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Kern J, Böhringer J, Timmann D, Trollmann R, Stendel C, Kamm C, Röbl M, Santhanakumaran V, Groeschel S, Beck-Wödl S, Göricke S, Krägeloh-Mann I, Synofzik M. Clinical, Imaging, Genetic, and Disease Course Characteristics in Patients With GM2 Gangliosidosis: Beyond Age of Onset. Neurology 2024; 102:e207898. [PMID: 38165373 PMCID: PMC10834127 DOI: 10.1212/wnl.0000000000207898] [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: 03/08/2023] [Accepted: 09/27/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES GM2 gangliosidoses, a group of autosomal-recessive neurodegenerative lysosomal storage disorders, result from β-hexosaminidase (HEX) deficiency with GM2 ganglioside as its main substrate. Historically, GM2 gangliosidoses have been classified into infantile, juvenile, and late-onset forms. With disease-modifying treatment trials now on the horizon, a more fine-grained understanding of the disease course is needed. METHODS We aimed to map and stratify the clinical course of GM2 gangliosidoses in a multicenter cohort of pediatric and adult patients. Patients were stratified according to age at onset and age at diagnosis. The 2 resulting GM2 disease clusters were characterized in-depth for respective disease features (detailed standardized clinical, laboratory, and MRI assessments) and disease evolution. RESULTS In 21 patients with GM2 gangliosidosis (17 Tay-Sachs, 2 GM2 activator deficiency, 2 Sandhoff disease), 2 disease clusters were discriminated: an early-onset and early diagnosis cluster (type I; n = 8, including activator deficiency and Sandhoff disease) and a cluster with very variable onset and long interval until diagnosis (type II; n = 13 patients). In type I, rapid onset of developmental stagnation and regression, spasticity, and seizures dominated the clinical picture. Cherry red spot, startle reactions, and elevated AST were only seen in this cluster. In type II, problems with balance or gait, muscle weakness, dysarthria, and psychiatric symptoms were specific and frequent symptoms. Ocular signs were common, including supranuclear vertical gaze palsy in 30%. MRI involvement of basal ganglia and peritrigonal hyperintensity was seen only in type I, whereas predominant infratentorial atrophy (or normal MRI) was characteristic in type II. These types were, at least in part, associated with certain genetic variants. DISCUSSION Age at onset alone seems not sufficient to adequately predict different disease courses in GM2 gangliosidosis, as required for upcoming trial planning. We propose an alternative classification based on age at disease onset and dynamics, predicted by clinical features and biomarkers, into type I-an early-onset, rapid progression cluster-and type II-a variable onset, slow progression cluster. Specific diagnostic workup, including GM2 gangliosidosis, should be performed in patients with combined ataxia plus lower motor neuron weakness to identify type II patients.
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Affiliation(s)
- Jan Kern
- From the Department of Neuropediatrics (J.K., J.B., V.S., S. Groeschel, I.K.-M.), Developmental Neurology and Social Pediatrics, University of Tübingen; Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS) (D.T.), University Hospital Essen, University of Duisburg-Essen; Department of Neuropediatrics (R.T.), Friedrich-Alexander University of Erlangen-Nürnberg; Department of Neurology (C.S.), Friedrich-Baur-Institute, University Hospital LMU, Munich; Department of Neurology (C.K.), University of Rostock; Department of Pediatrics (M.R.), University of Göttingen; Institute of Medical Genetics and Applied Genomics (S.B.-W.), University of Tübingen; Institute of Diagnostic and Interventional Radiology and Neuroradiology (S. Göricke), Essen University Hospital, University of Duisburg-Essen; and Research Division Translational Genomics of Neurodegenerative Diseases (M.S.), Center for Neurology & Hertie-Institute for Clinical Brain Research, University of Tübingen; German Center for Neurodegenerative Diseases, Germany
| | - Judith Böhringer
