Progressive Osseous Heteroplasia
NORD is very grateful to Frederick S. Kaplan, MD, Isaac & Rose Nassau Professor of Orthopaedic Molecular Medicine; Chief, Division of Orthopaedic Molecular Medicine and Director, Center for Research in FOP & Related Disorders, The Perelman School of Medicine at The University of Pennsylvania and Eileen M. Shore, PhD, Cali/Weldon Professor of FOP Research, Departments of Orthopaedic Surgery and Genetics, and Co-Director, Center for Research in FOP & Related Disorders, The Perelman School of Medicine at The University of Pennsylvania, for assistance in the preparation of this report.
Synonyms of Progressive Osseous Heteroplasia
- No subdivisions found.
Progressive osseous heteroplasia (POH) is an extremely rare disorder characterized by abnormal development of bone in areas of the body where bone is not normally present (heterotopic ossification). The disorder first appears as areas of patchy bone formation (ossification) in the skin during infancy; heterotopic ossification progresses to involve superficial and deep connective tissues, areas of fat beneath the skin (subcutaneous fat), muscles, tendons, ligaments, and the sheets of fibrous tissue that envelop muscle (fascia). This abnormal formation of bone may restrict the movement of affected joints and/or hinder the growth of affected limbs. The course of the disease is unpredictable; some areas of the body may become severely affected while others may remain unaffected.
The symptoms of POH are usually present at birth (congenital) or within the first few weeks of life, and they tend to progress slowly and asymmetrically as an affected individual grows older. Infants with POH typically have a maculopapular rash (with the appearance of patchy areas of bone within the dermis). Initially, affected skin may feel abnormally rough.
The major finding in infants with POH is the development of bone in areas of the body where bone is not normally present (heterotopic ossification). Initially, bone growth may develop within the skin (osseous nodules or plaques called osteoma cutis). These areas may become progressively widespread and may grow together (coalesce) to form even larger areas of hardened and thickened skin (dermal ossification). As the disease progresses, these bony growths may extend into the deeper layers of the skin (subcutaneous layers). Eventually, abnormal bony growths occur in various connective tissues of the body such as fascia and skeletal muscle.
As the abnormal development of bone progresses, it may restrict movement in certain joints and eventually lock the joints (ankylosis), such as the knees and ankles. POH may also restrict movement in the hips, wrists, jaw, shoulders, and/or other areas of the body. Affected arms and legs may become malformed and not grow to full length. This can occur on one side of the body and lead to unequal growth; one leg or one arm may become shorter than the other, for example. Some areas of the body may be severely affected, while other areas may remain unaffected. In some patients, lesion formation occurs predominantly or exclusively on one side (either left or right) of the body (hemimelic progressive osseous heteroplasia).
Children with POH may also have sharp, needle-like projections of bone (spicules) that break through the surface of the skin, causing irritation or superficial infection. In addition, when bone growth occurs around the spine, some affected individuals may develop an abnormal sideways curvature of the spine (scoliosis).
The progression of POH is highly variable even among members of the same family. In some individuals, it may progress extremely slowly; in others it may progress more rapidly. Most individuals experience a gradual progression of the condition.
Bone formation in POH tends to be more intramembranous than endochondral in nature, and no inflammatory component has been identified. Histologically, bone can be seen to arise directly from adipose stromal tissue although the exact cell(s) of origin remain unknown.
Most cases of POH occur randomly as the result of a spontaneous (sporadic) genetic change (i.e., new mutation) of a specific gene. This mutation can be inherited as an autosomal dominant trait indicating that only one of the two copies of a gene in a cell needs to be mutated in order to cause the disease.
Investigators have determined that some cases of POH may be caused by disruption or changes (mutations) of the GNAS gene located on the long arm (q) of chromosome 20. Chromosomes are found in the nucleus of all body cells. They carry the genetic characteristics of each individual. Pairs of human chromosomes are numbered from 1 through 22, with an unequal 23rd pair of X and Y chromosomes for males and two X chromosomes for females. Each chromosome has a short arm designated as "p" and a long arm identified by the letter "q." About three-fourths of examined POH patients have inactivating GNAS gene mutations.
