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Lin AE, Scimone ER, Thom RP, Balaguru D, Kinane TB, Moschovis PP, Cohen MS, Tan W, Hague CD, Dannheim K, Levitsky LL, Lilly E, DiGiacomo DV, Masse KM, Kadzielski SM, Zar-Kessler CA, Ginns LC, Neumeyer AM, Colvin MK, Elder JS, Learn CP, Mou H, Weagle KM, Buch KA, Butler WE, Alhadid K, Musolino PL, Sultana S, Bandyopadhyay D, Rapalino O, Peacock ZS, Chou EL, Heidary G, Dorfman AT, Morris SA, Bergin JD, Rayment JH, Schimmenti LA, Lindsay ME. Emergence of the natural history of Myhre syndrome: 47 patients evaluated in the Massachusetts General Hospital Myhre Syndrome Clinic (2016-2023). Am J Med Genet A 2024:e63638. [PMID: 38779990 DOI: 10.1002/ajmg.a.63638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 04/03/2024] [Accepted: 04/11/2024] [Indexed: 05/25/2024]
Abstract
Myhre syndrome is an increasingly diagnosed ultrarare condition caused by recurrent germline autosomal dominant de novo variants in SMAD4. Detailed multispecialty evaluations performed at the Massachusetts General Hospital (MGH) Myhre Syndrome Clinic (2016-2023) and by collaborating specialists have facilitated deep phenotyping, genotyping and natural history analysis. Of 47 patients (four previously reported), most (81%) patients returned to MGH at least once. For patients followed for at least 5 years, symptom progression was observed in all. 55% were female and 9% were older than 18 years at diagnosis. Pathogenic variants in SMAD4 involved protein residues p.Ile500Val (49%), p.Ile500Thr (11%), p.Ile500Leu (2%), and p.Arg496Cys (38%). Individuals with the SMAD4 variant p.Arg496Cys were less likely to have hearing loss, growth restriction, and aortic hypoplasia than the other variant groups. Those with the p.Ile500Thr variant had moderate/severe aortic hypoplasia in three patients (60%), however, the small number (n = 5) prevented statistical comparison with the other variants. Two deaths reported in this cohort involved complex cardiovascular disease and airway stenosis, respectively. We provide a foundation for ongoing natural history studies and emphasize the need for evidence-based guidelines in anticipation of disease-specific therapies.
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Affiliation(s)
- Angela E Lin
- Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eleanor R Scimone
- Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robyn P Thom
- Lurie Center for Autism, Mass General for Children, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Duraisamy Balaguru
- Pediatric Cardiology, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - T Bernard Kinane
- Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter P Moschovis
- Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael S Cohen
- Pediatric Otorhinolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Weizhen Tan
- Pediatric Nephrology, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Cole D Hague
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Katelyn Dannheim
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lynne L Levitsky
- Pediatric Endocrinology, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Evelyn Lilly
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel V DiGiacomo
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kara M Masse
- Department of Physical Therapy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah M Kadzielski
- Lurie Center for Autism, Mass General for Children, Boston, Massachusetts, USA
- Pediatric Gastroenterology, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Claire A Zar-Kessler
- Pediatric Gastroenterology, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Leo C Ginns
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ann M Neumeyer
- Lurie Center for Autism, Mass General for Children, Boston, Massachusetts, USA
- Pediatric Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mary K Colvin
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jack S Elder
- Division of Pediatric Urology, Department of Urology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher P Learn
- Division of Cardiology, Department of Medicine, Corrigan Minehan Heart Center, Adult Congenital Heart Disease, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hongmei Mou
- Mucosal Immunology and Biology Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kathryn M Weagle
- Department of Child Life, Pediatric Imaging Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Karen A Buch
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William E Butler
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kenda Alhadid
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Patricia L Musolino
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sadia Sultana
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Otto Rapalino
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Zachary S Peacock
- Oral and Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, Massachusetts, USA
| | - Elizabeth L Chou
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gena Heidary
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Aaron T Dorfman
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shaine A Morris
- Division of Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - James D Bergin
- Division of Cardiology, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Jonathan H Rayment
- Respiratory Medicine, Department of Pediatrics, British Columbia Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa A Schimmenti
- Department of Clinical Genomics, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otorhinolaryngology, Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark E Lindsay
- Pediatric Cardiology, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
