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Hanson J, Bonnen PE. Cerebrotendinous Xanthomatosis occurs at high frequency in Ashkenazi Jews. Mol Genet Metab 2025; 144:109041. [PMID: 39874852 DOI: 10.1016/j.ymgme.2025.109041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2024] [Revised: 01/14/2025] [Accepted: 01/14/2025] [Indexed: 01/30/2025]
Abstract
Cerebrotendinous Xanthomatosis (CTX) is a treatable, inborn error of bile acids metabolism caused by pathogenic variants in CYP27A1. CTX is a multi-organ system disorder that progresses over decades. Clinical features include cerebellar dysfunction, pyramidal tract dysfunction, cognitive deficits and decline, peripheral neuropathy, chronic diarrhea, bilateral cataracts, and tendon xanthomas. Treatment is effective when started early, but diagnostic delays often result in individuals not being diagnosed until after the window of highest treatment efficacy. CTX is documented to occur in most global populations, however, no CTX-causing genetic variants have been reported in Ashkenazi Jews. We conducted a systematic review of every case of CTX reported in a person identified as Jewish and the specific CYP27A1 variants present. We also leveraged the Israeli Medical Genetics Database and the population genetics data resource gnomAD to identify CTX-causing alleles in Ashkenazi Jews. We found that there are three pathogenic CYP27A1 variants in the Ashkenazi Jewish population segregating at an appreciable frequency, with a gene carrier rate of 0.002 based on the gnomAD Ashkenazi Jewish data. One pathogenic variant appears only in the Ashkenazi Jewish group in gnomAD, which contains genetic data from across the globe. We compared the carrier frequency for CTX to the carrier frequencies for diseases that are commonly included in carrier screening for Ashkenazi Jews. These results show that CTX occurs in Ashkenazi Jews, and that both Sephardi and Ashkenazi Jews may benefit from newborn and carrier screening for CTX.
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Affiliation(s)
- Jennifer Hanson
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Penelope E Bonnen
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA.
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Camelo-Filho AE, Lima PLGSB, Cavalcante FLHB, Miyajima OR, Santos CF, da Rosa RF, Pessoa ALS, Braga-Neto P, Nóbrega PR. Polyneuropathy in Cerebrotendinous Xanthomatosis: Diagnostic Challenges and Potential for Therapeutic Intervention. Brain Sci 2024; 14:1159. [PMID: 39595922 PMCID: PMC11591590 DOI: 10.3390/brainsci14111159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2024] [Revised: 11/15/2024] [Accepted: 11/18/2024] [Indexed: 11/28/2024] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is a rare metabolic disorder caused by mutations in the CYP27A1 gene, leading to cholestanol accumulation in various tissues, including peripheral nerves. Polyneuropathy is an underrecognized feature with considerable variability in clinical presentation and neurophysiological findings in CTX. This review assesses the prevalence, clinical manifestations, and diagnostic methodologies of polyneuropathy in CTX, exploring its underlying mechanisms and potential treatment outcomes. A literature review was conducted using PubMed, Embase, and the Virtual Health Library databases with search terms related to CTX and polyneuropathy. A total of 892 articles were initially identified, with 59 selected for in-depth analysis. The review focused on studies examining peripheral nerve involvement in CTX, including nerve conduction studies, electromyography, and nerve ultrasound. Polyneuropathy in CTX was observed in 50% to 77.7% of patients across multiple case series. Neurophysiological findings varied, with reports of axonal, demyelinating, and mixed polyneuropathies. Clinical presentation included lower limb atrophy, pes cavus, and distal weakness, with sensory symptoms less frequently reported. Treatment with chenodeoxycholic acid (CDCA) showed potential in improving nerve conduction parameters, although the response was variable and dependent on the timing of intervention. Polyneuropathy in CTX presents significant diagnostic challenges due to its heterogeneous presentation and varying neurophysiological findings. Early recognition and intervention are crucial for improving patient outcomes. Peripheral nerve ultrasound is a promising diagnostic tool, complementing traditional neurophysiological assessments. Further research is needed to standardize protocols and explore the full therapeutic potential of CDCA in managing CTX-related polyneuropathy.
