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#redirect: [[Exocrine pancreatic insufficiency]]
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==Overview==
'''Johanson–Blizzard syndrome''' (JBS) is a rare, sometimes fatal  [[autosome|autosomal]] [[dominance (genetics)|recessive]] multisystem [[congenital disorder]] featuring abnormal development of the [[pancreas]], [[Human nose|nose]] and [[scalp]], with [[mental retardation]], [[hearing loss]] and [[growth failure]].<ref name=jbaur>{{cite journal |pmid=19058315 |date=Nov 2008 |vauthors=Alkhouri N, Kaplan B, Kay M, Shealy A, Crowe C, Bauhuber S, Zenker M |title=Johanson-Blizzard syndrome with mild phenotypic features confirmed by UBR1 gene testing |volume=14 |issue=44 |pages=6863–6866 |journal=World Journal of Gastroenterology : WJG |url=http://www.wjgnet.com/1007-9327/14/6863.asp |format=Free full text |doi=10.3748/wjg.14.6863 |pmc=2773884}}</ref> It is sometimes described as a form of [[ectodermal dysplasia]].<ref name=jbec>{{cite journal |pmid=15630323 |date=Dec 2004 |vauthors=Kulkarni ML, Shetty SK, Kallambella KS, Kulkarni PM |title=Johanson--blizzard syndrome |volume=71 |issue=12 |pages=1127–1129 |journal=Indian Journal of Pediatrics |doi=10.1007/BF02829829}}</ref>
 
The disorder is especially noted for causing profound developmental errors and exocrine dysfunction of the pancreas, and it is considered to be an inherited pancreatic disease.<ref name=gpan06>{{cite journal |pmid=16632090 |date=Jun 2006 |vauthors=Zenker M, Mayerle J, Reis A, Lerch MM |title=Genetic basis and pancreatic biology of Johanson-Blizzard syndrome |volume=35 |issue=2 |pages=243–253, vii-viii |doi=10.1016/j.ecl.2006.02.013 |journal=Endocrinology and Metabolism Clinics of North America}}</ref>
 
== Characteristics ==
 
=== Exocrine ===
The most prominent effect of JBS is [[exocrine pancreas|pancreatic]] [[exocrine pancreatic insufficiency|exocrine insufficiency]].<ref name=jbaur/><ref name=jbgh>{{cite journal |vauthors=Sandhu BK, Brueton MJ | title = Concurrent pancreatic and growth hormone insufficiency in Johanson-Blizzard syndrome | journal = J. Pediatr. Gastroenterol. Nutr. | volume = 9 | issue = 4 | pages = 535–8 |date=November 1989 | pmid = 2621533 | doi =  10.1097/00005176-198911000-00026 }}</ref><ref name=pand00>{{cite journal |pmid=11154160 |date=Nov 2000 |vauthors=Steinbach WJ, Hintz RL |title=Diabetes mellitus and profound insulin resistance in Johanson-Blizzard syndrome. |volume=13 |issue=9 |pages=1633–1636 |issn=0334-018X |journal=Journal of Pediatric Endocrinology & Metabolism : JPEM |doi=10.1515/jpem.2000.13.9.1633}}</ref><ref name=jbge>{{cite journal |pmid=16311597 |date=Dec 2005 |vauthors=Zenker M, Mayerle J, Lerch MM, Tagariello A, Zerres K, Durie PR, Beier M, Hülskamp G, Guzman C, Rehder H, Beemer FA, Hamel B, Vanlieferinghen P, Gershoni-Baruch R, Vieira MW, Dumic M, Auslender R, Gil-Da-Silva-Lopes VL, Steinlicht S, Rauh M, Shalev SA, Thiel C, Ekici AB, Winterpacht A, Kwon YT, Varshavsky A, Reis A |title=Deficiency of UBR1, a ubiquitin ligase of the N-end rule pathway, causes pancreatic dysfunction, malformations and mental retardation (Johanson-Blizzard syndrome). |volume=37 |issue=12 |pages=1345–1350 |doi=10.1038/ng1681 |journal=Nature Genetics}}</ref><ref name=jb98>{{cite journal |pmid=9846268 |date=Oct 1998 |vauthors=Rosanowski F, Hoppe U, Hies T, Eysholdt U |title=Johanson-Blizzard syndrome. A complex dysplasia syndrome with aplasia of the nasal alae and inner ear deafness |volume=46 |issue=10 |pages=876–878 |journal=HNO |doi=10.1007/s001060050328}}</ref> Varying degrees of decreased [[secretion]] of [[lipase]]s, [[pancreatic juice]]s such as [[trypsin]], [[trypsinogen]] and others, as well as [[malabsorption]] of [[fat]]s and disruptions of [[glucagon]] secretion and its response to [[hypoglycemia]] caused by [[insulin]] activity are major concerns when JBS is diagnosed.<ref name=jbaur/><ref name=gpan06/><ref name=gluc04>{{cite journal |pmid=15379429 |date=Aug 2004 |vauthors=Takahashi T, Fujishima M, Tsuchida S, Enoki M, Takada G |title=Johanson-blizzard syndrome: loss of glucagon secretion response to insulin-induced hypoglycemia. |volume=17 |issue=8 |pages=1141–1144 |issn=0334-018X |journal=Journal of Pediatric Endocrinology & Metabolism : JPEM |doi=10.1515/jpem.2004.17.8.1141}}</ref> Associated with developmental errors, impaired [[apoptosis]], and both prenatal and chronic [[inflammation|inflammatory]] damage, [[necrosis]] and [[fibrosis]] of the pancreatic [[acinus|acini]] (clusters of pancreatic [[exocrine gland]] tissue, where secretion of pancreatic juice and related [[enzyme]]s occurs), pancreatic exocrine insufficiency in JBS can additionally stem from congenital replacement of the acini with [[adipose tissue|fatty tissue]].<ref name=jbaur/><ref name=gpan06/><ref name=gluc04/><ref name=adip79>{{cite journal |pmid=474625 |year=1979 |month= |vauthors=Daentl DL, Frías JL, Gilbert EF, Opitz JM |title=The Johanson-Blizzard syndrome: case report and autopsy findings. |volume=3 |issue=2 |pages=129–135 |doi=10.1002/ajmg.1320030203 |journal=American Journal of Medical Genetics}}</ref><ref name=path94>{{cite journal |pmid=8071749 |date=Sep 1994 |vauthors=Jones NL, Hofley PM, Durie PR |title=Pathophysiology of the pancreatic defect in Johanson-Blizzard syndrome: a disorder of acinar development. |volume=125 |issue=3 |pages=406–408 |journal=The Journal of Pediatrics |doi=10.1016/S0022-3476(05)83286-X}}</ref> Near total replacement of the entire pancreas with fatty tissue has also been reported. This is a progressive, sometimes fatal consequence of the disorder.<ref name=adip79/>
 
