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Berger SI, Miller I, Tochen L. Recessive GCH1 Deficiency Causing DOPA-Responsive Dystonia Diagnosed by Reported Negative Exome. Pediatrics 2022; 149:184563. [PMID: 35083481 PMCID: PMC8840640 DOI: 10.1542/peds.2021-052886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 02/03/2023] Open
Abstract
An exome sequencing result on a child with atypical gait was reported as negative; follow-up biochemical evaluation and reanalysis led to diagnosis of treatable DOPA-responsive dystonia.
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Affiliation(s)
- Seth I. Berger
- Children’s National Rare Disease Institute and Division of Genetics and Metabolism,Center for Genetic Medicine Research, Children’s National Research Institute, Washington, District of Columbia,Departments of Genomics and Precision Medicine,Pediatrics, School of Medicine and Health Sciences, George Washington University,Address correspondence to Seth I. Berger, MD, PhD, Center for Genetic Medicine Research, Children’s National Research Institute, 111 Michigan Ave NW, Washington DC 20010. E-mail:
| | - Ilana Miller
- Children’s National Rare Disease Institute and Division of Genetics and Metabolism
| | - Laura Tochen
- Pediatrics, School of Medicine and Health Sciences, George Washington University,Division of Neurology, Children’s National Hospital, Washington, District of Columbia
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Salles PA, Terán-Jimenez M, Vidal-Santoro A, Chaná-Cuevas P, Kauffman M, Espay AJ. Recognizing Atypical Dopa-Responsive Dystonia and Its Mimics. Neurol Clin Pract 2022; 11:e876-e884. [PMID: 34992971 DOI: 10.1212/cpj.0000000000001125] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/07/2021] [Indexed: 11/15/2022]
Abstract
Purpose of Review Dopa-responsive dystonia (DRD) encompasses a group of phenotypically and genetically heterogeneous neurochemical disorders. Classic GTP cyclohydrolase 1 (GCH-1)-associated DRD consists of early-onset lower limb asymmetrical dystonia, with sleep benefit, diurnal variation, and excellent and sustained response to low l-dopa doses. Recent Findings Unlike the classic phenotype, GCH-1-associated DRD may include features inconsistent with the original phenotype. We describe a GCH-1-associated late-onset DRD case with a family history of parkinsonism and cervical dystonia whose response to levodopa was poor and complicated with dyskinesia, blepharospasm, and severe nonmotor symptoms. We use this case as a springboard to review the spectrum of atypical DRD, DRD-plus, and DRD mimics. Summary GCH-1-related dystonia may exhibit wide intrafamilial phenotypic variability, no diurnal fluctuation, poor response to l-dopa, and such complications as dyskinesia, epilepsy, sleep disorders, autonomic dysfunction, oculogyric crisis, myoclonus, or tics. More recently, rare GCH-1 variants have been found to be associated with Parkinson disease. Clinicians should be aware of atypical DRD, DRD-plus, and DRD mimics.
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Affiliation(s)
- Philippe A Salles
- Center for the Study of Movement Disorders (CETRAM) (PAS, MT-J, PC-C), Santiago de Chile University, Santiago, Chile; Movement Disorders Section (PAS, MT-J), Neuroscience Department, Davila Clinic, Santiago, Chile; Movement Disorders Section (MT-J), Neurology Department, Felix Bulnes Hospital, Mayor University, Santiago, Chile; Neurology Department (AV-S), Fuérza Aérea de Chile Hospital, Mayor University, Santiago, Chile; Neurogenetics Unit (MK), Neurology Division, J.M. Ramos Mejía Hospital, University Center of Neurology "J.M. Ramos Mejia". Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina; Department of Neurology (AJE); and UC Gardner Neuroscience Institute and Gardner Family Center for Parkinson's Disease and Movement Disorders (AZ, AJE), University of Cincinnati, OH
| | - Mérida Terán-Jimenez
- Center for the Study of Movement Disorders (CETRAM) (PAS, MT-J, PC-C), Santiago de Chile University, Santiago, Chile; Movement Disorders Section (PAS, MT-J), Neuroscience Department, Davila Clinic, Santiago, Chile; Movement Disorders Section (MT-J), Neurology Department, Felix Bulnes Hospital, Mayor University, Santiago, Chile; Neurology Department (AV-S), Fuérza Aérea de Chile Hospital, Mayor University, Santiago, Chile; Neurogenetics Unit (MK), Neurology Division, J.M. Ramos Mejía Hospital, University Center of Neurology "J.M. Ramos Mejia". Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina; Department of Neurology (AJE); and UC Gardner Neuroscience Institute and Gardner Family Center for Parkinson's Disease and Movement Disorders (AZ, AJE), University of Cincinnati, OH
| | - Alvaro Vidal-Santoro
