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Yolcu G, Huseynli L, Kenis-Coskun O, Karadag-Saygi E. Small touches to big walks -the impact of rehabilitation on Sjögren-Larsson syndrome: A case report. J Pediatr Rehabil Med 2022; 15:533-537. [PMID: 35871376 DOI: 10.3233/prm-201521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Sjögren-Larsson syndrome (SLS) is a rare neurocutaneous disorder characterized by the presence of congenital ichthyosis, spasticity, and mental retardation. As with other rare genetic diseases, treatment is mainly symptomatic. Due to the absence of definitive treatment, lifelong follow-up and support of patients are important to improve the quality of life. A 7-year-old female child who was diagnosed as having SLS was referred to the rehabilitation clinic. After 20 sessions of a rehabilitation program, she started walking independently with the additional contribution of ankle-foot orthoses (AFOs). The contribution of the short-term rehabilitation approach and especially the administration of AFOs to the independence level of the patient is emphasized herein.
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Affiliation(s)
- Gunay Yolcu
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Leyla Huseynli
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Ozge Kenis-Coskun
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Evrim Karadag-Saygi
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, Istanbul, Turkey
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Impaired skin barrier function due to reduced ω- O-acylceramide levels in a mouse model of Sjögren-Larsson syndrome. Mol Cell Biol 2021; 41:e0035221. [PMID: 34370553 DOI: 10.1128/mcb.00352-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Sjögren-Larsson syndrome (SLS) is an inherited neurocutaneous disorder whose causative gene encodes the fatty aldehyde dehydrogenase ALDH3A2. To date, the detailed molecular mechanism of the skin pathology of SLS has remained largely unclear. We generated double knockout (DKO) mice for Aldh3a2 and its homolog Aldh3b2 (a pseudogene in humans). These mice showed hyperkeratosis and reduced fatty aldehyde dehydrogenase activity and skin barrier function. The levels of ω-O-acylceramides (acylceramides), which are specialized ceramides essential for skin barrier function, in the epidermis of DKO mice were about 60% of those in wild type mice. In the DKO mice, levels of acylceramide precursors (ω-hydroxy ceramides and triglycerides) were increased, suggesting that the final step of acylceramide production was inhibited. A decrease in acylceramide levels was also observed in human immortalized keratinocytes lacking ALDH3A2. Differentiated keratinocytes prepared from the DKO mice exhibited impaired long-chain base metabolism. Based on these results, we propose that the long-chain-base-derived fatty aldehydes that accumulate in DKO mice and SLS patients attack and inhibit the enzyme involved in the final step of acylceramide. Our findings provide insight into the pathogenesis of the skin symptoms of SLS, i.e., decreased acylceramide production, and its molecular mechanism.
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Shortall K, Djeghader A, Magner E, Soulimane T. Insights into Aldehyde Dehydrogenase Enzymes: A Structural Perspective. Front Mol Biosci 2021; 8:659550. [PMID: 34055881 PMCID: PMC8160307 DOI: 10.3389/fmolb.2021.659550] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/28/2021] [Indexed: 12/30/2022] Open
Abstract
Aldehyde dehydrogenases engage in many cellular functions, however their dysfunction resulting in accumulation of their substrates can be cytotoxic. ALDHs are responsible for the NAD(P)-dependent oxidation of aldehydes to carboxylic acids, participating in detoxification, biosynthesis, antioxidant and regulatory functions. Severe diseases, including alcohol intolerance, cancer, cardiovascular and neurological diseases, were linked to dysfunctional ALDH enzymes, relating back to key enzyme structure. An in-depth understanding of the ALDH structure-function relationship and mechanism of action is key to the understanding of associated diseases. Principal structural features 1) cofactor binding domain, 2) active site and 3) oligomerization mechanism proved critical in maintaining ALDH normal activity. Emerging research based on the combination of structural, functional and biophysical studies of bacterial and eukaryotic ALDHs contributed to the appreciation of diversity within the superfamily. Herewith, we discuss these studies and provide our interpretation for a global understanding of ALDH structure and its purpose–including correct function and role in disease. Our analysis provides a synopsis of a common structure-function relationship to bridge the gap between the highly studied human ALDHs and lesser so prokaryotic models.