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Affiliation(s)
- Antonio Edvan Camelo-Filho
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza 60430-372, Ceara, Brazil; (A.E.C.-F.); (P.L.G.S.B.L.); (F.L.H.B.C.); (R.F.d.R.); (A.L.S.P.); (P.R.N.)
| | - Pedro Lucas Grangeiro Sá Barreto Lima
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza 60430-372, Ceara, Brazil; (A.E.C.-F.); (P.L.G.S.B.L.); (F.L.H.B.C.); (R.F.d.R.); (A.L.S.P.); (P.R.N.)
| | - Francisco Luciano Honório Barreto Cavalcante
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza 60430-372, Ceara, Brazil; (A.E.C.-F.); (P.L.G.S.B.L.); (F.L.H.B.C.); (R.F.d.R.); (A.L.S.P.); (P.R.N.)
| | - Oliver Reiks Miyajima
- Center of Health Sciences, State University of Ceara, Fortaleza 60714-903, Ceara, Brazil;
| | - Carolina Figueiredo Santos
- Curso de Medicina, Universidade de Fortaleza, Fortaleza 60150-160, Ceara, Brazil;
- Division of Neuropediatrics, Hospital Infantil Albert Sabin, Fortaleza 60410-794, Ceara, Brazil
| | - Rodrigo Fagundes da Rosa
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza 60430-372, Ceara, Brazil; (A.E.C.-F.); (P.L.G.S.B.L.); (F.L.H.B.C.); (R.F.d.R.); (A.L.S.P.); (P.R.N.)
| | - André Luiz Santos Pessoa
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza 60430-372, Ceara, Brazil; (A.E.C.-F.); (P.L.G.S.B.L.); (F.L.H.B.C.); (R.F.d.R.); (A.L.S.P.); (P.R.N.)
- Division of Neuropediatrics, Hospital Infantil Albert Sabin, Fortaleza 60410-794, Ceara, Brazil
| | - Pedro Braga-Neto
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza 60430-372, Ceara, Brazil; (A.E.C.-F.); (P.L.G.S.B.L.); (F.L.H.B.C.); (R.F.d.R.); (A.L.S.P.); (P.R.N.)
- Center of Health Sciences, State University of Ceara, Fortaleza 60714-903, Ceara, Brazil;
| | - Paulo Ribeiro Nóbrega
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza 60430-372, Ceara, Brazil; (A.E.C.-F.); (P.L.G.S.B.L.); (F.L.H.B.C.); (R.F.d.R.); (A.L.S.P.); (P.R.N.)
- Campus Parque Ecológico, Centro Universitário Christus, Fortaleza 60160-230, Ceara, Brazil
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DeBarber AE, Schaefer EJ, Do J, Ray JW, Larson A, Redder S, Fowler M, Duell PB. Genetically and clinically confirmed atypical cerebrotendinous xanthomatosis with normal cholestanol and marked elevations of bile acid precursors and bile alcohols. J Clin Lipidol 2024; 18:e465-e476. [PMID: 38637260 DOI: 10.1016/j.jacl.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 02/07/2024] [Accepted: 03/13/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive lipid disorder. Affected patients often remain undiagnosed until the age of 20-30 years, when they have already developed significant neurologic disease that may not be reversible. An elevated plasma cholestanol concentration has been accepted as a diagnostic criterion for CTX for decades. OBJECTIVE Full biochemical characterization was performed for three genetically and clinically confirmed atypical CTX cases with normal plasma cholestanol levels. METHODS Clinical assessment and genetic/biochemical testing for patients with CTX was performed by their physician providing routine standard of care. RESULTS We report three new atypical CTX cases with large extensor tendon xanthomas but normal plasma cholestanol levels. All three cases had marked elevations of bile acid precursors and bile alcohols in plasma and urine that decreased on treatment with chenodeoxycholic acid. We also review eight published cases of atypical CTX with normal/near normal circulating cholestanol levels. CONCLUSION The atypical biochemical presentation of these cases provides a diagnostic challenge for CTX, a disorder for which cholestanol has been believed to be a sensitive biomarker. These cases demonstrate measurements of plasma cholestanol alone are insufficient to exclude a diagnosis of CTX. The data presented is consistent with the concept that bile acid precursors and bile alcohols are sensitive biomarkers for atypical CTX with normal cholestanol, and that such testing is indicated, along with CYP27A1 gene analyses, in patients presenting with significant tendon and/or tuberous xanthomas and/or neurologic disease in early adulthood despite normal or near normal cholesterol and cholestanol levels.
