HUMAN M UTATION
M UTATION IN BRIEF
HUMAN MUTATION Mutation in Brief #1066, 30:E673-681 (2009) Online
Phenotypic Spectrum of STRA6 Mutations: from
Matthew-Wood Syndrome to Non-lethal
Nicolas Chassaing1,2,3, Christelle Golzio4,5, Sylvie Odent6, Léopoldine Lequeux3, Adeline Vigouroux3,
Jelena Martinovic-Bouriel7, Francesco Danilo Tiziano8, Lucia Masini9, Francesca Piro10, Giovanna Maragliano11,
Anne-Lise Delezoide12, Tania Attié-Bitach4,5,7, Sylvie Manouvrier-Hanu13, Heather C. Etchevers1,4,
and Patrick Calvas1,2,3*
1 INSERM, U563, Centre de Physiopathologie de Toulouse Purpan, Toulouse, 31300 France; 2 Université Toulouse III Paul-
Sabatier, Toulouse, 31400 France; 3 CHU Toulouse, Hôpital Purpan, Service de Génétique Médicale, Toulouse, 31300 France;
4 INSERM, U781, Hôpital Necker-Enfants Malades, Paris Cedex 15, 75743 France; 5 Université Paris Descartes, Hôpital
Necker-Enfants Malades, Paris, 75743 France; 6 CHU Rennes, Hôpital Sud, Service de Génétique Médicale, Rennes, 35203
France; 7 Départem ent de Génétique, Hôpital Necker-Enfants Malades, Paris Cedex 15, 75743 France
8 Institute of Medical Genetics, Catholic University, Rom e, Italy; 9 Institute of Obstetrics and Gynecology, Catholic University,
Rom e, Italy; 10 Operative Unit of Pathology, S. Giovanni Hospital, Rom e, Italy; 11 Com plex Unit of Neonatology, S. Giovanni
Hospital, Rom e, Italy; 12 GHU Nord, Hôpital Robert Debré, Service de Biologie du Développem ent, Paris Cedex 19, 75935
France; 13 CHRU Lille, Hôpital Jeanne de Flandre, Service de Génétique Clinique, Lille Cedex, 59037 France
* Correspondence to Pr Patrick Calvas, Service de Génétique Médicale, Pavillon Lefebvre, CHU Purpan, Place du Dr Baylac,
31059 Toulouse Cedex 9, France.
Tel.: +33 5 61 77 90 79; fax: +33 5 62 74 45 58.
E-m ail : email@example.com
Com m unicated by Mark H. Paalm an
ABSTRACT: Matthew-Wood, Spear, PDAC or MCOPS9 syndrome are alternative names used to
refer to combinations of microphthalmia/anophthalmia, malformative cardiac defects, pulmonary
dysgenesis, and diaphragmatic hernia. Recently, mutations in STRA6, encoding a membrane
receptor for vitamin A-bearing plasma retinol binding protein, have been identified in such
patients. We performed STRA6 molecular analysis in three fetuses and one child diagnosed with
Matthew-Wood syndrome and in three siblings where two adult living brothers are affected with
combinations of clinical anophthalmia, tetralogy of Fallot, and mental retardation. Among these
patients, six novel mutations were identified, bringing the current total of known STRA6 mutations
to seventeen. We extensively reviewed clinical data pertaining to all twenty-one reported patients
with STRA6 mutations (the seven of this report and fourteen described elsewhere) and discuss
additional features that may be part of the syndrome. The clinical spectrum associated with STRA6
deficiency is even more variable than initially described. ©2009 Wiley-Liss, Inc.
KEY WORDS: STRA6, anophthalmia, Matthew-Wood syndrome, PDAC syndrome, MCOPS9
© 2009 WILEY-LISS, INC.
Received 11 Decem ber 2008; accepted revised m anuscript 24 February 2009.
E674 Chassaing et al.
