Genetic Analysis for the Diagnosis of Disorders of Sexual Development in Indonesia

Disorders of sex development (DSD) is defined by congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical, while in clinical practice this term means any abnormality of the external genitalia. DSD patients have been managed by a multidisciplinary gender team in our center as collaboration between Dr. Kariadi province referral hospital and Faculty of Medicine Diponegoro University. Diagnosis should be established by specific physical examination hormonal, chromosomal and DNA studies; and imaging for most of the cases depending on indication.Since 2004 the involvement of molecular and cytogenetic analysis so far can diagnosed many of the DSD cases. Most of the genetically proven cases were Congenital Adrenal hyperplasia, Androgen Insensitivity syndrome and sex chromosomal DSD that lead abnormal gonadal development.  Many of them remain undiagnosed, further testing such as advanced DNA study should be carried out in collaboration with other center in overseas.The novel genes were found in some cases that contributed for the management of DSD.  Information for medical professionals, patients, family members and community about the availability and necessity of DSD diagnosis should be delivered to improve DSD management and patient quality of life

Cytogenetic Analysis for Research and Services

AbstractThat the correct chromosome number in man is 46 was first recognized by Tjio and Levan in 1956. Perhaps few Indonesians know that Tjio was an Indonesian scientist studying in Sweden and then living in the US. Cytogenetic analyses are commonly performed to determine both structural and numerical chromosome aberration, whilst changes in chromosomes can lead to birth defects, syndromes, or even cancer.  Several chromosomal aneuploidy syndromes were identified after the establishment of various chromosome banding techniques in late 1960’s.  Specific cell culture media was found to express fragile site in the beginning of 1970’s and since then, inherited Fragile X Mental Retardation syndrome could be diagnosed.  However, some female permutation cases have been often misdiagnosed. Further molecular analysis has resolved this problem by revealing more CGG repeats in the promoter region FMR1 gene, which is related to the expression of fragile site and the severity of the diseases.In Disorder of Sex Development (DSD), early gender assignment and reconstruction surgery has been challenged because of the dilemma of gender identity development in later life. Cytogenetic analysis for the first-line gender assignment is important in newborn with DSD. Proper diagnosis with hormonal and mutation analysis should be elucidated to avoid medical, psychological, and social aspect in adult life. The most frequent genetic cases in our clinical experiences have been Androgen Insensitivity Syndrome and Congenital Adrenal Hyperplasia. Female Complete Androgen Insensitivity Syndrome (CAIS) with main symptom primary amenorrhea without cytogenetic analysis has often been diagnosed as inguinal hernia because of testicle location and size.Diagnosis and treatment of several leukemias and lymphomas, as well as some solid tumors, depend on cytogenetic analyses to demonstrate consistent, specific chromosomal aberrations. Chromosome analysis in hematologic malignancy is indicated to support diagnosis, select therapy regimen, and elaborate prognosis. Specific chromosome translocations have been identified for hematologic malignancy. The breakpoints of several of these translocations have been cloned. Several loci of oncogene have been identified and sequenced.  Molecular genetic analysis will replace cytogenetic analysis and shift the requirement for studying metaphase cells. Therefore, chromosome analysis in genetic disease and cancer should be attained with advanced molecular techniques, such as Fluorescence In Situ Hybridization (FISH) and microarray CGH analysis.  Cytogenetic analysis is still useful and applicable in genetic disease diagnosis, sexual assignment, and hematologic malignancy in the laboratory with minimal equipments. Molecular analysis as a part of health care services in Indonesia has been limited in research centers in university setting; therefore, a comprehensive diagnosis with genetic analysis has often been improbable