- Center for the Study of Movement Disorders (CETRAM) (PAS, MT-J, PC-C), Santiago de Chile University, Santiago, Chile; Movement Disorders Section (PAS, MT-J), Neuroscience Department, Davila Clinic, Santiago, Chile; Movement Disorders Section (MT-J), Neurology Department, Felix Bulnes Hospital, Mayor University, Santiago, Chile; Neurology Department (AV-S), Fuérza Aérea de Chile Hospital, Mayor University, Santiago, Chile; Neurogenetics Unit (MK), Neurology Division, J.M. Ramos Mejía Hospital, University Center of Neurology "J.M. Ramos Mejia". Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina; Department of Neurology (AJE); and UC Gardner Neuroscience Institute and Gardner Family Center for Parkinson's Disease and Movement Disorders (AZ, AJE), University of Cincinnati, OH
| | - Pedro Chaná-Cuevas
- Center for the Study of Movement Disorders (CETRAM) (PAS, MT-J, PC-C), Santiago de Chile University, Santiago, Chile; Movement Disorders Section (PAS, MT-J), Neuroscience Department, Davila Clinic, Santiago, Chile; Movement Disorders Section (MT-J), Neurology Department, Felix Bulnes Hospital, Mayor University, Santiago, Chile; Neurology Department (AV-S), Fuérza Aérea de Chile Hospital, Mayor University, Santiago, Chile; Neurogenetics Unit (MK), Neurology Division, J.M. Ramos Mejía Hospital, University Center of Neurology "J.M. Ramos Mejia". Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina; Department of Neurology (AJE); and UC Gardner Neuroscience Institute and Gardner Family Center for Parkinson's Disease and Movement Disorders (AZ, AJE), University of Cincinnati, OH
| | - Marcelo Kauffman
- Center for the Study of Movement Disorders (CETRAM) (PAS, MT-J, PC-C), Santiago de Chile University, Santiago, Chile; Movement Disorders Section (PAS, MT-J), Neuroscience Department, Davila Clinic, Santiago, Chile; Movement Disorders Section (MT-J), Neurology Department, Felix Bulnes Hospital, Mayor University, Santiago, Chile; Neurology Department (AV-S), Fuérza Aérea de Chile Hospital, Mayor University, Santiago, Chile; Neurogenetics Unit (MK), Neurology Division, J.M. Ramos Mejía Hospital, University Center of Neurology "J.M. Ramos Mejia". Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina; Department of Neurology (AJE); and UC Gardner Neuroscience Institute and Gardner Family Center for Parkinson's Disease and Movement Disorders (AZ, AJE), University of Cincinnati, OH
| | - Alberto J Espay
- Center for the Study of Movement Disorders (CETRAM) (PAS, MT-J, PC-C), Santiago de Chile University, Santiago, Chile; Movement Disorders Section (PAS, MT-J), Neuroscience Department, Davila Clinic, Santiago, Chile; Movement Disorders Section (MT-J), Neurology Department, Felix Bulnes Hospital, Mayor University, Santiago, Chile; Neurology Department (AV-S), Fuérza Aérea de Chile Hospital, Mayor University, Santiago, Chile; Neurogenetics Unit (MK), Neurology Division, J.M. Ramos Mejía Hospital, University Center of Neurology "J.M. Ramos Mejia". Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina; Department of Neurology (AJE); and UC Gardner Neuroscience Institute and Gardner Family Center for Parkinson's Disease and Movement Disorders (AZ, AJE), University of Cincinnati, OH
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Opladen T, López-Laso E, Cortès-Saladelafont E, Pearson TS, Sivri HS, Yildiz Y, Assmann B, Kurian MA, Leuzzi V, Heales S, Pope S, Porta F, García-Cazorla A, Honzík T, Pons R, Regal L, Goez H, Artuch R, Hoffmann GF, Horvath G, Thöny B, Scholl-Bürgi S, Burlina A, Verbeek MM, Mastrangelo M, Friedman J, Wassenberg T, Jeltsch K, Kulhánek J, Kuseyri Hübschmann O. Consensus guideline for the diagnosis and treatment of tetrahydrobiopterin (BH 4) deficiencies. Orphanet J Rare Dis 2020; 15:126. [PMID: 32456656 PMCID: PMC7251883 DOI: 10.1186/s13023-020-01379-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/07/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Tetrahydrobiopterin (BH4) deficiencies comprise a group of six rare neurometabolic disorders characterized by insufficient synthesis of the monoamine neurotransmitters dopamine and serotonin due to a disturbance of BH4 biosynthesis or recycling. Hyperphenylalaninemia (HPA) is the first diagnostic hallmark for most BH4 deficiencies, apart from autosomal dominant guanosine triphosphate cyclohydrolase I deficiency and sepiapterin reductase deficiency. Early supplementation of neurotransmitter precursors and where appropriate, treatment of HPA results in significant improvement of motor and cognitive function. Management approaches differ across the world and therefore these guidelines have been developed aiming to harmonize and optimize patient care. Representatives of the International Working Group on Neurotransmitter related Disorders (iNTD) developed the guidelines according to the SIGN (Scottish Intercollegiate Guidelines Network) methodology by evaluating all available evidence for the diagnosis and treatment of BH4 deficiencies. CONCLUSION Although the total body of evidence in the literature was mainly rated as low or very low, these consensus guidelines will help to harmonize clinical practice and to standardize and improve care for BH4 deficient patients.
