Novel Mutation in PTHLH Related to Brachydactyly Type E2 Initially Confused with Unclassical Pseudopseudohypoparathyroidism

BACKGROUND: Autosomal-dominant brachydactyly type E is a congenital abnormality characterized by small hands and feet, which is a consequence of shortened metacarpals and metatarsals. We recently encountered a young gentleman exhibiting shortening of 4th and 5th fingers and toes. Initially, we suspected him having pseudopseudohypoparathyroidism (PPHP) because of normal biochemical parameters, including electrolyte, Ca, P, and parathyroid hormone (PTH) levels; however, his mother and maternal grandmother had the same conditions in their hands and feet. Furthermore, his mother showed normal biochemical parameters. To the best of our knowledge, PPHP is inherited via a mutated paternal allele, owing to the paternal imprinting of GNAS (guanine nucleotide binding protein, alpha stimulating) in the renal proximal tubule. Therefore, we decided to further analyze the genetic background in this family. METHODS: Whole exome sequencing was performed using genomic DNA from the affected mother, son, and the unaffected father as a negative control. RESULTS: We selected the intersection between 45,490 variants from the mother and 45,646 variants from the son and excluded 27,512 overlapping variants identified from the father. By excluding homogenous and compound heterozygous variants and removing all previously reported variants, 147 variants were identified to be shared by the mother and son. Variants that had least proximities among species were excluded and finally 23 variants remained. CONCLUSION: Among them, we identified a defect in parathyroid hormone like hormone (PTHLH), encoding the PTH-related protein, to be disease-causative. Herein, we report a family affected with brachydactyly type E2 caused by a novel PTHLH mutation, which was confused with PPHP with unclassical genetic penetrance.

Avaliação fenotípica e de defeitos moleculares no GNAS em pacientes com pseudo-hipoparatireoidismo (PHP) e pseudopseudo-hipoparatireoidismo (PPHP) / Evaluation of the phenotype and molecular defect in GNAS in patients with pseudohypoparathyroidism (PHP) and pseudopseudohypoparathyroidism

INTRODUÇÃO: A primeira doença humana atribuída à resistência hormonal foi o pseudo-hipoparatireoidismo (PHP), uma doença rara caracterizada por hipocalcemia, hiperfosfatemia e níveis elevados de hormônio paratireoidiano (PTH) na presença de função renal normal, quadro condizente com resistência ao PTH. A classificação original do PHP leva em consideração a osteodistrofia hereditária de Albright (AHO): presente no PHP1a e ausente no PHP1b. Na medida em que as bases moleculares do PHP têm sido compreendidas, uma classificação baseada no genótipo tem surgido. Segundo ela, pacientes com PHP1a apresentam mutações na região codificadora da Gsalfa do GNAS e o padrão de herança é autossômico dominante relacionado à transmissão materna. Por outro lado, o PHP1b é caracterizado por alterações nas regiões diferencialmente metiladas (DMRs) do GNAS por mecanismos não completamente esclarecidos, limitando a previsão do seu padrão de herança. Pacientes que apresentam a AHO na ausência de resistência hormonal têm o diagnóstico de pseudopseudo-hipoparatireoidismo (PPHP) e seu padrão de herança é autossômico dominante relacionado à transmissão paterna de mutações na região codificadora da Gsalfa do GNAS. OBJETIVOS: Classificar 25 pacientes com PHP com base em defeitos no GNAS e caracterizar seu fenótipo. Pesquisar mutações no GNAS nos quatro pacientes com PPHP e também caracterizar seu fenótipo. MÉTODOS: A avaliação fenotípica incluiu análise das resistências hormonais, pesquisa de repercussões crônicas da hipocalcemia/hiperfosfatemia (calcificações em sistema nervoso central: SNC e catarata) e identificação da AHO. A análise do GNAS foi feita por sequenciamento automático e MLPA (região codificadora da Gsalfa) e por MS-MLPA (região regulatória: DMRs). RESULTADOS: Resistência ao PTH foi identificada nos 25 pacientes com PHP e resistência ao TSH em 17/25. Calcificações em SNC e catarata estiveram presentes em 18 e 10 pacientes com PHP, respectivamente. A...

