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Lin D, Li H, Tian L, Liu L, Zhang J, Wang Y, Zhang J, Su L, Zeng Q, Wu Q. Prenatal sonographic evidence of hypohidrotic ectodermal dysplasia and postnatal genetic testing of a family line of child. Quant Imaging Med Surg 2024; 14:3174-3179. [PMID: 38617155 PMCID: PMC11007524 DOI: 10.21037/qims-23-1429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/16/2024] [Indexed: 04/16/2024]
Affiliation(s)
- Dongxi Lin
- School of Traditional Chinese Medical Science, Henan University of Traditional Chinese Medicine, Zhengzhou, China
| | - Hong Li
- Department of Ultrasound, Fuzhou Fuxing Maternity Hospital, Fuzhou, China
| | - Li Tian
- School of Traditional Chinese Medical Science, Henan University of Traditional Chinese Medicine, Zhengzhou, China
- Department of Ultrasound, The Third Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, China
| | - Luhao Liu
- School of Traditional Chinese Medical Science, Henan University of Traditional Chinese Medicine, Zhengzhou, China
| | - Jintao Zhang
- Department of Network Engineering, Shanghai Lianying Medical Technology Co., Ltd., Wuhan Branch, Wuhan, China
| | - Yong Wang
- Department of Ultrasound, Shimen County People’s Hospital Attached to Changsha Medical College, Changsha, China
| | - Jiacheng Zhang
- School of Traditional Chinese Medical Science, Henan University of Traditional Chinese Medicine, Zhengzhou, China
| | - Linlin Su
- School of Traditional Chinese Medical Science, Henan University of Traditional Chinese Medicine, Zhengzhou, China
| | - Qingyu Zeng
- School of Traditional Chinese Medical Science, Henan University of Traditional Chinese Medicine, Zhengzhou, China
| | - Qiumei Wu
- Department of Ultrasound, Fujian Provincial Maternity and Children’s Hospital, Fuzhou, China
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2
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Reinhold V, Syrjänen S, Kankuri‐Tammilehto M. New observation of severe tooth malformation in a female patient with ectodermal dysplasia due to the EDA splice acceptor variant c.742-2A>G. Mol Genet Genomic Med 2023; 11:e2275. [PMID: 37665136 PMCID: PMC10724520 DOI: 10.1002/mgg3.2275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND Ectodermal dysplasias are inherited disorders, which are characterized by congenital defects in two or more ectodermal structures such as skin, sweat glands, hair, nails, teeth, and mucous membranes. METHOD Here, we describe a new observation of significant oligodontia in a female patient with the EDA gene variant c.742-2A>G. RESULTS The results strongly suggest that the EDA gene variant c.742-2A>G is pathogenic. The oligodontia in the proband was exceptionally severe. CONCLUSION We demonstrate that the very rare splice acceptor variant EDA c.742-2A>G is associated with severe oligodontia even in females. Our study points that this variant is pathogenic. An early identification of this variant is crucial for planning adequate treatment and follow-up in time by a multidisciplinary team.
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Affiliation(s)
| | - Stina Syrjänen
- Department of Oral Pathology and Radiology, Faculty of MedicineUniversity of TurkuTurkuFinland
- Department of PathologyTurku University Hospital, University of TurkuTurkuFinland
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Aftab H, Escudero IA, Sahhar F. X-Linked Hypohidrotic Ectodermal Dysplasia (XLHED): A Case Report and Overview of the Diagnosis and Multidisciplinary Modality Treatments. Cureus 2023; 15:e40383. [PMID: 37456454 PMCID: PMC10344640 DOI: 10.7759/cureus.40383] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Hypohidrotic ectodermal dysplasia (HED) is a rare genetic disorder caused by a mutation in either the ectodysplasin (EDA), ectodysplasin A receptor (EDAR), EDAR associated via death domain (EDARADD), or Wnt family member 10A (WNT10A) genes that result in impaired development of ectodermal-derived structures. The literature defines two types of ectodermal dysplasia, which are hypohidrotic and hidrotic. X-linked hypohidrotic ectodermal dysplasia (XLHED), also known as Christ-Siemens-Touraine syndrome, is the most common form and is a variant of ectodermal dysplasia characterized by a classical triad of hypo/adontia, hypohidrosis, and hypotrichosis; whereas, hidrotic type of ectodermal dysplasia, also known as Clouston syndrome, is characterized by a triad of onychodysplasia, hypotrichosis, and palmoplantar hyperkeratosis while sparing the sweat glands. Symptoms of XLHED can begin early in life between the ages of one month to 23 months. XLHED is more commonly seen in males due to the x-linked characteristics of the gene mutations. This disease can be diagnosed by physical exam alone, or in combination with molecular genetic testing. XLHED specifically has an estimated occurrence of one in every 20,000 newborns worldwide. Approximately 5,000 people in the United States have the disease. In this case report, we present an adult patient diagnosed with XLHED. Our objective is to emphasize the significance of early diagnosis, advocate for a multidisciplinary management approach, and shed light on the potential of recombinant protein and targeted gene therapy for further research. By raising awareness of this condition, we aim to improve patient outcomes not only in newborns but also in adults who have already been diagnosed with XLHED.
