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Belmokhtar KY, Cherkaoui I, Lhousni S, Elidrissi Errahhali M, Elidrissi Errahhali M, Charif M, Boulouiz R, Ouarzane M, Elouali A, Ghanam A, Babakhouya A, Rkain M, Benajiba N, Bellaoui M. Triple-A Syndrome in Morocco: Founder Effect, Age Estimation of the AAAS c.1331+1G>A Variant, and Implications for Genetic Diagnosis. Mol Syndromol 2024; 15:96-103. [PMID: 38585542 PMCID: PMC10996341 DOI: 10.1159/000533894] [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: 06/19/2023] [Accepted: 08/29/2023] [Indexed: 04/09/2024] Open
Abstract
Introduction Triple-A syndrome (Triple-A) is an autosomal recessive disorder characterized by alacrimia, achalasia, and adrenal insufficiency. Several variants on the AAAS gene have been described, and some variants are clustered in particular geographical areas, such as the c.1331+1G>A variant which is very frequent in North Africa. Here, we describe the genetic features of Triple-A in a series of unrelated families from Morocco. Methods Screening for the AAAS c.1331+1G>A variant was performed by direct sequencing or by PCR-RFLP. Haplotype analysis using Single Tandem Repeat (STR) markers flanking AAAS gene was performed in order to evaluate the founder effect and estimate the age of the c.1331+1G>A variant. Results Seven unrelated families with ten individuals clinically diagnosed with Triple-A were evaluated for sequence variations in the AAAS gene. The median age at diagnosis was 3 years, with a range between 2 and 11 years. Molecular analysis revealed that all patients were homozygous for the c.1331+1G>A variant. This variant was not found in 200 healthy controls, indicating that carriers are very rare in the general Moroccan population. Subsequently, STR marker analysis revealed a founder effect and that the most recent common ancestor of Triple-A patients in Morocco would have lived 125 years ago. Conclusion This is the largest series of Triple-A in Morocco. The same AAAS c.1331+1G>A variant was found in all patients, suggesting a founder effect in Morocco which was subsequently confirmed by microsatellite marker analysis. Therefore, this variant should be systematically investigated to diagnose Triple-A in Morocco.
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Affiliation(s)
- Karam Yahya Belmokhtar
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Imane Cherkaoui
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Saida Lhousni
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
- BRO Biobank, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Mounia Elidrissi Errahhali
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
- BRO Biobank, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Manal Elidrissi Errahhali
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
- BRO Biobank, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Majida Charif
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
- BRO Biobank, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
- Genetics and Immuno-Cell Therapy Team, Faculty of Science, University Mohammed Premier, Oujda, Morocco
| | - Redouane Boulouiz
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
- BRO Biobank, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Meryem Ouarzane
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
- BRO Biobank, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Aziza Elouali
- Department of Pediatrics, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Ayad Ghanam
- Department of Pediatrics, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Abdeladim Babakhouya
- Department of Pediatrics, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Maria Rkain
- Department of Pediatrics, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Noufissa Benajiba
- Department of Pediatrics, Mohammed VI University Hospital, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
| | - Mohammed Bellaoui
- Genetics Unit, Medical Sciences Research Laboratory, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
- BRO Biobank, Faculty of Medicine and Pharmacy, University Mohammed Premier, Oujda, Morocco
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Azmoodeh E, Kheirieh A, Mahdavi S, Toufan F, Nazemi S. The first report of a known 4A syndrome patient with suspected manifestations of COVID-19, what was the final outcome? Heliyon 2022; 8:e11766. [PMID: 36440457 PMCID: PMC9675088 DOI: 10.1016/j.heliyon.2022.e11766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 09/01/2022] [Accepted: 11/14/2022] [Indexed: 11/20/2022] Open
Abstract
The present study was performed on a 24-year-old Iranian man referred to Hospital with suspected symptoms of COVID-19, including fever, weakness, and cough. According to medical history, he had Alacrima, esophageal Achalasia, and adrenal insufficiency from childhood. Based on medical records and clinical examinations, the physician suspected 3A syndrome in the patient and requested further examination for MRI, CXR, and COVID-19 RT-PCR test. The result of the COVID-19 RT-PCR test was negative the next day. The patient's CXR showed ground-glass opacity (GGO) and pulmonary fibrosis. Based on images and MRI reports, severe posterior cortical atrophy disproportionate to chronological age and bilateral atrophy of the lacrimal gland were reported. After reviewing and summarizing the records, history, examinations, and Paraclinical tests, the patient was identified as a case of 4A syndrome.
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Affiliation(s)
- Elham Azmoodeh
- School of Medicine, Shahroud University of Medical Sciences, Shahroud, Iran
| | | | - Sepideh Mahdavi
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Toufan
- Department of Internal Medicine, Clinical Research Development Unit, Bahar Hospital, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Sepideh Nazemi
- Department of Internal Medicine, Clinical Research Development Unit, Imam Hossein Hospital, Shahroud University of Medical Sciences, Shahroud, Iran,Corresponding author.
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Savarino E, Bhatia S, Roman S, Sifrim D, Tack J, Thompson SK, Gyawali CP. Achalasia. Nat Rev Dis Primers 2022; 8:28. [PMID: 35513420 DOI: 10.1038/s41572-022-00356-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 02/07/2023]
Abstract
Achalasia is a rare disorder of the oesophageal smooth muscle characterized by impaired relaxation of the lower oesophageal sphincter (LES) and absent or spastic contractions in the oesophageal body. The key pathophysiological mechanism is loss of inhibitory nerve function that probably results from an autoimmune attack targeting oesophageal myenteric nerves through cell-mediated and, possibly, antibody-mediated mechanisms. Achalasia incidence and prevalence increase with age, but the disorder can affect all ages and both sexes. Cardinal symptoms consist of dysphagia, regurgitation, chest pain and weight loss. Several years can pass between symptom onset and an achalasia diagnosis. Evaluation starts with endoscopy to rule out structural causes, followed by high-resolution manometry and/or barium radiography. Functional lumen imaging probe can provide complementary evidence. Achalasia subtypes have management and prognostic implications. Although symptom questionnaires are not useful for diagnosis, the Eckardt score is a simple symptom scoring scale that helps to quantify symptom response to therapy. Oral pharmacotherapy is not particularly effective. Botulinum toxin injection into the LES can temporize symptoms and function as a bridge to definitive therapy. Pneumatic dilation, per-oral endoscopic myotomy and laparoscopic Heller myotomy can provide durable symptom benefit. End-stage achalasia with a dilated, non-functioning oesophagus may require oesophagectomy or enteral feeding into the stomach. Long-term complications can, rarely, include oesophageal cancer, but surveillance recommendations have not been established.
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Affiliation(s)
- Edoardo Savarino
- Gastroenterology Unit, Azienda Ospedale Università di Padova (AOUP), Padua, Italy. .,Department of Surgery, Oncology and Gastroenterology (DiSCOG), University of Padua, Padua, Italy.
| | - Shobna Bhatia
- Department of Gastroenterology, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Sabine Roman
- Hospices Civils de Lyon, Digestive Physiology, Hopital E Herriot, Lyon, France.,Université Lyon 1, Villeurbanne, France.,Inserm U1032, LabTAU, Lyon, France
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
| | - Jan Tack
- Division of Gastroenterology, University Hospital of Leuven, Leuven, Belgium
| | - Sarah K Thompson
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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Chatterjee S, Majumder A. Non-conventional Genetic Basis of Congenital Adrenal Hypoplasia in South Asia. Cureus 2022; 14:e23527. [PMID: 35495001 PMCID: PMC9038574 DOI: 10.7759/cureus.23527] [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] [Accepted: 03/25/2022] [Indexed: 11/06/2022] Open
Abstract
Congenital adrenal hypoplasia or adrenal hypoplasia congenita (AHC) is a rare disorder ascribed to mutations in three genes, namely, the dosage-sensitive sex reversal-adrenal hypoplasia congenita critical region on the X chromosome, gene 1 (DAX-1/NROB1 gene), steroidogenic factor-1 gene (SF-1/NR5A1 gene), and Achalasia-Addisonianism-Alacrima syndrome gene (AAAS gene). Five cases of AHC of local South Asian origin are described here. Golden Helix VarSeq 2.2.0 (Golden Helix Inc., Bozeman, MT, United States), the clinical genomics interpretation and reporting platform, was used for genetic study. No subject had congenital adrenal hyperplasia (CAH). Four male neonates presented with hypoglycemia, and one older female child presented with hyperpigmentation. This girl had a recognized mutation in the AAAS gene, while none of the four male neonates had any of the recognized mutations associated with AHC. Further, none were salt-losing, which is the conventional Western phenotype. Thus, additional, yet unknown, gene(s) must be operative in AHC among South Asian subsets.
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Saha A, Dhar S, Roy S, Ghosh A. Triple-A syndrome: A rare cause of addisonian pigmentation. INDIAN JOURNAL OF PAEDIATRIC DERMATOLOGY 2022. [DOI: 10.4103/ijpd.ijpd_155_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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6
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Alhassoun M, Almakadma AH, Almustanyir S, AlLehibi A, Alotaibi N. Triple A Multisystem Disorder: Allgrove Syndrome. Cureus 2021; 13:e17476. [PMID: 34513526 PMCID: PMC8405170 DOI: 10.7759/cureus.17476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 11/08/2022] Open
Abstract
Allgrove syndrome (AS), also known as triple A syndrome, is an autosomal recessive inherited disorder characterized by a triad of alacrimia, achalasia, and adrenocorticotrophic hormone (ACTH) resistant adrenal insufficiency. We present a case of a 16-year-old male presenting with the classic triad and a homozygous mutation in the Aladin WD Repeat Nucleoporin (AAAS gene). Genetic analysis and detection of AAAS gene mutation is the cornerstone of diagnosis. Delayed detection results in multiple hospital admissions and life-threatening complications. More data and research are needed to aid in expanding the knowledge about Allgrove syndrome in the literature.
