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Sheppard AJ, Paravastu SS, Farhadi F, Donnelly E, Hartley IR, Gafni RI, Saboury B, Collins MT, Roszko KL. Structural and molecular imaging-based characterization of soft tissue and vascular calcification in hyperphosphatemic familial tumoral calcinosis. J Bone Miner Res 2024; 39:1327-1339. [PMID: 39046425 PMCID: PMC11371904 DOI: 10.1093/jbmr/zjae115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 05/16/2024] [Accepted: 07/23/2024] [Indexed: 07/25/2024]
Abstract
Hyperphosphatemic familial tumoral calcinosis (HFTC) is a rare disorder caused by deficient FGF23 signaling and resultant ectopic calcification. Here, we systematically characterized and quantified macro- and micro-calcification in a HFTC cohort using CT and 18F-sodium fluoride PET/CT (18F-NaF PET/CT). Fourier-transform infrared (FTIR) spectroscopy was performed on 4 phenotypically different calcifications from a patient with HFTC, showing the dominant component to be hydroxyapatite. Eleven patients with HFTC were studied with CT and/or 18F-NaF PET/CT. Qualitative review was done to describe the spectrum of imaging findings on both modalities. CT-based measures of volume (eg, total calcific burden and lesion volume) and density (Hounsfield units) were quantified and compared to PET-based measures of mineralization activity (eg, mean standardized uptake values-SUVs). Microcalcification scores were calculated for the vasculature of 6 patients using 18F-NaF PET/CT and visualized on a standardized vascular atlas. Ectopic calcifications were present in 82% of patients, predominantly near joints and the distal extremities. Considerable heterogeneity was observed in total calcific burden per patient (823.0 ± 670.1 cm3, n = 9) and lesion volume (282.5 ± 414.8 cm3, n = 27). The largest lesions were found at the hips and shoulders. 18F-NaF PET offered the ability to differentiate active vs quiescent calcifications. Calcifications were also noted in multiple anatomic locations, including brain parenchyma (50%). Vascular calcification was seen in the abdominal aorta, carotid, and coronaries in 50%, 73%, and 50%, respectively. 18F-NaF-avid, but CT-negative calcification was seen in a 17-year-old patient, implicating early onset vascular calcification. This first systematic assessment of calcifications in a cohort of patients with HFTC has identified the early onset, prevalence, and extent of calcification. It supports 18F-NaF PET/CT as a clinical tool for distinguishing between active and inactive calcification, informing disease progression, and quantification of ectopic and vascular disease burden.
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MESH Headings
- Humans
- Calcinosis/diagnostic imaging
- Calcinosis/pathology
- Calcinosis/genetics
- Female
- Male
- Hyperphosphatemia/diagnostic imaging
- Hyperphosphatemia/pathology
- Hyperphosphatemia/complications
- Hyperphosphatemia/genetics
- Adult
- Positron Emission Tomography Computed Tomography
- Vascular Calcification/diagnostic imaging
- Vascular Calcification/pathology
- Vascular Calcification/metabolism
- Middle Aged
- Fibroblast Growth Factor-23
- Adolescent
- Child
- Molecular Imaging/methods
- Hyperostosis, Cortical, Congenital/diagnostic imaging
- Hyperostosis, Cortical, Congenital/genetics
- Hyperostosis, Cortical, Congenital/pathology
- Hyperostosis, Cortical, Congenital/complications
- Hyperostosis, Cortical, Congenital/metabolism
- Sodium Fluoride
- Young Adult
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Affiliation(s)
- Aaron J Sheppard
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD 20892, United States
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, United States
| | - Sriram S Paravastu
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD 20892, United States
- University of Missouri - Kansas City School of Medicine, Kansas City, MO 64108, United States
| | - Faraz Farhadi
- Department of Radiology and Imaging Sciences, Clinical Center, NIH, Bethesda, MD 20892, United States
- Geisel School of Medicine, Dartmouth, Hanover, NH 03755, United States
- Institute of Nuclear Medicine, Bethesda, MD 20892, United States
| | - Eve Donnelly
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY 14853, United States
| | - Iris R Hartley
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD 20892, United States
| | - Rachel I Gafni
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD 20892, United States
| | - Babak Saboury
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD 20892, United States
- Institute of Nuclear Medicine, Bethesda, MD 20892, United States
| | - Michael T Collins
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD 20892, United States
| | - Kelly L Roszko
- National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD 20892, United States
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Cherian KE, Cherian J, Vinodhini D, Paul TV. Clinical Characteristics, Therapeutic Options, and Outcomes in Hyperphosphatemic Tumoral Calcinosis: A Systematic Review. Calcif Tissue Int 2024; 115:215-228. [PMID: 38951179 DOI: 10.1007/s00223-024-01247-8] [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: 03/18/2024] [Accepted: 06/15/2024] [Indexed: 07/03/2024]
Abstract
This systematic review was performed to understand better the myriad presentations, various therapeutic options, response to therapy, and its clinical outcomes in hyperphosphatemic tumoral calcinosis (HTC). Full texts were selected according to strict inclusion criteria. All case reports of HTC wherein baseline phosphate was measured, treatment offered was mentioned, and information on follow-up and response to therapy that were available were included. A total of 43 of 188 eligible studies (N = 63 patients) met the inclusion criteria. A list of desired data was extracted and graded for methodological quality. A total of 63 individuals (Males = 33) were included from the 43 eligible case studies. The median age of the patients was 18 (IQR 8-32) years. The most frequently involved sites were the hip/gluteal region (34/63; 53.9%) followed by the elbow/forearm (26/63; 41.2%), and the shoulder (18/63; 28.5%). Three patients had conjunctival calcific deposits. The mean (SD) phosphate was 6.9 (1.1) mg/dL. Among the subjects, 36/63 (57.1%) underwent surgical excision with some form of medical therapy. Two patients underwent only surgical excision (2.1%). One patient was maintained on follow-up (1.6%) and 24/63 (38.1%) patients were treated with medical measures. The median (IQR) follow-up duration was 3 (1-9) years. Regression or reduction in lesion size was reported in 19/63 (30.2%) subjects; 20/63 (31.7%) showed progression, 24/63 (38.1%) had features of stable disease, and mortality was reported in 3 patients (4.7%). We report for the first time a detailed description of the clinical and therapeutic response of HTC. A combination of medical measures aimed at lowering serum phosphate appears to be the cornerstone of treatment, although clinical responses may vary.
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Affiliation(s)
| | | | | | - Thomas Vizhalil Paul
- Department of Endocrinology, Christian Medical College, Vellore, Tamil Nadu, 632004, India.
