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- Biomarcadores nas doenças lisossomais de sobrecarga: o que são e o que nos dizem?Publication . Gaspar, Paulo; Rocha, Hugo; Neiva, Raquel; Azevedo, Olga; Maia, Tabita; Aguiar, Patrício; Cardoso, Teresa; Chaves, Paulo; Alves, Sandra; Vilarinho, LauraAs Doenças Lisossomais de Sobrecarga (DLSs) são um conjunto de patologias raras, crónicas, multissistémicas com modo de apresentação e gravidade muito variáveis. No seu conjunto afetam aproximadamente 1:5000 nados vivos e são causadas pela acumulação de metabolitos não degradados no interior do lisossoma. As esfingolipidoses são o grupo de DLS com maior prevalência e incluem a doença de Gaucher, a doença de Fabry e a doença de Niemann-Pick. Por vezes, parte do produto primário de acumulação, através de uma reação de desacilação, é convertido na respetiva base esfingoide, que se encontra bastante elevada em casos de patologia. Em alguns doentes, estes compostos já se encontram aumentados, mesmo antes do aparecimento dos primeiros sintomas. Os tratamentos disponíveis para estas patologias (terapia de substituição enzimática, terapia de redução de substrato de chaperones farmacológicos) conduzem a um decréscimo da concentração destas bases esfingoides, tornando o doseamento destes compostos útil também para aferir a eficácia da terapêutica utilizada. Pela primeira vez em Portugal, é disponibilizado o estudo destes biomarcadores para as DLSs, através da tecnologia de espectrometria de massa em tandem (MS/MS). Os autores apresentam os resultados obtidos do doseamento destes lisolípidos em diferentes doentes de DLSs, com a clara demonstração da especificidade destes biomarcadores, permitindo um diagnóstico atempado, um melhor conhecimento da evolução da doença e monitorização da eficácia do respetivo tratamento.
- Familial and Multifactorial Chylomicronemia Syndrome: Insights from Clinically Diagnosed Cases in PortugalPublication . Alves, Ana Catarina; Ferreira, Maria; Ferreira, Ana Cristina; Padeira, Gonçalo; Gaspar, Ana; Duarte, João Sequeira; Rato, Quitéria; Gonçalves, Filipa Sousa; Aguiar, Patrício; Cruz, Diogo; Bourbon, MafaldaFamilial Chylomicronemia Syndrome (FCS) is a rare autosomal recessive disorder caused by biallelic pathogenic variants in one of five canonical genes, LPL, APOC2, GPIHBP1, APOA5, and LMF1. These variants result in impaired hydrolysis of triglyceride-rich lipoproteins, leading to clinical features such as xanthomas, abdominal pain, hepatomegaly, hepatosplenomegaly, lipemia retinalis, and recurrent pancreatitis. In contrast, Multifactorial Chylomicronemia Syndrome (MCS) often involves monoallelic variants in these genes and/or a high polygenic risk score, contributing to the severe hypertriglyceridemia phenotype. Clinically, FCS and MCS have a similar presentation, requiring genetic analysis for differentiation. This study aimed to clinically and molecularly characterize 42 individuals with severe hypertriglyceridemia in Portugal. Biochemical lipid profile and molecular analysis of the five canonical genes were performed. Moulin's score was applied to 14 cases; for the remaining cases, all data could not be obtained. The average pre-treatment triglyceride level was 2570 mg/dL. Fourteen individuals had pancreatitis, four had hepatomegaly, and three presented with both conditions. Eight cases have biallelic variants: five in LPL (three with identical variants, two with different variants), one in APOC2, one frameshift variant in LMF1 and one total exon 4 deletion in GPIHBP1 (all with identical variants). For these cases, the Moulin score obtained was FCS very likely. Twenty cases have heterozygous variants in LPL, APOA5, LMF1, and GPIHBP1 and were classified as MCS. For one of these cases, the Moulin score was FCS very likely. Ten patients have a negative genetic study, 5 of which had a score of unlikely FCS. Four are still under study. Early identification of FCS is critical to prevent or mitigate its severe complications. A confirmed molecular diagnosis enables accurate differentiation between FCS and MCS, leading to improved clinical management and prognosis. This study underscores the importance of integrating genetic analysis into the diagnostic workup of severe hypertriglyceridemia.
