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Türkmen H, Uysal F, Bostan ÖM. A rare and fatal cause of hypertrophic cardiomyopathy: Danon disease. Cardiol Young 2023; 33:1448-1450. [PMID: 36601912 DOI: 10.1017/s1047951122004164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Danon disease is a rare and fatal disease caused by a mutation in the lysosome-associated membrane protein 2 gene. Impaired intracellular autophagy causes lysosomal vacuoles to accumulate mainly in myocardial and skeletal muscle cells, leading to hypertrophic cardiomyopathy, skeletal myopathy, and varying degrees of intellectual disability. Two distinct childhood presentations of Danon disease are described in this report.
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Affiliation(s)
- Hasan Türkmen
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Bursa Uludag University, 16059 Görükle, Bursa, Turkey
| | - Fahrettin Uysal
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Bursa Uludag University, 16059 Görükle, Bursa, Turkey
| | - Özlem Mehtap Bostan
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Bursa Uludag University, 16059 Görükle, Bursa, Turkey
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Zhai Y, Miao J, Peng Y, Wang Y, Dong J, Zhao X. Clinical features of Danon disease and insights gained from LAMP-2 deficiency models. Trends Cardiovasc Med 2023; 33:81-89. [PMID: 34737089 DOI: 10.1016/j.tcm.2021.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 10/06/2021] [Accepted: 10/28/2021] [Indexed: 02/07/2023]
Abstract
Danon disease (DD) is an X-linked multisystem disorder with clinical features characterized by the triad of hypertrophic cardiomyopathy, skeletal muscle weakness, and mental retardation. Cardiac involvement can be fatal in the absence of an effective treatment option such as heart transplantation. Molecular studies have proved that LAMP-2 protein deficiency, mainly LAMP-2B isoform, resulting from LAMP2 gene mutation, is the culprit for DD. Autophagy impairment due to LAMP-2 deficiency mediated the accumulation of abnormal autophagic vacuoles in cells. While it is not ideal for mimicking DD phenotypes in humans, the emergence of LAMP-2-deficient animal models and induced pluripotent stem cells from DD patients provided powerful tools for exploring DD mechanism. In both in vitro and in vivo studies, much evidence has demonstrated that mitochondria dysfunction and fragmentation can result in DD pathology. Fundamental research contributes to the therapeutic transformation. By targeting the molecular core, several potential therapies have demonstrated promising results in partial phenotypes improvement. Among them, gene therapies anticipate inaugurate a class of symptom control and prevention drugs as their in vivo effects are promising, and one clinical trial is currently underway.
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Affiliation(s)
- Yafei Zhai
- Centre for Cardiovascular Diseases, Henan Key Laboratory of Hereditary Cardiovascular Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, P.R. China
| | - Jinxin Miao
- Academy of Medical Sciences, Zhengzhou University, Zhengzhou, P.R. China;Department of Science and Technology, Henan University of Chinese Medicine, Zhengzhou, Henan, P.R. China; Sino-British Research Center for Molecular Oncology, National Center for the International Research in Cell and Gene Therapy, School of Basic Sciences, Academy of Medical Sciences, Zhengzhou University, Zhengzhou, Henan, P. R. China
| | - Ying Peng
- Centre for Cardiovascular Diseases, Henan Key Laboratory of Hereditary Cardiovascular Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, P.R. China
| | - Yaohe Wang
- Sino-British Research Center for Molecular Oncology, National Center for the International Research in Cell and Gene Therapy, School of Basic Sciences, Academy of Medical Sciences, Zhengzhou University, Zhengzhou, Henan, P. R. China; Centre for Molecular Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Jianzeng Dong
- Centre for Cardiovascular Diseases, Henan Key Laboratory of Hereditary Cardiovascular Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, P.R. China; Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
| | - Xiaoyan Zhao
- Centre for Cardiovascular Diseases, Henan Key Laboratory of Hereditary Cardiovascular Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, P.R. China.
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Xu J, Li Z, Liu Y, Zhang X, Niu F, Zheng H, Wang L, Kang L, Wang K, Xu B. Danon disease: a case report and literature review. Diagn Pathol 2021; 16:39. [PMID: 33933120 PMCID: PMC8088694 DOI: 10.1186/s13000-021-01100-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 04/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Danon disease (DD) is a rare x-linked dominant multisystemic disorder with a clinical triad of severe cardiomyopathy, skeletal myopathy, and mental retardation. It is caused by a defect in the lysosomal-associated membrane protein-2 (LAMP2) gene, which leads to the formation of autophagic vacuoles containing glycogen granule deposits in skeletal and cardiac muscle fibers. So far, more than 50 different mutations in LAMP2 have been identified. CASE PRESENTATION Here, we report an 18-year-old male patient who was hospitalized for heart failure. Biopsy of the left lateral femoral muscle revealed scattered autophagic vacuoles in the muscle fibers with increased glycogen. Next generation sequencing (NGS) was used to detect gene mutations of the proband sample and a novel frameshift mutation (c.1052delG) has been identified in exon 8 of LAMP2, which leads to truncation of the protein. CONCLUSION We found a novel frameshift mutation, a hemizygous mutation (c.1052delG) in exon 8 of LAMP2, identified as presenting the hypertrophic cardiomyopathy (HCM) phenotype. Genetic analysis is the gold standard for the diagnosis of DD and is essential to determine appropriate treatment strategies and to confirm the genetic risk of family members.
