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Isolated congenital anosmia (MIM 107200) is a very rare condition characterised by a complete smelling defect that is present from birth in otherwise normal subjects. To our knowledge, nine sporadic cases of isolated congenital anosmia have been known,1,2 and patients reported by Lygonis3 and those by us4 were only familial isolated congenital anosmia. Other cases of familial congenital anosmia had some additional manifestations5–9 or had Kallmann syndrome. The defective smelling in isolated congenital anosmia may be attributed to the absence of olfactory function—that is, either replacement of the olfactory epithelium by respiratory epithelium,2 or aplasia of the olfactory bulbs, sulci, and tract.1 Diagnosis of isolated congenital anosmia is made by one or more of history, physical examinations, a standardised smelling test, computed tomography, magnetic resonance imaging, and biopsy of the nasal mucous tissue. Patients with isolated congenital anosmia had been unable to smell as back as they could remember, and had no history of other causes of anosmia, such as significant head trauma, neoplasm involving the olfactory system, or upper respiratory infection leading to damage of the olfactory epithelium. Physical examinations are useful to exclude an association of anosmia with other symptoms and to exclude secondary anosmia. A standardised smelling test confirms complete olfactory dysfunction. Computed tomography and magnetic resonance imaging may disclose other anomalies of the central nervous system, and biopsy may show abnormal replacement of the olfactory epithelium. An autosomal dominant mode of inheritance was suggested in a family reported by Lygonis3 and two families by us.4 However, nothing has been known for the disease gene localisation. Here we report the result of a genome-wide linkage analysis of the two unrelated Iranian families.
MATERIALS AND METHODS
Families and patients
Two unrelated Iranian families with isolated congenital anosmia (families 1 and 2), reported previously,4 were analysed in the present study. Family 1 consisted of three affected members in three generations, and family 2 contained nine patients in two generations. A total of 54 members of the two families agreed to participate in the present study with written informed consent. Of the 54 members, seven were diagnosed as having isolated congenital anosmia (fig 1). By clinical history, physical examination, and smelling testing by intravenous injection of combined vitamins (Alinamin™, Takeda Pharmaceutical Co Ltd, Japan), the disease was confirmed in each affected member. All affected people had a history of never being able to smell, and had never had hypogonadism signs, nasal polyposis, rhinoscleroma, or any underlying infections or other neurological disorders. Clinical manifestations of deceased persons (I-1 in family 1, and I-2, I-10, and II-13 in family 2) were presumed by their relatives’ recollection.
Isolated congenital anosmia is a condition characterised by lifelong inability to smell in otherwise normal individuals.
We performed a genome-wide linkage analysis of two unrelated Iranian families in which a total of 54 members were available for this study and seven of them had isolated congenital anosmia.
In both families, the isolated congenital anosmia trait appeared to be inherited as an autosomal dominant fashion with incomplete penetrance.
Two point linkage analysis revealed a maximum lod score of 5.14 (recombination fraction θ = 0.00) at penetrance of 0.8 for the D18S1108 microsatellite marker locus.
Haplotype analysis revealed that all the affected individuals shared each common haplotype for each family between D18S452 and D18S475 at the 18p11.23-q12.2 region.
Although all exon and exon-intron boundaries of eight candidate genes, GNAL, VAPA, PTPRM, PTPN2, CABYR, RNMT, CDH2, and NOL4, mapped within the region, were sequenced, no mutations were found in any affected family members.
Genotyping, linkage analysis, and sequencing
Genomic DNA was extracted from whole blood of the 54 family members, and PCR was performed using standard methods. The amplified samples were genotyped at 400 microsatellite marker loci with an average distance of 10 cM in the genome (Linkage Mapping Set version 2 (LMS-MD10, Applied Biosystems, Foster City, CA) on a DNA sequencer (Model 377, Applied Biosystems), and marker alleles were assigned using software, Genescan™ and Genotyper™ (Applied Biosystems). When data assigned to a chromosomal region were obtained, additional markers around the critical region were used to confirm a linkage and narrow the region (fig 1).
Two point linkage analysis was performed under an assumption that isolated congenital anosmia in the two families is inherited in an autosomal dominant fashion with incomplete penetrance. Lod scores were calculated separately in each family, at the same penetrance, using the computer program MLINK of FASTLINK version 4.1P.10–12 Allele frequencies at the 400 marker loci were set as 1/N (where N is the observed number of alleles), while those at seven loci (D18S452, D18S53, D18S66, D18S1108, D18S56, D18S1133, and D18S1128) around the critical region were calculated among 40 chromosomes from unrelated healthy Iranian individuals.
Eight genes or expressed sequence tags of interest; GNAL, VAPA, PTPRM, PTPN2, CABYR, RNMT, CDH2, and NOL4, were analysed for their sequences, to see whether affected members in the families had mutations in them. All their exons and exon-intron boundaries were amplified by PCR. PCR products were sequenced directly using BigDye™ Terminator ver. 3.0 Cycle Sequencing kit (Perkin-Elmer, Foster, CA, USA), and samples were run on an automated sequencer model 3100 (Applied Biosystems).
