death in utero. Plasma cholesterol concentration was inversely correlated with clinical severity. Little relationship was seen between severity score and 7-dehydrocholesterol concentration. However, 10% of patients had normal serum cholesterol concentrations and would have been missed without quantification of 7-dehydrocholesterol. Syndactyly of toes 2 and 3 was found in 79 of the 80 patients. Johnson (1975) reported 2/3 toe syndactyly in only 73% of his 55 SLO syndrome patients. This finding suggested to Cunniff et al. (1997) that as many as one quarter of previously documented SLOS patients may have had a different genetic disorder. Ryan et al. (1998) reported a review of all known cases of SLOS in the U. K. A total of 86 cases were initially identified with a diagnosis of SLOS, and a group of 49 with proven 7-dehydrocholesterol reductase deficiency were studied. Thirty-five (71%) were male. Twenty-four individuals were alive at the time of study; 20 had died, including 1 stillbirth, and 5 fetuses had been terminated. The frequent occurrence of hypospadias was thought to account for the high percentage of recognized cases being male. Mental retardation was present in 23 of 25 individuals; photosensitivity in 13 of 24; abnormal sleep pattern in 16 of 23; microcephaly in 32 of 40; short or proximally placed thumbs in 24; and congenital cardiac abnormalities in 18, with an atrioventricular septal defect present in 6. The typical facial appearance was found to become less obvious with age, and 20% of cases did not have 2/3 toe syndactyly. Serum 7-dehydrocholesterol levels did not correlate with clinical severity. Anderson et al. (1998) reported 2 sibs with variant SLOS and atypical sterol metabolism. Both sibs had mild growth retardation, mild developmental delay, ptosis, micrognathia, and mild syndactyly of toes 2 and 3. They both had low plasma cholesterol, but higher than that typically seen in SLOS patients. In addition, they both had only modest elevations of plasma 7-dehydrocholesterol. The parents had higher 7-dehydrocholesterol/cholesterol ratios compared to those of parents of classic SLOS patients. The authors postulated that this milder phenotype with more severe abnormalities of sterol metabolism in patients and parents may represent a phenocopy of classic SLOS. Alternatively, the Southeastern Cherokee ancestry shared by the parents may have affected the phenotype. Nowaczyk et al. (1998) reported 2 brothers and their female first cousin, all of nonconsanguineous unions, with mild SLOS. All children had moderate mental retardation and syndactyly of toes 2 and 3, but mild facial abnormalities. The brothers had mild ptosis, anteverted nares, mild micrognathia, and normal genitalia. The girl had mild retrognathia and syndactyly of the second and third toes apparent only from the plantar aspect. The authors suggested that the delay in diagnosis for these children, 31 months for the older brother and 11 years for the cousin, was due to lack of knowledge about SLOS among general and developmental pediatricians. They also suggested that the carrier rate of 1 to 2% among northern European Caucasians may be too low. Nowaczyk et al. (2001) reported the DHCR7 mutations in this family. The brothers' father had the rare thr289-to-ile missense mutation (T289I; 602858.0015). The 2 unrelated mothers were carriers of the common IVS8-1G-C (602858.0001) mutation. All 3 affected cousins had the IVS8-1G-C/T289I genotype. The authors suggested that the observed incidence of IVS8-1G-C homozygotes may be underestimated because of prenatal or perinatal lethality.
Koo et al. (2010) reported a girl who had a severe form of SLOS at birth, with multiple congenital anomalies affecting many organ systems. However, after birth, she showed less neurologic impairment than expected. She rolled from side ... Koo et al. (2010) reported a girl who had a severe form of SLOS at birth, with multiple congenital anomalies affecting many organ systems. However, after birth, she showed less neurologic impairment than expected. She rolled from side to side at age 7 months, could stand with assistance at 11 months, and gained some fine motor control. Serum 7-dehydrocholesterol was increased at age 4 months but later fell to normal range, and serum cholesterol was normal. Compared to patients with a more severe phenotype and with a less severe phenotype, Koo et al. (2010) observed a discordance in this patient: she was more severely affected, but had a lower 7-dehydrocholesterol/cholesterol ratio, which was usually observed in less severely affected individuals. Genetic analysis identified compound heterozygosity for 2 mutations in the DHCR7 gene: the common IVS8-1G-C splice site mutation (602858.0001) and a splice site mutation in intron 5 (602858.0022). RT-PCR studies of patient fibroblasts showed 3 bands, including a wildtype band, indicating that some residual wildtype protein was produced from the intron 5 mutation. However, patient fibroblasts showed a defect in sterol synthesis in cholesterol-deficient medium. Koo et al. (2010) noted that there is a high need for cholesterol during embryonic development, which may have explained why this child was born with so many abnormalities. After birth, the residual enzyme activity conferred by the intron 5 mutation and the addition of dietary cholesterol may have been sufficient to allow some developmental acquisition.
