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Roston TM, Bezzerides VJ, Roberts JD, Abrams DJ. Management of ultrarare inherited arrhythmia syndromes. Heart Rhythm 2024:S1547-5271(24)03142-4. [PMID: 39154872 DOI: 10.1016/j.hrthm.2024.08.023] [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: 05/01/2024] [Revised: 08/06/2024] [Accepted: 08/08/2024] [Indexed: 08/20/2024]
Abstract
Ultrarare inherited arrhythmia syndromes are increasingly diagnosed as a result of increased awareness as well as increased availability and reduced cost of genetic testing. Yet by definition, their rarity and heterogeneous expression make development of evidence-based management strategies more challenging, typically employing strategies garnered from similar genetic cardiac disorders. For the most part, reliance on anecdotal experiences, expert opinion, and small retrospective cohort studies is the only means to diagnose and to treat these patients. Here we review the management of specific ultrarare inherited arrhythmic syndromes together with the genetic and molecular basis, which will become increasingly important with the development of targeted therapies to correct the biologic basis of these disorders.
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Affiliation(s)
- Thomas M Roston
- Division of Cardiology and Centre for Cardiovascular Innovation, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Vassilios J Bezzerides
- Center for Cardiovascular Genetics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jason D Roberts
- Population Health Research Institute, McMaster University, and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Dominic J Abrams
- Center for Cardiovascular Genetics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
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2
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Xu W, Cao Y, Stephens SB, Arredondo MJ, Chen Y, Perez W, Sun L, Yu AC, Kim JJ, Lalani SR, Li N, Horrigan FT, Altamirano F, Wehrens XH, Miyake CY, Zhang L. Folate as a potential treatment for lethal ventricular arrhythmias in TANGO2-deficiency disorder. JCI Insight 2024; 9:e171005. [PMID: 38855866 PMCID: PMC11382877 DOI: 10.1172/jci.insight.171005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 04/23/2024] [Indexed: 06/11/2024] Open
Abstract
TANGO2-deficiency disorder (TDD) is an autosomal-recessive genetic disease caused by biallelic loss-of-function variants in the TANGO2 gene. TDD-associated cardiac arrhythmias are recalcitrant to standard antiarrhythmic medications and constitute the leading cause of death. Disease modeling for TDD has been primarily carried out using human dermal fibroblast and, more recently, in Drosophila by multiple research groups. No human cardiomyocyte system has been reported, which greatly hinders the investigation and understanding of TDD-associated arrhythmias. Here, we established potentially novel patient-derived induced pluripotent stem cell differentiated cardiomyocyte (iPSC-CM) models that recapitulate key electrophysiological abnormalities in TDD. These electrophysiological abnormalities were rescued in iPSC-CMs with either adenoviral expression of WT-TANGO2 or correction of the pathogenic variant using CRISPR editing. Our natural history study in patients with TDD suggests that the intake of multivitamin/B complex greatly diminished the risk of cardiac crises in patients with TDD. In agreement with the clinical findings, we demonstrated that high-dose folate (vitamin B9) virtually abolishes arrhythmias in TDD iPSC-CMs and that folate's effect was blocked by the dihydrofolate reductase inhibitor methotrexate, supporting the need for intracellular folate to mediate antiarrhythmic effects. In summary, data from TDD iPSC-CM models together with clinical observations support the use of B vitamins to mitigate cardiac crises in patients with TDD, providing potentially life-saving treatment strategies during life-threatening events.
