Cleft lip and palate as predictors of EEC syndrome: a clinical case

Расщелина губы и нёба является одной из самых распространенных врожденных патологий лица и занимает 3-е место в структуре всех врожденных пороков развития. Изолированная форма данной патологии встречается в 7,6-41,4% случаев, в составе симптомокомплексов расщелины губы и/или нёба – в 21,1-61,2% случаев. Расщелины губы и нёба могут являться предикторами синдрома эктодермальной дисплазии, эктродактилии, расщелины губы и нёба (EEC-синдром). Это редкое аутосомно-доминантное заболевание с высокой пенетрантностью. В период новорожденности диагностика может быть затруднена, так как ряд признаков (отсутствие волос и зубов) является возрастной нормой. Значительную помощь в ранней диагностике синдрома EEC может оказать выявление расщелины губы и нёба в сочетании с патологией дистальных отделов конечностей, особенно на этапе пренатальной диагностики. Чаще всего данный порок удается установить на сроке 16-30 недель. Несмотря на это, диагноз синдрома EEC устанавливается достаточно редко, состояние чаще описывается как множественные пороки развития. В статье приводятся клинические случаи диагностики синдрома EEC у двух детей из одной семьи, описаны фенотипические особенности пациентов. Подчеркивается, что множественные пороки развития расщелины губы и нёба в сочетании с патологией дистальных отделов конечностей могут стать предикторами EEC-синдрома. Указывается на большое значение ранней диагностики EEC-синдрома в составлении корректного плана лечения на основе патогенеза заболевания. Лечение отдельных клинических проявлений, входящих в EEC-синдром (расщелина губы и нёба, дерматит, адентия, ксеростомия, атрезия слезных путей), без объединения их в единую нозологическую форму может быть длительным, дорогостоящим и безуспешным. Выявление патологии у родителей – носителей синдрома EEC позволяет прогнозировать рождение детей с данным синдромом. Методом выбора является применение вспомогательных репродуктивных технологий, например, использование донорских яйцеклеток или сперматозоидов. Cleft lip and palate is one of the most common congenital pathologies of the face and ranks 3rd in the structure of all congenital malformations. An isolated form of this pathology occurs in 7,6-41,4% of cases; as part of symptomatic complexes of a cleft lip and palate, 21,1-61,2% are described. Cleft lip and palate may be predictors of EEC syndrome. EEC syndrome (ectodermal dysplasia, ectrodactyly, cleft lip and palate) is a rare, autosomal dominant disorder with high penetrance. During the neonatal period, diagnosis can be difficult, since a number of signs (lack of hair, teeth) are the age norm. The detection of a cleft lip and palate in combination with pathology of the distal extremities, especially at the stage of prenatal diagnosis, can provide significant assistance in the early diagnosis of EEC syndrome. Most often, this defect can be established at a period of 16-30 weeks. Despite this, the diagnosis of EEC syndrome is rarely made, the condition is more often described as «multiple malformations». The article presents clinical cases of the diagnosis of EEC syndrome in 2 children from the same family, describes the phenotypic characteristics of patients. It is emphasized that in the presence of multiple malformations of the cleft lip and palate in combination with the pathology of the distal extremities can be predictors of the EEC syndrome. The authors point out the great importance of early diagnosis of EEC syndrome in drawing up a correct treatment plan based on the pathogenesis of the disease. Treatment of individual clinical manifestations included in the EEC syndrome (cleft lip and palate, dermatitis, adentia, xerostomia, atresia of the lacrimal ducts), without combining them into a single nosological form, can be long, expensive and unsuccessful. The detection of pathology in parents who are carriers of the EEC syndrome allows predicting the birth of children with this syndrome. The method of choice is the use of assisted reproductive technologies.