BACKGROUND: The first human disease attributed to hormone resistance was pseudohypoparathyroidism (PHP), a rare disease characterized by hypocalcemia, hyperphosphatemia and elevated parathyroid hormone (PTH) levels in the presence of normal renal function, consistent picture of PTH resistance. The original classification of PHP takes into account the Albright hereditary osteodystrophy (AHO): present in PHP1a and absent in PHP1b. As the molecular bases of PHP have been understood, a classification based on genotype has emerged. According to it, PHP1a patients present mutations in the Gsalpha coding region of the GNAS and the pattern of inheritance is autosomal dominant related to maternal transmission. On the other hand, PHP1b is characterized by alterations in differentially methylated regions (DMRs) of the GNAS by mechanisms not completely clear, limiting the prediction of the pattern of inheritance. Patients who present AHO in the absence of hormone resistance have the diagnosis of pseudopseudohypoparathyroidism (PPHP) and their pattern of inheritance is autosomal dominant related to paternal transmission of mutations in the Gsalfa coding region of the GNAS. OBJECTIVE: To classify 25 patients with PHP based on GNAS molecular defects and to characterize their phenotype. To search for GNAS mutations in four patients with PPHP and also to characterize their phenotype. METHODS: The phenotypic evaluation included analysis of hormone resistances, research of chronic repercussions of hypocalcemia/hyperphosphatemia (calcifications in central nervous system: CNS and cataract) and identification of AHO. The analysis of the GNAS was done by automated sequencing and MLPA (Gsalphaa coding region) and by MS-MLPA (regulatory region: DMRs). RESULTS: PTH resistance was identified in 25 patients with PHP and TSH resistance in 17/25. Calcifications in CNS and cataract were present in 18 and 10 patients with PHP, respectively. AHO was characterized by: rounded face (n=18),...

Polyglandular Autoimmune Syndrome Type III with Primary Hypoparathyroidism

Polyglandular autoimmune syndrome is defined as multiple endocrine gland insufficiencies accompanied by autoimmune diseases of the endocrine and nonendocrine system. After Schmidt introduced a case of nontuberculosis adrenal gland dysfunction with thyroiditis in 1926, Neufeld defined polyglandular autoimmune syndrome by I, II, and III subtypes in 1980 by their presentation of occurrence age, heredity methods, relationship with human leukocyte antigen, and accompanying diseases. We report a case of a 32-year-old female with polyglandular autoimmune syndrome III accompanied by type 1 diabetes mellitus that was treated with insulin (36 units per day) for 11 years. She had insulin deficiency and Hashimoto thyroiditis as an autoimmune disorder. In addition, she had several features similar to Albright's hereditary osteodystrophy including short stature, truncal obesity, round face, short neck, low intelligence (full IQ 84), and decreased memory. Although Albright's hereditary osteodystrophy is morphological evidence of pseudohypoparathyroidism or pseudopseudohypoparathyroidism, she had primary hypoparathyroidism on laboratory results. Here, we report a case of polyglandular autoimmune syndrome III with type 1 diabetes mellitus, autoimmune thyroiditis, and primary hypoparathyroidism, accompanied by clinical features similar to Albright's hereditary osteodystrophy.

A Case of Osteoma Cutis, a Diagnostic Clue for Albright's Hereditary Osteodystrophy / 대한피부과학회지

Albright's hereditary osteodystrophy (AHO) has a broad spectrum of physical findings, including short stature, flattened nasal bridge, round facies, obesity, skeletal anomalies of the hands with brachydactyly, osteoma cutis, mental retardation, dental defects, cataracts, and calcification in the basal ganglia. It also includes endocrinologic abnormalities such as pseudohypoparathyroidism and pseudopseudohypoparathyroidism. Primary osteoma cutis, which can precede other physical findings of AHO, might be a diagnostic clue for AHO. Therefore, close follow-up and regular laboratory tests should be done to detect the early development of AHO in young children with primary osteoma cutis. Early diagnosis and treatment of AHO can prevent irreversible mental retardation and developmental delay.

