1. RESEARCH LETTER
Concomitant 11p15.4-p15.5 Duplication and
Terminal 22q13.33 Deletion in a Patient with
Features of Beckwith–Wiedemann Syndrome
Jess F. Peterson,1,2
* David P. Bick,3,4
Gabrielle C. Geddes,3
Julie McCarrier,3
John W. Grignon Jr,2
Brett Chirempes,4
Ulrich Broeckel,3,5
Fatima Abidi,6
Richard C. Rogers,6
Luigi Boccuto,6
Barbara DuPont,6
and Peter vanTuinen1,2
1
Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
2
Wisconsin Diagnostic Laboratories, Milwaukee, Wisconsin
3
Department of Pediatrics, Section of Genetics, Medical College of Wisconsin, Milwaukee, Wisconsin
4
Advanced Genomics Laboratory, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
5
Department of Pediatrics, Section of Genomic Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
6
Greenwood Genetic Center, Greenwood, South Carolina
Manuscript Received: 24 April 2016; Manuscript Accepted: 10 August 2016
TO THE EDITOR:
Beckwith–Wiedemann syndrome (BWS, OMIM 130650) is a
clinically heterogeneous pediatric overgrowth disorder that can
be attributed to various molecular etiologies [Choufani et al.,
2013; Mussa et al., 2015]. Clinical features of BWS can include
macroglossia, organomegaly, omphalocele, earlobe creases and
pits, and symmetric or asymmetric growth that continues
throughout childhood [Choufani et al., 2013; Mussa et al.,
2016]. Importantly, children with BWS have an increased risk
for embryonal tumors, including Wilms tumor, hepatoblastoma,
neuroblastoma, rhabdomyosarcoma, and adrenocortical carci-
noma [Choufani et al., 2013; Mussa et al., 2016]. While 98–99%
of BWS cases result from the unbalanced expression of imprinted
genes on the 11p15.5 region due to point mutations, epigenetic
or genomic alterations, approximately 1–2% are due to cyto-
genetic rearrangements [Choufani et al., 2013; Mussa et al.,
2015].
Deletions involving the chromosome region 22q13.33, also
known as Phelan–McDermid syndrome (PMS, OMIM 606232),
are the result of either de novo terminal or interstitial deletions, or
less commonly by unbalanced chromosomal rearrangements in-
volving 22q13.33 [Wilson et al., 2003; Dhar et al., 2010; Misceo
et al., 2011; Phelan and McDermid, 2012; Macedoni-Luksic et al.,
2013]. Clinical features of PMS are highly variable and can include
global developmental delay, intellectual impairment, hypotonia,
severely delayed or absent speech, autism, or autistic-like behavior,
and seizures [Phelan and McDermid, 2012]. The PMS proposed
critical region (22q13.33) includes SHANK3, ACR, and RABL2,
although many other genes in larger deletions may have a pheno-
typic role. Recently, several studies have narrowed the PMS critical
region to the SHANK3 gene [Dhar et al., 2010; Macedoni-Luksic
et al., 2013], which also appears to be the most likely candidate for
neurological impairments [Luciani et al., 2003; Wilson et al., 2003;
Phelan and McDermid, 2012].
We report a 6-week-old Caucasian female with a complex
karyotype involving rearrangements between chromosomes 11,
22, and an unknown acrocentric chromosome resulting in an
11p15.4-p15.5 duplication, terminal 22q13.33 deletion, and
marker chromosome. While the 11p15.4-p15.5 duplication is
located on the distal long arm of a bisatellited chromosome 22,
the marker chromosome is thought to be a remnant of the
unknown acrocentric chromosome. To our knowledge, this is
Conflicts of interest: The authors have no conflict of interest to declare.
Ã
Correspondence to:
Jess F. Peterson, M.D., Department of Pathology, Medical College of
Wisconsin, Froedtert/MCW Laboratory Building, 9200 W Wisconsin
Ave, Milwaukee, WI 53226. E-mail: jepeterson@mcw.edu
Article first published online in Wiley Online Library
(wileyonlinelibrary.com): 23 August 2016
DOI 10.1002/ajmg.a.37939
How to Cite this Article:
Peterson JF, Bick DP, Geddes GC,
McCarrier J, Grignon JW Jr, Chirempes B,
Broeckel U, Abidi F, Rogers RC, Boccuto L,
DuPont B, vanTuinen P. 2016.
