A splice site mutation confirms the role of LPIN2 in Majeed syndrome.
ABSTRACT Majeed syndrome is an autoinflammatory disorder consisting of chronic recurrent multifocal osteomyelitis, congenital dyserythropoietic anemia, and neutrophilic dermatosis. To date, 2 unrelated families with Majeed syndrome have been reported. Mutations in LPIN2 have been found in both families. Here we report a third consanguineous family with Majeed syndrome with a novel mutation. The patient, a 3-year-old Arabic girl, had hepatosplenomegaly and anemia as a neonate. At age 15 months, she developed recurrent episodes of fever and multifocal osteomyelitis. In addition, bone marrow aspiration demonstrated significant dyserythropoiesis, suggesting Majeed syndrome. Coding sequences and splice sites of LPIN2 were sequenced in the patient and her mother. A homozygous single-basepair change was detected in the donor splice site of exon 17 (c.2327+1G>C) in the patient; her mother was heterozygous at this site. These data confirm the role of LPIN2 mutations in the etiology of Majeed syndrome.
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ABSTRACT: A number of inborn errors of metabolism (IEM) have been shown to result in predominantly immunologic phenotypes, manifesting in part as inborn errors of immunity. These phenotypes are mostly caused by defects that affect the (i) quality or quantity of essential structural building blocks (e.g., nucleic acids, and amino acids), (ii) cellular energy economy (e.g., glucose metabolism), (iii) post-translational protein modification (e.g., glycosylation) or (iv) mitochondrial function. Presenting as multisystemic defects, they also affect innate or adaptive immunity, or both, and display various types of immune dysregulation. Specific and potentially curative therapies are available for some of these diseases, whereas targeted treatments capable of inducing clinical remission are available for others. We will herein review the pathogenesis, diagnosis, and treatment of primary immunodeficiencies (PIDs) due to underlying metabolic disorders.Journal of Clinical Immunology 08/2014; · 2.65 Impact Factor
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ABSTRACT: Many diseases result in polyostotic bone lesions including benign entities, benign entities with malignant potential, intermediate entities, and malignant entities. Imaging plays a key role in identifying complications of these disorders, most importantly malignant transformation of a benign lesion. The most common polyostotic bone lesions are reviewed and examples of malignant transformation are highlighted.Current Problems in Diagnostic Radiology 07/2014; 43(4):186-204.
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ABSTRACT: The innate immune system is involved in the pathophysiology of systemic autoinflammatory diseases (SAIDs), an enlarging group of disorders caused by dysregulated production of proinflammatory cytokines, such as interleukin-1β and tumor necrosis factor-α, in which autoreactive T-lymphocytes and autoantibodies are indeed absent. A widely deranged innate immunity leads to overactivity of proinflammatory cytokines and subsequent multisite inflammatory symptoms depicting various conditions, such as hereditary periodic fevers, granulomatous disorders, and pyogenic diseases, collectively described in this review. Further research should enhance our understanding of the genetics behind SAIDs, unearth triggers of inflammatory attacks, and result in improvement for their diagnosis and treatment.Mediators of Inflammation 01/2014; 2014:948154. · 2.42 Impact Factor
ARTHRITIS & RHEUMATISM
Vol. 56, No. 3, March 2007, pp 960–964
© 2007, American College of Rheumatology
A Splice Site Mutation Confirms the Role of LPIN2 in
Zakiya S. Al-Mosawi,1Khulood K. Al-Saad,1Roya Ijadi-Maghsoodi,2Hatem I. El-Shanti,2
and Polly J. Ferguson2
Majeed syndrome is an autoinflammatory disor-
der consisting of chronic recurrent multifocal osteomy-
elitis, congenital dyserythropoietic anemia, and neutro-
philic dermatosis. To date, 2 unrelated families with
Majeed syndrome have been reported. Mutations in
LPIN2 have been found in both families. Here we report
a third consanguineous family with Majeed syndrome
with a novel mutation. The patient, a 3-year-old Arabic
girl, had hepatosplenomegaly and anemia as a neonate.
