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Almahmoud R, Mekki M, El-Hattab AW. Cerebral folate deficiency: A report of two affected siblings. Mol Genet Metab Rep 2023; 35:100975. [PMID: 37101857 PMCID: PMC10123369 DOI: 10.1016/j.ymgmr.2023.100975] [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: 03/08/2023] [Revised: 04/08/2023] [Accepted: 04/09/2023] [Indexed: 04/28/2023] Open
Abstract
Cerebral folate deficiency (CFD) is a rare progressive neurological condition characterized by normal blood folate level and low 5-methyltetrahydrofolate (5-MTHF) levels in the cerebrospinal fluid. Patients present with different neurological findings including hypotonia and microcephaly. Later, patients develop ataxia, seizures, para or quadri-plagia. Herein, we report two siblings; born to consanguineous parents; who had normal neurological development in early childhood. Subsequently they developed drug-resistant seizures, neurological regression, and spastic quadriplegia. After thorough investigations patients had brain MRI which showed abnormal white matter signals and ventricular dilatation, CSF with low 5-MTHF, and whole exome sequencing (WES) revealed a novel homozygous variant in FOLR1 (c.245A > G; p.Tyr82Cys) consistent with the diagnosis of cerebral folate deficiency. They were treated with folinic acid in addition to standard anti-seizure medications. WES aids in reaching CFD diagnosis due to FOLR1 pathogenic variants. These results can be used for future counselling to prevent recurrence in future pregnancies by preimplantation genetic testing prior to implanting the embryo in the uterus. Treatment with folinic acid was shown to improve the neurological symptoms namely reduced the seizures and spasticity.
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Affiliation(s)
- Rabah Almahmoud
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Corresponding author at: College of Medicine, University of Sharjah, PO BOX 27272, Sharjah, United Arab Emirates.
| | - Mohammed Mekki
- Department of Pediatrics, AlQassimi Women and Children Hospital, Sharjah, United Arab Emirates
| | - Ayman W. El-Hattab
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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Bitanihirwe BKY, Lizano P, Woo TUW. Deconstructing the functional neuroanatomy of the choroid plexus: an ontogenetic perspective for studying neurodevelopmental and neuropsychiatric disorders. Mol Psychiatry 2022; 27:3573-3582. [PMID: 35618887 PMCID: PMC9133821 DOI: 10.1038/s41380-022-01623-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 04/15/2022] [Accepted: 05/11/2022] [Indexed: 02/08/2023]
Abstract
The choroid plexus (CP) is a delicate and highly vascularized structure in the brain comprised of a dense network of fenestrated capillary loops that help in the synthesis, secretion and circulation of cerebrospinal fluid (CSF). This unique neuroanatomical structure is comprised of arachnoid villi stemming from frond-like surface projections-that protrude into the lumen of the four cerebral ventricles-providing a key source of nutrients to the brain parenchyma in addition to serving as a 'sink' for central nervous system metabolic waste. In fact, the functions of the CP are often described as being analogous to those of the liver and kidney. Beyond forming a barrier/interface between the blood and CSF compartments, the CP has been identified as a modulator of leukocyte trafficking, inflammation, cognition, circadian rhythm and the gut brain-axis. In recent years, advances in molecular biology techniques and neuroimaging along with the use of sophisticated animal models have played an integral role in shaping our understanding of how the CP-CSF system changes in relation to the maturation of neural circuits during critical periods of brain development. In this article we provide an ontogenetic perspective of the CP and review the experimental evidence implicating this structure in the pathophysiology of neurodevelopmental and neuropsychiatric disorders.
