Background/Aims: A 33-year-old man was referred for the first time to the Division of Neurology because of the presence and progression of neurological symptoms. Dysphagia, weakness, reduced tear production, and nasal speech were present. In order to point the attention of late-onset triple A syndrome we describe this case and review the literature. Methods: Hormonal and biochemical evaluation, Schirmer test, tilt test and genetic testing for AAAS gene mutations. Results: Late-onset triple A syndrome caused by a novel homozygous missense mutation in the AAAS gene (A167V in exon 6) was diagnosed at least 17 years after symptom onset. Conclusions: The association between typical signs and symptoms of triple A syndrome should suggest the diagnosis even if they manifest in adulthood. The diagnosis should be confirmed by Schirmer test, endocrine testing (both basal and dynamic), genetic analysis, and detailed gastroenterological and neurological evaluations. Awareness of the possible late onset of the disease and of diagnosis in adulthood is still poor among clinicians, the acquaintance with the disease is more common among pediatricians. The importance of an adequate multidisciplinary clinical approach, dynamic testing for early diagnosis of adrenal insufficiency and periodical reassessment of adrenal function are emphasized. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Autosomal recessive triple A syndrome is caused by mutations in the AAAS gene encoding the protein ALADIN. The disorder manifests with the triad of adrenocorticotropin-resistant adrenal insufficiency, achalasia of the stomach cardia and impaired tear production (alacrima) in combination with progressive neurological impairment of the central, peripheral and autonomic nervous systems. ALADIN is part of the nuclear pore complex acting as a scaffold nucleoporin. In this work the role of ALADIN in the human adrenocortical tumour cell line NCI-H295R1 was investigated. These cells were engineered to either over-express or down-regulate AAAS by inducible stable transfection. Alterations in steroidogenic gene expression and functional consequences were determined. In addition, the role of ALADIN on cell viability and oxidative stress response was analysed. Using both the human adrenal NCI-H295R1-TR AAAS knock-down and over-expression models the potential impairment of the nuclear import of aprataxin, DNA ligase 1 and ferritin heavy chain 1 was investigated. For this YFP-specific vectors transiently transfected into the cell lines were employed. The findings indicate that AAAS knock-down induces a down-regulation of genes coding for type II microsomal cytochrome P450 hydroxylases CYP17A1 and CYP21A2 and their electron donor enzyme cytochrome P450 oxidoreductase, thereby decreasing biosynthesis of precursor metabolites required for glucocorticoid and androgen production. Furthermore I demonstrate that ALADIN deficiency leads to increased susceptibility to oxidative stress and alteration in redox homeostasis after paraquat treatment. Finally, I show significantly impaired nuclear import of DNA ligase 1, aprataxin and ferritin heavy chain 1 in ALADIN knock-down cells. I conclude that down-regulating ALADIN results in decreased oxidative stress response leading to alteration in steroidogenesis, highlighting the knock-down cell model as an important in vitro tool for studying the adrenal phenotype in triple A syndrome. In an approach to identify new interaction partners of ALADIN, co-immunoprecipitation followed by proteome analyses using mass spectrometry was conducted in a GFP-ALADIN over-expression model using the human adrenocortical tumor cell line NCI-H295R. These results were verified in co-immunoprecipitation assays of endogenous ALADIN using NCI-H295R wild-type cells. The results suggest a possible interaction between ALADIN and microsomal flavoprotein cytochrome P450 oxidoreductase and progesterone receptor membrane compartment 2. Co-localisation analyses of these findings were done using immunofluorescence. The data are suggestive for an involvement of ALADIN in the export of nuclear-encoded mitochondrial proteins. Regulation of adrenocortical steroidogenesis is complex and there is increasing evidence that oxidative stress due to ROS accumulation and mitochondria