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Lopergolo D, Rosini F, Pretegiani E, Bargagli A, Serchi V, Rufa A. Autosomal recessive cerebellar ataxias: a diagnostic classification approach according to ocular features. Front Integr Neurosci 2024; 17:1275794. [PMID: 38390227 PMCID: PMC10883068 DOI: 10.3389/fnint.2023.1275794] [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: 08/10/2023] [Accepted: 11/10/2023] [Indexed: 02/24/2024] Open
Abstract
Autosomal recessive cerebellar ataxias (ARCAs) are a heterogeneous group of neurodegenerative disorders affecting primarily the cerebellum and/or its afferent tracts, often accompanied by damage of other neurological or extra-neurological systems. Due to the overlap of clinical presentation among ARCAs and the variety of hereditary, acquired, and reversible etiologies that can determine cerebellar dysfunction, the differential diagnosis is challenging, but also urgent considering the ongoing development of promising target therapies. The examination of afferent and efferent visual system may provide neurophysiological and structural information related to cerebellar dysfunction and neurodegeneration thus allowing a possible diagnostic classification approach according to ocular features. While optic coherence tomography (OCT) is applied for the parametrization of the optic nerve and macular area, the eye movements analysis relies on a wide range of eye-tracker devices and the application of machine-learning techniques. We discuss the results of clinical and eye-tracking oculomotor examination, the OCT findings and some advancing of computer science in ARCAs thus providing evidence sustaining the identification of robust eye parameters as possible markers of ARCAs.
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Affiliation(s)
- Diego Lopergolo
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
- UOC Neurologia e Malattie Neurometaboliche, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Francesca Rosini
- UOC Stroke Unit, Department of Emergenza-Urgenza, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Elena Pretegiani
- Unit of Neurology, Centre Hospitalier Universitaire Vaudoise Lausanne, Unit of Neurology and Cognitive Neurorehabilitation, Universitary Hospital of Fribourg, Fribourg, Switzerland
| | - Alessia Bargagli
- Evalab-Neurosense, Department of Medicine Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Valeria Serchi
- Evalab-Neurosense, Department of Medicine Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Alessandra Rufa
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
- UOC Neurologia e Malattie Neurometaboliche, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
- Evalab-Neurosense, Department of Medicine Surgery and Neuroscience, University of Siena, Siena, Italy
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2
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Ribeiro RM, Vasconcelos SC, Lima PLGDSB, Coelho EF, Oliveira AMN, Gomes EDABM, Mota LDA, Radtke LS, Carvalho MDS, Araújo DABS, Pinheiro MSN, Gama VCDV, Júnior RMM, Braga Neto P, Nóbrega PR. Pathophysiology and Treatment of Lipid Abnormalities in Cerebrotendinous Xanthomatosis: An Integrative Review. Brain Sci 2023; 13:979. [PMID: 37508912 PMCID: PMC10377253 DOI: 10.3390/brainsci13070979] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 06/19/2023] [Accepted: 06/19/2023] [Indexed: 07/30/2023] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is an autosomal recessive disorder caused by pathogenic variants in CYP27A1, leading to a deficiency in sterol 27-hydroxylase. This defect results in the accumulation of cholestanol and bile alcohols in various tissues, including the brain, tendons and peripheral nerves. We conducted this review to evaluate lipid profile abnormalities in patients with CTX. A search was conducted in PubMed, Embase and the Virtual Health Library in January 2023 to evaluate studies reporting the lipid profiles of CTX patients, including the levels of cholestanol, cholesterol and other lipids. Elevated levels of cholestanol were consistently observed. Most patients presented normal or low serum cholesterol levels. A decrease in chenodeoxycholic acid (CDCA) leads to increased synthesis of cholesterol metabolites, such as bile alcohols 23S-pentol and 25-tetrol 3-glucuronide, which may serve as surrogate follow-up markers in patients with CTX. Lipid abnormalities in CTX have clinical implications. Cholestanol deposition in tissues contributes to clinical manifestations, including neurological symptoms and tendon xanthomas. Dyslipidemia and abnormal cholesterol metabolism may also contribute to the increased risk of atherosclerosis and cardiovascular complications observed in some CTX patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Lucas Soares Radtke
- Faculty of Medicine, Federal University of Ceara, Fortaleza 60430-372, Brazil
| | | | | | | | | | | | - Pedro Braga Neto
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceara, Fortaleza 60430-372, Brazil
| | - Paulo Ribeiro Nóbrega
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceara, Fortaleza 60430-372, Brazil
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3
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Cohen H, Hassin-Baer S, Shaish A. Features of the metabolic syndrome and subclinical atherosclerosis in patients with cerebrotendinous xanthomatosis: An augmented risk for premature cardiovascular disease. Front Genet 2022; 13:997069. [PMID: 36238157 PMCID: PMC9550927 DOI: 10.3389/fgene.2022.997069] [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: 07/18/2022] [Accepted: 08/17/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Cerebrotendinous xanthomatosis (CTX) is a rare lipid storage disease, caused by deficiency of sterol-27-hydroxylase. Xanthomatous lesions in numerous tissues, and an elevation of cholestanol levels, characterize the disease. Its natural course is progressive neurologic deterioration, leading to premature death. Chronic treatment with oral chenodeoxycholic acid (CDCA) reduces cholestanol levels. Occurrence of premature atherosclerosis has been described in CTX in an unknown mechanism. Aim: The aim of the current work was to evaluate the potential metabolic abnormalities and preclinical vascular changes in Israeli CTX patients. Methods: Ten subjects with CTX were studied. Features of the metabolic syndrome were evaluated, and carotid intima media thickness (cIMT) was measured in the common carotid arteries. Results: All patients were diagnosed with CTX, and all received treatment with CDCA, which resulted in normalization of their plasma cholestanol levels. At the conclusion of the follow up, risk factors for CVD and features of MS were present in all the patients and in three patients, cIMT was higher compared to control subjects. Conclusion: Cardiovascular risk factors and premature vascular changes exist in young CTX patients and proper assessment should be implemented with preventive measures to reduce the risk of atherosclerotic cardiovascular disease in CTX patients.
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Affiliation(s)
- H. Cohen
- The Bert W. Strassburger Metabolic Center, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
- *Correspondence: H. Cohen,
| | - S. Hassin-Baer
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
- The Movement Disorders Institute and Department of Neurology, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - A. Shaish
- The Bert W. Strassburger Metabolic Center, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
- Achva Academic College, Arugot, Israel
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4
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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: 28] [Impact Index Per Article: 9.3] [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.
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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
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5
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Rossi M, Wainsztein N, Merello M. Cardiac Involvement in Movement Disorders. Mov Disord Clin Pract 2021; 8:651-668. [PMID: 34307738 DOI: 10.1002/mdc3.13188] [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: 05/16/2020] [Revised: 02/23/2021] [Accepted: 03/02/2021] [Indexed: 02/06/2023] Open
Abstract
Background Several conditions represented mainly by movement disorders are associated with cardiac disease, which can be overlooked in clinical practice in the context of a prominent primary neurological disorder. Objectives To review neurological conditions that combine movement disorders and primary cardiac involvement. Methods A comprehensive and structured literature search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria was conducted to identify disorders combining movement disorders and cardiac disease. Results Some movement disorders are commonly or prominently associated with cardiac disease. Neurological and cardiac symptoms may share underlying physiopathological mechanisms in diseases, such as Friedreich's ataxia and Wilson's disease, and in certain metabolic disorders, including Refsum disease, Gaucher disease, a congenital disorder of glycosylation, or cerebrotendinous xanthomatosis. In certain conditions, such as Sydenham's chorea or dilated cardiomyopathy with ataxia syndrome (ATX-DNAJC19), heart involvement can present early in the course of disease, whereas in others such as Friedreich's ataxia or Refsum disease, cardiac symptoms tend to present in later stages. In another 68 acquired or inherited conditions, cardiac involvement or movement disorders are seldom reported. Conclusions As cardiac disease is part of the phenotypic spectrum of several movement disorders, heart involvement should be carefully investigated and increased awareness of this association encouraged as it may represent a leading cause of morbidity and mortality.
