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Shaikh U, Khan A, Kumari P, Ishfaq A, Ekhator C, Yousuf P, Halappa Nagaraj R, Raza H, Ur Rehman U, Zaman MU, Lakshmipriya Vetrivendan G, Nguyen N, Kadel B, Sherpa TN, Ullah A, Bellegarde SB. Novel Therapeutic Targets for Fibrodysplasia Ossificans Progressiva: Emerging Strategies and Future Directions. Cureus 2023; 15:e42614. [PMID: 37521595 PMCID: PMC10378717 DOI: 10.7759/cureus.42614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 08/01/2023] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP), also known as Stoneman syndrome, is a rare genetic disorder characterized by abnormal bone development caused by activating mutations of the ACVR1 gene. FOP affects both the developmental and postnatal stages, resulting in musculoskeletal abnormalities and heterotopic ossification. Current treatment options for FOP are limited, emphasizing the need for innovative therapeutic approaches. Challenges in the development of management criteria for FOP include difficulties in recruitment due to the rarity of FOP, disease variability, the absence of reliable biomarkers, and ethical considerations regarding placebo-controlled trials. This narrative review provides an overview of the disease and explores emerging strategies for FOP treatment. Gene therapy, particularly the CRISPR-Cas9 (clustered regularly interspaced short palindromic repeats-associated protein 9) system, holds promise in treating FOP by specifically targeting the ACVR1 gene mutation. Another gene therapy approach being investigated is RNA interference, which aims to silence the mutant ACVR1 gene. Small molecule inhibitors targeting glycogen synthase kinase-3β and modulation of the bone morphogenetic protein signaling pathway are also being explored as potential therapies for FOP. Stem cell-based approaches, such as mesenchymal stem cells and induced pluripotent stem cells, show potential in tissue regeneration and inhibiting abnormal bone formation in FOP. Immunotherapy and nanoparticle delivery systems provide alternative avenues for FOP treatment.
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Affiliation(s)
- Usman Shaikh
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Anoosha Khan
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Priya Kumari
- Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | | | - Chukwuyem Ekhator
- Neuro-Oncology, New York Institute of Technology, College of Osteopathic Medicine, Old Westbury, USA
| | - Paras Yousuf
- Emergency Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
| | | | - Hassan Raza
- Internal Medicine, Lahore Medical and Dental College, Lahore, PAK
| | | | | | | | - Nhan Nguyen
- Medicine, University of Debrecen, Debrecen, HUN
| | - Bijan Kadel
- Internal Medicine, Nepal Medical College and Teaching Hospitals, Kathmandu, NPL
| | - Tenzin N Sherpa
- Internal Medicine, Nepal Medical College and Teaching Hospitals, Kathmandu, NPL
| | | | - Sophia B Bellegarde
- Pathology and Laboratory Medicine, American University of Antigua, Saint John's, ATG
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2
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Pignolo RJ, Hsiao EC, Al Mukaddam M, Baujat G, Berglund SK, Brown MA, Cheung AM, De Cunto C, Delai P, Haga N, Kannu P, Keen R, Le Quan Sang KH, Mancilla EE, Marino R, Strahs A, Kaplan FS. Reduction of New Heterotopic Ossification (HO) in the Open-Label, Phase 3 MOVE Trial of Palovarotene for Fibrodysplasia Ossificans Progressiva (FOP). J Bone Miner Res 2023; 38:381-394. [PMID: 36583535 DOI: 10.1002/jbmr.4762] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 12/22/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare, severely disabling genetic disorder of progressive heterotopic ossification (HO). The single-arm, open-label, phase 3 MOVE trial (NCT03312634) assessed efficacy and safety of palovarotene, a selective retinoic acid receptor gamma agonist, in patients with FOP. Findings were compared with FOP natural history study (NHS; NCT02322255) participants untreated beyond standard of care. Patients aged ≥4 years received palovarotene once daily (chronic: 5 mg; flare-up: 20 mg for 4 weeks, then 10 mg for ≥8 weeks; weight-adjusted if skeletally immature). The primary endpoint was annualized change in new HO volume versus NHS participants (by low-dose whole-body computed tomography [WBCT]), analyzed using a Bayesian compound Poisson model (BcPM) with square-root transformation. Twelve-month interim analyses met futility criteria; dosing was paused. An independent Data Monitoring Committee recommended trial continuation. Post hoc 18-month interim analyses utilized BcPM with square-root transformation and HO data collapsed to equalize MOVE and NHS visit schedules, BcPM without transformation, and weighted linear mixed-effects (wLME) models, alongside prespecified analysis. Safety was assessed throughout. Eighteen-month interim analyses included 97 MOVE and 101 NHS individuals with post-baseline WBCT. BcPM analyses without transformation showed 99.4% probability of any reduction in new HO with palovarotene versus NHS participants (with transformation: 65.4%). Mean annualized new HO volume was 60% lower in MOVE versus the NHS. wLME results were similar (54% reduction fitted; nominal p = 0.039). All palovarotene-treated patients reported ≥1 adverse event (AE); 97.0% reported ≥1 retinoid-associated AE; 29.3% reported ≥1 serious AE, including premature physeal closure (PPC)/epiphyseal disorder in 21/57 (36.8%) patients aged <14 years. Post hoc computational analyses using WBCT showed decreased vertebral bone mineral density, content, and strength, and increased vertebral fracture risk in palovarotene-treated patients. Thus, post hoc analyses showed evidence for efficacy of palovarotene in reducing new HO in FOP, but high risk of PPC in skeletally immature patients. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, the Eli and Edythe Broad Institute for Regeneration Medicine, and the Institute of Human Genetics, Department of Medicine, and the UCSF Program in Craniofacial Biology, University of California-San Francisco, San Francisco, CA, USA
| | - Mona Al Mukaddam
- Departments of Orthopaedic Surgery & Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Geneviève Baujat
- Département de Génétique, Institut IMAGINE and Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - Staffan K Berglund
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Matthew A Brown
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Genomics England Ltd, London, UK
| | - Angela M Cheung
- Department of Medicine and Joint Department of Medical Imaging, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Patricia Delai
- Centro de Pesquisa Clinica, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Nobuhiko Haga
- Department of Rehabilitation Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Peter Kannu
- Hospital for Sick Children, Toronto, ON, Canada
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Kim-Hanh Le Quan Sang
- Département de Génétique, Institut IMAGINE and Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - Edna E Mancilla
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Frederick S Kaplan
- Departments of Orthopaedic Surgery & Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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3
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Nagar G, Mittal P, Gupta SRR, Pahuja M, Sanger M, Mishra R, Singh A, Singh IK. Multi-omics therapeutic perspective on ACVR1 gene: from genetic alterations to potential targeting. Brief Funct Genomics 2022; 22:123-142. [PMID: 36003055 DOI: 10.1093/bfgp/elac026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/04/2022] [Accepted: 07/20/2022] [Indexed: 11/13/2022] Open
Abstract
Activin A receptor type I (ACVR1), a transmembrane serine/threonine kinase, belongs to the transforming growth factor-β superfamily, which signals via phosphorylating the downstream effectors and SMAD transcription factors. Its central role in several biological processes and intracellular signaling is well known. Genetic variation in ACVR1 has been associated with a rare disease, fibrodysplasia ossificans progressive, and its somatic alteration is reported in rare cancer diffuse intrinsic pontine glioma. Furthermore, altered expression or variation of ACVR1 is associated with multiple pathologies such as polycystic ovary syndrome, congenital heart defects, diffuse idiopathic skeletal hyperostosis, posterior fossa ependymoma and other malignancies. Recent advancements have witnessed ACVR1 as a potential pharmacological target, and divergent promising approaches for its therapeutic targeting have been explored. This review highlights the structural and functional characteristics of receptor ACVR1, associated signaling pathways, genetic variants in several diseases and cancers, protein-protein interaction, gene expression, regulatory miRNA prediction and potential therapeutic targeting approaches. The comprehensive knowledge will offer new horizons and insights into future strategies harnessing its therapeutic potential.
