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Nickel M, Gissen P, Greenaway R, Cappelletti S, Hamborg C, Ragni B, Ribitzki T, Schulz A, Tondo I, Specchio N. Language Delay in Patients with CLN2 Disease: Could It Support Earlier Diagnosis? Neuropediatrics 2023; 54:402-406. [PMID: 37329878 PMCID: PMC10643021 DOI: 10.1055/s-0043-1770143] [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: 01/13/2023] [Accepted: 04/26/2023] [Indexed: 06/19/2023]
Abstract
Neuronal ceroid lipofuscinosis type 2 (CLN2 disease) is a rare pediatric disorder associated with rapid neurodegeneration, and premature death in adolescence. An effective enzyme replacement therapy (cerliponase alfa) has been approved that can reduce this predictable neurological decline. The nonspecific early symptoms of CLN2 disease frequently delay diagnosis and appropriate management. Seizures are generally recognized as the first presenting symptom of CLN2 disease, but emerging data show that language delay may precede this. An improved understanding of language deficits in the earliest stage of CLN2 disease may support the early identification of patients. In this article, CLN2 disease experts examine how language development is affected by CLN2 disease in their clinical practices. The authors' experiences highlighted the timings of first words and first use of sentences, and language stagnation as key features of language deficits in CLN2 disease, and how deficits in language may be an earlier sign of the disease than seizures. Potential challenges in identifying early language deficits include assessing patients with other complex needs, and recognizing that a child's language abilities are not within normal parameters given the variability of language development in young children. CLN2 disease should be considered in children presenting with language delay and/or seizures to facilitate earlier diagnosis and access to treatment that can significantly reduce morbidity.
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Affiliation(s)
- Miriam Nickel
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paul Gissen
- National Institute for Health Research Great Ormond Street Hospital Biomedical Research Centre, University College London, London, United Kingdom
| | - Rebecca Greenaway
- Neurodisability Service, Great Ormond Street Hospital, London, United Kingdom
| | - Simona Cappelletti
- Rare and Complex Epilepsy Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network: EpiCARE, Rome, Italy
| | | | - Benedetta Ragni
- Rare and Complex Epilepsy Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network: EpiCARE, Rome, Italy
| | | | - Angela Schulz
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ilaria Tondo
- Rare and Complex Epilepsy Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network: EpiCARE, Rome, Italy
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Bambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network: EpiCARE, Rome, Italy
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2
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Bernardi S, Gemignani F, Marchese M. The involvement of Purkinje cells in progressive myoclonic epilepsy: Focus on neuronal ceroid lipofuscinosis. Neurobiol Dis 2023; 185:106258. [PMID: 37573956 PMCID: PMC10480493 DOI: 10.1016/j.nbd.2023.106258] [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: 05/25/2023] [Revised: 08/01/2023] [Accepted: 08/11/2023] [Indexed: 08/15/2023] Open
Abstract
The progressive myoclonic epilepsies (PMEs) are a group of rare neurodegenerative diseases characterized by myoclonus, epileptic seizures, and progressive neurological deterioration with cerebellar involvement. They include storage diseases like Gaucher disease, Lafora disease, and forms of neuronal ceroid lipofuscinosis (NCL). To date, 13 NCLs have been reported (CLN1-CLN8, CLN10-CLN14), associated with mutations in different genes. These forms, which affect both children and adults, are characterized by seizures, cognitive and motor impairments, and in most cases visual loss. In NCLs, as in other PMEs, central nervous system (CNS) neurodegeneration is widespread and involves different subpopulations of neurons. One of the most affected regions is the cerebellar cortex, where motor and non-motor information is processed and transmitted to deep cerebellar nuclei through the axons of Purkinje cells (PCs). PCs, being GABAergic, have an inhibitory effect on their target neurons, and provide the only inhibitory output of the cerebellum. Degeneration of PCs has been linked to motor impairments and epileptic seizures. Seizures occur when some insult upsets the normal balance in the CNS between excitatory and inhibitory impulses, causing hyperexcitability. Here we review the role of PCs in epilepsy onset and progression following their PME-related loss. In particular, we focus on the involvement of PCs in seizure phenotype in NCLs, highlighting findings from case reports and studies of animal models in which epilepsy can be linked to PC loss.
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Affiliation(s)
- Sara Bernardi
- Department Neurobiology and Molecular Medicine, IRCCS Fondazione Stella Maris, 56128 Pisa, Italy; Department of Biology, University of Pisa, Pisa, Italy
| | | | - Maria Marchese
- Department Neurobiology and Molecular Medicine, IRCCS Fondazione Stella Maris, 56128 Pisa, Italy.
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3
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Ho ML, Wirrell EC, Petropoulou K, Sakonju A, Chu D, Seratti G, Palasis S. Role of Electroencephalogram (EEG) and Magnetic Resonance Imaging (MRI) Findings in Early Recognition and Diagnosis of Neuronal Ceroid Lipofuscinosis Type 2 Disease. J Child Neurol 2022; 37:984-991. [PMID: 36184928 DOI: 10.1177/08830738221128773] [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]
Abstract
Neuronal ceroid lipofuscinosis type 2 (CLN2) disease is a very rare neurodegenerative lysosomal storage disorder. Progression is rapid and irreversible, making early diagnosis crucial for timely treatment. A group of pediatric neurologists and neuroradiologists with expertise in CLN2 convened to discuss early electroencephalogram (EEG) and magnetic resonance imaging (MRI) findings in CLN2 diagnosis. Of 18 CLN2 cases, 16 (88.9%) had background slowing and 16 (88.9%) had epileptiform discharges on initial EEG. Seven of 17 (41.2%) patients who received intermittent low-frequency photic stimulation had a photoparoxysmal response. Initial MRIs showed subtle cerebellar (n = 14, 77.8%) or cerebral (n = 9, 50.0%) atrophy, white matter abnormalities (n = 11, 61.1%), and basal ganglia T2 hypointensity (n = 6, 33.3%), which became more apparent on follow-up MRI. The recognition of even subtle cerebellar atrophy and white matter signal changes in children aged 2-5 years who present with language delay, new-onset seizures, and an EEG with epileptiform discharges and background slowing should prompt investigation for CLN2. Because these early signs are not unique to CLN2, genetic testing is essential early in the diagnostic journey.
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Affiliation(s)
- Mai-Lan Ho
- Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | - Ai Sakonju
- 12302SUNY Upstate Medical University, Syracuse, NY, USA
| | - Dorna Chu
- 10926BioMarin Pharmaceutical Inc, Novato, CA, USA
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4
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Guelbert G, Guelbert N. Neuronal Ceroid Lipofuscinosis Type 2: A Case Series from Argentina. JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2022. [DOI: 10.1590/2326-4594-jiems-2022-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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5
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Unraveling neuronal ceroid lipofuscinosis type 2 (CLN2) disease: A tertiary center experience for determinants of diagnostic delay. Eur J Paediatr Neurol 2021; 33:94-98. [PMID: 34119739 DOI: 10.1016/j.ejpn.2021.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/27/2021] [Accepted: 05/30/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the clinical phenotype, disease course, laboratory, and genetic features of patients with CLN2 disease over a 20 year period with a special emphasis on risk factors for diagnostic delay. METHODS Thirty patients (23 families) with CLN2 disease, evaluated between 1996 and 2019 in a tertiary referral center in Turkey, were included. Clinical features, diagnostic pathway, disease course, genetic data, electrophysiological, and neuroimaging findings were analyzed, retrospectively. The patients diagnosed between 1996 and 2009, and 2010-2019 were defined as group 1 (G1), and group 2 (G2), respectively. Patients in these two groups were also compared. RESULTS The median age at symptom-onset was 36 months (20 months-7 years). Most common presenting symptoms were seizures (70%), followed by language delay (43%), and psychomotor regression (27%). Median age at diagnosis was 5.2 years (1.6-11 years) with a median 27 months (1 month-7 years) of diagnostic delay. Age at diagnosis was earlier in G2 (4.6 years vs 7 years, p = 0.002), with a shorter time to diagnosis (21 months vs 39 months, p = 0.004). Median time between the onset of first symptoms and death was 8.3 years (SE 1.0). Electroencephalograms (EEG) revealed abnormal features predominantly in posterior hemispheral regions and a photoparoxysmal response to intermittent photic stimulation was detected in 53% of the patients. Cerebellar (96%)/cerebral atrophy (83%), and white matter changes (57%) were the most common radiological abnormalities. CONCLUSIONS Most of our patients presented with late-infantile onset seizures. Despite increased availability of enzymatic and molecular testing, there is still a considerable diagnostic delay.