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Fabbriciani G, Colombini A, Messina C, Adami G. Novel genetic mutation associated with hyperphosphatemic familial tumoral calcinosis/hyperostosis-hyperphosphatemia syndrome treated with denosumab: a case report. Reumatismo 2024; 76. [PMID: 38916164 DOI: 10.4081/reumatismo.2024.1687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/02/2024] [Indexed: 06/26/2024] Open
Abstract
In this case report, a novel N-acetylgalactosaminyltransferase 3 homozygous mutation (c.782 G>A; p.R261Q) associated with hyperphosphatemic familial tumoral calcinosis/hyperostosis-hyperphosphatemia syndrome is described. The patient had elbow, pelvis, and lower limb pain and a hard mass in the hip and olecranon regions. Increased levels of inorganic phosphorus (Pi) and C-reactive protein were observed. After treating the patient with conventional drugs, we tested denosumab, which reduced but did not normalize the Pi.
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Affiliation(s)
- G Fabbriciani
- Complex Operative Unit of Medicine, Hospital of Asissi-USL Umbria 1, Assisi.
| | - A Colombini
- Laboratory of Applied Biotechnology in Orthopedics, IRCCS Galeazzi Orthopedic Institute, Milan.
| | - C Messina
- IRCCS Galeazzi Orthopedic Institute, Milan; Department of Biomedical Sciences for Health, University of Milan.
| | - G Adami
- Rheumatology Unit, Integrated University Hospital of Verona, University of Verona.
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Fukumoto S. Tumor-induced osteomalacia. Panminerva Med 2024; 66:188-197. [PMID: 38127062 DOI: 10.23736/s0031-0808.23.05047-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Tumor-induced osteomalacia is one of paraneoplastic syndromes characterized by hypophosphatemia caused by excessive actions of fibroblast growth factor 23 (FGF23). Since the cloning of FGF23 about 20 years ago, more widespread awareness of this disease has been achieved. However, there still remain several difficulties in the management of patients with this disease. In this review, these clinical problems are discussed together with the physiological and pathophysiological functions of FGF23. Personal proposals in the management of patients with suspected patients with tumor-induced osteomalacia are also presented.
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Affiliation(s)
- Seiji Fukumoto
- Department of Diabetes and Endocrinology, Tamaki-Aozora Hospital, Tokushima, Japan -
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Leow MKS, Ang J, Bi X, Koh ET, McFarlane C. Alterations in SAMD9, AHSG, FRG2C, and FGFR4 Genes in a Case of Late-Onset Massive Tumoral Calcinosis. AACE Clin Case Rep 2023; 9:153-157. [PMID: 37736313 PMCID: PMC10509374 DOI: 10.1016/j.aace.2023.05.004] [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] [Received: 10/27/2022] [Revised: 03/29/2023] [Accepted: 05/05/2023] [Indexed: 09/23/2023] Open
Abstract
Background/Objective Tumoral calcinosis (TC) is a rare, arcane, and debilitating disorder of phosphate metabolism manifesting as hard masses in soft tissues. Primary hyperphosphatemic TC has been shown to be caused by pathogenic variants in the genes encoding FGF23, GALNT3, and KLOTHO. We report a case of massive TC mechanistically associated with phosphatonin resistance associated with heterozygous alterations in the sterile alfa motif domain-containing protein-9 gene (SAMD9), alfa 2-Heremans-Schmid glycoprotein gene (AHSG), FSHD region gene 2-family member-C gene (FRG2C), and fibroblast growth factor receptor-4 gene (FGFR4). Case Report A middle-aged Malay woman with systemic sclerosis presented with painful hard lumps of her axillae, lower limbs, and external genitalia. She was eucalcemic with mild hyperphosphatemia associated with reduced urinary phosphate excretion. Magnetic resonance imaging revealed calcified soft tissue masses. Paradoxically, the serum intact FGF23 level increased to 89.6 pg/mL, corroborated by Western blots, which also showed overexpression of sFRP4 and MEPE, consistent with phosphatonin resistance. Discussion Whole genome sequencing identified 2 heterozygous alterations (p.A454T and p.T479M) in SAMD9, 2 heterozygous alterations (p.M248T and p.S256T) in AHSG, a frameshift alteration (p.Arg156fs) in FRG2C, and a heterozygous alteration (p.G388R) in FGFR4, all of which are associated with calcinosis. Nonsynonymous alterations of FRP4 and MEPE were also detected. Conclusion This highlights that the simultaneous occurrence of alterations in several genes critical in phosphate homeostasis may trigger massive TC despite their heterozygosity. These findings should prompt functional studies in cell and animal models to reveal mechanistic insights in the pathogenesis of such crippling mineralization disorders.
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Affiliation(s)
- Melvin Khee Shing Leow
- Singapore Institute for Clinical Sciences (A∗STAR), Brenner Centre for Molecular Medicine, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Cardiovascular and Metabolic Disorders Program, Duke-NUS Medical School, Singapore
- Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore
| | - Joshur Ang
- Singapore Institute for Clinical Sciences (A∗STAR), Brenner Centre for Molecular Medicine, Singapore
| | - Xinyan Bi
- Singapore Institute of Food and Biotechnology Innovation (A∗STAR), Singapore
| | - Ee Tzun Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Craig McFarlane
- Department of Molecular & Cell Biology, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
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6
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Burbelo PD, Ji Y, Iadarola MJ. Advancing Luciferase-Based Antibody Immunoassays to Next-Generation Mix and Read Testing. BIOSENSORS 2023; 13:303. [PMID: 36979515 PMCID: PMC10046223 DOI: 10.3390/bios13030303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 06/18/2023]
Abstract
Antibody measurements play a central role in the diagnosis of many autoimmune and infectious diseases. One antibody detection technology, Luciferase Immunoprecipitation Systems (LIPS), utilizes genetically encoded recombinant luciferase antigen fusion proteins in an immunoglobulin capture format to generate robust antibody measurement with high diagnostic sensitivity and specificity. The LIPS technology has been highly useful in detecting antibodies for research diagnostics and the discovery of new autoantigens. The methodology of the assay requires immunoglobulin binding reagents such as protein A/G beads and washing steps to process the immune complex before antibody levels are measured by light production with a luminometer. Recently, simplified mix and read immunoassays based on split components of the nanoluciferase enzyme in a complementation format have been developed for antibody measurements without requiring immunoglobulin-capturing beads or washing steps. The mix and read immunoassays utilize two or three nanoluciferase fragments which when reconstituted via antigen-specific antibody binding generate a functional enzyme. At present, these split luciferase tests have been developed mainly for detecting SARS-CoV-2 antibodies. Here, we describe the traditional LIPS technology and compare it to the new split luciferase methodologies focusing on their technical features, strengths, limitations, and future opportunities for diagnostic research, and clinical applications.