In 3 unrelated patients with SLOS, Wassif et al. (1998) identified 4 different mutations in the DHCR7 gene (602858.0001-602858.0004). Fitzky et al. (1998) identified mutations in the DHCR7 gene (see, e.g., 602858.0009 and 602858.0011) in patients with SLOS. ... In 3 unrelated patients with SLOS, Wassif et al. (1998) identified 4 different mutations in the DHCR7 gene (602858.0001-602858.0004). Fitzky et al. (1998) identified mutations in the DHCR7 gene (see, e.g., 602858.0009 and 602858.0011) in patients with SLOS. Yu et al. (2000) reported a simple PCR-based restriction endonuclease digestion assay for rapid detection of a G-to-C transversion in the splice acceptor site of exon 9 (IVS8-1G-C) of DHCR7 (602858.0001). The mutation results in abnormal splicing of exon 9 with a 134-basepair insertion of intron 8 sequences, a resultant frameshift, and a premature translation stop. The authors identified this mutation in 21 of 33 SLOS propositi (21/66 alleles). Since none of their patients was homozygous for the mutation, the authors hypothesized that homozygosity for the mutation may often be prenatally lethal. They also screened unrelated normal individuals for the prevalence of the mutation, including 90 American Caucasians, 120 Finnish Caucasians, 121 Sierra Leone Africans, 95 Han Chinese, and 103 Japanese. One IVS8-1G-C mutation was identified in the American Caucasian population; none was observed in the other populations. Yu et al. (2000) concluded that the IVS8-1G-C transversion is a very common mutation in SLOS patients from the U.S. Yu et al. (2000) screened an additional 32 patients with SLOS, 28 from the U.S. and 4 from Sweden. Twenty missense mutations, 1 nonsense mutation (602858.0012), and 1 splice site mutation (IVS8-1G-C; 602858.0001) were detected. All probands were heterozygous for mutations. Three mutations accounted for 54% of those observed in their cohort, IVS8-1G-C (22/64 alleles, 34%), T93M (602858.0009) (8/64, 12.5%), and V326L (602858.0011) (5/64, 7.8%). Severity of SLOS was negatively correlated with both plasma cholesterol and relative plasma cholesterol, but not with 7-dehydrocholesterol, the immediate precursor, confirming previous observations. However, no correlation was observed between mutations and phenotype, suggesting that the degree of severity may be affected by other factors. The authors estimated that 33 to 42% of the variation in the SLOS severity score is accounted for by variation in plasma cholesterol, suggesting that factors other than plasma cholesterol are additionally involved in determining severity. Nowaczyk et al. (2001) described a fetus and 2 newborns with a severe form of SLOS that included holoprosencephaly; all 3 were homozygous for the common DHCR7 mutation, IVS-1G-C (602858.0001), a truncating mutation that is expected to result in virtually absent enzyme activity. Nowaczyk et al. (2001) stated that of 6 previously reported severely affected newborns with SLOS who were homozygous for this mutation, none had holoprosencephaly. Langius et al. (2003) reported 3 patients from 2 families with a very mild clinical presentation of SLOS. Their plasma cholesterol values were normal and their plasma levels of 7- and 8-DHC were only slightly elevated. In cultured skin fibroblasts, a significant residual 7-DHCR activity was found. All 3 patients were compound heterozygotes for a novel mutation (M1L; 602858.0017) affecting initiation translation. In 2 of the patients, the other mutation present in heterozygous state was the common splice site mutation IVS8-1G-C. The third patient had an E448K missense mutation (602858.0018) in the DHCR7 gene. - Modifier Genes Witsch-Baumgartner et al. (2004) determined common APOE (107741) and DHCR7 genotypes in 137 unrelated patients with Smith-Lemli-Opitz syndrome and 108 of their parents (59 mothers and 49 fathers). There was a significant correlation between patients' clinical severity scores and maternal APOE genotypes (p = 0.028) but not between severity scores and patients' or paternal APOE genotypes. Presence of the maternal APOE2 allele was associated with a more severe phenotype, and the association persisted after stratification for DHCR7 genotype. Witsch-Baumgartner et al. (2004) suggested that the efficiency of cholesterol transport from the mother to the embryo is affected by maternal APOE genotype, and that APOE plays a role in modulation of embryonic development and malformations.
