Björnstad syndrome is a rare disorder characterized by abnormal hair and hearing problems. Affected individuals have a condition known as pili torti, which means "twisted hair," so named because the strands appear twisted when viewed under a microscope. The hair is brittle and breaks easily, leading to short hair that grows slowly. In Björnstad syndrome, pili torti usually affects only the hair on the head; eyebrows, eyelashes, and hair on other parts of the body are normal. The proportion of hairs affected and the severity of brittleness and breakage can vary. This hair abnormality commonly begins before the age of 2. It may become milder with age, particularly after puberty.

People with Björnstad syndrome also have hearing problems that become evident in early childhood. The hearing loss, which is caused by changes in the inner ear (sensorineural deafness), can range from mild to severe. Mildly affected individuals may be unable to hear sounds at certain frequencies, while severely affected individuals may not be able to hear at all.

Björnstad syndrome is caused by mutations in the BCS1L gene. The protein produced from this gene is found in cell structures called mitochondria, which convert the energy from food into a form that cells can use. In mitochondria, the BCS1L protein plays a role in oxidative phosphorylation, which is a multistep process through which cells derive much of their energy. The BCS1L protein is critical for the formation of a group of proteins known as complex III, which is one of several protein complexes involved in this process. As a byproduct of its action in oxidative phosphorylation, complex III produces reactive oxygen species, which are harmful molecules that can damage DNA and tissues.

BCS1L gene mutations involved in Björnstad syndrome alter the BCS1L protein and impair its ability to aid in complex III formation. The resulting decrease in complex III activity reduces oxidative phosphorylation. For unknown reasons, overall production of reactive oxygen species is increased, although production by complex III is reduced. Researchers believe that tissues in the inner ears and hair follicles are particularly sensitive to reactive oxygen species and are damaged by the abnormal amount of these molecules, leading to the characteristic features of Björnstad syndrome.

Normal Function

The BCS1L gene provides instructions for making a protein that functions in cell structures called mitochondria, which convert the energy from food into a form that cells can use. The BCS1L protein is critical for the formation of a group of proteins known as complex III. Specifically, BCS1L adds a component called Rieske Fe/S protein to the complex. In mitochondria, complex III performs one step of the multistep process known as oxidative phosphorylation, in which oxygen and simple sugars are used to create adenosine triphosphate (ATP), the cell's main energy source.

As a byproduct of its action in oxidative phosphorylation, complex III produces reactive oxygen species, which are harmful molecules that can damage DNA and tissues. The reactive oxygen species produced by complex III are thought to also play a role in normal cell signaling, particularly when levels of oxygen in the body are low (hypoxia).

Some researchers believe the BCS1L protein is involved in the breakdown (metabolism) of iron, although the mechanism is unknown.

Health Conditions Related to Genetic Changes

Björnstad syndrome

At least six BCS1L gene mutations have been found to cause Björnstad syndrome, a condition characterized by a hair abnormality known as pili torti (or "twisted hair") and hearing loss. BCS1L gene mutations associated with this condition alter the BCS1L protein and impair its ability to interact with other proteins. These changes reduce BCS1L's ability to add the Rieske Fe/S protein to complex III. As a result, complex III is incomplete, and excess Rieske Fe/S protein builds up in mitochondria. The resulting decrease in complex III activity reduces oxidative phosphorylation to approximately 60 percent of normal.

Studies show that in people with Björnstad syndrome, complex III produces little or no reactive oxygen species; however, for unknown reasons, another protein complex involved in oxidative phosphorylation called complex I produces excessive amounts of reactive oxygen species, even more than would be produced by normally functioning complex III. Researchers believe that tissues in the inner ears and hair follicles are particularly sensitive to reactive oxygen species and are damaged by the abnormal amount of these molecules, leading to the characteristic features of Björnstad syndrome. It is unclear if a lack of cellular energy due to the reduction of complex III function also contributes to the features of this condition.

GRACILE syndrome

At least one mutation in the BCS1L gene can cause GRACILE syndrome, a severe condition that affects several body systems and is found almost exclusively in Finland. Affected infants are small at birth; they have kidney and liver problems and elevated levels of iron in the body. These infants do not survive more than a few months after birth.

The BCS1L gene mutation that causes GRACILE syndrome changes a single protein building block (amino acid) in the BCS1L protein. The amino acid serine is replaced by the amino acid glycine at position 78 (written as Ser78Gly or S78G). This alteration likely changes the shape of the protein, and the abnormal protein is broken down more quickly than the normal protein. What little protein remains is able to help form some complete complex III, although the amount is severely reduced, particularly in the liver and kidneys. As a result, complex III activity and oxidative phosphorylation are decreased in these organs in people with GRACILE syndrome. It is not clear why the liver and kidneys are specifically affected.

Researchers believe that impaired oxidative phosphorylation can lead to cell death by reducing the amount of energy available in the cell. Damage to the affected organs and tissues leads to many of the features of GRACILE syndrome. It is not clear why a change in the BCS1L gene leads to iron accumulation in people with this condition.

Mitochondrial complex III deficiency

Mitochondrial complex III deficiency can be caused by BCS1L gene mutations. When associated with mutations in this gene, the condition is most often characterized by problems with the liver (hepatopathy), kidneys (tubulopathy), and brain (encephalopathy). The BCS1L gene mutations associated with this condition alter the BCS1L protein and severely reduce the function of complex III. As in Björnstad syndrome, the loss of complex III function reduces production of reactive oxygen species from complex III but increases production from complex I. In addition, in BCS1L-related mitochondrial complex III deficiency, cells contain more mitochondria than normal, probably to compensate for the severe reduction in oxidative phosphorylation; this increase further elevates the production of reactive oxygen species to levels higher than those found in Björnstad syndrome. The loss of complex III function also reduces the amount of energy available in cells, much like in GRACILE syndrome. Damage to the kidneys, liver, and brain from reactive oxygen species and lack of available energy likely leads to the features of mitochondrial complex III deficiency.

Leigh syndrome

MedlinePlus Genetics provides information about Leigh syndrome

Other Names for This Gene

• BC1 (ubiquinol-cytochrome c reductase) synthesis-like
• BCS1
• BCS1-like protein
• BCS1_HUMAN
• h-BCS1
• Hs.6719
• mitochondrial chaperone BCS1
• mitochondrial complex III assembly

Genomic Location

Björnstad syndrome is inherited in an autosomal recessive pattern, which means both copies of the gene in each cell have mutations. The parents of an individual with an autosomal recessive condition each carry one copy of the mutated gene, but they typically do not show signs and symptoms of the condition.

Björnstad syndrome is a rare condition, although its prevalence is unknown. It has been found in populations worldwide.