A personalized medicine approach to optimize care for a pediatric cystic
fibrosis patient with atypical clinical symptoms
Abstract
Mutations in the cystic fibrosis (CF) transmembrane conductance
regulator (CFTR) gene typically cause severe health complications in
multiple organ systems, including the respiratory and gastrointestinal
systems. Certain CFTR mutations, however, cause milder clinical
phenotypes which may delay confirmatory diagnosis and treatment.
Moreover, rare CFTR variants are not studied frequently or
approved for genotype specific CFTR modulator therapies, creating
further disadvantage. Herein, we describe a personalized medicine
approach for a CF patient with three CFTR variants and mild
clinical disease to aid in the diagnosis of CF and development of an
optimized treatment plan. This strategy relied on the synergistic
combination of advanced genetic analyses, patient-derived models of CFTR
function and modulation, and personalized clinical care delivery. Whole
Exome Sequencing revealed three compound heterozygous CFTR
variants: c.2249C>T (p.P750L), c.1408G>A
(p.V470M), and c.1251C>A (p.N417K). The CFTR channel
function and nature of protein defects for both V470M and N417K
mutations are not previously characterized. Patient-derived intestinal
organoid models demonstrated residual CFTR channel activity, with
improvement in channel function following treatment with the CFTR
modulators. / n vitro studies in heterologous model system
demonstrated that P750L has the features of Class II CFTR mutations,
whereas V470M/N417K exhibited characteristics of Class II, III, and IV
mutations, with all three variants responding to the combination
modulator therapy of elexacaftor, tezacaftor, and ivacaftor (ETI) and
showing functional rescue to near-wild-type CFTR levels. The laboratory
data was then utilized to inform patient care, including off-label
prescription of ETI. Following 18 months of ETI therapy, significant
improvements were noted in key clinical outcomes, including sweat
chloride, nutritional parameters, and respiratory and gastrointestinal
symptoms. This study demonstrates a personalized medicine approach
across clinical and laboratory domains used to care for CF patients with
atypical symptoms and/or rare CFTR mutations.