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The Role of Genetic Testing in Patients with Heritable Thoracic Aortic Diseases. Diagnostics (Basel) 2023; 13:diagnostics13040772. [PMID: 36832261 PMCID: PMC9955043 DOI: 10.3390/diagnostics13040772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
Heritable thoracic aortic disease (HTAD) is a term used to define a large group of disorders characterized by the occurrence of aortic events, mainly represented by aneurysm or dissection. These events generally involve the ascending aorta, although the involvement of other districts of the aorta or peripheral vessels may occur. HTAD can be classified as non-syndromic if the disorder is limited to the aorta, and syndromic when associated with extra-aortic features. About 20-25% of patients with non-syndromic HTAD exhibit a family history of aortic disease. Thus, a careful clinical evaluation of the proband and the first-degree family members is required to differentiate familial and sporadic cases. Genetic testing is essential since it allows confirmation of the etiological diagnosis of HTAD (particularly in patients with a significant family history) and may guide family screening. In addition, genetic diagnosis significantly impacts patients' management since the different conditions significantly differ with respect to natural history and treatment strategies. The prognosis in all HTADs is determined by the progressive dilation of the aorta, potentially leading to acute aortic events, such as dissection or rupture. Moreover, the prognosis varies according to the underlying genetic mutations. This review aims to describe the clinical characteristics and natural history of the most common HTADs, with particular emphasis on the role of genetic testing in risk stratification and management.
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Gouda P, Kay R, Habib M, Aziz A, Aziza E, Welsh R. Clinical features and complications of Loeys-Dietz syndrome: A systematic review. Int J Cardiol 2022; 362:158-167. [PMID: 35662564 DOI: 10.1016/j.ijcard.2022.05.065] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/23/2022] [Accepted: 05/29/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Loeys-Dietz syndrome (LDS) is a connective tissue disorder that arises from mutations altering the transforming growth factor β signalling pathway. Due to the recent discovery of the underlying genetic mutations leading to LDS, the spectrum of characteristics and complications is not fully understood. METHODS Our search included five databases (Pubmed, SCOPUS, Web of Science, EMBASE and google scholar) and included variations of "Loeys-Dietz Syndrome" as search terms, using all available data until February 2021. All study types were included. Three reviewers screened 1394 abstracts, of which 418 underwent full-text review and 392 were included in the final analysis. RESULTS We identified 3896 reported cases of LDS with the most commonly reported features and complications being: aortic aneurysms and dissections, arterial tortuosity, high arched palate, abnormal uvula and hypertelorism. LDS Types 1 and 2 share many clinical features, LDS Type 2 appears to have a more aggressive aortic disease. LDS Type 3 demonstrated an increased prevalence of mitral valve prolapse and arthritis. LDS Type 4 and 5 demonstrated a lower prevalence of musculoskeletal and cardiovascular involvement. Amongst 222 women who underwent 522 pregnancies, 4% experienced an aortic dissection and the peripartum mortality rate was 1%. CONCLUSION We observed that LDS is a multisystem connective tissue disorder that is associated with a high burden of complications, requiring a multidisciplinary approach. Ongoing attempts to better characterise these features will allow clinicians to appropriately screen and manage these complications.
