1
|
Beerepoot S, Boelens JJ, Lindemans C, de Witte MA, Nierkens S, Vrancken AFJE, van der Knaap MS, Bugiani M, Wolf NI. Progressive demyelinating polyneuropathy after hematopoietic cell transplantation in metachromatic leukodystrophy: a case series. J Neurol 2024; 271:4028-4038. [PMID: 38564053 PMCID: PMC11233286 DOI: 10.1007/s00415-024-12322-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 03/05/2024] [Accepted: 03/10/2024] [Indexed: 04/04/2024]
Abstract
Metachromatic leukodystrophy (MLD) is a neuro-metabolic disorder due to arylsulfatase A deficiency, causing demyelination of the central and peripheral nervous system. Hematopoietic cell transplantation (HCT) can provide a symptomatic and survival benefit for pre-symptomatic and early symptomatic patients by stabilizing CNS disease. This case series, however, illustrates the occurrence of severely progressive polyneuropathy shortly after HCT in two patients with late-infantile, one with late-juvenile, and one with adult MLD, leading to the inability to walk or sit without support. The patients had demyelinating polyneuropathy before HCT, performed at the ages of 2 years in the first two patients and at 14 and 23 years in the other two patients. The myeloablative conditioning regimen consisted of busulfan, fludarabine and, in one case, rituximab, with anti-thymocyte globulin, cyclosporine, steroids, and/or mycophenolate mofetil for GvHD prophylaxis. Polyneuropathy after HCT progressed parallel with tapering immunosuppression and paralleled bouts of infection and graft-versus-host disease (GvHD). Differential diagnoses included MLD progression, neurological GvHD or another (auto)inflammatory cause. Laboratory, electroneurography and pathology investigations were inconclusive. In two patients, treatment with immunomodulatory drugs led to temporary improvement, but not sustained stabilization of polyneuropathy. One patient showed recovery to pre-HCT functioning, except for a Holmes-like tremor, for which a peripheral origin cannot be excluded. One patient showed marginal response to immunosuppressive treatment and died ten months after HCT due to respiratory failure. The extensive diagnostic and therapeutic attempts highlight the challenge of characterizing and treating progressive polyneuropathy in patients with MLD shortly after HCT. We advise to consider repeat electro-neurography and possibly peripheral nerve biopsy in such patients. Nerve conduction blocks, evidence of the presence of T lymphocytes and macrophages in the neuronal and surrounding nerve tissue, and beneficial effects of immunomodulatory drugs may indicate a partially (auto)immune-mediated pathology. Polyneuropathy may cause major residual disease burden after HCT. MLD patients with progressive polyneuropathy could potentially benefit from a more intensified immunomodulatory drug regime following HCT, especially at times of immune activation.
Collapse
Affiliation(s)
- Shanice Beerepoot
- Amsterdam UMC, Department of Child Neurology, Amsterdam Leukodystrophy Center, Emma's Children's Hospital, VU University, Amsterdam, The Netherlands
- Neuroscience, Cellular & Molecular Mechanisms, VU University, Amsterdam, The Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Jaap Jan Boelens
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Pediatrics, Stem Cell Transplant and Cellular Therapies, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Caroline Lindemans
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Regenerative Medicine Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Moniek A de Witte
- Department of Hematology, University Medical Center, Utrecht, The Netherlands
| | - Stefan Nierkens
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Alexander F J E Vrancken
- Department of Neurology, Brain Centre University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marjo S van der Knaap
- Amsterdam UMC, Department of Child Neurology, Amsterdam Leukodystrophy Center, Emma's Children's Hospital, VU University, Amsterdam, The Netherlands
- Neuroscience, Cellular & Molecular Mechanisms, VU University, Amsterdam, The Netherlands
- Department of Functional Genomics, Center for Neurogenomics and Cognitive Research, VU University, Amsterdam, The Netherlands
| | - Marianna Bugiani
- Neuroscience, Cellular & Molecular Mechanisms, VU University, Amsterdam, The Netherlands
- Amsterdam UMC, Department of Pathology, VU University Amsterdam, Amsterdam, The Netherlands
| | - Nicole I Wolf
- Amsterdam UMC, Department of Child Neurology, Amsterdam Leukodystrophy Center, Emma's Children's Hospital, VU University, Amsterdam, The Netherlands.
- Neuroscience, Cellular & Molecular Mechanisms, VU University, Amsterdam, The Netherlands.
