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Courtney A, Hill A, Smith D, Agha A. Familial hypocalciuric hypercalcaemia type 1 caused by a novel heterozygous missense variant in the CaSR gene, p(His41Arg): two case reports. BMC Endocr Disord 2022; 22:324. [PMID: 36536367 PMCID: PMC9761639 DOI: 10.1186/s12902-022-01231-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Familial hypocalciuric hypercalcaemia (FHH) is a rare, inherited disorder of extracellular calcium sensing. It is clinically characterised by mild to moderate parathyroid hormone dependent hypercalcaemia, an autosomal dominant pattern of inheritance, and a normal to reduced urinary calcium excretion in spite of high serum calcium. CASE PRESENTATION We report two cases of FHH in a family caused by a novel pathogenic missense variant in the CaSR gene, p. His41Arg. Case 1, describes a 17 year old female with no significant past medical history, admitted with acute appendicitis requiring laparoscopic appendectomy and reporting a six month history of polydipsia. Routine investigations were significant for hypercalcaemia, corrected calcium 3.19 mmol/L (2.21-2.52mmol/L), elevated parathyroid hormone of 84pg/ml (15-65pg/ml) and a low 24-hour urine calcium of 0.75mmol/24 (2.50-7.50mmol/24). She was initially managed with intravenous fluids and Zolendronic acid with temporary normalisation of calcium though ultimately required commencement of Cinacalcet 30 mg daily for persistent symptomatic hypercalcaemia. Genetic analysis was subsequently positive for the above variant. Case 2, a 50-year-old female, was referred to the endocrine outpatient clinic for the management of type 2 diabetes and reported a longstanding history of asymptomatic hypercalcaemia which had not been investigated previously. Investigation revealed hypercalcaemia; corrected calcium of 2.6 mmol/L (reference range: 2.21-2.52 mmol/L); PTH of 53.7ng/L (reference range: 15-65 ng/L) and an elevated 24-hour urine calcium of 10 mmol/24 (2.50-7.50 mmol/24hr) with positive genetic analysis and is managed conservatively. Despite sharing this novel mutation, these cases have different phenotypes and their natural history is yet to be determined. Two further relatives are currently undergoing investigation for hypercalcaemia and the family have been referred for genetic counselling. CONCLUSION Accurate diagnosis of FHH and differentiation from classic primary hyperparathyroidism can be challenging, however it is essential to avoid unnecessary investigations and parathyroid surgery. Genetic analysis may be helpful in establishing a diagnosis of FHH in light of the biochemical heterogeneity in this population and overlap with other causes of hypercalcaemia.
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Affiliation(s)
- Aoife Courtney
- Department of Endocrinology and Diabetes Mellitus, Beaumont Hospital/RCSI Medical School, Dublin, Ireland.
| | - Arnold Hill
- Department of General Surgery, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - Diarmuid Smith
- Department of Endocrinology and Diabetes Mellitus, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - Amar Agha
- Department of Endocrinology and Diabetes Mellitus, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
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Familial Hypocalciuric Hypercalcemia and Primary Hyperparathyroidism in the Same Patient. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03346-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Palmieri S, Grassi G, Guarnieri V, Chiodini I, Arosio M, Eller-Vainicher C. Case Report: Unusual Presentations of Loss-of-Function Mutations of the Calcium-Sensing Receptor. Front Med (Lausanne) 2022; 8:809067. [PMID: 35141253 PMCID: PMC8818680 DOI: 10.3389/fmed.2021.809067] [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: 11/04/2021] [Accepted: 12/21/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundIn recent years, heterozygous loss-of-function mutations of the Calcium Sensing Receptor gene (CaSR) were implicated in different hypercalcemic syndromes besides familial hypocalciuric hypercalcemia (FHH), including neonatal severe primary hyperparathyroidism (NSHPT) and primary hyperparathyroidism (PHPT).Cases presentationHere we describe two unusual presentations of heterozygous inactivating CaSR mutations. Case 1: a case of NSHPT due to a de novo, p.(ArgR185Gln) CaSR mutation and successfully treated with cinacalcet monotherapy for 8 years until definitive surgical resolution. Case 2: a 37 years-old woman with PHPT complicated with hypercalcemia and nephrocalcinosis with a novel heterozygous p.(Pro393Arg) CaSR mutation and cured with parathyroidectomy.ConclusionsThese cases reinforce the fact that the clinical spectrum of inactivating mutations of the CaSR has widened and, although carrying a mutation suggestive of FHH, some patients may have different clinical phenotypes and complications requiring individualized therapies.
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Affiliation(s)
- Serena Palmieri
- Unit of Endocrinology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda—Ospedale Maggiore Policlinico, Milan, Italy
- *Correspondence: Serena Palmieri
| | - Giorgia Grassi
- Unit of Endocrinology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | - Vito Guarnieri
- Division of Medical Genetics, Fondazione IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Milan, Italy
| | - Iacopo Chiodini
- Department of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy
- Departments of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Maura Arosio
- Unit of Endocrinology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda—Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Cristina Eller-Vainicher
- Unit of Endocrinology, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda—Ospedale Maggiore Policlinico, Milan, Italy
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Performance of the pro-FHH score in a delayed diagnosis of familial hypocalciuric hypercalcemia type-1. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2021. [DOI: 10.1016/j.jecr.2021.100093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Marstrand SD, Tofteng CL, Jarløv A, Borgwardt L, Schwarz P. Concomitant familial hypocalciuric hypercalcemia and single parathyroid adenoma: a case report. J Med Case Rep 2021; 15:471. [PMID: 34556169 PMCID: PMC8461853 DOI: 10.1186/s13256-021-03051-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/06/2021] [Indexed: 12/30/2022] Open
Abstract
Background Primary hyperparathyroidism (PHPT) is a common endocrine disorder and the most frequent benign cause of hypercalcemia. PHPT is characterized by autonomous hypersecretion of parathyroid hormone (PTH), regardless of serum calcium levels. Familial hypocalciuric hypercalcemia (FHH) is a rare, benign syndrome only affecting the regulation of calcium metabolism. FHH is an autosomal-dominant genetic disease with high penetrance, caused by an inactivating variant in the CASR gene encoding the calcium-sensing receptor (CaSR). We present a unique case of concomitant PHPT and FHH without clinically actionable variants in MEN1. Case presentation A 47-year-old Caucasian man with severe hypercalcemia, genetic FHH, and initially normal parathyroid scintigraphy was referred for endocrine evaluation due to nonspecific symptoms. Biochemical evaluation showed elevated serum ionized calcium and PTH. The calcium–creatinine clearance ratio was low. All other biochemical measures were normal, including kidney function. Genetic evaluation was redone and confirmed FHH. A new parathyroid scintigraphy showed a significant single adenoma corresponding to the lower left gland. The patient underwent parathyroidectomy, and a parathyroid adenoma was removed. A reduced level of hypercalcemia persisted due to FHH. Conclusions The correct diagnosis of the underlying cause of hypercalcemia is important to ensure the right treatment. Patients with FHH should avoid operative treatment, and PHPT should be differentiated from MEN1 to determine whether surgery should include parathyroidectomy with removal of one adenoma or 3.5 hyperplastic parathyroid glands.
