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Alves RJ, Nunes VS, Junior NCDCB, Nakandakare ER, Quintão ECR. Rare genetic cerebrotendinous xanthomatosis (CTX) cases without cholestanol elevation but with prominent cholesterol-rich tendon xanthomas. J Clin Lipidol 2024; 18:e631-e635. [PMID: 38906752 DOI: 10.1016/j.jacl.2024.04.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/09/2024] [Accepted: 04/14/2024] [Indexed: 06/23/2024]
Abstract
Cerebrotendinous xanthomatosis (CTX) is a rare inherited metabolic disease attributed to the mutation of the gene CYP27A1, resulting in sterol 27-hydroxylase deficiency characterized by deposition of cholestanol and cholesterol in several tissues, like the central nervous system and tendons. Furthermore, cataracts, gallstones, diarrhea and premature atherosclerosis have been reported. Nonetheless, clinical development is extremely heterogeneous in CTX. We report here two cases of CTX genetic alteration in the absence of cholestanol elevation in plasma and tendons but with prominent xanthomas. We propose that CTX may not be characteized by increased plasma cholestanol concentration due to alteration in the sterol 27-hydroxylase gene, but is a more complex pathology where there is significant genetic heterogeneity caused by various CYP27A1 mutations.
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Affiliation(s)
- Renato Jorge Alves
- Cardiology Division, Faculty of Medical Science of the Santa Casa of Sao Paulo, Santa Casa Hospital. Dr Cesário Motta Junior street, 112, São Paulo, Brazil (Dr Alves and Junior)
| | - Valéria Sutti Nunes
- Laboratorio de Lipides (LIM10), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR., Av. Dr. Arnaldo 455, room 3305, 01246-000, São Paulo, Brazil (Dr Nunes, Nakandakare and Quintão)
| | - Ney Carter do Carmo Borges Junior
- Cardiology Division, Faculty of Medical Science of the Santa Casa of Sao Paulo, Santa Casa Hospital. Dr Cesário Motta Junior street, 112, São Paulo, Brazil (Dr Alves and Junior)
| | - Edna Regina Nakandakare
- Laboratorio de Lipides (LIM10), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR., Av. Dr. Arnaldo 455, room 3305, 01246-000, São Paulo, Brazil (Dr Nunes, Nakandakare and Quintão)
| | - Eder Carlos Rocha Quintão
- Laboratorio de Lipides (LIM10), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR., Av. Dr. Arnaldo 455, room 3305, 01246-000, São Paulo, Brazil (Dr Nunes, Nakandakare and Quintão).
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Zubarioglu T, Kıykım E, Köse E, Eminoğlu FT, Teke Kısa P, Balcı MC, Özer I, İnci A, Çilesiz K, Canda E, Yazıcı H, Öztürk-Hişmi B, Bulut FD, Dorum S, Akgun A, Yalçın-Çakmaklı G, Kılıç-Yıldırım G, Soyuçen E, Akçalı A, Güneş D, Durmuş A, Gündüz A, Kasapkara ÇS, Göksoy E, Akar HT, Ersoy M, Erdöl Ş, Yıldız Y, Hanağası HA, Arslan N, Aktuğlu-Zeybek Ç. Clinical, biochemical, and molecular insights into Cerebrotendinous Xanthomatosis: A nationwide study of 100 Turkish individuals. Mol Genet Metab 2024; 142:108493. [PMID: 38772327 DOI: 10.1016/j.ymgme.2024.108493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 05/23/2024]
Abstract
OBJECTIVE Cerebrotendinous xanthomatosis (CTX) is an inherited metabolic disorder characterized by progressive neurologic and extraneurologic findings. The aim of this retrospective, descriptive study was to explore the time of presentation and diagnosis, and to expand the phenotype and genotype of CTX, based on a nationwide and comprehensive series of patients in Turkey. METHODS The demographic, clinical, biochemical and genotypic characteristics of the CTX patients were reviewed. Data on molecular analysis, age of onset and diagnosis, diagnostic delay, neurologic and extraneurologic symptomatology, results of plasma cholestanol levels, brain magnetic resonance imaging and electromyography at the time of diagnosis were reviewed. RESULTS 100 confirmed CTX patients from 72 families were included. The mean age at diagnosis was 28.16 ± 14.28 years, and diagnostic delay was 18.39 ± 13.71 years. 