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Belmokhtar KY, Cherkaoui I, Lhousni S, Elidrissi Errahhali M, Elidrissi Errahhali M, Charif M, Boulouiz R, Ouarzane M, Elouali A, Ghanam A, Babakhouya A, Rkain M, Benajiba N, Bellaoui M. Triple-A Syndrome in Morocco: Founder Effect, Age Estimation of the AAAS c.1331+1G>A Variant, and Implications for Genetic Diagnosis. Mol Syndromol 2024; 15:96-103. [PMID: 38585542 PMCID: PMC10996341 DOI: 10.1159/000533894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/29/2023] [Indexed: 04/09/2024] Open
Abstract
Introduction Triple-A syndrome (Triple-A) is an autosomal recessive disorder characterized by alacrimia, achalasia, and adrenal insufficiency. Several variants on the AAAS gene have been described, and some variants are clustered in particular geographical areas, such as the c.1331+1G>A variant which is very frequent in North Africa. Here, we describe the genetic features of Triple-A in a series of unrelated families from Morocco. Methods Screening for the AAAS c.1331+1G>A variant was performed by direct sequencing or by PCR-RFLP. Haplotype analysis using Single Tandem Repeat (STR) markers flanking AAAS gene was performed in order to evaluate the founder effect and estimate the age of the c.1331+1G>A variant. Results Seven unrelated families with ten individuals clinically diagnosed with Triple-A were evaluated for sequence variations in the AAAS gene. The median age at diagnosis was 3 years, with a range between 2 and 11 years. Molecular analysis revealed that all patients were homozygous for the c.1331+1G>A variant. This variant was not found in 200 healthy controls, indicating that carriers are very rare in the general Moroccan population. Subsequently, STR marker analysis revealed a founder effect and that the most recent common ancestor of Triple-A patients in Morocco would have lived 125 years ago. Conclusion This is the largest series of Triple-A in Morocco. The same AAAS c.1331+1G>A variant was found in all patients, suggesting a founder effect in Morocco which was subsequently confirmed by microsatellite marker analysis. Therefore, this variant should be systematically investigated to diagnose Triple-A in Morocco.
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Affiliation(s)
- Karam Yahya Belmokhtar
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Imane Cherkaoui
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Saida Lhousni
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
- BRO Biobank, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Mounia Elidrissi Errahhali
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
- BRO Biobank, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Manal Elidrissi Errahhali
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
- BRO Biobank, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Majida Charif
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
- BRO Biobank, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
- Genetics and Immuno-Cell Therapy Team, Faculty of Science, University Mohammed Premier, Oujda, Morocco
| | - Redouane Boulouiz
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
- BRO Biobank, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Meryem Ouarzane
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
- BRO Biobank, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Aziza Elouali
- Department of Pediatrics, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Ayad Ghanam
- Department of Pediatrics, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Abdeladim Babakhouya
- Department of Pediatrics, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Maria Rkain
- Department of Pediatrics, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Noufissa Benajiba
- Department of Pediatrics, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Mohammed Bellaoui
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
- BRO Biobank, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
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Sultan MN, Shakoo N, Razouk A, Alari Y, Aldaher B, Niazi A. A 16-year-old boy presented with triple-A syndrome associated with neuromuscular disorders: a case report. Ann Med Surg (Lond) 2024; 86:1758-1761. [PMID: 38463068 PMCID: PMC10923340 DOI: 10.1097/ms9.0000000000001779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/23/2024] [Indexed: 03/12/2024] Open
Abstract
Introduction and importance Allgrove syndrome (AS) (AAA syndrome) is a rare autosomal recessive disease caused by mutations in the AAAS gene located on chromosome 12q13. The AAAS gene encodes for the ALADIN protein (alacrima, achalasia, adrenal insufficiency, neurologic disorder). AS can manifest with a plethora of symptoms. Early recognition of the syndrome remains challenging due to its rarity and progressive nature. This report presents an unusual case of triple-A syndrome (TAS) with concurrent neuromuscular manifestations. Understanding the atypical presentation of this syndrome is vital for early diagnosis and appropriate management. Case presentation We report a 16-year-old boy with severe malnutrition presented with painful swallowing, fatigue, and bilateral congenital ptosis. Barium swallow, upper gastrointestinal endoscopy, and Shimmer test were performed, which led to the diagnosis of TAS. Treatment included laparoscopic Heller's procedure, artificial tears, hydrocortisone. Clinical discussion TAS, also known as AS, is a rare multisystem disorder characterized by achalasia, Addison's disease, and alacrima. This syndrome is occasionally referred to as 4A syndrome due to the inclusion of autonomic dysfunction. There is no treatment for AS. Management includes artificial tears for alacrima, glucocorticoid replacement therapy to treat adrenal insufficiency, and treatment of achalasia. Conclusion This case emphasizes the importance of considering atypical presentations of TAS. Early diagnosis and treatment are paramount in addressing the varied components of this rare disorder. Understanding the clinical complexities of this syndrome aids in improved patient care and underscores the necessity for comprehensive evaluation and management in similar cases.
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Affiliation(s)
| | | | | | | | | | - Ammar Niazi
- Surgery Department, Aleppo University Hospital, Aleppo, Syria
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Vigano' M, Mantero V, Basilico P, Pirro F, Ronchi D, Di Fonzo A, Salmaggi A. Don't forget Allgrove syndrome in adult patients as a bulbar-ALS mimicker. Neurol Sci 2023; 44:3703-3705. [PMID: 37458842 DOI: 10.1007/s10072-023-06961-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/11/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Allgrove syndrome is a genetic disorder characterized by a multisystem involvement manifesting mainly in childhood with esophageal achalasia, adrenal insufficiency, and alacrima. Associated neurological manifestations are frequent in patients with late-onset forms and include peripheral, central, and autonomic dysfunction. The definitive diagnosis remains genetic, but neurological symptoms/signs could be a relevant clue for the diagnosis. DISCUSSION This syndrome is rare, but it is not impossible for it to occur in adults, so all neurologists must be alert. Moreover, in this regard, neurological symptoms can sometimes be very similar to those of motor neuron disease patients, so that, although rare, Allgrove syndrome may also enter into the differential diagnosis with the bulbar variant of amyotrophic lateral sclerosis. Nevertheless, attention to extra-neurological symptoms must remain high as these play an equally important role in reaching the diagnosis. CASE REPORT Here we present the case of a patient with some peculiarities that are onset at an advanced age, genetic confirmation of the diagnosis, and prominent neurological involvement, which also opens the differential diagnosis to amyotrophic lateral sclerosis.