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Affiliation(s)
- Byron K Y Bitanihirwe
- Humanitarian and Conflict Response Institute, University of Manchester, Manchester, UK.
| | - Paulo Lizano
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Translational Neuroscience Division, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tsung-Ung W Woo
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Program in Molecular Neuropathology, McLean Hospital, Belmont, MA, USA
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3
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Ramaekers VT, Quadros EV. Cerebral Folate Deficiency Syndrome: Early Diagnosis, Intervention and Treatment Strategies. Nutrients 2022; 14:nu14153096. [PMID: 35956272 PMCID: PMC9370123 DOI: 10.3390/nu14153096] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 02/05/2023] Open
Abstract
Cerebral folate deficiency syndrome (CFDS) is defined as any neuropsychiatric or developmental disorder characterized by decreased CSF folate levels in the presence of normal folate status outside the nervous system. The specific clinical profile appears to be largely determined by the presence or absence of intrauterine folate deficiency as well as postnatal age at which cerebral folate deficiency occurs. The primary cause of CFDS is identified as the presence of serum folate receptor-alpha (FRα) autoantibodies impairing folate transport across the choroid plexus to the brain whereas, in a minority of cases, mitochondrial disorders, inborn errors of metabolism and loss of function mutations of the FRα (FOLR1) gene are identified. Early recognition and diagnosis of CFDS and prompt intervention is important to improve prognosis with successful outcomes. In this article we focus on FRα autoimmunity and its different age-dependent clinical syndromes, the diagnostic criteria, and treatments to be considered, including prevention strategies in this at-risk population.
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Folate Related Pathway Gene Analysis Reveals a Novel Metabolic Variant Associated with Alzheimer’s Disease with a Change in Metabolic Profile. Metabolites 2022; 12:metabo12060475. [PMID: 35736408 PMCID: PMC9230919 DOI: 10.3390/metabo12060475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 11/30/2022] Open
Abstract
Metabolic disorders may be important potential causative pathways to Alzheimer’s disease (AD). Cerebrospinal fluid (CSF) decreasing output, raised intracranial pressure, and ventricular enlargement have all been linked to AD. Cerebral folate metabolism may be a key player since this is significantly affected by such changes in CSF, and genetic susceptibilities may exist in this pathway. In the current study, we aimed to identify whether any single nucleotide polymorphism (SNPs) affecting folate and the associated metabolic pathways were significantly associated with AD. We took a functional nutrigenomics approach to look for SNPs in genes for the linked folate, methylation, and biogenic amine neurotransmitter pathways. Changes in metabolism were found with the SNPs identified. An abnormal SNP in methylene tetrahydrofolate dehydrogenase 1 (MTHFD1) was significantly predictive of AD and associated with an increase in tissue glutathione. Individuals without these SNPs had normal levels of glutathione but significantly raised MTHFD1. Both changes would serve to decrease potentially neurotoxic levels of homocysteine. Seven additional genes were associated with Alzheimer’s and five with normal ageing. MTHFD1 presents a strong prediction of susceptibility and disease among the SNPs associated with AD. Associated physiological changes present potential biomarkers for identifying at-risk individuals.
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Stover PJ, Garza C, Durga J, Field MS. Emerging Concepts in Nutrient Needs. J Nutr 2020; 150:2593S-2601S. [PMID: 33000157 PMCID: PMC7527270 DOI: 10.1093/jn/nxaa117] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 03/12/2020] [Accepted: 04/02/2020] [Indexed: 12/14/2022] Open
Abstract
Dietary reference intakes (DRIs) are quantitative, nutrient intake-based standards used for assessing the diets and specific nutrient intakes of healthy individuals and populations and for informing national nutrition policy and nutrition programs. Because nutrition needs vary by age, sex, and physiological state, DRIs are often specified for healthy subgroups within a population. Diet is known to be the leading modifiable risk factor for chronic disease, and the prevalence of chronic disease is growing in all populations globally and across all subgroups, but especially in older adults. It is known that nutrient needs can change in some chronic disease and other clinical states. Disease states and/or disease treatment can cause whole-body or tissue-specific nutrient depletion or excess, resulting in the need for altered nutrient intakes. In other cases, disease-related biochemical dysfunction can result in a requirement for a nonessential nutrient, rendering it as conditionally essential, or result in toxicity for a food component at levels usually tolerated by healthy people, as seen in inborn errors of metabolism. Here we summarize examples from a growing body of literature of disease-altering nutrient requirements, supporting the need to give more consideration to special nutrient requirements in disease states.
