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Theis M, Donath H, Woelke S, Bakhtiar S, Salzmann-Manrique E, Zielen S, Kieslich M. Peripheral polyneuropathy in children and young adults with ataxia-telangiectasia. Eur J Neurol 2023; 30:3842-3853. [PMID: 37540892 DOI: 10.1111/ene.16028] [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: 02/17/2023] [Revised: 07/12/2023] [Accepted: 07/30/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND AND PURPOSE Ataxia-telangiectasia (A-T) is a rare, autosomal recessive, multisystem disorder that leads to progressive neurodegeneration with cerebellar ataxia and peripheral polyneuropathy. Cerebellar neurodegeneration is well described in A-T. However, peripheral nervous system involvement is an underdiagnosed but important additional target for supportive and systemic therapies. The aim of this study was to conduct neurophysiological measurements to assess peripheral neurodegeneration and the development of age-dependent neuropathy in A-T. METHODS In this prospective study, 42 classical A-T patients were assessed. The motor and sensory nerve conduction of the median and tibial nerves was evaluated. Data were compared to published standard values and a healthy age- and gender-matched control group of 23 participants. Ataxia scores (Klockgether, Scale for the Assessment and Rating of Ataxia) were also assessed. RESULTS In A-T, neurophysiological assessment revealed neuropathic changes as early as the first year of life. Subjective symptomatology of neuropathy is rarely described. In the upper extremities, motor neuropathy was predominantly that of a demyelinating type and sensory neuropathy was predominantly that of a mixed type. In the lower extremities, motor and sensory neuropathy was predominantly that of a mixed type. We found significant correlations between age and the development of motor and sensory polyneuropathy in A-T compared with healthy controls (p < 0.001). CONCLUSIONS In A-T, polyneuropathy occurs mostly subclinically as early as the first year of life. The current study of a large national A-T cohort demonstrates that development of neuropathy in A-T differs in the upper and lower extremities.
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Affiliation(s)
- Marius Theis
- Department for Children and Adolescents, Division of Pediatric Neurology, Neurometabolics, and Prevention, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Helena Donath
- Department for Children and Adolescents, Division of Allergology, Pulmonology, and Cystic Fibrosis, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Sandra Woelke
- Department for Children and Adolescents, Division of Allergology, Pulmonology, and Cystic Fibrosis, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Shahrzad Bakhtiar
- Department for Children and Adolescents, Division for Stem Cell Transplantation, Immunology, and Intensive Care Medicine, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Emilia Salzmann-Manrique
- Department for Children and Adolescents, Division for Stem Cell Transplantation, Immunology, and Intensive Care Medicine, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Stefan Zielen
- Department for Children and Adolescents, Division of Allergology, Pulmonology, and Cystic Fibrosis, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Matthias Kieslich
- Department for Children and Adolescents, Division of Pediatric Neurology, Neurometabolics, and Prevention, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
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Pastorczak A, Attarbaschi A, Bomken S, Borkhardt A, van der Werff ten Bosch J, Elitzur S, Gennery AR, Hlavackova E, Kerekes A, Křenová Z, Mlynarski W, Szczepanski T, Wassenberg T, Loeffen J. Consensus Recommendations for the Clinical Management of Hematological Malignancies in Patients with DNA Double Stranded Break Disorders. Cancers (Basel) 2022; 14:2000. [PMID: 35454905 PMCID: PMC9029535 DOI: 10.3390/cancers14082000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 12/03/2022] Open
Abstract
Patients with double stranded DNA repair disorders (DNARDs) (Ataxia Telangiectasia (AT) and Nijmegen Breakage syndrome (NBS)) are at a very high risk for developing hematological malignancies in the first two decades of life. The most common neoplasms are T-cell lymphoblastic malignancies (T-cell ALL and T-cell LBL) and diffuse large B cell lymphoma (DLBCL). Treatment of these patients is challenging due to severe complications of the repair disorder itself (e.g., congenital defects, progressive movement disorders, immunological disturbances and progressive lung disease) and excessive toxicity resulting from chemotherapeutic treatment. Frequent complications during treatment for malignancies are deterioration of pre-existing lung disease, neurological complications, severe mucositis, life threating infections and feeding difficulties leading to significant malnutrition. These complications make modifications to commonly used treatment protocols necessary in almost all patients. Considering the rarity of DNARDs it is difficult for individual physicians to obtain sufficient experience in treating these vulnerable patients. Therefore, a team of experts assembled all available knowledge and translated this information into best available evidence-based treatment recommendations.
