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Yeganeh M, March K, Jones C, Ho G, Selby KA, Chanoine JP, Stockler S, Salvarinova R, Horvath G, Brunel-Guitton C. Use of dexamethasone in acute rhabdomyolysis in LPIN1 deficiency. Mol Genet Metab Rep 2023; 35:100961. [PMID: 36941958 PMCID: PMC10024045 DOI: 10.1016/j.ymgmr.2023.100961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/12/2023] Open
Abstract
Introduction LPIN1 deficiency is an autosomal recessive form of early childhood recurrent severe rhabdomyolysis. Although not completely lucid yet, LPIN1 has been shown to modulate endosomal-related pro-inflammatory responses via peroxisome proliferator-activated receptor α (PPARα) and PPARγ coactivator 1α (PGC-1α). Treatment with anti-inflammatory agents such as dexamethasone has been proposed to improve the outcome. Case We report a male toddler with recurrent episodes of complicated rhabdomyolysis, requiring prolonged intensive care unit admissions. Whole exome sequencing revealed a common homozygous 1.7 kb intragenic deletion in LPIN1. Despite optimal metabolic cares, the patient presented with an extremely high CK level where he benefited from intravenous dexamethasone (0.6 mg/Kg/day) for a period of 6 days. Results Dexamethasone administration shortened the course of active rhabdomyolysis, intensive care admission and rehabilitation. It also prevented rhabdomyolysis-related complications such as kidney injury and compartment syndrome. Conclusion Our patient showed a favorable response to parenteral dexamethasone, in addition to hyperhydration with IV fluids, sufficient calorie intake, and restricted dietary fat. The improvement with corticosteroids suggests an uncontrolled inflammatory response as the pathophysiology of LPIN1 deficiency.
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Affiliation(s)
- Mehdi Yeganeh
- Division of Biochemical Genetics, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver V6H 3N1, BC, Canada
| | - Kaitlin March
- Division of Biochemical Genetics, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver V6H 3N1, BC, Canada
| | - Catherine Jones
- Division of Biochemical Genetics, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver V6H 3N1, BC, Canada
| | - Gloria Ho
- Division of Biochemical Genetics, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver V6H 3N1, BC, Canada
| | - Kathryn A. Selby
- Division of Neurology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, V6H 3N1, BC, Canada
| | - Jean-Pierre Chanoine
- Division of Endocrinology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, V6H 3N1, BC, Canada
| | - Sylvia Stockler
- Division of Biochemical Genetics, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver V6H 3N1, BC, Canada
| | - Ramona Salvarinova
- Division of Biochemical Genetics, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver V6H 3N1, BC, Canada
| | - Gabriella Horvath
- Division of Biochemical Genetics, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver V6H 3N1, BC, Canada
| | - Catherine Brunel-Guitton
- Division of Biochemical Genetics, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver V6H 3N1, BC, Canada
- Corresponding author.
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2
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Tuchmann-Durand C, Roda C, Renard P, Mortamet G, Bérat CM, Altenburger L, de Larauz MH, Thevenet E, Cottart CH, Moulin F, Bouchereau J, Brassier A, Arnoux JB, Schiff M, Bednarek N, Lamireau D, Garros A, Mention K, Cano A, Finger L, Pelosi M, Brochet CS, Caccavelli L, Raphalen JH, Renolleau S, Oualha M, de Lonlay P. Systemic corticosteroids for the treatment of acute episodes of rhabdomyolysis in lipin-1-deficient patients. J Inherit Metab Dis 2023. [PMID: 36680547 DOI: 10.1002/jimd.12592] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/13/2023] [Accepted: 01/19/2023] [Indexed: 01/22/2023]
Abstract
Mutations in the LPIN1 gene constitute a major cause of severe rhabdomyolysis (RM). The TLR9 activation prompted us to treat patients with corticosteroids in acute conditions. In patients with LPIN1 mutations, RM and at-risk situations that can trigger RM have been treated in a uniform manner. Since 2015, these patients have also received intravenous corticosteroids. We retrospectively compared data on hospital stays by corticosteroid-treated patients vs. patients not treated with corticosteroids. Nineteen patients were hospitalized. The median number of admissions per patient was 21 overall and did not differ when comparing the 10 corticosteroid-treated patients with the 9 patients not treated with corticosteroids. Four patients in the non-corticosteroid group died during a RM (mean age at death: 5.6 years). There were no deaths in the corticosteroid group. The two groups did not differ significantly in the number of RM episodes. However, for the six patients who had RM and occasionally been treated with corticosteroids, the median number of RM episodes was significantly lower when intravenous steroids had been administered. The peak plasma creatine kinase level and the area under the curve were or tended to be higher in patients treated with corticosteroids-even after the exclusion of deceased patients or focusing on the period after 2015. The median length of stay (10 days overall) was significantly longer for corticosteroid-treated patients but was similar after the exclusion of deceased patients. The absence of deaths and the higher severity of RM observed among corticosteroid-treated patients could suggest that corticotherapy is associated with greater survival.
