A case of ovarioleukodystrophy without eIF2B mutations

Journal of the Neurological Sciences 268 (2008) 183 – 186 www.elsevier.com/locate/jns

Short communication

A case of ovarioleukodystrophy without eIF2B mutations Carmen Gaudiano, Carol Di Perri, Ornella Scali, Alessandra Rufa, Carla Battisti, Nicola De Stefano, Antonio Federico ⁎ Department of Neurological and Behavioural Sciences, University of Siena, Italy Received 4 July 2007; received in revised form 7 September 2007; accepted 29 October 2007 Available online 3 December 2007

Abstract A new association of Vanishing White Matter (VWM) and premature ovarian failure (POF) was recently described as a sole entity called ovarioleukodystrophy. Seven out of eight patients reported by Fogli et al. had translation initiation factor (eIF2B) mutations, specific to the VWM. The only patient without mutations had a distinctive neurological presentation that included cognitive deterioration without motor signs and white matter abnormalities restricted to the frontal lobe. We describe here a case suggestive of ovarioleukodistrophy carrying no eIF2B mutations. © 2007 Elsevier B.V. All rights reserved. Keywords: Ovarioleukodystrophy; eIF2B mutations; Genetic heterogeneity

1. Introduction Ovarian failure (OF) is defined as primary amenorrhea or as secondary amenorrhea lasting N6 months, associated with elevated gonadotrophin levels at age b40 years. Premature OF affects 1% of all women and occurs in 0.1% of cases at age b 30 years [1]. Besides kariotype abnormalities, very few genes are known to be associated with this ovarian dysfunction. A recent report [2] has described four patients with the unusual association of Ovarian failure (OF) with white matter (WM) abnormalities observed in cerebral MRI suggestive of Vanishing White Matter disease (VWM) [3,4], this entity was termed “ovarioleukodystrophy” [2]. As the VWM [5], this condition was found to be related to eIF2B mutations [1], suggesting a common pathophysiological mechanism between the two disease entities.

⁎ Corresponding author. Neurometabolic Unit, Department of Neurological and Behavioral Sciences, University of Siena, Viale Bracci 2, 53100 Siena, Italy. Tel.: +39 577 585760; fax: +39 577 40327. E-mail address: [email protected] (A. Federico). 0022-510X/$ - see front matter © 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.jns.2007.10.027

Here we report on a patient with premature ovarian failure (POF) and leukodystrophy (LD) of unknown cause (ovarioleukodystrophy), who did not carry any eIF2B mutation. 2. Case report The patient was 34 years old when she was admitted to our department in November 2001. She was the 3rd child of 6 sisters and 1 brother of non-consanguineous parents. At the family history, it is relevant that one sister had amenorrhea (only one menstrual episode when she was 12), gait impairment and cognitive deterioration since the age of 25 years, diffuse WM abnormalities on brain MRI. She died at the age of 30 years for bronchopneumonia. In our patient, no complications during pregnancy and after delivery were reported. She had menarche at 12 years and regular periods until the age of 22 years, when she could have menstruation only with estro-progestinic treatment. Her initial mental and motor development was normal. At age 32 she presented depression and attention impairment. One year later she gradually developed progressive spastic tetraparesis and cognitive impairment. At presentation, her neurological exam showed severe dysphagia, anarthria, brisk deep reflexes of

