Rubinstein-Taybi syndrome (RSTS) is characterized by distinctive facial features, broad and often angulated thumbs and great toes, short stature, and moderate to severe intellectual disability. The characteristic craniofacial features are downslanted palpebral fissures, low hanging columella, high palate, grimacing smile, and talon cusps. Prenatal growth is often normal; however, height, weight, and head circumference percentiles rapidly drop in the first few months of life. Obesity may occur in childhood or adolescence. IQ scores range from 25 to 79; average IQ is between 36 and 51. Other variable findings are coloboma, cataract, congenital heart defects, renal abnormalities, and cryptorchidism.
The diagnosis of RSTS is primarily based on clinical features. Chromosome abnormalities are occasionally observed on routine cytogenetic testing. CREBBP and EP300 are the only genes currently known to be associated with RSTS. FISH analysis of CREBBP detects microdeletions in approximately 10% of individuals with RSTS. Sequence analysis detects CREBBP pathogenic variants in another 40%-50% of affected individuals. Pathogenic variants in EP300 are identified in approximately 3%-8% of individuals with RSTS.
Treatment of manifestations: Early intervention programs, special education, vocational training to address developmental disabilities, and referral to behavioral specialists/psychologists and support groups/resources for family members; standard treatment for eye abnormalities, hearing loss, cardiac defects, cryptorchidism, and sleep apnea; surgical repair of significantly angulated thumbs or duplicated halluces; aggressive management of gastroesophageal reflux and constipation.
Surveillance: Monitoring of growth and feeding, especially in the first year of life; annual eye and hearing evaluations; and routine monitoring for cardiac, dental, and renal anomalies.
RSTS is inherited in an autosomal dominant manner. RSTS typically occurs as the result of a de novo pathogenic variant in the family; most individuals represent simplex cases (i.e., the only affected member in a family). In most instances, the parents of an individual with RSTS are not affected. When the parents are clinically unaffected, the empiric recurrence risk for sibs is less than 1%. Individuals with RSTS rarely reproduce. The risk to offspring is 50%. Prenatal testing for pregnancies at increased risk is possible if the pathogenic variant or deletion in the family is known.
The diagnosis of Rubinstein-Taybi syndrome (RSTS) is established by clinical findings.
- Craniofacial appearance (see Figure 1)
- Downslanted palpebral fissures
- Convex nasal ridge with low hanging columella
- High palate
- Grimacing smile
- Talon cusps, an accessory cusp-like structure on the lingual side of the tooth, usually occurring on the maxillary incisors of the permanent dentition
- The thumbs and great toes are almost always broad and often angulated.
- The distal phalanges of the fingers may appear broad.
- The proximal phalanges may be abnormally shaped. Radiographs of the hands and feet in individuals with RSTS are unusual but not necessarily diagnostic.
- Almost all males have undescended testes.
- Structural abnormalities of the urinary tract are common.
- Congenital heart defects of various types occur in approximately one third of individuals with RSTS.
- While prenatal growth is often normal, height, weight, and head circumference percentiles rapidly drop in the first few months of life. Short stature is typical in adulthood.
- Obesity may occur in childhood or adolescence and short stature is typical in adulthood.
Intellectual disability. The average IQ ranges between 35 and 50; however, developmental outcome varies considerably. A few individuals have been reported with IQs in the 70s.
Molecular Genetic Testing
Genes. CREBBP and EP300 are the only genes currently known to be associated with Rubinstein-Taybi syndrome (RSTS) [Roelfsema et al 2005].
Confirming the diagnosis in a proband. The diagnosis of RSTS is primarily clinical.
When the diagnosis is in question or features are atypical or very severe:
- Sequence analysis of CREBBP can be considered first; followed by duplication/deletion analysis if no pathogenic variant is detected through sequence analysis.
- If a pathogenic variant in CREBBP is not identified, sequence analysis and/or deletion/duplication analysis of EP300 may be considered.
