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Jonckheere AI, Kingma SDK, Eyskens F, Bordon V, Jansen AC. Metachromatic leukodystrophy: To screen or not to screen? Eur J Paediatr Neurol 2023; 46:1-7. [PMID: 37354699 DOI: 10.1016/j.ejpn.2023.06.005] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/11/2023] [Accepted: 06/17/2023] [Indexed: 06/26/2023]
Abstract
Metachromatic leukodystrophy (MLD) is a neurodegenerative lysosomal storage disorder caused by biallelic pathogenic variants in the gene encoding arylsulfatase A. Disease onset is variable (with late infantile, early and late juvenile, and adult forms) and treatment options depend on age and disease symptoms at onset. In the past, allo-hematopoietic stem cell transplantation (allo-HSCT) has been the best treatment option, following strict selection criteria. The outcome however is variable and morbidity remains high. This paved the way to the development of new treatment options, some of them aiming to be curative. In the light of this changing therapeutic field, newborn screening is becoming a valuable option. This narrative review aims to describe the outcome of allo-HSCT in the different MLD disease forms, and, in addition, reviews new treatment options. Finally, the shift of the field towards newborn screening for MLD is discussed.
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Affiliation(s)
- An I Jonckheere
- Department of Child Neurology, Antwerp University Hospital, University of Antwerp, Edegem, Belgium; Centre for Metabolic Diseases, University Hospital Antwerp, University of Antwerp, Edegem, Belgium.
| | - Sandra D K Kingma
- Centre for Metabolic Diseases, University Hospital Antwerp, University of Antwerp, Edegem, Belgium
| | - François Eyskens
- Centre for Metabolic Diseases, University Hospital Antwerp, University of Antwerp, Edegem, Belgium
| | - Victoria Bordon
- Department of Child Oncology, Ghent University Hospital, Ghent, Belgium
| | - Anna C Jansen
- Department of Child Neurology, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
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Martin S, Harris N, Romanus D. Evaluating meaningful changes in physical functioning and cognitive declines in metachromatic leukodystrophy: a caregiver interview study. J Patient Rep Outcomes 2023; 7:70. [PMID: 37458805 DOI: 10.1186/s41687-023-00595-7] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 05/23/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Metachromatic leukodystrophy (MLD) is a rare lysosomal storage disease caused by deficient activity of arylsulfatase A (ASA). Treatment options for patients are limited; gene therapy based on haematopoietic stem cell transplantation is the only approved treatment for some subtypes of MLD. Any therapeutic benefit of treatments must be meaningful for patients and their families. We evaluated the clinical meaningfulness of slowing the decline in gross motor function as measured by the Gross Motor Function Classification in MLD (GMFC-MLD) from the caregiver perspective via semi-structured telephone interviews with caregivers of children with late-infantile MLD. We also evaluated the perceived significance of declines in communication abilities measured by the Expressive Language Function Classification in MLD (ELFC-MLD). This work could help to inform the endpoints of a phase 2 clinical trial (NCT03771898) assessing the efficacy of intrathecal recombinant human ASA in MLD. RESULTS Twelve caregivers were recruited, reporting on 12 children with MLD. Children had a mean age of 6.1 years; mean age at symptom onset was 17.6 months. Most children (10/12) progressed from walking without support (categories 0-1) to a loss of locomotion (categories 5-6) in ≤ 2 years. Caregivers felt that GMFC-MLD and ELFC-MLD accurately described motor and language declines in their children, respectively. Most caregivers (10/12) reported that the idea of delaying disease progression would be meaningful. Further, a slowing of motor function decline in GMFC-MLD, from category 1 to category 3 or from category 2 to category 4 over 2 years, was seen as meaningful by all caregivers asked; however, only 3/12 caregivers reported that delayed decline would be meaningful if baseline category was ≥ 3. Caregivers also reported that delaying expressive language decline at any level that did not indicate a complete loss of expressive language (indicated by categories 1-3) would be meaningful. CONCLUSIONS Caregivers of children with MLD felt that a delayed decline in gross motor function, as assessed by the GMFC-MLD, would be meaningful, supporting the selection of primary and secondary endpoints for the phase 2 clinical trial. Communication abilities were another area of significance for consideration in future clinical trial design.