=== Endocrine ===
Endocrine insufficiency of the pancreas occurs with JBS, though it is sometimes less common and less pronounced than the more prominent effects on exocrine function.<ref name=jbaur/> The [[islets of Langerhans]] are ducts in the pancreas where endocrine activity such as the release of [[hormone]]s glucagon, [[somatostatin]] and insulin takes place. Pancreatic endocrine insufficiency in JBS can be associated with either a buildup of [[connective tissue]] in the islet regions, congenital replacement of the islets with fatty tissue, or improper [[nerve]] signalling to the islets.<ref name=jbaur/><ref name=pand00/><ref name=gluc04/><ref name=diab93>{{cite journal |pmid=8448911 |date=Feb 1993 |vauthors=Nagashima K, Yagi H, Kuroume T |title=A case of Johanson-Blizzard syndrome complicated by diabetes mellitus |volume=43 |issue=2 |pages=98–100 |issn=0009-9163 |journal=Clinical Genetics |doi=10.1111/j.1399-0004.1993.tb04458.x}}</ref><ref name=jboy89>{{cite journal |pmid=2669481 |date=Jun 1989 |vauthors=Gould NS, Paton JB, Bennett AR |title=Johanson-Blizzard syndrome: clinical and pathological findings in 2 sibs. |volume=33 |issue=2 |pages=194–199 |doi=10.1002/ajmg.1320330212 |journal=American Journal of Medical Genetics}}</ref> Endocrine dysfunction of the pancreas often results in [[diabetes mellitus]]. Both [[insulin resistance]] and diabetes have been observed with JBS, and it is suggested that diabetes should be considered as a complication of JBS and its course.<ref name=pand00/><ref name=diab93/>
 
Ductular output of fluids and [[electrolyte]]s is preserved in the pancreas of many with JBS, as well as moderate to normal levels of functioning [[bicarbonate]].<ref name=jbaur/>
 
Endocrine abnormalities in other areas have also been present with the disorder. These include [[hypothyroidism]],<ref name=jbec/> [[growth hormone deficiency]]<ref name=jbaur/><ref name=gluc04/> and [[hypopituitarism]].<ref name=jbaur/> Findings affecting pituitary function in some JBS patients have included such anomalies as the formation of a [[hamartoma|glial hamartoma]] (a [[neoplasm]], or [[tumor]] composed of [[glial cell]]s) on a lobe of the [[pituitary gland]], as well congenital underdevelopment of the [[anterior pituitary]].<ref name=pit07>{{cite journal |pmid=17378628 |date=Jan 2007 |vauthors=Hoffman WH, Lee JR, Kovacs K, Chen H, Yaghmai F |title=Johanson-Blizzard syndrome: autopsy findings with special emphasis on hypopituitarism and review of the literature. |volume=10 |issue=1 |pages=55–60 |doi=10.2350/06-05-0085.1 |journal=Pediatric and Developmental Pathology : the official journal of the Society for Pediatric Pathology and the Paediatric Pathology Society}}</ref> Growth failure and associated [[short stature]] ([[dwarfism]]) in JBS can be attributed to growth hormone deficiency caused by diminished anterior pituitary function, with malabsorption of fats playing a subsequent role.<ref name=jbaur/><ref name=jbgh/><ref name=jbdw>{{cite journal |vauthors=Fichter CR, Johnson GA, Braddock SR, Tobias JD | title = Perioperative care of the child with the Johanson-Blizzard syndrome | journal = Paediatric Anaesthesia | volume = 13 | issue = 1 | pages = 72–5 |date=January 2003 | pmid = 12535044 | doi = 10.1046/j.1460-9592.2003.00957.x }}</ref>
 
=== Nasal ===
The primary malformation apparent with JBS is [[hypoplasia]] (underdevelopment) of the nasal alae, or "[[wing of the nose]]".<ref name=jbaur/><ref name=jbec/><ref name=jb98/> Both hypoplasia and [[aplasia]] (partial or complete absence) of structural [[cartilage]] and [[tissue (biology)|tissue]] in this area of the nose, along with the underlying [[depressor septi nasi muscle|alae nasi muscle]], are prevailing features of the disorder. Together, these malformations give the nose and [[nostril]]s an odd shape and appearance.<ref name=jb98/><ref name=omim>{{OMIM|243800}}</ref>
 
=== Neurological ===
Mental retardation ranging from mild to severe is present in the majority of JBS patients, and is related to the deleterious nature of the known mutagen responsible for the disorder and its effects on the developing [[central nervous system]].<ref name=jbaur/><ref name=jbge/><ref name=intel>{{cite journal |vauthors=Moeschler JB, Polak MJ, Jenkins JJ, Amato RS | title = The Johanson-Blizzard syndrome: a second report of full autopsy findings | journal = Am. J. Med. Genet. | volume = 26 | issue = 1 | pages = 133–8 |date=January 1987 | pmid = 3812553 | doi = 10.1002/ajmg.1320260120 }}</ref> Normal intelligence and age appropriate social development, however, have been reported in a few instances of JBS.<ref name=jboy89/><ref name=intel/>
 