Rubinstein-Taybi syndrome (RSTS) is frequently recognized at birth or in infancy because of the striking facial features and characteristic hand and foot findings. Problems in early life include respiratory difficulties, feeding problems, poor weight gain, recurrent infections, and severe constipation. Moderate intellectual disability is typical.
Neurologic. Occasional craniospinal and posterior fossa abnormalities including Chiari malformation, syringomyelia, os odontoideum and cervical cord compression have been reported [Marzuillo et al 2013].
Eye. Eye findings include strabismus, refractory errors, ptosis, nasolacrimal duct obstruction, cataracts, coloboma, nystagmus, glaucoma, and corneal abnormalities. van Genderen et al  demonstrated a high frequency of retinal dysfunction on ERG.
Cardiac. Approximately one third of affected individuals have a variety of congenital heart defects.
Genitourinary. Renal abnormalities are very common and almost all boys have undescended testes.
Orthopedic. Orthopedic issues include dislocated patellas, lax joints, spine curvatures, Legg-Perthes disease, slipped capital femoral epiphysis, and cervical vertebral abnormalities [Yamamoto et al 2005].
Sleep apnea. Obstructive sleep apnea is often a considerable problem and may be caused by the combination of a narrow palate, micrognathia, hypotonia, obesity, and easy collapsibility of the laryngeal walls.
Skin. Keloids may occur with only minimal trauma to the skin. Pilomatrixomas have been reported [Bayle et al 2004].
Dental. Dental problems include crowding of teeth, malocclusion, multiple caries, hypodontia, hyperdontia, natal teeth, and talon cusps on the upper incisors of the secondary dentition.
Tumors. Tumors reported in individuals with RSTS include meningioma, pilomatrixoma, rhabdomyosarcoma, pheochromocytoma, neuroblastoma, medulloblastoma, oligodendroglioma, leioyosarcoma, seminoma, odontoma, choristoma, and leukemia [Roelfsema & Peters 2007].
Growth. Although prenatal growth is usually normal, parameters for height, weight, and head circumference fall below the fifth percentile during infancy. Males often become overweight during childhood while females become overweight during adolescence. Average height for adult males is 153.1 cm and for adult females is 146.7 cm. Stevens et al  published growth grids.
Puberty. Puberty and sexual development are normal.
Intellect. Delayed development is typical in children with RSTS. In one study, the average age of walking was 30 months, first words 25 months, and toilet training 62 months. Speech delay occurs in 90% of children and some remain largely nonverbal.
The average IQ in one study was 51 and in another study was 36. IQ scores range from 25 to 79. The performance IQ is usually higher than the verbal IQ.
In one study of adults with RSTS [Stevens et al 2011] families reported a decline in abilities over time in 32%, including decreased social interaction, more limited speech, and worsening stamina and mobility.
Behavior. Short attention span, decreased tolerance for noise and crowds, impulsivity, and moodiness are frequently observed. Schorry et al  noted frequent autistic behaviors in their study of 93 affected individuals. Other abnormal behaviors included attention problems, hyperactivity, self-injurious behaviors, and aggressive behaviors. Similar concerns regarding behavior were reported in adults with RSTS, with approximately 62% of affected adults reported to have autistic-like behaviors [Stevens et al 2011].
Schorry et al  studied 93 individuals with RSTS and noted 52 with definitive CREBBP pathogenic variants. No significant differences were found in congenital anomalies, tumors, dysmorphic features, or level of intellectual impairment between those with and without pathogenic variants. Growth retardation tended to be greater in the group without pathogenic variants but this was not statistically significant. However, seizures were more common in those with CREBBP pathogenic variants. Individuals with large deletions trended toward more severe cognitive impairment and autistic behavior, although this did not reach statistical significance.
See Genetically Related Disorders for a discussion of contiguous gene deletions involving CREBBP.
Several individuals have been found to have EP300 pathogenic variants [Bartholdi et al 2007, Zimmermann et al 2007, Bartsch et al 2010b, Negri et al 2015]. The features in these persons are said to be milder, particularly the skeletal findings. Some have normal hands and feet. Intellectual development also appears to be less affected, with intelligence ranging from normal to moderate intellectual disability.
