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Zubarioglu T, Kıykım E, Köse E, Eminoğlu FT, Teke Kısa P, Balcı MC, Özer I, İnci A, Çilesiz K, Canda E, Yazıcı H, Öztürk-Hişmi B, Bulut FD, Dorum S, Akgun A, Yalçın-Çakmaklı G, Kılıç-Yıldırım G, Soyuçen E, Akçalı A, Güneş D, Durmuş A, Gündüz A, Kasapkara ÇS, Göksoy E, Akar HT, Ersoy M, Erdöl Ş, Yıldız Y, Hanağası HA, Arslan N, Aktuğlu-Zeybek Ç. Clinical, biochemical, and molecular insights into Cerebrotendinous Xanthomatosis: A nationwide study of 100 Turkish individuals. Mol Genet Metab 2024; 142:108493. [PMID: 38772327 DOI: 10.1016/j.ymgme.2024.108493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 05/23/2024]
Abstract
OBJECTIVE Cerebrotendinous xanthomatosis (CTX) is an inherited metabolic disorder characterized by progressive neurologic and extraneurologic findings. The aim of this retrospective, descriptive study was to explore the time of presentation and diagnosis, and to expand the phenotype and genotype of CTX, based on a nationwide and comprehensive series of patients in Turkey. METHODS The demographic, clinical, biochemical and genotypic characteristics of the CTX patients were reviewed. Data on molecular analysis, age of onset and diagnosis, diagnostic delay, neurologic and extraneurologic symptomatology, results of plasma cholestanol levels, brain magnetic resonance imaging and electromyography at the time of diagnosis were reviewed. RESULTS 100 confirmed CTX patients from 72 families were included. The mean age at diagnosis was 28.16 ± 14.28 years, and diagnostic delay was 18.39 ± 13.71 years. 36 patients were diagnosed in childhood. Frequency of intention tremor (p = 0.069), peripheral neuropathy (p = 0.234) and psychiatric manifestations (p = 0.396) did not differ between two groups, demonstrating the high rate in pediatric patients. Three adult patients showed a milder phenotype without neurologic involvement. Seven patients had normal plasma cholestanol levels despite neurological impairment. Sequencing of the CYP27A1 gene revealed 25 different variants, with a novel c.671_672del variant not previously described in literature. CONCLUSION Based on the observations of this Turkish CTX cohort, it is emphasized that the true prevalence of CTX is probably underestimated and that it has a wide spectrum of clinical phenotypes even without neurological impairment. In children, abnormal cerebellar findings, peripheral neuropathy and psychiatric findings associated with intellectual disability have been suggested as warning signs to avoid diagnostic delay. In cases of clinical suspicion, molecular analysis is recommended despite normal plasma cholestanol levels, as severe neurologic involvement may occur in CTX patients without elevated cholestanol levels.
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Affiliation(s)
- Tanyel Zubarioglu
- İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Division of Pediatric Nutrition and Metabolism, İstanbul, Turkey.
| | - Ertuğrul Kıykım
- İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Division of Pediatric Nutrition and Metabolism, İstanbul, Turkey
| | - Engin Köse
- Ankara University, Faculty of Medicine, Department of Pediatric Metabolism, Ankara, Turkey; Ankara University Rare Diseases Application and Research Center, Ankara, Turkey
| | - Fatma Tuba Eminoğlu
- Ankara University, Faculty of Medicine, Department of Pediatric Metabolism, Ankara, Turkey; Ankara University Rare Diseases Application and Research Center, Ankara, Turkey
| | - Pelin Teke Kısa
- Dokuz Eylul University Medical Faculty, Division of Pediatric Nutrition and Metabolism, Izmir, Turkey
| | - Mehmet Cihan Balcı
- Istanbul University, Istanbul Medical Faculty Children's Hospital, Division of Nutrition and Metabolism, Istanbul, Turkey
| | - Işıl Özer
- Ondokuz Mayıs University, Faculty of Medicine, Department of Pediatric Metabolism, Samsun, Turkey; Kafkas University, Division of Pediatric Nutrition and Metabolism, Kars, Turkey
| | - Aslı İnci
- Gazi University School of Medicine, Division of Pediatric Nutrition and Metabolism, Ankara, Turkey
| | - Kübra Çilesiz
- Gazi University School of Medicine, Division of Pediatric Nutrition and Metabolism, Ankara, Turkey
| | - Ebru Canda
- Ege University Medical Faculty, Division of Pediatric Nutrition and Metabolism, İzmir, Turkey
| | - Havva Yazıcı
- Ege University Medical Faculty, Division of Pediatric Nutrition and Metabolism, İzmir, Turkey
| | - Burcu Öztürk-Hişmi
- Marmara University School of Medicine, Division of Pediatric Metabolic Disorders, İstanbul, Turkey
| | - Fatma Derya Bulut
- Cukurova University Medical Faculty, Division of Pediatric Metabolism and Nutrition, Adana, Turkey
| | - Sevil Dorum
- Health Sciences University, Bursa Yuksek Ihtisas Training and Research Hospital, Division of Pediatric Nutrition and Metabolism, Bursa, Turkey
| | - Abdurrahman Akgun
- Firat University, School of Medicine, Department of Pediatrics, Division of Pediatric Metabolic Diseases, Elazığ, Turkey
| | - Gül Yalçın-Çakmaklı
- Hacettepe University Faculty of Medicine, Department of Neurology, Ankara, Turkey
| | - Gonca Kılıç-Yıldırım
- Eskisehir Osmangazi University, Faculty of Medicine, Pediatric Nutrition and Metabolism Unit, Eskişehir, Turkey
| | - Erdoğan Soyuçen
- Akdeniz University Faculty of Medicine, Department of Pediatrics, Division of Inherited Pediatric Metabolic Diseases, Antalya, Turkey
| | - Aylin Akçalı
- Gaziantep University Faculty of Medicine, Department of Neurology, Gaziantep, Turkey
| | - Dilek Güneş
- Bağcılar Training and Research Hospital, Division of Inborn Metabolic Disease, İstanbul, Turkey
| | - Aslı Durmuş
- Kanuni Training and Research Hospital, Division of Pediatric Metabolism, Trabzon, Turkey
| | - Ayşegül Gündüz
- İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Department of Neurology, İstanbul, Turkey
| | - Çiğdem Seher Kasapkara
- Ankara Yıldırım Beyazıt University, Ankara Bilkent City Hospital, Department of Pediatric Metabolism, Ankara, Turkey
| | - Emine Göksoy
- Adnan Menderes University Medical Faculty, Division of Pediatric Metabolism, Aydın, Turkey
| | - Halil Tuna Akar
- Ankara Etlik City Hospital, Pediatric Metabolic Diseases Unit, Ankara, Turkey
| | - Melike Ersoy
- Health Sciences University, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Pediatrics, Division of Pediatric Metabolic Diseases, İstanbul, Turkey
| | - Şahin Erdöl
- Bursa Uludag University Faculty of Medicine, Department of Pediatrics, Division of Metabolism, Bursa, Turkey
| | - Yılmaz Yıldız
- Hacettepe University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Metabolism, Ankara, Turkey
| | | | - Nur Arslan
- Dokuz Eylul University Medical Faculty, Division of Pediatric Nutrition and Metabolism, Izmir, Turkey
| | - Çiğdem Aktuğlu-Zeybek
- İstanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Division of Pediatric Nutrition and Metabolism, İstanbul, Turkey
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Zhao W, Han J, Tao D, Zheng H. Cerebrotendinous xanthomatosis with tremor as the main manifestation: A case report. Medicine (Baltimore) 2024; 103:e37976. [PMID: 38669366 PMCID: PMC11049754 DOI: 10.1097/md.0000000000037976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 04/01/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Cerebrotendinous xanthomatosis (CTX) is an autosomal recessive lipid metabolism disorder. It is caused by a defect in the sterol-27-hydroxylase gene, leading to the deposition of cholesteryl and bile alcohol in large amounts, causing a variety of clinical manifestations; however, tremor as the main manifestation of CTX has not been reported. PATIENTS CONCERNS AND CLINICAL FINDINGS Herein, we report a 27-year-old woman, who developed head and body tremors at the age of 12 years. Many hospitals misdiagnosed her condition as idiopathic tremor and Parkinson disease, with a poor curative effect. PRIMARY DIAGNOSIS AND INTERVENTION We diagnosed her with CTX and treated with chenodeoxycholic acid and clonazepam. CONCLUSION The patient's condition considerably improved. This case could help avoid misdiagnosis and mistreatment in clinical practice.
