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Shovlin CL, Buscarini E, Sabbà C, Mager HJ, Kjeldsen AD, Pagella F, Sure U, Ugolini S, Torring PM, Suppressa P, Rennie C, Post MC, Patel MC, Nielsen TH, Manfredi G, Lenato GM, Lefroy D, Kariholu U, Jones B, Fialla AD, Eker OF, Dupuis O, Droege F, Coote N, Boccardi E, Alsafi A, Alicante S, Dupuis-Girod S. The European Rare Disease Network for HHT Frameworks for management of hereditary haemorrhagic telangiectasia in general and speciality care. Eur J Med Genet 2022; 65:104370. [PMID: 34737116 DOI: 10.1016/j.ejmg.2021.104370] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/24/2021] [Accepted: 10/26/2021] [Indexed: 12/22/2022]
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a complex, multisystemic vascular dysplasia affecting approximately 85,000 European Citizens. In 2016, eight founding centres operating within 6 countries, set up a working group dedicated to HHT within what became the European Reference Network on Rare Multisystemic Vascular Diseases. By launch, combined experience exceeded 10,000 HHT patients, and Chairs representing 7 separate specialties provided a median of 24 years' experience in HHT. Integrated were expert patients who focused discussions on the patient experience. Following a 2016-2017 survey to capture priorities, and underpinned by more than 40 monthly meetings, and new data acquisitions, VASCERN HHT generated position statements that distinguish expert HHT care from non-expert HHT practice. Leadership was by specialists in the relevant sub-discipline(s), and 100% consensus was required amongst all clinicians before statements were published or disseminated. One major set of outputs targeted all healthcare professionals and their HHT patients, and include the new Orphanet definition; Do's and Don'ts for common situations; Outcome Measures suitable for all consultations; COVID-19; and anticoagulation. The second output set span aspects of vascular pathophysiology where greater understanding will assist organ-specific specialist clinicians to provide more informed care to HHT patients. These cover cerebral vascular malformations and screening; mucocutaneous telangiectasia and differential diagnosis; anti-angiogenic therapies; circulatory interplays between anaemia and arteriovenous malformations; and microbiological strategies to counteract loss of normal pulmonary capillary function. Overall, the integrated outputs, and documented current practices, provide frameworks for approaches that augment the health and safety of HHT patients in diverse health-care settings.
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Affiliation(s)
- C L Shovlin
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK; National Heart and Lung Institute, Imperial College London, UK.
| | - E Buscarini
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy.
| | - C Sabbà
- VASCERN HHT Reference Centre, Centro Sovraziendale Malattie Rare, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Italy.
| | - H J Mager
- VASCERN HHT Reference Centre, St Antonius Ziekenhuis, Nieuwegein, Netherlands.
| | - A D Kjeldsen
- VASCERN HHT Reference Centre, Odense University Hospital, Syddansk Universitet, Odense, Denmark.
| | - F Pagella
- VASCERN HHT Reference Centre, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy.
| | - U Sure
- VASCERN HHT Reference Centre, Essen University Hospital, Essen, Germany; Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany.
| | - S Ugolini
- VASCERN HHT Reference Centre, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy.
| | - P M Torring
- VASCERN HHT Reference Centre, Odense University Hospital, Syddansk Universitet, Odense, Denmark.
| | - P Suppressa
- VASCERN HHT Reference Centre, Centro Sovraziendale Malattie Rare, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Italy.
| | - C Rennie
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - M C Post
- VASCERN HHT Reference Centre, St Antonius Ziekenhuis, Nieuwegein, Netherlands; Department of Cardiology, University Medical Center Utrecht, The Netherlands.
| | - M C Patel
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - T H Nielsen
- VASCERN HHT Reference Centre, Odense University Hospital, Syddansk Universitet, Odense, Denmark.
| | - G Manfredi
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy.
| | - G M Lenato
- VASCERN HHT Reference Centre, Centro Sovraziendale Malattie Rare, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Italy.
| | - D Lefroy
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - U Kariholu
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - B Jones
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - A D Fialla
- VASCERN HHT Reference Centre, Odense University Hospital, Syddansk Universitet, Odense, Denmark.
| | - O F Eker
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France.
| | - O Dupuis
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France.
| | - F Droege
- VASCERN HHT Reference Centre, Essen University Hospital, Essen, Germany; Department of ENT Surgery, University Hospital Essen, Germany.
| | - N Coote
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - E Boccardi
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy; Niguarda Hospital, Milan, Italy.
| | - A Alsafi
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - S Alicante
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy.
| | - S Dupuis-Girod
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France.
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Alsafi A, Shovlin CL, Jackson JE. Transpleural systemic artery-to-pulmonary artery communications in the absence of chronic inflammatory lung disease. A case series and review of the literature. Clin Radiol 2021; 76:711.e9-711.e15. [PMID: 33902886 DOI: 10.1016/j.crad.2021.03.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
AIM To describe the causes and computed tomography (CT) and angiographic appearances of transpleural systemic artery-to-pulmonary artery shunts in patients without chronic inflammatory lung disease and determine their best management. MATERIALS AND METHODS All patients referred to a tertiary referral unit between January 2009 and January 2020 in whom a diagnosis of a systemic-to-pulmonary artery communication without underlying chronic inflammatory lung disease was subsequently made have been included in this report. Medical records and imaging findings were reviewed retrospectively. RESULTS Ten patients (male: female ratio = 7:3; median age 42 years [range 22-70 years]) with systemic artery-to-pulmonary artery shunts without chronic inflammatory lung disease were identified. Five were misdiagnosed as having a pulmonary arteriovenous malformation and had been referred for embolisation. In six patients, there was either a history of accidental or iatrogenic thoracic trauma or of inflammatory disease involving the pleura, and in two patients, in whom a previous medical history could not be obtained, there were CT features suggesting previous pleural inflammatory disease. Two shunts were thought to be congenital. All individuals were asymptomatic other than one with localised thoracic discomfort that dated from the time of surgery. All patients were managed conservatively and have remained well with a median follow-up of 4.5 years (range 1-11.3 years). CONCLUSIONS Localised transpleural systemic artery-to-pulmonary artery shunts in the absence of chronic inflammatory lung disease are usually related to previous thoracic trauma/intervention or abdominal or pulmonary sepsis involving a pleural or diaphragmatic surface. Congenital shunts are rare. The present study and much of the literature supports conservative management.
