1
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Lupo V, Di Gregorio MG, Mastrogiorgio G, Magliozzi M, Scapillati ME, Maglione V, Romanelli E, Alegiani C, Haass C, Novelli A. Neonatal diagnosis of ACTA2-related disease: A case report and review of literature. Am J Med Genet A 2023; 191:1111-1118. [PMID: 36607831 DOI: 10.1002/ajmg.a.63118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/14/2022] [Accepted: 12/26/2022] [Indexed: 01/07/2023]
Abstract
Multisystemic smooth muscle dysfunction syndrome (MSMDS, OMIM # 613834) is a rare autosomal dominant condition caused by pathogenetic variants of ACTA2 gene that result in impaired muscle contraction. MSMDS is characterized by an increased susceptibility to aneurismal dilatations and dissections, patent ductus arteriosus, early onset coronary artery disease, congenital mydriasis, chronic interstitial lung disease, hypoperistalsis, hydrops of gall bladder, and hypotonic bladder. Here, we report an early diagnosis of a MSMDS related to ACTA2 p.Arg179His (R179H) mutation in a newborn and performed a review of the literature. An early diagnosis of MSMDS is extremely important, because of the severe involvement of cardiovascular system in the MSMDS. Multidisciplinary care and surveillance and timely management of symptoms are important to reduce the risk of complications.
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Affiliation(s)
- Viviana Lupo
- Medical Genetics Unit, San Pietro-Fatebenefratelli Hospital, Rome, Italy
| | | | | | - Monia Magliozzi
- Laboratory of Medical Genetics, Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
| | | | - Vittorio Maglione
- Medical Genetics Unit, San Pietro-Fatebenefratelli Hospital, Rome, Italy
| | - Ester Romanelli
- Medical Genetics Unit, San Pietro-Fatebenefratelli Hospital, Rome, Italy
| | - Caterina Alegiani
- Neonatal Intensive Unit, San Pietro-Fatebenefratelli Hospital, Rome, Italy
| | - Cristina Haass
- Neonatal Intensive Unit, San Pietro-Fatebenefratelli Hospital, Rome, Italy
| | - Antonio Novelli
- Laboratory of Medical Genetics, Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
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2
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Yang WX, Zhang HH, Hu JN, Zhao L, Li YY, Shao XL. ACTA2 mutation is responsible for multisystemic smooth muscle dysfunction syndrome with seizures: A case report and review of literature. World J Clin Cases 2021; 9:8789-8796. [PMID: 34734057 PMCID: PMC8546807 DOI: 10.12998/wjcc.v9.i29.8789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 07/19/2021] [Accepted: 09/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND ACTA2 gene is a specific gene that encodes actin α2. Multisystem smooth muscle dysfunction syndrome (MSMDS) is a multisystem disease characterized by aortic and cerebrovascular lesions caused by ACTA2 gene mutations. There have been many reports of cardiac, pulmonary and cerebrovascular lesions caused by MSMDS; however, few studies have focused on seizures caused by MSMDS.
CASE SUMMARY Our patient was a girl aged 7 years and 8 mo with recurrent cough, asthma and seizures for 7 years. She was diagnosed with severe pneumonia, congenital heart disease, cardiac insufficiency, and malnutrition in the local hospital. Cardiac ultrasonography revealed congenital heart disease, patent ductus arteriosus (with a diameter of 0.68 cm), left coronary arteriectasis, patent oval foramen (0.12 cm), tricuspid and pulmonary regurgitation, and pulmonary hypertension. Cerebral magnetic resonance imaging and magnetic resonance angiography indicated stiffness in the brain vessels, together with multiple aberrant signaling shadows in bilateral paraventricular regions. A heterozygous mutation (c.536G>A) was identified in the ACTA2 gene, resulting in generation of p.R179H. Finally, the girl was diagnosed with MSMDS combined with epilepsy. The patient had 4 episodes of seizures before treatment, and no onset of seizure was reported after oral administration of sodium valproate for 1 year.
CONCLUSION MSMDS has a variety of clinical manifestations and unique cranial imaging features. Cerebrovascular injury and white matter injury may lead to seizures. Gene detection can confirm the diagnosis and prevent missed diagnosis or misdiagnosis.
