Multifactorial diseases.

Alzheimer disease, Parkinson disease, autism, epilepsy,

multiple sclerosis, schizophrenia,
neuronal tube defects, spina bifida, diabetes mellitus,
hypertension, myocardial infarction,
stroke, atherosclerosis

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Useful definitions and facts, facilitating the
understanding of multifactorial diseases

GWAS- Genome Wide Association Study

Observational study of a genome-wide set of genetic variants (usually SNPs)
in different patients to see if any variant is associated with a disease

EPIGENETICS- changes in gene expression resulting in

modification of gene expression not by mutation,
but by either DNA methylation or histone
posttranslational modifications.
Basic gene nucleotide sequence remains unaltered

NEXT GENERATION SEQUENCING- Nucleic acids sequencing.

Reveals the information about nucleotide sequence
in DNA (regular and methylated)
and RNA (mRNA, microRNA, others types of RNA)
WGS- Whole Genome Sequencing
WES- Whole Exome Sequencing (all exons in mRNA- protein coding)
Target sequencing- sequence of gene or group of genes
Most important: NGS is sequencing of absolutely all genes/transcripts in a
sample- high throughput technique
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
Central Nervous System dysfunctions and diseases:
Alzheimer disease,
Parkinson disease
autism,
epilepsy,
multiple sclerosis
schizophrenia

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Alzheimer disease (AD)

Tanzi RE, Bertram L. Twenty years of the Alzheimer's disease amyloid hypothesis: a Steiner H, Fukumori A, Tagami S, Okochi M. Making the final cut: pathogenic amyloid-β
genetic perspective. Cell. 2005 Feb 25;120(4):545-55. doi: 10.1016/j.cell.2005.02.008. peptide generation by γ-secretase. Cell Stress. 2018 Oct 28;2(11):292-310. doi:
PMID: 15734686. 10.15698/cst2018.11.162. PMID: 31225454; PMCID: PMC6551803.

Serý O, Povová J, Míšek I, Pešák L, Janout V. Molecular mechanisms of neuropathological

changes in Alzheimer's disease: a review. Folia Neuropathol. 2013;51(1):1-9. doi: Mantzavinos V, Alexiou A. Biomarkers for Alzheimer's Disease Diagnosis. Curr Alzheimer
10.5114/fn.2013.34190. PMID: 23553131. Res. 2017;14(11):1149-1154. doi: 10.2174/1567205014666170203125942. PMID:
28164766; PMCID: PMC5684784.
Hampel H, Mitchell A, Blennow K, Frank RA, Brettschneider S, Weller L, Möller HJ. Core
biological marker candidates of Alzheimer's disease - perspectives for diagnosis, prediction of
outcome and reflection of biological activity. J Neural Transm (Vienna). 2004 Mar;111(3):247- Weller J, Budson A. Current understanding of Alzheimer's disease diagnosis and
72. doi: 10.1007/s00702-003-0065-z. Epub 2003 Dec 3. PMID: 14991453. treatment. F1000Res. 2018 Jul 31;7:F1000 Faculty Rev-1161. doi:
10.12688/f1000research.14506.1. PMID: 30135715; PMCID: PMC6073093.
Lane CA, Hardy J, Schott JM. Alzheimer's disease. Eur J Neurol. 2018 Jan;25(1):59-70. doi:
10.1111/ene.13439. Epub 2017 Oct 19. PMID: 28872215. Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Alzheimer disease (AD)
DEMENTIA
a clinical syndrome characterized by progressive
decline in two or more cognitive domains, including
memory, language, executive and visuospatial
function, personality, and behavior, which causes
loss of abilities to perform instrumental and/or
basic activities of daily living.
DEMENTIA is a general term for a decline in
cognitive ability severe enough to interfere
with daily life.
Alzheimer’s disease (AD) is by far the most common
cause of dementia and accounts for up to 80% of all
dementia diagnoses
Typical AD -the most common clinical phenotype
of AD:
Early and progressive episodic memory deficit
that dominates in the following stages of the
disease and coexists with other cognitive disorders
(executive dysfunction, language, praxis, and
complex visual processing impairments).
8 categories for AD: Prodromal AD, AD dementia,
Typical AD, Atypical AD, Mixed AD, Preclinical
States of AD, Alzheimer’s Pathology and Mild
Cognitive Impairment (MCI)
Sporadic AD 98%
Familial AD about 2%
Alzheimer’s disease is mainly characterized
by the Aβ peptide pathology which is found
in amyloid precursor protein gene (APP,
21q21). Aβ deposits lead to plaques
creation, the AMYLOID fibrils accumulated
in the cell’s outer space and grouped into
globe shape. AMYLOID-β can also be
deposited in media and adventitia of small
and mid-sized arteries, in which case we
refer to Cerebral Αmyloid Αngiopathy
Neuronal tangles inside neuronal cells
composed of hyperphosphorylated tau (τ)
protein are also prominent

Direct and indirect costs for healthcare related to

AD are estimated at nearly $500 billion annually Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Alzheimer disease (AD)
THE DEFINITIVE DIAGNOSIS
of AD requires post-mortem evaluation of
brain tissue
Other useful diagnostic techniques
 specialized Positron Emission
Tomography (PET) scan that detects the
deposition of amyloid-β (Aβ) peptides into
plaques in the living brain. (and detect
neurological injury)
up to 96% sensitivity and 100% specificity
 Examination of cerebrospinal fluid (CSF)
for Aβ42, hyperphosphorylated tau peptide
(p-tau), and total tau protein content.
less diagnostic accuracy (85–90%),
carries the risks and inconveniences
involved with a lumbar puncture procedure
and…..
CSF markers of amyloid and tau are reliable
diagnostic tools to detect dementia
 Magnetic Resonance Imaging (MRI), can
easily show the neurodegeneration
D-serine levels have been identified and measured in
higher levels in the hippocampus and parietal cortex of AD
patients and incriminated as a potential risk factor.
Four miRNAs, the miR-31, miR-93, miR-143, and miR-146a
are observed to be decreased in AD patient’s serum
Aβ is a small hydrophobic ~4 kDa peptide:
sequential proteolytic processing of the amyloid
precursor protein (APP)
Normal tau protein stabilizes microtubules
in the cytoskeleton of neurons,
promote neurite outgrowth, membrane
interactions, facilitate enzyme anchoring ,
axonal transport of organelles to nerve terminals
The phosphorylation of tau protein
regulates microtubule binding and assembly.
Hyperphosphorylation occurs downstream of Aβ
plaques formation, with research suggesting that
accumulation of Aβ may initiate the process of
organization of tau into tangles (NFT) masses inside
nerve cell bodies.
AD is one of Tauopathies- diseases involving tau protein
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Inside the cell- A central pathological
sAPPα role of Aβ42 is evident.
Outside space of vessicles
APP
the cell sAPPβ
Constitutive α- Outside
secretase is ADAM10 the cell
Plays a protective role Aβ
in AD for Processing of Excretion by
APP via the exocytosis
α-secretase pathway β
α
p3

γ/ε/ζ γ/ε/ζ

γ-secretase is a big complex composed

Amyloid precursor protein β-secretase 1 (BACE1)
from a few components, mainly from
Absence of the α-secretase cleavage leads to
four proteins: presenilin (PS1 or PS2),
APP molecules internalization into endocytic
nicastrin, anterior pharynx-defective-1
compartments where they are subjected to
(APH-1) and presenilin enhancer-2 (PEN-
cleavage by β- and γ-secretases to generate Aβ.
2)