=== Auditory ===
Findings with the [[inner ear]] in JBS give explanation to the presence of bilateral [[sensorineural hearing loss]] in most patients affected by the disorder. The formation of [[cyst]]ic tissue in both the [[cochlea]] and [[vestibule of the ear|vestibule]], with resulting [[wikt:dilate|dilation]] (widening) and malformation of these delicate structures has been implicated.<ref name=jb98/><ref name=adip79/><ref name=jbear>{{cite journal |vauthors=Braun J, Lerner A, Gershoni-Baruch R | title = The temporal bone in the Johanson-Blizzard syndrome. A CT study | journal = Pediatric Radiology | volume = 21 | issue = 8 | pages = 580–3 | year = 1991 | pmid = 1815181 | doi = 10.1007/BF02012603 }}</ref> Congenital deformations of the [[temporal bone]] and associated adverse anatomical effects on innervation and development of the inner ear also contribute to this type of hearing loss.<ref name=jbear/><ref>{{cite journal |vauthors=Bamiou DE, Phelps P, Sirimanna T | title = Temporal bone computed tomography findings in bilateral sensorineural hearing loss | journal = Arch. Dis. Child. | volume = 82 | issue = 3 | pages = 257–60 |date=March 2000 | pmid = 10685935 | pmc = 1718255 | doi = 10.1136/adc.82.3.257}}</ref>
 
=== Craniofacial ===
Other abnormalities, affecting the scalp, [[head]], [[face]], [[jaw]] and [[teeth]] may be found with JBS. These include: [[ectoderm]]al mid-line scalp defects with sparse, oddly-patterned [[hair]] growth;<ref name=jbec/><ref name=adip79/> aplasia [[cutis (biology)|cutis]]  (underdeveloped, very thin [[skin]]) over the head,<ref name=jb78>{{cite journal |vauthors=Mardin MK, Ghandour M, Sakati NA, Nyhan WL |title=Johanson-Blizzard syndrome in a large inbred kindred with three involved members |journal=Clin Genet |volume=14 |issue=5 |pages=247–250 |date=Nov 1978 |pmid=709902}}</ref> an enlarged [[fontanelle]] ("soft spot" on the head of young [[infant]]s),<ref name=jbdw/> [[microcephaly]] (undersized [[Human skull|skull]]),<ref name=jb78/> prominent [[forehead]],<ref name=jbdw/> absence of [[eyebrow]]s and [[eyelash]]es,<ref name=jbdw/> [[mongoloid race|mongoloidal]] [[human eye|eye]] shape,<ref name=jbear/> [[nasolacrimal duct|nasolacrimo-]][[cutaneous]] [[fistula]]e (this refers to the formation of an abnormal secondary passageway from either the tear duct or [[lacrimal sac]] to the facial skin surface, possibly discharging fluid),<ref name=adip79/> flattened [[ear]]s,<ref name=jbdw/> [[micrognathism]] of the [[maxilla]] and [[human mandible|mandible]] (underdevelopment of the upper and lower jaw, respectively), with the maxilla more prominently affected in some cases;<ref name=jbdw/><ref name=surg95>{{cite journal |pmid=9020718 |vauthors=Kobayashi S, Ohmori K, Sekiguchi J |title=Johanson-Blizzard syndrome facial anomaly and its correction using a microsurgical bone graft and tripartite osteotomy |journal=J Craniofac Surg |volume=6 |issue=5 |pages=382–385 |date=Sep 1995 |doi=10.1097/00001665-199509000-00011 }}</ref><ref name=crafac>{{cite journal |vauthors=Motohashi N, Pruzansky S, Day D |title=Roentgencephalometric analysis of craniofacial growth in the Johanson-Blizzard syndrome |journal=J Craniofac Genet Dev Biol |volume=1 |issue=1 |pages=57–72 |year=1981 |pmid=7341643 }}</ref> congenital clefting of [[bone]]s surrounding the [[orbit (anatomy)|optical orbit]] (eye socket), such as the [[frontal bone|frontal]] and [[lacrimal bone]];<ref name=surg95/> and maldeveloped [[deciduous teeth]] ("baby teeth"), with an absence of [[permanent teeth]].<ref name=adip79/><ref name=jbdw/>
 
=== Effects on other organ systems ===
Additional congenital anomalies, effects on other [[organ (anatomy)|organs]], and less common features of JBS have included: [[imperforate anus]] (occlusion of the [[anus]]),<ref name=jbliver>{{cite journal |vauthors=Al-Dosari MS, Al-Muhsen S, Al-Jazaeri A, Mayerle J, Zenker M, Alkuraya FS | title = Johanson-Blizzard syndrome: report of a novel mutation and severe liver involvement | journal = Am J Med Genet A | volume = 146A | issue = 14 | pages = 1875–9 |date=July 2008 | pmid = 18553553 | doi = 10.1002/ajmg.a.32401 }}</ref> [[vesicoureteral reflux]] (reversal of the flow of [[urine]], from the [[bladder]] back into the [[ureter]]s, toward the [[kidney]]s);<ref name=jbdw/> [[wikt:duplex|duplex]] of the [[uterus]] and [[vagina]] in [[female]] infants,<ref name=jb98/> [[neonatal cholestasis]] of the [[liver]], with [[cirrhosis]] and [[portal hypertension]] ([[hypertension|high blood pressure]] in the [[hepatic portal vein]]);<ref name=jbliver/> [[dilated cardiomyopathy]],<ref name=card08>{{cite journal |vauthors=Elting M, Kariminejad A, de Sonnaville ML, Ottenkamp J, Bauhuber S, Bozorgmehr B, Zenker M, Cobben JM | title = Johanson-Blizzard syndrome caused by identical UBR1 mutations in two unrelated girls, one with a cardiomyopathy | journal = Am J Med Genet A | volume = 146A | issue = 23 | pages = 3058–61 |date=December 2008 | pmid = 19006206 | doi = 10.1002/ajmg.a.32566 }}</ref> [[dextrocardia]] (congenital displacement of the [[heart]] to the right side of the [[chest]]),<ref name=jbaur/> [[atrial septal defect|atrial]] and [[ventricular septal defect]];<ref name=jbaur/> [[small for gestational age|low birth-weight]],<ref name=cata>{{cite journal |vauthors=Dumić M, Ille J, Bobonj G, Kordić R, Batinica S | title = Johanson-Blizzardov sindrom |trans_title=The Johanson-Blizzard syndrome |language=Croatian | journal = Lijec Vjesn | volume = 120 | issue = 5 | pages = 114–6 |date=May 1998 | pmid = 9748788 | doi = }}</ref> [[failure to thrive]],<ref name=cata/> [[hypotonia]] (decreased [[muscle tone]]);<ref name=jb78/> [[sacral hiatus]] (a structural deficiency of the [[sacrum|sacral vertebrae]]),<ref name=cata/> [[cataract|congenital cataracts]],<ref name=cata/> and [[cafe-au-lait spot]]s.<ref name=jbec/>
 
