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Terhal P, Venhuizen AJ, Lessel D, Tan WH, Alswaid A, Grün R, Alzaidan HI, von Kroge S, Ragab N, Hempel M, Kubisch C, Novais E, Cristobal A, Tripolszki K, Bauer P, Fischer-Zirnsak B, Nievelstein RAJ, van Dijk A, Nikkels P, Oheim R, Hahn H, Bertoli-Avella A, Maurice MM, Kornak U. AXIN1 bi-allelic variants disrupting the C-terminal DIX domain cause craniometadiaphyseal osteosclerosis with hip dysplasia. Am J Hum Genet 2023; 110:1470-1481. [PMID: 37582359 PMCID: PMC10502735 DOI: 10.1016/j.ajhg.2023.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/17/2023] Open
Abstract
Sclerosing skeletal dysplasias result from an imbalance between bone formation and resorption. We identified three homozygous, C-terminally truncating AXIN1 variants in seven individuals from four families affected by macrocephaly, cranial hyperostosis, and vertebral endplate sclerosis. Other frequent findings included hip dysplasia, heart malformations, variable developmental delay, and hematological anomalies. In line with AXIN1 being a central component of the β-catenin destruction complex, analyses of primary and genome-edited cells harboring the truncating variants revealed enhanced basal canonical Wnt pathway activity. All three AXIN1-truncating variants resulted in reduced protein levels and impaired AXIN1 polymerization mediated by its C-terminal DIX domain but partially retained Wnt-inhibitory function upon overexpression. Addition of a tankyrase inhibitor attenuated Wnt overactivity in the AXIN1-mutant model systems. Our data suggest that AXIN1 coordinates the action of osteoblasts and osteoclasts and that tankyrase inhibitors can attenuate the effects of AXIN1 hypomorphic variants.
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Affiliation(s)
- Paulien Terhal
- Division of Laboratories, Pharmacy and Biomedical Genetics, University Medical Centre Utrecht, 3584EA Utrecht, the Netherlands.
| | - Anton J Venhuizen
- Center for Molecular Medicine and Oncode Institute, University Medical Centre Utrecht, 3584CG Utrecht, the Netherlands
| | - Davor Lessel
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; Institute of Human Genetics, University Hospital Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Wen-Hann Tan
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA 02115, USA
| | - Abdulrahman Alswaid
- Department of Pediatrics, King Abdullah Specialized Children's Hospital, Riyadh 14611, Saudi Arabia; King Saud Bin Abdulaziz University For Health Sciences, Riyadh 22490, Saudi Arabia
| | - Regina Grün
- Institute of Human Genetics, University Medical Center Göttingen, 37073 Göttingen, Germany
| | - Hamad I Alzaidan
- Medical Genetics Department, King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh 11211, Saudi Arabia
| | - Simon von Kroge
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, 22529 Hamburg, Germany
| | - Nada Ragab
- Institute of Human Genetics, University Medical Center Göttingen, 37073 Göttingen, Germany
| | - Maja Hempel
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; Institute of Human Genetics, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Christian Kubisch
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Eduardo Novais
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA 02115, USA
| | - Alba Cristobal
- Center for Molecular Medicine and Oncode Institute, University Medical Centre Utrecht, 3584CG Utrecht, the Netherlands
| | | | - Peter Bauer
- Centogene GmbH, 18055 Rostock, Germany; University Hospital Rostock, Internal Medicine, Hemato-oncology, 18057 Rostock, Germany
| | - Björn Fischer-Zirnsak
- Institute of Medical Genetics and Human Genetics, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Rutger A J Nievelstein
- Department of Radiology & Nuclear Medicine, University Medical Centre Utrecht, 3584CX Utrecht, the Netherlands
| | - Atty van Dijk
- Expert Center for Skeletal Dysplasia, Wilhelmina Children's Hospital, University Medical Center Utrecht, 3584EA Utrecht, the Netherlands
| | - Peter Nikkels
- Department of Pathology, University Medical Centre Utrecht, 3584CX Utrecht, the Netherlands
| | - Ralf Oheim
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, 22529 Hamburg, Germany
| | - Heidi Hahn
- Institute of Human Genetics, University Medical Center Göttingen, 37073 Göttingen, Germany
| | | | - Madelon M Maurice
- Center for Molecular Medicine and Oncode Institute, University Medical Centre Utrecht, 3584CG Utrecht, the Netherlands
| | - Uwe Kornak
- Institute of Human Genetics, University Medical Center Göttingen, 37073 Göttingen, Germany; Institute of Medical Genetics and Human Genetics, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany.