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Alzheimer disease (AD)
Familial AD sporadic forms of AD
• Mutations in APP and presenilin (the genetic components, increasing the risk of
catalytic subunit of γ-secretase).→Increase in developing the disease:
the Aβ42/Aβ40 ratio • ε4 allele of the apolipo-protein E (APOE)
• A double mutation at the β-secretase gene, which affects Aβ aggregation and/or
cleavage site occurring in a Swedish family; clearance
duplication of the APP gene → increase in the • as well as the microglial protein TREM2
total amounts of Aβ generated (triggering receptor expressed on myeloid cells 2)
• mutations were also found in the N- -involved in the clearance of Aβ plaques
terminal and mid-domain of Aβ →
increase the aggregation properties of Aβ
High cholesterol levels have been linked
to overproduction of Aβ
the most mutations associated with FAD are
Familial AD
found in the Presenilin 1 (PS1) gene. To date
Individuals who inherit Presenilin-1, Presenilin-2
over 210 pathogenic mutations have been
mutations AD age of onset earlier than their 40-
identified covering ~25% of the residues
45. AD heredity with autosomal dominant
pattern with 50% probability for each generation
Interestingly, another mutation close to the
to develop AD. These mutations lead to plaque
β-secretase cleavage site that lowers Aβ
creation, tangles, cell loss and dementia.
levels and protects against AD has been
However, the percentage of AD patients
identified in the Icelandic population.
due to genetic mutations are less than 2% of the
total AD population

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Alzheimer disease (AD)

Cholinesterase inhibitors
donepezil, rivastigmine, and galantamine are recommended therapy for patients with
mild, moderate, or severe AD dementia as well as Parkinson’s disease dementia.
Memantine,
which has activity as both a non-competitive N-methyl-D-aspartate (NMDA) receptor
antagonist and a dopamine agonist, is approved for use in patients with moderate-to-
severe AD.
These medications have been shown to enhance the quality of life for both patient
and caregiver when prescribed at the appropriate time during the course of illness;
however, they do not change the course of illness or the rate of decline

Mediterranean diet
Meals consisting of fresh products, wholegrains, olive oil, legumes, and seafood while
limiting dairy and poultry products and avoiding red meat, sweets, and processed foods)
have reduced risk of developing cognitive decline and AD

Physical activity-
both before disease and during reduces symptoms and prolongs age of onset
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Parkinson disease

Ascherio A, Schwarzschild MA. The epidemiology of Parkinson's disease: risk factors and prevention.
Lancet Neurol. 2016 Nov;15(12):1257-1272. doi: 10.1016/S1474-4422(16)30230-7. Epub 2016 Oct 11.
PMID: 27751556.

Lotankar S, Prabhavalkar KS, Bhatt LK. Biomarkers for Parkinson's Disease: Recent Advancement. Neurosci
Bull. 2017 Oct;33(5):585-597. doi: 10.1007/s12264-017-0183-5. Epub 2017 Sep 21. PMID: 28936761;
PMCID: PMC5636742.

Hayes MT. Parkinson's Disease and Parkinsonism. Am J Med. 2019 Jul;132(7):802-807. doi:
10.1016/j.amjmed.2019.03.001. Epub 2019 Mar 16. PMID: 30890425.

Tysnes OB, Storstein A. Epidemiology of Parkinson's disease. J Neural Transm (Vienna). 2017
Aug;124(8):901-905. doi: 10.1007/s00702-017-1686-y. Epub 2017 Feb 1. PMID: 28150045.
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Parkinson disease (PD)
• James Parkinson in his ‘‘Essay on the
shaking palsy’’ from 1817
• Most common movement disorder
• Second most common degenerative
disease of the central nervous system.
• The prevalence 100-200/100,000;
annual incidence is 15/100,000
• affect 1 million people in the United
States and 4 million people worldwide
• Late age of onset: affects 1% of the
population above 60 years, 4%
in the highest age groups, usually at an age
of 65 to 70 years. Onset before the age of
40 is seen in less than 5% of the cases
(genetic variants)
genetic factors are thought to be
involved in 5–10% of the cases, may be
more
• Sex-dependent: occurs 2 years
earlier, on average, in men than women and
that twice as many men as women are
affected
Three cardinal signs:
 tremor
 rigidity
 bradykinesia: slowing of movement and the
simplification of complex motor tasks- eg. „Face
mask”, spontaneous swallowing is reduced, writing
becomes cramped and small - micrographia).
Over the years postural changes in general and
postural instability in particular was used as a fourth
cardinal sign, but later excluded. Even post-mortem
analysis of brain does not give the hallmark
PD is characterized neuropathologically by the
presence of α-synuclein-containing Lewy bodies in
the substantia nigra of the brain (α-synucleinopathy).
Lewy bodies are abnormal insoluble fibrillary
aggregates that develop inside nerve cells in PD
Loss of dopaminergic neurons in the pars compacta of
the substantia nigra leads to reduced facilitation
of voluntary movements. α-synuclein accumulation
becomes more widespread in the brain during the
progression of PD
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Parkinson disease (PD)
The new diagnostic criteria define supportive
criteria, absolute exclusion criteria and red flags
A diagnosis of ‘‘clinically established PD’’ requires at
least two supportive criteria, the absence of absolute
exclusion criteria, and no red flags. The supportive
criteria include both motor and non-motor aspects of
the disease, namely effect of dopaminergic therapy,
presence of levodopa-induced dyskinesia, asymmetric
rest tremor and positive tests on cardiac sympathetic
denervation or olfactory loss. Absolute exclusion
criteria are cerebellar abnormalities, supra nuclear gaze
palsy, frontotemporal cognitive changes, slow
progression, use of anti-dopaminergic therapy, absence
of levodopa response, cortical findings like apraxia, and
normal DAT scan. Red flags are early gait impairment,
absence of progression, early bulbar dysfunction,
inspiratory
respiratory dysfunction (most frequently seen in
MSA), severe autonomic failure during the first year of
the disease, recurrent falls due to reduced balance, early
antecollis, pyramidal tract signs, bilateral symmetric
parkinsonism throughout the disease course and
absence of any of the common non-motor features
seen in PD like sleep dysfunction, autonomic
dysfunction or hyposmia
The cause of PD is unknown
for most identified cases
Leucine-rich repeat kinase (LRRK2)
mutations that in selected populations cause
up to 40% of the cases
The LRRK2 mutation Gly2019Ser is the most
common genetic cause of Parkinson’s disease
worldwide. The mutation has the highest
frequency in Ashkenazi Jewish and Arab-Berber
populations
PD associated with SNCA (α-synuclein)
mutations is more early-onset, has a moderate
response to levodopa with
more rapid progression, and pyramidal signs,
psychiatric symptoms and cognitive decline
are frequently evident
Heterozygous GBA mutations, α-synuclein
variants and tau variants are examples of
genetic risk factors for PD
Analysis for mutations in SNCA, Parkin,
PINK1, DJ1, LRRK2 and GBA is of utmost
importance
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Parkinson disease (PD)
Levodopa was the first effective medication for
Parkinson's disease and is still the most potent.
Virtually all patients will use levodopa at some point Deep brain stimulation (DBS) has
during their disease. It is the immediate precursor to become a staple of treatment in patients
dopamine, which can cross the blood–brain barrier with complications of medical treatment
But side effects!: that include precipitous and
Particularly nausea. Other side effects include: unpredictable motor fluctuations and
hallucinations, delusions, somnolence, dystonia, and disabling dyskinesia or the presence of
prominently, dyskinesias. Dyskinesia (involuntary intractable tremor
movements) often limits the dose that can be used
Dopamine agonists (pramipexole, ropinirole, and
rotigotine) stimulate dopaminergic receptors in the DBS does not impact the progression
central nervous system, which alleviate symptoms of of cognitive decline or axial
Parkinson. While they improve symptoms, they are instability, which is to be expected,
predictably less potent than levodopa. as dopaminergic medications tend
Catechol-O-methyl transferase inhibitors not to improve these symptoms
(entacapone) and monoamine oxidase aldehyde either
dehydrogenase B (MAO-B) inhibitors (rasagiline and
selegiline) inhibit enzymes involved in the
breakdown of levodopa and dopamine. They prolong
the effect of carbidopa/levodopa

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Parkinson disease (PD)

Differential diagnosis
• Lewy Body Disease → α-synucleinopathy
• Drug-Induced Parkinsonism-due to postsynaptic
blockade of dopamine receptors (especially D2 receptors)
→ neuroleptics, gastrointestinal prokinetics like
metoclopramide and domperidone
• Progressive Supranuclear Palsy (PSP) → tauopathy
• Multiple System Atrophy → α-synucleinopathy
• Corticobasal Degeneration → tauopathy

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Autism, AUTISM SPECTRUM DISORDERS (ASD)

Tick B, Bolton P, Happé F, Rutter M, Rijsdijk F. Heritability of autism spectrum disorders: a meta-analysis of
twin studies. J Child Psychol Psychiatry. 2016 May;57(5):585-95. doi: 10.1111/jcpp.12499. Epub 2015 Dec
27. PMID: 26709141; PMCID: PMC4996332.