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Affiliation(s)
- Wei Zhao
- Neurology Department, Ji AO Brain Hospital of Siping, Si Ping, Jilin Province, China
| | - Jie Han
- Neurological Intensive Care Unit Department, The First Affiliated Hospital of Dalian Medical University, Da Lian, Liaoning Province, China
| | - Dingbo Tao
- Neurological Intensive Care Unit Department, The First Affiliated Hospital of Dalian Medical University, Da Lian, Liaoning Province, China
| | - Hongliang Zheng
- Neurology Department, Ji AO Brain Hospital of Siping, Si Ping, Jilin Province, China
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3
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Klippel E, Moshagen V. [Neurological manifestation of cerebrotendinous xanthomatosis-Clinical findings and cranial imaging in low-field MRI]. DER NERVENARZT 2023; 94:142-144. [PMID: 36357537 DOI: 10.1007/s00115-022-01402-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Ekkehard Klippel
- Neurozentrum Schlosscarree, Ritterbrunnen 7, 38100, Braunschweig, Deutschland.
| | - Volker Moshagen
- Neurozentrum Schlosscarree, Ritterbrunnen 7, 38100, Braunschweig, Deutschland
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Chun MY, Heo NJ, Seo SW, Jang H, Suh YL, Jang JH, Kim YE, Kim EJ, Moon SY, Jung NY, Lee SM, Kim HJ. Case report: Cerebrotendinous xanthomatosis with a novel mutation in the CYP27A1 gene mimicking behavioral variant frontotemporal dementia. Front Neurol 2023; 14:1131888. [PMID: 36959818 PMCID: PMC10029355 DOI: 10.3389/fneur.2023.1131888] [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: 12/26/2022] [Accepted: 02/14/2023] [Indexed: 03/09/2023] Open
Abstract
Background Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive lipid storage disease caused by a mutation in the CYP27A1 gene. Due to the disruption of bile acid synthesis leading to cholesterol and cholestanol accumulation, CTX manifests as premature cataracts, chronic diarrhea, and intellectual disability in childhood and adolescence. This report presents a case of CTX with an unusual phenotype of behavioral variant frontotemporal dementia (bvFTD) in middle age. Case presentation A 60-year-old woman presented with behavioral and personality changes. She showed disinhibition, such as hoarding and becoming aggressive over trifles; compulsive behavior, such as closing doors; apathy; and dietary change. The patient showed a progressive cognitive decline and relatively sparing memory and visuospatial function. She had hyperlipidemia but no family history of neurodegenerative disorders. Initial fluid-attenuated inversion recovery (FLAIR) images showed a high signal in the periventricular area, and brain spectroscopy showed hypoperfusion in the frontal and temporal lobes, mimicking bvFTD. However, on physical examination, xanthomas were found on both the dorsum of the hands and the Achilles tendons. Hyperactive deep tendon reflexes in the bilateral biceps, brachioradialis, and knee and positive Chaddock signs on both sides were observed. Four years later, FLAIR images showed symmetrical high signals in the bilateral dentate nuclei of the cerebellum. Her serum cholestanol (12.4 mg/L; normal value ≤6.0) and 7α,12α-dihydroxycholest-4-en-3-one (0.485 nmol/mL; normal value ≤0.100) levels were elevated. A novel likely pathogenic variant (c.1001T>A, p.Met334Lys) and a known pathogenic variant (c.1420C>T, p.Arg474Trp) of the CYP27A1 gene were found in trans-location. The patient was diagnosed with CTX and prescribed chenodeoxycholic acid (750 mg/day). Conclusions This report discusses the case of a middle-aged CTX patient with an unusual phenotype of bvFTD. A novel likely pathogenic variant (c.1001T>A, p.Met334Lys) was identified in the CYP27A1 gene. Early diagnosis is important because supplying chenodeoxycholic acid can prevent CTX progression.
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Affiliation(s)
- Min Young Chun
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Neurology, Yongin Severance Hospital, Yonsei University Health System, Yongin, Republic of Korea
| | - Nam Jin Heo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang Won Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
- Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
- Alzheimer's Disease Convergence Research Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Hyemin Jang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
- Alzheimer's Disease Convergence Research Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Yeon-Lim Suh
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ja-Hyun Jang
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young-Eun Kim
- Departments of Laboratory Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Eun-Joo Kim
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Medical Research Institute, Busan, Republic of Korea
| | - So Young Moon
- Department of Neurology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Na-Yeon Jung
- Department of Neurology, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Republic of Korea
| | - Sun Min Lee
- Department of Neurology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Hee Jin Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
- Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
- Alzheimer's Disease Convergence Research Center, Samsung Medical Center, Seoul, Republic of Korea
- *Correspondence: Hee Jin Kim
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Molina-Gonzalez I, Miron VE, Antel JP. Chronic oligodendrocyte injury in central nervous system pathologies. Commun Biol 2022; 5:1274. [PMID: 36402839 PMCID: PMC9675815 DOI: 10.1038/s42003-022-04248-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 11/10/2022] [Indexed: 11/21/2022] Open
Abstract
Myelin, the membrane surrounding neuronal axons, is critical for central nervous system (CNS) function. Injury to myelin-forming oligodendrocytes (OL) in chronic neurological diseases (e.g. multiple sclerosis) ranges from sublethal to lethal, leading to OL dysfunction and myelin pathology, and consequent deleterious impacts on axonal health that drive clinical impairments. This is regulated by intrinsic factors such as heterogeneity and age, and extrinsic cellular and molecular interactions. Here, we discuss the responses of OLs to injury, and perspectives for therapeutic targeting. We put forward that targeting mature OL health in neurological disease is a promising therapeutic strategy to support CNS function.