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Pathophysiology and Emerging Molecular Therapeutic Targets in Heterotopic Ossification. Int J Mol Sci 2022; 23:ijms23136983. [PMID: 35805978 PMCID: PMC9266941 DOI: 10.3390/ijms23136983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/19/2022] [Accepted: 06/22/2022] [Indexed: 12/23/2022] Open
Abstract
The term heterotopic ossification (HO) describes bone formation in tissues where bone is normally not present. Musculoskeletal trauma induces signalling events that in turn trigger cells, probably of mesenchymal origin, to differentiate into bone. The aetiology of HO includes extremely rare but severe, generalised and fatal monogenic forms of the disease; and as a common complex disorder in response to musculoskeletal, neurological or burn trauma. The resulting bone forms through a combination of endochondral and intramembranous ossification, depending on the aetiology, initiating stimulus and affected tissue. Given the heterogeneity of the disease, many cell types and biological pathways have been studied in efforts to find effective therapeutic strategies for the disorder. Cells of mesenchymal, haematopoietic and neuroectodermal lineages have all been implicated in the pathogenesis of HO, and the emerging dominant signalling pathways are thought to occur through the bone morphogenetic proteins (BMP), mammalian target of rapamycin (mTOR), and retinoic acid receptor pathways. Increased understanding of these disease mechanisms has resulted in the emergence of several novel investigational therapeutic avenues, including palovarotene and other retinoic acid receptor agonists and activin A inhibitors that target both canonical and non-canonical signalling downstream of the BMP type 1 receptor. In this article we aim to illustrate the key cellular and molecular mechanisms involved in the pathogenesis of HO and outline recent advances in emerging molecular therapies to treat and prevent HO that have had early success in the monogenic disease and are currently being explored in the common complex forms of HO.
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Wang H, Zhang Q, Kaplan FS, Pignolo RJ. Clearance of Senescent Cells From Injured Muscle Abrogates Heterotopic Ossification in Mouse Models of Fibrodysplasia Ossificans Progressiva. J Bone Miner Res 2022; 37:95-107. [PMID: 34633114 PMCID: PMC8770661 DOI: 10.1002/jbmr.4458] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 09/19/2021] [Accepted: 10/02/2021] [Indexed: 11/10/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disease caused by mutations in activin A receptor type I/activin-like kinase 2 (ACVR1/ALK2), a bone morphogenetic protein (BMP) type I receptor, resulting in the formation of extraskeletal or heterotopic ossification (HO) and other features consistent with premature aging. During the first decade of life, episodic bouts of inflammatory swellings (flare-ups) occur, which are typically triggered by soft tissue trauma. Through an endochondral process, these exacerbations ultimately result in skeletal muscles, tendons, ligaments, fascia, and aponeuroses transforming into ectopic bone, rendering movement impossible. We have previously shown that soft tissue injury causes early FOP lesions characterized by cellular hypoxia, cellular damage, and local inflammation. Here we show that muscle injury in FOP also results in senescent cell accumulation, and that senescence promotes tissue reprogramming toward a chondrogenic fate in FOP muscle but not wild-type (WT) muscle. Using a combination of senolytic drugs we show that senescent cell clearance and reduction in the senescence associated secretory phenotype (SASP) ameliorate HO in mouse models of FOP. We conclude that injury-induced senescent cell burden and the SASP contribute to FOP lesion formation and that tissue reprogramming in FOP is mediated by cellular senescence, altering myogenic cell fate toward a chondrogenic cell fate. Furthermore, pharmacological removal of senescent cells abrogates tissue reprogramming and HO formation. Here we provide proof-of-principle evidence for senolytic drugs as a future therapeutic strategy in FOP. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Haitao Wang
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Qiang Zhang
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA, USA
| | - Robert J Pignolo
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
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Warner SE, Kaplan FS, Pignolo RJ, Smith SE, Hsiao EC, De Cunto C, Di Rocco M, Harnett K, Grogan D, Genant HK. Whole-body Computed Tomography Versus Dual Energy X‑ray Absorptiometry for Assessing Heterotopic Ossification in Fibrodysplasia Ossificans Progressiva. Calcif Tissue Int 2021; 109:615-625. [PMID: 34331548 PMCID: PMC8531122 DOI: 10.1007/s00223-021-00877-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/09/2021] [Indexed: 11/24/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare genetic disorder that leads to heterotopic ossification (HO), resulting in progressive restriction of physical function. In this study, low-dose, whole-body computed tomography (WBCT) and dual energy X-ray absorptiometry (DXA) were evaluated to determine the preferred method for assessing total body burden of HO in patients with FOP. This was a non-interventional, two-part natural history study in patients with FOP (NCT02322255; date of registration: December 2014). In Part A (described here), WBCT and DXA scans were individually assessed for HO presence and severity across 15 anatomical regions. All images were independently reviewed by an expert imaging panel. Ten adult patients were enrolled across four sites. The sensitivity to HO presence and severity varied considerably between the two imaging modalities, with WBCT demonstrating HO in more body regions than DXA (76/138 [55%] versus 47/113 [42%]) evaluable regions). Inability to evaluate HO presence, due to overlapping body regions (positional ambiguity), occurred less frequently by WBCT than by DXA (mean number of non-evaluable regions per scan 1.2 [standard deviation: 1.5] versus 2.4 [1.4]). Based on the increased sensitivity and decreased positional ambiguity of low-dose WBCT versus DXA in measuring HO in patients with FOP, low-dose WBCT was chosen as the preferred imaging for measuring HO. Therefore, low-dose WBCT was carried forward to Part B of the natural history study, which evaluated disease progression over 36 months in a larger population of patients with FOP.
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Affiliation(s)
- Sarah E Warner
- Scientific and Medical Services, PAREXEL International (dba Calyx), Billerica, MA, USA.
| | - Frederick S Kaplan
- Departments of Orthopaedic Surgery & Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Stacy E Smith
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, and The Neil and Elise Wallace STRATUS Center for Medical Simulation, Harvard Medical School, Boston, MA, USA
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, and the Institute of Human Genetics, Department of Medicine, and the UCSF Program in Craniofacial Biology, University of California-San Francisco, San Francisco, CA, USA
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Maja Di Rocco
- Unit of Rare Diseases, Department of Pediatrics, Giannina Gaslini Institute, Genoa, Italy
| | | | | | - Harry K Genant
- Departments of Radiology, Medicine and Orthopaedic Surgery, University of California, San Francisco, CA, USA
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Nascimento DR, Balaniuc SLB, Palhares DB, Underwood A, Palhares MG, Alves F, Vieira FO, Souza-Fagundes EM, Giuliani LDR, Xavier PCN, Puerto HLD, Santos RAS, Milsted A, Brum JM, Silva IS, Martins AS. Rare and intractable fibrodysplasia ossificans progressiva shows different PBMC phenotype possibly modulated by ascorbic acid and propranolol treatment. Intractable Rare Dis Res 2021; 10:179-189. [PMID: 34466340 PMCID: PMC8397826 DOI: 10.5582/irdr.2021.01012] [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: 01/15/2021] [Revised: 04/02/2021] [Accepted: 04/29/2021] [Indexed: 11/05/2022] Open
Abstract
Fibrodysplasia Ossificans Progressiva (FOP) is a rare congenital intractable disease associated with a mutation in ACVR1 gene, characterized by skeleton malformations. Ascorbic acid (AA) and propranolol (PP) in combination is reported to minimize flare-ups in patients. FOP leukocyte phenotype may possibly be modulated by AA and PP treatment. In this study, expression of 22 potential target genes was analyzed by RT-PCR in peripheral blood mononuclear cells culture (PBMC) from FOP patients and controls to determine effectiveness of the combination therapy. PBMC were treated with AA, PP and AA+PP combination. Basal expression of 12 of the 22 genes in FOP PBMC was statistically different from controls. ACVR1, ADCY2, ADCY9 and COL3 were downregulated while COL1 was upregulated. ADRB1, ADRB2, RUNX2, TNF-α and ACTB, were all overexpressed in FOP PBMC. In control, AA upregulated COL1, SVCT1, ACTB, AGTR2 and downregulated ADCY2. In FOP cells, AA upregulated ACVR1, BMP4, COL1, COL3, TNF-α, ADCY2, ADCY9, AGTR2 and MAS, while downregulated ADBR2, RUNX2, ADCY1, SVCT1 and ACTB. PP increased ADBR1 and decreased RUNX2, TNF-α, AGTR1, ACTB and CHRNA7 genes in treated control PBMC compared to untreated. PP upregulated ADBR1, ADBR2 and MAS, and downregulated TNF-α and ACTB in treated FOP PBMC versus untreated. AA+PP augmented ADRB1 and ADRB2 expressions in control PBMC. In FOP PBMC, AA+PP augmented ACVR1, COL1, COL3, ADBR1, AGTR2 and MAS expression and downregulated ADBR2, RUNX2, ACTB and MRGD. These data show distinct gene expression modulation in leukocytes from FOP patients when treated with AA and or PP.