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6
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Singh RB, Gupta P, Kartik A, Farooqui N, Singhal S, Shergill S, Singh KP, Agarwal A. Ocular Manifestations of Neuronal Ceroid Lipofuscinoses. Semin Ophthalmol 2021; 36:582-595. [PMID: 34106804 DOI: 10.1080/08820538.2021.1936571] [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: 10/21/2022]
Abstract
Neuronal ceroid lipofuscinoses (NCLs) are a group of rare neurodegenerative storage disorders associated with devastating visual prognosis, with an incidence of 1/1,000,000 in the United States and comparatively higher incidence in European countries. The pathophysiological mechanisms causing NCLs occur due to enzymatic or transmembrane defects in various sub-cellular organelles including lysosomes, endoplasmic reticulum, and cytoplasmic vesicles. NCLs are categorized into different types depending upon the underlying cause i.e., soluble lysosomal enzyme deficiencies or non-enzymatic deficiencies (functions of identified proteins), which are sub-divided based on an axial classification system. In this review, we have evaluated the current evidence in the literature and reported the incidence rates, underlying mechanisms and currently available management protocols for these rare set of neuroophthalmological disorders. Additionally, we also highlighted the potential therapies under development that can expand the treatment of these rare disorders beyond symptomatic relief.
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Affiliation(s)
- Rohan Bir Singh
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA.,Department of Ophthalmology, Leiden University Medical Center, Leiden, The Netherlands
| | - Prakash Gupta
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Akash Kartik
- Department of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Naba Farooqui
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sachi Singhal
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sukhman Shergill
- Department of Anesthesiology, Yale-New Haven Hospital, New Haven, CT, USA
| | - Kanwar Partap Singh
- Department of Ophthalmology, Dayanand Medical College & Hospital, Ludhiana, India
| | - Aniruddha Agarwal
- Eye Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
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7
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Rigaudière F, Nasser H, Pichard-Oumlil S, Delouvrier E, Lopez-Hernandez E, Milani P, Auvin S, Delanoë C. Evolution of the retinal function by flash-ERG in one child suffering from neuronal ceroid lipofuscinosis CLN2 treated with cerliponase alpha: case report. Doc Ophthalmol 2021; 143:99-106. [PMID: 33956290 DOI: 10.1007/s10633-021-09825-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 01/25/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Neuronal ceroid lipofuscinoses (CLN) are neurodegenerative disorders among the most frequent, inherited as an autosomal recessive trait. Affected patients can present with progressive decline in cognitive and motor functions, seizures, a shortened life span and visual deficiency. CLN2 is one of the rare CLN that benefits from treatment by cerliponase alpha an enzyme replacement therapy. Preliminary results on treated animal models have shown delayed neurological signs and prolonged life span. However, cerliponase alpha did not prevent vision loss or retinal degeneration in those animal models. Cerliponase alpha has currently been delivered to a few CLN2-affected patients. We report the case of one patient suffering from CLN2 treated with intracerebroventricular infusions of cerliponase alpha 300 mg every two weeks. Evolution of his retinal function was assessed by three successive flash-ERG and flash-VEP recordings throughout his treatment over a 4-year period. RESULTS Before treatment at the age of 4 years 5 months, patient's retinas were normal (normal fundi and normal flash-ERG). After 29 infusions at the age of 6 years 10 months, a-wave combined response was absent, while cone and flicker responses were normal. After 80 infusions at the age of 8 years 9 months, a-wave cone response was absent with b-wave peak time increased, and no combined response. COMMENTS Despite treatment, our patient's retinas showed a progressive abnormal and inhomogeneous function. Rods function was altered first, then the scotopic system and afterward, the cones. This result differs from those recorded in animal models. The relative preservation of cone functioning for a while could not be unequivocally attributed to enzyme replacement therapy as we lack comparison with the evolution of flash-ERGs recorded in untreated subjects.
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Affiliation(s)
- Florence Rigaudière
- Service de Physiologie Clinique. Explorations Fonctionnelles, Hôpital Lariboisière, AP-HP, Paris, France. .,Faculté de Médecine Paris-Diderot, Université de Paris, Paris, France. .,Service des Explorations Fonctionnelles, Hôpital Robert Debré, AP-HP, Paris, France.
| | - Hala Nasser
- Service des Explorations Fonctionnelles, Hôpital Robert Debré, AP-HP, Paris, France.,Département de Génétique, Hôpital Robert Debré, AP-HP, Paris, France
| | | | - Eliane Delouvrier
- Service d'Ophtalmologie Pédiatrique, Hôpital Robert Debré, AP-HP, Paris, France
| | | | - Paolo Milani
- Service de Physiologie Clinique. Explorations Fonctionnelles, Hôpital Lariboisière, AP-HP, Paris, France
| | - Stéphane Auvin
- Faculté de Médecine Paris-Diderot, Université de Paris, Paris, France.,Neurologie Pédiatrique, Hôpital Robert Debré, AP-HP, Paris, France
| | - Catherine Delanoë
- Service des Explorations Fonctionnelles, Hôpital Robert Debré, AP-HP, Paris, France
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8
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Mole SE, Schulz A, Badoe E, Berkovic SF, de Los Reyes EC, Dulz S, Gissen P, Guelbert N, Lourenco CM, Mason HL, Mink JW, Murphy N, Nickel M, Olaya JE, Scarpa M, Scheffer IE, Simonati A, Specchio N, Von Löbbecke I, Wang RY, Williams RE. Guidelines on the diagnosis, clinical assessments, treatment and management for CLN2 disease patients. Orphanet J Rare Dis 2021; 16:185. [PMID: 33882967 PMCID: PMC8059011 DOI: 10.1186/s13023-021-01813-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 04/06/2021] [Indexed: 11/28/2022] Open
Abstract
Background CLN2 disease (Neuronal Ceroid Lipofuscinosis Type 2) is an ultra-rare, neurodegenerative lysosomal storage disease, caused by an enzyme deficiency of tripeptidyl peptidase 1 (TPP1). Lack of disease awareness and the non-specificity of presenting symptoms often leads to delayed diagnosis. These guidelines provide robust evidence-based, expert-agreed recommendations on the risks/benefits of disease-modifying treatments and the medical interventions used to manage this condition. Methods An expert mapping tool process was developed ranking multidisciplinary professionals, with knowledge of CLN2 disease, diagnostic or management experience of CLN2 disease, or family support professionals. Individuals were sequentially approached to identify two chairs, ensuring that the process was transparent and unbiased. A systematic literature review of published evidence using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance was independently and simultaneously conducted to develop key statements based upon the strength of the publications. Clinical care statements formed the basis of an international modified Delphi consensus determination process using the virtual meeting (Within3) online platform which requested experts to agree or disagree with any changes. Statements reaching the consensus mark became the guiding statements within this manuscript, which were subsequently assessed against the Appraisal of Guidelines for Research and Evaluation (AGREEII) criteria. Results Twenty-one international experts from 7 different specialities, including a patient advocate, were identified. Fifty-three guideline statements were developed covering 13 domains: General Description and Statements, Diagnostics, Clinical Recommendations and Management, Assessments, Interventions and Treatment, Additional Care Considerations, Social Care Considerations, Pain Management, Epilepsy / Seizures, Nutritional Care Interventions, Respiratory Health, Sleep and Rest, and End of Life Care. Consensus was reached after a single round of voting, with one exception which was revised, and agreed by 100% of the SC and achieved 80% consensus in the second voting round. The overall AGREE II assessment score obtained for the development of the guidelines was 5.7 (where 1 represents the lowest quality, and 7 represents the highest quality). Conclusion This program provides robust evidence- and consensus-driven guidelines that can be used by all healthcare professionals involved in the management of patients with CLN2 disease and other neurodegenerative disorders. This addresses the clinical need to complement other information available. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-01813-5.
