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Charfi Triki C, Zouari Mallouli S, Ben Jdila M, Ben Said M, Kamoun Feki F, Weckhuysen S, Masmoudi S, Fakhfakh F. First report of Tunisian patients with CDKL5-related encephalopathy. Epilepsia Open 2024; 9:906-917. [PMID: 37701975 PMCID: PMC11145601 DOI: 10.1002/epi4.12824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 09/09/2023] [Indexed: 09/14/2023] Open
Abstract
OBJECTIVE Mutations in the cyclin-dependent kinase-like 5 gene (CDKL5) are associated with a wide spectrum of clinical presentations. Early-onset epileptic encephalopathy (EOEE) is the most recognized phenotype. Here we describe phenotypic features in eight Tunisian patients with CDKL5-related encephalopathy. METHODS We included all cases with clinical features consistent with CDKL5-related encephalopathy: infantile epileptic spasm, acquired microcephaly, movement disorders and visual impairment. We collected data about seizure types, electroencephalogram, magnetic resonance imaging, and metabolic analysis. The diagnosis of CDKL5 mutation was made thanks to Sanger sequencing with an ABI PRISM 3100-Avant automated DNA sequencer using a Big Dye Terminator Cycle Sequencing Reaction Kit v1.1. and Next Generation Sequencing (NGS) since the development of a gene panel responsible for DEE within the framework of "Strengthening the Sfax University Expertise for diagnosis and management of epileptic encephalopathies". RESULTS We collected four boys and four girls aged meanly 6 years old with confirmed mutation on CDKL5 gene. Overall, we identified five de novo CDKL5 mutations including three Frame-shift mutations, one missense mutation, and a splicing variant. The mean age at first seizure onset was 4 months. The first seizure type was infantile epileptic spasm (4/8) followed by tonic (2/8) and myoclonic seizures (2/8). Out of eight cases, four exhibited two stages epileptic course while epilepsy in three other patients progressed on three stages. Regarding development, most cases (6/8) had psychomotor retardation from the start whilst the two others showed psychomotor regression with the onset of seizures. Additional clinical features included visual impairment (7/8), tone abnormalities (7/8), stereotypies (7/8), and acquired microcephaly (6/8). SIGNIFICANCE Our present report delineates an unusual phenotype of CDKL5-related encephalopathy with male gender predominance and delayed onset epilepsy. It interestingly described new phenotypic features and uncommon benign developmental profiles in boys, different patterns of CDKL5-epilepsy, neuroimaging findings, and CDKL5 mutational spectrum.
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Affiliation(s)
- Chahnez Charfi Triki
- Child Neurology Department, Hedi Chaker Sfax University Hospital, and Research Laboratory LR19ES15University of SfaxSfaxTunisia
| | - Salma Zouari Mallouli
- Child Neurology Department, Hedi Chaker Sfax University Hospital, and Research Laboratory LR19ES15University of SfaxSfaxTunisia
| | - Marwa Ben Jdila
- Laboratory of Molecular and Functional Genetics, Faculty of Science of SfaxUniversity of SfaxSfaxTunisia
| | - Mariem Ben Said
- Laboratory of Molecular and Cellular Screening Processes (LPCMC), Center of Biotechnology of SfaxUniversity of SfaxSfaxTunisia
| | - Fatma Kamoun Feki
- Child Neurology Department, Hedi Chaker Sfax University Hospital, and Research Laboratory LR19ES15University of SfaxSfaxTunisia
| | - Sarah Weckhuysen
- Applied & Translational Neurogenomics Group, VIB Center for Molecular Neurology, VIBUniversity of AntwerpAntwerpBelgium
- Department of NeurologyAntwerp University HospitalAntwerpBelgium
- Translational Neurosciences, Faculty of Medicine and Health ScienceUniversity of AntwerpAntwerpBelgium
| | - Sabeur Masmoudi
- Laboratory of Molecular and Cellular Screening Processes (LPCMC), Center of Biotechnology of SfaxUniversity of SfaxSfaxTunisia
| | - Faiza Fakhfakh
- Laboratory of Molecular and Functional Genetics, Faculty of Science of SfaxUniversity of SfaxSfaxTunisia
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Perinelli MG, Naboni C, Balagura G, Amadori E, Vari MS, Capra V, Lentoiou C, Foiadelli T, Sirchia F, Luparia A, Marseglia G, Ramenghi LA, Striano P. Early Developmental Intervention and Enriched Environment in CDKL5 Developmental and Epileptic Encephalopathy: A Case Report. Neurol Clin Pract 2024; 14:e200287. [PMID: 38660576 PMCID: PMC11042840 DOI: 10.1212/cpj.0000000000200287] [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: 11/22/2023] [Accepted: 02/07/2024] [Indexed: 04/26/2024]
Abstract
Objectives CDKL5 developmental and epileptic encephalopathy (CDKL5-DEE) is a rare X-linked dominant genetic disorder. Family-centered Early Intervention (EI) programs, which promote axonal plasticity and synaptic reorganization through exposure to an enriched environment, should be integrated into clinical practice. However, there is presently a dearth of dedicated EI protocols for patients with CDKL5-DEE and cerebral visual impairment (CVI). Methods We present a girl with a deletion of the CDKL5 gene (MIM*300203). At the age of 2 months, the child presented with severe epilepsy. The neurologic examination was abnormal, and she had severe CVI. At the first assessment, at 5 months old, her Developmental Quotient (DQ) on the Griffiths Mental Developmental Scales III (GMDS-III) was equivalent to 3-month-old skills (95% CI). The child was enrolled in an EI program for 6 months. Results At 12 months of age, the DQ score was 91. There has been improvement in the neurovisual functions. The findings from the scales show a gradual improvement in neuromotor and psychomotor development, which is in contrast to the expected outcome of the disease. Discussion The case study shows that a family-centered EI and prompt assessment of CVI can promote and enhance neurodevelopment.
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Affiliation(s)
- Martina Giorgia Perinelli
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Cecilia Naboni
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Ganna Balagura
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Elisabetta Amadori
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Maria Stella Vari
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Valeria Capra
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Camelia Lentoiou
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Thomas Foiadelli
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Fabio Sirchia
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Antonella Luparia
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Gianluigi Marseglia
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Luca A Ramenghi
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Pasquale Striano
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
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Amin S, Møller RS, Aledo‐Serrano A, Arzimanoglou A, Bager P, Jóźwiak S, Kluger GJ, López‐Cabeza S, Nabbout R, Partridge C, Schubert‐Bast S, Specchio N, Kälviäinen R. Providing quality care for people with CDKL5 deficiency disorder: A European expert panel opinion on the patient journey. Epilepsia Open 2024; 9:832-849. [PMID: 38450883 PMCID: PMC11145618 DOI: 10.1002/epi4.12914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 01/21/2024] [Indexed: 03/08/2024] Open
Abstract
Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) is a developmental and epileptic encephalopathy caused by variants in the CDKL5 gene. The disorder is characterized by intractable early-onset seizures, severe neurodevelopmental delay, hypotonia, motor disabilities, cerebral (cortical) visual impairment and microcephaly. With no disease-modifying therapies available for CDD, treatment is symptomatic with an initial focus on seizure control. Another unmet need in the management of people with CDD is the lack of evidence to aid standardized care and guideline development. To address this gap, experts in CDD and representatives from patient advocacy groups from Denmark, Finland, France, Germany, Italy, Poland, Spain, and the United Kingdom convened to form an Expert Working Group. The aim was to provide an expert opinion consensus on how to ensure quality care in routine clinical practice within the European setting, including in settings with limited experience or resources for multidisciplinary care of CDD and other developmental and epileptic encephalopathies. By means of one-to-one interviews around the current treatment landscape in CDD, insights from the Expert Working Group were collated and developed into a Europe-specific patient journey for individuals with CDD, which was later validated by the group. Further discussions followed to gain consensus of opinions on challenges and potential solutions for achieving quality care in this setting. The panel recognized the benefit of early genetic testing, a holistic personalized approach to seizure control (taking into consideration various factors such as concomitant medications and comorbidities), and age- and comorbidity-dependent multidisciplinary care for optimizing patient outcomes and quality of life. However, their insights and experiences also highlighted much disparity in management approaches and resources across different European countries. Development of standardized European recommendations is required to align realistic diagnostic criteria, treatment goals, and management approaches that can be adapted for different settings. PLAIN LANGUAGE SUMMARY: Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) is a rare condition caused by a genetic mutation with a broad range of symptoms apparent from early childhood, including epileptic seizures that do not respond to medication and severe delays in development. Due to the lack of guidance on managing CDD, international experts and patient advocates discussed best practices in the care of people with CDD in Europe. The panel agreed that early testing, a personalized approach to managing seizures, and access to care from different disciplines are beneficial. Development of guidelines to ensure that care is standardized would also be valuable.
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Affiliation(s)
- Sam Amin
- University Hospitals BristolBristolUK
| | - Rikke S. Møller
- The Danish Epilepsy Centre, FiladelfiaDianalundDenmark
- Department of Regional Health Research, Faculty of Health SciencesUniversity of Southern DenmarkOdenseDenmark
| | - Angel Aledo‐Serrano
- Vithas Madrid La Milagrosa University HospitalVithas Hospital GroupMadridSpain
| | | | | | | | - Gerhard Josef Kluger
- Epilepsy Center for Children and AdolescentsVogtareuthGermany
- Paracelsus Medical University SalzburgSalzburgAustria
| | | | - Rima Nabbout
- Necker‐Enfants Malades HospitalUniversité Paris Cité, Imagine InstituteParisFrance
| | | | - Susanne Schubert‐Bast
- Center of Neurology and NeurosurgeryEpilepsy Center Frankfurt Rhine‐MainGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER)Goethe‐UniversityFrankfurt am MainGermany
- University Children's HospitalGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
| | | | - Reetta Kälviäinen
- University of Eastern Finland and Epilepsy CenterKuopio University HospitalKuopioFinland
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4
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Borghi E, Xynomilakis O, Ottaviano E, Ceccarani C, Viganò I, Tognini P, Vignoli A. Gut microbiota profile in CDKL5 deficiency disorder patients. Sci Rep 2024; 14:7376. [PMID: 38548767 PMCID: PMC10978852 DOI: 10.1038/s41598-024-56989-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/13/2024] [Indexed: 04/01/2024] Open
Abstract
CDKL5 deficiency disorder (CDD) is a neurodevelopmental condition characterized by global developmental delay, early-onset seizures, intellectual disability, visual and motor impairments. Unlike Rett Syndrome (RTT), CDD lacks a clear regression period. Patients with CDD frequently encounter gastrointestinal (GI) disturbances and exhibit signs of subclinical immune dysregulation. However, the underlying causes of these conditions remain elusive. Emerging studies indicate a potential connection between neurological disorders and gut microbiota, an area completely unexplored in CDD. We conducted a pioneering study, analyzing fecal microbiota composition in individuals with CDD (n = 17) and their healthy relatives (n = 17). Notably, differences in intestinal bacterial diversity and composition were identified in CDD patients. In particular, at genus level, CDD microbial communities were characterized by an increase in the relative abundance of Clostridium_AQ, Eggerthella, Streptococcus, and Erysipelatoclostridium, and by a decrease in Eubacterium, Dorea, Odoribacter, Intestinomonas, and Gemmiger, pointing toward a dysbiotic profile. We further investigated microbiota changes based on the severity of GI issues, seizure frequency, sleep disorders, food intake type, impairment in neuro-behavioral features and ambulation capacity. Enrichment in Lachnoclostridium and Enterobacteriaceae was observed in the microbiota of patients with more severe GI symptoms, while Clostridiaceae, Peptostreptococcaceae, Coriobacteriaceae, Erysipelotrichaceae, Christensenellaceae, and Ruminococcaceae were enriched in patients experiencing daily epileptic seizures. Our findings suggest a potential connection between CDD, microbiota and symptom severity. This study marks the first exploration of the gut-microbiota-brain axis in subjects with CDD. It adds to the growing body of research emphasizing the role of the gut microbiota in neurodevelopmental disorders and opens doors to potential interventions that target intestinal microbes with the aim of improving the lives of patients with CDD.
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Affiliation(s)
- Elisa Borghi
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Ornella Xynomilakis
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- Dipartimento di Scienze Biomediche e Cliniche, Università Degli Studi di Milano, 20157, Milan, Italy
| | | | - Camilla Ceccarani
- Institute of Biomedical Technologies, National Research Council, Segrate, Milan, Italy
| | - Ilaria Viganò
- Epilepsy Center-Child Neuropsychiatric Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Paola Tognini
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.
- Health Science Interdisciplinary Center, Sant'Anna School of Advanced Studies, Pisa, Italy.
| | - Aglaia Vignoli
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
- Childhood and Adolescence Neurology and Psychiatry Unit, ASST GOM Niguarda, Milan, Italy
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Silvestre M, Dempster K, Mihaylov SR, Claxton S, Ultanir SK. Cell type-specific expression, regulation and compensation of CDKL5 activity in mouse brain. Mol Psychiatry 2024:10.1038/s41380-024-02434-7. [PMID: 38326557 DOI: 10.1038/s41380-024-02434-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/04/2024] [Accepted: 01/15/2024] [Indexed: 02/09/2024]
Abstract
CDKL5 is a brain-enriched serine/threonine kinase, associated with a profound developmental and epileptic encephalopathy called CDKL5 deficiency disorder (CDD). To design targeted therapies for CDD, it is essential to determine where CDKL5 is expressed and is active in the brain and test if compensatory mechanisms exist at cellular level. We generated conditional Cdkl5 knockout mice in excitatory neurons, inhibitory neurons and astrocytes. To assess CDKL5 activity, we utilized a phosphospecific antibody for phosphorylated EB2, a well-known substrate of CDKL5. We found that CDKL5 and EB2 pS222 were prominent in excitatory and inhibitory neurons but were not detected in astrocytes. We observed that approximately 15-20% of EB2 pS222 remained in Cdkl5 knockout brains and primary neurons. Surprisingly, the remaining phosphorylation was modulated by NMDA and PP1/PP2A in neuronal CDKL5 knockout cultures, indicating the presence of a compensating kinase. Using a screen of candidate kinases with highest homology to the CDKL5 kinase domain, we found that CDKL2 and ICK can phosphorylate EB2 S222 in HEK293T cells and in primary neurons. We then generated Cdkl5/Cdkl2 dual knockout mice to directly test if CDKL2 phosphorylates EB2 in vivo and found that CDKL2 phosphorylates CDKL5 substrates in the brain. This study is the first indication that CDKL2 could potentially replace CDKL5 functions in the brain, alluding to novel therapeutic possibilities.