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Affiliation(s)
- Jiamin Xu
- Department of Cardiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, 210008, P.R. China
| | - Zhu Li
- Department of Cardiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, 210008, P.R. China
| | - Yihai Liu
- Department of Cardiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, 210008, P.R. China
| | - Xinlin Zhang
- Department of Cardiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, 210008, P.R. China
| | - Fengnan Niu
- Department of Pathology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, 210008, P.R. China
| | - Hongyan Zheng
- Department of Cardiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, 210008, P.R. China
| | - Lian Wang
- Department of Cardiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, 210008, P.R. China
| | - Lina Kang
- Department of Cardiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, 210008, P.R. China.
| | - Kun Wang
- Department of Cardiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, 210008, P.R. China.
| | - Biao Xu
- Department of Cardiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, 210008, P.R. China.
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Cenacchi G, Papa V, Pegoraro V, Marozzo R, Fanin M, Angelini C. Review: Danon disease: Review of natural history and recent advances. Neuropathol Appl Neurobiol 2019; 46:303-322. [DOI: 10.1111/nan.12587] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 11/02/2019] [Indexed: 12/16/2022]
Affiliation(s)
- G. Cenacchi
- Department of Biomedical and Neuromotor Sciences “Alma Mater” University of Bologna Bologna Italy
| | - V. Papa
- Department of Biomedical and Neuromotor Sciences “Alma Mater” University of Bologna Bologna Italy
| | - V. Pegoraro
- Neurobiology Laboratory IRCCS San Camillo Hospital VeniceItaly
| | - R. Marozzo
- Neurobiology Laboratory IRCCS San Camillo Hospital VeniceItaly
| | - M. Fanin
- Department of Neurosciences University of Padova Padova Italy
| | - C. Angelini
- Neuromuscular Department IRCCS San Camillo Hospital Venice Italy
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Guo S, Zhou L, Wang R, Lv Z, Xu H, Han B, Korantzopoulos P, Hu F, Liu T. Danon disease: Two patients with atrial fibrillation in a single family and review of the literature. Exp Ther Med 2019; 18:1527-1532. [PMID: 31410105 PMCID: PMC6676149 DOI: 10.3892/etm.2019.7777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 05/31/2019] [Indexed: 11/05/2022] Open
Abstract
The present study reports on a family with two members affected by Danon disease but having different phenotypes. The clinical manifestations of Danon disease include cardiomyopathy, skeletal myopathy and different degrees of intellectual disability that varies greatly among patients. The present case study reports on two siblings, an older sister and a younger brother, with Danon disease from an affected pedigree, presenting with distinctly different phenotypes. The sister was diagnosed with dilated cardiomyopathy at the age of 26 years with an unfavorable outcome, while her younger brother presented with hypertrophic cardiomyopathy in a relatively stable state. The two probands shared the same mutation, c.974delTinsAA in exon 8, in the lysosomal-associated membrane protein-2 gene. Of note, the two patients had a pre-excitation pattern in the electrocardiogram on initial presentation and later developed atrial fibrillation (AF), which markedly aggravated heart failure. To the best of our knowledge, AF has not been widely reported in patients with Danon disease. The development of AF may have a prognostic value under these circumstances.
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Affiliation(s)
- Shaohua Guo
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin 300211, P.R. China
| | - Linghuan Zhou
- Department of Cardiology, Shijiazhuang Great Wall Hospital of Integrated Traditional Chinese and Western Medicine, Shijiazhuang, Hebei 050035, P.R. China
| | - Renping Wang
- Department of Cardiology, Shijiazhuang Great Wall Hospital of Integrated Traditional Chinese and Western Medicine, Shijiazhuang, Hebei 050035, P.R. China
| | - Zhixin Lv
- Department of Cardiology, Shijiazhuang Great Wall Hospital of Integrated Traditional Chinese and Western Medicine, Shijiazhuang, Hebei 050035, P.R. China
| | - Hongzun Xu
- Department of Cardiology, Shijiazhuang Great Wall Hospital of Integrated Traditional Chinese and Western Medicine, Shijiazhuang, Hebei 050035, P.R. China
| | - Baoli Han
- Department of Cardiology, Shijiazhuang Great Wall Hospital of Integrated Traditional Chinese and Western Medicine, Shijiazhuang, Hebei 050035, P.R. China
| | | | - Fuli Hu
- Department of Cardiology, Shijiazhuang Great Wall Hospital of Integrated Traditional Chinese and Western Medicine, Shijiazhuang, Hebei 050035, P.R. China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin 300211, P.R. China
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A new phenotype of severe dilated cardiomyopathy associated with a mutation in the LAMP2 gene previously known to cause hypertrophic cardiomyopathy in the context of Danon disease. Eur J Med Genet 2018; 62:77-80. [PMID: 29753918 DOI: 10.1016/j.ejmg.2018.05.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 05/02/2018] [Accepted: 05/08/2018] [Indexed: 11/20/2022]
Abstract
Danon disease is a rare X-linked cardiac and skeletal muscle disorder with multisystem clinical manifestations. Genetic defects at the lysosome-associated membrane 2 protein (LAMP2) are the cause of the disorder. Due to the rarity of the disease, there is limited progress in understanding the correlation between genotype and phenotype, and explaining the large variability of the clinical features of the disease. In this study, we report two patients, twin sisters, referred to our hospital for end stage heart failure due to dilated cardiomyopathy, requiring heart transplant evaluation. Genetic analysis, using targeted next generation sequencing, showed that the proband carried a LAMP2 missense variant, c.928G > A. The mutation was also detected in her twin sister by sanger sequencing. This variant has already been reported by other investigators and was correlated with the clinical triad of Danon disease i.e. hypertrophic cardiomyopathy, mental retardation and peripheral myopathy. The new phenotype of dilated cardiomyopathy associated with this mutation, confirms the phenotypic heterogeneity of the particular mutation, as well as of Danon disease.
