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Theis M, Donath H, Woelke S, Bakhtiar S, Salzmann-Manrique E, Zielen S, Kieslich M. Peripheral polyneuropathy in children and young adults with ataxia-telangiectasia. Eur J Neurol 2023; 30:3842-3853. [PMID: 37540892 DOI: 10.1111/ene.16028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/12/2023] [Accepted: 07/30/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND AND PURPOSE Ataxia-telangiectasia (A-T) is a rare, autosomal recessive, multisystem disorder that leads to progressive neurodegeneration with cerebellar ataxia and peripheral polyneuropathy. Cerebellar neurodegeneration is well described in A-T. However, peripheral nervous system involvement is an underdiagnosed but important additional target for supportive and systemic therapies. The aim of this study was to conduct neurophysiological measurements to assess peripheral neurodegeneration and the development of age-dependent neuropathy in A-T. METHODS In this prospective study, 42 classical A-T patients were assessed. The motor and sensory nerve conduction of the median and tibial nerves was evaluated. Data were compared to published standard values and a healthy age- and gender-matched control group of 23 participants. Ataxia scores (Klockgether, Scale for the Assessment and Rating of Ataxia) were also assessed. RESULTS In A-T, neurophysiological assessment revealed neuropathic changes as early as the first year of life. Subjective symptomatology of neuropathy is rarely described. In the upper extremities, motor neuropathy was predominantly that of a demyelinating type and sensory neuropathy was predominantly that of a mixed type. In the lower extremities, motor and sensory neuropathy was predominantly that of a mixed type. We found significant correlations between age and the development of motor and sensory polyneuropathy in A-T compared with healthy controls (p < 0.001). CONCLUSIONS In A-T, polyneuropathy occurs mostly subclinically as early as the first year of life. The current study of a large national A-T cohort demonstrates that development of neuropathy in A-T differs in the upper and lower extremities.
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Affiliation(s)
- Marius Theis
- Department for Children and Adolescents, Division of Pediatric Neurology, Neurometabolics, and Prevention, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Helena Donath
- Department for Children and Adolescents, Division of Allergology, Pulmonology, and Cystic Fibrosis, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Sandra Woelke
- Department for Children and Adolescents, Division of Allergology, Pulmonology, and Cystic Fibrosis, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Shahrzad Bakhtiar
- Department for Children and Adolescents, Division for Stem Cell Transplantation, Immunology, and Intensive Care Medicine, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Emilia Salzmann-Manrique
- Department for Children and Adolescents, Division for Stem Cell Transplantation, Immunology, and Intensive Care Medicine, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Stefan Zielen
- Department for Children and Adolescents, Division of Allergology, Pulmonology, and Cystic Fibrosis, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Matthias Kieslich
- Department for Children and Adolescents, Division of Pediatric Neurology, Neurometabolics, and Prevention, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
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Woelke S, Szelenyi A, Dreßler M, Trischler J, Donath H, Hutter M, Blümchen K, Zielen S. Methacholine and FeNO Measurement in Patients with Habit Cough. Klin Padiatr 2023; 235:84-89. [PMID: 36720225 DOI: 10.1055/a-2004-3477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Chronic cough is one of the most common symptoms in childhood. Making a definite diagnosis is a challenge for all pediatricians especially in patients when cough is without an organic cause like in habit cough. PATIENTS AND METHODS In this retrospective analysis, all electronic outpatient charts of the Division of Allergology and Pneumology, between January 1, 2010 and December 31, 2019 were reviewed in order to study all children with potential habit cough. All children underwent the following diagnostic algorithms, skin prick test (SPT), measurement of fractional exhaled nitric oxide (FeNO), spirometry and methacholine challenge test (MCT). The value of a normal MCT and FeNO measurement for diagnosing habit cough was investigated. RESULTS The chart review revealed 482 patients with chronic cough>4 weeks. Of these, 99 (20.5%) with suspected habit cough were collected. 13 patients had to be excluded for other diagnosis and a complete data set was available in 55 patients. 33 (60.0%) of 55 patients were SPT negative and 22 (40.0%) had sensitization to common allergens. Five patients had elevated FeNO≥20 ppb and three showed severe bronchial hyperresponsiveness<0.1 mg methacholine, challenging the diagnosis of habit cough. CONCLUSION A normal FeNO and MCT can help confirm the clinical diagnosis of habit cough. However, in patients with positive MCT and/or elevated FeNO habit cough can be present. Especially in patients with elevated FeNO and severe BHR cough variant asthma and eosinophilic bronchitis have to be ruled out.
