Fatigue in systemic lupus: the role of disease activity and its correlates.

OBJECTIVES: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that leads to a variety of negative health outcomes resulting from inflammation in various organ systems. Although treatment continues to advance, fatigue remains one of the most salient, poorly understood and addressed patient complaints. Understanding the mechanisms of fatigue can help guide the development of interventions to improve health outcomes. The aim of this research was to evaluate the contribution of six variables (disease activity, insomnia, depression, stress, pain and physical health) to fatigue in SLE without concomitant fibromyalgia (FM). METHODS: A total of 116 ethnically diverse, primarily female participants (91%) with SLE, receiving care at university medical centers, completed assessments of disease activity and quality of life outcomes (FACIT-FT, Insomnia Severity Index, Perceived Stress Scale (PSS-4), Pain Inventory, Depression-PHQ-9, and LupusPRO-physical function). All patients met the American College of Rheumatology classification criteria for SLE and did not have a known diagnosis of FM. Multivariate linear and stepwise regression analyses were conducted with fatigue (FACIT-FT) as the dependent variable, and the above six variables as independent variables. RESULTS: Mean (SD) age was 39.80 (13.87) years; 50% were African American, 21% Caucasian, 13% Hispanic, 9% Asian and 8% other. Mean (SD) FACIT-FT was 20.09 (12.76). Collectively, these six variables explained 57% of the variance in fatigue. In the multivariate model, depression, stress and pain were significantly and independently associated with fatigue, but not disease activity, sleep or physical health. Stress had the largest effect on fatigue (ß 0.77, 95% CI 0.17-1.38, p = 0.01), followed by depression (ß 0.66, 95% CI 0.21-1.10, p = 0.005). On stepwise regression analysis, only stress, depression and pain were retained in the model, and collectively explained 56% of the variance in fatigue. All three remained independent correlates of fatigue, with the largest contribution being stress (ß 0.84, 95% CI 0.27-1.42, p = 0.005), followed by depression (ß 0.79, 95% CI 0.44-1.14, p < 0.001) with fatigue. CONCLUSION: Stress, depression and pain are the largest independent contributors to fatigue among patients with SLE, without concurrent FM. Disease activity, sleep and physical health were not associated with fatigue. The evaluation of stress, depression and pain needs to be incorporated during assessments and clinical trials of individuals with SLE, especially within fatigue. This stress-depression-fatigue model requires further validation in longitudinal studies and clinical trials. Significance and innovation: • Disease activity, sleep, pain, stress, depression, and physical health have been reported individually to be associated with fatigue in lupus. This analysis evaluated the role of each and all of these six variables collectively in fatigue among patients with SLE without a known diagnosis of FM. • Disease activity, sleep and physical health were not significantly related to fatigue, but depression, stress and pain were. • The results emphasize the need to evaluate and treat fatigue in individuals with SLE utilizing a biopsychosocial approach, particularly in the realm of clinical trials. Behavioral medicine interventions are shown to be most effective for the treatment of depression, stress and pain.

Functional assessment of tyrosinase variants identified in individuals with albinism is essential for unequivocal determination of genotype-to-phenotype correlation.

BACKGROUND: Oculocutaneous albinism type 1 (OCA1), caused by pathogenic variations in the tyrosinase gene (TYR), is the most frequent and severe form of hypopigmentary disorder worldwide. While OCA1A manifests as a complete loss of melanin pigment, patients with OCA1B show residual pigmentation of the skin, hair and eyes. Limited experimental evidence suggests retention of TYR in the endoplasmic reticulum (ER) causes OCA1 pathogenesis. However, a comprehensive functional analysis of TYR missense variations and correlation with genotype is lacking. OBJECTIVES: Functional characterization of nonsynonymous tyrosinase variants in patients with OCA1 reported in the Albinism Database, dbSNP and the published literature, and an attempt to correlate them with reported and predicted phenotypes. METHODS: Thirty-four reported missense variants of TYR were subcloned by site-directed mutagenesis, and the dual-enzyme activities of the variant proteins were compared with the wild-type. The degree of ER retention was also checked for each of the variants through endoglycosidase H (Endo H) digestion followed by immunoprecipitation and densitometric analysis. RESULTS: Functional studies revealed one reported OCA1A variation with nearly 100% enzyme activity, 10 OCA1B variants lacking any enzyme activity, eight nonsynonymous single-nucleotide polymorphisms (SNPs) with ~30-70% of enzyme activity, and three SNPs that completely lacked activity altogether. The Endo H assay corroborated these results. CONCLUSIONS: Loss of enzyme activity of TYR variants was completely in agreement with ER retention across all variants examined. The results of the assay clearly established that determination of the biological activity of identified variants in patients with OCA is essential to correlate the identified suspect genotype with the obvious phenotype of the disease.