== Genetics ==
[[Image:Autosomal recessive - en.svg|thumb|right|Johanson-Blizzard syndrome has an autosomal recessive pattern of inheritance.]]
JBS is inherited in an autosomal recessive manner.<ref name=jbaur/> This means the defective gene responsible for the disorder is located on an [[autosome]], and two copies of the defective gene (one inherited from each parent) are required in order to be born with the disorder. The parents of an individual with an autosomal recessive disorder both [[genetic carrier|carry]] one copy of the defective gene, but usually do not experience any signs or symptoms of the disorder.
 
== Pathophysiology ==
 
Johanson–Blizzard syndrome is caused by [[mutation]]s in the ''[[UBR1]]'' gene, which encodes one of several ''[[ubiquitin ligase]]'' enzymes of the N-end rule pathway.<ref name=jbaur/><ref name=jbge/>
 
The protein [[ubiquitin]] is a universal, "[[wikt:ubiquitous|ubiquitously]]" expressed protein common to [[eukaryote|eukaryotic]] [[organism]]s. Ubiquitin plays a role in the [[post-translational regulation|regulation]] of other proteins by tagging them for eventual degradation by [[proteasome]]s.<ref name=ubick>{{cite journal |vauthors=Wang J, Maldonado MA | title = The ubiquitin-proteasome system and its role in inflammatory and autoimmune diseases | journal = Cell Mol Immunol | volume = 3 | issue = 4 | pages = 255–61 |date=August 2006 | pmid = 16978533 | doi = }}</ref> This process begins when ''ubiquitin ligase'' [[covalent bond|covalently]] attaches a ubiquitin [[molecule]] to the [[lysine]] [[side chain]] of the target protein [[Substrate (biochemistry)|substrate]] (the misfolded, damaged, malfunctioning or unneeded protein that needs to be degraded). This is repeated a number of times in succession forming a chain of ubiquitin molecules, which is a process referred to as polyubiquitination. The polyubiquitination of the target protein signals the proteasome to break it down, which it does via [[proteolysis]].<ref name=ubick/> The ubiquitin-proteasome system plays a crucial role in the [[lysosome|non-lysosomal]] degradation of intracellular proteins, and ubiquitin can also participate in [[posttranslational modification|modifying]] proteins to perform certain tasks.<ref name=ubick/><ref name=u94>{{cite journal | author = Ciechanover A | title = The ubiquitin-mediated proteolytic pathway: mechanisms of action and cellular physiology | journal = Biol Chem Hoppe-Seyler | volume = 375 | issue = 9 | pages = 565–81 |date=September 1994 | pmid = 7840898 | doi = 10.1515/bchm3.1994.375.8.565 }}</ref><ref name=u04>{{cite journal |vauthors=Ciechanover A, Iwai K | title = The ubiquitin system: from basic mechanisms to the patient bed | journal = IUBMB Life | volume = 56 | issue = 4 | pages = 193–201 |date=April 2004 | pmid = 15230346 | doi = 10.1080/1521654042000223616 }}</ref> Both degradation and modification of proteins within the cell are part of a broader regulatory scheme, necessary for cellular processes such as [[cell division]], [[cell signalling]], [[receptor (biochemistry)|cell surface receptor]] function, [[apoptosis]], [[DNA]] maintenance, inflammatory response and  developmental quality control associated with the [[cell cycle]] and [[homeostasis]] in general.<ref name=u94/><ref name=u04/>
 
Ubiquitin-mediated degradation of proteins occurs through the [[N-end rule]] pathway.<ref name=nend97>{{cite journal | author = Varshavsky A | title = The N-end rule pathway of protein degradation | journal = Genes Cells | volume = 2 | issue = 1 | pages = 13–28 |date=January 1997 | pmid = 9112437 | doi = 10.1046/j.1365-2443.1997.1020301.x }}</ref><ref name=nend91>{{cite journal |vauthors=Baker RT, Varshavsky A | title = Inhibition of the N-end rule pathway in living cells | journal = Proc Natl Acad Sci USA | volume = 88 | issue = 4 | pages = 1090–4 |date=February 1991 | pmid = 1899923 | pmc = 50962 | doi =  10.1073/pnas.88.4.1090}}</ref> In eukaryotes, including humans, the N-end rule pathway is part of the ubiquitin system.<ref name=nend97/> Composed of a highly selective [[residue (chemistry)|single-residue]] code (a single [[amino acid]] [[nucleotide]] sequence), the N-end rule serves as a mechanism which can relate the stability of a protein to the identity of the amino acid at its [[N-terminus]] (the end of the [[polypeptide]] with an [[amino group]], which in the ubiquitin system may be involved in the reactive destabilization of the protein).<ref name=nend97/><ref name=nend91/><ref name=nend89>{{cite journal |vauthors=Gonda DK, Bachmair A, Wünning I, Tobias JW, Lane WS, Varshavsky A | title = Universality and structure of the N-end rule | journal = J Biol Chem | volume = 264 | issue = 28 | pages = 16700–12 |date=October 1989 | pmid = 2506181 | doi = }}</ref>
 