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Affiliation(s)
- Martina Vigano'
- Department of Neurology and Stroke Unit, ASST Lecco Ospedale Alessandro Manzoni, Via Eremo 9/11, LC, 23900, Lecco, Italy.
| | - Vittorio Mantero
- Department of Neurology and Stroke Unit, ASST Lecco Ospedale Alessandro Manzoni, Via Eremo 9/11, LC, 23900, Lecco, Italy
| | - Paola Basilico
- Department of Neurology and Stroke Unit, ASST Lecco Ospedale Alessandro Manzoni, Via Eremo 9/11, LC, 23900, Lecco, Italy
| | - Fiammetta Pirro
- Department of Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Dario Ronchi
- Dino Ferrari Center, Neuroscience Section, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alessio Di Fonzo
- Neurology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Salmaggi
- Department of Neurology and Stroke Unit, ASST Lecco Ospedale Alessandro Manzoni, Via Eremo 9/11, LC, 23900, Lecco, Italy
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Bitetto G, Lopez G, Ronchi D, Pittaro A, Melzi V, Peverelli E, Cribiù FM, Comi GP, Mantovani G, Di Fonzo A. SCARB1 downregulation in adrenal insufficiency with Allgrove syndrome. Orphanet J Rare Dis 2023; 18:152. [PMID: 37331934 DOI: 10.1186/s13023-023-02763-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 06/04/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND Allgrove disease is a rare genetic syndrome characterized by adrenal insufficiency, alacrimia, achalasia and complex neurological involvement. Allgrove disease is due to recessive mutations in the AAAS gene, which encodes for the nucleoporin Aladin, implicated in the nucleocytoplasmic transport. The adrenal insufficiency has been suggested to rely on adrenal gland-ACTH resistance. However, the link between the molecular pathology affecting the nucleoporin Aladin and the glucocorticoid deficiency is still unknown. RESULTS By analyzing postmortem patient's adrenal gland, we identified a downregulation of Aladin transcript and protein. We found a downregulation of Scavenger receptor class B-1 (SCARB1), a key component of the steroidogenic pathway, and SCARB1 regulatory miRNAs (mir125a, mir455) in patient's tissues. With the hypothesis of an impairment in the nucleocytoplasmic transport of the SCARB1 transcription enhancer cyclic AMP-dependent protein kinase (PKA), we detected a reduction of nuclear Phospho-PKA and a cytoplasmic mislocalization in patient's samples. CONCLUSIONS These results shed a light on the possible mechanisms linking ACTH resistance, SCARB1 impairment, and defective nucleocytoplasmic transport.
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Affiliation(s)
- Giacomo Bitetto
- Neurology Unit, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Gianluca Lopez
- Division of Pathology, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Dario Ronchi
- Neurology Unit, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Alessandra Pittaro
- Division of Pathology, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Valentina Melzi
- Neurology Unit, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Erika Peverelli
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Fulvia Milena Cribiù
- Division of Pathology, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Giacomo P Comi
- Neurology Unit, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Giovanna Mantovani
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessio Di Fonzo
- Neurology Unit, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.
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Hasenmajer V, Ferrigno R, Minnetti M, Pellegrini B, Isidori AM, Lenzi A, Salerno M, Cappa M, Chan L, De Martino MC, Savage MO. Rare forms of genetic paediatric adrenal insufficiency: Excluding congenital adrenal hyperplasia. Rev Endocr Metab Disord 2023; 24:345-363. [PMID: 36763264 PMCID: PMC10023752 DOI: 10.1007/s11154-023-09784-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 02/11/2023]
Abstract
Adrenal insufficiency (AI) is a severe endocrine disorder characterized by insufficient glucocorticoid (GC) and/or mineralocorticoid (MC) secretion by the adrenal glands, due to impaired adrenal function (primary adrenal insufficiency, PAI) or to insufficient adrenal stimulation by pituitary ACTH (secondary adrenal insufficiency, SAI) or tertiary adrenal insufficiency due to hypothalamic dysfunction. In this review, we describe rare genetic causes of PAI with isolated GC or combined GC and MC deficiencies and we also describe rare syndromes of isolated MC deficiency. In children, the most frequent cause of PAI is congenital adrenal hyperplasia (CAH), a group of adrenal disorders related to steroidogenic enzyme deficiencies, which will not be included in this review. Less frequently, several rare diseases can cause PAI, either affecting exclusively the adrenal glands or with systemic involvement. The diagnosis of these diseases is often challenging, due to the heterogeneity of their clinical presentation and to their rarity. Therefore, the current review aims to provide an overview on these rare genetic forms of paediatric PAI, offering a review of genetic and clinical features and a summary of diagnostic and therapeutic approaches, promoting awareness among practitioners, and favoring early diagnosis and optimal clinical management in suspect cases.
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Affiliation(s)
- Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Rosario Ferrigno
- UOSD Auxology and Endocrinology, Department of Pediatric, AORN Santobono-Pausilipon, Naples, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Bianca Pellegrini
- Dipartimento Di Medicina Clinica E Chirurgia, Federico II University, Naples, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Marco Cappa
- Endocrinology Unit, Pediatric University Department, Bambino Gesù Children's Hospital, Rome, Italy
| | - Li Chan
- Endocrinology Centre, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
| | | | - Martin O Savage
- Endocrinology Centre, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
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Dumić K, Krnić N, Jovanović I, Ruška B, Adamec I, Fanciulli A, Habek M. Insular damage causing transient baroreflex dysfunction in a teenager with Allgrove syndrome. Clin Auton Res 2021; 31:581-584. [PMID: 33560460 DOI: 10.1007/s10286-021-00779-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 01/23/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Katja Dumić
- Department of Pediatric Endocrinology and Diabetes, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Nevena Krnić
- Department of Pediatric Endocrinology and Diabetes, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivan Jovanović
- Department of Neuroradiology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Berislav Ruška
- Department of Neurology, Referral Center for Autonomic Nervous System Disorders, University Hospital Center Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Ivan Adamec
- Department of Neurology, Referral Center for Autonomic Nervous System Disorders, University Hospital Center Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Alessandra Fanciulli
- Autonomic Unit, Division of Neurobiology, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Mario Habek
- School of Medicine, University of Zagreb, Zagreb, Croatia. .,Department of Neurology, Referral Center for Autonomic Nervous System Disorders, University Hospital Center Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia.
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Hentschel A, Czech A, Münchberg U, Freier E, Schara-Schmidt U, Sickmann A, Reimann J, Roos A. Protein signature of human skin fibroblasts allows the study of the molecular etiology of rare neurological diseases. Orphanet J Rare Dis 2021; 16:73. [PMID: 33563298 PMCID: PMC7874489 DOI: 10.1186/s13023-020-01669-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 12/23/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The elucidation of pathomechanisms leading to the manifestation of rare (genetically caused) neurological diseases including neuromuscular diseases (NMD) represents an important step toward the understanding of the genesis of the respective disease and might help to define starting points for (new) therapeutic intervention concepts. However, these "discovery studies" are often limited by the availability of human biomaterial. Moreover, given that results of next-generation-sequencing approaches frequently result in the identification of ambiguous variants, testing of their pathogenicity is crucial but also depending on patient-derived material. METHODS Human skin fibroblasts were used to generate a spectral library using pH8-fractionation of followed by nano LC-MS/MS. Afterwards, Allgrove-patient derived fibroblasts were subjected to a data independent acquisition approach. In addition, proteomic signature of an enriched nuclear protein fraction was studied. Proteomic findings were confirmed by immunofluorescence in a muscle biopsy derived from the same patient and cellular lipid homeostasis in the cause of Allgrove syndrome was analysed by fluorescence (BODIPY-staining) and coherent anti-Stokes Raman scattering (CARS) microscopy. RESULTS To systematically address the question if human skin fibroblasts might serve as valuable biomaterial for (molecular) studies of NMD, we generated a protein library cataloguing 8280 proteins including a variety of such linked to genetic forms of motoneuron diseases, congenital myasthenic syndromes, neuropathies and muscle disorders. In silico-based pathway analyses revealed expression of a diversity of proteins involved in muscle contraction and such decisive for neuronal function and maintenance suggesting the suitability of human skin fibroblasts to study the etiology of NMD. Based on these findings, next we aimed to further demonstrate the suitability of this in vitro model to study NMD by a use case: the proteomic signature of fibroblasts derived from an Allgrove-patient was studied. Dysregulation of paradigmatic proteins could be confirmed in muscle biopsy of the patient and protein-functions could be linked to neurological symptoms known for this disease. Moreover, proteomic investigation of nuclear protein composition allowed the identification of protein-dysregulations according with structural perturbations observed in the muscle biopsy. BODIPY-staining on fibroblasts and CARS microscopy on muscle biopsy suggest altered lipid storage as part of the underlying disease etiology. CONCLUSIONS Our combined data reveal that human fibroblasts may serve as an in vitro system to study the molecular etiology of rare neurological diseases exemplified on Allgrove syndrome in an unbiased fashion.
