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Pfau K, Lengyel I, Ossewaarde-van Norel J, van Leeuwen R, Risseeuw S, Leftheriotis G, Scholl HPN, Feltgen N, Holz FG, Pfau M. Pseudoxanthoma elasticum - Genetics, pathophysiology, and clinical presentation. Prog Retin Eye Res 2024; 102:101274. [PMID: 38815804 DOI: 10.1016/j.preteyeres.2024.101274] [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: 02/04/2024] [Revised: 05/17/2024] [Accepted: 05/20/2024] [Indexed: 06/01/2024]
Abstract
Pseudoxanthoma elasticum (PXE) is an autosomal-recessively inherited multisystem disease. Mutations in the ABCC6-gene are causative, coding for a transmembrane transporter mainly expressed in hepatocytes, which promotes the efflux of adenosine triphosphate (ATP). This results in low levels of plasma inorganic pyrophosphate (PPi), a critical anti-mineralization factor. The clinical phenotype of PXE is characterized by the effects of elastic fiber calcification in the skin, the cardiovascular system, and the eyes. In the eyes, calcification of Bruch's membrane results in clinically visible lesions, including peau d'orange, angioid streaks, and comet tail lesions. Frequently, patients must be treated for secondary macular neovascularization. No effective therapy is available for treating the cause of PXE, but several promising approaches are emerging. Finding appropriate outcome measures remains a significant challenge for clinical trials in this slowly progressive disease. This review article provides an in-depth summary of the current understanding of PXE and its multi-systemic manifestations. The article offers a detailed overview of the ocular manifestations, including their morphological and functional consequences, as well as potential complications. Lastly, previous and future clinical trials of causative treatments for PXE are discussed.
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Affiliation(s)
- Kristina Pfau
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland; Department of Ophthalmology, University Hospital Bonn, Bonn, Germany.
| | - Imre Lengyel
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom; Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | | | - Redmer van Leeuwen
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Sara Risseeuw
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Georges Leftheriotis
- University Hospital Nice, Vascular Physiology and Medicine Unit, 06000, Nice, France
| | | | - Nicolas Feltgen
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland
| | - Frank G Holz
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
| | - Maximilian Pfau
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland; Institute of Molecular and Clinical Ophthalmology Basel, Basel, Basel-Stadt, Switzerland
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Fésűs L, Kiss N, Farkas K, Plázár D, Pálla S, Navasiolava N, Róbert L, Wikonkál NM, Martin L, Medvecz M. Correlation of systemic involvement and presence of pathological skin calcification assessed by ex vivo nonlinear microscopy in Pseudoxanthoma elasticum. Arch Dermatol Res 2023; 315:1897-1908. [PMID: 36847829 PMCID: PMC10366029 DOI: 10.1007/s00403-023-02557-x] [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: 02/09/2022] [Revised: 12/24/2022] [Accepted: 01/28/2023] [Indexed: 03/01/2023]
Abstract
Pseudoxanthoma elasticum (PXE (OMIM 264800)) is an autosomal recessive connective tissue disorder mainly caused by mutations in the ABCC6 gene. PXE results in ectopic calcification primarily in the skin, eye and blood vessels that can lead to blindness, peripheral arterial disease and stroke. Previous studies found correlation between macroscopic skin involvement and severe ophthalmological and cardiovascular complications. This study aimed to investigate correlation between skin calcification and systemic involvement in PXE. Ex vivo nonlinear microscopy (NLM) imaging was performed on formalin fixed, deparaffinized, unstained skin sections to assess the extent of skin calcification. The area affected by calcification (CA) in the dermis and density of calcification (CD) was calculated. From CA and CD, calcification score (CS) was determined. The number of affected typical and nontypical skin sites were counted. Phenodex + scores were determined. The relationship between the ophthalmological, cerebro- and cardiovascular and other systemic complications and CA, CD and CS, respectively, and skin involvement were analyzed. Regression models were built for adjustment to age and sex. We found significant correlation of CA with the number of affected typical skin sites (r = 0.48), the Phenodex + score (r = 0.435), extent of vessel involvement (V-score) (r = 0.434) and disease duration (r = 0.48). CD correlated significantly with V-score (r = 0.539). CA was significantly higher in patients with more severe eye (p = 0.04) and vascular (p = 0.005) complications. We found significantly higher CD in patients with higher V-score (p = 0.018), and with internal carotid artery hypoplasia (p = 0.045). Significant correlation was found between higher CA and the presence of macula atrophy (β = - 0.44, p = 0.032) and acneiform skin changes (β = 0.40, p = 0.047). Based on our results, the assessment of skin calcification pattern with nonlinear microscopy in PXE may be useful for clinicians to identify PXE patients who develop severe systemic complications.