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Affiliation(s)
- Sandra Woelke
- Department for Children and Adolescence, Division of Allergy, Pulmonology and Cystic fibrosis, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Alexandra Szelenyi
- Department for Children and Adolescence, Division of Allergy, Pulmonology and Cystic fibrosis, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Melanie Dreßler
- Department for Children and Adolescence, Division of Allergy, Pulmonology and Cystic fibrosis, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Jordis Trischler
- Department for Children and Adolescence, Division of Allergy, Pulmonology and Cystic fibrosis, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Helena Donath
- Department for Children and Adolescence, Division of Allergy, Pulmonology and Cystic fibrosis, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Martin Hutter
- Department for Children and Adolescence, Division of Allergy, Pulmonology and Cystic fibrosis, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Katharina Blümchen
- Department for Children and Adolescence, Division of Allergy, Pulmonology and Cystic fibrosis, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Stefan Zielen
- Department for Children and Adolescence, Division of Allergy, Pulmonology and Cystic fibrosis, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
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Zielen S, Duecker RP, Woelke S, Donath H, Bakhtiar S, Buecker A, Kreyenberg H, Huenecke S, Bader P, Mahlaoui N, Ehl S, El-Helou SM, Pietrucha B, Plebani A, van der Flier M, van Aerde K, Kilic SS, Reda SM, Kostyuchenko L, McDermott E, Galal N, Pignata C, Pérez JLS, Laws HJ, Niehues T, Kutukculer N, Seidel MG, Marques L, Ciznar P, Edgar JDM, Soler-Palacín P, von Bernuth H, Krueger R, Meyts I, Baumann U, Kanariou M, Grimbacher B, Hauck F, Graf D, Granado LIG, Prader S, Reisli I, Slatter M, Rodríguez-Gallego C, Arkwright PD, Bethune C, Deripapa E, Sharapova SO, Lehmberg K, Davies EG, Schuetz C, Kindle G, Schubert R. Simple Measurement of IgA Predicts Immunity and Mortality in Ataxia-Telangiectasia. J Clin Immunol 2021; 41:1878-1892. [PMID: 34477998 PMCID: PMC8604875 DOI: 10.1007/s10875-021-01090-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/25/2021] [Indexed: 11/29/2022]
Abstract
Patients with ataxia-telangiectasia (A-T) suffer from progressive cerebellar ataxia, immunodeficiency, respiratory failure, and cancer susceptibility. From a clinical point of view, A-T patients with IgA deficiency show more symptoms and may have a poorer prognosis. In this study, we analyzed mortality and immunity data of 659 A-T patients with regard to IgA deficiency collected from the European Society for Immunodeficiencies (ESID) registry and from 66 patients with classical A-T who attended at the Frankfurt Goethe-University between 2012 and 2018. We studied peripheral B- and T-cell subsets and T-cell repertoire of the Frankfurt cohort and survival rates of all A-T patients in the ESID registry. Patients with A-T have significant alterations in their lymphocyte phenotypes. All subsets (CD3, CD4, CD8, CD19, CD4/CD45RA, and CD8/CD45RA) were significantly diminished compared to standard values. Patients with IgA deficiency (n = 35) had significantly lower lymphocyte counts compared to A-T patients without IgA deficiency (n = 31) due to a further decrease of naïve CD4 T-cells, central memory CD4 cells, and regulatory T-cells. Although both patient groups showed affected TCR-ß repertoires compared to controls, no differences could be detected between patients with and without IgA deficiency. Overall survival of patients with IgA deficiency was significantly diminished. For the first time, our data show that patients with IgA deficiency have significantly lower lymphocyte counts and subsets, which are accompanied with reduced survival, compared to A-T patients without IgA deficiency. IgA, a simple surrogate marker, is indicating the poorest prognosis for classical A-T patients. Both non-interventional clinical trials were registered at clinicaltrials.gov 2012 (Susceptibility to infections in ataxia-telangiectasia; NCT02345135) and 2017 (Susceptibility to Infections, tumor risk and liver disease in patients with ataxia-telangiectasia; NCT03357978)
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Affiliation(s)
- Stefan Zielen
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Ruth Pia Duecker
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany.
