PURPOSE:The implementation of the next-generation sequencing (NGS) in clinical practice has improved the genetic diagnosis of Hereditary Breast and Ovarian Cancer Syndrome (HBOC). We aimed to evaluate the diagnostic outcomes of using an NGS cancer gene panel in clinical practice for patients selected based on personal and/or family history of breast, ovarian, prostate, melanoma, and other HBOC-associated cancers. METHODS:The study series included 2561 consecutive Spanish individuals referred for genetic testing, comprising 2445 cancer patients and 116 healthy individuals with family history of HBOC. Eleven HBOC susceptibility genes (BRCA1, BRCA2, PALB2, ATM, CHEK2, BARD1, BRIP1, RAD51C, RAD51D, TP53, and PTEN) and three Lynch Syndrome genes (MLH1, MSH2, and MSH6) available for opportunistic testing were analyzed using a commercial Hereditary Cancer Panel and an in-house bioinformatics pipeline. RESULTS:Overall, the diagnostic yield was 11.0% in cancer patients and 8.6% in healthy individuals with a family history of breast/ovarian cancer. Pathogenic variants in high-risk genes were more frequent in patients with multiple HBOC tumors and a family history of different HBOC cancers. Additionally, we diagnosed five families with Lynch syndrome through opportunistic testing. CONCLUSION:Testing cancer susceptibility genes using an agnostic strategy confers a diagnostic benefit for hereditary cancer syndromes compared to phenotype-driven test, without adding complexity to the study. The analysis of healthy individuals with a family history of HBOC detects pathogenic variants in a cost-efficient percentage of cases, resulting in a good alternative strategy when the index case is unavailable.

BACKGROUND: In early-stage triple negative breast cancer (TNBC), the addition of carboplatin (CBDCA) to neoadjuvant chemotherapy (CT) increases pathologic complete response (pCR) and relapsed-free survival. However, it is unclear whether CBDCA improves overall survival (OS). In addition, the prognostic and/or predictive role of pathogenic germline variants (PGV) in BRCA1/2 genes and other cancer risk in this setting is not fully understood. Here, we assessed the efficacy of (neo)adjuvant CBDCA and the prognostic and predictive role of a panel of 14 genes in patients (pts) with eTNBC. METHODS: This is a retrospective study on 117 pts diagnosed with early-stage TNBC between 2000-2021 at Hospital Clinic of Barcelona. Eighty-one pts (69%) were candidates for PGV testing. Overall, 14 genes (PGV) (BRCA1, BRCA2, PALB2, BRIP1, CHEK2, TP53, ATM, RAD51C, RAD51D, BARD1, MLH1, MSH2, MSH6 and PMS2) were assessed using the TruSight hereditary cancer panel (Illumina MySeq platform) according to local guidelines. Univariable and multivariable logistic regression and Cox regression analyses were performed to identify clinical and molecular predictors of pCR and relapse-free survival (RFS), respectively. Chi-squared or Fisher’s exact tests were used to assess characteristics’ distribution as appropriate. RESULTS: Of 117 pts, 83 (71%) received CT in the neoadjuvant setting and 28 (24%) in the adjuvant setting. CBDCA was added to standard CT in 68 pts (82%) in the neoadjuvant cohort and 7 pts (6%) in the adjuvant cohort. Among pts with germline testing, 32/81 (39%) harbored PGV. BRCA1 was the most frequently mutated gene (18/32, 56%), followed by BRCA2 (5/32, 16%), PALB2 (4/32, 13%), BRIP1 (2/32, 6%), CHEK2, TP53 and PMS2 (3/32, 6%). Percentages of pts receiving CBDCA were similar between patients with and without PGV (14/16,87% and wild type (53/67,79%)(p=0.120). In the neoadjuvant cohort (n=83), CBDCA was the only variable significantly associated with pCR at both univariate (pCR rates of 58.5% with CBCDA and 14.3% without CBCDA; odds ratio [OR]=8.2 [95% CIs 2.0-55.7], p=0.008) and remained statistically significant after adjusting for PGV, tumor size and nodal status (OR=6.9 [95% CIs 1.4-53.0], p=0.028). pCR rates according to PGV are reported in Table 1. In terms of RFS, addition of CBDCA to neoadjuvant therapy (hazard ratio [HR]=0.2 [0.1-0.45], p< 0.001), PGV (HR=0.2 [0.05-0.9], p=0.048), pCR (HR=0.2 [0.1-0.6], p=0.004) and nodal status (HR=5.1 [1.7-15.2], p< 0.003) were significantly associated with RFS in univariate analyses. In a multivariable model, CBDCA remained an independent predictor of improved RFS along with pCR. When the neoadjuvant and adjuvant cohort were pooled together (n=117), platinum-based CT remained significantly associated with better RFS (HR=0.2 [0.14-0.86], p=0.021) regardless of time of administration (i.e., neoadjuvant or adjuvant). With a median follow-up of 5 years, CBCDA use was not found associated with OS (HR=0.7 [0.3-1.8], p= 0.560). CONCLUSIONS: The addition of CBDCA to standard CT was significantly associated with pCR and RFS but not OS, consistent with the phase III data. The benefit in terms of RFS was independent of the presence and the type of pathogenic germline alterations. Table 1. pCR rates according to PGV Citation Format: Adela Rodríguez Hernández, Benedetta Conte, Laia Fernández, Fara Brasó-Maristany, Belén Pastor, Miriam Potrony, Lorena Moreno, Elia Grau, Joan Antón Puig-Butillé, Aurora Sánchez, Blanca González-Farré, Esther Sanfeliu, Olga Martínez-Sáez, Claudette Falato, Maria Vidal, Nuria Chic, Tomás Pascual, Francesco Schettini, Montserrat Muñoz, Francesc Balaguer, Aleix Prat, Barbara Adamo. Efficacy of platinum-based chemotherapy and germline mutational status in early-stage triple-negative breast cancer: a unicenter retrospective analysis with long-term follow-up [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-01-09.

