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Papapetropoulos S, Gelfand JM, Konno T, Ikeuchi T, Pontius A, Meier A, Foroutan F, Wszolek ZK. Clinical presentation and diagnosis of adult-onset leukoencephalopathy with axonal spheroids and pigmented glia: a literature analysis of case studies. Front Neurol 2024; 15:1320663. [PMID: 38529036 PMCID: PMC10962389 DOI: 10.3389/fneur.2024.1320663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/16/2024] [Indexed: 03/27/2024] Open
Abstract
Introduction Because adult-onset leukoencephalopathy with axonal spheroids and pigmented glia (ALSP) is a rare, rapidly progressive, debilitating, and ultimately fatal neurodegenerative disease, a rapid and accurate diagnosis is critical. This analysis examined the frequency of initial misdiagnosis of ALSP via comprehensive review of peer-reviewed published cases. Methods Data were extracted from a MEDLINE search via PubMed (January 1, 1980, through March 22, 2022) from eligible published case reports/series for patients with an ALSP diagnosis that had been confirmed by testing for the colony-stimulating factor-1 receptor gene (CSF1R) mutation. Patient demographics, clinical symptoms, brain imaging, and initial diagnosis data were summarized descriptively. Categorical data for patient demographics, symptoms, and brain imaging were stratified by initial diagnosis category to test for differences in initial diagnosis based on each variable. Results Data were extracted from a cohort of 291 patients with ALSP from 93 published case reports and case series. Mean (standard deviation) age of symptom onset was 43.2 (11.6) years. A family history of ALSP was observed in 59.1% of patients. Cognitive impairment (47.1%) and behavioral and psychiatric abnormalities (26.8%) were the most frequently reported initial symptoms. Of 291 total cases, an accurate initial diagnosis of ALSP was made in 72 cases (24.7%) and the most frequent initial misdiagnosis categories were frontotemporal dementia (28 [9.6%]) and multiple sclerosis (21 [7.2%]). Of the 219 cases (75.3%) that were initially mis- or undiagnosed, 206 cases (94.1%) were later confirmed as ALSP by immunohistology, imaging, and/or genetic testing; for the remaining 13 cases, no final diagnosis was reported. Initial diagnosis category varied based on age, family history, geographic region, mode of inheritance, and presenting symptoms of pyramidal or extrapyramidal motor dysfunction, behavioral and psychiatric abnormalities, cognitive impairment, and speech difficulty. Brain imaging abnormalities were common, and initial diagnosis category was significantly associated with white matter hyperintensities, white matter calcifications, and ventricular enlargement. Discussion In this literature analysis, ALSP was frequently misdiagnosed. Improving awareness of this condition and distinguishing it from other conditions with overlapping presenting symptoms is important for timely management of a rapidly progressive disease such as ALSP.
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Affiliation(s)
| | | | - Takuya Konno
- Brain Research Institute, Niigata University, Niigata, Japan
| | - Takeshi Ikeuchi
- Brain Research Institute, Niigata University, Niigata, Japan
| | | | - Andreas Meier
- Vigil Neuroscience, Inc., Watertown, MA, United States
| | - Farid Foroutan
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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Kondo Y, Matsushima A, Nagasaki S, Nakamura K, Sekijima Y, Yoshida K. Factors predictive of the presence of a CSF1R mutation in patients with leukoencephalopathy. Eur J Neurol 2019; 27:369-375. [PMID: 31520500 PMCID: PMC6973227 DOI: 10.1111/ene.14086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 09/09/2019] [Indexed: 11/26/2022]
Abstract
Background and purpose The purpose was to identify statistically factors that correlate with the presence of a colony‐stimulating factor 1 receptor (CSF1R) mutation and to reevaluate the accuracy of the current diagnostic criteria for CSF1R‐related leukoencephalopathy. Methods CSF1R testing was conducted on 145 consecutive leukoencephalopathy cases who were clinically suspected of having adult‐onset leukoencephalopathy with axonal spheroids and pigmented glia. From these, 135 cases whose detailed clinical information was available were enrolled. Forward logistic stepwise regression was performed to generate a probability model to predict a positive CSF1R mutation result. The current diagnostic criteria were also applied to our cohort and their sensitivity and specificity were calculated. Results Twenty‐eight CSF1R‐mutation‐positive cases and 107 CSF1R‐mutation‐negative cases were identified. Our probability model suggested that factors raising the probability of a CSF1R‐mutation‐positive result were younger onset, parkinsonism, thinning of the corpus callosum and diffusion‐restricted lesions. It also showed that involuntary movements and brainstem or cerebellar atrophy were negative predictors of a CSF1R‐mutation‐positive result. In our cohort, the sensitivity and specificity for ‘probable’ or ‘possible’ CSF1R‐related leukoencephalopathy were 81% and 14%, respectively. Conclusions Clinical and brain imaging features predictive of the presence of a CSF1R mutation are proposed. Consideration of these factors will help prioritize patients for CSF1R testing.