In British Columbia, Lowry (1982) found the RSH syndrome (Opitz's designation for SLOS) to be the second most frequent recessive disorder (after cystic fibrosis). Chasalow et al. (1985) suggested that the carrier frequency of this disorder may be ... In British Columbia, Lowry (1982) found the RSH syndrome (Opitz's designation for SLOS) to be the second most frequent recessive disorder (after cystic fibrosis). Chasalow et al. (1985) suggested that the carrier frequency of this disorder may be as high as 1 to 2%. Tint et al. (1994) estimated the frequency of the SLO syndrome as 1 in 20,000 to 1 in 40,000. SLOS occurs in relatively high frequency: approximately 1 in 20,000 to 30,000 births in populations of northern and central European background (Ryan et al., 1998). Nowaczyk et al. (2001) estimated that the incidence of SLOS in the population of European origin in Ontario, Canada, was at least 1 in 22,700. As infants with mild forms of SLOS born during the period of the study may have been undiagnosed, this number was probably an underestimate. The authors suggested that this observation had implications for prenatal and newborn screening. To determine the carrier frequency of SLOS, Battaile et al. (2001) screened 1,503 anonymous blood samples of random newborn screening blood spot cards from Oregon for the presence of the common SLOS mutation IVS8-1G-C (602858.0001). Sixteen carriers were identified. Since this mutation accounts for about one-third of known SLOS mutations, the calculated carrier frequency for all mutations is 1 in 30, predicting an SLOS incidence between 1 in 1,590 to 1 in 13,500 and suggesting a higher incidence of SLOS than was previously suspected. However, even a slight variation in the frequency of the IVS8-1G-C mutation among SLOS gene mutations would dramatically change the carrier rate. Witsch-Baumgartner et al. (2001) reported mutation analysis of the DHCR7 gene in 59 SLOS patients; 15 patients were from Poland, 22 from Germany/Austria, and 22 from Great Britain. Mutations were detected on 114 of 118 SLOS chromosomes (96.6%). Altogether, 35 different mutations were identified, but in all 3 populations 3 mutations accounted for more than 50% of SLOS alleles. The mutation spectra were, however, significantly different across these populations. W151X (602858.0010) was the most frequent mutation in the Polish population (33.3%), had an intermediate frequency in German/Austrian patients (18.2%), and was rare in British patients (2.3%). The V326L mutation (602858.0011) showed the same east-west gradient. In contrast, the IVS8-1G-C mutation (602858.0001) was most frequent in Britain (34.1%), intermediate in Germany/Austria (20.5%), and rare in Poland (3.3%). Haplotype analysis using 8 single nucleotide polymorphisms in the coding sequence of the DHCR7 gene gave evidence for both recurrent mutations and founder effects; all IVS8-1G-C and V326L alleles shared the same haplotype, whereas the W151X allele occurred on different haplotypes. Witsch-Baumgartner et al. (2001) concluded that the distribution pattern of DHCR7 mutations in Europe may reflect ancient and modern migrations in Europe. Witsch-Baumgartner et al. (2008) confirmed the findings of Witsch-Baumgartner et al. (2001) by mutation analysis of 263 European SLOS patients. The mutation spectrum varied significantly between populations, with increased frequency of IVS8-1G-C in the northwest, W151X and V326L in the northeast, and T93M in southern Europe. SLOS was virtually absent in Finland. Haplotype and chimpanzee ortholog analyses indicated that the IVS8-1G-C and Y151X mutations appeared about 3,000 years ago in northwest and northeast Europe, respectively. The T93M mutation probably arose about 6,000 years ago in the eastern Mediterranean region. Kalb et al. (2012) identified the T93M mutation in 9 (36%) of 26 mutant alleles from 13 Turkish patients with SLO syndrome. Three probands were homozygous for the mutation. No carriers of T93M were identified in 771 control individuals. The allele frequency was estimated to be no more than 1 in 420. Among 15,825 ethnically diverse individuals screened for Smith-Lemli-Opitz carrier status, Lazarin et al. (2013) identified 232 carriers (1.5%), for an estimated carrier frequency of 1 in 68. Three 'carrier couples' were identified.
Clinical diagnostic criteria have not been established for Smith-Lemli-Opitz syndrome (SLOS). A pattern of congenital anomalies suggests the diagnosis. The following are the most commonly observed features:...
Diagnosis
Clinical DiagnosisClinical diagnostic criteria have not been established for Smith-Lemli-Opitz syndrome (SLOS). A pattern of congenital anomalies suggests the diagnosis. The following are the most commonly observed features:Characteristic facial featuresMicrocephalyPostaxial polydactyly2-3 syndactyly of the toesGrowth retardation and intellectual disabilityCleft palateHypospadias in malesTestingDecreased activity of the enzyme 7-dehydrocholesterol (7-DHC) reductase results in failure to convert 7-DHC to cholesterol [Irons et al 1993, Irons et al 1994, Tint et al 1994, Elias & Irons 1995]:Serum concentration of 7-DHC. The diagnostic test is an elevation of serum concentration of 7-DHC as defined by the laboratory for a given patient. Note: (1) 7-DHC concentration is usually measured in blood samples, but can be measured in other tissues. (2) Some individuals on psychotropic medications can have elevated 7-DHC levels secondary to the medication, giving rise to true false-positive test results. Such individuals rarely have the physical features of SLOS, but may be tested for SLOS because of neurocognitive issues; molecular genetic testing and/or fibroblast testing is needed to clarify the diagnosis. (3) Different laboratories may report results in different units. Laboratories in the US report results as milligrams per deciliter or