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Affiliation(s)
- Margaux Silvestre
- Kinases and Brain Development Laboratory, The Francis Crick Institute, London, UK
| | - Kelvin Dempster
- Kinases and Brain Development Laboratory, The Francis Crick Institute, London, UK
| | - Simeon R Mihaylov
- Kinases and Brain Development Laboratory, The Francis Crick Institute, London, UK
| | - Suzanne Claxton
- Kinases and Brain Development Laboratory, The Francis Crick Institute, London, UK
| | - Sila K Ultanir
- Kinases and Brain Development Laboratory, The Francis Crick Institute, London, UK.
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Olson HE, Amin S, Bahi-Buisson N, Devinsky O, Marsh ED, Pestana-Knight E, Rajaraman RR, Aimetti AA, Rybak E, Kong F, Miller I, Hulihan J, Demarest S. Long-term treatment with ganaxolone for seizures associated with cyclin-dependent kinase-like 5 deficiency disorder: Two-year open-label extension follow-up. Epilepsia 2024; 65:37-45. [PMID: 37950390 DOI: 10.1111/epi.17826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/08/2023] [Accepted: 11/08/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE In the placebo-controlled, double-blind phase of the Marigold study (NCT03572933), ganaxolone significantly reduced major motor seizure frequency (MMSF) in patients with cyclin-dependent kinase-like 5 deficiency disorder (CDD). We report 2-year safety and clinical outcomes data from the open-label extension (OLE) phase of Marigold. METHODS Patients with CDD who completed the double-blind phase were eligible to continue in the OLE. Efficacy assessments included MMSF reduction from prerandomization baseline, responder rates, and Clinical Global Impression-Improvement scores, including assessment of seizure intensity and duration (CGI-CSID). Safety assessments included treatment-emergent adverse events (TEAEs) and TEAEs leading to discontinuation. RESULTS Of 101 patients who enrolled in Marigold, 88 (87.1%) entered the OLE (median age = 5 years, 79.5% female). Median 28-day MMSF at baseline was 50.6. At 2 years in the OLE (months 22-24), MMSF was reduced by a median of 48.2% (n = 50); when missing data were imputed, median reduction in MMSF was 43.8% using a mixed effects model and 27.4% using a last observation carried forward model. During months 22-24, 23 of 50 (46.0%) patients experienced reductions in MMSF of ≥50%; 12 of 50 (24.0%) patients experienced MMSF reductions of ≥75%. During months 22-24, 40 of 49 (81.6%) patients were rated by caregivers as having improvement in seizure-related outcomes based on CGI-CSID scores. Thirty-seven patients discontinued ganaxolone due to lack of efficacy (n = 13), withdrawal by caregiver (n = 12), adverse event (n = 10), physician decision (n = 1), or death (n = 1; unrelated to study drug). The most common treatment-related TEAEs were somnolence (17.0%), seizure (11.4%), and decreased appetite (5.7%). Patients reported serious TEAEs (n = 28, 31.8%); those reported in ≥3% of patients were seizure (n = 6), pneumonia (n = 5), acute respiratory failure (n = 3), aspiration pneumonia (n = 3), and dehydration (n = 3). SIGNIFICANCE Sustained reductions in MMSF at 2 years in the OLE support the efficacy of ganaxolone in seizures associated with CDD. Safety findings in the OLE were consistent with the double-blind phase.
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Affiliation(s)
- Heather E Olson
- Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sam Amin
- University Hospitals Bristol and Weston, Bristol, UK
| | - Nadia Bahi-Buisson
- Pediatric Neurology, Necker Enfants Malades University Hospital, Paris, France
| | - Orrin Devinsky
- New York University Langone Comprehensive Epilepsy Center, New York, New York, USA
| | - Eric D Marsh
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine and Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | - Alex A Aimetti
- Marinus Pharmaceuticals, Inc., Radnor, Pennsylvania, USA
| | - Eva Rybak
- Marinus Pharmaceuticals, Inc., Radnor, Pennsylvania, USA
| | - Fanhui Kong
- Marinus Pharmaceuticals, Inc., Radnor, Pennsylvania, USA
| | - Ian Miller
- Marinus Pharmaceuticals, Inc., Radnor, Pennsylvania, USA
| | - Joseph Hulihan
- Marinus Pharmaceuticals, Inc., Radnor, Pennsylvania, USA
| | - Scott Demarest
- Department of Pediatrics and Neurology, University of Colorado School of Medicine, Precision Medicine Institute, Children's Hospital Colorado, Aurora, Colorado, USA
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Abstract
Rett syndrome is a neurodevelopmental disorder caused by loss-of-function mutations in the methyl-CpG binding protein-2 (MeCP2) gene that is characterized by epilepsy, intellectual disability, autistic features, speech deficits, and sleep and breathing abnormalities. Neurologically, patients with all three disorders display microcephaly, aberrant dendritic morphology, reduced spine density, and an imbalance of excitatory/inhibitory signaling. Loss-of-function mutations in the cyclin-dependent kinase-like 5 (CDKL5) and FOXG1 genes also cause similar behavioral and neurobiological defects and were referred to as congenital or variant Rett syndrome. The relatively recent realization that CDKL5 deficiency disorder (CDD), FOXG1 syndrome, and Rett syndrome are distinct neurodevelopmental disorders with some distinctive features have resulted in separate focus being placed on each disorder with the assumption that distinct molecular mechanisms underlie their pathogenesis. However, given that many of the core symptoms and neurological features are shared, it is likely that the disorders share some critical molecular underpinnings. This review discusses the possibility that deregulation of common molecules in neurons and astrocytes plays a central role in key behavioral and neurological abnormalities in all three disorders. These include KCC2, a chloride transporter, vGlut1, a vesicular glutamate transporter, GluD1, an orphan-glutamate receptor subunit, and PSD-95, a postsynaptic scaffolding protein. We propose that reduced expression or activity of KCC2, vGlut1, PSD-95, and AKT, along with increased expression of GluD1, is involved in the excitatory/inhibitory that represents a key aspect in all three disorders. In addition, astrocyte-derived brain-derived neurotrophic factor (BDNF), insulin-like growth factor 1 (IGF-1), and inflammatory cytokines likely affect the expression and functioning of these molecules resulting in disease-associated abnormalities.
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Affiliation(s)
- Santosh R D’Mello
- Department of Biological Sciences, Louisiana State University Shreveport, Shreveport, LA 71104, USA
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8
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Zhu ZA, Li YY, Xu J, Xue H, Feng X, Zhu YC, Xiong ZQ. CDKL5 deficiency in adult glutamatergic neurons alters synaptic activity and causes spontaneous seizures via TrkB signaling. Cell Rep 2023; 42:113202. [PMID: 37777961 DOI: 10.1016/j.celrep.2023.113202] [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: 05/04/2023] [Revised: 07/26/2023] [Accepted: 09/16/2023] [Indexed: 10/03/2023] Open
Abstract
CDKL5 deficiency disorder (CDD) is a severe epileptic encephalopathy resulting from pathological mutations in the X-linked cyclin-dependent kinase-like 5 (CDKL5) gene. Despite significant progress in understanding the neuronal function of CDKL5, the molecular mechanisms underlying CDD-associated epileptogenesis are unknown. Here, we report that acute ablation of CDKL5 from adult forebrain glutamatergic neurons leads to elevated neural network activity in the dentate gyrus and the occurrence of early-onset spontaneous seizures via tropomyosin-related kinase B (TrkB) signaling. We observe increased expression of brain-derived neurotrophic factor (BDNF) and enhanced activation of its receptor TrkB in the hippocampus of Cdkl5-deficient mice prior to the onset of behavioral seizures. Moreover, reducing TrkB signaling in these mice rescues the altered synaptic activity and suppresses recurrent seizures. These results suggest that TrkB signaling mediates epileptogenesis in a mouse model of CDD and that targeting this pathway might be effective for treating epilepsy in patients affected by CDKL5 mutations.
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Affiliation(s)
- Zi-Ai Zhu
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Shanghai 200031, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Yi-Yan Li
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Shanghai 200031, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Juan Xu
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Shanghai 200031, China
| | - Hui Xue
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Shanghai 200031, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Xue Feng
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Shanghai 200031, China
| | - Yong-Chuan Zhu
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China.
| | - Zhi-Qi Xiong
- Institute of Neuroscience, State Key Laboratory of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Shanghai 200031, China; University of Chinese Academy of Sciences, Beijing 100049, China; School of Life Science and Technology, ShanghaiTech University, Shanghai 201210, China; Shanghai Center for Brain Science and Brain-Inspired Intelligence Technology, Shanghai 201210, China; School of Future Technology, University of Chinese Academy of Sciences, Beijing 100049, China.
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9
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Tassinari M, Uguagliati B, Trazzi S, Cerchier CB, Cavina OV, Mottolese N, Loi M, Candini G, Medici G, Ciani E. Early-onset brain alterations during postnatal development in a mouse model of CDKL5 deficiency disorder. Neurobiol Dis 2023; 182:106146. [PMID: 37164289 DOI: 10.1016/j.nbd.2023.106146] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/05/2023] [Accepted: 05/07/2023] [Indexed: 05/12/2023] Open
Abstract
Mutations in the CDKL5 gene are the cause of CDKL5 deficiency disorder (CDD), a rare and severe neurodevelopmental condition characterized by early-onset epilepsy, motor impairment, intellectual disability, and autistic features. A mouse model of CDD, the Cdkl5 KO mouse, that recapitulates several aspects of CDD symptomology, has helped to highlight brain alterations leading to CDD neurological defects. Studies of brain morphogenesis in adult Cdkl5 KO mice showed defects in dendritic arborization of pyramidal neurons and in synaptic connectivity, a hypocellularity of the hippocampal dentate gyrus, and a generalized microglia over-activation. Nevertheless, no studies are available regarding the presence of these brain alterations in Cdkl5 KO pups, and their severity in early stages of life compared to adulthood. A deeper understanding of the CDKL5 deficient brain during an early phase of postnatal development would represent an important milestone for further validation of the CDD mouse model, and for the identification of the optimum time window for treatments that target defects in brain development. In sight of this, we comparatively evaluated the dendritic arborization and spines of cortical pyramidal neurons, cortical excitatory and inhibitory connectivity, microglia activation, and proliferation and survival of granule cells of the hippocampal dentate gyrus in hemizygous Cdkl5 KO male (-/Y) mice aged 7, 14, 21, and 60 days. We found that most of the structural alterations in Cdkl5 -/Y brains are already present in pups aged 7 days and do not worsen with age. In contrast, the difference in the density of excitatory and inhibitory terminals between Cdkl5 -/Y and wild-type mice changes with age, suggesting an age-dependent cortical excitatory/inhibitory synaptic imbalance. Confirming the precocious presence of brain defects, Cdkl5 -/Y pups are characterized by an impairment in neonatal sensory-motor reflexes.
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Affiliation(s)
- Marianna Tassinari
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126 Bologna, Italy
| | - Beatrice Uguagliati
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126 Bologna, Italy
| | - Stefania Trazzi
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126 Bologna, Italy.
| | - Camilla Bruna Cerchier
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126 Bologna, Italy
| | - Ottavia Vera Cavina
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126 Bologna, Italy
| | - Nicola Mottolese
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126 Bologna, Italy
| | - Manuela Loi
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126 Bologna, Italy
| | - Giulia Candini
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126 Bologna, Italy
| | - Giorgio Medici
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126 Bologna, Italy
| | - Elisabetta Ciani
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126 Bologna, Italy.
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10
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Aznar-Laín G, Fernández-Mayoralas DM, Caicoya AG, Rocamora R, Pérez-Jurado LA. CDKL5 Deficiency Disorder Without Epilepsy. Pediatr Neurol 2023; 144:84-89. [PMID: 37201242 DOI: 10.1016/j.pediatrneurol.2023.04.015] [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] [Received: 08/05/2022] [Revised: 01/14/2023] [Accepted: 04/19/2023] [Indexed: 05/20/2023]
Abstract
Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) has epilepsy as a cardinal feature. Here we report two new female patients and review six previously published patients, one male and five females, with features of CDD but who never developed epilepsy. In contrast with the classical and severe CDD phenotype, they presented with milder gross motor delays, autism spectrum disorder, and no visual cortical impairment. Prolonged video electroencephalography was normal in adult cases but showed interictal frontal-temporal bilateral spikes and sharp waves in sleep in the three-year-old girl. Causative CDKL5 variants included two likely gene damaging (nonsense and frameshift) and six missense variants, being de novo or maternally inherited from asymptomatic females with skewed X-chromosome inactivation (two missense variants). Our data indicate that a milder form of CDD without epilepsy can occur in some cases without clear correlation with specific variants in the CDKL5 gene.