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Affiliation(s)
| | | | | | - Adam Underwood
- Walsh University, Division of Mathematics and Sciences, North Canton, OH, USA
| | | | - Fabiana Alves
- UFMG/ Department of Physiology and Biophysics, Belo Horizonte, MG, Brazil
- Centro Universitário Metodista Izabela Hendrix- IMIH, Belo Horizonte, MG, Brazil
| | - Francisco Oliveira Vieira
- UFMG/ Department of Physiology and Biophysics, Belo Horizonte, MG, Brazil
- Centro Universitário Metodista Izabela Hendrix- IMIH, Belo Horizonte, MG, Brazil
| | | | | | | | | | | | - Amy Milsted
- Walsh University, Division of Mathematics and Sciences, North Canton, OH, USA
| | - Jose Mauro Brum
- Procter & Gamble Health Care & Global Clinical Sciences, Mason, OH, USA
| | | | - Almir Sousa Martins
- UFMS/ Faculty of Medicine, Campo Grande, MS, Brazil
- UFMG/ Department of Physiology and Biophysics, Belo Horizonte, MG, Brazil
- Address correspondence to:Almir Sousa Martins, UFMG/ Department of Physiology and Biophysics, Av Antonio Carlos, 6627, A4-256, Belo Horizonte, MG, Brasil - 31.270-900. E-mail: ;
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8
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Grgurevic L, Novak R, Hrkac S, Salai G, Grazio S. Post-COVID-19 exacerbation of fibrodysplasia ossificans progressiva with multiple flare-ups and extensive heterotopic ossification in a 45-year-old female patient. Rheumatol Int 2021; 41:1495-1501. [PMID: 34110466 PMCID: PMC8190523 DOI: 10.1007/s00296-021-04911-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 06/03/2021] [Indexed: 12/21/2022]
Abstract
Fibrodyplasia ossificans progressiva (FOP) is a rare hereditary disease, which has a variable course characterized by occasional flare-ups of heterotopic ossification (HO) in soft tissues that are followed by swelling, stiffness, pain and warmth. Here, we report for the first time a case of a 45-year-old female patient with known FOP recovering from COVID-19 with disease progression potentially linked with the viral illness. In December 2020 the patient contracted a mild form of COVID-19 infection without need for hospital admission. Since January 2021, the patient felt unwell, with occasional abdominal pain which progressively intensified. In March 2021 she presented with new onset of HO, complaining of pain, swelling and thickening sensation in the lower abdomen and left part of the neck. Computerized tomography (CT) and cytokine analysis were performed. CT scan revealed new heterotopic bone formation in multiple soft tissue areas of the neck indicating clear radiological progression. Radiotherapy, which has proven to be an efficient tool to control HO in this patient, was not able to halt HO formation after COVID-19 infection. Cytokine analysis of a plasma sample obtained during a flare-up after COVID-19 infection showed a significantly elevated pro-inflammatory cytokines compared to a flare-up panel prior to infection. Of the 23 analyzed levels of cytokines, a staggering number of 21 were above normal levels. This case is the first confirmation of uncontrolled post-COVID-19 effects in a FOP patient, which manifested with flare-ups followed by progressive HO, possibly caused by a thus far, never described form of post-COVID syndrome.
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Affiliation(s)
- Lovorka Grgurevic
- Department of Anatomy, School of Medicine, University of Zagreb, Zagreb, Croatia. .,Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, Salata 11, Zagreb, Croatia.
| | - Rudjer Novak
- Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, Salata 11, Zagreb, Croatia
| | - Stela Hrkac
- Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, Salata 11, Zagreb, Croatia
| | - Grgur Salai
- Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, Salata 11, Zagreb, Croatia
| | - Simeon Grazio
- Department of Rheumatology, Physical and Rehabilitation, Medicine University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
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9
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Martín-García D, Towler OW, Xu M, Alfonso-Hernández O, Oliveira PR, Alonso-Clavo M, Shore EM, Kaplan FS. Nonclassic fibrodysplasia ossificans progressiva: A child from Angola with an ACVR1 G328E variant. Am J Med Genet A 2021; 185:2572-2575. [PMID: 33973349 DOI: 10.1002/ajmg.a.62253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/03/2021] [Accepted: 04/24/2021] [Indexed: 11/09/2022]
Abstract
Little is known about FOP in Africa and few cases of nonclassic fibrodysplasia ossificans progressiva (FOP) have been reported on the continent. Here we report a three-year-old girl from Angola with a nonclassic FOP clinical presentation that is characterized by complex malformations of the toes and fingers, reduction defects of the digits, absence of nails, progressive heterotopic ossification, and a confirmed heterozygous ACVR1 variant at c.983G > A. Emerging knowledge of FOP can serve as a catalyst for increasing awareness of FOP in under-represented medical communities by achieving a correct FOP diagnosis, improving access of individuals with FOP to clinical trial recruitment, and enhancing the ability of affected individuals to be part of and interact with the international FOP community.
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Affiliation(s)
| | - O Will Towler
- Departments of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Meiqi Xu
- Departments of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Osmany Alfonso-Hernández
- Faculty of Medicine, Katyavala Bwila University, Benguela, Angola.,Division of Orthopedics, Benguela's General Hospital, Benguela, Angola
| | - Paula R Oliveira
- Faculty of Medicine, Katyavala Bwila University, Benguela, Angola
| | - Marleny Alonso-Clavo
- Faculty of Medicine, Katyavala Bwila University, Benguela, Angola.,Division of Pediatrics, Benguela's General Hospital, Benguela, Angola
| | - Eileen M Shore
- Departments of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Departments of Genetics, The Perelman School of Medicine at the University of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Frederick S Kaplan
- Departments of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Departments of Medicine, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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10
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Kaplan FS, Al Mukaddam M, Stanley A, Towler OW, Shore EM. Fibrodysplasia ossificans progressiva (FOP): A disorder of osteochondrogenesis. Bone 2020; 140:115539. [PMID: 32730934 PMCID: PMC7502483 DOI: 10.1016/j.bone.2020.115539] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/01/2020] [Accepted: 07/04/2020] [Indexed: 10/23/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare genetic disorder of extraskeletal bone formation, but could appropriately be viewed as a seminal disorder of osteochondrogenesis. Many, if not most, of the musculoskeletal features of FOP are related to dysregulated chondrogenesis including abnormal articular cartilage formation, abnormal diarthrodial joint specification, growth plate dysplasia, osteochondroma formation, heterotopic endochondral ossification (HEO), and precocious arthropathy. In FOP, causative activating mutations of Activin receptor A type I (ACVR1), a bone morphogenetic protein (BMP) type I receptor, are responsible for the osteochondrodysplasia that impacts developmental phenotypes as well as postnatal features of this illustrative disorder. Here, we highlight the myriad developmental and postnatal effects on osteochondrogenesis that emanate directly from mutant ACVR1 and dysregulated bone morphogenetic protein (BMP) signaling in FOP.
