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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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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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Verschuere S, Van Gils M, Nollet L, Vanakker OM. From membrane to mineralization: the curious case of the ABCC6 transporter. FEBS Lett 2020; 594:4109-4133. [PMID: 33131056 DOI: 10.1002/1873-3468.13981] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 12/13/2022]
Abstract
ATP-binding cassette subfamily C member 6 gene/protein (ABCC6) is an ATP-dependent transmembrane transporter predominantly expressed in the liver and the kidney. ABCC6 first came to attention in human medicine when it was discovered in 2000 that mutations in its encoding gene, ABCC6, caused the autosomal recessive multisystemic mineralization disease pseudoxanthoma elasticum (PXE). Since then, the physiological and pathological roles of ABCC6 have been the subject of intense research. In the last 20 years, significant findings have clarified ABCC6 structure as well as its physiological role in mineralization homeostasis in humans and animal models. Yet, several facets of ABCC6 biology remain currently incompletely understood, ranging from the precise nature of its substrate(s) to the increasingly complex molecular genetics. Nonetheless, advances in our understanding of pathophysiological mechanisms causing mineralization lead to several treatment options being suggested or already tested in pilot clinical trials for ABCC6 deficiency. This review highlights current knowledge of ABCC6 and the challenges ahead, particularly the attempts to translate basic science into clinical practice.
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Affiliation(s)
- Shana Verschuere
- Center for Medical Genetics, Ghent University Hospital, Belgium.,Department of Biomolecular Medicine, Ghent University, Belgium.,Ectopic Mineralization Research Group Ghent, Ghent, Belgium
| | - Matthias Van Gils
- Center for Medical Genetics, Ghent University Hospital, Belgium.,Department of Biomolecular Medicine, Ghent University, Belgium.,Ectopic Mineralization Research Group Ghent, Ghent, Belgium
| | - Lukas Nollet
- Center for Medical Genetics, Ghent University Hospital, Belgium.,Department of Biomolecular Medicine, Ghent University, Belgium.,Ectopic Mineralization Research Group Ghent, Ghent, Belgium
| | - Olivier M Vanakker
- Center for Medical Genetics, Ghent University Hospital, Belgium.,Department of Biomolecular Medicine, Ghent University, Belgium.,Ectopic Mineralization Research Group Ghent, Ghent, Belgium
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Abstract
Pseudoxanthoma elasticum (PXE) is a genetic metabolic disease with autosomal recessive inheritance caused by mutations in the ABCC6 gene. The lack of functional ABCC6 protein leads to ectopic mineralization that is most apparent in the elastic tissues of the skin, eyes and blood vessels. The clinical prevalence of PXE has been estimated at between 1 per 100,000 and 1 per 25,000, with slight female predominance. The first clinical sign of PXE is almost always small yellow papules on the nape and sides of the neck and in flexural areas. The papules coalesce, and the skin becomes loose and wrinkled. The mid-dermal elastic fibers are short, fragmented, clumped and calcified. Dystrophic calcification of Bruch's membrane, revealed by angioid streaks, may trigger choroidal neovascularization and, ultimately, loss of central vision and blindness in late-stage disease. Lesions in small and medium-sized artery walls may result in intermittent claudication and peripheral artery disease. Cardiac complications (myocardial infarction, angina pectoris) are thought to be relatively rare but merit thorough investigation. Ischemic strokes have been reported. PXE is a metabolic disease in which circulating levels of an anti-mineralization factor are low. There is good evidence to suggest that the factor is inorganic pyrophosphate (PPi), and that the circulating low levels of PPi and decreased PPi/Pi ratio result from the lack of ATP release by hepatocytes harboring the mutant ABCC6 protein. However, the substrate(s) bound, transported or modulated by the ABCC6 protein remain unknown. More than 300 sequence variants of the ABCC6 gene have been identified. There is no cure for PXE; the main symptomatic treatments are vascular endothelial growth factor inhibitor therapy (for ophthalmic manifestations), lifestyle, lipid-lowering and dietary measures (for reducing vascular risk factors), and vascular surgery (for severe cardiovascular manifestations). Future treatment options may include gene therapy/editing and pharmacologic chaperone therapy.
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Affiliation(s)
- Dominique P Germain
- Division of Medical Genetics, University of Versailles - Saint Quentin en Yvelines, Paris-Saclay University, 2 avenue de la source de la Bièvre, F-78180, Montigny, France.
