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Cryptogenic stroke and small fiber neuropathy of unknown etiology in patients with alpha-galactosidase A -10T genotype.

Schelleckes M, Lenders M, Guske K, Schmitz B, Tanislav C, Ständer S, Metze D, Katona I, Weis J, Brand SM, Duning T, Brand E - Orphanet J Rare Dis (2014)

Bottom Line: Patients' mean GLA mRNA expression level was reduced to ~70% (p < 0.0001) and a dose-dependent effect of the -10T allele on GLA mRNA expression was observed in hemi/homozygous compared to heterozygous patients (p < 0.0001).Molecular analyzes revealed that the -10T allele resulted in a reduced promoter activity and an altered transcription factor binding, while a functional relevance of the co-segregated intronic variants was excluded by exon trapping.Based on this complementary approach of clinical observation and functional testing, we conclude that the GLA -10T allele could be causal for the observed neurological manifestations.

View Article: PubMed Central - PubMed

Affiliation: Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany. Michael.Schelleckes@ukmuenster.de.

ABSTRACT

Background: Fabry disease (FD) is a multisystemic disorder with typical neurological manifestations such as stroke and small fiber neuropathy (SFN), caused by mutations of the alpha-galactosidase A (GLA) gene. We analyzed 15 patients carrying the GLA haplotype -10C>T [rs2071225], IVS2-81_-77delCAGCC [rs5903184], IVS4-16A>G [rs2071397], and IVS6-22C>T [rs2071228] for potential neurological manifestations.

Methods and results: Patients were retrospectively analyzed for stroke, transient ischemic attack (TIA), white matter lesions (WML) and SFN with neuropathic pain. Functional impact of the haplotype was determined by molecular genetic methods including real-time PCR, exon trapping, promoter deletion constructs and electrophoretic mobility shift assays. Symptomatic -10T allele carriers suffered from stroke, TIA, WML, and SFN with neuropathic pain. Patients' mean GLA mRNA expression level was reduced to ~70% (p < 0.0001) and a dose-dependent effect of the -10T allele on GLA mRNA expression was observed in hemi/homozygous compared to heterozygous patients (p < 0.0001). Molecular analyzes revealed that the -10T allele resulted in a reduced promoter activity and an altered transcription factor binding, while a functional relevance of the co-segregated intronic variants was excluded by exon trapping.

Conclusions: Based on this complementary approach of clinical observation and functional testing, we conclude that the GLA -10T allele could be causal for the observed neurological manifestations. Future studies are needed to clarify whether affected patients benefit from GLA enzyme replacement therapy for end-organ damage prevention.

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Related in: MedlinePlus

Magnetic resonance imaging (MRI) and small fiber neuropathy diagnosis by PGP9.5 immunofluorescence. (A-C) Fluid attenuated inversion recovery (FLAIR) MRI of patient #1 showed multiple, punctuated white matter lesions from periventricular (yellow arrows and circles) to subcortical (red arrows and circles) without gadolinium enhancement. (D) Skin biopsy analysis of patient #2 showed the reduction of the small epidermal nerve fibers (arrow). Scale bar = 20 μm. (E-F). The number of focal axonal swellings (arrows) larger than 1.5 μm was increased. Scale bar = 10 μm. (G) Skin biopsy of a healthy control. Scale bar = 30 μm.
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Fig2: Magnetic resonance imaging (MRI) and small fiber neuropathy diagnosis by PGP9.5 immunofluorescence. (A-C) Fluid attenuated inversion recovery (FLAIR) MRI of patient #1 showed multiple, punctuated white matter lesions from periventricular (yellow arrows and circles) to subcortical (red arrows and circles) without gadolinium enhancement. (D) Skin biopsy analysis of patient #2 showed the reduction of the small epidermal nerve fibers (arrow). Scale bar = 20 μm. (E-F). The number of focal axonal swellings (arrows) larger than 1.5 μm was increased. Scale bar = 10 μm. (G) Skin biopsy of a healthy control. Scale bar = 30 μm.

