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Pervin S, Islam MS, Tada N, Tsutsui T, Rahman MM, Yabuki A, Tacharina MR, Rakib TM, Maki S, Yamato O. Screening and Carrier Rate of Neuronal Ceroid Lipofuscinosis in Chihuahua Dogs in Japan. Animals (Basel) 2022; 12:1210. [PMID: 35565635 PMCID: PMC9106037 DOI: 10.3390/ani12091210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/27/2022] [Accepted: 05/04/2022] [Indexed: 02/01/2023] Open
Abstract
Neuronal ceroid lipofuscinosis (NCL) is a group of rare lethal neurodegenerative lysosomal storage diseases that occur in a range of dog breeds, including Chihuahuas. Recently, a homozygous single base-pair deletion (c.846delT), which causes a frame shift generating a premature stop codon (p.Phe282Leufs13*) in the canine CLN7/MFSD8 gene, has been identified as a causative mutation for NCL in Chihuahuas. The objective of this study was to determine the frequency of the mutant allele and/or carrier rate of NCL in Chihuahuas in Japan using a newly designed real-time PCR assay. Samples of saliva were randomly collected from 1007 Chihuahua puppies during physical examinations prior to the transportation to pet shops. Screening results revealed a carrier rate of 1.29%, indicating a mutant allele frequency (0.00645) that is considered sufficiently high to warrant measures for the control and prevention of this lethal disease. The genotyping assay designed in this study could make a valuable contribution to the control and prevention of NCL.
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Affiliation(s)
- Shahnaj Pervin
- Laboratory of Clinical Pathology, Joint Faculty of Veterinary Medicine, Kagoshima University, 1-21-24 Korimoto, Kagoshima 890-0065, Japan; (S.P.); (M.S.I.); (N.T.); (M.M.R.); (A.Y.); (M.R.T.); (T.M.R.); (S.M.)
| | - Md Shafiqul Islam
- Laboratory of Clinical Pathology, Joint Faculty of Veterinary Medicine, Kagoshima University, 1-21-24 Korimoto, Kagoshima 890-0065, Japan; (S.P.); (M.S.I.); (N.T.); (M.M.R.); (A.Y.); (M.R.T.); (T.M.R.); (S.M.)
- Department of Pathology and Parasitology, Faculty of Veterinary Medicine, Chattogram Veterinary and Animal Sciences University, Khulshi, Chattogram 4225, Bangladesh
| | - Naomi Tada
- Laboratory of Clinical Pathology, Joint Faculty of Veterinary Medicine, Kagoshima University, 1-21-24 Korimoto, Kagoshima 890-0065, Japan; (S.P.); (M.S.I.); (N.T.); (M.M.R.); (A.Y.); (M.R.T.); (T.M.R.); (S.M.)
- Japan Institute of Small Animal Reproduction (Bio Art), 3-16-9 Uchikanda, Chiyoda-ku, Tokyo 101-0047, Japan;
| | - Toshihiko Tsutsui
- Japan Institute of Small Animal Reproduction (Bio Art), 3-16-9 Uchikanda, Chiyoda-ku, Tokyo 101-0047, Japan;
| | - Mohammad Mahbubur Rahman
- Laboratory of Clinical Pathology, Joint Faculty of Veterinary Medicine, Kagoshima University, 1-21-24 Korimoto, Kagoshima 890-0065, Japan; (S.P.); (M.S.I.); (N.T.); (M.M.R.); (A.Y.); (M.R.T.); (T.M.R.); (S.M.)
- Department of Pathology and Parasitology, Faculty of Veterinary Medicine, Chattogram Veterinary and Animal Sciences University, Khulshi, Chattogram 4225, Bangladesh
| | - Akira Yabuki
- Laboratory of Clinical Pathology, Joint Faculty of Veterinary Medicine, Kagoshima University, 1-21-24 Korimoto, Kagoshima 890-0065, Japan; (S.P.); (M.S.I.); (N.T.); (M.M.R.); (A.Y.); (M.R.T.); (T.M.R.); (S.M.)
| | - Martia Rani Tacharina
- Laboratory of Clinical Pathology, Joint Faculty of Veterinary Medicine, Kagoshima University, 1-21-24 Korimoto, Kagoshima 890-0065, Japan; (S.P.); (M.S.I.); (N.T.); (M.M.R.); (A.Y.); (M.R.T.); (T.M.R.); (S.M.)
