Gitelman’s Syndrome Associated with Chondrocalcinosis: A Ca
Rheumatology: Current Research

Rheumatology: Current Research
Open Access

ISSN: 2161-1149 (Printed)


Case Report - (2015) Volume 5, Issue 3

Gitelman’s Syndrome Associated with Chondrocalcinosis: A Case Study from the Azores Islands (Portugal)

Parreira B1,2,3*, Couto AR1,2,3, Menezes S3, Machado V4, Soares M1,2,3, Pinheiro JP1,2,3, Lima M1,2,5 and Bruges-Armas J1,2,3
1University of Porto, IBMC - Institute for Molecular and Cell Biology, GARG- Genetics and Arthritis Research Group Porto, Portugal
2Santo Espírito Hospital of Terceira Island, EPE, Epidemiology and Molecular Biology Service (SEEBMO) Angra do Heroísmo, Portugal
3Santo Espírito Hospital of Terceira Island, EPE, Hospital Oncology service Angra do Heroísmo, Azores, Portugal
4University of Azores, Department of Biology, Ponta Delgada, Azores, Portugal
5University of Azores, Department of Biology, Ponta Delgada, Azores, Portugal
*Corresponding Author: Parreira B, Researcher, Hospital de Santo Espirito, da Ilha Terceira, Serviço Especializado, de Epidemiologia e Biologia Molecular, Canada do Breado, 9700, Portugal, Tel: 00351968322116, Fax: 00351295216263 Email:


Gitelman syndrome (GS) is a rare autossomal recessive inherited tubulopathy, characterized by defective tubular reabsorption of magnesium and potassium, mostly caused by mutations in the SLC12A3 gene. The association of GS with chondrocalcinosis (CC) has been described in the literature as a typical example of hypomagnesemiainduced crystal deposition disease. We are presenting one case where the genetic cause for GS was identified in a proband with secondary early onset CC. A 60 years-old male patient with CC, hypomagnesemia and hypokalemia was identified in our hospital as a result of clinical and laboratory assessments. The clinical diagnosis of GS was performed and SLC12A3 gene was screened in the proband; variants detected were further searched in family members. The proband was homozygous for the S615L mutation; additionally, only one from the seven family members which were heterozygous presents CC. The presence of CC in two other individuals is most likely sporadic, in agreement with their advanced age.


Keywords: Chondrocalcinosis; Calcium pyrophosphate dehydrate; Genetic studies


Gitelman Syndrome (GS, OMIM 263800; ORPHA358) is a rare autossomal recessive tubulopathy, with a prevalence of approximately 1:40 000 in the Caucasian population. Onset is usually in adult life, but cases with onset in childhood are also known [1]. GS is characterized by hypomagnesemia, hypokalemia, metabolic alkalosis, hypocalciuria and hyperreninemic hyperaldosteronism. The clinical spectrum is wide and includes: cramps, myalgies, muscle weakness, tetania, and paralysis [2]. GS is mostly caused by loss of function mutations in the solute carrier family 12, member 3 (SLC12A3 gene) which consists of 26 exons and is located on the long arm of 16th chromosome [1]; this gene encodes the thiazide-sensitive sodium-chloride cotransporter (NCCT), expressed in the distal convoluted tubule of the kidney [3].

NCCT is a polypeptide which consists of 1021 amino acids. Its 2-D structure is predicted to contain 12 transmembrane domains and intracellular amino and carboxyterminal regions [3]. At present, according to the Human Gene Mutation Database (, more than 100 different variants have been identified in patients with GS. They are missense, non-sense, frameshift, and splice-site variations and are scattered throughout the transporter protein with a possible clustering of variations in the carboxy-terminal tail [4].

The association of GS with chondrocalcinosis (CC) has been described in the literature as a typical example of hypomagnesemia-induced crystal deposition disease [2]. CC is characterized by deposition of crystals of calcium pyrophosphate dihydrate (CPPD) in articular hyaline and fibro-cartilage [2]. Seventeen cases of GS associated with CC due to CCPD have been published in the literature, including 10 females and 7 males with a mean age of 51.4 ± 15.9 years [2,5-15]. The role of hypomagnesemia in the development of CCPD is, however, not fully understood [16]. Magnesium is an important cofactor for alkaline pyrophosphatase, an enzyme that plays a key role by converting inorganic pyrophosphate (PPi) to orthophosphate (Pi). A reduction in the activity of this enzyme due to hypomagnesemia could induce CCPD by raising extracellular levels of PPi. Both PPi and calcium are crucial precursors for crystal nucleation. CCPD may be found in other conditions associated with hypomagnesemia, such as short bowel syndrome or in liver transplantation patients [16].