184

C. Gaudiano et al. / Journal of the Neurological Sciences 268 (2008) 183–186

all limbs, more pronounced on the left side, and bilateral Babinski sign. The neuropsychological assessment showed severe cognitive impairment. Routine blood and urine exams, pyruvate, lactate, very long chain fatty acids, urinary oligosaccharides, sulfatides, amino acids, glycosilation of serum transferring (to rule out carbohydrate-deficient glycoprotein syndrome), lysosomial enzymes (galactocerebrosidase, α-mannosidase, α-β galactosidase, hexosaminidase A and B, α-fucosidase, β-glucuronidase, arysulfatase A) were normal. Serum levels of ACTH, thyroid hormones and beta-HCG were also normal. Serum HIV and Lues markers were negative. Serum levels of LH, FSH, estradiol, progesterone and prolactine were suggestive of a menopausal condition (Table 1). Routine CSF exams and the assessment of neurotropic viruses, HIV and Lues markers in CSF were negative. Neurophtalmological examination indicated bilateral optic atrophy. EMG and nerve conduction velocity were normal. EEG showed irregular electrical activity especially in the right temporal region. Pelvic ultrasonography showed hypoplasic uterus and ovaries. 2.1. Genetic test Following informed consent, total genomic DNA was extracted from peripheral blood using a QIAamp DNA blood kit (QIAGEN, Germany). The 57 exons and flanking intronic DNA of the EIF2B1, EIF2B2, EIF2B3, EIF2B4, EIF2B5 genes were amplified by PCR and the products were sequenced in both forward and reverse directions by automated sequencing. PCR was performed with primers (including intron–exon boundaries) specific for exons of the eIF2B genes. Primers reference sequences codes used, published on Pub-Med, are: GeneBank NM_001414 for EIF2B1; NM_014239 for EIF2B2; NM_020365 for EIF2B3; NM_015636 for EIF2B4; NM_003907 for EIF2B5. Table 1 Blood exams

Serum levels

Normal value

LH

28,4 mUI/ml

FSH

98,7 mUI/ml

Estradiol

24 pg/ml

Progesteron

0,29 ng/ml

Prolactine

776.6 uUI/ml

Fol.p.1.9–12.5 Ov.p. 8.7–76.3 Lut.p. 0.5–16.9 preg. b 1.4 p men. 15.9–54 Fol.p. 2.5–10.2 Ov.p. 3.4–33.4 Lut p. 1.5–9.1 preg. b 0.9, p.men. 23–116 Fol p. 30–160, Lut.p. 30–190, p.men. b 40 Fol.p. 0.2–1.3, Lut.p. 3.3–25, p.men. b 0.6 100.0–450.50

Fol.p. = follicular phase; Ov.p. = ovulation phase, Lut.p. = luteal phase; preg. = pregnancy; p. men = post menopause.

PCR reactions were performed in 25 μl reaction volumes containing 100 ng genomic DNA, 10 pmol forward and reverse primers, 100 mM dNTPs, 1U DNA polymerase (Red Hot DNA polymerase; ABgene, UK), 1.5 mM MgSO4, 1 × Reation Buffer, using a DNA thermal cycler (PTC-200; MJ Research, MA). The mixtures were amplified with annealing temperature for each primer couple. Following purification of PCR products, sequencing was performed using the automated sequencer ABI 3730 (Applied Biosystems, CA). Analysed sequences were compared with reference NCBI data. No mutations in the 5 genes encoding for the 5 subunits of eIF2B were identified. 2.2. Proton MRI and MR spectroscopic imaging The patient underwent combined brain proton MRI and MR spectroscopic imaging (1H-MRSI) examination using a Philips Gyroscan NT system operating at 1.5 T (Philips Medical Systems, Best, The Netherlands). Multislice spinecho (TR = 2151 ms; TE = 20,90 ms; slice thickness 3 mm), FLAIR (TR = 9000 ms; TE = 150 ms; slice thickness 3 mm) and T1-weighted (TR/TE = 35 ms/10, slice thickness 3 mm) images were obtained in the transverse plan parallel to the anterior–posterior commissure line The MR images were used to position an intracranial volume of interest (VOI) for spectroscopy, which was centered on the corpus callosum to include mostly WM of both hemispheres. The VOI measured 80 mm anteroposterior × 20 mm craniocaudal × 95 mm left–right. Two-dimensional spectroscopic imaging was obtained by using a PRESS sequence for volume selection (TR = 2000 ms, TE 272 ms, 250 × 250 mm field of view, 32 × 32 phase encoding steps, 1 signal average per step) as previously described [6]. Raw data were then post-processed as previously described [6]. The minimal voxel size was 8 × 8 × 20 mm, giving a resolution of about 12 × 12 × 20 mm after k-space filtering. Chemical shifts were calculated relative to the resonance intensities of N-acetylaspartate resonance at 2.02 ppm. Conventional brain MRI examination showed a severe leukoencephalopathy with symmetrical, diffuse signal alteration in the periventricular and deep WM of both hemispheres, severe atrophy and less severe in the abnormalities of the basal ganglia (see Fig. 1A). 1H-MRSI examination showed a bilateral, severe loss of signal in the cerebral WM of all the metabolites normally detected with this 1H-MRSI method (i.e., choline, creatine and N-acetylaspartate). In contrast, the resonance intensities of lactate, undetectable in normal condition using this method, were diffusely increased (see Fig. 1B). 3. Discussion We reported a case suggestive of secondary OF associated with normal anterior pituitary function and neuroimaging evidence of a leukoencephalopathy. Primary and secondary

