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Ou Y, Cao J, Duan Y, Chen F, Zhou J, Li J, Gan X. Exploring the clinical complexity of cardio-facio-cutaneous syndrome: insights from a pediatric case series. Front Pediatr 2024; 12:1355277. [PMID: 38859980 PMCID: PMC11163133 DOI: 10.3389/fped.2024.1355277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/13/2024] [Indexed: 06/12/2024] Open
Abstract
Background Cardio-Facio-Cutaneous syndrome (CFCS) is a rare autosomal dominant genetic disorder primarily caused by BRAF gene mutations, posing diagnostic challenges due to its multifaceted clinical presentation. Objective To elucidate the clinical characteristics of pediatric CFCS patients, expanding the phenotypic spectrum to enhance early diagnostic capabilities, while also presenting the relationship between genotye and corresponding phenotype severity. Methods From January 2015 to March 2022, four children diagnosed with CFCS in Children's Hospital of Chongqing Medical University were included for analysis. Whole exome sequencing (WES) was conducted to identify the types and locations of possible gene mutations. Neurological development was assessed using electroencephalography (EEG), magnetic resonance imaging (MRI) and Gesell developmental evaluation. Results All four CFCS patients exhibited de novo BRAF gene mutations, manifesting with cardiac malformations, distinctive facial features, skin and hair changes, and neurological abnormalities. WES revealed that the specific BRAF mutations were closely linked to their clinical severity. Three patients displayed milder symptoms (case 1-3, genotype I or II), demonstrating stability or slight improvement, whereas one patient (case 4, genotype III) suffered from a severe phenotype characterized by profound neurological and digestive system impairments, leading to a significantly reduced quality of life and a grim prognosis. Conclusion In CFCS patients, severe developmental delay and seizures are predominant neurological features, possibly accompanied by continuous spike-and-wave during sleep (CSWS) and severe sleep disturbances. CFCS generally carries a poor prognosis, underscoring the importance of disease awareness and early genetic testing.
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Affiliation(s)
- Yuexu Ou
- Department of General Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
| | - Jie Cao
- Department of General Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
| | - Yuanhui Duan
- Department of General Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
| | - FengHua Chen
- Department of General Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
| | - Jiwei Zhou
- Department of General Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
| | - Jieling Li
- Department of General Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
| | - Xiaoming Gan
- Department of General Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
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Huang Y, Sun H, Chen Q, Shen J, Han J, Shan S, Wang S. Computer-based facial recognition as an assisting diagnostic tool to identify children with Noonan syndrome. BMC Pediatr 2024; 24:361. [PMID: 38783283 PMCID: PMC11118109 DOI: 10.1186/s12887-024-04827-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Noonan syndrome (NS) is a rare genetic disease, and patients who suffer from it exhibit a facial morphology that is characterized by a high forehead, hypertelorism, ptosis, inner epicanthal folds, down-slanting palpebral fissures, a highly arched palate, a round nasal tip, and posteriorly rotated ears. Facial analysis technology has recently been applied to identify many genetic syndromes (GSs). However, few studies have investigated the identification of NS based on the facial features of the subjects. OBJECTIVES This study develops advanced models to enhance the accuracy of diagnosis of NS. METHODS A total of 1,892 people were enrolled in this study, including 233 patients with NS, 863 patients with other GSs, and 796 healthy children. We took one to 10 frontal photos of each subject to build a dataset, and then applied the multi-task convolutional neural network (MTCNN) for data pre-processing to generate standardized outputs with five crucial facial landmarks. The ImageNet dataset was used to pre-train the network so that it could capture generalizable features and minimize data wastage. We subsequently constructed seven models for facial identification based on the VGG16, VGG19, VGG16-BN, VGG19-BN, ResNet50, MobileNet-V2, and squeeze-and-excitation network (SENet) architectures. The identification performance of seven models was evaluated and compared with that of six physicians. RESULTS All models exhibited a high accuracy, precision, and specificity in recognizing NS patients. The VGG19-BN model delivered the best overall performance, with an accuracy of 93.76%, precision of 91.40%, specificity of 98.73%, and F1 score of 78.34%. The VGG16-BN model achieved the highest AUC value of 0.9787, while all models based on VGG architectures were superior to the others on the whole. The highest scores of six physicians in terms of accuracy, precision, specificity, and the F1 score were 74.00%, 75.00%, 88.33%, and 61.76%, respectively. The performance of each model of facial recognition was superior to that of the best physician on all metrics. CONCLUSION Models of computer-assisted facial recognition can improve the rate of diagnosis of NS. The models based on VGG19-BN and VGG16-BN can play an important role in diagnosing NS in clinical practice.
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Affiliation(s)
- Yulu Huang
- Department of Pediatric Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan 2nd Road, Yuexiu District, Guangzhou, China
| | - Haomiao Sun
- Key Laboratory of Intelligent Information Processing, Institute of Computing Technology, Chinese Academy of Sciences, No. 6 South Science Academy Road, Haidian District, Beijing, China
- University of Chinese Academy of Sciences, No. 80 Zhongguancun Road East, Haidian District, Beijing, China
| | - Qinchang Chen
- Department of Pediatric Cardiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106, Zhongshan 2nd Road, Yuexiu District, Guangzhou, China
| | - Junjun Shen
- Department of Pediatric Cardiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106, Zhongshan 2nd Road, Yuexiu District, Guangzhou, China
| | - Jin Han
- Prenatal diagnosis center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No. 9 Jinsui Road, Tianhe District, Guangzhou, China
| | - Shiguang Shan
- Key Laboratory of Intelligent Information Processing, Institute of Computing Technology, Chinese Academy of Sciences, No. 6 South Science Academy Road, Haidian District, Beijing, China.
- University of Chinese Academy of Sciences, No. 80 Zhongguancun Road East, Haidian District, Beijing, China.
| | - Shushui Wang
- Department of Pediatric Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan 2nd Road, Yuexiu District, Guangzhou, China.
- Department of Pediatric Cardiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, No. 106, Zhongshan 2nd Road, Yuexiu District, Guangzhou, China.
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Padhiyar J, Mahajan R, Panda M. RASopathies: Evolving Concepts in Pathogenetics, Clinical Features, and Management. Indian Dermatol Online J 2024; 15:392-404. [PMID: 38845651 PMCID: PMC11152490 DOI: 10.4103/idoj.idoj_594_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/27/2023] [Accepted: 10/01/2023] [Indexed: 06/09/2024] Open
Abstract
RASopathies refers to the group of disorders which are caused by a mutation in various genes of the RAS/MAPK (RAT sarcoma virus/Mitogen activated protein kinase) pathway. It includes many genes with varied functions, which are responsible for cell cycle regulation. As the mutation in one gene affects the entire pathway, there are many overlapping features among the various syndromes which are included under an umbrella term "RASopathies." However, neuroectodermal involvement is a unifying feature among these syndromes, which are caused by germline mutations affecting genes along this pathway. Recently, many other RASopathies have been described to involve blood vessels, lymphatics, and immune system. Also, many cutaneous mosaic disorders have been found to have mutations in the concerned pathway. The purpose of this article is to briefly review the pathogenesis of RASopathies with cutaneous manifestations, and summarise the features that can be helpful as diagnostic clues to dermatologists. As we understand more about the pathogenesis of the pathway at the cellular level, the research on genotype-phenotype correlation and therapeutic options broadens. Targeted therapy is in the clinical and preclinical trial phase, which may brighten the future of many patients.
