Rett syndrome

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Rett syndrome/disorder
ICD-10	F84.2
ICD-9	330.8
OMIM	312750
DiseasesDB	29908
MeSH	C10.574.500.775

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Rett syndrome is a X-linked dominant neurodevelopmental disorder occurring commonly in girls who undergo the phase of regression after acquiring all the developmental skills. It demonstrates variety of symptoms such as gait abnormalities, head regression, loss of speech, loss of verbal skills, problems with socialization hand-wringing movements and breathing abnormalities. Nearly 90% of cases are due to inherited mutations in methyl-CpG-binding protein 2(MECP2) gene mutation. The other gene involved in rare cases is cyclin dependent kinase like 5(CDKL5). Being one of the most frequent causes of mental disabilities, affected children may have associated scoliosis and ambulatory problems. Girls with Rett syndrome are prone to gastrointestinal disorders and up to 80% have seizures.

Cause

Rett syndrome (symbolized RTT) is caused by mutations in the gene MECP2, a transcriptional regulator gene, located on the X chromosome. The mutations can arise (1) sporadically or (2) from germline mutations. Two more genes have been identified in the recent studies namely; CDKL5(Cyclin dependent kinase gene 5 and FOXG1(FORKHEAD box G1). Mutations in CDKL5 is associated with seizure variant of Rett syndrome.

Sporadic mutations

Rett syndrome is usually caused (95% or more) by a de novo mutation in the child (so it is inherited from a genotypically normal mother, i.e. one without a MECP2 mutation).

In sporadic cases of Rett syndrome, it is thought that the mutated MECP2 is usually derived from the male copy of the X chromosome.

Germline mutations

It can also be inherited from phenotypically normal mothers who have a germline mutation in the gene encoding methyl-CpG-binding protein-2, MECP2. MECP2 is found near the end of the long arm of the X chromosome at Xq28. An atypical form of Rett syndrome, characterized by infantile spasms or early onset epilepsy, can also be caused by a mutation to the gene encoding cyclin-dependent kinase-like 5 (CDKL5). Rett syndrome affects one in every 12,500 female live births by age 12 years.

Gender and Rett syndrome

It almost exclusively affects girls -- male fetuses with the disorder rarely survive to term. Development is typically normal until 6-18 months, when language and motor milestones regress, purposeful hand use is lost and acquired deceleration in the rate of head growth (resulting in microcephaly in some) is seen. Hand stereotypes are typical and breathing irregularities such as hyperventilation, breath holding, or sighing are seen in many. Early on, autistic-like behavior could also be seen.

Most individuals with Rett syndrome are female. Because the disease-causing gene is found on the X chromosome , a female born with a MECP2 mutation on her X chromosome has another X chromosome with an ostensibly normal copy of an equivalent gene, while a male with the mutation on his X chromosome has no other X chromosome, only a Y chromosome; thus, he has no normal gene. Without a traditional gene to supply normal proteins additionally to the abnormal proteins caused by a MECP2 mutation, the XY karyotype male fetus is unable to see the development of the disease, hence the failure of the many male fetuses with a MECP2 mutation to survive to term. Females with a MECP2 mutation, however, have a non-mutant chromosome that gives them enough normal protein to survive a minimum of to birth. Research shows that males with Rett's syndrome almost all have Klinefelter's syndrome as well (in which the male has an XXY karyotype).[4] Thus, a non-mutant MECP2 gene is necessary for a Rett's-affected embryo to survive in most cases, and the embryo, male or female, must have another X chromosome.