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Affiliation(s)
| | | | | | - Abed AlLehibi
- Gastroenterology, King Fahad Medical City, Riyadh, SAU
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7
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Georgiev GA, Gh MS, Romano J, Dias Teixeira KL, Struble C, Ryan DS, Sia RK, Kitt JP, Harris JM, Hsu KL, Libby A, Odrich MG, Suárez T, McKown RL, Laurie GW. Lacritin proteoforms prevent tear film collapse and maintain epithelial homeostasis. J Biol Chem 2020; 296:100070. [PMID: 33187980 PMCID: PMC7948570 DOI: 10.1074/jbc.ra120.015833] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 11/10/2020] [Accepted: 11/13/2020] [Indexed: 12/14/2022] Open
Abstract
Lipids in complex, protein-enriched films at air/liquid interfaces reduce surface tension. In the absence of this benefit, the light refracting and immunoprotective tear film on eyes would collapse. Premature collapse, coupled with chronic inflammation compromising visual acuity, is a hallmark of dry eye disease affecting 7 to 10% of individuals worldwide. Although collapse seems independent of mutation (unlike newborn lung alveoli), selective proteome and possible lipidome changes have been noted. These include elevated tissue transglutaminase and consequent inactivation through C-terminal cross-linking of the tear mitogen lacritin, leading to significant loss of lacritin monomer. Lacritin monomer restores homeostasis via autophagy and mitochondrial fusion and promotes basal tearing. Here, we discover that lacritin monomer C-terminal processing, inclusive of cysteine, serine, and metalloproteinase activity, generates cationic amphipathic α-helical proteoforms. Such proteoforms (using synthetic peptide surrogates) act like alveolar surfactant proteins to rapidly bind and stabilize the tear lipid layer. Immunodepletion of C- but not N-terminal proteoforms nor intact lacritin, from normal human tears promotes loss of stability akin to human dry eye tears. Stability of these and dry eye tears is rescuable with C- but not N-terminal proteoforms. Repeated topical application in rabbits reveals a proteoform turnover time of 7 to 33 h with gradual loss from human tear lipid that retains bioactivity without further processing. Thus, the processed C-terminus of lacritin that is deficient or absent in dry eye tears appears to play a key role in preventing tear film collapse and as a natural slow release mechanism that restores epithelial homeostasis.
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Affiliation(s)
- Georgi A Georgiev
- Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | | | - Jeff Romano
- Department of Cell Biology, University of Virginia, Charlottesville, Virginia, USA
| | | | - Craig Struble
- Drug Metabolism, Covance Laboratories Inc, Madison, Wisconsin, USA
| | - Denise S Ryan
- Warfighter Refractive Eye Surgery Program and Research Center at Fort Belvoir, Fort Belvoir, Virginia, USA
| | - Rose K Sia
- Warfighter Refractive Eye Surgery Program and Research Center at Fort Belvoir, Fort Belvoir, Virginia, USA
| | - Jay P Kitt
- Department of Chemistry, University of Utah, Salt Lake City, Utah, USA
| | - Joel M Harris
- Department of Chemistry, University of Utah, Salt Lake City, Utah, USA
| | - Ku-Lung Hsu
- Department of Chemistry, University of Virginia, Charlottesville, Virginia, USA
| | - Adam Libby
- Department of Chemistry, University of Virginia, Charlottesville, Virginia, USA
| | - Marc G Odrich
- Department of Ophthalmology, University of Virginia, Charlottesville, Virginia, USA
| | - Tatiana Suárez
- Department of Research, Development and Innovation, FAES FARMA, Bizkaia, Spain
| | - Robert L McKown
- Department of Integrated Science and Technology, James Madison University, Harrisonburg, Virginia, USA
| | - Gordon W Laurie
- Department of Cell Biology, University of Virginia, Charlottesville, Virginia, USA; Department of Ophthalmology, University of Virginia, Charlottesville, Virginia, USA; Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia, USA.
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8
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Volkova NI, Davidenko IY, Reshetnikov IB, Brovkina SS. [Allgrove syndrome: how to suspect the problem? Endocrinologists experience]. ACTA ACUST UNITED AC 2020; 66:64-69. [PMID: 33351314 DOI: 10.14341/probl10296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 04/10/2020] [Accepted: 04/11/2020] [Indexed: 11/06/2022]
Abstract
Allgrove syndrome (Alacrimia, Achalasia, Adrenal insufficiency, AAAS) is a rare autosomal recessive multisystem disease characterized by chronic adrenal insufficiency, alacrimia and achalasia of the cardia. This disease is often associated with various neurological disorders, amyotrophy, in such cases, it is named 4A and 5A syndrome, but sometimes there is also 2A syndrom. The occurrence of the disease is due to a mutation in the gene AAAS (12q13), which encodes the protein ALADIN. Here is a clinical observation of a patient with Allgrove syndrome. The patient had a typical clinic: alacrimia, achalasia, adrenal insufficiency, convulsive syndrome. However, a neurological disorder, manifested by convulsive syndrome, passed with time. Despite the full clinical picture, the diagnosis was made only after 14 years. Allgrove syndrome was verified through genetic analysis revealed a pathogenic mutation c.43C>T gene AAAS. Progression of the severity of alacrimia and need of glucocorticoids over time was noted. We shown the difficulty of diagnosis is due to the lack of awareness of clinicians about the disease, the importance of interdisciplinary interaction, as well as the need for follow-up of such patients.
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9
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MaheshKumar K, Mahadevan S, Ramaswamy P. 4th A in a triple A syndrome - A rare case report. J Basic Clin Physiol Pharmacol 2020; 31:jbcpp-2019-0293. [PMID: 32589602 DOI: 10.1515/jbcpp-2019-0293] [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: 10/19/2019] [Accepted: 03/03/2020] [Indexed: 11/15/2022]
Abstract
Objectives AAA (Allgrove) syndrome is a rare genetic disorder characterized by cardinal features of adrenal insufficiency, achalasia, and alacrimia. Case presentation A 21 year girl of known case of Triple A syndrome was referred for the evaluation of autonomic function. She was born full term with developmental delay and abnormal gait. Esophageal manometry study by pneumatic balloon dilatation revealed the presence of achalasia cardia. She had signs of peripheral neuropathy and had episodes of fainting and suspected orthostatic hypotension. Cardiovascular autonomic function and heart rate variability tests were conducted as per Ewing protocol, revealed that the patient had sympathovagal imbalance and sympathetic dominance. Conclusions The presence of autonomic dysfunction adds the 4th A to the Triple A syndrome (Adrenal insufficiency, Achalasia, Alacrimia and Autonomic dysfunction). Noninvasive autonomic function tests are recommended for Triple A syndrome patients to reduce the morbidity associated with autonomic dysfunction.
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Affiliation(s)
- K MaheshKumar
- Department of Biochemistry and Physiology, Government Yoga and Naturopathy Medical College and Hospital, Chennai, Tamil Nadu, India
| | - Shriraam Mahadevan
- Department of Endocrinology, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, Tamil Nadu, India
| | - Padmavathi Ramaswamy
- Department of Physiology, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, Tamil Nadu, India
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Lu C, Lee TA, Pan DH, Pereira EM, Zhou P. Clinical Course of a Unique Case of Allgrove Syndrome and Challenges of Hypoglycemia Management. AACE Clin Case Rep 2019; 5:e357-e361. [DOI: 10.4158/accr-2019-0210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 07/09/2019] [Indexed: 11/15/2022] Open
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Flokas ME, Tomani M, Agdere L, Brown B. Triple A syndrome (Allgrove syndrome): improving outcomes with a multidisciplinary approach. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2019; 10:99-106. [PMID: 31695556 PMCID: PMC6718240 DOI: 10.2147/phmt.s173081] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 07/11/2019] [Indexed: 12/22/2022]
Abstract
Allgrove syndrome or triple A (3A) syndrome is a multisystem disorder which classically involves the triad of esophageal achalasia, alacrima, and adrenal insufficiency due to adrenocorticotropin hormone insensitivity. It follows an autosomal recessive pattern of inheritance and is associated with mutations in the AAAS (achalasia–addisonianism–alacrima syndrome) gene. Since its first description in 1978, the knowledge on clinical and genetic characteristics has been expanding; however, the current literature is limited to case reports and case reviews. Early recognition of the syndrome is challenging, given the rarity of the condition and high phenotypic heterogeneity even among members of kin. The coordination of care for these patients requires a multidisciplinary team of specialists, including endocrinologists, neurologists, gastroenterologists, ophthalmologists, developmental specialists, dentists, geneticists, and surgeons. In this review, we aim to summarize the current recommendations for the diagnosis, management, and follow-up of patients with 3A syndrome.
