Clinical characteristics.

Floating-Harbor syndrome (FHS) 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. Difficulties with temperament and behavior that are present in many children tend to improve in adulthood. Other features can include hyperopia and/or strabismus, conductive hearing loss, seizures, gastroesophageal reflux, renal anomalies (e.g., hydronephrosis / renal pelviectasis, cysts, and/or agenesis), and genital anomalies (e.g., hypospadias and/or undescended testes).

Diagnosis/testing.

The diagnosis is established by identification of a heterozygous SRCAP pathogenic variant in those with clinical findings of FHS.

Management.

Treatment of manifestations: Early intervention programs, special education, and vocational training to address developmental disabilities; communication rehabilitation with sign language or alternative means of communication; and behavior management by a behavioral specialist/psychologist with consideration of medication as needed. Referral to an endocrinologist for consideration of human growth hormone (HGH) therapy; however, data on use of HGH in FHS are limited. Standard treatment for refractive errors and strabismus, hearing loss, seizures, gastroesophageal reflux, and renal and genitourinary anomalies.

Surveillance: Close monitoring of growth, especially in the first year. Annual: ophthalmologic evaluation, hearing screening, blood pressure measurement, and assessment of renal function. Sonographic evaluation for renal cysts in teenage/adult years is indicated.

Genetic counseling.

FHS is inherited in an autosomal dominant manner. The majority of affected individuals have a de novo pathogenic variant. Each child of an individual with FHS has a 50% chance of inheriting the pathogenic variant. Prenatal testing is possible for families in which the pathogenic variant has been identified.

Suggestive Findings

Floating-Harbor syndrome (FHS) should be suspected in individuals with the following clinical and radiographic features.

Craniofacial appearance (see Figure 1)

Figure 1.

Facial appearance of a girl age 11 years with FHS (SRCAP pathogenic variant p.Arg2444Ter) A. Note triangular face with deep-set eyes; short philtrum; long nose with narrow bridge and broad base with low-hanging columella; and thin upper lip.

• Triangular face
• Deep-set eyes
• Short philtrum
• Wide mouth with a thin vermilion border of the upper lip
• Long nose with a narrow bridge, broad base, broad tip, and low-hanging columella
• Low-set ears

Other features

• Significant delay in bone age (≥2 SD below the mean) with normalization between ages six and 12 years
• Skeletal anomalies. Brachydactyly, broad fingertips that give the appearance of clubbing, clinodactyly, short thumbs, prominent joints, clavicular abnormalities (See Figure 2.)
• Short adult stature. 140-155 cm (See Figure 3.)

Figure 2.

Dorsal (A) and palmar (B) view of the hands of the girl in Figure 1. Note clinodactyly, widened fingertips, and prominent joints.

Figure 3.

Frontal view of the girl in Figure 1. She has proportionate short stature with height <3rd centile.

Speech and language

• Dysarthria and verbal dyspraxia with phoneme imprecision
• Hypernasality
• High-pitched voice
• Severe receptive and expressive language impairment across all domains of function

Intellectual disability. All individuals have some degree of intellectual impairment and/or learning disability ranging from borderline normal to moderate intellectual disability.

Establishing the Diagnosis

The diagnosis of FHS is established in a proband with Suggestive Findings by identification of a heterozygous pathogenic (or likely pathogenic) variant in SRCAP on molecular genetic testing (see Table 1).

Note: (1) Per ACMG/AMP variant interpretation guidelines, the terms "pathogenic variants" and "likely pathogenic variants" are synonymous in a clinical setting, meaning that both are considered diagnostic and both can be used for clinical decision making [Richards et al 2015]. Reference to "pathogenic variants" in this section is understood to include any likely pathogenic variants. (2) Identification of a heterozygous SRCAP variant of uncertain significance does not establish or rule out the diagnosis.

Molecular genetic testing approaches can include a combination of gene-targeted testing (single-gene testing, multigene panel) and comprehensive genomic testing (exome sequencing, genome sequencing) depending on the phenotype.

Gene-targeted testing requires that the clinician determine which gene(s) are likely involved, whereas genomic testing does not. Because the phenotype of FHS is broad, individuals with the distinctive findings described in Suggestive Findings are likely to be diagnosed using gene-targeted testing (see Option 1), whereas those with a phenotype indistinguishable from many other inherited disorders with short stature and/or intellectual disability are more likely to be diagnosed using genomic testing (see Option 2).

Clinical Description

Prior to the molecular characterization of Floating-Harbor syndrome (FHS) by Hood et al [2012], a number of reports included descriptions of individuals in whom the diagnosis of FHS could be questioned. This GeneReview only includes information on those 73 individuals with molecularly confirmed FHS (i.e., presence of a heterozygous SRCAP pathogenic variant) [Hood et al 2012, Le Goff et al 2013, Nikkel et al 2013, Dong et al 2014, Kehrer et al 2014, Nagasaki et a 2014, Seifert et al 2014, Amita et al 2016, Coughlin et al 2017, Singh et al 2017, Budisteanu et al 2018, Choi et al 2018, Milani et al 2018, Shields et al 2019]. The 41 females and 32 males range in age from eight months to 52 years.