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Bottillo I, Giordano C, Cerbelli B, D'Angelantonio D, Lipari M, Polidori T, Majore S, Bertini E, D'Amico A, Giannarelli D, De Bernardo C, Masuelli L, Musumeci F, Avella A, Re F, Zachara E, d'Amati G, Grammatico P. A novel LAMP2 mutation associated with severe cardiac hypertrophy and microvascular remodeling in a female with Danon disease: a case report and literature review. Cardiovasc Pathol 2016; 25:423-31. [PMID: 27497751 DOI: 10.1016/j.carpath.2016.07.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 07/19/2016] [Accepted: 07/20/2016] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Danon disease (DD) is a rare disorder characterized by cardiomyopathy, intellectual disability, and proximal myopathy. It is caused by mutations in the LAMP2 gene on X chromosome. Female patients most often present with late-onset cardiomyopathy and slow disease progression, but early-onset cases with unfavorable prognosis have been reported. CASE REPORT We describe the clinical, pathological, and molecular features of a novel LAMP2 c.453delT mutation in a female patient with severe hypertrophic cardiomyopathy, Wolff Parkinson White (WPW) syndrome and rapid progression to heart failure, requiring heart transplant. Immunohistochemical analysis of LAMP2 in the explanted heart revealed a mosaic pattern of distribution, with discrete clusters of either stained or unstained cardiac myocytes, the latter being more frequent in the septum. These findings paralleled X chromosome inactivation within the myocardium. Interestingly, multiple foci of microscarring were found on histology in the Left Ventricle (LV) free wall and septum, in a close spatial relationship with remodeling and severe stenosis of intramural coronary arterioles. CONCLUSIONS Our findings suggest that several features may contribute to the early and severe cardiac phenotype in female DD patients. The type of mutation may account for the early disease onset, while both the inhomogeneous distribution of LAMP2 loss and the presence of microvascular remodeling may be determinant in the rapid progression to heart failure.
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Affiliation(s)
- Irene Bottillo
- Medical Genetics Laboratory, Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy.
| | - Carla Giordano
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Bruna Cerbelli
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Daniela D'Angelantonio
- Medical Genetics Laboratory, Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy
| | - Martina Lipari
- Medical Genetics Laboratory, Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy
| | - Taisia Polidori
- Medical Genetics Laboratory, Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy
| | - Silvia Majore
- Medical Genetics Laboratory, Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy
| | - Enrico Bertini
- Unit for Muscular and Neurodegenerative Disorders, Laboratory of Molecular Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Adele D'Amico
- Unit for Muscular and Neurodegenerative Disorders, Laboratory of Molecular Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Diana Giannarelli
- Biostatistic Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - Carmelilia De Bernardo
- Medical Genetics Laboratory, Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy
| | - Laura Masuelli
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Francesco Musumeci
- Department of Cardiac Surgery, San Camillo-Forlanini Hospital, Rome, Italy
| | - Andrea Avella
- Cardiomyopathies Unit, Division of Cardiology and Cardiac Arrhythmias, San Camillo-Forlanini Hospital, Rome, Italy
| | - Federica Re
- Cardiomyopathies Unit, Division of Cardiology and Cardiac Arrhythmias, San Camillo-Forlanini Hospital, Rome, Italy
| | - Elisabetta Zachara
- Cardiomyopathies Unit, Division of Cardiology and Cardiac Arrhythmias, San Camillo-Forlanini Hospital, Rome, Italy
| | - Giulia d'Amati
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Paola Grammatico
- Medical Genetics Laboratory, Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy
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Rowland TJ, Sweet ME, Mestroni L, Taylor MRG. Danon disease - dysregulation of autophagy in a multisystem disorder with cardiomyopathy. J Cell Sci 2016; 129:2135-43. [PMID: 27165304 PMCID: PMC4920246 DOI: 10.1242/jcs.184770] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Danon disease is a rare, severe X-linked form of cardiomyopathy caused by deficiency of lysosome-associated membrane protein 2 (LAMP-2). Other clinical manifestations include skeletal myopathy, cognitive defects and visual problems. Although individuals with Danon disease have been clinically described since the early 1980s, the underlying molecular mechanisms involved in pathological progression remain poorly understood. LAMP-2 is known to be involved in autophagy, and a characteristic accumulation of autophagic vacuoles in the affected tissues further supports the idea that autophagy is disrupted in this disease. The LAMP2 gene is alternatively spliced to form three splice isoforms, which are thought to play different autophagy-related cellular roles. This Commentary explores findings from genetic, histological, functional and tissue expression studies that suggest that the specific loss of the LAMP-2B isoform, which is likely to be involved in macroautophagy, plays a crucial role in causing the Danon phenotype. We also compare findings from mouse and cellular models, which have allowed for further molecular characterization but have also shown phenotypic differences that warrant attention. Overall, there is a need to better functionally characterize the LAMP-2B isoform in order to rationally explore more effective therapeutic options for individuals with Danon disease.