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Affiliation(s)
- Y Kondo
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan.,Department of Neurology, Nagano Municipal Hospital, Nagano, Japan
| | - A Matsushima
- Department of Neurology, JA Nagano Koseiren Kakeyu-Misayama Rehabilitation Center Kakeyu Hospital, Ueda, Japan
| | - S Nagasaki
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - K Nakamura
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan.,Center for Medical Genetics, Shinshu University Hospital, Matsumoto, Japan
| | - Y Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - K Yoshida
- Department of Brain Disease Research, Shinshu University School of Medicine, Matsumoto, Japan
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Leng C, Lu L, Wang G, Zhang Y, Xu Y, Lin X, Shen N, Xu X, Qun S, Sun M, Ge W. A novel dominant-negative mutation of the CSF1R gene causes adult-onset leukoencephalopathy with axonal spheroids and pigmented glia. Am J Transl Res 2019; 11:6093-6101. [PMID: 31632577 PMCID: PMC6789214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/30/2019] [Indexed: 06/10/2023]
Abstract
Adult-onset leukoencephalopathy with axonal spheroids and pigmented glia (ALSP) is a rare autosomal dominant disorder that is caused by mutations in the colony-stimulating factor 1 receptor (CSF1R) gene. Functional haplo-insufficiency of the CSF1R gene has been considered for the underlying genetic mechanisms. A novel mutation of CSF1R and its effects on CSF1R expression or clinical characteristics were explored in an ALSP family. Clinical data and imaging data were collected from the family members with ALSP. Peripheral blood samples were collected for DNA and RNA extraction. Whole-exome sequencing and quantitative PCR were used to identify mutations and to determine the expression of CSF1R. The family had a history of a dominant hereditary pattern. Patients in this family presented motor symptoms, emotional abnormality, or memory impairment at onset. MRI findings showed high hyperintensity signals of T2-weighted imaging in the white matter and atrophy of the corpus callosum. NOTCH3 gene sequencing ruled out the diagnosis of CADASIL. Whole-exome sequencing identified a novel splice-site mutation (c.2319+1C>A) in intron 16 of the CSF1R gene. CSF1R mRNA was significantly decreased (~15%) in the peripheral blood samples of affected patients, which was much lower than the expected 50%. Our findings not only supported the pathological implication of this splice-site mutation but also demonstrated for the first time a dominant-negative effect on CSF1R expression. This report extends the genetic spectrum of ALSP with CSF1R mutations and provides evidence for the clinical heterogeneity of ALSP.
