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Costa CRR, Chalgoumi R, Baker A, Guillou C, Yamaguti PM, Simancas Escorcia V, Abbad L, Amorin BR, de Lima CL, Cannaya V, Benassarou M, Berdal A, Chatziantoniou C, Cases O, Cosette P, Kozyraki R, Acevedo AC. Gingival proteomics reveals the role of TGF beta and YAP/TAZ signaling in Raine syndrome fibrosis. Sci Rep 2024; 14:9497. [PMID: 38664418 PMCID: PMC11045870 DOI: 10.1038/s41598-024-59713-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
Raine syndrome (RNS) is a rare autosomal recessive osteosclerotic dysplasia. RNS is caused by loss-of-function disease-causative variants of the FAM20C gene that encodes a kinase that phosphorylates most of the secreted proteins found in the body fluids and extracellular matrix. The most common RNS clinical features are generalized osteosclerosis, facial dysmorphism, intracerebral calcifications and respiratory defects. In non-lethal RNS forms, oral traits include a well-studied hypoplastic amelogenesis imperfecta (AI) and a much less characterized gingival phenotype. We used immunomorphological, biochemical, and siRNA approaches to analyze gingival tissues and primary cultures of gingival fibroblasts of two unrelated, previously reported RNS patients. We showed that fibrosis, pathological gingival calcifications and increased expression of various profibrotic and pro-osteogenic proteins such as POSTN, SPARC and VIM were common findings. Proteomic analysis of differentially expressed proteins demonstrated that proteins involved in extracellular matrix (ECM) regulation and related to the TGFβ/SMAD signaling pathway were increased. Functional analyses confirmed the upregulation of TGFβ/SMAD signaling and subsequently uncovered the involvement of two closely related transcription cofactors important in fibrogenesis, Yes-associated protein (YAP) and transcriptional coactivator with PDZ-binding motif (TAZ). Knocking down of FAM20C confirmed the TGFβ-YAP/TAZ interplay indicating that a profibrotic loop enabled gingival fibrosis in RNS patients. In summary, our in vivo and in vitro data provide a detailed description of the RNS gingival phenotype. They show that gingival fibrosis and calcifications are associated with, and most likely caused by excessed ECM production and disorganization. They furthermore uncover the contribution of increased TGFβ-YAP/TAZ signaling in the pathogenesis of the gingival fibrosis.
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Affiliation(s)
- Cláudio Rodrigues Rezende Costa
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris Cité, Oral Molecular Pathophysiology, 75006, Paris, France
- Oral Center for Inherited Diseases, University Hospital of Brasília, Oral Histopathology Laboratory, Department of Dentistry, Health Sciences Faculty, University of Brasília (UnB), Brasília, Brazil
- Department of Dentistry, Health Group of Natal (GSAU-NT), Brazilian Air Force, Natal, Parnamirim, Brazil
| | - Rym Chalgoumi
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris Cité, Oral Molecular Pathophysiology, 75006, Paris, France
| | - Amina Baker
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris Cité, Oral Molecular Pathophysiology, 75006, Paris, France
| | - Clément Guillou
- Rouen University, INSA Rouen Normandie, CNRS, Normandie Univ, PBS UMR 6270, 76000, Rouen, France
- Rouen University, INSERM US51, CNRS UAR 2026, HeRacles PISSARO, 76000, Rouen, France
| | - Paulo Marcio Yamaguti
- Oral Center for Inherited Diseases, University Hospital of Brasília, Oral Histopathology Laboratory, Department of Dentistry, Health Sciences Faculty, University of Brasília (UnB), Brasília, Brazil
| | - Victor Simancas Escorcia
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris Cité, Oral Molecular Pathophysiology, 75006, Paris, France
- Grupo de Investigación GENOMA, Universidad del Sinú, Cartagena, Colombia
| | - Lilia Abbad
- MRS1155, INSERM, Sorbonne Université, 75020, Paris, France
| | - Bruna Rabelo Amorin
- Oral Center for Inherited Diseases, University Hospital of Brasília, Oral Histopathology Laboratory, Department of Dentistry, Health Sciences Faculty, University of Brasília (UnB), Brasília, Brazil
| | - Caroline Lourenço de Lima
- Oral Center for Inherited Diseases, University Hospital of Brasília, Oral Histopathology Laboratory, Department of Dentistry, Health Sciences Faculty, University of Brasília (UnB), Brasília, Brazil
| | - Vidjea Cannaya
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris Cité, Oral Molecular Pathophysiology, 75006, Paris, France
| | - Mourad Benassarou
- Service de Chirurgie Maxillo-Faciale et Stomatologie, Hôpital de La Pitié Salpétrière, Sorbonne Université, 75006, Paris, France
| | - Ariane Berdal
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris Cité, Oral Molecular Pathophysiology, 75006, Paris, France
- CRMR O-RARES, Hôpital Rothshild, UFR d'Odontologie-Garancière, Université de Paris Cité, 75012, Paris, France
| | | | - Olivier Cases
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris Cité, Oral Molecular Pathophysiology, 75006, Paris, France
| | - Pascal Cosette
- Rouen University, INSA Rouen Normandie, CNRS, Normandie Univ, PBS UMR 6270, 76000, Rouen, France
- Rouen University, INSERM US51, CNRS UAR 2026, HeRacles PISSARO, 76000, Rouen, France
| | - Renata Kozyraki
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris Cité, Oral Molecular Pathophysiology, 75006, Paris, France.
