Diffuse lipofuscinosis of the central nervous system

Pigment Variant of Neuronal Ceroid-Lipofuscinosis (Kufs’ Disease)

A case of pigment variant of Kufs’ disease is presented. The nature of the extra-neuronal pigment is discussed. Despite some of the histochemical discrepancies that existed between this pigment and the material that had accumulated in the nerve cells, they seemed to he ultrastructurally related. The hepatocytes contained numerous heterogeneous cytosomes, some of which resembled the storage material of Niemann-Pick’s disease.

Clinically the syndrome may present with progressive ataxia, spontaneous and reflex, coarse myoclonic jerks and eventual mental deterioration as well as epilepsy and muscle wasting. The pigment variant cannot be distinguished from Kufs’ disease except pathologically.

Electroencephalographic findings in Kufs disease

OBJECTIVE

To characterize the electroencephalographic (EEG) findings in patients with Kufs disease, the adult autosomal recessive form of neuronal ceroid-lipofuscinosis.

METHODS

We reviewed the EEG findings in 5 patients with biopsy-proven Kufs disease from our institution and 14 case reports of Kufs disease in the literature. The criteria used for patient inclusion were clinical evidence of a progressive neurodegenerative disorder, biopsy-proven evidence of Kufs disease, and EEG recordings during the course of the illness.

RESULTS

One patient had phenotype A with generalized atypical spike and slow wave complexes and marked photoparoxysmal responses, particularly at low flash frequencies. Three patients had phenotype B with generalized slowing. One patient in the miscellaneous category showed focal sharp and spike waves and quasi-periodic slow waves maximal over anterior regions of the head. Review of the literature identified 14 case reports that met the inclusion criteria.

CONCLUSIONS

The inheritance, mechanism, and manifestations of Kufs disease are not well understood. EEG findings may guide clinicians toward a confirmatory pathological diagnosis and distinguish various phenotypes of this disorder.

SIGNIFICANCE

The EEG may assist in the diagnosis of Kufs disease.

Photoparoxysmal response in late infantile neuronal ceroid-lipofuscinosis

A patient presented with rapid developmental regression whose MRI findings suggested a leukodystrophy, but nerve, muscle, skin, and bone marrow biopsies were unrevealing. A characteristic photoparoxysmal response on electroencephalogram provided an important clue for the correct diagnosis of late infantile neuronal ceroid-lipofuscinosis, which was confirmed later with electron microscope examination of a brain biopsy. In patients with rapid neurologic deterioration, diagnosis of neuronal ceroid-lipofuscinosis should be considered and an electroencephalogram should be performed using photic stimulation to look for characteristic findings.

The adult and a new late adult forms of neuronal ceroid lipofuscinosis

Three cases of the late adult form of neuronal ceroid lipofuscinosis (NCL) are reported. Two of these are siblings with a late clinical onset at ages 26 and 44 years. The third case, sporadic, has the oldest reported age for the onset of NCL, at 63 years and may be regarded as the first example of the "presenile" form of NCL. The clinical, morphological, histochemical, ultrastructural and genetic features of these three cases are discussed. The literature of the clinicopathological NCL cases with an onset at age of 25 and older is reviewed. The clinical and morphological differences between the late adult form and the presenile form of NCL as well as the difficulties in making the diagnosis are discussed.

A case of childhood Kufs' disease

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Neuronal lipopigment: a marker for cognitive impairment and long-term effects of psychotropic drugs

Lipopigment, identifiable in the fluorescence microscope, is thought to be cellular debris partly derived from free-radical-induced peroxidation of cellular constituents. The volume of neuronal lipopigment has been positively correlated with advancing age, Alzheimer dementia, and the neuronal ceroidoses, while various changes in neuronal lipopigment have been reported in association with the chronic administration of dihydroergotoxine, ethanol, phenytoin, centrophenoxine, and chlorpromazine. An increase in the volume of neuronal lipopigment may indicate increased functional activity of the cell, impaired removal of pigment or anoxia. Chronic administration of agents which can be correlated with decreased neuronal lipopigment in animal models might protect neuronal function against any adverse effects associated with (but not necessarily resulting from) lipopigment accumulation in normal ageing, anoxia, or certain degenerative diseases. Long-term studies of the prophylactic use of such agents, or of drugs which neutralise free radicals, may be indicated. Other clinical applications of such drugs may include protection against the effects of free radicals formed during periods of oxygen deprivation.

