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MECP2 Duplication Syndrome

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Copyright 2013

NORD is very grateful to Melissa B. Ramocki MD, PhD, Assistant Professor, Department of Pediatrics, Section of Pediatric Neurology and Developmental Neuroscience, Baylor College of Medicine and Texas Children's Hospital, for assistance in the preparation of this report.

Synonyms of MECP2 Duplication Syndrome

Disorder Subdivisions

General Discussion

Summary
MECP2 duplication syndrome is a rare genetic neurodevelopmental disorder characterized by a wide variety of symptoms including low muscle tone (hypotonia), potentially severe intellectual disability, developmental delays, recurrent respiratory infections, speech abnormalities, seizures, and progressive spasticity, a condition characterized by muscle stiffness that is worsened with movement and can be associated with involuntary muscle spasms. Additional symptoms can occur. MECP2 duplication syndrome is caused by the duplication of genetic material on a specific region on the X chromosome (Xq28). This region includes the MECP2 gene and typically several adjacent genes. In most cases, the MECP2 duplication is inherited in an X-linked manner; in rare cases, the duplication may occur randomly for no apparent reason (de novo duplication). The disorder predominantly affects males, but females who carry the duplication on one X chromosome (heterozygotes) may exhibit some signs of the disorder. In specific, rare cases, females can develop a severe form of the disorder similar to males.

Introduction
One of the first descriptions in the medical literature of this disorder as a distinct neurological entity was by Lubs et al. in 1999. The discovery that microduplications involving the MECP2 gene on the X chromosome cause a distinct neurological disorder (now known as MECP2 duplication syndrome) was first reported in the medical literature in 2005. Mutations of the MECP2 gene are known to cause Rett syndrome, a neurological disorder that primarily affects females. These disorders are sometimes grouped together as MECP2-related disorders.

Symptoms

MECP2 duplication syndrome is characterized by a wide variety of symptoms. Although researchers have been able to establish a clear syndrome with characteristic or “core” symptoms, much about the disorder is not fully understood. Several factors including the small number of identified cases, the lack of large clinical studies, and the possibility of other genes influencing the disorder prevent physicians from developing an accurate picture of associated symptoms and prognosis. Therefore, it is important to note that affected individuals may not have all of the symptoms discussed below. Parents should talk to their children’s physician and medical team about their specific case, associated symptoms and overall prognosis.

One of the initial signs of MECP2 duplication syndrome may be feeding difficulties during the first few weeks of life likely resulting from diminished muscle tone (hypotonia). Affected children may also experience difficulty swallowing, gastroesophageal reflux and excessive drooling. Affected children will often fail to gain weight or grow at the expected rate for age and gender (failure to thrive) and may be at risk of aspiration, however, some infants experience no recognized problems in the newborn (neonatal) period and concern is not raised until other developmental milestones are missed.

Children with MECP2 duplication have moderate to severe intellectual disability and experience delays in attaining developmental milestones including sitting and crawling. Consequently, walking is also delayed and, in some cases, individuals develop an unsteady, uncoordinated gait. This abnormal gait can result in the development of exaggerated inward curvature of the lower spine (lumbar hyperlordosis). As affected individuals grow older, they may experience neurological regression that ultimately results in the loss of previously acquired skills such as the ability to walk.

The majority of affected individuals do not develop the ability to talk. Some individuals may be able to speak a few words during early childhood or have a limited use of speech, but frequently this ability is progressively lost during adolescence. Most affected individuals have better receptive language skills (i.e. understanding what is said to them). In rare cases, some boys do retain the use of speech into adulthood.

In many affected children, hypotonia may progress to spasticity, a condition that is generally defined in the medical literature as an abnormal increase in muscle tone or stiffness of affected muscles. Spasticity can be associated with muscle spasms, increased deep tendon reflexes, and fixed joints (contractures). Spasticity affects the legs more severely and, over time, mild to severe contractures of the hips, knees and ankles may develop. A contracture is a condition in which a joint becomes permanently fixed in a bent (flexed) or straightened (extended) position, completely or partially restricting the movement of the affected joint.

