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Salardaine Q, Shor N, Villain N, Bozon F, Amador MDM, Duchon C, Mélé N, Schiff M, Brassier A, Nadjar Y. Cognitive impairment in children and adults with cerebrotendinous xanthomatosis: A French cohort study. J Inherit Metab Dis 2024. [PMID: 38897600 DOI: 10.1002/jimd.12765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/06/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024]
Abstract
Cerebrotendinous xanthomatosis is a rare and treatable metabolic disorder related to the accumulation of cholestanol. This disorder is primarily associated with motor and cognitive impairments, although the latter has not been extensively characterized. The objectives of this work were to define the cognitive profile found in cerebrotendinous xanthomatosis patients, investigate the progression of cognitive impairment over time, and search for radio-clinical correlations. Through a multicentric chart review study, we collected cognitive and radiological data from nine children and eighteen adults with genetically proven cerebrotendinous xanthomatosis. We performed a volumetric and morphological analysis of the brain magnetic resonance imaging. In our cohort, 44% (4/9) of children and 78% (14/18) of adults exhibited cognitive impairment that can be severe. The study revealed a significant impairment in various cognitive domains, specifically executive, attentional, language, and visuo-spatial. Among adults, 16% (3/18) developed dementia after age 50. These three patients had delayed chenodeoxycholic acid treatment and important cerebral atrophy. Besides these three cases of late-onset cognitive decline, Mini-Mental State Evaluation was generally stable, suggesting cognitive impairment due to a neurodevelopmental disorder and persisting in adulthood. Cognitive impairment was less common in children, possibly related to early chenodeoxycholic acid treatment in our cohort. The severity of magnetic resonance imaging abnormalities did not predict cognitive impairment in patients. Overall, in cerebrotendinous xanthomatosis, cognitive impairment can be severe and mainly neurodevelopmental. Early chenodeoxycholic acid treatment might be associated with a reduced risk of cognitive decline.
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Affiliation(s)
- Quentin Salardaine
- Neurology Department, AP-HP Sorbonne University, Pitié-Salpêtrière University Hospital, Paris, France
| | - Natalia Shor
- Neuroradiology Department, Pitié-Salpêtrière University Hospital, AP-HP, Sorbonne University, Paris, France
| | - Nicolas Villain
- Neurology Department, AP-HP Sorbonne University, Pitié-Salpêtrière University Hospital, Paris, France
- Institut du Cerveau - ICM, Sorbonne Université, INSERM U1127, CNRS 7225, Paris, France
| | - Frédérique Bozon
- Neurology Department, AP-HP Sorbonne University, Pitié-Salpêtrière University Hospital, Paris, France
| | - Maria Del Mar Amador
- Neurology Department, National Reference center ALS, Pitié-Salpêtrière University Hospital, AP-HP Sorbonne University, Paris, France
| | - Clarisse Duchon
- Inherited Metabolic Disease Department and National Reference Centre for Inherited Metabolic diseases, Necker Hospital, AP-HP Centre-Paris University, Paris, France
| | - Nicolas Mélé
- Neurology Department, GHU Paris Psychiatrie et Neurosciences, Université Paris Cité, Sainte-Anne Hospital, Paris, France
| | - Manuel Schiff
- Paediatrics Department, Reference Center for Inborn Error of Metabolism, Necker and Robert-Debré Hospital, AP-HP, Université Paris Cité, Paris, France
| | - Anaïs Brassier
- Inherited Metabolic Disease Department and National Reference Centre for Inherited Metabolic diseases, Necker Hospital, AP-HP Centre-Paris University, Paris, France
| | - Yann Nadjar
- Neurology Department, Reference Center for Neurological Metabolic and Lysosomal Diseases, Pitié-Salpêtrière University Hospital, AP-HP Sorbonne University, Paris, France
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Zubarioglu T, Kıykım E, Köse E, Eminoğlu FT, Teke Kısa P, Balcı MC, Özer I, İnci A, Çilesiz K, Canda E, Yazıcı H, Öztürk-Hişmi B, Bulut FD, Dorum S, Akgun A, Yalçın-Çakmaklı G, Kılıç-Yıldırım G, Soyuçen E, Akçalı A, Güneş D, Durmuş A, Gündüz A, Kasapkara ÇS, Göksoy E, Akar HT, Ersoy M, Erdöl Ş, Yıldız Y, Hanağası HA, Arslan N, Aktuğlu-Zeybek Ç. Clinical, biochemical, and molecular insights into Cerebrotendinous Xanthomatosis: A nationwide study of 100 Turkish individuals. Mol Genet Metab 2024; 142:108493. [PMID: 38772327 DOI: 10.1016/j.ymgme.2024.108493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 05/23/2024]
Abstract
OBJECTIVE Cerebrotendinous xanthomatosis (CTX) is an inherited metabolic disorder characterized by progressive neurologic and extraneurologic findings. The aim of this retrospective, descriptive study was to explore the time of presentation and diagnosis, and to expand the phenotype and genotype of CTX, based on a nationwide and comprehensive series of patients in Turkey. METHODS The demographic, clinical, biochemical and genotypic characteristics of the CTX patients were reviewed. Data on molecular analysis, age of onset and diagnosis, diagnostic delay, neurologic and extraneurologic symptomatology, results of plasma cholestanol levels, brain magnetic resonance imaging and electromyography at the time of diagnosis were reviewed. RESULTS 100 confirmed CTX patients from 72 families were included. The mean age at diagnosis was 28.16 ± 14.28 years, and diagnostic delay was 18.39 ± 13.71 years. 36 patients were diagnosed in childhood. Frequency of intention tremor (p = 0.069), peripheral neuropathy (p = 0.234) and psychiatric manifestations (p = 0.396) did not differ between two groups, demonstrating the high rate in pediatric patients. Three adult patients showed a milder phenotype without neurologic involvement. Seven patients had normal plasma cholestanol levels despite neurological impairment. Sequencing of the CYP27A1 gene revealed 25 different variants, with a novel c.671_672del variant not previously described in literature. CONCLUSION Based on the observations of this Turkish CTX cohort, it is emphasized that the true prevalence of CTX is probably underestimated and that it has a wide spectrum of clinical phenotypes even without neurological impairment. In children, abnormal cerebellar findings, peripheral neuropathy and psychiatric findings associated with intellectual disability have been suggested as warning signs to avoid diagnostic delay. In cases of clinical suspicion, molecular analysis is recommended despite normal plasma cholestanol levels, as severe neurologic involvement may occur in CTX patients without elevated cholestanol levels.