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Affiliation(s)
- Hammad Aftab
- Department of Family Medicine, Detroit Medical Center-DMC/Michigan State University College of Medicine, Detroit, USA
| | - Ivan A Escudero
- Department of Family Medicine, Detroit Medical Center-DMC/Michigan State University College of Medicine, Detroit, USA
| | - Fatin Sahhar
- Department of Family Medicine, Detroit Medical Center-DMC/Michigan State University College of Medicine, Detroit, USA
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4
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Schneider H, Schweikl C, Faschingbauer F, Hadj-Rabia S, Schneider P. A Causal Treatment for X-Linked Hypohidrotic Ectodermal Dysplasia: Long-Term Results of Short-Term Perinatal Ectodysplasin A1 Replacement. Int J Mol Sci 2023; 24:ijms24087155. [PMID: 37108325 PMCID: PMC10138843 DOI: 10.3390/ijms24087155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/05/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
X-linked hypohidrotic ectodermal dysplasia (XLHED), caused by a genetic deficiency of ectodysplasin A1 (EDA1), is a rare developmental disorder of ectodermal derivatives such as hair, sweat glands, and teeth. The absence of sweat glands and perspiration can evoke life-threatening hyperthermia. As molecular genetic findings are not always conclusive, the concentrations of circulating EDA1 may help to distinguish between total and partial EDA1 deficiencies. We previously treated nine male patients with obvious signs of XLHED with a recombinant EDA1 replacement protein, Fc-EDA, either shortly after birth (n = 3) or by prenatal administration in gestational week 26 and beyond (n = 6). Here, we present the long-term follow-up for up to six years. In patients who had received Fc-EDA after birth, neither sweat glands nor sweating ability were detected at the age of 12-60 months. In contrast, prenatal EDA1 replacement resulted in ample sweat gland development and pilocarpine-inducible sweating in all treated subjects, who also attained more permanent teeth than their untreated affected relatives. Normal perspiration has persisted for six years in the two oldest boys treated repeatedly with Fc-EDA in utero. When they had a sauna, adequate thermoregulation was evidenced. Lower sweat production after single prenatal dosing may indicate a dose-response relationship. The absence of circulating EDA1 in five prenatally treated subjects proved that these children would have been unable to perspire if they had been left untreated. The sixth infant was shown to produce an EDA1 molecule that, albeit interacting with its cognate receptor, cannot activate EDA1 signaling. In conclusion, a causal treatment of XLHED before birth is feasible.
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Affiliation(s)
- Holm Schneider
- Center for Ectodermal Dysplasias & Department of Pediatrics, University Hospital Erlangen, Loschgestr. 15, 91054 Erlangen, Germany
| | - Christine Schweikl
- Center for Ectodermal Dysplasias & Department of Pediatrics, University Hospital Erlangen, Loschgestr. 15, 91054 Erlangen, Germany
| | - Florian Faschingbauer
- Department of Obstetrics and Gynecology, University Hospital Erlangen, Universitätsstraße 21-23, 91054 Erlangen, Germany
| | - Smail Hadj-Rabia
- Department of Dermatology and Reference Center for Rare Skin Diseases (MAGEC), Institut Imagine, Université de Paris-Centre, Hôpital Necker-Enfants Malades, 149 Rue de Sèvres, 75743 Paris, France
| | - Pascal Schneider
- Department of Immunobiology, University of Lausanne, Chemin des Boveresses 155, 1066 Epalinges, Switzerland
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5
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Schneider H, Hadj-Rabia S, Faschingbauer F, Bodemer C, Grange DK, Norton ME, Cavalli R, Tadini G, Stepan H, Clarke A, Guillén-Navarro E, Maier-Wohlfart S, Bouroubi A, Porte F. Protocol for the Phase 2 EDELIFE Trial Investigating the Efficacy and Safety of Intra-Amniotic ER004 Administration to Male Subjects with X-Linked Hypohidrotic Ectodermal Dysplasia. Genes (Basel) 2023; 14:153. [PMID: 36672894 PMCID: PMC9858920 DOI: 10.3390/genes14010153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/09/2022] [Accepted: 12/28/2022] [Indexed: 01/09/2023] Open
Abstract
X-linked hypohidrotic ectodermal dysplasia (XLHED) is a rare genetic disorder characte-rised by abnormal development of the skin and its appendages, such as hair and sweat glands, the teeth, and mucous glands of the airways, resulting in serious, sometimes life-threatening complications like hyperthermia or recurrent respiratory infections. It is caused by pathogenic variants of the ectodysplasin A gene (EDA). Most affected males are hemizygous for EDA null mutations that lead to the absence or inactivity of the signalling protein ectodysplasin A1 (EDA1) and, thus, to the full-blown phenotype with inability to perspire and few if any teeth. There are currently no long-term treatment options for XLHED. ER004 represents a first-in-class protein replacement molecule designed for specific, high-affinity binding to the endogenous EDA1 receptor (EDAR). Its proposed mechanism of action is the replacement of missing EDA1 in yet unborn patients with XLHED. Once bound to EDAR, ER004 activates the EDA/NFκB signalling pathway, which triggers the transcription of genes involved in the normal development of multiple tissues. Following preclinical studies, named-patient use cases demonstrated significant potential of ER004 in affected males treated in utero during the late second and third trimesters of pregnancy. In order to confirm these results, we started the EDELIFE trial, a prospective, open-label, genotype-match controlled, multicentre clinical study to investigate the efficacy and safety of intra-amniotic ER004 administration as a prenatal treatment for male subjects with XLHED. This article summarises the rationale, the study protocol, ethical issues of the trial, and potential pitfalls.
