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Zubarioglu T, Kıykım E, Köse E, Eminoğlu FT, Teke Kısa P, Balcı MC, Özer I, İnci A, Çilesiz K, Canda E, Yazıcı H, Öztürk-Hişmi B, Bulut FD, Dorum S, Akgun A, Yalçın-Çakmaklı G, Kılıç-Yıldırım G, Soyuçen E, Akçalı A, Güneş D, Durmuş A, Gündüz A, Kasapkara ÇS, Göksoy E, Akar HT, Ersoy M, Erdöl Ş, Yıldız Y, Hanağası HA, Arslan N, Aktuğlu-Zeybek Ç. Clinical, biochemical, and molecular insights into Cerebrotendinous Xanthomatosis: A nationwide study of 100 Turkish individuals. Mol Genet Metab 2024; 142:108493. [PMID: 38772327 DOI: 10.1016/j.ymgme.2024.108493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 05/23/2024]
Abstract
OBJECTIVE Cerebrotendinous xanthomatosis (CTX) is an inherited metabolic disorder characterized by progressive neurologic and extraneurologic findings. The aim of this retrospective, descriptive study was to explore the time of presentation and diagnosis, and to expand the phenotype and genotype of CTX, based on a nationwide and comprehensive series of patients in Turkey. METHODS The demographic, clinical, biochemical and genotypic characteristics of the CTX patients were reviewed. Data on molecular analysis, age of onset and diagnosis, diagnostic delay, neurologic and extraneurologic symptomatology, results of plasma cholestanol levels, brain magnetic resonance imaging and electromyography at the time of diagnosis were reviewed. RESULTS 100 confirmed CTX patients from 72 families were included. The mean age at diagnosis was 28.16 ± 14.28 years, and diagnostic delay was 18.39 ± 13.71 years. 36 patients were diagnosed in childhood. Frequency of intention tremor (p = 0.069), peripheral neuropathy (p = 0.234) and psychiatric manifestations (p = 0.396) did not differ between two groups, demonstrating the high rate in pediatric patients. Three adult patients showed a milder phenotype without neurologic involvement. Seven patients had normal plasma cholestanol levels despite neurological impairment. Sequencing of the CYP27A1 gene revealed 25 different variants, with a novel c.671_672del variant not previously described in literature. CONCLUSION Based on the observations of this Turkish CTX cohort, it is emphasized that the true prevalence of CTX is probably underestimated and that it has a wide spectrum of clinical phenotypes even without neurological impairment. In children, abnormal cerebellar findings, peripheral neuropathy and psychiatric findings associated with intellectual disability have been suggested as warning signs to avoid diagnostic delay. In cases of clinical suspicion, molecular analysis is recommended despite normal plasma cholestanol levels, as severe neurologic involvement may occur in CTX patients without elevated cholestanol levels.
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Affiliation(s)
- Tanyel Zubarioglu
- İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Division of Pediatric Nutrition and Metabolism, İstanbul, Turkey.
| | - Ertuğrul Kıykım
- İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Division of Pediatric Nutrition and Metabolism, İstanbul, Turkey
| | - Engin Köse
- Ankara University, Faculty of Medicine, Department of Pediatric Metabolism, Ankara, Turkey; Ankara University Rare Diseases Application and Research Center, Ankara, Turkey
| | - Fatma Tuba Eminoğlu
- Ankara University, Faculty of Medicine, Department of Pediatric Metabolism, Ankara, Turkey; Ankara University Rare Diseases Application and Research Center, Ankara, Turkey
| | - Pelin Teke Kısa
- Dokuz Eylul University Medical Faculty, Division of Pediatric Nutrition and Metabolism, Izmir, Turkey
| | - Mehmet Cihan Balcı
- Istanbul University, Istanbul Medical Faculty Children's Hospital, Division of Nutrition and Metabolism, Istanbul, Turkey
| | - Işıl Özer
- Ondokuz Mayıs University, Faculty of Medicine, Department of Pediatric Metabolism, Samsun, Turkey; Kafkas University, Division of Pediatric Nutrition and Metabolism, Kars, Turkey
| | - Aslı İnci
- Gazi University School of Medicine, Division of Pediatric Nutrition and Metabolism, Ankara, Turkey
| | - Kübra Çilesiz
- Gazi University School of Medicine, Division of Pediatric Nutrition and Metabolism, Ankara, Turkey
| | - Ebru Canda
- Ege University Medical Faculty, Division of Pediatric Nutrition and Metabolism, İzmir, Turkey
| | - Havva Yazıcı
- Ege University Medical Faculty, Division of Pediatric Nutrition and Metabolism, İzmir, Turkey
| | - Burcu Öztürk-Hişmi
- Marmara University School of Medicine, Division of Pediatric Metabolic Disorders, İstanbul, Turkey
| | - Fatma Derya Bulut