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Affiliation(s)
- Luca Fésűs
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Street 41, Budapest, 1085, Hungary
| | - Norbert Kiss
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Street 41, Budapest, 1085, Hungary
| | - Klára Farkas
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Street 41, Budapest, 1085, Hungary
| | - Dóra Plázár
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Street 41, Budapest, 1085, Hungary
| | - Sára Pálla
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Street 41, Budapest, 1085, Hungary
| | - Nastassia Navasiolava
- PXE National Reference Centre, Angers University Hospital, 4 Rue Larrey, 49100, Angers, France
| | - Lili Róbert
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Street 41, Budapest, 1085, Hungary
| | - Norbert M Wikonkál
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Street 41, Budapest, 1085, Hungary
| | - Ludovic Martin
- PXE National Reference Centre, Angers University Hospital, 4 Rue Larrey, 49100, Angers, France
| | - Márta Medvecz
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Mária Street 41, Budapest, 1085, Hungary.
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Therapy of Pseudoxanthoma Elasticum: Current Knowledge and Future Perspectives. Biomedicines 2021; 9:biomedicines9121895. [PMID: 34944710 PMCID: PMC8698611 DOI: 10.3390/biomedicines9121895] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/05/2021] [Accepted: 12/07/2021] [Indexed: 12/24/2022] Open
Abstract
Pseudoxanthoma elasticum (PXE) is a rare, genetic, metabolic disease with an estimated prevalence of between 1 per 25,000 and 56,000. Its main hallmarks are characteristic skin lesions, development of choroidal neovascularization, and early-onset arterial calcification accompanied by a severe reduction in quality-of-life. Underlying the pathology are recessively transmitted pathogenic variants of the ABCC6 gene, which results in a deficiency of ABCC6 protein. This results in reduced levels of peripheral pyrophosphate, a strong inhibitor of peripheral calcification, but also dysregulation of blood lipids. Although various treatment options have emerged during the last 20 years, many are either already outdated or not yet ready to be applied generally. Clinical physicians often are left stranded while patients suffer from the consequences of outdated therapies, or feel unrecognized by their attending doctors who may feel uncertain about using new therapeutic approaches or not even know about them. In this review, we summarize the broad spectrum of treatment options for PXE, focusing on currently available clinical options, the latest research and development, and future perspectives.
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Marconi B, Bobyr I, Campanati A, Molinelli E, Consales V, Brisigotti V, Scarpelli M, Racchini S, Offidani A. Pseudoxanthoma elasticum and skin: Clinical manifestations, histopathology, pathomechanism, perspectives of treatment. Intractable Rare Dis Res 2015; 4:113-22. [PMID: 26361562 PMCID: PMC4561240 DOI: 10.5582/irdr.2015.01014] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 06/09/2015] [Accepted: 06/10/2015] [Indexed: 01/10/2023] Open
Abstract
Pseudoxantoma elasticum (PXE), also known as Groenblad-Strandberg syndrome, is a rare heritable disease with an estimated prevalence of 1:50,000 in the general population. PXE is considered a prototype of multisystem ectopic mineralization disorders and it is characterized by aberrant mineralization of soft connective tissue with degeneration of the elastic fibers, involving primarily the eyes, the cardiovascular system, and the skin. Cutaneous lesions consist of small, asymptomatic, yellowish papules or larger coalescent plaques, typically located on the neck and the flexural areas. PXE is caused by mutations in the ABCC6 (ATP-binding cassette subfamily C member 6) gene that encodes a transmembrane ATP binding efflux transporter, normally expressed in the liver and the kidney; however, the exact mechanism of ectopic mineralization remains largely unknown. The histological examination of cutaneous lesions, revealing accumulation of pleomorphic elastic structures in middermis, is essential for the definitive diagnosis of PXE, excluding PXE-like conditions. PXE is currently an intractable disease; although the cutaneous findings primarily present a cosmetic problem, they signify the risk for development of ocular and cardiovascular complications associated with considerable morbidity and mortality. The purpose of this review is to present a comprehensive overview of this rare form of hereditary connective tissue disorders, focus on the pathogenesis, the clinical manifestation, and the differential diagnosis of PXE. Emphasis is also placed on the management of cutaneous lesions and treatment perspectives of PXE.
