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Al Rawahi Y, Al Sunaidi O, Al-Masqari M, Al Jamei A, Rahamtalla D, Al-Maawali A. Biallelic variants of the first Kunitz domain of SPINT2 cause a non-syndromic form of congenital diarrhea and tufting enteropathy. Am J Med Genet A 2024; 194:e63474. [PMID: 37960980 DOI: 10.1002/ajmg.a.63474] [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: 07/04/2023] [Revised: 10/08/2023] [Accepted: 11/03/2023] [Indexed: 11/15/2023]
Abstract
Biallelic SPINT2 pathogenic variants cause a syndromic form of congenital diarrhea and enteropathy (OMIM 270420). To date, 35 patients have been reported and all presented with additional extra-intestinal features, apart from one case. We report on a 5-year-old girl who presented early in life with diarrhea and was found to have a novel homozygous variant in SPINT2. Pathological studies confirmed tufting enteropathy, and during her 5 years of life, she has not developed any extra-intestinal features. Molecular analysis detected a homozygous variant (NM_021102.4: c.203A>G (p. [Tyr68Cys]) in SPINT2. This is the first missense variant reported in the first Kunitz domain (KD1) of SPINT2 in humans. In vitro functional studies of this variant confirmed the deleterious effect leading to the loss of inhibitory activity of the intestinal serine proteases. This is the first description of SPINT2-related diarrhea in a patient who lived without long-term total parenteral nutrition. This study expands the clinical and molecular characteristics of SPINT2-related conditions.
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Affiliation(s)
- Yusriya Al Rawahi
- Child Health Department, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Omar Al Sunaidi
- Child Health Department, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Mohammed Al-Masqari
- Department of Histopathology, Royal Hospital, Ministry of Health, Muscat, Oman
| | - Adawiya Al Jamei
- Child Health Department, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Dafalla Rahamtalla
- Child Health Department, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Almundher Al-Maawali
- Department of Genetics, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
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2
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Congenital Tufting Enteropathy, a Rare Cause of Diarrhea and Malnourishment in Arab Child with Genetic and Histopathology Investigations. Case Rep Pediatr 2023; 2023:6301065. [PMID: 36743443 PMCID: PMC9891835 DOI: 10.1155/2023/6301065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 10/03/2022] [Accepted: 01/13/2023] [Indexed: 01/27/2023] Open
Abstract
Congenital tufting enteropathy (CTE), also known as intestinal epithelial dysplasia (IED), is a rare autosomal recessive disorder due to EPCAM gene mutation. It is a rare congenital enteropathy that presents in early infancy as an intractable diarrhea that is independent of breast formula feeding that requires life-long total parental nutrition (TPN) to acquire adequate calories and fluid intake or small bowel transplantation in severe cases. Here, we report a case of intestinal failure due to congenital tufting enteropathy in a 3-year-old girl who presented with loose stools and failure to thrive. This study aims to review the literature about CTE and discuss the clinicopathological aspects and to be able to distinguish it from other causes of congenital diarrheal disorders (CDDs).
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The genetics of monogenic intestinal epithelial disorders. Hum Genet 2022; 142:613-654. [PMID: 36422736 PMCID: PMC10182130 DOI: 10.1007/s00439-022-02501-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/23/2022] [Indexed: 11/27/2022]
Abstract
Monogenic intestinal epithelial disorders, also known as congenital diarrheas and enteropathies (CoDEs), are a group of rare diseases that result from mutations in genes that primarily affect intestinal epithelial cell function. Patients with CoDE disorders generally present with infantile-onset diarrhea and poor growth, and often require intensive fluid and nutritional management. CoDE disorders can be classified into several categories that relate to broad areas of epithelial function, structure, and development. The advent of accessible and low-cost genetic sequencing has accelerated discovery in the field with over 45 different genes now associated with CoDE disorders. Despite this increasing knowledge in the causal genetics of disease, the underlying cellular pathophysiology remains incompletely understood for many disorders. Consequently, clinical management options for CoDE disorders are currently limited and there is an urgent need for new and disorder-specific therapies. In this review, we provide a general overview of CoDE disorders, including a historical perspective of the field and relationship to other monogenic disorders of the intestine. We describe the genetics, clinical presentation, and known pathophysiology for specific disorders. Lastly, we describe the major challenges relating to CoDE disorders, briefly outline key areas that need further study, and provide a perspective on the future genetic and therapeutic landscape.