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Affiliation(s)
- Pishoy Gouda
- University of Alberta, Division of Cariology, Edmonton, Alberta, Canada
| | - Robert Kay
- University of Alberta, Division of Cariology, Edmonton, Alberta, Canada
| | - Marina Habib
- Flinders University, School of Medicine, Adelaide, Australia
| | - Amir Aziz
- University of Alberta, Division of Cariology, Edmonton, Alberta, Canada
| | - Eitan Aziza
- University of Alberta, Division of Cariology, Edmonton, Alberta, Canada
| | - Robert Welsh
- University of Alberta, Division of Cariology, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
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Prablek MA, LoPresti M, Bertot B, Morris SA, Bauer D, Lam S, Ravindra V. Evaluation of cervical spine pathology in children with Loeys-Dietz syndrome. Surg Neurol Int 2022; 13:96. [PMID: 35399906 PMCID: PMC8986760 DOI: 10.25259/sni_48_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/25/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Loeys-Dietz syndrome (LDS) is a genetic connective tissue disorder associated with multiple musculoskeletal anomalies, including cervical spine instability. We sought to examine the nature of imaging for cervical spine instability in children with LDS due to likely pathogenic or pathogenic variants in TGFBR1, TGFBR2, TGFB2, SMAD3, or TGFB3. Methods: A retrospective chart review was conducted, examining relevant data for all children with LDS screened at our institution from 2004 through 2021. Cervical spine X-rays were used to assess cervical instability, cervical lordosis, and basilar impression. Results: A total of 39 patients were identified; 16 underwent cervical spine screening (56.25% male). Median age at initial screening was 7 years (Q1-Q3: 3.75–14, range: 0.1–19). Six of 16 patients evaluated (37.5%) had radiographical evidence of cervical instability. Mean angles of cervical lordosis were 20° (SD = 14.1°, range = 4°–33°) and 17.3° (SD = 16.4°, range = 2°–41°), respectively. Three patients demonstrated radiographical basilar impression. Radiographic progression of cervical instability was seen in one case. All but two were managed conservatively with observation, one patient underwent surgical fixation and fusion of C1-2, the other underwent complex cervical reconstruction anterior and posterior instrumentation. Conclusion: Cervical spine evaluation is important in this cohort; we identified 37.5% had evidence of cervical spine instability, and many had concurrent spinal pathology. From our experience, we agree with the recent advisement for screening at diagnosis and for those previously diagnosed that have not undergone screening. Future study may outline more specific screening practices.
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Affiliation(s)
| | - Melissa LoPresti
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas,
| | - Brandon Bertot
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,
| | | | - David Bauer
- Departments of Neurosurgery, Texas Children’s Hospital, Houston, Texas,
| | - Sandi Lam
- Department of Neurosurgery, Lurie Children’s Hospital, Chicago, Illinois,
| | - Vijay Ravindra
- Department of Neurosurgery, University of California San Diego, San Diego, California, United States
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Riise N, Lindberg BR, Kulseth MA, Fredwall SO, Lundby R, Estensen ME, Drolsum L, Merckoll E, Krohg-Sørensen K, Paus B. Clinical diagnosis of Larsen syndrome, Stickler syndrome and Loeys-Dietz syndrome in a 19-year old male: a case report. BMC MEDICAL GENETICS 2018; 19:155. [PMID: 30170566 PMCID: PMC6119281 DOI: 10.1186/s12881-018-0671-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 08/22/2018] [Indexed: 01/06/2023]
Abstract
Background Larsen syndrome is a hereditary disorder characterized by osteochondrodysplasia, congenital large-joint dislocations, and craniofacial abnormalities. The autosomal dominant type is caused by mutations in the gene that encodes the connective tissue protein, filamin B (FLNB). Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder characterized by arterial aneurysms, dissections and tortuosity, and skeletal, including craniofacial, manifestations. Mutations in five genes involved in the transforming growth factor beta (TGF-β) signaling pathway cause five types of LDS. Stickler syndrome is a genetically heterogeneous arthro-ophthalmopathy caused by defects in collagen, exhibiting a wide specter of manifestations in connective tissue. A rare case is reported that was diagnosed with all these three hereditary connective tissue disorders. Case presentation A 19 year-old, Norwegian male with a clinical diagnosis of Larsen syndrome and with healthy, non-consanguineous parents attended a reference center for rare connective tissue disorders. Findings at birth were hypotonia, joint hypermobility, hyperextended knees, adductovarus of the feet, cervical kyphosis, craniofacial abnormalities, and an umbilical hernia. From toddlerhood, he required a hearing aid due to combined conductive and sensorineural hearing loss. Eye examination revealed hyperopia, astigmatism, and exotropia. At 10 years of age, he underwent emergency surgery for rupture of an ascending aortic aneurysm. At 19 years of age, a diagnostic re-evaluation was prompted by the findings of more distal aortic dilation, tortuosity of precerebral arteries, and skeletal findings. High throughput sequencing of 34 genes for hereditary connective tissue disorders did not identify any mutation in FLNB, but did identify a de novo missense mutation in TGFBR2 and a nonsense mutation in COL2A1 that was also present in his unaffected father. The diagnosis was revised to LDS Type 2. The patient also fulfills the proposed criteria for Stickler syndrome with bifid uvula, hearing loss, and a known mutation in COL2A1. Conclusion LDS should be considered in patients with a clinical diagnosis of Larsen syndrome, in particular in the presence of arterial aneurysms or tortuosity. Due to genetic heterogeneity and extensive overlap of clinical manifestations, genetic high throughput sequencing analysis is particularly useful for the differential diagnosis of hereditary connective tissue disorders.