| |
Collapse
|
2
|
Adang LA, Bonkowsky JL, Boelens JJ, Mallack E, Ahrens-Nicklas R, Bernat JA, Bley A, Burton B, Darling A, Eichler F, Eklund E, Emrick L, Escolar M, Fatemi A, Fraser JL, Gaviglio A, Keller S, Patterson MC, Orchard P, Orthmann-Murphy J, Santoro JD, Schöls L, Sevin C, Srivastava IN, Rajan D, Rubin JP, Van Haren K, Wasserstein M, Zerem A, Fumagalli F, Laugwitz L, Vanderver A. Consensus guidelines for the monitoring and management of metachromatic leukodystrophy in the United States. Cytotherapy 2024; 26:739-748. [PMID: 38613540 PMCID: PMC11348704 DOI: 10.1016/j.jcyt.2024.03.487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/20/2024] [Accepted: 03/24/2024] [Indexed: 04/15/2024]
Abstract
Metachromatic leukodystrophy (MLD) is a fatal, progressive neurodegenerative disorder caused by biallelic pathogenic mutations in the ARSA (Arylsulfatase A) gene. With the advent of presymptomatic diagnosis and the availability of therapies with a narrow window for intervention, it is critical to define a standardized approach to diagnosis, presymptomatic monitoring, and clinical care. To meet the needs of the MLD community, a panel of MLD experts was established to develop disease-specific guidelines based on healthcare resources in the United States. This group developed a consensus opinion for best-practice recommendations, as follows: (i) Diagnosis should include both genetic and biochemical testing; (ii) Early diagnosis and treatment for MLD is associated with improved clinical outcomes; (iii) The panel supported the development of newborn screening to accelerate the time to diagnosis and treatment; (iv) Clinical management of MLD should include specialists familiar with the disease who are able to follow patients longitudinally; (v) In early onset MLD, including late infantile and early juvenile subtypes, ex vivo gene therapy should be considered for presymptomatic patients where available; (vi) In late-onset MLD, including late juvenile and adult subtypes, hematopoietic cell transplant (HCT) should be considered for patients with no or minimal disease involvement. This document summarizes current guidance on the presymptomatic monitoring of children affected by MLD as well as the clinical management of symptomatic patients. Future data-driven evidence and evolution of these recommendations will be important to stratify clinical treatment options and improve clinical care.
Collapse
Affiliation(s)
- Laura A Adang
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | | | - Jaap Jan Boelens
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Eric Mallack
- Kennedy Krieger Institute, Baltimore, Maryland, USA
| | | | - John A Bernat
- University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Annette Bley
- University Children's Hospital, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Barbara Burton
- Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | | | | | - Lisa Emrick
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Maria Escolar
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Forge Biologics, Grove City, Ohio, USA
| | - Ali Fatemi
- Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Jamie L Fraser
- Children's National Hospital, Washington, District of Columbia, USA
| | - Amy Gaviglio
- Division of Laboratory Services, Newborn Screening and Molecular Biology Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA; Association of Public Health Laboratories, Silver Spring, Maryland, USA
| | | | - Marc C Patterson
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Clinical Genomics, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul Orchard
- University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Jonathan D Santoro
- University of Southern California, Children's Hospital Los Angeles, Keck School of Medicine, Los Angeles, California, USA
| | - Ludger Schöls
- Department of Neurology and Hertie-Institute for Clinical Brain Research German Center of Neurodegenerative Diseases (DZNE), Tübingen, Germany
| | | | - Isha N Srivastava
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Deepa Rajan
- University of Pittsburgh, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Keith Van Haren
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Melissa Wasserstein
- Department of Pediatrics, Albert Einstein College of Medicine and the Children's Hospital at Montefiore, Bronx, New York, USA
| | - Ayelet Zerem
- Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Lucia Laugwitz
- Department of Pediatric Neurology and Developmental Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Adeline Vanderver
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
3
|
Zhou J, Ding C, Dai L, Ren S. Basal nuclei lesions and cholecystitis as initial findings of late infantile metachromatic leukodystrophy. Clin Neurol Neurosurg 2022; 224:107543. [PMID: 36509016 DOI: 10.1016/j.clineuro.2022.107543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 11/27/2022]
Abstract
Metachromatic leukodystrophy (MLD) is an autosomal recessive lysosomal disease. MLD can be divided into three clinical forms: late infantile, juvenile, and adult, with late infantile being the most common. Infantile MLD with unusual onset has been reported. In the study, we reported a case of late infantile MLD with basal nuclei lesions and cholecystitis as the initial findings, which further broadens late infantile MLD onset and contributes to early clinical diagnosis.
Collapse
Affiliation(s)
- Ji Zhou
- Department of neurology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Changhong Ding
- Department of neurology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China.
| | - Lifang Dai
- Department of neurology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Shuhong Ren
- Department of neurology, Baoding Children's Hospital, China
| |
Collapse
|
4
|
Adang L. Leukodystrophies. Continuum (Minneap Minn) 2022; 28:1194-1216. [PMID: 35938662 PMCID: PMC11320896 DOI: 10.1212/con.0000000000001130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article reviews the most common leukodystrophies and is focused on diagnosis, clinical features, and emerging therapeutic options. RECENT FINDINGS In the past decade, the recognition of leukodystrophies has exponentially increased, and now this class includes more than 30 distinct disorders. Classically recognized as progressive and fatal disorders affecting young children, it is now understood that leukodystrophies are associated with an increasing spectrum of neurologic trajectories and can affect all ages. Next-generation sequencing and newborn screening allow the opportunity for the recognition of presymptomatic and atypical cases. These new testing opportunities, in combination with growing numbers of natural history studies and clinical consensus guidelines, have helped improve diagnosis and clinical care. Additionally, a more granular understanding of disease outcomes informs clinical trial design and has led to several recent therapeutic advances. This review summarizes the current understanding of the clinical manifestations of disease and treatment options for the most common leukodystrophies. SUMMARY As early testing becomes more readily available through next-generation sequencing and newborn screening, neurologists will better understand the true incidence of the leukodystrophies and be able to diagnose children within the therapeutic window. As targeted therapies are developed, it becomes increasingly imperative that this broad spectrum of disorders is recognized and diagnosed. This work summarizes key advances in the leukodystrophy field.
