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Pagon RA, Adam MP, Bird TD, et al., editors. GeneReviews™ [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2013.

Bookshelf ID: NBK1479PMID: 20301652

Sotos Syndrome

Synonym: Cerebral Gigantism

Katrina Tatton-Brown, BM BCh, MD, Trevor RP Cole, MB ChB, and Nazneen Rahman, BM BCh, PhD.

Author Information

Initial Posting: December 17, 2004; Last Update: March 8, 2012.

Summary

Disease characteristics. Sotos syndrome is characterized by the cardinal features of typical facial appearance, overgrowth (height and/or head circumference ≥2 SD above the mean), and learning disability ranging from mild (children attend mainstream schools and are likely to be independent as adults) to severe (lifelong care and support will likely be required). Sotos syndrome is associated with the major features of behavioral problems, congenital cardiac anomalies, neonatal jaundice, renal anomalies, scoliosis, and seizures.

Diagnosis/testing. The diagnosis of Sotos syndrome is established by a combination of clinical findings and molecular genetic testing. NSD1 is the only gene in which mutations are known to cause Sotos syndrome. About 80%-90% of individuals with Sotos syndrome have a demonstrable NSD1 abnormality.

Management. Treatment of manifestations: Referral to appropriate specialists for management of learning disability/speech delays, behavior problems, cardiac abnormalities, renal anomalies, scoliosis, seizures; no intervention if MRI shows ventricular dilatation without raised intracranial pressure.

Surveillance: Regular review by a general pediatrician for younger children, individuals with many medical complications, and families requiring more support than average; less frequent review of older children/teenagers and those individuals without many medical complications.

Other: Education of affected individuals and their families regarding natural history, treatment, mode of inheritance, genetic risks to other family members, and consumer-oriented resources; genetic counseling of young adults regarding risk to offspring.

Genetic counseling. Sotos syndrome is inherited in an autosomal dominant manner. More than 95% of individuals have a de novo mutation. If neither parent of a proband has Sotos syndrome, the risk to sibs of the proband is low (<1%). The risk to offspring of affected individuals is 50%. Prenatal testing is possible for pregnancies at risk if the NSD1 disease-causing mutation has been identified in an affected family member.

Diagnosis

Clinical Diagnosis

The clinical diagnosis of Sotos syndrome can be made if an individual has a characteristic facial gestalt, a learning disability, and overgrowth [Rio et al 2003, Turkmen et al 2003, Cecconi et al 2005, Faravelli 2005, Tatton-Brown et al 2005b, Waggoner et al 2005]. Based on the analysis of more than 500 individuals with an NSD1 abnormality, these three cardinal features were shown to occur in at least 90% of affected individuals [Tatton-Brown et al 2005b]. Where an individual does not fulfill all three clinical criteria, the clinical suspicion of Sotos syndrome can be confirmed with genetic testing (see Molecular Genetic Testing).

Characteristic facial appearance. The facial gestalt is the most specific diagnostic criterion for Sotos syndrome and also the feature most open to observer error and inexperience. The gestalt is most easily recognizable between ages one and six years. In older children and adults, the facial features, although still typical, can be more subtle [Allanson & Cole 1996, Tatton-Brown et al 2005b].

Typical facial features include malar flushing, sparse frontotemporal hair, high bossed forehead, downslanting palpebral fissures, a long narrow face, and prominent narrow jaw; the head is said to resemble an inverted pear. The facial shape is retained into adulthood, but with time the chin becomes squarer in shape and more prominent.
Learning disability. Delay of early developmental milestones is very common and motor skills may appear particularly delayed because of the large size, hypotonia, and poor coordination. Language delay is also usually apparent [Ball et al 2005]. The great majority of affected individuals have some degree of intellectual impairment. However, the extent is highly variable, ranging from mild (in which children attend mainstream schools and are likely to be independent in adulthood) to severe (in which lifelong care and support are required) [Tatton-Brown et al 2005b].
Overgrowth. Approximately 90% of children have a height and/or head circumference two or more SD above the mean [Tatton-Brown et al 2005b]. Height may normalize in adulthood, but macrocephaly is usually present at all ages [Agwu et al 1999; Cole, personal communication].

Testing

Cytogenetic testing. Most affected individuals do not have a cytogenetic abnormality. Rarely, a cytogenetic abnormality such as a translocation involving 5q35 results in Sotos syndrome [Kurotaki et al 2002].

Molecular Genetic Testing

Gene. NSD1 is the only gene in which mutations are currently known to cause Sotos syndrome.