Hennekam et al [1990b] reported a birth prevalence of 1:100,000 to 1:125,000 for RSTS in the Netherlands.
The majority of individuals reported with RSTS are of European origin; however, some black and Asian individuals with RSTS have been seen. Whether the occurrence of RSTS is lower in non-white populations or the observed difference is the result of other factors is not known.
Genetically Related (Allelic) Disorders
No phenotypes other than those discussed in this GeneReview are known to be associated with germline mutation of CREBBP and EP300.
Microduplications of CREBBP have been reported in several individuals [Marangi et al 2008, Thienpont et al 2010, Mattina et al 2012, Demeer et al 2013]. The phenotype consists of mild to moderate intellectual disability, normal growth, characteristic facial appearance minor extremity abnormalities and variable other features.
Deletions of 16p encompassing CREBBP. Although several authors reported no phenotypic differences in individuals with and without 16p deletions encompassing CREBBP [Blough et al 2000, Petrij et al 2000], Hennekam et al  found an increased frequency of microcephaly, partial duplication of the hallux, and angulation of the first rays of the hands and feet in those with deletions. No difference in mental functioning was apparent.
Hou  suggested that disease severity correlated with size of deletion including CREBBP. Bartsch et al  reported three individuals with severe RSTS (including failure to thrive, life-threatening infections, and death in infancy) who had large deletions encompassing CREBBP and the contiguous genes DNASE1 and TRAP1. However, Gervasini et al  and Stef et al  reported affected individuals with deletions of similar scope who did not have a severe phenotype.
Given the distinctive facial features and hand and foot abnormalities, the diagnosis of Rubinstein-Taybi syndrome (RSTS) is usually straightforward.
Broad/angulated thumbs and great toes may be seen in the FGFR-related craniosynostosis syndromes (i.e., Pfeiffer syndrome and Apert syndromes), Saethre-Chotzen syndrome, and Greig cephalopolysyndactyly syndrome. The presence of craniosynostosis and the difference in facial features should differentiate these disorders.
The eight disorders considered as part of the FGFR-related craniosynostosis syndromes are Pfeiffer syndrome, Apert syndrome, Crouzon syndrome, Beare-Stevenson syndrome, FGFR2-related isolated coronal synostosis, Jackson-Weiss syndrome, Crouzon syndrome with acanthosis nigricans, and Muenke syndrome (FGFR3-related isolated coronal synostosis). All but Muenke syndrome and FGFR2-related isolated coronal synostosis are characterized by bicoronal craniosynostosis or cloverleaf skull, distinctive facial features, and variable hand and foot findings; Muenke syndrome and FGFR2-related isolated coronal synostosis are characterized only by uni- or bicoronal craniosynostosis. The diagnosis of Muenke syndrome (FGFR3-related coronal synostosis) is based on identification of a pathogenic variant in FGFR3. The diagnosis of FGFR2-related isolated coronal synostosis is based on identification of a pathogenic variant in FGFR2. The diagnosis of the other six FGFR-related craniosynostoses is based on clinical findings; however, molecular genetic testing of FGFR1, FGFR2, and FGFR3 may be helpful in establishing the diagnosis of these syndromes in questionable cases. FGFR-related craniosynostosis is inherited in an autosomal dominant manner.
Classic Saethre-Chotzen syndrome is characterized by coronal synostosis (unilateral or bilateral), facial asymmetry (particularly in individuals with unicoronal synostosis), ptosis, and characteristic appearance of the ear (small pinna with a prominent crus). Syndactyly of digits two and three of the hand is variably present. Although mild-to-moderate developmental delay and intellectual disability have been reported, normal intelligence is more common. Less common manifestations of Saethre-Chotzen syndrome include short stature, parietal foramina, vertebral fusions, radioulnar synostosis, cleft palate, maxillary hypoplasia, widely spaced eyes, hallux valgus, duplicated distal hallucal phalanx, and congenital heart malformations. The diagnosis of Saethre-Chotzen syndrome is made primarily on clinical findings. Occasionally, affected individuals have a chromosome translocation involving 7p21 or ring chromosome 7. TWIST1 is the only gene known to be associated with Saethre-Chotzen syndrome. TWIST1 pathogenic variants are identified in 46%-80% of affected individuals using a combination of deletion/duplication analysis and sequence analysis (exon 1). Saethre-Chotzen syndrome is inherited in an autosomal dominant manner.