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Affiliation(s)
- Weiyi Xu
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Yingqiong Cao
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Sara B Stephens
- Department of Pediatrics, Division of Pediatric Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Maria Jose Arredondo
- Department of Pediatrics, Division of Pediatric Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Yifan Chen
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - William Perez
- Department of Cardiovascular Sciences, Houston Methodist Research Institute, Houston, Texas, USA
| | - Liang Sun
- Department of Integrative Physiology
| | - Andy C Yu
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Jean J Kim
- Department of Molecular and Cellular Biology
- Human Stem Cell Core, Advanced Technology Cores
| | - Seema R Lalani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Na Li
- Department of Medicine (Section of Cardiovascular Research), and
- Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA
| | | | - Francisco Altamirano
- Department of Cardiovascular Sciences, Houston Methodist Research Institute, Houston, Texas, USA
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, Cornell University, Ithaca, New York, USA
| | - Xander Ht Wehrens
- Department of Integrative Physiology
- Department of Medicine (Section of Cardiovascular Research), and
- Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA
- Department of Neuroscience
- Department of Pediatrics
- Center for Space Medicine, and
| | - Christina Y Miyake
- Department of Pediatrics, Division of Pediatric Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, Texas, USA
| | - Lilei Zhang
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
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3
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Owlett LD, Zapanta B, Sandkuhler SE, Ames EG, Hickey SE, Mackenzie SJ, Meisner JK. Multicenter appraisal of comorbid TANGO2 deficiency disorder in patients with 22q11.2 deletion syndrome. Am J Med Genet A 2024:e63778. [PMID: 38829177 DOI: 10.1002/ajmg.a.63778] [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: 10/17/2023] [Revised: 05/16/2024] [Accepted: 05/19/2024] [Indexed: 06/05/2024]
Abstract
TANGO2 deficiency disorder (TDD) is a rare, autosomal recessive condition caused by pathogenic variants in TANGO2, a gene residing within the region commonly deleted in 22q11.2 deletion syndrome (22q11.2DS). Although patients with 22q11.2DS are at substantially higher risk for comorbid TDD, it remains underdiagnosed within 22q11.2DS, likely due to overlapping symptomatology and a lack of knowledge about TDD. Initiation of B-vitamin supplementation may provide therapeutic benefit in TDD, highlighting the need for effective screening methods to improve diagnosis rates in this at-risk group. In this retrospective, multicenter study, we evaluated two cohorts of patients with 22q11.2DS (total N = 435) for possible comorbid TDD using two different symptom-based screening methods (free text-mining and manual chart review versus manual chart review alone). The methodology of the cohort 1 screening method successfully identified a known 22q11.2DS patient with TDD. Combined, these two cohorts identified 21 living patients meeting the consensus recommendation for TANGO2 testing for suspected comorbid TDD. Of the nine patients undergoing TANGO2 sequencing with del/dup analysis, none were ultimately diagnosed with TDD. Of the 12 deaths in the suspected comorbid TDD cohort, some of these patients exhibited symptoms (rhabdomyolysis, cardiac arrhythmia, or metabolic crisis) suspicious of comorbid TDD contributing to their death. Collectively, these findings highlight the need for robust prospective screening tools for diagnosing comorbid TDD in patients with 22q11.2DS.
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Affiliation(s)
- Laura D Owlett
- Department of Neurology, Division of Child Neurology, University of Rochester, Rochester, New York, USA
| | - Bianca Zapanta
- Department of Pediatrics, Section of Genetic and Genomic Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Sarah E Sandkuhler
- Department of Pathology, University of Rochester, Rochester, New York, USA
| | - Elizabeth G Ames
- Department of Pediatrics, Division of Genetics, Metabolism & Genomic Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Scott E Hickey
- Department of Pediatrics, Section of Genetic and Genomic Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Samuel J Mackenzie
- Department of Neurology, Division of Child Neurology, University of Rochester, Rochester, New York, USA
| | - Joshua K Meisner
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan, USA
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4
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Sacher M, DeLoriea J, Mehranfar M, Casey C, Naaz A, Gamberi C. TANGO2 deficiency disease is predominantly caused by a lipid imbalance. Dis Model Mech 2024; 17:dmm050662. [PMID: 38836374 PMCID: PMC11179719 DOI: 10.1242/dmm.050662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024] Open
Abstract
TANGO2 deficiency disease (TDD) is a rare genetic disorder estimated to affect ∼8000 individuals worldwide. It causes neurodegeneration often accompanied by potentially lethal metabolic crises that are triggered by diet or illness. Recent work has demonstrated distinct lipid imbalances in multiple model systems either depleted for or devoid of the TANGO2 protein, including human cells, fruit flies and zebrafish. Importantly, vitamin B5 supplementation has been shown to rescue TANGO2 deficiency-associated defects in flies and human cells. The notion that vitamin B5 is needed for synthesis of the lipid precursor coenzyme A (CoA) corroborates the hypothesis that key aspects of TDD pathology may be caused by lipid imbalance. A natural history study of 73 individuals with TDD reported that either multivitamin or vitamin B complex supplementation prevented the metabolic crises, suggesting this as a potentially life-saving treatment. Although recently published work supports this notion, much remains unknown about TANGO2 function, the pathological mechanism of TDD and the possible downsides of sustained vitamin supplementation in children and young adults. In this Perspective, we discuss these recent findings and highlight areas for immediate scientific attention.
