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Pramio J, Grings M, da Rosa AG, Ribeiro RT, Glanzel NM, Signori MF, Marcuzzo MB, Bobermin LD, Wyse ATS, Quincozes-Santos A, Wajner M, Leipnitz G. Sulfite Impairs Bioenergetics and Redox Status in Neonatal Rat Brain: Insights into the Early Neuropathophysiology of Isolated Sulfite Oxidase and Molybdenum Cofactor Deficiencies. Cell Mol Neurobiol 2023; 43:2895-2907. [PMID: 36862242 DOI: 10.1007/s10571-023-01328-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 02/14/2023] [Indexed: 03/03/2023]
Abstract
Isolated sulfite oxidase (ISOD) and molybdenum cofactor (MoCD) deficiencies are genetic diseases biochemically characterized by the toxic accumulation of sulfite in the tissues of patients, including the brain. Neurological dysfunction and brain abnormalities are commonly observed soon after birth, and some patients also have neuropathological alterations in the prenatal period (in utero). Thus, we investigated the effects of sulfite on redox and mitochondrial homeostasis, as well as signaling proteins in the cerebral cortex of rat pups. One-day-old Wistar rats received an intracerebroventricular administration of sulfite (0.5 µmol/g) or vehicle and were euthanized 30 min after injection. Sulfite administration decreased glutathione levels and glutathione S-transferase activity, and increased heme oxygenase-1 content in vivo in the cerebral cortex. Sulfite also reduced the activities of succinate dehydrogenase, creatine kinase, and respiratory chain complexes II and II-III. Furthermore, sulfite increased the cortical content of ERK1/2 and p38. These findings suggest that redox imbalance and bioenergetic impairment induced by sulfite in the brain are pathomechanisms that may contribute to the neuropathology of newborns with ISOD and MoCD. Sulfite disturbs antioxidant defenses, bioenergetics, and signaling pathways in the cerebral cortex of neonatal rats. CII: complex II; CII-III: complex II-III; CK: creatine kinase; GST: glutathione S-transferase; HO-1: heme oxygenase-1; SDH: succinate dehydrogenase; SO32-: sulfite.
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Affiliation(s)
- Júlia Pramio
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, RS, 90035-003, Brazil
| | - Mateus Grings
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, RS, 90035-003, Brazil
| | - Amanda Gasparin da Rosa
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, RS, 90035-003, Brazil
| | - Rafael Teixeira Ribeiro
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, RS, 90035-003, Brazil
| | - Nícolas Manzke Glanzel
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, RS, 90035-003, Brazil
| | - Marian Flores Signori
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, RS, 90035-003, Brazil
| | - Manuela Bianchin Marcuzzo
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, RS, 90035-003, Brazil
| | - Larissa Daniele Bobermin
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, RS, 90035-003, Brazil
| | - Angela T S Wyse
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, RS, 90035-003, Brazil
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, RS, 90035-003, Brazil
| | - André Quincozes-Santos
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, RS, 90035-003, Brazil
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, RS, 90035-003, Brazil
| | - Moacir Wajner
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, RS, 90035-003, Brazil
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, RS, 90035-003, Brazil
- Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Porto Alegre, RS, 90035-903, Brazil
| | - Guilhian Leipnitz
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, RS, 90035-003, Brazil.
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, Porto Alegre, RS, 90035-003, Brazil.
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Li JT, Chen ZX, Chen XJ, Jiang YX. Mutation analysis of SUOX in isolated sulfite oxidase deficiency with ectopia lentis as the presenting feature: insights into genotype-phenotype correlation. Orphanet J Rare Dis 2022; 17:392. [PMID: 36303223 PMCID: PMC9615255 DOI: 10.1186/s13023-022-02544-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/25/2022] [Accepted: 10/04/2022] [Indexed: 11/12/2022] Open
Abstract
Background Isolated sulfite oxidase deficiency (ISOD) caused by sulfite oxidase gene (SUOX) mutations is a rare neurometabolic disease associated with ectopia lentis (EL). However, few genotype–phenotype correlations have been established yet. Methods Potentially pathogenic SUOX mutations were screened from a Chinese cohort of congenital EL using panel-based next-generation sequencing and analyzed with multiple bioinformatics tools. The genotype–phenotype correlations were evaluated via a systematic review of SUOX mutations within our data and from the literature. Results A novel paternal missense mutation, c.205G > C (p.A69P), and a recurrent maternal nonsense mutation, c.1200 C > G (p.Y400*), of SUOX were identified in a 4-year-old boy from 312 probands. The biochemical assays manifested elevated urine sulfite and S-sulfocysteine accompanied by decreased homocysteine in the blood. The patient had bilateral EL and normal fundus, yet minimal neurological involvement and normal brain structure. Molecular modeling simulation revealed the p.A69P mutant had an unstable structure but an unchanged affinity for sulfite, while the truncated p.Y400* mutant showed decreased binding capacity. Genotype–phenotype analysis demonstrated patients with biallelic missense mutations had milder symptoms (P = 0.023), later age of onset (P < 0.001), and a higher incidence of regression (P = 0.017) than other genotypes. No correlations were found regarding EL and other neurological symptoms. Conclusion The data from this study not only enrich the known mutation spectrum of SUOX but also suggest that missense mutations are associated with mild and atypical symptoms. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02544-x.
