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Bukhari-Parlakturk N, Frucht SJ. Isolated and combined dystonias: Update. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:425-442. [PMID: 37620082 DOI: 10.1016/b978-0-323-98817-9.00005-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Dystonia is a hyperkinetic movement disorder with a unique motor phenomenology that can manifest as an isolated clinical syndrome or combined with other neurological features. This chapter reviews the characteristic features of dystonia phenomenology and the syndromic approach to evaluating the disorders that may allow us to differentiate the isolated and combined syndromes. We also present the most common types of isolated and combined dystonia syndromes. Since accelerated gene discoveries have increased our understanding of the molecular mechanisms of dystonia pathogenesis, we also present isolated and combined dystonia syndromes by shared biological pathways. Examples of these converging mechanisms of the isolated and combined dystonia syndromes include (1) disruption of the integrated response pathway through eukaryotic initiation factor 2 alpha signaling, (2) disease of dopaminergic signaling, (3) alterations in the cerebello-thalamic pathway, and (4) disease of protein mislocalization and stability. The discoveries that isolated and combined dystonia syndromes converge in shared biological pathways will aid in the development of clinical trials and therapeutic strategies targeting these convergent molecular pathways.
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Affiliation(s)
- Noreen Bukhari-Parlakturk
- Department of Neurology, Movement Disorders Division, Duke University (NBP), Durham, NC, United States.
| | - Steven J Frucht
- Department of Neurology, NYU Grossman School of Medicine (SJF), New York, NY, United States
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Lourenço CM, Dovidio J, Lopes IF, Silva LC, Almeida M, Vagnini L, Fonseca J, Carneiro ZA, Thöny B. Sapropterin dihydrochloride therapy in dihydropteridine reductase deficiency: Insight from the first case with molecular diagnosis in Brazil. JIMD Rep 2021; 61:19-24. [PMID: 34485013 PMCID: PMC8411105 DOI: 10.1002/jmd2.12224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 04/03/2021] [Accepted: 04/19/2021] [Indexed: 11/08/2022] Open
Abstract
Tetrahydrobiopterin (BH4) is a cofactor that participates in the biogenesis reactions of a variety of biomolecules, including l-tyrosine, l-3,4-dihydroxyphenylalanine, 5-hydroxytryptophan, nitric oxide, and glycerol. Dihydropteridine reductase (DHPR, EC 1.5.1.34) is an enzyme involved in the BH4 regeneration. DHPR deficiency (DHPRD) is an autosomal recessive disorder, leading to severe and progressive neurological manifestations, which cannot be exclusively controlled by l-phenylalanine (l-Phe) restricted diet. In fact, the supplementation of neurotransmitter precursors is more decisive in the disease management, and the administration of sapropterin dihydrochloride may also provide positive effects. From the best of our knowledge, there is limited information regarding DHPRD in the past 5 years in the literature. Here, we describe the medical journey of the first patient to have DHPRD confirmed by molecular diagnostic methods in Brazil. The patient presented with two pathogenic variants of the quinoid dihydropteridine reductase (QDPR) gene-which codes for the DHPR protein, one containing the in trans missense mutation c.515C>T (pPro172Leu) in exon 5 and the other containing the same type of mutation in the exon 7 (c.635T>C [p.Phe212Ser]). The authors discuss their experience with sapropterin dihydrochloride for the treatment of DHPRD in this case report.
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Affiliation(s)
| | - Janaina Dovidio
- Centro Universitário Estácio de Ribeirão PretoSão PauloBrazil
| | | | - Laís C. Silva
- Centro Universitário Estácio de Ribeirão PretoSão PauloBrazil
| | - Marcela Almeida
- Centro Universitário Estácio de Ribeirão PretoSão PauloBrazil
| | - Laura Vagnini
- Centro Paulista de Diagnóstico e Pesquisa em Genética ClínicaSão PauloBrazil
| | | | | | - Beat Thöny
- Division of MetabolismUniversity Children's HospitalZürichSwitzerland
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Smit M, Bartels AL, van Faassen M, Kuiper A, Niezen-Koning KE, Kema IP, Dierckx RA, de Koning TJ, Tijssen MA. Serotonergic perturbations in dystonia disorders-a systematic review. Neurosci Biobehav Rev 2016; 65:264-75. [PMID: 27073048 DOI: 10.1016/j.neubiorev.2016.03.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/02/2016] [Accepted: 03/22/2016] [Indexed: 11/26/2022]
Abstract
Dystonia is a hyperkinetic movement disorder characterized by sustained or intermittent muscle contractions. Emerging data describe high prevalences of non-motor symptoms, including psychiatric co-morbidity, as part of the phenotype of dystonia. Basal ganglia serotonin and serotonin-dopamine interactions gain attention, as imbalances are known to be involved in extrapyramidal movement and psychiatric disorders. We systematically reviewed the literature for human and animal studies relating to serotonin and its role in dystonia. An association between dystonia and the serotonergic system was reported with decreased levels of 5-hydroxyindolacetic acid, the main metabolite of serotonin. A relation between dystonia and drugs affecting the serotonergic system was described in 89 cases in 49 papers. Psychiatric co-morbidity was frequently described, but likely underestimated as it was not systematically examined. Currently, there are no good (pharmaco)therapeutic options for most forms of dystonia or associated non-motor symptoms. Further research using selective serotonergic drugs in appropriate models of dystonia is required to establish the role of the serotonergic system in dystonia and to guide us to new therapeutic strategies.