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Affiliation(s)
- Malco Rossi
- Sección Movimientos Anormales, Departamento de Neurociencias Instituto de Investigaciones Neurológicas Raúl Carrea, Fleni Buenos Aires Argentina.,Argentine National Scientific and Technological Research Council Buenos Aires Argentina
| | - Nestor Wainsztein
- Departamento de Medicina Interna Unidad de Cuidados Críticos, Fleni Buenos Aires Argentina
| | - Marcelo Merello
- Sección Movimientos Anormales, Departamento de Neurociencias Instituto de Investigaciones Neurológicas Raúl Carrea, Fleni Buenos Aires Argentina.,Argentine National Scientific and Technological Research Council Buenos Aires Argentina.,Pontificia Universidad Católica Argentina Buenos Aires Argentina
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6
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A case of effort angina complicated with cerebrotendinous xanthomatosis involving severe coronary artery calcification and the detection of a calcified nodule on optical coherence tomography. Cardiovasc Interv Ther 2020; 35:409-410. [DOI: 10.1007/s12928-020-00650-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 02/05/2020] [Indexed: 11/28/2022]
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7
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Sekijima Y, Koyama S, Yoshinaga T, Koinuma M, Inaba Y. Nationwide survey on cerebrotendinous xanthomatosis in Japan. J Hum Genet 2018. [PMID: 29321515 DOI: 10.1038/s10038‐017‐0389‐4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cerebrotendinous xanthomatosis (CTX) is likely to be underdiagnosed and precise epidemiological characteristics of CTX are largely unknown as knowledge on the disorder is based mainly on case reports. We conducted a nationwide survey on CTX to elucidate the frequency, clinical picture, and molecular biological background of Japanese CTX patients. In this first Japanese nationwide survey on CTX, 2541 questionnaires were sent to clinical departments across Japan. A total of 1032 (40.6%) responses were returned completed for further analysis. Forty patients with CTX (50.0% male) were identified between September 2012 and August 2015. The mean age of onset was 24.5 ± 13.6 years, mean age at diagnosis was 41.0 ± 11.6 years, and corresponding mean duration of illness from onset to diagnosis was 16.5 ± 13.5 years. The most common initial symptom was tendon xanthoma, followed next by spastic paraplegia, cognitive dysfunction, cataract, ataxia, and epilepsy. The most predominant mutations in the CYP27A1 gene were c.1214G> A (p.R405Q, 31.6%), c.1421G> A (p.R474Q, 26.3%), and c.435G> T (p.G145=, 15.8%). Therapeutic interventions that included chenodeoxycholic acid, HMG-CoA reductase inhibitor, and LDL apheresis reduced serum cholestanol level in all patients and improved clinical symptoms in 40.5% of patients. Although CTX is a treatable neurodegenerative disorder, our nationwide survey revealed an average 16.5-year diagnostic delay. CTX may be underdiagnosed in Japan, especially during childhood. Early diagnosis and treatment are essential to improve the prognosis of CTX.
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Affiliation(s)
- Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan. .,Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan.
| | - Shingo Koyama
- Department of Internal Medicine III, Division of Neurology and Clinical Neuroscience, Yamagata University School of Medicine, Yamagata, Japan
| | - Tsuneaki Yoshinaga
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan.,Center for Medical Genetics, Shinshu University Hospital, Matsumoto, Japan
| | - Masayoshi Koinuma
- Center of Clinical Research, Shinshu University Hospital, Matsumoto, Japan.,Faculty of Pharmaceutical Sciences, Teikyo Heisei University, Tokyo, Japan
| | - Yuji Inaba
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
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8
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Sekijima Y, Koyama S, Yoshinaga T, Koinuma M, Inaba Y. Nationwide survey on cerebrotendinous xanthomatosis in Japan. J Hum Genet 2018; 63:271-280. [PMID: 29321515 DOI: 10.1038/s10038-017-0389-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 10/04/2017] [Accepted: 10/30/2017] [Indexed: 12/25/2022]
Abstract
Cerebrotendinous xanthomatosis (CTX) is likely to be underdiagnosed and precise epidemiological characteristics of CTX are largely unknown as knowledge on the disorder is based mainly on case reports. We conducted a nationwide survey on CTX to elucidate the frequency, clinical picture, and molecular biological background of Japanese CTX patients. In this first Japanese nationwide survey on CTX, 2541 questionnaires were sent to clinical departments across Japan. A total of 1032 (40.6%) responses were returned completed for further analysis. Forty patients with CTX (50.0% male) were identified between September 2012 and August 2015. The mean age of onset was 24.5 ± 13.6 years, mean age at diagnosis was 41.0 ± 11.6 years, and corresponding mean duration of illness from onset to diagnosis was 16.5 ± 13.5 years. The most common initial symptom was tendon xanthoma, followed next by spastic paraplegia, cognitive dysfunction, cataract, ataxia, and epilepsy. The most predominant mutations in the CYP27A1 gene were c.1214G> A (p.R405Q, 31.6%), c.1421G> A (p.R474Q, 26.3%), and c.435G> T (p.G145=, 15.8%). Therapeutic interventions that included chenodeoxycholic acid, HMG-CoA reductase inhibitor, and LDL apheresis reduced serum cholestanol level in all patients and improved clinical symptoms in 40.5% of patients. Although CTX is a treatable neurodegenerative disorder, our nationwide survey revealed an average 16.5-year diagnostic delay. CTX may be underdiagnosed in Japan, especially during childhood. Early diagnosis and treatment are essential to improve the prognosis of CTX.
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Affiliation(s)
- Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan. .,Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan.
| | - Shingo Koyama
- Department of Internal Medicine III, Division of Neurology and Clinical Neuroscience, Yamagata University School of Medicine, Yamagata, Japan
| | - Tsuneaki Yoshinaga
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan.,Center for Medical Genetics, Shinshu University Hospital, Matsumoto, Japan
| | - Masayoshi Koinuma
- Center of Clinical Research, Shinshu University Hospital, Matsumoto, Japan.,Faculty of Pharmaceutical Sciences, Teikyo Heisei University, Tokyo, Japan
| | - Yuji Inaba
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
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9
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Salen G, Steiner RD. Epidemiology, diagnosis, and treatment of cerebrotendinous xanthomatosis (CTX). J Inherit Metab Dis 2017; 40:771-781. [PMID: 28980151 DOI: 10.1007/s10545-017-0093-8] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/08/2017] [Accepted: 09/14/2017] [Indexed: 01/05/2023]
Abstract
Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive disorder of bile acid synthesis caused by mutations in the cytochrome P450 CYP27A1 gene that result in production of a defective sterol 27-hydroxylase enzyme. CTX is associated with abnormally high levels of cholestanol in the blood and accumulation of cholestanol and cholesterol in the brain, tendon xanthomas, and bile. Hallmark clinical manifestations of CTX include chronic diarrhea, bilateral cataracts, tendon xanthomas, and neurologic dysfunction. Although CTX is a rare disorder, it is thought to be underdiagnosed, as presenting signs and symptoms may be nonspecific with significant overlap with other more common conditions. There is marked variability in signs and symptoms, severity, and age of onset between patients. The disease course is progressive and potentially debilitating or fatal, particularly with respect to neurologic presentations that can include intellectual disability, autism, behavioral and psychiatric problems, and dementia, among others. Treatment with chenodeoxycholic acid (CDCA; chenodiol) is the current standard of care. CDCA can help restore normal sterol, bile acid, bile alcohol, and cholestanol levels. CDCA also appears to be generally effective in preventing adverse clinical manifestations of the disease from occurring or progressing if administered early enough. Improved screening and awareness of the condition may help facilitate early diagnosis and treatment.
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Affiliation(s)
- Gerald Salen
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Robert D Steiner
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Genetics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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10
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Abstract
Cerebrotendinous xanthomatosis (CTX) is a rare autosomal-recessive lipid storage disease caused by mutations in the CYP27A1 gene, which lead to deficiency of the mitochondrial enzyme, sterol 27-hydroxylase, resulting in the accumulation of cholestanol in the serum and many affected lesions. To date, more than 50 different CYP27A1 mutations, including missense mutations, frameshifts, and splice site mutations, have been reported worldwide in patients with CTX. Clinical presentation is characterized by neonatal jaundice or cholestasis, refractory diarrhea, juvenile cataracts, tendon xanthomas, osteoporosis, coronary heart disease, and progressive neuropsychiatric disturbances; however, combinations of symptoms vary from patient to patient. Neuropsychiatric abnormalities include mental retardation or dementia, psychiatric symptoms, cerebellar signs, pyramidal signs, progressive myelopathy, peripheral neuropathy, extrapyramidal manifestations, and seizures. Replacement treatment with chenodeoxycholic acid in the early stage of the disease has been reported to improve or even prevent clinical symptoms of CTX. After significant neurological pathology is established, the effect of the treatment is limited and the deterioration of clinical manifestations may continue; therefore, early diagnosis of CTX is crucial.
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Affiliation(s)
- Shingo Koyama
- Department of Neurology, Hematology, Metabolism, Endocrinology, and Diabetology, Yamagata University Faculty of Medicine
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11
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Abe R, Sekijima Y, Kinoshita T, Yoshinaga T, Koyama S, Kato T, Ikeda SI. Spinal form cerebrotendinous xanthomatosis patient with long spinal cord lesion. J Spinal Cord Med 2016; 39:726-729. [PMID: 25941960 PMCID: PMC5137569 DOI: 10.1179/1079026815z.000000000409] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
CONTEXT Cerebrotendinous xanthomatosis (CTX) is an autosomal recessively inherited lipid storage disease caused by mutation in the CYP27A1 gene. Spinal form CTX is a rare clinical subgroup of CTX and only 14 patients from 11 families have been reported to date. Here, we report the first Asian patient with spinal form CTX showing characteristic radiological findings. FINDINGS The patient, a 46-year-old Japanese male, developed sensory disturbance of the lower legs at 39 and spastic gait at 46 years of age. Spinal cord magnetic resonance imaging (MRI) revealed a long hyperintense lesion involving lateral corticospinal tracts and gracile tracts in the cervical and thoracic cord on T2-weighted images. Gallium-67 (67Ga) scintigraphy revealed abnormal uptake in the Achilles tendons and the serum cholestanol level was elevated. CYP27A1 gene analysis identified homozygous missense mutation, c.1214G>A (p.R405Q). The patient was treated with atorvastatin monotherapy, which reduced serum cholestanol to less than 50% of the pretreatment level. CONCLUSION Spinal form CTX should be considered in the differential diagnosis of cryptogenic myelopathy, especially in patients with a long spinal cord lesion, as treatment with chenodeoxycholic acid and/or competitive inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase reverse the metabolic derangement and prevent the neurologiccal dysfunction.
