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Kurtanović N, Gogić E, Džubur A, Begić E, Bijedić A. Fibrodysplasia Ossificans Progressiva: A Man Turned to Stone. Cureus 2024; 16:e61661. [PMID: 38966484 PMCID: PMC11223740 DOI: 10.7759/cureus.61661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 07/06/2024] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an exceptionally rare genetic disorder, representing humans' most debilitating form of extraskeletal ossification. It is characterized by progressive postnatal heterotopic ossification of connective tissue and malformations of the big toes. In FOP, ectopic ossification usually begins in the upper paraspinal muscles and then spreads from axial to appendicular regions, cranial to caudal directions, and proximal to distal sites. The mean life expectancy for these patients is typically 40-50 years. Most patients need partial or complete assistance with walking by age 30, and common causes of death include thoracic insufficiency syndrome and pneumonia. We present the case of a patient with an advanced stage of FOP, highlighting its complex and progressive nature. The patient exhibits severe impairment of jaw mobility, swallowing difficulties, speech impediments, and hearing impairment. Additionally, severe kyphoscoliosis, heterotopic ossification of intercostal and paravertebral muscles, and ankylosis of the spine and all major joints of the upper and lower extremities, except the metacarpophalangeal and proximal interphalangeal joints, are evident. We discuss disease presentation, current management options, and rehabilitation challenges. To our knowledge, this is the first reported case of this rare disease from our country.
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Affiliation(s)
- Nadina Kurtanović
- Physical Medicine and Rehabilitation, Health Institution Spa Gata Bihać, Bihać, BIH
| | - Ena Gogić
- Physical Medicine and Rehabilitation, Clinical Center University of Sarajevo, Sarajevo, BIH
| | - Alen Džubur
- Cardiology, Clinical Center University of Sarajevo, Sarajevo, BIH
| | - Edin Begić
- Cardiology, Sarajevo School of Science and Technology, Sarajevo, BIH
| | - Asja Bijedić
- Physical Medicine and Rehabilitation, University Clinical Center Tuzla, Tuzla, BIH
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Guyolla YH, Abebe FT, Ahmed AJ. Fibrodysplasia Ossificans Progressiva: A rare disease due to unawareness, case report and literature review. Int J Surg Case Rep 2024; 117:109548. [PMID: 38513414 PMCID: PMC10966195 DOI: 10.1016/j.ijscr.2024.109548] [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: 02/20/2024] [Revised: 03/09/2024] [Accepted: 03/14/2024] [Indexed: 03/23/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Fibrodysplasia Ossificans Progressiva is an ultra-rare genetic disorder of progressive soft tissue ossification. Due to unawareness and poor clinical suspicion, the rate of misdiagnosis, delay in diagnosis, and unnecessary diagnostic procedures leading to permanent injury and lifelong disability is common. Here we report this rare genetic disorder in a six years old child who was initially misdiagnosed as multiple exostoses and operated on. CASE PRESENTATION A 6 year old child presented with swellings over the posterior neck and back for four years. The patient was misdiagnosed as a case of multiple exostoses and an excisional biopsy was done a year back. The swelling worsened after the excision; currently, she cannot move her neck from side to side, and flex and extend. Examination revealed multiple hard and slightly tender masses over the posterior neck, para scapular and thoracolumbar para spinal region. She also has hallux valgus deformity that had been present since birth. CT (computed tomography) scan confirmed extensive extra-skeletal soft tissue ossification. CLINICAL DISCUSSION The progression of heterotopic ossification is characteristically anatomic and orderly, typically initially involving the body's dorsal, axial, cranial, and proximal regions and later in the ventral, appendicular, caudal, and distal regions. Skeletal muscles of the tongue, diaphragm, extra-ocular muscles, cardiac muscles, and smooth muscles are inexplicably spared. CONCLUSION Early diagnosis prevents potentially harmful diagnostic and therapeutic procedures. The characteristic big toes malformation is the most important and best key for the early suspicion of the diagnosis.
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Affiliation(s)
- Yabello Hirbo Guyolla
- Jimma University Medical Centre, College of Health Sciences, Department of Surgery, Jimma, Ethiopia.
| | - Fasil Tesfaye Abebe
- Jimma University Medical Centre, College of Health Sciences, Department of Surgery, Jimma, Ethiopia
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Korableva NN, Berestnev EV, Kiselyov SM, Chipsanova NF. Fibrodysplasia Ossificans Progressiva: Literature Review and Case Report. CURRENT PEDIATRICS 2022. [DOI: 10.15690/vsp.v21i6s.2482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background. Fibrodysplasia ossificans progressiva (FOP) is a genetic disease of the heterotopic ossification group associated with the mutation in ACVR1/ALK2 gene. FOP is characterized by progressive heterotopic endochondral ossification of connective tissue that occurs in postnatal period. It leads to formation of qualitatively normal bone in extraskeletal areas. Congenital hallux deformity is typical for this disease. The clinical picture is characterized by aggravations that are usually caused by trauma or viral infections. Formation of Heterotopic ossificate formation can be observed during aggravations. There is no etiological treatment for FOP. Systemic glucocorticosteroids, non-steroidal anti-inflammatory drug (NSAIDs), mast cell stabilisers, antileukotriene drugs and bisphosphonates can be used in these patients. Clinical case description. The child was born with congenital hallux deformity typical for FOP. The disease onset was noted at the age of 2 years 8 months with a tumor-like painful mass on the neck. Oncological (lymphoproliferative) disease was suspected but biopsy from the lesion did not confirm its malignant nature. The child was consulted by pediatric rheumatologist who has diagnosed FOP. Etanercept and zoledronic acid were administrated, though etanercept was later discontinued. For now, the child receives zoledronic acid infusions 2 times per year and daily NSAIDs. Conclusion. The difficulties in FOP diagnosing are associated to its sporadic nature and clinical picture similarity to other diseases. Suspected malignancy leads to biopsy that is highly undesirable in FOP patients due to high risk of iatrogenic complications.
