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Bi H, Guo H, Wang Q, Zhang X, Zhao Y, Li J, Zhao W, Tuo H, Zhang Y. A Novel Variation in the Mitochondrial Complex I Assembly Factor NDUFAF5 Causes Isolated Bilateral Striatal Necrosis in Childhood. Front Neurol 2021; 12:675616. [PMID: 34177781 PMCID: PMC8223072 DOI: 10.3389/fneur.2021.675616] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/13/2021] [Indexed: 01/30/2023] Open
Abstract
Background: Bilateral striatal necrosis (BSN) is characterized by symmetrical degeneration, predominantly of the caudate and putamen nucleus, in the basal ganglia. It is associated with numerous acquired and hereditary neuro-developmental and motor dysfunction-related pathological conditions. BSN results in high morbidity and mortality among infants and children, and its diagnosis is clinically challenging due to several overlapping disease phenotypes. Therefore, a precise genetic diagnosis is urgently needed for accurate genetic counseling and improved prognostic outcomes as well. Objective: To identify novel missense mutations in the NDUFAF5 gene as a cause of childhood BSN in members of a Chinese family and summarize the clinical characteristics of patients with the NDUFAF5 gene mutations. Methods: This study included a large family living in a remote northwestern area of China. Three siblings developed a neurological disorder characterized by generalized dystonia within the first decade of their lives. Cerebral computed tomography (CT) and magnetic resonance imaging (MRI) showed bilateral lesions of the putamen. Biochemical and genetic approaches were used to identify the cause of BSN. Results: Sequence analysis showed no pathogenic variation in PANK2, SLC25A19, SLC19A3, and NUP62 genes and in the entire mitochondrial genome as well. Whole-exome sequencing revealed compound heterozygous mutations consisting of NDUFAF5:c.425A > C(p.E142A) and c.836T > G (p.M279R). The father, a healthy sister, and a healthy brother of the affected siblings carried the c.836T > G mutation, and the mother carried the c.425A > C mutation. These variants were absent in 100 ethnically matched non-BSN controls. In silico analysis demonstrated that the E142A and M279R mutations in NDUFAF5 protein significantly perturbed the normal conformation of the protein due to alterations in the hydrogen bonding patterns around the evolutionarily conserved catalytic domains, leading to its loss of function in the early stage of mitochondrial complex I assembly. Conclusions: We identified a novel compound heterozygous mutation (c.425A > C and c.836T > G) in the NDUFAF5 gene as the potential cause of autosomal recessive childhood BSN, which extended the pathogenic variation spectrum of the NDUFAF5 gene. This study provides substantial evidence for further improvement of genetic counseling and better clinical management of BSN affected individuals.
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Affiliation(s)
- Hongyan Bi
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hui Guo
- Center for Medical Genetics and Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Central South University, Changsha, China
| | - Qianfei Wang
- CAS Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China
| | - Xiao Zhang
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yaming Zhao
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jimei Li
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Weiqin Zhao
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Houzhen Tuo
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yongbo Zhang
- Department of Neurology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Morales-Briceño H, Mohammad SS, Post B, Fois AF, Dale RC, Tchan M, Fung VSC. Clinical and neuroimaging phenotypes of genetic parkinsonism from infancy to adolescence. Brain 2019; 143:751-770. [DOI: 10.1093/brain/awz345] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/29/2019] [Accepted: 09/06/2019] [Indexed: 12/11/2022] Open
Abstract
AbstractGenetic early-onset parkinsonism presenting from infancy to adolescence (≤21 years old) is a clinically diverse syndrome often combined with other hyperkinetic movement disorders, neurological and imaging abnormalities. The syndrome is genetically heterogeneous, with many causative genes already known. With the increased use of next-generation sequencing in clinical practice, there have been novel and unexpected insights into phenotype-genotype correlations and the discovery of new disease-causing genes. It is now recognized that mutations in a single gene can give rise to a broad phenotypic spectrum and that, conversely different genetic disorders can manifest with a similar phenotype. Accurate phenotypic characterization remains an essential step in interpreting genetic findings in undiagnosed patients. However, in the past decade, there has been a marked expansion in knowledge about the number of both disease-causing genes and phenotypic spectrum of early-onset cases. Detailed knowledge of genetic disorders and their clinical expression is required for rational planning of genetic and molecular testing, as well as correct interpretation of next-generation sequencing results. In this review we examine the relevant literature of genetic parkinsonism with ≤21 years onset, extracting data on associated movement disorders as well as other neurological and imaging features, to delineate syndromic patterns associated with early-onset parkinsonism. Excluding PRKN (parkin) mutations, >90% of the presenting phenotypes have a complex or atypical presentation, with dystonia, abnormal cognition, pyramidal signs, neuropsychiatric disorders, abnormal imaging and abnormal eye movements being the most common features. Furthermore, several imaging features and extraneurological manifestations are relatively specific for certain disorders and are important diagnostic clues. From the currently available literature, the most commonly implicated causes of early-onset parkinsonism have been elucidated but diagnosis is still challenging in many cases. Mutations in ∼70 different genes have been associated with early-onset parkinsonism or may feature parkinsonism as part of their phenotypic spectrum. Most of the cases are caused by recessively inherited mutations, followed by dominant and X-linked mutations, and rarely by mitochondrially inherited mutations. In infantile-onset parkinsonism, the phenotype of hypokinetic-rigid syndrome is most commonly caused by disorders of monoamine synthesis. In childhood and juvenile-onset cases, common genotypes include PRKN, HTT, ATP13A2, ATP1A3, FBX07, PINK1 and PLA2G6 mutations. Moreover, Wilson’s disease and mutations in the manganese transporter are potentially treatable conditions and should always be considered in the differential diagnosis in any patient with early-onset parkinsonism.
