Waardenburg syndrome

Waardenburg syndrome
Synonyms	Waardenburg Shah syndrome, Waardenburg-Klein syndrome

Facial features of Waardenburg syndrome
Classification and external resources
Specialty	medical genetics
ICD-10	E70.3 (ILDS E70.32)
ICD-9-CM	270.2
DiseasesDB	14021 33475
MedlinePlus	001428
eMedicine	ped/2422 derm/690
MeSH	D014849

Waardenburg syndrome is a rare genetic disorder most often characterized by varying degrees of deafness, minor defects in structures arising from the neural crest, and pigmentation changes.

It was first described in 1951.^[1]

Signs and symptoms

Symptoms vary from one type of the syndrome to another and from one patient to another, but they include:

Very pale or brilliantly blue eyes, eyes of two different colors (complete heterochromia), or eyes with one iris having two different colours (sectoral heterochromia)^[2]
A forelock of white hair (poliosis), or premature graying of the hair
Appearance of wide-set eyes due to a prominent, broad nasal root (dystopia canthorum)—particularly associated with Type I) also known as telecanthus
Moderate to profound hearing loss (higher frequency associated with Type II);^[2]
A low hairline and eyebrows that meet in the middle (synophrys)
Patches of white skin pigmentation, in some cases
Abnormalities of the arms, associated with Type III
neurologic manifestations, associated with Type IV

Waardenburg syndrome has also been associated with a variety of other congenital disorders, such as intestinal and spinal defects, elevation of the scapula and cleft lip and palate. Sometimes this is concurrent with Hirschsprung disease.

Genetics

This condition is usually inherited in an autosomal dominant pattern, which means one copy of the altered gene is sufficient to cause the disorder. In most cases, an affected person has one parent with the condition. A small percentage of cases result from new mutations in the gene; these cases occur in people with no history of the disorder in their family.

Some cases of type II and type IV Waardenburg syndrome appear to have an autosomal recessive pattern of inheritance, which means two copies of the gene must be altered for a person to be affected by the disorder. Most often, the parents of a child with an autosomal recessive disorder are not affected but are carriers of one copy of the altered gene.

Waardenburg syndrome is usually inherited in an autosomal dominant pattern.
Types II and IV Waardenburg syndrome may sometimes have an autosomal recessive pattern of inheritance.

Types I and III inheritance of this trait is autosomal dominant. If an affected parent is homozygous dominant there is a 100% that the child will be affected and if the affected parent is heterozygous dominant then there is a 50% chance that a child of an affected parent will be affected. Symptoms vary and so the extremity of symptoms cannot be determined. Types II and IV is autosomal recessive, symptoms are not definite they vary just as the other type’s symptoms will. A study was done on a rare case of a double heterozygous child with each parent having only single mutations in MTIF or PAX3. The effect of double heterozygous mutations in the genes MTIF and PAX3 in WS1 and WS2 can increase the pigment-affected symptoms. It leads to the conclusion that the double mutation of MTIF is associated with the extremity of Waardenburg Syndrome and may affect the phenotypes or symptoms of the syndrome ^[3]

Classification

Subtypes of the syndrome are traceable to different genetic variations and presentations:

Type	OMIM	Gene	Locus	Features
Type I, WS1	193500	PAX3	2q35	Almost always have eyes that appear widely spaced^[2] Hearing loss more common than in type II^[2] Hearing loss is congenital.^[2]
Type IIa, WS2A (originally WS2)	193510	MITF	3p14.1-p12.3	Most common^[4] Permanent hearing loss^[4] Heterochromia of the irises^[4]
Type IIb, WS2B	600193	WS2B	1p21-p13.3
Type IIc, WS2C	606662	WS2C	8p23
Type IId, WS2D (very rare)	608890	SNAI2	8q11
Type III, WS3	148820	PAX3	2q35	Abnormalities of the upper limbs Hearing loss over time^[4] Changes in skin pigmentation^[2]
Type IVa, WS4A	277580	EDNRB	13q22	Characteristics of Waardenburg syndrome, in addition to Hirschsprung disease which can be life-threatening and requires surgery if the colon is enlarged.^[2]^[4]
Type IVb, WS4B	613265	EDN3	20q13
Type IVc, WS4C	613266	SOX10	22q13