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Affiliation(s)
- Tanyel Zubarioglu
- İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Division of Pediatric Nutrition and Metabolism, İstanbul, Turkey.
| | - Ertuğrul Kıykım
- İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Division of Pediatric Nutrition and Metabolism, İstanbul, Turkey
| | - Engin Köse
- Ankara University, Faculty of Medicine, Department of Pediatric Metabolism, Ankara, Turkey; Ankara University Rare Diseases Application and Research Center, Ankara, Turkey
| | - Fatma Tuba Eminoğlu
- Ankara University, Faculty of Medicine, Department of Pediatric Metabolism, Ankara, Turkey; Ankara University Rare Diseases Application and Research Center, Ankara, Turkey
| | - Pelin Teke Kısa
- Dokuz Eylul University Medical Faculty, Division of Pediatric Nutrition and Metabolism, Izmir, Turkey
| | - Mehmet Cihan Balcı
- Istanbul University, Istanbul Medical Faculty Children's Hospital, Division of Nutrition and Metabolism, Istanbul, Turkey
| | - Işıl Özer
- Ondokuz Mayıs University, Faculty of Medicine, Department of Pediatric Metabolism, Samsun, Turkey; Kafkas University, Division of Pediatric Nutrition and Metabolism, Kars, Turkey
| | - Aslı İnci
- Gazi University School of Medicine, Division of Pediatric Nutrition and Metabolism, Ankara, Turkey
| | - Kübra Çilesiz
- Gazi University School of Medicine, Division of Pediatric Nutrition and Metabolism, Ankara, Turkey
| | - Ebru Canda
- Ege University Medical Faculty, Division of Pediatric Nutrition and Metabolism, İzmir, Turkey
| | - Havva Yazıcı
- Ege University Medical Faculty, Division of Pediatric Nutrition and Metabolism, İzmir, Turkey
| | - Burcu Öztürk-Hişmi
- Marmara University School of Medicine, Division of Pediatric Metabolic Disorders, İstanbul, Turkey
| | - Fatma Derya Bulut
- Cukurova University Medical Faculty, Division of Pediatric Metabolism and Nutrition, Adana, Turkey
| | - Sevil Dorum
- Health Sciences University, Bursa Yuksek Ihtisas Training and Research Hospital, Division of Pediatric Nutrition and Metabolism, Bursa, Turkey
| | - Abdurrahman Akgun
- Firat University, School of Medicine, Department of Pediatrics, Division of Pediatric Metabolic Diseases, Elazığ, Turkey
| | - Gül Yalçın-Çakmaklı
- Hacettepe University Faculty of Medicine, Department of Neurology, Ankara, Turkey
| | - Gonca Kılıç-Yıldırım
- Eskisehir Osmangazi University, Faculty of Medicine, Pediatric Nutrition and Metabolism Unit, Eskişehir, Turkey
| | - Erdoğan Soyuçen
- Akdeniz University Faculty of Medicine, Department of Pediatrics, Division of Inherited Pediatric Metabolic Diseases, Antalya, Turkey
| | - Aylin Akçalı
- Gaziantep University Faculty of Medicine, Department of Neurology, Gaziantep, Turkey
| | - Dilek Güneş
- Bağcılar Training and Research Hospital, Division of Inborn Metabolic Disease, İstanbul, Turkey
| | - Aslı Durmuş
- Kanuni Training and Research Hospital, Division of Pediatric Metabolism, Trabzon, Turkey
| | - Ayşegül Gündüz
- İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Department of Neurology, İstanbul, Turkey
| | - Çiğdem Seher Kasapkara
- Ankara Yıldırım Beyazıt University, Ankara Bilkent City Hospital, Department of Pediatric Metabolism, Ankara, Turkey
| | - Emine Göksoy
- Adnan Menderes University Medical Faculty, Division of Pediatric Metabolism, Aydın, Turkey
| | - Halil Tuna Akar
- Ankara Etlik City Hospital, Pediatric Metabolic Diseases Unit, Ankara, Turkey
| | - Melike Ersoy
- Health Sciences University, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Pediatrics, Division of Pediatric Metabolic Diseases, İstanbul, Turkey
| | - Şahin Erdöl
- Bursa Uludag University Faculty of Medicine, Department of Pediatrics, Division of Metabolism, Bursa, Turkey
| | - Yılmaz Yıldız
- Hacettepe University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Metabolism, Ankara, Turkey
| | | | - Nur Arslan
- Dokuz Eylul University Medical Faculty, Division of Pediatric Nutrition and Metabolism, Izmir, Turkey
| | - Çiğdem Aktuğlu-Zeybek
- İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Division of Pediatric Nutrition and Metabolism, İstanbul, Turkey
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DeBarber AE, Schaefer EJ, Do J, Ray JW, Larson A, Redder S, Fowler M, Duell PB. Genetically and clinically confirmed atypical cerebrotendinous xanthomatosis with normal cholestanol and marked elevations of bile acid precursors and bile alcohols. J Clin Lipidol 2024:S1933-2874(24)00039-4. [PMID: 38637260 DOI: 10.1016/j.jacl.