PEHO syndrome caused by compound heterozygote variants in ZNHIT3 gene.

PEHO syndrome is characterized by Progressive Encephalopathy with Edema, Hypsarrhythmia, and Optic atrophy, which was first described in Finnish patients. A homozygous missense substitution p.Ser31Leu in ZNHIT3 was recently identified as the primary cause of PEHO syndrome in Finland. Variants in ZNHIT3 have not been identified in patients with PEHO or PEHO-like syndrome in other populations. It has therefore been suggested that PEHO syndrome caused by ZNHIT3 variants does not occur outside of the Finnish population. We describe the first patient outside Finland who carries compound heterozygous variants in ZNHIT3 gene causing PEHO syndrome. Trio genome sequencing was carried out and the identified variants were confirmed by Sanger sequencing. The patient filled all diagnostic clinical criteria of PEHO syndrome. We identified biallelic missense variants in ZNHIT3 gene: the c.92C > T p.(Ser31Leu) variant (NM_004773.3), which is described previously as causing PEHO syndrome and the second novel variant c.41G > T p.(Cys14Phe). There are only eight heterozygous carriers of c.41G > T variant in the gnomAD database and it is predicted damaging by multiple in silico algorithms. The ZNHIT3-associated PEHO syndrome exists outside of the Finnish population.

Genetic manipulation for inherited neurodegenerative diseases: myth or reality?

Rare genetic diseases affect about 7% of the general population and over 7000 distinct clinical syndromes have been described with the majority being due to single gene defects. This review will provide a critical overview of genetic strategies that are being pioneered to halt or reverse disease progression in inherited neurodegenerative diseases. This field of research covers a vast area and only the most promising treatment paradigms will be discussed with a particular focus on inherited eye diseases, which have paved the way for innovative gene therapy paradigms, and mitochondrial diseases, which are currently generating a lot of debate centred on the bioethics of germline manipulation.

RNA-binding proteins in neurodegenerative disease: TDP-43 and beyond.

Neurodegenerative diseases are a diverse group of disorders that affect different neuron populations, differ in onset and severity, and can be either inherited or sporadic. One common pathological feature of most of these diseases is the presence of insoluble inclusions in and around neurons, which largely consist of misfolded and aggregated protein. For this reason, neurodegenerative diseases are typically thought to be disorders of aberrant protein processing, in which the cumulative effects of misfolded protein aggregates overwhelm the neuron's proteostatic capacity. However, a growing body of evidence suggests a role for abnormal RNA processing in neurodegenerative disease. The importance of RNA metabolism in disease was highlighted by the discovery of TDP-43 (TAR DNA-binding protein of 43 kDa), an RNA-binding protein (RBP), as a primary component of insoluble aggregates in patients with sporadic amyotrophic lateral sclerosis (ALS). Subsequently, inherited mutations in TDP-43 and the structurally related RBP, FUS/TLS (fused in sarcoma/translated in liposarcoma), were found to cause ALS. These exciting findings have ushered in a new era of ALS research in which the deregulation of RNA metabolism is viewed as a central cause of motor neuron deterioration. In addition, the fact that neuropathologically and anatomically distinct neurodegenerative diseases display altered RNA metabolism suggests that common pathologic mechanisms may underlie many of these disorders.

Neurodegeneration in D-bifunctional protein deficiency: diagnostic clues and natural history using serial magnetic resonance imaging.

We report serial neurodegenerative changes on neuroimaging in a rare peroxisomal disease called D-bifunctional protein deficiency. The pattern of posterior to anterior demyelination with white matter disease resembles X-linked adrenoleukodystrophy. We feel this case is important to (1) highlight that D-bifunctional protein deficiency should be considered in cases where the neuroimaging resembles X-linked adrenoleukodystrophy, (2) to show different stages of progression to help identify this disease using neuroimaging in children, and (3) to show that neuroimaging suggesting a leukodystrophy can warrant peroxisomal beta-oxidation studies in skin fibroblasts even when plasma very long chain fatty acids are normal.

[An economic consideration of the lower respiratory tract infection treatment in children with severe neurodegradative diseases under the hospice care]. / Ekonomiczny aspekt leczenia zakazen dolnego ukladu oddechowego u dzieci z ciezkimi schorzeniami neurodegradacyjnymi objetych domowa opieka hospicyjna.