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Affiliation(s)
- Kim Shortall
- Department of Chemical Sciences, Bernal Institute, University of Limerick, Limerick, Ireland
| | - Ahmed Djeghader
- Department of Chemical Sciences, Bernal Institute, University of Limerick, Limerick, Ireland
| | - Edmond Magner
- Department of Chemical Sciences, Bernal Institute, University of Limerick, Limerick, Ireland
| | - Tewfik Soulimane
- Department of Chemical Sciences, Bernal Institute, University of Limerick, Limerick, Ireland
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Franzen MH, LeRiger MM, Kugler JA, Pellegrino KP, Rizzo WB. Sjögren-Larsson syndrome: Anesthetic considerations and practical recommendations. Paediatr Anaesth 2020; 30:1390-1395. [PMID: 33037729 PMCID: PMC8916001 DOI: 10.1111/pan.14034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/01/2020] [Accepted: 10/06/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Sjögren-Larsson syndrome is a rare inherited neurocutaneous disorder characterized by congenital ichthyosis, spasticity, intellectual disability, seizures, and ophthalmologic changes. Most individuals with Sjögren-Larsson syndrome live well into adulthood and often require surgical intervention to manage their symptomatology. AIMS The aim of this work was to review the clinical aspects of Sjögren-Larsson syndrome, highlight the unique anesthetic considerations associated with this disease, and provide practical recommendations about anesthetic management. METHODS A retrospective case review from February 2013 to October 2019 was performed based on subject participation in a Sjögren-Larsson syndrome longitudinal study at the University of Nebraska Medical Center. Anesthetic and surgical records were reviewed for the following data: age, sex, relevant comorbid conditions, anesthetic induction and maintenance agents, intravenous and oral analgesics, muscle relaxants, and anesthetic-related complications. RESULTS Fourteen patients with Sjögren-Larsson syndrome undergoing 48 anesthetic events were identified. A variety of anesthetic techniques was utilized. No serious adverse events were encountered. The most common clinical observations were related to the ichthyosis seen in Sjögren-Larsson syndrome, which led to difficulty in adherence of electrocardiogram leads and intravenous catheter dressings. CONCLUSIONS We found that anesthesia can be safely administered in patients with Sjögren-Larsson syndrome. Providers should be aware of anesthetic management issues in Sjögren-Larsson syndrome including challenges placing and securing lines and monitors secondary to the ichthyosis.
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Affiliation(s)
- Marcellene H. Franzen
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA,Division of Pediatric Anesthesiology, Children’s Hospital and Medical Center, Omaha, NE, USA
| | - Michelle M. LeRiger
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA,Division of Pediatric Anesthesiology, Children’s Hospital and Medical Center, Omaha, NE, USA
| | - Jane A. Kugler
- Department of Pediatric Anesthesiology, Boys Town National Research Hospital, Omaha, NE, USA
| | - Kaitlyn P. Pellegrino
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA,Division of Pediatric Anesthesiology, Children’s Hospital and Medical Center, Omaha, NE, USA
| | - William B. Rizzo
- Department of Pediatrics and Child Health Research Institute, University of Nebraska Medical Center, Omaha, NE, USA
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Abidi KT, Kamal NM, Bakkar A AA, Alotaibi M, Asseri H, Bokari KA. Sjogren-Larsson Syndrome: A case series of five members from an extended family with a novel mutation. Mol Genet Genomic Med 2020; 8:e1487. [PMID: 32930514 PMCID: PMC7667322 DOI: 10.1002/mgg3.1487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUNDD Sjogren-Larsson syndrome (SLS) is a rare autosomal recessive disorder, characterized by a triad of spastic tetraplegia or diplegia, congenital ichthyosis, and intellectual disability. METHODS We report a seven-years-old female born to consanguineous parents who presented with erythematous dry scaly skin all over the body sparing the face, without collodion membrane which started since birth. There were associated with global developmental delay and seizure disorder. SLS was suspected and hence sequence analysis of the ALDH3A2 gene by next-generation sequencing was performed for the patient. RESULTS A novel nucleotide exchange in homozygous state at position c.1320 in exon 9 of the ALDH3A2 gene (c.1320T>A), leading to a stop of the protein sequence (p.Tyr440) was detected in the patient. Genetic testing of the patient's extended family revealed another four affected family members with the same mutation. CONCLUSIONS SLS should be suspected in any patient with a triad of ichthyosis, intellectual disability and spastic di/tetraplegia. Molecular genetic testing of the ALDH3A2 gene should be performed to confirm the diagnosis. Extended family screening is highly recommended.