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Affiliation(s)
- Jia-Tong Li
- Department of Neurology, Huashan Hospital and Institute of Neurology, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Ze-Xu Chen
- Eye Institute and Department of Ophthalmology, Eye and ENT Hospital of Fudan University, 83 Fenyang Rd, 200031, Shanghai, China.,Key Laboratory of Myopia, NHC Key Laboratory of Myopia (Fudan University), Chinese Academy of Medical Sciences, 200031, Shanghai, China.,Shanghai Key Laboratory of Visual Impairment and Restoration, 200031, Shanghai, China
| | - Xiang-Jun Chen
- Department of Neurology, Huashan Hospital and Institute of Neurology, Fudan University, Shanghai, China. .,National Center for Neurological Disorders, Shanghai, China. .,Human Phenome Institute, Fudan University, Shanghai, China.
| | - Yong-Xiang Jiang
- Eye Institute and Department of Ophthalmology, Eye and ENT Hospital of Fudan University, 83 Fenyang Rd, 200031, Shanghai, China. .,Key Laboratory of Myopia, NHC Key Laboratory of Myopia (Fudan University), Chinese Academy of Medical Sciences, 200031, Shanghai, China. .,Shanghai Key Laboratory of Visual Impairment and Restoration, 200031, Shanghai, China.
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Zhang R, Hao Y, Xu Y, Qin J, Wang Y, Kumar Dey S, Li C, Wang H, Banerjee S. Whole exome sequencing identified a homozygous novel mutation in SUOX gene causes extremely rare autosomal recessive isolated sulfite oxidase deficiency. Clin Chim Acta 2022; 532:115-122. [PMID: 35679912 DOI: 10.1016/j.cca.2022.06.005] [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: 10/21/2021] [Revised: 05/29/2022] [Accepted: 06/03/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Isolated sulfite oxidase deficiency (ISOD) is a rare type of life-threatening neurometabolic disorders characterized by neonatal intractable seizures and severe developmental delay with an autosomal recessive mode of inheritance. Germline mutation in SUOX gene causes ISOD. Till date, only 32 mutations of SUOX gene have been identified and reported to be associated with ISOD. METHODS Here, we investigated a 5-days old Chinese female child, presented with intermittent tremor or seizures of limbs, neonatal encephalopathy, subarachnoid cyst and haemorrhage, dysplasia of corpus callosum, neonatal convulsion, hyperlactatemia, severe metabolic acidosis, hyperglycemia, and hyperkalemia. RESULTS Whole exome sequencing identified a novel homozygous transition (c.1227G > A) in exon 6 of the SUOX gene in the proband. This novel homozygous variant leads to the formation of a truncated sulfite oxidase (p.Trp409*) of 408 amino acids. This variant causes partial loss of the dimerization domain of sulfite oxidase. Hence, it is a loss-of-function variant. Proband's father and mother is carrying this novel variant in a heterozygous state. This variant was not found in 200 ethnically matched normal healthy control individuals. CONCLUSIONS Our study not only expanded the mutational spectrum of SUOX gene associated with ISOD, but also strongly suggested the significance of whole exome sequencing for identifying candidate genes and novel disease-causing variants.
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Affiliation(s)
- Rui Zhang
- Division of Maternal-Fetal Medicine, Jinan University-affiliated Shenzhen Bao'an Women's and Children's Hospital, Shenzhen 518102, China
| | - Yajing Hao
- Department of Radiology, Jinan University-affiliated Shenzhen Bao'an Women's and Children's Hospital, Jinan University, Shenzhen 518102, China
| | - Ying Xu
- Department of Ultrasound, Jinan University-affiliated Shenzhen Bao'an Women's and Children's Hospital, Shenzhen 518102, China
| | - Jiale Qin
- Department of Radiology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yanfang Wang
- Department of Ultrasound, Jinan University-affiliated Shenzhen Bao'an Women's and Children's Hospital, Shenzhen 518102, China
| | - Subrata Kumar Dey
- Department of Biotechnology, Centre for Genetic Studies, School of Biotechnology and Biological Sciences, Maulana Abul Kalam Azad University of Technology (Formerly West Bengal University of Technology), Salt Lake City, Kolkata, India
| | - Chen Li
- Department of Cell Biology and Medical Genetics, School of Medicine, Zhejiang University, Hangzhou, China
| | - Huilin Wang
- Division of Maternal-Fetal Medicine, Jinan University-affiliated Shenzhen Bao'an Women's and Children's Hospital, Shenzhen 518102, China.
| | - Santasree Banerjee
- Department of Genetics, College of Basic Medical Sciences, Jilin University, Changchun, Jilin 130021, China.