- Pediatric Cardiology, Department of Pediatrics, Cardiovascular Genetics Program, Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Furness L, Riley P, Wright N, Banka S, Eyre S, Jackson A, Briggs TA. Monogenic disorders as mimics of juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2022; 20:44. [PMID: 35717242 PMCID: PMC9206249 DOI: 10.1186/s12969-022-00700-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 05/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Juvenile idiopathic arthritis is the most common chronic rheumatic disease of childhood. The term JIA encompasses a heterogenous group of diseases. The variability in phenotype of patients affected by the disease means it is not uncommon for mimics of JIA to be misdiagnosed. CASE PRESENTATION We present four cases who were treated in single tertiary rheumatology centre for JIA who were subsequently diagnosed with a rare monogenic disease. All four patients shared the unifying features of presenting in early childhood and subsequently suffered with refractory disease, not amenable to usual standards of treatment. Multicentric Carpotarsal Osteolysis Syndrome and Camptodactyly-arthropathy-coxa vara-pericarditis syndrome are non-inflammatory conditions and patients typically present with arthropathy, normal inflammatory markers and atypical radiological features. Blau syndrome is an autosomal dominant condition and patients will typically have symmetrical joint involvement with a strong family history of arthritis, signifying the genetic aetiology. CONCLUSIONS We share our learning from these cases to add to the growing portfolio of JIA mimics and to highlight when to consider an alternative diagnosis. In cases of refractory disease and diagnostic uncertainty further imaging and genetic testing can play a crucial role in establishing the aetiology. In all of these cases the correct diagnosis was made due to careful, longitudinal clinical phenotyping and a close working relationship between rheumatology, radiology and clinical genetics; highlighting the importance of the multidisciplinary team in managing complex patients.
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Affiliation(s)
- Laura Furness
- Royal Manchester Childrens Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Phil Riley
- grid.498924.a0000 0004 0430 9101Department of Paediatric Rheumatology, Royal Manchester Childrens Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Neville Wright
- grid.498924.a0000 0004 0430 9101Department of Paediatric Rheumatology, Royal Manchester Childrens Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Siddharth Banka
- grid.498924.a0000 0004 0430 9101NW Genomic Laboratory Hub, Manchester Centre for Genomic Medicine, St Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK ,grid.5379.80000000121662407Division of Evolution and Genomic Sciences, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Stephen Eyre
- grid.5379.80000000121662407The University of Manchester, Versus Arthritis Centre for Genetics and Genomics, Centre for Musculoskeletal Research, Manchester, UK ,grid.498924.a0000 0004 0430 9101Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Adam Jackson
- grid.5379.80000000121662407Manchester Centre for Genomic Medicine, Division of Evolution & Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9WL UK
| | - Tracy A. Briggs
- grid.498924.a0000 0004 0430 9101NW Genomic Laboratory Hub, Manchester Centre for Genomic Medicine, St Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK ,grid.5379.80000000121662407Division of Evolution and Genomic Sciences, School of Biological Sciences, University of Manchester, Manchester, UK
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Yilmaz S, Uludağ Alkaya D, Kasapçopur Ö, Barut K, Akdemir ES, Celen C, Youngblood MW, Yasuno K, Bilguvar K, Günel M, Tüysüz B. Genotype-phenotype investigation of 35 patients from 11 unrelated families with camptodactyly-arthropathy-coxa vara-pericarditis (CACP) syndrome. Mol Genet Genomic Med 2018; 6:230-248. [PMID: 29397575 PMCID: PMC5902402 DOI: 10.1002/mgg3.364] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 11/12/2017] [Accepted: 11/16/2017] [Indexed: 11/09/2022] Open
Abstract
Background The camptodactyly–arthropathy–coxa vara–pericarditis syndrome (CACP) is a rare autosomal recessive condition characterized by camptodactyly, noninflammatory arthropathy, coxa vara, and pericarditis. CACP is caused by mutations in the proteoglycan 4 (PRG4) gene, which encodes a lubricating glycoprotein present in the synovial fluid and at the surface of articular cartilage. Methods In the present study, we compared the clinical and molecular findings of CACP syndrome in 35 patients from 11 unrelated families. In 28 patients, whole exome sequencing was used to investigate genomic variations. Results We found that camptodactyly of hands was the first symptom presented by most patients. Swelling of wrists, knees, and elbows began before 4 years of age, while the age of joint involvement was variable. Patients reported an increased pain level after the age of 10, and severe hip involvement developed after 20 years old. All patients presented developmental coxa vara and seven patients (~22%) had pleural effusion, pericarditis, and/or ascites. We identified nine novel genomic alterations, including the first case of homozygous complete deletion of exon 1 in the PRG4 gene. Conclusion With this study, we contribute to the catalog of CACP causing variants. We confirm that the skeletal component of this disease worsens with age, and presents the potential mechanisms for interfamily variability, by discussing the influence of a modifier gene and escape from nonsense‐mediated mRNA decay. We believe that this report will increase awareness of this familial arthropathic condition and the characteristic clinical and radiological findings will facilitate the differentiation from the common childhood rheumatic diseases such as juvenile idiopathic arthritis.