In JBS, mutations in the ''UBR1'' gene alter, disrupt or prevent the synthesis of ''ubiquitin ligase''.<ref name=jbaur/><ref name=jbge/> In the pancreatic acinar cells, ''UBR1'' is more highly expressed than anywhere else in the body.<ref name=jbaur/> Impairment of the ubiquitin-proteasome system directly related to insufficient activity of ''ubiquitin ligase'' has been established as the cause of both congenital and progressive inflammatory damage, fatty tissue replacement, connective tissue proliferation and errors in innervation of the acini and islets, correlating to failures of normal apoptotic destruction of damaged cells and constitutive malpresence of proteins.<ref name=jbaur/><ref name=gpan06/><ref name=jbge/> This also applies to other areas affected by deleterious ''UBR1'' expression, such as the craniofacial area, musculoskeletal and nervous systems, dentition and organs.<ref name=jbaur/><ref name=jbge/><ref name=jbliver/>
 
[[missense mutation|Missense]], [[nonsense mutation|nonsense]] and [[splice site mutation]]s of the ''UBR1'' gene in both parents have been found with JBS, confirming the [[homozygous]] nature of the JBS [[phenotype]]. Variability of the phenotype, associated with residual ''ubiquitin ligase'' activity in some patients, has also been attributed to [[Muller's morphs#Hypomorph|hypomorphic]] mutations occasionally found in either of the carrier parents.<ref name=jbaur/><ref name=gpan06/><ref name=jbge/><ref name=jbliver/><ref name=card08/> The ''UBR1'' gene is located on human [[chromosome]] [[chromosome 15|15]].<ref name=jbge/>
 
== Treatment ==
 
While there is no cure for JBS, treatment and management of specific symptoms and features of the disorder are applied and can often be successful. Variability in the severity of JBS on a case-by-case basis determines the requirements and effectiveness of any treatment selected.
 
Pancreatic insufficiency and malabsorption can be managed with [[pancreatic enzyme replacement therapy]], such as [[pancrelipase]] supplementation and other related methods.<ref name=jbaur/>
 
Craniofacial and skeletal deformities may require surgical correction, using techniques including [[bone graft]]s and [[osteotomy]] procedures.<ref name=surg95/> Sensorineural hearing loss can be managed with the use of [[hearing aid]]s and educational services designated for the hearing impaired.<ref name=jboy89/><ref name=jbear/>
 
Special education, specialized counseling methods and [[occupational therapy]] designed for those with mental retardation have proven to be effective, for both the patient and their families.<ref>{{cite journal |vauthors=Prater JF, D'Addio K | title = Johanson-Blizzard syndrome--a case study, behavioral manifestations, and successful treatment strategies | journal = Biol Psychiatry | volume = 51 | issue = 6 | pages = 515–7 |date=March 2002 | pmid = 11922888 | doi = 10.1016/S0006-3223(01)01337-3 }}</ref> This, too, is carefully considered for JBS patients.
 
== Eponym ==
Johanson–Blizzard syndrome was named after [[Ann J. Johanson]] and [[Robert M. Blizzard]], the pediatricians who first described the disorder in a 1971 journal report.<ref name=omim/><ref>{{cite journal |vauthors=Johanson A, Blizzard R | title = A syndrome of congenital aplasia of the alae nasi, deafness, hypothyroidism, dwarfism, absent permanent teeth, and malabsorption | journal = J Pediatr | volume = 79 | issue = 6 | pages = 982–7 |date=December 1971 | pmid = 5171616 | doi = 10.1016/S0022-3476(71)80194-4 }}
</ref>
 
== See also ==
*[[Chronic pancreatitis]]
*[[Skeletal dysplasia]]
*[[Lipid]]
{{Clear}}
 
== References ==
{{Reflist|35em}}
 
{{Congenital malformations and deformations of digestive system}}
{{Posttranslational modification disorders}}
 
{{DEFAULTSORT:Johanson-Blizzard Syndrome}}
[[Category:Congenital disorders of digestive system]]
[[Category:Autosomal recessive disorders]]
[[Category:Rare diseases]]
[[Category:Syndromes]]
[[Category:Genodermatoses]]

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

Overview

Johanson–Blizzard syndrome (JBS) is a rare, sometimes fatal autosomal recessive multisystem congenital disorder featuring abnormal development of the pancreas, nose and scalp, with mental retardation, hearing loss and growth failure.[1] It is sometimes described as a form of ectodermal dysplasia.[2]

The disorder is especially noted for causing profound developmental errors and exocrine dysfunction of the pancreas, and it is considered to be an inherited pancreatic disease.[3]

Characteristics

Exocrine

The most prominent effect of JBS is pancreatic exocrine insufficiency.[1][4][5][6][7] Varying degrees of decreased secretion of lipases, pancreatic juices such as trypsin, trypsinogen and others, as well as malabsorption of fats and disruptions of glucagon secretion and its response to hypoglycemia caused by insulin activity are major concerns when JBS is diagnosed.[1][3][8] Associated with developmental errors, impaired apoptosis, and both prenatal and chronic inflammatory damage, necrosis and fibrosis of the pancreatic acini (clusters of pancreatic exocrine gland tissue, where secretion of pancreatic juice and related enzymes occurs), pancreatic exocrine insufficiency in JBS can additionally stem from congenital replacement of the acini with fatty tissue.[1][3][8][9][10] Near total replacement of the entire pancreas with fatty tissue has also been reported. This is a progressive, sometimes fatal consequence of the disorder.[9]

Endocrine

Endocrine insufficiency of the pancreas occurs with JBS, though it is sometimes less common and less pronounced than the more prominent effects on exocrine function.[1] The islets of Langerhans are ducts in the pancreas where endocrine activity such as the release of hormones glucagon, somatostatin and insulin takes place. Pancreatic endocrine insufficiency in JBS can be associated with either a buildup of connective tissue in the islet regions, congenital replacement of the islets with fatty tissue, or improper nerve signalling to the islets.[1][5][8][11][12] Endocrine dysfunction of the pancreas often results in diabetes mellitus. Both insulin resistance and diabetes have been observed with JBS, and it is suggested that diabetes should be considered as a complication of JBS and its course.[5][11]

Ductular output of fluids and electrolytes is preserved in the pancreas of many with JBS, as well as moderate to normal levels of functioning bicarbonate.[1]