Postorino V, Kerns CM, Vivanti G, Bradshaw J, Siracusano M, Mazzone L. Anxiety Disorders and Obsessive-
Compulsive Disorder in Individuals with Autism Spectrum Disorder. Curr Psychiatry Rep. 2017 Oct
30;19(12):92. doi: 10.1007/s11920-017-0846-y. PMID: 29082426; PMCID: PMC5846200.

Fattorusso A, Di Genova L, Dell'Isola GB, Mencaroni E, Esposito S. Autism Spectrum Disorders and the Gut
Microbiota. Nutrients. 2019 Feb 28;11(3):521. doi: 10.3390/nu11030521. PMID: 30823414; PMCID:
PMC6471505.

Sanchack KE, Thomas CA. Autism Spectrum Disorder: Primary Care Principles. Am Fam Physician. 2016 Dec
15;94(12):972-979. PMID: 28075089.

Mukherjee SB. Autism Spectrum Disorders - Diagnosis and Management. Indian J Pediatr. 2017
Apr;84(4):307-314. doi: 10.1007/s12098-016-2272-2. Epub 2017 Jan 19. PMID: 28101829.
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Autism, AUTISM SPECTRUM DISORDERS (ASD)
Key diagnostic features:
 deficits in social communication
restricted, repetitive patterns of
behavior, interest, or activities.
 problems relating to others and
a high sensitivity to changes in their
environment
• continuum of severity and
functional impairment
• Males affected more: male-to-
female ratio of 4.5-to-1.2 These
data correlate with other studies
across multiple nations and widely
separated locations
• Prevalence rates in the general
population of 58–67/10,000 and an
incidence of 1 in 68-88 children in
2012 in the United States 1% of the
population worldwide has ASD
There is considerable variability in core symptoms, onset, presentation, severity and
extent of disability which range from subtle to overt
Umbrella diagnosis of ASD, consolidating
four previously separate disorders:
• Autistic disorder,
• Asperger syndrome,
• Childhood disintegrative disorder,
• Pervasive developmental disorder not
otherwise specified
Social deficits and delays in spoken language
are the most prominent features in children
younger than three years
• Deficits in Social Interaction
• Deficits in Communication
• Unusual Stereotypic Behavior
• Deviant (increased or decreased)
Sensory Perception
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Autism, AUTISM SPECTRUM DISORDERS (ASD)

Prenatal risks
The genetic contribution to ASD occurs via
Advanced paternal or maternal age
a diverse group of mutational mechanisms
Maternal metabolic conditions:
along many biologic pathways,
diabetes mellitus, hypertension, and obesity.
interplay of multiple factors; genetic,
maternal high-fat diet during pregnancy
epigenetic and environmental
In utero risks
valproate (Depacon) exposure,
Strong associations are found
maternal infections,
with some genetic and
traffic-related air pollution,
metabolic disorders
pesticide exposure
(Angelman’s, Prader–Willi, Fragile X
congenital rubella, encephalitis
Smith–Lemli–Opitz syndromes) .
Perinatal
low birth weight and preterm delivery
increase the risk of ASD as a part Breast-feeding is associated with a lower risk of
of the greater overall risk of ASD
neurodevelopmental injury There could be potential influence of gut
microbiota in ASD

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Autism, AUTISM SPECTRUM DISORDERS (ASD)

Medical management may

Research suggests that cognitive-
also target comorbid diagnoses,
behavioral therapy (CBT), an empirically
such as anxiety disorders,
supported treatment for anxiety, is highly
attention-deficit/hyperactivity
effective for treating youth with anxiety,
disorder (ADHD),
ASD, and average to above average IQs
and sleep disorders

Outcome markers for adults with ASD

therapeutic horseback riding
include independent living,
showed improvements in
employment, friendship, and marriage.
irritability and hyperactivity in
Early studies found that more than one-
children, with secondary outcomes
half of infants with autism were
of improved social communication
institutionalized. A high percentage of
and new word acquisition
patients were described as having poor
or very poor outcomes

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Schizophrenia (SZ, SCZ)
Kato T. Molecular genetics of bipolar disorder and depression. Psychiatry Clin Neurosci. 2007 Feb;61(1):3-
19. doi: 10.1111/j.1440-1819.2007.01604.x. PMID: 17239033.

Zai CC, Tiwari AK, Zai GC, Maes MS, Kennedy JL. New findings in pharmacogenetics of schizophrenia. Curr
Opin Psychiatry. 2018 May;31(3):200-212. doi: 10.1097/YCO.0000000000000417. PMID: 29528898.

Modai S, Shomron N. Molecular Risk Factors for Schizophrenia. Trends Mol Med. 2016 Mar;22(3):242-253.
doi: 10.1016/j.molmed.2016.01.006. Epub 2016 Feb 9. PMID: 26869297.

Sarnyai Z, Kraeuter AK, Palmer CM. Ketogenic diet for schizophrenia: clinical implication. Curr Opin
Psychiatry. 2019 Sep;32(5):394-401. doi: 10.1097/YCO.0000000000000535. PMID: 31192814.

Skene NG, Bryois J, Bakken TE, Breen G, Crowley JJ, Gaspar HA, Giusti-Rodriguez P, Hodge RD, Miller JA,
Muñoz-Manchado AB, O'Donovan MC, Owen MJ, Pardiñas AF, Ryge J, Walters JTR, Linnarsson S, Lein ES;
Major Depressive Disorder Working Group of the Psychiatric Genomics Consortium, Sullivan PF, Hjerling-
Leffler J. Genetic identification of brain cell types underlying schizophrenia. Nat Genet. 2018 Jun;50(6):825-
833. doi: 10.1038/s41588-018-0129-5. Epub 2018 May 21. PMID: 29785013; PMCID: PMC6477180.

Kotlar AV, Mercer KB, Zwick ME, Mulle JG. New discoveries in schizophrenia genetics reveal
neurobiological pathways: A review of recent findings. Eur J Med Genet. 2015 Dec;58(12):704-14. doi:
10.1016/j.ejmg.2015.10.008. Epub 2015 Oct 19. PMID: 26493318; PMCID: PMC4679408.

Corvin A, Sullivan PF. What Next in Schizophrenia Genetics for the Psychiatric Genomics Consortium?
Schizophr Bull. 2016 May;42(3):538-41. doi: 10.1093/schbul/sbw014. Epub 2016 Mar 18. PMID:
26994396; PMCID: PMC4838114.