36 patients were diagnosed in childhood. Frequency of intention tremor (p = 0.069), peripheral neuropathy (p = 0.234) and psychiatric manifestations (p = 0.396) did not differ between two groups, demonstrating the high rate in pediatric patients. Three adult patients showed a milder phenotype without neurologic involvement. Seven patients had normal plasma cholestanol levels despite neurological impairment. Sequencing of the CYP27A1 gene revealed 25 different variants, with a novel c.671_672del variant not previously described in literature. CONCLUSION Based on the observations of this Turkish CTX cohort, it is emphasized that the true prevalence of CTX is probably underestimated and that it has a wide spectrum of clinical phenotypes even without neurological impairment. In children, abnormal cerebellar findings, peripheral neuropathy and psychiatric findings associated with intellectual disability have been suggested as warning signs to avoid diagnostic delay. In cases of clinical suspicion, molecular analysis is recommended despite normal plasma cholestanol levels, as severe neurologic involvement may occur in CTX patients without elevated cholestanol levels.
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Affiliation(s)
- Tanyel Zubarioglu
- İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Division of Pediatric Nutrition and Metabolism, İstanbul, Turkey.
| | - Ertuğrul Kıykım
- İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Division of Pediatric Nutrition and Metabolism, İstanbul, Turkey
| | - Engin Köse
- Ankara University, Faculty of Medicine, Department of Pediatric Metabolism, Ankara, Turkey; Ankara University Rare Diseases Application and Research Center, Ankara, Turkey
| | - Fatma Tuba Eminoğlu
- Ankara University, Faculty of Medicine, Department of Pediatric Metabolism, Ankara, Turkey; Ankara University Rare Diseases Application and Research Center, Ankara, Turkey
| | - Pelin Teke Kısa
- Dokuz Eylul University Medical Faculty, Division of Pediatric Nutrition and Metabolism, Izmir, Turkey
| | - Mehmet Cihan Balcı
- Istanbul University, Istanbul Medical Faculty Children's Hospital, Division of Nutrition and Metabolism, Istanbul, Turkey
| | - Işıl Özer
- Ondokuz Mayıs University, Faculty of Medicine, Department of Pediatric Metabolism, Samsun, Turkey; Kafkas University, Division of Pediatric Nutrition and Metabolism, Kars, Turkey
| | - Aslı İnci
- Gazi University School of Medicine, Division of Pediatric Nutrition and Metabolism, Ankara, Turkey
| | - Kübra Çilesiz
- Gazi University School of Medicine, Division of Pediatric Nutrition and Metabolism, Ankara, Turkey
| | - Ebru Canda
- Ege University Medical Faculty, Division of Pediatric Nutrition and Metabolism, İzmir, Turkey
| | - Havva Yazıcı
- Ege University Medical Faculty, Division of Pediatric Nutrition and Metabolism, İzmir, Turkey
| | - Burcu Öztürk-Hişmi
- Marmara University School of Medicine, Division of Pediatric Metabolic Disorders, İstanbul, Turkey
| | - Fatma Derya Bulut
- Cukurova University Medical Faculty, Division of Pediatric Metabolism and Nutrition, Adana, Turkey
| | - Sevil Dorum
- Health Sciences University, Bursa Yuksek Ihtisas Training and Research Hospital, Division of Pediatric Nutrition and Metabolism, Bursa, Turkey
| | - Abdurrahman Akgun
- Firat University, School of Medicine, Department of Pediatrics, Division of Pediatric Metabolic Diseases, Elazığ, Turkey
| | - Gül Yalçın-Çakmaklı
- Hacettepe University Faculty of Medicine, Department of Neurology, Ankara, Turkey
| | - Gonca Kılıç-Yıldırım
- Eskisehir Osmangazi University, Faculty of Medicine, Pediatric Nutrition and Metabolism Unit, Eskişehir, Turkey
| | - Erdoğan Soyuçen