At age 15 months, she developed recurrent episodes of
fever and multifocal osteomyelitis. In addition, bone
marrow aspiration demonstrated significant dyseryth-
ropoiesis, suggesting Majeed syndrome. Coding se-
quences and splice sites of LPIN2 were sequenced in the
patient and her mother. A homozygous single-basepair
change was detected in the donor splice site of exon 17
(c.2327?1G>C) in the patient; her mother was het-
erozygous at this site. These data confirm the role of
LPIN2 mutations in the etiology of Majeed syndrome.
Majeed syndrome is a rare, autosomal-recessive
autoinflammatory disorder first reported in 1989 (MIM
no. #609628) (1). Phenotypically, the disease is charac-
terized by a triad of chronic recurrent multifocal osteo-
myelitis (CRMO), congenital dyserythropoietic anemia
(CDA), and an inflammatory dermatosis (1–4). To date,
it has been described in 6 individuals from 3 sibships
from 2 unrelated Arabic families (1–4).
As a distinct clinical entity, CRMO manifests as
recurrent episodes of sterile multifocal inflammatory
bone lesions (with or without fever) and is often associ-
ated with a comorbid inflammatory condition such as
psoriasis, pustulosis palmoplantaris, Sweet syndrome,
spondylarthropathy, or inflammatory bowel disease (5–
7). The age at onset typically ranges from 4 to 14 years,
and the disease generally runs a self-limited course
(5,6,8). The etiology of CRMO remains unclear, but
evidence suggests a genetic contribution. Although most
cases of CRMO are sporadic, there are reports of
affected siblings, concordance in monozygotic twins, and
of a chronic osteomyelitis in both a parent and a child
(9,10). In 2002, Golla et al reported evidence for a
CRMO susceptibility locus at 18q21.3–18q22 (10). In
addition, first- and second-degree relatives of children
with CRMO have an increased incidence of having a
chronic inflammatory disorder, most commonly pso-
In contrast to sporadic CRMO, Majeed syn-
drome is an autosomal-recessive disorder with a more
severe phenotype. CRMO presents earlier (at age ?2
years), and there are more frequent recurrences of bone
inflammation, shorter remissions, and a longer duration
of disease (continuing into adulthood). It is associated
with poor linear growth and may lead to permanent joint
The CDAs are a group of red blood cell disorders
characterized by abnormal normoblast morphology in
the bone marrow and decreased erythrocyte output (12).
Unlike the well-described inherited CDAs, which are
either macrocytic or normocytic, the CDA of Majeed
syndrome is microcytic. The dermatosis reported in
Majeed syndrome is Sweet syndrome (1), with psoriasis
present in some carriers.
The genetic basis of Majeed syndrome was estab-
Supported by the NIH (National Institute of Arthritis and
Musculoskeletal and Skin Diseases grants 1-R21-AR-053924-01 and 1-
R03-AR-051130-01) and the University of Iowa (Carver Medical
Research Initiative Grant).
1Zakiya S. Al-Mosawi, MD, Khulood K. Al-Saad, MD: Sal-
manyia Medical Complex, Manama, Kingdom of Bahrain;
Ijadi-Maghsoodi, BS, Hatem I. El-Shanti, MD, Polly J. Ferguson, MD:
University of Iowa Carver College of Medicine, Iowa City.
Address correspondence and reprint requests to Polly J.
Ferguson, MD, Department of Pediatrics, University of Iowa Carver
College of Medicine, 200 Hawkins Drive, 2532 JCP, Iowa City, IA
52242. E-mail: firstname.lastname@example.org.
Submitted for publication August 25, 2006; accepted in
revised form November 28, 2006.
lished by mapping the disease locus to a 5.5-cM (1.8-Mb)
interval on the short arm of chromosome 18 followed by
examination of the candidate genes within the region.
Homozygous mutations in LPIN2 were identified in
affected individuals from the 2 unrelated Arabic families
(2). Each family had a unique mutation; one family had
a frameshift mutation due to a 2-consecutive-basepair
deletion resulting in a premature stop codon, while the
other family had a missense mutation replacing a highly
conserved serine with a leucine. Although the function
of lipin 2 is yet to be defined, the phenotype suggests
that it plays a role in the regulation of the innate
immune response (2). Here we describe the clinical
features of another child with Majeed syndrome, and we
report a novel mutation in LPIN2. Majeed syndrome
needs to be included in the differential diagnosis of
periodic fevers, unexplained congenital anemia, and
The patient was an Arabic female born after 36
weeks of gestation to first-cousin parents (Figure 1). In
the neonatal period, she developed cholestatic jaundice
and was noted to have mild-to-moderate hepatospleno-
megaly. Laboratory studies revealed a hemoglobin level
of 9.5 gm/dl, mean corpuscular volume (MCV) of 101 fl
(normal 82–97) with a reticulocytosis of 3.4%, and an
absolute neutrophil count of 1,080/mm3. Liver function
tests revealed an alanine aminotransferase level of 169
units/liter (normal 30–65), a ?-glutamyl transferase level
of 238 units/liter (normal 5–85), and an alkaline phos-
phatase (AP) level of 727 units/liter (normal 35–104).