Congenital and acquired neurodegradative diseases are always the reason for prolonged stay in hospital, at the beginning of the establishment of diagnosis and treatment and afterwards for stabilizing all functional adaptation to an existence with the severe disability. Also infections of the lower respiratory tract accompanying the later course of the disease are usually directed to hospital treatment. The aim of the study was to delineate the role of hospice care of patients staying at home, in economical approach to the medical care of severly and incurably ill children. The study group consisted of 29 children with neurodegradative diseases, aged 6 months to 18 years, admitted to the home care of Priest Józef Tischner Cracovian Children' Hospice. The costs of yearly treatment (based on 2008 data) of the infections of the lower airways in the studied group, performed at home under the hospice care and in hospital, were compared. The actual expenses of home treatment were counted. Considering the hospital therapy costs, the simulation was performed following median expenses of a 10-day-treatment of a 20 kg-in-weight child with uncomplicated lower respiratory tract infection in pediatric department with the use of the first line therapy antibiotic. Three parameters were taken to calculations: the medical care costs, the expenses of laboratory tests and X-ray pictures and the costs of antibiotics. In studied children 61 cases of lower respiratory tract infections were diagnosed in 2008 (the median incidence was 2,1 per year; ranged 0-7), of which 48 cases were treated at home. The median time of antibiotics administration in home treatment was 13 days. In 31% of infections more than one antibiotic was used. In 19% of cases in home therapy parenteral medicine was necessary. The median summarized cost of treat- ment at home was calculated as 2657 zl. The need for hospital care in our group concerned 13 incidences. The median estimated cost of treatment of the lower airways infection in hospital for one child equaled 4942 zl. The expenses of home treatment of the lower airways infections under the hospice care were twice lower than the costs of the therapy in hospital. Apart from the obvious psychological and social benefits, also economic aspect contributes to the promotion of the hospice care of staying-at-home patient in the improvement of medical care for children with severe neurodegradative diseases.

Is prophylactic fundoplication necessary in neurologically impaired children?

BACKGROUND: Previously, concomitant antireflux surgery was performed in all neurologically impaired children undergoing gastrostomy tube placement in our department. This fundoplication procedure, not necessarily performed for symptomatic gastroesophageal reflux, increased the postoperative complications. This practice was changed and fundoplication was offered to only those children who had clear surgical indications for an antireflux procedure on follow-up after a feeding gastrostomy. METHODS: In the period from 1996 to 2007, all children who underwent gastrostomy with fundoplication were compared with those in whom feeding gastrostomy alone was done. The clinical symptoms, investigations and indications for gastrostomy and fundoplication were recorded. The children who underwent gastrostomy were followed up for symptoms of gastroesophageal reflux and the need for subsequent fundoplication was studied. The complications directly related to surgery were also studied and statistically analyzed. RESULTS: A total of 137 children had gastrostomy insertion, 60 of whom underwent fundoplication. Of these 60 children, 45 had concomitant fundoplication and gastrostomy. In the patients who had gastrostomy alone, a subsequent fundoplication procedure was required only in 17.1% (14 of 82). The complication rate as well as the severity of complications directly related to surgery was found to be higher in the gastrostomy+fundoplication group (18 of 60) compared with those who had only gastrostomy (12 of 82) (p=0.036). CONCLUSION: Prophylactic fundoplication may not be necessary in neurologically impaired children undergoing gastrostomy for feeding purposes. It increases the postoperative morbidity compared to gastrostomy alone in this group of children. It should be offered selectively to children continuing to have reflux-related complications after gastrostomy. The technical difficulties with a pre-existing gastrostomy can be overcome in the hands of experienced laparoscopic surgeons.

Familial microhydranencephaly, a family that does not map to 16p13.13-p12.2: relationship with hereditary fetal brain degeneration and fetal brain disruption sequence.

Microhydranencephaly (MHAC) is a serious developmental brain anomaly characterized by microcephaly with severe reduction of brain hemispheres and intracranial space filled with cerebrospinal fluid without signs of intracranial hypertension. Clinical findings are very similar to fetal brain disruption sequence - severe microcephaly, scalp rugae, and profound developmental delay; however, although fetal brain disruption sequence is a sporadic condition caused by an external disruptive event, familial cases of MHAC presumably result from a process of progressive brain damage also termed as 'hereditary fetal brain degeneration'. Familial occurrence of this phenotype is very rare - only three reports on four families have been published so far. Here we present two new patients - affected brothers from Slovakia - and provide an update on a previously described case from a Turkish Anatolian family. We also present data excluding linkage to an MHAC locus 16p13.13-p12.2 in the Slovak family. We compare clinical and imaging findings in all five families and suggest genetic heterogeneity for this condition. In genetic counseling for this phenotype, especially in the absence of any known teratogenic factors in pregnancy, we suggest that the possibility of recurrence should be considered.

Severe form of congenital cerebral and cerebellar atrophy: a neurodegenerative disorder of fetal onset.

Infantile olivopontocerebellar atrophy (OPCA) is a rare congenital disorder likely due to an intrauterine neurodegenerative condition. Characteristic presentations are failure to thrive, cerebellar ataxia, respiratory insufficiency, and hypotonia or hypertonia. A few cases with severe manifestations (eg, the Pena-Shokeir phenotype) presenting in the neonatal period have also been reported. We present a case of infantile OPCA with the Pena-Shokeir II phenotype and severe atrophy of the cerebellum and cerebral hemispheres. Comparison of prenatal sonographic findings of the fetal brain at 30 weeks' menstrual age and CT findings during the neonatal period indicated prenatal onset of the neurodegenerative process, which progressed rapidly during the last trimester.

Mutations linked to leukoencephalopathy with vanishing white matter impair the function of the eukaryotic initiation factor 2B complex in diverse ways.