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Affiliation(s)
- A Alsafi
- Imaging Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS, UK.
| | - C L Shovlin
- Vascular Science, National Heart and Lung Institute, ICTEM, Imperial College London, London, UK; VASCERN HHT European Reference Centre and Respiratory Medicine, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS, UK
| | - J E Jackson
- Imaging Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS, UK
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Gawecki F, Strangeways T, Amin A, Perks J, McKernan H, Thurainatnam S, Rizvi A, Jackson JE, Santhirapala V, Myers J, Brown J, Howard LSGE, Tighe HC, Shovlin CL. Exercise capacity reflects airflow limitation rather than hypoxaemia in patients with pulmonary arteriovenous malformations. QJM 2019; 112:335-342. [PMID: 30657990 DOI: 10.1093/qjmed/hcz023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pulmonary arteriovenous malformations (PAVMs) generate a right-to-left shunt. Impaired gas exchange results in hypoxaemia and impaired CO2 clearance. Most patients compensate effectively but some are dyspneic, and these are rarely the most hypoxaemic. AIM To test degrees of concurrent pathology influencing exercise capacity. DESIGN Replicate, sequential single centre, prospective studies. METHODS Cardiopulmonary exercise tests (CPETs) were performed in 26 patients with PAVMs, including individuals with and without known airflow obstruction. To replicate, relationships were tested prospectively in an independent cohort where self-reported exercise capacity evaluated by the Veterans Specific Activity Questionnaire (VSAQ) was used to calculate metabolic equivalents (METs) at peak exercise (n = 71). Additional measurements included oxygen saturation (SpO2), forced expiratory volume in 1 s (FEV1), vital capacity (VC), fractional exhaled nitric oxide (FeNO), haemoglobin and iron indices. RESULTS By CPET, the peak work rate was only minimally associated with low SpO2 or low arterial oxygen content (calculated as CaO2=1.34 × SpO2 × haemoglobin), but was reduced in patients with low FEV1 or VC. Supranormal work rates were seen in patients with severe right-to-left shunting and SpO2 < 90%, but only if FEV1 was >80% predicted. VSAQ-calculated METS also demonstrated little relationship with SpO2, and in crude and CaO2-adjusted regression, were lower in patients with lower FEV1 or VC. Bronchodilation increased airflow even where spirometry was in the normal range: exhaled nitric oxide measurements were normal in 80% of cases, and unrelated to any PAVM-specific variable. CONCLUSIONS Exercise capacity is reduced by relatively mild airflow limitation (obstructive or restrictive) in the setting of PAVMs.
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Affiliation(s)
- F Gawecki
- School of Medicine, Imperial College, London, UK
| | | | - A Amin
- School of Medicine, Imperial College, London, UK
| | - J Perks
- Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - H McKernan
- Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | | | - A Rizvi
- School of Medicine, Imperial College, London, UK
| | - J E Jackson
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK
| | | | - J Myers
- Cardiology Division, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - J Brown
- Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - L S G E Howard
- Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - H C Tighe
- Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - C L Shovlin
- Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
- NHLI Cardiovascular Sciences, Imperial College, London, UK
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Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a dominantly inherited genetic vascular disorder with an estimated prevalence of 1 in 6,000, characterized by recurrent epistaxis, cutaneous telangiectasia, and arteriovenous malformations (AVMs) that affect many organs including the lungs, gastrointestinal tract, liver, and brain. Its diagnosis is based on the Curaçao criteria, and is considered definite if at least 3 of the 4 following criteria are fulfilled: (1) spontaneous and recurrent epistaxis, (2) telangiectasia, (3) a family history, and (4) pulmonary, liver, cerebral, spinal, or gastrointestinal AVMs. The focus of this review is on delineating how HHT affects the lung.
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Affiliation(s)
- Sophie Dupuis-Girod
- Service de génétique - centre de référence national pour la maladie de Rendu-Osler, Hôpital Femme-Mère-Enfants, Hospices Civils de Lyon, Bron, France
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Patel T, Elphick A, Jackson JE, Shovlin CL. P36 Injections of intravenous contrast for computerised tomography scans precipitate migraines in hereditary haemorrhagic telangiectasia subjects at risk of paradoxical emboli: implications for right-to-left shunt risks. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Boother EJ, Brownlow S, Jackson JE, Shovlin CL. P35 A retrospective observational study designed to characterise individuals with pulmonary Arteriovenous Malformations (PAVMS) and cerebral abscesses at a single institution. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Tighe HC, McKernan H, Springett JT, Babawale L, Perks J, Patel T, Shovlin CL. P33 Patients with pulmonary arteriovenous malformations and hereditary haemorrhagic telangiectasia report forced expiratory manoeuvres during pulmonary function tests provoke nosebleeds and migraines. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Shovlin CL, Hughes JMB, Layton M, Boother E, Allison DJ, Jackson JE. P34 Long term outcomes for patients with pulmonary arteriovenous malformations considered for lung transplantation. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Patel T, Elphick A, Jackson JE, Shovlin CL. S1* Does paradoxical emboli of particulate matter through pulmonary arteriovenous malformations precipitate migraines? Thorax 2015. [DOI: 10.1136/thoraxjnl-2015-207770.7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Shovlin CL, Chamali B, Santhirapala V, Williams L, Jackson JE, Tighe H. S51 Arterial oxygen content reflects haemoglobin more than oxygenation indices in 440 patients with pulmonary arteriovenous malformations. Thorax 2015. [DOI: 10.1136/thoraxjnl-2015-207770.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Hall T, Tighe H, Hornby K, Park M, Santhirapala V, Murphy K, Jackson JE, Howard L, Shovlin CL. S4 Pulmonary Artery Pressure and Exercise Tolerance in Patients with Pulmonary Arteriovenous Malformations. Thorax 2015. [DOI: 10.1136/thoraxjnl-2015-207770.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Rizvi AF, Babawale L, Hughes JMB, Jackson JE, Shovlin CL. S52 The effect of age on arterial oxygen content in patients with pulmonary arteriovenous malformations (PAVMs). Thorax 2015. [DOI: 10.1136/thoraxjnl-2015-207770.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Shovlin CL. Curable hypoxia in an octogenarian with an undiagnosed inherited condition: a case commentary. Breathe (Sheff) 2014. [DOI: 10.1183/20734735.102114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Santhirapala V, Chamali B, McKernan H, Tighe HC, Williams LC, Springett JT, Bellenberg HR, Whitaker AJ, Shovlin CL. Orthodeoxia and postural orthostatic tachycardia in patients with pulmonary arteriovenous malformations: a prospective 8-year series. Thorax 2014; 69:1046-7. [DOI: 10.1136/thoraxjnl-2014-205289] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Hosman AE, Devlin HL, Silva BM, Elphick AH, Shovlin CL. P83 Should children from HHT families undergo screening thoracic CT scans for the diagnosis of pulmonary arteriovenous malformations? Survey data on breast cancer incidence. Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Santhirapala V, Williams LC, Tighe HC, Jackson JE, Shovlin CL. S42 Effect of iron deficiency on oxygen transport in hypoxaemic patients: implications for haemodynamics and clinical management. Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.49] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Santhirapala V, Springett JT, Wolfenden H, Tighe HC, Jackson JE, Shovlin CL. S44 Orthodeoxia, and postural orthostatic tachycardia, in 165 consecutive, unselected patients with pulmonary arteriovenous malformations. Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Santhirapala V, Howard LSG, Murphy K, Mukherjee B, Busbridge M, Tighe HC, Hughes JMB, Jackson JE, Shovlin CL. S43 Dyspnea and exercise capacity are not related to arterial hypoxemia in the absence of alveolar hypoxia: prospective studies in patients with pulmonary arteriovenous malformations. Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Hosman AE, Devlin HL, Silva BM, Elphick AH, Shovlin CL. P9 Epidemiological survey suggests lung cancer is less common in patients with hereditary haemorrhagic telangiectasia compared to controls. Thorax 2013. [DOI: 10.1136/thoraxjnl-2013-204457.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Govani FS, Giess A, Mollet IG, Begbie ME, Jones MD, Game L, Shovlin CL. Directional next-generation RNA sequencing and examination of premature termination codon mutations in endoglin/hereditary haemorrhagic telangiectasia. Mol Syndromol 2013; 4:184-96. [PMID: 23801935 DOI: 10.1159/000350208] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2012] [Indexed: 01/12/2023] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a disease characterised by abnormal vascular structures, and most commonly caused by mutations in ENG, ACVRL1 or SMAD4 encoding endothelial cell-expressed proteins involved in TGF-β superfamily signalling. The majority of mutations reported on the HHT mutation database are predicted to lead to stop codons, either due to frameshifts or direct nonsense substitutions. The proportion is higher for ENG (67%) and SMAD4 (65%) than for ACVRL1 (42%), p < 0.0001. Here, by focussing on ENG, we report why conventional views of these mutations may need to be revised. Of the 111 stop codon-generating ENG mutations, on ExPASy translation, all except one were premature termination codons (PTCs), sited at least 50-55 bp upstream of the final exon-exon boundary of the main endoglin isoform, L-endoglin. This strongly suggests that the mutated RNA species will undergo nonsense-mediated decay. We provide new in vitro expression data to support dominant negative activity of stable truncated endoglin proteins but suggest these will not generate HHT: the single natural stop codon mutation in L-endoglin (sited within 50-55 nucleotides of the final exon-exon boundary) is unlikely to generate functional protein since it replaces the entire transmembrane domain, as would 8 further natural stop codon mutations, if the minor S-endoglin isoform were implicated in HHT pathogenesis. Finally, next-generation RNA sequencing data of 7 different RNA libraries from primary human endothelial cells demonstrate that multiple intronic regions of ENG are transcribed. The potential consequences of heterozygous deletions or duplications of such regions are discussed. These data support the haploinsufficiency model for HHT pathogenesis, explain why final exon mutations have not been detected to date in HHT, emphasise the potential need for functional examination of non-PTC-generating mutations, and lead to proposals for an alternate stratification system of mutational types for HHT genotype-phenotype correlations.