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Affiliation(s)
- Peter D. Burbelo
- Adeno-Associated Virus Biology Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 202892, USA
| | - Youngmi Ji
- Adeno-Associated Virus Biology Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 202892, USA
| | - Michael J. Iadarola
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, Bethesda, MD 202892, USA
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Shore RM. Disorders of phosphate homeostasis in children, part 2: hypophosphatemic and hyperphosphatemic disorders. Pediatr Radiol 2022; 52:2290-2305. [PMID: 35536416 DOI: 10.1007/s00247-022-05373-z] [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: 09/19/2021] [Revised: 02/07/2022] [Accepted: 04/01/2022] [Indexed: 11/25/2022]
Abstract
Phosphorus, predominantly in the form of inorganic phosphate PO4-3, has many essential physiological functions. In the skeleton, phosphate and calcium form the mineral component and phosphate is also essential in regulating function of skeletal cells. Considerable advances have been made in our understanding of phosphate homeostasis since the recognition of fibroblast growth factor-23 (FGF23) as a bone-derived phosphaturic hormone. This second part of a two-part review of disorders of phosphate homeostasis in children covers hypophosphatemic and hyperphosphatemic disorders that are of interest to the pediatric radiologist, emphasizing, but not limited to, those related to abnormalities of FGF23 signaling.
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Affiliation(s)
- Richard M Shore
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL, 60611, USA.
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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8
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Ashrafzadeh-Kian SL, Ito N, Srivastava T, Garg U, Kato H, Algeciras-Schimnich A, Bornhorst JA. The effect of burosumab on intact and C-terminal FGF23 measurements. Clin Endocrinol (Oxf) 2022. [PMID: 36263608 DOI: 10.1111/cen.14832] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/14/2022] [Accepted: 10/18/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate the effect of CRYSVITA® (burosumab-twza) on FGF23 measurements in an intact and a C-terminal immunoassay. METHODS An intact serum FGF23 (MedFrontier) and a C-terminal plasma FGF23 assay (Immutopics) were used. Serum/plasma pools were spiked to span the burosumab therapeutic range (1.4-11.3 μg/ml) and FGF23 recovery was assessed. Patient serum and plasma samples obtained pre and post-burosumab treatment were evaluated on both assays and compared with corresponding phosphorus measurements RESULTS: Spiking burosumab (1.4-11.3 μg/ml) into sample pools resulted in a dose-dependent negative analytical interference on intact FGF23 measurements and no significant interference for C-terminal FGF23 measurements. However, more than a 500-fold median increase (post- vs. pre-burosumab administration) in in vivo FGF23 concentrations were observed by both assays. CONCLUSIONS Therapeutic concentrations of burosumab result in a negative analytical interference of the intact, but not the C-terminal FGF23 immunoassay. Despite this in vitro analytical interference in the intact assay, relatively large elevations of both intact FGF23 and C-terminal FGF23 measurements were observed in vivo following burosumab administration. Following burosumab administration, FGF23 measurements must be interpreted within the clinical context of the patient and other relevant biomarker results. SUMMARY This article describes a negative analytical interference by burosumab in an intact FGF23 immunoassay. The recovery of C-terminal FGF23 is not significantly affected by the presence of burosumab. In vivo, both assays demonstrate extreme FGF23 elevations in the presence of the drug. Furthermore, the measurement of FGF23 blocked by burosumab is not clinically useful regarding hypophosphataemia.
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Affiliation(s)
| | - Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Tarak Srivastava
- Department of Pediatrics, Section of Nephrology, Children's Mercy Hospital, Missouri, Kansas City, USA
| | - Uttam Garg
- Department of Pathology & Laboratory Medicine, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Hajime Kato
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Joshua A Bornhorst
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Minnesota, Rochester, USA
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9
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Collins MT, Marcucci G, Anders HJ, Beltrami G, Cauley JA, Ebeling PR, Kumar R, Linglart A, Sangiorgi L, Towler DA, Weston R, Whyte MP, Brandi ML, Clarke B, Thakker RV. Skeletal and extraskeletal disorders of biomineralization. Nat Rev Endocrinol 2022; 18:473-489. [PMID: 35578027 DOI: 10.1038/s41574-022-00682-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2022] [Indexed: 12/15/2022]
Abstract
The physiological process of biomineralization is complex and deviation from it leads to a variety of diseases. Progress in the past 10 years has enhanced understanding of the genetic, molecular and cellular pathophysiology underlying these disorders; sometimes, this knowledge has both facilitated restoration of health and clarified the very nature of biomineralization as it occurs in humans. In this Review, we consider the principal regulators of mineralization and crystallization, and how dysregulation of these processes can lead to human disease. The knowledge acquired to date and gaps still to be filled are highlighted. The disorders of mineralization discussed comprise a broad spectrum of conditions that encompass bone disorders associated with alterations of mineral quantity and quality, as well as disorders of extraskeletal mineralization (hyperphosphataemic familial tumoural calcinosis). Included are disorders of alkaline phosphatase (hypophosphatasia) and phosphate homeostasis (X-linked hypophosphataemic rickets, fluorosis, rickets and osteomalacia). Furthermore, crystallopathies are covered as well as arterial and renal calcification. This Review discusses the current knowledge of biomineralization derived from basic and clinical research and points to future studies that will lead to new therapeutic approaches for biomineralization disorders.
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Affiliation(s)
- Michael T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, NIH, Bethesda, MD, USA.