are significantly involved. Furthermore, there may be an important cross-talk between functional organelles comprising nucleus, ER and mitochondria which presumably involves lipid metabolism. The goal of this work was to elucidate the function of ALADIN for the cellular oxidative stress response and its possible consequences for adrenocortical steroidogenesis in triple A syndrome patients. / Mutationen im AAAS Gen verursachen die autosomal rezessive Krankheit Triple-A-Syndrom. AAAS kodiert das Nukleoporin ALADIN, welches Bestandteil des nukleären Porenkomplexes ist. Phänotypische Charakteristika des Triple-A-Syndroms sind Nebennierenrinden-Insuffizienz, Achalasie des unteren Speiseröhrenschließmuskels und eine fehlende Tränenproduktion (Alakrimie). Diese Symptome sind kombiniert mit progredienten neurologischen Störungen des zentralen, peripheren und autonomen Nervensystems. In dieser Arbeit wurde die Rolle von ALADIN in der humanen Karzinom-Zelllinie NCI-H295R1 untersucht. Diese Nebennierenrinden-Zellen wurden stabil transfiziert und mit einem induzierbaren Expressionssystem modifiziert, so dass sie AAAS entweder überexprimierten oder herunterregulierten. In NCI-H295R1-Zellen wurden Veränderungen der Genexpression von Enzymen der Steroidogenese und funktionelle Konsequenzen der Überexpression oder Herunterregulation von ALADIN gemessen. Des Weiteren wurde die Rolle von ALADIN auf die Zellviabilität und die Redox-Homöostase analysiert. ALADIN überexprimierende und herunterregulierte Zellen wurden verwendet, um die potentielle Behinderung des nukleären Imports von Proteinen zu untersuchen, welche den Zellkern gegen oxidativen Stress schützen (z.B. Aprataxin, DNA-Ligase 1 und Ferritin Heavy Chain 1). Dazu wurden YFP-spezifische Vektoren transient in diese Zellen gebracht. Mit den Ergebnissen dieser Arbeit wurde gezeigt, dass die Herunterregulation von AAAS eine Verminderung der Genexpression von CYP17A1 und CYP21A2 und deren Elektronendonor Cytochrom P450 Oxidoreduktase bewirken. Die Biosynthese der Vorläufermetabolite von Kortisol und Aldosteron ist in diesen Zellen ebenfalls vermindert. Des Weiteren zeigen die ALADIN-defizienten NCIH295R1-Zellen eine erhöhte Sensitivität gegenüber oxidativem Stress und eine veränderte Redox-Homöostase nach der Behandlung mit Paraquat. Darüber hinaus konnte in dieser Studie auch gezeigt werden, dass herunterregulierte ALADIN NCI-H295R1-Zellen einen verminderten Zellkernimport von Aprataxin, DNA-Ligase 1 und Ferritin heavy chain 1 besitzen. Aus diesen Ergebnissen kann geschlussfolgert werden, dass ALADIN-defiziente Nebennierenzellen eine verminderte Stressantwort auf oxidativen Stress besitzen; dies führt schlussendlich zu einer veränderten Steroidogenese. Das beschriebene ALADIN knock-down Modell in NCI-H295R1-Zellen ist ein wichtiges in vitro Werkzeug, um die Pathogenese der Nebennierenveränderungen im Triple-A-Syndrom zu erforschen. Neue Interaktionspartner von ALADIN wurden mit Hilfe von Co-Immunpräzipitation gefolgt von Proteom-Analysen durch Massenspektrometrie in einem GFP-ALADIN Überexpressionsmodell in NCI-H295R charakterisiert. Die Ergebnisse wurden durch Experimente auf endogenem Niveau in NCI-H295R-Wildtypzellen verifiziert. Mit diesen Daten wird in dieser Arbeit erstmals eine Interaktion zwischen ALADIN und dem Flavoprotein Cytochrom P450 Oxidoreduktase und Progesterone Receptor Membrane Compartment 2 nachgewiesen. Diese Ergebnisse wurden mit Co-Lokalisierungsanalysen durch Immunfluoreszenzfärbung von ALADIN und Cytochrome P450 Oxidoreduktase ergänzt. Außerdem gibt die Arbeit Hinweise darauf, dass ALADIN als Nukleoporin an dem nuklearen Export mitochondrialer Vorläuferproteine beteiligt ist. Die Regulation der Steroidogenese in der Nebennierenrinde ist komplex und es existieren zahlreiche Hinweise darauf, dass oxidativer Stress aufgrund der Ansammlung reaktiver Sauerstoffradikale und. dass die Mitochondrien involviert sind. Außerdem ist ein funktionelles Zusammenspiel verschiedener Organellen, darunter Nukleus, ER und Mitochondrien, von großer Bedeutung. Das Ziel dieser Arbeit war die Identifizierung der Funktion von ALADIN in der zellulären oxidativen Stressantwort und die möglichen Konsequenzen für die Steroidogenese in der Nebennierenrinden in Triple-A-Syndrom-Patienten.

