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Weinstock A, Bebin EM, Checketts D, Clark GD, Szaflarski JP, Seltzer LE, Thiele EA, Sahebkar F. Long-term efficacy and safety of cannabidiol in patients with tuberous sclerosis complex: 3-year results from the cannabidiol expanded access program. Epilepsia Open 2024; 9:1816-1825. [PMID: 39088193 PMCID: PMC11450615 DOI: 10.1002/epi4.13013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/27/2024] [Accepted: 07/05/2024] [Indexed: 08/02/2024] Open
Abstract
OBJECTIVE The cannabidiol (CBD) Expanded Access Program provided compassionate access to CBD for patients with treatment-resistant epilepsy, including tuberous sclerosis complex (TSC), at 35 US epilepsy centers. Here, we present the long-term efficacy and safety outcomes for add-on CBD treatment in patients with TSC. METHODS Patients received plant-derived, highly purified CBD (Epidiolex® 100 mg/mL, oral solution), increasing from 2 to 10 mg/kg/d to tolerance or maximum of 25-50 mg/kg/d. Efficacy endpoints were percentage change from baseline in median monthly convulsive, focal, and total seizure frequency and ≥ 50%, ≥75%, and 100% responder rates across 12-week visit windows through 144 weeks. Adverse events (AEs) are reported through 233 weeks. RESULTS Thirty-four patients with confirmed TSC were included. Mean age was 12.4 years (range, 1.8-31.2), and patients were receiving a median of 3 (range, 1-7) antiseizure medications (ASMs) at baseline. Median CBD dose was 25-28 mg/kg/d for 36 weeks and then 20-50 mg/kg/d through 228 weeks. Dose reduction from baseline occurred for most ASMs, except topiramate. Median reduction in the frequency of convulsive, focal, and total seizures was 44%-81%, 51%-87%, and 44%-87%, respectively, through 144 weeks. Responder rates (≥50%, ≥75%, and 100% reduction) were 43%-71%, 14%-58%, and 0%-25% for convulsive seizures; 52%-75%, 35%-60%, and 7%-32% for focal seizures; and 46%-79%, 26%-65%, and 0%-13% for total seizures. A total of 94% of patients experienced ≥1 AE; 47% had serious AEs, considered treatment unrelated by the investigator. Treatment-related AEs (TRAEs) occurred in 71% of patients. The most frequently reported TRAEs were somnolence, diarrhea, and ataxia. Two patients experienced AEs leading to discontinuation. There were no deaths. SIGNIFICANCE Long-term add-on CBD use was associated with reduced seizure frequency through 144 weeks. The safety profile was consistent with previous reports. PLAIN LANGUAGE SUMMARY In this study, we evaluated efficacy and safety of cannabidiol (CBD) treatment in patients with tuberous sclerosis complex receiving CBD in addition to other antiseizure treatments in an Expanded Access Program. After starting CBD, 46%-79% of patients had at least 50% reduction and 26%-65% had at least 75% reduction in the number of seizures per month; up to 13% had no seizures through 144 weeks. Safety results were similar to prior studies; sleepiness and diarrhea were common treatment-related side effects. These results show that long-term CBD treatment was associated with fewer seizures and mild/moderate side effects.
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Affiliation(s)
- Arie Weinstock
- University at Buffalo/Oishei Children's HospitalBuffaloNew YorkUSA
| | | | | | - Gary D. Clark
- Texas Children's Hospital/Baylor College of MedicineHoustonTexasUSA
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Loubert F, House AA, Larochelle C, Major P, Keezer MR. Development and internal validation of a clinical risk score to predict incident renal and pulmonary tumours in people with tuberous sclerosis complex. J Med Genet 2024; 61:943-949. [PMID: 38977299 DOI: 10.1136/jmg-2023-109717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 06/25/2024] [Indexed: 07/10/2024]
Abstract
OBJECTIVE This study aims to develop and internally validate a clinical risk score to predict incident renal angiomyolipoma (AML) and pulmonary lymphangioleiomyomatosis (LAM) in people with tuberous sclerosis complex (TSC). STUDY DESIGN Data from 2420 participants in the TSC Alliance Natural History Database were leveraged for these analyses. Logistic regression was used to predict AML and LAM development using 10 early-onset clinical manifestations of TSC as potential predictors, in addition to sex and genetic mutation. For our models, we divided AML into three separate outcomes: presence or absence of AML, unilateral or bilateral and whether any are ≥3 cm in diameter. The resulting regression models were turned into clinical risk scores which were then internally validated using bootstrap resampling, measuring discrimination and calibration. RESULTS The lowest clinical risk scores predicted a risk of AML and LAM of 1% and 0%, while the highest scores predicted a risk of 99% and 73%, respectively. Calibration was excellent for all three AML outcomes and good for LAM. Discrimination ranged from good to strong. C-statistics of 0.84, 0.83, 0.83 and 0.92 were seen for AML, bilateral AML, AML with a lesion≥3 cm and LAM, respectively. CONCLUSION Our work is an important step towards identifying individuals who could benefit from preventative strategies as well as more versus less frequent screening imaging. We expect that our work will allow for more personalised medicine in people with TSC. External validation of the risk scores will be important to confirm the robustness of our findings.
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Affiliation(s)
| | | | - Catherine Larochelle
- Université de Montréal, Montreal, Quebec, Canada
- Department of Neurosciences, Université de Montréal, Montreal, Quebec, Canada
| | - Philippe Major
- Research Center, Saint Justine University Hospital Research Centre, Montreal, Quebec, Canada
| | - Mark R Keezer
- CRCHUM, Montreal, Quebec, Canada
- Department of Neurosciences, Université de Montréal, Montreal, Quebec, Canada
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Nunes BA, Romano AKFG, Pasa Morgan MA, Gonçalves AA, Cardozo LFM, de Almeida LGD, Haddad LA, Crippa ACDS, Antoniuk SA, Abagge KT. A dermatological assessment of pediatric patients with tuberous sclerosis complex (TSC). An Bras Dermatol 2024; 99:662-669. [PMID: 38658236 PMCID: PMC11342998 DOI: 10.1016/j.abd.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/09/2023] [Accepted: 11/17/2023] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a multisystem neurocutaneous syndrome with variable phenotypes. Recent updates of TSC diagnostic criteria reaffirmed the defined genetic diagnostic criterion as the finding of a pathogenic DNA alteration in either TSC1 or TSC2 genes. It also slightly modified definite clinical diagnostic criteria. TSC-associated skin lesions in infancy are important clinical signs to select individuals with possible TSC for a closer clinical follow-up and genetic testing. OBJECTIVE To raise awareness of the updated TSC diagnosis criteria; to assess the frequency of skin lesions in TSC patients as well as the first dermatological presentation; and to associate the findings with either TSC1 or TSC2 mutations. METHODS Observational cross-sectional study. Clinical and genetic data were retrospectively collected from 37 TSC patients from a Brazilian University Hospital. Patients with skin signs were examined and prospectively assessed for 12 months. RESULTS The earliest cutaneous lesions were hypomelanotic macules, which together with angiofibromas were the most frequent dermatological lesions. The total pathogenic DNA alteration ratio between TSC2 and TSC1 genes was 8:1. The frequency of a TSC2 pathogenic variant was 10-fold greater in the presence of ungual fibromas. STUDY LIMITATIONS Small sample and a limited number of patients with TSC1 pathogenic variants. CONCLUSION Clinicians should be knowledgeable about TSC updated diagnostic criteria. Patients need to be followed up by a multidisciplinary team and treated accordingly. Early detection of cutaneous lesions is important for TSC diagnosis. A significant association between TSC2 gene pathogenic alterations and ungual fibromas is described.
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Affiliation(s)
| | | | - Mariana Aparecida Pasa Morgan
- Department of Pediatrics, Universidade Federal do Paraná, Curitiba, PR, Brazil; Postgraduate Program in Child and Adolescent Health, Complexo Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | | | - Laís Faria Masulk Cardozo
- Postgraduate Program in Child and Adolescent Health, Complexo Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Luiz Gustavo Dufner de Almeida
- Department of Genetics and Evolutionary Biology, Centro de Pesquisa do Genoma Humano e Células-Tronco, Instituto de Biociências, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luciana Amaral Haddad
- Department of Genetics and Evolutionary Biology, Centro de Pesquisa do Genoma Humano e Células-Tronco, Instituto de Biociências, Universidade de São Paulo, São Paulo, SP, Brazil
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Vasseghi M, Behan C, Connolly A, Cunningham D, Dempsey E, Flynn C, Galvin M, Griffin G, Moloney P, Murphy M, Owen Y, O’Malley S, O’Rourke G, O’Sullivan O, Doherty CP. Widespread service fragmentation for patients and families with tuberous sclerosis complex (TSC) in the Republic of Ireland. JOURNAL OF RARE DISEASES (BERLIN, GERMANY) 2024; 3:24. [PMID: 39165678 PMCID: PMC11330946 DOI: 10.1007/s44162-024-00049-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 05/20/2024] [Indexed: 08/22/2024]
Abstract
Background Tuberous sclerosis complex (TSC) is a rare approximate 1:6000 birth incidence, a genetic disease with a wide variability of physical and neuropsychiatric symptoms. Patients require lifelong care from multiple healthcare specialities, for which International and United Kingdom (UK) TSC consensus recommendations exist. Personalised care delivered by a centralised coordinated team of TSC experts is recommended. There is no such service for the estimated 600 TSC patients in the Republic of Ireland (ROI) and there is a paucity of information regarding the healthcare of this group. Purpose Evaluate the baseline care of patients with TSC attending epilepsy services in the Republic of Ireland (ROI) against UK TSC consensus recommendations. Methods Patients with a diagnosis of TSC attending 12 adult and paediatric epilepsy centres in the ROI were identified. Clinical audits measured the baseline care of a subset of these patients against UK, TSC clinical recommendations. Data was anonymised and analysed at Trinity College Dublin. Results One hundred thirty-five TSC patients attending twelve epilepsy centres were identified. Adults (n = 67) paediatric (n = 68). The care of 83 patients was audited (n = 63 ≥ 18 years) and (n = 20 < 18 years). Many baseline tests were completed, however, they required intra or interhospital referral. Care appears fragmented and there was no evidence of formal disease surveillance plans. Conclusions The number of TSC patients attending epilepsy services is lower than expected (n = 135). Specialist services and treatments for TSC are available through informal referral pathways. Although UK, TSC consensus baseline recommendations are roughly adhered to, care is fragmented. Increased coordination of care could benefit disease management. Supplementary Information The online version contains supplementary material available at 10.1007/s44162-024-00049-8.
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Affiliation(s)
- M. Vasseghi
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin (The University of Dublin), Dublin, Ireland
- FutureNeuro, SFI Research Centre, Dublin, Ireland
| | - C. Behan
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin (The University of Dublin), Dublin, Ireland
- St James’s Hospital, Dublin, Ireland
- FutureNeuro, SFI Research Centre, Dublin, Ireland
| | - A. Connolly
- Childrens Health Ireland at Tallaght, Dublin, Ireland
| | - D. Cunningham
- Childrens Health Ireland at Tallaght, Dublin, Ireland
| | - E. Dempsey
- Mater Misericordiae Hospital, Dublin, Ireland
| | - C. Flynn
- St. Vincent’s University Hospital, Dublin, Ireland
| | - M. Galvin
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin (The University of Dublin), Dublin, Ireland
- FutureNeuro, SFI Research Centre, Dublin, Ireland
| | - G. Griffin
- Childrens Health Ireland, Dublin, Ireland
| | | | - M. Murphy
- Cork University Hospital, Cork, Ireland
| | - Y. Owen
- St. Vincent’s University Hospital, Dublin, Ireland
| | - S. O’Malley
- Childrens Health Ireland at Temple Street, Dublin, Ireland
| | | | | | - C. P. Doherty
- Academic Unit of Neurology, School of Medicine, Trinity College Dublin (The University of Dublin), Dublin, Ireland
- St James’s Hospital, Dublin, Ireland
- FutureNeuro, SFI Research Centre, Dublin, Ireland
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Duan J, Pan S, Ye Y, Hu Z, Chen L, Liang D, Fu T, Zhan L, Li Z, Liao J, Zhao X. Uncovering hidden genetic variations: long-read sequencing reveals new insights into tuberous sclerosis complex. Front Cell Dev Biol 2024; 12:1415258. [PMID: 39144255 PMCID: PMC11321964 DOI: 10.3389/fcell.2024.1415258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/10/2024] [Indexed: 08/16/2024] Open
Abstract
Background Tuberous sclerosis is a multi-system disorder caused by mutations in either TSC1 or TSC2. The majority of affected patients (85%-90%) have heterozygous variants, and a smaller number (around 5%) have mosaic variants. Despite using various techniques, some patients still have "no mutation identified" (NMI). Methods We hypothesized that the causal variants of patients with NMI may be structural variants or deep intronic variants. To investigate this, we sequenced the DNA of 26 tuberous sclerosis patients with NMI using targeted long-read sequencing. Results We identified likely pathogenic/pathogenic variants in 13 of the cases, of which 6 were large deletions, four were InDels, two were deep intronic variants, one had retrotransposon insertion in either TSC1 or TSC2, and one was complex rearrangement. Furthermore, there was a de novo Alu element insertion with a high suspicion of pathogenicity that was classified as a variant of unknown significance. Conclusion Our findings expand the current knowledge of known pathogenic variants related to tuberous sclerosis, particularly uncovering mosaic complex structural variations and retrotransposon insertions that have not been previously reported in tuberous sclerosis. Our findings suggest a higher prevalence of mosaicism among tuberous sclerosis patients than previously recognized. Our results indicate that long-read sequencing is a valuable approach for tuberous sclerosis cases with no mutation identified (NMI).
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Affiliation(s)
- Jing Duan
- Department of Neurology, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | | | - Yuanzhen Ye
- Department of Neurology, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Zhanqi Hu
- Department of Neurology, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Li Chen
- Department of Neurology, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Dachao Liang
- Shenzhen A-Smart Medical Research Center, Shenzhen Research Institute of the Chinese University of Hong Kong, Shenzhen, Guangdong, China
| | - Tao Fu
- Shenzhen A-Smart Medical Research Center, Shenzhen Research Institute of the Chinese University of Hong Kong, Shenzhen, Guangdong, China
| | | | - Zhuo Li
- Shenzhen A-Smart Medical Research Center, Shenzhen Research Institute of the Chinese University of Hong Kong, Shenzhen, Guangdong, China
| | - Jianxiang Liao
- Department of Neurology, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
| | - Xia Zhao
- Department of Neurology, Shenzhen Children’s Hospital, Shenzhen, Guangdong, China
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Santamarina MG, Necochea Raffo JA, Lavagnino Contreras G, Recasens Thomas J, Volpacchio M. Predominantly multiple focal non-cystic renal lesions: an imaging approach. Abdom Radiol (NY) 2024:10.1007/s00261-024-04440-3. [PMID: 38913137 DOI: 10.1007/s00261-024-04440-3] [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: 05/02/2024] [Revised: 06/06/2024] [Accepted: 06/06/2024] [Indexed: 06/25/2024]
Abstract
Multiple non-cystic renal lesions are occasionally discovered during imaging for various reasons and poses a diagnostic challenge to the practicing radiologist. These lesions may appear as a primary or dominant imaging finding or may be an additional abnormality in the setting of multiorgan involvement. Awareness of the imaging appearance of the various entities presenting as renal lesions integrated with associated extrarenal imaging findings along with clinical information is crucial for a proper diagnostic approach and patient work-up. This review summarizes the most relevant causes of infectious, inflammatory, vascular, and neoplastic disorders presenting as predominantly multiple focal non-cystic lesions.
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Affiliation(s)
- Mario G Santamarina
- Radiology Department, Hospital Naval Almirante Nef, Subida Alesandri S/N., Viña del Mar, Provincia de Valparaíso, Chile.
- Radiology Department, Hospital Dr. Eduardo Pereira, Valparaiso, Chile.
| | - Javier A Necochea Raffo
- Radiology Department, Hospital Naval Almirante Nef, Subida Alesandri S/N., Viña del Mar, Provincia de Valparaíso, Chile
| | | | - Jaime Recasens Thomas
- Departamento de Radiología, Escuela de Medicina, Universidad de Valparaíso, Valparaiso, Chile
| | - Mariano Volpacchio
- Radiology Department, Centro de Diagnóstico Dr. Enrique Rossi, Buenos Aires, Argentina
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Lazea C, Țaranu I, Bolboacă SD. Exploring Cardiovascular Involvement in Tuberous Sclerosis: Insights for Pediatric Clinicians. CHILDREN (BASEL, SWITZERLAND) 2024; 11:674. [PMID: 38929253 PMCID: PMC11201926 DOI: 10.3390/children11060674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/22/2024] [Accepted: 05/23/2024] [Indexed: 06/28/2024]
Abstract
Tuberous sclerosis is a rare genetic disorder involving mainly the nervous and cardiovascular systems. The early recognition of the cardiovascular manifestations by the pediatrician allows an appropriate management and therefore enhances the quality of life of the affected children. Cardiac rhabdomyomas and the associated arrhythmias are the first cardiac features and they might represent a diagnosis challenge given their wide spectrum of clinical manifestations. We aimed to provide the paediatric practitioners with current knowledge regarding the cardiovascular complications in children with tuberous sclerosis. We overviewed the antenatal and postnatal evolution of cardiovascular manifestations, the systematic screening and long-term follow-up strategy of cardiac rhabdomyomas and arrhythmias in children with tuberous sclerosis.
