Fibrodysplasia Ossificans Progressiva: Clinical and Genetic Aspects

Fibrodysplasia ossificans progressiva (FOP) is a severely disabling heritable disorder of connective tissue characterized by congenital malformations of the great toes and progressive heterotopic ossification that forms qualitatively normal bone in characteristic extraskeletal sites. The worldwide prevalence is approximately 1/2,000,000. There is no ethnic, racial, gender, or geographic predilection to FOP. Children who have FOP appear normal at birth except for congenital malformations of the great toes. During the first decade of life, sporadic episodes of painful soft tissue swellings (flare-ups) occur which are often precipitated by soft tissue injury, intramuscular injections, viral infection, muscular stretching, falls or fatigue. These flare-ups transform skeletal muscles, tendons, ligaments, fascia, and aponeuroses into heterotopic bone, rendering movement impossible. Patients with atypical forms of FOP have been described. They either present with the classic features of FOP plus one or more atypical features [FOP plus], or present with major variations in one or both of the two classic defining features of FOP [FOP variants]. Classic FOP is caused by a recurrent activating mutation (617G>A; R206H) in the gene ACVR1/ALK2 encoding Activin A receptor type I/Activin-like kinase 2, a bone morphogenetic protein (BMP) type I receptor. Atypical FOP patients also have heterozygous ACVR1 missense mutations in conserved amino acids. The diagnosis of FOP is made by clinical evaluation. Confirmatory genetic testing is available. Differential diagnosis includes progressive osseous heteroplasia, osteosarcoma, lymphedema, soft tissue sarcoma, desmoid tumors, aggressive juvenile fibromatosis, and non-hereditary (acquired) heterotopic ossification. Although most cases of FOP are sporadic (noninherited mutations), a small number of inherited FOP cases show germline transmission in an autosomal dominant pattern. At present, there is no definitive treatment, but a brief 4-day course of high-dose corticosteroids, started within the first 24 hours of a flare-up, may help reduce the intense inflammation and tissue edema seen in the early stages of the disease. Preventative management is based on prophylactic measures against falls, respiratory decline, and viral infections. The median lifespan is approximately 40 years of age. Most patients are wheelchair-bound by the end of the second decade of life and commonly die of complications of thoracic insufficiency syndrome.     

Molecular Consequences of the ACVR1R206H Mutation of Fibrodysplasia Ossificans Progressiva

Fibrodysplasia ossificans progressiva (FOP), a rare genetic and catastrophic disorder characterized by progressive heterotopic ossification, is caused by a point mutation, c.617G>A; p.R206H, in the activin A receptor type 1 (ACVR1) gene, one of the bone morphogenetic protein type I receptors (BMPR-Is). Although altered BMP signaling has been suggested to explain the pathogenesis, the molecular consequences of this mutation are still elusive. Here we studied the impact of ACVR1 R206H mutation on BMP signaling and its downstream signaling cascades in murine myogenic C2C12 cells and HEK 293 cells. We found that ACVR1 was the most abundant of the BMPR-Is expressed in mesenchymal cells but its contribution to osteogenic BMP signal transduction was minor. The R206H mutant caused weak activation of the BMP signaling pathway, unlike the Q207D mutant, a strong and constitutively active form. The R206H mutant showed a decreased binding affinity for FKBP1A/FKBP12, a known safeguard molecule against the leakage of transforming growth factor (TGF)-β or BMP signaling. The decreased binding affinity of FKBP1A to the mutant R206H ACVR1 resulted in leaky activation of the BMP signal, and moreover, it decreased steady-state R206H ACVR1 protein levels. Interestingly, while WT ACVR1 and FKBP1A were broadly distributed in plasma membrane and cytoplasm without BMP-2 stimulation and then localized in plasma membrane on BMP-2 stimulation, R206H ACVR1 and FKBP1A were mainly distributed in plasma membrane regardless of BMP-2 stimulation. The impaired binding to FKBP1A and an altered subcellular distribution by R206H ACVR1 mutation may result in mild activation of osteogenic BMP-signaling in extraskeletal sites such as muscle, which eventually lead to delayed and progressive ectopic bone formation in FOP patients.     

