JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 88 April 1995

The genetic background of anticipation

J R Soc Med 1995;88:185-187

Keywords: genetics; anticipation; triplet repeats; neurological disorders

Anticipation was controversial impairment and increased infant mortality were observed.
Anticipation may be defined as the occurrence of a genetic The sequence of events often ends in congenital MD with its
disorder at progressively earlier ages in successive severe clinical manifestation of mental retardation and
generations. The disease moreover occurs with increasing muscular dystrophy. Later, clinical studies confirmed these
severity. The concept emerged early in this century mainly observations and described a dominant inheritance pattern
through descriptive dinical studies of myotonic dystrophy1'2. which could not be explained by classical Mendelian
Later studies have added other disease entities to a list of mechanisms8.
states showing anticipation, the most notable being Another phenomenon which did not fit easily into the
Huntington's disease3. In one form of inherited mental concepts of genetics was the finding that congenital MD was
retardation, the fragile X syndrome, the term 'the Sherman transmitted almost exclusively via affected mothers9.
paradox' describes a very similar phenomenon4. In the fragile X syndrome, anticipation is manifested in a
Towards the middle of this century, basic research in different manner. This is the most common cause of familial
genetics had given us a much clearer understanding of mental retardation. It segregates in families as an X-linked
Mendelian inheritance. It became increasingly difficult to dominant disorder with reduced penetrance. When
reconcile the originally described phenomenon of chromosomes are stained a fragile site on the X
anticipation with a concept of genes as stable elements chromosome may be seen in a proportion of cells taken
only changed by the rare mutation. Leading geneticists from a patient. Again, it was observed that the chances of
therefore regarded the term with scepticism to say the least. having the disease increase in successive generations of a
Lionel Penrose in 1948 dismissed the clinical data, and family. Approximately 30% of carrier females were affected,
concluded that postulated anticipation was the result of and 20% of males carrying the fragile X chromosome were
observational and ascertainment bias5. This view was largely phenotypically normal, but were able to transmit the
accepted, perhaps in a rather uncritical manner, by leading disorder to their grandsons (the Sherman paradox)4. In
geneticists. An important textbook of genetics denied the addition to the mental retardation, which is variable in
validity of the term as late as in 19866. The era when severity, affected males exhibit additional clinical features
geneticists solved any problem concerning inheritance with including macroorchidism and distinctive facies.
statistical treatment of data, good or bad, was coming to an The clinical picture of Huntington's disease (HD) is one
end, however. Molecular genetics revealed that DNA is not of distinctive choreic movements. The disease typically has a
as stable as was thought7. Even careful family studies could subtle, insidious onset in the fourth to fifth decade of life
at this time show that anticipation was fact and not fiction8. which gradually worsens with mental impairment. Death
occurs after 10-20 years. It is inherited in an autosomal
dominant fashion. Anticipation is less dramatically
Anticipation in the clinical setting manifested, but progressively earlier age of onset may be
In myotonic dystrophy (MD) Fleischerl'2 demonstrated that observed in successive generations. When the disease
the disease showed remarkable evolution in subsequent manifests itself at a very early age the dinical picture may
generations. He studied families with common ancestors. In be more severe. Rigidity and a more rapid course may be
the first generations neither the family histories nor early seen. In this disorder anticipation is observed mainly when
deaths indicated the occurrence of MD. There often the entity is inherited through the father.
followed one or two generations with patients showing
only senile or presenile cataracts. The subsequent generation The molecular genetics of anticipation
then included patients with classical MD. In this, and also
later generations, celibacy, childless marriages, mental Classical genetics, as it emerged through studies in the first
half of this century, taught us that genes as units of
inheritance were stable elements only changed by the rare
mutation. These mutations were again stable and inheritable.
Medisinsk poiidlinikk, Rikshospitalet, University of Oslo, 0027 Oslo, Norway Molecular genetics has revealed that this concept cannot be 185
 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 88 April 1995