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Affiliation(s)
- Cecilia Lazea
- Pediatric Clinic 1, Emergency Pediatric Hospital, Calea Moților, No. 68, 400370 Cluj-Napoca, Romania;
- Department Mother and Child, Iuliu Hațieganu University of Medicine and Pharmacy, Calea Moților, No. 68, 400370 Cluj-Napoca, Romania
| | - Ioana Țaranu
- Department of Medical Informatics and Biostatistics, Iuliu Hațieganu University of Medicine and Pharmacy, Louis Pasteur Str., No. 6, 400349 Cluj-Napoca, Romania;
| | - Sorana D. Bolboacă
- Department of Medical Informatics and Biostatistics, Iuliu Hațieganu University of Medicine and Pharmacy, Louis Pasteur Str., No. 6, 400349 Cluj-Napoca, Romania;
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Lee HY, Lin CH, Wang XA, Tsai JD. Neuropsychiatric comorbidities in tuberous sclerosis complex patients with epilepsy: results of the TAND checklist survey. Acta Neurol Belg 2024; 124:973-979. [PMID: 38523222 DOI: 10.1007/s13760-024-02510-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 02/23/2024] [Indexed: 03/26/2024]
Abstract
PURPOSE In addition to epilepsy, individuals with tuberous sclerosis complex (TSC) experience a wide range of behavioral, psychiatric, intellectual, academic, and psychosocial problems. They usually exert a large psychological burden on individuals with these illnesses. METHODS This cross-sectional study used TSC-associated neuropsychiatric disorders (TAND) checklist interviews conducted at a single medical center. The enrollment of all subjects was > 6 years, and the comorbidities of neurodevelopmental disorders were assessed by clinical psychologists before enrollment. To assess the spectrum of TAND, the TAND checklist was applied as stated in the protocol, and the responses to the TAND checklist were evaluated by clinical psychologists. RESULTS In the behavioral concerns of patients with TSC without epilepsy, those with epilepsy had excessive shyness, language delay, lack of eye contact, rigid behavior, inattentiveness, and restlessness. In psychiatric disorders, autism spectrum disorder and attention-deficit/hyperactivity disorder are significantly correlated with epilepsy history. Diminished academic skills, including reading, writing, and mathematics skills, are significantly associated with epilepsy history. For intellectual ability, TSC patients without epilepsy is associated normal intelligence level. Among neuropsychological skills, deficits in attention, dual tasking/multi-tasking, visuospatial tasking, and executive skills are significantly associated with epilepsy history. CONCLUSIONS Epilepsy in patients with TSC contributes to comorbid neuropsychiatric disorders. In addition to epilepsy evaluation, it is crucial to evaluate the heterogeneous spectrum of neuropsychiatric disorders using a standard checklist during the annual clinical follow-up of patients with TSC.
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Affiliation(s)
- Hom-Yi Lee
- Department of Psychology, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Room of Psychology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chien-Heng Lin
- School of Medicine, China Medical University, Taichung, Taiwan
- Department of Paediatrics, China Medical University Hospital, Taichung, Taiwan
| | - Xing-An Wang
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Paediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Jeng-Dau Tsai
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan.
- Department of Paediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan.
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Hofmann C, Syrbe S, Hebe J, Kreft J, Stark S, Milde T, Völkers M, Hoffmann GF, Gorenflo M, Kovacevic A. Long-term use of everolimus for refractory arrhythmia in a child with tuberous sclerosis complex. Am J Med Genet A 2024; 194:e63508. [PMID: 38130096 DOI: 10.1002/ajmg.a.63508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/01/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023]
Abstract
Tuberous sclerosis complex is associated with the occurrence of cardiac rhabdomyomas that may result in life-threatening arrhythmia unresponsive to standard antiarrhythmic therapy. We report the case of an infant with multiple cardiac rhabdomyomas who developed severe refractory supraventricular tachycardia (SVT) that was successfully treated with everolimus. Pharmacological mTOR inhibition rapidly improved arrhythmia within few weeks after treatment initiation and correlated with a reduction in tumor size. Intermediate attempts to discontinue everolimus resulted in rhabdomyoma size rebound and recurrence of arrhythmic episodes, which resolved on resumption of therapy. While everolimus treatment led to successful control of arrhythmia in the first years of life, episodes of SVT reoccurred at the age of 6 years. Electrophysiologic testing confirmed an accessory pathway that was successfully ablated, resulting in freedom of arrhythmic events. In summary we present an in-depth evaluation of the long-term use of everolimus in a child with TSC-associated SVT, including the correlation between drug use and arrhythmia outcome. This case report provides important information on the safety and efficacy of an mTOR inhibitor for the treatment of a potentially life-threatening cardiac disease manifestation in TSC for which the optimal treatment strategy is still not well established.
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Affiliation(s)
- Christoph Hofmann
- Department of Internal Medicine III (Cardiology, Angiology, and Pneumology), Heidelberg University Hospital, Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Steffen Syrbe
- Department of General Pediatrics, Division of Neuropediatrics and Metabolic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Joachim Hebe
- Center for Electrophysiology Bremen, Bremen, Germany
| | - Jannis Kreft
- Department of Internal Medicine III (Cardiology, Angiology, and Pneumology), Heidelberg University Hospital, Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Sebastian Stark
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), NCT Heidelberg, Partnership Between German Cancer Research Center (DKFZ) and Heidelberg University Hospital, Germany
- Department of Pediatric Oncology, Hematology and Immunology, Heidelberg University Hospital, Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
| | - Till Milde
- Hopp Children's Cancer Center Heidelberg (KiTZ), Heidelberg, Germany
- National Center for Tumor Diseases (NCT), NCT Heidelberg, Partnership Between German Cancer Research Center (DKFZ) and Heidelberg University Hospital, Germany
- Department of Pediatric Oncology, Hematology and Immunology, Heidelberg University Hospital, Heidelberg, Germany
- Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ) and German Consortium for Translational Cancer Research (DKTK), Heidelberg, Germany
| | - Mirko Völkers
- Department of Internal Medicine III (Cardiology, Angiology, and Pneumology), Heidelberg University Hospital, Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Georg Friedrich Hoffmann
- Department of General Pediatrics, Division of Neuropediatrics and Metabolic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Gorenflo
- Department of Pediatric and Congenital Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Alexander Kovacevic
- Department of Pediatric and Congenital Cardiology, Heidelberg University Hospital, Heidelberg, Germany
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Licchetta L, Bruschi G, Stipa C, Belotti LMB, Ferri L, Mostacci B, Vignatelli L, Minardi R, Di Vito L, Muccioli L, Boni A, Tinuper P, Bisulli F. Tuberous sclerosis complex in adulthood: focus on epilepsy prognosis. Epilepsy Behav 2024; 153:109688. [PMID: 38428171 DOI: 10.1016/j.yebeh.2024.109688] [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: 11/04/2023] [Revised: 01/18/2024] [Accepted: 02/05/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE Typically diagnosed in early childhood or adolescence, TSC is a chronic, multisystemic disorder with age-dependent manifestations posing a challenge for transition and for specific surveillance throughout the lifetime. Data on the clinical features and severity of TSC in adults and on the prognosis of epilepsy are scarce. We analyzed the clinical and genetic features of a cohort of adult patients with TSC, to identify the prognostic predictors of seizure remission after a long follow-up. METHOD We conducted a retrospective analysis of patients diagnosed with TSC according to the updated international diagnostic criteria. Pearson's chi-square or Fisher's exact test and Mann Whitney U test were used to compare variables among the Remission (R) and Non-Remission (NR) group. Univariate and multivariate logistic regression analyses were performed. RESULTS We selected 43 patients with TSC and neurological involvement in terms of epilepsy and/or brain lesions, attending the Epilepsy Center of our Institute: of them, 16 (37.2%) were transitioning from the pediatric care and 6 (13.9%) were referred by other specialists. Multiorgan involvement includes cutaneous (86.0%), nephrological (70.7%), hepatic (40.0%), ocular (34.3%), pneumological (28.6%) and cardiac (26.3%) manifestations. Thirty-nine patients (90.7 %) had epilepsy. The mean age at seizure onset was 4 ± 7.3 years: most patients (29, 76.3 %) presented with focal seizures or spasms by age 3 years; only 2 (5.3 %) had seizure onset in adulthood. Twenty-seven patients (69.2 %) experienced multiple seizure types overtime, 23 (59.0 %) had intellectual disability (ID). At last assessment, 14 (35.9 %) were seizure free (R group) and 25 (64.1 %) had drug-resistant seizures (NR group). At logistic regression univariate analysis, ID (OR 7.9, 95 % CI 1.8--34.7), multiple seizure types lifelong (OR 13.2, 95 % CI 2.6- 67.2), spasms/tonic seizures at presentation (OR 6.5, 95 % CI 1.2--35.2), a higher seizure frequency at onset (OR 5.4, 95 % CI 1.2--24.3), abnormal neurological examination (OR 9.8, 95 % CI 1.1--90.6) and pathogenic variants in TSC2 (OR 5.4, 95 % CI 1.2--24.5) were significantly associated with non-remission. In the multivariate analysis, both ID and multiple seizure types lifelong were confirmed as independent predictors of poor seizure outcome. CONCLUSIONS In our cohort of adult patients with TSC, epilepsy remains one of the main neurological challenges with only 5.3% of cases manifesting in adulthood. Approximately 64% of these patients failed to achieve seizure remission. ID and multiple seizure types were the main predictors of poor outcome. Nephrological manifestations require continuous specific follow-up in adults.
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Affiliation(s)
- Laura Licchetta
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Giulia Bruschi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy; Unit of Neurology and Unit of Clinical Neurophysiology, Department of Neuroscience, University of Padua, Padua, Italy
| | - Carlotta Stipa
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Laura Maria Beatrice Belotti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Lorenzo Ferri
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna Italy.
| | - Barbara Mostacci
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Luca Vignatelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Raffaella Minardi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Lidia Di Vito
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy
| | - Lorenzo Muccioli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna Italy
| | - Antonella Boni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell'età Pediatrica, via Altura 3, Bologna 40138, Italy
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna Italy
| | - Francesca Bisulli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, European Reference Network for Rare and Complex Epilepsies (EpiCARE), Bologna, Italy; Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna Italy
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Johnson J, Somerfield W, Johnson SR. Lymphangioleiomyomatosis in patients with tuberous sclerosis: a national centre audit. Orphanet J Rare Dis 2024; 19:137. [PMID: 38532450 DOI: 10.1186/s13023-024-03115-y] [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: 09/29/2023] [Accepted: 03/03/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Lymphangioleiomyomatosis (LAM) is common in tuberous sclerosis complex (TSC) yet under recognised with management mostly based upon evidence obtained from patients with sporadic LAM. We performed a prospective audit of patients with TSC-LAM attending a national referral centre to inform management guidelines. METHODS The UK LAM Centre was established in 2011 and conducts a prospective audit of pre-defined quality outcomes for all subjects. Audit data are reported on all patients with TSC-LAM and a comparator population of patients with sporadic LAM. RESULTS Between 2011 and 2022, 73 patients were seen with TSC-LAM. All were women with a mean (SD) age of 39 (12) years. Referral rates were similar over the study period including after the introduction of CT screening. Median age of diagnosis with TSC was 11 years (range 0-70) with one third diagnosed with TSC as adults. Compared with all TSC patients in the 'TOSCA' registry, TSC-LAM patients tended to have been diagnosed with TSC at an older age, had fewer neuro-cognitive manifestations and were more likely to have angiomyolipoma. The most common presentations of TSC-LAM were following workup for angiomyolipoma, pneumothorax or dyspnoea with only one fifth detected after CT screening. Baseline FEV1 and DLCO at first assessment were reduced to 77 and 63% predicted respectively and were similar to patients with sporadic LAM. During follow-up, FEV1 fell by a mean of 81 ml/year and DLCO fell by 0.309 mmol/ml/kPa/year in patients not being treated with an mTOR inhibitor. 55% required treatment with either sirolimus or Everolimus for LAM or angiomyolipoma respectively. For those treated with an mTOR inhibitor, mean FEV1 fell by 3 ml/year and DLCO increased by 0.032 mmol/ml/kPa/year and was similar to sporadic LAM. Risk of death due to LAM or need for lung transplant in patients with TSC-LAM was 0.67%/year. CONCLUSIONS Despite screening recommendations, LAM is often diagnosed in TSC after symptoms develop which may delay treatment. Complications including pneumothorax and loss of lung function are significant and similar to sporadic LAM. Work is needed to implement the recommended CT screening for LAM and improve respiratory care for TSC-LAM.
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Affiliation(s)
- Jan Johnson
- Centre for Respiratory Research, Translational Medical Sciences and Biodiscovery Institute, School of Medicine, University of Nottingham, Nottingham, UK
| | - Wendy Somerfield
- National Centre for Lymphangioleiomyomatosis, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Simon R Johnson
- Centre for Respiratory Research, Translational Medical Sciences and Biodiscovery Institute, School of Medicine, University of Nottingham, Nottingham, UK.
- National Centre for Lymphangioleiomyomatosis, Nottingham University Hospitals NHS Trust, Nottingham, UK.
- Nottingham NIHR Biomedical Research Centre, Nottingham, UK.
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Sauter M, Weber L, Jung D, Weremko M, Bachmann D, Fischereder M, Bachmann HS. Patients' and physicians' awareness of clinical symptoms and disease severity in tuberous sclerosis complex. Orphanet J Rare Dis 2024; 19:106. [PMID: 38459571 PMCID: PMC10921799 DOI: 10.1186/s13023-024-03118-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/03/2024] [Indexed: 03/10/2024] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare inherited disease with the potential to affect virtually every organ system. Clinical presentation is age- and partly sex-dependent and varies broadly with respect to disease manifestations including treatment-refractory epilepsy, intellectual disability and TSC-associated neuropsychiatric disorders, chronic kidney disease or progressive lung function decline. Given the complexity of this disease, multidisciplinary care in specialized TSC centres is recommended. We aimed to elucidate the state of knowledge of patients/caregivers and physicians on individual disease manifestations. We further examined whether the association to a TSC centre has an impact on the comprehensive consideration of potential disease manifestations. Therefore, a survey was performed in a cohort of German TSC patients and their physicians. Complete information was available for 94 patients with a median age of 18 years [range 1-55] and a sex distribution of 53.2% (male): 48.8% (female). Using almost identical questionnaires for patients/caregivers and their respective physician, there was a good correlation for disease assessments associated with relevant morbidity and mortality like epilepsy, renal angiomyolipoma, cardiac rhabdomyomas or intellectual disability. Correlation was moderate for several neuropsychiatric disorders and only poor for hypomelanotic macules, dental pits or retinal achromic patches. Estimation of overall disease severity using a numeric rating scale correlated highly significantly (Pearson correlation coefficient = 0.767; p < 0.001) between patients/caregivers and physicians. In general, physicians more likely quoted items as 'unknown' than patients (822 answers vs. 435 answers in the respective groups). Questionnaires completed by physicians who were associated with a specialized TSC centre declared a significantly lower proportion of items as unknown (mean 8.7% vs. 20.5%; p < 0.001). These findings indicate that patients treated by specialized TSC centres seem to obtain a more comprehensive surveillance. Furthermore, it shows that there were reasonable surveillance strategies in general and sufficient patient/caregiver interaction and education in the examined cohort. However, for the most prominent disease characteristics there was a good awareness within both the patients/caregivers and the physicians group.
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Affiliation(s)
- Matthias Sauter
- Klinikverbund Allgäu, Robert-Weixler-Str. 50, 87439, Kempten, Germany
| | - Lea Weber
- Institute of Pharmacology and Toxicology, Centre for Biomedical Education and Research (ZBAF), School of Medicine, Witten/Herdecke University, Witten, Germany
| | - Dominik Jung
- Institute of Pharmacology and Toxicology, Centre for Biomedical Education and Research (ZBAF), School of Medicine, Witten/Herdecke University, Witten, Germany
| | - Michael Weremko
- Institute of Pharmacogenetics, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Dorothea Bachmann
- Institute of Pharmacology and Toxicology, Centre for Biomedical Education and Research (ZBAF), School of Medicine, Witten/Herdecke University, Witten, Germany
| | - Michael Fischereder
- Tuberöse Sklerose Zentrum, Klinikum Der Universität München, Ziemssenstr. 5, 80336, Munich, Germany
| | - Hagen Sjard Bachmann
- Institute of Pharmacology and Toxicology, Centre for Biomedical Education and Research (ZBAF), School of Medicine, Witten/Herdecke University, Witten, Germany.
- Institute of Pharmacogenetics, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.