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Affiliation(s)
- Caroline Tuchmann-Durand
- Imagine Institute, Biotherapy Clinical Investigation Center, Biotherapy Department, Necker-Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Célina Roda
- Université Paris Cité, Health Environmental Risk Assessment (HERA) Team, CRESS, INSERM, INRAE, Paris, France
- Faculté de Pharmacie de Paris, Université Paris Cité, Paris, France
| | - Perrine Renard
- INSERM U1151, Institut Necker Enfants-Malades (INEM), Paris, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Claire-Marine Bérat
- Reference Center for Inherited Metabolic Diseases, Necker-Enfants-Malades University Hospital, APHP, Imagine Institute, G2M, MetabERN, Paris, France
| | - Lucile Altenburger
- Reference Center for Inherited Metabolic Diseases, Necker-Enfants-Malades University Hospital, APHP, Imagine Institute, G2M, MetabERN, Paris, France
| | - Marie Hug de Larauz
- Imagine Institute, Biotherapy Clinical Investigation Center, Biotherapy Department, Necker-Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Eloise Thevenet
- Imagine Institute, Biotherapy Clinical Investigation Center, Biotherapy Department, Necker-Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Charles-Henry Cottart
- Faculté de Pharmacie de Paris, Université Paris Cité, Paris, France
- Biochemistry Unit, Biology Department, Assistance Publique Hôpitaux de Paris (AP-HP), Necker-Enfants-Malades University Hospital, Paris, France
| | - Florence Moulin
- Pediatric Intensive Care Unit for, Necker-Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Juliette Bouchereau
- Reference Center for Inherited Metabolic Diseases, Necker-Enfants-Malades University Hospital, APHP, Imagine Institute, G2M, MetabERN, Paris, France
| | - Anais Brassier
- Reference Center for Inherited Metabolic Diseases, Necker-Enfants-Malades University Hospital, APHP, Imagine Institute, G2M, MetabERN, Paris, France
| | - Jean-Baptiste Arnoux
- Reference Center for Inherited Metabolic Diseases, Necker-Enfants-Malades University Hospital, APHP, Imagine Institute, G2M, MetabERN, Paris, France
| | - Manuel Schiff
- Reference Center for Inherited Metabolic Diseases, Necker-Enfants-Malades University Hospital, APHP, Imagine Institute, G2M, MetabERN, Paris, France
- Medical School, Université Paris Cité, Paris, France
| | - Nathalie Bednarek
- Intensive Care Unit and Competence Center for Inherited Metabolic Diseases, Reims University Hospital, Reims, France
| | - Delphine Lamireau
- Competence Center for Inherited Metabolic Diseases, Pellegrin University Hospital, Bordeaux, France
| | - Alexa Garros
- Competence Center for Inherited Metabolic Diseases, Grenoble Alpes University Hospital, Grenoble, France
| | - Karine Mention
- Reference Center for Inherited Metabolic Diseases, Jeanne de Flandre Hospital, MetabERN, Lille, France
| | - Aline Cano
- Reference Center for Inherited Metabolic Diseases, La Timone University Hospital, MetabERN, Marseille, France
| | - Lionel Finger
- Biochemistry Unit, Biology Department, Troyes Hospital, Troyes, France
| | - Michele Pelosi
- Reference Center for Inherited Metabolic Diseases, Necker-Enfants-Malades University Hospital, APHP, Imagine Institute, G2M, MetabERN, Paris, France
| | | | - Laure Caccavelli
- INSERM U1151, Institut Necker Enfants-Malades (INEM), Paris, France
- Reference Center for Inherited Metabolic Diseases, Necker-Enfants-Malades University Hospital, APHP, Imagine Institute, G2M, MetabERN, Paris, France
| | - Jean-Herlé Raphalen
- Adult Intensive Care Unit, Necker-Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Sylvain Renolleau
- Pediatric Intensive Care Unit for, Necker-Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Medical School, Université Paris Cité, Paris, France
| | - Mehdi Oualha
- Pediatric Intensive Care Unit for, Necker-Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Medical School, Université Paris Cité, Paris, France
| | - Pascale de Lonlay
- INSERM U1151, Institut Necker Enfants-Malades (INEM), Paris, France
- Reference Center for Inherited Metabolic Diseases, Necker-Enfants-Malades University Hospital, APHP, Imagine Institute, G2M, MetabERN, Paris, France
- Medical School, Université Paris Cité, Paris, France
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LPIN1 rhabdomyolysis: A single site cohort description and treatment recommendations. Mol Genet Metab Rep 2022; 30:100844. [PMID: 35242575 PMCID: PMC8856908 DOI: 10.1016/j.ymgmr.2022.100844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/21/2022] Open
Abstract
Individuals with LPIN1 deficiency have early recurrent, life-threatening rhabdomyolysis but the full phenotypic spectrum and optimal treatment of the disorder remains unknown. Here we report the clinical details and treatment outcomes of 6 patients from our health system. The average age of presentation in our cohort was 23.8 months ±11.6 months (range 15–46 months). The average number of days for each hospitalization for this cohort is 11.7±13.2 days. Creatinine kinase (CK) levels peak during our care averaged 607,725 units/L (range 157,000-1,100,000 units/L). We observed that aspartate aminotransferase levels paralleled the CK levels in its elevation and resolution (Pearson's correlation R = 0.995); while alanine aminotransferase paralleled the elevation but lagged in the resolution of CK levels (R = 0.728). Unlike historical accounts, in our patient population, rhabdomyolysis was sometimes seen without inciting viral or traumatic events. We also cared for multiple individuals that had received treatment at other centers. This allowed us to compare multiple practice approaches and led to a standardized Care Recommendations.
