1
|
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.
Collapse
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
| |
Collapse
|
2
|
Yılmaz BK, Çelik H. Malar rash and hand tremor in early symptoms of cerebrotendinous xanthomatosis and the effect of chenodeoxycholic acid on them. J Clin Lipidol 2024; 18:e452-e464. [PMID: 38461119 DOI: 10.1016/j.jacl.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Cerebrotendinous xanthomatosis (CTX, OMIM #213700) is a rare but treatable lipid storage disease resulting from mutations in the CYP27A1 gene. PURPOSE The study aims to evaluate patients diagnosed with CTX and reveal new information, especially about the signs of CTX and patients' response to the treatment. METHODS The study was conducted retrospectively in 12 definitively diagnosed CTX patients. The patients' clinical, laboratory, imaging, genetic findings, and chenodeoxycholic acid (CDCA) treatment results were analyzed. RESULTS The median age at diagnosis for the patients was 16.5 years (minimum-maximum: 7-32). Juvenile cataracts, detected in more than 90% (11/12) of the patients, were the most common clinical finding. Malar rash, not previously reported in the literature for CTX, was present in 75% (9/12) of the patients. Hand tremors, the first neurological symptom, occurred in adolescence and were the initial symptom of the disease in five patients. Hand tremors were present in 83.3% (10/12) of the patients. Hand tremors (in 5 patients) and malar rash (in 2 patients) were clinical findings with full recovery due to the CDCA treatment. CONCLUSION The study defines the malar rash finding, which has not been reported in the literature before, as a possible new clinical finding in CTX disease, attributed to its partial or full recovery with CDCA treatment. Additionally, as a novelty in the literature, our study highlights the full recovery of neurological findings, such as hand tremors, in CTX. Patients presenting with hand tremors and malar rash, especially in adolescence, should undergo CTX investigation for early diagnosis and treatment.
Collapse
Affiliation(s)
- Banu Kadıoğlu Yılmaz
- Department of Pediatric Metabolism, Konya City Hospital, University of Health Sciences, Konya, Turkey (Dr Yılmaz); Department of Pediatric Nutrition and Metabolism, Faculty of Medicine, Selçuk University, Konya, Turkey (Dr Yılmaz).
| | - Halil Çelik
- Department of Pediatric Neurology, Konya City Hospital, University of Health Sciences, Konya, Turkey (Dr Çelik)
| |
Collapse
|
3
|
Köroğlu M, Karakaplan M, Gündüz E, Kesriklioğlu B, Ergen E, Aslantürk O, Özdemir ZM. Cerebrotendinous Xanthomatosis patients with late diagnosed in single orthopedic clinic: two novel variants in the CYP27A1 gene. Orphanet J Rare Dis 2024; 19:53. [PMID: 38336741 PMCID: PMC10858589 DOI: 10.1186/s13023-024-03082-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 02/05/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Cerebrotendinous Xanthomatosis (CTX) is a rare autosomal recessive lipid storage disorder caused by loss of function variants in the CYP27A1 gene which encodes sterol 27-hydroxylase, on chromosome 2q35. Although the symptoms begin commonly in infancy, CTX diagnosis is often delayed. The aim of this study is to review the orthopedic findings of the disease by providing an overview of the clinical features of the disease. It is to raise awareness of this condition for which early diagnosis and treatment are important. METHODS We retrospectively evaluated the clinical, laboratory, radiological, and genetic findings of eight patients from four families who were admitted to our Orthopedics and Traumatology Department between 2017 and 2022 due to bilateral Achilles tendon xanthomas, were found to have high cholestanol and CYP27A1 gene mutations. RESULTS The mean age of patients was 37, and five of them were male. The mean age at the onset of symptoms was 9.25 years. The mean age of initial diagnosis was 33.75 years. Between symptom onset and clinical diagnosis, an average delay of 24.5 years was observed. All patients had bilateral Achilles tendon xanthoma. Notably, a novel variant (c.670_671delAA) in CYP27A1 gene was identified in three patients who also presented with peripheral neuropathy and bilateral pes cavus. One patient had osteoporosis and four patients had osteopenia. Five patients had a history of bilateral cataracts. Furthermore, three of the patients had early-onset chronic diarrhea and three of the patients had ataxia. Two of the patients had epilepsy and seven of the patients had behavior-personality disorder. All patients had low intelligence, but none of them had cardiac disease. CONCLUSION We present the diagnostic process and clinical features which the largest CTX case series ever reported from single orthopedic clinic. We suggest that patients with normal cholesterol levels presenting with xanthoma being genetically analyzed by testing at their serum cholestanol level, and that all siblings of patients diagnosed with CTX be examined.
