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Akula SK, Quiroz V, D'Gama AM, Chiu MY, Koh HY, Saffari A, Zaman Z, Tam A, Srouji R, Valentine R, Wiltrout K, Pinto A, Harini C, Pearl PL, Poduri A, Ebrahimi‐Fakhari D. The spectrum of movement disorders in young children with ARX-related epilepsy-dyskinesia syndrome. Ann Clin Transl Neurol 2024; 11:1643-1647. [PMID: 38711225 PMCID: PMC11187834 DOI: 10.1002/acn3.52055] [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] [Received: 01/03/2024] [Revised: 03/06/2024] [Accepted: 03/18/2024] [Indexed: 05/08/2024] Open
Abstract
Children with developmental and epileptic encephalopathies often present with co-occurring dyskinesias. Pathogenic variants in ARX cause a pleomorphic syndrome that includes infantile epilepsy with a variety of movement disorders ranging from focal hand dystonia to generalized dystonia with frequent status dystonicus. In this report, we present three patients with severe movement disorders as part of ARX-associated epilepsy-dyskinesia syndrome, including a patient with a novel pathogenic missense variant (p.R371G). These cases illustrate diagnostic and management challenges of ARX-related disorder and shed light on broader challenges concerning epilepsy-dyskinesia syndromes.
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Affiliation(s)
- Shyam K. Akula
- Movement Disorders Program, Department of Neurology, Boston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Division of Genetics and Genomics, Boston Children's HospitalHarvard Medical SchoolBostonMassachusetts02115USA
| | - Vicente Quiroz
- Movement Disorders Program, Department of Neurology, Boston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Alissa M. D'Gama
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Michelle Y. Chiu
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Hyun Yong Koh
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Afshin Saffari
- Movement Disorders Program, Department of Neurology, Boston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Division of Child Neurology and Inherited Metabolic DiseasesHeidelberg University HospitalHeidelbergGermany
| | - Zainab Zaman
- Movement Disorders Program, Department of Neurology, Boston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Amy Tam
- Movement Disorders Program, Department of Neurology, Boston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Rasha Srouji
- Movement Disorders Program, Department of Neurology, Boston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Rozalia Valentine
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Kimberly Wiltrout
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Anna Pinto
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Chellamani Harini
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Phillip L. Pearl
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Annapurna Poduri
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Darius Ebrahimi‐Fakhari
- Movement Disorders Program, Department of Neurology, Boston Children's HospitalHarvard Medical SchoolBostonMassachusettsUSA
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Vogt LM, Yang K, Tse G, Quiroz V, Zaman Z, Wang L, Srouji R, Tam A, Estrella E, Manzi S, Fasano A, Northam WT, Stone S, Moharir M, Gonorazky H, McAlvin B, Kleinman M, LaRovere KL, Gorodetsky C, Ebrahimi-Fakhari D. Recommendations for the Management of Initial and Refractory Pediatric Status Dystonicus. Mov Disord 2024. [PMID: 38619077 DOI: 10.1002/mds.29794] [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: 11/03/2023] [Revised: 03/07/2024] [Accepted: 03/11/2024] [Indexed: 04/16/2024] Open
Abstract
Status dystonicus is the most severe form of dystonia with life-threatening complications if not treated promptly. We present consensus recommendations for the initial management of acutely worsening dystonia (including pre-status dystonicus and status dystonicus), as well as refractory status dystonicus in children. This guideline provides a stepwise approach to assessment, triage, interdisciplinary treatment, and monitoring of status dystonicus. The clinical pathways aim to: (1) facilitate timely recognition/triage of worsening dystonia, (2) standardize supportive and dystonia-directed therapies, (3) provide structure for interdisciplinary cooperation, (4) integrate advances in genomics and neuromodulation, (5) enable multicenter quality improvement and research, and (6) improve outcomes. © 2024 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Lindsey M Vogt
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kathryn Yang
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Movement Disorders Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriel Tse
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Vicente Quiroz
- Movement Disorders Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Zainab Zaman
- Movement Disorders Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura Wang
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rasha Srouji
- Movement Disorders Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amy Tam
- Movement Disorders Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elicia Estrella