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Affiliation(s)
- F S Govani
- NHLI Cardiovascular Sciences, Hammersmith Campus, Imperial College London, London, UK
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Verkerk MM, Shovlin CL, Lund VJ. Silent threat? A retrospective study of screening practices for pulmonary arteriovenous malformations in patients with hereditary haemorrhagic telangiectasia. Rhinology 2013; 50:277-83. [PMID: 22888484 DOI: 10.4193/rhino12.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Patients with hereditary haemorrhagic telangiectasia (HHT) are at risk of pulmonary arteriovenous malformations (PAVMs) that may be complicated by stroke and brain abscess. ENT surgeons are well placed to direct patients to screening, which was recommended for all HHT patients in recently published international guidelines. METHODOLOGY/PRINCIPAL A retrospective study of patients with known HHT was performed based on responses to a telephone questionnaire. Epistaxis was assessed using a validated epistaxis severity scoring system. RESULTS 123 patients responded, with ages ranging from 14-86 years (mean 57 years). 80% of patients experienced their first symptom of HHT by 30 years old. Epistaxis was assessed at time of questionnaire as mild (26 patients), moderate (52 patients) or severe (45 patients). 71 patients (57.7% of total) underwent screening for PAVMs. 30 patients (42.2% of screened individuals) reported PAVMs detected by screening. 18 patients received treatment and 12 patients were found to have PAVMs too small for treatment. The modal screening method was computed tomography (CT, 58 patients) and the majority of patients with treatable PAVMs received trans-catheter embolisation (15 patients). Only 9 patients reported being under long term follow up for PAVMs. Shortness of breath (70.0% vs 41.5%, p<0.05) and migraine (43.3% vs 24.4%, p<0.05) were more common amongst patients found to have PAVMs than those without PAVMs. There was no difference in age of onset of HHT symptoms or epistaxis severity between patients with PAVMs and those without. CONCLUSIONS PAVMs are common in HHT patients and carry a risk of morbidity and mortality. Safe and effective treatment exists for PAVMs although a significant minority of patients has received no screening to date. Clinicians should refer all patients for screening regardless of symptoms.
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Ahmedzai S, Balfour-Lynn IM, Bewick T, Buchdahl R, Coker RK, Cummin AR, Gradwell DP, Howard L, Innes JA, Johnson AOC, Lim E, Lim WS, McKinlay KP, Partridge MR, Popplestone M, Pozniak A, Robson A, Shovlin CL, Shrikrishna D, Simonds A, Tait P, Thomas M. Managing passengers with stable respiratory disease planning air travel: British Thoracic Society recommendations. Thorax 2011; 66 Suppl 1:i1-30. [PMID: 21856702 DOI: 10.1136/thoraxjnl-2011-200295] [Citation(s) in RCA: 132] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- S Ahmedzai
- School of Medicine and Biomedical Sciences, University of Sheffield, Sheffield, UK
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Shovlin CL, Gibbs JSR, Jackson JE. Management of pulmonary arteriovenous malformations in pulmonary hypertensive patients: a pressure to embolise? Eur Respir Rev 2011; 18:4-6. [PMID: 20956115 DOI: 10.1183/09059180.00011102] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Livesey JA, Jackson JE, Shovlin CL. S99 Multiple regression analyses in a cohort of hereditary haemorrhagic telangiectasia patients suggest a novel role for iron in thrombosis. Thorax 2010. [DOI: 10.1136/thx.2010.150938.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Key NS, DE Paepe A, Malfait F, Shovlin CL. Vascular haemostasis. Haemophilia 2010; 16 Suppl 5:146-51. [PMID: 20590874 DOI: 10.1111/j.1365-2516.2010.02313.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
SUMMARY While the majority of this session will deal with selected inherited vascular abnormalities that may manifest as a haemorrhagic disorder, the initial discussion by Dr Key will focus on the interplay between the vessel wall and components of the coagulation system, with a focus on haemophilia A and B. Although it is generally accepted that physiological haemostasis is triggered by contact of blood with tissue factor (TF), there remains some controversy regarding the cellular origin of TF in vivo. In addition, the initiation and propagation of thrombin generation are highly dependent on the balance of pro- and anticoagulant functions of endothelium, a profile that varies significantly throughout the vasculature. Drs De Paepe and Malfait address heritable collagen disorders such as the Ehlers-Danlos syndromes (EDS), a heterogeneous group of diseases involving the skin, ligaments and joints, blood vessels and internal organs. Most EDS subtypes are caused by mutations in genes encoding fibrillar collagens, or in genes coding for enzymes involved in posttranslational modifications of collagens. Accurate biochemical and molecular testing is now available for most EDS subtypes and can direct genetic counselling and medical management for these disorders. Dr Shovlin reviews recent developments in hereditary haemorrhagic telengiectasia (HHT), a frequently undiagnosed disorder characterized by arteriovenous malformations in multiple organs. These abnormal blood vessels are the result of mutations in one of a number of genes whose protein products influence TGF-beta signalling in vascular endothelial cells. Several HHT management guidelines have been published and are discussed.
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Affiliation(s)
- N S Key
- Harold R Roberts Comprehensive Hemophilia Diagnostic and Treatment Center, University of North Carolina, Chapel Hill, NC, USA.