Clinical testing

Table 1. Summary of Molecular Genetic Testing Used in Sotos Syndrome

Gene Symbol	Test Method	Mutations Detected	Mutation Detection Frequency by Test Method ¹		Test Availability
Gene Symbol	Test Method	Mutations Detected	Japanese	Non-Japanese	Test Availability
NSD1	Sequence analysis / mutation scanning ²	Sequence variants ³	~12% ⁴	27%-93% ⁵	Clinical
	Deletion / duplication analysis ⁶	5q35 microdeletion encompassing NSD1 and NSD1 partial-gene deletions	~50% ^7, 8, 9	~15% ^8, 9
	FISH	5q35 microdeletion encompassing NSD1	~50% ^4, 8, 10	~10% ^5, 8, 10

: 1. The ability of the test method used to detect a mutation that is present in the indicated gene
: 2. Sequence analysis and mutation scanning of the entire gene can have similar mutation detection frequencies; however, mutation detection rates for mutation scanning may vary considerably among laboratories depending on the specific protocol used.
: 3. Examples of mutations detected by sequence analysis may include small intragenic deletions/insertions and missense, nonsense, and splice site mutations.
: 4. Limited mutation screening has been undertaken in Japanese individuals [Kurotaki et al 2003, Miyake et al 2003, Tei et al 2006].
: 5. The variability in detection rate reflects different eligibility criteria for screening [Douglas et al 2003, Rio et al 2003, Cecconi et al 2005, Faravelli 2005, Melchior et al 2005, Waggoner et al 2005, Saugier-Veber et al 2007]. An NSD1 detection rate of at least 90% was achieved when the clinical diagnosis of Sotos syndrome had been made by clinicians with expertise in the condition [Turkmen et al 2003, Tatton-Brown et al 2005b].
: 6. Testing that identifies deletions/duplications not readily detectable by sequence analysis of the coding and flanking intronic regions of genomic DNA; a variety of methods including quantitative PCR, long-range PCR, multiplex ligation-dependent probe amplification (MLPA), or targeted array GH (gene/segment-specific) may be used. A full array GH analysis that detects deletions/duplications across the genome may also include this gene/segment.
: 7. The contribution of partial-gene deletions to Sotos syndrome in Japanese individuals is currently unknown [Douglas et al 2005, Tatton-Brown et al 2005b].
: 8. The microdeletions can be detected with equal sensitivity by FISH or other deletion/duplication analytic methods (e.g., multiplex ligation-dependent probe amplification [MLPA]) [Douglas et al 2003, Kurotaki et al 2003, Rio et al 2003, Turkmen et al 2003, Cecconi et al 2005, Tatton-Brown et al 2005a, Visser et al 2005, Waggoner et al 2005].
: 9. Exonic/multiexonic deletions (i.e., deletion of one or more exons) are responsible for an estimated 5% of Sotos syndrome [Douglas et al 2005, Tatton-Brown et al 2005b]. Deletion/duplication analytic methods (see footnote 6) are required; typically, FISH cannot detect exonic/multiexonic gene deletions. Deletions encompassing exons 1 and 2 are most common, likely reflecting the high density of Alu repeats in the flanking sequences [Douglas et al 2005].
: 10. Typically, FISH cannot detect exonic/multiexonic gene deletions.

Interpretation of test results. All frameshift and nonsense mutations, splicing variants at consensus residues, partial-gene deletions, and microdeletions encompassing NSD1 are predicted to be pathogenic.

Missense variants require more careful interpretation.

De novo variants in a simplex case of Sotos syndrome are highly likely to be pathogenic.
Pathogenic missense mutations typically occur at conserved, functionally relevant residues within protein domains [Tatton-Brown et al 2005b]. Missense variants outside conserved domains should be assumed to be normal variants in the absence of additional data in favor of pathogenicity (e.g., demonstration that the variant is de novo, results of a functional assay).

For issues to consider in interpretation of sequence analysis results, click here.

Information on specific allelic variants may be available in Molecular Genetics (see Table A. Genes and Databases and/or Pathologic allelic variants).

Testing Strategy

To confirm/establish the diagnosis in a proband

If a diagnosis of Sotos syndrome is suspected, NSD1 molecular genetic testing should be considered to confirm the clinical diagnosis and to provide information about risk of recurrence.
- For individuals of non-Japanese ancestry, sequencing analysis is the first line of testing, followed by deletion/duplication or FISH analysis if the sequencing is does not identify a mutation.
- In individuals of Japanese ancestry, deletion/duplication or FISH analysis may be considered first.
  
