Ring Chromosome 4

National Organization for Rare Disorders, Inc.

Skip to the navigation


It is possible that the main title of the report Ring Chromosome 4 is not the name you expected. Please check the synonyms listing to find the alternate name(s) and disorder subdivision(s) covered by this report.


  • r(4)
  • ring 4
  • ring 4, chromosome

Disorder Subdivisions

  • None

General Discussion

Ring chromosome 4 is a rare disorder that is typically characterized by loss (deletion) of genetic material from both ends of the 4th chromosome and joining of the chromosomal ends to form a ring. Associated symptoms and findings may vary greatly, depending on the location of lost genetic material and/or other factors. Some affected infants may have a low birth weight; growth retardation; delays in the acquisition of skills requiring the coordination of mental and physical activities (psychomotor retardation); an abnormally small head (microcephaly); a broad, "beaked" nose; and/or various additional physical abnormalities that are present at birth (congenital anomalies). However, cases have also been reported in which ring chromosome 4 is primarily associated with growth retardation, with no major physical anomalies and normal psychomotor development. Ring chromosome 4 is usually caused by spontaneous (de novo) errors very early in the development of the embryo that appear to occur randomly for unknown reasons (sporadically).


As noted above, associated symptoms and physical findings may be extremely variable from case to case. Some infants with ring chromosome 4 may have multiple characteristic features, such as a low birth weight, feeding difficulties, failure to grow and gain weight at the expected rate (failure to thrive), developmental delays, malformations of the skull and facial (craniofacial) region, heart defects, and/or other physical abnormalities. In addition, certain features may be similar to those seen in individuals with Wolf-Hirschhorn syndrome, which is a chromosomal disorder characterized by partial deletion (monosomy) of the short arm (p) of chromosome 4 (partial monosomy 4p) or features similar to those seen in individuals with partial deletion (monosomy) of the long arm (q) of chromosome 4 (partial monosomy 4q. (For further information on this disorder, please see the "Related Disorders" section of this report below.) Investigators indicate that others with ring chromosome 4 may have few symptoms and be primarily affected by growth delays (failure to thrive), with no major physical anomalies.

In some infants and children, ring chromosome 4 may be associated with mental retardation and delays in the development of physical, mental, and behavioral skills that are typically acquired at particular stages (developmental milestones). For example, there are usually delays in language and speech development. However, others with ring chromosome 4 may have normal intelligence and normal psychomotor development.

Craniofacial malformations associated with ring chromosome 4 may include an unusually small head (microcephaly); a broad, rounded, or "beaked" nose; a small jaw (micrognathia); and/or malformed (dysplastic) ears. In some cases, other craniofacial abnormalities may also be present, such as incomplete closure of the roof of the mouth (cleft palate), drooping of the upper eyelids (ptosis), and/or other findings.

Some affected individuals may also have abnormal bending or deviation of one or more fingers (clinodactyly); abnormal skin ridge patterns on the palms of the hands (palmar creases); and/or, in affected males, abnormal placement of the urinary opening on the underside of the penis (hypospadias). There have also been a few reports in which ring chromosome 4 is associated with underdevelopment of the kidneys at birth (congenital renal hypoplasia) or a missing kidney (renal agenesis). These conditions may lead to chronic renal failure or an impaired ability of the kidneys to excrete waste products through urine, regulate the balance of salt and water in the body, and perform their other vital functions. In addition, in some cases, ring chromosome 4 may also be associated with additional congenital anomalies.


In most affected individuals, ring chromosome 4 appears to result from loss (deletion) of genetic material from both ends of the 4th chromosome and a joining of the ends to form a ring. Chromosomes are found in the nucleus of all body cells. They carry the genetic characteristics of each individual. Pairs of human chromosomes are numbered from 1 through 22, with an unequal 23rd pair of X and Y chromosomes for males and two X chromosomes for females. Each chromosome has a short arm designated as "p", a long arm identified by the letter "q" and a narrowed region at which the two arms are joined (centromere). Chromosomes are further subdivided into bands that are numbered outward from the centromere. For example, "chromosome 4p16" refers to band 16 on the short arm of chromosome 4.

In individuals with ring chromosome 4, the variability of associated symptoms and findings may depend upon the location of genetic material lost from the 4th chromosome, the percentage of cells containing the chromosomal abnormality (see below*), the stability of the ring chromosome during subsequent cellular divisions (mitosis), and/or other factors. For example, reports indicate that affected individuals with deletions of chromosome 4q35 and 4p16 have similar symptoms and findings to those with deletions of 4q33 and 4p16. According to investigators, such findings suggest that certain features often seen in those with ring chromosome 4 appear to result from deletions of genetic material at 4p16. In addition, in some cases, only some of an individual's cells may contain ring chromosome 4, while other cells may have a normal chromosomal makeup (a finding known as "chromosomal mosaicism*"), potentially affecting the variability of associated symptoms and findings.