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Affiliation(s)
| | | | - Anne Jarløv
- Department of Endocrinology & Diabetes and Bone-metabolic Research Unit, Rigshospitalet, Copenhagen, Denmark
| | - Line Borgwardt
- Center for Genomic Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Peter Schwarz
- Department of Endocrinology & Diabetes and Bone-metabolic Research Unit, Rigshospitalet, Copenhagen, Denmark. .,Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark. .,Department of Endocrinology, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
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Mariathasan S, Andrews KA, Thompson E, Challis BG, Wilcox S, Pierce H, Hale J, Spiden S, Fuller G, Simpson HL, Fish B, Jani P, Seetho I, Armstrong R, Izatt L, Joshi M, Velusamy A, Park SM, Casey RT. Genetic testing for hereditary hyperparathyroidism and familial hypocalciuric hypercalcaemia in a large UK cohort. Clin Endocrinol (Oxf) 2020; 93:409-418. [PMID: 32430905 DOI: 10.1111/cen.14254] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/29/2020] [Accepted: 05/10/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Primary hyperparathyroidism (PHPTH) is a common endocrine disorder and an estimated 10% of cases are hereditary, related to syndromes including; multiple endocrine neoplasia (MEN) type 1, MEN type 4, MEN2A and hereditary hyperparathyroidism-jaw tumour syndrome. Establishing the underlying genetic cause for PHPTH allows for personalized and cost-effective management. Familial hypocalicuric hypercalcaemia (FHH) is a benign disorder of hypercalcaemia associated with an inappropriately low urinary calcium excretion, which is quantified by the calcium creatinine clearance ratio (CCCR). Recent NHS England National Genomic Test Directory testing criteria for familial hyperparathyroidism state testing patients presenting with PHPTH and CCCR > 0.02 presenting (i) <35 years of age, or (ii) <45y with one of (a) multiglandular disease, or (b) hyperplasia on histology, or (c) ossifying fibroma(s) of the maxilla and/ or mandible, or (d) a family history of unexplained PHPTH. The testing criterion for FHH is a CCCR < 0.02. AIMS AND METHODS A retrospective review of patients referred for genetic testing over a 4 year period for suspected hereditary HPTH was performed. Genetic analysis was performed by next-generation sequencing of the following genes; MEN1, CDC73, CASR, CDKN1A, CDKN1B, CDKN2B, CDKN2C, RET, GCM2, GNA11, and AP2S1 in NHS-accredited Regional Genetic laboratories. Aims of this study were to better define testing criteria for suspected hereditary PHPTH in a UK cohort. RESULTS A total of 121 patients were included in this study (92 female) with a mean age of 41 years (SD 17). A pathogenic germline variant was identified in 16% (n = 19). A pathogenic variant was identified in the PHPTH genes CDC73 in a single patient and MEN1 in six patients (6% of total), in the FHH genes, CASR in 11 patients and AP2S1 in a single paediatric case (10% of total). A variant of uncertain significance (VUS) was identified in eight patients (6%) but over the course of this study familial segregation studies and computational analysis enabled re-classification of four of the variants, with two VUS's in the CASR gene being upgraded to likely pathogenic variants. Age at diagnosis and multiglandular disease as sole risk factors were not predictive of a pathogenic germline variant in this cohort but a positive family history was strongly predictive (P = .0002). A significant difference in the mean calcium creatinine clearance ratio (CCCR) in those patients with an identified CASR pathogenic variant versus those without (P = .0001) was demonstrated in this study. Thirty-three patients were aged over 50 years and the diagnostic rate of a pathogenic variant was 15.1% in those patients >50 years of age compared to 15.9% in those <50 years. Five patients >50 years and with a CCCR of <0.01, were diagnosed with a pathogenic variant in CASR. CONCLUSION Family history was the strongest predictor of hereditary PHPTH in this cohort. This study has highlighted the importance of re-evaluating VUS's in order to inform patient management and enable appropriate genetic counselling. Finally, this study has demonstrated the need to consider genetic testing for PHPTH in patients of any age, particularly those with additional risk factors.
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Affiliation(s)
- Sashi Mariathasan
- Department of Endocrinology, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Katrina A Andrews
- Department of Clinical Genetics, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Edward Thompson
- East Midlands and East of England NHS Genomic Laboratory Hub, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Ben G Challis
- Department of Endocrinology, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Translational Science & Experimental Medicine, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Sarah Wilcox
- Department of Clinical Genetics, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Heather Pierce
- Department of Clinical Genetics, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Julia Hale
- Department of Endocrinology, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Sarah Spiden
- East Midlands and East of England NHS Genomic Laboratory Hub, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Gavin Fuller
- East Midlands and East of England NHS Genomic Laboratory Hub, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Helen L Simpson
- Department of Endocrinology, University College Hospital, London, UK
| | - Brian Fish
- Department of Head and Neck Surgery, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Piyush Jani
- Department of Head and Neck Surgery, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Ian Seetho
- Department of Endocrinology, Northwick Park Hospital, London North West University Hospital NHS Trust, London, UK
| | - Ruth Armstrong
- Department of Clinical Genetics, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Louise Izatt
- Department of Clinical Genetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mamta Joshi
- Department of Endocrinology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Anand Velusamy
- Department of Endocrinology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Soo-Mi Park
- Department of Clinical Genetics, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Ruth T Casey
- Department of Endocrinology, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Department of Medical Genetics, Cambridge University, Cambridge, UK
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Mouly C, Vargas-Poussou R, Lienhardt A, Silve C, Hureaux M, Magdelaine C, Buffet A, Grunenwald S, Kuhn JM, Brue T, Reznik Y, Tabarin A, Martin-Coignard D, Haymann JP, Tack I, Bennet A, Caron P, Linglart A, Vezzosi D. Clinical characteristics of familial hypocalciuric hypercalcaemia type 1: A multicentre study of 77 adult patients. Clin Endocrinol (Oxf) 2020; 93:248-260. [PMID: 32347971 DOI: 10.1111/cen.14211] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/17/2020] [Accepted: 03/31/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Familial hypocalciuric hypercalcaemia type 1 (FHH1), related to heterozygous loss-of-function mutations of the calcium-sensing receptor gene, is the main differential diagnosis for primary hyperparathyroidism. The aim of our study was to describe clinical characteristics of adult patients living in France with a genetically confirmed FHH1. DESIGN AND PATIENTS This observational, retrospective, multicentre study included 77 adults, followed up in 32 clinical departments in France, with a genetic FHH1 diagnosis between 2001 and 2012. RESULTS Hypercalcaemia was diagnosed at a median age of 53 years [IQR: 38-61]. The diagnosis was made after clinical manifestations, routine analysis or familial screening in 56, 34 and 10% of cases, respectively, (n = 58; data not available for 19 patients). Chondrocalcinosis was present in 11/51 patients (22%), bone fractures in 8/56 (14%) and renal colic in 6/55 (11%). The median serum calcium was 2.74 mmol/L [IQR: 2.63-2.86 mmol/L], the median plasma parathyroid hormone level was 4.9 pmol/L [3.1-7.1], and the median 24-hour urinary calcium excretion was 2.8 mmol/24 hours [IQR: 1.9-4.0]. Osteoporosis (dual X-ray absorptiometry) or kidney stones (renal ultrasonography) were found in 6/38 patients (16%) and 9/32 patients (28%), respectively. Fourteen patients (18%) underwent parathyroid surgery; parathyroid adenoma was found in three patients (21%) and parathyroid hyperplasia in nine patients (64%). No correlation between genotype and phenotype was established. CONCLUSION This large cohort study demonstrates that FHH1 clinical characteristics can be atypical in 33 patients (43%). Clinicians should be aware of this rare differential diagnosis in order to adopt an appropriate treatment strategy.