Collapse
Affiliation(s)
- Muhammed Köroğlu
- Orthopaedics and Traumatology Department, Turgut Özal Medical Center, İnönü University Medical School, Malatya, 44280, Turkey
| | - Mustafa Karakaplan
- Orthopaedics and Traumatology Department, Turgut Özal Medical Center, İnönü University Medical School, Malatya, 44280, Turkey.
| | - Enes Gündüz
- Orthopaedics and Traumatology Department, Şarkışla State Hospital, Sivas, Turkey
| | - Betül Kesriklioğlu
- Department of Medical Genetics, Cerrahpaşa Faculty of Medicine, İstanbul University, Istanbul, Turkey
| | - Emre Ergen
- Orthopaedics and Traumatology Department, Turgut Özal Medical Center, İnönü University Medical School, Malatya, 44280, Turkey
| | - Okan Aslantürk
- Orthopaedics and Traumatology Department, Turgut Özal Medical Center, İnönü University Medical School, Malatya, 44280, Turkey
| | - Zeynep Maraş Özdemir
- Department of Radiology, Turgut Özal Medical Center, İnönü University Medical School, Malatya, Turkey
| |
Collapse
|
4
|
Freedman SF, Del Monte MA, Diva U, Donahue SP, Drack AV, Dutta R, Fung SSM, Imperiale M, Jordan CO, Lenhart PD, Lim ME, McCourt EA, Nihalani BR, Sabahi T, Stahl ED, Miraldi Utz VA, Wilson ME, Yen KG, VanderVeen DK. Prevalence of cerebrotendinous xanthomatosis among patients diagnosed with early-onset idiopathic bilateral cataracts: final analysis. J AAPOS 2023; 27:208-211. [PMID: 37321343 DOI: 10.1016/j.jaapos.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/17/2023] [Indexed: 06/17/2023]
Abstract
Cerebrotendinous xanthomatosis (CTX) is a rare, autosomal recessive bile acid synthesis disorder caused by pathologic variants in CYP27A1, a gene involved in bile acid synthesis. Impaired function in this gene leads to accumulation of plasma cholestanol (PC) in various tissues, often in early childhood, resulting in such clinical signs as infantile diarrhea, early-onset bilateral cataracts, and neurological deterioration. The current study aimed to identify cases of CTX in a population of patients with a greater CTX prevalence than the general population, to facilitate early diagnosis. Patients diagnosed with early-onset, apparently idiopathic, bilateral cataracts between the ages of 2 and 21 years were enrolled. Genetic testing of patients with elevated PC and urinary bile alcohol (UBA) levels was used to confirm CTX diagnosis and determine CTX prevalence. Of 426 patients who completed the study, 26 met genetic testing criteria (PC ≥ 0.4 mg/dL and positive UBA test), and 4 were confirmed to have CTX. Prevalence was found to be 0.9% in enrolled patients, and 15.4% in patients who met the criteria for genetic testing.
Collapse
Affiliation(s)
- Sharon F Freedman
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina.
| | - Monte A Del Monte
- Department of Ophthalmology and Visual Sciences, University of Michigan, Kellogg Eye Center, Ann Arbor, Michigan
| | | | - Sean P Donahue
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Arlene V Drack
- Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals & Clinics, Iowa City, Iowa
| | - Rana Dutta
- Travere Therapeutics Inc, San Diego, California
| | | | | | | | - Phoebe D Lenhart
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Maria E Lim
- Dean McGee Eye Institute, University of Oklahoma, Oklahoma City, Oklahoma
| | - Emily A McCourt
- Department of Ophthalmology, University of Colorado School of Medicine, Children's Hospital of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Bharti R Nihalani
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Erin D Stahl
- Department of Ophthalmology, Children's Mercy Kansas City, UMKC School of Medicine, Kansas City, Missouri
| | | | - M Edward Wilson
- Department of Ophthalmology and Pediatrics, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina
| | - Kimberly G Yen
- Division of Ophthalmology, Department of Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Deborah K VanderVeen
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
5
|
Kim S, Park JS, Lee JH, Shin HY, Yang HJ, Shin JH. Clinical, electrophysiological, and genetic characteristics of cerebrotendinous xanthomatosis in South Korea. Neurocase 2022; 28:477-482. [PMID: 36803198 DOI: 10.1080/13554794.2023.2176777] [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] [Indexed: 02/21/2023]
Abstract
Cerebrotendinous xanthomatosis (CTX) is an autosomal recessive lipid storage disorder caused by 27-hydroxylase deficiency. We report the clinical characteristics of six Korean CTX patients. The median age of onset was 22.5 years, the median age at diagnosis was 42 years, and the diagnostic delay was 18.1 years. The most common clinical symptoms were tendon xanthoma and spastic paraplegia. Four of five patients exhibited latent central conduction dysfunction. All patients carried the same mutation in CYP27A1 (c.1214 G>A [p.R405Q]). CTX is a treatable neurodegenerative disorder; however, our results revealed that patients with CTX in Korea might receive the diagnosis after a prolonged delay. .