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Schizophrenia (SZ)
The core symptoms:
• perception of reality,
thinking, behavior, and
motivation severly affected
• typical age of onset: teens,
early adulthood
• a long-term course - episodic
or continuous illness
• significant functional
impairment in many cases
The disorder is largely heritable,
heritability is yet to be explained→
common risk loci identified: 150
they collectively explain
<5% of the disease variance
and………..
social factors contribute to risk
Schizophrenia is a devastating neurodevelopmental
disorder characterized by a complex set of symptoms,
including hallucinations, delusions, stereotyped
behaviours, social withdrawal and impairment in
executive function and attentional processes
alterations in brain glutamatergic neurotransmission
systemic and central proinflammatory processes,
and impaired systemic and cerebral energy
metabolism
Schizophrenia is a public health problem, as it
affects almost 1% of adults and is associated
with significant morbidity and premature
mortality (by 10–20 years)
The Schizophrenia Psychiatric Genome-Wide
Association Study Consortium (PGC-SCZ) is the
largest consortium and biological experiment
in psychiatry
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 For most affected individuals, schizophrenia has a polygenic architecture in which
hundreds or even thousands of variants collectively contribute to risk. Most cases
of schizophrenia are likely to involve polygenic risk spread across many variants

SOME GENES PROBABLY ENGAGED and Rare variants

PROMISING TARGETS FOR TREATMENT:
• G protein coupled signalling (DRD2, GRM3)
• genes involved in glutamatergic
neurotransmission (GRIN2A, SRR, CLCN3, GRIA1),
• mechanisms involving neuronal calcium
signaling (e.g., CACNA1C, CACNA1l, CACNB2,
RIMS1)
• synaptic function (KCTD13, CNTN4, PAK6)
 The top signals of the association
with schizophrenia come from the major
histocompatibility complex (MHC) locus
copy number variants (CNVs)
rare chromosomal rearrangements
involving deletion, duplication,
inversion, or translocation of DNA
• N-methyl-D-aspartate receptor
(NMDAR) protein complex, neuronal
activity-regulated cytoskeleton-
associated postsynaptic signaling
complex (ARC)
• fragile X mental retardation (FMRP),
• possibly voltage-gated calcium ion
channels
• EPIGENETICS!
SETD1A – methyltransferase that
catalyzes the methylation of lysine
residues in histone H3 and is a regulator
of gene transcription.
Even in the absence of a psychiatric diagnosis,
carriers of CNVs associated with schizophrenia
have significant, but variable cognitive
deficits

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Schizophrenia (SZ)
TREATMENT
The currently used atypical antipsychotics, acting primarily through D2 dopamine serotonin 2A
receptors, are only partially effective in managing some, but not all, symptoms and they result in
considerable side effects, such as weight gain, metabolic syndrome and cardiovascular consequences

Schizophrenia: impaired glucose/energy metabolism and mitochondrial function

Specifically, in pyramidal neurons, monocarboxylate

transporter 1 mRNA expression was increased, and
HXK1, PFK1, glucose transporter 1 (GLUT1), and
GLUT3 mRNA expression were decreased, collectively
suggesting abnormal bioenergetic function, as well as
a neuron-specific defect in glucose utilization, in
schizophrenia
circumventing glycolysis, provides
alternative energy substrates in the form of
ketone bodies and resetting the processes
underlying glucose and energy metabolism

KETOGENIC DIET
Metabolically, the ketogenic diet leads to
improved insulin sensitivity,
decreased blood glucose levels and weight Diets rich in fat and
loss. β-Hydroxybutyrate (BHB), the main low in carbohydrates
circulating ketone body, is fully oxidized as an
energy substrate in the brain

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Epilepsy

Seminar in Epileptology Epileptic Disord 2020; 22 (4): 399-420How to diagnose and classifyidiopathic
(genetic)generalized epilepsies
Ayse Deniz Elmali, Stéphane Auvin, Thomas Bast,Guido Rubboli, Michalis Koutroumanidis
Thijs RD, Surges R, O'Brien TJ, Sander JW. Epilepsy in adults. Lancet. 2019 Feb 16;393(10172):689-701. doi:
10.1016/S0140-6736(18)32596-0. Epub 2019 Jan 24. PMID: 30686584.
Manford M. Recent advances in epilepsy. J Neurol. 2017 Aug;264(8):1811-1824. doi: 10.1007/s00415-017-
8394-2. Epub 2017 Jan 24. PMID: 28120042; PMCID: PMC5533817.
Helbig I, Heinzen EL, Mefford HC; ILAE Genetics Commission. Primer Part 1-The building blocks of epilepsy
genetics. Epilepsia. 2016 Jun;57(6):861-8. doi: 10.1111/epi.13381. Epub 2016 May 25. PMID: 27226047.
Myers CT, Mefford HC. Advancing epilepsy genetics in the genomic era. Genome Med. 2015 Aug
25;7(1):91. doi: 10.1186/s13073-015-0214-7. PMID: 26302787; PMCID: PMC4549122.
Symonds JD, Zuberi SM, Johnson MR. Advances in epilepsy gene discovery and implications
for epilepsy diagnosis and treatment. Curr Opin Neurol. 2017 Apr;30(2):193-199. doi:
10.1097/WCO.0000000000000433. PMID: 28212175.
Zack M, Luncheon C. Adults with an epilepsy history, notably those 45-64 years old or at the
lowest income levels, more often report heart disease than adults without an epilepsy
history. Epilepsy Behav. 2018 Sep;86:208-210. doi: 10.1016/j.yebeh.2018.05.021. Epub 2018
Jun 13. PMID: 29908906; PMCID: PMC6113097.
Sapkota S, Kobau R, Pastula DM, Zack MM. People with epilepsy are diagnosed most often
with unspecified epilepsy, followed by focal epilepsy, generalized convulsive epilepsy, and
generalized nonconvulsive epilepsy-US MarketScan data, 2010-2015. Epilepsy Behav. 2018
Feb;79:244-246. doi: 10.1016/j.yebeh.2017.11.004. Epub 2017 Dec 15. PMID: 29249447.

Hani AJ, Mikati HM, Mikati MA. Genetics of pediatric epilepsy. Pediatr Clin North Am. 2015 Jun;62(3):703-
22. doi: 10.1016/j.pcl.2015.03.013. PMID: 26022171.
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Epilepsy
Definitions in epilepsy have always been
problematic
 seizures (but not all seizures are due to
epilepsy—febrile seizures or drug-induced
seizures
Diagnosis is difficult because the diagnostic
electrical hallmark of epilepsy may be:
• absent, especially in adults
• seizures are infrequent
• epileptiform discharges may occasionally
be present but without seizures
• ‘‘epileptic EEG’’ may be associated with
An epileptic encephalopathy
The International League Against
Epilepsy
STATUS EPILEPTICUS: a condition
resulting either from the failure of
the mechanisms responsible for
seizure termination or from the
initiation of mechanisms,
which lead to abnormally, prolonged
seizures (after time point t1). It is a
condition, which can have long-term
consequences (after time point t2),
including neuronal death, neuronal
injury, and alteration of neuronal
networks, depending on the type and
duration of seizures’

Seizures may be caused by: brain diseases- tumors, parasites,

infections, injuries, medicines, chronic chemical exposure, drugs

The diagnosis criteria have improved after International League Against Epilepsy consensus
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Epilepsy
3 levels:
The framework for the classification of
seizure type (generalized onset, focal
epilepsies divides causes into six groups
onset and unknown onset), epilepsy
chosen for their treatment implications
type (generalized, focal, combined
– structural, genetic, infectious,
generalized and focal and unknown
metabolic, immune and unknown.
type) and epilepsy syndrome.