Approximately 50% of individuals develop seizures by some estimates. However, the true prevalence of seizures by adulthood may be much higher. The age of onset varies from early childhood to the second decade of life. In some individuals, seizures may not respond to treatment (refractory) and the onset and severity of seizures may correlate with neurological deterioration (e.g. loss of speech, hand use, and ambulation). Seizure types that have been reported in individuals with MECP duplication syndrome include head/neck and trunk drop attacks, absence seizures, myoclonic seizures, and generalized or secondarily generalized tonic-clonic or simply tonic seizures (once known as grand mal seizures).

Some individuals with MECP2 duplication syndrome experience dysfunction of the immune system, which causes them to be prone to recurrent infections such as respiratory tract infections. Affected individuals may develop recurrent pneumonia that is sometimes severe requiring mechanical ventilation. Middle ear infections (otitis media) and sinusitis are also common. Additional infections have been reported including meningitis or urinary tract infections. Recurrent infections can cause life-threatening complications.

Many individuals with MECP2 duplication syndrome meet formal criteria for diagnosis with an autism spectrum disorder due to poor expressive language skills, abnormal social affect, and restricted/repetitive behaviors. Mood disorders such as anxiety sometimes occur.

Affected individuals often have clinically significant constipation. Bladder dysfunction has also been seen. According to some reports, affected individuals may have chronic intestinal pseudo-obstruction (CIP), a condition characterized by abnormalities affecting the involuntary, coordinated muscular contractions (peristalsis) that propels food and other material through the digestive system. Symptoms may develop due to obstruction of the small bowel and can include nausea, vomiting, abdominal pain, abdominal swelling and constipation. Ultimately, normal nutritional requirements cannot be met leading to unintended weight loss and malnourishment. The acute onset of GI symptoms such as abdominal pain, unusual distension, or vomiting warrants urgent medical evaluation as it can precede life-threatening complications.

Individuals with MECP2 duplication may have distinctive facial features including an abnormally flat back of the head (brachycephaly), underdevelopment of the middle of the face (midface hypoplasia), ear anomalies, large ears, deep-set eyes, prominent chin, pointed nose, and an abnormally flat bridge of the nose.

Additional findings have been reported in some cases of MECP2 duplication syndrome including pre and postnatal growth retardation, abnormally small head circumference based upon age and gender (microcephaly), and underdeveloped (hypoplastic) genitalia. Affected males may also experience failure of the testes to descend (cryptorchidism) and have the urinary opening located on the underside of the penis (hypospadias) rather than at the end.

AFFECTED FEMALES
Although MECP2 duplication syndrome is primarily associated with males, females can develop mild symptoms of the disorder or, in rare cases, a severe form of the disorder. Some researchers have noted that women who have a MECP2 duplication on one of their X chromosomes (heterozygote or carrier females) may be prone to developing neuropsychiatric features including depression, anxiety, and specific personality traits. In addition, recent reports have identified women (i.e., women with unfavorable X-linked inactivation) who developed some symptoms of the disorder including recurrent infections, poor speech development, or seizures. In rare cases, females may have a genetic abnormality, known as a translocation, which involves the X chromosome and a non-sex chromosome (autosome). Females with this specific underlying genetic abnormality may develop a severe form of the disorder similar to that seen in males. For more information, on X-linked inactivation and translocations, see the Causes section below.

Causes

MECP2 duplication syndrome is caused by a genetic abnormality in which a portion of the X chromosome appears three times in the cells of the body instead to twice (duplication). By definition, the affected region always contains the methyl-CpG-binding protein 2 (MECP2) gene. Most cases involved have very small duplications called microduplications, but larger, more complex rearrangements (e.g. translocations) can also cause the disorder. Depending upon the exact size and location of the duplicated area, additional genes are also duplicated. The duplication size is unique to each affected family or individual.

