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Nishimura-Kinoshita N, Ohata Y, Sawai H, Izawa M, Takeyari S, Kubota T, Omae Y, Ozono K, Tokunaga K, Hamajima T. A case of hyperphosphatemic familial tumoral calcinosis due to maternal uniparental disomy of a GALNT3 variant. Clin Pediatr Endocrinol 2023; 32:161-167. [PMID: 37362161 PMCID: PMC10288290 DOI: 10.1297/cpe.2022-0071] [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: 11/16/2022] [Accepted: 03/13/2023] [Indexed: 06/28/2023] Open
Abstract
Hyperphosphatemic familial tumoral calcinosis (HFTC) is a rare, inherited autosomal recessive disorder caused by fibroblast growth factor-23 (FGF23), N-acetylgalactosaminyltransferase 3 (GALNT3), or Klotho (KL) gene variants. Here, we report the case of a Japanese boy who presented with a mass in his left elbow at the age of three. Laboratory test results of the patient revealed normocalcemia (10.3 mg/dL) and hyperphosphatemia (8.7 mg/dL); however, despite hyperphosphatemia, serum intact FGF23 level was low, renal tubular reabsorption of phosphate (TRP) level was inappropriately increased, and 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) level was inappropriately normal. Genetic analysis revealed maternal uniparental disomy (UPD) of chromosome 2, which included a novel GALNT3 variant (c.1780-1G>C). Reverse transcription-polymerase chain reaction (RT-PCR) analysis of GALNT3 mRNA confirmed that this variant resulted in the destruction of exon 11. We resected the mass when the patient was five years old, owing to its gradual enlargement. No relapse or new pathological lesions were observed four years after tumor resection. This is the first case report of a Japanese patient with HFTC associated with a novel GALNT3 variant, as well as the first case of HFTC caused by maternal UPD of chromosome 2 that includes the GALNT3 variant.
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Affiliation(s)
- Naoko Nishimura-Kinoshita
- Department of Pediatrics, Tango Central Hospital, Kyoto, Japan
- Department of Endocrinology and Metabolism, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Yasuhisa Ohata
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiromi Sawai
- Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masako Izawa
- Department of Endocrinology and Metabolism, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Shinji Takeyari
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takuo Kubota
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yosuke Omae
- Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Genome Medical Science Project (Toyama), National Center for Global Health and Medicine, Tokyo, Japan
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Katsushi Tokunaga
- Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Genome Medical Science Project (Toyama), National Center for Global Health and Medicine, Tokyo, Japan
| | - Takashi Hamajima
- Department of Endocrinology and Metabolism, Aichi Children's Health and Medical Center, Aichi, Japan
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Shore RM. Disorders of phosphate homeostasis in children, part 2: hypophosphatemic and hyperphosphatemic disorders. Pediatr Radiol 2022; 52:2290-2305. [PMID: 35536416 DOI: 10.1007/s00247-022-05373-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 02/07/2022] [Accepted: 04/01/2022] [Indexed: 11/25/2022]
Abstract
Phosphorus, predominantly in the form of inorganic phosphate PO4-3, has many essential physiological functions. In the skeleton, phosphate and calcium form the mineral component and phosphate is also essential in regulating function of skeletal cells. Considerable advances have been made in our understanding of phosphate homeostasis since the recognition of fibroblast growth factor-23 (FGF23) as a bone-derived phosphaturic hormone. This second part of a two-part review of disorders of phosphate homeostasis in children covers hypophosphatemic and hyperphosphatemic disorders that are of interest to the pediatric radiologist, emphasizing, but not limited to, those related to abnormalities of FGF23 signaling.
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Affiliation(s)
- Richard M Shore
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL, 60611, USA.
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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3
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Döneray H, Özden A, Gürbüz K. The Successful Treatment of Deep Soft-tissue Calcifications with Topical Sodium Thiosulphate and Acetazolamide in a Boy with Hyperphosphatemic Familial Tumoral Calcinosis due to a Novel Mutation in FGF23. J Clin Res Pediatr Endocrinol 2022; 14:239-243. [PMID: 33685073 PMCID: PMC9176085 DOI: 10.4274/jcrpe.galenos.2021.2020.0269] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Hyperphosphatemic familial tumoral calcinosis (HFTC) is a rare autosomal recessive disorder. Topical sodium thiosulfate (STS) and acetazolamide can be a safe and effective treatment for patients who do not respond to conventional therapy for ectopic calcifications. We report the successful treatment of deep soft-tissue calcifications with topical STS and acetazolamide in a boy diagnosed with HFTC due to a novel homozygous mutation of FGF23.