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Affiliation(s)
- Michael Sacher
- Department of Biology, Concordia University, Montreal H4B 1R6, Canada
- Department of Anatomy and Cell Biology, McGill University, Montreal H3A 0C7, Canada
| | - Jay DeLoriea
- Department of Biology, Coastal Carolina University, Conway, SC 29526, USA
| | - Mahsa Mehranfar
- Department of Chemistry and Biochemistry, Concordia University, Montreal H4B 1R6, Canada
| | - Cody Casey
- Department of Biology, Coastal Carolina University, Conway, SC 29526, USA
| | - Aaliya Naaz
- Department of Biology, Concordia University, Montreal H4B 1R6, Canada
| | - Chiara Gamberi
- Department of Biology, Coastal Carolina University, Conway, SC 29526, USA
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5
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Walters B, McConkey N, Imundo JR. TANGO2: A Rare but Important Mutation. J Innov Card Rhythm Manag 2024; 15:5871-5875. [PMID: 38808169 PMCID: PMC11129830 DOI: 10.19102/icrm.2024.15054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/29/2024] [Indexed: 05/30/2024] Open
Abstract
We report the case of a 7-year-old boy who presented with post-viral myositis, rhabdomyolysis, and hepatitis, who was later readmitted due to a seizure-like activity and ultimately found to have episodes of recalcitrant polymorphic ventricular tachycardia secondary to simultaneous QT prolongation and severe hypothyroidism. Temporary transvenous atrial pacing was successful at controlling the ventricular arrhythmias in the intensive care unit. With levothyroxine therapy and cessation of QT-prolonging medications, the corrected QT (QTc) normalized. A comprehensive arrhythmia panel identified a pathogenic mutation in KCNQ1, consistent with long QT syndrome (LQTS) type 1. After the patient experienced progressive neurodegeneration and seizures, he was referred to a genetics clinic to rule out genetic epilepsy. On the epilepsy panel of genetic testing, he was found to have two pathogenic variants in TANGO2. TANGO2 deficiency explains the initial presentation of myositis, rhabdomyolysis, hypothyroidism, and life-threatening arrhythmias surrounding a viral illness more so than the initial diagnosis of mere LQTS. However, the TANGO2 gene is not included in most comprehensive arrhythmia and cardiomyopathy panels. TANGO2 deficiency is a rare condition that often presents with arrhythmias but may be unfamiliar to many cardiologists and electrophysiologists. This case describes management strategies and caveats, which could aid in the successful diagnosis and treatment of TANGO2 deficiency at the time of presentation.
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Affiliation(s)
- Benjamin Walters
- Pennsylvania State University School of Medicine, Hershey, PA, USA
| | - Nathan McConkey
- Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Jason R. Imundo
- Division of Pediatric Cardiology, Penn State Health Children’s Hospital, Hershey, PA, USA
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Miyake CY, Mackenzie SJ, Zhang L. Top Stories on arrhythmias in TANGO2 deficiency disorder. Heart Rhythm 2024; 21:707-709. [PMID: 38692818 DOI: 10.1016/j.hrthm.2024.03.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 05/03/2024]
Affiliation(s)
- Christina Y Miyake
- Department of Pediatrics, Division of Pediatric Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas; Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, Texas.
| | - Samuel J Mackenzie
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Lilei Zhang
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, Texas; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
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7
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Wedman JJ, Sibon OCM, Mastantuono E, Iuso A. Impaired coenzyme A homeostasis in cardiac dysfunction and benefits of boosting coenzyme A production with vitamin B5 and its derivatives in the management of heart failure. J Inherit Metab Dis 2024. [PMID: 38591231 DOI: 10.1002/jimd.12737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/10/2024]
Abstract
Coenzyme A (CoA) is an essential cofactor required for over a hundred metabolic reactions in the human body. This cofactor is synthesized de novo in our cells from vitamin B5, also known as pantothenic acid, a water-soluble vitamin abundantly present in vegetables and animal-based foods. Neurodegenerative disorders, cancer, and infectious diseases have been linked to defects in de novo CoA biosynthesis or reduced levels of this coenzyme. There is now accumulating evidence that CoA limitation is a critical pathomechanism in cardiac dysfunction too. In the current review, we will summarize our current knowledge on CoA and heart failure, with emphasis on two primary cardiomyopathies, phosphopantothenoylcysteine synthetase and phosphopantothenoylcysteine decarboxylase deficiency disorders biochemically characterized by a decreased level of CoA in patients' samples. Hence, we will discuss the potential benefits of CoA restoration in these diseases and, more generally, in heart failure, by vitamin B5 and its derivatives pantethine and 4'-phosphopantetheine.
