A Patient With Hereditary ATTR and a Novel AGel p A Patient With Hereditary ATTR and a Novel AGel p.Ala578Pro Amyloidosis  Meera Sridharan, MD, PhD, W. Edward Highsmith, PhD, Paul J. Kurtin, MD, Michael T. Zimmermann, PhD, Jason D. Theis, BS, Surendra Dasari, PhD, David Dingli, MD, PhD  Mayo Clinic Proceedings  Volume 93, Issue 11, Pages 1678-1682 (November 2018) DOI: 10.1016/j.mayocp.2018.06.016 Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 1 Proteomic identification of hereditary ATTR in endomyocardial biopsy. A, Protein identification report showing the universal amyloid markers (highlighted with blue stars) and type deterministic marker (highlighted with double stars). The numbers displayed in green boxes represent the total number of MS/MS spectra matched to the listed protein. B, Germline Sanger sequencing of TTR gene shows G>A mutation, resulting in V122I (p.Val122Ile) amino acid change. Mutation is highlighted with blue arrows. C, Corresponding mutant peptide detected in the amyloid deposits. Portion of the mutated TTR sequence detected is highlighted in bold black letters on a yellow background. The MS/MS spectrum of the TTR mutant peptide is shown. Blue arrow marks the location of the p.Val122Ile amino acid change. Mayo Clinic Proceedings 2018 93, 1678-1682DOI: (10.1016/j.mayocp.2018.06.016) Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 2 Detection of novel AGel p.Ala578Pro mutation and its amyloidogenicity. A, Protein identification report showing the universal amyloid markers (highlighted with blue stars) and type deterministic gelsolin marker (highlighted with double stars). The numbers displayed in green boxes represent the total number of MS/MS spectra matched to the listed protein. B, Germline Sanger sequencing of GSN gene shows G>C mutation, resulting in A578P (p.Ala578Pro) amino acid change. Mutation is highlighted with blue arrows. C, Corresponding mutant peptide detected in the amyloid deposits. Portion of the mutated GSN sequence detected is highlighted in bold black letters on a yellow background. The MS/MS spectrum of the GSN mutant peptide is shown. Blue arrow marks the location of the p.Ala578Pro amino acid change. D, Dominant motions (principal components, PCs) of full-length GSN from MD simulations were computed. The simulations demonstrated that all the sequences studied sampled similar large-scale motions, but revealed that amyloid-associated variants lead to increased activation of them. The differential activation of the dominant motions is visualized for WT and A578P using smoothed densities where more intense color indicates greater probability. E-H, We investigated motions of the GSN-L5 (E and G) and GSN-L2 (F and H) domains alone. The motilities of each residue according to PC1 (E and F) and PC3 (G and H) are shown using a color scale where blue indicates small amount of mobility, white an intermediate amount, and red large mobility. For both domains, loops nearby the variant-containing sites exhibit the most mobility. GSN = gelsolin; MD = molecular dynamics; WT = wild type. Mayo Clinic Proceedings 2018 93, 1678-1682DOI: (10.1016/j.mayocp.2018.06.016) Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 3 Gelsolin 3-dimensional structure and location of amyloidogenic variants. A, Each domain is colored uniquely with linking residues colored tan. The 3 previously identified variants are localized to the second GSN-like domain and their positions are indicated by orange spheres, whereas the novel A578P variant is within the fifth domain and is indicated by a red sphere. B, The dominant motions are visualized on the initial WT structure using black cones at each Cα atom. The first motion represents a rotation of domains 2 and 3 (blue and yellow) relative to domain 5 (green). PC1 = principal component 1; GSN = gelsolin; WT = wild type. Mayo Clinic Proceedings 2018 93, 1678-1682DOI: (10.1016/j.mayocp.2018.06.016) Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions