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Kehar M, Klaassen RJ, Sergi CM. Heterozygous missense mutation of the fibrinogen gene associated with cryptogenic liver disease in a 15-months-old Canadian caucasian child. Ultrastruct Pathol 2025; 49:235-242. [PMID: 39739370 DOI: 10.1080/01913123.2024.2447853] [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: 10/29/2024] [Revised: 12/17/2024] [Accepted: 12/24/2024] [Indexed: 01/02/2025]
Abstract
Hepatic fibrinogen storage disease is an uncommon autosomal dominant hereditary illness marked by hypofibrinogenemia and the accumulation of variant fibrinogen in the hepatic endoplasmic reticulum. We present an asymptomatic 15-month-old male with elevated liver enzymes. Test results indicate hypofibrinogenemia. The liver biopsy revealed circular eosinophilic inclusion bodies within the hepatocyte cytoplasm. After diastase pretreatment, the inclusion bodies did not stain using the periodic acid - Schiff procedure. Ultrastructural examination revealed the characteristic fibrinogen storage curvilinear inclusions. Sequence analysis using the Blueprint Genetics (BpG) FLEX Bleeding Disorder/Coagulopathy Panel identified a heterozygous missense variant FGG c.1075 G>C, p. (Gly359Arg). Thus, the patient was diagnosed with hepatic fibrinogen storage disease. Our findings suggest that in patients with asymptomatic elevated liver enzymes presenting with unanticipated hypofibrinogenemia, hepatic fibrinogen storage disorder must be included in the differential diagnosis. Furthermore, our results underscore the significance of molecular diagnosis in patients diagnosed with cryptogenic liver disease.
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Affiliation(s)
- Mohit Kehar
- Division of Pediatric Gastroenterology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Robert J Klaassen
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Consolato M Sergi
- Anatomical Pathology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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2
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Song Z, Thepsuwan P, Hur WS, Torres M, Wu SA, Wei X, Tushi NJ, Wei J, Ferraresso F, Paton AW, Paton JC, Zheng Z, Zhang K, Fang D, Kastrup CJ, Jaiman S, Flick MJ, Sun S. Regulation of hepatic inclusions and fibrinogen biogenesis by SEL1L-HRD1 ERAD. Nat Commun 2024; 15:9244. [PMID: 39455574 PMCID: PMC11512042 DOI: 10.1038/s41467-024-53639-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 10/16/2024] [Indexed: 10/28/2024] Open
Abstract
Impaired secretion of an essential blood coagulation factor fibrinogen leads to hepatic fibrinogen storage disease (HFSD), characterized by the presence of fibrinogen-positive inclusion bodies and hypofibrinogenemia. However, the molecular mechanisms underlying the biogenesis of fibrinogen in the endoplasmic reticulum (ER) remain unexplored. Here we uncover a key role of SEL1L-HRD1 complex of ER-associated degradation (ERAD) in the formation of aberrant inclusion bodies, and the biogenesis of nascent fibrinogen protein complex in hepatocytes. Acute or chronic deficiency of SEL1L-HRD1 ERAD in the hepatocytes leads to the formation of hepatocellular inclusion bodies. Proteomics studies followed by biochemical assays reveal fibrinogen as a major component of the inclusion bodies. Mechanistically, we show that the degradation of misfolded endogenous fibrinogen Aα, Bβ, and γ chains by SEL1L-HRD1 ERAD is indispensable for the formation of a functional fibrinogen complex in the ER. Providing clinical relevance of these findings, SEL1L-HRD1 ERAD indeed degrades and thereby attenuates the pathogenicity of two disease-causing fibrinogen γ mutants. Together, this study demonstrates an essential role of SEL1L-HRD1 ERAD in fibrinogen biogenesis and provides insight into the pathogenesis of protein-misfolding diseases.