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Affiliation(s)
| | | | - Dorothy Romanus
- Takeda Development Center Americas, Inc., Lexington, MA, USA
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Feldmann J, Martin P, Bender B, Laugwitz L, Zizmare L, Trautwein C, Krägeloh-Mann I, Klose U, Groeschel S. MR-spectroscopy in metachromatic leukodystrophy: A model free approach and clinical correlation. Neuroimage Clin 2023; 37:103296. [PMID: 36563646 PMCID: PMC9800432 DOI: 10.1016/j.nicl.2022.103296] [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] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/23/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Metachromatic leukodystrophy (MLD) is a lysosomal enzyme deficiency disorder leading to demyelination and subsequently to a progressive decline in cognitive and motor function. It affects mainly white matter where changes during the course of the disease can be visualized on T2-weighted MRI as hyperintense areas. Associated changes in brain metabolism can be quantified by MR spectroscopy (MRS) and may give complementary information as biomarkers for disease characterisation and progression. Our study aimed to further investigate the correlation of MRS with clinical parameters for motor and cognitive function by using a model free MRS analysis approach that would be precise and straightforward to implement. MATERIALS AND METHODS 53 MRS datasets derived from 29 patients (10 late-infantile, 19 juvenile) and 12 controls were acquired using a semi-LASER CSI sequence covering a slice through the centrum semiovale above the corpus callosum. We defined four regions of interest in the white matter (frontal white matter [FWM] and the cortico-spinal tract [CST] area, each left and right) and one in cortical grey matter. Spectra were analysed using a model and fitting free approach by calculating the definite integral of 10 intervals which were distributed along the whole spectrum. These 10 intervals were orientated towards the main peaks of the metabolites N-acetylaspartate (NAA), creatine, myo-inositol, choline, glutamine/glutamate and aspartate to approximately attribute changes in the intervals to corresponding metabolites. Their ratios to the main creatine peak integral were correlated with clinical parameters assessing motor and cognitive abilities. Furthermore, in a post-hoc analysis, NAA levels of a subset of 21 MR datasets were correlated to NAA levels in urine measured by 1H (proton) nuclear magnetic resonance (NMR) spectroscopy. The applied interval integration method was validated in the control cohort against the standard approach, using spectral profile templates of known metabolites (LCModel). Both methods showed good agreement, with coefficients of variance being slightly lower for our approach compared to the related LCModel results. Moreover, the new approach was able to extract information out of the frequency range around the main peaks of aspartate and glutamine where LCModel showed only few usable values for the respective metabolites. RESULTS MLD spectra clearly differed from controls. The most pronounced differences were found in white matter (much less in grey matter), with larger values corresponding to main peaks of myo-inositol, choline and aspartate, and smaller values associated with NAA and glutamine. Late-infantile patients had more severe changes compared to later-onset patients, especially in intervals corresponding to NAA, aspartate, myo-inositol, choline and glutamine. There was a high correlation of several intervals in the corticospinal tract region with motor function (with the most relevant interval corresponding to NAA peak with a correlation coefficient of -0.75; p < 0.001), while cognitive function, by means of IQ, was found to be most correlating in frontal white matter corresponding to the NAA peak (r = 0.84, p < 0.001). The post-hoc analysis showed that the main NAA peak interval correlated negatively with the NAA in urine (r = -0.584, p < 0.001). CONCLUSION The applied model and fitting free interval integration approach to analyse MRS data of a semi-LASER sequence at 3T suits well to detect and quantify pathological changes in MLD patients through the different courses of the disease and correlates well with clinical symptoms while showing smaller dimensions of variation compared to the more sophisticated single metabolite analysis using LCModel. NAA seems the most clinically meaningful biomarker to use in this context. Its correlation with urine measurements further underlines its potential as a clinically and biologically useful parameter of disease progression in MLD.