Neurological disorders (ND) are diseases that affect the brain and the central and autonomic nervous systems, such as neurodevelopmental disorders, cerebellar ataxias, Parkinson's disease, or epilepsies. Nowadays, recommendations of the American College of Medical Genetics and Genomics strongly recommend applying next generation sequencing (NGS) as a first-line test in patients with these disorders. Whole exome sequencing (WES) is widely regarded as the current technology of choice for diagnosing monogenic ND. The introduction of NGS allows for rapid and inexpensive large-scale genomic analysis and has led to enormous progress in deciphering monogenic forms of various genetic diseases. The simultaneous analysis of several potentially mutated genes improves the diagnostic process, making it faster and more efficient. The main aim of this report is to discuss the impact and advantages of the implementation of WES into the clinical diagnosis and management of ND. Therefore, we have performed a retrospective evaluation of WES application in 209 cases referred to the Department of Biochemistry and Molecular Genetics of the Hospital Clinic of Barcelona for WES sequencing derived from neurologists or clinical geneticists. In addition, we have further discussed some important facts regarding classification criteria for pathogenicity of rare variants, variants of unknown significance, deleterious variants, different clinical phenotypes, or frequency of actionable secondary findings. Different studies have shown that WES implementation establish diagnostic rate around 32% in ND and the continuous molecular diagnosis is essential to solve the remaining cases.

McLeod syndrome (MLS) is a very rare genetic X-linked condition due to XK gene mutations and characterized by the development of chorea, psychiatric and cognitive impairment, seizures, cardiomyopathy, muscular involvement and the presence of acanthocytes.1 We present the case of a patient with very long lasting mild myalgia and elevated creatine kinase (CK) who developed late-onset chorea and was finally diagnosed with MLS. This is a 61-year-old man with a 20-year history of mild myalgia and elevated CK, with values ranging from 600 to 3,000 IU/L. Electromyography showed the presence of isolated polyphasic potentials of reduced amplitude in both quadriceps. Muscle biopsy revealed mild myopathic changes. The routine clinical approach in paucisymptomatic hyperCKemia including dried blood spot for Pompe disease, ischemic forearm test and carnitine profiles, showed normal results. Whole-body muscle MRI performed more recently, showed severe fatty infiltration in several leg muscles (Fig. 1C). He was referred to our neurology outpatient clinics because of the presence of generalized involuntary movements, which had increased slightly in severity over time but without interfering with his daily life activities. In fact, he is still working as a carpenter. Past history was relevant for an only episode of generalized seizure that he suffered at the age of 55. Electroencephalogram recording was normal. Family history disclosed that his younger brother had been diagnosed with epilepsy since childhood and died suddenly at the age of 43, while his older brother, diagnosed with schizophrenia, also died suddenly at the age of 45. At examination he showed slight but frequent choreatic movements on the lips, face, trunk, and limbs, involving mainly both feet (Video 1). Impaired ocular saccadic movements, tongue impersistence, slight dysarthria, slight bradykinesia and unsteadiness in the tandem walking were also present. The total motor score of the Unified Huntington's Disease Rating (HD) Scale was 20. There was not muscle weakness. The osteotendinous reflexes were absent. No significant cognitive or psychiatric alterations were detected on neuropsychological assessment. Brain MRI revealed bilateral atrophy of caudate nuclei (Fig. 1A,B) and genetic testing ruled out HD. Considering the relevance of chorea together with the persistent elevated CK, a peripheral blood smear was performed demonstrating the presence of abundant acanthocytes. The immunohematology study detected a weak expression of Kell system antigens, and the patient's red blood cells did not react with antibodies anti-Kx. Genetic study demonstrated the presence of a nonsense mutation (c.397C>T) at exon 2 of XK gene leading to a premature stop codon (p.Arg133Ter). Cardiac holter monitoring was normal but cardiac MRI revealed mild left ventricle hypertrophy (septum 14 mm; lateral wall 12 mm) (Fig. 1D), mild dilated cardiomyopathy, and reduced cardiac ejection fraction (40%). McLeod syndrome together with chorea-acanthocytosis (VPS13A disease)1 constitute the core of the neuroacanthocytosis syndromes. They not only share an HD-like phenotype but probably also common pathogenic mechanisms related to dysregulation of VPS13A-XK complex interaction.2, 3 The main features distinguishing MLS from VPS13A disease are X-linked inheritance, older age at onset, erythrocyte immunophenotype and more frequent and severe cardiac involvement.4 At least 29 different mutations at XK have been identified.5 The mutation c.397C>T found in our patient lead to a truncated protein of 132 amino acids. Several cases with the p.R133X (p.Arg133Ter) mutation have previously been reported.3, 6-9 The initial symptoms of mutation carriers usually consist of psychiatric alterations and/or chorea (Table 1). The age at onset is variable, ranging from 30 to 65. HyperCKemia and caudate atrophy on the MRI were reported in all patients but one. Compared to the patients described, our case stands out for the isolated long lasting mild muscle involvement associated to very late onset chorea and the absence of psychiatric and cognitive symptoms so far. The absence of neuropsychiatric illness in our patient is somehow discrepant from the usual finding in MLS, in which schizophrenia-like psychosis, obsessive–compulsive disorder, dysexecutive syndromes, and depression are common symptoms.4 On the other hand, the history of schizophrenia in one of his brothers, points out the possibility of intrafamilial phenotype variability in MLS.10 Cardiac involvement has been reported in about 60% of patients and is considered the main cause of sudden death in MLS.4 Our patient was diagnosed with dilated cardiomyopathy and his brothers, suspected of being affected by the disease, died suddenly suggesting also possible heart damage. McLeod syndrome diagnosis is challenging due to the disease rarity and its phenotypic variability. MLS should be considered in male patients with chorea and psychiatric symptoms after exclusion of other choreas, mainly HD. Diagnostic keys should be the presence of cardiomyopathy and muscle involvement with elevated CK levels associated to a HD-like phenotype. However, our case raises the question to consider MLS by specialized neuromuscular units in patients with isolated long lasting hyperCKemia of unknown etiology even in absence of other clinical features such as chorea, psychiatric symptoms or cardiomyopathy. (1) Research Project: A. Conception, B. Organization, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript Preparation: A. Writing of the first draft, B. Review and Critique. VT: 1B, 1C, 3A, 3B; CP: 1B, 3B; PS: 1B, 3B; AS: 1B, 1C, 3B; CS: 1B, 1C, 3B; JMG: 1B, 1C, 3B; EM: 1A, 1B, 1C, 3B. The approval of an institutional review board was not required for this work. Informed patient consent was obtained. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines. No specific funding was received for this work and the authors declare that there are no conflicts of interest relevant to this work. The authors declare that there are no additional disclosures to report.