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Shovlin CL, Sodhi V, McCarthy A, Lasjaunias P, Jackson JE, Sheppard MN. Estimates of maternal risks of pregnancy for women with hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome): suggested approach for obstetric services. BJOG 2008; 115:1108-15. [PMID: 18518871 DOI: 10.1111/j.1471-0528.2008.01786.x] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Hereditary haemorrhagic telangiectasia (HHT) affects 1 in 5-8000 individuals. Pregnancy outcomes are rarely reported. The major reason is that most women do not have their HHT diagnosed prior to pregnancy. Using a large well-characterised series, we studied all pregnancies known to have occurred in HHT-affected women, whether or not their diagnosis was known at the time of pregnancy. Our aim was to estimate rates and types of major complications of HHT in pregnancy, to guide management decisions. DESIGN Cohort study, with prospective, retrospective and familial components. SETTING/POPULATION Tertiary referral centre population. METHODS All 262 pregnancies in the 111 women with HHT and pulmonary arteriovenous malformations (PAVMs) reviewed between 1999 and 2005 were studied. Eighty-two women (74%) did not have a diagnosis of HHT/PAVM at the time of pregnancy. 222 pregnancies in their 86 HHT-affected relatives were also studied. MAIN OUTCOME MEASURES PAVM bleed, stroke and maternal death. RESULTS Thirteen women experienced life-threatening events during pregnancy: 1.0% (95% CI 0.1-1.9) of pregnancies resulted in a major PAVM bleed; 1.2% (0.3-2.2%) in stroke (not all were HHT related); and 1.0% (0.13-1.9%) in maternal death. All deaths occurred in women previously considered well. In women experiencing a life-threatening event, prior awareness of HHT or PAVM diagnosis was associated with improved survival (P = 0.041, Fisher's exact test). CONCLUSIONS Most HHT pregnancies proceed normally. Rare major complications, and improved survival outcome following prior recognition, means that pregnancy in a woman with HHT should be considered high risk. Recommendations for pregnancy management are provided.
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Affiliation(s)
- C L Shovlin
- NHLI Cardiovascular Sciences, Imperial College London, London, UK.
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Shovlin CL, Tighe HC, Davies RJ, Gibbs JSR, Jackson JE. Embolisation of pulmonary arteriovenous malformations: no consistent effect on pulmonary artery pressure. Eur Respir J 2008; 32:162-9. [PMID: 18385173 DOI: 10.1183/09031936.00126207] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Increasing evidence supports the use of embolisation to treat pulmonary arteriovenous malformations (AVMs). Most pulmonary AVM patients have hereditary haemorrhagic telangiectasia (HHT), a condition that may be associated with pulmonary hypertension. The current authors tested whether pulmonary AVM embolisation increases pulmonary artery pressure (P(pa)) in patients without baseline severe pulmonary hypertension. P(pa) was measured at the time of pulmonary AVM embolisation in 143 individuals, 131 (92%) of whom had underlying HHT. Angiography/embolisation was not performed in four individuals with severe pulmonary hypertension, whose systemic arterial oxygen saturation exceeded levels usually associated with dyspnoea in pulmonary AVM patients. In 143 patients undergoing pulmonary AVM embolisation, P(pa) was significantly correlated with age, with the most significant increase occurring in the upper quartile (aged >58 yrs). In 43 patients with repeated measurements, there was no significant increase in P(pa) as a result of embolisation. In half, embolisation led to a fall in P(pa). The maximum rise in mean P(pa) was 8 mmHg: balloon test occlusion was performed in one of these individuals, and did not predict the subsequent rise in P(pa) following definitive embolisation of the pulmonary AVMs. In the present series of patients, which excluded those with severe pulmonary hypertension, pulmonary artery pressure was not increased significantly by pulmonary arteriovenous malformation embolisation.
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Affiliation(s)
- C L Shovlin
- NHLI Cardiovascular Sciences Unit, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 0NN, UK.
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Shovlin CL, Jackson JE, Bamford KB, Jenkins IH, Benjamin AR, Ramadan H, Kulinskaya E. Primary determinants of ischaemic stroke/brain abscess risks are independent of severity of pulmonary arteriovenous malformations in hereditary haemorrhagic telangiectasia. Thorax 2007; 63:259-66. [PMID: 17981912 DOI: 10.1136/thx.2007.087452] [Citation(s) in RCA: 224] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Brain abscesses and ischaemic strokes complicate pulmonary arteriovenous malformations (PAVMs). At risk individuals are poorly recognised. Stroke/abscess risk factors have not been defined. METHODS A cohort study of 323 consecutive individuals with PAVMs (n = 219) and/or the commonly associated condition hereditary haemorrhagic telangiectasia (HHT, n = 305) was performed. Most of the 201 individuals with PAVMs and HHT had no respiratory symptoms, and were unaware they had HHT. Anderson-Gill models assessed constant and time dependent potential predictive variables for stroke/abscess, and rate reduction by PAVM embolisation. RESULTS 57 individuals with PAVMs and HHT experienced brain abscess or ischaemic stroke, usually prior to the diagnosis of underlying PAVMs/HHT. The primary determinants of stroke and abscess risks were unrelated to severity of PAVMs. Males had higher brain abscess rates (hazard ratio 3.61 (95% CI 1.58, 8.25), p = 0.0024); interventional histories and bacteriological isolates suggested dental sources. Once adjusted for gender, there was a marginal association between brain abscess and low oxygen saturation. For ischaemic stroke, there was no association with any marker of PAVM severity, or with conventional neurovascular risk factors. Surprisingly, low mean pulmonary artery pressure was strongly associated with ischaemic stroke (hazard ratio 0.89 (95% CI 0.83, 0.95) per mm Hg increase; p = 6.2x10(-5)). PAVM embolisation significantly reduced ischaemic stroke rate (p = 0.028); no strokes/abscesses occurred following obliteration of all angiographically visible PAVMs. The mean PAVM diagnosis-treatment interval was longer, however, when neurological risks were unrecognised. CONCLUSIONS Ischaemic strokes and brain abscesses occur commonly in undiagnosed HHT patients with PAVMs. Risk reduction could be improved.
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Affiliation(s)
- C L Shovlin
- NHLI Cardiovascular Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK.
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Abstract
Patients with hereditary haemorrhagic telangiectasia (HHT, or Osler-Weber-Rendu syndrome) have variable presentation patterns and a high risk of preventable complications. Diagnostic tests for mutations in endoglin (HHT type 1) and ALK-1 (HHT type 2) are available. Some HHT patients are now known to have HHT-juvenile polyposis overlap syndrome due to Smad4 mutations. Families were ascertained following the presentation of probands for embolization of pulmonary arteriovenous malformations. Genome-wide linkage studies using over 700 polymorphic markers, and sequencing of candidate genes, were performed. In a previously described HHT family unlinked to endoglin or ALK-1, linkage to Smad4 was excluded, and no mutations were identified in the endoglin, ALK-1, or Smad4 genes. Two point LOD scores and recombination mapping identified a 5.4 cM HHT3 disease gene interval on chromosome 5 in which a single haplotype was inherited by all affected members of the pedigree. The remainder of the genome was excluded to a 2-5 cM resolution. We are currently studying a further family potentially linked to HHT3. We conclude that classical HHT with pulmonary involvement can result from mutations in an unidentified gene on chromosome 5. Identification of HHT3 should further illuminate HHT pathogenic mechanisms in which aberrant transforming growth factor (TGF)-beta signalling is implicated.
