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Statha E, Paltoglou G, Doulgeraki A, Vakali E, Vlachopapadopoulou E, Economou S, Sakou II, Soldatou A, Karavanaki K, Fryssira E. A toddler with severe vitamin D-dependent rickets type 1 A (VDDR1A), hungry bone syndrome, and severe RSV infection: presentation and therapeutic challenges. Hormones (Athens) 2024:10.1007/s42000-024-00579-2. [PMID: 39034346 DOI: 10.1007/s42000-024-00579-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 06/25/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Vitamin D-dependent rickets type 1 A (VDDR1A) is an autosomal recessive disorder due to mutations in the CYP27B1 gene which result in inability to generate 1,25(OH)2D. CASE PRESENTATION An 18-month-old boy with VDDR1A presented with hypotonia and respiratory distress. He had been diagnosed 2 months earlier, having been evaluated for stunted growth, hypotonia, and delayed developmental milestones. He was stabilized with oxygen and bronchodilators for his bronchiolitis and high doses of alfacalcidol, calcium, and phosphate supplements for his hungry bone syndrome. Of note, the patient sustained upper limb fractures after a fall from his bed during admission. Overall, he had a protracted disease course; however, his bone profile gradually improved and he steadily recovered. CONCLUSION VDDR1A causes failure to thrive, hypotonia, and increased fracture risk and may complicate the clinical course of lower respiratory tract infections. Furthermore, management of hungry bone syndrome requires supraphysiologic doses of vitamin D metabolites and calcium.
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Affiliation(s)
- Eleni Statha
- 2nd Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), "P. & A. Kyriakou" Children's Hospital, Athens, Greece
| | - George Paltoglou
- 2nd Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), "P. & A. Kyriakou" Children's Hospital, Athens, Greece
| | - Artemis Doulgeraki
- Department of Bone and Mineral Metabolism, Institute of Child Health, Athens, Greece
| | - Eleni Vakali
- Department of Endocrinology-Growth and Development, P. & A. Kyriakou Children's Hospital, Athens, Greece
| | - Elpis Vlachopapadopoulou
- Department of Endocrinology-Growth and Development, P. & A. Kyriakou Children's Hospital, Athens, Greece.
| | - Stavroula Economou
- 2nd Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), "P. & A. Kyriakou" Children's Hospital, Athens, Greece
| | - Irini-Ikbale Sakou
- 2nd Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), "P. & A. Kyriakou" Children's Hospital, Athens, Greece
| | - Alexandra Soldatou
- 2nd Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), "P. & A. Kyriakou" Children's Hospital, Athens, Greece
| | - Kyriaki Karavanaki
- 2nd Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), "P. & A. Kyriakou" Children's Hospital, Athens, Greece
| | - Elena Fryssira
- Medical Genetics Laboratory, National and Kapodistrian University of Athens (NKUA), Aghia Sophia Children's Hospital, Athens, Greece
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Wang LKP, Shanmugasundaram M, Cooney E, Lee PDK. Siblings with vitamin D-dependent rickets type 1A: Importance of genetic testing and a review of genotype-phenotype correlations. Am J Med Genet A 2024:e63780. [PMID: 38822637 DOI: 10.1002/ajmg.a.63780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/09/2024] [Accepted: 05/18/2024] [Indexed: 06/03/2024]
Abstract
Vitamin D-dependent rickets type 1A (VDDR1A) is a rare condition caused by biallelic pathogenic variants in CYP27B1, which encodes 25-hydroxyvitamin D3-1-α-hydroxylase. Inadequate activity of this enzyme results in deficient 1α-hydroxylation of inactive 25-hydroxyvitamin D to biologically active 1,25-dihydroxyvitamin D, with consequent adverse effects on calcium and phosphate metabolism. A female child was clinically diagnosed at 18 months old with hypophosphatemic rickets based on phenotype and biochemical testing, with neither parent affected. A subsequent affected male sibling led to the reconsideration of the diagnosis. Exome sequencing showed a homozygous CYP27B1 c.1040T>A (p.Ile347Asn) variant for both children. No variants were found in genes associated with hypophosphatemic rickets. A review of published cases of VDDR1A with homozygous CYP27B1 variants indicates variable clinical presentation, lack of genotype-phenotype correlation, and low serum phosphate at diagnosis in most cases. These findings emphasize the clinical importance of molecular testing as part of the diagnostic evaluation for cases of non-nutritional rickets.