- Faculty of Veterinary Medicine, Airlangga University, Campus C, Jl. Mulyorejo, Surabaya 60115, Indonesia
| | - Tofazzal Md Rakib
- Laboratory of Clinical Pathology, Joint Faculty of Veterinary Medicine, Kagoshima University, 1-21-24 Korimoto, Kagoshima 890-0065, Japan; (S.P.); (M.S.I.); (N.T.); (M.M.R.); (A.Y.); (M.R.T.); (T.M.R.); (S.M.)
- Department of Pathology and Parasitology, Faculty of Veterinary Medicine, Chattogram Veterinary and Animal Sciences University, Khulshi, Chattogram 4225, Bangladesh
| | - Shinichiro Maki
- Laboratory of Clinical Pathology, Joint Faculty of Veterinary Medicine, Kagoshima University, 1-21-24 Korimoto, Kagoshima 890-0065, Japan; (S.P.); (M.S.I.); (N.T.); (M.M.R.); (A.Y.); (M.R.T.); (T.M.R.); (S.M.)
| | - Osamu Yamato
- Laboratory of Clinical Pathology, Joint Faculty of Veterinary Medicine, Kagoshima University, 1-21-24 Korimoto, Kagoshima 890-0065, Japan; (S.P.); (M.S.I.); (N.T.); (M.M.R.); (A.Y.); (M.R.T.); (T.M.R.); (S.M.)
- Faculty of Veterinary Medicine, Airlangga University, Campus C, Jl. Mulyorejo, Surabaya 60115, Indonesia
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Adult-Onset Neuronal Ceroid Lipofuscinosis in a Shikoku Inu. Vet Sci 2021; 8:vetsci8100227. [PMID: 34679057 PMCID: PMC8538799 DOI: 10.3390/vetsci8100227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/02/2021] [Accepted: 10/05/2021] [Indexed: 01/18/2023] Open
Abstract
A two-year-and-eleven-month-old male Shikoku Inu was referred for evaluation of progressive gait abnormality that had begun three months prior. Neurological examination revealed ventral flexion of the neck, a wide-based stance in the hindlimb, wide excursions of the head from side to side, tremor in all four limbs, hypermetria in all four limbs, proprioceptive deficits in all four limbs, reduced patellar reflex in both hindlimbs, and postural vertical nystagmus. Later, behavioral and cognitive dysfunction, ataxia, and visual deficits slowly progressed. Magnetic resonance imaging revealed symmetrical progressive atrophy of the whole brain and cervical spinal cord. Bilateral retinal degeneration was observed, and both flush and flicker electroretinograms were bilaterally non-recordable at the age of five years and eight months, and the dog was euthanized. Histopathologically, faint-to-moderate deposition of light-brown pigments was frequently observed in the cytoplasm of neurons throughout the cerebrum, cerebellum, and nuclei of the brainstem. The pigments were positive for Luxol fast blue, periodic acid–Schiff, and Sudan black B, and exhibited autofluorescence. Electron microscopic examination revealed the accumulation of membranous material deposition in the neuronal cytoplasm. Small foci of pigment-containing macrophages were frequently observed around the capillary vessels. Based on these clinical and pathological findings, the animal was diagnosed with adult-onset neuronal ceroid lipofuscinosis.
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Katz ML, Rustad E, Robinson GO, Whiting REH, Student JT, Coates JR, Narfstrom K. Canine neuronal ceroid lipofuscinoses: Promising models for preclinical testing of therapeutic interventions. Neurobiol Dis 2017; 108:277-287. [PMID: 28860089 DOI: 10.1016/j.nbd.2017.08.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/26/2017] [Indexed: 10/19/2022] Open
Abstract
The neuronal ceroid lipofuscinoses (NCLs) are devastating inherited progressive neurodegenerative diseases, with most forms having a childhood onset of clinical signs. The NCLs are characterized by progressive cognitive and motor decline, vision loss, seizures, respiratory and swallowing impairment, and ultimately premature death. Different forms of NCL result from mutations in at least 13 genes. The clinical signs of some forms overlap significantly, so genetic testing is the only way to definitively determine which form an individual patient suffers from. At present, an effective treatment is available for only one form of NCL. Evidence of NCL has been documented in over 20 canine breeds and in mixed-breed dogs. To date, 12 mutations in 8 different genes orthologous to the human NCL genes have been found to underlie NCL in a variety of dog breeds. A Dachshund model with a null mutation in one of these genes is being utilized to investigate potential therapeutic interventions, including enzyme replacement and gene therapies. Demonstration of the efficacy of enzyme replacement therapy in this model led to successful completion of human clinical trials of this treatment. Further research into the other canine NCLs, with in-depth characterization and understanding of the disease processes, will likely lead to the development of successful therapeutic interventions for additional forms of NCL, for both human patients and animals with these disorders.
