Family Descriptions

Family Descriptions

Pedigree 1

Patient III.2 (proband) was a 35-year-old Caucasian female diagnosed in infancy with a tracheo-esophageal fistula (TEF) and esophageal atresia (EA). In her mid-20’s, imaging (by X-ray and MRI) after a traumatic injury revealed the presence of multiple congenital vertebral anomalies, including cervical and thoracic scoliosis, with tall and narrow vertebral bodies from C7 to T3. Imaging obtained through our research protocol also showed the presence of spina bifida occulta (SBO) at S2. Evidence for renal anomalies included multiple (over 40) urinary tract infections, though ultrasound did not show evidence of anatomic anomalies. She had no cardiac (by echocardiogram) or limb (by X-ray and physical examination) anomalies, and no evidence of anal atresia. Ultrasound performed on a research basis revealed the presence of a 2 cm accessory spleen. There was no history of cognitive impairment, no other anomalies or dysmorphic features on physical examination, no other major medical issues, and no features suggesting an alternate diagnosis. The patient has a healthy one-year-old son who has no features of VACTERL associationor other major medical issues (the son was also examined in person at the NIH). Microrray comparative genomic hybridization (array CGH)(1M-Duo, Illumina) was normal, as was sequencing of candidate genes SHH, FOXF1, and TWSG1.

Patient II.2 (the proband’s father) was a 64-year-old Caucasian male with multiple vertebral anomalies, including SBO at S1 and moderate lumbar scoliosis. He suffered severe and incapacitating back pain secondary to these vertebral anomalies despite numerous types of interventions. A ventricular septal defect (VSD) was diagnosed in infancy, and did not require surgical repair, but was still present (by echocardiogram) at 38 years of age. The patient had a history of congenital left ureteral stenosis and numerous episodes of nephrolithiasis due to idiopathic hypercalciuria, but renal ultrasound revealed no other anomalies. There were no limb (by X-ray and clinical examination) anomalies or evidence of TEF or anal atresia. There was no evidence of neurocognitive impairment, no other anomalies or dysmorphic features on physical examination, no features suggestive of an alternate diagnosis, and he had no other related health issues. The diagnosis of findings related to VACTERL association had not been raised until the birth of his daughter (III.2). There was no family history of other individuals with findings of VACTERL association (all of the siblings of both individuals II.2 and III.2 were examined in person as part of our research study). His sister (II.3) reported that she had “extra bones” in her feet ascertained coincidentally after a foot injury, but X-rays performed on a research basis at the NIH revealed simply the presence of accessory ossicles of digits 2-4 bilaterally, and hand and upper extremities were normal (by X-ray and physical examination). Array CGH (1M-Duo, Illumina) was normal, as was sequencing of candidate genes SHH and FOXF1.

Pedigree 2

Patient II.1(proband) was a 6-month-oldCaucasian male diagnosed and treated in infancy for a TEF and EA. X-rays initially performed post-operatively revealed a hemivertebra at T8 resulting in focal scoliosis, and MRI of the spine showed a fatty filum terminale. Hydronephrosis had been diagnosed on routine prenatal ultrasound, and imaging after birth showed right kidney malrotation and a small right kidney. He also had grade 3-4 vesicoureteral reflux (VUR). There was no evidence of cardiac anomalies (by echocardiogram), limb anomalies (by X-ray and physical examination), or anal atresia, and he did not have any other medical issues. He had no dysmorphic features, and no other features suggesting an alternate diagnosis. The patient’s developmental level was appropriate for his age. Physical examination revealed a mildly bifid uvula, which was also present in his otherwise healthy 2-year-old sister. Neither parent had a bifid uvula (or other palatal or related midline anomalies), but the patient’s maternal uncle (not shown) had a bifid uvula as well. Array CGH (1M-Duo, Illumina) was normal, as was sequencing of candidate genes SHH, FOXF1 and TWSG1.

Patient I.2 (the proband’s mother) was a 35-year-old Caucasian female whose only health issue was hypothyroidism (research testing at the NIH showed evidence for a non-centraletiology). She reported a history of rib asymmetry, which was evident on physical examination, and X-ray of the spine showed moderate lumbosacral scoliosis secondary to focal lumbar vertebral dysplasia. There was no evidence for other anomalies, and she was not dysmorphic on physical examination. She reported that her mother, the maternal grandmother of the proband, had a similar appearance of the ribs, but she was not available for examination. There was no other family history of other congenital malformations.

Pedigree 3

Patient II.1 (proband) was a 10-year-old Caucasian female diagnosed in infancy with a TEF and EA. She had vertebral anomalies including multiple thoracic hemivertebrae and scoliosis. Cardiopulmonary anomalies included dextrocardia, an absent right lung, and severe aortic stenosis. Renal anomalies were not well characterized, but she had additionally had right VUR. There was no evidence of limb anomalies or anal atresia. There was no evidence for neurocognitive impairment or other malformations. This patient was not examined in person, but extensive review of her medical history and examination of numerous photographs did not show evidence for dysmorphic features or an alternate diagnosis. Array CGH (1M-Duo, Illumina) was normal, as was sequencing of candidate genes SHH, FOXF1 and TWSG1.

