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Badura-Stronka M, Hirschfeld AS, Winczewska-Wiktor A, Budzyńska E, Jakubiuk-Tomaszuk A, Piontek A, Steinborn B, Kozubski W. First case series of Polish patients with cerebrotendinous xanthomatosis and systematic review of cases from the 21st century. Clin Genet 2021; 101:190-207. [PMID: 34689324 DOI: 10.1111/cge.14079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 12/27/2022]
Abstract
Cerebrotendinous xanthomatosis (CTX) is an inborn error of metabolism caused by recessive variants in the cytochrome P450 CYP27A1 gene. CTX is said to manifest with childhood-onset chronic diarrhea and the classic triad of juvenile-onset cataracts, Achilles tendons xanthomas, and progressive ataxia. It is currently one of the few inherited neurometabolic disorders amenable to a specific treatment. The diagnosis may be significantly delayed resulting in permanent neurological impairment. A retrospective review of the clinical characteristics and diagnostic findings in case series of six Polish patients with CTX. Additional retrospective review of symptoms and pathogenic variants of 568 CTX available cases and case series from the past 20 years. To the best of our knowledge, this is the widest review of CTX cases reported in years 2000-2021. We report the largest cohort of Polish patients ever published, with the identification of two hot-spot mutations. During the review of available 568 cases, we found significant differences in the clinical phenotypes and the localization of variants within the gene between Asian and non-Asian populations. These findings may facilitate molecular testing in the Polish and Asian populations. Invariably better screening for CTX and wider awareness is needed.
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Affiliation(s)
- Magdalena Badura-Stronka
- Department of Medical Genetics, Poznan University of Medical Sciences, Poznan, Poland.,Centers for Medical Genetics GENESIS, Poznan, Poland
| | | | | | - Edyta Budzyńska
- Central Teaching Hospital, The Medical University of Lodz, Poland
| | - Anna Jakubiuk-Tomaszuk
- Department of Pediatric Neurology and Rehabilitation, Medical University of Bialystok, Poland.,Medical Genetics Unit, Mastermed Medical Center, Poland
| | - Anita Piontek
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Barbara Steinborn
- Department of Child Neurology, Poznan University of Medical Sciences, Poznan, Poland
| | - Wojciech Kozubski
- Department of Neurology, Poznan University of Medical Sciences, Poznan, Poland
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Abstract
A 19 year old male presented with progressive enlargement of both tendoachilles for 2 years and difficulty in walking for 3 months. The neurological history and examination revealed progressive mental deterioration and ataxia. The blood investigation revealed hypercholesterolemia. We report this rare case of cerebrotendinous xanthomatosis with bilateral tendoachilles enlargement, which was treated by excision of bilateral tendoachilles and reconstruction with fascia lata. The American Orthopedic Foot and Ankle Society hindfoot score was 93/100 bilaterally and the subjective evaluation of the patient showed very good results.
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Affiliation(s)
- Vikas Saxena
- Department of Orthopedics, BRD Medical College, Gorakhpur, Uttar Pradesh, India
| | - Pavan Pradhan
- Department of Orthopedics, BRD Medical College, Gorakhpur, Uttar Pradesh, India
| | - Ashok Yadav
- Department of Orthopedics, BRD Medical College, Gorakhpur, Uttar Pradesh, India
| | - Neeraj Nathani
- Department of Plastic Surgery, BRD Medical College, Gorakhpur, Uttar Pradesh, India
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Abstract
Cerebrotendinous xanthomatosis is a rare autosomal recessive lipid storage disorder affecting the biosynthetic pathway of bile acids, leading to increased cholestanol formation and its accumulation in various tissues. Patients can present with tendon xanthomas, gait abnormalities, osteoporosis with or without a pathological fracture, diminished vision, intractable diarrhoea, seizures, ataxia, psychosis, and mental retardation. We report a 20-year-old man who presented with multiple recurrent tendon swellings and seizures. The earlier diagnosis and treatment helps in preventing the devastating neurological sequalae of this sinister condition. Treatment with chenodeoxycholic acid is crucial in preventing the progression of this rare disorder.