Two Cases of Albright's Hereditary Osteodystrophy Occurring in Pseudopseudohypoparathyroidism / 대한피부과학회지

A 36 year-old man and his 6 month-old daughter presented with multiple, slightly depressed, skin-colored, hard nodules and plaques on the abdomen, back, and both extremities. They also showed abnormal physical appearance, including short stature and neck, round face, and short digits, which suggested Albright's hereditary osteodystrophy (AHO). Histopathologically, various sized bony spicules were present in the dermis. The laboratory results showed normal serum calcium, phosphorus and parathyroid hormone levels. On the basis of clinical, laboratory and histologic findings, we diagnosed these cases as Albright's hereditary osteodystrophy with cutaneous ossification occurring in pseudopseudohypoparathyroidism.

Two Cases of Albright's Hereditary Osteodystrophy Occurring in Pseudopseudohypoparathyroidism / 대한피부과학회지

A 36 year-old man and his 6 month-old daughter presented with multiple, slightly depressed, skin-colored, hard nodules and plaques on the abdomen, back, and both extremities. They also showed abnormal physical appearance, including short stature and neck, round face, and short digits, which suggested Albright's hereditary osteodystrophy (AHO). Histopathologically, various sized bony spicules were present in the dermis. The laboratory results showed normal serum calcium, phosphorus and parathyroid hormone levels. On the basis of clinical, laboratory and histologic findings, we diagnosed these cases as Albright's hereditary osteodystrophy with cutaneous ossification occurring in pseudopseudohypoparathyroidism.

Osteoma Cutis as the Presenting Feature of Albright Hereditary Osteodystrophy Associated with Pseudopseudohypoparathyroidism

Primary osteoma cutis is characterized by the formation of normal bone tissue in the dermis or subcutis without any underlying tissue abnormality or pre-existing calcification. This illness is associated with Albright hereditary osteodystrophy (AHO), which is characterized by such physical features as a short stature, round face, obesity, brachydactyly and osteoma cutis. Pseudohypoparathyroidism (PHP) is an inherited metabolic disorder that's characterized by resistance to parathyroid hormone, and PHP is present in most AHO patients. An AHO phenotype without hormonal resistance is called pseudopseudohypoparathyroidism (PPHP). Osteoma cutis is less common in patients with PPHP than in patients with PHP. We present here a case of osteoma cutis as the cardinal manifestation of AHO associated with PPHP. Osteoma cutis is an important sign of AHO and its significance should not be overlooked, even if the patient has normal values on the serum biochemical tests.

Osteoma Cutis as the Presenting Feature of Albright Hereditary Osteodystrophy Associated with Pseudopseudohypoparathyroidism

Primary osteoma cutis is characterized by the formation of normal bone tissue in the dermis or subcutis without any underlying tissue abnormality or pre-existing calcification. This illness is associated with Albright hereditary osteodystrophy (AHO), which is characterized by such physical features as a short stature, round face, obesity, brachydactyly and osteoma cutis. Pseudohypoparathyroidism (PHP) is an inherited metabolic disorder that's characterized by resistance to parathyroid hormone, and PHP is present in most AHO patients. An AHO phenotype without hormonal resistance is called pseudopseudohypoparathyroidism (PPHP). Osteoma cutis is less common in patients with PPHP than in patients with PHP. We present here a case of osteoma cutis as the cardinal manifestation of AHO associated with PPHP. Osteoma cutis is an important sign of AHO and its significance should not be overlooked, even if the patient has normal values on the serum biochemical tests.

Albright's hereditary osteodystrophy.

Albright's hereditary osteodystrophy is a rare inherited metabolic disorder characterized by a typical phenotype. It may be associated with or without resistance to parathyroid hormone (pseudohypoparathyroidism). Both forms may co-exist in the same family. Pseudohypoparathyroidism Type 1 and Pseudo-pseudohypoparathyroidism occur as a consequence of reduced erythrocyte membrane coupled with Gs alpha activity. We report here the variable inheritance of hormone resistance in the presence of characteristic phenotype and reduced Gs alpha activity in the same family.