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Pignolo RJ, Baujat G, Brown MA, De Cunto C, Hsiao EC, Keen R, Al Mukaddam M, Le Quan Sang KH, Wilson A, Marino R, Strahs A, Kaplan FS. The natural history of fibrodysplasia ossificans progressiva: A prospective, global 36-month study. Genet Med 2022; 24:2422-2433. [PMID: 36152026 DOI: 10.1016/j.gim.2022.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/16/2022] [Accepted: 08/16/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE We report the first prospective, international, natural history study of the ultra-rare genetic disorder fibrodysplasia ossificans progressiva (FOP). FOP is characterized by painful, recurrent flare-ups, and disabling, cumulative heterotopic ossification (HO) in soft tissues. METHODS Individuals aged ≤65 years with classical FOP (ACVR1R206H variant) were assessed at baseline and over 36 months. RESULTS In total, 114 individuals participated; 33 completed the study (mean follow up: 26.8 months). Median age was 15.0 (range: 4-56) years; 54.4% were male. During the study, 82 (71.9%) individuals reported 229 flare-ups (upper back: 17.9%, hip: 14.8%, shoulder: 10.9%). After 84 days, 14 of 52 (26.9%) imaged flare-ups had new HO at the flare-up site (mean new HO volume: 28.8 × 103 mm3). Mean baseline low-dose whole-body computed tomography (excluding head) HO volume was 314.4 × 103 mm3; lowest at 2 to <8 years (68.8 × 103 mm3) and increasing by age (25-65 years: 575.2 × 103 mm3). The mean annualized volume of new HO was 23.6 × 103 mm3/year; highest at 8 to <15 and 15 to <25 years (21.9 × 103 and 41.5 × 103 mm3/year, respectively) and lowest at 25 to 65 years (4.6 × 103 mm3/year). CONCLUSION Results from individuals receiving standard care for up to 3 years in this natural history study show the debilitating effect and progressive nature of FOP cross-sectionally and longitudinally, with greatest progression during childhood and early adulthood.
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Affiliation(s)
| | - Geneviève Baujat
- Département de Génétique, Hôpital Universitaire Necker-Enfants Malades, Institut Imagine, Université Paris Cité, Paris, France
| | - Matthew A Brown
- Department of Medicine and Molecular Genetics, Faculty of Life Sciences and Medicine, School of Basic and Medical Biosciences, King's College London, London, United Kingdom; Genomics England, London, United Kingdom
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, the Eli and Edyth Broad Institute for Regeneration Medicine, and the Institute of Human Genetics, Department of Medicine, and the UCSF Program in Craniofacial Biology, University of California San Francisco, San Francisco, CA
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Mona Al Mukaddam
- Departments of Orthopaedic Surgery and Medicine, Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kim-Hanh Le Quan Sang
- Département de Génétique, Hôpital Universitaire Necker-Enfants Malades, Institut Imagine, Université Paris Cité, Paris, France
| | | | | | | | - Frederick S Kaplan
- Departments of Orthopaedic Surgery and Medicine, Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Al Mukaddam M, Toder KS, Davis M, Cali A, Liljesthröm M, Hollywood S, Croskery K, Grandoulier AS, Böing EA, Whalen JD, Kaplan FS. The impact of fibrodysplasia ossificans progressiva (FOP) on patients and their family members: results from an international burden of illness survey. Expert Rev Pharmacoecon Outcomes Res 2022; 22:1199-1213. [PMID: 36017643 DOI: 10.1080/14737167.2022.2115360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare, genetic disorder of heterotopic ossification, which transforms soft, connective tissues into bone, resulting in limited joint function and severe disability. We present results from an international burden of illness survey (NCT04665323) assessing physical, quality of life (QoL), and economic impacts of FOP on patients and family members. METHODS Patient associations in 15 countries invited their members to participate; individuals with FOP and their family members were eligible. The survey was available online, in 11 languages, from January 18-April 30, 2021. Participants responded to assessments measuring joint function, QoL, healthcare service and living adaptation utilization, out-of-pocket costs, employment, and travel. RESULTS The survey received 463 responses (patients, n=219; family members, n=244). For patients, decreased joint function was associated with reduced QoL and greater reliance on living adaptations. Nearly half of primary caregivers experienced a mild to moderate impact on their health/psychological wellbeing. Most primary caregivers and patients (≥18 years) reported that FOP impacted their career decisions. CONCLUSIONS Data from this survey will improve understanding of the impact of FOP on patients and family members, which is important for identifying unmet needs, optimizing care, and improving support for the FOP community.
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Affiliation(s)
- Mona Al Mukaddam
- Departments of Orthopaedic Surgery and Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Katherine S Toder
- Departments of Orthopaedic Surgery and Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Amanda Cali
- The Radiant Hope Foundation, Mountain Lakes, NJ, USA.,The Ian Cali FOP Research Fund, PENN Medicine, The Center for Research in FOP and Related Disorders, Philadelphia, PA, USA.,Tin Soldiers: Global Patient Identification Program, Johannesburg, South Africa
| | - Moira Liljesthröm
- Fundación FOP, Buenos Aires, Argentina.,Argentine Representative to the International President's Council of the International FOP Association, Buenos Aires, Argentina
| | | | | | | | | | | | - Frederick S Kaplan
- Departments of Orthopaedic Surgery and Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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6
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Kannu P, Levy CE. Improving the Diagnosis of Fibrodysplasia Ossificans Progressiva. J Pediatr 2021; 232S:S3-S8. [PMID: 33896450 DOI: 10.1016/j.jpeds.2021.02.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/11/2021] [Accepted: 02/16/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Peter Kannu
- The Hospital for Sick Children and Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada; University of Alberta, Toronto, Ontario, Canada.
| | - Charles E Levy
- Center for Arts in Medicine, College of the Arts, University of Florida, Gainesville, FL
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Cardiopulmonary and Neurologic Dysfunctions in Fibrodysplasia Ossificans Progressiva. Biomedicines 2021; 9:biomedicines9020155. [PMID: 33562570 PMCID: PMC7915901 DOI: 10.3390/biomedicines9020155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/20/2021] [Accepted: 01/28/2021] [Indexed: 12/28/2022] Open
Abstract
Fibrodysplasia Ossificans Progressiva (FOP) is an ultra-rare but debilitating disorder characterized by spontaneous, progressive, and irreversible heterotopic ossifications (HO) at extraskeletal sites. FOP is caused by gain-of-function mutations in the Activin receptor Ia/Activin-like kinase 2 gene (Acvr1/Alk2), with increased receptor sensitivity to bone morphogenetic proteins (BMPs) and a neoceptor response to Activin A. There is extensive literature on the skeletal phenotypes in FOP, but a much more limited understanding of non-skeletal manifestations of this disease. Emerging evidence reveals important cardiopulmonary and neurologic dysfunctions in FOP including thoracic insufficiency syndrome, pulmonary hypertension, conduction abnormalities, neuropathic pain, and demyelination of the central nervous system (CNS). Here, we review the recent research and discuss unanswered questions regarding the cardiopulmonary and neurologic phenotypes in FOP.