maintained. There are sequences on the genome that mutate normal population sample of 282 individuals all
frequently. They may, in some instances, change each time chromosomes showed from five to maximally 27 repeats.
they are transmitted from parents to their children. In this The normal variability was large. In these individuals more
discovery we can see an aspect of the effect of human than 75% were heterozygous, i.e. they had different
genome mapping which is not often focused upon: the numbers of repeats on their two chromosomes. In MD
revelation of the totally unexpected. The geneticists found populations it has been demonstrated that patients with 50
what they were not looking for, and the unstable genetic to 80 repeats on the extended chromosome have very slight
elements proved to be of immense interest with regard to manifestations of disease, and symptoms and signs appear
our understanding of important inherited diseases. late in life. The more severely affected patients have from
Unstable DNA occurs in the repetitive DNA sequences 100 to thousands of triplet copies. The genetic basis of
which are common in the human genome. Each repeat may anticipation can clearly be demonstrated. The patients with
contain from two to hundreds of nucleotides repeating from the largest repeats have earlier onset and more severe
a few to thousands of times: the term simple tandem repeat disease manifestations. Patients with congenital MD all have
has been used. They often show a high degree of variability very large CTG repeats.
between individuals, in other words different individuals There is good evidence from MD population studies that
have different numbers of repeats on their chromosomes. instability is associated with certain haplotypes16. This means
There are even usually varying numbers of repeats on the that certain chromosomes seem predestined to instability.
two chromosomes of the same individual. Nothing is known One, or a few mutations may lay behind all observed cases
of their normal function, but the interpersonal variability has in the populations studied so far. It is at present not possible
been employed for the unique identification potential which to identify the normal-number triplet repeats that in the
they confer (genetic fingerprints)7. These extremely future will undergo expansion.
polymorphic systems have also been used extensively for The MD triplet repeat is transcribed, but is situated in
gene mapping purposes. the untranslated part of the gene. The gene codes for a
The connection between this phenomenon of unstable polypeptide that is a member of the protein kinase family.
DNA repeats and anticipation was made in 1991 when The expanded repeat seems to inhibit the expression of the
different groups identified, and subsequently characterized, gene17'18. Lack of the gene product may explain disease
the gene causing the fragile X syndromel112. Of the four manifestations although little is known about exact disease
different bases making up human DNA [adenine (A), mechanisms. A puzzling and unexplained aspect of MD
cytosine (C), guanine (G) and thymine (T)] a repeating genetics is the obervation that congenital MD is only
series of the trinudeotide containing CGG was found in this inherited from the mother.
position at the fragile site. In the normal X chromosome The HD gene has been mapped to the short arm of
between six and 50 repeating units were found. The chromosome 4. The gene has been cloned and codes for an
chromosomes containing the fragile site have from 250 to aminoacid sequence that does not correspond with any
several thousand units of CGG. In the intermediate range known protein19. The normal gene contains between six and
may be found the normal carriers. The repeating region of 37 repeats of the nucleotide sequence containing cytosine-
the carriers is highly unstable and tends to expand from adenine-guanine (CAG). Individuals who inherit more than
generation to generation. Manifest disease thus appears. 37 repeats from one parent are at high risk of developing
Expansion more often occurs when the repeat is transmitted HD. There may be a slight overlap between normals and
from women to children of either sex. The repeat is located patients in the 30-39 range. The magnitude of the expansion
in the untranslated part of the gene. The function of the is less dramatic in HD than in fragile X and MD. The largest
protein coded for by the gene is unknown, but expression of repeats found are in the range 60-70. The repeat tends to
the fragile X syndrome is associated with direct inactivation expand through the generations, but the phenomenon of
of the gene. anticipation is less pronounced than in the two previously
In the next couple of years at least seven different disease described disorders. Large repeats are, however, associated
states were shown to be caused by expanding trinucleotide with juvenile onset and marked rigidity. Expansion leading
repeats, the best known being MD and HD. The others to manifest disease is most often seen in HD when the gene
include the rare entities spinobulbar muscular atrophy, is transmitted from the father3.
spinocerebellar ataxia type I, dentatorubral and The triplet repeat is located in the transcribed and
pallidoluysian atrophy and the so-called FRAXE syndrome. translated part of the gene. CAG codes for the aminoacid
The MD gene is located on chromosome 19. The gene glutamine, and the protein thus contains a polyglutamine
was cloned and shown to contain a triplet repeat undergoing stretch. The function of the protein is unknown.
expansion in MD13-15. The trinucleotide repeat contains the There is evidence indicating that RD develops from one
186 base sequence cytosine-thymine-guanine (CTG). In a or a few predisposing ancestral mutations. The mutant gene
 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 88 April 1995

