Alternative titles; symbols
Other entities represented in this entry:
SNOMEDCT: 45414006; ORPHA: 869, 99777; DO: 0050602;
| Location | Phenotype |
Phenotype MIM number |
Inheritance |
Phenotype mapping key |
Gene/Locus |
Gene/Locus MIM number |
|---|---|---|---|---|---|---|
| 12q13.13 | Achalasia-addisonianism-alacrimia syndrome | 231550 | Autosomal recessive | 3 | AAAS | 605378 |
A number sign (#) is used with this entry because of evidence that the triple-A syndrome (AAAS) is caused by homozygous or compound heterozygous mutation in the gene encoding aladin (AAAS; 605378) on chromosome 12q13.
The association of adrenal and neurologic disease in the triple-A syndrome is similar to that in X-linked adrenoleukodystrophy (300100). See 200400 for a familial form of isolated achalasia.
Allgrove et al. (1978) reported 2 pairs of sibs (3 boys and 1 girl) with glucocorticoid deficiency and achalasia of the stomach cardia. Three had defective tear formation (alacrima) and 1 showed other signs of autonomic dysfunction. Postmortem studies of 1 patient showed absence of the zona fasciculata and zona reticularis with almost normal zona glomerulosa. The authors knew of 2 other families with the association. Allgrove et al. (1978) stated that 2 sisters reported by Kelch et al. (1972) had developed achalasia, 1 of whom also had ACTH-resistant adrenal insufficiency. Vaughan and Williams (1973) reported 2 brothers with achalasia, 1 of whom was found to have skin pigmentation and adrenal insufficiency.
Lanes et al. (1980) reported the case of an 8-year-old Saudi Arabian girl with alacrima, achalasia and adrenal insufficiency which included partial mineralocorticoid deficiency as well as glucocorticoid deficiency. Lanes et al. (1980) suggested that a degenerative process of progressive nature may be responsible for the 3 features of this syndrome of alacrima-achalasia-addisonianism, and suggested that the 'triple-A syndrome' may be a useful designation. Ehrich et al. (1987) reported 2 brothers with achalasia, adrenal insufficiency (both glucocorticoid and mineralocorticoid), and alacrima, as well as short stature, microcephaly, ataxia, optic atrophy, and severe developmental delay. Ehrich et al. (1987) commented on the significant impairment of the central nervous system in the 2 brothers, and noted that some previous reports had described delay in motor and speech developments, ataxia, and anisocoria.
Grant et al. (1992) provided follow-up on the patients originally described by Allgrove et al. (1978) and documented that they had developed neurologic manifestations, including polyneuropathy with sensory, motor, and autonomic components, long-tract degeneration, parkinsonism, and mild dementia. Tsao et al. (1994) reported the cases of 2 first cousins, a 17-year-old girl and a 9-year-old boy, with adrenal insufficiency and microcephaly who also developed peripheral neuropathy, achalasia, and alacrima. In this kindred, 2 brothers had married 2 sisters. A sister of the 9-year-old boy had died at the age of 18 months of the same disorder. Because of the similarities to adrenoleukodystrophy and adrenomyeloneuropathy, Tsao et al. (1994) excluded these possibilities by demonstrating normal levels of plasma very long chain fatty acids, pipecolic acid and phytanic acid, and normal cranial CT scan. Muscle mitochondrial respiratory chain enzymes were also normal.
In a review of ACTH resistance syndromes, Clark and Weber (1994) reported that no mutations in the ACTH receptor (607397), which cause familial glucocorticoid deficiency (202200), had been demonstrated in triple-A syndrome. They pointed out that the triple-A syndrome has some features of a contiguous gene syndrome. There are patients in whom only 2 of the 3 features are present, and the occurrence and nature of the neurologic defects seem to vary considerably from one family to another. Glucocorticoid replacement therapy seems to have no influence on the development and progression of neurologic features.