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Affiliation(s)
- Holm Schneider
- Center for Ectodermal Dysplasias and Department of Pediatrics, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Smail Hadj-Rabia
- Department of Dermatology, Reference Centre for Genodermatoses and Rare Skin Diseases (MAGEC), Hopital Universitaire Necker-Enfants Malades, Assistance Publique—Hospitals of Paris, University of Paris-Cité, 75743 Paris, France
| | - Florian Faschingbauer
- Department of Obstetrics and Gynecology, University Hospital Erlangen, 91054 Erlangen, Germany
| | - Christine Bodemer
- Department of Dermatology, Reference Centre for Genodermatoses and Rare Skin Diseases (MAGEC), Hopital Universitaire Necker-Enfants Malades, Assistance Publique—Hospitals of Paris, University of Paris-Cité, 75743 Paris, France
| | - Dorothy K. Grange
- Department of Pediatrics, Division of Genetics and Genomic Medicine, Washington University, St. Louis, MO 63110, USA
| | - Mary E. Norton
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA 94143, USA
| | - Riccardo Cavalli
- Pediatric Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, 20122 Milan, Italy
| | - Gianluca Tadini
- Pediatric Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, 20122 Milan, Italy
| | - Holger Stepan
- Department of Obstetrics, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Angus Clarke
- Institute of Medical Genetics, Division of Cancer & Genetics, School of Medicine, Cardiff University, Cardiff, CF10 3AT, UK
| | - Encarna Guillén-Navarro
- Medical Genetics Section, Department of Pediatrics, Virgen de la Arrixaca University Hospital, IMIB-Arrixaca, University of Murcia, and CIBERER, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Sigrun Maier-Wohlfart
- Center for Ectodermal Dysplasias and Department of Pediatrics, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
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Schweikl C, Maier-Wohlfart S, Schneider H, Park J. Ectodysplasin A1 Deficiency Leads to Osteopetrosis-like Changes in Bones of the Skull Associated with Diminished Osteoclastic Activity. Int J Mol Sci 2022; 23:12189. [PMID: 36293046 PMCID: PMC9603288 DOI: 10.3390/ijms232012189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/30/2022] [Accepted: 10/10/2022] [Indexed: 08/30/2023] Open
Abstract
Pathogenic variants of the gene Eda cause X-linked hypohidrotic ectodermal dysplasia (XLHED), which is characterized by structural abnormalities or lack of ectodermal appendages. Signs of dysplasia are not restricted to derivatives of the ectodermal layer, but mesodermal abnormalities, such as craniofacial dysmorphism, are also frequently observed, suggesting close reciprocal interactions between the ectoderm and mesoderm; however, a causal link has remained unsubstantiated. We investigated the functional impact of defective ectodysplasin A1 (Eda1) signaling on postnatal bone homeostasis in Eda1-deficient Tabby mice. Interestingly, Eda1 was detected in wild-type mouse calvariae throughout postnatal lifetime. In calvariae, bone-lining Osterix (Osx)+ osteoblasts stained positive for Eda1, and osteoclasts were revealed as Eda receptor (Edar)-positive. Moreover, adult Eda1-deficient calvarial bone showed osteopetrosis-like changes with significantly diminished marrow space, which was maintained during adulthood. Concomitantly with osteopetrosis-like changes, Tabby calvarial bone and Tabby bone marrow-derived osteoclasts had far less osteoclastic activity-associated co-enzymes including cathepsin K, Mmp9, Trap, and Tcirg1 (V-type proton ATPase a3 subunit) compared with wild-type calvariae in vivo or osteoclasts in vitro, indicating that Eda1 deficiency may affect the activity of osteoclasts. Finally, we confirmed that nuclear Nfatc1-positive osteoclasts were strongly diminished during mature osteoclastic differentiation under M-CSF and RANKL in the Tabby model, while Fc-EDA treatment of Tabby-derived osteoclasts significantly increased nuclear translocation of Nfatc1. Furthermore, we identified enhanced Nfatc1 and NF-κB transcriptional activity following Fc-EDA treatment in vitro using luciferase assays. Overall, the results indicate that diminished expressions of osteoclastic activity-associated co-enzymes may lead to disturbed bone homeostasis in Tabby calvariae postnatally.
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Affiliation(s)
- Christine Schweikl
- Department of Pediatrics, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
- Center for Ectodermal Dysplasias, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Sigrun Maier-Wohlfart
- Department of Pediatrics, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
- Center for Ectodermal Dysplasias, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Holm Schneider
- Department of Pediatrics, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
- Center for Ectodermal Dysplasias, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Jung Park
- Department of Pediatrics, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
- Center for Ectodermal Dysplasias, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
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7
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Schneider H. Ectodermal dysplasias: New perspectives on the treatment of so far immedicable genetic disorders. Front Genet 2022; 13:1000744. [PMID: 36147498 PMCID: PMC9485875 DOI: 10.3389/fgene.2022.1000744] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 08/04/2022] [Indexed: 11/13/2022] Open
Abstract
The past decade has witnessed an expansion of molecular approaches facilitating the differential diagnosis of ectodermal dysplasias, a group of genetic diseases characterized by the lack or malformation of hair, teeth, nails, and certain eccrine glands. Moreover, advances in translational research have increased the therapeutic opportunities for such rare diseases, and new dental, surgical, and ophthalmic treatment options are likely to offer relief to many individuals affected by ectodermal dysplasias. In X-linked hypohidrotic ectodermal dysplasia (XLHED), the genetic deficiency of the signaling molecule ectodysplasin A1 (EDA1) may even be overcome before birth by administration of a recombinant replacement protein. This has been shown at least for the key problem of male subjects with XLHED, the nearly complete absence of sweat glands and perspiration which can lead to life-threatening hyperthermia. Prenatal treatment of six boys by injection of an EDA1 replacement protein into the amniotic fluid consistently induced the development of functional sweat glands. Normal ability to sweat has so far persisted for >5 years in the two oldest boys treated in utero. Thus, timely replacement of a missing protein appears to be a promising therapeutic strategy for the most frequent ectodermal dysplasia and possibly additional congenital disorders.