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Affiliation(s)
- Hugo Morales-Briceño
- Movement Disorders Unit, Neurology Department, Westmead Hospital, Westmead, NSW 2145, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW 2145, Australia
| | - Shekeeb S Mohammad
- Neurology Department, Children’s Westmead Hospital, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
| | - Bart Post
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Parkinson Centre Nijmegen (ParC) Nijmegen, The Netherlands
| | - Alessandro F Fois
- Movement Disorders Unit, Neurology Department, Westmead Hospital, Westmead, NSW 2145, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW 2145, Australia
| | - Russell C Dale
- Neurology Department, Children’s Westmead Hospital, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
| | - Michel Tchan
- Sydney Medical School, University of Sydney, Sydney, NSW 2145, Australia
- Department of Genetic Medicine, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Victor S C Fung
- Movement Disorders Unit, Neurology Department, Westmead Hospital, Westmead, NSW 2145, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW 2145, Australia
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3
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Almuqbil M, Chinsky JM, Srivastava S. Metabolic Strokes in Propionic Acidemia: Transient Hemiplegic Events Without Encephalopathy. Child Neurol Open 2019; 6:2329048X19873242. [PMID: 31523698 PMCID: PMC6727095 DOI: 10.1177/2329048x19873242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/02/2019] [Accepted: 07/14/2019] [Indexed: 11/16/2022] Open
Abstract
Metabolic strokes are a notable feature associated with acute catabolic crises in patients with propionic acidemia. Despite their importance, these events are not well characterized. Here, we present the clinical history of a patient with propionic acidemia who developed 5 episodes of acute hemiparesis between 3 and 11 years of age. The clinical finding of hemiparesis associated with 4 of these 5 events were shorted lived (2-5 days). Neuroimaging showed signal changes in the basal ganglia manifesting many years following the initial episode. Two of the episodes were accompanied by definite seizures. Based on these factors, the hemiparetic events were most consistent with metabolic strokes, though what is distinctive is that most of the events occurred without evidence of metabolic decompensation; brain magnetic resonance imaging findings were not suggestive in the acute setting. We present a framework for evaluating suspected metabolic stroke in propionic acidemia, in light of the sometimes perplexing clinical heterogeneity underlining these events.
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Affiliation(s)
- Mohammed Almuqbil
- Institute of Genetic Medicine, Johns Hopkins Hospital, Baltimore, MD, USA.,Division of Pediatric Neurology, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, King Abdullah Specialist Children's Hospital-Ministry of National Guard, Riyadh, Saudi Arabia
| | - Jeffrey M Chinsky
- Institute of Genetic Medicine, Johns Hopkins Hospital, Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD, USA
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4
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van Egmond ME, Eggink H, Kuiper A, Sival DA, Verschuuren-Bemelmans CC, Tijssen MAJ, de Koning TJ. Crossing barriers: a multidisciplinary approach to children and adults with young-onset movement disorders. JOURNAL OF CLINICAL MOVEMENT DISORDERS 2018; 5:3. [PMID: 29636982 PMCID: PMC5887190 DOI: 10.1186/s40734-018-0070-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 03/22/2018] [Indexed: 11/10/2022]
Abstract
Background Diagnosis of less common young-onset movement disorders is often challenging, requiring a broad spectrum of skills of clinicians regarding phenotyping, normal and abnormal development and the wide range of possible acquired and genetic etiologies. This complexity often leads to considerable diagnostic delays, paralleled by uncertainty for patients and their families. Therefore, we hypothesized that these patients might benefit from a multidisciplinary approach. We report on the first 100 young-onset movement disorders patients who visited our multidisciplinary outpatient clinic. Methods Clinical data were obtained from the medical records of patients with disease-onset before age 18 years. We investigated whether the multidisciplinary team, consisting of a movement disorder specialist, pediatric neurologist, pediatrician for inborn errors of metabolism and clinical geneticist, revised the movement disorder classification, etiological diagnosis, and/or treatment. Results The 100 referred patients (56 males) had a mean age of 12.5 ± 6.3 years and mean disease duration of 9.2 ± 6.3 years. Movement disorder classification was revised in 58/100 patients. Particularly dystonia and myoclonus were recognized frequently and supported by neurophysiological testing in 24/29 patients. Etiological diagnoses were made in 24/71 (34%) formerly undiagnosed patients, predominantly in the genetic domain. Treatment strategy was adjusted in 60 patients, of whom 43 (72%) reported a subjective positive effect. Conclusions This exploratory study demonstrates that a dedicated tertiary multidisciplinary approach to complex young-onset movement disorders may facilitate phenotyping and improve recognition of rare disorders, with a high diagnostic yield and minimal diagnostic delay. Future studies are needed to investigate the cost-benefit ratio of a multidisciplinary approach in comparison to regular subspecialty care.