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Affiliation(s)
- J J Wedman
- Department of Biomedical Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - O C M Sibon
- Department of Biomedical Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - E Mastantuono
- Regenerative Medicine in Cardiovascular Diseases, First Department of Medicine, Klinikum Rechts der Isar, Technical University of Munich, School of Medicine and Health, Munich, Germany
- First Department of Medicine, Cardiology, Klinikum Rechts der Isar, Technical University of Munich, School of Medicine and Health, Munich, Germany
| | - A Iuso
- Institute of Neurogenomics, Helmholtz Zentrum München, Neuherberg, Germany
- Institute of Human Genetics, Technical University of Munich, School of Medicine and Health, Munich, Germany
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Yılmaz-Gümüş E, Elcioglu NH, Genç E, Arıcı Ş, Öztürk G, Yapıcı Ö, Akalın F, Öztürk-Hişmi B. Management of acute metabolic crisis in TANGO2 deficiency: a case report. J Pediatr Endocrinol Metab 2023; 36:983-987. [PMID: 37381587 DOI: 10.1515/jpem-2023-0172] [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: 04/19/2023] [Accepted: 06/20/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVES TANGO2 deficiency is a rare inborn error of metabolism, with distinct clinical features. The clinical presentations of TANGO2 deficiency are developmental delay, speech difficulties, intellectual disability, non-life-threatening paroxysmal neurologic episodes (TANGO2 spells), acute metabolic crises, cardiac crises, seizures and hypothyroidism. Patients may die in acute metabolic crises. Here we report our experience in the management of an acute metabolic crisis in TANGO2 deficiency. CASE PRESENTATION A 9-year-old patient diagnosed with TANGO2 deficiency was admitted with fever, fatigue, unable to walk. In follow up, encephalopathy, rhabdomyolysis and arrhythmia were detected. Vitamin B-complex was started. Our patient's mental status and rhabdomyolysis improved dramatically, and cardiac crises ended without Torsades de pointes, ventricular tachycardia and/or fibrillation or myocardial dysfunction. CONCLUSIONS With this report, we aimed to show the effectiveness of vitamin B-complex in the management of acute metabolic crises.
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Affiliation(s)
- Emel Yılmaz-Gümüş
- Department of Pediatrics, Division of Pediatric Metabolic Diseases, Marmara University School of Medicine, Istanbul, Türkiye
| | - Nursel H Elcioglu
- Department of Pediatrics, Division of Pediatric Genetics, Marmara University School of Medicine, Istanbul, Türkiye
- Eastern Mediterranean University School of Medicine, Famagusta, Türkiye
| | - Emine Genç
- Department of Pediatrics, Division of Pediatric Metabolic Diseases, Marmara University School of Medicine, Istanbul, Türkiye
| | - Şule Arıcı
- Department of Pediatrics, Division of Pediatric Cardiology, Marmara University School of Medicine, Istanbul, Türkiye
| | - Gülten Öztürk
- Department of Pediatrics, Division of Pediatric Neurology, Marmara University School of Medicine, Istanbul, Türkiye
| | - Özge Yapıcı
- Department of Pediatric Radiology, Marmara University School of Medicine, Istanbul, Türkiye
| | - Figen Akalın
- Department of Pediatrics, Division of Pediatric Cardiology, Marmara University School of Medicine, Istanbul, Türkiye
| | - Burcu Öztürk-Hişmi
- Department of Pediatrics, Division of Pediatric Metabolic Diseases, Marmara University School of Medicine, Istanbul, Türkiye
