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Huntington's Disease

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Huntington Disease
Rachelle Jelosek
Idaho State University

Jackson is a healthy twenty-seven year old male who recently presented to his doctors office inquiring about genetic testing. Jackson recently married, and his wife Alisha is anxious to start a family. Unfortunately Jackson does not share Alisha's enthusiasm because he fears that he is a carrier of a deadly genetic mutation. Just five years ago Jackson's mother was diagnosed with Huntington's Disease at the age of 43 and Jackson's grandmother succumbed to the disease at the age of 68. Jackson is an only child and although unconfirmed and heavily denied by his family Jackson is convinced that his mother discovered her ill fate shortly after he was born. Jackson's wife and father do not want him to be tested for the disorder because they fear a positive diagnosis will destroy any life he has now and in the future . Jackson has endured years of watching his loved ones suffer and does not want to pass the disorder on to his children. The purpose of this paper is to define and describe Huntington's disease (HD), explain inheritance patterns, describe the specific gene mutation seen in patients with HD, discuss reproductive issue and outline the ethical and social implications associated with genetic testing. Huntington's disease was named after Dr. George Huntington, who is credited for discovering the hereditary disorder in 1872(Huntington’s Disease Society of America, 2008). HD progressively destroys neurons in the basal ganglia of the brain. This destruction of brain cells causes deterioration of both mental and physical abilities(Huntington’s Disease Society of America, 2008, para. 2). Symptoms of the disease consist of motor, cognitive and behavioral malfunctions. Motor degeneration affects internal and external organs and develops gradually over time. Involuntary movements such as jerking of the limbs and facial muscles as well as quivering of the abdomen and shoulders is frequently seen. Many lose the ability to swallow properly causing constant choking, and aspiration pneumonia is a common cause of death (Leontini, 2006, p. 2). Speech becomes slow and slurred and cognitive decline affects short-term memory, attention span, concentration and decision making. Often affected individuals become depressed, suicidal, hallucinate and experience schizophrenia-like symptoms (Leontini, 2006). In the last stages of HD spastic movements decline and muscle rigidity sets in causing physical paralysis and eventually respiratory arrest. Onset of symptoms seen in HD usually occur after the third or fourth generation of life with the vast majority of sufferers being adults between the ages of 35 to 45 years old(Leontini, 2006). Early indications of HD are depression, irritability, and emotional outbursts. The course of HD, from observable symptoms to death, is estimated at 15 years. HD affects roughly one in 20,000 individuals worldwide and is transmitted as an autosomal dominant heterozygous trait where an affected individual carries both a normal and an altered copy of the gene. HD is one of the most common Mendelian disorders in people of European decent with a 50 percent risk of inheritance("Huntington disease: Predictive genetic testing", 2003). Located near the short arm on chromosome four is a gene that codes for a protein referred to as huntingtin. This protein carries the amino acid glutamine that is critical to the functioning of countless metabolic processes (Paulsen, 2010). The average number of repeats for a normal Huntington Gene is between 10 and 15 and the mutated form of the gene occurs when an excessive number of “C A G” repetitions occur. Individuals who have less than 32 repetitions are not considered carriers of the disease but someone who has more than 38 repetitions will most certainly develop the disease (Paulsen, 2010) . Treatment for HD is directed at symptom control and comfort care because currently there is no cure for the disorder (Huntington’s Disease Society of America, 2008, para. 8). The goal of treatment is to slow down the course of the disease and help the individual function as comfortably as possible. Various medications can be given to control the psychological effects of HD such as antipsychotics, antidepressants, tranquilizers, and mood stabilizers. Some practitioners inject botulinum toxin to help with muscle dystonia and involuntary spasms and recent evidence suggests that co-enzyme Q10 may also help slow down the course of the disease ("Huntington disease: Predictive genetic testing", 2003). Many types of genetic testing and services are available for the detection and management of HD. Predictive genetic testing by mutation analysis is an option that was made available in 1993. Predictive testing is done by a relatively inexpensive laboratory blood test because every individual affected with HD carries the same mutation on the same gene ("Huntington disease: Predictive genetic testing", 2003, p. 3). Predictive genetic testing analyzes the number of CAG repeats on the gene inherited from the individual's mother and the gene inherited from the individual's father. Only a small blood sample is required for the test and it is no longer necessary to have DNA samples from any other family members ("Huntington disease: Predictive genetic testing", 2003). Predictive testing is a viable option for Jackson who was discussed in the case study presented at the beginning of this paper. Jackson wants to know if he is a carrier of the mutated Huntington gene so that he can prepare himself for the future and avoid passing the gene on to future offspring. Although not recommended Jackson can complete the testing entirely by himself, confidentially without involving his family in the process. Genetic counseling done by a professional advisor is available for pre and post-testing consultations to ensure that at-risk individuals such as Jackson are fully informed of the issues involved with predictive testing. A minimum of two counseling sessions to prepare for the test and one follow-up session is highly recommended ("Huntington disease: Predictive genetic testing", 2003). Genetic counseling is ideal for Jackson's situation because he lacks familial support and a positive result indicating a terminal illness will be life altering even with careful preparation and decision making. A possible referral for Jackson would be the National Society of Genetic Counselors. This nation-wide referral source will work with Jackson's provider to find a genetic counselor in his geographical area who will interpret information about genetic disorders such as HD, analyze inheritance patterns and risk of recurrence and review available treatment options with Jackson (National Society of Genetic Counselors, 2009). Because HD is passed on genetically by an affected parent to their offspring with a 50 percent inheritance ratio procreating can be an emotional dilemma that must be considered. Preimplantation genetic testing (PGT) provides an approach in which antenatal diagnosis can be offered without incurring the adverse effects of predictive diagnosis ("Preimplantation and genetic testing", 2009, para. 2). PGT uses in vitro fertilization to biopsy embryos prior to implantation. Prenatal diagnoses have been accurately made by this method with no known adverse effects on the fetus (Harper & Handyside, 1994). High risk patients such as Jackson and his wife can participate in antenatal testing with or without having predictive testing done on Jackson prior to having children. Many advantages and disadvantages occur with genetic testing. It is estimated that more than half of the individuals tested for HD by predictive testing each year receive favorable results and can go on worry free for the rest of their lives ("Huntington disease: Predictive genetic testing", 2003). The remaining individuals receive unfavorable results and must come to terms with the fact that they will develop a terminal illness that will end their life. Positive HD results may increase the cost of medical and life insurance, cause the individual to become uninsurable, lead to job discrimination, and inflict severe emotional hardships on family members, relatives and friends. All of these implications must be carefully reviewed and addressed before testing is done.