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Affiliation(s)
| | - Angela Schulz
- Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Eben Badoe
- Korle Bu Teaching Hospital, University of Ghana Medical School, Accra, Ghana
| | - Samuel F Berkovic
- Austin Health Victoria, University of Melbourne, Heidelberg, VIC, Australia
| | | | - Simon Dulz
- Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Paul Gissen
- University College London, London, UK.,NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | | | - Charles M Lourenco
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto, Riberirao Preto, Brazil
| | | | - Jonathan W Mink
- Golisano Childrens' Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Noreen Murphy
- Batten Disease Support and Research Association (BDSRA), Columbus, OH, USA
| | - Miriam Nickel
- Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Joffre E Olaya
- Children's Hospital of Orange County, Orange County, CA, USA
| | - Maurizio Scarpa
- Regional Coordinating Center for Rare Diseases, University Hospital Udine, Udine, Italy
| | - Ingrid E Scheffer
- Austin Health Victoria, University of Melbourne, Heidelberg, VIC, Australia.,Royal Children's Hospital, Florey and Murdoch Children's Research Institutes, Melbourne, Australia
| | - Alessandro Simonati
- Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona School of Medicine, Verona, Italy
| | | | | | - Raymond Y Wang
- Children's Hospital of Orange County, Orange County, CA, USA
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9
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Mazurkiewicz-Bełdzińska M, Del Toro M, Haliloğlu G, Huidekoper HH, Kravljanac R, Mühlhausen C, Andersen BN, Prpić I, Striano P, Auvin S. Managing CLN2 disease: a treatable neurodegenerative condition among other treatable early childhood epilepsies. Expert Rev Neurother 2021; 21:1275-1282. [PMID: 33538188 DOI: 10.1080/14737175.2021.1885374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Neuronal ceroid lipofuscinosis type 2 (CLN2 disease) is a rare pediatric neurodegenerative condition, which is usually fatal by mid-adolescence. Seizures are one of the most common early symptoms of CLN2 disease, but patients often experience language deficits, movement disorders, and behavioral problems. Diagnosis of CLN2 disease is challenging (particularly when differentiating between early-onset developmental, metabolic, or epileptic syndromes), and diagnostic delays often overlap with rapid disease progression. An enzyme replacement therapy (cerliponase alfa) is now available, adding CLN2 disease to the list of potentially treatable disorders requiring a prompt diagnosis. AREAS COVERED Although advances in enzymatic activity testing and genetic testing have facilitated diagnoses of CLN2 disease, our review highlights the presenting symptoms that are vital in directing clinicians to perform appropriate tests or seek expert opinion. We also describe common diagnostic challenges and some potential misdiagnoses that may occur during differential diagnosis. EXPERT OPINION An awareness of CLN2 disease as a potentially treatable disorder and increased understanding of the key presenting symptoms can support selection of appropriate tests and prompt diagnosis. The available enzyme replacement therapy heralds an even greater imperative for early diagnosis, and for clinicians to direct patients to appropriate diagnostic pathways.
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Affiliation(s)
| | - Mireia Del Toro
- Department of Pediatric Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Göknur Haliloğlu
- Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Hidde H Huidekoper
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ružica Kravljanac
- Institute for Mother and Child Healthcare of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Chris Mühlhausen
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Göttingen, Germany
| | - Brian Nauheimer Andersen
- Department of Pediatric and Adolescent Medicine, Centre for Rare Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Igor Prpić
- Faculty of Medicine, Clinical Hospital Centre Rijeka, University of Rijeka, Rijeka, Croatia
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Stéphane Auvin
- Pediatric Neurology Department, Rare Epilepsy Center, Université de Paris, Robert Debré University Hospital, Paris, France
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10
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Madaan P, Jauhari P, Luhar ZM, Chakrabarty B, Gulati S. Autism, Epilepsy, and Neuroregression: Photosensitivity on Electroencephalography Solved the Riddle. Clin EEG Neurosci 2020; 51:399-402. [PMID: 31903771 DOI: 10.1177/1550059419899327] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Autistic epileptiform regression is an uncommon but extensively described malady in children. The clinico-etiological spectrum of this entity ranges from electrical status epilepticus in sleep to various neurogenetic and neurodegenerative disorders. Identification of these disorders is crucial considering their therapeutic and prognostic implications. Simple investigations such as neuroimaging and electroencephalography with activation procedures can provide valuable diagnostic clues in resource-limited settings; facilitating targeted genetic/metabolic testing. Here we report a 3.5-year-old girl with autistic regression and epilepsy. Neuronal ceroid lipofuscinosis was suspected as her electroencephalogram showed photoparoxysmal response on low-frequency (1-3 Hz) intermittent photic stimulation. A deficient leukocyte tripeptidyl peptidase 1 enzyme confirmed the diagnosis of late infantile neuronal ceroid lipofuscinosis.
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Affiliation(s)
- Priyanka Madaan
- Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Prashant Jauhari
- Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Zulfiqar M Luhar
- Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Biswaroop Chakrabarty
- Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sheffali Gulati
- Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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11
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Gowda VK, Vegda H, Sugumar K, Narayanappa G, Srinivasan VM, Santhoshkumar R, Bhat M, Balu S, Naveen MR. Neuronal Ceroid Lipofuscinosis: Clinical and Laboratory Profile in Children from Tertiary Care Centre in South India. J Pediatr Genet 2020; 10:266-273. [PMID: 34849271 DOI: 10.1055/s-0040-1715575] [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: 05/12/2020] [Accepted: 07/08/2020] [Indexed: 10/23/2022]
Abstract
Neuronal ceroid Lipofuscinosis (NCL), inherited disorders of lysosomal storage disorders, constitute the most common progressive encephalopathies with an incidence of 1.3 to 7 in 100,000 live births. We reported clinical, electrophysiological, radiological, ultrastructural, and molecular genetic features of NCL. This is a retrospective review, in a tertiary care center from January 2016 to December 2019. All children with clinical features of NCL and confirmed by pathogenic mutation and/or enzyme assay were included. A total of 60 children (male:female = 3:1) were studied. The commonest type was CLN 2 (41.7%). Neuroregression, seizures, and ataxia were present in all cases. Retinal arterial attenuation was seen in 38.33% cases. Magnetic resonance imaging (MRI) brain was abnormal in all patients, thalamic and caudate nucleus atrophy common in CLN1 (62%). Electroencephalography was abnormal in all children, but photoparoxysmal response at low intermittent photic stimulation frequencies was seen in four children of CLN2. Electron microscopy done in 43 children revealed abnormal inclusions in 20 (46.52%) children. Enzyme study showed low levels in 36 (78%) out of 46 cases. Of these, 21 had low tripeptidyl peptidase and 15 had low palmitoyl protein thioesterase levels. Molecular testing done in 26 cases showed pathogenic variant in 23 (88%) cases. Infantile onset with thalamic atrophy on MRI is common in CLN1 and refractory epilepsy, visual impairment and specific EEG changes are common in CLN2. These features are helpful in selecting enzyme assay for CLN1 versus CLN2. Electron microscopy helped in the diagnosis and genetic testing in subtyping. Thus, a multimode approach played a role in the diagnosis of NCL.
