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Ashrafi F, Salari M, Nouri F, Shiravi F. Dementia as a core clinical feature of a patient with aceruloplasminemia. Clin Case Rep 2022; 10:e05581. [PMID: 35310305 PMCID: PMC8918479 DOI: 10.1002/ccr3.5581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 02/03/2022] [Accepted: 02/16/2022] [Indexed: 11/06/2022] Open
Abstract
Aceruloplasminemia is an autosomal recessive disease, caused by systemic iron accumulation due to mutations in the Ceruloplasmin gene. We report two Iranian siblings who have been diagnosed with aceruloplasminemia. Although dementia has not been published as the first neurological feature, one of our cases was presented with pure dementia.
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Affiliation(s)
- Farzad Ashrafi
- Functional Neurosurgery Research Center Shohada‐e‐Tajrish Neurosurgical Center of Excellence Shahid Beheshti University of Medical Sciences Tehran Iran
| | - Mehri Salari
- Functional Neurosurgery Research Center Shohada‐e‐Tajrish Neurosurgical Center of Excellence Shahid Beheshti University of Medical Sciences Tehran Iran
| | - Fatemeh Nouri
- Student Research Committee School of Medicine Shahid Beheshti University of Medical Science Tehran Iran
| | - Fatemeh Shiravi
- Student Research Committee School of Medicine Shahid Beheshti University of Medical Science Tehran Iran
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Xu WQ, Ni W, Wang RM, Dong Y, Wu ZY. A novel ceruloplasmin mutation identified in a Chinese patient and clinical spectrum of aceruloplasminemia patients. Metab Brain Dis 2021; 36:2273-2281. [PMID: 34347207 DOI: 10.1007/s11011-021-00799-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 07/07/2021] [Indexed: 12/19/2022]
Abstract
Aceruloplasminemia (ACP) is a rare disorder of iron overload resulting from ceruloplasmin (CP) variants. Because of its rarity and heterogeneity, the diagnosis of ACP is often missed or misdiagnosed. Here, we aim to present a clinical spectrum of ACP and raise more attention to the early diagnosis. Whole exome sequencing (WES) was performed in a Chinese female patient suspected with ACP and her clinical data were collected in detail. The PubMed databases was searched for published ACP patients within the last decade, and we present a systematic review of their clinical features with data extracted from these researches. A novel pathogenic variant (c.2689delC) and a known pathogenic variant (c.606dupA) within ceruloplasmin gene were identified in our patient and confirmed the diagnosis of ACP. Then we reviewed 51 ACP patients including the case we reported here. A possible timeline of symptoms was discovered, anemia appears first (29.7 years old on average), followed by diabetes (37.3 years old) and finally neurological symptoms (50.7 years old). The delay in diagnosis was significantly shortened in patients without neurological symptoms. Biochemical triad including anemia, low to undetectable serum ceruloplasmin, low serum iron and/or hyperferritinemia, showed better sensitivity in diagnosis than clinical triad including diabetes, neurological symptoms, and retinal degeneration. Due to the variable symptom spectrum, patients with ACP often visit different departments, which can lead to misdiagnosis. Clinical attention needs to be paid to symptoms and tests that have a warning effect. Prompt diagnosis in the early stage of the disease can be beneficial.
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Affiliation(s)
- Wan-Qing Xu
- Department of Neurology and Research Center of Neurology in Second Affiliated Hospital, and Key Laboratory of Medical Neurobiology of Zhejiang Province, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Wang Ni
- Department of Neurology and Research Center of Neurology in Second Affiliated Hospital, and Key Laboratory of Medical Neurobiology of Zhejiang Province, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Rou-Min Wang
- Department of Neurology and Research Center of Neurology in Second Affiliated Hospital, and Key Laboratory of Medical Neurobiology of Zhejiang Province, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Yi Dong
- Department of Neurology and Research Center of Neurology in Second Affiliated Hospital, and Key Laboratory of Medical Neurobiology of Zhejiang Province, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Zhi-Ying Wu
- Department of Neurology and Research Center of Neurology in Second Affiliated Hospital, and Key Laboratory of Medical Neurobiology of Zhejiang Province, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China.