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Affiliation(s)
- Martin L Katz
- Mason Eye Institute, School of Medicine, University of Missouri, Columbia, MO 65212, USA.
| | - Eline Rustad
- Blue Star Animal Hospital, Göteborg 417 07, Sweden
| | - Grace O Robinson
- Mason Eye Institute, School of Medicine, University of Missouri, Columbia, MO 65212, USA
| | - Rebecca E H Whiting
- Mason Eye Institute, School of Medicine, University of Missouri, Columbia, MO 65212, USA
| | - Jeffrey T Student
- Mason Eye Institute, School of Medicine, University of Missouri, Columbia, MO 65212, USA
| | - Joan R Coates
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, MO 65211, USA
| | - Kristina Narfstrom
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, MO 65211, USA
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Nolte A, Bello A, Drögemüller M, Leeb T, Brockhaus E, Baumgärtner W, Wohlsein P. Neuronal ceroid lipofuscinosis in an adult American Staffordshire Terrier. TIERAERZTLICHE PRAXIS AUSGABE KLEINTIERE HEIMTIERE 2016; 44:431-437. [PMID: 27778018 DOI: 10.15654/tpk-150766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 06/07/2016] [Indexed: 11/13/2022]
Abstract
A female, 5-year-old American Staffordshire Terrier with severe progressive neurological deficits, particularly in terms of ataxia and keeping balance, was examined pathomorphologically and a genetic analysis was performed. In neurons of various localizations of the central nervous system an accumulation of a finely granular pale eosinophilic or light brown material was found. In addition, the cerebellum revealed marked degeneration and loss of Purkinje and inner granule cells. The accumulated PAS-positive, argyrophilic, autofluorescent material showed ultrastructurally a lamellar appearance suggestive of lipofuscin. Genetic analysis revealed the presence of a sequence variant in the ARSG gene encoding the lysosomal enzyme arylsulfatase G. This case report describes an adult-onset of a neuronal ceroid lipofuscinosis that shows similarities with a human disorder termed Kufs disease.
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Affiliation(s)
| | | | | | | | | | | | - Peter Wohlsein
- Dr. Peter Wohlsein, Institut für Pathologie, Tierärztliche Hochschule Hannover, Bünteweg 17, 30559 Hannover, E-Mail:
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Ashwini A, D'Angelo A, Yamato O, Giordano C, Cagnotti G, Harcourt-Brown T, Mhlanga-Mutangadura T, Guo J, Johnson GS, Katz ML. Neuronal ceroid lipofuscinosis associated with an MFSD8 mutation in Chihuahuas. Mol Genet Metab 2016; 118:326-32. [PMID: 27211611 DOI: 10.1016/j.ymgme.2016.05.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/12/2016] [Accepted: 05/12/2016] [Indexed: 10/21/2022]
Abstract
The neuronal ceroid lipofuscinoses (NCLs) are hereditary neurodegenerative disorders characterized by progressive declines in neurological functions, seizures, and premature death. NCLs result from mutations in at least 13 different genes. Canine versions of the NCLs can serve as important models in developing effective therapeutic interventions for these diseases. NCLs have been described in a number of dog breeds, including Chihuahuas. Studies were undertaken to further characterize the pathology of Chihuahua NCL and to verify its molecular genetic basis. Four unrelated client owned Chihuahuas from Japan, Italy and England that exhibited progressive neurological signs consistent with a diagnosis of NCL underwent neurological examinations. Brain and in some cases also retinal and heart tissues were examined postmortem for the presence of lysosomal storage bodies characteristic of NCL. The affected dogs exhibited massive accumulation of autofluorescent lysosomal storage bodies in the brain, retina and heart accompanied by brain atrophy and retinal degeneration. The dogs were screened for known canine NCL mutations previously reported in a variety of dog breeds. All 4 dogs were homozygous for the MFSD8 single base pair deletion (MFSD8:c.843delT) previously associated with NCL in a Chinese Crested dog and in 2 affected littermate Chihuahuas from Scotland. The dogs were all homozygous for the normal alleles at the other genetic loci known to cause different forms of canine NCL. The MFSD8:c.843delT mutation was not present in 57 Chihuahuas that were either clinically normal or suffered from unrelated diseases or in 1761 unaffected dogs representing 186 other breeds. Based on these data it is almost certain that the MFSD8:c.843delT mutation is the cause of NCL in Chihuahuas. Because the disorder occurred in widely separated geographic locations or in unrelated dogs from the same country, it is likely that the mutant allele is widespread among Chihuahuas. Genetic testing for this mutation in other Chihuahuas is therefore likely to identify intact dogs with the mutant allele that could be used to establish a research colony that could be used to test potential therapeutic interventions for the corresponding human disease.