Variable combinations of microphthalmia/anophthalmia, pulmonary agenesis/dysplasia, diaphragmatic hernia
and malformative cardiac defects have been infrequently reported over the last three decades (Ostor et al., 1978;
Spear et al., 1987; Smith et al., 1994; Seller et al., 1996; Berkenstadt et al., 1999; Priolo et al., 2004; Lee et al.,
2006; Li and Wei, 2006; Chitayat et al., 2007; Golzio et al., 2007; Pasutto et al., 2007). Such associations have
been called Matthew-Wood or Spear syndrome, while Chitayat et al. (2007) devised the acronym PDAC
(Pulmonary hypoplasia/agenesis, Diaphragmatic hernia/eventration, Anophthalmia/microphthalmia and Cardiac
Defect), and the Mendelian Inheritance in Man database has adopted the term MCOPS9 for “syndromic
microphthalmia 9” (MIM# 601186). Recently, mutations in STRA6 (MIM# 610745), encoding a membrane
receptor for the vitamin A-bearing plasma retinol binding protein, have been found in patients with malformations
in the PDAC spectrum (Golzio et al., 2007; Pasutto et al., 2007; White et al., 2008; West et al., 2009).
We report herein novel STRA6 mutations in three fetuses and one child diagnosed with Matthew-Wood
syndrome, and in three siblings where two adult living brothers are affected with combinations of clinical
anophthalmia, tetralogy of Fallot, and mental retardation. This is the first description of adult patients bearing
STRA6 mutations. These additional cases emphasize that the clinical spectrum associated with STRA6 mutations is
PATIENTS AND METHODS
This male fetus from healthy and unrelated parents was delivered at 23 weeks of gestation after an ultrasound
scan documented bilateral diaphragmatic hernia, anophthalmia and cardiopathy. Autopsy confirmed the presence
of bilateral severe microphthalmia (Fig 1A), bilateral diaphragmatic hernia, and a complex heart malformation
(hypoplastic left heart syndrome with common atrium and dextroposition of the aorta). The lungs were hypoplastic
and dysplastic. The karyotype was 46, XY.
This patient has previously been described (Chitayat et al., 2007; patient 7). Briefly, she was the fifth child of
consanguineous parents, born at term after a normal pregnancy, with normal growth parameters. She displayed an
association of bilateral anophthalmia (Fig 1B), heart malformation, subglottic laryngeal stenosis, bilateral unilobar
lungs, hypoplastic left kidney and right vesico-ureteral reflux, supernumerary spleen and hypoplastic uterus. Her
karyotype was 46, XX. She died at 19 months post-operatively for an unknown reason, after surgery was
performed to expand ocular orbits.
Family 3 (Cases 3-1, 3-2, 3-3)
A 40 year old patient was referred after his healthy sister came in for genetic counseling. He is the first child of
healthy and unrelated parents. He has moderate mental retardation associated with bilateral anophthalmia and
tetralogy of Fallot. Facial dysmorphy includes very short palpebral fissures and closed eyelids, a thin nasal bridge
and broad nasal tip (Fig 1C). The hands are small and broad. His height is 160 cm (-2.25 SD) and his karyotype is
A sister of case 3-1 died in the first days of life from a tetralogy of Fallot. She reportedly had bilateral clinical
anophthalmia but did not undergo autopsy.
Expanding the Clinical Spectrum of STRA6 Mutations E675
The adult brother of cases 3-1 and 3-2 is more severely mentally retarded than case 3-1, associated with autistic
features. Cerebral CT scan demonstrates small residual ocular structures and presence of optic nerves, thus
indicating an extreme bilateral microphthalmia. Cardiac examination shows no malformations. Radiological
findings show decreased bone mineral density and a spina bifida occulta at L5-S1.
Family 4 (cases 4-1 and 4-2)
This was the third child of consanguineous parents. At 26 weeks of pregnancy, micro/anophthalmia, congenital
heart disease and diaphragmatic hernia were diagnosed by ultrasound. Karyotype analysis was performed fetal
blood sample (46,XY). At 38 weeks, an elective cesarean section was performed. The child died soon after birth
due to respiratory insufficiency. At autopsy, the following observations were made: anophthalmia (absent globes
but presence of optic nerves), left diaphragmatic hernia with partial herniation of stomach into thorax, a complex
congenital heart malformation characterized by truncus arteriosus (absence of truncal septum, single valvular
orifice and short common tract). Liver, pancreas, and gut were normal both macroscopically and histologically.