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Affiliation(s)
| | - Cutberto Garza
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Jane Durga
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Martha S Field
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
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Zhilyaeva T, Akimova E, Sergeeva A, Blagonravova A, Mazo G. Association of MTHFR 677C > T genetic polymorphism with extrapyramidal side effects of antipsychotic treatment. GENE REPORTS 2020. [DOI: 10.1016/j.genrep.2020.100717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Masingue M, Benoist JF, Roze E, Moussa F, Sedel F, Lubetzki C, Nadjar Y. Cerebral folate deficiency in adults: A heterogeneous potentially treatable condition. J Neurol Sci 2019; 396:112-118. [DOI: 10.1016/j.jns.2018.11.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/19/2018] [Accepted: 11/09/2018] [Indexed: 11/16/2022]
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The role of methionine on metabolism, oxidative stress, and diseases. Amino Acids 2017; 49:2091-2098. [DOI: 10.1007/s00726-017-2494-2] [Citation(s) in RCA: 152] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 09/11/2017] [Indexed: 12/14/2022]
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Krsička D, Geryk J, Vlčková M, Havlovicová M, Macek M, Pourová R. Identification of likely associations between cerebral folate deficiency and complex genetic- and metabolic pathogenesis of autism spectrum disorders by utilization of a pilot interaction modeling approach. Autism Res 2017; 10:1424-1435. [DOI: 10.1002/aur.1780] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 02/01/2017] [Accepted: 02/23/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Daniel Krsička
- Department of Biology and Medical Genetics, 2nd Faculty of Medicine; Charles University and University Hospital Motol; V Úvalu 84, 150 06 Prague Czech Republic
| | - Jan Geryk
- Department of Biology and Medical Genetics, 2nd Faculty of Medicine; Charles University and University Hospital Motol; V Úvalu 84, 150 06 Prague Czech Republic
| | - Markéta Vlčková
- Department of Biology and Medical Genetics, 2nd Faculty of Medicine; Charles University and University Hospital Motol; V Úvalu 84, 150 06 Prague Czech Republic
| | - Markéta Havlovicová
- Department of Biology and Medical Genetics, 2nd Faculty of Medicine; Charles University and University Hospital Motol; V Úvalu 84, 150 06 Prague Czech Republic
| | - Milan Macek
- Department of Biology and Medical Genetics, 2nd Faculty of Medicine; Charles University and University Hospital Motol; V Úvalu 84, 150 06 Prague Czech Republic
| | - Radka Pourová
- Department of Biology and Medical Genetics, 2nd Faculty of Medicine; Charles University and University Hospital Motol; V Úvalu 84, 150 06 Prague Czech Republic
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Folate nutrition and blood-brain barrier dysfunction. Curr Opin Biotechnol 2017; 44:146-152. [PMID: 28189938 DOI: 10.1016/j.copbio.2017.01.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 01/09/2017] [Accepted: 01/12/2017] [Indexed: 01/30/2023]
Abstract
Mammals require essential nutrients from dietary sources to support normal metabolic, physiological and neuronal functions, to prevent diseases of nutritional deficiency as well as to prevent chronic disease. Disease and/or its treatment can modify fundamental biological processes including cellular nutrient accretion, stability and function in cells. These effects can be isolated to a specific diseased organ in the absence of whole-body alterations in nutrient status or biochemistry. Loss of blood-brain barrier function, which occurs in in-born errors of metabolism and in chronic disease, can cause brain-specific folate deficiency and contribute to disease co-morbidity. The role of brain folate deficiency in neuropsychiatric disorders is reviewed, as well as emerging diagnostic and nutritional strategies to identify and address brain folate deficiency in blood-brain barrier dysfunction.