Autosomal recessive triple A syndrome is caused by mutations in the AAAS gene encoding the protein ALADIN. The disorder manifests with the triad of adrenocorticotropin-resistant adrenal insufficiency, achalasia of the stomach cardia and impaired tear production (alacrima) in combination with progressive neurological impairment of the central, peripheral and autonomic nervous systems. ALADIN is part of the nuclear pore complex acting as a scaffold nucleoporin. In this work the role of ALADIN in the human adrenocortical tumour cell line NCI-H295R1 was investigated. These cells were engineered to either over-express or down-regulate AAAS by inducible stable transfection. Alterations in steroidogenic gene expression and functional consequences were determined. In addition, the role of ALADIN on cell viability and oxidative stress response was analysed. Using both the human adrenal NCI-H295R1-TR AAAS knock-down and over-expression models the potential impairment of the nuclear import of aprataxin, DNA ligase 1 and ferritin heavy chain 1 was investigated. For this YFP-specific vectors transiently transfected into the cell lines were employed. The findings indicate that AAAS knock-down induces a down-regulation of genes coding for type II microsomal cytochrome P450 hydroxylases CYP17A1 and CYP21A2 and their electron donor enzyme cytochrome P450 oxidoreductase, thereby decreasing biosynthesis of precursor metabolites required for glucocorticoid and androgen production. Furthermore I demonstrate that ALADIN deficiency leads to increased susceptibility to oxidative stress and alteration in redox homeostasis after paraquat treatment. Finally, I show significantly impaired nuclear import of DNA ligase 1, aprataxin and ferritin heavy chain 1 in ALADIN knock-down cells. I conclude that down-regulating ALADIN results in decreased oxidative stress response leading to alteration in steroidogenesis, highlighting the knock-down cell model as an important in vitro tool for studying the adrenal phenotype in triple A syndrome. In an approach to identify new interaction partners of ALADIN, co-immunoprecipitation followed by proteome analyses using mass spectrometry was conducted in a GFP-ALADIN over-expression model using the human adrenocortical tumor cell line NCI-H295R. These results were verified in co-immunoprecipitation assays of endogenous ALADIN using NCI-H295R wild-type cells. The results suggest a possible interaction between ALADIN and microsomal flavoprotein cytochrome P450 oxidoreductase and progesterone receptor membrane compartment 2. Co-localisation analyses of these findings were done using immunofluorescence. The data are suggestive for an involvement of ALADIN in the export of nuclear-encoded mitochondrial proteins. Regulation of adrenocortical steroidogenesis is complex and there is increasing evidence that oxidative stress due to ROS accumulation and mitochondria are significantly involved. Furthermore, there may be an important cross-talk between functional organelles comprising nucleus, ER and mitochondria which presumably involves lipid metabolism. The goal of this work was to elucidate the function of ALADIN for the cellular oxidative stress response and its possible consequences for adrenocortical steroidogenesis in triple A syndrome patients. / Mutationen im AAAS Gen verursachen die autosomal rezessive Krankheit Triple-A-Syndrom. AAAS kodiert das Nukleoporin ALADIN, welches Bestandteil des nukleären Porenkomplexes ist. Phänotypische Charakteristika des Triple-A-Syndroms sind Nebennierenrinden-Insuffizienz, Achalasie des unteren Speiseröhrenschließmuskels und eine fehlende Tränenproduktion (Alakrimie). Diese Symptome sind kombiniert mit progredienten neurologischen Störungen des zentralen, peripheren und autonomen Nervensystems. In dieser Arbeit wurde die Rolle von ALADIN in der humanen Karzinom-Zelllinie NCI-H295R1 untersucht. Diese Nebennierenrinden-Zellen wurden stabil transfiziert und mit einem induzierbaren Expressionssystem modifiziert, so dass sie AAAS entweder überexprimierten oder herunterregulierten. In NCI-H295R1-Zellen wurden Veränderungen der Genexpression von Enzymen der Steroidogenese und funktionelle Konsequenzen der Überexpression oder Herunterregulation von ALADIN gemessen. Des