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Affiliation(s)
- Ryuta Abe
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan,Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan,Corresponding author: Yoshiki Sekijima, Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan.
| | - Tomomi Kinoshita
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Tsuneaki Yoshinaga
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Shingo Koyama
- Department of Neurology, Hematology, Metabolism, Endocrinology, and Diabetology, Yamagata University Faculty of Medicine, Japan
| | - Takeo Kato
- Department of Neurology, Hematology, Metabolism, Endocrinology, and Diabetology, Yamagata University Faculty of Medicine, Japan
| | - Shu-ichi Ikeda
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan,Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan
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12
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Parente F, Vesnaver M, Massie R, Baass A. An unusual cause of Achilles tendon xanthoma. J Clin Lipidol 2016; 10:1040-1044. [DOI: 10.1016/j.jacl.2016.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 05/07/2016] [Indexed: 11/28/2022]
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13
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Kim JM, Kim MW, Do HJ. Influence of Hyperlipidemia on the Treatment of Supraspinatus Tendinopathy With or Without Tear. Ann Rehabil Med 2016; 40:463-9. [PMID: 27446783 PMCID: PMC4951365 DOI: 10.5535/arm.2016.40.3.463] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 10/05/2015] [Indexed: 12/16/2022] Open
Abstract
Objective To investigate the influence of hyperlipidemia on the treatment of supraspinatus tendinopathy, with or without tear. Methods We retrospectively reviewed the data of patients with shoulder pain and patients with supraspinatus tendinopathy, with or without tear, were included in the study. Exclusion criteria were prior shoulder surgery, prior steroid injection, neurological diseases that could lead to shoulder pain, and use of lipid-lowering medication. According to the serum lipid profiles, patients were assigned to either the hyperlipidemia or non-hyperlipidemia group. By analyzing the numeric rating scale (NRS) before treatment, and at 2 weeks and 8 weeks after treatment, we compared the difference in treatment effect between the two groups. Results No significant baseline difference was found among the two groups for age, gender, body mass index, duration of pain, side of pain, range of motion of affected shoulder, or physical examination. On the repeated-measures analysis of variance, NRS scores significantly decreased with time for both groups (p<0.001). When analyzing the effect of time between the subjects factor, there was significant difference in the treatment effect between the two groups (p<0.001), namely NRS was less decreased in the hyperlipidemia group. Conclusion We found that hyperlipidemia may be an adversely affecting factor in the treatment of supraspinatus tendinopathy with or without tear.
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Affiliation(s)
- Jae-Min Kim
- Department of Rehabilitation, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Min-Wook Kim
- Department of Rehabilitation, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Hyun-Jung Do
- Department of Rehabilitation, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
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14
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Yanagihashi M, Kano O, Terashima T, Kawase Y, Hanashiro S, Sawada M, Ishikawa Y, Shiraga N, Ikeda K, Iwasaki Y. Late-onset spinal form xanthomatosis without brain lesion: a case report. BMC Neurol 2016. [PMID: 26861945 DOI: 10.1186/s12883‐016‐0542‐2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive sterol storage disease caused by a mutated sterol 27-hydroxylase (CYP27A1) gene. Patients with typical CTX show neurological dysfunction including bilateral cataracts, paresis, cerebral ataxia, dementia, and psychiatric disorders, and magnetic resonance imaging (MRI) has revealed symmetrical lesions in the cerebellar white matter. CASE PRESENTATION We report the case of a patient with late-onset spinal form CTX without brain lesion. He showed pyramidal tract signs, and impaired joint position and vibration sensation in the lower limbs. Cervical sagittal MRI demonstrated a longitudinally extensive white matter abnormality in the dorsal column of the C2-C7 spinal cord; however, a brain MRI revealed an absence of lesions, including in the cerebellar white matter. Genetic analysis of CYP27A1 revealed that the patient was compound heterozygous for p.Gln85Arg in exon 1, a novel mutation, and p.Arg405Gln in exon 7, a previously reported mutation. CONCLUSION This is the first report of late-onset spinal form CTX without typical neurological symptoms, and the first report of p.Gln85Arg in CYP27A1. We speculate that spinal form CTX without brain lesion is a clinically and radiologically rare variation of CTX. Therefore, spinal xanthomatosis should be included in the differential diagnosis of chronic myelopathy even with late-onset and/or no other typical neurological findings.
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Affiliation(s)
- Masaru Yanagihashi
- Division of Neurology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Osamu Kano
- Division of Neurology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Tomoya Terashima
- Department of Stem Cell Biology and Regenerative Medicine, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan.
| | - Yuji Kawase
- Division of Neurology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Sayori Hanashiro
- Division of Neurology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Masahiro Sawada
- Division of Neurology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Yuichi Ishikawa
- Division of Neurology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Nobuyuki Shiraga
- Department of Radiology, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Ken Ikeda
- Division of Neurology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Yasuo Iwasaki
- Division of Neurology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
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Yanagihashi M, Kano O, Terashima T, Kawase Y, Hanashiro S, Sawada M, Ishikawa Y, Shiraga N, Ikeda K, Iwasaki Y. Late-onset spinal form xanthomatosis without brain lesion: a case report. BMC Neurol 2016; 16:21. [PMID: 26861945 PMCID: PMC4748474 DOI: 10.1186/s12883-016-0542-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 02/02/2016] [Indexed: 11/11/2022] Open
Abstract
Background Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive sterol storage disease caused by a mutated sterol 27-hydroxylase (CYP27A1) gene. Patients with typical CTX show neurological dysfunction including bilateral cataracts, paresis, cerebral ataxia, dementia, and psychiatric disorders, and magnetic resonance imaging (MRI) has revealed symmetrical lesions in the cerebellar white matter. Case presentation We report the case of a patient with late-onset spinal form CTX without brain lesion. He showed pyramidal tract signs, and impaired joint position and vibration sensation in the lower limbs. Cervical sagittal MRI demonstrated a longitudinally extensive white matter abnormality in the dorsal column of the C2-C7 spinal cord; however, a brain MRI revealed an absence of lesions, including in the cerebellar white matter. Genetic analysis of CYP27A1 revealed that the patient was compound heterozygous for p.Gln85Arg in exon 1, a novel mutation, and p.Arg405Gln in exon 7, a previously reported mutation. Conclusion This is the first report of late-onset spinal form CTX without typical neurological symptoms, and the first report of p.Gln85Arg in CYP27A1. We speculate that spinal form CTX without brain lesion is a clinically and radiologically rare variation of CTX. Therefore, spinal xanthomatosis should be included in the differential diagnosis of chronic myelopathy even with late-onset and/or no other typical neurological findings.
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Affiliation(s)
- Masaru Yanagihashi
- Division of Neurology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Osamu Kano
- Division of Neurology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Tomoya Terashima
- Department of Stem Cell Biology and Regenerative Medicine, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan.
| | - Yuji Kawase
- Division of Neurology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Sayori Hanashiro
- Division of Neurology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Masahiro Sawada
- Division of Neurology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Yuichi Ishikawa
- Division of Neurology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Nobuyuki Shiraga
- Department of Radiology, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Ken Ikeda
- Division of Neurology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Yasuo Iwasaki
- Division of Neurology, Department of Internal Medicine, Toho University School of Medicine, 6-11-1 Omorinishi, Ota-ku, Tokyo, 143-8541, Japan.
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Sastri V, Ravindranath VS, Metikala S, Kumar M. Bilateral Xanthomas of Tendoachilles in A Patient of Cerebrotendinous Xanthomatosis - A Rare Case Report and Review of Literature. J Orthop Case Rep 2014; 4:40-3. [PMID: 27299000 PMCID: PMC4719269 DOI: 10.13107/jocr.2250-0685.223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Cerebrotendinous xanthomatosis is a very rare disorder of cholesterol metabolism with autosomal recessive inheritance. It can present to the out-patient clinics of orthopaedic department with painful and swollen tendoachilles on one or both sides. It is commonly mistaken for a local disorder and excision may be recommended without realizing its systemic nature. Case Report: We find such a rare and perplexing case in a 19 year boy who presented with painful swellings of both achilles tendons causing signification limitation of walking distance. This was initially interpreted as a localized benign disorder and was offered surgical treatment. Excision of the swollen achilles tendon followed by reconstruction using peroneus brevis tendon was done, first on the more symptomatic right side. The diagnosis of cerebrotendinous xanthomatosis was made retrospectively after histopathological as well as biochemical analyses and appropriate medical therapy was initiated. Conclusion: Cerebrotendinous xanthomatosis commonly manifests with bilateral swollen tendoachilles, which is actually a part of systemic pathology with poor prognosis. High suspicion is warranted and surgical excision should not be the primary option without the confirmation of the cause. A detailed history with clinical assessment followed by the laboratory investigations certainly leads to the correct diagnosis. The treatment is more of medical means and appropriate medication can even retard the disease progression, if initiated early in life.