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Affiliation(s)
- Martje E van Egmond
- 1Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Department of Neurology, Ommelander Ziekenhuis Groningen, Delfzijl and Winschoten, PO Box 30.001, 9700 RB Groningen, the Netherlands
| | - Hendriekje Eggink
- 1Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Anouk Kuiper
- 1Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Deborah A Sival
- 3Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Marina A J Tijssen
- 1Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Tom J de Koning
- 1Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,3Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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5
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Ganos C, Crowe B, Stamelou M, Kresojević N, Lukić MJ, Bras J, Guerreiro R, Taiwo F, Balint B, Batla A, Schneider SA, Erro R, Svetel M, Kostić V, Kurian MA, Bhatia KP. The clinical syndrome of dystonia with anarthria/aphonia. Parkinsonism Relat Disord 2016; 24:20-7. [DOI: 10.1016/j.parkreldis.2016.01.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/10/2016] [Accepted: 01/25/2016] [Indexed: 10/22/2022]
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6
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Biegen VR, McCue JP, Donovan TA, Shelton GD. Metabolic Encephalopathy and Lipid Storage Myopathy Associated with a Presumptive Mitochondrial Fatty Acid Oxidation Defect in a Dog. Front Vet Sci 2015; 2:64. [PMID: 26664991 PMCID: PMC4672276 DOI: 10.3389/fvets.2015.00064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 11/12/2015] [Indexed: 12/31/2022] Open
Abstract
A 1-year-old spayed female Shih Tzu presented for episodic abnormalities of posture and mentation. Neurological examination was consistent with a bilaterally symmetric multifocal encephalopathy. The dog had a waxing-and-waning hyperlactemia and hypoglycemia. Magnetic resonance imaging revealed bilaterally symmetric cavitated lesions of the caudate nuclei with less severe abnormalities in the cerebellar nuclei. Empirical therapy was unsuccessful, and the patient was euthanized. Post-mortem histopathology revealed bilaterally symmetric necrotic lesions of the caudate and cerebellar nuclei and multi-organ lipid accumulation, including a lipid storage myopathy. Malonic aciduria and ketonuria were found on urinary organic acid screen. Plasma acylcarnitine analysis suggested a fatty acid oxidation defect. Fatty acid oxidation disorders are inborn errors of metabolism documented in humans, but poorly described in dogs. Although neurological signs have been described in humans with this group of diseases, descriptions of advanced imaging, and histopathology are severely lacking. This report suggests that abnormalities of fatty acid metabolism may cause severe, bilateral gray matter necrosis, and lipid accumulation in multiple organs including the skeletal muscles, liver, and kidneys. Veterinarians should be aware that fatty acid oxidation disorders, although potentially fatal, may be treatable. A timely definitive diagnosis is essential in guiding therapy.
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Affiliation(s)
| | | | | | - G Diane Shelton
- The Department of Pathology, School of Medicine, University of California San Diego , La Jolla, CA , USA
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8
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Bilo L, Peluso S, Antenora A, De Rosa A, Auletta G, Pappatà S, De Michele G. Parkinsonism may be part of the symptom complex of DOOR syndrome. Parkinsonism Relat Disord 2014; 20:463-5. [PMID: 24486243 DOI: 10.1016/j.parkreldis.2014.01.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 12/18/2013] [Accepted: 01/15/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Leonilda Bilo
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Silvio Peluso
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy.
| | - Antonella Antenora
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Anna De Rosa
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Gennaro Auletta
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Sabina Pappatà
- Biostructure and Bioimaging Institute, CNR, Naples, Italy
| | - Giuseppe De Michele
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
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Gascon GG, Kaya N. Pinar T. Ozand: Clinician-Scientist Extraordinaire. J Child Neurol 2013; 30:0883073813498934. [PMID: 24084628 DOI: 10.1177/0883073813498934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Generoso Gutierrez Gascon
- Professor Emeritus, Clinical Neuroscience and Pediatrics Alpert School of Medicine, Brown University Providence, Rhode Island
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10
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Cardoso F. Commentary. Mov Disord 2013; 28:1057-8. [DOI: 10.1002/mds.25540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 05/01/2013] [Accepted: 05/06/2013] [Indexed: 11/11/2022] Open
Affiliation(s)
- Francisco Cardoso
- Movement Disorders Unit, Neurology Service, Internal Medicine Department; Federal University of Minas Gerias; Belo Horizonte Minas Gerais Brazil
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Rosentreter A, Gaki S, Dinslage S, Dietlein T. Juveniles Glaukom bei Propionazidämie. Ophthalmologe 2012; 109:1211-3. [DOI: 10.1007/s00347-012-2596-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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12
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Sutton VR, Chapman KA, Gropman AL, MacLeod E, Stagni K, Summar ML, Ueda K, Ah Mew N, Franks J, Island E, Matern D, Peña L, Smith B, Urv T, Venditti C, Chakarapani A. Chronic management and health supervision of individuals with propionic acidemia. Mol Genet Metab 2012; 105:26-33. [PMID: 21963082 DOI: 10.1016/j.ymgme.2011.08.034] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 08/30/2011] [Accepted: 08/30/2011] [Indexed: 01/28/2023]
Abstract
Propionic acidemia is a relatively rare inborn error of metabolism. Individuals with propionic acidemia often have life-threatening episodes of hyperammonemia and metabolic acidosis, as well as intellectual disability. There are many reports of additional problems, including poor growth, stroke-like episodes of the basal ganglia, seizures, cardiomyopathy, long QTc syndrome, immune defects, pancreatitis and optic neuropathy; however, there is little information about the incidence of these problems in this rare disease. Additionally, there are no clear guidelines for medical or surgical management of individuals with propionic acidemia. Through a comprehensive and systematic review of the current medical literature and survey of expert opinion, we have developed practice guidelines for the chronic management of individuals with propionic acidemia, including dietary therapy, use of medications, laboratory monitoring, chronic health supervision, use of gastrostomy tubes and liver transplantation.
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Affiliation(s)
- V Reid Sutton
- Department of Molecular & Human Genetics, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA.