Collapse
Affiliation(s)
- Sunyoung Kim
- Department of Neurology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Jin-Sung Park
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | - Jae-Hyeok Lee
- Department of Neurology, Pusan National University Yangsan Hospital, Pusan National University, Yangsan, Republic of Korea
| | - Ha-Young Shin
- Department of Neurology, Yonsei Unviersity College of Medicine, Seoul, Republic of Korea
| | - Hui-Jun Yang
- Department of Neurology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Jin-Hong Shin
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| |
Collapse
|
6
|
Ashrafi MR, Pourbakhtyaran E, Rohani M, Shalbafan B, Tavasoli AR, Hosseinpour S, Rasulinezhad M, Rezaei Z, Zare Dehnavi A, Hosseiny SMM, Haghighi R, Ghabeli H, Heidari M. Follow‐up of 25 patients with treatable ataxia: A comprehensive case series study. Clin Case Rep 2022; 10:e05777. [PMID: 35474986 PMCID: PMC9020174 DOI: 10.1002/ccr3.5777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 03/01/2022] [Accepted: 03/28/2022] [Indexed: 11/09/2022] Open
Abstract
Autosomal recessive cerebellar ataxias are a group of heterogeneous early‐onset progressive disorders that some of them are treatable. We performed a 4‐year follow‐up for 25 patients who had treatable ataxia. According to our study, patients would benefit from early detection of treatable ataxia, close observation, and follow‐up.
Collapse
Affiliation(s)
- Mahmoud Reza Ashrafi
- Department of Paediatrics Division of Paediatric Neurology, Growth and Development Research Center Children's Medical Centre Paediatrics Centre of Excellence Tehran University of Medical Sciences Tehran Iran
| | - Elham Pourbakhtyaran
- Department of Paediatrics Division of Paediatric Neurology, Growth and Development Research Center Children's Medical Centre Paediatrics Centre of Excellence Tehran University of Medical Sciences Tehran Iran
| | - Mohammad Rohani
- Department of Neurology School of Medicine Hazrat Rasool‐E Akram General Hospital Iran University of Medical Sciences Tehran Iran
| | - Bita Shalbafan
- Clinical Research Development Center of Labbafinejad Hospital Shahid Beheshti University of Medical Sciences Tehran Iran
| | - Ali Reza Tavasoli
- Pediatric Neurology Division Children's Medical Center Pediatrics Center of Excellence Myelin Disorders Clinic Tehran University of Medical Sciences Tehran Iran
| | - Sareh Hosseinpour
- Department of Pediatric Neurology Vali‐e‐Asr Hospital Imam Khomeini Hospital Complex Tehran University of Medical Sciences Tehran Iran
| | - Maryam Rasulinezhad
- Pediatric Neurology Division Children's Medical Center Pediatrics Center of Excellence Myelin Disorders Clinic Tehran University of Medical Sciences Tehran Iran
| | - Zahra Rezaei
- Department of Paediatrics Division of Paediatric Neurology, Growth and Development Research Center Children's Medical Centre Paediatrics Centre of Excellence Tehran University of Medical Sciences Tehran Iran
| | - Ali Zare Dehnavi
- Department of Paediatrics Division of Paediatric Neurology, Growth and Development Research Center Children's Medical Centre Paediatrics Centre of Excellence Tehran University of Medical Sciences Tehran Iran
| | - Seyyed Mohammad Mahdi Hosseiny
- Pediatric Neurology Division Children's Medical Center Pediatrics Center of Excellence Myelin Disorders Clinic Tehran University of Medical Sciences Tehran Iran
| | - Roya Haghighi
- Pediatric Neurology Division Children's Medical Center Pediatrics Center of Excellence Myelin Disorders Clinic Tehran University of Medical Sciences Tehran Iran
| | - Homa Ghabeli
- Pediatric Neurology Division Children's Medical Center Pediatrics Center of Excellence Myelin Disorders Clinic Tehran University of Medical Sciences Tehran Iran
| | - Morteza Heidari
- Department of Paediatrics Division of Paediatric Neurology, Growth and Development Research Center Children's Medical Centre Paediatrics Centre of Excellence Tehran University of Medical Sciences Tehran Iran
- Pediatric Neurology Division Children's Medical Center Pediatrics Center of Excellence Myelin Disorders Clinic Tehran University of Medical Sciences Tehran Iran
| |
Collapse
|
7
|
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: 4] [Impact Index Per Article: 1.3] [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.