| | - Gemma Marcucci
- Bone Metabolic Diseases Unit, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Hans-Joachim Anders
- Department of Medicine IV, Hospital of the University of Munich, Ludwig-Maximilians University, Munich, Germany
| | - Giovanni Beltrami
- Department Paediatric Orthopedic Oncology, Careggi and Meyer Children Hospital, Florence, Italy
| | - Jane A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Rajiv Kumar
- Departments of Medicine, Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Agnès Linglart
- APHP, Endocrinologie et diabète de l'enfant, Paris, France
| | - Luca Sangiorgi
- Medical Genetics and Skeletal Rare Diseases, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Dwight A Towler
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ria Weston
- Cardiovascular Research Group, Manchester Metropolitan University, Manchester, UK
| | - Michael P Whyte
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children-St Louis, St Louis, MO, USA
- Division of Bone and Mineral Diseases, Department of Internal Medicine, Washington University School of Medicine, St Louis, MO, USA
| | | | - Bart Clarke
- Mayo Clinic Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Rochester, MN, USA
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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Găman MA, Gad MM, Bazarbashi N, Gilkeson R, Gupta A. Incidental Finding of Secondary Tumoral Calcinosis Following Cardiothoracic Surgery: The Role of Multimodality Imaging Including Spectral Detector Computed Tomography. Cureus 2022; 14:e26929. [PMID: 35989838 PMCID: PMC9379215 DOI: 10.7759/cureus.26929] [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: 07/16/2022] [Indexed: 11/25/2022] Open
Abstract
Tumoral calcinosis is a rare syndrome that affects mostly soft tissues. It is characterized by calcium salt deposition in the periarticular soft tissue surrounding bony structures forming slow-growing, seldom asymptomatic masses. This case report describes a 41-year-old male with end-stage renal disease on home hemodialysis, who presented with an unusual rapidly progressive mass overlying the manubrium and suprasternal notch, following recent cardiothoracic surgery, which was initially felt to be a hematoma. The case highlights the role of spectral detector computed tomography (SDCT) in reaching the correct diagnosis of tumoral calcinosis as well as demonstrating additional changes of ectopic parathyroid hyperplasia in the anterior mediastinum.
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Induction of FGF23-related hypophosphatemic osteomalacia by alcohol consumption. Bone Rep 2021; 15:101144. [PMID: 34901334 PMCID: PMC8640868 DOI: 10.1016/j.bonr.2021.101144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/07/2021] [Accepted: 10/12/2021] [Indexed: 02/03/2023] Open
Abstract
Context Fibroblast growth factor (FGF) 23 is a hormone that regulates serum phosphate levels, the excess action of which causes chronic hypophosphatemic rickets/osteomalacia. To date, there are only two identified causes of acquired FGF23-related hypophosphatemic osteomalacia: tumor-induced osteomalacia (TIO) and osteomalacia induced by the intravenous infusion of some forms of iron preparations. In the current study, two cases of FGF23-related hypophosphatemia probably induced by chronic alcohol consumption were first introduced. Case description Case 1 and case 2 had been drinking high amounts of alcohol for more than twenty years until they were admitted to the hospital. Case 1 was a 43-year-old man with progressive worsening multiple pains and muscle weakness who exhibited chronic hypophosphatemia with increased intact FGF23 levels. A week after admission, the serum phosphate level recovered to the reference range, and the intact FGF23 level declined. Case 1 resumed drinking after discharge, and hypophosphatemia concomitant with high intact FGF23 levels recurred. The alleviation of FGF23-related hypophosphatemia was observed each time he temporarily abstained from drinking for a short period. Case 2 was a 60-year-old man with recurrent fractures and exacerbation of pain in multiple joints who also exhibited hypophosphatemia with increased intact FGF23 levels. After admission, the serum phosphate level gradually increased to the lower limit of the normal range. The intact FGF23 level decreased, but it was still higher than 30 pg/ml, and causative FGF23-producing tumors were not identified even with thorough examinations, including somatostatin receptor scintigraphy, fluorine-18-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG-PET/CT) and systemic venous FGF23 sampling. He completely abstained from alcohol after discharge. Along with the serum phosphate level, intact FGF23 was subsequently decreased and had been normalized for 5 months. Both patients had no genetic mutation related to hereditary FGF23-related hypophosphatemic rickets/osteomalacia, including autosomal dominant hypophosphatemic rickets/osteomalacia (ADHR). Conclusion Two cases of FGF23-related hypophosphatemia probably induced by alcohol were first introduced in this study. Identifying this reversible condition among acquired FGF23-related hypophosphatemic osteomalacia is critical to obtain better patient outcomes and save medical resources. This condition is similar to iron infusion-induced FGF23-related hypophosphatemia in terms of the dysregulation of FGF23 due to exogenous factors. Future research to elucidate the precise mechanism of these conditions is warranted. Two adults with acquired FGF23-related hypophosphatemic osteomalacia were studied. Tumor-induced osteomalacia was suspected initially, but no tumor was identified. Cessation of alcohol led to recovery from FGF23-related hypophosphatemia. Alcohol is a well-recognized cause of hypophosphatemia, but osteomalacia is uncommon. Alcohol-induced FGF23-related osteomalacia is a totally new and distinct phenomenon.
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12
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Lee AE, Hartley IR, Roszko KL, Vanek C, Gafni RI, Collins MT. Hyperphosphatemic Familial Tumoral Calcinosis Hidden in Plain Sight for 73 Years: A Case Report. FRONTIERS IN DENTAL MEDICINE 2021. [DOI: 10.3389/fdmed.2021.719752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
While dental pulp calcifications and root anomalies may be inconsequential incidental findings in dental radiographs, they can, especially in combination, represent a clue, hidden in plain sight, for the diagnosis of hyperphosphatemic familial tumoral calcinosis (HFTC). HFTC is an autosomal recessive disease of mineral metabolism characterized by sometimes massive, painful calcification around large joints, systemic inflammation, dental pulp calcification, and thistle-shaped roots. This paper describes a woman with HFTC who endured not only the symptoms of HFTC for decades, but also the frustration of not knowing the cause. The diagnosis was finally made at the age of 73 years, when the connection between a large right shoulder calcification and hyperphosphatemia was made. The dental findings were likely present on her initial radiographs taken in childhood. Increased awareness of the association between characteristic dental findings and HFTC may allow for earlier diagnosis and interventions to improve the care of patients with this rare condition.