  Note: If a molecular diagnosis of Sotos syndrome has been made, x-rays for bone age and MRI scan of the brain are not required to confirm the diagnosis.
If the clinical diagnosis of Sotos syndrome is uncertain or if molecular testing is negative, routine karyotype, array CGH, and molecular genetic testing for fragile X syndrome should be undertaken. (See Differential Diagnosis.)

Prenatal diagnosis and preimplantation genetic diagnosis (PGD) for at-risk pregnancies require prior identification of the disease-causing mutation in the family.

Genetically Related (Allelic) Disorders

NSD1 abnormalities have high specificity and sensitivity for Sotos syndrome. Molecular genetic testing failed to identify mutations in NSD1 in more than 500 individuals with clinical diagnoses other than Sotos syndrome, including Marshall-Smith syndrome, autosomal dominant macrocephaly, nonspecific overgrowth, and individuals with macrocephaly in association with autism spectrum disorders [Turkmen et al 2003, Tatton-Brown et al 2005b, Waggoner et al 2005, Buxbaum et al 2007].

In rare cases, other clinical conditions that show overlap with Sotos syndrome and involve NSD1 mutations have been reported:

A family with macrocephaly, tall stature, and normal intelligence [van Haelst et al 2005]
An individual with Nevo syndrome [Kanemoto et al 2006] who has many clinical features consistent with Sotos syndrome. In addition, Nevo syndrome has been shown to be allelic to Ehlers-Danlos syndrome Type VIA. Both conditions are caused by biallelic mutations in PLOD1 [Giunta et al 2005].
Two individuals with Beckwith-Wiedemann syndrome (BWS) [Baujat et al 2004] whose findings were not typical for BWS. Both showed considerable overlap with Sotos syndrome [Tatton-Brown & Rahman 2004].
Six individuals with Weaver syndrome [Douglas et al 2003, Rio et al 2003]. Weaver and Sotos syndrome show greatest overlap in infancy, and in some of the individuals with Weaver syndrome and NSD1 mutations, the clinical phenotype evolved over time to be fairly classic of Sotos syndrome [Douglas et al 2003, Tatton-Brown et al 2005b]. Weaver syndrome has recently been shown to be caused by mutations in another histone methyl transferase gene, EZH2, providing further evidence that Weaver syndrome is a clinical entity distinct from Sotos syndrome [Tatton-Brown et al 2011, Gibson et al 2012].

Clinical Description

Natural History

Based on a review of 230 persons with NSD1 abnormalities, the clinical features of Sotos syndrome were classified as cardinal features (occurring in at least 90% of affected individuals), major features (occurring in 15%-89%), and associated features (occurring in ≥2% and <15% of persons) [Tatton-Brown et al 2005b].

It is very likely that additional associated features will be recognized as new cases are identified. It is also possible that some associated features (e.g., constipation) occur with greater frequency than appreciated now and thus could be reclassified as major features in the future.

Cardinal Features (present in ≥90% of persons with Sotos syndrome)

Characteristic facial appearance
Learning disability
Overgrowth

Major Features (present in 15%-89% of persons with Sotos syndrome)

Behavioral problems
Advanced bone age
Cardiac anomalies
Cranial MRI/CT abnormalities
Joint hyperlaxity/pes planus
Maternal preeclampsia
Neonatal complications
Renal anomalies
Scoliosis
Seizures

Cardinal Features

Characteristic facial appearance. The facial gestalt of Sotos syndrome is evident at birth, but becomes most recognizable between ages one and six years. The head is dolichocephalic and the forehead broad and prominent. Often the hair in the frontotemporal region is sparse. The palpebral fissures are usually downslanting. Malar flushing may be present. At birth, the mandible appears small, but by childhood it is pointed, and in adulthood, often prominent and square [Allanson & Cole 1996, Tatton-Brown & Rahman 2004].

Learning disability. The majority of individuals with Sotos syndrome have some degree of intellectual impairment. The spectrum is broad and ranges from mild learning disability (affected individuals would be expected to live independently and have their own families) to severe learning disability (affected individuals would be unlikely to live independently as adults). It has been suggested that children with Sotos syndrome have difficulties with speech and language, particularly expressive language and articulation [Ball et al 2005]. The majority have mild-moderate learning disability; the level of intellectual impairment generally remains stable throughout life [Tatton-Brown et al 2005b; Authors, unpublished data].