Gazarian et al. (1995) described 4 children, of whom 2 were sibs, with what they referred to as the 4A syndrome: adrenocortical insufficiency associated with achalasia, alacrima, autonomic and other neurologic abnormalities. The children were between 3 and 6 years of age at the time of diagnosis. All of them had clinical neurologic abnormalities when examined between 6 and 8 years of age. Cardiovascular autonomic testing in 3 of the subjects showed abnormal heart rate variation during deep breathing in all 3, abnormal Valsalva ratio in 2, and abnormal postural systolic blood pressure response in 1. Pupillary reflexes were abnormal in the only subject in which they could be measured. Gazarian et al. (1995) proposed that autonomic neuropathy be considered an integral feature of this disorder, making it the 4A syndrome rather than the triple-A syndrome.
Chu et al. (1996) reported orthostatic hypotension with compensatory tachycardia in 2 unrelated Hispanic teenagers with Allgrove syndrome. They suggested that Allgrove syndrome could be explained by a 'progressive loss of cholinergic function.'
Caksen et al. (2002) described a 7-year-old boy with classic features of Allgrove syndrome associated with a small ectopic left kidney in the pelvis. The authors suggested that the ectopic kidney was coincidental because the incidence of renal ectopia was placed as high as 1 in 900 in the population (Elder, 2000).
Goizet et al. (2002) reported a Portuguese woman who presented at age 33 years with progressive bulbospinal amyotrophy and autonomic dysfunction associated with typical features of the triple-A syndrome that had been present since birth. She was found to have a homozygous nonsense mutation (605378.0002) in the AAAS gene. The authors noted that marked bulbospinal amyotrophy can be part of the phenotypic neurologic spectrum in triple-A syndrome and suggested that autonomic dysfunction and amyotrophy be added to the eponym. De Carvalho and Houlden (2002) reported that they had seen patients with the triple-A syndrome with severe neurologic involvement, including spastic tetraparesis, bulbospinal amyotrophy, and motor peripheral neuropathy.
Prpic et al. (2003) demonstrated the marked phenotypic variability in 3 patients with genetically confirmed triple-A syndrome. Two patients had achalasia, alacrima, and adrenocortical deficiency as well as neurologic and autonomic dysfunction. The third patient had only achalasia and neurologic dysfunction. All patients were homozygous for mutations in the AAAS gene. In the patient with isolated achalasia, the diagnosis of triple-A syndrome could only be made on the basis of the molecular genetic analysis of the AAAS gene, which identified a mutation (605378.0007). Prpic et al. (2003) remarked on the variable pattern of neurologic and autonomic dysfunction demonstrated by patients with triple-A syndrome, including mental retardation, hyperreflexia, impaired visual evoked potentials, muscle weakness, abnormal sweating, anisocoria (106240), and postural hypotension. The authors proposed that the diagnosis of triple-A syndrome should be made on the basis of molecular analysis of the AAAS gene and may therefore include patients with 1 or 2 of the 3 main symptoms.
Bitetto et al. (2019) described a 75-year-old man with AAAS. He had onset of achalasia at age 47 years. He also had a history of orthostatic hypotension and adrenal insufficiency. At age 59, he developed progressive gait impairment. On examination he had miosis, absent pupillary reflexes, hypophonic speech, tongue atrophy, hypotrophy of the lower limbs, and an ataxic gait. A brain MRI demonstrated atrophy of the cerebellum, frontal cortex, and basal ganglia. Electromyography showed chronic and active neurogenic damage suggestive of motor neuron involvement. A biopsy of the gastrocnemius muscle showed substitution of muscle fibers with fibrous-adipose material, and biopsies of the sural and ilioinguinal nerves demonstrated reduction of the myelinic fibers. Schirmer test demonstrated hypolacrimation. He died at age 78 due to aspiration pneumonia.
Achalasia-Alacrima Syndrome
Efrati and Mares (1985) described a 5-year-old Arabian girl with infantile achalasia in association with alacrima. Nussinson et al. (1988) observed a family in which 3 of 5 sibs with achalasia and absent tear production were born to consanguineous parents. None of the sibs described by Nussinson et al. (1988) showed any clinical evidence of adrenal insufficiency, which was excluded on specific testing in 1 of the sibs. Haverkamp et al. (1989) described another Arabian family in which a boy and 2 girls had achalasia and alacrima without adrenal insufficiency. They suggested that this may represent a disorder distinct from the triple-A syndrome by reason of lack of adrenal insufficiency.