Typical Greig cephalopolysyndactyly syndrome (GCPS) is characterized by preaxial polydactyly or mixed pre- and postaxial polydactyly, widely spaced eyes, and macrocephaly. Individuals with mild GCPS may have subtle craniofacial findings. The mild end of the GCPS spectrum is a continuum with preaxial polysyndactyly type 4 and crossed polydactyly (preaxial polydactyly of the feet and postaxial polydactyly of the hands plus syndactyly of fingers 3-4 and toes 1-3). Individuals with severe GCPS can have seizures, hydrocephalus, and intellectual disability. The diagnosis of GCPS is based on clinical findings and family history. GLI3 is the only gene known to be associated with GCPS; GLI3 alterations (i.e., cytogenetic abnormalities involving GLI3 or pathogenic variants of GLI3) can be identified in more than 75% of typically affected individuals. It is inherited in an autosomal dominant manner.
Broad thumbs are seen in brachydactyly type D as an isolated finding. Unilateral or bilateral shortening of the distal phalanx of the thumb is present. Inheritance is autosomal dominant.
The facial features of Floating-Harbor syndrome can appear similar to RSTS in some individuals. This syndrome is characterized by typical craniofacial features; low birth weight, normal head circumference, and short stature; bone age delay that normalizes between ages six and 12 years; skeletal anomalies (brachydactyly, clubbing, clinodactyly, short thumbs, prominent joints, clavicular abnormalities); severe receptive and expressive language impairment; hypernasality and high-pitched voice; and intellectual disability that is typically mild to moderate. The hand and foot findings are distinct from those of RSTS. Floating-Harbor syndrome is caused by a pathogenic variant in SRCAP, which encodes an SNF2-related chromatin-remodeling factor that serves as a coactivator for CREBBP. This likely accounts for the phenotypic overlap with RSTS.
Cotsirilos et al  reported a mother and two children with RSTS-like facial and extremity features but with normal intelligence.
Keipert syndrome is characterized by broad thumbs and halluces but is distinguished by hearing loss and characteristic facial features.
Kargi et al  reported an individual with hand and foot findings similar to those of RSTS who also had mild pterygia.
Evaluations Following Initial Diagnosis
To establish the extent of disease and needs in an individual diagnosed with Rubinstein-Taybi syndrome (RSTS), the following evaluations are suggested [Wiley et al 2003]:
- Measurement of growth and plotting of parameters on published syndrome-specific growth charts
- Multidisciplinary developmental evaluation including assessment of gross and fine motor skills, speech/language, cognitive abilities, and vocational skills
- Ophthalmologic examination
- Hearing evaluation using auditory brain stem evoked response testing (see Deafness and Hereditary Hearing Loss Overview for details of evaluation)
- Dental and orthodontic evaluations
- Echocardiogram or evaluation by cardiologist for structural heart defects
- Assessment for gastroesophageal reflux as warranted
- Assessment for constipation
- Renal ultrasound examination
- Assessment for presence of cryptorchidism in males
- Orthopedic assessment of thumbs and halluces, joints and spine
- Evaluation of obstructive sleep apnea if indicated by snoring, particular sleeping posture, wakefulness at night, and excessive sleepiness during the daytime.
- Ultrasound of the spinal canal in the neonatal period to screen for tethered cord; MRI of the spinal canal should be performed in older children, if symptomatic.