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Affiliation(s)
- Thomas Opladen
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany.
| | - Eduardo López-Laso
- Pediatric Neurology Unit, Department of Pediatrics, University Hospital Reina Sofía, IMIBIC and CIBERER, Córdoba, Spain
| | - Elisenda Cortès-Saladelafont
- Inborn errors of metabolism Unit, Institut de Recerca Sant Joan de Déu and CIBERER-ISCIII, Barcelona, Spain
- Unit of Pediatric Neurology and Metabolic Disorders, Department of Pediatrics, Hospital Germans Trias i Pujol, and Faculty of Medicine, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Toni S Pearson
- Department of Neurology, Washington University School of Medicine, St. Louis, USA
| | - H Serap Sivri
- Department of Pediatrics, Section of Metabolism, Hacettepe University, Faculty of Medicine, 06100, Ankara, Turkey
| | - Yilmaz Yildiz
- Department of Pediatrics, Section of Metabolism, Hacettepe University, Faculty of Medicine, 06100, Ankara, Turkey
| | - Birgit Assmann
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany
| | - Manju A Kurian
- Developmental Neurosciences, UCL Great Ormond Street-Institute of Child Health, London, UK
- Department of Neurology, Great Ormond Street Hospital, London, UK
| | - Vincenzo Leuzzi
- Unit of Child Neurology and Psychiatry, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Simon Heales
- Neurometabolic Unit, National Hospital, Queen Square, London, UK
| | - Simon Pope
- Neurometabolic Unit, National Hospital, Queen Square, London, UK
| | - Francesco Porta
- Department of Pediatrics, AOU Città della Salute e della Scienza, Torino, Italy
| | - Angeles García-Cazorla
- Inborn errors of metabolism Unit, Institut de Recerca Sant Joan de Déu and CIBERER-ISCIII, Barcelona, Spain
| | - Tomáš Honzík
- Department of Paediatrics and Adolescent Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Roser Pons
- First Department of Pediatrics of the University of Athens, Aghia Sofia Hospital, Athens, Greece
| | - Luc Regal
- Department of Pediatric, Pediatric Neurology and Metabolism Unit, UZ Brussel, Brussels, Belgium
| | - Helly Goez
- Department of Pediatrics, University of Alberta Glenrose Rehabilitation Hospital, Edmonton, Canada
| | - Rafael Artuch
- Clinical biochemistry department, Institut de Recerca Sant Joan de Déu, CIBERER and MetabERN Hospital Sant Joan de Déu, Barcelona, Spain
| | - Georg F Hoffmann
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany
| | - Gabriella Horvath
- Department of Pediatrics, Division of Biochemical Genetics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Beat Thöny
- Division of Metabolism, University Children's Hospital Zurich, Zürich, Switzerland
| | - Sabine Scholl-Bürgi
- Clinic for Pediatrics I, Medical University of Innsbruck, Anichstr 35, Innsbruck, Austria
| | - Alberto Burlina
- U.O.C. Malattie Metaboliche Ereditarie, Dipartimento della Salute della Donna e del Bambino, Azienda Ospedaliera Universitaria di Padova - Campus Biomedico Pietro d'Abano, Padova, Italy
| | - Marcel M Verbeek
- Departments of Neurology and Laboratory Medicine, Alzheimer Centre, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Mario Mastrangelo
- Unit of Child Neurology and Psychiatry, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Jennifer Friedman
- UCSD Departments of Neuroscience and Pediatrics, Rady Children's Hospital Division of Neurology; Rady Children's Institute for Genomic Medicine, San Diego, USA
| | - Tessa Wassenberg
- Department of Pediatric, Pediatric Neurology and Metabolism Unit, UZ Brussel, Brussels, Belgium
| | - Kathrin Jeltsch
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany
| | - Jan Kulhánek
- Department of Paediatrics and Adolescent Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.
