Background
Methods
Cohort
Prader-Willi syndrome diagnostic testing
Sample collection and DNA extraction
Next-generation sequencing (NGS) and analysis
PWS Region Gene | Region Analyzeda (Ensembl GRCh37 release 89b) | Percent of Analyzed Bases Covered > 20× by NGS |
---|---|---|
MKRN3
| chr15:23810929–23812453 | 100 |
MAGEL2
| chr15:23889139–23892889 | 71 (100% by Sanger sequencing) |
NDN
| chr15:23931398–23932364 | 68 (Previously excluded [5]) |
NPAP1
| chr15:24921014–24924485 | 91 (100% covered > 10×)c |
SNURF-SNRPN
| chr15:25219600-25219603 | 91 (100% covered > 10×)c |
chr15:25220504–25220656 | ||
chr15:25221451–25221563 | ||
chr15:25222023–25222176 | ||
chr15:25222924–25223063 | ||
chr15:25223339–25223465 | ||
chr15:25223553–25223591 | ||
SNORD107
| chr15: 25227140–25227215 | 100 |
SNORD64
| chr15: 25230246–25230313 | 100 |
SNORD109A
| chr15:25287120–25287187 | 100 |
SNORD116 (cluster) | See Additional file 1 | 100 |
SNORD115 (cluster) | See Additional file 1 | 98d |
SNORD109B
| chr15:25523489–25523556 | 100 |
Sanger sequencing
Results
ROHHAD vs. PWS – Clinical comparison
Feature | Present in ROHHAD | Present in PWS |
---|---|---|
Main Features of ROHHAD | ||
Normal neonatal development | Yes | No |
Rapid-onset obesity |
Yes
Over 3–12 months.
|
Yes
Less steep trajectory.
|
Hypoventilation |
Yes
|
Sometimes
|
Hypothalamic dysfunction |
Yes
|
Yes
|
Inability to maintain normal water balance | Yes | No |
Failed growth hormone stimulation test or growth hormone insufficiency |
Sometimes
Only rarely manifests as slowed growth rate or short stature.
|
Yes
Growth hormone deficiency results in the characteristic short stature of PWS patients.
|
Hyperprolactinemia | Yes | No |
Hypothyroidism |
Sometimes
|
Sometimes
|
Adrenal insufficiency |
Sometimes
|
Sometimes
|
Early or late puberty |
Sometimes
|
Sometimes
|
Autonomic dysregulation |
Yes
|
Yes
|
Bradycardia | Sometimes
Typically temperature-related.
| No |
Gastrointestinal dysmotility |
Yes
|
Sometimes
|
Neural crest tumors (typically benign) | Yes
40–50% of cases
| No |
Ophthalmologic manifestations |
Yes
|
Yes
|
Pain perception altered (elevated threshold) |
Yes
|
Yes
|
Sweating (profuse) | Yes | No |
Thermal dysregulation (reduced core temperature) |
Yes
Manifests most typically as hypothermia, despite a preference for light weight clothing regardless of ambient temperature.
|
Yes
PWS patients are seen to have unstable temperatures, becoming hyper- or hypothermic easily in hot or cold environments and responding poorly to fevers, with very high temperatures occurring when ill, and sometimes without explanation. PWS patients also have a higher threshold for thermal sensing.
|
Vasomotor tone (ice cold hands and feet) | Yes | No |
Main Features of PWS | ||
Decreased fetal movement | No | Yes |
Neonatal hypotonia | No | Yes |
Neonatal feeding problems | No | Yes |
Neonatal lethargy | No | Yes |
Delayed motor skills | No | Yes |
Hypogonadism | No | Yes |
Early or delayed puberty, stalled puberty |
Sometimes
|
Yes
|
Intellectual disability or developmental delay preceding obesity | No | Yes
Children with PWS are delayed in reaching cognitive, motor, and language milestones. Older PWS patients have IQ scores ranging from the high range for intellectual disability to the low range of normal, with most PWS patients showing mild intellectual disability. In addition, most PWS patients have learning disabilities.
|
Autism spectrum disorder | No | Yes
Diagnosed in up to a quarter of PWS patients.
|
Maladaptive behavior (impulsive, compulsive, manipulative) |
Sometimes
It has been our experience that most ROHHAD patients, as long as their hypoventilation has been adequately managed, have no disordered behavior. However, there are case reports of severe behavioral issues including anxiety, depression, rage, aggressiveness, psychosis, and obsessive compulsive disorder [1, 23, 25, 35‐37]. It has been hypothesized however, that these issues occur only after inadequate oxygenation due to undiagnosed or improperly managed hypoventilation, since these symptoms are not seen in patients who were diagnosed early and managed conservatively, and have not experienced a frank cardiopulmonary arrest [8] |
Yes
There is a characteristic disordered behavioral pattern among PWS patients that includes temper tantrums, stubbornness, rigidity, compulsiveness, and controlling or manipulative behaviors. Psychosis is seen in a small number of PWS patients (5–10%).
|
Eye abnormalities (strabismus) |
Yes
|
Yes
|
Growth hormone deficiency |
Sometimes
|
Yes
|
Short stature | No | Yes |
Excessive weight gain independent of oral intake |
Yes
|
Yes
|
Hyperphagia-induced obesity | No
Initial weight gain is accompanied by only mild hyperphagia. But while a restricted diet can usually slow weight gain in ROHHAD, weight gain cannot be halted completely, and weight loss is exceedingly difficult to achieve.
| Yes
Weight gain initially occurs without noticeable hyperphagia, but then even greater weight gain occurs with extreme hyperphagia later in childhood.
|
Excessive daytime sleepiness | No | Yes |
Sleep abnormalities | No | Yes |
Central apnea |
Rarely
(hypoventilation is more characteristic)
|
Yes
|
Obstructive sleep apnea |
Sometimes
Initially, but resolves with intervention.
|
Yes
|
Reduced activity | No | Yes |
Higher threshold for thermal sensing | No | Yes |
Decreased saliva flow | No | Yes |
High vomiting threshold | No | Yes |
Scoliosis |
Sometimes
In ROHHAD, scoliosis is generally associated with thoracic neural crest tumors, whereas these tumors do not occur in PWS. However there is one reported case of a ROHHAD patient with scoliosis without a neural crest tumor [38]. |
Yes
Scoliosis is more common in PWS than in ROHHAD, and likely due to the PWS-related hypotonia.
|
Additional Features of PWS | ||
Small hands/feet | No | Sometimes |
Dysmorphic facial features | No | Sometimes |
Central hypothyroidism |
Sometimes
|
Sometimes
|
Central adrenal insufficiency |
Sometimes
|
Sometimes
|
Hip dysplasia | No | Sometimes |
Osteopenia and osteoporosis | No | Sometimes |
Skin picking | No | Sometimes |
Temperature instability | No | Sometimes |
Hypopigmentation | No | Sometimes |
Seizures |
Sometimes
In ROHHAD, seizures are typically linked to episodes of hypoxemia.
|
Sometimes
A subset of PWS patients suffers from a generalized seizure disorder of ranging severity (from febrile seizures to generalized epilepsy) [39]. |