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Affiliation(s)
- Akanksha Ashwini
- Department of Veterinary Pathobiology, University of Missouri, Columbia MO, USA
| | - Antonio D'Angelo
- Department of Veterinary Science, School of Veterinary Medicine, Turin, Italy
| | - Osamu Yamato
- Department of Veterinary Medicine, Kagoshima University, Kagoshima 890-0065, Japan
| | - Cristina Giordano
- Department of Veterinary Science, School of Veterinary Medicine, Turin, Italy
| | - Giulia Cagnotti
- Department of Veterinary Science, School of Veterinary Medicine, Turin, Italy
| | | | | | - Juyuan Guo
- Department of Veterinary Pathobiology, University of Missouri, Columbia MO, USA
| | - Gary S Johnson
- Department of Veterinary Pathobiology, University of Missouri, Columbia MO, USA
| | - Martin L Katz
- Department of Ophthalmology, University of Missouri School of Medicine, Columbia, MO, USA.
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Cesta MF, Mozzachio K, Little PB, Olby NJ, Sills RC, Brown TT. Neuronal Ceroid Lipofuscinosis in a Vietnamese Pot-bellied Pig (Sus scrofa). Vet Pathol 2016; 43:556-60. [PMID: 16847000 DOI: 10.1354/vp.43-4-556] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The neuronal ceroid ipofuscinoses (NCL) are a group of heritable, neurodegenerative, storage diseases, typically with an autosomal recessive mode of inheritance. Cytoplasmic accumulation of storage material in cells of the nervous system and, variably in other tissues, characterizes NCL. NCL has been reported in many animal species, but to the authors' knowledge, this is the first report of the disease in a pig. Blindness and seizures are common clinical signs of disease, neither of which was a feature in this pig. The lesions were restricted to the central nervous system, which was diffusely affected, with the most severe lesions in the hippocampus, cerebral cortex, and cerebellum. The histologic lesions included neuronal loss and gliosis, which contributed to mild cerebrocortical and cerebellar atrophy and accumulation of autofluorescent storage material in neurons and glial cells. The storage material had morphologic, histologic, and ultrastructural properties typical of NCL.
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Affiliation(s)
- M F Cesta
- Integrated Laboratory Systems, Inc., PO Box 13501, Research Triangle Park, NC 27709 (USA).
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Use of model organisms for the study of neuronal ceroid lipofuscinosis. Biochim Biophys Acta Mol Basis Dis 2013; 1832:1842-65. [PMID: 23338040 DOI: 10.1016/j.bbadis.2013.01.009] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 01/07/2013] [Accepted: 01/08/2013] [Indexed: 12/26/2022]
Abstract
Neuronal ceroid lipofuscinoses are a group of fatal progressive neurodegenerative diseases predominantly affecting children. Identification of mutations that cause neuronal ceroid lipofuscinosis, and subsequent functional and pathological studies of the affected genes, underpins efforts to investigate disease mechanisms and identify and test potential therapeutic strategies. These functional studies and pre-clinical trials necessitate the use of model organisms in addition to cell and tissue culture models as they enable the study of protein function within a complex organ such as the brain and the testing of therapies on a whole organism. To this end, a large number of disease models and genetic tools have been identified or created in a variety of model organisms. In this review, we will discuss the ethical issues associated with experiments using model organisms, the factors underlying the choice of model organism, the disease models and genetic tools available, and the contributions of those disease models and tools to neuronal ceroid lipofuscinosis research. This article is part of a Special Issue entitled: The Neuronal Ceroid Lipofuscinoses or Batten Disease.
