Menkes' syndrome: an updated review

Menkes' syndrome is an X-linked recessive multisystem disease which is usually fatal prior to 5 years of age. Though originally felt to be a disorder of copper deficiency, it now appears to be a copper storage disease, with the observed defects resulting from inappropriate systemic copper distribution. Disorders in the metabolism of metallothionein, a metalloprotein involved in cellular copper transport, may be the primary defect in this syndrome. This review summarizes the relevant clinical and pathologic findings seen in this condition to date. It also describes some of the abnormalities in the metabolism of copper and metallothionein in these infants.

Menkes' syndrome with vascular and adrenergic nerve abnormalities

Using the formaldehyde-induced fluorescence method, we found a peculiar rosary-type swelling of the adrenergic axons in the peripheral nerves, deficiency of the perivascular adrenergic plexuses in the visceral and cerebral arteries, and reduction of noradrenergic fluorescence in the tegmental and hypothalamic regions of a 3-year-old boy who had typical Menkes' syndrome (kinky hair syndrome). The nigrostriated neurons retained moderate intensity of fluorescence compared with those in postmortem (control) brains. Histologically, marked dilatation of the visceral, meningeal and cerebral arteries were noted. Copper deficiency, the cause of this disease, induces failure of central and peripheral noradrenergic neurons and leads to abnormal vasodilatation.

Mitochondrial abnormalities in Menkes' kinky hair disease (MKHD). Electron-microscopic study of the brain from an autopsy case

The brain of an autopsy case of Menkes' kinky hair disease (MKHD), after routine histological examination, was studied extensively by electron microscopy, particularly the mitochondrial alteration. There were widespread mitochondrial abnormalities, including enlargement with tubulo-vesiculated cristae, swelling, and dense body formation and occasional accumulation of glycogen within mitochondria, in addition to increased numbers of mitochondria in some neurons. These abnormalities of mitochondria were present in decreasing severity in the following: Purkinje cells, neurons of the molecular and granule cell layers of the cerebellum, and neurons of the cerebral cortex, globus pallidus, lateral nuclei of the thalamus, caudate nucleus, and the myelinated axons in the white matter. This distribution and the degree of mitochondrial abnormalities in the various structures of the brain were compared with those of degenerative lesions in the respective structures. The comparison disclosed that there was a positive correlation between the two. The mitochondrial enlargement and swelling as in the present study had been well documented in the brain of the brindled mouse; mitochondrial dense bodies had also been reported in previous case reports of MKHD by other authors. The present study strongly suggests that the mitochondrial disease is an essential abnormality and may be responsible for the progressive degeneration of the CNS in MKHD.

[Neuropathological study of Menkes' kinky hair disease: on the mechanism of development of cerebrovascular lesions (author's transl)]

In order to elucidate the mechanism of development of cerebrovascular lesions in Menkes' kinky hair disease (MKHD), the authors examined the brain and its vasculature of an autopsied case of this disease in light and electron microscopy. The gross and light microscopic examinations revealed that focal degeneration including pseudolaminar necrosis of cerebral cortices roughly concentrated on the gyri in and around the Sylvian fissures where tortuous vessels with congestion and dilatation were most prominently present. Despite their conspicuous irregularity in shape of the lumens and in thickness of the walls, the vessels were devoid of significant changes in elastic lamina and intima. In contrast, mitochondrial disease manifested by enlargement and/or rounding of mitochondria with tubular cristae and dense body as well as vacuolar degeneration were noted in various sizes of vessels in endothelial cells, pericytes and medial muscle cells, which exhibited various degrees of degeneration. On the other hand the preliminary observation had disclosed the mitochondrial changes of the same character in the neurons in various structures of this brain, such as Purkinje cells, granule cells, and neurons in cerebral cortex, thalamus and globus pallidus, and even in glial cells. Therefore it seemed reasonable to consider that the mitochondrial disease in MKHD might be ubiquituous in the brain including its vasculature. The observations of various degrees of degeneration of vessel wall cells due to mitochondrial disease and of irregular proliferation of reticulin fibrils in the spaces among degenerated muscle cells of the tunica media may be the evidences responsible for the tortuosity, dilatation and congestion of vessels, which eventually give rise to the vascular lesions in the brain parenchyme in MKHD. The findings of increased numbers of enlarged specific granules in the endothelium of dilated vessels, and dense material accumulation in their perivascular spaces with proliferation of basal lamina may have something to do with dilatation of small vessels and alteration of their blood brain barrier.

