Véronique ; Pons

Corinne Rolland

Michel Nauze

Marie Danjoux

Gérald Gaibelet

Anne H Durandy

Agnes Sassolas

Emile Lévy

François Tercé

Xavier Collet

Agnès Sassolas

MD Emmanuel Mas
email: mas.e@chu-toulouse.fr

Agnès Sassolas

A severe form of abetalipoproteinemia caused by new

Keywords: abetalipoproteinemia, MTTP, triglyceride transfer, endoplasmic reticulum, intestinal HDL abetalipoproteinemia, MTTP, triglyceride transfer, intestinal HDL, endoplasmic reticulum abetalipoproteinemia, MTTP, triglyceride transfer, intestinal HDL, endoplasmic reticulum

de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

 (MTTP, OMIM 157147). ABL is characterized by the absence of apolipoprotein B (apoB)-containing lipoproteins from plasma. MTTP is a 97 kDa protein, containing 894 amino acids, that forms a heterodimer with the 55 kDa protein disulfide isomerase (PDI). MTTP is mainly found in the endoplasmic reticulum (ER) of hepatocytes and enterocytes (Wetterau, et al., 1992).

MTTP is required for the transfer of neutral lipids to nascent apoB-lipoproteins, resulting in the secretion of very low-density lipoproteins (VLDL) in the liver or chylomicrons (CM) in the intestine. When MTTP is deficient, nascent apoB is degraded by the proteasome (Benoist and Grand-Perret, 1997). It differs from familial hypobetalipoproteinemia, displaying dysfunctional apoB and leading to the absence of apoB-lipoproteins in the plasma. Familial hypobetalipoproteinemia is a co-dominant disorder and even if heterozygotes can be asymptomatic, they had low levels of total cholesterol (TC), low density lipoprotein (LDL)cholesterol and apoB (OMIM 107730).

ABL was characterized as the consequence of MTTP absence or dysfunction in 1992 by Wettereau et al. (Wetterau, et al., 1992). The genetic defects in MTTP gene, located on chromosome 4q22-24, were confirmed one year later (Sharp, et al., 1993;Shoulders, et al., 1993). ABL is a very uncommon disease, which highlights the crucial role of this protein.

Indeed, the mttp-deficient mice died at embryonic day 10.5 with abnormal neurological development (exencephalia) (Raabe, et al., 1998). When a specific inducible intestinal deletion of mttp is generated in mice, they presented a phenotype similar to ABL, with steatorrhea, growth arrest and decreased cholesterol absorption (Xie, et al., 2006).

During evolution, MTTP has progressively acquired TG transfer activity in vertebrates whereas invertebrate MTTP is known to only transfer phospholipids (Rava and Hussain,

MATERIALS AND METHODS

Patients:

We report 2 new cases of ABL, whose diagnosis was performed when AM was a 13 monthold boy and his sister PM was 6 years-old. They were born from Caucasian nonconsanguineous parents. We received the agreement of both parents for genetic investigations.

Endoscopy and duodenal biopsies:

Upper gastrointestinal endoscopy was realized under general anesthesia with a Pentax EG-1870K. Duodenal biopsies were fixed in Bouin for pathology or immediately frozen in liquid nitrogen for further investigations (Western blot and MTTP activity assay). For routine microscopy, biopsies were embedded in paraformaldehyde and sections were hematoxylin/eosin-stained.

Intestinal MTTP analyses:

Proteins were extracted from duodenal biopsies to perform a western blot of MTTP. MTTP activity was measured by radiolabelled TG transfer from donor to acceptor vesicles as previously described (Levy, et al., 2002).

Plasma sample analyses:

Blood samples were collected for lipids, lipoproteins, vitamin A and E investigations, and ALT. TG and TC were measured by an enzymatic method (Roche). HDL and VLDLcholesterol were measured by a dextran/PEG method (Roche). LDL-cholesterol was calculated by Friedwald method. ApoA-I and apoB were determined by immuno-turbidimetry (Roche).

Lipid chromatography:

The FPLC system consisted of a Hitachi L7250 auto-sampler, a L7100 pump system and two detectors: L7400 (Hitachi) and UVD170U (Dionex).  20µL of plasma were injected and Formatted: Font: Italic lipoproteins were separated on SuperoseTM6 10/300GL column (GE Healthcare) with 0.15M NaCl solution at a flow rate of 0.4mL/min. The column effluent was split equally into two lines by a microsplitter 50:50, mixing with cholesterol or triglyceride reagents (Biolabo), thus achieving a simultaneous profile from single injection. The two enzymatic reagents were each pumped at a rate of 0.2mL/min. Both enzymatic reactions proceeded at 37°C in a Teflon reactor coil (15mLx0.4mm id). Proteins were measured directly at 280nm.

Genomic DNA sequencing of MTTP:

DNA from patients was extracted from blood samples and then exons and introns of MTTP gene (NCBI Reference Sequence: NG_011469.1) were sequenced with Applied ABI Prism.

mRNA sequencing of MTTP:

Total RNA was extracted using RNeasy Mini Kit (Qiagen) from either EBV-immortalized B lymphocytes for both children or primary lymphocytes for both children and their parents.

Primary lymphocytes were isolated from blood samples using a ficoll technique. A reverse transcription was performed and nested PCR was used to amplify exon 6 and exon 10 with 5' and 3' flanking regions (see primers in Supp. Table S2). PCR products were separated on agarose gel, then extracted with a QIAquick Gel Extraction Kit (Qiagen) and directly inserted into pCR2.1 vector (Invitrogen) before sequencing analyses.

Nucleotide numbering reflects cDNA numbering with +1 corresponding to the A of the ATG translation initiation codon in the reference sequence (www.hgvs.org/mutnomen). The initiation codon is codon 1.

Constructs:

WT-MTTP cDNA was a generous gift of Dr M.Hussain (New-York). We produced by PCR WT-MTTP and MTTP mutants with deletions of patients: ∆6-MTTP and ∆10-MTTP. PCR fragments (WT-MTTP, ∆6-MTTP and ∆10-MTTP) were digested using BamHI and HindIII restriction enzymes, purified with a QIAquick Gel Extraction Kit (Qiagen) and then inserted Formatted: Font: Italic in pEGFP-N1 or in p2xMyc-N1, generated by replacing the EGFP from pEGFP-N1 with a 2xMyc epitope. pDsRed2-ER vector (Clontech) was used to encode an ER marker.

Cell culture and transfection:

HepG2 (human hepatocellular carcinoma), HeLa (human cervix carcinoma) or Caco-2 (human epithelial colorectal adenocarcinoma) cells were grown in Dulbecco's modified Eagle's medium (Invitrogen) supplemented with 10% fetal bovine serum (Invitrogen), 0.1 mM non essential amino acids (Invitrogen), and 100 µg/ml penicillin/streptomycin (Invitrogen) in a humidified atmosphere containing 5% CO 2 . HepG2 and HeLa cells were transfected using GenJuice (Novagen, Merck) or Fugene (Roche) respectively.