Focal areas of a high rate of fragile X in Indonesia: a long term follow up

Fragile X syndrome (FXS) is the most common cause of inherited intellectual disability (ID) and a leading cause of autism spectrum disorder (ASD). FXS is caused by an expansion of CGG repeats >200 in the 5′ untranslated region of the promotor region fragile X mental retardation 1 gene (FMR1), which is located on Xq27.3.  The abnormal CGG expansion leads to methylation and transcriptional silencing of the FMR1 gene, resulting in a reduction or loss of fragile X mental retardation 1 protein (FMRP) and causes long, thin, and immature dendritic spines, which lead to deficits in cognitive function, behavioral problems, and learning abilit

ANALISIS PREVALENSI DAN FAKTOR RISIKO PASIEN DENGAN ISOLATED HYPOSPADIAS DI LABORATORIUM CEBIOR

Background: Hypospadias is a common congenital anomaly characterized by the location of orificium urethra external between perineum and its normal position at the tip of the glans. It occurs in 17 per 10.000 male births. The risk factors of hypospadias are still unclear, so hypospadias is still difficult to prevent. Aims: To analyze prevalence and risk factors isolated hypospadias in patients referred to the Center for Biomedical Research (CEBIOR). Methods: Two hundred and forty nine patients were registered during the period January 2005-April 2015. Prevalence and risk factors were analyzed descriptively using secondary data and risk factors were also analyzed with Chi-Square test. Results: The declining number of patients with isolated hypospadias in CEBIOR was found because of the movement process of laboratory and alteration system of assurance. All of patients with isolated hypospadias had male karyotype 46, XY (100%). Based on the anatomic position of orificium urethra external, most of isolated hypospadias cases were penile hypospadias (60.69%). An increased risk of severe isolated hypospadias was found in mother aged older than 35 years old (PR: 1.976, 95% CI: 1.048-3.726). Parity, low birth weight, smoking father, pesticide exposure, mosquito repellant incense exposure, hormonal contraceptive use, and taking certain medication were not associated with increased severity of isolated hypospadias (p>0.05). Conclusions: The number of patients with isolated hypospadias in CEBIOR was decreased recently. The advanced maternal age was the risk factor of severe isolated hypospadias. Keywords: Isolated hypospadias, prevalence, parity, maternal age, birth weight, environmental facto

Factors Affecting Parents' Acceptance towards Children with Familial Intellectual Disability (ID)

Background: Familial intellectual disability (ID) is a condition where two or more family members are affected ID, which may influence the whole family well-being. Children with intellectual disability often receive negative response from the society, which may trigger different reactions from the parents, such as denial or neglect of their child. Besides, most parents give more attention and provide the best care for their children. Factors that may influence parents’ acceptance towards children with familial ID are social support, religious coping, supporting facilities, family income, education, mothers’s age, and other significant factors.Objective: This study was aimed to analyze factors that affect parents’ acceptance towards children with familial intellectual disabilities (ID).Methods: This was an analytic observational study with cross sectional approach. Data were collected using interview with 20 mothers of familial intellectually disabled children including demographic data, pedigree construction, using Parental Rejection Questionnaire (PARQ), Brief Arab Religious Coping Scale (BARCS), Social Support Questionnaire Short Form (SSQSR) and Supporting Facilities Questionnaires. Data was analyzed using multivariate logistic regression.Results: Parents’ acceptance was significantly affect by social support (p0.05).Conclusion: Social support has influenced parent’s acceptance of their familial ID Childre