Collapse
|
5
|
Eroglu-Ertugrul NG, Yousefi M, Pekgül F, Doran T, Günbey C, Topcu M, Oguz KK, Ozkara HA, Vural A, Anlar B. Myelin oligodendrocyte glycoprotein antibodies in genetic leukodystrophies. J Neuroimmunol 2022; 369:577916. [PMID: 35752102 DOI: 10.1016/j.jneuroim.2022.577916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 05/25/2022] [Accepted: 06/07/2022] [Indexed: 10/18/2022]
Abstract
Accumulation of intermediate metabolites due to enzyme deficiencies and demyelination can provoke inflammation in genetic leukodystrophies. Thirty patients with genetic leukodystrophy and 48 healthy control sera were tested for anti-myelin oligodendrocyte glycoprotein (MOG) antibodies by fixed and/or live cell-based assays. MOG-IgG was detected in two late infantile metachromatic leukodystrophy (MLD) cases, both of which were also weakly positive for IgG1, and one with IgG3 as the dominant anti-MOG IgG subclass. MOG-IgG was borderline positive in a vanishing white matter (VWM) disease patient. These results suggest that inherited metabolic or degenerative processes can have an autoimmune component, possibly as an epiphenomenon.
Collapse
Affiliation(s)
| | - Mohammadreza Yousefi
- Research Center for Translational Medicine, Koç University School of Medicine, Istanbul, Turkey
| | - Faruk Pekgül
- Department of Medical Biochemistry, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Tansu Doran
- Research Center for Translational Medicine, Koç University School of Medicine, Istanbul, Turkey
| | - Ceren Günbey
- Department of Pediatric Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Meral Topcu
- Department of Pediatric Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Kader K Oguz
- Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Hatice Asuman Ozkara
- Department of Medical Biochemistry, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Atay Vural
- Research Center for Translational Medicine, Koç University School of Medicine, Istanbul, Turkey; Department of Neurology, Koç University School of Medicine, Istanbul, Turkey
| | - Banu Anlar
- Department of Pediatric Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
6
|
Motley W, Chaudry V, Lloyd TE. Treatment and Management of Hereditary Neuropathies. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00014-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
7
|
Shaimardanova AA, Chulpanova DS, Solovyeva VV, Mullagulova AI, Kitaeva KV, Allegrucci C, Rizvanov AA. Metachromatic Leukodystrophy: Diagnosis, Modeling, and Treatment Approaches. Front Med (Lausanne) 2020; 7:576221. [PMID: 33195324 PMCID: PMC7606900 DOI: 10.3389/fmed.2020.576221] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/18/2020] [Indexed: 12/31/2022] Open
Abstract
Metachromatic leukodystrophy is a lysosomal storage disease, which is characterized by damage of the myelin sheath that covers most of nerve fibers of the central and peripheral nervous systems. The disease occurs due to a deficiency of the lysosomal enzyme arylsulfatase A (ARSA) or its sphingolipid activator protein B (SapB) and it clinically manifests as progressive motor and cognitive deficiency. ARSA and SapB protein deficiency are caused by mutations in the ARSA and PSAP genes, respectively. The severity of clinical course in metachromatic leukodystrophy is determined by the residual ARSA activity, depending on the type of mutation. Currently, there is no effective treatment for this disease. Clinical cases of bone marrow or cord blood transplantation have been reported, however the therapeutic effectiveness of these methods remains insufficient to prevent aggravation of neurological disorders. Encouraging results have been obtained using gene therapy for delivering the wild-type ARSA gene using vectors based on various serotypes of adeno-associated viruses, as well as using mesenchymal stem cells and combined gene-cell therapy. This review discusses therapeutic strategies for the treatment of metachromatic leukodystrophy, as well as diagnostic methods and modeling of this pathology in animals to evaluate the effectiveness of new therapies.
Collapse
Affiliation(s)
- Alisa A Shaimardanova
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russia
| | - Daria S Chulpanova
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russia.,Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, The Russian Academy of Sciences, Moscow, Russia
| | - Valeriya V Solovyeva
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russia.,Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, The Russian Academy of Sciences, Moscow, Russia
| | - Aysilu I Mullagulova
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russia
| | - Kristina V Kitaeva
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russia
| | - Cinzia Allegrucci
- School of Veterinary Medicine and Science (SVMS) and Biodiscovery Institute, University of Nottingham, Nottingham, United Kingdom
| | - Albert A Rizvanov
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russia
| |
Collapse
|
8
|
