Case Report Osteopetrosis Complicated by Schizophrenia Results from Mutations on Chromosome 16

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Int J Clin Exp Med 2016;9(9):18673-18677 www.ijcem.com /ISSN:1940-5901/IJCEM0016860

Case Report Osteopetrosis complicated by schizophrenia results from mutations on Chromosome 16

Yuwei Zhang, Decai Chen, Fang Zhang, Qingguo Lv, Lizhi Tang, Nanwei Tong

Division of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan, China Received September 25, 2015; Accepted December 8, 2015; Epub September 15, 2016; Published September 30, 2016

Abstract: Objective: To investigate the genetic pathogenesis and diagnosis of osteopetrosis, and its relationship with schizophrenia. Methods: Conducting extensive review of literature related to osteopetrosis patients with schizophrenia, summing common disease genes and diagnosis of osteopetrosis in association with schizophrenia. Results and Conclusion: Osteopetrosis is a rare inherited metabolic bone disease, with 12 kinds of common disease genes. In particular, mutations at 16p13.3 are closely related to schizophrenia. In recent years, molecular studies have identified three genes on chromosome 16 closely associated with schizophrenia, located at 16p13.3, 16p11.2, 16p13.11. Thus osteopetrosis and schizophrenia may not be two independent diseases, and understanding their relationship may help to identify schizophrenia at an earlier stage in osteopetrosis patients with mutations of chromosome 16. Conversely, patients with a family history of schizophrenia may be at increased risk for developing osteopetrosis.

Keywords: Osteopetrosis, schizophrenia, pathogenic gene, diagnosis

Introduction the possibility of such an association in the present case study of a patient diagnosed with Osteopetrosis is an extremely rare hereditary both disorders and possessing common identi- metabolic bone disease characterized by a fied genetic mutations. In this study, the patient decrease in number or functionality of osteo- was given a written informed consent. clasts, resulting in defective bone resorption. Typical clinical manifestations include increa- Case report and results sed bone density, skeletal deformities, and var- ious associated complications. Osteopetrosis The patient is a 25 year old female, presenting is also known as marble bone disease or with a 2 year history of continuous, low-intensi- Albers-Schönberg disease. Schizophrenia is a ty lower back pain that initiated as a result of an group of diseases with a complex etiology com- accidental fall (landing on her lower back). She prising hereditary, neurodevelopmental, neuro- experienced no limitations of activities and chemical and socio-environmental factors. The thus did not seek medical attention. 3 months clinical syndrome of schizophrenia is character- ago, following the pass away of her brother, she ized by dysfunction of reasoning, emotions, reports an increase in intensity of her pain, with insight and other aspects of thought and behav- a sensation of rigidity located in her lumbar ior. Patients generally have intact conscious- spine, and activity limitation. The symptoms ness, acceptable intellectual capacity, although improved with rest and were exacerbated with during the course of their disease they may emotional stress. During this time, she also have episodes of disturbed cognitive function. reports oligomenorrhea (once per 2-3 months, At first glance, there seems to be no discern- low flow volume), as well as gradual onset of able connection between osteopetrosis and depressed mood, auditory hallucinations, th- schizophrenia, the former being a metabolic oughts of self-harm and suicide. She was sub- bone disease, and the latter being a neuropsy- sequently admitted to our hospital for evalua- chiatric disorder. However, we seek to explore tion of lower back pain and psychiatric symp- A case report of osteopetrosis