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Curatolo P, Scheper M, Emberti Gialloreti L, Specchio N, Aronica E. Is tuberous sclerosis complex-associated autism a preventable and treatable disorder? World J Pediatr 2024; 20:40-53. [PMID: 37878130 DOI: 10.1007/s12519-023-00762-2] [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: 05/05/2023] [Accepted: 09/10/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a genetic disorder caused by inactivating mutations in the TSC1 and TSC2 genes, causing overactivation of the mechanistic (previously referred to as mammalian) target of rapamycin (mTOR) signaling pathway in fetal life. The mTOR pathway plays a crucial role in several brain processes leading to TSC-related epilepsy, intellectual disability, and autism spectrum disorder (ASD). Pre-natal or early post-natal diagnosis of TSC is now possible in a growing number of pre-symptomatic infants. DATA SOURCES We searched PubMed for peer-reviewed publications published between January 2010 and April 2023 with the terms "tuberous sclerosis", "autism", or "autism spectrum disorder"," animal models", "preclinical studies", "neurobiology", and "treatment". RESULTS Prospective studies have highlighted that developmental trajectories in TSC infants who were later diagnosed with ASD already show motor, visual and social communication skills in the first year of life delays. Reliable genetic, cellular, electroencephalography and magnetic resonance imaging biomarkers can identify pre-symptomatic TSC infants at high risk for having autism and epilepsy. CONCLUSIONS Preventing epilepsy or improving therapy for seizures associated with prompt and tailored treatment strategies for autism in a sensitive developmental time window could have the potential to mitigate autistic symptoms in infants with TSC.
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Affiliation(s)
- Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Rome, Italy
| | - Mirte Scheper
- Department of Neuropathology, Amsterdam Neuroscience, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Leonardo Emberti Gialloreti
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133, Rome, Italy
| | - Nicola Specchio
- Clinical and Experimental Neurology, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARE, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Eleonora Aronica
- Department of Neuropathology, Amsterdam Neuroscience, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, Amsterdam, The Netherlands
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14
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Shafiee F, Sarbaz M, Marouzi P, Banaye Yazdipour A, Kimiafar K. Providing a framework for evaluation disease registry and health outcomes Software: Updating the CIPROS checklist. J Biomed Inform 2024; 149:104574. [PMID: 38101688 DOI: 10.1016/j.jbi.2023.104574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 11/27/2023] [Accepted: 12/08/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND AND AIMS Properly designed and implemented registry systems play an important role in improving health outcomes and reducing care costs, and can provide a true representation of clinical practice, disease outcomes, safety, and efficacy. Therefore, the aim of this study was to redesign and develop a checklist with items for a patient registry software system (CIPROS) Checklist. METHOD The study is descriptive-cross-sectional. The extraction of the data elements of the checklist was first done through a comprehensive review of the texts in PubMed, Science Direct and Scopus databases and receiving articles related to the evaluation of registry systems. Based on the extracted data, a five-point Likert scale questionnaire was created and 30 experts in this field were asked for their opinions using the two-step Delphi method. RESULTS A total of 100 information items were determined as a registry software evaluation checklist. This checklist included 12 groups of software architecture factors, development, interfaces and interactivity, semantics and standardization, internationality, data management, data quality and usability, data analysis, security, privacy, organizational, education and public factors. CONCLUSION By using the results of this research, it is possible to identify the defects and possible strengths of the registry software and put it at the disposal of the relevant officials to make a decision in this field. In this way, among the designers and developers of these softwares, the best and most appropriate ones are selected with the needs of the registry programs.
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Affiliation(s)
- Fatemeh Shafiee
- Department of Health Information Technology, School of Paramedical and Rehabilitation Sciences, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Masoume Sarbaz
- Department of Health Information Technology, School of Paramedical and Rehabilitation Sciences, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Parviz Marouzi
- Department of Health Information Technology, School of Paramedical and Rehabilitation Sciences, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Alireza Banaye Yazdipour
- Department of Health Information Technology, School of Paramedical and Rehabilitation Sciences, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Health Information Management and Medical Informatics, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran; Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran.
| | - Khalil Kimiafar
- Department of Health Information Technology, School of Paramedical and Rehabilitation Sciences, Mashhad University of Medical Sciences, Mashhad, Iran.
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Riley VA, Shankar V, Holmberg JC, Sokolov AM, Neckles VN, Williams K, Lyman R, Mackay TF, Feliciano DM. Tsc2 coordinates neuroprogenitor differentiation. iScience 2023; 26:108442. [PMID: 38107199 PMCID: PMC10724693 DOI: 10.1016/j.isci.2023.108442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/22/2023] [Accepted: 11/09/2023] [Indexed: 12/19/2023] Open
Abstract
Neural stem cells (NSCs) of the ventricular-subventricular zone (V-SVZ) generate numerous cell types. The uncoupling of mRNA transcript availability and translation occurs during the progression from stem to differentiated states. The mTORC1 kinase pathway acutely controls proteins that regulate mRNA translation. Inhibiting mTORC1 during differentiation is hypothesized to be critical for brain development since somatic mutations of mTORC1 regulators perturb brain architecture. Inactivating mutations of TSC1 or TSC2 genes cause tuberous sclerosis complex (TSC). TSC patients have growths near the striatum and ventricles. Here, it is demonstrated that V-SVZ NSC Tsc2 inactivation causes striatal hamartomas. Tsc2 removal altered translation factors, translatomes, and translational efficiency. Single nuclei RNA sequencing following in vivo loss of Tsc2 revealed changes in NSC activation states. The inability to decouple mRNA transcript availability and translation delayed differentiation leading to the retention of immature phenotypes in hamartomas. Taken together, Tsc2 is required for translational repression and differentiation.
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Affiliation(s)
- Victoria A. Riley
- Department of Biological Sciences, Clemson University, Clemson, SC, USA
| | - Vijay Shankar
- Department of Biochemistry and Genetics, Clemson University, Clemson, SC, USA
- Center for Human Genetics, Clemson University, Greenwood, SC, USA
| | | | - Aidan M. Sokolov
- Department of Biological Sciences, Clemson University, Clemson, SC, USA
| | | | - Kaitlyn Williams
- Clemson University Genomics and Bioinformatics Facility (CUGBF), Clemson University, Clemson, SC, USA
| | - Rachel Lyman
- Department of Biochemistry and Genetics, Clemson University, Clemson, SC, USA
- Center for Human Genetics, Clemson University, Greenwood, SC, USA
| | - Trudy F.C. Mackay
- Department of Biochemistry and Genetics, Clemson University, Clemson, SC, USA
- Center for Human Genetics, Clemson University, Greenwood, SC, USA
| | - David M. Feliciano
- Department of Biological Sciences, Clemson University, Clemson, SC, USA
- Center for Human Genetics, Clemson University, Greenwood, SC, USA
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Vitale G, Terrone G, Vitale S, Vitulli F, Aiello S, Bravaccio C, Pisano S, Bove I, Rizzo F, Seetahal-Maraj P, Wiese T. The Evolving Landscape of Therapeutics for Epilepsy in Tuberous Sclerosis Complex. Biomedicines 2023; 11:3241. [PMID: 38137462 PMCID: PMC10741146 DOI: 10.3390/biomedicines11123241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 10/30/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare multisystem genetic disorder characterized by benign tumor growth in multiple organs, including the brain, kidneys, heart, eyes, lungs, and skin. Pathogenesis stems from mutations in either the TSC1 or TSC2 gene, which encode the proteins hamartin and tuberin, respectively. These proteins form a complex that inhibits the mTOR pathway, a critical regulator of cell growth and proliferation. Disruption of the tuberin-hamartin complex leads to overactivation of mTOR signaling and uncontrolled cell growth, resulting in hamartoma formation. Neurological manifestations are common in TSC, with epilepsy developing in up to 90% of patients. Seizures tend to be refractory to medical treatment with anti-seizure medications. Infantile spasms and focal seizures are the predominant seizure types, often arising in early childhood. Drug-resistant epilepsy contributes significantly to morbidity and mortality. This review provides a comprehensive overview of the current state of knowledge regarding the pathogenesis, clinical manifestations, and treatment approaches for epilepsy and other neurological features of TSC. While narrative reviews on TSC exist, this review uniquely synthesizes key advancements across the areas of TSC neuropathology, conventional and emerging pharmacological therapies, and targeted treatments. The review is narrative in nature, without any date restrictions, and summarizes the most relevant literature on the neurological aspects and management of TSC. By consolidating the current understanding of TSC neurobiology and evidence-based treatment strategies, this review provides an invaluable reference that highlights progress made while also emphasizing areas requiring further research to optimize care and outcomes for TSC patients.
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Affiliation(s)
- Giovanni Vitale
- Neuroscience and Rare Diseases, Discovery and Translational Area, Roche Pharma Research and Early Development (pRED), F. Hoffmann–La Roche, 4070 Basel, Switzerland
| | - Gaetano Terrone
- Department of Translational Medical Sciences, Child and Adolescent Neuropsychiatry, University of Naples Federico II, 80138 Naples, Italy; (G.T.); (C.B.)
| | - Samuel Vitale
- School of Medicine and Surgery, University of Naples Federico II, 80138 Naples, Italy;
| | - Francesca Vitulli
- Department of Neurosciences and Reproductive and Dental Sciences, Division of Neurosurgery, University of Naples Federico II, 80138 Naples, Italy (I.B.)
| | - Salvatore Aiello
- Department of Translational Medical Sciences, Child and Adolescent Neuropsychiatry, University of Naples Federico II, 80138 Naples, Italy; (G.T.); (C.B.)
| | - Carmela Bravaccio
- Department of Translational Medical Sciences, Child and Adolescent Neuropsychiatry, University of Naples Federico II, 80138 Naples, Italy; (G.T.); (C.B.)
| | - Simone Pisano
- Department of Translational Medical Sciences, Child and Adolescent Neuropsychiatry, University of Naples Federico II, 80138 Naples, Italy; (G.T.); (C.B.)
| | - Ilaria Bove
- Department of Neurosciences and Reproductive and Dental Sciences, Division of Neurosurgery, University of Naples Federico II, 80138 Naples, Italy (I.B.)
| | - Francesca Rizzo
- Department of Neuroscience “Rita Levi Montalcini”, University of Turin, 10126 Turin, Italy;
| | | | - Thomas Wiese
- Neuroscience and Rare Diseases, Discovery and Translational Area, Roche Pharma Research and Early Development (pRED), F. Hoffmann–La Roche, 4070 Basel, Switzerland
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Cockerell I, Christensen J, Hoei-Hansen CE, Holst L, Grenaa Frederiksen M, Issa-Epe AI, Nedregaard B, Solhoff R, Heimdal K, Johannessen Landmark C, Lund C, Nærland T. Effectiveness and safety of everolimus treatment in patients with tuberous sclerosis complex in real-world clinical practice. Orphanet J Rare Dis 2023; 18:377. [PMID: 38042867 PMCID: PMC10693167 DOI: 10.1186/s13023-023-02982-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 11/18/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND The randomised double-blinded placebo-controlled EXIST-1-3 studies have showed everolimus effective with adverse effects reported as acceptable in treatment of symptoms in patients with tuberous sclerosis complex (TSC), although evidence of outcomes in clinical practice remains limited. This study aimed to investigate, in clinical practice, the effectiveness and safety of everolimus for epilepsy, renal angiomyolipoma (rAML), and subependymal giant cell astrocytoma (SEGA) in patients with TSC. RESULTS The study included 64 patients with TSC (median age: 19, range 0.9-54 years) receiving everolimus treatment (Norway: n = 35; Denmark: n = 29). Among 45 patients with epilepsy, 14 (31%) were responders experiencing ≥ 50% reduction in seizure frequency in the last 3 months of treatment compared with the last 3 months before treatment. Nineteen (42%) patients changed their anti-seizure medications (ASMs). Responders were more common among patients < 18 years (46%) than among patients ≥ 18 years (14%, p = 0.03). In 29 patients with rAML, everolimus reduced (≥ 30% decrease) and stabilized (< 20% increase, ≤ 30% decrease) longest diameter of rAML in 38% and 59%, respectively, after a mean treatment duration of 37 months. SEGA volume was reduced in three patients by 71%, 43%, and 48% after 39, 34, and 82 months. Adverse effects were reported in 61 of 64 patients (95%) after a median treatment duration of 31 months (range 0-106), with oral ulceration/stomatitis (63%) and upper respiratory tract infections (38%) being the most common. The most common laboratory abnormalities were increased cholesterol (41%), anaemia (30%), and leucopoenia (25%). Grade 3-4 adverse effects were reported in 36% of cases, and life-threatening conditions were reported in two patients. Nine patients discontinued everolimus treatment. CONCLUSIONS Seizure reduction in this study sample was consistent with results from EXIST, but might be lower than expected, given that changes in concomitant ASMs are part of clinical practice. Seizure reduction was associated with younger age. As with EXIST, everolimus reduced or stabilised rAML size in most patients. SEGA volume was reduced in all three patients. Close follow-up is needed for this group, especially for children and patients who may not be able to report adverse effects.
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Affiliation(s)
- Ine Cockerell
- Department of Rare Disorders and Disabilities, National Centre for Rare Epilepsy-Related Disorders, Oslo University Hospital, Pb 4950, 0424, Nydalen, Oslo, Norway.
| | - Jakob Christensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Affiliated Member of the European Reference Network EpiCARE, Aarhus, Denmark
| | - Christina E Hoei-Hansen
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Paediatrics, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lotte Holst
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Aart Imran Issa-Epe
- Section of Abdominal Radiology, Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Bård Nedregaard
- Section of Neuroradiology, Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Ragnar Solhoff
- Department of Neurology, Sørlandet Hospital, Arendal, Norway
| | - Ketil Heimdal
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Cecilie Johannessen Landmark
- Department of Pharmacy, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- The National Center for Epilepsy (SSE), Member of the ERN EpiCare, Oslo University Hospital, Oslo, Norway
- Section for Clinical Pharmacology, SSE, Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Caroline Lund
- Department of Rare Disorders and Disabilities, National Centre for Rare Epilepsy-Related Disorders, Oslo University Hospital, Pb 4950, 0424, Nydalen, Oslo, Norway
| | - Terje Nærland
- K.G. Jebsen Center for Neurodevelopmental Disorders, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- NevSom, Department of Rare Disorders and Disabilities, Oslo University Hospital, Oslo, Norway
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Mammadova D, Vecko J, Hofmann M, Schüssler SC, Deiters L, Canda A, Wieland AK, Gollwitzer S, Hamer H, Trollmann R. A single-center observational study on long-term neurodevelopmental outcomes in children with tuberous sclerosis complex. Orphanet J Rare Dis 2023; 18:349. [PMID: 37946245 PMCID: PMC10637019 DOI: 10.1186/s13023-023-02959-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 10/25/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a rare multisystem disorder caused by mutations in the TSC1 or TSC2 gene. More than 90% of patients with TSC develop neurological and/or neuropsychiatric manifestations. The aim of the present study was to determine the developmental and cognitive long-term outcomes of pediatric TSC patients. METHODS This cross-sectional, monocenter study included pediatric TSC patients who received multidisciplinary long-term care with a last visit between 2005 and 2019. Neurological manifestations and cognitive development (BSID, K-ABC) were analyzed in relation to age and type of mutation. RESULTS Thirty-five patients aged 13.5 ± 7.8 years were included in the study. Diagnosis was confirmed genetically in 65.7% of patients (TSC1, 26.1%; TSC2, 65.2%; NMI, 8.7%). Mean age at diagnosis was 1.3 ± 3.5 years; 74.3% of the patients had been diagnosed within the first year of life due to seizures (62.9%) or/and cardiac rhabdomyomas (28.6%). The most common TSC manifestations included structural brain lesions (cortical tubers, 91.4%; subependymal nodules, 82.9%), epilepsy (85.7%), and cardiac rhabdomyomas (62.9%). Mean age at seizure onset was 1.5 ± 2.3 years, with onset in 80.0% of patients within the first two years of life. Infantile spasms, which were the first seizure type in 23.3% of the patients, developed earlier (0.6 ± 0.4 years) than focal seizures (1.8 ± 2.5 years). Refractory epilepsy was present in 21 (70.0%) patients, mild or severe intellectual impairment in 66.6%, and autism spectrum disorders in 11.4%. Severe cognitive impairment (33.3%) was significantly associated with epilepsy type and age at seizure onset (p < 0.05). CONCLUSIONS The results emphasized the phenotypic variability of pediatric-onset TSC and the high rate of neurological and neuropsychiatric morbidity. Early-onset refractory epilepsy was associated with impaired cognitive development. Children of all ages with TSC require multidisciplinary long-term care and individual early-intervention programs.
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Affiliation(s)
- D Mammadova
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - J Vecko
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - M Hofmann
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - S C Schüssler
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - L Deiters
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - A Canda
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
| | - A K Wieland
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany
- Center of Rare Diseases Erlangen (ZSEER), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - S Gollwitzer
- Department of Neurology, Epilepsy Center, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Center of Rare Diseases Erlangen (ZSEER), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - H Hamer
- Department of Neurology, Epilepsy Center, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Center of Rare Diseases Erlangen (ZSEER), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Regina Trollmann
- Department of Pediatric and Adolescent Medicine, Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestr. 15, 91054, Erlangen, Germany.
- Center of Rare Diseases Erlangen (ZSEER), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.
