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Triple-A syndrome with prominent ophthalmic features and a novel mutation in the AAASgene: a case report

  • Brian P Brooks1, 2Email author,
  • Robert Kleta1,
  • Rafael C Caruso2,
  • Caroline Stuart1,
  • Jonathan Ludlow3 and
  • Constantine A Stratakis4
BMC Ophthalmology20044:7

DOI: 10.1186/1471-2415-4-7

Received: 26 February 2004

Accepted: 24 June 2004

Published: 24 June 2004

Abstract

Background

Triple-A syndrome (Allgrove syndrome) is an autosomal recessive disorder characterized by adrenal insufficiency, alacrima, achalasia, and – occasionally – autonomic instability. Mutations have been found in the AAAS gene on 12q13.

Case presentation

We present the case of a 12 year-old boy with classic systemic features of triple-A syndrome and several prominent ophthalmic features, including: accommodative spasm, dry eye, superficial punctate keratopathy, and pupillary hypersensitivity to dilute pilocarpine. MRI showed small lacrimal glands bilaterally. DNA sequencing of PCR-amplified fragments from the 16 exons of the AAAS gene revealed compound heterozygosity for a new, out-of-frame 5-bp deletion in exon 15, c1368-1372delGCTCA, and a previously-described nonsense mutation in exon 9, c938C>T, R286X.

Conclusions

In addition to known ophthalmic manifestations, triple-A syndrome can present with accommodative dysregulation and ocular signs of autonomic dysfunction.

Background

Triple-A syndrome (also known as Allgrove syndrome, OMIM #231550) is a rare, autosomal recessive disease characterized by alacrima, achalasia, ACTH-resistant adrenal insufficiency, autonomic dysfunction and neurodegeneration. [1, 2] Ophthalmic manifestations include alacrima and keratoconjunctivitis sicca, sometimes resulting in corneal melt; lacrimal gland atrophy; pupillary abnormalities, including sluggish pupils, tonic pupils, and hypersensitivity to dilute miotics; and optic atrophy. [38] The phenotype in triple-A syndrome patients is highly variable. [9] Mutations in the AAAS gene on chromosome 12q13 have been described in several pedigrees with triple-A syndrome (Table 1). [7, 919] Molecular data coupled with a detailed ophthalmic examination have not be reported in the literature.
Table 1

Reported mutations in the AAAS gene in subjects with triple A syndrome. The numbering of nucleotides corresponds to the conventions of Dunnen and Antonarakis. [26] The most commonly-reported mutation is IVS 14+1G>A.

Position

Protein

cDNA Mutation

References

IVS 4

 

IVS 4-2A>G

Tullio-Pelet et al. (2000)

Ex 9

R312X

934C>T

Tullio-Pelet et al. (2000)

Ex10

S328fsX363

981_982insT

Tullio-Pelet et al. (2000)

IVS 14

 

IVS 14+1G>A

Tullio-Pelet et al. (2000), Sandrini et al. (2001); Reshmi-Skarja et al (2003); Roubergue A et al (2004)

Ex 16

R478X

1432C>T

Tullio-Pelet et al. (2000); Yuksel et al. (2004)

Ex 1

Q15K

43C>A

Handschug et al. (2001), Sandrini et al. (2001), Houlden et al. (2002); Prpic et al. (2003)

Ex 2

W84X

251G>A

Handschug et al. (2001)

Ex 6

H160R

479A>G

Handschug et al. (2001)

Ex 6

F157fsX171

470_471delTT

Handschug et al. (2001)

Ex 8

S263P

787T>C

Handschug et al. (2001), Houlden et al. (2002); Prpic et al. (2003)

Ex 15

S463fsX549

1389delC

Handschug et al. (2001)

Ex 9

R286X

856C>T

Handschug et al. (2001), this report

Ex 11

R342X

1024C>T

Handschug et al. (2001)

Ex 9

W295X

884G>A

Schmittmann-Ohters (2001)

IVS 11

 

IVS 11+1G>A

Sandrini et al. (2001)

Ex 16

R478X

1432C>T

Goizet et al. (2002), Yuksel et al. (2004)