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Affiliation(s)
- Jigna Padhiyar
- Department of DVL, Gujarat Cancer Society Medical College, Hospital and Research Centre, Ahmedabad, Gujarat, India
| | - Rahul Mahajan
- Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Maitreyee Panda
- Department of Dermatology, IMS and SUM Hospital, Bhubaneshwar, Odisha, India
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Rodríguez-Martín M, Báez-Flores J, Ribes V, Isidoro-García M, Lacal J, Prieto-Matos P. Non-Mammalian Models for Understanding Neurological Defects in RASopathies. Biomedicines 2024; 12:841. [PMID: 38672195 PMCID: PMC11048513 DOI: 10.3390/biomedicines12040841] [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: 02/27/2024] [Revised: 03/27/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
RASopathies, a group of neurodevelopmental congenital disorders stemming from mutations in the RAS/MAPK pathway, present a unique opportunity to delve into the intricacies of complex neurological disorders. Afflicting approximately one in a thousand newborns, RASopathies manifest as abnormalities across multiple organ systems, with a pronounced impact on the central and peripheral nervous system. In the pursuit of understanding RASopathies' neurobiology and establishing phenotype-genotype relationships, in vivo non-mammalian models have emerged as indispensable tools. Species such as Danio rerio, Drosophila melanogaster, Caenorhabditis elegans, Xenopus species and Gallus gallus embryos have proven to be invaluable in shedding light on the intricate pathways implicated in RASopathies. Despite some inherent weaknesses, these genetic models offer distinct advantages over traditional rodent models, providing a holistic perspective on complex genetics, multi-organ involvement, and the interplay among various pathway components, offering insights into the pathophysiological aspects of mutations-driven symptoms. This review underscores the value of investigating the genetic basis of RASopathies for unraveling the underlying mechanisms contributing to broader neurological complexities. It also emphasizes the pivotal role of non-mammalian models in serving as a crucial preliminary step for the development of innovative therapeutic strategies.
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Affiliation(s)
- Mario Rodríguez-Martín
- Laboratory of Functional Genetics of Rare Diseases, Department of Microbiology and Genetics, University of Salamanca, 37007 Salamanca, Spain; (M.R.-M.); (J.B.-F.)
- Institute of Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain; (M.I.-G.); (P.P.-M.)
| | - Juan Báez-Flores
- Laboratory of Functional Genetics of Rare Diseases, Department of Microbiology and Genetics, University of Salamanca, 37007 Salamanca, Spain; (M.R.-M.); (J.B.-F.)
- Institute of Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain; (M.I.-G.); (P.P.-M.)
| | - Vanessa Ribes
- Institut Jacques Monod, Université Paris Cité, CNRS, F-75013 Paris, France;
| | - María Isidoro-García
- Institute of Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain; (M.I.-G.); (P.P.-M.)
- Clinical Biochemistry Department, Hospital Universitario de Salamanca, 37007 Salamanca, Spain
- Clinical Rare Diseases Reference Unit DiERCyL, 37007 Castilla y León, Spain
- Department of Medicine, University of Salamanca, 37007 Salamanca, Spain
| | - Jesus Lacal
- Laboratory of Functional Genetics of Rare Diseases, Department of Microbiology and Genetics, University of Salamanca, 37007 Salamanca, Spain; (M.R.-M.); (J.B.-F.)
- Institute of Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain; (M.I.-G.); (P.P.-M.)
| | - Pablo Prieto-Matos
- Institute of Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain; (M.I.-G.); (P.P.-M.)
- Clinical Rare Diseases Reference Unit DiERCyL, 37007 Castilla y León, Spain
- Department of Pediatrics, Hospital Universitario de Salamanca, 37007 Salamanca, Spain
- Department of Biomedical and Diagnostics Science, University of Salamanca, 37007 Salamanca, Spain
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Feng B, Li X, Zhang Q, Wang Y, Gu S, Yao RE, Li Z, Gao S, Chang G, Li Q, Li N, Fu L, Wang J, Wang X. Molecular and phenotypic spectrum of cardio-facio-cutaneous syndrome in Chinese patients. Orphanet J Rare Dis 2023; 18:284. [PMID: 37697378 PMCID: PMC10496309 DOI: 10.1186/s13023-023-02878-0] [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: 09/28/2022] [Accepted: 08/24/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Cardio-facio-cutaneous (CFC) syndrome is a RASopathy subtype that presents with unique craniofacial dysmorphology, congenital heart disease, dermatologic abnormalities, growth retardation, and intellectual disability. This study describes the phenotypic spectrum of CFC in China and its association with CFC syndrome gene variants. RESULTS Twenty Chinese CFC patients, aged 0.6-9.5 years old, were included in this study and their clinical phenotypic spectrum was compared with that of 186 patients with CFC from non-Chinese ethnicities. All 20 Chinese patients with CFC carried de novo heterozygous BRAF, MAP2K1, and MAP2K2 variants. Two novel variants were detected and consistently predicted to be deleterious using bioinformatic tools. The clinical features of CFC in the Chinese patients included hypertrophic cardiomyopathy (2/20, 10%), pulmonary valve stenosis (2/20, 10%), curly or sparse hair (7/20, 35%), epilepsy (1/20, 5%), and hypotonia (10/20, 50%); these features were less frequently observed in Chinese patients than non-Chinese patients (p < 0.05). In contrast, feeding difficulties (19/20, 95%) were more frequently observed in the Chinese patients. Absent eyebrows and severe short stature were more common in patients with BRAF variants than in those with MAP2K1/2 variants. Facial recognition software was used to recognize most CFC patients using artificial intelligence. CONCLUSION This study identified novel and common variants in our cohort of 20 Chinese patients with CFC. We uncovered differences in clinical features between Chinese and non-Chinese patients and detected genotype-phenotype correlations among the BRAF and MAP2K1/2 variant subgroups. This is the largest cohort of Chinese CFC patients to our knowledge, providing new insights into a subtype of RASopathy.