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Affiliation(s)
- N Riise
- TRS National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesoddtangen, N-1450, Oslo, Norway.
| | - B R Lindberg
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | - M A Kulseth
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - S O Fredwall
- TRS National Resource Centre for Rare Disorders, Sunnaas Rehabilitation Hospital, Nesoddtangen, N-1450, Oslo, Norway
| | - R Lundby
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - M-E Estensen
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - L Drolsum
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - E Merckoll
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - K Krohg-Sørensen
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - B Paus
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Quiñones-Pérez B, VanNoy GE, Towne MC, Shen Y, Singh MN, Agrawal PB, Smith SE. Three-generation family with novel contiguous gene deletion on chromosome 2p22 associated with thoracic aortic aneurysm syndrome. Am J Med Genet A 2018; 176:560-569. [DOI: 10.1002/ajmg.a.38590] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 11/23/2017] [Accepted: 12/01/2017] [Indexed: 12/21/2022]
Affiliation(s)
- Bianca Quiñones-Pérez
- Division of Genetics and Genomics; Boston Children's Hospital; Boston Massachusetts
- Division of General Pediatrics; Boston Children's Hospital; Boston Massachusetts
| | - Grace E. VanNoy
- Division of Genetics and Genomics; Boston Children's Hospital; Boston Massachusetts
- The Manton Center for Orphan Disease Research; Boston Children's Hospital; Boston Massachusetts
| | - Meghan C. Towne
- Division of Genetics and Genomics; Boston Children's Hospital; Boston Massachusetts
- The Manton Center for Orphan Disease Research; Boston Children's Hospital; Boston Massachusetts
| | - Yiping Shen
- Division of Genetics and Genomics; Boston Children's Hospital; Boston Massachusetts
| | - Michael N. Singh
- Department of Cardiology; Boston Children's Hospital; Boston Massachusetts
| | - Pankaj B. Agrawal
- Division of Genetics and Genomics; Boston Children's Hospital; Boston Massachusetts
- The Manton Center for Orphan Disease Research; Boston Children's Hospital; Boston Massachusetts
- Division of Newborn Medicine; Boston Children's Hospital; Boston Massachusetts
| | - Sharon E. Smith
- Division of Genetics and Genomics; Boston Children's Hospital; Boston Massachusetts
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Valenzuela I, Fernández-Alvarez P, Munell F, Sanchez-Montanez A, Giralt G, Vendrell T, Tizzano EF. Arthrogryposis as neonatal presentation of Loeys-Dietz syndrome due to a novel TGFBR2 mutation. Eur J Med Genet 2017; 60:303-307. [PMID: 28344185 DOI: 10.1016/j.ejmg.2017.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/10/2017] [Accepted: 03/22/2017] [Indexed: 11/30/2022]
Abstract
Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder characterized mainly by cardiovascular, craniofacial and skeletal features. We report on a patient with LDS, whose prenatal examination was compatible with the diagnosis of arthrogryposis multiplex congenita. Neonatal assessment showed craniofacial and cardiovascular findings suggestive of LDS whose diagnosis was confirmed by the detection of a novel mutation (HGVN: NM_003242.5 (TGFBR2): c.1381T > C (p.(Cys461Arg))) in the TGFBR2 gene. Few prenatal and neonatal cases of LDS have been reported in the literature. We reviewed all cases reported to date with perinatal onset to delineate the clinical manifestations that allow us to prompt diagnosis of this syndrome at an early stage to prevent fatal cardiovascular complications. Furthermore we discuss the multidisciplinary follow up required in these patients.
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Affiliation(s)
- Irene Valenzuela
- Department of Clinical and Molecular Genetics and Rare Disease Unit, University Hospital Vall d'Hebron, CIBERER, Barcelona, Spain
| | - Paula Fernández-Alvarez
- Department of Clinical and Molecular Genetics and Rare Disease Unit, University Hospital Vall d'Hebron, CIBERER, Barcelona, Spain
| | - Francina Munell
- Neuropediatrics Service, University Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Gemma Giralt
- Pediatric Cardiology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Teresa Vendrell
- Department of Clinical and Molecular Genetics and Rare Disease Unit, University Hospital Vall d'Hebron, CIBERER, Barcelona, Spain
| | - Eduardo F Tizzano
- Department of Clinical and Molecular Genetics and Rare Disease Unit, University Hospital Vall d'Hebron, CIBERER, Barcelona, Spain.