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8
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Ectodysplasin A (EDA) Signaling: From Skin Appendage to Multiple Diseases. Int J Mol Sci 2022; 23:ijms23168911. [PMID: 36012178 PMCID: PMC9408960 DOI: 10.3390/ijms23168911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 12/03/2022] Open
Abstract
Ectodysplasin A (EDA) signaling is initially identified as morphogenic signaling regulating the formation of skin appendages including teeth, hair follicles, exocrine glands in mammals, feathers in birds and scales in fish. Gene mutation in EDA signaling causes hypohidrotic ectodermal dysplasia (HED), a congenital hereditary disease with malformation of skin appendages. Interestingly, emerging evidence suggests that EDA and its receptors can modulate the proliferation, apoptosis, differentiation and migration of cancer cells, and thus may regulate tumorigenesis and cancer progression. More recently, as a newly discovered hepatocyte factor, EDA pathway has been demonstrated to be involved in the pathogenesis of nonalcoholic fatty liver disease (NAFLD) and type II diabetes by regulating glucose and lipid metabolism. In this review, we summarize the function of EDA signaling from skin appendage development to multiple other diseases, and discuss the clinical application of recombinant EDA protein as well as other potential targets for disease intervention.
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Wang Y, Zhang C, Zhou B, Hui L, Zheng L, Chen X, Wang S, Yang L, Hao S, Zhang Q. Three Variants Affecting Exon 1 of Ectodysplasin A Cause X-Linked Hypohidrotic Ectodermal Dysplasia: Clinical and Molecular Characteristics. Front Genet 2022; 13:916340. [PMID: 35873474 PMCID: PMC9298733 DOI: 10.3389/fgene.2022.916340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Ectodysplasin A (EDA) variations are major pathogenic factors for hypohidrotic ectodermal dysplasia (HED), the most common form of ectodermal dysplasia (ED), characterized by hypotrichosis, hypohidrosis, hypodontia, and other oral features. Methods: Molecular genetic defects in three HED families were detected by whole-exome sequencing and confirmed by Sanger sequencing or multiplex ligation-dependent probe amplification. The effect of splicing variant was further verified by EDA minigene in vitro analysis. De novo deletion was confirmed by chromosomal microarray analysis. Results: Three variants (c.396 + 1 G > C, c.171-173 del GTT, and exon 1 deletion) were identified, all affecting exon 1 of the EDA gene. Variants c.396 + 1 G > C and c.171-173 del GTT were first identified. Minigene analysis of the splicing variant (c.396 + 1 G > C) displayed a prolonged EDA-A1 transcript containing extra 699 bp at the start of intron 1, representing a functional cryptic splice site formation in vitro. Combining the results of chromosomal microarray analysis and whole-exome sequencing, the deletion variant was over 87 kb. Three variants were predicted to affect protein function to differing degrees, and were responsible for X-linked HED with varying phenotype. Conclusion: Investigating the clinical and molecular characteristics of these variations broadens our understanding of EDA gene variants, supporting clinical diagnosis, genetic counseling, and prenatal diagnosis of HED.