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Zhao J, An Y, Jiang H, Wu H, Che F, Yang Y. Novel Compound Heterozygous Pathogenic Variants in SUOX Cause Isolated Sulfite Oxidase Deficiency in a Chinese Han Family. Front Genet 2021; 12:607085. [PMID: 34025712 PMCID: PMC8139553 DOI: 10.3389/fgene.2021.607085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 04/13/2021] [Indexed: 11/13/2022] Open
Abstract
Aim To explore the clinical imaging, laboratory and genetic characteristics of a newborn boy with isolated sulfite oxidase deficiency (ISOD) in a Chinese mainland cohort. Methods Homocysteine and uric acid in plasma and cysteine and total homocysteine in the blood spot were assessed in a Chinese newborn patient with progressive encephalopathy, tonic seizures, abnormal muscle tone, and feeding difficulties. Whole exome sequencing and Sanger sequencing facilitated an accurate diagnosis. The pathogenicity predictions and conservation analysis of the identified mutations were conducted by bioinformatics tools. Results Low total homocysteine was detected in the blood spot, while homocysteine and uric acid levels were normal in the plasma. S-sulfocysteine was abnormally elevated in urine. A follow-up examination revealed several progressive neuropathological findings. Also, intermittent convulsions and axial dystonia were observed. However, the coordination of sucking and swallowing was slightly improved. A novel paternal nonsense variant c.475G > T (p.Glu159∗) and a novel maternal missense variant c.1201A > G (p.Lys401Glu) in SUOX were identified in this case by co-segregation verification. Conclusion This is the second report of early-onset ISOD case in a non-consanguineous Chinese mainland family. Combined with the clinical characteristics and biochemical indexes, we speculated that these two novel pathogenic variants of the SUOX gene underlie the cause of the disease in this patient. Next-generation sequencing (NGS) and Sanger sequencing provided reliable basis for clinical and prenatal diagnoses of this family, it also enriched the mutation spectrum of the SUOX gene.
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Affiliation(s)
- Jiangang Zhao
- Department of Neonatology, Xi'an Children's Hospital, Xi'an, China
| | - Yao An
- Department of Neonatology, Xi'an Children's Hospital, Xi'an, China
| | - Haoxiang Jiang
- Department of Radiology, Xi'an Children's Hospital, Xi'an, China
| | - Haibin Wu
- Shaanxi Institute for Pediatric Diseases, Xi'an Children's Hospital, Xi'an, China
| | - Fengyu Che
- Shaanxi Institute for Pediatric Diseases, Xi'an Children's Hospital, Xi'an, China
| | - Ying Yang
- Shaanxi Institute for Pediatric Diseases, Xi'an Children's Hospital, Xi'an, China
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Du P, Hassan RN, Luo H, Xie J, Zhu Y, Hu Q, Yan J, Jiang W. Identification of a novel SUOX pathogenic variants as the cause of isolated sulfite oxidase deficiency in a Chinese pedigree. Mol Genet Genomic Med 2021; 9:e1590. [PMID: 33405344 PMCID: PMC8077164 DOI: 10.1002/mgg3.1590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 11/07/2020] [Accepted: 12/15/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Isolated sulfite oxidase deficiency (ISOD) is a life-threatening rare autosomal recessive disorder caused by pathogenic variants in SUOX (OMIM 606887) gene. The aim of our study was to establish a comprehensive genetic diagnosis strategy for the pathogenicity analysis of the SUOX gene within a limited time and to lay the foundation for precise genetic counseling, prenatal diagnosis, and preimplantation genetic diagnosis. METHODS Two offspring from one set of parents were studied. Next-generation sequencing (NGS) was used to screen for disease-causing gene variants in a family with ISOD. Then, Sanger sequencing was performed to verify the presence of candidate variants. Sulfite, homocysteine and uric acid levels were detected in the patients. According to the ACMG/AMP guidelines, the pathogenicity level of novel variants was annotated. RESULTS The nonsense pathogenic variant (c.1200C > G (p.Y400*)) and a duplication (c.1549_1574dup (p.I525 Mfs*102)) were found in the SUOX gene in the proband. The nonsense mutation (c.1200C > G (p.Y400*), pathogenic, isolated sulfite oxidase deficiency, autosomal recessive) has been reported as pathogenic and the duplication (c.1549_1574dup (p.I525 Mfs*102), pathogenic, isolated sulfite oxidase deficiency, autosomal recessive) was novel, which was classified as pathogenic according to the ACMG/AMP Standards and Guidelines. CONCLUSION We established the pathogenicity assessment in ISOD patients based on ACMG/AMP Standards and Guidelines and this is the first ISOD patient reported in mainland China. We also discovered that ISOD is caused by SUOX gene duplication mutation, which enriches the spectrum of SUOX pathogenic variants.