- Cukurova University Medical Faculty, Division of Pediatric Metabolism and Nutrition, Adana, Turkey
| | - Sevil Dorum
- Health Sciences University, Bursa Yuksek Ihtisas Training and Research Hospital, Division of Pediatric Nutrition and Metabolism, Bursa, Turkey
| | - Abdurrahman Akgun
- Firat University, School of Medicine, Department of Pediatrics, Division of Pediatric Metabolic Diseases, Elazığ, Turkey
| | - Gül Yalçın-Çakmaklı
- Hacettepe University Faculty of Medicine, Department of Neurology, Ankara, Turkey
| | - Gonca Kılıç-Yıldırım
- Eskisehir Osmangazi University, Faculty of Medicine, Pediatric Nutrition and Metabolism Unit, Eskişehir, Turkey
| | - Erdoğan Soyuçen
- Akdeniz University Faculty of Medicine, Department of Pediatrics, Division of Inherited Pediatric Metabolic Diseases, Antalya, Turkey
| | - Aylin Akçalı
- Gaziantep University Faculty of Medicine, Department of Neurology, Gaziantep, Turkey
| | - Dilek Güneş
- Bağcılar Training and Research Hospital, Division of Inborn Metabolic Disease, İstanbul, Turkey
| | - Aslı Durmuş
- Kanuni Training and Research Hospital, Division of Pediatric Metabolism, Trabzon, Turkey
| | - Ayşegül Gündüz
- İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Department of Neurology, İstanbul, Turkey
| | - Çiğdem Seher Kasapkara
- Ankara Yıldırım Beyazıt University, Ankara Bilkent City Hospital, Department of Pediatric Metabolism, Ankara, Turkey
| | - Emine Göksoy
- Adnan Menderes University Medical Faculty, Division of Pediatric Metabolism, Aydın, Turkey
| | - Halil Tuna Akar
- Ankara Etlik City Hospital, Pediatric Metabolic Diseases Unit, Ankara, Turkey
| | - Melike Ersoy
- Health Sciences University, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Pediatrics, Division of Pediatric Metabolic Diseases, İstanbul, Turkey
| | - Şahin Erdöl
- Bursa Uludag University Faculty of Medicine, Department of Pediatrics, Division of Metabolism, Bursa, Turkey
| | - Yılmaz Yıldız
- Hacettepe University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Metabolism, Ankara, Turkey
| | | | - Nur Arslan
- Dokuz Eylul University Medical Faculty, Division of Pediatric Nutrition and Metabolism, Izmir, Turkey
| | - Çiğdem Aktuğlu-Zeybek
- İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Division of Pediatric Nutrition and Metabolism, İstanbul, Turkey
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2
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DeBarber AE, Schaefer EJ, Do J, Ray JW, Larson A, Redder S, Fowler M, Duell PB. Genetically and clinically confirmed atypical cerebrotendinous xanthomatosis with normal cholestanol and marked elevations of bile acid precursors and bile alcohols. J Clin Lipidol 2024; 18:e465-e476. [PMID: 38637260 DOI: 10.1016/j.jacl.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 02/07/2024] [Accepted: 03/13/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive lipid disorder. Affected patients often remain undiagnosed until the age of 20-30 years, when they have already developed significant neurologic disease that may not be reversible. An elevated plasma cholestanol concentration has been accepted as a diagnostic criterion for CTX for decades. OBJECTIVE Full biochemical characterization was performed for three genetically and clinically confirmed atypical CTX cases with normal plasma cholestanol levels. METHODS Clinical assessment and genetic/biochemical testing for patients with CTX was performed by their physician providing routine standard of care. RESULTS We report three new atypical CTX cases with large extensor tendon xanthomas but normal plasma cholestanol levels. All three cases had marked elevations of bile acid precursors and bile alcohols in plasma and urine that decreased on treatment with chenodeoxycholic acid. We also review eight published cases of atypical CTX with normal/near normal circulating cholestanol levels. CONCLUSION The atypical biochemical presentation of these cases provides a diagnostic challenge for CTX, a disorder for which cholestanol has been believed to be a sensitive biomarker. These cases demonstrate measurements of plasma cholestanol alone are insufficient to exclude a diagnosis of CTX. The data presented is consistent with the concept that bile acid precursors and bile alcohols are sensitive biomarkers for atypical CTX with normal cholestanol, and that such testing is indicated, along with CYP27A1 gene analyses, in patients presenting with significant tendon and/or tuberous xanthomas and/or neurologic disease in early adulthood despite normal or near normal cholesterol and cholestanol levels.