- Movement Disorders Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shannon Manzi
- Department of Pharmacy, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Krembil Brain Institute, University of Toronto, Toronto, Ontario, Canada
| | - Weston T Northam
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Scellig Stone
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mahendranath Moharir
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hernan Gonorazky
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brian McAlvin
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Monica Kleinman
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kerri L LaRovere
- Neurocritical Care Consult Service, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Carolina Gorodetsky
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Darius Ebrahimi-Fakhari
- Movement Disorders Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Neurocritical Care Consult Service, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Rodgers J, Calvert S, Shoubridge C, McGaughran J. A novel ARX loss of function variant in female monozygotic twins is associated with chorea. Eur J Med Genet 2021; 64:104315. [PMID: 34419634 DOI: 10.1016/j.ejmg.2021.104315] [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: 11/07/2020] [Revised: 06/29/2021] [Accepted: 08/18/2021] [Indexed: 10/20/2022]
Abstract
Pathogenic variants in ARX lead to a variety of phenotypes with intellectual disability being a uniform feature. Other features can include severe epilepsy, spasticity, movement disorders, agenesis of the corpus callosum, lissencephaly, hydranencephaly and ambiguous genitalia in males. We present the first report of monozygotic female twins with a de novo ARX pathogenic variant (c.1406_1415del; p. Ala469Aspfs*20), predicted to result in a truncated ARX protein missing the important regulatory Aristaless domain. The twins presented with profound developmental delay and seizures, consistent with the known genotype-phenotype correlation. Twin 2's features were significantly more severe. She also developed chorea; the first time this movement disorder has been seen in an ARX variant other than an expansion of the first polyalanine tract. Differential X-chromosome inactivation was the most likely explanation for the differing severities but could not be conclusively proven.
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Affiliation(s)
- Jonathan Rodgers
- Genetic Health Queensland, Royal Brisbane and Women's Hospital, QLD, Australia; School of Medicine, The University of Queensland, Brisbane, QLD, Australia.
| | - Sophie Calvert
- Department of Neurosciences, Queensland Children's Hospital, Brisbane, QLD, Australia; School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Cheryl Shoubridge
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia; Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Julie McGaughran
- Genetic Health Queensland, Royal Brisbane and Women's Hospital, QLD, Australia; School of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Scalia B, Venti V, Ciccia LM, Criscione R, Lo Bianco M, Sciuto L, Falsaperla R, Zanghì A, Praticò AD. Aristaless-Related Homeobox (ARX): Epilepsy Phenotypes beyond Lissencephaly and Brain Malformations. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1727140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractThe Aristaless-related homeobox (ARX) transcription factor is involved in the development of GABAergic and cholinergic neurons in the forebrain. ARX mutations have been associated with a wide spectrum of neurodevelopmental disorders in humans and are responsible for both malformation (in particular lissencephaly) and nonmalformation complex phenotypes. The epilepsy phenotypes related to ARX mutations are West syndrome and X-linked infantile spasms, X-linked myoclonic epilepsy with spasticity and intellectual development and Ohtahara and early infantile epileptic encephalopathy syndrome, which are related in most of the cases to intellectual disability and are often drug resistant. In this article, we shortly reviewed current knowledge of the function of ARX with a particular attention on its consequences in the development of epilepsy during early childhood.
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Affiliation(s)
- Bruna Scalia
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Valeria Venti
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Lina M. Ciccia
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Roberta Criscione
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Manuela Lo Bianco
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Laura Sciuto
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Raffaele Falsaperla
- Unit of Pediatrics and Pediatric Emergency, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
- Neonatal Intensive Care unit and Neonatology, University Hospital “Policlinico Rodolico-San Marco,” Catania, Italy
| | - Antonio Zanghì
- Department of Medical and Surgical Sciences and Advanced Technology “G.F. Ingrassia,” University of Catania, Catania, Italy
| | - Andrea D. Praticò
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Catania, Italy
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