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Affiliation(s)
- Saliha Yilmaz
- Department of Neurosurgery, Program on Neurogenetics, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Dilek Uludağ Alkaya
- Department of Pediatric Genetics, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Özgür Kasapçopur
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ekin S Akdemir
- Department of Neurosurgery, Program on Neurogenetics, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Cemre Celen
- Department of Neurosurgery, Program on Neurogenetics, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Mark W Youngblood
- Department of Neurosurgery, Program on Neurogenetics, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Katsuhito Yasuno
- Department of Neurosurgery, Program on Neurogenetics, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Kaya Bilguvar
- Department of Genetics, Yale Center for Genome Analysis, Yale School of Medicine, New Haven, CT, USA
| | - Murat Günel
- Department of Neurosurgery, Program on Neurogenetics, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Beyhan Tüysüz
- Department of Pediatric Genetics, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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Teeple E, Karamchedu NP, Larson KM, Zhang L, Badger GJ, Fleming BC, Jay GD. Arthroscopic irrigation of the bovine stifle joint increases cartilage surface friction and decreases superficial zone lubricin. J Biomech 2016; 49:3106-3110. [PMID: 27511596 PMCID: PMC5056145 DOI: 10.1016/j.jbiomech.2016.07.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 07/21/2016] [Accepted: 07/22/2016] [Indexed: 11/21/2022]
Abstract
The purpose of this study was to determine the effects of arthroscopic irrigation on cartilage superficial zone lubricin and surface friction. Arthroscopic partial meniscectomy is one of the most commonly performed orthopedic surgeries in the United States, but rates of osteoarthritis progression following this procedure are high. The effect of arthroscopic irrigation on articular surface lubrication has not been previously considered as a contributing factor in outcomes after arthroscopy. Fourteen bovine stifle joints were randomized to receive arthroscopic irrigation (n=7) or no treatment (n=7). Full-thickness osteochondral explants from these joints underwent friction testing to measure static and dynamic coefficients of friction. Following mechanical testing, samples were fixed and stained for lubricin. Percent integrated density, a measure of the amount of lubricin in the superficial zone (0-100µm depth), was determined. Static and dynamic coefficients of friction were found to be significantly greater in arthroscopy specimens compared to controls (p=0.02 and p<0.001, respectively). Percent integrated density of lubricin in the superficial zone was significantly lower in arthroscopy specimens compared to controls (p<0.001).
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Affiliation(s)
- Erin Teeple
- Department of Occupational and Environmental Medicine, Harvard School of Public Health, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women׳s Hospital, Boston, MA, USA
| | - Naga Padmini Karamchedu
- Bioengineering Laboratory, Department of Orthopaedics, Warren Alpert Medical School, Brown University/Rhode Island Hospital, Providence, RI, USA
| | | | - Ling Zhang
- Department of Emergency Medicine, Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Gary J Badger
- Department of Medical Biostatistics, University of Vermont, Burlington, VT, USA
| | - Braden C Fleming
- School of Engineering, Brown University, Providence, RI, USA; Bioengineering Laboratory, Department of Orthopaedics, Warren Alpert Medical School, Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Gregory D Jay
- School of Engineering, Brown University, Providence, RI, USA; Department of Emergency Medicine, Brown University/Rhode Island Hospital, Providence, RI, USA.
