Triple A syndrome: genotype-phenotype assessment.

The triple A or Allgrove syndrome is an autosomal-recessive disease (MIM*231550) characterized by the triad of achalasia, alacrima and adrenocorticotropic hormone (ACTH)-resistant adrenal insufficiency. Associated features of the syndrome are neurological and dermatological abnormalities. Until the discovery of the AAAS gene as the responsible gene in triple A syndrome, the diagnosis was based on characteristic clinical features. Here we present the clinical and molecular genetic data which demonstrated the marked phenotypic variability in three unrelated patients with triple A syndrome. The final diagnosis of triple A syndrome was confirmed by molecular analysis. In one patient with isolated achalasia, the diagnosis of triple A syndrome could only be made on the basis of the molecular genetic analysis of the AAAS gene. We therefore suggest that the diagnosis of triple A syndrome should be considered in patients who exhibit only one or two of the main symptoms (i.e. alacrima, achalasia or adrenal insufficiency). These patients require careful neurological investigation, and mutation analysis of the AAAS gene should be performed.

New insights into the molecular basis of the triple A syndrome.

The triple A syndrome (MIM*231550) is a rare autosomal recessive disorder characterized by adrenocorticotropic hormone (ACTH) resistant adrenal failure, achalasia, alacrima and a variety of neurological and dermatological features. Adrenal insufficiency usually presents in the first decade of life, however in some patients it may occur later in life or may even lack completely. Recently, we and others identified a novel gene on chromosome 12q13, designated AAAS (Achalasia-Addisonianism-Alacrima-Syndrome gene) which is mutated in patients with triple A syndrome. We investigated n=84 families including 111 patients with clinically suggested triple A syndrome and identified homozygous or compound heterozygous AAAS mutations in 78 families. Genotype/phenotype analyses revealed a highly variable occurrence, age of onset and severity of all clinical symptoms between patients with the same AAAS mutation. The obvious lack of a genotype/phenotype relationship is suggestive of modifying genes/factors which need to be determined. The AAAS protein function is unknown. With four WD repeats it belongs to the family of WD repeat-containing proteins which may exhibit a high degree of functional diversity. The subcellular localization of the protein and the determination of its putative binding partners will shed light on the role of the AAAS protein for the development and function of the adrenal gland and other neuroendocrine structures.

Triple A syndrome is caused by mutations in AAAS, a new WD-repeat protein gene.

The triple A syndrome (MIM 231550) is a rare autosomal recessive disorder characterized by adrenal insufficiency, achalasia and alacrima. The frequent association with a variety of neurological features may result in a severely disabling disease. We previously mapped the syndrome to a 6 cM interval on chromosome 12q13 and have now refined the critical region to 0 cM between KRT8 and D12S1651. Overlapping bacterial artificial chromosome (BAC) sequences of a high resolution BAC/P1-derived artificial chromosome (PAC) contig were screened for gene content and a novel gene encoding a 546 amino acid polypeptide was identified. In nine triple A syndrome patients eight different homozygous and compound heterozygous mutations were found in this gene, most of them leading to a truncated protein suggesting loss of function. RNA blotting experiments revealed marked expression in neuroendocrine and gastrointestinal structures, which are predominantly affected in triple A syndrome, supporting the hypothesis that mutations in this triple A syndrome gene (AAAS) are responsible for the disease. The predicted protein belongs to the family of WD repeat-containing proteins which exhibit a high degree of functional diversity including regulation of signal transduction, RNA processing and transcription.

Triple A syndrome--clinical aspects and molecular genetics.

The triple A syndrome or Allgrove syndrome (MIM*231550) is characterized by adrenocorticotropic hormone (ACTH) resistant Adrenal insufficiency, Achalasia of the cardia and Alacrima. In addition to the main features, patients frequently suffer from neurological disturbances. Dermatological abnormalities such as palmoplantar hyperkeratosis as well as other signs like short stature, microcephaly and osteoporosis point to the multisystemic character of the disorder. The molecular defect of the autosomal recessively inherited triple A syndrome is not known. We initially performed a systematic genome linkage scan in eight triple A families and were able to map the syndrome to a 6 cM interval on human chromosome 12q13 near the type II keratin gene cluster. A refinement of the triple A critical region was achieved by detailed haplotype analysis in a further 37 families from different ethnic backgrounds. There was no indication of genetic heterogeneity. The achalasia-alacrima (AA) syndrome which has been defined as a distinct clinical entity (MIM 200440) is most likely a variant of the triple A syndrome as shown by haplotype analysis in three AA families. We constructed a high-resolution BAC/PAC-based transcript map of the region which will greatly facilitate the identification of the triple A syndrome gene. The considerable intra- and interfamilial variability of the severity of the disorder implies a variable expression of an impaired pleiotropically acting gene.