Weiteren wurde die Rolle von ALADIN auf die Zellviabilität und die Redox-Homöostase analysiert. ALADIN überexprimierende und herunterregulierte Zellen wurden verwendet, um die potentielle Behinderung des nukleären Imports von Proteinen zu untersuchen, welche den Zellkern gegen oxidativen Stress schützen (z.B. Aprataxin, DNA-Ligase 1 und Ferritin Heavy Chain 1). Dazu wurden YFP-spezifische Vektoren transient in diese Zellen gebracht. Mit den Ergebnissen dieser Arbeit wurde gezeigt, dass die Herunterregulation von AAAS eine Verminderung der Genexpression von CYP17A1 und CYP21A2 und deren Elektronendonor Cytochrom P450 Oxidoreduktase bewirken. Die Biosynthese der Vorläufermetabolite von Kortisol und Aldosteron ist in diesen Zellen ebenfalls vermindert. Des Weiteren zeigen die ALADIN-defizienten NCIH295R1-Zellen eine erhöhte Sensitivität gegenüber oxidativem Stress und eine veränderte Redox-Homöostase nach der Behandlung mit Paraquat. Darüber hinaus konnte in dieser Studie auch gezeigt werden, dass herunterregulierte ALADIN NCI-H295R1-Zellen einen verminderten Zellkernimport von Aprataxin, DNA-Ligase 1 und Ferritin heavy chain 1 besitzen. Aus diesen Ergebnissen kann geschlussfolgert werden, dass ALADIN-defiziente Nebennierenzellen eine verminderte Stressantwort auf oxidativen Stress besitzen; dies führt schlussendlich zu einer veränderten Steroidogenese. Das beschriebene ALADIN knock-down Modell in NCI-H295R1-Zellen ist ein wichtiges in vitro Werkzeug, um die Pathogenese der Nebennierenveränderungen im Triple-A-Syndrom zu erforschen. Neue Interaktionspartner von ALADIN wurden mit Hilfe von Co-Immunpräzipitation gefolgt von Proteom-Analysen durch Massenspektrometrie in einem GFP-ALADIN Überexpressionsmodell in NCI-H295R charakterisiert. Die Ergebnisse wurden durch Experimente auf endogenem Niveau in NCI-H295R-Wildtypzellen verifiziert. Mit diesen Daten wird in dieser Arbeit erstmals eine Interaktion zwischen ALADIN und dem Flavoprotein Cytochrom P450 Oxidoreduktase und Progesterone Receptor Membrane Compartment 2 nachgewiesen. Diese Ergebnisse wurden mit Co-Lokalisierungsanalysen durch Immunfluoreszenzfärbung von ALADIN und Cytochrome P450 Oxidoreduktase ergänzt. Außerdem gibt die Arbeit Hinweise darauf, dass ALADIN als Nukleoporin an dem nuklearen Export mitochondrialer Vorläuferproteine beteiligt ist. Die Regulation der Steroidogenese in der Nebennierenrinde ist komplex und es existieren zahlreiche Hinweise darauf, dass oxidativer Stress aufgrund der Ansammlung reaktiver Sauerstoffradikale und. dass die Mitochondrien involviert sind. Außerdem ist ein funktionelles Zusammenspiel verschiedener Organellen, darunter Nukleus, ER und Mitochondrien, von großer Bedeutung. Das Ziel dieser Arbeit war die Identifizierung der Funktion von ALADIN in der zellulären oxidativen Stressantwort und die möglichen Konsequenzen für die Steroidogenese in der Nebennierenrinden in Triple-A-Syndrom-Patienten.

Mutations in the AAAS gene coding for the nuclear pore complex protein ALADIN lead to the autosomal recessive disorder triple A syndrome. Triple A patients present with a characteristic phenotype including alacrima, achalasia and adrenal insufficiency. Patient fibroblasts show increased levels of oxidative stress, and several in vitro studies have demonstrated that the nucleoporin ALADIN is involved in both the cellular oxidative stress response and adrenal steroidogenesis. It is known that ALADIN knock-out mice lack a phenotype resembling human triple A syndrome. The objective of this study was to determine whether the application of chronic oxidative stress by ingestion of paraquat would generate a triple A-like phenotype in ALADIN null mice. Adult male mice were fed either a paraquat (0.25 g/kg diet) or control diet for 11 days. After application of chronic oxidative stress, ALADIN knock-out mice presented with an unexpected compensated glutathione metabolism, but lacked a phenotype resembling human triple A syndrome. We did not observe increased levels of oxidative stress and alterations in adrenal steroidogenesis in mice depleted for ALADIN. This study stresses the species-specific role of the nucleoporin ALADIN, which in mice involves a novel compensatory mechanism for regulating the cellular glutathione redox response.