Immunoprecipitation:

The cells were lysed for 30 min in lysis buffer (20 mM Tris-HCl, pH 7.5, 150 mM NaCl, 1% Nonidet P-40, 10% glycerol) containing protease and phosphatase inhibitors. Soluble material was then incubated overnight at 4°C with 5 µg of monoclonal anti-Myc antibody (clone 9E10) or polyclonal anti-PDI antibody (DL-11). The antigen-antibody complex was incubated with a mix of protein-G and protein-A Sepharose for 1h and then washed in lysis buffer containing 0.1% Nonidet P-40. The bound proteins were eluted by boiling the beads in Laemmli buffer and analyzed by immunoblotting.

Immunoblotting:

The proteins were separated by SDS-polyacrylamide gel electrophoresis under reducing conditions, transferred onto nitrocellulose membrane, and analyzed by immunoblotting according to standard protocols using indicated antibodies. Anti-MTTP antibody was a generous gift of Drs. J. R. Wetterau and H. Jamil. We used a mouse monoclonal antibody against Myc (clone 9E10) from BD Biosciences, a rabbit polyclonal antibody against PDI (DL-11) from Sigma and a mouse monoclonal antibody against GFP from Roche. HRPlabelled secondary antibodies were from Santa-Cruz or Roche Diagnostics.

RESULTS

Severe form of abetalipoproteinemia:

When AM was 13-months-old, he presented with a failure to thrive. An intestinal malabsorption was suspected on the basis of abdominal distension, abnormal stools (diarrhea or constipation) and hydro-aeric levels on abdominal X-ray. An upper gastrointestinal endoscopy was performed and revealed a white aspect of duodenal villi characteristic of intestinal fat malabsorption and abnormal lipid storage (Figure 1A), as confirmed by histology (large fat inclusions located within enterocytes, Figure 1B). Blood analyses revealed a severe hypocholesterolemia and hypotriglyceridemia without LDL particles and apoB (Table 1). Since parents have normal lipid values as well as apoB and LDL levels, we ruled out a hypo-betalipoproteinemia which is a dominant inheritance disease. Thus ABL was suspected. They also had an increased level of alanine amino-transferase (ALT) and a hyperechogeneic aspect of the liver on ultra-sound scan. Furthermore, both children presented a severe vitamin E deficiency secondary to intestinal fat malabsorption. His sister (PM), 6years-old at the time of diagnosis, had no rotula reflex (the very early diagnosis of AM prevented the development of peripheral neuropathy). However, both of them have no sign of retinopathy.

Abnormal lipoprotein profiles:

We assessed the blood lipoprotein profiles by FPLC analysis. Both children presented a complete absence of LDL and an almost complete absence VLDL in TC and TG moieties (Figure 1C and 1D). Although HDL-cholesterol levels are only 20% of control, HDL particles remain the only lipid class, with a normal ratio of cholesterol ester to TC (Table 1) reflecting a functional lecithin cholesterol acyl-transferase (LCAT) activity. The HDL pattern differs between patient and control. Patient had 2 peaks of HDL particles. The early peak is specific of the patient while the later one appears at the same time than control, as it is suggested by

Immunoglobulin synthesis abnormalities:

Both of these children had also a congenital hypogammaglobulinemia requiring regular immunoglobulin substitution. They were diagnosed as immunodeficient on serum IgG, IgM and IgA levels that were performed because of a failure to thrive in the first months of age (Table 2). There was no protein loosing enteropathy. Mild hypogammaglobulinemia was discovered, affecting IgM and IgG in both children. IgA was also slightly decreased in the brother AM during the first years of age. AM and PM had normal T and B cell populations (data not shown). B cell phenotype was found normal in PM but absence of memory switched B cells was observed in the younger brother AM. In contrast, in vitro B cell immunoglobulin production was found normal (data not shown).

MTTP mutations:

Genomic DNA sequencing of MTTP gene showed 2 different mutations: c.619G>T and c.1237-28A>G (Supp. Table S3). The first one c.619G>T was located at the first nucleotide of exon 6 and the second one c.1237-28A>G was located within intron 9. In order to understand the consequences of such mutations, we extracted mRNA from lymphocytes and analyzed MTTP transcripts. MTTP is mainly expressed in the liver and in the intestine, but can also be detected from EBV-immortalized B lymphocytes. After reverse transcription and PCR amplification, products were analyzed by gel migration, thereby revealing a decrease in size for both mutations in patient compared to the control (Figure 2A and 2C). As expected, we obtained in control a band at 228 pb and 888 pb for exons 6 and 10 respectively, whereas lower fragments were revealed in patient. Those fragments were detected at the size of ∼90pb and ∼780pb, suggesting the loss of exons 6 and 10 respectively. Sequencing confirmed that these two mutations are responsible for abnormal splicing of exons 6 and 10 (∼25kDa). The second DNA mutation c.1237-28A>G induces a frank deletion of exon 10 (36 amino acids), with no shift in the reading frame, leading to a protein of 858 amino acids (∼94kDa) (Figure 2E). These mutations were also confirmed with sequencing analyses from primary lymphocytes from parents and children, meaning that abnormal splicing of MTTP was a consequence of genomic mutations and not of EBV immortalization.

As children are compound heterozygotes, these results confirm the genetic diagnosis of ABL.

Loss of function of MTTP protein:

Duodenal biopsies were performed and samples were analyzed for MTTP expression and activity. In patient, we detected a band with a slight decrease of the apparent MTTP size compared to control or Caco-2 cells (Figure 3A), which probably corresponds to ∆10-MTTP with the loss of 36 amino acids (3kDa) due to exon 10 deletion. We observed no band at a size of 25kDa, corresponding to the expected size of ∆6-MTTP (data not shown), suggesting that ∆6-MTTP might be degraded by the proteasome. MTTP activity was also measured on these samples and showed a complete loss of TG transfer activity (5-8%/mg protein in control versus 0.08-0.8%/mg protein in AM, Figure 3B).

We further investigated the ability of both ∆6-MTTP and ∆10-MTTP mutants to interact with PDI and their subcellular localization by first generating constructs encoding GFP-or 2xMyc-tagged WT-MTTP, ∆6-MTTP or ∆10-MTTP. Tagged MTTP mutants as well as WT-MTTP were expressed in HeLa cells and analyzed by immunoblotting. We observed that ∆6-MTTP and ∆10-MTTP were detected, as well as WT form (Figure 4A and4B). This Formatted: Font: Italic is in contrast to the mutant MTTP analysis in duodenal biopsy since ∆6-MTTP could not be detected. The overexpression level of tagged proteins might overcome the degradation machinery, thereby allowing the detection of a part of ∆6-MTTP and ∆10-MTTP. However, ∆10-MTTP seemed to be lower expressed compared to WT-MTTP, either expressed as GFPor 2xMyc-∆10-MTTP (quantification in Figure 4C), probably because a part of abnormal proteins was degraded by proteasome.

Since MTTP is localized in the ER through its binding with PDI, we tested the association of MTTP mutants with PDI. 2xMyc-tagged MTTP mutant and WT proteins were expressed in both HeLa and HepG2 cells and immunoprecipitation was performed using antimyc antibody (Figure 4D) or anti-PDI antibody (Figure 4E). As expected, we found that WT-MTTP interacted with PDI (Figure 4D and4E, upper panel). By contrast, neither ∆6-MTTP nor ∆10-MTTP was able to associate with PDI (Figure 4D and4E, middle and lower panels).