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Affiliation(s)
- Kamel T Abidi
- Faculty of Medicine, Al Manar University, Tunis, Tunisia
| | - Naglaa M Kamal
- Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
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Staps P, van Gaalen J, van Domburg P, Steijlen PM, Ferdinandusse S, den Heijer T, Seyger MMB, Theelen T, Willemsen MAAP. Sjögren-Larsson syndrome: The mild end of the phenotypic spectrum. JIMD Rep 2020; 53:61-70. [PMID: 32395410 PMCID: PMC7203653 DOI: 10.1002/jmd2.12099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 01/19/2020] [Accepted: 01/21/2020] [Indexed: 12/18/2022] Open
Abstract
Sjögren-Larsson syndrome (SLS) is a rare inborn error of lipid metabolism. The syndrome is caused by mutations in the ALDH3A2 gene, resulting in a deficiency of fatty aldehyde dehydrogenase. Most patients have a clearly recognizable severe phenotype, with congenital ichthyosis, intellectual disability, and spastic diplegia. In this study, we describe two patients with a remarkably mild phenotype. In both patients, males with actual ages of 45 and 61 years, the diagnosis was only established at an adult age. Their skin had been moderately affected from childhood onward, and both men remained ambulant with mild spasticity of their legs. Cognitive development, as reflected by school performance and professional career, had been unremarkable. Magnetic resonance spectroscopy of the first patient was lacking the characteristic lipid peak. We performed a literature search to identify additional SLS patients with a mild phenotype. We compared the clinical, radiologic, and molecular features of the mildly affected patients with the classical phenotype. We found 10 cases in the literature with a molecular proven diagnosis and a mild phenotype. Neither a genotype-phenotype correlation nor an alternative explanation for the strikingly mild phenotypes was found. New biochemical techniques to study the underlying metabolic defect in SLS, like lipidomics, may in the future help to unravel the reasons for the exceptionally mild phenotypes. In the meantime, it is important to recognize these mildly affected patients to provide them with appropriate care and genetic counseling, and to increase our insights in the true disease spectrum of SLS.
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Affiliation(s)
- Pippa Staps
- Department of Pediatric NeurologyRadboud University Medical Center, Amalia Children's Hospital, Donders Institute for Brain Cognition and BehaviourNijmegenThe Netherlands
| | - Judith van Gaalen
- Department of Neurology, Donders Institute for Brain Cognition and BehaviourRadboud University Medical CenterNijmegenThe Netherlands
| | | | - Peter M. Steijlen
- Department of Dermatology, The GROW School for Oncology and Developmental BiologyMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Sacha Ferdinandusse
- Laboratory Genetic Metabolic Diseases, Amsterdam Gastroenterology & MetabolismAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - Tom den Heijer
- Department of NeurologyFranciscus Gasthuis and VlietlandRotterdamThe Netherlands
| | - Marieke M. B. Seyger
- Department of DermatologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Thomas Theelen
- Department of Ophthalmology, Donders Institute for Brain Cognition and BehaviourRadboud University Medical CenterNijmegenThe Netherlands
| | - Michèl A. A. P. Willemsen
- Department of Pediatric NeurologyRadboud University Medical Center, Amalia Children's Hospital, Donders Institute for Brain Cognition and BehaviourNijmegenThe Netherlands
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Abstract
Cerebral palsy is a syndrome that encompasses a large group of childhood movement and posture disorders that result from a lesion occurring in the developing brain. The clinical presentation of many metabolic and genetic conditions, particularly in highly consanguineous populations, can mimic cerebral palsy particularly at early age. The aim of this review article is to identify the clinical features that should alert the physician to the possibility of disorders that resemble cerebral palsy, the clinical and neuroimaging red flags, and highlight some metabolic and genetic conditions which may present with spasticity, ataxia and dyskinesia. In the case of metabolic or genetic disorder, making a precise diagnosis is particularly important for the possibility of treatment, accurate prognosis and genetic counseling.