In silico analyses of missense mutations in coagulation factor VIII: identification of severity determinants of haemophilia A.

Factor VIII (FVIII) mutations cause haemophilia A (HA), an X-linked recessive coagulation disorder. Over 1000 missense mutations in FVIII are known and they lead to variable clinical phenotypes (severe, moderate and mild). The exact molecular basis of this phenotypic heterogeneity by FVIII missense mutations is elusive to date. In this study, we aimed to identify the severity determinants that cause phenotypic heterogeneity of HA. We compiled and curated a data set of 766 missense mutations from the repertoire of missense mutations in FVIII. We analysed these mutations by computational programs (e.g. Swiss-PdbViewer) and different mutation analysis servers (e.g. SIFT, PROVEAN, CUPSAT, PolyPhen2, MutPred); and various sequence- and structure-based parameters were assessed for any significant distribution bias among different HA phenotypes. Our analyses suggest that 'mutations in evolutionary conserved residues', 'mutations in buried residues', mutation-induced 'steric clash' and 'surface electrostatic potential alteration' act as risk factors towards severe HA. We have developed a grading system for FVIII mutations combining the severity determinants, and the grading pattern correlates with HA phenotype. This study will help to correctly associate the HA phenotype with a mutation and aid early characterization of novel variants.

The SLE-associated Pbx1-d isoform acts as a dominant-negative transcriptional regulator.

Pbx1 is a transcription factor involved in multiple cellular processes, including the maintenance of self-renewal of hematopoietic progenitors. We have shown that the CD4(+) T-cell expression of a novel splice isoform of Pbx1, Pbx1-d, is associated with lupus susceptibility in the NZM2410 mouse and in lupus patients. The function of Pbx1 in T cells is unknown, but the splicing out of the DNA-binding domain in Pbx1-d predicts a dominant-negative function. In support of this hypothesis, we have shown that Pbx1-d transduction accelerates differentiation of MC3T3-E1 osteoblast pregenitors and mimics the effect of short hairpin RNA silencing of Pbx1. Conversely, Pbx1-d transduction reduced the expression of Sox3, a gene strongly transactivated by Pbx1, and Pbx1-d did not bind the Sox3 promoter. These results constitute a first step towards the understanding on how Pbx1-d contributes to systemic autoimmunity in the NZM2410 mouse model as well as in lupus patients.

Sero-prevalence and risk factors of Toxoplasma gondii infection in wild cervids in Denmark.

Toxoplasma gondii is a zoonotic protozoan parasite capable of infecting possibly all warm-blooded animals including humans, and is one of the most widespread zoonotic pathogens known. Free-ranging wildlife can be valuable sentinels for oocyst contaminated environments, as well as a potential source for human foodborne infection with T. gondii. Here we aimed to determine the sero-prevalence of T. gondii in Danish wild deer populations and examine risk factors associated with increased exposure to the parasite. Blood samples were collected from 428 cervids (87 fallow deer (Dama dama), 272 red deer (Cervus elaphus), 55 roe deer (Capreolus capreolus) and 14 sika deer (Cervus Nippon) from 23 hunting sites in Denmark. The animals were shot during the hunting season 2017/2018, and screened for antibodies against T. gondii using a commercial ELISA kit. One hundred and five (24.5%) cervids were sero-positive. Sero-prevalence was significantly different between species (p < 0.05), with odds of sero-positivity being 4.5 times higher in roe deer than fallow deer, and 3.0 times higher in red deer than in fallow deer. A significant increase in sero-prevalence with age was observed, driven by a significant increase in risk in adult red deer compared to calves (OR: 13.22; 95% CI: 5.96-33.7). The only other significant risk factor associated with wild cervid T. gondii sero-positivity was fencing, with the highest exposure associated with deer from non-fenced hunting areas (OR: 2.21; 95% CI: 1.05-4.99). This study documented a widespread exposure to T. gondii in Danish cervids. Therefore the meat of the wild deer, in particular from roe deer and red deer, should be considered a significant risk of T. gondii infections to humans, if not properly cooked. Further, molecular studies to confirm the presence of infective parasitic stages in the muscles of deer used for consumption is recommended.