There have, however, been several cases of 46,XY Karyotype males with a MECP2 mutation (associated with classical Rett syndrome in females) carried to term, who were affected by neonatal encephalopathy and died before 2 years of age.[5] The incidence of Rett syndrome in males is unknown, partly due to low survival of male fetuses with the Rett syndrome associated MECP2 mutations, and partly to differences between symptoms caused by MECP2 mutations and those caused by Rett's.[6][7] T he severity of Rett syndrome in females can vary counting on the sort and position of the mutation of MECP2 and therefore the pattern of X-chromosome inactivation. It is generally assumed that 50% of a female's cells use the maternal X chromosome while the other 50% uses the paternal X chromosome (see X-inactivation). However, if most cells within the brain activate the X chromosome with the functional MECP2 allele, the individual will have very mild Rett syndrome; likewise, if most neurons activate the X chromosome with the mutated MECP2 allele, the individual will have very severe Rett syndrome even as males with MECP2 mutations do (as they only have one X chromosome).

Development and symptoms

The infant with Rett syndrome is not detected until 6-18 months due to a relatively normal appearance and normal development. The manifestations appear progressively over 4 stages: stagnation(6-18 months, rapid regression(1-4 years), pseudo-stationary(2-potential life) and late motor deterioration(10 years to life). Characteristic features include loss of speech and acquired motor skills, repetitive hand movements, breathing difficulties and seizures. Few children may have gastrointestinal problems, bruxism, screaming spells and early onset osteoporosis. During regression some features are similar to those of autism. It is, hence, easy to mistakenly diagnose Rett syndrome for autism.

STAGES OF RETT SYNDROME

• STAGE 1-STAGNATION: This includes developmental delay, postural delays, hypotonia and microcephaly.
• STAGE 2-RAPID REGRESSION: This is associated with repetitive stereotype hand movements, loss of motor skills and communication, breathing difficulties, and worsening of microcephaly.
• STAGE 3-PSEUDO-STATIONARY: There is prominent hand apraxia/dyspraxia in this stage. Seizures are common during this period.
• STAGE 4-MOTOR DETERIORATION: During this period affected individual exhibits severe physical disability due to wasting, scoliosis or dystonia. Not all girls progress to this stage.

Symptoms of Rett syndrome that are similar to autism:

• screaming fits
• panic attack
• inconsolable crying
• avoidance of eye contact
• lack of social/emotional reciprocity
• general lack of interest
• markedly impaired use of nonverbal behaviors to regulate social interaction
• loss of speech
• Balance and coordination problems, including losing the ability to walk in many cases

Symptoms of Rett syndrome that are also present in cerebral palsy (regression of the type seen in Rett syndrome would be unusual in cerebral palsy; this confusion should rarely be made):

• possible short stature, and/or might be unusually proportioned because of difficulty walking or malnutrition due to difficulty swallowing.
• hypotonia
• delayed or absent ability to walk
• gait/movement difficulties
• ataxia
• microcephaly in some - abnormally small head, poor head growth
• some forms of spasticity
• chorea - spasmodic movements of hand or facial muscles
• dystonia
• bruxism - grinding of teeth

Symptoms may stabilize for many decades, particularly for interaction and cognitive function such as making choices. Anti-social behavior may change to highly social behavior. Motor functions may slow as rigidity and dystonia appear. Seizures may be problematic, with a wide range of severity. Scoliosis occurs in most and requires corrective surgery in about 10%. Those who remain ambulatory tend to have less progression of scoliosis.

Differential diagnosis

Rett syndrome must be differentiated from other diseases that cause neurological manifestations in infants.