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Affiliation(s)
- Biyun Feng
- Department of Endocrinology, Metabolism and Genetics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127 China
| | - Xin Li
- Department of Endocrinology, Metabolism and Genetics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127 China
| | - Qianwen Zhang
- Department of Endocrinology, Metabolism and Genetics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127 China
| | - Yirou Wang
- Department of Endocrinology, Metabolism and Genetics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127 China
| | - Shili Gu
- Department of Endocrinology, Metabolism and Genetics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127 China
| | - Ru-en Yao
- Department of Genetic Molecular Diagnostic Laboratory, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127 China
| | - Zhiying Li
- Department of Endocrinology, Metabolism and Genetics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127 China
| | - Shiyang Gao
- Department of Endocrinology, Metabolism and Genetics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127 China
| | - Guoying Chang
- Department of Endocrinology, Metabolism and Genetics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127 China
| | - Qun Li
- Department of Endocrinology, Metabolism and Genetics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127 China
| | - Niu Li
- Department of Genetic Molecular Diagnostic Laboratory, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127 China
| | - Lijun Fu
- Department of Cardiology, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127 China
| | - Jian Wang
- Department of Genetic Molecular Diagnostic Laboratory, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127 China
| | - Xiumin Wang
- Department of Endocrinology, Metabolism and Genetics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127 China
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Patti G, Scaglione M, Maiorano NG, Rosti G, Divizia MT, Camia T, De Rose EL, Zucconi A, Casalini E, Napoli F, Di Iorgi N, Maghnie M. Abnormalities of pubertal development and gonadal function in Noonan syndrome. Front Endocrinol (Lausanne) 2023; 14:1213098. [PMID: 37576960 PMCID: PMC10422880 DOI: 10.3389/fendo.2023.1213098] [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: 04/27/2023] [Accepted: 07/10/2023] [Indexed: 08/15/2023] Open
Abstract
Background Noonan syndrome (NS) is a genetic multisystem disorder characterised by variable clinical manifestations including dysmorphic facial features, short stature, congenital heart disease, renal anomalies, lymphatic malformations, chest deformities, cryptorchidism in males. Methods In this narrative review, we summarized the available data on puberty and gonadal function in NS subjects and the role of the RAS/mitogen-activated protein kinase (MAPK) signalling pathway in fertility. In addition, we have reported our personal experience on pubertal development and vertical transmission in NS. Conclusions According to the literature and to our experience, NS patients seem to have a delay in puberty onset compared to the physiological timing reported in healthy children. Males with NS seem to be at risk of gonadal dysfunction secondary not only to cryptorchidism but also to other underlying developmental factors including the MAP/MAPK pathway and genetics. Long-term data on a large cohort of males and females with NS are needed to better understand the impact of delayed puberty on adult height, metabolic profile and well-being. The role of genetic counselling and fertility related-issues is crucial.
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Affiliation(s)
- Giuseppa Patti
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Marco Scaglione
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Nadia Gabriella Maiorano
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Giulia Rosti
- Department of Clinical Genetics and Genomics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Maria Teresa Divizia
- Department of Clinical Genetics and Genomics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Tiziana Camia
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Elena Lucia De Rose
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Alice Zucconi
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Emilio Casalini
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Flavia Napoli
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Natascia Di Iorgi
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Mohamad Maghnie
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
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Salik D, Richert B, Smits G. Clinical and molecular diagnosis of genodermatoses: Review and perspectives. J Eur Acad Dermatol Venereol 2023; 37:488-500. [PMID: 36502512 DOI: 10.1111/jdv.18769] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 11/08/2022] [Indexed: 11/23/2022]
Abstract
Genodermatoses are a complex and heterogeneous group of genetic skin disorders characterized by variable expression and clinical and genetic heterogeneity, rendering their diagnosis challenging. DNA-based techniques, like whole-exome sequencing, can establish a diagnosis in 50% of cases. RNA-sequencing is emerging as an attractive tool that can obtain information regarding gene expression while integrating functional genomic data with regard to the interpretation of variants. This increases the diagnostic rate by an additional 10-15%. In the present review, we detail the clinical steps involved in the diagnosis of genodermatoses, as well as the current DNA-based technologies available to clinicians. Herein, the intention is to facilitate a better understanding of the possibilities and limitations of these diagnostic technologies. In addition, this review could guide dermatologists through new emerging techniques, such as RNA-sequencing and its applications to familiarizing them with future techniques. Currently, this multi-omics approach is likely the best strategy designed to promote the diagnosis of patients with genodermatoses and discover new skin disease genes that could result in novel targeted therapies.
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Affiliation(s)
- Deborah Salik
- Department of Dermatology, CHU Saint-Pierre, CHU Brugmann and Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Bertrand Richert
- Department of Dermatology, CHU Saint-Pierre, CHU Brugmann and Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Guillaume Smits
- Department of Genetics, Hôpital Erasme, ULB Center of Human Genetics, Université Libre de Bruxelles (ULB), Brussels, Belgium.,Department of Genetics, Hôpital Universitaire des Enfants Reine Fabiola, ULB Center of Human Genetics Université Libre de Bruxelles (ULB), Brussels, Belgium.,Interuniversity Institute of Bioinformatics in Brussels, Université Libre de Bruxelles, Brussels, Belgium
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Tritto V, Capitanio D, Gelfi C, Riva P. Changes of RAS Pathway Phosphorylation in Lymphoblastoid Cell Lines from Noonan Syndrome Patients Carrying Hypomorphic Variants in Two NS Genes. Int J Mol Sci 2023; 24:4035. [PMID: 36835447 PMCID: PMC9959625 DOI: 10.3390/ijms24044035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 02/19/2023] Open
Abstract
Noonan syndrome (NS) is an autosomal dominant multisystem disorder, characterized by variable expressivity and locus heterogeneity, being caused by mutations in one of a subset of RAS pathway genes. Nevertheless, for 20-30% of patients it is not possible to provide molecular diagnosis, suggesting that further unknown genes or mechanisms are involved in NS pathogenesis. Recently, we proposed a digenic inheritance of subclinical variants as an alternative NS pathogenic model in two NS patients negative for molecular diagnosis. They showed hypomorphic variants of RAS pathway genes co-inherited from both their healthy parents that we hypothesized to generate an additive effect. Here, we report on the phosphoproteome and proteome analysis by liquid chromatography tandem mass spectrometry (LC-MS/MS) performed on the immortalized peripheral blood mononuclear cells (PBMCs) from the two above trios. Our results indicate that the two unrelated patients show overlapped profiles in both protein abundances and their phosphorylation levels not reached by their parents. IPA software predicted RAS-related pathways as significantly activated in the two patients. Interestingly, they remained unchanged or only slightly activated in both patients' parents. These findings suggest that the presence of one subclinical variant can activate the RAS pathway below the pathological threshold, which can instead be exceeded by the additive effect due to the co-presence of two subclinical variants causing NS, supporting our digenic inheritance hypothesis.
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Affiliation(s)
- Viviana Tritto
- Dipartimento di Biotecnologie Mediche e Medicina Traslazionale, Università degli Studi di Milano, 20054 Segrate, Italy
| | - Daniele Capitanio
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20133 Milan, Italy
| | - Cecilia Gelfi
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20133 Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
| | - Paola Riva
- Dipartimento di Biotecnologie Mediche e Medicina Traslazionale, Università degli Studi di Milano, 20054 Segrate, Italy
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Torres-Pérez JV, Anagianni S, Mech AM, Havelange W, García-González J, Fraser SE, Vallortigara G, Brennan CH. baz1b loss-of-function in zebrafish produces phenotypic alterations consistent with the domestication syndrome. iScience 2022; 26:105704. [PMID: 36582821 PMCID: PMC9793288 DOI: 10.1016/j.isci.2022.105704] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/15/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022] Open
Abstract
BAZ1B is a ubiquitously expressed nuclear protein with roles in chromatin remodeling, DNA replication and repair, and transcription. Reduced BAZ1B expression disrupts neuronal and neural crest development. Variation in the activity of BAZ1B has been proposed to underly morphological and behavioral aspects of domestication through disruption of neural crest development. Knockdown of baz1b in Xenopus embryos and Baz1b loss-of-function (LoF) in mice leads to craniofacial defects consistent with this hypothesis. We generated baz1b LoF zebrafish using CRISPR/Cas9 gene editing to test the hypothesis that baz1b regulates behavioral phenotypes associated with domestication in addition to craniofacial features. Zebrafish with baz1b LoF show mild underdevelopment at larval stages and distinctive craniofacial features later in life. Mutant zebrafish show reduced anxiety-associated phenotypes and an altered ontogeny of social behaviors. Thus, in zebrafish, developmental deficits in baz1b recapitulate both morphological and behavioral phenotypes associated with the domestication syndrome in other species.