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Affiliation(s)
- Peng Du
- Department of Medical Genetics, ZhongShan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Reem N Hassan
- Department of Medical Genetics, ZhongShan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Hualei Luo
- Department of Medical Genetics, ZhongShan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Jie Xie
- Department of Medical Genetics, ZhongShan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Yue Zhu
- Department of Medical Genetics, ZhongShan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Qiuyue Hu
- Department of Medical Genetics, ZhongShan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Jin Yan
- Department of Medical Genetics, ZhongShan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Weiying Jiang
- Department of Medical Genetics, ZhongShan School of Medicine, Sun Yat-sen University, Guangzhou, China
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Misko AL, Liang Y, Kohl JB, Eichler F. Delineating the phenotypic spectrum of sulfite oxidase and molybdenum cofactor deficiency. Neurol Genet 2020; 6:e486. [PMID: 32802950 PMCID: PMC7371372 DOI: 10.1212/nxg.0000000000000486] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/08/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To define the phenotypic spectrum of isolated sulfite oxidase (ISOD) and molybdenum cofactor deficiency (MoCD), aiming to promote timely diagnosis and assist in future clinical trial design. METHODS We analyzed clinical, radiographic, biochemical, and genetic data from 146 patients reported in the literature. RESULTS We stratified patients into 2 phenotypic subgroups based on clinical and radiographic characteristics. In the first (Class I), patients presented early in life (age 1-50 days) with acute onset of neurologic symptoms and development of diffuse brain injury with cystic leukomalacia. Patients in the second subgroup (Class II) presented later in life (age 30 days-23 years) with prominent movement abnormalities and selective injury of the basal ganglia and cerebellum. A significant difference in survival estimates correlated with milder disease severity among Class II patients. Substantial overlap in sulfur-containing metabolite levels prevented discrimination of subgroups based on diagnostic biomarkers, but genotype-phenotype correlations suggested that residual SUOX activity may contribute to milder phenotypes. CONCLUSIONS Patients with SUOX and MoCD gravitate toward 1 of 2 distinct clinicoradiographic profiles. Patient stratification may help promote accurate diagnosis, prognostication, and aid in the design of future clinical trials.
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Affiliation(s)
- Albert L Misko
- Departments of Neurology (A.L.M., Y.L., F.E.), Massachusetts General Hospital and Harvard Medical School, Boston; and the Department of Chemistry (J.B.K.), Institute of Biochemistry, University of Cologne, Germany
| | - Ye Liang
- Departments of Neurology (A.L.M., Y.L., F.E.), Massachusetts General Hospital and Harvard Medical School, Boston; and the Department of Chemistry (J.B.K.), Institute of Biochemistry, University of Cologne, Germany
| | - Joshua B Kohl
- Departments of Neurology (A.L.M., Y.L., F.E.), Massachusetts General Hospital and Harvard Medical School, Boston; and the Department of Chemistry (J.B.K.), Institute of Biochemistry, University of Cologne, Germany
| | - Florian Eichler
- Departments of Neurology (A.L.M., Y.L., F.E.), Massachusetts General Hospital and Harvard Medical School, Boston; and the Department of Chemistry (J.B.K.), Institute of Biochemistry, University of Cologne, Germany
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Metabolic crisis after trivial head trauma in late-onset isolated sulfite oxidase deficiency: Report of two new cases and review of published patients. Brain Dev 2020; 42:157-164. [PMID: 31806255 DOI: 10.1016/j.braindev.2019.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 10/25/2019] [Accepted: 11/18/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Isolated sulfite oxidase deficiency (ISOD) is a rare autosomal recessively inherited inborn error of metabolism, caused by mutation in SUOX gene. ISOD has two kind of presentation; early and late-onset. The late-onset form is extremely rare and only 10 cases have been reported. METHODS We report two new cases of late-onset ISOD with biochemical and genetic confirmation. We did a review of the previously published cases of late-onset ISOD. RESULTS Together with the presented two cases, 12 cases were available for analysis. The median age at symptom onset and at diagnosis was 8.5 and 23 months respectively. Almost all children had acute regression of milestones followed by slow recovery. The common presenting signs and symptoms were movement disorders, seizures, ectopia lentis and hypertonia. Five children had antecedent events. Trivial trauma precipitating the metabolic crisis was unique to the two cases we report. The most common MRI feature was globus pallidi changes followed by cerebellar white matter changes, vermian hypoplasia and thinned out corpus callosum. Diffusion weighted sequence was performed in 3 children and all had diffusion restriction in the affected area. CONCLUSION Trivial trauma can precipitate metabolic crisis in late-onset ISOD. Low plasma homocysteine and involvement of globus pallidi with diffusion restriction on the MRI are important diagnostic clues. Early diagnosis and intervention with special diet may be effective in preventing long term neurodisability.