Table 1. Auxiliary examinations: bone density Genetic analysis of lumbar vertebrae CLCN7 mutation, locus 16p13.3. L1 L2 L3 L4 Average L1-4 T-score 3.4 2.9 3.3 2.7 3.0 Discussion Z-score 3.5 3.0 3.4 2.8 3.1 Osteopetrosis is a generic disease composed of a group of rare bone disorders characterized toms. A preliminary diagnosis of schizophrenia by increase of bone mass due to defective was made based on positive family history, as osteoclast function. It is divided into ARO (auto- well as the suicide-death of her brother 3 somal recessive osteopetrosis) and ADO (auto- months prior. somal dominant osteopetrosis) types. Furth- er divisions are as follows [1-4]: Autosomal Physical examination Recessive Osteopetrosis (ARO): 1. Intermediate The patient had stable vital signs on admission, subtype: thickening of calvarium, stunted gro- clear consciousness, psychomotor excitement, wth, osteomyelitis, mild anemia; 2. Severe sub- normal cardiopulmonary and abdominal exami- type: earlier age of onset, including within post- nation, and without notable trunk and limb natal months. Sick children can have recurrent deformities. infections and frequent bleeding secondary to medullar hyperplasia. They can also have Biochemical markers of bone turnover blindness and deafness caused by compres- sions of cranial nerves. Autosomal Dominant Serum calcium (Ca) 2.19 mmol/L, serum inor- Osteopetrosis (ADO): 1. ADO subtype I: mild dif- ganic phosphorus (P) 1.49 mmol/L, bone alka- fuse generalized osteosclerosis; 2. ADO sub- line phosphatase (B-ALP) 14.81 µg/L, C-ter- type II: thickening of superior and inferior minal telopeptide of type I collagen (CTX-1) aspects of vertebral bodies, high rate of long 0.605 ng/mL, N-MID osteocalcin (NMID) 31.3 bone fractures, classic sandwich-like change of ng/mL, parathyroid hormone (PTH) 6.51 vertebral bodies (rugger-jersey sign), growth pmol/L, thyroid hormone (TSH) 6.14 mU/L, thy- rings appearance, significant increase in serum roid peroxidase antibody (TPOAb) 131.1 IU/mL. ALP and creatine kinase BB (CK-BB); 3. ADO Her bone mass density was detected as below subtype III: “eccentric osteopetrosis” with os- (Table 1). teosclerosis mainly involving distal extremities and skull. Our patient’s radiographic findings Serology of sandwich-like change of vertebral bodies, Immunoglobulin G (IgG) 20.1 g/L, Immunog- increased bone density and heterogeneous lobulin A (IgA) < 66.7 mg/L, Immunoglobulin M increase in density of bilateral femoral head, (IgM) 2350 mg/L, antinuclear antibody (ANA) acetabulum and right sacroiliac joint conform weakly positive, anti-neutrophil cytoplasmic to manifestations of ADO subtype II, which is antibody (ANCA) negative, erythrocyte sedi- also called benign osteoptrosis. Current re- mentation rate (ESR) 20 mm/h, C-reactive pro- search lists 12 common genetic mutations for tein (CRP) 4.24 mg/L, urinary light chains nor- osteopetrosis, as follows (Table 2) [3, 5-14]: mal, rheumatoid factor (RF) < 20.00 IU/mL Our patient has an identified mutation of CLCN7 Radiography at 16p13.3, which allows for a genetic diagnosis of chromosome 16 (CLCN7) mutation The three images displayed as bellow. Figure induced ADO subtype II. Concurrent diagnosis 1A shows normal appearance of heart and of schizophrenia with positive family history as lungs, increased density of superior and inferi- well as exacerbation of her back pain with emo- or aspects of vertebral bodies, with sandwich tional stress leads us to speculate on a connec- sign. Figure 1B presents sandwich-like change tion between osteopetrosis and schizophrenia. of vertebral bodies, increased bone density. After searching our nationwide and internation- From Figure 1C, we can see heterogeneous al database, mutations in 3 etiologic genes for increase in density of bilateral femoral head, schizophrenia are identified on chromosome acetabulum and right sacroiliac joint, growth 16, specifically at 16p11.2, 16p13.11, 16p13.3 rings appearance. [15-24], note the proximity of the 3 loci. Our

18674 Int J Clin Exp Med 2016;9(9):18673-18677 A case report of osteopetrosis

Figure 1. Radiography Imagines. A. Increased density of superior and inferior aspects of vertebral bodies, with sandwich sign; B. Sandwich-like change of vertebral bodies, increased bone density; C. Heterogeneous increase in density of bilateral femoral head, acetabulum and right sacroiliac joint, growth rings appearance.

Table 2. Twelve genetic mutations for osteo- be entirely independent, but rather share a petrosis common genetic basis. Furthermore, we pro- Gene Locus pose to increase screening of schizophrenia in osteopetrosis patients with identified muta- CAII 8q22 tions of chromosome 16, as well as performing TCIRG1 11q13.2 related prevention for osteopetrosis in applica- CLCN7 16p13.3 ble schizophrenic patients, all in the effort to OSTM1 6q21 decrease co-morbidity with a second disease. RANKL 13q17 Disclosure of conflict of interest PLEKHM1 17q21.3 Kindlin-3 11q13.1 None. RANK 18q22.1 CalDAG-GEFI 11q13.1 Address correspondence to: Dr. Nanwei Tong, Division of Endocrinology and Metabolism, West NEMO Xq28 China Hospital, Sichuan University, 37 Guoxuexiang, LRP5 11q13.4 Chengdu 610041, Sichuan, China. Tel: 00 + 86- SNX10 7p15.2 18980601196; Fax: 00 + 86-28-85423459; E-mail: [email protected] patient has an identified mutation at 16p13.3. References Therefore, we boldly speculate that this mutation on chromosome 16 may be responsible for [1] Del Fattore A, Cappariello A, Teti A. Genetics, the pathogenesis of both osteopetrosis and pathogenesis and complications of osteope- schizophrenia, and that the 2 diseases may not trosis. Bone 2008; 42: 19-29.

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18677 Int J Clin Exp Med 2016;9(9):18673-18677