Osteoma cutis in Albright's Hereditary Osteodystrophy / 대한피부과학회지

Albright's hereditary osteodystrophy is an inherited syndrome that encompasses endocrinologic anomaly of pseudohypoparathyroidim or less commonly, pseudo-pseudohypoparathyroidism and various physical stigmata such as mental retardation, short stature, skeletal anomaly of the hands, abnormal dentition, round facies, and osteoma cutis. Primary osteoma cutis in this syndrome presents at birth or in early infancy, preceding most of the other manifestations. This case is a typical presentation with osteoma cutis as the sole initial manifestation. Rather unfamiliar to dermatologists, Albright's hereditary osteodystrophy still deserves to be included in the differentials when an isolated case of osteoma cutis presents in a young child.

A Case of Pseudopseudohypoparathyroidism with Partial Empty Sella / 대한내분비학회지

Pseudohypoparathyroidism (PHP) is a rare endocrine syndrome, which is characterized by Albright's hereditary osteodystrophy (AHO). Pseudopseudohypoparathyroidism (PPHP) presents with AHO features, but does not show clinical symptoms or the same laboratory finding as hypoparathyroidism. A 54 aged woman visited our department with lower abdominal pain. She had a history of a total hysterectomy due to persistent uterine bleeding 30 years previously. She showed abnormal physical findings, including a round face, short stature and brachydactyly. Her hormonal data were within normal limits, as follows: PTH 40.72 pg/mL, calcium 8.6 mg/dL, phosphorus 4.0 mg/dL and 24 hour urine cAMP 3.2 nmol/mg. On a pituitary challenge test, the basal levels and response rates of FSH and LH were low, and a sella CT scan showed partially empty sella. Herein is reported a case of PPHP, with partial empty sella, with a review of the literature

A Case of Pseudopseudohypoparathyroidism with Partial Empty Sella / 대한내분비학회지

Pseudohypoparathyroidism (PHP) is a rare endocrine syndrome, which is characterized by Albright's hereditary osteodystrophy (AHO). Pseudopseudohypoparathyroidism (PPHP) presents with AHO features, but does not show clinical symptoms or the same laboratory finding as hypoparathyroidism. A 54 aged woman visited our department with lower abdominal pain. She had a history of a total hysterectomy due to persistent uterine bleeding 30 years previously. She showed abnormal physical findings, including a round face, short stature and brachydactyly. Her hormonal data were within normal limits, as follows: PTH 40.72 pg/mL, calcium 8.6 mg/dL, phosphorus 4.0 mg/dL and 24 hour urine cAMP 3.2 nmol/mg. On a pituitary challenge test, the basal levels and response rates of FSH and LH were low, and a sella CT scan showed partially empty sella. Herein is reported a case of PPHP, with partial empty sella, with a review of the literature

A Case of Cutaneous Ossification occurring in Pseudohypoparathyroidism

In Albright's hereditary osteodystrophy (AHO) including the syndromes of pseudohypoparathyroidism (PHP) and pseudopseudohypoparathyroidism (PPHP), multiple areas of intracutaneous ossification are often encountered. The characteristic features are short stature, round face, short neck, obesity, cutaneous ossifications, and various skeletal anomalies including short metacarpal and metatarsal bones, curve of radius, and brachydactyly. The patient was a 10-month-old male infant. He presented slightly depressed erythematous hard plaques on the left upper chest and left thigh. We had taken biopsies from both skin lesions, confirming cutaneous ossification or bone formation. He also had the characteristic features of AHO. He had a history of admission due to patent ductus arteriosus and atrial septal defect. The laboratory results showed slightly decreased calcium, increased phosphorus and PTH levels. The patient received no specific corrective measures because his calcium and phosphorus levels were not far from normal values until newly developed similar skin lesions appeared.