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Affiliation(s)
- Vykuntaraju K Gowda
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bangalore, India
| | - Hemadri Vegda
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bangalore, India
| | - Kiruthiga Sugumar
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bangalore, India
| | - Gayathri Narayanappa
- Department of Neuropathology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | | | - Rashmi Santhoshkumar
- Electron Microscope Laboratory, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Maya Bhat
- Department of Neuroradiology, National institute of Mental Health and Neurosciences, Bangalore, India
| | - Sam Balu
- Molecular Genetics Department, Eurofins Clinical Genetics, Bangalore, India
| | - Mohan Rao Naveen
- Molecular Genetics Department, Eurofins Clinical Genetics, Bangalore, India
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12
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Johnson AM, Mandelstam S, Andrews I, Boysen K, Yaplito‐Lee J, Fietz M, Nagarajan L, Rodriguez‐Casero V, Ryan MM, Smith N, Scheffer IE, Ellaway C. Neuronal ceroid lipofuscinosis type 2: an Australian case series. J Paediatr Child Health 2020; 56:1210-1218. [PMID: 32329550 PMCID: PMC7497200 DOI: 10.1111/jpc.14890] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/03/2020] [Accepted: 03/23/2020] [Indexed: 02/05/2023]
Abstract
AIM Late infantile neuronal ceroid lipofuscinosis type 2 (CLN2) disease is a rare neurodegenerative disorder presenting in children aged 2-4 years with seizures and loss of motor and language skills, followed by blindness and death in late childhood. Initial presenting features are similar to a range of common epilepsies. We aim to highlight typical clinical and radiological features that may prompt diagnosis of CLN2 disease in early disease stages. METHODS We present a series of 13 Australian patients with CLN2 disease, describing clinical features, disease evolution, neuroimaging, electroencephalogram, biochemical and genetic results. Expert neuroradiological magnetic resonance imaging (MRI) analysis was retrospectively performed on 10 cases. RESULTS Twelve patients presented with seizures, with initial seizures being focal (n = 4), generalised tonic-clonic (n = 3), absence (n = 3) and febrile (n = 2). Eleven patients (85%) had a language delay before the onset of seizures. Cerebellar or cerebral atrophy was noted in all patients on centralised MRI review, with abnormalities of the brain-stem, ventricles, corpus callosum and hippocampi. CONCLUSIONS Early language delay with the onset of seizures at 2-4 years of age is the hallmark of CLN2 disease. MRI findings of early subtle atrophy in the cerebellum or posterior cortical regions should hasten testing for CLN2 disease to enable early initiation of enzyme replacement therapy.
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Affiliation(s)
- Alexandra M Johnson
- Department of NeurologySydney Children's HospitalSydneyNew South WalesAustralia
| | - Simone Mandelstam
- Department of PaediatricsUniversity of MelbourneMelbourneVictoriaAustralia,Department of RadiologyUniversity of MelbourneMelbourneVictoriaAustralia,Imaging and Epilepsy GroupThe Florey Institute of Neuroscience and Mental HealthMelbourneVictoriaAustralia,Department of Paediatric RadiologyThe Royal Children's Hospital MelbourneMelbourneVictoriaAustralia,Murdoch Children's Research InstituteThe Royal Children's Hospital MelbourneMelbourneVictoriaAustralia
| | - Ian Andrews
- Department of NeurologySydney Children's HospitalSydneyNew South WalesAustralia
| | - Katja Boysen
- Department of PaediatricsThe Royal Children's Hospital MelbourneMelbourneVictoriaAustralia
| | - Joy Yaplito‐Lee
- Department of PaediatricsUniversity of MelbourneMelbourneVictoriaAustralia,Department of Metabolic medicineThe Royal Children's Hospital MelbourneMelbourneVictoriaAustralia
| | - Michael Fietz
- Clinical InformaticsIllumina AustraliaMelbourneVictoriaAustralia,Diagnostic genomicsPathWest Laboratory Medicine WAPerthWestern AustraliaAustralia,National Referral LaboratorySA PathologyAdelaideSouth AustraliaAustralia
| | - Lakshmi Nagarajan
- Children's Neuroscience ServicePerth Children's HospitalPerthWestern AustraliaAustralia,Faculty of Health and Medical SciencesThe University of Western AustraliaPerthWestern AustraliaAustralia
| | - Victoria Rodriguez‐Casero
- Department of PaediatricsUniversity of MelbourneMelbourneVictoriaAustralia,Neurology DepartmentThe Royal Children's Hospital MelbourneMelbourneVictoriaAustralia
| | - Monique M Ryan
- Department of PaediatricsUniversity of MelbourneMelbourneVictoriaAustralia,Murdoch Children's Research InstituteThe Royal Children's Hospital MelbourneMelbourneVictoriaAustralia,Neurology DepartmentThe Royal Children's Hospital MelbourneMelbourneVictoriaAustralia
| | - Nicholas Smith
- Department of Neurology and Clinical NeurophysiologyWomen's and Children's HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical SchoolThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Ingrid E Scheffer
- Imaging and Epilepsy GroupThe Florey Institute of Neuroscience and Mental HealthMelbourneVictoriaAustralia,Murdoch Children's Research InstituteThe Royal Children's Hospital MelbourneMelbourneVictoriaAustralia,Neurology DepartmentThe Royal Children's Hospital MelbourneMelbourneVictoriaAustralia,Department of NeurologyAustin HealthMelbourneVictoriaAustralia
| | - Carolyn Ellaway
- Genetic Metabolic Disorders ServiceThe Sydney Children's Hospitals NetworkSydneyNew South WalesAustralia,Disciplines of Genetic Medicine and Child and Adolescent HealthThe University of SydneySydneyNew South WalesAustralia
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13
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Amadori E, Scala M, Cereda GS, Vari MS, Marchese F, Di Pisa V, Mancardi MM, Giacomini T, Siri L, Vercellino F, Serino D, Orsini A, Bonuccelli A, Bagnasco I, Papa A, Minetti C, Cordelli DM, Striano P. Targeted re-sequencing for early diagnosis of genetic causes of childhood epilepsy: the Italian experience from the 'beyond epilepsy' project. Ital J Pediatr 2020; 46:92. [PMID: 32631363 PMCID: PMC7339579 DOI: 10.1186/s13052-020-00860-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/01/2020] [Indexed: 01/12/2023] Open
Abstract
Background Childhood epilepsies are a heterogeneous group of conditions differing in diagnostic criteria, management, and outcome. Late-infantile neuronal ceroid lipofuscinosis type 2 (CLN2) is a neurodegenerative condition caused by biallelic TPP1 variants. This disorder presents with subtle and relatively non-specific symptoms, mimicking those observed in more common paediatric epilepsies and followed by rapid psychomotor deterioration and drug-resistant epilepsy. A prompt diagnosis is essential to adopt appropriate treatment and disease management strategies. Methods This is a prospective, multicentre study on the efficiency of targeted re-sequencing in the early identification of the genetic causes of childhood epilepsy, with particular regard to CLN2. After phenotypic characterization, a 283-gene Next Generation Sequencing panel was performed in 21 Italian children with neurodevelopmental abnormalities, aged between 24 and 60 months, experiencing first unprovoked seizure after 2 years of age. Results The average age at enrolment was 39.9 months, with a mean age at seizure onset of 30.9 months and a mean time interval between seizure onset and targeted resequencing of 9 months. Genetic confirmation was achieved in 4 out of 21 patients, with a diagnostic yield of 19%. In one case, the homozygous splice acceptor variant c.509-1G > C in TPP1 was identified, leading to a CLN2 diagnosis. Three pathogenic variants in MECP2 were also detected in three patients, including the frameshift variant c.1157_1186delinsA (p.Leu386Hisfs*9) in a girl with negative single gene sequencing. Variants of unknown significance (VUS) were found in 11 out of 21 (52.4%) individuals, whereas no clinically significant variants were observed in the remaining 6 subjects. Conclusions Our findings support the efficacy of target re-sequencing in the identification of the genetic causes of childhood epilepsy and suggest that this technique might prove successful in the early detection of CLN2 as well as other neurodevelopmental conditions.