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5
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Lin AE, Michot C, Cormier-Daire V, L'Ecuyer TJ, Matherne GP, Barnes BH, Humberson JB, Edmondson AC, Zackai E, O'Connor MJ, Kaplan JD, Ebeid MR, Krier J, Krieg E, Ghoshhajra B, Lindsay ME. Gain-of-function mutations in SMAD4 cause a distinctive repertoire of cardiovascular phenotypes in patients with Myhre syndrome. Am J Med Genet A 2016; 170:2617-31. [PMID: 27302097 DOI: 10.1002/ajmg.a.37739] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 04/28/2016] [Indexed: 02/03/2023]
Abstract
Myhre syndrome is a rare, distinctive syndrome due to specific gain-of-function mutations in SMAD4. The characteristic phenotype includes short stature, dysmorphic facial features, hearing loss, laryngotracheal anomalies, arthropathy, radiographic defects, intellectual disability, and a more recently appreciated spectrum of cardiovascular defects with a striking fibroproliferative response to surgical intervention. We report four newly described patients with typical features of Myhre syndrome who had (i) a mildly narrow descending aorta and restrictive cardiomyopathy; (ii) recurrent pericardial and pleural effusions; (iii) a large persistent ductus arteriosus with juxtaductal aortic coarctation; and (iv) restrictive pericardial disease requiring pericardiectomy. Additional information is provided about a fifth previously reported patient with fatal pericardial disease. A literature review of the cardiovascular features of Myhre syndrome was performed on 54 total patients, all with a SMAD4 mutation. Seventy percent had a cardiovascular abnormality including congenital heart defects (63%), pericardial disease (17%), restrictive cardiomyopathy (9%), and systemic hypertension (15%). Pericarditis and restrictive cardiomyopathy are associated with high mortality (three patients each among 10 deaths); one patient with restrictive cardiomyopathy also had epicarditis. Cardiomyopathy and pericardial abnormalities distinguish Myhre syndrome from other disorders caused by mutations in the TGF-β signaling cascade (Marfan, Loeys-Dietz, or Shprintzen-Goldberg syndromes). We hypothesize that the expanded spectrum of cardiovascular abnormalities relates to the ability of the SMAD4 protein to integrate diverse signaling pathways, including canonical TGF-β, BMP, and Activin signaling. The co-occurrence of congenital and acquired phenotypes demonstrates that the gene product of SMAD4 is required for both developmental and postnatal cardiovascular homeostasis. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Angela E Lin
- Genetics Unit, Massachusetts General Hospital, MassGeneral Hospital for Children, Harvard Medical School, Boston, Massachusetts.
| | - Caroline Michot
- INSERM UMR1163 Unit, Department of Genetics, Institut Imagine, Paris Descartes University-Sorbonne Paris Cité, Necker Enfants-Malades Hospital, Paris, France
| | - Valerie Cormier-Daire
- INSERM UMR1163 Unit, Department of Genetics, Institut Imagine, Paris Descartes University-Sorbonne Paris Cité, Necker Enfants-Malades Hospital, Paris, France
| | - Thomas J L'Ecuyer
- Division of Cardiology, Department of Pediatrics, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - G Paul Matherne
- Division of Cardiology, Department of Pediatrics, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Barrett H Barnes
- Division of Gastroenterology, Department of Pediatrics, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Jennifer B Humberson
- Division of Genetics, Department of Pediatrics, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Andrew C Edmondson
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elaine Zackai
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew J O'Connor
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Julie D Kaplan
- Division of Medical Genetics, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Makram R Ebeid
- Division of Cardiology, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Joel Krier
- Division of Genetics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Krieg
- Division of Genetics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brian Ghoshhajra
- Thoracic Aortic Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark E Lindsay
- Thoracic Aortic Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Pediatric Cardiology, Department of Pediatrics, MassGeneral Hospital for Children, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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6