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Affiliation(s)
- Agata Pastorczak
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, 91-738 Lodz, Poland;
| | - Andishe Attarbaschi
- Department of Pediatrics, Pediatric Hematology and Oncology, St. Anna Children’s Hospital, Medical University of Vienna, 1090 Vienna, Austria;
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Simon Bomken
- Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK; (S.B.); (A.R.G.)
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Arndt Borkhardt
- Department of Pediatric Oncology, Hematology and Clinical Immunology, University Children’s Hospital, Medical Faculty, Heinrich Heine University, 40225 Düsseldorf, Germany;
| | - Jutte van der Werff ten Bosch
- Department of Pediatric Hematology, Oncology and Immunology, University Hospital Brussels, 1090 Jette Brussels, Belgium;
| | - Sarah Elitzur
- Pediatric Hematology-Oncology, Schneider Children’s Medical Center, Petach Tikvah 4920235, Israel;
| | - Andrew R. Gennery
- Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK; (S.B.); (A.R.G.)
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Eva Hlavackova
- Department of Pediatric Oncology, University Hospital and Faculty of Medicine, Masaryk University, 662 63 Brno, Czech Republic; (E.H.); (Z.K.)
- Department of Clinical Immunology and Allergology, St. Anne’s University Hospital in Brno, Faculty of Medicine, Masaryk University, 662 63 Brno, Czech Republic;
| | - Arpád Kerekes
- Department of Clinical Immunology and Allergology, St. Anne’s University Hospital in Brno, Faculty of Medicine, Masaryk University, 662 63 Brno, Czech Republic;
| | - Zdenka Křenová
- Department of Pediatric Oncology, University Hospital and Faculty of Medicine, Masaryk University, 662 63 Brno, Czech Republic; (E.H.); (Z.K.)
| | - Wojciech Mlynarski
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, 91-738 Lodz, Poland;
| | - Tomasz Szczepanski
- Department of Pediatric Hematology and Oncology, Medical University of Silesia (SUM), 41-800 Zabrze, Poland;
| | - Tessa Wassenberg
- Department of Neurology and Child Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
| | - Jan Loeffen
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands;
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3
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van Os NJH, van Deuren M, Weemaes CMR, van Gaalen J, Hijdra H, Taylor AMR, van de Warrenburg BPC, Willemsen MAAP. Classic ataxia-telangiectasia: the phenotype of long-term survivors. J Neurol 2019; 267:830-837. [PMID: 31776720 PMCID: PMC7035236 DOI: 10.1007/s00415-019-09641-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/10/2019] [Accepted: 11/14/2019] [Indexed: 12/15/2022]
Abstract
Objective Patients with classic ataxia–telangiectasia (A–T) generally die in the second or third decade of life. Clinical descriptions of A–T tend to focus on the symptoms at presentation. However, during the course of the disease, other symptoms and complications emerge. As long-term survivors with classic A–T develop a complex multisystem disorder with a largely unknown extent and severity, we aimed to comprehensively assess their full clinical picture. Methods Data from Dutch patients with classic A–T above the age of 30 years were retrospectively collected. In addition, we searched the literature for descriptions of classic A–T patients who survived beyond the age of 30 years. Results In the Dutch cohort, seven classic A–T patients survived beyond 30 years of age. Fourteen additional patients were retrieved by the literature search. Common problems in older patients with classic A–T were linked to ageing. Most patients had pulmonary, endocrine, cardiovascular, and gastro-intestinal problems. All patients had a tetraparesis with contractures. This led to immobilization and frequent hospital admissions. Most patients expressed the wish to no longer undergo intensive medical treatments, and waived follow-up programs. Conclusions Paucity of descriptions in the literature, and withdrawal from medical care complicate the acquisition of follow-up data on the natural history of long-term survivors. Irrespective of these limitations, we have obtained impression of the many problems that these patients face when surviving beyond 30 years of age. Awareness of these problems is needed to guide follow-up, counselling, and (palliative) care; decisions about life-prolonging treatments should be well considered. Electronic supplementary material The online version of this article (10.1007/s00415-019-09641-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nienke J H van Os
- Department of Pediatric Neurology, Radboudumc Amalia Children's Hospital, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands. .,Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Marcel van Deuren
- Department of Internal Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Corry M R Weemaes
- Department of Pediatrics, Pediatric Infectious Disease and Immunology, Radboudumc Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Judith van Gaalen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Helma Hijdra
- Department of Rehabilitation Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexander M R Taylor
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Bart P C van de Warrenburg
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michèl A A P Willemsen