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Affiliation(s)
- Joana Feldmann
- Department of Neuropediatrics, Developmental Neurology and Social Pediatrics, University of Tübingen, 72076 Tübingen, Germany
| | - Pascal Martin
- Department of Neurology and Epileptology, Hertie Institute for Clinical Brain Research, University of Tübingen, 72076 Tübingen, Germany.
| | - Benjamin Bender
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Tübingen, 72076 Tübingen, Germany
| | - Lucia Laugwitz
- Department of Neuropediatrics, Developmental Neurology and Social Pediatrics, University of Tübingen, 72076 Tübingen, Germany
| | - Laimdota Zizmare
- Werner Siemens Imaging Center, University of Tübingen, 72076 Tübingen, Germany
| | - Christoph Trautwein
- Werner Siemens Imaging Center, University of Tübingen, 72076 Tübingen, Germany
| | - Ingeborg Krägeloh-Mann
- Department of Neuropediatrics, Developmental Neurology and Social Pediatrics, University of Tübingen, 72076 Tübingen, Germany
| | - Uwe Klose
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Tübingen, 72076 Tübingen, Germany
| | - Samuel Groeschel
- Department of Neuropediatrics, Developmental Neurology and Social Pediatrics, University of Tübingen, 72076 Tübingen, Germany
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Martin P, Hagberg GE, Schultz T, Harzer K, Klose U, Bender B, Nägele T, Scheffler K, Krägeloh-Mann I, Groeschel S. T2-Pseudonormalization and Microstructural Characterization in Advanced Stages of Late-infantile Metachromatic Leukodystrophy. Clin Neuroradiol 2021; 31:969-980. [PMID: 33226437 PMCID: PMC8648649 DOI: 10.1007/s00062-020-00975-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/27/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE T2-weighted signal hyperintensities in white matter (WM) are a diagnostic finding in brain magnetic resonance imaging (MRI) of patients with metachromatic leukodystrophy (MLD). In our systematic investigation of the evolution of T2-hyperintensities in patients with the late-infantile form, we describe and characterize T2-pseudonormalization in the advanced stage of the natural disease course. METHODS The volume of T2-hyperintensities was quantified in 34 MRIs of 27 children with late-infantile MLD (median age 2.25 years, range 0.5-5.2 years). In three children with the most advanced clinical course (age >4 years) and for whom the T2-pseudonormalization was the most pronounced, WM microstructure was investigated using a multimodal MRI protocol, including diffusion-weighted imaging, MR spectroscopy (MRS), myelin water fraction (MWF), magnetization transfer ratio (MTR), T1-mapping and quantitative susceptibility mapping. RESULTS T2-hyperintensities in cerebral WM returned to normal in large areas of 3 patients in the advanced disease stage. Multimodal assessment of WM microstructure in areas with T2-pseudonormalization revealed highly decreased values for NAA, neurite density, isotropic water, mean and radial kurtosis, MWF and MTR, as well as increased radial diffusivity. CONCLUSION In late-infantile MLD patients, we found T2-pseudonormalization in WM tissue with highly abnormal microstructure characterizing the most advanced disease stage. Pathological hallmarks might be a loss of myelin, but also neuronal loss as well as increased tissue density due to gliosis and accumulated storage material. These results suggest that a multimodal MRI protocol using more specific microstructural parameters than T2-weighted sequences should be used when evaluating the effect of treatment trials in MLD.
