Accepted Manuscript

Congenital sideroblastic anemia: Advances in gene mutations and

pathophysiology

Zhangbiao Long, Hongmin Li, Yali Du, Bing Han

PII: S0378-1119(18)30571-7
DOI: doi:10.1016/j.gene.2018.05.074
Reference: GENE 42885
To appear in: Gene
Received date: 30 April 2018
Accepted date: 18 May 2018

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 ACCEPTED MANUSCRIPT

Congenital sideroblastic anemia: advances in gene mutations and

pathophysiology

Zhangbiao Longa*, Hongmin Lia*, Yali Dua, Bing Hana†

a
Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and

Peking Union Medical College, Beijing, 100730, China

†
E-mail: hanbingpumch@sina.com

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*
Zhangbiao Long and Hongmin Li contributed equally to this work

Abstract

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Congenital sideroblastic anemia (CSA) is a series of rare, heterogeneous disorders,

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characterized by iron overload in the mitochondria of erythroblasts and ringed sideroblasts in

bone marrow. In recent years, rapid development of next-generation sequencing technology

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brings great advance in understanding of genetic and pathophysiologic features of CSA.

Based on the pathophysiology of mitochondrial iron metabolism, causative genes of CSA can
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be divided into three subtypes: Heme biosynthesis related; iron-sulfur cluster biosynthesis and

transportation related; and mitochondrial respiratory chain synthesis related. Patients with

CSA present various clinical manifestation due to relevant mutation gene and require different
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treatment strategies. The recognition of the causative genes and evolution of pathogenicity is
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critical. In this review, we summarize the recent progress in mutation genes of CSA, and its
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potential role in the pathogenesis, diagnosis and treatment.

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Keywords: congenital sideroblastic anemia, iron metabolism, gene, pathogenesis

1. Introduction
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Sideroblastic anemia is a heterogeneous group of rare disorders due to impaired heme

biosynthesis or iron utilization when hemoglobin synthesis, and characterized by the presence

of ringed sideroblasts in bone marrow, which reflects abnormal mitochondrial iron

accumulation by the erythroblasts (Bottomley et al., 2014; Furuyama et al., 2002). Impaired

iron utilization could disturb reduction-oxidation reaction in cellular and induce apoptosis,

leading to ineffective erythropoiesis (Fleming, 2011; Harigae et al., 2010), thus present

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clinically with anemia (usually hypochromic microcytic anemia), serum iron and ferritin

increase. Sideroblastic anemia consists of congenital and acquired sideroblastic anemia,

congenital sideroblastic anemia (CSA) comprise a series of sideroblastic anemia caused by

iron metabolism related genes mutation, can be classified in three types according to

pathophysiology: mutations of genes involved in heme synthesis, iron-sulfur (Fe-S) cluster

synthesis and transportation, mitochondrial respiratory chain synthesis(Fujiwara et al., 2013).

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Recently, some new mutation genes and genetic sites were found along with the application

of next-generation sequence technology, these findings facilitate people understanding the

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pathogenesis of CSA (An et al., 2015; Camaschella, 2009). However, because of CSA is a

relatively rare disease, the genetic and pathophysiologic features of CSA remain elusive. This

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review will present recent advances in gene mutations and pathophysiology of CSA according

to pathogenic pathways.
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2. Gene mutations involve in heme biosynthesis

Glycine and succinyl-coenzyme A (CoA) synthesis δ- amino levulinic acid (ALA) with
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catalyzed by δ-aminolevulinate synthase (ALAS) in the erythroblastic mitochondria, next

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ALA transports to the cytoplasm, then undergoes deamination, decarboxylation, and

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oxidation reaction to form protoporphyrinogen (PPgen) IX. PPgen IX returns to the

erythroblastic mitochondria, to form proporphyrin IX with catalyzed by PPgen oxidase,

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subsequently proporphyrin IX generates heme through catalysis by ferrochelatase (FECH)

(Fujiwara et al., 2015; Roumenina et al., 2016). Heme combines with iron to synthesize
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hemoglobin, hence any limited enzyme impairment in the heme synthesis pathway could

cause heme synthesis abnormally and affect iron utilization theoretically, result in iron

overload in the erythroblastic mitochondria, with the clinical manifestation of sideroblastic

anemia(Bottomley, 2006; Fontenay et al., 2006). To date, three genes encode limited enzyme

in heme synthesis mutation can lead to sideroblastic anemia: ALAS2 gene mutation leads to

Delta-aminolevulinate synthase 2 (ALAS2) enzyme defect, SLC25A38 gene mutation leads to

SLC25A38 transporter defect, and SLC19A2 gene mutation leads to high affinity thiamine
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transporter 1 protein (THTR-1) defect. Some EPP patients accompanied by the features of a

sideroblastic anemia since 1973(Scott et al., 1973), such as iron deposition in the

mitochondria of erythroblasts, and mild anemia due to heme generate disturbance

(Rademakers et al., 1993). However, in consideration of EPP with sideroblastic anemia is a

specific type of EPP, we remain categorize erythropoietic protoporphyria (EPP) in to

protoporphyria but not CSA in this review.

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2.1 ALAS2 gene mutations

ALAS2 gene is located on chromosome Xp11.21 and encodes ALAS2, which is the first

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enzyme in heme synthesis. ALAS2 deficiency disturbs the ALA synthesis and affects the

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heme generation, result in iron overload and anemia, and is called X-linked sideroblastic

anemia (XLSA). In the process of ALA synthesis, pyridoxal 5-phosphate (PLP), as a cofactor,
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binds to the lysine residue from exon 9 and enhance the activity of ALAS2 enzyme (Cazzola

et al., 2015). XLSA is the most common disorder in CSA and was first reported in 1945 by
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Thomas Cooley, but the mapping of ALAS2 gene was not performed until the year of

1990(Bishop et al., 1990; Cotter et al., 1994). So far, more than sixty mutations distribute
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from exon5 to exon11 in ALAS2 have been reported, the pattern of mutations contain
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missense mutation, nonsense mutation and frame shifts, which result in ALAS2 enzyme
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deficiency. Further, some new mutation sites in the enhancer and intron have been reported

(Campagna et al., 2014; Kaneko et al., 2014), these mutations lead to defects of enhancer or
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enhancer binding domain, and effect ALAS2 gene transcription eventually. Clinical symptoms

of XLSA include hypochromic microcytic anemia and iron overload, however, some patients
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with XLSA present with macrocytic anemia (Katsurada et al., 2016; Sankaran et al., 2015).

Although XLSA is a hereditary disease, some patients also can show their clinical

manifestations later in their lives, the latest onset time has been reported was 81-year-old, the

patient was diagnosed with chronic renal failure and treated with hemodialysis for 2.5 years,

developed sideroblastic anemia, and the diagnosis with XLSA was confirmed by

identification of the ALAS2 gene(Furuyama et al., 2003). The anemia symptom of XLSA

patient is always relatively mild, but in this case the chronic hemodialysis aggravated

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pyridoxine deficiency, caused obvious anemia and uncovered underlying occult inherited

enzymatic deficiency. Recently, a late onset congenital macrocytic sideroblastic anemia

caused by a novel heterozygous ALAS2 mutation has been reported(Fujiwara et al., 2017).

These reports suggested that clinical symptoms of XLSA express variously. More than half of

XLSA patients respond to oral pyridoxine because pyridoxine can enhance the activity of

ALAS2 enzyme as a co-factor. Clinical effect varies due to different ALAS2 mutation sites (G.

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Liu et al., 2013; May et al., 1998). In addition, iron burden also influences the effect of

pyridoxine, indicating the importance of chelation therapy for the patients with iron overload.

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2.2 SLC25A38 gene mutations

SLC25A38 gene is located on chromosome 3p22.1 and encodes mitochondrial transporter

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SLC25A38, which locates in the inner mitochondrial membrane and imports glycine into

mitochondria (Lunetti et al., 2016). SLC25A38 gene mutation was first reported in 2009,
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some CSA patients without ALAS2 gene mutation were sequenced, variations in SLC25A38

including stop codons, frame shift, splice acceptor were founded, further the function analysis
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of these mutations were performed through yeast and zebrafish models (Guernsey et al.,

2009). Kannengiesser et al analyzed the gene mutation sites and clinical data in 24 patients
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with CSA negative for ALAS2 mutations (Kannengiesser et al., 2011), and found nine
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homozygous variation and two compound heterozygous variation for SLC25A38, all patients
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displayed severe microcytic and hypochromic anemia, and were transfusion-dependent.