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Dias JV, Carvalho AA, Freixo JP, Antunes D, Martins AA, Painho T, Jacinto S. TANGO2 Deficiency Disorder: Two Cases of Developmental Delay Preceding Metabolic Crisis. Pediatr Neurol 2023; 147:52-55. [PMID: 37562170 DOI: 10.1016/j.pediatrneurol.2023.07.010] [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: 02/08/2023] [Revised: 07/07/2023] [Accepted: 07/09/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND TANGO2 deficiency disorder is a rare genetic disease caused by biallelic defects in TANGO2 gene. METHODS We report the clinical phenotype of two children with TANGO2 deficiency disorder. RESULTS Patient 1 is a female child presenting with developmental delay and microcephaly during the second year of life, who evolved with severe cognitive impairment, facial dysmorphisms, spastic paraparesis, and atonic seizures. At age 13 years, she was hospitalized due to an episode of rhabdomyolysis complicated with cardiac arrhythmia and hypothyroidism. Patient 2 is a female child with dysmorphic facial features, cleft palate, and developmental delay who was diagnosed with DiGeorge syndrome. At age three years, she presented with an acute episode of severe rhabdomyolysis in the context of human herpesvirus 6 infection. After the resolution of this acute episode, she maintained recurrent muscle weakness with axial hypotonia and progressive spasticity of the lower extremities. In both patients, diagnosis of TANGO2 deficiency disorder was only confirmed after an acute metabolic crisis. CONCLUSIONS A high index of suspicion for TANGO2 deficiency disorder is needed in patients with developmental delay or other neurological symptoms and episodic rhabdomyolysis.
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Affiliation(s)
| | - Ana Araújo Carvalho
- Pediatric Department, Hospital Dona Estefânia, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - João Parente Freixo
- Center for Predictive and Preventive Genetics, Institute of Molecular and Cell Biology, Porto, Portugal; i3S - Instituto de Investigação e Inovação em Saúde da Universidade do Porto, Porto, Portugal
| | - Diana Antunes
- Medical Genetics Department, Centro Hospital Universitário de Lisboa Central, Lisbon, Portugal
| | - Ana Antunes Martins
- Pediatric Neurology Department, Hospital Dona Estefânia, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal; Pediatric Neurology Unit, Hospital da Luz, Lisbon, Portugal
| | - Teresa Painho
- Pediatric Neurology Department, Hospital Dona Estefânia, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Sandra Jacinto
- Pediatric Neurology Department, Hospital Dona Estefânia, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
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Kim ES, Casey JG, Tao BS, Mansur A, Mathiyalagan N, Wallace ED, Ehrmann BM, Gupta VA. Intrinsic and extrinsic regulation of rhabdomyolysis susceptibility by Tango2. Dis Model Mech 2023; 16:dmm050092. [PMID: 37577943 PMCID: PMC10499024 DOI: 10.1242/dmm.050092] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 08/09/2023] [Indexed: 08/15/2023] Open
Abstract
Rhabdomyolysis is a clinical emergency characterized by severe muscle damage, resulting in the release of intracellular muscle components, which leads to myoglobinuria and, in severe cases, acute kidney failure. Rhabdomyolysis is caused by genetic factors linked to increased disease susceptibility in response to extrinsic triggers. Recessive mutations in TANGO2 result in episodic rhabdomyolysis, metabolic crises, encephalopathy and cardiac arrhythmia. The underlying mechanism contributing to disease onset in response to specific triggers remains unclear. To address these challenges, we created a zebrafish model of Tango2 deficiency. Here, we demonstrate that the loss of Tango2 in zebrafish results in growth defects, early lethality and increased susceptibility of skeletal muscle defects in response to extrinsic triggers, similar to TANGO2-deficient patients. Using lipidomics, we identified alterations in the glycerolipid pathway in tango2 mutants, which is critical for membrane stability and energy balance. Therefore, these studies provide insight into key disease processes in Tango2 deficiency and have increased our understanding of the impacts of specific defects on predisposition to environmental triggers in TANGO2-related disorders.