Type III is also known as Klein-Waardenburg syndrome, and type IV is also known as Waardenburg-Shah syndrome.^[2]

Treatment

There is currently no treatment or cure for Waardenburg syndrome. The symptom most likely to be of practical importance is deafness, and this is treated as any other irreversible deafness would be. In marked cases there may be cosmetic issues. Other abnormalities (neurological, structural, Hirschsprung disease) associated with the syndrome are treated symptomatically.

Epidemiology

The overall incidence is ~1/42,000 to 1/50,000 people. Types I and II are the most common types of the syndrome, whereas types III and IV are rare. Type 4 is also known as Waardenburg‐Shah syndrome (association of Waardenburg syndrome with Hirschsprung disease).

Type 4 is rare with only 48 cases reported up to 2002.^[5]

About 1 in 30 students in schools for the deaf have Waardenburg syndrome. All races and sexes are affected equally. The highly variable presentation of the syndrome makes it difficult to arrive at precise figures for its prevalence.

History

Waardenburg-Klein syndrome is named after Petrus Johannes Waardenburg (1886–1979), a Dutch ophthalmologist and geneticist, and David Klein, a Swiss human geneticist and ophthalmologist.
Mende's syndrome II is named after Irmgard Mende (1938–), a German-American physician.
Van der Hoeve-Halbertsma-Waardenburg Syndrome is named after Jan Van der Hoeve (1878–1952), a Dutch ophthalmologist, Nicolaas Adolf Halbertsma (1889–1968), Dutch physician and Petrus Johannes Waardenburg (1886–1979).
Van der Hoeve-Halbertsma-Gualdi syndrome is named for Jan Van der Hoeve (1878–1952), Nicolaas Adolf Halbertsma (1889–1968) and Vincenzo Gualdi (1891–1976), an Italian physician.
Vogt’s syndrome is named for Cecile Vogt (1875–1962), a French-German neuropathologist.

Society and culture

Name

Waardenburg syndrome is named after Dutch ophthalmologist Petrus Johannes Waardenburg (1886–1979), who described the syndrome in detail in 1951.^[1]^[6] The condition he described is now categorized as WS1. Swiss ophthalmologist David Klein also made contributions towards the understanding of the syndrome.^[7]

WS2 was identified in 1971, to describe cases where dystopia canthorum did not present.^[8] WS2 is now split into subtypes, based upon the gene responsible.

Other types have been identified, but they are less common.

Mutations in the EDN3, EDNRB, MITF, PAX3, SNAI2, and SOX10 genes are implicated in Waardenburg Syndrome. Some of these genes are involved in the making of melanocytes, which makes the pigment melanin. Melanin is an important pigment in the development of hair, eye color, skin, and functions of the inner ear, so the mutation of these genes can lead to abnormal pigmentation and hearing loss.^[9] PAX3 and MTIF gene mutation occurs in type I and II (WS1 and WS2). Type III (WS3) shows mutations of the PAX3 gene also. SOX10, EDN3, or EDNRB gene mutations occur in type IV. Type IV (WS4) can also affect portions of nerve cell development that potentially can lead to intestinal issues.

Popular culture

In the season 6 episode of Bones, 'The Signs in the Silence', the team must solve a case in which the suspected killer has Waardenburg syndrome.

Enzo Macleod, protagonist of Peter May's series The Enzo Files, has Waardenburg syndrome. His eyes are different colors and he has a white streak in his hair. See pp. 17–18 of Extraordinary People (2006) by Peter May. Also "Blacklight Blue" Chapter 11.

The book Reconstructing Amelia by Kimberly McCreight features several characters with Waardenburg symptoms.

The book Closer Than You Think by Karen Rose features three characters, siblings, with Waardenburg Syndrome.