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Affiliation(s)
- Teisha J Rowland
- Cardiovascular Institute and Adult Medical Genetics Program, University of Colorado Denver, Aurora, CO 80045, USA
| | - Mary E Sweet
- Cardiovascular Institute and Adult Medical Genetics Program, University of Colorado Denver, Aurora, CO 80045, USA
| | - Luisa Mestroni
- Cardiovascular Institute and Adult Medical Genetics Program, University of Colorado Denver, Aurora, CO 80045, USA
| | - Matthew R G Taylor
- Cardiovascular Institute and Adult Medical Genetics Program, University of Colorado Denver, Aurora, CO 80045, USA
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D'souza RS, Levandowski C, Slavov D, Graw SL, Allen LA, Adler E, Mestroni L, Taylor MRG. Danon disease: clinical features, evaluation, and management. Circ Heart Fail 2014; 7:843-9. [PMID: 25228319 DOI: 10.1161/circheartfailure.114.001105] [Citation(s) in RCA: 136] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ryan S D'souza
- From the Adult Medical Genetics Program and Division of Cardiology, University of Colorado, Denver (R.S.D., C.L., D.S., S.L.G., L.A.A., L.M., M.R.G.T.); and Division of Cardiology, University of California, San Diego (E.A.)
| | - Cecilia Levandowski
- From the Adult Medical Genetics Program and Division of Cardiology, University of Colorado, Denver (R.S.D., C.L., D.S., S.L.G., L.A.A., L.M., M.R.G.T.); and Division of Cardiology, University of California, San Diego (E.A.)
| | - Dobromir Slavov
- From the Adult Medical Genetics Program and Division of Cardiology, University of Colorado, Denver (R.S.D., C.L., D.S., S.L.G., L.A.A., L.M., M.R.G.T.); and Division of Cardiology, University of California, San Diego (E.A.)
| | - Sharon L Graw
- From the Adult Medical Genetics Program and Division of Cardiology, University of Colorado, Denver (R.S.D., C.L., D.S., S.L.G., L.A.A., L.M., M.R.G.T.); and Division of Cardiology, University of California, San Diego (E.A.)
| | - Larry A Allen
- From the Adult Medical Genetics Program and Division of Cardiology, University of Colorado, Denver (R.S.D., C.L., D.S., S.L.G., L.A.A., L.M., M.R.G.T.); and Division of Cardiology, University of California, San Diego (E.A.)
| | - Eric Adler
- From the Adult Medical Genetics Program and Division of Cardiology, University of Colorado, Denver (R.S.D., C.L., D.S., S.L.G., L.A.A., L.M., M.R.G.T.); and Division of Cardiology, University of California, San Diego (E.A.)
| | - Luisa Mestroni
- From the Adult Medical Genetics Program and Division of Cardiology, University of Colorado, Denver (R.S.D., C.L., D.S., S.L.G., L.A.A., L.M., M.R.G.T.); and Division of Cardiology, University of California, San Diego (E.A.)
| | - Matthew R G Taylor
- From the Adult Medical Genetics Program and Division of Cardiology, University of Colorado, Denver (R.S.D., C.L., D.S., S.L.G., L.A.A., L.M., M.R.G.T.); and Division of Cardiology, University of California, San Diego (E.A.).