Koehler et al. (2008) reported a 14-year-old girl who presented with a slowly progressive axonal motor neuropathy with conspicuous muscle wasting of the hypothenar and calf muscles since the first years of life. She also had pes cavus. Nerve conduction studies clearly indicated a motor axonal neuropathy, but EMG, muscle ultrasound, muscle MRI and muscle biopsy showed nonspecific myopathic features. Other features included alacrima since infancy, difficulty swallowing, hyperreflexia, and hyperkeratosis of the soles. There was no evidence of adrenal insufficiency. Genetic analysis identified compound heterozygosity for 2 mutations in the AAAS gene (605378.0009 and 605378.0010).
After excluding as candidate genes for triple-A syndrome those for ACTH receptor (202200), vasoactive intestinal peptide (192320), VIP1 receptor (192321), pituitary adenylate cyclase activating peptide (102980), and neurotrophin-3 (162660), Weber et al. (1996, 1996) performed a systematic linkage screen in 8 families with the triple-A syndrome including the large highly inbred kindred described by Moore et al. (1991). Weber et al. (1996) obtained conclusive evidence for linkage of the triple-A syndrome to markers on 12q13 (maximum lod score = 10.81 at D12S368), with no indication of genetic heterogeneity. Multipoint and haplotype analyses allowed Weber et al. (1996) to refine the interval to a 4-cM genetic segment between D12S368 and D12S1586. They pointed out that this region harbors the type II keratin gene cluster; features of the triple-A syndrome include hyperkeratosis of palms and soles.
Stratakis et al. (1997) also found linkage of the AAA syndrome with polymorphic markers at 12q13 (maximum lod score = 1.7) in 4 small Puerto Rican kindreds with no known consanguinity.
Using linkage analysis in 12 families with triple-A syndrome, mostly originating from North Africa, Hadj-Rabia et al. (2000) confirmed that the disease locus maps to 12q13 (maximum lod score = 10.89 at marker D12S1604). Analysis of markers at 5 contiguous loci showed that most of the triple-A chromosomes were derived from a single founder chromosome, and the authors speculated that the triple-A mutation was due to an ancient Arabian founder effect that occurred before migration to North Africa.
The transmission pattern of triple-A syndrome in the families reported by Tullio-Pelet et al. (2000) was consistent with autosomal recessive inheritance.
In 14 families in which at least 1 member was affected with triple-A syndrome, Tullio-Pelet et al. (2000) found 5 homozygous truncating mutations (605378.0001-605378.0005) in the AAAS gene. Most of the families were consanguineous. Nine of 10 families from North Africa had the same splice site mutation (605378.0005), and the authors calculated that this founder mutation first occurred more than 2,400 years ago. Two unrelated patients from 2 of the families with the founder mutation had achalasia and alacrima without adrenal insufficiency, while each of their sibs had all 3 disease features. The authors suggested that other unlinked genes or environmental factors may modify the expression of the mutant genotype.
In 9 patients with triple-A syndrome, Handschug et al. (2001) found 8 different homozygous and compound heterozygous mutations (see, e.g., 605378.0006) in the AAAS gene, most of which predicted truncation of the protein. Northern blot analysis revealed marked expression in neuroendocrine and gastrointestinal structures, which are predominantly affected in triple-A syndrome.
In a 75-year-old man with triple-A syndrome, Bitetto et al. (2019) identified a homozygous mutation at a conserved site in exon 6 of the AAAS gene (R155H; 605378.0011). RT-PCR in patient fibroblasts showed decreased expression of AAAS isoform 1 and upregulation of AAAS isoform 2. Transcript analysis in postmortem frontal cortex, cerebellum, and spinal cord tissue from the patient showed decreased expression of AAAS isoform 1 and no change in expression of AAAS isoform 2. Aladin protein expression was reduced in the patient's nervous system tissues and to a lesser extent in patient fibroblasts.
Brooks et al. (2005) studied 6 patients with triple-A syndrome and identified homozygous or compound heterozygous mutations in the AAAS gene in 3 patients with a broad spectrum of clinical presentations. Of the remaining 3 patients with 'classic' triple-A syndrome, 1 was heterozygous for a mutation in the AAAS gene, and the other 2 had no mutations. Brooks et al. (2005) suggested that triple-A syndrome is a genetically heterogeneous disorder, although other genetic mechanisms could not be excluded.
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