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Affiliation(s)
- Wen-Xian Yang
- Department of Pediatrics, Shaoxing University School of Medicine, Shaoxing 312000, Zhejiang Province, China
| | - Hang-Hu Zhang
- Department of Pediatrics, Shaoxing Peoples’ Hospital, The First Affiliated Hospital of Shaoxing University, Shaoxing 312000, Zhejiang Province, China
| | - Jia-Ni Hu
- Department of Pediatrics, Shaoxing Peoples’ Hospital, The First Affiliated Hospital of Shaoxing University, Shaoxing 312000, Zhejiang Province, China
| | - Li Zhao
- Department of Radiology, Shaoxing Peoples’ Hospital, The First Affiliated Hospital of Shaoxing University, Shaoxing 312000, Zhejiang Province, China
| | - Yan-Yun Li
- Department of Pediatrics, Shaoxing Peoples’ Hospital, The First Affiliated Hospital of Shaoxing University, Shaoxing 312000, Zhejiang Province, China
| | - Xiao-Li Shao
- Department of Pediatrics, Shaoxing Peoples’ Hospital, The First Affiliated Hospital of Shaoxing University, Shaoxing 312000, Zhejiang Province, China
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3
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Kanamori K, Sakaguchi Y, Tsuda K, Ihara S, Miyama S. Refractory cerebral infarction in a child with an ACTA2 mutation. Brain Dev 2021; 43:585-589. [PMID: 33342581 DOI: 10.1016/j.braindev.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/01/2020] [Accepted: 12/03/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTIONS A specific mutation in the ACTA2 gene is known to cause multisystemic smooth muscle dysfunction syndrome, which is associated with cerebrovascular diseases and various organ disorders. Cerebral infarctions resulting from severe vasculopathy can be refractory; however, there are no previous reports describing the detailed clinical course of recurrent cerebral infarctions due to an ACTA2 mutation. Herein, we report a patient with an ACTA2 mutation who experienced multiple refractory cerebral infarctions in early childhood. PATIENT DESCRIPTION The patient was aged 1 year and 5 months at her first episode of cerebral infarction. Arteriopathy due to an ACTA2 mutation was diagnosed based on the characteristic cerebrovascular findings and abnormal physical findings, such as bilateral dilated pupils. Bilateral encephaloduroarteriosynangiosis and encephalogaleosynangiosis were performed after the first episode. Because the cerebral infarctions recurred postoperatively, administration of cilostazol followed by bosentan was started. However, despite these treatments she experienced seven cerebral infarctions by age 2 years and 6 months. INTERPRETATION Cerebral infarctions in patients with a specific ACTA2 mutation can occur even in early childhood, recur frequently, and cause severe motor and cognitive impairment. Physicians should be highly aware of this disease and be ready to provide the medical and surgical interventions necessary to minimize the disabling sequelae.
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Affiliation(s)
- Keita Kanamori
- Department of Neurology, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8561, Japan.
| | - Yuri Sakaguchi
- Department of Neurology, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8561, Japan
| | - Kyoji Tsuda
- Department of Neurosurgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8561, Japan
| | - Satoshi Ihara
- Department of Neurosurgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8561, Japan
| | - Sahoko Miyama
- Department of Neurology, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8561, Japan
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4
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Grossi A, Severino M, Rusmini M, Tortora D, Ramenghi LA, Cama A, Rossi A, Di Rocco M, Ceccherini I, Bertamino M, G A, L B, V C, R C, F C, C G, T G, AC M, P M, A M, L N, A P, M P, G P, A R, A R, S S, S U. Targeted re-sequencing in pediatric and perinatal stroke. Eur J Med Genet 2020; 63:104030. [DOI: 10.1016/j.ejmg.2020.104030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 07/20/2020] [Accepted: 07/31/2020] [Indexed: 02/07/2023]
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5
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Sabo TM, Stokes MA, Karbhari N, Veltkamp DL, Pfeifer CM. ACTA2 leukovasculopathy: A rare pediatric white matter disorder. Radiol Case Rep 2020; 15:1285-1288. [PMID: 32595813 PMCID: PMC7306539 DOI: 10.1016/j.radcr.2020.05.031] [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: 05/05/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 01/13/2023] Open
Abstract
A 3-year-old girl presented with ataxia, dilated pupils, and behavioral change prompting work up for stroke. Her medical history included chronic mydriasis and patent ductus arteriosus requiring aortoplasty. Magnetic resonance imaging of the brain demonstrated confluent white matter signal abnormality concerning for leukodystrophy. Magnetic resonance angiography revealed a cerebral vessel arteriopathy with a "broomstick appearance" and other neuroradiographic findings consistent with ACTA2 mutation. Pathogenic Arg179His ACTA2 mutation was confirmed in the patient. ACTA2-related leukovasculopathy should be considered during workup of patients with abnormal white matter (eg, leukodystrophies), childhood stroke, and arteriopathies. Recognizing the combination of commonly associated physical and medical conditions associated with radiographic features of this neurogenetic condition will prompt appropriate care and screening for comorbidities associated with this disorder.
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Affiliation(s)
- Tonia M. Sabo
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
- Department of Pediatrics, Division of Pediatric Neurology, University of Texas Southwestern Medical Center, Dallas, TX 75390
| | - Mathew A. Stokes
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
- Department of Pediatrics, Division of Pediatric Neurology, University of Texas Southwestern Medical Center, Dallas, TX 75390
| | - Nishika Karbhari
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Daniel L. Veltkamp
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
- Department of Radiology, Division of Pediatric Radiology, University of Texas Southwestern Medical Center, Dallas, TX 75390
| | - Cory M. Pfeifer
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
- Department of Radiology, Division of Pediatric Radiology, University of Texas Southwestern Medical Center, Dallas, TX 75390
- Corresponding author.
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6
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Chen SN, Wang YQ, Hao CL, Lu YH, Jiang WJ, Gao CY, Wu M. Multisystem smooth muscle dysfunction syndrome in a Chinese girl: A case report and review of the literature. World J Clin Cases 2019; 7:4355-4365. [PMID: 31911919 PMCID: PMC6940346 DOI: 10.12998/wjcc.v7.i24.4355] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/22/2019] [Accepted: 11/26/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Multisystemic smooth muscle dysfunction syndrome (MSMDS) is a rare genetic disease worldwide. The main mutation is the actin alpha 2 (ACTA2) gene p.R179H. In this paper, we report a Chinese MSMDS patient and systematically review the previous literature.