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Affiliation(s)
- Zhenfeng Song
- Department of Pharmacology, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
- Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Pattaraporn Thepsuwan
- Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Woosuk Steve Hur
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27514, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27514, USA
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27514, USA
| | - Mauricio Torres
- Department of Molecular & Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, 48105, USA
| | - Shuangcheng Alivia Wu
- Department of Molecular Physiology and Biological Physics, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | - Xiaoqiong Wei
- Department of Molecular Physiology and Biological Physics, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
| | - Nusrat Jahan Tushi
- Department of Pharmacology, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA
- Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Juncheng Wei
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
- Department of Cardiovascular Sciences and Center for Metabolic Disease Research, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Francesca Ferraresso
- Blood Research Institute, Versiti Blood Center of Wisconsin, Milwaukee, WI, 53226, USA
- Departments of Surgery, Biochemistry, Biomedical Engineering, and Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Adrienne W Paton
- Research Centre for Infectious Diseases, Department of Molecular and Biomedical Science, University of Adelaide, Adelaide, South Australia, 5005, Australia
| | - James C Paton
- Research Centre for Infectious Diseases, Department of Molecular and Biomedical Science, University of Adelaide, Adelaide, South Australia, 5005, Australia
| | - Ze Zheng
- Blood Research Institute, Versiti Blood Center of Wisconsin, Milwaukee, WI, 53226, USA
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Kezhong Zhang
- Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Deyu Fang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Christian J Kastrup
- Blood Research Institute, Versiti Blood Center of Wisconsin, Milwaukee, WI, 53226, USA
- Departments of Surgery, Biochemistry, Biomedical Engineering, and Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Sunil Jaiman
- Department of Pathology, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Matthew James Flick
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27514, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27514, USA
- UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27514, USA
| | - Shengyi Sun
- Department of Pharmacology, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA.
- Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, 48201, USA.
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3
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Pelland-Marcotte MC, Avram AT, Néron H, Demers C, Castilloux J, Gauthier J, Neerman-Arbez M, Casini A, Rivard GE. A novel FGG missense variant associated with fibrinogen storage disease in a large family from Quebec. Haemophilia 2024; 30:858-861. [PMID: 38561627 DOI: 10.1111/hae.15006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/14/2024] [Accepted: 03/18/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Marie-Claude Pelland-Marcotte
- Department of Paediatrics, Division of Haematology, Centre Mère Enfant Soleil, Centre Hospitalier de l'Université de Québec, Quebec City, Canada
- Centre de recherche du CHU de Québec, axe Reproduction, santé de la mère et de l'enfant, Québec, Canada
| | - Adelina-Teona Avram
- Department of Hematology, Centre Hospitalier de l'Université de Québec, Quebec City, Canada
| | - Hélène Néron
- Department of Hematology, Centre Hospitalier de l'Université de Québec, Quebec City, Canada
| | - Christine Demers
- Department of Hematology, Centre Hospitalier de l'Université de Québec, Quebec City, Canada
| | - Julie Castilloux
- Department of Pediatrics, Division of Gastro-Enterology, Centre Mère Enfant Soleil, Centre Hospitalier de l'Université de Québec, Quebec City, Canada
| | - Julie Gauthier
- Division of Genetics, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Canada
| | - Marguerite Neerman-Arbez
- Department of Genetic Medicine and Development, University Medical School of Geneva, Geneva, Switzerland
- Faculty of Medicine of Geneva, Geneva, Switzerland
| | - Alessandro Casini
- Angiology and Haemostasis University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
- Faculty of Medicine of Geneva, Geneva, Switzerland
| | - Georges-Etienne Rivard
- Division of Hematology/Oncology, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Canada
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Asselta R, Paraboschi EM, Duga S. Hereditary Hypofibrinogenemia with Hepatic Storage. Int J Mol Sci 2020; 21:ijms21217830. [PMID: 33105716 PMCID: PMC7659954 DOI: 10.3390/ijms21217830] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/21/2020] [Accepted: 10/21/2020] [Indexed: 12/14/2022] Open
Abstract
Fibrinogen is a 340-kDa plasma glycoprotein constituted by two sets of symmetrical trimers, each formed by the Aα, Bβ, and γ chains (respectively coded by the FGA, FGB, and FGG genes). Quantitative fibrinogen deficiencies (hypofibrinogenemia, afibrinogenemia) are rare congenital disorders characterized by low or unmeasurable plasma fibrinogen antigen levels. Their genetic basis is represented by mutations within the fibrinogen genes. To date, only eight mutations, all affecting a small region of the fibrinogen γ chain, have been reported to cause hereditary hypofibrinogenemia with hepatic storage (HHHS), a disorder characterized by protein aggregation in the endoplasmic reticulum, hypofibrinogenemia, and liver disease of variable severity. Here, we will briefly review the clinic characteristics of HHHS patients and the histological feature of their hepatic inclusions, and we will focus on the molecular genetic basis of this peculiar type of coagulopathy.