- CRMR O-RARES, Hôpital Rothshild, UFR d'Odontologie-Garancière, Université de Paris Cité, 75012, Paris, France.
- Rouen University, UFR SANTE ROUEN NORMANDIE, Inserm 1096, 76000, Rouen, France.
| | - Ana Carolina Acevedo
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris Cité, Oral Molecular Pathophysiology, 75006, Paris, France
- Oral Center for Inherited Diseases, University Hospital of Brasília, Oral Histopathology Laboratory, Department of Dentistry, Health Sciences Faculty, University of Brasília (UnB), Brasília, Brazil
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Baroncelli GI, Comberiati P, Aversa T, Baronio F, Cassio A, Chiarito M, Cosci o di Coscio M, De Sanctis L, Di Iorgi N, Faienza MF, Fintini D, Franceschi R, Kalapurackal M, Longhi S, Mariani M, Pitea M, Secco A, Tessaris D, Vierucci F, Wasniewska M, Weber G, Mora S. Diagnosis, treatment, and management of rickets: a position statement from the Bone and Mineral Metabolism Group of the Italian Society of Pediatric Endocrinology and Diabetology. Front Endocrinol (Lausanne) 2024; 15:1383681. [PMID: 38706696 PMCID: PMC11066174 DOI: 10.3389/fendo.2024.1383681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/03/2024] [Indexed: 05/07/2024] Open
Abstract
Rickets results from impaired mineralization of growing bone due to alterations in calcium and phosphate homeostasis. Clinical signs of rickets are related to the age of the patient, the duration of the disease, and the underlying disorder. The most common signs of rickets are swelling of the wrists, knees or ankles, bowing of the legs (knock-knees, outward bowing, or both) and inability to walk. However, clinical features alone cannot differentiate between the various forms of rickets. Rickets includes a heterogeneous group of acquired and inherited diseases. Nutritional rickets is due to a deficiency of vitamin D, dietary calcium or phosphate. Mutations in genes responsible for vitamin D metabolism or function, the production or breakdown of fibroblast growth factor 23, renal phosphate regulation, or bone mineralization can lead to the hereditary form of rickets. This position paper reviews the relevant literature and presents the expertise of the Bone and Mineral Metabolism Group of the Italian Society of Pediatric Endocrinology and Diabetology (SIEDP). The aim of this document is to provide practical guidance to specialists and healthcare professionals on the main criteria for diagnosis, treatment, and management of patients with rickets. The various forms of rickets are discussed, and detailed references for the discussion of each form are provided. Algorithms to guide the diagnostic approach and recommendations to manage patients with rare forms of hereditary rickets are proposed.
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Affiliation(s)
- Giampiero I. Baroncelli
- Pediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
| | - Pasquale Comberiati
- Pediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
- Department of Clinical and Experimental Medicine, Section of Paediatrics, University of Pisa, Pisa, Italy
| | - Tommaso Aversa
- Department of Human Pathology of Adulthood and Childhood, University of Messina, Messina, Italy
- Pediatric Unit, University Hospital “G. Martino”, Messina, Italy
| | - Federico Baronio
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessandra Cassio
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Mariangela Chiarito
- Pediatric Unit, Department of Precision and Regenerative Medicine and Ionian Area, University “A. Moro” of Bari, Bari, Italy
| | - Mirna Cosci o di Coscio
- Pediatric and Adolescent Endocrinology, Division of Pediatrics, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
| | - Luisa De Sanctis
- Division of Pediatric Endocrinology, Department of Public Health and Pediatrics, University of Turin, Regina Margherita Children’s Hospital, Turin, Italy
| | - Natascia Di Iorgi
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Maria Felicia Faienza
- Pediatric Unit, Department of Precision and Regenerative Medicine and Ionian Area, University “A. Moro” of Bari, Bari, Italy
| | - Danilo Fintini
- Endocrinology and Diabetology Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Roberto Franceschi
- Department of Pediatrics, Santa Chiara Hospital of Trento, APSS, Trento, Italy
| | - Mila Kalapurackal
- Department of Pediatrics, Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University (PMU), Bolzano, Italy
| | - Silvia Longhi
- Department of Pediatrics, Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University (PMU), Bolzano, Italy
| | - Michela Mariani
- Endocrinology and Diabetology Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Marco Pitea
- Pediatric Endocrinology Unit, Department of Pediatrics, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Andrea Secco
- Pediatric and Pediatric Emergency Unit, Children Hospital, Azienda Ospedaliera SS Antonio e Biagio e C. Arrigo, Alessandria, Italy
| | - Daniele Tessaris
- Division of Pediatric Endocrinology, Department of Public Health and Pediatrics, University of Turin, Regina Margherita Children’s Hospital, Turin, Italy
| | | | - Malgorzata Wasniewska
- Department of Human Pathology of Adulthood and Childhood, University of Messina, Messina, Italy
| | - Giovanna Weber
- Pediatric Endocrinology Unit, Department of Pediatrics, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Stefano Mora
- Laboratory of Pediatric Endocrinology, Department of Pediatrics, IRCCS Ospedale San Raffaele, Milan, Italy
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AlSubaihin A, Harrington J. Hereditary Rickets: A Quick Guide for the Pediatrician. Curr Pediatr Rev 2024; 20:380-394. [PMID: 36475338 DOI: 10.2174/1573396319666221205123402] [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: 04/12/2022] [Revised: 09/10/2022] [Accepted: 11/01/2022] [Indexed: 12/12/2022]
Abstract
With the increased discovery of genes implicated in vitamin D metabolism and the regulation of calcium and phosphate homeostasis, a growing number of genetic forms of rickets are now recognized. These are categorized into calciopenic and phosphopenic rickets. Calciopenic forms of hereditary rickets are caused by genetic mutations that alter the enzymatic activity in the vitamin D activation pathway or impair the vitamin D receptor action. Hereditary forms of phosphopenic rickets, on the other hand, are caused by genetic mutations that lead to increased expression of FGF23 hormone or that impair the absorptive capacity of phosphate at the proximal renal tubule. Due to the clinical overlap between acquired and genetic forms of rickets, identifying children with hereditary rickets can be challenging. A clear understanding of the molecular basis of hereditary forms of rickets and their associated biochemical patterns allow the health care provider to assign the correct diagnosis, avoid non-effective interventions and shorten the duration of the diagnostic journey in these children. In this mini-review, known forms of hereditary rickets listed on the Online Mendelian Inheritance in Man database are discussed. Further, a clinical approach to identify and diagnose children with hereditary forms of rickets is suggested.