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Abstract
Chorea is a common movement disorder that can be caused by a large variety of structural, neurochemical (including pharmacologic), or metabolic disturbances to basal ganglia function, indicating the vulnerability of this brain region. The diagnosis is rarely indicated by the simple phenotypic appearance of chorea, and can be challenging, with many patients remaining undiagnosed. Clues to diagnosis may be found in the patient's family or medical history, on neurologic examination, or upon laboratory testing and neuroimaging. Increasingly, advances in genetic medicine are identifying new disorders and expanding the phenotype of recognized conditions. Although most therapies at present are supportive, correct diagnosis is essential for appropriate genetic counseling, and ultimately, for future molecular therapies.
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Affiliation(s)
- Ruth H Walker
- Department of Neurology, James J. Peters Veterans Affairs Medical Center, Bronx, NY 10468, USA.
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14
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Kirkham FJ, Haywood P, Kashyape P, Borbone J, Lording A, Pryde K, Cox M, Keslake J, Smith M, Cuthbertson L, Murugan V, Mackie S, Thomas NH, Whitney A, Forrest KM, Parker A, Forsyth R, Kipps CM. Movement disorder emergencies in childhood. Eur J Paediatr Neurol 2011; 15:390-404. [PMID: 21835657 DOI: 10.1016/j.ejpn.2011.04.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Accepted: 04/17/2011] [Indexed: 12/27/2022]
Abstract
The literature on paediatric acute-onset movement disorders is scattered. In a prospective cohort of 52 children (21 male; age range 2mo-15y), the commonest were chorea, dystonia, tremor, myoclonus, and Parkinsonism in descending order of frequency. In this series of mainly previously well children with cryptogenic acute movement disorders, three groups were recognised: (1) Psychogenic disorders (n = 12), typically >10 years of age, more likely to be female and to have tremor and myoclonus (2) Inflammatory or autoimmune disorders (n = 22), including N-methyl-d-aspartate receptor encephalitis, opsoclonus-myoclonus, Sydenham chorea, systemic lupus erythematosus, acute necrotizing encephalopathy (which may be autosomal dominant), and other encephalitides and (3) Non-inflammatory disorders (n = 18), including drug-induced movement disorder, post-pump chorea, metabolic, e.g. glutaric aciduria, and vascular disease, e.g. moyamoya. Other important non-inflammatory movement disorders, typically seen in symptomatic children with underlying aetiologies such as trauma, severe cerebral palsy, epileptic encephalopathy, Down syndrome and Rett syndrome, include dystonic posturing secondary to gastro-oesophageal reflux (Sandifer syndrome) and Paroxysmal Autonomic Instability with Dystonia (PAID) or autonomic 'storming'. Status dystonicus may present in children with known extrapyramidal disorders, such as cerebral palsy or during changes in management e.g. introduction or withdrawal of neuroleptic drugs or failure of intrathecal baclofen infusion; the main risk in terms of mortality is renal failure from rhabdomyolysis. Although the evidence base is weak, as many of the inflammatory/autoimmune conditions are treatable with steroids, immunoglobulin, plasmapheresis, or cyclophosphamide, it is important to make an early diagnosis where possible. Outcome in survivors is variable. Using illustrative case histories, this review draws attention to the practical difficulties in diagnosis and management of this important group of patients.
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Affiliation(s)
- F J Kirkham
- Southampton University Hospitals NHS Trust, UK.
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15
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Wolf B. The neurology of biotinidase deficiency. Mol Genet Metab 2011; 104:27-34. [PMID: 21696988 DOI: 10.1016/j.ymgme.2011.06.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Revised: 06/03/2011] [Accepted: 06/03/2011] [Indexed: 11/28/2022]
Abstract
Biotinidase deficiency is an autosomal recessively inherited metabolic disorder in which the enzyme, biotinidase, is defective and the vitamin, biotin, is not recycled. Individuals with biotinidase deficiency, if not treated with biotin, usually exhibit neurological and cutaneous abnormalities. Biotin treatment can ameliorate or prevent symptoms. Biotinidase deficiency meets the major criteria for inclusion in newborn screening programs. With the advent of universal newborn screening for the disorder, the "window-of-opportunity" to characterize the consequences of the untreated disease is essentially gone. To understand the neurology of biotinidase deficiency, we must depend on what is already known about symptomatic individuals with the disorder. Therefore, in this review, the neurological findings of symptomatic individuals with profound biotinidase deficiency have been compiled to catalog the characteristic features of the disorder and the consequences of biotin treatment on these findings. In addition, based on the available evidence, I have speculated on the cause of neurological problems associated with the disorder. Future studies in biotinidase-deficient animals should allow us to demonstrate more definitively if these speculations are correct.
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Affiliation(s)
- Barry Wolf
- Department of Medical Genetics, Henry Ford Hospital, Detroit, MI 48202, USA.
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16
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Christopher R, Sankaran BP. An insight into the biochemistry of inborn errors of metabolism for a clinical neurologist. Ann Indian Acad Neurol 2011; 11:68-81. [PMID: 19893643 PMCID: PMC2771954 DOI: 10.4103/0972-2327.41873] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Revised: 06/16/2008] [Accepted: 06/16/2008] [Indexed: 11/16/2022] Open
Abstract
Neurological dysfunction is an important manifestation of inherited metabolic disorders. Although these are more common in childhood, adult onset forms with a different clinical presentation are often encountered. Recent advances in the diagnosis and treatment of these conditions have substantially improved the outcome in many of these conditions. This makes it essential that the practicing physician be familiar with the clinical presentation and diagnosis of these disorders. For the evaluation of a patient with a possible inborn error of metabolism, simple screening tests may aid in the diagnosis and provide direction for more comprehensive laboratory analysis. In this review, we present a practical approach to diagnosis of neurometabolic disorders. Establishing a specific diagnosis in these disorders will enable the clinician in offering a definitive long-term treatment, prognosis and genetic counselling.