CASE SUMMARY Here, we report a 9.6-month-old Chinese girl who was diagnosed with MSMDS based on her history and symptoms, such as recurrent cough, wheezing, and complications with congenital fixed dilated pupils. Chest high-resolution computed tomography revealed inhomogeneous lung transparency, obvious exudative lesions, and some lung fissures that were markedly thickened. Cranial magnetic resonance imaging excluded bleeding and infarction but showed abnormal signals in the centrum ovale majus and bilateral periventricular regions. Echocardiography only showed patent foramen ovale, and no patent ductus arteriosus, pulmonary artery dilatation, or pulmonary hypertension was found. Bronchoscopy indicated moderate bronchial malacia. These examinations in conjunction with the typical eye abnormality suggested a diagnosis of MSMDS, and sequencing of exon 6 of the ACTA2 gene demonstrated the heterozygous mutation c.536G>A, p.R179H. However, her parents’ gene analyses were normal.
CONCLUSION MSMDS is a rare genetic disease mainly caused by the mutation of the ACTA2 gene p.R179H. Early genetic diagnosis should be performed for children presenting with congenital fixed dilated pupils and patent ductus arteriosus. During the process of diagnosis and treatment, clinicians should be on high alert for cerebrovascular, cardiovascular, and pulmonary complications.
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Affiliation(s)
- Sai-Nan Chen
- Department of Respiratory Medicine, Children’s Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Yu-Qing Wang
- Department of Respiratory Medicine, Children’s Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Chuang-Li Hao
- Department of Respiratory Medicine, Children’s Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Yan-Hong Lu
- Department of Respiratory Medicine, Children’s Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Wu-Jun Jiang
- Department of Respiratory Medicine, Children’s Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Chun-Yan Gao
- Department of Respiratory Medicine, Children’s Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Min Wu
- Department of Respiratory Medicine, Children’s Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
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7
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van de Laar IMBH, Arbustini E, Loeys B, Björck E, Murphy L, Groenink M, Kempers M, Timmermans J, Roos-Hesselink J, Benke K, Pepe G, Mulder B, Szabolcs Z, Teixidó-Turà G, Robert L, Emmanuel Y, Evangelista A, Pini A, von Kodolitsch Y, Jondeau G, De Backer J. European reference network for rare vascular diseases (VASCERN) consensus statement for the screening and management of patients with pathogenic ACTA2 variants. Orphanet J Rare Dis 2019; 14:264. [PMID: 31752940 PMCID: PMC6868850 DOI: 10.1186/s13023-019-1186-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 08/30/2019] [Indexed: 12/13/2022] Open
Abstract
The ACTA2 gene encodes for smooth muscle specific α-actin, a critical component of the contractile apparatus of the vascular smooth muscle cell. Pathogenic variants in the ACTA2 gene are the most frequently encountered genetic cause of non-syndromic hereditary thoracic aortic disease (HTAD). Although thoracic aortic aneurysm and/or dissection is the main clinical manifestation, a variety of occlusive vascular disease and extravascular manifestations occur in ACTA2-related vasculopathy. Current data suggest possible mutation-specific manifestations of vascular and extra-aortic traits.Despite its relatively high prevalence, comprehensive recommendations on the care of patients and families with pathogenic variants in ACTA2 have not yet been established. We aimed to develop a consensus document to provide medical guidance for health care professionals involved in the diagnosis and treatment of patients and relatives with pathogenic variants in ACTA2.The HTAD Working Group of the European Reference Network for Rare Vascular Diseases (VASCERN) convened to review current literature and discuss expert opinions on clinical management of ACTA2 related vasculopathy. This consensus statement summarizes our recommendations on diagnosis, monitoring, treatment, pregnancy, genetic counselling and testing in patients with ACTA2-related vasculopathy. However, there is a clear need for additional prospective multicenter studies to further define proper guidelines.
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Affiliation(s)
- Ingrid M B H van de Laar
- Department of Clinical Genetics and Cardiology and VASCERN HTAD European Reference Centre, Erasmus MC, University Medical Center Rotterdam, Wytemaweg 80, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands. .,VASCERN HTAD European Reference Centre, Ghent, Belgium.