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4
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Wang H, Chan TW, Vashisht AA, Drew BG, Calkin AC, Harris TE, Wohlschlegel JA, Xiao X, Reue K. Lipin 1 modulates mRNA splicing during fasting adaptation in liver. JCI Insight 2021; 6:e150114. [PMID: 34494556 PMCID: PMC8492312 DOI: 10.1172/jci.insight.150114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/23/2021] [Indexed: 01/03/2023] Open
Abstract
Lipin 1 regulates cellular lipid homeostasis through roles in glycerolipid synthesis (through phosphatidic acid phosphatase activity) and transcriptional coactivation. Lipin 1-deficient individuals exhibit episodic disease symptoms that are triggered by metabolic stress, such as stress caused by prolonged fasting. We sought to identify critical lipin 1 activities during fasting. We determined that lipin 1 deficiency induces widespread alternative mRNA splicing in liver during fasting, much of which is normalized by refeeding. The role of lipin 1 in mRNA splicing was largely independent of its enzymatic function. We identified interactions between lipin 1 and spliceosome proteins, as well as a requirement for lipin 1 to maintain homeostatic levels of spliceosome small nuclear RNAs and specific RNA splicing factors. In fasted Lpin1-/- liver, we identified a correspondence between alternative splicing of phospholipid biosynthetic enzymes and dysregulated phospholipid levels; splicing patterns and phospholipid levels were partly normalized by feeding. Thus, lipin 1 influences hepatic lipid metabolism through mRNA splicing, as well as through enzymatic and transcriptional activities, and fasting exacerbates the deleterious effects of lipin 1 deficiency on metabolic homeostasis.
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Affiliation(s)
- Huan Wang
- Human Genetics, David Geffen School of Medicine at UCLA
| | | | - Ajay A Vashisht
- Biological Chemistry, University of California, Los Angeles, California, USA
| | - Brian G Drew
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Anna C Calkin
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Baker Department of Cardiometabolic Health, University of Melbourne, Parkville, Victoria, Australia
| | - Thurl E Harris
- Pharmacology, University of Virginia, Charlottesville, Virginia, USA
| | - James A Wohlschlegel
- Biological Chemistry, University of California, Los Angeles, California, USA.,Molecular Biology Institute and
| | - Xinshu Xiao
- Bioinformatics Interdepartmental Program and.,Molecular Biology Institute and.,Integrative Biology and Physiology, University of California, Los Angeles, California, USA
| | - Karen Reue
- Human Genetics, David Geffen School of Medicine at UCLA,,Molecular Biology Institute and
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5
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Tong K, Yu GS. Acute recurrent rhabdomyolysis in a Chinese boy associated with a novel compound heterozygous LPIN1 variant: a case report. BMC Neurol 2021; 21:42. [PMID: 33514355 PMCID: PMC7844980 DOI: 10.1186/s12883-021-02050-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/07/2021] [Indexed: 01/04/2023] Open
Abstract
Background LPIN1-related acute recurrent rhabdomyolysis (RM), first reported in 2008, is an autosomal recessive inherited metabolic disease. In recent years, LPIN1 gene variants have been identified as one of the main causes of severe RM in children in Western countries. The disease is extremely rare in China, and we report a case of acute recurrent RM caused by a novel compound heterozygous LPIN1 variant. Case presentation A 15-year-old Chinese boy presented with myalgia after strenuous exercise, accompanied by transient increases in serum creatine kinase and myoglobin and persistent hyperuricaemia and hyperbilirubinaemia. Genetic analysis using high-throughput genomic sequencing and Sanger sequencing revealed that there was a compound heterozygous variant in the LPIN1 gene of the proband: the paternal c.2047A > G(p.I683V) was an unreported missense variant, and the maternal c.2107_2108 insAGG(p.Q703delin sQE) was an unreported in-frame variant. Conclusions In children with RM, LPIN1 variants should always be considered in the differential diagnosis. The clinical features of our case are atypical, which highlights the importance of an accurate diagnosis by genetic testing. If detected early, the condition may be controlled, and the prognosis may be improved.