An abdominal ultrasound revealed hepatosplenomegaly
with normal appearance of the liver, bile duct, and gall
By age 10 months, the patient’s liver enzymes had
normalized but her AP level remained mildly elevated at
350 units/liter. She had a microcytic, hypochromic,
Coombs’ test–negative anemia (hemoglobin 7.5 gm/dl,
MCV 67.8 fl) with continued reticulocytosis and mild
neutropenia. Iron therapy failed to correct her anemia.
At age 15 months, she began having left leg pain and
recurrent low-grade fevers. The febrile episodes oc-
curred every 2–3 weeks and lasted 3–4 days. At age 17
months, she was noted to have objective swelling of the
soft tissue overlying the left distal femur and had re-
duced range of motion in the left knee, with an eryth-
rocyte sedimentation rate (ESR) of 96 mm/hour. Her
hemoglobin level was 8.9 gm/dl. Plain radiographs of the
lower extremities demonstrated no osseous abnormali-
ties, while a bone scan showed increased99mTc radio-
isotope uptake in the left distal femur, left proximal and
distal tibia, and left calcaneus and midfoot on vascular
flow images at 10 minutes as well as on delayed uptake
images obtained at 3 hours (Figure 2). Blood cultures
were negative. The patient was treated empirically with
a 6-week course of antibiotics for presumed osteomyeli-
tis, but with no improvement.
At age 19 months, the patient was readmitted
with swelling of both ankles and fevers. Her ESR was 66
mm/hour and her C-reactive protein (CRP) level was 30
mg/liter with normal C3 and C4 levels. Tests for the
presence of circulating rheumatoid factor and antinu-
clear antibodies yielded negative results. Blood cultures
were negative. Findings on plain radiographs of both
ankles were normal. She received an additional course
of intravenous antibiotics on the assumption of septic
arthritis, but without clinical improvement. At this time,
CRMO was raised as a diagnostic possibility. A bone
biopsy was suggested but refused by her parents. The
patient was started on naproxen treatment (10 mg/kg
twice daily) and discharged.
One month later, the patient’s ESR had fallen to
27 mm/hour, but her anemia and neutropenia persisted
(hemoglobin 8.7 gm/dl, absolute neutrophil count 750/
mm3). Bone marrow aspiration was performed and
revealed normoblastic erythroid hyperplasia with
marked dyserythropoiesis, a myeloid:erythroid ratio of
1:1.6, increased iron stores, and normal maturation of
granulocytes (Figure 2), consistent with CDA. An acid
hemolysin test yielded negative results, and her serum
Figure 1. Pedigree constructed for the patient. The pedigree reveals a
marriage between first cousins (individuals III-1 and III-2). The
patient (individual IV-3) is designated by the solid circle and the
proband arrow. Open symbols ? unaffected subjects. The open
diamond represents an unborn child from a current pregnancy.
LPIN2 IN MAJEED SYNDROME 961
vitamin B12and folate levels were normal. Majeed
syndrome was suspected. A skeletal survey yielded nor-
mal findings. A few weeks later, she presented with
painful swelling of the right distal forearm and right
ankle. She continued to have hepatosplenomegaly, and
her ESR was 72 mm/hour, her CRP level was 47.8
mg/liter, and her hemoglobin level was 7.7 gm/dl. Pred-
nisolone (1.4 mg/kg/day) was started. One month later,
the hepatosplenomegaly had regressed and there were
no musculoskeletal abnormalities on examination. Her
ESR decreased to 15 mm/hour, and her hemoglobin
level increased to 11.8 gm/dl. The prednisolone dosage
was tapered to 0.7 mg/kg/day, and 8 months later, at age
3 years, she remains asymptomatic.