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Affiliation(s)
- Andreas Hentschel
- Leibniz-Institut für Analytische Wissenschaften - ISAS - e.V, Dortmund, Germany
| | - Artur Czech
- Leibniz-Institut für Analytische Wissenschaften - ISAS - e.V, Dortmund, Germany
| | - Ute Münchberg
- Leibniz-Institut für Analytische Wissenschaften - ISAS - e.V, Dortmund, Germany
| | - Erik Freier
- Leibniz-Institut für Analytische Wissenschaften - ISAS - e.V, Dortmund, Germany
| | - Ulrike Schara-Schmidt
- Department of Pediatric Neurology, Faculty of Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Albert Sickmann
- Leibniz-Institut für Analytische Wissenschaften - ISAS - e.V, Dortmund, Germany
| | - Jens Reimann
- Muscle Laboratory, Department of Neurology, University of Bonn, Medical Centre, Bonn, Germany
| | - Andreas Roos
- Department of Pediatric Neurology, Faculty of Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.
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Vezzoli V, Duminuco P, Pogliaghi G, Saccone M, Cangiano B, Rosatelli MC, Meloni A, Persani L, Bonomi M. Two novel truncating variants of the AAAS gene causative of the triple A syndrome. J Endocrinol Invest 2020; 43:973-982. [PMID: 31939195 DOI: 10.1007/s40618-020-01180-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/06/2020] [Indexed: 01/15/2023]
Abstract
PURPOSE The triple A syndrome (AAAS) is an inherited condition associated with mutations in the AAAS gene, which encodes a protein of 546 amino acids known as ALADIN (alacrima achalasia adrenal insufficiency neurologic disorder) whose function is not well understood. This protein belongs to the WD-repeat family of regulatory proteins and is located in the nuclear pore complexes. Only a few cohorts of AAAS patients have been reported and fully characterized. Thus, the objective of the present study was to report on a mini cohort of Italian AAAS patients and to get insights on their predisposing genetic defects. METHODS Genetic analysis of AAAS gene in triple A syndrome patient and molecular and functional characterization of the novel identified allelic variants. RESULTS Here we describe three newly diagnosed cases of AAAS, in whom genetic analysis allowed us to identify two novel allelic variants in the AAAS gene: the frameshift substitution c.765 dupT (p.Gly256Trp fsX67) in exon 8 and the splice site mutation in intron 11(c.997-2 A > G, IVS11-2A > G). Both variants result in a truncated non-functional protein, as we demonstrate by transcript analysis and expression studies. CONCLUSIONS Our findings establish a pathogenic role for both new variants. Moreover, our data highlight the essential role of the C-terminal domain of the protein for its correct targeting and function and underline the importance of sequencing splice sites surrounding the intron-exon junctions to ensure accurate molecular diagnosis and correct genetic counseling in AAAS patients.
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Affiliation(s)
- V Vezzoli
- Dipartimento di Scienze Cliniche e di Comunità, Division of Endocrine and Metabolic Diseases and Lab. of Endocrine and Metabolic Research, Dipartimento di Medicina Endocrino-Metabolica, Università degli studi di Milano, IRCCS Istituto Auxologico Italiano, Piazzale Brescia 20, 20149, Milano, Italy
| | - P Duminuco
- Dipartimento di Scienze Cliniche e di Comunità, Division of Endocrine and Metabolic Diseases and Lab. of Endocrine and Metabolic Research, Dipartimento di Medicina Endocrino-Metabolica, Università degli studi di Milano, IRCCS Istituto Auxologico Italiano, Piazzale Brescia 20, 20149, Milano, Italy
| | - G Pogliaghi
- Dipartimento di Scienze Cliniche e di Comunità, Division of Endocrine and Metabolic Diseases and Lab. of Endocrine and Metabolic Research, Dipartimento di Medicina Endocrino-Metabolica, Università degli studi di Milano, IRCCS Istituto Auxologico Italiano, Piazzale Brescia 20, 20149, Milano, Italy
| | - M Saccone
- Dipartimento di Scienze Cliniche e di Comunità, Division of Endocrine and Metabolic Diseases and Lab. of Endocrine and Metabolic Research, Dipartimento di Medicina Endocrino-Metabolica, Università degli studi di Milano, IRCCS Istituto Auxologico Italiano, Piazzale Brescia 20, 20149, Milano, Italy
| | - B Cangiano
- Dipartimento di Scienze Cliniche e di Comunità, Division of Endocrine and Metabolic Diseases and Lab. of Endocrine and Metabolic Research, Dipartimento di Medicina Endocrino-Metabolica, Università degli studi di Milano, IRCCS Istituto Auxologico Italiano, Piazzale Brescia 20, 20149, Milano, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - M C Rosatelli
- Pediatric Hospital "Microcitemico" Antonio Cao, Azienda Ospedaliera Brotzu, University of Cagliari, Cagliary, Italy
| | - A Meloni
- Pediatric Hospital "Microcitemico" Antonio Cao, Azienda Ospedaliera Brotzu, University of Cagliari, Cagliary, Italy
| | - L Persani
- Dipartimento di Scienze Cliniche e di Comunità, Division of Endocrine and Metabolic Diseases and Lab. of Endocrine and Metabolic Research, Dipartimento di Medicina Endocrino-Metabolica, Università degli studi di Milano, IRCCS Istituto Auxologico Italiano, Piazzale Brescia 20, 20149, Milano, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - M Bonomi
- Dipartimento di Scienze Cliniche e di Comunità, Division of Endocrine and Metabolic Diseases and Lab. of Endocrine and Metabolic Research, Dipartimento di Medicina Endocrino-Metabolica, Università degli studi di Milano, IRCCS Istituto Auxologico Italiano, Piazzale Brescia 20, 20149, Milano, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
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Zheng H, Iyer RS, Pacheco MC, Soares JJ, Johnson K, Len M, Ambartsumyan L. Respiratory infections and chronic cough due to triple A (Allgrove) syndrome. Clin Case Rep 2020; 8:437-440. [PMID: 32185032 PMCID: PMC7069866 DOI: 10.1002/ccr3.2683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/31/2019] [Accepted: 11/18/2019] [Indexed: 11/29/2022] Open
Abstract
Cough and respiratory infections are common in pediatrics. Our case report illustrates the need for pediatricians to consider rare diagnoses such as genetic syndromes and primary gastrointestinal motility disorders in patients with unremitting respiratory and gastrointestinal symptoms. Early identification provides early intervention and reduces long-term morbidity for pediatric patients.