micrograms per milliliter; European laboratories most often report results as millimoles per liter. Thus, direct comparison of values between laboratories requires caution.Serum concentration of cholesterol. Although most affected individuals have hypocholesterolemia, serum concentration of cholesterol values in normal and affected individuals can overlap, particularly when the affected individuals are older or have a milder phenotype [Kelley 1995]. Because normal serum concentrations of cholesterol change with age, values must be considered in the context of the individual. Note: Serum concentration of cholesterol determined by the method employed in most hospital laboratories, which measures total cholesterol (cholesterol plus the precursors), does not identify all individuals with SLOS because total cholesterol levels can be in the normal range.Carrier detectionBecause of considerable overlap between the ranges of serum concentration of cholesterol and 7-DHC in carriers and non-carriers, carrier status cannot be determined by measuring the serum concentration of either compound.However, biochemical testing of fibroblasts has been successful in carrier detection [Shefer et al 1997].Carrier testing is also possible by molecular genetic analysis if the disease-causing mutations in the family are known.Molecular Genetic TestingGene. DHCR7, encoding 7-DHC reductase [Fitzky et al 1998, Wassif et al 1998, Waterham et al 1998], is the only gene in which mutation is known to cause SLOS.Clinical testing. Most affected individuals are compound heterozygotes for two different abnormal alleles, with an overall mutation detection rate of 96% in one series of 133 individuals [Witsch-Baumgartner et al 2001]. Most of the affected individuals studied have two detectable mutations; rare individuals had only one detectable mutation [Yu & Patel 2005]. It has been hypothesized that mutations that are not found by routine testing methods are regulatory mutations that affect either transcription or stability of the DHCR7 mRNA [Correa-Cerro & Porter 2005]:Sequence analysis. Sequence analysis of all exons and all intron-exon boundaries detects mutations in approximately 96% of affected individuals [Witsch-Baumgartner et al 2001].Targeted mutation analysis. In addition to offering sequence analysis of the coding region, some laboratories offer targeted mutation analysis of common mutation(s). The mutations included in testing panels vary among laboratories.Table 1. Summary of Molecular Genetic Testing Used in Smith-Lemli-Opitz SyndromeView in own windowTest MethodMutations DetectedMutation Detection Frequency by Test Method 1Test AvailabilitySequence analysis
Point mutations in DHCR7>80%Clinical Targeted mutation analysisMutations in testing panels (variable by laboratory)Variable1. The ability of the test method used to detect a mutation that is present in the indicated geneInterpretation of test results. For issues to consider in interpretation of sequence analysis results, click here.Testing StrategyTo confirm the diagnosis in a proband with equivocal biochemical test results. Molecular genetic testing of DHCR7 is generally considered a second-tier test and may be useful in instances in which serum concentration of 7-DHC is difficult to interpret, or in which only DNA from the affected individual is available.Carrier testing for at-risk relatives requires molecular genetic testing; prior identification of the disease-causing mutations in the family is necessary.Note: Carriers are heterozygotes for an autosomal recessive disorder and are not at risk of developing the disorder.Prenatal diagnosis and preimplantation genetic diagnosis (PGD) for at-risk pregnancies require molecular genetic testing; prior identification of the disease-causing mutations in the family is necessary.Genetically Related (Allelic) DisordersNo other phenotypes are known to be associated with mutations in DHCR7.
Classic Smith-Lemli-Opitz syndrome (SLOS) is characterized by prenatal and postnatal growth retardation, microcephaly, moderate to severe intellectual disability, and multiple major and minor malformations including characteristic facial features, cleft palate, abnormal gingivae, cardiac defects, hypospadias, ambiguous genitalia (failure of masculinization of male genitalia), postaxial polydactyly, and 2-3 toe syndactyly [Cunniff et al 1997, Ryan et al 1998, Krajewska-Walasek et al 1999, Kelley & Hennekam 2000]. Individuals with milder forms may have only subtle facial characteristics, hypotonia, 2-3 toe syndactyly, and mild developmental delay. Clinical variability is noted even within families as sibs with SLOS have been reported with medical and developmental problems of different degrees....
Natural History
Classic Smith-Lemli-Opitz syndrome (SLOS) is characterized by prenatal and postnatal growth retardation, microcephaly, moderate to severe intellectual disability, and multiple major and minor malformations including characteristic facial features, cleft palate, abnormal gingivae, cardiac defects, hypospadias, ambiguous genitalia (failure of masculinization of male genitalia), postaxial polydactyly, and 2-3 toe syndactyly [Cunniff et al 1997, Ryan et al 1998, Krajewska-Walasek et al 1999, Kelley & Hennekam 2000]. Individuals with milder forms may have only subtle facial characteristics, hypotonia, 2-3 toe syndactyly, and mild developmental delay. Clinical variability is noted even within families as sibs with SLOS have been reported with medical and developmental problems of different degrees.Prematurity and breech presentation are common. Neonates frequently have poor suck, irritability, and failure to thrive [Pinsky & DiGeorge 1965].Infants with SLOS frequently have feeding problems secondary to a combination of hypotonia, oral-motor incoordination, and gastrointestinal problems that include dysmotility, hypomotility, gastrointestinal