Zixu Zhang1,2 · Shengru Hu1,2 · Yaxuan Chen1  · Ting He2  · Wei Xie2  · Mingdao Mu1,2

1 School of Medicine, Southeast University, Nanjing 210009, China 

2 The Key Laboratory of Developmental Genes and Human Disease, Ministry of Education, The School of Life Science and Technology, Southeast University, Nanjing 210008, China

Abstract

The paired-like homeobox transcription factor 2B (PHOX2B) is a master regulator whose mutations cause a spectrum of severe neurological and neurodevelopmental disorders, including Congenital central hypoventilation syndrome (CCHS), Hirschsprung disease, and neuroblastoma. For decades, a central paradox has challenged the field: how can PHOX2B’s seemingly restricted expression in the brainstem account for the broad, multi-system clinical phenotypes observed in patients? Here, we elucidate how this paradox has been resolved by recent methodological advances. We synthesize evidence from multiple complementary methodologies, including single-cell transcriptomics, spatial transcriptomics, and viral circuit tracing, which have revealed a vastly expanded PHOX2B anatomical landscape. These advances uncover previously unrecognized expression in caudal midbrain and higher brainstem regions, supportive glial populations, and peripheral components, extending far beyond classical autonomic nuclei. Furthermore, while mapping evidence predominantly derives from murine models, insights from human disease models, such as pluripotent stem cell-derived brainstem organoids, suggest that PHOX2B orchestrates integrated neuro-glial networks rather than isolated functions. Consequently, we propose reconceptualizing CCHS and related conditions as a class of multi-system network disorders termed PHOX2B circuitopathies. This circuitopathy framework critically differentiates primary circuit disruptions from secondary systemic cascades (such as hypoxia-induced cognitive deficits), providing a cohesive mechanistic basis for the constellation of cardiovascular, metabolic, and neurobehavioral symptoms. Crucially, it advances the field beyond the reactive, symptomatic management predominantly outlined in current clinical guidelines. By shifting the focus toward proactive, precision drug discovery and circuit-targeted strategies, this paradigm establishes a roadmap for developing network-based biomarkers and exploring novel disease-modifying interventions beyond conventional ventilatory support.

Keywords

PHOX2B; Autonomic nervous system; CCHS; Neural circuits; Brainstem; Circuitopathy; Network dysfunction

[SpringerLink]