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Affiliation(s)
- Andrea E DeBarber
- University Shared Resources, Oregon Health & Science University (OHSU), Portland, OR, United States of America (Dr DeBarber, Ms Redder and Ms Fowler).
| | - Ernst J Schaefer
- Boston Heart Diagnostics/Eurofins Scientific Network, Framingham, MA, United States of America and Department of Medicine, Tufts University School of Medicine, Boston, MA, United States of America (Dr Schaefer)
| | - Jenny Do
- Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, United States of America (Ms Do and Dr Ray)
| | - Joseph W Ray
- Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, United States of America (Ms Do and Dr Ray)
| | - Austin Larson
- University of Colorado School of Medicine, Aurora, CO, United States of America (Dr Larson)
| | - Samantha Redder
- University Shared Resources, Oregon Health & Science University (OHSU), Portland, OR, United States of America (Dr DeBarber, Ms Redder and Ms Fowler)
| | - Maya Fowler
- University Shared Resources, Oregon Health & Science University (OHSU), Portland, OR, United States of America (Dr DeBarber, Ms Redder and Ms Fowler)
| | - P Barton Duell
- Center for Preventive Cardiology, Knight Cardiovascular Institute & Division of Endocrinology, Diabetes & Clinical Nutrition, OHSU, Portland, OR, United States of America (Dr Duell)
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Nóbrega PR, Bernardes AM, Ribeiro RM, Vasconcelos SC, Araújo DABS, Gama VCDV, Fussiger H, Santos CDF, Dias DA, Pessoa ALS, Pinto WBVDR, Saute JAM, de Souza PVS, Braga-Neto P. Cerebrotendinous Xanthomatosis: A practice review of pathophysiology, diagnosis, and treatment. Front Neurol 2022; 13:1049850. [PMID: 36619921 PMCID: PMC9816572 DOI: 10.3389/fneur.2022.1049850] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
Cerebrotendinous Xanthomatosis represents a rare and underdiagnosed inherited neurometabolic disorder due to homozygous or compound heterozygous variants involving the CYP27A1 gene. This bile acid metabolism disorder represents a key potentially treatable neurogenetic condition due to the wide spectrum of neurological presentations in which it most commonly occurs. Cerebellar ataxia, peripheral neuropathy, spastic paraparesis, epilepsy, parkinsonism, cognitive decline, intellectual disability, and neuropsychiatric disturbances represent some of the most common neurological signs observed in this condition. Despite representing key features to increase diagnostic index suspicion, multisystemic involvement does not represent an obligatory feature and can also be under evaluated during diagnostic work-up. Chenodeoxycholic acid represents a well-known successful therapy for this inherited metabolic disease, however its unavailability in several contexts, high costs and common use in patients at late stages of disease course limit more favorable neurological outcomes for most individuals. This review article aims to discuss and highlight the most recent and updated knowledge regarding clinical, pathophysiological, neuroimaging, genetic and therapeutic aspects related to Cerebrotendinous Xanthomatosis.
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Affiliation(s)
- Paulo Ribeiro Nóbrega
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Brazil,Neurogenetics Unit, Department of Neurology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Anderson Moura Bernardes
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Rodrigo Mariano Ribeiro
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Sophia Costa Vasconcelos
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Brazil
| | | | | | - Helena Fussiger
- School of Medicine, Universidade Federação de Estabelecimentos de Ensino Superior em Novo Hamburgo, Novo Hamburgo, Brazil,Graduate Program in Medicine: Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | - André Luíz Santos Pessoa
- Hospital Infantil Albert Sabin, Fortaleza, Brazil,Center of Health Science, Universidade Estadual do Ceará, Fortaleza, Brazil
| | | | - Jonas Alex Morales Saute
- Graduate Program in Medicine: Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil,Medical Genetics Service and Neurology Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil,Department of Internal Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Paulo Victor Sgobbi de Souza
- Neurometabolic Unit, Division of Neuromuscular Diseases, Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, Brazil,*Correspondence: Paulo Victor Sgobbi de Souza ✉
| | - Pedro Braga-Neto
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Brazil,Center of Health Science, Universidade Estadual do Ceará, Fortaleza, Brazil
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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: 7] [Impact Index Per Article: 1.8] [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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Guenzel AJ, DeBarber A, Raymond K, Dhamija R. Familial variability of cerebrotendinous xanthomatosis lacking typical biochemical findings. JIMD Rep 2021; 59:3-9. [PMID: 33977023 PMCID: PMC8100391 DOI: 10.1002/jmd2.12197] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 12/11/2022] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive disorder of bile acid synthesis caused by pathogenic variants in the CYP27A1 gene encoding the mitochondrial enzyme sterol 27-hydroxylase. Patients with CTX can present with a wide range of symptoms, but most often have evidence of tendon xanthomas along with possible cataracts, atherosclerosis, or neurological dysfunction. Regardless of clinical phenotype, CTX patients typically exhibit levels of cholestanol and bile acid precursors in the circulation that are many fold increased over normal control concentrations. Here we report two siblings, one with the rare spinal xanthomatosis phenotype and the other with a very mild form of CTX manifesting as minor tendon xanthomatosis and gastrointestinal complaints who both carry compound heterozygous variants in CYP27A1: NM_000784.3: c.410G > A (p.Arg137Gln) and c.1183C > T (p.Arg395Cys). However, biochemical analysis of these patients revealed normal levels of serum cholestanol and relatively mild elevations of the bile acid precursors 7α-hydroxy-4-cholesten-3-one and 7α,12α-dihydroxy-4-cholesten-3-one. The atypical biochemical presentation of these cases represents a diagnostic challenge for a disorder once thought to have a sensitive biomarker in cholestanol and highlight the need for thorough investigation of patients with symptomatology consistent with CTX that includes bile acid precursor biochemical testing and molecular analysis.