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Affiliation(s)
- Frederick S Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Mona Al Mukaddam
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Alexandra Stanley
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - O Will Towler
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Eileen M Shore
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Genetics, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
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11
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Pulik Ł, Mierzejewski B, Ciemerych MA, Brzóska E, Łęgosz P. The Survey of Cells Responsible for Heterotopic Ossification Development in Skeletal Muscles-Human and Mouse Models. Cells 2020; 9:cells9061324. [PMID: 32466405 PMCID: PMC7349686 DOI: 10.3390/cells9061324] [Citation(s) in RCA: 16] [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: 04/17/2020] [Revised: 05/16/2020] [Accepted: 05/21/2020] [Indexed: 12/18/2022] Open
Abstract
Heterotopic ossification (HO) manifests as bone development in the skeletal muscles and surrounding soft tissues. It can be caused by injury, surgery, or may have a genetic background. In each case, its development might differ, and depending on the age, sex, and patient's conditions, it could lead to a more or a less severe outcome. In the case of the injury or surgery provoked ossification development, it could be, to some extent, prevented by treatments. As far as genetic disorders are concerned, such prevention approaches are highly limited. Many lines of evidence point to the inflammatory process and abnormalities in the bone morphogenetic factor signaling pathway as the molecular and cellular backgrounds for HO development. However, the clear targets allowing the design of treatments preventing or lowering HO have not been identified yet. In this review, we summarize current knowledge on HO types, its symptoms, and possible ways of prevention and treatment. We also describe the molecules and cells in which abnormal function could lead to HO development. We emphasize the studies involving animal models of HO as being of great importance for understanding and future designing of the tools to counteract this pathology.
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Affiliation(s)
- Łukasz Pulik
- Department of Orthopaedics and Traumatology, Medical University of Warsaw, Lindley 4 St, 02-005 Warsaw, Poland;
| | - Bartosz Mierzejewski
- Department of Cytology, Faculty of Biology, University of Warsaw, Miecznikowa 1 St, 02-096 Warsaw, Poland; (B.M.); (M.A.C.)
| | - Maria A. Ciemerych
- Department of Cytology, Faculty of Biology, University of Warsaw, Miecznikowa 1 St, 02-096 Warsaw, Poland; (B.M.); (M.A.C.)
| | - Edyta Brzóska
- Department of Cytology, Faculty of Biology, University of Warsaw, Miecznikowa 1 St, 02-096 Warsaw, Poland; (B.M.); (M.A.C.)
- Correspondence: (E.B.); (P.Ł.); Tel.: +48-22-5542-203 (E.B.); +48-22-5021-514 (P.Ł.)
| | - Paweł Łęgosz
- Department of Orthopaedics and Traumatology, Medical University of Warsaw, Lindley 4 St, 02-005 Warsaw, Poland;
- Correspondence: (E.B.); (P.Ł.); Tel.: +48-22-5542-203 (E.B.); +48-22-5021-514 (P.Ł.)
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12
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Pignolo RJ, Cheung K, Kile S, Fitzpatrick MA, De Cunto C, Al Mukaddam M, Hsiao EC, Baujat G, Delai P, Eekhoff EMW, Di Rocco M, Grunwald Z, Haga N, Keen R, Levi B, Morhart R, Scott C, Sherman A, Zhang K, Kaplan FS. Self-reported baseline phenotypes from the International Fibrodysplasia Ossificans Progressiva (FOP) Association Global Registry. Bone 2020; 134:115274. [PMID: 32062004 DOI: 10.1016/j.bone.2020.115274] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/11/2020] [Accepted: 02/13/2020] [Indexed: 11/21/2022]
Abstract
A global, patient-reported registry has been established to characterize the course of disease and track clinical outcomes in patients with fibrodysplasia ossificans progressiva (FOP), an ultra-rare genetic condition of progressive heterotopic ossification (HO) that results in ankylosis of joints and renders most affected individuals immobile by the second decade of life. Here, we present baseline phenotypes on 299 patients (median age 21 years; range 0.1 to 78 years) from 54 countries based on aggregate data from the International FOP Association (IFOPA) Global Registry (the "FOP Registry"). The mean current age of the patients is 23.7 years (range, 0.1 to 78 years). Baseline characteristics are presented for FOP diagnosis, HO, flare-ups and precedent events, system-based prevalent symptomatology, encounters with medical and dental care providers, Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Scale scores, physical function, as well as the use of aids, assistive devices, and adaptations. Correlations of PROMIS Global Health scores with HO burden and physical function are calculated. Associations of joint mobility with PROMIS Global Health scores, physical function, and use of aids, assistive devices, and adaptations are summarized. Overall, the FOP Registry database contains a broad sample of the global FOP patient population, providing a useful tool for expanding knowledge of FOP, designing clinical trials and facilitating evidence-based decisions about the optimal monitoring and management of affected individuals.
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Affiliation(s)
- Robert J Pignolo
- Department of Medicine, Mayo Clinic School of Medicine, Mayo Clinic, Rochester, MN, United States.
| | - Kin Cheung
- BioSAS Consulting, Inc., Wellesley, MA, United States
| | - Sammi Kile
- International FOP Association, 1520 Clay St, Suite H2, North Kansas City, MO, United States.
| | - Mary Anne Fitzpatrick
- International FOP Association, 1520 Clay St, Suite H2, North Kansas City, MO, United States.
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Mona Al Mukaddam
- Departments of Medicine and Orthopaedic Surgery, The Center for Research in FOP and Related Disorders, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, United States.
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, The UCSF Metabolic Bone Clinic, The Institute of Human Genetics, the UCSF Program in Craniofacial Biology, Department of Medicine, University of California-San Francisco, San Francisco, CA, United States.
| | - Genevieve Baujat
- Departement de Genetique, Institut IMAGINE, Hôpital Necker-Enfants Malades, Paris, France.
| | - Patricia Delai
- Hospital Israelita Albert Einstein, Instituto de Ensino e Pesquisa, São Paulo, SP, Brazil.
| | - Elisabeth M W Eekhoff
- VU Medical Center Amsterdam, Department of Internal Medicine/Section Endocrinology, Amsterdam, the Netherlands.
| | - Maja Di Rocco
- Unit of Rare Diseases, Department of Pediatrics, Giannina Gaslini Institute, Genoa, Italy.
| | - Zvi Grunwald
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, United States.
| | - Nobuhiko Haga
- Department of Rehabilitation Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, Middlesex, United Kingdom.
| | - Benjamin Levi
- Department of Surgery, University of Michigan, Ann Arbor, MI, United States.
| | - Rolf Morhart
- Department of Pediatrics, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Germany.
| | - Christiaan Scott
- Department of Paediatric Rheumatology, Red Cross Children's Hospital, Cape Town, South Africa.
| | - Adam Sherman
- International FOP Association, 1520 Clay St, Suite H2, North Kansas City, MO, United States.
| | - Keqin Zhang
- Tongji Hospital, Shanghai Tongji University, Shanghai, PR China
| | - Fredrick S Kaplan
- Departments of Orthopaedic Surgery and Medicine, The Center for Research in FOP & Related Disorders, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, United States.
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13
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Pignolo RJ, Kaplan FS. Druggable targets, clinical trial design and proposed pharmacological management in fibrodysplasia ossificans progressiva. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1751122] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Robert J. Pignolo
- Departments of Medicine, Physiology & Biomedical Engineering, and the Robert and Arlene Kogod Center on Aging, Alix School of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Frederick S. Kaplan
- Departments of Orthopaedic Surgery, Medicine, and the Center for Research in FOP & Related Disorders, The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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14
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Shi F, Gao J, Zou J, Ying Y, Lin H. Targeting heterotopic ossification by inhibiting activin receptor‑like kinase 2 function (Review). Mol Med Rep 2019; 20:2979-2989. [PMID: 31432174 PMCID: PMC6755183 DOI: 10.3892/mmr.2019.10556] [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: 02/11/2019] [Accepted: 07/15/2019] [Indexed: 11/17/2022] Open
Abstract
Heterotopic ossification (HO) refers to the appearance of osteoblasts in soft tissues under pathological conditions, such as trauma or infection. HO arises in an unpredictable way without any recognizable initiation. Activin receptor-like kinase-2 (ALK2) is a type I cell surface receptor for bone morphogenetic proteins (BMPs). The dysregulation of ALK2 signaling is associated with a variety of diseases, including cancer and HO. At present, the prevention and treatment of HO in the clinic predominantly includes nonsteroidal anti-inflammatory drugs (NSAIDs), bisphosphonates and other drug treatments, low-dose local radiation therapy and surgical resection, rehabilitation treatment and physical therapy. However, most of these therapies have adverse effects. These methods do not prevent the occurrence of HO. The pathogenesis of HO is not being specifically targeted; the current treatment strategies target the symptoms, not the disease. These treatments also cannot solve the fundamental problem of the occurrence of HO. Therefore, scholars have been working to develop targeted therapies based on the pathogenesis of HO. The present review focuses on advances in the understanding of the underlying mechanisms of HO, and possible options for the prevention and treatment of HO. In addition, the role of ALK2 in the process of HO is introduced and the progress made towards the targeted inhibition of ALK2 is discussed. The present study aims to offer a platform for further research on possible targets for the prevention and treatment of HO.
