Congenital Secretory Diarrhoea Caused by Activating Germline
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Downloaded from http://gut.bmj.com/ on February 22, 2018 - Published by group.bmj.com Colon ORIGINAL ARTICLE Congenital secretory diarrhoea caused by activating germline mutations in GUCY2C Thomas Müller,1 Insha Rasool,2 Peter Heinz-Erian,1 Eva Mildenberger,3 Christian Hülstrunk,3 Andreas Müller,4 Laurent Michaud,5 Bart G P Koot,6 Antje Ballauff,7 Julia Vodopiutz,8 Stefan Rosipal,9 Britt-Sabina Petersen,10 Andre Franke,10 Irene Fuchs,1 Heiko Witt,11 Heinz Zoller,12 Andreas R Janecke,1 Sandhya S Visweswariah3 For numbered affiliations see ABSTRACT end of article. Objective Congenital sodium diarrhoea (CSD) refers to Significance of this study Correspondence to a form of secretory diarrhoea with intrauterine onset and Ass-Prof Dr Andreas Janecke, high faecal losses of sodium without congenital Department of Pedatrics I, malformations. The molecular basis for CSD remains What is already known on this subject? Medical University of unknown. We clinically characterised a cohort of infants ▸ Congenital diarrhoeal diseases represent a group Innsbruck, 6020 Innsbruck, with CSD and set out to identify disease-causing Austria; of rare inherited enteropathies with a [email protected] mutations by genome-wide genetic testing. disease-onset early in life. There is a broad range Design We performed whole-exome sequencing and of different monogenic conditions, and a number Prof Sandhya S Visweswariah, chromosomal microarray analyses in 4 unrelated patients, of patients have not been classified so far. Department of Molecular followed by confirmatory Sanger sequencing of the likely ▸ A GUCY2C mutation, p.S840I, has been Reproduction, Development and Genetics, Indian Institute disease-causing mutations in patients and in their family describedin32affectedmembersofalarge of Science, Biological Sciences members, followed by functional studies. Norwegian family with autosomal dominantly Building, GA09, Bangalore Results We identified novel de novo missense inherited diarrhoea of infantile onset, frequently 560012, Karnataka, India; mutations in GUCY2C, the gene encoding receptor associated with IBS, bowel obstruction and IBD. [email protected] guanylate cyclase C (GC-C) in 4 patients with CSD. One GUCY2C encodes guanylate cyclase C (GC-C), TM, IR and PH-E contributed patient developed severe, early-onset IBD and chronic and ligand binding to GC-C results in production equally. ARJ and SSV arthritis at 4 years of age. GC-C is an intestinal brush of cyclic guanosine monophosphate (cGMP). The contributed equally. border membrane-bound guanylate cyclase, which mutation conferred a higher cGMP production functions as receptor for guanylin, uroguanylin and Received 22 February 2015 upon ligand-binding to GC-C. Revised 9 April 2015 Escherichia coli heat-stable enterotoxin. Mutations in GUCY2C were present in different intracellular domains What are the new findings? Accepted 10 April 2015 ▸ Published Online First of GC-C, and were activating mutations that enhanced We identify the molecular basis of a clinical 20 May 2015 intracellular cyclic guanosine monophosphate entity, congenital sodium diarrhoea (CSD) as four accumulation in a ligand-independent and ligand- distinct de novo mutations of GUCY2C occurring stimulated manner, following heterologous expression in in four patients. GUCY2C mutations identified in HEK293T cells. patients with CSD caused increases in basal and Conclusions Dominant gain-of-function GUCY2C ligand-stimulated GC-C activities. mutations lead to elevated intracellular cyclic guanosine ▸ We report that patients with GUCY2C monophosphate levels and could explain the chronic mutations presented with intrauterine onset of diarrhoea as a result of decreased intestinal sodium and diarrhoea requiring ileostomata within the 1st water absorption and increased chloride secretion. Thus, month of age. One patient with a p.L775P mutations in GUCY2C indicate a role for this receptor in mutation in GC-C developed IBD and arthritis the pathogenesis of sporadic CSD. at 4 years of age thereby implicating GUCY2C as an IBD gene. How might it impact on clinical practice in the foreseeable future? INTRODUCTION ▸ This study provides a rationale for including Congenital diarrhoeal disorders are rare and het- GUCY2C into a fast, targeted or panel-based erogeneous enteropathies, generally with severe routine testing of patients suspected with CSD clinical manifestations. These disorders can be or patients with diarrhoeal disease. caused by defects in absorption and transport of ▸ Studying patient-derived tissues or organoids nutrients and electrolytes, in enterocyte differenti- with GUCY2C mutations might contribute to ation and polarisation, in enteroendocrine cell dif- the understanding of cGMP-mediated ferentiation, and by modulations of the intestinal stimulation of chloride secretion by cystic immune response. Clinical and histological criteria fibrosis transmembrane conductance regulator To cite: Müller T, Rasool I, and, increasingly, mutation detection in known (CFTR) and inhibition of sodium absorption by Heinz-Erian P, et al. Gut disease genes are used to classify these disorders.1 – the sodium-hydrogen exchanger 3 (NHE3). 