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Affiliation(s)
- Euri S. Kim
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA 02115, USA
| | - Jennifer G. Casey
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA 02115, USA
| | - Brian S. Tao
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA 02115, USA
| | - Arian Mansur
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA 02115, USA
| | - Nishanthi Mathiyalagan
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA 02115, USA
| | - E. Diane Wallace
- Department of Chemistry, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Brandie M. Ehrmann
- Department of Chemistry, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Vandana A. Gupta
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA 02115, USA
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Miyake CY, Ehsan SA, Zhang L, Mackenzie SJ, Azamian MS, Scott DA, Hernandez-Garcia A, Lalani SR. Early initiation of B-vitamin supplementation may reduce symptoms and explain intrafamilial variability: Insights from two sibling pairs from the TANGO2 natural history study. Am J Med Genet A 2023; 191:2433-2439. [PMID: 37421366 PMCID: PMC10612108 DOI: 10.1002/ajmg.a.63331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 05/07/2023] [Accepted: 05/26/2023] [Indexed: 07/10/2023]
Abstract
TANGO2-deficiency disorder (TDD) is an autosomal recessive condition arising from pathogenic biallelic variants in the TANGO2 gene. TDD is characterized by symptoms typically beginning in late infancy including delayed developmental milestones, cognitive impairment, dysarthria, expressive language deficits, and gait abnormalities. There is wide phenotypic variability where some are severely affected while others have mild symptoms. This variability has been documented even among sibling pairs who share the same genotype, but reasons for this variability have not been well understood. Emerging data suggest a potential link between B-complex or multivitamin supplementation and decreased metabolic crises in TDD. In this report, we describe two sibling pairs from unreladiagnosed with TDD with marked differences in symptoms. In both families, the older siblings suffered multiple metabolic crises and are clinically more affected than their younger siblings who have very mild to no symptoms; they are the least impaired among 70 other patients in our ongoing international natural history study. Unlike their older siblings, the two younger siblings started taking B-complex vitamins early between 9 and 16 months. This report delineates the mildest presentation of TDD in two families. These data may support a role for early diagnosis and initiation of vitamin supplementation to not only prevent metabolic crises but also improve neurologic outcomes in this life-threatening disorder.
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Affiliation(s)
- Christina Y. Miyake
- Department of Pediatrics, Division of Cardiology, Texas Children’s Hospital, Houston, TX, 77030, USA
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, TX, 77030, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Saad A. Ehsan
- Baylor College School of Medicine, Houston, TX, 77030, USA
| | - Lilei Zhang
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, TX, 77030, USA
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, 77030, USA
| | - Samuel J. Mackenzie
- Department of Neurology, University of Rochester Medical Center, Rochester, NY USA, 14642, USA
| | - Mahshid S. Azamian
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, 77030, USA
| | - Daryl A. Scott
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, TX, 77030, USA
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, 77030, USA
| | - Andres Hernandez-Garcia
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, 77030, USA
| | - Seema R. Lalani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, 77030, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, 77030, USA
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Miyake CY, Lay EJ, Soler-Alfonso C, Glinton KE, Houck KM, Tosur M, Moran NE, Stephens SB, Scaglia F, Howard TS, Kim JJ, Pham TD, Valdes SO, Li N, Murali CN, Zhang L, Kava M, Yim D, Beach C, Webster G, Liberman L, Janson CM, Kannankeril PJ, Baxter S, Singer-Berk M, Wood J, Mackenzie SJ, Sacher M, Ghaloul-Gonzalez L, Pedroza C, Morris SA, Ehsan SA, Azamian MS, Lalani SR. Natural history of TANGO2 deficiency disorder: Baseline assessment of 73 patients. Genet Med 2023; 25:100352. [PMID: 36473599 PMCID: PMC10306319 DOI: 10.1016/j.gim.2022.11.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/30/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE TANGO2 deficiency disorder (TDD), an autosomal recessive disease first reported in 2016, is characterized by neurodevelopmental delay, seizures, intermittent ataxia, hypothyroidism, and life-threatening metabolic and cardiac crises. The purpose of this study was to define the natural history of TDD. METHODS Data were collected from an ongoing natural history study of patients with TDD enrolled between February 2019 and May 2022. Data were obtained through phone or video based parent interviews and medical record review. RESULTS Data were collected from 73 patients (59% male) from 57 unrelated families living in 16 different countries. The median age of participants at the time of data collection was 9.0 years (interquartile range = 5.3-15.9 years, range = fetal to 31.8 years). A total of 24 different TANGO2 alleles were observed. Patients showed normal development in early infancy, with progressive delay in developmental milestones thereafter. Symptoms included ataxia, dystonia, and speech difficulties, typically starting between the ages of 1 to 3 years. A total of 46/71 (65%) patients suffered metabolic crises, and of those, 30 (65%) developed cardiac crises. Metabolic crises were significantly decreased after the initiation of B-complex or multivitamin supplementation. CONCLUSION We provide the most comprehensive review of natural history of TDD and important observational data suggesting that B-complex or multivitamins may prevent metabolic crises.