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Affiliation(s)
- Hengqi Zheng
- Division of GastroenterologySeattle Children's HospitalSeattleWashington
| | - Ramesh S. Iyer
- Department of RadiologySeattle Children's HospitalSeattleWashington
| | | | | | - Kaalan Johnson
- Department of OtolaryngologySeattle Children's HospitalSeattleWashington
| | - Mary Len
- Division of GastroenterologySeattle Children's HospitalSeattleWashington
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Polat R, Ustyol A, Tuncez E, Guran T. A broad range of symptoms in allgrove syndrome: single center experience in Southeast Anatolia. J Endocrinol Invest 2020; 43:185-196. [PMID: 31435881 DOI: 10.1007/s40618-019-01099-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 08/09/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Allgrove syndrome (OMIM 231550) is a rare autosomal recessive disease characterized by non-CAH primary adrenal insufficiency (non-CAH PAI), alacrima, and achalasia. It is caused by mutations in the AAAS gene. The syndrome is also associated with variable progressive neurological impairment and dermatological abnormalities. METHODS AND RESULTS We diagnosed 23 patients from 14 families with Allgrove syndrome, based on the presence of at least two characteristic symptoms, usually adrenal insufficiency and alacrima, between 2008 and 2018. A previously described nonsense variant of AAAS was detected in 19 patients from 12 families at homozygous state. Another novel homozygous mutation (c.394-397delCTGT) in AAAS was detected in four patients from two families. Presenting symptoms were alacrima (23/23; 100%), adrenal insufficiency (18/23; 78%), achalasia (13/23; 57%), short stature/growth retardation (16/23; 70%), hyperreflexia (15/23; 65%), palmoplantar hyperkeratosis (13/23; 57%), hyperpigmentation of the skin (10/23; 43%), hypoglycemia-induced convulsion (7/23; 30%), swallowing difficulty and vomiting (6/23; 26%). Serum DHEAS concentrations were low in all patients (23/23; 100%). CONCLUSIONS Clinical symptoms vary even among patients carrying the same mutation. Triple A syndrome should be considered in the etiology of non-CAH PAI in Arab populations and in Southeast Turkey. Any child with non-CAH PAI should be evaluated for the presence of alacrima and/or achalasia or family history of alacrima and/or achalasia. Children with alacrima and/or achalasia should also be investigated for adrenal insufficiency. Definitive molecular diagnosis is essential for early diagnosis and management of adrenal insufficiency, neurological symptoms, and growth retardation in patients and early diagnosis of as yet asymptomatic cases in the family, together with genetic counseling.
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Affiliation(s)
- R Polat
- Department of Pediatric Endocrinology and Diabetes, Sakarya University, Ministry of Health, Sakarya Training and Research Hospital, 54100, Sakarya, AZ, Turkey.
| | - A Ustyol
- Department of Pediatric Endocrinology and Diabetes, Ministry of Health, Sanlıurfa Training and Research Hospital, Sanlıurfa, Turkey
| | - E Tuncez
- Department of Genetics, Ministry of Health, Sanlıurfa Training and Research Hospital, Sanlıurfa, Turkey
| | - T Guran
- Department of Pediatric Endocrinology and Diabetes, Marmara University, Ministry of Health, Pendik Training and Research Hospital, Istanbul, Turkey
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11
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Abstract
OBJECTIVE Triple A syndrome is a rare autosomal recessive disorder caused by mutations in the AAAS gene on chromosome 12q13. Its main clinical features are alacrima, achalasia, and adrenal insufficiency, with most patients also having neurological symptoms and autonomic dysfunction. The neurologic manifestations are less well-understood, especially in children. Here, we examine two siblings who were found to have a novel mutation in the AAAS gene and who were found to have subtle, but important, neurologic findings. DESIGN This is a case report of two siblings. RESULTS We discuss two siblings exhibiting different signs of the disorder including neurologic dysfunction found at varying ages. Genetic analysis revealed that both patients have the same compound heterozygous mutations in the AAAS gene consisting of one novel mutation (c.500 C>A, A167E) and one previously described mutation (c.1331+1G> A/IVS14+1 G>A). A diagnosis of triple A syndrome was reached based on their clinical and genetic findings. CONCLUSIONS The unique characteristic of these two cases is the novel mutation in the AAAS gene, which is likely pathogenic. In addition, they showcase the genotype-phenotype variability of the disease, as well as the importance of early identification of the neurologic abnormalities, which can result in early intervention and possibly improved outcomes.
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Affiliation(s)
- Athanasia Bouliari
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Center Drive, Building 10, Room 1-3330, Bethesda, MD, 20892, USA
| | - Xuexin Lu
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Center Drive, Building 10, Room 1-3330, Bethesda, MD, 20892, USA
| | - Rebecca W Persky
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Center Drive, Building 10, Room 1-3330, Bethesda, MD, 20892, USA.
| | - Constantine A Stratakis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Center Drive, Building 10, Room 1-3330, Bethesda, MD, 20892, USA
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12
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Berrani H, Meskini T, Zerkaoui M, Merhni H, Ettair S, Sefiani A, Mouane N. Clinical and molecular report of c.1331 + 1G > A mutation of the AAAS gene in a Moroccan family with Allgrove syndrome: a case report. BMC Pediatr 2018; 18:184. [PMID: 29866068 PMCID: PMC5987581 DOI: 10.1186/s12887-018-1161-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 05/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Allgrove syndrome is a rare autosomal recessive disorder characterized by the triad of achalasia, alacrimia and adrenal insufficiency. It is caused by the mutations of the AAAS gene located on chromosome 12q13. The c.1331 + 1G > A mutation is one of the most common described in North Africa including Tunisia, Algeria and Libya. We report here the clinical and genetic profile of a Moroccan family with Allgrove syndrome. CASE PRESENTATION A Moroccan sister and brother born to consanguineous parents were found, at the ages of twelve and fifteen months old respectively, to have alacrimia and isolated glucocorticoid deficiency. Later, they developed achalasia whereupon Allgrove syndrome was diagnosed clinically and confirmed by DNA sequencing which revealed a c.1331 + 1G > A mutation in the AAAS gene. CONCLUSION This finding reinforces previous studies in demonstrating the geographic expansion of the ancestral mutation c.1331 + 1G > A in North African patients and thus enabling targeted genetic counseling. To the best of our knowledge, this is the first report of the AAAS gene mutation in Moroccan patients.
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Affiliation(s)
- H Berrani
- Pediatrics III, Children's Hospital of Rabat, University Mohammed V, Belarbi El Alaoui Avenue, 6203, Rabat, PB, Morocco. .,Nutrition and Food Science Departments, Faculty of Medicine and Pharmacy, Mohammed V University-Rabat, Belarbi El Alaoui Avenue, 6203, Rabat, Morocco.
| | - T Meskini
- Pediatrics III, Children's Hospital of Rabat, University Mohammed V, Belarbi El Alaoui Avenue, 6203, Rabat, PB, Morocco.,Nutrition and Food Science Departments, Faculty of Medicine and Pharmacy, Mohammed V University-Rabat, Belarbi El Alaoui Avenue, 6203, Rabat, Morocco
| | - M Zerkaoui
- Medical Genetics Institute, Institut National d'Hygiène, University Mohammed V, Rabat, Morocco
| | - H Merhni
- Medical Genetics Institute, Institut National d'Hygiène, University Mohammed V, Rabat, Morocco
| | - S Ettair
- Pediatrics III, Children's Hospital of Rabat, University Mohammed V, Belarbi El Alaoui Avenue, 6203, Rabat, PB, Morocco.,Nutrition and Food Science Departments, Faculty of Medicine and Pharmacy, Mohammed V University-Rabat, Belarbi El Alaoui Avenue, 6203, Rabat, Morocco
| | - A Sefiani
- Medical Genetics Institute, Institut National d'Hygiène, University Mohammed V, Rabat, Morocco
| | - N Mouane
- Pediatrics III, Children's Hospital of Rabat, University Mohammed V, Belarbi El Alaoui Avenue, 6203, Rabat, PB, Morocco.,Nutrition and Food Science Departments, Faculty of Medicine and Pharmacy, Mohammed V University-Rabat, Belarbi El Alaoui Avenue, 6203, Rabat, Morocco
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13
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Fragoso MCBV, Albuquerque EVDA, Cardoso ALDA, da Rosa PWL, de Paulo RB, Schimizu MHM, Seguro AC, Passarelli M, Koehler K, Huebner A, Almeida MQ, Latronico AC, Arnhold IJP, Mendonca BB. Triple A Syndrome: Preliminary Response to the Antioxidant N-Acetylcysteine Treatment in a Child. Horm Res Paediatr 2018; 88:167-171. [PMID: 28395280 DOI: 10.1159/000465520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 02/21/2017] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Triple A syndrome (AAAS) is a rare autosomal recessive disorder characterized by alacrima, achalasia, ACTH-resistant adrenal insufficiency, autonomic dysfunction, and progressive neurodegeneration. Increased oxidative stress, demonstrated in patients' fibroblasts in vitro, may be a central disease mechanism. N-acetylcysteine protects renal function in patients with kidney injuries associated with increased oxidative stress and improves viability of AAAS-knockdown adrenal cells in vitro. PATIENT AND RESULTS A boy diagnosed with AAAS presented with short stature and increased oxidative stress in vivo assessed by increased thiobarbituric acid reactive substances (TBARS), which are markers of lipid peroxidation, and by the susceptibility of LDL to oxidation and the capacity of HDL to prevent it. A homozygous missense germline mutation (c.523G>T, p.Val175Phe) in AAAS was identified. N-acetylcysteine (600 mg orally, twice daily) decreased oxidative stress but did not change the patient's growth pattern. CONCLUSIONS An increase in oxidative stress is reported for the first time in vivo in an AAAS patient. N-acetylcysteine was capable of decreasing TBARS levels, reducing the susceptibility of LDL to oxidation and improving the antioxidant role of HDL. The long-term effect of antioxidant treatment should be evaluated to determine the real benefit for the prevention of the degenerative process in AAAS.