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Affiliation(s)
- Elisabetta Amadori
- Pediatric Neurology and Muscular Diseases Unit, IRCCS 'G. Gaslini' Institute, 16147, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Marcello Scala
- Pediatric Neurology and Muscular Diseases Unit, IRCCS 'G. Gaslini' Institute, 16147, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Giulia Sofia Cereda
- Pediatric Neurology and Muscular Diseases Unit, IRCCS 'G. Gaslini' Institute, 16147, Genoa, Italy
| | - Maria Stella Vari
- Pediatric Neurology and Muscular Diseases Unit, IRCCS 'G. Gaslini' Institute, 16147, Genoa, Italy
| | - Francesca Marchese
- Pediatric Neurology and Muscular Diseases Unit, IRCCS 'G. Gaslini' Institute, 16147, Genoa, Italy
| | - Veronica Di Pisa
- Child Neurology and Psychiatry Unit, Department of Medical and Surgical Sciences (DIMEC), S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Maria Margherita Mancardi
- Child Neuropsychiatry Unit, Epilepsy Centre, Department of Clinical and Surgical Neurosciences and Rehabilitation, IRCSS 'G. Gaslini' Institute, Genoa, Italy
| | - Thea Giacomini
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.,Child Neuropsychiatry Unit, Epilepsy Centre, Department of Clinical and Surgical Neurosciences and Rehabilitation, IRCSS 'G. Gaslini' Institute, Genoa, Italy
| | - Laura Siri
- Child Neuropsychiatry Unit, IRCSS 'G. Gaslini' Institute, Genoa, Italy
| | - Fabiana Vercellino
- Department of Child Neurology and Psychiatry, Cesare Arrigo Hospital, Alessandria, Italy
| | - Domenico Serino
- Department of Paediatric Neurology, Royal Aberdeen Children's Hospital, Aberdeen, UK.,Child Neurology and Psychiatry Unit, ASL CN1, Cuneo, Italy
| | - Alessandro Orsini
- Pediatric Neurology, Pediatric Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Alice Bonuccelli
- Pediatric Neurology, Pediatric Department, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Irene Bagnasco
- Division of Child Neuropsychiatry, Martini Hospital, via Tofane 71, 10141, Torino, Italy
| | - Amanda Papa
- Department of Child Neuropsychiatry, AOU Maggiore della Carita, Novara, Italy
| | - Carlo Minetti
- Pediatric Neurology and Muscular Diseases Unit, IRCCS 'G. Gaslini' Institute, 16147, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Duccio Maria Cordelli
- Child Neurology and Psychiatry Unit, Department of Medical and Surgical Sciences (DIMEC), S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS 'G. Gaslini' Institute, 16147, Genoa, Italy. .,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy.
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14
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Abstract
The progressive myoclonic epilepsies (PMEs) represent a rare but devastating group of syndromes characterized by epileptic myoclonus, typically action-induced seizures, neurological regression, medically refractory epilepsy, and a variety of other signs and symptoms depending on the specific syndrome. Most of the PMEs begin in children who are developing as expected, with the onset of the disorder heralded by myoclonic and other seizure types. The conditions are considerably heterogenous, but medical intractability to epilepsy, particularly myoclonic seizures, is a core feature. With the increasing use of molecular genetic techniques, mutations and their abnormal protein products are being delineated, providing a basis for disease-based therapy. However, genetic and enzyme replacement or substrate removal are in the nascent stage, and the primary therapy is through antiepileptic drugs. Epilepsy in children with progressive myoclonic seizures is notoriously difficult to treat. The disorder is rare, so few double-blinded, placebo-controlled trials have been conducted in PME, and drugs are chosen based on small open-label trials or extrapolation of data from drug trials of other syndromes with myoclonic seizures. This review discusses the major PME syndromes and their neurogenetic basis, pathophysiological underpinning, electroencephalographic features, and currently available treatments.
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Affiliation(s)
- Gregory L Holmes
- Department of Neurological Sciences, Larner College of Medicine, University of Vermont College of Medicine, Stafford Hall, 118C, Burlington, VT, 05405, USA.
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15
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Specchio N, Pietrafusa N, Trivisano M. Changing Times for CLN2 Disease: The Era of Enzyme Replacement Therapy. Ther Clin Risk Manag 2020; 16:213-222. [PMID: 32280231 PMCID: PMC7127909 DOI: 10.2147/tcrm.s241048] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/18/2020] [Indexed: 01/23/2023] Open
Abstract
Neuronal ceroid lipofuscinosis type 2 (CLN2 disease) is a progressive neurodegenerative disease that results in early-onset, severe, progressive, neurological disabilities, leading to death in late childhood or early adolescence. Management has relied on symptomatic care, and supportive and palliative strategies, but the approval of the enzyme replacement therapy cerliponase alfa in the USA and Europe in 2017 brought different treatment opportunities. We describe the natural history of CLN2 disease, its diagnosis and management, and the preclinical and clinical development of cerliponase alfa. A PubMed search was undertaken for cerliponase alfa and rhTPP1 to identify preclinical and clinical studies. The hallmark-presenting symptoms of CLN2 disease are unprovoked seizures and a history of language delay, and progression involves motor dysfunction, and cognitive and visual decline. Cerliponase alfa has shown efficacy and tolerability in mouse and canine models of CLN2 disease when delivered intracerebroventricularly. Administration of cerliponase alfa in patients with CLN2 disease has led to significant reductions in the rate of decline of motor and language functions in comparison with a natural history population. The approval of cerliponase alfa has brought a new era for CLN2 disease, highlighting the need to understand different patterns of disease progression and clinical needs in treated patients.
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Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Nicola Pietrafusa
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marina Trivisano
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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16
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Guelbert N, Atanacio N, Denzler I, Embiruçu EK, Mancilla N, Naranjo R, Pessoa A, Spécola N, Tavera L, Troncoso M, Vergara D. Position of Experts Regarding Follow-Up of Patients with Neuronal Ceroid Lipofuscinosis-2 Disease in Latin America. JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2020. [DOI: 10.1590/2326-4594-jiems-2020-0012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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17
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Abstract
The lysosomal storage diseases (LSDs) are a group of inherited metabolic disorders that are caused for the most part by enzyme deficiencies within the lysosome resulting in accumulation of undegraded substrate. This storage process leads to a broad spectrum of clinical manifestations depending on the specific substrate and site of accumulation. Examples of LSDs include the mucopolysaccharidoses, mucolipidoses, oligosaccharidoses, Pompe disease, Gaucher disease, Fabry disease, the Niemann-Pick disorders, and neuronal ceroid lipofuscinoses. This review summarizes the main clinical features, diagnosis, and management of LSDs with an emphasis on those for which treatment is available.
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Affiliation(s)
- Angela Sun
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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18
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Abstract
The lysosomal storage diseases (LSDs) are a group of inherited metabolic disorders that are caused for the most part by enzyme deficiencies within the lysosome resulting in accumulation of undegraded substrate. This storage process leads to a broad spectrum of clinical manifestations depending on the specific substrate and site of accumulation. Examples of LSDs include the mucopolysaccharidoses, mucolipidoses, oligosaccharidoses, Pompe disease, Gaucher disease, Fabry disease, the Niemann-Pick disorders, and neuronal ceroid lipofuscinoses. This review summarizes the main clinical features, diagnosis, and management of LSDs with an emphasis on those for which treatment is available.
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Affiliation(s)
- Angela Sun
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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19
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Chen ZR, Liu DT, Meng H, Liu L, Bian WJ, Liu XR, Zhu WW, He Y, Wang J, Tang B, Su T, Yi YH. Homozygous missense TPP1 mutation associated with mild late infantile neuronal ceroid lipofuscinosis and the genotype-phenotype correlation. Seizure 2018; 69:180-185. [PMID: 31059981 DOI: 10.1016/j.seizure.2018.08.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 12/23/2022] Open
Abstract
PURPOSE TPP1 mutations have been identified in patients with variable phenotypes such as late infantile neuronal ceroid lipofuscinosis (LINCL), juvenile neuronal ceroid lipofuscinosis (JNCL), and spinocerebellar ataxia 7. However, the mechanism underlying phenotype variation is unknown. We screened TPP1 mutations in patients with epilepsies and analyzed the genotype-phenotype correlation to explain the phenotypic variations. METHODS We performed targeted next-generation sequencing in a cohort of 330 patients with epilepsies. All previously reported TPP1 mutations were systematically retrieved from the PubMed and NCL Mutation Database. RESULTS The homozygous missense TPP1 mutation c.646 G > A/ p.Val216Met was identified in a family with two affected siblings. The proband presented with seizures from three years of age, while no ataxia, cognitive regression, or visual abnormalities were observed. Further analysis of all reported TPP1 mutations revealed that the LINCL group had a significantly higher frequency of truncating and invariant splice-site mutations than the JNCL group. In contrast, the JNCL group had a higher frequency of variant splice-site mutations than LINCL. There was a significant correlation between phenotype severity and the frequency of destructive mutation. CONCLUSION This study suggested that the phenotype of mainly epilepsy can be included in the phenotypic spectrum of TPP1 mutations, which are candidate targets for genetic screening in patients with epilepsy. With the development of therapy techniques, early genetic diagnosis may enable the improvement of etiology-targeted treatments. The relationship between phenotype severity and the genotype of TPP1 mutations may help explain the phenotypic variations.