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Affiliation(s)
- Gemma Aznar-Laín
- Paediatric Neurology, Hospital del Mar, Barcelona, Spain; Program in Neurosciences, Hospital del Mar Research Institute (IMIM), Barcelona, Spain; Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain.
| | | | - Anne G Caicoya
- Epilepsy Monitoring Unit, Quironsalud Hospital, Madrid, Spain
| | - Rodrigo Rocamora
- Program in Neurosciences, Hospital del Mar Research Institute (IMIM), Barcelona, Spain; Epilepsy Monitoring Unit, Department of Neurology, Hospital del Mar, Barcelona, Spain
| | - Luis A Pérez-Jurado
- Program in Neurosciences, Hospital del Mar Research Institute (IMIM), Barcelona, Spain; Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain; Genetics Service, Hospital del Mar, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, Barcelona, Spain
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11
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Damiani F, Cornuti S, Tognini P. The gut-brain connection: Exploring the influence of the gut microbiota on neuroplasticity and neurodevelopmental disorders. Neuropharmacology 2023; 231:109491. [PMID: 36924923 DOI: 10.1016/j.neuropharm.2023.109491] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 02/22/2023] [Accepted: 03/05/2023] [Indexed: 03/17/2023]
Abstract
Neuroplasticity refers to the ability of brain circuits to reorganize and change the properties of the network, resulting in alterations in brain function and behavior. It is traditionally believed that neuroplasticity is influenced by external stimuli, learning, and experience. Intriguingly, there is new evidence suggesting that endogenous signals from the body's periphery may play a role. The gut microbiota, a diverse community of microorganisms living in harmony with their host, may be able to influence plasticity through its modulation of the gut-brain axis. Interestingly, the maturation of the gut microbiota coincides with critical periods of neurodevelopment, during which neural circuits are highly plastic and potentially vulnerable. As such, dysbiosis (an imbalance in the gut microbiota composition) during early life may contribute to the disruption of normal developmental trajectories, leading to neurodevelopmental disorders. This review aims to examine the ways in which the gut microbiota can affect neuroplasticity. It will also discuss recent research linking gastrointestinal issues and bacterial dysbiosis to various neurodevelopmental disorders and their potential impact on neurological outcomes.
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Affiliation(s)
| | - Sara Cornuti
- Laboratory of Biology, Scuola Normale Superiore, Pisa, Italy
| | - Paola Tognini
- Laboratory of Biology, Scuola Normale Superiore, Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.
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12
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Cardiac Functional and Structural Abnormalities in a Mouse Model of CDKL5 Deficiency Disorder. Int J Mol Sci 2023; 24:ijms24065552. [PMID: 36982627 PMCID: PMC10059787 DOI: 10.3390/ijms24065552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/02/2023] [Accepted: 03/11/2023] [Indexed: 03/15/2023] Open
Abstract
CDKL5 (cyclin-dependent kinase-like 5) deficiency disorder (CDD) is a severe neurodevelopmental disease that mostly affects girls, who are heterozygous for mutations in the X-linked CDKL5 gene. Mutations in the CDKL5 gene lead to a lack of CDKL5 protein expression or function and cause numerous clinical features, including early-onset seizures, marked hypotonia, autistic features, gastrointestinal problems, and severe neurodevelopmental impairment. Mouse models of CDD recapitulate several aspects of CDD symptomology, including cognitive impairments, motor deficits, and autistic-like features, and have been useful to dissect the role of CDKL5 in brain development and function. However, our current knowledge of the function of CDKL5 in other organs/tissues besides the brain is still quite limited, reducing the possibility of broad-spectrum interventions. Here, for the first time, we report the presence of cardiac function/structure alterations in heterozygous Cdkl5 +/− female mice. We found a prolonged QT interval (corrected for the heart rate, QTc) and increased heart rate in Cdkl5 +/− mice. These changes correlate with a marked decrease in parasympathetic activity to the heart and in the expression of the Scn5a and Hcn4 voltage-gated channels. Interestingly, Cdkl5 +/− hearts showed increased fibrosis, altered gap junction organization and connexin-43 expression, mitochondrial dysfunction, and increased ROS production. Together, these findings not only contribute to our understanding of the role of CDKL5 in heart structure/function but also document a novel preclinical phenotype for future therapeutic investigation.
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13
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Odgis JA, Gallagher KM, Rehman AU, Marathe P, Bonini KE, Sebastin M, Di Biase M, Brown K, Kelly NR, Ramos MA, Thomas-Wilson A, Guha S, Okur V, Ganapathi M, Elkhoury L, Edelmann L, Zinberg RE, Abul-Husn NS, Diaz GA, Greally JM, Suckiel SA, Jobanputra V, Horowitz CR, Kenny EE, Wasserstein MP, Gelb BD. Detection of mosaic variants using genome sequencing in a large pediatric cohort. Am J Med Genet A 2023; 191:699-710. [PMID: 36563179 PMCID: PMC10266700 DOI: 10.1002/ajmg.a.63062] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 11/07/2022] [Accepted: 11/18/2022] [Indexed: 12/24/2022]
Abstract
The increased use of next-generation sequencing has expanded our understanding of the involvement and prevalence of mosaicism in genetic disorders. We describe a total of eleven cases: nine in which mosaic variants detected by genome sequencing (GS) and/or targeted gene panels (TGPs) were considered to be causative for the proband's phenotype, and two of apparent parental mosaicism. Variants were identified in the following genes: PHACTR1, SCN8A, KCNT1, CDKL5, NEXMIF, CUX1, TSC2, GABRB2, and SMARCB1. In addition, we identified one large duplication including three genes, UBE3A, GABRB3, and MAGEL2, and one large deletion including deletion of ARFGAP1, EEF1A2, CHRNA4, and KCNQ2. All patients were enrolled in the NYCKidSeq study, a research program studying the communication of genomic information in clinical care, as well as the clinical utility and diagnostic yield of GS for children with suspected genetic disorders in diverse populations in New York City. We observed variability in the correlation between reported variant allele fraction and the severity of the patient's phenotype, although we were not able to determine the mosaicism percentage in clinically relevant tissue(s). Although our study was not sufficiently powered to assess differences in mosaicism detection between the two testing modalities, we saw a trend toward better detection by GS as compared with TGP testing. This case series supports the importance of mosaicism in childhood-onset genetic conditions and informs guidelines for laboratory and clinical interpretation of mosaic variants detected by GS.
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Affiliation(s)
- Jacqueline A. Odgis
- The Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Katie M. Gallagher
- Department of Pediatrics, Division of Pediatric Genetic Medicine, Children’s Hospital at Montefiore/Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Atteeq U. Rehman
- Molecular Diagnostics, New York Genome Center, New York, NY, USA
| | - Priya Marathe
- The Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Katherine E. Bonini
- The Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Monisha Sebastin
- Department of Pediatrics, Division of Pediatric Genetic Medicine, Children’s Hospital at Montefiore/Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Miranda Di Biase
- Department of Pediatrics, Division of Pediatric Genetic Medicine, Children’s Hospital at Montefiore/Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kaitlyn Brown
- Department of Pediatrics, Division of Pediatric Genetic Medicine, Children’s Hospital at Montefiore/Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Nicole R. Kelly
- Department of Pediatrics, Division of Pediatric Genetic Medicine, Children’s Hospital at Montefiore/Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michelle A. Ramos
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Saurav Guha
- Molecular Diagnostics, New York Genome Center, New York, NY, USA
| | - Volkan Okur
- Molecular Diagnostics, New York Genome Center, New York, NY, USA
| | | | | | | | - Randi E. Zinberg
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Noura S. Abul-Husn
- The Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - George A. Diaz
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John M. Greally
- Department of Pediatrics, Division of Pediatric Genetic Medicine, Children’s Hospital at Montefiore/Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sabrina A. Suckiel
- The Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vaidehi Jobanputra
- Molecular Diagnostics, New York Genome Center, New York, NY, USA
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA
| | - Carol R. Horowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eimear E. Kenny
- The Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Melissa P. Wasserstein
- Department of Pediatrics, Division of Pediatric Genetic Medicine, Children’s Hospital at Montefiore/Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Bruce D. Gelb
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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14
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Yasmen N, Sluter MN, Yu Y, Jiang J. Ganaxolone for management of seizures associated with CDKL5 deficiency disorder. Trends Pharmacol Sci 2023; 44:128-129. [PMID: 36517284 PMCID: PMC10031766 DOI: 10.1016/j.tips.2022.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/18/2022] [Accepted: 11/21/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Nelufar Yasmen
- Department of Pharmaceutical Sciences and Drug Discovery Center, College of Pharmacy, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Madison N Sluter
- Department of Pharmaceutical Sciences and Drug Discovery Center, College of Pharmacy, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Ying Yu
- Department of Pharmaceutical Sciences and Drug Discovery Center, College of Pharmacy, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Jianxiong Jiang
- Department of Pharmaceutical Sciences and Drug Discovery Center, College of Pharmacy, The University of Tennessee Health Science Center, Memphis, TN 38163, USA.
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15
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Gorchkhanova ZK, Nikolaeva EA, Pivovarova AM, Bochenkov SV, Belousova ED. Difficulties in the differential diagnosis of Angelman’s syndrome. ROSSIYSKIY VESTNIK PERINATOLOGII I PEDIATRII (RUSSIAN BULLETIN OF PERINATOLOGY AND PEDIATRICS) 2023. [DOI: 10.21508/1027-4065-2022-67-6-113-122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Angelman syndrome is a rare neurogenetic disease caused by the loss of the function of the maternal allele of the UBE3A gene on chromosome 15 (site 15q11.2–q13) and is characterized by severe mental retardation, lack of speech, epilepsy, microcephaly and a characteristic facial phenotype with a unique behavior in the form of frequent laughter. The combination of microcephaly, epilepsy, speechlessness and mental retardation poses a problem for differential diagnosis with many genetic diseases presenting with similar symptoms. Epileptic encephalopathy due to CDKL5 gene mutation and Rett syndrome have the greatest similarity. The hallmark of Angelman syndrome are laughter attacks and specific EEG changes. The authors have presented a table of the differential diagnosis of Angelman syndrome with some phenotypically similar genetic syndromes, indicating the most significant distinguishing features, which should facilitate for the pediatrician and neurologist the diagnostic path of establishing the correct diagnosis.
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Affiliation(s)
- Z. K. Gorchkhanova
- Veltischev Research and Clinical Institute for Pediatrics of the Pirogov Russian National Research Medical University
| | - E. A. Nikolaeva
- Veltischev Research and Clinical Institute for Pediatrics of the Pirogov Russian National Research Medical University
| | - A. M. Pivovarova
- Veltischev Research and Clinical Institute for Pediatrics of the Pirogov Russian National Research Medical University
| | - S. V. Bochenkov
- Veltischev Research and Clinical Institute for Pediatrics of the Pirogov Russian National Research Medical University
| | - E. D. Belousova
- Veltischev Research and Clinical Institute for Pediatrics of the Pirogov Russian National Research Medical University
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16
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CDKL5 deficiency causes epileptic seizures independent of cellular mosaicism. J Neurol Sci 2022; 443:120498. [PMID: 36417806 DOI: 10.1016/j.jns.2022.120498] [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: 07/20/2022] [Revised: 10/06/2022] [Accepted: 11/12/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE In a study using a mouse model of CDKL5 deficiency disorder (CDD), seizures are specific to female mice heterozygous for Cdkl5 mutations and not observed in hemizygous knockout males or homozygous knockout females. The aim of this study was to examine whether the clinical phenotype of patients with CDD can be impacted by the type of genetic variant. METHODS Eleven CDD patients (six females and five males) were included in this study. The molecular diagnosis of hemizygous male patients was performed using digital PCR and their clinical phenotypes were compared with those of patients with mosaic or heterozygous CDKL5 variants. The severity of clinical phenotypes was graded by using CDKL5 Developmental Score and the adapted version of the CDKL5 Clinical Severity Assessment. The effect of cellular mosaicism on the severity of CDD was studied by comparing the clinical characteristics and comorbidities between individuals with hemizygous and mosaic or heterozygous CDKL5 variants. RESULTS One of the five male patients was mosaic for the CDKL5 variant. All patients developed seizures irrespective of their genetic status of the pathogenic variant. However, cellular mosaicism of CDKL5 deficiency was associated with lesser severity of other comorbidities such as feeding, respiratory, and visual functional impairments. SIGNIFICANCE This study provided evidence that cellular mosaicism of CDKL5 deficiency was not necessarily required for developing epilepsy. CDD patients not only exhibited clinical features of epilepsy but also exhibited the developmental consequences arising directly from the effect of the CDKL5 pathogenic variant.
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17
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Rodak M, Jonderko M, Rozwadowska P, Machnikowska-Sokołowska M, Paprocka J. CDKL5 Deficiency Disorder (CDD)-Rare Presentation in Male. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121806. [PMID: 36553250 PMCID: PMC9776588 DOI: 10.3390/children9121806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/07/2022] [Accepted: 11/18/2022] [Indexed: 11/25/2022]
Abstract
CDKL5 deficiency disorder (CDD) is a developmental encephalopathy caused by pathogenic variants in the X-linked cyclin-dependent kinase 5 (CDKL5) gene. This rare disorder occurs more frequently in females than in males. The incidence is estimated to be approximately 1: 40,000-60,000 live births. So far, 50 cases have been described in boys. The clinical course in males tends to be more severe and is often associated with death in the first or second decade of life. The authors present an unreported 2.5-year-old male patient with drug-resistant epilepsy who was diagnosed with a de novo mutation in the CDKL5 gene. First seizures developed in the fifth week of life and have progressed steadily since then. The child's psychomotor development was strongly delayed, and generalized hypotonia was noticed since birth. Brain MRI showed areas of incomplete myelination, posterior narrowing of the corpus callosum, a pineal cyst of up to 3 mm, and open islet lids. Intensive antiseizure medications (ASMs), a ketogenic diet, and steroid therapy were not successful. Short-term improvement was achieved with the implantation of a vagal nerve stimulator (VNS). Due to the progressive course of the disease, the boy requires frequent modification of ASMs.
