Molecular Immunology 36 (1999) 863±867

www.elsevier.com/locate/molimm

Review

Properdin de®ciency: molecular basis and disease association

C.A.P. Fijen a,*, R. van den Bogaard b, M. Schipper b, M. Mannens b, M. Schlesinger c,
Fredrikson G. Nordin d, J. Dankert a, M.R. Daha e, A.G. SjoÈholm f, L. Truedsson f,
E.J. Kuijper a
a
Department of Medical Microbiology, AMC/University of Amsterdam, Amsterdam, The Netherlands
b
Department of Clinical Genetics, AMC/University of Amsterdam, Amsterdam, The Netherlands
c
Department of Pediatrics, Barzilai Medical Center, Ashkelon, Israel
d
Department of Medicine, Section For Exp. Cardiovasc. Res., Wallenberg Lab., MalmoÈ University Hospital, MalmoÈ, Sweden
e
Department of Nephrology, University of Leiden, Leiden, The Netherlands
f
Department of Lab. Medicine, Section MIG, Lund University, Lund, Sweden

Keywords: Properdin; Complement; Meningococci; Neisseria meningitidis; Alternative pathway

1. Introduction 2. The protein

The ®rst description of the properdin system of
complement activation by Pillemer et al. in 1954,
based on his observations of complement activation by
baker's yeast, was initially met with great interest
(Pillemer et al., 1954), but then with scienti®c scepti-
cism. Properdin was held as a contaminant. Only in
the late 1960's it became clear that the initial obser-
vations by Pillemer were reproducible and represented
an alternative pathway of complement activation,
involving C3, Factor B, Factor D and properdin.
These factors were puri®ed and identi®ed in the early
70's (GoÈtze and MuÈller-Eberhard, 1971). So the
alternative pathway became established. In 1992 the
sequence of the properdin gene became available
(Nolan et al., 1992). The ®rst properdin de®cient
family was found in Sweden in 1982, and properdin
de®ciency was associated with fulminant meningococ-
cal disease (SjoÈholm et al., 1982). In 1994 the ®rst
description of the genetic basis of a properdin de-
®ciency was published (Nordin et al., 1994).
* Corresponding author. Fax: +31-75-6502803.
E-mail address: ®jen.c@deheel.nl (C.A.P. Fijen).
Properdin is a basic glycoprotein of 442 amino acids
with a carbohydrate content of 9.8% (Nolan et al.,
1992). Serum concentration of the protein is about
25 mg/L. The protein is present as a mixture of cyclic
oligomers, composed of asymmetric monomers
(Pangburn,1989). The molecular mass of the unglyco-
sylated monomer is 53,267 Da (Nolan, 1990). By head
to tail interactions they form dimers, trimers and tetra-
mers in plasma. The tetramer is, on a molar base, ten
times more active than the dimer (Pangburn,1989).
This is believed to result from increased anity due to
the presence of multiple binding sites in the tetramer.
The properdin molecule is composed of distinct N-
and C- terminal regions ¯anking 6 tandemly repeated
units related to the type I repeat sequence (TSR) ®rst
identi®ed in thrombospondin (Goundis and Reid,
1988). TSR consist of about 60 amino acids. TSRs are
thought to be involved in binding to molecular struc-
tures.
Central in the activation of the alternative pathway
of complement activation is the generation of the C3
convertase, C3bBb, by the interactions of the com-
ponents C3b, Factor B and Factor D. Properdin
ampli®es activation by binding to the C3 convertase
and stabilizes this complex against intrinsic decay of
Bb from the complex, prolonging the half-life from 1±

0161-5890/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved.
PII: S 0 1 6 1 - 5 8 9 0 ( 9 9 ) 0 0 1 0 7 - 8
864 C.A.P. Fijen et al. / Molecular Immunology 36 (1999) 863±867

Fijen et al. (1996), van den Bogaard et al. (1999)

2 to 18 min (Fearon and Austen, 1975). The C3bBbP
complex is also more resistant than C3bBb to the inac-

Sjoholm et al. (1982), Westberg et al. (1995)

SjoÈholm et al. (1998b), Nordin et al. (1996)

tivation events mediated by the regulatory components

Fijen et al. (1996), Bogaard et al. (1999)

Fijen et al. (1996), Bogaard et al. (1999)

Fijen et al. (1996), Bogaard et al. (1999)

Fijen et al. (1996), Bogaard et al. (1999)

Fijen et al. (1996), Bogaard et al. (1999)

SjoÈholm (1988a), Westberg et al. (1995)

factor H and I.
Studies with mutant forms of properdin, lacking a
single TSR showed that the C3b binding site resides in
TSR5 (Higgins et al., 1995). It is reported that during

Manuscript in preparation
Manuscript in preparation

Manuscript in preparation
complement activation C3b may also become cova-

Truedsson et al. (1997)

Truedsson et al. (1997)

lently bound to properdin (Whiteman et al., 1995).