Because SLC25A38 is responsible for the transportation of glycine into mitochondria, some
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researchers suggest supplementation with glycine or ALA may ameliorate anemia and

transfusion-dependence (Bergmann et al., 2010). Recently, a study demonstrated glycine and

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folate could ameliorate CSA in yeast and zebrafish models, which may provide a promising

therapeutic strategy for patients with CSA due to SLC25A38 (Fernandez-Murray et al., 2016).

Another study verified supplementation with glycine and folate could decrease the blood

transfusion frequency in congenital SLC25A38 mutated sideroblastic anemia (LeBlanc et al.,

2016).

2.3 SLC19A2 gene mutations

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SLC19A2 gene is located on chromosome 1q23.3 and encodes high affinity thiamine

transporter 1 protein (THTR-1). THTR-1 deficiency leads to thiamine deficiency, then affects

the synthesis of succinyl COA, ultimately damages the generation of heme(Labay et al., 1999;

Setoodeh et al., 2013). More than thirty SLC19A2 gene mutation sites have been reported till

now. SLC19A2 genes are widely expressed in human tissues including bone marrow, pancreas,

brain, heart, retina, skeletal muscle, kidney and so on. Therefore SLC19A2 mutations lead to

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thiamine deficiency in the bone marrow and other affected tissues (Mee et al., 2009; Reidling

et al., 2003; Reidling et al., 2002). The main clinical manifestations consist of childhood

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onset megaloblastic anemia, diabetes, and sensory deafness (Beshlawi et al., 2014; Ricketts et

al., 2006). Other clinical symptoms like congenital heart disorders, dysrhythmia, retinal

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dystrophy, optic nerve atrophy, developmental retardation, stokes may also occur (Aycan et

al., 2011; Bergmann et al., 2009; Mozzillo et al., 2013). Interestingly, Chinese patients in our
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report did not have diabetes, which was different from the patients reported by other countries

(G. Liu, Yang, et al., 2014). High dose thiamine can ameliorate the anemia and diabetes
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mellitus in patients with SLC19A2 mutation. So these disorders are named as

thiamine-responsive megaloblastic anemia (TRMA), However, neurological symptoms

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including hearing loss do not respond to thiamine (Ghaemi et al., 2013; Ortigoza-Escobar et
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al., 2016).
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3. Gene mutations involved in iron-sulfur cluster biosynthesis and transportation

One portion of mitochondrial iron in erythroblast combines with proporphyrin IX to

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synthesize heme, one portion is stored in the form of ferritin, and another portion is used to

Fe-S cluster biosynthesis. The desulfurase binds to the substrate cysteine in mitochondria,

forms the persulfide, next persulfide transfers to the iron-sulfur clusterscaffold protein (ISCU),

where it combines with iron to generate the Fe-S cluster(Adrover et al., 2015; Blanc et al.,

2014). Then the Fe-S cluster transports out of the mitochondria, binds to iron regulatory

protein 1(IRP1) and enhances the activity of IRP1. Activated IRP1 combines with

iron-responsive element (IRE) which is located on the 5’ terminal UTR of ALAS mRNA and

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regulates the transcription of ALAS mRNA. Additionally, IRP1 binds to transferrin receptor

mRNA and downregulates the level of transferrin, results in inhibition of iron import (Rouault

et al., 2017). Therefore, Fe-S cluster has a critical role in the maintenance of iron homeostasis

and regulation of ALAS2 biogenesis. When the formation and transportation of Fe-S cluster is

impaired, the iron can deposit in mitochondria, and heme biosynthesis is disturbed, which

leads to CSA. Hitherto three disease-causing genes involved in Fe-S cluster functions were

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founded: the mutation of GLRX5 gene leading to abnormality of Fe-S cluster biosynthesis, the

mutation of ABCB7 gene leading to abnormality of Fe-S cluster transportation, and the

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mutation of HSPA9 gene leading to defection of Fe-S cluster assembly.

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3.1 GLRX5 gene mutations

GLRX5 gene is located on chromosome 14q32.13 and encodes glutaredoxin 5 (GLRX5),

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which is an essential peroxiredoxin in mitochondria. Absence of GLRX5 causes iron

accumulation in the cells and inactivation of enzymes required in Fe-S cluster synthesis in the
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yeast model (Rodriguez-Manzaneque et al., 2002). And deficiency of GLRX5 could cause

Fe-S cluster assembly impairment, heme biogenesis blocking, and ultimately result in
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hypochromic anemia in zebrafish and mice model (Wingert et al., 2005). Furthermore,
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CLRX5 is essential for biosynthesis of Fe-S cluster, and maintains the iron homeostasis in
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human cells (Ye et al., 2010). By far only two CSA cases due to GLRX5 gene mutation have

been reported. One case caused by a homozygous mutation in GLRXS that interferes with
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intron 1 splicing (Camaschella et al., 2007), and the other case reported by our team

demonstrated two compound heterozygous missense mutations in GLRX5 (G. Liu, Guo, et al.,
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2014). Both of the two cases onset in middle age (64 and 46 years old, respectively), and

presented with hypochromic anemia, iron overload, hepatosplenomegaly, and bone marrow

ringed sideroblasts.

3.2 ABCB7 gene mutations

ABCB7 gene is located on chromosome Xp13.3 and encodes an ATP-binding cassette

(ABC) subfamily B member 7 (ABCB7) in mitochondrial membrane, which is responsible for

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exportation of Fe-S cluster from the mitochondria to the cytosol (Bekri et al., 2000). ABCB7

gene mutation can lead to the defect in the transportation of ABCB7, result in iron retention in

mitochondria of erythrocytes (Nikpour et al., 2013). Furthermore, the ABCB7 gene expresses

not only in bone marrow but also in the cerebellum, therefore iron overload can happen in the

mitochondria of nervous system(Napier et al., 2005). For these reasons, CSA patients with

ABCB7 gene mutation can present with hypochromic anemia, ringed sideroblasts in bone

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marrow and ataxia, which are named as X-linked sideroblastic anemia with ataxia

(XLSA/A)(D'Hooghe et al., 2012; Napier et al., 2005). XLSA/A can start from childhood,

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with usually mild anemia and stable symptom of ataxia. Till today, only five ABCB7 gene

mutation sites have been reported (Protasova et al., 2016). The underlying mechanism of

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anemia caused by the transporter ABCB7 disturbance has not yet been elucidated. ALAS2

function may not be influenced by the loss-of-function mutation of ABCB7 because the level
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of erythrocyte protoporphyrin increased in the ABCB7 mutation mouse model (Pondarre et al.,

2007). Some studies found that ABCB7 activation could enhance the activity of FECH, thus
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the ABCB7 function deficiency could affect the biosynthesis of heme, and result in anemia

(Taketani et al., 2003).

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3.3 HSPA9 gene mutation

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HSPA9 gene is located on chromosome 5q31.2 and encodes heat shock protein 9 (HSPA9).

HSPA9 could interact with and stabilizes the mitochondrial Fe-S cluster biogenesis including
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ISCU, Fe-S cluster scaffold protein (Nfu), and frataxin, nitrogen fixation a homolog (Nfs1).

Further, depletion of HSPA9 can damage aconitase activity and increase IRP1 binding
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activity (Shan et al., 2016). In mice and zebrafish models, deficiency of HSPA9 damage the

function of erythroid differentiation and hematopoiesis (Chen et al., 2011; Craven et al.,

2005). In human CD34+ hematopoietic progenitor cells, knockdown of HSPA9 could induces

apoptosis. Moreover, treatment of bone marrow cells with HSPA9 inhibitor also induce

apoptosis (T. Liu et al., 2017). Schmitz-Abe and colleagues reported mutations in HSPA9

which leading to loss of function, and altered transcription of HSPA9, could cause CSA

phenotype in a recessive or pseudodominant model (Schmitz-Abe et al., 2015).