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Affiliation(s)
- Pascal Martin
- Department of Neurology and Epileptology, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.
| | - Gisela E Hagberg
- High Field Magnetic Resonance, Max-Planck Institute for Biological Cybernetics, Tübingen, Germany
- Biomedical Magnetic Resonance, University Hospital, Tübingen, Germany
| | - Thomas Schultz
- B-IT and Institute of Computer Science, University of Bonn, Bonn, Germany
| | - Klaus Harzer
- Department of Neuropediatrics, University Children's Hospital, Tübingen, Germany
| | - Uwe Klose
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Tübingen, Tübingen, Germany
| | - Benjamin Bender
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Tübingen, Tübingen, Germany
| | - Thomas Nägele
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Tübingen, Tübingen, Germany
| | - Klaus Scheffler
- High Field Magnetic Resonance, Max-Planck Institute for Biological Cybernetics, Tübingen, Germany
- Biomedical Magnetic Resonance, University Hospital, Tübingen, Germany
| | | | - Samuel Groeschel
- Department of Neuropediatrics, University Children's Hospital, Tübingen, Germany
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Í Dali C, Groeschel S, Moldovan M, Farah MH, Krägeloh-Mann I, Wasilewski M, Li J, Barton N, Krarup C. Intravenous arylsulfatase A in metachromatic leukodystrophy: a phase 1/2 study. Ann Clin Transl Neurol 2020; 8:66-80. [PMID: 33332761 PMCID: PMC7818087 DOI: 10.1002/acn3.51254] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/12/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Metachromatic leukodystrophy (MLD) is an autosomal recessive lysosomal storage disease caused by deficient activity of arylsulfatase A (ASA), resulting in severe motor and cognitive dysfunction. This phase 1/2 study evaluated the safety and efficacy of intravenous (IV) recombinant human ASA (rhASA; HGT-1111, previously known as Metazym) in children with MLD. METHODS Thirteen children with MLD (symptom onset < 4 years of age) were enrolled in an open-label, nonrandomized, dose-escalation trial and received IV rhASA at 50, 100, or 200 U/kg body weight every 14 (± 4) days for 52 weeks (NCT00418561; NCT00633139). Eleven children continued to receive rhASA at 100 or 200 U/kg during a 24-month extension period (NCT00681811). Outcome measures included safety observations, changes in motor and cognitive function, and changes in nerve conduction and morphometry. RESULTS There were no serious adverse events considered related to IV rhASA. Motor function and developmental testing scores declined during the study in all dose groups; no significant differences were observed between groups. Nerve conduction studies and morphometric analysis indicated that peripheral nerve pathology did not worsen during the study in any dose group. INTERPRETATION IV rhASA was generally well tolerated. There was no evidence of efficacy in preventing motor and cognitive deterioration, suggesting that IV rhASA may not cross the blood-brain barrier in therapeutic quantities. The relative stability of peripheral nerve function during the study indicates that rhASA may be beneficial if delivered to the appropriate target site and supports the development of rhASA for intrathecal administration in MLD.
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Affiliation(s)
- Christine Í Dali
- Department of Clinical Genetics, Rigshospitalet, Copenhagen, Denmark
| | - Samuel Groeschel
- Department of Neuropediatrics, University Children's Hospital Tübingen, Tübingen, Germany
| | - Mihai Moldovan
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark.,Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark
| | - Mohamed H Farah
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ingeborg Krägeloh-Mann
- Department of Neuropediatrics, University Children's Hospital Tübingen, Tübingen, Germany
| | - Margaret Wasilewski
- Shire (a member of the Takeda group of companies), Lexington, Massachusetts, USA
| | - Jing Li
- Shire (a member of the Takeda group of companies), Lexington, Massachusetts, USA
| | - Norman Barton
- Shire (a member of the Takeda group of companies), Lexington, Massachusetts, USA
| | - Christian Krarup
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark.,Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark