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Affiliation(s)
- Myrto Eleni Flokas
- Department of Pediatrics, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Michael Tomani
- Department of Pediatrics, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Levon Agdere
- Department of Pediatrics, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Brande Brown
- Department of Pediatrics, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
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Bouliari A, Lu X, Persky RW, Stratakis CA. Triple A syndrome: two siblings with a novel mutation in the AAAS gene. Hormones (Athens) 2019; 18:109-112. [PMID: 30612286 PMCID: PMC6447433 DOI: 10.1007/s42000-018-0089-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 11/29/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Triple A syndrome is a rare autosomal recessive disorder caused by mutations in the AAAS gene on chromosome 12q13. Its main clinical features are alacrima, achalasia, and adrenal insufficiency, with most patients also having neurological symptoms and autonomic dysfunction. The neurologic manifestations are less well-understood, especially in children. Here, we examine two siblings who were found to have a novel mutation in the AAAS gene and who were found to have subtle, but important, neurologic findings. DESIGN This is a case report of two siblings. RESULTS We discuss two siblings exhibiting different signs of the disorder including neurologic dysfunction found at varying ages. Genetic analysis revealed that both patients have the same compound heterozygous mutations in the AAAS gene consisting of one novel mutation (c.500 C>A, A167E) and one previously described mutation (c.1331+1G> A/IVS14+1 G>A). A diagnosis of triple A syndrome was reached based on their clinical and genetic findings. CONCLUSIONS The unique characteristic of these two cases is the novel mutation in the AAAS gene, which is likely pathogenic. In addition, they showcase the genotype-phenotype variability of the disease, as well as the importance of early identification of the neurologic abnormalities, which can result in early intervention and possibly improved outcomes.
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Affiliation(s)
- Athanasia Bouliari
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Center Drive, Building 10, Room 1-3330, Bethesda, MD, 20892, USA
| | - Xuexin Lu
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Center Drive, Building 10, Room 1-3330, Bethesda, MD, 20892, USA
| | - Rebecca W Persky
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Center Drive, Building 10, Room 1-3330, Bethesda, MD, 20892, USA.
| | - Constantine A Stratakis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Center Drive, Building 10, Room 1-3330, Bethesda, MD, 20892, USA
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Goyal A, Boro H, Khandelwal D, Khadgawat R. ACTH Resistance Syndrome: An Experience of Three Cases. Indian J Endocrinol Metab 2018; 22:843-847. [PMID: 30766828 PMCID: PMC6330879 DOI: 10.4103/ijem.ijem_501_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The term adrenocorticotropin (ACTH) resistance syndrome is used for a group of rare inherited disorders, which present with primary adrenal insufficiency during childhood. The syndrome includes two disorders inherited in an autosomal recessive fashion - familial glucocorticoid deficiency and triple A syndrome. Herein, we report our experience of three cases with ACTH resistance syndrome, highlighting the approach to diagnosis and management in such patients.
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Affiliation(s)
- Alpesh Goyal
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Hiya Boro
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Khandelwal
- Department of Endocrinology and Metabolism, Maharaja Agrasen Hospital, Punjabi Bagh, New Delhi, India
| | - Rajesh Khadgawat
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
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Leveille E, Gonorazky HD, Rioux MF, Hazrati LN, Ruskey JA, Carnevale A, Spiegelman D, Dionne-Laporte A, Rouleau GA, Yoon G, Gan-Or Z. Triple A syndrome presenting as complicated hereditary spastic paraplegia. Mol Genet Genomic Med 2018; 6:1134-1139. [PMID: 30381913 PMCID: PMC6305671 DOI: 10.1002/mgg3.492] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/26/2018] [Accepted: 10/05/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Hereditary spastic paraplegia (HSP) is a group of rare disorders characterized by spastic paraparesis and other symptoms. Often, other diseases can mimic HSP, which may delay diagnosis and treatment. METHODS Whole exome sequencing was performed in families with clinically suspected HSP without a genetic diagnosis. RESULTS We report three patients from two families who presented with lower limb spasticity, muscular atrophy, and other neurological symptoms, who were clinically diagnosed with complicated HSP. Whole exome sequencing revealed bi-allelic AAAS nonsense mutations; one individual was homozygous for the p.(Arg478*) mutation, and two siblings were homozygous for the p.(Arg286*) mutation, leading to the diagnosis of triple A syndrome. This rare syndrome is typically characterized by a triad of symptoms: achalasia, adrenal insufficiency, and alacrima, and is often accompanied by other neurological abnormalities. CONCLUSIONS Our findings suggest that triple A syndrome should be suspected in complicated HSP patients without a known genetic cause, especially if at least one of the main triad of triple A syndrome symptoms is present.
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Affiliation(s)
- Etienne Leveille
- Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Hernan D Gonorazky
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Marie-France Rioux
- Department of Neurology, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Lili-Naz Hazrati
- Department of Laboratory Medicine and Pathobiology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer A Ruskey
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada.,Department of Neurology and Neurosurgery, McGill University, Montréal, Québec, Canada
| | - Amanda Carnevale
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Dan Spiegelman
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada.,Department of Neurology and Neurosurgery, McGill University, Montréal, Québec, Canada
| | - Alexandre Dionne-Laporte
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada.,Department of Neurology and Neurosurgery, McGill University, Montréal, Québec, Canada
| | - Guy A Rouleau
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada.,Department of Neurology and Neurosurgery, McGill University, Montréal, Québec, Canada.,Department of Human Genetics, McGill University, Montréal, Québec, Canada
| | - Grace Yoon
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Division of Clinical and Metabolic Genetics, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ziv Gan-Or
- Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada.,Department of Neurology and Neurosurgery, McGill University, Montréal, Québec, Canada.,Department of Human Genetics, McGill University, Montréal, Québec, Canada
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15
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de Freitas MR, Orsini M, Araújo APDQC, Jr. LJA, Barbosa GM, França MC, Correia L, Bastos VH, Trajano E, Jr. MDS. Allgrove syndrome and motor neuron disease. Neurol Int 2018; 10:7436. [PMID: 30069287 PMCID: PMC6050446 DOI: 10.4081/ni.2018.7436] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 10/26/2017] [Indexed: 11/23/2022] Open
Abstract
Allgrove or triple A syndrome (AS or AAA) is a rare autosomal recessive syndrome with variable phenotype due to mutations in AAAS gene which encodes a protein called ALADIN. Generally, it's characterized by of adrenal insufficiency in consequence of adrenocorticotropic hormone (ACTH) resistance, besides of achalasia, and alacrimia. Neurologic features are varied and have been the subject of several case reports and reviews. A few cases of Allgrove syndrome with motor neuron disease have been already described. A 25-year-old white man, at the age of four, presented slowly progressive distal amyotrophy and weakness, autonomic dysfunction, dysphagia and lack of tears. He suffered later of orthostatic hypotension and erectile dysfunction. He presented distal amytrophy in four limbs, tongue myofasiculations, alacrimia, hoarseness and dysphagia due to achalasia. The ENMG showed generalized denervation with normal conduction velocities. Genetic testing revealed 2 known pathogenic variants in the AAAS gene (c.938T>C and c.1144_1147delTCTG). Our case presented a distal spinal amyotrophy with slow evolution and symptoms and signs of AS with a mutation in AAAS gen. Some cases of motor neuron disease, as ours, may be due to AAS. Early diagnosis is extremely important for symptomatic treatment.
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Affiliation(s)
| | - Marco Orsini
- Applied Science in Health, Severino Sombra University, Vassouras
- Laboratory Mapping and Cerebral Plasticity (LAMPLACE/ UFPI), Federal University of Piauí
| | | | - Luiz João Abraão Jr.
- Department of Gastroenterology, Department of Clinical Medicine (UFRJ), Rio de Janeiro
| | | | | | - Luan Correia
- Laboratory Mapping and Cerebral Plasticity (LAMPLA CE/UFPI), Federal University of Piauí Biomedical Sciences Program, PPGCBM, Federal University of Piauí, Parnaíba;
| | - Victor Hugo Bastos
- Laboratory Mapping and Cerebral Plasticity (LAMPLA CE/UFPI), Federal University of Piauí Biomedical Sciences Program, PPGCBM, Federal University of Piauí, Parnaíba;
| | - Eduardo Trajano
- Applied Science in Health, Severino Sombra University, Vassouras
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16
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Tibussek D, Ghosh S, Huebner A, Schaper J, Mayatepek E, Koehler K. "Crying without tears" as an early diagnostic sign-post of triple A (Allgrove) syndrome: two case reports. BMC Pediatr 2018; 18:6. [PMID: 29334914 PMCID: PMC5769402 DOI: 10.1186/s12887-017-0973-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 12/13/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Triple A syndrome (or Allgrove syndrome) is a rare autosomal recessive disorder characterized by alacrima, achalasia, adrenal insufficiency and autonomic/neurological abnormalities. The majority of cases are caused by mutations in the AAAS gene located on chromosome 12q13. However, the clinical picture as well as genetic testing may be complex since symptomatology is variable and mutations cannot be identified in all clinically diagnosed patients. We present two unrelated patients with triple-A syndrome illustrating the importance of alacrima as an early clinical sign. CASE PRESENTATION A 3.5 year old girl presented with repeated hypoglycaemic myoclonic events. Adrenal insufficiency was diagnosed. In addition, alacrima, obvious since early infancy, was incidentally reported by the mother and finally lead to the clinical diagnosis of triple A syndrome. This was confirmed by positive mutation analysis of the AAAS gene. The second patient, an 8 months old boy was presented because of anisocoria and unilateral optic atrophy. MRI revealed cerebellar vermis hypotrophy. Psychomotor retardation, failure to thrive, and frequent vomiting lead to further diagnostic work-up. Achalasia was diagnosed radiologically. In addition, the mother mentioned absence of tears since birth leading to the clinical diagnosis of triple A syndrome. In contrast to the first cases genetic testing was negative. CONCLUSION These two patients illustrate the heterogeneity of triple A syndrome in both terms, clinical expression and genetic testing. We particularly aim to stress the importance of alacrima, which should be considered as a red flag symptom. Further differential diagnosis is required in every child affected by alacrima.