The GNAS (Guanine Nucleotide-Binding Protein, Alpha-Stimulating Polypeptide) gene contains instructions for creating (encoding) a protein that researchers believe may be involved in regulating the activity of proteins (created by other genes) that promote bone growth and direct cell fate decisions. Mutation of the gene results in deficiency or dysfunction of this protein. The exact manner in which mutations of the GNAS gene bring about the symptoms of POH is not yet known, however recent evidence implicates activation of the “hedgehog” signaling pathway in this process.
A specific process associated with POH is known as genetic imprinting. Everyone has two copies of every gene (except those genes on X and Y chromosomes) - one received from the father and one received from the mother. In most cases, both genes are "turned on" or active. However, some genes are preferentially silenced or "turned off" based upon which parent that gene came from (genetic imprinting). Genetic imprinting is controlled by chemical switches through a process called DNA methylation. Proper genetic imprinting is necessary for normal development. Defective imprinting has been associated with several human diseases including POH. In individuals with POH, the defective copy of the GNAS gene is inherited from the father. If a defective GNAS gene is inherited from the mother, individuals typically develop related, yet clinically distinct, disorders known as Albright hereditary osteodystrophy and/or pseudohypoparathyrodism type 1a (PHP1a).
More than 50 cases of progressive osseous heteroplasia have been identified around the world. Although the majority of the cases reported initially occurred in females, the disorder appears to affect males and females in equal numbers. Because POH often goes unrecognized or misdiagnosed, determining the true frequency of the disorder in the general population is difficult. In the most severe cases, symptoms are usually apparent at birth or within the first few weeks of life. Symptoms usually progress as affected individual’s age.
POH was first described in 1994.
Symptoms of the following diseases may be similar to those of progressive osseous heteroplasia. Comparisons may be useful for differential diagnosis:
Fibrodysplasia ossificans progressiva (FOP) is a very rare inherited connective tissue disorder characterized by the abnormal development of bone in areas of the body where bone is not normally present (heterotopic ossification), such as the ligaments, tendons, and muscles. Specifically, this disorder causes the body's skeletal muscles and soft connective tissue to undergo a transformation into bone, progressively locking joints in place and making movement difficult or impossible. FOP is characterized by malformation of the big toe that is present at birth (congenital). Other skeletal malformations variably occur. As the disease progresses, there may be abnormal development of bone in soft tissues that may lead to stiffness in affected areas and limited movement in affected joints (e.g., knees, wrists, shoulders, spine, and/or neck). FOP usually begins during early childhood and progresses throughout life. Most cases of FOP occur randomly (sporadic). The genetic mutation that results in this disorder has been identified. FOP is caused by the mutation of a gene in the "BMP pathway" (ACVR1/ALK2) which is associated with the formation of the skeleton in the embryo and the repair of the skeleton following birth. (For more information on this disorder, choose "Fibrodysplasia Ossificans Progressiva" as your search term in the Rare Disease Database.)
Albright hereditary osteodystrophy (AHO) is a rare disorder characterized by short stature, an unusually round face, abnormally short fingers (brachydactyly), and/or the development of bony growths (osseous plaques) on the surface of the skin but not in the deep connective tissue. These growths may spread to the lower level of the skin as well (subcutaneous ossification). Other symptoms may include mild mental retardation, abnormally low levels of calcium in the blood (hypocalcemia), and/or the clinical features of pseudohypoparathyroidism. Pseudohypoparathyroidism is caused by defective G-proteins that are needed to properly respond to parathyroid hormone and other hormones. In addition to hormone resistance, symptoms of pseudohypoparathyroidism include weakness, muscle cramps, excessive nervousness, headaches, and/or abnormal sensations such as tingling, burning, and numbness of the hands. AHO and PHP1a are caused by mutations of the same gene (GNAS) that causes POH. Each condition can be inherited as an autosomal dominant genetic trait. While POH occurs only when the mutant gene is inherited from fathers, AHO features are associated with gene mutations that are inherited either from mothers or fathers. PHP1a and/or AHO-associated obesity occur when the mutant gene is inherited from mothers. (For more information on this disorder, choose "Albright" as your search term in the Rare Disease Database.)