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8
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Kaliya-Perumal AK, Carney TJ, Ingham PW. Fibrodysplasia ossificans progressiva: current concepts from bench to bedside. Dis Model Mech 2020; 13:13/9/dmm046441. [PMID: 32988985 PMCID: PMC7522019 DOI: 10.1242/dmm.046441] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Heterotopic ossification (HO) is a disorder characterised by the formation of ectopic bone in soft tissue. Acquired HO typically occurs in response to trauma and is relatively common, yet its aetiology remains poorly understood. Genetic forms, by contrast, are very rare, but provide insights into the mechanisms of HO pathobiology. Fibrodysplasia ossificans progressiva (FOP) is the most debilitating form of HO. All patients reported to date carry heterozygous gain-of-function mutations in the gene encoding activin A receptor type I (ACVR1). These mutations cause dysregulated bone morphogenetic protein (BMP) signalling, leading to HO at extraskeletal sites including, but not limited to, muscles, ligaments, tendons and fascia. Ever since the identification of the causative gene, developing a cure for FOP has been a focus of investigation, and studies have decoded the pathophysiology at the molecular and cellular levels, and explored novel management strategies. Based on the established role of BMP signalling throughout HO in FOP, therapeutic modalities that target multiple levels of the signalling cascade have been designed, and some drugs have entered clinical trials, holding out hope of a cure. A potential role of other signalling pathways that could influence the dysregulated BMP signalling and present alternative therapeutic targets remains a matter of debate. Here, we review the recent FOP literature, including pathophysiology, clinical aspects, animal models and current management strategies. We also consider how this research can inform our understanding of other types of HO and highlight some of the remaining knowledge gaps. Summary: Fibrodysplasia ossificans progressiva is a rare disease characterised by progressive heterotopic bone formation. Here, we present a comprehensive summary of the recent literature on this debilitating condition and discuss approaches to solving this clinical puzzle.
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Affiliation(s)
- Arun-Kumar Kaliya-Perumal
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 59 Nanyang Drive, 636921, Singapore
| | - Tom J Carney
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 59 Nanyang Drive, 636921, Singapore.,Institute of Molecular and Cell Biology (IMCB), Agency for Science, Technology and Research (A*STAR), 61 Biopolis Drive, Proteos 138673, Singapore
| | - Philip W Ingham
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 59 Nanyang Drive, 636921, Singapore .,Institute of Molecular and Cell Biology (IMCB), Agency for Science, Technology and Research (A*STAR), 61 Biopolis Drive, Proteos 138673, Singapore
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9
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Pignolo RJ, Cheung K, Kile S, Fitzpatrick MA, De Cunto C, Al Mukaddam M, Hsiao EC, Baujat G, Delai P, Eekhoff EMW, Di Rocco M, Grunwald Z, Haga N, Keen R, Levi B, Morhart R, Scott C, Sherman A, Zhang K, Kaplan FS. Self-reported baseline phenotypes from the International Fibrodysplasia Ossificans Progressiva (FOP) Association Global Registry. Bone 2020; 134:115274. [PMID: 32062004 DOI: 10.1016/j.bone.2020.115274] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/11/2020] [Accepted: 02/13/2020] [Indexed: 11/21/2022]
Abstract
A global, patient-reported registry has been established to characterize the course of disease and track clinical outcomes in patients with fibrodysplasia ossificans progressiva (FOP), an ultra-rare genetic condition of progressive heterotopic ossification (HO) that results in ankylosis of joints and renders most affected individuals immobile by the second decade of life. Here, we present baseline phenotypes on 299 patients (median age 21 years; range 0.1 to 78 years) from 54 countries based on aggregate data from the International FOP Association (IFOPA) Global Registry (the "FOP Registry"). The mean current age of the patients is 23.7 years (range, 0.1 to 78 years). Baseline characteristics are presented for FOP diagnosis, HO, flare-ups and precedent events, system-based prevalent symptomatology, encounters with medical and dental care providers, Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Scale scores, physical function, as well as the use of aids, assistive devices, and adaptations. Correlations of PROMIS Global Health scores with HO burden and physical function are calculated. Associations of joint mobility with PROMIS Global Health scores, physical function, and use of aids, assistive devices, and adaptations are summarized. Overall, the FOP Registry database contains a broad sample of the global FOP patient population, providing a useful tool for expanding knowledge of FOP, designing clinical trials and facilitating evidence-based decisions about the optimal monitoring and management of affected individuals.
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Affiliation(s)
- Robert J Pignolo
- Department of Medicine, Mayo Clinic School of Medicine, Mayo Clinic, Rochester, MN, United States.
| | - Kin Cheung
- BioSAS Consulting, Inc., Wellesley, MA, United States
| | - Sammi Kile
- International FOP Association, 1520 Clay St, Suite H2, North Kansas City, MO, United States.
| | - Mary Anne Fitzpatrick
- International FOP Association, 1520 Clay St, Suite H2, North Kansas City, MO, United States.
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Mona Al Mukaddam
- Departments of Medicine and Orthopaedic Surgery, The Center for Research in FOP and Related Disorders, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, United States.