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Affiliation(s)
- Daniel Tibussek
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - Sujal Ghosh
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Center of Child and Adolescent Health, Heinrich-Heine-University, Düsseldorf, Germany
| | - Angela Huebner
- Department of Pediatrics, Medizinische Fakultät, Technische Universität Dresden, Dresden, Germany
| | - Joerg Schaper
- Department of Diagnostic and Interventional Radiology, Heinrich-Heine-University, Düsseldorf, Germany
| | - Ertan Mayatepek
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Katrin Koehler
- Department of Pediatrics, Medizinische Fakultät, Technische Universität Dresden, Dresden, Germany
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17
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Shah SWH, Butt AK, Malik K, Alam A, Shahzad A, Khan AA. AAA Syndrome, Case Report of a Rare Disease. Pak J Med Sci 2017; 33:1512-1516. [PMID: 29492088 PMCID: PMC5768854 DOI: 10.12669/pjms.336.13684] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 10/25/2017] [Accepted: 11/30/2017] [Indexed: 02/07/2023] Open
Abstract
Triple A (Allgrove) syndrome, an autosomal recessive disease is characterized by achalasia, alacrimia and ACTH-resistant adrenal failure with progressive neurological syndrome including central, peripheral and autonomic nervous system impairment, and mild mental retardation. The triple A syndrome gene, designated AAAS, localized on chromosome 12q 13 encodes for a 546 amino acid protein called ALADIN (Alacrimia-Achlasia-Adrenal Insufficiency and Neurologic disorder). This report relates to two sisters, aged 8 and 12 years, who had vomiting, muscle weakness, alacrimia, excessive fatigue and dysphagia. Abdominal sonography, esophago-gastroduodenoscopy, barium swallow, esophageal manometry, CT scan abdomen and brain, biochemical profiles, as well as neurologic and ophthalmic evaluations were consistent with Allgrove's syndrome. Management consisted of pneumatic balloon dilatation for achalasia and initiation of cortisone therapy with successful resolution of dysphagia and other symptoms.
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Affiliation(s)
- S. Waqar H. Shah
- Dr. S. Waqar H. Shah, MBBS. Department of
Gastroenterology-Hepatology, Shaikh Zayed Medical Complex, Lahore, Pakistan
| | - Arshad K. Butt
- Dr. Arshad K. Butt, FCPS. Department of
Gastroenterology-Hepatology, Shaikh Zayed Medical Complex, Lahore, Pakistan
| | - K. Malik
- Dr. K. Malik, FCPS. Department of
Gastroenterology-Hepatology, Shaikh Zayed Medical Complex, Lahore, Pakistan
| | - Altaf Alam
- Dr. Altaf Alam FRCP. Department of
Gastroenterology-Hepatology, Shaikh Zayed Medical Complex, Lahore, Pakistan
| | - Adnan Shahzad
- Adnan Shahzad, MBBS. Doctors Hospital and Medical Center,
Lahore, Pakistan
| | - Anwaar A. Khan
- Dr. Anwaar A. Khan, M.D, MACP, FACG, FRCP. Doctors Hospital
and Medical Center, Lahore, Pakistan
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18
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Patt H, Koehler K, Lodha S, Jadhav S, Yerawar C, Huebner A, Thakkar K, Arya S, Nair S, Goroshi M, Ganesh H, Sarathi V, Lila A, Bandgar T, Shah N. Phenotype-genotype spectrum of AAA syndrome from Western India and systematic review of literature. Endocr Connect 2017; 6:901-913. [PMID: 29180348 PMCID: PMC5705786 DOI: 10.1530/ec-17-0255] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 10/25/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To study genotype-phenotype spectrum of triple A syndrome (TAS). METHODS Retrospective chart analysis of Indian TAS patients (cohort 1, n = 8) and review of genotyped TAS cases reported in world literature (cohort 2, n = 133, 68 publications). RESULTS Median age at presentation was 4.75 years (range: 4-10) and 5 years (range: 1-42) for cohorts 1 and 2, respectively. Alacrima, adrenal insufficiency (AI), achalasia and neurological dysfunction (ND) were seen in 8/8, 8/8, 7/8 and 4/8 patients in cohort 1, and in 99, 91, 93 and 79% patients in cohort 2, respectively. In both cohorts, alacrima was present since birth while AI and achalasia manifested before ND. Mineralocorticoid deficiency (MC) was uncommon (absent in cohort 1, 12.5% in cohort 2). In cohort 1, splice-site mutation in exon 1 (p.G14Vfs*45) was commonest, followed by a deletion in exon 8 (p.S255Vfs*36). Out of 65 mutations in cohort 2, 14 were recurrent and five exhibited regional clustering. AI was more prevalent, more often a presenting feature, and was diagnosed at younger age in T group (those with truncating mutations) as compared to NT (non-truncating mutations) group. ND was more prevalent, more common a presenting feature, with later age at onset in NT as compared to T group. CONCLUSION Clinical profile of our patients is similar to that of patients worldwide. Alacrima is the earliest and most consistent finding. MC deficiency is uncommon. Some recurrent mutations show regional clustering. p.G14Vfs*45 and p.S255Vfs*36 account for majority of AAAS mutations in our cohort. Phenotype of T group differs from that of NT group and merits future research.
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Affiliation(s)
- Hiren Patt
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Katrin Koehler
- Department of PaediatricsUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - Swati Jadhav
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Chaitanya Yerawar
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Angela Huebner
- Department of PaediatricsUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Kunal Thakkar
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Sneha Arya
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Sandhya Nair
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Manjunath Goroshi
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Hosahithlu Ganesh
- Department of EndocrinologyAJ Institute of Medical sciences, Mangalore, India
| | - Vijaya Sarathi
- Department of EndocrinologyVydehi Institute of Medical Sciences and Research Center, Bengaluru, India
| | - Anurag Lila
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Tushar Bandgar
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Nalini Shah
- Department of EndocrinologySeth G.S. Medical College & KEM Hospital, Mumbai, Maharashtra, India
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19
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Bron AJ, de Paiva CS, Chauhan SK, Bonini S, Gabison EE, Jain S, Knop E, Markoulli M, Ogawa Y, Perez V, Uchino Y, Yokoi N, Zoukhri D, Sullivan DA. TFOS DEWS II pathophysiology report. Ocul Surf 2017; 15:438-510. [PMID: 28736340 DOI: 10.1016/j.jtos.2017.05.011] [Citation(s) in RCA: 1001] [Impact Index Per Article: 143.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 05/26/2017] [Indexed: 12/18/2022]
Abstract
The TFOS DEWS II Pathophysiology Subcommittee reviewed the mechanisms involved in the initiation and perpetuation of dry eye disease. Its central mechanism is evaporative water loss leading to hyperosmolar tissue damage. Research in human disease and in animal models has shown that this, either directly or by inducing inflammation, causes a loss of both epithelial and goblet cells. The consequent decrease in surface wettability leads to early tear film breakup and amplifies hyperosmolarity via a Vicious Circle. Pain in dry eye is caused by tear hyperosmolarity, loss of lubrication, inflammatory mediators and neurosensory factors, while visual symptoms arise from tear and ocular surface irregularity. Increased friction targets damage to the lids and ocular surface, resulting in characteristic punctate epithelial keratitis, superior limbic keratoconjunctivitis, filamentary keratitis, lid parallel conjunctival folds, and lid wiper epitheliopathy. Hybrid dry eye disease, with features of both aqueous deficiency and increased evaporation, is common and efforts should be made to determine the relative contribution of each form to the total picture. To this end, practical methods are needed to measure tear evaporation in the clinic, and similarly, methods are needed to measure osmolarity at the tissue level across the ocular surface, to better determine the severity of dry eye. Areas for future research include the role of genetic mechanisms in non-Sjögren syndrome dry eye, the targeting of the terminal duct in meibomian gland disease and the influence of gaze dynamics and the closed eye state on tear stability and ocular surface inflammation.
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Affiliation(s)
- Anthony J Bron
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Vision and Eye Research Unit, Anglia Ruskin University, Cambridge, UK.
| | - Cintia S de Paiva
- Department of Ophthalmology, Baylor College of Medicine, Houston, TX, USA
| | - Sunil K Chauhan
- Schepens Eye Research Institute & Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Stefano Bonini
- Department of Ophthalmology, University Campus Biomedico, Rome, Italy
| | - Eric E Gabison
- Department of Ophthalmology, Fondation Ophtalmologique Rothschild & Hôpital Bichat Claude Bernard, Paris, France
| | - Sandeep Jain
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Erich Knop
- Departments of Cell and Neurobiology and Ocular Surface Center Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Maria Markoulli
- School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
| | - Yoko Ogawa
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Victor Perez
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA
| | - Yuichi Uchino
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Norihiko Yokoi
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Driss Zoukhri
- Tufts University School of Dental Medicine, Boston, MA, USA
| | - David A Sullivan
- Schepens Eye Research Institute & Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
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20
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Meyer A, Catto-Smith A, Crameri J, Simpson D, Alex G, Hardikar W, Cameron D, Oliver M. Achalasia: Outcome in children. J Gastroenterol Hepatol 2017; 32:395-400. [PMID: 27411173 DOI: 10.1111/jgh.13484] [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] [Accepted: 07/03/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Oesophageal achalasia is well-recognized but relatively rare in children, occasionally appearing as the "triple A" syndrome (with adrenal insufficiency and alacrima). Treatment modalities, as in adult practice, are not curative, often needing further interventions and spurring the search for better management. The outcome for syndromic variants is unknown. We sought to define the efficacy of treatments for children with achalasia with and without triple A syndrome. METHODS We conducted a retrospective analysis of presentation and outcomes for 42 children with achalasia presenting over three decades to a major pediatric referral center. Long term impact of the diagnosis was assessed by questionnaire. RESULTS We identified 42 children including six with triple A syndrome. The median overall age at diagnosis was 10.8 years and median follow-up 1593 days. Initial Heller myotomy in 17 required further interventions in 11 (65%), while initial treatment with botulinum toxin (n = 20) was ultimately followed by myotomy in 17 (85%). Ten out of 35 patients who underwent myotomy required a repeat myotomy (29%). Patients with triple A syndrome developed symptoms earlier, but had delayed diagnosis, were more underweight at diagnosis and at last follow up. Questionnaire results suggested a significant long term deleterious impact on the quality of life of children and their families. CONCLUSION Many children with achalasia relapse after initial treatment, undergoing multiple, different procedures, despite which symptoms persist and impact on quality of life. Symptoms develop earlier in patients with triple A syndrome, but the diagnosis is delayed and this has substantial nutritional impact.
