Prader-Willi Syndrome - PWS

  • Diagnosis
  • Algorithms
  • Background
  • Lab Tests
  • References
  • Related Topics

Indications for Testing

  • Suspicion based on physical findings

Criteria for Diagnosis

  • Consensus criteria for testing
    • Major criteria
      • Neonatal and infantile central hypotonia with poor suck; improvement with age
      • Feeding problems and/or failure to thrive in infancy, with need for gavage feeding or other special feeding techniques
      • Onset of rapid weight gain between ages 12 months and six years, causing central obesity
      • Hyperphagia
      • Characteristic facial features – narrow bifrontal diameter, almond-shaped palpebral fissures, downturned mouth
      • Hypogonadism manifestations
        • Genital hypoplasia – small labia minora and clitoris in females; hypoplastic scrotum and cryptorchidism in males
        • Incomplete and delayed puberty
      • Infertility
      • Developmental delay (mild to moderate), multiple learning disabilities
    • Minor criteria
      • Decreased fetal movement and infantile lethargy, improving with age
      • Behavior problems, including temper tantrums, obsessive-compulsive behavior, stubbornness, rigidity, stealing, and lying
      • Sleep disturbance or sleep apnea
      • Short stature by age 15 (based on the individual family)
      • Hypopigmentation
      • Hands and feet small for height age
      • Narrow hands with straight ulnar border
      • Esotropia, myopia
      • Thick, viscous saliva
      • Speech articulation defects
      • Skin picking
    • To score, major criteria are weighted at 1 point each, and minor criteria are weighted at 1/2 point each; supportive findings increase the certainty of diagnosis but are not scored
      • For children ≤3 years, 5 points are required, 4 of which should come from major criteria
      • For children >3 years and for adults, 8 points are required with 5 or more points coming from major criteria

Laboratory Testing

  • Absolute diagnosis depends on genetic testing
  • Initial diagnostic testing – methylation PCR
    • Confirms Prader-Willi syndrome (PWS) in 99% of individuals with symptoms meeting consensus criteria
  • Determination of molecular mechanism for PWS
    • Methylation-sensitive PCR detects 99% of affected individuals but will not specify molecular mechanism of PWS; however, current standard of care for PWS patients does not differ based on identified molecular mechanism
    • Cytogenetic testing (FISH metaphase) detects a deletion in the Prader-Willi critical region (PWCR) on chromosome 15 (15q11-q13) in 70% of affected individuals
    • Uniparental disomy testing detects 20-25% of cases
    • Chromosome analysis detects balanced chromosome rearrangements that interrupt the PWCR in <1% of affected individuals
  • Prenatal diagnosis – rarely made but theoretically could use amniocentesis or chorionic villus sampling samples

Differential Diagnosis

  • Craniopharyngioma
  • Growth hormone deficiency
  • Hypotonia in infancy
    • Congenital myotonic dystrophy
    • Spinal muscular atrophy
  • Bardet-Biedl syndrome
  • Developmental delay in childhood
    • Fragile X syndrome
    • Rett syndrome
    • Other rare developmental delay disorders, including Cohen syndrome, Albright hereditary osteodystrophy

Prader-Willi syndrome (PWS) is a complex neurodevelopmental genetic disorder characterized by severe hypotonia and feeding difficulties in infancy with gradual development of hyperphagia and morbid obesity in early childhood, as well as development of short stature, scoliosis, and maladaptive and compulsive behaviors.

Epidemiology

  • Incidence – 1/10,000-25,000
  • Sex – M:F, equal

Recurrence Risk

  • To determine the recurrence risk for parents, the specific genetic mechanism causing PWS in the prior affected child must be determined
    • Recurrence risk for parents whose previous child has an imprinting center mutation – up to 50%
    • Recurrence risk for parents whose affected child has PWS due to any mechanism besides an imprinting center mutation – <1%

Pathophysiology

  • 15q11-q13 region harbors several genes regulated by genomic imprinting
    • Genes are expressed from one parental allele – gene is functionally haploid
  • Three disorders occur from deletion/duplications at this locus – PWS, Angelman syndrome, dup 15q syndrome
    • 70% have a deletion on one number 15 chromosome involving bands 15q11-q13, known as the PWS/Angelman syndrome (AS) critical region
    • 25% have maternal uniparental disomy of chromosome 15
    • <5% have an imprinting center defect 

Clinical Presentation

  • Severe hypotonia and feeding difficulties in infancy
  • Delayed motor and language milestones (developmental delay)
  • Behavioral problems – temper tantrums, stubbornness, obsessive-compulsive traits
    • Autism reported in patients with maternal uniparental disomy
  • Hypogonadism, cryptorchidism
  • Short stature, small hands and feet
  • Facial features – narrow bifrontal diameter, downturned mouth, almond-shaped palpebral fissures
  • Hyperphagia and morbid obesity (begins between ages 1-6 years)
  • Complications of obesity are the main cause of morbidity and mortality