The diagnosis of progressive osseous heteroplasia may be confirmed by a thorough clinical evaluation, characteristic physical findings, and tests that demonstrate the presence of heterotopic ossification (e.g., x-ray and roentgenograms) with characteristic appearance for POH. An additional test may include the removal and testing of tissues (biopsy). In some cases, there may be temporarily (transient) increased levels of alkaline phosphatase in the blood serum
Special shoes, braces, and other devices to assist in walking and weight-bearing have been used to help people with POH involving the lower limbs. Occupational therapy evaluations and appropriate assistive devices for activities of daily living may be helpful for those in whom POH involves the upper limbs. Immunizations should be given on areas of the skin that are unaffected by the bony growths that are prevalent with this disorder.
Genetic counseling will be of benefit for affected individuals and their families. A team approach for infants with this disorder will be of benefit and may include special social, educational, and medical services. Other treatment is symptomatic and supportive.
Surgery, radiation therapy, and several different types of drugs, including nonsteroidal anti-inflammatory drugs (NSAIDs), have been used in the past to treat disorders involving the abnormal development of bone (heterotopic ossification). Surgery may be considered because of the complications associated with improper bone growth (e.g., stiffening of affected joints), but extreme caution is advised as operative procedures often exacerbate bone growth in POH. Surgical removal of improper bone growth has provided temporary relief in some cases; in other cases, the improper bone growth has recurred massively after the surgery. In some disorders of improper bone growth, surgery may hasten the progression of the disorder or result in other complications. Extreme caution should be used in considering surgery for individuals affected by POH. It is rarely indicated. More research must be conducted to determine the effectiveness of radiation and various drug therapies when used to treat POH.
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Progressive Osseous Heteroplasia Resources
Kaplan, FS, Pignolo RJ, and Shore EM. Fibrodysplasia (myositis) ossificans progressiva. In: Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism, Eighth Edition. C. Rosen, Editor. ASBMR, Washington, DC. 2013;Chapter 98; pp. 815-821.
Shore, EM and Kaplan FS. Extraskeletal Bone Formation. Pediatric Bone, Second Edition. F.H. Glorieux, J.M. Pettifor, H. Juppner, Editors, Academic Press. 2011;Chapter 30; pp.821-840.
Kaplan, F.S. and Shore EM. Fibrodysplasia (myositis) ossificans progressiva. In: Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism, Seventh Edition. C. Rosen, Editor. ASBMR, Washington, DC. 2008.
Shore EM, Kaplan FS. Progressive Osseous Heteroplasia. NORD Guide to Rare Disorders. Lippincott Williams & Wilkins. Philadelphia, PA. 2003:203-204.
Shore EM, Kaplan FS. Inherited human diseases of heterotopic bone formation. Nat Rev Rheumatol. 2010:6; 518-527.
Shore, E.M. and F.S. Kaplan.Insights from a rare genetic disorder of extra-skeletal bone formation, fibrodysplasia ossificans progressiva (FOP). Bone. 2008;43, 427-433.
Shore E.M. and F. S. Kaplan.FOP and POH: Two Genetic Disorders of Heterotopic Ossification. Clinical Reviews in Bone and Mineral Metabolism.2005;3:(3-4), 257-260.
Kaplan FS, Shore EM. Progressive osseous heteroplasia. J Bone Miner Res. 2000;15:2084-94.
Stoll C, Javier MR, Bellocq JP. Progressive osseous heteroplasia: an uncommon cause of ossification of soft tissues. Ann Genet. 2000;43:75-80.