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Affiliation(s)
- Céline Mouly
- Department of Endocrinology, Larrey Hospital, CardioMet Institute, University Hospital Centre of Toulouse, Toulouse, France
| | | | - Anne Lienhardt
- Department of Medical Paediatrics, University Hospital Centre of Limoges, Limoges, France
| | - Caroline Silve
- Department of Molecular Biochemistry and Genetics, Cochin Hospital, Paris, France
| | - Marguerite Hureaux
- Department of Genetics, European Hospital Georges Pompidou, Paris, France
| | - Corinne Magdelaine
- Department of Molecular Genetic Biochemistry, University Hospital Centre of Limoges, Limoges, France
| | - Alexandre Buffet
- Department of Endocrinology, Larrey Hospital, CardioMet Institute, University Hospital Centre of Toulouse, Toulouse, France
| | - Solange Grunenwald
- Department of Endocrinology, Larrey Hospital, CardioMet Institute, University Hospital Centre of Toulouse, Toulouse, France
| | - Jean-Marc Kuhn
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Hospital Centre of Rouen, Rouen, France
| | - Thierry Brue
- Department of Endocrinology, Diabetes and Metabolic Disorders, University Hospital Centre of Marseille, Marseille, France
| | - Yves Reznik
- Department of Endocrinology-Diabetology, University Hospital Centre of Caen, Caen, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetology, Metabolic Diseases and Nutrition, University Hospital Centre of Bordeaux, Bordeaux, France
| | | | | | - Ivan Tack
- Department of Physiological Function Tests, University Hospital Centre of Toulouse, Toulouse, France
| | - Antoine Bennet
- Department of Endocrinology, Larrey Hospital, CardioMet Institute, University Hospital Centre of Toulouse, Toulouse, France
| | - Philippe Caron
- Department of Endocrinology, Larrey Hospital, CardioMet Institute, University Hospital Centre of Toulouse, Toulouse, France
| | - Agnès Linglart
- Department of Paediatric Endocrinology, Diabetology and Severe Obesity, Bicêtre Hospital, Paris, France
| | - Delphine Vezzosi
- Department of Endocrinology, Larrey Hospital, CardioMet Institute, University Hospital Centre of Toulouse, Toulouse, France
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Sharma A, Bahowairath F, Uduku C, Ostberg JE. Double jeopardy: a patient's tale of two concurrent hypercalcaemic syndromes. BMJ Case Rep 2020; 13:13/8/e237036. [PMID: 32843465 DOI: 10.1136/bcr-2020-237036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Primary hyperparathyroidism (PHPT) is the most common cause of parathyroid hormone (PTH) dependent hypercalcaemia, however there are few reported cases of its co-occurrence in patients with familial hypocalciuric hypercalcaemia (FHH). This case highlights the challenges in managing a rare case of dual pathology. A 49-year-old Caucasian woman with symptoms of hypercalcaemia presented with an adjusted serum calcium of 2.77 mmol/L and PTH of 11.5 pmol/L. Neck ultrasound and sestamibi scan were concordant with a left lower parathyroid adenoma, and a preoperative dual-energy X-ray absorptiometry scan confirmed osteopenia. Parathyroidectomy resulted in a PTH reduction from 11.5 pmol/L to 2.7 pmol/L. Interestingly, her lowest pre-operative adjusted serum calcium of 2.67 mmol/L remained unchanged 14 months post-parathyroidectomy. Twenty-four hours urine calcium:creatinine clearance ratio performed postoperatively was low and sequencing analysis of the calcium-sensing receptor gene confirmed the coexistence of FHH. Although surgery is not indicated in FHH, parathyroidectomy may help reduce hypercalcaemia and its associated complications if there is coexistent PHPT.
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Affiliation(s)
- Aditi Sharma
- Section of Investigative Medicine, Imperial College London, London, UK
| | - Fatima Bahowairath
- Deaprtment of Endocrine and Diabetes, Watford General Hospital, Watford, Hertfordshire, UK
| | - Chukwuma Uduku
- Section of Investigative Medicine, Imperial College London, London, UK
| | - Julia E Ostberg
- Deaprtment of Endocrine and Diabetes, Watford General Hospital, Watford, Hertfordshire, UK
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Madhavan P, Van Do TH, Bale A, Majumdar S. A NOVEL MUTATION IN CALCIUM-SENSING RECEPTOR PRESENTING AS FAMILIAL HYPOCALCIURIC HYPERCALCEMIA IN A YOUNG MAN. AACE Clin Case Rep 2020; 5:e226-e229. [PMID: 31967040 DOI: 10.4158/accr-2018-0236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 01/20/2019] [Indexed: 12/28/2022] Open
Abstract
Objective Familial hypocalciuric hypercalcemia (FHH) is considered a relatively benign condition characterized by elevated serum calcium with relatively low urinary calcium excretion. It typically results from an altered set point in calcium homeostasis originating from mutations in the calcium-sensing receptor (CASR), AP2S1, or GNA11 genes, which encode for the calcium-sensing receptor (CaSR), adaptor-related protein complex 2, and G-protein alpha-11 subunit, respectively. Despite numerous reports of novel variants in these genes associated with FHH, new variants continue to be discovered. Methods We describe a 20-year-old man with a family history of hypercalcemia who had clinical findings compatible with FHH and no evidence of multiple endocrine neoplasia who underwent CASR gene sequencing for evaluation of hypercalcemia. Parathyroid gland single-photon emission computerized tomography scan was normal. Results CASR gene sequencing revealed a previously unreported heterozygous intronic variant at position 1608+3A>G (chromosome 3: 121994892) resulting in a 77-residue deletion. His mother has a history of bipolar disorder and hyperparathyroidism with an adenoma found on imaging, yet our patient had no evidence of adenoma and therefore no surgical intervention was recommended. Given that CaSR plays a role in parathyroid growth, some variants in CASR may ultimately lead to parathyroid hypertrophy and be mistaken for primary hyperparathyroidism. Conclusion Long-term clinical follow up will be helpful in understanding the ultimate effects of specific CASR mutations on parathyroid growth or progression to significant hypercalcemia.
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Abstract
A genetic disorder should be suspected in patients with hypercalcemia, notably those who are young; have family members with hypercalcemia; or have had a tumor of the endocrine pancreas, thyroid, pituitary, adrenal gland, or jaw bone. All forms of hypercalcemia should be interpreted according to the serum level of parathyroid hormone (PTH). Genetic forms are thus classified as related or unrelated to a parathyroid gland disorder. When the PTH level is elevated or is not depressed despite the hypercalcemia, findings that suggest family history of hypercalcemia due to a genetic cause include syndromic manifestations in the patient or family members, parathyroid cancer (either suspected before surgery or confirmed during parathyroidectomy), multiple or recurrent parathyroid tumors, a family history of primary hyperparathyroidism, and the onset of primary hyperthyroidism before 50 years of age. In patients with moderate hypercalcemia, a normal PTH level, and relative hypocalciuria, the first hypothesis is a mutation in the calcium-sensing receptor gene, which is often difficult to distinguish from primary hyperparathyroidism, particularly when there is no known family history of hyperparathyroidism, as is often the case. A low PTH level suggests non-parathyroid hypercalcemia due to a genetic defect in patients with no evidence of other conditions associated with hypercalcemia and low PTH levels and in those whose calcitriol levels are elevated or normal (instead of depressed as expected when PTH is elevated). Patients with hypercalciuria but no evidence of conditions such as granulomatous diseases should be evaluated for increased vitamin D sensitivity due to a CYP 4A1 mutation. Other very rare causes include hypophosphatasia due to ALPL mutations, which is characterized by a low alkaline phosphatase level; and renal phosphate wasting due to an NPT2A mutation, in which serum phosphate levels are low. A thorough analysis of the clinical and laboratory data can point toward a genetic disorder in patients with hypercalcemia. The diagnosis is then confirmed by obtaining genetic tests tailored to the clinical and laboratory test abnormalities. The current development of diagnostic genetic testing is shedding new light on the phenotypes, thereby improving their management.