Science has revealed a great deal about how and where the HD protein causes its damage and the effect it has on hundreds of cellular processes and components. New studies using mice have added to our knowledge about the disease ("Small changes", 2009). Research in mice has shown that the disease can be modified by drugs, supplements and interventions that hopefully will be ready for human use within the next five years ("Small changes", 2009). Knowing where the mutation occurs on the specific gene allows researchers to find and alter existing drugs that affect the mutation and also to develop new drugs for potential treatments. The decision to have genetic testing is controversial at best. Jackson and his provider must consider every aspect before proceeding with the test and family support is highly recommended. In conclusion the support of a knowledgeable genetic counselor will help Jackson find an acceptable solution to his difficult situation.
References
Huntington disease: Predictive genetic testing. (2003). Encyclopedia of the Human Genome. Retrieved from http://www.credoreference.com/entry/wileyhg/huntington_disease_predictive_genetic_ testing_
Huntington’s Disease Society of America. (2008). http://www.hdsa.org
Leontini, R. (2006, June). Looking forward, looking back: the narrative of testing positive to Huntington’s disease. Health Sociology Review, 15(2), 144-158. Retrieved from http://find.galegroup.com.ezproxy.apollolibrary.com/gps/infomark.do?&contentSet=IAC-Documents&type=retrieve&tabID=T002&prodId=IPS&docId=A158525938&source=gale&srcprod=AONE&userGroupName=uphoenix&version=1.0
National Center for Biotechnology Information. (2008). http://www.ncbi.nlm.nih.gov
National Society of Genetic Counselors. (2009). http://www.nsgc.org
PDRhealth.com. (2009). www.PDRhealth.com
Paulsen, J. S. (2010, Jan). Early detection of Huntington’s disease. Future Neurology, 5(1), 85-105. Retrieved from http://find.galegroup.com.ezproxy.apollolibrary.com/gps/infomark.do?&contentSet=IAC-Documents&type=retrieve&tabID=T002&prodId=IPS&docId=A217432461&source=gale&srcprod=AONE&userGroupName=uphoenix&version=1.0
Porth, C. M. (2009). Alterations in the cardiovascular system. In Advanced Pathophysiology (pp. 322-325). Philadelphia, PA: Lippincott, Williams,& Wilkins.
Preimplantation and genetic testing. (2009). Retrieved from http://www.givf.com/library/pgdhuntington.cfm
Schwartz, R. R. (2010, June). Ripples from a stone skipping across the lake: a narrative approach to the meaning of Huntington’s disease. Journal of Neuroscience Nursing, 42(3), 157-169. Retrieved from http://find.galegroup.com.ezproxy.apollolibrary.com/gps/start.do?prodId=IPS&userGroupName=uphoenix
Small changes in protein chemistry play large role in Huntington disease. (2009, December 24). National Institutes of Health: News and Events. Retrieved from http://www.nih.gov/news/health/dec2009/ninds-24.htm
Southwell, A. L., & Ko, L. (2009). Intrabody gene therapy ameliorates motor, cognitive, and neuropathological symptoms in multiple mouse models of Huntington’s disease. Journal of Neuroscience, 29(43). Retrieved from http://find.galegroup.com.ezproxy.apollolibrary.com/gps/infomark.do?&contentSet=IAC-Documents&type=retrieve&tabID=T002&prodId=IPS&docId=A224881845&source=gale&srcprod=AONE&userGroupName=uphoenix&version=1.0
Williams, J., Schutte, D., Evers, C., & Forcucci, C. (1999). Adults seeking presymptomatic gene testing for Huntington disease. Journal of Nursing Scholarship, 31(2), 109-114. Retrieved from http://find.galegroup.com.ezproxy.apollolibrary.com/gps/infomark.do?&contentSet=IAC-Documents&type=retrieve&tabID=T002&prodId=IPS&docId=A148859775&source=gale&srcprod=ITOF&userGroupName=uphoenix&version=1.0

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