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Affiliation(s)
- Hakan Döneray
- Atatürk University Faculty of Medicine, Department of Pediatric Endocrinology, Erzurum, Turkey,Atatürk University, Clinical Research Development and Design Application and Research Center, Erzurum, Turkey,* Address for Correspondence: Atatürk University Faculty of Medicine, Department of Pediatric Endocrinology; Atatürk University, Clinical Research Development and Design Application and Research Center, Erzurum, Turkey Phone: +90 535 944 43 07 E-mail:
| | - Ayşe Özden
- Atatürk University Faculty of Medicine, Department of Pediatric Endocrinology, Erzurum, Turkey
| | - Kadri Gürbüz
- Atatürk University Faculty of Medicine, Department of Pediatrics, Erzurum, Turkey
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Habibollahi S, Lozano-Calderon S, Chang CY. Common Soft Tissue Mass-like Lesions that Mimic Malignancy. Radiol Clin North Am 2022; 60:301-310. [DOI: 10.1016/j.rcl.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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5
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Zuo Q, Yang W, Liu B, Yan D, Wang Z, Wang H, Deng W, Cao X, Yang J. A novel FGF23 mutation in hyperphosphatemic familial tumoral calcinosis and its deleterious effect on protein O-glycosylation. Front Endocrinol (Lausanne) 2022; 13:1008800. [PMID: 36213261 PMCID: PMC9540505 DOI: 10.3389/fendo.2022.1008800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/01/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hyperphosphatemic familial tumoral calcinosis (HFTC) is a rare disease characterized by hyperphosphatemia and ectopic calcification, predominantly at periarticular locations. This study was performed to characterize the clinical profile of tumoral calcinosis and to identify gene mutations associated with HFTC and elucidated its pathogenic role. METHODS The three subjects (two male and one female) were aged 30, 25 and 15 years, respectively. The clinical features, histopathological findings, and outcomes of three subjects with HFTC were retrospectively reviewed. The three subjects were analyzed for FGF23, GALNT3 and KL mutations. Function of mutant gene was analyzed by western blotting and wheat germ agglutinin affinity chromatography. RESULTS All subjects had hyperphosphatemia and elevated calcium-phosphorus product. Calcinosis positions included the left shoulder, left index finger, and right hip. Bone and joint damage were present in two cases and multiple foci influenced body growth in one case. The histopathological features were firm, rubbery masses comprising multiple nodules of calcified material bordered by the proliferation of mononuclear or multinuclear macrophages, osteoclastic-like giant cells, fibroblasts, and chronic inflammatory cells. The novel mutation c.484A>G (p.N162D) in exon 3 of FGF23 was identified in one subject and his family members. Measurement of circulating FGF23 in the subject confirmed low intact FGF23 and increased C-terminal fragment. In vitro experiments showed that the mutant FGF23 proteins had defective O-glycosylation and impaired protein proteolysis protection. CONCLUSION We identified a novel FGF23 missense mutation, and confirmed its damaging role in FGF23 protein O-glycosylation. Our findings expand the current spectrum of FGF23 variations that influence phosphorus metabolism.
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Affiliation(s)
- Qingyao Zuo
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, China
| | - Weili Yang
- Beijing Diabetes Institute, Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Baoyue Liu
- Department of Pathology, Beijing Jishuitan Hospital, Beijing, China
| | - Dong Yan
- Department of Radiology, Beijing Jishuitan Hospital, Beijing, China
| | - Zhixin Wang
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, China
| | - Hong Wang
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, China
| | - Wei Deng
- Department of Endocrinology, Beijing Jishuitan Hospital, Beijing, China
| | - Xi Cao
- Beijing Diabetes Institute, Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- *Correspondence: Xi Cao, ; Jinkui Yang,
| | - Jinkui Yang
- Beijing Diabetes Institute, Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- *Correspondence: Xi Cao, ; Jinkui Yang,
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6
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Abstract
Great strides over the past few decades have increased our understanding of the pathophysiology of hypophosphatemic disorders. Phosphate is critically important to a variety of physiologic processes, including skeletal growth, development and mineralization, as well as DNA, RNA, phospholipids, and signaling pathways. Consequently, hypophosphatemic disorders have effects on multiple systems, and may cause a variety of nonspecific signs and symptoms. The acute effects of hypophosphatemia include neuromuscular symptoms and compromise. However, the dominant effects of chronic hypophosphatemia are the effects on musculoskeletal function including rickets, osteomalacia and impaired growth during childhood. While the most common causes of chronic hypophosphatemia in children are congenital, some acquired conditions also result in hypophosphatemia during childhood through a variety of mechanisms. Improved understanding of the pathophysiology of these congenital conditions has led to novel therapeutic approaches. This article will review the pathophysiologic causes of congenital hypophosphatemia, their clinical consequences and medical therapy.