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Affiliation(s)
- Anell Meyer
- Department of Gastroenterology and Clinical Nutrition, Australia.,Department of Pediatrics and Child Health, University of Pretoria, Pretoria, South Africa
| | - Anthony Catto-Smith
- Department of Gastroenterology and Clinical Nutrition, Australia.,Department of Pediatrics, University of Melbourne, Australia.,Murdoch Children's Research Institute, Australia.,Queensland University of Technology and Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Joe Crameri
- Department of Surgery, The Royal Children's Hospital Melbourne, Victoria, Australia
| | - Di Simpson
- Department of Gastroenterology and Clinical Nutrition, Australia
| | - George Alex
- Department of Gastroenterology and Clinical Nutrition, Australia
| | - Winita Hardikar
- Department of Gastroenterology and Clinical Nutrition, Australia.,Department of Pediatrics, University of Melbourne, Australia.,Murdoch Children's Research Institute, Australia
| | - Donald Cameron
- Department of Gastroenterology and Clinical Nutrition, Australia.,Department of Pediatrics, University of Melbourne, Australia.,Murdoch Children's Research Institute, Australia
| | - Mark Oliver
- Department of Gastroenterology and Clinical Nutrition, Australia.,Department of Pediatrics, University of Melbourne, Australia.,Murdoch Children's Research Institute, Australia
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21
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Clinical and Genetic Characterization of 26 Tunisian Patients with Allgrove Syndrome. Arch Med Res 2016; 47:105-10. [PMID: 27133709 DOI: 10.1016/j.arcmed.2016.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 04/11/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIMS Allgrove syndrome is characterized by achalasia, alacrima, and adrenal insufficiency as well as being associated with progressive neurological signs. This is an autosomal recessive disorder due to mutations in the AAAS gene located on chromosome 12q13. The AAAS gene encodes a protein of 546 amino acids, ALADIN. Mutations in this genwere reported in families from North Africa and Europe. Our objective is to conduct a clinical, molecular and genetic study of 26 Tunisian patients with Allgrove syndrome. METHODS We report 26 Tunisian patients with between two and four clinical features associated with Allgrove syndrome. Blood samples were collected and isolated DNA derived from subjects was amplified. The entire sequence of the AAAS gene was analyzed by PCR and sequencing. PCR-RFLP method was performed to identify the frequent mutations found. RESULTS Sequencing of the AAAS gene revealed a major homozygous mutation (c.1331+1G>A) in 25 patients and R286X mutation in one patient. The presence of a major mutation in several unrelated affected individuals suggests the presence of a founder effect in Tunisia and allows for a fast and targeted molecular diagnosis. CONCLUSIONS We created an easy and rapid molecular enzymatic protocol based on PCR-RFLP using MvaI restriction enzyme that directly targets this major mutation and can be used for prenatal diagnosis and genetic counseling for Tunisian families at risk. To the best of our knowledge, this is the first major series report of Allgrove syndrome in Tunisia.
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22
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Erginel B, Gün F, Kocaman H, Çelik A, Salman T. Three cases of triple A syndrome (Allgrove syndrome) in pediatric surgeons' view. Acta Chir Belg 2016; 116:119-21. [PMID: 27385299 DOI: 10.1080/00015458.2016.1139835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Triple A syndrome, also known as Allgrove syndrome, is a rare disease, and presents mainly in children. Its cardinal symptoms are achalasia, alacrima, and adrenocorticotropic hormone (ACTH) insensitivity. We report three cases of Triple A syndrome. Our aim is to inform pediatric surgeons about the existence of this rare syndrome and to highlight the need for suspicion of alacrima and ACTH insensitivity in cases of pediatric achalasia. Triple A syndrome should be considered in patients presenting with achalasia. Alacrima should be investigated by a Schirmer test, and adrenal dysfunction should be tested in cases of suspected triple A.
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23
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Dumic M, Putarek NR, Kusec V, Barisic N, Koehler K, Huebner A. Low bone mineral density for age/osteoporosis in triple A syndrome-an overlooked symptom of unexplained etiology. Osteoporos Int 2016; 27:521-6. [PMID: 26243364 DOI: 10.1007/s00198-015-3265-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 07/24/2015] [Indexed: 01/11/2023]
Abstract
UNLABELLED Triple A syndrome (alacrima, achalasia, adrenal failure, progressive neurodegenerative disease) is caused by mutations in the AAAS gene which encodes the protein alacrima achalasia adrenal insufficiency neurologic disorder (ALADIN). Our investigation suggests that low bone mineral density (BMD) for age/osteoporosis could be a common but overlooked symptom of unexplained etiology in this rare multisystemic disease. INTRODUCTION The purpose of this study is to evaluate incidence and etiology of BMD for age/osteoporosis, a possibly overlooked symptom in triple A syndrome. METHODS Dual-energy X-ray absorptiometry (DXA) of the femoral neck, total hip, lumbar spine, and radius, bone turnover markers, minerals, total alkaline phosphatase (ALP), 25-hydroxy vitamin D (25-OHD), 1,25-dihydroxy vitamin D (1,25-OH2D), intact parathyroid hormone (PTH), and adrenal androgens (dehydroepiandrosterone sulfate (DHEAS) and androstenedione) were measured in five male and four female patients. RESULTS At time of diagnosis, low BMD for age was suspected on X-ray in seven of nine patients aged 2-11 years (not performed in two patients); normal levels of minerals and ALP were found in nine patients and low levels of adrenal androgens in eight patients (not measured in one patient). Reevaluation 5-35 years after introduction of 12 mg/m(2)/day hydrocortisone showed low BMD for age in two children, osteopenia in one, and osteoporosis in six adults. Normal levels of minerals, ALP, PTH, 1,25-OH2D, procollagen type 1, crosslaps, and osteocalcin were found in all patients. Low levels of adrenal androgens were found in all and 25OHD deficiency in six patients. Body mass index was <25 % for age and sex in eight of nine patients. CONCLUSION Low BMD for age/osteoporosis in our patients probably is not a result of glucocorticoid therapy but could be the consequence of low level of adrenal androgens, neurological impairment causing physical inactivity, inadequate sun exposure, and protein malnutrition secondary to achalasia. Considering ubiquitous ALADIN expression, low BMD/osteoporosis may be a primary phenotypic feature of the disease. Besides optimizing glucocorticoid dose, physical activity, adequate sun exposure, appropriate nutrition, and vitamin D supplementation, therapy with DHEA should be considered.
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Affiliation(s)
- M Dumic
- Department of Pediatrics, Clinical Hospital Centre Zagreb, University of Zagreb Medical School, Kispaticeva 12, 10000, Zagreb, Croatia.
| | - N R Putarek
- Department of Pediatrics, Clinical Hospital Centre Zagreb, University of Zagreb Medical School, Kispaticeva 12, 10000, Zagreb, Croatia
| | - V Kusec
- Klinik für Kinder-und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - N Barisic
- Department of Pediatrics, Clinical Hospital Centre Zagreb, University of Zagreb Medical School, Kispaticeva 12, 10000, Zagreb, Croatia
| | - K Koehler
- Klinik für Kinder-und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - A Huebner
- Klinik für Kinder-und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
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24
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Li W, Gong C, Qi Z, Wu DI, Cao B. Identification of AAAS gene mutation in Allgrove syndrome: A report of three cases. Exp Ther Med 2015; 10:1277-1282. [PMID: 26622478 PMCID: PMC4578041 DOI: 10.3892/etm.2015.2677] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 07/09/2015] [Indexed: 01/11/2023] Open
Abstract
Allgrove syndrome (AS) is an autosomal recessive congenital disease, caused by mutations in the AAAS gene, and is characterized by the triad of Addison's disease, achalasia and alacrima. The present study describes three newly diagnosed cases of AS, in which genetic analysis of the AAAS gene was used to identify AAAS gene mutations, to enhance the understanding of the pathogenesis and clinical manifestations of AS in the Chinese population. Two of the cases exhibited homozygous mutations of c.771delG (p.Arg258GlyfsX33) in exon 8 and one case exhibited a homozygous mutation of c.1366C>T (p.Q456X) in exon 15. A review of the current literature suggests that the AAAS c.771delG mutation has only been reported in the Chinese population. Genetic analysis of the AAAS gene in Chinese AS patients at a young age may facilitate an earlier diagnosis and the timely initiation of the appropriate treatment, ultimately improving the patient outcome.