Environmental DNA in human and veterinary parasitology - Current applications and future prospects for monitoring and control.

Parasites are important pathogens with significant global economic, public and animal health impacts. Successful control or elimination of many parasitic diseases, not least neglected tropical parasites, will require scalable, sensitive and cost-effective monitoring tools. Environmental DNA (eDNA) methods, used extensively in ecology for biomonitoring in natural ecosystems, offer promising advantages such reduced costs and labor requirements for species monitoring. Yet, the use of eDNA-based methods in parasitology and disease surveillance, has only recently begun to be explored. With this review, we wish to give an up-to-date overview of current uses and limitations of eDNA in human and veterinary parasitology, and how existing challenges can be overcome to fully utilize the potential of eDNA for monitoring and control of parasitic diseases. We begin by systematically searching published literature to identify studies that apply eDNA methods in parasitology and synthesize the main findings from these studies. We find that eDNA applications in parasitology only account for a small proportion (73/1960) of all eDNA publications up to now, and even fewer (27/73) studies, that apply eDNA methods specifically for parasites of human or veterinary importance. The majority of studies concern snail-borne trematodes and their intermediate host snails, while a few apply eDNA for mosquito vector species detection. A strong geographical bias, with only very few studies undertaken on the African continent, where parasites are of the biggest public health concern, is also noted. Current obstacles hindering further advances of eDNA methods in parasitology include incomplete reference databases, and challenges related to real-time monitoring in remote areas, and in certain LMIC settings. Finally, we point to future opportunities for eDNA-based research in parasitology and highlight recent innovations in eDNA research, which could further develop its application for monitoring and control of parasitic diseases and vectors in the future.

Comprehensive analysis of the molecular basis of oculocutaneous albinism in Indian patients lacking a mutation in the tyrosinase gene.

BACKGROUND: Oculocutaneous albinism (OCA) refers to a group of inherited disorders where the patients have little or no pigment in the eyes, skin and hair. Mutations in genes regulating multi-step melanin biosynthesis are the basis of four 'classical' OCA types with overlapping clinical features. There are a few reports on defects in TYR and a single report on SLC45A2 in Indians affected with OCA but no report on OCA2 (a major locus related to the disease) and TYRP1. OBJECTIVES: To assess and describe a comprehensive picture of the molecular genetic basis of OCA among Indians with no apparent mutations in TYR. METHODS: Twenty-four affected pedigrees from 14 different ethnicities were analysed for mutations in OCA2, TYRP1, SLC45A2 and SLC24A5 using the polymerase chain reaction-sequencing approach. RESULTS: Two splice-site and four missense mutations were detected in OCA2 in seven unrelated pedigrees, including four novel mutations. Haplotype analysis revealed a founder mutation (Ala787Thr) in two unrelated families of the same ethnicity. A patient homozygous for a novel SLC45A2 mutation also harboured a novel OCA2 defect. No mutation was detected in TYRP1 or SLC24A5. CONCLUSIONS: Our results suggest that an OCA2 gene defect is the second most prevalent type of OCA in India after TYR. The presence of homozygous mutations in the affected pedigrees underscores the lack of intermixing between the affected ethnicities. Direct detection of the genetic lesions prevalent in specific ethnic groups could be used for carrier detection and genetic counselling to contain the disease.

Prevalence and significance of antiphospholipid antibodies in selected at-risk obstetrics cases: a comparative prospective study.

In a prospective comparative study we screened 112 women with a past history either of pre-eclampsia, eclampsia, recurrent abortion, IUGR, IUFD or abruptio placentae, with no apparent aetiology and a demographically matched cohort of 106 women having a past history of uncomplicated pregnancy outcome for the presence of antiphospholipid antibodies (aPL) and their significance. In the former group, the prevalence of aPL ranged from 10-46.87% compared with 8.49% in the later group. In women with the presence of aPL, the incidence of pre-eclampsia, early onset pre-eclampsia and abruptio placentae were 25%, 14.58% and 18.75%, respectively. In the same group, the abortion rate was 25% and live-birth rate was 64.58% with IUFD rate of 10.42%. Fetal morbidity rates were also higher in the mothers with aPL positivity, the incidence of IUGR was 27.08% and oligohydramnios was 33.33% in them. All these complications were statistically significant when compared with those of aPL negative mothers.