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Affiliation(s)
- Cuihua Leng
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical UniversityXuzhou City, Jiangsu, China
- Department of Neurology, The Second Affiliated Hospital of Soochow UniversitySuzhou City, Jiangsu, China
| | - Likui Lu
- Institute of Fetal Medicine, The First Affiliated Hospital of Soochow UniversitySuzhou City, Jiangsu, China
| | - Guoping Wang
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of ChinaHefei City, Anhui, China
| | - Yingying Zhang
- Institute of Fetal Medicine, The First Affiliated Hospital of Soochow UniversitySuzhou City, Jiangsu, China
| | - Yan Xu
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical UniversityXuzhou City, Jiangsu, China
| | - Xiaoqian Lin
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical UniversityXuzhou City, Jiangsu, China
| | - Nana Shen
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical UniversityXuzhou City, Jiangsu, China
| | - Xingshun Xu
- Department of Neurology, The Second Affiliated Hospital of Soochow UniversitySuzhou City, Jiangsu, China
| | - Sen Qun
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of ChinaHefei City, Anhui, China
| | - Miao Sun
- Institute of Fetal Medicine, The First Affiliated Hospital of Soochow UniversitySuzhou City, Jiangsu, China
| | - Wei Ge
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical UniversityXuzhou City, Jiangsu, China
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Konno T, Miura T, Harriott AM, Mezaki N, Edwards ES, Rademakers R, Ross OA, Meschia JF, Ikeuchi T, Wszolek ZK. Partial loss of function of colony-stimulating factor 1 receptor in a patient with white matter abnormalities. Eur J Neurol 2018; 25:875-881. [PMID: 29509319 DOI: 10.1111/ene.13611] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 02/28/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE Mutations in colony-stimulating factor 1 receptor (CSF1R) cause adult-onset leukoencephalopathy with axonal spheroids and pigmented glia (ALSP). Patients with ALSP can be misdiagnosed as having acute ischemic stroke due to hyperintensity lesions on diffusion-weighted magnetic resonance imaging. Mutant CSF1R proteins identified in ALSP show a complete loss of autophosphorylation of CSF1R. METHODS We conducted mutation screening of CSF1R in 123 patients with definite acute ischemic cerebrovascular syndrome and positive family history of stroke. The pathogenicity of identified variants was evaluated using functional analyses. The levels of autophosphorylation of CSF1R in response to treatment with ligands of CSF1R were examined in cells transfected with wild-type and mutant CSF1R. RESULTS We identified eight CSF1R variants, six were known non-pathogenic polymorphisms, whereas the other two were missense variants inducing substitution of amino acid residues (p.Glu573Lys and p.Gly747Arg). Functional assay showed that the levels of autophosphorylation of p.Gly747Arg were similar to those of wild-type when treated with ligands. The autophosphorylation of p.Glu573Lys was detectable, but significantly decreased compared with those of wild-type CSF1R (P < 0.001, two-way anova with Bonferroni). The clinical presentation of the patient with p.Glu573Lys was consistent with cerebral embolism. The patient did not have typical clinical findings of ALSP. However, periventricular white matter abnormalities, unrelated to the recent infarct, were evident on brain magnetic resonance imaging. CONCLUSIONS In contrast to ALSP-associated missense mutations, CSF1R p.Glu573Lys variant in a patient with acute ischemic cerebrovascular syndrome showed a partial loss of autophosphorylation of CSF1R; its clinical significance warrants further investigation.