may be inherited for generations without undergoing 4 Sherman SL, Jacobs PA, Morton NE, Froster-Iskenius U, Howard-
expansion. There is, thus, a pool of dormant disease genes Peebles PN, Nielsen KB, et a). Further segretation analysis of the fragile
X syndrome with special reference to transmitting males. Hum Genet
in the population. 1985;69:3289-99
Why do some triple repeats in the genome undergo 5 Penrose LS. The problem of anticipation in pedigrees of dystrophia
expansion or what some authors call dynamic mutations? myotonica. Ann Eugen 1948;14:125-32
Nothing is known about the mechanisms that go wrong in 6 Vogel F, Motulsky AG. Human Genetics. Berlin, Heidelberg: Springer
Verlag, 1986
the replication process. Simple meiotic recombination is not
7 Jeffreys AJ, Wilson V, Thein SL. Hypervariable "minisatellite" regions
important. In the fragile X syndrome the risk of expansion in human DNA. Nature 1985;314:67-73
correlates well with the size of the allele. It has been 8 Howeler CJ, Busch HFM, Geraedt JPM, Niermeijer MF, Staal A.
postulated that these repeats are predisposed to slippage. Anticipation in myotonic dystrophy: fact or fiction? Brain
The replicating mechanism may thus copy the repeat a small 1989;112:779-97
number of times. Slippage during replication may also occur 9 Harper PS, Dyken PR. Early onset dystrophia myotonica-evidence
supporting a maternal environmental factor. Lancet 1972;ii:53-5
if the DNA strand being replicated breaks. It should,
10 Fu Y-H, Kuhl DPA, Pizzuti A, Pieretti M, Sutcliffe JS, Richards S et
however, be obvious that triplet repeats in general are not al.Variation of the CGG repeat at the fragile- X site results in genetic
inherently unstable. We all have many of them. An error in instability: resolution of the 'Sheman paradox. Cell 1991 ;67: 1047-58
DNA repair mechanisms has been suggested as another 11 Kremer EJ, Pritchard M, Lynch M, Yu S, Holman K, Baker E et a).
possible predisposing factor. Mapping of DNA instability at the fragile X to a trinucleotide repeat
sequence p(CCG)n. Science 1991;252:1711-15
In several of these conditions a striking parental sex bias
12 Verkerk AJMH, Pieretti M, Sutcliffe JS, Fu Y-H, Kiihl DPA, Pizzuti A.
has been observed. Again, nothing is as yet known about the Identification of a gene (FMR-1) containing a CGG repeat coincident
mechanism behind the preference for triplet expansion in with a fragile X break point cluster region which exhibits length
one of the sexes. variation in fragile X syndrome. Cell 1991;65:905-14
May these repeats leading to disease sometimes undergo 13 Brook JD, McCurrach ME, Harley HG, Buckler AJ, Church D,
Aburatani H, et al.Molecular basis of myotonic dystrophy: expansion of
contraction, become smaller, in the process of replication? a trinudeotide (CTG) repeat at the 3 end of a transcript encoding a
There is indeed evidence both from the fragile X. syndrome protein kinase family member. Cell 1992;68:799-808
and MD that this may happen, but the phenomenon seems 14 Fu Y-H., Pizzuti A, Fenwick RG, King J, Rajnarayan S, Dunne PW, et
to be very rare. al.An unstable triple repeat in a gene related to myotonic muscular
dystrophy. Science 1992;255:1256-8
Triplet expansion leading to disease has so far been seen 15 Mahadevan M, Tsifidis C, Sabourin L, Shutler G, Amemiya C, Jansen
in nervous system disorders only. Whether this mechanism G, et al.Myotonic dystrophy mutation: an unstable CTG repeat in the 3
may operate in genes mainly expressed in other organ untranslated region of the gene. Science 1992;255:1253-6
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a]. Expansion of an unstable DNA region and phenotypic variation in
eagerly looking for trinucleotide repeats in several different myotonic dystrophy. Nature 1992;355:5454
disorders, including cancer. 17 Carango P, Noble JE, Marks HG, Funanage VL. Absence of myotonic
dystrophy protein kinase (DMPK) mRNA as a result of a triplet repeat
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