C. Gaudiano et al. / Journal of the Neurological Sciences 268 (2008) 183–186

185

Fig. 1. A. Conventional FLAIR (top) and T1-weighted (bottom) MR images on transversal orientation relative to the patient with ovarioleukodystrophy. The MR images show diffuse white matter abnormalities (increase signal intensity in FLAIR images and decreased signal on T1-weighted images), diffuse cortical and subcortical atrophy. FLAIR images show also a milder hypointense of both thalami. On FLAIR images, note the low signal intensity in the deep anterior and posterior WM suggestive of intense WM damage and rarefaction. B. Conventional MRI image of the patient and proton MR spectra from voxels located in the deep white matter of both hemispheres. Note the homogeneous loss of resonance signals throughout the WM, with more pronounced decreases of Nacetylaspartate and large increases of lactate. A spectrum of the brain white matter of an adult normal control is shown for comparison. In the figure: Cho = choline, Cr = creatine, NAA = N-acetylaspartate, Lac = lactate.

186

C. Gaudiano et al. / Journal of the Neurological Sciences 268 (2008) 183–186

OF have been described in association with leukoencephalopathy in a syndrome known as ovarioleukodystrophy [2], which has been recently associated with eIF2B mutations [1]. The clinical features of our patient were similar to those of the ovarioleukodystrophy patient described previously [1,2]. Secondary OF, with a normal anteriory pituitary functions, supported by clinical and laboratory evidences, was associated with a progressive cognitive, bulbar and appendicular motor dysfunction. Episodic acute exacerbations of neurological dysfunction, common of the disease [5,7], were not seen in our patient. Laboratory tests excluded other causes of leukoencephalopathies such as lysosomial, peroxisomal, infective diseases. Conventional brain MRI showed diffuse abnormalities in the cerebral WM (decreased signal on T1-weighted images and corresponding increase signal intensity in FLAIR images, see Fig. 1A) and atrophy consistent with the pattern described in VWM/CACH [8]. Also the milder signal abnormalities found in the basal ganglia (i.e, hypointense were present in the thalamus) can be more rarely seen in VWM/CACH or in some phenotypic variation of the diseases [9]. No brain cysts were seen, but FLAIR images showed, in association with WM abnormalities, low signal intensity in the deep anterior and posterior WM that likely represents the initial evidence of progressive rarefaction of the WM leading to cystic degeneration. In any case, brain cysts might not be present in some cases [4] and their absence cannot exclude the diagnosis [1,7]. In addition, consistently with VWM diagnosis, 1H-MRSI showed diffuse reduction of all metabolites and increase of lactate [3] (see Fig. 1B). The presence of parenchymal lactate signal, undetectable in normal condition using this method, may raise the doubt of the presence of mitochondrial impairment in the brain of this patient [10]. However, the diffuse and large decrease of all other metabolite resonance intensities (i.e., choline, creatine and N-acetylaspartate) with some increases in lactate in the cerebral WM configure a 1H-MRSI pattern usually found in VWM/CACH and suggestive of the WM rarefaction. The inheritance of this disease appeared to be recessive. Cases of typical clinical and MRI features of VWM in the absence of eIF2B mutations have been recently described [11] suggesting a genetic heterogeneity. A case of ovarioleukodystrophy without eIF2B mutations has also been recently described [1] but in that case the only patient (one out of eight) without identified eIF2B mutations had a distinctive neurological presentation that included cognitive deterioration without motor signs and WM abnormalities restricted to the frontal lobes [1]. Although eIF2B mutations appear to be correlated to ovarioleukodystrophy, they seem to be absent in women with premature OF, as reported in a recent study [12], suggesting that eIF2B mutations are an uncommon cause of pure spontaneous premature ovarian failure, and therefore they may play a role in OF only when associated with CACH/VWM.