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Peters B, Schuurs-Hoeijmakers JHM, Fuijkschot J, Reimer A, van der Flier M, Lugtenberg D, Hoppenreijs EP. Protein-losing enteropathy in camptodactyly-arthropathy-coxa vara-pericarditis (CACP) syndrome. Pediatr Rheumatol Online J 2016; 14:32. [PMID: 27224999 PMCID: PMC4880819 DOI: 10.1186/s12969-016-0093-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/11/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Camptodactyly-arthropathy-coxa vara-pericarditis (CACP, OMIM: #208250) syndrome is a rare autosomal recessive disease that can be difficult to recognise not only because of its wide clinical variability but also because of its clinical resemblance to juvenile idiopathic arthritis (JIA). PRG4 is the only gene so far known to be associated with CACP syndrome. Children with CACP syndrome lack the glycoprotein lubricin due to recessive mutations in PRG4. Lubricin serves as a lubricant in joints, tendons and visceral cavities (pleural cavity, pericardium) and inhibits synovial proliferation. Children with CACP syndrome suffer from congenital camptodactyly, arthropathy, coxa vara and sometimes pericarditis. This report concerns a child with CACP syndrome complicated by protein-losing enteropathy (PLE), caused by constrictive pericarditis and so contributes to knowledge of the presentation of CACP syndrome. CASE PRESENTATION A 10- year-old girl with consanguineous parents suffered from congenital camptodactyly and progressive swollen and painful joints. Her father and his sister had similar childhood-onset joint complaints. Laboratory tests showed no signs of inflammation but showed persistent low protein- and IgG- levels, indicating a secondary immunodeficiency. Increased alpha antitrypsin clearance confirmed PLE. Abdominal ultrasound with Doppler showed hepatomegaly and portal hypertension. Echocardiography suggested constrictive pericarditis. However, heart catheterization could not confirm this. Ultrasound and X-ray examination of the joints combined with a puncture of the synovial fluid were performed. These results, combined with the clinical presentation and the consanguinity, suggested CACP syndrome. Due to excessive enteral protein losses, the patient was treated with Cotrimoxazol prophylaxis and immunoglobulin supplements. These supplements were inadequate to achieve normal IgG values. As constrictive pericarditis with subsequent PLE was the best explanation for the excessive IgG losses, pericardiectomy was performed with good results. Genetic testing in our patient was complicated but revealed a pathogenic mutation within the repeat sequence in exon 7 of the PRG4 gene. CONCLUSION PLE resulting from constrictive pericarditis can be a complication of CACP syndrome. As serious complications can arise from the resulting secondary immunodeficiency, we recommend regular evaluation of clinical symptoms of constrictive pericarditis and PLE in children with CACP syndrome.
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Affiliation(s)
- Bram Peters
- Department of Paediatrics, Radboud University Nijmegen Medical Centre, Radboud umc. Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands.
| | - Janneke H. M. Schuurs-Hoeijmakers
- Department of Human Genetics, Radboud University Nijmegen Medical Centre, Radboud umc. Geert Grooteplein Zuid 10, Nijmegen, 6525 GA The Netherlands
| | - Joris Fuijkschot
- Department of Paediatrics, Radboud University Nijmegen Medical Centre, Radboud umc. Geert Grooteplein Zuid 10, Nijmegen, 6525 GA The Netherlands
| | - Annette Reimer
- Department Paediatric Cardiology, Radboud University Nijmegen Medical Centre, Radboud umc. Geert Grooteplein Zuid 10, Nijmegen, 6525 GA The Netherlands
| | - Michiel van der Flier
- Department of Paediatrics, Radboud University Nijmegen Medical Centre, Radboud umc. Geert Grooteplein Zuid 10, Nijmegen, 6525 GA The Netherlands ,Radboud Institute for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Radboud umc. Geert Grooteplein Zuid 10, Nijmegen, 6525 GA The Netherlands
| | - Dorien Lugtenberg
- Department of Human Genetics, Radboud University Nijmegen Medical Centre, Radboud umc. Geert Grooteplein Zuid 10, Nijmegen, 6525 GA The Netherlands
| | - Esther P.A.H. Hoppenreijs
- Department of Paediatrics, Radboud University Nijmegen Medical Centre, Radboud umc. Geert Grooteplein Zuid 10, Nijmegen, 6525 GA The Netherlands ,Paediatric Rheumatology, Radboud University Nijmegen Medical Centre, Radboud umc. Geert Grooteplein Zuid 10, Nijmegen, 6525 GA The Netherlands ,Sint Maartenskliniek, Hengstdal 3, Ubbergen, 6574 NA The Netherlands
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7