Mentions: An index patient (patient #1) presented at the Fabry center of the University Hospital of Muenster (IFAZ) with severely impaired daily activity and reduced quality of life due to neuropathic pain of the distal extremities with “burning” hands and feet and physical weakness at the age of 56 years (Tables 1 and 2, Additional file 1: Table S1). She reported about first neuropathic pain symptoms at the age of 40 years. In-depths clinical and laboratory investigations revealed a SFN and widespread periventricular to subcortical WML (Figure 2A-C). Left-ventricular hypertrophy and diastolic ventricular dysfunction indicated cardiac involvement. A detailed laboratory investigation and cerebrospinal fluid (CSF) analysis were unrevealing. The patient had an unrevealing cardiovascular risk profile and no evidence of extracerebral arteriopathy, vasculitis or other inflammatory disease. Since further investigations revealed no evidence for common causes of SFN, the patient was tested for FD. Direct GLA sequencing revealed -10T heterozygosity in the 5′-UTR in a haplotype with the three intronic variants (IVS2-81_-77delCAGCC, IVS4-16A>G and IVS6-22C>T). No other mutation within the GLA coding region or exon-intron boundaries was found (Table 1, Additional file 1: Table S1). Since several reports existed on -10T heterozygosity and Fabry-typical manifestations [4–6] we retrospectively analyzed additional 14 -10T allele carriers (44.4 [12–72] years of age) from our database (Figure 1, Tables 1 and 2, Additional file 1: Table S1). Out of 15 -10T carriers 13 presented with neuropathic pain (symptom onset: patients #3-7 and #9-11 in childhood; #2 at 20 and #8 at 40 years of age) and/or cerebrovascular manifestations such as WML, TIA or stroke (Table 1). Blood count (including total leukocyte count), renal and liver function tests as well as homocysteine level and angiotensin-converting enzyme were normal. Serum antibodies against thyroid peroxidase, thyreoglobulin, glutamic acid decarboxylase, and onconeural antibodies (anti-amphiphysin, anti-Ri, anti-Yo, anti-Hu, anti-CV2/CRMP5, anti-Ma2/Ta, anti-NMDA, LGI-1, GAD) as well as anti-cardiolipin immunoglobulin were all negative. A screen for antibodies against extractable nuclear and anti-nuclear antigens was also negative. No patient had evidence of an inflammatory disease since serological testing excluded borreliosis, syphilis and HIV-1 infection. Cerebral MR-angiography was obtained in all patients with WML and showed no evidence of vasculitis. Sonography of the extracranial vessels were performed in all patients with stroke/TIA or WML (patients #1; #7; #8; #10-13) and showed no severe arteriopathy. Further examination revealed no evidence for common causes of SFN since blood glucose and hemoglobin A1c levels, blood count including total leukocyte count, c-reactive protein, thyroid and liver parameters, vitamins B1, B6, B12 and homocysteine levels, serum protein and immunoelectrophoresis were normal. CSF analyses were obtained in patients #1, #2, #8, and #11-13 and showed unrevealing results. Since CSF analyses were not performed in all patients, we could not definitively exclude inflammatory disease. However, no patient fulfilled the diagnostic criteria of primary vasculitis of the CNS or multiple sclerosis, regardless of CSF analysis results. Furthermore, the course of the disease and the additional diagnostic results did not agree with this diagnosis. All patients who presented with WML or stroke/TIA were non-smokers. Except for patients #8 and #12 who presented with well-controlled arterial hypertension, the remaining patients with stroke/TIA or WML had normal blood pressure. Only patient #6 was consecutively diagnosed with type 2 diabetes mellitus. Fabry-typical manifestations such as hypohidrosis, angiokeratoma, severe gastrointestinal disturbances and tinnitus were also observed (Additional file 1: Table S1), while only two patients presented renal manifestations.Table 1


Cryptogenic stroke and small fiber neuropathy of unknown etiology in patients with alpha-galactosidase A -10T genotype.