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4. Gene mutations involved in mitochondrial protein biosynthesis

Mitochondrial respiratory chain consists of complexes which subunits are encoded by

both mitochondrial DNA (mtDNA) and NDUFB11, these subunits constitute the complex and

participate in oxidative phosphorylation as “catalytic core” and “ancillary”. Dysfunction of

the respiratory chain could lead to lactic acidosis in cells (Gibson et al., 1992) and result in a

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deficiency of cytochrome c oxidase, then the process of iron reduction fails. Whereas only

ferrous iron (Fe2+) can used for heme synthesis, thus excessive trivalent iron (Fe3+) deposits in

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the erythroblastic mitochondria and causes sideroblastic anemia (Gattermann et al., 1997;

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Grasso et al., 1980). Therefore, the impairment of mitochondrial respiratory chain

biosynthesis could affect iron metabolism, lead to iron overload in mitochondria. So far, six
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genes have been found involved in the pathway which could cause CSA: PUS1, YARS2,

LARS2 and TRNT1 gene mutations lead to mitochondrial ribosomal RNAs modification
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damage, which may affect respiratory complex, whereas mitochondrial DNA defects and

nuclear gene NDUFB11 mutation directly harm the respiratory chain.

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4.1 PUS1 or YARS2 gene mutations

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PUS1 gene is located on chromosome 12q24.33 and encodes pseudouridylate synthase,

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which forms pseudouridine. Pseudouridine could modify tRNA and strengthen the base pair
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of tRNA(Bekri et al., 2000; Bykhovskaya et al., 2004; Patton et al., 2005). PUS1 gene

mutation disturbs the synthesis of pseudouridylate and destroys the translation of respiratory
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complexes, particularly complex I and IV (Fernandez-Vizarra et al., 2007). YARS2 gene is

located on chromosome 12p11.21 and encodes mitochondrial tyrosyl- tRNA synthetase.

YARS2 gene mutation can affect tRNA modification, similar to PUS1 gene mutation (Riley et

al., 2013; Sommerville et al., 2017). Clinical symptoms caused by these two gene mutations

include myopathy, lactic acidosis and sideroblastic anemia (MLASA). MLASA is an

autosomal recessive disorder, usually onset in childhood. Currently the main medical care for

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MLASA is symptomatic treatment but less effective, although few patients survive to

adulthood, the majority of patients die in childhood (Cao et al., 2016).

4.2 LARS2 gene mutations

LARS2 gene is located on chromosome 3p21.3 and encodes mitochondrial leucyl-tRNA

synthetase, which can attach leucine to its cognate tRNA. LARS2 gene mutation results in

leucyl-tRNA defect and causes “Perrault syndrome”--premature ovarian failure and hearing

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loss(Newman et al., 1993) . A neonatal child presented with severe lactic acidosis, hydrops

and sideroblastic anemia has been reported in 2016(Riley et al., 2016). At first, the patient

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was suspected to have a CSA caused by YARS2 gene mutation but no YARS2 mutation was

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identified. Whole exome sequencing of DNA displayed compound heterozygous mutations in

LARS2 and western blot analysis showed a reduced level of LARS2 in liver and reduced level
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of complex I protein in muscle and liver. It was verified that LARS2 mutations led to complex

I protein defect and were responsible for the variable phenotypes in this case.
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4.3 TRNT1 gene mutations

TRNT1 gene is located on chromosome 3p26.1 and encodes tRNA nucleotidyl transferase
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1(TRNT1), TRNT1 is response for the addition of the cytosine/ cytosine/ adenine (CCA)
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trinucleotide to the 3’ end of newly synthesized tRNAs, result in aminoacylation of both

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mitochondrial and cytosolic tRNAs, which is an essential post-transcriptional modification to

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tRNAs(Sasarman et al., 2015). TRNT1 gene deficiency can cause sideroblastic anemia, B cell

immunodeficiency, periodic fevers and developmental delay, which is called SIFD syndrome.
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Additionally, patients with SIFD could also present symptoms like cardiomyopathy,

sensorineural deafness, seizures, nephrocalcinosis and hydrops (Barton et al., 2017;

Chakraborty et al., 2014; Wiseman et al., 2013). This is an autosomal recessive disorder,

which always onsets in the neonatal period. Treatments include blood transfusion, intravenous

immunoglobulin and iron chelation, with little effect on the disease progression. Patients

always succumb in their first decade of life (Wedatilake et al., 2016). One child who received

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allogeneic transplantation successfully reversed his hematologic and immunologic

abnormalities, providing a rational treatment of SIFD patients (Wiseman et al., 2013).

4.4 Gene mutations in mitochondrial DNA

Mitochondrial DNA (mtDNA) is an approximately 16.5kb long circular double-stranded

molecule. It encodes proteins and ribosomal RNAs (rRNA) and transfers RNAs (tRNA) who

participate in the respiratory chain and oxidative phosphorylation system(Schapira, 2002).

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Deletion of mitochondrial DNA can obviously affect the function of the respiratory chain and

the reduction of iron in mitochondria. In 1979, Pearson and colleagues reported a

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mitochondrial disorder present with macrocytic anemia, neutropenia and thrombocytopenia,

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characterized by vacuolization of hematopoietic precursor cells in bone marrow, growth

retardation due to exocrine pancreatic dysfunction, which is named as pearson

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marrow-pancreas syndrome (PMPS)(Pearson et al., 1979). According to the previous reports,

patients with PMPS could present renal tubulopathy, hepatomegaly, cholestasis, diabetes
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mellitus, neuromuscular involvement, and cardiac manifestation (Al-Tamemi, 2009; Atale et

al., 2009; Superti-Furga et al., 1993). mtDNA deletion always occur in the oocyte or during
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early stages of embryonic development, and is usually large-scale deletion according to

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reports (in approximately eighty percent of patients with PMPS). Deletion spans from
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ATPase8 gene to ND5 gene (Kleinle et al., 1997). The initial presentation of PMPS usually

occurs in the neonatal period, and becomes fatal before three-year old. Patients always died of
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septicemia, lactic acidosis or multiple organ failure (Falcon et al., 2017; Shapira et al., 2014).

Treatments include blood transfusion, erythropoietin, pancreatic enzyme and bicarbonate,

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with frustrating efficiency (Farruggia et al., 2016; Finsterer et al., 2017). Allogeneic stem cell

transplantation can be an option because some patients recovered from the hematological and

metabolic symptoms according to the literatures (Faraci et al., 2007; Hoyoux et al., 2008;

Tumino et al., 2011). Not only a large-scale deletion, but also point mutation in mtDNA could

lead to CSA. A patient with MLASA due to single nucleotide variation in the mtDNA

encoded ATP6 gene has been reported, and this mutation caused a respiratory chain complex

V defect(Burrage et al., 2014). Unlike MLASA caused by PUS1 or YARS2 gene mutation,

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MLASA patients with ATP6 gene mutation are not autosomal recessive inheritance, but

maternal inheritance or sporadic occurrence.

4.5 NDUFB11 gene mutations

NDUFB11 gene is located on chromosome X p11.23 and encodes supernumerary subunits

of respiratory chain complex I. Initially, NDUFB1 gene mutation was found in 2015 as a

causative gene for microphthalmia with linear skin defects syndrome (MLS) and histiocytoid

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cardiomyopathy, both are X-linked male-lethal disease caused by the abnormal of

mitochondrial respiratory chain(Shehata et al., 2015; van Rahden et al., 2015). Recently,

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some studies reported patients with NDUFB11 mutation had early onset CSA. Besides,

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several patients had myopathy, lactic acidosis, short, and organ dysgenesis (Lichtenstein et al.,

2016; Torraco et al., 2017). Lichtensein and colleagues illustrated NDUFB11 mutation did
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harm to the proliferation of K562 cell, but had a mild effect on erythroid differentiation

(Lichtenstein et al., 2016).

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5. Conclusions
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Nowadays, the diagnosis of CSA depends on the combination of clinical characters and
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results of gene sequencing. Recognition of the pathogenesis and causative genes not only

avoids misdiagnose, but also promotes management and provides the potential for gene
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therapy. Patients with mutations in the heme biosynthesis pathway had relatively mild

features with many long-term survival. Supplement with pyridoxine, glycine and thiamine
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may effective in some patients. Patients with mutation in Fe-S cluster pathway are mild as

well, treatment remains symptomatic and no known best treatment due to the rareness of the

case reports. Different from above, gene mutations in mitochondrial respiratory chain

synthesis pathway impair respiratory chain both in erythrocytes and other tissues, thus

patients with these genes mutation always have an early onset and die in childhood.