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Affiliation(s)
- Andrea E DeBarber
- University Shared Resources, Oregon Health & Science University (OHSU), Portland, OR, United States of America (Dr DeBarber, Ms Redder and Ms Fowler).
| | - Ernst J Schaefer
- Boston Heart Diagnostics/Eurofins Scientific Network, Framingham, MA, United States of America and Department of Medicine, Tufts University School of Medicine, Boston, MA, United States of America (Dr Schaefer)
| | - Jenny Do
- Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, United States of America (Ms Do and Dr Ray)
| | - Joseph W Ray
- Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, United States of America (Ms Do and Dr Ray)
| | - Austin Larson
- University of Colorado School of Medicine, Aurora, CO, United States of America (Dr Larson)
| | - Samantha Redder
- University Shared Resources, Oregon Health & Science University (OHSU), Portland, OR, United States of America (Dr DeBarber, Ms Redder and Ms Fowler)
| | - Maya Fowler
- University Shared Resources, Oregon Health & Science University (OHSU), Portland, OR, United States of America (Dr DeBarber, Ms Redder and Ms Fowler)
| | - P Barton Duell
- Center for Preventive Cardiology, Knight Cardiovascular Institute & Division of Endocrinology, Diabetes & Clinical Nutrition, OHSU, Portland, OR, United States of America (Dr Duell)
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3
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Kiely C, Douglas KAA, Douglas VP, Miller JB, Lizano P. Overlap between ophthalmology and psychiatry - A narrative review focused on congenital and inherited conditions. Psychiatry Res 2024; 331:115629. [PMID: 38029629 PMCID: PMC10842794 DOI: 10.1016/j.psychres.2023.115629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/23/2023] [Accepted: 11/24/2023] [Indexed: 12/01/2023]
Abstract
A number of congenital and inherited diseases present with both ocular and psychiatric features. The genetic inheritance and phenotypic variants play a key role in disease severity. Early recognition of the signs and symptoms of those disorders is critical to earlier intervention and improved prognosis. Typically, the associations between these two medical subspecialties of ophthalmology and psychiatry are poorly understood by most practitioners so we hope to provide a narrative review to improve the identification and management of these disorders. We conducted a comprehensive review of the literature detailing the diseases with ophthalmic and psychiatric overlap that were more widely represented in the literature. Herein, we describe the clinical features, pathophysiology, molecular biology, diagnostic tests, and the most recent approaches for the treatment of these diseases. Recent studies have combined technologies for ocular and brain imaging such as optical coherence tomography (OCT) and functional imaging with genetic testing to identify the genetic basis for eye-brain connections. Additional work is needed to further explore these potential biomarkers. Overall, accurate, efficient, widely distributed and non-invasive tests that can help with early recognition of these diseases will improve the management of these patients using a multidisciplinary approach.
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Affiliation(s)
- Chelsea Kiely
- Department of Psychiatry, Beth Israel Deaconess Medical Center, 75 Fenwood Rd, 612, Boston, MA, United States
| | - Konstantinos A A Douglas
- Department of Psychiatry, Beth Israel Deaconess Medical Center, 75 Fenwood Rd, 612, Boston, MA, United States; Harvard Retinal Imaging Lab, Massachusetts Eye and Ear, Boston, MA, United States
| | | | - John B Miller
- Harvard Retinal Imaging Lab, Massachusetts Eye and Ear, Boston, MA, United States; Retina Service, Department of Ophthalmology, Massachusetts Eye and Ear, Boston, MA, United States; Department of Ophthalmology, Harvard Medical School, Boston, MA, United States
| | - Paulo Lizano
- Department of Psychiatry, Beth Israel Deaconess Medical Center, 75 Fenwood Rd, 612, Boston, MA, United States; Department of Psychiatry, Harvard Medical School, Boston, MA, United States; Division of Translational Neuroscience, Beth Israel Deaconess Medical Center, Boston, MA, United States.
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4
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A new CYP27A1 mutation in a case of cerebrotendinous xanthomatosis. Neurologia 2022. [DOI: 10.1016/j.nrl.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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5
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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: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is an autosomal recessive lipid storage disorder caused by mutations in the
CYP27A1
gene, which encodes the mitochondrial enzyme sterol 27-hydroxylase. Decreased sterol 27-hydroxylase activity results in impaired bile acid synthesis, leading to reduced production of bile acids, especially chenodeoxycholic acid (CDCA), as well as elevated serum cholestanol and urine bile alcohols. The accumulation of cholestanol and cholesterol mainly in the brain, lenses, and tendons results in the characteristic clinical manifestations of CTX. Clinical presentation is characterized by systemic symptoms including neonatal jaundice or cholestasis, refractory diarrhea, juvenile cataracts, tendon xanthomas, osteoporosis, coronary heart disease, and a broad range of neuropsychiatric manifestations. The combinations of symptoms vary from patient to patient and the presenting symptoms, especially in the early disease phase, may be nonspecific, which leads to a substantial diagnostic delay or underdiagnosis. Replacement of CDCA has been approved as a first-line treatment for CTX, and can lead to biochemical and clinical improvements. However, the effect of CDCA treatment is limited once significant neuropsychiatric manifestations are established. The age at diagnosis and initiation of CDCA treatment correlate with the prognosis of patients with CTX. Therefore, early diagnosis and subsequent treatment initiation are essential.