GAMBARAN GEN JAK2 PADA PENDERITA POLISITEMIA VERA DI LABORATORIUM CEBIOR

Background: Polycythemia vera ( PV ) is one of the myeloproliferative malignancies. The Jak2V617F mutation is found in approximately 96 percent of people with PV. JAK2 gene mutation results in the production of an activated JAK2 protein, which appears to increase the production of blood cells. The identification of Jak2V617F mutation on Polycythemia Vera assists the doctors in diagnosing and determining the target of therapy. This molecular diagnosis is quite common in the developed countries but in Indonesia only Center for Biomedical Research (Cebior) Medical Faculty of Diponegoro University conducts it. The study aims to know the distribution of Jak2 gene on polycythemia vera’s patients at Cebior in Semarang from May 2012 to April 2015. Subject and method: The research employs descriptive retrospective observational cross-sectional design. The subject of the study were all patients suspected PV who were reffered to Cebior for Jak2V617F examination during May 2012 to April 2015. Result: Out of 138 patients who were referred for Jak2V617F examination at Cebior, 50 patients with referral diagnosis of PV and the incidence of PV increased every year . The result of the examination showed that 30 patients (60%) were positive of Jak2V617F. Conclusion: The identification of Jak2V617F mutation was done to 50 subjects and identified Jak2V617F mutation in 30 patients . The relatively high incidence of PV in CEBIOR further suggests the importance of the identification of Jak2V617F mutation to established the diagnoses of PV. Key words: Polycythemia vera, Jak2V617

PROFIL SITOGENETIKA DAN DISMORFOLOGI PADA PASIEN DENGAN ANOMALI KONGENITAL MULTIPEL

Latar belakang: Pasien Anomali Kongenital Multipel (MCA) merupakan kelainan serius yang berpengaruh besar baik terhadap aspek medis, sosial maupun kosmetik dengan gambaran dismorfologi yang bermacam-macam. Perlu pemetaan sebaran dismorfologi dan pemeriksaan sitogenetika untuk keperluan aspek medis maupun untuk melihat distribusi pasien MCA. Tujuan: Mengetahui profil sitogenetika dan dismorfologi pada pasien dengan anomali kongenital multipel di CEBIOR FK UNDIP Semarang. Metode: Penelitian ini menggunakan desain deskriptif retrospektif untuk mengetahui profil sitogenetika dan dismorfologi pasien MCA yang terdata di Pusat Riset Biomedik (Center for Biomedical Research/CEBIOR) Fakultas Kedokteran Universitas Diponegoro Semarang sejak periode Januari 2010 – Desember 2015. Hasil: Dari total 36 pasien yang terdata, pasien paling banyak didapatkan pada tahun 2013 sebanyak 11 pasien yang kemudian mengalami penurunan signifikan pada tahun-tahun berikutnya. Pasien laki-laki lebih banyak dari pasien perempuan dengan perbandingan 2:1, usia mayoritas kurang dari 1 tahun dan riwayat antenatal yang normal. Sebanyak 21 kariotip pasien (58,3%) tidak ditemukan kelainan kromosom pada pemeriksaan sitogenetika, sedangkan pada pasien yang ditemukan kelainan kromosom, terbanyak adalah berupa kelainan numerik. Terdapat total 300 kelainan dismorfologi dari 36 pasien dengan rincian 139 kelainan mayor dan 161 kelainan minor dari 22 jenis kelainan. Kesimpulan: Mayoritas pasien MCA tidak ditemukan kelainan kromosom pada pemeriksaan sitogenetika dan pada pasien yang ditemukan kelainan kromosom, kelainan terbanyak berupa kelainan numerik. Gambaran dismorfologi pasien lebih didominasi pada bagian kepala dan leher dengan kelainan minor lebih banyak dari pada kelainan mayor. Kata kunci: MCA, dismorfologi, profil sitogenetika

Lower Erythrocyte GST activity in Autism Spectrum Disorder (ASD) patients compared to normal controls

Glutathione S-transferases (GST) are antioxidant enzymes that play an important role in the cellular detoxification and excretion of environmental pollutants including heavy metals. GST mu (GSTM1) and G theta (GSTT1) are known to be highly polymorphic and homozygous deletions of these genes result in the lack of enzyme activity and when combined with decreased levels of antioxidants, they have been associated with the Autism Spectrum Disorder (ASD). This preliminary study was performed to investigate the role of GSTM1 and GSTT1 polymorphisms as risk factors of ASD associated with GST activity and phenotype expression. Fifty one ASD patients and 45 controls were recruited for GSTM1 and GSTT1 genotyping while 6 ASD patients and 8 controls were assessed for GST activity. The results showed no significant differences in frequencies of GSTM1 null, GSTT1 null and combination both genotype between ASD patients and controls. However the mean erythrocyte GST activity in ASD is significantly decreased compared with controls (p = 0.043). The mean erythrocyte GST activity is lower in the severely autistic group compare to the mild to moderately autistic group, although it was not statistically significant. Further investigations are needed with a bigger sample size, analyzing multiple GST genes and GST activity determination to find out the gene susceptibility of ASD and factors that contribute to the phenotype expression of ASD