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Affiliation(s)
- Christina Y Miyake
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX; Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston TX.
| | - Erica J Lay
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | | | - Kevin E Glinton
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Kimberly M Houck
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Mustafa Tosur
- Division of Diabetes and Endocrinology, Department of Pediatrics, USDA/ARS Children's Nutrition Research Center, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Nancy E Moran
- USDA/ARS Children's Nutrition Research Center, Division of Nutrition, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Sara B Stephens
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Fernando Scaglia
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX; BCM-CUHK Center of Medical Genetics, Prince of Wales Hospital, Hong Kong, Special Administrative Region
| | - Taylor S Howard
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Jeffrey J Kim
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Tam Dam Pham
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Santiago O Valdes
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Na Li
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston TX; Department of Medicine, Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX
| | - Chaya N Murali
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Lilei Zhang
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston TX; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Maina Kava
- Department of Neurology, Perth Children's Hospital, Perth, Western Australia, Australia; Departments of Metabolic Medicine and Rheumatology, Perth Children's Hospital, Perth, Western Australia, Australia; Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Deane Yim
- Department of Cardiology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Cheyenne Beach
- Division of Cardiology, Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, CT
| | - Gregory Webster
- Division of Cardiology, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Nortwestern University Feinberg School of Medicine, Chicago, IL
| | - Leonardo Liberman
- Division of Cardiology, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Christopher M Janson
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Prince J Kannankeril
- Center for Pediatric Precision Medicine, Department of Pediatrics, Vanderbilt University Medical Center and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | | | | | - Jordan Wood
- Broad Institute of MIT and Harvard, Cambridge, MA
| | - Samuel J Mackenzie
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
| | - Michael Sacher
- Department of Biology, Concordia University, Montreal, Quebec, Canada; Department of Anatomy and Cell Biology, McGill University, Montreal, Quebec, Canada
| | - Lina Ghaloul-Gonzalez
- Division of Genetic and Genomic Medicine, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Claudia Pedroza
- Department of Pediatrics, McGovern Medical School, University of Texas Health Center at Houston, Houston, TX
| | - Shaine A Morris
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | | | - Mahshid S Azamian
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Seema R Lalani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
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Asadi P, Milev MP, Saint-Dic D, Gamberi C, Sacher M. Vitamin B5, a coenzyme A precursor, rescues TANGO2 deficiency disease-associated defects in Drosophila and human cells. J Inherit Metab Dis 2023; 46:358-368. [PMID: 36502486 PMCID: PMC10464931 DOI: 10.1002/jimd.12579] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/22/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
Mutations in the Transport and Golgi Organization 2 (TANGO2) gene are associated with intellectual deficit, neurodevelopmental delay and regression. Individuals can also present with an acute metabolic crisis that includes rhabdomyolysis, cardiomyopathy, and cardiac arrhythmias, the latter of which are potentially lethal. While preventing metabolic crises has the potential to reduce mortality, no treatments currently exist for this condition. The function of TANGO2 remains unknown but is suspected to be involved in some aspect of lipid metabolism. Here, we describe a model of TANGO2-related disease in the fruit fly Drosophila melanogaster that recapitulates crucial disease traits. Pairing a new fly model with human cells, we examined the effects of vitamin B5, a coenzyme A (CoA) precursor, on alleviating the cellular and organismal defects associated with TANGO2 deficiency. We demonstrate that vitamin B5 specifically improves multiple defects associated with TANGO2 loss-of-function in Drosophila and rescues membrane trafficking defects in human cells. We also observed a partial rescue of one of the fly defects by vitamin B3, though to a lesser extent than vitamin B5. Our data suggest that a B complex supplement containing vitamin B5/pantothenate may have therapeutic benefits in individuals with TANGO2-deficiency disease. Possible mechanisms for the rescue are discussed that may include restoration of lipid homeostasis.