Brother of case 4-1. At 26 weeks of gestation, ultrasound revealed suspicion of anophthalmia, hypoplastic left
lung and complex congenital heart disease (left rotation of cardiac axis, and thickened wall of the right heart),
suggesting the recurrence of a clinical phenotype strikingly similar to the previous pregnancy. The child died soon
after birth, again due to respiratory insufficiency. Clinical anophthalmia (Fig 1D) and hypoplastic left lung was
confirmed. Echocardiography showed left rotation of the cardiac axis secondary to lung hypoplasia, but without
Figure 1. Representative oculofacial phenotypes. A: Case 1 had short palpebral fissures reflecting bilateral severe
microphthalmia. B: Case 2 presented deep-set orbits, narrow palpebral fissures associated with anophthalmia and wide, diffuse
implantation of eyebrows. C: Case 3-1 has mild facial dysmorphy with a broad nasal tip. This patient has orbital implants. D:
Case 4-2 also had a broad nasal bridge and the deep-set orbits associated with clinical anophthalmia.
E676 Chassaing et al.
STRA6 molecular analysis
After informed consent for inclusion in the study was obtained from the parents, DNA was isolated by standard
procedures from paraffin-embedded blocks of case 1, from frozen tissue samples of case 2, and from peripheral
blood of cases 3-1, 3-3, 4-2 and their unaffected parents and siblings. STRA6 noncoding and coding exons and
exon-intron junctions were amplified by PCR using previously published primers (Golzio et al., 2007).
PCR fragments were subsequently purified with QIAquick Gel Extraction kits (QIAGEN SA France), and
sequenced using the Big Dye DNA sequencing kit (Applied Biosystems, UK). Reactions were analyzed in an
ABI3100 sequencer (Applied Biosystems, UK).
A sequence variant was considered as disease-causing when: (1) the variant cosegregated with the disease
phenotype; and (2a) the sequence variant resulted in the prediction of a stop codon, or was predicted to lead to
splice-site alteration (BDGP splice site prediction software); or (2b) the substitution involved an amino acid
conserved between three vertebrate subclasses (ClustalW software) or (2c) the substitution was predicted to be
functionally damaging (PolyPhen software); and (3) the sequence variant was absent from a panel of 200
chromosomes from unaffected, unrelated individuals.
Sequence variations were numbered based on GenBank accession NM_022369.3. Nucleotide numbering
reflects cDNA numbering with +1 corresponding to the A of the ATG translation initiation codon in the reference
sequence, according to journal guidelines (www.hgvs.org/mutnomen). The initiation codon is codon 1.
Table 1. PDAC/MCOPS9 features in STRA6 mutated patients
+ + + + -
+ - + +
- - + + Mental retardation
- - + + -
- - + -
- + + + -
+ - + - -
Expanding the Clinical Spectrum of STRA6 Mutations E677
+ - + +
- - + + -
7 - + + +
- + + - -
+ + + -
Failure to thrive
- - + + -
+ + + - Hydronephrosis
+ - ? + Horseshoe kidney
+ - + +
+ + + +
+ + + -
+ + + +
- - + -
+ + + +
+ : presence ; - : absence ; ?: unknown ;
* These patients had no molecular analysis but their genotype was deduced from that of an affected sib.
Sequence variations were numbered based on GenBank accession NM_022369.3, with +1 corresponding to the A of ATG
translation initiation codon.
E678 Chassaing et al.