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Affiliation(s)
- Erik Allen Imel
- Division of Endocrinology, Departments of Medicine and Pediatrics, Indiana University School of Medicine, 1120 West Michigan Street, Gatch Building Room 365, Indianapolis, IN, 46112, USA.
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Research Models for Studying Vascular Calcification. Int J Mol Sci 2020; 21:ijms21062204. [PMID: 32210002 PMCID: PMC7139511 DOI: 10.3390/ijms21062204] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 12/14/2022] Open
Abstract
Calcification of the vessel wall contributes to high cardiovascular morbidity and mortality. Vascular calcification (VC) is a systemic disease with multifaceted contributing and inhibiting factors in an actively regulated process. The exact underlying mechanisms are not fully elucidated and reliable treatment options are lacking. Due to the complex pathophysiology, various research models exist evaluating different aspects of VC. This review aims to give an overview of the cell and animal models used so far to study the molecular processes of VC. Here, in vitro cell culture models of different origins, ex vivo settings using aortic tissue and various in vivo disease-induced animal models are summarized. They reflect different aspects and depict the (patho)physiologic mechanisms within the VC process.
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8
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Guerra MG, Videira T, de Fonseca D, Vieira R, Dos Santos J, Pinto S. Hyperphosphataemic familial tumoral calcinosis: case report of a rare and challenging disease. Scand J Rheumatol 2020; 49:80-81. [PMID: 31213107 DOI: 10.1080/03009742.2019.1602883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2019] [Indexed: 01/01/2023]
Affiliation(s)
- M G Guerra
- Rheumatology Department, Vila Nova de Gaia/Espinho Hospital, Unit I, Vila Nova de Gaia, Portugal
| | - Tmfc Videira
- Rheumatology Department, Vila Nova de Gaia/Espinho Hospital, Unit I, Vila Nova de Gaia, Portugal
| | - Dmgg de Fonseca
- Rheumatology Department, Vila Nova de Gaia/Espinho Hospital, Unit I, Vila Nova de Gaia, Portugal
| | - Rcc Vieira
- Rheumatology Department, Vila Nova de Gaia/Espinho Hospital, Unit I, Vila Nova de Gaia, Portugal
| | - Jpaa Dos Santos
- Rheumatology Department, Vila Nova de Gaia/Espinho Hospital, Unit I, Vila Nova de Gaia, Portugal
| | - Spam Pinto
- Rheumatology Department, Vila Nova de Gaia/Espinho Hospital, Unit I, Vila Nova de Gaia, Portugal
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9
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Leung J, Crook M. Disorders of phosphate metabolism. J Clin Pathol 2019; 72:741-747. [DOI: 10.1136/jclinpath-2018-205130] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 06/13/2019] [Accepted: 07/20/2019] [Indexed: 12/26/2022]
Abstract
Phosphate in both inorganic and organic form is essential for several functions in the body. Plasma phosphate level is maintained by a complex interaction between intestinal absorption, renal tubular reabsorption, and the transcellular movement of phosphate between intracellular fluid and bone storage pools. This homeostasis is regulated by several hormones, principally the parathyroid hormone, 1,25-dihydroxyvitamin D and fibroblast growth factor 23. Abnormalities in phosphate regulation can lead to serious and fatal complications. In this review phosphate homeostasis and the aetiology, pathophysiology, clinical features, investigation and management of hypophosphataemia and hyperphosphataemia will be discussed.