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 02/07/2024] [Accepted: 03/13/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive lipid disorder. Affected patients often remain undiagnosed until the age of 20-30 years, when they have already developed significant neurologic disease that may not be reversible. An elevated plasma cholestanol concentration has been accepted as a diagnostic criterion for CTX for decades. OBJECTIVE Full biochemical characterization was performed for three genetically and clinically confirmed atypical CTX cases with normal plasma cholestanol levels. METHODS Clinical assessment, and genetic/biochemical testing for patients with CTX was performed by their physician providing routine standard of care. RESULTS We report three new atypical CTX cases with large extensor tendon xanthomas but normal plasma cholestanol levels. All three cases had marked elevations of bile acid precursors and bile alcohols in plasma and urine that decreased on treatment with chenodeoxycholic acid. We also review eight published cases of atypical CTX with normal/near normal circulating cholestanol levels. CONCLUSION The atypical biochemical presentation of these cases provides a diagnostic challenge for CTX; a disorder for which cholestanol has been believed to be a sensitive biomarker. These cases demonstrate measurements of plasma cholestanol alone are insufficient to exclude a diagnosis of CTX. The data presented is consistent with the concept that bile acid precursors and bile alcohols are sensitive biomarkers for atypical CTX with normal cholestanol, and that such testing is indicated, along with CYP27A1 gene analyses, in patients presenting with significant tendon and/or tuberous xanthomas and/or neurologic disease in early adulthood despite normal or near normal cholesterol and cholestanol levels.
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Affiliation(s)
- Andrea E DeBarber
- University Shared Resources, Oregon Health & Science University (OHSU), Portland, OR, United States of America (Dr DeBarber, Ms Redder and Ms Fowler).
| | - Ernst J Schaefer
- Boston Heart Diagnostics/Eurofins Scientific Network, Framingham, MA, United States of America and Department of Medicine, Tufts University School of Medicine, Boston, MA, United States of America (Dr Schaefer)
| | - Jenny Do
- Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, United States of America (Ms Do and Dr Ray)
| | - Joseph W Ray
- Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, United States of America (Ms Do and Dr Ray)
| | - Austin Larson
- University of Colorado School of Medicine, Aurora, CO, United States of America (Dr Larson)
| | - Samantha Redder
- University Shared Resources, Oregon Health & Science University (OHSU), Portland, OR, United States of America (Dr DeBarber, Ms Redder and Ms Fowler)
| | - Maya Fowler
- University Shared Resources, Oregon Health & Science University (OHSU), Portland, OR, United States of America (Dr DeBarber, Ms Redder and Ms Fowler)
| | - P Barton Duell
- Center for Preventive Cardiology, Knight Cardiovascular Institute & Division of Endocrinology, Diabetes & Clinical Nutrition, OHSU, Portland, OR, United States of America (Dr Duell)
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Steiner RD, DeBarber A, Larson A, Blanchard B, Laurie S, Odedara N, Rosengrant H, Dutta R. Living with Cerebrotendinous Xanthomatosis: Patient, Caregiver, and Expert Perspectives. Adv Ther 2024; 41:467-475. [PMID: 38110654 PMCID: PMC10838853 DOI: 10.1007/s12325-023-02687-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/14/2023] [Indexed: 12/20/2023]
Abstract
In this article, patients with cerebrotendinous xanthomatosis (CTX) and caregivers detail their experience with lifelong symptoms, diagnosis, treatment and efficacy, and ongoing disease management. One patient and four caregivers describe the challenges associated with pursuing a correct diagnosis for years before testing confirmed a CTX diagnosis. They also detail their ongoing struggles and desire for greater access to physicians with CTX knowledge and to reliable online resources to continue their education about the disease and strategies for symptom management. The expert perspective is a direct response by three CTX researchers, including physicians who are treating patients with CTX in the United States and experts whose laboratories provide genetic and biochemical testing for CTX. They respond to many of the patient and caregiver concerns, including steps that are being taken to identify CTX earlier and provide access to confirmatory diagnostic testing sooner, and suggest the best online resources for CTX-related information and access to webinars and support groups. While the expert perspective is a direct response to the patient and caregiver authors' CTX journeys, it should be beneficial to any patient with CTX or their caregivers.
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Affiliation(s)
- Robert D Steiner
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Andrea DeBarber
- University Shared Resources, Oregon Health and Science University, Portland, OR, USA
| | - Austin Larson
- Department of Pediatrics, Section of Genetics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | | | | | - Rana Dutta
- Mirum Pharmaceuticals, Inc., 950 Tower Lane Suite 1050, Foster City, CA, 94404, USA.