Investigators have determined that the MECP2 gene is located on the long arm (q) of the X chromosome (Xq28). Chromosomes, which are present in the nucleus of human cells, carry the genetic information for each individual. Human body cells normally have 46 chromosomes. Pairs of human chromosomes are numbered from 1 through 22 (autosomes) and the sex chromosomes are designated X and Y. Males have one X and one Y chromosome and females have two X chromosomes. Each chromosome has a short arm designated "p" and a long arm designated "q". Chromosomes are further sub-divided into many bands that are numbered. For example, "chromosome Xq28" refers to band 28 on the long arm of the X chromosome. The numbered bands specify the location of the thousands of genes that are present on each chromosome.

The MECP2 gene contains instructions for producing (encoding) a protein called MeCP2. This protein is essential for normal brain function and most likely has several different functions in the body. Researchers believe that the protein may regulate other genes in the brain by switching those genes on and off. The presence of an extra copy of the MECP2 gene leads to overproduction (overexpression) of the MeCP2 protein. This overexpression is believed to impair the protein from functioning properly within the body. Researchers believe that the more excess protein produced the worse the associated symptoms. In extremely rare cases, affected males have MECP2 triplication, in which there are two extra copies of the MECP2 gene. In these cases, MeCP2 overexpression is greater and the associated symptoms have been more severe.

Researchers have recently discovered that MECP2 overexpression can impair the function of the immune system. The immune system is divided into several components, the combined actions of which are responsible for defending against different infectious agents (i.e. invading microscopic life-forms [microorganisms]). One specific part of the immune system affected in this disorder is the T cell system, which helps to fight several viruses, some bacteria and yeast and fungi. Researchers believe that MECP2 overexpression suppresses the secretion of a protein known as interferon-gamma from certain T cells leading to a partially immunodeficient state. More research is necessary to determine the specific pathogens that affect individuals with MECP2 duplication syndrome and how to best treat the abnormal immune system.

In most cases, male children inherit the disorder from a carrier mother who has favorable skewing of random X-chromosome inactivation and no symptoms or extremely mild symptoms of the disorder. When a mother is a known carrier of the MECP2 mutation, there is a 50% chance of passing that mutation on to her children. In extremely rare cases, the duplication that causes the disorder occurs randomly for no apparent reason (de novo duplication). Affected males can also develop the disorder due to a translocation involving the X chromosome and a non-sex chromosome (autosome). In such cases, the parent’s chromosomes are unaffected and the disorder is not inherited.

Random X-chromosome inactivation is a normal process in females. Females have two X chromosomes, whereas males have one X chromosome and one Y chromosome. In females, certain disease traits on the X chromosome such as a mutated gene may be "masked" by the normal gene on the other X chromosome (random X-chromosome inactivation). Basically, in each cell of the body one X chromosome is active and one is turned off or "silenced". This occurs randomly and generally happens as a 50-50 split. However, in some cases, females may have favorable X-inactivation, in which the affected X chromosome is silenced in most of the cells. In such cases, they may only have mild symptoms of the disorder. In other cases, females may have unfavorable X-inactivation, in which the unaffected X chromosome is silenced in most of the cells. In such cases, affected females usually have a severe expression of the disorder.

In the initial reports, most women with a MECP2 duplication have had preferentially favorable X-inactivation (near 100% inactivation of the duplication-bearing X chromosome). As previously discussed, these women generally have no symptoms or only mild symptoms of the disorder. However, recent reports have identified women, in whom, the percentage of cells with the duplication-bearing X chromosome is more numerous. Consequently, these women have developed symptoms of the disorder.

In addition, in rare cases, females with a MECP2 duplication have developed a severe form of the disorder similar to that seen in affected males. This occurs when an additional (concomitant) abnormality involving the X chromosome occurs, such as an unbalanced translocation. An unbalanced translocation occurs when a region of one chromosome breaks off and is attached to another chromosome, causing a shifting of genetic material. In these specific cases, the Xq28 region breaks off and attaches to an autosome (non-sex chromosome). Because the duplicated material on the X chromosome has been translocated to an autosome, this prevents the normal X-inactivation of the duplicated segment. An unbalanced translocation occurs randomly (de novo).