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Affiliation(s)
- Maria Candida Barisson Villares Fragoso
- Unidade de Suprarrenal, Divisão de Endocrinologia & Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Edoarda Vasco de Albuquerque Albuquerque
- Endocrinologia do Desenvolvimento, Divisão de Endocrinologia & Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ana Luiza de Almeida Cardoso
- Endocrinologia do Desenvolvimento, Divisão de Endocrinologia & Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Paula Waki Lopes da Rosa
- Endocrinologia do Desenvolvimento, Divisão de Endocrinologia & Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Rodrigo Bomeny de Paulo
- Endocrinologia do Desenvolvimento, Divisão de Endocrinologia & Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Maria Heloisa Massola Schimizu
- Laboratório de Pesquisa Básica em Doenças Renais LIM 12, Hospital das Clínicas Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Antonio Carlos Seguro
- Laboratório de Pesquisa Básica em Doenças Renais LIM 12, Hospital das Clínicas Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marisa Passarelli
- Laboratório de Lípides (LIM 10) da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Katrin Koehler
- Klinik für Kinder- und Jugendmedizin, Technische Universität, Dresden, Germany
| | - Angela Huebner
- Klinik für Kinder- und Jugendmedizin, Technische Universität, Dresden, Germany
| | - Madson Q Almeida
- Unidade de Suprarrenal, Divisão de Endocrinologia & Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ana Claudia Latronico
- Endocrinologia do Desenvolvimento, Divisão de Endocrinologia & Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Laboratório de Hormônios e Genética Molecular LIM 42, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ivo Jorge Prado Arnhold
- Endocrinologia do Desenvolvimento, Divisão de Endocrinologia & Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Laboratório de Hormônios e Genética Molecular LIM 42, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Berenice Bilharinho Mendonca
- Endocrinologia do Desenvolvimento, Divisão de Endocrinologia & Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Laboratório de Hormônios e Genética Molecular LIM 42, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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14
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de Freitas MR, Orsini M, Araújo APDQC, Jr. LJA, Barbosa GM, França MC, Correia L, Bastos VH, Trajano E, Jr. MDS. Allgrove syndrome and motor neuron disease. Neurol Int 2018; 10:7436. [PMID: 30069287 PMCID: PMC6050446 DOI: 10.4081/ni.2018.7436] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 10/26/2017] [Indexed: 11/23/2022] Open
Abstract
Allgrove or triple A syndrome (AS or AAA) is a rare autosomal recessive syndrome with variable phenotype due to mutations in AAAS gene which encodes a protein called ALADIN. Generally, it's characterized by of adrenal insufficiency in consequence of adrenocorticotropic hormone (ACTH) resistance, besides of achalasia, and alacrimia. Neurologic features are varied and have been the subject of several case reports and reviews. A few cases of Allgrove syndrome with motor neuron disease have been already described. A 25-year-old white man, at the age of four, presented slowly progressive distal amyotrophy and weakness, autonomic dysfunction, dysphagia and lack of tears. He suffered later of orthostatic hypotension and erectile dysfunction. He presented distal amytrophy in four limbs, tongue myofasiculations, alacrimia, hoarseness and dysphagia due to achalasia. The ENMG showed generalized denervation with normal conduction velocities. Genetic testing revealed 2 known pathogenic variants in the AAAS gene (c.938T>C and c.1144_1147delTCTG). Our case presented a distal spinal amyotrophy with slow evolution and symptoms and signs of AS with a mutation in AAAS gen. Some cases of motor neuron disease, as ours, may be due to AAS. Early diagnosis is extremely important for symptomatic treatment.
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Affiliation(s)
| | - Marco Orsini
- Applied Science in Health, Severino Sombra University, Vassouras
- Laboratory Mapping and Cerebral Plasticity (LAMPLACE/ UFPI), Federal University of Piauí
| | | | - Luiz João Abraão Jr.
- Department of Gastroenterology, Department of Clinical Medicine (UFRJ), Rio de Janeiro
| | | | | | - Luan Correia
- Laboratory Mapping and Cerebral Plasticity (LAMPLA CE/UFPI), Federal University of Piauí Biomedical Sciences Program, PPGCBM, Federal University of Piauí, Parnaíba;
| | - Victor Hugo Bastos
- Laboratory Mapping and Cerebral Plasticity (LAMPLA CE/UFPI), Federal University of Piauí Biomedical Sciences Program, PPGCBM, Federal University of Piauí, Parnaíba;
| | - Eduardo Trajano
- Applied Science in Health, Severino Sombra University, Vassouras
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15
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Nakamura J, Hikichi T, Inoue H, Watanabe K, Kikuchi H, Takagi T, Suzuki R, Sugimoto M, Konno N, Waragai Y, Asama H, Takasumi M, Sato Y, Irie H, Obara K, Ohira H. Per-oral endoscopic myotomy for esophageal achalasia in a case of Allgrove syndrome. Clin J Gastroenterol 2018; 11:273-7. [PMID: 29383495 DOI: 10.1007/s12328-018-0819-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 01/18/2018] [Indexed: 02/07/2023]
Abstract
Allgrove syndrome, also known as Triple A syndrome, is a rare autosomal recessive genetic disease characterized by three signs: esophageal achalasia, adrenocorticotropic hormone refractoriness, and alacrima. A 31-year-old male presented to our hospital for treatment of difficulty swallowing caused by esophageal achalasia. Because he had complicating alacrima, a neurologic disease, and a family history of consanguineous marriage, a genetic neurologic disease was suspected. Then, a mutation in the achalasia-addisonianism-alacrima syndrome gene was identified. With the diagnosis of Allgrove syndrome, a per-oral endoscopic myotomy (POEM) was performed for esophageal achalasia. After the POEM, the symptoms and the esophageal pressure findings ameliorated quickly, with no recurrence noted throughout a follow-up of more than 1 year. Here, we report the first case of POEM performed for esophageal achalasia in Allgrove syndrome.