We then investigated the cellular localization of WT-MTTP as well as ∆6-MTTP and ∆10-MTTP. After expression in both HeLa and HepG2 cells, WT-MTTP, ∆6-MTTP and ∆10-MTTP displayed an identical pattern, showing a reticular localization throughout the cytosol, reminiscent of ER staining (Supp. Figure S1). However, in HepG2 cells but not in HeLa cells, ∆6-MTTP also displays a non specific localization both in the nucleus and throughout the cytosol (Supp. Figure S1B, see inset in ∆6-MTTP-GFP), much like GFP alone. This suggests that in HepG2 cells, ∆6-MTTP-GFP protein can be degraded, as we observed by immunoblotting in duodenal biopsies. Surprisingly, WT-MTTP as well as ∆6-MTTP and ∆10-MTTP co-localized with ER markers such as ER-DsRed, a red marker consisting of a fusion of the DsRed and the ER retention sequence, KDEL (Figure 5A) and PDI (Figure 5B). By contrast, no co-localization was observed with cis-Golgi marker such as Golgin 97 (Supp. and1D andTable 1). These particles are mainly synthesized in peripheral tissues to ensure the reverse cholesterol transport to the liver. But, HDL are also produced at the basolateral membrane of enterocytes, via ATP Binding Cassette-A1 (ABCA1) efflux of cholesterol to apoA-I (Levy, et al., 2007). Cholesterol is transported by enterocytes in two different pathways: the apoB-dependent and the apoB-independent pathways resulting respectively in the production of CM or HDL lipoproteins (Iqbal, et al., 2003). Some differences exist between these two pathways. Cholesterol ester is only secreted within CM while free cholesterol is secreted by both pathways. The apoB-dependent pathway is also regulated by MTTP and contributes to cholesterol absorption during post-prandial states.

MTTP is not required for cholesterol secretion by the apoB-independent pathway that may be more important during fasting states. In the human epithelial Caco-2 cell line, Liver X Receptor/Retinoid X Receptor activation increases ABCA1 gene expression and basolateral efflux of cholesterol in intestinal HDL (Murthy, et al., 2002). In ABL patients, neurological impairment (ataxia and peripheral neuropathy) and retinopathy are the consequences of vitamin E deficiency. Like cholesterol, these two routes also exist for vitamin E absorption by enterocytes (Anwar, et al., 2007). In MTTP-deficient enterocytes, the HDL pathway is used to deliver vitamin E. Vitamin E secretion within HDL lipoproteins is not increased by MTTP inhibition (Anwar, et al., 2007). This pathway is not as important as chylomicron synthesis but, in ABL patients, intestinal HDL represent the only route for lipids or vitamin E from Formatted: Font: Italic intestine to the liver (Anwar, et al., 2007;Anwar, et al., 2006). These ABL patients have a specific class of HDL particles that have a lower density and a lower protein content.

MTTP is also expressed in natural killer T (NKT) cells. Inhibition of MTTP in fetal thymocyte organ culture results in a complete loss of NKT cells (Dougan, et al., 2007). In these antigen presenting cells, MTTP loads lipids onto nascent CD1d and regulates presentation of glycolipid antigens (Dougan, et al., 2005). MTTP deficiency could impair the recycling of CD1d from lysosome to the plasma membrane (Sagiv, et al., 2007). Interestingly, both patients present with a hypogammaglobulinemia that was mild but however required immunoglobulin substitution. We only found an absence of memory switched B cells in one patient while both of them had a normal in vitro immunoglobulin production (Table 2). Since such an association between mild B lymphocyte immunodeficiency and abetalipoproteinemia has not been previously reported in ABL patients, it is unlikely that MTTP defect is directly involved in hypogammaglobulinemia. However, this point should be further investigated, looking for a subtle defect in immunoglobulin levels in abetalipoproteinemia patients.

Recently, Zeissig et al. characterized the loss of CD1 function in ABL patients (Zeissig, et al., 2010). They found a defect of all antigen-presenting CD1 family members in dendritic cells from ABL patients. Similarly to apoB, MTTP deficiency in the ER leads to the degradation of group 1 CD1 by the proteasome pathway, which altered activation of NKT cells.

In these new patients with ABL, we characterized mutations of MTTP by analyzing genomic DNA and mRNA products. Sequencing revealed abnormal splicing leading to deletion of exon 6 or 10, as a result of two genomic mutations, c.619G>T and c.1237-28A>G respectively. c.619G>T is not only a missense mutation (207 Val>Phe), but induces as well an abnormal splicing (Mitchell, et al., 1986). The deletion of 140 bp of exon 6 causes a shift in the reading frame and a truncated protein because of a premature stop codon in position 234.

Recently, Najah et al. (Najah, et al., 2009) found similar results with c.619-3T>G mutation Formatted: Font: Italic located in intron 5 of MTTP. We showed that this truncated protein is not detected in duodenal biopsies (data not shown), suggesting that ∆6-MTTP is degraded by the proteasome pathway (Pan, et al., 2007). c.1237-28A>G located in intron 9 leads to the frank deletion of 108 bp of exon 10, with no shift in the reading frame, resulting in the loss of 36 amino acids.

Human MTTP structure contains an N-terminal β-barrel (β N ) (residues 22-297), a central α-helical domain (α) (residues 298-603), and two C-terminal β-sheets (β C and β A ) (residues 604-894). β N is conserved in apoB, lipovitellin, and apolipophorin and may be one of the two phospholipid binding sites of MTTP. Helices 4-6, β C and β A domains of MTTP are conserved in vertebrates, but not in invertebrates, suggesting that they are involved in TG transfer activity (Rava and Hussain, 2007). β N mediates the interaction with the N-terminus of apoB; the middle α-helical domain mediates the interaction with both PDI (residues 520-598) and apoB (residues 517-603); and the C-terminal mediates the lipid-binding and transfer catalytic activity of MTTP (Mann, et al., 1999;Read, et al., 2000). Expression of MTTP constructs in HepG2 and HeLa cells showed that ∆6-MTTP and ∆10-MTTP proteins are located at ER (Figure 5) but are not associated with PDI (Figure 4D and4E). MTTP mutants might be retained in the ER as defective or misfolded proteins and a part might be retrotranslocated to the cytosol for proteasomal degradation. The truncated ∆6-MTTP protein only conserved one apoB-binding domain. By contrast, ∆10-MTTP protein is characterized by the loss of residues 413-448, that are not directly involved in PDI binding but their loss could alter the tertiary structure of the protein. Finally, these residues, corresponding to helices 7-9 of the central α-helical domain, belong to a critical domain for TG transfer activity as described by Rava and Hussain (Rava and Hussain, 2007).