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Cattalini M, Khubchandani R, Cimaz R. When flexibility is not necessarily a virtue: a review of hypermobility syndromes and chronic or recurrent musculoskeletal pain in children. Pediatr Rheumatol Online J 2015; 13:40. [PMID: 26444669 PMCID: PMC4596461 DOI: 10.1186/s12969-015-0039-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 10/01/2015] [Indexed: 01/09/2023] Open
Abstract
Chronic or recurrent musculoskeletal pain is a common complaint in children. Among the most common causes for this problem are different conditions associated with hypermobility. Pediatricians and allied professionals should be well aware of the characteristics of the different syndromes associated with hypermobility and facilitate early recognition and appropriate management. In this review we provide information on Benign Joint Hypermobility Syndrome, Ehlers-Danlos Syndrome, Marfan Syndrome, Loeys-Dietz syndrome and Stickler syndrome, and discuss their characteristics and clinical management.
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Affiliation(s)
- Marco Cattalini
- Pediatric Clinic, University of Brescia and Spedali Civili di Brescia, Brescia, Italy.
| | - Raju Khubchandani
- Pediatric Rheumatology Clinic, Department of Paediatrics, Jaslok Hospital and Research Centre, Mumbai, India.
| | - Rolando Cimaz
- Anna Meyer Children's Hospital and University of Florence, Florence, Italy.
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8
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Fuhrhop SK, McElroy MJ, Dietz HC, MacCarrick GL, Sponseller PD. High prevalence of cervical deformity and instability requires surveillance in Loeys-Dietz syndrome. J Bone Joint Surg Am 2015; 97:411-9. [PMID: 25740032 PMCID: PMC4344594 DOI: 10.2106/jbjs.n.00680] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Loeys-Dietz syndrome is a connective tissue disorder characterized by vascular, craniofacial, and musculoskeletal malformation. Our goal was to report the manifestations, surgical treatment, and complications in the cervical spine in patients with Loeys-Dietz syndrome. METHODS We reviewed the clinical and cervical spine imaging data of eighty patients with Loeys-Dietz syndrome who were seen at our institution from January 2005 through January 2014. Their mean age at presentation was 17.3 years (range, three months to seventy-five years). We tested associations with use of the Fisher exact test (type of TGF-βR [transforming growth factor-beta receptor] mutation and cervical abnormalities) and the Student t test (age at presentation and type of TGF-βR mutation) (significance, p = 0.05). RESULTS Vertebral anomalies and cervical instability were common; we found no significant association of TGF-βR-type with cervical abnormalities or age at presentation. Twenty-eight patients had atlas defects (anterior and/or posterior arch defects or hypoplasia), fifty-three had axis malformations (elongation, apex-anterior dens angulation, or spondylolysis), and twelve had focal kyphosis. Ten patients had hypoplastic subaxial vertebrae, leading to focal kyphosis (eight) and subaxial instability (nine). Eight patients had atlantoaxial instability. Of the thirteen patients with cervical instability, nine were treated surgically: fusion (eight patients) and halo application (one) (mean age, four years; range, three months to twelve years). Postoperative complications (seven patients) were pseudarthrosis, failure of fixation, junctional kyphosis or instability, and development of occipital-cervical instability. CONCLUSIONS Cervical midline defects (most often C1-C3) are common in Loeys-Dietz syndrome. Patients have a high prevalence of cervical instability, particularly a pattern of instability at C2-C3 associated with C3 vertebral body hypoplasia and C2-C3 focal kyphosis. Patients requiring surgery typically present in early childhood.