Nordin et al. (1998)

Spath et al. (1999)
TSR4 has a function in the stabilization of the C3bBb
complex but is not a binding site for C3b. Properdin
lacking TSR6 is unable to form oligomers (Higgins et

Reference
al., 1995).
Blood monocytes, neutrophil granulocytes, T-cells,

.
hepatocytes (human Hep-G2 cell line) and astrocytes
may contribute to properdin synthesis in vivo.
Properdin synthesis does not rise in the acute phase re-

Israel (Moroccan)
Israel (Tunesian)

Israel (Tunesian)
The Netherlands

The Netherlands

The Netherlands
The Netherlands

The Netherlands
The Netherlands

The Netherlands
sponse. At which stage properdin polymerizes into

South America
functional oligomers still needs to be clari®ed, but

Denmark
monomers of properdin are present intracellularly

Sweden

Sweden
Sweden
Origin

Swiss
before secretion.

3. The gene

The properdin gene has been localized on the short Number of families
arm of the X-chromosome in the Xp11.3-Xp11.23
band (Coleman et al., 1991). Two polymorphic dinu-
cleotide repeat regions, interrupted by 83 bp, are pre-
sent 16 kb downstream of the properdin gene and
1
1
1
5
1
1

3
1

3
1
1
1
1
1
1

1
cosegregate with the gene (Fijen et al., 1996). The
human properdin gene is composed of 10 exons span-
ning approximately 6.0 kb (Nolan et al., 1992). Exon 1
197 Del Cys+frameshift, Stop
235 Del Gly Pro+frameshift
remains untranslated, exon 2 includes the translation
Molecular genetic characterisation of properdin de®ciences from 24 families

start site and a sequence encoding 24 amino acids of

leader peptide and exon 3 encodes the N-terminal
region of the mature properdin protein. TSRs 1±5 are
Codon change

Arg 134 Stop

Gln 160 Stop
Gln 160 Stop

Arg 319 Cyst

encoded by exons 4±8, one TSR per exon. The ®rst 38
Ser 179 Stop

Gln 316 Arg

Tyr 387 Asp
Trp 294 Gly
Trp 294 Gly
Arg 52 Stop
Arg 52 Stop

Gly 271 Val

Trp 294 Ser

Arg 73 Trp
amino acids of TSR6 are encoded by exon 9 while the
remaining part of TSR6 and the C-terminal region of
properdin are contained in exon 10. A region of 25
amino acids containing the glycosylation site is
inserted in TSR6 (Higgins et al., 1995, Nolan et al.,
1992).
Position exon

4. The de®ciencies
4
4
5
5
5
6
6
7
7
8
8
8
8
4
8
9

De®ciencies of properdin are rather uncommon and

so far 82 de®cient persons, all Caucasians, have been
De®ciency phenotype

described (Figueroa and Densen, 1991; Fijen et al.,

1996). On the basis of immunochemical and functional
analyses, three di€erent types of properdin de®ciency
have been described (SjoÈholm, 1990). Type 1 is charac-
Table 1