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Affiliation(s)
- Jose V. Torres-Pérez
- School of Biological and Behavioural Sciences, Queen Mary University of London, London E1 4NS, UK
- Departament de Biologia Cel·lular, Biologia Funcional i Antropologia física, Fac. de CC. Biològiques, Universitat de València, C/ Dr. Moliner 50, Burjassot, València 46100, Spain
- Corresponding author
| | - Sofia Anagianni
- School of Biological and Behavioural Sciences, Queen Mary University of London, London E1 4NS, UK
| | - Aleksandra M. Mech
- School of Biological and Behavioural Sciences, Queen Mary University of London, London E1 4NS, UK
| | - William Havelange
- School of Biological and Behavioural Sciences, Queen Mary University of London, London E1 4NS, UK
| | - Judit García-González
- School of Biological and Behavioural Sciences, Queen Mary University of London, London E1 4NS, UK
- Department of Genetics and Genomic Sciences, Icahn School of Medicine, Mount Sinai, New York, NY 10029, USA
| | - Scott E. Fraser
- Michelson Center for Convergent Bioscience, University of Southern California, Los Angeles, CA, USA
| | | | - Caroline H. Brennan
- School of Biological and Behavioural Sciences, Queen Mary University of London, London E1 4NS, UK
- Corresponding author
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10
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Tano S, Kotani T, Yoshihara M, Nakamura N, Matsuo S, Ushida T, Imai K, Ito M, Oka Y, Sato E, Hayashi S, Ogi T, Kajiyama H. A case of non-immune hydrops fetalis with maternal mirror syndrome diagnosed by trio-based exome sequencing: An autopsy case report and literature review. Mol Genet Metab Rep 2022; 33:100925. [PMID: 36274670 PMCID: PMC9579035 DOI: 10.1016/j.ymgmr.2022.100925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/06/2022] [Accepted: 10/08/2022] [Indexed: 11/19/2022] Open
Abstract
Non-immune hydrops fetalis (NIHF) indicates the risk for stillbirth. Although the causes vary and most NIHFs have no identifiable cause, recent advances in exome sequencing have increased diagnostic rates. We report a case of NIHF that developed into a giant cystic hygroma complicated by maternal mirror syndrome. Trio-based exome sequencing showed a de novo heterozygous missense variant in the RIT1 (NM_006912: c.246 T > G [p.F82L]). The RIT1 variants are known causative variants of Noonan syndrome (NS; OMIM #163950). The location of the RIT1 variants in the previously reported NS cases with NIHF or/and maternal mirror syndrome was mainly in the switch II region, including the present case. While a further accumulation of cases is needed, exome sequencing, which can identify the variant type in detail, might help predict the phenotype and severity of NIHF.
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Affiliation(s)
- Sho Tano
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan,Department of Genetics, Research Institute of Environmental Medicine (RIeM), Nagoya University, Nagoya, Aichi, Japan
| | - Tomomi Kotani
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan,Division of Perinatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Aichi, Japan,Corresponding author at: Division of Perinatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Aichi 466-8560, Japan.
| | - Masato Yoshihara
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Noriyuki Nakamura
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan,Department of Genetics, Research Institute of Environmental Medicine (RIeM), Nagoya University, Nagoya, Aichi, Japan
| | - Seiko Matsuo
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takafumi Ushida
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kenji Imai
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Miharu Ito
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Yasuyoshi Oka
- Department of Genetics, Research Institute of Environmental Medicine (RIeM), Nagoya University, Nagoya, Aichi, Japan,Department of Human Genetics and Molecular Biology, Graduate School of Medicine, Nagoya University, Nagoya, Aichi, Japan
| | - Emi Sato
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Shin Hayashi
- Department of Genetics, Institute for Developmental Research, Aichi Developmental Disability Center, Kasugai, Aichi, Japan
| | - Tomoo Ogi
- Department of Genetics, Research Institute of Environmental Medicine (RIeM), Nagoya University, Nagoya, Aichi, Japan,Department of Human Genetics and Molecular Biology, Graduate School of Medicine, Nagoya University, Nagoya, Aichi, Japan
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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11
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Molecular and clinical profile of patients referred as Noonan or Noonan-like syndrome in Greece: a cohort of 86 patients. Eur J Pediatr 2022; 181:3691-3700. [PMID: 35904599 DOI: 10.1007/s00431-022-04574-w] [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: 06/10/2022] [Revised: 07/12/2022] [Accepted: 07/21/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED Noonan syndrome (NS) is an autosomal dominant disorder characterized by clinical and genetic heterogeneity. It belongs to a wider group of pathologies, known as Rasopathies, due to the implication of genes encoding components of the Ras/MAPK signalling pathway. Recording the genetic alterations across populations helps assessing specific features to specific genes which is essential for better disease's recognition, prognosis and monitoring. Herein, we report the clinical and molecular data of a Greek cohort comprising of 86 NS or NS-like patients admitted at a single tertiary Centre in Athens, Greece. The analysis was performed using Sanger and next-generation sequencing, comprising 14 different genes. The mutational rates of the confirmed NS-associated genes in the Greek NS population are as follows: PTPN11 32.5%; RIT1 5.8%; SOS1 4.7%; BRAF 1.2%; CBL 1.2%; KRAS 1.2%; MAP2K1 1.2%; RAF1 1.2%; SHOC2 1.2%, corresponding to 50% of positivity in total NS population. The genotype-phenotype analysis showed statistically significant differences in craniofacial dysmorphisms (p = 0.005) and pulmonary valve stenosis (PS) (p < 0.001) frequencies between patients harbouring a pathogenic variant and patients without pathogenic variant in any of the tested genes. Patients with at least a pathogenic variant had 6.71 times greater odds to develop PS compared to pathogenic variant-negative patients (OR = 6.71, 95%; CI = (2.61, 17.27)). PTPN11 positive patients showed higher frequency of epicanthal folds (p = 0.004), ptosis (p = 0.001) and coarseness (p = 0.001) and lower frequency of neurological findings (p = 0.006), compared to patients carrying pathogenic variants in other genes. CONCLUSION Craniofacial dysmorphism and PS prevail among pathogenic variant positive compared to pathogenic variant negative NS and NS-like patients while neurological defects are less common in PTPN11-affected NS patients compared to patients harbouring pathogenic variants in other genes. The significant prevalence of the Ras/MAPK pathogenic variants (17.4%), other than PTPN11, in Greek NS patients, highlights the necessity of a wider spectrum of molecular diagnosis. WHAT IS KNOWN • Noonan syndrome (NS) has been associated with pathogenic variants in molecules-components of the Ras/MAPK pathway. • Clinical and genetic description of NS patients worldwide helps establishing personalized monitoring. WHAT IS NEW • NS and NS-like mutational rate in Greece reaches 50% with pathogenic variants identified mostly in PTPN11 (32.5%), RIT1 (6%) and SOS1 (4.7%) genes. • The risk for pulmonary stenosis increases 6.71-fold in NS patients with a pathogenic variant compared to patients without genetic alterations.