Foamy spheroid bodies in the substantia nigra. Report of an unusual case with recurrent attacks of peculiar twilight state

An unusual case of recurrent attacks of peculiar twilight state persisting for 41 years is the subject of this clinicopathological report. During the attacks the patient had depersonalization, showing a stiff face, and the electroencephalogram showed constant 5 Hz diffuse theta waves. The unique and characteristic neuropathological finding were many foamy spheroid bodies (FSB) in the substantia nigra which sometimes contained varying numbers of fine or coarse eosinophilic granules. Ultrastructurally, the FSB contained various small electron-dense granules and/or membranous structures quite different from so-called spheroids (axonal swellings). Bodian staining demonstrated that some FSB were situated within the bundles of the neuronal processes, suggesting that the FSB has originated from the degeneration of the axon and/or dendrites in the substantia nigra.

Ramsay Hunt syndrome and coeliac disease: a new association?

Two patients with the syndrome of Ramsay Hunt (dyssynergia cerebellaris myoclonica, DCM), associated with malabsorption due to adult coeliac disease, are reported. Both presented with progressive cerebellar ataxia, action myoclonus, and epilepsy. One had gastrointestinal symptoms (recurrent diarrhea and weight loss which responded satisfactorily to a gluten-free diet), but the other did not. In both patients, jejunal biopsy revealed subtotal villous atrophy; serum folate and vitamin E level were also reduced. Neither a gluten-free diet nor vitamin supplements improved the neurological picture. However, some symptomatic relief was afforded by treatment with clonazepam, sodium valproate, carbamazepine, and piracetam. It could be argued that the association between these two disorders is coincidental. However, since we have found this combination in 2 of 14 consecutive cases with DCM, a causal relationship seems likely, although the underlying mechanism remains unknown. Patients with the Ramsay Hunt syndrome should be investigated for malabsorption, and also undergo small intestinal biopsy.

Three types of cytoplasmic granules in cardiac muscle cells of cynomolgus monkeys (Macaca fascicularis)

Ceroid, lipofuscin, and hyaline-type intracytoplasmic granules found in cardiac muscle cells of cynomolgus monkeys were studied using histologic, histochemical, and fluorescent microscopic techniques. The studies indicated that the ceroid granules contained an insoluble lipid as well as a component that was stainable with Luxol fast blue and Mallory's phloxine stain for hyaline. Lipofuscin granules had staining reactions characteristic of the classical age-related pigment. Hyaline granules were devoid of lipid component and were distinctly different from either ceroid or lipofuscin. All three types of granules were located at the poles of cardiac muscle cell nuclei.

Autofluorescence emission spectra of neuronal lipopigment in a case of adult-onset ceroidosis (Kufs' disease)

The study reports characteristics of the autofluorescence emission spectra from abnormal accumulations of intraneuronal lipopigment in a case of adult-onset neuronal ceroidosis (Kufs' disease). These are compared with emission spectra from 14 non-diseased brains, and from cases of childhood-onset neuronal ceroidoses (Batten's disease) and animal ceroidoses which have been previously reported. The emission spectra derived from the case of Kufs' disease could be distinguished from the spectra from the non-diseased brains and from the cases of Batten's disease and animal ceroidoses. The characteristics of an emission spectrum probably reflect the composition of the lipopigment, and spectral analysis may aid the identification of different pathogenic mechanisms which underly the various types of neuronal ceroidosis.

Neuronal ceroid lipofuscinosis: clinical and histochemical observations in 2 cases

Two cases of neuronal ceroid lipofuscinosis are presented with detailed accounts of the clinical, histopathological and histochemical changes in the brain. In one of them, neurochemical analysis of the brain was found to be essentially normal. Despite the pathological and histochemical similarity in these two cases, the clinical forms were quite distinct. The clinical patterns are attributed to differences in the topography of neuronal involvement. The pathogenesis of this extremely rare form of neurolipidosis is discussed with reference to recent literature.

Degenerative progressive myoclonic epilepsy electrokymographic observations

Clinical and pathological findings in two cases of degenerative progressive myoclonic epilepsy (PME) are described. The clinically difficult task of differentiating a "cerebellar" tremor from an action myoclonus is emphasized. Simultaneous electroencephalography and electrokymography was done, using capacity to ground transients for recording hand movements. This method was found useful in corroborating the cerebellar nature of the remaining disorder, after successful treatment of the myoclonic element with anticonvulsants.