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Cakir B, Teksam M, Kosehan D, Akin K, Koktener A. Inborn Errors of Metabolism Presenting in Childhood. J Neuroimaging 2011; 21:e117-33. [DOI: 10.1111/j.1552-6569.2011.00575.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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18
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Rojas JC, Simola N, Kermath BA, Kane JR, Schallert T, Gonzalez-Lima F. Striatal neuroprotection with methylene blue. Neuroscience 2009; 163:877-89. [PMID: 19596056 DOI: 10.1016/j.neuroscience.2009.07.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2009] [Revised: 07/03/2009] [Accepted: 07/07/2009] [Indexed: 12/31/2022]
Abstract
Recent literature indicates that low-dose Methylene Blue (MB), an autoxidizable dye with powerful antioxidant and metabolic enhancing properties, might prevent neurotoxin-induced neural damage and associated functional deficits. This study evaluated whether local MB may counteract the anatomical and functional effects of the intrastriatal infusion of the neurotoxin rotenone (Rot) in the rat. To this end, stereological analyses of striatal lesion volumes were performed and changes in oxidative energy metabolism in the striatum and related motor regions were mapped using cytochrome oxidase histochemistry. The influence of MB on striatal levels of oxidative stress induced by Rot was determined, and behavioral tests were used to investigate the effect of unilateral MB coadministration on motor asymmetry. Rot induced large anatomical lesions resembling "metabolic strokes," whose size was greatly reduced in MB-treated rats. Moreover, MB prevented the decrease in cytochrome oxidase activity and the perilesional increase in oxidative stress associated with Rot infusion in the striatum. MB also prevented the indirect effects of the Rot-induced lesion on cytochrome oxidase activity in related motor regions, such as the striatal regions rostral and caudal to the lesion, the substantia nigra compacta and reticulata, and the pedunculopontine nucleus. At a network level, MB maintained a global strengthening of functional connectivity in basal ganglia-thalamocortical motor circuits, as opposed to the functional decoupling observed in Rot-alone subjects. Finally, MB partially prevented the behavioral sensorimotor asymmetries elicited by Rot. These results are consistent with protective effects of MB against neurotoxic damage in the brain parenchyma. This study provides the first demonstration of the anatomical, metabolic and behavioral neuroprotective effects of MB in the striatum in vivo, and supports the notion that MB could be a valuable intervention against neural damage associated with oxidative stress and energy hypometabolism.
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Affiliation(s)
- J C Rojas
- Institute for Neuroscience, University of Texas at Austin, Austin, TX, USA
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19
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Gitiaux C, Roze E, Kinugawa K, Flamand-Rouvière C, Boddaert N, Apartis E, Valayannopoulos V, Touati G, Motte J, Devos D, Mention K, Dobbelaere D, Rodriguez D, Roubertie A, Chabrol B, Feillet F, Vidailhet M, Bahi-Buisson N. Spectrum of movement disorders associated with glutaric aciduria type 1: A study of 16 patients. Mov Disord 2008; 23:2392-7. [DOI: 10.1002/mds.22313] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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20
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Aniello MS, Martino D, Petruzzella V, Eleopra R, Mancuso M, Dell'Aglio R, Cavallo M, Siciliano G, Defazio G. Bilateral striatal necrosis, dystonia and multiple mitochondrial DNA deletions: Case study and effect of deep brain stimulation. Mov Disord 2008; 23:114-8. [DOI: 10.1002/mds.21760] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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21
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García-Cazorla A, Rabier D, Touati G, Chadefaux-Vekemans B, Marsac C, de Lonlay P, Saudubray JM. Pyruvate carboxylase deficiency: metabolic characteristics and new neurological aspects. Ann Neurol 2006; 59:121-7. [PMID: 16278852 DOI: 10.1002/ana.20709] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Pyruvate carboxylase (PC) deficiency is a rare metabolic disease. Recently, therapeutic possibilities have been introduced. We aimed to report the largest series of the B type of PC deficiency, focusing on some neurological aspects that have not yet been documented. METHODS We retrospectively studied nine patients with the severe neonatal form of PC deficiency diagnosed in our hospital. Detailed clinical features, brain imaging, biochemical characteristics, and global outcome are reported. RESULTS All patients had axial hypotonia and tachypnea during the first hours of life. The initial level of consciousness was preserved in most patients. Abnormal movements (high-amplitude tremor and hypokinesia) and bizarre ocular behavior were the most common findings, whereas epilepsy was infrequent. Brain magnetic resonance imaging mostly disclosed cystic periventricular leukomalacia. Hypoglycemia, lactic acidosis, and hypercitrullinemia were invariably found. Hyperammoniemia, hypernatremia, and high proline and lysine were frequently detected. A rapid fatal outcome was observed in most patients. INTERPRETATION Clinical and biochemical characteristics of this deficiency are highly suggestive. Abnormal movements such as rigidity and hypokinesia (hypokinetic-rigid syndrome) are an important hallmark and may orientate to PC deficiency when associated with severe lactic acidosis.
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Affiliation(s)
- Angels García-Cazorla
- Metabolic Diseases Unit, Centre Hospitalier Universitaire Necker Enfants-Malades, Paris, France.