Other animals

Waardenburg syndrome is known to occur in ferrets. The affected individual will usually have a small white stripe along the top or back of the head and sometimes down the back of the neck (this is known as a "blaze" coat pattern), or a solid white head from nose to shoulders (known as a "panda" coat pattern). The ferret will often have a very slightly flatter skull than ferrets without the syndrome and may have unusually wide-set eyes. As a ferret's sense of hearing is poor to begin with, associated deafness is not easily noticeable except for a lack of reaction to loud noises. As the disorder is easily spread to offspring, the affected animal will not be used for breeding by private, reputable breeders, although it may still be neutered and sold as a pet. However, largely as a result of mass-breeding due to the "exotic" markings it gives, 75% of US ferrets with a blaze or white head sold from pet stores are deaf.^[10]

Domesticated cats with blue eyes and white coats are often completely deaf.^[11] Whether or not this is a result of Waardenburg syndrome remains unclear.^[12] Deafness is far more common in white cats than in those with other coat colors. According to the ASPCA Complete Guide to Cats, "17 to 20 percent of white cats with nonblue eyes are deaf; 40 percent of "odd-eyed" white cats with one blue eye are deaf; and 65 to 85 percent of blue-eyed white cats are deaf."^[13] In the 1980s, college genetic classes taught that the genes for deafness and white coat color were closely linked, resulting in the majority of cats with completely white coats and bluer eyes being deaf.^[14] The newer evidence cited above refutes this simplistic idea.

References

1 2 Waardenburg PJ (September 1951). "A New Syndrome Combining Developmental Anomalies of the Eyelids, Eyebrows and Noseroot with Pigmentary Anomalies of the Iris and Head Hair and with Congenital Deafness; Dystopia canthi medialis et punctorum lacrimalium lateroversa, Hyperplasia supercilii medialis et radicis nasi, Heterochromia iridum totalis sive partialis, Albinismus circumscriptus (leucismus, poliosis) et Surditas congenita (surdimutitas)". Am. J. Hum. Genet. 3 (3): 195–253. PMC 1716407. PMID 14902764.
1 2 3 4 5 6 7 8 "Waardenburg syndrome". Genetics Home Reference. Reviewed October 2012. Check date values in: |date= (help)
↑ Yang, T, et al. “Double Heterozygous Mutations Of MTIF and PAX3 Result in Waardenburg Syndrome With Increased Penetrance In Pigmentary defects.” Clinical Genetics 83.1 (2013): 78-62. Academic Search Premier. Web. 3 Apr. 2014.
1 2 3 4 5 Baral Viviane; et al. (2012). "Screening of MTIF and SOX10 Regulatory Regions In Waardenburg Syndrome Type 2". PLOS ONE. 7 (7): 1–8.
↑ Egbalian F (2008). "Waardenburg-Shah Syndrome; A Case Report and Review of the Literature" (PDF). Iranian Journal of Pediatrics. 18 (1): 71–74.
↑ Petrus Johannes Waardenburg at Who Named It?
↑ Klein-Waardenburg syndrome at Who Named It?
↑ Arias S (1971). "Genetic Heterogeneity in the Waardenburg Syndrome". Birth Defects Original Article Series. 7 (4): 87–101. PMID 5006208.
↑ Kumar, Sudesh, and Kiran Rao. "Waardenburg Syndrome: A Rare Genetic Disorder, A Report of Two Cases." Indian Journal of Human Genetics 18.2 (2012): 254-255. Academic Search Premier. Web. 4 Apr. 2014.,
↑ Matulich E. "Deafness in Ferrets". Cypresskeep.com.
↑ Webb AA, Cullen CC (2010). "Coat color and coat color pattern-related neurologic and neuro-ophthalmic diseases" (PDF). The Canadian Veterinary Journal. 51 (6): 653–657. PMC 2871368. PMID 20808581.
↑ Geigy CA, Heid S, Steffen F, Danielson K, Jaggy A, Gaillard C (2007). "Does a pleiotropic gene explain deafness and blue irises in white cats?". Veterinary Journal. 173 (3): 548–553. doi:10.1016/j.tvjl.2006.07.021. PMID 16956778.
↑ Richards J (1999). ASPCA Complete Guide to Cats: Everything You Need to Know About Choosing and Caring for Your Pet. Chronicle Books. p. 71. ISBN 9780811819299.
↑ DeeAnn Williams Visk, personal recollection.