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Dulamea AO, Arbune AA, Anghel D, Boscaiu V, Andronesi A, Ismail G. Neurological and Dermatological Manifestations of Tuberous Sclerosis Complex: Report from a Romanian Tertiary Hospital Cohort. J Clin Med 2023; 12:6550. [PMID: 37892688 PMCID: PMC10607726 DOI: 10.3390/jcm12206550] [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: 09/23/2023] [Revised: 10/09/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
Tuberous sclerosis complex is a rare multisystem genetic disorder characterized by multiorgan involvement, frequently associated with intellectual impairment and epilepsy. The aim of our study was to describe the neurological and dermatological manifestations of TSC in 32 adult patients (of whom 19 were females) who attended the Neurology and Nephrology Clinics of Fundeni Clinical Institute in Romania from 2015 to 2020. Seventeen patients were diagnosed with epilepsy, nine patients had intellectual impairment, and complete neuroimaging was available for twenty-two patients. As expected, the most frequent dermatological lesions were cutaneous angiofibromas in 20 patients, but with a lower frequency than described in the current literature. Statistical analysis was performed considering the small number of patients. Cortical tubers in neuroimaging seemed to be associated with the diagnosis of epilepsy, while subependymal nodules represented a risk factor for intellectual impairment. Males showed a larger number of dermatological types of lesions, especially café -au-lait patches. Interestingly, we found a statistically significant positive association between epilepsy and the presence of cutaneous angiofibromas, as well as total dermatological involvement. Females had significantly higher Charlson comorbidity index scores, indicating a higher burden of disease. Everolimus seemed to be a well-tolerated treatment and showed promising results in controlling epileptic seizures alone in two patients. More studies, with the inclusion of a larger number of patients, are needed to confirm these results.
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Affiliation(s)
- Adriana Octaviana Dulamea
- Neurology Clinic, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.O.D.); (D.A.)
- Department III, Dental Medicine Faculty, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Anca Adriana Arbune
- Neurology Clinic, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.O.D.); (D.A.)
| | - Daniela Anghel
- Neurology Clinic, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.O.D.); (D.A.)
- Department III, Dental Medicine Faculty, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Voicu Boscaiu
- Institute of Mathematical Statistics and Applied Mathematics “Gheorghe Mihoc-Caius Iacob”, 050711 Bucharest, Romania
| | - Andreea Andronesi
- Nephrology Clinic, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.A.); (G.I.)
- Department 3, Medicine Faculty, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Gener Ismail
- Nephrology Clinic, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.A.); (G.I.)
- Department 3, Medicine Faculty, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
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20
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Curatolo P, Trivisano M, Specchio N. Updated Genotype-Phenotype Correlations in TSC. Semin Pediatr Neurol 2023; 47:101086. [PMID: 37919037 DOI: 10.1016/j.spen.2023.101086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
GENOTYPE/PHENOTYPE CORRELATIONS IN TUBEROUS SCLEROSIS COMPLEX Paolo Curatolo MD, Romina Moavero MD, Denis Roberto, Federica Graziola Seminars in Pediatric Neurology Volume 22, Issue 4, December 2015, Pages 259-273 Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by the development of widespread hamartomatous lesions in various organs, including brain, skin, kidneys, heart, and eyes. Central nervous system is almost invariably involved, with up to 85% of patients presenting with epilepsy, and at least half of patients having intellectual disability or other neuropsychiatric disorders including autism spectrum disorder. TSC is caused by the mutation in one of the 2 genes TSC1, at 9q34, and TSC2, at 16p13.3. They respectively encode for hamartin and tuberin, which form an intracellular complex inhibiting the mammalian target of rapamycin. Mammalian target of rapamycin overactivation following the genetic defect determines the cell growth and proliferation responsible for TSC-related lesions, as well as the alterations in neuronal excitability and synaptogenesis leading to epilepsy and neuropsychiatric disorders. A causative mutation for the disorder is identified in about 85% of patients with a clinical diagnosis of TSC. Mosaicism and technology limits likely explain most of the no mutation identified cases. This review confirms that patients with TSC2 mutations considered as a group usually present a more severe phenotype, characterized by higher number of tubers, earlier age at seizure onset and higher prevalence of intellectual disability. However, the clinical phenotype of the disease presents a high variability, thus making the prediction of the phenotype on an individual basis still challenging. The increasing application of new molecular techniques to subjects with TSC has the potential to significantly reduce the rate of patients with no mutation demonstrated and to identify an increasing higher number of mutations. This would hopefully allow a better characterization of higher risk mutations, which might help clinicians to plan individualized surveillance plans. Furthermore, the increasing availability of disease registries to collect clinical and genetics data of patients help to define more valid and clinically oriented genotype or phenotype correlations.
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Affiliation(s)
- Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Rome, Italy
| | - Marina Trivisano
- Child Neurology, Epilepsy and Movement Disorders, Bambino Gesù, IRCCS Children's Hospital, Full Member of European Reference Network EpiCARE, Rome, Italy
| | - Nicola Specchio
- Child Neurology, Epilepsy and Movement Disorders, Bambino Gesù, IRCCS Children's Hospital, Full Member of European Reference Network EpiCARE, Rome, Italy.
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21
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Sawhney S, Vagha K, Gomase S, Lohiya S, Hampe P, Ansari AA, Vagha JD, Sood A. The Early Presentation of a Classic Case of Tuberous Sclerosis: A Case Report. Cureus 2023; 15:e47241. [PMID: 38021796 PMCID: PMC10654451 DOI: 10.7759/cureus.47241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Tuberous sclerosis (TS) is a potentially severe medical disorder that poses a life-threatening risk and can lead to drastic lifestyle changes. In infants and young children, the typical diagnostic criteria for this condition encompass cutaneous manifestations and seizures, and the development of cellular growths termed hamartomas, astrocytomas, myolipomas, and even carcinomas observed within the cardiac, cerebral, renal, and retinal tissues. The usual age of presentation varies widely, which affects the prognosis. We report a case of a four-month-old male patient who presented with early signs of TS. The patient showed signs of infantile spasms and seizures. On further examination, he had neurological, cutaneous, cardiac, and retinal manifestations, which pointed toward the diagnosis of TS. This case report emphasizes the importance of screening for TS at an early age due to the possibility of patients presenting earlier than the usual age of presentation. To the best of our knowledge, there is scarce data on this kind of early-onset signs of TS; therefore, we feel that it is imperative to start screening infants earlier to improve the prognosis and decrease the complications of this disease. The screening tests and the incidence of screening will vary based on the cost and availability of proper diagnostic and screening tests and the accessibility of efficient treatments.
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Affiliation(s)
- Shraddha Sawhney
- Department of Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Keta Vagha
- Department of Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shantanu Gomase
- Department of Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sham Lohiya
- Department of Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Priyanka Hampe
- Department of Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Ayesha A Ansari
- Department of Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Jayant D Vagha
- Department of Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Anshul Sood
- Department of Radiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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22
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de Vries PJ, Heunis TM, Vanclooster S, Chambers N, Bissell S, Byars AW, Flinn J, Gipson TT, van Eeghen AM, Waltereit R, Capal JK, Cukier S, Davis PE, Smith C, Kingswood JC, Schoeters E, Srivastava S, Takei M, Gardner-Lubbe S, Kumm AJ, Krueger DA, Sahin M, De Waele L, Jansen AC. International consensus recommendations for the identification and treatment of tuberous sclerosis complex-associated neuropsychiatric disorders (TAND). J Neurodev Disord 2023; 15:32. [PMID: 37710171 PMCID: PMC10503032 DOI: 10.1186/s11689-023-09500-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/28/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is associated with a wide range of physical manifestations for which international clinical recommendations for diagnosis and management have been established. TSC is, however, also associated with a wide range of TSC-Associated Neuropsychiatric Disorders (TAND) that are typically under-identified and under-treated yet associated with a profound burden of disease. The contemporary evidence base for the identification and treatment of TAND is much more limited and, to date, consensus recommendations for the diagnosis and management of TAND have also been limited and non-specific. METHODS The TANDem project was launched with an international, interdisciplinary, and participatory consortium of 24 individuals, including TSC family representatives, from all World Health Organization (WHO) regions but one. One of the aims of the TANDem project was to generate consensus recommendations for the identification and treatment of TAND. At the time of this project, no internationally adopted standard methodology and methodological checklists existed for the generation of clinical practice recommendations. We therefore developed our own systematic procedure for evidence review and consensus-building to generate evidence-informed consensus recommendations of relevance to the global TSC community. RESULTS At the heart of the consensus recommendations are ten core principles surrounded by cluster-specific recommendations for each of the seven natural TAND clusters identified in the literature (autism-like, dysregulated behavior, eat/sleep, mood/anxiety, neuropsychological, overactive/impulsive, and scholastic) and a set of wraparound psychosocial cluster recommendations. The overarching recommendation is to "screen" for TAND at least annually, to "act" using appropriate next steps for evaluation and treatment, and to "repeat" the process to ensure early identification and early intervention with the most appropriate biological, psychological, and social evidence-informed approaches to support individuals with TSC and their families. CONCLUSIONS The consensus recommendations should provide a systematic framework to approach the identification and treatment of TAND for health, educational, social care teams and families who live with TSC. To ensure global dissemination and implementation of these recommendations, partnerships with the international TSC community will be important. One of these steps will include the generation of a "TAND toolkit" of "what to seek" and "what to do" when difficulties are identified in TAND clusters.
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Affiliation(s)
- Petrus J de Vries
- Division of Child and Adolescent Psychiatry, Centre for Autism Research in Africa (CARA), University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa.
| | - Tosca-Marie Heunis
- Mental Health and Wellbeing Research Group, Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
| | - Stephanie Vanclooster
- Mental Health and Wellbeing Research Group, Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
| | - Nola Chambers
- Division of Child and Adolescent Psychiatry, Centre for Autism Research in Africa (CARA), University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa
| | - Stacey Bissell
- School of Psychology, University of Birmingham, Birmingham, UK
| | - Anna W Byars
- TSC Clinic Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Neurology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Tanjala T Gipson
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, TN, USA
- Le Bonheur Children's Hospital and Boling Center for Developmental Disabilities, Memphis, TN, USA
| | - Agnies M van Eeghen
- Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, Netherlands
- TAND Expert Centre, 'S Heeren Loo, Hoofddorp, Netherlands
| | - Robert Waltereit
- Child and Adolescent Psychiatry, University Medical Center Göttingen, Göttingen, Germany
| | - Jamie K Capal
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sebastián Cukier
- Department of Psychopathology and Mental Health, Pedro de Elizalde Hospital, Buenos Aires, Argentina
| | - Peter E Davis
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - J Chris Kingswood
- Department of Clinical Genetics, St George's University Hospitals, London, UK
- Sussex Renal Unit, The Royal Sussex County Hospital, Brighton, UK
| | | | - Shoba Srivastava
- Division of Child and Adolescent Psychiatry, Centre for Autism Research in Africa (CARA), University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa
- Society of Parents of Children With Autistic Disorders (SOPAN), Mumbai, India
| | - Megumi Takei
- Japanese Society of Tuberous Sclerosis Complex, Family Network, Tokyo, Japan
| | - Sugnet Gardner-Lubbe
- MuViSU (Centre for Multi-Dimensional Data Visualisation), Department of Statistics and Actuarial Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Aubrey J Kumm
- Division of Child and Adolescent Psychiatry, Centre for Autism Research in Africa (CARA), University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa
| | - Darcy A Krueger
- TSC Clinic Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Neurology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mustafa Sahin
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Rosamund Stone Zander Translational Neuroscience Center, Boston Children's Hospital, Boston, MA, USA
| | - Liesbeth De Waele
- Department of Paediatric Neurology, University Hospitals Leuven, Louvain, Belgium
- Department of Development and Regeneration, KU Leuven, Louvain, Belgium
| | - Anna C Jansen
- Mental Health and Wellbeing Research Group, Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Pediatrics, Koningin Mathilde Moeder-en Kindcentrum, Antwerp University Hospital, Antwerp, Belgium
- Department of Translational Neurosciences, University of Antwerp, Antwerp, Belgium
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23
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Prezioso G, Chiarelli F, Matricardi S. Efficacy and safety of vigabatrin in patients with tuberous sclerosis complex and infantile epileptic spasm syndrome: a systematic review. Expert Rev Neurother 2023; 23:661-671. [PMID: 37243682 DOI: 10.1080/14737175.2023.2216385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/17/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Tuberous sclerosis complex (TSC) is a common genetic cause of epilepsy. Infantile epileptic spasm syndrome (IESS) is often the presenting neurologic feature, progressively evolving into refractory epilepsy. Vigabatrin (VGB) is often used in clinical practice as a first-line therapy in TSC with IESS. This systematic review aims to collect and analyze the efficacy data about VGB in TSC cases with IESS, in order to evaluate the strength of evidence in the literature. METHODS A systematic search of trials, observational studies, and case series involving patients with TSC and IESS treated with VGB was performed using MEDLINE, CENTRAL, and the US NIH Clinical Trials Registry. Single case studies, animal and non-English language studies were excluded. Seventeen studies were selected, of which 3 were RCTs and 14 were observational studies. RESULTS An overall response rate of 67% (231/343 responders) resulted from the analysis, with a spasm-free rate restricted to RCTs of 88% (29/33 subjects). CONCLUSIONS Although all the studies analyzed reported beneficial effects of VGB in TSC patients with IESS, with higher response rates in comparison to non-TSC subjects with IESS, a low level of evidence and high heterogeneity do not guarantee sufficient strength for therapeutic recommendations.
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Affiliation(s)
- Giovanni Prezioso
- Pediatric Neurologist, Department of Pediatrics, G. D'Annunzio University, Chieti, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, Department of Pediatrics, G. D'Annunzio University, Chieti, Italy
| | - Sara Matricardi
- Pediatric Neurologist, Department of Pediatrics, G. D'Annunzio University, Chieti, Italy
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24
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Cottin V, Blanchard E, Kerjouan M, Lazor R, Reynaud-Gaubert M, Taille C, Uzunhan Y, Wemeau L, Andrejak C, Baud D, Bonniaud P, Brillet PY, Calender A, Chalabreysse L, Court-Fortune I, Desbaillets NP, Ferretti G, Guillemot A, Hardelin L, Kambouchner M, Leclerc V, Lederlin M, Malinge MC, Mancel A, Marchand-Adam S, Maury JM, Naccache JM, Nasser M, Nunes H, Pagnoux G, Prévot G, Rousset-Jablonski C, Rouviere O, Si-Mohamed S, Touraine R, Traclet J, Turquier S, Vagnarelli S, Ahmad K. French recommendations for the diagnosis and management of lymphangioleiomyomatosis. Respir Med Res 2023; 83:101010. [PMID: 37087906 DOI: 10.1016/j.resmer.2023.101010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/12/2023] [Accepted: 03/13/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND The present article is an English-language version of the French National Diagnostic and Care Protocol, a pragmatic tool to optimize and harmonize the diagnosis, care pathway, management and follow-up of lymphangioleiomyomatosis in France. METHODS Practical recommendations were developed in accordance with the method for developing a National Diagnosis and Care Protocol for rare diseases of the Haute Autorité de Santé and following international guidelines and literature on lymphangioleiomyomatosis. It was developed by a multidisciplinary group, with the help of patient representatives and of RespiFIL, the rare disease network on respiratory diseases. RESULTS Lymphangioleiomyomatosis is a rare lung disease characterised by a proliferation of smooth muscle cells that leads to the formation of multiple lung cysts. It occurs sporadically or as part of a genetic disease called tuberous sclerosis complex (TSC). The document addresses multiple aspects of the disease, to guide the clinicians regarding when to suspect a diagnosis of lymphangioleiomyomatosis, what to do in case of recurrent pneumothorax or angiomyolipomas, what investigations are needed to make the diagnosis of lymphangioleiomyomatosis, what the diagnostic criteria are for lymphangioleiomyomatosis, what the principles of management are, and how follow-up can be organised. Recommendations are made regarding the use of pharmaceutical specialties and treatment other than medications. CONCLUSION These recommendations are intended to guide the diagnosis and practical management of pulmonary lymphangioleiomyomatosis.