- Department of Pediatric Neurology, Radboudumc Amalia Children's Hospital, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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Ferreira B, Palinkas M, Gonçalves L, da Silva G, Arnoni V, Regalo I, Vasconcelos P, Júnior WM, Hallak J, Regalo S, Siéssere S. Spinocerebellar ataxia: Functional analysis of the stomatognathic system. Med Oral Patol Oral Cir Bucal 2019; 24:e165-e171. [PMID: 30818308 PMCID: PMC6441597 DOI: 10.4317/medoral.22839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 02/27/2019] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Neurodegenerative diseases that affect the cerebellum, especially in elderly individuals, cause impairment of motor coordination and quality of life. The presente study evaluated the electromyographic activity and thickness of the right and left masseter and temporal muscles, and the maximum molar bite force of individuals with spinocerebellar ataxia. MATERIAL AND METHODS Twenty-eight individuals were divided into two groups: those with (n=14) and without (n=14) spinocerebellar ataxia. Data on the masticatory muscles obtained from the electromyographic activity (resting, right and left laterality and protrusion), muscle thickness (maximal voluntary contraction and tensile strength) and maximum bite force (right and left) were tabulated and descriptive analysis using Student's t-test (P ≤ 0.05). RESULTS In the comparison between groups, greater electromyographic activity was demonstrated for individuals with spinocerebellar ataxia, with a statistically significant difference in protrusion and laterality for the temporal muscles (P = 0.05). There was no statistically significant difference between the groups for masticatory muscles thickness in the conditions evaluated. For maximum molar bite force, the group with spinocerebellar ataxia showed lower bite force (P ≤ 0.05). CONCLUSIONS The data obtained suggest that spinocerebellar ataxia promotes functional reduction in the stomatognathic system, mainly affecting the electromyographic activity and bite force, hindering chewing, with a resultant alteration of nutritional intake and a decrease of quality of life.
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Affiliation(s)
- B Ferreira
- School of Dentistry of Ribeirão Preto, University of São Paulo, Avenida do Café s/n, Bairro Monte Alegre, CEP 14040-904 Ribeirão Preto SP, Brazil,
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Dawson AJ, Marles S, Tomiuk M, Riordan D, Gatti RA. Ataxia-telangiectasia with female fertility. Am J Med Genet A 2015; 167A:1937-9. [DOI: 10.1002/ajmg.a.37084] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 03/15/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Angelika J. Dawson
- Cytogenetic Laboratory/HSC; Diagnostic Services of Manitoba; Winnipeg Manitoba Canada
- Deptartments of Biochemistry & Medical Genetics and Pediatrics & Child Health; University of Manitoba; Winnipeg Manitoba Canada
- Genetics & Metabolism Program; WRHA; Winnipeg Manitoba Canada
| | - Sandra Marles
- Deptartments of Biochemistry & Medical Genetics and Pediatrics & Child Health; University of Manitoba; Winnipeg Manitoba Canada
- Genetics & Metabolism Program; WRHA; Winnipeg Manitoba Canada
| | - Michelle Tomiuk
- Cytogenetic Laboratory/HSC; Diagnostic Services of Manitoba; Winnipeg Manitoba Canada
| | - Diane Riordan
- Cytogenetic Laboratory/HSC; Diagnostic Services of Manitoba; Winnipeg Manitoba Canada
| | - Richard A. Gatti
- Department of Pathology & Laboratory Medicine, and Human Genetics; UCLA/Geffen School of Medicine; Los Angeles California
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DNA repair abnormalities leading to ataxia: shared neurological phenotypes and risk factors. Neurogenetics 2014; 15:217-28. [PMID: 25038946 DOI: 10.1007/s10048-014-0415-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 07/11/2014] [Indexed: 02/06/2023]
Abstract
Since identification of mutations in the ATM gene leading to ataxia-telangiectasia, enormous efforts have been devoted to discovering the roles this protein plays in DNA repair as well as other cellular functions. Even before the identification of ATM mutations, it was clear that other diseases with different genomic loci had very similar neurological symptoms. There has been significant progress in understanding why cancer and immunodeficiency occur in ataxia-telangiectasia even though many details remain to be determined, but the field is no closer to determining why the nervous system requires ATM and other DNA repair genes. Even though rodent disease models have similar DNA repair abnormalities as the human diseases, they have no consistent, robust neuropathological phenotype making it difficult to understand the neurological underpinnings of disease. Therefore, it may be useful to reassess the neurological and neuropathological characteristics of ataxia-telangiectasia in human patients to look for potential commonalities in DNA repair diseases that result in ataxia. In doing so, it is clear that ataxia-telangiectasia and similar diseases share neurological features other than merely ataxia, such as length-dependent motor and sensory neuropathies, and that the neuroanatomical localization for these symptoms is understood. Cells affected in ataxia-telangiectasia and similar diseases are some of the largest single nucleated cells in the body. In addition, a subset of these diseases also has extrapyramidal movements and oculomotor apraxia. These neurological and neuropathological similarities may indicate a common DNA repair related pathogenesis with very large cell size as a critical risk factor.