1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
3

terized by the total absence of the properdin antigen

Type
Type
Type
Type
Type
Type
Type
Type
Type
Type
Type
Type
Type
Type
Type
Type

and function. This type is the most common. In the

 C.A.P. Fijen et al. / Molecular Immunology 36 (1999) 863±867
Fig. 1. Alignment of thrombospondin type 1 repeats from the human properdin-derived protein sequences with indication of amino acid changes
causing properdin de®ciency.
type 2 de®ciency state, properdin antigen serum levels
are 1±10% of the normal level, and the properdin
appeared to be functionally active in one family
(SjoÈholm et al., 1988a). Type 2 de®ciency has been
recognized in Denmark and Sweden (SjoÈholm, 1990).
The properdin antigen serum levels are normal, but
functionally defective in type 3 de®ciency. So far it has
only been detected in one large Dutch family (SjoÈholm
et al.,1988b).
Molecular genetic characterisation of properdin de-
®ciencies from 24 families is presented in Table 1.
Properdin type I de®ciency shows a remarkable allelic
heterogeneity. In the Netherlands many di€erent alleles
causing de®ciency were found, whereas in Israel a dis-
tinct regional founders e€ect has been observed.
Point mutations giving rise to a stop codon were
found in exons 4, 5 and 6. In individuals of one of
these families studied no properdin was detected intra-
cellularly in monocytes but the transcription to mRNa
was not impaired (Westberg et al., 1995). A truncated
molecule is supposed to be formed and to be rapidly
degraded, intracellularly. Most probably, the fate of
properdin is similar in families with type 1 de®ciency
due to non-synonymous mutations or deletions result-
ing in frameshifts. In Fig. 1 it is indicated that the
non-synonymous mutations of the type 1 de®cient
families occurred all in amino acids highly conserved
between the various TSRs from humans and mice
(Higgins et al., 1995), suggesting that they are essential
for the protein structure.
Type 2 properdin de®ciency occurred in two families
with distinct mutations resulting in substitution of not
conserved or not-completely conserved amino acids
(Fig. 1). Remarkably, the mutation changing arginine
865
to tryptophan at amino acid 73 in TSR1 resulted in
type 2 de®ciency, but a change on an equivalent place
in TSR5 at amino acid 319 from arginine to cysteine
resulted in type 1 de®ciency. A study of monocytes
from one of the de®cient persons showed that proper-
din is synthesized and secreted in normal amounts, but
that the oligomerization to tri- and tetramers is
impaired (Nordin et al., 1998). The low serum levels of
properdin are probably due to increased catabolism of
the abnormal properdin molecules.
In the properdin type 3 de®cient family a point mu-
tation in exon 9 gives rise to replacement of tyrosine
by aspartic acid. This amino acid substitution did not
a€ect oligomerization, synthesis or secretion, and
neither could one demonstrate a direct e€ect of the
amino acid substitution on the C3b binding of a deca-
peptide based on the modi®ed properdin sequence
(Nordin et al., 1996). However, the dysfunctional
properdin did not bind C3b in a ELISA system. So it
was concluded that the dysfunction was due to defec-
tive C3b binding, which was most likely caused by
conformational changes.
The di€erence in frequency of properdin de®ciency
between various countries, and the restriction of the
founder e€ect within national borders may suggest
that the gene mutations causing the de®ciencies are
rather recent. However, these ®ndings may also be
explained by an incomplete ascertainment of properdin
de®ciencies.
5. The inheritance pattern
From the ®rst described properdin de®cient family it
866 C.A.P. Fijen et al. / Molecular Immunology 36 (1999) 863±867
became clear that the de®ciency was inherited in an X-
linked pattern (SjoÈholm et al., 1982). This inheritance
pattern applies to all 3 kinds of de®ciency and is
explained by the properdin gene localisation on the
short arm of the X-chromosome. The mean level of
properdin in female carriers was half the level in the
normal population, with a range from nearly total de-
®ciency to a normal level (Fijen et al., 1996). A study
among 28 obligate female carriers revealed normal
serum levels of properdin in 2 (7%) of them, empha-
sizing the application of molecular biological tools to
®nd all female carriers (Bogaard et al., 1999; Fijen et
al., 1996; SpaÈth et al., 1999). Both study of the pro-
portion of monocytes producing properdin and of the
percentage of the a€ected chromosomes inactivated in-
dicate an uneven inactivation of the X-chromosome
among the female carriers, in accordance with the
Lyon hypothesis (van den Bogaard et al., 1999;
Nordin et al., 1996).
6. Clinical disease associated with the de®ciencies
The ®rst type 1 properdin de®ciency was identi®ed
in a family with four cases of fulminant lethal menin-
gococcal disease (SjoÈholm et al., 1982). Subsequently,
more families were detected with properdin de®ciency
by studying patients with familial meningococcal dis-
ease, severe meningococcal disease, meningococcal dis-
ease over the age of 10 years or meningococcal disease
by uncommon meningococcal serogroups W135, X, Y,
Z or non-groupable meningococci (Fijen et al., 1999a;
Nielsen et al., 1989; Schlesinger et al., 1993). These
strategies were successful but induced a bias in the
concept of properdin de®ciency associated disease. A
study among relatives of the properdin type 1 de®cient
patients revealed that 18% of the de®cient relatives
developed meningococcal disease (Fijen et al., 1999a)
and suggested that only meningococcal disease is sig-
ni®cantly associated with the de®ciency. The risk for
contracting meningococcal disease in properdin type 1
de®cient persons was 250 times higher than that in the
general population (Fijen et al., 1999a). Two properdin
type 1 de®cient persons with recurrent meningococcal
disease have been reported, either representing an
ascertainment bias or indicating a higher risk for
recurrent disease in the properdin de®cient patients
than in the general population (Cunli€e et al., 1995,
Nielsen et al., 1990). Remarkable among the reported
properdin de®cient patients is the high age at the time
of infection (mean 14 years) and the frequent occur-
rence of uncommon serogroups (Figueroa and Densen,
1991; Fijen et al., 1999a; Nielsen et al., 1989;
Schlesinger et al., 1993; SjoÈholm, 1990). Although
most disease histories are less fulminant than in the
®rst described family (Schlesinger et al., 1993; SjoÈholm
et al., 1982), the development of sepsis and the lethal-
ity seem higher in the properdin de®cient patients than
in non-de®cient patients (Fijen et al., 1999a). The
meningococcal disease among properdin type 2 and
type 3 de®cient persons has similar characteristics
(SjoÈholm, 1990). The association of properdin de-
®ciency with meningococcal disease at ages at which
normally protective antibodies have been developed is
not yet understood. In the presence of an intact classi-
cal pathway the association may be explained by the
strong need for ampli®cation at the C3 level of the
classical pathway induced complement activation by
the alternative pathway. At the meningococcal surface,
this ampli®cation may be necessary to develop e€ective
bactericidal and opsonic activity (Brandtzaeg et al.,
1996, Fijen et al., 1999b, Jarvis, 1995), because the
meningococcal surface has strong complement acti-
vation downregulating characteristics (Jarvis, 1995).
Acknowledgements
Part of the work was performed in the context of
collaboration within EUBioMed2 Program BMH4-
CT961005.
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