Growth. Sotos syndrome is associated with overgrowth of prenatal onset. Delivery is typically at term. The average birth length approximates to the 98th centile and the average birth head circumference is between the 91st and 98th centiles. Average birth weight is within the normal range (between the 50th and 91st centile).

Before age ten years, affected children demonstrate rapid linear growth. They are often described as being considerably taller than their peers. Height and/or head circumference are generally 2 SD or more above the mean. However, growth is also influenced by parental heights and some individuals do not have growth parameters above the 98th centile [Cole & Hughes 1994, Tatton-Brown et al 2005b].

Data on final adult height are scarce; however, in both men and women, the range of final adult height is broad [Agwu et al 1999; Tatton-Brown & Rahman, unpublished data].

The de Boer et al [2005] study of auxologic data supports that of Agwu et al [1999] and shows that individuals with NSD1 mutations have an increased arm span/height ratio, decreased sitting/standing height ratio, and increased hand length. These data suggest that the increased height in Sotos syndrome is predominantly the result of an increase in limb length [Agwu et al 1999, de Boer et al 2005].

Major Features

Behavioral problems. A wide range of behavioral problems are common at all ages: autistic spectrum disorder, phobias, and aggression have been described [Tatton-Brown, personal communication]. Often difficulty with peer group relationships is precipitated by large size, naiveté, and lack of awareness of social cues [Finegan et al 1994]. These observations were confirmed in a study of individuals with a clinical diagnosis of Sotos syndrome (some with and some without an NSD1 mutation); it was additionally noted that attention-deficit hyperactivity disorder (ADHD) is not common among individuals with Sotos syndrome [de Boer et al 2006]

Bone age. Bone age often reflects the accelerated growth velocity and is advanced in 75%-80% of prepubertal children. However, bone age interpretation is influenced by the "threshold" taken as significant, the method of assessment, subjective interpretative error, and the age at which the assessment is made.

Cardiac abnormalities. About 20% of individuals have cardiac anomalies that range in severity from single, often self-limiting anomalies including PDA, ASD, and VSD to more severe, complex cardiac abnormalities. Recently two unrelated individuals with Sotos syndrome were shown to have left ventricular non-compaction [Martinez et al 2011]. Only a minority of the cardiac abnormalities associated with Sotos syndrome require surgical intervention.

Cranial MRI/CT abnormalities are identified in the majority of individuals with Sotos syndrome and an NSD1 mutation. Ventricular dilatation (particularly in the trigone region) is most frequently identified, but other abnormalities include midline changes (hypoplasia or agenesis of the corpus callosum, mega cisterna magna, cavum septum pellucidum), cerebral atrophy, and small cerebellar vermis [Waggoner et al 2005].

Dental abnormalities. Premature dental eruption and poor dental quality have been reported [Cole & Hughes 1994, Leventopoulos et al 2009].

Joint hyperlaxity/pes planus. Joint laxity is reported in at least 20% of individuals with Sotos syndrome.

Pregnancy. Complications in pregnancy may occur. In particular, maternal preeclampsia occurs in about 15% of pregnancies of children with Sotos syndrome.

Neonatal complications. Neonates may have jaundice (~65%), hypotonia (~75%), and poor feeding (~70%). These complications tend to resolve spontaneously, but in a small minority intervention is required.

Renal abnormalities. About 15% of individuals with an NSD1 mutation have a renal abnormality; vesicoureteric reflux is the most common. Some individuals may have quiescent vesicoureteric reflux and may present in adulthood with renal impairment.

Scoliosis. Present in about 30% of affected individuals, scoliosis is only rarely severe enough to require bracing or surgery.

Seizures. Approximately 25% of individuals with Sotos syndrome develop non-febrile seizures at some point in their lives and some require ongoing therapy. Absence, tonic-clonic, myoclonic, and partial complex seizures have all been reported.

Other

Tumors. Tumors occur in approximately 3% of persons with Sotos syndrome and include sacrococcygeal teratoma, neuroblastoma, presacral ganglioma, acute lymphoblastic leukemia (ALL) and small cell lung cancer [Hersh et al 1992, Tatton-Brown & Rahman 2004]. De Boer and colleagues have characterized and reviewed these problems and compared persons with Sotos syndrome who have NSD1 mutations to those who do not [de Boer et al 2006].