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, The UCSF Metabolic Bone Clinic, The Institute of Human Genetics, the UCSF Program in Craniofacial Biology, Department of Medicine, University of California-San Francisco, San Francisco, CA, United States.
| | - Genevieve Baujat
- Departement de Genetique, Institut IMAGINE, Hôpital Necker-Enfants Malades, Paris, France.
| | - Patricia Delai
- Hospital Israelita Albert Einstein, Instituto de Ensino e Pesquisa, São Paulo, SP, Brazil.
| | - Elisabeth M W Eekhoff
- VU Medical Center Amsterdam, Department of Internal Medicine/Section Endocrinology, Amsterdam, the Netherlands.
| | - Maja Di Rocco
- Unit of Rare Diseases, Department of Pediatrics, Giannina Gaslini Institute, Genoa, Italy.
| | - Zvi Grunwald
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, United States.
| | - Nobuhiko Haga
- Department of Rehabilitation Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, Middlesex, United Kingdom.
| | - Benjamin Levi
- Department of Surgery, University of Michigan, Ann Arbor, MI, United States.
| | - Rolf Morhart
- Department of Pediatrics, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Germany.
| | - Christiaan Scott
- Department of Paediatric Rheumatology, Red Cross Children's Hospital, Cape Town, South Africa.
| | - Adam Sherman
- International FOP Association, 1520 Clay St, Suite H2, North Kansas City, MO, United States.
| | - Keqin Zhang
- Tongji Hospital, Shanghai Tongji University, Shanghai, PR China
| | - Fredrick S Kaplan
- Departments of Orthopaedic Surgery and Medicine, The Center for Research in FOP & Related Disorders, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, United States.
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Shah ZA, Rausch S, Arif U, El Yafawi B. Fibrodysplasia ossificans progressiva (stone man syndrome): a case report. J Med Case Rep 2019; 13:364. [PMID: 31785620 PMCID: PMC6885308 DOI: 10.1186/s13256-019-2297-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 10/18/2019] [Indexed: 11/29/2022] Open
Abstract
Background Fibrodysplasia ossificans progressiva is an ultrarare autosomal dominant disorder and disabling syndrome characterized by postnatal progressive heterotopic ossification of the connective tissue and congenital malformation of the big toes. Fibrodysplasia ossificans progressiva has worldwide prevalence of about 1 in 2 million births. Nearly 90% of patients with fibrodysplasia ossificans progressiva are misdiagnosed and mismanaged and thus undergo unnecessarily interventions. So far, the number of reported existing cases worldwide is about 700. Clinical examination, radiological evaluation, and genetic analysis for mutation of the ACVR1 gene are considered confirmatory tools for early diagnosis of the disease. Association of fibrodysplasia ossificans progressiva with heterotopic ossification is well documented; however, postsurgical exaggerated response has never been reported previously, to the best of our knowledge. Case presentation We report a case of a 10-year-old Pakistani boy brought by his parents to our institution. He had clinical and radiological features of fibrodysplasia ossificans progressive and presented with multiple painful lumps on his back due to hard masses and stiffness of his shoulders, neck, and left hip. He underwent surgical excision of left hip ossification followed by an exaggerated response in ossification with early disability. Radiological examination revealed widespread heterotopic ossification. All of his laboratory blood test results were normal. Conclusion Fibrodysplasia ossificans progressiva is a very rare and disabling disorder that, if misdiagnosed, can lead to unnecessary surgical intervention and disastrous results of early disability. We need to spread knowledge to physicians and patients’ family members about the disease, as well as its features for early diagnosis and how to prevent flare-up of the disease to promote better quality of life in these patients.
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Affiliation(s)
- Zakir Ali Shah
- Department of Trauma and Orthopedic, Rashid Hospital, Dubai, 4545, United Arab Emirates.
| | - Sascha Rausch
- Department of Trauma and Orthopedic, Rashid Hospital, Dubai, 4545, United Arab Emirates
| | - Uzma Arif
- Department of Diagnostic Radiology, Sheikh Zayed Hospital, Lahore, Pakistan
| | - Bilal El Yafawi
- Department of Trauma and Orthopedic, Rashid Hospital, Dubai, 4545, United Arab Emirates
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11
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Valer JA, Sánchez-de-Diego C, Pimenta-Lopes C, Rosa JL, Ventura F. ACVR1 Function in Health and Disease. Cells 2019; 8:cells8111366. [PMID: 31683698 PMCID: PMC6912516 DOI: 10.3390/cells8111366] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 12/12/2022] Open
Abstract
Activin A receptor type I (ACVR1) encodes for a bone morphogenetic protein type I receptor of the TGFβ receptor superfamily. It is involved in a wide variety of biological processes, including bone, heart, cartilage, nervous, and reproductive system development and regulation. Moreover, ACVR1 has been extensively studied for its causal role in fibrodysplasia ossificans progressiva (FOP), a rare genetic disorder characterised by progressive heterotopic ossification. ACVR1 is linked to different pathologies, including cardiac malformations and alterations in the reproductive system. More recently, ACVR1 has been experimentally validated as a cancer driver gene in diffuse intrinsic pontine glioma (DIPG), a malignant childhood brainstem glioma, and its function is being studied in other cancer types. Here, we review ACVR1 receptor function and signalling in physiological and pathological processes and its regulation according to cell type and mutational status. Learning from different functions and alterations linked to ACVR1 is a key step in the development of interdisciplinary research towards the identification of novel treatments for these pathologies.
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Affiliation(s)
- José Antonio Valer
- Departament de Ciències Fisiològiques, Universitat de Barcelona, IDIBELL, L'Hospitalet de Llobregat, 08907 Barcelona, Spain.
| | - Cristina Sánchez-de-Diego
- Departament de Ciències Fisiològiques, Universitat de Barcelona, IDIBELL, L'Hospitalet de Llobregat, 08907 Barcelona, Spain.
| | - Carolina Pimenta-Lopes
- Departament de Ciències Fisiològiques, Universitat de Barcelona, IDIBELL, L'Hospitalet de Llobregat, 08907 Barcelona, Spain.
| | - Jose Luis Rosa
- Departament de Ciències Fisiològiques, Universitat de Barcelona, IDIBELL, L'Hospitalet de Llobregat, 08907 Barcelona, Spain.
| | - Francesc Ventura
- Departament de Ciències Fisiològiques, Universitat de Barcelona, IDIBELL, L'Hospitalet de Llobregat, 08907 Barcelona, Spain.