Comorbidities in a nationwide US survey

No epilepsy (%) Epilepsy (%)
Anxiety 13.9 22.4
Approximately 50-70 million people
Depression 25.6 32.5 worldwide have epilepsy . It is the
Bipolar disorder 6.7 14.1
ADHD 5.5 13.2 most common chronic and severe
Sleep disorder/apnea 13.6 19.6 neurological disease worldwide
Movement disorder/tremor 4.6 9.3
Migraine 20.6 27.9
Chronic pain 17.7 25.4 Increased risk of mortality and
Fibromyalgia 7.5 15.4
Neuropathic pain 5.6 8.7 psychological and socioeconomic
Asthma 16.6 20.7 consequences impairing quality of
Diabetes 15.2 15.2
Hypertension 36.7 36.2 life.
Manford M. Recent advances in epilepsy. J Neurol. 2017 Aug;264(8):1811-1824.
doi: 10.1007/s00415-017-8394-2. Epub 2017 Jan 24. PMID: 28120042; PMCID:
PMC5533817

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Epilepsy
A recent genome wide association The first major application of pharmacogenetics
study: SCN1A, protocadherins in epilepsy, has been the identification of patients
PCDH7 and PCDH19, both known to from South East Asia who are HLA-B*1502
be associated with epilepsy and positive, putting them at high risk for Stevens–
learning disability Johnson syndrome from carbamazepine

Mutations of the SCN8A gene are also

GRIND2 mutations resulting in gain of activity
associated with epilepsy, sometimes
of the NMDA receptor
with a Dravet-like syndrome

Retigabine (ezogabine) increases DEPDC5 (DEP domain containing 5,

activity at KCNQ2 channels and has
been used to treat the neonatal
epileptic encephalopathy associated
with reduced function mutations of
the KCNQ2 channel
involved in G-protein signalling) correlated
with cortical dysplasia and in up to 12% of
small families of patients with familial focal
epilepsy phenotypes

Most consistently effective is the use of ketogenic diet to switch cerebral energy
metabolism away from glucose in patients with Glut-1 deficiency, which may be
dramatically successful
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Epilepsy – monogenic epilepsy
MONOGENIC EPILEPSY in which a single variant of large effect is considered causative and
COMPLEX GENETIC EPILEPSY in which a presumed combinatorial effect of multiple
susceptibility variants is thought to underlie the disease

GABA receptor mutations: Mutations in the NMDA receptor subunit genes:

• GABRA1 GRIN2A and GRIN2B
in a family with dominantly inherited neurodevelopmental epilepsy including
Juvenile Myoclonic Epilepsy, • epilepsy – aphasia spectrum disorders,
severe infantile onset epileptic • idiopathic focal epilepsy with rolandic spikes
encephalopathies GRIN1 mutations:
• GABRB3 epilepsy with profound developmental delay
Childhood Absence Epilepsy, epileptic associated with a hyperkinetic movement disorder
encephalopathy and infantile
• GABRB1 hypotonia
Encephalopathy presenting with epileptic mutations in GRIN2D:
seizures and developmental regression in in some patients with severe infantile-onset
infancy epilepsy

Potassium channell subunit KCNA2.

De novo mutations severe childhood-onset epilepsy, autosomal-dominant family
with the predominant phenotype of infantile-onset pharmacoresponsive epilepsy
in the setting of normal intellect and episodic ataxia
gain-of function and loss-of-functions → distinct epilepsy phenotypes

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Epilepsy – monogenic epilepsy
SCN1A and SCN2A-related epilepsy:
mutations in the same gene can give rise to a spectrum of epilepsy severity, from
severe childhood epilepsy with developmental delay to pharmacoresponsive self-
limiting epilepsy

Potassium channel subunit gene KCNT1

• epilepsy of infancy with migrating focal
seizures (EIMFS)
• West syndrome
• early-onset epileptic encephalopathy

And again EPIGENETICS!

Epilepsy and genes involved in transcriptional regulation through chromatin remodeling.
• CHD2 associated with myoclonic encephalopathy and photosensitivity,
• SMARCA2 associated with Nicolaides– Baraitser Syndrome and Myoclonic Astatic Epilepsy
• SMC1A, associated with a severe epilepsy with clusters of seizures in women

May be involved: Interleukin 2 receptor, Insulin receptor

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Epilepsy
In general pharmacological treatment is ok:
63% of unselected patients in an epilepsy service were rendered seizure free with
medication……..
…..but for example………
the effect of benzodiazepines in status epilepticus disappears very rapidly

Ethosuximide, often forgotten by adult neurologists, has the most specific

mechanism in relation to its role in the absence epilepsy. It acts on T-type
calcium channels, implicated in the thalamocortical disturbance believed for
decades to underlie generalized epilepsies

Valproate and ethosuximide have Quinidine is a blocker of KCNT1 channels,

clearly demonstrated greater suggesting that the drug might be a precision
efficacy over lamotrigine in therapy in epilepsy associated with gain-of-
childhood absence epilepsy function KCNT1 mutation.

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Multiple Sclerosis (MS)

Dobson R, Giovannoni G. Multiple sclerosis - a review. Eur J Neurol. 2019 Jan;26(1):27-40. doi:
10.1111/ene.13819. Epub 2018 Nov 18. PMID: 30300457.

Oh J, Vidal-Jordana A, Montalban X. Multiple sclerosis: clinical aspects. Curr Opin Neurol. 2018
Dec;31(6):752-759. doi: 10.1097/WCO.0000000000000622. PMID: 30300239.

Hollenbach JA, Oksenberg JR. The immunogenetics of multiple sclerosis: A comprehensive review. J
Autoimmun. 2015 Nov;64:13-25. doi: 10.1016/j.jaut.2015.06.010. Epub 2015 Jul 2. PMID: 26142251;
PMCID: PMC4687745.

Axisa PP, Hafler DA. Multiple sclerosis: genetics, biomarkers, treatments. Curr Opin Neurol. 2016
Jun;29(3):345-53. doi: 10.1097/WCO.0000000000000319. PMID: 27058221.

Doshi A, Chataway J. Multiple sclerosis, a treatable disease. Clin Med (Lond). 2016 Dec;16(Suppl 6):s53-
s59. doi: 10.7861/clinmedicine.16-6-s53. PMID: 27956442; PMCID: PMC6329568.

Howard J, Trevick S, Younger DS. Epidemiology of Multiple Sclerosis. Neurol Clin. 2016 Nov;34(4):919-939.
doi: 10.1016/j.ncl.2016.06.016. Epub 2016 Aug 18. PMID: 27720001.
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Multiple Sclerosis (MS)
Multiple sclerosis is a chronic disease of central
nervous system and one of the most common
causes of neurological disability in young adults
globally
• Immune-mediated demyelinating disease
with progressive neurodegeneration caused by
an autoimmune response to self-antigens
• inflammation, demyelination, and axonal
loss occurs in even early stages of the disease
• increasing in incidence and prevalence
globally, even in traditionally low-prevalence
regions of the world
• The onset usually in young adulthood,
between 20 and 40 years of age
• women are two to three times more
frequently affected than men
multifactorial cause is accepted
where both genetic and
environmental factors determine
an individual’s disease risk in a
complex interplay that is not fully
understood
median prevalence 33/100 000 people
significant variance between different
countries:
North America and Europe -
the highest prevalence (108-140/100 000)
Asia and sub-Saharan Africa countries –
the lowest prevalence (2.2-2.1/100 000)
four distinct clinical phenotypes:
relapsing–remitting (RRMS),
secondary-progressive (SPMS),
primary progressive (PPMS),
progressive relapsing (PRMS)
ENVIRONMENTAL FACTORS
EBV, sunshine (UVB), smoking and vitamin
D, combined with an individual’s genetic
background, play important roles in the
causal pathway that results in MS
development
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Multiple Sclerosis (MS)
DIAGNOSIS
lesions in the CNS that are disseminated
in space (DIS) and time (DIT).
 MRI
the most recent criteria incorporate MRI
findings to establish the
presence of DIS and DIT
→ earlier diagnosis → earlier treatment
MRI is the most sensitive tool to detect the
presence of brain and spinal cord lesions in
multiple sclerosis, and is also helpful to
exclude other diseases
Magnetic Resonance Imaging in
multiple sclerosis (MAGNIMS) network
The presence of IgG oligoclonal
bands (OCBs) in cerebrospinal fluid
(CSF) that are absent in serum,
together with an elevated IgG index,
are usually found in multiple
sclerosis patients
McDonald diagnostic criteria for
multiple sclerosis ver. year 2017
vastly exceeding the volume of this
lecture
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Multiple Sclerosis (MS)
GWASs defined 194 genetic variants
associated with multiple sclerosis,
that number likely to rise to over 400
Regions/loci/pathways corelated with MS:
• The MHC region
• immunoglobulin heavy-chain locus
• variants within the NFκB signaling cascade
• variants within the STAT3/4/5 signaling
cascades
genetic variants corelate with cerebrospinal
fluid immunoglobulin G (IgG) levels and
oligoclonal bands (OCBs)
PROTEIN BIOMARKERS
CNS neurofilaments (Nfl) are released after
axonal damage. Several studies suggest that Nfl
levels could be a prognostic biomarker for an
aggressive disease course and high risk for
secondary progression and correlate with
treatment response to fingolimod,
natalizumab, and rituximab
Osteopontin (OPN) is an early activation
marker on T cells with a role in T-cell
costimulation and interferon (IFN)-γ
expression. OPN is highly expressed within
multiple sclerosis lesions and is significantly
higher in multiple sclerosis blood and CSF
than healthy controls.
YKL-40 (Chitinase-3-like 1) is an activation
marker for glia, macrophages, vascular
smooth muscle cells, airway epithelia, and
chondrocytes. Elevated YKL-40 levels have
been found in the serum of many
inflammatory conditions
CD163 is a monocyte/macrophage
specific membrane marker. Upon
activation, macrophages cleave CD163
from the surface and shed soluble CD163
(sCD163) that can be detected in the
blood and CSF
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Multiple Sclerosis (MS)
Evidence for a genetic component in MS Risk variants:
pathogenesis: HLA-DRB1*15:01
• clustering of affected individuals in DQB1*06:02
families DRB1*08:01 in an Ashkenazi cohort
• high disease concordance rate in HLA-A*03:01 was predisposing in MS
monozygotic twins DRB1*04:05 “Asian“ MS
• differences in disease prevalence clinically distinct disease course →
among different ancestral groups earlier age of onset, reduced severity,
lack of brain lesions
Currently, a total of 110 polymorphisms in 103
discrete loci outside the major
Protection variants
histocompatibility complex (MHC) have been
The class II allele most consistently associated
firmly associated with susceptibility
with protection from MS in European populations
Main signal genome-wide maps to the class II is DRB1*14:01. Protection mediated by DRB1*14
region of the human leukocyte antigen (HLA) appears to be dominant, abrogating
gene cluster and explains up to 10.5% of the susceptibility attributed to DRB1*15:01
genetic variance underlying risk. HLA*B44:02 appears to afford protection in MS