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Affiliation(s)
- Ke Tong
- Department of Cardiovascular Disease, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China.,Ministry of Education Key Laboratory of Child Development and Disorders, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China.,National Clinical Research Center for Child Health and Disorders (Chongqing), 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China.,Chongqing Key Laboratory of Pediatrics, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China
| | - Geng-Sheng Yu
- Department of Cardiovascular Disease, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China. .,Ministry of Education Key Laboratory of Child Development and Disorders, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China. .,National Clinical Research Center for Child Health and Disorders (Chongqing), 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China. .,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China. .,Chongqing Key Laboratory of Pediatrics, 136 Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China.
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6
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Lu S, Lyu Z, Wang Z, Kou Y, Liu C, Li S, Hu M, Zhu H, Wang W, Zhang C, Kuan YS, Liu YW, Chen J, Tian J. Lipin 1 deficiency causes adult-onset myasthenia with motor neuron dysfunction in humans and neuromuscular junction defects in zebrafish. Theranostics 2021; 11:2788-2805. [PMID: 33456573 PMCID: PMC7806489 DOI: 10.7150/thno.53330] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/12/2020] [Indexed: 12/03/2022] Open
Abstract
Lipin 1 is an intracellular protein acting as a phosphatidic acid phosphohydrolase enzyme controlling lipid metabolism. Human recessive mutations in LPIN1 cause recurrent, early-onset myoglobinuria, a condition normally associated with muscle pain and weakness. Whether and how lipin 1 deficiency in humans leads to peripheral neuropathy is yet unclear. Herein, two novel compound heterozygous mutations in LPIN1 with neurological disorders, but no myoglobinuria were identified in an adult-onset syndromic myasthenia family. The present study sought to explore the pathogenic mechanism of LPIN1 in muscular and neural development. Methods: The clinical diagnosis of the proband was compared to the known 48 cases of LPIN1 recessive homozygous mutations. Whole-exome sequencing was carried out on the syndromic myasthenia family to identify the causative gene. The pathogenesis of lipin 1 deficiency during somitogenesis and neurogenesis was investigated using the zebrafish model. Whole-mount in situ hybridization, immunohistochemistry, birefringence analysis, touch-evoke escape response and locomotion assays were performed to observe in vivo the changes in muscles and neurons. The conservatism of the molecular pathways regulated by lipin 1 was evaluated in human primary glioblastoma and mouse myoblast cells by siRNA knockdown, drug treatment, qRT-PCR and Western blotting analysis. Results: The patient exhibited adult-onset myasthenia accompanied by muscle fiber atrophy and nerve demyelination without myoglobinuria. Two novel heterozygous mutations, c.2047A>C (p.I683L) and c.2201G>A (p.R734Q) in LPIN1, were identified in the family and predicted to alter the tertiary structure of LPIN1 protein. Lipin 1 deficiency in zebrafish embryos generated by lpin1 morpholino knockdown or human LPIN1 mutant mRNA injections reproduced the myotomes defects, a reduction both in primary motor neurons and secondary motor neurons projections, morphological changes of post-synaptic clusters of acetylcholine receptors, and myelination defects, which led to reduced touch-evoked response and abnormalities of swimming behaviors. Loss of lipin 1 function in zebrafish and mammalian cells also exhibited altered expression levels of muscle and neuron markers, as well as abnormally enhanced Notch signaling, which was partially rescued by the specific Notch pathway inhibitor DAPT. Conclusions: These findings pointed out that the compound heterozygous mutations in human LPIN1 caused adult-onset syndromic myasthenia with peripheral neuropathy. Moreover, zebrafish could be used to model the neuromuscular phenotypes due to the lipin 1 deficiency, where a novel pathological role of over-activated Notch signaling was discovered and further confirmed in mammalian cell lines.
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7
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Summerlin ML, Regier DS, Fraser JL, Chapman KA, Kafashzadeh D, Billington C, Kisling M, Grochowsky A, Ah Mew N, Shur N. Use of dexamethasone in idiopathic, acute pediatric rhabdomyolysis. Am J Med Genet A 2020; 185:500-507. [PMID: 33300687 DOI: 10.1002/ajmg.a.62000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/12/2020] [Accepted: 11/14/2020] [Indexed: 12/18/2022]
Abstract
Current rhabdomyolysis treatment guidelines vary based on the etiology and diagnosis, yet many cases evade conclusive diagnosis. In these cases, treatment options remain largely limited to fluids and supportive therapy. We present two cases of acute rhabdomyolysis diagnosed in the emergency department: a 5-year-old boy with sudden onset bilateral flank pain, and a 13-year-old boy with 2-3 days of worsening pectoral and shoulder pain. Each patient had a prior similar episode requiring hospitalization in the past. The 5-year-old had no inciting trauma or trigger, medication use, or illness. The 13-year-old previously had an upper respiratory infection during the week prior and had been strenuously exercising at the time of onset. Genetic testing results were unknown for both patients during their hospitalizations, and insurance and other barriers led to delay. Later results for the first patient revealed a heterozygous deletion in intron 19 on the LPIN1 gene interpreted as a variant of unknown significance. During their hospitalizations, both children were started on intravenous (i.v.) fluids, and creatine kinase (CK) initially trended downward, but then began to rise or plateau. After reviewing the cases, prior literature, and anecdotal evidence of benefit from corticosteroid therapy in rhabdomyolysis with our consultant metabolic physicians, dexamethasone was initiated. In both patients, dexamethasone use correlated with relief of patient symptoms, significantly decreased CK value, and our ability to discharge these patients home quickly. Our cases, discussion, and literature review all lead to the consideration of the use of dexamethasone in conjunction with standard therapy for acute rhabdomyolysis.