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12
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Sedaghat-Hamedani F, Rebs S, El-Battrawy I, Chasan S, Krause T, Haas J, Zhong R, Liao Z, Xu Q, Zhou X, Akin I, Zitron E, Frey N, Streckfuss-Bömeke K, Kayvanpour E. Identification of SCN5a p.C335R Variant in a Large Family with Dilated Cardiomyopathy and Conduction Disease. Int J Mol Sci 2021; 22:ijms222312990. [PMID: 34884792 PMCID: PMC8657717 DOI: 10.3390/ijms222312990] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/08/2021] [Accepted: 11/26/2021] [Indexed: 12/30/2022] Open
Abstract
Introduction: Familial dilated cardiomyopathy (DCM) is clinically variable and has been associated with mutations in more than 50 genes. Rapid improvements in DNA sequencing have led to the identification of diverse rare variants with unknown significance (VUS), which underlines the importance of functional analyses. In this study, by investigating human-induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs), we evaluated the pathogenicity of the p.C335R sodium voltage-gated channel alpha subunit 5 (SCN5a) variant in a large family with familial DCM and conduction disease. Methods: A four-generation family with autosomal dominant familial DCM was investigated. Next-generation sequencing (NGS) was performed in all 16 family members. Clinical deep phenotyping, including endomyocardial biopsy, was performed. Skin biopsies from two patients and one healthy family member were used to generate human-induced pluripotent stem cells (iPSCs), which were then differentiated into cardiomyocytes. Patch-clamp analysis with Xenopus oocytes and iPSC-CMs were performed. Results: A SCN5a variant (c.1003T>C; p.C335R) could be detected in all family members with DCM or conduction disease. A novel truncating TTN variant (p.Ser24998LysfsTer28) could also be identified in two family members with DCM. Family members with the SCN5a variant (p.C335R) showed significantly longer PQ and QRS intervals and lower left ventricular ejection fractions (LV-EF). All four patients who received CRT-D were non-responders. Electrophysiological analysis with Xenopus oocytes showed a loss of function in SCN5a p.C335R. Na+ channel currents were also reduced in iPSC-CMs from DCM patients. Furthermore, iPSC-CM with compound heterozygosity (SCN5a p.C335R and TTNtv) showed significant dysregulation of sarcomere structures, which may be contributed to the severity of the disease and earlier onset of DCM. Conclusion: The SCN5a p.C335R variant is causing a loss of function of peak INa in patients with DCM and cardiac conduction disease. The co-existence of genetic variants in channels and structural genes (e.g., SCN5a p.C335R and TTNtv) increases the severity of the DCM phenotype.
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Affiliation(s)
- Farbod Sedaghat-Hamedani
- Department of Medicine III, Institute for Cardiomyopathies Heidelberg (ICH), University of Heidelberg, 69120 Heidelberg, Germany; (F.S.-H.); (S.C.); (T.K.); (J.H.); (E.Z.); (N.F.)
- DZHK (German Centre for Cardiovascular Research), Heidelberg-Mannheim, 17475 Greifswald, Germany; (I.E.-B.); (X.Z.); (I.A.)
| | - Sabine Rebs
- Clinic for Cardiology and Pneumology, Georg-August-University Göttingen, 37073 Göttingen, Germany; (S.R.); (K.S.-B.)
- DZHK (German Centre for Cardiovascular Research), 37073 Göttingen, Germany
- Institute of Pharmacology and Toxicology, University of Würzburg, 97070 Würzburg, Germany
| | - Ibrahim El-Battrawy
- DZHK (German Centre for Cardiovascular Research), Heidelberg-Mannheim, 17475 Greifswald, Germany; (I.E.-B.); (X.Z.); (I.A.)
- Department of Medicine, University Medical Centre Mannheim (UMM), 68159 Mannheim, Germany; (R.Z.); (Z.L.); (Q.X.)
| | - Safak Chasan
- Department of Medicine III, Institute for Cardiomyopathies Heidelberg (ICH), University of Heidelberg, 69120 Heidelberg, Germany; (F.S.-H.); (S.C.); (T.K.); (J.H.); (E.Z.); (N.F.)
- DZHK (German Centre for Cardiovascular Research), Heidelberg-Mannheim, 17475 Greifswald, Germany; (I.E.-B.); (X.Z.); (I.A.)
| | - Tobias Krause
- Department of Medicine III, Institute for Cardiomyopathies Heidelberg (ICH), University of Heidelberg, 69120 Heidelberg, Germany; (F.S.-H.); (S.C.); (T.K.); (J.H.); (E.Z.); (N.F.)
| | - Jan Haas
- Department of Medicine III, Institute for Cardiomyopathies Heidelberg (ICH), University of Heidelberg, 69120 Heidelberg, Germany; (F.S.-H.); (S.C.); (T.K.); (J.H.); (E.Z.); (N.F.)
- DZHK (German Centre for Cardiovascular Research), Heidelberg-Mannheim, 17475 Greifswald, Germany; (I.E.-B.); (X.Z.); (I.A.)
| | - Rujia Zhong
- Department of Medicine, University Medical Centre Mannheim (UMM), 68159 Mannheim, Germany; (R.Z.); (Z.L.); (Q.X.)
| | - Zhenxing Liao
- Department of Medicine, University Medical Centre Mannheim (UMM), 68159 Mannheim, Germany; (R.Z.); (Z.L.); (Q.X.)
| | - Qiang Xu
- Department of Medicine, University Medical Centre Mannheim (UMM), 68159 Mannheim, Germany; (R.Z.); (Z.L.); (Q.X.)
| | - Xiaobo Zhou
- DZHK (German Centre for Cardiovascular Research), Heidelberg-Mannheim, 17475 Greifswald, Germany; (I.E.-B.); (X.Z.); (I.A.)
- Department of Medicine, University Medical Centre Mannheim (UMM), 68159 Mannheim, Germany; (R.Z.); (Z.L.); (Q.X.)
| | - Ibrahim Akin
- DZHK (German Centre for Cardiovascular Research), Heidelberg-Mannheim, 17475 Greifswald, Germany; (I.E.-B.); (X.Z.); (I.A.)
- Department of Medicine, University Medical Centre Mannheim (UMM), 68159 Mannheim, Germany; (R.Z.); (Z.L.); (Q.X.)
| | - Edgar Zitron
- Department of Medicine III, Institute for Cardiomyopathies Heidelberg (ICH), University of Heidelberg, 69120 Heidelberg, Germany; (F.S.-H.); (S.C.); (T.K.); (J.H.); (E.Z.); (N.F.)
- DZHK (German Centre for Cardiovascular Research), Heidelberg-Mannheim, 17475 Greifswald, Germany; (I.E.-B.); (X.Z.); (I.A.)
| | - Norbert Frey
- Department of Medicine III, Institute for Cardiomyopathies Heidelberg (ICH), University of Heidelberg, 69120 Heidelberg, Germany; (F.S.-H.); (S.C.); (T.K.); (J.H.); (E.Z.); (N.F.)
