Mosaic Activating Mutations in GNA11 and GNAQ Are Associated with Phakomatosis Pigmentovascularis and Extensive Dermal Melanocytosis  Anna C. Thomas,

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Mosaic Activating Mutations in GNA11 and GNAQ Are Associated with Phakomatosis Pigmentovascularis and Extensive Dermal Melanocytosis  Anna C. Thomas, Zhiqiang Zeng, Jean-Baptiste Rivière, Ryan O’Shaughnessy, Lara Al-Olabi, Judith St.-Onge, David J. Atherton, Hélène Aubert, Lorea Bagazgoitia, Sébastien Barbarot, Emmanuelle Bourrat, Christine Chiaverini, W. Kling Chong, Yannis Duffourd, Mary Glover, Leopold Groesser, Smail Hadj-Rabia, Henning Hamm, Rudolf Happle, Imran Mushtaq, Jean-Philippe Lacour, Regula Waelchli, Marion Wobser, Pierre Vabres, E. Elizabeth Patton, Veronica A. Kinsler  Journal of Investigative Dermatology  Volume 136, Issue 4, Pages 770-778 (April 2016) DOI: 10.1016/j.jid.2015.11.027 Copyright © 2016 The Authors Terms and Conditions

Figure 1 Clinical examples of dermatological, ophthalmological, and neurological aspects of phakomatosis pigmentovascularis. (a–c) Dermal melanocytosis and capillary malformation (port wine stain type) on the face, extensive dermal melanocytosis on the back and legs, and capillary malformation on the sole of the right foot. (d) Bilateral scleral melanocytosis with bilateral glaucoma. Capillary malformation and hemihypertrophy are just visible on right side of face. (e) Axial T1-weighed magnetic resonance image of the brain at the level of the lateral ventricles after administration of intravenous gadolinium contrast agent showing bilateral and asymmetrical thickening and enhancement of the pia mater. (Written consent for publication obtained in all cases.) Journal of Investigative Dermatology 2016 136, 770-778DOI: (10.1016/j.jid.2015.11.027) Copyright © 2016 The Authors Terms and Conditions

Figure 2 Sequencing results demonstrating mosaic GNA11 and GNAQ mutations. (a) Sanger sequencing of skin biopsy showing a very low peak in GNA11 at position c.547C>T (p.Arg183Cys) (asterisk). (b) Sanger sequencing of the same skin biopsy deoxyribonucleic acid after restriction enzyme digest of the normal allele, and hemi-nested amplification, revealing the mutation (asterisk). (c) Targeted next-generation sequencing showing low allele percentage mutations in skin but undetectable in blood, GNA11 c.547C>T (p.Arg183Cys) in 5% of reads. (d) GNAQ c.548G>A (p.Arg183Gln) in 6% of reads from skin but undetectable in blood. Journal of Investigative Dermatology 2016 136, 770-778DOI: (10.1016/j.jid.2015.11.027) Copyright © 2016 The Authors Terms and Conditions

Figure 3 Mutant GNA11 leads to activation of downstream signaling pathways. (a) Western blot for Flag, total GNA11, and the phosphorylated and total p38, JNK, ERK and AKT in total protein lysates from HEK293T cells transfected with either vector, wild-type GNA11 (WT), or one of two mutants R183C or Q209L mutant GNA11. (b) Ratio of phosphorylated to total p38, JNK, ERK, and AKT normalized by actin loading control. Bars indicate 1 standard deviation. ∗P < 0.05, unpaired t-test. Journal of Investigative Dermatology 2016 136, 770-778DOI: (10.1016/j.jid.2015.11.027) Copyright © 2016 The Authors Terms and Conditions

Figure 4 Mosaic expression of GNA11 promotes ectopic pigmentary lesions in zebrafish. (a) Images of adult zebrafish mosaic for GNA11, GNA11R183C, or GNA11Q209L expression. Large, ectopic pigmentary lesions are indicated next to white arrows. Dashed box indicates zoomed areas that show detail of pigmentary lesions. (b) Numbers of pigmentary lesions per fish expressing GNA11, GNA11R183C, or GNA11Q209L. Dark circles indicate ectopic pigmentary lesions. White circles indicate fish without pigmentary lesions. (c) Histology hematoxylin and eosin staining of a wild-type and GNA11R183C zebrafish skin at ×100 and ×400 magnification. Melanocytes are clearly visible in the dermis by the black melanin (blue arrows), frequently also in the epidermis (not shown) and in a few cases within underlying muscle (yellow arrow). Journal of Investigative Dermatology 2016 136, 770-778DOI: (10.1016/j.jid.2015.11.027) Copyright © 2016 The Authors Terms and Conditions