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Aceruloplasminemia: a multimodal imaging study in an Italian family with a novel mutation. Neurol Sci 2021; 43:1791-1797. [PMID: 34559338 DOI: 10.1007/s10072-021-05613-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/10/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Structural abnormalities in thalami and basal ganglia, in particular the globus pallidus (GP), are a neuroimaging hallmark of hereditary aceruloplasminemia (HA), yet few functional imaging data exit in HA carriers. This study investigated the iron-related structural and functional abnormalities in an Italian HA family. METHODS Multimodal imaging was used including structural 3 T MRI, functional imaging (SPECT imaging with 123I-ioflupane (DAT-SPECT), cardiac 123I metaiodobenzylguanidine (123I-MIBG) scintigraphy, and 18F-fluorodeoxyglucose (18F-FDG)-PET imaging). In the proband, MRI and scintigraphic evaluations were performed at baseline, 2 and 4 years (structural imaging), and 2 years of follow-up period (functional imaging). RESULTS We investigated two cousins carrying a novel splicing homozygous mutation in intron 6 (IVS6 + 1 G > A) of CP gene. Interestingly, MRI features in both subjects were characterized by marked iron accumulation in the thalami and basal ganglia nuclei, while GP was not affected. MRI performed in the proband at 2 and 4 years of follow-up confirmed progressive neurodegeneration of the thalami and basal ganglia without the involvement of GP. Functional imaging showed reduced putaminal DAT uptake in both cousins, whereas cardiac MIBG and FDG uptakes performed in the proband were normal. Longitudinal scintigraphic investigations did not show significant changes over the time. CONCLUSIONS For HA carriers, our findings demonstrate that GP was spared by iron accumulation over the time. The nigrostriatal presynaptic dopaminergic system was damaged while the cardiac sympathetic system remained longitudinally preserved, thus expanding the imaging features of this rare inherited disorder.
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Iankova V, Karin I, Klopstock T, Schneider SA. Emerging Disease-Modifying Therapies in Neurodegeneration With Brain Iron Accumulation (NBIA) Disorders. Front Neurol 2021; 12:629414. [PMID: 33935938 PMCID: PMC8082061 DOI: 10.3389/fneur.2021.629414] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 03/05/2021] [Indexed: 12/11/2022] Open
Abstract
Neurodegeneration with Brain Iron Accumulation (NBIA) is a heterogeneous group of progressive neurodegenerative diseases characterized by iron deposition in the globus pallidus and the substantia nigra. As of today, 15 distinct monogenetic disease entities have been identified. The four most common forms are pantothenate kinase-associated neurodegeneration (PKAN), phospholipase A2 group VI (PLA2G6)-associated neurodegeneration (PLAN), beta-propeller protein-associated neurodegeneration (BPAN) and mitochondrial membrane protein-associated neurodegeneration (MPAN). Neurodegeneration with Brain Iron Accumulation disorders present with a wide spectrum of clinical symptoms such as movement disorder signs (dystonia, parkinsonism, chorea), pyramidal involvement (e.g., spasticity), speech disorders, cognitive decline, psychomotor retardation, and ocular abnormalities. Treatment remains largely symptomatic but new drugs are in the pipeline. In this review, we discuss the rationale of new compounds, summarize results from clinical trials, provide an overview of important results in cell lines and animal models and discuss the future development of disease-modifying therapies for NBIA disorders. A general mechanistic approach for treatment of NBIA disorders is with iron chelators which bind and remove iron. Few studies investigated the effect of deferiprone in PKAN, including a recent placebo-controlled double-blind multicenter trial, demonstrating radiological improvement with reduction of iron load in the basal ganglia and a trend to slowing of disease progression. Disease-modifying strategies address the specific metabolic pathways of the affected enzyme. Such tailor-made approaches include provision of an alternative substrate (e.g., fosmetpantotenate or 4′-phosphopantetheine for PKAN) in order to bypass the defective enzyme. A recent randomized controlled trial of fosmetpantotenate, however, did not show any significant benefit of the drug as compared to placebo, leading to early termination of the trials' extension phase. 4′-phosphopantetheine showed promising results in animal models and a clinical study in patients is currently underway. Another approach is the activation of other enzyme isoforms using small molecules (e.g., PZ-2891 in PKAN). There are also compounds which counteract downstream cellular effects. For example, deuterated polyunsaturated fatty acids (D-PUFA) may reduce mitochondrial lipid peroxidation in PLAN. In infantile neuroaxonal dystrophy (a subtype of PLAN), desipramine may be repurposed as it blocks ceramide accumulation. Gene replacement therapy is still in a preclinical stage.