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Senarathne UD, Indika NLR, Jezela-Stanek A, Ciara E, Frye RE, Chen C, Stepien KM. Biochemical, Genetic and Clinical Diagnostic Approaches to Autism-Associated Inherited Metabolic Disorders. Genes (Basel) 2023; 14:genes14040803. [PMID: 37107561 PMCID: PMC10138025 DOI: 10.3390/genes14040803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/22/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
Autism spectrum disorders (ASD) are a heterogeneous group of neurodevelopmental disorders characterized by impaired social interaction, limited communication skills, and restrictive and repetitive behaviours. The pathophysiology of ASD is multifactorial and includes genetic, epigenetic, and environmental factors, whereas a causal relationship has been described between ASD and inherited metabolic disorders (IMDs). This review describes biochemical, genetic, and clinical approaches to investigating IMDs associated with ASD. The biochemical work-up includes body fluid analysis to confirm general metabolic and/or lysosomal storage diseases, while the advances and applications of genomic testing technology would assist with identifying molecular defects. An IMD is considered likely underlying pathophysiology in ASD patients with suggestive clinical symptoms and multiorgan involvement, of which early recognition and treatment increase their likelihood of achieving optimal care and a better quality of life.
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Affiliation(s)
- Udara D. Senarathne
- Department of Biochemistry, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda 10250, Sri Lanka
- Department of Chemical Pathology, Monash Health Pathology, Monash Health, Melbourne, VIC 3168, Australia
| | - Neluwa-Liyanage R. Indika
- Department of Biochemistry, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda 10250, Sri Lanka
| | - Aleksandra Jezela-Stanek
- Department of Genetics and Clinical Immunology, National Institute of Tuberculosis and Lung Diseases, 01-138 Warsaw, Poland
| | - Elżbieta Ciara
- Department of Medical Genetics, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland
| | - Richard E. Frye
- Autism Discovery and Treatment Foundation, Phoenix, AZ 85050, USA
| | - Cliff Chen
- Clinical Neuropsychology Department, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Karolina M. Stepien
- Adult Inherited Metabolic Diseases, Mark Holland Unit, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester M13 9PL, UK
- Correspondence:
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Pramparo T, Steiner RD, Rodems S, Jenkinson C. Allelic prevalence and geographic distribution of cerebrotendinous xanthomatosis. Orphanet J Rare Dis 2023; 18:13. [PMID: 36650582 PMCID: PMC9843874 DOI: 10.1186/s13023-022-02578-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/20/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Cerebrotendinous xanthomatosis (CTX) is a rare recessive genetic disease characterized by disruption of bile acid synthesis due to inactivation of the CYP27A1 gene. Treatment is available in the form of bile acid replacement. CTX is likely underdiagnosed, and prevalence estimates based on case diagnosis are probably inaccurate. Large population-based genomic databases are a valuable resource to estimate prevalence of rare recessive diseases as an orthogonal unbiased approach building upon traditional epidemiological studies. METHODS We leveraged the Hardy-Weinberg principle and allele frequencies from gnomAD to calculate CTX prevalence. ClinVar and HGMD were used to identify high-confidence pathogenic missense variants and to calculate a disease-specific cutoff. Variant pathogenicity was also assessed by the VarSome implementation of the ACMG/AMP algorithm and the REVEL in silico predictor. RESULTS CTX prevalence estimates were highest in Asians (1:44,407-93,084) and lowest in the Finnish population (1:3,388,767). Intermediate estimates were found in Europeans, Americans, and Africans/African Americans (1:70,795-233,597). The REVEL-predicted pathogenic variants accounted for a greater increase in prevalence estimates for Europeans, Americans, and Africans/African Americans compared with Asians. We identified the most frequent alleles designated pathogenic in ClinVar (p.Gly472Ala, p.Arg395Cys), labeled pathogenic based on sequence consequence (p.Met1?), and predicted to be pathogenic by REVEL (p.Met383Lys, p.Arg448His) across populations. Also, we provide a prospective geographic map of estimated disease distribution based on CYP27A1 variation queries performed by healthcare providers from selected specialties. CONCLUSIONS Prevalence estimates calculated herein support and expand upon existing evidence indicating underdiagnosis of CTX, suggesting that improved detection strategies are needed. Increased awareness of CTX is important for early diagnosis, which is essential for patients as early treatment significantly slows or prevents disease progression.
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Affiliation(s)
- Tiziano Pramparo
- Travere Therapeutics, Inc., 3611 Valley Centre Dr Suite 300, San Diego, CA, 92130, USA.
| | - Robert D. Steiner
- grid.14003.360000 0001 2167 3675Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 USA
| | - Steve Rodems
- Travere Therapeutics, Inc., 3611 Valley Centre Dr Suite 300, San Diego, CA 92130 USA
| | - Celia Jenkinson
- Travere Therapeutics, Inc., 3611 Valley Centre Dr Suite 300, San Diego, CA 92130 USA
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van de Burgt N, van Doesum W, Grevink M, van Niele S, de Koning T, Leibold N, Martinez-Martinez P, van Amelsvoort T, Cath D. Psychiatric manifestations of inborn errors of metabolism: A systematic review. Neurosci Biobehav Rev 2023; 144:104970. [PMID: 36436739 DOI: 10.1016/j.neubiorev.2022.104970] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
Inborn errors of metabolism (IEMs) are characterized by deficits in metabolic enzymes as a result of an inherited disease, leading to the accumulation or decreased excretion of proteins, carbohydrates and lipids. Although IEMs are often diagnosed during childhood, adolescent and adult onset variants may be accompanied by less somatic and more psychiatric manifestations, which often hampers recognition by psychiatrists of the distinction between a primary and secondary psychiatric disorder. To help clinicians in the diagnostic process, we aimed to provide an overview of psychiatric manifestations in IEMs. Our literature search yielded 4380 records in total, of which 88 studies were included in the qualitative synthesis. Reported psychiatric disorders in adolescent and adult IEMs included depression, anxiety disorder, psychosis, attention deficit hyperactivity disorder, autism spectrum disorder, bipolar disorder and obsessive-compulsive disorder as assessed by semi-structured diagnostic interviews and validated questionnaires. A diagnostic screener and multidisciplinary IEM clinics are proposed to help clinicians during the diagnostic process, to prevent diagnostic delay and to raise awareness of the psychiatric manifestations among IEMs.
