pediatria polska 88 (2013) 467–471

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Case report/Kazuistyka

Tetraploidy in the era of molecular karyotyping –

What we need to remember
Tetraploidia w erze kariotypowania molekularnego - o czym
należy pamiętać

Joanna Bothur-Nowacka 1,*, Aleksandra Jezela-Stanek 2, Katarzyna Zaniuk 1,

Bożenna Goryluk-Kozakiewicz 2, Małgorzata Krajewska-Walasek 2,
Anna Dobrzańska 1
1
Department of Neonatology, Pathology and Intensive Care, The Children's Memorial Health Institute, Warsaw, Poland
2
Department of Medical Genetics, The Children's Memorial Health Institute, Warsaw, Poland

article info abstract

Article history: Tetraploidy is a condition in which there are four complete sets of chromosomes in
Received: 08.05.2013 a single cell. In humans, this would be 92 pairs of chromosomes per cell. A great majority
Accepted: 11.06.2013 of pregnancies with a tetraploid fetus end in miscarriage, or if the pregnancy goes to full
Available online: 14.06.2013 term, the infant dies shortly after birth. Longer surveillance is rarely described. The only
method for confirming tetraploidy is karyotyping, in many cases using classical G-ban-
Keywords: ding methods. In this paper we would like to present another living individual with
 Tetraploidy tetraploidy and to revise the syndrome in the light of its diagnostics in the era of mole-
 Newborn cular karyotyping, with array Comparative Genomic Hybridization (aCGH, arrayCGH).
 Karyotyping © 2013 Polish Pediatric Society. Published by Elsevier Urban & Partner Sp. z o.o. All
rights reserved.

chromosomal rearrangements, including numerical and

Introduction
Tetraploid is a term used to describe organisms having four
instead of two paired (homologous) sets of chromosomes. It
is a known genetic aberration in humans, but because of its
high intrauterine lethality (it is found in 1–2% of early
miscarriages), only several clinical reports of infants diagno-
sed with tetraploidy are available [1–10]. The clinical conse-
quences of tetraploidy are varied and include limited life
expectancy and multiple congenital anomalies (MCA).
A reliable diagnosis can be established only by cytogenetic
analyses, which allow the visualization of chromosomes for
structural aberrations.
In this paper we report a 1.5-year-old boy with complete
tetraploidy and review clinical features described in this
aberration so far in order to raise clinicians' awareness of
the symptoms, and point to G-banded karyotyping as a first-
tier test.
Case presentation
The proband is the second child of healthy, non-consangui-
neous parents. His family history is unremarkable. Prenatal

* Corresponding author at: The Children's Memorial Health Institute, Aleja Dzieci Polskich 20, 04-730 Warsaw, Poland.
Tel.: +48 22 815 77 66; fax: +48 22 815 17 85.
E-mail addresses: joanna.bothur@wp.pl, noworodek@czd.pl (J. Bothur-Nowacka).
0031-3939/$ – see front matter © 2013 Polish Pediatric Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.
http://dx.doi.org/10.1016/j.pepo.2013.06.002
468 pediatria polska 88 (2013) 467–471