Ashrafi MR, Amanat M, Garshasbi M, Kameli R, Nilipour Y, Heidari M, Rezaei Z, Tavasoli AR. An update on clinical, pathological, diagnostic, and therapeutic perspectives of childhood leukodystrophies. Expert Rev Neurother 2019; 20:65-84. [PMID: 31829048 DOI: 10.1080/14737175.2020.1699060] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Leukodystrophies constitute heterogenous group of rare heritable disorders primarily affecting the white matter of central nervous system. These conditions are often under-appreciated among physicians. The first clinical manifestations of leukodystrophies are often nonspecific and can occur in different ages from neonatal to late adulthood periods. The diagnosis is, therefore, challenging in most cases.Area covered: Herein, the authors discuss different aspects of leukodystrophies. The authors used MEDLINE, EMBASE, and GOOGLE SCHOLAR to provide an extensive update about epidemiology, classifications, pathology, clinical findings, diagnostic tools, and treatments of leukodystrophies. Comprehensive evaluation of clinical findings, brain magnetic resonance imaging, and genetic studies play the key roles in the early diagnosis of individuals with leukodystrophies. No cure is available for most heritable white matter disorders but symptomatic treatments can significantly decrease the burden of events. New genetic methods and stem cell transplantation are also under investigation to further increase the quality and duration of life in affected population.Expert opinion: The improvements in molecular diagnostic tools allow us to identify the meticulous underlying etiology of leukodystrophies and result in higher diagnostic rates, new classifications of leukodystrophies based on genetic information, and replacement of symptomatic managements with more specific targeted therapies.Abbreviations: 4H: Hypomyelination, hypogonadotropic hypogonadism and hypodontia; AAV: Adeno-associated virus; AD: autosomal dominant; AGS: Aicardi-Goutieres syndrome; ALSP: Axonal spheroids and pigmented glia; APGBD: Adult polyglucosan body disease; AR: autosomal recessive; ASO: Antisense oligonucleotide therapy; AxD: Alexander disease; BAEP: Brainstem auditory evoked potentials; CAA: Cerebral amyloid angiopathy; CADASIL: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy; CARASAL: Cathepsin A-related arteriopathy with strokes and leukoencephalopathy; CARASIL: Cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy; CGH: Comparative genomic hybridization; ClC2: Chloride Ion Channel 2; CMTX: Charcot-Marie-Tooth disease, X-linked; CMV: Cytomegalovirus; CNS: central nervous system; CRISP/Cas9: Clustered regularly interspaced short palindromic repeat/CRISPR-associated 9; gRNA: Guide RNA; CTX: Cerebrotendinous xanthomatosis; DNA: Deoxyribonucleic acid; DSB: Double strand breaks; DTI: Diffusion tensor imaging; FLAIR: Fluid attenuated inversion recovery; GAN: Giant axonal neuropathy; H-ABC: Hypomyelination with atrophy of basal ganglia and cerebellum; HBSL: Hypomyelination with brainstem and spinal cord involvement and leg spasticity; HCC: Hypomyelination with congenital cataracts; HEMS: Hypomyelination of early myelinated structures; HMG CoA: Hydroxy methylglutaryl CoA; HSCT: Hematopoietic stem cell transplant; iPSC: Induced pluripotent stem cells; KSS: Kearns-Sayre syndrome; L-2-HGA: L-2-hydroxy glutaric aciduria; LBSL: Leukoencephalopathy with brainstem and spinal cord involvement and elevated lactate; LCC: Leukoencephalopathy with calcifications and cysts; LTBL: Leukoencephalopathy with thalamus and brainstem involvement and high lactate; MELAS: Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke; MERRF: Myoclonic epilepsy with ragged red fibers; MLC: Megalencephalic leukoencephalopathy with subcortical cysts; MLD: metachromatic leukodystrophy; MRI: magnetic resonance imaging; NCL: Neuronal ceroid lipofuscinosis; NGS: Next generation sequencing; ODDD: Oculodentodigital dysplasia; PCWH: Peripheral demyelinating neuropathy-central-dysmyelinating leukodystrophy-Waardenburg syndrome-Hirschprung disease; PMD: Pelizaeus-Merzbacher disease; PMDL: Pelizaeus-Merzbacher-like disease; RNA: Ribonucleic acid; TW: T-weighted; VWM: Vanishing white matter; WES: whole exome sequencing; WGS: whole genome sequencing; X-ALD: X-linked adrenoleukodystrophy; XLD: X-linked dominant; XLR: X-linked recessive.
Collapse
Affiliation(s)
- Mahmoud Reza Ashrafi
- Myelin Disorders Clinic, Department of Pediatric Neurology, Children's Medical Center, Pediatrics Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Man Amanat
- Faculty of Medicine, Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Garshasbi
- Department of Medical Genetics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Reyhaneh Kameli
- Myelin Disorders Clinic, Department of Pediatric Neurology, Children's Medical Center, Pediatrics Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Yalda Nilipour
- Pediatric pathology research center, research institute for children's health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Morteza Heidari
- Myelin Disorders Clinic, Department of Pediatric Neurology, Children's Medical Center, Pediatrics Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Rezaei
- Myelin Disorders Clinic, Department of Pediatric Neurology, Children's Medical Center, Pediatrics Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Reza Tavasoli
- Myelin Disorders Clinic, Department of Pediatric Neurology, Children's Medical Center, Pediatrics Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
9
|
Abstract
The peripheral nervous system (PNS) is composed of motor neurons, nerve roots, plexuses, peripheral nerves (motor, sensory and autonomic), neuromuscular junction, and skeletal muscles. Disorders of the PNS in neonates most frequently cause weakness, hypotonia, and contractures, which may be generalized or focal. Since these findings may also occur with brain and spinal cord lesions, key features of the history and neurologic exam, together with diagnostic testing, are helpful in reaching a diagnosis. This review covers the diagnostic approach to PNS disorders in the neonate and includes a discussion of representative diseases of the motor neuron, brachial plexus, peripheral nerves, neuromuscular junction, and muscles. The importance of reaching a precise genetic diagnosis is highlighted with a discussion of current and emerging treatments for neonatal PNS diseases, particularly spinal muscular atrophy.
