Expanding spectrum of ciliopathy beyond the airway

Andrew Bush MB BS (Hons) MA MD FRCP FRCPCH

Professor of Paediatric Respirology, Imperial School of Medicine at

National Heart and Lung Institute; and Honorary Consultant Paediatric
Chest Physician, Royal Brompton Hospital.

Correspondence: Department of Paediatric Respiratory Medicine, Royal

Brompton Hospital, Sydney Street, London SW3 6NP, UK.

Tel: -207-351-8232
Fax: -207-351-8763
e mail:- a.bush@rbh.nthames.nhs.uk

Abstract Primary ciliary dyskinesia (PCD)is characterised by chronic upper and

lower respiratory tract infection, and in nearly 50% of cases, mirror image
arrangement. This is the archetypal ciliary disease, but it is now clear that it is
part of a wide spectrum. Clinical features now recogised as intrinsic components
of PCD include heterotaxy and complex congenital heart disease, oesophageal
disease and primary ciliary dyskinesia. It is dysfunction of motile cilia that is
responsible for the clinical manifestations of PCD, but malfunction of primary and
nodal cilia is also important. The complexities of ciliary structure and function are
only beginning to be appreciated; primary cilia may have mechano- and
chemosensory functions as well as possibly secretory, through the ill-understood
process of intraflagellar transport. Dysfunction of nodal cilia is implicated in
cystic disease in particular of the kidneys and liver. Ciliary dysfunction is
important in the pathophysiology of retinitis pigmentosa, Jeunes asphyxiating
thoracic dystrophy, and complex neurodevelopmental, sketal and other
multisystem syndromes. This review covers PCD, as well as acting as an
introduction to the many complex conditions caused by underlying ciliary
dysfunction.
Keywords: cilia, heterotaxy, bronchiectasis, congenital heart disease,
polycystic kidney disease, retinitis pigmentosa

The initial description of ciliopathy was the triad of sinusitis, bronchiectasis and
situs inversus (Kartageners syndrome). The structure and genetics of cilia, and
the upper and lower airway manifestations of ciliopathy (primary ciliary
dyskinesia, PCD) have been described in previous presentations and elsewhere
[1,2]. It is clear that PCD is only the tip of the iceberg of ciliary diseases. The
purpose of this presentation is briefly to review the standard manifestations of
PCD; to review the expanding spectrum of other manifestations of PCD; and to
discuss other diseases related to ciliary dysfunction. If nitric oxide was the
molecule of the 1990s, cilia are clearly the structures of the new millennium.

Nomenclature of the different types of cilia

Primary cilia (which confusingly are not the root cause of PCD) are solitary
structures widely distributed in epithelial cells. Their primary structure is nine
outer doublets, but no inner pair. The structure may vary along the axoneme,
and there may be regions with central singlets. They are probably mechano- or
chemo-sensors, and are not motile. They arise from a proximal and distal
centriole. They are found on the vast majority of non-mitotic cells in the body [3].
Nodal cilia overlap between primary and motile cilia. They are responsible for
determining situs in the developing embryo [4]. They are structurally primary in
type (no central pairs), but unlike other primary cilia, some are motile. There are
also sensory cilia within the embryonic node.
Motile cilia are responsible either for propelling unicellular organisms through
liquids (e.g. chlamydomonas) or moving mucus along epithelial surfaces. These
are the cilia which are abnormal in PCD. They are complex structure, with nine
outer doublets and an inner pair, containing more than 200 proteins [5]. Key
structures are the inner and outer dynein arms, which are mechanochemical
ATPases, similar in function to myosin and kynesin, and radial spokes and nexin
links. The complexity of these structures means that there are likely many PCD
genes. Human locations of cilia are listed at
http://members.global2000.net/bowser/cilialist.htm/; they are widely distributed
in the plant and animal kingdoms. The human rods and cones of the retina,
sperm tails and olfactory cells are related human structures.

Intraflagellar transport
In addition to the functions described above, the complex processes of
intraflagellar transport are being discovered. The purpose of this complex
process is not clear, but may relate to ciliary nutrition [6,7]. It has been
suggested this may be a ciliary secretory function [8]. It is linked to ciliary
signalling pathways via sonic hedgehog in particular [9], but this is also not well
defined. A and B rafts are moved anterogradely to the ciliary tip, and
retrogradely to the base of the cilia. Mutations in A and B raft genes lead to
short, stumpy cilia. There is a link to Jeunes asphyxiating thoracic dystrophy
(below).

