Flecainide provocation reveals concealed brugada syndrome in a long QT syndrome family with a novel L1786Q mutation in SCN5A.

BACKGROUND: Mutations in SCN5A can result in both long QT type 3 (LQT3) and Brugada syndrome (BrS), and a few mutations have been found to have an overlapping phenotype. Long QT syndrome is characterized by prolonged QT interval, and a prerequisite for a BrS diagnosis is ST elevation in the right precordial leads of the electrocardiogram. METHODS AND RESULTS: In a Danish family suffering from long QT syndrome, a novel missense mutation in SCN5A, changing a leucine residue into a glutamine residue at position 1786 (L1786Q), was found to be present in heterozygous form co-segregating with prolonged QT interval. The proband presented with an aborted cardiac arrest, and his mother died suddenly and unexpectedly at the age of 65. Flecainide treatment revealed coved ST elevation in all mutation carriers. Electrophysiological investigations of the mutant in HEK293 cells indicated a reduced peak current, a negative shift in inactivation properties and a positive shift in activation properties, compatible with BrS. Furthermore, the sustained (I(Na,late)) tetrodotoxin-sensitive sodium current was found to be drastically increased, explaining the association between the mutation and LQT syndrome. CONCLUSIONS: The L1786Q mutation is associated with a combined LQT3 and concealed BrS phenotype explained by gating characteristics of the mutated ion channel protein. Hence, sodium channel blockade should be considered in clinical evaluation of apparent LQT3 patients.

Mutations in Danish patients with long QT syndrome and the identification of a large founder family with p.F29L in KCNH2.

BACKGROUND: Long QT syndrome (LQTS) is a cardiac ion channelopathy which presents clinically with palpitations, syncope or sudden death. More than 700 LQTS-causing mutations have been identified in 13 genes, all of which encode proteins involved in the execution of the cardiac action potential. The most frequently affected genes, covering > 90% of cases, are KCNQ1, KCNH2 and SCN5A. METHODS: We describe 64 different mutations in 70 unrelated Danish families using a routine five-gene screen, comprising KCNQ1, KCNH2 and SCN5A as well as KCNE1 and KCNE2. RESULTS: Twenty-two mutations were found in KCNQ1, 28 in KCNH2, 9 in SCN5A, 3 in KCNE1 and 2 in KCNE2. Twenty-six of these have only been described in the Danish population and 18 are novel. One double heterozygote (1.4% of families) was found. A founder mutation, p.F29L in KCNH2, was identified in 5 "unrelated" families. Disease association, in 31.2% of cases, was based on the type of mutation identified (nonsense, insertion/deletion, frameshift or splice-site). Functional data was available for 22.7% of the missense mutations. None of the mutations were found in 364 Danish alleles and only three, all functionally characterised, were recorded in the Exome Variation Server, albeit at a frequency of < 1:1000. CONCLUSION: The genetic etiology of LQTS in Denmark is similar to that found in other populations. A large founder family with p.F29L in KCNH2 was identified. In 48.4% of the mutations disease causation was based on mutation type or functional analysis.

Fabry disease mimicking hypertrophic cardiomyopathy: genetic screening needed for establishing the diagnosis in women.

AIMS: Fabry disease, an X-linked storage disorder caused by defective lysosomal enzyme alpha-galactosidase A activity, may resemble sarcomere-gene-associated hypertrophic cardiomyopathy (HCM). The 'cardiac variant' of Fabry disease which only affects the heart may be missed unless specifically tested for. METHODS AND RESULTS: We evaluated 90 consecutively recruited HCM probands and their relatives. Probands without sarcomere-gene mutations were tested for alpha-galactosidase A gene (GLA) mutations. Of the 90 families, 31 (34%) had sarcomere gene mutations and were therefore excluded. In the remaining 59 probands, 3 (5%) had GLA mutations as follows. The first proband, a female with asymmetric septal hypertrophy (ASH), a significant left ventricular outflow tract gradient, and chronic obstructive pulmonary disease, was heterozygous for a novel missense mutation (p.N139S). The second proband, a male with ASH and multiple episodes of ventricular tachycardia, was hemizygous for a missense mutation (p.A156T). His daughter was heterozygous, but had normal enzyme activity. The third proband was a female with ASH, and no other indices of Fabry disease. She was heterozygous for a GLA missense mutation (p.G271S). She had one affected daughter but her two other children were unaffected. The affected daughter had three children, of whom two were also affected--a boy aged 8 and a daughter aged 10 years. CONCLUSION: This is the first report of systematic mutation screening of GLA in HCM patients without sarcomere gene mutations. GLA mutations were found in 3/90 (3%) of HCM families and in 2/20 (10%) of females without sarcomere-gene mutations. None of the probands presented other indices of Fabry disease. This, in combination with putative reversibility of cardiac changes by enzyme replacement therapy, supports systematic testing for Fabry disease. Enzyme measurements are sufficient in men, but genetic testing is needed in women.

The variation of the sarcolipin gene (SLN) in atrial fibrillation, long QT syndrome and sudden arrhythmic death syndrome.