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Affiliation(s)
- Abdulmajeed AlSubaihin
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- King Saud University Medical City, Riyadh, Saudi Arabia
| | - Jennifer Harrington
- Division of Endocrinology, Women's and Children's Health Network, North Adelaide, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
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Liu P, Li J, Tang L, Cong W, Jin H, Zhang H, Cui B, Yang S, Xiao J, Liu C, Saiyin W. Mutations of family with sequence similarity 20-member C gene causing lethal and nonlethal Raine syndrome causes hypophosphatemia rickets. J Cell Physiol 2023; 238:2556-2569. [PMID: 37698039 DOI: 10.1002/jcp.31105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 09/13/2023]
Abstract
Family with sequence similarity 20-member C (FAM20C) is a kinase specific to most of the secreted phosphoproteome. FAM20C has been identified as the causative gene of Raine syndrome, initially characterized by lethal osteosclerosis bone dysplasia. However, since the identification of the cases of nonlethal Raine syndrome characterized by hypophosphatemia rickets, the previous definition of Raine syndrome has become debatable and raised a question about the role of mutations of FAM20C in controversial skeletal manifestation in the two forms of the disease. In this study, we aimed to investigate the influence of FAM20C mutations on skeletogenesis. We developed transgenic mice expressing Fam20c mutations mimicking those associated with human lethal and nonlethal Raine syndrome. The results revealed that transgenic mice expressing the mutant Fam20c found in the lethal (KO;G374R) and nonlethal (KO;D446N) Raine syndrome exhibited osteomalacia without osteosclerotic features. Additionally, both mutants significantly increased the expression of the Fgf23, indicating that Fam20c deficiency in skeletal compartments causes hypophosphatemia rickets. Furthermore, as FAM20C kinase activity catalyzes the phosphorylation of secreted proteomes other than those in the skeletal system, global FAM20C deficiency may trigger alterations in other systems resulting in osteosclerosis secondary to hypophosphatemia rickets. Together, the findings of this study suggest that FAM20C deficiency primarily causes hypophosphatemia rickets or osteomalacia; however, the heterogeneous skeletal manifestation in Raine syndrome was not determined solely by specific mutations of FAM20C. The findings also implicated that rickets or osteomalacia caused by FAM20C deficiency would deteriorate into osteosclerosis by the defects from other systems or environmental impacts.
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Affiliation(s)
- Peihong Liu
- Department of Stomatology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Laboratory of Longjiang Scholar, The First Affifiliated Hospital of Harbin Medical University, Harbin, China
| | - Jiaxuan Li
- Department of Stomatology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Linghao Tang
- Department of Otorhinolaryngology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Wei Cong
- Department of Oral Pathology, School of Stomatology, Dalian Medical University, Dalian, China
| | - Han Jin
- Heilongjiang Provincial Key Laboratory of Hard Tissue Development and Regeneration, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hong Zhang
- Department of Stomatology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bing Cui
- Department of Stomatology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Shan Yang
- Department of Stomatology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jing Xiao
- Department of Oral Pathology, School of Stomatology, Dalian Medical University, Dalian, China
| | - Chao Liu
- Department of Oral Pathology, School of Stomatology, Dalian Medical University, Dalian, China
| | - Wuliji Saiyin
- Department of Stomatology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
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Roomaney IA, Kabbashi S, Beshtawi K, Moosa S, Chothia MY, Chetty M. Case report: Enamel renal syndrome: a case series from sub-Saharan Africa. FRONTIERS IN ORAL HEALTH 2023; 4:1228760. [PMID: 37675434 PMCID: PMC10477592 DOI: 10.3389/froh.2023.1228760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/04/2023] [Indexed: 09/08/2023] Open
Abstract
Enamel Renal Syndrome (ERS) (OMIM # 204690) is a rare genetic condition characterised by hypoplastic amelogenesis imperfecta, failed tooth eruption, intra-pulpal calcifications, gingival enlargement and occasionally nephrocalcinosis. In this case series, we report on four unrelated patients with a confirmed molecular diagnosis of ERS (FAM20A pathogenic variants) from Sub-Saharan Africa. The pathognomonic oral profile of ERS was mostly fulfilled in these patients, with the notable addition of an odontoma in one patient. The cases presented a spectrum of phenotypic severity both dentally and systemically. One patient presented with nephrocalcinosis and abnormal kidney function, one had reduced kidney size with normal kidney function, and two had no renal abnormalities. Patients presenting with the oral profile of ERS should receive a prompt referral to a nephrologist and a geneticist. They should receive long-term management from a multidisciplinary medical and dental team.