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Lee AE, Chu EY, Gardner PJ, Duverger O, Saikali A, Wang SK, Gafni RI, Hartley IR, Ten Hagen KG, Somerman MJ, Collins MT. A Cross-Sectional Cohort Study of the Effects of FGF23 Deficiency and Hyperphosphatemia on Dental Structures in Hyperphosphatemic Familial Tumoral Calcinosis. JBMR Plus 2021; 5:e10470. [PMID: 33977199 PMCID: PMC8101615 DOI: 10.1002/jbm4.10470] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 01/26/2021] [Indexed: 11/10/2022] Open
Abstract
Hyperphosphatemic familial tumoral calcinosis (HFTC) is a rare autosomal recessive disorder caused by mutations in FGF23, GALNT3, KLOTHO, or FGF23 autoantibodies. Prominent features include high blood phosphate and calcific masses, usually adjacent to large joints. Dental defects have been reported, but not systematically described. Seventeen patients with HFTC followed at the National Institutes of Health underwent detailed clinical, biochemical, molecular, and dental analyses. Studies of teeth included intraoral photos and radiographs, high-resolution μCT, histology, and scanning electron microscopy (SEM). A scoring system was developed to assess the severity of tooth phenotype. Pulp calcification was found in 13 of 14 evaluable patients. Short roots and midroot bulges with apical thinning were present in 12 of 13 patients. Premolars were most severely affected. μCT analyses of five HFTC teeth revealed that pulp density increased sevenfold, whereas the pulp volume decreased sevenfold in permanent HFTC teeth compared with age- and tooth-matched control teeth. Histology revealed loss of the polarized odontoblast cell layer and an obliterated pulp cavity that was filled with calcified material. The SEM showed altered pulp and cementum structures, without differences in enamel or dentin structures, when compared with control teeth. This study defines the spectrum and confirms the high penetrance of dental features in HFTC. The phenotypes appear to be independent of genetic/molecular etiology, suggesting hyperphosphatemia or FGF23 deficiency may be the pathomechanistic driver, with prominent effects on root and pulp structures, consistent with a role of phosphate and/or FGF23 in tooth development. Given the early appearance and high penetrance, cognizance of HFTC-related features may allow for earlier diagnosis and treatment. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Alisa E Lee
- National Institute of Dental and Craniofacial Research, National Institutes of HealthBethesdaMDUSA
| | - Emily Y Chu
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of HealthBethesdaMDUSA
| | - Pamela J Gardner
- National Institute of Dental and Craniofacial Research, National Institutes of HealthBethesdaMDUSA
| | - Olivier Duverger
- National Institute of Dental and Craniofacial Research, National Institutes of HealthBethesdaMDUSA
| | - Amanda Saikali
- National Institute of Dental and Craniofacial Research, National Institutes of HealthBethesdaMDUSA
| | - Sean K Wang
- National Institute of Dental and Craniofacial Research, National Institutes of HealthBethesdaMDUSA
| | - Rachel I Gafni
- National Institute of Dental and Craniofacial Research, National Institutes of HealthBethesdaMDUSA
| | - Iris R Hartley
- National Institute of Dental and Craniofacial Research, National Institutes of HealthBethesdaMDUSA
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaMDUSA
| | - Kelly G Ten Hagen
- National Institute of Dental and Craniofacial Research, National Institutes of HealthBethesdaMDUSA
| | - Martha J Somerman
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of HealthBethesdaMDUSA
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Burbelo PD, Iadarola MJ, Keller JM, Warner BM. Autoantibodies Targeting Intracellular and Extracellular Proteins in Autoimmunity. Front Immunol 2021; 12:548469. [PMID: 33763057 PMCID: PMC7982651 DOI: 10.3389/fimmu.2021.548469] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 01/04/2021] [Indexed: 12/16/2022] Open
Abstract
Detecting autoantibodies provides foundational information for the diagnosis of most autoimmune diseases. An important pathophysiological distinction is whether autoantibodies are directed against extracellular or intracellular proteins. Autoantibodies targeting extracellular domains of proteins, such as membrane receptors, channels or secreted molecules are often directly pathogenic, whereby autoantibody binding to the autoantigen disrupts the normal function of a critical protein or pathway, and/or triggers antibody-dependent cell surface complement killing. By comparison, autoantibodies directed against intracellular proteins are recognized as useful diagnostic biomarkers of abnormal autoimmune activity, but the link between antigenicity and pathogenicity is less straightforward. Because intracellular autoantigens are generally inaccessible to autoantibody binding, for the most part, they do not directly contribute to pathogenesis. In a few diseases, autoantibodies to intracellular targets cause damage indirectly by immune complex formation, immune activation, and other processes. In this review, the general features of and differences between autoimmune diseases segregated on the basis of intracellular or extracellular autoantigens are explored using over twenty examples. Expression profiles of autoantigens in relation to the tissues targeted by autoimmune disease and the temporal appearance of autoantibodies before clinical diagnosis often correlate with whether the respective autoantibodies mostly recognize either intracellular or extracellular autoantigens. In addition, current therapeutic strategies are discussed from this vantage point. One drug, rituximab, depletes CD20+ B-cells and is highly effective for autoimmune disorders associated with autoantibodies against extracellular autoantigens. In contrast, diseases associated with autoantibodies directed predominately against intracellular autoantigens show much more complex immune cell involvement, such as T-cell mediated tissue damage, and require different strategies for optimal therapeutic benefit. Understanding the clinical ramifications of autoimmunity derived by autoantibodies against either intracellular or extracellular autoantigens, or a spectrum of both, has practical implications for guiding drug development, generating monitoring tools, stratification of patient interventions, and designing trials based on predictive autoantibody profiles for autoimmune diseases.
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Affiliation(s)
- Peter D Burbelo
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, United States
| | - Michael J Iadarola
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Jason M Keller
- Department of Perioperative Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Blake M Warner
- Salivary Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, United States
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15
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Daryadel A, Ruiz PA, Gehring N, Stojanovic D, Ugrica M, Bettoni C, Sabrautzki S, Pastor‐Arroyo E, Frey‐Wagner I, Lorenz‐Depiereux B, Strom TM, Angelis MH, Rogler G, Wagner CA, Rubio‐Aliaga I. Systemic Jak1 activation provokes hepatic inflammation and imbalanced FGF23 production and cleavage. FASEB J 2021; 35:e21302. [DOI: 10.1096/fj.202002113r] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 12/24/2022]
Affiliation(s)
- Arezoo Daryadel
- Institute of Physiology University of Zurich (UZH), and National Center of Competence in Research NCCR Kidney.CH Zurich Switzerland
| | - Pedro A. Ruiz
- Department of Gastroenterology and Hepatology University Hospital of Zurich, University of Zurich Zurich Switzerland
| | - Nicole Gehring
- Institute of Physiology University of Zurich (UZH), and National Center of Competence in Research NCCR Kidney.CH Zurich Switzerland
| | - Dragana Stojanovic
- Institute of Physiology University of Zurich (UZH), and National Center of Competence in Research NCCR Kidney.CH Zurich Switzerland
| | - Marko Ugrica
- Institute of Physiology University of Zurich (UZH), and National Center of Competence in Research NCCR Kidney.CH Zurich Switzerland
| | - Carla Bettoni