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Affiliation(s)
- Catherine Cormier
- Hôpital Cochin assistance publique, hôpitaux de Paris, 27, rue du faubourg Saint-Jacques, 75014 Paris, France.
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Kay S, Piltin M, Loseva V, Sinnott B, Brennan J, Mehrotra S, Terris D. Collision Diagnoses: Primary Hyperparathyroidism Layered on Familial Hypocalciuric Hypercalcemia. AACE Clin Case Rep 2018. [DOI: 10.4158/accr-2018-0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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12
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Bertocchio JP, Tafflet M, Koumakis E, Maruani G, Vargas-Poussou R, Silve C, Nissen PH, Baron S, Prot-Bertoye C, Courbebaisse M, Souberbielle JC, Rejnmark L, Cormier C, Houillier P. Pro-FHH: A Risk Equation to Facilitate the Diagnosis of Parathyroid-Related Hypercalcemia. J Clin Endocrinol Metab 2018; 103:2534-2542. [PMID: 29727008 DOI: 10.1210/jc.2017-02773] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 04/27/2018] [Indexed: 02/13/2023]
Abstract
CONTEXT Parathyroid-related hypercalcemia is due to primary hyperparathyroidism (PHPT) or to familial hypocalciuric hypercalcemia (FHH). PHPT can lead to complications that necessitate parathyroidectomy. FHH is a rare genetic disease resembling PHPT; surgery is ineffective. A reliable method for distinguishing FHH from PHPT is needed. OBJECTIVE To develop an easy-to-use tool to predict if a patient has PHPT. DESIGN Retrospective analysis of two prospective cohorts. Development of an unsupervised risk equation (Pro-FHH). SETTING University hospitals in Paris, France, and Aarhus, Denmark. PARTICIPANTS Patients (Paris: 65 with FHH, 85 with PHPT; Aarhus: 38 with FHH, 55 with PHPT) were adults with hypercalcemia and PTH concentration within normal range. MAIN OUTCOME MEASURES Performance of Pro-FHH to predict PHPT. RESULTS Pro-FHH takes into account plasma calcium, PTH, and serum osteocalcin concentrations, and calcium-to-creatinine clearance ratio calculated from 24-hour urine collection (24h-CCCR). In the Paris cohort, area under the receiver operating characteristic curve (AUROC) of Pro-FHH was 0.961, higher than that of 24h-CCCR. With a cutoff value of 0.928, Pro-FHH had 100% specificity and 100% positive predictive value for the diagnosis of PHPT; it correctly categorized 51 of 85 patients with PHPT; the remaining 34 were recommended to undergo genetic testing. No patients with FHH were wrongly categorized. In an independent cohort from Aarhus, AUROC of Pro-FHH was 0.951, higher than that of 24h-CCCR. CONCLUSION Pro-FHH effectively predicted whether a patient has PHPT. A prospective trial is necessary to assess its usefulness in a larger population and in patients with elevated PTH concentration.
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Affiliation(s)
- Jean-Philippe Bertocchio
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Département de Physiologie, Paris, France
- Université Paris Descartes, Faculté de Médecine, Paris, France
- Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte, Paris, France
- INSERM, UMRS1138, Centre de Recherche des Cordeliers, Paris, France
| | - Muriel Tafflet
- INSERM, U970, Paris Cardiovascular Research Center, University Paris Descartes, Sorbonne Paris Cité, UMR-S970, Paris, France
| | - Eugénie Koumakis
- Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Service de Rhumatologie, Paris, France
| | - Gérard Maruani
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Département de Physiologie, Paris, France
- Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte, Paris, France
- Assistance Publique-Hôpitaux de Paris, Institut Necker-Enfants Malades, INSERM U1151 -CNRS UMR 8253, Paris, France
| | - Rosa Vargas-Poussou
- Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte, Paris, France
- INSERM, UMRS1138, Centre de Recherche des Cordeliers, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France
| | - Caroline Silve
- Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Biochimie et Génétique Moléculaires, Paris, France
- INSERM, U1169, Université Paris Sud, Hôpital Bicêtre, Le Kremlin Bicêtre, France
- Centre de Référence des Maladies Rares du Métabolisme du Phosphore et du Calcium Filière de Santé Maladies Rares OSCAR, Paris, France
| | - Peter H Nissen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus N, Denmark
| | - Stéphanie Baron
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Département de Physiologie, Paris, France
- Université Paris Descartes, Faculté de Médecine, Paris, France
- Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte, Paris, France
| | - Caroline Prot-Bertoye
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Département de Physiologie, Paris, France
- Université Paris Descartes, Faculté de Médecine, Paris, France
- Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte, Paris, France
- INSERM, UMRS1138, Centre de Recherche des Cordeliers, Paris, France
| | - Marie Courbebaisse
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Département de Physiologie, Paris, France
- Université Paris Descartes, Faculté de Médecine, Paris, France
- Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte, Paris, France
- Assistance Publique-Hôpitaux de Paris, Institut Necker-Enfants Malades, INSERM U1151 -CNRS UMR 8253, Paris, France
| | - Jean-Claude Souberbielle
- Assistance Publique-Hôpitaux de Paris, Institut Necker-Enfants Malades, Laboratoires d'Explorations Fonctionnelles, Paris, France
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, THG, Aarhus University Hospital, Aarhus C, Aarhus, Denmark
| | - Catherine Cormier
- Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Service de Rhumatologie, Paris, France
| | - Pascal Houillier
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Département de Physiologie, Paris, France
- Université Paris Descartes, Faculté de Médecine, Paris, France
- Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte, Paris, France
- INSERM, UMRS1138, Centre de Recherche des Cordeliers, Paris, France
- CNRS, ERL8228, Paris, France
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Vahe C, Benomar K, Espiard S, Coppin L, Jannin A, Odou MF, Vantyghem MC. Diseases associated with calcium-sensing receptor. Orphanet J Rare Dis 2017; 12:19. [PMID: 28122587 PMCID: PMC5264458 DOI: 10.1186/s13023-017-0570-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/13/2017] [Indexed: 12/29/2022] Open
Abstract
The calcium-sensing receptor (CaSR) plays a pivotal role in systemic calcium metabolism by regulating parathyroid hormone secretion and urinary calcium excretion. The diseases caused by an abnormality of the CaSR are genetically determined or are more rarely acquired. The genetic diseases consist of hyper- or hypocalcemia disorders. Hypercalcaemia disorders are related to inactivating mutations of the CASR gene either heterozygous (autosomal dominant familial benign hypercalcaemia, still named hypocalciuric hypercalcaemia syndrome type 1) or homozygous (severe neonatal hyperparathyroidism). The A986S, R990G and Q1011E variants of the CASR gene are associated with higher serum calcium levels than in the general population, hypercalciuria being also associated with the R990G variant. The differential diagnosis consists in the hypocalciuric hypercalcaemia syndrome, types 2 (involving GNA11 gene) and 3 (involving AP2S1 gene); hyperparathyroidism; abnormalities of vitamin D metabolism, involving CYP24A1 and SLC34A1 genes; and reduced GFR. Hypocalcemia disorders, which are more rare, are related to heterozygous activating mutations of the CASR gene (type 1), consisting of autosomal dominant hypocalcemia disorders, sometimes with a presentation of pseudo-Bartter’s syndrome. The differential diagnosis consists of the hypercalciuric hypocalcaemia syndrome type 2, involving GNA11 gene and other hypoparathyroidism aetiologies. The acquired diseases are related to the presence of anti-CaSR antibodies, which can cause hyper- or especially hypocalcemia disorders (for instance in APECED syndromes), determined by their functionality. Finally, the role of CaSR in digestive, respiratory, cardiovascular and neoplastic diseases is gradually coming to light, providing new therapeutic possibilities. Two types of CaSR modulators are known: CaSR agonists (or activators, still named calcimimetics) and calcilytic antagonists (or inhibitors of the CasR). CaSR agonists, such as cinacalcet, are indicated in secondary and primary hyperparathyroidism. Calcilytics have no efficacy in osteoporosis, but could be useful in the treatment of hypercalciuric hypocalcaemia syndromes.