Killer-immunoglobulin-like Absence of the inhibitory KIR2DL3 was shown to be

receptors (KIR) are highly predisposing in MS, implicating either KIR2DL2
polymorphic receptors expressed [which segregates as the alternate allele of the same
on natural killer (NK) cells locus] or the closely linked KIR2DS2 in disease

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Multiple Sclerosis (MS)
THERAPY OPTIONS
Induction – where high efficacy drugs are used earlier in disease to possibly prevent
disability accrual, despite their significant side effect profile.
Escalation – starting with a less efficacious, but potentially safer, therapy and then moving
up the treatment ladder if there is treatment failure.
1 acute relapse management
high-dose methylprednisolone therapy, corticosteroids,
plasma exchange physiotherapy, should
2 disease-modifying treatments (DMTs) also be used early
β-interferon and glatiramer acetate, teriflunamide, to enhance recovery
dimethyl fumarate, fingolimod,
or alemtuzumab and natalizumab
3 symptomatic treatments.
Curiosity: a good medicine that helps to kill patient (sometimes)
Natalizumab (Tysabri) is a monoclonal antibody targeted to the α4 integrin. Blockade of α4β1 results in
diminished T-cell trafficking to the CNS and reduces relapse rate by 68%.
However, progressive multifocal leukoencephalopathy (PML) emerged as a rare adverse event from
natalizumab treatment, generally occurring late (24 months) after initiating treatment.
PML is caused by reactivation of a latent John Cunningham virus in immunocompromised individuals.
This leads to a debilitating encephalopathy that is often fatal
so You should………
First: John Cunningham virus test , then Natalizumab therapy (if test is negative)
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Central Nervous System developmental diseases:
Neural tube defects
Spina bifida
Dean JH, Pauly R, Stevenson RE. Neural Tube Defects and Associated Anomalies before and
after Folic Acid Fortification. J Pediatr. 2020 Jul 5:S0022-3476(20)30845-3. doi:
10.1016/j.jpeds.2020.07.002. Epub ahead of print. PMID: 32634404.
Zou J, Wang F, Yang X, Wang H, Niswander L, Zhang T, Li H. Association between rare variants
in specific functional pathways and human neural tube defects multiple subphenotypes.
Neural Dev. 2020 Jul 10;15(1):8. doi: 10.1186/s13064-020-00145-7. PMID: 32650820;
PMCID: PMC7353782.
Paul S, Sadhukhan S, Munian D, Bankura B, Das M. Association of FOLH1, DHFR, and MTHFR
gene polymorphisms with susceptibility of Neural Tube Defects: A case control study from
Eastern India. Birth Defects Res. 2018 Aug 15;110(14):1129-1138. doi: 10.1002/bdr2.1365.
Epub 2018 Aug 18. PMID: 30120883.
Khattak MT, Supriyanto E, Aman MN, Al-Ashwal RH. Predicting Down syndrome and neural
tube defects using basic risk factors. Med Biol Eng Comput. 2019 Jul;57(7):1417-1424. doi:
10.1007/s11517-019-01969-0. Epub 2019 Mar 15. PMID: 30877513.
Gaitanis J, Tarui T. Nervous System Malformations. Continuum (Minneap Minn). 2018
Feb;24(1, Child Neurology):72-95. doi: 10.1212/CON.0000000000000561. PMID: 29432238;
PMCID: PMC6463295.
Hillman P, Baker C, Hebert L, Brown M, Hixson J, Ashley-Koch A, Morrison AC, Northrup H, Au
KS. Identification of novel candidate risk genes for myelomeningocele within the glucose
homeostasis/oxidative stress and folate/one-carbon metabolism networks. Mol Genet
Genomic Med. 2020 Sep 22:e1495. doi: 10.1002/mgg3.1495. Epub ahead of print. PMID:
32960507.
Brei T, Houtrow A. Spina Bifida. J Pediatr Rehabil Med. 2017 Dec 11;10(3-4):165-166.
doi: 10.3233/PRM-170469. PMID: 29154296.
Phillips LA, Burton JM, Evans SH. Spina Bifida Management. Curr Probl Pediatr Adolesc
Health Care. 2017 Jul;47(7):173-177. doi: 10.1016/j.cppeds.2017.06.007. Epub 2017
Jul 19. PMID: 28734746.
Orriss IR, Lanham S, Savery D, Greene NDE, Stanier P, Oreffo R, Copp AJ, Galea GL.
Spina bifida-predisposing heterozygous mutations in Planar Cell Polarity genes and
Zic2 reduce bone mass in young mice. Sci Rep. 2018 Feb 20;8(1):3325. doi:
10.1038/s41598-018-21718-x. PMID: 29463853; PMCID: PMC5820290.
Nikolopoulou E, Galea GL, Rolo A, Greene ND, Copp AJ. Neural tube closure: cellular,
molecular and biomechanical mechanisms. Development. 2017 Feb 15;144(4):552-
566. doi: 10.1242/dev.145904. PMID: 28196803; PMCID: PMC5325323.
Ross ME, Mason CE, Finnell RH. Genomic approaches to the assessment of human
spina bifida risk. Birth Defects Res. 2017 Jan 30;109(2):120-128. doi:
10.1002/bdra.23592. PMID: 27883265; PMCID: PMC5388593.
Trudell AS, Odibo AO. Diagnosis of spina bifida on ultrasound: always termination?
Best Pract Res Clin Obstet Gynaecol. 2014 Apr;28(3):367-77. doi:
10.1016/j.bpobgyn.2013.10.006. Epub 2013 Dec 3. PMID: 24373566.
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Neural Tube Defects (NTDs)
The nervous system undergoes
rapid developmental changes
throughout gestation and
continues to evolve after birth
and into early adulthood.
Disruption of the developing
nervous system can occur at any
stage. The timing and nature of
disruptions account for the
specific malformations
head
ventral view
Brain and spinal cord development begins with
neurulation, which is the process of neural tube
formation that occurs in the third and fourth weeks
of gestation.
• In the fifth and sixth weeks, prosencephalic
development occurs, giving shape to the
developing brain.
• Cortical development is divided into stages of
cell proliferation, neuronal migration, and
postmigrational cortical organization.
• Myelination and cortical organization are the
final steps of brain development and continue
well beyond birth
neural tube
plana transversalia
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Neural Tube Defects (NTDs)
Neural tube defects (NTDs)
congenital malformations of the central
nervous system occurring secondary to
incomplete closure of the
neural tube:
in the region of the head- anencephaly,
below the head- spina bifida, (SB)
or along its entire length – craniorachischisis
• NTDs - second most common
complex congenital malformation
following congenital heart defects
• estimated worldwide birth
prevalence of 18.6 per 10,000 live births
• significant regional variation exists
A multifactorial etiology of NTDs with both
genetic and environmental contributions.
A genetic component evidence:
• increased familial recurrence,
• preponderance in monozygotic twins,
• effects of ethnicity on incidence.
The (purely) genetic causes include
chromosomal aberrations, microduplications,
microdeletions, and single-gene disorders.
Environmental components evidence:
• variation of incidence rate across time,
seasons, geography, and socioeconomic
status
• maternal infections: Zika virus,
cytomegalovirus, Toxoplasma gondii
• best associated environmental factors
conferring an increased risk: folate
status and glucose metabolism,
specifically maternal folate deficiency
and maternal glucose excess
(hyperglycaemia).
• Medicines: antiepileptic drugs, diuretics,
antihistamine drugs, sulphonamides
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Neural Tube Defects (NTDs)
Folate status
A huge number of evidences indicate that
folate one carbon metabolism (FOCM)
pathway and dietary folate status play an
important role in neural tube formation
Folate (vitamin B9) exists in cells as an
important cofactor in enzymes that transfer
methyl groups - one-carbon units (for
methylation of various substrates)
EPIGENETICS
Changes in DNA methylation patterns:
• observed in NTD fetuses,
correlated with folate levels in mothers
• metabolic studies found changes
in intermediate metabolites of FOCM
in women with NTD affected pregnancies.
• the range of these abnormalities
illustrate the broad impact of defects in the
FOCM network
• Changes in histone methylation
Glucose metabolism
Maternal diabetes, elevated glycemic index
obesity, and valproic acid exposure are
the best known of a limited number of
environmental influences which increase
the risk of neural tube defects with or
without associated anomalies.
Proposed secondary teratogenic
mechanisms resulting from maternal
diabetes include nutritional
deficiencies, mitochondrial disturbances,
enhanced cellular stress, hypoxia,
increased apoptosis, decreased autophagy,
altered metalloproteinases, and epigenetic
changes
Increased oxidative stress
leads to increased proapoptotic signaling
and mitochondrial dysfunction, associated
with an overall increased risk of birth
defects
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Neural Tube Defects (NTDs)
The NTD phenotypes variability
Craniorachischisis -anencephaly continuous with exposed spinal cord,
Anencephaly- lack of brain and cranial vault subsequent to failure to close the cranial
neural tube,
Encephalocele- meningeal sac, often containing brain tissue, protruding from the skull,
spina bifida aperta- exposed spinal cord, usually called meningomyelocele,
spina bifida cystica- spinal cord defect covered by meningeal sac,
Spina bifida occulta - skin-covered lesion involving two or more vertebrae, also called
spina dysraphism
Patients survive, disability depends on many factors (like where on spine lesion occured)
GENES/PATHWAYS INVOLVED IN NTDs
PUTATIVELY DAMAGING RARE VARIANTS (PDRVs) Signaling through the BMP, Sonic
chromatin remodeling ACTL6A, CECR2, SMARCA4, hedgehog (Shh), FGF, Wnt
SMARCC1, ATRX pathways and cilia-related genes
pro-apoptotic genes TP53, APAF1, CASP9, CASP3 coordinate patterning of the
Retinoic acid metabolism CYP26B1, CYP26A1 and neural tissue
retinoic acid receptor loss of function rare variants
Digenic, polygenic PDRVs