2016;65:1306 1313. Some types of congenital diarrhoeal disorders are 1306 Müller T, et al. Gut 2016;65:1306–1313. doi:10.1136/gutjnl-2015-309441 Downloaded from http://gut.bmj.com/ on February 22, 2018 - Published by group.bmj.com Colon amenable to dietary treatment, while others require chronic human genome (hg19) with Burrows-Wheeler transformation,8 nutritional support or small bowel transplantation. sorted, converted to BAM format and indexed with SAMtools.9 Congenital sodium diarrhoea (CSD) refers to a secretory diar- PCR duplicates were removed with PICARD (http://picard. rhoea presenting with maternal polyhydramnios, prominent sourceforge.net) and SNPs and small indels were identified with abdominal distension due to dilated fluid-filled loops of the the SAMtools mpileup software. All variants were submitted to intestine, which may lead to intestinal obstruction at birth, and SeattleSeq (http://snp.gs.washington.edu/SeattleSeqAnnotation/) high faecal losses of sodium and chloride. CSD associated with for annotation, categorisation into synonymous and non- choanal atresia, corneal erosions and tufting enteropathy (syn- synonymous SNPs or indels, and for filtering using the data dromic CSD) can be distinguished from the originally described from dbSNP138, the 1000 Genomes Project, the National classic form of CSD.2 Syndromic CSD is caused by SPINT2 Heart, Lung, and Blood Institute Exome Sequencing Project. loss-of-function mutations,3 whereas the molecular basis for The exome aggregation consortium server (exac.broadinstitute. classic CSD remains unknown.34 org) was subsequently searched for known GUCY2C variants. Known genetic entities of CCDs are most often autosomal Single exons of GUCY2C were sequenced in the index cases and recessively inherited; however, a single heterozygous mutation in available family members to test for the presence of mutations in GUCY2C, encoding guanylate cyclase C (GC-C) has been detected in index patients by whole-exome sequencing. PCR and reported as the cause of a dominantly inherited form of secre- sequencing primer sequences were based on the ENSEMBL refer- tory diarrhoea (Familial Diarrhoea Syndrome) in 32 individuals ence entries for mRNA (NCBI reference sequence for mRNA of a Norwegian family.5 The mutation in the Norwegian study NM_004963.3), Ensembl reference entry (ENST00000261170) was a hyperactivating mutation present in the catalytic domain and for genomic DNA (ENSG00000070019); sequences are avail- of GC-C. This mutation resulted in increased sensitivity of able from the authors upon request. Codon numbering was based GC-C to its endogenous ligands guanylin and uroguanylin and on the published online amino acid and mRNA sequences of these to the heat-stable enterotoxin (ST) of Escherichia coli, giving genes (http://www.ncbi.nlm.nih.gov/) using the first methionine as rise to increased levels of cyclic guanosine monophosphate an initiation codon. GoTaq polymerase and buffer (Promega, (cGMP) in the epithelial cell, resulting in enhanced fluid and Mannheim, Germany) were used to PCR-amplify 20–50 ng of ion secretion, and diarrhoea. In contrast, inactivating mutations genomic DNA in 35 cycles of 20 s at 95°C, 20 s at 60°C and 30 s of GUCY2C in three Bedouin families resulted in meconium at 72°C in addition to a 7 min final extension, applied to all sets of ileus67as a consequence of diminished fluid and ion secretion primers (table 2). The amplicons were cleaned using ExoSap-IT that is normally maintained by the action of guanylin and uro- (USB, Vienna, Austria), and subsequently sequenced using an M13 guanylin on GC-C. universal primer on an ABI 3730s automated sequencer, with In the Norwegian kindred, the predominant phenotype of BigDye terminator mix (Applera, Vienna, Austria). Sequence chro- affected family members mimicked IBS, resulting in three to matographs were analysed using the Sequence Pilot computer four loose stools daily, while 8 out of the 32 affected family program ( JSI medical systems, Kippenheim, Germany). members already presented in infancy with severe dehydration. Small-bowel obstruction and/or IBD were/was diagnosed in Site-directed mutagenesis and characterisation of mutant 20–25% of these patients. As opposed to this relatively mild GC-C proteins type of diarrhoea, the four patients with CSD described here We generated mutant complementary DNA