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Affiliation(s)
- Nikita van de Burgt
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNs), Faculty of Health and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands.
| | - Willem van Doesum
- Department of Psychiatry, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands; Department of Specialized Training, GGZ Drenthe Mental Health Institute, Assen, the Netherlands
| | - Mirjam Grevink
- Department of Specialized Training, GGZ Drenthe Mental Health Institute, Assen, the Netherlands
| | - Stephanie van Niele
- Department of Specialized Training, GGZ Drenthe Mental Health Institute, Assen, the Netherlands
| | - Tom de Koning
- Department of Specialized Training, GGZ Drenthe Mental Health Institute, Assen, the Netherlands; Department of Neurology and Genetics, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands; Department of Pediatrics, Lund University, Lund, Sweden
| | - Nicole Leibold
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNs), Faculty of Health and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands
| | - Pilar Martinez-Martinez
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNs), Faculty of Health and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands
| | - Therese van Amelsvoort
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNs), Faculty of Health and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands
| | - Danielle Cath
- Department of Psychiatry, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands; Department of Specialized Training, GGZ Drenthe Mental Health Institute, Assen, the Netherlands
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8
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Badura-Stronka M, Hirschfeld AS, Winczewska-Wiktor A, Budzyńska E, Jakubiuk-Tomaszuk A, Piontek A, Steinborn B, Kozubski W. First case series of Polish patients with cerebrotendinous xanthomatosis and systematic review of cases from the 21st century. Clin Genet 2021; 101:190-207. [PMID: 34689324 DOI: 10.1111/cge.14079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 12/27/2022]
Abstract
Cerebrotendinous xanthomatosis (CTX) is an inborn error of metabolism caused by recessive variants in the cytochrome P450 CYP27A1 gene. CTX is said to manifest with childhood-onset chronic diarrhea and the classic triad of juvenile-onset cataracts, Achilles tendons xanthomas, and progressive ataxia. It is currently one of the few inherited neurometabolic disorders amenable to a specific treatment. The diagnosis may be significantly delayed resulting in permanent neurological impairment. A retrospective review of the clinical characteristics and diagnostic findings in case series of six Polish patients with CTX. Additional retrospective review of symptoms and pathogenic variants of 568 CTX available cases and case series from the past 20 years. To the best of our knowledge, this is the widest review of CTX cases reported in years 2000-2021. We report the largest cohort of Polish patients ever published, with the identification of two hot-spot mutations. During the review of available 568 cases, we found significant differences in the clinical phenotypes and the localization of variants within the gene between Asian and non-Asian populations. These findings may facilitate molecular testing in the Polish and Asian populations. Invariably better screening for CTX and wider awareness is needed.
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Affiliation(s)
- Magdalena Badura-Stronka
- Department of Medical Genetics, Poznan University of Medical Sciences, Poznan, Poland.,Centers for Medical Genetics GENESIS, Poznan, Poland
| | | | | | - Edyta Budzyńska
- Central Teaching Hospital, The Medical University of Lodz, Poland
| | - Anna Jakubiuk-Tomaszuk
- Department of Pediatric Neurology and Rehabilitation, Medical University of Bialystok, Poland.,Medical Genetics Unit, Mastermed Medical Center, Poland
| | - Anita Piontek
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Barbara Steinborn
- Department of Child Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Wojciech Kozubski
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
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Stelten BML, Dotti MT, Verrips A, Elibol B, Falik-Zaccai TC, Hanman K, Mignarri A, Sithole B, Steiner RD, Verma S, Yahalom G, Zubarioglu T, Mochel F, Federico A. Expert opinion on diagnosing, treating and managing patients with cerebrotendinous xanthomatosis (CTX): a modified Delphi study. Orphanet J Rare Dis 2021; 16:353. [PMID: 34362411 PMCID: PMC8349076 DOI: 10.1186/s13023-021-01980-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/25/2021] [Indexed: 11/10/2022] Open
Abstract
Background Cerebrotendinous xanthomatosis (CTX) is a rare, chronic, progressive, neurodegenerative disorder requiring life-long care. Patients with CTX often experience a diagnostic delay. Although early diagnosis and treatment initiation can improve symptoms and prognosis, a standardised approach to diagnosis, treatment and management of patients is not yet established. Aim To assess expert opinion on best care practices for patients with CTX using a modified Delphi method. Methods A multidisciplinary group of healthcare professionals with expertise in CTX responded to a 3-round online questionnaire (n = 10 in Rounds 1 and 2; n = 9 in Round 3), containing questions relating to the diagnosis, treatment, monitoring, multidisciplinary care and prognosis of patients with CTX. Determination of consensus achievement was based on a pre-defined statistical threshold of ≥ 70% Delphi panellists selecting 1–2 (disagreement) or 5–6 (agreement) for 6-point Likert scale questions, or ≥ 70% Delphi panellists choosing the same option for ranking and proportion questions. Results Of the Round 1 (n = 22), Round 2 (n = 32) and Round 3 (n = 26) questions for which consensus was assessed, 59.1%, 21.9% and 3.8% reached consensus, respectively. Consensus agreement that genetic analyses and/or determination of serum cholestanol levels should be used to diagnose CTX, and dried bloodspot testing should facilitate detection in newborns, was reached. Age at diagnosis and early treatment initiation (at birth, where possible) were considered to have the biggest impact on treatment outcomes. All panellists agreed that chenodeoxycholic acid (CDCA) is a lifetime replacement therapy which, if initiated early, can considerably improve prognosis as it may be capable of reversing the pathophysiological process in CTX. No consensus was reached on the value of cholic acid therapy alone. Monitoring patients through testing plasma cholestanol levels and neurologic examination was recommended, although further research regarding monitoring treatment and progression of the disease is required. Neurologists and paediatricians/metabolic specialists were highlighted as key clinicians that should be included in the multidisciplinary team involved in patients’ care. Conclusions The results of this study provide a basis for standardisation of care and highlight key areas where further research is needed to inform best practices for the diagnosis, treatment and management of patients with CTX. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-01980-5.