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Affiliation(s)
- I. A. Roomaney
- Department of Craniofacial Biology, Pathology and Radiology, Faculty of Dentistry, University of Western Cape, Cape Town, South Africa
| | - S. Kabbashi
- Department of Craniofacial Biology, Pathology and Radiology, Faculty of Dentistry, University of Western Cape, Cape Town, South Africa
| | - K. Beshtawi
- Department of Craniofacial Biology, Pathology and Radiology, Faculty of Dentistry, University of Western Cape, Cape Town, South Africa
- Department of Dental Sciences, Faculty of Graduate Study, Arab American University, Jenin, Palestine
| | - S. Moosa
- Division of Molecular Biology and Human Genetics, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
- Medical Genetics, Tygerberg Hospital, Cape Town, South Africa
| | - M. Y. Chothia
- Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - M. Chetty
- Department of Craniofacial Biology, Pathology and Radiology, Faculty of Dentistry, University of Western Cape, Cape Town, South Africa
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Palma-Lara I, García Alonso-Themann P, Pérez-Durán J, Godínez-Aguilar R, Bonilla-Delgado J, Gómez-Archila D, Espinosa-García AM, Nolasco-Quiroga M, Victoria-Acosta G, López-Ornelas A, Serrano-Bello JC, Olguín-García MG, Palacios-Reyes C. Potential Role of Protein Kinase FAM20C on the Brain in Raine Syndrome, an In Silico Analysis. Int J Mol Sci 2023; 24:ijms24108904. [PMID: 37240249 DOI: 10.3390/ijms24108904] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023] Open
Abstract
FAM20C (family with sequence similarity 20, member C) is a serine/threonine-specific protein kinase that is ubiquitously expressed and mainly associated with biomineralization and phosphatemia regulation. It is mostly known due to pathogenic variants causing its deficiency, which results in Raine syndrome (RNS), a sclerosing bone dysplasia with hypophosphatemia. The phenotype is recognized by the skeletal features, which are related to hypophosphorylation of different FAM20C bone-target proteins. However, FAM20C has many targets, including brain proteins and the cerebrospinal fluid phosphoproteome. Individuals with RNS can have developmental delay, intellectual disability, seizures, and structural brain defects, but little is known about FAM20C brain-target-protein dysregulation or about a potential pathogenesis associated with neurologic features. In order to identify the potential FAM20C actions on the brain, an in silico analysis was conducted. Structural and functional defects reported in RNS were described; FAM20C targets and interactors were identified, including their brain expression. Gene ontology of molecular processes, function, and components was completed for these targets, as well as for potential involved signaling pathways and diseases. The BioGRID and Human Protein Atlas databases, the Gorilla tool, and the PANTHER and DisGeNET databases were used. Results show that genes with high expression in the brain are involved in cholesterol and lipoprotein processes, plus axo-dendritic transport and the neuron part. These results could highlight some proteins involved in the neurologic pathogenesis of RNS.
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Affiliation(s)
- Icela Palma-Lara
- Laboratorio de Morfología Celular y Molecular, Escuela Superior de Medicina, Instituto Politécnico Nacional, Ciudad de México 11340, Mexico
| | | | - Javier Pérez-Durán
- Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Ciudad de México 11000, Mexico
| | | | - José Bonilla-Delgado
- Unidad de Investigación, Hospital Regional de Ixtapaluca, Ixtapaluca 56530, Mexico
- Departamento de Biotecnología, Escuela de Ingeniería y Ciencias, Instituto Tecnológico de Monterrey, Toluca de Lerdo 50110, Mexico
| | - Damián Gómez-Archila
- Departamento de Oncología Quirúrgica, Hospital de Gineco-Obstetricia 3, Centro Médico Nacional "La Raza", Ciudad de México 02990, Mexico
| | | | - Manuel Nolasco-Quiroga
- Coordinación de Enseñanza e Investigación, Clínica Hospital Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Huauchinango 73177, Mexico
| | | | - Adolfo López-Ornelas
- División de Investigación, Hospital Juárez de México, Ciudad de México 11340, Mexico
| | - Juan Carlos Serrano-Bello
- Departamento de Patología Clínica y Experimental, Hospital Infantil de México Federico Gómez, Ciudad de México 06720, Mexico
| | | | - Carmen Palacios-Reyes
- División de Investigación, Hospital Juárez de México, Ciudad de México 11340, Mexico
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Chirteș C, Bogliș A, Toth A, Rac C, Bănescu C. Compound heterozygous FAM20C gene variants in a patient with severe Raine syndrome: a case report. Front Genet 2023; 14:1179163. [PMID: 37180977 PMCID: PMC10171555 DOI: 10.3389/fgene.2023.1179163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/13/2023] [Indexed: 05/16/2023] Open