Synergism in immunotoxicological effects due to repeated combined administration of arsenic and lead in mice.

Arsenic and lead are considered potent human hazards because of their neoplastic outcomes; increasing epidemiologic evidence indicates a link between heavy metal exposure and health risk. Since health risks of singly administered metals are well-established, in the present study we determined whether simultaneous repeated multimetal (arsenic + lead) exposure influences the development of immunotoxicity in mice exposed (in vivo) to lead acetate (10 mg/kg b.w.) and sodium arsenite (0.5 mg/kg b.w.) simultaneously. We report that in vivo multimetal exposure alters cell morphology, inhibits cell adhesion, nitric oxide release, intracellular killing ability, chemotactic migration, myeloperoxidase release, bacterial clearance from blood and spleen and increases DNA fragmentation. On measuring bacterial density in blood and spleen after 0, 24, 48 and 72 h post infection (with Staphylococcus aureus MC524) in control and multimetal treated groups, bacterial load showed delayed clearance from blood and spleen in the multimetal exposed group. We also found that in vivo exposure to the multimetal caused a decrease in cell adhesion, indicated by a fall in absorbance at 570 nm with respect to control. Exposure to multimetal led to morphological changes in macrophages, since more deformed cells were obtained in repeated combined exposure to arsenic and lead compared to control. Nitric oxide, which has a potent microbicidal activity in macrophages, was found to be released in fewer amounts in the multimetal exposed group from that of control group. It was observed that the viability of bacteria gradually decreased in control macrophage with time, whereas, in macrophages of multimetal exposed mice, the viability of S. aureus gradually increased. Chemotactic migration of splenic macrophages significantly decreased in the multimetal exposed group from that of control. Lysosomal enzyme release from splenic macrophages decreased upon simultaneous exposure to arsenic and lead, as is evident from the decrease in myeloperoxidase release in multimetal group from that in control. That the structural integrity of splenic macrophages is decreased in the multimetal exposed group is also evident from the enhanced percentage of DNA fragmentation after multimetal exposure, suggesting apoptotic death of splenic macrophage. Intracellular viable bacteria in the splenic macrophage from multimetal exposed group was 89.16 +/- 3.54% while that from control group was 49.19 +/- 1.16%, whereas single metal exposed groups showed a bacterial viability of 69.6 +/- 2.45% and 71.71 +/- 1.89% in arsenic and lead treated groups respectively. What is essentially noteworthy from the observed results is that lead and arsenic causes a greater immunotoxic effect when administered together as multimetal than when singly administered. Simultaneous exposure to lead and arsenic appears to be additive as is further established from the isobologram constructed by plotting the concentration of arsenic against the concentration of lead at which effect (in this case myeloperoxidase release) remained constant, a convex line showing synergism was demonstrated. The present study reports a definite synergistic trend of immunotoxicity during simultaneous exposure to arsenic and lead, that is, a multimetal challenge, as compared to the effects of independent exposure to them.

Arsenic burden of cooked rice: Traditional and modern methods.

Arsenic contamination of rice by irrigation with contaminated groundwater and secondarily increased soil arsenic compounds the arsenic burden of populations dependent on subsistence rice-diets. The arsenic concentration of cooked rice is known to increase with the arsenic concentration of the cooking water but the effects of cooking methods have not been defined. We tested the three major rice cooking procedures followed globally. Using low-arsenic water (As < 3 microg/L), the traditional method of the Indian subcontinent (wash until clear; cook with rice: water::1:6; discard excess water) removed up to 57% of the arsenic from rice containing arsenic 203-540 microg/kg. Approximately half of the arsenic was lost in the wash water, half in the discard water. A simple inexpensive rice cooker based on this method has been designed and used for this purpose. Despite the use of low-arsenic water, the contemporary method of cooking unwashed rice at rice:water::1:1.5-2.0 until no discard water remains did not modify the arsenic content. Preliminary washing until clear did remove 28% of the rice arsenic. The results were not influenced by water source (tubewell, dug well, pond or rain); cooking vessel (aluminium, steel, glass or earthenware); or the absolute weight of rice or volume of water. The use of low-As water in the traditional preparation of arsenic contaminated rice can reduce the ingested burden of arsenic.