| | - Eloisa Arbustini
- VASCERN HTAD European Reference Centre, Ghent, Belgium.,Center for Inherited Cardiovascular Diseases and VASCERN HTAD European Reference Centre, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
| | - Bart Loeys
- VASCERN HTAD European Reference Centre, Ghent, Belgium.,Center of Medical Genetics and VASCERN HTAD European Reference Centre, University Hospital of Antwerp University of Antwerp, Antwerp, Belgium.,Department of Clinical Genetics and Cardiology and VASCERN HTAD European Reference Centre, Radboud university medical center, Nijmegen, Netherlands
| | - Erik Björck
- VASCERN HTAD European Reference Centre, Ghent, Belgium.,Department of Clinical Genetics and Department of Molecular medicine and Surgery and VASCERN HTAD European Reference Centre, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Lise Murphy
- VASCERN Patient Group (ePAG) and Swedish Marfan organization and VASCERN HTAD European Reference Centre, Färjestaden, Sweden
| | - Maarten Groenink
- VASCERN HTAD European Reference Centre, Ghent, Belgium.,Department of Cardiology, and VASCERN HTAD European Reference Centre, Academic Medical Center, Amsterdam, Netherlands
| | - Marlies Kempers
- Department of Clinical Genetics and Cardiology and VASCERN HTAD European Reference Centre, Radboud university medical center, Nijmegen, Netherlands
| | - Janneke Timmermans
- Department of Clinical Genetics and Cardiology and VASCERN HTAD European Reference Centre, Radboud university medical center, Nijmegen, Netherlands
| | - Jolien Roos-Hesselink
- Department of Clinical Genetics and Cardiology and VASCERN HTAD European Reference Centre, Erasmus MC, University Medical Center Rotterdam, Wytemaweg 80, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.,VASCERN HTAD European Reference Centre, Ghent, Belgium
| | - Kalman Benke
- VASCERN HTAD European Reference Centre, Ghent, Belgium.,Heart and Vascular Center and VASCERN HTAD European Reference Centre, Semmelweis University, Budapest, Hungary
| | - Guglielmina Pepe
- VASCERN HTAD European Reference Centre, Ghent, Belgium.,Regional Tuscany Reference Center for Marfan Syndrome and related disorders and VASCERN HTAD European Reference Centre, Careggi Hospital, University of Florence, Florence, Italy
| | - Barbara Mulder
- Department of Cardiology, and VASCERN HTAD European Reference Centre, Academic Medical Center, Amsterdam, Netherlands
| | - Zoltan Szabolcs
- Heart and Vascular Center and VASCERN HTAD European Reference Centre, Semmelweis University, Budapest, Hungary
| | - Gisela Teixidó-Turà
- Servei de Cardiologia and VASCERN HTAD European Reference Centre, Hospital Universitari Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Leema Robert
- VASCERN HTAD European Reference Centre, Ghent, Belgium.,South East Thames Regional Genetics Service and VASCERN HTAD European Reference Centre, Guy's Hospital, London, UK
| | - Yaso Emmanuel
- VASCERN HTAD European Reference Centre, Ghent, Belgium.,South East Thames Regional Genetics Service and VASCERN HTAD European Reference Centre, Guy's Hospital, London, UK
| | - Arturo Evangelista
- Servei de Cardiologia and VASCERN HTAD European Reference Centre, Hospital Universitari Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Alessandro Pini
- VASCERN HTAD European Reference Centre, Ghent, Belgium.,Centro Malattie Rare Cardilogiche - Marfan Clinic and VASCERN HTAD European Reference Centre, Azienda Socio Sanitaria Territoriale Fatebenefratelli - Sacco Milan, Milan, Italy
| | - Yskert von Kodolitsch
- VASCERN HTAD European Reference Centre, Ghent, Belgium.,Department of Vascular Medicine, Department of General and Interventional Cardiology and VASCERN HTAD European Reference Centre, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Guillaume Jondeau
- VASCERN HTAD European Reference Centre, Ghent, Belgium.,CRMR Marfan Syndrome and related disorders, and VASCERN HTAD European Reference Centre Service de cardiologie, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France.,INSERM U1148 LVTS and VASCERN HTAD European Reference Centre, Université Paris, Paris, France
| | - Julie De Backer
- VASCERN HTAD European Reference Centre, Ghent, Belgium.,Department of Cardiology and Center for Medical Genetics Ghent and VASCERN HTAD European Reference Centre, Ghent University Hospital, Ghent, Belgium
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8
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D'Arco F, Alves CA, Raybaud C, Chong WKK, Ishak GE, Ramji S, Grima M, Barkovich AJ, Ganesan V. Expanding the Distinctive Neuroimaging Phenotype of ACTA2 Mutations. AJNR Am J Neuroradiol 2018; 39:2126-2131. [PMID: 30262641 DOI: 10.3174/ajnr.a5823] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 08/16/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Arg179His mutations in ACTA2 are associated with a distinctive neurovascular phenotype characterized by a straight course of intracranial arteries, absent basal Moyamoya collaterals, dilation of the proximal internal carotid arteries, and occlusive disease of the terminal internal carotid arteries. We now add to the distinctive neuroimaging features in these patients by describing their unique constellation of brain malformative findings that could flag the diagnosis in cases in which targeted cerebrovascular imaging has not been performed. MATERIALS AND METHODS Neuroimaging studies from 13 patients with heterozygous Arg179His mutations in ACTA2 and 1 patient with pathognomonic clinicoradiologic findings for ACTA2 mutation were retrospectively reviewed. The presence and localization of brain malformations and other abnormal brain MR imaging findings are reported. RESULTS Characteristics bending and hypoplasia of the anterior corpus callosum, apparent absence of the anterior gyrus cinguli, and radial frontal gyration were present in 100% of the patients; flattening of the pons on the midline and multiple indentations in the lateral surface of the pons were demonstrated in 93% of the patients; and apparent "squeezing" of the cerebral peduncles in 85% of the patients. CONCLUSIONS Because α-actin is not expressed in the brain parenchyma, only in vascular tissue, we speculate that rather than a true malformative process, these findings represent a deformation of the brain during development related to the mechanical interaction with rigid arteries during the embryogenesis.