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Affiliation(s)
- Fuli Shi
- Jiangxi Province Key Laboratory of Tumor Pathogens and Molecular Pathology, Department of Pathophysiology, School of Basic Medicine Sciences, Nanchang University Medical College, Nanchang, Jiangxi 330006, P.R. China
| | - Jiayu Gao
- Jiangxi Province Key Laboratory of Tumor Pathogens and Molecular Pathology, Department of Pathophysiology, School of Basic Medicine Sciences, Nanchang University Medical College, Nanchang, Jiangxi 330006, P.R. China
| | - Junrong Zou
- Jiangxi Province Key Laboratory of Tumor Pathogens and Molecular Pathology, Department of Pathophysiology, School of Basic Medicine Sciences, Nanchang University Medical College, Nanchang, Jiangxi 330006, P.R. China
| | - Ying Ying
- Jiangxi Province Key Laboratory of Tumor Pathogens and Molecular Pathology, Department of Pathophysiology, School of Basic Medicine Sciences, Nanchang University Medical College, Nanchang, Jiangxi 330006, P.R. China
| | - Hui Lin
- Jiangxi Province Key Laboratory of Tumor Pathogens and Molecular Pathology, Department of Pathophysiology, School of Basic Medicine Sciences, Nanchang University Medical College, Nanchang, Jiangxi 330006, P.R. China
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15
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The role of Activin A in fibrodysplasia ossificans progressiva: a prominent mediator. Biosci Rep 2019; 39:BSR20190377. [PMID: 31341010 PMCID: PMC6680371 DOI: 10.1042/bsr20190377] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 07/16/2019] [Accepted: 07/23/2019] [Indexed: 12/31/2022] Open
Abstract
Heterotopic ossification (HO) is the aberrant formation of mature, lamellar bone in nonosseous tissue. Fibrodysplasia ossificans progressiva (FOP) is a rare and devastating genetic disorder that causes progressive HO in the ligaments, tendons, and muscles throughout the body. FOP is attributed to an autosomal mutation in activin receptor-like kinase 2 (ALK2), a bone morphogenetic protein (BMP) type I receptor. Initial studies show that mutant ALK2 drives HO by constitutively activating the BMP signaling pathway. Recently, mutant ALK2 has been shown to transduce Smad1/5 signaling and enhance chondrogenesis, calcification in response to Activin A, which normally signals through Smad2/3 and inhibits BMP signaling pathway. Furthermore, Activin A induces heterotopic bone formation via mutant ALK2, while inhibition of Activin A blocks spontaneous and trauma-induced HO. In this manuscript, we describe the molecular mechanism of the causative gene ALK2 in FOP, mainly focusing on the prominent role of Activin A in HO. It reveals a potential strategy for prevention and treatment of FOP by inhibition of Activin A. Further studies are needed to explore the cellular and molecular mechanisms of Activin A in FOP in more detail.
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16
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Grgurević L, Novak R, Trkulja V, Hamzić LF, Hrkač S, Grazio S, Santini M. Elevated plasma RANTES in fibrodysplasia ossificans progressiva - A novel therapeutic target? Med Hypotheses 2019; 131:109313. [PMID: 31443758 DOI: 10.1016/j.mehy.2019.109313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 07/15/2019] [Accepted: 07/19/2019] [Indexed: 12/13/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare hereditary disease caused by a mutation in the intracellular domain of the activin A receptor type I and is characterized by episodes (flare-ups) of progressive heterotopic endochondral ossification (HO) in the soft tissues. The mutation alone is not sufficient for the occurrence of HO since flare-ups are triggered by inflammation and activation of the innate immune system. A number of cellular and humoral mediators have been implicated in animal and in vitro models. Observations in humans support the inflammatory nature of the condition, but data on the involved mediators are variable. We hypothesize that for induction of flare-ups in patients with FOP increase in at least one of the pro-inflammatory cytokines is both essential and sufficient to trigger the entire process of the inflammatory cells influx resulting in the novel ectopic bone formation and we suggest that C-C motif ligand 5 (CCL5), a pro-inflammatory chemokine also known as Regulated on activation, normal T-cell expressed and secreted (RANTES), might be the key candidate. CCL5 is a chemoattractant for all cellular types implicated in HO and is produced by the cells of the tissue microenvironment at the sites of HO as well as by the pro-inflammatory cellular mediators. CCL5 induces ossification in cultured human pluripotent mesenchymal cells (hMSCs) and in the primary culture of monocytes from FOP patients (but not from their healthy relatives), stimulation with lipopolysaccharide induces CCL5 expression. Finally, in a pilot study we used a panel of 23 cytokines and chemokines to screen the plasma samples of three subjects: a female patient with FOP during a flare-up; a female patient with hyperostosis corticalis generalisata (van Buchem disease), another rare disease characterized by excessive bone formation at the sites where it regularly occurs that does not include inflammatory events; and a healthy woman without bone disorders. There appeared a rather clear-cut signal of a 2-fold higher level of CCL5 in the FOP patient vs. the healthy subject and the van Buchem patient. Evaluation of the hypothesis would require an international prospective study, with main motivation being the lack of a conclusive treatment as the major unmet need in FOP. A treatment targeting CCL5 receptor already exists and is used in HIV-infected patients.
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Affiliation(s)
- Lovorka Grgurević
- Drago Perović Department of Anatomy, School of Medicine, University of Zagreb, Zagreb, Croatia; Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, Zagreb, Croatia.
| | - Ruđer Novak
- Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Vladimir Trkulja
- Department of Pharmacology, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Lejla Ferhatović Hamzić
- Center for Translational and Clinical Research, Department of Proteomics, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Stela Hrkač
- Drago Perović Department of Anatomy, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Simeon Grazio
- University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - Marija Santini
- University Hospital for Infectious Diseases "Dr. Fran Mihaljević", Zagreb, Croatia
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17
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Gucev Z, Tasic V, Plaseska-Karanfilska D, Dimishkovska M, Laban N, Bozinovski Z, Kostovski M, Saveski A, Polenakovic M, Towler OW, Shore EM, Kaplan FS. Severe digital malformations in a rare variant of fibrodysplasia ossificans progressiva. Am J Med Genet A 2019; 179:1310-1314. [PMID: 31012264 DOI: 10.1002/ajmg.a.61153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/23/2019] [Accepted: 04/01/2019] [Indexed: 11/06/2022]
Abstract
A 16-year-old girl with a history of nontraumatic swelling of both forearms, osteochondromas of the knees, heterotopic ossification of the neck and back, severe malformations of all digits with hypoplastic or absent nails, alopecia partialis of the scalp, and moderate cognitive impairment was seen for diagnostic evaluation. Whole exome sequencing identified an activating mutation of ACVR1 (c.983G > A; p.Gly328Glu) which confirmed a suspected FOP variant. The delayed diagnosis of an FOP variant in this patient could have been avoided if the significance of severe digital malformations had been recognized, especially in the setting of progressive heterotopic ossification.