Patient I.1 (the proband’s father) was diagnosed with a “congenital heart malformation”, but further specifics were not available. The family history was otherwise noncontributory.

Pedigree 4

Patient III.1 (proband) was a 27-year-old Caucasian male with a history of a TEF and EA diagnosed in infancy, and multiple congenital vertebral anomalies, including congenital fusion of C6 and C7 and the three lower thoracic and the two upper lumbar vertebrae, multiple upper thoracic hemivertebrae, and thoracic scoliosis. He had no cardiac anomalies (by echocardiogram), anal atresia, or limb anomalies (by X-ray and physical examination). He did not have dysmorphic features, other malformations, or features suggesting an alternate diagnosis. The patient was adopted, but around the time of his birth, his adoptive mother contacted the biological mother and obtained a brief medical history. This medical history included evidence of vertebral anomalies in the patient’s father (at least severe scoliosis) and maternal uncle (spondylolisthesis with vertebral dislocation, requiring a spinal fusion at 16 years of age) and grandmother (scoliosis), and a “collapsing trachea” (further details unknown) in both the paternal grandmother and maternal uncle. Array CGH (1M-Duo, Illumina) was normal, as was sequencing of candidate genes SHH, FOXF1 and TWSG1.

Pedigree 5

Patient IV.1 (proband) was a Caucasian female infant born at 39 weeks gestation after a pregnancy in which mild intrauterine growth restriction had been noted. The patient died within 15 minutes of birth. Autopsy notedanal atresia, absent vaginal and urethral orifices, a persistent cloaca connecting the rectum and bladder, ambiguous genitalia, and a bicornuate uterus, consistent with a urorectal septum malformation sequence. Cardiac anomalies consisted of an anomalous left superior vena cava, a right retroesophageal subclavian artery, an atrial septal defect, a membranous VSD, and a patent ductus arteriosus. The patient had proximal EA with a distal TEF. She had bilateral renal agenesis and atretic ureters, and consequent evidence of oligohydramnios. She additionally was noted to have duodenal atresia, a Meckel’s diverticulum, and asplenia. A single umbilical artery was present. No other anomalies were noted, and she had normal limbs and neuroanatomy. Genetic testing was not performed.

Patient IV.2 (the proband’s sister) was a 23-year-old Caucasian female with severe lumbothoracic vertebral dysplasia resulting in severe scoliosis requiring Harrington rod placement. She was otherwise healthy, and had no dysmorphic features or suggestions of an alternate diagnosis. Her paternal first cousin, once removed (III.3), was reported to have scoliosis, and her maternal great-grandmother (I.1)had unilateral kidney agenesis. There was no other known family history of features of VACTERL association or other malformations.

Pedigree 6

Patient II.1 (proband) was a 10-year-old male diagnosed with a TEF and EA in infancy. He also had vertebral anomalies including multiple hemivertebrae, as well as extra cervical ribs. The patient had minor cardiac anomalies including mitral valve prolapse, tricuspid regurgitation, but no other major cardiac malformations. His kidneys were bilaterally small, with evidence of anomalous ureteral junctions. He had hypoplastic limb musculature, but no other limb anomalies. There wasclinical evidence for mitochondrial dysfunction (including dysautonomia, severe failure to thrive, erratic blood glucose levels including both hypo- and hyperglycemia, and a dramatic response to carnitine supplementation as part of a “mitochondrial cocktail”).

The proband’s brother (II.3) was a deceased twin described as having multiple features of VACTERL association, though further details were not available.

Pedigree 7

The proband (II.1) was an 11-month-old Caucasian male with unilateral ectrodactyly, but with no other anomalies, and with normal development. Array CGH (Signature) was normal, as was mutation analysis of TP63. He had a deceased sibling (II.2) with a diagnosis of VACTERL association, whose malformations included a TEFand other major component features by report, though full details are not available. The deceased sibling was also described as having findings consistent with hydrocephalus.There was no other family history of individuals with any features of VACTERL association or other malformations or hydrocephalus.

Supplementary Table 1. Description of major component features and other anomalies for the 78 probands.