- DZHK (German Centre for Cardiovascular Research), Heidelberg-Mannheim, 17475 Greifswald, Germany; (I.E.-B.); (X.Z.); (I.A.)
| | - Katrin Streckfuss-Bömeke
- Clinic for Cardiology and Pneumology, Georg-August-University Göttingen, 37073 Göttingen, Germany; (S.R.); (K.S.-B.)
- DZHK (German Centre for Cardiovascular Research), 37073 Göttingen, Germany
- Institute of Pharmacology and Toxicology, University of Würzburg, 97070 Würzburg, Germany
| | - Elham Kayvanpour
- Department of Medicine III, Institute for Cardiomyopathies Heidelberg (ICH), University of Heidelberg, 69120 Heidelberg, Germany; (F.S.-H.); (S.C.); (T.K.); (J.H.); (E.Z.); (N.F.)
- DZHK (German Centre for Cardiovascular Research), Heidelberg-Mannheim, 17475 Greifswald, Germany; (I.E.-B.); (X.Z.); (I.A.)
- Correspondence:
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13
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Yang H, Hu XR, Sun L, Hong D, Zheng YY, Xin Y, Liu H, Lin MY, Wen L, Liang DP, Wang SS. Automated Facial Recognition for Noonan Syndrome Using Novel Deep Convolutional Neural Network With Additive Angular Margin Loss. Front Genet 2021; 12:669841. [PMID: 34163525 PMCID: PMC8215580 DOI: 10.3389/fgene.2021.669841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/12/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Noonan syndrome (NS), a genetically heterogeneous disorder, presents with hypertelorism, ptosis, dysplastic pulmonary valve stenosis, hypertrophic cardiomyopathy, and small stature. Early detection and assessment of NS are crucial to formulating an individualized treatment protocol. However, the diagnostic rate of pediatricians and pediatric cardiologists is limited. To overcome this challenge, we propose an automated facial recognition model to identify NS using a novel deep convolutional neural network (DCNN) with a loss function called additive angular margin loss (ArcFace). METHODS The proposed automated facial recognition models were trained on dataset that included 127 NS patients, 163 healthy children, and 130 children with several other dysmorphic syndromes. The photo dataset contained only one frontal face image from each participant. A novel DCNN framework with ArcFace loss function (DCNN-Arcface model) was constructed. Two traditional machine learning models and a DCNN model with cross-entropy loss function (DCNN-CE model) were also constructed. Transfer learning and data augmentation were applied in the training process. The identification performance of facial recognition models was assessed by five-fold cross-validation. Comparison of the DCNN-Arcface model to two traditional machine learning models, the DCNN-CE model, and six physicians were performed. RESULTS At distinguishing NS patients from healthy children, the DCNN-Arcface model achieved an accuracy of 0.9201 ± 0.0138 and an area under the receiver operator characteristic curve (AUC) of 0.9797 ± 0.0055. At distinguishing NS patients from children with several other genetic syndromes, it achieved an accuracy of 0.8171 ± 0.0074 and an AUC of 0.9274 ± 0.0062. In both cases, the DCNN-Arcface model outperformed the two traditional machine learning models, the DCNN-CE model, and six physicians. CONCLUSION This study shows that the proposed DCNN-Arcface model is a promising way to screen NS patients and can improve the NS diagnosis rate.
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Affiliation(s)
- Hang Yang
- Department of Pediatric Cardiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Structural Heart Disease, Guangzhou, China
- Department of Pediatrics, Shantou University Medical College, Shantou, China
| | - Xin-Rong Hu
- Department of Computer Science and Engineering, University of Notre Dame, South Bend, IN, United States
| | - Ling Sun
- Department of Pediatric Cardiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Structural Heart Disease, Guangzhou, China
| | - Dian Hong
- Department of Pediatric Cardiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Structural Heart Disease, Guangzhou, China
| | - Ying-Yi Zheng
- Cardiac Center, Guangdong Women and Children Hospital, Guangzhou, China
| | - Ying Xin
- Department of Cardiology, Shenzhen Children’s Hospital, Shenzhen, China
| | - Hui Liu
- Department of Pediatric Cardiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Structural Heart Disease, Guangzhou, China
| | - Min-Yin Lin
- Department of Pediatric Cardiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Structural Heart Disease, Guangzhou, China
- Department of Pediatrics, Shantou University Medical College, Shantou, China
| | - Long Wen
- Department of Pediatric Cardiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Structural Heart Disease, Guangzhou, China
| | - Dong-Po Liang
- Department of Pediatric Cardiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Structural Heart Disease, Guangzhou, China
| | - Shu-Shui Wang
- Department of Pediatric Cardiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Structural Heart Disease, Guangzhou, China
- *Correspondence: Shu-Shui Wang,
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14
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Brinkmann J, Lissewski C, Pinna V, Vial Y, Pantaleoni F, Lepri F, Daniele P, Burnyte B, Cuturilo G, Fauth C, Gezdirici A, Kotzot D, Güleç EY, Iotova V, Schanze D, Ramond F, Havlovicová M, Utine GE, Simsek-Kiper PO, Stoyanova M, Verloes A, De Luca A, Tartaglia M, Cavé H, Zenker M. The clinical significance of A2ML1 variants in Noonan syndrome has to be reconsidered. Eur J Hum Genet 2020; 29:524-527. [PMID: 33082526 DOI: 10.1038/s41431-020-00743-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 09/22/2020] [Accepted: 09/30/2020] [Indexed: 12/22/2022] Open
Abstract
The RASopathies are a group of clinically and genetically heterogeneous developmental disorders caused by dysregulation of the RAS/MAPK signalling pathway. Variants in several components and regulators of this pathway have been identified as the pathogenetic cause. In 2015, missense variants in A2ML1 were reported in three unrelated families with clinical diagnosis of Noonan syndrome (NS) and a zebrafish model was presented showing heart and craniofacial defects similar to those caused by a NS-associated Shp2 variant. However, a causal role of A2ML1 variants in NS has not been confirmed since. Herein, we report on 15 individuals who underwent screening of RASopathy-associated genes and were found to carry rare variants in A2ML1, including variants previously proposed to be causative for NS. In cases where parental DNA was available, the respective A2ML1 variant was found to be inherited from an unaffected parent. Seven index patients carrying an A2ML1 variant presented with an alternate disease-causing genetic aberration. These findings underscore that current evidence is insufficient to support a causal relation between variants in A2ML1 and NS, questioning the inclusion of A2ML1 screening in diagnostic RASopathy testing.