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Affiliation(s)
- S G Cole
- The Eric Bywaters Centre, Respiratory Section, National Heart and Lung Institute, Imperial College Faculty of Medicine, Hammersmith Hospital, London W12 ONN, UK
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Easey AJ, Wallace GMF, Hughes JMB, Jackson JE, Taylor WJ, Shovlin CL. Should asymptomatic patients with hereditary haemorrhagic telangiectasia (HHT) be screened for cerebral vascular malformations? Data from 22,061 years of HHT patient life. J Neurol Neurosurg Psychiatry 2003; 74:743-8. [PMID: 12754343 PMCID: PMC1738468 DOI: 10.1136/jnnp.74.6.743] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND The frequency of haemorrhage in individuals with hereditary haemorrhagic telangiectasia (HHT), 10% of whom will have cerebral arteriovenous (AV) malformations, could be high enough to justify screening. This would allow presymptomatic treatment to prevent early onset stroke in a condition that affects at least 1 in 8000 individuals. This is an important issue in view of the contrast between transatlantic management approaches, the worldwide dissemination of patient information, and the ethical implications of the diagnosis for the untreated patient. OBJECTIVES To define the annual incidence of haemorrhagic stroke in individuals with HHT. METHODS Retrospective study on stroke incidence in individuals with HHT and their immediate families (n = 674; 22,061 HHT patient years), specifically analysing patients under 46 years of age (17,515 patient years). The results were compared with stroke risk in the general population. RESULTS In the majority of cases, the haemorrhage was the first significant neurological event. Overcorrecting for any bias towards overestimation that would be introduced in excluding non-penetrant family members, cerebral haemorrhages were more than 20 times more common in male HHT subjects under the age of 45 years than in the general population (standardised ratio 22.99; 95% confidence interval, 13.14 to 37.33). Haemorrhages were also six times more common in female HHT subjects (6.18; 2.27 to 13.45). The incidence ratio of cerebral haemorrhage in male patients (1.84; 1.05 to 2.99) yielded a haemorrhage rate in individuals with cerebral AV malformations of 1.4-2.0% per annum, comparable to figures in the non-HHT cerebral AV malformation population. CONCLUSIONS These data contradict accepted wisdom in many countries that asymptomatic HHT patients are at a low (and acceptable) risk of haemorrhage. The data justify a more aggressive screening approach to identify small causative lesions amenable to treatment.
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Affiliation(s)
- A J Easey
- HHT Programme, Hammersmith Hospital Trust and Imperial College Faculty of Medicine, London W12, UK
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Abstract
Hereditary haemorrhagic telangiectasia (HHT) affects one in 5-8000, and no longer can be viewed as solely causing anaemia (due to nasal and gastrointestinal bleeding) and characteristic mucocutaneous telangiectasia. Arteriovenous malformations commonly occur, and in the pulmonary and cerebral circulations demand knowledge of risks and benefits of asymptomatic screening and treatment. HHT is inherited as an autosomal dominant trait and there is no age cut off when apparently unaffected offspring of an individual with HHT can be told they are unaffected. This review focuses on the evolving evidence base for HHT management, issues regarding pregnancy and prothrombotic treatments, and discusses the molecular and cellular changes that underlie this disease.
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Affiliation(s)
- M E Begbie
- Respiratory Medicine, National Heart and Lung Institute, Imperial College Faculty of Medicine, Hammersmith Hospital, London, UK
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Gupta P, Mordin C, Curtis J, Hughes JMB, Shovlin CL, Jackson JE. Pulmonary arteriovenous malformations: effect of embolization on right-to-left shunt, hypoxemia, and exercise tolerance in 66 patients. AJR Am J Roentgenol 2002; 179:347-55. [PMID: 12130431 DOI: 10.2214/ajr.179.2.1790347] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This study assessed the effect and safety of percutaneous transcatheter coil embolization of pulmonary arteriovenous malformations. MATERIALS AND METHODS In 58 (88%) of 66 patients, all malformations with feeding vessels greater than or equal to 3 mm in diameter were embolized with steel coils. Arterial oxygen saturation at rest and exercise, intrapulmonary right-to-left anatomic shunt fraction ((99m)Tc-macroaggregate injection), maximum exercise capacity (incremental work rate test), and pulmonary function were measured before and after embolization. Complications were analyzed. RESULTS Three categories of patients were identified. Patients in group 1 (27%) had complete occlusion of all angiographically visible pulmonary arteriovenous malformations; patients in group 2 (61%) had complete occlusion of all malformations with feeding vessels greater than or equal to 3 mm in diameter, but with smaller lesions persisting; and patients in group 3 (12%) had incomplete embolization, with feeding vessels greater than or equal to 3 mm in diameter remaining. The mean right-to-left shunt after embolization was least in group 1 (7%), intermediate in group 2 (10%), and greatest in group 3 (19%). Arterial oxygen saturation and right-to-left shunt fraction returned to normal levels (>96% and <3.5%, respectively) in 33% of patients. A significant improvement occurred after embolization in carbon monoxide diffusing capacity per unit of alveolar volume and in exercise capacity in 16 and 10 patients, respectively. In 93 procedures, 12 complications (13%) occurred. CONCLUSION Coil embolization of pulmonary arteriovenous malformations is effective in reducing right-to-left anatomic shunt fraction and in improving arterial oxygenation. Coil embolization of pulmonary arteriovenous malformations is well tolerated and has a low complication rate.
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Affiliation(s)
- P Gupta
- Department of Imaging, Imperial College Faculty of Medicine, Hammersmith Hospital, Du Cane Rd., London W12 0NN, England
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Whittle AT, Davis M, Shovlin CL, Ganly PS, Haslett C, Greening AP. Alveolar macrophage activity and the pulmonary complications of haematopoietic stem cell transplantation. Thorax 2001; 56:941-6. [PMID: 11713357 PMCID: PMC1745976 DOI: 10.1136/thorax.56.12.941] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The success of haematopoietic (bone marrow or peripheral blood) stem cell transplantation (SCT) is compromised by pulmonary complications. We hypothesised that a proinflammatory alveolar microenvironment, reflected in alveolar macrophage (AM) cytokine production, would predispose to such complications. METHODS AM were isolated from adult SCT recipients by bronchoalveolar lavage before SCT (n=32) and during post-transplant pancytopenia (n=23). Concentrations of tumour necrosis factor (TNF)alpha, granulocyte-macrophage colony stimulating factor (GM-CSF), interleukin (IL)-1 beta, IL-6, and IL-8 in 24 hour AM culture medium were measured by enzyme linked immunosorbent assay and compared with both the occurrence of post-SCT lung disease and with subjects' previous respiratory histories. RESULTS Eleven subjects developed lung disease within 6 months of SCT. These subjects had higher median pre-transplant AM TNFalpha (8 (IQR 1-8) v 2 (1-5) ng/10(6)AM, p=0.01, median difference (D) = 3, 95% CI 0.1 to 7), GM-CSF (5 (0.7-8) v 0.2 (0.1-0.8), p=0.006, D = 4, 95% CI 0.5 to 7), and IL-6 (0.5 (0.1-1) v 0.1 (0.02-0.3), p=0.049, D = 0.3, 95% CI 0.0002 to 1) production than remaining subjects; IL-1 beta and IL-8 did not differ. During pancytopenia high AM GM-CSF production again predicted later lung disease (1 (0.7-9) v 0.1 (0.06-0.3), p=0.01, D = 1, 95% CI 0.1 to 6). A history of recent chest disease was associated with high AM TNFalpha and GM-CSF production and with post-SCT lung disease. Pre-SCT lung function was unrelated to post-SCT lung disease. CONCLUSIONS Recent respiratory disease and persistent proinflammatory AM behaviour detectable before transplantation are associated with lung disease following SCT. These associations may prove useful in pre-transplant risk assessment.