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Affiliation(s)
- Małgorzata Rodak
- Students’ Scientific Society, Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Mariola Jonderko
- Students’ Scientific Society, Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Patrycja Rozwadowska
- Students’ Scientific Society, Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Magdalena Machnikowska-Sokołowska
- Department of Diagnostic Imaging, Radiology and Nuclear Medicine, Faculty of Medical Science in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Justyna Paprocka
- Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
- Correspondence:
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18
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Philip SS, Guzzetta A, Gole GA, Boyd RN. Clinimetric properties of visuo-perceptual and visuo-cognitive assessment tools used for children with cerebral visual impairment and cerebral palsy or developmental delay: a systematic review. Disabil Rehabil 2022; 44:6984-6996. [PMID: 34787029 DOI: 10.1080/09638288.2021.1990421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE The aim of this systematic review is to evaluate the psychometrics and clinical utility of visuo-perceptual and visuo-cognitive assessment tools in children with cerebral visual impairment (CVI) and cerebral palsy (CP) or neurodevelopmental delay (DD). MATERIALS AND METHODS Five databases (PubMed, EMBASE, SCOPUS, CINAHL, and Cochrane Database) were comprehensively searched from 1970 till June 2021. The PRISMA checklist was utilised to report on the process of selecting eligible papers. The methodological quality of included studies was evaluated using COnsenus-based Standards for the selection of health Measurement INstrument (COSMIN) checklist. RESULTS Of the 26 assessment tools identified, only seven tools had psychometric evidence supporting their use. Based on COSMIN guidelines, 60% of included studies were rated as inadequate or doubtful for their methodological quality of measurement properties, with equal number being rated as indeterminate on the overall rating. CONCLUSIONS Cerebral visual impairment due to its varied clinical presentation is often missed in children with CP and DD. There is a paucity of studies reporting on the validity and reliability of functional vision tools. Further studies are needed to conduct high-quality psychometric reporting using the updated COSMIN guidelines to identify appropriate functional vision tools for children with CP or DD.Implications for rehabilitationThere are paucity of studies evaluating the validity and reliability of existing perceptual and cognitive assessment tools in children with cerebral visual impairment (CVI) and cerebral palsy (CP).Development of age-appropriate assessment tools evaluating all aspects of functional vision will assist in providing more holistic child-centric rehabilitation programs.A combination of detailed perinatal history, direct observation, and clinical assessments of functional vision are important to recognise CVI in children with CP.
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Affiliation(s)
- Swetha Sara Philip
- The University of Queensland, Queensland Cerebral Palsy and Rehabilitation Research Centre, Centre for Children's Health Research, Faculty of Medicine, Brisbane, Australia.,Department of Ophthalmology, Queensland Children's Hospital, Brisbane, Australia
| | - Andrea Guzzetta
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Department of Developmental Neuroscience, IRCCS Fondazione Stella Maris, Pisa, Italy
| | - Glen A Gole
- Mayne Academy of Paediatrics, The University of Queensland, Brisbane, Australia
| | - Roslyn N Boyd
- The University of Queensland, Queensland Cerebral Palsy and Rehabilitation Research Centre, Centre for Children's Health Research, Faculty of Medicine, Brisbane, Australia
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19
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Comprehensive In Silico Functional Prediction Analysis of CDKL5 by Single Amino Acid Substitution in the Catalytic Domain. Int J Mol Sci 2022; 23:ijms232012281. [PMID: 36293137 PMCID: PMC9603577 DOI: 10.3390/ijms232012281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 11/05/2022] Open
Abstract
Cyclin-dependent kinase-like 5 (CDKL5) is a serine/threonine protein kinase whose pathological mutations cause CDKL5 deficiency disorder. Most missense mutations are concentrated in the catalytic domain. Therefore, anticipating whether mutations in this region affect CDKL5 function is informative for clinical diagnosis. This study comprehensively predicted the pathogenicity of all 5700 missense substitutions in the catalytic domain of CDKL5 using in silico analysis and evaluating their accuracy. Each missense substitution was evaluated as “pathogenic” or “benign”. In silico tools PolyPhen-2 HumDiv mode/HumVar mode, PROVEAN, and SIFT were selected individually or in combination with one another to determine their performance using 36 previously reported mutations as a reference. Substitutions predicted as pathogenic were over 88.0% accurate using each of the three tools. The best performance score (accuracy, 97.2%; sensitivity, 100%; specificity, 66.7%; and Matthew’s correlation coefficient (MCC), 0.804) was achieved by combining PolyPhen-2 HumDiv, PolyPhen-2 HumVar, and PROVEAN. This provided comprehensive information that could accurately predict the pathogenicity of the disease, which might be used as an aid for clinical diagnosis.
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20
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Liu HF, Yuan TY, Yang JW, Li F, Wang F, Fu HM. A novel de novo heterozygous variant of the KCNQ2 gene: Contribution to early‑onset epileptic encephalopathy in a female infant. Mol Med Rep 2022; 26:282. [PMID: 35856407 PMCID: PMC9364154 DOI: 10.3892/mmr.2022.12797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 06/29/2022] [Indexed: 11/16/2022] Open
Abstract
Early-onset epileptic encephalopathy (EOEE) represents one of the most severe epilepsies, characterized by recurrent seizures during early infancy, electroencephalogram (EEG) abnormalities and varying degrees of neurodevelopmental delay. The KCNQ2 gene has been reported to have a major role in EOEE. In the present study, a 3-month-old female infant from the Chinese Lisu minority with EOEE was analyzed. Detailed clinical evaluations and next-generation sequencing were performed to investigate the clinical and genetic characteristics of this patient, respectively. Furthermore, the three-dimensional structure of the mutant protein was predicted by SWISS-Model and the expression of KCNQ2 protein in the patient was assessed by flow cytometry. It was observed that the patient presented with typical clinical features of EOEE, including repeated non-febrile seizures and significant EEG abnormalities. A novel heterozygous missense variant c.431G>C (p.R144P) in KCNQ2 was identified in the patient and the genotyping of KCNQ2 in the patient's parents suggested that this variant was de novo. Subsequently, the breakage of hydrogen bonds between certain amino acids was predicted by structural analysis of the mutant protein. Flow cytometric analysis detected a significant reduction buts not complete loss of native KCNQ2 protein expression in the patient (25.1%). In conclusion, a novel variant in KCNQ2 was confirmed as the genetic cause for EOEE in this patient. The present study expanded the pathogenic mutation spectrum of KCNQ2, enhanced the understanding of the molecular pathogenesis of EOEE and provided novel clues for research on the genotype-phenotype correlation in this disease.
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Affiliation(s)
- Hai-Feng Liu
- Department of Pulmonary and Critical Care Medicine, Kunming Children's Hospital and Yunnan Key Laboratory of Children's Major Disease Research, Kunming, Yunnan 650034, P.R. China
| | - Ting-Yun Yuan
- Department of Pulmonary and Critical Care Medicine, Kunming Children's Hospital and Yunnan Key Laboratory of Children's Major Disease Research, Kunming, Yunnan 650034, P.R. China
| | - Jia-Wu Yang
- Department of Pulmonary and Critical Care Medicine, Kunming Children's Hospital and Yunnan Key Laboratory of Children's Major Disease Research, Kunming, Yunnan 650034, P.R. China
| | - Feng Li
- Department of Pulmonary and Critical Care Medicine, Kunming Children's Hospital and Yunnan Key Laboratory of Children's Major Disease Research, Kunming, Yunnan 650034, P.R. China
| | - Fan Wang
- Department of Pulmonary and Critical Care Medicine, Kunming Children's Hospital and Yunnan Key Laboratory of Children's Major Disease Research, Kunming, Yunnan 650034, P.R. China
| | - Hong-Min Fu
- Department of Pulmonary and Critical Care Medicine, Kunming Children's Hospital and Yunnan Key Laboratory of Children's Major Disease Research, Kunming, Yunnan 650034, P.R. China
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21
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McKnight D, Bean L, Karbassi I, Beattie K, Bienvenu T, Bonin H, Fang P, Chrisodoulou J, Friez M, Helgeson M, Krishnaraj R, Meng L, Mighion L, Neul J, Percy A, Ramsden S, Zoghbi H, Das S. Recommendations by the ClinGen Rett/Angelman-like expert panel for gene-specific variant interpretation methods. Hum Mutat 2022; 43:1097-1113. [PMID: 34837432 PMCID: PMC9135956 DOI: 10.1002/humu.24302] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/05/2021] [Accepted: 11/21/2021] [Indexed: 11/11/2022]
Abstract
The genes MECP2, CDKL5, FOXG1, UBE3A, SLC9A6, and TCF4 present unique challenges for current ACMG/AMP variant interpretation guidelines. To address those challenges, the Rett and Angelman-like Disorders Variant Curation Expert Panel (Rett/AS VCEP) drafted gene-specific modifications. A pilot study was conducted to test the clarity and accuracy of using the customized variant interpretation criteria. Multiple curators obtained the same interpretation for 78 out of the 87 variants (~90%), indicating appropriate usage of the modified guidelines the majority of times by all the curators. The classification of 13 variants changed using these criteria specifications compared to when the variants were originally curated and as present in ClinVar. Many of these changes were due to internal data shared from laboratory members however some changes were because of changes in strength of criteria. There were no two-step classification changes and only 1 clinically relevant change (Likely pathogenic to VUS). The Rett/AS VCEP hopes that these gene-specific variant curation rules and the assertions provided help clinicians, clinical laboratories, and others interpret variants in these genes but also other fully penetrant, early-onset genes associated with rare disorders.
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Affiliation(s)
| | | | | | | | | | | | | | - John Chrisodoulou
- Murdoch Childrens Research Institute and the University of Melbourne,University of Sydney
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22
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Varela T, Varela D, Martins G, Conceição N, Cancela ML. Cdkl5 mutant zebrafish shows skeletal and neuronal alterations mimicking human CDKL5 deficiency disorder. Sci Rep 2022; 12:9325. [PMID: 35665761 PMCID: PMC9167277 DOI: 10.1038/s41598-022-13364-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/12/2022] [Indexed: 12/17/2022] Open
Abstract
CDKL5 deficiency disorder (CDD) is a rare neurodevelopmental condition characterized primarily by seizures and impairment of cognitive and motor skills. Additional phenotypes include microcephaly, dysmorphic facial features, and scoliosis. Mutations in cyclin-dependent kinase-like 5 (CDKL5) gene, encoding a kinase essential for normal brain development and function, are responsible for CDD. Zebrafish is an accepted biomedical model for the study of several genetic diseases and has many advantages over other models. Therefore, this work aimed to characterize the phenotypic, behavioral, and molecular consequences of the Cdkl5 protein disruption in a cdkl5 mutant zebrafish line (sa21938). cdkl5sa21938 mutants displayed a reduced head size, suggesting microcephaly, a feature frequently observed in CDD individuals. Double staining revealed shorter craniofacial cartilage structures and decrease bone mineralization in cdkl5 homozygous zebrafish indicating an abnormal craniofacial cartilage development and impaired skeletal development. Motor behavior analysis showed that cdkl5sa21938 embryos had less frequency of double coiling suggesting impaired glutamatergic neurotransmission. Locomotor behavior analysis revealed that homozygous embryos swim shorter distances, indicative of impaired motor activity which is one of the main traits of CCD. Although no apparent spontaneous seizures were observed in these models, upon treatment with pentylenetetrazole, seizure behavior and an increase in the distance travelled were observed. Quantitative PCR showed that neuronal markers, including glutamatergic genes were dysregulated in cdkl5sa21938 mutant embryos. In conclusion, homozygous cdkl5sa21938 zebrafish mimic several characteristics of CDD, thus validating them as a suitable animal model to better understand the physiopathology of this disorder.
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Affiliation(s)
- Tatiana Varela
- Centre of Marine Sciences, University of Algarve, Faro, Portugal
- Faculty of Medicine and Biomedical Sciences, University of Algarve, Faro, Portugal
| | - Débora Varela
- Centre of Marine Sciences, University of Algarve, Faro, Portugal
- Faculty of Medicine and Biomedical Sciences, University of Algarve, Faro, Portugal
| | - Gil Martins
- Centre of Marine Sciences, University of Algarve, Faro, Portugal
- Faculty of Medicine and Biomedical Sciences, University of Algarve, Faro, Portugal
| | - Natércia Conceição
- Centre of Marine Sciences, University of Algarve, Faro, Portugal.
- Faculty of Medicine and Biomedical Sciences, University of Algarve, Faro, Portugal.
- Algarve Biomedical Center, University of Algarve, Faro, Portugal.
| | - M Leonor Cancela
- Centre of Marine Sciences, University of Algarve, Faro, Portugal.
- Faculty of Medicine and Biomedical Sciences, University of Algarve, Faro, Portugal.
- Algarve Biomedical Center, University of Algarve, Faro, Portugal.
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23
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Leonard H, Downs J, Benke TA, Swanson L, Olson H, Demarest S. CDKL5 deficiency disorder: clinical features, diagnosis, and management. Lancet Neurol 2022; 21:563-576. [PMID: 35483386 PMCID: PMC9788833 DOI: 10.1016/s1474-4422(22)00035-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 12/19/2021] [Accepted: 01/18/2022] [Indexed: 12/25/2022]
Abstract
CDKL5 deficiency disorder (CDD) was first identified as a cause of human disease in 2004. Although initially considered a variant of Rett syndrome, CDD is now recognised as an independent disorder and classified as a developmental epileptic encephalopathy. It is characterised by early-onset (generally within the first 2 months of life) seizures that are usually refractory to polypharmacy. Development is severely impaired in patients with CDD, with only a quarter of girls and a smaller proportion of boys achieving independent walking; however, there is clinical variability, which is probably genetically determined. Gastrointestinal, sleep, and musculoskeletal problems are common in CDD, as in other developmental epileptic encephalopathies, but the prevalence of cerebral visual impairment appears higher in CDD. Clinicians diagnosing infants with CDD need to be familiar with the complexities of this disorder to provide appropriate counselling to the patients' families. Despite some benefit from ketogenic diets and vagal nerve stimulation, there has been little evidence that conventional antiseizure medications or their combinations are helpful in CDD, but further treatment trials are finally underway.
