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Department of Human Genetics (C.F.M., M.A.T., W.D.F.), McGill University, Montréal, Québec, Canada H3A 1B1; Division of Medical Genetics (W.D.F.), Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada H3T 1E2; Vascular Biology Group (H.C., C.H.O., J.G.P., R.A.H.), Robarts Research Institute, London, Ontario, Canada N6A 5K8; and Department of Medicine (J.G.P., R.A.H.), Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada N6A 5C1
Address all correspondence and requests for reprints to: Robert A. Hegele, M.D., F.R.C.P.C., F.A.C.P., Blackburn Cardiovascular Genetics Laboratory, Robarts Research Institute, London, Ontario, Canada N6A 5K8. E-mail: hegele{at}robarts.ca.
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Abstract |
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Objective: The objective of the study was to carry out mutational analysis of LMNA in two sisters with a particularly severe FPLD2 phenotype.
Design: This was a descriptive case report with molecular studies.
Setting: The study was conducted at a referral center.
Patients: We report two sisters of South Asian origin. The first presented with acanthosis nigricans at age 5 yr, diabetes with insulin resistance, hypertension and hypertriglyceridemia at age 13 yr, and partial lipodystrophy starting at puberty. Her sister and their mother had a similar metabolic profile and physical features, and their mother died of vascular disease at age 32 yr.
Interventions: There were no interventions.
Main Outcome Measures and Results: LMNA sequencing showed that the sisters were each heterozygous for a novel G>C mutation at the intron 8 consensus splice donor site, which was absent from the genomes of 300 healthy individuals. The retention of intron 8 in mRNA predicted a prematurely truncated lamin A isoform (516 instead of 664 amino acids) with 20 nonsense 3'-terminal residues. The mutant lamin A isoform failed to interact normally with emerin and failed to localize to the nuclear envelope.
Conclusions: This is the first LMNA splicing mutation to be associated with FPLD2, and it causes a severe clinical and metabolic phenotype.
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Introduction |
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(2). FPLD2 is a laminopathy and is one of 16 distinct disease phenotypes that have been shown to result from more than 100 different LMNA mutations, including 12 autosomal dominant and four autosomal recessive phenotypes (3). The mutation position in the primary genomic DNA sequence of LMNA is associated with tissue and organ pathology (3). To date, more than 90% of LMNA mutations are missense mutations (3). All reported mutations in FPLD2 are LMNA missense mutations, usually occurring within the 3'-half of the protein (3). A few heterozygous nonsense mutations underlie some cases of dilated cardiomyopathy (3) and Emery-Dreifuss muscular dystrophy (3). Heterozygous LMNA splicing mutations have been reported in some cases of progeria (4), restrictive dermopathy (5), and limb girdle muscular dystrophy (6). We report the first individuals with FPLD2 who are heterozygous for a novel LMNA mutation that affects RNA splicing and who initially presented with strikingly severe clinical and metabolic features of FPLD2. |
Subjects and Methods |
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Proband 1. The index patient, a female of South Asian ancestry, was referred to the Medical Genetics Clinic at age 20 yr. Her medical history revealed the presence of acanthosis nigricans starting at age 5 yr. Hypertension, hypertriglyceridemia, and hyperinsulinemia were diagnosed at age 13 yr, and she developed type 2 diabetes (T2DM) soon thereafter. At age 13 yr, significant facial and body hirsutism, a male body habitus, and moderately severe acne were noted, and hidradenitis suppurativa was diagnosed after removal of cysts from pubic and axillary regions. She had menarche at age 9 yr, with secondary amenorrhea since age 10 yr. At age 10 yr, she was diagnosed with depression. A renal ultrasound at age 13 yr and head computed tomography (CT) scan at age 14 yr were both normal. At age 14 yr, an electrocardiogram (EKG) showed prolongation of the QT interval with diffuse repolarization abnormalities, whereas an echocardiogram was normal. Acute pancreatitis secondary to hypertriglyceridemia resulted in one hospital admission at age 17 yr, at which time no hepatomegaly was seen on abdominal CT scanning. At age 21 yr, she had a vocal cord polyp removed; an EKG revealed normal sinus rhythm, and a persantine myocardial perfusion study was normal.