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12
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Pignolo RJ, Wang H, Kaplan FS. Fibrodysplasia Ossificans Progressiva (FOP): A Segmental Progeroid Syndrome. Front Endocrinol (Lausanne) 2019; 10:908. [PMID: 31998237 PMCID: PMC6966325 DOI: 10.3389/fendo.2019.00908] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 12/12/2019] [Indexed: 12/16/2022] Open
Abstract
Segmental progeroid syndromes are commonly represented by genetic conditions which recapitulate aspects of physiological aging by similar, disparate, or unknown mechanisms. Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disease caused by mutations in the gene for ACVR1/ALK2 encoding Activin A receptor type I/Activin-like kinase 2, a bone morphogenetic protein (BMP) type I receptor, and results in the formation of extra-skeletal ossification and a constellation of others features, many of which resemble accelerated aging. The median estimated lifespan of individuals with FOP is approximately 56 years of age. Characteristics of precocious aging in FOP include both those that are related to dysregulated BMP signaling as well as those secondary to early immobilization. Progeroid features that may primarily be associated with mutations in ACVR1 include osteoarthritis, hearing loss, alopecia, subcutaneous lipodystrophy, myelination defects, heightened inflammation, menstrual abnormalities, and perhaps nephrolithiasis. Progeroid features that may secondarily be related to immobilization from progressive heterotopic ossification include decreased vital capacity, osteoporosis, fractures, sarcopenia, and predisposition to respiratory infections. Some manifestations of precocious aging may be attributed to both primary and secondary effects of FOP. At the level of lesion formation in FOP, soft tissue injury resulting in hypoxia, cell damage, and inflammation may lead to the accumulation of senescent cells as in aged tissue. Production of Activin A, platelet-derived growth factor, metalloproteinases, interleukin 6, and other inflammatory cytokines as part of the senescence-associated secretory phenotype could conceivably mediate the initial signaling cascade that results in the intense fibroproliferative response as well as the tissue-resident stem cell reprogramming leading up to ectopic endochondral bone formation. Consideration of FOP as a segmental progeroid syndrome offers a unique perspective into potential mechanisms of normal aging and may also provide insight for identification of new targets for therapeutic interventions in FOP.
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Affiliation(s)
- Robert J. Pignolo
- Department of Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
- Department of Physiology-Biomedical Engineering, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
- Kogod Center on Aging, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
- *Correspondence: Robert J. Pignolo
| | - Haitao Wang
- Department of Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
- Department of Physiology-Biomedical Engineering, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
- Kogod Center on Aging, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
| | - Frederick S. Kaplan
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
- Center for Research in FOP and Related Disorders, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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Bauer AH, Bonham J, Gutierrez L, Hsiao EC, Motamedi D. Fibrodysplasia ossificans progressiva: a current review of imaging findings. Skeletal Radiol 2018; 47:1043-1050. [PMID: 29445932 DOI: 10.1007/s00256-018-2889-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/28/2017] [Accepted: 01/12/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Fibrodysplasia ossificans progressiva is a rare genetic disorder characterized by congenital skeletal deformities and soft tissue masses that progress to heterotopic ossification. Deformities of the great toes are distinctive, and heterotopic ossification in the soft tissues follows an expected anatomic and temporal pattern. In addition to heterotopic ossification, osteochondromata, middle ear ossification, demyelination, lymphedema, and venous thrombosis are characteristic. Awareness of this constellation of findings is important to early diagnosis and surveillance. CONCLUSIONS Recognition of the imaging manifestations of fibrodysplasia ossificans progressiva is imperative to early diagnosis in order to appropriately direct patient care and preclude unnecessary biopsies or surgical procedures.
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Affiliation(s)
- Adam H Bauer
- Kaiser Fontana Medical Center, Fontana, CA, USA.
| | - Jeff Bonham
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Luis Gutierrez
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Edward C Hsiao
- Division of Endocrinology, Diabetes, and Metabolism and the Institute for Human Genetics, Department of Medicine, University of California, San Francisco, CA, USA
| | - Daria Motamedi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
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Di Rocco M, Baujat G, Bertamino M, Brown M, De Cunto CL, Delai PLR, Eekhoff EMW, Haga N, Hsiao E, Keen R, Morhart R, Pignolo RJ, Kaplan FS. International physician survey on management of FOP: a modified Delphi study. Orphanet J Rare Dis 2017; 12:110. [PMID: 28606101 PMCID: PMC5468985 DOI: 10.1186/s13023-017-0659-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 05/19/2017] [Indexed: 11/10/2022] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP), a disabling disorder of progressive heterotopic ossification (HEO), is caused by heterozygous gain-of- function mutations in Activin receptor A, type I (ACVR1, also known as ALK2), a bone morphogenetic protein (BMP) type I receptor. Presently, symptomatic management is possible, but no definitive treatments are available. Although extensive guidelines for symptomatic management are widely used, regional preferences exist. In order to understand if there was worldwide consensus among clinicians treating FOP patients, an expert panel of physicians directly involved in FOP patient care was convened. Using a modified Delphi method, broad international consensus was reached on four main topics: diagnosis, prevention of flare-ups, patient and family-centered care and general clinical management issues. This study of physician preferences provides a basis for standardization of clinical management for FOP.
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Affiliation(s)
- Maja Di Rocco
- Department of Pediatrics, Unit of Rare Diseases, Giannina Gaslini Institute, Largo Gaslini 5, 16147, Genoa, Italy.