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Affiliation(s)
- Helen Leonard
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia.
| | - Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia; Curtin School of Allied Health, Curtin University, Perth, WA, Australia
| | - Tim A Benke
- Department of Neurology, Children's Hospital Colorado, Aurora, CO, USA; Department of Pediatrics, University of Colorado at Denver, Aurora, CO, USA; Department of Pharmacology, University of Colorado at Denver, Aurora, CO, USA; Department of Neurology, University of Colorado at Denver, Aurora, CO, USA; Department of Otolaryngology, University of Colorado at Denver, Aurora, CO, USA
| | - Lindsay Swanson
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Heather Olson
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Scott Demarest
- Department of Neurology, Children's Hospital Colorado, Aurora, CO, USA; Department of Pediatrics, University of Colorado at Denver, Aurora, CO, USA; Department of Neurology, University of Colorado at Denver, Aurora, CO, USA
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24
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Dini G, Tulli E, Dell’Isola GB, Mencaroni E, Di Cara G, Striano P, Verrotti A. Improving Therapy of Pharmacoresistant Epilepsies: The Role of Fenfluramine. Front Pharmacol 2022; 13:832929. [PMID: 35668937 PMCID: PMC9164301 DOI: 10.3389/fphar.2022.832929] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/29/2022] [Indexed: 01/24/2023] Open
Abstract
Epilepsy is among the most common neurological chronic disorders, with a prevalence of 0.5-1%. Despite the introduction of new antiepileptic drugs during recent years, about one third of the epileptic population remain drug-resistant. Hence, especially in the pediatric population limited by different pharmacokinetics and pharmacodynamics and by ethical and regulatory issues it is needed to identify new therapeutic resources. New molecules initially used with other therapeutic indications, such as fenfluramine, are being considered for the treatment of pharmacoresistant epilepsies, including Dravet Syndrome (DS) and Lennox-Gastaut Syndrome (LGS). Drug-refractory seizures are a hallmark of both these conditions and their treatment remains a major challenge. Fenfluramine is an amphetamine derivative that was previously approved as a weight loss drug and later withdrawn when major cardiac adverse events were reported. However, a new role of fenfluramine has emerged in recent years. Indeed, fenfluramine has proved to be a promising antiepileptic drug with a favorable risk-benefit profile for the treatment of DS, LGS and possibly other drug-resistant epileptic syndromes. The mechanism by which fenfluramine provide an antiepileptic action is not fully understood but it seems to go beyond its pro-serotoninergic activity. This review aims to provide a comprehensive analysis of the literature, including ongoing trials, regarding the efficacy and safety of fenfluramine as adjunctive treatment of pharmacoresistant epilepsies.
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Affiliation(s)
- Gianluca Dini
- Department of Pediatrics, University of Perugia, Genoa, Italy,*Correspondence: Gianluca Dini,
| | - Eleonora Tulli
- Department of Pediatrics, University of Perugia, Genoa, Italy
| | | | | | | | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS “G. Gaslini” Institute, Genoa, Italy,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
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25
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Knight EMP, Amin S, Bahi-Buisson N, Benke TA, Cross JH, Demarest ST, Olson HE, Specchio N, Fleming TR, Aimetti AA, Gasior M, Devinsky O, Belyaev O, Ben-Zeev B, Brunklaus A, Ciliberto MA, Darra F, Davis R, De Giorgis V, Doronina O, Fahey M, Guerrini R, Heydemann P, Khaletskaya O, Lisewski P, Marsh ED, Moosa AN, Perry S, Philip S, Rajaraman RR, Renfroe B, Saneto RP, Scheffer IE, Sogawa Y, Suter B, Sweney MT, Tarquinio D, Veggiotti P, Wallace G, Weisenberg J, Wilfong A, Wirrell EC, Zafar M, Zolnowska M. Safety and efficacy of ganaxolone in patients with CDKL5 deficiency disorder: results from the double-blind phase of a randomised, placebo-controlled, phase 3 trial. Lancet Neurol 2022; 21:417-427. [PMID: 35429480 DOI: 10.1016/s1474-4422(22)00077-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 02/01/2022] [Accepted: 02/09/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND CDKL5 deficiency disorder (CDD) is a rare, X-linked, developmental and epileptic encephalopathy characterised by severe global developmental impairment and seizures that can begin in the first few months after birth and are often treatment refractory. Ganaxolone, an investigational neuroactive steroid, reduced seizure frequency in an open-label, phase 2 trial that included patients with CDD. We aimed to further assess the efficacy and safety of ganaxolone in patients with CDD-associated refractory epilepsy. METHODS In the double-blind phase of this randomised, placebo-controlled, phase 3 trial, done at 39 outpatient clinics in eight countries (Australia, France, Israel, Italy, Poland, Russia, the UK, and the USA), patients were eligible if they were aged 2-21 years with a pathogenic or probably pathogenic CDKL5 variant and at least 16 major motor seizures (defined as bilateral tonic, generalised tonic-clonic, bilateral clonic, atonic, or focal to bilateral tonic-clonic) per 28 days in each 4-week period of an 8-week historical period. After a 6-week prospective baseline period, patients were randomly assigned (1:1) via an interactive web response system to receive either enteral adjunctive ganaxolone or matching enteral adjunctive placebo (maximum dose 63 mg/kg per day for patients weighing ≤28 kg or 1800 mg/day for patients weighing >28 kg) for 17 weeks. Patients, caregivers, investigators (including those analysing data), trial staff, and the sponsor (other than the investigational product manager) were masked to treatment allocation. The primary efficacy endpoint was percentage change in median 28-day major motor seizure frequency from the baseline period to the 17-week double-blind phase and was analysed (using a Wilcoxon-rank sum test) in all patients who received at least one dose of trial treatment and for whom baseline data were available. Safety (compared descriptively across groups) was analysed in all patients who received at least one dose of trial treatment. This study is registered with ClinicalTrials.gov, NCT03572933, and the open-label extension phase is ongoing. FINDINGS Between June 25, 2018, and July 2, 2020, 114 patients were screened for eligibility, of whom 101 (median age 6 years [IQR 3 to 10]) were randomly assigned to receive either ganaxolone (n=50) or placebo (n=51). All patients received at least one dose of a study drug, but seizure frequency for one patient in the ganaxolone group was not recorded at baseline and so the primary endpoint was analysed in a population of 100 patients. There was a median percentage change in 28-day major motor seizure frequency of -30·7% (IQR -49·5 to -1·9) in the ganaxolone group and of -6·9% (-24·1 to 39·7) in the placebo group (p=0·0036). The Hodges-Lehmann estimate of median difference in responses to ganaxolone versus placebo was -27·1% (95% CI -47·9 to - 9·6). Treatment-emergent adverse events occurred in 43 (86%) of 50 patients in the ganaxolone group and in 45 (88%) of 51 patients in the placebo group. Somnolence, pyrexia, and upper respiratory tract infections occurred in at least 10% of patients in the ganaxolone group and more frequently than in the placebo group. Serious adverse events occurred in six (12%) patients in the ganaxolone group and in five (10%) patients in the placebo group. Two (4%) patients in the ganaxolone group and four (8%) patients in the placebo group discontinued the trial. There were no deaths in the double-blind phase. INTERPRETATION Ganaxolone significantly reduced the frequency of CDD-associated seizures compared with placebo and was generally well tolerated. Results from what is, to our knowledge, the first controlled trial in CDD suggest a potential treatment benefit for ganaxolone. Long-term treatment is being assessed in the ongoing open-label extension phase of this trial. FUNDING Marinus Pharmaceuticals.
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Affiliation(s)
- Elia M Pestana Knight
- Epilepsy Center, Cleveland Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Sam Amin
- Pediatric Neurology, University Hospitals Bristol and Weston, Bristol, UK
| | - Nadia Bahi-Buisson
- Pediatric Neurology, Necker Enfants Malades University Hospital, Paris, France
| | - Tim A Benke
- Department of Pediatrics and Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - J Helen Cross
- UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK
| | - Scott T Demarest
- Department of Pediatrics and Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Heather E Olson
- Division of Epilepsy and Clinical Neurophysiology and Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Thomas R Fleming
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | | | - Orrin Devinsky
- New York University Langone Comprehensive Epilepsy Center, New York, NY, USA
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26
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Watkins LV, O'Dwyer M, Shankar R. A review of the pharmacotherapeutic considerations for managing epilepsy in people with autism. Expert Opin Pharmacother 2022; 23:841-851. [PMID: 35341433 DOI: 10.1080/14656566.2022.2055461] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Autism, like other neurodevelopmental disorders (NDDs), has a strong association with epilepsy. There are known common genetic pathways in both autism and epilepsy. There are also specific genetic syndromes associated with both complex epilepsy and the autism phenotype. AREAS COVERED This review explores the evidence for common genetic etiologies and pathophysiological pathways in relation to both epilepsy and autism. Autism with comorbid epilepsy are associated with a high prevalence of medical and psychiatric comorbidities. This paper discusses how this influences assessment, treatment, and outcomes. The evidence for the treatment of specific seizure types in the context of NDDs is also examined alongside clinical commentary. EXPERT OPINION Despite the strong association, there is a limited evidence base to support the efficacy and tolerability of anti-seizure medications specifically in autism, with no Level 1 evidence or National Guidance available. Autism and epilepsy should be approached under a NDD model with cautious introduction and titration of anti-seizure medication. Alongside this, there is evidence to support a move toward precision medicine in specific genetic syndromes such as Tuberous Sclerosis Complex and other genetic seizure disorders. The first-line treatments that should be considered for focal seizures include carbamazepine, lamotrigine, and levetiracetam.
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Affiliation(s)
- Lance V Watkins
- Epilepsy Specialist Service Swansea Bay University Health Board, Cardiff, UK
| | - Maire O'Dwyer
- School of Pharmacy and Pharmaceutical Sciences Trinity College, Dublin 2, Ireland
| | - Rohit Shankar
- Department of Intellectual Disability Neuropsychiatry, Cornwall Partnership NHS Foundation Trust, Truro, UK.,Cornwall Intellectual Disability Equitable Research (CIDER) University of Plymouth Medical School, Truro, UK
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27
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Frasca A, Pavlidou E, Bizzotto M, Gao Y, Balestra D, Pinotti M, Dahl HA, Mazarakis ND, Landsberger N, Kinali M. Not Just Loss-of-Function Variations: Identification of a Hypermorphic Variant in a Patient With a CDKL5 Missense Substitution. Neurol Genet 2022; 8:e666. [PMID: 35280940 PMCID: PMC8906656 DOI: 10.1212/nxg.0000000000000666] [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: 07/07/2021] [Accepted: 12/21/2021] [Indexed: 11/15/2022]
Abstract
Background and Objectives CDKL5 deficiency disorder (CDD) is a neurodevelopmental encephalopathy characterized by early-onset epilepsy and impaired psychomotor development. Variations in the X-linked CDKL5 gene coding for a kinase cause CDD. Molecular genetics has proved that almost all pathogenic missense substitutions localize in the N-terminal catalytic domain, therefore underlining the importance for brain development and functioning of the kinase activity. CDKL5 also features a long C-terminal domain that acts as negative regulator of the enzymatic activity and modulates its subcellular distribution. CDD is generally attributed to loss-of-function variations, whereas the clinical consequences of increased CDKL5 activity remain uncertain. We have identified a female patient characterized by mild epilepsy and neurologic symptoms, harboring a novel c.2873C>G nucleotide substitution, leading to the missense variant p.(Thr958Arg). To increase our comprehension of genetic variants in CDKL5-associated neurologic disorders, we have characterized the molecular consequences of the identified substitution. Methods MRI and video EEG telemetry were used to describe brain activity and capture seizure. The Bayley III test was used to evaluate the patient development. Reverse transcriptase PCR was used to analyze whether the identified nucleotide variant affects messenger RNA stability and/or splicing. The X chromosome inactivation pattern was analyzed determining the DNA methylation status of the androgen receptor (AR) gene and by sequencing of expressed alleles. Western blotting was used to investigate whether the novel Thr958Arg substitution affects the stability and/or enzymatic activity of CDKL5. Immunofluorescence was used to define whether CDKL5 subcellular distribution is affected by the Thr958Arg substitution. Results Our data suggested that the proband tends toward a skewed X chromosome inactivation pattern in favor of the novel variant. The molecular investigation revealed that the p.(Thr958Arg) substitution leads to a significant increase in the autophosphorylation of both the TEY motif and residue Tyr171 of CDKL5, as well as in the phosphorylation of the target protein MAP1S, indicating an hyperactivation of CDKL5. This occurs without evidently affecting the kinase subcellular distribution. Discussion Our data provide a strong indication that the c.2873C>G nucleotide substitution represents an hypermorphic pathogenic variation of CDKL5, therefore highlighting the importance of a tight control of CDKL5 activity in the brain.
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Affiliation(s)
- Angelisa Frasca
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Efterpi Pavlidou
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Matteo Bizzotto
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Yunan Gao
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Dario Balestra
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Mirko Pinotti
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Hans Atli Dahl
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Nicholas D Mazarakis
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Nicoletta Landsberger
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
| | - Maria Kinali
- Department of Medical Biotechnology and Translational Medicine (A.F., M.B., N.L.), University of Milan, Italy; Department of Speech and Language Therapy (E.P.), University of Ioannina, Greece; Gene Therapy (Y.G., N.D.M.), Division of Neuroscience, Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Campus, United Kingdom; Department of Life Sciences and Biotechnology (D.B., M.P.), University of Ferrara, Italy; Amplexa Genetics A/S (H.A.D.), Odense, Denmark; Department of Paediatric Neurology (M.K.), The Portland Hospital, HCA Healthcare UK; and Imperial College (M.K.), London, United Kingdom
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28
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Beltrán-Corbellini Á, Aledo-Serrano Á, Møller RS, Pérez-Palma E, García-Morales I, Toledano R, Gil-Nagel A. Epilepsy Genetics and Precision Medicine in Adults: A New Landscape for Developmental and Epileptic Encephalopathies. Front Neurol 2022; 13:777115. [PMID: 35250806 PMCID: PMC8891166 DOI: 10.3389/fneur.2022.777115] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/27/2022] [Indexed: 12/14/2022] Open
Abstract
This review aims to provide an updated perspective of epilepsy genetics and precision medicine in adult patients, with special focus on developmental and epileptic encephalopathies (DEEs), covering relevant and controversial issues, such as defining candidates for genetic testing, which genetic tests to request and how to interpret them. A literature review was conducted, including findings in the discussion and recommendations. DEEs are wide and phenotypically heterogeneous electroclinical syndromes. They generally have a pediatric presentation, but patients frequently reach adulthood still undiagnosed. Identifying the etiology is essential, because there lies the key for precision medicine. Phenotypes modify according to age, and although deep phenotyping has allowed to outline certain entities, genotype-phenotype correlations are still poor, commonly leading to long-lasting diagnostic odysseys and ineffective therapies. Recent adult series show that the target patients to be identified for genetic testing are those with epilepsy and different risk factors. The clinician should take active part in the assessment of the pathogenicity of the variants detected, especially concerning variants of uncertain significance. An accurate diagnosis implies precision medicine, meaning genetic counseling, prognosis, possible future therapies, and a reduction of iatrogeny. Up to date, there are a few tens of gene mutations with additional concrete treatments, including those with restrictive/substitutive therapies, those with therapies modifying signaling pathways, and channelopathies, that are worth to be assessed in adults. Further research is needed regarding phenotyping of adult syndromes, early diagnosis, and the development of targeted therapies.