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16
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Tibussek D, Ghosh S, Huebner A, Schaper J, Mayatepek E, Koehler K. "Crying without tears" as an early diagnostic sign-post of triple A (Allgrove) syndrome: two case reports. BMC Pediatr 2018; 18:6. [PMID: 29334914 PMCID: PMC5769402 DOI: 10.1186/s12887-017-0973-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 12/13/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Triple A syndrome (or Allgrove syndrome) is a rare autosomal recessive disorder characterized by alacrima, achalasia, adrenal insufficiency and autonomic/neurological abnormalities. The majority of cases are caused by mutations in the AAAS gene located on chromosome 12q13. However, the clinical picture as well as genetic testing may be complex since symptomatology is variable and mutations cannot be identified in all clinically diagnosed patients. We present two unrelated patients with triple-A syndrome illustrating the importance of alacrima as an early clinical sign. CASE PRESENTATION A 3.5 year old girl presented with repeated hypoglycaemic myoclonic events. Adrenal insufficiency was diagnosed. In addition, alacrima, obvious since early infancy, was incidentally reported by the mother and finally lead to the clinical diagnosis of triple A syndrome. This was confirmed by positive mutation analysis of the AAAS gene. The second patient, an 8 months old boy was presented because of anisocoria and unilateral optic atrophy. MRI revealed cerebellar vermis hypotrophy. Psychomotor retardation, failure to thrive, and frequent vomiting lead to further diagnostic work-up. Achalasia was diagnosed radiologically. In addition, the mother mentioned absence of tears since birth leading to the clinical diagnosis of triple A syndrome. In contrast to the first cases genetic testing was negative. CONCLUSION These two patients illustrate the heterogeneity of triple A syndrome in both terms, clinical expression and genetic testing. We particularly aim to stress the importance of alacrima, which should be considered as a red flag symptom. Further differential diagnosis is required in every child affected by alacrima.
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Affiliation(s)
- Daniel Tibussek
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - Sujal Ghosh
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Center of Child and Adolescent Health, Heinrich-Heine-University, Düsseldorf, Germany
| | - Angela Huebner
- Department of Pediatrics, Medizinische Fakultät, Technische Universität Dresden, Dresden, Germany
| | - Joerg Schaper
- Department of Diagnostic and Interventional Radiology, Heinrich-Heine-University, Düsseldorf, Germany
| | - Ertan Mayatepek
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Katrin Koehler
- Department of Pediatrics, Medizinische Fakultät, Technische Universität Dresden, Dresden, Germany
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17
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Patt H, Koehler K, Lodha S, Jadhav S, Yerawar C, Huebner A, Thakkar K, Arya S, Nair S, Goroshi M, Ganesh H, Sarathi V, Lila A, Bandgar T, Shah N. Phenotype-genotype spectrum of AAA syndrome from Western India and systematic review of literature. Endocr Connect 2017; 6:901-913. [PMID: 29180348 PMCID: PMC5705786 DOI: 10.1530/ec-17-0255] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 10/25/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To study genotype-phenotype spectrum of triple A syndrome (TAS). METHODS Retrospective chart analysis of Indian TAS patients (cohort 1, n = 8) and review of genotyped TAS cases reported in world literature (cohort 2, n = 133, 68 publications). RESULTS Median age at presentation was 4.75 years (range: 4-10) and 5 years (range: 1-42) for cohorts 1 and 2, respectively. Alacrima, adrenal insufficiency (AI), achalasia and neurological dysfunction (ND) were seen in 8/8, 8/8, 7/8 and 4/8 patients in cohort 1, and in 99, 91, 93 and 79% patients in cohort 2, respectively. In both cohorts, alacrima was present since birth while AI and achalasia manifested before ND. Mineralocorticoid deficiency (MC) was uncommon (absent in cohort 1, 12.5% in cohort 2). In cohort 1, splice-site mutation in exon 1 (p.G14Vfs*45) was commonest, followed by a deletion in exon 8 (p.S255Vfs*36). Out of 65 mutations in cohort 2, 14 were recurrent and five exhibited regional clustering. AI was more prevalent, more often a presenting feature, and was diagnosed at younger age in T group (those with truncating mutations) as compared to NT (non-truncating mutations) group. ND was more prevalent, more common a presenting feature, with later age at onset in NT as compared to T group. CONCLUSION Clinical profile of our patients is similar to that of patients worldwide. Alacrima is the earliest and most consistent finding. MC deficiency is uncommon. Some recurrent mutations show regional clustering. p.G14Vfs*45 and p.S255Vfs*36 account for majority of AAAS mutations in our cohort. Phenotype of T group differs from that of NT group and merits future research.
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Affiliation(s)
- Hiren Patt
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Katrin Koehler
- Department of PaediatricsUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - Swati Jadhav
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Chaitanya Yerawar
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Angela Huebner
- Department of PaediatricsUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Kunal Thakkar
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Sneha Arya
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Sandhya Nair
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Manjunath Goroshi
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Hosahithlu Ganesh
- Department of EndocrinologyAJ Institute of Medical sciences, Mangalore, India
| | - Vijaya Sarathi
- Department of EndocrinologyVydehi Institute of Medical Sciences and Research Center, Bengaluru, India
| | - Anurag Lila
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Tushar Bandgar
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Nalini Shah
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
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18
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Reimann J, Kohlschmidt N, Tolksdorf K, Weis J, Kuchelmeister K, Roos A. Muscle Pathology as a Diagnostic Clue to Allgrove Syndrome. J Neuropathol Exp Neurol 2017; 76:337-341. [PMID: 28371804 DOI: 10.1093/jnen/nlx016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Allgrove or triple A syndrome is a rare autosomal recessive disorder that can present with a variable range of multi-system manifestations, including optic atrophy, cerebellar ataxia, upper and lower motoneuron signs and various neuropathic abnormalities. These cases are a diagnostic challenge, particularly when the eponymous combination of achalasia, Addisonianism and alacrima is incomplete. Therefore, it is in the differential diagnosis for multisystem conditions and should be known to pathologists who diagnose disorders of skeletal muscle. Here, we describe new findings in skeletal muscle histology from the case of a boy of consanguineous Turkish origin whose achalasia provided the only specific clinical clue to the diagnosis. These include myocyte nuclear abnormalities with partially abnormal anti-lamin A/C immunohistochemistry and altered nuclear ultrastructure but without overt abnormalities of nuclear pore morphology. In this case, the condition was associated with a hitherto unreported c.762delC mutation in the nucleoporin gene AAAS.