Patient / Gender / V / A / C / TE / R / L / Other
1 (Pedigree 1) / F / X / X / X
2 (Pedigree 2) / M / X / X / X / Bifid uvula
3 (Pedigree 3) / F / X / X / X / X / Absent R lung
4 (Pedigree 4) / M / X / X
5 (Pedigree 5) / F / ? / X / X / X / Cloaca
6 (Pedigree 6) / M / X / ? / X / ? / Hypospadias, pyloric stenosis
7 (Pedigree 7) / U / X / Hydrocephalus
8 / M / X / X / X / Cryptorchid
9 / F / X / X / X
10 / F / X / X / X / Inner ear anomalies
11 / U / X / X / X / X / X
12 / F / X / X / X / X / Absent gallbladder
13 / M / X / X / X / X
14 / M / X / X / X / Cleft lip/palate
15 / M / X / X / X
16 / M / X / X / X / X
17 / M / X / X / X
18 / F / X / X / X / X / X / Cloaca
19 / M / X / X / X
20 / M / X / X / X
21 / M / X / X / X / X / X
22 / M / X / X / X
23 / M / X / X / X
24 / M / X / X / X / X / Chiari I, duodenal atresia
25 / M / X / X / X / Recto-urethral fistula
26 / M / X / X / X
27 / M / X / X / X / X / X / Chiari I
28 / M / X / X / X
29 / F / X / X / X / X
30 / F / X / X / X / Urogenital abnormality
31 / M / X / X / X
32 / M / X / X / X
33 / M / X / X / X / X
34 / M / X / X / X / X / X / X
35 / F / X / X / X / Spina bifida
36 / F / X / X / X / X
37 / F / X / X / X
38 / M / X / X / X
39 / M / X / X / X / X / X / Hydrocephalus
40 / M / X / X / X / X / X / Hypospadias
41 / M / X / X / X / X / Ambiguous genitalia
42 / M / X / X / X / X
43 / M / X / X / X
44 / M / X / X / X / X
45 / F / X / X / X / X / X / X / Cloaca
46 / F / X / X / X
47 / F / X / X / X
48 / F / X / X / X / X / X
49 / M / X / X / X / Hydrocephalus
50 / F / X / X / X / X / Hydrocephalus
51 / M / X / X / X / X
52 / M / X / X / X / X / X
53 / F / X / X / X / X / X
54 / F / X / X / X / X
55 / F / X / X / X / X / X
56 / F / X / X / X / X / X / X / Nystagmus
57 / M / X / X / X / X
58 / M / X / X / X / X / X
59 / F / X / X / X / X / Rectovaginal sinus
60 / F / X / X / X / Urogenital abnormalities
61 / F / X / X / X / X / GI organ atresia, hydrocephalus
62 / M / X / X / Cystic hygroma, hypospadias
63 / F / X / X / X / X / Duodenal atresia
64 / F / X / X / X / Cloaca
65 / M / X / X / X / X / X / Cleft palate
66 / F / X / X / X / X / X / Heterotaxy
67 / F / X / X / X / Cloaca
68 / F / X / X / X
69 / M / X / X / X / X
70 / F / X / X / X
71 / F / X / X / X / X / Rectovaginal fistula
72 / F / X / X / X / X
73 / F / X / X / X
74 / F / X / X / X / X / Duodenal atresia
75 / F / X / X / X / X / X / X
76 / F / X / X
77 / F / X / X / X / X
78 / F / X / X / X / X

V: Vertebral defects; A: Anal atresia; C: Cardiac malformations; TE: Tracheo-Esophageal fistula; R: Renal anomalies; L: Limb anomalies; M: Male; F: Female; X: presence of specified component feature.

Supplementary Table 2. Comparison of major component features with other cohorts.

Component Feature / Patients with VACTERL association:
This Study
N = 78 (%) / Patients with VATER association:
(Weaver et al. 1986 a)
N = 46 (%)
p-value* / Patients with VACTERL association (Rittler et al. 1996)
N = 524 (%)
p-value / Infants (Rittler et al. 1996)
N = 2,493,999 (%)
V / 63 (81) / 27 (59%)
0.0119 / 142 (27%)
<0.001 / 337 (0.0135%)
A / 44 (56) / 26 (57%)
1 / 251 (48%)
0.1821 / 887 (0.0356%)
C / 58 (74) / 36 (78%)
0.6701 / 273 (52%)
0.0002 / 2,780 (0.111%)
TE / 41 (53) / 31 (67%)
0.1326 / 177 (34%)
0.0016 / 591 (0.0234%)
R / 54 (69) / 29 (61%)
0.5545 / 246 (47%)
0.0002 / 800 (0.0321%)
Lb / 33 (42) / NS / 97 (19%)
<0.0001 / 734 (0.0294%)

V: Vertebral defects; A: Anal atresia; C: Cardiac malformations; TE: Tracheo-Esophageal fistula; R: Renal abnormalities; L: Limb anomalies; M: Male; F: Female; NS: Not specified or data not sufficient for analysis.

a Included some patients who would likely have been eliminated using our inclusion criteria.

bLimb abnormalities in Weaver et al. (1986) included only radial anomalies; Rittler et al. (1996) included only preaxial abnormalities.
*P-values calculated by two-tailed two-sample proportion test. Statistically significant values are shown in bold.