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Affiliation(s)
- Irene Molina-Gonzalez
- grid.4305.20000 0004 1936 7988United Kingdom Dementia Research Institute at The University of Edinburgh, Edinburgh, Scotland UK ,grid.4305.20000 0004 1936 7988Centre for Discovery Brain Sciences, Chancellor’s Building, The University of Edinburgh, Edinburgh, Scotland UK ,grid.4305.20000 0004 1936 7988Medical Research Council Centre for Reproductive Health, The Queen’s Medical Research Institute, The University of Edinburgh, Edinburgh, Scotland UK
| | - Veronique E. Miron
- grid.4305.20000 0004 1936 7988United Kingdom Dementia Research Institute at The University of Edinburgh, Edinburgh, Scotland UK ,grid.4305.20000 0004 1936 7988Centre for Discovery Brain Sciences, Chancellor’s Building, The University of Edinburgh, Edinburgh, Scotland UK ,grid.4305.20000 0004 1936 7988Medical Research Council Centre for Reproductive Health, The Queen’s Medical Research Institute, The University of Edinburgh, Edinburgh, Scotland UK ,grid.415502.7Barlo Multiple Sclerosis Centre and Keenan Research Centre for Biomedical Science, Toronto, Canada ,grid.17063.330000 0001 2157 2938Department of Immunology, University of Toronto, Toronto, Canada
| | - Jack P. Antel
- grid.14709.3b0000 0004 1936 8649Neuroimmunology Unit, Montreal Neurological Institute, McGill University, Montreal, QC Canada
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6
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Nowacki JC, Fields AM, Fu MM. Emerging cellular themes in leukodystrophies. Front Cell Dev Biol 2022; 10:902261. [PMID: 36003149 PMCID: PMC9393611 DOI: 10.3389/fcell.2022.902261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/30/2022] [Indexed: 11/18/2022] Open
Abstract
Leukodystrophies are a broad spectrum of neurological disorders that are characterized primarily by deficiencies in myelin formation. Clinical manifestations of leukodystrophies usually appear during childhood and common symptoms include lack of motor coordination, difficulty with or loss of ambulation, issues with vision and/or hearing, cognitive decline, regression in speech skills, and even seizures. Many cases of leukodystrophy can be attributed to genetic mutations, but they have diverse inheritance patterns (e.g., autosomal recessive, autosomal dominant, or X-linked) and some arise from de novo mutations. In this review, we provide an updated overview of 35 types of leukodystrophies and focus on cellular mechanisms that may underlie these disorders. We find common themes in specialized functions in oligodendrocytes, which are specialized producers of membranes and myelin lipids. These mechanisms include myelin protein defects, lipid processing and peroxisome dysfunction, transcriptional and translational dysregulation, disruptions in cytoskeletal organization, and cell junction defects. In addition, non-cell-autonomous factors in astrocytes and microglia, such as autoimmune reactivity, and intercellular communication, may also play a role in leukodystrophy onset. We hope that highlighting these themes in cellular dysfunction in leukodystrophies may yield conceptual insights on future therapeutic approaches.
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7
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Guidara W, Messedi M, Naifar M, Maalej M, Khrouf W, Grayaa S, Maalej M, Bonnefont-Rousselot D, Lamari F, Ayadi F. Plasma oxysterols in drug-free patients with schizophrenia. J Steroid Biochem Mol Biol 2022; 221:106123. [PMID: 35550868 DOI: 10.1016/j.jsbmb.2022.106123] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/29/2022] [Accepted: 05/05/2022] [Indexed: 11/15/2022]
Abstract
Evidence from clinical, genetic, and medical studies has shown the neuronal developmental disorder aspect of schizophrenia (SZ). Whereas oxysterols are vital factors in neurodevelopment, it is still unknown whether they are involved in the pathophysiology of SZ. The current study aims to explore the profile of oxysterols in plasma, ratio to total cholesterol (Tchol) and the association with clinical factors in patients with SZ. Forty men diagnosed with SZ and forty healthy controls matched for age and sex were included in the study. The ratios of cholestane-3β,5α,6β-triol, 27-hydroxycholesterol (27-OHC) and Cholestanol to Tchol increased in the schizophrenic group compared to controls. However, levels of 24S-hydroxycholesterol (24-OHC) were not significantly different between patients and controls. For the SZ patients, the plasma 24-OHC levels were positively correlated with the positive and negative syndrome total scores (PANSS) but negatively correlated with the Montreal Cognitive Assessment scores (MOCA). Moreover, the ratio Cholestanol to Tchol was negatively correlated with MOCA scores and positively correlated with PANSS general. The binary logistic regression analysis revealed that the ratio Cholestane-3β,5α,6β-triol/TChol could be considered as an independent risk factor for SZ. On the other hand, the receiver's operating characteristics analysis corresponding to potential biomarkers on SZ showed Areas Under the Curve (AUCs) of 82.1%; 69.7% and 77.6% for the ratio of Cholestane-3β,5α,6β-triol/TChol, 27-OHC/TChol and Cholestanol/TChol respectively. The relevance of Cholestane-3β,5α,6β-triol, 27-OHC and Cholestanol assays as biomarkers of this disease deserves further investigation.
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Affiliation(s)
- Wassim Guidara
- Research Laboratory "Molecular Basis of Human Diseases", LR19ES13, Sfax Medicine School, University of Sfax, Tunisia.
| | - Meriam Messedi
- Research Laboratory "Molecular Basis of Human Diseases", LR19ES13, Sfax Medicine School, University of Sfax, Tunisia
| | - Manel Naifar
- Research Laboratory "Molecular Basis of Human Diseases", LR19ES13, Sfax Medicine School, University of Sfax, Tunisia; Biochemistry Laboratory, Habib Bourguiba Hospital, Sfax, Tunisia
| | - Manel Maalej
- Psychiatry C-department, Hédi Chaker Hospital, Sfax, Tunisia
| | - Walid Khrouf
- Service de Biochimie Métabolique, AP-HP.Sorbonne Université, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix, DMU BioGeM, F-75013 Paris, France
| | - Sahar Grayaa
- Research Laboratory "Molecular Basis of Human Diseases", LR19ES13, Sfax Medicine School, University of Sfax, Tunisia
| | - Mohamed Maalej
- Psychiatry C-department, Hédi Chaker Hospital, Sfax, Tunisia
| | - Dominique Bonnefont-Rousselot
- Service de Biochimie Métabolique, AP-HP.Sorbonne Université, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix, DMU BioGeM, F-75013 Paris, France; Université de Paris, CNRS, Inserm, UTCBS, F-75006 Paris, France
| | - Foudil Lamari
- Service de Biochimie Métabolique, AP-HP.Sorbonne Université, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix, DMU BioGeM, F-75013 Paris, France
| | - Fatma Ayadi
- Research Laboratory "Molecular Basis of Human Diseases", LR19ES13, Sfax Medicine School, University of Sfax, Tunisia; Biochemistry Laboratory, Habib Bourguiba Hospital, Sfax, Tunisia
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Badura-Stronka M, Hirschfeld AS, Winczewska-Wiktor A, Budzyńska E, Jakubiuk-Tomaszuk A, Piontek A, Steinborn B, Kozubski W. First case series of Polish patients with cerebrotendinous xanthomatosis and systematic review of cases from the 21st century. Clin Genet 2021; 101:190-207. [PMID: 34689324 DOI: 10.1111/cge.14079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 12/27/2022]
Abstract
Cerebrotendinous xanthomatosis (CTX) is an inborn error of metabolism caused by recessive variants in the cytochrome P450 CYP27A1 gene. CTX is said to manifest with childhood-onset chronic diarrhea and the classic triad of juvenile-onset cataracts, Achilles tendons xanthomas, and progressive ataxia. It is currently one of the few inherited neurometabolic disorders amenable to a specific treatment. The diagnosis may be significantly delayed resulting in permanent neurological impairment. A retrospective review of the clinical characteristics and diagnostic findings in case series of six Polish patients with CTX. Additional retrospective review of symptoms and pathogenic variants of 568 CTX available cases and case series from the past 20 years. To the best of our knowledge, this is the widest review of CTX cases reported in years 2000-2021. We report the largest cohort of Polish patients ever published, with the identification of two hot-spot mutations. During the review of available 568 cases, we found significant differences in the clinical phenotypes and the localization of variants within the gene between Asian and non-Asian populations. These findings may facilitate molecular testing in the Polish and Asian populations. Invariably better screening for CTX and wider awareness is needed.
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Affiliation(s)
- Magdalena Badura-Stronka
- Department of Medical Genetics, Poznan University of Medical Sciences, Poznan, Poland.,Centers for Medical Genetics GENESIS, Poznan, Poland
| | | | | | - Edyta Budzyńska
- Central Teaching Hospital, The Medical University of Lodz, Poland
| | - Anna Jakubiuk-Tomaszuk
- Department of Pediatric Neurology and Rehabilitation, Medical University of Bialystok, Poland.,Medical Genetics Unit, Mastermed Medical Center, Poland
| | - Anita Piontek
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Barbara Steinborn
- Department of Child Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Wojciech Kozubski
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
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9
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Hsu CL, Iwanowski P, Hsu CH, Kozubski W. Genetic diseases mimicking multiple sclerosis. Postgrad Med 2021; 133:728-749. [PMID: 34152933 DOI: 10.1080/00325481.2021.1945898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Multiple sclerosis (MS) is an inflammatory neurodegenerative disorder manifesting as gradual or progressive loss of neurological functions. Most patients present with relapsing-remitting disease courses. Extensive research over recent decades has expounded our insights into the presentations and diagnostic features of MS. Groups of genetic diseases, CADASIL and leukodystrophies, for example, have been frequently misdiagnosed with MS due to some overlapping clinical and radiological features. The delayed identification of these diseases in late adulthood can lead to severe neurological complications. Herein we discuss genetic diseases that have the potential to mimic multiple sclerosis, with highlights on clinical identification and practicing pearls that may aid physicians in recognizing MS-mimics with genetic background in clinical settings.
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Affiliation(s)
- Chueh Lin Hsu
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Piotr Iwanowski
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Chueh Hsuan Hsu
- Department of Neurology, China Medical University, Taichung, Taiwan
| | - Wojciech Kozubski
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
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Koyama S, Sekijima Y, Ogura M, Hori M, Matsuki K, Miida T, Harada-Shiba M. Cerebrotendinous Xanthomatosis: Molecular Pathogenesis, Clinical Spectrum, Diagnosis, and Disease-Modifying Treatments. J Atheroscler Thromb 2021; 28:905-925. [PMID: 33967188 PMCID: PMC8532057 DOI: 10.5551/jat.rv17055] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is an autosomal recessive lipid storage disorder caused by mutations in the
CYP27A1
gene, which encodes the mitochondrial enzyme sterol 27-hydroxylase. Decreased sterol 27-hydroxylase activity results in impaired bile acid synthesis, leading to reduced production of bile acids, especially chenodeoxycholic acid (CDCA), as well as elevated serum cholestanol and urine bile alcohols. The accumulation of cholestanol and cholesterol mainly in the brain, lenses, and tendons results in the characteristic clinical manifestations of CTX. Clinical presentation is characterized by systemic symptoms including neonatal jaundice or cholestasis, refractory diarrhea, juvenile cataracts, tendon xanthomas, osteoporosis, coronary heart disease, and a broad range of neuropsychiatric manifestations. The combinations of symptoms vary from patient to patient and the presenting symptoms, especially in the early disease phase, may be nonspecific, which leads to a substantial diagnostic delay or underdiagnosis. Replacement of CDCA has been approved as a first-line treatment for CTX, and can lead to biochemical and clinical improvements. However, the effect of CDCA treatment is limited once significant neuropsychiatric manifestations are established. The age at diagnosis and initiation of CDCA treatment correlate with the prognosis of patients with CTX. Therefore, early diagnosis and subsequent treatment initiation are essential.
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Affiliation(s)
- Shingo Koyama
- Division of Neurology and Clinical Neuroscience, Department of Internal Medicine III, Yamagata University Faculty of Medicine
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine.,Institute for Biomedical Sciences, Shinshu University
| | - Masatsune Ogura
- Department of Molecular Innovation in Lipidology, National Cerebral and Cardiovascular Center Research Institute
| | - Mika Hori
- Department of Endocrinology, Research Institute of Environmental Medicine, Nagoya University
| | - Kota Matsuki
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine
| | - Takashi Miida
- Department of Clinical Laboratory Medicine, Juntendo University Graduate School of Medicine
| | - Mariko Harada-Shiba
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center Research Institute
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11
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Abstract
OBJECTIVE Cerebrotendinous xanthomatosis (CTX) belongs to a heterogeneous group of neurological disorders known as autosomal recessive cerebellar ataxias. Low awareness of CTX can result in misdiagnoses in the differential diagnostic process and may limit one's ability to offer suitable recommendations. While neurodegeneration is a recognized manifestation of CTX, there is scant literature to characterize the nature of cortical symptoms and even less detailing of its associated neurocognitive and neuropsychiatric manifestations. METHOD Based on the lack of representation of CTX in neuropsychological literature, we sought to present a case seen in a 39-year-old patient within our own clinic. RESULTS Evaluation of the patient's neurocognitive functioning revealed global impairment consistent with a CTX diagnosis and neuroimaging findings noting significant cerebellar involvement. CONCLUSIONS Neuropsychologists are increasingly called upon to make treatment recommendations and provide information that may be helpful in differential diagnosis as part of multidisciplinary teams. Referrals from neurology are common, and it is important for neuropsychologists to be aware of diseases that affect the central nervous system; CTX is one such example. The goal of this case study is to build awareness of this condition and increase interest in a more systematic approach to research and clinical care of this population.
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12
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Amador MDM, Masingue M, Debs R, Lamari F, Perlbarg V, Roze E, Degos B, Mochel F. Treatment with chenodeoxycholic acid in cerebrotendinous xanthomatosis: clinical, neurophysiological, and quantitative brain structural outcomes. J Inherit Metab Dis 2018; 41:799-807. [PMID: 29560583 DOI: 10.1007/s10545-018-0162-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 02/11/2018] [Accepted: 02/19/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cerebrotendinous xanthomatosis (CTX) is a rare neurodegenerative disease related to sterols metabolism. It affects both central and peripheral nervous systems but treatment with chenodeoxycholic acid (CDCA) has been reported to stabilize clinical scores and improve nerve conduction parameters. Few quantitative brain structural studies have been conducted to assess the effect of CDCA in CTX. METHODS AND RESULTS We collected retrospectively clinical, neurophysiological, and quantitative brain structural data in a cohort of 14 patients with CTX treated by CDCA over a mean period of 5 years. Plasma cholestanol levels normalized under treatment with CDCA within a few months. We observed a significant clinical improvement in patients up to 25 years old, whose treatment was initiated less than 15 years after the onset of neurological symptoms. Conversely, patients whose treatment was initiated more than 25 years after neurological disease onset continued their clinical deterioration. Eleven patients presented with a length-dependent peripheral neuropathy, whose electrophysiological parameters improved significantly under CDCA. Volumetric analyses in a subset of patients showed no overt volume loss under CDCA. Moreover, diffusion weighted imaging showed improved fiber integrity of the ponto-cerebellar and the internal capsule with CDCA. CDCA was well tolerated in all patients with CTX. CONCLUSION CDCA may reverse the pathophysiological process in patients with CTX, especially if treatment is initiated early in the disease process. Besides tendon xanthoma, this study stresses the need to consider plasma cholestanol measurement in any patient with infantile chronic diarrhea and/or jaundice, juvenile cataract, learning disability and/or autism spectrum disorder, pyramidal signs, cerebellar syndrome or peripheral neuropathy.