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22
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Épidémiologie des accidents vasculaires cérébraux : son impact dans la pratique médicale. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/s0246-0378(06)28757-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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23
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Patay Z. Diffusion-weighted MR imaging in leukodystrophies. Eur Radiol 2005; 15:2284-303. [PMID: 16021451 DOI: 10.1007/s00330-005-2846-2] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2005] [Revised: 05/23/2005] [Accepted: 05/31/2005] [Indexed: 11/30/2022]
Abstract
Leukodystrophies are genetically determined metabolic diseases, in which the underlying biochemical abnormality interferes with the normal build-up and/or maintenance of myelin, which leads to hypo- (or arrested) myelination, or dysmyelination with resultant demyelination. Although conventional magnetic resonance imaging has significantly contributed to recent progress in the diagnostic work-up of these diseases, diffusion-weighted imaging has the potential to further improve our understanding of underlying pathological processes and their dynamics through the assessment of normal and abnormal diffusion properties of cerebral white matter. Evaluation of conventional diffusion-weighted and ADC map images allows the detection of major diffusion abnormalities and the identification of various edema types, of which the so-called myelin edema is particularly relevant to leukodystrophies. Depending on the nature of histopathological changes, stage and progression gradient of diseases, various diffusion-weighted imaging patterns may be seen in leukodystrophies. Absent or low-grade myelin edema is found in mucopolysaccharidoses, GM gangliosidoses, Zellweger disease, adrenomyeloneuropathy, L-2-hydroxyglutaric aciduria, non-ketotic hyperglycinemia, classical phenylketonuria, Van der Knaap disease and the vanishing white matter, medium grade myelin edema in metachromatic leukodystrophy, X-linked adrenoleukodystrophy and HMG coenzyme lyase deficiency and high grade edema in Krabbe disease, Canavan disease, hyperhomocystinemias, maple syrup urine disease and leukodystrophy with brainstem and spinal cord involvement and high lactate.
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Affiliation(s)
- Zoltan Patay
- Department of Radiology, MBC 28, King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, 11211, Riyadh, Kingdom of Saudi Arabia.
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24
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Zeng WQ, Al-Yamani E, Acierno JS, Slaugenhaupt S, Gillis T, MacDonald ME, Ozand PT, Gusella JF. Biotin-responsive basal ganglia disease maps to 2q36.3 and is due to mutations in SLC19A3. Am J Hum Genet 2005; 77:16-26. [PMID: 15871139 PMCID: PMC1226189 DOI: 10.1086/431216] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2005] [Accepted: 04/14/2005] [Indexed: 01/19/2023] Open
Abstract
Biotin-responsive basal ganglia disease (BBGD) is a recessive disorder with childhood onset that presents as a subacute encephalopathy, with confusion, dysarthria, and dysphagia, and that progresses to severe cogwheel rigidity, dystonia, quadriparesis, and eventual death, if left untreated. BBGD symptoms disappear within a few days with the administration of high doses of biotin (5-10 mg/kg/d). On brain magnetic resonance imaging examination, patients display central bilateral necrosis in the head of the caudate, with complete or partial involvement of the putamen. All patients diagnosed to date are of Saudi, Syrian, or Yemeni ancestry, and all have consanguineous parents. Using linkage analysis in four families, we mapped the genetic defect near marker D2S2158 in 2q36.3 (LOD=5.9; theta=0.0) to a minimum candidate region (approximately 2 Mb) between D2S2354 and D2S1256, on the basis of complete homozygosity. In this segment, each family displayed one of two different missense mutations that altered the coding sequence of SLC19A3, the gene for a transporter related to the reduced-folate (encoded by SLC19A1) and thiamin (encoded by SLC19A2) transporters.
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Affiliation(s)
- Wen-Qi Zeng
- Molecular Neurogenetics Unit, Center for Human Genetic Research, Massachusetts General Hospital, Charlestown, MA 02129-2000, USA
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25
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Abstract
OBJECTIVE Propionic acidemia is a rare metabolic disorder that is diagnosed in the early neonatal period. The disorder is characterized by life-threatening ketoacidosis, lethargy, failure to thrive, and developmental delay. Herein we report the ocular findings in a prospective series of six patients with propionic acidemia. DESIGN Prospective case series. PARTICIPANTS Six children (three male and three female) between the ages of 2 and 10 years with propionic acidemia who were examined at Children's Hospital Los Angeles. METHODS A complete ophthalmic examination was performed on each of the six children. The examination included visual acuity testing, ocular motility, anterior segment examination, and funduscopic evaluation. Emphasis was placed on the function of the optic nerve and on the appearance of the optic disc, looking for possible atrophic changes. MAIN OUTCOME MEASURES The clinical appearance of the optic disc and evidence of optic neuropathy. RESULTS Optic nerve atrophy was present exclusively in all of the male patients in the series; none of the female patients demonstrated any detectable impairment of optic nerve function. The optic nerve atrophy was symmetric and age dependent and varied from moderate to severe. There were no other anterior or posterior segment abnormalities, other than one case of unilateral morning glory syndrome, diagnosed at birth. There was no correlation between metabolic control and the development and progression of optic nerve atrophy. CONCLUSIONS Males with propionic acidemia have moderate to severe bilateral optic atrophy.
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Affiliation(s)
- Tsontcho Ianchulev
- Department of Ophthalmology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.