Collapse
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
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Kısa PT, Yildirim GK, Hismi BO, Dorum S, Kusbeci OY, Topak A, Baydan F, Celik FND, Gorukmez O, Gulten ZA, Ekici A, Ozkan S, Yaman A, Arslan N. Patients with cerebrotendinous xanthomatosis diagnosed with diverse multisystem involvement. Metab Brain Dis 2021; 36:1201-1211. [PMID: 33704661 DOI: 10.1007/s11011-021-00714-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/05/2021] [Indexed: 02/02/2023]
Abstract
Cerebrotendinous xanthomatosis (CTX) is a lipid storage disease caused by deficiency of sterol 27-hydroxylase enzyme encoded by CYP27A1 gene. This multicenter, cross-sectional descriptive study aimed to document clinical characteristics of CTX patients of different ages, clinical presentations of early-diagnosed patients, and responses to short-term chenodeoxycholic acid (CDCA) treatment. Seven of 11 CTX patients were diagnosed in childhood. Three patients (27%) had neonatal cholestasis, seven (63%) patients had a history of frequent watery defecation started in infantile period, and eight (72.7%) patients had juvenile cataract. Four patients in the adult age group had pyramidal signs and parkinsonism symptoms. The mean Mignarri score at diagnosis was significantly lower in the pediatric patients (267.8 ± 51.4) than in the adult patients (450.0 ± 64.0, p = 0.001). No significant difference was determined between pediatric patients and adult patients regarding plasma cholestanol concentration at diagnosis (p = 0.482). The frequency of defecation decreased with treatment in six children, who had diarrhea at admission. Compared to pretreatment values, patients' body weight and standardized body mass index significantly increased at the 12th month of treatment. In conclusion, Mignarri scores are lower in the pediatric patients than in adult patients since the most determinative signs of the CTX disease are not apparent yet in the childhood. The disease is frequently overlooked in routine practice as the disease presents itself with different clinical combinations both in adults and in children. CTX is potentially a treatable disease; thereby, enhanced awareness is critically important for early diagnosis particularly in children.
Collapse
Affiliation(s)
- Pelin Teke Kısa
- Department of Pediatrics, Division of Pediatric Metabolism and Nutrition, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
- Dr. Behçet Uz Children's Research and Training Hospital, Department of Pediatric Metabolism and Nutrition, Izmir University of Health Sciences, Izmir, Turkey
| | - Gonca Kilic Yildirim
- Department of Pediatrics, Division of Pediatric Metabolism and Nutrition, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Burcu Ozturk Hismi
- Department of Pediatrics, Division of Pediatric Metabolism and Nutrition, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Sevil Dorum
- Bursa Yuksek Ihtisas Training and Research Hospital, Pediatric Metabolic Diseases Clinic, Bursa University of Health Sciences, Bursa, Turkey
| | - Ozge Yilmaz Kusbeci
- Department of Neurology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Ali Topak
- Bursa Yuksek Ihtisas Training and Research Hospital, Medical Genetics Clinic, Bursa University of Health Sciences, Bursa, Turkey
| | - Figen Baydan
- Tepecik Training and Research Hospital, Department of Child Health and Diseases, Division of Pediatric Neurology, Izmir University of Health Sciences, Izmir, Turkey
| | | | - Orhan Gorukmez
- Bursa Yuksek Ihtisas Training and Research Hospital, Medical Genetics Clinic, Bursa University of Health Sciences, Bursa, Turkey
| | - Zumrut Arslan Gulten
- Department of Pediatrics, Division of Pediatric Metabolism and Nutrition, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Arzu Ekici
- Bursa Yuksek Ihtisas Training and Research Hospital, Pediatric Neurology Clinic, Bursa University of Health Sciences, Bursa, Turkey
| | - Serhat Ozkan
- Department of Neurology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Aylin Yaman
- Faculty of Medicine, Department of Ophthalmology, Dokuz Eylul University, Izmir, Turkey
| | - Nur Arslan
- Department of Pediatrics, Division of Pediatric Metabolism and Nutrition, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey.