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Affiliation(s)
| | | | - Erin Cooney
- Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas, USA
| | - Phillip D K Lee
- Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas, USA
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Wimalawansa SJ. Physiology of Vitamin D-Focusing on Disease Prevention. Nutrients 2024; 16:1666. [PMID: 38892599 PMCID: PMC11174958 DOI: 10.3390/nu16111666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 05/23/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024] Open
Abstract
Vitamin D is a crucial micronutrient, critical to human health, and influences many physiological processes. Oral and skin-derived vitamin D is hydroxylated to form calcifediol (25(OH)D) in the liver, then to 1,25(OH)2D (calcitriol) in the kidney. Alongside the parathyroid hormone, calcitriol regulates neuro-musculoskeletal activities by tightly controlling blood-ionized calcium concentrations through intestinal calcium absorption, renal tubular reabsorption, and skeletal mineralization. Beyond its classical roles, evidence underscores the impact of vitamin D on the prevention and reduction of the severity of diverse conditions such as cardiovascular and metabolic diseases, autoimmune disorders, infection, and cancer. Peripheral target cells, like immune cells, obtain vitamin D and 25(OH)D through concentration-dependent diffusion from the circulation. Calcitriol is synthesized intracellularly in these cells from these precursors, which is crucial for their protective physiological actions. Its deficiency exacerbates inflammation, oxidative stress, and increased susceptibility to metabolic disorders and infections; deficiency also causes premature deaths. Thus, maintaining optimal serum levels above 40 ng/mL is vital for health and disease prevention. However, achieving it requires several times more than the government's recommended vitamin D doses. Despite extensive published research, recommended daily intake and therapeutic serum 25(OH)D concentrations have lagged and are outdated, preventing people from benefiting. Evidence suggests that maintaining the 25(OH)D concentrations above 40 ng/mL with a range of 40-80 ng/mL in the population is optimal for disease prevention and reducing morbidities and mortality without adverse effects. The recommendation for individuals is to maintain serum 25(OH)D concentrations above 50 ng/mL (125 nmol/L) for optimal clinical outcomes. Insights from metabolomics, transcriptomics, and epigenetics offer promise for better clinical outcomes from vitamin D sufficiency. Given its broader positive impact on human health with minimal cost and little adverse effects, proactively integrating vitamin D assessment and supplementation into clinical practice promises significant benefits, including reduced healthcare costs. This review synthesized recent novel findings related to the physiology of vitamin D that have significant implications for disease prevention.
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Kaygusuz SB, Alavanda C, Kirkgoz T, Eltan M, Yavas Abali Z, Helvacioglu D, Guran T, Ata P, Bereket A, Turan S. Does Genotype-Phenotype Correlation Exist in Vitamin D-Dependent Rickets Type IA: Report of 13 New Cases and Review of the Literature. Calcif Tissue Int 2021; 108:576-586. [PMID: 33386952 DOI: 10.1007/s00223-020-00784-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/28/2020] [Indexed: 11/28/2022]
Abstract
Vitamin D-dependent rickets type IA (VDDR-IA) is caused by biallelic mutations in CYP27B1. Data regarding genotype-phenotype correlation in VDDR-IA are scarce. Here, we aimed to investigate clinical/genotypic features and long-term follow-up of 13 new cases with VDDR-IA and genotype-phenotype correlation of reported cases in the literature. Thirteen patients with VDDR-IA were evaluated. Eight patients had reached their final height at the time of the study and, for whom, long-term outcome data were analyzed. Further, all VDDR-IA patients in the literature (n:183) were analyzed and clinical-genetic features were recorded. The median age of diagnosis was 2.55 ± 1.13 (1.0-12) years. Initial diagnoses before referral to our clinic were nutritional rickets (n:7), hypophosphatemic rickets (n:2), and pseudohypoparathyroidism (n:1). All had biochemical evidence suggestive of VDDR-IA; except one with elevated 1,25(OH)2D3 and another with hyperphosphatemia, in whom pseudohypoparathyroidism was excluded with molecular tests. Combined analyses of our cohort and other series in the literature demonstrated that three most common CYP27B1 mutations are p.F443Pfs*24, c.195 + 2T > G, and p.V88Wfs*71. In Turkish population, p.K192E mutation along with the former two is the most common mutations. Comparison of clinical features demonstrated that c.195 + 2T > G mutation causes the most severe and p.K192E mutation causes the least severe phenotype with respect to age and height at presentation and calcitriol requirement. We found a clear genotype-phenotype correlation in VDDR-IA, notably CYP27B1 intronic c.195 + 2T > G mutation causes a more severe phenotype with lower height SDS at presentation and, higher calcitriol requirement, while less severe phenotype occurs in p.K192E mutation.