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Affiliation(s)
- Wenjing Li
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, Beijing 100045, P.R. China
| | - Chunxiu Gong
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, Beijing 100045, P.R. China
| | - Zhan Qi
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, Beijing 100045, P.R. China
| | - D I Wu
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, Beijing 100045, P.R. China
| | - Bingyan Cao
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, Beijing 100045, P.R. China
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Ikeda M, Hirano M, Shinoda K, Katsumata N, Furutama D, Nakamura K, Ikeda SI, Tanaka T, Hanafusa T, Kitajima H, Kohno H, Nakagawa M, Nakamura Y, Ueno S. Triple A syndrome in Japan. Muscle Nerve 2013; 48:381-6. [PMID: 23861206 DOI: 10.1002/mus.23770] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2012] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Triple A syndrome is an autosomal recessive disease, characterized by esophageal achalasia, alacrima, and adrenal insufficiency, as well as involvement of the central, peripheral, and autonomic nervous systems. This disease mimics amyotrophic lateral sclerosis in some patients. The causative gene encodes ALADIN, a nuclear pore complex (NPC) component. Only 5 patients have been reported in Japan. METHODS We conducted the first nationwide survey of triple A syndrome. Identified mutants were expressed as GFP-fusion proteins in cultured cells. RESULTS Two new patients were identified, and 1 had a novel mutation (p.Ser182fsX19). All mutant proteins tested were mislocalized from NPC to cytoplasm. CONCLUSIONS The most consistent neurological manifestation of triple A syndrome in Japanese patients was progressive bulbospinal muscular atrophy with both upper and lower motor neuron involvement, which mimicked motor neuron disease, similar to that seen in patients in Western countries. The identification of the new patients suggests that more cases are undiagnosed in Japan.
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Affiliation(s)
- Masanori Ikeda
- Department of Neurology, Nara Medical University School of Medicine, Kashihara, Nara, Japan
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Bizzarri C, Benevento D, Terzi C, Huebner A, Cappa M. Triple A (Allgrove) syndrome: an unusual association with syringomyelia. Ital J Pediatr 2013; 39:39. [PMID: 23800107 PMCID: PMC3704905 DOI: 10.1186/1824-7288-39-39] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 06/19/2013] [Indexed: 01/26/2023] Open
Abstract
Triple A (Allgrove) syndrome was first described by Allgrove in 1978 in two pairs of siblings. Since then, about 100 cases have been reported, all of them displaying an autosomal recessive pattern of inheritance. Clinical picture is characterized by achalasia, alacrimia and ACTH-resistant adrenal failure. A progressive neurological syndrome including central, peripheral and autonomic nervous system impairment, and mild mental retardation is often associated. The triple A syndrome gene, designated AAAS, is localized on chromosome 12q13. It consists of 16 exons, encoding for a 546 aminoacid protein called ALADIN (Alacrimia-Achalasia-aDrenal Insufficiency Neurologic disorder). We report on a 13 year-old boy presenting with Addison’s disease, dysphagia, muscle weakness, excessive fatigue and recent onset gait ataxia. The analysis of the AAAS gene revealed a homozygous missense mutation in exon 12. It was a T > G transversion at nucleotide position 1224, resulting in a change of leucine at amino acid position 381 into arginine (Leu381Arg or L381R). Brain appearance was found normal at magnetic resonance imaging (MRI) and functional spectroscopy analysis showed normal levels of the main metabolites. Spine MRI showed a cystic cavity within the spinal cord (syringomyelia), localized between the sixth cervical vertebra and the first thoracic vertebra. Cerebellar tonsils descended 7 mm caudal to foramen magnum, consistently with a mild type 1 Chiari malformation. Mild posterior inter-vertebral disk protrusions were evident between T9 and T10 and between L4 and L5. To our knowledge, this is the first report describing type 1 Chiari malformation and multiple spinal cord abnormalities in a patient with Allgrove syndrome.
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Longitudinal neuropsychological profile in a patient with triple a syndrome. Case Rep Pediatr 2013; 2013:604921. [PMID: 23691407 PMCID: PMC3638496 DOI: 10.1155/2013/604921] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 03/20/2013] [Indexed: 12/26/2022] Open
Abstract
Triple A syndrome is an autosomal recessive disorder characterized by the triad of adrenocorticotropic hormone resistant adrenal insufficiency, achalasia, and alacrima. Our aim was to describe the neuropsychological characteristics and the cooccurring psychopathological and neurological disorders in an Italian male child suffering from Triple A syndrome at the time of admission (T0) and after one year of follow-up (T1). Many difficulties were observed in the motor domain, as well as in manual dexterity and static/dynamic balance domains of the motor task over time. In sharp contrast with previous literature reports on frequent mild cognitive dysfunction in patients with Triple A syndrome, our child did not show any mental retardation. By contrast, he showed an average IQ at T0 with a slight improvement at T1. To our knowledge, this report is the first describing neuropsychological profile and co-occurring psychopathological problems in a child with Triple A syndrome. Considering that the Triple A syndrome is a progressive disorder which can take years to develop the full-blown clinical picture, these patients require periodical medical controls. Moreover, assessment of neuropsychological and psychopathological features should be performed in patients with this disease, in order to underline the variability of this syndrome.
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Papageorgiou L, Mimidis K, Katsani KR, Fakis G. The genetic basis of triple A (Allgrove) syndrome in a Greek family. Gene 2012; 512:505-9. [PMID: 23073554 DOI: 10.1016/j.gene.2012.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Revised: 09/27/2012] [Accepted: 10/08/2012] [Indexed: 02/07/2023]
Abstract
Triple A (or Allgrove) syndrome is an autosomal recessive genetic disorder. Patients typically suffer from chronic adrenal insufficiency due to resistance to ACTH (Addison's disease), achalasia of the cardia, and defective tear formation (alacrima). The syndrome is caused by mutations in the AAAS gene which encodes the protein ALADIN, a constituent of eukaryotic nuclear pore complexes. The multi-systemic nature and variable manifestations of the triple A syndrome often confound its diagnosis and limit our understanding of its exact pathogenesis. We performed mutational screening of the AAAS gene in a Greek family of four individuals, including an affected propositus with typical symptoms of late-onset triple A syndrome. Our results are consistent with an autosomal recessive pattern of inheritance within the family, caused by a functional c.43C>A mutation in exon 1 of the AAAS gene. All members of the family were also homozygous for a silent c.855C>T nucleotide change within exon 9 of the AAAS gene, representing a common single nucleotide polymorphism. The compromising c.43C>A mutation is predicted to cause a p.Gln15Lys amino acid substitution in the ALADIN protein. However, it has been suggested that the functional impact of this mutation may be more severe, causing a shift in the reading frame of AAAS gene via formation of an aberrant premature donor splice site within exon 1. We propose that mutational analysis of the AAAS gene should be considered in adult patients with one or more clinical signs of the disease, as diagnosis of late-onset cases can be ambiguous.
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Affiliation(s)
- Labrini Papageorgiou
- School of Molecular Biology and Genetics, Democritus University of Thrace, Alexandroupolis, Greece
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Capataz Ledesma M, Méndez Pérez P, Rodríguez López R, Galán Gómez E. [Allgrove syndrome (triple A). Finding of a mutation not described in the AAAS gene]. An Pediatr (Barc) 2012; 78:109-12. [PMID: 22824007 DOI: 10.1016/j.anpedi.2012.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 05/16/2012] [Accepted: 06/09/2012] [Indexed: 11/18/2022] Open
Abstract
Allgrove syndrome (triple A) is a rare autosomal recessive disease. The classic triad includes, congenital adrenal insufficiency due to ACTH resistance, achalasia of the cardia and alacrimia. Neurological abnormalities are associated with autonomic neuropathy, sensory and motor defects, deafness, mental retardation, Parkinsonism and dementia. The gene responsible is the ADRACALIN or AAAS encoding a protein called ALADIN. We report a case of a 19 year-old male, assessed when he was 10 years old in our department due to suspected storage disease. Mild mental and language retardation, hypernasal voice, sensory-motor neuropathy with autonomic involvement and signs of spastic paraparesis, alacrimia. gastroesophageal reflux, and achalasia. Molecular studies showed to mutations, the undescribed p.Tyr 19 Cys, and IVS14 +1 G.
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Stratakis CA. "patients can have as many gene variants as they damn well please": why contemporary genetics presents us daily with a version of Hickam's dictum. J Clin Endocrinol Metab 2012; 97:E802-4. [PMID: 22563116 PMCID: PMC3339892 DOI: 10.1210/jc.2012-1650] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
OBJECTIVE The association of adrenocorticotropic hormone (ACTH) insensitivity with achalasia and alacrimia (Allgrove syndrome, 3A) constitutes a rare multisystem disorder. Its evolution is not well known. The aim of this study was to describe clinical and esophageal manometric characteristics and outcomes in Allgrove syndrome. PATIENTS AND METHODS This multicenter retrospective study compared clinical and manometric characteristics at diagnosis and on follow-up of 9 children presenting with 3A (mean age at diagnosis 7.1 years) with those of 9 children with idiopathic achalasia (IA) (mean age at diagnosis 8.3 years). RESULTS At the time of diagnosis, 3 children with 3A presented with no digestive or respiratory signs because they were identified during a family screening; 1 remained asymptomatic 8 years later. ACTH levels were high in patients with 3A. All of the patients with IA were symptomatic at diagnosis. No significant difference was observed when comparing any of the manometric parameters of the first esophageal manometry of 3A with those of IA. Seven children with 3A were operated on using the Heller procedure, completed by pneumatic esophageal dilation in 2 of these 7. One patient with 3A was treated only by nifedipine. Failure of treatment was observed in 3 children with 3A and 1 child with IA, partial success in 4 with 3A and 1 with IA, and total success in 2 with 3A and 7 with IA (P < 0.03). Control manometry showed that in the 3A group, partial success after surgery was always associated with abnormally low or normal lower esophageal sphincter (LES) pressure, whereas failure after surgery was associated with high LES pressure. CONCLUSIONS Our data showed that 3A presented a more severe course than IA despite presymptomatic diagnosis in cases of family screening. The high LES pressure noted in some patients with 3A is suggestive of a peculiar pattern in 3A affecting the LES and the lower part of the esophagus.