RESULTS AND DISCUSSION
STRA6 molecular analysis was performed in cases 1, 2, 3-1, 3-3, and 4-2. Case 1 was compound heterozygous
for a splicing mutation (c.1090+1G>A) and a stop codon (c.859C>T; p.Gln287X), both leading to the prediction of
premature termination of transcription. Case 2 was homozygous for the mutation c.1662delG
(p.Arg555GlufsX16), with a predicted premature stop codon. Case 3-1, like case 3-3, was compound heterozygous
for two missense mutations, c.1313A>G (p.Gln438Arg) and c.1913G>C (p.Arg638Pro). Mutation p.Arg638Pro
was inherited from the mother and p.Gln438Arg was inherited from the father. Both mutations involved a
conserved amino acid (Figure 2), and were predicted in silico to be damaging (Polyphen software). Case 4-2, was
homozygous for the mutation c.1329delC (p.Leu444TrpfsX34) leading to a premature termination of the
translation. The positions of STRA6 mutations described to date are represented on Figure 3.
Figure 2: Alignment of part of human, murine, and avian STRA6
proteins, showing conservation of glutamine 438 and arginine 638
(shaded) in these species.
Figure 3: Locations of the different mutations identified to date. Missense mutations are positioned above the representation of
STRA6 gene, while nonsense and frameshift mutations are positioned underneath. Novel mutations identified in this study are
indicated with an asterisk (*).
To date, no correlations between the nature of a STRA6 mutation and phenotypic severity have been found.
Patients with missense mutations have had severe phenotypes, whereas some patients with truncating mutations
have had milder clinical involvement (Golzio et al., 2007; Pasutto et al., 2007). In previously reported families,
there was little intrafamilial variation in severity (Chitayat et al., 2007; Pasutto et al., 2007). Likewise, in the first
family reported here, all three affected siblings had bilateral severe microphthalmia, while none was described
having diaphragmatic or lung involvement. However, case 3-2 died in the first days of life in the 1970s without
further investigation, and a lung defect or diaphragmatic hernia can not be ruled out. In addition, patients 3-1 and
3-2 had a tetralogy of Fallot while patient 3-3 had no cardiac malformation but rather a neural tube closure defect,
not previously observed in association with PDAC syndrome.
Patients 3-1 and 3-3 are the first adult patients described with STRA6 mutations, although other mutated
children have already been reported (Pasutto et al., 2007; White et al., 2008). It is interesting to note that apart
from clinical anophthalmia, none of the other principal features of PDAC syndrome (diaphragmatic, pulmonary or
Expanding the Clinical Spectrum of STRA6 Mutations E679
cardiac involvement) is systematically present in those patients with STRA6 mutations currently reported.
Including these seven cases, mutations in STRA6 have been observed in 21 phenotypically diverse patients sharing
features of the MCOPS9 syndrome (Golzio et al., 2007; Pasutto et al., 2007; White et al., 2008; West et al., 2009).
Their clinical presentation is summarized in Table 1. Phenotypic variability could be related to vitamin A
metabolic variability (from absorption to degradation) in either fetuses or their pregnant mothers.
Bilateral microphthalmia/anophthalmia was constant and cardiopathy frequent (14/21; 67 %); pulmonary and/or
diaphragmatic involvement were present in about half of the patients. Moreover, additional features appear to be
associated with STRA6 mutations, such as renal abnormalities (6/21), intra-uterine growth retardation (3/21),
uterine malformations (2/21), and spleen and/or pancreatic malformations with attendant duodenal atresia (2/21)
(Martinovic-Bouriel et al., 2007; White et al., 2008; West et al., 2009). Interestingly, mental retardation appears to
be a constant finding in living patients.
Considering this phenotypic variability, it remains difficult to conclude whether Matthew-Wood/Spear/PDAC is
a genetically homogeneous syndrome or an association of distinct syndromes overlapping in their clinical
presentation. Negative molecular analysis for STRA6 mutations in some PDAC patients suggests that this spectrum
of anomalies is probably genetically heterogeneous, even though STRA6 screening may ignore some mutations
(such as exonic rearrangements, splicing mutations distant from the coding sequence, or mutations in regulatory
sequences) (Chitayat et al., 2007; Golzio et al., 2007; Pasutto et al., 2007). STRA6 was recently identified as the
cell membrane receptor for plasma retinol binding protein, which transfers circulating vitamin A from the blood
into target cells (Kawaguchi et al., 2007). All STRA6 mutations associated with human disease to date have been
shown to largely abolish vitamin A uptake activity (Kawaguchi et al., 2008). It therefore remains likely that other
genes implicated in the control of vitamin A intracellular levels during embryonic development are causative in
those MCOPS9 associations not linked to STRA6 mutations. The vitamin A signalling pathway directly regulates
the levels of over 500 target proteins (Blomhoff and Blomhoff, 2006) and its own metabolism, while imperfectly
understood, involves dozens of intracellular enzymes.