Abstract
Raine syndrome is a congenital disorder caused by biallelic mutations in the FAM20C gene. While most diagnosed cases of the syndrome are lethal in the first few months of life, there are also reports of non-lethal cases with Raine syndrome. The characteristic of this syndrome is typical facial dysmorphism and generalized osteosclerosis, as well as possible intracranial calcification, hearing loss, and seizures. We report a case of a 4-day-old patient at the time of examination, born with a distinct facial dysmorphism, short neck, narrow chest, and curved tibia. The parents, affirmative gypsy and non-consanguineous, had a previous male child born with the same phenotype who died at 4 months old. The computed tomography scan revealed choanal atresia, while transfontanelar ultrasound showed hypoplasia of the frontal and temporal lobes, corpus callosum dysgenesis, and multiple areas of intracranial hyperechogenicity. The chest X-Ray revealed generalized increased bone density. A skeletal disorders gene panel was performed which identified two variants in the FAM20C gene: a pathogenic variant c.1291C>T (p.Gln431*) and a likely pathogenic variant (c.1135G>A) (p.Gly379Arg), confirming the clinical diagnosis. The parents were also tested, and each was found to carry one of the variants. The particularity of this case is the severe phenotype in a compound heterozygous case that consists of FAM20C c.1291C>T (p.Gln431*) variant that has recently been reported in the literature. Also, our case is one of the few compound-heterozygous mutations in the FAM20C gene that has been described in a non-consanguineous marriage.
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Affiliation(s)
- Camelia Chirteș
- Laboratory of Genetics, Department of Genetics, Emergency County Hospital, Târgu Mureș, Romania
- *Correspondence: Camelia Chirteș,
| | - Alina Bogliș
- Laboratory of Genetics, Department of Genetics, Emergency County Hospital, Târgu Mureș, Romania
- Department of Genetics, George Emil Palade University of Medicine, Pharmacy, Science and Technology, Târgu Mureș, Romania
| | - Andrea Toth
- Department of Neonatology, Emergency County Hospital, Târgu Mureș, Romania
| | - Corina Rac
- Department of Neonatology, Emergency County Hospital, Târgu Mureș, Romania
| | - Claudia Bănescu
- Laboratory of Genetics, Department of Genetics, Emergency County Hospital, Târgu Mureș, Romania
- Department of Genetics, George Emil Palade University of Medicine, Pharmacy, Science and Technology, Târgu Mureș, Romania
- Center for Advanced Medical and Pharmaceutical Research, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, Târgu Mureș, Romania
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FAM20C plays a critical role in the development of mouse vertebra. Spine J 2022; 22:337-348. [PMID: 34343663 DOI: 10.1016/j.spinee.2021.07.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Family with sequence similarity 20-member C (FAM20C) is a protein kinase that is responsible for the phosphorylation of many secretory proteins; however, its roles in spine or vertebra development have not be studied. PURPOSE The aim of this investigation is to analyze the roles of FAM20C in vertebra development. STUDY DESIGN/SETTING A mouse study of the Fam20c gene using conditional knockout to assess the effects of its inactivation on vertebra development. METHODS By breeding Sox2-Cre mice with Fam20cflox/flox mice, Sox2-Cre;Fam20cflox/flox mice (abbreviated as cKO mice) are created. X-ray radiography, resin-casted scanning electron microscopy, Hematoxylin and Eosin staining, safranin O staining, Goldner's Masson trichrome staining, Von Kossa staining, tartrate-resistant alkaline phosphatase staining, immunohistochemistry staining, Western Immunoblotting and real-time PCR were employed to characterize the vertebrae of cKO mice compared to the normal control mice. RESULTS Inactivation of Fam20c in mice results in remarkable spine deformity, severe morphology and mineralization defects, altered levels of osteoblast differentiation markers, reduction of activity of the Wnt/β-catenin signaling pathway and reduced level of osteoclastogenesis in the vertebrae. CONCLUSIONS FAM20C plays an essential role in vertebral development; it may regulate vertebral formation through the Wnt/β-catenin signaling pathway. CLINICAL SIGNIFICANCE Mutations in the human FAM20C gene are associated with Raine syndrome. The findings of this study provide valuable clues for the clinical management of Raine syndrome regarding spine manifestations in patients.