- Familial Chylomicronemia Syndrome: Clinical and Molecular Data From a Portuguese CohortPublication . Alves, Ana Catarina; Ferreira, Maria; Ferreira, Ana Cristina; Padeira, Gonçalo; Gaspar, Ana; Duarte, João Sequeira; Rato, Quitéria; Gonçalves, Filipa Sousa; Aguiar, Patrício; Cruz, Diogo; Raimundo, Anabela; Bourbon, MafaldaFamilial Chylomicronemia Syndrome (FCS) is a rare autosomal recessive disorder caused by biallelic variants in LPL, APOC2, GPIHBP1, APOA5, or LMF1. These defects impair triglyceride-rich lipoprotein hydrolysis, leading to xanthomas, abdominal pain, hepatomegaly, lipemia retinalis, and recurrent pancreatitis. Multifactorial Chylomicronemia Syndrome (MCS) often results from monoallelic variants in these genes and/or a high polygenic risk score, presenting a similar phenotype; thus, genetic testing is required for accurate differentiation. This study aimed to clinically and genetically characterize 45 individuals with severe hypertriglyceridemia in Portugal. Lipid profile and molecular analysis of the five canonical genes were performed. Moulin’s score was applied in 17 cases. The mean pretreatment triglyceride level was 2570 mg/dL. Sixteen individuals had pancreatitis, four had hepatomegaly, and three both conditions. Ten cases carried biallelic variants: five in LPL (three identical, two compound heterozygous), one in APOC2, one frameshift in LMF1, one frameshift and one stop in APOA5, and one total exon 4 deletion in GPIHBP1 (all identical variants). All were classified as “very likely FCS” by Moulin’s score. Twenty-one individuals had heterozygous variants in LPL, APOA5, LMF1, and GPIHBP1 and were considered MCS; three of them also scored as “very likely FCS.” Ten patients had negative genetic studies (five scored as “unlikely FCS”), and four remain under investigation. Early recognition of FCS is crucial to prevent life-threatening complications. A confirmed molecular diagnosis enables precise distinction between FCS and MCS, improving management and prognosis. These findings underscore the importance of incorporating genetic testing into the diagnostic workup of severe hypertriglyceridemia in Portugal.
- Hipercolesterolemia familiar homozigótica em Portugal: caracterização de casos diagnosticados geneticamente no âmbito do Estudo Português de Hipercolesterolemia Familiar, 1999-2023Publication . Medeiros, Ana Margarida; Alves, Ana Catarina; Miranda, Beatriz; Chora, Joana Rita; Aguiar, Patrício; Amaro, Mário; Bruges, Margarida; Ferreira, Sofia; Furtado, António; Gaspar, Ana; Gonçalves, Filipa Sousa; Lobarinhas, Goreti; Lourenço, Guilherme; Martins, Paula; Antunes, Sofia Moura; Palma, Isabel; Rato, Quitéria; Torres, Diogo; Rico, Miguel Toscano; Travessa, André; Bourbon, MafaldaHipercolesterolemia Familiar (FH) é uma condição autossómica semidominante causada por variantes patogénicas ou provavelmente patogénicas nos genes LDLR, APOB e PCSK9. A FH pode apresentar-se na forma monoalélica (FH heterozigótica) ou bialélica (FH homozigótica). A forma homozigótica é mais rara e com fenótipo mais grave. Indivíduos com FH homozigótica geralmente apresentam hipercolesterolemia severa (LDL>400mg/dL), xantomas e doença cardiovascular aterosclerótica (DCVA) prematura em idade jovem. Até 2023, foram referenciados ao Estudo Português de Hipercolesterolemia Familiar 1291 casos-índex. Neste estudo foram analisados os casos com FH homozigótica. Foram identificados 15 casos com FH homozigótica: 5 com a mesma variante bialélica no LDLR, 7 com variantes bialélicas diferentes no LDLR, 1 com variantes bialélicas diferentes no PCSK9, e 2 com variantes nos genes LDLR e APOB. A maioria dos indivíduos eram adultos (73%) e do sexo feminino (87%), 13% apresentando xantomas tendinosos e 36% com DCVA. Variantes de alelo nulo estão associadas a um fenótipo mais grave e a uma menor resposta ao tratamento, sendo necessária terapêutica independente da atividade do recetor de LDL. O diagnóstico genético permite identificar com precisão as variantes e os tipos de alelos, e implementar uma abordagem terapêutica mais personalizada nestes indivíduos.