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Wolf NI, Breur M, Plug B, Beerepoot S, Westerveld ASR, van Rappard DF, de Vries SI, Kole MHP, Vanderver A, van der Knaap MS, Lindemans CA, van Hasselt PM, Boelens JJ, Matzner U, Gieselmann V, Bugiani M. Metachromatic leukodystrophy and transplantation: remyelination, no cross-correction. Ann Clin Transl Neurol 2020; 7:169-180. [PMID: 31967741 PMCID: PMC7034505 DOI: 10.1002/acn3.50975] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/17/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE In metachromatic leukodystrophy, a lysosomal storage disorder due to decreased arylsulfatase A activity, hematopoietic stem cell transplantation may stop brain demyelination and allow remyelination, thereby halting white matter degeneration. This is the first study to define the effects and therapeutic mechanisms of hematopoietic stem cell transplantation on brain tissue of transplanted metachromatic leukodystrophy patients. METHODS Autopsy brain tissue was obtained from eight (two transplanted and six nontransplanted) metachromatic leukodystrophy patients, and two age-matched controls. We examined the presence of donor cells by immunohistochemistry and microscopy. In addition, we assessed myelin content, oligodendrocyte numbers, and macrophage phenotypes. An unpaired t-test, linear regression or the nonparametric Mann-Whitney U-test was performed to evaluate differences between the transplanted, nontransplanted, and control group. RESULTS In brain tissue of transplanted patients, we found metabolically competent donor macrophages expressing arylsulfatase A distributed throughout the entire white matter. Compared to nontransplanted patients, these macrophages preferentially expressed markers of alternatively activated, anti-inflammatory cells that may support oligodendrocyte survival and differentiation. Additionally, transplanted patients showed higher numbers of oligodendrocytes and evidence for remyelination. Contrary to the current hypothesis on therapeutic mechanism of hematopoietic cell transplantation in metachromatic leukodystrophy, we detected no enzymatic cross-correction to resident astrocytes and oligodendrocytes. INTERPRETATION In conclusion, donor macrophages are able to digest accumulated sulfatides and may play a neuroprotective role for resident oligodendrocytes, thereby enabling remyelination, albeit without evidence of cross-correction of oligo- and astroglia. These results emphasize the importance of immunomodulation in addition to the metabolic correction, which might be exploited for improved outcomes.
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Affiliation(s)
- Nicole I. Wolf
- Department of Child NeurologyCenter for Childhood White Matter DiseasesEmma Children’s HospitalAmsterdam University Medical CentersVrije Universiteit Amsterdam, and Amsterdam NeuroscienceAmsterdamThe Netherlands
| | - Marjolein Breur
- Department of Child NeurologyCenter for Childhood White Matter DiseasesEmma Children’s HospitalAmsterdam University Medical CentersVrije Universiteit Amsterdam, and Amsterdam NeuroscienceAmsterdamThe Netherlands
- Department of PathologyAmsterdam NeuroscienceAmsterdam University Medical CentersVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Bonnie Plug
- Department of Child NeurologyCenter for Childhood White Matter DiseasesEmma Children’s HospitalAmsterdam University Medical CentersVrije Universiteit Amsterdam, and Amsterdam NeuroscienceAmsterdamThe Netherlands
- Department of PathologyAmsterdam NeuroscienceAmsterdam University Medical CentersVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Shanice Beerepoot
- Department of Child NeurologyCenter for Childhood White Matter DiseasesEmma Children’s HospitalAmsterdam University Medical CentersVrije Universiteit Amsterdam, and Amsterdam NeuroscienceAmsterdamThe Netherlands
- Center for Translational ImmunologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Aimee S. R. Westerveld
- Department of Child NeurologyCenter for Childhood White Matter DiseasesEmma Children’s HospitalAmsterdam University Medical CentersVrije Universiteit Amsterdam, and Amsterdam NeuroscienceAmsterdamThe Netherlands
- Department of PathologyAmsterdam NeuroscienceAmsterdam University Medical CentersVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Diane F. van Rappard
- Department of Child NeurologyCenter for Childhood White Matter DiseasesEmma Children’s HospitalAmsterdam University Medical CentersVrije Universiteit Amsterdam, and Amsterdam NeuroscienceAmsterdamThe Netherlands