An adult case of canine neuronal ceroid-lipofuscinosis

Intraneuronal accumulation of cytosomes with the fluorescent and tinctorial properties of ceroidlipofuscin occurred in the C.N.S. of a fully matured dog with signs of slowly progressive cerebellar disease. Ultrastructural study revealed various membrane-bound inclusions in addition to typical lipofuscin granules. The clinicopathologic findings in this case were contrasted with those occurring in English Setters with juvenile neuronal ceroid-lipofuscinosis, and compared with those reported in Kufs' disease in man.

A dominant form of adult neuronal ceroidlipofuscinosis (Kufs' disease) with an associated occipital astrocytoma: early diagnosis by cortical biopsy

A patient with a dominantly inherited form of Kuf's disease and an associated occipital astrocytoma is presented. This is the first reported case in which the diagnosis of Kufs' disease was made by a cortical biopsy several years before its expected clinical onset. The nosology of this disease, and its clinical, genetic, and histopathological characteristics are discussed. The establishment of an early diagnosis by cortical biopsy and its implications are considered.

Mental retardation, hypotonia, and generalized seizures associated with astrocytic "residual" bodies. An ultrastructural study

Two siblings suffering since birth from convulsions, hypotonia, and mental retardation are presented. In the older sibling (eight and one-half years of age) frontal lobe biopsy revealed abnormal cytosomes with lamellar profiles in astrocytes, macrophages, and to a lesser degree in neurons. Similar cytosomes have not yet been reported in cases of sphingolipidoses or in late infantile-juvenile amaurotic idiocy. These cytosomes stained intensely with silver proteinate, an ultrastructural cytochemical stain for carbohydrate moieties. In contrast, lipofuscin did not stain with silver proteinate. Multilamellar (crescentic curvilinear) cytosomes from a reported case of late infantile amaurotic idocy (Batten-Vogt-Spielmeyer disease) did not stain with silver proteinate. Abnormal cytosomes were not found in blood cells, liver, and peripheral nerve. In the younger sibling (14 months old) postmortem ultrastructural studies of cerebral tissue showed very few abnormal cytosomes. On the basis of the clinical and ultrastructural findings, we conclude that these two cases can be distinguished from those with multilamellar (crescentic-curvilinear) inclusions and from cases of the so-called "neuronal ceroid-lipofuscinosis" syndrome.

Progressive myoclonic epilepsy due to Gaucher's disease in an adult

A 39 year old Jewish male with a 22 year history of progressive myoclonic epilepsy was found to have Gaucher cells in his sternal bone marrow. The diagnosis of Gaucher's disease was confirmed by the demonstration of beta-glucosidase deficiency in fibroblasts. Although neurological involvement is extremely rare in adults with Gaucher's disease, this disease is another lipidosis which should be considered in patients with progressive myoclonic epilepsy.

Neuronal ceroid-lipofuscinosis, a type of amaurotic family idiocy. Clinical and pathological study of four cases

Neuronal ceroid-lipofuscinosis (NCL) is a recent term, proposed for acurate designation of the late-onset types of Amaurotic Family Idiocy (AFI). Histopathology shows ubiquitous intraneuronal accumulation of lipopigments, being the most important factor for characterization of the entity at present time. Biochemical changes and pathogenesis are obscure. NCL is in contrast to the infantile type of AFI (Tay-Sachs disease), in which intraneuronal accumulation of gangliosides (sphingolipids) is due to the well known deficiency of a lysosomal enzyme. The authors report on four cases of NCL, two brothers of the late infantile (Jansky-Bielschowsky) type and a brother and a sister of the juvenile (Spielmeyer-Sjögren) type. One autopsy and three cortical biopsies revealed moderate to severe distention of the neurons by lipopigment, with nerve cell loss, gliosis and cerebral atrophy. Lipopigment was also increased in liver, heart and spleen. The patients were the first in Brazilian literature in whom the storage material was identified as lipopigment by histochemical methods. A brief summary of the clinical features of NCL is presented, and relevant problems are discussed, concerning interpretation of the nature of the storage material, and significance of the disease for gerontological research.

Progressive myoclonus epilepsy without Lafora bodies

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