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Silva S, Rosas M, Guerra B, Muñoz M, Fujita A, Sakamoto M, Matsumoto N. Adolescent-onset epilepsy and deterioration associated with CAD deficiency: A case report. Brain Dev 2024:S0387-7604(24)00057-3. [PMID: 38641466 DOI: 10.1016/j.braindev.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/15/2024] [Accepted: 04/15/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION CAD (MIM*114010) encodes a large multifunctional protein with the enzymatic activity of the first three enzymes initiating and controlling the de novo pyrimidine biosynthesis pathway. Biallelic pathogenic variants in CAD cause the autosomal recessive developmental and epileptic encephalopathy 50 (MIM #616457) or CAD deficiency presenting with epilepsy, status epilepticus (SE), neurological deterioration and anemia with anisopoikilocytosis. Mortality is around 9% of patients, mainly related to the no use of its specific treatment with uridine. Majority of reported cases have an early onset during infancy, with some few starting later in childhood. CASE REPORT Here we report a deceased female patient with CAD deficiency whose epilepsy started at 14 years. She showed a rapid neurologic deterioration including cognitive decline, electroencephalographic background slowing which later evolved to a fatal refractory SE and supra and infratentorial atrophy on neuroimaging. Anemia developed after SE onset. METHODS AND RESULTS her post-mortem whole exome sequencing identified biallelic missense variants in CAD (NM_004341.5): c.[2944G > A];[5366G > A] p.[(Asp982Asn)];[(Arg1789Gln)]. Our review of twenty-eight reported cases (2015-2023) revealed an epilepsy age onset from neonatal period to 7 years and the SE prevalence of 46 %. DISCUSSION With our case, we highlight the relevance of suspecting this treatable condition in older patients and in SE with no evident etiology.
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Affiliation(s)
- Sebastián Silva
- Child Neurology Service, Hospital de Puerto Montt, Puerto Montt, Chile; Escuela de Medicina, Universidad San Sebastián, Sede Patagonia, Puerto Montt, Chile
| | - Mónica Rosas
- Adult Neurology Service, Hospital de Puerto Montt, Puerto Montt, Chile
| | - Benjamín Guerra
- Escuela de Medicina, Universidad San Sebastián, Sede Patagonia, Puerto Montt, Chile
| | - Marión Muñoz
- Child Neurology Service, Hospital de Puerto Montt, Puerto Montt, Chile
| | - Atsushi Fujita
- Department of Human Genetics, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Masamune Sakamoto
- Department of Human Genetics, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Naomichi Matsumoto
- Department of Human Genetics, Graduate School of Medicine, Yokohama City University, Yokohama, Japan.
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Duan L, Ye L, Yin R, Sun Y, Yu W, Zhang Y, Zhong H, Bao X, Tian X. Novel CAD gene mutations in a boy with developmental and epileptic encephalopathy 50 with dramatic response to uridine therapy: a case report and a review of the literature. BMC Pediatr 2024; 24:160. [PMID: 38454370 PMCID: PMC10921618 DOI: 10.1186/s12887-024-04593-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 01/25/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Developmental and epileptic encephalopathy-50 (DEE-50) is a rare clinical condition believed to be caused by a mutation in the CAD gene and is associated with a bleak prognosis. CAD-related diseases have a wide range of clinical manifestations and other symptoms that may be easily overlooked. Like other rare diseases, the clinical manifestations and the treatment of DEE-50 necessitate further investigation. CASE PRESENTATION A 1-year-old male patient presented with developmental delay, seizures, and anaemia at 3 months of age. He further developed refractory status epilepticus (SE), rapid deterioration of cognitive and motor function, and even became comatose at 5 months of age. Whole-exome sequencing of trios (WES-trios) revealed a compound heterozygous variant in the CAD gene, with one locus inherited from his father (c.1252C>T: p.Q418* nonsense mutation) and one from his mother (c.6628G>A: p.G2210S, missense mutation). This compound heterozygous CAD variant was unreported in the Human Gene Mutation Database. After uridine treatment, his cognitive faculties dramatically improved and he remained seizure-free. Forty two cases with CAD gene mutation reported in the literatures were reviewed. Among them, 90% had onset before 3 years of age, with average of 1.6±1.8 years old. The average age of diagnosis was 7.7 ± 10 years. The mortality rate was approximately 9.5%, with all reported deaths occurring in patients without uridine treatment. The clinical entity could be improved dramatically when the patient treated with uridine. CONCLUSIONS We present a boy with DEE 50 caused by novel CAD gene mutations and reviewed the clinical features of 42 patients reported previously. DEE 50 has early onset, refractory seizures, even status epilepticus leading to death, with favorable response to treatment with oral uridine. Early uridine treatment is recommended if CAD defect is suspected or genetically diagnosed. This study enhances the knowledge of DEE 50 and expands the spectrum of CAD gene mutations.