HomeCirculation: Heart FailureVol. 15, No. 3BAG3 Genetic Cardiomyopathy May Overlap Fulminant Myocarditis Clinical Findings Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessCase ReportPDF/EPUBBAG3 Genetic Cardiomyopathy May Overlap Fulminant Myocarditis Clinical Findings Paloma Jordà, Daniel Martínez, Marta Farrero, María Ángeles Marcos, Elena Sandoval, María Ángeles Castel, Daniel Pereda, Eduard Quintana, Elena Arbelo, Aurora Sánchez, Òscar Campuzano, Coloma Tirón de Llano, Ramon Brugada, Josep Brugada, Manuel Castellá, Félix Pérez-Villa and Ana García-Álvarez Paloma JordàPaloma Jordà Correspondence to: Paloma Jordà, MD, Cardiology Department, Institut Clínic Cardiovascular, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Universitat de Barcelona, C/Villarroel 170, 6 Esc. 3, 08036 Barcelona, Spain. Email E-mail Address: [email protected] https://orcid.org/0000-0002-9236-1713 Cardiology Department, Institut Clínic Cardiovascular (P.J., M.F., M.A.C., E.A., J.B., F.P.-V., A.G.-Á.), Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain (P.J., D.M., M.F., E.S., M.A.C., D.P., E.Q., E.A., A.S., J.B., M.C., F.P.-V., A.G.-Á). Search for more papers by this author , Daniel MartínezDaniel Martínez https://orcid.org/0000-0001-7492-5311 Pathology Department (D.M.) Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain (P.J., D.M., M.F., E.S., M.A.C., D.P., E.Q., E.A., A.S., J.B., M.C., F.P.-V., A.G.-Á). Search for more papers by this author , Marta FarreroMarta Farrero Cardiology Department, Institut Clínic Cardiovascular (P.J., M.F., M.A.C., E.A., J.B., F.P.-V., A.G.-Á.), Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain (P.J., D.M., M.F., E.S., M.A.C., D.P., E.Q., E.A., A.S., J.B., M.C., F.P.-V., A.G.-Á). Search for more papers by this author , María Ángeles MarcosMaría Ángeles Marcos Microbiology Department (M.Á.M.), Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain Search for more papers by this author , Elena SandovalElena Sandoval https://orcid.org/0000-0002-4242-5133 Cardiovascular Surgery Department, Institut Clínic Cardiovascular (E.S., D.P., E.Q., M.C.), Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain (P.J., D.M., M.F., E.S., M.A.C., D.P., E.Q., E.A., A.S., J.B., M.C., F.P.-V., A.G.-Á). Search for more papers by this author , María Ángeles CastelMaría Ángeles Castel https://orcid.org/0000-0002-5887-6326 Cardiology Department, Institut Clínic Cardiovascular (P.J., M.F., M.A.C., E.A., J.B., F.P.-V., A.G.-Á.), Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain (P.J., D.M., M.F., E.S., M.A.C., D.P., E.Q., E.A., A.S., J.B., M.C., F.P.-V., A.G.-Á). Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain (M.A.C., E.A., Ò.C., R.B., J.B.). Search for more papers by this author , Daniel PeredaDaniel Pereda https://orcid.org/0000-0002-0526-8722 Cardiovascular Surgery Department, Institut Clínic Cardiovascular (E.S., D.P., E.Q., M.C.), Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain (P.J., D.M., M.F., E.S., M.A.C., D.P., E.Q., E.A., A.S., J.B., M.C., F.P.-V., A.G.-Á). Search for more papers by this author , Eduard QuintanaEduard Quintana https://orcid.org/0000-0002-5386-7463 Cardiovascular Surgery Department, Institut Clínic Cardiovascular (E.S., D.P., E.Q., M.C.), Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain (P.J., D.M., M.F., E.S., M.A.C., D.P., E.Q., E.A., A.S., J.B., M.C., F.P.-V., A.G.-Á). Search for more papers by this author , Elena ArbeloElena Arbelo https://orcid.org/0000-0003-0424-6393 Cardiology Department, Institut Clínic Cardiovascular (P.J., M.F., M.A.C., E.A., J.B., F.P.-V., A.G.-Á.), Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain (P.J., D.M., M.F., E.S., M.A.C., D.P., E.Q., E.A., A.S., J.B., M.C., F.P.-V., A.G.-Á). Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain (M.A.C., E.A., Ò.C., R.B., J.B.). Search for more papers by this author , Aurora SánchezAurora Sánchez https://orcid.org/0000-0003-1167-1451 Department of Genetics, Institut de Bioquímica i Genètica Molecular (A.S.), Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain (P.J., D.M., M.F., E.S., M.A.C., D.P., E.Q., E.A., A.S., J.B., M.C., F.P.-V., A.G.-Á). Search for more papers by this author , Òscar CampuzanoÒscar Campuzano https://orcid.org/0000-0001-5298-5276 Universitat de Girona, Spain (Ò.C., R.B.). Cardiovascular Genetics Center, Institut d'Investigació Biomèdica de Girona Dr. Josep Trueta, Spain (Ò.C., C.T.d.L., R.B.). Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain (M.A.C., E.A., Ò.C., R.B., J.B.). Search for more papers by this author , Coloma Tirón de LlanoColoma Tirón de Llano https://orcid.org/0000-0002-8424-5907 Cardiovascular Genetics Center, Institut d'Investigació Biomèdica de Girona Dr. Josep Trueta, Spain (Ò.C., C.T.d.L., R.B.). Cardiology Department, Hospital Universitari Dr. Josep Trueta, Girona, Spain (C.T.d.L., R.B.). Search for more papers by this author , Ramon BrugadaRamon Brugada https://orcid.org/0000-0001-6607-3032 Universitat de Girona, Spain (Ò.C., R.B.). Cardiovascular Genetics Center, Institut d'Investigació Biomèdica de Girona Dr. Josep Trueta, Spain (Ò.C., C.T.d.L., R.B.). Cardiology Department, Hospital Universitari Dr. Josep Trueta, Girona, Spain (C.T.d.L., R.B.). Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain (M.A.C., E.A., Ò.C., R.B., J.B.). Search for more papers by this author , Josep BrugadaJosep Brugada https://orcid.org/0000-0002-5662-8302 Cardiology Department, Institut Clínic Cardiovascular (P.J., M.F., M.A.C., E.A., J.B., F.P.-V., A.G.-Á.), Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain (P.J., D.M., M.F., E.S., M.A.C., D.P., E.Q., E.A., A.S., J.B., M.C., F.P.-V., A.G.-Á). Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain (M.A.C., E.A., Ò.C., R.B., J.B.). Search for more papers by this author , Manuel CastelláManuel Castellá Cardiovascular Surgery Department, Institut Clínic Cardiovascular (E.S., D.P., E.Q., M.C.), Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain (P.J., D.M., M.F., E.S., M.A.C., D.P., E.Q., E.A., A.S., J.B., M.C., F.P.-V., A.G.-Á). Search for more papers by this author , Félix Pérez-VillaFélix Pérez-Villa https://orcid.org/0000-0001-9244-938X Cardiology Department, Institut Clínic Cardiovascular (P.J., M.F., M.A.C., E.A., J.B., F.P.-V., A.G.-Á.), Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain (P.J., D.M., M.F., E.S., M.A.C., D.P., E.Q., E.A., A.S., J.B., M.C., F.P.-V., A.G.-Á). Search for more papers by this author and Ana García-ÁlvarezAna García-Álvarez Correspondence to: Ana García-Álvarez, MD, PhD, Cardiology Department, Institut Clínic Cardiovascular, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Universitat de Barcelona, C/Villarroel 170, 6 Esc. 3, 08036 Barcelona, Spain. Email E-mail Address: [email protected] Cardiology Department, Institut Clínic Cardiovascular (P.J., M.F., M.A.C., E.A., J.B., F.P.-V., A.G.-Á.), Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Spain (P.J., D.M., M.F., E.S., M.A.C., D.P., E.Q., E.A., A.S., J.B., M.C., F.P.-V., A.G.-Á). Search for more papers by this author Originally published6 Dec 2021https://doi.org/10.1161/CIRCHEARTFAILURE.121.008443Circulation: Heart Failure. 2022;15:e008443Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: December 6, 2021: Ahead of Print We present a clinical report on severe cardiomyopathy caused by a rare variant of the BAG3 gene among individuals with European ancestry that debuted as acute heart failure (HF) with clinical features of acute myocarditis but coinciding with suspicious familial history.The first case occurred in 2004. A 15-year-old girl (IV.4) was admitted for dyspnea, preceded by 15 days of abdominal pain and vomiting, that rapidly progressed to cardiogenic shock. ECG demonstrated sinus tachycardia, low voltages and flattened T-waves in limb leads, late R-wave transition, J-point elevation in anterior leads, and isodiphasic T-waves in lateral leads (Figure S1, 1); and in the echocardiography severe biventricular dysfunction and left ventricle (LV) dilatation was observed. She required a biventricular assist device and emergent heart transplantation. Diagnostic suspicion was fulminant myocarditis as the cardiac biopsy showed myocardial neutrophilic infiltration (borderline diagnosis of myocarditis according to Dallas criteria; Figure [A and B]). The explanted heart depicted fibrin-hemorrhagic pericarditis, thickened LV wall, and biventricular dilatation.Download figureDownload PowerPointFigure. Family tree of the related cases and iconography of the radiologic, echocardiographic, and histopathologic findings.A and B correspond to case IV.4. A depicts hematoxylin-eosin staining of the cardiac biopsy specimen which shows foci of neutrophilic perivascular infiltration (marked with black asterisks) and occasional eosinophils but no myocyte degeneration. B shows CD15 immunohistochemical staining for neutrophils in brown. C through G correspond to case IV.5. C depicts vacuolated cardiomyocytes, diffuse distortion of myocardial fibers, and interfibrillary edema but no inflammation infiltrates nor necrosis in the cardiac biopsy tissue. Thoracic x-ray (D) and echocardiography (E and F) at admission show dilated left ventricle (LV) and pulmonary congestion. Biventricular dilatation of the explanted heart is shown in G. H depicts cosegregation of the BAG3 p.88* pathogenic mutation in the related individuals. I and J describe the findings in the unrelated patient with the same BAG3 mutation. Histopathology of the explanted heart depicted mild lymphocytic infiltration and focal myocyte necrosis (I) in a thickened and dilated LV (J). DCM indicates dilated cardiomyopathy.In 2005, her mother’s cousin (III.1) was admitted at the age of 38 due to a 45-day onset of progressive HF preceded by fever and myalgias. Echocardiography depicted severe LV impairment and dilatation. He was transplanted 2 days later in an Interagency Registry for Mechanically Assisted Circulatory Support 2 situation. Clinical course suggested myocarditis, but no inflammation was observed in the explanted heart.Nine years later, in 2016, the sister of the index case (IV.5) was admitted due to cardiogenic shock at 17 years old after a 15-day course of rhinorrhea and dry coughing. ECG demonstrated