- Homozygous Familial Hypercholesterolaemia: Insights From Portuguese Cases and Follow-up DataPublication . Medeiros, Ana Margarida; Alves, Ana Catarina; Miranda, Beatriz; Chora, Joana Rita; Aguiar, Patrício; Amaro, Mário; Bruges, Margarida; Ferreira, Sofia; Furtado, António; Gaspar, Ana; Gonçalves, Filipa Sousa; Lobarinhas, Goreti; Lourenço, Guilherme; Martins, Paula; Antunes, Sofia Moura; Palma, Isabel; Rato, Quitéria; Torres, Diogo; Rico, Miguel Toscano; Travessa, André; Bourbon, MafaldaAims: Present the clinical/genetic and follow-up data on individuals genetically identified with HoFH.
- Insights Into Homozygous Familial Hypercholesterolemia In PortugalPublication . Medeiros, Ana Margarida; Alves, Ana Catarina; Miranda, Beatriz; Chora, Joana Rita; Aguiar, Patrício; Amaro, Mário; Ferreira, Sofia; Gaspar, Ana; Gonçalves, Filipa Sousa; Lobarinhas, Goreti; Lourenço, Guilherme; Martins, Paula; Antunes, Sofia Moura; Palma, Isabel; Rato, Quitéria; Torres, Diogo; Rico, Miguel Toscano; Travessa, André; Bourbon, MafaldaBackground and Aims: Homozygous Familial Hypercholesterolemia (HoFH) is a rare, biallelic semidominant condition caused by pathogenic/likely pathogenic (P/LP) variants in LDLR, APOB, and/or PCSK9 genes. HoFH is characterized by a severe phenotype with LDL-C >400 mg/dL, xanthomas, and early-onset atherosclerotic cardiovascular disease (ASCVD). This work presents the clinical/genetic and follow-up data on individuals genetically identified with HoFH. Methods: A total of 1291 index-cases, with clinical diagnosis of FH, were referred to the Portuguese FH Study. Genetic diagnosis was performed using Sanger sequencing or NGS FH panel. Results: Fifteen individuals were identified as HoFH: 5 with identical biallelic LDLR variants, 8 with different biallelic variants (7 in LDLR, 1 in PCSK9), and 2 with biallelic variants in LDLR and APOB (digenic). Most variants are classified as P/LP; 3 are variants of unknown significance (VUS), but exhibited defects in LDL receptor activity. The cohort included mostly adults (73%) and females (87%), with a median age of 29.9±15.3years at referral (adults: 36.5±12.5years, children/adolescents: 12.0±1.9years). Clinical manifestations included tendon xanthomas (13%) and ASCVD (36%). At referral, all individuals were on statins therapy, with 50% using statin ezetimibe combination, 13% with PCSK9 inhibitors (PCSK9i), and 13% performed LDL apheresis. Five individuals carry at least one null allele (<10% activity), 9 carry defective alleles (10-70% activity), and one has null/null alleles. The latter presented the most severe phenotype (LDL-C=702mg/dL) despite intensive treatment (rosuvastatin, ezetimibe, LDL apheresis, and PCSK9i). Follow-up data were collected for 4 individuals: 2 with defective/defective alleles are now using PCSK9i, while 2 with null/defective and null/null are now using ANGPTL3 inhibitors. Conclusions: In general, Portuguese HoFH individuals are diagnosed late and do not reach the recommended target LDL-C levels. Genetic diagnosis enables precise identification of allele type, allowing more personalized therapeutic approaches, especially for null/null allele carriers who present reduced treatment responsiveness and require therapies independent of LDL receptor function.
