Calcium pyrophosphate deposition (CPPD) disease is a common crystal arthropathy in the elderly, but its early-onset forms are rare. While secondary hypomagnesemia is a recognized contributor to CCPD, inherited renal magnesium-wasting syndromes remain underdiagnosed. Here we performed a whole exome sequencing (ES) in order to detect pathogenic variants in a 58-year-old male patient with early and severe, refractory CPPD disease. We conducted a comprehensive clinical, biochemical, radiological, and genetic evaluation of the patient. ES was performed and filtered for rare, likely pathogenic variants following ACMG/AMP criteria. Cascade genetic testing was performed in family members. Hypomagnesemia with inappropriate renal magnesium loss was found. Radiographs revealed diffuse chondrocalcinosis ES identified a novel heterozygous Cyclin and CBS Domain Divalent Metal Cation Transport Mediator (CNNM2) missense variant (c.319G>C; p.Gly107Arg), absent from population databases and predicted deleterious (REVEL 0.82). This variant affects a highly conserved residue in the extracellular β-barrel domain. Family screening revealed two additional carriers with isolated hypomagnesemia, consistent with autosomal dominant inheritance. CNNM2 encodes a basolateral magnesium transporter in the tubule. This is the first reported case of CPPD linked to a CNNM2 variant through persistent hypomagnesemia. Its variants have been linked to renal hypomagnesemia, neurological comorbidities, but no link to CPPD has been described. This expands the phenotypic spectrum of CNNM2-related disorders and highlights the relevance of genetic testing in CPPD cases with unexplained hypomagnesemia. Building on published functional studies and domain-level protein modeling, we propose a simplified three-tier classification scheme that organizes CNNM2 variants into clinically meaningful categories.

Overproduction of extracellular diphosphate due to hydrolysis of ATP by NPP1 leads to pathological calcium diphosphate (pyrophosphate) dihydrate deposition (CPPD) in cartilage, resulting in a degenerative joint disease that today lacks a cure. Here, we targeted the identification of novel NPP1 inhibitors as potential therapeutic agents for CPPD deposition disease. Specifically, we synthesized novel analogs of AMP (NPP1 reaction product) and ADP (NPP1 inhibitor). These derivatives incorporate several chemical modifications of the natural nucleotides including (1) a methylene group replacing the Pα,β-bridging oxygen atom to provide metabolic resistance, (2) sulfonate group(s) replacing phosphonate(s) to improve binding to NPP1's catalytic zinc ions, (3) an acyclic nucleotide analog to allow flexible binding in the NPP1 catalytic site, and (4) a benzimidazole base replacing adenine. Among the investigated compounds, adenine-N9-(methoxy)ethyl-β-bisphosphonate, 10, was identified as an NPP1 inhibitor (Ki 16.3 μM vs. the artificial substrate p-nitrophenyl thymidine-5'-monophosphate (p-Nph-5'-TMP), and 9.60 μM vs. the natural substrate, ATP). Compound 10 was selective for NPP1 vs. human NPP3, human CD39, and tissue non-specific alkaline phosphatase (TNAP), but also inhibited human CD73 (Ki 12.6 μM). Thus, 10 is a dual NPP1/CD73 inhibitor, which could not only be of interest for treating CPPD deposition disease and calcific aortic valve disease but may also be considered for the immunotherapy of cancer. Compound 10 proved to be a promising inhibitor, which almost completely reduces NPPase activity in human osteoarthritic chondrocytes at a concentration of 100 μM.

Aberrant nucleotide pyrophosphatase/phosphodiesterase-1 (NPP1) activity is associated with chondrocalcinosis, osteoarthritis, and type 2 diabetes. The potential of NPP1 inhibitors as therapeutic agents, and the scarceness of their structure-activity relationship, encouraged us to develop new NPP1 inhibitors. Specifically, we synthesized ATP-α-thio-β,γ-CH2 (1), ATP-α-thio-β,γ-CCl2 (2), ATP-α-CH2-γ-thio (3), and 8-SH-ATP (4) and established their resistance to hydrolysis by NPP1,3 and NTPDase1,2,3,8 (<5% hydrolysis) (NTPDase = ectonucleoside triphosphate diphosphohydrolase). Analogues 1-3 at 100 μM inhibited thymidine 5'-monophosphate p-nitrophenyl ester hydrolysis by NPP1 and NPP3 by >90% and 23-43%, respectively, and only slightly affected (0-40%) hydrolysis of ATP by NTPDase1,2,3,8. Analogue 3 is the most potent NPP1 inhibitor currently known, Ki = 20 nM and IC50 = 0.39 μM. Analogue 2a is a selective NPP1 inhibitor with Ki = 685 nM and IC50 = 0.57 μM. Analogues 1-3 were found mostly to be nonagonists of P2Y1/P2Y2/P2Y11 receptors. Docking analogues 1-3 into the NPP1 model suggested that activity correlates with the number of H-bonds with binding site residues. In conclusion, we propose analogues 2a and 3 as highly promising NPP1 inhibitors.