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Affiliation(s)
- Maria Del Mar Amador
- Assistance Publique-Hôpitaux de Paris, Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Marion Masingue
- Assistance Publique-Hôpitaux de Paris, Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Rabab Debs
- Assistance Publique-Hôpitaux de Paris, Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
- Assistance Publique-Hôpitaux de Paris, Département de Neurophysiologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Foudil Lamari
- Assistance Publique-Hôpitaux de Paris, Laboratoire de Biochimie Métabolique, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
- Centre de Référence Neurométabolique Adulte, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
- Université Pierre et Marie Curie, Groupe de Recherche Clinique Neurométabolique, Paris, France
| | - Vincent Perlbarg
- Sorbonne Universités, UPMC-Paris 6, UMR S 1127 and Inserm U 1127, and CNRS UMR 7225, and ICM, F-75013, Paris, France
- Laboratoire d'imagerie biomédicale (LIB), F-75013, Paris, France
- Bioinformatics and Biostatistics Core Facility, iCONICS, IHU-A-ICM, ICM, F-75013, Paris, France
| | - Emmanuel Roze
- Assistance Publique-Hôpitaux de Paris, Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
- Centre de Référence Neurométabolique Adulte, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
- Sorbonne Universités, UPMC-Paris 6, UMR S 1127 and Inserm U 1127, and CNRS UMR 7225, and ICM, F-75013, Paris, France
| | - Bertrand Degos
- CNRS-UMR 7241/INSERM U1050, CIRB, Collège de France, UPMC, Paris, France
- Assistance Publique-Hôpitaux de Paris, Service de Neurologie, Hôpital Universitaire d'Avicenne, Bobigny, France
| | - Fanny Mochel
- Centre de Référence Neurométabolique Adulte, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
- Université Pierre et Marie Curie, Groupe de Recherche Clinique Neurométabolique, Paris, France.
- Sorbonne Universités, UPMC-Paris 6, UMR S 1127 and Inserm U 1127, and CNRS UMR 7225, and ICM, F-75013, Paris, France.
- Assistance Publique-Hôpitaux de Paris, Département de Génétique, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
- Reference Center for Neurometabolic Diseases, Department of Genetics, La Pitié-Salpêtrière University Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France.
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13
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Wong JC, Walsh K, Hayden D, Eichler FS. Natural history of neurological abnormalities in cerebrotendinous xanthomatosis. J Inherit Metab Dis 2018; 41:647-656. [PMID: 29484516 DOI: 10.1007/s10545-018-0152-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 01/25/2018] [Accepted: 01/31/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Cerebrotendinous xanthomatosis (CTX) is a rare inherited neurodegenerative disorder in bile acid synthesis. The natural history of neurological abnormalities in CTX is not well understood. The object of this study was to determine neurological progression in CTX. METHODS A literature search on PubMed for "cerebrotendinous xanthomatosis" yielded 91 publications that reported cases of CTX patients. Two independent reviewers abstracted information about the presence and age of onset of neurological abnormalities in published CTX cases. For each neurological abnormality, we estimated the probability of its onset at any given age using cumulative incidence function analysis. We also present our own case series, in which five CTX patients were evaluated. RESULTS The literature search yielded 194 CTX cases (ages ranging from newborn to 67 years old). The most common neurological abnormalities were corticospinal tract abnormalities including weakness, hyperreflexia, spasticity, Babinski sign (59.8%), ataxia (58.8%), cognitive decline (46.4%), and gait difficulty (38.1%); 68 (35.0%) had baseline cognitive problems. Cumulative incidence function analysis revealed that ataxia, gait difficulties, and corticospinal tract abnormalities developed throughout life, while cognitive decline tended to develop later in life. Of the less common neurological abnormalities, seizures, psychiatric changes and speech changes developed throughout life, while parkinsonism and sensory changes tended to develop later in life. Our case series corroborated this temporal pattern of neurological abnormalities. CONCLUSION We provide estimates for the neurological progression of CTX, categorizing neurological abnormalities according to time and probability of development. Our approach may be applicable to other rare disorders.
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Affiliation(s)
- Janice C Wong
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Kailey Walsh
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, ACC 708, Boston, MA, 02114, USA
| | - Douglas Hayden
- Harvard Medical School, Boston, MA, USA
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Florian S Eichler
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, ACC 708, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, USA.
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14
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Catarino CB, Vollmar C, Küpper C, Seelos K, Gallenmüller C, Bartkiewicz J, Biskup S, Hörtnagel K, Klopstock T. Brain diffusion tensor imaging changes in cerebrotendinous xanthomatosis reversed with treatment. J Neurol 2017. [PMID: 29260356 DOI: 10.1007/s00415‐017‐8711‐9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cerebrotendinous xanthomatosis (CTX, MIM 213700) is a rare autosomal recessive lipid storage disorder caused by CYP27A1 mutations. Treatment with chenodeoxycholic acid (CDCA) may slow the progression of the disease and reverse some symptoms in a proportion of patients. In a non-consanguineous Caucasian family, two siblings with CTX were evaluated before treatment and prospectively followed-up every 6 months after starting CDCA therapy, using systematic clinical examination, neuropsychological tests, laboratory tests, electroencephalography (EEG) and brain MRI, diffusion tensor imaging (DTI) and tractography. A 30-year-old patient and her 27-year-old brother were referred for progressive spastic paraparesis. Both had epilepsy, learning difficulties, chronic diarrhoea and juvenile-onset cataracts. CTX was diagnosed by increased cholestanol levels and compound heterozygosity for CYP27A1 mutations. Therapy with CDCA led to resolution of chronic diarrhoea, normalisation of serum cholestanol and EEG, and a progressive improvement in gait, cognition and seizure control. Before treatment, conventional brain MRI showed no CTX-related abnormalities for the proband and no cerebellar abnormalities for the brother, while DTI showed reduced fractional anisotropy (FA) and tract-density in the cerebellum and widespread cerebral reductions of FA in both patients, compared to a group of 35 healthy controls. Repeated DTI after starting therapy showed progressive increases of cerebellar tract density and of cerebral FA. In patients with CTX, therapy with CDCA may lead to significant clinical improvement, with normalisation of biochemical and electrophysiological biomarkers. DTI and tractography may detect changes when the conventional MRI is unremarkable and may provide potential neuroimaging biomarkers for monitoring treatment response in CTX, while the conventional MRI remains unchanged.