Ex 8

Q237X

709C>T

Katsumata et al. (2002)

Ex 2

I70fsX92

210delC

Houlden et al. (2002)

Ex 7

R230X

678C>T

Houlden et al. (2002), Reshmi-Skarja et al. (2003)

Ex 10

V313A

1238T>C

Houlden et al. (2002)

Ex 11

L356fsX362

1066-1067delCT

Houlden et al. (2002)

Ex 12

S382fsX413

1144-1147delTCTG

Houlden et al. (2002)

Ex 12

D368fsX382

1104-1105insC

Houlden et al. (2002)

Ex 13

397fxs27

1191insA

Houlden et al. (2002)

Ex 16

W474X

1421G>A

Houlden et al. (2002)

Ex 12

Q387X

1159C>T

Prpic et al. (2003)

Ex 2

H71fsX92

211delC

Reshmi-Skarja et al. (2003)

Ex 4

R119X

355C>T

Reshmi-Skarja et al. (2003)

Ex 5

Q145X

433C>T

Reshmi-Skarja et al. (2003)

IVS 5

 

IVS 5+3insT

Reshmi-Skarja et al. (2003)

Ex 15

Q456X

1366C>T

Reshmi-Skarja et al. (2003)

Ex 15

X492

1368-1372delGCTCA

this report

We report a case and a novel mutation in the AAAS gene in a 12 year-old boy with triple-A syndrome who exhibited evidence of accommodative spasms, in addition to dry eye and pupillary hypersensitivity to 0.125% pilocarpine.

Case presentation

Clinical studies

The subject was examined at the National Eye Institute and the National Institute of Child Health and Human Development at the National Institutes of Health. Informed parental consent and subject assent were obtained prior to examination and molecular studies. This study was performed in accordance with the Declaration of Helsinki.

Pupillography was performed using a standard pupilometry eye tracking system (ISAN Co, Burlington, Massachusetts). Pupil diameter was digitized at 60 Hz; binocular 150 ms stimuli delivered by green LEDs were used to elicit the light reaction.

Genetic studies

Analysis of AAAS mutations was performed as follows: Genomic DNA was isolated from whole blood following standard procedures. Intronic primers (Invitrogen) were appropriately chosen in order to sequence both splice sites of each exon. Primer sequences are available upon request. PCR products of each exon were run on agarose gels, specific bands were cut and the DNA was isolated following standard procedures. This DNA was sequences in both directions using a Beckman Coulter CEQ8000 following the manufacturer's protocol.

History and examination

The subject was diagnosed with adrenocortical insufficiency with elevated plasma ACTH at age 1 after a hypoglycemic seizure and was subsequently pharmacologically supplemented with glucocorticoids. Mineralocorticoid supplementation was initially instituted, but was subsequently discontinued. He cried without tears since birth. At age 2 he developed achalasia, which was treated successfully with surgery. The diagnosis of triple-A syndrome was made at age 4. Pregnancy and birth history were unremarkable. The subject was previously diagnosed with accommodative esotropia and treated with hyperopic correction. The proband's parents and three siblings did not have similar symptoms and were healthy. The parents' grandparents were from the same town in Italy, but there was no known consanguinity. The subject had speech delay as a child and receives speech therapy. He is currently enrolled in a normal 5th grade class with special aids for English, social studies and math. Over the past few years, he has developed ataxia. Review of systems was notable for photophobia and dry mouth.

Physical examination was remarkable for a fissured, dry tongue; palmar and plantar keratosis; +4 upper- and lower-extremity reflexes; 3–4 beats of lower-extremity clonus; a positive Babinski sign; and ataxic responses to tandem gait and finger-to-nose testing. The subject did not have orthostatic hypotension. Nerve conduction studies were not performed. An echocardiogram and an electrocardiogram were normal. CT of the abdomen was remarkable for little to no adrenal gland tissue. MRI of the brain showed no abnormalities, but the main lacrimal glands appeared small bilaterally (Figure 1).
https://static-content.springer.com/image/art%3A10.1186%2F1471-2415-4-7/MediaObjects/12886_2004_Article_24_Fig1_HTML.jpg
Figure 1

MRI of the brain of 12 year-old boy with triple-A syndrome showing hypoplastic lacrimal glands (yellow arrows.)