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Majer F, Vlaskova H, Krol L, Kalina T, Kubanek M, Stolnaya L, Dvorakova L, Elleder M, Sikora J. Danon disease: a focus on processing of the novel LAMP2 mutation and comments on the beneficial use of peripheral white blood cells in the diagnosis of LAMP2 deficiency. Gene 2012; 498:183-95. [PMID: 22365987 DOI: 10.1016/j.gene.2012.02.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 02/02/2012] [Accepted: 02/04/2012] [Indexed: 11/17/2022]
Abstract
Danon disease (DD) is a monogenic X-linked disorder characterized by cardiomyopathy, skeletal myopathy and variable degrees of intellectual disability. DD develops due to mutations in the gene encoding lysosomal-associated membrane protein 2 (LAMP2). We report on a family exhibiting the clinical phenotype comprising of hypertrophic cardiomyopathy and ventricular pre-excitation, myopia and mild myopathy in two male patients and cardiomyopathy and myopia in a female patient. The diagnosis of DD in this family was based on the assessment of the clinical phenotypes and the absence of LAMP2 in skeletal and/or cardiac muscle biopsy specimens. Sequence analysis of the LAMP2 gene and its mRNA revealed a novel LAMP2 mutation (c.940delG) in all three patients. Approximately 25% of the female patient's cardiomyocytes were LAMP2 positive apparently due to the unfavorable skewing of X chromosome inactivation. We further performed qualitative LAMP2 immunohistochemistry on peripheral white blood cells using the smear technique and revealed the absence of LAMP2 in the male patients. LAMP2 expression was further assessed in granulocytes, CD4+ and CD8+ T lymphocytes, CD20+ B lymphocytes, CD14+ monocytes and CD56+ natural killer cells by quantitative polychromatic flow cytometry. Whereas the male DD patients lacked LAMP2 in all WBC populations, the female patient expressed LAMP2 in 15.1% and 12.8% of monocytes and granulocytes, respectively. LAMP2 expression ratiometrics of highly vs. weakly expressing WBC populations discriminated the DD patients from the healthy controls. WBCs are thus suitable for initial LAMP2 expression testing when DD is a differential diagnostic option. Moreover, flow cytometry represents a quantitative method to assess the skewing of LAMP2 expression in female heterozygotes. Because LAMP2 is a major protein constituent of the membranes of a number of lysosome-related organelles, we also tested the exocytic capacity of the lytic granules from CD8+ T lymphocytes in the patient samples. The degranulation triggered by a specific stimulus (anti-CD3 antibody) was normal. Therefore, this process can be considered LAMP2 independent in human T cells. The c.940delG mutation results in a putatively truncated protein (p.A314QfsX32), which lacks the transmembrane domain and the cytosolic tail of the wild-type LAMP2. We tested whether this variant becomes exocytosed because of a failure in targeting to late endosomes/lysosomes. Western blotting of cardiac muscle, WBCs and cultured skin fibroblasts (and their culture media) showed no intra- or extracellular truncated LAMP2. By comparing the expression pattern and intracellular targeting in cultured skin fibroblasts of normal LAMP2 isoforms (A, B and C) tagged with green fluorescent protein (GFP) and the A314Qfs32-GFP fusion, we found that the A314Qfs32-GFP protein is not even expressed. These observations suggest that the truncated protein is unstable and is co-translationally or early post-translationally degraded.
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Affiliation(s)
- F Majer
- Charles University in Prague, 1st Faculty of Medicine, Institute of Inherited Metabolic Disorders, Ke Karlovu 2, 128 08 Prague, Czech Republic
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Cheng Z, Cui Q, Tian Z, Xie H, Chen L, Fang L, Zhu K, Fang Q. Danon disease as a cause of concentric left ventricular hypertrophy in patients who underwent endomyocardial biopsy. Eur Heart J 2012; 33:649-56. [PMID: 22108829 DOI: 10.1093/eurheartj/ehr420] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2023] Open
Abstract
BACKGROUND Danon disease is an X-linked dominant disorder; concentric left ventricular hypertrophy (LVH) is one of its manifestations. In this study, we investigated the prevalence of Danon disease in patients with concentric LVH who underwent endomyocardial biopsy (EMB). METHODS AND RESULTS A total of 50 patients with concentric LVH underwent EMB from January 2008 to December 2010. Cardiac amyloidosis was diagnosed in 14 patients; genetic analysis of lysosome-associated membrane protein 2 (LAMP2) was done in the remaining 36 patients. Three novel LAMP2 frameshift mutations were found. They were c.808_809 insG in exon 6, c.320_321 insCATC in exon 3, and c.257_258delCC in exon 3, leading to a premature stop codon on cDNA analysis. The prevalence of Danon disease was seen in 6% (3 of 50) of unselected concentric LVH patients who underwent EMB, or 8% (3 of 36) after excluding cardiac amyloidosis through EMB. All the three patients were male teenagers with a mean age of 15 ± 1 years, and had mild mental retardation, two of the three with Wolff-Parkinson-White (WPW) syndrome and markedly increased left ventricular voltage. All the three patients had increased serum hepatic enzymes and creatine kinase (CK) concentrations. There was no death or cardiovascular hospitalization during 20 ± 15 months of follow-up. CONCLUSIONS Danon disease may account for a number of patients with concentric LVH who underwent EMB. Danon disease should be suspected in the male teenager with concentric LVH, especially with elevated serum hepatic enzymes and CK concentrations, and/or WPW syndrome with markedly increased voltage of the left ventricle. Genetic analysis of LAMP2 can help make the diagnosis.
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Affiliation(s)
- Zhongwei Cheng
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
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Abstract
BACKGROUND Danon disease is a rare but serious cardiac and skeletal myopathy leading to substantial morbidity and early mortality due to arrhythmia and cardiomyopathy. The X-linked nature of inheritance accounts for reported differences in phenotypic severity between men and women. The rarity of Danon disease has limited understanding of the complete phenotype. Clinical estimates of ages of disease onset and survival based on gender have not been published. METHODS AND RESULTS We present data on 82 patients with Danon disease from 36 families, the largest series to date. Men were severely affected with cognitive disabilities (100%), hypertrophic cardiomyopathy (88%), and muscle weakness (80%). Men had a high morbidity and were unlikely to reach the age of 25 years without a cardiac transplantation. Women were less severely affected but reported higher than expected levels of cognitive (47%) and skeletal muscle complaints (50%) and manifesting an equal prevalence of dilated cardiomyopathy and hypertrophic cardiomyopathy. Combining our data with that of 63 other Danon disease case reports in the literature, the average ages of first symptom, cardiac transplantation, and death were 12.1, 17.9, and 19.0 years in men and 27.9, 33.7, and 34.6 years in women, respectively. CONCLUSION These data more broadly illuminate the Danon disease phenotype and should prove useful to physicians working with and providing genetic counseling to families with Danon disease. Women with Danon disease present with clinical symptoms and events approximately 15 years after men and report a higher proportion of cognitive and skeletal muscle problems than previously recognized.