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26
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Desai NK, Runge VM, Crisp DE, Crisp MB, Naul LG. Magnetic resonance imaging of the brain in glutaric acidemia type I: a review of the literature and a report of four new cases with attention to the basal ganglia and imaging technique. Invest Radiol 2003; 38:489-96. [PMID: 12874515 DOI: 10.1097/01.rli.0000080405.62988.f6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
RATIONALE AND OBJECTIVES In glutaric acidemia type I (GA I), a pediatric neurometabolic disease that may be mistaken for nonaccidental trauma, expeditious detection is critical as early treatment may substantially improve psychomotor dysfunction. In this study, we examine in depth the magnetic resonance (MR) findings, with special attention to the basal ganglia, in 4 new cases and compare the findings with those described in the literature. METHODS MR studies of 4 children, diagnosed to have GA I via cultured fibroblast enzyme studies or urine metabolite assays, were performed on a 1.5 T system in the axial plane using spin echo T(1)-weighted, fast spin echo T(2)-weighted, and fluid-attenuated inversion recovery (FLAIR) technique. Three of 4 patients were followed with serial exams to document temporal evolution of the disease. RESULTS On T(2)-weighted images, abnormal increased signal intensity was seen in both the putamen and globus pallidus in all cases. However, in contradistinction to cases reported in the literature, involvement of the caudate nucleus was minimal or absent even on serial MR exams. In children 15 months and older, FLAIR improved recognition of basal ganglia and white matter abnormalities. The previously described widened cerebrospinal fluid spaces anterior to the temporal lobes, increased T(2)-weighted signal intensity in the periventricular white matter, and widened sylvian fissures characteristic of GA I were noted in all patients. CONCLUSIONS Abnormalities of the caudate nucleus are not a prominent presentation of these patients and the absence of this finding should not exclude a diagnosis of GA I. FLAIR scans, as an adjunct to more conventional T(1)- and T(2)-weighted sequences, can play an important role in children 15 months or older despite immature myelination in these patients.
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Affiliation(s)
- Nilesh K Desai
- Texas A&M University College of Medicine, Temple, TX, USA.
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Abstract
The term "myoclonus" sounds esoteric, yet it is part of our normal physiology, occurring as a muscle jerk on drowsiness or falling asleep, during rapid eye movement (REM) sleep, and as hiccoughs. Myoclonus is also a developmental feature of the human nervous system, comprising some of the earliest fetal movements. In pathologic settings, myoclonus may be the only neurologic abnormality, as in essential myoclonus, but more often it is one symptom of a larger neurologic problem. The vast etiologic spectrum of symptomatic myoclonus can be bewildering, but defining the underlying problem may provide the opportunity to develop specific therapies. Otherwise, treatment is merely symptomatic. The approach to the patient should be to verify the nature of the movement disorder and establish a specific etiologic diagnosis. A battery of neurophysiologic, neuroradiologic, and other laboratory studies is needed to localize the origin of the myoclonus and identify causative lesions. Drug treatment is largely empiric but must be systematic and aimed at restoring activities of everyday living. Unlike in epilepsies, in myoclonus multiple drugs usually must be combined to attain functional improvement.
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Affiliation(s)
- Michael R Pranzatelli
- Department of Neurology, National Pediatric Myoclonus Center, Southern Illinois University School of Medicine, Springfield, IL 62702, USA
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28
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Abstract
Recent developments in understanding the pathophysiology of disordered motor control in cerebral palsy are reviewed. In spastic cerebral palsy, evidence for abnormal segmental as well as supraspinal control of motor neuron output exists. Impaired Ia inhibition of antagonist muscles has been suggested but recently contested. Evidence also supports the role of decreased presynaptic inhibition of Ia afferents and decreased nonreciprocal Ib inhibition. Furthermore, early cerebral injury results in reorganization of supraspinal (corticospinal) inputs to motor neuron pools. In extrapyramidal cerebral palsy, injury of basal ganglia or thalamus has been demonstrated. A scheme for understanding the neurochemical circuitry of the extrapyramidal system is discussed. Animal models and certain specific human diseases provide examples of how this circuitry may be disturbed, thereby resulting in an imbalance between the direct and indirect striatal output systems and in impaired motor control. Future studies employing postmortem neurochemical analysis, functional magnetic resonance imaging, and positron emission tomographic scanning may foster progress in this area.
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Affiliation(s)
- F M Filloux
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, USA
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Kamei S, Takasu T, Mori N, Yoshihashi K, Shikata E. Serial imaging of bilateral striatal necrosis associated with acidaemia in adults. Neuroradiology 1996; 38:437-40. [PMID: 8837086 DOI: 10.1007/bf00607268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Bilateral striatal necrosis in acute encephalopathy has been reported in a small number of adults with methanol or cyanide intoxication, hypoxic encephalopathy or haemolytic-uraemic syndrome. Acute encephalopathy with bilateral striatal necrosis has been reported in infants and children. However, the pathogenesis of the necrosis remains unclear. This is the first report of serial imaging from the very early to chronic stage in two acute encephalopathic adults with bilateral striatal necrosis. A clinicoradiological study is presented for clarification of the pathological process and pathogenesis. Striatal lesions were not detected in the very early stages, but only thereafter. Serial studies suggested that the lesions were caused by delayed neuronal death. These patients had severe lactic acidosis, near the limit for survival. There have been few reports of adults with acute encephalopathy and bilateral striatal necrosis in whom arterial pH was described; all these exhibited marked acidosis. The common pathophysiological condition among these encephalopathies with bilateral striatal necrosis could be lactic acidosis elicited by impairment of ATP generation through the Krebs cycle. The striatum might represent one of the target areas of Krebs-cycle blockade.