Visual acuity with his current spectacles (+3.25+1.50 × 120 OD, +3.25+1.50 × 100 OS) was 20/200 OD and 20/150 OS. Manifest refraction of -0.25+1.00 × 120 OD and +0.75 + 1.25 × 60 OS improved acuity to 20/50 and 20/70, respectively. Near vision at 14 inches was J7 OD and J3 OS. The subject had 400" of stereopsis on Titmus testing and had a red-green color deficiency (saw 3 of 15 Ishihara plates with each eye). Ocular motility was full and without nystagmus. Alternate cover testing with his current spectacles showed a 16–18 PD esotropia (ET) at 1/3 m and an 8 PD ET at 6 m. When allowed to wear a +3.00 D over his current refraction for several minutes, his ET decreased at near to 2–3 PD. Near point of accommodation was 11 cm OD and 9 cm OS. The patient had a somewhat variable, 35–40 ET at distance and near without correction. Clinically, his pupils were 5 mm OD and 5.5 mm OS and were somewhat sluggishly reactive to light. However, his light reaction to LED stimuli recorded with pupillography showed a relatively normal wave form. There was no afferent pupillary defect and constriction at near was not tested. The right pupil was tested with 0.125% pilocarpine and showed constriction to 2.5 mm in approximately 10 minutes. Schirmer testing results with anesthesia were 6 mmOD and 12 mmOS. Slit lamp examination was remarkable for trace injection, a decreased tear lake, and mild, bilateral superficial punctate keratopathy. Intraocular pressures were 11 mm Hg OD and 15 mmHg OS. His optic nerves, vessels, maculae, and retinal peripheries were normal on dilated examination. Cycloplegic refraction was +2.75 + 1.75 × 70 OD and +3.00 + 1.00 × 120. With this refraction, the subject could read 20/50 OD and 20/70 OS. After approximately 1 year of spectacle correction and amblyopia treatment, the subject's best-corrected vision improved to 20/30 OD and 20/40 OS. His stereopsis improved to 100 seconds of arc and his performance on Ishihara color-plate testing was stable.

Molecular testing

After informed consent, 5 cc of blood was drawn for research purposes. Sequencing of all 16 coding exons of the AAAS gene revealed compound heterozygosity for two mutations, both of which are predicted to premature stops in translation. In exon 9, the nonsense mutation leads to a shortened protein of 286, instead of 546, amino acids. In exon 15, and out-of-frame 5-bp deletion, c1368-1372delGCTCA, leads to a premature stop codon and a shortened protein of 492 amino acids (Figure 2.) Because both sequence changes are expected to result in premature truncation of the AAAS protein, they are likely pathological. This sequence alterations were not present in 100 control chromosomes from unaffected individuals.
https://static-content.springer.com/image/art%3A10.1186%2F1471-2415-4-7/MediaObjects/12886_2004_Article_24_Fig2_HTML.jpg
Figure 2

Compound heterozygous mutations in AAAS gene in subject with triple-A syndrome. The subject has a novel, five base-pair deletion in exon 15 (A, deletion boxed in control panel) predicted to cause a frameshift and a premature truncation of the Aladin protein. He also had a cytosine to thymidine mutation (B) in exon 9, predicted to cause a premature stop of protein translation.

Discussion

We present the case of an 12 year-old boy with classic triple-A syndrome who is a compound heterozygote for mutations in the AAAS gene. One mutation (R286X) has been previously reported and the other (c1368-1372delGCTCA) is novel. [11] The ophthalmic features consistent with the diagnosis of triple-A syndrome in this patient included: decreased tear production with a history of no spontaneous tearing; superficial punctate keratopathy; and increased pupillary sensitivity to 0.125% pilocarpine. In addition, the subject also appeared to inappropriately accommodate, as comparison of the uncyclopleged manifest refraction and the cycloplegic refraction suggested. This is not likely to be simply manifestation of his accommodative esotropia, per se. Although his esotropia improved with hyperopic correction, his vision did not until accommodation was pharmacologically blocked or until a compensatory refraction was given.