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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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6
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Guenzel AJ, DeBarber A, Raymond K, Dhamija R. Familial variability of cerebrotendinous xanthomatosis lacking typical biochemical findings. JIMD Rep 2021; 59:3-9. [PMID: 33977023 PMCID: PMC8100391 DOI: 10.1002/jmd2.12197] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 12/11/2022] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive disorder of bile acid synthesis caused by pathogenic variants in the CYP27A1 gene encoding the mitochondrial enzyme sterol 27-hydroxylase. Patients with CTX can present with a wide range of symptoms, but most often have evidence of tendon xanthomas along with possible cataracts, atherosclerosis, or neurological dysfunction. Regardless of clinical phenotype, CTX patients typically exhibit levels of cholestanol and bile acid precursors in the circulation that are many fold increased over normal control concentrations. Here we report two siblings, one with the rare spinal xanthomatosis phenotype and the other with a very mild form of CTX manifesting as minor tendon xanthomatosis and gastrointestinal complaints who both carry compound heterozygous variants in CYP27A1: NM_000784.3: c.410G > A (p.Arg137Gln) and c.1183C > T (p.Arg395Cys). However, biochemical analysis of these patients revealed normal levels of serum cholestanol and relatively mild elevations of the bile acid precursors 7α-hydroxy-4-cholesten-3-one and 7α,12α-dihydroxy-4-cholesten-3-one. The atypical biochemical presentation of these cases represents a diagnostic challenge for a disorder once thought to have a sensitive biomarker in cholestanol and highlight the need for thorough investigation of patients with symptomatology consistent with CTX that includes bile acid precursor biochemical testing and molecular analysis.
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Affiliation(s)
- Adam J. Guenzel
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | - Andrea DeBarber
- Department of Chemical Physiology and BiochemistryOregon Health and Science UniversityPortlandOregonUSA
| | - Kimiyo Raymond
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | - Radhika Dhamija
- Department of Clinical Genomics and NeurologyMayo ClinicScottsdaleArizonaUSA
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7
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Höflinger P, Hauser S, Yutuc E, Hengel H, Griffiths L, Radelfahr F, Howell OW, Wang Y, Connor SL, Duell PB, DeBarber AE, Martus P, Lütjohann D, Griffiths WJ, Schöls L. Metabolic profiling in serum, cerebrospinal fluid, and brain of patients with cerebrotendinous xanthomatosis. J Lipid Res 2021; 62:100078. [PMID: 33891937 PMCID: PMC8135047 DOI: 10.1016/j.jlr.2021.100078] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 11/25/2022] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is caused by autosomal recessive loss-of-function mutations in CYP27A1, a gene encoding cytochrome p450 oxidase essential for bile acid synthesis, resulting in altered bile acid and lipid metabolism. Here, we aimed to identify metabolic aberrations that drive ongoing neurodegeneration in some patients with CTX despite chenodeoxycholic acid (CDCA) supplementation, the standard treatment in CTX. Using chromatographic separation techniques coupled to mass spectrometry, we analyzed 26 sterol metabolites in serum and cerebrospinal fluid (CSF) of patients with CTX and in one CTX brain. Comparing samples of drug naive patients to patients treated with CDCA and healthy controls, we identified 7α,12α-dihydroxycholest-4-en-3-one as the most prominently elevated metabolite in serum and CSF of drug naive patients. CDCA treatment substantially reduced or even normalized levels of all metabolites increased in untreated patients with CTX. Independent of CDCA treatment, metabolites of the 27-hydroxylation pathway were nearly absent in all patients with CTX. 27-hydroxylated metabolites accounted for ∼45% of total free sterol content in CSF of healthy controls but <2% in patients with CTX. Metabolic changes in brain tissue corresponded well with findings in CSF. Interestingly, 7α,12α-dihydroxycholest-4-en-3-one and 5α-cholestanol did not exert toxicity in neuronal cell culture. In conclusion, we propose that increased 7α,12α-dihydroxycholest-4-en-3-one and lack of 27-hydroxycholesterol may be highly sensitive metabolic biomarkers of CTX. As CDCA cannot reliably prevent disease progression despite reduction of most accumulated metabolites, supplementation of 27-hydroxylated bile acid intermediates or replacement of CYP27A1 might be required to counter neurodegeneration in patients with progressive disease despite CDCA treatment.