On physical examination at age 20 yr she was noted to have a round face and a deep and hoarse voice. She had generalized acanthosis nigricans, skin tags and cysts in axillary and pubic regions, severe lipodystrophy with muscle and labia majora pseudohypertrophy, prominent veins, absence of gluteal fat, hirsutism, and Cushingoid habitus but without catabolic or other somatic manifestations.
Proband 2. The sister of proband 1 was first assessed in the Medical Genetics Clinic at age 26 yr. She was diagnosed with T2DM, hypertriglyceridemia, and hypertension at age 17 yr. EKG at age 17 yr revealed a left ventricular strain pattern, although an echocardiogram was normal. At age 18 yr, she was noted to have numerous skin findings, including velvety light-brown papillomatous hypertrophic plaques over the nape and sides of her neck, axillae, and groin; verrucous hyperkeratosis of the flexural regions of the elbows; dorsum of hands and ankles; and numerous skin tags over neck and axillae. At age 19 yr, she was hospitalized with acute pancreatitis, secondary to hypertriglyceridemia, which was complicated by a pseudocyst requiring subtotal pancreatectomy. An abdominal CT scan showed diffuse fatty liver and hepatomegaly. Upon starting insulin treatment, the dermatological changes regressed, leaving only mild acanthosis nigricans. Menses were normal. Bilateral sixth cranial nerve palsies occurred on two occasions. She was also diagnosed with depression during her adolescence. At age 24 yr, she noted lower extremity weakness with decreased endurance. A neurological evaluation demonstrated proximal muscle weakness of both upper and lower extremities, decreased temperature and pain sensation of the lower limbs, and decreased deep tendon reflexes. An electromyogram study revealed nonspecific abnormalities consistent with a myopathic process. Serum creatine kinase was not elevated.
On physical examination at age 26 yr, she was noted to have a round face, mild nuchal acanthosis nigricans, skin tags, severe lipodystrophy with muscle pseudohypertrophy, prominent veins, absence of gluteal fat, and hirsutism. Her lipodystrophy phenotype was less severe than that of proband 1. Like her sister, she reported a voracious appetite and heat intolerance.
Probands’ mother. The history of the probands’ mother was obtained from medical records. At age 23 yr, atrial fibrillation was diagnosed and treated with digoxin. She did not receive anticoagulation therapy. At age 25 yr, she complained of recurrent abdominal pain and was diagnosed with paroxysmal tachycardia. Hepatomegaly and elevated serum transaminases were reported on several occasions. Investigations at age 27 yr for suspected muscle atrophy revealed a normal neurological examination, electromyogram, and serum creatine kinase concentration. A muscle biopsy showed small type 1 fibers and increased connective tissue, consistent with a benign fiber type disproportion syndrome. T2DM was diagnosed at age 28 yr; however, the lipid profile result was unavailable. She had persistent severe acne. At age 28 yr, she presented with right hemiparesis caused by a left cerebrovascular accident of cardiogenic origin. Echocardiography revealed a bicuspid aortic valve, mitral stenosis, and cardiomyopathy that was considered secondary to valvular disease. Anticoagulation was started and a cardiac pacemaker was placed the next year. Compliance with medication was inconsistent. At age 32 yr, she presented with a massive right hemisphere infarct. At the time, she was noted to be hypertensive and to have multiple papulopustular lesions over her back, chest, and extremities; hirsutism; and significant atrophy of muscles on extremities with preservation of girdle musculature. She died of respiratory failure shortly thereafter.
Review of childhood photographs of the sisters and their mother suggested that they had normal fat distribution as children, with lipodystrophy beginning at the onset of puberty.
Other family history. The probands’ nonconsanguineous parents were of Punjabi origin. A maternal aunt had a cardiac problem but no diabetes or lipodystrophy. A maternal uncle had T2DM since age 60 yr, and his son had diabetes since age 3 yr. The maternal grandfather had longstanding hypertension. The girls’ father had hypertension, and two paternal aunts and the paternal grandmother had diabetes.