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Hoffmann C, Zong S, Mané-Damas M, Molenaar P, Losen M, Martinez-Martinez P. Autoantibodies in Neuropsychiatric Disorders. Antibodies (Basel) 2016; 5:antib5020009. [PMID: 31557990 PMCID: PMC6698850 DOI: 10.3390/antib5020009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/01/2016] [Accepted: 04/06/2016] [Indexed: 12/15/2022] Open
Abstract
Little is known about the etiology of neuropsychiatric disorders. The identification of autoantibodies targeting the N-methyl-d-aspartate receptor (NMDA-R), which causes neurological and psychiatric symptoms, has reinvigorated the hypothesis that other patient subgroups may also suffer from an underlying autoimmune condition. In recent years, a wide range of neuropsychiatric diseases and autoantibodies targeting ion-channels or neuronal receptors including NMDA-R, voltage gated potassium channel complex (VGKC complex), α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPA-R), γ-aminobutyric acid receptor (GABA-R) and dopamine receptor (DR) were studied and conflicting reports have been published regarding the seroprevalence of these autoantibodies. A clear causative role of autoantibodies on psychiatric symptoms has as yet only been shown for the NMDA-R. Several other autoantibodies have been related to the presence of certain symptoms and antibody effector mechanisms have been proposed. However, extensive clinical studies with large multicenter efforts to standardize diagnostic procedures for autoimmune etiology and animal studies are needed to confirm the pathogenicity of these autoantibodies. In this review, we discuss the current knowledge of neuronal autoantibodies in the major neuropsychiatric disorders: psychotic, major depression, autism spectrum, obsessive-compulsive and attention-deficit/hyperactivity disorders.
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Affiliation(s)
- Carolin Hoffmann
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
| | - Shenghua Zong
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
| | - Marina Mané-Damas
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
| | - Peter Molenaar
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
| | - Mario Losen
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
| | - Pilar Martinez-Martinez
- Division Neurosciences, School for Mental Health and Neurosciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
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Repchak AT, Quinn DK. Epileptic Catatonia: A Case Series and Systematic Review. PSYCHOSOMATICS 2015; 57:217-25. [PMID: 26892327 DOI: 10.1016/j.psym.2015.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 11/18/2015] [Accepted: 11/19/2015] [Indexed: 12/14/2022]
Affiliation(s)
| | - Davin K Quinn
- Department of Psychiatry, University of New Mexico, Albuquerque, NM
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Ramaekers VT, Thöny B, Sequeira JM, Ansseau M, Philippe P, Boemer F, Bours V, Quadros EV. Folinic acid treatment for schizophrenia associated with folate receptor autoantibodies. Mol Genet Metab 2014; 113:307-14. [PMID: 25456743 DOI: 10.1016/j.ymgme.2014.10.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 09/30/2014] [Accepted: 10/01/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Auto-antibodies against folate receptor alpha (FRα) at the choroid plexus that block N(5)-methyltetrahydrofolate (MTHF) transfer to the brain were identified in catatonic schizophrenia. Acoustic hallucinations disappeared following folinic acid treatment. Folate transport to the CNS prevents homocysteine accumulation and delivers one-carbon units for methyl-transfer reactions and synthesis of purines. The guanosine derivative tetrahydrobiopterin acts as common co-factor for the enzymes producing dopamine, serotonin and nitric oxide. METHODS Our study selected patients with schizophrenia unresponsive to conventional treatment. Serum from these patients with normal plasma homocysteine, folate and vitamin B12 was tested for FR autoantibodies of the blocking type on serial samples each week. Spinal fluid was analyzed for MTHF and the metabolites of pterins, dopamine and serotonin. The clinical response to folinic acid treatment was evaluated. RESULTS Fifteen of 18 patients (83.3%) had positive serum FR auto-antibodies compared to only 1 in 30 controls (3.3%) (χ(2)=21.6; p<0.0001). FRα antibody titers in patients fluctuated over time varying between negative and high titers, modulating folate flux to the CNS, which explained low CSF folate values in 6 and normal values in 7 patients. The mean±SD for CSF MTHF was diminished compared to previously established controls (t-test: 3.90; p=0.0002). A positive linear correlation existed between CSF MTHF and biopterin levels. CSF dopamine and serotonin metabolites were low or in the lower normal range. Administration of folinic acid (0.3-1mg/kg/day) to 7 participating patients during at least six months resulted in clinical improvement. CONCLUSION Assessment of FR auto-antibodies in serum is recommended for schizophrenic patients. Clinical negative or positive symptoms are speculated to be influenced by the level and evolution of FRα antibody titers which determine folate flux to the brain with up- or down-regulation of brain folate intermediates linked to metabolic processes affecting homocysteine levels, synthesis of tetrahydrobiopterin and neurotransmitters. Folinic acid intervention appears to stabilize the disease process.