| | - Sandra Woelke
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Helena Donath
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Sharhzad Bakhtiar
- Division for Stem Cell Transplantation, Immunology and Intensive Care Unit, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Aileen Buecker
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Hermann Kreyenberg
- Division for Stem Cell Transplantation, Immunology and Intensive Care Unit, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Sabine Huenecke
- Division for Stem Cell Transplantation, Immunology and Intensive Care Unit, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Peter Bader
- Division for Stem Cell Transplantation, Immunology and Intensive Care Unit, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Nizar Mahlaoui
- Pediatric Immunology-Hematology and Rheumatology Unit, French National Reference Center for Primary Immune Deficiencies (CEREDIH), Necker Children's University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Stephan Ehl
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sabine M El-Helou
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- RESIST - Cluster of Excellence 2155 To Hanover Medical School, Satellite Center Freiburg, Freiburg, Germany
- Department of Rheumatology and Immunology, Hannover Medical School, Hannover, Germany
| | - Barbara Pietrucha
- Department of Immunology, The Children's Memorial Health Institute, Av. Dzieci Polskich 20, 04-730, Warsaw, Poland
| | - Alessandro Plebani
- Pediatrics Clinic and Institute for Molecular Medicine A. Nocivelli, Department of Clinical and Experimental Sciences, University of Brescia and ASST-Spedali Civili di Brescia, Brescia, Italy
| | - Michiel van der Flier
- Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Koen van Aerde
- Department of Pediatrics, Amalia's Children Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Sara S Kilic
- Department of Pediatric Immunology and Rheumatology, the School of Medicine, Uludag University, Bursa, Turkey
| | - Shereen M Reda
- Department of Pediatrics, Children's Hospital, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Larysa Kostyuchenko
- Center of Pediatric Immunology, Western Ukrainian Specialized Children's Medical Centre, Lviv, Ukraine
| | - Elizabeth McDermott
- Clinical Immunology and Allergy Unit, Nottingham University Hospitals, Nottingham, UK
| | - Nermeen Galal
- Department of Pediatrics, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Claudio Pignata
- Department of Translational Medical Sciences, Section of Pediatrics, Federico II University, Naples, Italy
| | - Juan Luis Santos Pérez
- Infectious Diseases and Immunodeficiencies Unit, Service of Pediatrics, Hospital Universitario Virgen de Las Nieves, Granada, Spain
| | - Hans-Juergen Laws
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Center of Child and Adolescent Health, Heinrich-Heine University, Duesseldorf, Germany
| | - Tim Niehues
- Centre for Child and Adolescent Health, Helios Klinikum Krefeld, Krefeld, Germany
| | - Necil Kutukculer
- Faculty of Medicine, Department of Pediatric Immunology, Ege University, Izmir, Turkey
| | - Markus G Seidel
- Research Unit for Pediatric Hematology and Immunology, Division of Pediatric Hemato-Oncology, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
| | - Laura Marques
- Pediatric Department, Infectious Diseases and Immunodeficiencies Unit, Porto Hospital Center, Porto, Portugal
| | - Peter Ciznar
- Pediatric Department, Faculty of Medicine, Children University Hospital in Bratislava, Comenius University in Bratislava, Bratislava, Slovakia
| | | | - Pere Soler-Palacín
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Vall D'Hebron Research Institute, Hospital Universitari Vall D'Hebron, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Horst von Bernuth
- Department of Pediatric Pneumology, Immunology and Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Immunology, Labor Berlin Charité - Vivantes GmbH, Berlin, Germany
- Berlin Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Renate Krueger
- Department of Pediatric Pneumology, Immunology and Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Isabelle Meyts
- Department of Pediatrics, University Hospitals Leuven, and the Laboratory for Inborn Errors of Immunity, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Ulrich Baumann