Regard, J.B., D. Malhotra, J. Gvozdenovic-Jeremic, M. Josey, M. Chen, L.S. Weinstein, E.M. Shore, F.S. Kaplan, and Y. Yang. Activation of Hedgehog signaling by loss of GNAS causes heterotopic ossification. Nature Medicine. 2013:19:1505-1512.
Cairns, D.M., R.J. Pignolo, T. Uchimura, T.A. Brennan, C.M. Lindborg, M. Xu, F.S. Kaplan, E.M. Shore, and L. Zeng.Somitic disruption of GNAS in chick embryos mimics progressive osseous heteroplasia. J. Clinical Invest. 2013;123:3624-3633.
Zhang, S. F.S. Kaplan, E.M. Shore.Different roles of Gnas and cAMP signaling during early and late stages of osteogenic differentiation. Hormone Metab. Res. 2012;44:724-731.
Liu, J., E. Russell, D. Zhang, F.S. Kaplan, R.J. Pignolo, and E.M. Shore.Paternally inherited Gsa mutation impairs adipogenesis and potentiates a lean phenotype in vivo. Stem Cells.2012;30:1477-1485.
Pignolo RJ, Xu M, Russell E, et al.Heterozygous inactivation of Gnas in adipose-derived mesenchymal progenitor cells enhances osteoblast differentiation and promotes heterotopic ossification. J Bone Miner Res. 2011;26(11):2647-55.
Schimmel RJ, Pasmans SG, Xu M, Stadhouders-Keet SA, Shore EM, Kaplan FS, Wulfraat NM. GNAS-associated disorders of cutaneous ossification: two different clinical presentations. Bone. 2010: 46; 868-872.
Adegbite, NS, Xu M, Kaplan FS, Shore EM, Pignolo RJ. Clinical features, GNAS mutational analysis, and diagnostic criteria for progressive osseous heteroplasia (POH) and POH-like syndromes. Amer. J. Med. Genet.2008;146A(14): 1788-1796.
Gelfand, I., Hub RS, Shore EM, Kaplan FS, DiMeglio LA..Progressive Osseous Heteroplasia-Like Heterotopic Ossification in a Male Infant with Pseudohypoparathyroidism Type Ia: A Case Report. Bone.2007; 40, 1425-1428.
Kaplan FS, Glaser DL, Hebela N, Shore EM. Heterotopic ossification. J Am Acad Ortho Surg. 2004;12:116-125.
Faust, RA, Shore EM, Stevens CE, Xu M, Shah S, Phillips CD, and Kaplan FS. Progressive osseous heteroplasia in the face of a child. Amer. J. Med. Genet.2003;118A, 71-75.
Shore EM, Ahn J, Jan de Beur S, et al. Paternally inherited inactivating mutations of the GNAS1 gene in progressive osseous heteroplasia. N Engl J Med. 2002;346:99-106.
Rosenfeld SR, Kaplan FS. Progressive osseous heteroplasia in male patients: Two new case reports. Clin Orthop. 1995;317:243-45.
Kaplan FS, Hahn JV, Zasloff MA. Heterotopic ossification: two rare forms and what they can teach us. J Am Acad Orthop Surg. 1994;2:288-96.
Schmidt AH, Vincent KA, Aiona MD. Hemimelic progressive osseous heteroplasia: a case report. J Bone Joint Surg Am. 1994;76:Pp. 907-12.
Athanasou NA, Benson MK, Brenton BP, Smith R. Progressive osseous heteroplasia: a case report. Bone. 1994;15:471-75.
Kaplan FS, Craver R, MacEwen GD, et al. Progressive osseous heteroplasia: a distinct developmental disorder of heterotopic ossification. Two new case reports and follow-up of three previously reported cases. J Bone Joint Surg Am. 1994;76:425-36.
McKusick VA, ed. Online Mendelian Inheritance in Man (OMIM). Baltimore. MD: The Johns Hopkins University; Entry No: 166350 available at http://omim.org/entry/166350 Last Edit: 10/1/13. Accessed Jan 22, 2014.
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