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Affiliation(s)
- Satyadev Vadapalli
- Department of Orthopaedics, Konaseema Institute of Medical Sciences (KIMS), Amalapuram, East Godavari District, Andhra Pradesh, India,Address for correspondence: Dr. Satyadev Vadapalli, Prof. of Orthopaedics, Department of Orthopaedics, Konaseema Institute of Medical Sciences (KIMS), Amalapuram, East Godavari District, Andhra Pradesh 533201, India. E-mail:
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Moroney PJ, Besse JL. Resection of bilateral massive Achilles tendon xanthomata with reconstruction using a flexor hallucis longus tendon transfer and Bosworth turndown flap: A case report and literature review. Foot Ankle Surg 2012; 18:e25-8. [PMID: 22857971 DOI: 10.1016/j.fas.2012.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Revised: 02/07/2012] [Accepted: 03/22/2012] [Indexed: 02/04/2023]
Abstract
Tumours of the Achilles tendon are rare. Reconstruction of the large defect following excision, however, is often a challenge and is sometimes a factor in deciding against operative treatment of a benign lesion. We report a case of excision of bilateral Achilles tendon xanthomata, with reconstruction using a flexor hallucis longus tendon transfer and Bosworth turndown flap.
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Affiliation(s)
- P J Moroney
- Department of Orthopaedic Surgery, Centre Hospitalier Lyon-Sud, 69495 Pierre-Benite Cedex, Lyon, France.
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Ahn JH, Chun TJ, Lee S. Nodular excision for painful localized Achilles tendon xanthomas in type II hyperlipoproteinemia: a case report. J Foot Ankle Surg 2011; 50:603-6. [PMID: 21621429 DOI: 10.1053/j.jfas.2011.04.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Indexed: 02/03/2023]
Abstract
Achilles tendon xanthomas are often associated with type II hyperlipoproteinemia, in which low-density lipoprotein derived from the circulation accumulates in the tendons. Sometimes coronary artery disease can jeopardize the life of the patient if the condition is neglected. We describe the case of bilateral painful Achilles tendon xanthomas in a heterozygous type II hyperlipoproteinemia family. Her symptoms were not alleviated despite anti-inflammatory medication and eccentric exercise for 6 months. She was treated with nodular excision of the xanthomas bilaterally and then with postoperative statins to avoid recurrence.
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Affiliation(s)
- Jae Hoon Ahn
- Department of Orthopaedic Surgery, The Catholic University of Korea, Seoul, Korea
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Scagnelli R, Bianco G, Imarisio D. Cadaver bone-tendon graft for xanthomatosis of the tendo Achillis. ACTA ACUST UNITED AC 2009; 91:968-71. [DOI: 10.1302/0301-620x.91b7.22315] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We describe a 63-year-old man who had xanthomatosis of the right tendo Achillis. He had undergone excision of the left tendo Achillis 17 years earlier without reconstruction for the same condition. The neurological history and examination were normal. Blood investigations showed hypercholestrolaemia, for which he was being treated with statins. He was referred with pain in the right tendo Achillis and problems with footwear. He was treated by excision of the right tendo Achillis, the xanthomatous nodules and the involved skin, followed by reconstruction with a cadaver bone-tendon graft. At follow-up eight months postoperatively, the scar had healed well. He walked without pain and could wear any type of shoe. Plain radiographs showed that the bone graft had healed. The American Orthopaedic Foot and Ankle Society hindfoot score was 95/100. The patient’s subjective evaluation of the result was very good.
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Affiliation(s)
- R. Scagnelli
- Department of Orthopaedics and Traumatology Ospedale Civile di Saluzzo, Via Spielberg 58, 12037 Saluzzo, Italy
| | - G. Bianco
- Department of Orthopaedics and Traumatology Ospedale Civile di Saluzzo, Via Spielberg 58, 12037 Saluzzo, Italy
| | - D. Imarisio
- Department of Orthopaedics and Traumatology Ospedale Civile di Saluzzo, Via Spielberg 58, 12037 Saluzzo, Italy
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Zacherl M, Sourij H, Beham A, Emberger W, Leithner A, Windhager W. [Cerebrotendinous xanthomatosis. Hereditary lipid storage disease leading to bilateral swelling of Achilles tendon]. DER ORTHOPADE 2008; 37:704-8. [PMID: 18483801 DOI: 10.1007/s00132-008-1275-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cerebrotendinous xanthomatosis is a rare hereditary lipid storage disease characterised by deposits of cholestanol. In a female patient with bilateral swelling of the Achilles tendon who underwent biopsy, cerebrotendinous xanthomatosis was confirmed by combining disease patterns. She suffered from ataxia, depression, epilepsy, reduced intelligence, bilateral cataracts, gallstones, and atherosclerosis. Concentration of serum cholestanol was 10 times higher than normal. As causal therapy, ursodeoxycholic acid and statin drugs were prescribed to halt progression.