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Affiliation(s)
- Vincent Cottin
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France; UMR 754, INRAE, Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69008 Lyon, France.
| | - Elodie Blanchard
- Centre de Compétence des maladies pulmonaires rares (OrphaLung), GH Sud Haut-Lévêque, Avenue Magellan, 33600 Pessac, France
| | - Mallorie Kerjouan
- Centre de Compétence des maladies pulmonaires rares (OrphaLung), CHU Pontchailloux, 2 rue Henri le Guilloux, 35000 Rennes, France
| | - Romain Lazor
- Service de Pneumologie, Centre Hospitalier Universitaire Vaudois, BU44/07.2137, Rue du Bugnon 46, 1011 Lausanne, Suisse
| | - Martine Reynaud-Gaubert
- Centre de Compétence des maladies pulmonaires rares (OrphaLung), Hôpital Nord, Chemin Bourrely, 13015 Marseille, France; URMITE-CNRS-IRD UMR 6236, Aix-Marseille Université, 51 boulevard Pierre Dramard, 13344 Marseille cedex 15, France
| | - Camille Taille
- Centre de Référence Constitutif des maladies pulmonaires rares (OrphaLung), Hôpital Bichat, 46 rue Henri Huchard, 75018 Paris, France; Université Paris-Diderot, 17 rue Jean Antoine de Baïf, 75013 Paris, France
| | - Yurdagül Uzunhan
- Centre de Référence constitutif des maladies pulmonaires rares (OrphaLung), Hôpital Avicenne, 125 rue Stalingrad, 93000 Bobigny, France; Université Sorbonne Paris Nord, INSERM UMR 1272 "Hypoxie et Poumon", 1 rue Chablis, 93000 Bobigny, Paris, France
| | - Lidwine Wemeau
- Centre de Référence constitutif des maladies pulmonaires rares, CHRU, 5 rue Oscar Lambret, 59000 Lille, France
| | - Claire Andrejak
- Service de pneumologie, CHU Amiens, 1 Place Victor Pauchet, 80054 Amiens, France; UFR de médecine, 3 rue Louvels, 80000 Amiens, France
| | - Dany Baud
- Hôpital Suisse de Paris, 10 rue Minard, 92130 Issy les Moulineaux, France
| | - Philippe Bonniaud
- Centre de Référence constitutif des maladies pulmonaires rares, CHU de Dijon, BP 77908, 21079, Dijon, France; INSERM, LNC UMR1231, LipSTIC LabEx Team, 21000 Dijon, France
| | - Pierre-Yves Brillet
- Université Sorbonne Paris Nord, INSERM UMR 1272 "Hypoxie et Poumon", 1 rue Chablis, 93000 Bobigny, Paris, France; Service de radiologie, hôpital Avicenne, 125 rue Stalingrad, 93000 Bobigny, France
| | - Alain Calender
- Département de génétique, Hospices Civils de Lyon, 28 avenue Doyen Lepine, 69677 Lyon, France; IBCP, Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69008 Lyon, France
| | - Lara Chalabreysse
- Service de pathologie, Groupe hospitalier est, Hospices Civils de Lyon, 28 avenue Doyen Lepine, 69677 Lyon, France; Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69008 Lyon, France
| | | | | | - Gilbert Ferretti
- Pole imagerie, CHU Grenoble Alpes, Boulevard Chantourne, 38700 La Tronche, France
| | - Anne Guillemot
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France
| | - Laurane Hardelin
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France
| | - Marianne Kambouchner
- Service d'anatomopatholologie, Hôpital Avicenne, 125 rue Stalingrad, 93000 Bobigny, France
| | - Violette Leclerc
- Association France Lymphangioléiomyomatose, 4, Rue des Vieux-Moulins, 56 680 Plouhinec, France
| | - Mathieu Lederlin
- Service de radiologie, CHU Pontchailloux, 2 rue Henri le Guilloux, 35000 Rennes, France
| | | | - Alain Mancel
- Association France Lymphangioléiomyomatose, 4, Rue des Vieux-Moulins, 56 680 Plouhinec, France
| | - Sylvain Marchand-Adam
- Centre de Compétence des maladies pulmonaires rares (OrphaLung), Hôpital Bretonneau, CHRU Tours, 2 Boulevard Tonnellé, 37000 Tours, France; Université de Tours, CEPR INSERMU1100, 10 Boulevard Tonnellé, 37000 Tours, France
| | - Jean-Michel Maury
- Service de chirurgie thoracique, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, 69677 Lyon, France
| | - Jean-Marc Naccache
- Service de pneumologie, Hôpital Saint Joseph, 185 rue Raymond Losserand, 75014 Paris, France
| | - Mouhamad Nasser
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France
| | - Hilario Nunes
- Centre de Référence constitutif des maladies pulmonaires rares (OrphaLung), Hôpital Avicenne, 125 rue Stalingrad, 93000 Bobigny, France; Université Sorbonne Paris Nord, INSERM UMR 1272 "Hypoxie et Poumon", 1 rue Chablis, 93000 Bobigny, Paris, France
| | - Gaële Pagnoux
- Service de radiologie, Hôpital Edouard Herriot, 5 place d'Arsonval, 69008 Lyon, France
| | - Grégoire Prévot
- Centre de Compétence des maladies pulmonaires rares (OrphaLung), service de pneumologie, hôpital Larrey, 24 chemin de Pouvourville, 31059 Toulouse cedex 9, France
| | | | - Olivier Rouviere
- Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69008 Lyon, France; Service de radiologie, Hôpital Edouard Herriot, 5 place d'Arsonval, 69008 Lyon, France
| | - Salim Si-Mohamed
- Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69008 Lyon, France; Service d'imagerie, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, 69677 Lyon, France
| | - Renaud Touraine
- Laboratoire de Génétique Chromosomique et Moléculaire, CHU-Hôpital Nord, Laboratoire AURAGEN (Plan France Médecine Génomique 2025), 42270 Saint Priest en Jarest, France
| | - Julie Traclet
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France
| | - Ségolène Turquier
- Service d'exploration fonctionnelle respiratoire, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, 69677 Lyon, France
| | - Stéphane Vagnarelli
- Centre de Référence constitutif des maladies pulmonaires rares (OrphaLung), Hôpital Avicenne, 125 rue Stalingrad, 93000 Bobigny, France
| | - Kaïs Ahmad
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France
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Calderón-Garcidueñas AL, Piña-Ballantyne SA, Espinosa-Aguilar EJ. Subependymal Giant Cell Astrocytoma Non-Associated With Tuberous Sclerosis Complex and Expression of OCT-4 and INI-1: A Case Report. Cureus 2023; 15:e39187. [PMID: 37378241 PMCID: PMC10292187 DOI: 10.7759/cureus.39187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2023] [Indexed: 06/29/2023] Open
Abstract
Subependymal giant cell astrocytoma (SEGA) is a rare, slow-growing tumor with a dual (neuroglial) component that is typically associated with tuberous sclerosis complex (TSC). We present the case of a healthy 19-year-old man with mild occipital trauma followed by two weeks of intense headache, with no response to analgesics. Imaging studies revealed a well-defined tumor in the left paraventricular zone. A biopsy showed a SEGA (GFAP+, NF+, nestin+, CK-EA3/EA4+, and TTF1+). TSC was ruled out. An immunohistochemistry (IHC) panel showed aberrant cytoplasmic expression of octamer-binding transcription factor 4 (OCT-4) in endothelial cells, pericytes, and some astrocyte-type cells; integrase interactor 1 (INI-1) expression was observed in the cytoplasm of neoplastic cells; SEGA was not associated with TSC; the expression of nestin and OCT-4 suggested their origin in neuroepithelial stem cells; thyroid transcription factor 1 (TTF-1) expression supported its origin in diencephalic structures. Tuberin expression was decreased. An aberrant pattern of INI-1 was observed, which, together with OCT-4 findings, has not been previously described.
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Skrobanski H, Vyas K, Bowditch S, Hubig L, Dziadulewicz E, Fish L, Takhar P, Lo SH. The Burden of Caring for Individuals with Tuberous Sclerosis Complex (TSC) Who Experience Epileptic Seizures: A Descriptive UK Survey. PHARMACOECONOMICS - OPEN 2023; 7:299-312. [PMID: 36757566 PMCID: PMC10043106 DOI: 10.1007/s41669-023-00387-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Tuberous sclerosis complex (TSC) is a rare multisystem genetic condition characterised by benign tumours; prevalent manifestations include epilepsy and neuropsychiatric disorders. This study examined the burden of TSC for primary caregivers and families, exploring the impact of characteristics such as seizures. METHODS Primary caregivers of individuals with TSC in the United Kingdom participated in an online survey, comprising the Pediatric Quality of Life Inventory™ Family Impact Module, Hospital Anxiety and Depression Scale (HADS), and TSC-specific items. Responses were analysed using descriptive and regression analysis statistics (closed-ended) or qualitative content analysis (open-ended). RESULTS Seventy-three participants partially completed and 59 fully completed the survey; 95% were female, and 90% were parents of an individual with TSC. A median (range) of 2 (1-11) household members were carers. Primary caregivers spent a mean (standard deviation [SD]) of 104.3 (51.7) hours caring in the previous week, reporting high mean (SD) HADS scores of 11.2 (4.8) (anxiety) and 7.9 (4.4) (depression) and considerable family burden. Increased seizure frequency increased hours spent caring by primary caregivers (p = 0.01) and was associated with a decreased mean (SD) family functioning score of 46.2 (23.0) and parent health-related quality of life (HRQL) score of 45.4 (20.3) (both p = 0.03). Multivariable models predicted intellectual disability increased hours spent caring by primary caregivers (p = 0.01-0.04), and neuropsychiatric comorbidities decreased family functioning (p = 0.02) and caregiver HRQL (p < 0.01). CONCLUSION These findings highlight the role of epileptic seizures and neuropsychiatric disorders in the considerable burden of TSC on primary caregivers and families.
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Affiliation(s)
| | - Kishan Vyas
- Jazz Pharmaceuticals, Inc., 1 Cavendish Place, London, W1G 0QF, UK
| | - Sally Bowditch
- Jazz Pharmaceuticals, Inc., 1 Cavendish Place, London, W1G 0QF, UK.
| | - Lena Hubig
- Acaster Lloyd Consulting Ltd, London, UK
| | | | - Louise Fish
- Genetic Alliance UK, London, UK
- Tuberous Sclerosis Association, London, UK
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Jurca CM, Kozma K, Petchesi CD, Zaha DC, Magyar I, Munteanu M, Faur L, Jurca A, Bembea D, Severin E, Jurca AD. Tuberous Sclerosis, Type II Diabetes Mellitus and the PI3K/AKT/mTOR Signaling Pathways-Case Report and Literature Review. Genes (Basel) 2023; 14:433. [PMID: 36833359 PMCID: PMC9957184 DOI: 10.3390/genes14020433] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/23/2023] [Accepted: 02/05/2023] [Indexed: 02/11/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare autosomal dominant neurocutaneous syndrome. It is manifested mainly in cutaneous lesions, epilepsy and the emergence of hamartomas in several tissues and organs. The disease sets in due to mutations in two tumor suppressor genes: TSC1 and TSC2. The authors present the case of a 33-year-old female patient registered with the Bihor County Regional Center of Medical Genetics (RCMG) since 2021 with a TSC diagnosis. She was diagnosed with epilepsy at eight months old. At 18 years old she was diagnosed with tuberous sclerosis and was referred to the neurology department. Since 2013 she has been registered with the department for diabetes and nutritional diseases with a type 2 diabetes mellitus (T2DM) diagnosis. The clinical examination revealed: growth delay, obesity, facial angiofibromas, sebaceous adenomas, depigmented macules, papillomatous tumorlets in the thorax (bilateral) and neck, periungual fibroma in both lower limbs, frequent convulsive seizures; on a biological level, high glycemia and glycated hemoglobin levels. Brain MRI displayed a distinctive TS aspect with five bilateral hamartomatous subependymal nodules associating cortical/subcortical tubers with the frontal, temporal and occipital distribution. Molecular diagnosis showed a pathogenic variant in the TSC1 gene, exon 13, c.1270A>T (p. Arg424*). Current treatment targets diabetes (Metformin, Gliclazide and the GLP-1 analog semaglutide) and epilepsy (Carbamazepine and Clonazepam). This case report presents a rare association between type 2 diabetes mellitus and Tuberous Sclerosis Complex. We suggest that the diabetes medication Metformin may have positive effects on both the progression of the tumor associated with TSC and the seizures specific to TSC and we assume that the association of TSC and T2DM in the presented cases is accidental, as there are no similar cases reported in the literature.
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Affiliation(s)
- Claudia Maria Jurca
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410081 Oradea, Romania
- Regional Center of Medical Genetics Bihor, County Emergency Clinical Hospital Oradea (Part of ERN-ITHACA), 410469 Oradea, Romania
| | - Kinga Kozma
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410081 Oradea, Romania
- Regional Center of Medical Genetics Bihor, County Emergency Clinical Hospital Oradea (Part of ERN-ITHACA), 410469 Oradea, Romania
| | - Codruta Diana Petchesi
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410081 Oradea, Romania
- Regional Center of Medical Genetics Bihor, County Emergency Clinical Hospital Oradea (Part of ERN-ITHACA), 410469 Oradea, Romania
| | - Dana Carmen Zaha
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410081 Oradea, Romania
| | - Ioan Magyar
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410081 Oradea, Romania
| | - Mihai Munteanu
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410081 Oradea, Romania
| | - Lucian Faur
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410081 Oradea, Romania
| | - Aurora Jurca
- Faculty of Medicine and Pharmacy, University of Oradea, 410081 Oradea, Romania
| | - Dan Bembea
- Faculty of Medicine, University of Medicine and Pharmacy ”Iuliu Hațieganu”, 400012 Cluj Napoca, Romania
| | - Emilia Severin
- Department of Genetics, University of Medicine and Pharmacy ”Carol Davila”, 020021 Bucharest, Romania
| | - Alexandru Daniel Jurca
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410081 Oradea, Romania
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28
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Prelevic V, Juric I, Bevc S, Marcun-Varda N, Aleckovic-Halilovic M, Mesic E, Bilic H, Grujicic M, Zabic I, Josipovic J, Vujicic B, Marinaki S, Simic-Ogrizovic S, Milinkovic M, Azasevac T, Idrizi A, Arnol M, Radunovic D, Antunovic T, Jukic NB. Association of multiple retinal nodular hamartomas and "confetti" skin lesions with end-stage renal disease in patients with tuberous sclerosis. Int Urol Nephrol 2023; 55:477-482. [PMID: 36030358 DOI: 10.1007/s11255-022-03352-9] [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: 08/11/2021] [Accepted: 08/22/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE The main purpose of this study is to explore characteristics of patients with chronic kidney disease in tuberous sclerosis (TSC) and to underline differences in clinical characteristics between end-stage renal disease (ESRD) patients and patients in earlier stages of chronic kidney disease. METHODS This multicentric, retrospective study included data for 48 patients from seven South-Eastern European countries (Albania, Bosnia and Herzegovina, Croatia, Greece, Montenegro, Serbia, Slovenia) in the period from February to August 2020. Researchers collected data from local and national nephrological and neurological registries and offered clinical and laboratory results from medical histories in follow-up periods. RESULTS This study enrolled 48 patients with a median age of 32.3 years (range, 18-46 years), and predominant female gender (60.45%). The percentage of patients with chronic kidney disease (CKD) diagnosis of the total number of patients was 66.90%, with end-stage renal disease development in 39.6%. The most prevalent renal lesions leading to chronic kidney disease were angiomyolipomas (AMLs) in 76.6%, while multiple renal cysts were present in 42.6% of patients. Nephrectomy was performed in 43% of patients, while the mTOR inhibitors were used in 18 patients (37.5%). The majority of patients had cutaneous manifestations of tuberous sclerosis-83.30% had hypomelanotic cutaneous lesions, and 68.80% had angiofibromas. Multiple retinal nodular hamartomas and "confetti" skin lesions were more frequent in end-stage renal disease (ESRD) than in patients with earlier stages of chronic kidney disease (p-0.033 and 0.03, respectively). CONCLUSION Our study has also shown that retinal hamartomas and "confetti" skin lesions are more frequent in end-stage renal diseases (ESRD) patients than in other chronic kidney disease (CKD) patients. Usage of mTOR inhibitors can also reduce the number of complications and associated with tuberous sclerosis, such as dermatological manifestations and retinal hamartoma, which are more common in the terminal stage of chronic kidney disease.