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Affiliation(s)
- Maxwell L Summerlin
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Debra S Regier
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Jamie L Fraser
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Kimberly A Chapman
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Dariush Kafashzadeh
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Charles Billington
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Monisha Kisling
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Angela Grochowsky
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Nicholas Ah Mew
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Natasha Shur
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
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8
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Potential causal role of l-glutamine in sickle cell disease painful crises: A Mendelian randomization analysis. Blood Cells Mol Dis 2020; 86:102504. [PMID: 32949984 DOI: 10.1016/j.bcmd.2020.102504] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 01/12/2023]
Abstract
In a recent clinical trial, the metabolite l-glutamine was shown to reduce painful crises in sickle cell disease (SCD) patients. To support this observation and identify other metabolites implicated in SCD clinical heterogeneity, we profiled 129 metabolites in the plasma of 705 SCD patients. We tested correlations between metabolite levels and six SCD-related complications (painful crises, cholecystectomy, retinopathy, leg ulcer, priapism, aseptic necrosis) or estimated glomerular filtration rate (eGFR), and used Mendelian randomization (MR) to assess causality. We found a potential causal relationship between l-glutamine levels and painful crises (N = 1278, odds ratio (OR) [95% confidence interval] = 0.68 [0.52-0.89], P = 0.0048). In two smaller SCD cohorts (N = 299 and 406), the protective effect of l-glutamine was observed (OR = 0.82 [0.50-1.34]), although the MR result was not significant (P = 0.44). We identified 66 significant correlations between the levels of other metabolites and SCD-related complications or eGFR. We tested these correlations for causality using MR analyses and found no significant causal relationship. The baseline levels of quinolinic acid were associated with prospectively ascertained survival in SCD patients, and this effect was dependent on eGFR. Metabolomics provide a promising approach to prioritize small molecules that may serve as biomarkers or drug targets in SCD.
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9
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Finsterer J, Aliyev R. Detection of compound heterozygous variants in LPIN1 does not necessarily imply pathogenicity in a patient with rhabdomyolysis. F1000Res 2020; 9:15. [PMID: 32913636 PMCID: PMC7429921 DOI: 10.12688/f1000research.21589.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2020] [Indexed: 11/23/2022] Open
Abstract
In a recent article by Yim
et al., a 15-month-old male is described who experienced severe rhabdomyolysis with a creatine-kinase value (CKV) of 127494 U/l one day after intramuscular injection of an unidentified drug by the general practitioner. Rhabdomyolysis was not attributed to this injected drug but to compound heterozygous variants in LPIN1. The study has a number of shortcomings. Triggers of rhabdomyolysis should be unequivocally identified, a more extensive family history should be taken, and previous CKVs should be provided. Functional and biochemical tests should be carried out to confirm or exclude pathogenicity of the LPIN1 variants.
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Affiliation(s)
- Josef Finsterer
- Neurological Department, Krankenanstalt Rudolfstiftung, Messerli Institute, Vienna, 1180, Austria
| | - Rahim Aliyev
- Department of Neurology and Clinical Neurophysiology, Azerbaijan State Advanced Training Institute for Doctors named after A. Aliyev, Baku, Azerbaijan
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10
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Kaur B, Rattalino M. Target-controlled infusion of Propofol and Remifentanil in a child with recurrent rhabdomyolysis secondary to LPIN1 deficiency. Paediatr Anaesth 2020; 30:726-727. [PMID: 33210425 DOI: 10.1111/pan.13887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 04/07/2020] [Accepted: 04/13/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Balvindar Kaur
- Department of Anaesthesia and Pain Management, The Royal Children's Hospital Melbourne, Parkville, Vic., Australia
| | - Marcos Rattalino
- Department of Anaesthesia and Pain Management, The Royal Children's Hospital Melbourne, Parkville, Vic., Australia
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11
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Pons L, Acquaviva-Bourdain C, Teyssedre S, Didier C, Veauville A, Steffann J, Gobin S, de Lonlay P, Guffon N, Fouilhoux A. Intrafamilial Variability in LPIN1-Related Rhabdomyolysis. Mol Syndromol 2020. [DOI: 10.1159/000507719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Lipin-1 Deficiency-Associated Recurrent Rhabdomyolysis and Exercise-Induced Myalgia Persisting into Adulthood: A Case Report and Review of Literature. Case Rep Med 2020; 2020:7904190. [PMID: 32549891 PMCID: PMC7275236 DOI: 10.1155/2020/7904190] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 03/08/2020] [Accepted: 03/12/2020] [Indexed: 12/18/2022] Open
Abstract
Phosphatidate phosphatase-1 (lipin-1) is encoded by LPIN1 gene. Lipin-1 deficiency has been reported as the second most common cause of early-onset rhabdomyolysis after primary fatty acid oxidation disorders. We report a case of a 32-year-old Sri Lankan female with a history of more than 10 episodes of rhabdomyolysis and exercise intolerance since childhood. These episodes were triggered by infections and exercise. A temporal relationship between the acute episodes and use of drugs such as theophylline, mefenamic acid, co-trimoxazole, and combined oral contraceptive pills was also noted. There was marked elevation of serum creatine kinase and transaminases during acute episodes. Family history revealed parental consanguinity and an affected sibling who died of an acute episode associated with muscle weakness, dark coloured urine, and cyanosis, at the age of 2 years. The histochemical findings of the patient under discussion were consistent with a metabolic myopathy affecting membrane integrity. A homozygous, likely pathogenic variant c.1684G>T encoding p.(Glu562∗) was identified by clinical exome sequencing. Even though the studies to date give no convincing evidence of a possible causal or contributory relationship between the drugs under discussion and lipin-1 related rhabdomyolysis, this case highlights the importance of pharmacovigilance and reporting adverse drug reactions in patients with lipin-1 deficiency.