- Izmir Biomedicine and Genome Center (İBG-izmir), 35340, Balcova, Izmir, Turkey.
| |
Collapse
|
10
|
Koyama S, Sekijima Y, Ogura M, Hori M, Matsuki K, Miida T, Harada-Shiba M. Cerebrotendinous Xanthomatosis: Molecular Pathogenesis, Clinical Spectrum, Diagnosis, and Disease-Modifying Treatments. J Atheroscler Thromb 2021; 28:905-925. [PMID: 33967188 PMCID: PMC8532057 DOI: 10.5551/jat.rv17055] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is an autosomal recessive lipid storage disorder caused by mutations in the
CYP27A1
gene, which encodes the mitochondrial enzyme sterol 27-hydroxylase. Decreased sterol 27-hydroxylase activity results in impaired bile acid synthesis, leading to reduced production of bile acids, especially chenodeoxycholic acid (CDCA), as well as elevated serum cholestanol and urine bile alcohols. The accumulation of cholestanol and cholesterol mainly in the brain, lenses, and tendons results in the characteristic clinical manifestations of CTX. Clinical presentation is characterized by systemic symptoms including neonatal jaundice or cholestasis, refractory diarrhea, juvenile cataracts, tendon xanthomas, osteoporosis, coronary heart disease, and a broad range of neuropsychiatric manifestations. The combinations of symptoms vary from patient to patient and the presenting symptoms, especially in the early disease phase, may be nonspecific, which leads to a substantial diagnostic delay or underdiagnosis. Replacement of CDCA has been approved as a first-line treatment for CTX, and can lead to biochemical and clinical improvements. However, the effect of CDCA treatment is limited once significant neuropsychiatric manifestations are established. The age at diagnosis and initiation of CDCA treatment correlate with the prognosis of patients with CTX. Therefore, early diagnosis and subsequent treatment initiation are essential.
Collapse
Affiliation(s)
- Shingo Koyama
- Division of Neurology and Clinical Neuroscience, Department of Internal Medicine III, Yamagata University Faculty of Medicine
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine.,Institute for Biomedical Sciences, Shinshu University
| | - Masatsune Ogura
- Department of Molecular Innovation in Lipidology, National Cerebral and Cardiovascular Center Research Institute
| | - Mika Hori
- Department of Endocrinology, Research Institute of Environmental Medicine, Nagoya University
| | - Kota Matsuki
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine
| | - Takashi Miida
- Department of Clinical Laboratory Medicine, Juntendo University Graduate School of Medicine
| | - Mariko Harada-Shiba
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center Research Institute
| |
Collapse
|
11
|
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.