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Affiliation(s)
- Sara K. Fuhrhop
- c/o Rachel Box, MS, ELS, Senior Editor and Director,
Editorial Services, Department of Orthopaedic Surgery, The Johns Hopkins
University/Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, #A665,
Baltimore, MD 21224-2780. E-mail address for R. Box:
| | - Mark J. McElroy
- c/o Rachel Box, MS, ELS, Senior Editor and Director,
Editorial Services, Department of Orthopaedic Surgery, The Johns Hopkins
University/Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, #A665,
Baltimore, MD 21224-2780. E-mail address for R. Box:
| | - Harry C. Dietz
- c/o Rachel Box, MS, ELS, Senior Editor and Director,
Editorial Services, Department of Orthopaedic Surgery, The Johns Hopkins
University/Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, #A665,
Baltimore, MD 21224-2780. E-mail address for R. Box:
| | - Gretchen L. MacCarrick
- c/o Rachel Box, MS, ELS, Senior Editor and Director,
Editorial Services, Department of Orthopaedic Surgery, The Johns Hopkins
University/Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, #A665,
Baltimore, MD 21224-2780. E-mail address for R. Box:
| | - Paul D. Sponseller
- c/o Rachel Box, MS, ELS, Senior Editor and Director,
Editorial Services, Department of Orthopaedic Surgery, The Johns Hopkins
University/Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, #A665,
Baltimore, MD 21224-2780. E-mail address for R. Box:
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9
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Pieroni A, Castori M, Caso P, Di Bernardini E, De Michele M, Ritelli M, Colombi M, Toni D. Aortic dissection and stroke in a 37-year-old woman: discovering an emerging heritable connective tissue disorder. Intern Emerg Med 2015; 10:165-70. [PMID: 25589165 DOI: 10.1007/s11739-015-1187-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 12/30/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Alessio Pieroni
- Emergency Department Stroke Unit, Department of Neurology and Psychiatry, Policlinico Umberto I Hospital, Sapienza University, Viale del Policlinico 155, 00161, Rome, Italy,
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10
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MacCarrick G, Black JH, Bowdin S, El-Hamamsy I, Frischmeyer-Guerrerio PA, Guerrerio AL, Sponseller PD, Loeys B, Dietz HC. Loeys-Dietz syndrome: a primer for diagnosis and management. Genet Med 2014; 16:576-87. [PMID: 24577266 PMCID: PMC4131122 DOI: 10.1038/gim.2014.11] [Citation(s) in RCA: 335] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 01/13/2014] [Indexed: 12/20/2022] Open
Abstract
Loeys-Dietz syndrome is a connective tissue disorder predisposing individuals to aortic and arterial aneurysms. Presenting with a wide spectrum of multisystem involvement, medical management for some individuals is complex. This review of literature and expert opinion aims to provide medical guidelines for care of individuals with Loeys-Dietz syndrome.
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Affiliation(s)
- Gretchen MacCarrick
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sarah Bowdin
- Division of Clinical and Metabolic Genetics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | | | - Anthony L Guerrerio
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Bart Loeys
- Center for Medical Genetics, University of Antwerp, Antwerp, Belgium
| | - Harry C Dietz
- 1] McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA [2] Howard Hughes Institute, Chevy Chase, Maryland, USA
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11
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Rhodes SD, Wu X, He Y, Chen S, Yang H, Staser KW, Wang J, Zhang P, Jiang C, Yokota H, Dong R, Peng X, Yang X, Murthy S, Azhar M, Mohammad KS, Xu M, Guise TA, Yang FC. Hyperactive transforming growth factor-β1 signaling potentiates skeletal defects in a neurofibromatosis type 1 mouse model. J Bone Miner Res 2013; 28:2476-89. [PMID: 23703870 PMCID: PMC6774615 DOI: 10.1002/jbmr.1992] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 04/29/2013] [Accepted: 05/10/2013] [Indexed: 01/04/2023]
Abstract