PCD: airway manifestations

The classical phenotype of PCD is of upper and lower airway disease, with, in
around 50% of cases, mirror image arrangement. The presentation and diagnosis
of PCD have been reviewed in detail [1,2], and are summarised in Tables 1 and 2
respectively. Absolutely essential in the diagnostic process is to ensure that
ciliary abnormalities secondary to infection are not mis-diagnosed as PCD. If
there is any doubt, and in atypical cases, testing should be repeated a few
months later. Typically there are combinations of upper and lower airway
disease; isolated cough is rarely due to PCD. The diagnosis is frequently delayed
into adult life [10], probably because many of the symptoms (cough, rhinitis,
chronic serous otitis media) are very common in otherwise normal children [11].
There is a spectrum; mild disease may be diagnosed in apparently well siblings
after the finding of PCD in an index case [10]. This means that there is often
substantial impairment of lung function [12]; stabilisation can be achieved [12,
13], but significant and sustained improvement is rare. Established
bronchiectasis is frequently found in children diagnosed late. Thus diagnostic
vigilance is essential, and this usually has to rely on a carefully focussed history
and clinical examination.
Treatment is empirical, and largely based on cystic fibrosis (CF) protocols. This is
not logical, given the different pathophysiology (ciliary dysfunction versus airway
surface dehydration [14]), and indeed, treatments such as rhDNase which are
very effective in CF, may be useless or even harmful in other chronic chest
conditions [15]. Lower respiratory tract treatment is by combinations of airway
clearance techniques [13]; early on Staphylococcus aureus and Haemophilus
influenza are common. Isolates of these orhanisms are treated with a 2-4 week
course of an appropriate oral antibiotic such as Augmentin. Repeated isolates
merit consideration of prophylactic antibiotics, and symptoms non-responsive to
oral therapy are treated with intravenous antibiotic. Mucoid and non-mucoid
strains of Pseudomonas aeruginosa and atypical Mycobacteris species are not
usually seen until adult life. Most centres use eradication protocols for
Pseudomonas similar to CF, and also use chronic suppressive nebulised
antibiotics if infection has become established. Intravenous antibiotics are used
as needed, usually a combination of an aminoglycoside and a third generation
cephalosporin. The management of atypical Mycobacteria is complex in CF; there
is even less evidence in PCD.
The treatment of the upper airway complications is significantly different from
what might be expected [16]. Secretory otitis media is treated conservatively
the placement of tympnostomy tubes almost invariably leads to prolonged
otorrhea with no improvement of hearing. Long-term, improvement can be
anticipated, and hearing loss is minimal [17]. If hearing is problematic in PCD
patients, then a short period of the use of hearing aids may be needed, but these
are usually able to be discarded in the teenage years. Sinusitis is also managed
conservatively where possible. Nasal polyps are very rare in PCD, in my
experience. The management of PCD has recently been reviewed in detail [1, 2].

PCD: more than just an airway disease

The spectrum of PCD has been extended to include hydrocephalus (a rare
manifestation), infertility, and heterotaxy and complex congenital heart disease
[18]. Hydrocephalus is seen more commonly in animal models of PCD; there are
cilia bathed in cerebrospinal fluid, but their function is not clear. Sperm tails may
be immotile in men with PCD, but this is not inevitable [19]. There is said to be a

higher prevalence of ectopic pregnancy in women with PCD due to immotility of

cilia in the Fallopian tubes [20]. In terms of heterotaxy, a large series (n=337) of
PCD patients [18], 46% had usual organ arrangement, 48% had mirror image,
and 6% (21/337) had disorders of heterotaxy (including n=1 right isomerism with
asplenia, n=11 left isomerism with polyspenia). Complex congenital heart
disease was seen in 8 patients, and there was a 200-fold higher prevalence than
normal of complex congenital heart diease in PCD with heterotaxy, an overall
prevalence of one in fifty. Complex congenital heart disease was particularly
common in the presence of outer dynein arm defects (especially DNAH1 and
DNAI5). Therefore it is essential to remember PCD in the context of congenital
heart disease with laterality disorder, and screen for PCD if there is the least
suspicion of associated respiratory disorders.
Taken together, the facts that nodal cilia are responsible for situs, and ciliary
dysfunction affects cardiac structure, presumably due to motility effects during
the development of the heart, one could speculate that other organ malpositions,
in particular gastrointestinal malrotation, may be an effect of ciliary dysfunction.
Indeed, malrotation is associated with right and left isomerism [21], and we have
described malrotation and a gastrointestinal motility disorder in a cilipathy
related condition, Jeunes asphyxiating thoracic dystrophy (below). In this regard,
the finding of disordered neural crest migration and Hirschprungs disease in
Bardet-Biedl syndrome lends support to the hypothesis that gastrointestinal
motility disorders may in part be cilia related [22].
Another co-morbidity, which should prompt exclusion of PCD, is biliary atresia
[23]. Although mild to moderate gastro-oesophageal reflux is common in many
respiratory diseases, there seems to be an increased risk of really severe reflux,
and other oesophageal disease, in PCD [24]. Whether there is an oesophageal
motility disorder in PCD has yet to be determined.