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Güvenoğlu M, Şimşek-Kiper PÖ, Koşukcu C, Taskiran EZ, Saltık-Temizel İN, Gucer S, Utine E, Boduroğlu K. Homozygous Missense Epithelial Cell Adhesion Molecule Variant in a Patient with Congenital Tufting Enteropathy and Literature Review. Pediatr Gastroenterol Hepatol Nutr 2022; 25:441-452. [PMID: 36451688 PMCID: PMC9679307 DOI: 10.5223/pghn.2022.25.6.441] [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: 04/20/2022] [Revised: 06/28/2022] [Accepted: 09/21/2022] [Indexed: 11/22/2022] Open
Abstract
Congenital diarrheal disorders (CDDs) with genetic etiology are uncommon hereditary intestinal diseases characterized by chronic, life-threatening, intractable watery diarrhea that starts in infancy. CDDs can be mechanistically divided into osmotic and secretory diarrhea. Congenital tufting enteropathy (CTE), also known as intestinal epithelial dysplasia, is a type of secretory CDD. CTE is a rare autosomal recessive enteropathy that presents with intractable neonatal-onset diarrhea, intestinal failure, severe malnutrition, and parenteral nutrition dependence. Villous atrophy of the intestinal epithelium, crypt hyperplasia, and irregularity of surface enterocytes are the specific pathological findings of CTE. The small intestine and occasionally the colonic mucosa include focal epithelial tufts. In 2008, Sivagnanam et al. discovered that mutations in the epithelial cell adhesion molecule (EpCAM, MIM# 185535) were the genetic cause of CTE (MIM# 613217). More than a hundred mutations have been reported to date. Furthermore, mutations in the serine peptidase inhibitor Kunitz type 2 (SPINT2, MIM# 605124) have been linked to syndromic CTE. In this study, we report the case of a 17-month-old male infant with congenital diarrhea. Despite extensive etiological workup, no etiology could be established before admission to our center. The patient died 15 hours after being admitted to our center in a metabolically decompensated state, probably due to a delay in admission and diagnosis. Molecular autopsy with exome sequencing revealed a previously reported homozygous missense variant, c.757G>A, in EpCAM, which was confirmed by histopathological examination.
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Affiliation(s)
- Merve Güvenoğlu
- Department of Pediatric Genetics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | - Can Koşukcu
- Department of Bioinformatics, Institute of Health Sciences, Hacettepe University, Ankara, Turkey
| | - Ekim Z Taskiran
- Department of Medical Genetics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - İnci Nur Saltık-Temizel
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Safak Gucer
- Division of Pediatric Pathology, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Eda Utine
- Department of Pediatric Genetics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Koray Boduroğlu
- Department of Pediatric Genetics, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Gonzalez-Hakspiel LC, Wilches-Cuadros MA, Nausa-Suárez PA, Fernández F, Patiño-Ascencio P, Manrique-Guerrero A, Díaz-Díaz DD, Castro-Rojas CR. Severe congenital diarrhea secondary to tufting enteropathy. Case report. CASE REPORTS 2022. [DOI: 10.15446/cr.v8n1.90883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction: Tufting enteropathy is a rare cause of congenital diarrhea in neonates. It is characterized by the abnormal distribution of epithelial adhesion molecules, which causes enterocytes to shed into the lumen, forming the characteristic tufts.