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Affiliation(s)
- Adam J. Guenzel
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | - Andrea DeBarber
- Department of Chemical Physiology and BiochemistryOregon Health and Science UniversityPortlandOregonUSA
| | - Kimiyo Raymond
- Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | - Radhika Dhamija
- Department of Clinical Genomics and NeurologyMayo ClinicScottsdaleArizonaUSA
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Wong JC, Walsh K, Hayden D, Eichler FS. Natural history of neurological abnormalities in cerebrotendinous xanthomatosis. J Inherit Metab Dis 2018; 41:647-656. [PMID: 29484516 DOI: 10.1007/s10545-018-0152-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 01/25/2018] [Accepted: 01/31/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Cerebrotendinous xanthomatosis (CTX) is a rare inherited neurodegenerative disorder in bile acid synthesis. The natural history of neurological abnormalities in CTX is not well understood. The object of this study was to determine neurological progression in CTX. METHODS A literature search on PubMed for "cerebrotendinous xanthomatosis" yielded 91 publications that reported cases of CTX patients. Two independent reviewers abstracted information about the presence and age of onset of neurological abnormalities in published CTX cases. For each neurological abnormality, we estimated the probability of its onset at any given age using cumulative incidence function analysis. We also present our own case series, in which five CTX patients were evaluated. RESULTS The literature search yielded 194 CTX cases (ages ranging from newborn to 67 years old). The most common neurological abnormalities were corticospinal tract abnormalities including weakness, hyperreflexia, spasticity, Babinski sign (59.8%), ataxia (58.8%), cognitive decline (46.4%), and gait difficulty (38.1%); 68 (35.0%) had baseline cognitive problems. Cumulative incidence function analysis revealed that ataxia, gait difficulties, and corticospinal tract abnormalities developed throughout life, while cognitive decline tended to develop later in life. Of the less common neurological abnormalities, seizures, psychiatric changes and speech changes developed throughout life, while parkinsonism and sensory changes tended to develop later in life. Our case series corroborated this temporal pattern of neurological abnormalities. CONCLUSION We provide estimates for the neurological progression of CTX, categorizing neurological abnormalities according to time and probability of development. Our approach may be applicable to other rare disorders.
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Affiliation(s)
- Janice C Wong
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Kailey Walsh
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, ACC 708, Boston, MA, 02114, USA
| | - Douglas Hayden
- Harvard Medical School, Boston, MA, USA
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Florian S Eichler
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, ACC 708, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, USA.
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Mignarri A, Gallus GN, Dotti MT, Federico A. A suspicion index for early diagnosis and treatment of cerebrotendinous xanthomatosis. J Inherit Metab Dis 2014; 37:421-9. [PMID: 24442603 DOI: 10.1007/s10545-013-9674-3] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 12/05/2013] [Accepted: 12/18/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cerebrotendinous xanthomatosis (CTX) is an autosomal recessive lipid storage disorder characterized by a heterogeneous presentation and a broad spectrum of clinical manifestations. Since early diagnosis and replacement therapy with chenodeoxycholic acid can prevent clinical deterioration, our aim was to develop a diagnostic tool to identify and treat CTX patients at an initial stage of the disease. METHODS We devised a suspicion index, composed of weighted scores assigned to indicators such as family history characteristics and common systemic and neurological features, on the basis of a pooled analysis of selected international CTX series. The indicators were classified as very strong (score 100), strong (50) or moderate (25). The suspicion index was then applied retrospectively to our CTX population. RESULTS Early systemic signs such as cataract, diarrhea and neonatal cholestatic jaundice were considered strong indicators, together with neurological features such as intellectual impairment, psychiatric disturbances, ataxia, spastic paraparesis and dentate nuclei abnormalities at MRI. Tendon xanthomas were regarded as very strong indicators, as was an affected sibling. A total score ≥ 100 warranted serum cholestanol assessment. Elevated cholestanol or a total score ≥ 200, with one very strong or four strong indicators, warranted CYP27A1 gene analysis. In our patients, age at diagnosis was 35.5 ± 11.8 years (mean ± standard deviation), whereas with the diagnostic tool it became 10.6 ± 9.8 years (p < 0.01). CONCLUSIONS Our suspicion index provides a simple and inexpensive diagnostic tool allowing diagnosis and treatment of CTX before neurological disability occurs.