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Affiliation(s)
- Vrk Sastri
- Department of Orthopaedics and Traumatology, Osmania Medical College and General Hospital, Hyderabad. Andhra Pradesh - 500012, India
| | - V S Ravindranath
- Department of Orthopaedics and Traumatology, Osmania Medical College and General Hospital, Hyderabad. Andhra Pradesh - 500012, India
| | - Sreenivasulu Metikala
- Department of Orthopaedics and Traumatology, Osmania Medical College and General Hospital, Andhra Pradesh - 500012, India
| | - Madhusudhan Kumar
- Department of Orthopaedics and Traumatology, Osmania Medical College and General Hospital, Hyderabad. Andhra Pradesh - 500012, India
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Sastri V, Ravindranath VS, Metikala S, Kumar M. Bilateral Xanthomas of Tendoachilles in A Patient of Cerebrotendinous Xanthomatosis - A Rare Case Report and Review of Literature. J Orthop Case Rep 2014. [PMID: 27299000 DOI: 10.13107/jocr.2250‐0685.223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Cerebrotendinous xanthomatosis is a very rare disorder of cholesterol metabolism with autosomal recessive inheritance. It can present to the out-patient clinics of orthopaedic department with painful and swollen tendoachilles on one or both sides. It is commonly mistaken for a local disorder and excision may be recommended without realizing its systemic nature. CASE REPORT We find such a rare and perplexing case in a 19 year boy who presented with painful swellings of both achilles tendons causing signification limitation of walking distance. This was initially interpreted as a localized benign disorder and was offered surgical treatment. Excision of the swollen achilles tendon followed by reconstruction using peroneus brevis tendon was done, first on the more symptomatic right side. The diagnosis of cerebrotendinous xanthomatosis was made retrospectively after histopathological as well as biochemical analyses and appropriate medical therapy was initiated. CONCLUSION Cerebrotendinous xanthomatosis commonly manifests with bilateral swollen tendoachilles, which is actually a part of systemic pathology with poor prognosis. High suspicion is warranted and surgical excision should not be the primary option without the confirmation of the cause. A detailed history with clinical assessment followed by the laboratory investigations certainly leads to the correct diagnosis. The treatment is more of medical means and appropriate medication can even retard the disease progression, if initiated early in life.
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Affiliation(s)
- Vrk Sastri
- Department of Orthopaedics and Traumatology, Osmania Medical College and General Hospital, Hyderabad. Andhra Pradesh - 500012, India
| | - V S Ravindranath
- Department of Orthopaedics and Traumatology, Osmania Medical College and General Hospital, Hyderabad. Andhra Pradesh - 500012, India
| | - Sreenivasulu Metikala
- Department of Orthopaedics and Traumatology, Osmania Medical College and General Hospital, Andhra Pradesh - 500012, India
| | - Madhusudhan Kumar
- Department of Orthopaedics and Traumatology, Osmania Medical College and General Hospital, Hyderabad. Andhra Pradesh - 500012, India
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DeBarber AE, Luo J, Giugliani R, Souza CFM, Chiang JPW, Merkens LS, Pappu AS, Steiner RD. A useful multi-analyte blood test for cerebrotendinous xanthomatosis. Clin Biochem 2014; 47:860-3. [PMID: 24769274 PMCID: PMC4175980 DOI: 10.1016/j.clinbiochem.2014.04.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 04/10/2014] [Accepted: 04/13/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Cerebrotendinous xanthomatosis (CTX) is a rare genetic disorder of bile acid (BA) synthesis that can cause progressive neurological damage and premature death. Blood (normally serum or plasma) testing for CTX is performed by a small number of specialized laboratories, routinely by gas chromatography-mass spectrometry (GC-MS) measurement of elevated 5α-cholestanol. We report here on a more sensitive biochemical approach to test for CTX particularly useful for confirmation of CTX in the case of a challenging diagnostic sample with 5α-cholestanol that, although elevated, was below the cut-off used for diagnosis of CTX (10 μg/mL or 1.0 mg/dL). DESIGN AND METHODS We have previously described liquid chromatography-electrospray ionization-tandem mass spectrometry (LC-ESI-MS/MS) methodology utilizing keto derivatization to enable the sensitive quantification of plasma ketosterol BA precursors that accumulate in CTX. We have expanded this methodology to perform isotope dilution LC-ESI-MS/MS quantification of a panel of plasma ketosterol BA precursors, with internal standards readily generated using isotopically-enriched derivatization reagent. RESULTS Quantification of plasma ketosterol BA precursors (7α-hydroxy-4-cholesten-3-one, 7α,12α-dihydroxy-4-cholesten-3-one and 7α,12α-dihydroxy-5β-cholestan-3-one) in a single LC-ESI/MS/MS test provided better discrimination between a CTX-positive and negative samples analyzed (n=20) than measurement of 5α-cholestanol alone. CONCLUSIONS Quantification of plasma ketosterol BA precursors provides a more sensitive biochemical approach to discriminate between CTX negative and positive samples. A multiplexed LC-ESI-MS/MS test quantifying a panel of plasma ketosterols, with simple sample preparation, rapid analysis time and readily available internal standards, can be performed by most clinical laboratories. Wider availability of testing will benefit those affected with CTX.
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Affiliation(s)
- Andrea E DeBarber
- Department of Physiology & Pharmacology, Oregon Health & Science University (OHSU), Portland, OR 97239, USA.
| | - Jenny Luo
- Department of Physiology & Pharmacology, Oregon Health & Science University (OHSU), Portland, OR 97239, USA
| | - Roberto Giugliani
- Medical Genetics Service, Hospital de Clinicas de Porto Alegre, Brazil; Department of Genetics, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Carolina F M Souza
- Department of Genetics, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | | | - Robert D Steiner
- Department of Pediatrics, OHSU, USA; Department of Molecular & Medical Genetics, Child Development & Rehabilitation Center, Doernbecher Children's Hospital, OHSU, USA; Marshfield Research Clinic Foundation, Marshfield, WI 54449, USA
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DeBarber AE, Luo J, Star-Weinstock M, Purkayastha S, Geraghty MT, Chiang JPW, Merkens LS, Pappu AS, Steiner RD. A blood test for cerebrotendinous xanthomatosis with potential for disease detection in newborns. J Lipid Res 2013; 55:146-54. [PMID: 24186955 DOI: 10.1194/jlr.p043273] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is a rare, difficult-to-diagnose genetic disorder of bile acid (BA) synthesis that can cause progressive neurological damage and premature death. Detection of CTX in the newborn period would be beneficial because an effective oral therapy for CTX is available to prevent disease progression. There is no suitable test to screen newborn dried bloodspots (DBS) for CTX. Blood screening for CTX is currently performed by GC-MS measurement of elevated 5α-cholestanol. We present here LC-ESI/MS/MS methodology utilizing keto derivatization with (O-(3-trimethylammonium-propyl) hydroxylamine) reagent to enable sensitive detection of ketosterol BA precursors that accumulate in CTX. The availability of isotopically enriched derivatization reagent allowed ready tagging of ketosterols to generate internal standards for isotope dilution quantification. Ketosterols were quantified and their utility as markers for CTX was compared with 5α-cholestanol. 7α,12α-Dihydroxy-4-cholesten-3-one provided the best discrimination between CTX and unaffected samples. In two CTX, newborn DBS concentrations of this ketosterol (120-214 ng/ml) were ∼10-fold higher than in unaffected newborn DBS (16.4 ± 6.0 ng/ml), such that quantification of this ketosterol provides a test with potential to screen newborn DBS for CTX. Early detection and intervention through newborn screening would greatly benefit those affected with CTX by preventing morbidity and mortality.
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Affiliation(s)
- Andrea E DeBarber
- Department of Physiology & Pharmacology, Oregon Health & Science University, Portland, OR
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Lagarde J, Roze E, Apartis E, Pothalil D, Sedel F, Couvert P, Vidailhet M, Degos B. Myoclonus and dystonia in cerebrotendinous xanthomatosis. Mov Disord 2012; 27:1805-10. [PMID: 23115103 DOI: 10.1002/mds.25206] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 08/09/2012] [Accepted: 08/22/2012] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Cerebrotendinous xanthomatosis (CTX) is an inherited neurometabolic disorder. The main neurological manifestations of the disease are pyramidal syndrome, ataxia, peripheral neuropathy, cognitive impairment, epilepsy, and psychiatric disturbances. Myoclonic dystonia has been reported on in the setting of various neurometabolic diseases. Anecdotal reports describe movement disorders associated with CTX, but no dystonia with myoclonic events. METHODS We collected clinical, biochemical, electrophysiological, neuroradiological, and genetic data of 6 patients with myoclonus and mild dystonia associated with CTX. From a systematic literature review, we analyzed 31 patients with movement disorders secondary to CTX. RESULTS Our 6 patients presented distal myoclonus with mild dystonia of the upper limbs. Myoclonus was of subcortical origin, based on neurophysiological recordings, and differed from oromandibular myoclonus previously described in CTX patients. CONCLUSIONS These results expand the phenotype of CTX and suggest that myoclonus and/or dystonia are underdiagnosed. In keeping with our findings, tremors previously observed in CTX patients might actually correspond to myoclonic events. We hypothesize that a dysfunction of the dentate nuclei-basal ganglia pathway may be involved.