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Affiliation(s)
- Zi-Rong Chen
- Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou, Guangdong, China; Department of Neurology of the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - De-Tian Liu
- Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou, Guangdong, China
| | - Heng Meng
- Department of Neurology of the First Affiliated Hospital of Jinan University and Clinical Neuroscience Institute of Jinan University, Guangzhou, Guangdong, China
| | - Liu Liu
- Department of Neurology, Xiaoshan First People's Hospital, Hangzhou, Zhejiang, China
| | - Wen-Jun Bian
- Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou, Guangdong, China
| | - Xiao-Rong Liu
- Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou, Guangdong, China
| | - Wei-Wen Zhu
- Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou, Guangdong, China
| | - Yong He
- Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou, Guangdong, China
| | - Jie Wang
- Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou, Guangdong, China
| | - Bin Tang
- Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou, Guangdong, China
| | - Tao Su
- Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou, Guangdong, China
| | - Yong-Hong Yi
- Institute of Neuroscience and the Second Affiliated Hospital of Guangzhou Medical University, Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou, Guangdong, China.
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20
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Beltrán L, Valenzuela GR, Loos M, Vargas R, Lizama R, Spinsanti P, Caraballo R. Late-onset childhood neuronal ceroid lipofuscinosis: Early clinical and electroencephalographic markers. Epilepsy Res 2018; 144:49-52. [DOI: 10.1016/j.eplepsyres.2018.05.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 05/08/2018] [Accepted: 05/12/2018] [Indexed: 11/25/2022]
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21
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Disease characteristics and progression in patients with late-infantile neuronal ceroid lipofuscinosis type 2 (CLN2) disease: an observational cohort study. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:582-590. [PMID: 30119717 DOI: 10.1016/s2352-4642(18)30179-2] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 05/23/2018] [Accepted: 05/23/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Late-infantile neuronal ceroid lipofuscinosis type 2 (CLN2) disease, characterised by rapid psychomotor decline and epilepsy, is caused by deficiency of the lysosomal enzyme tripeptidyl peptidase 1. We aimed to analyse the characteristics and rate of progression of CLN2 disease in an international cohort of patients. METHODS We did an observational cohort study using data from two independent, international datasets of patients with untreated genotypically confirmed CLN2 disease: the DEM-CHILD dataset (n=74) and the Weill Cornell Medical College (WCMC) dataset (n=66). Both datasets included quantitative rating assessments with disease-specific clinical domain scores, and disease course was measured longitudinally in 67 patients in the DEM-CHILD cohort. We analysed these data to determine age of disease onset and diagnosis, as well as disease progression-measured by the rate of decline in motor and language summary scores (on a scale of 0-6 points)-and time from first symptom to death. FINDINGS In the combined DEM-CHILD and WCMC dataset, median age was 35·0 months (IQR 24·0-38·5) at first clinical symptom, 37·0 months (IQR 35·0 -42·0) at first seizure, and 54·0 months (IQR 47·5-60·0) at diagnosis. Of 74 patients in the DEM-CHILD dataset, the most common first symptoms of disease were seizures (52 [70%]), language difficulty (42 [57%]), motor difficulty (30 [41%]), behavioural abnormality (12 [16%]), and dementia (seven [9%]). Among the 41 patients in the DEM-CHILD dataset for whom longitudinal assessments spanning the entire disease course were available, a rapid annual decline of 1·81 score units (95% CI 1·50-2·12) was seen in motor-language summary scores from normal (score of 6) to no function (score of 0), which occurred over approximately 30 months. Among 53 patients in the DEM-CHILD cohort with available data, the median time between onset of first disease symptom and death was 7·8 years (SE 0·9) years. INTERPRETATION In view of its natural history, late-infantile CLN2 disease should be considered in young children with delayed language acquisition and new onset of seizures. CLN2 disease has a largely predictable time course with regard to the loss of language and motor function, and these data might serve as historical controls for the assessment of current and future therapies. FUNDING EU Seventh Framework Program, German Ministry of Education and Research, EU Horizon2020 Program, National Institutes of Health, Nathan's Battle Foundation, Cures Within Reach Foundation, Noah's Hope Foundation, Hope4Bridget Foundation.
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22
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Specchio N, Bellusci M, Pietrafusa N, Trivisano M, de Palma L, Vigevano F. Photosensitivity is an early marker of neuronal ceroid lipofuscinosis type 2 disease. Epilepsia 2017. [DOI: 10.1111/epi.13820] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Nicola Specchio
- Department of Neuroscience; Bambino Gesù Children's Hospital; IRCCS (Istituto di Ricerca e Cura a Carattere Scientifico); Rome Italy
| | - Marcello Bellusci
- Department of Neuroscience; Bambino Gesù Children's Hospital; IRCCS (Istituto di Ricerca e Cura a Carattere Scientifico); Rome Italy
- Pediatric Neurology; 12 October University Hospital; Madrid Spain
| | - Nicola Pietrafusa
- Department of Neuroscience; Bambino Gesù Children's Hospital; IRCCS (Istituto di Ricerca e Cura a Carattere Scientifico); Rome Italy
| | - Marina Trivisano
- Department of Neuroscience; Bambino Gesù Children's Hospital; IRCCS (Istituto di Ricerca e Cura a Carattere Scientifico); Rome Italy
| | - Luca de Palma
- Department of Neuroscience; Bambino Gesù Children's Hospital; IRCCS (Istituto di Ricerca e Cura a Carattere Scientifico); Rome Italy
| | - Federico Vigevano
- Department of Neuroscience; Bambino Gesù Children's Hospital; IRCCS (Istituto di Ricerca e Cura a Carattere Scientifico); Rome Italy
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23
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Williams RE, Adams HR, Blohm M, Cohen-Pfeffer JL, de Los Reyes E, Denecke J, Drago K, Fairhurst C, Frazier M, Guelbert N, Kiss S, Kofler A, Lawson JA, Lehwald L, Leung MA, Mikhaylova S, Mink JW, Nickel M, Shediac R, Sims K, Specchio N, Topcu M, von Löbbecke I, West A, Zernikow B, Schulz A. Management Strategies for CLN2 Disease. Pediatr Neurol 2017; 69:102-112. [PMID: 28335910 DOI: 10.1016/j.pediatrneurol.2017.01.034] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 01/11/2017] [Indexed: 10/20/2022]
Abstract
CLN2 disease (neuronal ceroid lipofuscinosis type 2) is a rare, autosomal recessive, pediatric-onset, rapidly progressive neurodegenerative lysosomal storage disorder caused by tripeptidyl peptidase 1 (TPP1) enzyme deficiency, and is characterized by language delay, seizures, rapid cognitive and motor decline, blindness, and early death. No management guidelines exist and there is a paucity of published disease-specific evidence to inform clinical practice, which currently draws upon experience from the field of childhood neurodisability. Twenty-four disease experts were surveyed on CLN2 disease management and a subset met to discuss current practice. Management goals and strategies are consistent among experts globally and are guided by the principles of pediatric palliative care. Goals and interventions evolve as the disease progresses, with a shift in focus from maintenance of function early in the disease to maintenance of quality of life. A multidisciplinary approach is critical for optimal patient care. This work represents an initial step toward the development of consensus-based management guidelines for CLN2 disease.
