Accepted Manuscript To the Editor: Combined immunodeficiency and hypoglycemia associated with mutations in hypoxia up-regulated 1 Emma M. Haapaniemi, MD, PhD, Christopher L. Fogarty, MSc, Salla Keskitalo, MSc, Shintaro Katayama, PhD, Helena Vihinen, D.Sc, Mette Ilander, PhD, Satu Mustjoki, MD, PhD, Kaarel Krjutškov, PhD, Markku Lehto, PhD, Timo Hautala, MD, Ove Eriksson, PhD, PhD, Eija Jokitalo, PhD, Vidya Velagapudi, PhD, Markku Varjosalo, PhD, Mikko Seppänen, MD, PhD, Juha Kere, MD, PhD PII:
S0091-6749(16)31375-6
DOI:
10.1016/j.jaci.2016.09.050
Reference:
YMAI 12473
To appear in:
Journal of Allergy and Clinical Immunology
Received Date: 25 January 2016 Revised Date:
26 August 2016
Accepted Date: 10 September 2016
Please cite this article as: Haapaniemi EM, Fogarty CL, Keskitalo S, Katayama S, Vihinen H, Ilander M, Mustjoki S, Krjutškov K, Lehto M, Hautala T, Eriksson O, Jokitalo E, Velagapudi V, Varjosalo M, Seppänen M, Kere J, To the Editor: Combined immunodeficiency and hypoglycemia associated with mutations in hypoxia up-regulated 1, Journal of Allergy and Clinical Immunology (2016), doi: 10.1016/ j.jaci.2016.09.050. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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To the Editor: Combined immunodeficiency and hypoglycemia associated with mutations in hypoxia upregulated 1
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Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, Sweden Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland 3 Research Programs Unit, Molecular Neurology, University of Helsinki, Helsinki, Finland; 4 Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland 5 Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland 6 Institute of Biotechnology, University of Helsinki, Helsinki, Finland 7 Center for Innovative Medicine, Karolinska Institutet, Huddinge, Sweden 8 Science for Life Laboratory, Solna, Sweden 9 Institute of Biotechnology, Electron Microscopy Unit, University of Helsinki, Helsinki, Finland 10 Hematology Research Unit Helsinki, Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland 11 Department of Clinical Chemistry, University of Helsinki, Helsinki, Finland. 12 Competence Centre on Health Technologies, Tartu, Estonia 13 Oulu University Hospital, Oulu, Finland 14 Department of Biochemistry and Developmental Biology, Faculty of Medicine, University of Helsinki 15 Metabolomics Unit, Institute for Molecular Medicine Finland FIMM, University of Helsinki, Finland 16 Rare Disease Center, Children’s Hospital and Adult Immunodeficiency Unit, Inflammation Center, Helsinki University and Helsinki University Hospital, Finland
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*These authors contributed equally to this work.
Corresponding author
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Emma M. Haapaniemi1, 2,3, MD, PhD, Christopher L. Fogarty2,4,5, MSc, Salla Keskitalo6, MSc, Shintaro Katayama1,7,8, PhD, Helena Vihinen9, D.Sc, Mette Ilander10,11, PhD, Satu Mustjoki10,11, MD, PhD, Kaarel Krjutškov1,7,12, PhD, Markku Lehto2,4,5, PhD, Timo Hautala13, MD, Ove Eriksson14, PhD, PhD, Eija Jokitalo9, PhD, Vidya Velagapudi15, PhD, Markku Varjosalo6, PhD, Mikko Seppänen16, MD, PhD* and Juha Kere1,2,3,7, MD, PhD*
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Emma Haapaniemi, M.D. Karolinska Institutet Department of Biosciences and Nutrition Novum SE-14183 Huddinge Sweden e-mail:
[email protected] Tel: +46-8-585 86895 Fax: +46-8-711 66 59 Word count (text): 951 Figure count: 1 Table count: 1 Reference count: 7
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Capsule summary
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We describe recessive mutations in hypoxia up-regulated 1 (HYOU1) in a patient that presented with generalized susceptibility to bacterial and herpetic infections as well as hypoglycemic episodes.
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Hypoxia up-regulated 1; neutropenia, severe congenital; antibody deficiency syndrome; dendritic cell; herpesviridae infections; mitochondrial diseases; endoplasmic reticulum; immunologic deficiency syndromes; hypoglycemia
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Immunodeficiencies featuring congenital neutropenia have varying presentations, including life-threatening bacterial infections. These conditions can be caused by defects in >10 genes (1-3). The majority of genes operate in the endolysosomal system, and their perturbed action induce unfolded protein response and altered mitochondrial function. The resulting cell stress drives neutrophils to apoptosis (1-3).