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Affiliation(s)
- F D'Arco
- From the Departments of Radiology (F.D'A., W.K.K.C.)
| | - C A Alves
- Radiology Department (C.A.A.), Hospital Das Clinicas, Sao Paulo, Brazil
| | - C Raybaud
- Department of Diagnostic Imaging (C.R.), Hospital for Sick Children, Toronto, Ontario, Canada
| | - W K K Chong
- From the Departments of Radiology (F.D'A., W.K.K.C.)
| | - G E Ishak
- Department of Radiology (G.E.I.), Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - S Ramji
- Department of Radiology (S.R.), Imperial College Healthcare National Health Service Trust, London, UK
| | - M Grima
- Department of Radiology (M.G.), University Hospital of North Staffordshire National Health Service Trust, Stoke-on-Trent, UK
| | - A J Barkovich
- Department of Radiology and Diagnostic Imaging (A.J.B.), University of California, San Francisco, San Francisco, California
| | - V Ganesan
- Neurology (V.G.), Great Ormond Street Hospital for Children National Health Service Foundation Trust, London, UK
- Neuroscience Unit (V.G.), UCL Great Ormond Street Institute of Child Health, London, UK
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9
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Regalado ES, Mellor-Crummey L, De Backer J, Braverman AC, Ades L, Benedict S, Bradley TJ, Brickner ME, Chatfield KC, Child A, Feist C, Holmes KW, Iannucci G, Lorenz B, Mark P, Morisaki T, Morisaki H, Morris SA, Mitchell AL, Ostergaard JR, Richer J, Sallee D, Shalhub S, Tekin M, Estrera A, Musolino P, Yetman A, Pyeritz R, Milewicz DM. Clinical history and management recommendations of the smooth muscle dysfunction syndrome due to ACTA2 arginine 179 alterations. Genet Med 2018; 20:1206-1215. [PMID: 29300374 PMCID: PMC6034999 DOI: 10.1038/gim.2017.245] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 11/16/2017] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Smooth muscle dysfunction syndrome (SMDS) due to heterozygous ACTA2 arginine 179 alterations is characterized by patent ductus arteriosus, vasculopathy (aneurysm and occlusive lesions), pulmonary arterial hypertension, and other complications in smooth muscle-dependent organs. We sought to define the clinical history of SMDS to develop recommendations for evaluation and management. METHODS Medical records of 33 patients with SMDS (median age 12 years) were abstracted and analyzed. RESULTS All patients had congenital mydriasis and related pupillary abnormalities at birth and presented in infancy with a patent ductus arteriosus or aortopulmonary window. Patients had cerebrovascular disease characterized by small vessel disease (hyperintense periventricular white matter lesions; 95%), intracranial artery stenosis (77%), ischemic strokes (27%), and seizures (18%). Twelve (36%) patients had thoracic aortic aneurysm repair or dissection at median age of 14 years and aortic disease was fully penetrant by the age of 25 years. Three (9%) patients had axillary artery aneurysms complicated by thromboembolic episodes. Nine patients died between the ages of 0.5 and 32 years due to aortic, pulmonary, or stroke complications, or unknown causes. CONCLUSION Based on these data, recommendations are provided for the surveillance and management of SMDS to help prevent early-onset life-threatening complications.
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Affiliation(s)
- Ellen S Regalado
- Department of Internal Medicine, University of Texas Health Science Center at Houston McGovern Medical School, Houston, USA, Texas
| | - Lauren Mellor-Crummey
- Department of Internal Medicine, University of Texas Health Science Center at Houston McGovern Medical School, Houston, USA, Texas
| | - Julie De Backer
- Center for Medical Genetics, University Hospital Ghent, Ghent, Belgium
| | - Alan C Braverman
- Cardiovascular Division, Washington University School of Medicine, St. Louis, USA, Missouri
| | - Lesley Ades
- Division of Pediatrics and Child Health, University of Sydney, Sydney, Australia, New South Wales
| | - Susan Benedict
- Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City, USA, Utah
| | - Timothy J Bradley
- Division of Cardiology, Department of Pediatrics, University of Saskatchewan, Saskatoon, Canada, Saskatchewan
| | - M Elizabeth Brickner
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, USA, Texas
| | - Kathryn C Chatfield
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, USA, Colorado
| | - Anne Child
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - Cori Feist
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, USA, Oregon
| | - Kathryn W Holmes
- Department of Pediatrics, Oregon Health and Science University, Portland, USA, Oregon
| | - Glen Iannucci
- Department of Pediatrics, Emory University School of Medicine, Atlanta, USA, Georgia
| | - Birgit Lorenz
- Department of Ophthalmology, Justus-Liebig-University Giessen, Giessen, Germany
| | - Paul Mark
- Department of Medical Genetics, Spectrum Health, Grand Rapids, USA, Michigan
| | - Takayuki Morisaki
- Tokyo University of Technology School of Health Sciences, Tokyo, Japan
| | - Hiroko Morisaki
- Department of Medical Genetics, Sakakibara Heart Institute, Tokyo, Japan
| | - Shaine A Morris
- Texas Children's Hospital, Baylor College of Medicine, Houston, USA, Texas
| | - Anna L Mitchell
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, USA, Ohio
| | - John R Ostergaard
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Julie Richer
- Department of Medical Genetics, Children's Hospital of Eastern Ontario, Ottawa, Canada, Ontario
| | - Denver Sallee
- Department of Pediatrics, Emory University School of Medicine, Atlanta, USA, Georgia
| | - Sherene Shalhub
- Department of Surgery, University of Washington, Seattle, USA, Washington
| | - Mustafa Tekin
- John P. Hussman Institute for Human Genomics and Dr. John T. Macdonald Foundation Department of Human Genetics, University of Miami Miller School of Medicine, Miami, USA, Florida
| | | | - Anthony Estrera
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston McGovern Medical School, Houston, USA, Texas
| | - Patricia Musolino
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA, Massachusetts
| | - Anji Yetman
- Department of Pediatrics, Children's Hospital & Medical Center, University of Nebraska, Omaha, USA, Nebraska
| | - Reed Pyeritz
- Perelman School of Medicine at the, University of Pennsylvania, Philadelphia, USA, Pennsylvania
| | - Dianna M Milewicz
- Department of Internal Medicine, University of Texas Health Science Center at Houston McGovern Medical School, Houston, USA, Texas.