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Affiliation(s)
- Claudia B Catarino
- Department of Neurology with Friedrich-Baur Institute, University Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany
| | - Christian Vollmar
- Department of Neurology with Friedrich-Baur Institute, University Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany.,Department of Neuroradiology, University Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany
| | - Clemens Küpper
- Department of Neurology with Friedrich-Baur Institute, University Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany.,German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Klaus Seelos
- Department of Neuroradiology, University Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany
| | - Constanze Gallenmüller
- Department of Neurology with Friedrich-Baur Institute, University Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany
| | - Joanna Bartkiewicz
- Department of Neurology with Friedrich-Baur Institute, University Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany
| | - Saskia Biskup
- CeGaT GmbH und Praxis für Humangenetik, Tübingen, Germany
| | | | - Thomas Klopstock
- Department of Neurology with Friedrich-Baur Institute, University Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany. .,German Center for Neurodegenerative Diseases (DZNE), Munich, Germany. .,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany.
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15
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Brain diffusion tensor imaging changes in cerebrotendinous xanthomatosis reversed with treatment. J Neurol 2017; 265:388-393. [PMID: 29260356 DOI: 10.1007/s00415-017-8711-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 12/10/2017] [Accepted: 12/11/2017] [Indexed: 10/18/2022]
Abstract
Cerebrotendinous xanthomatosis (CTX, MIM 213700) is a rare autosomal recessive lipid storage disorder caused by CYP27A1 mutations. Treatment with chenodeoxycholic acid (CDCA) may slow the progression of the disease and reverse some symptoms in a proportion of patients. In a non-consanguineous Caucasian family, two siblings with CTX were evaluated before treatment and prospectively followed-up every 6 months after starting CDCA therapy, using systematic clinical examination, neuropsychological tests, laboratory tests, electroencephalography (EEG) and brain MRI, diffusion tensor imaging (DTI) and tractography. A 30-year-old patient and her 27-year-old brother were referred for progressive spastic paraparesis. Both had epilepsy, learning difficulties, chronic diarrhoea and juvenile-onset cataracts. CTX was diagnosed by increased cholestanol levels and compound heterozygosity for CYP27A1 mutations. Therapy with CDCA led to resolution of chronic diarrhoea, normalisation of serum cholestanol and EEG, and a progressive improvement in gait, cognition and seizure control. Before treatment, conventional brain MRI showed no CTX-related abnormalities for the proband and no cerebellar abnormalities for the brother, while DTI showed reduced fractional anisotropy (FA) and tract-density in the cerebellum and widespread cerebral reductions of FA in both patients, compared to a group of 35 healthy controls. Repeated DTI after starting therapy showed progressive increases of cerebellar tract density and of cerebral FA. In patients with CTX, therapy with CDCA may lead to significant clinical improvement, with normalisation of biochemical and electrophysiological biomarkers. DTI and tractography may detect changes when the conventional MRI is unremarkable and may provide potential neuroimaging biomarkers for monitoring treatment response in CTX, while the conventional MRI remains unchanged.
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16
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Nie S, Chen G, Cao X, Zhang Y. Cerebrotendinous xanthomatosis: a comprehensive review of pathogenesis, clinical manifestations, diagnosis, and management. Orphanet J Rare Dis 2014; 9:179. [PMID: 25424010 PMCID: PMC4264335 DOI: 10.1186/s13023-014-0179-4] [Citation(s) in RCA: 190] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 11/04/2014] [Indexed: 12/20/2022] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) OMIM#213700 is a rare autosomal-recessive lipid storage disease caused by mutations in the CYP27A1 gene; this gene codes for the mitochondrial enzyme sterol 27-hydroxylase, which is involved in bile acid synthesis. The CYP27A1 gene is located on chromosome 2q33-qter and contains nine exons. A CYP27A1 mutation leads to decreased synthesis of bile acid, excess production of cholestanol, and consequent accumulation of cholestanol in tissues. Currently there is no consensus on the prevalence of CTX, one estimate being <5/100,000 worldwide. The prevalence of CTX due to the CYP27A1 mutation R362C alone is approximately 1/50,000 in Caucasians. Patients with CTX have an average age of 35 years at the time of diagnosis and a diagnostic delay of 16 years. Clinical signs and symptoms include adult-onset progressive neurological dysfunction (i.e., ataxia, dystonia, dementia, epilepsy, psychiatric disorders,peripheral neuropathy, and myopathy) and premature non-neurologic manifestations (i.e., tendon xanthomas, childhood-onset cataracts, infantile-onset diarrhea, premature atherosclerosis, osteoporosis, and respiratory insufficiency). Juvenile cataracts, progressive neurologic dysfunction, and mild pulmonary insufficiency are unique symptoms that distinguish CTX from other lipid storage disorders including familial dysbetalipoproteinemia, homozygous familial hypercholesterolemia, and sitosterolemia, all of which might also present with xanthomas and cardiovascular diseases. Brain magnetic resonance imaging (MRI) shows bilateral lesions in the dentate nucleus of the cerebellum and mild white matter lesions. The classical symptoms and signs, namely elevated levels of cholestanol and bile alcohols in serum and urine, brain MRI, and the mutation in the CYP27A1 gene confirm the diagnosis of CTX. Early diagnosis and long-term treatment with chenodeoxycholic acid (750 mg/d) improve neurological symptoms and contribute to a better prognosis.
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Affiliation(s)
- Shuke Nie
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.
| | - Guiqin Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.
| | - Xuebing Cao
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.
| | - Yunjian Zhang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.
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17
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99mTc-sestamibi thigh SPECT/CT imaging for assessment of myopathy in cerebrotendinous xanthomatosis with histopathological and immunohistochemical correlation. Clin Nucl Med 2014; 39:e202-7. [PMID: 23989447 DOI: 10.1097/rlu.0b013e3182a20d8e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE The aim of this study was to determine the effectiveness of using Tc-sestamibi thigh SPECT/CT imaging for evaluating myopathy in cerebrotendinous xanthomatosis (CTX). PATIENTS AND METHODS Four genetically proven CTX patients (Family I, Cases I-1 and I-2; Family II, Cases II-1 and II-2) were included. They all underwent muscle biopsies for histopathologic and ultrastructural studies. Immunohistochemical staining for vinculin expression was also performed. Tc-sestamibi thigh SPECT/CT imaging was conducted on all 4 CTX patients, and both visual interpretation and muscle-to-background (M/B) ratio count were applied for assessment. Correlation analysis of the imaging findings and results of the ultrastructural and immunohistochemical studies was done. RESULTS In the Tc-sestamibi thigh SPECT/CT imaging study, all 4 CTX cases had abnormal scores of visual interpretation and M/B ratios. The ultrastructural features of the skeletal muscle of the 4 CTX cases showed mitochondrial and membrane system abnormalities, with increased depositions of metabolites. They also had abnormal increases in vinculin expression after immunohistochemical staining of the skeletal muscle. CONCLUSIONS This is the first report on the use of Tc-sestamibi thigh SPECT/CT imaging to assess the mitochondrial status of CTX. The imaging findings may have a correlation with the ultrastructural and immunohistochemical findings on skeletal muscle. Although the Tc-sestamibi thigh SPECT/CT imaging is not specific for CTX, this noninvasive in vivo assessment can be an important tool for the detection and follow-up study of skeletal muscle involvement in CTX.