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10
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Gordon CM, Cleveland RH, Baltrusaitis K, Massaro J, D'Agostino RB, Liang MG, Snyder B, Walters M, Li X, Braddock DT, Kleinman ME, Kieran MW, Gordon LB. Extraskeletal Calcifications in Hutchinson-Gilford Progeria Syndrome. Bone 2019; 125:103-111. [PMID: 31077852 PMCID: PMC6628204 DOI: 10.1016/j.bone.2019.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 04/29/2019] [Accepted: 05/07/2019] [Indexed: 01/04/2023]
Abstract
PURPOSE Children with Hutchinson-Gilford progeria syndrome (HGPS), a rare premature aging disease, exhibit extraskeletal calcifications detected by radiographic analysis and on physical examination. The aim of this study was to describe the natural history and pathophysiology of these abnormal calcifications in HGPS, and to determine whether medications and/or supplements tested in clinical trials alter their development. METHODS Children from two successive clinical trials administering 1) lonafarnib (n = 26) and 2) lonafarnib + pravastatin + zoledronic acid (n = 37) were studied at baseline (pre-therapy), one year on therapy, and at end-of-therapy (3.3-4.3 years after the baseline visit). Calcium supplementation (oral calcium carbonate) was administered during the first year of the second trial and was subsequently discontinued. Information on calcifications was obtained from physical examinations, radiographs, and serum and urinary biochemical measures. The mineral content of two skin-derived calcifications was determined by x-ray diffraction. RESULTS Extraskeletal calcifications were detected radiographically in 12/39 (31%) patients at baseline. The odds of exhibiting calcifications increased with age (p = 0.045). The odds were unaffected by receipt of lonafarnib, pravastatin, and zoledronate therapies. However, administration of calcium carbonate supplementation, in conjunction with all three therapeutic agents, significantly increased the odds of developing calcifications (p = 0.009), with the odds plateauing after the supplement's discontinuation. Composition analysis of calcinosis cutis showed hydroxyapatite similar to bone. Although serum calcium, phosphorus, and parathyroid hormone (PTH) were within normal limits at baseline and on-therapy, PTH increased significantly after lonafarnib initiation (p < 0.001). Both the urinary calcium/creatinine ratio and tubular reabsorption of phosphate (TRP) were elevated at baseline in 22/39 (56%) and 31/37 (84%) evaluable patients, respectively, with no significant changes while on-therapy. The mean calcium × phosphorus product (Ca × Pi) was within normal limits, but plasma magnesium decreased over both clinical trials. Fibroblast growth factor 23 (FGF23) was lower compared to age-matched controls (p = 0.03). CONCLUSIONS Extraskeletal calcifications increased with age in children with HGPS and were composed of hydroxyapatite. The urinary calcium/creatinine ratio and TRP were elevated for age while FGF23 was decreased. Magnesium decreased and PTH increased after lonafarnib therapy which may alter the ability to mobilize calcium. These findings demonstrate that children with HGPS with normal renal function and an unremarkable Ca × Pi develop extraskeletal calcifications by an unidentified mechanism that may involve decreased plasma magnesium and FGF23. Calcium carbonate accelerated their development and is, therefore, not recommended for routine supplementation in these children.
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Affiliation(s)
- C M Gordon
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA.