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Affiliation(s)
- Vassilena Iankova
- Department of Neurology With Friedrich Baur Institute, University Hospital of Ludwig-Maximilians-Universität München, Munich, Germany
| | - Ivan Karin
- Department of Neurology With Friedrich Baur Institute, University Hospital of Ludwig-Maximilians-Universität München, Munich, Germany
| | - Thomas Klopstock
- Department of Neurology With Friedrich Baur Institute, University Hospital of Ludwig-Maximilians-Universität München, Munich, Germany.,German Center for Neurodegenerative Diseases (DZNE), Munich, Germany.,Munich Cluster for Systems Neurology, Munich, Germany
| | - Susanne A Schneider
- Department of Neurology With Friedrich Baur Institute, University Hospital of Ludwig-Maximilians-Universität München, Munich, Germany
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Caplan DN, Rapalino O, Karaa A, Rosovsky RP, Uljon S. Case 35-2020: A 59-Year-Old Woman with Type 1 Diabetes Mellitus and Obtundation. N Engl J Med 2020; 383:1974-1983. [PMID: 33176089 DOI: 10.1056/nejmcpc2002412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- David N Caplan
- From the Departments of Neurology (D.N.C.), Radiology (O.R.), Pediatrics (A.K.), Medicine (R.P.R.), and Pathology (S.U.), Massachusetts General Hospital, and the Departments of Neurology (D.N.C.), Radiology (O.R.), Pediatrics (A.K.), Medicine (R.P.R.), and Pathology (S.U.), Harvard Medical School - both in Boston
| | - Otto Rapalino
- From the Departments of Neurology (D.N.C.), Radiology (O.R.), Pediatrics (A.K.), Medicine (R.P.R.), and Pathology (S.U.), Massachusetts General Hospital, and the Departments of Neurology (D.N.C.), Radiology (O.R.), Pediatrics (A.K.), Medicine (R.P.R.), and Pathology (S.U.), Harvard Medical School - both in Boston
| | - Amel Karaa
- From the Departments of Neurology (D.N.C.), Radiology (O.R.), Pediatrics (A.K.), Medicine (R.P.R.), and Pathology (S.U.), Massachusetts General Hospital, and the Departments of Neurology (D.N.C.), Radiology (O.R.), Pediatrics (A.K.), Medicine (R.P.R.), and Pathology (S.U.), Harvard Medical School - both in Boston
| | - Rachel P Rosovsky
- From the Departments of Neurology (D.N.C.), Radiology (O.R.), Pediatrics (A.K.), Medicine (R.P.R.), and Pathology (S.U.), Massachusetts General Hospital, and the Departments of Neurology (D.N.C.), Radiology (O.R.), Pediatrics (A.K.), Medicine (R.P.R.), and Pathology (S.U.), Harvard Medical School - both in Boston
| | - Sacha Uljon
- From the Departments of Neurology (D.N.C.), Radiology (O.R.), Pediatrics (A.K.), Medicine (R.P.R.), and Pathology (S.U.), Massachusetts General Hospital, and the Departments of Neurology (D.N.C.), Radiology (O.R.), Pediatrics (A.K.), Medicine (R.P.R.), and Pathology (S.U.), Harvard Medical School - both in Boston
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Vroegindeweij LHP, Boon AJW, Wilson JHP, Langendonk JG. Effects of iron chelation therapy on the clinical course of aceruloplasminemia: an analysis of aggregated case reports. Orphanet J Rare Dis 2020; 15:105. [PMID: 32334607 PMCID: PMC7183696 DOI: 10.1186/s13023-020-01385-w] [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] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/14/2020] [Indexed: 12/17/2022] Open
Abstract
Background Aceruloplasminemia is a rare genetic iron overload disorder, characterized by progressive neurological manifestations. The effects of iron chelation on neurological outcomes have only been described in case studies, and are inconsistent. Aggregated case reports were analyzed to help delineate the disease-modifying potential of treatment. Methods Data on clinical manifestations, treatment and neurological outcomes of treatment were collected from three neurologically symptomatic Dutch patients, who received deferiprone with phlebotomy as a new therapeutic approach, and combined with other published cases. Neurological outcomes of treatment were compared between patients starting treatment when neurologically symptomatic and patients without