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Affiliation(s)
- C Vahe
- Service d'Endocrinologie et Métabolisme, Hôpital C Huriez Centre Hospitalo-universitaire de Lille, 1 rue Polonovski, 59 037, Lille Cedex, France
| | - K Benomar
- Service d'Endocrinologie et Métabolisme, Hôpital C Huriez Centre Hospitalo-universitaire de Lille, 1 rue Polonovski, 59 037, Lille Cedex, France
| | - S Espiard
- Service d'Endocrinologie et Métabolisme, Hôpital C Huriez Centre Hospitalo-universitaire de Lille, 1 rue Polonovski, 59 037, Lille Cedex, France
| | - L Coppin
- Service de Biochimie et Biologie Moléculaire, Centre de Biologie-Pathologie, Centre Hospitalo-universitaire de Lille, 1 rue Polonovski, 59 037, Lille Cedex, France
| | - A Jannin
- Service d'Endocrinologie et Métabolisme, Hôpital C Huriez Centre Hospitalo-universitaire de Lille, 1 rue Polonovski, 59 037, Lille Cedex, France
| | - M F Odou
- Service de Biochimie et Biologie Moléculaire, Centre de Biologie-Pathologie, Centre Hospitalo-universitaire de Lille, 1 rue Polonovski, 59 037, Lille Cedex, France
| | - M C Vantyghem
- Service d'Endocrinologie et Métabolisme, Hôpital C Huriez Centre Hospitalo-universitaire de Lille, 1 rue Polonovski, 59 037, Lille Cedex, France. .,Equipe INSERM 1190 Prise en charge translationnelle du diabète, Lille Cedex, France. .,Institut EGID (European Genomic Institute for Diabetes), Lille Cedex, France.
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Hovden S, Jespersen ML, Nissen PH, Poulsen PL, Rolighed L, Ladefoged SA, Rejnmark L. Multiple endocrine neoplasia phenocopy revealed as a co-occurring neuroendocrine tumor and familial hypocalciuric hypercalcemia type 3. Clin Case Rep 2016; 4:922-927. [PMID: 27761240 PMCID: PMC5054464 DOI: 10.1002/ccr3.657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 07/11/2016] [Indexed: 11/26/2022] Open
Abstract
Familial hypocalciuric hypercalcemia type 3 should be considered as differential diagnosis in patients with suspected primary hyperparathyroidism and/or suspected multiple neoplasia syndrome, as correct diagnosis will spare the patients for going through multiple futile parathyroidectomies and for the worry of being diagnosed with a cancer susceptibility syndrome.
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Affiliation(s)
- Silje Hovden
- Department of Clinical Biochemistry Aarhus University Hospital Aarhus Denmark
| | | | - Peter H Nissen
- Department of Clinical Biochemistry Aarhus University Hospital Aarhus Denmark
| | - Per Løgstrup Poulsen
- Department of Endocrinology and Internal Medicine Aarhus University Hospital Aarhus Denmark
| | - Lars Rolighed
- Department of Surgery Aarhus University Hospital Aarhus Denmark
| | - Søren A Ladefoged
- Department of Clinical Biochemistry Aarhus University Hospital Aarhus Denmark
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine Aarhus University Hospital Aarhus Denmark
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Abstract
Five syndromes share predominantly hyperplastic glands with a primary excess of hormones: neonatal severe primary hyperparathyroidism, from homozygous mutated CASR, begins severely in utero; congenital non-autoimmune thyrotoxicosis, from mutated TSHR, varies from severe with fetal onset to mild with adult onset; familial male-limited precocious puberty, from mutated LHR, expresses testosterone oversecretion in young boys; hereditary ovarian hyperstimulation syndrome, from mutated FSHR, expresses symptomatic systemic vascular permeabilities during pregnancy; and familial hyperaldosteronism type IIIA, from mutated KCNJ5, presents in young children with hypertension and hypokalemia. The grouping of these five syndromes highlights predominant hyperplasia as a stable tissue endpoint and as their tissue stage for all of the hormone excess. Comparisons were made among this and two other groups of syndromes, forming a continuum of gland staging: predominant oversecretions express little or no hyperplasia; predominant hyperplasias express little or no neoplasia; and predominant neoplasias express nodules, adenomas, or cancers. Hyperplasias may progress (5 of 5) to neoplastic stages while predominant oversecretions rarely do (1 of 6; frequencies differ P<0.02). Hyperplasias do not show tumor multiplicity (0 of 5) unlike neoplasias that do (13 of 19; P<0.02). Hyperplasias express mutation of a plasma membrane-bound sensor (5 of 5), while neoplasias rarely do (3 of 14; P<0.002). In conclusion, the multiple distinguishing themes within the hyperplasias establish a robust pathophysiology. It has the shared and novel feature of mutant sensors in the plasma membrane, suggesting that these are major contributors to hyperplasia.
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Affiliation(s)
- Stephen J Marx
- Genetics and Endocrinology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Building 10, Room 9C-103, Bethesda, Maryland 20892, USA
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Duan K, Gomez Hernandez K, Mete O. Clinicopathological correlates of hyperparathyroidism. J Clin Pathol 2015; 68:771-87. [PMID: 26163537 DOI: 10.1136/jclinpath-2015-203186] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 06/20/2015] [Indexed: 12/21/2022]
Abstract
Hyperparathyroidism is a common endocrine disorder with potential complications on the skeletal, renal, neurocognitive and cardiovascular systems. While most cases (95%) occur sporadically, about 5% are associated with a hereditary syndrome: multiple endocrine neoplasia syndromes (MEN-1, MEN-2A, MEN-4), hyperparathyroidism-jaw tumour syndrome (HPT-JT), familial hypocalciuric hypercalcaemia (FHH-1, FHH-2, FHH-3), familial hypercalciuric hypercalcaemia, neonatal severe hyperparathyroidism and isolated familial hyperparathyroidism. Recently, molecular mechanisms underlying possible tumour suppressor genes (MEN1, CDC73/HRPT2, CDKIs, APC, SFRPs, GSK3β, RASSF1A, HIC1, RIZ1, WT1, CaSR, GNA11, AP2S1) and proto-oncogenes (CCND1/PRAD1, RET, ZFX, CTNNB1, EZH2) have been uncovered in the pathogenesis of hyperparathyroidism. While bi-allelic inactivation of CDC73/HRPT2 seems unique to parathyroid malignancy, aberrant activation of cyclin D1 and Wnt/β-catenin signalling has been reported in benign and malignant parathyroid tumours. Clinicopathological correlates of primary hyperparathyroidism include parathyroid adenoma (80-85%), hyperplasia (10-15%) and carcinoma (<1-5%). Secondary hyperparathyroidism generally presents with diffuse parathyroid hyperplasia, whereas tertiary hyperparathyroidism reflects the emergence of autonomous parathyroid hormone (PTH)-producing neoplasm(s) from secondary parathyroid hyperplasia. Surgical resection of abnormal parathyroid tissue remains the only curative treatment in primary hyperparathyroidism, and parathyroidectomy specimens are frequently encountered in this setting. Clinical and biochemical features, including intraoperative PTH levels, number, weight and size of the affected parathyroid gland(s), are crucial parameters to consider when rendering an accurate diagnosis of parathyroid proliferations. This review provides an update on the expanding knowledge of hyperparathyroidism and highlights the clinicopathological correlations of this prevalent disease.