Schelleckes M, Lenders M, Guske K, Schmitz B, Tanislav C, Ständer S, Metze D, Katona I, Weis J, Brand SM, Duning T, Brand E - Orphanet J Rare Dis (2014)

Magnetic resonance imaging (MRI) and small fiber neuropathy diagnosis by PGP9.5 immunofluorescence. (A-C) Fluid attenuated inversion recovery (FLAIR) MRI of patient #1 showed multiple, punctuated white matter lesions from periventricular (yellow arrows and circles) to subcortical (red arrows and circles) without gadolinium enhancement. (D) Skin biopsy analysis of patient #2 showed the reduction of the small epidermal nerve fibers (arrow). Scale bar = 20 μm. (E-F). The number of focal axonal swellings (arrows) larger than 1.5 μm was increased. Scale bar = 10 μm. (G) Skin biopsy of a healthy control. Scale bar = 30 μm.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4255940&req=5

Fig2: Magnetic resonance imaging (MRI) and small fiber neuropathy diagnosis by PGP9.5 immunofluorescence. (A-C) Fluid attenuated inversion recovery (FLAIR) MRI of patient #1 showed multiple, punctuated white matter lesions from periventricular (yellow arrows and circles) to subcortical (red arrows and circles) without gadolinium enhancement. (D) Skin biopsy analysis of patient #2 showed the reduction of the small epidermal nerve fibers (arrow). Scale bar = 20 μm. (E-F). The number of focal axonal swellings (arrows) larger than 1.5 μm was increased. Scale bar = 10 μm. (G) Skin biopsy of a healthy control. Scale bar = 30 μm.
Mentions: An index patient (patient #1) presented at the Fabry center of the University Hospital of Muenster (IFAZ) with severely impaired daily activity and reduced quality of life due to neuropathic pain of the distal extremities with “burning” hands and feet and physical weakness at the age of 56 years (Tables 1 and 2, Additional file 1: Table S1). She reported about first neuropathic pain symptoms at the age of 40 years. In-depths clinical and laboratory investigations revealed a SFN and widespread periventricular to subcortical WML (Figure 2A-C). Left-ventricular hypertrophy and diastolic ventricular dysfunction indicated cardiac involvement. A detailed laboratory investigation and cerebrospinal fluid (CSF) analysis were unrevealing. The patient had an unrevealing cardiovascular risk profile and no evidence of extracerebral arteriopathy, vasculitis or other inflammatory disease. Since further investigations revealed no evidence for common causes of SFN, the patient was tested for FD. Direct GLA sequencing revealed -10T heterozygosity in the 5′-UTR in a haplotype with the three intronic variants (IVS2-81_-77delCAGCC, IVS4-16A>G and IVS6-22C>T). No other mutation within the GLA coding region or exon-intron boundaries was found (Table 1, Additional file 1: Table S1). Since several reports existed on -10T heterozygosity and Fabry-typical manifestations [4–6] we retrospectively analyzed additional 14 -10T allele carriers (44.4 [12–72] years of age) from our database (Figure 1, Tables 1 and 2, Additional file 1: Table S1). Out of 15 -10T carriers 13 presented with neuropathic pain (symptom onset: patients #3-7 and #9-11 in childhood; #2 at 20 and #8 at 40 years of age) and/or cerebrovascular manifestations such as WML, TIA or stroke (Table 1). Blood count (including total leukocyte count), renal and liver function tests as well as homocysteine level and angiotensin-converting enzyme were normal. Serum antibodies against thyroid peroxidase, thyreoglobulin, glutamic acid decarboxylase, and onconeural antibodies (anti-amphiphysin, anti-Ri, anti-Yo, anti-Hu, anti-CV2/CRMP5, anti-Ma2/Ta, anti-NMDA, LGI-1, GAD) as well as anti-cardiolipin immunoglobulin were all negative. A screen for antibodies against extractable nuclear and anti-nuclear antigens was also negative. No patient had evidence of an inflammatory disease since serological testing excluded borreliosis, syphilis and HIV-1 infection. Cerebral MR-angiography was obtained in all patients with WML and showed no evidence of vasculitis. Sonography of the extracranial vessels were performed in all patients with stroke/TIA or WML (patients #1; #7; #8; #10-13) and showed no severe arteriopathy. Further examination revealed no evidence for common causes of SFN since blood glucose and hemoglobin A1c levels, blood count including total leukocyte count, c-reactive protein, thyroid and liver parameters, vitamins B1, B6, B12 and homocysteine levels, serum protein and immunoelectrophoresis were normal. CSF analyses were obtained in patients #1, #2, #8, and #11-13 and showed unrevealing results. Since CSF analyses were not performed in all patients, we could not definitively exclude inflammatory disease. However, no patient fulfilled the diagnostic criteria of primary vasculitis of the CNS or multiple sclerosis, regardless of CSF analysis results. Furthermore, the course of the disease and the additional diagnostic results did not agree with this diagnosis. All patients who presented with WML or stroke/TIA were non-smokers. Except for patients #8 and #12 who presented with well-controlled arterial hypertension, the remaining patients with stroke/TIA or WML had normal blood pressure. Only patient #6 was consecutively diagnosed with type 2 diabetes mellitus. Fabry-typical manifestations such as hypohidrosis, angiokeratoma, severe gastrointestinal disturbances and tinnitus were also observed (Additional file 1: Table S1), while only two patients presented renal manifestations.Table 1