| | - Sharon I. de Vries
- Department of Axonal SignalingNetherlands Institute for NeuroscienceAmsterdamThe Netherlands
| | - Maarten H. P. Kole
- Department of Axonal SignalingNetherlands Institute for NeuroscienceAmsterdamThe Netherlands
- Cell Biology Faculty of ScienceUtrecht UniversityUtrechtThe Netherlands
| | - Adeline Vanderver
- Division of NeurologyDepartment of PediatricsChildren’s Hospital of PhiladelphiaUniversity of PennsylvaniaPhiladelphiaPennsylvania
- Department of NeurologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvania
| | - Marjo S. van der Knaap
- Department of Child NeurologyCenter for Childhood White Matter DiseasesEmma Children’s HospitalAmsterdam University Medical CentersVrije Universiteit Amsterdam, and Amsterdam NeuroscienceAmsterdamThe Netherlands
- Department of Functional GenomicsCenter for Neurogenomics and Cognitive ResearchVU UniversityAmsterdamThe Netherlands
| | - Caroline A. Lindemans
- Department of PediatricsUniversity Medical Center UtrechtUtrechtThe Netherlands
- Pediatric Blood and Marrow Transplantation ProgramPrincess Maxima CenterUtrechtThe Netherlands
| | - Peter M. van Hasselt
- Department of Metabolic DiseasesWilhelmina Children’s HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Jaap J. Boelens
- Department of PediatricsUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Ulrich Matzner
- Institute of Biochemistry and Molecular BiologyRheinische Friedrich‐Wilhelms UniversityBonnGermany
| | - Volkmar Gieselmann
- Institute of Biochemistry and Molecular BiologyRheinische Friedrich‐Wilhelms UniversityBonnGermany
| | - Marianna Bugiani
- Department of Child NeurologyCenter for Childhood White Matter DiseasesEmma Children’s HospitalAmsterdam University Medical CentersVrije Universiteit Amsterdam, and Amsterdam NeuroscienceAmsterdamThe Netherlands
- Department of PathologyAmsterdam NeuroscienceAmsterdam University Medical CentersVrije Universiteit AmsterdamAmsterdamThe Netherlands
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Elgün S, Waibel J, Kehrer C, van Rappard D, Böhringer J, Beck-Wödl S, Just J, Schöls L, Wolf N, Krägeloh-Mann I, Groeschel S. Phenotypic variation between siblings with Metachromatic Leukodystrophy. Orphanet J Rare Dis 2019; 14:136. [PMID: 31186049 PMCID: PMC6560893 DOI: 10.1186/s13023-019-1113-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [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: 03/01/2019] [Accepted: 06/04/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Metachromatic Leukodystrophy (MLD) is a rare autosomal-recessive lysosomal storage disorder caused by mutations in the ARSA gene. While interventional trials often use untreated siblings as controls, the genotype-phenotype correlation is only partly understood, and the variability of the clinical course between siblings is unclear with some evidence for a discrepant clinical course in juvenile patients. The aim of this study was to systematically investigate the phenotypic variation in MLD siblings in comparison to the variability in a larger MLD cohort and to case reports published in literature. RESULTS Detailed clinical information was available from 12 sibling-pairs (3 late-infantile, 9 juvenile) and 61 single patients (29 late-infantile, 32 juvenile). Variability of age at onset was similar between the siblings and randomly chosen pairs of the remaining cohort (no statistically different Euclidean distances). However, in children with juvenile MLD both the type of first symptoms and the dynamic of the disease were less variable between siblings compared to the general cohort. In late-infantile patients, type of first symptoms and dynamic of disease were similarly homogeneous between siblings and the whole MLD cohort. Thirteen published case reports of families with affected siblings with MLD are presented with similar findings. CONCLUSIONS In a systematic analysis of phenotypic variation in families with MLD, siblings with the late-infantile form showed a similar variability as unrelated pairs of children with late-infantile MLD, whereas siblings with juvenile MLD showed a more homogeneous phenotype regarding type of first symptoms and disease evolution in comparison to unrelated children with juvenile MLD, but not regarding their age at onset. These results are highly relevant with respect to the evaluation of treatment effects and for counseling of families with affected siblings.