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Affiliation(s)
- Julia Brinkmann
- Institute of Human Genetics, University Hospital Magdeburg, Magdeburg, Germany
| | - Christina Lissewski
- Institute of Human Genetics, University Hospital Magdeburg, Magdeburg, Germany
| | - Valentina Pinna
- Medical Genetics Section, IRCCS Fondazione Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Yoann Vial
- Department of Genetics, Hopital Robert Debré, Assistance Publique des Hopitaux de Paris (AP-HP), Paris, France.,Inserm U1131, Institut de Recherche Saint-Louis, Université de Paris, Paris, France
| | - Francesca Pantaleoni
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Francesca Lepri
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Paola Daniele
- Medical Genetics Section, IRCCS Fondazione Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Birute Burnyte
- Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Goran Cuturilo
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,University Children's Hospital, Belgrade, Serbia
| | - Christine Fauth
- Division of Human Genetics, Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Alper Gezdirici
- Health Sciences University, Istanbul Kanuni Sultan Suleyman Research and Training Hospital, Section of Medical Genetics, Istanbul, Turkey
| | - Dieter Kotzot
- Division of Human Genetics, Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Elif Yılmaz Güleç
- Health Sciences University, Istanbul Kanuni Sultan Suleyman Research and Training Hospital, Section of Medical Genetics, Istanbul, Turkey
| | - Violeta Iotova
- Department of Pediatrics, Medical University of Varna, Varna, Bulgaria
| | - Denny Schanze
- Institute of Human Genetics, University Hospital Magdeburg, Magdeburg, Germany
| | - Francis Ramond
- Department of Genetics, Hôpital Nord, Saint Etienne University Hospital, Lyon, France
| | - Markéta Havlovicová
- Department of Biology and Medical Genetics, Charles University 2nd Faculty of Medicine and University Hospital Motol, Prague, Czech Republic
| | - Gulen Eda Utine
- Department of Pediatric Genetics, Hacettepe University, Ankara, Turkey
| | | | - Milena Stoyanova
- Department of Medical Genetics, Varna Medical University, Varna, Bulgaria
| | - Alain Verloes
- Department of Genetics, Hopital Robert Debré, Assistance Publique des Hopitaux de Paris (AP-HP), Paris, France
| | - Alessandro De Luca
- Medical Genetics Section, IRCCS Fondazione Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Marco Tartaglia
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Hélène Cavé
- Department of Genetics, Hopital Robert Debré, Assistance Publique des Hopitaux de Paris (AP-HP), Paris, France.,Inserm U1131, Institut de Recherche Saint-Louis, Université de Paris, Paris, France
| | - Martin Zenker
- Institute of Human Genetics, University Hospital Magdeburg, Magdeburg, Germany.
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15
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16
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Ferrari L, Mangano E, Bonati MT, Monterosso I, Capitanio D, Chiappori F, Brambilla I, Gelfi C, Battaglia C, Bordoni R, Riva P. Digenic inheritance of subclinical variants in Noonan Syndrome patients: an alternative pathogenic model? Eur J Hum Genet 2020; 28:1432-1445. [PMID: 32514133 PMCID: PMC7608271 DOI: 10.1038/s41431-020-0658-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 04/21/2020] [Accepted: 05/22/2020] [Indexed: 11/22/2022] Open
Abstract
Noonan syndrome (NS) is an autosomal-dominant disorder with variable expressivity and locus heterogeneity. Despite several RAS pathway genes were implicated in NS, 20–30% of patients remain without molecular diagnosis, suggesting the involvement of further genes or multiple mechanisms. Eight patients out of 60, negative for conventional NS mutation analysis, with heterogeneous NS phenotype were investigated by means of target resequencing of 26 RAS/MAPK pathway genes. A trio was further characterized by means of whole-exome sequencing. Protein modeling and in silico prediction of protein stability allowed to identify possible pathogenic RAS pathway variants in four NS patients. A new c.355T>C variant in LZTR1 was found in patient 43. Two patients co-inherited variants in LRP1 and LZTR1 (patient 53), or LRP1 and SOS1 genes (patient 67). The forth patient (56) carried a compound heterozygote of RASAL3 gene variants and also an A2ML1 variant. While these subclinical variants are singularly present in healthy parents, they co-segregate in patients, suggesting their addictive effect and supporting a digenic inheritance, as alternative model to a more common monogenic transmission. The ERK1/2 and SAPK/JNK activation state, assessed on immortalized lymphocytes from patients 53 and 67 showed highest phosphorylation levels compared to their asymptomatic parents. These findings together with the lack of their co-occurrence in the 1000Genomes database strengthen the hypothesis of digenic inheritance in a subset of NS patients. This study suggests caution in the exclusion of subclinical variants that might play a pathogenic role providing new insights for alternative hereditary mechanisms.
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Affiliation(s)
- Luca Ferrari
- Dipartimento di Biotecnologie Mediche e Medicina Traslazionale (BIOMETRA), Università degli Studi di Milano, Segrate, Italy
| | - Eleonora Mangano
- Istituto di Tecnologie Biomediche (ITB) Centro Nazionale delle Ricerche (CNR), ITB-CNR, Segrate, Milano, Italy
| | - Maria Teresa Bonati
- Ambulatorio di Genetica Medica, IRCCS Istituto Auxologico Italiano, Milano, Italy.
| | - Ilaria Monterosso
- Dipartimento di Biotecnologie Mediche e Medicina Traslazionale (BIOMETRA), Università degli Studi di Milano, Segrate, Italy
| | - Daniele Capitanio
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milano, Italy.,IRCCS Istituto Ortopedico Galeazzi, Milano, Italy
| | - Federica Chiappori
- Istituto di Tecnologie Biomediche (ITB) Centro Nazionale delle Ricerche (CNR), ITB-CNR, Segrate, Milano, Italy
| | | | - Cecilia Gelfi
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milano, Italy.,IRCCS Istituto Ortopedico Galeazzi, Milano, Italy
| | - Cristina Battaglia
- Dipartimento di Biotecnologie Mediche e Medicina Traslazionale (BIOMETRA), Università degli Studi di Milano, Segrate, Italy.,Istituto di Tecnologie Biomediche (ITB) Centro Nazionale delle Ricerche (CNR), ITB-CNR, Segrate, Milano, Italy
| | - Roberta Bordoni
- Istituto di Tecnologie Biomediche (ITB) Centro Nazionale delle Ricerche (CNR), ITB-CNR, Segrate, Milano, Italy
| | - Paola Riva
- Dipartimento di Biotecnologie Mediche e Medicina Traslazionale (BIOMETRA), Università degli Studi di Milano, Segrate, Italy.
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17
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Li X, Yao R, Tan X, Li N, Ding Y, Li J, Chang G, Chen Y, Ma L, Wang J, Fu L, Wang X. Molecular and phenotypic spectrum of Noonan syndrome in Chinese patients. Clin Genet 2019; 96:290-299. [PMID: 31219622 DOI: 10.1111/cge.13588] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/24/2019] [Accepted: 06/10/2019] [Indexed: 12/26/2022]
Abstract
Noonan syndrome (NS) is a common autosomal dominant/recessive disorder. No large-scale study has been conducted on NS in China, which is the most populous country in the world. Next-generation sequencing (NGS) was used to identify pathogenic variants in patients that exhibited NS-related phenotypes. We assessed the facial features and clinical manifestations of patients with pathogenic or likely pathogenic variants in the RAS-MAPK signaling pathway. Gene-related Chinese NS facial features were described using artificial intelligence (AI).NGS identified pathogenic variants in 103 Chinese patients in eight NS-related genes: PTPN11 (48.5%), SOS1 (12.6%), SHOC2 (11.7%), KRAS (9.71%), RAF1 (7.77%), RIT1 (6.8%), CBL (0.97%), NRAS (0.97%), and LZTR1 (0.97%). Gene-related facial representations showed that each gene was associated with different facial details. Eight novel pathogenic variants were detected and clinical features because of specific genetic variants were reported, including hearing loss, cancer risk due to a PTPN11 pathogenic variant, and ubiquitous abnormal intracranial structure due to SHOC2 pathogenic variants. NGS facilitates the diagnosis of NS, especially for patients with mild/moderate and atypical symptoms. Our study describes the genotypic and phenotypic spectra of NS in China, providing new insights into distinctive clinical features due to specific pathogenic variants.