| | - Genevieve Baujat
- Service of Medical Genetics CHU Paris - Hôpital Necker-Enfants Malades, 149 rue de Sèvres, 75743, Paris, France
| | - Marta Bertamino
- Department of Pediatrics, Unit of Rare Diseases, Giannina Gaslini Institute, Largo Gaslini 5, 16147, Genoa, Italy
| | - Matthew Brown
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Translational Research Institute, Princess Alexandra Hospital, Woolloongabba, QLD, 4069, Australia
| | - Carmen L De Cunto
- Department of Pediatrics, Pediatric Rheumatology Section, Hospital Italiano de Buenos Aires, Gascón 450, 1181, Ciudad Autónoma de Buenos Aires, Argentina
| | - Patricia L R Delai
- Orthopaedic Department of Santa Casa de Misericórdia de São Paulo, School of Medicine Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Pedro de Toledo 129 cj 121, Vila Clementino, 04039-001, São Paulo, Brazil
| | - Elisabeth M W Eekhoff
- Department of Internal Medicine/Section Endocrinology, VU Medical Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Nobuhiko Haga
- Department of Rehabilitation Medicine Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Edward Hsiao
- Department of Endocrinology, Faculty Practice University of California-San Francisco, 400 Parnassus Ave., San Francisco, CA, 94143-1222, USA
| | - Richard Keen
- University College London Hospitals, London, NW1 2PQ, UK
| | - Rolf Morhart
- Department of Pediatrics Klinikum Garmisch-Partenkirchen GmbH, Auenstraße 6, 82467, Garmisch-Partenkirchen, Germany
| | - Robert J Pignolo
- Department of Medicine, Division of Geriatric Medicine & Gerontology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN, USA
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, Center for Research in FOP & Related Disorders, The Perelman School of Medicine, The University of Pennsylvania, 3737 Market Street, Philadelphia, PA, 19104, USA
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Abstract
Introduction: Myositis ossificans progressiva is very rare with a worldwide prevalence of approximately 1 case in 2 million individuals. No ethnic, racial, or geographic predisposition has been described. Although familial forms inherited on a dominant autosomal basis have been described, most cases are sporadic. Case Report: 16 yr female came to opd with complaints of progressive restriction of movements of bilateral elbow, bilateral shoulder, bilateral knee and bilateral hip for past 4 years. On examination patient is found to have short great toes of bilateral foot and ffd of all the joints. Patient is bed ridden and had acute pain for past 2 wks. Patient was evaluated and diagnosed to have myositis ossificans progressiva. Patient was treated with short course of steroids and bisphosphonates. Patient’s pain improved and the patient was discharged on request as she was not willing for further management. Conclusion: Myositis ossificans progressiva is a rare disease with limited treatment options. At present there is no available treatment to completely cure the disease. Short course of steroids and bisphosphonates helps to relieve symptoms of acute pain.
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Affiliation(s)
- Ganesan G Ram
- Department Of Orthopaedics, Sri Ramachandra Medical College, Porur, Chennai - 600116. India
| | - Karthik Anand K
- Department Of Orthopaedics, Sri Ramachandra Medical College, Porur, Chennai - 600116. India
| | - P V Vijayaraghavan
- Department Of Orthopaedics, Sri Ramachandra Medical College, Porur, Chennai - 600116. India
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Kaplan FS, Pignolo RJ, Shore EM. Granting immunity to FOP and catching heterotopic ossification in the Act. Semin Cell Dev Biol 2016; 49:30-6. [PMID: 26706149 PMCID: PMC4898187 DOI: 10.1016/j.semcdb.2015.12.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 12/14/2015] [Indexed: 01/02/2023]
Abstract
The progressive transformation of one organ system into another is a fundamental signature of fibrodysplasia ossificans progressiva (FOP), the most catastrophic form of extraskeletal bone formation in humans. In all affected individuals, FOP is caused by heterozygous missense gain-of-function mutations in Activin receptor A type I (ACVR1), a bone morphogenetic protein (BMP) type I receptor. Loss of autoinhibition of the mutant receptor (mACVR1) results in dysregulated BMP pathway signaling, and is necessary for the myriad developmental features of FOP, but does not appear sufficient to induce the episodic flare-ups that lead to disabling post-natal heterotopic endochondral ossification (HEO) and that are a hallmark of the disease. Post-natal FOP flare-ups strongly implicate an underlying immunological trigger involving inflammation and the innate immune system. Recent studies implicate canonical and non-canonical TGFβ/BMP family ligands in the amplification of mACVR1 signaling leading to the formation of FOP lesions and resultant HEO. BMP and Activin ligands that stimulate mACVR1 signaling also have critical regulatory functions in the immune system. Cross-talk between the morphogenetic and immunological pathways that regulate tissue maintenance and wound healing identifies potential robust therapeutic targets for FOP. Here we review current evidence for an immunological trigger for flare-ups and HEO in FOP, propose a working schema for the pathophysiology of observed phenomena, and highlight outstanding questions under investigation.
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Affiliation(s)
- Frederick S Kaplan
- The Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Robert J Pignolo
- The Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Eileen M Shore
- The Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Department of Genetics, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
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Morales-Piga A, Bachiller-Corral FJ, Sánchez-Duffhues G. ¿Es la «fibrodisplasia osificante progresiva» una enfermedad de origen vascular? Un modelo patogénico innovador. ACTA ACUST UNITED AC 2014; 10:389-95. [DOI: 10.1016/j.reuma.2014.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 03/14/2014] [Accepted: 05/01/2014] [Indexed: 12/26/2022]
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Hüning I, Gillessen-Kaesbach G. Fibrodysplasia ossificans progressiva: clinical course, genetic mutations and genotype-phenotype correlation. Mol Syndromol 2014; 5:201-11. [PMID: 25337067 DOI: 10.1159/000365770] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2014] [Indexed: 12/19/2022] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP, MIM 135100) is a rare autosomal dominant genetic disorder and the most disabling condition of heterotopic (extraskeletal) ossification in humans. Mutations in the ACVR1 gene (MIM 102576) were identified as a genetic cause of FOP [Shore et al., 2006]. Most patients with FOP have the same recurrent single nucleotide change c.617G>A, p.R206H in the ACVR1 gene. Furthermore, 11 other mutations in the ACVR1 gene have been described as a cause of FOP. Here, we review phenotypic and molecular findings of 130 cases of FOP reported in the literature from 1982 to April 2014 and discuss possible genotype-phenotype correlations in FOP patients.