- Akdeniz University Faculty of Medicine, Department of Pediatrics, Division of Inherited Pediatric Metabolic Diseases, Antalya, Turkey
| | - Aylin Akçalı
- Gaziantep University Faculty of Medicine, Department of Neurology, Gaziantep, Turkey
| | - Dilek Güneş
- Bağcılar Training and Research Hospital, Division of Inborn Metabolic Disease, İstanbul, Turkey
| | - Aslı Durmuş
- Kanuni Training and Research Hospital, Division of Pediatric Metabolism, Trabzon, Turkey
| | - Ayşegül Gündüz
- İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Department of Neurology, İstanbul, Turkey
| | - Çiğdem Seher Kasapkara
- Ankara Yıldırım Beyazıt University, Ankara Bilkent City Hospital, Department of Pediatric Metabolism, Ankara, Turkey
| | - Emine Göksoy
- Adnan Menderes University Medical Faculty, Division of Pediatric Metabolism, Aydın, Turkey
| | - Halil Tuna Akar
- Ankara Etlik City Hospital, Pediatric Metabolic Diseases Unit, Ankara, Turkey
| | - Melike Ersoy
- Health Sciences University, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Pediatrics, Division of Pediatric Metabolic Diseases, İstanbul, Turkey
| | - Şahin Erdöl
- Bursa Uludag University Faculty of Medicine, Department of Pediatrics, Division of Metabolism, Bursa, Turkey
| | - Yılmaz Yıldız
- Hacettepe University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Metabolism, Ankara, Turkey
| | | | - Nur Arslan
- Dokuz Eylul University Medical Faculty, Division of Pediatric Nutrition and Metabolism, Izmir, Turkey
| | - Çiğdem Aktuğlu-Zeybek
- İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Division of Pediatric Nutrition and Metabolism, İstanbul, Turkey
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DeBarber AE, Schaefer EJ, Do J, Ray JW, Larson A, Redder S, Fowler M, Duell PB. Genetically and clinically confirmed atypical cerebrotendinous xanthomatosis with normal cholestanol and marked elevations of bile acid precursors and bile alcohols. J Clin Lipidol 2024; 18:e465-e476. [PMID: 38637260 DOI: 10.1016/j.jacl.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 02/07/2024] [Accepted: 03/13/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive lipid disorder. Affected patients often remain undiagnosed until the age of 20-30 years, when they have already developed significant neurologic disease that may not be reversible. An elevated plasma cholestanol concentration has been accepted as a diagnostic criterion for CTX for decades. OBJECTIVE Full biochemical characterization was performed for three genetically and clinically confirmed atypical CTX cases with normal plasma cholestanol levels. METHODS Clinical assessment and genetic/biochemical testing for patients with CTX was performed by their physician providing routine standard of care. RESULTS We report three new atypical CTX cases with large extensor tendon xanthomas but normal plasma cholestanol levels. All three cases had marked elevations of bile acid precursors and bile alcohols in plasma and urine that decreased on treatment with chenodeoxycholic acid. We also review eight published cases of atypical CTX with normal/near normal circulating cholestanol levels. CONCLUSION The atypical biochemical presentation of these cases provides a diagnostic challenge for CTX, a disorder for which cholestanol has been believed to be a sensitive biomarker. These cases demonstrate measurements of plasma cholestanol alone are insufficient to exclude a diagnosis of CTX. The data presented is consistent with the concept that bile acid precursors and bile alcohols are sensitive biomarkers for atypical CTX with normal cholestanol, and that such testing is indicated, along with CYP27A1 gene analyses, in patients presenting with significant tendon and/or tuberous xanthomas and/or neurologic disease in early adulthood despite normal or near normal cholesterol and cholestanol levels.