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Rios JJ, Denton K, Russell J, Kozlitina J, Ferreira CR, Lewanda AF, Mayfield JE, Moresco E, Ludwig S, Tang M, Li X, Lyon S, Khanshour A, Paria N, Khalid A, Li Y, Xie X, Feng JQ, Xu Q, Lu Y, Hammer RE, Wise CA, Beutler B. Germline Saturation Mutagenesis Induces Skeletal Phenotypes in Mice. J Bone Miner Res 2021; 36:1548-1565. [PMID: 33905568 PMCID: PMC8862308 DOI: 10.1002/jbmr.4323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 04/07/2021] [Accepted: 04/21/2021] [Indexed: 12/28/2022]
Abstract
Proper embryonic and postnatal skeletal development require coordination of myriad complex molecular mechanisms. Disruption of these processes, through genetic mutation, contributes to variation in skeletal development. We developed a high-throughput N-ethyl-N-nitrosourea (ENU)-induced saturation mutagenesis skeletal screening approach in mice to identify genes required for proper skeletal development. Here, we report initial results from live-animal X-ray and dual-energy X-ray absorptiometry (DXA) imaging of 27,607 G3 mice from 806 pedigrees, testing the effects of 32,198 coding/splicing mutations in 13,020 genes. A total of 39.7% of all autosomal genes were severely damaged or destroyed by mutations tested twice or more in the homozygous state. Results from our study demonstrate the feasibility of in vivo mutagenesis to identify mouse models of skeletal disease. Furthermore, our study demonstrates how ENU mutagenesis provides opportunities to create and characterize putative hypomorphic mutations in developmentally essential genes. Finally, we present a viable mouse model and case report of recessive skeletal disease caused by mutations in FAM20B. Results from this study, including engineered mouse models, are made publicly available via the online Mutagenetix database. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Jonathan J Rios
- Center for Pediatric Bone Biology and Translational Research, Scottish Rite for Children, Dallas, TX, USA.,Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA.,McDermott Center for Human Growth and Development, UT Southwestern Medical Center, Dallas, TX, USA.,Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA.,Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kristin Denton
- Center for Pediatric Bone Biology and Translational Research, Scottish Rite for Children, Dallas, TX, USA
| | - Jamie Russell
- Center for Genetics of Host Defense, UT Southwestern Medical Center, Dallas, TX, USA
| | - Julia Kozlitina
- McDermott Center for Human Growth and Development, UT Southwestern Medical Center, Dallas, TX, USA
| | - Carlos R Ferreira
- Skeletal Genomics Unit, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Amy F Lewanda
- Rare Disease Institute, Children's National Hospital, Washington, DC, USA
| | - Joshua E Mayfield
- Department of Pharmacology, University of California, San Diego, CA, USA
| | - Eva Moresco
- Center for Genetics of Host Defense, UT Southwestern Medical Center, Dallas, TX, USA
| | - Sara Ludwig
- Center for Genetics of Host Defense, UT Southwestern Medical Center, Dallas, TX, USA
| | - Miao Tang
- Center for Genetics of Host Defense, UT Southwestern Medical Center, Dallas, TX, USA
| | - Xiaohong Li
- Center for Genetics of Host Defense, UT Southwestern Medical Center, Dallas, TX, USA
| | - Stephen Lyon
- Center for Genetics of Host Defense, UT Southwestern Medical Center, Dallas, TX, USA
| | - Anas Khanshour
- Center for Pediatric Bone Biology and Translational Research, Scottish Rite for Children, Dallas, TX, USA
| | - Nandina Paria
- Center for Pediatric Bone Biology and Translational Research, Scottish Rite for Children, Dallas, TX, USA
| | - Aysha Khalid
- Center for Pediatric Bone Biology and Translational Research, Scottish Rite for Children, Dallas, TX, USA
| | - Yang Li
- Center for Pediatric Bone Biology and Translational Research, Scottish Rite for Children, Dallas, TX, USA
| | - Xudong Xie
- Department of Restorative Sciences, School of Dentistry, Texas A&M University, Dallas, TX, USA
| | - Jian Q Feng
- Department of Restorative Sciences, School of Dentistry, Texas A&M University, Dallas, TX, USA
| | - Qian Xu
- Department of Restorative Sciences, School of Dentistry, Texas A&M University, Dallas, TX, USA
| | - Yongbo Lu
- Department of Restorative Sciences, School of Dentistry, Texas A&M University, Dallas, TX, USA
| | - Robert E Hammer
- Department of Biochemistry, UT Southwestern Medical Center, Dallas, TX, USA
| | - Carol A Wise
- Center for Pediatric Bone Biology and Translational Research, Scottish Rite for Children, Dallas, TX, USA.,Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA.,McDermott Center for Human Growth and Development, UT Southwestern Medical Center, Dallas, TX, USA.,Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Bruce Beutler
- Center for Genetics of Host Defense, UT Southwestern Medical Center, Dallas, TX, USA
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10
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FAM20C Overview: Classic and Novel Targets, Pathogenic Variants and Raine Syndrome Phenotypes. Int J Mol Sci 2021; 22:ijms22158039. [PMID: 34360805 PMCID: PMC8348777 DOI: 10.3390/ijms22158039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/16/2021] [Accepted: 07/18/2021] [Indexed: 12/24/2022] Open
Abstract
FAM20C is a gene coding for a protein kinase that targets S-X-E/pS motifs on different phosphoproteins belonging to diverse tissues. Pathogenic variants of FAM20C are responsible for Raine syndrome (RS), initially described as a lethal and congenital osteosclerotic dysplasia characterized by generalized atherosclerosis with periosteal bone formation, characteristic facial dysmorphisms and intracerebral calcifications. The aim of this review is to give an overview of targets and variants of FAM20C as well as RS aspects. We performed a wide phenotypic review focusing on clinical aspects and differences between all lethal (LRS) and non-lethal (NLRS) reported cases, besides the FAM20C pathogenic variant description for each. As new targets of FAM20C kinase have been identified, we reviewed FAM20C targets and their functions in bone and other tissues, with emphasis on novel targets not previously considered. We found the classic lethal and milder non-lethal phenotypes. The milder phenotype is defined by a large spectrum ranging from osteonecrosis to osteosclerosis with additional congenital defects or intellectual disability in some cases. We discuss our current understanding of FAM20C deficiency, its mechanism in RS through classic FAM20C targets in bone tissue and its potential biological relevance through novel targets in non-bone tissues.