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Affiliation(s)
- Bianca M L Stelten
- Department of Neurology, Catharina Hospital, Eindhoven, The Netherlands.
| | - Maria Teresa Dotti
- Department of Medicine, Surgery and Neurosciences, Medical School, University of Siena and UO Clinical Neurology and Neurometabolic Diseases, AOU Senese, Siena, Italy
| | - Aad Verrips
- Department of Neurology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Bülent Elibol
- Hacettepe University Medical Faculty Hospital, Ankara, Turkey
| | - Tzipora C Falik-Zaccai
- Institute of Human Genetics, Galilee Medical Center, Naharia, Israel.,The Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | | | - Andrea Mignarri
- UO Clinical Neurology and Neurometabolic Diseases, AOU Senese, Siena, Italy
| | | | - Robert D Steiner
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Marshfield Clinic Health System, Marshfield, WI, USA
| | | | - Gilad Yahalom
- Shaare Zedek Medical Center, Jerusalem, Israel.,Sheba Medical Center, Ramat Gan, Israel
| | - Tanyel Zubarioglu
- Division of Pediatric Nutrition and Metabolism, Department of Pediatrics, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Fanny Mochel
- Reference Center for Adult Neurometabolic Diseases, Department of Genetics, La Pitié-Salpêtrière University Hospital, Paris, France
| | - Antonio Federico
- Department of Medicine, Surgery and Neurosciences, Medical School, University of Siena, Siena, Italy
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10
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Guidara W, Messedi M, Maalej M, Naifar M, Khrouf W, Grayaa S, Maalej M, Bonnefont-Rousselot D, Lamari F, Ayadi F. Plasma oxysterols: Altered level of plasma 24-hydroxycholesterol in patients with bipolar disorder. J Steroid Biochem Mol Biol 2021; 211:105902. [PMID: 33901658 DOI: 10.1016/j.jsbmb.2021.105902] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 04/09/2021] [Accepted: 04/20/2021] [Indexed: 12/13/2022]
Abstract
Cholesterol and its oxygenated metabolites, including oxysterols, are intensively investigated as potential players in the pathophysiology of brain disorders. Altered oxysterol levels have been described in patients with numerous neuropsychiatric disorders. Recent studies have shown that Bipolar disorder (BD) is associated with the disruption of cholesterol metabolism. The present study was aimed at investigating the profile of oxysterols in plasma, their ratio to total cholesterol and their association with clinical parameters in patients with BD. Thirty three men diagnosed with BD and forty healthy controls matched for age and sex were included in the study. Oxysterol levels were measured by isotope-dilution ultra-performance liquid chromatography-tandem mass spectrometry. Significantly higher levels were observed for cholestane-3β,5α,6β-triol, 27-hydroxycholesterol (27-OHC) and Cholestanol in patients with BD. The concentration of 24-hydroxycholesterol (24-OHC) was significantly lower in patients compared to controls. 24-OHC was also negatively correlated to MAS subscale score (r =-0.343; p = 0.049). In patients, 24-OHC was inversely correlated with age (r = -0.240; p = 0.045). Multivariate analysis found that BD acute decompensation was independently related to the rise in plasma 24-OHC (p = 0.002; OR = 0.966, 95 % CI [0.945 - 0.987]). However, the 24-OHC assay relevance as a biomarker of this disease deserves further investigation in other studies.