In conclusion, we report here two new mutations of MTTP, c. Upper bands in the control and lower bands in patients were purified and then cloned into pCR2.1 vector before sequencing. In (B), electrophoregrams showed the exon 6 and 5' and 3' flanking regions with exon 5 and 7 in the control. In the patient, the exon 6 is deleted, leading to a frameshift and a premature stop codon. In (D), similarly, electrophoregrams showed the exon 10 and 5' and 3' flanking regions with exon 9 and 11 in the control. In the patient, the exon 10 is deleted. (E) The amino acid sequences corresponding to exons 6 and 10 are shown underlined and in blue in the normal MTTP sequence. // determined the deletion of exons 6 or MTTP could be used to lower cholesterol levels in patients with hypercholesterolemia (Cuchel, et al., 2007). However, adverse events like liver steatosis

or vitamin E deficiency should be prevented. MTTP promoter variant -579T/T is associated with peripheral arterial disease (Schgoer, et al., 2008). The -579G/T polymorphism contributes to fat liver accumulation in 3 infected patients with HCV genotype (Zampino, et al., 2008), but could also have a role in the steatosis of these children.

[A1]

Page 16: [32] Deleted PONS 1/31/2011 5:23:00 PM MTTP promoter serves as a novel negative insulin-responsive element (Au, et al., 2008). Forkhead box O1 (FoxO1) mediates insulin-regulated MTTP production, that may be a causative factor for VLDL overproduction and hypertriglyceridemia in diabetes (Kamagate, et al., 2008). Regulation of (Wetterau, et al., 1992).

MTTP is required for the transfer of neutral lipids to nascent apoB-lipoproteins, resulting in the secretion of very low-density lipoproteins (VLDL) in the liver or chylomicrons (CM) in the intestine. When MTTP is deficient, nascent apoB is degraded by the proteasome (Benoist and Grand-Perret, 1997). It differs from familial hypobetalipoproteinemia, displaying dysfunctional apoB and leading to the absence of apoB-lipoproteins in the plasma. Familial hypobetalipoproteinemia is a co-dominant disorder and even if heterozygotes can be asymptomatic, they had low levels of total cholesterol (TC), low density lipoprotein (LDL)cholesterol and apoB (OMIM 107730).

ABL was characterized as the consequence of MTTP absence or dysfunction in 1992 by Wettereau et al. (Wetterau, et al., 1992). The genetic defects in MTTP gene, located on chromosome 4q22-24, were confirmed one year later (Sharp, et al., 1993;Shoulders, et al., 1993). ABL is a very uncommon disease, which highlights the crucial role of this protein.

Indeed, the mttp-deficient mice died at embryonic day 10.5 with abnormal neurological development (exencephalia) (Raabe, et al., 1998). When a specific inducible intestinal deletion of mttp is generated in mice, they presented a phenotype similar to ABL, with steatorrhea, growth arrest and decreased cholesterol absorption (Xie, et al., 2006).

During

MATERIALS AND METHODS

Patients:

We report 2 new cases of ABL, whose diagnosis was performed when AM was a 13 monthold boy and his sister PM was 6 years-old. They were born from Caucasian nonconsanguineous parents. We received the agreement of both parents for genetic investigations.

Endoscopy and duodenal biopsies:

Upper gastrointestinal endoscopy was realized under general anesthesia with a Pentax EG-1870K. Duodenal biopsies were fixed in Bouin for pathology or immediately frozen in liquid nitrogen for further investigations (Western blot and MTTP activity assay). For routine microscopy, biopsies were embedded in paraformaldehyde and sections were hematoxylin/eosin-stained.

Intestinal MTTP analyses:

Proteins were extracted from duodenal biopsies to perform a western blot of MTTP. MTTP activity was measured by radiolabelled TG transfer from donor to acceptor vesicles as previously described (Levy, et al., 2002).

Plasma sample analyses:

Blood samples were collected for lipids, lipoproteins, vitamin A and E investigations, and ALT. TG and TC were measured by an enzymatic method (Roche). HDL and VLDLcholesterol were measured by a dextran/PEG method (Roche). LDL-cholesterol was calculated by Friedwald method. ApoA-I and apoB were determined by immuno-turbidimetry (Roche).

Lipid chromatography:

The FPLC system consisted of a Hitachi L7250 auto-sampler, a L7100 pump system and two detectors: L7400 (Hitachi) and UVD170U (Dionex).  20µL of plasma were injected and

Genomic DNA sequencing of MTTP:

DNA from patients was extracted from blood samples and then exons and introns of MTTP gene (NCBI Reference Sequence: NG_011469.1) were sequenced with Applied ABI Prism.

mRNA sequencing of MTTP:

Total RNA was extracted using RNeasy Mini Kit (Qiagen) from either EBV-immortalized B lymphocytes for both children or primary lymphocytes for both children and their parents.

Primary lymphocytes were isolated from blood samples using a ficoll technique. A reverse transcription was performed and nested PCR was used to amplify exon 6 and exon 10 with 5' and 3' flanking regions (see primers in Supp. Table S2). PCR products were separated on agarose gel, then extracted with a QIAquick Gel Extraction Kit (Qiagen) and directly inserted into pCR2.1 vector (Invitrogen) before sequencing analyses.

Nucleotide numbering reflects cDNA numbering with +1 corresponding to the A of the ATG translation initiation codon in the reference sequence (www.hgvs.org/mutnomen). The initiation codon is codon 1.

Constructs:

WT-MTTP cDNA was a generous gift of Dr M.Hussain (New-York). We produced by PCR WT-MTTP and MTTP mutants with deletions of patients: ∆6-MTTP and ∆10-MTTP. PCR fragments (WT-MTTP, ∆6-MTTP and ∆10-MTTP) were digested using BamHI and HindIII restriction enzymes, purified with a QIAquick Gel Extraction Kit (Qiagen) and then inserted in pEGFP-N1 or in p2xMyc-N1, generated by replacing the EGFP from pEGFP-N1 with a 2xMyc epitope. pDsRed2-ER vector (Clontech) was used to encode an ER marker.

Cell culture and transfection:

HepG2 (human hepatocellular carcinoma), HeLa (human cervix carcinoma) or Caco-2 (human epithelial colorectal adenocarcinoma) cells were grown in Dulbecco's modified Eagle's medium (Invitrogen) supplemented with 10% fetal bovine serum (Invitrogen), 0.1 mM non essential amino acids (Invitrogen), and 100 µg/ml penicillin/streptomycin (Invitrogen) in a humidified atmosphere containing 5% CO 2 . HepG2 and HeLa cells were transfected using GenJuice (Novagen, Merck) or Fugene (Roche) respectively.

Immunoprecipitation:

The cells were lysed for 30 min in lysis buffer (20 mM Tris-HCl, pH 7.5, 150 mM NaCl, 1%

Nonidet P-40, 10% glycerol) containing protease and phosphatase inhibitors. Soluble material was then incubated overnight at 4°C with 5 µg of monoclonal anti-Myc antibody (clone 9E10) or polyclonal anti-PDI antibody (DL-11). The antigen-antibody complex was incubated with a mix of protein-G and protein-A Sepharose for 1h and then washed in lysis buffer containing 0.1% Nonidet P-40. The bound proteins were eluted by boiling the beads in Laemmli buffer and analyzed by immunoblotting.