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Affiliation(s)
- S Kamei
- Department of Neurology, Nihon University School of Medicine, Tokyo, Japan
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30
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Rashed M, Ozand PT, al Aqeel A, Gascon GG. Experience of King Faisal Specialist Hospital and Research Center with Saudi organic acid disorders. Brain Dev 1994; 16 Suppl:1-6. [PMID: 7726374 DOI: 10.1016/0387-7604(94)90090-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The Inborn Errors of Metabolism and Neurology Services of the King Faisal Specialist Hospital and Research Centre (KFSH&RC) and Armed Forces Hospital have received more than 1,500 patients suspected of having an organic acid disorder (OAD) during a period of four years. Of these, 307 patients suspected of having an organic acid disorder (OAD) during a period of four years. Of these, 307 patients, approximately 20%, had a clearly identifiable disorder. Identified OAD's constituted one-quarter of all patients diagnosed as having various types of inborn errors of metabolism during this period, in these clinical services. Prolonged follow-up was available in the majority of cases, allowing detailed clinical, neuroradiologic and neurophysiologic descriptions. Fifty patients (16%) had rare disorders by standards in the West. Approximately 25% were 'neurologic organic acidurias.' This is a new term we are introducing for OAD's manifesting primarily with neurologic signs, but without appreciable acidosis, hypoglycemia or hyperammonemia. In this special issue, we present the KFSH&RC experience with the rare disorders as individual articles. We estimate the frequency of OAD's in Saudi Arabia as 1/740 births. The increased frequency of OAD's in Saudi Arabia is probably due to increased consanguinity, since most OAD's occurred in excess in certain tribes; and due to increased surveillance and testing by our group. Saudi Arabia provides a unique opportunity for research in this area of pediatrics.
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Affiliation(s)
- M Rashed
- Department of Pediatrics, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
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31
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al Aqeel A, Rashed M, Ozand PT, Gascon GG, Rahbeeni Z, al Garawi S, al Odaib A, Brismar J. A new patient with alpha-ketoglutaric aciduria and progressive extrapyramidal tract disease. Brain Dev 1994; 16 Suppl:33-7. [PMID: 7726379 DOI: 10.1016/0387-7604(94)90094-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A 4.5-year-old boy with chronic progressive encephalopathy is described. The clinical presentation initially included seizures and hypotonia which later evolved into severe extrapyramidal disease and dementia. The gas chromatography/mass spectrometry (GC/MS) analysis of urine indicated that alpha-ketoglutarate was increased 210 times and aconitic acid 80 times. No disturbance of acid/base balance, lactic acid or ammonia metabolism accompanied this clinical picture. The fibroblasts contained 29% of normal alpha-ketoglutarate dehydrogenase activity, while the activity of another mitochondrial marker enzyme, glutamate dehydrogenase, was normal. The neuroimaging studies revealed bilateral striatal necrosis. The clinical and biochemical findings were almost identical to two previously reported patients. Experience with this patient emphasizes the need for detailed organic acid biochemical investigation in any progressive encephalopathy and that extrapyramidal tract signs should evoke the possibility of alpha-ketoglutaric aciduria, among other 'neurologic organic acidemias'.
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Affiliation(s)
- A al Aqeel
- Department of Pediatrics, Armed Forces Hospital, Riyadh, Saudi Arabia
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32
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Dabbagh O, Brismar J, Gascon GG, Ozand PT. The clinical spectrum of biotin-treatable encephalopathies in Saudi Arabia. Brain Dev 1994; 16 Suppl:72-80. [PMID: 7726384 DOI: 10.1016/0387-7604(94)90099-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Ten patients with biotin-dependent, chronic progressive encephalopathies were studied retrospectively. In four patients, the underlying disease was either total or partial deficiency of biotinidase. In one patient, the disease was caused by a lack of holocarboxylase synthetase activity. Four patients presented with Leigh encephalopathy. However, a biochemical defect could not always be confirmed. All patients required the administration of large doses of biotin to maintain normal neurologic function.
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Affiliation(s)
- O Dabbagh
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Henriquez H, el Din A, Ozand PT, Subramanyam SB, al Gain SI. Emergency presentations of patients with methylmalonic acidemia, propionic acidemia and branched chain amino acidemia (MSUD). Brain Dev 1994; 16 Suppl:86-93. [PMID: 7726386 DOI: 10.1016/0387-7604(94)90101-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The charts of 16 patients with branched chain amino acidemia (MSUD) who had 48 emergency room (ER) visits, of 10 patients with propionic acidemia (PA) who had 57 ER visit, and of 13 patients with methylmalonic acidemia (MMA) who had 154 ER visits, were reviewed retrospectively for the most common clinical presentations, physical and laboratory findings. The most common clinical presentation was acute or chronic vomiting and the most common physical finding was dehydration. When hypoglycemia was found, the mental status of 55% of patients with MSUD and MMA and 20% of patients with PA, was alert. Mixed acid/base disturbance, i.e. alkalosis caused by vomiting mixed with metabolic acidosis caused by the disease, was present in 30% of MSUD, in 33% of PA, and 45% of MMA. There was no relationship between acidosis detected by the blood pH and mental status of the patients. A good correlation between base excess < -5 and serum bicarbonate < 21 mmol/l was found. Blood cultures were positive for bacteria and fungi in 15% of the visits with MSUD, in 23% with PA, and 3% with MMA. Patients with positive blood cultures did not necessarily have a temperature > 39 degrees C nor hypothermia. The results suggest that the mental status of the patients should not detract the ER physician from obtaining blood pH, gases and glucose and in all instances a blood culture should be secured, even if the patient has no fever.
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Affiliation(s)
- H Henriquez
- Emergency Medical Services, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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