BACKGROUND: Mutations in genes responsible for the cardiac action potential and control of intracellular Ca(2+)-distribution are associated with cardiac arrhythmia and sudden death. Sarcolipin is a 31-amino acid protein that inhibits the sarcoplasmic reticulum Ca(2+) ATPase pump (SERCA2). The sarcolipin gene, SLN, is expressed in the heart and a candidate gene for cardiomyopathy as well as atrial fibrillation (AF), long QT syndrome (LQTS) or sudden arrhythmic death syndrome (SADS). We examined the genetic variation of SLN in patients with the arrhythmic disorders AF, LQTS and SADS. METHODS: We screened the coding region of SLN for mutations using single strand conformation polymorphism/heteroduplex analysis on PCR-amplified genomic DNA from 95 unrelated LQTS patients, 59 SADS cases and 147 patients with atrial fibrillation (AF) and 92 controls. Aberrant conformers were sequenced. RESULTS: No mutations or polymorphisms were found in the coding sequence. A G>C transition in the highly conserved position +1 of the 3'untranslated region (3'UTR) was found in two SADS cases. A polymorphism, a G>C transition at position -65 in the 5'untranslated region (5'UTR), was found with a G allele frequency of 0.48. A borderline significant difference in genotype distribution of the latter polymorphism was found between the AF group and controls. CONCLUSION: Mutations in the coding region of SLN are not frequently involved in LQTS, SADS or AF. Whether the described 3'- and 5'UTR variants have functional significance must await further studies.

CRYAB promoter polymorphisms: influence on multiple sclerosis susceptibility and clinical presentation.

BACKGROUND: alphaB-crystallin is a molecular chaperone and potential myelin antigen, up-regulated in the earlier stages of multiple sclerosis (MS) lesions. In the alphaB-crystallin gene (CRYAB), single nucleotide polymorphisms (SNPs) have been associated with MS susceptibility (g.CRYAB-652A>G) and a rapidly progressive clinical course (g.CRYAB-650C>G). METHOD: CRYAB was screened for mutations in 233 MS patients and 96 controls. Genomic DNA was extracted and the coding and 3' and 5' untranslated regions were amplified by PCR. Subsequently, the products were analysed by Single Strand Conformation Polymorphism technique followed by DNA sequencing of aberrant conformers. RESULTS: In CRYAB (Genbank ) no mutations were found but SNPs were identified in the promoter region (g.CRYAB-249C>G, g.CRYAB-650C>G and g.CRYAB-652A>G), and intronic region (g.CRYAB.2398T>G). The g.CRYAB-249C>G genotype distribution was significantly different between groups (chi(2), p=0.01), caused by differences between Relapsing Remitting MS (RRMS) and controls (chi(2), p=0.025) and Secondary Progressive MS (SPMS) and controls (chi(2), p=0.05). In addition, a significant difference was observed in the g.CRYAB-249C>G allele distribution (chi(2), p=0.04), caused by a difference between SPMS and controls (chi(2), p=0.01). In RRMS and SPMS a tendency of the g.CRYAB-249GG genotype being associated with an earlier age of onset (p=0.05) and a slowly progressive cause (p=0.07) was found. Multiple sequence alignment showed conservation of the g.CRYAB-249*C between mammalian CRAYB genes and within the small heat shock protein gene family. CONCLUSION: CRYAB polymorphisms may be involved in the pathogenesis of MS by mechanisms that could involve increased expression of the superantigen alphaB-crystallin and modulation of the immune response. CRYAB polymorphisms should be included in future multivariate biomaker studies in MS.

(alpha)B-crystallin in cerebrospinal fluid of patients with multiple sclerosis.

BACKGROUND: (alpha)B-crystallin is a chaperone protein and a potential myelin antigen to human T cells in Multiple Sclerosis (MS). In this study we investigate the existence of (alpha)B-crystallin in the cerebrospinal fluid (CSF) of patients with clinical symptoms of MS and control individuals without these symptoms, using a newly developed (alpha)B-crystallin specific chicken antibody. METHODS: A chicken anti-(alpha)B-crystallin was raised against recombinant (alpha)B-crystallin, characterized and used in a semi-quantitative Western blot analysis of CSF from 16 MS patients and 16 neurological patients without MS. RESULTS: Western blot analysis revealed the presence of high molecular weight (alpha)B-crystallin in CSF. Possibly posttranslationally modified aggregates of (alpha)B-crystallin were found in human astroglioma U373 cells. CSF (alpha)B-crystallin was seen in the CSF in 100% of MS patients and 88% of neurological controls without MS. CONCLUSION: (alpha)B-crystallin is present in the CSF in patients with MS and other neurological controls. Furthermore, (alpha)B-crystallin in CSF and human astroglioma cell line U373 is found in aggregates.

Tetranectin in cerebrospinal fluid: biochemical characterisation and evidence of intrathecal synthesis or selective uptake into CSF.

BACKGROUND: Tetranectin (TN) is a 67 kDa glycoprotein thought to play a prominent role in the regulation of proteolytic processes via its binding to plasminogen and indirect activation of plasminogen. The TN concentration in serum is approximately 10 mg/l and is reduced in patients with several cancers. The TN concentration in the normal CSF has not been examined. METHODS: The TN concentration in the serum and CSF of 47 normal subjects without neurological disorders was established using a polyclonal sandwich ELISA. RESULTS: The median TN concentration (quartile range) was 10.8 mg/l (9.0-12.1) in serum and 0.43 mg/l (0.3-0.53) in CSF. The TN index median (quartile range), defined as (TN CSF concentration/TN serum concentration)/(Albumin CSF concentration/Albumin serum concentration), was found to be 5.5 (4.7-7.6), suggesting intrathecal synthesis or selective uptake of TN in CNS. Immunohistochemistry showed TN immunoreactivity in neurons and dendrites, but no staining in glial cells in the cerebrum and cerebellum. In plexus choroideus, the ependymal cells exhibited strong immunoreactivity. TN in serum and CSF were immunochemically identical and of similar size. CONCLUSION: TN is present in normal brain and CSF, and the TN index is very high, but further studies are necessary to decide whether TN is synthesised in the CNS or selectively transported over the blood-brain barrier.