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Affiliation(s)
- Xin Li
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ruen Yao
- Department of Medical Genetics and Molecular Diagnostic Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin Tan
- Department of Computer Science and Engineering, Shanghai Jiao Tong University, Shanghai, China.,MoE Key Lab of Artificial Intelligence, AI Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Niu Li
- Department of Medical Genetics and Molecular Diagnostic Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Ding
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Juan Li
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Guoying Chang
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yao Chen
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lizhuang Ma
- Department of Computer Science and Engineering, Shanghai Jiao Tong University, Shanghai, China.,MoE Key Lab of Artificial Intelligence, AI Institute, Shanghai Jiao Tong University, Shanghai, China.,School of Computer Science and Software Engineering, East China Normal University, Shanghai, China
| | - Jian Wang
- Department of Medical Genetics and Molecular Diagnostic Laboratory, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lijun Fu
- Department of Cardiology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiumin Wang
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
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18
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Yu KPT, Luk HM, Leung GKC, Mak CCY, Cheng SSW, Hau EWL, Chan DKH, Lam STS, Tong TMF, Chung BHY, Lo IFM. Genetic landscape of RASopathies in Chinese: Three decades' experience in Hong Kong. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2019; 181:208-217. [PMID: 30896080 DOI: 10.1002/ajmg.c.31692] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/29/2019] [Accepted: 02/20/2019] [Indexed: 12/31/2022]
Abstract
RASopathies are a group of genetic disorders due to dysregulation of the RAS-MAPK signaling pathway, which is important in regulating cell growth, proliferation, and differentiation. These include Noonan syndrome (NS), Noonan syndrome with multiple lentigines (NSML), cardiofaciocutaneous (CFC) syndrome, and Costello syndrome (CS), clinical manifestations include growth retardation, developmental delay, cardiac defects, and specific dysmorphic features. There were abundant publications describing the genotype and phenotype from the Western populations. However, detailed study of RASopathies in Chinese population is lacking. We present here the largest cohort of RASopathies ever reported in Chinese populations, detailing the mutation spectrum and clinical phenotypes of these patients. The Clinical Genetic Service, Department of Health, and Queen Mary Hospital are tertiary referral centers for genetic disorders in Hong Kong. We retrospectively reviewed all the genetically confirmed cases of RASopathies, including NS, NSML, CFC syndrome, and CS, over the past 29 years (from 1989 to 2017). Analyses of the mutation spectrum and clinical phenotypes were performed. One hundred and ninety-one ethnic Chinese patients with genetically confirmed RASopathies were identified, including 148 patients with NS, 23 NSML, 12 CFC syndrome, and eight CS. We found a lower incidence of hypertrophic cardiomyopathy in individuals with NSML (27.3%), and NS caused by RAF1 mutations (62.5%). Another significant finding was for those NS patients with myeloproliferative disorder, the mutations fall within Exon 3 of PTPN11 but not only restricted to the well-known hotspots, that is, p.Asp61 and p.Thr731, which suggested that re-evaluation of the current tumor surveillance recommendation maybe warranted.
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Affiliation(s)
- Kris P T Yu
- Department of Health, Clinical Genetic Service, HKSAR, Hong Kong
| | - Ho-Ming Luk
- Department of Health, Clinical Genetic Service, HKSAR, Hong Kong
| | - Gordon K C Leung
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, HKSAR, Hong Kong
| | - Christopher C Y Mak
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, HKSAR, Hong Kong
| | | | - Edgar W L Hau
- Department of Health, Clinical Genetic Service, HKSAR, Hong Kong
| | - David K H Chan
- Department of Health, Clinical Genetic Service, HKSAR, Hong Kong
| | - Stephen T S Lam
- Department of Health, Clinical Genetic Service, HKSAR, Hong Kong
| | - Tony M F Tong
- Department of Health, Clinical Genetic Service, HKSAR, Hong Kong
| | - Brian H Y Chung
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, HKSAR, Hong Kong
| | - Ivan F M Lo
- Department of Health, Clinical Genetic Service, HKSAR, Hong Kong
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19
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Meyer zum Büschenfelde U, Brandenstein LI, von Elsner L, Flato K, Holling T, Zenker M, Rosenberger G, Kutsche K. RIT1 controls actin dynamics via complex formation with RAC1/CDC42 and PAK1. PLoS Genet 2018; 14:e1007370. [PMID: 29734338 PMCID: PMC5937737 DOI: 10.1371/journal.pgen.1007370] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 04/18/2018] [Indexed: 12/12/2022] Open
Abstract
RIT1 belongs to the RAS family of small GTPases. Germline and somatic RIT1 mutations have been identified in Noonan syndrome (NS) and cancer, respectively. By using heterologous expression systems and purified recombinant proteins, we identified the p21-activated kinase 1 (PAK1) as novel direct effector of RIT1. We found RIT1 also to directly interact with the RHO GTPases CDC42 and RAC1, both of which are crucial regulators of actin dynamics upstream of PAK1. These interactions are independent of the guanine nucleotide bound to RIT1. Disease-causing RIT1 mutations enhance protein-protein interaction between RIT1 and PAK1, CDC42 or RAC1 and uncouple complex formation from serum and growth factors. We show that the RIT1-PAK1 complex regulates cytoskeletal rearrangements as expression of wild-type RIT1 and its mutant forms resulted in dissolution of stress fibers and reduction of mature paxillin-containing focal adhesions in COS7 cells. This effect was prevented by co-expression of RIT1 with dominant-negative CDC42 or RAC1 and kinase-dead PAK1. By using a transwell migration assay, we show that RIT1 wildtype and the disease-associated variants enhance cell motility. Our work demonstrates a new function for RIT1 in controlling actin dynamics via acting in a signaling module containing PAK1 and RAC1/CDC42, and highlights defects in cell adhesion and migration as possible disease mechanism underlying NS. Noonan syndrome (NS) belongs to the RASopathies, a group of developmental diseases caused by mutations in genes encoding RAS-MAPK pathway components. Germline mutations in RIT1 have been identified in NS. RIT1 belongs to the RAS superfamily, however, the cellular function of RIT1 remains elusive. We show that RIT1 binds p21-activated kinase 1 (PAK1), an effector of the RHO GTPases RAC1 and CDC42, which are important regulators of cytoskeletal dynamics. NS-associated RIT1 mutants enhance complex formation between RIT1, RAC1/CDC42 and PAK1. Expression of wild-type or mutant forms of RIT1 caused loss of stress fibers and mature focal adhesions and enhanced cell motility. Our data suggest that dysfunction in actin dynamics is a novel aspect in the pathophysiology of RASopathies.
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Affiliation(s)
| | | | - Leonie von Elsner
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristina Flato
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tess Holling
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Zenker
- Institute of Human Genetics, University Hospital Magdeburg, Magdeburg, Germany
| | - Georg Rosenberger
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- * E-mail: (KK); (GR)
| | - Kerstin Kutsche
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- * E-mail: (KK); (GR)
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