Desmosterolosis: an illustration of diagnostic ambiguity of cholesterol synthesis disorders
Orphanet Journal of Rare Diseases volume 9, Article number: 94 (2014)
Desmosterolosis is an autosomal recessive disorder of cholesterol biosynthesis caused by biallelic mutations of DHCR24 (homozygous or compound heterozygous), which encodes 3-β-hydroxysterol Δ-24-reductase. We report two sisters homozygous for the 571G>A (E191K) DHCR24 mutation. Comparison of the propositae to other reported individuals shows that psychomotor developmental delay, failure to thrive, dysgenesis of the corpus callosum, cerebral white matter atrophy and spasticity likely constitute the minimal desmosterolosis phenotype. The nonspecific features of desmosterolosis make it difficult to suspect clinically and therefore screening for it should be entertained early in the diagnostic evaluation.
Desmosterolosis is an infrequently reported disorder of cholesterol biosynthesis causing syndromic intellectual disability (ID) arising from biallelic mutations (homozygous or compound heterozygous) in DHCR24. DHCR24 encodes 3-β-hydroxysterol Δ-24-reductase (DHCR24) [1, 2], which catalyzes the C-24 NADPH-dependent reduction of the 24–25 double bond of cholesterol precursors [3, 4].
We present two sisters with syndromic ID and desmosterolosis. Following uncomplicated pregnancies, they were born at term with normal growth parameters. Each had transient neonatal seizures. Their family history was noncontributory.
Beginning in infancy, they manifested growth restriction and delayed milestones for speech, fine and gross motor, and adaptive development. Patient 1 was able to walk with support and communicate with short phrases by 6 years; Patient 2 developed these skills by 8 years. Patient 1 had an IQ of 42 at 10.5 years. Patient 2 had an IQ of 46 at 5.5 years. Neither lost skills although Patient 1 had progressive sensorineural hearing loss.
On examination at 13.8 and 9.1 years, respectively, each had similar dysmorphic features. Patient 1 had short stature (<1st centile) with proportionate limbs, a weight of 41 kg (13th centile), and a head circumference of 55.2 cm (86th centile). Patient 2 had a height of 117.8 cm (1st centile), a weight of 21.3 kg (3rd centile), and a head circumference of 49.5 cm (4th centile). They had mild generalized hirsutism, facial dysmorphism, high arched hard palates, optic atrophy, nystagmus, spasticity, deep tendon hyperreflexia, camptodactyly of the fingers and toes, and muscle wasting, particularly of the thenar and hypothenar muscles (Figure 1A, B, C, F, G and H). Patient 1 also had a midline cleft of the soft palate as well as a short neck and large ears (>97th centile). Patient 2 also had myopia.
Each had extensive non-diagnostic laboratory testing. This included normal profiles for urine organic acids, urine purines and pyrimidines, plasma amino acids, and plasma very long chain fatty acids as well as urine mucopolysaccharide and oligosaccharide screens, liver function studies, transferrin isoelectric focusing and levels for lactate, ammonia, uric acid, albumin, creatinine phosphokinase, and thyroid stimulating hormone. Each had a normal karyotype and no evidence of a genomic deletion or duplication detectable by array comparative genomic hybridization. Patient 1 also had normal nucleotide excision repair assays, electromyography and nerve conduction studies. Patient 2 had normal complete blood counts and levels for copper, ceruloplasmin and blood acylcarnitines; her EEG identified no focal seizure activity. The patients were unavailable for additional testing, specifically plasma sterols, which were not performed on initial assessment.
Radiological assessment showed that both had dislocated radial heads and bilateral equinovarus. In addition, Patient 1 had a small and deformed pelvis, lumbar scoliosis, and moderate osteopenia. Patient 2 had parietal foramina.Magnetic resonance imaging (MRI) identified mild brain atrophy, asymmetric ventriculomegaly, a thin corpus callosum, and a Chiari I malformation (Figure 1D, E, I and J) In addition, Patient 1 had a sacral cyst suggestive of a meningocele or dural/perineural cyst.
Exome sequencing and biochemical confirmation of desmosterolosis
Exome sequencing (for methods see Additional file 1)  identified a homozygous DHCR24 mutation (NM_014762.3:c.571G>A; p.E191K), a recognized cause of desmosterolosis (Additional file 1, Supplementary methods and Additional file 2: Figure S1A) . Sanger sequencing confirmed this and the carrier state of the parents (Additional file 2: Figure S1B). As predicted, gas chromatography-mass spectroscopy analysis of lysates from cultured lymphoblastoid cells  from the propositae detected an increased ratio of desmosterol to total sterols (Figure 2). All other sterols measured (Supplementary methods) including cholesterol and 7-dehydrocholesterol were within normal range compared to healthy controls.