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Affiliation(s)
- Philip Höflinger
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany; Department of Neurology and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany; Graduate School of Cellular and Molecular Neuroscience, University of Tübingen, Tübingen, Germany
| | - Stefan Hauser
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany; Department of Neurology and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Eylan Yutuc
- Swansea University Medical School, ILS1, Swansea, Wales, United Kingdom
| | - Holger Hengel
- Department of Neurology and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Lauren Griffiths
- Swansea University Medical School, ILS1, Swansea, Wales, United Kingdom
| | - Florentine Radelfahr
- Friedrich-Baur-Institute, Department of Neurology, University Hospital, LMU Munich, Munich, Germany; German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Owain W Howell
- Swansea University Medical School, ILS1, Swansea, Wales, United Kingdom
| | - Yuqin Wang
- Swansea University Medical School, ILS1, Swansea, Wales, United Kingdom
| | - Sonja L Connor
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - P Barton Duell
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Andrea E DeBarber
- Chemical Physiology and Biochemistry Department, Oregon Health & Science University, Portland, OR, USA
| | - Peter Martus
- Institute of Clinical Epidemiology and applied Biostatistics, University of Tübingen, Tübingen, Germany
| | - Dieter Lütjohann
- Institute of Clinical Chemistry and Clinical Pharmacology, University Hospital Bonn, Bonn, Germany
| | | | - Ludger Schöls
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany; Department of Neurology and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.
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8
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Abstract
PURPOSE OF REVIEW Cerebrotendinous xanthomatosis (CTX) is a rare genetic lipid storage disorder with highly pleomorphic clinical phenotype. Complications of this disease can be devastating and may include severe cognitive impairment and dementia in later stages. Disease progression can be prevented or stabilized by bile acid replacement therapy, although a subset of patients with advanced disease continue to deteriorate despite therapy. RECENT FINDINGS Delayed diagnosis of CTX continues to impede effective treatment. A clinical diagnostic algorithm for CTX was developed that can decrease the age of diagnosis of CTX. The strategy of screening children with bilateral juvenile cataracts for CTX also improved diagnosis, as this group had a 500-fold higher-rate of CTX than the general population. Improved diagnosis of CTX is critical, as patients treated early in the course of the disease have significantly better outcomes compared with those treated later. More sensitive and specific biochemical testing for CTX has been developed that is potentially more informative than blood cholestanol to assess treatment efficacy and medication compliance in CTX. SUMMARY Because we are recognizing more severe presentations of CTX in infants and children, and delayed diagnosis and treatment worsens the prognosis, CTX is an excellent candidate disorder for newborn screening using recently reported methods for newborn dried bloodspot analysis.
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Affiliation(s)
| | - P Barton Duell
- Knight Cardiovascular Institute, and Division of Endocrinology, Diabetes & Clinical Nutrition, Oregon Health & Science University, Portland, Oregon, USA
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9
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Jiang J, Chen G, Wu J, Luan X, Zhou H, Liu X, Zhu Z, Song X, Wang S, Qian X, Du J, Huang X, Zhang M, Xu W, Cao L. c.1263+1G>A Is a Latent Hotspot for CYP27A1 Mutations in Chinese Patients With Cerebrotendinous Xanthomatosis. Front Genet 2020; 11:682. [PMID: 32714376 PMCID: PMC7342084 DOI: 10.3389/fgene.2020.00682] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 06/03/2020] [Indexed: 12/25/2022] Open
Abstract
Background Cerebrotendinous xanthomatosis (CTX) is an autosomal recessive disorder of bile acid synthesis caused by mutations in the CYP27A1 gene. CTX is an underdiagnosed and potentially treatable disease, thus a detailed appreciation of the phenotypic spectrum and genetic characteristics are crucial for early diagnosis and treatment. Objectives and Methods Four CTX families with mutations in the CYP27A1 gene were enrolled in our study. We investigated the clinical characteristics and molecular genetic features of the probands with CTX. Genetic analysis was performed for detecting gene variants. Sanger sequencing and segregation analysis were conducted for haplotype analysis. Results All the four probands were compound heterozygote for two CYP27A1 variants, including one mutation in c.1263+1G>A (intron 7) splice site, two novel likely pathogenic mutations (c.255+1G>T and c.1561dupA) and three pathogenic mutations including c.379C>T, c.1263+1G>A and c.1537C>T previously reported. All of the subjects presented with spastic paraparesis. The other common clinical features included ataxia, childhood-onset diarrhea, cataracts, intellectual disability, tendinous xanthomas and dentate nuclei signal alterations at MRI. Conclusion Two novel likely pathogenic mutations (c.255+1G>T and c.1561dupA) were reported in our study. The 1263+1G>A mutation was commonly seen in Chinese reported case series (7/25, 28%) and could be a latent hotspot for Chinese CTX mutations. Our study expanded the mutation spectrum of CYP27A1 gene and provide an insightful view of the phenotypic spectrum and genetic characteristics to help early diagnosis and treatment with to improve neurologic dysfunction.