- Department of Paediatric Pulmonology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany
| | - Maria Kanariou
- Department of Immunology and Histocompatibility, Centre for Primary Immunodeficiencies, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Bodo Grimbacher
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- RESIST - Cluster of Excellence 2155 To Hanover Medical School, Satellite Center Freiburg, Freiburg, Germany
- DZIF-German Center for Infection Research, Satellite Center Freiburg, Freiburg, Germany; Centre for Integrative Biological Signalling Studies, Albert-Ludwigs University, Freiburg, Germany
| | - Fabian Hauck
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Dagmar Graf
- MVZ Dr. Reising-Ackermann Und Kollegen, Leipzig, Germany
| | - Luis Ignacio Gonzalez Granado
- Primary Immunodeficiencies Unit, Pediatrics, Hospital 12 Octubre, Complutense University School of Medicine, Madrid, Spain
| | - Seraina Prader
- Division of Immunology and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Ismail Reisli
- Department of Pediatrics, Division of Pediatric Immunology and Allergy, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Mary Slatter
- Primary Immunodeficiency Group, Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Translational and Clinical Research Institute, Great North Childrens' Hospital, Newcastle University, Newcastle upon Tyne, UK
| | - Carlos Rodríguez-Gallego
- Department of Immunology, Dr. Negrin University Hospital of Gran Canaria, University Fernando Pessoa Canarias, Las Palmas de Gran Canaria, Spain
| | - Peter D Arkwright
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester and Royal Manchester Children's Hospital, Manchester, UK
| | | | - Elena Deripapa
- National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Svetlana O Sharapova
- Research Department, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk region, Minsk, Belarus
| | - Kai Lehmberg
- Division for Pediatric Stem Cell Transplantation and Immunology, Clinic for Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - E Graham Davies
- Great Ormond Street Hospital and UCL Great Ormond Street Institute of Child Health, London, UK
| | - Catharina Schuetz
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Gerhard Kindle
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- FREEZE Biobank, Center for Biobanking, Medical Center and Faculty of Medicine, University of Freiburg, Breisacher Str. 115, 79106, Freiburg, Germany
| | - Ralf Schubert
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
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Bakhtiar S, Salzmann-Manrique E, Donath H, Woelke S, Duecker RP, Fritzemeyer S, Schubert R, Huenecke S, Kieslich M, Klingebiel T, Bader P, Zielen S. The incidence and type of cancer in patients with ataxia-telangiectasia via a retrospective single-centre study. Br J Haematol 2021; 194:879-887. [PMID: 34337741 DOI: 10.1111/bjh.17736] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/14/2021] [Indexed: 12/28/2022]
Abstract
Ataxia-telangiectasia (A-T) is a hereditary immune system disorder with neurodegeneration. Its first neurologic symptoms include ataxic gait in early childhood, with slowly progressive cerebellar ataxia, oculomotor apraxia, oculocutaneous telangiectasia, and progressive muscle weakness. Neonatal screening for severe T-cell deficiency was recently found to diagnose A-T patients with a significantly reduced naïve T-cell pool. Our study includes 69 A-T patients between 8 January 2002 and 1 December 2019. Nineteen cases of cancer were diagnosed in 17 patients (25%), with a median overall survival [OS; 95% cumulative indcidence (CI)] of 26·9 years for the entire cohort. The 15-year OS of 82·5% (72-95%) was significantly decreased among A-T patients with malignancies, who had a median OS of 2·11 years, with a two-year-estimated OS of 50·7% (31-82%). Haematological malignancies were the major causes of death within the initial years of life with a 15 times increased risk for death [HR (95% CI): 6·9 (3·1-15.2), P < 0·001] upon malignancy diagnosis. Male patients with A-T are at a higher cancer risk than their female counterparts. This manuscript highlights the need for cancer surveillance and prevention, as well as optimal treatment in this cohort.