Various other clinical features have been associated with Sotos syndrome. Some associated features, such as constipation and hearing problems caused by chronic otitis media, are common. If future studies show that some associated features occur in more than 15% of individuals with Sotos syndrome and therefore at higher frequencies than in the general population, these features may be secondary to disruption of NSD1 rather than incidental findings. The following features are seen in 2%-15% of individuals with Sotos syndrome [Tatton-Brown et al 2005b]:

Astigmatism
Cataract
Cholesteatoma
Conductive hearing loss
Constipation
Contractures
Craniosynostosis
Cryptorchidism
Gastroesophageal reflux
Hemangioma
Hemihypertrophy
Hydrocele
Hypercalcemia
Hypermetropia
Hypodontia
Hypoplastic nails
Hypospadias
Hypothyroidism
Inguinal hernia
Myopia
Neonatal hypoglycemia
Nystagmus
Pectus excavatum
Phimosis
Skin hyperpigmentation
Skin hypopigmentation
Strabismus
Talipes equinovarus
Tumors
Umbilical hernia
Vertebral anomalies
2/3 toe syndactyly

Genotype-Phenotype Correlations

Through evaluation of 234 individuals with Sotos syndrome with an NSD1 abnormality, it has been shown that, in general, individuals with a 5q35 microdeletion have less overgrowth and more severe learning disability than individuals with an intragenic mutation [Tatton-Brown et al 2005b].

Genotype-phenotype correlations are not evident between intragenic mutations and 5q35 microdeletions for other clinical features associated with Sotos syndrome (i.e., cardiac abnormalities, renal anomalies, seizures, scoliosis). In addition, no correlations were observed between type of intragenic mutation (missense vs truncating) and phenotype or between position of mutation (5' vs 3') and phenotype [Tatton-Brown et al 2005b].

Penetrance

More than 100 parental samples have been screened [Douglas et al 2003, Rio et al 2003, Turkmen et al 2003, Tatton-Brown et al 2005b]. To date, no NSD1 mutations/deletions have been identified in an unaffected parent or unaffected sib of a child with NSD1-positive Sotos syndrome. Thus, Sotos syndrome appears to be a fully penetrant condition.

Of note, expressivity is highly variable. Individuals with the same mutation, even within the same family, can be affected differently [Tatton-Brown et al 2005b].

Anticipation

Anticipation has not been reported in Sotos syndrome.

Nomenclature

Sotos syndrome takes its name from Juan Sotos, who reported five children with overgrowth, learning disability, and a characteristic facial appearance in 1964.

Prevalence

Sotos syndrome is estimated to occur in 1:14,000 live births [Rahman, unpublished data].

Differential Diagnosis

Overgrowth conditions that may be confused with Sotos syndrome:

Weaver syndrome (also known as Weaver-Smith syndrome). Weaver syndrome has recently been shown to be caused by mutations within the histone methyltransferase, EZH2 [Tatton-Brown et al 2011, Gibson et al 2012]. Affected individuals are tall, have a typical, but subtle, facial appearance, are frequently hypertonic at birth, and often have associated joint problems such as camptodactyly and contractures. The classic facial appearance overlaps with that of Sotos syndrome, particularly in infancy. However, the face in Weaver syndrome is round in shape with ocular hypertelorism. Prognathism is not a feature, but the chin appears "stuck on" and, frequently, a horizontal crease is present between the chin and lower lip. Because of the clinical overlap between Weaver syndrome and Sotos syndrome, NSD1 testing should be considered if an EZH2 mutation is not identified.
Beckwith-Wiedemann syndrome (BWS). Individuals with BWS typically have height and weight at least 2 SD above the mean; macrosomia is a major diagnostic criterion. However, many of the other findings in BWS, including macroglossia, anterior ear lobe creases/helical pits, omphalocele, and visceromegaly, are not evident in Sotos syndrome. Molecular genetic testing can identify epigenetic and genomic alterations of chromosome 11p15 in individuals with BWS: (1) loss of methylation on the maternal chromosome at imprinting center 2 (IC2) in 50% of affected individuals; (2) paternal uniparental disomy for chromosome 11p15 in 20%; and (3) gain of methylation on the maternal chromosome at imprinting center 1 (IC1) in 5%. Sequence analysis of CDKN1C identifies mutations in approximately 40% of familial cases and 5%-10% of cases with no family history of BWS.