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Affiliation(s)
- Rosanna Asselta
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy; (E.M.P.); (S.D.)
- Humanitas Clinical and Research Center, IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
- Correspondence: ; Tel.: +39-02-8224-5215
| | - Elvezia Maria Paraboschi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy; (E.M.P.); (S.D.)
- Humanitas Clinical and Research Center, IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Stefano Duga
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy; (E.M.P.); (S.D.)
- Humanitas Clinical and Research Center, IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
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Structural Characteristics in the γ Chain Variants Associated with Fibrinogen Storage Disease Suggest the Underlying Pathogenic Mechanism. Int J Mol Sci 2020; 21:ijms21145139. [PMID: 32698516 PMCID: PMC7404023 DOI: 10.3390/ijms21145139] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 11/24/2022] Open
Abstract
Particular fibrinogen γ chain mutations occurring in the γ-module induce changes that hamper γ-γ dimerization and provoke intracellular aggregation of the mutant fibrinogen, defective export and plasma deficiency. The hepatic storage predisposes to the development of liver disease. This condition has been termed hereditary hypofibrinogenemia with hepatic storage (HHHS). So far, seven of such mutations in the fibrinogen γ chain have been detected. We are reporting on an additional mutation occurring in a 3.5-year-old Turkish child undergoing a needle liver biopsy because of the concomitance of transaminase elevation of unknown origin and low plasma fibrinogen level. The liver biopsy showed an intra-hepatocytic storage of fibrinogen. The molecular analysis of the three fibrinogen genes revealed a mutation (Fibrinogen Trabzon Thr371Ile) at exon 9 of the γ chain in the child and his father, while the mother and the brother were normal. Fibrinogen Trabzon represents a new fibrinogen γ chain mutation fulfilling the criteria for HHHS. Its occurrence in a Turkish child confirms that HHHS can present in early childhood and provides relevant epidemiological information on the worldwide distribution of the fibrinogen γ chain mutations causing this disease. By analyzing fibrinogen crystal structures and calculating the folding free energy change (ΔΔG) to infer how the variants can affect the conformation and function, we propose a mechanism for the intracellular aggregation of Fibrinogen Trabzon and other γ-module mutations causing HHHS.
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Zen Y, Nishigami T. Rethinking fibrinogen storage disease of the liver: ground glass and globular inclusions do not represent a congenital metabolic disorder but acquired collective retention of proteins. Hum Pathol 2020; 100:1-9. [PMID: 32330484 DOI: 10.1016/j.humpath.2020.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 11/18/2022]
Abstract
Three types of intracytoplasmic inclusions immunoreactive to fibrinogen are collectively diagnosed as hepatic fibrinogen storage disease. This study aimed to better characterize ground glass (type II) and globular (type III) fibrinogen inclusions by the pathological examination of 3 cases and a literature review. Three adults (age: 32-64 years; male/female = 2:1) were unexpectedly found to have fibrinogen-positive ground glass changes (type II inclusions) by liver needle biopsy, against a background of acute hepatitis E, resolving acute cholangitis, or severe lobular hepatitis of unknown etiology. One patient also had fibrinogen-positive intracytoplasmic globules (type III inclusions) in the first biopsy, but they were not present in a second biopsy. None had coagulation abnormalities or hypofibrinogenemia. On immunostaining, both inclusions were strongly positive for not only fibrinogen but also C-reactive protein and C4d. Ultrastructurally, ground glass changes corresponded to membrane-bound cytoplasmic inclusions containing amorphous, granular material. The pathological features of type II fibrinogen inclusions were identical to those of pale bodies in hepatocellular carcinoma. The literature review suggested that type I fibrinogen inclusions characterized by a polygonal appearance are strongly associated with mutations in fibrinogen genes, coagulopathy, and family history, whereas type II/III inclusions are immunoreactive to multiple proteins and typically develop in cases of other unrelated liver diseases. In conclusion, type II and III fibrinogen inclusions do not represent a true hereditary storage disease but instead the collective retention of multiple proteins. Given the lack of clinical significance, a less specific name (e.g., pale body) may be more appropriate for those inclusions.