Regulation of Streptococcus mutans PTS Bio by the transcriptional repressor NigR.

Streptococcus mutans is implicated in human dental caries, and the carbohydrate metabolism of this organism plays an important role in the formation of this disease. Carbohydrate transport and metabolism are essential for the survival of S. mutans in the oral cavity. It is known that a unique phosphoenolpyruvate-sugar phosphotransferase system PTS(B) (io) of S. mutans UA159 is expressed in sucrose-grown biofilms (Mol Oral Microbiol 28: 2013; 114). In this study we analyzed the transcriptional regulation of the operon (O(B) (io) ) encoding the PTS(B) (io) and showed that it was repressed by NigR, a LacI-like transcriptional regulator. Using electro-mobility shift assay, we described two operators to which NigR bound with different affinities. We also identified the transcriptional start site and showed that one of the operators overlaps with the promoter and presumably represses initiation of transcription. Mutational analyses revealed the key nucleotides in the operators required for high-affinity binding of NigR. PTS(B) (io) is expressed in S. mutans biofilms so understanding its regulation may provide improved strategies for caries treatment and prevention.

Correlation of phospholipid loss in goat whole blood with solvochromic properties of antiamebics like emetine, metronidazole and diloxanide furoate.

Phospholipid content of whole blood lipid decreases significantly when goat blood is incubated for different length of time with different amebicidal agents (e.g., emetine, metronidazole and diloxanide furoate). The plots of relative per cent phosphate loss against incubation period show biphasic nature and suggest that the rates of phospholipid loss bears some relation with the drug's lipophilicity (log P in 1 octanol/water system). The absolute phospholipid loss seems to be governed by the drug's aquasolubility. Implication of these finding were discussed in terms of their clinical profiles assuming that the loss of phospholipid is due to drug's binding with the phospholipid layer in amebic cyst-coat, being the first step which may trigger a chain of events leading to the onset of drug action.

Multi-drug resistant typhoid fever with diarrhea.

OBJECTIVE: To provide information about the characteristics of diarrheal stool in multi-drug resistant typhoid fever and observe the clinical course after treatment with furazolidone or ciprofloxacin. SETTING: Hospital based. SUBJECTS AND METHODS: Twenty one male children who were positive for multi-drug resistant S. typhi by blood and stool cultures, having diarrhea at the time of hospitalization comprised the subjects. Serum and stool electrolytes were estimated. Stool samples were also processed to detect established enteropathogens, leukocytes and red blood cells. Children were treated either with furazolidone or ciprofloxacin and evaluated till recovery. RESULTS: Mean (+/- SD) pre-admission duration of fever and diarrhea of these cases were 19.1 (+/- 5.6) and 15.8 (+/- 4.6) days, respectively. Stool character in 81% of the patients was watery with mean (+/- SD) volume of stool 51.4 (+/- 25.1) ml per kg body weight in the first 24 hours of observation. Leukocyte count varied between 20-49 per high power field in 66.7% stool samples. Occult blood was present in only 19% cases. Fecal red blood cells in high power field were detected in 52.4% cases. Mean fecal electrolytes (mmol/liter) were as follows: sodium-53.8, potassium-51.4, chloride-41.6 and total CO2-24.3. Most of the children (71.4%) had no dehydration and had normal serum electrolytes. The isolated strains of S. typhi were multi-drug resistant. These children were treated successfully either with furazolidone or ciprofloxacin. CONCLUSION: The stools of multi-drug resistant typhoid fever patients were watery with little blood. Their electrolyte contents were more similar to the diarrheal stool seen in shigellosis rather than cholera. Uncontrolled observations revealed that children recovered with furazolidone or ciprofloxacin therapy.

Correlation of biological activity (therapeutic and toxic) with solvochromic properties of metronidazole, emetine hydrochloride and diloxanide furoate.

Goat blood, when incubated for different periods with diloxanide furoate, metronidazole and emetine hydrochloride, underwent changes in fatty acid constituents and their peroxidation products measured as malonaldehyde. These findings, together with the changes noted in the drug-lipid partition coefficient, are discussed in an attempt to correlate the lipid constitution and biological activity of the drugs.

Effect of lignocaine on blood lipid in relation to partition coefficient and biological activity.