Methods. A family history was obtained and a
pedigree was constructed (Figure 1). After written con-
sent was obtained (by KKA-S) at Salmanyia Medical
Complex, the coding regions and splice sites of LPIN2 in
the patient and her unaffected mother were sequenced.
DNA was extracted from whole blood by stan-
dard procedures. The sequence of LPIN2 (NM_014646)
was obtained from public databases (http://ncbi.nlm.
nih.gov, http://genome.ucsc.edu). Primer pairs utilized
to amplify the exons and splice sites of LPIN2 were
described previously (2). The coding regions and splice
sites of the 20 exons were amplified from genomic DNA
using polymerase chain reaction, run on agarose gels,
cut, and recovered utilizing column purification. Se-
quencing was performed in both forward and reverse
directions on an automated ABI sequencer (Applied
Biosystems, Foster City, CA) utilizing dye-terminator
chemistry. Using a single-strand conformational poly-
morphism (SSCP) assay followed by direct sequencing in
all suspicious bands, we had previously screened exon 17
for single-nucleotide polymorphisms (SNPs) in a control
population consisting of 367 anonymous Arabic controls
(2). In addition, exon 17 was sequenced in 52 additional
unaffected individuals of various ethnicities.
Results. A homozygous single-basepair change
was detected in the 5? (donor) splice site of exon 17
(c.2327?1G?C) in the patient (Figure 3). This splice
site mutation is predicted to produce an R776S change
followed by 65 amino acids prior to encountering a
stop codon in intron 17 (Arg776SerfsX66 unless another
splice site is encountered). The mother was heterozy-
gous C/G at this site. This SNP was not found in 367
unrelated Arabic controls as screened by SSCP analysis
followed by direct sequencing of DNA samples from
individuals who had a shift on SSCP, nor was this SNP
detected in ?50 other unaffected individuals of various
Our patient presented in the neonatal period
with anemia, reticulocytosis, mild neutropenia, hepato-
splenomegaly, and transient cholestatic jaundice. At age
15 months, she developed recurrent fever and multifocal
osteomyelitis. Subsequently, a bone marrow aspiration
Figure 2. Phenotypic findings of multifocal bone lesions and dyserythropoiesis. A, Bone scan reveals
increased uptake in the distal femur, proximal tibia and distal tibia, calcaneus, and midfoot, all on the left
(arrows). B, Bone marrow aspirate reveals normoblastic hyperplasia with dyserythropoiesis. Nuclei of late
normoblasts show multinucleation with nuclear budding (Wright stained; original magnification ? 1,000).
962 AL-MOSAWI ET AL
was performed and revealed dyserythropoiesis. Al-
though inflammatory dermatoses such as psoriasis,
palmar–plantar pustulosis, and Sweet syndrome have
been reported in association with Majeed syndrome or
nonsyndromic CRMO (5,6,13,14), neither our patient
nor any of her family members were affected with an
inflammatory skin condition. Neither cholestatic jaun-
dice nor neutropenia has been reported in cases of
LPIN2 mutation–proven Majeed syndrome. However, in
1986 Vermylen et al reported on a 13-year-old girl with
CRMO and CDA who had an absolute neutrophil count
of 1,160/mm3, suggesting that a degree of mild neutro-
penia may be part of the phenotype (15). Due to the rare
nature of Majeed syndrome, treatment remains em-
pirical. Nonsteroidal antiinflammatory drugs and corti-
costeroids have been used to control the symptoms. To
our knowledge, other therapies that have been tried in
nonsyndromic CRMO, including interferon, tumor ne-
crosis factor inhibition, or bisphosphonate treatment,
have not been utilized in any child with Majeed syn-
Previously, we have demonstrated 2 unique ho-
mozygous mutations in LPIN2 in affected individuals
from 2 unrelated kindreds (2). One mutation
(c.540_541delAT, a frameshift mutation) is predicted to
produce a truncated protein of 180 amino acids in
length. This mutation was not found in 3,034 control
chromosomes. The second family had a mutation in
exon 17 of LPIN2, resulting in an S734L change in the
highly conserved serine. While this mutation was absent
in 1,150 Centre d’Etude du Polymorphisme Humain
controls (2,300 chromosomes), it was present in 4 of 734
Arabic control chromosomes. The mutant allele fre-
quency in this ethnically matched control population was