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Affiliation(s)
- Wejdan S Hakami
- Division of Pediatric Neurology, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia
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Genetic assessment of ten Egyptian patients with Sjögren–Larsson syndrome: expanding the clinical spectrum and reporting a novel ALDH3A2 mutation. Arch Dermatol Res 2019; 311:721-730. [DOI: 10.1007/s00403-019-01953-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/23/2019] [Accepted: 07/13/2019] [Indexed: 12/19/2022]
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Sarret C, Ashkavand Z, Paules E, Dorboz I, Pediaditakis P, Sumner S, Eymard-Pierre E, Francannet C, Krupenko NI, Boespflug-Tanguy O, Krupenko SA. Deleterious mutations in ALDH1L2 suggest a novel cause for neuro-ichthyotic syndrome. NPJ Genom Med 2019; 4:17. [PMID: 31341639 PMCID: PMC6650503 DOI: 10.1038/s41525-019-0092-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/03/2019] [Indexed: 01/06/2023] Open
Abstract
Neuro-ichthyotic syndromes are a group of rare genetic diseases mainly associated with perturbations in lipid metabolism, intracellular vesicle trafficking, or glycoprotein synthesis. Here, we report a patient with a neuro-ichthyotic syndrome associated with deleterious mutations in the ALDH1L2 (aldehyde dehydrogenase 1 family member L2) gene encoding for mitochondrial 10-formyltetrahydrofolate dehydrogenase. Using fibroblast culture established from the ALDH1L2-deficient patient, we demonstrated that the enzyme loss impaired mitochondrial function affecting both mitochondrial morphology and the pool of metabolites relevant to β-oxidation of fatty acids. Cells lacking the enzyme had distorted mitochondria, accumulated acylcarnitine derivatives and Krebs cycle intermediates, and had lower ATP and increased ADP/AMP indicative of a low energy index. Re-expression of functional ALDH1L2 enzyme in deficient cells restored the mitochondrial morphology and the metabolic profile of fibroblasts from healthy individuals. Our study underscores the role of ALDH1L2 in the maintenance of mitochondrial integrity and energy balance of the cell, and suggests the loss of the enzyme as the cause of neuro-cutaneous disease.
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Affiliation(s)
- Catherine Sarret
- IGCNC, Institut Pascal, UMR CNRS-UCA-SIGMA, Aubière, France.,2Department of Clinical Genetics and Medical Cytogenetics, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Zahra Ashkavand
- 3Nutrition Research Institute, University of North Carolina, Chapel Hill, NC USA
| | - Evan Paules
- 3Nutrition Research Institute, University of North Carolina, Chapel Hill, NC USA.,4Department of Nutrition, University of North Carolina, Chapel Hill, NC USA
| | - Imen Dorboz
- 5INSERM UMR1141, DHU PROTECT, PARIS-DIDEROT, University Sorbonne Paris-Cite, Paris, France
| | - Peter Pediaditakis
- 3Nutrition Research Institute, University of North Carolina, Chapel Hill, NC USA
| | - Susan Sumner
- 3Nutrition Research Institute, University of North Carolina, Chapel Hill, NC USA.,4Department of Nutrition, University of North Carolina, Chapel Hill, NC USA
| | - Eléonore Eymard-Pierre
- 2Department of Clinical Genetics and Medical Cytogenetics, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Christine Francannet
- 2Department of Clinical Genetics and Medical Cytogenetics, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Natalia I Krupenko
- 3Nutrition Research Institute, University of North Carolina, Chapel Hill, NC USA.,4Department of Nutrition, University of North Carolina, Chapel Hill, NC USA
| | - Odile Boespflug-Tanguy
- 5INSERM UMR1141, DHU PROTECT, PARIS-DIDEROT, University Sorbonne Paris-Cite, Paris, France.,6Department of Child Neurology and Metabolic Disorders, LEUKOFRANCE, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sergey A Krupenko
- 3Nutrition Research Institute, University of North Carolina, Chapel Hill, NC USA.,4Department of Nutrition, University of North Carolina, Chapel Hill, NC USA
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Ott H. Guidance for assessment of erythroderma in neonates and infants for the pediatric immunologist. Pediatr Allergy Immunol 2019; 30:259-268. [PMID: 30702169 DOI: 10.1111/pai.13032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 11/24/2018] [Accepted: 11/26/2018] [Indexed: 12/25/2022]
Abstract
Neonatal and infantile erythroderma (NIE) represents the common clinical phenotype of heterogeneous diseases ranging from benign and transient skin conditions to fatal multiorgan disorders. NIE regularly demands a comprehensive diagnostic workup in a multiprofessional setting, especially if newborns and young infants with the disease develop a failure to thrive and concomitant infectious, neurologic, or metabolic complications. By obtaining a detailed medical history and performing a thorough clinical examination, targeted diagnostic steps can be scheduled for most affected children. If NIE occurs in the early neonatal period, lesional skin biopsy and histology are often indicated. Likewise, if monogenic skin or immunologic diseases are suspected, genetic testing with customized panels of potentially underlying genes is mandatory. Of note, if acute symptoms such as severe infections, metabolic acidosis, or seizures occur, rapid microbiologic and metabolic investigations are warranted to rule out immunodeficiency and inborn errors of metabolism.