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Marom D, Albin A, Schwartz C, Har-Zahav A, Straussberg R, Bartel F, Birk E, Inbar D, Basel-Vanagaite L. X-linked mental retardation with alacrima and achalasia-Triple A syndrome or a new syndrome? Am J Med Genet A 2011; 155A:1959-63. [DOI: 10.1002/ajmg.a.34121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 04/28/2011] [Indexed: 11/07/2022]
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Jung KW, Yoon IJ, Kim DH, Chung JW, Choi KS, Choi KD, Song HJ, Lee GH, Myung SJ, Kim JH, Maskey D, Kim MJ, Jung HY. Genetic evaluation of ALADIN gene in early-onset achalasia and alacrima patients. J Neurogastroenterol Motil 2011; 17:169-73. [PMID: 21602994 PMCID: PMC3093009 DOI: 10.5056/jnm.2011.17.2.169] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 02/09/2011] [Accepted: 02/18/2011] [Indexed: 01/29/2023] Open
Abstract
Background/Aims ALADIN gene has been known to cause achalasia, alacrima, adrenal abnormalities and a progressive neurological syndrome. A considerable proportion of achalasia patients has been known to show alacrima (decreased secretion of tear). However, the genetic mechanism between achalasia and alacrima has not been defined yet. We postulated that ALADIN gene may be involved in the occurrence of early-onset achalasia; thus, we investigated the correlation of ALADIN gene in early-onset achalasia patients. Methods From 1989 to 2007, patients who were diagnosed as primary achalasia before age 35 were enrolled. All of the enrolled patients were asked for (1) blood sampling for DNA, (2) Shirmer test and (3) dysphagia questionnaires. Results The ALADIN gene in exon 1, 2, 10, 11 and 12 from 19 patients was investigated (M:F = 12:7). The mean age of patients at diagnosis was 27 ± 5 (15-35) years old. Eight out of 19 (42%) showed alacrima by the positive Shirmer test. In spite of thorough exam in the genetic study, there was no definite abnormal genetic finding in this study. Conclusions A considerable number of achalasia patients showed alacrima. Due to the limitation of this study, it is difficult to conclude that early-onset achalasia may have significant correlations with the ALADIN gene.
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Affiliation(s)
- Kee Wook Jung
- Asan Digestive Disease Research Institute, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Dumić M, Barišić N, Rojnić-Putarek N, Kušec V, Stanimirović A, Koehler K, Huebner A. Two siblings with triple A syndrome and novel mutation presenting as hereditary polyneuropathy. Eur J Pediatr 2011; 170:393-6. [PMID: 20931227 DOI: 10.1007/s00431-010-1314-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 09/22/2010] [Indexed: 12/14/2022]
Abstract
The clinical and molecular data on triple A syndrome in two siblings (girl 3.5 years and boy 5.5 years at presentation) with early onset of neurological dysfunction are described. Both patients showed delayed developmental milestones and neurological dysfunctions (motor and sensory demyelinating neuropathy, marked hyperreflexia, calves hypothrophy, pes cavus, gait disturbance) in early childhood, when erroneously diagnosed with hereditary polyneuropathy, most likely Charcot-Marie-Tooth disease. After a severe adrenal crisis in the younger sister at the age of 3 years, the older brother aged 5.5 years was also evaluated and latent adrenal insufficiency was discovered. As both of the siblings had alacrima, hyperkeratosis of palms, cutis anserina, and nasal speech, diagnosis of triple A syndrome was considered. Sequencing of the AAAS gene detected a compound heterozygous mutation consisting of a novel mutation p.Ser296Tyr (c.887C>A) in exon 9 and a previously described p.Ser263Pro (c.787T>C) missense mutation in exon 8 in both siblings. In conclusion, triple A syndrome should be considered in patients presenting with early neurological dysfunction and developmental delay. Alacrima as the earliest and most consistent clinical sign should be investigated by Schirmer test. Patients should be regularly tested for adrenal dysfunction to prevent life-threatening adrenal crises.
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Affiliation(s)
- Miroslav Dumić
- Division of Endocrinology, Department of Pediatrics, University Hospital Zagreb, Kišpatićeva 12, 10 000 Zagreb, Croatia.
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Triple A syndrome: 32 years experience of a single centre (1977-2008). Eur J Pediatr 2010; 169:1323-8. [PMID: 20499090 DOI: 10.1007/s00431-010-1222-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Accepted: 05/05/2010] [Indexed: 12/24/2022]
Abstract
Triple A syndrome is an autosomal recessive disorder characterized by alacrima, achalasia, ACTH-resistant adrenal insufficiency, autonomic dysfunction, and neurodegeneration. Mutations in the AAAS gene on chromosome 12q13 encoding the nuclear pore protein ALADIN have been reported in these patients. Over the period 1977-2008 we evaluated ten subjects with the clinical diagnosis of triple A syndrome. Molecular analysis was performed in seven patients and revealed that all except one are compound heterozygotes for two mutations in the AAAS gene. Two novel mutations were detected: c.123+2T>C resulted in splice defect while c.1261_1262insG mutation resulted in a truncated protein (p.V421fs), which most probably is not functional. Genotype-phenotype correlation could not be established. In all our patients, except one sibling of previously diagnosed brother and sister, genetic analysis was performed when at least two symptoms were present, usually alacrima and achalasia. Based on our experience, we recommend that in case of the presence of alacrima and at least one more symptom of triple A syndrome, adrenal function testing and molecular analysis should be performed. In all children with mutation in AAAS gene, regular follow up of adrenal function is necessary to avoid adrenal crisis and start substitution therapy as soon as adrenal insufficiency is noted.
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Nakamura K, Yoshida K, Yoshinaga T, Kodaira M, Shimojima Y, Takei YI, Morita H, Kayanuma K, Ikeda SI. Adult or late-onset triple A syndrome: case report and literature review. J Neurol Sci 2010; 297:85-8. [PMID: 20674935 DOI: 10.1016/j.jns.2010.07.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2010] [Revised: 07/09/2010] [Accepted: 07/14/2010] [Indexed: 12/14/2022]
Abstract
Triple A syndrome is caused by mutations in the gene encoding ALADIN, leading to achalasia, alacrima and addisonism. Neurologic manifestations of the disease include motor neuron disease-like presentations, motor-sensory or autonomic neuropathy, optic atrophy, cerebellar ataxia, Parkinsonism, and mild dementia. We report a 60-year-old Japanese man with triple A syndrome. He was born to non-consanguineous parents. He underwent a surgical operation for achalasia at age 40, and thereafter, he developed a slowly progressive gait disturbance. Neurological examinations at age 60 revealed limb muscle wasting and weakness with pyramidal tract signs, distal-dominant sensory disturbance, optic atrophy, and autonomic dysfunction. Alacrima was detected using Schirmer test. All of these features were consistent with typical triple A syndrome. He lacked adrenal insufficiency that is frequently observed in patients with the classic phenotype of triple A syndrome. His sural nerve biopsy showed a moderate loss of myelinated fibers and hypomyelination. He was homozygous for a missense mutation, p.R155H, in the disease-causing gene, AAAS. Seven patients with genetically-confirmed, adult or late-onset triple A syndrome, including ours, have been reported to date. All the patients showed upper and lower motor neuron signs (100%), while sensory disturbance (29%) and autonomic dysfunction (57%) were less frequent. Careful assessment for alacrima followed by molecular genetic analysis of AAAS should be considered in patients who show a combined phenotype of motor neuron disease and sensory/autonomic disturbance, even in elderly patients.
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Affiliation(s)
- Katsuya Nakamura
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan
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Palka C, Giuliani R, Brancati F, Mohn A, Di Muzio A, Calabrese O, Huebner A, De Grandis D, Chiarelli F, Ferlini A, Stuppia L. Two Italian patients with novel AAAS gene mutation expand allelic and phenotypic spectrum of triple A (Allgrove) syndrome. Clin Genet 2010; 77:298-301. [PMID: 20447142 DOI: 10.1111/j.1399-0004.2009.01348.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
We review the current clinical evaluation and management of the most common esophageal and gastrointestinal motility disorders in children based on the literature and our experience in a pediatric motility center in the United States. The disorders discussed include esophageal achalasia, pre- and post-fundoplication motility disorders, gastroparesis, motility disorders occurring after repair of congenital atresias, motility disorders associated with gastroschisis, chronic intestinal pseudo-obstruction, motility after intestinal transplantation, motility disorders after colonic resection for Hirschsprung's disease, chronic functional constipation, and motility disorders associated with imperforate anus.
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Affiliation(s)
- Cheryl E Gariepy
- Center for Cell and Developmental Biology, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio 43205, USA.