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Affiliation(s)
- M Smit
- University of Groningen, University Medical Center Groningen, Department of Neurology, PO Box 30.001, 9700, RB Groningen, The Netherlands.
| | - A L Bartels
- University of Groningen, University Medical Center Groningen, Department of Neurology, PO Box 30.001, 9700, RB Groningen, The Netherlands; Ommelander Hospital Group, Department of Neurology, PO Box 30.000, 9930 RA Delfzijl, The Netherlands.
| | - M van Faassen
- University of Groningen, University Medical Center Groningen, Department of Laboratory Medicine, PO Box 30.001, 9700, RB Groningen, The Netherlands.
| | - A Kuiper
- University of Groningen, University Medical Center Groningen, Department of Neurology, PO Box 30.001, 9700, RB Groningen, The Netherlands.
| | - K E Niezen-Koning
- University of Groningen, University Medical Center Groningen, Department of Laboratory Medicine, PO Box 30.001, 9700, RB Groningen, The Netherlands.
| | - I P Kema
- University of Groningen, University Medical Center Groningen, Department of Laboratory Medicine, PO Box 30.001, 9700, RB Groningen, The Netherlands.
| | - R A Dierckx
- University of Groningen, University Medical Center Groningen, Department of Nuclear Medicine and Molecular Imaging, PO Box 30.001, 9700 RB Groningen, The Netherlands.
| | - T J de Koning
- University of Groningen, University Medical Center Groningen, Department of Genetics, PO Box 30.001, 9700 RB Groningen, The Netherlands.
| | - M A Tijssen
- University of Groningen, University Medical Center Groningen, Department of Neurology, PO Box 30.001, 9700, RB Groningen, The Netherlands.
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Ponzone A, Spada M, Ferraris S, Dianzani I, de Sanctis L. Dihydropteridine reductase deficiency in man: from biology to treatment. Med Res Rev 2004; 24:127-50. [PMID: 14705166 DOI: 10.1002/med.10055] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In 1975, dihydropteridine reductase (DHPR) deficiency was first recognized as a cause of tetrahydrobiopterin (BH(4)) deficiency, leading to hyperphenylalaninemia (HPA) and impaired biogenic amine deficiency. So far, more than 150 patients scattered worldwide have been reported and major progresses have been made in the understanding of physiopathology, screening, diagnosis, treatment, and molecular genetics of this inherited disease. Present knowledge on different aspects of DHPR deficiency, largely derived from authors' personal experience, is traced in this article.
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Zorzi G, Redweik U, Trippe H, Penzien JM, Thöny B, Blau N. Detection of sepiapterin in CSF of patients with sepiapterin reductase deficiency. Mol Genet Metab 2002; 75:174-7. [PMID: 11855937 DOI: 10.1006/mgme.2001.3273] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Sepiapterin reductase (SR) deficiency was recently described in patients with a severe biogenic amine deficiency presenting without hyperphenylalaninemia and it was suggested that the tetrahydrobiopterin (BH(4)) pathway may be different in different cells and tissues. We now developed a HPLC method for the measurement of yellow fluorescing sepiapterin for the rapid diagnosis of SR deficiency. Sepiapterin was elevated in CSF from two patients with SR deficiency (5.6 and 11.4 nmol/L) when compared with healthy controls (<0.5 nmol/L). Our data further support the hypothesis that sepiapterin is an intermediate in the salvage pathway of BH(4) and that it accumulates in the brain of patients with SR deficiency.