Anthropometric measurements
Height and body weight were measured by standard procedures. Skinfold thickness was measured with a Lange caliper (Cambridge Scientific Industries, Cambridge, MD) at five truncal (chest, midaxillary, abdomen, subscapular, and suprailiac) and four peripheral (biceps, triceps, midthigh, and calf) sites on the right side of the body. The mean of three repeat measurements at each site was calculated. Circumferences were also obtained of the chest, waist, hip, midarm, midthigh, and calf. Skinfold thickness and circumference measurement results were compared with the U.S. population reference values for the same age and sex group in percentile (7). The percentage of total body fat was determined by bioelectrical impedance analysis under fasting conditions, as described (8), and from the sum of skinfold thicknesses measured at four sites (9). Skeletal muscle mass was estimated from bioelectrical impedance analysis (10).
Genomic DNA analysis
The study was approved by the ethics review panel of the University of Western Ontario (protocol 07920E). Both patients provided informed consent to participate in the studies and for publication of their clinical, biochemical, and molecular genetic information. The coding regions and intron-exon boundaries of the LMNA gene were amplified, purified, and genomic DNA sequence read on an ABI 3730 Automated DNA Sequencer (PE Applied Biosystems, Mississauga, Ontario, Canada) using established protocols (11). Screening for the mutation used direct sequencing of exon 8; genomic DNA from 150 healthy individuals, each of Caucasian and South Asian ethnicity, was examined.
Gene expression analysis
Total RNA was isolated from patient whole blood using the PAXgene blood RNA kit (QIAGEN, Mississauga, Ontario, Canada). First-strand cDNA was synthesized from total RNA with an oligodT primer (Superscript first-strand synthesis system, Invitrogen, Burlington, Ontario, Canada). Two microliters of the first strand was amplified in a total of volume of 30 µl containing specific LMNA primers: 5'-GGC AGT CTG CTG AGA GGA AC and 5'-GAC ACT GGA GGC AGA AGA GC, which span from exon 5 to exon 11, inclusive of LMNA cDNA. Thirty amplification cycles were performed at an annealing temperature of 60 C. The PCR products were gel purified (QIAquick gel extraction kit; QIAGEN) and directly sequenced on an ABI 3730 Automated DNA Sequencer (PE Applied Biosystems).
Recombinant vector constructions
A 2.1-kb fragment containing human LMNA full-length cDNA was obtained by amplification using the primer pairs: 5'-TCC GAG CAG TCT CTG TCC TT and 5'-CTG GCA GGT GGC AGA TTA CAT and first-strand cDNA from patients as a template. The product was ligated into the TA cloning 2.1 vector (Invitrogen). The insert was subcloned to pcDNA3.1/myc-His vector (Invitrogen) after EcoRI digestion. For immunofluorescence microscopy, the amplified product of LMNA cDNA was subcloned into the pcDNA3.1/His vector with N-terminal tag encoding the Xpress epitope (Invitrogen) after EcoRI digestion using primers: 5'-CGG AAT TCA TGG AGA CCC CGT CCC AG and 5'-CGG AAT TCT TAC ATG ATG CTG CAG TTC TG. The fidelity of DNA amplification and satisfactory insertion of the respective control and mutant cDNAs were confirmed by DNA sequencing.
Cell culture transient transfection assay
Human HepG2 cells were grown in 
MEM supplemented with 100 U/ml penicillin, 100 µg/ml streptomycin, and 10% (vol/vol) heat-inactivated fetal calf serum (Invitrogen). COS-7 cells were maintained in DMEM containing 10% fetal calf serum, 100 U/ml penicillin, and 100 µg/ml streptomycin. Cells were seeded on culture plates to achieve greater than 90% confluence and were transfected, respectively, with normal and mutant LMNA constructs and empty control vector using Lipofectamine 2000 reagent according to the manufacturer’s instructions (Invitrogen). Cells were extracted after addition of mammalian protein extraction reagent (Pierce, Rockford, IL) 48 h after transfection, and precleared cell lysates were used for subsequent Western blot analysis.