Structure of the Bone Morphogenetic Protein Receptor ALK2 and Implications for Fibrodysplasia Ossificans Progressiva

Bone morphogenetic protein (BMP) receptor kinases are tightly regulated to control development and tissue homeostasis. Mutant receptor kinase domains escape regulation leading to severely degenerative diseases and represent an important therapeutic target. Fibrodysplasia ossificans progressiva (FOP) is a rare but devastating disorder of extraskeletal bone formation. FOP-associated mutations in the BMP receptor ALK2 reduce binding of the inhibitor FKBP12 and promote leaky signaling in the absence of ligand. To establish structural mechanisms of receptor regulation and to address the effects of FOP mutation, we determined the crystal structure of the cytoplasmic domain of ALK2 in complex with the inhibitors FKBP12 and dorsomorphin. FOP mutations break critical interactions that stabilize the inactive state of the kinase, thereby facilitating structural rearrangements that diminish FKBP12 binding and promote the correct positioning of the glycine-serine-rich loop and αC helix for kinase activation. The balance of these effects accounts for the comparable activity of R206H and L196P. Kinase activation in the clinically benign mutant L196P is far weaker than R206H but yields equivalent signals due to the stronger interaction of FKBP12 with R206H. The presented ALK2 structure offers a valuable template for the further design of specific inhibitors of BMP signaling.     

Antisense-Oligonucleotide Mediated Exon Skipping in Activin-Receptor-Like Kinase 2: Inhibiting the Receptor That Is Overactive in Fibrodysplasia Ossificans Progressiva

Fibrodysplasia ossificans progressiva (FOP) is a rare heritable disease characterized by progressive heterotopic ossification of connective tissues, for which there is presently no definite treatment. A recurrent activating mutation (c.617G→A; R206H) of activin receptor-like kinase 2 (ACVR1/ALK2), a BMP type I receptor, has been shown as the main cause of FOP. This mutation constitutively activates the BMP signaling pathway and initiates the formation of heterotopic bone. In this study, we have designed antisense oligonucleotides (AONs) to knockdown mouse ALK2 expression by means of exon skipping. The ALK2 AON could induce exon skipping in cells, which was accompanied by decreased ALK2 mRNA levels and impaired BMP signaling. In addition, the ALK2 AON potentiated muscle differentiation and repressed BMP6-induced osteoblast differentiation. Our results therefore provide a potential therapeutic approach for the treatment of FOP disease by reducing the excessive ALK2 activity in FOP patients.     

Zur Genetik der Myositis ossificans progressiva

Zusammenfassung Myositis ossificans progressiva ist durch ein bestimmtes Muster der Ossifikationen und der angeborenen Begleitmißbildungen an händen und Füßen gekennzeichnet. Zahnstellungsanomalien sind häufig, Infantilismus mit Hypogenitalismus bzw. verzögerte Genitalentwicklung kommen regelmäßig vor. Die Kranken sind im allgemeinen wegen der Verkrüppelung, der herabgesetzten Lebenserwartung und des Hypogenitalismus nicht fortpflanzungsfähig.Unter den rund 350 Fällen der Literature sind nur zweimal Vater und Sohn, zweimal Vater und Tochter und einmal — außer der Probandin — eine Tante mütterlicherseits betroffren. In weiteren 13 Fällen ist bei mindestens einem Familienmitglied eine Mißbildung der Gliedmaßen, davon siebenmal bei einem Elter, erwähnt.23 Probanden mit Myositis ossificans progressiva sind unsystematisch gesammelt worden. In ihren Familien kommen keine weiteren Fälle von Myositis ossificans vor. 37 von 46 Eltern und 33 von 55 Geschwistern konnten untersucht werden, dazu weitere 53 Familienangehörige. Von 28 Eltern liegen Röntgenaufnahmen der Hände und Füße vor. Die erhobenen Befunde sind uneinheitlich, und ein Zusammenhang mit Myositis ossificans ist fraglich. Allenfalls in zwei Fällen könnte man bei einem Elter den Verdacht auf eine Mutante haben: In einem Fall ist beim Vater seit der Kindheit der rechte Daumen im Grundgelenk versteift, die Endglieder beider Großzehen zeigen eine spornartige Epiphysenverbreiterung, und das linke Großzehenendglied ist etwas kürzer als das rechte; seine älteste Tochter hatte ein Myxosarkom am Metatarsophalangealgelenk der linken Großzehe. Im anderen Fall sind bei der Mutter in der Kindheit angeblich spontan kleine exostosenähnliche Auswüchse an der Stirn aufgetreten, und sie hat eine geringe Verkürzung der Grundphalanx der linken Großzehe.Über zwei konkordant betroffene EZ-Paare ist in der Literature berichtet worden.Chromosomenuntersuchungen an zwei Kranken von Viparelli und bei drei von unseren Kranken haben normale Karyogramme ergeben.Die Prüfung des Geburtenordnungseffektes an 23 selbst untersuchten und 45 Patienten der Literatur (nach dem Haldane-Smith-Verfahren) hat eine signifikant stärkere Besetzung der höheren Geburtenränge ergeben (Differenz zwischen Beobachtung und Erwartung von 6 A=339, dreifache Streuung des Erwartungswertes 3s=±226,2). Von den 68 Patienten stehen 39,7% an vierter oder höherer Stelle in ihrer Geschwisterreihe, während der entsprechende Anteil in der herangezogenen Vergleichsbevölkerung nur 23,6% beträgt.Das durchschnittliche Alter der Väter unserer 23 Patienten und weiterer 16 der Literatur beträgt 36,3 Jahre; es liegt um rund 4 Jahre höher als das Durchschnittsalter der Väter der Vergleichsbevölkerung.Die durchschnittliche Altersdifferenz der Elternpaare von 35 Patienten beträgt 6,2 Jahre. Sie liegt um etwa 2 1/2 Jahre höher als diejenige, die in der Durchschnittsbevölkerung angenommen werden kann. Die zunehmende Häufigkeit der Geburten von Kranken mit ansteigendem väterlichen Alter zeigt sich auch, wenn man in einzelnen Altersstufen den Prozentsatz von Vätern der Patienten in Bezug setzt zu den der Väter aller lebenden Neugeborenen einer angenommenen Durchschnittsbevölkerung (Tabelle 3). Der Anstieg der Geburtenkurve ist stärker als linear und ähnlich dem bei Achondroplasie und Apert-Syndrom.Myositis ossificans ist ein dominant erbliches Leiden, dessen Mutante einem starken Druck der Selektion unterliegt. Infolgedessen sind die Mehrzahl aller Fälle neue Mutanten, entstanden in den väterlichen Gonaden.