FHS is frequently recognized in early childhood because of the characteristic facial features (Figure 1). Infants and younger children are often referred for assessment of poor growth or developmental (predominantly speech and language) delay.

Craniofacial features include triangular face, deep-set eyes, short philtrum, wide mouth with a thin vermilion border of the upper lip, long nose with a narrow bridge, broad base, broad tip, and low-hanging columella, and low-set ears.

The features become more pronounced with age, especially the length of the nose and the width of the nasal tip.

Intellect. Although gross motor and fine motor milestones are within normal limits, affected individuals typically have mild-to-moderate intellectual disability. A disorder of speech and language is the most severe disability. Most aspects of communication are affected; expressive language is most consistently and severely affected. Dysarthria and verbal dyspraxia with phoneme imprecision is most common, with absent speech in some individuals. Voice is described as hypernasal and high-pitched. The majority of affected children receive mainstream education with individualized educational plans. Regression of skills is not typical of FHS.

Behavior. Many individuals with FHS have temperament and behavior differences and difficulties: temper tantrums in infancy and attention-deficit/hyperactivity disorder spectrum with impulsivity, inattention, and restlessness at school age. Aggressive and violent outbursts can occur. Obsessive compulsive disorder and anxiety have been observed. Behavior problems are reported to improve in adulthood.

Growth. Short stature is a cardinal sign of FHS. The majority of individuals with FHS have low birth weight (from 3 SD below the mean to 0 SD) and normal head circumference (2 SD below the mean to 0 SD). In the first years of life weight gain and linear growth are poor. A significant delay in bone age is reported (≥2 SD below the mean) with normalization between ages six and 12 years. Average adult height is 140-155 cm.

Puberty. Early puberty has been reported; data are insufficient to determine the incidence in either sex.

Eye. Five of 73 individuals have been reported with hyperopia and eight of 13 with strabismus. One individual had anterior chamber abnormalities.

Hearing. Conductive hearing loss has been seen in eleven of 73 individuals with FHS. Cochlear abnormality has been observed in one of 73.

Neurologic. Seizures have been observed in seven of 73 individuals.

Gastrointestinal. Reflux can be severe, requiring G-tube feeding in some. Constipation and colonic strictures have been observed. One of 73 individuals had celiac disease; two had transient gluten intolerance.

Genitourinary. Renal and genitourinary anomalies can occur and include hypospadias and undescended testes, epididymal cysts, varicocele, and posterior urethral valves in boys. Hydronephrosis/renal pelviectasis and nephrocalcinosis, renal cysts, and renal agenesis have been observed. One adult of the 73 reported individuals developed polycystic kidney disease and end-stage renal disease.

Orthopedic. The body habitus is often stocky with a broad chest and short neck. Additional features include hand anomalies such as clinodactyly, brachydactyly, short thumbs, and broad fingertips that give the appearance of clubbing (Figure 2). Clavicular anomalies including pseudarthrosis and clavicular hypoplasia have been observed, as have short metacarpals, 11 pairs of ribs, kyphoscoliosis, prominent joints, dysplastic hips, and dislocated radial heads. Perthes disease has also been reported.

Dental. A number of individuals with FHS have dental problems (e.g., caries, microdontia, oligodontia, delayed loss of primary teeth) and orthodontic problems (e.g., maxillary retrusion, underbite).

Cardiac. Cardiac malformations are not usually a feature of FHS. Of 73 affected individuals one had mild aortic coarctation, one had mesocardia with persistent left superior vena cava, two had atrial septal defect, and one individual had tetralogy of Fallot.

Genotype-Phenotype Correlations

Pathogenic variants in exons 33 and 34 of SRCAP that are predicted to cause truncation of the protein (removing 3 C-terminal AT-hook DNA-binding motifs while leaving the CBP-binding and ATPase domains intact) result in the FHS phenotype.

Prevalence

The prevalence of FHS is not known. Seventy-three individuals with a heterozygous SRCAP pathogenic variant have been reported to date [Hood et al 2012, Le Goff et al 2013, Nikkel et al 2013, Dong et al 2014, Kehrer et al 2014, Nagasaki et a 2014, Seifert et al 2014, Amita et al 2016, Coughlin et al 2017, Singh et al 2017, Budisteanu et al 2018, Choi et al 2018, Milani et al 2018, Shields et al 2019].

The majority of individuals reported with FHS are of European origin, but FHS has also been diagnosed in individuals of Chinese, South American, South Asian, Japanese, and Korean background [Hood et al 2012, Nikkel et al 2013, Nagasaki et al 2014, Amita et al 2016, Singh et al 2017, Choi et al 2018]. Whether the occurrence of FHS is lower in nonwhite populations or the observed difference is the result of other factors is not known.

Evaluations Following Initial Diagnosis

To establish the extent of disease and needs in an individual diagnosed with Floating-Harbor syndrome (FHS), the evaluations summarized in Table 3 (if not performed as part of the evaluation that led to the diagnosis) are recommended.