We present two sisters with the biallelic mutation NM_014762.3:c.571G>A in DHCR24. The recurrence of this mutation  in a different ethnic group implies that this mutation arose independently and suggests that mutations altering only certain amino acids give rise to a viable human with desmosterolosis (Table 1).
Assessing genotype-phenotype correlation, the propositae were discordant for microretrognathia, cleft palate, large joint contractures, deafness, and skull foramina (Table 1). In contrast, the previously reported four cousins of a consanguineous family were discordant for oculomotor abnormalities and seizures (Patients 4–7, Table 1). This might suggest either that the genetic backgrounds of the propositae are significantly different or that because of their consanguinity, the four family members reported by Zolotushko et al.  share other genomic or epigenetic variants modifying the expressivity of desmosterolosis.
Comparison of the propositae to Patient 3 (Table 1), who has the same DHCR24 mutation, provides an assessment of interfamilial genotype-phenotype concordance . They were discordant for dysmorphic facial features, oculomotor abnormalities, seizures, brain ventriculomegaly, cutis aplasia, limb anomalies, and congenital heart defects. They were concordant for ID, failure to thrive, short stature, spasticity, distal arthrogryposis, dysgenesis of the corpus callosum, and cerebral white matter atrophy. Comparison of the propositae to all reported in individuals with desmosterolosis (Table 1) [1, 2, 7–9] identifies ID, failure to thrive, spasticity, dysgenesis of the corpus callosum, and cerebral white matter atrophy as the minimal clinical phenotype for desmosterolosis. Distal arthrogryposis occurred in 8 of 9 individuals (Table 1). This minimal phenotype, which is not distinctive and the absence of sterol testing, explains the decade-long diagnostic odyssey of the propositae.
Review of all reported patients suggests a minimal genotype-phenotype correlation for desmosterolosis. Only individuals with mutations affecting the 3-β-hydroxysterol Δ-24-reductase cytoplasmic domain had rhizomelia (Patients 8 and 9, Table 1). Sharing this feature with the knockout mice , might suggest that mutations in the cytoplasmic domain disrupt enzyme function more severely than mutations in the FAD-binding domain (protein features of UniProt Q15392 ).
The neurological features of desmosterolosis might arise from either deficiency of cholesterol biosynthesis or the toxic effects of sterols accumulating upstream of 3-β-hydroxysterol Δ-24-reductase. Both mechanisms contribute to other disorders of cholesterol biosynthesis and thus likely apply here . The non-progressive neuropathology in desmosterolosis is in keeping with the primary impact occurring during brain development.
In summary, the pleiotropy and nonspecificity of desmosterolosis explain the long diagnostic odyssey of the propositae. Also, findings of developmental delay, CNS malformation, spasticity (with or without distal arthrogryposis), short stature with and without limb anomalies are sufficient indication to screen for disorders of cholesterol biosynthesis.
Patient consent and ethics approval
Individuals enrolled in the study gave informed consent for protocol H07-02142 (Vancouver, BC, Canada), approved by the University of British Columbia Research Ethics Board. Written informed consent was provided for the collection of samples, subsequent analysis and use of photographs by the parents of the children.
Central nervous system
Emopamil binding protein
Fluorescence in situ hybridization
Magnetic resonance imaging
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We thank the family for their generous participation and Dr. Rui F. Santos for interpretation of the radiological data. This work was supported in part by the Rare Disease Foundation. CD was supported by the Canadian Child Health Clinician Scientist Program and the Child and Family Research Institute.
The authors declare that they have no competing interests.
CD, RR and CFB interpreted the data and drafted and revised the manuscript. CD, BM, KC and LEK performed experimental work and interpreted the data. CFB, MD and RR provided clinical data. CD and MM performed and interpreted the bioinformatic analysis. All authors read and approved the final manuscript.
Cristina Dias, Rosemarie Rupps contributed equally to this work.
Electronic supplementary material
Additional file 1:Supplementary methods. Exome sequencing and Gas chromatography-mass spectroscopy analysis. (PDF 75 KB)
Additional file 2: Figure S1: Molecular confirmation of Desmosterolosis through exome sequencing and Sanger sequencing. NextGene (Softgenetics, Pennsylvania) view of the exome sequencing reads for one affected child (A) and dideoxy nucleotide sequencing validation (B) for the mother, father, and both affected children. The mother and father were heterozygous for NM_014762.3:c.571G > A (p.E191K) mutation. The propositae have the mutation in homozygosity. (PDF 3 MB)
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Dias, C., Rupps, R., Millar, B. et al. Desmosterolosis: an illustration of diagnostic ambiguity of cholesterol synthesis disorders. Orphanet J Rare Dis 9, 94 (2014). https://doi.org/10.1186/1750-1172-9-94