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Teeple E, Aslani K, Shalvoy MR, Medrano JE, Zhang L, Machan JT, Fleming BC, Jay GD. Lubricin deficiency in the murine lumbar intervertebral disc results in elevated torsional apparent modulus. J Biomech 2015; 48:2210-3. [PMID: 25907550 DOI: 10.1016/j.jbiomech.2015.03.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/23/2015] [Accepted: 03/24/2015] [Indexed: 12/26/2022]
Abstract
The purpose of this study was to investigate the mechanical consequences of proteoglycan 4 (Prg4) deficiency on intervertebral disc mechanics using a Prg4 knockout mouse model. Prg4, also called lubricin, was first identified as the boundary lubricant in synovial fluid but has subsequently been localized within a number of musculoskeletal tissues in areas subjected to shear and tensile stresses, including the intervertebral disc. The function of lubricin in the intervertebral disc has not been determined. Lumbar level 1-2 vertebral body-disc-vertebral body motion segments were isolated from Prg4 null mice and wild type (WT) litter mate controls. Disc dimensions were measured and motion segments were tested in axial loading and torsion. Torque measurements and disc dimensions were used to calculate the torsional apparent modulus for discs from Prg4 null and WT discs. Discs from Prg4 null mice had a significantly smaller mean transverse disc area (p=0.0057), with a significantly larger proportion of this area occupied by the nucleus pulposus (p<0.0001), compared to WT specimens. Apparent torsional moduli were found to be elevated in Prg4 null lumbar discs compared to WT controls at 10-10° (p=0.0048) and 10-30° (p=0.0127) rotation. This study suggests a functional role for Prg4 in the murine intervertebral disc. The absence of Prg4 was associated with an increased apparent torsional modulus and the structural consequences of Prg4 deficiency in the intervertebral disc, with expansion of the area of the nucleus pulposus relative to the transverse disc area in Prg4 null specimens.
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Affiliation(s)
- Erin Teeple
- Department of Occupational and Environmental Medicine, Harvard School of Public Health, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women׳s Hospital, OrACORe Group, 75 Francis St, BC-4016, Boston, MA 02115 USA.
| | - Koosha Aslani
- Bioengineering Laboratory, Department of Orthopaedics, Warren Alpert Medical School, Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Matthew R Shalvoy
- Bioengineering Laboratory, Department of Orthopaedics, Warren Alpert Medical School, Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Jade E Medrano
- Bioengineering Laboratory, Department of Orthopaedics, Warren Alpert Medical School, Brown University/Rhode Island Hospital, Providence, RI, USA
| | - Ling Zhang
- Department of Emergency Medicine, Rhode Island Hospital, Providence, RI, USA
| | - Jason T Machan
- Lifespan Biostatistics Core, Lifespan Hospital System, Providence, RI, USA; Departments of Orthopaedics & Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Braden C Fleming
- Bioengineering Laboratory, Department of Orthopaedics, Warren Alpert Medical School, Brown University/Rhode Island Hospital, Providence, RI, USA; School of Engineering, Brown University, Providence, RI, USA
| | - Gregory D Jay
- Department of Emergency Medicine, Rhode Island Hospital, Providence, RI, USA; School of Engineering, Brown University, Providence, RI, USA
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Emad Y, Ragab Y, Khalifa M, Bassyouni I, El-Shaarawy N, Rasker JJ. Axial involvement with facet joint arthropathy and bony ankylosis in a case of camptodactyly, arthropathy, coxa vara, pericarditis (CACP) syndrome. Joint Bone Spine 2013; 80:520-2. [PMID: 23931850 DOI: 10.1016/j.jbspin.2013.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 01/14/2013] [Indexed: 11/16/2022]
Abstract
Familial arthropathy associated with congenital camptodactyly has been previously recognized as a definite clinical entity in the literature. The clinical spectrum of this disease seems to be variable. The typical features of congenital camptodactyly, arthropathy, coxa vara and pericarditis (CACP syndrome) appear to be a more frequent presentation in children from the Middle East and North Africa. Musculoskeletal presentation of this rare familial form of arthropathy is unique and heterogeneous. In all previous reports, non-inflammatory pattern of arthropathy involving the peripheral joints with typical coxa vara deformity were described, and in a few cases spine abnormalities, including kyphosis, lordosis, or scoliosis. We describe the first case of axial involvement in a typical case of CACP syndrome with facet joint arthropathy and ankylosis at L5/S1 levels.