Fortunately, symptoms can be relieved by early Allo-SCT in some cases. More discoveries of

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gene mutation profiles and function interpretation can help us to the better understanding of

the underlying mechanism of CSA.

Abbreviations

ABC: ATP-binding cassette; ABCB7: ATP-binding cassette subfamily B member 7; ALA: δ-

amino levulinic acid; ALAS: δ-aminolevulinate synthase; CCA: cytosine/ cytosine/ adenine;

CoA: Glycine and succinyl-coenzyme A; CSA: Congenital sideroblastic anemia; EPP:

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erythropoietic porphyria; FECH: ferrochelatase; Fe-S: iron-sulfur; GLRX5: glutaredoxin 5;

HSPA9: heat shock protein 9; IRE: iron-responsive element; IRP1: iron regulatory protein 1;

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ISCU: iron-sulfur cluster scaffold protein; MLASA: myopathy, lactic acidosis and

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sideroblastic anemia; MLS: microphthalmia with linear skin defects syndrome; mtDNA:

mitochondrial DNA; PLP: pyridoxal 5-phosphate; PMPS: pearson marrow-pancreas

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syndrome; Ppgen: protoporphyrinogen; rRNA: ribosomal RNAs; THTR-1: thiamine

transporter 1 protein; TRMA: thiamine-responsive megaloblastic anemia; tRNA: transfers

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RNAs; TRNT1: tRNA nucleotidyl transferase 1; XLSA: X-linked sideroblastic anemia;

XLSA/A: X-linked sideroblastic anemia with ataxia.

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Ackonwledgements
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Not applicable
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Funding
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This study was supported by grants from the Chinese Academy of Medical Sciences

innovation fund for medical sciences (2016-I2M-3-004).

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Author’s contributions

LZ drafted the manuscript, LH and DY collected the related references. LZ and HB reviewed

and revised the manuscript. All authors read and approved the final version of the manuscript.

Competing interests
The authors declare that they have no competing interests.

References

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Adrover, M., Howes, B. D., Iannuzzi, C., Smulevich, G.andPastore, A.,2015. Anatomy of an
iron-sulfur cluster scaffold protein: Understanding the determinants of [2Fe-2S]
cluster stability on IscU. Biochim Biophys Acta. 1853, 1448-1456.
Al-Tamemi, S. H.,2009. Pearson's Marrow-Pancreas Syndrome. Sultan Qaboos Univ Med J. 9,
196-197.
An, W., Zhang, J., Chang, L., Zhang, Y., Wan, Y., Ren, Y., Niu, D., Wu, J., Zhu, X.andGuo,
Y.,2015. Mutation analysis of Chinese sporadic congenital sideroblastic anemia by
targeted capture sequencing. J Hematol Oncol. 8, 55.
Atale, A., Bonneau-Amati, P., Rotig, A., Fischer, A., Perez-Martin, S., de Lonlay, P., Niaudet,
P., De Parscau, L., Mousson, C., Thauvin-Robinet, C., Munnich, A., Huet,

PT
F.andFaivre, L.,2009. Tubulopathy and pancytopaenia with normal pancreatic
function: a variant of Pearson syndrome. Eur J Med Genet. 52, 23-26.

RI
Aycan, Z., Bas, V. N., Cetinkaya, S., Agladioglu, S. Y., Kendirci, H. N.andSenocak, F.,2011.
Thiamine-responsive megaloblastic anemia syndrome with atrial standstill: a case

SC
report. J Pediatr Hematol Oncol. 33, 144-147.
Barton, C., Kausar, S., Kerr, D., Bitetti, S.andWynn, R.,2017. SIFD as a novel cause of severe
fetal hydrops and neonatal anaemia with iron loading and marked extramedullary
NU
haemopoiesis. J Clin Pathol.
Bekri, S., Kispal, G., Lange, H., Fitzsimons, E., Tolmie, J., Lill, R.andBishop, D. F.,2000.
Human ABC7 transporter: gene structure and mutation causing X-linked sideroblastic
MA

anemia with ataxia with disruption of cytosolic iron-sulfur protein maturation. Blood.
96, 3256-3264.
Bergmann, A. K., Campagna, D. R., McLoughlin, E. M., Agarwal, S., Fleming, M. D.,
Bottomley, S. S.andNeufeld, E. J.,2010. Systematic molecular genetic analysis of
D

congenital sideroblastic anemia: evidence for genetic heterogeneity and identification

of novel mutations. Pediatr Blood Cancer. 54, 273-278.
E

Bergmann, A. K., Sahai, I., Falcone, J. F., Fleming, J., Bagg, A., Borgna-Pignati, C., Casey,
PT

R., Fabris, L., Hexner, E., Mathews, L., Ribeiro, M. L., Wierenga, K. J.andNeufeld, E.
J.,2009. Thiamine-responsive megaloblastic anemia: identification of novel
compound heterozygotes and mutation update. J Pediatr. 155, 888-892 e881.
CE

Beshlawi, I., Al Zadjali, S., Bashir, W., Elshinawy, M., Alrawas, A.andWali, Y.,2014.
Thiamine responsive megaloblastic anemia: the puzzling phenotype. Pediatr Blood
Cancer. 61, 528-531.
AC

Bishop, D. F., Henderson, A. S.andAstrin, K. H.,1990. Human delta-aminolevulinate synthase:

assignment of the housekeeping gene to 3p21 and the erythroid-specific gene to the X
chromosome. Genomics. 7, 207-214.
Blanc, B., Clemancey, M., Latour, J. M., Fontecave, M.andOllagnier de Choudens, S.,2014.
Molecular investigation of iron-sulfur cluster assembly scaffolds under stress.
Biochemistry. 53, 7867-7869.
Bottomley, S. S.,2006. Congenital sideroblastic anemias. Curr Hematol Rep. 5, 41-49.
Bottomley, S. S.andFleming, M. D.,2014. Sideroblastic anemia: diagnosis and management.
Hematol Oncol Clin North Am. 28, 653-670, v.

13
 ACCEPTED MANUSCRIPT

Burrage, L. C., Tang, S., Wang, J., Donti, T. R., Walkiewicz, M., Luchak, J. M., Chen, L. C.,
Schmitt, E. S., Niu, Z., Erana, R., Hunter, J. V., Graham, B. H., Wong, L.
J.andScaglia, F.,2014. Mitochondrial myopathy, lactic acidosis, and sideroblastic
anemia (MLASA) plus associated with a novel de novo mutation (m.8969G>A) in the
mitochondrial encoded ATP6 gene. Mol Genet Metab. 113, 207-212.
Bykhovskaya, Y., Casas, K., Mengesha, E., Inbal, A.andFischel-Ghodsian, N.,2004. Missense
mutation in pseudouridine synthase 1 (PUS1) causes mitochondrial myopathy and
sideroblastic anemia (MLASA). Am J Hum Genet. 74, 1303-1308.
Camaschella, C.,2009. Hereditary sideroblastic anemias: pathophysiology, diagnosis, and
treatment. Semin Hematol. 46, 371-377.

PT
Camaschella, C., Campanella, A., De Falco, L., Boschetto, L., Merlini, R., Silvestri, L., Levi,
S.andIolascon, A.,2007. The human counterpart of zebrafish shiraz shows

RI
sideroblastic-like microcytic anemia and iron overload. Blood. 110, 1353-1358.
Campagna, D. R., de Bie, C. I., Schmitz-Abe, K., Sweeney, M., Sendamarai, A. K., Schmidt,

SC
P. J., Heeney, M. M., Yntema, H. G., Kannengiesser, C., Grandchamp, B., Niemeyer,
C. M., Knoers, N. V., Swart, S., Marron, G., van Wijk, R., Raymakers, R. A., May,
A., Markianos, K., Bottomley, S. S., Swinkels, D. W.andFleming, M. D.,2014.
NU
X-linked sideroblastic anemia due to ALAS2 intron 1 enhancer element
GATA-binding site mutations. Am J Hematol. 89, 315-319.
Cao, M., Dona, M., Valentino, M. L., Semplicini, C., Maresca, A., Cassina, M., Torraco, A.,
MA

Galletta, E., Manfioli, V., Soraru, G., Carelli, V., Stramare, R., Bertini, E., Carozzo,
R., Salviati, L.andPegoraro, E.,2016. Clinical and molecular study in a long-surviving
patient with MLASA syndrome due to novel PUS1 mutations. Neurogenetics. 17,
65-70.
D

Cazzola, M.andMalcovati, L.,2015. Diagnosis and treatment of sideroblastic anemias: from

defective heme synthesis to abnormal RNA splicing. Hematology Am Soc Hematol
E

Educ Program. 2015, 19-25.