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10
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Logeswaran T, Friedburg C, Hofmann K, Akintuerk H, Biskup S, Graef M, Rad A, Weber A, Neubauer BA, Schranz D, Bouvagnet P, Lorenz B, Hahn A. Two patients with the heterozygous R189H mutation inACTA2and Complex congenital heart defects expands the cardiac phenotype of multisystemic smooth muscle dysfunction syndrome. Am J Med Genet A 2017; 173:959-965. [DOI: 10.1002/ajmg.a.38102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 12/05/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Thushiha Logeswaran
- Department of Pediatric Cardiology; Justus-Liebig-University of Giessen; Giessen Germany
| | - Christoph Friedburg
- Department of Ophthalmology; Justus-Liebig-University of Giessen; Giessen Germany
| | - Karoline Hofmann
- Department of Pediatric Cardiology; Justus-Liebig-University of Giessen; Giessen Germany
| | - Hakan Akintuerk
- Department of Pediatric Cardiac Surgery; Justus-Liebig-University of Giessen; Giessen Germany
| | - Saskia Biskup
- Center for Genomics and Transcriptomics; Tübingen Germany
| | - Michael Graef
- Department of Ophthalmology; Justus-Liebig-University of Giessen; Giessen Germany
| | - Ali Rad
- Department of Pediatric Cardiology; Justus-Liebig-University of Giessen; Giessen Germany
| | - Axel Weber
- Department of Human Genetics; Justus-Liebig-University of Giessen; Giessen Germany
| | - Bernd A. Neubauer
- Department of Child Neurology; Justus-Liebig-University of Giessen; Giessen Germany
| | - Dietmar Schranz
- Department of Pediatric Cardiology; Justus-Liebig-University of Giessen; Giessen Germany
| | - Patrice Bouvagnet
- Laboratoire Cardiogénétique, Hospices Civils de Lyon; et Université Lyon 1; Lyon France
| | - Birgit Lorenz
- Department of Ophthalmology; Justus-Liebig-University of Giessen; Giessen Germany
| | - Andreas Hahn
- Department of Child Neurology; Justus-Liebig-University of Giessen; Giessen Germany
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11
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Yuan SM. α-Smooth Muscle Actin and ACTA2 Gene Expressions in Vasculopathies. Braz J Cardiovasc Surg 2016; 30:644-9. [PMID: 26934405 PMCID: PMC4762557 DOI: 10.5935/1678-9741.20150081] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 11/23/2015] [Indexed: 12/27/2022] Open
Abstract
α-smooth muscle actin, encoded by ACTA2 gene, is an isoform of the
vascular smooth muscle actins, typically expressed in the vascular smooth muscle
cells contributing to vascular motility and contraction. ACTA2 gene mutations
cause a diversity of diffuse vasculopathies such as thoracic aortic aneurysms
and dissections as well as occlusive vascular diseases, including premature
coronary artery disease and ischemic stroke. Dynamics of
differentiation-specific α-smooth muscle actin in arterial smooth muscle
cells and proliferation of the proteins have been well described. Although a
variety of research works have been undertaken in terms of modifications of
α-smooth muscle actin and mutations of ACTA2 gene and myosin, the
underlying mechanisms towards the pathological processes by way of gene
mutations are yet to be clarified. The purpose of the present article is to
describe the phenotypes of α-smooth muscle actin and implications of
ACTA2 mutations in vasculopathies in order to enhance the understanding of
potential mechanisms of aortic and coronary disorders.
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12
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Rutledge WC, Choudhri O, Walcott BP, Benet A, Fox CK, Gupta N, Lawton MT. Indirect and direct revascularization of ACTA2 cerebral arteriopathy: feasibility of the superficial temporal artery to anterior cerebral artery bypass with posterior auricular artery interposition graft: case report. J Neurosurg Pediatr 2016; 18:339-43. [PMID: 27176728 DOI: 10.3171/2016.3.peds15694] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Mutations in the smooth muscle-specific isoform of alpha actin (ACTA2) cause smooth muscle dysfunction in arteries. This rare loss-of-function mutation may cause a diffuse occlusive cerebral arteriopathy, resulting in stroke. While ACTA2 arteriopathy is often described as moyamoya-like, it has a distinct phenotype characterized by dilation of the proximal internal carotid artery (ICA) and occlusion of the terminal ICA and proximal middle cerebral artery. Intracranial arteries have an abnormally straight course, often with small aneurysms. There is limited experience with revascularization procedures for ACTA2 arteriopathy, and the safety and efficacy of these procedures are unknown. In this paper the authors present a symptomatic 6-year-old patient with ACTA2 cerebral arteriopathy who underwent both indirect revascularization and direct cerebrovascular bypass. Postoperatively, the patient suffered an ischemic infarct in a neighboring vascular territory. While direct cerebrovascular bypass is technically feasible, patients with ACTA2 arteriopathy may be at increased risk for perioperative stroke compared with patients with moyamoya disease.