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Affiliation(s)
- Yasser Emad
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Cairo University, Cairo, Egypt; Rheumatology and Rehabilitation Department, Dr. Erfan and Bagedo General Hospital, Jeddah, Saudi Arabia.
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9
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Murphy JM, Vanderhave KL, Urquhart AG. Total hip arthroplasty in adolescents with severe hip arthropathy and dysplasia associated with camptodactyly-arthropathy-coxa vara-pericarditis syndrome. J Arthroplasty 2012; 27:1581.e5-8. [PMID: 22386609 DOI: 10.1016/j.arth.2012.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 01/12/2012] [Indexed: 02/01/2023] Open
Abstract
Camptodactyly-arthropathy-coxa vara-pericarditis (CACP) syndrome is a rare disorder. Patients with this syndrome experience early symptomatic arthropathy of the hips. We report a case of adolescent siblings with bilateral arthropathy associated with CACP syndrome in which total hip arthroplasty was performed as treatment of severe associated disability. Postoperative Harris Hip Scores for patient 1 were 86 for the right at 18 months and 96 for the left at 12 months. Postoperative Harris Hip Score at 6 months for patient 2 was 53; however, he had good range of motion and lacked deformity. Based on our limited experience and the limited available clinical data, we feel that total hip arthroplasty is a reasonable treatment option for adolescents with debilitating hip arthropathy associated with CACP syndrome.
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Affiliation(s)
- Joshua M Murphy
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
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10
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A novel deletion mutation in proteoglycan-4 underlies camptodactyly-arthropathy-coxa-vara-pericarditis syndrome in a consanguineous pakistani family. Arch Med Res 2011; 42:110-4. [PMID: 21565623 DOI: 10.1016/j.arcmed.2011.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2010] [Accepted: 02/14/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND AIMS Camptodactyly-arthropathy-coxa-vara-pericarditis (CACP) syndrome is an autosomal recessive condition that mostly affects joints and tendons but can also affect the pericardium, which is a surface surrounding the heart. CACP syndrome is caused by mutations in a secreted proteoglycan 4 (PRG4) gene, which expresses in skeletal as well as nonskeletal tissues. We undertook this study to genetically screen a large consanguineous Pakistani family segregating CACP in an autosomal recessive manner. METHODS Genome-wide homozygosity mapping of 10 members of a Pakistani family including six affected and four normal individuals was carried out using 250K SNP genotyping array. To screen for mutation in PRG4 gene, all coding exons and exon-intron junctions were sequenced using ABI prism 3730 automated DNA sequencer. RESULTS Genome-wide homozygosity mapping revealed a large homozygous region on chromosome 1 carried by all the affected individuals. This region contains the previously described PRG4 gene involved in CACP syndrome. Sequence analysis of PRG4 gene in affected individuals of the family presented here revealed a 2 base-pair (bp) deletion (c.2816_2817delAA) predicting a frame shift mutation (p.Lys939fsX38). To our knowledge, this is probably the first mutation identified in PRG4 gene in a Pakistani family. CONCLUSIONS We described a 2-bp novel deletion mutation in PRG4 gene in a Pakistani family with CACP. Our findings extend the body of evidence that only nonsense mutation in PRG4 gene triggers the phenotype.
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Offiah AC, Woo P, Prieur AM, Hasson N, Hall CM. Camptodactyly-Arthropathy-Coxa Vara-Pericarditis Syndrome Versus Juvenile Idiopathic Arthropathy. AJR Am J Roentgenol 2005; 185:522-9. [PMID: 16037531 DOI: 10.2214/ajr.185.2.01850522] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of our article was to highlight the important clinical and radiographic features of camptodactyly-arthropathy-coxa vara-pericarditis (CACP) syndrome. In particular, we emphasize those features that allow differentiation of CACP syndrome from juvenile idiopathic arthropathy. CONCLUSION CACP syndrome should be considered in all patients who present with a noninflammatory arthropathy or with "atypical juvenile idiopathic arthritis," particularly if radiographs reveal an absence of erosions. In the correct clinical setting, large acetabular cysts on pelvic radiographs may be considered pathognomonic of CACP syndrome.