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Affiliation(s)
- A T Whittle
- Department of Respiratory Medicine, Royal Perth Hospital, Perth, Western Australia.
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Affiliation(s)
- M R Wilkins
- Imperial College School of Medicine, Hammersmith Hospital, London, UK
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Abstract
BACKGROUND Pulmonary arteriovenous malformations (PAVMs) occur in over 25% of patients with the autosomal dominant disorder hereditary haemorrhagic telangiectasia (HHT). Mutations in two genes, endoglin and ALK-1, are known to cause HHT. Each encodes a protein expressed on vascular endothelial cells and involved in signalling by members of the transforming growth factor (TGF)-beta superfamily. To date, PAVMs have not been detected in ALK-1 families. There is evidence from a single HHT family without pulmonary involvement that a third HHT gene may exist. To establish the existence of a further HHT gene responsible for PAVMs, linkage analyses were performed on an expanded PAVM-HHT family in which HHT did not result from endoglin mutations. METHODS Family members were assessed clinically to assign HHT disease status and were screened for PAVMs. DNA was extracted from blood obtained from 20 individuals of known disease status. Short tandem repeat polymorphic markers spanning the intervals containing the endoglin and ALK-1 genes were amplified by the polymerase chain reaction using (33)P-labelled oligonucleotide primers, separated by denaturing polyacrylamide gel electrophoresis (PAGE), and the resultant autoradiographs were examined for allele sizes. Linkage analyses were performed using MLINK and GENEHUNTER. RESULTS Twelve members spanning four generations were affected with HHT. Two had proven PAVMs, one with a classical appearance, the other exhibiting microscopic PAVMs exacerbated by pregnancy. Two point lod and multipoint lod scores significantly excluded linkage to endoglin and ALK-1 in this pedigree. CONCLUSIONS This study confirms the existence of a third HHT locus that accounts for disease in some HHT patients with pulmonary involvement.
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Affiliation(s)
- G M Wallace
- Rayne Laboratories, Respiratory Medicine, University of Edinburgh, Edinburgh, UK
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Abstract
SUMMARY In the last decade there have been fundamental advances in our understanding of the pathogenesis of vascular malformations. These advances have resulted from the application of molecular methods to identify disease genes, rather than from immunohistochemical or physiological studies. This presentation reviews the genetic basis of a variety of cerebral vascular malformations which occur as part of well-characterised diseases inherited in an autosomal dominant manner. These highlight the diversity of mechanisms which can perturb vascular development, and should have significant implications for the development of new therapies.
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Affiliation(s)
- C L Shovlin
- Imperial College School of Medicine, National Heart and Lung Institute, Hammersmith Hospital, London, England -
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Shovlin CL, Guttmacher AE, Buscarini E, Faughnan ME, Hyland RH, Westermann CJ, Kjeldsen AD, Plauchu H. Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Am J Med Genet 2000. [PMID: 10751092 DOI: 10.1002/(sici)1096-8628(20000306)91:1<66::aid-ajmg12>3.0.co;2-p] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Hereditary Hemorrhagic Telangiectasia (HHT) is easily recognized in individuals displaying the classical triad of epistaxis, telangiectasia, and a suitable family history, but the disease is more difficult to diagnosis in many patients. Serious consequences may result if visceral arteriovenous malformations, particularly in the pulmonary circulation, are unrecognized and left untreated. In spite of the identification of two of the disease-causing genes (endoglin and ALK-1), only a clinical diagnosis of HHT can be provided for the majority of individuals. On behalf of the Scientific Advisory Board of the HHT Foundation International, Inc., we present consensus clinical diagnostic criteria. The four criteria (epistaxes, telangiectasia, visceral lesions and an appropriate family history) are carefully delineated. The HHT diagnosis is definite if three criteria are present. A diagnosis of HHT cannot be established in patients with only two criteria, but should be recorded as possible or suspected to maintain a high index of clinical suspicion. If fewer than two criteria are present, HHT is unlikely, although children of affected individuals should be considered at risk in view of age-related penetration in this disorder. These criteria may be refined as molecular diagnostic tests become available in the next few years.
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Affiliation(s)
- C L Shovlin
- Respiratory Medicine, National Heart and Lung Institute, Imperial College School of Medicine, Hammersmith Hospital, London, UK
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Shovlin CL, Guttmacher AE, Buscarini E, Faughnan ME, Hyland RH, Westermann CJ, Kjeldsen AD, Plauchu H. Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Am J Med Genet 2000. [PMID: 10751092 DOI: 10.1002/(sici)1096-8628(20000306)91] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Hereditary Hemorrhagic Telangiectasia (HHT) is easily recognized in individuals displaying the classical triad of epistaxis, telangiectasia, and a suitable family history, but the disease is more difficult to diagnosis in many patients. Serious consequences may result if visceral arteriovenous malformations, particularly in the pulmonary circulation, are unrecognized and left untreated. In spite of the identification of two of the disease-causing genes (endoglin and ALK-1), only a clinical diagnosis of HHT can be provided for the majority of individuals. On behalf of the Scientific Advisory Board of the HHT Foundation International, Inc., we present consensus clinical diagnostic criteria. The four criteria (epistaxes, telangiectasia, visceral lesions and an appropriate family history) are carefully delineated. The HHT diagnosis is definite if three criteria are present. A diagnosis of HHT cannot be established in patients with only two criteria, but should be recorded as possible or suspected to maintain a high index of clinical suspicion. If fewer than two criteria are present, HHT is unlikely, although children of affected individuals should be considered at risk in view of age-related penetration in this disorder. These criteria may be refined as molecular diagnostic tests become available in the next few years.