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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: 49] [Impact Index Per Article: 5.4] [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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Panettiere P, Marchetti L, Accorsi D. Arms lift in a case of pseudoxanthoma elasticum. Case Rep Dermatol Med 2013; 2013:870605. [PMID: 23365766 PMCID: PMC3556406 DOI: 10.1155/2013/870605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 12/20/2012] [Indexed: 11/17/2022] Open
Abstract
Pseudoxanthoma elasticum (PXE) is a rare hereditary disorder of elastin fibers, characterized by yellowish coalescent papules in flexural surfaces with abnormally lax and corrugated skin. It can be associated to systemic manifestations mostly regarding eyes and vessels. Aesthetic surgery of cutaneous hyperlaxity was described in the international literature only in few cases, mostly as neck lift. A 40-year-old woman presented with cutaneous signs of PXE, demanding brachioplasty. Results after a nine-month followup are quite satisfying, and no signs of local recurrence or scar alterations are present.
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Affiliation(s)
- P. Panettiere
- Dipartimento di Discipline Chirurgiche, Rianimatorie e dei Trapianti, Policlinico S.Orsola-Malpighi, Università degli Studi di Bologna, Via Massarenti 9, 40128 Bologna, Italy
- Insegnamento di Chirurgia Plastica, Università degli Studi di Bologna, Via Massarenti 9, 40127 Bologna, Italy
| | - L. Marchetti
- Dipartimento di Discipline Chirurgiche, Rianimatorie e dei Trapianti, Policlinico S.Orsola-Malpighi, Università degli Studi di Bologna, Via Massarenti 9, 40128 Bologna, Italy
- Servizio di Chirurgia, Villa Chiara Hospital Via Porrettana 170, Casalecchio di Reno, 40033 Bologna, Italy
| | - D. Accorsi
- Dipartimento di Discipline Chirurgiche, Rianimatorie e dei Trapianti, Policlinico S.Orsola-Malpighi, Università degli Studi di Bologna, Via Massarenti 9, 40128 Bologna, Italy
- Servizio di Chirurgia, Villa Chiara Hospital Via Porrettana 170, Casalecchio di Reno, 40033 Bologna, Italy
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Marwah M, Godse K, Patil S, Nadkarni N, Gautam M. Surgical correction of pseudoxanthoma elasticum. J Cutan Aesthet Surg 2012; 5:212-3. [PMID: 23112523 PMCID: PMC3483584 DOI: 10.4103/0974-2077.101390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Manjot Marwah
- Department of Dermatology, Dr. D.Y. Patil Medical College, Nerul, Navi Mumbai, Maharashtra, India E-mail:
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Rayatt S, Pandey U, Khanna A. Familial pseudo pseudoxanthoma elasticum. J Plast Reconstr Aesthet Surg 2006; 59:1127-9. [PMID: 16996445 DOI: 10.1016/j.bjps.2006.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2005] [Accepted: 01/27/2006] [Indexed: 11/22/2022]
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Galadari H, Lebwohl M. Pseudoxanthoma elasticum: Temporary treatment of chin folds and lines with injectable collagen. J Am Acad Dermatol 2003; 49:S265-6. [PMID: 14576648 DOI: 10.1016/s0190-9622(03)00468-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Pseudoxanthoma elasticum is characterized by calcification of dermal connective tissues. Typical rhytides and horizontal creases of the chin are cutaneous manifestations that begin at an early age and are often overlooked. We report 2 patients with pseudoxanthoma elasticum who had characteristic rhytides and horizontal creases of the chin ("mental" creases). Rhytides and horizontal creases were successfully treated with injectable collagen.
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Affiliation(s)
- Hassan Galadari
- Department of Dermatology, Mount Sinai School of Medicine, New York, NY 10029, USA
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Akali AU, Sharpe DT. Cervical midline Z-plasty revision surgery for pseudoxanthoma elasticum. BRITISH JOURNAL OF PLASTIC SURGERY 2003; 56:289-91. [PMID: 12859928 DOI: 10.1016/s0007-1226(03)00123-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
A 30-year-old woman with known pseudoxanthoma elasticum was referred for surgical correction of extensive loose neck skin. She underwent a standard rhytidectomy, which produced minimal improvement. Revision surgery using a vertical elliptical skin excision, incorporating a Z-plasty was undertaken 3 months later and resulted in a satisfactory outcome.
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Affiliation(s)
- A U Akali
- Department of Plastic and Reconstructive Surgery, Bradford Royal Infirmary, Bradford, UK
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