Case presentation: A 15-day-old female neonate was taken by her parents to the emergency department of a tertiary care hospital due to diarrheal stools she had been experiencing since birth. The patient presented with dehydration, abnormal weight loss, metabolic acidosis, and acute kidney failure. She received treatment with alizapride, loperamide, zinc sulfate, and probiotics, but after 75 days of treatment she was still symptomatic. An upper tract endoscopy and colonoscopy were performed, finding flattening of the villi and lymphoid cells in the lamina propria. However, the symptoms persisted, and she died at the age of ten months. A post-mortem exome sequencing reported tufting enteropathy.
Conclusions. When congenital diarrhea is present, tufting enteropathy should be considered. An early molecular study would allow to evaluate the possibility of performing an intestinal transplant or modifying the treatment to meet the patient’s palliative care needs.
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Montoya-Cerrillo D, Bernieh A, Saad AG. Critical diagnoses in paediatric gastrointestinal diseases. Pathology 2022; 54:195-206. [PMID: 35033374 DOI: 10.1016/j.pathol.2021.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/26/2021] [Accepted: 09/30/2021] [Indexed: 12/11/2022]
Abstract
Gastrointestinal biopsies represent an increasing proportion of the paediatric pathologist's workload, an increase fundamentally due to an expansion of the understanding of the basic clinical, molecular, genetic, and histopathological features of paediatric gastrointestinal disorders. The histological interpretation of endoscopically retrieved gastrointestinal biopsies in children requires a unique set of diagnostic expertise and detailed knowledge of various gastrointestinal disorders that have a predilection for the paediatric population. This article's major role is to highlight the unique problems inherent to paediatric gastrointestinal disorders that require immediate communication with the paediatric surgeon or the gastroenterologist. For this, we tried to cover the most important diseases that a paediatric pathologist might encounter in daily practice. Some of these diseases are relatively rare, such as microvillous inclusion disease and tufting enteropathy, but some are more common such as eosinophilic disorders and inflammatory bowel disease. Awareness of the histopathological features of these diseases, particularly those that are relatively uncommon, is crucial to spare the patient a lengthy and costly evaluation. We made a particular effort to abundantly reference this article should the reader wish to expand on the content of any section.
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Affiliation(s)
| | - Anas Bernieh
- Division of Pathology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Ali G Saad
- Department of Pathology, University of Miami Miller School of Medicine, Miami, FL, USA.
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Goulet O, Pigneur B, Charbit-Henrion F. Congenital enteropathies involving defects in enterocyte structure or differentiation. Best Pract Res Clin Gastroenterol 2022; 56-57:101784. [PMID: 35331396 DOI: 10.1016/j.bpg.2021.101784] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/15/2021] [Accepted: 12/22/2021] [Indexed: 01/31/2023]
Abstract
Congenital enteropathies (CE) are a group of rare inherited diseases with a typical onset early in life. They involve defects in enterocyte structure or differentiation. They can cause a severe condition of intestinal failure (IF). The diagnostic approach is based first on clinical presentation (consanguinity, prenatal expression, polyhydramnios, early neonatal onset, aspect of stools, persistence at bowel rest, associated extra-digestive manifestations….) and histo-pathological analyses. These rare intestinal diseases cause protracted diarrhea that might resolve, for a few, with a dietetic approach. However, protracted or permanent IF may require long term parenteral nutrition and, in limited cases, intestinal transplantation. With the progresses in both clinical nutrition and genetics, many of these CE are nowadays associated with recognized gene mutations. It improved our knowledge and the understanding in the patho-physiology of these diseases, thus, leading potentially to therapeutic perspectives. These review cover most of the early onset CE and excludes the immune related diarrhea.