- From the Department of Neuropediatrics (J.K., J.B., V.S., S. Groeschel, I.K.-M.), Developmental Neurology and Social Pediatrics, University of Tübingen; Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS) (D.T.), University Hospital Essen, University of Duisburg-Essen; Department of Neuropediatrics (R.T.), Friedrich-Alexander University of Erlangen-Nürnberg; Department of Neurology (C.S.), Friedrich-Baur-Institute, University Hospital LMU, Munich; Department of Neurology (C.K.), University of Rostock; Department of Pediatrics (M.R.), University of Göttingen; Institute of Medical Genetics and Applied Genomics (S.B.-W.), University of Tübingen; Institute of Diagnostic and Interventional Radiology and Neuroradiology (S. Göricke), Essen University Hospital, University of Duisburg-Essen; and Research Division Translational Genomics of Neurodegenerative Diseases (M.S.), Center for Neurology & Hertie-Institute for Clinical Brain Research, University of Tübingen; German Center for Neurodegenerative Diseases, Germany
| | - Dagmar Timmann
- From the Department of Neuropediatrics (J.K., J.B., V.S., S. Groeschel, I.K.-M.), Developmental Neurology and Social Pediatrics, University of Tübingen; Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS) (D.T.), University Hospital Essen, University of Duisburg-Essen; Department of Neuropediatrics (R.T.), Friedrich-Alexander University of Erlangen-Nürnberg; Department of Neurology (C.S.), Friedrich-Baur-Institute, University Hospital LMU, Munich; Department of Neurology (C.K.), University of Rostock; Department of Pediatrics (M.R.), University of Göttingen; Institute of Medical Genetics and Applied Genomics (S.B.-W.), University of Tübingen; Institute of Diagnostic and Interventional Radiology and Neuroradiology (S. Göricke), Essen University Hospital, University of Duisburg-Essen; and Research Division Translational Genomics of Neurodegenerative Diseases (M.S.), Center for Neurology & Hertie-Institute for Clinical Brain Research, University of Tübingen; German Center for Neurodegenerative Diseases, Germany
| | - Regina Trollmann
- From the Department of Neuropediatrics (J.K., J.B., V.S., S. Groeschel, I.K.-M.), Developmental Neurology and Social Pediatrics, University of Tübingen; Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS) (D.T.), University Hospital Essen, University of Duisburg-Essen; Department of Neuropediatrics (R.T.), Friedrich-Alexander University of Erlangen-Nürnberg; Department of Neurology (C.S.), Friedrich-Baur-Institute, University Hospital LMU, Munich; Department of Neurology (C.K.), University of Rostock; Department of Pediatrics (M.R.), University of Göttingen; Institute of Medical Genetics and Applied Genomics (S.B.-W.), University of Tübingen; Institute of Diagnostic and Interventional Radiology and Neuroradiology (S. Göricke), Essen University Hospital, University of Duisburg-Essen; and Research Division Translational Genomics of Neurodegenerative Diseases (M.S.), Center for Neurology & Hertie-Institute for Clinical Brain Research, University of Tübingen; German Center for Neurodegenerative Diseases, Germany
| | - Claudia Stendel
- From the Department of Neuropediatrics (J.K., J.B., V.S., S. Groeschel, I.K.-M.), Developmental Neurology and Social Pediatrics, University of Tübingen; Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS) (D.T.), University Hospital Essen, University of Duisburg-Essen; Department of Neuropediatrics (R.T.), Friedrich-Alexander University of Erlangen-Nürnberg; Department of Neurology (C.S.), Friedrich-Baur-Institute, University Hospital LMU, Munich; Department of Neurology (C.K.), University of Rostock; Department of Pediatrics (M.R.), University of Göttingen; Institute of Medical Genetics and Applied Genomics (S.B.-W.), University of Tübingen; Institute of Diagnostic and Interventional Radiology and Neuroradiology (S. Göricke), Essen University Hospital, University of Duisburg-Essen; and Research Division Translational Genomics of Neurodegenerative Diseases (M.S.), Center for Neurology & Hertie-Institute for Clinical Brain Research, University of Tübingen; German Center for Neurodegenerative Diseases, Germany
| | - Cristoph Kamm