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Affiliation(s)
- Saskia Elgün
- Department of Paediatric Neurology and Developmental Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Strasse 1, 72076, Tübingen, Germany
| | - Jakob Waibel
- Department of Paediatric Neurology and Developmental Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Strasse 1, 72076, Tübingen, Germany
| | - Christiane Kehrer
- Department of Paediatric Neurology and Developmental Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Strasse 1, 72076, Tübingen, Germany
| | - Diane van Rappard
- Department of Child Neurology, Emma Children's Hospital, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, and Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Judith Böhringer
- Department of Paediatric Neurology and Developmental Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Strasse 1, 72076, Tübingen, Germany
| | - Stefanie Beck-Wödl
- Department of Medical Genetics, University Hospital Tübingen, Tübingen, Germany
| | - Jennifer Just
- Clinical Neurogenetics Section, Department of Neurology and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Ludger Schöls
- Clinical Neurogenetics Section, Department of Neurology and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,German Center for Neurodegenerative Diseases (DZNE) Tübingen, Tübingen, Germany
| | - Nicole Wolf
- Department of Child Neurology, Emma Children's Hospital, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, and Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Ingeborg Krägeloh-Mann
- Department of Paediatric Neurology and Developmental Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Strasse 1, 72076, Tübingen, Germany
| | - Samuel Groeschel
- Department of Paediatric Neurology and Developmental Medicine, University Children's Hospital Tübingen, Hoppe-Seyler-Strasse 1, 72076, Tübingen, Germany.
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8
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Strölin M, Krägeloh-Mann I, Kehrer C, Wilke M, Groeschel S. Demyelination load as predictor for disease progression in juvenile metachromatic leukodystrophy. Ann Clin Transl Neurol 2017; 4:403-410. [PMID: 28589167 PMCID: PMC5454396 DOI: 10.1002/acn3.420] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 04/06/2017] [Accepted: 04/07/2017] [Indexed: 11/15/2022] Open
Abstract
Objective The aim of this study was to investigate whether the extent and topography of cerebral demyelination correlates with and predicts disease progression in patients with juvenile metachromatic leukodystrophy (MLD). Methods A total of 137 MRIs of 46 patients with juvenile MLD were analyzed. Demyelination load and brain volume were quantified using the previously developed Software “clusterize.” Clinical data were collected within the German Leukodystrophy Network and included full scale intelligence quotient (FSIQ) and gross motor function data. Voxel‐based lesion‐symptom mapping (VLSM) across the whole brain was performed to investigate the spatial relationship of cerebral demyelination with motor or cognitive function. The prognostic value of the demyelination load at disease onset was assessed to determine the severity of disease progression. Results The demyelination load (corrected by the individual brain volume) correlated significantly with gross motor function (r = +0.55) and FSIQ (r = −0.55). Demyelination load at disease onset was associated with the severity of disease progression later on (P < 0.01). VLSM results associated frontal lobe demyelination with loss in FSIQ and more central region demyelination with decline of motor function. Especially progression of demyelination within the motor area was associated with severe disease progression. Interpretation We were able to show for the first time in a large cohort of patients with juvenile MLD that the demyelination load correlates with motor and cognitive symptoms. Moreover, demyelination load at disease onset, especially the involvement of the central region, predicts severity of disease progression. Thus, demyelination load seems a functionally relevant MRI parameter.
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Affiliation(s)
- Manuel Strölin
- Department of Pediatric Neurology & Developmental Medicine University Children's Hospital Tübingen Germany
| | - Ingeborg Krägeloh-Mann
- Department of Pediatric Neurology & Developmental Medicine University Children's Hospital Tübingen Germany
| | - Christiane Kehrer
- Department of Pediatric Neurology & Developmental Medicine University Children's Hospital Tübingen Germany
| | - Marko Wilke
- Department of Pediatric Neurology & Developmental Medicine University Children's Hospital Tübingen Germany.,Experimental Pediatric Neuroimaging University Children's Hospital Tübingen Germany
| | - Samuel Groeschel
- Department of Pediatric Neurology & Developmental Medicine University Children's Hospital Tübingen Germany.,Experimental Pediatric Neuroimaging University Children's Hospital Tübingen Germany
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