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Liu Y, Croft KD, Hodgson JM, Mori T, Ward NC. Mechanisms of the protective effects of nitrate and nitrite in cardiovascular and metabolic diseases. Nitric Oxide 2020; 96:35-43. [PMID: 31954804 DOI: 10.1016/j.niox.2020.01.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/18/2019] [Accepted: 01/13/2020] [Indexed: 12/28/2022]
Abstract
Within the body, NO is produced by nitric oxide synthases via converting l-arginine to citrulline. Additionally, NO is also produced via the NOS-independent nitrate-nitrite-NO pathway. Unlike the classical pathway, the nitrate-nitrite-NO pathway is oxygen independent and viewed as a back-up function to ensure NO generation during ischaemia/hypoxia. Dietary nitrate and nitrite have emerged as substrates for endogenous NO generation and other bioactive nitrogen oxides with promising protective effects on cardiovascular and metabolic function. In brief, inorganic nitrate and nitrite can decrease blood pressure, protect against ischaemia-reperfusion injury, enhance endothelial function, inhibit platelet aggregation, modulate mitochondrial function and improve features of the metabolic syndrome. However, many questions regarding the specific mechanisms of these protective effects on cardiovascular and metabolic diseases remain unclear. In this review, we focus on nitrate/nitrite bioactivation, as well as the potential mechanisms for nitrate/nitrite-mediated effects on cardiovascular and metabolic diseases. Understanding how dietary nitrate and nitrite induce beneficial effect on cardiovascular and metabolic diseases could open up novel therapeutic opportunities in clinical practice.
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Affiliation(s)
- Yang Liu
- School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - Kevin D Croft
- School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - Jonathan M Hodgson
- School of Biomedical Sciences, University of Western Australia, Perth, Australia; School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
| | - Trevor Mori
- Medical School, University of Western Australia, Perth, Australia
| | - Natalie C Ward
- Medical School, University of Western Australia, Perth, Australia; School of Public Health and Curtin Health Innovation Research Institute, Curtin University, Perth, Australia.
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Tian M, Qu Y, Huang L, Su X, Li S, Ying J, Zhao F, Mu D. Stable clinical course in three siblings with late-onset isolated sulfite oxidase deficiency: a case series and literature review. BMC Pediatr 2019; 19:510. [PMID: 31870341 PMCID: PMC6927172 DOI: 10.1186/s12887-019-1889-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 12/15/2019] [Indexed: 11/16/2022] Open
Abstract
Background Isolated sulfite oxidase deficiency (ISOD) is an autosomal recessive disorder caused by a deficiency of sulfite oxidase, which is encoded by the sulfite oxidase gene (SUOX). Clinically, the disorder is classified as one of two forms: the late-onset mild form or the classic early-onset form. The latter is life-threatening and always leads to death during early childhood. Mild ISOD cases are rare and may benefit from dietary therapy. To date, no cases of ISOD have been reported to recover spontaneously. Here, we present three mild ISOD cases in one family, each with a stable clinical course and spontaneous recovery. Case presentation All three siblings had two novel compound heterozygous mutations in the SUOX gene (NM_000456; c.1096C > T [p.R366C] and c.1376G > A [p.R459Q]). The siblings included two males and one female with late ages of onset (12–16 months) and presented with specific neuroimaging abnormalities limited to the bilateral globus pallidus and substantia nigra. The three patients had decreased plasma homocysteine levels. They exhibited a monophasic clinical course continuing up to 8.5 years even without dietary therapy. Conclusion This is the first report of mild ISOD cases with a stable clinical course and spontaneous recovery without dietary therapy. Our study provides an expansion for the clinical spectrum of ISOD. Furthermore, we highlight the importance of including ISOD in the differential diagnosis for patients presenting with late-onset symptoms, bilaterally symmetric regions of abnormal intensities in the basal ganglia, and decreased plasma homocysteine levels.
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Affiliation(s)
- Maoqiang Tian
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, 610041, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, (Sichuan University), Ministry of Education, Chengdu, 610041, China.,Department of Pediatrics, Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
| | - Yi Qu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, 610041, China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children, (Sichuan University), Ministry of Education, Chengdu, 610041, China.