0.005, which would translate into a prevalence of 1 in
?35,000 utilizing the Hardy-Weinberg equilibrium
equation. This calculated prevalence is much higher
than the number of cases that have been reported,
leading some to question the role of LPIN2 in Majeed
Here we report a third unique mutation in LPIN2
in an Arabic female with CRMO and CDA. The R776S
nucleotide change affects a highly conserved nucleotide
residue at the 5? (donor) splice site of exon 17. It is
predicted to introduce a frameshift mutation resulting in
a premature stop codon being encountered in intron 17,
which would be predicted to produce a truncated mes-
sage (RNA was not available to test this prediction). The
R776S change was not found in 734 ethnically controlled
chromosomes or in a cohort of DNA samples from
unaffected individuals of various ethnicities. Based on
these data, the allele frequency of the R776S change
fulfills the definition of a mutation (?1%). Although we
cannot absolutely exclude the possibility that this is a
population-specific rare polymorphism, the cumulative
data demonstrating linkage to a 1.8-Mb region on 18p
Figure 3. Splice site mutation, conservation of R776, and location of known mutations in LPIN2. Top left,
Sequence of the 5? splice site of exon 17 (Ex17) of LPIN2 in the patient (A) and her heterozygous mother
(B). Also shown is the wild-type sequence (C). Arrow indicates mutated basepair. The patient is
homozygous C/C for the splice site mutation (c.2327?1G?C). Top right, Box demonstrates that the
arginine at position 776 (which is changed due to the splice site mutation) is highly conserved across
species. Bottom, Gene structure of LPIN2. LPIN2 is composed of 20 exons. Known mutations (in exon 4
and exon 17) are shown below the gene structure; solid circles represent previously reported mutations; star
shows the location of the c.2327?1G?C mutation.
LPIN2 IN MAJEED SYNDROME963
(which contains LPIN2), combined with detection of 3
different LPIN2 mutations in individuals with Majeed
syndrome, support our conclusion that mutations in
LPIN2 cause Majeed syndrome. We propose that the
discrepancy between the seemingly high estimated prev-
alence of 1 in ?35,000 in the ethnically matched popu-
lation and the paucity of reported cases of Majeed
syndrome in the literature is due at least in part to
underrecognition of this syndrome as a clinical entity.
The function of LPIN2 remains unclear. It is
named LPIN2 because it shares a lipin domain with
LPIN1. Mutations in murine lpin1 cause lipodystrophy,
suggesting a role in fat metabolism (16). Lipodystrophy
is not a phenotypic component of Majeed syndrome,
although specific laboratory tests have not been per-
formed to look for evidence of altered fat metabolism.
In our patient, levels of serum glucose, total cholesterol,
high-density lipoprotein and low-density lipoprotein
cholesterol, triglycerides, and insulin were all within
normal limits (results not shown).
The mammalian LPIN genes belong to an evolu-
tionarily conserved gene family that includes the Ned1
gene (17). Mutations in Ned1 are associated with a
chromosomal missegregation and the presence of aber-
rantly shaped nuclei in the fission yeast Schizosaccharo-
myces pombe, suggesting a role for this family of genes in
mitosis. This may explain the dyserythropoiesis seen in
Majeed syndrome. The immunologic abnormalities in
Majeed syndrome suggest that the defect predominantly
affects the innate immune system, resulting in dysregu-
lation of a pathway important in bone and skin inflam-
mation. Given that Majeed syndrome can have Sweet
syndrome as a phenotypic component, and given that
some obligate carriers of LPIN2 mutations have pso-
riasis, we are currently delineating the role of LPIN2 in
The authors wish to thank Dr. Durjoy K. Shome for
kindly providing the pathologic slides of bone marrow.
Dr. Ferguson had full access to all of the data in the study and
takes responsibility for the integrity of the data and the accuracy of the
Acquisition of data. Al-Mosawi, Al-Saad, El-Shanti, Ferguson.
Analysis and interpretation of data. El-Shanti, Ferguson.
Manuscript preparation. Al-Mosawi, Al-Saad, Ijadi-Maghsoodi, El-
Statistical analysis. El-Shanti, Ferguson.
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964AL-MOSAWI ET AL