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Abdelrahman HA, Akawi N, Al-Shamsi AM, Ali A, Al-Jasmi F, John A, Hertecant J, Al-Gazali L, Ali BR. Bi-allelic null variant in matrix metalloproteinase-15, causes congenital cardiac defect, cholestasis jaundice, and failure to thrive. Clin Genet 2022; 101:403-410. [PMID: 34988996 DOI: 10.1111/cge.14107] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 02/05/2023]
Abstract
Here, we delineate the phenotype of two siblings with a bi-allelic frameshift variant in MMP15 gene with congenital cardiac defects, cholestasis, and dysmorphism. Genome sequencing analysis revealed a recently reported homozygous frameshift variant (c.1058delC, p.Pro353Glnfs*102) in MMP15 gene that co-segregates with the phenotype in the family in a recessive mode of inheritance. Relative quantification of MMP15 mRNA showed evidence of degradation of the mutated transcript, presumably by nonsense mediated decay. Likewise, MMP15: p.Gly231Arg, a concurrently reported homozygous missense variant in another patient exhibiting a similar phenotype, was predicted to disrupt zinc ion binding to the MMP-15 enzyme catalytic domain, which is essential for substrate proteolysis, by structural modeling. Previous animal models and cellular findings suggested that MMP15 plays a crucial role in the formation of endocardial cushions. These findings confirm that MMP15 is an important gene in human development, particularly cardiac, and that its loss of function is likely to cause a severe disorder phenotype.
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Affiliation(s)
- Hanadi A Abdelrahman
- Department of Genetics and Genomics, College of Medicine and Heath Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Nadia Akawi
- Department of Genetics and Genomics, College of Medicine and Heath Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Aisha M Al-Shamsi
- Paediatrics Department, Tawam hospital, Al-Ain, United Arab Emirates
| | - Amanat Ali
- Department of Genetics and Genomics, College of Medicine and Heath Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Fatma Al-Jasmi
- Department of Genetics and Genomics, College of Medicine and Heath Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.,Department of Paediatrics, College of Medicine and Heath Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Anne John
- Department of Genetics and Genomics, College of Medicine and Heath Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Jozef Hertecant
- Paediatrics Department, Tawam hospital, Al-Ain, United Arab Emirates
| | - Lihadh Al-Gazali
- Department of Paediatrics, College of Medicine and Heath Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Bassam R Ali
- Department of Genetics and Genomics, College of Medicine and Heath Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.,Zayed Center for Health sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
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2
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Bonilla-Fornés S, Galán-Ledesma L, Pérez PM, Modamio-Høybjør S, Carbonell-Pérez JM, Parrón-Pajares M, Heath KE, Galán-Gómez E. Early clinical and radiological improvement in a young boy with metaphyseal anadysplasia type 2. Eur J Med Genet 2021; 64:104307. [PMID: 34407464 DOI: 10.1016/j.ejmg.2021.104307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/28/2021] [Accepted: 08/12/2021] [Indexed: 11/29/2022]
Abstract
Metaphyseal anadysplasia is a very rare hereditary skeletal dysplasia with onset occurring normally during the second and third years of life, but unlike many other dysplasias, symptoms appear to resolve by adolescence. Two types exist, the more severe form, type 1, with both autosomal dominant and recessive inheritance due to pathogenic variants in MMP13, whilst type 2, an even rarer form is due to biallelic MMP9 variants. To date, only two metaphyseal anadysplasia type 2 families have been reported. We describe a third family, a young boy, born to consanguineous parents, referred at 19 months old for abnormal gait due to bowed legs. Clinical and radiological examination revealed scoliosis, genu varum and metaphyseal abnormalities. A homozygous MMP9 nonsense variant, NM_004994.2:c.1764G>A; p.(Trp588*) was identified. By the age of 39 months, lower limb alignment and metaphyseal features had already significantly improved and scoliosis had disappeared. This case confirms that biallelic MMP9 variants cause this very rare skeletal dysplasia, metaphyseal anadysplasia type 2 but also shows that the skeletal manifestations can improve within a short period time and at an early age.
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Affiliation(s)
| | | | - Pilar Méndez Pérez
- Department of Pediatrics, Clinical Genetics Unit, University Children's Hospital, Badajoz, Spain
| | - Silvia Modamio-Høybjør
- Institute of Medical and Molecular Genetics (INGEMM), IdiPAZ and Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain; Skeletal Dysplasia Multidisciplinary Unit (UMDE) and ERN-BOND, Hospital Universitario La Paz, Madrid, Spain
| | | | - Manuel Parrón-Pajares
- Skeletal Dysplasia Multidisciplinary Unit (UMDE) and ERN-BOND, Hospital Universitario La Paz, Madrid, Spain; Dept. of Radiology, Hospital Universitario La Paz, Madrid, Spain
| | - Karen E Heath
- Institute of Medical and Molecular Genetics (INGEMM), IdiPAZ and Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain; Skeletal Dysplasia Multidisciplinary Unit (UMDE) and ERN-BOND, Hospital Universitario La Paz, Madrid, Spain; CIBERER, ISCIII, Madrid, Spain.
| | - Enrique Galán-Gómez
- Department of Pediatrics, Clinical Genetics Unit, University Children's Hospital, Badajoz, Spain; Chair of Pediatrics, Department of Biomedical Sciences, University of Extremadura, Badajoz, Spain.
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3
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Diaz Escagedo P, Fiscaletti M, Olivier P, Hudon C, Miranda V, Miron MC, Campeau PM, Alos N. Rickets manifestations in a child with metaphyseal anadysplasia, report of a spontaneously resolving case. BMC Pediatr 2021; 21:248. [PMID: 34022834 PMCID: PMC8140414 DOI: 10.1186/s12887-021-02716-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/12/2021] [Indexed: 12/04/2022] Open
Abstract
Introduction Rickets is not an unusual diagnosis for pediatricians even currently in developed countries. Children typically present with leg bowing, enlargement of wrists, rachitic rosary (swelling of costochondral junctions) and/or waddling gait. But not every child with growth delay and enlarged metaphyses is diagnosed with rickets. Metaphyseal anadysplasia (MAD) is a disorder of variable severity with metaphyseal flaring and irregularities, without vertebral abnormalities. MAD is characterized by an early onset and a regressive course in late childhood without treatment, despite persistent short stature. Autosomal dominant or recessive variants in the matrix metalloproteinase 13 gene (MMP13) are responsible for these transient metaphyseal changes. Case presentation We report a new pathogenic heterozygous variant in MMP13 (NM_002427.4: c.216G>C, p.Gln72His) in a toddler, initially thought to have rickets, and his father, with MAD phenotypes. Additionally, we review the seven reported MMP13 variants. Conclusion One should keep a wide differential diagnosis in cases of suspected rickets, including skeletal dysplasias which might have a regressive course. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02716-x.
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Affiliation(s)
- Patricia Diaz Escagedo
- Bone and mineral Clinic, Sainte-Justine Hospital Center, Department of Pediatrics, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada
| | - Melissa Fiscaletti
- Bone and mineral Clinic, Sainte-Justine Hospital Center, Department of Pediatrics, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada
| | - Patricia Olivier
- Bone and mineral Clinic, Sainte-Justine Hospital Center, Department of Pediatrics, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada
| | - Chloé Hudon
- Medical Genetics Service, Sainte-Justine Hospital Center, Department of Pediatrics, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada
| | - Valancy Miranda
- Medical Genetics Service, Sainte-Justine Hospital Center, Department of Pediatrics, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada
| | - Marie-Claude Miron
- Radiology Department, Sainte-Justine Hospital Center, Department of Pediatrics, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada
| | - Philippe M Campeau
- Medical Genetics Service, Sainte-Justine Hospital Center, Department of Pediatrics, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada. .,Research Center, Sainte-Justine Hospital Center, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada.
| | - Nathalie Alos
- Bone and mineral Clinic, Sainte-Justine Hospital Center, Department of Pediatrics, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada. .,Research Center, Sainte-Justine Hospital Center, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, Canada.
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4
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Su J, Zhang J, Zhu J, Liu Y. The promoting effect of MMP13 on mediating the development of HFLS-RA by the target of miR-19a through IL-17 signaling pathway. J Cell Biochem 2020; 121:4282-4294. [PMID: 31960999 DOI: 10.1002/jcb.29609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 12/19/2019] [Indexed: 02/05/2023]
Abstract
By investigating the expression profiles of miR-19a and metalloproteinases (MMP13) in human fibroblast-like synoviocytes-rheumatoid arthritis (HFLS-RA) and HFL cells lines, this study intends to confirm the directly target connection between them and reveal the effect of suppressing MMP13 on HLFS-RA migration, invasion and apoptosis. After screening the abnormal expressed messenger RNAs and microRNAs in synovial tissues of patients with RA, the underlying pathway was determined by Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis. The HFLS-RA cell line was transfected for the following experiments with pcDNA3.1(+) served as vector. The directly target association between miR-19a and MMP13 was confirmed by Luciferase reporter assay. Microarray analysis suggested that MMP13 was upregulated while miR-19a was downregulated in HFLS of RA tissues compared with the healthy control group. MMP13 was related to many proteins in protein-protein interaction network, which might be the main influencing factor of RA. KEGG pathway analysis identified that interleukin (IL)-17 pathway was activated in the regulation of MMP13 in the development of RA. Through observing the alteration of luciferase activity, miR-19a could indeed bind to the 3'UTR of the downstream of MMP13, the target association was then confirmed. The proliferation and invasion of HFLS-RA were promoted by overexpressing MMP13 protein. miR-19a could function as a suppressor of MMP13 and thereby retard the severity of RA. The results showed that miR-19a could regulate the expression of MMP13 in HFLS-RA by mediating the proliferation and invasion of HFLS-RA through IL-17 signaling pathway, thereby participating in the degradation of chondrocytes in the progression of RA.