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Pizzamiglio C, Lahiri N, Nirmalananthan N, Sood B, Somalanka S, Ostrowski P, Phadke R, O'Donovan DG, Muntoni F, Quinlivan R. First presentation of LPIN1 acute rhabdomyolysis in adolescence and adulthood. Neuromuscul Disord 2020; 30:566-571. [PMID: 32522502 DOI: 10.1016/j.nmd.2020.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 02/08/2023]
Abstract
LPIN1 mutations are a known common cause of autosomal recessive, recurrent and life-threatening acute rhabdomyolysis of childhood-onset. The first episode of rhabdomyolysis usually happens in nearly all cases before the age of 5 and death is observed in 1/3 of patients. Here we present two cases of acute rhabdomyolysis with a milder phenotype caused by LPIN1 mutation presenting in adolescence (11 years old) and adulthood (40 years old) after Parvovirus infection and metabolic stress, respectively. In our opinion, the mutation types, epigenetic factors, the environment exposition to triggers or the existence of proteins with a similar structure of LPIN1, may have a role in modulating the onset of rhabdomyolysis. LPIN1 should be included on a panel of genes analysed in the investigation of adult individuals with rhabdomyolysis. Metabolic and viral stressors should be included in the list of possible rhabdomyolysis precipitant.
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Affiliation(s)
- Chiara Pizzamiglio
- MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom.
| | - Nayana Lahiri
- Clinical Genetics Department, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Niranjanan Nirmalananthan
- Departments of Neurology and Neuroradiology, Atkinson Morley Regional Neurosciences Centre, St George's Hospital, London, United Kingdom
| | - Bhrigu Sood
- South West Thames Renal and Transplantation Unit and South West Thames Institute for Renal Research, Saint Helier Hospital, Carshalton, Surrey, United Kingdom
| | - Subash Somalanka
- South West Thames Renal and Transplantation Unit and South West Thames Institute for Renal Research, Saint Helier Hospital, Carshalton, Surrey, United Kingdom
| | - Philip Ostrowski
- South West Thames Regional Genetics Service, St George's University NHS Foundation Trust, London, United Kingdom
| | - Rahul Phadke
- Division of Neuropathology, Dubowitz Neuromuscular Centre, UCL Great Ormond Street Hospital for Children, United Kingdom; Division of Neuropathology, National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
| | - Dominic Gerard O'Donovan
- Neuropathology, Department of Histopathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Francesco Muntoni
- Paediatric Neurology, Dubowitz Neuromuscular Centre, UCL Institute of Child Health and Great Ormond Street Hospital for Children, London, United Kingdom
| | - Rosaline Quinlivan
- MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
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14
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A rare case of pediatric recurrent rhabdomyolysis with compound heterogenous variants in the LPIN1. BMC Pediatr 2020; 20:218. [PMID: 32410653 PMCID: PMC7222443 DOI: 10.1186/s12887-020-02134-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/11/2020] [Indexed: 11/10/2022] Open
Abstract
Background Lipin-1, encoded by LPIN1 gene, serves as an enzyme and a transcriptional co-regulator to regulate lipid metabolism and mitochondrial respiratory chain. Autosomal recessive mutations in LPIN1 were recognized as one of the most common causes of pediatric recurrent rhabdomyolysis in western countries. However, to date, there were only a few cases reported in Asian group. This study aims to report the first pediatric case of recurrent rhabdomyolysis with a novel LPIN1 mutation in China mainland in order to raise the awareness of both pediatricians and patients. Case presentations Here we report a Chinese pediatric case of recurrent rhabdomyolysis with compound heterozygous variants (p.Arg388* and p.Arg810Cys) in the LPIN1 gene. The c.2428C > T was a novel missense variant involved Arg-to-Cys substitution at position 810 (p.Arg810Cys), located in the highly conserved region which predicted to be damaging by multiple algorithms. The patient manifested as cola-colored urine, muscle weakness and tenderness, as well as acute kidney injury with peak blood creatine kinase level 109,570 U/l in 19-month old. In his second episode of 9 years old, the symtoms were relatively milder with peak creatine kinase level 50,948 U/l. He enjoyed quite normal life between the bouts but slightly elevation of serum creatine kinase level during the fever or long-term exercises. Prolonged weight training combined with calorie deprivation were speculated to be the triggers of his illness. Prompt symptomatic therapy including fluid therapy and nutritional support was given and the patient recovered soon. Conclusions LPIN1-related rhabdomyolysis is still quite new to physicians due to its seemly low-incidence especially in Asian countries. In the future, more active genetic test strategy and detailed prophylactic care education should be taken in patients with severe recurrent rhabdomyolysis, who are the high risk group of LPIN1 genetic defects.