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Affiliation(s)
| | - Ángel Aledo-Serrano
- Epilepsy Program, Neurology Department, Hospital Ruber Internacional, Madrid, Spain
- *Correspondence: Ángel Aledo-Serrano
| | - Rikke S. Møller
- Department of Epilepsy Genetics and Personalized Treatment, The Danish Epilepsy Centre, Dianalund, Denmark
| | - Eduardo Pérez-Palma
- Universidad del Desarrollo, Centro de Genética y Genómica, Facultad de Medicina Clínica Alemana, Santiago, Chile
| | - Irene García-Morales
- Epilepsy Program, Neurology Department, Hospital Ruber Internacional, Madrid, Spain
- Epilepsy Unit, Neurology Department, Clínico San Carlos University Hospital, Madrid, Spain
| | - Rafael Toledano
- Epilepsy Program, Neurology Department, Hospital Ruber Internacional, Madrid, Spain
- Epilepsy Unit, Neurology Department, Ramón y Cajal University Hospital, Madrid, Spain
| | - Antonio Gil-Nagel
- Epilepsy Program, Neurology Department, Hospital Ruber Internacional, Madrid, Spain
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29
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Patel PA, Hegert JV, Cristian I, Kerr A, LaConte LEW, Fox MA, Srivastava S, Mukherjee K. Complete loss of the X-linked gene CASK causes severe cerebellar degeneration. J Med Genet 2022; 59:1044-1057. [PMID: 35149592 DOI: 10.1136/jmedgenet-2021-108115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 01/13/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Heterozygous loss of X-linked genes like CASK and MeCP2 (Rett syndrome) causes developmental delay in girls, while in boys, loss of the only allele of these genes leads to epileptic encephalopathy. The mechanism for these disorders remains unknown. CASK-linked cerebellar hypoplasia is presumed to result from defects in Tbr1-reelin-mediated neuronal migration. METHOD Here we report clinical and histopathological analyses of a deceased 2-month-old boy with a CASK-null mutation. We next generated a mouse line where CASK is completely deleted (hemizygous and homozygous) from postmigratory neurons in the cerebellum. RESULT The CASK-null human brain was smaller in size but exhibited normal lamination without defective neuronal differentiation, migration or axonal guidance. The hypoplastic cerebellum instead displayed astrogliosis and microgliosis, which are markers for neuronal loss. We therefore hypothesise that CASK loss-induced cerebellar hypoplasia is the result of early neurodegeneration. Data from the murine model confirmed that in CASK loss, a small cerebellum results from postdevelopmental degeneration of cerebellar granule neurons. Furthermore, at least in the cerebellum, functional loss from CASK deletion is secondary to degeneration of granule cells and not due to an acute molecular functional loss of CASK. Intriguingly, female mice with heterozygous deletion of CASK in the cerebellum do not display neurodegeneration. CONCLUSION We suggest that X-linked neurodevelopmental disorders like CASK mutation and Rett syndrome are pathologically neurodegenerative; random X-chromosome inactivation in heterozygous mutant girls, however, results in 50% of cells expressing the functional gene, resulting in a non-progressive pathology, whereas complete loss of the only allele in boys leads to unconstrained degeneration and encephalopathy.
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Affiliation(s)
- Paras A Patel
- Fralin Biomedical Research Institute at VTC, Roanoke, Virginia, USA
| | - Julia V Hegert
- Department of Pathology, Orlando Health, Orlando, Florida, USA
| | | | - Alicia Kerr
- Fralin Biomedical Research Institute at VTC, Roanoke, Virginia, USA
| | | | - Michael A Fox
- Fralin Biomedical Research Institute at VTC, Roanoke, Virginia, USA.,School of Neuroscience, Blacksburg, Virginia, USA
| | - Sarika Srivastava
- Fralin Biomedical Research Institute at VTC, Roanoke, Virginia, USA.,Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Konark Mukherjee
- Fralin Biomedical Research Institute at VTC, Roanoke, Virginia, USA .,Department of Psychiatry, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
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30
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Serrano RJ, Lee C, Douek AM, Kaslin J, Bryson-Richardson RJ, Sztal TE. Novel pre-clinical model for CDKL5 Deficiency Disorder. Dis Model Mech 2021; 15:273746. [PMID: 34913468 PMCID: PMC8922025 DOI: 10.1242/dmm.049094] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 12/06/2021] [Indexed: 11/20/2022] Open
Abstract
Cyclin-dependent kinase-like-5 (CDKL5) deficiency disorder (CDD) is a severe X-linked neurodegenerative disease characterised by early-onset epileptic seizures, low muscle tone, progressive intellectual disability and severe motor function. CDD affects ∼1 in 60,000 live births, with many patients experiencing a reduced quality of life due to the severity of their neurological symptoms and functional impairment. There are no effective therapies for CDD, with current treatments focusing on improving symptoms rather than addressing the underlying causes of the disorder. Zebrafish offer many unique advantages for high-throughput preclinical evaluation of potential therapies for neurological diseases, including CDD. In particular, the large number of offspring produced, together with the possibilities for in vivo imaging and genetic manipulation, allows for the detailed assessment of disease pathogenesis and therapeutic discovery. We have characterised a loss-of-function zebrafish model for CDD, containing a nonsense mutation in cdkl5. cdkl5 mutant zebrafish display defects in neuronal patterning, seizures, microcephaly, and reduced muscle function caused by impaired muscle innervation. This study provides a powerful vertebrate model for investigating CDD disease pathophysiology and allowing high-throughput screening for effective therapies. This article has an associated First Person interview with the first author of the paper. Summary: Characterisation of a novel loss-of-function zebrafish model for CDKL5 deficiency disorder, containing a nonsense mutation, demonstrates its utility for investigating disease aetiology and allowing high-throughput screening for potentially effective therapies.
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Affiliation(s)
- Rita J Serrano
- School of Biological Sciences, Monash University, Melbourne, Australia
| | - Clara Lee
- School of Biological Sciences, Monash University, Melbourne, Australia
| | - Alon M Douek
- Australian Regenerative Medicine Institute, Monash University, Melbourne, Australia
| | - Jan Kaslin
- Australian Regenerative Medicine Institute, Monash University, Melbourne, Australia
| | | | - Tamar E Sztal
- School of Biological Sciences, Monash University, Melbourne, Australia
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31
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Inherited Developmental and Epileptic Encephalopathies. Neurol Int 2021; 13:555-568. [PMID: 34842787 PMCID: PMC8628919 DOI: 10.3390/neurolint13040055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 01/13/2023] Open
Abstract
Epileptic encephalopathies often have a genetic etiology. The epileptic activity itself exerts a direct detrimental effect on neurodevelopment, which may add to the cognitive impairment induced by the underlying mutation (“developmental and epileptic encephalopathy”). The focus of this review is on inherited syndromes. The phenotypes of genetic disorders affecting ion channels, metabolic signalling, membrane trafficking and exocytosis, cell adhesion, cell growth and proliferation are discussed. Red flags suggesting family of genes or even specific genes are highlighted. The knowledge of the phenotypical spectrum can indeed prompt the clinician to suspect specific etiologies, expediting the diagnosis.
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32
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Negraes PD, Trujillo CA, Yu NK, Wu W, Yao H, Liang N, Lautz JD, Kwok E, McClatchy D, Diedrich J, de Bartolome SM, Truong J, Szeto R, Tran T, Herai RH, Smith SEP, Haddad GG, Yates JR, Muotri AR. Altered network and rescue of human neurons derived from individuals with early-onset genetic epilepsy. Mol Psychiatry 2021; 26:7047-7068. [PMID: 33888873 PMCID: PMC8531162 DOI: 10.1038/s41380-021-01104-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 03/22/2021] [Accepted: 04/06/2021] [Indexed: 02/02/2023]
Abstract
Early-onset epileptic encephalopathies are severe disorders often associated with specific genetic mutations. In this context, the CDKL5 deficiency disorder (CDD) is a neurodevelopmental condition characterized by early-onset seizures, intellectual delay, and motor dysfunction. Although crucial for proper brain development, the precise targets of CDKL5 and its relation to patients' symptoms are still unknown. Here, induced pluripotent stem cells derived from individuals deficient in CDKL5 protein were used to generate neural cells. Proteomic and phosphoproteomic approaches revealed disruption of several pathways, including microtubule-based processes and cytoskeleton organization. While CDD-derived neural progenitor cells have proliferation defects, neurons showed morphological alterations and compromised glutamatergic synaptogenesis. Moreover, the electrical activity of CDD cortical neurons revealed hyperexcitability during development, leading to an overly synchronized network. Many parameters of this hyperactive network were rescued by lead compounds selected from a human high-throughput drug screening platform. Our results enlighten cellular, molecular, and neural network mechanisms of genetic epilepsy that could ultimately promote novel therapeutic opportunities for patients.
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Affiliation(s)
- Priscilla D Negraes
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | - Cleber A Trujillo
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA.
| | - Nam-Kyung Yu
- Department of Chemical Physiology, The Scripps Research Institute, La Jolla, CA, USA
| | - Wei Wu
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | - Hang Yao
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | - Nicholas Liang
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | - Jonathan D Lautz
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA, USA
- Graduate Program in Neuroscience, University of Washington, Seattle, WA, USA
| | - Ellius Kwok
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | - Daniel McClatchy
- Department of Chemical Physiology, The Scripps Research Institute, La Jolla, CA, USA
| | - Jolene Diedrich
- Department of Chemical Physiology, The Scripps Research Institute, La Jolla, CA, USA
| | | | - Justin Truong
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | - Ryan Szeto
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | - Timothy Tran
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
| | - Roberto H Herai
- Experimental Multiuser Laboratory, Graduate Program in Health Sciences, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Stephen E P Smith
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA, USA
- Graduate Program in Neuroscience, University of Washington, Seattle, WA, USA
| | - Gabriel G Haddad
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
- Department of Neurosciences, University of California San Diego, La Jolla, CA, USA
| | - John R Yates
- Department of Chemical Physiology, The Scripps Research Institute, La Jolla, CA, USA
| | - Alysson R Muotri
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA.
- Kavli Institute for Brain and Mind, University of California San Diego, La Jolla, CA, USA.
- Center for Academic Research and Training in Anthropogeny (CARTA), La Jolla, CA, USA.
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33
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Chin RF, Mingorance A, Ruban-Fell B, Newell I, Evans J, Vyas K, Nortvedt C, Amin S. Treatment Guidelines for Rare, Early-Onset, Treatment-Resistant Epileptic Conditions: A Literature Review on Dravet Syndrome, Lennox-Gastaut Syndrome and CDKL5 Deficiency Disorder. Front Neurol 2021; 12:734612. [PMID: 34759881 PMCID: PMC8573384 DOI: 10.3389/fneur.2021.734612] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/27/2021] [Indexed: 01/09/2023] Open
Abstract
Background: Dravet syndrome (DS), Lennox-Gastaut syndrome (LGS) and CDKL5 deficiency disorder (CDD) are rare epileptic conditions, characterised by drug-resistant seizures. Seizure management in these patients requires careful therapy selection. This targeted literature review (TLR) aimed to collate and synthesise information from country-specific and international treatment guidelines for DS, LGS and CDD. Methods: A TLR was performed between 25th January and 11th March 2021. Online rare diseases and guideline databases were manually searched in addition to websites of national health technology assessment bodies for the following countries: Australia, Canada, France, Germany, Israel, Italy, Japan, Spain, Switzerland, UK and US, as defined by pre-specified eligibility criteria. Search terms, developed for each condition, were translated into local languages where appropriate. Descriptive analyses were performed to examine the geographical distribution of included guidelines; methodologies used to develop guidelines; cross-referencing of treatment recommendations made within other guidelines; patterns of treatment recommendations. An author map was created using R version 3.5.1, to visualise the extent of collaboration between authors. Results: Forty total guidelines were included, of which 29, 34 and 0 contained recommendations for DS, LGS and CDD, respectively (some provided recommendations for ≥1 condition). Most were country-specific, with guideline authors predominantly publishing in regional groups. Five guidelines were classified as "International" and displayed connections between author groups in the US, UK, France and Italy. Reported guideline development processes were lacking [43% (17 guidelines) had unclear/absent literature review methodologies] and those reported were variable, including both systematic and targeted literature reviews. Use of expert consultation was also variable. A high degree of heterogeneity was observed in the availability of treatment recommendations across disorders, with 271 and 190 recommendations for LGS and DS, respectively, and contradictory positive and negative treatment recommendations for several drugs in each indication [35% (11/31) and 22% (6/27) in LGS and DS, respectively]. Conclusions: This review highlights the need for further high-quality international consensus-based treatment guidelines for LGS, DS, and particularly for CDD (for which no treatment guidelines were identified). Supra-national consensus guidance based on findings from a wider geographical range may improve resource allocation and establish an improved world-wide standard of care.