Endocrine abnormalities in other areas have also been present with the disorder. These include hypothyroidism,[2] growth hormone deficiency[1][8] and hypopituitarism.[1] Findings affecting pituitary function in some JBS patients have included such anomalies as the formation of a glial hamartoma (a neoplasm, or tumor composed of glial cells) on a lobe of the pituitary gland, as well congenital underdevelopment of the anterior pituitary.[13] Growth failure and associated short stature (dwarfism) in JBS can be attributed to growth hormone deficiency caused by diminished anterior pituitary function, with malabsorption of fats playing a subsequent role.[1][4][14]

Nasal

The primary malformation apparent with JBS is hypoplasia (underdevelopment) of the nasal alae, or "wing of the nose".[1][2][7] Both hypoplasia and aplasia (partial or complete absence) of structural cartilage and tissue in this area of the nose, along with the underlying alae nasi muscle, are prevailing features of the disorder. Together, these malformations give the nose and nostrils an odd shape and appearance.[7][15]

Neurological

Mental retardation ranging from mild to severe is present in the majority of JBS patients, and is related to the deleterious nature of the known mutagen responsible for the disorder and its effects on the developing central nervous system.[1][6][16] Normal intelligence and age appropriate social development, however, have been reported in a few instances of JBS.[12][16]

Auditory

Findings with the inner ear in JBS give explanation to the presence of bilateral sensorineural hearing loss in most patients affected by the disorder. The formation of cystic tissue in both the cochlea and vestibule, with resulting dilation (widening) and malformation of these delicate structures has been implicated.[7][9][17] Congenital deformations of the temporal bone and associated adverse anatomical effects on innervation and development of the inner ear also contribute to this type of hearing loss.[17][18]

Craniofacial

Other abnormalities, affecting the scalp, head, face, jaw and teeth may be found with JBS. These include: ectodermal mid-line scalp defects with sparse, oddly-patterned hair growth;[2][9] aplasia cutis (underdeveloped, very thin skin) over the head,[19] an enlarged fontanelle ("soft spot" on the head of young infants),[14] microcephaly (undersized skull),[19] prominent forehead,[14] absence of eyebrows and eyelashes,[14] mongoloidal eye shape,[17] nasolacrimo-cutaneous fistulae (this refers to the formation of an abnormal secondary passageway from either the tear duct or lacrimal sac to the facial skin surface, possibly discharging fluid),[9] flattened ears,[14] micrognathism of the maxilla and mandible (underdevelopment of the upper and lower jaw, respectively), with the maxilla more prominently affected in some cases;[14][20][21] congenital clefting of bones surrounding the optical orbit (eye socket), such as the frontal and lacrimal bone;[20] and maldeveloped deciduous teeth ("baby teeth"), with an absence of permanent teeth.[9][14]

Effects on other organ systems

Additional congenital anomalies, effects on other organs, and less common features of JBS have included: imperforate anus (occlusion of the anus),[22] vesicoureteral reflux (reversal of the flow of urine, from the bladder back into the ureters, toward the kidneys);[14] duplex of the uterus and vagina in female infants,[7] neonatal cholestasis of the liver, with cirrhosis and portal hypertension (high blood pressure in the hepatic portal vein);[22] dilated cardiomyopathy,[23] dextrocardia (congenital displacement of the heart to the right side of the chest),[1] atrial and ventricular septal defect;[1] low birth-weight,[24] failure to thrive,[24] hypotonia (decreased muscle tone);[19] sacral hiatus (a structural deficiency of the sacral vertebrae),[24] congenital cataracts,[24] and cafe-au-lait spots.[2]

Genetics

File:Autosomal recessive - en.svg
Johanson-Blizzard syndrome has an autosomal recessive pattern of inheritance.

JBS is inherited in an autosomal recessive manner.[1] This means the defective gene responsible for the disorder is located on an autosome, and two copies of the defective gene (one inherited from each parent) are required in order to be born with the disorder. The parents of an individual with an autosomal recessive disorder both carry one copy of the defective gene, but usually do not experience any signs or symptoms of the disorder.

Pathophysiology

Johanson–Blizzard syndrome is caused by mutations in the UBR1 gene, which encodes one of several ubiquitin ligase enzymes of the N-end rule pathway.[1][6]

The protein ubiquitin is a universal, "ubiquitously" expressed protein common to eukaryotic organisms. Ubiquitin plays a role in the regulation of other proteins by tagging them for eventual degradation by proteasomes.[25] This process begins when ubiquitin ligase covalently attaches a ubiquitin molecule to the lysine side chain of the target protein substrate (the misfolded, damaged, malfunctioning or unneeded protein that needs to be degraded). This is repeated a number of times in succession forming a chain of ubiquitin molecules, which is a process referred to as polyubiquitination. The polyubiquitination of the target protein signals the proteasome to break it down, which it does via proteolysis.[25] The ubiquitin-proteasome system plays a crucial role in the non-lysosomal degradation of intracellular proteins, and ubiquitin can also participate in modifying proteins to perform certain tasks.[25][26][27] Both degradation and modification of proteins within the cell are part of a broader regulatory scheme, necessary for cellular processes such as cell division, cell signalling, cell surface receptor function, apoptosis, DNA maintenance, inflammatory response and developmental quality control associated with the cell cycle and homeostasis in general.[26][27]

Ubiquitin-mediated degradation of proteins occurs through the N-end rule pathway.[28][29] In eukaryotes, including humans, the N-end rule pathway is part of the ubiquitin system.[28] Composed of a highly selective single-residue code (a single amino acid nucleotide sequence), the N-end rule serves as a mechanism which can relate the stability of a protein to the identity of the amino acid at its N-terminus (the end of the polypeptide with an amino group, which in the ubiquitin system may be involved in the reactive destabilization of the protein).[28][29][30]

In JBS, mutations in the UBR1 gene alter, disrupt or prevent the synthesis of ubiquitin ligase.[1][6] In the pancreatic acinar cells, UBR1 is more highly expressed than anywhere else in the body.[1] Impairment of the ubiquitin-proteasome system directly related to insufficient activity of ubiquitin ligase has been established as the cause of both congenital and progressive inflammatory damage, fatty tissue replacement, connective tissue proliferation and errors in innervation of the acini and islets, correlating to failures of normal apoptotic destruction of damaged cells and constitutive malpresence of proteins.[1][3][6] This also applies to other areas affected by deleterious UBR1 expression, such as the craniofacial area, musculoskeletal and nervous systems, dentition and organs.[1][6][22]

Missense, nonsense and splice site mutations of the UBR1 gene in both parents have been found with JBS, confirming the homozygous nature of the JBS phenotype. Variability of the phenotype, associated with residual ubiquitin ligase activity in some patients, has also been attributed to hypomorphic mutations occasionally found in either of the carrier parents.[1][3][6][22][23] The UBR1 gene is located on human chromosome 15.[6]

Treatment

While there is no cure for JBS, treatment and management of specific symptoms and features of the disorder are applied and can often be successful. Variability in the severity of JBS on a case-by-case basis determines the requirements and effectiveness of any treatment selected.