Of note, although Baujat et al [2004] reported NSD1 mutations in two individuals with BWS, the individuals do not fulfill the diagnostic criteria for BWS and do fulfill the diagnostic criteria for Sotos syndrome (see Genetically Related Disorders). BWS should be distinguishable from Sotos syndrome clinically. Molecular testing for both conditions is indicated in individuals with clinical overlap.
Simpson-Golabi-Behmel syndrome (SGBS). This X-linked condition is also associated with pre- and postnatal overgrowth in males. However, other features of SGBS not typically found in Sotos syndrome include polydactyly, supernumerary nipples, diastasis recti, and pectus excavatum. The facial gestalt also differs between the two disorders. Microdeletions and mutations of GPC3 encoding the protein glypican 3 are causative.
Bannayan-Riley-Ruvalcaba syndrome. This autosomal dominant condition is characterized by macrocephaly, vascular malformations, hamartomatous polyps of the distal ileum and colon, pigmented macules on the shaft of the penis, lipomas, and increased risk of thyroid and breast cancer. Mutations of PTEN have been found in about 60% of cases. A somewhat similar facial gestalt in combination with overgrowth may lead to confusion with Sotos syndrome, but a detailed clinical examination and molecular genetic testing should differentiate the two conditions.
Benign familial macrocephaly. This autosomal dominant condition is characterized by dolico- or macrocephaly in an individual who is otherwise neurologically normal. It is likely a heterogeneous condition and is usually a diagnosis of exclusion.
Fragile X syndrome. Similarities may exist between fragile X syndrome and Sotos syndrome. However, the two conditions are usually distinguishable on clinical grounds; molecular testing confirms the diagnosis.
Nevoid basal cell carcinoma syndrome (NBCCS, or Gorlin syndrome) is characterized by the development of multiple jaw keratocysts, frequently beginning in the second decade of life, and/or basal cell carcinomas usually from the third decade onwards. Most individuals have skeletal anomalies such as bifid ribs or wedge-shaped vertebrae. About 60% of individuals have a recognizable appearance with macrocephaly, bossing of the forehead, and coarse facial features. Head circumference increases above the 98th centile until age ten to 18 months, but is not usually associated with global developmental delay. NBCCS is caused by germline mutations in PTCH. Inheritance is autosomal dominant.
Chromosomal abnormalities. A Sotos syndrome-like phenotype has been associated with 4p duplications, mosaic 20p trisomy [Faivre et al 2000], and 22q13.3 deletion syndrome. Karyotyping should identify these chromosome abnormalities.
Nonspecific overgrowth. Many individuals with overgrowth do not fulfill the diagnostic criteria for any of the above conditions but nevertheless have other features (e.g., learning difficulties, distinctive facial features) that suggest an underlying genetic cause. Nonspecific overgrowth is likely to be a heterogeneous group of conditions with multiple causes.

Note to clinicians: For a patient-specific ‘simultaneous consult’ related to this disorder, go to , an interactive diagnostic decision support software tool that provides differential diagnoses based on patient findings (registration or institutional access required).

Management

Evaluations Following Initial Diagnosis

To establish the extent of disease in an individual diagnosed with Sotos syndrome, the following evaluations are recommended [Tatton-Brown & Rahman 2007]:

A thorough history to identify known features/associations of the disorder: learning difficulties, cardiac and renal anomalies, seizures, and scoliosis
Physical examination including cardiac auscultation, blood pressure measurement, and back examination for scoliosis
Investigations to detect abnormalities before they result in significant morbidity/mortality:
- In children in whom the diagnosis has just been established, echocardiogram and renal ultrasound examination
- In adults in whom the diagnosis has just been established, renal ultrasound examination to evaluate for renal damage from quiescent chronic vesicoureteric reflux
- Referral for audiologic assessment. Conductive hearing loss may occur at an increased frequency in Sotos syndrome; thus, the threshold for referral should be low.
Medical genetics consultation

Treatment of Manifestations

When clinical problems (e.g., cardiac abnormalities, seizures, renal problems, scoliosis) or difficulties with learning/behavior/speech are identified, referral to the appropriate specialist is recommended.

If MRI has been performed and ventricular dilatation demonstrated, shunting should not usually be necessary as the "arrested hydrocephalus" associated with Sotos syndrome is typically non-obstructive and not associated with raised intracranial pressure. If raised intracranial pressure is suspected, investigation and management in consultation with neurologists and neurosurgeons would be appropriate.

Some children in North America have been prescribed Ritalin^® with varying success; in Europe, behavioral management strategies are more commonly used, again with varying success.

Prevention of Secondary Complications

Antibiotic prophylaxis is indicated in individuals with proven vesicoureteric reflux.

Surveillance

Regular review (by a general pediatrician) is recommended for younger children, individuals with many medical complications needing coordination of medical specialists, and families requiring more support than average [Tatton-Brown & Rahman 2007].