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Hendrickx G, Boudin E, Steenackers E, Collet C, Mortier GR, Geneviève D, Van Hul W. A recessive form of craniodiaphyseal dysplasia caused by a homozygous missense variant in SP7/Osterix. Bone 2023; 167:116633. [PMID: 36436818 DOI: 10.1016/j.bone.2022.116633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/28/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Gretl Hendrickx
- Department of Medical Genetics, Antwerp University Hospital and University of Antwerp, 2650 Edegem, Belgium; Laboratory for Skeletal Dysplasia Research, Department of Human Genetics, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Eveline Boudin
- Department of Medical Genetics, Antwerp University Hospital and University of Antwerp, 2650 Edegem, Belgium
| | - Ellen Steenackers
- Department of Medical Genetics, Antwerp University Hospital and University of Antwerp, 2650 Edegem, Belgium
| | - Corinne Collet
- INSERM U1132 and Université de Paris, Reference Centre for Rare Bone Diseases, Hospital Robert Debré, F-75010 Paris, France
| | - Geert R Mortier
- Department of Medical Genetics, Antwerp University Hospital and University of Antwerp, 2650 Edegem, Belgium; Laboratory for Skeletal Dysplasia Research, Department of Human Genetics, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Center for Human Genetics, University Hospital Leuven, Leuven, Belgium
| | - David Geneviève
- Montpellier University and INSERM U1183, Montpellier, France; Competence Center for Bone Diseases, Clinical Genetics Unit, Montpellier University Hospital, Montpellier, France
| | - Wim Van Hul
- Department of Medical Genetics, Antwerp University Hospital and University of Antwerp, 2650 Edegem, Belgium.
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Martínez‐Gil N, Ovejero D, Garcia‐Giralt N, Bruque CD, Mellibovsky L, Nogués X, Rabionet R, Grinberg D, Balcells S. Genetic analysis in a familial case with high bone mineral density suggests additive effects at two
loci. JBMR Plus 2022; 6:e10602. [PMID: 35434450 PMCID: PMC9009133 DOI: 10.1002/jbm4.10602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 12/24/2021] [Accepted: 01/16/2022] [Indexed: 11/21/2022] Open
Abstract
Osteoporosis is the most common bone disease, characterized by a low bone mineral density (BMD) and increased risk of fracture. At the other end of the BMD spectrum, some individuals present strong, fracture‐resistant, bones. Both osteoporosis and high BMD are heritable and their genetic architecture encompasses polygenic inheritance of common variants and some cases of monogenic highly penetrant variants in causal genes. We have investigated the genetics of high BMD in a family segregating this trait in an apparently Mendelian dominant pattern. We searched for rare causal variants by whole‐exome sequencing in three affected and three nonaffected family members. Using this approach, we have identified 38 rare coding variants present in the proband and absent in the three individuals with normal BMD. Although we have found four variants shared by the three affected members of the family, we have not been able to relate any of these to the high‐BMD phenotype. In contrast, we have identified missense variants in two genes, VAV3 and ADGRE5, each shared by two of out of three affected members, whose loss of function fits with the phenotype of the family. In particular, the proband, a woman displaying the highest BMD (sum Z‐score = 7), carries both variants, whereas the other two affected members carry one each. VAV3 encodes a guanine‐nucleotide‐exchange factor with an important role in osteoclast activation and function. Although no previous cases of VAV3 mutations have been reported in humans, Vav3 knockout (KO) mice display dense bones, similarly to the high‐BMD phenotype present in our family. The ADGRE5 gene encodes an adhesion G protein‐coupled receptor expressed in osteoclasts whose KO mouse displays increased trabecular bone volume. Combined, these mouse and human data highlight VAV3 and ADGRE5 as novel putative high‐BMD genes with additive effects, and potential therapeutic targets for osteoporosis. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Núria Martínez‐Gil
- Department of Genetics, Microbiology and Statistics Faculty of Biology, Universitat de Barcelona, CIBERER, IBUB, IRSJD Barcelona Spain
| | - Diana Ovejero
- Musculoskeletal Research Group, IMIM (Hospital del Mar Medical Research Institute), Centro de Investigación Biomédica en Red en Fragilidad y Envejecimiento Saludable (CIBERFES), ISCIII Barcelona Spain
| | - Natalia Garcia‐Giralt
- Musculoskeletal Research Group, IMIM (Hospital del Mar Medical Research Institute), Centro de Investigación Biomédica en Red en Fragilidad y Envejecimiento Saludable (CIBERFES), ISCIII Barcelona Spain