| | - R H Cleveland
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA
| | - K Baltrusaitis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - J Massaro
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - R B D'Agostino
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - M G Liang
- Department of Dermatology, Boston Children's Hospital, Boston, MA, USA
| | - B Snyder
- Department of Orthopaedics, Boston Children's Hospital, Boston, MA, USA
| | - M Walters
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA
| | - X Li
- Department of Pathology, Yale University, New Haven, CT, USA
| | - D T Braddock
- Department of Pathology, Yale University, New Haven, CT, USA
| | - M E Kleinman
- Department of Anesthesiology, Preoperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - M W Kieran
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA, USA
| | - L B Gordon
- Department of Anesthesiology, Preoperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Hasbro Children's Hospital and Warren Alpert Medical School of Brown University, Providence, RI, USA
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Sha Y, Hong K, Liew MKM, Lum JL, Wong RCW. Juxta-articular tumoral calcinosis associated with the temporomandibular joint: a case report and concise review. BMC Oral Health 2019; 19:138. [PMID: 31288794 PMCID: PMC6617841 DOI: 10.1186/s12903-019-0816-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 06/05/2019] [Indexed: 12/13/2022] Open
Abstract
Background Tumoral calcinosis is an uncommon clinicopathological condition which is characterized by the formation of calcium salt deposition in intra-articular or peri-articular soft tissues. It usually presents as a focal growth of hard tissue, either solitary or multiple, beneath the skin and connective tissue. Diagnostic techniques mainly include clinical and radiographic evaluation. The most commonly involved locations include the hip, elbow, shoulder and knee. Involvement of the head and neck regions are far less common. There have been 5 case reports of temporomandibular joint involvement in the literature so far. Case presentation We present a case report which describes the diagnosis and management of a 59 year old female patient with chronic right temporomandibular joint pain and localized bony hard swelling over the right pre-auricular region. Patient retained normal range of motion and mouth opening. Computed tomography taken showed a radio-opaque juxta-articular ovoid mass over the right pre-auricular region in close proximity but not fused to the mandibular condyle. Surgical excision was performed for this swelling via a pre-auricular approach under general anaesthesia. Histological examination performed confirmed the diagnosis of tumoral calcinosis. Pain at the right temporomandibular joint was resolved after the surgery. Serum calcium and phosphate levels were normal in this patient. Conclusion Surgical excision is the primary treatment modality for tumoral calcinosis. Tumoral calcinosis may be associated with elevated serum calcium and phosphate levels. In patients with elevated serum electrolytes, it is important to consider the overall systemic health in management of this condition. Management of serum electrolytes levels plays a role in reducing recurrence rates. This case report and review aims to discuss the diagnosis, treatment and overall systemic management of this rare condition.
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Affiliation(s)
- Yang Sha
- Discipline of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore, Singapore
| | - Kanglun Hong
- Discipline of Oral and Maxillofacial Surgery, University Dental Cluster, National University Hospital Singapore, Singapore, Singapore
| | - Melvin Kang Ming Liew
- Discipline of Oral and Maxillofacial Surgery, University Dental Cluster, National University Hospital Singapore, Singapore, Singapore
| | - Jing Li Lum
- Discipline of Oral and Maxillofacial Surgery, University Dental Cluster, National University Hospital Singapore, Singapore, Singapore
| | - Raymond Chung Wen Wong
- Discipline of Oral and Maxillofacial Surgery, University Dental Cluster, National University Hospital Singapore, Singapore, Singapore. .,Discipline of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore, Singapore.
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12
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Imel EA, White KE. Pharmacological management of X-linked hypophosphataemia. Br J Clin Pharmacol 2018; 85:1188-1198. [PMID: 30207609 DOI: 10.1111/bcp.13763] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/05/2018] [Accepted: 09/05/2018] [Indexed: 12/25/2022] Open
Abstract
The most common heritable disorder of renal phosphate wasting, X-linked hypophosphataemia (XLH), was discovered to be caused by inactivating mutations in the phosphate regulating gene with homology to endopeptidases on the X-chromosome (PHEX) gene in 1995. Although the exact molecular mechanisms by which PHEX mutations cause disturbed phosphate handling in XLH remain unknown, focus for novel therapies has more recently been based upon the finding that the bone-produced phosphaturic hormone fibroblast growth factor-23 is elevated in XLH patient plasma. Previous treatment strategies for XLH were based upon phosphate repletion plus active vitamin D analogues, which are difficult to manage, fail to address the primary pathogenesis of the disease, and can have deleterious side effects. A novel therapy for XLH directly targeting fibroblast growth factor-23 via a humanized monoclonal antibody (burosumab-twza/CRYSVITA, henceforth referred to just as burosumab) has emerged as an effective, and recently approved, pharmacological treatment for both children and adults. This review will provide an overview of the clinical manifestations of XLH, the molecular pathophysiology, and summarize its current treatment.