Menkes' kinky hair disease. II. A clinicopathological report of three cases

The neuropathologic abnormalities in three new cases of Menkes' kinky hair disease are described. Principally the three cases were the same. Hypoplasia of the cerebellum, with a basal arachnoïdal cyst, was present in all three cases. The cysts were not described before in Menkes' disease. There was nerve cell loss and gliosis in the cerebral cortex, cerebellum and thalamus. The reduction of myelinated axons was widespread and the disease does not belong to the leukodystrophies. Cortical lamination disturbances were present indicating that the disease develops as early as the sixth fetal month. Abnormal arborization of Purkinje cells with swelling of dendrites was present and thought not to be identical with the Purkinje cell abnormalities seen in amaurotic idiocy. The difference in severity of the copper deficiency in 2 patients is compared with the situation in "brindled" and "blotchy" mutant mice.

Nature of copper and zinc compounds in tissues from a patient with Menkes kinky hair syndrome

Copper and zinc concentrations, and the nature of the copper- and zinc-binding proteins, were studied using tissues from a Menkes patient who had been given intravenous infusions of cupric acetate. The liver and brain copper contents were lower than in an untreated, non-Menkes control, and the spleen, intestine and kidney showed higher copper concentrations than control tissues. Zinc concentrations in all the organs (except the kidneys) from the Menkes patient were slightly lower than those the control child. Using Sephadex G-75 column chromatography of cytosols (105,000 x g supernatant), three copper- and zinc-containing peaks were eluted. In all the Menkes tissues studied, copper was prominent in peak 3. On the other hand, peak 3 was the smallest and peak 1 was the largest in the control tissues. Zinc predominated in peak 1 in both Menkes and control tissues, except for Menkes kidney. In this tissue peak 3 was again the largest. The copper- and zinc-binding material in peak 3 fractions from Menkes kidney was chromatographed on DEAE-cellulose columns. Three copper- and zinc-containing peaks were observed at the same positions as metallothionein from human adult kidneys.

The effect of copper supplementation on the brindled mouse: a clinico-pathological study

Brindled mottled is a neurological mutant mouse. Hemizygous males have many clinical and biochemical features in common with kinky hair syndrome (KHS) in humans, and usually die around postnatal day 15, after severe emaciation. Neuronal mitochondrial abnormalities and neuronal degeneration in the cerebrum and cerebellum were constant neuropathological findings in this mutant. A single intraperitoneal injection of cupric chloride, 10 micrograms/g body weight, resulted in an improvement of clinical symptoms and prevention of neuronal degeneration. The degree of improvement was dependent on the date of injection, and day 7 to 10 postnatal appeared to the most effective date. The male hemizygotes which received cupric chloride injections at day 7 or 10 overcame the lethality, and no neuronal degeneration was detected in these mice, although neuronal mitochondrial changes were still persistent. However, following two injections at days 7 and 10, no abnormalities were detected in the cerebral cortical neurons. Even at the ultrastructural level, abnormal mitochondria were very scarce. In the cerebellum, however, mitochondrial changes in the Purkinje cells, particularly in the rostral portion, and generation of white matter were noted in these mice, which were clinically perfectly healthy, judging from the growth rate and behavior. However, cerebellar changes were far less in those which received additional injections later on. These observations indicate that, at least in brindled mutant mice, supplementation of copper is quite beneficial for clinical improvement and the prevention of neuropathological lesions, but the date of administration appears to have crucial importance.