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Affiliation(s)
- Shahrzad Bakhtiar
- Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt/Main, Germany
| | - Emilia Salzmann-Manrique
- Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt/Main, Germany
| | - Helena Donath
- Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt/Main, Germany
| | - Sandra Woelke
- Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt/Main, Germany
| | - Ruth P Duecker
- Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt/Main, Germany
| | - Stefanie Fritzemeyer
- Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt/Main, Germany
| | - Ralf Schubert
- Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt/Main, Germany
| | - Sabine Huenecke
- Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt/Main, Germany
| | - Matthias Kieslich
- Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt/Main, Germany
| | - Thomas Klingebiel
- Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt/Main, Germany
| | - Peter Bader
- Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt/Main, Germany
| | - Stefan Zielen
- Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt/Main, Germany
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Donath H, Woelke S, Schubert R, Kieslich M, Theis M, Auburger G, Duecker RP, Zielen S. Neurofilament Light Chain Is a Biomarker of Neurodegeneration in Ataxia Telangiectasia. Cerebellum 2021; 21:39-47. [PMID: 33893614 PMCID: PMC8885493 DOI: 10.1007/s12311-021-01257-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 12/12/2022]
Abstract
Ataxia telangiectasia (A-T) is a progressive and life-limiting disease associated with cerebellar ataxia due to progressive cerebellar degeneration. In addition to ataxia, which is described in detail, the presence of chorea, dystonia, oculomotor apraxia, athetosis, parkinsonism, and myoclonia are typical manifestations of the disease. The study aimed to evaluate the specificity and sensitivity of neurofilament light chain (NfL) as a biomarker of neurodegeneration in relation to SARA score. In this prospective trial, one visit of 42 A-T patients aged 1.3–25.6 years (mean 11.6 ± 7.3 years) was performed, in which NfL was determined from serum by ELISA. Additionally, a neurological examination of the patients was performed. Blood was collected from 19 healthy volunteers ≥ 12 years of age. We found significantly increased levels of NfL in patients with A-T compared to healthy controls (21.5 ± 3.6 pg/mL vs. 9.3 ± 0.49 pg/mL, p ≤ 0.01). There was a significant correlation of NfL with age, AFP, and SARA. NfL is a new potential progression biomarker in blood for neurodegeneration in A-T which increases with age.
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Affiliation(s)
- H Donath
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany.
| | - S Woelke
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - R Schubert
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - M Kieslich
- Division of Pediatric Neurology, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - M Theis
- Division of Pediatric Neurology, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - G Auburger
- Experimental Neurology, Medical School, Goethe University, Frankfurt, Germany
| | - R P Duecker
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - S Zielen
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
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Donath H, Hess U, Kieslich M, Theis M, Ohlenschläger U, Schubert R, Woelke S, Zielen S. Diabetes in Patients With Ataxia Telangiectasia: A National Cohort Study. Front Pediatr 2020; 8:317. [PMID: 32733823 PMCID: PMC7363802 DOI: 10.3389/fped.2020.00317] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/18/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Ataxia telangiectasia (A-T) is a rare autosomal-recessive multisystem disorder characterized by pronounced cerebellar ataxia, telangiectasia, cancer predisposition and altered body composition. In addition, evidence is rising for endocrine dysfunction. Objectives: To determine the evolution of diabetes and its prevalence in a larger A-T cohort. Methods: A retrospective analysis of the patient charts of 39 subjects from the Frankfurt A-T cohort was performed between August 2002 and 2018 concerning HbA1c and oral glucose tolerance (OGTT). The median follow-up period was 4 years (1-16 years). In addition, in 31 A-T patients aged 1 to 38 years HbA1c and fasting glucose were studied prospectively from 2018 to 2019. Results: In the retrospective analysis, we could demonstrate a longitudinal increase of HbA1c. The prospective analysis showed a significant increase of HbA1c and fasting glucose with age (r = 0.79, p ≤ 0.0001). OGTT has a good sensitivity for insulin resistance screening, whereas HbA1c can be used to evaluate individual courses and therapy response. Seven out of 39 (17.9%) patients suffered from diabetes. Metformin did not always lead to sufficient diabetes control; one patient was treated successfully with repaglinide. Conclusion: Diabetes is a common finding in older A-T patients and often starts in puberty. Our data clearly demonstrate the need for an annual diabetes screening in patients > 12 years.