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Neural Tube Defects (NTDs)
GENES/PATHWAYS INVOLVED IN NTDs
Mutations in Planar Cell Polarity (PCP) Folate hydrolase 1 (FOLH1):
pathway core genes: VANGL1 and rs202676 (p.Tyr60His)
VANGL2 in craniorachischisis cases and Dihydrofolate reductase (DHFR):
other NTD patients. The contribution rs70991108 19 bp deletion in intron 1
of PCP gene mutations to human NTDs Methylenetetrahydrofolate reductase
is well-established in several cohorts (MTHFR): rs1801133 (p.Ala222Val),
rs1801131 (p. Glu429Ala)
TREATMENT AND PREVENTION
USA fortification of cereal grains with Spina bifida:
folic acid, leading to a decrease in • Surgery in utero is possible and has
incidence of NTDs by ~35% good outcomes.
• Surgery in 24-48 hour after birth
Periconceptional use of folic acid
• Neurosurgery of usual complications
supplements indicates intake for at least
like hydrocephalus
1 month before conception and 1 or
• Life long condition requiring additional
more months following conception
detailed follow up

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Neural Tube Defects (NTDs)
MYELOMENINGOCELE (SPINA BIFIDA)
• the most common disorder of
neurulation
• fetuses and infants can remain
viable.
• incidence in the US is
approximately
0.2 to 0.4 per 1000 live births
• The neurologic features of
myelomeningocele relate to the level
of involvement, presence of
hydrocephalus, and other associated
brain malformations
Diagnosis of spina bifida is usually
made prenatally
• measurement of alpha fetal
protein in the maternal serum at 16
weeks of gestation
• ultrasound of the fetus at
18–20 weeks of gestation.
• Testing is 85–90% accurate
HOLOPROSENCEPHALY— the absence of
hemispheric separation results in a single,
large forebrain ventricle that can be first
recognized on the prenatal ultrasound and
fetal MRI
Alobar holoprosencephaly is the most severe
form, in which the brain is a single spherical
structure
Facial anomalies, when present, can range
from as severe as cyclopia to as subtle as a
single central incisor
Sonic Hedgehog (SHH) gene at 7q36
SHH plays an important role in dorsal-ventral
patterning- homeiotic gene, responsible for
development of large parts of body
Curiosity- cyclopamine (Veratrum sp.)
can cause cyclopia by disrupting
SHH-cholesterol interaction
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Neural Tube Defects (NTDs)
AGENESIS OF THE CORPUS CALLOSUM
Both partial and complete isolated
agenesis of the corpus callosum can
have broad neurodevelopmental
presentations from mild to severe
impairments
MICROCEPHALY/
MICROLISSENCEPHALYPrimary
microcephaly -small head size when the
birth head circumference is three or
more standard deviations below normal
Mutations associated with primary
microcephaly alter neuroprogenitor cell
proliferation through cell cycle
regulation (MCPH1, CENPJ, CDK5RAP2),
centrosome function (NDE1), cell
proliferation (ASPM, STIL), mitotic
spindle formation (WDR62), or DNA
repair (PNKP, PCNT).
SEPTOOPTIC DYSPLASIA.—Septooptic
dysplasia is characterized by optic nerve
hypoplasia in combination with pituitary
dysfunction and absence of the septum
pellucidum
TUBEROUS SCLEROSIS COMPLEX.—
a multisystem dominantly inherited. It
has a high rate of spontaneous
mutations, and approximately one-half
of all patients do not have an affected
parent
TSC1 gene, located on chromosome
9q34, encodes for the protein
hamartin, which indirectly links the cell
membrane to the cytoskeleton. The
TSC2 gene, located at chromosome
16p13.3, encodes for the protein
tuberin, which functions in cellular
signaling pathways.
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Neural Tube Defects (NTDs)

CLASSIC LISSENCEPHALY.—Patients with classic lissencephaly have severe

reduction in gyral formation manifesting either as agyria (a total absence
of gyri) or pachygyria (a reduced number of abnormally large gyri).
Radiographically, agyria appears as a smooth brain surface

Pachygyria has a (malformation of the brain) posterior greater than anterior

gradient in LIS1, TUBA1A, and TUBB2B mutations (FIGURE 4–7) and an
anterior greater than posterior gradient in DCX, ACTB, and ACTG1
mutations.
Mutations of the platelet-activating factor acetylhydrolase gene (PAFAH1B1
[LIS1]) located on chromosome 17p13.3 is commonly seen
Abnormalities of the doublecortin (DCX or XLIS) gene, located on the X
chromosome, are also known to cause classic lissencephaly with an
anterior greater than posterior gradient.