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Affiliation(s)
- Kai Duan
- Department of Pathology, University Health Network, Toronto, Ontario, Canada Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Karen Gomez Hernandez
- Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, Ontario, Canada Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Ozgur Mete
- Department of Pathology, University Health Network, Toronto, Ontario, Canada Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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18
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Genetic evaluation in primary hyperparathyroidism: What investigation? For which patients? ANNALES D'ENDOCRINOLOGIE 2015; 76:142-4. [PMID: 25935325 DOI: 10.1016/j.ando.2015.03.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 03/27/2015] [Indexed: 11/21/2022]
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Abstract
CONTEXT Most syndromes with benign primary excess of a hormone show positive coupling of hormone secretion to size or proliferation in the affected hormone secretory tissue. Syndromes that lack this coupling seem rare and have not been examined for unifying features among each other. EVIDENCE ACQUISITION Selected clinical and basic features were analyzed from original reports and reviews. We examined indices of excess secretion of a hormone and indices of size of secretory tissue within the following three syndromes, each suggestive of uncoupling between these two indices: familial hypocalciuric hypercalcemia, congenital diazoxide-resistant hyperinsulinism, and congenital primary hyperaldosteronism type III (with G151E mutation of the KCNJ5 gene). EVIDENCE SYNTHESIS Some unifying features among the three syndromes were different from features present among common tumors secreting the same hormone. The unifying and distinguishing features included: 1) expression of hormone excess as early as the first days of life; 2) normal size of tissue that oversecretes a hormone; 3) diffuse histologic expression in the hormonal tissue; 4) resistance to treatment by subtotal ablation of the hormone-secreting tissue; 5) causation by a germline mutation; 6) low potential of the same mutation to cause a tumor by somatic mutation; and 7) expression of the mutated molecule in a pathway between sensing of a serum metabolite and secretion of hormone regulating that metabolite. CONCLUSION Some shared clinical and basic features of uncoupling of secretion from size in a hormonal tissue characterize three uncommon states of hormone excess. These features differ importantly from features of common hormonal neoplasm of that tissue.
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Affiliation(s)
- Stephen J Marx
- Genetics and Endocrinology Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
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20
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Forde HE, Hill AD, Smith D. Parathyroid adenoma in a patient with familial hypocalciuric hypercalcaemia. BMJ Case Rep 2014; 2014:bcr-2014-206473. [PMID: 25320261 DOI: 10.1136/bcr-2014-206473] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 57-year-old man with symptoms of fatigue, joint pains and insomnia was found to have hypercalcaemia secondary to hyperparathyroidism with a corrected calcium of 2.61 mmol/L (2.2-2.6 mmol/L) and a serum parathyroid hormone (PTH) of 86 pg/mL (10-65 pg/mL). Preoperative workup demonstrated a parathyroid adenoma in the right upper position and he proceeded to surgery. Postoperatively, however, his symptoms remained unchanged and the corrected calcium remained elevated at 2.87 mmol/L with a PTH of 59 pg/mL. He had no family history of hypercalcaemia. Further investigations revealed low 24 h urinary calcium level and a low urine calcium to creatinine ratio. Genetic testing revealed a mutation in exon 4 of the calcium sensing receptor (CaSR) confirming a diagnosis of familial hypocalciuric hyercalcaemia (FHH). The case is an example of a rare phenomenon when a parathyroid adenoma develops in patients with FHH.
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Affiliation(s)
| | - Arnold D Hill
- Department of Surgery, Beaumont/RCSI, Dublin 9, Ireland
| | - Diarmuid Smith
- Department of Surgery, Beaumont Hospital, Dublin, Ireland
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Kim DDW, Que L, Raizis AM, Florkowski CM. Novel inactivating mutation of the calcium-sensing receptor in a young woman with mild hypercalcaemia. Intern Med J 2014; 44:413-6. [PMID: 24754691 DOI: 10.1111/imj.12383] [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: 08/06/2013] [Accepted: 11/24/2013] [Indexed: 11/30/2022]
Abstract
A young woman with mild hypercalcaemia and an inappropriately normal serum parathyroid hormone had parathyroid scintigraphy suggestive of an active ectopic parathyroid tissue in the superior mediastinum. Urinary calcium to creatinine clearance ratio was low, and a subsequent genetic analysis confirmed a novel mutation (Q164K) in the calcium sensing receptor gene, consistent with familial hypocalciuric hypercalcaemia. We propose that this mutation accounts for her clinical and investigational findings, although a double pathology of Q164K and an ectopic parathyroid adenoma is also conceivable.
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Affiliation(s)
- D D W Kim
- Department of Endocrinology and Diabetes, Waitemata District Health Board, Auckland, New Zealand
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22
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Egan AM, Ryan J, Aziz MA, O'Dwyer TP, Byrne MM. Primary hyperparathyroidism in a patient with familial hypocalciuric hypercalcaemia due to a novel mutation in the calcium-sensing receptor gene. J Bone Miner Metab 2013; 31:477-80. [PMID: 23081733 DOI: 10.1007/s00774-012-0399-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Accepted: 10/01/2012] [Indexed: 10/27/2022]
Abstract
We describe the clinical and genetic findings in pedigree with a novel mutation in the calcium sensing receptor (CaSR) gene and the unusual coexistence of primary hyperparathyroidism (HPT) and familial hypocalciuric hypercalcaemia (FHH) and its clinical management. The occurrence of both FHH and primary HPT in the same patient has been described rarely. Our pedigree has a novel mutation in the CaSR gene. Parathyroidectomy led to a reduction, but not normalization of the calcium levels in the patient identified as having HPT. The coexistence of HPT and FHH was considered in this patient as her calcium and PTH levels were rising with time. Surgical resection of her parathyroid adenoma resulted in reduction of her calcium levels to above normal and significant reduction in her symptoms of fatigue and low mood.
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Affiliation(s)
- Aoife M Egan
- Department of Endocrinology, Mater Misericordiae University Hospital, Dublin, Ireland.
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23
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Hannan FM, Thakker RV. Calcium-sensing receptor (CaSR) mutations and disorders of calcium, electrolyte and water metabolism. Best Pract Res Clin Endocrinol Metab 2013; 27:359-71. [PMID: 23856265 DOI: 10.1016/j.beem.2013.04.007] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The extracellular calcium-sensing receptor (CaSR) is a family C G-protein-coupled receptor (GPCR) that is expressed at multiple sites, including the parathyroids and kidneys. The human CASR gene, located on chromosome 3q21.1, encodes a 1078 amino acid protein. More than 230 different disease-causing mutations of the CaSR have been reported. Loss-of-function mutations lead to three hypercalcemic disorders, which are familial hypocalciuric hypercalcemia (FHH), neonatal severe hyperparathyroidism and primary hyperparathyroidism. Gain-of-function mutations, on the other hand, result in the hypocalcemic disorders of autosomal dominant hypocalcemia and Bartter syndrome type V. Moreover, autoantibodies directed against the extracellular domain of the CaSR have been found to be associated with FHH in some patients, and also in some patients with hypoparathyroidism that may be part of autoimmune polyglandular syndrome type 1. Studies of disease-causing CASR mutations have provided insights into structure-function relationships and highlighted intra-molecular domains that are critical for ligand binding, intracellular signaling, and receptor trafficking.