The genome-wide linkage analysis first ruled out the loci for Kallmann syndrome types 1 and 2 (Xp22.3 for KAL1 and 8p11.2-p11.1 for KAL2) from the candidacy for the anosmia locus in the two families. The other locus, KAL3, was also ruled out normally because of its X-linked inheritance. A high two point lod score of 3.03 was obtained at the D18S53 locus on chromosome 18. Extensive linkage analysis to define the critical region using 52 additional markers flanking D18S53 finally reached the maximum lod score of 5.14 (1.85 for family 1, and 3.29 for family 2) at D18S1108, when penetrance was set at 0.8 for both families, and the recombination fraction to be 0.00 (table 1). Haplotype analysis demonstrated that affected members in each family each had a common haplotype including alleles at 35 marker loci between D18S452 and D18S475 (fig 1). A recombination between D18S452 and D18S1163 or between D18S464 and D18S1153 was observed in a patient (IV-12) of family 1 (fig 1). However, as only two markers have been known between D18S452 and D18S1153, more precise identification of recombination sites was not possible in this patient. Two recombination events were observed in a patient (II-8) of family 2, one between D18S452 and D18S1163, and the other between D18S57 (or D18S1128) and D18S475. These findings indicated that the isolated congenital anosmia locus lies in a 45.9 cM segment between D18S452 and D18S475 at 18p11.23-q12.2. The sequence analysis of the eight genes or expressed sequence tags revealed no mutation in any affected members of the two families.
Isolated congenital anosmia in our two families is compatible with an autosomal dominant pattern of inheritance with incomplete penetrance. Individuals II-5 in family 1, III-28 and III-37 in family 2 are definite non-penetrants, who inherited the disease-associated haplotype but had a normal sense of smell, as determined both by past medical history and a smelling test. The isolated congenital anosmia gene was transmitted by one of them (II-5 in family 1) to his affected son (III-16), but the other two non-penetrants did not have any children. Five unaffected members (III-4 and III-14 in family 1, and III-16, III-22, and III-27, in family 2) inherited a part of the critical haplotype (fig 1). However, it remains unknown who are non-penetrants or normal individuals, because none had any affected children. Inheritance patterns in family 2 appeared unusual; especially those in its third generation in which none of a total of 25 children of patients were affected (fig 1). This seemingly strange observation may be explained by incomplete penetrance, or just by chance as suggested in our previous report,4 or the existence of a modifier gene.
We have assigned the isolated congenital anosmia locus in the two families to the 45.9 cM interval between D18S452 and D18S47 at 18p11.23-q12.2. However, this interval is the maximum extent estimated under an assumption that all the seven unaffected members carrying the critical haplotype were non-penetrants or carriers. The interval might be reduced to 31.2 cM, if the recombination in IV-12 of family 1 had occurred between D18S464 and D18S1153 (fig 1). Among several genes and expressed sequence tags that are expressed in the central nervous system and have been assigned within the isolated congenital anosmia region, the GNAL (or the G protein α subunit, G (olf)) gene (guanine nucleotide binding protein, α activating activity polypeptide, olfactory type) located between D18S53 and D18S71 is one of the most interesting candidate genes for isolated congenital anosmia, since mice homozygous for a null mutation in Gnal are anosmic, showing reduced electrophysiological response of the primary olfactory sensory neurones to odours.13 However, by our preliminary study of affected members of the two families, no mutation has been found in this gene, or in seven other genes, VAPA, PTPRM, PTPN2, CABYR, RNMT, CDH2, and NOL.4, all located within the critical region.
The sense of smell is one of the first developed special sense organs in animals14 and plays a role in feeding, differentiation of a parent from others, and in reproductive behaviour.15 Male mice do not show mating behaviours or sexual development when their olfactory bulbs are removed shortly after birth.16,17 The role of the human olfactory system in reproduction and sexual development is supported by clinical features of Kallmann syndrome in which congenital anosmia is associated with hypogonadotropic hypogonadism. The existence of familial isolated congenital anosmia with a normal reproductive system, as has been shown in affected members of our families, may indicate the independent migration of the olfactory system from the LH-RH cells, and suggest that other factors may influence the relationship between the reproductive and olfactory systems. Isolation of the putative isolated congenital anosmia gene and its functional analysis will contribute to the better understanding of the development of the olfactory system.
We are indebted to the family members for their participation in this research. We also thank Dr Arthur L Beaudet at Baylor College of Medicine for his critical review of the manuscript and Miss Naoko Yanai at the Department of Human Genetics, Nagasaki University Graduate School of Biomedical Sciences for her great assistance.
NN was supported in part by a Grant-in-Aid for Scientific Research (Category S, No 13854024) from the Ministry of Education, Sports, Culture, Science, and Technology of Japan, and by CREST from the Japan Science and Technology Agency (JST).
Conflicts of interest: none declared.