| | - Oya Kuseyri Hübschmann
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany
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Strasser B, Sperner-Unterweger B, Fuchs D, Gostner JM. Mechanisms of Inflammation-Associated Depression: Immune Influences on Tryptophan and Phenylalanine Metabolisms. Curr Top Behav Neurosci 2016; 31:95-115. [PMID: 27278641 DOI: 10.1007/7854_2016_23] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Metabolic parameters have a direct role in the regulation of immune cell function. Thereby the inflammation-induced metabolism of aromatic amino acids, most importantly of tryptophan and phenylalanine, plays a central role. In addition, neuropsychiatric conditions that go along with disorders that are characterized by acute or chronic inflammation, such as the development of depression, decreased quality of life or cognitive impairments, are connected to disturbed amino acid and subsequent neurotransmitter metabolism.The bioanalytical procedures for the determination of concentrations of tryptophan and phenylalanine and their respective first stable intermediates kynurenine and tyrosine as well as some analytical finesses and potential sources of errors are discussed in this chapter. Monitoring of these immunometabolic parameters throughout therapies in addition to biomarkers of immune response and inflammation such as neopterin can be useful to determine disease progression but also to plan psychiatric interventions timely, thus to establish personalized treatments.
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Affiliation(s)
- Barbara Strasser
- Division of Medical Biochemistry, Biocenter, Innsbruck Medical University, Innsbruck, Austria
| | | | - Dietmar Fuchs
- Division of Biological Chemistry, Biocenter, Innsbruck Medical University, Innrain 80, Innsbruck, Austria.
| | - Johanna M Gostner
- Division of Medical Biochemistry, Biocenter, Innsbruck Medical University, Innsbruck, Austria
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Friedman J, Roze E, Abdenur JE, Chang R, Gasperini S, Saletti V, Wali GM, Eiroa H, Neville B, Felice A, Parascandalo R, Zafeiriou DI, Arrabal-Fernandez L, Dill P, Eichler FS, Echenne B, Gutierrez-Solana LG, Hoffmann GF, Hyland K, Kusmierska K, Tijssen MAJ, Lutz T, Mazzuca M, Penzien J, Poll-The BT, Sykut-Cegielska J, Szymanska K, Thöny B, Blau N. Sepiapterin reductase deficiency: a treatable mimic of cerebral palsy. Ann Neurol 2012; 71:520-30. [PMID: 22522443 DOI: 10.1002/ana.22685] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Sepiapterin reductase deficiency (SRD) is an under-recognized levodopa-responsive disorder. We describe clinical, biochemical, and molecular findings in a cohort of patients with this treatable condition. We aim to improve awareness of the phenotype and available diagnostic and therapeutic strategies to reduce delayed diagnosis or misdiagnosis, optimize management, and improve understanding of pathophysiologic mechanisms. METHODS Forty-three individuals with SRD were identified from 23 international medical centers. The phenotype and treatment response were assessed by chart review using a detailed standardized instrument and by literature review for cases for which records were unavailable. RESULTS In most cases, motor and language delays, axial hypotonia, dystonia, weakness, oculogyric crises, and diurnal fluctuation of symptoms with sleep benefit become evident in infancy or childhood. Average age of onset is 7 months, with delay to diagnosis of 9.1 years. Misdiagnoses of cerebral palsy (CP) are common. Most patients benefit dramatically from levodopa/carbidopa, often with further improvement with the addition of 5-hydroxytryptophan. Cerebrospinal fluid findings are distinctive. Diagnosis is confirmed by mutation analysis and/or enzyme activity measurement in cultured fibroblasts. INTERPRETATION Common, clinical findings of SRD, aside from oculogyric crises and diurnal fluctuation, are nonspecific and mimic CP with hypotonia or dystonia. Patients usually improve dramatically with treatment. Consequently, we recommend consideration of SRD not only in patients with levodopa-responsive motor disorders, but also in patients with developmental delays with axial hypotonia, and patients with unexplained or atypical presumed CP. Biochemical investigation of cerebrospinal fluid is the preferred method of initial investigation. Early diagnosis and treatment are recommended to prevent ongoing brain dysfunction.
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Affiliation(s)
- Jennifer Friedman
- Departments of Neurosciences and Pediatrics, University of California at San Diego and Rady Children's Hospital, USA.
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