Leukoencephalopathy with vanishing white matter (VWM) is a severe inherited human neurodegenerative disorder that is caused by mutations in the genes for the subunits of eukaryotic initiation factor 2B (eIF2B), a heteropentameric guanine nucleotide exchange factor that regulates both global and mRNA-specific translation. Marked variability is evident in the clinical severity and time course of VWM in patients. Here we have studied the effects of VWM mutations on the function of human eIF2B. All the mutations tested cause partial loss of activity. Frameshift mutations in genes for eIF2Bepsilon or eIF2Bbeta lead to truncated polypeptides that fail to form complexes with the other subunits and are effectively null mutations. Certain point mutations also impair the ability of eIF2Bbeta or -epsilon to form eIF2B holocomplexes and also diminish the intrinsic nucleotide exchange activity of eIF2B. A point mutation in the catalytic domain of eIF2Bepsilon impairs its ability to bind the substrate, while two mutations in eIF2Bbeta actually enhance eIF2 binding. We provide evidence that expression of VWM mutant eIF2B may enhance the translation of specific mRNAs. The variability of the clinical phenotype in VWM may reflect the multiple ways in which VWM mutations affect eIF2B function.

Neurodegenerative disease in infants with multiple congenital malformations--report of two cases.

During embryogenesis, about 40% of genes are involved in the development of the central nervous system (CNS). The same genes support the integrity and function of brain cells in humans. Birth defects cause different changes in genetic material during embryogenesis. They may also be responsible for precocious death of cells in postnatal period. We studied cases of two infants with similar congenital defects (prenatal onset growth deficiency, coloboma of iris, epicanthal folds, low set ears, clinodactyly of Vth fingers). The infants died at age 9 and 10 months with signs and symptoms of progressive CNS degeneration. In one case, chromosomal aberration was detected (4pter). Neuropathologicaly, there were small for the age brains, atrophy of cerebral cortex, white matter and basal ganglia (mainly nucleus caudatus) with loss of neurones, spongiosis and hypertrophic astroglia reaction as well as atrophy of cerebellar cortex. Severe damage of white matter was seen. We suggest that such cases are natural models for investigations of the role of genes in embryogenesis and pathogenesis of neurodegenerative diseases.

Alexander's disease in a neurologically normal child: a case report.

We report the clinical and MRI findings of symmetric hyperintensity involving the deep and subcortical white matter of the frontal lobes in a neurologically normal child with macrocephaly. In this patient, a serum test for mutations in glial fibrillary acidic protein, used to diagnose Alexander's disease (AD), was positive. This case indicates an extraordinarily mild or early form of juvenile-onset AD.

Neurodegenerative features in developmental brain disorders.

The authors examined the occurrence of neurofibrillary tangles (NFT), senile plaques, spheroids in Goll's nucleus, grumose or foamy spheroid bodies (GFSB) in the basal ganglia, and hyaline inclusions in the brainstem nuclei in 62 patients under 40 years of age with non-progressive developmental brain disorders. Five cases had demonstrated NFT, which tended to be confined to the subcortical nuclei, whereas no senile plaques were identified in any case. Spheroids in Goll's nucleus were significantly increased in three cases of congenital brain anomalies and five cases of perinatal hypoxic ischemic encephalopathy. The GFSB-positive subjects were clinicopathologically divided into two subgroups consisting of four cases of congenital malformations, which were also associated with severe respiratory failure, and six cases of perinatal brain disorders in which the basal ganglia were severely affected. Eosinophilic intracytoplasmic inclusions, unlike the hyaline inclusions of the Lewy type, were found in the substantia nigra and/or locus ceruleus in two subjects. It is speculated that a variety of mechanisms, including accelerated aging and anoxic insults, may be involved in the increased occurrence of NFT and/or spheroids in non-progressive developmental disorders. A detailed investigation is useful to clarify the neuronal changes secondary to the brain damages early in development.

[MRI in the diagnosis of congenital white matter diseases and other neurodegenerative diseases]. / Wartosc rezonansu magnetycznego w diagnostyce wrodzonych chorób istoty bialej i innych zwyrodnieniowych chorób osrodkowego ukladu nerwowego.

The results of cranial magnetic resonance imaging in 76 children (aged 3 weeks--17 years) with neurometabolic or other neurodegenerative diseases are presented. The number of diagnosed diseases was 22. MR symptomatology of 11 of them is presented. The list of characteristic images includes metachromatic leukodystrophy, mucopolysaccharidoses, X-linked adrenoleukodystrophy, Leigh, Menkes and Pelizaeus-Merzbacher diseases, glutaric aciduria type I, Canavan disease, neuronal ceroid lipofuscinosis, Hallervorden-Spatz and Huntington diseases. The diagnosis of neurometabolic/neurodegenerative diseases cannot be based on MRI alone but in some of them (metachromatic leukodystrophy, adrenoleukodystrophy, Leigh and Menkes diseases, glutaric aciduria type I, Canavan and Hallervorden-Spatz diseases) MRI can strongly suggest the diagnosis.