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Affiliation(s)
- Andrea E DeBarber
- University Shared Resources, Oregon Health & Science University (OHSU), Portland, OR, United States of America (Dr DeBarber, Ms Redder and Ms Fowler).
| | - Ernst J Schaefer
- Boston Heart Diagnostics/Eurofins Scientific Network, Framingham, MA, United States of America and Department of Medicine, Tufts University School of Medicine, Boston, MA, United States of America (Dr Schaefer)
| | - Jenny Do
- Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, United States of America (Ms Do and Dr Ray)
| | - Joseph W Ray
- Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, United States of America (Ms Do and Dr Ray)
| | - Austin Larson
- University of Colorado School of Medicine, Aurora, CO, United States of America (Dr Larson)
| | - Samantha Redder
- University Shared Resources, Oregon Health & Science University (OHSU), Portland, OR, United States of America (Dr DeBarber, Ms Redder and Ms Fowler)
| | - Maya Fowler
- University Shared Resources, Oregon Health & Science University (OHSU), Portland, OR, United States of America (Dr DeBarber, Ms Redder and Ms Fowler)
| | - P Barton Duell
- Center for Preventive Cardiology, Knight Cardiovascular Institute & Division of Endocrinology, Diabetes & Clinical Nutrition, OHSU, Portland, OR, United States of America (Dr Duell)
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Mochel F. What can pediatricians learn from adult inherited metabolic diseases? J Inherit Metab Dis 2024. [PMID: 38520225 DOI: 10.1002/jimd.12729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 03/02/2024] [Accepted: 03/05/2024] [Indexed: 03/25/2024]
Abstract
The field of inherited metabolic diseases (IMD) has initially emerged and developed over decades in pediatric departments. Still, today, about 50% of patients with IMD are adults, and adult metabolic medicine (AMM) is getting more structured at national and international levels. There are several domains in which pediatricians can learn from AMM. First, long-term evolution of IMD patients, especially those treated since childhood, is critical to determine nutritional and neuropsychiatric outcomes in adults so that these outcomes can be better monitored, and patient care adjusted as much as possible from childhood. Conversely, the observation of attenuated phenotypes in adults of IMD known to present with severe phenotypes in children calls for caution in the development of newborn screening programs and, more largely, in the interpretation of next-generation sequencing data. Third, it is important for pediatricians to be familiar with adult-onset IMD as they expand our understanding of metabolism, including in children, such as oxysterols and glycogen metabolism. Last, the identification of common molecular and cellular mechanisms in neurodevelopment and neurodegeneration opens the way to synergistic therapeutic developments that will benefit both fields of pediatric and adult medicine. Overall, these observations underline the need of strong interdisciplinarity between pediatricians and adult specialists for the diagnosis and the treatment of IMD well beyond the issues of patient transition from pediatric to adult medicine.
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Affiliation(s)
- Fanny Mochel
- AP-HP, Pitié-Salpêtrière University Hospital, Department of Medical Genetics, Reference Centers for Adult Neurometabolic Diseases and Adult Leukodystrophies, Paris, France
- INSERM U 1127, CNRS UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Paris Brain Institute, ICM, Paris, France
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Köroğlu M, Karakaplan M, Gündüz E, Kesriklioğlu B, Ergen E, Aslantürk O, Özdemir ZM. Cerebrotendinous Xanthomatosis patients with late diagnosed in single orthopedic clinic: two novel variants in the CYP27A1 gene. Orphanet J Rare Dis 2024; 19:53. [PMID: 38336741 PMCID: PMC10858589 DOI: 10.1186/s13023-024-03082-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 02/05/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Cerebrotendinous Xanthomatosis (CTX) is a rare autosomal recessive lipid storage disorder caused by loss of function variants in the CYP27A1 gene which encodes sterol 27-hydroxylase, on chromosome 2q35. Although the symptoms begin commonly in infancy, CTX diagnosis is often delayed. The aim of this study is to review the orthopedic findings of the disease by providing an overview of the clinical features of the disease. It is to raise awareness of this condition for which early diagnosis and treatment are important. METHODS We retrospectively evaluated the clinical, laboratory, radiological, and genetic findings of eight patients from four families who were admitted to our Orthopedics and Traumatology Department between 2017 and 2022 due to bilateral Achilles tendon xanthomas, were found to have high cholestanol and CYP27A1 gene mutations. RESULTS The mean age of patients was 37, and five of them were male. The mean age at the onset of symptoms was 9.25 years. The mean age of initial diagnosis was 33.75 years. Between symptom onset and clinical diagnosis, an average delay of 24.5 years was observed. All patients had bilateral Achilles tendon xanthoma. Notably, a novel variant (c.670_671delAA) in CYP27A1 gene was identified in three patients who also presented with peripheral neuropathy and bilateral pes cavus. One patient had osteoporosis and four patients had osteopenia. Five patients had a history of bilateral cataracts. Furthermore, three of the patients had early-onset chronic diarrhea and three of the patients had ataxia. Two of the patients had epilepsy and seven of the patients had behavior-personality disorder. All patients had low intelligence, but none of them had cardiac disease. CONCLUSION We present the diagnostic process and clinical features which the largest CTX case series ever reported from single orthopedic clinic. We suggest that patients with normal cholesterol levels presenting with xanthoma being genetically analyzed by testing at their serum cholestanol level, and that all siblings of patients diagnosed with CTX be examined.