Researchers have also reported cases in which ring chromosome 4 is present with no detectable loss of genetic material (as based upon chromosomal analysis). Such cases are sometimes referred to as "ring syndrome," a general term used to describe the presence of growth retardation in the absence of major malformations due to a ring chromosome. Investigators suggest that such ring chromosomes originate with abnormal fusion of the ends (i.e., telomeres) of a particular chromosome (e.g., chromosome 4) and that "ring syndrome" results due to instability of the ring chromosome during subsequent cellular divisions.

In most cases, ring chromosome 4 appears to be caused by spontaneous (de novo) errors very early in embryonic development. In such cases, the parents of the affected child usually have normal chromosomes and a relatively low risk of having another child with the chromosomal abnormality. However, chromosomal analysis and genetic counseling are typically recommended for parents of an affected child to help confirm or exclude the presence of certain chromosomal abnormalities in one of the parents, such as ring chromosome 4, potential mosaicism, or a "balanced translocation" involving chromosome 4. (Translocations occur when regions of certain chromosomes break off and are rearranged, resulting in shifting of genetic material and an altered set of chromosomes. If a chromosomal rearrangement is balanced, meaning that it consists of an altered but balanced set of chromosomes; it is usually harmless to the carrier. However, such a chromosomal rearrangement may be associated with an increased risk of abnormal chromosomal development in the carrier's offspring.)

Affected Populations

Since ring chromosome 4 was originally described, close to 40 cases have been reported in the medical literature. Males and females appear to be affected relatively equally.

Standard Therapies


In some cases, ring chromosome 4 may be suggested before birth (prenatally) by specialized tests such as ultrasound, amniocentesis, and/or chorionic villus sampling (CVS). During fetal ultrasonography, reflected sound waves create an image of the developing fetus, potentially revealing certain findings that suggest a chromosomal disorder or other abnormalities in the fetus. With amniocentesis, a sample of fluid that surrounds the developing fetus is removed and analyzed, while CVS involves the removal of tissue samples from a portion of the placenta. Chromosomal analysis performed on such fluid or tissue samples may reveal the presence of ring chromosome 4.

The disorder may be diagnosed or confirmed after birth (postnatally) based upon thorough clinical evaluation, detection of characteristic physical findings, and chromosomal analysis. Specialized tests may also be performed to help detect and/or characterize certain abnormalities that may be associated with the disorder.


The treatment of ring chromosome 4 is directed toward the specific symptoms that are apparent in each individual. In some cases, physicians may recommend surgical repair of certain malformations potentially associated with the disorder. The specific surgical procedures performed will depend upon the severity and location of the anatomical abnormalities, their associated symptoms, and other factors.

Early intervention may be important in ensuring that affected children reach their potential. Special services that may be beneficial include special education, speech therapy, and/or other medical, social, and/or vocational services. Genetic counseling will also be of benefit for affected individuals and their families. Other treatment for this disorder is symptomatic and supportive.

Investigational Therapies

Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.

For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:

Tollfree: (800) 411-1222

TTY: (866) 411-1010

Email: prpl@cc.nih.gov

For information about clinical trials sponsored by private sources, contact:


For information about clinical trials conducted in Europe, contact:




Schinzel A. Catalogue of Unbalanced Chromosome aberrations in Man. 2nd ed. New York, NY: Walter de Gruyter; 2001:191-193.

Jones KL. Smith's Recognizable Patterns of Human Malformation. 5th ed. Philadelphia, PA: W.B. Saunders Company; 1997:38-39.

Behrman RE, et al., eds. Nelson Textbook of Pediatrics. 15th ed. Philadelphia, PA: W.B. Saunders Company; 1996:317.

Gorlin RJ, et al., eds. Syndromes of the Head and Neck. 3rd ed. New York, NY: Oxford University Press; 1990:46-48.

Buyse ML. Birth Defects Encyclopedia. Dover, MA: Blackwell Scientific Publications, Inc.; 1990:336-37.


Dominguez, MG. et. al. Variegated-like mosaicism and ring syndrome in a r(4) boy. Appraisal of 38 patients with a fairly complete ring 4. Genet. Counsel. 2010; 21:411-422.

Chen CP, Hsu CY, Tzen CY, et al. Prenatal diagnosis of mosaic ring chromosome 4. Prenat Diagn. 2007; 27(5):485-7.

Balci S, Engiz O, Akta D, et al. Ring chromosome 4 and Wolf-Hirschhorn syndrome (WHS) in a child with multiple anomalies. Am J Med Genet A. 2006;140(6):628-32.