Spectrum of disorders of primary cilia

As might be expected given their wide distribution, there are many
manifestations of disorders of primary cilia. There is a wide spectrum of liver and
kidney cystic syndromes [25], of varying disease severity, and retinal
involvement, anosmia, obesity, ataxia and other central nervous system
abnormalities, and skeletal dysplasias are all described as part of this spectrum.
Many syndromes are rare and beyond the scope of this manuscript, the more
important will briefly be described below and see Table [26].
Renal manifestations of ciliopathy include adult and juvenile onset polycystic
kidney disease, and nephronophthisis. The mechanisms linking ciliary
dysfunction and cyst formation are unknown, although the WNT signalling
pathway is implicated [27]. There is also a fascinating link between kidney
disease and bronchiectasis [28]. Polycystin is found in the human respiratory
epithelium, although its function there is not known. In a comparison between
nearly 100 adult polycystic kidney patients and 100 other renal disease patients,
the prevalence of bronchiectasis was 37% in the polycystics versus 1: in the noncystic kidney patients, p=0.0022. However, 13% prevalence of bronchiectasis in
the control group is much higher than could be expected by chance. It has been
suggested that this might be related to the newly described primary cilia in
airway smooth muscle cells [29]. Whatever the explanation, it is suggested that
bronchiectasis should be excluded in any renal patient with respiratory
symptoms. Cilia connect the inner and outer retinal photoreceptor neurones.

There are many syndromes which include retinitis pigmentosa, with involvement
of other organ systems common. We are following a family in which the father
has retinitis pigmentosa and the two children have PCD. A number of similarly
poly-phenotypic kindreds have been described [30-2]. Jeune asphyxiating
thoracic dystrophy is an autosomal-recessive chondrodysplasia characterized by
short ribs and a narrow thorax, short long bones, inconstant polydactyly, and
trident acetabular roof. It is closely related to the short rib polydactyly syndrome
(SRP) type III, which is a more severe condition characterized by early prenatal
expression and lethality and variable malformations. Jeunes asphyxiating
thoracic dystrophy has been known to be associated with abnormalities of situs.
Recently, Jeunes was found to be associated with abnormalities in the IFT80
gene on chromosome 3 [33]. This is a poorly understood gene, which is
concerned in intraflagellar transport. More recently, a Jeunes gene to was
mapped to chromosome 11q14.3-q23.1 in a 20.4 Mb region and identified as the
cytoplasmic dynein 2 heavy chain 1 (DYNC2H1) gene [34]. DYNC2H1 is a
component of a cytoplasmic dynein complex and is directly involved in the
generation and maintenance of cilia. Polydactyly, renal degeneration and renal
cysts have also been described in this condition. We have described a child with
Jeunes syndrome, malrotation and gut dysmotility, hypothesising that these last
two features may be a feature of ciliopathy [35].
Ciliopathy: the future
Clearly, ciliary disease has come a long way from the days of Kartagener!
Ciliopathy is a rapidly expanding multisystem condition. We are good at
investigating the function of motile cilia in the respiratory tract, but it cannot be
assumed that anormalities in primary and nodal cilia are necessarily related to
motile cilia. Indeed, patients with PCD and motile sperm have been described,
underscoring the variability within cilia-like structures. We urgently need new
tests of ciliary function, particularly primary cilia. In the meantime, when seeing
a child with a multisystem disease, it is worth asking could this be another
ciliopathy?

Table 1. Clinical manifestations of PCD

Age

Classical
Manifestations

Antenatal

Mirror image arrangement on

antenatal ultrasound (not
diagnostic)

Newborn
period

Respiratory distress
Rhinitis
Positive family history

Childhood

Atypical asthma
Chronic productive cough
Bronchiectasis
Severe gastro-oesophageal
reflux
Rhinosinusitis
Chronic secretory otitis media
After diagnosis in a relative
As for childhood
Male infertility
Ectopic pregnancy

Adulthood

Non-Classical
Manifestations
Heterotaxy on antenatal
ultrasound
Complex congenital heart
disease on ultrasound
Heterotaxy
Complex congenital heart
disease
Biliary atresia
Oesophageal disease

Table 2. Summary of diagnostic testing for PCD

Screening for PCD

Ciliary function
Ciliary structure
Ciliary culture [42]
Genetic studies [5]
Immunohistochemistry [43]

Saccharine test [36]

Radionuclide scanning [37]
Nasal nitric oxide (less well established
in young children) [38-40]
Ciliary beat frequency and pattern [2]
Transmission electron microscopy [2,
41]
Only needed if clinical doubt
Many genes as yet undiscovered
Only limited availability

Table 3: The common associations of clinical features in five ciliary dysfunction

syndromes [44, 45]
Disease
Retinitis pigmentosa
Renal cystic disease
Polydactyly
Situs inversus/isomerism
Mental retardation/developmental
delay
Hypoplasia of the corpus callosum
Dandy-Walker mallformation
Posterior encephalocele
Hepatic disease
Total number of phenotypes in each
disorder
* In mice.

BBS

OF
D1

SeniorLoken

*
5

Meck
el

Joub
ert

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