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Affiliation(s)
- Jiang Su
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China.,Department of Rheumatology and Immunology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
| | - Jing Zhang
- Department of Rheumatology and Immunology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
| | - Jing Zhu
- Department of Rheumatology and Immunology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
| | - Yi Liu
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
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Balasubramaniyan M, Kaur A, Sinha A, Gopinathan NR. Metaphyseal dysplasia, Spahr type: a mimicker of rickets. BMJ Case Rep 2019; 12:12/8/e230257. [PMID: 31413057 DOI: 10.1136/bcr-2019-230257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Metaphyseal dysplasias are a heterogeneous group of skeletal dysplasias characterised by metaphyseal irregularities. Due to the presence of metaphyseal changes accompanied with bowing deformity of lower limb, they are likely to be mistaken for rickets. We present a case of a 7-year-old boy, finally diagnosed with metaphyseal dysplasia, Spahr type (MDST) (OMIM # 250400) after his exome sequencing revealed novel variations in the MMP13 gene (OMIM * 600108). This is a rare skeletal dysplasia with only a few cases reported in literature. A compilation of the presentation of the reported cases is given to help the reader understand this rare disorder. To the best of our knowledge, this case of MDST is the first to be reported from India.
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Affiliation(s)
- Muthuvel Balasubramaniyan
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anupriya Kaur
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anindita Sinha
- Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nirmal Raj Gopinathan
- Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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6
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Chlorogenic Acid Alleviates Thiram-Induced Tibial Dyschondroplasia by Modulating Caspases, BECN1 Expression and ECM Degradation. Int J Mol Sci 2019; 20:ijms20133160. [PMID: 31261680 PMCID: PMC6651234 DOI: 10.3390/ijms20133160] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 12/13/2022] Open
Abstract
Chlorogenic acid (CGA) is a widely applied traditional Chinese medicine ingredient which can be used for the treatment of osteoporosis. In this experiment, we investigated the potential therapeutic effect of chlorogenic acid on thiram-induced tibial dyschondroplasia (TD) and explored the underlying mechanisms that have been rarely mentioned by others yet. Performance indicator analysis and tibial parameter analysis showed that CGA exhibited a definite positive effect on thiram-induced TD chickens. In order to further explore the mechanisms underlying the positive actions of CGA, apoptotic, autophagic genes and MMPs involved in matrix mineralization of growth plate were evaluated in this study. The results showed that CGA decreased the expression of pro-apoptotic genes caspases-3 and caspases-9, leading to the reduction of apoptotic cells accumulated in growth plate. In addition, CGA also increased the level of BECN1, an important gene involved in autophagy, which benefits the survival of abnormal cells. Furthermore, CGA also increased the expression of MMP-9, MMP-10, and MMP-13, which can directly affect the ossification of bones. Altogether, these results demonstrate that CGA possesses a positive therapeutic effect on thiram-induced TD via modulating the expression of caspases and BECN1 and regulating the degradation of ECM (extracellular matrix).
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7
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Song C, Li N, Hu X, Shi Y, Chen L, Zhou T, Xu X, Shen J, Zhu M. A de novo variant in MMP13 identified in a patient with dominant metaphyseal anadysplasia. Eur J Med Genet 2018; 62:103575. [PMID: 30439533 DOI: 10.1016/j.ejmg.2018.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 10/05/2018] [Accepted: 11/09/2018] [Indexed: 01/26/2023]
Abstract
Metaphyseal anadysplasia 1 (MIM# 602111) belongs to a heterogeneous group of skeletal diseases characterized by an autosomal dominant form of growth defects due to metaphyseal changes with epiphyseal involvement similar to other metaphyseal disorders. Matrix metalloproteinase 13 encoded by MMP13 presumably plays important roles in bone formation and growth, and pathogenic variants in MMP13 have been identified to cause metaphyseal anadysplasia 1. Only six pathogenic variants in MMP13 have been previously reported worldwide. The genotype-phenotype correlation of MMP13-related disorders has not been fully understood. Here we reported the identification of a previously unreported pathogenic heterozygous de novo variant NM_002427.3:c.212T > C/p.Met71Thr in MMP13 in a Chinese male pediatric patient with metaphyseal anadysplasia 1 and additional phenotypes, including mild rickets-like changes observed on upper long bone metaphyses and patchy bone defects on the spine vertebrae particularly resolved by childhood. Our findings not only expand genotype and phenotype spectrums of MMP13-related disorders but also offer further information for precise diagnosis and classification of metaphyseal anadysplasia disorders.