Lee MH, Park SY, Kim YM, et al. Molecular cytogenetic characterization of ring chromosome 4 in a female having a chromosomally normal child. Cytogenet Genome Res. 2005;111(2):175-8.

Sigurdardottir S, et al. Clinical, cytogenetic, and fluorescence in situ hybridization findings in two cases of "complete ring" syndrome. Am J Med Genet. 1999;87:384-90.

Robertson SP et. al. The 4q syndrome: delineation of the minimal critical region to within 4q31, Clin Genet. 1998;53:70-73.

Anderson CE, et al. Ring chromosome 4 mosaicism coincidence of oligomeganephronia and signs of Seckel syndrome. Am J Med Genet. 1997;72:281-85.

Park SH, et al. Oligomeganephronia associated with 4p deletion type chromosomal anomaly. Pediatr Pathol. 1993;13:731-40.

Pezzolo A, et al. Presence of telomeric and subtelomeric sequences at the fusion points of ring chromosomes indicates that the ring syndrome is caused by ring instability. Hum Genet. 1993;92:23-27.

Giuffre L, et al. Ring chromosome 4 in twins. Pediatr Med Chir. 1987;9:349-50.

Gutkowska A, et al. Ring chromosome 4 : 46,XY, r(4) (p16q35) in a boy. Klin Padiatr. 1985;197:294-96.

Kosztolanyi G. Ring chromosome 4: Wolf syndrome and unspecific developmental anomalies. Acta Paediatr Hung. 1985;26:157-65.

Haspeslagh M, et al. Severe limb malformations in 4p deletion. Clin Genet. 1984;25:353-56.

del Mazo J, et al. Partial deletion of 4p16 band in a ring chromosome and Wolf Syndrome. Hum Genet. 1978;44:105-08.

Perez-Castillo A, et al. Ring chromosome 4 and Wolf syndrome. Hum Genet. 1977;37:87-91.


Children's Craniofacial Association

13140 Coit Road

Suite 517

Dallas, TX 75240


Tel: (214)570-9099

Fax: (214)570-8811

Tel: (800)535-3643

Email: contactCCA@ccakids.com

Internet: http://www.ccakids.com

March of Dimes Birth Defects Foundation

1275 Mamaroneck Avenue

White Plains, NY 10605

Tel: (914)997-4488

Fax: (914)997-4763

Internet: http://www.marchofdimes.com

The Arc

1825 K Street NW, Suite 1200

Washington, DC 20006

Tel: (202)534-3700

Fax: (202)534-3731

Tel: (800)433-5255

TDD: (817)277-0553

Email: info@thearc.org

Internet: http://www.thearc.org


PO Box 751112

Las Vegas, NV 89136


Tel: (702)769-9264

Fax: (702)341-5351

Tel: (888)486-1209

Email: info@ameriface.org

Internet: http://www.ameriface.org

Chromosome Disorder Outreach, Inc.

P.O. Box 724

Boca Raton, FL 33429-0724


Tel: (561)395-4252

Fax: (561)395-4252

Email: info@chromodisorder.org

Internet: http://www.chromodisorder.org/CDO/

NIH/National Kidney and Urologic Diseases Information Clearinghouse

3 Information Way

Bethesda, MD 20892-3580

Fax: (703)738-4929

Tel: (800)891-5390

TDD: (866)569-1162

Email: nkudic@info.niddk.nih.gov

Internet: http://www.kidney.niddk.nih.gov/

UNIQUE - Rare Chromosome Disorder Support Group


The Rare Chromosome Disorder Support Group

G1 The Stables

Station Road West, Oxted

Surrey, RH8 9EE

United Kingdom

Tel: 441883723356

Email: info@rarechromo.org or rarechromo@aol.com

Internet: http://www.rarechromo.org

Craniofacial Foundation of America

975 East Third Street

Chattanooga, TN 37403

Tel: (423)778-9176

Fax: (423)778-8172

Tel: (800)418-3223

Email: terry.smyth@erlanger.org

Internet: http://www.craniofacialfoundation.org

Genetic and Rare Diseases (GARD) Information Center

PO Box 8126

Gaithersburg, MD 20898-8126

Tel: (301)251-4925

Fax: (301)251-4911

Tel: (888)205-2311

TDD: (888)205-3223

Internet: http://rarediseases.info.nih.gov/GARD/

For a Complete Report

This is an abstract of a report from the National Organization for Rare Disorders, Inc.® (NORD). Cigna members can access the complete report by logging into myCigna.com. For non-Cigna members, a copy of the complete report can be obtained for a small fee by visiting the NORD website. The complete report contains additional information including symptoms, causes, affected population, related disorders, standard and investigational treatments (if available), and references from medical literature. For a full-text version of this topic, see http://www.rarediseases.org/search/rdblist.html.