C o m m e n t a r y
Dyskeratosis congenita genesDyskeratosis congenita (DC) was first described in 1910 in two brothers who presented with skin pigmentation anomalies, leukoplakia, and nail dystrophy in childhood (1). Anemia later emerged as a common DC feature, and autosomal dominant, recessive, and X-linked recessive forms of inheritance for this disease are now recognized. In the 1990s, the X-linked DC locus was mapped to chromosomal region Xq28 (2, 3), and DKC1, which encodes the 57 kD protein dyskerin, was identified in 1998 as the causative gene within Xq28 (4). Dyskerin is homologous to the wellcharacterized yeast protein Cbf5p, which is a pseudouridine synthase that acts on ribosomal RNA and spliceosomal small nuclear RNA (snRNA) (5, 6). Following the discovery that dyskerin was also part of the telomerase complex in vertebrates (7) -and the identification of mutations in telomerase RNA (8) and telomerase reverse transcriptase (TERT) (9, 10) as causes of autosomal dominant DC -dysfunctional telomere maintenance was recognized as the basis for the development of DC. Moreover, patients with DC generally have very short telomeres at presentation. In the last decade, seven additional genes have been linked to DC, making a total of ten known DC-causing genes (11), all of which encode products that are involved in telomere maintenance. Some of these products -including TERT, the telomerase RNA component (TERC), dyskerin, and ribonucleoproteins NOP10 and NHP2 -are components of the telomerase complex. TCAB1 is important for telomerase-complex assembly and trafficking. Mutations in TINF2 and ACD -genes that encode components of the shelterin complex, which protects telomeres from degradation or from being recognized by the DNA damage machinery -are also associated with DC (12). Still other DC-associated genes, such as CTS telomere maintenance complex component 1 (CTC1) and regulator of telomere elongation helicase 1 (RTEL1), are necessary for telomere replication. Patients with classical DC and other inherited forms of the disease can present with a wide range of features in addition to the classic mucocutaneous manifestations and BM aplasia. Pulmonary fibrosis, liver cirrhosis, enteropathy, and a variety of cancers -including leukemia -are also commonly observed in these individuals (13). ), which is in a conserved N-terminal domain of the protein that is essential for nuclease activity. In a second family, the individual with HHS was homozygous for a point mutation that abolishes a donor splicing site in the PARN transcript, and analysis of mRNA in blood from this patient revealed an absence of properly spliced PARN RNA and the presence of two different PARN transcripts, one of which was missing one exon and the other two exons. In a third family, the affected child was a compound heterozygote at the PARN locus and harbored one allele with a single base insertion that resulted in a frameshift and one allele with an insertion in a donor splice site that was predicted to abolish splicing. Moreover, compared to h...