sinus tachycardia and nonspecific repolarization abnormalities resembling those of her sister (Figure S1, 2). Echocardiography showed dilated LV and severe biventricular systolic dysfunction. A biventricular assist device assist device was implanted (Interagency Registry for Mechanically Assisted Circulatory Support 2), and she underwent heart transplantation 12 days later. Cardiac biopsy did not demonstrate inflammatory infiltrates but diffuse distortion of myocardial fibers with interfibrillary edema (Figure [C through G]).The third case in the same family raised the suspicion of a familial disease and genetic testing (next-generation sequencing panel including 50 genes associated with inherited cardiomyopathies) was performed revealing a BAG3 p.Gln88* pathogenic variant (American College of Medical Genetics and Genomics classification1), causing premature truncation of the protein. The index case (IV.4), her mother (III.4), grandmother (II.3), and her mother’s uncle and cousin (II.1 and III.1) carried the same rare pathogenic variant (Figure [H]). To our knowledge, this report is the first clinical description in literature of individuals carrying this variant. The 2 sisters (IV.4 and IV.5) also had a novel rare variant -p.(Pro52Arg)- in BAG3, absent in their mother, and classified as a variant of uncertain significance.1 This variant is absent in large international population databases2 and is predicted to be deleterious by in silico data.Clinical evaluation of the proband’s mother (III.4) at 45 years old demonstrated dilated cardiomyopathy with isolated LV involvement. Since she was at New York Heart Association functional class II and had left bundle branch block on ECG (Figure S1, 3), cardiac resynchronization therapy device was implanted. Proband’s grandmother (II.3) and great-uncle (II.1) had no dilated cardiomyopathy at the age of 67 and 76, respectively, although her grandmother’s ECG showed nonspecific negative T-waves in lateral leads (Figure S1, 4) along with moderate septal hypertrophy on echocardiography.Of note, we have found the same BAG3 p.Gln88* rare variant in an unrelated patient from our cohort of transplanted patients. Reviewing medical history, the story repeated. At 30 years old, he had a 10-day course of fever and progressive dyspnea presumed to be severe pneumonia. Echocardiography showed dilated and severely impaired LV. He was supported with intraaortic balloon pump and left ventricle assist device due to cardiogenic shock and underwent emergent heart transplantation subsequently. The diagnostic suspicion was acute myocarditis based on lymphocytic infiltration and focal myocyte necrosis in the explanted heart (Figure [I and J]). No other cases in this family have been found to date. Genotyping was performed in the course of a protocol investigating the genetic background of myocarditis.No patient was positive for IgM titers of cardiotropic viruses. Polymerase chain reaction viral analysis on the heart has been retrospectively performed, following current recommendations,3 in all transplanted patients except in case III.1 (no sample remained). A low viral load of parvovirus B19 was found in the index case and the unrelated patient. The absence of other cardiotropic viruses and the low viral load suggest that its presence lacks etiopathogenic relevance, as the role of parvovirus B19 in endomyocardial biopsies still remains unclear.4 Patient characteristics at diagnosis or at the time of family screening are presented in the Table.Table 1. Patient Characteristics at the Time of Diagnosis or Family ScreeningCaseMutationsAgeViral symptomsHF symptomsEchocardiography/CMRSuspected myocarditis3/Dallas criteria/cardiac viral PCRBiomarkersVAD or HTxIndex case (IV.4)BAG3 p.Gln88*, p.(Pro52Arg)15Gastrointestinal (also attributable to low cardiac output)HF rapidly progressing to CS (15 d)Severe LV dilatation and impairment. Moderated RV dilatation with severe RV impairment.Yes/Yes, borderline/Parvovirus B19: 92 copies per mL↑ CRP (×4), ↑ CK and Tnl (×1.2)IABP, BiVAD, and HTxSister (IV.5)BAG3 p.Gln88*, p.(Pro52Arg)17Respiratory (rhinorrhea and cough)HF rapidly progressing to CS (15 d)Dilated and impaired LV (LVEF 15%, LVEDd 66 mm). Nondilated but severe hypokinetic RV.Yes/No, but diffuse distortion of myocardial fibers with interfibrillary edema/NegativeNormal values of CRP, TnI and CKBiVAD and HTxMother (III.4)BAG3 p.Gln88*45NoNYHA functional class IIDilated and impaired LV (LVEDd 67 mm).CMR: Indexed LVED 185 mL/m2, LVEF 21%. Normal RV. No edema nor LGE.No/ – / –Normal values of TnI and CKNoGrandmother (II.3)BAG3 p.Gln88*67NoNoHypertensive cardiomyopathy (septal thickness 14 mm) with nondilated LV and normal LVEF.No/ – / –—NoGreat-uncle (II.1)BAG3 p.Gln88*76NoNoNormal echocardiography.No/ – / –—NoCousin (III.1)BAG3 p.Gln88*38Unspecific (fever and myalgias)HF progressing to CS (45 d)LV severely impaired and dilated and RV dysfunction.Yes/No/–↑↑ CRP (×10), normal CK and TnIIABP, BiVAD, and HTxURBAG3 p.Gln88*30FeverHF progressing to CS (10 d)LVEF 29%, LVEDd 57 mm. RV with mild dilatation and hypokinesia.CMR without edema nor