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Affiliation(s)
- Erik A Imel
- Department of Medicine, Division of Endocrinology and Metabolism, Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Pediatrics, Section of Endocrinology and Diabetology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kenneth E White
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
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Chakhtoura M, Ramnitz MS, Khoury N, Nemer G, Shabb N, Abchee A, Berberi A, Hourani M, Collins M, Ichikawa S, El Hajj Fuleihan G. Hyperphosphatemic familial tumoral calcinosis secondary to fibroblast growth factor 23 (FGF23) mutation: a report of two affected families and review of the literature. Osteoporos Int 2018; 29:1987-2009. [PMID: 29923062 DOI: 10.1007/s00198-018-4574-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/14/2018] [Indexed: 01/20/2023]
Abstract
Hyperphosphatemic familial tumoral calcinosis (HFTC), secondary to fibroblast growth factor 23 (FGF23) gene mutation, is a rare genetic disorder characterized by recurrent calcified masses. We describe young Lebanese cousins presenting with HFTC, based on a retrospective chart review and a prospective case study. In addition, we present a comprehensive review on the topic, based on a literature search conducted in PubMed and Google Scholar, in 2014 and updated in December 2017. While the patients had the same previously reported FGF23 gene mutation (homozygous c.G367T variant in exon 3 leading to a missense mutation), they presented with variable severity and age of disease onset (at 4 years in patient 1 and at 23 years in patient 2). A review of the literature revealed several potential patho-physiologic pathways of HFTC clinical manifestations, some of which may be independent of hyperphosphatemia. Most available treatment options aim at reducing serum phosphate level, by stimulating renal excretion or by inhibiting intestinal absorption. HFTC is a challenging disease. While the available medical treatment has a limited and inconsistent effect on disease symptomatology, surgical resection of calcified masses remains the last resort. Research is needed to determine the safety and efficacy of FGF23 replacement or molecular therapy, targeting the specific genetic aberration. Hyperphosphatemic familial tumoral calcinosis is a rare genetic disorder characterized by recurrent calcified masses, in addition to other visceral, skeletal, and vascular manifestations. It remains a very challenging disease.
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Affiliation(s)
- M Chakhtoura
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, American University of Beirut Medical Center, Beirut, Lebanon.
| | - M S Ramnitz
- Section on Skeletal Disorders and Mineral Homeostasis, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - N Khoury
- Department of Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - G Nemer
- Department of Biochemistry and Molecular Genetics, American University of Beirut Medical Center, Beirut, Lebanon
| | - N Shabb
- Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - A Abchee
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - A Berberi
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - M Hourani
- Department of Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - M Collins
- Section on Skeletal Disorders and Mineral Homeostasis, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - S Ichikawa
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - G El Hajj Fuleihan
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, American University of Beirut Medical Center, Beirut, Lebanon
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Jaeken J, Lefeber DJ, Matthijs G. Clinical Utility Gene Card For: GALNT3 defective congenital disorder of glycosylation. Eur J Hum Genet 2018; 26:1230-1233. [PMID: 29681618 PMCID: PMC6057978 DOI: 10.1038/s41431-017-0002-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 07/21/2017] [Accepted: 08/23/2017] [Indexed: 11/08/2022] Open
Affiliation(s)
- Jaak Jaeken
- Centre for Metabolic Disease, University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium.
| | - Dirk J Lefeber
- Department of Neurology, Translational Metabolic Laboratory, Radboudumc, Nijmegen, The Netherlands
| | - Gert Matthijs
- Department of Human Genetics, KU Leuven, Leuven, Belgium
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Goldenstein PT, Neves PD, Balbo BE, Elias RM, Pereira AC, Onuchic LF, Jüppner H, Jorgetti V, Abensur H, Moysés RM. Dialysis as a Treatment Option for a Patient With Normal Kidney Function and Familial Tumoral Calcinosis Due to a Compound Heterozygous FGF23 Mutation. Am J Kidney Dis 2018; 72:457-461. [PMID: 29548779 DOI: 10.1053/j.ajkd.2017.12.020] [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: 07/24/2017] [Accepted: 12/24/2017] [Indexed: 11/11/2022]
Abstract
Primary tumoral calcinosis is a rare autosomal recessive disorder characterized by ectopic calcified tumoral masses. Mutations in 3 genes (GALNT3, FGF23, and KL) have been linked to this human disorder. We describe a case of a 28-year-old man with a history of painful firm masses over his right and left gluteal region, right clavicle region, knees, and left elbow. Biochemical analysis disclosed hyperphosphatemia (phosphate, 9.0 mg/dL) and normocalcemia (calcium, 4.8 mg/dL), with normal kidney function and fractional excretion of phosphate of 3%. Parathyroid hormone was suppressed (15 pg/mL), associated with a low-normal 25-hydroxyvitamin D (26 ng/mL) concentration but high 1,25-dihydroxyvitamin D concentration (92 pg/mL). Serum intact FGF-23 (fibroblast growth factor 23) was undetectable. Genetic analysis revealed tumoral calcinosis due to a compound heterozygous mutation in FGF23, c.201G>C (p.Gln67His) and c.466C>T (p.Gln156*). Due to lack of other treatment options and because the patient was facing severe vascular complications, we initiated a daily hemodialysis program even in the setting of normal kidney function. This unusual therapeutic option successful controlled hyperphosphatemia and reduced metastatic tumoral lesions. This is a report of a new mutation in FGF23 in which dialysis was an effective treatment option for tumoral calcinosis with normal kidney function.