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Affiliation(s)
| | - Ana Mingorance
- The Loulou Foundation, London, United Kingdom
- Dracaena Consulting, Madrid, Spain
| | | | | | | | | | | | - Sam Amin
- Bristol Royal Hospital for Children, Bristol, United Kingdom
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34
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Saldaris J, Weisenberg J, Pestana-Knight E, Marsh ED, Suter B, Rajaraman R, Heidary G, Olson HE, Devinsky O, Price D, Jacoby P, Leonard H, Benke TA, Demarest S, Downs J. Content Validation of Clinician-Reported Items for a Severity Measure for CDKL5 Deficiency Disorder. J Child Neurol 2021; 36:998-1006. [PMID: 34378447 PMCID: PMC8458223 DOI: 10.1177/08830738211019576] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
CDKL5 deficiency disorder (CDD) results in early-onset seizures and severe developmental impairments. A CDD clinical severity assessment (CCSA) was previously developed with clinician and parent-report items to capture information on a range of domains. Consistent with US Food and Drug Administration (FDA) guidelines, content validation is the first step in evaluating the psychometric properties of an outcome measure. The aim of this study was to validate the content of the clinician-reported items in the CCSA (CCSA-Clinician). Eight neurologists leading the USA CDD Center of Excellence clinics were interviewed using the "think aloud" technique to critique 26 clinician-reported items. Common themes were aggregated, and a literature search of related assessments informed item modifications. The clinicians then participated in 2 consensus meetings to review themes and finalize the items. A consensus was achieved for the content of the CCSA-Clinician. Eight of the original items were omitted, 11 items were added, and the remaining 18 items were revised. The final 29 items were classified into 2 domains: functioning and neurologic impairments. This study enabled refinement of the CCSA-Clinician and provided evidence for its content validity. This preliminary validation is essential before field testing and further validation, in order to advance the instrument toward clinical trial readiness.
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Affiliation(s)
| | - Judith Weisenberg
- St. Louis Children’s Hospital and Washington University School of Medicine, St Louis, Missouri, USA
| | | | - Eric D. Marsh
- Division of Neurology, Children’s Hospital of Philadelphia and School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bernhard Suter
- Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas, USA
| | | | - Gena Heidary
- Department of Ophthalmology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Heather E. Olson
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Orrin Devinsky
- NYU Langone Health and Department of Neurology, New York University, New York, New York, USA
| | - Dana Price
- NYU Langone Health and Department of Neurology, New York University, New York, New York, USA
| | - Peter Jacoby
- Telethon Kids Institute, Perth, Western Australia, Australia
| | - Helen Leonard
- Telethon Kids Institute, Perth, Western Australia, Australia,The University of Western Australia, Perth, Western Australia, Australia
| | - Tim A. Benke
- Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Scott Demarest
- Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jenny Downs
- Telethon Kids Institute, Perth, Western Australia, Australia,The School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
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35
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Spoto G, Saia MC, Amore G, Gitto E, Loddo G, Mainieri G, Nicotera AG, Di Rosa G. Neonatal Seizures: An Overview of Genetic Causes and Treatment Options. Brain Sci 2021; 11:brainsci11101295. [PMID: 34679360 PMCID: PMC8534058 DOI: 10.3390/brainsci11101295] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/16/2021] [Accepted: 09/26/2021] [Indexed: 01/04/2023] Open
Abstract
Seizures are the most frequent neurological clinical symptoms of the central nervous system (CNS) during the neonatal period. Neonatal seizures may be ascribed to an acute event or symptomatic conditions determined by genetic, metabolic or structural causes, outlining the so-called 'Neonatal Epilepsies'. To date, three main groups of neonatal epilepsies are recognised during the neonatal period: benign familial neonatal epilepsy (BFNE), early myoclonic encephalopathy (EME) and 'Ohtahara syndrome' (OS). Recent advances showed the role of several genes in the pathogenesis of these conditions, such as KCNQ2, KCNQ3, ARX, STXBP1, SLC25A22, CDKL5, KCNT1, SCN2A and SCN8A. Herein, we reviewed the current knowledge regarding the pathogenic variants most frequently associated with neonatal seizures, which should be considered when approaching newborns affected by these disorders. In addition, we considered the new possible therapeutic strategies reported in these conditions.
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Affiliation(s)
- Giulia Spoto
- Unit of Child Neurology and Psychiatry, Department of Human Pathology of the Adult and Developmental Age “Gaetano Barresi”, University of Messina, 98125 Messina, Italy; (G.S.); (M.C.S.); (G.A.); (G.D.R.)
| | - Maria Concetta Saia
- Unit of Child Neurology and Psychiatry, Department of Human Pathology of the Adult and Developmental Age “Gaetano Barresi”, University of Messina, 98125 Messina, Italy; (G.S.); (M.C.S.); (G.A.); (G.D.R.)
| | - Greta Amore
- Unit of Child Neurology and Psychiatry, Department of Human Pathology of the Adult and Developmental Age “Gaetano Barresi”, University of Messina, 98125 Messina, Italy; (G.S.); (M.C.S.); (G.A.); (G.D.R.)
| | - Eloisa Gitto
- Unit of Neonatal Intensive Care, Department of Human Pathology of the Adult and Developmental Age “Gaetano Barresi”, University of Messina, 98125 Messina, Italy;
| | | | - Greta Mainieri
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, 40138 Bologna, Italy;
| | - Antonio Gennaro Nicotera
- Unit of Child Neurology and Psychiatry, Department of Human Pathology of the Adult and Developmental Age “Gaetano Barresi”, University of Messina, 98125 Messina, Italy; (G.S.); (M.C.S.); (G.A.); (G.D.R.)
- Correspondence: ; Tel.: +39-090-221-2911
| | - Gabriella Di Rosa
- Unit of Child Neurology and Psychiatry, Department of Human Pathology of the Adult and Developmental Age “Gaetano Barresi”, University of Messina, 98125 Messina, Italy; (G.S.); (M.C.S.); (G.A.); (G.D.R.)
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36
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Cope H, Barseghyan H, Bhattacharya S, Fu Y, Hoppman N, Marcou C, Walley N, Rehder C, Deak K, Alkelai A, Vilain E, Shashi V. Detection of a mosaic CDKL5 deletion and inversion by optical genome mapping ends an exhaustive diagnostic odyssey. Mol Genet Genomic Med 2021; 9:e1665. [PMID: 33955715 PMCID: PMC8372083 DOI: 10.1002/mgg3.1665] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/23/2021] [Accepted: 03/01/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Currently available structural variant (SV) detection methods do not span the complete spectrum of disease-causing SVs. Optical genome mapping (OGM), an emerging technology with the potential to resolve diagnostic dilemmas, was performed to investigate clinically-relevant SVs in a 4-year-old male with an epileptic encephalopathy of undiagnosed molecular origin. METHODS OGM was utilized to image long, megabase-size DNA molecules, fluorescently labeled at specific sequence motifs throughout the genome with high sensitivity for detection of SVs greater than 500 bp in size. OGM results were confirmed in a CLIA-certified laboratory via mate-pair sequencing. RESULTS OGM identified a mosaic, de novo 90 kb deletion and inversion on the X chromosome disrupting the CDKL5 gene. Detection of the mosaic deletion, which had been previously undetected by chromosomal microarray, an infantile epilepsy panel including exon-level microarray for CDKL5, exome sequencing as well as genome sequencing, resulted in a diagnosis of X-linked dominant early infantile epileptic encephalopathy-2. CONCLUSION OGM affords an effective technology for the detection of SVs, especially those that are mosaic, since these remain difficult to detect with current NGS technologies and with conventional chromosomal microarrays. Further research in undiagnosed populations with OGM is warranted.
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Affiliation(s)
- Heidi Cope
- Division of Medical GeneticsDepartment of PediatricsDuke University Medical CenterDurhamNCUSA
| | - Hayk Barseghyan
- Center for Genetic Medicine ResearchChildren’s National HospitalWashingtonDCUSA
- Department of genomics and Precision MedicineSchool of Medicine and Health SciencesGeorge Washington UniversityWashingtonDCUSA
- Bionano Genomics IncSan DiegoCAUSA
| | | | - Yulong Fu
- Center for Genetic Medicine ResearchChildren’s National HospitalWashingtonDCUSA
| | - Nicole Hoppman
- Division of Laboratory Genetics and GenomicsDepartment of Laboratory Medicine and PathologyMayo ClinicRochesterMNUSA
| | - Cherisse Marcou
- Division of Laboratory Genetics and GenomicsDepartment of Laboratory Medicine and PathologyMayo ClinicRochesterMNUSA
| | - Nicole Walley
- Division of Medical GeneticsDepartment of PediatricsDuke University Medical CenterDurhamNCUSA
| | - Catherine Rehder
- Department of PathologyDuke University Medical CenterDurhamNCUSA
| | - Kristen Deak
- Department of PathologyDuke University Medical CenterDurhamNCUSA
| | - Anna Alkelai
- Institute for Genomic MedicineColumbia University Medical CenterNew YorkNYUSA
| | - Eric Vilain
- Center for Genetic Medicine ResearchChildren’s National HospitalWashingtonDCUSA
- Department of genomics and Precision MedicineSchool of Medicine and Health SciencesGeorge Washington UniversityWashingtonDCUSA
| | - Vandana Shashi
- Division of Medical GeneticsDepartment of PediatricsDuke University Medical CenterDurhamNCUSA
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Siri B, Varesio C, Freri E, Darra F, Gana S, Mei D, Porta F, Fontana E, Galati G, Solazzi R, Niceta M, Veggiotti P, Alfei E. CDKL5 deficiency disorder in males: Five new variants and review of the literature. Eur J Paediatr Neurol 2021; 33:9-20. [PMID: 33989939 DOI: 10.1016/j.ejpn.2021.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 04/18/2021] [Accepted: 04/24/2021] [Indexed: 11/30/2022]
Abstract
The X-linked Cyclin-Dependent Kinase-Like 5 (CDKL5) gene encodes a serine-threonine kinase highly expressed in the developing brain. Loss of function of CDKL5 is pointed out to underlie the CDKL5 Deficiency Disorder (CDD), an X-linked dominant disease characterized by early-onset epileptic encephalopathy and developmental delay, usually affecting females more than males. To the best to our knowledge, only 45 males with CDD have been reported so far. Type and position of CDKL5 variants with different impact on the protein are reported to influence the clinical presentation. X-chromosome inactivation occurring in females and post-zygotic mosaicism in males are also believed to contribute to this variability. Based on these issues, genotype-phenotype correlations are still challenging. Here, we describe clinical features of five additional affected males with unreported CDKL5 variants, expanding the molecular spectrum of the disorder. We also reviewed the clinical profile of the previously reported 45 males with molecularly confirmed CDD. Severe developmental delay, cortical visual impairment, and early-onset refractory epilepsy characterize the CDD picture in males. By assessing the molecular spectrum, we confirm that germ-line truncating CDKL5 variants, equally distributed across the coding sequence, are the most recurrent mutations in CDD, and cause the worsen phenotype. While recurrence and relevance of missense substitutions within C-terminal remain still debated, disease-causing missense changes affecting the N-terminal catalytic domain correlate to a severe clinical phenotype. Finally, our data provide evidence that post-zygotic CDKL5 mosaicism may result in milder phenotypes and, at least in a subset of subjects, in variable response to antiepileptic treatments.
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Affiliation(s)
- Barbara Siri
- Department of Paediatrics, Ospedale Infantile Regina Margherita, University of Torino, Italy; Division of Metabolism, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Costanza Varesio
- Department of Child Neurology and Psychiatry, IRCCS Mondino Foundation, Italy; Department of Brain and Behavioral Sciences, University of Pavia, Italy.
| | - Elena Freri
- Department of Paediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesca Darra
- Child Neuropsychiatry, Department of Surgical Sciences, Dentistry, Gynecology and Paediatrics, University of Verona, AOUI Verona, Verona, Italy
| | - Simone Gana
- Medical Genetics Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Davide Mei
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Children's Hospital A. Meyer-University of Florence, Italy
| | - Francesco Porta
- Department of Paediatrics, AOU Città della Salute e della Scienza di Torino, University of Torino, Italy
| | - Elena Fontana
- Child Neuropsychiatry, Department of Surgical Sciences, Dentistry, Gynecology and Paediatrics, University of Verona, AOUI Verona, Verona, Italy
| | - Giulia Galati
- Child Neuropsychiatry, Department of Surgical Sciences, Dentistry, Gynecology and Paediatrics, University of Verona, AOUI Verona, Verona, Italy
| | - Roberta Solazzi
- Department of Paediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Marcello Niceta
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Pierangelo Veggiotti
- L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy; Paediatric Neurology Unit V. Buzzi Children's Hospital Milan, Italy
| | - Enrico Alfei
- Paediatric Neurology Unit V. Buzzi Children's Hospital Milan, Italy
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Kluckova D, Kolnikova M, Medova V, Bognar C, Foltan T, Svecova L, Gnip A, Kadasi L, Soltysova A, Ficek A. Clinical manifestation of CDKL5 deficiency disorder and identified mutations in a cohort of Slovak patients. Epilepsy Res 2021; 176:106699. [PMID: 34229227 DOI: 10.1016/j.eplepsyres.2021.106699] [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: 01/05/2021] [Revised: 06/06/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022]
Abstract
CDKL5 deficiency disorder (CDD) is an independent clinical entity associated with early-onset encephalopathy, which is often considered the type of epileptic encephalopathy with CDKL5 mutation also found in children diagnosed with early-onset seizure (Hanefeld) type of Rett syndrome, epileptic spasms, West syndrome, Lennox-Gastaut syndrome, or autism. Since early seizure onset is a prominent feature, in this study, a cohort of 54 unrelated patients consisting of 26 males and 28 females was selected for CDKL5 screening, with seizures presented before 12 months of age being the only clinical criterion. Five patients were found to have pathogenic or likely pathogenic variants in CDKL5 while 1 was found to have a variant of uncertain significance (p.L522V). Although CDKL5 variants are more frequently identified in female patients, we identified three male and three female patients (11.1 %, 6/54) in this study. Missense variant with unknown inheritance (p.L522V), de novo missense variant (p.E60 K), two de novo splicing (IVS15 + 1G > A, IVS16 + 2 T > A), and one de novo nonsense variant p.W125* were identified using Sanger sequencing. Whole exome analysis approach revealed de novo frameshift variant c.1247_1248delAG in a mosaic form in one of the males. Patient clinical features are reviewed and compared to those previously described in related literature. Variable clinical features were presented in CDKL5 positive patients characterised in this study. In addition to more common features, such as early epileptic seizures, severe intellectual disability, and gross motor impairment, inappropriate laughing/screaming spells and hypotonia appeared at the age of 1 year in all patients, regardless of the type of CDKL5 mutation or sex. All three CDKL5 positive males from our cohort were initially diagnosed with West syndrome, which suggests that the CDKL5 gene mutations are a significant cause of West syndrome phenotype, and also indicate the overlapping characteristics of these two clinical entities.