Collapse
Affiliation(s)
- Alex J Fay
- Department of Neurology, University of California, San Francisco, San Francisco, CA.
| |
Collapse
|
10
|
Beerepoot S, Nierkens S, Boelens JJ, Lindemans C, Bugiani M, Wolf NI. Peripheral neuropathy in metachromatic leukodystrophy: current status and future perspective. Orphanet J Rare Dis 2019; 14:240. [PMID: 31684987 PMCID: PMC6829806 DOI: 10.1186/s13023-019-1220-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 10/09/2019] [Indexed: 11/23/2022] Open
Abstract
Metachromatic leukodystrophy (MLD) is an autosomal recessively inherited metabolic disease characterized by deficient activity of the lysosomal enzyme arylsulfatase A. Its deficiency results in accumulation of sulfatides in neural and visceral tissues, and causes demyelination of the central and peripheral nervous system. This leads to a broad range of neurological symptoms and eventually premature death. In asymptomatic patients with juvenile and adult MLD, treatment with allogeneic hematopoietic stem cell transplantation (HCT) provides a symptomatic and survival benefit. However, this treatment mainly impacts brain white matter, whereas the peripheral neuropathy shows no or only limited response. Data about the impact of peripheral neuropathy in MLD patients are currently lacking, although in our experience peripheral neuropathy causes significant morbidity due to neuropathic pain, foot deformities and neurogenic bladder disturbances. Besides, the reasons for residual and often progressive peripheral neuropathy after HCT are not fully understood. Preliminary studies suggest that peripheral neuropathy might respond better to gene therapy due to higher enzyme levels achieved than with HCT. However, histopathological and clinical findings also suggest a role of neuroinflammation in the pathology of peripheral neuropathy in MLD. In this literature review, we discuss clinical aspects, pathological findings, distribution of mutations, and treatment approaches in MLD with particular emphasis on peripheral neuropathy. We believe that future therapies need more emphasis on the management of peripheral neuropathy, and additional research is needed to optimize care strategies.
Collapse
Affiliation(s)
- Shanice Beerepoot
- Department of Child Neurology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, and Amsterdam Neuroscience, De Boelelaan 1117, Amsterdam, the Netherlands.,Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Stefan Nierkens
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands.,Pediatric Blood and Marrow Transplantation Program, Princess Máxima Center and University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jaap Jan Boelens
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Pediatrics, Stem Cell Transplant and Cellular Therapies, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Caroline Lindemans
- Pediatric Blood and Marrow Transplantation Program, Princess Máxima Center and University Medical Center Utrecht, Utrecht, the Netherlands.,Regenerative medicine institute, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marianna Bugiani
- Department of Pathology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Neuroscience, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Nicole I Wolf
- Department of Child Neurology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, and Amsterdam Neuroscience, De Boelelaan 1117, Amsterdam, the Netherlands.
| |
Collapse
|
11
|
Raina A, Nair SS, Nagesh C, Thomas B, Nair M, Sundaram S. Electroneurography and Advanced Neuroimaging Profile in Pediatric-onset Metachromatic Leukodystrophy. J Pediatr Neurosci 2019; 14:70-75. [PMID: 31516623 PMCID: PMC6712919 DOI: 10.4103/jpn.jpn_155_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context Metachromatic leukodystrophy (MLD) is a rare autosomal-recessive disorder characterized by demyelination of central and peripheral nervous system. There is scarcity of literature on the electrophysiological aspects of peripheral nerves and the advanced neuroimaging findings in MLD. Aim The aim was to study the nerve conduction parameters and advanced neuroimaging findings in patients with MLD. Materials and Methods This study is a retrospective analysis conducted, between 2005 and 2016, of 12 patients who had biochemical, histopathological, or genetic confirmation of MLD and disease onset before 18 years of age. The clinical, electroneurography, and the advanced neuroimaging findings were reviewed and analyzed. Statistical Analysis The data were presented as percentages or mean ± standard deviation as defined appropriate for qualitative and quantitative variables. Results Mean age of onset was 4.84 (±4.60) years and seven patients were males. Eight patients had juvenile MLD and four had late infantile MLD. Clinical presentation of psychomotor regression was more common in infantile MLD (75%), whereas gait difficulty (62.5%) and cognitive impairment (37.5%) were more frequent in juvenile MLD. Nerve conduction study (NCS) revealed diffuse demyelinating sensorimotor peripheral neuropathy in 9 (75%) patients. One patient had a rare presentation with conduction blocks in multiple nerves with contrast enhancement of cauda equina. Diffusion restriction involving periventricular and central white matter was seen in five patients and bilateral globus pallidi blooming was noted in three patients. Conclusion This study highlights the utility of NCS and advanced magnetic resonance imaging sequences in the diagnosis of MLD.
Collapse
Affiliation(s)
- Abhinav Raina
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Sruthi S Nair
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Chinmay Nagesh
- Department of Imaging Sciences and Intervention Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Bejoy Thomas
- Department of Imaging Sciences and Intervention Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Muralidharan Nair
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Soumya Sundaram
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| |
Collapse
|
12
|
Silwal A, Pitt M, Phadke R, Mankad K, Davison JE, Rossor A, DeVile C, Reilly MM, Manzur AY, Muntoni F, Munot P. Clinical spectrum, treatment and outcome of children with suspected diagnosis of chronic inflammatory demyelinating polyradiculoneuropathy. Neuromuscul Disord 2018; 28:757-765. [PMID: 30072201 PMCID: PMC6509554 DOI: 10.1016/j.nmd.2018.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 05/23/2018] [Accepted: 06/04/2018] [Indexed: 11/18/2022]
Abstract
The diagnosis of CIDP can be challenging. In our cohort 52% were diagnosed as CIDP on re-evaluation. Cranial nerve abnormality is rare and may be only presenting symptom. Children require long-term follow up as the course may be protracted. With early treatment majority have good recovery and maintain ambulation.