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18
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A histogram-based similarity measure for quantitative magnetic resonance imaging: application in acute mild traumatic brain injury. J Comput Assist Tomogr 2014; 38:915-23. [PMID: 25162292 DOI: 10.1097/rct.0000000000000143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The most commonly used summary metric in neuroimaging is the mean value, but this pays little attention to the shape of the data distribution and can therefore be insensitive to subtle changes that alter the data distribution. METHODS We propose a distributional-based metric called the normalized histogram similarity measure (HSM) for characterization of quantitative images. We applied HSM to quantitative magnetic resonance imaging T1 relaxation data of 44 patients with mild traumatic brain injury and compared with data of 43 age-matched controls. RESULTS Significant differences were found between the patients and the controls in 8 gray matter regions using the HSM whereas in only 1 gray matter region based on the mean values. CONCLUSIONS Our results show that HSM is more sensitive than the standard mean values in detecting brain tissue changes. Future studies on brain tissue properties using quantitative magnetic resonance imaging should consider the use of HSM to properly capture any tissue changes.
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19
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Rieger D, Auerbach S, Robinson P, Gropman A. Neuroimaging of lipid storage disorders. ACTA ACUST UNITED AC 2014; 17:269-82. [PMID: 23798015 DOI: 10.1002/ddrr.1120] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2012] [Indexed: 01/09/2023]
Abstract
Lipid storage diseases, also known as the lipidoses, are a group of inherited metabolic disorders in which there is lipid accumulation in various cell types, including the central nervous system, because of the deficiency of a variety of enzymes. Over time, excessive storage can cause permanent cellular and tissue damage. The brain is particularly sensitive to lipid storage as the contents of the central nervous system must occupy uniform volume, and any increases in fluids or deposits will lead to pressure changes and interference with normal neurological function. In addition to primary lipid storage diseases, lysosomal storage diseases include the mucolipidoses (in which excessive amounts of lipids and carbohydrates are stored in the cells and tissues) and the mucopolysaccharidoses (in which abnormal glycosylated proteins cannot be broken down because of enzyme deficiency). Neurological dysfunction can be a manifestation of these conditions due to substrate deposition as well. This review will explore the modalities of neuroimaging that may have particular relevance to the study of the lipid storage disorder and their impact on elucidating aspects of brain function. First, the techniques will be reviewed. Next, the neuropathology of a few selected lipid storage disorders will be reviewed and the use of neuroimaging to define disease characteristics discussed in further detail. Examples of studies using these techniques will be discussed in the text.
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Affiliation(s)
- Deborah Rieger
- Department of Pediatrics, Children's National Medical Center and the George Washington University of the Health Sciences, Washington, District of Columbia, USA
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20
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Fraidakis MJ. Psychiatric manifestations in cerebrotendinous xanthomatosis. Transl Psychiatry 2013; 3:e302. [PMID: 24002088 PMCID: PMC3784765 DOI: 10.1038/tp.2013.76] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 07/19/2013] [Indexed: 12/26/2022] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is a rare and severe, but treatable, inborn disorder of bile acid biosynthesis and sterol storage with autosomal recessive inheritance and variable clinical presentation. CTX treatment consists of chenodeoxycholic acid and must be started as early as possible to prevent permanent disability. Psychiatric manifestations are rare and non-specific, and often lead to significant diagnostic and treatment delay. Therefore, better recognition of the gamut of psychiatric manifestations in CTX can diminish the risk of misdiagnosis and irreversible neurological deterioration. We hereby describe the psychiatric features in CTX. A complete review of all published cases of CTX in the medical literature was undertaken and the case reports with psychiatric presentation were collected and analyzed. We also describe the psychiatric features in relation to the neurological semeiology in six patients with CTX diagnosed at the La Salpêtrière Hospital. We conclude that psychiatric manifestations in CTX follow a bimodal/bitemporal pattern, appearing early in the disease course in the form of a behavioral/personality disorder associated with learning difficulties or mental retardation, or manifesting in advanced disease in the setting of dementia as rich neuropsychiatric syndromes, such as frontal, orbitofrontal or frontotemporal syndromes of cortico-subcortical dementia encompassing behavioral/personality disturbance, affective/mood disorders or psychotic disorders. Behavioral/personality disturbance in childhood or adolescence, especially when accompanied by learning difficulties, should therefore lead to further investigation to exclude CTX, as early diagnosis and treatment is critical for prognosis.
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Affiliation(s)
- M J Fraidakis
- Federation of Neurology, La Salpêtrière Hospital, Groupe Hopsitalier Pitié-Salpêtrière (GHPS), Paris, France,Department of Neurogenetics, La Salpêtrière Hospital, Groupe Hopsitalier Pitié-Salpêtrière (GHPS), Paris, France,Fédération de Neurologie, Hôpital de la Salpêtrière, Groupement Hospitalier Universitaire Est Pitié-Salpêtrière (GHPS), Boulevard de l'Hôpital 47–83, 75651 Paris, France. E-mail:
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21
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Walterfang M, Bonnot O, Mocellin R, Velakoulis D. The neuropsychiatry of inborn errors of metabolism. J Inherit Metab Dis 2013; 36:687-702. [PMID: 23700255 DOI: 10.1007/s10545-013-9618-y] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 04/29/2013] [Accepted: 04/30/2013] [Indexed: 12/15/2022]
Abstract
A number of metabolic disorders that affect the central nervous system can present in childhood, adolescence or adulthood as a phenocopy of a major psychiatric syndrome such as psychosis, depression, anxiety or mania. An understanding and awareness of secondary syndromes in metabolic disorders is of great importance as it can lead to the early diagnosis of such disorders. Many of these metabolic disorders are progressive and may have illness-modifying treatments available. Earlier diagnosis may prevent or delay damage to the central nervous system and allow for the institution of appropriate treatment and family and genetic counselling. Metabolic disorders appear to result in neuropsychiatric illness either through disruption of late neurodevelopmental processes (metachromatic leukodystrophy, adrenoleukodystrophy, GM2 gangliosidosis, Niemann-Pick type C, cerebrotendinous xanthomatosis, neuronal ceroid lipofuscinosis, and alpha mannosidosis) or via chronic or acute disruption of excitatory/inhibitory or monoaminergic neurotransmitter systems (acute intermittent porphyria, maple syrup urine disease, urea cycle disorders, phenylketonuria and disorders of homocysteine metabolism). In this manuscript we review the evidence for neuropsychiatric illness in major metabolic disorders and discuss the possible models for how these disorders result in psychiatric symptoms. Treatment considerations are discussed, including treatment resistance, the increased propensity for side-effects and the possibility of some treatments worsening the underlying disorder.
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Affiliation(s)
- Mark Walterfang
- Melbourne Neuropsychiatry Centre, University of Melbourne and Melbourne Health, Parkville, Australia.