PT

Chakraborty, P. K., Schmitz-Abe, K., Kennedy, E. K., Mamady, H., Naas, T., Durie, D.,
Campagna, D. R., Lau, A., Sendamarai, A. K., Wiseman, D. H., May, A., Jolles, S.,
Connor, P., Powell, C., Heeney, M. M., Giardina, P. J., Klaassen, R. J.,
CE

Kannengiesser, C., Thuret, I., Thompson, A. A., Marques, L., Hughes, S., Bonney, D.
K., Bottomley, S. S., Wynn, R. F., Laxer, R. M., Minniti, C. P., Moppett, J., Bordon,
V., Geraghty, M., Joyce, P. B., Markianos, K., Rudner, A. D., Holcik, M.andFleming,
AC

M. D.,2014. Mutations in TRNT1 cause congenital sideroblastic anemia with

immunodeficiency, fevers, and developmental delay (SIFD). Blood. 124, 2867-2871.
Chen, T. H., Kambal, A., Krysiak, K., Walshauser, M. A., Raju, G., Tibbitts, J. F.andWalter,
M. J.,2011. Knockdown of Hspa9, a del(5q31.2) gene, results in a decrease in
hematopoietic progenitors in mice. Blood. 117, 1530-1539.
Cotter, P. D., Rucknagel, D. L.andBishop, D. F.,1994. X-linked sideroblastic anemia:
identification of the mutation in the erythroid-specific delta-aminolevulinate synthase
gene (ALAS2) in the original family described by Cooley. Blood. 84, 3915-3924.

14
 ACCEPTED MANUSCRIPT

Craven, S. E., French, D., Ye, W., de Sauvage, F.andRosenthal, A.,2005. Loss of Hspa9b in
zebrafish recapitulates the ineffective hematopoiesis of the myelodysplastic syndrome.
Blood. 105, 3528-3534.
D'Hooghe, M., Selleslag, D., Mortier, G., Van Coster, R., Vermeersch, P., Billiet, J.andBekri,
S.,2012. X-linked sideroblastic anemia and ataxia: a new family with identification of
a fourth ABCB7 gene mutation. Eur J Paediatr Neurol. 16, 730-735.
Falcon, C. P.andHoward, T. H.,2017. An infant with Pearson syndrome: a rare cause of
congenital sideroblastic anemia and bone marrow failure. Blood. 129, 2710.
Faraci, M., Cuzzubbo, D., Micalizzi, C., Lanino, E., Morreale, G., Dallorso, S., Castagnola, E.,
Schiaffino, M. C., Bruno, C., Rossi, A., Dini, G.andCappelli, B.,2007. Allogeneic

PT
bone marrow transplantation for Pearson's syndrome. Bone Marrow Transplant. 39,
563-565.

RI
Farruggia, P., Di Cataldo, A., Pinto, R. M., Palmisani, E., Macaluso, A., Valvo, L. L.,
Cantarini, M. E., Tornesello, A., Corti, P., Fioredda, F., Varotto, S., Martire, B.,

SC
Moroni, I., Puccio, G., Russo, G., Dufour, C.andPillon, M.,2016. Pearson Syndrome:
A Retrospective Cohort Study from the Marrow Failure Study Group of A.I.E.O.P.
(Associazione Italiana Emato-Oncologia Pediatrica). JIMD Rep. 26, 37-43.
NU
Fernandez-Murray, J. P., Prykhozhij, S. V., Dufay, J. N., Steele, S. L., Gaston, D., Nasrallah,
G. K., Coombs, A. J., Liwski, R. S., Fernandez, C. V., Berman, J. N.andMcMaster, C.
R.,2016. Glycine and Folate Ameliorate Models of Congenital Sideroblastic Anemia.
MA

PLoS Genet. 12, e1005783.

Fernandez-Vizarra, E., Berardinelli, A., Valente, L., Tiranti, V.andZeviani, M.,2007.
Nonsense mutation in pseudouridylate synthase 1 (PUS1) in two brothers affected by
myopathy, lactic acidosis and sideroblastic anaemia (MLASA). J Med Genet. 44,
D

173-180.
Finsterer, J.andScorza, F. A.,2017. Renal manifestations of primary mitochondrial disorders.
E

Biomed Rep. 6, 487-494.

PT

Fleming, M. D.,2011. Congenital sideroblastic anemias: iron and heme lost in mitochondrial
translation. Hematology Am Soc Hematol Educ Program. 2011, 525-531.
Fontenay, M., Cathelin, S., Amiot, M., Gyan, E.andSolary, E.,2006. Mitochondria in
CE

hematopoiesis and hematological diseases. Oncogene. 25, 4757-4767.

Fujiwara, T., Fukuhara, N., Ichikawa, S., Kobayashi, M., Okitsu, Y., Onishi, Y., Furuyama,
K.andHarigae, H.,2017. A novel heterozygous ALAS2 mutation in a female with
AC

macrocytic sideroblastic anemia resembling myelodysplastic syndrome with ring

sideroblasts: a case report and literature review. Ann Hematol. 96, 1955-1957.
Fujiwara, T.andHarigae, H.,2013. Pathophysiology and genetic mutations in congenital
sideroblastic anemia. Pediatr Int. 55, 675-679.
Fujiwara, T.andHarigae, H.,2015. Biology of Heme in Mammalian Erythroid Cells and
Related Disorders. Biomed Res Int. 2015, 278536.
Furuyama, K., Harigae, H., Kinoshita, C., Shimada, T., Miyaoka, K., Kanda, C., Maruyama,
Y., Shibahara, S.andSassa, S.,2003. Late-onset X-linked sideroblastic anemia
following hemodialysis. Blood. 101, 4623-4624.

15
 ACCEPTED MANUSCRIPT

Furuyama, K.andSassa, S.,2002. Multiple mechanisms for hereditary sideroblastic anemia.

Cell Mol Biol (Noisy-le-grand). 48, 5-10.
Gattermann, N., Retzlaff, S., Wang, Y. L., Hofhaus, G., Heinisch, J., Aul, C.andSchneider,
W.,1997. Heteroplasmic point mutations of mitochondrial DNA affecting subunit I of
cytochrome c oxidase in two patients with acquired idiopathic sideroblastic anemia.
Blood. 90, 4961-4972.
Ghaemi, N., Ghahraman, M., Abbaszadegan, M. R., Baradaran-Heravi, A.andVakili, R.,2013.
Novel mutation in the SLC19A2 gene in an Iranian family with thiamine-responsive
megaloblastic anemia: a series of three cases. J Clin Res Pediatr Endocrinol. 5,
199-201.

PT
Gibson, K. M., Bennett, M. J., Mize, C. E., Jakobs, C., Rotig, A., Munnich, A.,
Lichter-Konecki, U.andTrefz, F. K.,1992. 3-Methylglutaconic aciduria associated

RI
with Pearson syndrome and respiratory chain defects. J Pediatr. 121, 940-942.
Grasso, J. A., Myers, T. J., Hines, J. D.andSullivan, A. L.,1980. Energy-dispersive X-ray

SC
analysis of the mitochondria of sideroblastic anaemia. Br J Haematol. 46, 57-72.
Guernsey, D. L., Jiang, H., Campagna, D. R., Evans, S. C., Ferguson, M., Kellogg, M. D.,
Lachance, M., Matsuoka, M., Nightingale, M., Rideout, A., Saint-Amant, L., Schmidt,
NU
P. J., Orr, A., Bottomley, S. S., Fleming, M. D., Ludman, M., Dyack, S., Fernandez,
C. V.andSamuels, M. E.,2009. Mutations in mitochondrial carrier family gene
SLC25A38 cause nonsyndromic autosomal recessive congenital sideroblastic anemia.
MA

Nat Genet. 41, 651-653.