Digital Transfer for Hand Reconstruction in Cleft Hand and Foot Differences

Background Digital transfer for hand reconstruction in children with cleft hand and foot differences present unique challenges with anomalous anatomy and rare opportunities to dramatically improve function of one- or two-digit hands. Methods Medical records were reviewed for patients with cleft hand and foot treated at two pediatric institutions between 1996 and 2018. Hospital records, clinical photographs, radiographs, and alginate molds were available on all patients. Patient characteristics, indications for transfer, associated syndromes, donor and recipient anatomy, and complications were examined. Results Twenty digital transfers were identified in 16 patients. The mean age at time of transfer was 6 years (range: 3–18 years). Associated syndromes in this study included ectrodactyly ectodermal dysplasia clefting (EEC) syndrome and Goltz's syndrome. Recipient sites included the thumb (n = 17) and index ray (n = 3) in 10 hands with monodactyly, 6 hands with a two-digit ulnar syndactyly, and 3 hands with central deficiency and associated polydactyly or other anomalies. Donor sites included the great toe (n = 7), fifth toe (n = 9), great toe polydactyly (n = 2), thumb polydactyly (n = 1), and second toe (n = 1). All transfers survived. Revisions included tenolysis (n = 2), repeat fixation for nonunion or malunion (n = 2), and fusion for instability (n = 3). Conclusion Digital transfer in cleft hand and foot patients is a functional endeavor. The transferred digits provide sensation, mobility, and stability for opposition. Technically challenging due to small structures and atypical anatomy, these rare cases represent unique opportunities to improve function and appearance in the pediatric hand. This is a therapeutic study and reflects level of evidence IV.

The case of prenatal ultrasound diagnosis of EEC syndrome (Ectrodactyly, Ectodermal dysplasia, Cleft lip/palate syndrome) at 14 weeks of gestation

Case of prenatal ultrasound diagnosis of EEC syndrome at 14 weeks of gestation is presented. A rare feature of the case was the ectrodactyly of all limbs.

Significance of foot length determination to enhance accuracy of fetal clubfoot diagnosis

Case of prenatal ultrasound diagnosis of EEC syndrome at 14 weeks of gestation is presented. A rare feature of the case was the ectrodactyly of all limbs. 29 women with fetal clubfoot have been examined. The principal sonographic sign of this pathology has been established to be the foot length shortening that varied between 1 week and 1 day in 13 weeks and 6 days of gestation and 4 weeks and 5 days in 37 weeks and 1 day of gestation. Some sort or other pathology was found in those fetuses in 86.2 % of follow-up cases, while combined with clubfoot in 48.3 %. In total, 30 various congenital abnormalities with the total number of 78 (which made 2.7 congenital abnormalities per one fetus) have been diagnosed in this group of fetuses

Single-cell RNA-seq identifies a reversible mesodermal activation in abnormally specified epithelia of p63 EEC syndrome

Mutations in transcription factor p63 are associated with developmental disorders that manifest defects in stratified epithelia including the epidermis. The underlying cellular and molecular mechanism is however not yet understood. We established an epidermal commitment model using human induced pluripotent stem cells (iPSCs) and characterized differentiation defects of iPSCs derived from ectrodactyly, ectodermal dysplasia, and cleft lip/palate (EEC) syndrome patients carrying p63 mutations. Transcriptome analyses revealed stepwise cell fate transitions during epidermal commitment: Specification from multipotent simple epithelium to basal stratified epithelia and ultimately to the mature epidermal fate. Differentiation defects of EEC iPSCs caused by p63 mutations occurred during the specification switch from the simple epithelium to the basal-stratified epithelial fate. Single-cell transcriptome and pseudotime analyses of cell states identified mesodermal activation that was associated with the deviated commitment route of EEC iPSCs. Integrated analyses of differentially regulated genes and p63-dependent dynamic genomic enhancers during epidermal commitment suggest that p63 directly controls epidermal gene activation at the specification switch and has an indirect effect on mesodermal gene repression. Importantly, inhibitors of mesodermal induction enhanced epidermal commitment of EEC iPSCs. Our findings demonstrate that p63 is required for specification of stratified epithelia, and that epidermal commitment defects caused by p63 mutations can be reversed by repressing mesodermal induction. This study provides insights into disease mechanisms underlying stratified epithelial defects caused by p63 mutations and suggests potential therapeutic strategies for the disease.