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Davies EG. Update on the management of the immunodeficiency in ataxia-telangiectasia. Expert Rev Clin Immunol 2014; 5:565-75. [DOI: 10.1586/eci.09.35] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Berciano J, García A, Infante J. Peripheral nerve involvement in hereditary cerebellar and multisystem degenerative disorders. HANDBOOK OF CLINICAL NEUROLOGY 2013; 115:907-32. [PMID: 23931821 DOI: 10.1016/b978-0-444-52902-2.00051-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hereditary ataxias (HA) encompass an increasing number of degenerative disorders characterized by progressive cerebellar ataxia usually accompanied by extracerebellar semeiology including peripheral nerve involvement. Classically, HA were classified according to their pathological hallmark comprising three main forms: (1) spinal form predominantly with degeneration of spinocerebellar tracts, posterior columns, and pyramidal tracts (Friedreich's ataxia, FA); (2) olivopontocerebellar atrophy (OPCA); and (3) cortical cerebellar atrophy (CCA). In the 1980s Harding proposed a clinico-genetic classification based upon age of onset, modality of transmission, and clinical semeiology. The main categories in this classification were as follows: (1) early onset cerebellar ataxia (EOCA) with age of onset below 25 years and usually with autosomal recessive (AR) transmission (this group encompasses FA and syndromes different from FA); (2) autosomal dominant cerebellar ataxia (ADCA) with adult onset and with either cerebellar-plus syndrome or pure cerebellar semeiology; and (3) idiopathic late onset onset cerebellar ataxia (ILOCA). With the advent of molecular genetics, the nosology of HA has been in a state of constant flux. At present EOCA comprises at least 17 genotypes (designated with the acronym of ARCA derived from AR cerebellar ataxia), whereas under the umbrella of ADCA 30 genotypes have been reported. In this chapter we will review peripheral nerve involvement in classical pathological entities (OPCA and CCA), ARCA, ADCA, and ILOCA paying special attention to the most prevalent syndromes in each category. As a general rule, nerve involvement is relatively common in any form of ataxia except ILOCA, the most common pattern being either sensory or sensorimotor neuronopathy with a dying-back process. An exception to this rule is AR spastic ataxia of Charlevoix-Saguenay where nerve conduction studies show the characteristic pattern of intermediate neuropathy implying that sacsin mutation causes both axonal and Schwann cell dysfunction.
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Affiliation(s)
- José Berciano
- Department of Neurology and Clinical Neurophysiology, University Hospital "Marqués de Valdecilla (IFIMAV)", University of Cantabria and Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas, Santander, Spain.
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Verhagen MMM, Last JI, Hogervorst FBL, Smeets DFCM, Roeleveld N, Verheijen F, Catsman-Berrevoets CE, Wulffraat NM, Cobben JM, Hiel J, Brunt ER, Peeters EAJ, Gómez Garcia EB, van der Knaap MS, Lincke CR, Laan LAEM, Tijssen MAJ, van Rijn MA, Majoor-Krakauer D, Visser M, van 't Veer LJ, Kleijer WJ, van de Warrenburg BPC, Warris A, de Groot IJM, de Groot R, Broeks A, Preijers F, Kremer BHPH, Weemaes CMR, Taylor MAMR, van Deuren M, Willemsen MAAP. Presence of ATM protein and residual kinase activity correlates with the phenotype in ataxia-telangiectasia: A genotype-phenotype study. Hum Mutat 2012; 33:561-71. [PMID: 22213089 DOI: 10.1002/humu.22016] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 12/20/2011] [Indexed: 12/22/2022]
Affiliation(s)
- Mijke M M Verhagen
- Department of Pediatric Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
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Vinck A, Verhagen MMM, Gerven MV, de Groot IJM, Weemaes CMR, Maassen BAM, Willemsen MAAP. Cognitive and speech-language performance in children with ataxia telangiectasia. Dev Neurorehabil 2012; 14:315-22. [PMID: 21870956 DOI: 10.3109/17518423.2011.603368] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To describe cognitive and speech-language functioning of patients with ataxia-telangiectasia (A-T) in relation to their deteriorating (oculo)motor function. DESIGN Observational case series. METHODS Cognitive functioning, language, speech and oral-motor functioning were examined in eight individuals with A-T (six boys, two girls), taking into account the confounding effects of motor functioning on test performance. RESULTS All patients, except the youngest one, suffered from mild-to-moderate/severe intellectual impairment. Compared to developmental age, patients showed cognitive deficits in attention, (non)verbal memory and verbal fluency. Furthermore, dysarthria and weak oral-motor performance was found. Language was one of the patients' assets. CONCLUSION In contrast to the severe deterioration of motor functioning in A-T, cognitive and language functioning appeared to level off with a typical profile of neuropsychological strengths and weaknesses. Based on our experiences with A-T, suggestions are made to determine a valid assessment of the cognitive and speech-language manifestations.