Harigae, H.andFuruyama, K.,2010. Hereditary sideroblastic anemia: pathophysiology and
gene mutations. Int J Hematol. 92, 425-431.
Hoyoux, C., Dresse, M. F., Robinet, S., Forget, P., Pieltain, C., Ketelslegers, O.andBeguin,
D

Y.,2008. Cord blood transplantation in a child with Pearson's disease. Pediatr Blood
Cancer. 51, 566.
E

Kaneko, K., Furuyama, K., Fujiwara, T., Kobayashi, R., Ishida, H., Harigae, H.andShibahara,
PT

S.,2014. Identification of a novel erythroid-specific enhancer for the ALAS2 gene and
its loss-of-function mutation which is associated with congenital sideroblastic anemia.
Haematologica. 99, 252-261.
CE

Kannengiesser, C., Sanchez, M., Sweeney, M., Hetet, G., Kerr, B., Moran, E., Fuster Soler, J.
L., Maloum, K., Matthes, T., Oudot, C., Lascaux, A., Pondarre, C., Sevilla Navarro, J.,
Vidyatilake, S., Beaumont, C., Grandchamp, B.andMay, A.,2011. Missense
AC

SLC25A38 variations play an important role in autosomal recessive inherited

sideroblastic anemia. Haematologica. 96, 808-813.
Katsurada, T., Kawabata, H., Kawabata, D., Kawahara, M., Nakabo, Y., Takaori-Kondo,
A.andYoshida, Y.,2016. A Japanese family with X-linked sideroblastic anemia
affecting females and manifesting as macrocytic anemia. Int J Hematol.
Kleinle, S., Wiesmann, U., Superti-Furga, A., Krahenbuhl, S., Boltshauser, E., Reichen,
J.andLiechti-Gallati, S.,1997. Detection and characterization of mitochondrial DNA
rearrangements in Pearson and Kearns-Sayre syndromes by long PCR. Hum Genet.
100, 643-650.

16
 ACCEPTED MANUSCRIPT

Labay, V., Raz, T., Baron, D., Mandel, H., Williams, H., Barrett, T., Szargel, R., McDonald,
L., Shalata, A., Nosaka, K., Gregory, S.andCohen, N.,1999. Mutations in SLC19A2
cause thiamine-responsive megaloblastic anaemia associated with diabetes mellitus
and deafness. Nat Genet. 22, 300-304.
LeBlanc, M. A., Bettle, A., Berman, J. N., Price, V. E., Pambrun, C., Yu, Z., Tiller, M.,
McMaster, C. R.andFernandez, C. V.,2016. Study of Glycine and Folic Acid
Supplementation to Ameliorate Transfusion Dependence in Congenital SLC25A38
Mutated Sideroblastic Anemia. Pediatr Blood Cancer. 63, 1307-1309.
Lichtenstein, D. A., Crispin, A. W., Sendamarai, A. K., Campagna, D. R., Schmitz-Abe, K.,
Sousa, C. M., Kafina, M. D., Schmidt, P. J., Niemeyer, C. M., Porter, J., May, A.,

PT
Patnaik, M. M., Heeney, M. M., Kimmelman, A., Bottomley, S. S., Paw, B. H.,
Markianos, K.andFleming, M. D.,2016. A recurring mutation in the respiratory

RI
complex 1 protein NDUFB11 is responsible for a novel form of X-linked
sideroblastic anemia. Blood. 128, 1913-1917.

SC
Liu, G., Guo, S., Anderson, G. J., Camaschella, C., Han, B.andNie, G.,2014. Heterozygous
missense mutations in the GLRX5 gene cause sideroblastic anemia in a Chinese
patient. Blood. 124, 2750-2751.
NU
Liu, G., Guo, S., Kang, H., Zhang, F., Hu, Y., Wang, L., Li, M., Ru, Y., Camaschella, C., Han,
B.andNie, G.,2013. Mutation spectrum in Chinese patients affected by congenital
sideroblastic anemia and a search for a genotype-phenotype relationship.
MA

Haematologica. 98, e158-160.

Liu, G., Yang, F., Han, B., Liu, J.andNie, G.,2014. Identification of four SLC19A2 mutations
in four Chinese thiamine responsive megaloblastic anemia patients without diabetes.
Blood Cells Mol Dis. 52, 203-204.
D

Liu, T., Krysiak, K., Shirai, C. L., Kim, S., Shao, J., Ndonwi, M.andWalter, M. J.,2017.
Knockdown of HSPA9 induces TP53-dependent apoptosis in human hematopoietic
E

progenitor cells. PLoS One. 12, e0170470.

PT

Lunetti, P., Damiano, F., De Benedetto, G., Siculella, L., Pennetta, A., Muto, L., Paradies, E.,
Marobbio, C. M., Dolce, V.andCapobianco, L.,2016. Characterization of Human and
Yeast Mitochondrial Glycine Carriers with Implications for Heme Biosynthesis and
CE

Anemia. J Biol Chem. 291, 19746-19759.

May, A.andBishop, D. F.,1998. The molecular biology and pyridoxine responsiveness of
X-linked sideroblastic anaemia. Haematologica. 83, 56-70.
AC

Mee, L., Nabokina, S. M., Sekar, V. T., Subramanian, V. S., Maedler, K.andSaid, H. M.,2009.
Pancreatic beta cells and islets take up thiamin by a regulated carrier-mediated
process: studies using mice and human pancreatic preparations. Am J Physiol
Gastrointest Liver Physiol. 297, G197-206.
Mozzillo, E., Melis, D., Falco, M., Fattorusso, V., Taurisano, R., Flanagan, S. E., Ellard,
S.andFranzese, A.,2013. Thiamine responsive megaloblastic anemia: a novel
SLC19A2 compound heterozygous mutation in two siblings. Pediatr Diabetes. 14,
384-387.
Napier, I., Ponka, P.andRichardson, D. R.,2005. Iron trafficking in the mitochondrion: novel
pathways revealed by disease. Blood. 105, 1867-1874.

17
 ACCEPTED MANUSCRIPT

Newman, W. G., Friedman, T. B.andConway, G. S. (1993). Perrault Syndrome. In M. P. Adam,

H. H. Ardinger, R. A. Pagon, S. E. Wallace, L. J. H. Bean, H. C. Mefford, K. Stephens, A.
Amemiya & N. Ledbetter (Eds.), GeneReviews(R). Seattle (WA).
Nikpour, M., Scharenberg, C., Liu, A., Conte, S., Karimi, M., Mortera-Blanco, T., Giai, V.,
Fernandez-Mercado, M., Papaemmanuil, E., Hogstrand, K., Jansson, M., Vedin, I.,
Wainscoat, J. S., Campbell, P., Cazzola, M., Boultwood, J., Grandien,
A.andHellstrom-Lindberg, E.,2013. The transporter ABCB7 is a mediator of the
phenotype of acquired refractory anemia with ring sideroblasts. Leukemia. 27,
889-896.
Ortigoza-Escobar, J. D., Molero-Luis, M., Arias, A., Marti-Sanchez, L., Rodriguez-Pombo, P.,

PT
Artuch, R.andPerez-Duenas, B.,2016. Treatment of genetic defects of thiamine
transport and metabolism. Expert Rev Neurother. 16, 755-763.