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Affiliation(s)
- Muhammed Köroğlu
- Orthopaedics and Traumatology Department, Turgut Özal Medical Center, İnönü University Medical School, Malatya, 44280, Turkey
| | - Mustafa Karakaplan
- Orthopaedics and Traumatology Department, Turgut Özal Medical Center, İnönü University Medical School, Malatya, 44280, Turkey.
| | - Enes Gündüz
- Orthopaedics and Traumatology Department, Şarkışla State Hospital, Sivas, Turkey
| | - Betül Kesriklioğlu
- Department of Medical Genetics, Cerrahpaşa Faculty of Medicine, İstanbul University, Istanbul, Turkey
| | - Emre Ergen
- Orthopaedics and Traumatology Department, Turgut Özal Medical Center, İnönü University Medical School, Malatya, 44280, Turkey
| | - Okan Aslantürk
- Orthopaedics and Traumatology Department, Turgut Özal Medical Center, İnönü University Medical School, Malatya, 44280, Turkey
| | - Zeynep Maraş Özdemir
- Department of Radiology, Turgut Özal Medical Center, İnönü University Medical School, Malatya, Turkey
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Tama Viteri FA, Cotán Marín D, Sánchez FAT, Sánchez MAT. Case Report: a novel CYP27A1 gene variant in a patient with cerebrotendinous xanthomatosis with unusual clinical findings. Int J Neurosci 2023:1-9. [PMID: 38153323 DOI: 10.1080/00207454.2023.2300735] [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: 06/08/2023] [Accepted: 12/26/2023] [Indexed: 12/29/2023]
Abstract
PURPOSE/AIM OF THE STUDY Cerebrotendinous xanthomatosis is a disease with important clinical and molecular heterogeneity. CYP27A1 gene was described as the cause of these defects, with more than 50 mutations involved in the disease. The objective of this study was to carry out a genetic study and a clinical description of a patient with unusual clinical manifestation of the disease. MATERIALS AND METHODS DNA sequencing was used for the evaluation of CYP27A1 exon sequences and their intron/exon boundaries. Copy number variants were calculated using a method based on depth of sequencing coverage. In addition, the potential effects of the missense variants were analyzed, and an in-silico protein modeling tool was used. Finally, a patient case description was performed in order to evaluate patient phenotype according to genetic results. RESULTS Patient clinical features indicate the possible presence of a disease milder phenotype. When analyzing the CYP27A1 gene, patient presents a pathogenic variant (p.Arg474Trp) and a variant of unknown significance (p.Met130Ile) that causes a slight modification of the protein functional structure. This variant in homozygosis or double or compound heterozygosis together with other biallelic pathological mutations may be the cause of the clinical phenotype observed in the reported patient. CONCLUSIONS Clinical manifestations of cerebrotendinous xanthomatosis are heterogeneous, and sometimes wrongly suggest the presence of other diseases. Some patients seem to present an "incomplete" phenotype, which could be redefined as a variant of the disease with further studies. The evaluation of new mutations allows for earlier diagnosis and greater effectiveness in its treatment.