Our reported case, presenting a phenotype suggestive of ovarioleukodystrophy carrying no eIF2B mutations, provides evidence for the presence of a genetic heterogeneity in this disease and therefore the possibility of either mutations in promoter regions of EIF2B genes (EIF2B1, EIF2B2, EIF2B3, EIF2B4, EIF2B5) or the involvement of other yet to be discovered genes in this myelin disorder associated with OF. Further studies are necessary to elucidate additional genes involved in this myelin disorder. Acknowledgements Research in part supported by Ministery of Health, Regione Toscana and Monte dei Paschi di Siena to AF.

References [1] Fogli A, Rodriguez D, Eymard-Pierre E, Bouhour F, Labauge P, Meaney BF, et al. Ovarian failure related to eukaryotic initiation factor 2B mutations. Am J Hum Genet 2003;72(6):1544–50. [2] Schiffmann R, Tedeschi G, Kinkel RP, Trapp BD, Frank JA, Kaneski CR, et al. Leukodystrophy in patients with ovarian dysgenesis. Ann Neurol 1997;41(5):654–61. [3] van der Knaap MS, Barth PG, Gabreels FJ, Franzoni E, Begeer JH, Stroink H, et al. A new leukoencephalopathy with vanishing white matter. Neurology 1997;48(4):845–55. [4] Schiffmann R, Moller JR, Trapp BD, Shih HH, Farrer RG, Katz DA, et al. Childhood ataxia with diffuse central nervous system hypomyelination. Ann Neurol 1994;35(3):331–40. [5] van der Knaap MS, Leegwater PA, Konst AA, Visser A, Naidu S, Oudejans CB, et al. Mutations in each of the five subunits of translation initiation factor eIF2B can cause leukoencephalopathy with vanishing white matter. Ann Neurol 2002;51(2):264–70. [6] De Stefano N, Narayanan S, Francis GS, Arnaoutelis R, Tartaglia MC, Antel JP, et al. Evidence of axonal damage in the early stages of multiple sclerosis and its relevance to disability. Arch Neurol 2001;58(1):65–70. [7] Federico A, Scali O, Stromillo ML, Di Perri C, Bianchi S, Sicurelli F, et al. Peripheral neuropathy in vanishing white matter disease with a novel EIF2B5 mutation. Neurology 2006;67(2):353–5. [8] van der Knaap MS, Pronk JC, Scheper GC. Vanishing white matter disease. Lancet Neurol 2006;5(5):413–23. [9] van der Knaap MS, Kamphorst W, Barth PG, Kraaijeveld CL, Gut E, Valk J. Phenotypic variation in leukoencephalopathy with vanishing white matter. Neurology 1998;51(2):540–7. [10] Linnankivi T, Lundbom N, Autti T, Hakkinen AM, Koillinen H, Kuusi T, et al. Five new cases of a recently described leukoencephalopathy with high brain lactate. Neurology 2004;63(4):688–92. [11] Labauge P, Gelot A, Fogli A, Boespflug–Tanguy O, Rodriguez D. Autosomal dominant leukodystrophy and childhood ataxia with nervous system hypomyelination syndrome. Ann Neurol 2006;60(4):485. [12] Fogli A, Gauthier-Barichard F, Schiffmann R, Vanderhoof VH, Bakalov VK, Nelson LM, et al. Screening for known mutations in EIF2B genes in a large panel of patients with premature ovarian failure. BMC Womens Health 2004;4(1):8.