LGE.Yes/Yes/Parvovirus B19: 9 copies per ml↑ CRP (×4), normal CK and TnIIABP, LVAD, and HTxDescription of the clinical, genetic, biochemical, and imaging characteristics of patients with acute presentation (IV.4, IV.5, III.1, and UR) at the time of disease onset or at the time of family screening in other related individuals. BiVAD indicates biventricular assist device; CK, creatine kinase; CMR, cardiac magnetic resonance; CRP, C-reactive protein; CS, cardiogenic shock; HF, heart failure; HTx, heart transplantation; IABP, intraaortic balloon pump; LGE, late gadolinium enhancement; LV, left ventricle; LVAD, left ventricle assist device; LVEDd, left ventricle end-diastolic diameter; LVEDv, left ventricle end-diastolic volume; LVEF, left ventricle ejection fraction; NYHA, New York Heart Association; PCR, polymerase chain reaction; RV, right ventricle; TnI, troponin I; UR, unrelated patient; and VAD, ventricular assist device.More than 100 genes have been reported associated with inherited dilated cardiomyopathy; 33 of these genes carry sufficient evidence to be classified as definitive disease-causing genes, including BAG3.5 In the largest cohort of BAG3 carriers described so far (n=129), 15.5% of them developed severe HF defined as the composite outcome of heart transplantation, left ventricle assist device or death due to HF.6 Our work describes other interesting findings. Severe cardiomyopathy with acute HF onset appeared at very young ages, specifically in 2 individuals (15 and 17 years old). Early onset in these patients may be partially explained by compound heterozygous rare variants in BAG3. In addition, 4 out of 7 individuals carrying the same BAG3 p.Gln88* mutation (one of them unrelated) were transplanted due to cardiogenic shock (57%) suggesting an aggressive disease course. Our findings regarding this specific variant do not replicate male-associated aggressive course previously reported.4 Of note, acute and severe presentation of this genetic cardiomyopathy in our patients associates clinical features (viral infection-like symptoms and acute onset) and pathological findings (myocardial inflammatory infiltrates and distortion of myocardial fibers) that may overlap with myocarditis typical findings, albeit other mechanisms may be present.Further research and characterization of myocardial infiltrates and immune activation (including immunohistochemical study of the heart and serum cardiac autoantibodies), as well as the presence of viral genome in the myocardium and peripheral blood,3 will help clarify the contribution of immune-mediated mechanisms to fulminant presentations of genetic cardiomyopathies. Furthermore, assessment of disease progression according to site-specific mutations in future cohorts may aid prognosis stratification.Article InformationAcknowledgmentsThe authors thank the anonymous reviewers for their contributions to this manuscript. Coauthor Félix Pérez-Villa, MD, PhD, died July 28, 2021. The authors want to acknowledge the achievements of this remarkable colleague and mentor; his legacy will be remembered forever.DisclosuresNone.Supplemental MaterialFigure S1Nonstandard Abbreviations and AcronymsHFheart failureLVleft ventricleFootnotesSupplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCHEARTFAILURE.121.008443.For Sources of Funding and Disclosures, see page 293.Correspondence to: Paloma Jordà, MD, Cardiology Department, Institut Clínic Cardiovascular, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Universitat de Barcelona, C/Villarroel 170, 6 Esc. 3, 08036 Barcelona, Spain. Email pjordab@clinic.catCorrespondence to: Ana García-Álvarez, MD, PhD, Cardiology Department, Institut Clínic Cardiovascular, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Universitat de Barcelona, C/Villarroel 170, 6 Esc. 3, 08036 Barcelona, Spain. Email anagarci@clinic.catReferences1. Richards S, Aziz N, Bale S, Bick D, Das S, Gastier-Foster J, Grody WW, Hegde M, Lyon E, Spector E, et al.; ACMG Laboratory Quality Assurance Committee. Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology.Genet Med. 2015; 17:405–424. doi: 10.1038/gim.2015.30CrossrefMedlineGoogle Scholar2. Karczewski KJ, Francioli LC, Tiao G, Cummings BB, Alföldi J, Wang Q, Collins RL, Laricchia KM, Ganna A, Birnbaum DP, et al.; Genome Aggregation Database Consortium. The mutational constraint spectrum quantified from variation in 141,456 humans.Nature. 2020; 581:434–443. doi: 10.1038/s41586-020-2308-7CrossrefMedlineGoogle Scholar3. Caforio AL, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, Fu M, Heliö T, Heymans S, Jahns R, et al.; European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases.Eur Heart J. 2013; 34:2636–48, 2648a. doi: 10.1093/eurheartj/eht210CrossrefMedlineGoogle Scholar4. Verdonschot J, Hazebroek M, Merken J, Debing Y, Dennert R, Brunner-La Rocca HP, Heymans S. Relevance of cardiac parvovirus B19 in myocarditis and dilated cardiomyopathy: review of the literature.Eur J Heart Fail. 2016; 18:1430–1441. doi: 10.1002/ejhf.665CrossrefMedlineGoogle Scholar5. McNally EM, Mestroni L. Dilated cardiomyopathy: genetic determinants and mechanisms.Circ Res. 2017; 121:731–748. doi: 10.1161/CIRCRESAHA.116.309396LinkGoogle Scholar6. Domínguez F, Cuenca S, Bilińska Z, Toro R, Villard E, Barriales-Villa R, Ochoa JP, Asselbergs F, Sammani A, Franaszczyk M, et al.; European Genetic Cardiomyopathies Initiative Investigators. Dilated cardiomyopathy due to BLC2-Associated Athanogene 3 (BAG3) Mutations.J Am Coll Cardiol. 