Unbalanced translocation involving the Xq segment can also cause MECP2 duplication syndrome in males. Translocation between the Xq segment and short arm (p) of the X chromosome, the Y chromosome, or an autosome has been reported.

As mentioned above, additional genes can be involved in the duplicated area on the X chromosome. These genes include IRAK1, L1CAM, FLNA and many others. It is possible that these genes contribute to the overall spectrum of disease associated with MECP2 duplication syndrome. The IRAK1 gene, which is involved in the immune system, is typically duplicated as well, even in individuals with very small duplications. Many individuals with very small duplications, involving only the MECP2 and IRAK1 genes, have developed the core symptoms associated with the disorder. However, larger duplications that contain additional genes may be associated with other symptoms. For example, the FLNA gene is associated with gastrointestinal problems such as pseudo-obstruction and may be associated with a distinct clinical phenotype involving this condition. The exact role that these adjacent genes play in the development of MECP2 duplication syndrome is not fully understood. More research is necessary to determine to what extent additional genes play a role or influence the development of MECP2 duplication syndrome.

Affected Populations

MECP2 duplication syndrome predominantly affects males. However, females may be affected by mild symptoms of the disorder and, in rare cases, a severe form of the disorder. The exact incidence and prevalence of MECP2 duplication syndrome in the general population is unknown. Because cases may go undiagnosed or misdiagnosed, determining the disorder’s true frequency in the general population is difficult. Approximately 130 male individuals from 36 different families have been reported in the medical literature. It has been estimated that approximately 1% of unexplained cases of X-linked intellectual disability may be due to MECP2 duplication syndrome.

Related Disorders

Symptoms of the following disorders can be similar to those of MECP2 duplication syndrome. Comparisons may be useful for a differential diagnosis.

Alpha thalassemia X-linked intellectual disability (ATR-X) syndrome is a rare genetic disorder affecting multiple organ systems of the body. ATR-X syndrome is characterized by intellectual disability, characteristic facial features, abnormalities of the genitourinary tract, and alpha thalassemia. Alpha thalassemia, which is a condition where there is a defect in the production of the oxygen-carrying pigments of red blood cells (hemoglobin), is not seen in every case. Additional abnormalities are usually present in most cases. ATR-X syndrome is inherited as an X-linked recessive genetic condition. (For more information on this disorder, choose "ATR-X" as your search term in the Rare Disease Database.)

L1 syndrome is an inherited, X-linked disorder occurring in males that primarily affects the nervous system. The disease is mainly characterized by hydrocephalus (increased cerebrospinal fluid in the center of the brain), spasticity of the lower limbs (muscle stiffness), adducted thumbs (clasped towards the palm), aphasia (difficulty with speaking), seizures, and agenesis of the corpus callosum (underdeveloped or absent connecting tissue between the left and right hemispheres of the brain). Affected individuals have intellectual disability in the mild to moderate range. L1 syndrome is caused by abnormalities (mutations) in the L1CAM gene, which affects about 1 in 30,000 males. (For more information on this disorder, choose "L1 syndrome" as your search term in the Rare Disease Database.)

There are additional X-linked disorders that cause intellectual disability and other symptoms that may be similar to those seen in MECP2 duplication syndrome. These disorders usually have other, distinguishing features. Such disorders include Lowe syndrome, Coffin-Lowry syndrome, MCT8-specific thyroid hormone cell transporter deficiency (Allan-Dudley-Herndon syndrome), Renpenning syndrome, and Juberg-Marsidi syndrome. (For more information on this disorder, choose the specific disorder name as your search term in the Rare Disease Database.)

Standard Therapies

Diagnosis
A diagnosis of MECP2 duplication syndrome is based upon the identification of characteristic symptoms, a detailed patient history, a thorough clinical evaluation and a variety of specialized tests. It should be included in the differential diagnosis of male infants with hypotonia.