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Affiliation(s)
- Jens Reimann
- From Muscle Lab, Department of Neurology, University of Bonn Medical Centre, Bonn, Germany (JR, KT), Institute of Clinical Genetics, Bonn, Germany (NK), Institute of Neuropathology, RWTH Aachen University Hospital, Aachen, Germany (JW, AR), Department of Neuropathology, University of Bonn Medical Centre, Bonn, Germany (KK), Leibniz-Institut für Analytische Wissenschaften - ISAS - e.V, Department of Bioanalytics, Tissue Omics group, Dortmund, Germany (AR), John Walton Muscular Dystrophy Research Centre (JWMDRC), Newcastle University, International Centre for Life, Central Parkway, UK, Newcastle upon Tyne (AR)
| | - Nicolai Kohlschmidt
- From Muscle Lab, Department of Neurology, University of Bonn Medical Centre, Bonn, Germany (JR, KT), Institute of Clinical Genetics, Bonn, Germany (NK), Institute of Neuropathology, RWTH Aachen University Hospital, Aachen, Germany (JW, AR), Department of Neuropathology, University of Bonn Medical Centre, Bonn, Germany (KK), Leibniz-Institut für Analytische Wissenschaften - ISAS - e.V, Department of Bioanalytics, Tissue Omics group, Dortmund, Germany (AR), John Walton Muscular Dystrophy Research Centre (JWMDRC), Newcastle University, International Centre for Life, Central Parkway, UK, Newcastle upon Tyne (AR)
| | - Karen Tolksdorf
- From Muscle Lab, Department of Neurology, University of Bonn Medical Centre, Bonn, Germany (JR, KT), Institute of Clinical Genetics, Bonn, Germany (NK), Institute of Neuropathology, RWTH Aachen University Hospital, Aachen, Germany (JW, AR), Department of Neuropathology, University of Bonn Medical Centre, Bonn, Germany (KK), Leibniz-Institut für Analytische Wissenschaften - ISAS - e.V, Department of Bioanalytics, Tissue Omics group, Dortmund, Germany (AR), John Walton Muscular Dystrophy Research Centre (JWMDRC), Newcastle University, International Centre for Life, Central Parkway, UK, Newcastle upon Tyne (AR)
| | - Joachim Weis
- From Muscle Lab, Department of Neurology, University of Bonn Medical Centre, Bonn, Germany (JR, KT), Institute of Clinical Genetics, Bonn, Germany (NK), Institute of Neuropathology, RWTH Aachen University Hospital, Aachen, Germany (JW, AR), Department of Neuropathology, University of Bonn Medical Centre, Bonn, Germany (KK), Leibniz-Institut für Analytische Wissenschaften - ISAS - e.V, Department of Bioanalytics, Tissue Omics group, Dortmund, Germany (AR), John Walton Muscular Dystrophy Research Centre (JWMDRC), Newcastle University, International Centre for Life, Central Parkway, UK, Newcastle upon Tyne (AR)
| | - Klaus Kuchelmeister
- From Muscle Lab, Department of Neurology, University of Bonn Medical Centre, Bonn, Germany (JR, KT), Institute of Clinical Genetics, Bonn, Germany (NK), Institute of Neuropathology, RWTH Aachen University Hospital, Aachen, Germany (JW, AR), Department of Neuropathology, University of Bonn Medical Centre, Bonn, Germany (KK), Leibniz-Institut für Analytische Wissenschaften - ISAS - e.V, Department of Bioanalytics, Tissue Omics group, Dortmund, Germany (AR), John Walton Muscular Dystrophy Research Centre (JWMDRC), Newcastle University, International Centre for Life, Central Parkway, UK, Newcastle upon Tyne (AR)
| | - Andreas Roos
- From Muscle Lab, Department of Neurology, University of Bonn Medical Centre, Bonn, Germany (JR, KT), Institute of Clinical Genetics, Bonn, Germany (NK), Institute of Neuropathology, RWTH Aachen University Hospital, Aachen, Germany (JW, AR), Department of Neuropathology, University of Bonn Medical Centre, Bonn, Germany (KK), Leibniz-Institut für Analytische Wissenschaften - ISAS - e.V, Department of Bioanalytics, Tissue Omics group, Dortmund, Germany (AR), John Walton Muscular Dystrophy Research Centre (JWMDRC), Newcastle University, International Centre for Life, Central Parkway, UK, Newcastle upon Tyne (AR)
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Tebaibia A, Boudjella MA, Boutarene D, Benmediouni F, Brahimi H, Oumnia N. Incidence, clinical features and para-clinical findings of achalasia in Algeria: Experience of 25 years. World J Gastroenterol 2016; 22:8615-8623. [PMID: 27784974 PMCID: PMC5064043 DOI: 10.3748/wjg.v22.i38.8615] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/06/2016] [Accepted: 08/05/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the incidence of achalasia in Algeria and to determine its clinical and para-clinical profile. To evaluate the impact of continuing medical education (CME) on the incidence of this disease.
METHODS From 1990 to 2014, 1256 patients with achalasia were enrolled in this prospective study. A campaign of CME on diagnosis involving different regions of the country was conducted between 1999 and 2003. Annual incidence and prevalence were calculated by relating the number of diagnosed cases to 105 inhabitants. Each patient completed a standardized questionnaire, and underwent upper endoscopy, barium swallow and esophageal manometry. We systematically looked for Allgrove syndrome and familial achalasia.
RESULTS The mean annual incidence raised from 0.04 (95%CI: 0.028-0.052) during the 1990s to 0.27/105 inhabitants/year (95%CI: 0.215-0.321) during the 2000s. The incidence of the disease was two and half times higher in the north and the center compared to the south of the country. One-hundred-and-twenty-nine (10%) were children and 97 (7.7%) had Allgrove syndrome. Familial achalasia was noted in 18 different families. Patients had dysphagia (99%), regurgitation (83%), chest pain (51%), heartburn 24.5% and weight loss (70%). The lower esophageal sphincter was hypertensive in 53% and hypotensive in 0.6%.
CONCLUSION The mean incidence of achalasia in Algeria is at least 0.27/105 inhabitants. A good impact on the incidence of CME was noted. A gradient of incidence between different regions of the country was found. This variability is probably related to genetic and environmental factors. The discovery of an infantile achalasia must lead to looking for Allgrove syndrome and similar cases in the family.
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Dhar M, Verma N, Singh RB, Pai VK. Triple A to triple S: From diagnosis, to anesthetic management of Allgrove syndrome. J Clin Anesth 2016; 33:141-3. [PMID: 27555148 DOI: 10.1016/j.jclinane.2016.02.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/29/2016] [Accepted: 02/18/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Allgrove syndrome (AS) is a rare autosomal recessive disorder characterized by achalasia cardia, alacrimia, and adrenocorticotropic hormone-resistant adrenal insufficiency which is sometimes associated with autonomic dysfunction. It has also been referred to as the triple A syndrome in view of the cardinal symptoms described above. First described by Allgrove et al in 1978, the disorder usually presents mostly during the first decade of life. These patients have the threat of adrenal crisis, shock, and hypoglycemia and are usually on steroid supplementation. CASE REPORT The anesthesiologist's encounter with such patients, although rare, is mostly for repair of the achalasia cardia. We thus report a similar case of AS in a 2-year-old girl who was scheduled to undergo Heller myotomy along with the preoperative evaluation and intraoperative management of the same. CONCLUSION Being aware of the pathophysiology of AS gives useful insight about the disease and successful perioperative management in the form of the triple S strategy, that is, stress dose of steroids, slow induction and positioning, and finally maintenance of stable hemodynamics and euglycemia.
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Kallabi F, Belghuith N, Aloulou H, Kammoun T, Ghorbel S, Hajji M, Gallas S, Chemli J, Chabchoub I, Azzouz H, Ben Chehida A, Sfaihi L, Makni S, Amouri A, Keskes L, Tebib N, Ben Becher S, Hachicha M, Kamoun H. Clinical and Genetic Characterization of 26 Tunisian Patients with Allgrove Syndrome. Arch Med Res 2016; 47:105-10. [PMID: 27133709 DOI: 10.1016/j.arcmed.2016.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 04/11/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIMS Allgrove syndrome is characterized by achalasia, alacrima, and adrenal insufficiency as well as being associated with progressive neurological signs. This is an autosomal recessive disorder due to mutations in the AAAS gene located on chromosome 12q13. The AAAS gene encodes a protein of 546 amino acids, ALADIN. Mutations in this genwere reported in families from North Africa and Europe. Our objective is to conduct a clinical, molecular and genetic study of 26 Tunisian patients with Allgrove syndrome. METHODS We report 26 Tunisian patients with between two and four clinical features associated with Allgrove syndrome. Blood samples were collected and isolated DNA derived from subjects was amplified. The entire sequence of the AAAS gene was analyzed by PCR and sequencing. PCR-RFLP method was performed to identify the frequent mutations found. RESULTS Sequencing of the AAAS gene revealed a major homozygous mutation (c.1331+1G>A) in 25 patients and R286X mutation in one patient. The presence of a major mutation in several unrelated affected individuals suggests the presence of a founder effect in Tunisia and allows for a fast and targeted molecular diagnosis. CONCLUSIONS We created an easy and rapid molecular enzymatic protocol based on PCR-RFLP using MvaI restriction enzyme that directly targets this major mutation and can be used for prenatal diagnosis and genetic counseling for Tunisian families at risk. To the best of our knowledge, this is the first major series report of Allgrove syndrome in Tunisia.
