Loss-Of-Function Mutations in the X-Linked Biglycan Gene Cause a Severe Syndromic Form of Thoracic Aortic Aneurysms and Dissections
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ORIGINAL RESEARCH ARTICLE Official journal of the American College of Medical Genetics and Genomics Open Loss-of-function mutations in the X-linked biglycan gene cause a severe syndromic form of thoracic aortic aneurysms and dissections Josephina A.N. Meester, MSc1, Geert Vandeweyer, PhD1, Isabel Pintelon, PhD2, Martin Lammens, MD, PhD3, Lana Van Hoorick, BSc1, Simon De Belder, BSc1, Kathryn Waitzman, MD4, Luciana Young, MD4, Larry W. Markham, MD5, Julie Vogt, MD6, Julie Richer, MD7, Luc M. Beauchesne, MD8, Sheila Unger, MD9, Andrea Superti-Furga, MD9, Milan Prsa, MD10, Rami Dhillon, MD11, Edwin Reyniers, MSc1, Harry C. Dietz, MD12,13, Wim Wuyts, PhD1, Geert Mortier, MD, PhD1, Aline Verstraeten, PhD1, Lut Van Laer, PhD1, and Bart L. Loeys, MD, PhD1 Purpose: Thoracic aortic aneurysm and dissection (TAAD) is typi- and dissection. Other recurrent findings include hypertelorism, pec- cally inherited in an autosomal dominant manner, but rare X-linked tus deformity, joint hypermobility, contractures, and mild skeletal families have been described. So far, the only known X-linked gene is dysplasia. Fluorescent staining revealed an increase in TGF-β signal- FLNA, which is associated with the periventricular nodular heteroto- ing, evidenced by an increase in nuclear pSMAD2 in the aortic wall. pia type of Ehlers-Danlos syndrome. However, mutations in this gene Our results are in line with those of prior reports demonstrating that explain only a small number of X-linked TAAD families. Bgn-deficient male BALB/cA mice die from aortic rupture. Methods: We performed targeted resequencing of 368 candidate Conclusion: In conclusion, BGN gene defects in humans cause an genes in a cohort of 11 molecularly unexplained Marfan probands. X-linked syndromic form of severe TAAD that is associated with Subsequently, Sanger sequencing of BGN in 360 male and 155 female preservation of elastic fibers and increased TGF-β signaling. molecularly unexplained TAAD probands was performed. Genet Med advance online publication 15 September 2016 Results: We found five individuals with loss-of-function mutations Key Words: biglycan; BGN; Loeys-Dietz syndrome; Marfan in BGN encoding the small leucine-rich proteoglycan biglycan. The syndrome; thoracic aortic aneurysm clinical phenotype is characterized by early-onset aortic aneurysm INTRODUCTION Marfan syndrome (MFS; MIM154700) is an autosomal dom- Thoracic aortic aneurysms (TAA) are often asymptomatic but inant connective tissue disorder; affected individuals present predispose to aortic dissections, which are associated with high with ocular, skeletal, and cutaneous signs in addition to aneu- mortality rates.1 TAAs and dissections (TAAD) can be subdi- rysm and dissection. Loeys-Dietz syndrome (LDS; MIM609192, vided into syndromic (associated with systemic manifestations) MIM610168, MIM613795, MIM614816, MIM615582, and and nonsyndromic forms. Most commonly, familial TAADs MIM601366) is an aneurysmal connective tissue disorder that segregate in an autosomal dominant manner, but rare X-linked can be distinguished from MFS by the unique presence of cra- families have been described.2 So far, FLNA is the only X-linked niofacial, skeletal, cutaneous, and/or vascular manifestations gene associated with a syndromic form of TAAD, namely, peri- and prominently includes hypertelorism, cleft palate, or bifid ventricular nodular heterotopia type 1 (PVNH1; also known as uvula and arterial tortuosity, with aneurysms distant from the the Ehlers-Danlos variant of PVNH, MIM300049). However, aortic root. In addition, aneurysms in individuals with LDS FLNA explains only a small number of the X-linked TAAD tend to dissect at an earlier age and smaller diameter compared families.3 to individuals with MFS.4 Whereas MFS is caused by mutations 1Center of Medical Genetics, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium; 2Department of Cell Biology and Histology, University of Antwerp, Antwerp, Belgium; 3Department of Pathology, University Hospital Antwerp, University of Antwerp, Antwerp, Belgium; 4Department of Pediatric Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA; 5Divisions of Pediatric and Adult Cardiology, Vanderbilt University, Nashville, Tennessee, USA; 6West Midlands Regional Genetics Service, Birmingham Women’s NHS Foundation Trust, Birmingham, UK; 7Department of Medical Genetics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada; 8Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; 9Service of Medical Genetics, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; 10Department of