- Institute of Physiology University of Zurich (UZH), and National Center of Competence in Research NCCR Kidney.CH Zurich Switzerland
| | - Sibylle Sabrautzki
- Institute of Experimental Genetics German Mouse Clinic, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH) Neuherberg85764Germany
| | - Eva‐Maria Pastor‐Arroyo
- Institute of Physiology University of Zurich (UZH), and National Center of Competence in Research NCCR Kidney.CH Zurich Switzerland
| | - Isabelle Frey‐Wagner
- Department of Gastroenterology and Hepatology University Hospital of Zurich, University of Zurich Zurich Switzerland
| | - Bettina Lorenz‐Depiereux
- Institute of Human Genetics, Helmholtz Zentrum München German Research Center for Environmental Health (GmbH) Neuherberg Germany
| | - Tim M. Strom
- Institut für Humangenetik Klinikum rechts der Isar der Technischen Universität München München Germany
| | - Martin Hrabě Angelis
- Institute of Experimental Genetics German Mouse Clinic, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH) Neuherberg85764Germany
- Lehrstuhl für Experimentelle Genetik Technische Universität München Freising‐Weihenstephan Germany
- Member of German Center for Diabetes Research (DZD) Neuherberg Germany
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology University Hospital of Zurich, University of Zurich Zurich Switzerland
| | - Carsten A. Wagner
- Institute of Physiology University of Zurich (UZH), and National Center of Competence in Research NCCR Kidney.CH Zurich Switzerland
| | - Isabel Rubio‐Aliaga
- Institute of Physiology University of Zurich (UZH), and National Center of Competence in Research NCCR Kidney.CH Zurich Switzerland
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16
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Ito N, Fukumoto S. Congenital Hyperphosphatemic Conditions Caused by the Deficient Activity of FGF23. Calcif Tissue Int 2021; 108:104-115. [PMID: 31965220 DOI: 10.1007/s00223-020-00659-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 01/09/2020] [Indexed: 02/07/2023]
Abstract
Congenital diseases that could result in hyperphosphatemia at an early age include hyperphosphatemic familial tumoral calcinosis (HFTC)/hyperostosis-hyperphosphatemia syndrome (HHS) and congenital hypoparathyroidism/pseudohypoparathyroidism due to the insufficient activity of fibroblast growth factor (FGF) 23 and parathyroid hormone. HFTC/HHS is a rare autosomal recessive disease caused by inactivating mutations in the FGF23, UDP-N-acetyl-alpha-D-galactosamine:polypeptide N-acetylgalactosaminyltransferase 3 (GALNT3), or Klotho (KL) genes, resulting in the excessive cleavage of active intact FGF23 (FGF23, GALNT3) or increased resistance to the action of FGF23 (KL). Massive ectopic calcification, known as tumoral calcinosis (TC), is seen in periarticular soft tissues, typically in the hip, elbow, and shoulder in HFTC/HHS, reducing the range of motion. However, other regions, such as the eye, intestine, vasculature, and testis, are also targets of ectopic calcification. The other symptoms of HFTC/HHS are painful hyperostosis of the lower legs, dental abnormalities, and systemic inflammation. Low phosphate diets, phosphate binders, and phosphaturic reagents such as acetazolamide are the treatment options for HFTC/HHS and have various consequences, which warrant the development of novel therapeutics involving recombinant FGF23.
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Affiliation(s)
- Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan.
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
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17
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Koumakis E, Cormier C, Roux C, Briot K. The Causes of Hypo- and Hyperphosphatemia in Humans. Calcif Tissue Int 2021; 108:41-73. [PMID: 32285168 DOI: 10.1007/s00223-020-00664-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/20/2020] [Indexed: 12/11/2022]
Abstract
Phosphate homeostasis involves several major organs that are the skeleton, the intestine, the kidney, and parathyroid glands. Major regulators of phosphate homeostasis are parathormone, fibroblast growth factor 23, 1,25-dihydroxyvitamin D, which respond to variations of serum phosphate levels and act to increase or decrease intestinal absorption and renal tubular reabsorption, through the modulation of expression of transcellular transporters at the intestinal and/or renal tubular level. Any acquired or genetic dysfunction in these major organs or regulators may induce hypo- or hyperphosphatemia. The causes of hypo- and hyperphosphatemia are numerous. This review develops the main causes of acquired and genetic hypo- and hyperphosphatemia.
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Affiliation(s)
- Eugénie Koumakis
- Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Reference Center for Rare Genetic Bone Disorders, OSCAR Filière, Rheumatology Department, Cochin Hospital, AP-HP Centre-Paris University, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France.
| | - Catherine Cormier
- Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Reference Center for Rare Genetic Bone Disorders, OSCAR Filière, Rheumatology Department, Cochin Hospital, AP-HP Centre-Paris University, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Christian Roux
- Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Reference Center for Rare Genetic Bone Disorders, OSCAR Filière, Rheumatology Department, Cochin Hospital, AP-HP Centre-Paris University, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Karine Briot
- Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Reference Center for Rare Genetic Bone Disorders, OSCAR Filière, Rheumatology Department, Cochin Hospital, AP-HP Centre-Paris University, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
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18
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Laurent MR, De Schepper J, Trouet D, Godefroid N, Boros E, Heinrichs C, Bravenboer B, Velkeniers B, Lammens J, Harvengt P, Cavalier E, Kaux JF, Lombet J, De Waele K, Verroken C, van Hoeck K, Mortier GR, Levtchenko E, Vande Walle J. Consensus Recommendations for the Diagnosis and Management of X-Linked Hypophosphatemia in Belgium. Front Endocrinol (Lausanne) 2021; 12:641543. [PMID: 33815294 PMCID: PMC8018577 DOI: 10.3389/fendo.2021.641543] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/19/2021] [Indexed: 12/11/2022] Open
Abstract
X-linked hypophosphatemia (XLH) is the most common genetic form of hypophosphatemic rickets and osteomalacia. In this disease, mutations in the PHEX gene lead to elevated levels of the hormone fibroblast growth factor 23 (FGF23), resulting in renal phosphate wasting and impaired skeletal and dental mineralization. Recently, international guidelines for the diagnosis and treatment of this condition have been published. However, more specific recommendations are needed to provide guidance at the national level, considering resource availability and health economic aspects. A national multidisciplinary group of Belgian experts convened to discuss translation of international best available evidence into locally feasible consensus recommendations. Patients with XLH may present to a wide array of primary, secondary and tertiary care physicians, among whom awareness of the disease should be raised. XLH has a very broad differential-diagnosis for which clinical features, biochemical and genetic testing in centers of expertise are recommended. Optimal care requires a multidisciplinary approach, guided by an expert in metabolic bone diseases and involving (according to the individual patient's needs) pediatric and adult medical specialties and paramedical caregivers, including but not limited to general practitioners, dentists, radiologists and orthopedic surgeons. In children with severe or refractory symptoms, FGF23 inhibition using burosumab may provide superior outcomes compared to conventional medical therapy with phosphate supplements and active vitamin D analogues. Burosumab has also demonstrated promising results in adults on certain clinical outcomes such as pseudofractures. In summary, this work outlines recommendations for clinicians and policymakers, with a vision for improving the diagnostic and therapeutic landscape for XLH patients in Belgium.