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Affiliation(s)
- M Zacherl
- Universitätsklinik für Orthopädie, Medizinische Universität, Graz.
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Gonzalez-Cuyar LF, Morrison AL, Perry G, DeJong JJ, Smith MA, Castellani RJ. Cerebrotendinous xanthomatosis: a critical update. FUTURE NEUROLOGY 2008. [DOI: 10.2217/14796708.3.4.491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Cerebrotendinous xanthomatosis (CTX) also known as van Bogaert–Scherer–Epstein syndrome, Thiebaut’s syndrome and cerebrotendinous cholesterosis, is an autosomal-recessive lipid-storage disease characterized by the triad of juvenile cataracts, tendon xanthomas and progressive neurodegeneration. Excess cholesterol and cholestanol are deposited in multiple organs, including the cerebrum, cerebellum, lens and tendons. Approximately 300 cases are reported worldwide, but it is suspected that the incidence of CTX is underestimated. The disease is attributed to approximately 50 mutations in the CYP27A1 gene coding for the enzyme sterol 27-hydoxylase, which is responsible for initial oxidation of the side chain of the cholesterol molecule in bile acid biosynthesis. CTX has varied clinical presentations, but no genotype–phenotype relationship has been documented. In some intrafamilial cases, clinical presentations may vary considerably. MRI for CTX is sensitive for diagnosis and classically demonstrates cerebral and cerebellar atrophy and xanthomatous lesions preferentially affecting the dentate nuclei. Patients have high serum levels of cholestanol with normal total cholesterol and increased urinary excretion of bile acids. Treatment of patients with chenodeoxycholic acid, particularly when used along with HMG-CoA reductase inhibitors (statins) or low-density lipoprotein apheresis, can normalize cholestanol levels as well as prevent further degeneration. Therefore, the need for early diagnosis is well documented in the literature, as it prevents the significant morbidity and mortality associated with this disease.
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Affiliation(s)
| | - Allan L Morrison
- University of Maryland, Department of Pathology, Baltimore, MD, USA
| | - George Perry
- Case Western Reserve University, Department of Pathology, 2103 Cornell Road, Cleveland, OH 44106, USA
| | - Joyce J DeJong
- Sparrow Health Systems, Division of Forensic Pathology, Lansing, MI, USA
| | - Mark A Smith
- Case Western Reserve University, Department of Pathology, 2103 Cornell Road, Cleveland, OH 44106, USA
| | - Rudy J Castellani
- University of Maryland, Department of Pathology, 22 South Greene Street, NBW81, Baltimore, MD 21201, USA
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Zacherl M, Sourij H, Beham A, Emberger W, Leithner A, Windhager W. [Cerebrotendinous xanthomatosis. Hereditary lipid storage disease leading to bilateral swelling of Achilles tendon]. DER ORTHOPADE 2008. [PMID: 18483801 DOI: 10.1007/s00132‐008‐1275‐8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cerebrotendinous xanthomatosis is a rare hereditary lipid storage disease characterised by deposits of cholestanol. In a female patient with bilateral swelling of the Achilles tendon who underwent biopsy, cerebrotendinous xanthomatosis was confirmed by combining disease patterns. She suffered from ataxia, depression, epilepsy, reduced intelligence, bilateral cataracts, gallstones, and atherosclerosis. Concentration of serum cholestanol was 10 times higher than normal. As causal therapy, ursodeoxycholic acid and statin drugs were prescribed to halt progression.
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Affiliation(s)
- M Zacherl
- Universitätsklinik für Orthopädie, Medizinische Universität, Graz.
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