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a treatable chronic disorder of the peripheral nervous system. We retrospectively studied 30 children with a suspected diagnosis of CIDP. The diagnosis of CIDP was compared against the childhood CIDP revised diagnostic criteria 2000. Of the 30 children, five did not meet the criteria and four others met the criteria but subsequently had alternative diagnosis, leaving a total of 21 children (12 male) with CIDP as the final diagnosis. Thirteen children presented with chronic symptom-onset (>8 weeks). The majority presented with gait difficulties or pain in legs (n = 16). 12 children (57%) met the neurophysiological criteria and 18/19 (94%) met the cerebrospinal fluid criteria. Nerve biopsy was suggestive in 3/9 (33%), with magnetic resonance imaging supportive in 9/20 (45%). Twenty-one children received immuno-modulatory treatment at first presentation, of which majority (n = 19, 90%) received IVIG (immunoglobulin) monotherapy with 13 (68%) showing a good response. 8 children received second line treatment with either IVIG or steroids or plasmapharesis (PE) and 4 needed other immune-modulatory agents. During a median follow-up of 3.6 years, 9 (43%) had a monophasic course and 12 (57%) had a relapsing–remitting course. At last paediatric follow up 7 (33%) were off all treatment, 9 (43%) left with no or minimal residual disability and 6 (28%) children were walking with assistance (n = 3) or were non-ambulant (n = 3). Our review highlights challenges in the diagnosis and management of paediatric CIDP. It also confirms that certain metabolic disorders may mimic CIDP.
Collapse
Affiliation(s)
- A Silwal
- The Dubowitz Neuromuscular Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford St, London, and MRC Centre for Neuromuscular Diseases & Neuroscience Unit, Great Ormond Street Hospital, London, UK.
| | - M Pitt
- The Dubowitz Neuromuscular Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford St, London, and MRC Centre for Neuromuscular Diseases & Neuroscience Unit, Great Ormond Street Hospital, London, UK
| | - R Phadke
- The Dubowitz Neuromuscular Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford St, London, and MRC Centre for Neuromuscular Diseases & Neuroscience Unit, Great Ormond Street Hospital, London, UK
| | - K Mankad
- Neuroradiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - J E Davison
- Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - A Rossor
- MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - C DeVile
- The Dubowitz Neuromuscular Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford St, London, and MRC Centre for Neuromuscular Diseases & Neuroscience Unit, Great Ormond Street Hospital, London, UK
| | - M M Reilly
- MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - A Y Manzur
- The Dubowitz Neuromuscular Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford St, London, and MRC Centre for Neuromuscular Diseases & Neuroscience Unit, Great Ormond Street Hospital, London, UK
| | - F Muntoni
- The Dubowitz Neuromuscular Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford St, London, and MRC Centre for Neuromuscular Diseases & Neuroscience Unit, Great Ormond Street Hospital, London, UK
| | - P Munot
- The Dubowitz Neuromuscular Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford St, London, and MRC Centre for Neuromuscular Diseases & Neuroscience Unit, Great Ormond Street Hospital, London, UK
| |
Collapse
|
13
|
Gonorazky HD, Amburgey K, Yoon G, Vajsar J, Widjaja E, Dowling JJ. Subacute demyelinating peripheral neuropathy as a novel presentation of late infantile metachromatic leukodystrophy. Muscle Nerve 2017; 56:E41-E44. [PMID: 28667691 DOI: 10.1002/mus.25737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/13/2017] [Accepted: 06/25/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Hernan D Gonorazky
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kimberly Amburgey
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Grace Yoon
- Division of Genetics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jiri Vajsar
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elysa Widjaja
- Division of Radiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - James J Dowling
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| |
Collapse
|
14
|
Grimm A, Schäffer E, Just J, Schöls L, Kehrer C, Bevot A, Ziemann U, Krageloh-Mann I. Thickening of the peripheral nerves in metachromatic leukodystrophy. J Neurol Sci 2016; 368:399-401. [PMID: 27538671 DOI: 10.1016/j.jns.2016.07.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/10/2016] [Accepted: 07/12/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Alexander Grimm
- Center of Neurology, Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany.
| | - Eva Schäffer
- Center of Neurology, Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Jennifer Just
- Center of Neurology, Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Ludger Schöls
- Center of Neurology, Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Christiane Kehrer
- Department of Pediatric Neurology, University Medical Center Tübingen, Tübingen, Germany
| | - Andrea Bevot
- Department of Pediatric Neurology, University Medical Center Tübingen, Tübingen, Germany
| | - Ulf Ziemann
- Center of Neurology, Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Ingeborg Krageloh-Mann
- Department of Pediatric Neurology, University Medical Center Tübingen, Tübingen, Germany
| |
Collapse
|
15
|
Wang Z, Lin Y, Zheng D, Yan A, Tu X, Lin J, Lan F. Whole-exome sequencing identifies compound heterozygous mutations in ARSA of two siblings presented with atypical onset of metachromatic leukodystrophy from a Chinese pedigree. Clin Chim Acta 2016; 460:135-7. [PMID: 27374302 DOI: 10.1016/j.cca.2016.06.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/26/2016] [Accepted: 06/29/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Metachromatic leukodystrophy (MLD) is a rare inherited lysosomal storage disorder caused mainly by variants in arylsulfatase A (ARSA) gene. MLD can be divided into three major clinical forms according to the age of onset: late infantile, juvenile, and adult. We report two siblings of late infantile MLD presenting with cerebellar ataxia as the only first clinical symptom. METHODS Because of the unspecific neurological manifestation, whole-exome sequencing (WES) was performed to find disease-causing mutations for molecular diagnosis. Then successive MRI and ARSA activity determination were performed to further confirm the diagnosis. Moreover, the prenatal diagnosis was carried out on the basis of molecular diagnosis. RESULTS The siblings exhibited compound heterozygous variants {[c.302G>T]+[c.1344dupC]} in the ARSA gene, and both of the variants have been reported as disease-causing mutations previously. The results of MRI and low ARSA activity confirmed the diagnosis of MLD. Prenatal diagnosis showed that the fetus was a heterozygous carrier. CONCLUSIONS It is recommended that WES be considered as a first line diagnostic procedure to discover potential disease-causing genetic variants in affected individuals with hereditary traits but without definite clinical diagnosis. However, the final diagnosis should be confirmed by comprehensive evaluations including biochemical, enzymatic or imaging investigations.