Dysregulated transforming growth factor beta (TGF-β) signaling is associated with a spectrum of osseous defects as seen in Loeys-Dietz syndrome, Marfan syndrome, and Camurati-Engelmann disease. Intriguingly, neurofibromatosis type 1 (NF1) patients exhibit many of these characteristic skeletal features, including kyphoscoliosis, osteoporosis, tibial dysplasia, and pseudarthrosis; however, the molecular mechanisms mediating these phenotypes remain unclear. Here, we provide genetic and pharmacologic evidence that hyperactive TGF-β1 signaling pivotally underpins osseous defects in Nf1(flox/-) ;Col2.3Cre mice, a model which closely recapitulates the skeletal abnormalities found in the human disease. Compared to controls, we show that serum TGF-β1 levels are fivefold to sixfold increased both in Nf1(flox/-) ;Col2.3Cre mice and in a cohort of NF1 patients. Nf1-deficient osteoblasts, the principal source of TGF-β1 in bone, overexpress TGF-β1 in a gene dosage-dependent fashion. Moreover, Nf1-deficient osteoblasts and osteoclasts are hyperresponsive to TGF-β1 stimulation, potentiating osteoclast bone resorptive activity while inhibiting osteoblast differentiation. These cellular phenotypes are further accompanied by p21-Ras-dependent hyperactivation of the canonical TGF-β1-Smad pathway. Reexpression of the human, full-length neurofibromin guanosine triphosphatase (GTPase)-activating protein (GAP)-related domain (NF1 GRD) in primary Nf1-deficient osteoblast progenitors, attenuated TGF-β1 expression levels and reduced Smad phosphorylation in response to TGF-β1 stimulation. As an in vivo proof of principle, we demonstrate that administration of the TGF-β receptor 1 (TβRI) kinase inhibitor, SD-208, can rescue bone mass deficits and prevent tibial fracture nonunion in Nf1(flox/-) ;Col2.3Cre mice. In sum, these data demonstrate a pivotal role for hyperactive TGF-β1 signaling in the pathogenesis of NF1-associated osteoporosis and pseudarthrosis, thus implicating the TGF-β signaling pathway as a potential therapeutic target in the treatment of NF1 osseous defects that are refractory to current therapies.
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Affiliation(s)
- Steven D Rhodes
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, IN, USA; Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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12
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Chung BHY, Bradley T, Grosse-Wortmann L, Blaser S, Dirks P, Hinek A, Chitayat D. Hand and fibrillin-1 deposition abnormalities in Loeys-Dietz syndrome--expanding the clinical spectrum. Am J Med Genet A 2013; 164A:461-6. [PMID: 24194458 DOI: 10.1002/ajmg.a.36246] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 08/21/2013] [Indexed: 11/06/2022]
Abstract
Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder characterized by hypertelorism, bifid uvula, cleft palate and arterial tortuosity. We report on a patient with LDS, bearing mutation in the TGFβR2 gene, whose prenatal examination demonstrated clenched fists and club feet, suggesting arthrogryposis multiplex congenita. Postnatal assessment showed digital abnormalities, including brachydactyly, camptodactyly, partial syndactyly and absent distal phalanges. With the lack of fibrillin-1 microfibril deposition as well as impaired and inadequate elastic fiber assembly in our patient's fibroblasts, we speculate that the skeletal abnormalities seen in this patient with LDS are the result of lack of these components in embryonal perichondrium and in blood vessels. We suggest that LDS should be included in the differential diagnosis of joint contractures seen pre and postnatally. Prenatal diagnosis of LDS would be important in parental counseling and early post natal diagnosis could prompt treatment before the development of detrimental vascular complications.
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Affiliation(s)
- Brian H Y Chung
- Department of Paediatrics and Adolescent Medicine, Centre for Reproduction, Growth and Development, The University of Hong Kong, Hong Kong, Hong Kong
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13
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Kalra VB, Gilbert JW, Malhotra A. Loeys-Dietz syndrome: cardiovascular, neuroradiological and musculoskeletal imaging findings. Pediatr Radiol 2011; 41:1495-504; quiz 1616. [PMID: 21785848 DOI: 10.1007/s00247-011-2195-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2011] [Revised: 06/04/2011] [Accepted: 06/10/2011] [Indexed: 11/29/2022]
Abstract
Loeys-Dietz syndrome (LDS) is an increasingly recognized autosomal-dominant connective tissue disorder with distinctive radiological manifestations, including arterial tortuosity/aneurysms, craniofacial malformations and skeletal abnormalities. LDS exhibits a more aggressive course than similar disorders, such as Marfan or the vascular subtype of Ehlers-Danlos syndrome, with morbidity and mortality typically resulting from complications of aortic/arterial dissections. Early diagnosis, short-interval follow-up imaging and prophylactic surgical intervention are essential in preventing catastrophic cardiovascular complications. This review focuses on the cardiovascular, neuroradiological and musculoskeletal imaging findings in this disorder and recommendations for follow-up imaging.
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Affiliation(s)
- Vivek B Kalra
- Department of Diagnostic Radiology, Yale-New Haven Medical Center, Box 208042, Tompkins East 2, 333 Cedar St., New Haven, CT 06520-8042, USA
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