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Affiliation(s)
- Dana Boucek
- Adult Medical Genetics Program, CU Cardiovascular Institute, University of Colorado Denver, Aurora, Colorado, USA
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13
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Cottinet SL, Bergemer-Fouquet AM, Toutain A, Sabourdy F, Maakaroun-Vermesse Z, Levade T, Chantepie A, Labarthe F. Danon disease: intrafamilial phenotypic variability related to a novel LAMP-2 mutation. J Inherit Metab Dis 2011; 34:515-22. [PMID: 21161685 DOI: 10.1007/s10545-010-9251-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 07/14/2010] [Accepted: 11/09/2010] [Indexed: 10/18/2022]
Abstract
Danon disease is an X-linked lysosomal disorder, characterized by hypertrophic cardiomyopathy, skeletal myopathy and mental retardation. We report a family with a novel mutation, in which the mother and her three sons were affected with various clinical presentations. A massive hypertrophy of the left ventricle was the predominant feature in the three male patients, with different degrees of severity of cardiac symptoms, from isolated palpitations to cardiac failure and sudden death. Muscle pain and weakness were also variable, but constantly associated with increased plasma CK levels. Finally, the male patients had variable degree of a mental retardation. The mother had an attenuated phenotype, limited to a mild hypertrophic cardiomyopathy with premature ventricular contractions diagnosed during her 40's. Microscopy examination of skeletal muscle biopsy, performed in the youngest patient, demonstrated atrophic myofibers with intracytoplasmic vacuoles suggesting lysosomal glycogen storage disease. Immunohistochemistry analyses in muscle specimen showed no detectable Lysosomal-Associated Membrane Protein-2 (LAMP-2), in keeping with the diagnosis of Danon disease. However, a very low expression of a shortened LAMP-2 protein could be evidenced by Western-blot in the patient's fibroblasts. Molecular investigations identified a novel splicing mutation (IVS6 + 1delG) in the LAMP-2 gene. This case report highlights the intrafamilial variability of Danon disease phenotype. In this case, morphological examination of muscle biopsy, showing lysosomal storage myopathy, and immunohistochemistry analyses can provide key elements for orienting etiologic investigations.
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Affiliation(s)
- Sarah-Louise Cottinet
- Service de Médecine Pédiatrique, CHRU de Tours, Université François Rabelais, Tours, France
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14
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Hatz DE, Sharma A, Germer KE, Rolfsmeyer EA, Bowen JM. Psychosis in a patient with Danon cardiomyopathy. Gen Hosp Psychiatry 2010; 32:328-9. [PMID: 20430238 DOI: 10.1016/j.genhosppsych.2010.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Revised: 01/14/2010] [Accepted: 01/19/2010] [Indexed: 11/19/2022]
Affiliation(s)
- Daniel E Hatz
- University of Nebraska Medical Center, Omaha, NE 68144, USA.
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15
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Yang Z, Funke BH, Cripe LH, Vick GW, Mancini-Dinardo D, Peña LS, Kanter RJ, Wong B, Westerfield BH, Varela JJ, Fan Y, Towbin JA, Vatta M. LAMP2 microdeletions in patients with Danon disease. CIRCULATION. CARDIOVASCULAR GENETICS 2010; 3:129-37. [PMID: 20173215 PMCID: PMC2895413 DOI: 10.1161/circgenetics.109.901785] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Danon disease is an X-linked dominant disorder characterized by the clinical triad of hypertrophic cardiomyopathy, skeletal myopathy, and variable mental retardation. Pathologically, autophagic vacuoles are noted in both skeletal and cardiac muscle. It exhibits an X-linked dominant mode of inheritance, and male carriers are severely affected, whereas female carriers develop milder and later-onset cardiac symptoms. Danon disease has been associated with mutations in the lysosome-associated membrane glycoprotein 2 (LAMP2) gene located at Xq24, typically resulting in splicing defects or protein truncation affecting the LAMP2. Because of its rarity, the full spectrum of genetic mutation resulting in Danon disease has not been elucidated. METHODS AND RESULTS We analyzed 3 male cases with clinical and pathological findings consistent with Danon disease. Comprehensive mutational analysis failed to yield detectable products for selected LAMP2 exons, and genomic DNA deletion was suspected. Genomic junction fragment polymerase chain reaction analysis in case 1 identified a novel Alu-mediated 34-kb microdeletion encompassing the entire 5'-untranslated region and exon 1 of LAMP2. In case 2 and 3, junctional polymerase chain reaction and Southern blot analyses mapped the breakpoint to an MIRb and (TA)(n) simple repeats present in intron 3, which determined a 64-kb and a 58-kb deletion, respectively, thereby ablating exons 4 to 10. Western blot analysis confirmed the absence of LAMP2 in protein extract from lymphocytes of index case 2. CONCLUSIONS This article is the first report of Danon disease caused by microdeletions at Xq24, which functionally ablate LAMP2. The microdeletion mechanism appears to involve 1 Alu-mediated unequal recombination and 2 chromosomal breakage points involving TA-rich repeat sequences.