Diseases	Type of motor abnormality				Clinical findings	Laboratory findings and diagnostic tests	Radiographic findings
	Spasticity	Hypotonia	Ataxia	Dystonia
Leigh syndrome	-	-	+	+	Progressive psychomotor regression Seizures External ophthalmoplegia Lactic acidosis Vomiting	Increased lactate levels in blood and CSF Genetic testing	MRI: abnormal white matter signal in the putamen, basal ganglia, and brainstem on T2 images
Niemann-Pick disease type C	-	-	+	+	Progressive neurodegeneration Hepatosplenomegaly Systemic involvement of liver, spleen, or lung preceedes neurologic symptoms	Abnormal liver function tests Fibroblast cell culture with filipin staining	MRI: Cerebral and cerebellar atrophy Thinning of the corpus callosum
Infantile Refsum disease	-	+	+	-	Abnormalities of the optic nerve and disc Retinitis pigmentosa Sensorineural hearing loss Hepatomegaly and cirrhosis Neurologic deterioration is slower than in Zellweger syndrome or ALD	Elevated plasma VLCFA levels	--
Adrenoleukodystrophy	+	-	-	-	Cognitive and behavioral abnormalities Adrenal insufficiency Hyperpigmented skin Gonadal dysfunction Neurologic deterioration progresses at a variable rate	Elevated plasma VLCFA levels Molecular genetic testing for mutations in the ABCD1 gene	--
Zellweger syndrome	-	+	-	-	Craniofacial dysmorphism Hepatomegaly Neonatal seizures Profound developmental delay MRI findings include cortical and white matter abnormalities Neurologic deterioration is rapid and infants rarely survive beyond six months of age	Elevated plasma VLCFA levels Elevated levels of phytanic acid, pristanic acid, and pipecolic acid in plasma and fibroblasts Reduced plasmalogen in erythrocytes Molecular genetic testing for mutations in the PEX1 or PEX6 genes	--
Pyruvate dehydrogenase deficiency	+	+	+	-	Lactic acidosis Seizures Intellectual disability	Elevated lactate and pyruvate levels in blood and CSF Abnormal PDH enzymatic activity in cultured fibroblasts	--
Arginase deficiency	+	-	-	-	Hyperammonemia Encephalopathy Respiratory alkalosis	Elevated ammonia level Elevated arginine level	--
Holocarboxylase synthetase deficiency	-	+	-	-	Ketoacidosis Dermatitis Alopecia Seizures Developmental delay	Elevated levels of: Beta-hydroxyisovalerate Beta-methylcrotonylglycine Beta-hydroxypropionate Methylcitrate Tiglylglycine	--
Glutaric aciduria type 1	-	-	-	+	Episodes of metabolic decompensation and encephalopathy often precipitated by infection and fever Rarely presents in the newborn period Microencephalic macrocephaly Seizures (approximately 20 percent) Cognitive function is preserved	Elevated levels of: glutaric acid 3-hydroxyglutaric acid	MRI: Frontal and temporal atrophy
Ataxia telangiectasia	-	-	+	-	Progressive cerebellar ataxia Abnormal eye movements Oculocutaneous telangiectasias Immune deficiency Increased risk of malignancy	Elevated serum alpha-fetoprotein level Low IgA and IgG levels Lymphopenia Genetic testing for mutation in the ATM gene	--
Pontocerebellar hypoplasias	-	+	-	-	Progressive muscle atrophy Microcephaly Developmental delay	Genetic testing for PCH gene mutations	MRI : Small cerebellum and brainstem including the pons
Metachromatic leukodystrophy	-	+	+	-	Regression of motor skills Seizures Optic atrophy Reduced or absent deep tendon reflexes Intellectual disability	Deficient arylsulfatase A enzyme activity in leukocytes or cultured skin fibroblasts	--
Pelizaeus-Merzbacher	+	-	+	-	Nystagmus Cognitive impairment Onset in infancy Slowly progressive Language development may be normal	Genetic testing for mutations in PLP1 gene	MRI: White matter abnormalities
Angelman syndrome	-	-	+	-	Profound intellectual disability Postnatal microcephaly Typical abnormal behaviors (paroxysmal laughter, easily excitable)	Methylation studies and chromosome microarray to detect chromosome 15 anomalies and UBE3A mutations	--
Rett syndrome	+	-	-	+	Occurs almost exclusively in females Normal development during first six months followed by regression and loss of milestones Loss of speech capability Stereotypic hand movements Seizures Autistic features	Clinical diagnosis Genetic testing for MECP2 mutations	--
Lesch-Nyhan syndrome	+	-	-	+	Self-mutilating behavior Urinary stones due to hyperuricemia	Elevated uric acid level Abnormal enzymatic activity of HPRT in cultured fibroblasts Genetic testing for HPRT gene mutations	--
Miller-Dieker lissencephaly	+	+	-	-	Lissencephaly Microcephaly Dysmorphic features Seizures Failure to thrive	Cytogenetic testing for 17p13.3 microdeletion	--
Dopa-responsive dystonia	+	-	-	+	Onset in early childhood Symptoms worsen with fatigue and exercise	Positive response to a trial of levodopa	--

Treatment and prognosis

Currently there is no cure for Rett syndrome, although there have been some promising results with gene therapy in mice.