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Diabetes mellitus

Kerner W, Brückel J; German Diabetes Association. Definition, classification and diagnosis of diabetes
mellitus. Exp Clin Endocrinol Diabetes. 2014 Jul;122(7):384-6. doi: 10.1055/s-0034-1366278. Epub 2014
Jul 11. PMID: 25014088.

The Lancet. Diabetes: a dynamic disease. Lancet. 2017 Jun 3;389(10085):2163. doi: 10.1016/S0140-
6736(17)31537-4. PMID: 28589879.

American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2013
Jan;36 Suppl 1(Suppl 1):S67-74. doi: 10.2337/dc13-S067. PMID: 23264425; PMCID: PMC3537273.

Schmidt AM. Highlighting Diabetes Mellitus: The Epidemic Continues. Arterioscler Thromb Vasc Biol. 2018
Jan;38(1):e1-e8. doi: 10.1161/ATVBAHA.117.310221. PMID: 29282247; PMCID: PMC5776687.

Guthrie RA, Guthrie DW. Pathophysiology of diabetes mellitus. Crit Care Nurs Q. 2004 Apr-Jun;27(2):113-
25. doi: 10.1097/00002727-200404000-00003. PMID: 15137354.

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Diabetes mellitus

The defining feature of diabetes is the Type 1 Diabetes

presence of hyperglycemia ▶ β-cell destruction which leads to
The most common forms of diabetes absolute insulin deficiency
are TYPE 1 diabetes- absolute ▶ Usually mediated by immune
deficiency of insulin ensues consequent mechanisms
to pancreatic beta cell destruction; and ▶ LADA (latent autoimmune
TYPE 2 diabetes, in which insulin diabetes in adults) is classified as
resistance may lead to hyperglycemia type 1 diabetes.
The complications of diabetes affect nearly
Type 2 Diabetes
every tissue of the body and diabetes is a
▶ Can range from predominant
leading cause of cardiovascular morbidity
insulin resistance with relative
and mortality, blindness, renal failure and
insulin deficiency to prevailing
amputations
defective secretion with insulin
The process of nonenzymatic glycation, that is, resistance.
formation of advanced glycation endproducts ▶ Is frequently associated with
(AGEs), induces profound effects on multiple other problems of the so-called
cell types and tissues in diabetes metabolic syndrome
Kerner W, Brückel J; German Diabetes Association. Definition, classification and diagnosis of diabetes
mellitus. Exp Clin Endocrinol Diabetes. 2014 Jul;122(7):384-6. doi: 10.1055/s-0034-1366278. Epub 2014
Jul 11. PMID: 25014088. Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Diabetes mellitus
Gestational diabetes mellitus (GDM)
Other Specific Diabetes Types
▶ Diseases of the exocrine pancreas (e. g. DIAGNOSIS:
pancreatitis, cystic fibrosis, Diabetes Mellitus
hemochromatosis) ▶ HbA1c ≥ 6.5 % (≥ 48 mmol/mol)
▶ Endocrinopathies (e. g. Cushing ▶ Random plasma glucose ≥ 200mg/dl
syndrome, acromegaly, (≥ 11.1 mmol/l)
pheochromocytoma) ▶ Fasting plasma glucose ≥ 126 mg/dl
▶ Drug induced (e. g. glucocorticoids, (≥ 7.0 mmol/dl)
neuroleptics, alpha-interferons, ▶ OGTT 2‑hour glucose in venous plasma
pentamidine) ≥ 200mg/dl (≥ 11.1 mmol/l)
▶ Genetic defects of the β-cell function (e.
g. MODY forms) Insulin - number of functions in different
▶ Genetic defects of insulin action cells.
▶ Other genetic syndromes which can be • It facilitates uptake of glucose into the
associated with diabetes cells and it storage.
▶ Infections • stimulates the enzymes making
▶ Rare forms of auto-immune mediated glycogen and fat suppresses the enzymes
diabetes that break down glycogen and fat.
 vascular and nerve tissues can take up
Kerner W, Brückel J; German Diabetes Association. Definition, glucose without the presence of insulin.
classification and diagnosis of diabetes mellitus. Exp Clin Endocrinol
Diabetes. 2014 Jul;122(7):384-6. doi: 10.1055/s-0034-1366278. Epub
2014 Jul 11. PMID: 25014088. Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
 Diabetes mellitus
T1DM: autoimmune disease
A few genes identified: HLA-DQA1∗0301, HLA-DQA1∗0302, HLA-DQB-1∗0602, HLA-DQW1.2.
The environmental factors that trigger the destruction of β cells are not yet fully identified.
• viruses, such as coxsackie viruses
• Cow’s milk has also been suspected but data so far are incomplete

Difficult to describe the pathophysiology of T2DM.

 Mutations of the insulin receptor (type
A insulin resistance)
Phenotype: hyperinsulinemia and modest
hyperglycemia to severe diabetes. Some
individuals acanthosis nigricans. Women may
be virilized and have enlarged, cystic ovaries.
 pediatric syndromes (extreme insulin
resistance):
• Leprechaunism- characteristic facial
features and is usually fatal in infancy
• Rabson- Mendenhall syndrome –
associated with abnormalities of teeth and
nails and pineal gland hyperplasia.
• research progresses is quick
• T2DM is not a single disease but is a group of
diseases, (syndrome with different genetics and
pathophysiology but similar symptoms and
outcome)
• T2DM is a combination of insulin resistance
and insulin deficiency
T2DM is a genetic disease. There are many
genes involved, most of which have not as
yet been identified. These genes control a
number of chemical steps in β cell action,
insulin secretion, insulin action at the cell
level, insulin receptor production by the cell,
and insulin action inside the cell.

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
 Diabetes mellitus
Diabetic ketoacidosis (DKA) is a common
critical care event for people with T1DM
1.Lack of glucose to the cells also causes a nonketotic hyperosmolar syndrome
state of starvation that stimulates the hunger
mechanism or polyphagia
2. fat is used to produce ketonic bodies- those
Recognition of the hypoglycemia
chemical compounds are slightly acidic
is the problem. Symptoms are
3. blood acidosis→sodium bicarbonate
shakiness, sweatiness, palpitations,
decomposition (CO2)
inappropriate behavior, and ultimately,
4. carbon dioxide is eliminated through if untreated, coma and seizures
respiration, causing the deep labored
respiration (Kussmaul respiration) so often
seen in DKA.
dehydration, acidosis, hyponatremia, and hypokalemia though the serum potassium can
be initially normal, low, or high depending on the state of dehydration and the renal
excretion rate for potassium. Sodium, potassium, and bicarbonate levels as well as arterial
pH, blood urea nitrogen, and creatinine should all be measured at admission and all
except arterial pH should be frequently measured until full recovery. The most common
causes of death in DKA are hypokalemia and cerebral edema.
Karol P. Ruszel, PhD Chair of Medical Genetics
karol.ruszel@umlub.pl Department of Clinical Genetics
Thank You for Your attention

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics
CARDIOVASCULAR and CEREBROVASCULAR diseases
hypertension
atherosclerosis
myocardial infarction
stroke

Karol P. Ruszel, PhD Chair of Medical Genetics

karol.ruszel@umlub.pl Department of Clinical Genetics