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Myositis ossificans progressiva is characterized by a distinct pattern of ossification and of accompanying congenital deformities of hands and feet. Anomalies of position of teeth are frequent, infantilism together with hypogenitalism, or delayed sexual development are found regularly. The patients usually have no children, as they are malformed, have a low expectation of life, and suffer from hypogenitalism.There are about 350 cases known in the literature. In two cases father and son were affected, twice father and daughter, and once a maternal aunt of a female proband. In 13 cases a deformity of extremities is mentioned in at least one member of the family, seven times in one parent.23 probands with myositis ossificans progressiva were collected and their families examined. It was possible to examine 37 of 46 parents and 33 of 55 siblings, and 53 other relatives. No more cases of myositis ossificans could be found. In 28 parents röntgenograms of the hands and feet were made. The results are not homogeneous and a relationship with myositis is doubtful. Only in two cases one could take into account the manifestation of a new mutant in one parent: In one case the right thumb of the father is stiffened in its metacarpo-phalangeal joint since childhood, the distal phalanges of both first toes show a spinelike broadening of the epiphysis, and the left distal phalanx of the first toe is a bit shorter than the right one. His eldest daughter had a myxosarcoma of the metatarso-phalangeal joint of the left first toe. In the other case exostose-like protuberances could be seen at the forehead of the mother, and the metatarso-phalangeal joint of the left first toe is a bit shorter than the other.Two monocygotic twin pairs are mentioned in the literature, both twins of each pair are affected.Chromosomes were examined in two patients by Viparelli and in three of our patients. All of them show a normal caryotype.The birth-order effect was examined in our 23 patients (see Table 2) and in 45 patients (see Table 4) of the literature (by the Haldane-Smith-method). Higher birth ranks were significantly more frequent (difference between observation and expectation of 6 A=339, 3-fold standard deviation of the expectation=±226,2).The average age of the fathers of our 23 patients and of further 16 patients of the literature is 36,3 years; it is about 4 years higher than the average age of the fathers of the control sample.The difference between mean ages of 35 parental pairs is 6,2 years. It is about 2 1/2 years higher than in the control sample. The increasing frequency of affected children with paternal age was examined by comparison of 5 years' gaps in a control sample (see Table 3). The slope of the age specific risk curve is steeper than linear and similar to that of achondroplasia, Apert-syndrome and haemophilia A (see Fig. 1).Myositis ossificans progressiva is caused by autosomal dominat mutations which are exposed to a strong selection pressure. Consequently the majority of all cases are new mutants, originating in the gonades of the fathers.

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Die Untersuchungen wurden mit Hilfe der Fritz Behrens-Stiftung durchgeführt.