Accommodation results from contraction of the ciliary muscles, relaxation of the lens zonules, and an increase in the effective refracting power of the lens. This process is mediated via cholinergic, parasympathetic motor fibers. Patients with triple-A syndrome often manifest signs of autonomic dysregulation, including decreased lacrimation, pupillary abnormalities, orthostatic hypotension, sexual impotence, disturbances of heart rate, and abnormal reactions to intradermal histamine. [5, 7] We hypothesize that the refractive difficulties experienced by our subject are related to autonomic dysfunction. Alternatively, because patients with triple-A syndrome have a neurodegenerative process that can affect cranial nerves, [14] the observed dysregulation may be due to central causes.

The decreased best-corrected visual acuity in this boy may have been due to superficial punctate keratopathy and/or amblyopia. Patients with triple-A syndrome sometimes develop optic atrophy. [7] Although our patient did not have clinical evidence of optic nerve dysfunction, we cannot rule out a subtle process that produced a moderate degree of visual impairment, despite the normal appearance of both the optic nerves and brain imaging. Similarly, it is possible that photoreceptor dysfunction in the retina – while never reported in triple-A syndrome – could explain some of the decreased best-corrected visual acuity and his red-green color deficiency. The patient was not available for follow-up testing with an electroretinogram, but his improvement with spectacle correction and amblyopia treatment over a year time argues against a progressive photoreceptor degeneration.

Lacrimation – both reflex and basal – is under parasympathetic control, as is pupillary miosis. [2022] Autonomic dysfunction at the level of the lacrimal glands and the pupil presumably explain the abnormalities seen in this condition. Mullaney et al. noted small lacrimal glands on orbital imaging and a reduced number of serous-secreting cells on lacrimal gland biopsy of three patients with triple-A syndrome. [4] The hypersensitivity to dilute pilocarpine is likely due to up-regulation of post-synaptic muscarinic receptors on the iris sphincter. Frequent ocular lubrication was recommended to this subject.

The AAAS gene contains 16 exons and codes for a 546 amino acid protein called ALADIN. [10] ALADIN does not have major homology to any known proteins, but contains four WD motifs. WD proteins are a functionally diverse family whose members are involved in processes such as cell division, cell-fate determination, transcription, transmembrane signaling and intracellular trafficking. [23] Proteomic analysis of the mammalian nuclear pore complex (NPC) has shown that ALADIN is part of this structure, which is critical for communication between the nucleus and the cytoplasm of cells. [24] When mutated, ALADIN localizes to the cytoplasm, rather than the NPC. [25] However, cells from a subject with triple-A syndrome showed morphologically normal NPCs. These findings suggest that ALADIN is likely critical for nuclear pore function, rather than NPC structure. ALADIN may therefore be critical for the development of maintenance of the cell types affected in triple-A syndrome. Reshmi-Skarja et al. recently described chromosome and/or chromatid breaks, whole chromosome arm deletions, and marker chromosomes involving 9q12, a heterochromatic region know to be a fragile site, in subjects with triple-A syndrome [17].

List of Abbreviations

ACTH: 

adrenocorticotropic hormone

CT: 

computed tomography

D: 

diopter

DNA: 

deoxyribonucleic acid

MRI: 

magnetic resonance imaging

OMIM: 

Online Mendelian Inheritance in Man

PCR: 

polymerase chain reaction

PD: 

prism diopter

Declarations

Acknowledgements

We would like to thank Stan Mackowiak, M.D. and Susan E. Stred, M.D., SUNY Upstate Medical University, for clinical care of the patient. We thank the subject's parents for consenting and the subject for assenting to the publication of this article.