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Abstract
Triple A syndrome, also known as Allgrove syndrome, is a rare disease, and presents mainly in children. Its cardinal symptoms are achalasia, alacrima, and adrenocorticotropic hormone (ACTH) insensitivity. We report three cases of Triple A syndrome. Our aim is to inform pediatric surgeons about the existence of this rare syndrome and to highlight the need for suspicion of alacrima and ACTH insensitivity in cases of pediatric achalasia. Triple A syndrome should be considered in patients presenting with achalasia. Alacrima should be investigated by a Schirmer test, and adrenal dysfunction should be tested in cases of suspected triple A.
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Li W, Gong C, Qi Z, Wu DI, Cao B. Identification of AAAS gene mutation in Allgrove syndrome: A report of three cases. Exp Ther Med 2015; 10:1277-1282. [PMID: 26622478 PMCID: PMC4578041 DOI: 10.3892/etm.2015.2677] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 07/09/2015] [Indexed: 01/11/2023] Open
Abstract
Allgrove syndrome (AS) is an autosomal recessive congenital disease, caused by mutations in the AAAS gene, and is characterized by the triad of Addison's disease, achalasia and alacrima. The present study describes three newly diagnosed cases of AS, in which genetic analysis of the AAAS gene was used to identify AAAS gene mutations, to enhance the understanding of the pathogenesis and clinical manifestations of AS in the Chinese population. Two of the cases exhibited homozygous mutations of c.771delG (p.Arg258GlyfsX33) in exon 8 and one case exhibited a homozygous mutation of c.1366C>T (p.Q456X) in exon 15. A review of the current literature suggests that the AAAS c.771delG mutation has only been reported in the Chinese population. Genetic analysis of the AAAS gene in Chinese AS patients at a young age may facilitate an earlier diagnosis and the timely initiation of the appropriate treatment, ultimately improving the patient outcome.
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Affiliation(s)
- Wenjing Li
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, Beijing 100045, P.R. China
| | - Chunxiu Gong
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, Beijing 100045, P.R. China
| | - Zhan Qi
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, Beijing 100045, P.R. China
| | - D I Wu
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, Beijing 100045, P.R. China
| | - Bingyan Cao
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, Beijing 100045, P.R. China
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Abstract
Allgrove syndrome is a rare autosomal recessive disorder, which manifests with adrenal insufficiency, achalasia cardia and alacrimia. Autonomic neuropathy can also be associated with it. Adrenal crisis can be precipitated by surgery, infection or trauma. This disorder poses a challenge to anaesthesiologists during anaesthesia for various surgeries. We report the anaesthetic management of a child with Allgrove syndrome.
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Affiliation(s)
- Bg Arun
- Department of Anaesthesiology, Critical Care and Pain, Fortis Hospital, Bengaluru, Karnataka, India
| | - Bs Deepak
- Department of Anaesthesiology, Critical Care and Pain, Fortis Hospital, Bengaluru, Karnataka, India
| | - Murali R Chakravarthy
- Department of Anaesthesiology, Critical Care and Pain, Fortis Hospital, Bengaluru, Karnataka, India
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Vishnu VY, Modi M, Prabhakar S, Bhansali A, Goyal MK. "A" motor neuron disease. J Neurol Sci 2014; 336:251-3. [PMID: 24139699 DOI: 10.1016/j.jns.2013.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Revised: 09/22/2013] [Accepted: 10/01/2013] [Indexed: 02/04/2023]
Abstract
IMPORTANCE Allgrove syndrome is a rare autosomal recessive disorder characterised by achalasia, alacrima, adrenal insufficiency, autonomic dysfunction and amyotrophy. The syndrome has been described in childhood and adult presentation, as in our case, is very rare. There is a considerable delay in diagnosis due to lack of awareness about the syndrome. OBSERVATIONS We report a single case of a 36 year old man who was initially diagnosed and treated for achalasia cardia in our institute 14 years before. After 8 years he presented again with weakness and wasting predominantly distally. He had tongue fasciculations, brisk reflexes and extensor plantar. After supportive electrophysiological studies he was diagnosed as Amyotrophic lateral sclerosis. After 5 years he presented with generalised fatigue without any significant worsening of his neurological status. On reevaluation he had alacrimia, autonomic dysfunction and mild ACTH resistance. CONCLUSIONS AND RELEVANCE Allgrove syndrome may be an underdiagnosed cause of multisystem neurological disease due to the heterogeneous clinical presentation as well as for ignorance of clinician about the syndrome. Based on our case, we also believe that there does exist a subgroup of patients who follow a less severe and chronic course. Recognition of syndrome allows for treatment of autonomic dysfunction, adrenal insufficiency and dysphagia.
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Parhizkar B, Maghsoodi N, Forootan M, Entezari AH. A 12 year old boy with recurrent episodes of pneumonia: triple A syndrome. Gastroenterol Hepatol Bed Bench 2012; 5:112-5. [PMID: 24834210 PMCID: PMC4017457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Accepted: 02/29/2012] [Indexed: 11/22/2022]
Abstract
Triple A syndrome (Allgrove syndrome) is a rare inherited autosomal recessive disease with a typical triad including adrenocorticotrophic-hormone-resistant glucocorticoid insufficiency, reduced or absent tearing (alacrima) and achalasia and a wide range of symptoms can be detected due to multi organ involvement. This report describes the case of a Triple Asyndrome, a12 year-old boy with a history of recurrent episodes of pneumonia and growth retardation due to failure to timely diagnosis of his problem.
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Affiliation(s)
- Baran Parhizkar
- Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nakisa Maghsoodi
- Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mojgan Forootan
- Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Razavi Z, Taghdiri MM, Eghbalian F, Bazzazi N. Premature Loss of Permanent Teeth in Allgrove (4A) Syndrome in Two Related Families. Iran J Pediatr 2010; 20:101-6. [PMID: 23056690 PMCID: PMC3446014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/07/2009] [Revised: 04/27/2009] [Accepted: 05/06/2009] [Indexed: 11/11/2022]
Abstract
BACKGROUND Allgrove syndrome is a rare autosomal recessive condition characterized by adrenal insufficiency, achalasia, alacrima and occasionally autonomic disturbances. Mutations in the AAAS gene, on chromosome 12q13 have been implicated as a cause of this disorder. CASE(S) PRESENTATION We present various manifestations of this syndrome in two related families each with two affected siblings in which several members had symptoms including reduced tear production, mild developmental delay, achalasia, neurological disturbances and also premature loss of permanent teeth in two of them. CONCLUSION The importance of this report is dental involvement (loss of permanent teeth) in Allgrove syndrome that has not been reported in literature.
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Affiliation(s)
- Zahra Razavi
- Department of Pediatrics, Hamadan University of Medical Sciences, IR Iran,Corresponding Author:Address: Be'ssat Hospital, Hamadan, IR Iran E-mail:
| | | | - Fatemeh Eghbalian
- Department of Pediatrics, Hamadan University of Medical Sciences, IR Iran
| | - Nooshin Bazzazi
- Department of Ophthalmology, Hamadan University of Medical Sciences, IR Iran
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