But researchers at Sanford-Burnham recently discovered three children (pictured above) with CDG who are mosaics—only some cells in some tissues have the mutation. For that reason, standard exome sequencing initially missed their mutations, highlighting the technique’s diagnostic limitations in some rare cases. These findings were published April 4 in the American Journal of Human Genetics.
“This study was one surprise after another,” said Hudson Freeze, Ph.D., director of Sanford-Burnham’s Genetic Disease Program and senior author of the study. “What we learned is that you have to be careful—you can’t simply trust that you’ll get all the answers from gene sequencing alone.”
Searching for a rare disease mutation
Complicated arrangements of sugar molecules decorate almost every protein and cell in the body. These sugars are crucial for cellular growth, communication, and many other processes. As a result of a mutation in an enzyme that assembles these sugars, children with CDG experience a wide variety of symptoms, including intellectual disability, digestive problems, seizures, and low blood sugar.
To diagnose CDG, researchers will test the sugar arrangements on a common protein called transferrin. Increasingly, they’ll also look for known CDG-related mutations by whole-exome sequencing, a technique that sequences only the small portion of the genome that encodes proteins. The patients are typically three to five years old.
A cautionary tale for genomic diagnostics
In this study, our researchers observed different proportions and representations of sugar arrangements depending on which tissues were examined. In other words, these children have the first demonstrated cases of CDG “mosaicism”—their mutations only appear in some cell types throughout the body, not all. As a result, the usual diagnostic tests, like whole-exome sequencing, missed the mutations. It was only when Freeze’s team took a closer look, examining proteins by hand using biochemical methods, did they identify the CDG mutations in these three children.
The team then went back to the three original children and examined their transferrin again. Surprisingly, these readings, which had previously shown abnormalities, had become normal. Freeze and his team believe this is because mutated cells in the children’s livers died and were replaced by normal cells over time. However, better transferrin did not revere all symptoms.
“If the transferrin test hadn’t been performed early on for these children, we never would’ve picked up these cases of CDG. We got lucky in this case, but it just shows that we can’t rely on any one test by itself in isolation,” Freeze said.
This research was funded by The Rocket Fund at Sanford-Burnham and the U.S. National Institutes of Health—National Institute of Diabetes and Digestive and Kidney Diseases grant R01DK55615 and National Human Genome Research Institute grant 1U54HG006493.
Ng, B., Buckingham, K., Raymond, K., Kircher, M., Turner, E., He, M., Smith, J., Eroshkin, A., Szybowska, M., Losfeld, M., Chong, J., Kozenko, M., Li, C., Patterson, M., Gilbert, R., Nickerson, D., Shendure, J., Bamshad, M., & Freeze, H. (2013). Mosaicism of the UDP-Galactose Transporter SLC35A2 Causes a Congenital Disorder of Glycosylation The American Journal of Human Genetics, 92 (4), 632-636 DOI: 10.1016/j.ajhg.2013.03.012
Sanford-Burnham Medical Research Institute.