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Affiliation(s)
- V T Ramaekers
- Division of Paediatric Neurology, Centre Hospitalier Universitaire de Liège, Liège, Belgium; Centre for Autism Liège, Centre Hospitalier Universitaire de Liège, Liège, Belgium.
| | - B Thöny
- Division of Metabolism, University Children's Hospital Zurich, Switzerland
| | - J M Sequeira
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - M Ansseau
- Department of Psychiatry, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - P Philippe
- Centre for Autism Liège, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - F Boemer
- Department of Human Genetics and Metabolism, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - V Bours
- Department of Human Genetics and Metabolism, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - E V Quadros
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
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Ramaekers V, Sequeira JM, Quadros EV. Clinical recognition and aspects of the cerebral folate deficiency syndromes. Clin Chem Lab Med 2013; 51:497-511. [DOI: 10.1515/cclm-2012-0543] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 10/25/2012] [Indexed: 01/08/2023]
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Kirsch SH, Herrmann W, Obeid R. Genetic defects in folate and cobalamin pathways affecting the brain. Clin Chem Lab Med 2013. [DOI: 10.1515/cclm-2012-0673] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Serrano M, Pérez-Dueñas B, Montoya J, Ormazabal A, Artuch R. Genetic causes of cerebral folate deficiency: clinical, biochemical and therapeutic aspects. Drug Discov Today 2012; 17:1299-306. [DOI: 10.1016/j.drudis.2012.07.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 05/18/2012] [Accepted: 07/17/2012] [Indexed: 11/26/2022]
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17
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Intravenous Lipid Emulsion-Associated Catatonia, Thrombocytopenia, and Leukopenia: A Case Report and the Role of NMDA Receptor. PSYCHOSOMATICS 2012; 53:193-5. [DOI: 10.1016/j.psym.2011.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 11/24/2011] [Accepted: 11/28/2011] [Indexed: 11/19/2022]
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Hyland K, Shoffner J, Heales SJ. Cerebral folate deficiency. J Inherit Metab Dis 2010; 33:563-70. [PMID: 20668945 DOI: 10.1007/s10545-010-9159-6] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Revised: 05/21/2010] [Accepted: 06/21/2010] [Indexed: 11/26/2022]
Abstract
Cerebral folate deficiency (CFD) is defined as any neurological syndrome associated with a low cerebrospinal fluid (CSF) concentration of 5-methyltetrahydrofolate (5MTHF) in the presence of normal peripheral folate status. CFD has a wide clinical presentation, with reported signs and symptoms generally beginning at around 4 months of age with irritability and sleep disturbances. These can be followed by psychomotor retardation, dyskinesia, cerebellar ataxia and spastic diplegia. Other signs may include deceleration of head growth, visual disturbances and sensorineural hearing loss. Identification of CFD is achieved by determining 5MTHF concentration in CSF. Once identified, CFD can in many cases be treated by administering oral folinic acid. Supplementation with folic acid is contraindicated and, if used, may exacerbate the CSF 5MTHF deficiency. Generation of autoantibodies against the folate receptor required to transport 5MTHF into CSF and mutations in the folate receptor 1 (FOLR1) gene have been reported to be causes of CFD. However, other mechanisms are probably also involved, as CFD has been reported in Aicardi-Goutiere's and Rett syndromes and in mitochondriopathies. Several metabolic conditions and a number of widely used drugs can also lead to a decrease in the concentration of CSF 5MTHF, and these should be considered in the differential diagnosis if a low concentration of 5MTHF is found following CSF analysis.
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