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Lounev V, Groppe JC, Brewer N, Wentworth KL, Smith V, Xu M, Schomburg L, Bhargava P, Al Mukaddam M, Hsiao EC, Shore EM, Pignolo RJ, Kaplan FS. Matrix metalloproteinase-9 deficiency confers resilience in fibrodysplasia ossificans progressiva in a man and mice. J Bone Miner Res 2024; 39:382-398. [PMID: 38477818 DOI: 10.1093/jbmr/zjae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 03/14/2024]
Abstract
Single case studies of extraordinary disease resilience may provide therapeutic insight into conditions for which no definitive treatments exist. An otherwise healthy 35-year-old man (patient-R) with the canonical pathogenic ACVR1R206H variant and the classic congenital great toe malformation of fibrodysplasia ossificans progressiva (FOP) had extreme paucity of post-natal heterotopic ossification (HO) and nearly normal mobility. We hypothesized that patient-R lacked a sufficient post-natal inflammatory trigger for HO. A plasma biomarker survey revealed a reduction in total matrix metalloproteinase-9 (MMP-9) compared to healthy controls and individuals with quiescent FOP. Whole exome sequencing identified compound heterozygous variants in MMP-9 (c.59C > T, p.A20V and c.493G > A, p.D165N). Structural analysis of the D165N variant predicted both decreased MMP-9 secretion and activity that were confirmed by enzyme-linked immunosorbent assay and gelatin zymography. Further, human proinflammatory M1-like macrophages expressing either MMP-9 variant produced significantly less Activin A, an obligate ligand for HO in FOP, compared to wildtype controls. Importantly, MMP-9 inhibition by genetic, biologic, or pharmacologic means in multiple FOP mouse models abrogated trauma-induced HO, sequestered Activin A in the extracellular matrix (ECM), and induced regeneration of injured skeletal muscle. Our data suggest that MMP-9 is a druggable node linking inflammation to HO, orchestrates an existential role in the pathogenesis of FOP, and illustrates that a single patient's clinical phenotype can reveal critical molecular mechanisms of disease that unveil novel treatment strategies.
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Affiliation(s)
- Vitali Lounev
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Jay C Groppe
- Department of Biomedical Sciences, Texas A & M University College of Dentistry, Dallas, TX 75246-2013, United States
| | - Niambi Brewer
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Kelly L Wentworth
- Department of Medicine, Division of Endocrinology and Metabolism, Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA 94143-0794, United States
- Department of Medicine, University of California, San Francisco, CA 94143-0794, United States
| | | | - Meiqi Xu
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Lutz Schomburg
- Institute for Experimental Endocrinology, Charite University Hospital, D-10115 Berlin, Germany
| | | | - Mona Al Mukaddam
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- Department of Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Edward C Hsiao
- Department of Medicine, University of California, San Francisco, CA 94143-0794, United States
- Division of Endocrinology and Metabolism, The Institute for Human Genetics, the Program in Craniofacial Biology, University of California, San Francisco, CA 94143-0794, United States
| | - Eileen M Shore
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- Department of Genetics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Robert J Pignolo
- Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- Department of Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
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