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Homozygous Null TBX4 Mutations Lead to Posterior Amelia with Pelvic and Pulmonary Hypoplasia

Journal article
Authors A. Kariminejad
E. Szenker-Ravi
C. Lekszas
H. Tajsharghi
Ali-Reza Moslemi
T. Naert
H. T. Tran
F. Ahangari
M. Rajaei
M. Nasseri
T. Haaf
A. Azad
A. Superti-Furga
R. Maroofian
S. Ghaderi-Sohi
H. Najmabadi
M. R. Abbaszadegan
K. Vleminckx
P. Nikuei
B. Reversade
Published in American Journal of Human Genetics
Volume 105
Issue 6
Pages 1294-1301
ISSN 0002-9297
Publication year 2019
Published at Institute of Biomedicine
Pages 1294-1301
Language en
Keywords t-box genes, small patella syndrome, holt-oram-syndrome, limb, dysplasia, initiation, evolution, identity, genome, Genetics & Heredity
Subject categories Medical Genetics


The development of hindlimbs in tetrapod species relies specifically on the transcription factor TBX4. In humans, heterozygous loss-offunction TBX4 mutations cause dominant small patella syndrome (SPS) due to haploinsufficiency. Here, we characterize a striking clinical entity in four fetuses with complete posterior amelia with pelvis and pulmonary hypoplasia (PAPPA). Through exome sequencing, we find that PAPPA syndrome is caused by homozygous TBX4 inactivating mutations during embryogenesis in humans. In two consanguineous couples, we uncover distinct germline TBX4 coding mutations, p.Tyr113* and p.Tyr127Asn, that segregated with SPS in heterozygous parents and with posterior amelia with pelvis and pulmonary hypoplasia syndrome (PAPPAS) in one available homozygous fetus. A complete absence of TBX4 transcripts in this proband with biallelic p.Tyr113* stop-gain mutations revealed nonsense-mediated decay of the endogenous mRNA. CRISPR/Cas9-mediated TBX4 deletion in Xenopus embryos confirmed its restricted role during leg development. We conclude that SPS and PAPPAS are allelic diseases of TBX4 deficiency and that TBX4 is an essential transcription factor for organogenesis of the lungs, pelvis, and hindlimbs in humans.

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