Authors’ Affiliations

(1)
National Human Genome Research Institute, National Institutes of Health, Department of Health and Human Services
(2)
The National Eye Institute, National Institutes of Health, Department of Health and Human Services
(3)
North Country Medical Eye Care
(4)
The National Instiute of Child Health and Development, National Institutes of Health, Department of Health and Human Services

References

  1. Allgrove J, Clayden GS, Grant DB, Macaulay JC: Familial glucocorticoid deficiency with achalasia of the cardia and deficient tear production. Lancet. 1978, 1: 1284-1286. 10.1016/S0140-6736(78)91268-0.View ArticlePubMedGoogle Scholar
  2. Grant DB, Dunger DB, Smith I, Hyland K: Familial glucocorticoid deficiency with achalasia of the cardia associated with mixed neuropathy, long-tract degeneration and mild dementia. Eur J Pediatr. 1992, 151: 85-89.View ArticlePubMedGoogle Scholar
  3. El-Rayyes Kalid, Hegab Samiha, Besisso Mohammed: A syndrome of alacrima, achlasia, and neuroloogic anomalies without adremocortical insufficiency. J Pediatr Ophthalmol Strabismus. 1991, 28: 35-37.PubMedGoogle Scholar
  4. Mullaney PB, Weatherhead R, Millar L, Ayyash II, Ayberk H, Cai F, Risco JM: Keratoconjunctivitis sicca associated with achalasia of the cardia, adrenocorticalinsufficiency, and lacrimal gland degeneration. Ophthalmology. 1998, 105: 643-650. 10.1016/S0161-6420(98)94018-0.View ArticlePubMedGoogle Scholar
  5. Makari G, Hoffman WH, Carroll JE, Savage DR, Van Der Zalm T: Autonomic dysfunction and adrenocortical unresponsiveness. J Child Neurol. 1988, 3: 174-176.View ArticlePubMedGoogle Scholar
  6. Ehrich E, Aranoff G, Johnson WG: Familial achalasia associated with adrenocortical insufficiency, alacrima, and neurological abnormalities. Am J Med Genet. 1987, 26: 637-644.View ArticlePubMedGoogle Scholar
  7. Houlden H, Smith S, de Carvalho M, Blake J, Mathias C, Wood NW, Reilly MM: Clinical and genetic characterization of families with triple A (Allgrove) syndrome. Brain. 2002, 125: 2681-2690. 10.1093/brain/awf270.View ArticlePubMedGoogle Scholar
  8. Tsilou E, Stratakis CA, Rubin BI, Hay BN, Patronas N, Kaiser-Kupfer MI: Ophthalmic manifestations of Allgrove syndrome: report of a case. Clin Dysmorphol. 2001, 10: 231-233. 10.1097/00019605-200107000-00016.View ArticlePubMedGoogle Scholar
  9. Prpic I, Huebner A, Persic M, Handschug K, Pavletic M: Triple A syndrome: genotype-phenotype assessment. Clin Genet. 2003, 63: 415-417. 10.1034/j.1399-0004.2003.00070.x.View ArticlePubMedGoogle Scholar
  10. Tullio-Pelet A, Salomon R, Hadj-Rabia S, Mugnier C, de Laet M, Chaouachi B, Bakiri F, Brottier P, Cattoloci L, Penet C, Begeot M, Naville D, Nicolino M, Chaussain JL, Weissenbach J, Munnich A, Lyonnet S: Mutant WD-repeat protein in triple-A syndrome. Nat Genet. 2000, 26: 332-335. 10.1038/81642.View ArticlePubMedGoogle Scholar
  11. Handschug K, Sperling S, Yoon S-JK, Henning S, Clark AJL, Huebner A: Triple A syndrome is caused by mutations in AAAS, a new WD-repeat protein gene. Hum Mol Genet. 2001, 10: 283-290. 10.1093/hmg/10.3.283.View ArticlePubMedGoogle Scholar
  12. Sandrini F, Farmakidis C, Kirschner LS, Wu SM, Tullio-Pelet A, Lyonnet S, Metzger DL, Bourdony CJ, Tiosano D, Chan WY, Stratakis CA: Spectrum of mutations of the AAAS gene in Allgrove syndrome: lack of mutations in six kindreds with isolated resistance to corticotropin. J Clin Endocrinol Metab. 2001, 86: 5433-5437. 10.1210/jc.86.11.5433.View ArticlePubMedGoogle Scholar