Clinical Testing and Workup
There are a variety of tests that can be used to diagnose MECP2 duplication syndrome including array comparative genomic hybridization (array-CGH). This test can detect the gain or loss of chromosomal material including microduplications.

Additional tests that can confirm CGH results or for direct clinical testing include polymerase chain reaction (PCR), fluorescent is situ hybridization (FISH) analysis, chromosome microarray SNP analysis, and multiplex ligation-dependent probe amplification (MLPA). PCR is a laboratory technique that has been described as "photocopying". It enables researchers to enlarge and repeatedly copy sequences of DNA. As a result, they are able to closely analyze DNA and more easily identify genes and genetic changes.

A FISH test can be used to determine a person’s karyotype. A karyotype is a visual representation of a person’s chromosomal makeup (i.e. the 46 chromosomes in a cell). The FISH test can detect chromosomal abnormalities such as duplications or translocation.

Chromosome microarray SNP analysis uses probes that can detect chromosomal abnormalities including microduplications, including those that are the underlying cause of many cases of MECP2 duplication syndrome.

The MLPA test is a relatively new method for assessing chromosomes and can detect certain chromosomal abnormalities including those associated with MECP2 duplication syndrome.

In cases where a parent has a known genetic abnormality (i.e. carrier mothers), pre-implantation genetic diagnosis (PGD) may be an option. PGD can be performed on embryos created through in vitro fertilization. PGD refers to testing an embryo to determine whether it has the same genetic abnormality as the parent. Families interested such an option should seek the counsel of a certified genetics professional.

Treatment
The treatment of MECP2 duplication syndrome is directed toward the specific symptoms that are apparent in each individual. Treatment may require the coordinated efforts of a team of specialists. Pediatricians, surgeons, pediatric neurologists, gastroenterologists, psychiatrists, speech pathologists, and other healthcare professionals may need to systematically and comprehensively plan an affected child’s treatment. Genetic counseling may be of benefit for affected individuals and their families.

Treatment options that may be used to treat individuals with MECP2 duplication syndrome are complex and varied. The specific treatment plan will need to be highly individualized. Decisions concerning the use of specific treatments should be made by physicians and other members of the health care team in careful consultation with an affected child’s parents or with an adult patient based upon the specifics of his or her case; a thorough discussion of the potential benefits and risks, including possible side effects and long-term effects; patient preference; and other appropriate factors.

Early developmental intervention is important to ensure that affected children reach their potential. Most affected children will benefit from occupational, physical and speech therapy. Various methods of rehabilitative and behavioral therapy may be beneficial. It is essential that therapies are continued on a year-round basis to promote development of new skills and to prevent regression. Some children who lose skills are able to re-learn them with intensive therapy. Additional medical, social and/or vocational services including special remedial education may be necessary. Psychosocial support for the entire family is essential as well.

Other treatment is symptomatic and supportive. Additional therapies for MECP2 duplication syndrome depend upon the specific abnormalities present and generally follow standard guidelines.

Some general therapies common for infants or children include monitoring feeding and swallowing difficulties. Insertion of a feeding tube through a surgical opening in the stomach (gastrostomy) may be necessary to ensure proper nutritional support and to prevent aspiration.

Drugs may be used to treat a variety of symptoms associated with MECP2 duplication syndrome. Anti-seizure medications (anti-convulsants) are usually effective in treating seizures; however, in a subset of cases these medications do not work (refractory seizures). In some cases, drugs may be used to improve spasticity and muscle rigidity, but can be ineffective or potentially worsen the condition. Working with a physical medicine and rehabilitation specialist to treat spasticity is recommended. Prompt treatment of spasticity may prevent the development of contractures.

Because of the susceptibility to infections, when affected individuals develop an infection, they should be treated immediately and aggressively with appropriate antibiotics. Recurrent infections, especially respiratory infections, can be severe enough to necessitate hospitalization and require assisted (mechanical) ventilation. Individuals who develop recurrent pneumonia should be evaluated by an immunology specialist since medical interventions including the use of prophylactic antibiotics and/or immunoglobulin therapy are indicated in some cases.