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Affiliation(s)
- C L Shovlin
- Respiratory Medicine, National Heart and Lung Institute, Imperial College School of Medicine, Hammersmith Hospital, London, UK
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Shovlin CL, Guttmacher AE, Buscarini E, Faughnan ME, Hyland RH, Westermann CJ, Kjeldsen AD, Plauchu H. Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Am J Med Genet 2000. [PMID: 10751092 DOI: 10.1002/(sici)1096-8628(20000306)91:] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hereditary Hemorrhagic Telangiectasia (HHT) is easily recognized in individuals displaying the classical triad of epistaxis, telangiectasia, and a suitable family history, but the disease is more difficult to diagnosis in many patients. Serious consequences may result if visceral arteriovenous malformations, particularly in the pulmonary circulation, are unrecognized and left untreated. In spite of the identification of two of the disease-causing genes (endoglin and ALK-1), only a clinical diagnosis of HHT can be provided for the majority of individuals. On behalf of the Scientific Advisory Board of the HHT Foundation International, Inc., we present consensus clinical diagnostic criteria. The four criteria (epistaxes, telangiectasia, visceral lesions and an appropriate family history) are carefully delineated. The HHT diagnosis is definite if three criteria are present. A diagnosis of HHT cannot be established in patients with only two criteria, but should be recorded as possible or suspected to maintain a high index of clinical suspicion. If fewer than two criteria are present, HHT is unlikely, although children of affected individuals should be considered at risk in view of age-related penetration in this disorder. These criteria may be refined as molecular diagnostic tests become available in the next few years.
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Affiliation(s)
- C L Shovlin
- Respiratory Medicine, National Heart and Lung Institute, Imperial College School of Medicine, Hammersmith Hospital, London, UK
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Shovlin CL, Guttmacher AE, Buscarini E, Faughnan ME, Hyland RH, Westermann CJ, Kjeldsen AD, Plauchu H. Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Am J Med Genet 2000. [PMID: 10751092 DOI: 10.1002/(sici)1096-8628(20000306)91: 1<66: : aid-ajmg12>3.0.co; 2-p] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hereditary Hemorrhagic Telangiectasia (HHT) is easily recognized in individuals displaying the classical triad of epistaxis, telangiectasia, and a suitable family history, but the disease is more difficult to diagnosis in many patients. Serious consequences may result if visceral arteriovenous malformations, particularly in the pulmonary circulation, are unrecognized and left untreated. In spite of the identification of two of the disease-causing genes (endoglin and ALK-1), only a clinical diagnosis of HHT can be provided for the majority of individuals. On behalf of the Scientific Advisory Board of the HHT Foundation International, Inc., we present consensus clinical diagnostic criteria. The four criteria (epistaxes, telangiectasia, visceral lesions and an appropriate family history) are carefully delineated. The HHT diagnosis is definite if three criteria are present. A diagnosis of HHT cannot be established in patients with only two criteria, but should be recorded as possible or suspected to maintain a high index of clinical suspicion. If fewer than two criteria are present, HHT is unlikely, although children of affected individuals should be considered at risk in view of age-related penetration in this disorder. These criteria may be refined as molecular diagnostic tests become available in the next few years.
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Affiliation(s)
- C L Shovlin
- Respiratory Medicine, National Heart and Lung Institute, Imperial College School of Medicine, Hammersmith Hospital, London, UK
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Shovlin CL, Guttmacher AE, Buscarini E, Faughnan ME, Hyland RH, Westermann CJ, Kjeldsen AD, Plauchu H. Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Am J Med Genet 2000; 91:66-67. [PMID: 10751092 DOI: 10.1002/(sici)1096-8628(20000306)91:1%3c66::aid-ajmg12%3e3.0.co;2-p] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Hereditary Hemorrhagic Telangiectasia (HHT) is easily recognized in individuals displaying the classical triad of epistaxis, telangiectasia, and a suitable family history, but the disease is more difficult to diagnosis in many patients. Serious consequences may result if visceral arteriovenous malformations, particularly in the pulmonary circulation, are unrecognized and left untreated. In spite of the identification of two of the disease-causing genes (endoglin and ALK-1), only a clinical diagnosis of HHT can be provided for the majority of individuals. On behalf of the Scientific Advisory Board of the HHT Foundation International, Inc., we present consensus clinical diagnostic criteria. The four criteria (epistaxes, telangiectasia, visceral lesions and an appropriate family history) are carefully delineated. The HHT diagnosis is definite if three criteria are present. A diagnosis of HHT cannot be established in patients with only two criteria, but should be recorded as possible or suspected to maintain a high index of clinical suspicion. If fewer than two criteria are present, HHT is unlikely, although children of affected individuals should be considered at risk in view of age-related penetration in this disorder. These criteria may be refined as molecular diagnostic tests become available in the next few years.
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Affiliation(s)
- C L Shovlin
- Respiratory Medicine, National Heart and Lung Institute, Imperial College School of Medicine, Hammersmith Hospital, London, UK
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Shovlin CL, Guttmacher AE, Buscarini E, Faughnan ME, Hyland RH, Westermann CJ, Kjeldsen AD, Plauchu H. Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Am J Med Genet 2000; 91:66-7. [PMID: 10751092 DOI: 10.1002/(sici)1096-8628(20000306)91:1<66::aid-ajmg12>3.0.co;2-p] [Citation(s) in RCA: 1039] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Hereditary Hemorrhagic Telangiectasia (HHT) is easily recognized in individuals displaying the classical triad of epistaxis, telangiectasia, and a suitable family history, but the disease is more difficult to diagnosis in many patients. Serious consequences may result if visceral arteriovenous malformations, particularly in the pulmonary circulation, are unrecognized and left untreated. In spite of the identification of two of the disease-causing genes (endoglin and ALK-1), only a clinical diagnosis of HHT can be provided for the majority of individuals. On behalf of the Scientific Advisory Board of the HHT Foundation International, Inc., we present consensus clinical diagnostic criteria. The four criteria (epistaxes, telangiectasia, visceral lesions and an appropriate family history) are carefully delineated. The HHT diagnosis is definite if three criteria are present. A diagnosis of HHT cannot be established in patients with only two criteria, but should be recorded as possible or suspected to maintain a high index of clinical suspicion. If fewer than two criteria are present, HHT is unlikely, although children of affected individuals should be considered at risk in view of age-related penetration in this disorder. These criteria may be refined as molecular diagnostic tests become available in the next few years.
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Affiliation(s)
- C L Shovlin
- Respiratory Medicine, National Heart and Lung Institute, Imperial College School of Medicine, Hammersmith Hospital, London, UK
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MESH Headings
- Abnormalities, Multiple/embryology
- Abnormalities, Multiple/genetics
- Animals
- Antigens, CD
- Disease Models, Animal
- Endoglin
- Genes, Lethal
- Humans
- Mice
- Mice, Inbred C57BL
- Mice, Inbred Strains
- Mice, Knockout
- Receptors, Cell Surface
- Telangiectasia, Hereditary Hemorrhagic/embryology
- Telangiectasia, Hereditary Hemorrhagic/genetics
- Vascular Cell Adhesion Molecule-1/genetics
- Vascular Cell Adhesion Molecule-1/physiology
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Affiliation(s)
- C L Shovlin
- Respiratory Medicine, Imperial College School of Medicine, National Heart and Lung Institute, Hammersmith Hospital, Du Cane Road, London W12 0NN, United Kingdom.