A Case of Benign Intracranial Hypertension in Pseudopseudohypoparathyroidism

We describe a rare case of pseudopseudohypoparathyroidism (PPHP) with benign intracranial hypertension (BIH). A 16 year-old male presented with headache, vomiting, ocular pain, blurred vision, and diplopia following minor head trauma. He showed developmental delay, short stature and short metacarpals and phalanges, which suggested Albright's hereditary osteodystrophy. Neurologic examination revealed bilateral sixth cranial nerve palsy and bilateral papilledema. Lumbar puncure disclosed an elevated opening CSF pressure with normal biochemical and celluar find-ings. However, the levels of serum calcium, phosphorus and parathyroid hormone were within the normal limits and chromosomal analyses were normal. Brain MRI revealed normal ventricular size and no structural abnormality. We concluded that PPHP seemed to have a key role for the genesis of BIH in this case, although previous mild head trauma might have a precipitating effect.

Psoríase e pseudo-hipoparatireoidismo / Psoriasis and pseudohypoparathyroidism

Relato de caso clínico de paciente do sexo masculino, de 24 anos de idade, com psoríase pustulosa havia dois meses. Apresentava antecedentes de crises convulsivas e retardo do desenvolvimento neuropsicomotor. Ao exame físico o sinal de Trousseau foi positivo, e a dosagem de cálcio no soro estava acentuadamente diminuída. O diagnóstico foi de psoríase pustulosa generalisada associada a pseudo-hipoparatireoidismo. Inicialmente o paciente foi tratado com etretinato, sem controle do quadro; porém, com detecçäo da hipocalcemia e a reposiçäo do cálcio, houve melhora acentuada das lesöes cutâneas. A remissäo completa foi obtida com a correçäo da hipocalcemia. Esses resultados indicam que a hipocalcemia estava diretamente relacionada com a manutençäo das lesöes de psoríase pustulosa generalizada e pseudo-hipoparatireoidismo

Diagnóstico por imágenes en el pseudo-pseudohipoparatiroidismo / Diagnostic imaging in pseudo-pseudohypoparathyroidism

El pseudo-pseudohipoparatiroidismo (PPHP) es una enfermedad rara, de probable origen genético sexual dominate, ligado al cromosoma X. Se la considera como una variedad normocalcémica del PHP (Pseudohipoparatiroidismo). Se describe una familia con diagnóstico clínico hormonal de PPHP. Se presentan los valores de laboratorio y la clínica de los miembros afectados. Se destaca la descripción imagenológica de las lesiones halladas, mediante TC, US y Rx simple

A Case Report of Pseudopseudohypoparathyroidism

A case of pseudopseudohypoparathyroidism is reported. The patient, a 23-year-old man, has suffered from generalized tonic-clonic seizure for 16 years and gait disturbance for 4 years. He has the phenotypic features of Albright's hereditary osteodystrophy. But the levels of parathyroid hormone, serum calcium and phosphorus are all normal. The case is presented with the reviewed of the literature.

Calcificaçöes intensas e simétricas dos gânglios da base e cerebelo visualizadas na tomografia computadorizada / Intensive and simmetric basal ganglia calcifications visualized in computerized tomography

Os autores apresentam 2 casos com calcificaçöes intensas e simétricas junto aos núcleos da base e núcleos do cerebelo visualizadas na tomografia computadorizada. O estudo metabólico mostrou que um dos pacientes tinha pseudohipoparatireoidismo e o outro hipoparatireoidismo (cirúrgico). O primeiro paciente teve crises convulsivas focais generalizadas que estavam se tornando cada vez mais freqüentes a despeito da medicaçäo. O tratamento da alteraçäo metabólica trouxe evidente melhora no controle das crises. O outro desenvolveu síndrome parkinsoniana, que obteve melhora parcial com L-Dopa. O relato é apresentado uma vez que näo foi encontrada publicaçäo nacional relativa ao assunto

Metatarsalgia em pseudopseudo-hipoparatiroidismo: apresentaçäo de um caso / Metatarsalgia in pseudopseudo-hypoparathyroidism: report of a case

Os autores apresentam 1 caso de metatarsalgia por pseudopseudo-hipoparatiroidismo (oesteodistrofia hereditária de Albright) e analisam o tratamento ortopédico das dismorfias esqueléticas