Extensive data from teratogenic and genetic animal models, as well as from Donnai-Barrow syndrome (MIM#
222448) patients with LRP2 mutations, confirm the important role of vitamin A in human diaphragm and lung
development (Kluth et al., 1990; Kantarci et al., 2007). Case 3.3, with a minor form of spina bifida, has the first
reported association of STRA6 mutations with a neural tube closure defect, which is a result of vitamin A
metabolite deficiency in mouse models (Kastner et al., 1995). Splenic, pancreatic, intestinal and urogenital
malformations sometimes observed in Matthew-Wood patients, as well as the conotruncal nature of the cardiac
defects, are also effects of lower perceived retinoid levels in the primordia of these organs in embryonic mice
(Kastner et al., 1995).
In conclusion, we report herein five new patients with MCOPS9 syndrome caused by STRA6 mutations. These
data contribute to an expanding database of STRA6 mutations and to the delineation of the phenotypic variability in
patients with such mutations. Further molecular studies on Matthew-Wood/Spear/PDAC/MCOPS9 patients may
identify mutations in other genes implicated in the retinoic acid signaling pathway.
The authors thank Drs. Férechté Encha-Razavi, Louise Devisme and Michel Vekemans for their advice and
Chantal Esculpavit and Sophie Audollent for their technical assistance. Patient recognizable photos were
reproduced with permission from the families, to whom the authors express their gratitude for their participation.
E680 Chassaing et al.
Berkenstadt M, Lev D, Achiron R, Rosner M, Barkai G. 1999. Pulmonary agenesis, microphthalmia, and diaphragmatic defect
(PMD): new syndrome or association? Am J Med Genet 86(1):6-8.
Blomhoff R, Blomhoff HK. 2006. Overview of retinoid metabolism and function. J Neurobiol 66(7):606-30.
Chitayat D, Sroka H, Keating S, Colby RS, Ryan G, Toi A, Blaser S, Viero S, Devisme L, Boute-Benejean O, Manouvrier-
Hanu S, Mortier G, Loeys B, Rauch A, Bitoun P. 2007. The PDAC syndrome (pulmonary hypoplasia/agenesis,
diaphragmatic hernia/eventration, anophthalmia/microphthalmia, and cardiac defect) (Spear syndrome, Matthew-Wood
syndrome): report of eight cases including a living child and further evidence for autosomal recessive inheritance. Am J
Med Genet A 143(12):1268-81.
Golzio C, Martinovic-Bouriel J, Thomas S, Mougou-Zrelli S, Grattagliano-Bessieres B, Bonniere M, Delahaye S, Munnich A,
Encha-Razavi F, Lyonnet S, Vekemans M, Attie-Bitach T etchevers HC. 2007. Matthew-Wood syndrome is caused by
truncating mutations in the retinol-binding protein receptor gene STRA6. Am J Hum Genet 80(6):1179-87.
Kantarci S, Al-Gazali L, Hill RS, Donnai D, Black GC, Bieth E, Chassaing N, Lacombe D, Devriendt K, Teebi A, Loscertales
M, Robson C, Liu T, Maclaughlin DT, Noonan KM, Russell MK, Walsh CA, Donahoe PK, Pober BR. 2007. Mutations in
LRP2, which encodes the multiligand receptor megalin, cause Donnai-Barrow and facio-oculo-acoustico-renal syndromes.
Nat Genet 39(8):957-9.
Kastner P, Mark M, Chambon P. 1995. Nonsteroid nuclear receptors: what are genetic studies telling us about their role in real
life? Cell 83(6):859-69.