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Affiliation(s)
- Fadil M Hannan
- Academic Endocrine Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Nuffield Department of Clinical Medicine, University of Oxford, Churchill Hospital, Oxford OX3 7LJ, UK.
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Roizen J, Levine MA. Primary hyperparathyroidism in children and adolescents. J Chin Med Assoc 2012; 75:425-34. [PMID: 22989537 PMCID: PMC3710287 DOI: 10.1016/j.jcma.2012.06.012] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 06/07/2012] [Indexed: 11/20/2022] Open
Abstract
Primary hyperparathyroidism (PHPT) is a common endocrine disorder in adults in whom the typical presentation is incidentally discovered as asymptomatic hypercalcemia. PHPT is much less common in children and adolescents, but has greater morbidity in this age group, as most young patients with PHPT will have symptomatic hypercalcemia or complications such as kidney stones, abdominal pain, and skeletal fragility. An important feature of PHPT in younger patients is the relatively high prevalence of germline inactivating mutations of the CASR gene, which encodes the calcium-sensing receptor. Biallelic CASR mutations cause neonatal severe hyperparathyroidism, a life-threatening condition that presents within days of life with marked hypercalcemia, respiratory distress, failure to thrive, and skeletal demineralization. By contrast, more common heterozygous CASR mutations are generally associated with a benign variant of PHPT termed familial hypocalciuric hypercalcemia. Appropriate management of PHPT in children and adolescents requires distinction between familial hypocalciuric hypercalcemia, which generally requires no specific treatment, and other forms of PHPT that are best treated by parathyroidectomy.
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Affiliation(s)
- Jeffrey Roizen
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael A. Levine
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Corresponding author. Dr. Michael A. Levine, Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, 34 and Civic Center Boulevard, Philadelphia, PA 19104, USA. (M.A. Levine)
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Christensen SE, Nissen PH, Vestergaard P, Mosekilde L. Familial hypocalciuric hypercalcaemia: a review. Curr Opin Endocrinol Diabetes Obes 2011; 18:359-70. [PMID: 21986511 DOI: 10.1097/med.0b013e32834c3c7c] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Hypercalcaemia is a potentially life-threatening condition. Familial hypocalciuric hypercalcaemia (FHH) is a rare, lifelong, benign condition. It is important to separate this condition from other hypercalcaemic states such as hypercalcaemia of malignancy and primary hyperparathyroidism (PHPT). RECENT FINDINGS FHH is caused by inactivating mutations in the calcium sensing receptor (CASR) gene leading to a general calcium-hyposensitivity, compensatory hypercalcaemia and hypocalciuria. The inheritance of FHH is autosomal dominant. Similar to PHPT, FHH is characterized by hypercalcaemia, unsuppressed or elevated plasma parathyroid hormone, and typically normal renal function. The phenotype is normal, and hypercalcaemic symptoms are generally absent. The hallmark is a relatively low urine calcium excretion in contrast to PHPT, in which urine calcium excretion is increased. The vitamin D status as measured by plasma 25-hydroxyvitamin D has been reported to be normal with normal seasonal variations, whereas plasma 1,25-dihydroxyvitamin D has been found slightly increased compared to normal. Bone mineral density Z-scores are normal in spite of a slightly increased bone turnover. Differential diagnoses include mainly PHPT, but in some cases also hypercalcaemia of malignancy and use of thiazide diuretics. SUMMARY In general, FHH does not require treatment. We recommend a two-step diagnostic procedure. First, the calcium/creatinine clearance ratio is measured from a 24-h urine. Second, all patients with calcium/creatinine clearance ratio of 0.020 or less are tested for mutations in the CASR gene. The diagnostic sensitivity of this setup is 98%.
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Affiliation(s)
- Signe E Christensen
- Department of Medicine and Endocrinology, Aarhus University Hospital, Aarhus C, Denmark.
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Livadariu E, Auriemma RS, Rydlewski C, Vandeva S, Hamoir E, Burlacu MC, Maweja S, Thonnard AS, Betea D, Vassart G, Daly AF, Beckers A. Mutations of calcium-sensing receptor gene: two novel mutations and overview of impact on calcium homeostasis. Eur J Endocrinol 2011; 165:353-8. [PMID: 21566074 DOI: 10.1530/eje-11-0121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Genetic disorders of calcium metabolism arise in a familial or sporadic setting. The calcium-sensing receptor (CASR) plays a key role in maintaining calcium homeostasis and study of the CASR gene can be clinically useful in determining etiology and appropriate therapeutic approaches. We report two cases of novel CASR gene mutations that illustrate the varying clinical presentations and discuss these in terms of the current understanding of CASR function. PATIENTS AND METHODS A 16-year-old patient had mild hypercalcemia associated with low-normal urinary calcium excretion and normal-to-high parathyroid hormone (PTH) levels. Because of negative family history, familial hypocalciuric hypercalcemia was originally excluded. The second patient was a 54-year-old man with symptomatic hypocalcemia, hyperphosphatemia, low PTH, and mild hypercalciuria. Familial investigation revealed the same phenotype in the patient's sister. The coding region of the CASR gene was sequenced in both probands and their available first-degree relatives. RESULTS The first patient had a novel heterozygous inactivating CASR mutation in exon 4, which predicted a p.A423K change; genetic analysis was negative in the parents. The second patient had a novel heterozygous activating CASR mutation in exon 6, which predicted a p.E556K change; the affected sister of the proband was also positive. CONCLUSIONS We reported two novel heterozygous mutations of the CASR gene, an inactivating mutation in exon 4 and the first activating mutation reported to date in exon 6. These cases illustrate the importance of genetic testing of CASR gene to aid correct diagnosis and to assist in clinical management.
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Affiliation(s)
- Elena Livadariu
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, University of Liège, 4000 Liège, Belgium
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Frank-Raue K, Leidig-Bruckner G, Haag C, Schulze E, Lorenz A, Schmitz-Winnenthal H, Raue F. Inactivating calcium-sensing receptor mutations in patients with primary hyperparathyroidism. Clin Endocrinol (Oxf) 2011; 75:50-5. [PMID: 21521328 DOI: 10.1111/j.1365-2265.2011.04059.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Primary hyperparathyroidism (HPT) is characterised by autonomous secretion of PTH from enlarged parathyroid glands leading, in most patients, to asymptomatic hypercalcaemia. Familial hypocalciuric hypercalcaemia (FHH) is an autosomal dominant disorder caused by inactivating mutations in the calcium-sensing receptor (CaSR) gene; it is characterised by lifelong and usually asymptomatic hypercalcaemia. Establishing the correct diagnosis is important because surgery can be curative in HPT, but ineffective in FHH. There is overlap in the diagnostic criteria for the two disorders and some patients carrying inactivating mutations in the CaSR gene, which is suggestive of FHH, also have HPT with hyperplastic parathyroid glands or adenomas. DESIGN AND PATIENTS CaSR gene mutations were analysed and clinical and biochemical parameters evaluated in 139 consecutive outpatients presenting with hypercalcaemia and suspected of having HPT. RESULTS Six different mutations of the CaSR gene were found in eight patients. In four patients, classical FHH was suspected based on clinical and biochemical results and was confirmed by the CaSR mutations. In the other four patients, HPT was diagnosed based on the biochemical profile or symptoms; in these four patients, the parathyroids were operated on and single adenomas were histologically confirmed. In all four patients, serum calcium decreased postoperatively; and in three patients, serum calcium normalised postoperatively. The CaSR mutations in these patients were R25X, E250K and Q926R. CONCLUSION The coexistence of HPT and FHH in four of 139 patients suggests a pathogenetic role of CaSR mutations in HPT. Despite also having a CaSR mutation, these patients benefited from parathyroid surgery.