External links

GeneReviews/NCBI/NIH/UW entry on Waardenburg Syndrome Type I
OMIM Genetic disorder catalog — Waardenburg syndrome

Inborn error of amino acid metabolism (E70–E72, 270)

K→acetyl-CoA

Lysine/straight chain	Glutaric acidemia type 1 type 2 Hyperlysinemia Pipecolic acidemia Saccharopinuria

Leucine	3-hydroxy-3-methylglutaryl-CoA lyase deficiency 3-Methylcrotonyl-CoA carboxylase deficiency 3-Methylglutaconic aciduria 1 Isovaleric acidemia Maple syrup urine disease

Tryptophan	Hypertryptophanemia

G→pyruvate→citrate

Glycine	D-Glyceric acidemia Glutathione synthetase deficiency Sarcosinemia Glycine→Creatine: GAMT deficiency Glycine encephalopathy

G→glutamate→
α-ketoglutarate

Histidine	Carnosinemia Histidinemia Urocanic aciduria

Proline	Hyperprolinemia Prolidase deficiency

Glutamate/glutamine	SSADHD

G→propionyl-CoA→
succinyl-CoA

Valine	Hypervalinemia Isobutyryl-CoA dehydrogenase deficiency Maple syrup urine disease

Isoleucine	2-Methylbutyryl-CoA dehydrogenase deficiency Beta-ketothiolase deficiency Maple syrup urine disease

Methionine	Cystathioninuria Homocystinuria Hypermethioninemia

General BC/OA	Methylmalonic acidemia Methylmalonyl-CoA mutase deficiency Propionic acidemia

G→fumarate

Phenylalanine/tyrosine

Phenylketonuria	6-Pyruvoyltetrahydropterin synthase deficiency Tetrahydrobiopterin deficiency

Tyrosinemia	Alkaptonuria/Ochronosis Type I tyrosinemia Type II tyrosinemia Type III tyrosinemia/Hawkinsinuria

Tyrosine→Melanin	Albinism: Ocular albinism (1) Oculocutaneous albinism (Hermansky–Pudlak syndrome) Waardenburg syndrome

Tyrosine→Norepinephrine	Dopamine beta hydroxylase deficiency reverse: Brunner syndrome

G→oxaloacetate

Urea cycle/Hyperammonemia (arginine aspartate)	Argininemia Argininosuccinic aciduria Carbamoyl phosphate synthetase I deficiency Citrullinemia N-Acetylglutamate synthase deficiency Ornithine transcarbamylase deficiency/translocase deficiency

Transport/
IE of RTT

Other

Pigmentation disorders/Dyschromia (L80–L81, 709.0)

Hypo-/
leucism

Loss of
melanocytes

Vitiligo	Quadrichrome vitiligo Vitiligo ponctué

Syndromic	Alezzandrini syndrome Vogt–Koyanagi–Harada syndrome

Melanocyte development	Piebaldism Waardenburg syndrome Tietz syndrome

Loss of melanin/
amelanism

Albinism	Oculocutaneous albinism Ocular albinism

Melanosome transfer	Hermansky–Pudlak syndrome Chédiak–Higashi syndrome Griscelli syndrome Elejalde syndrome Griscelli syndrome type 2 Griscelli syndrome type 3

Other	Cross syndrome ABCD syndrome Albinism–deafness syndrome Idiopathic guttate hypomelanosis Phylloid hypomelanosis Progressive macular hypomelanosis

Leukoderma w/o
hypomelanosis

Ungrouped

Hyper-

Melanin/
Melanosis/
Melanism

Reticulated	Dermatopathia pigmentosa reticularis Pigmentatio reticularis faciei et colli Reticulate acropigmentation of Kitamura Reticular pigmented anomaly of the flexures Naegeli–Franceschetti–Jadassohn syndrome Dyskeratosis congenita X-linked reticulate pigmentary disorder Galli–Galli disease Revesz syndrome