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Affiliation(s)
| | | | | | - Marcia A Tama Sánchez
- Facultad de Ciencias Médicas de la Universidad de Guayaquil-Ecuador, Guayaquil, Ecuador
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Genetic Heterogeneity of Familial Hypercholesterolemia: Repercussions for Molecular Diagnosis. Int J Mol Sci 2023; 24:ijms24043224. [PMID: 36834635 PMCID: PMC9961636 DOI: 10.3390/ijms24043224] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/10/2023] Open
Abstract
Genetics of Familial Hypercholesterolemia (FH) is ascribable to pathogenic variants in genes encoding proteins leading to an impaired LDL uptake by the LDL receptor (LDLR). Two forms of the disease are possible, heterozygous (HeFH) and homozygous (HoFH), caused by one or two pathogenic variants, respectively, in the three main genes that are responsible for the autosomal dominant disease: LDLR, APOB and PCSK9 genes. The HeFH is the most common genetic disease in humans, being the prevalence about 1:300. Variants in the LDLRAP1 gene causes FH with a recessive inheritance and a specific APOE variant was described as causative of FH, contributing to increase FH genetic heterogeneity. In addition, variants in genes causing other dyslipidemias showing phenotypes overlapping with FH may mimic FH in patients without causative variants (FH-phenocopies; ABCG5, ABCG8, CYP27A1 and LIPA genes) or act as phenotype modifiers in patients with a pathogenic variant in a causative gene. The presence of several common variants was also considered a genetic basis of FH and several polygenic risk scores (PRS) have been described. The presence of a variant in modifier genes or high PRS in HeFH further exacerbates the phenotype, partially justifying its variability among patients. This review aims to report the updates on the genetic and molecular bases of FH with their implication for molecular diagnosis.
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8
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Pramparo T, Steiner RD, Rodems S, Jenkinson C. Allelic prevalence and geographic distribution of cerebrotendinous xanthomatosis. Orphanet J Rare Dis 2023; 18:13. [PMID: 36650582 PMCID: PMC9843874 DOI: 10.1186/s13023-022-02578-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/20/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Cerebrotendinous xanthomatosis (CTX) is a rare recessive genetic disease characterized by disruption of bile acid synthesis due to inactivation of the CYP27A1 gene. Treatment is available in the form of bile acid replacement. CTX is likely underdiagnosed, and prevalence estimates based on case diagnosis are probably inaccurate. Large population-based genomic databases are a valuable resource to estimate prevalence of rare recessive diseases as an orthogonal unbiased approach building upon traditional epidemiological studies. METHODS We leveraged the Hardy-Weinberg principle and allele frequencies from gnomAD to calculate CTX prevalence. ClinVar and HGMD were used to identify high-confidence pathogenic missense variants and to calculate a disease-specific cutoff. Variant pathogenicity was also assessed by the VarSome implementation of the ACMG/AMP algorithm and the REVEL in silico predictor. RESULTS CTX prevalence estimates were highest in Asians (1:44,407-93,084) and lowest in the Finnish population (1:3,388,767). Intermediate estimates were found in Europeans, Americans, and Africans/African Americans (1:70,795-233,597). The REVEL-predicted pathogenic variants accounted for a greater increase in prevalence estimates for Europeans, Americans, and Africans/African Americans compared with Asians. We identified the most frequent alleles designated pathogenic in ClinVar (p.Gly472Ala, p.Arg395Cys), labeled pathogenic based on sequence consequence (p.Met1?), and predicted to be pathogenic by REVEL (p.Met383Lys, p.Arg448His) across populations. Also, we provide a prospective geographic map of estimated disease distribution based on CYP27A1 variation queries performed by healthcare providers from selected specialties. CONCLUSIONS Prevalence estimates calculated herein support and expand upon existing evidence indicating underdiagnosis of CTX, suggesting that improved detection strategies are needed. Increased awareness of CTX is important for early diagnosis, which is essential for patients as early treatment significantly slows or prevents disease progression.