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A rare case of adult onset LPIN1 associated rhabdomyolysis. Neuromuscul Disord 2020; 30:241-245. [PMID: 32115342 DOI: 10.1016/j.nmd.2020.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/11/2020] [Accepted: 01/22/2020] [Indexed: 01/17/2023]
Abstract
Pathogenic variants in LPIN1 are a recognised cause of severe and often fatal rhabdomyolysis in childhood. We present a rare case of adult onset recurrent rhabdomyolysis due to compound heterozygous variants in LPIN1. Despite first presenting with rhabdomyolysis in his twenties and having undergone extensive investigations, the patient did not receive a diagnosis until he was 46 years of age. DNA sequencing revealed a pathogenic deletion involving exon 18 of LPIN1 in conjunction with a c.2410G>A missense variant in exon 19. Whilst LPIN1 variants are a noteworthy cause of severe recurrent rhabdomyolysis in childhood, this is the first detailed description and only the second reported case of adult onset rhabdomyolysis. Variants in LPIN1 should be considered as a cause of recurrent severe rhabdomyolysis in adults when other more common causes have been excluded.
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16
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Stepien KM, Schmidt WM, Bittner RE, O'Toole O, McNamara B, Treacy EP. Long-term outcomes in a 25-year-old female affected with lipin-1 deficiency. JIMD Rep 2019; 46:4-10. [PMID: 31240148 PMCID: PMC6498837 DOI: 10.1002/jmd2.12016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 01/04/2019] [Indexed: 12/19/2022] Open
Abstract
Lipin-1 is a phosphatidic acid phosphohydrolase (EC 3.1.3.4) that catalyzes the dephosphorylation of phosphatidic acid to diacylglycerol and inorganic phosphate. Deficiency of this enzyme causes potentially fatal severe, recurrent episodes of rhabdomyolysis triggered by infection. The defect has only recently been recognized so little is known about the long-term outcome in adult patients with this disorder. We report the course and outcome of a 25-year-old female patient with lipin-1 deficiency after a recent episode of rhabdomyolysis requiring intensive care admission with a peak creatine kinase of 500 000 IU/L. One-year post discharge from intensive care, the patient has residual drop foot bilaterally consistent with bilateral common peroneal neuropathies in addition to a background residual distal myopathy.
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Affiliation(s)
- Karolina M. Stepien
- Mark Holland Metabolic Unit, Adult Inherited Metabolic DiseasesSalford Royal NHS Foundation TrustSalfordUnited Kingdom
| | - Wolfgang M. Schmidt
- Neuromuscular Research DepartmentCenter for Anatomy and Cell Biology, Medical University of ViennaViennaAustria
| | - Reginald E. Bittner
- Neuromuscular Research DepartmentCenter for Anatomy and Cell Biology, Medical University of ViennaViennaAustria
| | - Orna O'Toole
- Department of NeurologyMercy University HospitalCorkIreland
| | - Brian McNamara
- Department of Clinical NeurophysiologyCork University HospitalCorkIreland
| | - Eileen P. Treacy
- University College DublinDublinIreland
- Paediatrics DepartmentTrinity CollegeDublinIreland
- National Centre for Inherited Metabolic DiseasesThe Mater Misericordiae University HospitalDublinIreland
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17
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Cortés R, Kleinsteuber K, Vargas CP, de Los Ángeles Avaria M. Rabdomiólisis metabólica: actualización. REVISTA MÉDICA CLÍNICA LAS CONDES 2018. [DOI: 10.1016/j.rmclc.2018.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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18
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Burstal RJ. Volatile anesthesia for a child with LPIN1 gene mutation and recurrent rhabdomyolysis. Paediatr Anaesth 2018; 28:813-814. [PMID: 30035342 DOI: 10.1111/pan.13445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2018] [Indexed: 11/30/2022]
Abstract
We report the case of a boy with LPIN1 gene mutation presenting for adenotonsillectomy who was successfully managed with preoperative saline and glucose infusion followed by balanced anesthesia including sevoflurane. The anesthetic planning is described as there is no modern literature to guide the perioperative management of these children.