Case with Genetic Analysis

The proband, a 60 year-old caucasian male was first observed in the Rheumatic Diseases Clinic - HSEIT when he was 48 years old; he was born in Terceira island as well as both his parents. Symptoms started when he was 33 years old, mainly affecting knees, ankles, wrists, elbows and achilles tendons. In the proband, PPi crystals were identified in the synovial fluid aspirated from a right knee effusion. Since then he was under treatment with colchicine, NSAIDS (Nonsteroidal anti-inflammatory drugs), and oral potassium and magnesium. Laboratory tests revealed normal leukocyte, erythrocyte and platelet count.

Blood urea was 33 mg/dl, creatinine 0.9 mg/dl and glucose 177 mg/dl. Serum electrolyte concentrations were as follows: sodium 139 mEq/L, potassium 3.2 mEq/L, calcium 9.8 mg/dl, and magnesium 1.1 mg/dl (Table 1). In spite of the treatment with colchicine, patient still maintain hypokalemia and hypomagnesemia, however he showed some improvements. Using the diagnostic criteria of Bettinelli et al. [17] a clinical diagnosis of GS was suspected, and a diagnosis of knee CC was made after the identification of bilateral knee cartilage calcification (Figure 1). SLC12A3 sequence analysis in the proband revealed that he was homozygous for a missense substitution in exon 15, previously described as associated to GS [18]. This mutation (CM014403), a C to T transition at position c.1869, changes the small size and polar amino acid serine to a medium size and hydrophobic leucine at position 615 (S615L), has a SIFT score of 0 and a Polyphen value of 0.996, both values suggestive of a deleterious variation.

Individuals Sex Age Magnesium levelsa Potassium levelsb CC Pathogenic mutation S615L
III.2 M 60 1.1 3.2 + S615L/S615L
III.12 M 75 2.1 4.7 - S615L/WT
III.13 F 67 2.2 4.1 - WT/WT
III.16 M 75 2.0 4.6 + WT/WT
III.19 F 79 1.9 4.7 + S615L/WT
IV.1 M 35 2.3 3.7 - S615L/WT
IV.2 F 54 2.2 4.2 - S615L/WT
IV.4 M 46 1.9 4.0 - S615L/WT
IV.14 F 51 1.9 4.0 - WT/WT
IV.16 F 49 2.2 4.1 - WT/WT
IV.17 F 45 1.9 4.3 - WT/WT
IV.21 M 37 2.1 4.1 - S615L/WT
IV.22 F 36 2.0 3.7 - S615L/WT
V.1 F 25 2.0 4.7 - WT/WT

aNormal serum magnesium 1.5-2.5 mg/dL; bNormal serum potassium; 3.3-5.1 mmol/L; M: Male; F: Female; CC: Chondrocalcinosis; WT: Wild Type

Table 1: Characteristics and SLC12A3 gene variants identified in the proband and in thirteen individuals of his family pedigree. The proband is indicated by bold.


Figure 1: X-rays of proband showing classical chondrocalcinosis in knees.

Thirteen additional family members were investigated (5M: 8W; [25-79]; mean age 51); blood tests and x-rays were obtained for all of them (data not shown). The pedigree with investigated individuals is shown in Figure 2. The biochemical data in these patients show normal levels of serum magnesium ranging from 1.9 to 2.3 mg/dL and normal levels of potassium ranging from 3.7-4.7 mmol/L (Table 1).


Figure 2: Pedigree with 14 investigated individuals (6 males and 8 females). The CC affected individuals and the presence of the mutation S615L are also indicated. The proband with GS is denoted by the arrow.

When the S615L mutation was searched in the thirteen relatives of the proband, seven family members were found to be heterozygous, of which only one presented CC. Furthermore six individuals were wild-type homozygous; noteworthy, one of them (III.16) presented CC (Table 1 and Figure 2).


The GS patient described in this study has the S615L variation in homozygosity, while the other cases of GS with this variation were reported in compound heterozygotes [2]. In our study, seven individuals heterozygous for the S615L did not have either hypokalemia or hypomagnesemia, confirming that they were asymptomatic carriers of this variation.