ultrasound revealed no abnormalities. He was born at week

40 of gestation with a weight of 2415 g and scored 5-8-8
points on the Apgar scale. Facial dysmorphism, microphtal-
mia, skin defects of the scalp, and a loud systolic murmur
over the heart were noted at birth. Moreover, he presented
with severe breathing difficulties and therefore was referred
to the Department of Neonatology and Intensive Care of the
Children's Memorial Health Institute in Warsaw.
In the physical examination, numerous dysmorphic featu-
res were found: long cranium, sparse, fair hair, loss of skin on
top of the head (on an area of 2 cm  2 cm), hypoplastic, low-
set and rotated ears, long face, high forehead, short palpebral
fissures, lack of the right eyeball and small left eyeball, long
nose with pressed nasal tip and hypoplastic alae nasi, narrow
upper lip, microstomia, short neck (Fig. 1). Moreover, high
palate, club foot, long toes and arachnodactyly with long
fingernails, abnormal position of the thumbs (Fig. 2), hypo-
plastic external genitalia (micropenis, small testes in the
scrotum) were noted. The boy presented with muscle hypoto-
nia and low spontaneous activity.
Echocardiography revealed a significantly and atypically
rotated heart, patent ductus arteriosus (PDA), and atrial
septal defect (ASD). No abnormalities were noted in abdomi-
nal ultrasound, while transfontanellar study revealed small
cysts with a diameter of 2–4 mm in the floor of the lateral
ventricles and an uneven outline of the plexus choroideus.
After obtaining informed consent, peripheral blood sam-
ples were taken from the patient. Chromosome analysis at
the 550-band level was performed on peripheral blood
lymphocytes according to standard procedures using trypsin
and giemsa for G-banding. It showed regular tetraploidy
with the karyotype 92,XXYY (Fig. 3). This result was then
verified in fibroblast analyses, which confirmed this ploidy.
Taking into consideration this diagnosis, it was decided
to abstain from further cardiologic and ophthalmic tests.
The boy was transferred to the care of the Warsaw Hospice
for Children (WHD). At 24 days of life the patient was
discharged from the hospital in good condition to his home.
At present, at the age of one year and 8 months, he still
is at home under the care of the WHD. He is profoundly
Fig. 1 – Male patient with regular tetraploidy, facial
appearance
Fig. 2 – Male patient with regular tetraploidy
psychomotor retarded, blind, responds only to sound sti-
muli. His weight is about 10 kg, is teat-fed and partially
probe-fed. The dominant problems in the child's care are
severe, recurrent respiratory infections.
Discussion
Tetraploidy is a condition in which there are four complete
sets of chromosomes in a single cell. In humans, this would
be 92 sets of chromosomes per cell, i.e., 92,XXXX (in females)
or 92,XXYY (in males). The most probable origin of tetra-
ploidy is chromosome duplication in a somatic cell in an
early-cleavage-stage embryo, a postzygotic event. Fertiliza-
tion of a rare diploid ovum by an equally rare unreduced
sperm may be possible. Another rare event is fertilization of
one egg by three sperms, but this will develop as hydatidi-
form moles rather than a tetraploid fetus, because of the
genomic imprinting effect [11].
A great majority of pregnancies in which the fetus has
tetraploidy end in miscarriage (5–6% of genetically abnormal
miscarriages), or if the pregnancy goes to full term, usually
results in the infant's death shortly after birth. Longer
surveillance is rarely described. The patient presented
herein is the twelfth live-born case with regular tetraploidy
described in the literature so far [1–10]. Six were females
and six were males. Except for four cases, all were born at
term (38–42 weeks of gestation).
Numerous abnormalities were observed in the live-born
children (Table I). The most common were: intrauterine
hypotrophy and postnatal growth retardation, high and
prominent forehead, low-set and dysplastic ears, as well as
feet/hand abnormalities. Over 50% of these children had
microphthalmia and microcephaly. They presented with
a somewhat characteristic facial appearance caused by
a beaked nose and micrognathia/retrognathia (Figs. 1
and 2).
As presented in Table I, the spectrum of congenital
anomalies observed in children with tetraploidy is not
 pediatria polska 88 (2013) 467–471 469

Fig. 3 – Classical karyotype showing tetraploidy

Table I – Clinical overview of live-born patients with regular tetraploidy

Feature Number of cases
(including presented herein)
Head Microcephaly 5/9
Prominent forehead 9/10
Hypertelorism 6/10
Short palpebral fissures 8/11
Coloboma 2/3
Anophthalmia/microphthalmia 6/11
Cleft lip/palate 7/9
Micrognathia/retrognathia 8/10
Abnormal ears 8/9

Nervous system Meningomyelocele 3/12

Brain malformation (polymicrogyria, hydrocephalus, Arnold–Chiari 6/7
malformation, Dandy–Walker malformation, hypoplasia of optical
and olfactory nerves, cerebellar hypoplasia, cerebral atrophy,
hypoplasia of cerebrum, pons, and medulla, hypoplasia of the
pituitary gland and thymus)

Heart Patent ductus arteriosus (PDA), patent foramen ovale (PFO), 8/11
ventricular/atrial septal defect (VSD/ASD), mitral valve
prolapse, transposition of
the great vessels (TGV), tetralogy of Fallot (TF)