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Affiliation(s)
- Zoran Gucev
- Medical Faculty - Skopje, University Ss Cyril and Methodius of Skopje, Skopje, Republic of North Macedonia
| | - Velibor Tasic
- Medical Faculty - Skopje, University Ss Cyril and Methodius of Skopje, Skopje, Republic of North Macedonia
| | - Dijana Plaseska-Karanfilska
- Research Centre for Genetic Engineering and Biotechnology "Georgi D. Efremov", Macedonian Academy of Sciences and Arts, Skopje, Republic of North Macedonia
| | - Marija Dimishkovska
- Research Centre for Genetic Engineering and Biotechnology "Georgi D. Efremov", Macedonian Academy of Sciences and Arts, Skopje, Republic of North Macedonia
| | - Nevenka Laban
- Medical Faculty - Skopje, University Ss Cyril and Methodius of Skopje, Skopje, Republic of North Macedonia
| | - Zoran Bozinovski
- Medical Faculty - Skopje, University Ss Cyril and Methodius of Skopje, Skopje, Republic of North Macedonia
| | - Marko Kostovski
- Medical Faculty - Skopje, University Ss Cyril and Methodius of Skopje, Skopje, Republic of North Macedonia
| | - Alek Saveski
- Medical Faculty - Skopje, University Ss Cyril and Methodius of Skopje, Skopje, Republic of North Macedonia
| | - Momir Polenakovic
- Research Centre for Genetic Engineering and Biotechnology "Georgi D. Efremov", Macedonian Academy of Sciences and Arts, Skopje, Republic of North Macedonia
| | - O Will Towler
- Department of Orthopaedic Surgery, Center for Research in FOP & Related Disorders, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eileen M Shore
- Department of Orthopaedic Surgery, Center for Research in FOP & Related Disorders, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Genetics, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, Center for Research in FOP & Related Disorders, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Medicine, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania
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18
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Pignolo RJ, Wang H, Kaplan FS. Fibrodysplasia Ossificans Progressiva (FOP): A Segmental Progeroid Syndrome. Front Endocrinol (Lausanne) 2019; 10:908. [PMID: 31998237 PMCID: PMC6966325 DOI: 10.3389/fendo.2019.00908] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 12/12/2019] [Indexed: 12/16/2022] Open
Abstract
Segmental progeroid syndromes are commonly represented by genetic conditions which recapitulate aspects of physiological aging by similar, disparate, or unknown mechanisms. Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disease caused by mutations in the gene for ACVR1/ALK2 encoding Activin A receptor type I/Activin-like kinase 2, a bone morphogenetic protein (BMP) type I receptor, and results in the formation of extra-skeletal ossification and a constellation of others features, many of which resemble accelerated aging. The median estimated lifespan of individuals with FOP is approximately 56 years of age. Characteristics of precocious aging in FOP include both those that are related to dysregulated BMP signaling as well as those secondary to early immobilization. Progeroid features that may primarily be associated with mutations in ACVR1 include osteoarthritis, hearing loss, alopecia, subcutaneous lipodystrophy, myelination defects, heightened inflammation, menstrual abnormalities, and perhaps nephrolithiasis. Progeroid features that may secondarily be related to immobilization from progressive heterotopic ossification include decreased vital capacity, osteoporosis, fractures, sarcopenia, and predisposition to respiratory infections. Some manifestations of precocious aging may be attributed to both primary and secondary effects of FOP. At the level of lesion formation in FOP, soft tissue injury resulting in hypoxia, cell damage, and inflammation may lead to the accumulation of senescent cells as in aged tissue. Production of Activin A, platelet-derived growth factor, metalloproteinases, interleukin 6, and other inflammatory cytokines as part of the senescence-associated secretory phenotype could conceivably mediate the initial signaling cascade that results in the intense fibroproliferative response as well as the tissue-resident stem cell reprogramming leading up to ectopic endochondral bone formation. Consideration of FOP as a segmental progeroid syndrome offers a unique perspective into potential mechanisms of normal aging and may also provide insight for identification of new targets for therapeutic interventions in FOP.
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Affiliation(s)
- Robert J. Pignolo
- Department of Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
- Department of Physiology-Biomedical Engineering, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
- Kogod Center on Aging, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
- *Correspondence: Robert J. Pignolo
| | - Haitao Wang
- Department of Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
- Department of Physiology-Biomedical Engineering, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
- Kogod Center on Aging, Mayo Clinic Alix School of Medicine, Rochester, MN, United States
| | - Frederick S. Kaplan
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
- Center for Research in FOP and Related Disorders, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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Rohleder O, Mudry P, Neradil J, Noskova H, Slaby O, Sterba J. Letter to Editor: F.S. Kaplan, et al., Early clinical observations on the use of imatinibmesylate in FOP: A report of seven cases, Bone (2017). Bone 2018; 116:171. [PMID: 30096467 DOI: 10.1016/j.bone.2018.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/06/2018] [Indexed: 11/29/2022]
Affiliation(s)
- O Rohleder
- Pediatric Oncology Department, University Hospital Brno and School of Medicine, Masaryk University, Cernopolni 9, Brno 613 00, Czech Republic; Division of Medical Genetics, Department of Biology, University Hospital Brno and School of Medicine, Masaryk University, Cernopolni 9, Brno 613 00, Czech Republic.
| | - P Mudry
- Pediatric Oncology Department, University Hospital Brno and School of Medicine, Masaryk University, Cernopolni 9, Brno 613 00, Czech Republic.
| | - J Neradil
- Pediatric Oncology Department, University Hospital Brno and School of Medicine, Masaryk University, Cernopolni 9, Brno 613 00, Czech Republic; Laboratory of Tumor Biology, Department of Experimental Biology, School of Science, Masaryk University, Kotlarska 2, Brno 611 37, Czech Republic.
| | - H Noskova
- Central European Institute of Technology, Masaryk University, Kamenice 753/5, Brno 625 00, Czech Republic.
| | - O Slaby
- Central European Institute of Technology, Masaryk University, Kamenice 753/5, Brno 625 00, Czech Republic.
| | - J Sterba
- Pediatric Oncology Department, University Hospital Brno and School of Medicine, Masaryk University, Cernopolni 9, Brno 613 00, Czech Republic.
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Osteoinduction within BMP-2 transduced muscle tissue fragments with and without a fascia layer: implications for bone tissue engineering. Gene Ther 2018; 26:16-28. [PMID: 30368527 DOI: 10.1038/s41434-018-0047-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 08/27/2018] [Accepted: 09/12/2018] [Indexed: 12/21/2022]
Abstract
Bone can be engineered in vivo by implantation of gene-activated muscle tissue fragments. This expedited approach may be further improved by use of muscle tissue with attached fascia. The aim of this in vitro study was to provide an in depth comparison of the osteogenic differentiation capacity of muscle alone and muscle with fascia after BMP-2 transduction. Skeletal muscle tissue from rats was cut into pieces with and without a fascia layer on the surface. Adenoviral BMP-2 or GFP vectors were used for transduction. Osteogenic differentiation within the tissue fragments was evaluated and compared by qRT-PCR, alizarin red S staining, histomorphometry and immunohistology. Transduction efficiency and level of transgene expression were higher for muscle with fascia than muscle alone. Transduction with BMP-2 led to a significant upregulation of bone marker genes, proteins, and calcium deposition in both groups. Interestingly, histological evaluation revealed that osteoinduction did not occur within the fascia layer itself. The upregulation of bone marker genes in muscle with fascia was significantly lower after 2 weeks but similar after 4 weeks of in vitro culture in comparison to muscle alone. The fascia layer led to higher transduction efficiency and enhanced BMP-2 expression. Despite fascia's lower capacity for osteogenic differentiation, muscle implants may benefit from the fascia layer by the improved ability to deliver BMP-2. The presented data may contribute to the development of a novel, cost-effective, single-surgery bone engineering technology and encourage the evaluation of the osteoregenerative potential of muscle with fascia in an animal model.