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Shovlin CL, Letarte M. Hereditary haemorrhagic telangiectasia and pulmonary arteriovenous malformations: issues in clinical management and review of pathogenic mechanisms. Thorax 1999; 54:714-29. [PMID: 10413726 PMCID: PMC1745557 DOI: 10.1136/thx.54.8.714] [Citation(s) in RCA: 280] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- C L Shovlin
- Respiratory Medicine, Imperial College School of Medicine, National Heart and Lung Institute, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
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Shovlin CL. Glaxo/MRS Young Investigator Medal. Molecular studies on adenosine deaminase deficiency and hereditary haemorrhagic telangiectasia. Clin Sci (Lond) 1998; 94:207-18. [PMID: 9616253 DOI: 10.1042/cs0940207] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
1. This manuscript describes two different strategies to progress from the clinical assessment of patients to the identification of disease-causing mutations. In the first disease, recognition of a metabolic abnormality allowed direct molecular analysis of the causal gene. In contrast, localization of the second disease gene by linkage analysis was critical to implicate a gene with a previously unsuspected disease role. 2. Two sisters with chronic respiratory disease and recurrent infections were identified as the first cases of adult onset immunodeficiency due to adenosine deaminase deficiency. Autosomal recessive inheritance of two mutations in the adenosine deaminase gene was demonstrated. Enzyme replacement therapy improved the patients' immunological and clinical status. 3. Individuals with pulmonary arteriovenous malformations were used to identify families with hereditary haemorrhagic telangiectasia (HHT, Rendu-Osler-Weber Syndrome). Linkage studies mapped the HHT disease gene in some families to chromosome 9, and demonstrated genetic heterogeneity. The chromosome 9 disease interval was refined, and several candidate genes were assessed. Following the first description of disease-segregating mutations, a complete analysis of the endoglin gene (which encodes an endothelial cell transforming growth factor-beta receptor) identified seven novel mutations. Two mutations did not produce mutant mRNA, and disease severity was comparable between families, indicating that HHT results from stoichiometric insufficiency of endoglin. 4. Each study has implications extending beyond the relatively rare disease analysed. The adenosine-deaminase-deficient patients highlight a treatable cause of HIV-negative CD4+ lymphopenia in adults, perhaps accounting for further cases of 'non-HIV AIDS'. The HHT studies have illuminated a novel area of vascular pathophysiology, with potential relevance to further disease states.
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Affiliation(s)
- C L Shovlin
- Department of Medicine, University of Edinburgh (R.I.E.), Scotland, U.K
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Shovlin CL, Hughes JM, Scott J, Seidman CE, Seidman JG. Characterization of endoglin and identification of novel mutations in hereditary hemorrhagic telangiectasia. Am J Hum Genet 1997; 61:68-79. [PMID: 9245986 PMCID: PMC1715873 DOI: 10.1086/513906] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
To identify mutations that cause hereditary hemorrhagic telangiectasia (HHT, or Rendu-Osler-Weber syndrome), clinical evaluations and genetic studies were performed on 32 families. Linkage studies in four of eight families indicated an endoglin (ENG) gene mutation. ENG sequences of affected members of the four linked families and probands from the 24 small families were screened for mutations, by Southern blot analyses and by cycle sequencing of PCR-amplified DNA. Seven novel mutations were identified in eight families. Two mutations (a termination codon in exon 4 and a large genomic deletion extending 3' of intron 8) did not produce a stable ENG transcript in lymphocytes. Five other mutations (two donor splice-site mutations and three deletions) produce altered mRNAs that are predicted to encode markedly truncated ENG proteins. Mutations in other families are predicted to lie in ENG-regulatory regions or in one of the additional genes that may cause HHT. These data suggest that the molecular mechanism by which ENG mutations cause HHT is haploinsufficiency. Furthermore, because the clinical manifestation of disease in these eight families was similar, we hypothesize that phenotypic variation of HHT is not related to a particular ENG mutation.
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Affiliation(s)
- C L Shovlin
- Department of Genetics, Harvard Medical School, Boston, MA 02115, USA
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Shovlin CL. Molecular defects in rare bleeding disorders: hereditary haemorrhagic telangiectasia. Thromb Haemost 1997; 78:145-50. [PMID: 9198145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Vascular diseases may mimic coagulopathies by presenting as a haemorrhagic state. The archetypal example of an inherited disorder resulting in haemorrhage from dilated vessels of the microvasculature (telangiectasia) is Hereditary Haemorrhagic Telangiectasia (HHT, Rendu-Osler-Weber syndrome). This autosomal dominant disorder is characterised by haemorrhage from nasal, mucocutaneous and gastrointestinal telangiectasia, in addition to vascular anomalies in other organs, particularly in the pulmonary, hepatic and cerebral circulations. Linkage analyses have indicated there are at least three HHT loci, including the genes for endoglin on chromosome 9, and activin-like receptor kinase (ALK1) on chromosome 12. Mutations in these genes, together with recent data on the normal function of the encoded proteins highlight the role of TGF-b family members in the pathogenesis of HHT. Complimentary information from other telangiectatic states indicates potential precipitants, and indicate a critical role for TGF-beta ligand-receptor interactions in vascular homeostasis.
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Affiliation(s)
- C L Shovlin
- Department of Genetics, Harvard Medical School, Boston, MA, USA
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Abstract
This review focuses on a spectrum of inherited disorders in which recent genetic advances have made a significant contribution to our understanding of vascular pathology and homeostasis. They are discussed according to the type of blood vessel affected and the compounded physiological processes that include angiogenesis, vascular development, and defects in the structure and regulation of the mature vessel. Vascular malformations, arterial aneurysms and dissection, telangiectasia, infiltrative vascular disease, and inherited tumors and disorders of neovascularization are discussed in a variety of settings. Disease roles for endoglin, tissue inhibitor of metalloproteinases 3 (TIMP3), and vascular endothelial growth factor (VEGF) dysregulation are highlighted (175 references).
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Affiliation(s)
- C L Shovlin
- Department of Genetics, Harvard Medical School, Boston, Massachusetts 02115, USA
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Encinas JA, Lees MB, Sobel RA, Symonowicz C, Greer JM, Shovlin CL, Weiner HL, Seidman CE, Seidman JG, Kuchroo VK. Genetic analysis of susceptibility to experimental autoimmune encephalomyelitis in a cross between SJL/J and B10.S mice. J Immunol 1996; 157:2186-92. [PMID: 8757345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Experimental autoimmune encephalomyelitis (EAE), a model for human multiple sclerosis, is a T cell-mediated autoimmune disease that can be induced in experimental animals by immunization with myelin Ags. Inbred strains of mice show varying degrees of susceptibility to EAE, indicating that susceptibility is an inherited trait. To define the genetic factors that control susceptibility to EAE, we performed linkage analysis on the first backcross (BC1) between highly susceptible SJL/J mice and resistant B10.S mice, both of which are of the H-2s haplotype. Mice were immunized for disease with encephalitogenic myelin proteolipid protein peptide 139 to 151, and analysis was performed on 68 backcross mice showing the severe disease phenotype (disease score > or = 3)and 68 backcross mice of the resistant phenotype (no clinical or histologic signs of disease) using microsatellite markers covering >98% of the genome. We found the strongest linkage (p = 0.001) with clinical disease at two loci: one at the telomeric end of chromosome 2, and another near the center of chromosome 3. In addition, several other regions showing some evidence of linkage (p < or = 0.05) with clinical disease were found.
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Affiliation(s)
- J A Encinas
- Center for Neurologic Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
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Affiliation(s)
- C L Shovlin
- Department of Genetics, Harvard Medical School, Boston, MA 02115, USA.
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