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Affiliation(s)
- Richard J Burstal
- Department Anaesthesia, John Hunter Hospital, Newcastle, NSW, Australia
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19
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Schweitzer GG, Collier SL, Chen Z, McCommis KS, Pittman SK, Yoshino J, Matkovich SJ, Hsu FF, Chrast R, Eaton JM, Harris TE, Weihl CC, Finck BN. Loss of lipin 1-mediated phosphatidic acid phosphohydrolase activity in muscle leads to skeletal myopathy in mice. FASEB J 2018; 33:652-667. [PMID: 30028636 DOI: 10.1096/fj.201800361r] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Lipin 1 regulates glycerolipid homeostasis by acting as a phosphatidic acid phosphohydrolase (PAP) enzyme in the triglyceride-synthesis pathway and by regulating transcription factor activity. Mutations in human lipin 1 are a common cause of recurrent rhabdomyolysis in children. Mice with constitutive whole-body lipin 1 deficiency have been used to examine mechanisms connecting lipin 1 deficiency to myocyte injury. However, that mouse model is confounded by lipodystrophy not phenocopied in people. Herein, 2 muscle-specific mouse models were studied: 1) Lpin1 exon 3 and 4 deletion, resulting in a hypomorphic protein without PAP activity, but which preserved transcriptional coregulatory function; and 2) Lpin1 exon 7 deletion, resulting in total protein loss. In both models, skeletal muscles exhibited a chronic myopathy with ongoing muscle fiber necrosis and regeneration and accumulation of phosphatidic acid and, paradoxically, diacylglycerol. Additionally, lipin 1-deficient mice had abundant, but abnormal, mitochondria likely because of impaired autophagy. Finally, these mice exhibited increased plasma creatine kinase following exhaustive exercise when unfed. These data suggest that mice lacking lipin 1-mediated PAP activity in skeletal muscle may serve as a model for determining the mechanisms by which lipin 1 deficiency leads to myocyte injury and for testing potential therapeutic approaches.-Schweitzer, G. G., Collier, S. L., Chen, Z., McCommis, K. S., Pittman, S. K., Yoshino, J., Matkovich, S. J., Hsu, F.-F., Chrast, R., Eaton, J. M., Harris, T. E., Weihl, C. C., Finck, B. N. Loss of lipin 1-mediated phosphatidic acid phosphohydrolase activity in muscle leads to skeletal myopathy in mice.
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Affiliation(s)
- George G Schweitzer
- Division of Geriatrics and Nutritional Sciences, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sara L Collier
- Division of Geriatrics and Nutritional Sciences, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Zhouji Chen
- Division of Geriatrics and Nutritional Sciences, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kyle S McCommis
- Division of Geriatrics and Nutritional Sciences, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sara K Pittman
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jun Yoshino
- Division of Geriatrics and Nutritional Sciences, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Scot J Matkovich
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Fong-Fu Hsu
- Division of Endocrinology, Metabolism, and Lipid Research, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Roman Chrast
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden; and.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; and
| | - James M Eaton
- Department of Pharmacology, University of Virginia, Charlottesville, Virginia, USA
| | - Thurl E Harris
- Department of Pharmacology, University of Virginia, Charlottesville, Virginia, USA
| | - Conrad C Weihl
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Brian N Finck
- Division of Geriatrics and Nutritional Sciences, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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20
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Nunes D, Nogueira C, Lopes A, Chaves P, Rodrigues E, Cardoso T, Leão Teles E, Vilarinho L. LPIN1 deficiency: A novel mutation associated with different phenotypes in the same family. Mol Genet Metab Rep 2016; 9:29-30. [PMID: 27722093 PMCID: PMC5050266 DOI: 10.1016/j.ymgmr.2016.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 09/16/2016] [Indexed: 11/19/2022] Open
Affiliation(s)
- D Nunes
- Newborn Screening, Metabolism & Genetics Unit, Genetics Department, National Institute of Health, INSA, Porto, Portugal
| | - C Nogueira
- Newborn Screening, Metabolism & Genetics Unit, Genetics Department, National Institute of Health, INSA, Porto, Portugal
| | - A Lopes
- Newborn Screening, Metabolism & Genetics Unit, Genetics Department, National Institute of Health, INSA, Porto, Portugal
| | - P Chaves
- Metabolic Unit, CHSJ, Porto, Portugal
| | | | - T Cardoso
- Metabolic Unit, CHSJ, Porto, Portugal
| | | | - L Vilarinho
- Newborn Screening, Metabolism & Genetics Unit, Genetics Department, National Institute of Health, INSA, Porto, Portugal
- Corresponding author at: Genetics Department, National Institute of Health, INSA, Porto, Portugal, Rua Alexandre Herculano, 321, 4000-055, Porto, Portugal.Genetics DepartmentNational Institute of HealthINSA, Porto, PortugalRua Alexandre Herculano, 321Porto4000-055Portugal
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