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Affiliation(s)
- Julien Lagarde
- AP-HP Département de Neurologie, Hôpital de la Salpêtrière, Paris, France
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Su CS, Chang WN, Huang SH, Lui CC, Pan TL, Lu CH, Chuang YC, Huang CR, Tsai NW, Hsieh MJ, Chang CC. Cerebrotendinous xanthomatosis patients with and without parkinsonism: clinical characteristics and neuroimaging findings. Mov Disord 2010; 25:452-8. [PMID: 20108380 DOI: 10.1002/mds.22979] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Parkinsonism in cerebrotendinous xanthomatosis (CTX) is rare. There are no published studies with imaging findings of dopamine transporter using (99m)Tc-[2-[[2-[[[3-(4-chlorophenyl)-8-methyl-8-azabicyclo [3,2,1] oct-2-yl] methyl] (2-mercaptoethyl) amino] ethyl] amino]-ethanethiolato(3-)-N2,N2,S2,S2]oxo-[1R-(exo-exo)] ((99m)Tc-TRODAT-1) SPECT in CTX patients. This report is on the clinical details of five genetically-proven CTX patients (two with and three without parkinsonism). Imaging findings using cranial magnetic resonance (MR) imaging and (99m)Tc-TRODAT-1 SPECT are also shown. Clinical correlation of neuroimaging findings and clinical presentations was made. A literature review of the clinical and neuroimaging features of eight CTX patients with parkinsonism reported in the English literature is also presented. The parkinsonian features of our two cases and the other eight reported cases occurred before the age of 50 years. The MR imaging study showed variable findings, in which, besides the common diffuse cerebral and cerebellar white matter lesions shown in CTX, several focal brain lesions were also noted. Of the focal lesions, substantia nigra abnormalities were seen only in the two cases with parkinsonism. The (99m)Tc-TRODAT-1 SPECT study showed different degrees of unilateral or bilateral abnormalities in the striatal binding in both visual and semiquantitative assessments. parkinsonism can be one of the neurologic presentations of CTX. Even though abnormal findings of the substantia nigra were detected in both of our CTX patients with parkinsonism, basal ganglion lesions have not been uniformly described in MR imaging findings of reported CTX patients with parkinsonism. (99m)Tc-TRODAT-1 SPECT study can be of value in the detection of striatal involvement, and the study results also suggest pre-synaptic dopamine neuron involvement in CTX patients with parkinsonism.
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Affiliation(s)
- Chen-San Su
- Department of Neurology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Taylor JM, Borthwick F, Bartholomew C, Graham A. Overexpression of steroidogenic acute regulatory protein increases macrophage cholesterol efflux to apolipoprotein AI. Cardiovasc Res 2010; 86:526-34. [DOI: 10.1093/cvr/cvq015] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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23
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Nozue T, Higashikata T, Inazu A, Kawashiri MA, Nohara A, Kobayashi J, Koizumi J, Yamagishi M, Mabuchi H. Identification of a novel missense mutation in the sterol 27-hydroxylase gene in two Japanese patients with cerebrotendinous xanthomatosis. Intern Med 2010; 49:1127-31. [PMID: 20558929 DOI: 10.2169/internalmedicine.49.3277] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive sterol storage disease caused by a mutated sterol 27-hydroxylase (CYP27A1) gene. We analyzed the CYP27A1 gene in two Japanese CTX patients. The CYP27A1 gene was amplified by PCR and screened by PCR-SSCP. The nucleotide sequence was analyzed to confirm mutations. Case 1 was a compound heterozygote for Arg104Gln in exon 2 and Arg441Gln in exon 8. To our knowledge, this is the first report in which the Arg104Gln mutation is identified in CTX patients. Probably case 2 would be a compound heterozygote for Arg441Trp in exon 8 and a mutation that was not identified.
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Affiliation(s)
- Tsuyoshi Nozue
- Division of Cardiology, Department of Internal Medicine, Yokohama Sakae Kyosai Hospital, Federation of National Public Service Personnel Mutual Associations, Yokohama, Japan.
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Ferrándiz-Pulido C, Bartralot R, Girós M, Bassas P, Heras C, Bodet D, Savall R, García-Patos V. Xantomatosis cerebrotendinosa: descripción de 4 casos. ACTAS DERMO-SIFILIOGRAFICAS 2009. [DOI: 10.1016/s0001-7310(09)70538-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Cruysberg JRM. Children with cataract and chronic diarrhoea: cerebrotendinous xanthomatosis. J Inherit Metab Dis 2009; 32:309. [PMID: 19266310 DOI: 10.1007/s10545-009-1147-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Revised: 01/24/2009] [Accepted: 01/29/2009] [Indexed: 10/21/2022]
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26
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Ferrándiz-Pulido C, Bartralot R, Girós M, Bassas P, Heras C, Bodet D, Savall R, García-Patos V. Cerebrotendinous Xanthomatosis: Report of 4 Patients. ACTAS DERMO-SIFILIOGRAFICAS 2009. [DOI: 10.1016/s1578-2190(09)70048-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Pierre G, Setchell K, Blyth J, Preece MA, Chakrapani A, McKiernan P. Prospective treatment of cerebrotendinous xanthomatosis with cholic acid therapy. J Inherit Metab Dis 2008; 31 Suppl 2:S241-5. [PMID: 19125350 DOI: 10.1007/s10545-008-0815-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Revised: 09/24/2008] [Accepted: 10/08/2008] [Indexed: 12/17/2022]
Abstract
Cerebrotendinous xanthomatosis (CTX) OMIM#213700 is a rare disorder of bile acid synthesis caused by deficiency of the enzyme sterol 27-hydroxylase. It results in deficiency of bile acids and accumulation of abnormal bile alcohols and accelerated cholesterol synthesis. CTX usually presents in the second or third decade with slowly progressive neurological dysfunction, cerebellar ataxia and premature atherosclerosis. Treatment with bile acid supplementation improves but does not completely reverse the neurological signs and symptoms. However, CTX is now known to be associated with a period of neonatal cholestasis. If it is diagnosed at this point, treatment may prevent the onset of neurological problems. We present the case histories and developmental findings in two affected siblings treated from infancy. We plan to continue regular neurodevelopmental reviews.
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Affiliation(s)
- Germaine Pierre
- Department of Inherited Metabolic Disease, Birmingham Children's Hospital NHS Trust, Steelhouse Lane, Birmingham, B4 6NH, UK.
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Gonzalez-Cuyar LF, Morrison AL, Perry G, DeJong JJ, Smith MA, Castellani RJ. Cerebrotendinous xanthomatosis: a critical update. FUTURE NEUROLOGY 2008. [DOI: 10.2217/14796708.3.4.491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Cerebrotendinous xanthomatosis (CTX) also known as van Bogaert–Scherer–Epstein syndrome, Thiebaut’s syndrome and cerebrotendinous cholesterosis, is an autosomal-recessive lipid-storage disease characterized by the triad of juvenile cataracts, tendon xanthomas and progressive neurodegeneration. Excess cholesterol and cholestanol are deposited in multiple organs, including the cerebrum, cerebellum, lens and tendons. Approximately 300 cases are reported worldwide, but it is suspected that the incidence of CTX is underestimated. The disease is attributed to approximately 50 mutations in the CYP27A1 gene coding for the enzyme sterol 27-hydoxylase, which is responsible for initial oxidation of the side chain of the cholesterol molecule in bile acid biosynthesis. CTX has varied clinical presentations, but no genotype–phenotype relationship has been documented. In some intrafamilial cases, clinical presentations may vary considerably. MRI for CTX is sensitive for diagnosis and classically demonstrates cerebral and cerebellar atrophy and xanthomatous lesions preferentially affecting the dentate nuclei. Patients have high serum levels of cholestanol with normal total cholesterol and increased urinary excretion of bile acids. Treatment of patients with chenodeoxycholic acid, particularly when used along with HMG-CoA reductase inhibitors (statins) or low-density lipoprotein apheresis, can normalize cholestanol levels as well as prevent further degeneration. Therefore, the need for early diagnosis is well documented in the literature, as it prevents the significant morbidity and mortality associated with this disease.