Increased copper metallothionein in Menkes cultured skin fibroblasts

Menkes fibroblasts contain a significantly greater amount of cysteine-rich 10,000 dalton copper-binding protein(s) (metallotheionein) than normal cells. Mutant fibroblasts incorporated 30 to 40% more tritiated amino acids into 10,000 dalton protein(s) than normal cells. The protein(s) was deficient in aromatic amino acids The amount of 35S-cysteine incorporated by the same protein(s) in Menkes fibroblasts was twice that of normal fibroblasts. Comparison of the 35 S:3H isotopic ratios of chromatographic fractions of both normal and Menkes cell lysates showed that only the proteins eluted in the 10,000 dalton peak were enriched in 35S-cysteine, and this ratio was always greater than in Menkes than in normal cells. The 10,000 molecular weight 35S-cysteine- and 3H-amino acid-labeled peaks coincided with the 64Cu peak in both cell strains. The copper-labeled peak was always greater in Menkes than in normal cells. No difference in the 64Cu:35S isotopic ratio in the 10,000 dalton peak was observed between normal and Menkes fibroblast strains. This finding shows the direct relationship between the amount of cysteine-rich 10,000 dalton protein(s) and the amount of 64Cu bound by this protein(s) in both Menkes and normal fibroblasts. DEAE-cellulose ion-exchange chromatography resulted in a further two-fold enrichment of the 10,000 dalton, sulfur-rich proteins that were eluted from the Sephadex G-75 column. Most of the labeled proteins from both normal and Menkes fibroblasts were eluted from the ion-exchange column in a single peak at a chloride concentration of approximately 30 mM. Polyacrylamide disc gel electrophoresis of pooled fractions of the 10,000 dalton proteins eluted from the G-75 column and the DEAE-cellulose ion-exchange column showed no consistent differences in the staining pattern between normal and mutant fibroblast strains. When th acrylamide gels were sliced and subsequently counted for radioactive content, no band showed a further increase in the 35 S:3H isotopic ratio when compared to the electrophoresed samples that were eluted from the Sephadex G-75 or the ion-exchange columns. Also, no significant increase in the amount of radioactivity associated with a specific protein band could be demonstrated between the Menkes and the normal fibroblast strains.

Brindled mottled mouse: morphological changes of brain and visceral organs in hemizygous males following copper supplementation

Intraperitoneal injections of cupric chloride prevent neuronal degeneration in the hemizygous brindled mottle mouse, MO br/Y, a murine model of kinky hair syndrome (KHS) in humans. At 6-9 months after two i.p. injections, the brain of MO br/Y revealed slightly increased amounts of lipofuscin pigments in the cerebral cortical neurons, cytoplasmic inclusions in the thalamic neurons, and axonal spheroid formation in the tuber cinereum, cerebellum and brain stem. Increased numbers of mitoses, bizarre hyperchromatic giant nuclei, and numerous clear vacuoles were frequently seen in the proximal renal tubular epithelium. Numerous myelin figures were conspicuous features in these epithelial cells at ultrastructural level. Such changes were not found in the littermate controls but in the heterozygous brindled mottled mouse, MO br/ +, identical changes were noted in equal or even higher frequency. These observations suggest that cupric chloride injections effectively modify the expression of the genetic defect in MO br/ Y.

An ultrastructural study on the cerebellum of the brindled mouse

Chronological morphological alterations of the cerebellum, with particular attention to the Purkinje cells, were investigated in the brindled mottled MObr mouse, a neurological mutant mouse with close clinical similarity to Kinky hair syndrome (KHS) in humans. Seven days post-natally, slight irregularity in the morphology of mitochondria of the Purkinje cell perikarya was the only significant difference between hemizygous MObr mice and litter mate controls. With advancing age the mitochondrial change became more pronounced gradually in the former, not only in the perikarya but also in the dendrites. However, by day 31 or later the mitochondrial change subsided gradually and by day 91, the mitochondria in the majority of Purkinje cells became indistinguishable from those of littermate controls. Despite the extensive mitochondrial alteration, degeneration and necrosis of Purkinje cells were rather mild. Degeneration of white matter was quite conspicuous in the mutant mouse older than 31 days. These morphological changes of the cerebellum are compared with those of other neurological mutant mice, Nervous and Purkinje cell degeneration, and with KHS in humans.