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Affiliation(s)
- Barbara Marconi
- Dermatological Unit, Department of Clinical and Molecular Sciences, Polytehnic Marche University, Ancona, Italty
| | - Ivan Bobyr
- Dermatological Unit, Department of Clinical and Molecular Sciences, Polytehnic Marche University, Ancona, Italty
| | - Anna Campanati
- Dermatological Unit, Department of Clinical and Molecular Sciences, Polytehnic Marche University, Ancona, Italty
- Address correspondence to: Dr. Anna Campanati, Dermatological Unit, Department of Clinical and Molecular Sciences, Polytechnic Marche University, Via Conca 71, Ancona 60020, Italty. E-mail:
| | - Elisa Molinelli
- Dermatological Unit, Department of Clinical and Molecular Sciences, Polytehnic Marche University, Ancona, Italty
| | - Veronica Consales
- Dermatological Unit, Department of Clinical and Molecular Sciences, Polytehnic Marche University, Ancona, Italty
| | - Valerio Brisigotti
- Dermatological Unit, Department of Clinical and Molecular Sciences, Polytehnic Marche University, Ancona, Italty
| | - Marina Scarpelli
- Institute of Pathological Anatomy and Histopathology, Polytechnic University Marche, Ancona, Italty
| | - Stefano Racchini
- Institute of Pathological Anatomy and Histopathology, Polytechnic University Marche, Ancona, Italty
| | - Annamaria Offidani
- Dermatological Unit, Department of Clinical and Molecular Sciences, Polytehnic Marche University, Ancona, Italty
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Vilder EYGD, Vanakker OM. From variome to phenome: Pathogenesis, diagnosis and management of ectopic mineralization disorders. World J Clin Cases 2015; 3:556-574. [PMID: 26244149 PMCID: PMC4517332 DOI: 10.12998/wjcc.v3.i7.556] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 02/27/2015] [Accepted: 05/18/2015] [Indexed: 02/05/2023] Open
Abstract
Ectopic mineralization - inappropriate biomineralization in soft tissues - is a frequent finding in physiological aging processes and several common disorders, which can be associated with significant morbidity and mortality. Further, pathologic mineralization is seen in several rare genetic disorders, which often present life-threatening phenotypes. These disorders are classified based on the mechanisms through which the mineralization occurs: metastatic or dystrophic calcification or ectopic ossification. Underlying mechanisms have been extensively studied, which resulted in several hypotheses regarding the etiology of mineralization in the extracellular matrix of soft tissue. These hypotheses include intracellular and extracellular mechanisms, such as the formation of matrix vesicles, aberrant osteogenic and chondrogenic signaling, apoptosis and oxidative stress. Though coherence between the different findings is not always clear, current insights have led to improvement of the diagnosis and management of ectopic mineralization patients, thus translating pathogenetic knowledge (variome) to the phenotype (phenome). In this review, we will focus on the clinical presentation, pathogenesis and management of primary genetic soft tissue mineralization disorders. As examples of dystrophic calcification disorders Pseudoxanthoma elasticum, Generalized arterial calcification of infancy, Keutel syndrome, Idiopathic basal ganglia calcification and Arterial calcification due to CD73 (NT5E) deficiency will be discussed. Hyperphosphatemic familial tumoral calcinosis will be reviewed as an example of mineralization disorders caused by metastatic calcification.
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Abstract
BACKGROUND The problem of double capsules and late seromas is a relatively new phenomenon in breast augmentation surgery. METHODS The author's experience with double capsules in 14 patients is outlined. The author reviewed all primary bilateral breast augmentations and primary bilateral mastopexy-augmentations after the moratorium in 1992. There were 209 patients with saline implants, 160 patients with CML and CMH Microcell textured surface implants, 105 patients with Biocell textured surface silicone gel breast implants, and 152 patients with smooth round silicone gel breast implants. Complications and revisions were reviewed to see if any patterns emerged. RESULTS Fourteen patients were found to have double capsules. Double capsules were only seen with the Biocell textured surface implant. Three patients developed late seromas (more than a year after their original surgery), with two patients requiring urgent drainage of an expanding seroma/hematoma. Seven patients were found to have double capsules as an incidental finding for procedures, such as asymmetry and bottoming out, and five patients were found to have double capsules when surgery was performed for capsular contracture. The review of complications and revisions showed that the silicone gel implants were far better than saline implants. Highly cohesive Microcell textured CMH and CML implants had by far the best capsular contracture profile. Biocell texturing increased the capsular contracture rate. CONCLUSIONS Double capsules and late seromas are a relatively new problem in breast augmentation surgery. The problem was not seen in smooth saline or smooth silicone gel breast implants but only in aggressively textured implants.
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