Treatment of Rett syndrome includes:

• management of gastrointestinal (reflux, constipation) and nutritional (poor weight gain) issues
• surveillance of scoliosis and long QT syndrome
• increasing the patient's communication skills, especially with augmentative communication strategies
• parental counseling
• modifying social medications
• sleep aids
• SSRIs
• anti-psychotics (for self-harming behaviors)
• beta-blockers rarely for long QT syndrome
• Occupational therapy, Speech therapy and Physical therapy are use to treat children with Rett syndrome.

The challenge of developing therapies for MECP2 disorders

The recent studies demonstrating that neurological deficits resulting from loss of MeCP2 can be reversed upon restoration of gene function are quite exciting because they show that neurons that have suffered the consequences of loss of MeCP2 function are poised to regain functionality once MeCP2 is provided gradually and in the correct spatial distribution. This provides hope for restoring neuronal function in patients with RTT. However, the strategy in humans will require providing the critical factors that function downstream of MeCP2 because of the challenges in delivering the correct MeCP2 dosage only to neurons that lack it, given that the slightest perturbation in MeCP2 level is deleterious. Thus, therapeutic strategies necessitate the identification of the molecular mechanisms underlying individual RTT phenotypes and picking out the candidates that can be therapeutically targeted. The next phase of research needs to assess how complete the recovery is. Clearly, lethality, level of activity, and hippocampal plasticity are rescued, but are the animals free of any other RTT symptoms such as social behavior deficits, anxiety, and cognitive impairments? Since postnatal rescue results in viability, it will be important to evaluate if even the subtler phenotypes of RTT and MECP2 disorders are rescued when protein function is restored postnatally. This is particularly important given emerging data about early neonatal experiences and their long-term effects on behavior in adults.

Mortality

Males with pathogenic MECP2 mutations usually die within the first 2 years from severe encephalopathy, unless they have an extra X chromosome (often described as Klinefelter syndrome), or have somatic mosaicism.

Females can live up to 40 years or more. Laboratory studies on Rett syndrome may show abnormalities such as:

• EEG abnormalities from 2 years of age
• atypical brain glycolipids
• elevated CSF levels of beta-endorphins and glutamate
• reduction of substance P
• decreased levels of CSF nerve growth factors

A high proportion of deaths are abrupt, but most have no identifiable cause; in some instances death is the result most likely of:

• spontaneous brainstem dysfunction
• cardiac arrest
• seizures
• cardiac conduction abnormalities - abnormally prolonged QT interval on ECG
• gastric perforation

References

• "The Story of Rett Syndrome: From Clinic to Neurobiology",Neuron Vol 56, 422-437, 08 November 2007
• "Getting a Read on Rett Syndrome", Science 8 December 2006: Vol. 314. no. 5805, pp. 1536 - 1537
• Progress Is Reported on a Type of Autism

Further reading

• Ben Zeev Ghidoni B (2007). "Rett syndrome". Child Adolesc Psychiatr Clin N Am. 16 (3): 723–43. doi:10.1016/j.chc.2007.03.004. PMID 17562589.
• Bittner JG; et al. (2008). "Rett Syndrome and gastric perforation". Am Surg. 74 (4): 315–317.CS1 maint: Explicit use of et al. (link)

Rett Disorder and the Developing Brain. edited by Alison Kerr & Ingegerd Witt Engerstrom Oxford University Press ISBN 0-19-856815-0, 2005

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