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Affiliation(s)
- Irina Hüning
- Institut für Humangenetik, Universität zu Lübeck, Lübeck, Germany
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Kaplan FS, Pignolo RJ, Shore EM. From mysteries to medicines: drug development for fibrodysplasia ossificans progressive. Expert Opin Orphan Drugs 2013; 1:637-649. [PMID: 24800180 DOI: 10.1517/21678707.2013.825208] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Fibrodysplasia ossificans progressiva (FOP) is the most disabling disorder of skeletal metamorphosis in humans and leads to the formation of a second skeleton of heterotopic bone. Presently, there is no effective treatment. AREAS COVERED In this review, the authors discuss heterozygous activating mutations in Activin receptor A, type I/ Activin-like kinase 2 (ACVR1/ALK2), a bone morphogenetic protein (BMP) type I receptor that are the genetic cause of FOP and reveal a promising pharmacologic target in the BMP signaling pathway. Despite these germline mutations, episodic disease activation is induced by soft tissue injury and resultant inflammatory triggers that are dependent on responding progenitor cells and a tissue microenvironment that supports heterotopic ossification. EXPERT OPINION Here we review opportunities and challenges for the development of effective therapeutics for FOP. There are many potential approaches that may eventually be used to harness FOP. The long-term treatment of FOP is likely to involve not one, but several concomitant approaches that acknowledge molecular mechanisms involved in the induction and progression of the disease.
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Affiliation(s)
- Frederick S Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104 ; Department of Medicine, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104 ; The Center for Research In FOP and Related Disorders; The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104
| | - Robert J Pignolo
- Department of Orthopaedic Surgery, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104 ; Department of Medicine, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104 ; The Center for Research In FOP and Related Disorders; The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104
| | - Eileen M Shore
- Department of Orthopaedic Surgery, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104 ; Department of Genetics, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104 ; The Center for Research In FOP and Related Disorders; The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA 19104
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Kaplan FS, Chakkalakal SA, Shore EM. Fibrodysplasia ossificans progressiva: mechanisms and models of skeletal metamorphosis. Dis Model Mech 2013; 5:756-62. [PMID: 23115204 PMCID: PMC3484858 DOI: 10.1242/dmm.010280] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP; MIM #135100) is a debilitating genetic disorder of connective tissue metamorphosis. It is characterized by malformation of the great (big) toes during embryonic skeletal development and by progressive heterotopic endochondral ossification (HEO) postnatally, which leads to the formation of a second skeleton of heterotopic bone. Individuals with these classic clinical features of FOP have the identical heterozygous activating mutation (c.617G>A; R206H) in the gene encoding ACVR1 (also known as ALK2), a bone morphogenetic protein (BMP) type I receptor. Disease activity caused by this ACVR1 mutation also depends on altered cell and tissue physiology that can be best understood in the context of a high-fidelity animal model. Recently, we developed such a knock-in mouse model for FOP (Acvr1R206H/+) that recapitulates the human disease, and provides a valuable new tool for testing and developing effective therapies. The FOP knock-in mouse and other models in Drosophila, zebrafish, chickens and mice provide an arsenal of tools for understanding BMP signaling and addressing outstanding questions of disease mechanisms that are relevant not only to FOP but also to a wide variety of disorders associated with regenerative medicine and tissue metamorphosis.
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Affiliation(s)
- Frederick S Kaplan
- Departments of Orthopaedic Surgery, the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
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Kitterman JA, Strober JB, Kan L, Rocke DM, Cali A, Peeper J, Snow J, Delai PLR, Morhart R, Pignolo RJ, Shore EM, Kaplan FS. Neurological symptoms in individuals with fibrodysplasia ossificans progressiva. J Neurol 2012; 259:2636-43. [PMID: 22752062 DOI: 10.1007/s00415-012-6562-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 05/10/2012] [Accepted: 05/17/2012] [Indexed: 11/26/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP), a rare, disabling condition caused by gain-of-function mutations of a bone morphogenetic protein (BMP) type I receptor, leads to episodes of heterotopic ossification and resultant immobility. Neurological problems have not been associated with FOP, but neurological symptoms are commonly reported by FOP patients. To determine the prevalence of neurological symptoms and their characteristics in individuals with FOP, we conducted a survey of the 470 patient members of the International FOP Association (IFOPA) using a questionnaire about neurological symptoms. There were 168 responses (105 females, 63 males; age 1.5-68 years) from 30 countries representing 36 % of IFOPA members. Chronic neurological symptoms were reported by 86 (51 %). Prevalence of neuropathic pain (NP) was significantly increased (P < 0.001) compared to the general population, and tenfold more common in females (15 %) than males (1.6 %). Of those with NP, 94 % reported other sensory abnormalities. Prevalence of recurrent severe headaches (HA) (26 %) was similar to that in the general population, but prevalence in females with FOP (36 %) was almost fourfold greater than in males. Prevalence of NP, HA, and other sensory abnormalities was substantially higher in post-pubertal females; 33 % reported symptoms worsened during menstrual periods. Worsening of neurological symptoms during FOP flare-ups was reported by 23 %. Three patients with FOP (1.8 %) reported myoclonus, a prevalence much greater than reported in the general population (P < 0.001). Our worldwide survey indicates that neurological symptoms are common in FOP. We speculate that these symptoms are related to effects of dysregulated BMP signaling on the central and/or peripheral nervous systems.
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Affiliation(s)
- Joseph A Kitterman
- Department of Pediatrics, University of California San Francisco, Box 0734, San Francisco, CA 94143, USA.