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Affiliation(s)
- Lifen Duan
- Epilepsy Center, Kunming Children's Hospital (Children's Hospital affiliated of Kunming Medical University), Kunming, 650031, China
| | - Lei Ye
- Epilepsy Center, Kunming Children's Hospital (Children's Hospital affiliated of Kunming Medical University), Kunming, 650031, China
| | - Runxiu Yin
- Epilepsy Center, Kunming Children's Hospital (Children's Hospital affiliated of Kunming Medical University), Kunming, 650031, China
| | - Ying Sun
- Epilepsy Center, Kunming Children's Hospital (Children's Hospital affiliated of Kunming Medical University), Kunming, 650031, China
| | - Wei Yu
- Epilepsy Center, Kunming Children's Hospital (Children's Hospital affiliated of Kunming Medical University), Kunming, 650031, China
| | - Yi Zhang
- Epilepsy Center, Kunming Children's Hospital (Children's Hospital affiliated of Kunming Medical University), Kunming, 650031, China
| | - Haiyan Zhong
- Epilepsy Center, Kunming Children's Hospital (Children's Hospital affiliated of Kunming Medical University), Kunming, 650031, China
| | - Xinhua Bao
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, China.
| | - Xin Tian
- Department of Hematology, Kunming Children's Hospital (Children's Hospital affiliated of Kunming Medical University), Kunming, 650031, China.
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Steinberg-Shemer O, Yacobovich J, Noy-Lotan S, Dgany O, Krasnov T, Barg A, Landau YE, Kneller K, Somech R, Gilad O, Brik Simon D, Orenstein N, Izraeli S, Del Caño-Ochoa F, Tamary H, Ramón-Maiques S. Biallelic hypomorphic variants in CAD cause uridine-responsive macrocytic anaemia with elevated haemoglobin-A2. Br J Haematol 2024; 204:1067-1071. [PMID: 37984840 DOI: 10.1111/bjh.19215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/14/2023] [Accepted: 11/08/2023] [Indexed: 11/22/2023]
Abstract
Biallelic pathogenic variants in CAD, that encode the multienzymatic protein required for de-novo pyrimidine biosynthesis, cause early infantile epileptic encephalopathy-50. This rare disease, characterized by developmental delay, intractable seizures and anaemia, is amenable to treatment with uridine. We present a patient with macrocytic anaemia, elevated haemoglobin-A2 levels, anisocytosis, poikilocytosis and target cells in the blood smear, and mild developmental delay. A next-generation sequencing panel revealed biallelic variants in CAD. Functional studies did not support complete abrogation of protein function; however, the patient responded to uridine supplement. We conclude that biallelic hypomorphic CAD variants may cause a primarily haematological phenotype.