Collapse
Affiliation(s)
| | - P Barton Duell
- Knight Cardiovascular Institute, and Division of Endocrinology, Diabetes & Clinical Nutrition, Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
12
|
Zhang S, Li W, Zheng R, Zhao B, Zhang Y, Zhao D, Zhao C, Yan C, Zhao Y. Cerebrotendinous xanthomatosis with peripheral neuropathy: a clinical and neurophysiological study in Chinese population. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1372. [PMID: 33313117 PMCID: PMC7723652 DOI: 10.21037/atm-20-2746] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Cerebrotendinous xanthomatosis (CTX) is an inborn disorder of bile acid metabolism caused by deficiency of sterol 27-hydroxylase (CYP27A1) gene. CTX-related peripheral neuropathy has rarely been discussed in Chinese population. Here, we reported 6 CTX cases and performed a literature review focused on CTX with neuropathy to summarize its clinical and neurophysiological features. Methods All clinical data of 6 CTX cases were collected, and 21 reported Chinese CTX patients (including this study) were reviewed and summarized. Results Clinical manifestations of 6 CTX cases showed great heterogeneity. Cognitive decline, spastic paraplegia, cerebellar ataxia and advanced bulbar palsy were common neurological disorders, often accompanied by non-neurological signs like xanthomas, cataract, diarrhea and pes cavus. Dentate nuclei hyperintensity with or without hyposignal is a valuable MRI hallmark. Pooling our patients and literature review together, peripheral neuropathy was predominant sensorimotor demyelinating type in Chinese population, with an evident length dependent pattern and increased vulnerability in motor nerves. Demyelinating and axonal degeneration tend to exist in severe neuropathy. Three novel mutations including c.1055C>A; c.432T>G; c.472T>G were identified in CYP27A1 and predicted to be pathogenic. Oral CDCA therapy could ameliorate some of the existing symptoms and provide clinical stability, but it could not cease disease progression completely. Conclusions Our study broadens the phenotype and mutation spectrum of CTX. Patients with cognitive decline, spastic tetraparesis, cerebellar ataxia and bulbar palsy, should be highly suspicious of CTX even no xanthomas disclosed. Peripheral neuropathy was predominant sensorimotor demyelinating type in Chinese population, with mixed axonal and demyelinating type in severe cases. Three novel likely pathogenic mutations including c.1055C>A; c.432T>G; c.472T>G were identified in CYP27A1.
Collapse
Affiliation(s)
- Shu Zhang
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Shandong University, Jinan, China
| | - Wei Li
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Shandong University, Jinan, China
| | - Rui Zheng
- Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Bing Zhao
- Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Yongqing Zhang
- Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Dandan Zhao
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Shandong University, Jinan, China
| | - Cuiping Zhao
- Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Chuanzhu Yan
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Shandong University, Jinan, China.,Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Yuying Zhao
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Shandong University, Jinan, China
| |
Collapse
|
13
|
Aktuglu Zeybek C, Gunduz A, Enver EO, Tezen D, Kiykim E, Kızıltan ME. Movement disorders in the early-diagnosed cerebrotendinous xanthomatosis: An electrophysiological study. Parkinsonism Relat Disord 2020; 80:12-14. [PMID: 32927342 DOI: 10.1016/j.parkreldis.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 08/22/2020] [Accepted: 09/03/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Cigdem Aktuglu Zeybek
- Istanbul University- Cerrahpaşa, Cerrahpaşa School of Medicine, Department of Pediatrics, Department of Pediatric Nutrition and Metabolism, Istanbul, Turkey
| | - Aysegul Gunduz
- Istanbul University- Cerrahpaşa, Cerrahpaşa School of Medicine, Department of Neurology, Istanbul, Turkey.
| | - Ece Oge Enver
- Istanbul University- Cerrahpaşa, Cerrahpaşa School of Medicine, Department of Pediatrics, Department of Pediatric Nutrition and Metabolism, Istanbul, Turkey
| | - Didem Tezen
- Istanbul University- Cerrahpaşa, Cerrahpaşa School of Medicine, Department of Neurology, Istanbul, Turkey
| | - Ertugrul Kiykim
- Istanbul University- Cerrahpaşa, Cerrahpaşa School of Medicine, Department of Pediatrics, Department of Pediatric Nutrition and Metabolism, Istanbul, Turkey
| | - Meral E Kızıltan
- Istanbul University- Cerrahpaşa, Cerrahpaşa School of Medicine, Department of Neurology, Istanbul, Turkey
| |
Collapse
|
14
|
Evaluation of the effect of chenodeoxycholic acid treatment on skeletal system findings in patients with cerebrotendinous xanthomatosis. Turk Arch Pediatr 2019; 54:113-118. [PMID: 31384146 PMCID: PMC6666357 DOI: 10.14744/turkpediatriars.2019.23281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/21/2019] [Indexed: 11/20/2022]
Abstract
Aim: The primary purpose of the present study is to evaluate the effect of chenodeoxycholic acid treatment on skeletal system findings in patients with cerebrotendinous xanthomatosis. Material and Methods: This retrospective study was conducted between June 2013 and December 2018 with seven patients with cerebrotendinous xanthomatosis in Cerrahpasa Medical Faculty Pediatric Nutrition and Metabolism Department. The clinical, epidemiologic, and genotypic features of the patients were reviewed in detail and the following items, especially related with skeletal system involvement, were recorded from medical data: history of a bone fracture, plasma calcium, phosphate, alkaline phosphatase and 25-hydroxy-vitamin D concentrations, bone mineral density values of the posteroanterior lumbar spine (L1-L4), and femoral neck before and after chenodeoxycholic acid treatment. Results: Regarding the bone mineral metabolism, plasma calcium, phosphate, alkaline phosphatase levels were found in normal ranges in all patients. Plasma 25-hydroxy-vitamin D evaluation at the time of diagnosis showed deficiency in three patients and insufficiency in three patients. Following chenodeoxycholic acid therapy, 25-hydroxy-vitamin D deficiency persisted in only one patient, but insufficiency was observed in four patients. According to the bone mineral density assessments, four patients had Z-scores below the expected range for age both at initial examination and after chenodeoxycholic acid therapy. No significant difference was observed between plasma 25-hydroxy-vitamin D levels and bone mineral density Z-scores before or after treatment. Conclusion: This study elucidates the necessity of additional medical treatment as a part of chenodeoxycholic acid therapy to improve skeletal system findings in cerebrotendinous xanthomatosis.