2018; 72:2471–2481. doi: 10.1016/j.jacc.2018.08.2181CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails March 2022Vol 15, Issue 3 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.121.008443PMID: 35290091 Originally publishedDecember 6, 2021 Keywordsshock, cardiogenicmyocarditisinflammationheart failuregeneticsdyspneacardiomyopathiesPDF download Advertisement SubjectsCardiomyopathyGeneticsHeart FailureInflammatory Heart DiseaseTransplantation

Advances in high-throughput technologies and its implementation worldwide have had a considerable impact on the elucidation of the molecular causes underlying neurodevelopmental psychiatric disorders, especially for autism spectrum disorder and intellectual disability (ID). Nevertheless, etiology remains elusive in close to 50% of cases, even in those families with multiple affected individuals, strongly hinting at a genetic cause. Here we present a case report of two siblings affected with severe ID and other comorbidities, who embarked on a genetic testing odyssey until diagnosis was reached by using whole genome sequencing (WGS). WGS identified a maternally inherited novel missense variant (NM_031466.7:c.1037G > A; p.Gly346Glu) and a paternally inherited 90 kb intragenic deletion in TRAPPC9 gene. This report demonstrates the clinical utility of WGS in patients who remain undiagnosed after whole exome sequencing.

The term neuromuscular disorder (NMD) includes many genetic and acquired diseases and differential diagnosis can be challenging. Next-generation sequencing (NGS) is especially useful in this setting given the large number of possible candidate genes, the clinical, pathological, and genetic heterogeneity, the absence of an established genotype-phenotype correlation, and the exceptionally large size of some causative genes such as TTN, NEB and RYR1. We evaluated the diagnostic value of a custom targeted next-generation sequencing gene panel to study the mutational spectrum of a subset of NMD patients in Spain. In an NMD cohort of 207 patients with congenital myopathies, distal myopathies, congenital and adult-onset muscular dystrophies, and congenital myasthenic syndromes, we detected causative mutations in 102 patients (49.3%), involving 42 NMD-related genes. The most common causative genes, TTN and RYR1, accounted for almost 30% of cases. Thirty-two of the 207 patients (15.4%) carried variants of uncertain significance or had an unidentified second mutation to explain the genetic cause of the disease. In the remaining 73 patients (35.3%), no candidate variant was identified. In combination with patients’ clinical and myopathological data, the custom gene panel designed in our lab proved to be a powerful tool to diagnose patients with myopathies, muscular dystrophies and congenital myasthenic syndromes. Targeted NGS approaches enable a rapid and cost-effective analysis of NMD- related genes, offering reliable results in a short time and relegating invasive techniques to a second tier.

OBJECTIVE:Anoctamin 5 (ANO5) is a putative intracellular calcium-activated chloride channel. Recessive mutations in ANO5 may present from asymptomatic hyperCKemia and exercise-induced myalgia to proximal and/or distal muscle weakness. Here we describe the clinical, pathological, and molecular findings of three unrelated patients with ANO5-related muscular dystrophy.METHODS:In this retrospective study, we analyzed our database which includes 1700 muscle biopsies performed for diagnostic purposes from October 2004 to February 2019. Patients were attended by two myology experts, who performed and analyzed the muscle biopsies. Muscle biopsies were frozen in cooled isopenthane, cryostat sectioned, and routinely stained and reacted (minimum 16 stainings). A custom panel, including 115 genes (Nextera Rapid Capture, Illumina) and whole-exome sequencing analysis, was used for next-generation sequencing in cases without a definite pathological diagnosis.RESULTS:Three patients were diagnosed with ANO5-related muscular dystrophy, with all presenting the common exon 5 mutation c.191dup plus a compound heterozygous missense mutation. They showed three different phenotypes (distal myopathy, LGMD2L, and asymptomatic hyperCKemia). Curiously, all three muscle biopsies showed different patterns, but numerous ragged-red fibers with little endomysial inflammation and partial invasion cell by T lymphocytes were observed in one.CONCLUSION:ANO5-related muscular dystrophy is a heterogeneous disease with different clinical phenotypes as well as different histological patterns, which may even mimic a mitochondrial myopathy. The results of this study provide further knowledge of the clinical, histological, and pathological features related to ANO5 mutations.