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Affiliation(s)
- Orna Steinberg-Shemer
- Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Pediatric Hematology Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joanne Yacobovich
- Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Pediatric Hematology Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Noy-Lotan
- Pediatric Hematology Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel
| | - Orly Dgany
- Pediatric Hematology Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel
| | - Tanya Krasnov
- Pediatric Hematology Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel
| | - Assaf Barg
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
| | - Yuval E Landau
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Metabolic Disease Service, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Katya Kneller
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
| | - Raz Somech
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
| | - Oded Gilad
- Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dafna Brik Simon
- Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Naama Orenstein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Genetics Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Shai Izraeli
- Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Francisco Del Caño-Ochoa
- Structure of Macromolecular Targets Unit, Instituto de Biomedicina de Valencia (IBV), CSIC, Valencia, Spain
| | - Hannah Tamary
- Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Pediatric Hematology Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Santiago Ramón-Maiques
- Structure of Macromolecular Targets Unit, Instituto de Biomedicina de Valencia (IBV), CSIC, Valencia, Spain
- Group 739, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER)-Instituto de Salud Carlos III, Valencia, Spain
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Graifman JL, Lippa NC, Mulhern MS, Bergner AL, Sands TT. Clinical utility of exome sequencing in a pediatric epilepsy cohort. Epilepsia 2023; 64:986-997. [PMID: 36740579 DOI: 10.1111/epi.17534] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 02/02/2023] [Accepted: 02/02/2023] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Exome sequencing (ES) has played an important role in the identification of causative variants for individuals with epilepsy and has proven to be a valuable diagnostic tool. Less is known about its clinical utility once a diagnosis is received. This study systematically reviewed the impact of ES results on clinical decision-making and patient care in a pediatric epilepsy cohort at a tertiary care medical center. METHODS Pediatric patients with unexplained epilepsy were referred by their neurologist, and informed consent was obtained through an institutional review board-approved research ES protocol. For patients who received a genetic diagnosis, a retrospective chart review was completed of the probands and their relatives' medical records prior to and after genetic diagnosis. The following outcomes were explored: provider management recommendations, changes in care actually implemented, and anticipatory guidance provided regarding the proband's condition. RESULTS Fifty-three probands met the inclusion criteria. Genetic diagnosis led to at least one provider recommendation in 41.5% families (22/53). Recommendations were observed in the following categories: medication, screening for non-neurological comorbidities/referrals to specialists, referrals to clinical research/trials, and cascade testing. Anticipatory guidance including information about molecular diagnosis, prognosis, and relevant foundations/advocacy groups was also observed. SIGNIFICANCE Results demonstrate the clinical utility of ES for individuals with epilepsy across multiple aspects of patient care, including anti-seizure medication (ASM) selection; screening for non-neurological comorbidities and referrals to appropriate medical specialists; referral to reproductive genetic counseling; and access to research, information, and support resources. To our knowledge, this is the first study to evaluate the clinical utility of ES for a pediatric epilepsy cohort with broad epilepsy phenotypes. This work supports the implementation of ES as part of clinical care in this population.
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Affiliation(s)
- Jordana L Graifman
- Genetic Counseling Graduate Program, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Natalie C Lippa
- Genetic Counseling Graduate Program, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.,Institute for Genomic Medicine, Columbia University Irving Medical Center, New York, New York, USA.,Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Maureen S Mulhern
- Genetic Counseling Graduate Program, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.,Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.,Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Amanda L Bergner
- Genetic Counseling Graduate Program, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA.,Department of Genetics and Development, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Tristan T Sands
- Institute for Genomic Medicine, Columbia University Irving Medical Center, New York, New York, USA.,Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
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Smith L, Malinowski J, Ceulemans S, Peck K, Walton N, Sheidley BR, Lippa N. Genetic testing and counseling for the unexplained epilepsies: An evidence‐based practice guideline of the National Society of Genetic Counselors. J Genet Couns 2022; 32:266-280. [PMID: 36281494 DOI: 10.1002/jgc4.1646] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/27/2022] [Accepted: 10/01/2022] [Indexed: 11/10/2022]
Abstract
Epilepsy, defined by the occurrence of two or more unprovoked seizures or one unprovoked seizure with a propensity for others, affects 0.64% of the population and can lead to significant morbidity and mortality. A majority of unexplained epilepsy (seizures not attributed to an acquired etiology, such as trauma or infection) is estimated to have an underlying genetic etiology. Despite rapid progress in understanding of the genetic underpinnings of the epilepsies, there are no recent evidence-based guidelines for genetic testing and counseling for this population. This practice guideline provides evidence-based recommendations for approaching genetic testing in the epilepsies using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision framework. We used evidence from a recent systematic evidence review and meta-analysis of diagnostic yield of genetic tests in patients with epilepsy. We also compiled data from other sources, including recently submitted conference abstracts and peer-reviewed journal articles. We identified and prioritized outcomes of genetic testing as critical, important or not important and based our recommendations on outcomes deemed critical and important. We considered the desirable and undesirable effects, value and acceptability to relevant stakeholders, impact on health equity, cost-effectiveness, certainty of evidence, and feasibility of the interventions in individuals with epilepsy. Taken together, we generated two clinical recommendations: (1) Genetic testing is strongly recommended for all individuals with unexplained epilepsy, without limitation of age, with exome/genome sequencing and/or a multi-gene panel (>25 genes) as first-tier testing followed by chromosomal microarray, with exome/genome sequencing conditionally recommended over multi-gene panel. (2) It is strongly recommended that genetic tests be selected, ordered, and interpreted by a qualified healthcare provider in the setting of appropriate pre-test and post-test genetic counseling. Incorporation of genetic counselors into neurology practices and/or referral to genetics specialists are both useful models for supporting providers without genetics expertise to implement these recommendations.