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Affiliation(s)
- Karin Frank-Raue
- Endocrine Practice, Molecular LaboratoryDepartment of Surgery, University of Heidelberg, Heidelberg, Germany
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Fernández López I, Fernández Peña I, Cózar León MV, Viloria Peñas MM, Martínez De Pinillos Gordillo G, Fernández-Ladreda MT, Duran García S. [Usefulness of genetic tests in familial hypocalciuric hypercalcemia with atypical clinical presentation]. ACTA ACUST UNITED AC 2011; 58:325-30. [PMID: 21697018 DOI: 10.1016/j.endonu.2011.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 04/07/2011] [Accepted: 04/17/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Biochemical tests related to calcium and phosphorus metabolism have traditionally been considered as a reliable tool to differentiate familial hypocalciuric hypercalcemia (FHH) from primary hyperparathyroidism (PHPT). However, diagnosis may sometimes be difficult even for experienced clinicians. Our objective was to assess the accuracy of diagnostic tests in FHH and the circumstances in which genetic studies are required. PATIENTS AND METHODS A descriptive study was conducted of two families with hypercalcemia and suspected atypical FHH. Urinary calcium excretion was measured in 24-hour urine using different tests (calcium excretion (CE), urinary calcium/creatinine clearance ratio (UCCR)), and serum PTH and 25-hydroxyvitamin D levels were tested. Index cases underwent genetic study. RESULTS One patient from the first family showed overt, persistent hypercalciuria with values more consistent with PHPT than with FHH if we consider, as proposed by guidelines, a UCCR lower than 0.01 as diagnostic of FHH and a value higher than 0.02 as diagnostic of PHPT. The index case of the second family underwent surgery for a parathyroid adenoma. Both cases had a mutation c. 164C>T (Pro55Leu) in exon 2 in heterozygosis. CONCLUSIONS According to current clinical guidelines, definitive diagnosis of FHH requires genetic confirmation, which allowed in our case for detection of two families with FHH and atypical clinical presentations. We think that rational use of genetic tests may avoid unnecessary surgery and excess monitoring costs.
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Affiliation(s)
- Ignacio Fernández López
- Unidad de Gestión Clínica, Endocrinología y Nutrición, Hospital Universitario Virgen de Valme, Sevilla, España.
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Hannan FM, Nesbit MA, Christie PT, Lissens W, Van der Schueren B, Bex M, Bouillon R, Thakker RV. A homozygous inactivating calcium-sensing receptor mutation, Pro339Thr, is associated with isolated primary hyperparathyroidism: correlation between location of mutations and severity of hypercalcaemia. Clin Endocrinol (Oxf) 2010; 73:715-22. [PMID: 20846291 DOI: 10.1111/j.1365-2265.2010.03870.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Inactivating mutations of the calcium-sensing receptor (CaSR), a G-protein-coupled receptor with extracellular (ECD), transmembrane (TMD) and intracellular (ICD) domains, cause familial hypocalciuric hypercalcaemia, neonatal severe primary hyperparathyroidism and occasionally primary hyperparathyroidism in adults. OBJECTIVE To investigate a patient with typical symptomatic primary hyperparathyroidism for CaSR abnormalities. PATIENT AND DESIGN: A 51-year-old woman with primary hyperparathyroidism was investigated for CaSR abnormalities as her severe hypercalcaemia (3·75 mm) persisted after the removal of two large parathyroid adenomas and she was the daughter of normocalcaemic consanguineous parents. Following informed consent, CASR mutational analysis was undertaken using leucocyte DNA. Wild-type and mutant CaSR constructs were expressed in human embryonic kidney (HEK) 293 cells and assessed by measuring their intracellular calcium responses to changes in extracellular calcium. Clinical data were pooled with previous studies to search for genotype-phenotype correlations. RESULTS The proband was homozygous for a Pro339Thr CaSR missense mutation, located in the ECD, and her normocalcaemic relatives were heterozygous. The mutant Thr339 CaSR had a rightward shift in its dose-response curve with a significantly higher EC(50) = 3·18 mm ± 0·19 compared to the wild-type EC(50) = 2·16 mm ± 0·1 (P < 0·01), consistent with a loss-of-function mutation. An analysis of CaSR mutations in patients with primary hyperparathyroidism revealed that those of the ECD were associated with a significantly greater hypercalcaemia that was less likely to be corrected after removal of the parathyroid tumours. CONCLUSIONS A CaSR missense mutation causing a loss-of-receptor-function can cause symptomatic primary hyperparathyroidism in adulthood.
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Affiliation(s)
- Fadil M Hannan
- Academic Endocrine Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Guarnieri V, Canaff L, Yun FHJ, Scillitani A, Battista C, Muscarella LA, Wong BYL, Notarangelo A, D'Agruma L, Sacco M, Cole DEC, Hendy GN. Calcium-sensing receptor (CASR) mutations in hypercalcemic states: studies from a single endocrine clinic over three years. J Clin Endocrinol Metab 2010; 95:1819-29. [PMID: 20164288 DOI: 10.1210/jc.2008-2430] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
CONTEXT Inactivating mutations of the calcium-sensing receptor (CASR) are implicated in different hypercalcemic syndromes, including familial hypocalciuric hypercalcemia (FHH), primary hyperparathyroidism (PHPT), and familial isolated hyperparathyroidism (FIHP). However, molecular diagnostics applied to large nonselected hypercalcemic cohorts from a single center have not been reported. OBJECTIVE Our objective was to describe the prevalence, type, and potential pathogenicity of CASR mutations in a series of cases with FHH (n = 17), PHPT (n = 165), and FIHP (n = 3) and controls (n = 198) presenting at a single endocrine clinic. SUBJECTS All were prospectively evaluated at the "Casa Sollievo della Sofferenza" Hospital in southern Italy over a 3-yr period. METHODS CASR screening was conducted by denaturing HPLC. The variant CASRs were functionally characterized by transient transfection studies in kidney cells in vitro. RESULTS A single novel missense variant was identified in one PHPT case. However, in FHH probands, mutations were found in eight of 17 (47%). With a hypercalcemic family member, mutation detection rate in FHH rose to seven of eight (87%), whereas only one of nine sporadic cases was positive, and none of the three FIHP cases had detectable CASR mutations. Five missense variant CASRs, identified in control subjects, performed as wild type in functional assays, whereas the missense mutant CASRs identified in the FHH patients, and in the one PHPT case, exhibited significant impairment. A novel intronic mutation (IVS4-19a-->c) found in one FHH family, created an abnormally spliced product in an in vitro minigene assay. CONCLUSION CASR testing, with functional analysis, provides critical confirmatory evidence in the differential diagnosis of hypercalcemic states.
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Affiliation(s)
- Vito Guarnieri
- Departments of Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada M5G 1L5
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