Multiple endocrine neoplasia type 2 (MEN 2) is an autosomal dominant inherited disease, characterized by germ-line variants in RET proto-oncogene. Variants are frequently located in the RET extracellular cysteine-rich region domain, mainly affecting cysteines which are replaced by an alternative amino acid, resulting in a mispaired cysteine and the generation of RET dimers. We describe a novel c.1765A > T variant of RET proto-oncogene in a family with medullary thyroid carcinoma (MTC) that predicts the creation of an additional cysteine p.(Ser589Cys) in the cysteine-rich domain. In this site only three other punctual variants have been described, giving rise to extra cysteines. We have characterized the clinical phenotype of this family. The index case was a 79-year-old woman with MTC in both thyroid lobes. This variant co-segregates in this family in four affected members. One member was operated on at 31 years of age and already presented MTC, indicating that prophylactic thyroidectomy was appropriated. Variants predicting additional cysteines are not frequent in RET, and when present, they allow us to understand their implication in the disease. According to clinical data obtained in this family, this variant could be categorized as a moderate-risk of the disease.

Microcephaly is a rare condition in which the occipitofrontal circumference in a child is more than two standard deviations below the mean of children of the same age and gender. It is mainly caused by genetic abnormalities that interfere with the growth of the cerebral cortex during early months of fetal development. We present a case of a 12 years old patient with microcephaly. To identify a possible genetic origin of the phenotype, we performed array CGH and exome sequencing in the patient. Exome sequencing revealed the presence of a de novo missense mutation in the TUBB5 gene (E401K). Mutations in the TUBB5 are mainly responsible for microcephaly but the clinical spectrum is wide, from patients with severe developmental delay, and the presence of different brain malformations, to patients with only slightly cognitive impairment and normal motor development. Our patient shows a milder phenotype than other patients carrying the same mutation. These differences in the clinical features suggest that other factors, presumably genetic or epigenetic, could be modulating clinical expressivity of TUBB5. It is therefore evident that more functional studies are needed to understand the pathology that underlies the clinical spectrum of tubulin associated disease states.

Pallister-Killian syndrome (PKS; OMIM 601803) was first described in 1977 by the American physician Philip Pallister and later in 1981 by the Austrian physician Wolfgang Killian. PKS is a rare chromosomal disorder due to a sporadic mosaic tetrasomy of the short arm of isochromosome 12 (i12p). Hexasomic forms (2 isochromosomes) or the presence of a ring chromosome have been described. Prenatal ultrasound may show polyhydramnios, rhizomelic micromelia or macrosomia (Lloveras E et al., Fetal Diagn Ther 2013; 34: 172–175). Main clinical features in the newborn are hypotonia, feeding difficulties, pigmentary skin anomalies and seizures but physical head exam may give the clue for diagnosis. Hypertelorism, small nose, long philtrum, V-shaped upper lip ("Pallister lip"), low set posteriorly rotated ears, bilateral frontotemporal alopecia and a coarse facies (more pronounced with age) are characteristic for PKS. Further congenital cardiac defects, diaphragmatic hernia, renal or anal malformations may be associated. A phenotypical study of 22 PKS patients showed that profound intellectual disability is not universal, a considerable percentage of patients presented mild or moderate disability (Blyth M et al., J Med Genet 2015; 52: 454–464). Increased maternal age is an independent risk factor for PKS. i12p can be detected prenatally in chorionic villus and amniotic fluid cell samples or later in lymphocytes and skin fibroblast cultures. No evidence of genotype-phenotype correlation was found in PKS (Doray B et al., Prenat Diagn 2002; 22: 470–477). We describe a clinical case of PKS in a late premature patient without prenatal diagnosis. The mother has given written consent for the publication.

In order to contribute to the knowledge of type and frequency of chromosome abnormalities in early pregnancy losses, we analyzed the cytogenetic results from a large series of first trimester miscarriages, using a diagnostic approach with a high success rate and no maternal contamination. A total of 1,119 consecutive chorionic villi samples were obtained before evacuation, and karyotypes were prepared after short-term culture (STC). In 603 samples, a long-term culture (LTC) was also performed. The overall and individual frequencies of the different types of chromosome abnormalities were established, including placental mosaicisms, and their relationship with maternal age and gestational weeks was assessed. An abnormal karyotype was detected in 70.3% of the samples. Single autosomal trisomy was the most frequent abnormality (64.6% of the abnormal cases), followed by triploidy (13.1%) and monosomy X (10.4%). Chromosome rearrangements were found in 5.2%, combined abnormalities in 8.9%, and placental mosaicism in 3.5% of the cases with STC and LTC performed. Individual trisomies behaved differently with respect to maternal age and intrauterine survival. Due to the combination of STC and LTC, our study offers reliable information on the incidence and type of chromosome abnormalities and placental mosaicism in miscarriages and contributes to define the cytogenetic implication in their etiology.

The patient was referred for prenatal diagnosis due to the sonographic finding of a polymalformed male fetus, and an amniocentesis was performed before termination of pregnancy. The pathological study of the placenta did not show morphological alterations. In her next pregnancy, sonographic examination disclosed a missed abortion with a visible embryo, and a chorionic villi sample was obtained for cytogenetic analysis before evacuation. Macroscopic examination of the villi sample did not reveal molar vesicular appearance. QF-PCR and cytogenetic analyses were performed on amniotic fluid (first pregnancy) and chorionic villi samples (second pregnancy). A 69,XXY and 92,XXXY karyotype was found, respectively. QF-PCR results disclosed 2 maternal and 1 paternal alleles in the first pregnancy (digynic triploidy), and double maternal and double paternal contribution to the tetraploid pregnancy. Among the few reported cases of 92,XXXY tetraploidy, those associated with partial moles show a PPPM genotype (3 paternal and 1 maternal alleles), and the only case with a PPMM genotype was found in a spontaneously aborted fetus similar to our case. We are not aware of other cases with combination of a digynic triploid pregnancy and a tetraploid pregnancy with a PPMM contribution. Our case adds evidence to the influence of the balance between paternal and maternal genomic doses on the phenotype.