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Affiliation(s)
| | - Allan L Morrison
- University of Maryland, Department of Pathology, Baltimore, MD, USA
| | - George Perry
- Case Western Reserve University, Department of Pathology, 2103 Cornell Road, Cleveland, OH 44106, USA
| | - Joyce J DeJong
- Sparrow Health Systems, Division of Forensic Pathology, Lansing, MI, USA
| | - Mark A Smith
- Case Western Reserve University, Department of Pathology, 2103 Cornell Road, Cleveland, OH 44106, USA
| | - Rudy J Castellani
- University of Maryland, Department of Pathology, 22 South Greene Street, NBW81, Baltimore, MD 21201, USA
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Sundaram SS, Bove KE, Lovell MA, Sokol RJ. Mechanisms of disease: Inborn errors of bile acid synthesis. ACTA ACUST UNITED AC 2008; 5:456-68. [PMID: 18577977 DOI: 10.1038/ncpgasthep1179] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Accepted: 04/23/2008] [Indexed: 02/08/2023]
Abstract
Inborn errors of bile acid synthesis are rare genetic disorders that can present as neonatal cholestasis, neurologic disease or fat-soluble-vitamin deficiencies. There are nine known defects of bile acid synthesis, including oxysterol 7alpha-hydroxylase deficiency, Delta(4)-3-oxosteroid-5beta-reductase deficiency, 3beta-hydroxy-Delta(5)-C(27)-steroid dehydrogenase deficiency, cerebrotendinous xanthomatosis (also known as sterol 27-hydroxylase deficiency), alpha-methylacyl-CoA racemase deficiency, and Zellweger syndrome (also known as cerebrohepatorenal syndrome). These diseases are characterized by a failure to produce normal bile acids and an accumulation of unusual bile acids and bile acid intermediaries. Individuals with inborn errors of bile acid synthesis generally present with the hallmark features of normal or low serum bile acid concentrations, normal gamma-glutamyl transpeptidase concentrations and the absence of pruritus. Failure to diagnose any of these conditions can result in liver failure or progressive chronic liver disease. If recognized early, many patients can have a remarkable clinical response to oral bile acid therapy.
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Affiliation(s)
- Shikha S Sundaram
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine and The Children's Hospital, CO 80045, USA
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30
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Sedel F, Tourbah A, Fontaine B, Lubetzki C, Baumann N, Saudubray JM, Lyon-Caen O. Leukoencephalopathies associated with inborn errors of metabolism in adults. J Inherit Metab Dis 2008; 31:295-307. [PMID: 18344012 DOI: 10.1007/s10545-008-0778-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2007] [Revised: 12/17/2007] [Accepted: 12/31/2007] [Indexed: 11/28/2022]
Abstract
The discovery of a leukoencephalopathy is a frequent situation in neurological practice and the diagnostic approach is often difficult given the numerous possible aetiologies, which include multiple acquired causes and genetic diseases including inborn errors of metabolism (IEMs). It is now clear that IEMs can have their clinical onset from early infancy until late adulthood. These diseases are particularly important to recognize because specific treatments often exist. In this review, illustrated by personal observations, we give an overview of late-onset leukoencephalopathies caused by IEMs.
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MESH Headings
- Adrenoleukodystrophy/diagnosis
- Adrenoleukodystrophy/etiology
- Brain Diseases, Metabolic, Inborn/diagnosis
- Brain Diseases, Metabolic, Inborn/etiology
- Electron Transport
- Hereditary Central Nervous System Demyelinating Diseases/diagnosis
- Hereditary Central Nervous System Demyelinating Diseases/etiology
- Homocysteine/metabolism
- Humans
- Leukodystrophy, Globoid Cell/diagnosis
- Leukodystrophy, Globoid Cell/etiology
- Leukodystrophy, Metachromatic/diagnosis
- Leukodystrophy, Metachromatic/etiology
- Magnetic Resonance Imaging
- Phenylketonurias/diagnosis
- Phenylketonurias/etiology
- Xanthomatosis, Cerebrotendinous/diagnosis
- Xanthomatosis, Cerebrotendinous/etiology
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Affiliation(s)
- F Sedel
- Federation of Nervous System Diseases, Hôpital de la Salpêtrière and Université Pierre et Marie Curie (Paris VI), Assistance Publique-Hôpitaux de Paris, Paris, France.
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31
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Smithard A, Lamyman MJ, McCarthy CL, Gibbons CLMH, Cooke PJ, Athanasou N. Cerebrotendinous xanthomatosis presenting with bilateral Achilles tendon xanthomata. Skeletal Radiol 2007; 36:171-5. [PMID: 16715243 DOI: 10.1007/s00256-006-0139-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2005] [Revised: 01/27/2006] [Accepted: 02/02/2006] [Indexed: 02/02/2023]
Abstract
We report on a case of a 36-year-old lady who presented with large, painful soft-tissue swellings of both Achilles tendons. MRI demonstrated fusiform enlargement involving the Achilles tendons bilaterally. The tendons returned heterogeneous signal intensity characterised by a diffuse reticulated appearance. The right tendon mass was treated with a wide marginal excision and Achilles tendon reconstruction. The histology confirmed Achilles tendon xanthoma. Further metabolic investigation revealed the patient to have a rare autosomal recessive condition called cerebrotendinous xanthomatosis (CTX). Her brother was also affected. CTX is easily treatable if diagnosed early, and should be suspected in patients presenting with bilateral Achilles tendon xanthomas and normal plasma lipid levels.
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Affiliation(s)
- Abigail Smithard
- Tumour Surgery, Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7LD, UK
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32
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Sedel F. Leucodistrofie dell’adulto. Neurologia 2007. [DOI: 10.1016/s1634-7072(07)70551-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abstract
This review article discusses the historical origin of our continuously evolving model of the etiology of atherosclerotic cardiovascular disease. The basic molecular biologic concepts underlying the development of coronary artery disease and the dynamic connection between the immune system and arterial integrity are explored. Emphasis is placed on the role of inflammation as a driving force in the process of atherosclerosis and vascular endothelium as a modulating factor in the pathogenesis of coronary artery disease.
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Affiliation(s)
- Allison B Reiss
- Vascular Biology Institute, Winthrop University Hospital, 222 Station Plaza, North, Suite 511-A, Mineola, NY 11501, USA.
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34
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Brodsky JW, Beischer AD, Anat D, East C, Soltero E, Tint GS, Salen G, Silverman J. Cerebrotendinous xanthomatosis: a rare cause of bilateral Achilles tendon swelling and ataxia. A case report. J Bone Joint Surg Am 2006; 88:1340-4. [PMID: 16757769 DOI: 10.2106/jbjs.e.00872] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- James W Brodsky
- Baylor University Medical Center, 411 North Washington Avenue, Suite 7000, Dallas, TX 75246, USA
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35
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Sedel F, Tourbah A, Baumann N, Fontaine B, Aubourg P, Lubetzki C, Lyon-Caen O. [Adult onset hereditary leukoencephalopathies]. Rev Neurol (Paris) 2006; 161:916-31. [PMID: 16365621 DOI: 10.1016/s0035-3787(05)85155-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In clinical practice, the term "genetic leukoencephalopathy" refers to a group of genetic diseases whose common point is to give an aspect of diffuse leukoencephalopathy on MRI. With progress in diagnostic techniques including radiology, biochemistry or genetics, a large number of hereditary diseases causing leukoencephalopathy have been identified. Although generally beginning in childhood, these diseases often have more insidious clinical forms which can begin in adulthood. These forms remain poorly known. Some are accessible to treatment so their diagnosis appears essential. The diagnostic steps must be guided by clinical examination (neurological, ophthalmological and systemic), electromyography and MRI. The purpose of this review is to propose a classification of the genetic leukoencephalopathies and to give a progress report applicable in neurological practice.
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Affiliation(s)
- F Sedel
- Fédération des Maladies du Système Nerveux, Groupe Hospitalier Pitié-Salpêtrière, Paris.
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36
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Tsouli SG, Kiortsis DN, Argyropoulou MI, Mikhailidis DP, Elisaf MS. Pathogenesis, detection and treatment of Achilles tendon xanthomas. Eur J Clin Invest 2005; 35:236-44. [PMID: 15816992 DOI: 10.1111/j.1365-2362.2005.01484.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Tendon xanthomatosis often accompanies familial hypercholesterolaemia, but it can also occur in other pathologic states. Achilles tendons are the most common sites of tendon xanthomas. Low-density lipoprotein (LDL) derived from the circulation accumulates into tendons. The next steps leading to the formation of Achilles tendon xanthomas (ATX) are the transformation of LDL into oxidized LDL (oxLDL) and the active uptake of oxLDL by macrophages within the tendons. Although physical examination may reveal Achilles tendon xanthomas (ATX), there are several imaging methods for their detection. It is worth mentioning that ultrasonography is the method of choice in everyday clinical practice. Although several treatments for Achilles tendon xanthomas (ATX) have been proposed (LDL apheresis, statins, etc.), they target mostly in the treatment of the basic metabolic disorder of lipid metabolism, which is the main cause of these lesions. In this review we describe the formation, detection, differential diagnosis and treatment of ATX as well as the relationship between tendon xanthomas and atheroma.