Pediatrics, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; 11The Heart Unit, Birmingham Children’s Hospital, Birmingham, UK; 12Howard Hughes Medical Institute, Baltimore, Maryland, USA; 13McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Correspondence: Bart L. Loeys ([email protected]) Submitted 3 May 2016; accepted 15 July 2016; advance online publication 15 September 2016. doi:10.1038/gim.2016.126 386 Volume 19 | Number 4 | April 2017 | GEnEticS in mEdicinE BGN mutations cause thoracic aortic aneurysms and dissections | MEESTER et al ORIGINAL RESEARCH ARTICLE in FBN1 coding for an extracellular matrix (ECM) protein,5 Biosystems). Sequences were analyzed using CLC DNA work- LDS is caused by loss-of-function (LOF) mutations in genes bench (CLC Bio, Aarhus, Denmark). Microarray analysis coding for components of the transforming growth factor β was performed using the Illumina HumanCytoSNP12-V2.1 (TGF-β) signaling pathway (TGFBR1/2, SMAD2/3, TGFB2/3).6 BeadChip (Illumina, San Diego, CA) according to standard Recent work has demonstrated that both MFS and LDS lead to protocols. Copy-number variants (CNVs) were analyzed dysregulation of the TGF-β signaling pathway.4,7 using CNV-WebStore.12 Biglycan deficiency in male BALB/cA mice has been shown to lead to sudden death due to aortic rupture, suggesting that Cell culture biglycan might be essential for the structural integrity of the Skin fibroblasts were cultured in Roswell Park Memorial aortic wall. Additionally, BGN mRNA and protein expression Institute medium and supplemented with 15% fetal bovine are reduced in individuals with Turner syndrome (45,X),8 who serum, 1% L-glutamine, 1% sodium pyruvate, 1% Penicillin/ suffer more frequently from vascular anomalies including aor- Streptomycin, and 0.1% Primocin. Experiments were per- tic dissection and rupture.9 Human mutations in BGN have not formed at passages 2 to 4. The fibroblasts were incubated with been described in TAAD probands. and without puromycin (200 µg/ml) to inhibit nonsense-medi- Here, we report that BGN mutations in humans cause an ated decay (NMD). X-linked, severe, syndromic form of TAAD, including hyper- telorism, pectus deformity, joint hypermobility, contractures, cDNA sequencing and cloning and mild skeletal dysplasia. RNA was extracted from skin fibroblasts (from proband 5-II-1) to identify changes in BGN splicing using the RNeasy mini kit MATERIALS AND METHODS (Qiagen, Valencia, CA), followed by random hexamer cDNA Human participants, DNA, and aortic specimens conversion with the Superscript III First-Strand Synthesis kit The study was approved by the appropriate institutional for RT-PCR (Invitrogen, ThermoFisher Scientific, Waltham, ethics review boards, and the required informed consent MA). PCR was performed on the obtained cDNA using the was obtained from all participating subjects. Additionally, following primers: 5′-CAGAGAGGCTTCTGGGACTT-3′ and informed consent for the publication of photos was obtained 5′-GACGAGGGCGTAGAGGTG-3′. The resulting PCR prod- from the subjects or legal guardians. DNA of additional uct was then cloned into One Shot TOP10 cells (ThermoFisher affected and unaffected family members was requested Scientific), after which 94 colonies were picked. The different whenever it was considered informative. Aortic specimens splice products were sequenced with Sanger sequencing. from probands 3-III-2 and 5-II-1 as well as from two gen- der-matched control samples obtained from deceased indi- Histology and immunohistochemistry viduals who did not have cardiovascular diseases were at our Paraffin-embedded aortic tissue of affected individuals and disposal. As positive controls, we used available aortic speci- of control samples were sectioned (5 µm) with the HM340E mens from two individuals with LDS (TGFB3 mutation, Microm microtome (ThermoFisher Scientific). Histological p.Asp263His). Fibroblasts were cultured using skin biopsy staining, including Verhoeff-Van Gieson and Masson’s specimens from probands 4-II-1 and 5-II-1 and two gender- Trichrome, was performed using standard protocols. matched control individuals. Fluorescent staining of the aortic tissue with primary antibodies against biglycan (AF2667, 1:40; R&D Systems, Targeted resequencing Minneapolis, MN), decorin (AF143, 1:40: R&D Systems), We performed targeted resequencing of 368 ECM-related and and pSMAD2 (04-953, 1:100; Millipore, Billerica, MA) was TGF-β-related genes using the HaloPlex Target Enrichment performed as previously described13 but with the following System (Agilent Technologies, Santa Clara, CA). Samples were modifications: the secondary antibodies included chicken- paired-end sequenced using 2 × 100 bp on a HiSeq1500 in high- anti-goat Alexa Fluor 488 conjugate (A-21467, 1:200; Life output mode (Illumina, San Diego,