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Affiliation(s)
- Tiziano Pramparo
- Travere Therapeutics, Inc., 3611 Valley Centre Dr Suite 300, San Diego, CA, 92130, USA.
| | - Robert D. Steiner
- grid.14003.360000 0001 2167 3675Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 USA
| | - Steve Rodems
- Travere Therapeutics, Inc., 3611 Valley Centre Dr Suite 300, San Diego, CA 92130 USA
| | - Celia Jenkinson
- Travere Therapeutics, Inc., 3611 Valley Centre Dr Suite 300, San Diego, CA 92130 USA
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9
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Bonnet JB, Couvert P, Di-Filippo M, Boissiere F, Cristol JP, Sutra T, Cheillan D, Moulin P, Sultan A. Tuberous xanthomatosis is not necessarily associated with increased plasma concentrations of cholestanol in cerebrotendinous xanthomatosis. J Intern Med 2023; 293:121-123. [PMID: 36085581 DOI: 10.1111/joim.13568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jean-Baptiste Bonnet
- UMR 1302, Desbrest Institute of Epidemiology and Public Health, University of Montpellier, INSERM, CHU, Montpellier, France.,Endocrinology-Diabetes-Nutrition Department, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Philippe Couvert
- APHP, Sorbonne University, Pitié-Salpêtrière Hospital, Endocrine and Oncologic Biochemistry, Paris, France.,National Institute for Health and Medical Research (INSERM) UMR_S 1166, Faculty of Medicine Pitie-Salpêtriere, Paris, France.,Sorbonne University, Paris, France
| | - Mathilde Di-Filippo
- Dyslipidemia, Nutritional and Digestive Dysfunctions Unit, Department of Biochemistry and Molecular Biology, Biology and Pathology Center - East, Hospices Civils de Lyon, Bron, France.,CarMeN Laboratory, UMR INSERM U1060/INRA U1397, Claude Bernard Lyon 1 University, Bron, France
| | - Florian Boissiere
- Department of Plastic, Reconstructive and Aesthetic Surgery, Burns and Wound Healing Unit, CHRU Lapeyronie, Montpellier, France
| | - Jean-Paul Cristol
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, M, ontpellier, France.,Department of Biochemistry, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
| | - Thibault Sutra
- Department of Biochemistry, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
| | - David Cheillan
- CarMeN Laboratory, UMR INSERM U1060/INRA U1397, Claude Bernard Lyon 1 University, Bron, France.,Inborn Errors of Metabolism Unit, Department of Biochemistry and Molecular Biology, Biology and Pathology Center - East, Hospices Civils de Lyon, Bron, France
| | - Philippe Moulin
- CarMeN Laboratory, UMR INSERM U1060/INRA U1397, Claude Bernard Lyon 1 University, Bron, France.,Department of Endocrinology, Nutrition and Metabolic Diseases, Hospices Civils de Lyon, Louis Pradel Cardiovascular Hospital, Bron, France
| | - Ariane Sultan
- Endocrinology-Diabetes-Nutrition Department, CHU Montpellier, University of Montpellier, Montpellier, France.,PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, M, ontpellier, France
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Chang YY, Yu CQ, Zhu L. Progressive ataxia of cerebrotendinous xanthomatosis with a rare c.255+1G>T splice site mutation: A case report. World J Clin Cases 2022; 10:10681-10688. [PMID: 36312475 PMCID: PMC9602241 DOI: 10.12998/wjcc.v10.i29.10681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/09/2022] [Accepted: 09/07/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cerebrotendinous xanthomatosis is an autosomal recessive disorder of lipid metabolism caused by the mutation of the CYP27A1 gene encoding sterol 27-hydroxylase, an essential enzyme for the conversion of cholesterol to chenodeoxycholic and cholic acids. Cerebrotendinous xanthomatosis is a rare neurological disease with a wide range of clinical symptoms that are easily misdiagnosed.