RI
Patton, J. R., Bykhovskaya, Y., Mengesha, E., Bertolotto, C.andFischel-Ghodsian, N.,2005.
Mitochondrial myopathy and sideroblastic anemia (MLASA): missense mutation in

SC
the pseudouridine synthase 1 (PUS1) gene is associated with the loss of tRNA
pseudouridylation. J Biol Chem. 280, 19823-19828.
Pearson, H. A., Lobel, J. S., Kocoshis, S. A., Naiman, J. L., Windmiller, J., Lammi, A. T.,
NU
Hoffman, R.andMarsh, J. C.,1979. A new syndrome of refractory sideroblastic
anemia with vacuolization of marrow precursors and exocrine pancreatic dysfunction.
J Pediatr. 95, 976-984.
MA

Pondarre, C., Campagna, D. R., Antiochos, B., Sikorski, L., Mulhern, H.andFleming, M.
D.,2007. Abcb7, the gene responsible for X-linked sideroblastic anemia with ataxia,
is essential for hematopoiesis. Blood. 109, 3567-3569.
Protasova, M. S., Grigorenko, A. P., Tyazhelova, T. V., Andreeva, T. V., Reshetov, D. A.,
D

Gusev, F. E., Laptenko, A. E., Kuznetsova, I. L., Goltsov, A. Y., Klyushnikov, S. A.,
Illarioshkin, S. N.andRogaev, E. I.,2016. Whole-genome sequencing identifies a
E

novel ABCB7 gene mutation for X-linked congenital cerebellar ataxia in a large
PT

family of Mongolian ancestry. Eur J Hum Genet. 24, 550-555.

Rademakers, L. H., Koningsberger, J. C., Sorber, C. W., Baart de la Faille, H., Van Hattum,
J.andMarx, J. J.,1993. Accumulation of iron in erythroblasts of patients with
CE

erythropoietic protoporphyria. Eur J Clin Invest. 23, 130-138.

Reidling, J. C.andSaid, H. M.,2003. In vitro and in vivo characterization of the minimal
promoter region of the human thiamin transporter SLC19A2. Am J Physiol Cell
AC

Physiol. 285, C633-641.

Reidling, J. C., Subramanian, V. S., Dudeja, P. K.andSaid, H. M.,2002. Expression and
promoter analysis of SLC19A2 in the human intestine. Biochim Biophys Acta. 1561,
180-187.
Ricketts, C. J., Minton, J. A., Samuel, J., Ariyawansa, I., Wales, J. K., Lo, I. F.andBarrett, T.
G.,2006. Thiamine-responsive megaloblastic anaemia syndrome: long-term follow-up
and mutation analysis of seven families. Acta Paediatr. 95, 99-104.
Riley, L. G., Menezes, M. J., Rudinger-Thirion, J., Duff, R., de Lonlay, P., Rotig, A., Tchan,
M. C., Davis, M., Cooper, S. T.andChristodoulou, J.,2013. Phenotypic variability and

18
 ACCEPTED MANUSCRIPT

identification of novel YARS2 mutations in YARS2 mitochondrial myopathy, lactic

acidosis and sideroblastic anaemia. Orphanet J Rare Dis. 8, 193.
Riley, L. G., Rudinger-Thirion, J., Schmitz-Abe, K., Thorburn, D. R., Davis, R. L., Teo, J.,
Arbuckle, S., Cooper, S. T., Campagna, D. R., Frugier, M., Markianos, K., Sue, C. M.,
Fleming, M. D.andChristodoulou, J.,2016. LARS2 Variants Associated with Hydrops,
Lactic Acidosis, Sideroblastic Anemia, and Multisystem Failure. JIMD Rep. 28,
49-57.
Rodriguez-Manzaneque, M. T., Tamarit, J., Belli, G., Ros, J.andHerrero, E.,2002. Grx5 is a
mitochondrial glutaredoxin required for the activity of iron/sulfur enzymes. Mol Biol
Cell. 13, 1109-1121.

PT
Rouault, T. A.andMaio, N.,2017. Biogenesis and functions of mammalian iron-sulfur proteins
in the regulation of iron homeostasis and pivotal metabolic pathways. J Biol Chem.

RI
292, 12744-12753.
Roumenina, L. T., Rayes, J., Lacroix-Desmazes, S.andDimitrov, J. D.,2016. Heme:

SC
Modulator of Plasma Systems in Hemolytic Diseases. Trends Mol Med. 22, 200-213.
Sankaran, V. G., Ulirsch, J. C., Tchaikovskii, V., Ludwig, L. S., Wakabayashi, A., Kadirvel,
S., Lindsley, R. C., Bejar, R., Shi, J., Lovitch, S. B., Bishop, D. F.andSteensma, D.
NU
P.,2015. X-linked macrocytic dyserythropoietic anemia in females with an ALAS2
mutation. J Clin Invest. 125, 1665-1669.
Sasarman, F., Thiffault, I., Weraarpachai, W., Salomon, S., Maftei, C., Gauthier, J., Ellazam,
MA

B., Webb, N., Antonicka, H., Janer, A., Brunel-Guitton, C., Elpeleg, O., Mitchell,
G.andShoubridge, E. A.,2015. The 3' addition of CCA to mitochondrial
tRNASer(AGY) is specifically impaired in patients with mutations in the tRNA
nucleotidyl transferase TRNT1. Hum Mol Genet. 24, 2841-2847.
D

Schapira, A. H.,2002. Primary and secondary defects of the mitochondrial respiratory chain. J
Inherit Metab Dis. 25, 207-214.
E

Schmitz-Abe, K., Ciesielski, S. J., Schmidt, P. J., Campagna, D. R., Rahimov, F., Schilke, B.
PT

A., Cuijpers, M., Rieneck, K., Lausen, B., Linenberger, M. L., Sendamarai, A. K.,
Guo, C., Hofmann, I., Newburger, P. E., Matthews, D., Shimamura, A., Snijders, P. J.,
Towne, M. C., Niemeyer, C. M., Watson, H. G., Dziegiel, M. H., Heeney, M. M.,
CE

May, A., Bottomley, S. S., Swinkels, D. W., Markianos, K., Craig, E. A.andFleming,
M. D.,2015. Congenital sideroblastic anemia due to mutations in the mitochondrial
HSP70 homologue HSPA9. Blood. 126, 2734-2738.
AC

Scott, A. J., Ansford, A. J., Webster, B. H.andStringer, H. C.,1973. Erythropoietic

protoporphyria with features of a sideroblastic anaemia terminating in liver failure.
Am J Med. 54, 251-259.
Setoodeh, A., Haghighi, A., Saleh-Gohari, N., Ellard, S.andHaghighi, A.,2013. Identification
of a SLC19A2 nonsense mutation in Persian families with thiamine-responsive
megaloblastic anemia. Gene. 519, 295-297.
Shan, Y.andCortopassi, G.,2016. Mitochondrial Hspa9/Mortalin regulates erythroid
differentiation via iron-sulfur cluster assembly. Mitochondrion. 26, 94-103.

19
 ACCEPTED MANUSCRIPT

Shapira, A., Konopnicki, M., Hammad-Saied, M.andShabad, E.,2014. Pearson disease in an

infant presenting with severe hypoplastic anemia, normal pancreatic function, and
progressive liver failure. J Pediatr Hematol Oncol. 36, 402-403.
Shehata, B. M., Cundiff, C. A., Lee, K., Sabharwal, A., Lalwani, M. K., Davis, A. K.,
Agrawal, V., Sivasubbu, S., Iannucci, G. J.andGibson, G.,2015. Exome sequencing of
patients with histiocytoid cardiomyopathy reveals a de novo NDUFB11 mutation that
plays a role in the pathogenesis of histiocytoid cardiomyopathy. Am J Med Genet A.
167A, 2114-2121.
Sommerville, E. W., Ng, Y. S., Alston, C. L., Dallabona, C., Gilberti, M., He, L., Knowles, C.,
Chin, S. L., Schaefer, A. M., Falkous, G., Murdoch, D., Longman, C., de Visser, M.,

PT
Bindoff, L. A., Rawles, J. M., Dean, J. C. S., Petty, R. K., Farrugia, M. E., Haack, T.
B., Prokisch, H., McFarland, R., Turnbull, D. M., Donnini, C., Taylor, R.

RI
W.andGorman, G. S.,2017. Clinical Features, Molecular Heterogeneity, and
Prognostic Implications in YARS2-Related Mitochondrial Myopathy. JAMA Neurol.