reflux, constipation, and formula intolerance. In general, infants with the more severe phenotype have more feeding problems. Children and adults with SLOS are generally smaller than average.Pyloric stenosis and Hirschsprung disease have been reported [Dallaire & Fraser 1966, Patterson et al 1983, Lipson & Hayes 1984]. Constipation is a common problem. Liver disease is variable and can range from severe cholestasis (generally in those who are more severely affected) to mild/moderate stable elevation of serum amino transferases [Rossi et al 2005].Cognitive function ranges from borderline intellectual capability to severe intellectual disability. Low normal intellectual function can be seen in individuals with mild or variant forms of SLOS [Mueller et al 2003].Behavioral signs/symptoms include sensory hyperreactivity, irritability, sleep cycle disturbance, self-injurious behavior (hand biting and/or head banging), autism spectrum behaviors (46%-53%), temperament dysregulation, and social and communication deficits [Tierney et al 2000, Tierney et al 2001]. Many individuals require very little sleep, often only a few hours per night.Depression and other psychiatric problems have been reported in older individuals.Developmental abnormalities of the central nervous system include microcephaly (80%-84%), abnormalities of myelination, ventricular dilatation, malformations of the corpus callosum and/or cerebellum, Dandy-Walker malformation and its variants, and holoprosencephaly (5%) [Ryan et al 1998, Kelley & Hennekam 2000, Caruso et al 2004]. Hypotonia, which is common in young children, affects feeding and delays motor development. Older children often exhibit hypertonia.Photosensitivity, which is commonly seen in SLOS, appears to be UVA mediated [Anstey 2001]. Photosensitivity can be severe and can result from even brief exposure to sunlight. Many children cannot tolerate any exposure to sunlight; others can tolerate varying periods of exposure if properly clothed and protected with a UVA- and UVB-protection sunscreen.Hypospadias and/or bilateral cryptorchidism occur in 50% of reported males with SLOS [Gorlin et al 1990, Lin et al 1997]. Bicornuate uterus and septate vagina have been noted in 46,XX females [Lowry et al 1968]. Because genital abnormalities are easier to recognize in males than females, males are more likely than females to be evaluated for a diagnosis of SLOS [Pinsky & DiGeorge 1965, Dallaire & Fraser 1966, Gorlin et al 1990]. Other findings include persistent urogenital sinus and posterior labial fusion without clitoromegaly in a female with an XX karyotype [Chemaitilly et al 2003] and precocious puberty in girls with SLOS [Starck et al 1999; Irons, unpublished].Since the report of Curry et al [1987], it has been recognized that many 46,XY individuals with severe manifestations of SLOS have extreme undermasculinization of the external genitalia, resulting in female external genitalia (termed "sex reversal"). Lin et al [1997] reported that 20%-25% of individuals with SLOS described in the literature have a 46,XY karyotype with a female phenotype.Characteristic facial features include temporal narrowing, epicanthal folds, blepharoptosis, a broad nasal bridge and short nasal root, anteverted nares, cleft palate, often low-set and posteriorly rotated ears, and micrognathia [Lowry et al 1968, Fierro et al 1977]. Cleft palate is present in 40%-50% of affected individuals reported [Johnson 1975, Cunniff et al 1997] and may contribute to feeding and growth problems. The neck is often short with redundant skin at the nape.Congenital cataracts are present in approximately 20% of affected individuals [Finley et al 1969, Cunniff et al 1997, Lin et al 1997]. Other ophthalmologic manifestations include ptosis, strabismus, optic atrophy, and optic nerve hypoplasia [Atchaneeyasakul et al 1998].Cunniff et al [1997] and Lin et al [1997] reported that up to 50% of their patients had an identified cardiac defect. They also reported an increased incidence of atrioventricular canal defects and anomalous pulmonary venous return when compared with an unselected series of individuals with SLOS [Park et al 1968, Lin et al 1997].Cardiorespiratory problems can occur secondary to malformations of the heart or respiratory tract, including the trachea or larynx. An increased frequency of upper- and/or lower-respiratory infections is seen particularly in infancy and early childhood.Renal hypoplasia and cystic kidneys have been reported [Thompson & Baraitser 1986].Syndactyly of the second and third toes is a common, but not universal, finding. Postaxial polydactyly is present in one quarter to one half of all affected individuals [Gorlin et al 1990, Cunniff et al 1997, Lin et al 1997]. Less common findings include hypoplastic or short thumbs, clinodactyly, hammer toes, and dorsiflexed halluces [Pinsky & DiGeorge 1965, Opitz 1969].Because cholesterol is a precursor of steroid hormones, including cortisol, aldosterone, and testosterone, endocrine problems can be seen, including electrolyte abnormalities, hypoglycemia, and hypertension. Adrenal insufficiency can result in severe electrolyte abnormalities [Chemaitilly et al 2003]. Low serum concentrations of testosterone have been seen in severely affected males [Chasalow et al 1985].Other medical/dental issues include recurrent otitis media, splenomegaly, and hearing loss (both conductive and sensorineural). Seizures can occur but are not common.
Biochemical. Although strict correlations between the serum concentration of cholesterol and clinical outcome are not possible, most studies have identified an inverse correlation between serum concentration of cholesterol and clinical severity [Tint et al 1995, Cunniff et al 1997, Yu et al 2000b]. Mortality is particularly high in the group of individuals with the lowest cholesterol concentrations (~10 mg/dL)....