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Affiliation(s)
- Wassim Guidara
- Laboratory of Research "Molecular Basis of Human Diseases", LR19ES13, Faculty of Medicine, University of Sfax, Sfax, Tunisia.
| | - Meriam Messedi
- Laboratory of Research "Molecular Basis of Human Diseases", LR19ES13, Faculty of Medicine, University of Sfax, Sfax, Tunisia
| | - Manel Maalej
- Psychiatry C-department, University of Sfax & Hédi Chaker Hospital, Sfax, Tunisia
| | - Manel Naifar
- Laboratory of Research "Molecular Basis of Human Diseases", LR19ES13, Faculty of Medicine, University of Sfax, Sfax, Tunisia; Laboratory of Biochemistry, University of Sfax & Habib Bourguiba Hospital, Sfax, Tunisia
| | - Walid Khrouf
- AP-HP, Sorbonne University, La Pitié-Salpêtrière University Hospital, Department of Metabolic Biochemistry, Paris, France
| | - Sahar Grayaa
- Laboratory of Research "Molecular Basis of Human Diseases", LR19ES13, Faculty of Medicine, University of Sfax, Sfax, Tunisia
| | - Mohamed Maalej
- Psychiatry C-department, University of Sfax & Hédi Chaker Hospital, Sfax, Tunisia
| | - Dominique Bonnefont-Rousselot
- AP-HP, Sorbonne University, La Pitié-Salpêtrière University Hospital, Department of Metabolic Biochemistry, Paris, France; UTCBS, U1267 Inserm, UMR 8258 CNRS, Université de Paris, Paris, France
| | - Foudil Lamari
- AP-HP, Sorbonne University, La Pitié-Salpêtrière University Hospital, Department of Metabolic Biochemistry, Paris, France
| | - Fatma Ayadi
- Laboratory of Research "Molecular Basis of Human Diseases", LR19ES13, Faculty of Medicine, University of Sfax, Sfax, Tunisia; Laboratory of Biochemistry, University of Sfax & Habib Bourguiba Hospital, Sfax, Tunisia
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11
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Guenzel AJ, DeBarber A, Raymond K, Dhamija R. Familial variability of cerebrotendinous xanthomatosis lacking typical biochemical findings. JIMD Rep 2021; 59:3-9. [PMID: 33977023 PMCID: PMC8100391 DOI: 10.1002/jmd2.12197] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 12/11/2022] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive disorder of bile acid synthesis caused by pathogenic variants in the CYP27A1 gene encoding the mitochondrial enzyme sterol 27-hydroxylase. Patients with CTX can present with a wide range of symptoms, but most often have evidence of tendon xanthomas along with possible cataracts, atherosclerosis, or neurological dysfunction. Regardless of clinical phenotype, CTX patients typically exhibit levels of cholestanol and bile acid precursors in the circulation that are many fold increased over normal control concentrations. Here we report two siblings, one with the rare spinal xanthomatosis phenotype and the other with a very mild form of CTX manifesting as minor tendon xanthomatosis and gastrointestinal complaints who both carry compound heterozygous variants in CYP27A1: NM_000784.3: c.410G > A (p.Arg137Gln) and c.1183C > T (p.Arg395Cys). However, biochemical analysis of these patients revealed normal levels of serum cholestanol and relatively mild elevations of the bile acid precursors 7α-hydroxy-4-cholesten-3-one and 7α,12α-dihydroxy-4-cholesten-3-one. The atypical biochemical presentation of these cases represents a diagnostic challenge for a disorder once thought to have a sensitive biomarker in cholestanol and highlight the need for thorough investigation of patients with symptomatology consistent with CTX that includes bile acid precursor biochemical testing and molecular analysis.
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Affiliation(s)
- Adam J. Guenzel
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | - Andrea DeBarber
- Department of Chemical Physiology and BiochemistryOregon Health and Science UniversityPortlandOregonUSA
| | - Kimiyo Raymond
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | - Radhika Dhamija
- Department of Clinical Genomics and NeurologyMayo ClinicScottsdaleArizonaUSA
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12
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Abstract
PURPOSE OF REVIEW Cerebrotendinous xanthomatosis (CTX) is a rare genetic lipid storage disorder with highly pleomorphic clinical phenotype. Complications of this disease can be devastating and may include severe cognitive impairment and dementia in later stages. Disease progression can be prevented or stabilized by bile acid replacement therapy, although a subset of patients with advanced disease continue to deteriorate despite therapy. RECENT FINDINGS Delayed diagnosis of CTX continues to impede effective treatment. A clinical diagnostic algorithm for CTX was developed that can decrease the age of diagnosis of CTX. The strategy of screening children with bilateral juvenile cataracts for CTX also improved diagnosis, as this group had a 500-fold higher-rate of CTX than the general population. Improved diagnosis of CTX is critical, as patients treated early in the course of the disease have significantly better outcomes compared with those treated later. More sensitive and specific biochemical testing for CTX has been developed that is potentially more informative than blood cholestanol to assess treatment efficacy and medication compliance in CTX. SUMMARY Because we are recognizing more severe presentations of CTX in infants and children, and delayed diagnosis and treatment worsens the prognosis, CTX is an excellent candidate disorder for newborn screening using recently reported methods for newborn dried bloodspot analysis.