Diffuse/ circumscribed	Lentigo/Lentiginosis: Lentigo simplex Liver spot Centrofacial lentiginosis Generalized lentiginosis Inherited patterned lentiginosis in black persons Ink spot lentigo Lentigo maligna Mucosal lentigines Partial unilateral lentiginosis PUVA lentigines Melasma Erythema dyschromicum perstans Lichen planus pigmentosus Café au lait spot Poikiloderma (Poikiloderma of Civatte Poikiloderma vasculare atrophicans) Riehl melanosis

Linear	Incontinentia pigmenti Scratch dermatitis Shiitake mushroom dermatitis

Other/ ungrouped	Acanthosis nigricans Freckle Familial progressive hyperpigmentation Pallister–Killian syndrome Periorbital hyperpigmentation Photoleukomelanodermatitis of Kobori Postinflammatory hyperpigmentation Transient neonatal pustular melanosis

Other
pigments

Iron	Hemochromatosis Iron metallic discoloration Pigmented purpuric dermatosis Schamberg disease Majocchi's disease Gougerot–Blum syndrome Doucas and Kapetanakis pigmented purpura/Eczematid-like purpura of Doucas and Kapetanakis Lichen aureus Angioma serpiginosum Hemosiderin hyperpigmentation

Other metals	Argyria Chrysiasis Arsenic poisoning Lead poisoning Titanium metallic discoloration

Other	Carotenosis Tattoo Tar melanosis

Dyschromia

See also

Genetic disorder, protein biosynthesis: Transcription factor/coregulator deficiencies

(1) Basic domains

1.2	Feingold syndrome Saethre–Chotzen syndrome

1.3	Tietz syndrome

(2) Zinc finger
DNA-binding domains

2.1	(Intracellular receptor): Thyroid hormone resistance Androgen insensitivity syndrome PAIS MAIS CAIS Kennedy's disease PHA1AD pseudohypoaldosteronism Estrogen insensitivity syndrome X-linked adrenal hypoplasia congenita MODY 1 Familial partial lipodystrophy 3 SF1 XY gonadal dysgenesis

2.2	Barakat syndrome Tricho–rhino–phalangeal syndrome

2.3	Greig cephalopolysyndactyly syndrome/Pallister–Hall syndrome Denys–Drash syndrome Duane-radial ray syndrome MODY 7 MRX 89 Townes–Brocks syndrome Acrocallosal syndrome Myotonic dystrophy 2

2.5	Autoimmune polyendocrine syndrome type 1

(3) Helix-turn-helix domains

3.1	ARX Ohtahara syndrome Lissencephaly X2 MNX1 Currarino syndrome HOXD13 SPD1 Synpolydactyly PDX1 MODY 4 LMX1B Nail–patella syndrome MSX1 Tooth and nail syndrome OFC5 PITX2 Axenfeld syndrome 1 POU4F3 DFNA15 POU3F4 DFNX2 ZEB1 Posterior polymorphous corneal dystrophy Fuchs' dystrophy 3 ZEB2 Mowat–Wilson syndrome

3.2	PAX2 Papillorenal syndrome PAX3 Waardenburg syndrome 1&3 PAX4 MODY 9 PAX6 Gillespie syndrome Coloboma of optic nerve PAX8 Congenital hypothyroidism 2 PAX9 STHAG3

3.3	FOXC1 Axenfeld syndrome 3 Iridogoniodysgenesis, dominant type FOXC2 Lymphedema–distichiasis syndrome FOXE1 Bamforth–Lazarus syndrome FOXE3 Anterior segment mesenchymal dysgenesis FOXF1 ACD/MPV FOXI1 Enlarged vestibular aqueduct FOXL2 Premature ovarian failure 3 FOXP3 IPEX