Collapse
Affiliation(s)
- Zhihong Wang
- Research Center for Molecular Diagnosis of Genetic Diseases, Dongfang Hospital, Xiamen University Medical College, Fuzhou, China
| | - Yanhong Lin
- Research Center for Molecular Diagnosis of Genetic Diseases, Dongfang Hospital, Xiamen University Medical College, Fuzhou, China
| | - Dezhu Zheng
- Research Center for Molecular Diagnosis of Genetic Diseases, Dongfang Hospital, Xiamen University Medical College, Fuzhou, China
| | - Aizhen Yan
- Research Center for Molecular Diagnosis of Genetic Diseases, Dongfang Hospital, Xiamen University Medical College, Fuzhou, China
| | - Xiangdong Tu
- Research Center for Molecular Diagnosis of Genetic Diseases, Dongfang Hospital, Xiamen University Medical College, Fuzhou, China
| | - Juan Lin
- Research Center for Molecular Diagnosis of Genetic Diseases, Dongfang Hospital, Xiamen University Medical College, Fuzhou, China
| | - Fenghua Lan
- Research Center for Molecular Diagnosis of Genetic Diseases, Dongfang Hospital, Xiamen University Medical College, Fuzhou, China.
| |
Collapse
|
16
|
Hwang M, Zuccoli G, Panigrahy A, Rodriguez D, Poe MD, Escolar ML. Thickening of the cauda equina roots: a common finding in Krabbe disease. Eur Radiol 2016; 26:3377-82. [DOI: 10.1007/s00330-016-4233-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 01/12/2016] [Accepted: 01/20/2016] [Indexed: 11/29/2022]
|
17
|
Leukodystrophy presenting as acute-onset polyradiculoneuropathy. Pediatr Neurol 2014; 50:616-8. [PMID: 24685010 DOI: 10.1016/j.pediatrneurol.2014.01.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Revised: 01/04/2014] [Accepted: 01/08/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Sulfatides, the most abundant glycosphingolipids, are a major component of myelin. They are degraded by the combined action of sphingolipid activator protein and arylsulfatase A. Deficiency of either of these entities causes metachromatic leukodystrophy (MLD). On the basis of age of onset, this entity is divided into late infantile, juvenile, and adult subtypes. Late infantile form, the commonest subtype, can exhibit peripheral neuropathy as the initial manifestation. The other two forms usually manifest peripheral neuropathy later in the disease course. PATIENT A 1.5-year-old girl with preexisting isolated motor delay presented with acute-onset ascending flaccid quadriparesis, ptosis, and respiratory failure. Ptosis and respiratory failure responded completely to intravenous immunoglobulin, whereas quadriparesis showed minimal improvement. Nerve biopsy revealed metachromatic granules with demyelination, and serum arylsulfatase A levels were undetectable. CONCLUSION The severity and nature of the disease coupled with the response to immunotherapy makes this case unusual. This child may represent either an atypical presentation of MLD with coincidental response to immunotherapy or an episode of immune mediated neuropathy in an individual with already diseased nerves due to MLD.
Collapse
|
18
|
Lugowska A, Mierzewska H, Bekiesińska-Figatowska M, Szczepanik E, Goszczańska-Ciuchta A, Bednarska-Makaruk M. A homozygote for the c.459+1G>A mutation in the ARSA gene presents with cerebellar ataxia as the only first clinical sign of metachromatic leukodystrophy. J Neurol Sci 2013; 338:214-7. [PMID: 24411407 DOI: 10.1016/j.jns.2013.12.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 12/03/2013] [Accepted: 12/19/2013] [Indexed: 11/30/2022]
Abstract
Metachromatic leukodystrophy (MLD) is a rare lysosomal disorder caused by deficient activity of arylsulfatase A or the lack of saposin B, which results in the accumulation of sulfatide in the oligodendrocytes and in the Schwann cells. Three main clinical types of MLD can be distinguished according to the age of onset and the dynamics of clinical outcome: late infantile, juvenile, and adult. We report on a case of late infantile MLD presenting with cerebellar ataxia as the only first clinical sign preceding even changes in white matter visible in MR imaging. The diagnosis was made on the basis of successive MRI, characteristic of demyelination, which developed in the course of the disease, and on the results of the following biochemical and molecular analyses. Very low residual activity of arylsulfatase A was demonstrated in blood leukocytes and the patient was a homozygote for a common mutation c.459+1G>A in the ARSA gene. Since cerebellar ataxia is a relatively common but unspecific neurological symptom in toddlers, it is recommended that MLD be considered as part of the differential diagnosis even if the initial neuroimaging studies are normal and ataxia is the only clinical symptom of the disease.