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Affiliation(s)
- Olivier Goulet
- Division of Paediatric Gastroenterology Hepatology and Nutrition, University Paris-Centre, Hôpital Necker-Enfants Malades, 149, Rue de Sèvres, 75743, PARIS Cedex 15, France.
| | - Bénédicte Pigneur
- Division of Paediatric Gastroenterology Hepatology and Nutrition, University Paris-Centre, Hôpital Necker-Enfants Malades, 149, Rue de Sèvres, 75743, PARIS Cedex 15, France
| | - Fabienne Charbit-Henrion
- Department of Genetics, Hôpital Necker-Enfants Malades, 149, Rue de Sèvres, 75743, PARIS Cedex 15, France
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Ernst J, Hiasat J, Alabek ML, Scanga HL, Motley W, Nischal KK. Expansion of the ophthalmic phenotype of SPINT2-related syndromic congenital sodium diarrhea. Am J Med Genet A 2021; 185:1270-1274. [PMID: 33547739 DOI: 10.1002/ajmg.a.62094] [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: 10/19/2020] [Revised: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 11/08/2022]
Abstract
A 5-year-old girl presented with treatment-refractory dry eye and recurrent episodes of eye pain. She had been previously diagnosed with syndromic congenital sodium diarrhea (SCSD) caused by a pathogenic variant in SPINT2. Her local pediatric ophthalmologist had made the diagnosis of severe dry eye with corneal erosions, based on which, we arranged an eye exam under anesthesia (EUA) and punctal plug placement. Anterior segment optical coherence tomography (OCT) and corneal photographs were taken during the procedure. There are reports describing similar ophthalmic findings in this syndrome. However, to the best of our knowledge, this is the first case report to document OCT imaging and corneal photographs in a patient with SCSD, which we feel expands the ophthalmic phenotype of this rare genetic disorder.
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Affiliation(s)
- Julia Ernst
- Eye Center, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,The Division of Pediatric Ophthalmology, Strabismus and Adult Motility, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Medical University of Warsaw, Warsaw, Poland
| | - Jamila Hiasat
- Eye Center, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,The Division of Pediatric Ophthalmology, Strabismus and Adult Motility, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michelle L Alabek
- Eye Center, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,The Division of Pediatric Ophthalmology, Strabismus and Adult Motility, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hannah L Scanga
- Eye Center, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,The Division of Pediatric Ophthalmology, Strabismus and Adult Motility, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - William Motley
- Division of Pediatric Ophthalmology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Ken K Nischal
- Eye Center, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,The Division of Pediatric Ophthalmology, Strabismus and Adult Motility, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Das B, Sivagnanam M. Congenital Tufting Enteropathy: Biology, Pathogenesis and Mechanisms. J Clin Med 2020; 10:E19. [PMID: 33374714 PMCID: PMC7793535 DOI: 10.3390/jcm10010019] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/17/2020] [Accepted: 12/17/2020] [Indexed: 01/05/2023] Open
Abstract
Congenital tufting enteropathy (CTE) is an autosomal recessive disease of infancy that causes severe intestinal failure with electrolyte imbalances and impaired growth. CTE is typically diagnosed by its characteristic histological features, including villous atrophy, crypt hyperplasia and focal epithelial tufts consisting of densely packed enterocytes. Mutations in the EPCAM and SPINT2 genes have been identified as the etiology for this disease. The significant morbidity and mortality and lack of direct treatments for CTE patients demand a better understanding of disease pathophysiology. Here, the latest knowledge of CTE biology is systematically reviewed, including clinical aspects, disease genetics, and research model systems. Particular focus is paid to the pathogenesis of CTE and predicted mechanisms of the disease as these would provide insight for future therapeutic options. The contribution of intestinal homeostasis, including the role of intestinal cell differentiation, defective enterocytes, disrupted barrier and cell-cell junction, and cell-matrix adhesion, is vividly described here (see Graphical Abstract). Moreover, based on the known dynamics of EpCAM signaling, potential mechanistic pathways are highlighted that may contribute to the pathogenesis of CTE due to either loss of EpCAM function or EpCAM mutation. Although not fully elucidated, these pathways provide an improved understanding of this devastating disease.
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Affiliation(s)
- Barun Das
- Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093, USA;
| | - Mamata Sivagnanam
- Department of Pediatrics, University of California, San Diego, La Jolla, CA 92093, USA;
- Rady Children’s Hospital, San Diego, CA 92123, USA
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