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11
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The ABCs of the atypical Fam20 secretory pathway kinases. J Biol Chem 2021; 296:100267. [PMID: 33759783 PMCID: PMC7948968 DOI: 10.1016/j.jbc.2021.100267] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 12/12/2022] Open
Abstract
The study of extracellular phosphorylation was initiated in late 19th century when the secreted milk protein, casein, and egg-yolk protein, phosvitin, were shown to be phosphorylated. However, it took more than a century to identify Fam20C, which phosphorylates both casein and phosvitin under physiological conditions. This kinase, along with its family members Fam20A and Fam20B, defined a new family with altered amino acid sequences highly atypical from the canonical 540 kinases comprising the kinome. Fam20B is a glycan kinase that phosphorylates xylose residues and triggers peptidoglycan biosynthesis, a role conserved from sponges to human. The protein kinase, Fam20C, conserved from nematodes to humans, phosphorylates well over 100 substrates in the secretory pathway with overall functions postulated to encompass endoplasmic reticulum homeostasis, nutrition, cardiac function, coagulation, and biomineralization. The preferred phosphorylation motif of Fam20C is SxE/pS, and structural studies revealed that related member Fam20A allosterically activates Fam20C by forming a heterodimeric/tetrameric complex. Fam20A, a pseudokinase, is observed only in vertebrates. Loss-of-function genetic alterations in the Fam20 family lead to human diseases such as amelogenesis imperfecta, nephrocalcinosis, lethal and nonlethal forms of Raine syndrome with major skeletal defects, and altered phosphate homeostasis. Together, these three members of the Fam20 family modulate a diverse network of secretory pathway components playing crucial roles in health and disease. The overarching theme of this review is to highlight the progress that has been made in the emerging field of extracellular phosphorylation and the key roles secretory pathway kinases play in an ever-expanding number of cellular processes.
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12
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Bajaj S, Nabi F, Shah J, Sheth H. Recurrent variant c.1680C>A in FAM20C gene and genotype-phenotype correlation in a patient with Raine syndrome: a case report. BMC Pediatr 2021; 21:113. [PMID: 33676444 PMCID: PMC7936445 DOI: 10.1186/s12887-021-02582-7] [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: 11/19/2020] [Accepted: 03/01/2021] [Indexed: 12/17/2022] Open
Abstract
Background Bi-allelic mutations in FAM20C gene are known to cause a rare genetic disorder- Raine syndrome (RS). The FAM20C protein binds calcium and phosphorylates proteins involved in biomineralization of bones and teeth. RS is recognized as an osteosclerotic bone dysplasia. It is characterized by distinctive facial features, generalized osteosclerosis and respiratory insufficiency along with periosteal bone formation. RS is typically described as being an aggressive skeletal dysplasia with death in the neonatal period or early infancy. However, in the recent past an increasing number of individuals having an extended life span along with a highly heterogeneous phenotype has led to classifying RS into short and extended lifespan categories. Case presentation We report a case of RS with antenatal fractures, facial dysmorphism and osteosclerosis without significant respiratory manifestations. The child has a relatively extended lifespan, whereby she died at 17-months of age. Clinical exome sequencing revealed a previously known, homozygous, nonsense variant c.1680C > A (p.Cys560Ter) in exon 10 of FAM20C. Whilst the variant was initially classified as a variant of uncertain significance (VUS), through the latest release of gnomAD and GTEx data, this was subsequently re-classified as likely pathogenic. Furthermore, segregation analysis showed both parents to be carriers. In contrast, a previously reported case with the same variant had polyhydramnios, complex facial abnormalities and bright echogenic brain parenchyma with oval shaped skull and anterior flattening at 26 weeks of gestation. Conclusion The variant identified has been previously reported as a VUS. The present case provides further evidence towards the pathogenicity of the variant. A plausible genotype-phenotype correlation based on the location of the variant has been verified, wherein the position of a nonsense variant in the terminal exon of FAM20C gene, could have had a partial effect on the protein function, thereby resulting in a relatively milder phenotype and extended lifespan. Furthermore, the vast phenotypic variation on clinical comparison current case and a previously reported case, despite having the same genotype, could suggest an oligogenic effect and/ or environmental influence.
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Affiliation(s)
- Shruti Bajaj
- NH SRCC Children's Hospital, 1-1A, Keshavrao Khadye Marg, Haji Ali, Haji Ali Government Colony, Mahalakshmi, Mumbai, Maharashtra, 400034, India.
| | - Fazal Nabi
- NH SRCC Children's Hospital, 1-1A, Keshavrao Khadye Marg, Haji Ali, Haji Ali Government Colony, Mahalakshmi, Mumbai, Maharashtra, 400034, India
| | - Jhanvi Shah
- FRIGE's Institute of Human Genetics, FRIGE House, Jodhpur Gam Road, Satellite, Ahmedabad, 380015, India
| | - Harsh Sheth
- FRIGE's Institute of Human Genetics, FRIGE House, Jodhpur Gam Road, Satellite, Ahmedabad, 380015, India.