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We evaluated a 45-year old female showing symptoms of combined immunodeficiency and disturbed glucose metabolism since birth (see this article’s Online Repository at www.jacionline.org for detailed case description). She was born small for gestational age and her subsequent growth was poor. Her appearance was slightly dysmorphic, featuring oval face, pectus carinatum, and broad long bone metaphyses. During childhood, she experienced episodes of stress-induced hypoglycemia. From infancy to adulthood, she suffered from numerous septic infections of the respiratory tract, skin and mucous membranes. At age four, she had severe septic herpetic gingivostomatitis, after which herpetic stomatitis recurred monthly for several years. In adulthood, she contracted herpetic encephalitis followed by recurring condylomatous warts in her thighs and genital area. Granulocyte-macrophage colony-stimulating factor (GM-CSF) and intravenous immunoglobulin (IVIG) treatment were initiated in her 20’s, which led to the normalization of her absolute neutrophil count (ANC) and significantly decreased the rate of bacterial infections. An immunodysregulatory component was evident, as the patient developed hidradenitis suppurativa in her teens and relapsing Takayasu arteritis as an adult. Currently, the patient receives GM-CSF, immunoglobulin replacement therapy, rituximab, and oral prednisolone (5mg/day).
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Detailed immunological workup is presented in this article’s Online Repository at www.jacionline.org. The patient showed broad abnormalities in the myeloid lineage. She had microcytic anemia, fluctuating thrombocytopenia, and constant granulocytopenia (Table E1). Neutrophils showed poor chemotaxis and increased activation. Bone marrow biopsies showed inconstant myeloid maturation arrest that resolved upon GM-GSF treatment (data not shown).
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In addition, antigen presentation and adaptive immunity were affected. Both plasmacytoid (pDC) and monocytoid (mDC) dendritic cells were reduced in peripheral blood, and the expression of co-stimulatory CD86 molecule was low in both mDCs and monocytes. These together with a low phytohemagglutin stimulation response suggested impaired antigen presentation. In the T cell compartment, the proportions of CD4+ and CD8+ T cells were within normal range, with naive CCR7+CD45RA+ cells dominating the repertoire. The B cell count was very low, and B cell development skewed towards mature B cells with reduced switched memory B cells. Despite normal immunoglobulin levels, responses to polysaccharide antigens were completely absent. It is unlikely that the observed changes are due to the patient’s
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immunosuppressive regimen, as most studies were carried either without or with low dose immunosuppression (prednisolone (5mg/day). Due to a suspected novel primary immunodeficiency, we performed whole exome sequencing. We identified novel compound heterozygous missense mutations in the hypoxia up-regulated 1 (HYOU1) gene (Figure 1A and Online Repository at www.jacionline.org). (4, 5). The mutations (chr11: 118922614 C>G, p.A419P and chr11:118924936 A>G, p.Y231H) localized to the ATPase domain of HYOU1, negatively affecting conserved residues. HYOU1 is a chaperone that localizes to endoplasmic reticulum (ER) and mitochondria, and participates in cell stress responses, including oxidative stress and unfolded protein response (UPR) (4, 6, 7). Since most genes that cause congenital neutropenia perform similar functions, HYOU1 was considered a good candidate (see Online Repository at www.jacionline.org for detailed comparison). HYOU1 further belongs to herpes infection-induced proteome (8).
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We hypothesized that mutations in HYOU1 ATPase domain would impair ATP hydrolysis, thereby hampering the conformational changes required for HYOU1 chaperone function (4, 5). Consequently, this could lead to altered substrate binding. To test this, we performed affinity-purification mass spectrometry (AP-MS) on Strep-tagged WT and mutant HYOU1 proteins expressed in tetracycline inducible HEK293 cell lines. Both mutants bound with high affinity to a range of proteins that did not bind to WT HYOU1 (Figure 1C). Thus the binding profiles of the mutated HYOU1 proteins seemed altered, leading to ectopic protein binding.
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To measure ER stress, we performed RNA sequencing on patient and control primary skin fibroblasts with and without tunicamycin, a compound that induces unfolded protein response (Figure 1B and Online Repository at www.jacionline.org). Compared with normal controls, the transcriptional profile was strikingly different in patient cells, and transcripts from ectopic Y231H and A419P interaction partners were upregulated. In steady state, the transcriptome suggested enhanced protein synthesis, glucose metabolism, and redox enzyme transcription in patient cells. Interestingly, a clear enrichment in redox proteins was also noted among HYOU1 binding partners in AP-MS (Figure 1C).
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As results from RNA sequencing and AP-MS pointed to altered cell metabolism, we performed mass spectrometry based targeted analysis of 100 metabolites in patient and control fibroblasts (see this article’s Online Repository at www.jacionline.org). Again, we noted altered quantities of metabolites in pathways participating in redox balance.
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To further characterize the phenotype, we studied patient and healthy control neutrophils with electron microscopy. The ER morphology was normal. However, we noted increased numbers of mitochondria along with high reactive oxygen species (ROS) production in patient neutrophils (Figure 1D-E and Table 1). To see whether the increased mitochondrial quantity and altered redox balance were caused by defective mitochondrial respiration, we performed XF Cell Mito Stress test on patient and healthy control fibroblasts (see this article’s Online Repository at www.jacionline.org). The patient fibroblasts performed consistently on low normal scale; significant alterations, however, were not evident.