| | - Lingyi Huang
- West China College of Stomatology, Sichuan University, Chengdu, 610041, China
| | - Xiaojuan Su
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, 610041, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, (Sichuan University), Ministry of Education, Chengdu, 610041, China
| | - Shiping Li
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, 610041, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, (Sichuan University), Ministry of Education, Chengdu, 610041, China
| | - Junjie Ying
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, 610041, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, (Sichuan University), Ministry of Education, Chengdu, 610041, China
| | - Fengyan Zhao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, 610041, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, (Sichuan University), Ministry of Education, Chengdu, 610041, China
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, 610041, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, (Sichuan University), Ministry of Education, Chengdu, 610041, China
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Montaut S, Tranchant C, Drouot N, Rudolf G, Guissart C, Tarabeux J, Stemmelen T, Velt A, Fourrage C, Nitschké P, Gerard B, Mandel JL, Koenig M, Chelly J, Anheim M. Assessment of a Targeted Gene Panel for Identification of Genes Associated With Movement Disorders. JAMA Neurol 2019; 75:1234-1245. [PMID: 29913018 DOI: 10.1001/jamaneurol.2018.1478] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance Movement disorders are characterized by a marked genotypic and phenotypic heterogeneity, complicating diagnostic work in clinical practice and molecular diagnosis. Objective To develop and evaluate a targeted sequencing approach using a customized panel of genes involved in movement disorders. Design, Setting and Participants We selected 127 genes associated with movement disorders to create a customized enrichment in solution capture array. Targeted high-coverage sequencing was applied to DNA samples taken from 378 eligible patients at 1 Luxembourgian, 1 Algerian, and 25 French tertiary movement disorder centers between September 2014 and July 2016. Patients were suspected of having inherited movement disorders because of early onset, family history, and/or complex phenotypes. They were divided in 5 main movement disorder groups: parkinsonism, dystonia, chorea, paroxysmal movement disorder, and myoclonus. To compare approaches, 23 additional patients suspected of having inherited cerebellar ataxia were included, on whom whole-exome sequencing (WES) was done. Data analysis occurred from November 2015 to October 2016. Main Outcomes and Measures Percentages of individuals with positive diagnosis, variants of unknown significance, and negative cases; mutational frequencies and clinical phenotyping of genes associated with movement disorders. Results Of the 378 patients (of whom 208 were male [55.0%]), and with a median (range) age at disease onset of 31 (0-84) years, probable pathogenic variants were identified in 83 cases (22.0%): 46 patients with parkinsonism (55% of 83 patients), 21 patients (25.3%) with dystonia, 7 patients (8.4%) with chorea, 7 patients (8.4%) with paroxysmal movement disorders, and 2 patients (2.4%) with myoclonus as the predominant phenotype. Some genes were mutated in several cases in the cohort. Patients with pathogenic variants were significantly younger (median age, 27 years; interquartile range [IQR], 5-36 years]) than the patients without diagnosis (median age, 35 years; IQR, 15-46 years; P = .04). Diagnostic yield was significantly lower in patients with dystonia (21 of 135; 15.6%; P = .03) than in the overall cohort. Unexpected genotype-phenotype correlations in patients with pathogenic variants deviating from the classic phenotype were highlighted, and 49 novel probable pathogenic variants were identified. The WES analysis of the cohort of 23 patients with cerebellar ataxia led to an overall diagnostic yield of 26%, similar to panel analysis but at a cost 6 to 7 times greater. Conclusions and Relevance High-coverage sequencing panel for the delineation of genes associated with movement disorders was efficient and provided a cost-effective diagnostic alternative to whole-exome and whole-genome sequencing.
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Affiliation(s)
- Solveig Montaut
- Département de Neurologie, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Christine Tranchant
- Département de Neurologie, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France.,Institut de Génétique et de Biologie Moléculaire et Cellulaire, Illkirch, France
| | - Nathalie Drouot
- Institut de Génétique et de Biologie Moléculaire et Cellulaire, Illkirch, France
| | - Gabrielle Rudolf
- Département de Neurologie, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France.,Institut de Génétique et de Biologie Moléculaire et Cellulaire, Illkirch, France
| | - Claire Guissart
- EA7402, Laboratoire de Génétique Moléculaire, Institut de Recherche Clinique, Montpellier University Hospital, France
| | - Julien Tarabeux
- Laboratoire de Diagnostic Génétique, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Tristan Stemmelen
- Institut de Génétique et de Biologie Moléculaire et Cellulaire, Illkirch, France
| | - Amandine Velt
- Laboratoire de Diagnostic Génétique, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Cécile Fourrage
- Institut Imagine, Imagine Bioinformatics Platform, Paris Descartes University, Paris, France
| | - Patrick Nitschké
- Institut Imagine, Imagine Bioinformatics Platform, Paris Descartes University, Paris, France
| | - Bénédicte Gerard
- Laboratoire de Diagnostic Génétique, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Jean-Louis Mandel
- Institut de Génétique et de Biologie Moléculaire et Cellulaire, Illkirch, France.,Laboratoire de Diagnostic Génétique, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Michel Koenig
- EA7402, Laboratoire de Génétique Moléculaire, Institut de Recherche Clinique, Montpellier University Hospital, France
| | - Jamel Chelly
- Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France.,Institut de Génétique et de Biologie Moléculaire et Cellulaire, Illkirch, France.,Laboratoire de Diagnostic Génétique, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Mathieu Anheim
- Département de Neurologie, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France.,Institut de Génétique et de Biologie Moléculaire et Cellulaire, Illkirch, France
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11
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Kohl JB, Mellis A, Schwarz G. Homeostatic impact of sulfite and hydrogen sulfide on cysteine catabolism. Br J Pharmacol 2019; 176:554-570. [PMID: 30088670 PMCID: PMC6346071 DOI: 10.1111/bph.14464] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 06/22/2018] [Accepted: 07/02/2018] [Indexed: 12/30/2022] Open
Abstract
Cysteine is one of the two key sulfur-containing amino acids with important functions in redox homeostasis, protein functionality and metabolism. Cysteine is taken up by mammals via their diet and can also be derived from methionine via the transsulfuration pathway. The cellular concentration of cysteine is kept within a narrow range by controlling its synthesis and degradation. There are two pathways for the catabolism of cysteine leading to sulfate, taurine and thiosulfate as terminal products. The oxidative pathway produces taurine and sulfate, while the H2 S pathway involves different enzymatic reactions leading to the formation and clearance of H2 S, an important signalling molecule in mammals, resulting in thiosulfate and sulfate. Sulfite is a common intermediate in both catabolic pathways. Sulfite is considered as cytotoxic and produces neurotoxic S-sulfonates. As a result, a deficiency in the terminal steps of cysteine or H2 S catabolism leads to severe forms of encephalopathy with the accumulation of sulfite and H2 S in the body. This review links the homeostatic regulation of both cysteine catabolic pathways to sulfite and H2 S. LINKED ARTICLES: This article is part of a themed section on Chemical Biology of Reactive Sulfur Species. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.4/issuetoc.