Hypomagnesemia and hypocalciuria are found in most cases of GS, however, some cases with mutations in the NCCT do not show these conditions [19]. It is believed that hypomagnesemia causes CC by increasing formation and reducing solubility of CCP crystals [16]. Excess of PPi is the main precursor for CPPD crystal nucleation. Because the magnesium is a necessary cofactor for numerous enzymes, such as pyrophosphatases, and considering the fact that it increases the solubility of CPPD crystals, low levels of magnesium could induce CPPD deposition disease by raising PPi and/or reducing the saturation product of CPPD crystals [14]. The prevalence of CC increases with age (10-15% for people between 65 and 75 years) and is hence called sporadic in patients older than 60 years, whereas in younger individuals there are several putative underlying disorders causing CPPD deposition disease, such as hemochromatosis, hyperparathyroidism, hypomagnesemia or hypophosphatemia [20].

The assumption that GS is caused by a defect in the NCCT cotransporter in the renal distal tubule has been proven by the identification of numerous variations in the SLC12A3 gene in patients with GS [1,4,19,21]. In the present study the specific involvement of this cotransporter in the etiology of this disorder is further substantiated by the finding that the proband is homozygous for the S615L variation. The S615L identified in this study was previously described by Cruz and co-workers [18] in a study involved 36 kindreds from the United States, Canada and England and later reported in a study by Syrén et al. [22]. Although the SLC12A3 variations reported in previous studies are distributed throughout the whole protein [4,23], the study of Lemmink (1998) indicates that the carboxy-terminal end represents a hot spot for variations [4]. S615L is located at the intracellular C-terminal end of the SLC12A3 protein. It is conceivable that structural alterations due to SLC12A3 variations in the C-terminal domain interfere with phosphorylation of the NCCT protein and as such with its regulation [4].

Evidence for an association between CC and GS comes from uncontrolled case reports, case series and only one cross-sectional study. As a result, its epidemiology remains unknown 16. There have been few cases described with a definite diagnosis of CC due to GS. In some patients with CPPD deposition disease secondary to hypomagnesemia, the stabilization of magnesium and potassium levels can reduce the deposition of CPPD crystals in the synovium and synovial fluid, reducing the frequency of attacks of articular pain 14.


GS is a hereditary disease characterized by defective tubular reabsorption of magnesium and potassium, mostly caused by mutations in the SLC12A3 gene. Sometimes GS patients, as in our case, might come with a CC diagnosis. We identified the genetic cause for GS in a proband with secondary early onset CC. Further studies are needed in order to enlighten the pathophysiology and prevalence of CC in patients with GS.


This study was partially supported by a PhD fellowship M3.1.2/F/023/2011 (Bruna Parreira) from Fundo Regional para a Ciência (FRC).