Pancreatic insufficiency and malabsorption can be managed with pancreatic enzyme replacement therapy, such as pancrelipase supplementation and other related methods.[1]

Craniofacial and skeletal deformities may require surgical correction, using techniques including bone grafts and osteotomy procedures.[20] Sensorineural hearing loss can be managed with the use of hearing aids and educational services designated for the hearing impaired.[12][17]

Special education, specialized counseling methods and occupational therapy designed for those with mental retardation have proven to be effective, for both the patient and their families.[31] This, too, is carefully considered for JBS patients.

Eponym

Johanson–Blizzard syndrome was named after Ann J. Johanson and Robert M. Blizzard, the pediatricians who first described the disorder in a 1971 journal report.[15][32]

See also

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 Alkhouri N, Kaplan B, Kay M, Shealy A, Crowe C, Bauhuber S, Zenker M (Nov 2008). "Johanson-Blizzard syndrome with mild phenotypic features confirmed by UBR1 gene testing" (Free full text). World Journal of Gastroenterology : WJG. 14 (44): 6863–6866. doi:10.3748/wjg.14.6863. PMC 2773884. PMID 19058315.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Kulkarni ML, Shetty SK, Kallambella KS, Kulkarni PM (Dec 2004). "Johanson--blizzard syndrome". Indian Journal of Pediatrics. 71 (12): 1127–1129. doi:10.1007/BF02829829. PMID 15630323.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Zenker M, Mayerle J, Reis A, Lerch MM (Jun 2006). "Genetic basis and pancreatic biology of Johanson-Blizzard syndrome". Endocrinology and Metabolism Clinics of North America. 35 (2): 243–253, vii–viii. doi:10.1016/j.ecl.2006.02.013. PMID 16632090.
  4. ↑ 4.0 4.1 Sandhu BK, Brueton MJ (November 1989). "Concurrent pancreatic and growth hormone insufficiency in Johanson-Blizzard syndrome". J. Pediatr. Gastroenterol. Nutr. 9 (4): 535–8. doi:10.1097/00005176-198911000-00026. PMID 2621533.
  5. ↑ 5.0 5.1 5.2 Steinbach WJ, Hintz RL (Nov 2000). "Diabetes mellitus and profound insulin resistance in Johanson-Blizzard syndrome". Journal of Pediatric Endocrinology & Metabolism : JPEM. 13 (9): 1633–1636. doi:10.1515/jpem.2000.13.9.1633. ISSN 0334-018X. PMID 11154160.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Zenker M, Mayerle J, Lerch MM, Tagariello A, Zerres K, Durie PR, Beier M, Hülskamp G, Guzman C, Rehder H, Beemer FA, Hamel B, Vanlieferinghen P, Gershoni-Baruch R, Vieira MW, Dumic M, Auslender R, Gil-Da-Silva-Lopes VL, Steinlicht S, Rauh M, Shalev SA, Thiel C, Ekici AB, Winterpacht A, Kwon YT, Varshavsky A, Reis A (Dec 2005). "Deficiency of UBR1, a ubiquitin ligase of the N-end rule pathway, causes pancreatic dysfunction, malformations and mental retardation (Johanson-Blizzard syndrome)". Nature Genetics. 37 (12): 1345–1350. doi:10.1038/ng1681. PMID 16311597.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Rosanowski F, Hoppe U, Hies T, Eysholdt U (Oct 1998). "Johanson-Blizzard syndrome. A complex dysplasia syndrome with aplasia of the nasal alae and inner ear deafness". HNO. 46 (10): 876–878. doi:10.1007/s001060050328. PMID 9846268.
  8. ↑ 8.0 8.1 8.2 8.3 Takahashi T, Fujishima M, Tsuchida S, Enoki M, Takada G (Aug 2004). "Johanson-blizzard syndrome: loss of glucagon secretion response to insulin-induced hypoglycemia". Journal of Pediatric Endocrinology & Metabolism : JPEM. 17 (8): 1141–1144. doi:10.1515/jpem.2004.17.8.1141. ISSN 0334-018X. PMID 15379429.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Daentl DL, Frías JL, Gilbert EF, Opitz JM (1979). "The Johanson-Blizzard syndrome: case report and autopsy findings". American Journal of Medical Genetics. 3 (2): 129–135. doi:10.1002/ajmg.1320030203. PMID 474625.
  10. ↑ Jones NL, Hofley PM, Durie PR (Sep 1994). "Pathophysiology of the pancreatic defect in Johanson-Blizzard syndrome: a disorder of acinar development". The Journal of Pediatrics. 125 (3): 406–408. doi:10.1016/S0022-3476(05)83286-X. PMID 8071749.
  11. ↑ 11.0 11.1 Nagashima K, Yagi H, Kuroume T (Feb 1993). "A case of Johanson-Blizzard syndrome complicated by diabetes mellitus". Clinical Genetics. 43 (2): 98–100. doi:10.1111/j.1399-0004.1993.tb04458.x. ISSN 0009-9163. PMID 8448911.
  12. ↑ 12.0 12.1 12.2 Gould NS, Paton JB, Bennett AR (Jun 1989). "Johanson-Blizzard syndrome: clinical and pathological findings in 2 sibs". American Journal of Medical Genetics. 33 (2): 194–199. doi:10.1002/ajmg.1320330212. PMID 2669481.