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37
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Valdivielso P, Calandra S, Durán JC, Garuti R, Herrera E, González P. Coronary heart disease in a patient with cerebrotendinous xanthomatosis. J Intern Med 2004; 255:680-3. [PMID: 15147532 DOI: 10.1111/j.1365-2796.2004.01316.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Coronary heart disease is a prevalent condition and a leading cause of death in developed countries. Most cases are due to the cluster of classical risk factors, such as smoking, diabetes, high blood pressure and dyslipidaemia. However, a few patients develop severe and premature arteriosclerosis in spite of absence of common risk factors. Here, we present the clinical, analytical and molecular features of a 36-years-old man who died from advanced ischaemic heart disease as a result of cerebrotendinous xanthomatosis (CTX), a rare condition characterized by elevation in plasma and most tissues of cholestanol and where neurological impairment is the hallmark of this disease. We discuss the relevance of heart disease and the mechanism leading to accelerate arteriosclerosis is CTX.
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Affiliation(s)
- P Valdivielso
- Unidad de Lípidos y Dermatología, Hospital Clínico Universitario 'Virgen de la Victoria', Málaga, Spain.
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38
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Ozgurtas T, Yildiz C, Serdar M, Atesalp S, Kutluay T. Is high concentration of serum lipids a risk factor for Achilles tendon rupture? Clin Chim Acta 2003; 331:25-8. [PMID: 12691860 DOI: 10.1016/s0009-8981(03)00075-5] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The incidence of the Achilles tendon ruptures (ATR) seems to be increasing due to changes in life style and intensified sports activities in recent years. Intrinsic and extrinsic factors have been implicated as predisposing risk factors to rupture. The purpose of this study was to investigate whether the high serum lipid concentrations could be an intrinsic factor in patient with complete ruptures of Achilles tendon. METHODS The data were collected from the records of 47 patients with complete rupture of Achilles and the control group consisted of 26 subjects. RESULTS Total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) concentrations of the patients with ATR were higher (p<0.001), and their high-density lipoprotein cholesterol (HDL-C) was lower than the control group (p<0.05). Moreover, the concentrations of triglyceride (TG) and very low-density lipoprotein cholesterol (VLDL-C) were significantly higher than controls (p<0.05). CONCLUSIONS The causes of ATR are multifactorial and still unclear. However, high serum lipid concentrations might be considered, as a predisposing factor in patients with complete rupture of Achilles tendon and further investigations with larger groups would be better.
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Affiliation(s)
- Taner Ozgurtas
- Department of Biochemistry, Gülhane Military Medical Academy and Faculty, Etlik, Ankara, 06018, Turkey.
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39
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Kato H, Koyabu S, Aoki S, Tamai T, Sugawa M, Watanabe M, Shiraishi T. An autopsy case of gallbladder cancer developing in a Japanese man with cerebrotendinous xanthomatosis: genetic analysis of the sterol 27-hydroxylase and p53 genes. Pathology 2003. [DOI: 10.1080/0031302031000082241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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40
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Toba H, Fukuyama R, Sasaki M, Shiga K, Ishibashi S, Fushiki S. A Japanese patient with cerebrotendinous xanthomatosis has different mutations within two functional domains of CYP27. Clin Genet 2002; 61:77-8. [PMID: 11903362 DOI: 10.1034/j.1399-0004.2002.610116.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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41
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Verrips A, Hoefsloot LH, Steenbergen GC, Theelen JP, Wevers RA, Gabreëls FJ, van Engelen BG, van den Heuvel LP. Clinical and molecular genetic characteristics of patients with cerebrotendinous xanthomatosis. Brain 2000; 123 ( Pt 5):908-19. [PMID: 10775536 DOI: 10.1093/brain/123.5.908] [Citation(s) in RCA: 163] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is a lipid storage disease caused by a deficiency of the mitochondrial enzyme 27-sterol hydroxylase (CYP 27), due to mutations in its gene. In this study we report on mutations in 58 patients with CTX out of 32 unrelated families. Eight of these were novel mutations, two of which were found together with two already known pathogenic mutations. Twelve mutations found in this patient group have been described in the literature. In the patients from 31 families, mutations were found in both alleles. In the literature, 28 mutations in 67 patients with CTX out of 44 families have been described. Pooling our patient group and the patients from the literature together, 37 different mutations in 125 patients out of 74 families were obtained. Identical mutations have been found in families from different ethnic backgrounds. In 41% of all the patients, CYP 27 gene mutations are found in the region of exons 6-8. This region encodes for adrenodoxin and haem binding sites of the protein. Of these 125 patients, a genotype-phenotype analysis was done for 79 homozygous patients harbouring 23 different mutations, out of 45 families. The patients with compound heterozygous mutations were left out of the genotype-phenotype analysis. The genotype-phenotype analysis did not reveal any correlation.
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Affiliation(s)
- A Verrips
- Department of Neurology, University Hospital Nijmegen, Nijmegen, The Netherlands
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42
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Larking PW. Cancer and low levels of plasma cholesterol: the relevance of cholesterol precursors and products to incidence of cancer. Prev Med 1999; 29:383-90. [PMID: 10564630 DOI: 10.1006/pmed.1999.0550] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND It is proposed that the mechanism responsible for the low plasma cholesterol-cancer associations reported in the literature is related to blood and tissue levels of cholesterol precursors and products, reflecting rates of cholesterol synthesis rather than the plasma cholesterol level itself. METHODS Data have been collated from Japanese and Northern European studies on plasma levels of a cholesterol precursor, lathosterol, and one product, cholestanol, each a marker of cholesterol metabolism. Situations in which the rate of cholesterol synthesis is altered have also been examined for their relationship to cancer incidence. RESULTS The data though minimal suggest that lathosterol and cholestanol may be higher in the blood of the Japanese compared with the Northern Europeans, despite lower plasma cholesterol levels in the Japanese. In accord with the hypothesis the Japanese have a low incidence of many cancers. Cholesterol synthesis is lowered when dietary cholesterol and fat intake are increased and incidence of cancer is increased in these states. Conversely cholesterol synthesis is raised in vegetarianism, the Mediterranean diet, pregnancy, and lactation, and incidence of some cancers is lowered. CONCLUSIONS At least some of the variation in cancer incidence with plasma cholesterol levels and also with dietary saturated fat and cholesterol, as well as vegetarianism, the Mediterranean diet, pregnancy, and lactation, can be accounted for by their effects on the rate of cholesterol synthesis and the level of cholesterol precursors and/or products so generated.
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Affiliation(s)
- P W Larking
- Decision Support Group, Dunedin Hospital, First Floor, Private Bag, Dunedin, New Zealand.
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43
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Wakamatsu N, Hayashi M, Kawai H, Kondo H, Gotoda Y, Nishida Y, Kondo R, Tsuji S, Matsumoto T. Mutations producing premature termination of translation and an amino acid substitution in the sterol 27-hydroxylase gene cause cerebrotendinous xanthomatosis associated with parkinsonism. J Neurol Neurosurg Psychiatry 1999; 67:195-8. [PMID: 10406988 PMCID: PMC1736478 DOI: 10.1136/jnnp.67.2.195] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Mutational analysis of the sterol 27-hydroxylase (CYP27) gene was performed on three patients from two Japanese families who had cerebrotendinous xanthomatosis (CTX) associated with parkinsonism. METHODS Clinical evaluations, brain MRI studies, and laboratory analyses were completed on the three patients. The CYP27 gene was analysed for mutations by PCR amplification of gene segments followed by direct sequencing. RESULTS Two different, homozygous mutations were identified in these families. One is a novel transition, substituting T for G at Glu162 (GAG) resulting in a stop codon (TAG). The other is also a transition, substituting T for C at Arg441 (CGG) resulting in Trp (TGG). The second is located in two amino acids ahead of the heme ligand binding site (Cys443) of the protein likely rendering it non-functional. It is the most common CTX mutation in Japanese patients. CONCLUSIONS CTX with parkinsonism is caused by mutations with a severe impact on enzyme function. The two mutations described here are likely to cause loss of function because they are chain terminating or affect an essential site in the protein.
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Affiliation(s)
- N Wakamatsu
- First Department of Internal Medicine, School of Medicine, The University of Tokushima, Tokushima, Japan.
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Westman J, Kallin B, Björkhem I, Nilsson J, Diczfalusy U. Sterol 27-hydroxylase- and apoAI/phospholipid-mediated efflux of cholesterol from cholesterol-laden macrophages: evidence for an inverse relation between the two mechanisms. Arterioscler Thromb Vasc Biol 1998; 18:554-61. [PMID: 9555860 DOI: 10.1161/01.atv.18.4.554] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cholesterol-laden, human monocyte-derived macrophages were found to contain 27-hydroxycholesterol in proportion to their content of cholesterol ester. In accordance with previous work with human lung alveolar macrophages, there was a significant efflux of 27-hydroxycholesterol and 3beta-hydroxy-5-cholestenoic acid from the cultured cells. The efflux of 27-hydroxycholesterol was proportional to the cellular content of this steroid. Incubation of cholesterol-laden macrophages with reconstituted discoidal complexes made from apolipoprotein A-I and phospholipids resulted in a decrease in total cellular cholesterol, an increase in the efflux of free cholesterol, and a concomitant decrease in the total production and efflux of 27-oxygenated steroids, in particular, 3beta-hydroxy-5-cholestenoic acid. Reconstituted discoidal complexes with the Milano variant of apolipoprotein A-I gave virtually identical results, whereas high density lipoprotein was less efficient. These results suggest that cultured cholesterol-laden cells can export some of their excess cholesterol in the form of 27-hydroxycholesterol, 3beta-hydroxy-5-cholestenoic acid, and free cholesterol. In the presence of exogenous cholesterol acceptors, export of free cholesterol becomes more effective, resulting in less cholesterol exported via the 27-hydroxylase pathway. The balance between the two mechanisms for removal of cholesterol from macrophages may be of importance for formation of foam cells and development of atherosclerosis.