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Affiliation(s)
- Daniela Kluckova
- Department of Molecular Biology, Faculty of Natural Sciences, Comenius University, Ilkovicova 6, Bratislava, 842 15, Slovakia
| | - Miriam Kolnikova
- Department of Paediatric Neurology, Faculty of Medicine, Comenius University and National Institute of Children's Diseases, Limbova 1, 833 40, Bratislava, Slovakia
| | - Veronika Medova
- Institute for Clinical and Translational Research, Biomedical Research Centre, Slovak Academy of Sciences, Dubravska cesta 9, 845 05, Bratislava, Slovakia
| | - Csaba Bognar
- Department of Molecular Biology, Faculty of Natural Sciences, Comenius University, Ilkovicova 6, Bratislava, 842 15, Slovakia
| | - Tomas Foltan
- Department of Paediatric Neurology, Faculty of Medicine, Comenius University and National Institute of Children's Diseases, Limbova 1, 833 40, Bratislava, Slovakia
| | - Lucia Svecova
- Department of Paediatric Neurology, Faculty of Medicine, Comenius University and National Institute of Children's Diseases, Limbova 1, 833 40, Bratislava, Slovakia
| | - Andrej Gnip
- Medirex a.s., MEDIREX GROUP, Holubyho 35, 902 01, Pezinok, Slovakia
| | - Ludevit Kadasi
- Department of Molecular Biology, Faculty of Natural Sciences, Comenius University, Ilkovicova 6, Bratislava, 842 15, Slovakia; Institute for Clinical and Translational Research, Biomedical Research Centre, Slovak Academy of Sciences, Dubravska cesta 9, 845 05, Bratislava, Slovakia
| | - Andrea Soltysova
- Department of Molecular Biology, Faculty of Natural Sciences, Comenius University, Ilkovicova 6, Bratislava, 842 15, Slovakia; Institute for Clinical and Translational Research, Biomedical Research Centre, Slovak Academy of Sciences, Dubravska cesta 9, 845 05, Bratislava, Slovakia
| | - Andrej Ficek
- Department of Molecular Biology, Faculty of Natural Sciences, Comenius University, Ilkovicova 6, Bratislava, 842 15, Slovakia.
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Devinsky O, King L, Schwartz D, Conway E, Price D. Effect of fenfluramine on convulsive seizures in CDKL5 deficiency disorder. Epilepsia 2021; 62:e98-e102. [PMID: 33979451 PMCID: PMC8360137 DOI: 10.1111/epi.16923] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 01/09/2023]
Abstract
CDKL5 deficiency disorder (CDD) is an X-linked pharmacoresistant neurogenetic disorder characterized by global developmental delays and uncontrolled seizures. Fenfluramine (FFA), an antiseizure medication (ASM) indicated for treating convulsive seizures in Dravet syndrome, was assessed in six patients (five female; 83%) with CDD whose seizures had failed 5-12 ASMs or therapies. Median age at enrollment was 6.5 years (range: 2-26 years). Mean FFA treatment duration was 5.3 months (range: 2-9 months) at 0.4 mg/kg/day (n = 2) or 0.7 mg/kg/day (n = 4; maximum: 26 mg/day). One patient had valproate added for myoclonic seizures. The ASM regimens of all other patients were stable. Among five patients with tonic-clonic seizures, FFA treatment resulted in a median 90% reduction in frequency (range: 86%-100%). Tonic seizure frequency was reduced by 50%-60% in two patients with this seizure type. One patient experienced fewer myoclonic seizures; one patient first developed myoclonic seizures on FFA, which were controlled with valproate. Adverse events were reported in two patients. The patient with added valproate experienced lethargy; one patient had decreased appetite and flatus. No patient developed valvular heart disease or pulmonary arterial hypertension. Our preliminary results suggest that FFA may be a promising ASM for CDD. Randomized clinical trials are warranted.
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Affiliation(s)
| | - LaToya King
- NYU Langone Medical Center, New York, NY, USA
| | | | - Erin Conway
- NYU Langone Medical Center, New York, NY, USA
| | - Dana Price
- NYU Langone Medical Center, New York, NY, USA
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40
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Aledo-Serrano Á, Gómez-Iglesias P, Toledano R, Garcia-Peñas JJ, Garcia-Morales I, Anciones C, Soto-Insuga V, Benke TA, Del Pino I, Gil-Nagel A. Sodium channel blockers for the treatment of epilepsy in CDKL5 deficiency disorder: Findings from a multicenter cohort. Epilepsy Behav 2021; 118:107946. [PMID: 33848848 DOI: 10.1016/j.yebeh.2021.107946] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/21/2021] [Accepted: 03/21/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This study was aimed to analyze the effectiveness of sodium channel blockers (SCBs) in CDKL5 deficiency disorder (CDD)-related epilepsy. METHODS A retrospective, observational study was performed, including patients with CDD diagnosis evaluated between 2016 and 2019 at three tertiary Epilepsy Centers. Demographic, electroclinical and genetic features, as well as ASM treatments and their outcomes were analyzed, with special focus on SCBs. RESULTS Twenty-one patients evaluated at three tertiary Epilepsy Centers were included, of which 19 presented with epilepsy (90.5%); all had pathogenic mutations of CDKL5. Six patients (31.6%) were classified as SCB responders (more than 50% reduction), four being currently seizure free (mean seizure-free period of 8 years). Most frequent SCB drugs were oxcarbazepine (OXC), carbamazepine (CBZ), and lacosamide (LCM). None of them presented relevant adverse events. In contrast, three patients showed seizure aggravation in the non-responder group. When comparing both groups, responders had statistically significant younger age at SCB treatment and epilepsy onset, higher proportion of focal epileptiform activity and less frequent history of West syndrome. CONCLUSIONS The results of this study indicate that treatment with SCBs might be effective and safe in a subset of patients with CDD-related epilepsy.
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Affiliation(s)
- Ángel Aledo-Serrano
- Epilepsy Program. Neurology Department, Ruber Internacional Hospital, Madrid, Spain; Epilepsy Unit. Neuroscience Department, Corachan Clinic, Barcelona, Spain.
| | | | - Rafael Toledano
- Epilepsy Program. Neurology Department, Ruber Internacional Hospital, Madrid, Spain; Epilepsy Unit, Neurology Department, Ramon y Cajal University Hospital, Madrid, Spain
| | - Juan Jose Garcia-Peñas
- Department of Pediatric Neurology, Niño Jesus University Children's Hospital, Madrid, Spain
| | - Irene Garcia-Morales
- Epilepsy Program. Neurology Department, Ruber Internacional Hospital, Madrid, Spain; Epilepsy Unit. Neurology Department, Clínico San Carlos University Hospital, Madrid, Spain
| | - Carla Anciones
- Epilepsy Program. Neurology Department, Ruber Internacional Hospital, Madrid, Spain
| | - Victor Soto-Insuga
- Department of Pediatric Neurology, Niño Jesus University Children's Hospital, Madrid, Spain
| | - Timothy A Benke
- Departments of Pediatrics, Neurology, and Pharmacology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - Isabel Del Pino
- Principe Felipe Research Center (Centro de Investigación Principe Felipe, CIPF), Valencia, Spain
| | - Antonio Gil-Nagel
- Epilepsy Program. Neurology Department, Ruber Internacional Hospital, Madrid, Spain
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41
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Specchio N, Curatolo P. Developmental and epileptic encephalopathies: what we do and do not know. Brain 2021; 144:32-43. [PMID: 33279965 DOI: 10.1093/brain/awaa371] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/16/2020] [Accepted: 08/17/2020] [Indexed: 02/06/2023] Open
Abstract
Developmental encephalopathies, including intellectual disability and autistic spectrum disorder, are frequently associated with infant epilepsy. Epileptic encephalopathy is used to describe an assumed causal relationship between epilepsy and developmental delay. Developmental encephalopathies pathogenesis more independent from epilepsy is supported by the identification of several gene variants associated with both developmental encephalopathies and epilepsy, the possibility for gene-associated developmental encephalopathies without epilepsy, and the continued development of developmental encephalopathies even when seizures are controlled. Hence, 'developmental and epileptic encephalopathy' may be a more appropriate term than epileptic encephalopathy. This update considers the best studied 'developmental and epileptic encephalopathy' gene variants for illustrative support for 'developmental and epileptic encephalopathy' over epileptic encephalopathy. Moreover, the interaction between epilepsy and developmental encephalopathies is considered with respect to influence on treatment decisions. Continued research in genetic testing will increase access to clinical tests, earlier diagnosis, better application of current treatments, and potentially provide new molecular-investigated treatments.
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Affiliation(s)
- Nicola Specchio
- Department of Neuroscience, Bambino Gesu Children's Hospital, IRCCS, Full Member of European Reference Network on Rare and Complex Epilepsies EpiCARE, Piazza S, 00165 Rome, Italy
| | - Paolo Curatolo
- Systems Medicine Department, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, 00133 Rome, Italy
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42
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Tang Y, Wang ZI, Sarwar S, Choi JY, Wang S, Zhang X, Parikh S, Moosa AN, Pestana-Knight E. Brain morphological abnormalities in children with cyclin-dependent kinase-like 5 deficiency disorder. Eur J Paediatr Neurol 2021; 31:46-53. [PMID: 33621819 PMCID: PMC8026562 DOI: 10.1016/j.ejpn.2021.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 02/03/2021] [Accepted: 02/09/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND To quantitatively evaluate the brain MRI morphological abnormalities in patients with cyclin-dependent kinase-like 5 deficiency disorder (CDD) on a group level and longitudinally. METHODS We performed surface-based MRI analysis on high-resolution T1-weighted images on three CDD patients scanned at age of three years, and compared with 12 age- and gender-matched healthy controls. We further examined the longitudinal morphological changes in one patient with a follow-up of 5 years. RESULTS CDD patients presented significant reductions in total intracranial volume, total gray matter (GM) volume and subcortical GM volume compared to controls. For subcortical regions, significant GM volume reductions were seen in the brain stem, bilateral thalamus, bilateral hippocampus, bilateral cerebellum and left amygdala. Although GM volume of cortical mantle did not show statistical differences overall, significant reduction was detected in bilateral parietal, left occipital and right temporal lobes. Cortical thickness exhibited significant decreases in bilateral occipital, parietal and temporal lobes, while surface area did not show any significant differences. Longitudinal follow-up in one patient revealed a monotonic downward trend of relative volume in the majority of brain regions. The relative surface area appeared to gain age-related growth, whereas the relative cortical thickness exhibited a striking progressive decline over time. CONCLUSIONS Quantitative morphology analysis in children with CDD showed global volume loss in the cortex and more notably in the subcortical gray matter, with a progressive trend along with the disease course. Cortical thickness is a more sensitive measure to disclose cortical atrophy and disease progression than surface area.
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Affiliation(s)
- Yingying Tang
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, Sichuan, China; Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | | | - Shaheera Sarwar
- Northeast Ohio Medical University, Rootstown, OH, USA; Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Joon Yul Choi
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Shan Wang
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | | | - Sumit Parikh
- Center for Pediatric Neuroscience, Cleveland Clinic, Cleveland, OH, USA
| | - Ahsan N Moosa
- Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
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Takai A, Yamaguchi M, Yoshida H, Chiyonobu T. Investigating Developmental and Epileptic Encephalopathy Using Drosophila melanogaster. Int J Mol Sci 2020; 21:ijms21176442. [PMID: 32899411 PMCID: PMC7503973 DOI: 10.3390/ijms21176442] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 08/30/2020] [Accepted: 09/01/2020] [Indexed: 12/16/2022] Open
Abstract
Developmental and epileptic encephalopathies (DEEs) are the spectrum of severe epilepsies characterized by early-onset, refractory seizures occurring in the context of developmental regression or plateauing. Early infantile epileptic encephalopathy (EIEE) is one of the earliest forms of DEE, manifesting as frequent epileptic spasms and characteristic electroencephalogram findings in early infancy. In recent years, next-generation sequencing approaches have identified a number of monogenic determinants underlying DEE. In the case of EIEE, 85 genes have been registered in Online Mendelian Inheritance in Man as causative genes. Model organisms are indispensable tools for understanding the in vivo roles of the newly identified causative genes. In this review, we first present an overview of epilepsy and its genetic etiology, especially focusing on EIEE and then briefly summarize epilepsy research using animal and patient-derived induced pluripotent stem cell (iPSC) models. The Drosophila model, which is characterized by easy gene manipulation, a short generation time, low cost and fewer ethical restrictions when designing experiments, is optimal for understanding the genetics of DEE. We therefore highlight studies with Drosophila models for EIEE and discuss the future development of their practical use.
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Affiliation(s)
- Akari Takai
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan;
| | - Masamitsu Yamaguchi
- Department of Applied Biology, Kyoto Institute of Technology, Matsugasaki, Sakyo-ku, Kyoto 603-8585, Japan; (M.Y.); (H.Y.)
- Kansai Gakken Laboratory, Kankyo Eisei Yakuhin Co. Ltd., Kyoto 619-0237, Japan
| | - Hideki Yoshida
- Department of Applied Biology, Kyoto Institute of Technology, Matsugasaki, Sakyo-ku, Kyoto 603-8585, Japan; (M.Y.); (H.Y.)
| | - Tomohiro Chiyonobu
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan;
- Correspondence:
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