Concomitant 11p15.4-p15.5 duplication
and terminal 22q13.33 deletion in a patient
with features of Beckwith–Wiedemann
syndrome.
Am J Med Genet Part A 170A:3348–3351.
Ó 2016 Wiley Periodicals, Inc. 3348

2. the first clinical report of a patient with cytogenetic abnormalities
consistent with BWS (11p15.4-p15.5 duplication) and a terminal
22q13.33 deletion partially disrupting the SHANK3 gene.
The patient was referred to the pediatric genetics clinic due to
macrosomia and congenital macroglossia. She was born to a
31-year-old, G2P2002 mother and a 28-year-old father. Following
an uncomplicated vaginal delivery at 40 weeks gestation, neonatal
complications included hypoglycemia (35 mg/dl). Her birth weight
was 5.67 kg (98.68% based on WHO weight-for-age data), length
was 59.7 cm (99.35% based on WHO length-for-age data), and
head circumference was 43 cm (99.98% based on WHO head
circumference-for-age data). A complete physical exam was per-
formed and revealed the following clinically significant features:
broad nasal bridge, macroglossia, hepatomegaly (3–4 cm below the
costal margin), and central hypotonia with increased tone in the
periphery (Fig. 1A and B). An abdominal ultrasound was per-
formed at an outside hospital and reported normal abdominal
structures with no evidence of suprarenal mass. Family history
includes an older sister and parents who are all phenotypically
normal and of normal intelligence. There is no family history
of birth defects, learning disabilities, genetic diseases, recurrent
miscarriage, or consanguinity.
Classical cytogenetic analysis was performed on phytohemag-
glutinin (PHA) stimulated lymphocytes from a peripheral blood
specimen. All 20 cells indicated a female with a bisatellited chro-
mosome 22. In addition, 13 of the 20 cells contained a small marker
chromosome (Fig. 1C). Fluorescence in situ hybridization (FISH)
was performed on metaphase cells that contained the bisatellited
chromosome 22 and marker chromosome using the BAC probe
RP11-27N2 (Empire Genomics, Buffalo, NY), located within
the duplicated region of 11p15.4-p15.5. Hybridization of the
RP11-27N2 probe was observed on the short arms of both copies
of chromosome 11, in addition to the bisatellited chromosome 22
(Fig. 1D). Hybridization of RP11-27N2 was not observed on the
marker chromosome.
Array comparative genomic hybridization (aCGH) analysis was
performed on purified DNA from the proband using the CytoScan
HD microarray (Affymetrix, Santa Clara, CA), and scanned with a
FIG. 1. (A and B) Proband at 6-weeks of age. Note the broad nasal bridge, macroglossia, and enlarged abdomen. (C) Representative
metaphase cell from a peripheral blood specimen. Arrows point to both normal copies of chromosome 11, one normal copy of chromosome 22,
a bisatellited chromosome 22, and a marker chromosome. (D) Sequential FISH analysis of the representative metaphase cell (see C) using a
locus-specific probe (RP11-27N2) targeting chromosomal region 11p15.4-p15.5. Positive hybridization (arrows) was observed on both copies
of chromosome 11 in addition to the bisatellited chromosome 22. The marker chromosome (see C) is thought to be a remnant of an unknown
acrocentric chromosome. (Color figure can be seen in the online version of this article, available at http://wileyonlinelibrary.com/journal/
ajmga).
PETERSON ET AL. 3349

3. Genechip Scanner 3000 (Affymetrix). Microarray analysis revealed
a concomitant 10.3 Mb duplication in the 11p15.4-p15.5 region,
(Fig. 2A) and a 53 kb heterozygous deletion in the 22q13.33 region
(Fig. 2B). The 11p15.4-p15.5 duplication region contained a total
of 380 genes including 143 OMIM genes, and the 22q13.33 deletion
region contained a total of five genes including two OMIM genes,
SHANK3 and ACR. In addition, a methylation-specific multiplex
ligation-dependent probe amplification assay (MS-MLPA) (MRC-
Holland) was utilized to determine the methylation status of
imprinting control regions 1 and 2 (ICR1 and ICR2). The assay
confirmed the duplication between probes H19-5 and CDKN1C-1b
[HHA1] on chromosome 11p15.4-p15.5, and showed hyperme-
thylation of ICR1 and hypomethylation of ICR2, a pattern consis-
tent with a double paternal copy of the 11p15.4–15.5 region
resulting in BWS. Pyrosequencing was subsequently performed
and confirmed these results.