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Affiliation(s)
- Vladimir Prelevic
- Department of Nephrology, Clinical Center of Montenegro, Ljubljanska bb, 81000, Podgorica, Montenegro.
| | - Ivana Juric
- Department of Nephrology, Arterial Hypertension, Dialysis and Kidney Transplantation, University Hospital Center Zagreb, Zagreb, Croatia
| | - Sebastijan Bevc
- Department of Nephrology and Clinic for pediatrics, University Medical Center Maribor, Maribor, Slovenia
| | - Natasa Marcun-Varda
- Department of Nephrology and Clinic for pediatrics, University Medical Center Maribor, Maribor, Slovenia
| | - Mirna Aleckovic-Halilovic
- Department of Nephrology and Hemodialysis, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
| | - Enisa Mesic
- Department of Nephrology and Hemodialysis, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
| | - Hrvoje Bilic
- Department of Neurology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Milorad Grujicic
- Department of Nephrology with Plasmapheresis, University Clinical Center of the Republic of Srpska, Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Igor Zabic
- Department of Nephrology, General Hospital Koprivnica, Koprivnica, Croatia
| | - Josipa Josipovic
- Department of Nephrology, University Hospital Clinical Center "Sestre Milosrdnice", Zagreb, Croatia
| | - Bozidar Vujicic
- Department of Nephrology, Clinical Hospital Center Rijeka, Rijeka, Croatia
| | - Smaragdi Marinaki
- Department of Nephrology, Laiko University General Hospital, Athens, Greece
| | | | | | - Tijana Azasevac
- Clinic of Nephrology and Clinical Immunology, Clinical Center Vojvodina, Novi Sad, Serbia
| | - Alma Idrizi
- Department of Nephrology, University Hospital Center Tirana, Tirana, Albania
| | - Miha Arnol
- Department of Nephrology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Danilo Radunovic
- Department of Nephrology, Clinical Center of Montenegro, Ljubljanska bb, 81000, Podgorica, Montenegro
| | - Tanja Antunovic
- Center for Laboratory Diagnostic, Clinical Center of Montenegro, Podgorica, Montenegro
| | - Nikolina Basic- Jukic
- Department of Nephrology, Arterial Hypertension, Dialysis and Kidney Transplantation, University Hospital Center Zagreb, Zagreb, Croatia
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Subependymal Giant Cell Astrocytomas in Tuberous Sclerosis Complex-Current Views on Their Pathogenesis and Management. J Clin Med 2023; 12:jcm12030956. [PMID: 36769603 PMCID: PMC9917805 DOI: 10.3390/jcm12030956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/21/2023] [Accepted: 01/22/2023] [Indexed: 01/28/2023] Open
Abstract
Introduction, Tuberous sclerosis complex (TSC) is an autosomal-dominant disorder caused by mutations inactivating TSC1 or TSC2 genes and characterized by the presence of tumors involving many organs, including the brain, heart, kidneys, and skin. Subependymal giant cell astrocytoma (SEGA) is a slow-growing brain tumor almost exclusively associated with TSC. STATE OF THE ART Despite the fact that SEGAs are benign, they require well-considered decisions regarding the timing and modality of pharmacological or surgical treatment. In TSC children and adolescents, SEGA is the major cause of mortality and morbidity. CLINICAL IMPLICATIONS Until recently, surgical resection has been the standard therapy for SEGAs but the discovery of the role of the mTOR pathway and the introduction of mTOR inhibitors to clinical practice changed the therapeutic landscape of these tumors. In the current paper, we discuss the pros and cons of mTOR inhibitors and surgical approaches in SEGA treatment. FUTURE DIRECTIONS In 2021, the International Tuberous Sclerosis Complex Consensus Group proposed a new integrative strategy for SEGA management. In the following review, we discuss the proposed recommendations and report the results of the literature search for the latest treatment directions.
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30
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Nguyen TB, Lac Q, Abdi L, Banerjee D, Deng Y, Zhang Y. Harshening stem cell research and precision medicine: The states of human pluripotent cells stem cell repository diversity, and racial and sex differences in transcriptomes. Front Cell Dev Biol 2023; 10:1071243. [PMID: 36684445 PMCID: PMC9848738 DOI: 10.3389/fcell.2022.1071243] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/05/2022] [Indexed: 01/06/2023] Open
Abstract
In vitro investigation on human development, disease modeling, and drug discovery has been empowered by human induced pluripotent stem cell (hiPSC) technologies that form the foundation of precision medicine. Race and sex genetic backgrounds have become a major focus of many diseases modeling and drug response evaluation in the pharmaceutical industry. Here, we gathered data from major stem cell repositories to analyze the diversity with respect to ethnicity, sex, and disease types; and we also analyzed public datasets to unravel transcriptomics differences between samples of different ethnicities and sexes. We found a lack of diversity despite the large sample size of human induced pluripotent stem cells. In the ethnic comparison, the White group made up the majority of the banked hiPSCs. Similarly, for the organ/disease type and sex comparisons, the neural and male hiPSCs accounted for the majority of currently available hiPSCs. Bulk RNA-seq and single-cell transcriptomic analysis coupled with Machine Learning and Network Analysis revealed panels of gene features differently expressed in healthy hiPSCs and human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) of different races and sexes. The data highlights the current ethnic and sex inequality in stem cell research and demonstrates the molecular biological diversity of hiPSCs and cardiomyocytes from different races and genders. We postulate that future efforts in stem cell biology, regenerative and precision medicine should be guided towards an inclusive, diverse repository reflecting the prevalence of diseases across racial and ethnic groups and the sexes, important for both common and rare disease modeling, drug screening, and cell therapeutics.
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Affiliation(s)
- Thong Ba Nguyen
- Department of Anatomy, Biochemistry and Physiology, Honolulu, HI, United States
- Center for Cardiovascular Research, Honolulu, HI, United States
| | - Quan Lac
- Department of Anatomy, Biochemistry and Physiology, Honolulu, HI, United States
- Center for Cardiovascular Research, Honolulu, HI, United States
| | - Lovina Abdi
- Department of Anatomy, Biochemistry and Physiology, Honolulu, HI, United States
- Center for Cardiovascular Research, Honolulu, HI, United States
| | - Dipanjan Banerjee
- Center for Cardiovascular Research, Honolulu, HI, United States
- Department of Medicine, Honolulu, HI, United States
| | - Youping Deng
- Department of Quantitative Health Sciences, Honolulu, HI, United States
- Genomics and Bioinformatics Shared Resource, Honolulu, HI, United States
| | - Yiqiang Zhang
- Department of Anatomy, Biochemistry and Physiology, Honolulu, HI, United States
- Center for Cardiovascular Research, Honolulu, HI, United States
- Diabetes Research Center, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, United States
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31
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Shimada T, Yamagata K. Spine morphogenesis and synapse formation in tubular sclerosis complex models. Front Mol Neurosci 2022; 15:1019343. [PMID: 36606143 PMCID: PMC9807618 DOI: 10.3389/fnmol.2022.1019343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is caused by mutations in the Tsc1 or Tsc2 genes, whose products form a complex and inactivate the small G-protein Rheb1. The activation of Rheb1 may cause refractory epilepsy, intellectual disability, and autism, which are the major neuropsychiatric manifestations of TSC. Abnormalities in dendritic spines and altered synaptic structure are hallmarks of epilepsy, intellectual disability, and autism. In addition, spine dysmorphology and aberrant synapse formation are observed in TSC animal models. Therefore, it is important to investigate the molecular mechanism underlying the regulation of spine morphology and synapse formation in neurons to identify therapeutic targets for TSC. In this review, we focus on the representative proteins regulated by Rheb1 activity, mTORC1 and syntenin, which are pivotal downstream factors of Rheb1 in the alteration of spine formation and synapse function in TSC neurons.
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Affiliation(s)
- Tadayuki Shimada
- Child Brain Project, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan,*Correspondence: Tadayuki Shimada,
| | - Kanato Yamagata
- Child Brain Project, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan,Department of Psychiatry, Takada Nishishiro Hospital, Niigata, Japan,Kanato Yamagata,
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32
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Pereira CCDS, Dantas FDG, Manreza MLGD. Clinical profile of tuberous sclerosis complex patients with and without epilepsy: a need for awareness for early diagnosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:1004-1010. [PMID: 36535284 PMCID: PMC9770081 DOI: 10.1055/s-0042-1758456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is a multisystemic disorder. Its clinical features manifest differently in several organs, prompting the need for better knowledge. OBJECTIVE The goal of the present study is to evaluate the neurological findings of TSC, such as cerebral lesions and epilepsy, and to raise awareness of non-neurological findings that could contribute to an earlier diagnosis and treatment. METHODS This was a natural history study of patients with a definitive diagnosis of TSC who were referred to a specialized outpatient clinic and followed-up for 2 years with clinical and radiological exams. RESULTS A total of 130 TSC patients (59 males [45.4%], mean age 20.4 years old [1 to 56 years old]); 107 patients (82.3%) were diagnosed with epilepsy. Seizures predominantly began at < 1 year old (72.8%); focal seizures predominated (86.9%); epileptic spasms occurred in 34.5% of patients, and refractory epilepsy was present in 55.1%. Neuropsychiatric disorders, cortical tubers and cerebellar tubers were significantly more frequent in the epilepsy group. Moreover, rhabdomyomas were significantly more frequent in the epilepsy group (p = 0.044), while lymphangioleiomyomatosis was significantly less frequent in the epilepsy group (p = 0.009). Other non-neurological findings did not differ significantly between the groups with and without epilepsy. CONCLUSIONS The present study of TSC patients demonstrated the predominantly neurological involvement and significantly higher proportion of TSC-associated neuropsychiatric disorders in the epilepsy group. Higher proportions of cortical and cerebellar tubers may be a risk factor for epilepsy and neurodevelopmental disorders.
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Affiliation(s)
- Conceição Campanario da Silva Pereira
- Universidade de São Paulo, Hospital das Clinicas de São Paulo, Departamento de Neurologia Infantil, São Paulo SP, Brazil.,Address for correspondence Conceição Campanario da Silva Pereira
| | - Felipe Diego Gomes Dantas
- Universidade de São Paulo, Hospital das Clínicas de São Paulo, Departamento de Neurorradiologia, São Paulo SP, Brazil.
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Abstract
Tuberous sclerosis is an autosomal dominant disorder almost fully penetrant with highly variable expression. Most cases are de novo and this diagnosis is sometimes considered during prenatal life in case of cardiac tumor, unique or multiple. The couple should be referred to a specialized tertiary prenatal care center for expertise and information. Fetal molecular testing of the two genes TSC1 and TSC2 is often informative. Prognosis determination for Tuberous Sclerosis remains a difficult task. Cardiac tumors can be sometimes worrying but only a minority will have a pejorative issue and most cases are asymptomatic without any therapeutic intervention needed. Only few cases need surgical or medical treatment. Patients with Tuberous Sclerosis can develop skin, eye, kidney or lung lesions later on, but they are either of limited consequence or treatable. The crux of the matter is the neurological involvement with frequent intellectual deficiency and epilepsy that can be drug-resistant. The absence of lesion on fetal brain MRI is not predictive of any prognosis and does not rule out Tuberous Sclerosis. De novo TSC2 mutation is a negative prognosis factor and conversely, an inherited TSC1 mutation is a more favorable one, but with a severe issue still possible. Facing this cautious prognosis, some couple may opt for termination of pregnancy while others decide to pursue it. It is then fundamental to set cardiac and neurological regular follow-up for these newborns. © 2022 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.
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34
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Ye Z, Lin S, Zhao X, Bennett MF, Brown NJ, Wallis M, Gao X, Sun L, Wu J, Vedururu R, Witkowski T, Gardiner F, Stutterd C, Duan J, Mullen SA, McGillivray G, Bodek S, Valente G, Reagan M, Yao Y, Li L, Chen L, Boys A, Adikari TN, Cao D, Hu Z, Beshay V, Zhang VW, Berkovic SF, Scheffer IE, Liao J, Hildebrand MS. Mosaicism in tuberous sclerosis complex: Lowering the threshold for clinical reporting. Hum Mutat 2022; 43:1956-1969. [PMID: 36030538 DOI: 10.1002/humu.24454] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 07/20/2022] [Accepted: 08/21/2022] [Indexed: 01/25/2023]
Abstract
Tuberous sclerosis complex (TSC) is a multi-system genetic disorder. Most patients have germline mutations in TSC1 or TSC2 but, 10%-15% patients do not have TSC1/TSC2 mutations detected on routine clinical genetic testing. We investigated the contribution of low-level mosaic TSC1/TSC2 mutations in unsolved sporadic patients and families with TSC. Thirty-one sporadic TSC patients negative on routine testing and eight families with suspected parental mosaicism were sequenced using deep panel sequencing followed by droplet digital polymerase chain reaction. Pathogenic variants were found in 22/31 (71%) unsolved sporadic patients, 16 were mosaic (median variant allele fraction [VAF] 6.8% in blood) and 6 had missed germline mutations. Parental mosaicism was detected in 5/8 families (median VAF 1% in blood). Clinical testing laboratories typically only report pathogenic variants with allele fractions above 10%. Our findings highlight the critical need to change laboratory practice by implementing higher sensitivity assays to improve diagnostic yield, inform patient management and guide reproductive counseling.
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Affiliation(s)
- Zimeng Ye
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Sufang Lin
- Department of Neurology, Epilepsy Centre, Shenzhen Children's Hospital, Shenzhen, Guangdong Province, China
| | - Xia Zhao
- Department of Neurology, Epilepsy Centre, Shenzhen Children's Hospital, Shenzhen, Guangdong Province, China
| | - Mark F Bennett
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Heidelberg, Victoria, Australia.,Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia.,Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia
| | - Natasha J Brown
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, Royal Children's Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Victorian Clinical Genetics Services, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Mathew Wallis
- Austin Health, Heidelberg, Victoria, Australia.,Tasmania Clinical Genetics Service, Royal Hobart Hospital, Tasmania, Australia.,School of Medicine, University of Tasmania, Tasmania, Australia.,Menzies Institute for Medical Research, University of Tasmania, Tasmania, Australia
| | - Xinyi Gao
- AmCare Genomics Laboratory, Guangzhou, Guangdong Province, China
| | - Li Sun
- AmCare Genomics Laboratory, Guangzhou, Guangdong Province, China
| | - Jiarui Wu
- AmCare Genomics Laboratory, Guangzhou, Guangdong Province, China
| | - Ravikiran Vedururu
- Molecular Diagnostic Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Tom Witkowski
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Fiona Gardiner
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Heidelberg, Victoria, Australia
| | - Chloe Stutterd
- Victorian Clinical Genetics Services, Royal Children's Hospital, Parkville, Victoria, Australia.,Austin Health, Heidelberg, Victoria, Australia
| | - Jing Duan
- Department of Neurology, Epilepsy Centre, Shenzhen Children's Hospital, Shenzhen, Guangdong Province, China
| | - Saul A Mullen
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Heidelberg, Victoria, Australia.,Austin Health, Heidelberg, Victoria, Australia
| | - George McGillivray
- Victorian Clinical Genetics Services, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Simon Bodek
- Austin Health, Heidelberg, Victoria, Australia
| | | | - Matthew Reagan
- Department of Medicine, Peninsula Health, Monash University, Frankston, Victoria, Australia
| | - Yi Yao
- Department of Neurology, Epilepsy Centre, Shenzhen Children's Hospital, Shenzhen, Guangdong Province, China
| | - Lin Li
- Department of Neurology, Epilepsy Centre, Shenzhen Children's Hospital, Shenzhen, Guangdong Province, China
| | - Li Chen
- Department of Neurology, Epilepsy Centre, Shenzhen Children's Hospital, Shenzhen, Guangdong Province, China
| | - Amber Boys
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Thiuni N Adikari
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Heidelberg, Victoria, Australia.,School of Medicine, University of Tasmania, Tasmania, Australia
| | - Dezhi Cao
- Department of Neurology, Epilepsy Centre, Shenzhen Children's Hospital, Shenzhen, Guangdong Province, China
| | - Zhanqi Hu
- Department of Neurology, Epilepsy Centre, Shenzhen Children's Hospital, Shenzhen, Guangdong Province, China
| | - Victoria Beshay
- Molecular Diagnostic Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Victor W Zhang
- AmCare Genomics Laboratory, Guangzhou, Guangdong Province, China
| | - Samuel F Berkovic
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Heidelberg, Victoria, Australia.,Austin Health, Heidelberg, Victoria, Australia
| | - Ingrid E Scheffer
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Heidelberg, Victoria, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, Royal Children's Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Austin Health, Heidelberg, Victoria, Australia.,The Florey Institute, Parkville, Victoria, Australia
| | - Jianxiang Liao
- Department of Neurology, Epilepsy Centre, Shenzhen Children's Hospital, Shenzhen, Guangdong Province, China
| | - Michael S Hildebrand
- Epilepsy Research Centre, Department of Medicine, The University of Melbourne, Heidelberg, Victoria, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia.,Austin Health, Heidelberg, Victoria, Australia
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Cruz‐Zuniga RD, Alas‐Pineda C, Pineda‐Vijil HO, Gaitán‐Zambrano K, Flores‐Reyes DL, Pineda‐Villeda RH, Quiñonez‐Sánchez MA. Diagnosis of tuberous sclerosis complex in adulthood: A case report. Clin Case Rep 2022; 10:e6555. [PMID: 36478974 PMCID: PMC9718917 DOI: 10.1002/ccr3.6555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/02/2022] [Accepted: 10/15/2022] [Indexed: 12/04/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant genetic disorder. TSC consists of a wide variety of clinical manifestations, with neurological and dermatological symptoms being the most frequent. This study aims to describe the clinical characteristics and management of a pregnant patient incidentally diagnosed with TSC.