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Affiliation(s)
- Michaël R. Laurent
- Centre for Metabolic Bone Diseases, University Hospitals Leuven, Leuven, Belgium
- *Correspondence: Michaël R. Laurent,
| | - Jean De Schepper
- Division of Pediatric Endocrinology, KidZ Health Castle, University Hospital Brussels, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Department of Pediatric Endocrinology, University Hospital Ghent, Ghent, Belgium
| | - Dominique Trouet
- Department of Pediatric Nephrology, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
| | - Nathalie Godefroid
- Pediatric Nephrology, Cliniques Universitaires St. Luc (UCL), Brussels, Belgium
| | - Emese Boros
- Paediatric Endocrinology Unit, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Claudine Heinrichs
- Paediatric Endocrinology Unit, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Bert Bravenboer
- Department of Endocrinology, University Hospital Brussels, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Brigitte Velkeniers
- Department of Endocrinology, University Hospital Brussels, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Johan Lammens
- Department of Orthopaedic Surgery and Department of Development and Regeneration, Prometheus LRD Division of Skeletal Tissue Engineering, KU Leuven - University Hospitals Leuven, Leuven, Belgium
| | - Pol Harvengt
- XLH Belgium, Belgian X-Linked Hypophosphatemic Rickets (XLH) Patient Association, Waterloo, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, University Hospital Center of Liège, University of Liège, Liège, Belgium
| | - Jean-François Kaux
- Physical Medicine, Rehabilitation and Sports Traumatology, University and University Hospital of Liège, Liège, Belgium
| | - Jacques Lombet
- Division of Nephrology, Department of Pediatrics, University Hospital Center of Liège, Liège, Belgium
| | - Kathleen De Waele
- Department of Pediatric Endocrinology, University Hospital Ghent, Ghent, Belgium
| | - Charlotte Verroken
- Unit for Osteoporosis and Metabolic Bone Diseases, Department of Endocrinology and Metabolism, Ghent University Hospital, Ghent, Belgium
| | - Koenraad van Hoeck
- Department of Pediatric Nephrology, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
| | - Geert R. Mortier
- Department of Medical Genetics, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Elena Levtchenko
- Department of Pediatrics/Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Johan Vande Walle
- Department of Pediatric Nephrology, University Hospital Ghent, Ghent, Belgium
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Abstract
FGF23 is a phosphotropic hormone produced by the bone. FGF23 works by binding to the FGF receptor-Klotho complex. Klotho is expressed in several limited tissues including the kidney and parathyroid glands. This tissue-restricted expression of Klotho is believed to determine the target organs of FGF23. FGF23 reduces serum phosphate by suppressing the expression of type 2a and 2c sodium-phosphate cotransporters in renal proximal tubules. FGF23 also decreases 1,25-dihydroxyvitamin D levels by regulating the expression of vitamin D-metabolizing enzymes, which results in reduced intestinal phosphate absorption. Excessive actions of FGF23 cause several types of hypophosphatemic rickets/osteomalacia characterized by impaired mineralization of bone matrix. In contrast, deficient actions of FGF23 result in hyperphosphatemic tumoral calcinosis with high 1,25-dihydroxyvitamin D levels. These results indicate that FGF23 is a physiological regulator of phosphate and vitamin D metabolism and indispensable for the maintenance of serum phosphate levels.
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Mahjoubi F, Ghadir M, Samanian S, Heydari I, Honardoost M. Hyperphosphatemic familial tumoral calcinosis caused by a novel variant in the GALNT3 gene. J Endocrinol Invest 2020; 43:1125-1130. [PMID: 32125652 DOI: 10.1007/s40618-020-01203-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 02/19/2020] [Indexed: 10/24/2022]
Abstract
AIM Hyperphosphatemic familial tumoral calcinosis (HFTC) is a rare endocrine disorder caused by autosomal recessive variants in GALNT3, FGF23, and KL leading to progressive calcification of soft tissues and subsequent clinical effects. The aim of this was to study the cause of HFTC in an Iranian family. PATIENTS AND METHODS Four generations of a family with HFTC were studied for understanding the genetic pattern of the disease. Whole exome sequencing was applied on genomic DNA of the proband. Based on its result, genetically altered sequences were checked in his family through sanger sequencing. Then bioinformatics approaches as well as co-segregation analysis were applied to validate the genetic alteration. RESULTS A novel homozygous variant in exon four of GALNT3, namely p.R261Q was found. The parents and sister were carriers. CONCLUSION To our knowledge, it is the first-reported Iranian family with GALNT3-CDG novel variant.
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Affiliation(s)
- F Mahjoubi
- Genetic Foundation of Tehran, Solaleh Diagnostic Laboratory, Tehran, Iran
- Department of Clinical Genetics, Institute of Medical Biotechnology, National Institute of Genetic Engineering and Biotechnology (NIGEB), Tehran, Iran
| | - M Ghadir
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, No 10, Firoozeh St, Vali-asr Sq, Tehran, Iran
| | - S Samanian
- Genetic Foundation of Tehran, Solaleh Diagnostic Laboratory, Tehran, Iran
| | - I Heydari
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, No 10, Firoozeh St, Vali-asr Sq, Tehran, Iran
| | - M Honardoost
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, No 10, Firoozeh St, Vali-asr Sq, Tehran, Iran.
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Abstract
Matrix mineralization can be divided into physiological mineralization and pathological mineralization. There is a consensus among existing studies that matrix vesicles (MVs) are the starting sites of bone mineralization, and each component of MVs serves a certain function in mineralization. In addition, ectopic MVs pathologically promote undesired calcification, the primary focus of which is the promotion of vascular calcification. However, the specific mechanisms of the actions of MVs in bone-vascular axis cross-talk have not been fully elucidated. This review summarizes the latest research in this field and explores the roles of MVs in the bone-vascular axis with the aim of generating new ideas for the prevention and treatment of vascular calcification and bone metabolic disease.