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Affiliation(s)
- Yoh Zen
- Institute of Liver Studies, King's College Hospital & King's College London, London SE5 9RS, UK; Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan.
| | - Takashi Nishigami
- Department of Diagnostic Pathology, Steel Memorial Hirohata Hospital, Himeji 671-1122, Japan.
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Gu L, Wang B, Liu L, Gan Q, Liu X, Chen L, Chen L. Hepatic fibrinogen storage disease and hypofibrinogenemia caused by fibrinogen Aguadilla mutation: a case report. J Int Med Res 2020; 48:300060519898033. [PMID: 31965886 PMCID: PMC7169362 DOI: 10.1177/0300060519898033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 12/10/2019] [Indexed: 12/17/2022] Open
Abstract
Hepatic fibrinogen storage disease is a rare autosomal dominant genetic disorder characterized by hypofibrinogenemia, as well as the retention of variant fibrinogen within the hepatocellular endoplasmic reticulum. Here, we describe an asymptomatic 4-year-old boy with abnormal liver function test results and unexpected hypofibrinogenemia. Liver biopsy showed circular eosinophil inclusion bodies in the hepato-cytoplasm. Immunostaining results of eosinophil inclusion bodies were positive for fibrinogen. Following pretreatment with diastase, the inclusion bodies failed to stain with the periodic acid–Schiff technique; moreover, immunostaining results were positive for fibrinogen, but negative for alpha-1-antitrypsin. Genetic analysis identified a heterozygous missense mutation c.1201C > T (p. Arg401Trp) within the fibrinogen γ-chain (FGG) gene and an additional single nucleotide polymorphism c.-58 A > G within the 5′-untranslated region of the fibrinogen Aα-chain (FGA) gene. Thus, the patient was diagnosed with hepatic fibrinogen storage disease. Our results indicate that, for patients who exhibit chronic liver disease with unexpected hypofibrinogenemia, hepatic fibrinogen storage disease should be considered in the differential diagnosis. Moreover, our findings emphasize the importance of molecular diagnosis in patients with cryptogenic liver disease.
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Affiliation(s)
- Leilei Gu
- Department of Gastroenterology, Ruijin Hospital North, Shanghai JiaoTong University, School of Medicine, Shanghai, China
| | - Bin Wang
- Department of Pathology, School of Basic Medical Sciences of Fujian Medical University, Fuzhou, China
- Department of Pathology, Mengchao Hepatobiliary Hospital, Fujian Medical University, Fuzhou, China
| | - Lu Liu
- Department of Hepatology, Mengchao Hepatobiliary Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Qiaorong Gan
- Department of Hepatology, Mengchao Hepatobiliary Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Xiaolong Liu
- Department of Hepatology, Mengchao Hepatobiliary Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Lihong Chen
- Department of Pathology, School of Basic Medical Sciences of Fujian Medical University, Fuzhou, China
- Department of Pathology, Mengchao Hepatobiliary Hospital, Fujian Medical University, Fuzhou, China
| | - Li Chen
- Department of Gastroenterology, Ruijin Hospital North, Shanghai JiaoTong University, School of Medicine, Shanghai, China
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Callea F, Giovannoni I, Sari S, Guldal E, Dalgic B, Akyol G, Sogo T, Al-Hussaini A, Maggiore G, Bartuli A, Boldrini R, Francalanci P, Bellacchio E. Fibrinogen Gamma Chain Mutations Provoke Fibrinogen and Apolipoprotein B Plasma Deficiency and Liver Storage. Int J Mol Sci 2017; 18:ijms18122717. [PMID: 29244742 PMCID: PMC5751318 DOI: 10.3390/ijms18122717] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 12/07/2017] [Accepted: 12/13/2017] [Indexed: 01/12/2023] Open
Abstract