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All these experiments suggested that the unfolded protein response and mitochondrial function were altered in the index case. The findings were consistent with previous knowledge on HYOU1 function, and strengthened the causative role of the mutations.
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In conclusion, we describe a novel immunometabolic syndrome caused by recessive HYOU1 mutations. The condition features hypoglycemia and severe bacterial and herpetic infections. Immunologically, granulocytopenia, B cell and dendritic cell deficiency are evident. GM-CSF treatment is effective in correcting neutropenia and with IVIG reduces the rate of infections. Our results are in line with previous
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reports linking members of the endolysosomal system to congenital neutropenia, and suggest that perturbed redox balance plays a role in these conditions.
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Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, Sweden; 2Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland; 3Research Programs Unit, Molecular Neurology, University of Helsinki, Helsinki, Finland; 4Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; 5Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland; 6Institute of Biotechnology, University of Helsinki, Helsinki, Finland ; 7Center for Innovative Medicine, Karolinska Institutet, Huddinge, Sweden; 8Science for Life Laboratory, Solna, Sweden; 9Institute of Biotechnology, Electron Microscopy Unit, University of Helsinki, Helsinki, Finland; 10Hematology Research Unit Helsinki, Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland; 11Department of Clinical Chemistry, University of Helsinki, Helsinki, Finland; 12Competence Centre on Health Technologies, Tartu, Estonia; 13Oulu University Hospital, Oulu, Finland; 14Department of Biochemistry and Developmental Biology, Faculty of Medicine, University of Helsinki; 15Metabolomics Unit, Institute for Molecular Medicine Finland FIMM, University of Helsinki, Finland; 16Rare Disease Center, Children’s Hospital and Adult Immunodeficiency Unit, Inflammation Center, Helsinki University and Helsinki University Hospital, Finland. E-mail:
[email protected] *These authors contributed equally to this work.
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Emma M. Haapaniemi1, 2,3, MD Christopher L. Fogarty2,4,5, MSc Salla Keskitalo6, MSc Shintaro Katayama1,7,8, PhD Helena Vihinen9, D.Sc Mette Ilander10,11, PhD Satu Mustjoki10,11, MD Kaarel Krjutškov1,7,12, PhD Markku Lehto2,4,5, PhD Timo Hautala13, MD Ove Eriksson14, PhD Eija Jokitalo9, PhD Vidya Velagapudi15, PhD Markku Varjosalo6, PhD Mikko Seppänen16*, MD Juha Kere1,2,3,7*, MD
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We sincerely thank the patient for her co-operation and patience. Ari Much and Timo Otonkoski are acknowledged for obtaining and performing skin fibroblast cultures, and Meri Kokkonen and Jatin Nandania for performing the metabolomics profiling. Personnel at Science for Life laboratory Stockholm are acknowledged for their expert technical assistance. The computations were performed on resources provided by SNIC through Uppsala Multidisciplinary Center for Advanced Computational Science (UPPMAX) under Project b201022 and b201069. The Academy of Finland, Finnish Medical Foundation, Sigrid Juselius Foundation, Karolinska Institutet Research Foundation, Swedish Research Council and Strategic Research Programme in Diabetes supported this work.
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Author contributions
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E.H and C.F designed the study, performed experiments and wrote the manuscript. K.K. and S.Ka performed RNA sequencing and bioinformatics. H.V and E.J performed electron microscopy. S.K and M.V performed affinity-purification mass spectrometry. M.I and S.M performed blood immunophenotyping. M.S and T.H provided clinical care for the patient. V.V supervised and performed the metabolomics data analyses. M.S. and J.K co-designed and supervised the study.
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Disclosure of Conflicts of Interest
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M.S has received honoraria from Baxter, CSL Behring, Octapharma and Sanquin, and T.H has received honoraria from CSL Behring and Octapharma. S.M. has received honoraria from BMS and Novartis. Other authors declare no conflict of interest.
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Figure 1. a) HYOU1 structure (4) with the observed mutations. b) RNA expression profile in primary fibroblasts. c) Interaction partners of WT and mutant HYOU1 proteins as determined by affinity-purification mass-spectrometry (AP-MS). Black line denotes mitochondrial proteins. d-e) Electron micrograph figures of control (left) and patient (right) neutrophils show abundant mitochondria. f) Comparison of enriched pathways between RNA-sequencing, AP-MS (denoted as binding assay) and targeted metabolite profiling (referred as metabolic assay).
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References
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Peptide binding
ATPase
Alpha helical -lid
0.999
SIFT score AQYVAGMAA AQYVAGMAA AQYVAGMAA AQYVAGMAA AQYVAGMAA ERYWAC F S F AQYVAGMAA AQYVAGMAA
Poly-Phen score
Upregulated
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Pathway Redox
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Protein synthesis Glucose metabolism
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RNA-seq Redox balance (p