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22
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Positive correlation between the degree of visual field defect and optic radiation damage in glaucoma patients. Jpn J Ophthalmol 2013; 57:257-62. [DOI: 10.1007/s10384-013-0233-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 12/26/2012] [Indexed: 12/01/2022]
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23
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Caroppo P, D'Agata F, Mignarri A, Stromillo ML, Dotti MT, Mongini T. Brain metabolism changes after therapy with chenodeoxycholic acid in a case of cerebrotendinous xanthomatosis. Neurol Sci 2012. [PMID: 23212406 DOI: 10.1007/s10072‐012‐1262‐z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Paola Caroppo
- Department of Neuroscience, University of Turin, Via Cherasco, 15, 10126, Turin, Italy,
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Caroppo P, D'Agata F, Mignarri A, Stromillo ML, Dotti MT, Mongini T. Brain metabolism changes after therapy with chenodeoxycholic acid in a case of cerebrotendinous xanthomatosis. Neurol Sci 2012; 34:1693-6. [PMID: 23212406 DOI: 10.1007/s10072-012-1262-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 11/27/2012] [Indexed: 11/25/2022]
Affiliation(s)
- Paola Caroppo
- Department of Neuroscience, University of Turin, Via Cherasco, 15, 10126, Turin, Italy,
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Chen SF, Tsai NW, Chang CC, Lu CH, Huang CR, Chuang YC, Chang WN. Neuromuscular abnormality and autonomic dysfunction in patients with cerebrotendinous xanthomatosis. BMC Neurol 2011; 11:63. [PMID: 21627786 PMCID: PMC3119170 DOI: 10.1186/1471-2377-11-63] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2010] [Accepted: 05/31/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cerebrotendinous xanthomatosis (CTX) is a rare lipid-storage disease. Neuromuscular abnormality and autonomic system (ANS) dysfuction in CTX are rarely examined in large-scale studies in the literature. We studied the peripheral nervous system, myopathology, and autonomic system of four CTX patients and performed a literature review of the reported CTX patients with peripheral neuropathy. METHODS Four biochemically and genetically confirmed CTX patients, belonging to two families, were included for study and all received nerve conduction study (NCS), muscle biopsy for histopathologic and ultrastructural study, skin biopsy for intraepidermal nerve fiber (INEF) density measurement, autonomic testings including sympathetic skin response, R-R interval variation and head-up tilt test using an automated tilt table to record the changes of blood pressure and heart rate in different postures. The Q-Sweat test was also applied for the detection of sweat amount and onset time of response. The clinical characteristics, study methods and results of 13 studies of peripheral neuropathy in CTX patients in the literature were also recorded for analysis. RESULTS The results of NCS study showed axonal sensory-motor polyneuropathy in three CTX cases and mixed axonal and demyelinating sensor-motor polyneuropathy in one. The myopathological and histopathologic studies revealed mild denervation characteristics, but the ultrastructural study revealed changes of mitochondria and the membranous system, and increased amounts of glycogen, lipofuscin and lipid deposition. The ANS study revealed different degrees of abnormalities in the applied tests and the INEF density measurement showed small fiber neuropathy in three of the four CTX patients. The literature review of peripheral neuropathy in CTX revealed different types of peripheral neuropathy, of which axonal peripheral neuropathy was the most common. CONCLUSIONS Peripheral neuropathy, especially the subtype of axonal sensori-motor neuropathy, is common in patients with CTX. Evidence of lipid metabolic derangement in CTX can be reflected in ultrastructural studies of muscles. With an adequate multi-parametric evaluation, a high incidence of ANS abnormalities can be seen in this rare lipid-storage disease, and a high incidence of small fiber involvement is also reflected in the IENF density measurement of skin biopsies.
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Affiliation(s)
- Shu-Fang Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Biological Science, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Nai-Wen Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chung-Chih Chang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Biological Science, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Cheng-Hsien Lu
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chi-Ren Huang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yao-Chung Chuang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wen-Neng Chang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Pilo B, de Blas G, Sobrido MJ, Navarro C, Grandas F, Barrero FJ, Moya MA, Jimenez-Escrig A. Neurophysiological study in cerebrotendinous xanthomatosis. Muscle Nerve 2011; 43:531-6. [PMID: 21404287 DOI: 10.1002/mus.21905] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Cerebrotendinous xanthomatosis (CTX) is a rare autosomal-recessive disease due to mutations of the 27α-hydroxylase. It is characterized by cataracts, xanthomas, and neurological manifestations. Polyneuropathy has been reported, although it is unclear whether it is axonal or demyelinating. METHODS We report clinical and neurophysiological results of 13 patients with CTX diagnosed in Spain. RESULTS In 8 patients (62%), peripheral neuropathy was demonstrated (4 demyelinating, 3 axonal, and 1 mixed; 3 predominantly motor and 5 sensorimotor). All patients had clinical signs/symptoms of peripheral neuropathy. Upper limb somatosensory evoked potentials (SSEPs) were affected in 38% of patients, and lower limb SSEPs in 67%. Fifty percent of patients had delayed brainstem auditory evoked potentials, and 43% had affected visual evoked potentials. DISCUSSION In this series, polyneuropathy was predominantly sensorimotor and demyelinating. Neurophysiological studies correlated only partially with clinical follow-up. Therefore, we recommend neurophysiological follow-up studies only if clinical symptoms are present.
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Affiliation(s)
- Belen Pilo
- Neurology Division, Hospital del Sureste, c/ Ronda del Sur s/n, 28500 Madrid, Spain.
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SPECT imaging for brain improvement quantification in a patient with cerebrotendinous xanthomatosis. Clin Nucl Med 2011; 36:38-9. [PMID: 21157207 DOI: 10.1097/rlu.0b013e3181feed83] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cerebrotendinous xanthomatosis is a rare recessive autosomal disease caused by mutations of the sterol 27-hydroxylase gene (CYP27), which leads to reduced synthesis of bile acids, particularly chenodeoxycholic acid (Cali et al, J Biol Chem. 1991;266:7779-7783; Gallus et al, Neurol Sci. 2006;27:143-149). The disease is characterized by progressive neurologic dysfunction due to accumulation of cholestanol in neurologic tissues (Moghadasian et al, Arch Neurol. 2002;59:527-529; Selva-O'Callaghan et al, Rheumatology. 2007;46:1212-1213). Long-term treatment with chenodeoxycholic acid can arrest or even reverse progression of the disease (Pierre et al, J Inherit Metab Dis. In press).Brain SPECT with 740 MBq of Tc-99m ethyl cysteinate dimmer, using a double-head gamma camera (Siemens E.cam) with high-resolution, low-energy parallel collimators was performed in our patient at onset and 2 years after starting chenodeoxycholic acid treatment. SPECT acquisitions were performed using a 360-degree orbit, 1 image/30 seg/3 degree, and 128 × 128 matrix. Reconstruction was by means of filtered back-projection, Butterworth 5/0.25, without attenuation correction. Pre- and post-SPECT dicom images were reoriented into Talairach space using NeuroGam (Segami Corporation). To visually identify abnormal perfusion regions, volume render brain image was computed, where abnormal perfusion regions were found by comparing with age-matched normal database, and Brodmann areas (BA) were quantified. Pre- versus post-treatment changes were computed by means of relative percentage between counts. Post-treatment SPECT showed better perfusion than pretreatment SPECT with an increase between 5% and 10% in frontal cortex (BA 9, BA 24, BA 32, BA 46, BA 47), parietal cortex (BA 5, BA 31), and temporal cortex (BA 20, BA 22, BA 28, BA 36, BA 37, BA 38), and with an increase of more than 10% in frontal cortex (BA 45) and parietal cortex (BA 23). This case illustrates the benefit of bile acid therapy for halting and even reversing neurologic retardation in this condition.
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