p.R375W (Fibrinogen Aguadilla) is one out of seven identified mutations (Brescia, Aguadilla, Angers, Al du Pont, Pisa, Beograd, and Ankara) causing hepatic storage of the mutant fibrinogen γ. The Aguadilla mutation has been reported in children from the Caribbean, Europe, Japan, Saudi Arabia, Turkey, and China. All reported children presented with a variable degree of histologically proven chronic liver disease and low plasma fibrinogen levels. In addition, one Japanese and one Turkish child had concomitant hypo-APOB-lipoproteinemia of unknown origin. We report here on an additional child from Turkey with hypofibrinogenemia due to the Aguadilla mutation, massive hepatic storage of the mutant protein, and severe hypo-APOB-lipoproteinemia. The liver biopsy of the patient was studied by light microscopy, electron microscopy (EM), and immunohistochemistry. The investigation included the DNA sequencing of the three fibrinogen and APOB-lipoprotein regulatory genes and the analysis of the encoded protein structures. Six additional Fibrinogen Storage Disease (FSD) patients with either the Aguadilla, Ankara, or Brescia mutations were investigated with the same methodology. A molecular analysis revealed the fibrinogen gamma p.R375W mutation (Aguadilla) but no changes in the APOB and MTTP genes. APOB and MTTP genes showed no abnormalities in the other study cases. Light microscopy and EM studies of liver tissue samples from the child led to the demonstration of the simultaneous accumulation of both fibrinogen and APOB in the same inclusions. Interestingly enough, APOB-containing lipid droplets were entrapped within the fibrinogen inclusions in the hepatocytic Endoplasmic Reticulum (ER). Similar histological, immunohistochemical, EM, and molecular genetics findings were found in the other six FSD cases associated with the Aguadilla, as well as with the Ankara and Brescia mutations. The simultaneous retention of fibrinogen and APOB-lipoproteins in FSD can be detected in routinely stained histological sections. The analysis of protein structures unraveled the pathomorphogenesis of this unexpected phenomenon. Fibrinogen gamma chain mutations provoke conformational changes in the region of the globular domain involved in the "end-to-end" interaction, thus impairing the D-dimer formation. Each monomeric fibrinogen gamma chain is left with an abnormal exposure of hydrophobic patches that become available for interactions with APOB and lipids, causing their intracellular retention and impairment of export as a secondary unavoidable phenomenon.
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Affiliation(s)
- Francesco Callea
- Department Pathology and Molecular Histopathology, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy.
| | - Isabella Giovannoni
- Department Pathology and Molecular Histopathology, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy.
| | - Sinan Sari
- Department Pediatric Gastroenterology, Gazi University Ankara, 06560 Ankara, Turkey.
| | - Esendagli Guldal
- Department Pathology, Gazi University Ankara, 06560 Ankara, Turkey.
| | - Buket Dalgic
- Department Pediatric Gastroenterology, Gazi University Ankara, 06560 Ankara, Turkey.
| | - Gulen Akyol
- Department Pathology, Gazi University Ankara, 06560 Ankara, Turkey.
| | - Tsuyoshi Sogo
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital 3-6-1, Shimosueyoshi, Tsurumi Ward, Yokohama City, Kanagawa, Japan.
| | - Abdulrahman Al-Hussaini
- Division of Pediatric Gastroenterology, Children's Specialized Hospital, King Fahad Medical City, College of Medicine, Alfaisal University Riyadh 11525, Saudi Arabia.
| | - Giuseppe Maggiore
- Section of Pediatrics, Department of Medical Sciences, University of Ferrara, University Hospital Arcispedale Sant'Anna, 44100 Ferrara, Italy.
| | - Andrea Bartuli
- Rare Disease and Medical Genetics, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy.
| | - Renata Boldrini
- Department Pathology and Molecular Histopathology, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy.
| | - Paola Francalanci
- Department Pathology and Molecular Histopathology, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy.
| | - Emanuele Bellacchio
- Genetics and Rare Diseases, Research Division, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy.
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