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Affiliation(s)
- Jingwen Jiang
- Department of Neurology, Ruijin Hospital and Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guang Chen
- Department of Neurology, Ruijin Hospital and Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Neurology, The First People's Hospital of Huainan, The First Affiliated Hospital of Anhui University of Science and Technology, Huainan, China
| | - Jingying Wu
- Department of Neurology, Ruijin Hospital and Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinghua Luan
- Department of Neurology, Ruijin Hospital and Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haiyan Zhou
- Department of Neurology, Ruijin Hospital and Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoli Liu
- Department of Neurology, Shanghai Fengxian District Central Hospital, Shanghai Jiao Tong University Affiliated Sixth People's Hospital South Campus, Shanghai, China
| | - Zeyu Zhu
- Department of Neurology, Ruijin Hospital and Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoxuan Song
- Department of Neurology, Ruijin Hospital and Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shige Wang
- Department of Neurology, Ruijin Hospital and Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaohang Qian
- Department of Neurology, Ruijin Hospital and Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Juanjuan Du
- Department of Neurology, Ruijin Hospital and Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaojun Huang
- Department of Neurology, Ruijin Hospital and Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mei Zhang
- Department of Neurology, The First People's Hospital of Huainan, The First Affiliated Hospital of Anhui University of Science and Technology, Huainan, China
| | - Wei Xu
- Department of Neurology, Ruijin Hospital and Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Cao
- Department of Neurology, Ruijin Hospital and Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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10
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Sottero B, Rossin D, Staurenghi E, Gamba P, Poli G, Testa G. Omics analysis of oxysterols to better understand their pathophysiological role. Free Radic Biol Med 2019; 144:55-71. [PMID: 31141713 DOI: 10.1016/j.freeradbiomed.2019.05.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/30/2019] [Accepted: 05/24/2019] [Indexed: 12/12/2022]
Abstract
High amounts of cholesterol have been definitely associated with the pathogenesis of several diseases, including metabolic and neurodegenerative disorders, cardiovascular diseases, and cancer. In all these pathologies the exacerbation of pro-oxidant and inflammatory responses is a consistent feature. In this scenario, species derived from enzymatic and non-enzymatic cholesterol oxidation, namely oxysterols, are strongly suspected to play a primary role. The consideration of these bioactive lipids is therefore helpful in investigating pathological mechanisms and may also acquire clinical value for the diagnosis and treatment of diseases. For this purpose and considering that a great number of oxysterols may be present together in the body, the employment of lipidomics technology certainly represents a powerful strategy for the simultaneous detection and characterization of these compounds in biological specimens. In this review, we will discuss the applicability of the lipidomics approach in the study of the association between oxysterols and diseases.
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Affiliation(s)
- Barbara Sottero
- Department of Clinical and Biological Sciences, San Luigi Hospital, University of Torino, Italy.
| | - Daniela Rossin
- Department of Clinical and Biological Sciences, San Luigi Hospital, University of Torino, Italy
| | - Erica Staurenghi
- Department of Clinical and Biological Sciences, San Luigi Hospital, University of Torino, Italy
| | - Paola Gamba
- Department of Clinical and Biological Sciences, San Luigi Hospital, University of Torino, Italy
| | - Giuseppe Poli
- Department of Clinical and Biological Sciences, San Luigi Hospital, University of Torino, Italy
| | - Gabriella Testa
- Department of Clinical and Biological Sciences, San Luigi Hospital, University of Torino, Italy
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Developing an Enzyme-Assisted Derivatization Method for Analysis of C 27 Bile Alcohols and Acids by Electrospray Ionization-Mass Spectrometry. Molecules 2019; 24:molecules24030597. [PMID: 30736477 PMCID: PMC6384595 DOI: 10.3390/molecules24030597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 01/08/2023] Open
Abstract
Enzyme-assisted derivatization for sterol analysis (EADSA) is a technology designed to enhance sensitivity and specificity for sterol analysis using electrospray ionization⁻mass spectrometry. To date it has only been exploited on sterols with a 3β-hydroxy-5-ene or 3β-hydroxy-5α-hydrogen structure, using bacterial cholesterol oxidase enzyme to convert the 3β-hydroxy group to a 3-oxo group for subsequent derivatization with the positively charged Girard hydrazine reagents, or on substrates with a native oxo group. Here we describe an extension of the technology by substituting 3α-hydroxysteroid dehydrogenase (3α-HSD) for cholesterol oxidase, making the method applicable to sterols with a 3α-hydroxy-5β-hydrogen structure. The 3α-HSD enzyme works efficiently on bile alcohols and bile acids with this stereochemistry. However, as found by others, derivatization of the resultant 3-oxo group with a hydrazine reagent does not go to completion in the absence of a conjugating double bond in the sterol structure. Nevertheless, Girard P derivatives of bile alcohols and C27 acids give an intense molecular ion ([M]⁺) upon electrospray ionization and informative fragmentation spectra. The method shows promise for analysis of bile alcohols and 3α-hydroxy-5β-C27-acids, enhancing the range of sterols that can be analyzed at high sensitivity in sterolomic studies.