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Affiliation(s)
- Andrea Mignarri
- Unit of Neurology and Neurometabolic Disorders, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100, Siena, Italy
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9
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Fraidakis MJ. Psychiatric manifestations in cerebrotendinous xanthomatosis. Transl Psychiatry 2013; 3:e302. [PMID: 24002088 PMCID: PMC3784765 DOI: 10.1038/tp.2013.76] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 07/19/2013] [Indexed: 12/26/2022] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is a rare and severe, but treatable, inborn disorder of bile acid biosynthesis and sterol storage with autosomal recessive inheritance and variable clinical presentation. CTX treatment consists of chenodeoxycholic acid and must be started as early as possible to prevent permanent disability. Psychiatric manifestations are rare and non-specific, and often lead to significant diagnostic and treatment delay. Therefore, better recognition of the gamut of psychiatric manifestations in CTX can diminish the risk of misdiagnosis and irreversible neurological deterioration. We hereby describe the psychiatric features in CTX. A complete review of all published cases of CTX in the medical literature was undertaken and the case reports with psychiatric presentation were collected and analyzed. We also describe the psychiatric features in relation to the neurological semeiology in six patients with CTX diagnosed at the La Salpêtrière Hospital. We conclude that psychiatric manifestations in CTX follow a bimodal/bitemporal pattern, appearing early in the disease course in the form of a behavioral/personality disorder associated with learning difficulties or mental retardation, or manifesting in advanced disease in the setting of dementia as rich neuropsychiatric syndromes, such as frontal, orbitofrontal or frontotemporal syndromes of cortico-subcortical dementia encompassing behavioral/personality disturbance, affective/mood disorders or psychotic disorders. Behavioral/personality disturbance in childhood or adolescence, especially when accompanied by learning difficulties, should therefore lead to further investigation to exclude CTX, as early diagnosis and treatment is critical for prognosis.
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Affiliation(s)
- M J Fraidakis
- Federation of Neurology, La Salpêtrière Hospital, Groupe Hopsitalier Pitié-Salpêtrière (GHPS), Paris, France,Department of Neurogenetics, La Salpêtrière Hospital, Groupe Hopsitalier Pitié-Salpêtrière (GHPS), Paris, France,Fédération de Neurologie, Hôpital de la Salpêtrière, Groupement Hospitalier Universitaire Est Pitié-Salpêtrière (GHPS), Boulevard de l'Hôpital 47–83, 75651 Paris, France. E-mail:
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Gonzalez-Cuyar LF, Hunter B, Harris PLR, Perry G, Smith MA, Castellani RJ. Cerebrotendinous xanthomatosis: case report with evidence of oxidative stress. Redox Rep 2007; 12:119-24. [PMID: 17623518 DOI: 10.1179/135100007x200173] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Cerebrotendinous xanthomatosis is an autosomal recessive disorder of bile acid synthesis, characterized by mutation in the mitochondrial enzyme 27-hydroxylase that leads to an accumulation of cholestanol and cholesterol. Characterized clinically by premature bilateral cataracts, slowly progressive neurological deterioration with dementia, cerebellar and brainstem signs, peripheral neuropathy, and seizures, the disease presents pathologically with lipid granulomata with foamy histiocytes and cholesterol clefts. Replacement therapy with chenodeoxycholic acid slows progression of the disease but does not reverse neurological deficits. Here, we present the case of a 49-year-old woman diagnosed at autopsy with cerebrotendinous xanthomatosis, on the basis of bilateral Achilles tendon granulomas, and typical foamy histiocytic infiltration of the brain, most severe in the dentate nucleus, and a typical clinical presentation. To investigate the pathological manifestations of this disease further, we performed immunohistochemistry for N(epsilon)-(carboxymethyl)-lysine, an indicator of oxidative damage, and found strong labeling of cytoplasmic material within histiocytes. In summary, this case of undiagnosed cerebrotendinous xanthomatosis during life emphasizes the need for a greater awareness of the disease, and early diagnosis and treatment. Further, the involvement of oxidative stress in cerebrotendinous xanthomatosis indicates that combined therapy with chenodeoxycholic acid and antioxidants may improve clinical outcome.
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