| | - Carlos David Bruque
- Unidad de Conocimiento Traslacional Hospitalaria Patagónica, Hospital de Alta Complejidad SAMIC El Calafate Santa Cruz Argentina
| | - Leonardo Mellibovsky
- Musculoskeletal Research Group, IMIM (Hospital del Mar Medical Research Institute), Centro de Investigación Biomédica en Red en Fragilidad y Envejecimiento Saludable (CIBERFES), ISCIII Barcelona Spain
| | - Xavier Nogués
- Musculoskeletal Research Group, IMIM (Hospital del Mar Medical Research Institute), Centro de Investigación Biomédica en Red en Fragilidad y Envejecimiento Saludable (CIBERFES), ISCIII Barcelona Spain
| | - Raquel Rabionet
- Department of Genetics, Microbiology and Statistics Faculty of Biology, Universitat de Barcelona, CIBERER, IBUB, IRSJD Barcelona Spain
| | - Daniel Grinberg
- Department of Genetics, Microbiology and Statistics Faculty of Biology, Universitat de Barcelona, CIBERER, IBUB, IRSJD Barcelona Spain
| | - Susanna Balcells
- Department of Genetics, Microbiology and Statistics Faculty of Biology, Universitat de Barcelona, CIBERER, IBUB, IRSJD Barcelona Spain
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Verma V, Singh RK. A Case Report of Pycnodysostosis Associated with Multiple Pituitary Hormone Deficiencies and Response to Treatment. J Clin Res Pediatr Endocrinol 2020; 12:444-449. [PMID: 32248673 PMCID: PMC7711642 DOI: 10.4274/jcrpe.galenos.2020.2019.0194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Pycnodysostosis is a rare autosomal recessive osteosclerotic bone disorder associated with short stature and multiple bony abnormalities. Growth hormone (GH) deficiency may contribute to short stature in about 50% of patients. Available literature has rarely reported other pituitary hormone deficiencies in pyknodysostosis. Though the management remains conservative, recombinant human GH (rhGH) has been tried in selected patients. Here we present a case of pycnodysostosis which was evaluated for associated co-morbidities and found to have multiple pituitary hormone deficiencies. A 7-year-old girl was referred to our centre for evaluation of short stature. On examination, she had frontal and occipital bossing, limited mouth opening, hyperdontia with multiple carries, short and stubby digits and short stature. Investigation revealed dense sclerotic bones with frontal and occipital bossing, non-fusion of sutures with obtuse mandibular angle, non-pneumatised sinuses, small ‘J’ shaped sella turcica, acro-osteolysis of digits and absent medullary cavities. Cathepsin-K gene mutation analysis confirmed the diagnosis of pycnodysostosis. She was screened for associated co-morbidities and was found to have concomitant GH deficiency. Treatment with rhGH brought about an increase of 1 standard deviation score in height over 2 years and also unmasked central hypothyroidism at three months necessitating thyroxine replacement.
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Affiliation(s)
- Vishesh Verma
- Armed Forces Medical College, Department of Endocrinology, Pune, India,* Address for Correspondence: Armed Forces Medical College, Department of Endocrinology, Pune, India E-mail:
| | - RK Singh
- Command Hospital, Clinic of Paediatrics, Lucknow, India
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Van de Voorde N, Mortier GR, Vanhoenacker FM. Fibrous Dysplasia, Paget's Disease of Bone, and Other Uncommon Sclerotic Bone Lesions of the Craniofacial Bones. Semin Musculoskelet Radiol 2020; 24:570-578. [PMID: 33036044 DOI: 10.1055/s-0039-3400292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Imaging studies of the brain, head and neck, sinuses, and dental computed tomography are among the most frequently performed procedures in radiologic departments. Systematic evaluation in the bone window may reveal common and uncommon sclerotic osseous abnormalities of the craniofacial skeleton.Most of these findings are incidental and unrelated to the initial clinical indications. Sporadically symptoms may arise due to lesional mass effect with compression on adjacent structures and neuroforaminal encroachment, resulting in proptosis, vision, or hearing loss. Other symptoms include craniofacial deformity, mandibular occlusion deformity, and local pain.This article reviews the most common disorders characterized by an increased bone density involving the craniofacial bones including fibrous dysplasia, Paget's disease of bone, meningioma with associated hyperostosis, and osteoma. Finally, typical examples of rarer sclerosing bone dysplasias are discussed as well.Emphasis is placed on imaging features and the differential diagnosis.