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Affiliation(s)
- T Konno
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.,Department of Neurology, Brain Research Institute, Niigata University, Niigata
| | - T Miura
- Department of Neurology, Brain Research Institute, Niigata University, Niigata.,Department of Molecular Genetics, Brain Research Institute, Niigata University, Niigata, Japan
| | - A M Harriott
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - N Mezaki
- Department of Neurology, Brain Research Institute, Niigata University, Niigata.,Department of Molecular Genetics, Brain Research Institute, Niigata University, Niigata, Japan
| | - E S Edwards
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - R Rademakers
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA
| | - O A Ross
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA
| | - J F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - T Ikeuchi
- Department of Molecular Genetics, Brain Research Institute, Niigata University, Niigata, Japan
| | - Z K Wszolek
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
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Konno T, Yoshida K, Mizuta I, Mizuno T, Kawarai T, Tada M, Nozaki H, Ikeda SI, Onodera O, Wszolek ZK, Ikeuchi T. Diagnostic criteria for adult-onset leukoencephalopathy with axonal spheroids and pigmented glia due to CSF1R mutation. Eur J Neurol 2017; 25:142-147. [PMID: 28921817 DOI: 10.1111/ene.13464] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 09/07/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE To establish and validate diagnostic criteria for adult-onset leukoencephalopathy with axonal spheroids and pigmented glia (ALSP) due to colony-stimulating factor 1 receptor (CSF1R) mutation. METHODS We developed diagnostic criteria for ALSP based on a recent analysis of the clinical characteristics of ALSP. These criteria provide 'probable' and 'possible' designations for patients who do not have a genetic diagnosis. To verify its sensitivity and specificity, we retrospectively applied our criteria to 83 ALSP cases who had CSF1R mutations (24 of these were analyzed at our institutions and the others were identified from the literature), 53 cases who had CSF1R mutation-negative leukoencephalopathies and 32 cases who had cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) with NOTCH3 mutations. RESULTS Among the CSF1R mutation-positive cases, 50 cases (60%) were diagnosed as 'probable' and 32 (39%) were diagnosed as 'possible,' leading to a sensitivity of 99% if calculated as a ratio of the combined number of cases who fulfilled 'probable' or 'possible' to the total number of cases. With regard to specificity, 22 cases (42%) with mutation-negative leukoencephalopathies and 28 (88%) with CADASIL were correctly excluded using these criteria. CONCLUSIONS These diagnostic criteria are very sensitive for diagnosing ALSP with sufficient specificity for differentiation from CADASIL and moderate specificity for other leukoencephalopathies. Our results suggest that these criteria are useful for the clinical diagnosis of ALSP.
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Affiliation(s)
- T Konno
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.,Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - K Yoshida
- Department of Brain Disease Research, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - I Mizuta
- Department of Neurology, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Japan
| | - T Mizuno
- Department of Neurology, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Japan
| | - T Kawarai
- Department of Clinical Neuroscience, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - M Tada
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - H Nozaki
- Department of Medical Technology, School of Health Sciences Faculty of Medicine, Niigata University, Niigata, Japan
| | - S-I Ikeda
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - O Onodera
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Z K Wszolek
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - T Ikeuchi
- Department of Molecular Genetics, Brain Research Institute, Niigata University, Niigata, Japan
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Konno T, Yoshida K, Mizuno T, Kawarai T, Tada M, Nozaki H, Ikeda SI, Nishizawa M, Onodera O, Wszolek ZK, Ikeuchi T. Clinical and genetic characterization of adult-onset leukoencephalopathy with axonal spheroids and pigmented glia associated with CSF1R mutation. Eur J Neurol 2016; 24:37-45. [PMID: 27680516 PMCID: PMC5215554 DOI: 10.1111/ene.13125] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 08/09/2016] [Indexed: 01/13/2023]
Abstract
Background and purpose The clinical characteristics of colony stimulating factor 1 receptor (CSF1R) related adult‐onset leukoencephalopathy with axonal spheroids and pigmented glia (ALSP) have been only partially elucidated. Methods Clinical data from CSF1R mutation carriers who had been seen at our institutions or reported elsewhere were collected and analysed using a specific investigation sheet to standardize the data. Results In all, 122 cases from 90 families with CSF1R mutations were identified. The mean age of onset was 43 years (range 18–78 years), the mean age at death was 53 years (range 23–84 years) and the mean disease duration was 6.8 years (range 1–29 years). Women had a significantly younger age of onset than men (40 vs. 47 years, P = 0.0006, 95% confidence interval 3.158–11.177). There was an age‐dependent penetrance that was significantly different between the sexes (P = 0.0013). Motor dysfunctions were the most frequent initial symptom in women whose diseases began in their 20s. Thinning of the corpus callosum, abnormal signalling in pyramidal tracts, diffusion‐restricted lesions and calcifications in the white matter were characteristic imaging findings of ALSP. The calcifications were more frequently reported in our case series than in the literature (54% vs. 3%). Seventy‐nine per cent of the mutations were located in the distal part of the tyrosine kinase domain of CSF1R (102 cases). There were no apparent phenotype−genotype correlations. Conclusions The characteristics of ALSP were clarified. The phenotype of ALSP caused by CSF1R mutations is affected by sex.