Gel electrophoresis and immunoblotting
Cell lysates were diluted in SDS-PAGE sample buffer and resolved on 10% SDS-PAGE (Novex precast gel; Invitrogen). Proteins were transferred to nylon membranes following manufacturer’s protocol (Invitrogen). Membranes were incubated with blocking buffer [5% milk powder (wt/vol) and 0.05% Tween 20 in Tris-buffered saline] for 1 h at room temperature. Rabbit antilamin A/C (Cell Signaling Technology, Beverly, MA) was used at 1:1000 dilution and incubated with membrane overnight at 4 C. Membranes were rinsed three times with washing buffer (0.05% Tween 20 in Tris-buffered saline) and then incubated with 1:2000 dilution of horseradish peroxidase-conjugated second antibodies (donkey antirabbit; Amersham, Oakville, Ontario, Canada) for 1 h at room temperature. After rinsing, proteins on membranes were detected using SuperSignal West Pico chemiluminescent substrates (Pierce).
Coimmunoprecipitation analysis with emerin
The ProFound mammalian coimmunoprecipitation kit (Pierce) was used according to the manufacturer’s instructions. Briefly, precleared cell lysates from transfected Hep-G2 cells were incubated for 2 h with antiemerin antibody (Santa Cruz Biotechnology, Santa Cruz, CA) coupling gel at room temperature. Immunoprecipitated proteins and whole lysates obtained in radioimmunoprecipitation assay buffer were subjected to Western blotting. The membrane was probed with specific antiemerin and antilamin A/C antibodies as described (12).
Immunofluorescence microscopy
LMNA cDNA was amplified using primers 5'-CGG AAT TCA TGG AGA CCC CGT CCC AG and 5'-CGG AAT TCT TAC ATG ATG CTG CAG TTC TG. The amplified fragment was digested and then in-frame cloned into pcDNA3.1/His vector with N-terminal tag encoding the Xpress epitope (Invitrogen). The fidelity of amplification and insertion of respective control and mutant cDNAs were confirmed by DNA sequence analysis. COS-7 cells were cultured as described above. Transfected cells were grown on glass coverslips and fixed in methanol for 6 min at 10 C. After washes with PBS, the fixed cells were incubated with anti-Express-fluorescein isothiocyanate antibody at 1:500 dilution (Invitrogen) for 30 min at 37 C, washed with PBS, and mounted on slides. Transfection efficiency was approximately 30%. Immunofluorescence microscopy was performed as described (13).
Statistical analysis
All statistical analyses were performed using SAS (version 8.2 Cary, NC), with nominal P < 0.05.
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Results |
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The height, weight, and body mass index of proband 1 were 165 cm, 60.2 kg, and 22.1 kg/m2, respectively, and those of proband 2 were 160.3 cm, 49.2 kg, and 19.1 kg/m2, respectively. Proband 1 had the following skinfold thickness measurements: chest 8 mm, midaxillary 9 mm, subscapular 16 mm, suprailiac 11 mm, abdomen 14 mm, biceps 5 mm, triceps 6 mm, thigh 7 mm, and calf 5 mm. Circumference measurements were as follows: chest 93 cm, waist 73.5 cm (fifth to 10th percentile for age and sex), hip 87 cm, midarm 26.2 cm (15th to 25th percentile), midthigh 41.2 cm (less than fifth percentile), and calf 34 cm (15th to 25th percentile). Proband 2 had the following the skinfold thickness measurements: chest 6 mm, midaxillary 6 mm, subscapular 12 mm, suprailiac 6 mm, abdomen 9 mm, biceps 3 mm, triceps 5 mm, thigh 5 mm, and calf 4 mm. Circumference measurements were chest 84 cm, waist 68.5 cm (less than fifth percentile), hip 78.5 cm, midarm 22.2 cm (less than fifth percentile), thigh 36.2 cm (less than fifth percentile), and calf 30.5 cm (less than fifth percentile). The skinfold measurements are similar to those previously reported in individuals with FPLD2 (14), with all measurements falling in the low range (usually less than fifth percentile), compared with the normal population, with the exception of the subscapular skinfold measurement, which was approximately 50th percentile of normal for proband 1 and approximately 25th percentile for proband 2, respectively. Proband 1 also had a suprailiac skinfold measurement that fell between the 25th and 50th percentile. Circumference measurements demonstrated low-normal values. Bioelectrical impedance analysis indicated 23.1% body fat, 76.9% fat-free mass, and 25.1 kg of skeletal muscle mass for proband 1 and 17.8% body fat, 82.2% fat-free mass, and 23.7 kg of skeletal muscle mass for proband 2. It is notable that these sisters did not demonstrate any obvious abnormality in muscle mass. The clinical appearance of proband 1 is shown in Fig. 1
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The proband and her sister were each heterozygous for a single nucleotide change in their genomic DNA, specifically a novel G>C mutation at the intron 8 consensus splice donor site (Fig. 2A). The mutation was absent from the genomes of 300 healthy individuals, including 150 individuals of South Asian ethnicity.