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Affiliation(s)
- Paria Asadi
- Concordia University, Department of Biology, Montreal, Quebec, Canada, H4B1R6
| | - Miroslav P. Milev
- Concordia University, Department of Biology, Montreal, Quebec, Canada, H4B1R6
| | - Djenann Saint-Dic
- Concordia University, Department of Biology, Montreal, Quebec, Canada, H4B1R6
| | - Chiara Gamberi
- Coastal Carolina University, Department of Biology, Conway, South Carolina, USA, 29526
| | - Michael Sacher
- Concordia University, Department of Biology, Montreal, Quebec, Canada, H4B1R6
- McGill University, Department of Anatomy and Cell Biology, Montreal, Quebec, Canada, H3A0C7
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Restrepo-Vera JL, Muñoz-Cabello P, Pérez-Rodon J, Rovira-Moreno E, Codina-Solà M, Llauradó A, Salvadó M, Sánchez-Tejerina D, Sotoca J, Martínez-Sáez E, García-Arumí E, Juntas-Morales R. Limb-girdle myopathy and mild intellectual disability: the expanding spectrum of TANGO2-related disease. Neuromuscul Disord 2023; 33:463-467. [PMID: 37119590 DOI: 10.1016/j.nmd.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/29/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023]
Abstract
TANGO2-related disease is an autosomal recessive multisystem disease associated with developmental delay and infancy-onset recurrent metabolic crises with early mortality. Several studies have reported dysfunction in endoplasmic reticulum-to-Golgi traffic and mitochondrial homoeostasis as the underlying pathophysiology. We report a 40-year-old woman affected by limb-girdle weakness and mild intellectual disability caused by the recurrent deletion of exons 3-9 in homozygosity in the TANGO2 gene. Physical examination revealed hyperlordosis, waddling gait, calf pseudohypertrophy, and Aquilian tendon retractions. Laboratory investigations revealed elevation of serum biomarkers suggestive of mitochondrial dysfunction together with hypothyroidism. At the age of 24, the patient suffered a metabolic crisis with severe rhabdomyolysis and malignant cardiac arrhythmia. After recovery, no metabolic or arrhythmic crisis has recurred. Muscle histology two years later revealed increased endomysial fibrosis and other myopathic changes. Our findings illustrate the mildest end of the phenotypic spectrum of TANGO2-related disease and reveal further aspects related to chronic muscle damage in this disorder.
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Affiliation(s)
- Juan Luis Restrepo-Vera
- Department of Neurology, Neuromuscular Diseases Unit, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron, 119-135, Barcelona 08035, Spain
| | - Patricia Muñoz-Cabello
- Department of Clinical and Molecular Genetics, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona 08035, Spain; Medicine Genetics Group, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona (UAB), Barcelona 08035, Spain
| | - Jordi Pérez-Rodon
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Vall d'Hebrón Institut de Recerca, CIBER-CV, Barcelona, Spain
| | - Eulàlia Rovira-Moreno
- Department of Clinical and Molecular Genetics, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona 08035, Spain; Medicine Genetics Group, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona (UAB), Barcelona 08035, Spain
| | - Marta Codina-Solà
- Department of Clinical and Molecular Genetics, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona 08035, Spain; Medicine Genetics Group, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona (UAB), Barcelona 08035, Spain
| | - Arnau Llauradó
- Department of Neurology, Neuromuscular Diseases Unit, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron, 119-135, Barcelona 08035, Spain
| | - Maria Salvadó
- Department of Neurology, Neuromuscular Diseases Unit, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron, 119-135, Barcelona 08035, Spain
| | - Daniel Sánchez-Tejerina
- Department of Neurology, Neuromuscular Diseases Unit, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron, 119-135, Barcelona 08035, Spain
| | - Javier Sotoca
- Department of Neurology, Neuromuscular Diseases Unit, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron, 119-135, Barcelona 08035, Spain
| | - Elena Martínez-Sáez
- Department of Pathology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona 08035, Spain
| | - Elena García-Arumí
- Department of Clinical and Molecular Genetics, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona 08035, Spain; Research Group on Neuromuscular and Mitochondrial Diseases, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain; Biomedical Network Research Centre on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Raul Juntas-Morales
- Department of Neurology, Neuromuscular Diseases Unit, European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron, 119-135, Barcelona 08035, Spain.
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Roston TM, Sanatani S. A Dangerous Dance: Recurrent Cardiac Crises in TANGO2-deficiency Disorder. Heart Rhythm 2022; 19:1682-1683. [DOI: 10.1016/j.hrthm.2022.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 11/27/2022]
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