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Affiliation(s)
| | - Precil D Neves
- Nephrology Division, University of São Paulo School of Medicine, Sao Paulo-SP, Brazil
| | - Bruno E Balbo
- Nephrology Division, University of São Paulo School of Medicine, Sao Paulo-SP, Brazil
| | - Rosilene M Elias
- Nephrology Division, University of São Paulo School of Medicine, Sao Paulo-SP, Brazil
| | - Alexandre C Pereira
- Laboratory of Genetics and Molecular Cardiology, Heart Institute, University of Sao Paulo, Sao Paulo-SP, Brazil; Genetics Department, Harvard Medical School, Boston, MA
| | - Luiz F Onuchic
- Nephrology Division, University of São Paulo School of Medicine, Sao Paulo-SP, Brazil
| | - Harald Jüppner
- Endocrine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Pediatric Nephrology Units, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Vanda Jorgetti
- Nephrology Division, University of São Paulo School of Medicine, Sao Paulo-SP, Brazil
| | - Hugo Abensur
- Nephrology Division, University of São Paulo School of Medicine, Sao Paulo-SP, Brazil
| | - Rosa Maria Moysés
- Nephrology Division, University of São Paulo School of Medicine, Sao Paulo-SP, Brazil; Universidade Nove de Julho, São Paulo-SP, Brazil.
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Abstract
Fibroblast growth factor 23 (FGF23) is an important regulator of phosphate and vitamin D metabolism and its excessive or insufficient production leads to a wide variety of skeletal disorders. This article reviews the FGF23-α-Klotho signaling pathway, highlighting the latest developments in FGF23 regulation and action, and describes the disorders associated with FGF23 excess or deficiency.
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Affiliation(s)
- Anda R Gonciulea
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Suzanne M Jan De Beur
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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17
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Shawar SM, Ramadan AR, Ali BR, Alghamdi MA, John A, Hudaib FM. FGF23-S129F mutant bypasses ER/Golgi to the circulation of hyperphosphatemic familial tumoral calcinosis patients. Bone 2016; 93:187-195. [PMID: 26620085 DOI: 10.1016/j.bone.2015.11.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 11/15/2015] [Accepted: 11/21/2015] [Indexed: 02/05/2023]
Abstract
FGF23 is essential for the homeostasis of phosphate, and vitamin D. Loss-of-function mutations in this hormone cause hyperphosphatemic familial tumoral calcinosis (HFTC). Earlier reports suggested that intact FGF23 from loss of function mutants such as FGF23/S129F (iFGF23/S129F) is retained intracellularly while the carboxy-terminal fragment is secreted. We sought to investigate the fate of iFGF23/S129F mutant hormone in vivo and in vitro. Five patients clinically diagnosed with HFTC and confirmed by DNA sequencing to carry the c.386 C>T; p.S129F mutation in the homozygous state were studied. Healthy and heterozygous individuals were used as controls in the study. Using ELISA assays, we showed that iFGF23/S129F was 2-5 folds higher in patients' plasma, compared to heterozygous or healthy controls. Importantly, the mutant hormone could not be detected in the patients' sera. However, using proteinase inhibition profiling, we found that a serum metalloproteinase degraded the iFGF23/S129F explaining our failure to detect it in sera. The serum metalloproteinase degrades the WT and the mutant at different rates. Also, confocal microscopy imaging using wild-type (WT) FGF23 or FGF23/S129F mutant in transiently transfected HEK293 and HeLa cells showed weak staining of the Golgi complex with some vesicular staining resembling the ER. Additionally, FGF23 variants (FGF23/WT, FGF23/S129F, FGF23/S71G, and FGF23/R176Q) from stably transfected HEK293 cells secreted high levels into a serum-free medium that can be detected by ELISA and Western blot. Our results suggest that iFGF23/S129F mutant bypasses the ER/Golgi quality control system to the circulation of HFTC patients by an unknown pathway. Finally, we hypothesize that either the mutant hormone is unable to bind α-Klotho-FGFR1c, or it binds the dyad receptor with low affinity and, therefore, incapable of initiating maximal intracellular signaling. Our findings raise the potential use of the WT hormone in therapies of some HFTC patients.