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Affiliation(s)
- Yupei Wang
- Medical Genetics Center, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China.,Gansu Provincial Clinical Research Center for Birth Defects and Rare Diseases, Lanzhou, China
| | - Chuan Zhang
- Medical Genetics Center, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China.,Gansu Provincial Clinical Research Center for Birth Defects and Rare Diseases, Lanzhou, China
| | - Bingbo Zhou
- Medical Genetics Center, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China.,Gansu Provincial Clinical Research Center for Birth Defects and Rare Diseases, Lanzhou, China
| | - Ling Hui
- Medical Genetics Center, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China.,Gansu Provincial Clinical Research Center for Birth Defects and Rare Diseases, Lanzhou, China
| | - Lei Zheng
- Medical Genetics Center, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China.,Gansu Provincial Clinical Research Center for Birth Defects and Rare Diseases, Lanzhou, China
| | - Xue Chen
- Medical Genetics Center, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China.,Gansu Provincial Clinical Research Center for Birth Defects and Rare Diseases, Lanzhou, China
| | - Shifan Wang
- Medical Genetics Center, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China.,Gansu Provincial Clinical Research Center for Birth Defects and Rare Diseases, Lanzhou, China
| | - Lan Yang
- Medical Genetics Center, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China.,Gansu Provincial Clinical Research Center for Birth Defects and Rare Diseases, Lanzhou, China
| | - Shengju Hao
- Medical Genetics Center, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China.,Gansu Provincial Clinical Research Center for Birth Defects and Rare Diseases, Lanzhou, China
| | - Qinghua Zhang
- Medical Genetics Center, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China.,Gansu Provincial Clinical Research Center for Birth Defects and Rare Diseases, Lanzhou, China
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10
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Gökdere S, Schneider H, Hehr U, Willen L, Schneider P, Maier-Wohlfart S. Functional and clinical analysis of five EDA variants associated with ectodermal dysplasia but with a hard-to-predict significance. Front Genet 2022; 13:934395. [PMID: 35923710 PMCID: PMC9339965 DOI: 10.3389/fgene.2022.934395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/27/2022] [Indexed: 12/13/2022] Open
Abstract
Deficiency of ectodysplasin A1 (EDA1) due to variants of the gene EDA causes X-linked hypohidrotic ectodermal dysplasia (XLHED), a rare genetic condition characterized by abnormal development of ectodermal structures. XLHED is defined by the triad of hypotrichosis, hypo- or anhidrosis, and hypo- or anodontia. Anhidrosis may lead to life-threatening hyperthermia. A definite genetic diagnosis is, thus, important for the patients' management and amenability to a novel prenatal treatment option. Here, we describe five familial EDA variants segregating with the disease in three families, for which different prediction tools yielded discordant results with respect to their significance. Functional properties in vitro and levels of circulating serum EDA were compared with phenotypic data on skin, hair, eyes, teeth, and sweat glands. EDA1-Gly176Val, although associated with relevant hypohidrosis, still bound to the EDA receptor (EDAR). Subjects with EDA1-Pro389LeufsX27, -Ter392GlnfsX30, -Ser125Cys, and an EDA1 splice variant (c.924+7A > G) showed complete absence of pilocarpine-induced sweating. EDA1-Pro389LeufsX27 was incapable of binding to EDAR and undetectable in serum. EDA1-Ter392GlnfsX30, produced in much lower amounts than wild-type EDA1, could still bind to EDAR, and so did EDA1-Ser125Cys that was, however, undetectable in serum. The EDA splice variant c.924+7A > G resulted experimentally in a mix of wild-type EDA1 and EDA molecules truncated in the middle of the receptor-binding domain, with reduced EDA serum concentration. Thus, in vitro assays reflected the clinical phenotype in two of these difficult cases, but underestimated it in three others. Absence of circulating EDA seems to predict the full-blown phenotype of XLHED, while residual EDA levels may also be found in anhidrotic patients. This indicates that unborn subjects carrying variants of uncertain significance could benefit from an upcoming prenatal medical treatment even if circulating EDA levels or tests in vitro suggest residual EDA1 activity.
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Affiliation(s)
- Sare Gökdere
- Department of Pediatrics, Center for Ectodermal Dysplasias, University Hospital Erlangen, Erlangen, Germany
| | - Holm Schneider
- Department of Pediatrics, Center for Ectodermal Dysplasias, University Hospital Erlangen, Erlangen, Germany
| | - Ute Hehr
- Center for Human Genetics, Regensburg, Germany
| | - Laure Willen
- Department of Biochemistry, University of Lausanne, Lausanne, Switzerland
| | - Pascal Schneider
- Department of Biochemistry, University of Lausanne, Lausanne, Switzerland
| | - Sigrun Maier-Wohlfart
- Department of Pediatrics, Center for Ectodermal Dysplasias, University Hospital Erlangen, Erlangen, Germany
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Pacault M, Verebi C, Lopez M, Vaucouleur N, Orhant L, Deburgrave N, Leturcq F, Vidaud D, Girodon E, Bienvenu T, Nectoux J. Non-invasive prenatal diagnosis of single gene disorders by paternal mutation exclusion: 3 years of clinical experience. BJOG 2022; 129:1879-1886. [PMID: 35486001 DOI: 10.1111/1471-0528.17201] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 12/24/2021] [Accepted: 01/22/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Cell-free fetal DNA (cffDNA) analysis is performed routinely for aneuploidy screening, RhD genotyping or sex determination. Although applications to single gene disorders (SGD) are being rapidly developed worldwide, only a few laboratories offer cffDNA testing routinely as a diagnosis service for this indication. In a previous report, we described a standardised protocol for non-invasive exclusion of paternal variant in SGD. Three years later, we now report our clinical experience with the protocol. DESIGN Descriptive study. SETTING Multi-centre French. POPULATION Indications for referral included pregnancies at risk of 25% or 50% of paternally inherited SGD, and pregnancies associated with an increased risk of SGD due to a de novo variant, either from strongly suggestive ultrasound findings or from a possible parental germinal mosaicism in the context of a previously affected child. METHODS Non-invasive prenatal diagnosis was performed using custom assays for droplet digital PCR. Feasibility, diagnostic performance and turn-around time were evaluated. RESULTS Mean time for a new assay design and validation was evaluated at 14 days, and mean result reporting time was 6 days. All referred pathogenic variants could be targeted except one located in a complex genomic region. A result was obtained for every 198 referrals except two. CONCLUSION This service was successfully implemented as a routine laboratory practice. It has been widely adopted by French clinicians and patients for paternal variant exclusion in various disorders.