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Affiliation(s)
- Anja Vinck
- Department of Medical Psychology, Radboud University Nijmegen Medical Centre, The Netherlands.
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Verhagen MMM, Martin JJ, van Deuren M, Ceuterick-de Groote C, Weemaes CMR, Kremer BHPH, Taylor MAR, Willemsen MAAP, Lammens M. Neuropathology in classical and variant ataxia-telangiectasia. Neuropathology 2011; 32:234-44. [PMID: 22017321 DOI: 10.1111/j.1440-1789.2011.01263.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Ataxia-telangiectasia (A-T) is classically characterized by progressive neurodegeneration, oculocutaneous telangiectasia, immunodeficiency and elevated α-fetoprotein levels. Some patients, classified as variant A-T, exhibit a milder clinical course. In the latter patients extrapyramidal symptoms, instead of cerebellar ataxia, tend to be the dominating feature and other classical disease hallmarks, like telangiectasia, appear later or even may be absent. Some patients with variant disease have clinically pronounced anterior horn cell degeneration. Neuropathological studies of genetically proven A-T patients are lacking. The aims of our study were to describe the neuropathology of three A-T patients; in two of them the diagnosis was genetically confirmed. The neuropathological findings were compared with those of all known published autopsy findings in A-T patients up to now. Two classical A-T patients aged 19 and 22 and a 33-year-old patient with variant disease were autopsied. In line with previous reports, our patients had severe cerebellar atrophy, less pronounced degeneration of the dentate nucleus and inferior olive, degeneration of the posterior columns and neurogenic muscular atrophy. In addition, all three had anterior horn cell degeneration, which was most prominent at the lumbar level. Compared to the literature, the degenerative changes in the brain stem of the variant A-T patient were somewhat less than anticipated for his age. Degenerative changes in the cerebellum and spinal cord were comparable with those in the literature. Progeric changes were lacking. In conclusion, compared to classical A-T, the variant A-T patient showed essentially the same, only slightly milder neuropathological abnormalities, except for anterior horn degeneration.
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Affiliation(s)
- Mijke M M Verhagen
- Department of Pediatric Neurology, Donders Institute for Brain, Cognition and Behaviour Pathology, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands
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12
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Abstract
BACKGROUND The onset of progressive cerebellar ataxia in early childhood is considered a key feature of ataxia-telangiectasia (A-T), accompanied by ocular apraxia, telangiectasias, immunodeficiency, cancer susceptibility and hypersensitivity to ionizing radiation. METHODS We describe the clinical features and course of three Mennonite children who were diagnosed with A-T following the completion of therapy for lymphoid malignancies. RESULTS Prior to cancer therapy, all had non-progressive atypical neurological abnormalities, with onset by age 30 months, including dysarthria, dyskinesia, hypotonia and/or dystonia, without telangiectasias. Cerebellar ataxia was noted in only one of the children and was mild until his death at age eight years. None had severe infections. All three children were "cured" of their lymphoid malignancies, but experienced severe adverse effects from the treatments administered. The two children who received cranial irradiation developed supratentorial primitive neuroectodermal tumors of the brain, an association not previously described, with fatal outcomes. CONCLUSIONS The range of neurological presentations of A-T is broad. Ataxia and telangiectasias may be minimal or absent and the course seemingly non-progressive. The diagnosis of A-T should be considered in all children with neuromotor dysfunction or peripheral neuropathy, particularly those who develop lymphoid malignancies. The consequences of missing the diagnosis may be dire. Radiation therapy and radiomimetic drugs should be avoided in individuals with A-T.
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