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Affiliation(s)
- Said M Shawar
- Life Sciences Department, Medical Biotechnology, Arabian Gulf University, Manama, Bahrain.
| | - Ahmad R Ramadan
- Life Sciences Department, Medical Biotechnology, Arabian Gulf University, Manama, Bahrain
| | - Bassam R Ali
- Pathology Department, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Manal A Alghamdi
- Life Sciences Department, Medical Biotechnology, Arabian Gulf University, Manama, Bahrain
| | - Anne John
- Pathology Department, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Ferial M Hudaib
- Life Sciences Department, Medical Biotechnology, Arabian Gulf University, Manama, Bahrain
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Niemann KE, Kröpil F, Hoffmann MF, Coulibaly MO, Schildhauer TA. A 23-year-old patient with secondary tumoral calcinosis: Regression after subtotal parathyroidectomy: A case report. Int J Surg Case Rep 2016; 23:56-60. [PMID: 27088846 PMCID: PMC4855743 DOI: 10.1016/j.ijscr.2016.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 04/07/2016] [Indexed: 11/19/2022] Open
Abstract
Tumoral calcinosis needs to be diagnosed correctly. Subtotal parathyroidectomy leads to rapid regression. Potential mutilations may be avoid by early subtotal parathyroidectomy.
Introduction Tumoral calcinosis (TC) is a rare disorder defined by hyperphosphatemia and ectopic calcifications in various locations. The most common form of TC is associated with disorders such as renal insufficiency, hyperparathyroidism, or hypervitaminosis D. The primary (hereditary) TC is caused by inactivating mutations in either the fibroblast growth factor 23 (FGF23), the GalNAc transferase 3 (GALNT3) or the KLOTHO (KL) gene. Presentation of case We report here a case of secondary TC in end-stage renal disease. The patient was on regular hemodialysis and presented with severe painful soft-tissue calcifications around her left hip and shoulder that had been increasing over the last two years. Initially, she was treated with dietary phosphate restriction and phosphate binders. Because of high phosphate blood levels, which were not yet managed with dialysis and medical therapy, a subtotal parathyroidectomy (sP) was performed. This approach demonstrated significant response. Three months after surgery a rapid regression of the tumors was observed. Disscusion Regardless of the etiology, the two types of TC do not differ in their radiologic or histopathologic presentations but need to be diagnosed correctly to initiate targeted and effective treatment. Considering the primary TC, primary treatment is early and complete surgical excision. In case of secondary TC surgical excision of the tumoral masses should be avoid because of extensive complications. These patients benefit from sP. Conclusion After initial conservative therapy chronic kidney disease patients with TC might benefit from sP to avoid prolonged suffering and potential mutilations.
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Affiliation(s)
- Katharina E Niemann
- Department of General and Trauma Surgery, BG University Hospital, Bergmannsheil Bochum, Buerkle de la Camp-Platz 1, 44789 Bochum, Germany.
| | - Feride Kröpil
- Department of Surgery, Heinrich-Heine-University, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany.
| | - Martin F Hoffmann
- Department of General and Trauma Surgery, BG University Hospital, Bergmannsheil Bochum, Buerkle de la Camp-Platz 1, 44789 Bochum, Germany.
| | - Marlon O Coulibaly
- Department of General and Trauma Surgery, BG University Hospital, Bergmannsheil Bochum, Buerkle de la Camp-Platz 1, 44789 Bochum, Germany.
| | - Thomas A Schildhauer
- Department of General and Trauma Surgery, BG University Hospital, Bergmannsheil Bochum, Buerkle de la Camp-Platz 1, 44789 Bochum, Germany.
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