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Yamazumi Y, Kamiya A, Nishida A, Nishihara A, Iemura SI, Natsume T, Akiyama T. The transmembrane nucleoporin NDC1 is required for targeting of ALADIN to nuclear pore complexes. Biochem Biophys Res Commun 2009; 389:100-4. [DOI: 10.1016/j.bbrc.2009.08.096] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Accepted: 08/18/2009] [Indexed: 10/20/2022]
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Elias LLK, Clark AL. The molecular basis of adrenocorticotrophin resistance syndrome. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2009; 88:155-71. [PMID: 20374727 DOI: 10.1016/s1877-1173(09)88005-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Adrenocorticotrophin resistance syndromes comprise familial glucocorticoid deficiency (FGD) and triple A syndrome, which are rare autosomal recessive diseases with distinct clinical features and molecular etiologies. Mutations of melanocortin-2 receptor (MC2R) have been described in segregation with FGD in 25% of patients. More recently melanocortin-2 receptor accessory protein (MRAP), a small single-transmembrane domain protein, was described as an essential protein for the traffic of MC2R and its expression on the plasma membrane. About 20% of FGD patients carry homozygous mutations of MRAP. The ALADIN protein (for alacrima/achalasia/adrenal insufficiency/neurologic disorder) was identified as the molecular basis of triple A syndrome. The elucidation of the genetic basis of the ACTH resistance syndrome has contributed to the better understanding of MC2R function. However, in some patients the molecular etiology is not yet known and awaits further genetic studies.
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Affiliation(s)
- Lucila L K Elias
- Department of Physiology, School of Medicine of Ribeirao Preto, University of Sao Paulo, Sao Paulo, Brazil
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Cho AR, Yang KJ, Bae Y, Bahk YY, Kim E, Lee H, Kim JK, Park W, Rhim H, Choi SY, Imanaka T, Moon S, Yoon J, Yoon SK. Tissue-specific expression and subcellular localization of ALADIN, the absence of which causes human triple A syndrome. Exp Mol Med 2009; 41:381-6. [PMID: 19322026 DOI: 10.3858/emm.2009.41.6.043] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Triple A syndrome is a rare genetic disorder caused by mutations in the achalasia-addisonianism-alacrima syndrome (AAAS) gene which encodes a tryptophan aspartic acid (WD) repeat-containing protein named alacrima-achalasia-adrenal insufficiency neurologic disorder (ALADIN). Northern blot analysis shows that the 2.1 kb AAAS mRNA is expressed in various tissues with stronger expression in testis and pancreas. We show that human ALADIN is a protein with an apparent molecular weight of 60 kDa, and expressed in the adrenal gland, pituitary gland and pancreas. Furthermore, biochemical analysis using anti-ALADIN antibody supports the previous finding of the localization of ALADIN in the nuclear membrane. The mutations S544G and S544X show that alteration of S544 residue affects correct targeting of ALADIN to the nuclear membrane.
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Affiliation(s)
- A Ri Cho
- Department of Research Institute of Molecular Genetics, The Catholic University of Korea, Seoul 137-040, Korea
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Villanueva-Mendoza C, Martínez-Guzmán O, Rivera-Parra D, Zenteno JC. Triple A or Allgrove Syndrome. A Case Report with Ophthalmic Abnormalities and a Novel Mutation in theAAASGene. Ophthalmic Genet 2009; 30:45-9. [DOI: 10.1080/13816810802502962] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Clinical and molecular genetic findings in a 6-year-old Bosnian boy with triple A syndrome. Eur J Pediatr 2009; 168:317-20. [PMID: 18551317 DOI: 10.1007/s00431-008-0758-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2008] [Accepted: 05/06/2008] [Indexed: 12/20/2022]
Abstract
The triple A syndrome is a rare autosomal recessive disease that is characterised by the triad of adrenocorticotropin (ACTH)-resistant adrenal insufficiency, achalasia and alacrima. In most patients, neurological and dermatological abnormalities are associated features. We report on the first Bosnian patient with triple A syndrome. Endocrine investigation confirmed primary adrenal insufficiency at the age of 5.8 years. Two months later, achalasia was diagnosed, and in the presence of alacrima, the patient satisfies the diagnostic criteria of triple A syndrome. In addition, a large number of associated neurological and dermatological features were present in this patient. Moreover, he has dysmorphic facial features, which have not been previously described in triple A syndrome. Triple A syndrome was confirmed by molecular analysis, revealing a nonsense mutation p.W84X in the AAAS gene. The parents are both heterozygous carriers of the mutation. The affected twin brother unfortunately died from hypoglycaemic shock, despite a normal cortisol rise in an ACTH stimulation test. Further, triple A syndrome patients carrying the identical homozygous p.W84X mutation have to be studied to assess a genotype-phenotype relationship for this mutation.
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Huynh T, McGown I, Nyunt O, Cowley D, Harris M, Cotterill AM, Leong GM. A Novel V185DfsX4 Mutation of the AAAS Gene in a 2-year-old Boy with Triple A Syndrome. Clin Pediatr Endocrinol 2009; 18:73-5. [PMID: 24790383 PMCID: PMC4004906 DOI: 10.1297/cpe.18.73] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Accepted: 12/15/2008] [Indexed: 11/08/2022] Open
Affiliation(s)
- Tony Huynh
- Department of Paediatric Endocrinology and Diabetes, Mater Children's Hospital, South Brisbane, Queensland, Australia
| | - Ivan McGown
- Department of Clinical Chemistry, Mater Health Services, South Brisbane, Queensland, Australia
| | - Ohn Nyunt
- Department of Paediatric Endocrinology and Diabetes, Mater Children's Hospital, South Brisbane, Queensland, Australia
| | - David Cowley
- Department of Clinical Chemistry, Mater Health Services, South Brisbane, Queensland, Australia
| | - Mark Harris
- Department of Paediatric Endocrinology and Diabetes, Mater Children's Hospital, South Brisbane, Queensland, Australia
| | - Andrew M Cotterill
- Department of Paediatric Endocrinology and Diabetes, Mater Children's Hospital, South Brisbane, Queensland, Australia
| | - Gary M Leong
- Department of Paediatric Endocrinology and Diabetes, Mater Children's Hospital, South Brisbane, Queensland, Australia
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Collares CVA, Antunes-Rodrigues J, Moreira AC, Franca SN, Pereira LA, Soares MMS, Elias Junior J, Clark AJ, de Castro M, Elias LLK. Heterogeneity in the molecular basis of ACTH resistance syndrome. Eur J Endocrinol 2008; 159:61-8. [PMID: 18426811 DOI: 10.1530/eje-08-0079] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE ACTH resistance syndromes are rare, autosomal, and genetically heterogeneous diseases that include familial glucocorticoid deficiency (FGD) and triple A syndrome. FGD has been shown to segregate with mutations in the gene coding for ACTH receptor (MC2R) or melanocortin 2 receptor accessory protein (MRAP), whereas mutations in the triple A syndrome (AAAS, Allgrove syndrome) gene have been found in segregation with triple A syndrome. We describe the clinical findings and molecular analysis of MC2R, MRAP, and AAAS genes in five Brazilian patients with ACTH resistance syndrome. DESIGN AND METHODS Genomic DNA from patients and their unaffected relatives was extracted from peripheral blood leucocytes and amplified by PCR, followed by automated sequencing. Functional analysis was carried out using Y6 cells expressing wild-type and mutant MC2R. RESULTS All five patients showed low cortisol and elevated plasma ACTH levels. One patient had achalasia and alacrima, besides the symptoms of adrenal insufficiency. The molecular analysis of FGD patients revealed a novel p.Gly116Val mutation in the MC2R gene in one patient and p.Met1Ile mutation in the MRAP gene in another patient. Expression of p.Gly116Val MC2R mutant in Y6 cells revealed that this variant failed to stimulate cAMP production. The analysis of the AAAS gene in the patient with triple A syndrome showed a novel g.782_783delTG deletion. The molecular analysis of DNA from other two patients showed no mutation in MC2R, MRAP, or AAAS gene. CONCLUSIONS In conclusion, the molecular basis of ACTH resistance syndrome is heterogeneous, segregating with genes coding for proteins involved with ACTH receptor signaling/expression or adrenal gland development and other unknown genes.
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Altieri F, Grillo C, Maceroni M, Chichiarelli S. DNA damage and repair: from molecular mechanisms to health implications. Antioxid Redox Signal 2008; 10:891-937. [PMID: 18205545 DOI: 10.1089/ars.2007.1830] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
DNA is subjected to several modifications, resulting from endogenous and exogenous sources. The cell has developed a network of complementary DNA-repair mechanisms, and in the human genome, >130 genes have been found to be involved. Knowledge about the basic mechanisms for DNA repair has revealed an unexpected complexity, with overlapping specificity within the same pathway, as well as extensive functional interactions between proteins involved in repair pathways. Unrepaired or improperly repaired DNA lesions have serious potential consequences for the cell, leading to genomic instability and deregulation of cellular functions. A number of disorders or syndromes, including several cancer predispositions and accelerated aging, are linked to an inherited defect in one of the DNA-repair pathways. Genomic instability, a characteristic of most human malignancies, can also arise from acquired defects in DNA repair, and the specific pathway affected is predictive of types of mutations, tumor drug sensitivity, and treatment outcome. Although DNA repair has received little attention as a determinant of drug sensitivity, emerging knowledge of mutations and polymorphisms in key human DNA-repair genes may provide a rational basis for improved strategies for therapeutic interventions on a number of tumors and degenerative disorders.
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Affiliation(s)
- Fabio Altieri
- Department of Biochemical Sciences, A. Rossi Fanelli, University La Sapienza, Rome, Italy.
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Chang AJ, Kline MM, Currie Y, Perez MO, Hartiala J, Wijesuriya H, Buchanan TA, Watanabe RM, Allayee H. Allgrove syndrome in a Mexican American family is caused by an ancestral mutation derived from North Africa. Clin Genet 2008; 73:385-7. [DOI: 10.1111/j.1399-0004.2008.00965.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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