- From the Department of Neuropediatrics (J.K., J.B., V.S., S. Groeschel, I.K.-M.), Developmental Neurology and Social Pediatrics, University of Tübingen; Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS) (D.T.), University Hospital Essen, University of Duisburg-Essen; Department of Neuropediatrics (R.T.), Friedrich-Alexander University of Erlangen-Nürnberg; Department of Neurology (C.S.), Friedrich-Baur-Institute, University Hospital LMU, Munich; Department of Neurology (C.K.), University of Rostock; Department of Pediatrics (M.R.), University of Göttingen; Institute of Medical Genetics and Applied Genomics (S.B.-W.), University of Tübingen; Institute of Diagnostic and Interventional Radiology and Neuroradiology (S. Göricke), Essen University Hospital, University of Duisburg-Essen; and Research Division Translational Genomics of Neurodegenerative Diseases (M.S.), Center for Neurology & Hertie-Institute for Clinical Brain Research, University of Tübingen; German Center for Neurodegenerative Diseases, Germany
| | - Markus Röbl
- From the Department of Neuropediatrics (J.K., J.B., V.S., S. Groeschel, I.K.-M.), Developmental Neurology and Social Pediatrics, University of Tübingen; Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS) (D.T.), University Hospital Essen, University of Duisburg-Essen; Department of Neuropediatrics (R.T.), Friedrich-Alexander University of Erlangen-Nürnberg; Department of Neurology (C.S.), Friedrich-Baur-Institute, University Hospital LMU, Munich; Department of Neurology (C.K.), University of Rostock; Department of Pediatrics (M.R.), University of Göttingen; Institute of Medical Genetics and Applied Genomics (S.B.-W.), University of Tübingen; Institute of Diagnostic and Interventional Radiology and Neuroradiology (S. Göricke), Essen University Hospital, University of Duisburg-Essen; and Research Division Translational Genomics of Neurodegenerative Diseases (M.S.), Center for Neurology & Hertie-Institute for Clinical Brain Research, University of Tübingen; German Center for Neurodegenerative Diseases, Germany
| | - Vidiyaah Santhanakumaran
- From the Department of Neuropediatrics (J.K., J.B., V.S., S. Groeschel, I.K.-M.), Developmental Neurology and Social Pediatrics, University of Tübingen; Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS) (D.T.), University Hospital Essen, University of Duisburg-Essen; Department of Neuropediatrics (R.T.), Friedrich-Alexander University of Erlangen-Nürnberg; Department of Neurology (C.S.), Friedrich-Baur-Institute, University Hospital LMU, Munich; Department of Neurology (C.K.), University of Rostock; Department of Pediatrics (M.R.), University of Göttingen; Institute of Medical Genetics and Applied Genomics (S.B.-W.), University of Tübingen; Institute of Diagnostic and Interventional Radiology and Neuroradiology (S. Göricke), Essen University Hospital, University of Duisburg-Essen; and Research Division Translational Genomics of Neurodegenerative Diseases (M.S.), Center for Neurology & Hertie-Institute for Clinical Brain Research, University of Tübingen; German Center for Neurodegenerative Diseases, Germany
| | - Samuel Groeschel
- From the Department of Neuropediatrics (J.K., J.B., V.S., S. Groeschel, I.K.-M.), Developmental Neurology and Social Pediatrics, University of Tübingen; Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS) (D.T.), University Hospital Essen, University of Duisburg-Essen; Department of Neuropediatrics (R.T.), Friedrich-Alexander University of Erlangen-Nürnberg; Department of Neurology (C.S.), Friedrich-Baur-Institute, University Hospital LMU, Munich; Department of Neurology (C.K.), University of Rostock; Department of Pediatrics (M.R.), University of Göttingen; Institute of Medical Genetics and Applied Genomics (S.B.-W.), University of Tübingen; Institute of Diagnostic and Interventional Radiology and Neuroradiology (S. Göricke), Essen University Hospital, University of Duisburg-Essen; and Research Division Translational Genomics of Neurodegenerative Diseases (M.S.), Center for Neurology & Hertie-Institute for Clinical Brain Research, University of Tübingen; German Center for Neurodegenerative Diseases, Germany
| | - Stefanie Beck-Wödl