Immunoblotting:

The proteins were separated by SDS-polyacrylamide gel electrophoresis under reducing conditions, transferred onto nitrocellulose membrane, and analyzed by immunoblotting according to standard protocols using indicated antibodies. Anti-MTTP antibody was a generous gift of Drs. J. R. Wetterau and H. Jamil. We used a mouse monoclonal antibody against Myc (clone 9E10) from BD Biosciences, a rabbit polyclonal antibody against PDI (DL-11) from Sigma and a mouse monoclonal antibody against GFP from Roche. HRPlabelled secondary antibodies were from Santa-Cruz or Roche Diagnostics.

Immunological investigation:

Serum immunoglobulin levels were determined by nephelemetry. B lymphocyte phenotype and function were analyzed as previously described (Peron, et al., 2008).

RESULTS

Severe form of abetalipoproteinemia:

When AM was 13-months-old, he presented with a failure to thrive. An intestinal malabsorption was suspected on the basis of abdominal distension, abnormal stools (diarrhea or constipation) and hydro-aeric levels on abdominal X-ray. An upper gastrointestinal endoscopy was performed and revealed a white aspect of duodenal villi characteristic of intestinal fat malabsorption and abnormal lipid storage (Figure 1A), as confirmed by histology (large fat inclusions located within enterocytes, Figure 1B). Blood analyses revealed a severe hypocholesterolemia and hypotriglyceridemia without LDL particles and apoB (Table 1). Since parents have normal lipid values as well as apoB and LDL levels, we ruled out a hypo-betalipoproteinemia which is a dominant inheritance disease. Thus ABL was suspected. They also had an increased level of alanine amino-transferase (ALT) and a hyperechogeneic aspect of the liver on ultra-sound scan. Furthermore, both children presented a severe vitamin E deficiency secondary to intestinal fat malabsorption. His sister (PM), 6years-old at the time of diagnosis, had no rotula reflex (the very early diagnosis of AM prevented the development of peripheral neuropathy). However, both of them have no sign of retinopathy.

Abnormal lipoprotein profiles:

We assessed the blood lipoprotein profiles by FPLC analysis. Both children presented a complete absence of LDL and an almost complete absence VLDL in TC and TG moieties (Figure 1C and1D). Although HDL-cholesterol levels are only 20% of control, HDL particles remain the only lipid class, with a normal ratio of cholesterol ester to TC (Table 1) reflecting a functional lecithin cholesterol acyl-transferase (LCAT) activity. The HDL pattern differs between patient and control. Patient had 2 peaks of HDL particles. The early peak is specific of the patient while the later one appears at the same time than control, as it is suggested by

Immunoglobulin synthesis abnormalities:

Both of these children had also a congenital hypogammaglobulinemia requiring regular immunoglobulin substitution. They were diagnosed as immunodeficient on serum IgG, IgM and IgA levels that were performed because of a failure to thrive in the first months of age (Table 2). There was no protein loosing enteropathy. Mild hypogammaglobulinemia was discovered, affecting IgM and IgG in both children. IgA was also slightly decreased in the brother AM during the first years of age. AM and PM had normal T and B cell populations (data not shown). B cell phenotype was found normal in PM but absence of memory switched B cells was observed in the younger brother AM. In contrast, in vitro B cell immunoglobulin production was found normal (data not shown).

MTTP mutations:

Genomic DNA sequencing of MTTP gene showed 2 different mutations: c.619G>T and c.1237-28A>G (Supp. Table S3). The first one c.619G>T was located at the first nucleotide of exon 6 and the second one c.1237-28A>G was located within intron 9. In order to understand the consequences of such mutations, we extracted mRNA from lymphocytes and analyzed MTTP transcripts. MTTP is mainly expressed in the liver and in the intestine, but can also be detected from EBV-immortalized B lymphocytes. After reverse transcription and PCR amplification, products were analyzed by gel migration, thereby revealing a decrease in size for both mutations in patient compared to the control (Figure 2A and2C). As expected, we obtained in control a band at 228 pb and 888 pb for exons 6 and 10 respectively, whereas lower fragments were revealed in patient. Those fragments were detected at the size of ∼90pb and ∼780pb, suggesting the loss of exons 6 and 10 respectively. Sequencing confirmed that these two mutations are responsible for abnormal splicing of exons 6 and 10 (∼25kDa). The second DNA mutation c.1237-28A>G induces a frank deletion of exon 10 (36 amino acids), with no shift in the reading frame, leading to a protein of 858 amino acids (∼94kDa) (Figure 2E).

These mutations were also confirmed with sequencing analyses from primary lymphocytes from parents and children, meaning that abnormal splicing of MTTP was a consequence of genomic mutations and not of EBV immortalization.

As children are compound heterozygotes, these results confirm the genetic diagnosis of ABL.

Loss of function of MTTP protein:

Duodenal biopsies were performed and samples were analyzed for MTTP expression and activity. In patient, we detected a band with a slight decrease of the apparent MTTP size compared to control or Caco-2 cells (Figure 3A), which probably corresponds to ∆10-MTTP with the loss of 36 amino acids (3kDa) due to exon 10 deletion. We observed no band at a size of 25kDa, corresponding to the expected size of ∆6-MTTP (data not shown), suggesting that ∆6-MTTP might be degraded by the proteasome. MTTP activity was also measured on these samples and showed a complete loss of TG transfer activity (5-8%/mg protein in control versus 0.08-0.8%/mg protein in AM, Figure 3B).

We further investigated the ability of both ∆6-MTTP and ∆10-MTTP mutants to interact with PDI and their subcellular localization by first generating constructs encoding GFP-or 2xMyc-tagged WT-MTTP, ∆6-MTTP or ∆10-MTTP. Tagged MTTP mutants as well as WT-MTTP were expressed in HeLa cells and analyzed by immunoblotting. We observed that ∆6-MTTP and ∆10-MTTP were detected, as well as WT form (Figure 4A and4B). This is in contrast to the mutant MTTP analysis in duodenal biopsy since ∆6-MTTP could not be detected. The overexpression level of tagged proteins might overcome the degradation machinery, thereby allowing the detection of a part of ∆6-MTTP and ∆10-MTTP. However, ∆10-MTTP seemed to be lower expressed compared to WT-MTTP, either expressed as GFPor 2xMyc-∆10-MTTP (quantification in Figure 4C), probably because a part of abnormal proteins was degraded by proteasome.

Since MTTP is localized in the ER through its binding with PDI, we tested the association of MTTP mutants with PDI. 2xMyc-tagged MTTP mutant and WT proteins were expressed in both HeLa and HepG2 cells and immunoprecipitation was performed using antimyc antibody (Figure 4D) or anti-PDI antibody (Figure 4E). As expected, we found that WT-MTTP interacted with PDI (Figure 4D and 4E,upper panel). By contrast, neither ∆6-MTTP nor ∆10-MTTP was able to associate with PDI (Figure 4D and 4E, middle and lower panels).