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Affiliation(s)
- Zhao Yang
- Department of Pediatrics (Cardiology) and John Welsh Cardiovascular Diagnostic Laboratory, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Birgit H. Funke
- Laboratory for Molecular Medicine Partners Center for Personalized Genetic Medicine 65 Landsdowne St, Cambridge, MA
| | - Linda H. Cripe
- Heart Institute, Department of Pediatrics and Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - G. Wesley Vick
- Department of Pediatrics (Cardiology) and John Welsh Cardiovascular Diagnostic Laboratory, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Debora Mancini-Dinardo
- Laboratory for Molecular Medicine Partners Center for Personalized Genetic Medicine 65 Landsdowne St, Cambridge, MA
| | - Liana S. Peña
- Department of Pediatrics (Cardiology) and John Welsh Cardiovascular Diagnostic Laboratory, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Ronald J. Kanter
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Brenda Wong
- Heart Institute, Department of Pediatrics and Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Brandy H. Westerfield
- Department of Pediatrics (Cardiology) and John Welsh Cardiovascular Diagnostic Laboratory, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Jaquelin J Varela
- Department of Pediatrics (Cardiology) and John Welsh Cardiovascular Diagnostic Laboratory, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Yuxin Fan
- Department of Pediatrics (Cardiology) and John Welsh Cardiovascular Diagnostic Laboratory, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Jeffrey A. Towbin
- Heart Institute, Department of Pediatrics and Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matteo Vatta
- Department of Pediatrics (Cardiology) and John Welsh Cardiovascular Diagnostic Laboratory, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, TX
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16
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Sabourdy F, Michelakakis H, Anastasakis A, Garcia V, Mavridou I, Nieto M, Pons MC, Skiadas C, Moraitou M, Manta P, Elleder M, Levade T. Danon disease: further clinical and molecular heterogeneity. Muscle Nerve 2009; 39:837-44. [PMID: 19373884 DOI: 10.1002/mus.21252] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Two families of Greek patients with subclinical to severe cardiomyopathy are presented. The diagnosis of Danon disease was supported by a total lack of LAMP2 immunostaining in cultured skin fibroblasts and muscle biopsies. The LAMP2 mutation carried by one patient (c.928G>A) has already been reported but with different symptoms. The second patient had a novel point deletion. This has not been described previously, but it could be detected easily by restriction analysis. This mutation was also found in the patient's brother, and it was associated with severe cardiomyopathy leading to heart failure. Surprisingly, the proband also had partial reduction of alpha-galactosidase A activity, despite the absence of characteristic clinical features of Fabry disease. A substitution in the GLA gene (c.937G>T) was found, and its involvement in the cardiac disease is discussed.
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Affiliation(s)
- Frédérique Sabourdy
- Laboratoire de Biochimie "Maladies Métaboliques," Institut Fédératif de Biologie, CHU Purpan, Toulouse, France
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17
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Maron BJ, Roberts WC, Arad M, Haas TS, Spirito P, Wright GB, Almquist AK, Baffa JM, Saul JP, Ho CY, Seidman J, Seidman CE. Clinical outcome and phenotypic expression in LAMP2 cardiomyopathy. JAMA 2009; 301:1253-9. [PMID: 19318653 PMCID: PMC4106257 DOI: 10.1001/jama.2009.371] [Citation(s) in RCA: 249] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Mutations in X-linked lysosome-associated membrane protein gene (LAMP2; Danon disease) produce a cardiomyopathy in young patients that clinically mimics severe hypertrophic cardiomyopathy (HCM) due to sarcomere protein mutations. However, the natural history and phenotypic expression of this newly recognized disease is incompletely resolved and its identification may have important clinical implications. OBJECTIVES To determine the clinical consequences, outcome, and phenotypic expression of LAMP2 cardiomyopathy associated with diagnostic and management strategies. DESIGN, SETTING, AND PATIENTS Clinical course and outcome were assessed prospectively in 7 young patients (6 boys) with defined LAMP2 mutations from the time of diagnosis (age 7-17 years; median, 14 years) to October 2008. Phenotypic expression of this disease was assessed both clinically and at autopsy. MAIN OUTCOME MEASURES Progressive heart failure, cardiac death, and transplant. RESULTS Over a mean (SD) follow-up of 8.6 (2.6) years, and by age 14 to 24 years, the study patients developed left ventricular systolic dysfunction (mean [SD] ejection fraction, 25% [7%]) and cavity enlargement, as well as particularly adverse clinical consequences, including progressive refractory heart failure and death (n = 4), sudden death (n = 1), aborted cardiac arrest (n = 1), or heart transplantation (n = 1). Left ventricular hypertrophy was particularly marked (maximum thickness, 29-65 mm; mean [SD], 44 [15] mm), including 2 patients with massive ventricular septal thickness of 60 mm and 65 mm at ages 23 and 14 years, respectively. In 6 patients, a ventricular pre-excitation pattern at study entry was associated with markedly increased voltages of R-wave or S-wave (15-145 mm; mean [SD], 69 [39] mm), and deeply inverted T-waves. Autopsy findings included a combination of histopathologic features that were consistent with a lysosomal storage disease (ie, clusters of vacuolated myocytes) but also typical of HCM due to sarcomere protein mutations (ie, myocyte disarray, small vessel disease, myocardial scarring). CONCLUSIONS LAMP2 cardiomyopathy is a profound disease process characterized by progressive clinical deterioration leading rapidly to cardiac death in young patients (<25 years). These observations underscore the importance of timely molecular diagnosis for predicting prognosis and early consideration of heart transplantation.