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Affiliation(s)
- J Westman
- King Gustav V Research Institute, Karolinska Hospital, Stockholm, Sweden
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45
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Babiker A, Andersson O, Lund E, Xiu RJ, Deeb S, Reshef A, Leitersdorf E, Diczfalusy U, Björkhem I. Elimination of cholesterol in macrophages and endothelial cells by the sterol 27-hydroxylase mechanism. Comparison with high density lipoprotein-mediated reverse cholesterol transport. J Biol Chem 1997; 272:26253-61. [PMID: 9334194 DOI: 10.1074/jbc.272.42.26253] [Citation(s) in RCA: 198] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Cultured macrophages and endothelial cells have been reported to secrete 27-oxygenated metabolites of cholesterol. This mechanism was compared with the classical high density lipoprotein (HDL)-dependent reverse cholesterol transport. Under standard conditions, macrophage preparations had considerably higher capacity to secrete 27-hydroxycholesterol and 3beta-hydroxy-5-cholestenoic acid than had endothelial cells and fibroblasts. Western blotting showed that lung macrophages contained the most sterol 27-hydroxylase protein of the cells tested. The relative amounts of 3beta-hydroxy-5-cholestenoic acid produced by the macrophages were also highest. Macrophages derived from monocytes of patients with sterol 27-hydroxylase deficiency did not secrete 27-oxygenated products, demonstrating that sterol 27-hydroxylase is the critical enzyme for the conversion of cholesterol into the 27-oxygenated steroids. That sterol 27-hydroxylase is responsible not only for 27-hydroxylation of cholesterol but also for the further oxidation of this steroid into 3beta-hydroxy-5-cholestenoic acid was shown with use of tritium-labeled 27-hydroxycholesterol and an inhibitor of sterol 27-hydroxylase. Secretion of 27-oxygenated products by the cultured macrophages as well as the ratio between the alcohol and the acid appeared to be dependent upon total 27-hydroxylase activity, the availability of substrate cholesterol, and the presence of an acceptor for 27-hydroxycholesterol in the medium. With albumin as extracellular acceptor, the major secreted product was 3beta-hydroxy-5-cholestenoic acid. Under such conditions, secretion of labeled 27-oxygenated products was higher than that of labeled cholesterol from lung alveolar macrophages preloaded with [4-14C]cholesterol. With HDL as acceptor, 27-hydroxycholesterol was the major secreted product, and the total secretion of labeled 27-oxygenated products was only about 10% of that of labeled cholesterol. Thus, 27-hydroxycholesterol and cholesterol may compete for HDL-mediated efflux from the cells. The results support the contention that the sterol 27-hydroxylase-mediated elimination of cholesterol is more important in macrophages than in endothelial cells. This mechanism may be an alternative and/or a complement to the classical HDL-mediated reverse cholesterol transport in macrophages, in particular when the concentration of HDL is low.
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Affiliation(s)
- A Babiker
- Department of Medical Laboratory Sciences and Technology, The Karolinska Institute, SE-141 86, Huddinge, Sweden
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46
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Novel homozygous and compound heterozygous mutations of sterol 27-hydroxylase gene (CYP27) cause cerebrotendinous xanthomatosis in three Japanese patients from two unrelated families. J Lipid Res 1997. [DOI: 10.1016/s0022-2275(20)37212-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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47
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Crisby M, Nilsson J, Kostulas V, Björkhem I, Diczfalusy U. Localization of sterol 27-hydroxylase immuno-reactivity in human atherosclerotic plaques. BIOCHIMICA ET BIOPHYSICA ACTA 1997; 1344:278-85. [PMID: 9059518 DOI: 10.1016/s0005-2760(96)00152-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
It has recently been shown that extrahepatic cells can eliminate intracellular cholesterol by enzymatic conversion into 27-hydroxy-cholesterol and 3 beta-hydroxy-5-cholestenoic acid. Using immunohistochemical methods, we studied the presence of the enzyme responsible for these conversions, sterol 27-hydroxylase, in human carotid atherosclerotic plaques. All plaques examined were found to contain sterol 27-hydroxylase immuno-reactive cells. While some endothelial cells stained for sterol 27-hydroxylase, the majority of the immunoreactive cells co-localized with macrophages. Accumulation of sterol 27-hydroxylase-positive cells were often observed in macrophage-rich core regions of complicated lesions. High concentrations of 27-hydroxycholesterol were found in plaques, while the concentration in non-atherosclerotic human vessels was lower by two orders of magnitude. The rabbit, which is particularly sensitive to dietary cholesterol and easily develops fatty streaks, had low plasma levels of 27-hydroxycholesterol, 3 ng/ml compared to 150 ng/ml in humans. The concentration of 27-hydroxycholesterol in the atherosclerotic rabbit vessels was also lower compared to human atherosclerotic plaques. The results are consistent with our hypothesis that sterol 27-hydroxylase may be utilized by human macrophages as a defence towards a high cholesterol load. This mechanism may be less important in some other species.
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Affiliation(s)
- M Crisby
- King Gustaf Vth Research Institute, Department of Medicine, Karolinska Hospital, Stockholm, Sweden
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48
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Chen W, Kubota S, Nishimura Y, Nozaki S, Yamashita S, Nakagawa T, Kameda-Takemura K, Menju M, Matsuzawa Y, Björkhem I, Eggertsen G, Seyama Y. Genetic analysis of a Japanese cerebrotendinous xanthomatosis family: identification of a novel mutation in the adrenodoxin binding region of the CYP 27 gene. BIOCHIMICA ET BIOPHYSICA ACTA 1996; 1317:119-26. [PMID: 8950197 DOI: 10.1016/s0925-4439(96)00043-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Cerebrotendinous xanthomatosis (CTX), an autosomal recessive lipid-storage hereditary disorder, is caused by mutations in the sterol 27-hydroxylase gene (CYP 27). A 24-year-old female Japanese CTX patient and her parents were studied for a CYP 27 mutation. Multiple xanthomas were the main complaint of the patient and plasma cholestanol level was markedly elevated. Sterol analysis of a xanthoma biopsy confirmed cholesterol and cholestanol deposition, and the cholestanol accounted for 8.1% of the total sterols. Sterol 27-hydroxylase activity in fibroblasts derived from the patient was undetectable, while the activities in fibroblasts from her mother and father were 54% and 41% of the normal level, respectively. Direct sequence analysis showed a missense mutation of A for G substitution in the CYP 27 gene at codon 362 (CGT 362Arg to CAT 362His) with a homozygous pattern in the patient, and a heterozygous pattern in the parents. The mutation, which eliminates a normal HgaI endonuclease site at position 1195 of the cDNA and is located at the adrenodoxin binding region of the gene, is most probably responsible for the decreased sterol 27-hydroxylase activity in this Japanese CTX family. The combined data strongly support that the primary enzymatic defect in CTX is the disruption of sterol 27-hydroxylase and that the disease is inherited in an autosomal recessive trait.
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Affiliation(s)
- W Chen
- Department of Physiological Chemistry and Nutrition, Faculty of Medicine, University of Tokyo, Japan
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van Heijst AF, Wevers RA, Tangerman A, Cruysberg JR, Renier WO, Tolboom JJ. Chronic diarrhoea as a dominating symptom in two children with cerebrotendinous xanthomatosis. Acta Paediatr 1996; 85:932-6. [PMID: 8863874 DOI: 10.1111/j.1651-2227.1996.tb14189.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The objective of this study was to describe diarrhoea as a dominating symptom of cerebrotendinous xanthomatosis (CTX), a lipid storage disease, and investigate its cause. Two children with chronic diarrhoea as the dominating symptom of CTX are presented. Before and after therapy with orally administered chenodeoxycholic acid (15 mg kg-1 24 h, in three divided doses) bile alcohol excretion in urine, serum cholestanol level, serum bile acid patterns and faecal bile acids were measured. All routine gastro-intestinal investigations before therapy were normal. Diarrhoea ceased immediately after starting treatment with chenodeoxycholic acid. Abnormal bile alcohol excretion in urine decreased rapidly during the first days and elevated serum cholestanol level normalized in 2 years. We postulate the presence of bile alcohols in the lumen of the gut as most likely cause for diarrhoea in CTX, since the rapid decrease of bile alcohol excretion is associated with prompt cessation of diarrhoea after starting treatment with chenodeoxycholic acid.
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Affiliation(s)
- A F van Heijst
- Department of Paediatrics, University Hospital Nijmegen St Radboud, The Netherlands
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Okuyama E, Tomita S, Takeuchi H, Ichikawa Y. A novel mutation in the cytochrome P450(27) (CYP27) gene caused cerebrotendinous xanthomatosis in a Japanese family. J Lipid Res 1996. [DOI: 10.1016/s0022-2275(20)37604-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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