p63 cooperates with CTCF to modulate chromatin architecture in skin keratinocytes

The transcription factor p63 regulates epidermal genes and the enhancer landscape in skin keratinocytes. Its molecular function in controlling the chromatin structure is however not yet completely understood. Here we integrated multi-omics profiles, including the transcriptome, transcription factor DNA-binding and chromatin accessibility, in skin keratinocytes isolated from EEC syndrome patients carrying p63 mutations, to examine the role of p63 in shaping the chromatin architecture. We found decreased chromatin accessibility in p63-and CTCF-bound open chromatin regions that potentially contributed to gene deregulation in mutant keratinocytes. Cooperation of p63 and CTCF seemed to assist chromatin interactions between p63-bound enhancers and gene promoters in skin keratinocytes. Our study suggests an intriguing model where cell type-specific transcription factors such as p63 cooperate with the genome organizer CTCF in the three-dimensional chromatin space to regulate the transcription program important for the proper cell identity.

The case of prenatal diagnosis of the EEC syndrome (ectrodactyly – ectodermal dysplasia – clefting syndrome)

The case of prenatal ultrasound diagnosis of EEC syndrome (ectrodactyly — ectodermal dysplasia — clefting syndrome) in the third trimester of gestation is presented. According to the ultrasound research, the fetus presents with: left-sided cleft lip and palate, on the right hand there is syndactyly of the third and the fourth fingers, on the left hand there is absence of the third finger, which looks like a wide interdigital space. Examination of the feet revealed bilateral symmetric syndactyly of one to second and third to fourth toes. The difficulty of prenatal syndromal diagnosis of EEC is connected with wide variability in the clinical picture and low incidence in the population. The diagnosis was confirmed in the postnatal period.

Single-cell RNA-seq identifies a reversible epithelial-mesenchymal transition in abnormally specified epithelia of p63 EEC syndrome

Mutations in transcription factor p63 are associated with developmental disorders that manifest defects in stratified epithelia including the epidermis. The underlying cellular and molecular mechanism is however not yet understood. We established an epidermal commitment model using human induced pluripotent stem cells (iPSCs) and characterized differentiation defects of iPSCs derived from ectrodactyly, ectodermal dysplasia, and cleft lip/palate (EEC) syndrome patients carrying p63 mutations. Transcriptome analyses revealed distinct step-wise cell fate transitions during epidermal commitment; from multipotent simple epithelium to basal stratified epithelia, and ultimately to the mature epidermal fate. Differentiation defects of EEC iPSCs caused by mutant p63 occurred during the specification switch from the simple epithelium to the basal stratified epithelial fate. Single-cell transcriptome and pseudotime analyses identified signatures of embryonic epithelial-mesenchymal transition (EMT) associated with the deviated commitment route of EEC iPSCs. Repressing mesodermal activation reversed the EMT and enhanced epidermal commitment. Our findings demonstrate that p63 is required for specification of stratified epithelia, probably by repressing embryonic EMT during epidermal commitment. This study provides insights into disease mechanisms underlying stratified epithelial defects caused by p63 mutations and suggests potential therapeutic strategies for the disease.Significance statementMutations in p63 cause several developmental disorders with defects of epithelial related organs and tissues including the epidermis. Our study is to dissect the unknown cellular and molecular pathomechanism. We utilized human induced pluripotent stem cells (iPSCs) derived from ectrodactyly, ectodermal dysplasia, and cleft lip/palate (EEC) syndrome patients carrying p63 mutations and studied transcriptome changes during differentiation of these cells to epidermal cells. Our analyses showed that the specification of the proper epithelial cell fate was affected by p63 EEC mutations, with an abnormal embryonic epithelial-mesenchymal transition (EMT). Repressing mesodermal activation reversed the EMT and enhanced epidermal commitment. This study provides insights into disease mechanisms associated with p63 mutations and suggests potential therapeutic strategies.