- Leukocyte Imbalances in Mucopolysaccharidoses PatientsPublication . Lopes, Nuno; Maia, Maria L.; Pereira, Cátia S.; Mondragão-Rodrigues, Inês; Martins, Esmeralda; Ribeiro, Rosa; Gaspar, Ana; Aguiar, Patrício; Garcia, Paula; Cardoso, Maria Teresa; Rodrigues, Esmeralda; Leão-Teles, Elisa; Giugliani, Roberto; Coutinho, Maria F.; Alves, Sandra; Macedo, M. FátimaMucopolysaccharidoses (MPSs) are rare inherited lysosomal storage diseases (LSDs) caused by deficient activity in one of the enzymes responsible for glycosaminoglycans lysosomal degradation. MPS II is caused by pathogenic mutations in the IDS gene, leading to deficient activity of the enzyme iduronate-2-sulfatase, which causes dermatan and heparan sulfate storage in the lysosomes. In MPS VI, there is dermatan sulfate lysosomal accumulation due to pathogenic mutations in the ARSB gene, leading to arylsulfatase B deficiency. Alterations in the immune system of MPS mouse models have already been described, but data concerning MPSs patients is still scarce. Herein, we study different leukocyte populations in MPS II and VI disease patients. MPS VI, but not MPS II patients, have a decrease percentage of natural killer (NK) cells and monocytes when compared with controls. No alterations were identified in the percentage of T, invariant NKT, and B cells in both groups of MPS disease patients. However, we discovered alterations in the naïve versus memory status of both helper and cytotoxic T cells in MPS VI disease patients compared to control group. Indeed, MPS VI disease patients have a higher frequency of naïve T cells and, consequently, lower memory T cell frequency than control subjects. Altogether, these results reveal MPS VI disease-specific alterations in some leukocyte populations, suggesting that the type of substrate accumulated and/or enzyme deficiency in the lysosome may have a particular effect on the normal cellular composition of the immune system.
- Sitosterolemia In iberoamerican countries: 16 new cases and phenotype genotype analysisPublication . Alves, Ana Catarina; Chora, Joana Rita; Miranda, Beatriz; Medeiros, Ana Margarida; Graça, Rafael; Bañares, Virginia G.; Araujo, Maria Beatriz; Vilagut, Ferrán Trías; Soler, Cristina; Meavilla, Silvia; Toledo, Maria J. Benitez; Volpe, Camila Garcia; Reyes, Ximena; Dell'Oca, Nicolás; Martins, Paula; Marado, Diana; Vilarinho, Laura; Dias, Aureliano Jorge; Ferreira, Ana Cristina; Padeira, Gonçalo; Casañas, Marta; Alegre-González, Diana; Lozano, José Mosquera; Aguiar, Patrício; Gonçalves, Filipa Sousa; Ernaga, Ander; Apellaniz-Ruiz, Maria; Rubi, Rodrigo; Figueroa, Nahún Muñoz; Vasquez, Norma Alejandra; Valdivielso, Pedro; Bourbon, Mafalda; ElsevierBackground: Sitosterolemia is a rare autosomal recessive lipid disorder caused by biallelic pathogenic variants in ABCG5 or ABCG8 genes. It is characterized by elevated plasma plant sterol concentrations, xanthomas, and an increased risk of premature cardiovascular disease. As happens with familial hypercholesterolemia (FH), sitosterolemia is subdiagnosed and is frequently confounded with FH, resulting in inappropriate management. This study aims to describe newly identified cases across Iberoamerican countries and to highlight the need for improved diagnostic strategies. Methods: We report 16 cases of molecularly confirmed sitosterolemia from 5 Iberoamerican countries (Argentina, Mexico, Portugal, Spain, and Uruguay), including 12 index cases and 4 relatives identified by cascade screening. Clinical, biochemical, and molecular data were collected and analyzed. β-sitosterol levels were measured when possible, and variant classification followed American College of Medical Genetics and Genomics (ACMG) guidelines with disease-specific adaptations. Results: Fifteen individuals had biallelic variants in ABCG8 and 1 had a homozygous frameshift variant in ABCG5. Ten distinct ABCG8 variants were identified, including 7 nonsense and 3 missense variants. Xanthomas were observed in 56% of cases. Most cases were initially diagnosed as FH, with a diagnostic delay of up to 30 years. Treatment with ezetimibe, alone or combined with statins, led to biochemical and clinical improvement, including xanthoma regression in some cases. Conclusion: Sitosterolemia remains underdiagnosed due to lack of systematic screening and clinical overlap with FH. Our findings highlight the importance of including ABCG5/8 in genetic testing panels and of recognizing clinical clues for early diagnosis, enabling targeted treatment and prevention of adverse outcomes. Adapted ACMG variant classification improves interpretability for ABCG5/8-related sitosterolemia.