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Affiliation(s)
- Hagen Ott
- Division of Pediatric Dermatology, Children's Hospital AUF DER BULT, Hannover, Germany.,Epidermolysis bullosa Centre, Hannover, Germany
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Ciliopathy: Sjögren-Larsson Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018. [PMID: 30578509 DOI: 10.1007/978-3-319-95046-4_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
Glistening yellow-white crystalline inclusions in foveal and parafoveal areas are almost pathognomonic (Fig. 36.1). These inclusions are evident at 1-2 years old and increase with age. Patients may have corneal stromal opacities, punctate keratitis, myopia, and astigmatism. About 50% have pigmentary degeneration of the retina, with decreased visual acuity and marked photophobia. Patients have dry, scaly skin (ichthyosis). Affected infants tend to be born prematurely. They also have neurological problems due to leukoencephalopathy (affecting the white matter of the brain). Intellectual disability varies from mild to severe, along with dysarthria and delayed speech.
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Neurodegeneration in an adolescent with Sjogren-Larsson syndrome: a decade-long follow-up case report. BMC MEDICAL GENETICS 2018; 19:152. [PMID: 30157790 PMCID: PMC6114270 DOI: 10.1186/s12881-018-0663-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 08/06/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Sjogren-Larsson syndrome is a hereditary neurocutaneous syndrome that is non-progressive in nature. Although neuroregression has been reported in seizure-prone preschool children requiring anti-epileptic treatment, teenage-onset dystonia precipitating neurodegeneration without any immediate causal events has yet to be reported. CASE PRESENTATION We describe a young woman with spastic diplegia and intellectual disability who began to show progressive neurological deterioration from 12 years of age, with the onset of dystonia and tremor. She was initially diagnosed with spastic cerebral palsy and periventricular leukomalacia based on brain magnetic resonance imaging. Follow-up brain imaging from 13 years of age did not reveal apparent changes, though abnormal electroencephalographic findings occurred in parallel with her decline in motor function. By 19 years of age, she had developed dysphagia and became completely dependent on others for most activities of daily living. Ultimately, whole-exome sequencing revealed a heterozygous compound mutation in the ALDH3A2 gene that corresponds to Sjogren-Larsson syndrome: an exon 9 deletion (1291-1292delAA) from the mother and an exon 5 splicing mutation (798 + 1delG) from the father. Neuroregression has been reported in preschool children after seizures requiring treatment, though our patient did not experience any immediate causal events. This report summarizes the clinical, radiologic, and electrophysiological findings observed over a decade concurrent with neurological deterioration after the onset of dystonia and tremor at the age of developmental ceiling in Sjogren-Larsson syndrome. CONCLUSIONS In addition to the influence of additive variants or other environmental factors, accumulation of metabolites due to defective fatty aldehyde dehydrogenase is a potential pathomechanism of neurodegeneration in this patient. Neurological deterioration may be a presentation that is unnoticed in Sjogren-Larsson syndrome due to the rarity of the disease. This report highlights a unique clinical feature of Sjogren-Larsson syndrome with progressive neurodegeneration associated with dystonia and tremor.
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