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Affiliation(s)
| | | | | | | | - Christine K Fox
- Neurology, and.,Pediatrics, University of California, San Francisco, California
| | - Nalin Gupta
- Departments of 1 Neurological Surgery.,Pediatrics, University of California, San Francisco, California
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13
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Moreno CA, Metze K, Lomazi EA, Bertola DR, Barbosa RHA, Cosentino V, Sobreira N, Cavalcanti DP. Visceral myopathy: Clinical and molecular survey of a cohort of seven new patients and state of the art of overlapping phenotypes. Am J Med Genet A 2016; 170:2965-2974. [PMID: 27481187 DOI: 10.1002/ajmg.a.37857] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 06/13/2016] [Indexed: 12/14/2022]
Abstract
Visceral motility dysfunction is a key feature of genetic disorders such as megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS, MIM moved from 249210 to 155310), chronic intestinal pseudo-obstruction (CIPO, MIM609629), and multisystemic smooth muscle dysfunction syndrome (MSMDS, MIM613834). The genetic bases of these conditions recently begun to be clarified with the identification of pathogenic variants in ACTG2, ACTA2, and MYH11 in individuals with visceral motility dysfunction. The MMIHS was associated with the heterozygous variant in ACTG2 and homozygous variant in MYH11, while the heterozygous variant in ACTA2 was observed in patients with MSMDS. In this study, we describe the clinical data as well as the molecular investigation of seven individuals with visceral myopathy phenotypes. Five patients presented with MMIHS, including two siblings from consanguineous parents, one had CIPO, and the other had MSMDS. In three individuals with MMIHS and in one with CIPO we identified heterozygous variant in ACTG2, one being a novel variant (c.584C>T-p.Thr195Ile). In the individual with MSMDS we identified a heterozygous variant in ACTA2. We performed the whole-exome sequencing in one sibling with MMIHS and her parents; however, the pathogenic variant responsible for her phenotype could not be identified. These results reinforce the clinical and genetic heterogeneity of the visceral myopathies. Although many cases of MMIHS are associated with ACTG2 variants, we suggest that other genes, besides MYH11, could cause the MMIHS with autosomal recessive pattern. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Carolina Araujo Moreno
- Faculty of Medical Sciences, Departmentof Medical Genetics, State University of Campinas, Campinas, Brazil
| | - Konradin Metze
- Faculty of Medical Sciences, Department of Pathology, State University of Campinas, Campinas, Brazil
| | - Elizete Aparecida Lomazi
- Faculty of Medical Sciences, Department of Pediatrics, State University of Campinas, Campinas, Brazil
| | - Débora Romeo Bertola
- Genetic Unit, Faculty of Medicine, Children's Institute, University of São Paulo, São Paulo, Brazil
| | | | - Viviana Cosentino
- CEMIC (Center for Medical Education and Clinical Research), Buenos Aires, Argentina
| | - Nara Sobreira
- Department of Pediatrics, McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Denise Pontes Cavalcanti
- Faculty of Medical Sciences, Departmentof Medical Genetics, State University of Campinas, Campinas, Brazil.
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14
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Georgescu MM, Pinho MDC, Richardson TE, Torrealba J, Buja LM, Milewicz DM, Raisanen JM, Burns DK. The defining pathology of the new clinical and histopathologic entity ACTA2-related cerebrovascular disease. Acta Neuropathol Commun 2015; 3:81. [PMID: 26637293 PMCID: PMC4670506 DOI: 10.1186/s40478-015-0262-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 11/24/2015] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Smooth muscle cell contraction is an essential function of arteries and relies on the integrity of the actin-myosin apparatus. The tissue-specific α2-smooth muscle actin, encoded by ACTA2, is predominantly expressed in vascular smooth muscle cells. ACTA2 mutations predispose to development of aortic aneurysms and early onset coronary and cerebrovascular disease. Based on arteriographic findings, a distinct cerebrovascular disease has been proposed for ACTA2 heterozygous patients carrying the R179H mutation. RESULTS We present the first integrated analysis of a severely compromised patient with the R179H mutation and define the arterial pathology of ACTA2-related cerebrovascular disease. Histologically, striking morphological abnormalities were present in cerebral arteries of all sizes. Massive intimal smooth muscle cell proliferation, fragmentation of the elastic laminae and medial fibromuscular proliferation characterized large arteries whereas prominent vessel wall thickening, fibrosis and smooth muscle cell proliferation were unique changes in small arteries. The medial fibrosis and smooth muscle cell proliferation explain the characteristic radiologic appearance of "straight arteries" and suggest impaired function of mutant smooth muscle cells. Actin three-dimensional molecular modeling revealed critical positioning of R179 at the interface between the two strands of filamentous actin and destabilization of inter-strand bundling by the R179H mutation, explaining the severe associated phenotype. CONCLUSIONS In conclusion, these characteristic clinical and pathologic findings confirm ACTA2-related cerebrovascular disease as a new cerebrovascular disorder for which new therapeutic strategies need to be designed.