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Affiliation(s)
- Helena Donath
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Ursula Hess
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Matthias Kieslich
- Division of Pediatric Neurology, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Marius Theis
- Division of Pediatric Neurology, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Ute Ohlenschläger
- Division of Pediatric Neurology, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Ralf Schubert
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Sandra Woelke
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Stefan Zielen
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
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Donath H, Woelke S, Theis M, Heß U, Knop V, Herrmann E, Krauskopf D, Kieslich M, Schubert R, Zielen S. Progressive Liver Disease in Patients With Ataxia Telangiectasia. Front Pediatr 2019; 7:458. [PMID: 31788461 PMCID: PMC6856634 DOI: 10.3389/fped.2019.00458] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 10/21/2019] [Indexed: 12/17/2022] Open
Abstract
Ataxia telangiectasia (A-T) is a devastating multi-system disorder characterized by progressive cerebellar ataxia, immunodeficiency, genetic instability, premature aging and growth retardation. Due to better care the patients get older than in the past and new disease entities like disturbed glucose tolerance and liver disease emerge. The objective of the present investigation is to determine the evolution of liver disease and its relation to age and neurological deterioration. The study included 67 patients aged 1 to 38 years with classical A-T. At least two measurements of liver enzymes were performed within a minimum interval of 6 months in 56 patients. The median follow-up period was 4 years (1-16 years). A total of 316 liver enzyme measurements were performed. For analysis, patients were divided into two age groups (Group 1: <12 years; group 2: ≥12 years). In addition, ultrasound of the liver and Klockgether Ataxia Score (KAS) were analyzed. We found significantly higher levels of alpha-fetoprotein (AFP) (226,8 ± 20.87 ng/ml vs. 565,1 ± 24.3 ng/ml, p < 0.0001), and liver enzymes like ALT (23.52 ± 0.77 IU/L vs. 87.83 ± 5.31 IU/L, p < 0.0001) in patients in group 2. In addition, we could show a significant correlation between age and AFP, GGT, and KAS. Ultrasound revealed hepatic steatosis in 11/19 (57.9%) patients in group 2. One female patient aged 37 years died due to a hepato-cellular carcinoma (HCC). Liver disease is present in the majority of older A-T patients. Structural changes, non-alcoholic fatty liver disease and fibrosis are frequent findings. Progress of liver disease is concomitant to neurological deterioration.