Genotype-Phenotype Correlations
Biochemical. Although strict correlations between the serum concentration of cholesterol and clinical outcome are not possible, most studies have identified an inverse correlation between serum concentration of cholesterol and clinical severity [Tint et al 1995, Cunniff et al 1997, Yu et al 2000b]. Mortality is particularly high in the group of individuals with the lowest cholesterol concentrations (~10 mg/dL).Molecular genetic. A strict genotype-phenotype correlation is difficult because most affected individuals are compound heterozygotes. However, a severe phenotype has been described in homozygotes for the two functional null alleles c.832-1G>C (IVS8-1G>C, the intron 8 splice acceptor) and p.Trp151, and for the missense mutation p.Arg404Cys [Witsch-Baumgartner et al 2000].Witsch-Baumgartner et al [2000] found a general correlation in severity, depending on whether the mutation was a putative null mutation, a mutation in the large cytoplasmic domain, a transmembrane domain mutation, or a C-terminal mutation. However, the significant variation seen in severity, even among individuals with similar mutations, suggests significant influences on phenotype other than the DHCR7 mutation [Porter 2000]. One important factor may include transport of cholesterol from the mother to the fetus early in pregnancy. A more severe phenotype has been seen in offspring of women who have an APOE E2 allele [Witsch-Baumgartner et al 2004, Woollett 2005], which may interfere with binding of apo E-containing maternal lipoproteins in the placenta.
Although many malformation syndromes share at least some of the clinical features of SLOS (e.g., polydactyly, hypospadias, cleft palate), they rarely have more than two of these features in common. In particular, the Y-shaped 2-3 toe syndactyly, present in most individuals with SLOS, is rarely seen in other disorders. The biochemical findings (Clinical Diagnosis) should allow for ready differentiation between individuals with SLOS and those with conditions that are clinically and biochemically similar....
Differential Diagnosis
Although many malformation syndromes share at least some of the clinical features of SLOS (e.g., polydactyly, hypospadias, cleft palate), they rarely have more than two of these features in common. In particular, the Y-shaped 2-3 toe syndactyly, present in most individuals with SLOS, is rarely seen in other disorders. The biochemical findings (Clinical Diagnosis) should allow for ready differentiation between individuals with SLOS and those with conditions that are clinically and biochemically similar.Other sterol metabolic disorders include the following (although the pattern of sterol abnormalities is distinct from that seen in SLOS):Beta-sitosterolemia (abnormal sterol biosynthesis, normal to elevated cholesterol levels, episodic hemolysis, tuberous xanthomatosis, early atherosclerosis).CHILD syndrome (congenital hemidysplasia, ichthyosiform nevus, limb defects)Desmosterolosis (macrocephaly, hypoplastic nasal bridge, thick alveolar ridges, gingival nodules, cleft palate, total anomalous pulmonary venous drainage, ambiguous genitalia, short limbs, generalized osteosclerosis)Mevalonicaciduria (normal to slightly reduced cholesterol levels, developmental delay, dysmorphic facial features, central cataracts, anemia, hepatosplenomegaly).X-linked dominant chondrodysplasia punctata (alopecia, cataracts, ichthyosis, punctate calcification of bones, rhizomelic limb shortening)Disorders with similar clinical findings include the following:Trisomy 13 syndrome (holoprosencephaly, cleft lip and cleft palate, cardiac defects, polydactyly)Trisomy 18 syndrome (growth retardation, characteristic facial appearance, short sternum, cardiac defects, camptodactyly, early lethality)Dubowitz syndrome (growth retardation, blepharophimosis, toe syndactyly, eczema, immune deficiency)Meckel-Gruber syndrome (encephalocele, cystic renal disease, polydactyly)Noonan syndrome (growth retardation, downslanting palpebral fissures, broad posterior neck, pulmonic stenosis, hypospadias)Russell-Silver syndrome (intrauterine growth retardation, limb asymmetry, fifth finger clinodactyly)Simpson-Golabi-Behmel syndrome (macrosomia, facial clefts, polydactyly)Pseudotrisomy 13 syndrome (holoprosencephaly, polydactyly)Pallister-Hall syndrome (hypothalamic hamartoblastoma, polydactyly)Nguyen syndrome [Nakane et al 2005]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 Smith-Lemli-Opitz syndrome (SLOS), the following evaluations are recommended:...