- Clinical genetics consultation
Treatment of Manifestations
The following are appropriate:
- Early intervention programs, special education, and vocational training to address developmental disabilities
- Standard treatment for refractive errors, strabismus, glaucoma, cataracts, and other eye abnormalities if identified
- Standard treatment for hearing loss if identified
- Standard treatment for cardiac defects if identified
- Aggressive management of gastroesophageal reflux and constipation
- Standard treatment for cryptorchidism if identified
- Surgical repair of significantly angulated thumbs or duplicated halluces
- Appropriate treatment for sleep apnea if identified
- Behavior management strategies including referral to a behavioral specialist/psychologist and consideration of medication if needed
- Referral of the family to support groups and other resources
Prevention of Secondary Complications
Individuals with RSTS can be difficult to intubate because of the easy collapsibility of the laryngeal wall. An anesthesiologist comfortable with managing complex pediatric airway problems should therefore administer general anesthesia when needed. Because of these problems, individuals with RSTS may require earlier intubation and later extubation than other individuals undergoing similar procedures.
Surveillance includes the following:
- Close monitoring of growth, especially in the first year of life
- Annual follow-up evaluation for ophthalmologic abnormalities
- Yearly audiologic screens; more frequent evaluation if a history of multiple episodes of otitis media exists
- Monitoring as per routine for cardiac or renal anomalies
- Regular dental and orthodontic follow up
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 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
Rubinstein-Taybi syndrome (RSTS) is inherited in an autosomal dominant manner.
Risk to Family Members
Parents of a proband
- RSTS typically occurs as a de novo event in the family; most individuals are the only affected member of their families. The parents of most individuals with RSTS are not affected. However, because of variable clinical expression, and reports of mildly affected parents with somatic mosaicism [Chiang et al 2009, Bartsch et al 2010a], there is a small chance that a parent with normal intelligence could have a CREBBP pathogenic variant.
- Recommendations for the evaluation of parents of a proband include clinical examination for physical findings associated with RSTS. Bartsch et al [2010a] recommended that parents of an individual identified to have a mild CREBBP pathogenic variant, such as a missense variant or small in-frame deletion, should undergo molecular testing for the pathogenic variant.
Sibs of a proband
- The risk to the sibs of the proband depends on the genetic status of the proband's parents.
- When the parents are clinically unaffected, the empiric recurrence risk for sibs is less than 1%.
- If neither parent of the proband has the CREBBP or EP300 pathogenic variant identified in the proband detectable in their DNA, it is presumed that the proband has a de novo pathogenic variant and the risk to the sibs of the proband depends on the probability of germline mosaicism. Germline mosaicism has been reported in the parents of individuals with RSTS [Chiang et al 2009, Tajir et al 2013].
Offspring of a proband. Parent-to-child transmission of RSTS has been reported [Cotsirilos et al 1987, Hennekam et al 1989, Marion et al 1993, Petrij et al 2000, Bartsch et al 2010a]. The risk to offspring of an individual with RSTS of inheriting RSTS is 50%.
Other family members of a proband. The risk to other family members of a proband depends on the genetic status of the proband’s parents.
Related Genetic Counseling Issues
- 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 have had a child with RSTS.
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, allelic variants, and diseases will improve in the future, consideration should be given to banking DNA of affected individuals.
Prenatal Testing and Preimplantation Genetic Diagnosis
Once the CREBBP or EP300 pathogenic variant has been identified in an affected family member, prenatal testing and preimplantation genetic diagnosis for a pregnancy at increased risk for Rubinstein-Taybi syndrome are possible options.
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.
- National Library of Medicine Genetics Home Reference
- Rubinstein-Taybi Parent GroupKSPhone: 785-697-2984Fax: 785-697-2985Email: email@example.com
- Rubinstein-Taybi Syndrome Book for Families
Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED.
|Gene||Chromosome Locus||Protein||Locus Specific||HGMD|
|CREBBP||16p13||CREB-binding protein||CREB Binding Protein (CREBBP) @ LOVD||CREBBP|
|EP300||22q13||Histone acetyltransferase p300||E1A binding protein p300 (EP300) @ LOVD||EP300|
Gene structure. CREBBP is 154 kb in size and includes 31 transcribed exons (NM_004380.2 ) [Petrij et al 2000, Coupry et al 2002, Petrij et al 2004]. For a detailed summary of gene and protein information see Table A, Gene.