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Affiliation(s)
- Giovanna Zorzi
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital, Steinwiesstrasse 75, 8032 Zurich, Switzerland
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Blau N, Bonafé L, Thöny B. Tetrahydrobiopterin deficiencies without hyperphenylalaninemia: diagnosis and genetics of dopa-responsive dystonia and sepiapterin reductase deficiency. Mol Genet Metab 2001; 74:172-85. [PMID: 11592814 DOI: 10.1006/mgme.2001.3213] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
DOPA responsive dystonia (DRD) and sepiapterin reductase (SR) deficiency are inherited disorders of tetrahydrobiopterin (BH4) metabolism characterized by the signs and symptoms related to monoamine neurotransmitter deficiency. In contrast to classical forms of BH4 deficiency DRD and SR deficiency present without hyperphenylalaninemia and thus cannot be detected by the neonatal screening for phenylketonuria (PKU). While DRD is mostly caused by autosomal dominant mutations in the GTP cyclohydrolase I gene (GCH1), SR deficiency is an autosomal recessive disease. The most important biochemical investigations for the diagnosis of these neurological diseases includes CSF investigations for neurotransmitter metabolites and pterins as well as neopterin and biopterin production in cytokine-stimulated fibroblasts. Discovery of SR deficiency opened new insights into alternative pathways of the cofactor BH4 via carbonyl, aldose, and dihydrofolate reductases. As a consequence of the low dihydrofolate reductase activity in the brain, dihydrobiopterin intermediate accumulates and inhibits tyrosine and tryptophan hydroxylases and uncouples nitric oxide synthase (nNOS), leading to neurotransmitter deficiency and possibly also to neuronal cell death.
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Affiliation(s)
- N Blau
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital, Steinwiesstrasse 75, Zurich, 8032, Switzerland.
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Bonafé L, Thöny B, Penzien JM, Czarnecki B, Blau N. Mutations in the sepiapterin reductase gene cause a novel tetrahydrobiopterin-dependent monoamine-neurotransmitter deficiency without hyperphenylalaninemia. Am J Hum Genet 2001; 69:269-77. [PMID: 11443547 PMCID: PMC1235302 DOI: 10.1086/321970] [Citation(s) in RCA: 151] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2001] [Accepted: 05/31/2001] [Indexed: 11/03/2022] Open
Abstract
Classic tetrahydrobiopterin (BH(4)) deficiencies are characterized by hyperphenylalaninemia and deficiency of monoamine neurotransmitters. In this article, we report two patients with progressive psychomotor retardation, dystonia, severe dopamine and serotonin deficiencies (low levels of 5-hydroxyindoleacetic and homovanillic acids), and abnormal pterin pattern (high levels of biopterin and dihydrobiopterin) in cerebrospinal fluid. Furthermore, they presented with normal urinary pterins and without hyperphenylalaninemia. Investigation of skin fibroblasts revealed inactive sepiapterin reductase (SR), the enzyme catalyzing the final two-step reaction in the biosynthesis of BH(4). Mutations in the SPR gene were detected in both patients and their family members. One patient was homozygous for a TC-->CT dinucleotide exchange, predicting a truncated SR (Q119X). The other patient was a compound heterozygote for a genomic 5-bp deletion (1397-1401delAGAAC) resulting in abolished SPR-gene expression and an A-->G transition leading to an R150G amino acid substitution and to inactive SR as confirmed by recombinant expression. The absence of hyperphenylalaninemia and the presence of normal urinary pterin metabolites and of normal SR-like activity in red blood cells may be explained by alternative pathways for the final two-step reaction of BH(4) biosynthesis in peripheral and neuronal tissues. We propose that, for the biosynthesis of BH(4) in peripheral tissues, SR activity may be substituted by aldose reductase (AR), carbonyl reductase (CR), and dihydrofolate reductase, whereas, in the brain, only AR and CR are fully present. Thus, autosomal recessive SR deficiency leads to BH(4) and to neurotransmitter deficiencies without hyperphenylalaninemia and may not be detected by neonatal screening for phenylketonuria.