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Affiliation(s)
- Ruth E Williams
- Children's Neurosciences Centre, Evelina London Children's Hospital, London, United Kingdom.
| | - Heather R Adams
- Department of Neurology, University of Rochester School of Medicine, Rochester, New York
| | - Martin Blohm
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Emily de Los Reyes
- Department of Pediatric Neurology, Nationwide Children's Hospital, Columbus, Ohio
| | - Jonas Denecke
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Charlie Fairhurst
- Children's Neurosciences Centre, Evelina London Children's Hospital, London, United Kingdom
| | - Margie Frazier
- Batten Disease Support and Research Association (BDSRA), Columbus, Ohio
| | - Norberto Guelbert
- Metabolic Diseases Section, Children's Hospital of Cordoba, Cordoba, Argentina
| | - Szilárd Kiss
- Department of Ophthalmology, Weill Cornell Medical College, New York, New York
| | - Annamaria Kofler
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - John A Lawson
- Department of Neurology, Sydney Children's Hospital, Randwick, Australia
| | - Lenora Lehwald
- Department of Pediatric Neurology, Nationwide Children's Hospital, Columbus, Ohio
| | - Mary-Anne Leung
- Children's Neurosciences Centre, Evelina London Children's Hospital, London, United Kingdom
| | - Svetlana Mikhaylova
- Department of Medical Genetics, Russian Children's Clinical Hospital, Moscow, Russia; Department of Molecular and Cell Genetics, Russian National Research Medical University, Moscow, Russia
| | - Jonathan W Mink
- Department of Neurology, University of Rochester School of Medicine, Rochester, New York
| | - Miriam Nickel
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Katherine Sims
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nicola Specchio
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Meral Topcu
- Department of Pediatric Neurology, Hacettepe University, Ankara, Turkey
| | | | - Andrea West
- Batten Disease Family Association (BDFA), Farnborough, United Kingdom
| | - Boris Zernikow
- Paediatric Palliative Care Centre, Children's and Adolescents' Hospital, Datteln, Germany; Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health-School of Medicine, Witten/Herdecke University, Germany
| | - Angela Schulz
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Fietz M, AlSayed M, Burke D, Cohen-Pfeffer J, Cooper JD, Dvořáková L, Giugliani R, Izzo E, Jahnová H, Lukacs Z, Mole SE, Noher de Halac I, Pearce DA, Poupetova H, Schulz A, Specchio N, Xin W, Miller N. Diagnosis of neuronal ceroid lipofuscinosis type 2 (CLN2 disease): Expert recommendations for early detection and laboratory diagnosis. Mol Genet Metab 2016; 119:160-7. [PMID: 27553878 DOI: 10.1016/j.ymgme.2016.07.011] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 07/23/2016] [Accepted: 07/24/2016] [Indexed: 10/21/2022]
Abstract
Neuronal ceroid lipofuscinoses (NCLs) are a heterogeneous group of lysosomal storage disorders. NCLs include the rare autosomal recessive neurodegenerative disorder neuronal ceroid lipofuscinosis type 2 (CLN2) disease, caused by mutations in the tripeptidyl peptidase 1 (TPP1)/CLN2 gene and the resulting TPP1 enzyme deficiency. CLN2 disease most commonly presents with seizures and/or ataxia in the late-infantile period (ages 2-4), often in combination with a history of language delay, followed by progressive childhood dementia, motor and visual deterioration, and early death. Atypical phenotypes are characterized by later onset and, in some instances, longer life expectancies. Early diagnosis is important to optimize clinical care and improve outcomes; however, currently, delays in diagnosis are common due to low disease awareness, nonspecific clinical presentation, and limited access to diagnostic testing in some regions. In May 2015, international experts met to recommend best laboratory practices for early diagnosis of CLN2 disease. When clinical signs suggest an NCL, TPP1 enzyme activity should be among the first tests performed (together with the palmitoyl-protein thioesterase enzyme activity assay to rule out CLN1 disease). However, reaching an initial suspicion of an NCL or CLN2 disease can be challenging; thus, use of an epilepsy gene panel for investigation of unexplained seizures in the late-infantile/childhood ages is encouraged. To confirm clinical suspicion of CLN2 disease, the recommended gold standard for laboratory diagnosis is demonstration of deficient TPP1 enzyme activity (in leukocytes, fibroblasts, or dried blood spots) and the identification of causative mutations in each allele of the TPP1/CLN2 gene. When it is not possible to perform both analyses, either demonstration of a) deficient TPP1 enzyme activity in leukocytes or fibroblasts, or b) detection of two pathogenic mutations in trans is diagnostic for CLN2 disease.
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Affiliation(s)
- Michael Fietz
- Department of Diagnostic Genomics, PathWest Laboratory Medicine WA, Nedlands, Australia
| | - Moeenaldeen AlSayed
- Department of Medical Genetics, Alfaisal University, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Derek Burke
- Chemical Pathology, Camelia Botnar Laboratories, Great Ormond Street Hospital, London, UK
| | | | - Jonathan D Cooper
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Lenka Dvořáková
- Institute of Inherited Metabolic Disorders, First Faculty of Medicine, Charles University in Prague, General University Hospital in Prague, Prague, Czech Republic
| | - Roberto Giugliani
- Medical Genetics Service, HCPA, Department of Genetics, UFRGS, INAGEMP, Porto Alegre, Brazil
| | | | - Helena Jahnová
- Institute of Inherited Metabolic Disorders, First Faculty of Medicine, Charles University in Prague, General University Hospital in Prague, Prague, Czech Republic
| | - Zoltan Lukacs
- Newborn Screening and Metabolic Diagnostics Unit, Hamburg University Medical Center, Hamburg, Germany
| | - Sara E Mole
- MRC Laboratory for Molecular Cell Biology, UCL Institute of Child Health, University College London, London, UK
| | - Ines Noher de Halac
- Facultad de Ciencias Médicas, Universidad Nacional de Córdoba and National Research Council-CONICET, Córdoba, Argentina
| | - David A Pearce
- Sanford Children's Health Research Center, Sioux Falls, SD, USA
| | - Helena Poupetova
- Institute of Inherited Metabolic Disorders, First Faculty of Medicine, Charles University in Prague, General University Hospital in Prague, Prague, Czech Republic
| | - Angela Schulz
- Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicola Specchio
- Department of Neuroscience, Bambino Gesù Children's Hospital, Rome, Italy
| | - Winnie Xin
- Neurogenetics DNA Diagnostic Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Dy ME, Sims KB, Friedman J. TPP1 deficiency: Rare cause of isolated childhood-onset progressive ataxia: Table 1. Neurology 2015. [DOI: 10.1212/wnl.0000000000001876] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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26
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Canafoglia L, Gilioli I, Invernizzi F, Sofia V, Fugnanesi V, Morbin M, Chiapparini L, Granata T, Binelli S, Scaioli V, Garavaglia B, Nardocci N, Berkovic SF, Franceschetti S. Electroclinical spectrum of the neuronal ceroid lipofuscinoses associated with CLN6 mutations. Neurology 2015; 85:316-24. [PMID: 26115733 DOI: 10.1212/wnl.0000000000001784] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 03/31/2015] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES To describe the clinical and neurophysiologic patterns of patients with neuronal ceroid lipofuscinoses associated with CLN6 mutations. METHODS We reviewed the features of 11 patients with different ages at onset. RESULTS Clinical disease onset occurred within the first decade of life in 8 patients and in the second and third decades in 3. All children presented with progressive cognitive regression associated with ataxia and pyramidal and extrapyramidal signs. Recurrent seizures, visual loss, and myoclonus were mostly reported after a delay from onset; 7 children were chairbound and had severe dementia less than 4 years from onset. One child, with onset at 8 years, had a milder course. Three patients with a teenage/adult onset presented with a classic progressive myoclonic epilepsy phenotype that was preceded by learning disability in one. The EEG background was slow close to disease onset in 7 children, and later showed severe attenuation; a photoparoxysmal response (PPR) was present in all. The 3 teenage/adult patients had normal EEG background and an intense PPR. Early attenuation of the electroretinogram was seen only in children with onset younger than 5.5 years. Somatosensory evoked potentials were extremely enlarged in all patients. CONCLUSIONS In all patients, multifocal myoclonic jerks and seizures were a key feature, but myoclonic seizures were an early and prominent sign in the teenage/adult form only. Conversely, the childhood-onset form was characterized by initial and severe cognitive impairment coupled with electroretinogram and EEG attenuation. Cortical hyperexcitability, shown by the PPR and enlarged somatosensory evoked potentials, was a universal feature.