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21
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Betz VM, Ren B, Messmer C, Jansson V, Betz OB, Müller PE. Bone morphogenetic protein-2 is a stronger inducer of osteogenesis within muscle tissue than heterodimeric bone morphogenetic protein-2/6 and -2/7: Implications for expedited gene-enhanced bone repair. J Gene Med 2018; 20:e3042. [DOI: 10.1002/jgm.3042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 11/09/2022] Open
Affiliation(s)
- Volker M. Betz
- Department of Gene Therapy; University of Ulm; Ulm Germany
- Center for Rehabilitation; RKU - University and Rehabilitation Hospitals Ulm; Ulm Germany
| | - Bin Ren
- Department of Orthopedic Surgery, Physical Medicine and Rehabilitation; University Hospital Grosshadern, Ludwig-Maximilians-University Munich; Munich Germany
| | - Carolin Messmer
- Center for Rehabilitation; RKU - University and Rehabilitation Hospitals Ulm; Ulm Germany
| | - Volkmar Jansson
- Department of Orthopedic Surgery, Physical Medicine and Rehabilitation; University Hospital Grosshadern, Ludwig-Maximilians-University Munich; Munich Germany
| | - Oliver B. Betz
- Department of Orthopedic Surgery, Physical Medicine and Rehabilitation; University Hospital Grosshadern, Ludwig-Maximilians-University Munich; Munich Germany
- Department of Chemical Engineering; Massachusetts Institute of Technology; Cambridge MA USA
| | - Peter E. Müller
- Department of Orthopedic Surgery, Physical Medicine and Rehabilitation; University Hospital Grosshadern, Ludwig-Maximilians-University Munich; Munich Germany
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22
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Tiwari V, Behera P, Sarawagi R, Rafi BM, Sahu S, Raj H, Rajpoot M. Atypical Presentation of Fibrodysplasia Ossificans Progressiva: A Case Report and Review of Literature. Cureus 2018; 10:e2955. [PMID: 30214843 PMCID: PMC6132596 DOI: 10.7759/cureus.2955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disease characterized by widespread areas of abnormal bone formation in muscles, ligaments, tendons and joint capsules. Typically, the symptoms begin in the first decade of life with episodes of painful inflammatory soft tissue swellings. Gradually, there occurs restriction of motion at various joints, severely limiting the activities of daily living and the quality of life of such patients by the third decade of life. There is no definite cure available for the disease and the current treatment options target symptomatic and palliative management. We describe the case of a 10-year-old child who presented to our institute with a severe disability of upper limbs due to joint contractures along with several bony masses at various locations of the body but without having any prior complaints of painful soft tissue lesions or the characteristic flare-ups of the disease ever. Identification of typical soft tissue ossified masses in the specific anatomic pattern, along with the presence of short and malformed great toes helped us in reaching the diagnosis. Surgical procedures including biopsies should be strictly avoided in such patients to prevent triggering the development of more lesions, which occurred in our patient after inadvertent removal of the first swelling by an orthopaedic specialist.
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Affiliation(s)
- Vivek Tiwari
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
| | - Prateek Behera
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
| | - Radha Sarawagi
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhopal, IND
| | - Babu Mohammed Rafi
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
| | - Saurabh Sahu
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Bhopal, IND
| | - Hemanth Raj
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
| | - Manish Rajpoot
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
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23
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Kaplan FS, Andolina JR, Adamson PC, Teachey DT, Finklestein JZ, Ebb DH, Whitehead B, Jacobs B, Siegel DM, Keen R, Hsiao E, Pignolo RJ. Early clinical observations on the use of imatinib mesylate in FOP: A report of seven cases. Bone 2018; 109:276-280. [PMID: 28736245 DOI: 10.1016/j.bone.2017.07.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 07/15/2017] [Accepted: 07/18/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Fibrodysplasia ossificans progressiva (FOP) is an ultrarare genetic disorder of progressive, disabling heterotopic ossification (HO) for which there is presently no definitive treatment. Research studies have identified multiple potential targets for therapy in FOP, and novel drug candidates are being developed for testing in clinical trials. A complementary approach seeks to identify approved drugs that could be re-purposed for off-label use against defined targets in FOP. One such drug is imatinib mesylate, a tyrosine kinase inhibitor originally developed for use in patients with chronic myeloid leukemia (CML). Imatinib has the desirable effect of attacking multiple targets involved in the early hypoxic and inflammatory stages of FOP flare-ups, including HIF1-α, PDGFRα, c-KIT, and multiple MAP kinases. RESULTS Based on compelling biologic rationale, strong preclinical data, and a favorable safety profile, imatinib has been prescribed on an off-label basis in a non-trial setting in seven children with continuous FOP flare-ups, predominantly in the axial regions, and which were not responsive to standard-of-care regimens. Anecdotal reports in these seven isolated cases document that the medication was well-tolerated with a ubiquitous reported decrease in the intensity of flare-ups in the six children who took the medication. CONCLUSIONS These early clinical observations support the implementation of clinical trials in children with uncontrolled FOP flare-ups to determine if imatinib may ameliorate symptoms or alter the natural history of this debilitating and life-threatening disease.
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Affiliation(s)
- Frederick S Kaplan
- Departments of Orthopaedic Surgery and Medicine, Center for Research in FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States.
| | - Jeffrey R Andolina
- Department of Pediatrics, Division of Hematology-Oncology, University of Rochester School of Medicine, Rochester, NY 14642, United States.
| | - Peter C Adamson
- Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States.
| | - David T Teachey
- Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States.
| | - Jerry Z Finklestein
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Jonathan Jacques Children's Cancer Center, Long Beach, CA 90806, United States
| | - David H Ebb
- Department of Pediatrics, Division of Hematology-Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, United States.
| | - Benjamin Whitehead
- Lady Cilento Children's Hospital, Rheumatology Department, South Brisbane 4101, Australia.
| | - Benjamin Jacobs
- Department of Paediatrics, the Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP, United Kingdom.
| | - David M Siegel
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY 14642, United States.
| | - Richard Keen
- Department of Rheumatology, the Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP, United Kingdom.
| | - Edward Hsiao
- Division of Endocrinology and Metabolism, Department of Medicine, Institute for Human Genetics, University of California-San Francisco School of Medicine, San Francisco, CA 94143, United States.
| | - Robert J Pignolo
- Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, United States.
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24
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Kaplan FS, Al Mukaddam M, Pignolo RJ. Acute unilateral hip pain in fibrodysplasia ossificans progressiva (FOP). Bone 2018; 109:115-119. [PMID: 28822791 DOI: 10.1016/j.bone.2017.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/15/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Flare-ups of the hips are among the most feared and disabling complications of fibrodysplasia ossificans progressiva (FOP) and are poorly understood. In order to better understand the nature of hip flare-ups in FOP, we evaluated 25 consecutive individuals with classic FOP (14 males, 11 females; 3-56years old, median age, 17years old) who presented with acute unilateral hip pain. RESULTS All 25 individuals were suspected of having a flare-up of the hip based on clinical history and a favorable response to a four day course of high-dose oral prednisone. Ten individuals (40%) experienced rebound symptoms of pain and/or stiffness within seven days after discontinuation of prednisone and all ten subsequently developed heterotopic ossification (HO) or decreased mobility of the affected hip. None of the 14 individuals who experienced sustained relief of symptoms following a course of oral prednisone experienced HO or decreased mobility. Incidental radiographic findings at the time of presentation were multifactoral and included osteochondromas of the proximal femur (18/25; 72%), degenerative arthritis (17/25; 68%), developmental hip dysplasia (15/25; 60%), previously existing heterotopic ossification (12/25; 48%), intra-articular synovial osteochondromatosis (8/25; 32%) or traumatic fractures through pre-existing heterotopic bone (1/25; 4%). CONCLUSIONS Developmental joint pathology may confound clinical evaluation of hip pain in FOP. The most useful modality for suspecting an ossification-prone flare-up of the hip was lack of sustained response to a brief course of oral prednisone. Evaluation of soft tissue edema by ultrasound or magnetic resonance imaging showed promise in identifying ossification-prone flare-ups and warrants further analysis in prospective studies.
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Affiliation(s)
- Frederick S Kaplan
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Mona Al Mukaddam
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Clinical Medicine, Division of Endocrinology, Diabetes and Metabolism, Center for Research in FOP & Related Disorders, Penn Medicine University City, 3737 Market Street, 3rd floor, United States.
| | - Robert J Pignolo
- Department of Medicine, Mayo Clinic School of Medicine, Mayo Clinic, Rochester, MN, United States.