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Affiliation(s)
- Helena Donath
- Division of Allergology, Department for Children and Adolescents, Pulmonology and Cystic Fibrosis, Goethe University, Frankfurt, Germany
| | - Sandra Woelke
- Division of Allergology, Department for Children and Adolescents, Pulmonology and Cystic Fibrosis, Goethe University, Frankfurt, Germany
| | - Marius Theis
- Division of Pediatric Neurology, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Ursula Heß
- Division of Allergology, Department for Children and Adolescents, Pulmonology and Cystic Fibrosis, Goethe University, Frankfurt, Germany
| | - Viola Knop
- Department for Internal Medicine, Goethe University, Frankfurt, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modeling, Goethe University, Frankfurt, Germany
| | - Dorothea Krauskopf
- Division of Pediatric Neurology, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Matthias Kieslich
- Division of Pediatric Neurology, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Ralf Schubert
- Division of Allergology, Department for Children and Adolescents, Pulmonology and Cystic Fibrosis, Goethe University, Frankfurt, Germany
| | - Stefan Zielen
- Division of Allergology, Department for Children and Adolescents, Pulmonology and Cystic Fibrosis, Goethe University, Frankfurt, Germany
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Bakhtiar S, Woelke S, Huenecke S, Kieslich M, Taylor AM, Schubert R, Zielen S, Bader P. Pre-emptive Allogeneic Hematopoietic Stem Cell Transplantation in Ataxia Telangiectasia. Front Immunol 2018; 9:2495. [PMID: 30420857 PMCID: PMC6215822 DOI: 10.3389/fimmu.2018.02495] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 10/09/2018] [Indexed: 11/13/2022] Open
Abstract
Ataxia telangiectasia (A-T) is a primary immunodeficiency with mutations in the gene encoding the A-T mutated (ATM) protein that interacts with immune, hematopoietic, and endocrine targets resulting in broad multi-systemic clinical manifestations with a devastating outcome. Apart from a progressive neurodegenerative disorder, A-T leads to significantly increased susceptibility to malignancies. It is a matter of discussion whether pre-emptive allogeneic hematopoietic stem cell transplantation (alloHSCT) using a reduced intensity conditioning regimen would be an option to restore immune-competence and prevent malignancy, as shown in animal models, because conventional treatment protocols of malignant diseases using radio- and/or chemotherapy have a high rate of therapy-related morbidity and mortality in these patients. We present the course of the disease, including immune reconstitution and neurological outcome following pre-emptive alloHSCT in a 4-year-old boy with A-T on a 6 year follow-up. Our manuscript provides a proof-of-concept of alloHSCT as an individual pre-emptive treatment strategy from which some A-T patients might benefit.
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Affiliation(s)
- Shahrzad Bakhtiar
- Division for Stem Cell Transplantation and Immunology, Children's Hospital, Goethe-Universität Frankfurt am Main, Frankfurt, Germany
| | - Sandra Woelke
- Department of Allergology, Pneumology and Cystic Fibrosis, Children's Hospital, Goethe-Universität Frankfurt am Main, Frankfurt, Germany
| | - Sabine Huenecke
- Division for Stem Cell Transplantation and Immunology, Children's Hospital, Goethe-Universität Frankfurt am Main, Frankfurt, Germany
| | - Matthias Kieslich
- Department of Neuropaediatrics, Children's Hospital, Goethe-Universität Frankfurt am Main, Frankfurt, Germany
| | | | - Ralf Schubert
- Department of Allergology, Pneumology and Cystic Fibrosis, Children's Hospital, Goethe-Universität Frankfurt am Main, Frankfurt, Germany
| | - Stefan Zielen
- Department of Allergology, Pneumology and Cystic Fibrosis, Children's Hospital, Goethe-Universität Frankfurt am Main, Frankfurt, Germany
| | - Peter Bader
- Division for Stem Cell Transplantation and Immunology, Children's Hospital, Goethe-Universität Frankfurt am Main, Frankfurt, Germany
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Woelke S, Valesky E, Bakhtiar S, Pommerening H, Pfeffermann LM, Schubert R, Zielen S. Treatment of Granulomas in Patients With Ataxia Telangiectasia. Front Immunol 2018; 9:2000. [PMID: 30279689 PMCID: PMC6153364 DOI: 10.3389/fimmu.2018.02000] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 08/14/2018] [Indexed: 12/12/2022] Open
Abstract