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Affiliation(s)
- Mathilde Pacault
- Service de Médecine Génomique des Maladies de Système et d'Organe, Centre Université de Paris - Fédération de Génétique et de Médecine Génomique, Hôpital Cochin, APHP, Paris, France.,Laboratoire de Génétique Moléculaire et d'Histocompatibilité, Centre Hospitalier Régional Universitaire, Brest, France
| | - Camille Verebi
- Service de Médecine Génomique des Maladies de Système et d'Organe, Centre Université de Paris - Fédération de Génétique et de Médecine Génomique, Hôpital Cochin, APHP, Paris, France
| | - Maureen Lopez
- Service de Médecine Génomique des Maladies de Système et d'Organe, Centre Université de Paris - Fédération de Génétique et de Médecine Génomique, Hôpital Cochin, APHP, Paris, France
| | - Nicolas Vaucouleur
- Service de Médecine Génomique des Maladies de Système et d'Organe, Centre Université de Paris - Fédération de Génétique et de Médecine Génomique, Hôpital Cochin, APHP, Paris, France
| | - Lucie Orhant
- Service de Médecine Génomique des Maladies de Système et d'Organe, Centre Université de Paris - Fédération de Génétique et de Médecine Génomique, Hôpital Cochin, APHP, Paris, France
| | - Nathalie Deburgrave
- Service de Médecine Génomique des Maladies de Système et d'Organe, Centre Université de Paris - Fédération de Génétique et de Médecine Génomique, Hôpital Cochin, APHP, Paris, France
| | - France Leturcq
- Service de Médecine Génomique des Maladies de Système et d'Organe, Centre Université de Paris - Fédération de Génétique et de Médecine Génomique, Hôpital Cochin, APHP, Paris, France
| | - Dominique Vidaud
- Service de Médecine Génomique des Maladies de Système et d'Organe, Centre Université de Paris - Fédération de Génétique et de Médecine Génomique, Hôpital Cochin, APHP, Paris, France
| | - Emmanuelle Girodon
- Service de Médecine Génomique des Maladies de Système et d'Organe, Centre Université de Paris - Fédération de Génétique et de Médecine Génomique, Hôpital Cochin, APHP, Paris, France
| | - Thierry Bienvenu
- Service de Médecine Génomique des Maladies de Système et d'Organe, Centre Université de Paris - Fédération de Génétique et de Médecine Génomique, Hôpital Cochin, APHP, Paris, France
| | - Juliette Nectoux
- Service de Médecine Génomique des Maladies de Système et d'Organe, Centre Université de Paris - Fédération de Génétique et de Médecine Génomique, Hôpital Cochin, APHP, Paris, France
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12
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Thornton CS, Puttagunta L, Helmersen D, Thakrar MV, Nagendran J, Lien D, Varughese RA. ANOTHER syndrome-Familial presentations of progressive lung disease leading to double lung transplantation: A case report and literature review. Respirol Case Rep 2021; 9:e0872. [PMID: 34765225 PMCID: PMC8569409 DOI: 10.1002/rcr2.872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/17/2021] [Accepted: 10/19/2021] [Indexed: 11/08/2022] Open
Abstract
Ectodermal dysplasias (EDs) are a heterogeneous rare group of disorders with an incidence at 1/100,000 live births. Currently, there are limited case reports of patients requiring lung transplantation. Here, we report two brothers who present with a constellation of features including alopecia, nail dystrophy, ophthalmic complications, thyroid disease, hypohidrosis, ephelides, enteropathy and recurrent respiratory tract infections, known as ANOTHER syndrome, a rare autosomal recessive variant of ED. Both presented in early childhood with progressive respiratory decline and eventual failure. Chronic respiratory decline was refractory to standard therapy. Both patients required lung transplantation for sequelae of end-stage lung disease. Pathology demonstrated multifocal bronchiectasis with areas of fibrosis and small airway obstruction. ANOTHER syndrome is rare with a paucity of data in the literature. Given the limited therapeutic options available with natural progression towards respiratory failure, lung transplantation may be considered.