Kawaguchi R, Yu J, Honda J, Hu J, Whitelegge J, Ping P, Wiita P, Bok D, Sun H. 2007. A membrane receptor for retinol
binding protein mediates cellular uptake of vitamin A. Science 315(5813):820-5.
Kawaguchi R, Yu J, Wiita P, Honda J, Sun H. 2008. An Essential Ligand-binding Domain in the Membrane Receptor for
Retinol-binding Protein Revealed by Large-scale Mutagenesis and a Human Polymorphism. J Biol Chem 283(22):15160-8.
Kluth D, Kangah R, Reich P, Tenbrinck R, Tibboel D, Lambrecht W. 1990. Nitrofen-induced diaphragmatic hernias in rats: an
animal model. J Pediatr Surg 25(8):850-4.
Lee SYR, Shiu YK, Ng WF, Chow CB. 2006. Another patient with pulmonary hypoplasia, microphthalmia and diaphragmatic
hernia. Clin Dysmorphol 15(1):43-4.
Li L, Wei J. 2006. A newborn with anophthalmia and pulmonary hypoplasia (the Matthew-Wood syndrome). Am J Med Genet
Martinovic-Bouriel J, Bernabe-Dupont C, Golzio C, Grattagliano-Bessieres B, Malan V, Bonniere M, Esculpavit C, Fallet-
Bianco C, Mirlesse V, Le Bidois J, Aubry MC, Vekemans M, Morichon N etchevers H, Attie-Bitach T, Encha-Razavi F,
Benachi A. 2007. Matthew-Wood syndrome: report of two new cases supporting autosomal recessive inheritance and
exclusion of FGF10 and FGFR2. Am J Med Genet A 143(3):219-28.
Ostor AG, Stillwell R, Fortune DW. 1978. Bilateral pulmonary agenesis. Pathology 10(3):243-8.
Pasutto F, Sticht H, Hammersen G, Gillessen-Kaesbach G, Fitzpatrick DR, Nurnberg G, Brasch F, Schirmer-Zimmermann H,
Tolmie JL, Chitayat D, Houge G, Fernandez-Martinez L, Keating S, Mortier G, Hennekam RC, von der Wense A,
Slavotinek A, Meinecke P, Bitoun P, Becker C, Nurnberg P, Reis A, Rauch A. 2007. Mutations in STRA6 cause a broad
spectrum of malformations including anophthalmia, congenital heart defects, diaphragmatic hernia, alveolar capillary
dysplasia, lung hypoplasia, and mental retardation. Am J Hum Genet 80(3):550-60.
Priolo M, Casile G, Lagana C. 2004. Pulmonary agenesis/hypoplasia, microphthalmia, and diaphragmatic defects: report of an
additional case. Clin Dysmorphol 13(1):45-6.
Seller MJ, Davis TB, Fear CN, Flinter FA, Ellis I, Gibson AG. 1996. Two sibs with anophthalmia and pulmonary hypoplasia
(the Matthew-Wood syndrome). Am J Med Genet 62(3):227-29.
Smith SA, Martin KE, Dodd KL, Young ID. 1994. Severe microphthalmia, diaphragmatic hernia and Fallot's tetralogy
associated with a chromosome 1;15 translocation. Clin Dysmorphol 3(4):287-91.
Expanding the Clinical Spectrum of STRA6 Mutations E681 Download full-text
Spear GS, Yetur P, Beyerlein RA. 1987. Bilateral pulmonary agenesis and microphthalmia. Am J Med Genet Suppl 3:379-82.
West B, Bove KE, Slavotinek AM. 2009. Two novel STRA6 mutations in a patient with anophthalmia and diaphragmatic
eventration. Am J Med Genet A.
White T, Lu T, Metlapally R, Katowitz J, Kherani F, Wang TY, Tran-Viet KN, Young TL. 2008. Identification of STRA6 and
SKI sequence variants in patients with anophthalmia/microphthalmia. Mol Vis 14:2458-65.