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Affiliation(s)
- Amaka C Offiah
- Department of Radiology, Great Ormond Street Hospital for Children, Great Ormond St., London WC1N 3JH, UK
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Shayan K, Ho M, Edwards V, Laxer R, Thorner PS. Synovial pathology in camptodactyly-arthropathy-coxa vara-pericarditis syndrome. Pediatr Dev Pathol 2005; 8:26-33. [PMID: 15702367 DOI: 10.1007/s10024-004-3035-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2004] [Accepted: 10/06/2004] [Indexed: 10/25/2022]
Abstract
At least 25 families with camptodactyly-arthropathy-coxa vara-pericarditis (CACP syndrome) have been reported, with descriptions of a distinctive synovial pathology based largely on light microscopy. Although described as "proliferative," with numerous multinucleated giant cells, the natures of proliferating cells and giant cells have not been determined. To clarify the pathogenesis of this disorder, we studied 3 patients who had CACP syndrome and underwent synovial biopsy. Cells in the biopsies were studied by immunohistochemistry and electron microscopy. Giant cells were identified as macrophage in origin based on CD68 expression and electron microscopic features of macrophages. Most cells in the synovium were CD68 positive, in keeping with macrophages. The degree of proliferation in synovial biopsies was estimated by MIB1 immunostaining, which showed that up to 30% of cells were cycling compared with fewer than 10% in control synovial biopsies. None of the giant cells was cycling. By double immunostaining, proliferating cells were determined to be fibroblastic synoviocytes rather than macrophages. Thus the proliferative synovitis in this CACP syndrome can be more accurately thought of as hypercellularity by infiltrating macrophages with a contribution by proliferating fibroblastic synoviocytes. The synoviocyte proliferation is likely a response to the underlying genetic mutations involving the proteoglycan-4 (or CACP) gene. The encoded protein normally acts as a lubricant and possibly controls cell proliferation. Loss of one or another of these functions may be a possible mechanism that leads to synoviocyte proliferation in this disease, but the exact pathophysiology leading to this change requires further study.
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Affiliation(s)
- Katayoon Shayan
- Division of Pathology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
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Choi BR, Lim YH, Joo KB, Paik SS, Kim NS, Lee JK, Yoo DH. Camptodactyly, arthropathy, coxa vara, pericarditis (CACP)syndrome: a case report. J Korean Med Sci 2004; 19:907-10. [PMID: 15608409 PMCID: PMC2816297 DOI: 10.3346/jkms.2004.19.6.907] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The camptodactyly-arthropathy-coxa vara-pericarditis syndrome (CACP) is characterized by congenital or early-onset camptodactyly, childhood-onset noninflammatory arthropathy associated with synovial hyperplasia. Some patients have progressive coxa vara deformity and/or noninflammatory pericardial effusion. CACP is inherited as an autosomal recessive mode and the disease gene is assigned to a 1.9-cM interval on human chromosome 1q25-31. We describe a 10-yr-old boy who has typical features of CACP without familial association.
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Affiliation(s)
- Byung-Ryul Choi
- The Hospital of Rheumatic Diseases, Department of Internal Medicine, Hanyang University, Seoul, Korea
| | - Young-Hyo Lim
- The Hospital of Rheumatic Diseases, Department of Internal Medicine, Hanyang University, Seoul, Korea
| | - Kyung-Bin Joo
- Department of Diagnostic Radiology, Hanyang University, Seoul, Korea
| | - Seung Sam Paik
- Department of Pathology, Hanyang University, Seoul, Korea
| | - Nam Su Kim
- Department of Pediatrics, Hanyang University, Seoul, Korea
| | | | - Dae-Hyun Yoo
- The Hospital of Rheumatic Diseases, Department of Internal Medicine, Hanyang University, Seoul, Korea
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