Background: Ataxia telangiectasia (A-T) is a devastating multi-system disorder characterized by progressive cerebellar ataxia, growth retardation, immunodeficiency, chronic pulmonary disease and chromosomal instability. Cutaneous granulomas are a known phenomenon in A-T but extra-dermal manifestation of granulomas at bone and synovia has not been reported so far. The clinical presentation, immunological findings, the long-term course and treatment options of eight patients with severe granulomas will be reported. Methods: From our cohort of 44 classical A-T patients, eight patients aged 2–11 years (18.2%) presented with granulomas. Immunological features of patients with and without granulomas were compared. Five patients suffered from cutaneous manifestation, in two patients we detected a bone and in one a joint involvement. Patients with significant extra-dermal involvement as well as one patient with massive skin manifestation were treated with TNF inhibitors. The patient with granulomas at his finger joint and elbow was treated with hematopoietic stem cell transplantation (HSCT). Results: Interestingly, seven of eight patients with granulomas were total IgA deficient, but there were no differences in IgG and IgM levels. All lymphocytes subsets were equally distributed except patients with granuloma had significantly lower naïve CD8 cells. In patients without treatment, four of eight showed a slow but significant enlargement of the granuloma. Treatment success with TNF inhibitors was variable. In one patient, treatment with TNF inhibitors led to a total remission for 3 years up to now. In two patients, treatment with TNF inhibitors led to a partial regression of granulomas. Treatment interruptions caused deterioration again. Conclusions: Granulomas in A-T progress slowly over years and can lead to significant morbidity.Treatment with TNF inhibitors was safe and in part successful in our patients. Interestingly HSCT leads to complete remission, and indicates that aberrant immune function is responsible for granulomas in A-T patients. What This Study Adds to the Field: Granulomas in A-T progress slowly over years and can lead to significant morbidity. Treatment with TNF inhibitors was safe and in part successful in our patients. AT A GLANCE COMMENTARY: Scientific knowledge on the subject: Little is known about the clinical presentation, course and treatment of granulomas in ataxia telangiectasia (A-T). In addition, this is the first report of extra-dermal manifestation of granulomas at bone and synovia in patients with A-T. What This Study Adds to the Field: Granulomas in A-T progress slowly over years and can lead to significant morbidity. Treatment with TNF inhibitors was safe and in part successful in our patients.
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Affiliation(s)
- Sandra Woelke
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Eva Valesky
- Department of Dermatology, Venereology and Allergology, Goethe University, Frankfurt, Germany
| | - Shahrzad Bakhtiar
- Division for Stem Cell Transplantation and Immunology, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Helena Pommerening
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - L M Pfeffermann
- Division for Stem Cell Transplantation and Immunology, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Ralf Schubert
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
| | - Stefan Zielen
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
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Abstract
INTRODUCTION Ataxia telangiectasia (A-T) is a devastating autosomal recessive disorder with chromosomal instability and growth failure. Low levels of growth hormone (GH) and growth factors may be related to advanced neurological deterioration, wasting syndrome and more pronounced immunodeficiency. OBJECTIVE The objective of this study is to study safety and effectiveness of GH therapy in patients with A-T and evaluate the effect of GH on ataxia and lymphocyte subsets. METHODS Three patients with classical A-T were treated with GH (0.3 mg/kg/d) for 1 year. Growth rate, ataxia score and lymphocyte subsets were monitored. RESULTS GH treatment was well tolerated. All patients showed a significant increase of height SDS of +1.3 (mean height SDS -1.994), a mean increase of 8 (6-11) cm/12 months. Lymphocytes subsets and ataxia were not altered before and after GH treatment. CONCLUSIONS Treatment with GH is feasible and effective in A-T patients with severe growth arrest, but no effect on ataxia and lymphocytes could be recorded.
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Affiliation(s)
- Sandra Woelke
- a Division for Allergy, Pneumology and Cystic Fibrosis, Department for Children and Adolescents , Goethe University , Frankfurt am Main , Germany
| | - Helena Pommerening
- a Division for Allergy, Pneumology and Cystic Fibrosis, Department for Children and Adolescents , Goethe University , Frankfurt am Main , Germany
| | - Matthias Kieslich
- b Division for Neurology, Department for Children and Adolescents , Goethe-University , Frankfurt am Main , Germany
| | - Ralf Schubert
- a Division for Allergy, Pneumology and Cystic Fibrosis, Department for Children and Adolescents , Goethe University , Frankfurt am Main , Germany
| | - Stefan Zielen
- a Division for Allergy, Pneumology and Cystic Fibrosis, Department for Children and Adolescents , Goethe University , Frankfurt am Main , Germany
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