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12
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Duell PB, Salen G, Eichler FS, DeBarber AE, Connor SL, Casaday L, Jayadev S, Kisanuki Y, Lekprasert P, Malloy MJ, Ramdhani RA, Ziajka PE, Quinn JF, Su KG, Geller AS, Diffenderfer MR, Schaefer EJ. Diagnosis, treatment, and clinical outcomes in 43 cases with cerebrotendinous xanthomatosis. J Clin Lipidol 2018; 12:1169-1178. [PMID: 30017468 DOI: 10.1016/j.jacl.2018.06.008] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/28/2018] [Accepted: 06/19/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Cerebrotendinous xanthomatosis (CTX) is a rare disorder due to defective sterol 27-hydroxylase causing a lack of chenodeoxycholic acid (CDCA) production and high plasma cholestanol levels. OBJECTIVES Our objective was to review the diagnosis and treatment results in 43 CTX cases. METHODS We conducted a careful review of the diagnosis, laboratory values, treatment, and clinical course in 43 CTX cases. RESULTS The mean age at diagnosis was 32 years; the average follow-up was 8 years. Cases had the following conditions: 53% chronic diarrhea, 74% cognitive impairment, 70% premature cataracts, 77% tendon xanthomas, 81% neurologic disease, and 7% premature cardiovascular disease. The mean serum cholesterol concentration was 190 mg/dL; the mean plasma cholestanol level was 32 mg/L (normal <5.0 mg/L), which decreased to 6.0 mg/L (-81%) with CDCA therapy generally given as 250 mg orally 3 times daily. Of those tested on treatment, 63% achieved cholestanol levels of <5.0 mg/L; 91% had normal liver enzyme levels; none had significant liver problems after dose adjustment. Treatment improved symptoms in 57% at follow-up, but 20% with advanced disease continued to deteriorate. In the United States, CDCA has been approved for gallstone dissolution, but not for CTX despite long-term efficacy and safety data. CONCLUSIONS Health care providers seeing young patients with tendon xanthomas and relatively normal cholesterol levels, especially those with cataracts and learning problems, should consider the diagnosis of CTX so they can receive treatment. CDCA should receive regulatory approval to facilitate therapy for the prevention of the complications of the disease.
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Affiliation(s)
- P Barton Duell
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Gerald Salen
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Florian S Eichler
- Department of Neurology, Massachusetts General Hospital for Children, Boston, MA, USA
| | - Andrea E DeBarber
- Department of Physiology and Pharmacology, Oregon Health and Science University, Portland, OR, USA
| | - Sonja L Connor
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Lise Casaday
- Department of Neurology, University of South Florida, Tampa, FL, USA
| | - Suman Jayadev
- Department of Neurology, Western Medical Center, University of Washington, Seattle, WA, USA
| | - Yasushi Kisanuki
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Mary J Malloy
- Division of Endocrinology, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Ritesh A Ramdhani
- Department of Neurology, New York University Medical Center, New York, NY, USA
| | | | - Joseph F Quinn
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Kimmy G Su
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Andrew S Geller
- Boston Heart Diagnostics, Framingham, MA, USA; Cardiovascular Nutrition Laboratory, Human Nutrition Research Center on Aging at Tufts University, Boston, MA, USA
| | | | - Ernst J Schaefer
- Boston Heart Diagnostics, Framingham, MA, USA; Cardiovascular Nutrition Laboratory, Human Nutrition Research Center on Aging at Tufts University, Boston, MA, USA; The Dyslipidemia Foundation, Natick, MA, USA.
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13
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Griffiths WJ, Wang Y. An update on oxysterol biochemistry: New discoveries in lipidomics. Biochem Biophys Res Commun 2018; 504:617-622. [PMID: 29421651 PMCID: PMC6381446 DOI: 10.1016/j.bbrc.2018.02.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 02/02/2018] [Indexed: 12/22/2022]
Abstract
Oxysterols are oxidised derivatives of cholesterol or its precursors post lanosterol. They are intermediates in the biosynthesis of bile acids, steroid hormones and 1,25-dihydroxyvitamin D3. Although often considered as metabolic intermediates there is a growing body of evidence that many oxysterols are bioactive and their absence or excess may be part of the cause of a disease phenotype. Using global lipidomics approaches oxysterols are underrepresented encouraging the development of targeted approaches. In this article, we discuss recent discoveries important in oxysterol biochemistry and some of the targeted lipidomic approaches used to make these discoveries. Oxysterols can regulate both the innate and adaptive immune systems. Oxysterols can be tumour suppressors and on cometabolites. Oxysterols can inhibit or activate the Hh signalling pathway.
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Affiliation(s)
- William J Griffiths
- Institute of Life Science, Swansea University Medical School, Singleton Park, Swansea SA2 8PP, UK.
| | - Yuqin Wang
- Institute of Life Science, Swansea University Medical School, Singleton Park, Swansea SA2 8PP, UK.