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Boyce AM, Lee AE, Roszko KL, Gafni RI. Hyperphosphatemic Tumoral Calcinosis: Pathogenesis, Clinical Presentation, and Challenges in Management. Front Endocrinol (Lausanne) 2020; 11:293. [PMID: 32457699 PMCID: PMC7225339 DOI: 10.3389/fendo.2020.00293] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/20/2020] [Indexed: 02/02/2023] Open
Abstract
Hyperphosphatemic familial tumoral calcinosis (HFTC) is a rare and disabling disorder of fibroblast growth factor 23 (FGF23) deficiency or resistance. The disorder is manifest by hyperphosphatemia, inappropriately increased tubular reabsorption of phosphate and 1,25-dihydroxy-Vitamin D, and ectopic calcifications. HFTC has been associated with autosomal recessive pathogenic variants in: (1) the gene encoding FGF23; (2) GALNT3, which encodes a protein responsible for FGF23 glycosylation; and (3) KL, the gene encoding KLOTHO, a critical co-receptor for FGF23 signaling. An acquired autoimmune form of hyperphosphatemic tumoral calcinosis has also been reported. Periarticular tumoral calcinosis is the primary cause of disability in HFTC, leading to pain, reduced range-of-motion, and impaired physical function. Inflammatory disease is also prominent, including diaphysitis with cortical hyperostosis. Multiple treatment strategies have attempted to manage blood phosphate, reduce pain and inflammation, and address calcifications and their complications. Unfortunately, efficacy data are limited to case reports and small cohorts, and no clearly effective therapies have been identified. The purpose of this review is to provide a background on pathogenesis and clinical presentation in HFTC, discuss current approaches to clinical management, and outline critical areas of need for future research.
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23
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Fukumoto S, Takashi Y, Tsoumpra MK, Sawatsubashi S, Matsumoto T. How do we sense phosphate to regulate serum phosphate level? J Bone Miner Metab 2020; 38:1-6. [PMID: 31797064 DOI: 10.1007/s00774-019-01066-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/05/2019] [Indexed: 12/25/2022]
Abstract
Abnormal phosphate levels result in several pathological conditions such as rickets/osteomalacia and ectopic calcification indicating that there must be a system that regulates phosphate level within a narrow range. FGF23 has been shown to be an essential hormone regulating serum phosphate level. FGF23 binds to Klotho-FGF receptor complex to reduce serum phosphate level. Several reports suggested that FGF receptor is involved in the regulation of FGF23 production. It has been also shown that high extracellular phosphate can activate several intracellular signaling pathways. However, it has been unclear whether and how phosphate regulates FGF23 production in vivo. Our recent results indicate that high extracellular phosphate directly activates FGF receptor 1 and the downstream intracellular signaling enhances FGF23 production. Thus, there is a negative feedback system for the regulation of serum phosphate level involving FGF receptor and FGF23. We propose that FGF receptor works at least as one of phosphate sensors in the maintenance of serum phosphate level.
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Affiliation(s)
- Seiji Fukumoto
- Department of Molecular Endocrinology, Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, Tokushima, 770-8503, Japan.
| | - Yuichi Takashi
- Department of Molecular Endocrinology, Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, Tokushima, 770-8503, Japan
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino, 818-8502, Japan
| | - Maria K Tsoumpra
- Department of Molecular Endocrinology, Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, Tokushima, 770-8503, Japan
- Department of Molecular Therapy, National Institute of Neuroscience, National Center for Neurology and Psychiatry, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo, 187-8502, Japan
| | - Shun Sawatsubashi
- Department of Molecular Endocrinology, Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, Tokushima, 770-8503, Japan
| | - Toshio Matsumoto
- Department of Molecular Endocrinology, Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima, Tokushima, 770-8503, Japan
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25
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Burbelo PD, Chaturvedi A, Notkins AL, Gunti S. Luciferase-Based Detection of Antibodies for the Diagnosis of HPV-Associated Head and Neck Squamous Cell Carcinoma. Diagnostics (Basel) 2019; 9:diagnostics9030089. [PMID: 31390810 PMCID: PMC6787723 DOI: 10.3390/diagnostics9030089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 07/29/2019] [Accepted: 07/31/2019] [Indexed: 11/16/2022] Open
Abstract
Point-of-care tests are needed for the screening of head and neck squamous cell carcinoma (HNSCC) and other malignancies. Luciferase immunoprecipitation systems (LIPS), employing light-emitting proteins, were used to examine serum antibodies against several cancer-associated targets in blood donor controls and subjects with colon cancer (CC) and HNSCC. The assessment of antibodies against the wild type p53 tumor antigen showed that approximately 25% of the CC and 20% of the HNSCC patients were seropositive. In addition, humoral responses against two p53 mutants, p53-R175H and p53-R273H, generally tracked the antibody responses seen against wild type p53. Analysis of antibodies against highly specific biomarkers of HPV-16-associated malignancy, E2, E6, and E7 oncoproteins, revealed no seropositivity in blood donors and CC patients. However, 45% (9/20) of the HNSCC patients showed E6 seropositivity, which overlapped all the detectable E2 (40%; 8/20) and E7 seropositive subjects (35%; 7/20). Using neodymium magnets, ultrarapid LIPSTICKS testing of HPV-16 E6 antibodies in <60 s per HNSCC sample demonstrated almost the same diagnostic performance (40% sensitivity and 100% specificity) as LIPS testing in 2.5 h. While additional improvements and standardization are needed, these results highlight the possibility of using these approaches for the diagnosis of HPV-16-associated HNSCC.
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Affiliation(s)
- Peter D Burbelo
- Dental Clinical Research Core, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Adrija Chaturvedi
- Dental Clinical Research Core, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
| | - Abner L Notkins
- Experimental Medicine Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
| | - Sreenivasulu Gunti
- Experimental Medicine Section, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892, USA
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Bär L, Stournaras C, Lang F, Föller M. Regulation of fibroblast growth factor 23 (FGF23) in health and disease. FEBS Lett 2019; 593:1879-1900. [PMID: 31199502 DOI: 10.1002/1873-3468.13494] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 12/19/2022]
Abstract
Fibroblast growth factor 23 (FGF23) is mainly produced in the bone and, upon secretion, forms a complex with a FGF receptor and coreceptor αKlotho. FGF23 can exert several endocrine functions, such as inhibiting renal phosphate reabsorption and 1,25-dihydroxyvitamin D3 production. Moreover, it has paracrine activities on several cell types, including neutrophils and hepatocytes. Klotho and Fgf23 deficiencies result in pathologies otherwise encountered in age-associated diseases, mainly as a result of hyperphosphataemia-dependent calcification. FGF23 levels are also perturbed in the plasma of patients with several disorders, including kidney or cardiovascular diseases. Here, we review mechanisms controlling FGF23 production and discuss how FGF23 regulation is perturbed in disease.
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Affiliation(s)
- Ludmilla Bär
- Institute of Agricultural and Nutritional Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Christos Stournaras
- Institute of Biochemistry, University of Crete Medical School, Heraklion, Greece
| | - Florian Lang
- Institute of Physiology, University of Tübingen, Germany
| | - Michael Föller
- Institute of Physiology, University of Hohenheim, Stuttgart, Germany
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