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Affiliation(s)
- Lacey Smith
- Epilepsy Genetics Program, Department of Neurology Boston Children's Hospital Boston Massachusetts USA
| | | | - Sophia Ceulemans
- Department of Genetics, Department of Neurology Rady Children's Hospital San Diego California USA
| | - Katlin Peck
- Department of Laboratory Management eviCore Healthcare Bluffton South Carolina USA
| | - Nephi Walton
- Intermountain Precision Genomics Intermountain Healthcare St. George Utah USA
| | - Beth Rosen Sheidley
- Epilepsy Genetics Program, Department of Neurology Boston Children's Hospital Boston Massachusetts USA
| | - Natalie Lippa
- Instititute for Genomic Medicine Columbia University Irving Medical Center New York New York USA
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Al-Otaibi A, AlAyed A, Al Madhi A, Saeed L, Ng BG, Freeze HH, Almannai M. Uridine monophosphate (UMP)-responsive developmental and epileptic encephalopathy: A case report of two siblings and a review of literature. Mol Genet Metab Rep 2022; 30:100835. [PMID: 35242569 PMCID: PMC8856910 DOI: 10.1016/j.ymgmr.2021.100835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/11/2021] [Accepted: 12/11/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Ali Al-Otaibi
- Department of Pediatric Neurology, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Alaa AlAyed
- Section of Medical Genetics, Children's Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Asma Al Madhi
- Department of Pediatric Neurology, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Leena Saeed
- Section of Clinical Pharmacy, Neurology Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Bobby G. Ng
- Human Genetics Program, Sanford Burnham Prebys, La Jolla, CA 92037, USA
| | - Hudson H. Freeze
- Human Genetics Program, Sanford Burnham Prebys, La Jolla, CA 92037, USA
| | - Mohammed Almannai
- Section of Medical Genetics, Children's Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
- Corresponding author.
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Peng X, Xia LP, Zhang HJ, Zhang J, Yu SQ, Wang S, Xu YM, Yao B, Ye J. A Treatable Genetic Disease Caused by CAD Mutation. Front Pediatr 2022; 10:771374. [PMID: 35356445 PMCID: PMC8959624 DOI: 10.3389/fped.2022.771374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 01/17/2022] [Indexed: 11/13/2022] Open
Abstract
Type 50 early infantile epileptic encephalopathy, or EIEE-50 for short, is an autosomal recessive genetic disorder resulting from CAD mutations. So far, little has been reported on the disease. In this article, we will discuss the case of a male infant who is 8 years and 5 months old. A whole-exome sequencing of the boy revealed CAD compound heterozygous mutations. He suffered from global developmental delay and regression, refractory epilepsy, and anemia. After his diagnosis, we used uridine treatment and gained encouraging results. In this article, we will analyze our case studies in the context of the literature, so as to improve pediatricians' understanding of the disease.
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Affiliation(s)
- Xia Peng
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, China
| | - Li-Ping Xia
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hai-Ju Zhang
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jing Zhang
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shi-Qian Yu
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shun Wang
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yu-Ming Xu
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, China
| | - Baozhen Yao
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jingping Ye
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, China
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