We then investigated the cellular localization of WT-MTTP as well as ∆6-MTTP and ∆10-MTTP. After expression in both HeLa and HepG2 cells, WT-MTTP, ∆6-MTTP and ∆10-MTTP displayed an identical pattern, showing a reticular localization throughout the cytosol, reminiscent of ER staining (Supp. Figure S1). However, in HepG2 cells but not in HeLa cells, ∆6-MTTP also displays a non specific localization both in the nucleus and throughout the cytosol (Supp. Figure S1B, see inset in ∆6-MTTP-GFP), much like GFP alone. This suggests that in HepG2 cells, ∆6-MTTP-GFP protein can be degraded, as we observed by immunoblotting in duodenal biopsies. Surprisingly, WT-MTTP as well as ∆6-MTTP and ∆10-MTTP co-localized with ER markers such as ER-DsRed, a red marker consisting of a fusion of the DsRed and the ER retention sequence, KDEL (Figure 5A) and PDI (Figure 5B).

By contrast, no co-localization was observed with cis-Golgi marker such as Golgin 97 (Supp. and1D andTable 1). These particles are mainly synthesized in peripheral tissues to ensure the reverse cholesterol transport to the liver. But, HDL are also produced at the basolateral membrane of enterocytes, via ATP Binding Cassette-A1 (ABCA1) efflux of cholesterol to apoA-I (Levy, et al., 2007). Cholesterol is transported by enterocytes in two different pathways: the apoB-dependent and the apoB-independent pathways resulting respectively in the production of CM or HDL lipoproteins (Iqbal, et al., 2003). Some differences exist between these two pathways. Cholesterol ester is only secreted within CM while free cholesterol is secreted by both pathways. The apoB-dependent pathway is also regulated by MTTP and contributes to cholesterol absorption during post-prandial states.

MTTP is not required for cholesterol secretion by the apoB-independent pathway that may be more important during fasting states. In the human epithelial Caco-2 cell line, Liver X

Receptor/Retinoid X Receptor activation increases ABCA1 gene expression and basolateral efflux of cholesterol in intestinal HDL (Murthy, et al., 2002). In ABL patients, neurological impairment (ataxia and peripheral neuropathy) and retinopathy are the consequences of vitamin E deficiency. Like cholesterol, these two routes also exist for vitamin E absorption by enterocytes (Anwar, et al., 2007). In MTTP-deficient enterocytes, the HDL pathway is used to deliver vitamin E. Vitamin E secretion within HDL lipoproteins is not increased by MTTP inhibition (Anwar, et al., 2007). This pathway is not as important as chylomicron synthesis but, in ABL patients, intestinal HDL represent the only route for lipids or vitamin E from intestine to the liver (Anwar, et al., 2007;Anwar, et al., 2006). These ABL patients have a specific class of HDL particles that have a lower density and a lower protein content.

MTTP is also expressed in natural killer T (NKT) cells. Inhibition of MTTP in fetal thymocyte organ culture results in a complete loss of NKT cells (Dougan, et al., 2007). In these antigen presenting cells, MTTP loads lipids onto nascent CD1d and regulates presentation of glycolipid antigens (Dougan, et al., 2005). MTTP deficiency could impair the recycling of CD1d from lysosome to the plasma membrane (Sagiv, et al., 2007). Interestingly, both patients present with a hypogammaglobulinemia that was mild but however required immunoglobulin substitution. We only found an absence of memory switched B cells in one patient while both of them had a normal in vitro immunoglobulin production (Table 2). Since such an association between mild B lymphocyte immunodeficiency and abetalipoproteinemia has not been previously reported in ABL patients, it is unlikely that MTTP defect is directly involved in hypogammaglobulinemia. However, this point should be further investigated, looking for a subtle defect in immunoglobulin levels in abetalipoproteinemia patients.

Recently, Zeissig et al. characterized the loss of CD1 function in ABL patients (Zeissig, et al., 2010). They found a defect of all antigen-presenting CD1 family members in dendritic cells from ABL patients. Similarly to apoB, MTTP deficiency in the ER leads to the degradation of group 1 CD1 by the proteasome pathway, which altered activation of NKT cells.

In these new patients with ABL, we characterized mutations of MTTP by analyzing genomic DNA and mRNA products. Sequencing revealed abnormal splicing leading to deletion of exon 6 or 10, as a result of two genomic mutations, c.619G>T and c.1237-28A>G respectively. c.619G>T is not only a missense mutation (207 Val>Phe), but induces as well an abnormal splicing (Mitchell, et al., 1986). The deletion of 140 bp of exon 6 causes a shift in the reading frame and a truncated protein because of a premature stop codon in position 234.

Recently, Najah et al. (Najah, et al., 2009) found similar results with c.619-3T>G mutation located in intron 5 of MTTP. We showed that this truncated protein is not detected in duodenal biopsies (data not shown), suggesting that ∆6-MTTP is degraded by the proteasome pathway (Pan, et al., 2007). c.1237-28A>G located in intron 9 leads to the frank deletion of 108 bp of exon 10, with no shift in the reading frame, resulting in the loss of 36 amino acids.

Human MTTP structure contains an N-terminal β-barrel (β N ) (residues 22-297), a central α-helical domain (α) (residues 298-603), and two C-terminal β-sheets (β C and β A ) (residues 604-894). β N is conserved in apoB, lipovitellin, and apolipophorin and may be one of the two phospholipid binding sites of MTTP. Helices 4-6, β C and β A domains of MTTP are conserved in vertebrates, but not in invertebrates, suggesting that they are involved in TG transfer activity (Rava and Hussain, 2007). β N mediates the interaction with the N-terminus of apoB; the middle α-helical domain mediates the interaction with both PDI (residues 520-598)

and apoB (residues 517-603); and the C-terminal mediates the lipid-binding and transfer catalytic activity of MTTP (Mann, et al., 1999;Read, et al., 2000). Expression of MTTP constructs in HepG2 and HeLa cells showed that ∆6-MTTP and ∆10-MTTP proteins are located at ER (Figure 5) but are not associated with PDI (Figure 4D and4E). MTTP mutants might be retained in the ER as defective or misfolded proteins and a part might be retrotranslocated to the cytosol for proteasomal degradation. The truncated ∆6-MTTP protein only conserved one apoB-binding domain. By contrast, ∆10-MTTP protein is characterized by the loss of residues 413-448, that are not directly involved in PDI binding but their loss could alter the tertiary structure of the protein. Finally, these residues, corresponding to helices 7-9 of the central α-helical domain, belong to a critical domain for TG transfer activity as described by Rava and Hussain (Rava and Hussain, 2007).

In conclusion, we report here two new mutations of MTTP, c. Benayoun, et al., 2007Ricci, et al., 1995Wang, et al., 1999 exon Al Shali, et al., 2003Berthier, et al., 2004Narcisi, et al., 1995Ohashi, et al., 2000 exon 13, c

  , OMIM 200100) is a rare autosomal recessive disease caused by the deficiency of the microsomal triglyceride transfer protein

Formatted

Formatted

  the concordance of protein chromatogram. HDL particles of the early peak seem to be cholesterol-enriched and to have less protein than HDL of the second peak.