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Affiliation(s)
- Christina S. Thornton
- Division of Respirology, Department of MedicineCumming School of Medicine, University of CalgaryCalgaryAlbertaCanada
| | - Lakshmi Puttagunta
- Department of Laboratory Medicine and PathologyUniversity of AlbertaEdmontonAlbertaCanada
| | - Douglas Helmersen
- Division of Respirology, Department of MedicineCumming School of Medicine, University of CalgaryCalgaryAlbertaCanada
| | - Mitesh V. Thakrar
- Division of Respirology, Department of MedicineCumming School of Medicine, University of CalgaryCalgaryAlbertaCanada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of SurgeryUniversity of AlbertaEdmontonAlbertaCanada
| | - Dale Lien
- Division of Pulmonary Medicine, Department of MedicineUniversity of AlbertaEdmontonAlbertaCanada
| | - Rhea A. Varughese
- Division of Respirology, Department of MedicineCumming School of Medicine, University of CalgaryCalgaryAlbertaCanada
- Division of Pulmonary Medicine, Department of MedicineUniversity of AlbertaEdmontonAlbertaCanada
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13
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Schneider H, De Luca M. Editorial: Gene, Cell and Protein Replacement Therapy for Genetic Muscle, Bone and Skin Disorders. Front Genet 2021; 12:771611. [PMID: 34733321 PMCID: PMC8558391 DOI: 10.3389/fgene.2021.771611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/28/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Holm Schneider
- Department of Pediatrics, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Michele De Luca
- Centre for Regenerative Medicine "Stefano Ferrari", University of Modena and Reggio Emilia, Modena, Italy
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14
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Gene Mutations of the Three Ectodysplasin Pathway Key Players ( EDA, EDAR, and EDARADD) Account for More than 60% of Egyptian Ectodermal Dysplasia: A Report of Seven Novel Mutations. Genes (Basel) 2021; 12:genes12091389. [PMID: 34573371 PMCID: PMC8468066 DOI: 10.3390/genes12091389] [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: 08/03/2021] [Revised: 08/30/2021] [Accepted: 09/03/2021] [Indexed: 12/22/2022] Open
Abstract
Ectodermal dysplasia (ED) is a diverse group of genetic disorders caused by congenital defects of two or more ectodermal-derived body structures, namely, hair, teeth, nails, and some glands, e.g., sweat glands. Molecular pathogenesis of ED involves mutations of genes encoding key proteins of major developmental pathways, including ectodysplasin (EDA) and wingless-type (WNT) pathways. The most common ED phenotype is hypohidrotic/anhidrotic ectodermal dysplasia (HED) featuring hypotrichosis, hypohidrosis/anhidrosis, and hypodontia. Molecular diagnosis is fundamental for disease management and emerging treatments. We used targeted next generation sequencing to study EDA, EDAR, EDARADD, and WNT10A genes in 45 Egyptian ED patients with or without hypohidrosis. We present genotype and phenotype data of 28 molecularly-characterized patients demonstrating genetic heterogeneity, variable expressivity, and intrafamilial phenotypic variability. Thirteen mutations were reported, including four novel EDA mutations, two novel EDARADD, and one novel EDAR mutations. Identified mutations congregated in exons encoding key functional domains. EDA is the most common gene contributing to 85% of the identified Egyptian ED genetic spectrum, followed by EDARADD (10%) and EDAR (5%). Our cohort represents the first and largest cohort from North Africa where more than 60% of ED patients were identified emphasizing the need for exome sequencing to explore unidentified cases.
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15
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das Neves J, Notario-Pérez F, Sarmento B. Women-specific routes of administration for drugs: A critical overview. Adv Drug Deliv Rev 2021; 176:113865. [PMID: 34280514 DOI: 10.1016/j.addr.2021.113865] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 12/19/2022]
Abstract
The woman's body presents a number of unique anatomical features that can constitute valuable routes for the administration of drugs, either for local or systemic action. These are associated with genitalia (vaginal, endocervical, intrauterine, intrafallopian and intraovarian routes), changes occurring during pregnancy (extra-amniotic, intra-amniotic and intraplacental routes) and the female breast (breast intraductal route). While the vaginal administration of drug products is common, other routes have limited clinical application and are fairly unknown even for scientists involved in drug delivery science. Understanding the possibilities and limitations of women-specific routes is of key importance for the development of new preventative, diagnostic and therapeutic strategies that will ultimately contribute to the advancement of women's health. This article provides an overview on women-specific routes for the administration of drugs, focusing on aspects such as biological features pertaining to drug delivery, relevance in current clinical practice, available drug dosage forms/delivery systems and administration techniques, as well as recent trends in the field.
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16
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Kossel CS, Wahlbuhl M, Schuepbach-Mallepell S, Park J, Kowalczyk-Quintas C, Seeling M, von der Mark K, Schneider P, Schneider H. Correction of Vertebral Bone Development in Ectodysplasin A1-Deficient Mice by Prenatal Treatment With a Replacement Protein. Front Genet 2021; 12:709736. [PMID: 34456978 PMCID: PMC8385758 DOI: 10.3389/fgene.2021.709736] [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: 05/14/2021] [Accepted: 07/19/2021] [Indexed: 11/28/2022] Open
Abstract
X-linked hypohidrotic ectodermal dysplasia with the cardinal symptoms hypodontia, hypotrichosis and hypohidrosis is caused by a genetic deficiency of ectodysplasin A1 (EDA1). Prenatal EDA1 replacement can rescue the development of skin appendages and teeth. Tabby mice, a natural animal model of EDA1 deficiency, additionally feature a striking kink of the tail, the cause of which has remained unclear. We studied the origin of this phenomenon and its response to prenatal therapy. Alterations in the distal spine could be noticed soon after birth, and kinks were present in all Tabby mice by the age of 4 months. Although their vertebral bones frequently had a disorganized epiphyseal zone possibly predisposing to fractures, cortical bone density was only reduced in vertebrae of older Tabby mice and even increased in their tibiae. Different availability of osteoclasts in the spine, which may affect bone density, was ruled out by osteoclast staining. The absence of hair follicles, a well-known niche of epidermal stem cells, and much lower bromodeoxyuridine uptake in the tail skin of 9-day-old Tabby mice rather suggest the kink being due to a skin proliferation defect that prevents the skin from growing as fast as the skeleton, so that caudal vertebrae may be squeezed and bent by a lack of skin. Early postnatal treatment with EDA1 leading to delayed hair follicle formation attenuated the kink, but did not prevent it. Tabby mice born after prenatal administration of EDA1, however, showed normal tail skin proliferation, no signs of kinking and, interestingly, a normalized vertebral bone density. Thus, our data prove the causal relationship between EDA1 deficiency and kinky tails and indicate that hair follicles are required for murine tail skin to grow fast enough. Disturbed bone development appears to be partially pre-determined in utero and can be counteracted by timely EDA1 replacement, pointing to a role of EDA1 also in osteogenesis.