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Simancas Escorcia V, Diarra A, Naveau A, Dessombz A, Felizardo R, Cannaya V, Chatziantoniou C, Quentric M, Vikkula M, Cases O, Berdal A, De La Dure-Molla M, Kozyraki R. Lack of FAM20A, Ectopic Gingival Mineralization and Chondro/Osteogenic Modifications in Enamel Renal Syndrome. Front Cell Dev Biol 2021; 8:605084. [PMID: 33425910 PMCID: PMC7793853 DOI: 10.3389/fcell.2020.605084] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/16/2020] [Indexed: 11/13/2022] Open
Abstract
Enamel renal syndrome (ERS) is a rare recessive disorder caused by loss-of-function mutations in FAM20A (family with sequence similarity 20 member A, OMIM #611062). Enamel renal syndrome is characterized by amelogenesis imperfecta, delayed or failed tooth eruption, intrapulpal calcifications, gingival overgrowth and nephrocalcinosis. Although gingival overgrowth has consistently been associated with heterotopic calcifications the pathogenesis, structure and interactions of the mineral deposits with the surrounding connective tissue are largely unknown. We here report a novel FAM20A mutation in exon 1 (c.358C > T) introducing a premature stop codon (p.Gln120*) and resulting in a complete loss of FAM20A. In addition to the typical oral findings and nephrocalcinosis, ectopic calcified nodules were also seen in the cervical and thoracic vertebrae regions. Histopathologic analysis of the gingiva showed an enlarged papillary layer associated with aberrant angiogenesis and a lamina propria displaying significant changes in its extracellular matrix composition, including disruption of the collagen I fiber network. Ectopic calcifications were found throughout the connective gingival tissue. Immunomorphological and ultrastructural analyses indicated that the calcification process was associated with epithelial degeneration and transformation of the gingival fibroblasts to chondro/osteoblastic-like cells. Mutant gingival fibroblasts cultures were prone to calcify and abnormally expressed osteoblastic markers such as RUNX2 or PERIOSTIN. Our findings expand the previously reported phenotypes and highlight some aspects of ERS pathogenesis.
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Affiliation(s)
- Victor Simancas Escorcia
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris, Laboratory of Oral Molecular Pathophysiology, Paris, France
| | - Abdoulaziz Diarra
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris, Laboratory of Oral Molecular Pathophysiology, Paris, France
| | - Adrien Naveau
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris, Laboratory of Oral Molecular Pathophysiology, Paris, France
| | - Arnaud Dessombz
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris, Laboratory of Oral Molecular Pathophysiology, Paris, France
| | - Rufino Felizardo
- CRMR O-RARES, Hôpital Rothshild, UFR d'Odontologie-Garancière, Université de Paris, Paris, France
| | - Vidjeacoumary Cannaya
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris, Laboratory of Oral Molecular Pathophysiology, Paris, France
| | | | - Mickaël Quentric
- Department of Human Genetics, De Duve Institute, Université catholique de Louvain, Brussels, Belgium
| | - Miikka Vikkula
- Department of Human Genetics, De Duve Institute, Université catholique de Louvain, Brussels, Belgium
| | - Olivier Cases
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris, Laboratory of Oral Molecular Pathophysiology, Paris, France
| | - Ariane Berdal
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris, Laboratory of Oral Molecular Pathophysiology, Paris, France.,CRMR O-RARES, Hôpital Rothshild, UFR d'Odontologie-Garancière, Université de Paris, Paris, France
| | - Muriel De La Dure-Molla
- CRMR O-RARES, Hôpital Rothshild, UFR d'Odontologie-Garancière, Université de Paris, Paris, France.,Institut des maladies génétiques, Imagine, Paris, France
| | - Renata Kozyraki
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris, Laboratory of Oral Molecular Pathophysiology, Paris, France.,CRMR O-RARES, Hôpital Rothshild, UFR d'Odontologie-Garancière, Université de Paris, Paris, France
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14
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Hypophosphataemic Rickets Secondary to Raine Syndrome: A Review of the Literature and Case Reports of Three Paediatric Patients' Dental Management. Case Rep Pediatr 2021; 2021:6637180. [PMID: 33505751 PMCID: PMC7808805 DOI: 10.1155/2021/6637180] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/20/2020] [Accepted: 12/23/2020] [Indexed: 12/26/2022] Open
Abstract
Raine Syndrome (RS) also referred to as lethal osteosclerotic bone dysplasia describes an exceptionally rare autosomal recessive disorder with an estimated prevalence of <1 in 1,000,000. Endocrinological manifestations such as hypophosphataemic rickets depict a recent finding within the phenotypic spectrum of nonlethal RS. The dental sequelae of hypophosphataemic rickets are significant. Spontaneous recurrent abscesses on noncarious teeth result in significant odontogenic pain and multiple dental interventions. The dental presentations of nonlethal RS are less widely described within the literature. Amelogenesis Imperfecta (AI), however, was recently postulated as a key characteristic. This article presents the dental manifestations and extensive restorative and oral surgical intervention of three siblings with hypophosphataemic rickets secondary to Raine Syndrome treated at Great Ormond Street Hospital for Children, a tertiary referral hospital.
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