  13. Schmittmann-Ohters K, Huebner A, Richter-Unruh A, Hauffa BP: Clinical and novel molecular findings in a 6.8-year-old Turkish boy with triple A syndrome. Horm Res. 2001, 56: 67-72. 10.1159/000048093.View ArticlePubMedGoogle Scholar
  14. Goizet C, Catargi B, Tison F, Tullio-Pelet A, Hadj-Rabia S, Pujol F, Lagueny A, Lyonnet S, Lacombe D: Progressive bulbospinal amyotrophy in triple A syndrome with AAAS gene mutation. Neurology. 2002, 58: 962-965.View ArticlePubMedGoogle Scholar
  15. Katsumata M, Hirose H, Kagami M, Tanaka T: Analysis of the AAAS gene in Japanese patients with triple A syndrome. Endocr J. 2002, 49: 49-53.View ArticlePubMedGoogle Scholar
  16. Huebner A, Kaindl A<, Braun R, Handschug K: New insights into the molecular basis of the triple A syndrome. Endocr Res. 2002, 28: 733-739. 10.1081/ERC-120016998.View ArticlePubMedGoogle Scholar
  17. Reshmi-Skarja S, Huebner A, Handschug K, Finegold DN, Clark AJ, Gollin SM: Chromosomal fragility in patients with triple A syndrome. Am J Med Genet. 2003, 117A: 30-36. 10.1002/ajmg.a.10846.View ArticlePubMedGoogle Scholar
  18. Roubergue A, Apartis E, Vidailhet M, Mignot C, Tullio-Pelet A, Lyonnet S, de Villemeur TB: Myoclonus and generalized digestive dysmotility in triple A syndrome with AAAS gene mutation. Mov Disord. 2004, 19: 344-346. 10.1002/mds.10660.View ArticlePubMedGoogle Scholar
  19. Yuksel B, Braun R, Topaloglu AK, Mungan NO, Ozer G, Huebner A: Three children with triple A ayndrome due to a mutation (R478X) in the AAAS gene. Horm Res. 2004, 61: 3-6. 10.1159/000075190.View ArticlePubMedGoogle Scholar
  20. Ruskell GL: Changes in nerve terminals and acini of the lacrimal gland and changes in secretion induced by autonomic denervation. Z Zellforsch Mikrosk Anat. 1969, 94: 261-281.View ArticlePubMedGoogle Scholar
  21. Dunnington JH: Congenital alacrima in familial autonomic dysfunction. Trans Am Ophthalmol Soc. 1954, 52: 23-32.PubMedPubMed CentralGoogle Scholar
  22. Seifert P, Spitznas M: Demonstration of nerve fibers in human accessory lacrimal glands. Graefes Arch Clin Exp Ophthalmol. 1994, 232: 107-114.View ArticlePubMedGoogle Scholar
  23. Smith TF, Gaitatzes C, Saxena K, Neer EJ: The WD repeat: a common architecture for diverse functions. Trends Biochem Sci. 1999, 24: 181-185. 10.1016/S0968-0004(99)01384-5.View ArticlePubMedGoogle Scholar
  24. Cronshaw JM, Krutchinsky AN, Zhang W, Chait BT, Matunis MJ: Proteomic analysis of the mammalian nuclear pore complex. J Cell Biol. 2002, 158: 915-927. 10.1083/jcb.200206106.View ArticlePubMedPubMed CentralGoogle Scholar
  25. Cronshaw JM, Matunis MJ: The nuclear pore complex protein ALADIN is mislocalized in triple A syndrome. Proc Natl Acad Sci U S A. 2003, 100: 5823-5827. 10.1073/pnas.1031047100.View ArticlePubMedPubMed CentralGoogle Scholar
  26. den Dunnen JT, Antonarakis SE: Nomenclature for the description of human sequence variations. Hum Genet. 2001, 109: 121-124. 10.1007/s004390100505.View ArticlePubMedGoogle Scholar
  27. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2415/4/7/prepub

Copyright

© Brooks et al; licensee BioMed Central Ltd. 2004

This article is published under license to BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL.

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