In the past three years, there has been considerable progress in delineating the mechanism of calcium-containing crystal-induced cell activation: (1) the identification of Ca2+ influx and p42/44 mitogen-activated protein kinase activation as the signal transduction pathways; (2) induction of nuclear transcription factors of cyclic adenosine monophosphate (cAMP) response element binding protein, activator protein-1, and nuclear factor kappaB; (3) the differential role of crystal endocytosis and dissolution in crystal-induced metalloproteinase synthesis and mitogenesis; (4) crystal upregulation of matrix metalloproteinases, including MMP-13 but downregulation of tissue inhibitor of metalloproteinase-1 and -2, thus magnifying the degenerative effect of crystals. Phosphocitrate, a specific inhibitor of biologic effect of calcium crystals, reverses the degenerative effects of crystals.

We report the clinical and biological picture of 34 primary hyperparathyroidism (PHT) cases, diagnosed in rheumatology. It concerned 25 women and 9 men, aged 61 + 11 years. The PHT was often asymptomatic (47 p. cent of cases) at the time of diagnosis. The clinical manifestations were dominated by asthenia (50 p. cent) and renal lithiasis (47 p. cent). We found a chondrocalcinosis in 29 p. cent of patients. No patient presented any bony manifestations of cystic osteitis; 7 out of 34 patients (including 6 women between 57 and 74 years) presented vertebral compression. The mean calcemia was 117 +/- 9 mg/l. There were no hypercalcemic attack. The dosage of PTH and cyclic AMP were elevated in 29 out of 32 and 28 out of 31 patients respectively. In all patients, the level of either of these two tests was increased. The chloremia/phosphoremia ratio was also extremely predictive of HBP, since it was increased, exceeding 3.3 in 33 out of 34 patients. The 25-hydroxyvitamin D levels (25 (OH) D) were normal. The levels of 1,25 (OH) 2D were markedly spread (37 +/- 16 pg/ml) and not significantly different from the reference group. Patients with lithiasis did not present a higher level of 1,25 (OH) 2D. A bone histomorphometry carried out in 15 patients showed a bone trabecular volume similar to that of the reference with the same age. The osteoclastic resorption was increased in all cases and was not correlated with the PTH level, but was significantly correlated with the level of 1,25 (OH) 2D (r = 0.79 p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

In cultured monolayers of human articular chondrocytes we have observed an enzyme activity which catalyzes the extracellular conversion of ATP to AMP and PPi. The enzyme was active at very low concentrations of ATP (microM) and exhibited optimal activity at concentrations of ATP of approx. 100 microM. The enzyme was active in intact cells as judged by measurement of the release of the cytoplasmic marker enzyme lactate dehydrogenase. No increase in production of PPi from ATP was observed on mechanically disrupting the cells and no activity was shed into the medium by intact cells. Activity was stable between days 4 and 8 after subculturing the cells and was not affected by the timing of the final medium change prior to assay. Activity was also observed with other nucleoside triphosphates (GTP, CTP and UTP). We suggest that this activity is attributable to ecto-nucleoside triphosphate pyrophosphatase. This observation may be important in relation to the pathogenesis of the human disease of chondrocalcinosis in which crystals of calcium pyrophosphate dihydrate deposit in articular cartilage.

A model is described of acute inflammation in the pleural cavity of rats using calcium pyrophosphate as the irritant. This model would seem to simulate the pseudogout syndrome. It has been shown to be acute in onset, dominated by polymorphonuclear cells, complement independent. The advantage of the model is that volume of exudate, numbers and types of cells may be quantitated. Prostaglandins and cyclic AMP have been measured in the migrating cells. The significance of these findings has been discussed.