The clinician may wish to review less frequently older children/teenagers and those individuals without many medical complications.

The following are appropriate at the clinical review:

Thorough history to identify known clinical sequelae of Sotos syndrome
Examination for curvature of the spine
Cardiac auscultation
Blood pressure measurement
Referral for audiologic assessment if hearing is a concern or if the child has had many upper respiratory tract infections
Referral to an ophthalmologist if strabismus or other problem with vision is suspected
Urine dipstick to assess for quiescent urine infection
Referral to the appropriate clinical specialist if problems are identified

Note: Cancer screening is not recommended. (1) The absolute risk of sacrococcygeal teratoma and neuroblastoma is low (~1%) [Tatton-Brown et al 2005b, Tatton-Brown & Rahman 2007]. This level of risk does not warrant routine screening, particularly as screening for neuroblastoma has not been shown to decrease mortality and can lead to false positive results [Schilling et al 2002]. (2) Wilms tumor risk is not significantly increased and routine renal ultrasound examination is not indicated [Scott et al 2006].

Evaluation of Relatives at Risk

See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.

Therapies Under Investigation

Search ClinicalTrials.gov for access to information on clinical studies for a wide range of diseases and conditions. Note: There may not be clinical trials for this disorder.

Genetic Counseling

Genetic counseling is the process of providing individuals and families with information on the nature, inheritance, and implications of genetic disorders to help them make informed medical and personal decisions. The following section deals with genetic risk assessment and the use of family history and genetic testing to clarify genetic status for family members. This section is not meant to address all personal, cultural, or ethical issues that individuals may face or to substitute for consultation with a genetics professional. —ED.

Mode of Inheritance

Sotos syndrome is inherited in an autosomal dominant manner.

Risk to Family Members

Parents of a proband

About 5% of individuals diagnosed with Sotos syndrome have an affected parent.
The remaining approximately 95% of individuals have a de novo mutation.
If a parent of an individual with an identified NSD1 aberration does not have any clinical features of Sotos syndrome, that parent is very unlikely to have a mutation in NSD1. This can be confirmed with molecular genetic testing if the NSD1 mutation has been identified in the proband.

Sibs of a proband

The risk to the sibs of a proband depends on the genetic status of the proband's parents.
If a parent of the proband has a pathogenic mutation, the risk to the sibs of inheriting the mutation is 50%.
The risk to the sibs of a proband with clinically unaffected parents is less than 1%. This residual risk is based on the theoretic risk for germline mosaicism and the background risk for a second de novo mutation occurring in the same family. To date, no recurrences caused by germline mosaicism have been reported.

Offspring of a proband

Each child of an individual with an identified NSD1 aberration or a clinical diagnosis of Sotos syndrome has a 50% chance of inheriting the mutation.
Phenotypic expression can vary from one generation to the next and thus it is not possible to accurately predict how offspring may be affected.

Other family members of a proband

The risk to other family members depends on the status of the proband's parents.
If a parent is affected, his or her family members may be at risk.

Related Genetic Counseling Issues

Considerations in families with an apparent de novo mutation. When neither parent of a proband with an autosomal dominant condition has the pathogenic mutation or clinical evidence of the disorder, it is extremely likely that the proband has a de novo mutation. However, possible non-medical explanations including alternate paternity or maternity (e.g., with assisted reproduction) or undisclosed adoption could also be explored.

Family planning

The optimal time for determination of genetic risk and discussion of the availability of prenatal testing is before pregnancy.
It is appropriate to offer genetic counseling (including discussion of potential risks to offspring and reproductive options) to young adults who are affected.

DNA banking is the storage of DNA (typically extracted from white blood cells) for possible future use. Because it is likely that testing methodology and our understanding of genes, mutations, and diseases will improve in the future, consideration should be given to banking DNA of affected individuals.

Prenatal Testing

Molecular genetic testing. If the disease-causing mutation has been identified in the family, prenatal diagnosis for pregnancies at increased risk is possible by analysis of DNA extracted from fetal cells obtained by amniocentesis (usually performed at ~15-18 weeks’ gestation) or chorionic villus sampling (usually performed at ~10-12 weeks’ gestation).

Ultrasound examination. Prenatal diagnosis cannot be accurately accomplished by ultrasound examination: the features of Sotos syndrome likely to be detected by ultrasound examination, such as macrocephaly and increased length, are nonspecific.

Note: Gestational age is expressed as menstrual weeks calculated either from the first day of the last normal menstrual period or by ultrasound measurements.