Management
Evaluations Following Initial DiagnosisTo establish the extent of disease in an individual diagnosed with Smith-Lemli-Opitz syndrome (SLOS), the following evaluations are recommended:Physical examination with special attention to growth parameters, congenital anomalies, and neurologic findings (hypotonia/hypertonia, seizures)Developmental assessmentOphthalmologic evaluation for strabismus, cataracts, and functional eye problemsCardiac evaluation (ECG and echocardiogram) for congenital defectsMusculoskeletal evaluation for delineation of syndactyly, polydactyly, abnormalities of tone, and need for ankle-foot orthoses (AFOs) or other orthoticsGenitourinary examination for anomalies of external genitalia in males and femalesEvaluation for functional problems of the gastrointestinal system by history and, if indicated, studies for pyloric stenosis and gastroesophageal reflux. Particular attention should also be given to stooling pattern, abdominal distention, or other signs of possible bowel obstruction, particularly in children with a more severe phenotype, because of their risk for Hirschsprung disease.Nutritional assessment for feeding problems and poor weight gainPossible MRI or other cranial imaging to evaluate for holoprosencephaly and/or other brain anomaliesRenal ultrasound evaluation for renal anomaliesHearing evaluation for either sensorineural or conductive hearing lossLaboratory evaluation including glucose and electrolytes (for adrenal insufficiency), serum concentrations of amino transferases and bilirubin (for cholestatic liver disease), and testosterone in malesTreatment of ManifestationsCholesterol SupplementationDevising a treatment strategy for SLOS has been difficult as all factors contributing to the clinical phenotype are not yet known with certainty. It is likely that both low cholesterol levels and elevation of the cholesterol precursors 7-DHC and 8-DHC contribute to many of the clinical findings in affected individuals. Therefore, treatment strategies to date have focused on supplying exogenous cholesterol (either as egg yolks or as crystalline cholesterol in either an oil-based or aqueous suspension) in an attempt to raise cholesterol levels and secondarily decrease the levels of the precursors 7-DHC and 8-DHC. In general, patients with a more severe biochemical defect require larger doses of cholesterol.It should be emphasized that dietary studies on cholesterol supplementation have not been conducted in a randomized fashion. Although improved growth [Elias et al 1997, Irons et al 1997], reduced photosensitivity [Azurdia et al 2001, Starck et al 2002a], and increased nerve conduction velocity [Starck et al 2002a] have been objectively documented, evidence for other benefits such as behavioral and developmental improvement is largely anecdotal [Elias et al 1997, Nwokoro & Mulvihill 1997]. Nonetheless, cholesterol supplementation should be considered in all individuals with SLOS because it may result in clinical improvement and has minimal side effects [Elias et al 1997, Nwokoro & Mulvihill 1997, Battaile & Steiner 2000].Other TreatmentsReferral to appropriate early intervention and physical/occupational/speech therapies is often required for identified disabilities.Many infants have difficulty with suck and/or swallow and may require gastrostomy for feeding and support of a nutritionist to help monitor caloric intake and growth. Infants with severe feeding problems generally require the insertion of gastrostomy tubes and/or the use of hypoallergenic, elemental formulas. Because children with SLOS have low muscle mass, careful monitoring of weight gain and growth is necessary so that overconsumption of calories does not lead to obesity.For those with frequent vomiting or apparent gastroesophageal reflux, a diagnosis of pyloric stenosis should be considered and treated as in the general population. Gastrointestinal reflux and/or constipation require treatment by a gastroenterologist.Neonatal cholestatic liver disease often resolves with cholesterol and/or bile acid therapy.Surgical repair may be required for cataracts, ptosis, and/or strabismus.Syndactyly of hands and/or feet and/or polydactyly may require surgical repair.Orthopedic management of the early hypotonia and later hypertonia includes the use of AFOs and other orthotics, as well as physical and occupational therapy.Tendon release surgery or Botox® therapy may be indicated in older children with significant hypertonia.Dental management can be challenging. Proper positioning, choice of dental devices, and sedation techniques need to be considered [Muzzin & Harper 2003].Recurrent otitis media may require tympanostomy tube placement.Photosensitivity can be severe and many children cannot tolerate any exposure to sunlight; others can tolerate varying periods of exposure if properly clothed and protected with a UVA- and UVB-protection sunscreen.Prevention of Secondary ComplicationsIn moderately to more severely affected patients, treatment with stress steroids in doses customarily used for children with congenital adrenal hyperplasia (see 21-Hydroxylase-Deficient Congenital Adrenal Hyperplasia) is recommended during periods of illness, stress, or prolonged decrease in oral intake.Anesthetic problems including muscular rigidity and malignant hyperthermia have been reported [Choi & Nowaczyk 2000]. Airway management during anesthesia may be challenging; use of a laryngeal mask airway has been successful [Leal-Pavey 2004, Matveevskii et al 2006].SurveillanceRoutine health supervision by a physician familiar with SLOS, its complications, and its treatment includes the following:History, physical examination, and monitoring of growth parameters, with the frequency to be determined by the severity of the child's conditionAge-appropriate developmental assessment at least twice a year until age three years and annually thereafterNutritional assessment at least every three to four months until age two years and twice yearly thereafterMonitoring of cholesterol and serum concentration of 7-DHC and serum amino transferases (ALT and AST) every three to four months in the first few years of life and twice yearly thereafterAgents/Circumstances to AvoidTreatment with haloperidol, which has a high affinity for the DHCR7 substrate binding site, may exacerbate the biochemical sterol abnormalities in patients with SLOS and cause an increase in symptoms. It is likely that other drugs in this class will cause the same change in sterol levels [Kelley & Hennekam 2000].Thus, one must weigh the benefit of such medications fagainst the potential negative side effects. As many patients with SLOS do require psychotropic medications, close monitoring of clinical signs/symptoms and serum concentration of 7-DHC is recommended.Photosensitivity can be severe and extended periods of sun exposure should be avoided, as severe sunburn can occur with only limited exposure; however, limited sun exposure is possible for some affected individuals as long as protective clothing is worn and a sunscreen with UVA and UVB properties is used.Evaluation of Relatives at RiskAll sibs should be tested either prenatally or shortly after birth.See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.Therapies Under InvestigationJira et al [2000] used the HMG-CoA reductase inhibitor simvastatin to treat two affected individuals for 14 and 23 months, resulting in normalization of cholesterol levels and a decrease of plasma precursors by 28% and 33%. Improvement in the precursor/cholesterol ratio in the cerebrospinal fluid was also found. Morphometric parameters improved in both individuals, and no adverse side effects were observed.Starck et al [2002b] treated two affected individuals with simvastatin, cholesterol supplementation, and bile acids and found reduction in absolute and relative serum concentration of 7-DHC. However, in one of these individuals, simvastatin was discontinued after hepatotoxic side effects and increased photosensitivity were observed.Search ClinicalTrials.gov for access to information on clinical studies for a wide range of diseases and conditions.OtherFor more severely affected infants with SLOS, the issues of surgical management of congenital anomalies such as cleft palate, congenital heart disease, and genital anomalies need to be considered as they would be in any other infant with a severe, usually lethal disorder.Reassignment of sex of rearing for infants with a 46,XY karyotype and female genitalia may not always be appropriate because most will have early death, and the process of gender reassignment can be highly disruptive to a family already coping with the difficult issues of having a child with a genetic disorder characterized by life-threatening medical complications.
Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED....
Molecular Genetics
Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED.Table A. Smith-Lemli-Opitz Syndrome: Genes and DatabasesView in own windowGene SymbolChromosomal LocusProtein NameLocus SpecificHGMDDHCR711q13.4
7-dehydrocholesterol reductaseDHCR7 homepage - Mendelian genesDHCR7Data 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 Smith-Lemli-Opitz Syndrome (View All in OMIM) View in own window 270400SMITH-LEMLI-OPITZ SYNDROME; SLOS 6028587-@DEHYDROCHOLESTEROL REDUCTASE; DHCR7Normal allelic variants. DHCR7 contains nine exons and eight introns and spans 14,100 base pairs; exons 3-9 encode the protein 7-dehydrocholesterol reductase [Witsch-Baumgartner et al 2001]. The gene has an open reading frame of 1425 nucleotides.Pathologic allelic variants. More than 120 mutations have been described [Correa-Cerro & Porter 2005, Yu & Patel 2005] (see Table 2).The most frequently found abnormal allele (28.2%) is c.832-1G>C (IVS8-1G>C), a splice site acceptor mutation in the last base of intron 8 that leads to an alternative upstream cryptic splice acceptor site. This results in the insertion of 134 base pairs of intronic sequence into the DHCR7 mRNA, resulting in a frameshift and premature stop codon.Other common abnormal alleles and their estimated frequencies include p.Thr93Met (10.4%), p.Trp151* (6.0%), p.Arg404Cys (5.2%), p.Val326Leu (5.0%), p.Arg352Trp (3.2%), p.Glu448Lys (3.2%), p.Gly410Ser (2.2%), p.Arg242Cys (1.8%), p.Ser169Leu (1.7%), p.Phe302Leu (1.3%), and p.Arg242His (1.0%). The 12 mutations account for 69.2% of reported alleles [Correa-Cerro & Porter 2005].Approximately 90% of mutations are missense mutations distributed among all coding exons, in addition to a relatively few nonsense mutations, splicing defects, insertions, and deletions, which presumably result in loss of enzymatic activity and represent functional null alleles [Witsch-Baumgartner et al 2001].Table 2. Selected DHCR7 Pathologic Allelic VariantsView in own windowDNA Nucleotide Change (Alias 1)Protein Amino Acid ChangeReference Sequence c.278C>Tp.Thr93MetNM_001360.2c.452G>Ap.Trp151*c.506C>Tp.Ser169Leuc.724C>Tp. Arg242Cysc.725G>Ap.Arg242Hisc.906C>Gp.Phe302Leuc.976G>Tp.Val326Leuc.1054C>Tp.Arg352Trpc.1210C>Tp.Arg404Cysc.1228G>Ap.Gly410Serc.832-1G>C (IVS8-1G>C)--c.1342G>Ap.Glu448LysSee Quick Reference for an explanation of nomenclature. GeneReviews follows the standard naming conventions of the Human Genome Variation Society (www.hgvs.org).1. Variant designation that does not conform to current naming conventionsNormal gene product. The gene has an open reading frame of 1425 nucleotides and encodes a 475-amino acid polypeptide with a predicted molecular weight of 54.5 kd [Porter 2000]. The normal gene product is 7-dehydrocholesterol (7-DHC) reductase (3β-hydroxysteroid-Δ7-reductase), the last enzymatic step in cholesterol biosynthesis [Irons et al 1993, Irons et al 1994, Tint et al 1994, Elias & Irons 1995], which catalyzes the conversion of 7-DHC to cholesterol.Abnormal gene product. Decreased function of 7-DHC reductase fails to convert 7-DHC to cholesterol, resulting in elevation of the cholesterol precursors 7-DHC and 8-DHC and generally decreased levels of cholesterol.