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25
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Wang H, Behrens EM, Pignolo RJ, Kaplan FS. ECSIT links TLR and BMP signaling in FOP connective tissue progenitor cells. Bone 2018; 109:201-209. [PMID: 29288875 DOI: 10.1016/j.bone.2017.12.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 12/26/2017] [Indexed: 01/12/2023]
Abstract
Clinical and laboratory observations strongly suggest that the innate immune system induces flare-ups in the setting of dysregulated bone morphogenetic protein (BMP) signaling in fibrodysplasia ossificans progressiva (FOP). In order to investigate the signaling substrates of this hypothesis, we examined toll-like receptor (TLR) activation and bone morphogenetic protein (BMP) signaling in connective tissue progenitor cells (CTPCs) from FOP patients and unaffected individuals. We found that inflammatory stimuli broadly activate TLR expression in FOP CTPCs and that TLR3/TLR4 signaling amplifies BMP pathway signaling through both ligand dependent and independent mechanisms. Importantly, Evolutionarily Conserved Signaling Intermediate in the Toll Pathway (ECSIT) integrates TLR injury signaling with dysregulated BMP pathway signaling in FOP CTPCs. These findings provide novel insight into the cell autonomous integration of injury signals from the innate immune system with dysregulated response signals from the BMP signaling pathway and provide new exploratory targets for therapeutic approaches to blocking the induction and amplification of FOP lesions.
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Affiliation(s)
- Haitao Wang
- Department of Physiology and Biomedical Research, The Mayo Clinic, Rochester, MN, United States
| | - Edward M Behrens
- Department of Pediatrics, Division of Rheumatology, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA, United States
| | - Robert J Pignolo
- Department of Medicine, The Mayo Clinic, Rochester, MN, United States.
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA, United States; Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA, United States; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA, United States.
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26
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Kaplan FS, Zeitlin L, Dunn SP, Benor S, Hagin D, Al Mukaddam M, Pignolo RJ. Acute and chronic rapamycin use in patients with Fibrodysplasia Ossificans Progressiva: A report of two cases. Bone 2018; 109:281-284. [PMID: 29241828 DOI: 10.1016/j.bone.2017.12.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 12/10/2017] [Indexed: 12/28/2022]
Abstract
Fibrodysplasia Ossificans Progressiva (FOP) is an ultrarare genetic disorder of progressive, disabling heterotopic ossification for which there is presently no definitive treatment. Several recent studies in genetic mouse models of FOP support involvement of the mechanistic target of rapamycin complex 1 (mTORC1) pathway in the pathophysiology of FOP and propose the repurposed use of rapamycin, an inhibitor of mTORC1 signaling in clinical trials for the management of FOP. Here we report two patients with the classic FOP mutation who received rapamycin-one for four months on a compassionate basis for treatment of acute flare-ups of the neck and back that were refractory to corticosteroid therapy-and the other for 18years for chronic immunosuppression following liver transplantation for intercurrent cytomegalovirus infection. In both patients, FOP progressed despite the use of rapamycin. This report highlights the real-world use of rapamycin in two FOP patients and provides insight into the use of rapamycin in clinical trials for the management of FOP.
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Affiliation(s)
- Frederick S Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States; Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States.
| | - Leonid Zeitlin
- Department of Medicine, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, University of Tel Aviv, 6 Weizmann St, 64239 Tel Aviv, Israel.
| | - Stephen P Dunn
- Department of Surgery, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE 19803, United States.
| | - Shira Benor
- Department of Medicine, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, University of Tel Aviv, 6 Weizmann St, 64239 Tel Aviv, Israel.
| | - David Hagin
- Department of Medicine, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, University of Tel Aviv, 6 Weizmann St, 64239 Tel Aviv, Israel.
| | - Mona Al Mukaddam
- Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States.
| | - Robert J Pignolo
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, United States.
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27
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Lees-Shepard JB, Goldhamer DJ. Stem cells and heterotopic ossification: Lessons from animal models. Bone 2018; 109:178-186. [PMID: 29409971 PMCID: PMC5866227 DOI: 10.1016/j.bone.2018.01.029] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 01/22/2018] [Accepted: 01/24/2018] [Indexed: 12/21/2022]
Abstract
Put most simply, heterotopic ossification (HO) is the abnormal formation of bone at extraskeletal sites. HO can be classified into two main subtypes, genetic and acquired. Acquired HO is a common complication of major connective tissue injury, traumatic central nervous system injury, and surgical interventions, where it can cause significant pain and postoperative disability. A particularly devastating form of HO is manifested in the rare genetic disorder, fibrodysplasia ossificans progressiva (FOP), in which progressive heterotopic bone formation occurs throughout life, resulting in painful and disabling cumulative immobility. While the central role of stem/progenitor cell populations in HO is firmly established, the identity of the offending cell type(s) remains to be conclusively determined, and little is known of the mechanisms that direct these progenitor cells to initiate cartilage and bone formation. In this review, we summarize current knowledge of the cells responsible for acquired HO and FOP, highlighting the strengths and weaknesses of animal models used to interrogate the cellular origins of HO.
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Affiliation(s)
- John B Lees-Shepard
- Department of Molecular & Cell Biology, University of Connecticut Stem Cell Institute, University of Connecticut, Storrs, CT 06269, United States
| | - David J Goldhamer
- Department of Molecular & Cell Biology, University of Connecticut Stem Cell Institute, University of Connecticut, Storrs, CT 06269, United States.
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28
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Qi Z, Luan J, Zhou X, Cui Y, Han J. Fibrodysplasia ossificans progressiva: Basic understanding and experimental models. Intractable Rare Dis Res 2017; 6:242-248. [PMID: 29259851 PMCID: PMC5735276 DOI: 10.5582/irdr.2017.01055] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Fibrodysplasia ossificans progressive (FOP) is an extremely rare autosomal dominant disorder characterized by congenital malformations of the great toes and progressive heterotopic ossification that can induce a disabling second skeleton. Spontaneously occurring flare-ups can cause inflammatory soft tissue to swell, followed by progressive and disabling heterotopic endochondral ossification. FOP is very rare, with an estimated incidence of one case per two million individuals. There is no definitive treatment for FOP, but the longevity of patients with FOP can be extended by early diagnosis and appropriate prevention of flares-up. Some promising treatment strategies and targets have recently been reported. The current review describes the classical phenotype and genotype of FOP, useful methods of diagnosing the condition, therapeutic approaches and commonly used drugs, and experimental models used to study this disease.
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Affiliation(s)
- Zijuan Qi
- School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Science, Ji'nan, China
- Key Laboratory for Rare Disease Research of Shandong Province, Key Laboratory for Biotech Drugs of the Ministry of Health, Shandong Medical Biotechnological Center, Shandong Academy of Medical Sciences, Ji'nan, China
| | - Jing Luan
- Key Laboratory for Rare Disease Research of Shandong Province, Key Laboratory for Biotech Drugs of the Ministry of Health, Shandong Medical Biotechnological Center, Shandong Academy of Medical Sciences, Ji'nan, China
| | - Xiaoyan Zhou
- Key Laboratory for Rare Disease Research of Shandong Province, Key Laboratory for Biotech Drugs of the Ministry of Health, Shandong Medical Biotechnological Center, Shandong Academy of Medical Sciences, Ji'nan, China
| | - Yazhou Cui
- Key Laboratory for Rare Disease Research of Shandong Province, Key Laboratory for Biotech Drugs of the Ministry of Health, Shandong Medical Biotechnological Center, Shandong Academy of Medical Sciences, Ji'nan, China
| | - Jinxiang Han
- Key Laboratory for Rare Disease Research of Shandong Province, Key Laboratory for Biotech Drugs of the Ministry of Health, Shandong Medical Biotechnological Center, Shandong Academy of Medical Sciences, Ji'nan, China
- Address correspondence to: Dr. Jinxiang Han, Key Laboratory for Rare Disease Research of Shandong Province, Key Laboratory for Biotech Drugs of the Ministry of Health, Shandong Medical Biotechnological Center, Shandong Academy of Medical Sciences, Ji'nan, Shandong 250062, China. E-mail:
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