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). The sequence of the mutant 1121-bp band showed retention of intron 8 within the mRNA sequence: the aberrant transcript encoded 496 normal lamin A/C residues, followed by 20 new amino acids and a premature stop codon (Fig. 2C). Western analysis and coimmunoprecipitation with emerin
Results of Western analysis of lysates of HepG2 cells transfected with wild-type and mutant LMNA cDNA from proband P1 and probed with antilamin A antibody are shown in Fig. 3A. Normal lamin A/C was detected in all transfected cell lysates, but the truncated lamin A isoform was detected only in the lysate of the cells that were transfected with mutant LMNA. Thus, the truncation mutation could be translated and transcribed in vitro.
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. Probing of these whole cell lysates with antilamin A antibody showed strong bands at the position of normal lamin A for all transfected cells and a strong band at the position of the truncated mutant lamin A for cells transfected with mutant LMNA. Probing of whole-cell lysates with antiemerin antibody showed strong bands at the position of normal emerin for all transfected cells. After coimmunoprecipitation with antiemerin and blotting, probing of whole-cell lysates with antilamin A antibody showed bands at the position of normal lamin A for all transfected cells and loss of the band at the position of mutant lamin A for cells transfected with mutant LMNA, suggesting that the mutant lamin A had lost the ability to interact with emerin. After coimmunoprecipitation with antiemerin and blotting, probing of whole-cell lysates with antiemerin antibody showed bands at the position of emerin for all transfected cells. Thus, emerin coprecipitated with normal lamin A but not with the truncated isoform. Immunofluorescence microscopy
Immunostained nuclei from cells transfected with wild-type and mutant LMNA cDNA are shown in Fig. 4. Lamin localized specifically around the nuclear envelope in wild-type transfected cells but was diffusely localized throughout the cytoplasm in mutant transfected cells. From 70 cells that were transfected with wild-type LMNA, 19 had a visible lamin A signal: in 18 cells (95%) lamin A colocalized with the nuclear rim (Fig. 4A), with the one remaining cell showing presence of lamin A signal in the cytoplasm. From 89 cells that were transfected with mutant LMNA, 16 had a visible lamin A signal: in all 16 (100%), lamin A signal was seen in the cytoplasm, with no colocalization along the nuclear rim (Fig. 4B). This difference in proportion of cells transfected with wild-type vs. mutant LMNA showing nuclear rim vs. cytoplasmic localization of the antilamin antibody was highly significant (2 x 2 
2 = 31.2, P < 0.00001).
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Discussion |
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The most striking features in the family we are reporting are the early age of onset and the severity of the typical features of FPLD2. The onset of clinical features in FPLD2 typically occurs at puberty (15). Based on clinical observations in FPLD2 patients with LMNA missense mutations R482Q and R482W, it has been assumed that the precipitating event is the loss of fat tissue occurring late in childhood or early in puberty. It was presumed that insulin resistance and the intermediate biochemical phenotypes followed the loss of fat. However, it is of interest that proband 1 in this report had stigmata of insulin resistance, specifically acanthosis nigricans, at age 5 yr, with early menarche followed by a diagnosis of T2DM years before the fat loss was noted clinically. This anecdotal observation suggests that insulin resistance might precede the clinically apparent fat loss, making it temporally the primary disturbance. Fat loss has traditionally been considered to be the inciting event that precedes the development of metabolic complications in FPLD2, such as insulin resistance (1, 2). The ability to genotype children in FPLD2 families, combined with more sensitive biochemical markers and noninvasive tools to detect fat loss may help to sort out the precise order of evolution of the characteristic disturbances in FPLD2.