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Affiliation(s)
| | - P Barton Duell
- Knight Cardiovascular Institute, and Division of Endocrinology, Diabetes & Clinical Nutrition, Oregon Health & Science University, Portland, Oregon, USA
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13
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Affiliation(s)
- Qian Qian
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Du Cao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - You-Dong Wei
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Neurobiology, Chongqing, China
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14
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Stelten BM, Huidekoper HH, van de Warrenburg BP, Brilstra EH, Hollak CE, Haak H, Kluijtmans LA, Wevers RA, Verrips A. Long-term treatment effect in cerebrotendinous xanthomatosis depends on age at treatment start. Neurology 2018; 92:e83-e95. [DOI: 10.1212/wnl.0000000000006731] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 08/20/2018] [Indexed: 12/11/2022] Open
Abstract
ObjectiveTo evaluate the effect of chenodeoxycholic acid treatment on disease progression in cerebrotendinous xanthomatosis (CTX).MethodsIn this retrospective cohort study, we report the clinical long-term follow-up characteristics of 56 Dutch patients with CTX. Age at diagnosis was correlated with clinical characteristics and with the course of modified Rankin Scale (mRS) and Expanded Disability Status Scale (EDSS) scores at follow-up.ResultsMedian follow-up time was 8 years (6 months–31.5 years). Patients diagnosed and treated before the age of 24 years had a significantly better outcome at follow-up. When considering only patients with a good treatment adherence (n = 43), neurologic symptoms, if present, disappeared in all patients who were diagnosed before the age of 24 and treated since. Furthermore, treatment prevented the development of new neurologic symptoms during follow-up. In contrast, 61% of the patients diagnosed and treated after the age of 24 showed deterioration of the neurologic symptoms, with parkinsonism as a treatment-resistant feature. There was an improvement or stabilization in favor of patients diagnosed and treated before the age of 24 compared to those treated after the age of 24: 100% vs 58% for mRS scores and 100% vs 50% for EDSS scores, respectively.ConclusionsTreatment start at an early age can reverse and even prevent the development of neurologic symptoms in CTX. This study emphasizes the importance of early diagnosis in CTX and provides a rationale to include CTX in newborn screening programs.
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15
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Amador MDM, Masingue M, Debs R, Lamari F, Perlbarg V, Roze E, Degos B, Mochel F. Treatment with chenodeoxycholic acid in cerebrotendinous xanthomatosis: clinical, neurophysiological, and quantitative brain structural outcomes. J Inherit Metab Dis 2018; 41:799-807. [PMID: 29560583 DOI: 10.1007/s10545-018-0162-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 02/11/2018] [Accepted: 02/19/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cerebrotendinous xanthomatosis (CTX) is a rare neurodegenerative disease related to sterols metabolism. It affects both central and peripheral nervous systems but treatment with chenodeoxycholic acid (CDCA) has been reported to stabilize clinical scores and improve nerve conduction parameters. Few quantitative brain structural studies have been conducted to assess the effect of CDCA in CTX. METHODS AND RESULTS We collected retrospectively clinical, neurophysiological, and quantitative brain structural data in a cohort of 14 patients with CTX treated by CDCA over a mean period of 5 years. Plasma cholestanol levels normalized under treatment with CDCA within a few months. We observed a significant clinical improvement in patients up to 25 years old, whose treatment was initiated less than 15 years after the onset of neurological symptoms. Conversely, patients whose treatment was initiated more than 25 years after neurological disease onset continued their clinical deterioration. Eleven patients presented with a length-dependent peripheral neuropathy, whose electrophysiological parameters improved significantly under CDCA. Volumetric analyses in a subset of patients showed no overt volume loss under CDCA. Moreover, diffusion weighted imaging showed improved fiber integrity of the ponto-cerebellar and the internal capsule with CDCA. CDCA was well tolerated in all patients with CTX. CONCLUSION CDCA may reverse the pathophysiological process in patients with CTX, especially if treatment is initiated early in the disease process. Besides tendon xanthoma, this study stresses the need to consider plasma cholestanol measurement in any patient with infantile chronic diarrhea and/or jaundice, juvenile cataract, learning disability and/or autism spectrum disorder, pyramidal signs, cerebellar syndrome or peripheral neuropathy.
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Affiliation(s)
- Maria Del Mar Amador
- Assistance Publique-Hôpitaux de Paris, Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Marion Masingue
- Assistance Publique-Hôpitaux de Paris, Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Rabab Debs
- Assistance Publique-Hôpitaux de Paris, Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
- Assistance Publique-Hôpitaux de Paris, Département de Neurophysiologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Foudil Lamari
- Assistance Publique-Hôpitaux de Paris, Laboratoire de Biochimie Métabolique, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
- Centre de Référence Neurométabolique Adulte, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
- Université Pierre et Marie Curie, Groupe de Recherche Clinique Neurométabolique, Paris, France
| | - Vincent Perlbarg
- Sorbonne Universités, UPMC-Paris 6, UMR S 1127 and Inserm U 1127, and CNRS UMR 7225, and ICM, F-75013, Paris, France
- Laboratoire d'imagerie biomédicale (LIB), F-75013, Paris, France
- Bioinformatics and Biostatistics Core Facility, iCONICS, IHU-A-ICM, ICM, F-75013, Paris, France
| | - Emmanuel Roze
- Assistance Publique-Hôpitaux de Paris, Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
- Centre de Référence Neurométabolique Adulte, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
- Sorbonne Universités, UPMC-Paris 6, UMR S 1127 and Inserm U 1127, and CNRS UMR 7225, and ICM, F-75013, Paris, France
| | - Bertrand Degos
- CNRS-UMR 7241/INSERM U1050, CIRB, Collège de France, UPMC, Paris, France
- Assistance Publique-Hôpitaux de Paris, Service de Neurologie, Hôpital Universitaire d'Avicenne, Bobigny, France
| | - Fanny Mochel
- Centre de Référence Neurométabolique Adulte, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
- Université Pierre et Marie Curie, Groupe de Recherche Clinique Neurométabolique, Paris, France.
- Sorbonne Universités, UPMC-Paris 6, UMR S 1127 and Inserm U 1127, and CNRS UMR 7225, and ICM, F-75013, Paris, France.
- Assistance Publique-Hôpitaux de Paris, Département de Génétique, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
- Reference Center for Neurometabolic Diseases, Department of Genetics, La Pitié-Salpêtrière University Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France.
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