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Affiliation(s)
- Rubén D. Cruz‐Zuniga
- Departamento de Medicina Interna Hospital Nacional Dr. Mario Catarino Rivas San Pedro Sula Honduras
| | - César Alas‐Pineda
- Departamento de Epidemiología Hospital Nacional Dr. Mario Catarino Rivas San Pedro Sula Honduras
| | - Héctor O. Pineda‐Vijil
- Departamento de Neurología Hospital Nacional Dr. Mario Catarino Rivas San Pedro Sula Honduras
| | - Kristhel Gaitán‐Zambrano
- Facultad de Medicina y Cirugía Universidad Católica de Honduras – Campus San Pedro y San Pablo San Pedro Sula Honduras
| | - Diana L. Flores‐Reyes
- Escuela Universitaria de las Ciencias de la Salud Universidad Nacional Autónoma de Honduras ‐ Valle de Sula San Pedro Sula Honduras
| | - Reenie H. Pineda‐Villeda
- Escuela Universitaria de las Ciencias de la Salud Universidad Nacional Autónoma de Honduras ‐ Valle de Sula San Pedro Sula Honduras
| | - Marco A. Quiñonez‐Sánchez
- Departamento de Cuidados Intensivos Hospital Nacional Dr. Mario Catarino Rivas San Pedro Sula Honduras
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Litwa K. Shared mechanisms of neural circuit disruption in tuberous sclerosis across lifespan: Bridging neurodevelopmental and neurodegenerative pathology. Front Genet 2022; 13:997461. [PMID: 36506334 PMCID: PMC9732432 DOI: 10.3389/fgene.2022.997461] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/06/2022] [Indexed: 11/27/2022] Open
Abstract
Tuberous Sclerosis (TS) is a rare genetic disorder manifesting with multiple benign tumors impacting the function of vital organs. In TS patients, dominant negative mutations in TSC1 or TSC2 increase mTORC1 activity. Increased mTORC1 activity drives tumor formation, but also severely impacts central nervous system function, resulting in infantile seizures, intractable epilepsy, and TS-associated neuropsychiatric disorders, including autism, attention deficits, intellectual disability, and mood disorders. More recently, TS has also been linked with frontotemporal dementia. In addition to TS, accumulating evidence implicates increased mTORC1 activity in the pathology of other neurodevelopmental and neurodegenerative disorders. Thus, TS provides a unique disease model to address whether developmental neural circuit abnormalities promote age-related neurodegeneration, while also providing insight into the therapeutic potential of mTORC1 inhibitors for both developing and degenerating neural circuits. In the following review, we explore the ability of both mouse and human brain organoid models to capture TS pathology, elucidate disease mechanisms, and shed light on how neurodevelopmental alterations may later contribute to age-related neurodegeneration.
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Genotype and Phenotype Landscape of 283 Japanese Patients with Tuberous Sclerosis Complex. Int J Mol Sci 2022; 23:ijms231911175. [PMID: 36232477 PMCID: PMC9569560 DOI: 10.3390/ijms231911175] [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: 08/31/2022] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 11/16/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by multiple dysplastic organ lesions and neuropsychiatric symptoms, caused by loss of function mutations in either TSC1 or TSC2. Genotype and phenotype analyses are conducted worldwide, but there have been few large-scale studies on Japanese patients, and there are still many unclear points. This study analyzed 283 Japanese patients with TSC (225 definite, 53 possible, and 5 genetic diagnoses). A total of 200 mutations (64 TSC1, 136 TSC2) were identified, of which 17 were mosaic mutations, 11 were large intragenic deletions, and four were splicing abnormalities due to deep intronic mutations. Several lesions and symptoms differed in prevalence and severity between TSC1 and TSC2 patients and were generally more severe in TSC2 patients. Moreover, TSC2 missense and in-frame mutations may attenuate skin and renal symptoms compared to other TSC2 mutations. Genetic testing revealed that approximately 20% of parents of a proband had mild TSC, which could have been missed. The patient demographics presented in this study revealed a high frequency of TSC1 patients and a low prevalence of epilepsy compared to global statistics. More patients with mild neuropsychiatric phenotypes were diagnosed in Japan, seemingly due to a higher utilization of brain imaging, and suggesting the possibility that a significant amount of mild TSC patients may not be correctly diagnosed worldwide.
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Riley VA, Holmberg JC, Sokolov AM, Feliciano DM. Tsc2 shapes olfactory bulb granule cell molecular and morphological characteristics. Front Mol Neurosci 2022; 15:970357. [PMID: 36277492 PMCID: PMC9581303 DOI: 10.3389/fnmol.2022.970357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
Tuberous Sclerosis Complex (TSC) is a neurodevelopmental disorder caused by mutations that inactivate TSC1 or TSC2. Hamartin and tuberin are encoded by TSC1 and TSC2 which form a GTPase activating protein heteromer that inhibits the Rheb GTPase from activating a growth promoting protein kinase called mammalian target of rapamycin (mTOR). Growths and lesions occur in the ventricular-subventricular zone (V-SVZ), cortex, olfactory tract, and olfactory bulbs (OB) in TSC. A leading hypothesis is that mutations in inhibitory neural progenitor cells cause brain growths in TSC. OB granule cells (GCs) are GABAergic inhibitory neurons that are generated through infancy by inhibitory progenitor cells along the V-SVZ. Removal of Tsc1 from mouse OB GCs creates cellular phenotypes seen in TSC lesions. However, the role of Tsc2 in OB GC maturation requires clarification. Here, it is demonstrated that conditional loss of Tsc2 alters GC development. A mosaic model of TSC was created by performing neonatal CRE recombinase electroporation into inhibitory V-SVZ progenitors yielded clusters of ectopic cytomegalic neurons with hyperactive mTOR complex 1 (mTORC1) in homozygous Tsc2 mutant but not heterozygous or wild type mice. Similarly, homozygous Tsc2 mutant GC morphology was altered at postnatal days 30 and 60. Tsc2 mutant GCs had hypertrophic dendritic arbors that were established by postnatal day 30. In contrast, loss of Tsc2 from mature GCs had negligible effects on mTORC1, soma size, and dendrite arborization. OB transcriptome profiling revealed a network of significantly differentially expressed genes following loss of Tsc2 during development that altered neural circuitry. These results demonstrate that Tsc2 has a critical role in regulating neural development and shapes inhibitory GC molecular and morphological characteristics.
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Affiliation(s)
| | | | | | - David M. Feliciano
- Department of Biological Sciences, Clemson University, Clemson, SC, United States
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Advances in the genetics and neuropathology of tuberous sclerosis complex: edging closer to targeted therapy. Lancet Neurol 2022; 21:843-856. [DOI: 10.1016/s1474-4422(22)00213-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 03/09/2022] [Accepted: 05/11/2022] [Indexed: 12/23/2022]
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Tuberöse-Sklerose-Komplex. DIE RADIOLOGIE 2022; 62:1058-1066. [PMID: 35945379 DOI: 10.1007/s00117-022-01053-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 10/15/2022]
Abstract
CLINICAL BACKGROUND Tuberous sclerosis complex (TSC) is a phakomatosis and is a tumor predisposition syndrome. As a genetic multisystem disease, patients present with a broad range of changes in the brain, heart, skin, kidneys, and lungs. OBJECTIVES Which imaging modalities are required to monitor TSC patients according to current international recommendations? MATERIALS AND METHODS Common findings in TSC are cortical tubers, subependymal nodules, and giant cell astrocytomas in the central nervous system (CNS), rhabdomyomas in the heart, and cysts and angiomyolipomas in the kidneys. Magnetic resonance imaging (MRI) of the brain and kidneys and abdominal ultrasound are the imaging modalities of choice, due to the very good soft tissue contrast and lack of X‑ray radiation. RESULTS Using standard and functional MRI sequences in a multimodal approach, the type, malignancy, size, and morphology of changes in TSC can be reliably determined. Abdominal ultrasound using high-resolution transducers can be used to rapidly and reliably detect even the smallest changes in the kidneys. CONCLUSION Regular follow-up of patients with TSC using MRI and ultrasound is necessary for early detection of complications, for planning individualized therapy, and for optimal lifelong care.
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Scheper M, Romagnolo A, Besharat ZM, Iyer AM, Moavero R, Hertzberg C, Weschke B, Riney K, Feucht M, Scholl T, Petrak B, Maulisova A, Nabbout R, Jansen AC, Jansen FE, Lagae L, Urbanska M, Ferretti E, Tempes A, Blazejczyk M, Jaworski J, Kwiatkowski DJ, Jozwiak S, Kotulska K, Sadowski K, Borkowska J, Curatolo P, Mills JD, Aronica E. miRNAs and isomiRs: Serum-Based Biomarkers for the Development of Intellectual Disability and Autism Spectrum Disorder in Tuberous Sclerosis Complex. Biomedicines 2022; 10:biomedicines10081838. [PMID: 36009385 PMCID: PMC9405248 DOI: 10.3390/biomedicines10081838] [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: 06/24/2022] [Revised: 07/22/2022] [Accepted: 07/28/2022] [Indexed: 11/16/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare multi-system genetic disorder characterized by a high incidence of epilepsy and neuropsychiatric manifestations known as tuberous-sclerosis-associated neuropsychiatric disorders (TANDs), including autism spectrum disorder (ASD) and intellectual disability (ID). MicroRNAs (miRNAs) are small regulatory non-coding RNAs that regulate the expression of more than 60% of all protein-coding genes in humans and have been reported to be dysregulated in several diseases, including TSC. In the current study, RNA sequencing analysis was performed to define the miRNA and isoform (isomiR) expression patterns in serum. A Receiver Operating Characteristic (ROC) curve analysis was used to identify circulating molecular biomarkers, miRNAs, and isomiRs, able to discriminate the development of neuropsychiatric comorbidity, either ASD, ID, or ASD + ID, in patients with TSC. Part of our bioinformatics predictions was verified with RT-qPCR performed on RNA isolated from patients’ serum. Our results support the notion that circulating miRNAs and isomiRs have the potential to aid standard clinical testing in the early risk assessment of ASD and ID development in TSC patients.
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Affiliation(s)
- Mirte Scheper
- Department of (Neuro)Pathology Amsterdam Neuroscience, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.S.); (A.R.); (A.M.I.)
| | - Alessia Romagnolo
- Department of (Neuro)Pathology Amsterdam Neuroscience, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.S.); (A.R.); (A.M.I.)
| | - Zein Mersini Besharat
- Department of Experimental Medicine, Sapienza University of Rome, 00161 Rome, Italy; (Z.M.B.); (E.F.)
| | - Anand M. Iyer
- Department of (Neuro)Pathology Amsterdam Neuroscience, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.S.); (A.R.); (A.M.I.)
- Internal Medicine, Erasmus MC, 3015 GD Rotterdam, The Netherlands
| | - Romina Moavero
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, 00133 Rome, Italy; (R.M.); (P.C.)
- Child Neurology Unit, Neuroscience Department, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Christoph Hertzberg
- Diagnose-und Behandlungszentrum für Kinder, Vivantes-Klinikum Neukölln, 12351 Berlin, Germany;
| | - Bernhard Weschke
- Department of Neuropediatrics, Charité University Medicine Berlin, 13353 Berlin, Germany;
| | - Kate Riney
- Faculty of Medicine, The University of Queensland, Herston, QLD 4029, Australia;
- Neurosciences Unit, Queensland Children’s Hospital, South Brisbane, QLD 4101, Australia
| | - Martha Feucht
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, “Member of ERN EpiCARE”, 1090 Vienna, Austria; (M.F.); (T.S.)
| | - Theresa Scholl
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, “Member of ERN EpiCARE”, 1090 Vienna, Austria; (M.F.); (T.S.)
| | - Borivoj Petrak
- Motol University Hospital, Charles University, 15000 Prague, Czech Republic; (B.P.); (A.M.)
| | - Alice Maulisova
- Motol University Hospital, Charles University, 15000 Prague, Czech Republic; (B.P.); (A.M.)
| | - Rima Nabbout
- Reference Centre for Rare Epilepsies, Department of Pediatric Neurology, Necker Enfants Malades University Hospital, APHP, Member of ERN EpiCARE, Université de Paris, 149 Rue de Sèvres, 75015 Paris, France;
| | - Anna C. Jansen
- Department of Translational Neurosciences, University of Antwerp, 2000 Antwerp, Belgium;
| | - Floor E. Jansen
- Department of Child Neurology, Brain Center University Medical Center, Member of ERN EpiCare, 3584 BA Utrecht, The Netherlands;
| | - Lieven Lagae
- Department of Development and Regeneration Section Pediatric Neurology, University Hospitals KU Leuven, 3000 Leuven, Belgium;
| | - Malgorzata Urbanska
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (M.U.); (S.J.); (K.K.); (K.S.); (J.B.)
| | - Elisabetta Ferretti
- Department of Experimental Medicine, Sapienza University of Rome, 00161 Rome, Italy; (Z.M.B.); (E.F.)
| | - Aleksandra Tempes
- International Institute of Molecular and Cell Biology, 02-109 Warsaw, Poland; (A.T.); (M.B.); (J.J.)
| | - Magdalena Blazejczyk
- International Institute of Molecular and Cell Biology, 02-109 Warsaw, Poland; (A.T.); (M.B.); (J.J.)
| | - Jacek Jaworski
- International Institute of Molecular and Cell Biology, 02-109 Warsaw, Poland; (A.T.); (M.B.); (J.J.)
| | | | - Sergiusz Jozwiak
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (M.U.); (S.J.); (K.K.); (K.S.); (J.B.)
- Department of Child Neurology, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (M.U.); (S.J.); (K.K.); (K.S.); (J.B.)
| | - Krzysztof Sadowski
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (M.U.); (S.J.); (K.K.); (K.S.); (J.B.)
| | - Julita Borkowska
- Department of Neurology and Epileptology, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (M.U.); (S.J.); (K.K.); (K.S.); (J.B.)
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, 00133 Rome, Italy; (R.M.); (P.C.)
| | - James D. Mills
- Department of (Neuro)Pathology Amsterdam Neuroscience, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.S.); (A.R.); (A.M.I.)
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1E 6BT, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, UK
- Correspondence: (J.D.M.); (E.A.)
| | - Eleonora Aronica
- Department of (Neuro)Pathology Amsterdam Neuroscience, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (M.S.); (A.R.); (A.M.I.)
- Correspondence: (J.D.M.); (E.A.)
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Deng S, Shi W, Cai Y, Tang Y, Liu W, Yin P, Chen C, Meng L, Dong H, Huang J, Liu Y. Tuberous sclerosis complex with skin lesions as the initial presentation: A case report and multidisciplinary discussion. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2022; 47:973-980. [PMID: 36039596 PMCID: PMC10930287 DOI: 10.11817/j.issn.1672-7347.2022.210452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Indexed: 06/15/2023]
Abstract
We reported a case of tuberous sclerosis complex with facial angiofibroma as the initial presentation and conducted a multidisciplinary discussion. The patient, a young female, was admitted to the Department of Dermatology for cosmetic purpose. After the examination, she was found to have multiple system involvement, including a large renal angiomyolipoma pressing on the liver. She never had any subjective symptom. After consultation by the multidisciplinary team of tuberous sclerosis complex, the patient was treated with everolimus orally and followed up regularly. It is suggested that dermatologists should pay attention to the systemic involvement of patients with tuberous sclerosis complex. Early intervention can prolong the life of patients and improve their life quality. Multidisciplinary collaboration for lifelong disease management is the key to enhance the diagnosis and treatment for tuberous sclerosis complex and enhance the prognosis of patients.
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Affiliation(s)
- Sihan Deng
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha 410008.
| | - Wei Shi
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha 410008.
| | - Yi Cai
- Department of Urology, Xiangya Hospital, Central South University, Changsha 410008
| | - Yongjun Tang
- Department of Respiratory and Critical Care Medicine, Xiangya Hospital, Central South University, Changsha 410008
| | - Weiping Liu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha 410008
| | - Ping Yin
- Department of Stomatology, Xiangya Hospital, Central South University, Changsha 410008
| | - Chen Chen
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha 410008
| | - Li Meng
- Department of Radiology, Xiangya Hospital, Central South University, Changsha 410008
| | - Huixi Dong
- Mental Health Center, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Jundong Huang
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha 410008
| | - Yu Liu
- Department of Dermatology, Xiangya Hospital, Central South University, Changsha 410008
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Genotype/phenotype correlation in 123 Chinese patients with Tuberous Sclerosis Complex. Eur J Med Genet 2022; 65:104573. [PMID: 35918040 DOI: 10.1016/j.ejmg.2022.104573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 05/31/2022] [Accepted: 07/20/2022] [Indexed: 11/24/2022]
Abstract
Tuberous Sclerosis Complex (TSC) is a multisystemic neurocutaneous disorder with autosomal dominant inheritance. We performed mutation analyses on 123 Chinese patients with "definite TSC" according to the latest diagnostic criteria. Pathogenic / likely-pathogenic variants were identified in 72.2% of all index patients (70/97), in which 35.7% (25/70) had TSC1 variants and 64.3% (45/70) had TSC2 variants. 84.5% (82/97) cases were sporadic and 15.5% (15/97) cases were familial. 62 unique variants were reported, in which 41.9% (26/62) were novel. Male patients had significantly more subependymal nodules (p=0.029) than females, whereas renal angiomyolipoma (p=0.032) occurred predominantly in females. Sporadic cases also had more renal angiomyolipoma (p=0.004), cortical tubers (p=0.008), hypopigmented macules (p=0.018) and fibrous cephalic plaques (p=0.028) than cases with known inheritance. Patients with TSC2 pathogenic variants were more likely to have mental retardation (p<0.001), cardiac rhabdomyoma (p=0.004), renal angiomyolipoma (p=0.006) and facial angiofibromas (p=0.026) than those with TSC1 pathogenic variants, while mutation-negative cases showed a mixed phenotype between those with TSC1 and TSC2 variants. There were no significant phenotypic differences between patients with and without TSC1/TSC2 variants, but TSC2 missense and in-frame variants were associated with higher frequencies of mental retardation (P<0.001), renal angiomyolipoma (p=0.001), cardiac rhabdomyoma (p=0.012) and facial angiofibroma (p=0.021) than those with TSC1 frameshift and splice site variants. Furthermore, a higher frequency of mental retardation (p=0.013) was observed in patients with TSC2 missense and in-frame variants than those with frameshift and splice site variants. All 14 antenatal-onset patients had cardiac rhabdomyoma. They had fewer seizures (p=0.028) than patients with paediatric-onset, but were more likely to have mental retardation (p=0.035) than individuals with adult-onset disease. Generally, paediatric-onset patients had more neurological manifestations, while initial presentations of adult-onset TSC were more diverse.