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14
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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: 105] [Impact Index Per Article: 15.0] [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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15
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Griffiths WJ, Abdel-Khalik J, Crick PJ, Yutuc E, Wang Y. New methods for analysis of oxysterols and related compounds by LC-MS. J Steroid Biochem Mol Biol 2016; 162:4-26. [PMID: 26639636 DOI: 10.1016/j.jsbmb.2015.11.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Revised: 11/23/2015] [Accepted: 11/25/2015] [Indexed: 12/21/2022]
Abstract
Oxysterols are oxygenated forms of cholesterol or its precursors. They are formed enzymatically and via reactive oxygen species. Oxysterols are intermediates in bile acid and steroid hormone biosynthetic pathways and are also bioactive molecules in their own right, being ligands to nuclear receptors and also regulators of the processing of steroid regulatory element-binding proteins (SREBPs) to their active forms as transcription factors regulating cholesterol and fatty acid biosynthesis. Oxysterols are implicated in the pathogenesis of multiple disease states ranging from atherosclerosis and cancer to multiple sclerosis and other neurodegenerative diseases including Alzheimer's and Parkinson's disease. Analysis of oxysterols is challenging on account of their low abundance in biological systems in comparison to cholesterol, and due to the propensity of cholesterol to undergo oxidation in air to generate oxysterols with the same structures as those present endogenously. In this article we review the mass spectrometry-based methods for oxysterol analysis paying particular attention to analysis by liquid chromatography-mass spectrometry (LC-MS).
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Affiliation(s)
- William J Griffiths
- College of Medicine, Grove Building, Swansea University, Singleton Park, Swansea SA2 8PP, UK.
| | - Jonas Abdel-Khalik
- College of Medicine, Grove Building, Swansea University, Singleton Park, Swansea SA2 8PP, UK
| | - Peter J Crick
- College of Medicine, Grove Building, Swansea University, Singleton Park, Swansea SA2 8PP, UK
| | - Eylan Yutuc
- College of Medicine, Grove Building, Swansea University, Singleton Park, Swansea SA2 8PP, UK
| | - Yuqin Wang
- College of Medicine, Grove Building, Swansea University, Singleton Park, Swansea SA2 8PP, UK.
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16
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Nie S, Chen G, Cao X, Zhang Y. Cerebrotendinous xanthomatosis: a comprehensive review of pathogenesis, clinical manifestations, diagnosis, and management. Orphanet J Rare Dis 2014; 9:179. [PMID: 25424010 PMCID: PMC4264335 DOI: 10.1186/s13023-014-0179-4] [Citation(s) in RCA: 186] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 11/04/2014] [Indexed: 12/20/2022] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) OMIM#213700 is a rare autosomal-recessive lipid storage disease caused by mutations in the CYP27A1 gene; this gene codes for the mitochondrial enzyme sterol 27-hydroxylase, which is involved in bile acid synthesis. The CYP27A1 gene is located on chromosome 2q33-qter and contains nine exons. A CYP27A1 mutation leads to decreased synthesis of bile acid, excess production of cholestanol, and consequent accumulation of cholestanol in tissues. Currently there is no consensus on the prevalence of CTX, one estimate being <5/100,000 worldwide. The prevalence of CTX due to the CYP27A1 mutation R362C alone is approximately 1/50,000 in Caucasians. Patients with CTX have an average age of 35 years at the time of diagnosis and a diagnostic delay of 16 years. Clinical signs and symptoms include adult-onset progressive neurological dysfunction (i.e., ataxia, dystonia, dementia, epilepsy, psychiatric disorders,peripheral neuropathy, and myopathy) and premature non-neurologic manifestations (i.e., tendon xanthomas, childhood-onset cataracts, infantile-onset diarrhea, premature atherosclerosis, osteoporosis, and respiratory insufficiency). Juvenile cataracts, progressive neurologic dysfunction, and mild pulmonary insufficiency are unique symptoms that distinguish CTX from other lipid storage disorders including familial dysbetalipoproteinemia, homozygous familial hypercholesterolemia, and sitosterolemia, all of which might also present with xanthomas and cardiovascular diseases. Brain magnetic resonance imaging (MRI) shows bilateral lesions in the dentate nucleus of the cerebellum and mild white matter lesions. The classical symptoms and signs, namely elevated levels of cholestanol and bile alcohols in serum and urine, brain MRI, and the mutation in the CYP27A1 gene confirm the diagnosis of CTX. Early diagnosis and long-term treatment with chenodeoxycholic acid (750 mg/d) improve neurological symptoms and contribute to a better prognosis.
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Affiliation(s)
- Shuke Nie
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.
| | - Guiqin Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.
| | - Xuebing Cao
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.
| | - Yunjian Zhang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.
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