Triple A syndrome, formerly known as Allgrove syndrome, is an autosomal recessive disorder characterized clinically by adrenal insufficiency, alacrima, achalasia, and neurological abnormalities. We report a 17-year-old boy presented to the endocrine clinic with delayed puberty and a 4-year’s history of fatigue and muscle weakness. He had achalasia, alacrima, and skin and mucosal hyperpigmentation. Hormonal assessment revealed isolated glucocorticoid deficiency. Clinical diagnosis of triple A syndrome was confirmed by sequencing the entire coding region including exon-intron boundaries of the AAAS gene. Analysis revealed a homozygous novel indel mutation encompassing intron 7 to intron 10 of the gene (g.16166_17813delinsTGAGGCCTGCTG; NG_016775). This is the first report of triple A syndrome in Jordan with a novel indel mutation and presenting with delayed puberty.

Introduction: Triple A syndrome (AAAS) is a rare autosomal recessive disorder characterized by alacrima, achalasia, ACTH-resistant adrenal insufficiency, autonomic dysfunction, and progressive neurodegeneration. Increased oxidative stress, demonstrated in patients’ fibroblasts in vitro, may be a central disease mechanism. N-acetylcysteine protects renal function in patients with kidney injuries associated with increased oxidative stress and improves viability of AAAS-knockdown adrenal cells in vitro. Patient and Results: A boy diagnosed with AAAS presented with short stature and increased oxidative stress in vivo assessed by increased thiobarbituric acid reactive substances (TBARS), which are markers of lipid peroxidation, and by the susceptibility of LDL to oxidation and the capacity of HDL to prevent it. A homozygous missense germline mutation (c.523G>T, p.Val175Phe) in AAAS was identified. N-acetylcysteine (600 mg orally, twice daily) decreased oxidative stress but did not change the patient’s growth pattern. Conclusions: An increase in oxidative stress is reported for the first time in vivo in an AAAS patient. N-acetylcysteine was capable of decreasing TBARS levels, reducing the susceptibility of LDL to oxidation and improving the antioxidant role of HDL. The longterm effect of antioxidant treatment should be evaluated to determine the real benefit for the prevention of the degenerative process in AAAS.

Background/Aims: A 33-year-old man was referred for the first time to the Division of Neurology because of the presence and progression of neurological symptoms. Dysphagia, weakness, reduced tear production, and nasal speech were present. In order to point the attention of late-onset triple A syndrome we describe this case and review the literature. Methods: Hormonal and biochemical evaluation, Schirmer test, tilt test and genetic testing for AAAS gene mutations. Results: Late-onset triple A syndrome caused by a novel homozygous missense mutation in the AAAS gene (A167V in exon 6) was diagnosed at least 17 years after symptom onset. Conclusions: The association between typical signs and symptoms of triple A syndrome should suggest the diagnosis even if they manifest in adulthood. The diagnosis should be confirmed by Schirmer test, endocrine testing (both basal and dynamic), genetic analysis, and detailed gastroenterological and neurological evaluations. Awareness of the possible late onset of the disease and of diagnosis in adulthood is still poor among clinicians, the acquaintance with the disease is more common among pediatricians. The importance of an adequate multidisciplinary clinical approach, dynamic testing for early diagnosis of adrenal insufficiency and periodical reassessment of adrenal function are emphasized. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Mutations in the AAAS gene coding for the nuclear pore complex protein ALADIN lead to the autosomal recessive disorder triple A syndrome. Triple A patients present with a characteristic phenotype including alacrima, achalasia and adrenal insufficiency. Patient fibroblasts show increased levels of oxidative stress, and several in vitro studies have demonstrated that the nucleoporin ALADIN is involved in both the cellular oxidative stress response and adrenal steroidogenesis. It is known that ALADIN knock-out mice lack a phenotype resembling human triple A syndrome. The objective of this study was to determine whether the application of chronic oxidative stress by ingestion of paraquat would generate a triple A-like phenotype in ALADIN null mice. Adult male mice were fed either a paraquat (0.25 g/kg diet) or control diet for 11 days. After application of chronic oxidative stress, ALADIN knock-out mice presented with an unexpected compensated glutathione metabolism, but lacked a phenotype resembling human triple A syndrome. We did not observe increased levels of oxidative stress and alterations in adrenal steroidogenesis in mice depleted for ALADIN. This study stresses the species-specific role of the nucleoporin ALADIN, which in mice involves a novel compensatory mechanism for regulating the cellular glutathione redox response.