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Wang X, Wang W, Zhao Y, Wang Z, Zhang Y. Analysis of Clinical Features and Next-Generation Sequencing of 12 Tuberous Sclerosis Families in China. Front Med (Lausanne) 2022; 9:840709. [PMID: 35712104 PMCID: PMC9197381 DOI: 10.3389/fmed.2022.840709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background Tuberous sclerosis complex (TSC) is a rare autosomal dominant genetic disease with systemic organ involvement. So far, only a few TSC families in China have been reported. Therefore, more data on the clinical and genetic features of TSC families are required. Materials and Methods We retrospectively analyzed 12 TSC family probands and their family members. Next-generation sequencing (NGS) has been applied to confirm the type of TSC mutation along with a detailed physical examination. Results In this study, twenty-seven patients in 12 TSC families were reported, including 12 male and 15 female patients, aged 8-67 years. Skin lesions were detected among all patients with TSC, including 25 cases of facial angiofibromas, 18 cases of hypomelanotic macules, 15 cases of ungual fibromas, and 13 cases of shagreen patch. Other clinical features were also revealed: 14 cases of renal angiomyolipoma, 6 cases of subependymal nodules (SENs), and 3 cases of lymphangioleiomyomatosis. All twenty-seven patients with TSC were tested by NGS. Totally, TSC2 mutations were reported in 19 cases (7 frameshift mutations, 10 nonsense mutations, and 2 missense mutations), TSC1 mutations were reported in 4 cases (4 nonsense mutations), and 4 cases were genetically negative. The novel causal mutations (TSC2: c.208dup, c.1874C > G, c.1852del) identified in three families were first reported in TSC. Conclusion Our findings expand the mutation spectrum of patients with TSC in China. The clinical characteristics can vary among patients with TSC with the same pathogenic mutation. The genetic results and summary of clinical features of 12 TSC families contribute to a more accurate diagnosis and further genetic counseling.
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Affiliation(s)
- Xu Wang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenda Wang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Zhao
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhan Wang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yushi Zhang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Shrestha AB, Shrestha S, Seemanta S, Pokharel P, Alam W. Epilepsy associated tuberous sclerosis; a case report from Bangladesh. Ann Med Surg (Lond) 2022; 78:103738. [PMID: 35600170 PMCID: PMC9118511 DOI: 10.1016/j.amsu.2022.103738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 05/01/2022] [Accepted: 05/08/2022] [Indexed: 11/24/2022] Open
Abstract
Tuberous sclerosis or Bourneville's disease is a rare autosomal dominant disease affecting many organs like the brain, heart, lungs, eyes, kidneys and skin. It is characterized by neurological manifestation like epilepsy, cutaneous changes and the formation of benign lesions in multiple organs. The symptoms are apparent only in late childhood, which limits the early diagnosis in infancy. Here, we report a case of a 15 year old female child with tuberous sclerosis.
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Affiliation(s)
- Abhigan Babu Shrestha
- Department of Internal Medicine, M Abdur Rahim Medical College, Dinajpur, Bangladesh
| | - Sajina Shrestha
- Department of Internal Medicine, KIST Medical College, Imadol, Patan, Nepal
| | - Senjuti Seemanta
- Department of Internal Medicine, M Abdur Rahim Medical College, Dinajpur, Bangladesh
| | - Pashupati Pokharel
- Department of Internal Medicine, Maharajgunj Medical Campus, Kathmandu, Nepal
| | - Waqar Alam
- Department of Internal Medicine, M Abdur Rahim Medical College, Dinajpur, Bangladesh
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46
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Lee HY, Yang SH, Sheu JN, Tsai JD. Reading Ability in Patients With Tuberous Sclerosis Complex: Results of Chinese Character Reading and Reading Comprehension Tests. Front Psychol 2022; 13:849334. [PMID: 35645943 PMCID: PMC9137399 DOI: 10.3389/fpsyg.2022.849334] [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: 01/05/2022] [Accepted: 04/19/2022] [Indexed: 11/17/2022] Open
Abstract
Background Most tuberous sclerosis complex (TSC) patients have neurological disorders and are at high risk of academic difficulties. Among academic skills, reading ability is the most important academic skill. The study applied the Chinese character fluency test to measure the word recognition and reading comprehension of TSC children to observe whether they have the characteristics of reading disability, as an indicator of the spectrum of reading ability in TSC patients. Methods The patients were assessed using the Chinese character fluency test and reading comprehension test to explore the differences in reading ability in terms of gender, age, epilepsy history, genotype, and intelligence level. Results Of the 27 patients, the assessment of reading accuracy showed statistical differences between intellectual level > 80, PR (p = 0.024), and pass numbers (p = 0.018). For the fluency assessment, there was a difference between different intellectual level (p = 0.050). In the reading comprehension test, there was differences for intellectual level in positivity (p = 0.07) and pass numbers (p = 0.06). Conclusion The Chinese character fluency and reading comprehension test measure the word recognition and reading comprehension and the spectrum of reading ability in TSC patients. All individuals with TSC, especially those with below average of intellectual ability, should be considered for potential academic difficulties.
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Affiliation(s)
- Hom-Yi Lee
- Department of Psychology, Chung Shan Medical University, Taichung, Taiwan
| | - Sheng-Hui Yang
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Ji-Nan Sheu
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Paediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Jeng-Dau Tsai
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Paediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
- *Correspondence: Jeng-Dau Tsai,
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Serra I, Stravs A, Osório C, Oyaga MR, Schonewille M, Tudorache C, Badura A. Tsc1 Haploinsufficiency Leads to Pax2 Dysregulation in the Developing Murine Cerebellum. Front Mol Neurosci 2022; 15:831687. [PMID: 35645731 PMCID: PMC9137405 DOI: 10.3389/fnmol.2022.831687] [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: 12/08/2021] [Accepted: 04/04/2022] [Indexed: 12/03/2022] Open
Abstract
Tuberous sclerosis complex 1 (TSC1) is a tumor suppressor that promotes the inhibition of mechanistic target of rapamycin (mTOR) pathway, and mutations in TSC1 lead to a rare complex disorder of the same name. Despite phenotype heterogeneity, up to 50% of TSC patients present with autism spectrum disorder (ASD). Consequently, TSC models are often used to probe molecular and behavioral mechanisms of ASD development. Amongst the different brain areas proposed to play a role in the development of ASD, the cerebellum is commonly reported to be altered, and cerebellar-specific deletion of Tsc1 in mice is sufficient to induce ASD-like phenotypes. However, despite these functional changes, whether Tsc1 haploinsufficiency affects cerebellar development is still largely unknown. Given that the mTOR pathway is a master regulator of cell replication and migration, we hypothesized that dysregulation of this pathway would also disrupt the development of cell populations during critical periods of cerebellar development. Here, we used a mouse model of TSC to investigate gene and protein expression during embryonic and early postnatal periods of cerebellar development. We found that, at E18 and P7, mRNA levels of the cerebellar inhibitory interneuron marker paired box gene 2 (Pax2) were dysregulated. This dysregulation was accompanied by changes in the expression of mTOR pathway-related genes and downstream phosphorylation of S6. Differential gene correlation analysis revealed dynamic changes in correlated gene pairs across development, with an overall loss of correlation between mTOR- and cerebellar-related genes in Tsc1 mutants compared to controls. We corroborated the genetic findings by characterizing the mTOR pathway and cerebellar development on protein and cellular levels with Western blot and immunohistochemistry. We found that Pax2-expressing cells were largely unchanged at E18 and P1, while at P7, their number was increased and maturation into parvalbumin-expressing cells delayed. Our findings indicate that, in mice, Tsc1 haploinsufficiency leads to altered cerebellar development and that cerebellar interneuron precursors are particularly susceptible to mTOR pathway dysregulation.
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Affiliation(s)
- Ines Serra
- Department of Neuroscience, Erasmus MC, Rotterdam, Netherlands
| | - Ana Stravs
- Department of Neuroscience, Erasmus MC, Rotterdam, Netherlands
- Institute of Biology Leiden, Leiden University, Leiden, Netherlands
| | - Catarina Osório
- Department of Neuroscience, Erasmus MC, Rotterdam, Netherlands
| | - Maria Roa Oyaga
- Department of Neuroscience, Erasmus MC, Rotterdam, Netherlands
| | | | | | - Aleksandra Badura
- Department of Neuroscience, Erasmus MC, Rotterdam, Netherlands
- *Correspondence: Aleksandra Badura,
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Sadowski K, Sijko K, Domańska-Pakieła D, Borkowska J, Chmielewski D, Ulatowska A, Józwiak S, Kotulska K. Antiepileptic Effect and Safety Profile of Rapamycin in Pediatric Patients With Tuberous Sclerosis Complex. Front Neurol 2022; 13:704978. [PMID: 35572924 PMCID: PMC9100395 DOI: 10.3389/fneur.2022.704978] [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: 05/04/2021] [Accepted: 02/04/2022] [Indexed: 11/25/2022] Open
Abstract
Background Epilepsy develops in 70–90% of children with Tuberous Sclerosis Complex (TSC) and is often resistant to medication. Treatment with mTOR pathway inhibitors is an important therapeutic option in drug-resistant epilepsy associated with TSC. Our study evaluated the antiepileptic effect of rapamycin in the pediatric population of patients diagnosed with TSC. Methods This single center, open-label study evaluated safety and anti-epileptic efficacy of 12 months of rapamycin treatment in 32 patients aged from 11 months to 14 years with drug-resistant TSC- associated epilepsy. Results After the first 6 months of treatment, the improvement in seizure frequency, defined as at least a 50% reduction in the number of seizures per week compared to baseline, was seen in 18 individuals (56.25%). We observed no change in 12 individuals (37.5%) and worsening, defined as increase in the number of seizures—in 2 patients (6.25%). The overall improvement defined as at least a 50% reduction in seizure frequency was found in 65.6% of all patients after 12 months with 28% of patients obtaining complete remission. Another five patients experienced at least an 80% reduction in the frequency of seizures. Concomitant treatment with vigabatrin, and to a much lesser extent topiramate and levetiracetam, was an additional favorable prognostic factor for the success of the therapy. A linear relationship between the cumulative dose of rapamycin and its therapeutic effect was observed. The safety profile of the drug was satisfactory. In none of the observed cases did the adverse events reach the level that required withdrawal of the rapamycin treatment. The reason for dropouts was insufficient drug efficacy in 3 cases. Conclusions Long-term use of rapamycin, especially in combination with vigabatrin, might be a beneficial therapeutic option in the treatment of drug-resistant epilepsy in children with TSC.
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Affiliation(s)
- Krzysztof Sadowski
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
- *Correspondence: Krzysztof Sadowski
| | - Kamil Sijko
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
- Transition Technologies, Warsaw, Poland
| | - Dorota Domańska-Pakieła
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
| | - Julita Borkowska
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
| | - Dariusz Chmielewski
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
| | - Agata Ulatowska
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
| | - Sergiusz Józwiak
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, Children's Memorial Health Institute, Warsaw, Poland
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Ruiz-Falcó Rojas ML, Feucht M, Macaya A, Wilken B, Hahn A, Maamari R, Hirschberg Y, Ridolfi A, Kingswood JC. Real-World Evidence Study on the Long-Term Safety of Everolimus in Patients With Tuberous Sclerosis Complex: Final Analysis Results. Front Pharmacol 2022; 13:802334. [PMID: 35462939 PMCID: PMC9023743 DOI: 10.3389/fphar.2022.802334] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/07/2022] [Indexed: 01/20/2023] Open
Abstract
The TuberOus SClerosis registry to increase disease Awareness (TOSCA) Post-Authorization Safety Study (PASS) was a non-interventional, multicenter, safety substudy that assessed the long-term safety of everolimus in patients with tuberous sclerosis complex (TSC) receiving everolimus for its licensed indications in the European Union (EU). This substudy also aimed to address TSC-associated neuropsychiatric disorders (TAND), sexual development, and male infertility. Eligible patients were enrolled from 39 sites across 11 countries in the EU. Outcomes of interest included the incidence of adverse events (AEs), serious adverse events (SAEs), treatment-related AEs (TRAEs), AEs leading to everolimus discontinuation, AEs of special interest (AESIs), the observed relationship between everolimus blood levels and incidence of AESIs, TAND, and reproductive clinical features. Herein, we present the final analysis results from this substudy (data cutoff date: 22 January 2020). At data cutoff, 179 patients were enrolled (female, 59.2%; age ≥18 years, 65.9%), of which the majority completed the study (76%). Overall, 121 patients (67.6%) had AEs regardless of causality. The most frequent TRAEs (≥5%) were stomatitis (7.8%), aphthous ulcer (6.7%), and hypercholesterolemia (6.1%). The most common treatment-related SAEs (>1%) were pneumonia (3.4%), influenza, pyelonephritis, aphthous ulcer, stomatitis, dyslipidemia, and hypercholesterolemia (1.1% each). Ten patients (5.6%) reported AEs leading to everolimus discontinuation. The common psychiatric disorders (N = 179) were autism spectrum disorder (21.8%), anxiety disorder (12.8%), “other” psychiatric disorders (8.9%), attention-deficit hyperactivity disorder, and depressive disorder (7.8% each). Of 179 patients, 88 (49.2%) had ≥1 behavioral problem. Of these (n = 88), the most common (>20%) were sleep difficulties (47.7%), anxiety (43.2%), mood swings (37.5%), depression mood (35.2%), impulsivity (30.7%), severe aggression (23.9%), and overactivity (22.7%). Of 179 patients, four (2.2%) reported abnormal puberty onset, and three (1.7%) reported other reproductive disorders. Of 106 females, 23 (21.7%) reported menstrual cycle disorders and 10 (9.4%) reported amenorrhea. Available data did not show delays in sexual maturation or an association between sexual development and infertility. The results demonstrate that everolimus has a manageable long-term safety profile in the TSC treatment setting. No new safety signals emerged. This substudy also contributed to the mapping of TAND and reproductive clinical features in patients with TSC.
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Affiliation(s)
| | - Martha Feucht
- Universitäts-Klinik für Kinder-und Jugendheilkunde Wien, Vienna, Austria
| | - Alfons Macaya
- Hospital Universitari Vall d’ Hebron, Barcelona, Spain
| | | | - Andreas Hahn
- Abteilung Kinderneurologie, Universitätsklinikum Giessen und Marburg GmbH, Giessen, Germany
| | - Ricardo Maamari
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | - Yulia Hirschberg
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
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50
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Lin S, Liao J, Zhao X, Hu Y, Chen L, Chen Y, Liu G, Yao Y, Su Q, Scheffer IE, Wen F. Focal Epilepsy in Children With Tuberous Sclerosis Complex: Does Vigabatrin Control Focal Seizures? J Child Neurol 2022; 37:329-333. [PMID: 35321578 DOI: 10.1177/08830738211048326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We evaluated the efficacy and safety of vigabatrin in focal epilepsy associated with tuberous sclerosis complex by retrospectively reviewing patients with focal epilepsy and tuberous sclerosis complex treated with vigabatrin at a pediatric epilepsy center over an 8-year period. Of 85 patients, 20 (23.5%) were seizure-free for >12 months, 45 (52.9%) were responders (≥50% seizure reduction), and 20 (23.5%) were nonresponders. The median age (in months) at seizure onset in the seizure-free group (median, 15; interquartile range [IQR], 6-23.3) was higher than that of responders (median, 5; IQR, 3-14) and nonresponders (median, 6; IQR, 2-12). Fewer patients in the seizure-free group had calcification in their largest tubers, but the presence of tuber calcification did not differ among groups. Vigabatrin is more likely to result in seizure freedom in children with tuberous sclerosis complex who have later infantile onset of focal seizures and no calcification in their largest tuber.
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Affiliation(s)
- Sufang Lin
- Department of Pediatrics, The First Affiliated Hospital 162698Jinan University, Guangzhou, Guangdong, China
- Department of Neurology, 85113Shenzhen Children's Hospital, Shenzhen, Guangdong, China
- Department of Epilepsy Surgery, Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Jianxiang Liao
- Department of Neurology, 85113Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Xia Zhao
- Department of Neurology, 85113Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Yan Hu
- Department of Neurology, 85113Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Li Chen
- Department of Neurology, 85113Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Yan Chen
- Department of Epilepsy Surgery, Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Guosheng Liu
- Department of Pediatrics, The First Affiliated Hospital 162698Jinan University, Guangzhou, Guangdong, China
| | - Yi Yao
- Department of Epilepsy Surgery, Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Qiru Su
- Institute of Pediatrics, Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Ingrid E Scheffer
- University of Melbourne, Austin Health and Royal Children's Hospital, Florey and Murdoch Institutes, Melbourne, Australia
| | - Feiqiu Wen
- Department of Pediatrics, The First Affiliated Hospital 162698Jinan University, Guangzhou, Guangdong, China
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Shenzhen, Guangdong, China
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