To correlate lipophilicity of lignocaine with changes in lipid composition of blood as a result of in vitro incubation with the drug, phosphorus content and fatty acid compositions of blood lipids before and after lignocaine treatment have been compared with those of a standard phospholipid, lecithin, under similar conditions of drug treatment. The change in fatty acid constituents has been correlated with the biological activity (both therapeutic and toxic) of lignocaine.

Effect of propranolol hydrochloride on blood cell lipids in relation to partition coefficient and biological activity.

Considering the high lipophilicity of propranolol (log P = 3.56), its interactions with the cell membrane lipids of goat blood have been investigated. It is observed that lipid loss after incubation of blood cells with propranolol hydrochloride in salt glucose medium for varying periods of time was accompanied with significant increases in PUFAs. Amongst the PUFAs studied the omega 3 and omega 6 fatty acids, the two important precursors of eicosenoids, have shown increase in varying amounts. This phenomenon is presumably responsible for the significant cardiovascular activity of this drug.

Dengue haemorrhagic fever (DHF) outbreak in Calcutta--1990.

An outbreak of Dengue Haemorrhagic Fever (DHF) occurred in Calcutta between September and December, 1990. Children and young adults were the major victims. Haemorrhagic manifestations and shocks were the main features in most of the hospitalised cases. Five mouse pathogenic agents were isolated from 105 acute cases and all were identified as DEN-3. HI and CF test with 55 paired sera revealed evidence of dengue infection in 33 (60 per cent) and flavivirus group reaction including dengue in 17 (30.9 per cent). It was for the first time, that DEN-3 was considered to be the etiologic agent for DHF in Calcutta.

Effect of isosorbide dinitrate on enzymatically estimated infarction size and on clinical condition of the patients of acute myocardial infarction.

With the aim of reducing myocardial infarction size, isosorbide dinitrate (ISDN) was tried in 27 patients of acute myocardial infarction (AMI). There was 11% reduction of infarction size, in the ISDN treated group, in comparison to that of non treated group, though the result was not statistically significant. But, many of the in-hospital complications were significantly less in the treated group. After a critical analysis of the result it was concluded that a statistically insignificant result, as regard reduction of infarction size in AMI, cannot always exclude the utility of a drug therapy in AMI.

Quantitative dermatoglyphic asymmetry: a comparative study between schizophrenic patients and control groups of West Bengal, India.

Quantitative Fluctuating (FA) and Directional asymmetry (DA) of dermatoglyphics on digito-palmar complex were analyzed in a group of 111 patients (males: 61, females: 50) with schizophrenia (SZ), and compared to an ethnically matched phenotypically healthy control (males: 60, females: 60) through MANOVA, ANOVA and canonical Discriminant analyses. With few exceptions, asymmetries are higher among patients, and this is more prominent in FA than DA. Statistically significant differences were observed between patient and control groups, especially in males. In both sexes, FA of combined dermatoglyphic traits (e.g. total finger ridge count, total palmar pattern ridge count) are found to be a strong discriminator between the two groups with a correct classification of over 83% probability.

Molecular basis of albinism in India: evaluation of seven potential candidate genes and some new findings.

Albinism represents a group of genetic disorders with a broad spectrum of hypopigmentary phenotypes dependent on the genetic background of the patients. Oculocutaneous albinism (OCA) patients have little or no pigment in their eyes, skin and hair, whereas ocular albinism (OA) primarily presents the ocular symptoms, and the skin and hair color may vary from near normal to very fair. Mutations in genes directly or indirectly regulating melanin production are responsible for different forms of albinism with overlapping clinical features. In this study, 27 albinistic individuals from 24 families were screened for causal variants by a PCR-sequencing based approach. TYR, OCA2, TYRP1, SLC45A2, SLC24A5, TYRP2 and SILV were selected as candidate genes. We identified 5 TYR and 3 OCA2 mutations, majority in homozygous state, in 8 unrelated patients including a case of autosomal recessive ocular albinism (AROA). A homozygous 4-nucleotide novel insertion in SLC24A5 was detected in a person showing with extreme cutaneous hypopigmentation. A potential causal variant was identified in the TYRP2 gene in a single patient. Haplotype analyses in the patients carrying homozygous mutations in the classical OCA genes suggested founder effect. This is the first report of an Indian AROA patient harboring a mutation in OCA2. Our results also reveal for the first time that mutations in SLC24A5 could contribute to extreme hypopigmentation in humans.