ANALISIS KROMOSOM PADA PENDERITA DENGAN ANOMALI KONGENITAL MULTIPEL DI LABORATORIUM CEBIOR

Background : Multiple congenital anomalies are structural or functional disorders including two or more organ systems that occured during prenatal period and appear after birth. Multiple congenital anomalies count for 7% of all congenital anomaly cases or with rate of 15.9 cases per 10.000 birth. Untill today, the true risk factors of multiple congenital anomalies are still debatable, this condition makes the occurence of this disorder difficult to prevent. Aim : To analyze the prevalence of chromosomal abnormality and its pattern in patient with multiple congenital anomalies at Center for Biomedical Research (CEBIOR). Method : This was a retrospective and prospective designed study. This study included patients with multiple congenital anomalies who referred to CEBIOR for chromosomal analysis from Januari 2006 to April 2015 . Result : The lowest number patients with multiple congenital anomalies referred to CEBIOR was 1 case in 2006, whilst the highest number was 12 cases in 2014. The patients with multiple congenital anomalies were dominated by male (n=35) compared to female (n=18). Twenty nine patients had male karyotype, 46,XY, while those with 46,XX karyotype were 14 cases, 1 case with 47,XXY, 7 cases with trisomy 21, 1 case with trisomy 18, and 1 case with deletion on 9q chromosome. Patients with multiple congenital anomalies were mostly below 5 years old (25 cases) followed by patients between 5-10 years old (13 patients) and 15 patients were older than 10 years old. Conclusion : The incidence of multiple congenital anomalies at CEBIOR was increased. The patients were mostly below 5 years old. Chromosomal abnormality were mostly trisomi 21. Keywords : Multiple congenital anomalies, prevalence, chromosom

Autosomal Recessive Limb Girdle Muscular Dystrophy In A Complex Consanguineous Family: The First Cases Series In Indonesia

Background: Limb girdle muscular dystrophy (LGMD) is a neuromuscular abnormality with clinical heterogeneity and various severity, where over 30 subtypes have been identified. Meanwhile, molecular diagnosis of LGMD is not commonly carried out in Indonesia. We present a large pedigree of familial LGMD, with over 14 years of follow-up.Case Presentation: A 12-year old female patient came with muscle weakness. She had toe walking since age of 6, followed by calf hypertrophy for over three years. Family history revealed complex consanguinity. Her younger sister and her parents’ cousin had similar condition, with the latter was already bedridden.Physical examination results were waddling gait, lordotic spine, and absent deep tendon reflexes. Muscle biopsy showed sign of dystrophic process. Immunoperoxidase staining of some proteins resulted normal. Single nucleotide polymorphism (SNP) array in two siblings revealed homozygosity on chromosome 15 containing CAPN3 gene of LGMD2A subtype.Recently, the patient is wheelchair bound and undergoes rehabilitation. Her sister is still able to walk with abnormal gait, while her parents’ cousin had passed away in age 55. From the multiple consanguinity, it could be concluded as autosomal recessive type LGMD.Conclusion: A large family with LGMD from Indonesia was presented with more than 14 years of care. Clinical diagnosis was made based on physical and additional examination, however molecular analysis for establishing definitive diagnosis is still limited. Further studies such as targeted or whole exome sequencing is warranted to elucidate the cause of disease. Long-term evaluation and supportive care, in addition to proper counseling may increase quality of life