CASE SUMMARY Here we report the clinical, biochemical, and molecular characterization of a 33-year-old female patient with cerebrotendinous xanthomatosis. The patient developed ataxia and had the typical symptoms of juvenile cataracts, tendon xanthomata, and progressive nervous system dysfunction. Magnetic resonance imaging of the brain revealed bilateral dentate nucleus lesions and white matter abnormalities. This patient was misdiagnosed for 2 years resulting in severe neurological complications. After 2 years of chenodeoxycholic acid treatment, she still presented with ataxia and dysarthria. The pathogenic sites of CYP27A1 were identified as c.255+1G>T and c.1263+1G>T, which were both caused by shear denaturation.
CONCLUSION Cerebrotendinous xanthomatosis requires a multidisciplinary diagnosis that must be made early to avoid progressive neurological degeneration. c.1263+1G>T is a known mutation, but c.255+1G>T is a rare mutation site.
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Affiliation(s)
- Yue-Yue Chang
- Department of Neurology, The First Affiliated Hospital of Anhui University of Science and Technology, First People’s Hospital of Huainan, Huainan 232007, Anhui Province, China
| | - Chuan-Qing Yu
- Department of Neurology, The First Affiliated Hospital of Anhui University of Science and Technology, First People’s Hospital of Huainan, Huainan 232007, Anhui Province, China
| | - Lei Zhu
- Department of Neurology, The First Affiliated Hospital of Anhui University of Science and Technology, First People’s Hospital of Huainan, Huainan 232007, Anhui Province, China
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Corrigendum. J Intern Med 2022; 291:392. [PMID: 35188310 DOI: 10.1111/joim.13473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hollak CEM. Expanding the clinical spectrum of cerebrotendinous xanthomatosis: Implications for newborn screening, follow-up and treatment. J Intern Med 2021; 290:942-943. [PMID: 33760321 DOI: 10.1111/joim.13276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 02/23/2021] [Indexed: 11/30/2022]
Affiliation(s)
- C E M Hollak
- From the, Department of Internal Medicine / Endocrinology and Metabolism, Academic Medical Center, Amsterdam, the Netherlands
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Badura-Stronka M, Hirschfeld AS, Winczewska-Wiktor A, Budzyńska E, Jakubiuk-Tomaszuk A, Piontek A, Steinborn B, Kozubski W. First case series of Polish patients with cerebrotendinous xanthomatosis and systematic review of cases from the 21st century. Clin Genet 2021; 101:190-207. [PMID: 34689324 DOI: 10.1111/cge.14079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 12/27/2022]
Abstract
Cerebrotendinous xanthomatosis (CTX) is an inborn error of metabolism caused by recessive variants in the cytochrome P450 CYP27A1 gene. CTX is said to manifest with childhood-onset chronic diarrhea and the classic triad of juvenile-onset cataracts, Achilles tendons xanthomas, and progressive ataxia. It is currently one of the few inherited neurometabolic disorders amenable to a specific treatment. The diagnosis may be significantly delayed resulting in permanent neurological impairment. A retrospective review of the clinical characteristics and diagnostic findings in case series of six Polish patients with CTX. Additional retrospective review of symptoms and pathogenic variants of 568 CTX available cases and case series from the past 20 years. To the best of our knowledge, this is the widest review of CTX cases reported in years 2000-2021. We report the largest cohort of Polish patients ever published, with the identification of two hot-spot mutations. During the review of available 568 cases, we found significant differences in the clinical phenotypes and the localization of variants within the gene between Asian and non-Asian populations. These findings may facilitate molecular testing in the Polish and Asian populations. Invariably better screening for CTX and wider awareness is needed.
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Affiliation(s)
- Magdalena Badura-Stronka
- Department of Medical Genetics, Poznan University of Medical Sciences, Poznan, Poland.,Centers for Medical Genetics GENESIS, Poznan, Poland
| | | | | | - Edyta Budzyńska
- Central Teaching Hospital, The Medical University of Lodz, Poland
| | - Anna Jakubiuk-Tomaszuk
- Department of Pediatric Neurology and Rehabilitation, Medical University of Bialystok, Poland.,Medical Genetics Unit, Mastermed Medical Center, Poland
| | - Anita Piontek
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Barbara Steinborn
- Department of Child Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Wojciech Kozubski
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
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