Kinky hair disease. Biochemical, histochemical, and ultrastructural studies

The biosynthetic activities of protein and collagen from the patient of kinky hair disease, were reduced to 70 and 50%, respectively, compared with control. In tissue cultures, fast-green FCF staining coarse granules were found in the cytoplasm of skin fibroblasts from the patient. Ultrastructurally, collagen fibrils by iliac cartilage biopsy were irregular in width. Ruthenium red staining granules, presumed to be proteoglycans in the cartilage matrix, were relatively small in size and few in number. Chondrocytes showed poor development of organelles and relatively small glycogen accumulation.

Ultrastructure of cartilage in heritable disorders of connective tissue

Ultrastruct of cartilage were examined in Marfan syndrome, Menkes kinky hair syndrome, achondroplasia, asphyxiating thoracic dysplasia, mild diastrophic dysplasia and mucopolysaccharidoses I and III. Ruthenium red staining revealed decrease of proteoglycans in cases with Marfan syndrome and kinky hair syndrome, and increase in cases with osteochondrodysplasia and mucopolysaccharidosis III. This morphologic tendency coincided with the result obtained by biochemical analysis of glycosaminoglycan contents in cartilage matrix from cases with Marfan syndrome (decreased content) and asphyxiating thoracic dysplasia (increased content). It was postulated that proteoglycan content in cartilage matrix might be related to excessive or reduced skeletal growth in Marfan syndrome or osteochondrodysplasia.

Degeneration of the cerebellar system in X-chromosome-linked copper malabsorption

Examination of the cerebellar system of 5 autopsied patients with X-chromosome-linked copper malabsorption led to the discovery that among cerebellar afferent systems, only the dorsal spinocerebellar tract showed consistent degenerative changes. Cerebellar cortical lesions comprised granule cell loss and Purkinje cell abnormalities that included nuclear and cytoplasmic degenerative changes with cell loss and deficient dendritic arborization as well as the presence of somatic sprouts. Perisomatic baskets were often absent in the area of sprouting Purkinje cells. Cerebellar cortical topographical analysis revealed relative sparing of the caudal portion of the cerebellum. The nodulus was intact in all patients. The dentate nucleus and the superior cerebellar peduncle were preserved. The red nucleus was consistently degenerated.

Thalamic degeneration in X-chromosome--linked copper malabsorption

Thalamic degeneration was present in 5 autopsied cases of X-chromosome-linked copper malabsorption (X-cLCM), Menkes' kinky hair disease. Among the thalamic nuclei, those in the formatio paraventricularis, intralamellaris, and extralamellaris were spared. The nuclei projecting to the granular cortices had severe neuronal depopulation. The thalamic nuclei that send axons to the agranular cortices were less often and less severely involved. The thalamic afferent system was intact except for degeneration of the red nucleus. Cerebral cortical lesions varied from case to case and usually were less marked than thalamic neuronal changes.

CT scans in Menkes disease

The clinical courses and serial computerized tomography (CT) scans of four patients with Menkes disease are described. Although the initial clinical presentations were similar, head growth and serial CT scans showed striking individual differences. The CT scans varied from showing no abnormalities early in the disease to showing diffuse cortical atrophy, subdural accumulation of fluid, or multifocal areas of ischemic infarction. The pathologic findings in one patient showed only cerebral and cerebellar atrophy, whereas the findings in another patient showed areas of ischemic infarction, probably secondary to abnormal vessels. Menkes disease should be suspected in male infants with psychomotor deterioration and seizures, or when trauma is suspected from subdural hematoma and multiple fractures.