Collapse
Affiliation(s)
- Agnieszka Lugowska
- Institute of Psychiatry and Neurology, Department of Genetics, Warsaw, Poland.
| | - Hanna Mierzewska
- Institute of Mother and Child, Clinic of Neurology of Child and Adolescents, Warsaw, Poland
| | | | - Elżbieta Szczepanik
- Institute of Mother and Child, Clinic of Neurology of Child and Adolescents, Warsaw, Poland
| | | | | |
Collapse
|
19
|
Abstract
Hereditary neuropathies (HN) with onset in childhood are categorized according to clinical presentation, pathogenic mechanism based on electrophysiology, genetic transmission and, in selected cases, pathological findings. Especially relevant to pediatrics are the items "secondary" versus "primary" neuropathy, "syndromic versus nonsyndromic," and "period of life." Different combinations of these parameters frequently point toward specific monogenic disorders. Ruling out a neuropathy secondary to a generalized metabolic disorder remains the first concern in pediatrics. As a rule, metabolic diseases include additional, orienting symptoms or signs, and their biochemical diagnosis is based on logical algorithms. Primary, motor sensory are the most frequent HN and are dominated by demyelinating autosomal dominant (AD) forms (CMT1). Other forms include demyelinating autosomal recessive (AR) forms, axonal AD/AR forms, and forms with "intermediate" electrophysiological phenotype. Peripheral motor neuron disorders are dominated by AR SMN-linked spinal muscular atrophies. (Distal) hereditary motor neuropathies represent <10% of HN but exhibit large clinical and genetic heterogeneity. Sensory/dysautonomic HN involves five classic subtypes, each one related to specific genes. However, genetic heterogeneity is larger than initially suspected. Syndromic HN distinguish "purely neurological syndromes", which are multisystemic, such as spinocerebellar atrophies +, spastic paraplegias +, etc. Peripheral neuropathy is possibly the presenting feature, including in childhood. Autosomal recessive forms, on average, start more frequently in childhood. "Multiorgan syndromes", on the other hand, are more specific to Pediatrics. AR forms, which are clearly degenerative, prompt the investigation of a large set of pleiotropic genes. Other syndromes expressed in the perinatal period are mainly developmental disorders, and can sometimes be related to specific transcription factors. Systematic malformative workup and ethical considerations are necessary. Altogether, >40 genes with various biological functions have been found to be responsible for primary HN. Many are responsible for various phenotypes, including some without the polyneuropathic trait, and some for various types of transmission.
Collapse
Affiliation(s)
- Pierre Landrieu
- Department of Pediatric Neurology, CHU Paris sud, Hôpital Bicêtre, Paris, France.
| | | |
Collapse
|
20
|
Abstract
The prenatal and infantile neuropathies are an uncommon and complex group of conditions, most of which are genetic. Despite advances in diagnostic techniques, approximately half of children presenting in infancy remain without a specific diagnosis. This review focuses on inherited demyelinating neuropathies presenting in the first year of life. We clarify the nomenclature used in these disorders, review the clinical features of demyelinating forms of Charcot-Marie-Tooth disease with early onset, and discuss the demyelinating infantile neuropathies associated with central nervous system involvement. Useful clinical, neurophysiologic, and neuropathologic features in the diagnostic work-up of these conditions are also presented.
Collapse
Affiliation(s)
- Eppie M Yiu
- Children's Neuroscience Centre, Royal Children's Hospital, Flemington Road, Parkville, Victoria, Australia
| | | |
Collapse
|
21
|
Eichler F, Grodd W, Grant E, Sessa M, Biffi A, Bley A, Kohlschuetter A, Loes DJ, Kraegeloh-Mann I. Metachromatic leukodystrophy: a scoring system for brain MR imaging observations. AJNR Am J Neuroradiol 2009; 30:1893-7. [PMID: 19797797 DOI: 10.3174/ajnr.a1739] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Metachromatic leukodystrophy (MLD) is a devastating demyelinating disease for which novel therapies are being tested. We hypothesized that MR imaging of brain lesion involvement in MLD could be quantified along a scale. MATERIALS AND METHODS Thirty-four brain MR images in 28 patients with proved biochemical and genetic defects for MLD were reviewed: 10 patients with late infantile, 16 patients with juvenile, and 2 patients with adult MLD. All MR images were reviewed by experienced neuroradiologists and neurologists (2 readers in Germany, 2 readers in the United States) for global disease burden, as seen on the T2 and fluid-attenuated inversion recovery images. A visual scoring method was based on a point system (range, 0-34) derived from the location of white matter involvement and the presence of global atrophy, analogous to the scoring system developed for adrenoleukodystrophy. The readers were blinded to the neurologic findings. RESULTS Thirty-three of 34 MR images showed confluent T2 hyperintensities of white matter. The inter-rater reliability coefficient was 0.988. Scores between readers were within 2 points of each other. Serial MR imaging studies in 6 patients showed significant progressive disease in 3 patients (initial score average, 4; mean follow-up, 24.3) and no change or 1 point progression in 3 patients (initial score average, 12; mean follow-up, 12.66). Projection fibers and the cerebellum tended to be involved only in advanced stages of disease. CONCLUSIONS The MLD MR severity scoring method can be used to provide a measure of brain MR imaging involvement in MLD patients.
Collapse
Affiliation(s)
- F Eichler
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|