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Original research
Pathogenic variations in MAML2 and MAMLD1 contribute to congenital hypothyroidism due to dyshormonogenesis by regulating the Notch signalling pathway
  1. Feng-Yao Wu1,
  2. Rui-Meng Yang1,
  3. Hai-Yang Zhang1,
  4. Ming Zhan2,
  5. Ping-Hui Tu1,
  6. Ya Fang1,
  7. Cao-Xu Zhang1,
  8. Shi-Yang Song1,
  9. Mei Dong1,
  10. Ren-Jie Cui1,
  11. Xiao-Yu Liu1,
  12. Liu Yang1,
  13. Chen-Yan Yan1,
  14. Feng Sun1,
  15. Rui-Jia Zhang1,
  16. Zheng Wang1,
  17. Jun Liang3,
  18. Huai-Dong Song1,
  19. Feng Cheng4,
  20. Shuang-Xia Zhao1
  1. 1 The Core Laboratory in Medical Center of Clinical Research, Department of Molecular Diagnostics & Endocrinology, State Key Laboratory of Medical Genomics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
  2. 2 Department of Urology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
  3. 3 Department of Endocrinology, The Central Hospital of Xuzhou Affiliated to Xuzhou Medical College, Xuzhou, China
  4. 4 Department of Laboratory Medicine, Fujian Provincial Maternity and Children's Hospital, Fuzhou, China
  1. Correspondence to Shuang-Xia Zhao, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China; zhaozhao1215{at}; Professor Huai-Dong Song; huaidong_s1966{at}; Dr Feng Cheng; fcheng99{at}


Background In several countries, thyroid dyshormonogenesis is more common than thyroid dysgenesis in patients with congenital hypothyroidism (CH). However, known pathogenic genes are limited to those directly involved in hormone biosynthesis. The aetiology and pathogenesis of thyroid dyshormonogenesis remain unknown in many patients.

Methods To identify additional candidate pathogenetic genes, we performed next-generation sequencing in 538 patients with CH and then confirmed the functions of the identified genes in vitro using HEK293T and Nthy-ori 3.1 cells, and in vivo using zebrafish and mouse model organisms.

Results We identified one pathogenic MAML2 variant and two pathogenic MAMLD1 variants that downregulated canonical Notch signalling in three patients with CH. Zebrafish and mice treated with N-[N-(3,5-difluorophenacetyl)-l-alanyl]-S-phenylglycine t-butylester, a γ-secretase inhibitor exhibited clinical manifestations of hypothyroidism and thyroid dyshormonogenesis. Through organoid culture of primary mouse thyroid cells and transcriptome sequencing, we demonstrated that Notch signalling within thyroid cells directly affects thyroid hormone biosynthesis rather than follicular formation. Additionally, these three variants blocked the expression of genes associated with thyroid hormone biosynthesis, which was restored by HES1 expression. The MAML2 variant exerted a dominant-negative effect on both the canonical pathway and thyroid hormone biosynthesis. MAMLD1 also regulated hormone biosynthesis through the expression of HES3, the target gene of the non-canonical pathway.

Conclusions This study identified three mastermind-like family gene variants in CH and revealed that both canonical and non-canonical Notch signalling affected thyroid hormone biosynthesis.

  • congenital, hereditary, and neonatal diseases and abnormalities
  • endocrine system diseases
  • genetics, medical

Data availability statement

Data are available on reasonable request.

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  • F-YW, R-MY, H-YZ and MZ are joint first authors.

  • H-DS, FC and S-XZ contributed equally.

  • Contributors F-YW designed the study, conducted the statistical analysis and drafted the manuscript. R-MY designed the study and revised the manuscript. H-YZ and MZ conducted the statistical analysis. FC, P-HT, C-XZ, S-YS, MD, R-JC, X-YL, FS, R-JZ, C-YY, ZW, LY and JL collected the clinical data of patients. HS and S-XZ guided the design of the study and revised the manuscript. S-XZ acts as a guarantor.

  • Funding This work was supported by grants from National Science Foundation of China (numbers 82070816, 81870537, 82170802), Shanghai Municipal Education Commission Two-hundred Talent (number 20161318), Shanghai Science and Technology Committee (number 19140904200), Innovative Research Team of High-Level Local Universities in Shanghai (SHSMU-ZDCX20210901, SHSMU-ZDCX20212501).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.