Preimplantation genetic diagnosis (PGD) may be an option for some families in which the disease-causing mutation has been identified.

Resources

GeneReviews staff has selected the following disease-specific and/or umbrella support organizations and/or registries for the benefit of individuals with this disorder and their families. GeneReviews is not responsible for the information provided by other organizations. For information on selection criteria, click here.

Sotos Syndrome Support Association (SSSA)
PO Box 4626
Wheaton IL 60189
Phone: 888-246-7772 (toll-free)
Email: info@sotosyndrome.org
www.sotossyndrome.org

Molecular Genetics

Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED.

Table A. Sotos Syndrome: Genes and Databases

Gene Symbol	Chromosomal Locus	Protein Name	Locus Specific	HGMD
NSD1	5q35.2-q35.3	Histone-lysine N-methyltransferase, H3 lysine-36 and H4 lysine-20 specific	Nuclear receptor binding SET Domain protein 1 (NSD1) @ LOVD	NSD1

: Data are compiled from the following standard references: gene symbol from HGNC; chromosomal locus, locus name, critical region, complementation group from OMIM; protein name from UniProt. For a description of databases (Locus Specific, HGMD) to which links are provided, click here.

Table B. OMIM Entries for Sotos Syndrome (View All in OMIM)

117550	SOTOS SYNDROME 1; SOTOS1
606681	NUCLEAR RECEPTOR-BINDING Su-var, ENHANCER OF ZESTE, AND TRITHORAX DOMAIN PROTEIN 1; NSD1

Normal allelic variants. NSD1 comprises 22 coding exons (NM_022455.4). Many normal variants have been identified [Douglas et al 2003, Kurotaki et al 2003, Rio et al 2003, Turkmen et al 2003, Tatton-Brown et al 2005b].

Pathologic allelic variants. More than 100 pathogenic allelic variants have been published. No mutational hot spots have been identified [Douglas et al 2003, Kurotaki et al 2003, Rio et al 2003, Turkmen et al 2003, Faravelli 2005, Tatton-Brown et al 2005b]. See Table A.

A recurrent 1.9-Mb 5q35 microdeletion encompassing NSD1 has been reported in most Japanese and some non-Japanese individuals with Sotos syndrome [Kurotaki et al 2003, Tatton-Brown et al 2005a, Tatton-Brown et al 2005b, Visser et al 2005]. The majority are generated by nonallelic homologous recombination between flanking low-copy repeats [Kurotaki et al 2003, Tatton-Brown et al 2005a, Visser et al 2005]. Many of these recurrent deletions have the same breakpoints, and a specific chromatin structure may increase recurrent crossover events and predispose to recombination hot spots at 5q35 [Visser et al 2005].

Normal gene product. Only limited data exist regarding the functions of histone-lysine N-methyltransferase, H3 lysine-36 and H4 lysine-20 specific (NSD1), a protein of 2696 amino acids. It is expressed in the brain, kidney, skeletal muscle, spleen, thymus, and lung. NSD1 contains at least 12 functional domains including two nuclear receptor interaction domains (NID^-L and NID^+L), two proline-tryptophan-tryptophan-proline (PWWP) domains, five plant homeo domains (PHD), and a SET (su(var)3-9, enhancer of zeste, trithorax) domain. The most distinctive of these domains are the SET and associated SAC (SET-associated Cys-rich) domains, which are found in histone methyltransferases that regulate chromatin states. The SET domain of NSD1 has unique histone specificity, methylating K36 on H3 and K20 on H4 [Rayasam et al 2003]. PHDs are also typically found in proteins that act at the chromatin level, and PWWP domains are implicated in protein-protein interactions and are often found in methyltransferases. The nuclear receptors of NSD1, NID^-L, and NID^+L are typical of those found in corepressors and coactivators [Huang et al 1998]. The presence of these distinctive domains suggests that NSD1 is a histone methyltransferase that acts as a transcriptional intermediary factor capable of both negatively and positively influencing transcription, depending on the cellular context [Kurotaki et al 2001].

Abnormal gene product. How functional abrogation of NSD1 results in Sotos syndrome is not currently known.

References

Medical Genetic Searches: A specialized PubMed search designed for clinicians that is located on the PubMed Clinical Queries page

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Chapter Notes

Revision History

8 March 2012 (me) Comprehensive update posted live
10 December 2009 (me) Comprehensive update posted live
23 March 2007 (me) Comprehensive update posted live
17 December 2004 (me) Review posted to live Web site
26 May 2004 (tc) Original submission

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