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Affiliation(s)
- Joshua B Kohl
- Institute of Biochemistry, Department of Chemistry and Center for Molecular Medicine CologneUniversity of CologneCologneGermany
| | - Anna‐Theresa Mellis
- Institute of Biochemistry, Department of Chemistry and Center for Molecular Medicine CologneUniversity of CologneCologneGermany
| | - Guenter Schwarz
- Institute of Biochemistry, Department of Chemistry and Center for Molecular Medicine CologneUniversity of CologneCologneGermany
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12
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Boyer M, Sowa M, Wang R, Abdenur J. Isolated Sulfite Oxidase Deficiency: Response to Dietary Treatment in a Patient with Severe Neonatal Presentation. JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2019. [DOI: 10.1590/2326-4594-jiems-2019-0001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | - Raymond Wang
- CHOC Children’s Hospital, USA; University of California-Irvine, USA
| | - Jose Abdenur
- CHOC Children’s Hospital, USA; University of California-Irvine, USA
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13
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The Role of Oxidative Stress and Bioenergetic Dysfunction in Sulfite Oxidase Deficiency: Insights from Animal Models. Neurotox Res 2018; 35:484-494. [DOI: 10.1007/s12640-018-9986-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/13/2018] [Accepted: 11/26/2018] [Indexed: 02/07/2023]
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14
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Development of a rapid UPLC–MS/MS determination of urine sulfocysteine for diagnosis of sulfocysteinuria and molybdenum co-factor deficiencies. Bioanalysis 2018; 10:747-756. [DOI: 10.4155/bio-2017-0278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aim: Molybdenum co-factor deficiencies and isolated sulfite oxidase deficiency are rare autosomal recessively inherited diseases characterized by severe psychomotor impairment, intractable seizures, dislocated lens and dysmorphic facial features. The biochemical diagnosis of these diseases requires the determination of urine sulfocysteine. Materials & methods: Urine sulfocysteine was quantified by an ultra-high performance liquid chromatography–MS/MS assay. The method was validated for linearity, accuracy, precision, recovery and stability. Results & conclusion: Total imprecision of accuracy was less than 6%. Intra-assay and inter-assay precisions were less than 5%. The recovery was higher than 98%. The method is inexpensive, fast, accurate and has been successfully used for identifying five molybdenum co-factor deficient and six sulfite oxidase deficient patients since deployed.
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15
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Claerhout H, Witters P, Régal L, Jansen K, Van Hoestenberghe MR, Breckpot J, Vermeersch P. Isolated sulfite oxidase deficiency. J Inherit Metab Dis 2018; 41:101-108. [PMID: 28980090 DOI: 10.1007/s10545-017-0089-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 08/29/2017] [Accepted: 08/30/2017] [Indexed: 11/27/2022]
Abstract
Isolated sulfite oxidase deficiency (ISOD) is a life-threatening, autosomal recessive disease characterized by severe neurological impairment. As no long-term effective treatment is available, distinction from other treatable diseases, such as molybdenum cofactor deficiency (MoCD) type A, should be made. We reviewed 47 patients (45 previously reported in the literature). Cases were reviewed for consanguinity, sex, age at onset, death, clinical findings (including spasticity, seizures, psychomotor retardation, feeding difficulties, ectopia lentis, microcephaly), laboratory findings [urinary sulfite, S-sulfocysteine (in plasma and urine), plasma cystine, total homocysteine, uric acid, and oxypurines in urine] and radiological findings (including cerebral/cerebellar atrophy, cystic white matter changes, ventriculomegaly). We also aligned the published SUOX gene mutations to the reference sequence NM_000456.2. Onset occurred mostly during the first 72 h of life (57%) and within the first year of life in all but two patients (96%). All patients presented with neurological abnormalities, such as neonatal axial hypotonia and/or peripheral hypertonia (100%), (pharmacoresistant) seizures (84%), or developmental delay (97%). Feeding problems were also common. As found in our review, measurement of homocysteine in plasma, amino acids in plasma/urine, and sulfite in fresh urine supports the diagnosis of ISOD. Analysis of uric acid (plasma) and oxypurines (urine) is useful to rule out MoCD. In all patients in whom brain magnetic resonance imaging/computed tomography (MRI/CT) was performed, brain abnormalities were found. The purpose of this literature review is to provide a thorough overview of clinical, neuroimaging, biochemical, and genetic findings of patients with ISOD.