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Affiliation(s)
- Nick Van de Voorde
- Department of Radiology, Antwerp University Hospital and Antwerp University, Edegem, Belgium
| | - Geert R Mortier
- Department of Medical Genetics, Antwerp University Hospital and Antwerp University, Edegem, Belgium
| | - Filip M Vanhoenacker
- Department of Radiology, Antwerp University Hospital and Antwerp University, Edegem, Belgium.,Department of Medical Genetics, Antwerp University Hospital and Antwerp University, Edegem, Belgium.,Department of Radiology, AZ Sint-Maarten, Mechelen, Belgium.,Department of Radiology and Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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6
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Abstract
The phenotypic trait of high bone mass (HBM) is an excellent example of the nexus between common and rare disease genetics. HBM may arise from carriage of many 'high bone mineral density [BMD]'-associated alleles, and certainly the genetic architecture of individuals with HBM is enriched with high BMD variants identified through genome-wide association studies of BMD. HBM may also arise as a monogenic skeletal disorder, due to abnormalities in bone formation, bone resorption, and/or bone turnover. Individuals with monogenic disorders of HBM usually, though not invariably, have other skeletal abnormalities (such as mandible enlargement) and thus are best regarded as having a skeletal dysplasia rather than just isolated high BMD. A binary etiological division of HBM into polygenic vs. monogenic, however, would be excessively simplistic: the phenotype of individuals carrying rare variants of large effect can still be modified by their common variant polygenic background, and by the environment. HBM disorders-whether predominantly polygenic or monogenic in origin-are not only interesting clinically and genetically: they provide insights into bone processes that can be exploited therapeutically, with benefits both for individuals with these rare bone disorders and importantly for the many people affected by the commonest bone disease worldwide-i.e., osteoporosis. In this review we detail the genetic architecture of HBM; we provide a conceptual framework for considering HBM in the clinical context; and we discuss monogenic and polygenic causes of HBM with particular emphasis on anabolic causes of HBM.
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Affiliation(s)
- Celia L. Gregson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- *Correspondence: Celia L. Gregson, ; Emma L. Duncan,
| | - Emma L. Duncan
- Department of Twin Research & Genetic Epidemiology, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- *Correspondence: Celia L. Gregson, ; Emma L. Duncan,
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Sabir AH, Cole T. The evolving therapeutic landscape of genetic skeletal disorders. Orphanet J Rare Dis 2019; 14:300. [PMID: 31888683 PMCID: PMC6937740 DOI: 10.1186/s13023-019-1222-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/09/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Rare bone diseases account for 5% of all birth defects yet very few have personalised treatments. Developments in genetic diagnosis, molecular techniques and treatment technologies however, are leading to unparalleled therapeutic advance. This review explores the evolving therapeutic landscape of genetic skeletal disorders (GSDs); the key conditions and there key differentials. METHODS A retrospective literature based review was conducted in December 2018 using a systematic search strategy for relevant articles and trials in Pubmed and clinicaltrials.gov respectively. Over 140 articles and 80 trials were generated for review. RESULTS Over 20 personalised therapies are discussed in addition to several novel disease modifying treatments in over 25 GSDs. Treatments discussed are at different stages from preclinical studies to clinical trials and approved drugs, including; Burosumab for X-linked hypophosphatemia, Palovarotene for Hereditary Multiple Exostoses, Carbamazepine for Metaphyseal Chondrodysplasia (Schmid type), Lithium carbonate and anti-sclerostin therapy for Osteoporosis Pseudoglioma syndrome and novel therapies for Osteopetrosis. We also discuss therapeutic advances in Achondroplasia, Osteogenesis Imperfecta (OI), Hypophosphotasia (HPP), Fibrodysplasia Ossificans Progressiva, and RNA silencing therapies in preclinical studies for OI and HPP. DISCUSSION It is an exciting time for GSD therapies despite the challenges of drug development in rare diseases. In discussing emerging therapies, we explore novel approaches to drug development from drug repurposing to in-utero stem cell transplants. We highlight the improved understanding of bone pathophysiology, genetic pathways and challenges of developing gene therapies for GSDs.