Bottom Line: Patients' mean GLA mRNA expression level was reduced to ~70% (p < 0.0001) and a dose-dependent effect of the -10T allele on GLA mRNA expression was observed in hemi/homozygous compared to heterozygous patients (p < 0.0001).Molecular analyzes revealed that the -10T allele resulted in a reduced promoter activity and an altered transcription factor binding, while a functional relevance of the co-segregated intronic variants was excluded by exon trapping.Based on this complementary approach of clinical observation and functional testing, we conclude that the GLA -10T allele could be causal for the observed neurological manifestations.

View Article: PubMed Central - PubMed

Affiliation: Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany. Michael.Schelleckes@ukmuenster.de.

ABSTRACT

Background: Fabry disease (FD) is a multisystemic disorder with typical neurological manifestations such as stroke and small fiber neuropathy (SFN), caused by mutations of the alpha-galactosidase A (GLA) gene. We analyzed 15 patients carrying the GLA haplotype -10C>T [rs2071225], IVS2-81_-77delCAGCC [rs5903184], IVS4-16A>G [rs2071397], and IVS6-22C>T [rs2071228] for potential neurological manifestations.

Methods and results: Patients were retrospectively analyzed for stroke, transient ischemic attack (TIA), white matter lesions (WML) and SFN with neuropathic pain. Functional impact of the haplotype was determined by molecular genetic methods including real-time PCR, exon trapping, promoter deletion constructs and electrophoretic mobility shift assays. Symptomatic -10T allele carriers suffered from stroke, TIA, WML, and SFN with neuropathic pain. Patients' mean GLA mRNA expression level was reduced to ~70% (p < 0.0001) and a dose-dependent effect of the -10T allele on GLA mRNA expression was observed in hemi/homozygous compared to heterozygous patients (p < 0.0001). Molecular analyzes revealed that the -10T allele resulted in a reduced promoter activity and an altered transcription factor binding, while a functional relevance of the co-segregated intronic variants was excluded by exon trapping.

Conclusions: Based on this complementary approach of clinical observation and functional testing, we conclude that the GLA -10T allele could be causal for the observed neurological manifestations. Future studies are needed to clarify whether affected patients benefit from GLA enzyme replacement therapy for end-organ damage prevention.

Show MeSH
Related in: MedlinePlus