Formatted

  2B and 2D). The first genomic DNA mutation c.619G>T induces a frank deletion of exon 6 and a shift in the open reading frame leading to a premature stop codon at position 234 and resulting in an abnormal truncated protein consisting of 233 amino acids

Formatted

Figure S2 )

 S2 FigureS2) or trans-Golgi marker such as TGN46 (data not shown).

Formatted

Formatted

Formatted

  619G>T and c.1237-28A>G, resulting respectively in ∆6-MTTP protein, a truncated protein of 233 amino acids and ∆10-MTTP protein, deleted of exon 10. Despite these mutations do not change ER Deleted: MTTP regulation could enable us to improve treatment of ABL patients. Moreover, inhibition of Deleted: MTP Deleted: MTTP could be used to lower cholesterol levels in patients with hypercholesterolemia (Cuchel, et al., Deleted: MTP Deleted: MTTP transcription is Deleted: MTP Deleted: MTTP mRNA when mice are fed with high-cholesterol and high-fat Deleted: MTP Deleted: MTTP promoter variant -579T/T is associated with peripheral Deleted: ed Deleted: 2 Deleted: MTP Deleted: MTTP promoter serves as a novel negative insulin-responsive element Deleted: MTP Deleted: MTTP production, that may be a causative factor for VLDL Deleted: MTP Deleted: MTTP expression and CM production is controlled by inositol-Formatted: Font: Italic localization of mutant MTTP proteins, they abolish their binding with PDI and totally impaired their TG transfer activity.

Figure 1 .

 1 FIGURES LEGENDS

Figure 2 .

 2 Figure 2. Sequence analysis of mutant MTTP transcription products (A and C) After mRNA extraction and reverse transcription from control and patient (AM) EBV-immortalized lymphocytes, PCR was performed to amplify exon 6 (A) and exon 10 (C) with 5' and 3' flanking regions. PCR products were analyzed by migration on agarose gel. Arrowhead points at the lower band found in patient compared to the control. (B and D)

Formatted

  mutant. For ∆6-MTTP, the frame-shift mutation results in an abnormal sequence described in red and in italic.

Figure 3 .

 3 Figure 3. MTTP expression and activity in duodenal biopsy (A) Duodenal biopsy from control (Ctrl) or patient (AM) and Caco-2 cell lysate were analyzed by SDS gel electrophoresis and western blotting with antibodies against MTTP. (B) The triglyceride transfer activity of MTTP was measured on duodenal biopsy from control or patient (AM). Values are expressed as the mean of three independent experiments; standard errors are indicated.

Figure 4 .FormattedFigure 5 .Formatted

 45 Figure 4. Interaction of WT and mutant MTTP with PDI (A and B) HeLa cells were transfected or not with WT-MTTP, ∆6-MTTP or ∆10-MTTP tagged with EGFP (A) or 2xMyc (B). Cell lysates (100 µg) were analyzed by SDS gel electrophoresis and western blotting with antibodies against GFP (A), Myc (B) and Rab5 as loading control. Arrowheads point at WT-MTTP, ∆6-MTTP or ∆10-MTTP and arrows point at non specific band (ns). Blots in (B) were scanned and the quantification is shown in (C). Each experiment was repeated at least 3 times, and (C) shows a representative example. (D and E) HeLa cells were transfected with 2xMyc-tagged WT-MTTP, ∆6-MTTP or ∆10-MTTP. Cell lysates (Lys) were subjected to immunoprecipitation with (+) or without (-) the anti-myc antibody (D) or the anti-PDI antibody (E). Analysis was performed by SDS gel electrophoresis and western blotting with antibodies against Myc or PDI. Arrowheads point at immunoprecipitated WT-MTTP, ∆6-MTTP or ∆10-MTTP (D) or PDI (E) and arrows point at non specific band (ns). IgG HC represents heavy chain of anti-PDI antibody used for immunoprecipitation.

  on SuperoseTM6 10/300GL column (GE Healthcare) with 0.15M NaCl solution at a flow rate of 0.4mL/min. The column effluent was split equally into two lines by a microsplitter 50:50, mixing with cholesterol or triglyceride reagents (Biolabo), thus achieving a simultaneous profile from single injection. The two enzymatic reagents were each pumped at a rate of 0.2mL/min. Both enzymatic reactions proceeded at 37°C in a Teflon reactor coil (15mLx0.4mm id). Proteins were measured directly at 280nm.

  HepG2 and HeLa cells were grown on collagen I coated or glass coverslips respectively. Cells were fixed in 4% paraformaldehyde, permeabilized with 0.05% saponin, saturated with PBS containing 10% fetal bovine serum and incubated with the anti-PDI rabbit polyclonal antibody (Sigma) or the anti-Golgin 97 mouse monoclonal antibody (Molecular Probes) and then with Cy3-labelled secondary antibody (Jackson Immunoresearch Laboratories). Pictures were captured using a Zeiss LSM 510 META confocal microscope equipped with a 63x Plan-Apochromat objective.

  protein chromatogram. HDL particles of the early peak seem to be cholesterol-enriched and to have less protein than HDL of the second peak.

  2B and 2D). The first genomic DNA mutation c.619G>T induces a frank deletion of exon 6 and a shift in the open reading frame leading to a premature stop codon at position 234 and resulting in an abnormal truncated protein consisting of 233 amino acids

Figure

  FigureS2) or trans-Golgi marker such as TGN46 (data not shown).

  data showed that MTTP mutants lost TG transfer activity. They are still localized in the ER despite their inability to interact with PDI. expressed in enterocytes and hepatocytes where it participates in the synthesis of chylomicrons and VLDL respectively. These patients presented fat storage in the small intestine (Figure1A and 1B) and in the liver (as suggested by increased ALT levels and hyperechogeneic aspect), as a consequence of MTTP dysfunction.Lipids are almost exclusively transported in blood into HDL lipoproteins in ABL patients(Figures 1C

  FIGURES LEGENDS

Figure 2 .Figure 3 .

 23 Figure 2. Sequence analysis of mutant MTTP transcription products

Figure 4 .

 4 Figure 4. Interaction of WT and mutant MTTP with PDI

Figure 5 .

 5 Figure 5. Localization of WT and mutant MTTP and ER marker

Table Formatted :

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	both patients were reported at the diagnosis of hypogammaglobulinemia, just after the diagnosis of abetalipoproteinemia and at the last follow-up. Deleted: TABLES ¶ Formatted Deleted: Immunoglobulin levels of ¶

Table 1 . Biochemical diagnosis of abetalipoproteinemia

 1

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	Deleted: Table 2. Immunoglobulin
	levels ¶
	Deleted: ¶
	Deleted: ¶
	Comment [A2]: Reviewer 2 :
	supplementary data
	Deleted: ¶

Table 3 . Genomic mutations of

 3

		... [36]
		... [37]
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	Page 30 of 78 Page 32 of 78 Page 34 of 78		Human Mutation Human Mutation Human Mutation Human Mutation Human Mutation	Page 31 of 78 Page 33 of 78
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		MTP MTP MTP (Zamel, et al., 2008)
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Table 1 . Clinical and biological findings in abetalipoproteinemia patients and their parents AM PM

 1

	F o r
	P
	e
	e r
	R
	e
	v i e
	w

Table 2 . Immunoglobulin levels AM, born the 21/01/2004 PM, born the 25/07/1999 29/04/2004 11/10/2005 27/07/2010 30/09/1999 29/11/2005 27/07/2010

 2 Immunoglobulin levels of both patients were reported at the diagnosis of hypogammaglobulinemia, just after the diagnosis of abetalipoproteinemia and at the last follow-up.