  13. ↑ Hoffman WH, Lee JR, Kovacs K, Chen H, Yaghmai F (Jan 2007). "Johanson-Blizzard syndrome: autopsy findings with special emphasis on hypopituitarism and review of the literature". Pediatric and Developmental Pathology : the official journal of the Society for Pediatric Pathology and the Paediatric Pathology Society. 10 (1): 55–60. doi:10.2350/06-05-0085.1. PMID 17378628.
  14. ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 14.7 Fichter CR, Johnson GA, Braddock SR, Tobias JD (January 2003). "Perioperative care of the child with the Johanson-Blizzard syndrome". Paediatric Anaesthesia. 13 (1): 72–5. doi:10.1046/j.1460-9592.2003.00957.x. PMID 12535044.
  15. ↑ 15.0 15.1 Online Mendelian Inheritance in Man (OMIM) 243800
  16. ↑ 16.0 16.1 Moeschler JB, Polak MJ, Jenkins JJ, Amato RS (January 1987). "The Johanson-Blizzard syndrome: a second report of full autopsy findings". Am. J. Med. Genet. 26 (1): 133–8. doi:10.1002/ajmg.1320260120. PMID 3812553.
  17. ↑ 17.0 17.1 17.2 17.3 Braun J, Lerner A, Gershoni-Baruch R (1991). "The temporal bone in the Johanson-Blizzard syndrome. A CT study". Pediatric Radiology. 21 (8): 580–3. doi:10.1007/BF02012603. PMID 1815181.
  18. ↑ Bamiou DE, Phelps P, Sirimanna T (March 2000). "Temporal bone computed tomography findings in bilateral sensorineural hearing loss". Arch. Dis. Child. 82 (3): 257–60. doi:10.1136/adc.82.3.257. PMC 1718255. PMID 10685935.
  19. ↑ 19.0 19.1 19.2 Mardin MK, Ghandour M, Sakati NA, Nyhan WL (Nov 1978). "Johanson-Blizzard syndrome in a large inbred kindred with three involved members". Clin Genet. 14 (5): 247–250. PMID 709902.
  20. ↑ 20.0 20.1 20.2 Kobayashi S, Ohmori K, Sekiguchi J (Sep 1995). "Johanson-Blizzard syndrome facial anomaly and its correction using a microsurgical bone graft and tripartite osteotomy". J Craniofac Surg. 6 (5): 382–385. doi:10.1097/00001665-199509000-00011. PMID 9020718.
  21. ↑ Motohashi N, Pruzansky S, Day D (1981). "Roentgencephalometric analysis of craniofacial growth in the Johanson-Blizzard syndrome". J Craniofac Genet Dev Biol. 1 (1): 57–72. PMID 7341643.
  22. ↑ 22.0 22.1 22.2 22.3 Al-Dosari MS, Al-Muhsen S, Al-Jazaeri A, Mayerle J, Zenker M, Alkuraya FS (July 2008). "Johanson-Blizzard syndrome: report of a novel mutation and severe liver involvement". Am J Med Genet A. 146A (14): 1875–9. doi:10.1002/ajmg.a.32401. PMID 18553553.
  23. ↑ 23.0 23.1 Elting M, Kariminejad A, de Sonnaville ML, Ottenkamp J, Bauhuber S, Bozorgmehr B, Zenker M, Cobben JM (December 2008). "Johanson-Blizzard syndrome caused by identical UBR1 mutations in two unrelated girls, one with a cardiomyopathy". Am J Med Genet A. 146A (23): 3058–61. doi:10.1002/ajmg.a.32566. PMID 19006206.
  24. ↑ 24.0 24.1 24.2 24.3 Dumić M, Ille J, Bobonj G, Kordić R, Batinica S (May 1998). "Johanson-Blizzardov sindrom". Lijec Vjesn (in Croatian). 120 (5): 114–6. PMID 9748788. Unknown parameter |trans_title= ignored (help)
  25. ↑ 25.0 25.1 25.2 Wang J, Maldonado MA (August 2006). "The ubiquitin-proteasome system and its role in inflammatory and autoimmune diseases". Cell Mol Immunol. 3 (4): 255–61. PMID 16978533.
  26. ↑ 26.0 26.1 Ciechanover A (September 1994). "The ubiquitin-mediated proteolytic pathway: mechanisms of action and cellular physiology". Biol Chem Hoppe-Seyler. 375 (9): 565–81. doi:10.1515/bchm3.1994.375.8.565. PMID 7840898.
  27. ↑ 27.0 27.1 Ciechanover A, Iwai K (April 2004). "The ubiquitin system: from basic mechanisms to the patient bed". IUBMB Life. 56 (4): 193–201. doi:10.1080/1521654042000223616. PMID 15230346.
  28. ↑ 28.0 28.1 28.2 Varshavsky A (January 1997). "The N-end rule pathway of protein degradation". Genes Cells. 2 (1): 13–28. doi:10.1046/j.1365-2443.1997.1020301.x. PMID 9112437.
  29. ↑ 29.0 29.1 Baker RT, Varshavsky A (February 1991). "Inhibition of the N-end rule pathway in living cells". Proc Natl Acad Sci USA. 88 (4): 1090–4. doi:10.1073/pnas.88.4.1090. PMC 50962. PMID 1899923.
  30. ↑ Gonda DK, Bachmair A, Wünning I, Tobias JW, Lane WS, Varshavsky A (October 1989). "Universality and structure of the N-end rule". J Biol Chem. 264 (28): 16700–12. PMID 2506181.
  31. ↑ Prater JF, D'Addio K (March 2002). "Johanson-Blizzard syndrome--a case study, behavioral manifestations, and successful treatment strategies". Biol Psychiatry. 51 (6): 515–7. doi:10.1016/S0006-3223(01)01337-3. PMID 11922888.
  32. ↑ Johanson A, Blizzard R (December 1971). "A syndrome of congenital aplasia of the alae nasi, deafness, hypothyroidism, dwarfism, absent permanent teeth, and malabsorption". J Pediatr. 79 (6): 982–7. doi:10.1016/S0022-3476(71)80194-4. PMID 5171616.

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