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15
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Yetman AT, Starr LJ, Bleyl SB, Meyers L, Delaney JW. Progressive Aortic Dilation Associated With ACTA2 Mutations Presenting in Infancy. Pediatrics 2015; 136:e262-6. [PMID: 26034244 DOI: 10.1542/peds.2014-3032] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2015] [Indexed: 12/16/2022] Open
Abstract
Mutations in the gene ACTA2 are a recognized cause of aortic aneurysms with aortic dissection in adulthood. Recently, a specific mutation (Arg179His) in this gene has been associated with multisystem smooth muscle dysfunction presenting in childhood. We describe 3 patients with an R179H mutation, all of whom presented with an aneurysmal patent ductus arteriosus. Detailed information on the rate of aortic disease progression throughout childhood is provided. Death or need for ascending aortic replacement occurred in all patients. Genetic testing for ACTA2 mutations should be considered in all infants presenting with ductal aneurysms.
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Affiliation(s)
| | - Lois J Starr
- Genetics, Children's Hospital and Medical Center Omaha and The University of Nebraska Medical Center, Omaha, Nebraska; and
| | - Steven B Bleyl
- Division of Pediatric Cardiology, University of Utah, Salt Lake City, Utah
| | - Lindsay Meyers
- Division of Pediatric Cardiology, University of Utah, Salt Lake City, Utah
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16
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Congenital fixed dilated pupils due to ACTA2- multisystemic smooth muscle dysfunction syndrome. J Neuroophthalmol 2014; 34:137-43. [PMID: 24621862 DOI: 10.1097/wno.0000000000000090] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Congenital fixed dilated pupils (congenital mydriasis) is characterized by hypoplasia or aplasia of the iris muscles, with absence of iris between the collarette and pupillary border, creating a scalloped pupillary margin. This condition has been reported in a multisystemic smooth muscle cell dysfunction syndrome, combined with congenital patent ductus arteriosus, cerebrovascular disease (Moya-moya-like), coronary artery disease, thoracic aorta aneurysm, and dysfunction of smooth muscle cells in organs throughout the body. All affected individuals carry a p.R179H heterozygous mutation in the ACTA2 gene. We add to the ophthalmologic involvement with 3 more patients. Congenital fixed dilated pupils is a rare condition and should alert ophthalmologists to the possibility of the coexistence of systemic life-threatening disorders.
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17
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Ware SM, Shikany A, Landis BJ, James JF, Hinton RB. Twins with progressive thoracic aortic aneurysm, recurrent dissection and ACTA2 mutation. Pediatrics 2014; 134:e1218-23. [PMID: 25225139 DOI: 10.1542/peds.2013-2503] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Thoracic aortic aneurysm (TAA) is a genetically mediated disease with variable age of onset. In the pediatric age range, nonsyndromic TAA frequently has a milder course than syndromic forms of TAA, such as Marfan syndrome or Loeys-Dietz syndrome. Herein, we describe 17-year-old identical twin brothers with severe progressive TAA due to a novel de novo ACTA2 mutation. Interestingly, both boys were diagnosed at age 11 with congenital mydriasis, a recently recognized manifestation of some ACTA2 mutations due to smooth muscle dysfunction. One of the brothers presented with acute-onset lower back pain that was identified as dissection of an abdominal aortic aneurysm. Imaging of the chest at this time showed severe fusiform TAA. Cardiac imaging in his twin showed similar TAA, but no abdominal aortic aneurysm. Both brothers underwent valve-sparing aortic root replacement, but have had progressive aortic disease with recurrent dissection requiring multiple surgeries. This case emphasizes the importance of identifying physical stigmata of smooth muscle dysfunction, such as mydriasis, as potential markers for associated aortopathy and vascular diseases.
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Affiliation(s)
- Stephanie M Ware
- Division of Human Genetics, and Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Amy Shikany
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Benjamin J Landis
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeanne F James
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Robert B Hinton
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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18
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Brodsky MC, Turan KE, Khanna CL, Patton A, Kirmani S. Congenital mydriasis and prune belly syndrome in a child with an ACTA2 mutation. J AAPOS 2014; 18:393-5. [PMID: 24998021 DOI: 10.1016/j.jaapos.2014.02.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 02/24/2014] [Accepted: 02/25/2014] [Indexed: 12/14/2022]
Abstract
We report the association of congenital mydriasis with prune belly syndrome and cerebrovascular anomalies in a 9-year-old boy who was found to have an ACTA2 mutation. This case illustrates the spectrum of systemic malformations that are attributable to mutations in ACTA2 and expands the spectrum of cerebrovascular anomalies that are now known to accompany congenital mydriasis.
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Affiliation(s)
| | - Kadriye Erkan Turan
- Department of Ophthalmology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Cheryl L Khanna
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | - Alice Patton
- Department of Medical Genetics Radiology, Mayo Clinic, Rochester, Minnesota
| | - Salman Kirmani
- Department of Medical Genetics, Mayo Clinic, Rochester, Minnesota
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