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Affiliation(s)
- Ataf Hussain Sabir
- West Midlands Clinical Genetics Unit, Birmingham Women's and Children's NHS FT and Birmingham Health Partners, Birmingham, UK.
| | - Trevor Cole
- West Midlands Clinical Genetics Unit, Birmingham Women's and Children's NHS FT and Birmingham Health Partners, Birmingham, UK
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Rossi M, Battafarano G, Pepe J, Minisola S, Del Fattore A. The Endocrine Function of Osteocalcin Regulated by Bone Resorption: A Lesson from Reduced and Increased Bone Mass Diseases. Int J Mol Sci 2019; 20:ijms20184502. [PMID: 31514440 PMCID: PMC6769834 DOI: 10.3390/ijms20184502] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/10/2019] [Accepted: 09/10/2019] [Indexed: 02/06/2023] Open
Abstract
Bone is a peculiar tissue subjected to a continuous process of self-renewal essential to assure the integrity of the skeleton and to explicate the endocrine functions. The study of bone diseases characterized by increased or reduced bone mass due to osteoclast alterations has been essential to understand the great role played by osteocalcin in the endocrine functions of the skeleton. The ability of osteoclasts to regulate the decarboxylation of osteocalcin and to control glucose metabolism, male fertility, and cognitive functions was demonstrated by the use of animal models. In this review we described how diseases characterized by defective and increased bone resorption activity, as osteopetrosis and osteoporosis, were essential to understand the involvement of bone tissue in whole body physiology. To translate this knowledge into humans, recently published reports on patients were described, but further studies should be performed to confirm this complex hormonal regulation in humans.
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Affiliation(s)
- Michela Rossi
- Bone Physiopathology Group, Multifactorial Disease and Complex Phenotype Research Area, Bambino Gesù Children's Hospital, IRCCS, 00146 Rome, Italy.
| | - Giulia Battafarano
- Bone Physiopathology Group, Multifactorial Disease and Complex Phenotype Research Area, Bambino Gesù Children's Hospital, IRCCS, 00146 Rome, Italy.
| | - Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, 00186 Rome, Italy.
| | - Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, 00186 Rome, Italy.
| | - Andrea Del Fattore
- Bone Physiopathology Group, Multifactorial Disease and Complex Phenotype Research Area, Bambino Gesù Children's Hospital, IRCCS, 00146 Rome, Italy.
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9
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Van Hul W, Boudin E, Vanhoenacker FM, Mortier G. Camurati-Engelmann Disease. Calcif Tissue Int 2019; 104:554-560. [PMID: 30721323 DOI: 10.1007/s00223-019-00532-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 01/28/2019] [Indexed: 12/12/2022]
Abstract
Camurati-Engelmann disease or progressive diaphyseal dysplasia is a rare autosomal dominant sclerosing bone dysplasia. Mainly the skull and the diaphyses of the long tubular bones are affected. Clinically, the patients suffer from bone pain, easy fatigability, and decreased muscle mass and weakness in the proximal parts of the lower limbs resulting in gait disturbances. The disease-causing mutations are located within the TGFβ-1 gene and expected to or thought to disrupt the binding between TGFβ1 and its latency-associated peptide resulting in an increased signaling of the pathway and subsequently accelerated bone turnover. In preclinical studies, it was shown that targeting the type I receptor ameliorates the high bone turnover. In patients, treatment options are currently mostly limited to corticosteroids that may relieve the pain, and improve the muscle weakness and fatigue. In this review, the clinical and radiological characteristics as well as the molecular genetics of this condition are discussed.
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Affiliation(s)
- Wim Van Hul
- Department of Medical Genetics, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium.
- Department of Medical Genetics, University of Antwerp, Prins Boudewijnlaan 43, 2650, Edegem, Belgium.
| | - Eveline Boudin
- Department of Medical Genetics, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Filip M Vanhoenacker
- AZ Sint-Maarten, Antwerp University Hospital and Ghent University, Mechelen, Belgium
| | - Geert Mortier
- Department of Medical Genetics, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
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