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Affiliation(s)
- Luisa Bonafé
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital, Zurich; Children’s Hospital, Augsburg; and Children’s Hospital Königsborn, Unna, Germany
| | - Beat Thöny
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital, Zurich; Children’s Hospital, Augsburg; and Children’s Hospital Königsborn, Unna, Germany
| | - Johann M. Penzien
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital, Zurich; Children’s Hospital, Augsburg; and Children’s Hospital Königsborn, Unna, Germany
| | - Barbara Czarnecki
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital, Zurich; Children’s Hospital, Augsburg; and Children’s Hospital Königsborn, Unna, Germany
| | - Nenad Blau
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital, Zurich; Children’s Hospital, Augsburg; and Children’s Hospital Königsborn, Unna, Germany
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Ozelius LJ, Page CE, Klein C, Hewett JW, Mineta M, Leung J, Shalish C, Bressman SB, de Leon D, Brin MF, Fahn S, Corey DP, Breakefield XO. The TOR1A (DYT1) gene family and its role in early onset torsion dystonia. Genomics 1999; 62:377-84. [PMID: 10644435 DOI: 10.1006/geno.1999.6039] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Most cases of early onset torsion dystonia are caused by a 3-bp deletion (GAG) in the coding region of the TOR1A gene (alias DYT1, DQ2), resulting in loss of a glutamic acid in the carboxy terminal of the encoded protein, torsin A. TOR1A and its homologue TOR1B (alias DQ1) are located adjacent to each other on human chromosome 9q34. Both genes comprise five similar exons; each gene spans a 10-kb region. Mutational analysis of most of the coding region and splice junctions of TOR1A and TOR1B did not reveal additional mutations in typical early onset cases lacking the GAG deletion (N = 17), in dystonic individuals with apparent homozygosity in the 9q34 chromosomal region (N = 5), or in a representative Ashkenazic Jewish individual with late onset dystonia, who shared a common haplotype in the 9q34 region with other late onset individuals in this ethnic group. A database search revealed a family of nine related genes (50-70% similarity) and their orthologues in species including human, mouse, rat, pig, zebrafish, fruitfly, and nematode. At least four of these genes occur in the human genome. Proteins encoded by this gene family share functional domains with the AAA/HSP/Clp-ATPase superfamily of chaperone-like proteins, but appear to represent a distinct evolutionary branch.
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Affiliation(s)
- L J Ozelius
- Molecular Neurogenetics Unit, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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Abstract
Diagnostic testing for genetically determined metabolic disease has for many years relied heavily on the use of generalized screening tests that analyze groups of related compounds in easily accessible peripheral fluids such as plasma and urine. Organic acid profiles in urine and amino acid analysis in plasma are two of the most commonly requested tests; these, together with other protocols that examine peripheral fluids, have been and continue to be invaluable tools. There is, however, an emerging realization that many metabolic encephalopathies do not arise secondary to peripheral metabolic changes but rather have their origins within the central nervous system. In these cases, testing of peripheral fluids might be uninformative. This review is designed to examine the role of cerebrospinal fluid analyses in the investigation of infants and children with undefined encephalopathies. The aims are to review the conditions in which measurement of metabolites in cerebrospinal fluid is critical if a diagnosis is to be made, and to emphasize that considerable forethought is often required to ensure correct collection and handling of cerebrospinal fluid. Thus, fidelity of the diagnostic analytic procedures is maintained. This review will help the pediatric neurologist establish practical diagnostic guidelines that in turn will help in the recognition of recently described conditions. Those conditions can, in general, be identified only after specialized cerebrospinal fluid testing.
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Affiliation(s)
- K Hyland
- Department of Neurochemistry, Institute of Metabolic Disease, Baylor University Medical Center, Dallas, TX 75226, USA.
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Abstract
The purpose of the current review is to present a brief background examining the mechanisms controlling synthesis, storage, release and action of the biogenic amine neurotransmitters and to provide examples of newly defined conditions that expand our awareness of the diversity and complexity of the inherited diseases that affect these important regulators of central and peripheral homeostasis.
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Affiliation(s)
- K Hyland
- Institute of Metabolic Disease, Baylor University Medical Center, Dallas, TX 75226, USA.
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Blau N, Thöny B, Renneberg A, Penzien JM, Hyland K, Hoffmann GF. Variant of dihydropteridine reductase deficiency without hyperphenylalaninaemia: effect of oral phenylalanine loading. J Inherit Metab Dis 1999; 22:216-20. [PMID: 10384371 DOI: 10.1023/a:1005584627797] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- N Blau
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital, Zürich, Switzerland.
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Abstract
For many years, all of the described cases of monoamine neurotransmitter deficiency were associated with hyperphenylalaninemia that was generally detected at neonatal screening. It is now clear that inherited deficiency of monoamines often occurs in the absence of hyperphenylalaninemia and that the normal battery of screening tests used to investigate individuals with suspected metabolic disease will not detect these cases. Diagnosis in this situation must rely heavily on clinical suspicion. This article, therefore, describes the presentation and clinical symptoms that result from defective monoamine neurotransmission; outlines therapeutic approaches; and explains how cerebrospinal fluid profiles of monoamine metabolites, their precursors, and the cofactor required for monoamine synthesis can be used to pinpoint the exact site of the metabolic lesion.
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Affiliation(s)
- K Hyland
- Department of Neurochemistry, Institute of Metabolic Disease, Baylor University Medical Center, Dallas, TX 75226, USA
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