  1. Glaudemans B, Yntema HG, San-Cristobal P, Schoots J, Pfundt R, et al. (2012) Novel NCC mutants and functional analysis in a new cohort of patients with Gitelman syndrome. Eur J Hum Genet 20: 263-270.
  2. Gutierrez M, Silveri F, Bertolazzi C, Giacchetti G, Tardella M, et al. (2010) [Gitelman syndrome associated with chondrocalcinosis: description of two cases]. Reumatismo 62: 60-64.
  3. Simon DB, Nelson-Williams C, Bia MJ, Ellison D, Karet FE, et al. (1996) Gitelman's variant of Bartter's syndrome, inherited hypokalaemic alkalosis, is caused by mutations in the thiazide-sensitive Na-Cl cotransporter. Nat Genet 12: 24-30.
  4. Lemmink HH, Knoers NV, Károlyi L, van Dijk H, Niaudet P, et al. (1998) Novel mutations in the thiazide-sensitive NaCl cotransporter gene in patients with Gitelman syndrome with predominant localization to the C-terminal domain. Kidney Int 54: 720-730.
  5. Hisakawa N, Yasuoka N, Itoh H, Takao T, Jinnouchi C, et al. (1998) A case of Gitelman's syndrome with chondrocalcinosis. Endocr J 45: 261-267.
  6. Punzi L, Calò L, Schiavon F, Pianon M, Rosada M, et al. (1998) Chondrocalcinosis is a feature of Gitelman's variant of Bartter's syndrome. A new look at the hypomagnesemia associated with calcium pyrophosphate dihydrate crystal deposition disease. Rev Rhum Engl Ed 65: 571-574.
  7. Cobeta-Garcia JC, Gascón A, Iglesias E, Estopiñán V (1998) Chondrocalcinosis and Gitelman's syndrome. A new association? Ann Rheum Dis 57: 748-749.
  8. Vezzoli G, Soldati L, Jansen A, Pierro L (2000) Choroidal calcifications in patients with Gitelman's syndrome. Am J Kidney Dis 36: 855-858.
  9. García Nieto V, Cantabrana A, Müller D, Claverie-Martín F (2003) [Chondrocalcinosis and hypomagnesaemia in a patient with a new mutation in the gene of the thiazide-sensitive Na-Cl cotransporter]. Nefrologia 23: 504-509.
  10. Ea HK, Blanchard A, Dougados M, Roux C (2005) Chondrocalcinosis secondary to hypomagnesemia in Gitelman's syndrome. J Rheumatol 32: 1840-1842.
  11. Gupta R, Hu V, Reynolds T, Harrison R (2005) Sclerochoroidal calcification associated with Gitelman syndrome and calcium pyrophosphate dihydrate deposition. J Clin Pathol 58: 1334-1335.
  12. Hashida T, Yamada M, Hashimoto K, Satoh T, Okada S, et al. (2006) Loss of consciousness and hypokalemia in an elderly man with a mutation of the thiazide-sensitive Na-Cl cotransporter gene. Endocr J 53: 859-863.
  13. Volpe A, Caramaschi P, Thalheimer U, Fava C, Ravagnani V, et al. (2007) Familiar association of Gitelman's syndrome and calcium pyrophosphate dihydrate crystal deposition disease - a case report. Rheumatology (Oxford) 46: 1506-1508.
  14. Gutierrez M, Silveri F, Bertolazzi C, Salaffi F, Giacchetti G, et al. (2010) Gitelman syndrome, calcium pyrophosphate dihydrate deposition disease and crowned dens syndrome. A new association? Rheumatology (Oxford) 49: 610-613.
  15. Koçkara AŞ, Candan F, Hüzmeli C, Kayataş M, Alaygut D (2013) Gitelman's syndrome associated with chondrocalcinosis: a case report. Ren Fail 35: 1285-1288.
  16. Favero M, Calò LA, Schiavon F, Punzi L (2011) Miscellaneous non-inflammatory musculoskeletal conditions. Bartter's and Gitelman's diseases. Best Pract Res Clin Rheumatol 25: 637-648.
  17. Bettinelli A, Bianchetti MG, Borella P, Volpini E, Metta MG, et al. (1995) Genetic heterogeneity in tubular hypomagnesemia-hypokalemia with hypocalcuria (Gitelman's syndrome). Kidney Int 47: 547-551.
  18. Cruz DN, Shaer AJ, Bia MJ, Lifton RP, Simon DB; Yale Gitelman's and Bartter's Syndrome Collaborative Study Group (2001) Gitelman's syndrome revisited: an evaluation of symptoms and health-related quality of life. Kidney Int 59: 710-717.
  19. Yagi H, Yahata K, Usui T, Hasegawa C, Seta K, et al. (2011) Inheritance of an autosomal recessive disorder, Gitelman's syndrome, across two generations in one family. Intern Med 50: 1211-1214.
  20. Hahn M, Raithel M, Hagel A, Biermann T, Manger B (2012) Chronic calcium pyrophosphate crystal inflammatory arthritis induced by extreme hypomagnesemia in short bowel syndrome. BMC Gastroenterol 12: 129.
  21. Nakhoul F, Nakhoul N, Dorman E, Berger L, Skorecki K, et al. (2012) Gitelman's syndrome: a pathophysiological and clinical update. Endocrine 41: 53-57.
  22. Syrén ML, Tedeschi S, Cesareo L, Bellantuono R, Colussi G, et al. (2002) Identification of fifteen novel mutations in the SLC12A3 gene encoding the Na-Cl Co-transporter in Italian patients with Gitelman syndrome. Hum Mutat 20: 78.
  23. Mastroianni N, Bettinelli A, Bianchetti M, Colussi G, De Fusco M, et al. (1996) Novel molecular variants of the Na-Cl cotransporter gene are responsible for Gitelman syndrome. Am J Hum Genet 59: 1019-1026.
Citation: Parreira B, Couto AR, Menezes S, Machado V, Soares M, et al. (2015) Gitelman’s Syndrome Associated with Chondrocalcinosis: A Case Study from the Azores Islands (Portugal). Rheumatology (Sunnyvale) 5:163.

Copyright: © 2015 Parreira B, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.