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Affiliation(s)
- Sare Betul Kaygusuz
- Department of Pediatric Endocrinology and Diabetes, Marmara University School of Medicine, Istanbul, Turkey
| | - Ceren Alavanda
- Department of Medical Genetics, Marmara University School of Medicine, Istanbul, Turkey
| | - Tarik Kirkgoz
- Department of Pediatric Endocrinology and Diabetes, Marmara University School of Medicine, Istanbul, Turkey
| | - Mehmet Eltan
- Department of Pediatric Endocrinology and Diabetes, Marmara University School of Medicine, Istanbul, Turkey
| | - Zehra Yavas Abali
- Department of Pediatric Endocrinology and Diabetes, Marmara University School of Medicine, Istanbul, Turkey
| | - Didem Helvacioglu
- Department of Pediatric Endocrinology and Diabetes, Marmara University School of Medicine, Istanbul, Turkey
| | - Tulay Guran
- Department of Pediatric Endocrinology and Diabetes, Marmara University School of Medicine, Istanbul, Turkey
| | - Pinar Ata
- Department of Medical Genetics, Marmara University School of Medicine, Istanbul, Turkey
| | - Abdullah Bereket
- Department of Pediatric Endocrinology and Diabetes, Marmara University School of Medicine, Istanbul, Turkey
| | - Serap Turan
- Department of Pediatric Endocrinology and Diabetes, Marmara University School of Medicine, Istanbul, Turkey.
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Bonaretti S, Majumdar S, Lang TF, Khosla S, Burghardt AJ. The comparability of HR-pQCT bone measurements is improved by scanning anatomically standardized regions. Osteoporos Int 2017; 28:2115-2128. [PMID: 28391447 PMCID: PMC5526099 DOI: 10.1007/s00198-017-4010-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 03/13/2017] [Indexed: 12/16/2022]
Abstract
UNLABELLED We investigated the sensitivity of distal bone density, structure, and strength measurements by high-resolution peripheral quantitative computed tomography (HR-pQCT) to variability in limb length. Our results demonstrate that HR-pQCT should be performed at a standard %-of-total-limb-length to avoid substantial measurement bias in population study comparisons and the evaluation of individual skeletal status in a clinical context. INTRODUCTION High-resolution peripheral quantitative computed tomography (HR-pQCT) measures of bone do not account for anatomic variability in bone length: a 1-cm volume is acquired at a fixed offset from an anatomic landmark. Our goal was to evaluate HR-pQCT measurement variability introduced by imaging fixed vs. proportional volumes and to propose a standard protocol for relative anatomic positioning. METHODS Double-length (2-cm) scans were acquired in 30 adults. We compared measurements from 1-cm sub-volumes located at the default fixed offset, and the average %-of-length offset. The average position corresponded to 4.0% ± 1.1 mm for radius, and 7.2% ± 2.2 mm for tibia. We calculated the RMS difference in bone parameters and T-scores to determine the measurement variability related to differences in limb length. We used anthropometric ratios to estimate the mean limb length for published HR-pQCT reference data, and then calculated mean %-of-length offsets. RESULTS Variability between fixed vs. relative scan positions was highest in the radius, and for cortical bone in general (RMS difference Ct.Th = 19.5%), while individuals had T-score differentials as high as +3.0 SD (radius Ct.BMD). We estimated that average scan position for published HR-pQCT reference data corresponded to 4.0% at the radius, and 7.3% at tibia. CONCLUSION Variability in limb length introduces significant bias to HR-pQCT measures, confounding cross-sectional analyses and limiting the clinical application for individual assessment of skeletal status. We propose to standardize scan positioning using 4.0 and 7.3% of total bone length for the distal radius and tibia, respectively.
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Affiliation(s)
- S Bonaretti
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California, QB3 Building, Suite 203, 1700 4th St, San Francisco, CA, 94158, USA
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - S Majumdar
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California, QB3 Building, Suite 203, 1700 4th St, San Francisco, CA, 94158, USA
| | - T F Lang
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California, QB3 Building, Suite 203, 1700 4th St, San Francisco, CA, 94158, USA
| | - S Khosla
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - A J Burghardt
- Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical Imaging, University of California, QB3 Building, Suite 203, 1700 4th St, San Francisco, CA, 94158, USA.
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Miller WL. Genetic disorders of Vitamin D biosynthesis and degradation. J Steroid Biochem Mol Biol 2017; 165:101-108. [PMID: 27060335 DOI: 10.1016/j.jsbmb.2016.04.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 04/03/2016] [Accepted: 04/05/2016] [Indexed: 01/10/2023]
Abstract
Vitamin D, an inactive secosteroid pro-hormone, is produced by the action of ultraviolet light on 7-dehydrocholesterol in the skin. The active hormone, 1,25(OH)2D is produced by sequential 25-hydroxylation in the liver, principally by CYP2R1, and 1α-hydroxylation in the kidney by CYP27B1. Mutations in CYP27B1 cause 1α-hydroxylase deficiency, also known as vitamin D dependent rickets type I or hereditary pseudo-vitamin D deficient rickets; very rare mutations in CYP2R1 can cause 25-hydroxylase deficiency. Both deficiencies cause hypocalcemia, secondary hyperparathyroidism, severe rickets in infancy, and low serum concentrations of 1,25(OH)2D; both disorders respond to hormonal replacement therapy with calcitriol. The inactivation of vitamin D is principally initiated by its 23- and 24-hydroxylation by CYP24A1. Mutations in CYP24A1 can cause both severe neonatal hypercalcemia and a less severe adult hypercalcemic syndrome. Other pathways of vitamin D metabolism are under investigation, notably its 20-hydroxylation by the cholesterol side-chain cleavage enzyme, CYP11A1.