3.5	IRF6 Van der Woude syndrome Popliteal pterygium syndrome

(4) β-Scaffold factors
with minor groove contacts

4.2	Hyperimmunoglobulin E syndrome

4.3	Holt–Oram syndrome Li–Fraumeni syndrome Ulnar–mammary syndrome

4.7	Campomelic dysplasia MODY 3 MODY 5 SF1 SRY XY gonadal dysgenesis Premature ovarian failure 7 SOX10 Waardenburg syndrome 4c Yemenite deaf-blind hypopigmentation syndrome

4.11	Cleidocranial dysostosis

(0) Other transcription factors

0.6	Kabuki syndrome

Ungrouped

Transcription coregulators

Coactivator:	CREBBP Rubinstein–Taybi syndrome

Corepressor:	HR (Atrichia with papular lesions)

Cell surface receptor deficiencies

G protein-coupled receptor
(including hormone)

Class A	TSHR (Congenital hypothyroidism 1) LHCGR (Luteinizing hormone insensitivity, Leydig cell hypoplasia, Male-limited precocious puberty) FSHR (Follicle-stimulating hormone insensitivity, XX gonadal dysgenesis) GnRHR (Gonadotropin-releasing hormone insensitivity) EDNRB (ABCD syndrome, Waardenburg syndrome 4a, Hirschsprung's disease 2) AVPR2 (Nephrogenic diabetes insipidus 1) PTGER2 (Aspirin-induced asthma)

Class B	PTH1R (Jansen's metaphyseal chondrodysplasia)

Class C	CASR (Familial hypocalciuric hypercalcemia)

Class F	FZD4 (Familial exudative vitreoretinopathy 1)

Enzyme-linked receptor
(including
growth factor)

RTK	ROR2 (Robinow syndrome) FGFR1 (Pfeiffer syndrome, KAL2 Kallmann syndrome) FGFR2 (Apert syndrome, Antley–Bixler syndrome, Pfeiffer syndrome, Crouzon syndrome, Jackson–Weiss syndrome) FGFR3 (Achondroplasia, Hypochondroplasia, Thanatophoric dysplasia, Muenke syndrome) INSR (Donohue syndrome Rabson–Mendenhall syndrome) NTRK1 (Congenital insensitivity to pain with anhidrosis) KIT (KIT Piebaldism, Gastrointestinal stromal tumor)

STPK	AMHR2 (Persistent Müllerian duct syndrome II) TGF beta receptors: Endoglin/Alk-1/SMAD4 (Hereditary hemorrhagic telangiectasia) TGFBR1/TGFBR2 (Loeys–Dietz syndrome)

GC	GUCY2D (Leber's congenital amaurosis 1)

JAK-STAT

MPL (Congenital amegakaryocytic thrombocytopenia)

TNF receptor

TNFRSF1A (TNF receptor associated periodic syndrome)
TNFRSF13B (Selective immunoglobulin A deficiency 2)
TNFRSF5 (Hyper-IgM syndrome type 3)
TNFRSF13C (CVID4)
TNFRSF13B (CVID2)
TNFRSF6 (Autoimmune lymphoproliferative syndrome 1A)

Lipid receptor

LRP: LRP2 (Donnai–Barrow syndrome)
LRP4 (Cenani–Lenz syndactylism)
LRP5 (Worth syndrome, Familial exudative vitreoretinopathy 4, Osteopetrosis 1)

LDLR (LDLR Familial hypercholesterolemia)

Other/ungrouped

Immunoglobulin superfamily: AGM3, 6

EDAR (EDAR hypohidrotic ectodermal dysplasia)

See also: cell surface receptors

Extracellular ligand disorders

Cytokine	EDA Hypohidrotic ectodermal dysplasia Camurati–Engelmann disease

Ephrin	Craniofrontonasal dysplasia

WNT	Tetra-amelia syndrome

TGF	OFC 11

Fas ligand	Autoimmune lymphoproliferative syndrome 1B

Endothelin	EDN3 Waardenburg syndrome IVb Hirschsprung's disease 4

Other	DHH (DHH XY gonadal dysgenesis) BMP15 (Premature ovarian failure 4) TSHB (Congenital hypothyroidism 4) See also intercellular signaling peptides and proteins

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