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Nakamoto Y, Yamato O, Uchida K, Nibe K, Tamura S, Ozawa T, Ueoka N, Nukaya A, Yabuki A, Nakaichi M. Neuronal Ceroid-Lipofuscinosis in Longhaired Chihuahuas: Clinical, Pathologic, and MRI Findings. J Am Anim Hosp Assoc 2011; 47:e64-70. [DOI: 10.5326/jaaha-ms-5564] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Nibe K, Miwa Y, Matsunaga S, Chambers JK, Uetsuka K, Nakayama H, Uchida K. Clinical and pathologic features of neuronal ceroid-lipofuscinosis in a ferret (Mustela putorius furo). Vet Pathol 2011; 48:1185-9. [PMID: 21383119 DOI: 10.1177/0300985811400441] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Clinical and pathologic features of neuronal ceroid-lipofuscinosis in a 4-month-old ferret are reported. Clinical signs including neurological symptoms appeared at 3 months of age and progressed rapidly. By magnetic resonance imaging, severe cerebral atrophy was recognized. Histopathologically, there was severe neuronal loss and diffuse astrogliosis with macrophage accumulations; lesions were found predominantly in the cerebral cortex. Intracytoplasmic pigments were observed in surviving neurons and macrophages throughout the brain. The pigments were intensely positive for periodic acid-Schiff, Luxol fast blue, and Sudan black B and exhibited a green autofluorescence. Electron microscopic examination revealed the accumulation of electron-dense granular material within lysosomes of neurons and macrophages. Immunohistochemically, a large number of saposin-positive granules accumulated in the neuronal cells, astrocytes, and macrophages of the lesions, but significant immunoreactivity for subunit c of mitochondrial adenosine triphosphate synthase was not observed. Based on these findings, the animal was diagnosed as affected by neuronal ceroid-lipofuscinosis.
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Affiliation(s)
- K Nibe
- Faculty of Agriculture, Miyazaki University, Miyazaki, Japan
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McLellan GJ, Cappello R, Mayhew IG, Elks R, Lybaert P, Watté C, Bedford PGC. Clinical and pathological observations in English cocker spaniels with primary metabolic vitamin E deficiency and retinal pigment epithelial dystrophy. Vet Rec 2003; 153:287-92. [PMID: 14509574 DOI: 10.1136/vr.153.10.287] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Fifteen English cocker spaniels with confirmed vitamin E deficiency were examined physically, ophthalmologically and neurologically. Eleven of them had clinical signs of neurological dysfunction which included ataxia, proprioceptive deficits, abnormal spinal reflexes and muscle weakness. In the two dogs examined histopathologically there was central neuronal fibre degeneration with prominent neuroaxonal dystrophy, particularly within the sensory relay nuclei of the brainstem, and one of the dogs had severe intestinal lipofuscinosis.
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Affiliation(s)
- G J McLellan
- Royal Veterinary College, University of London, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire AL9 7TA
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Kuwamura M, Hattori R, Yamate J, Kotani T, Sasai K. Neuronal ceroid-lipofuscinosis and hydrocephalus in a chihuahua. J Small Anim Pract 2003; 44:227-30. [PMID: 12779175 DOI: 10.1111/j.1748-5827.2003.tb00148.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A two-year-old, female chihuahua presented with a six-month history of visual dysfunction. Computed tomography revealed dilation of the lateral ventricles in the central nervous system (CNS). The dog was tentatively diagnosed as having hydrocephalus and a month later was euthanased at the owner's request. The skull was expanded and dome-like in shape and an open fontanelle was observed on postmortem examination. Histologically, swollen neurons possessing yellowish pigment granules in the cytoplasm were observed throughout the CNS. These storage materials stained positively with periodic acid Schiff, Schmorl method for lipofuscin and oil red O for lipid, and showed autofluorescence under fluorescence microscopy. Ultrastructurally, the storage materials consisted of dense lamellar structures. This case was unique in having ceroid-lipofuscinosis in association with hydrocephalus.
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Affiliation(s)
- M Kuwamura
- Laboratory of Veterinary Pathology, Osaka Prefecture University, Sakai, Osaka 599-8531, Japan
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Mitchison HM, Mole SE. Neurodegenerative disease: the neuronal ceroid lipofuscinoses (Batten disease). Curr Opin Neurol 2001; 14:795-803. [PMID: 11723391 DOI: 10.1097/00019052-200112000-00019] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In the past decade there have been significant advances in our understanding of the molecular genetic basis of the neuronal ceroid lipofuscinoses, a clinically and genetically heterogeneous group of childhood neurodegenerative storage disorders. Recent research progress is reviewed here, to summarize new disease gene identification, diagnostics, treatment, protein functional studies and investigations into the underlying molecular pathogenesis of these devastating disorders.
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Affiliation(s)
- H M Mitchison
- Department of Paediatrics and Child Health, Royal Free and University College Medical School, University College London, London WC1E 6JJ, UK.
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