- From the Department of Neuropediatrics (J.K., J.B., V.S., S. Groeschel, I.K.-M.), Developmental Neurology and Social Pediatrics, University of Tübingen; Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS) (D.T.), University Hospital Essen, University of Duisburg-Essen; Department of Neuropediatrics (R.T.), Friedrich-Alexander University of Erlangen-Nürnberg; Department of Neurology (C.S.), Friedrich-Baur-Institute, University Hospital LMU, Munich; Department of Neurology (C.K.), University of Rostock; Department of Pediatrics (M.R.), University of Göttingen; Institute of Medical Genetics and Applied Genomics (S.B.-W.), University of Tübingen; Institute of Diagnostic and Interventional Radiology and Neuroradiology (S. Göricke), Essen University Hospital, University of Duisburg-Essen; and Research Division Translational Genomics of Neurodegenerative Diseases (M.S.), Center for Neurology & Hertie-Institute for Clinical Brain Research, University of Tübingen; German Center for Neurodegenerative Diseases, Germany
| | - Sophia Göricke
- From the Department of Neuropediatrics (J.K., J.B., V.S., S. Groeschel, I.K.-M.), Developmental Neurology and Social Pediatrics, University of Tübingen; Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS) (D.T.), University Hospital Essen, University of Duisburg-Essen; Department of Neuropediatrics (R.T.), Friedrich-Alexander University of Erlangen-Nürnberg; Department of Neurology (C.S.), Friedrich-Baur-Institute, University Hospital LMU, Munich; Department of Neurology (C.K.), University of Rostock; Department of Pediatrics (M.R.), University of Göttingen; Institute of Medical Genetics and Applied Genomics (S.B.-W.), University of Tübingen; Institute of Diagnostic and Interventional Radiology and Neuroradiology (S. Göricke), Essen University Hospital, University of Duisburg-Essen; and Research Division Translational Genomics of Neurodegenerative Diseases (M.S.), Center for Neurology & Hertie-Institute for Clinical Brain Research, University of Tübingen; German Center for Neurodegenerative Diseases, Germany
| | - Ingeborg Krägeloh-Mann
- From the Department of Neuropediatrics (J.K., J.B., V.S., S. Groeschel, I.K.-M.), Developmental Neurology and Social Pediatrics, University of Tübingen; Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS) (D.T.), University Hospital Essen, University of Duisburg-Essen; Department of Neuropediatrics (R.T.), Friedrich-Alexander University of Erlangen-Nürnberg; Department of Neurology (C.S.), Friedrich-Baur-Institute, University Hospital LMU, Munich; Department of Neurology (C.K.), University of Rostock; Department of Pediatrics (M.R.), University of Göttingen; Institute of Medical Genetics and Applied Genomics (S.B.-W.), University of Tübingen; Institute of Diagnostic and Interventional Radiology and Neuroradiology (S. Göricke), Essen University Hospital, University of Duisburg-Essen; and Research Division Translational Genomics of Neurodegenerative Diseases (M.S.), Center for Neurology & Hertie-Institute for Clinical Brain Research, University of Tübingen; German Center for Neurodegenerative Diseases, Germany
| | - Matthis Synofzik
- From the Department of Neuropediatrics (J.K., J.B., V.S., S. Groeschel, I.K.-M.), Developmental Neurology and Social Pediatrics, University of Tübingen; Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS) (D.T.), University Hospital Essen, University of Duisburg-Essen; Department of Neuropediatrics (R.T.), Friedrich-Alexander University of Erlangen-Nürnberg; Department of Neurology (C.S.), Friedrich-Baur-Institute, University Hospital LMU, Munich; Department of Neurology (C.K.), University of Rostock; Department of Pediatrics (M.R.), University of Göttingen; Institute of Medical Genetics and Applied Genomics (S.B.-W.), University of Tübingen; Institute of Diagnostic and Interventional Radiology and Neuroradiology (S. Göricke), Essen University Hospital, University of Duisburg-Essen; and Research Division Translational Genomics of Neurodegenerative Diseases (M.S.), Center for Neurology & Hertie-Institute for Clinical Brain Research, University of Tübingen; German Center for Neurodegenerative Diseases, Germany