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Affiliation(s)
- Helena Claerhout
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Peter Witters
- Center for Metabolic Diseases, University Hospitals Leuven, Leuven, Belgium
- Clinical Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Luc Régal
- Clinical Department of Pediatric Neurology and metabolism, UZ Brussel, Brussels, Belgium
| | - Katrien Jansen
- Center for Metabolic Diseases, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Pieter Vermeersch
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium.
- Center for Metabolic Diseases, University Hospitals Leuven, Leuven, Belgium.
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16
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Neurological Disorders Associated with Striatal Lesions: Classification and Diagnostic Approach. Curr Neurol Neurosci Rep 2016; 16:54. [PMID: 27074771 DOI: 10.1007/s11910-016-0656-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Neostriatal abnormalities can be observed in a very large number of neurological conditions clinically dominated by the presence of movement disorders. The neuroradiological picture in some cases has been described as "bilateral striatal necrosis" (BSN). BSN represents a condition histo-pathologically defined by the involvement of the neostriata and characterized by initial swelling of putamina and caudates followed by degeneration and cellular necrosis. After the first description in 1975, numerous acquired and hereditary conditions have been associated with the presence of BSN. At the same time, a large number of disorders involving neostriata have been described as BSN, in some cases irrespective of the presence of signs of cavitation on MRI. As a consequence, the etiological spectrum and the nosographic boundaries of the syndrome have progressively become less clear. In this study, we review the clinical and radiological features of the conditions associated with MRI evidence of bilateral striatal lesions. Based on MRI findings, we have distinguished two groups of disorders: BSN and other neostriatal lesions (SL). This distinction is extremely helpful in narrowing the differential diagnosis to a small group of known conditions. The clinical picture and complementary exams will finally lead to the diagnosis. We provide an update on the etiological spectrum of BSN and propose a diagnostic flowchart for clinicians.
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Screening of a clinically and biochemically diagnosed SOD patient using exome sequencing: A case report with a mutations/variations analysis approach. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2016. [DOI: 10.1016/j.ejmhg.2015.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Omar SA, Webb AJ. Nitrite reduction and cardiovascular protection. J Mol Cell Cardiol 2014; 73:57-69. [PMID: 24486197 DOI: 10.1016/j.yjmcc.2014.01.012] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 01/20/2014] [Accepted: 01/22/2014] [Indexed: 10/25/2022]
Abstract
Inorganic nitrite, a metabolite of endogenously produced nitric oxide (NO) from NO synthases (NOS), provides the largest endocrine source of directly bioavailable NO. The conversion of nitrite to NO occurs mainly through enzymatic reduction, mediated by a range of proteins, including haem-globins, molybdo-flavoproteins, mitochondrial proteins, cytochrome P450 enzymes, and NOS. Such nitrite reduction is particularly favoured under hypoxia, when endogenous formation of NO from NOS is impaired. Under normoxic conditions, the majority of these nitrite reductases also scavenge NO, or diminish its bioavailability via reactive oxygen species (ROS) production, suggesting an intricate balance. Moreover, nitrite, whether produced endogenously, or derived from exogenous nitrite or nitrate administration (including dietary sources via the Nitrate-Nitrite-NO pathway) beneficially modulates many key cardiovascular pathological processes. In this review, we highlight the landmark studies which revealed nitrite's function in biological systems, and inspect its evolving role in cardiovascular protection. Whilst these effects have mainly been ascribed to the activity of one or more nitrite reductases, we also discuss newly-identified mechanisms, including nitrite anhydration, the involvement of s-nitrosothiols, nitro-fatty acids, and direct nitrite normoxic signalling, involving modification of mitochondrial structure and function, and ROS production. This article is part of a Special Issue entitled "Redox Signalling in the Cardiovascular System".
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Affiliation(s)
- Sami A Omar
- King's College London British Heart Foundation Centre, Cardiovascular Division, Department of Clinical Pharmacology, 4th Floor North Wing, St. Thomas' Hospital, London SE1 7EH, UK; Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK.
| | - Andrew James Webb
- King's College London British Heart Foundation Centre, Cardiovascular Division, Department of Clinical Pharmacology, 4th Floor North Wing, St. Thomas' Hospital, London SE1 7EH, UK; Biomedical Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK.
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