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Affiliation(s)
- Clara-Sophie Kossel
- Department of Pediatrics, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany.,Center for Ectodermal Dysplasias, University Hospital Erlangen, Erlangen, Germany
| | - Mandy Wahlbuhl
- Department of Pediatrics, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany.,Center for Ectodermal Dysplasias, University Hospital Erlangen, Erlangen, Germany
| | | | - Jung Park
- Department of Pediatrics, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany.,Center for Ectodermal Dysplasias, University Hospital Erlangen, Erlangen, Germany
| | | | - Michaela Seeling
- Department of Biology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Klaus von der Mark
- Department of Experimental Medicine I, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Pascal Schneider
- Department of Biochemistry, University of Lausanne, Epalinges, Switzerland
| | - Holm Schneider
- Department of Pediatrics, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany.,Center for Ectodermal Dysplasias, University Hospital Erlangen, Erlangen, Germany
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17
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Doolan BJ, Onoufriadis A, Kantaputra P, McGrath JA. WNT10A, dermatology and dentistry. Br J Dermatol 2021; 185:1105-1111. [PMID: 34184264 DOI: 10.1111/bjd.20601] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2021] [Indexed: 12/31/2022]
Abstract
WNTs (Wingless-related integration sites) are secreted glycoproteins that are involved in signalling pathways critical to organ development and tissue regeneration. Of the 19 known WNT ligands, one member of this family, WNT10A, appears to have specific relevance to skin, its appendages and teeth. This review focuses on how variants in the WNT10A gene have been associated with various ectodermal disorders and how such changes may have clinical relevance to dermatologists and dentists. Germline mutations in WNT10A underlie several forms of autosomal recessive ectodermal dysplasia in which heterozygous carriers may also display some lesser ectodermal anomalies. Within the general population, multiple heterozygous variants in WNT10A can cause skin, hair, sweat gland or dental alterations, also known as ectodermal derivative impairments. WNT10A variants have also been implicated in hair thickness, male androgenetic alopecia, hair curl, acne vulgaris, lipodystrophy, keloids, wound healing, tooth size, tooth agenesis, hypodontia, taurodontism and oral clefting. Beyond dermatology and dentistry, WNT10A abnormalities have also been identified in kidney fibrosis, keratoconus, certain malignancies (particularly gastrointestinal) and neuropathic pain pathways. In this review, we detail how WNT10A is implicated as a key physiological and pathological contributor to syndromic and nonsyndromic disorders, as well as population variants, affecting the skin and teeth, and document all reported mutations in WNT10A with genotype-phenotype correlation.
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Affiliation(s)
- B J Doolan
- St John's Institute of Dermatology, School of Basic and Medical Biosciences, King's College London, London, UK
| | - A Onoufriadis
- St John's Institute of Dermatology, School of Basic and Medical Biosciences, King's College London, London, UK
| | - P Kantaputra
- Division of Pediatric Dentistry, Department of Orthodontics and Pediatric Dentistry, Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand.,Center of Excellence in Medical Genetics Research, Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand
| | - J A McGrath
- St John's Institute of Dermatology, School of Basic and Medical Biosciences, King's College London, London, UK
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18
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Körber I, Klein OD, Morhart P, Faschingbauer F, Grange DK, Clarke A, Bodemer C, Maitz S, Huttner K, Kirby N, Durand C, Schneider H. Safety and immunogenicity of Fc-EDA, a recombinant ectodysplasin A1 replacement protein, in human subjects. Br J Clin Pharmacol 2020; 86:2063-2069. [PMID: 32250462 PMCID: PMC7495278 DOI: 10.1111/bcp.14301] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/20/2020] [Accepted: 03/16/2020] [Indexed: 12/20/2022] Open
Abstract
In X‐linked hypohidrotic ectodermal dysplasia, the most frequent ectodermal dysplasia, an inherited deficiency of the signalling protein ectodysplasin A1 (EDA1) impairs the development of the skin and its appendages, various eccrine glands, and dentition. The severe hypohidrosis common to X‐linked hypohidrotic ectodermal dysplasia patients may lead to life‐threatening hyperthermia, especially during hot weather or febrile illness. Fc‐EDA, an EDA1 replacement protein known to prevent the disease in newborn animals, was tested in 2 clinical trials (human adults and neonates) and additionally administered under compassionate use to 3 infants in utero. The data support the safety of Fc‐EDA and efficacy if applied prenatally. Anti‐drug antibodies were detected after intravenous administration in adult males and nonpregnant females, but not in pregnant women when Fc‐EDA was delivered intra‐amniotically. Most importantly, there was no detectable immune response to the investigational drug in neonates treated by intravenous infusions and in infants who had received Fc‐EDA in utero. In conclusion, the safety profile of this drug encourages further development of prenatal EDA1 replacement therapy.
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Affiliation(s)
- Iris Körber
- Center for Ectodermal Dysplasias, University Hospital Erlangen, Germany
| | | | - Patrick Morhart
- Center for Ectodermal Dysplasias, University Hospital Erlangen, Germany
| | | | | | | | | | - Silvia Maitz
- San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | | | - Neil Kirby
- Edimer Pharmaceuticals, Cambridge, MA, USA
| | | | - Holm Schneider
- Center for Ectodermal Dysplasias, University Hospital Erlangen, Germany
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