	Normal
	range

  Supplementary TableS1. Description of MTTP mutations reported in the literature

		Human Mutation
				number
				of
	exon/intron mutations exon/intron mutations	consequency	patients	references
	intron 9, c.1237-1G>A,	intron 9, c.1237-1G>A,	abnormal splicing site,
	maternal unidisomy	maternal unidisomy	exon 10 deletion	1	Yang, et al., 1999
	exon 13, c.1820delG	exon 13, c.1820delG	abnormal reading frame	1	Wang, et al., 1999
	exon 16, c.2237G>A	exon 18, c.2524A>T	p.G746E / p.K842X	1	Wang, et al., 1999
	exon 12, c.1619G>A	exon 12, c.1619G>A	p.R540H	1	Wang, et al., 1999
	exon 18, c.2593G>T	exon 18, c.2593G>T	p.G865X	7
		F o r
		P
		e
		e r
			R
			e
			v i e
			w

Page 77 of 78 John Wiley & Sons, Inc.

		Human Mutation
			abnormal splicing site /
	intron 13, c.1867+1G>A intron 14, c.1990-1G>A	abnormal splicing site	1	Narcisi, et al., 1995
			abnormal reading frame
	exon 4, c.419insA	intron 13, c.1867+5G>A	/ abnormal splicing site	1	Narcisi, et al., 1995
					Narcisi, et al., 1995
	intron 13, c.1867+5G>A intron 13, c.1867+5G>A abnormal splicing site	2	Shoulders, et al., 1993
			abnormal splicing site /
	intron 1, 147+2T>C	exon 4, c.419insA	abnormal reading frame	1	Dische, et al., 1970
			abnormal splicing site /
	intron 1, 147+1G>C	exon 12, c.1692T>C	p.I564T	1	Sakamoto, et al., 2006
			abnormal splicing site /
	exon 6, c.619G>T	intron 9, c.1237-28A>G	abnormal splicing site	2	this report
	.1783C>T exon 16, c.2338A>T exon 9, c.1228delCCCinsT intron 9, c.1237-1G>A exon 9, c.1151 A>C exon 15, c.2212delT intron 1, c.148-2A>G exon 3, c.307A>T large deletion of 481 kb large deletion of 481 kb intron 15, c.2218-2A>G exon 16, c.2338A>T exon 9, c.1228delCCCinsT NA exon14, c.1982 G>C exon 15, c.2212delT intron 1, c.148-2A>G exon 3, c.307A>T exon 15, c.2076-39_2303+52del319 exon 15, c.2076-39_2303+52del319 exon 2, c.215delC exon 2, c.215delC F F o r F o r o r P P P e abnormal reading frame p.R595X, abnormal splicing site p.D780Y abnormal splicing site, exon 10 deletion p.D384A / p.G661A abnormal reading frame abnormal splicing site p.K103X loss of MTP and 8 other genes exon 15 deletion abnormal reading frame w e e r e e r e r R e v i e R e v i e w 1 1 1 1 1 3 2 1 1 1 1 R e v i e w	Ohashi, et al., 2000 Ohashi, et al., 2000 Di Leo, et al., 2005 Di Leo, et al., 2005 Di Leo, et al., 2005 Benayoun, et al., 2007 Narcisi, et al., 1995 Benayoun, et al., 2007 Benayoun, et al., 2007 Benayoun, et al., 2007 al., 2007 Sharp, et al., 1993 Vongsuvanh, et
	exon 13, c.1783C>T	exon 13, c.1783C>T 190x254mm (96 x 96 DPI) p.R595X 190x254mm (96 x 96 DPI)	2	Chardon, et al., 2009 Sharp, et al., 1993
	exon 17,	exon 17,
	c.2346insACTG	c.2346insACTG	abnormal reading frame	1	Heath, et al., 1997
	exon1, c.59del17	exon1, c.59del17	abnormal reading frame	1	Chardon, et al., 2009
	exon 5, c.582C>A	exon 5, c.582C>A	p.Cys194X	2	Chardon, et al., 2009
			abnormal splicing site,
	intron 5, c.619-3T>G	intron 5, c.619-3T>G	exon 6 deletion	1	Najah, et al., 2009
	exon 8, c.923G>A	exon 8, c.923G>A	p.W308X	1	Najah, et al., 2009
	exon 10, c.1237-		exon 10 deletion /
	1344del107	exon 12, c.1619G>A	p.R540H	1	Rehberg JBC 1996
	exon 9, c.1147delA	exon 9, c.1147delA	abnormal reading frame	1	Narcisi, et al., 1995
	intron 10, c.1344+5del7 intron 10, c.1344+5del7 abnormal splicing site	1	Narcisi, et al., 1995
	exon 4, c.419insA	exon 11, 1401insA	abnormal reading frame	1	Narcisi, et al., 1995

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ACKNOWLEDGEMENTS

The authors thank these children and their parents, and also pediatricians taking care of them (Dr. E. Fournié-Gardini and Dr. A.I. Bertozzi). We also thank J. Bertrand-Michel and V.

Roques (Lipidomic Plateau of IFR-BMT/IFR150) for lipidomic analysis, advice and technical assistance. We are grateful to Pr. T. Levade (Toulouse, France) for immortalization of B lymphocytes. This work was supported by grants from INSERM, ANR (PNRA-2006 ABSINTE) and by grants from Canadian Institutes of Health Research, MOP 10584 (E.L). V.P and E.M were the recipients of a fellowship from the Fondation pour la Recherche Médicale. V.P is a young researcher with temporary contract from INSERM. X.C was a recipient of a "Contrat d'Interface" from CHU of Toulouse. Deleted: MTP Deleted: ed ACKNOWLEDGEMENTS The authors thank these children and their parents, and also pediatricians taking care of them (Dr. E. Fournié-Gardini and Dr. A.I. Bertozzi). We also thank J. Bertrand-Michel and V. Roques (Lipidomic Plateau of IFR-BMT/IFR150) for lipidomic analysis, advice and technical assistance. We are grateful to Pr. T. Levade (Toulouse, France) for immortalization of B lymphocytes. This work was supported by grants from INSERM, ANR (PNRA-2006 ABSINTE) and by grants from Canadian Institutes of Health Research, MOP 10584 (E.L). V.P and E.M were the recipients of a fellowship from the Fondation pour la Recherche Médicale. V.P is a young researcher with temporary contract from INSERM. X.C was a recipient of a "Contrat d'Interface" from CHU of Toulouse.

HeLa cells were transfected with GFP-tagged WT-MTTP, ∆6-MTTP or ∆10-MTTP and were then processed for immunofluorescence using anti-Golgin 97 antibody. Bar: 10µm