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Affiliation(s)
- T Konno
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.,Department of Neurology, Niigata University, Niigata, Japan
| | - K Yoshida
- Department of Brain Disease Research, Shinshu University School of Medicine, Matsumoto, Japan
| | - T Mizuno
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - T Kawarai
- Department of Clinical Neuroscience, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - M Tada
- Department of Neurology, Niigata University, Niigata, Japan
| | - H Nozaki
- Department of Medical Technology, School of Health Sciences Faculty of Medicine, Niigata University, Niigata, Japan
| | - S-I Ikeda
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - M Nishizawa
- Department of Neurology, Niigata University, Niigata, Japan
| | - O Onodera
- Department of Molecular Neuroscience, Niigata University, Niigata, Japan
| | - Z K Wszolek
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - T Ikeuchi
- Department of Molecular Genetics, Brain Research Institute, Niigata University, Niigata, Japan
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Abstract
Neuroimaging and genomic analysis greatly aid in the identification of young-onset dementia antemortem. We present the case of a 33-year-old female with a 2-year rapid decline to dementia and immobility marked by personality change, executive deficits including compulsions, attention deficit, apraxia, Parkinsonism, and pyramidal signs. She had unique and dramatic calcifications and confluent white matter changes on imaging and was found to have a novel mutation in the colony stimulating factor 1 receptor gene causing adult-onset leukoencephalopathy with axonal spheroids and pigmented glia (ALSP). Here, we review ALSP and briefly discuss differential diagnoses.
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Affiliation(s)
- Ethan Gore
- a Department of Neurology , Case Western Reserve University Hospitals , Beachwood , OH , USA
| | - Andrew Manley
- b Department of Neurology , University of South Alabama , Mobile , AL , USA
| | - Daniel Dees
- b Department of Neurology , University of South Alabama , Mobile , AL , USA
| | - Brian S Appleby
- a Department of Neurology , Case Western Reserve University Hospitals , Beachwood , OH , USA
| | - Alan J Lerner
- a Department of Neurology , Case Western Reserve University Hospitals , Beachwood , OH , USA
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Chitu V, Gokhan Ş, Nandi S, Mehler MF, Stanley ER. Emerging Roles for CSF-1 Receptor and its Ligands in the Nervous System. Trends Neurosci 2016; 39:378-393. [PMID: 27083478 DOI: 10.1016/j.tins.2016.03.005] [Citation(s) in RCA: 220] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 03/07/2016] [Accepted: 03/09/2016] [Indexed: 02/06/2023]
Abstract
The colony-stimulating factor-1 receptor (CSF-1R) kinase regulates tissue macrophage homeostasis, osteoclastogenesis, and Paneth cell development. However, recent studies in mice have revealed that CSF-1R signaling directly controls the development and maintenance of microglia, and cell autonomously regulates neuronal differentiation and survival. While the CSF-1R-cognate ligands, CSF-1 and interleukin-34 (IL-34) compete for binding to the CSF-1R, they are expressed in a largely non-overlapping manner by mature neurons. The recent identification of a dominantly inherited, adult-onset, progressive dementia associated with inactivating mutations in the CSF-1R highlights the importance of CSF-1R signaling in the brain. We review the roles of the CSF-1R and its ligands in microglial and neural development and function, and their relevance to our understanding of neurodegenerative disease.
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Affiliation(s)
- Violeta Chitu
- Department of Developmental and Molecular Biology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Şölen Gokhan
- Institute for Brain Disorders and Neural Regeneration, Departments of Neurology, Neuroscience, and Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Sayan Nandi
- Departments of Neuroscience and Genetics, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Mark F Mehler
- Institute for Brain Disorders and Neural Regeneration, Departments of Neurology, Neuroscience, and Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - E Richard Stanley
- Department of Developmental and Molecular Biology, Albert Einstein College of Medicine, Bronx, NY 10461, USA.
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