Neuronal degeneration in the brain of the brindled mouse--a light microscope study

The brindled mouse (Mobr) is a neurological mutant mouse with a deficiency in copper transport. This mutant has many clinical as well as biochemical features in common with Kinky hair syndrome (KHS) in humans (Tab. 1). Male hemizygotes (Mobr/Y) are characterized by the absence of fur pigment and curly whiskers. They become inactive, losing weight at around the 10th-12th post-natal day. They usually die in an emaciated state around the 15th-16th postnatal day. The brain weight is usually about three fourths of that of littermate controls. Microscopically, widespread neuronal degeneration was noted in the cerebral cortex and thalamic nuclei of male hemizygotes after the 12th post-natal day. The degeneration continued to increase until death. Scattered degenerated cells were also noted in the cerebellum. No such degenerative changes were observed in the brain of female heterozygotes (Mobr/+) or in normal or starved littermates. These degenerative changes of neurons in the brindled hemizygote mouse will be compared with the neuropathological changes observed in KHS and in experimental animals with copper deficiency, and the possible pathogenesis of these changes will be discussed.

Biochemistry of the elastic fibers in normal connective tissues and its alterations in diseases

The elastic fibers present in various connective tissues of the body are responsible for physiologic elasticity of the organs. These fibers consist of 2 distinct components, elastin and the elastic fiber microfibrils. Controlled synthesis and balanced interaction of these 2 components are essential for normal fibrillogenesis. The intracellular biosynthesis of elastin by connective tissue cells, such as smooth muscle cells, involves assembly of the polypeptide chains on the membrane-bound ribosomes, hydroxylation of some prolyl residues to hydroxyproline, and secretion of the polypeptides packaged in Golgi vacuoles. In the extracellular space the elastin molecules assemble into fiber structures which are stabilized by the synthesis of complex covalent cross-links, desmosines. Recently, aberrations in the structure or metabolism of elastin have been detected in a variety of heritable and acquired diseases affecting skin and other connective tissues. These conditions include pseudoxanthoma elasticum, cutis laxa, and elastosis perforans serpiginosa, as well as arteriosclerosis and other degenerative changes of the vascular connective tissues.

[Monophylic vacuolisation of promyelocytes in Menke's-syndrome (trichopoliodystrophy) (author's transl)]

In one case of Menkes' Syndrome (Trichopoliodystrophy), a monophylic vacuolisation of myeloic cells (promyelocytes) of the bone marrow was observed. This finding correlates with an identical observation reported in medical literature, as well as with vacuolisations of metabolic active cells of the brain, musculature and skin observed in patients suffering from this disease. In the present paper, this finding is interpreted as an expression of the underlying disease and of the deficiency of oxidative cell ferment systems, and is discussed as a possible diagnostic and therapeutic criterion.

An autopsy case of Menkes kinky hair disease

An autopsy cases of Menkes kinky hair disease in a 1 year and 8 months old male infant is presented and compared with the morphological findings of the previous literatures. The main pathological changes are atrophy of the whole cerebellar cortex and bilateral temporal lobe, atrophy with demyelination of the white matter, tortuous running of the cerebral arteries, multiple diverticulosis of the urinary bladder and hyaline-like deposition in the gastric submucosa. Microscopically, the peculiar degenerative change of Purkinje cell (somal sprout) is the only characteristic lesion in our case and the others. It is suggested that Menkes kinky hair disease may be a syndrome due to metabolic disturbance appearing not only in ectoderm such as the central nervous system, but also in mesoderm such as connective tissue and bone.