neurological manifestations. Results Therapeutic approaches for aceruloplasminemia have been described in 48 patients worldwide, including our three patients. Initiation of treatment in a presymptomatic stage of the disease delayed the estimated onset of neurological manifestations by 10 years (median age 61 years, SE 5.0 vs. median age 51 years, SE 0.6, p = 0.001). Although in 11/20 neurologically symptomatic patients neurological manifestations remained stable or improved during treatment, these patients were treated significantly shorter than patients who deteriorated neurologically (median 6 months vs. median 43 months, p = 0.016). Combined iron chelation therapy with deferiprone and phlebotomy for up to 34 months could be safely performed in our patients without symptomatic anemia (2/3), but did not prevent further neurological deterioration. Conclusions Early initiation of iron chelation therapy seems to postpone the onset of neurological manifestations in aceruloplasminemia. Publication bias and significant differences in duration of treatment should be considered when interpreting reported treatment outcomes in neurologically symptomatic patients. Based on theoretical grounds and the observed long-term safety and tolerability in our study, we recommend iron chelation therapy with deferiprone in combination with phlebotomy for aceruloplasminemia patients without symptomatic anemia.
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Affiliation(s)
- Lena H P Vroegindeweij
- Department of Internal Medicine, Center for Lysosomal and Metabolic Diseases, Porphyria Center Rotterdam, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Agnita J W Boon
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - J H Paul Wilson
- Department of Internal Medicine, Center for Lysosomal and Metabolic Diseases, Porphyria Center Rotterdam, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Janneke G Langendonk
- Department of Internal Medicine, Center for Lysosomal and Metabolic Diseases, Porphyria Center Rotterdam, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Marchi G, Busti F, Lira Zidanes A, Castagna A, Girelli D. Aceruloplasminemia: A Severe Neurodegenerative Disorder Deserving an Early Diagnosis. Front Neurosci 2019; 13:325. [PMID: 31024241 PMCID: PMC6460567 DOI: 10.3389/fnins.2019.00325] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 03/21/2019] [Indexed: 01/01/2023] Open
Abstract
Aceruloplasminemia (ACP) is a rare, adult-onset, autosomal recessive disorder, characterized by systemic iron overload due to mutations in the Ceruloplasmin gene (CP), which in turn lead to absence or strong reduction of CP activity. CP is a ferroxidase that plays a key role in iron export from various cells, especially in the brain, where it maintains the appropriate iron homeostasis with neuroprotective effects. Brain iron accumulation makes ACP unique among systemic iron overload syndromes, e.g., various types of genetic hemochromatosis. The main clinical features of fully expressed ACP include diabetes, retinopathy, liver disease, and progressive neurological symptoms reflecting iron deposition in target organs. However, biochemical signs of the disease, namely a mild anemia mimicking iron deficiency anemia because of microcytosis and low transferrin saturation, but with "paradoxical" hyperferritinemia, usually precedes the onset of clinical symptoms of many years and sometimes decades. Prompt diagnosis and therapy are crucial to prevent neurological complications of the disease, as they are usually irreversible once established. In this mini-review we discuss some major issues about this rare disorder, pointing out the early clues to the right diagnosis, instrumental to reduce significant disability burden of affected patients.
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Affiliation(s)
- Giacomo Marchi
- Department of Medicine, University of Verona, Verona, Italy
| | - Fabiana Busti
- Department of Medicine, University of Verona, Verona, Italy
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