Investigational Therapies

Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.

For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:

Toll-free: (800) 411-1222
TTY: (866) 411-1010
Email: prpl@cc.nih.gov

For information about clinical trials sponsored by private sources, in the main, contact:
www.centerwatch.com

Contact for additional information about MECP2 duplication syndrome:

Melissa B. Ramocki M.D., Ph.D.
Assistant Professor
Department of Pediatrics
Section of Pediatric Neurology and Developmental Neuroscience
Baylor College of Medicine and Texas Children's Hospital
6701 Fannin St. Suite 1250
Houston, Texas 77030
Email: mramocki@bcm.edu

MECP2 Duplication Syndrome Resources

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References

JOURNAL ARTICLES
Yang T, Ramocki MB, Neul JL, et al. Overexpression of methyl-CpG binding protein 2 impairs TH1 responses. Sci Transl Med. 2012;4:163ra158. http://www.ncbi.nlm.nih.gov/pubmed/23220634

Vignoli A, Borgatti R, Peron A, et al. Electroclinical pattern in MECP2 duplication syndrome: eight new reported cases and review of the literature. Epilepsia. 2012;53:1146-1155. http://www.ncbi.nlm.nih.gov/pubmed/22578097

Bijlsma EK, Collins A, Papa FT, et al. Xq28 duplications including MECP2 in five females: expanding the phenotype to severe mental retardation. Eur J Med Genet. 2012;55-540:404-413. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383992/

Ramocki MB, Jane Tavyev Y, Peters SU. The MECP2 duplication syndrome. Am J Med Genet A. 2010;152A:1079-1088. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2861792/?tool=pubmed

Clayton-Smith J, Walters S, Hobson E, et al. Xq28 duplication presenting with intestinal and bladder dysfunction and a distinctive facial appearance. Eur J Hum Genet. 2009:17:434-443. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2986219/

Sanlaville D, Schluth-Bolard C, Turleau C. Distal X duplication and functional Xq disomy. Orphanet J Rare Dis. 2009;4:4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2649904/

Lugtenberg D, Kleefstra T, Oudakker AR, et al. Structural variation in Xq28: MECP2 duplications in 1% of patients with unexplained XLMR and in 2% of male patients with severe encephalopathy. Eur J Hum Genet. 2009;17:444-453. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2986218/

Friez MJ, Jones JR, Clarkson K, et al. Recurrent infections, hypotonia, and mental retardation caused by duplication of MECP2 and adjacent region in Xq28. Pediatrics. 2006;118:e1687-1695. http://www.ncbi.nlm.nih.gov/pubmed/17088400

Van Esch H, Bauters M, Ignatius J. Duplication of the MECP2 region is a frequent cause of severe mental retardation and progressive neurological symptoms in males. Am J Hum Genet. 2005;77:442-453. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1226209/

Meins M, Lehmann J, Gerresheim F, et al. Submicroscopic duplication in Xq28 causes increased expression of the MECP2 gene in a boy with severe mental retardation and features of Rett syndrome. J Med Genet. 2005;42:e.12. http://jmg.bmj.com/content/42/2/e12.full

INTERNET
Van Esch H. Updated:06/24/2010. MECP2 Duplication Syndrome. In: GeneReviews at GeneTests: Medical Genetics Information Resource (database online). Copyright, University of Washington, Seattle. 1997-2003. Available at: http://www.ncbi.nlm.nih.gov/books/NBK1284/ Accessed On: September 15, 2012.

Sanlaville D, Schluth-Bolard C, Turleau C. Trisomy Xq28. Orphanet Encyclopedia, February 2009. Available at: http://www.orpha.net/ Accessed on: September 15, 2012 .

McKusick VA., ed. Online Mendelian Inheritance in Man (OMIM). Baltimore. MD: The Johns Hopkins University; Entry No:300260; Last Update:06/04/2012. Available at: http:// http://omim.org/entry/300260 Accessed on: September 15, 2012.

Report last updated: 2013/01/28 00:00:00 GMT+0