Treatment of Manifestations

Treatment includes the following:

• Early intervention programs, special education, and vocational training to address developmental disabilities
• Communication rehabilitation with sign language or alternative means of communication
• 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
• Standard treatment for any of the following if identified:
  • Refractive errors and strabismus
  • Hearing loss
  • Seizures
  • Renal disease
  • Cryptorchidism
  • Orthopedic complications
  • Dental problems
• Referral to an endocrinologist for consideration of human growth hormone (HGH) therapy. HGH therapy with modest response has been reported in three children with FHS. Caution is indicated as limited information about HGH therapy in FHS is available.
• Investigation for celiac disease if indicated by clinical features

Surveillance

Evaluation of Relatives at Risk

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

Pregnancy Management

No specific pregnancy complications for the mother or the fetus have been observed in the two women with SRCAP pathogenic variants who had children with FHS.

Therapies Under Investigation

Search ClinicalTrials.gov in the US and EU Clinical Trials Register in Europe for information on clinical studies for a wide range of diseases and conditions. Note: There may not be clinical trials for this disorder.

Mode of Inheritance

Floating-Harbor syndrome (FHS) is inherited in an autosomal dominant manner.

Risk to Family Members

Parents of a proband

• Most individuals with FHS have the disorder as the result of a de novo SRCAP pathogenic variant and therefore represent simplex cases (i.e., a single occurrence in the family).
• Transmission of an SRCAP pathogenic variant from an affected mother to her child has been reported in two families to date [Nikkel et al 2013].
• Molecular genetic testing and clinical evaluation for signs of FHS are recommended for the parents of a proband with an apparent de novo pathogenic variant.
• If the pathogenic variant found in the proband cannot be detected in the leukocyte DNA of either parent, the proband most likely has a de novo pathogenic variant; another possible explanation is germline mosaicism in a parent. Though theoretically possible, no instances of germline mosaicism have been reported.
• The family history of some individuals diagnosed with FHS may appear to be negative because of failure to recognize the disorder in a family member with a milder phenotype. Therefore, an apparently negative family history cannot be confirmed unless appropriate clinical evaluation and/or molecular genetic testing has been performed on the parents of the proband.
• An advanced paternal age effect is suggested. In their series of 13 individuals with a heterozygous SRCAP pathogenic variant, Hood et al [2012] reported a mean paternal age of 36.9 years (range 29-44 years).

Sibs of a proband. The risk to the sibs of the proband depends on the clinical/genetic status of the proband's parents:

• In the rare case of a parent being affected and/or known to have the pathogenic variant identified in the proband, the risk to sibs is 50%.
• If the proband has a known SRCAP pathogenic variant that cannot be detected in the leukocyte DNA of either parent, the recurrence risk to sibs is estimated to be 1% because of the theoretic possibility of parental germline mosaicism [Rahbari et al 2016].

Offspring of a proband. Each child of an individual with FHS has a 50% chance of inheriting the SRCAP pathogenic variant.

Other family members. The risk to other family members depends on the status of the proband's parents: if a parent has the FHS-causing pathogenic variant, the parent's family members may be at risk.

Related Genetic Counseling Issues

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

Family planning

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

Prenatal Testing and Preimplantation Genetic Testing

Once the SRCAP pathogenic variant has been identified in an affected family member, prenatal testing for a pregnancy at increased risk for FHS and preimplantation genetic testing are possible.

Differences in perspective may exist among medical professionals and within families regarding the use of prenatal testing. While most centers would consider use of prenatal testing to be a personal decision, discussion of these issues may be helpful.

Molecular Pathogenesis

Introduction. Helicase SRCAP is a nuclear protein that mediates different intracellular signaling pathways as well as chromatin remodeling. The encoded protein is an ATPase that is necessary for the incorporation of a histone variant into nucleosomes.

SRCAP functions as a transcriptional activator for CREB and CBP-mediated transcription, along with Notch-mediated and steroid receptor-mediated transcription [Hood et al 2016]. Alteration in SRCAP has the potential for producing widespread target-gene dysregulation.

Mechanism of disease causation. Unknown. However, the non-random clustering of pathogenic variants (see Genotype-Phenotype Correlations) that predict truncated SRCAP strongly suggests a dominant-negative disease mechanism due to loss of one or more critical domain(s) – for instance, the three C-terminal AT-hook DNA-binding motifs (see Hood et al [2016] for details of SRCAP domains).

Cancer and Benign Tumors

The Cancer Genome Atlas summarizes somatic pathogenic variants in genes (including SRCAP) involved in chromatin remodeling which may have a role in regulating genes in human malignancies. SRCAP is frequently mutated in numerous cancers including melanomas, lung cancers, stomach adenocarcinoma, and colorectal adenocarcinoma [Chen et al 2016].

Revision History

• 20 October 2022 (sw) Revision: epigenetic signature analysis (Establishing the Diagnosis, Option 2)
• 23 May 2019 (sw) Comprehensive update posted live
• 24 January 2013 (cd) Revision: prenatal testing available clinically
• 29 November 2012 (me) Review posted live
• 26 June 2012 (mjmn) Original submission

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