nature genetics Mg101 Mutations in PYCRl cause cutis laxa with progeroid features Bruno Reversade1 •33, Nathalie Escande-Beillard Aikaterini Dimopoulou2, Björn Fischer2, Serene C Chng1, Yun Li3, Mohammad Shboul1, Puay-Yoke Tham1, Hülya Kayserilf, Lihadh Al-Gazali5, Monzer Shahwan6, Francesco Brancati7'8, Hane Lee9, Brian D O'Connor9, Mareen Schmidt-von Kegler2' 10, Barry Merriman9, Stanley F Nelson9, Amira Masri11 , Fawaz Deanna Guerra12, Paola Ferrari13, Arti Nanda14, Anna Rajab 15 , David Markie16, Mary Gray16, John Nelson17, Arthur Grix18, Annemarie Sommer19, Ravi Savarirayan20, Andreas R Janecke21 , 22, 23, lal Elisabeth Steichen David Sillence Ingrid HauBer24, e Birgit Budde25, Gudrun Nürnberg25, Peter Nürnberg25, Petra Seemann10,26, Desiree Kunkel26, Giovanna Zamhruno27, Bruno Dallapiccola7, Markus Schuelke28, Stephen Robertson29, Hanan Hamamy6, Ol 32 2 10 26 ·;:: Bernd Lionel Van Maldergem , Stefan Mundlos • • & Uwe Autosomal recessive cutis laxa (ARCL) describes a group findings link mutations in PYCR1 to altered mitochondrial of syndromal disorders that are often associated with a function and progeroid changes in connective tissues. progeroid appearance, lax and wrinkled skin, osteopenia and mental retardation 1- 3• Homozygosity mapping in Wrinkly skin and bone loss are typical features associated with several kindreds with ARCL identified a candidate region aging. In some monogenetic diseases these changes occur prema- e on chromosome 17q25. By high-throughput sequencing of turely, resulting in a progeroid appearance of affected individuals. 1ii the entire candidate region, we detected disease-causing As a clinical feature, wrinkly skin or cutis laxa is used as a z mutations in the gene PYCR1. We found that the gene common denominator of several overlapping syndromal disorders product, an enzyme involved in proline metabolism, localizes including autosomal dominant cutis laxa (MIM123700), autoso- to mitochondria. Altered mitochondrial morphology, mal recessive cutis laxa type I (MIM219100), autosomal recessive membrane potential and increased apoptosis rate upon cutis laxa type II (ARCL2; MIM219200, also called wrinkly skin oxidative stress were evident in from affected syndrome (WSS; MIM2782S0)), de Barsy syndrome (DBS; & individuals. Knockdown of the orthologous genes in Xenopus MIM219150), and gerodermia osteodysplastica (MIM231070)1-4. and led to epidermal hypoplasia and blistering that Diagnosis is often difficult in thesc conditions owing to a broad - was accompanied by a massive increase of apoptosis. Our clinical overlap5•6• of Medical Biology, A*STAR, Singapore, Singapore. 2Institute of Medical Genetics, Charite Universitaetsmedizin Berlin, Germany. 3Center tor Molecular Medicine Cologne, University of Cologne, Cologne, Germany. 4 Medical Genetics Department, lstanbul Medical Faculty, University of lstanbul, Turkey. 5 Department of Paediatrics, Faculty of and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates. Center for Endocrinology and Genetics, Amman, Jordan. 70spedale Casa Sollievo della Sofferenza (CSS), San Giovanni Rotanda and lstituto CSS-Mendel, Rome, ltaly. 8centro Studi lnvecchiamento (Ce.S.I.), Department of Biomedical Sciences, Gabriele d'Annunzio University, Chieti, ltaly. 9Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA. 10Max Planck lnstitute for Molecular Genetics, Bertin, Germany. 11 Departments of Pediatrics, and Gynecology, Faculty of Medicine, The University of Jordan, Amman, Jordan. 12 Department of Biomedical Sciences, University of Modena and Reggio Emilia, Modena, ltaly. 13Department of Pediatrics, University of Modena and Reggio Emilia, Modena, ltaly. 14As'ad AI-Hamad Dermatology Center, Al-Sabah Hospital, Kuwait City, Kuwait. 15Genetic Unit, Directorate General of Health Affairs, Ministry of Health, Muscat, Sultanate of Oman. 16Department of Pathology, University of Otago, Dunedin, New Zealand. 17Genetic Services of Western Australia, King Edward Memorial Hospital tor Women, Perth, Australia. 18The Permanente Medical Group, Sacramento, California, USA. 19The Ohio State University College of Medicine and Nationwide Children's Hospital, Molecular and Human Genetics, Columbus, USA. 20university of Melbourne, Murdoch Childrens Research lnstitute, Royal Children's Hospital, and Genetic Health Services Victoria, Parkville, Victoria, 21 Division of Clinical Genetics, lnnsbruck Medical University, lnnsbruck, Austria. 22 Kiinik fuer Kinder- und Jugendheilkunde, Universitaet lnnsbruck, lnnsbruck. Austria. 23Department of Clinical Genetics, The Children's Hospital at Westmead, Sydney, New South Wales, Australia. 24Universitaets-Hautklinik Heidelberg, Heidelberg, Germany. 25Cologne Center tor Genomics, Universitat zu Köln, Germany. 