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Kell P, Sidhu R, Qian M, Mishra S, Nicoli ER, D'Souza P, Tifft CJ, Gross AL, Gray-Edwards HL, Martin DR, Sena-Esteves M, Dietzen DJ, Singh M, Luo J, Schaffer JE, Ory DS, Jiang X. A pentasaccharide for monitoring pharmacodynamic response to gene therapy in GM1 gangliosidosis. EBioMedicine 2023; 92:104627. [PMID: 37267847 PMCID: PMC10277919 DOI: 10.1016/j.ebiom.2023.104627] [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: 01/28/2023] [Revised: 04/29/2023] [Accepted: 05/10/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND GM1 gangliosidosis is a rare, fatal, neurodegenerative disease caused by mutations in the GLB1 gene and deficiency in β-galactosidase. Delay of symptom onset and increase in lifespan in a GM1 gangliosidosis cat model after adeno-associated viral (AAV) gene therapy treatment provide the basis for AAV gene therapy trials. The availability of validated biomarkers would greatly improve assessment of therapeutic efficacy. METHODS The liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to screen oligosaccharides as potential biomarkers for GM1 gangliosidosis. The structures of pentasaccharide biomarkers were determined with mass spectrometry, as well as chemical and enzymatic degradations. Comparison of LC-MS/MS data of endogenous and synthetic compounds confirmed the identification. The study samples were analyzed with fully validated LC-MS/MS methods. FINDINGS We identified two pentasaccharide biomarkers, H3N2a and H3N2b, that were elevated more than 18-fold in patient plasma, cerebrospinal fluid (CSF), and urine. Only H3N2b was detectable in the cat model, and it was negatively correlated with β-galactosidase activity. Following intravenous (IV) AAV9 gene therapy treatment, reduction of H3N2b was observed in central nervous system, urine, plasma, and CSF samples from the cat model and in urine, plasma, and CSF samples from a patient. Reduction of H3N2b accurately reflected normalization of neuropathology in the cat model and improvement of clinical outcomes in the patient. INTERPRETATIONS These results demonstrate that H3N2b is a useful pharmacodynamic biomarker to evaluate the efficacy of gene therapy for GM1 gangliosidosis. H3N2b will facilitate the translation of gene therapy from animal models to patients. FUNDING This work was supported by grants U01NS114156, R01HD060576, ZIAHG200409, and P30 DK020579 from the National Institutes of Health (NIH) and a grant from National Tay-Sachs and Allied Diseases Association Inc.
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Affiliation(s)
- Pamela Kell
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Rohini Sidhu
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Mingxing Qian
- Department of Developmental Biology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Sonali Mishra
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Elena-Raluca Nicoli
- Medical Genetics Branch and Office of the Clinical Director, NHGRI, NIH, Bethesda, MD 20892, USA
| | - Precilla D'Souza
- Medical Genetics Branch and Office of the Clinical Director, NHGRI, NIH, Bethesda, MD 20892, USA; Office of the Clinical Director, NHGRI, NIH, Bethesda, MD, 20892, USA
| | - Cynthia J Tifft
- Medical Genetics Branch and Office of the Clinical Director, NHGRI, NIH, Bethesda, MD 20892, USA; Office of the Clinical Director, NHGRI, NIH, Bethesda, MD, 20892, USA
| | - Amanda L Gross
- Scott-Ritchey Research Center, Auburn University College of Veterinary Medicine, Auburn, AL, 36849, USA
| | - Heather L Gray-Edwards
- Scott-Ritchey Research Center, Auburn University College of Veterinary Medicine, Auburn, AL, 36849, USA
| | - Douglas R Martin
- Scott-Ritchey Research Center, Auburn University College of Veterinary Medicine, Auburn, AL, 36849, USA
| | - Miguel Sena-Esteves
- Department of Neurology, Horae Gene Therapy Center, University of Massachusetts Medical School, Worcester, MA, 01605, USA
| | - Dennis J Dietzen
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Manmilan Singh
- Department of Chemistry, Washington University, St. Louis, MO, 63130, USA
| | - Jingqin Luo
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Jean E Schaffer
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Daniel S Ory
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Xuntian Jiang
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, 63110, USA.
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