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Affiliation(s)
- Cui Song
- Department of Endocrinology and Genetic Metabolic Diseases, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, 400014, Chongqing, China
| | - Niu Li
- Department of Medical Genetics and Molecular Diagnostic Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 200127, Shanghai, China
| | - Xuyun Hu
- Center for Medical Genetics, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, 100045, Beijing, China
| | - Yu Shi
- Department of Clinical Laboratory, Children's Hospital of Chongqing Medical University, 400014, Chongqing, China
| | - Lili Chen
- Department of Endocrinology and Genetic Metabolic Diseases, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, 400014, Chongqing, China
| | - Ting Zhou
- Department of Endocrinology and Genetic Metabolic Diseases, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, 400014, Chongqing, China
| | - Xuejiao Xu
- Department of Endocrinology and Genetic Metabolic Diseases, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, 400014, Chongqing, China
| | - Jun Shen
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
| | - Min Zhu
- Department of Endocrinology and Genetic Metabolic Diseases, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, 400014, Chongqing, China.
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8
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Matrix metalloproteinase-13: A special focus on its regulation by signaling cascades and microRNAs in bone. Int J Biol Macromol 2018; 109:338-349. [DOI: 10.1016/j.ijbiomac.2017.12.091] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 12/15/2017] [Accepted: 12/17/2017] [Indexed: 01/03/2023]
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9
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Sharony R, Borochowitz Z, Cohen L, Shtorch-Asor A, Rosenfeld R, Modai S, Reinstein E. Prenatal course of metaphyseal anadysplasia associated with homozygous mutation in MMP9 identified by exome sequencing. Clin Genet 2017; 92:645-648. [PMID: 28342220 DOI: 10.1111/cge.13020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 12/27/2016] [Accepted: 01/11/2017] [Indexed: 11/28/2022]
Abstract
Metaphyseal anadysplasia (MANDP) is a rare autosomal recessive form of skeletal dysplasia characterized by normal length at birth and transitory bowing of the legs. Although several families with MANDP have been reported, homozygous mutations in the matrix metalloproteinase type 9 (MMP9) gene have been described in only one consanguineous family, and thus the pre and postnatal phenotypic spectrum is still obscure. A clinically similar but more severe type is caused by autosomal-dominant inheritance and is caused by mutations in matrix metalloproteinase type 13 gene (MMP13). Here, we report the prenatal and early postnatal course of two affected sib fetuses with early sonographic evidence of long bone shortening and postnatally no metaphyseal changes. Whole-exome sequencing revealed homozygous mutation in MMP9 in both fetuses suggesting a diagnosis of MANDP. We propose that MANDP should be considered in pregnancies with early prenatal shortening of the long bones without associated finding of lethal skeletal dysplasias. In addition, the finding of homozygous mutation in non-consanguineous parents of Jewish-Caucasus ancestry may suggest unawareness of such relation or the occurrence of a founder mutation in this gene.
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Affiliation(s)
- R Sharony
- Medical Genetics Institute, Meir Medical Center, Kfar Saba, Israel.,Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Z Borochowitz
- Rappaport Faculty of Medicine, Technion Israeli Institute of Technology, Haifa, Israel.,Genetics Clinic, Assuta Medical Center, Haifa, Israel
| | - L Cohen
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Raphael Recanati Genetics Institute, Rabin Medical Center, Beilinson Campus, Petah Tikva 4941492, Israel.,Pediatric Genetics Unit, Schneider Children's Medical Center of Israel, Petah Tikva 49202, Israel
| | - A Shtorch-Asor
- Medical Genetics Institute, Meir Medical Center, Kfar Saba, Israel
| | - R Rosenfeld
- Medical Genetics Institute, Meir Medical Center, Kfar Saba, Israel
| | - S Modai
- Clinical Operations, Variantyx, Inc, Herzliya, Israel
| | - E Reinstein
- Medical Genetics Institute, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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10
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Abstract
We report on two siblings of Iraqi descent with clinical and radiographic features of metaphyseal dysplasia, Spahr type (MDST), born to consanguineous unaffected parents. Molecular testing confirmed pathogenic mutations in MMP13. We review the considerable overlap between MDST and other related disorders. These cases confirm the phenotypic variability and regressive nature of MDST in addition to suggesting bone fragility as a feature.
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