26Berlin-Brandenburg Center for Regenerative Therapies, Charite Universitaetsmedizin Berlin, Germany. 27 Laboratory of Molecular and Celi Biology, lstituto Dermopatico dell'lmmacolata-lstituto di Ricovero e Cura a Carattere Rome, ltaly. 28Department of Neuropediatrics and NeuroCure Clinical Research Center, Charite Universitaetsmedizin Beri in, Germany. 29Department of Paediatrics and Child Health, University of Otago, Dunedin, New Zealand. 3°Cologne Excellence Ciuster on Cellular Stress Responses Aging-Associated (CECAD), University of Cologne, Cologne, Germany. 31 institute of Human Genetics, University of Cologne, Cologne, Germany. 32Centre de Genetique Humaine, Centre Hospitalier Universitaire du iman, Universite de Liege, Liege, Belgi um. 33These authors contributed equally to !his work. Correspondence should be addressed to B.R.([email protected]) or S.M.([email protected]). Received 15 April; accepted 3 June; published online 2 August 2D09; doi:10.1038/ng.413 1016 VOLUME 41 1 NUMBER 9 1 SEPTEMBER 2009 NATURE GENETICS Table 1 Phenotypic characteristics of investigated subjects with ARCL Phenotypic findings Mutations L.ax, Abnormal Literature Na. aff. wrinkly H ip Osteo- corpus Mental Athetoid in iti al ref. on Family Origin ind. IUGR skin dislocation Hernias penia callosum retardation movernents Cataract diagnosis Status cDNA Consequence Exor phenotype J.I. lraq + ++ + + wss Horn 13B+IG>A ND 2 T.P. Palestine + + ND + + + wss Horn 616G>T G206W 5 7 S.P. Palestine 3 + ++ + + +/- +/- GO or WSS Hom 617 _633+6del ND 5 5 I.K. Kuwait 2 + ++ ++ ++ ++ + GO or WSS Hom 797G>A R266Q + splicing 6 6 F.S. Kuwait + + ++ ++ ++ + GO or WSS Hom 797G>A R266Q + splic,ng 6 6 S.J. Jordan 5 + ++ + ND + + wss Horn 797+2_797 K215_D319del 6 +5del D.I. ltaly + ++ ++ ++ ND + GO Het lldelG G4fsX50 Het 355C>G Rl 19G 4 s.o. Oman ++ + + GO Het 356G>A Rl19H 4 Het 566C> T A189V 5 G.O Oman 3 ND ++ + ND + GO Hom 356G>A Rl19H 4 H.B. Bahrain 2 + ++ ++ + ND + GO Hom 535G>A A179T 4 M.A. Austria 1 + + ++ + ++ ND + GO Hom 540+1G>A ND 4 M.Q Qalar ND ++ ++ + ++ ND + GO Hom 616G>A G206R 5 H.U. United States + + G) + + GO Hom 633+!G>C ND 5 8 NA Australia + ++ + + ND ND + GD Het 633+1G>C ND 5 G) Het 797+1G> T ND 6 A.S. Syria + + + + + + GO Hom 797+2_797+5del K215_D319del 6 5 e D.T Turkey + ++ ND ND +/- DBS Hom 355C>G Rll9G 4 M.F. ltaly + ++ ND ++ ND ND + DBS Het 355C>G Rl19G 4 3 E01 ·;:: DBS Het 356G>A Rt I9H 4 S.T. Turkey 2 + + ND + + DBS Hom 540+1G>A ND 6 E.U. Un ited States 1 + ++ + ++ ND + + + DBS Hom 752G>A R251H 6 J.A. Australia (,) 3 + ++ ND ND ++ + DBS Hom 769G>A A257T 6 9 K.l Turkey .5 + + ND + + DBS Hom 797G>A R266Q + 6 I.T. Turkey t + + + ND + DBS Hom 797+2_797+5del K2 l 5_D319del 6 ;: GO, gerodermia osteodysplastica; WSS, wrinkly skin syndrome; DBS, de Barsy syndrome. No. afi. ind., number of affected individuals family; G) IUGR, intrauterine growth retardation; Hom, homozygous; Het, heterozygous. ND, not determined; +/-, mild; average; E +, ++, strong. For hernias: +, unilateral; ++, bilateral. < f Here we describe mutations in PYCRJ associated with a spectrum Both methods identified mutations in PYCRl, the gene encoding the 1ii of disorders characterized by wrinkly skin, osteopenia and progeroid enzyme A1-pyrroline-5-carboxylate reductase 1 (PYCRl). z appearance. The clinical features of the 35 affected individuals from 22 In total, we identified eight missense mutations, one frameshift families included in our study are summarized in Table 1. They mutation, fivc splice-sitc mutations and one 22-bp deletion encom- include congenital skin wrinkling, most pronounced on the dorsum of passing the exon-intron boundary of exon 5 (Table 1 and Supple- hands and teet; generalized connective tissue weakness; finger con- mentary Fig. la). Six of these mutations were recurrent, even tractures; hernias; osteopenia; and a triangular face with a progeroid though the affected individuals did not have a common ethnic & appearance that is due to lax skin and hypoplasia of the jaw often background. Bioinformatic analysis predicted deleterious effects for W resulting in prognathism (Fig. Ia-d), Ultrastructural investigation of ali changes with the exception of the heterozygous Al89V, for the skin showed rarefaction and fragmentation of elastic fibers similar which we cannot rule aut the possibility that it is a rare variant to changes described in ARCL2 (Fig. le-h). No glycosylation abnorm- (Supplementary Fig. Ih). alities were detected by standard diagnostics (data not shown). A As skin was the most severely affected organ, we isolated skin variable degree of mental retardation was observed in all cases but one. fibroblasts from probands and their unaffected siblings to In many subjects,