Genito-urinary tract Hypoplastic external genitalia/genital ambigiuty 7/10

Bilateral hypoplasia of the adrenal glands and kidneys 1/12

Musculo-sceletal system Positional limb defects/hand abnormalities 10/11

Arachnodactyly 8/10
Feet abnormalities 4/4

Other Hypoplastic lungs 2/2

Enteric cyst located behind the urinary bladder, 1/12

Birth weight (g) 1728–2650 (mean: 2181) 11

470 pediatria polska 88 (2013) 467–471
definitely unique. There are, however, features that are
apparently infrequent and uncommon in other chromoso-
mal aberrations. These are: anophtalmia/severe microphtal-
mia and meningomyelocele. We would like to point out
these clinical signs, which, in our opinion, should direct
clinicians' attention to diagnostics toward tetraploidy.
Cytogenetic analysis is a standard procedure in the
evaluation of patients with unexplained developmental
delay/intellectual disability (DD/ID) and MCA. Until recently,
G-banded karyotyping has been the standard first-tier test
for detection of genetic imbalance at all genetic centers, and
in many, still is. This method allows the visualization and
analysis of chromosomes for chromosomal rearrangements,
including numerical (aneuploidy and polyploidy) and struc-
tural aberrations (deletion, duplication, inversion). The reso-
lution of this conventional method lies in the range 5–
10 Mb. Therefore, microdeletions and microduplications
smaller than 5 Mb will often go undetected.
Presently, a commonly ordered clinical genetic test for the
patients mentioned above is array Comparative Genomic
Hybridization (aCGH, arrayCGH), microarray-based genomic
copy-number analysis, known as ‘‘chromosomal microarray’’
(CMA), or ‘‘molecular karyotyping’’ [12]. It offers a much
higher diagnostic yield (15–20%) for genetic testing of indivi-
duals with unexplained DD/ID or MCA than a G-banded
karyotype (3%, excluding Down syndrome and other recog-
nizable chromosomal syndromes) [13]. The level of resolution
of aCGH is essentially without limitation, depending only on
the size and distance between the arrayed interrogating
probes. Molecular karyotyping has, however a few limitations,
one of which is detection of regular polyploidy.
According to the practice guidelines of the American
College of Medical Genetics (ACMG), aCGH should be a first-
tier, postnatal test in individuals with multiple anomalies
not specific to well-delineated genetic syndromes, indivi-
duals with apparently nonsyndromic developmental delay
or intellectual disability, and individuals with autism spec-
trum disorders [13]. This is primarily because of aCGH's high
sensitivity for submicroscopic deletions and duplications.
Some pathogenic chromosome imbalances are large enough
to be detected with conventional chromosome analysis (5–
10 Mb), but many pathogenic rearrangements are at or
below the limits of resolution of G-banding chromosome
analysis (approximately 5 Mb).
There are some limitations of aCGH. These are detection
of low-level mosaicism (below 5%-10%), balanced transloca-
tion and inversion. Another is detection of polyploidy. Due
to the normalization of intensity ratios to the most frequent
ratio level, which is considered ‘‘normal’’, array CGH does
not provide information such to ploidy. Since a tetraploid
clone without further rearrangements has a balanced DNA
content, it would appear normal [14–16].
The last limitation is not a rule in all cases, however.
Ballif et al. have used a Klinefelter cell line (47,XXY) as
a reference control in aCGH tests on products of conception
(POCs). Their results suggest that microarrays can poten-
tially detect >80% of all chromosomally abnormal POCs,
including some common triploids and other abnormalities
of the sex chromosomes [17].
This shows that the analysis of ploidy by genomic
microarrays is possible, but it remains a diagnostic challenge.
Therefore, we would like to stress in this paper that conven-
tional G-banded karyotyping is better and still necessary
when evaluating patients with clinical features of polyploidy.
Only this method allows identification of triploidy 69,XXX
and tetraploidy 92,XXYY, which is not possible in microarray
analyses.
An interesting characteristic of tetraploidy is life expec-
tancy. Most reported individuals have died between birth
and the age of one year [2–4, 7, 9, 10]. The oldest described
non-mosaics tetraploid patient was aged 26 months [8],
another female was at least 22-months-old [5]. Our patient
presented here is now 18 months old. The prognosis in
terms of survival seems to be an important issue for genetic,
especially prenatal, counseling. Obstetricians, neonatologists
and clinical geneticists should keep in mind both the unique
clinical features of tetraploidy (anophtalmia/microphtalmia
and meningomyelocele) and that, in rare cases, complete
tetraploidy is compatible with life.
Conclusions
Tetraploidy is an extremely rare, usually lethal form of
chromosomal aberration. The clinical picture is dominated
by intrauterine hypotrophy, profound delay in psychomotor
development, microcephaly, and craniofacial defects. Due to
the widespread phenotype consequences, the diagnosis
must be confirmed, however, by cytogenetic analyses using
classical G-banding methods.
Authors' contributions/Wkład autorów
JB-N, AJ-S MK-W, and AD performed study design. JB-N, AJ-S
and BG-K made data collection, where AJ-S made data
interpretation and KZ performed literature search also. MK-
W and AD verified the final manuscript version.
Conflict of interest/Konflikt interesu
None declared.
Financial support/Finansowanie
None declared.
Ethics/Etyka
The work described in this article has been carried out in
accordance with The Code of Ethics of the World Medical
Association (Declaration of Helsinki) for experiments invol-
ving humans; EU Directive 2010/63/EU for animal experi-
ments; Uniform Requirements for manuscripts submitted to
Biomedical journals.
 pediatria polska 88 (2013) 467–471
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