Collapse
|
15
|
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.
Collapse
|
16
|
DeBarber AE, Kalfon L, Fedida A, Fleisher Sheffer V, Ben Haroush S, Chasnyk N, Shuster Biton E, Mandel H, Jeffries K, Shinwell ES, Falik-Zaccai TC. Newborn screening for cerebrotendinous xanthomatosis is the solution for early identification and treatment. J Lipid Res 2018; 59:2214-2222. [PMID: 30135217 DOI: 10.1194/jlr.m087999] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/19/2018] [Indexed: 12/13/2022] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is a progressive metabolic leukodystrophy. Early identification and treatment from birth onward effectively provides a functional cure, but diagnosis is often delayed. We conducted a pilot study using a two-tier test for CTX to screen archived newborn dried bloodspots (DBSs) or samples collected prospectively from a high-risk Israeli newborn population. All DBS samples were analyzed with flow injection analysis (FIA)-MS/MS, and 5% of samples were analyzed with LC-MS/MS. Consecutively collected samples were analyzed to identify CTX-causing founder genetic variants common among Druze and Moroccan Jewish populations. First-tier analysis with FIA-MS/MS provided 100% sensitivity to detect CTX-positive newborn DBSs, with a low false-positive rate (0.1-0.5%). LC-MS/MS, as a second-tier test, provided 100% sensitivity to detect CTX-positive newborn DBSs with a false-positive rate of 0% (100% specificity). In addition, 5β-cholestane-3α,7α,12α,25-tetrol-3-O-β-D-glucuronide was identified as the predominant bile-alcohol disease marker present in CTX-positive newborn DBSs. In newborns identifying as Druze, a 1:30 carriership frequency was determined for the c.355delC CYP27A1 gene variant, providing an estimated disease prevalence of 1:3,600 in this population. These data support the feasibility of two-tier DBS screening for CTX in newborns and set the stage for large-scale prospective pilot studies.
Collapse
Affiliation(s)
- Andrea E DeBarber
- Physiology and Pharmacology Department, Oregon Health and Science University (OHSU), Portland, OR
| | - Limor Kalfon
- Institute of Human Genetics, Galilee Medical Center, Naharia, Israel
| | - Ayalla Fedida
- Institute of Human Genetics, Galilee Medical Center, Naharia, Israel.,Azrieli Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel; and
| | | | - Shani Ben Haroush
- Institute of Human Genetics, Galilee Medical Center, Naharia, Israel
| | - Natalia Chasnyk
- Institute of Human Genetics, Galilee Medical Center, Naharia, Israel
| | | | - Hanna Mandel
- Institute of Human Genetics, Galilee Medical Center, Naharia, Israel
| | - Krystal Jeffries
- Physiology and Pharmacology Department, Oregon Health and Science University (OHSU), Portland, OR
| | - Eric S Shinwell
- Azrieli Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel; and.,Department of Neonatology, Ziv Medical Center, Tzfat, Israel
| | - Tzipora C Falik-Zaccai
- Institute of Human Genetics, Galilee Medical Center, Naharia, Israel .,Azrieli Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel; and
| |
Collapse
|