Other clinical features in our patients that emphasize the severity of the FPLD2 phenotype associated with this LMNA splicing mutation include the early age of onset of hypertension, T2DM, and severe hypertriglyceridemia with secondary pancreatitis, occurring in the teenage years for both probands. In addition, our patients have several features not previously reported in FPLD2. Proband 1 had hidradenitis suppurativa, an acneiform infection of the cutaneous apocrine glands that also can involve adjacent sc tissue and fascia. Proband 2 had two occurrences of sixth nerve palsy. Although depression has been reported in at least one other patient (14), our patients were diagnosed during childhood, and proband 1 required numerous hospitalizations during her teenage years. They continue to be followed up and treated.
There is some suggestion of overlapping involvement of other organ systems, such as cardiac and neurological systems, associated with this mutation in the probands and their mother. However, the occurrences of sixth cranial nerve palsies in proband 2 have not been reported in FPLD2 due to other LMNA mutations. Similarly, the possibility of a cardiomyopathy in the probands’ mother was suggested by atrial fibrillation diagnosed at age 25 yr and a diagnosis of nonspecific cardiomyopathy necessitating placement of a cardiac pacemaker. Another FPLD2 patient with the LMNA R62G mutation had cardiomyopathy and conduction defects in addition to the typical features of FPLD (16). Other patients had cardiac and lipodystrophic signs associated with LMNA R527P and R60G mutations (17). A patient with the LMNA R133L mutation had hypertrophic cardiomyopathy with valvular involvement (18). Muscle weakness previously reported in patients with FPLD2 tends to be proximal, and several have significant limb girdle weakness. Proband 2 had muscle weakness but had no elevation in serum creatine kinase, which has been reported previously (17, 19). A patient with the LMNA R482W missense mutation had severe limb girdle muscle dystrophy with loss of ambulation, in addition to FPLD2 (19). Recently a patient with arthropathy, tendinous calcinosis, and progeria was found to have a homozygous LMNA S573L missense mutation (20).
In summary, we report the first LMNA splicing mutation in FPLD2, which was associated with a severe phenotype and altered in vitro function, including inability to interact with emerin and failure to localize at the nuclear envelope. In general, the position of the mutation within the LMNA gene determines the type and extent of tissue involvement (3), particularly for missense mutations. However, this unique mutation might serve as a natural probe in future in vitro and in vivo studies designed to understand pathogenesis and phenotypic consequences of disrupted nuclear envelope function in human disease.
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Acknowledgments |
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Footnotes |
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Disclosure: The authors have no conflicts to disclose.
First Published Online April 24, 2006
1 C.F.M., M.A.T., and H.C. contributed equally to this work. 
Abbreviations: CT, Computed tomography; EKG, electrocardiogram; FPLD, familial partial lipodystrophy; MIM, Mendelian Inheritance in Man; T2DM, type 2 diabetes.
Received December 16, 2005.
Accepted April 17, 2006.
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References |
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-helical rod domains of the lamin A/C gene. Am J Med 112:549–555[CrossRef][Medline]This article has been cited by other articles:
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  C.-Y. Tsao and J. R. Mendell Partial Epilepsy in an Adolescent Male With Limb-Girdle Muscular Dystrophy 1B J Child Neurol, March 1, 2009; 24(3): 346 - 348. [Abstract] [PDF]
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 A. Decaudain, M.-C. Vantyghem, B. Guerci, A.-C. Hecart, M. Auclair, Y. Reznik, H. Narbonne, P.-H. Ducluzeau, B. Donadille, C. Lebbe, et al. New Metabolic Phenotypes in Laminopathies: LMNA Mutations in Patients with Severe Metabolic Syndrome J. Clin. Endocrinol. Metab., December 1, 2007; 92(12): 4835 - 4844. [Abstract] [Full Text] [PDF]
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 R. A. Hegele, T. R. Joy, S. A. Al-Attar, and B. K. Rutt Thematic review series: Adipocyte Biology. Lipodystrophies: windows on adipose biology and metabolism J. Lipid Res., July 1, 2007; 48(7): 1433 - 1444. [Abstract] [Full Text] [PDF]
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