Different expression of the alpha2-macroglobulin receptor/low-density lipoprotein receptor-related protein in human keratinocytes and fibroblasts.

We compared, using a combination of different immunological methods and by competitive PCR, the expression of the alpha2-macroglobulin receptor/low-density lipoprotein receptor-related protein (alpha2-M-R/LRP) in human keratinocytes and fibroblasts. This receptor has previously been found in skin only in dermal cells associated with fibroblasts and dendritic cells. For immunodetection we used mouse monoclonal antibodies against the two subunits of the receptor and against the receptor-associated protein (RAP), known as the regulatory protein of the receptor activity. The alpha2-M-R/LRP was found to be predominantly located intracellularly in keratinocytes whereas a distinct labelling of the outer membrane surface was found in fibroblasts. RAP is abundant in fibroblasts but is less expressed in keratinocytes. In frozen skin sections receptor immunoreactivity was detected in the epidermis with increased reactivity of basal keratinocytes, as well as in the dermis in association with dermal fibroblasts. By immunoprecipitation of biotinylated cell extracts, polypeptides were identified corresponding to the alpha-subunit and beta-subunit of the receptor as well as to the coprecipitating RAP. Competitive PCR revealed the presence of 67.9 and 2049.7 ag of alpha2-M-R/LRP mRNA per cell in keratinocytes and fibroblasts, respectively. The results demonstrate that both cell types express alpha-M-R/LRP mRNA and contain receptor protein as well as RAP but in different quantities and subcellular localizations.

Angiotensin-converting enzyme gene insertion/deletion polymorphism and peripheral arterial occlusive disease.

BACKGROUND: The deletion polymorphism of the ACE gene is linked to a high risk of cardiovascular disease due to the permanent activation of the local and systemic renin-angiotensin systems (RAS). The aim of this prospective study was 1. to compare the ACE insertion/deletion polymorphism in individuals with a healthy vasculature with that of patients suffering from peripheral arterial occlusive disease (PAOD), and 2. to determine whether associations existed between specific clinical parameters and the ACE genotype which the PAOD patients expressed. PATIENTS AND METHODS: Determinations of ACE I/D gene polymorphism were made using a polymerase chain reaction (PCR) technique on 98 patients with clinical stage II PAOD according to Fontaine and 240 healthy individuals who served as controls. All patients and controls came from central Germany. Clinical variables which included duration of clinical symptoms, a familial history of the disease, arteriosclerosis score (ASF, providing an estimate of the extent of atheromatosis at femoral artery bifurcation) and plasma ACE activity were correlated with the genotypes taking the cardiovascular disease risk factors which were present into consideration. RESULTS: Differences in ACE genotypes between patients with PAOD (D/I: 0.57/0.43) and control group individuals (D/I: 0.59/0.41) were not observed. In comparison with the II genotype, the DD genotype was associated with a shorter duration of disease (p = 0.01), a positive family medical history (p = 0.022) and a higher plasma ACE activity (p = 0.026). The ASF did not correlate with the ACE I/D gene polymorphism. CONCLUSION: Evidence that the deletion allele is linked to the manifestation of PAOD could not be found in the patients studied. One can assume, however, that the deletion allele has a progression promoting effect on the disease.

Low-density lipoprotein receptor-related protein in atherosclerosis development: up-regulation of gene expression in patients with coronary obstruction.

The low-density lipoprotein receptor-related protein (LRP) is a multifunctional cell-surface receptor that binds and mediates the endocytosis of several structurally and functionally distinct ligands. Involved in a variety of biological processes, including the regulation of the coagulation-fibrinolysis balance, the lipoprotein metabolism, cellular migration, proliferative processes and degenerative diseases, it has very recently become an interesting candidate for functional studies of the development of atherosclerosis. We investigated the individual cellular LRP gene expressions in 100 patients with angiographically confirmed severe coronary obstructions (myocardial infarction, patients with coronary angioplasty and patients with coronary bypass). Using a competitive reverse transcriptase polymerase chain reaction analysis we measured the specific LRP mRNA levels in monocytes from venous blood. In comparison with 110 unselected controls (122.1 ag/cell) the patient group demonstrated significantly higher LRP message levels (171.92 ag/cell). We found the most evident increase in the coronary angioplasty group (+43.5%). Investigating the intraindividual range of expression in healthy controls over a period of 4 weeks, we found nearly constant individual levels. Our results demonstrate a significant correlation of increased LRP mRNA levels with atherosclerotic processes (P<0.001), suggest an important implication of the LRP in atherosclerotic vascular processes, and emphasize the inclusion of LRP investigations in risk constellation studies.