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Affiliation(s)
- Walter L Miller
- Center for Reproductive Sciences and Department of Pediatrics, HSE 1634, University of California San Francisco, San Francisco, CA 94143-0556, USA.
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7
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Koek WNH, Zillikens MC, van der Eerden BCJ, van Leeuwen JPTM. Novel Compound Heterozygous Mutations in the CYP27B1 Gene Lead to Pseudovitamin D-Deficient Rickets. Calcif Tissue Int 2016; 99:326-31. [PMID: 27364341 DOI: 10.1007/s00223-016-0165-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/15/2016] [Indexed: 12/01/2022]
Abstract
Pseudovitamin D deficiency is the consequence of a genetic defect in the CYP27B1 gene resulting in diminished or absent conversion of 25-hydroxyvitamin D3 (25-(OH)D3) into 1,25-dihydroxyvitamin D3 (1,25-(OH)2D3) and leads to growth retardation and rickets, usually in the first 2 years of life. DNA obtained from human leucocytes from a patient suspected of pseudovitamin D deficiency and her healthy parents was sequenced for a genetic defect in the CYP27B1 gene. In silico analyses on the mutations were performed using online available software. The 1α-hydroxylase activity of the patient, her parents, and a sample derived from a mixed buffy coat of healthy blood donors was measured by culturing peripheral blood mononuclear cells with 25-(OH)D3 and measuring 1,25-(OH)2D3 production. DNA sequencing of the patient suspected of pseudovitamin D deficiency revealed compound heterozygosity in the CYP27B1 gene for a (c413G>T) mutation in exon 3 (R138L) and a (c1232G>A) mutation in exon 8 (C411Y). In silico analyses confirmed that mutations at these positions are probably damaging for the protein since the amino acids are situated in a highly conserved region. In vitro analyses showed a nearly absent 1α-hydroxylase activity in the patient compared to the healthy blood donors. Her healthy parents each of whom carried one of the mutations also had compromised conversion of 25-(OH)D3 into 1,25-(OH)2D3 in peripheral blood mononuclear cells, being only marginally higher than in the patient. We discovered novel compound heterozygous mutations in the CYP27B1 gene in a young girl presenting with pseudovitamin D-deficient rickets, leading to severely decreased 1,25-(OH)2D3 production. Furthermore, both heterozygous parents showed a diminished 1α-hydroxylase activity.
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Affiliation(s)
- W Nadia H Koek
- Department of Internal Medicine, Erasmus MC, Po. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus MC, Po. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Bram C J van der Eerden
- Department of Internal Medicine, Erasmus MC, Po. Box 2040, 3000 CA, Rotterdam, The Netherlands
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Füchtbauer L, Brusgaard K, Ledaal P, Frost M, Frederiksen AL. Case report: vitamin D-dependent rickets type 1 caused by a novel CYP27B1 mutation. Clin Case Rep 2015; 3:1012-6. [PMID: 26734137 PMCID: PMC4693699 DOI: 10.1002/ccr3.406] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 08/17/2015] [Accepted: 08/27/2015] [Indexed: 01/31/2023] Open
Abstract
Vitamin D‐dependent rickets type 1 VDDR‐1 is a recessive inherited disorder with impaired activation of vitamin D, caused by mutations in CYP27B1. We present long‐time follow‐up of a case with a novel mutation including high‐resolution peripheral quantitative computed tomography of the bone. Adequate treatment resulted in a normalized phenotype.
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Affiliation(s)
- Laila Füchtbauer
- Department of Endocrinology Sahlgrenska Universitetssjukhuset Gothenburg Sweden
| | - Klaus Brusgaard
- Department of Clinical Genetics Odense University Hospital Odense Denmark
| | - Pål Ledaal
- Pediatric Department Sygehus Sønderjylland Sønderborg Denmark
| | - Morten Frost
- Department of Endocrinology M Odense University Hospital Odense Denmark
| | - Anja L Frederiksen
- Department of Clinical Genetics Odense University Hospital Odense Denmark
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