The cellular pathology of Menkes steely hair syndrome

The principal neuropathologic abnormality observed in three autopsy cases of Menkes steely hair syndrome was widespread nerve cell loss and gliosis, especially severe in the cerebral and cerebellar cortex and in the relay nuclei of the thalamus. Granular stellate cells of neocortical layer IV and the granule cells of the cerebellum are cell classes which were particularly severely depopulated. The degree of reduction of myelinated axons is consistent with axonal degeneration secondary to nerve cell loss. There are also prominent abnormalities in the patterns of dendritic arborization of surviving cortical pyramids and cerebellar Purkinje cells as seen in Golgi impregnations. The deviant neuronal forms are probably due, in part, to failure of innervation by afferent fiber systems during the fetal as well as postnatal epochs.

[Macular dystrophy in menkes disease. Histological ocular study (author's transl)]

Pathological ocular study of a boy presenting Menkes disease and died at age 5 months showed rarefaction of outer nuclear layer and degenerative visual cells' outer segments in macular area.

[Menkes' disease (new skin and hair ultrastructural abnormalities) (author's transl)]

The authors report the sixth case of Menkes' kinky hair disease. This boy has been observed for as long as 16 months, and he his still alive at the time of publication. This genetic, X linked disorder of copper metabolism is always fatal in childhood. Diagnosis is evoked when is noted the conjunction of progressive cerebral degeneration, seizures, with pili torti and monilethrix. It can be asserted with the very low copper and cerulo-plasmin blood levels. Recognition of the disease in utero might be possible. New findings in skin' electron microscopy and hair' scanning electron microscopy are reported here. And two RX scanner of the brain have been performed.

Generalized giant axonal neuropathy: a filament-forming disease of neuronal, endothelial, glial, and schwann cells in a patient without kinky hair

The process of Giant Axonal Neuropathy (GAN) is not restricted to the peripheral nerves, but also involves the central nervous system. In a 25 year old man with normal hair, abundant axon swellings and spheroids were observed in the spinal cord, brain system, and cerebral cortex. The findings in the sural nerve have already been published by Boltshauser et al. (1977). Accumulations of filaments in the axons and in the perineural cells were accompanied by Rosenthal fibres. The ultrastructural pattern of GAN differs clearly from that of Neuroaxonal Dystrophies.

[Menke's disease. A case report (author's transl)]

A seven month old male with Menkes' disease ("Kinky hair") is presented. Low ranges of copper and caeruloplasmin were found. The angiogram of all intracranial arteries revealed torturous form. Biopsy of an extracranial artery (branch of the temporal artery) was normal. Authors review previously reported cases and possible causes that can contribute to hypomyelination of central nervous system.

Congenital hypocupraemia syndrome with and without steely hair: report of two Japanese infants

Two Japanese infants with Menke's kinky hair syndrome are reported. The unusual finding in one infant was the absence of the hair abnormality characteristic of this disease; other findings were consistent with the diagnosis. It is suggested that hair abnormality cannot be relied upon for the diagnosis and that the term "kinky hair" is anappropriate. In its place "congenital hypocupraemia" is proposed as the diagnostic term to embrace patients with and without hair abnormality. Serum copper determination is a simple and reliable test in the diagnosis of this syndrome and should be done routinely in all male patients with unexpected deterioration. The angiographic features present in these patients with unexpected deterioration. The angiographic features present in these patients are characteristic but not pathognomonic of the disease. Subdural hygroma, a common finding, is the result of severe brain atrophy and little can be expected by surgical intervention.

Fine structure of the cerebellar cortex in Menkes Kinky-hair disease. X-chromosome-linked copper malabsorption

The cerebellar cortices in two patients with X-chromosome-linked copper malabsorption (Menkes kinky-hair disease) were examined with both the light and electron microscope. Somatic sprouts and grotesque dendritic arborization were among the obvious light microscopical changes. At the fine structural level, the Purkinje cells were characterized by the presence of somatic spines although the surviving granule cells had already descended. Most spines were parts of synaptic complexes, but some were unattached to any presynaptic element. Similar spines were also observed on dendritic trunks. Astrocytic gliosis and nonspecific endothelial cell changes were noted.