Treatment

  • Multidisciplinary approach – physical, speech, occupational and behavioral therapies
  • Consider growth hormone treatment
  • Orthopedic treatment for scoliosis
  • Screen for causes of possible morbidity, including central adrenal insufficiency due to stressful conditions and obstructive/central sleep apnea
  • Weight management programs
  • Consider sex steroid replacement based on individual assessment and bone mineral density
  • Discourage pregnancy in females because of cognitive dysfunction and the risk of Angelman syndrome in offspring of mothers with 15q11-q13 deletion
  • Alert medical team performing surgical procedures to potential increased risk of complications from anesthesia
Tests generally appear in the order most useful for common clinical situations. Click on number for test-specific information in the ARUP Laboratory Test Directory.

Angelman Syndrome and Prader-Willi Syndrome by Methylation-Sensitive PCR 2005077
Method: Methylation Sensitive Polymerase Chain Reaction/Fluorescence Monitoring

Recommended Use 

Preferred initial diagnostic test for Angelman syndrome (AS) or PWS

Clinical sensitivity – 78% (Lossie, 2001)

Analytical sensitivity – 99%

Limitations 

Specific molecular mechanism responsible for abnormal methylation results cannot be determined

AS resulting from molecular mechanisms that do not affect methylation patterns will not be identified

Diagnostic errors can occur due to rare sequence variations

Chromosome FISH, Metaphase 2002299
Method: Fluorescence in situ Hybridization

Recommended Use 

FISH probes for specific microdeletion/microduplication syndromes must be specified

If no specific syndrome is in question, genomic microarray should be ordered instead of screening multiple loci by FISH

Tests for deletion in 15q11-q13 band in individuals known or suspected to have PWS

Indicate names of probes needed for testing

Clinical sensitivity for PWS – 70%

ARUP Constitutional FISH Probes menu

Limitations 

PWS caused by uniparental disomy or imprinting center defects will not be detected; therefore, it is recommended that the methylation sensitive polymerase chain reaction/fluorescent monitoring test be performed instead of the FISH assay

General References

Buiting K. Prader-Willi syndrome and Angelman syndrome. Am J Med Genet C Semin Med Genet. 2010; 154C(3): 365-76. PubMed

Chen C, Visootsak J, Dills S, Graham JM. Prader-Willi syndrome: an update and review for the primary pediatrician. Clin Pediatr (Phila). 2007; 46(7): 580-91. PubMed

Driscoll D, Miller J, Schwartz S, Cassidy S. Prader-Willi Syndrome. In: Pagon RA, Adam MP, Ardinger HH, et al, editors. GeneReviews, University of Washington, 1993-2015. Seattle, WA [Last updated Jan 2014; Accessed: Nov 2015]

Goldstone AP, Holland AJ, Hauffa BP, Hokken-Koelega AC, Tauber M, speakers contributors at the Second Expert Meeting of the Comprehensive Care of Patients with PWS. Recommendations for the diagnosis and management of Prader-Willi syndrome. J Clin Endocrinol Metab. 2008; 93(11): 4183-97. PubMed

Kalsner L, Chamberlain SJ. Prader-Willi, Angelman, and 15q11-q13 Duplication Syndromes. Pediatr Clin North Am. 2015; 62(3): 587-606. PubMed

Wattendorf DJ, Muenke M. Prader-Willi syndrome. Am Fam Physician. 2005; 72(5): 827-30. PubMed

References from the ARUP Institute for Clinical and Experimental Pathology®

Procter M, Chou L, Tang W, Jama M, Mao R. Molecular diagnosis of Prader-Willi and Angelman syndromes by methylation-specific melting analysis and methylation-specific multiplex ligation-dependent probe amplification. Clin Chem. 2006; 52(7): 1276-83. PubMed

Medical Reviewers

Lamb, Allen N., PhD, FACMG, Medical Director, Cytogenetics and Genomic Microarray, ARUP Laboratories; Associate Professor of Clinical Pathology, University of Utah

Lyon, Elaine, PhD, Medical Director, Genetics, and Co-Medical Director, Pharmacogenomics at ARUP Laboratories; Associate Professor of Clinical Pathology, University of Utah

Mao, Rong, MD, Medical Director, Molecular Genetics and Genomics at ARUP Laboratories; Associate Professor of Clinical Pathology and Co-director, Clinical Medical Genetics Fellowship Program, University of Utah

Last Update: August 2017