SC
74, 686-694.
Superti-Furga, A., Schoenle, E., Tuchschmid, P., Caduff, R., Sabato, V., DeMattia, D.,
Gitzelmann, R.andSteinmann, B.,1993. Pearson bone marrow-pancreas syndrome
NU
with insulin-dependent diabetes, progressive renal tubulopathy, organic aciduria and
elevated fetal haemoglobin caused by deletion and duplication of mitochondrial DNA.
Eur J Pediatr. 152, 44-50.
MA

Taketani, S., Kakimoto, K., Ueta, H., Masaki, R.andFurukawa, T.,2003. Involvement of
ABC7 in the biosynthesis of heme in erythroid cells: interaction of ABC7 with
ferrochelatase. Blood. 101, 3274-3280.
Torraco, A., Bianchi, M., Verrigni, D., Gelmetti, V., Riley, L., Niceta, M., Martinelli, D.,
D

Montanari, A., Guo, Y., Rizza, T., Diodato, D., Di Nottia, M., Lucarelli, B.,
Sorrentino, F., Piemonte, F., Francisci, S., Tartaglia, M., Valente, E. M., Dionisi-Vici,
E

C., Christodoulou, J., Bertini, E.andCarrozzo, R.,2017. A novel mutation in

PT

NDUFB11 unveils a new clinical phenotype associated with lactic acidosis and
sideroblastic anemia. Clin Genet. 91, 441-447.
Tumino, M., Meli, C., Farruggia, P., La Spina, M., Faraci, M., Castana, C., Di Raimondo, V.,
CE

Alfano, M., Pittala, A., Lo Nigro, L., Russo, G.andDi Cataldo, A.,2011. Clinical
manifestations and management of four children with Pearson syndrome. Am J Med
Genet A. 155A, 3063-3066.
AC

van Rahden, V. A., Fernandez-Vizarra, E., Alawi, M., Brand, K., Fellmann, F., Horn, D.,
Zeviani, M.andKutsche, K.,2015. Mutations in NDUFB11, encoding a complex I
component of the mitochondrial respiratory chain, cause microphthalmia with linear
skin defects syndrome. Am J Hum Genet. 96, 640-650.
Wedatilake, Y., Niazi, R., Fassone, E., Powell, C. A., Pearce, S., Plagnol, V., Saldanha, J. W.,
Kleta, R., Chong, W. K., Footitt, E., Mills, P. B., Taanman, J. W., Minczuk, M.,
Clayton, P. T.andRahman, S.,2016. TRNT1 deficiency: clinical, biochemical and
molecular genetic features. Orphanet J Rare Dis. 11, 90.
Wingert, R. A., Galloway, J. L., Barut, B., Foott, H., Fraenkel, P., Axe, J. L., Weber, G. J.,
Dooley, K., Davidson, A. J., Schmid, B., Paw, B. H., Shaw, G. C., Kingsley, P., Palis,

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J., Schubert, H., Chen, O., Kaplan, J., Zon, L. I.andTubingen Screen, C.,2005.
Deficiency of glutaredoxin 5 reveals Fe-S clusters are required for vertebrate haem
synthesis. Nature. 436, 1035-1039.
Wiseman, D. H., May, A., Jolles, S., Connor, P., Powell, C., Heeney, M. M., Giardina, P. J.,
Klaassen, R. J., Chakraborty, P., Geraghty, M. T., Major-Cook, N., Kannengiesser, C.,
Thuret, I., Thompson, A. A., Marques, L., Hughes, S., Bonney, D. K., Bottomley, S.
S., Fleming, M. D.andWynn, R. F.,2013. A novel syndrome of congenital
sideroblastic anemia, B-cell immunodeficiency, periodic fevers, and developmental
delay (SIFD). Blood. 122, 112-123.
Ye, H., Jeong, S. Y., Ghosh, M. C., Kovtunovych, G., Silvestri, L., Ortillo, D., Uchida, N.,

PT
Tisdale, J., Camaschella, C.andRouault, T. A.,2010. Glutaredoxin 5 deficiency causes
sideroblastic anemia by specifically impairing heme biosynthesis and depleting

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cytosolic iron in human erythroblasts. J Clin Invest. 120, 1749-1761.

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Figure 1. Schematic of the mutation genes and pathogenesis involve in congenital
sideroblastic anemia.
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CoA: succinyl-coenzyme A. ALA: delta-aminolevulinate synthase. PPgen: protoporphyrinogen. PPIX:
protoporphyrin IX. IRP: iron regulatory protein 1. Fe-S: iron-sulfur.
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Italic font with underling indicate causative genes involved in CSA. ALAS2: delta-aminolevulinate synthase 2.
SLC25A38: solute carrier family 25 member 38. SLC19A2: solute carrier family 19 member 2. HSPA9: heat
shock protein 9. ABCB7: ATP-binding cassette subfamily B member 7. GLRX5: glutaredoxin 5. PUS1:
tRNA pseudouridine synthase 1. YARS2: tyrosyl-tRNA synthetase 2. TRNT1: tRNA nucleotidyl transferase 1.
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LARS2: leucyl-tRNA synthetase. NDUFB11: NADH dehydrogenase (ubiquinone) 1 beta subcomplex subunit 1.
E
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Figure 2. Process schematic of congenital sideroblastic anemia diagnosis and

management.
Allo-SCT: allogeneic stem cell transplantation. WES: whole-exome sequencing. WGS: whole genome sequencing.
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Table 1. Genes and clinical characters in congenital sideroblastic anemia.

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XLSA: X-linked sideroblastic anemia. SA: sideroblastic anemia. TRMA: thiamine-responsive megaloblastic
anemia. EPP: erythropoietic protoporphyria. XLSA/A: X-linked sideroblastic anemia with ataxia. PMPS:
pearson marrow pancreas syndrome. MLASA: myopathy, lactic acidosis and sideroblastic anemia.
SIFD: sideroblastic anemia with immunodeficiency, fevers and developmental delay syndrome.

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Table 1. Genes and clinical characters in congenital sideroblastic anemia.

Pathway Gene Chromosome Inheritance Disorder Manifestation Treatment

Heme ALAS2 Xp11.21 X-linked XLSA hypochromic microcytic pyridoxine

biosynthesis anemia, iron overload

SLC25A38 3p22.1 autosomal SA hypochromic microcytic allo-SCT, glycine?

recessive anemia

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SLC19A2 1q23.3 autosomal TRMA megaloblastic anemia, high dose thiamine

recessive diabetes, sensory

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deafness

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Fe-S cluster GLRX5 14q32.13 autosomal SA hypochromic microcytic blood transfusion

biosynthesis recessive anemia,

& transport hepatosplenomegaly,

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iron overload

ABCB7 Xp13.3 X-linked XLSA/A hypochromic microcytic blood transfusion

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anemia, ataxia

HSPA9 5q31.2 autosomal SA sideroblastic anemia no enough available

recessive data
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Mitochondrial mtDNA Mitochondria maternal or PMPS macrocytic anemia, blood transfusion,

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respiratory (deletion) sporadic growth retardation pancreatic enzyme

chain replacement,
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biosynthesis bicarbonate

supplementation
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mtDNA Mitochondria maternal or MLSA myopathy, lactic blood transfusion &

(point sporadic acidosis, sideroblastic symptomatic

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mutation) anemia treatment

NDUFB11 Xp11.23 X-linked XLSA sideroblastic anemia, no enough available

myopathy, lactic data

acidosis, short,

neurodevelopmental,

organ dysgenesis

PUS1 12p24.33 autosomal MLSA myopathy, lactic blood transfusion &

recessive acidosis, sideroblastic symptomatic

anemia treatment

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YARS2 12p11.21 autosomal MLSA myopathy, lactic blood transfusion &

recessive acidosis, sideroblastic symptomatic

anemia treatment

LARS2 3p21.3 autosomal SA lactic acidosis, hydrops, symptomatic

recessive sideroblastic anemia treatment

TRNT1 3p26.1 autosomal SIFD sideroblastic anemia, blood transfusion,

recessive immunodeficiency, IVIG, iron chelation,

fevers developmental
allo-SCT

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delay

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XLSA: X-linked sideroblastic anemia. SA: sideroblastic anemia. TRMA: thiamine-responsive megaloblastic

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anemia. EPP: erythropoietic protoporphyria. XLSA/A: X-linked sideroblastic anemia with ataxia. PMPS:
pearson marrow pancreas syndrome. MLASA: myopathy, lactic acidosis and sideroblastic anemia.
SIFD: sideroblastic anemia with immunodeficiency, fevers and developmental delay syndrome.
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Figure 1
Figure 2