Pathogenic allelic variants. Evidence suggests that Rubinstein-Taybi syndrome (RSTS) is caused by haploinsufficiency of CREBBP product [Petrij et al 2001]. Microdeletions are seen in approximately 10% of individuals with RSTS [Petrij et al 2000, Petrij et al 2004, Schorry et al 2008]. More than 150 pathogenic variants in CREBBP are known; they include frameshift, nonsense, splice site and missense variants [van Belzen et al 2011].
Normal gene product. The CREBB-binding protein (CREBBP) is ubiquitously expressed and is involved in transcriptional coactivation of many different transcription factors. It has intrinsic histone acetyltransferase activity and acts as a scaffold to stabilize additional protein interactions with the transcription complex via chromatin remodeling. It is a mediator of different signaling pathways and can also act as a negative regulator of the cell cycle by repressing the transition from G1 to S phase [Petrij et al 2001].
Abnormal gene product. Germline pathogenic variants in CREBBP may lead to a truncated CREB-binding protein or one with an amino acid substitution. Pathogenic variants in the HAT domain interfere with the acetylation of histones, which is an important step in transcription activation. Somatic pathogenic variants in CREBBP may lead to cancer, as CREBBP also functions as a tumor suppressor.
Pathogenic allelic variants. RSTS can be caused by pathogenic variants in EP300 [Roelfsema et al 2005] including deletions, duplications, and single-nucleotide variants [Negri et al 2015]. Three of 92 individuals with RSTS studied by Roelfsema et al  were found to have pathogenic variants in EP300. Negri et al  studied 33 CREBBP-negative patients with RSTS and identified six with pathogenic variants in EP300.
Pathogenic variants in EP300 may also lead to cancer, as the gene functions as a tumor suppressor.
Normal gene product. EP300 encodes the p300 transcriptional co-activator protein, which shares 63% homology with CREBBP at the amino acid level [Iyer et al 2004]. It functions as histone acetyltransferase that regulates transcription via chromatin remodeling and is important in the processes of cell proliferation and differentiation [Gayther et al 2000].
Abnormal gene product. Pathogenic variants result in truncated p300 protein or absence of allele expression, which may lead to loss of HAT activity.
Cancer and Benign Tumors
CREBBP and EP300 participate in various tumor-suppressor pathways and somatic pathogenic variants of these genes occur in a number of malignancies. Somatic translocations t(8;16) (p11;p11.3) involving CREBBP and t(8;22)(p11;q13) involving EP300 [Kitabayashi et al 2001] are associated with acute myelogenous leukemia and treatment-related hematologic disorders [Iyer et al 2004]. Some heterozygous Crebbp-knockout mice develop lymphomas.
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The Rubinstein-Taybi Syndrome Program at Cincinnati Children’s is one of the country’s leading programs for the care of children with RTS and provides expert confirmation of diagnosis as well as the latest treatments and support.
- 7 August 2014 (me) Comprehensive update posted live
- 20 August 2009 (cd) Revision: sequence analysis, deletion/duplication analysis, and prenatal diagnosis available clinically for EP300 mutations
- 16 April 2009 (me) Comprehensive update posted live
- 26 June 2007 (cd) Revision: sequence analysis and mutation scanning available clinically
- 2 October 2006 (me) Comprehensive update posted to live Web site
- 20 December 2005 (cs) Revision: EP300 mutations found to cause some cases of RSTS
- 13 September 2004 (cd) Revision: testing
- 22 July 2004 (me) Comprehensive update posted to live Web site
- 30 August 2002 (tk,me) Review posted to live Web site
- 5 April 2002 (cs) Original submission
University of Tennessee College of Medicine
Initial Posting: August 30, 2002; Last Update: August 7, 2014.
University of Washington, Seattle, Seattle (WA)
Stevens CA. Rubinstein-Taybi Syndrome. 2002 Aug 30 [Updated 2014 Aug 7]. In: Pagon RA, Adam MP, Ardinger HH, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2016.