To confirm the partial SHANK3 deletion, purified DNA from
the proband was analyzed at an outside institution (Greenwood
Genetic Center, Greenwood, SC) using a custom exon-specific
array (Agilent Technologies, Santa Clara, CA) and scanned with a
SureScan Microarray Scanner (Agilent Technologies). Microarray
analysis revealed a partial SHANK3 deletion spanning exons 17–22
located within the 22q13.33 region (Fig. 2C). Importantly, the
exon-specific array includes SHANK3 but no other genes within
the terminal region of 22q13.3. The final karyotype of the
proband was: mos 47,XX,22qs,þmar[13]/46,XX,22qs[7].ish(22qs)
(RP11-27N2 þ).arr[hg19] 11p15.5p15.4(230,615–10,552,968)
x3,22q13.33(51,144,903–51,197,716)x1. Parental genetic studies
included classical cytogenetic analysis. Both parents had normal
karyotypes and were not carriers of a balanced translocation or
marker chromosome.
Beckwith–Wiedemann and Phelan–McDermid syndromes are
both rare with an estimated prevalence of 1/13,700 for BWS
[Choufani et al., 2013], and while the incidence of PMS has not
been determined, approximately 1,200 cases have been diagnosed
world-wide [Kolevzon et al., 2014]. While multiple molecular
etiologies resulting in BWS have been described, the majority of
which involve epigenomic or genomic alterations of genes within
imprinting control centers 1 (IC1) or 2 (IC2), approximately 1–2%
of cases are attributed to 11p15.5 duplications [Choufani et al.,
2013; Mussa et al., 2016]. The diagnosis of BWS has tremendous
clinical significance as these patients have an increased risk of
FIG. 2. (A) Array CGH profile showing a 10.3 Mb duplication of 11p15.4-p15.5 region. (B) Array CGH profile showing a 53 kb terminal deletion
of 22q13.33 regions. (C) Custom exon-specific array results demonstrating a partial SHANK3 deletion spanning exons 17–22. (Color figure can
be seen in the online version of this article, available at http://wileyonlinelibrary.com/journal/ajmga).
3350 AMERICAN JOURNAL OF MEDICAL GENETICS PART A

4. embryonal tumors that require early tumor surveillance protocols
[Mussa et al., 2016]. Deletions spanning the 22q13.33 region that
include the SHANK3, ACR, and RABL2 genes result in PMS
[Luciani et al., 2003; Wilson et al., 2003]. In addition, intragenic
SHANK3 deletions have also been reported to produce the full
clinical spectrum of PMS [Misceo et al., 2011; Macedoni-Luksic
et al., 2013]. The prompt diagnosis of PMS is also of importance, as
screening protocols for hypothyroidism, hearing impairment,
arachnoid cysts, and renal anomalies are recommended [Phelan
and McDermid, 2012].
Our case is unique in that, it is the first reported concomitant
11p15.4-p15.5duplicationand22q13.33deletionthatlikelyresulted
from a complex chromosomal rearrangement involving chromo-
somes 11, 22, and an unknown acrocentric chromosome. Our
patient presented with the typical neonatal findings of BWS. The
clinical significance of the 22q13.33 rearrangement will not be
known until later since most of the common phenotypic features
associated with PMS, such as periorbital fullness, hypohidrosis and
heat intolerance, dysplastic nails, intellectual disability, autism, and
seizures present in early childhood. The only identifiable feature of
PMS presented by the patient at the time of the evaluation is central
hypotonia, although this is usually more severe in typical cases with
22q13.33 deletions and it persists in adulthood, unlike in BWS. In
addition, the molecular abnormalities are also rare for each respec-
tive syndrome (11p15 duplication for BWS, unbalanced chromo-
somal rearrangement for PMS). Furthermore, this case illustrates
that a multifaceted approach may be necessary to resolve complex
chromosomal rearrangements in constitutional disorders.
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