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Affiliation(s)
- Laura Canafoglia
- From the Neurophysiopathology and Epilepsy Centre (L. Canafoglia, I.G., S.B., V. Scaioli, S.F.), Neuropathology-Neurology 5 (V.F., M.M.), Neuroradiology (L. Chiapparini), and Child Neurology and Psychiatry (T.G., N.N.), IRCCS Foundation C. Besta Neurological Institute, Milan; Molecular Neurogenetics (F.I., B.G.), IRCCS Foundation C. Besta Neurological Institute-Bicocca, Milan; G.F. Ingrassia Department (V. Sofia), University of Catania, Italy; and Epilepsy Research Center (S.F.B.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia.
| | - Isabella Gilioli
- From the Neurophysiopathology and Epilepsy Centre (L. Canafoglia, I.G., S.B., V. Scaioli, S.F.), Neuropathology-Neurology 5 (V.F., M.M.), Neuroradiology (L. Chiapparini), and Child Neurology and Psychiatry (T.G., N.N.), IRCCS Foundation C. Besta Neurological Institute, Milan; Molecular Neurogenetics (F.I., B.G.), IRCCS Foundation C. Besta Neurological Institute-Bicocca, Milan; G.F. Ingrassia Department (V. Sofia), University of Catania, Italy; and Epilepsy Research Center (S.F.B.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia
| | - Federica Invernizzi
- From the Neurophysiopathology and Epilepsy Centre (L. Canafoglia, I.G., S.B., V. Scaioli, S.F.), Neuropathology-Neurology 5 (V.F., M.M.), Neuroradiology (L. Chiapparini), and Child Neurology and Psychiatry (T.G., N.N.), IRCCS Foundation C. Besta Neurological Institute, Milan; Molecular Neurogenetics (F.I., B.G.), IRCCS Foundation C. Besta Neurological Institute-Bicocca, Milan; G.F. Ingrassia Department (V. Sofia), University of Catania, Italy; and Epilepsy Research Center (S.F.B.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia
| | - Vito Sofia
- From the Neurophysiopathology and Epilepsy Centre (L. Canafoglia, I.G., S.B., V. Scaioli, S.F.), Neuropathology-Neurology 5 (V.F., M.M.), Neuroradiology (L. Chiapparini), and Child Neurology and Psychiatry (T.G., N.N.), IRCCS Foundation C. Besta Neurological Institute, Milan; Molecular Neurogenetics (F.I., B.G.), IRCCS Foundation C. Besta Neurological Institute-Bicocca, Milan; G.F. Ingrassia Department (V. Sofia), University of Catania, Italy; and Epilepsy Research Center (S.F.B.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia
| | - Valeria Fugnanesi
- From the Neurophysiopathology and Epilepsy Centre (L. Canafoglia, I.G., S.B., V. Scaioli, S.F.), Neuropathology-Neurology 5 (V.F., M.M.), Neuroradiology (L. Chiapparini), and Child Neurology and Psychiatry (T.G., N.N.), IRCCS Foundation C. Besta Neurological Institute, Milan; Molecular Neurogenetics (F.I., B.G.), IRCCS Foundation C. Besta Neurological Institute-Bicocca, Milan; G.F. Ingrassia Department (V. Sofia), University of Catania, Italy; and Epilepsy Research Center (S.F.B.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia
| | - Michela Morbin
- From the Neurophysiopathology and Epilepsy Centre (L. Canafoglia, I.G., S.B., V. Scaioli, S.F.), Neuropathology-Neurology 5 (V.F., M.M.), Neuroradiology (L. Chiapparini), and Child Neurology and Psychiatry (T.G., N.N.), IRCCS Foundation C. Besta Neurological Institute, Milan; Molecular Neurogenetics (F.I., B.G.), IRCCS Foundation C. Besta Neurological Institute-Bicocca, Milan; G.F. Ingrassia Department (V. Sofia), University of Catania, Italy; and Epilepsy Research Center (S.F.B.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia
| | - Luisa Chiapparini
- From the Neurophysiopathology and Epilepsy Centre (L. Canafoglia, I.G., S.B., V. Scaioli, S.F.), Neuropathology-Neurology 5 (V.F., M.M.), Neuroradiology (L. Chiapparini), and Child Neurology and Psychiatry (T.G., N.N.), IRCCS Foundation C. Besta Neurological Institute, Milan; Molecular Neurogenetics (F.I., B.G.), IRCCS Foundation C. Besta Neurological Institute-Bicocca, Milan; G.F. Ingrassia Department (V. Sofia), University of Catania, Italy; and Epilepsy Research Center (S.F.B.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia
| | - Tiziana Granata
- From the Neurophysiopathology and Epilepsy Centre (L. Canafoglia, I.G., S.B., V. Scaioli, S.F.), Neuropathology-Neurology 5 (V.F., M.M.), Neuroradiology (L. Chiapparini), and Child Neurology and Psychiatry (T.G., N.N.), IRCCS Foundation C. Besta Neurological Institute, Milan; Molecular Neurogenetics (F.I., B.G.), IRCCS Foundation C. Besta Neurological Institute-Bicocca, Milan; G.F. Ingrassia Department (V. Sofia), University of Catania, Italy; and Epilepsy Research Center (S.F.B.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia
| | - Simona Binelli
- From the Neurophysiopathology and Epilepsy Centre (L. Canafoglia, I.G., S.B., V. Scaioli, S.F.), Neuropathology-Neurology 5 (V.F., M.M.), Neuroradiology (L. Chiapparini), and Child Neurology and Psychiatry (T.G., N.N.), IRCCS Foundation C. Besta Neurological Institute, Milan; Molecular Neurogenetics (F.I., B.G.), IRCCS Foundation C. Besta Neurological Institute-Bicocca, Milan; G.F. Ingrassia Department (V. Sofia), University of Catania, Italy; and Epilepsy Research Center (S.F.B.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia
| | - Vidmer Scaioli
- From the Neurophysiopathology and Epilepsy Centre (L. Canafoglia, I.G., S.B., V. Scaioli, S.F.), Neuropathology-Neurology 5 (V.F., M.M.), Neuroradiology (L. Chiapparini), and Child Neurology and Psychiatry (T.G., N.N.), IRCCS Foundation C. Besta Neurological Institute, Milan; Molecular Neurogenetics (F.I., B.G.), IRCCS Foundation C. Besta Neurological Institute-Bicocca, Milan; G.F. Ingrassia Department (V. Sofia), University of Catania, Italy; and Epilepsy Research Center (S.F.B.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia
| | - Barbara Garavaglia
- From the Neurophysiopathology and Epilepsy Centre (L. Canafoglia, I.G., S.B., V. Scaioli, S.F.), Neuropathology-Neurology 5 (V.F., M.M.), Neuroradiology (L. Chiapparini), and Child Neurology and Psychiatry (T.G., N.N.), IRCCS Foundation C. Besta Neurological Institute, Milan; Molecular Neurogenetics (F.I., B.G.), IRCCS Foundation C. Besta Neurological Institute-Bicocca, Milan; G.F. Ingrassia Department (V. Sofia), University of Catania, Italy; and Epilepsy Research Center (S.F.B.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia
| | - Nardo Nardocci
- From the Neurophysiopathology and Epilepsy Centre (L. Canafoglia, I.G., S.B., V. Scaioli, S.F.), Neuropathology-Neurology 5 (V.F., M.M.), Neuroradiology (L. Chiapparini), and Child Neurology and Psychiatry (T.G., N.N.), IRCCS Foundation C. Besta Neurological Institute, Milan; Molecular Neurogenetics (F.I., B.G.), IRCCS Foundation C. Besta Neurological Institute-Bicocca, Milan; G.F. Ingrassia Department (V. Sofia), University of Catania, Italy; and Epilepsy Research Center (S.F.B.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia
| | - Samuel F Berkovic
- From the Neurophysiopathology and Epilepsy Centre (L. Canafoglia, I.G., S.B., V. Scaioli, S.F.), Neuropathology-Neurology 5 (V.F., M.M.), Neuroradiology (L. Chiapparini), and Child Neurology and Psychiatry (T.G., N.N.), IRCCS Foundation C. Besta Neurological Institute, Milan; Molecular Neurogenetics (F.I., B.G.), IRCCS Foundation C. Besta Neurological Institute-Bicocca, Milan; G.F. Ingrassia Department (V. Sofia), University of Catania, Italy; and Epilepsy Research Center (S.F.B.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia
| | - Silvana Franceschetti
- From the Neurophysiopathology and Epilepsy Centre (L. Canafoglia, I.G., S.B., V. Scaioli, S.F.), Neuropathology-Neurology 5 (V.F., M.M.), Neuroradiology (L. Chiapparini), and Child Neurology and Psychiatry (T.G., N.N.), IRCCS Foundation C. Besta Neurological Institute, Milan; Molecular Neurogenetics (F.I., B.G.), IRCCS Foundation C. Besta Neurological Institute-Bicocca, Milan; G.F. Ingrassia Department (V. Sofia), University of Catania, Italy; and Epilepsy Research Center (S.F.B.), Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Australia
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