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Affiliation(s)
- Barry J Maron
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, 920 E 28th St, Ste 620, Minneapolis, MN 55407, USA.
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18
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Burusnukul P, de Los Reyes EC, Yinger J, Boué DR. Danon disease: an unusual presentation of autism. Pediatr Neurol 2008; 39:52-4. [PMID: 18555174 DOI: 10.1016/j.pediatrneurol.2008.03.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 02/13/2008] [Accepted: 03/17/2008] [Indexed: 11/26/2022]
Abstract
Danon disease is an X-linked cardioskeletal myopathy, originally reported as "lysosomal glycogen storage disease with normal acid maltase," resulting from a primary deficiency of lysosome-associated membrane protein-2 because of mutations in the lysosome-associated membrane protein-2 gene. Classic clinical features in males include cardiomyopathy (100%, eventually), myopathy (90%), and mental retardation (70%), but mostly of a mild degree. We report on an unusual presentation in a patient with autism, motor delay, and a normal cardiac evaluation. The presence of multiorgan involvement, including elevated liver enzymes, abnormal cranial magnetic resonance imaging, and diffuse hypotonia with swallowing difficulties, prompted a muscle biopsy. A quadriceps muscle biopsy was performed, and the findings were most suspicious for a glycogen storage-type disease. Subsequently, a pathogenic lysosome-associated membrane protein-2 mutation was found. To our knowledge, there are no previous clinical reports of autism in children with Danon disease.
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Affiliation(s)
- Prinyarat Burusnukul
- Department of Pediatrics and Neurology, Nationwide Children's Hospital and Ohio State University, 700 Children's Drive, Columbus, Ohio 43205, USA.
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19
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Bui YK, Renella P, Martinez-Agosto JA, Verity A, Madikians A, Alejos JC. Danon disease with typical early-onset cardiomyopathy in a male: focus on a novel LAMP-2 mutation. Pediatr Transplant 2008; 12:246-50. [PMID: 18282207 DOI: 10.1111/j.1399-3046.2007.00874.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report a case of a 16-yr-old male with Danon disease caused by a novel mutation in the LAMP-2 gene. Mutations in the LAMP-2 gene result in the absence of LAMP-2 on immunohistochemical staining of muscle tissue, thus defining Danon disease, a rare X-linked myopathy. It is characterized clinically by HCM or left ventricular hypertrophy, a WPW pattern on ECG, variable degrees of muscular weakness (skeletal myopathy), mental retardation, and retinal changes. The patient presented with severe skeletal muscular weakness and respiratory failure. He also had a history of two OHTs, the first one for severe HCM and the second for allograft rejection. The patient's myopathy was initially presumed to be exclusively related to steroid-induced "critical care myopathy." However, further evaluation with a thigh muscle biopsy revealed autophagic vacuoles with sarcolemnal features suggestive of a lysosomal storage disorder. DNA analysis ultimately identified a previously unreported hemizygous IVS6+3_+6delGAGT splice site deletion mutation in the LAMP-2 gene located within the 5' splice site of intron 6, consistent with Danon disease.
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Affiliation(s)
- Yen K Bui
- Department of Pediatrics, Moffitt Children's Hospital, UCSF, San Francisco, CA 94143, USA.
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20
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Javier García Seara F, Luis Martínez Sande J, Cid Álvarez B, González Juanatey JR. Síndrome de Wolff-Parkinson-White y enfermedad de Danon. Med Clin (Barc) 2008; 130:277. [DOI: 10.1157/13116563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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21
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Abstract
Danon disease, an extremely rare X-linked dominant disorder, is characterized clinically by hypertrophic cardiomyopathy (HCM), skeletal myopathy, and variable degree of mental retardation with autophagic vacuoles in skeletal and cardiac muscle. Reportedly, Danon disease is caused by a primary deficiency of a major lysosomal membrane glycoprotein, LAMP2 (lysosome-associated membrane protein 2). Here we review the clinical features, molecular genetics, related animal model, and differential diagnosis of Danon disease.
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Affiliation(s)
- Zhao Yang
- Baylor College of Medicine, Department of Pediatrics, Houston, TX 77030, USA
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22
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Mittnacht AJC, Moung C, Lai WW. Massive Cardiac Hypertrophy in a Patient with Danon Disease: An Intraoperative Transesophageal Echocardiographic Evaluation. Anesth Analg 2007; 105:963-5. [PMID: 17898373 DOI: 10.1213/01.ane.0000281072.33254.4f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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