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Miao J, Zhang C, Wu S, Peng Z, Tania M. Genetic abnormalities in Fibrodysplasia Ossificans Progressiva. Genes Genet Syst 2012; 87:213-9. [DOI: 10.1266/ggs.87.213] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Jinglei Miao
- Department of Orthopedics, The Third Xiangya Hospital of Central South University
| | - Chaoyue Zhang
- Department of Orthopedics, The Third Xiangya Hospital of Central South University
| | - Song Wu
- Department of Orthopedics, The Third Xiangya Hospital of Central South University
| | - Zhi Peng
- Department of Orthopedics, The Third Xiangya Hospital of Central South University
| | - Mousumi Tania
- Department of Biochemistry, School of Biological Science and Technology, Central South University
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Pignolo RJ, Shore EM, Kaplan FS. Fibrodysplasia ossificans progressiva: clinical and genetic aspects. Orphanet J Rare Dis 2011; 6:80. [PMID: 22133093 PMCID: PMC3253727 DOI: 10.1186/1750-1172-6-80] [Citation(s) in RCA: 190] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 12/01/2011] [Indexed: 01/13/2023] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a severely disabling heritable disorder of connective tissue characterized by congenital malformations of the great toes and progressive heterotopic ossification that forms qualitatively normal bone in characteristic extraskeletal sites. The worldwide prevalence is approximately 1/2,000,000. There is no ethnic, racial, gender, or geographic predilection to FOP. Children who have FOP appear normal at birth except for congenital malformations of the great toes. During the first decade of life, sporadic episodes of painful soft tissue swellings (flare-ups) occur which are often precipitated by soft tissue injury, intramuscular injections, viral infection, muscular stretching, falls or fatigue. These flare-ups transform skeletal muscles, tendons, ligaments, fascia, and aponeuroses into heterotopic bone, rendering movement impossible. Patients with atypical forms of FOP have been described. They either present with the classic features of FOP plus one or more atypical features [FOP plus], or present with major variations in one or both of the two classic defining features of FOP [FOP variants]. Classic FOP is caused by a recurrent activating mutation (617G>A; R206H) in the gene ACVR1/ALK2 encoding Activin A receptor type I/Activin-like kinase 2, a bone morphogenetic protein (BMP) type I receptor. Atypical FOP patients also have heterozygous ACVR1 missense mutations in conserved amino acids. The diagnosis of FOP is made by clinical evaluation. Confirmatory genetic testing is available. Differential diagnosis includes progressive osseous heteroplasia, osteosarcoma, lymphedema, soft tissue sarcoma, desmoid tumors, aggressive juvenile fibromatosis, and non-hereditary (acquired) heterotopic ossification. Although most cases of FOP are sporadic (noninherited mutations), a small number of inherited FOP cases show germline transmission in an autosomal dominant pattern. At present, there is no definitive treatment, but a brief 4-day course of high-dose corticosteroids, started within the first 24 hours of a flare-up, may help reduce the intense inflammation and tissue edema seen in the early stages of the disease. Preventative management is based on prophylactic measures against falls, respiratory decline, and viral infections. The median lifespan is approximately 40 years of age. Most patients are wheelchair-bound by the end of the second decade of life and commonly die of complications of thoracic insufficiency syndrome.
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Affiliation(s)
- Robert J Pignolo
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Rarely occurring mutation of ACVR1 gene in Moroccan patient with fibrodysplasia ossificans progressiva. Clin Rheumatol 2009; 29:119-21. [PMID: 19795179 DOI: 10.1007/s10067-009-1283-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 09/09/2009] [Accepted: 09/15/2009] [Indexed: 10/20/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP, MIM 135100) is a rare autosomal dominant disorder characterized by postnatal progressive heterotopic ossification of the connective tissue and congenital malformation of the big toes. Recently, FOP has been associated with a specific mutation of ACVR1, the gene coding for a bone morphogenetic protein type I receptor. We report the case of a Moroccan patient with FOP carrying a rarely occurring mutation of ACVR1 gene.
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Leavitt BD, Teeples TJ, Viozzi CF. Submandibular space swelling in a patient with fibrodysplasia ossificans progressiva: a diagnostic dilemma. J Oral Maxillofac Surg 2009; 67:668-73. [PMID: 19231799 DOI: 10.1016/j.joms.2008.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Accepted: 07/02/2008] [Indexed: 11/16/2022]
Affiliation(s)
- Bryce D Leavitt
- Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Kaplan FS, Le Merrer M, Glaser DL, Pignolo RJ, Goldsby RE, Kitterman JA, Groppe J, Shore EM. Fibrodysplasia ossificans progressiva. Best Pract Res Clin Rheumatol 2008; 22:191-205. [PMID: 18328989 DOI: 10.1016/j.berh.2007.11.007] [Citation(s) in RCA: 210] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP), a rare and disabling genetic condition of congenital skeletal malformations and progressive heterotopic ossification (HO), is the most catastrophic disorder of HO in humans. Episodic disease flare-ups are precipitated by soft tissue injury, and immobility is cumulative. Recently, a recurrent mutation in activin receptor IA/activin-like kinase 2 (ACVR1/ALK2), a bone morphogenetic protein (BMP) type I receptor, was reported in all sporadic and familial cases of classic FOP, making this one of the most highly specific disease-causing mutations in the human genome. The discovery of the FOP gene establishes a critical milestone in understanding FOP, reveals a highly conserved target for drug development in the transforming growth factor (TGF)-beta/BMP signalling pathway, and compels therapeutic approaches for the development of small molecule signal transduction inhibitors for ACVR1/ALK2. Present management involves early diagnosis, assiduous avoidance of iatrogenic harm, and symptomatic amelioration of painful flare-ups. Effective therapies for FOP, and possibly for other common conditions of HO, may potentially be based on future interventions that block ACVR1/ALK2 signalling.
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Affiliation(s)
- Frederick S Kaplan
- Departments of Orthopedic Surgery & Medicine, The University of Pennsylvania School of Medicine, c/o Hospital of The University of Pennsylvania, Philadelphia, PA, USA.
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Rezidivierende Weichteilschwellungen am Rücken und Hypoplasie der Daumen und Großzehen. Monatsschr Kinderheilkd 2007. [DOI: 10.1007/s00112-006-1452-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Gonçalves AL, Masruha MR, de Campos CC, Delai PLR, Vilanova LCP. Fibrodysplasia ossificans progressiva: case report. ARQUIVOS DE NEURO-PSIQUIATRIA 2006; 63:1090-3. [PMID: 16400434 DOI: 10.1590/s0004-282x2005000600032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare autosomal dominant disorder characterized by postnatal progressive heterotopic ossification of the connective tissue and congenital malformation of the big toes. We report on a nine-year-old girl with clinical and radiological features of FOP. She was born with bilateral hallux valgus and at the age of nine presented an indurate mass in the left cervical region that was painful. A significant decreased range of motion in all levels of the spine and shoulder girdle was found. The radiographs showed heterotopic ossification in the thoracic region. The patient had two outbreaks of the disease ("flare-ups") that were treated with prednisone 2 mg/kg/day for four days. After the "flare-ups", she had a continuous therapy with a Cox-2 inhibitor (25 mg/day) and a leukotriene inhibitor, montelukast (10 mg/day).
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Affiliation(s)
- Andre Leite Gonçalves
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, SP, Brazil.
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