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Menkes' kinky hair disease. II. A clinicopathological report of three cases
Menkes' Kinky Hair Disease. II. A Clinicopathological Report of Three Cases Dirk Troost, MD, Adriaan van Rossum, MD, Will em Straks, MD and Jacobus Willemse, MD
The neuropathologic abnormalities in three new cases of Menkes' kinky hair disease are described. Principally the three cases were the same. Hypoplasia of the cerebellum, with a basal arachnoidal cyst, was present in all three cases. The cysts were not described before in Menkes' disease. There was nerve cell loss and gliosis in the cerebral cortex, cerebellum and thalamus. The reduction of myelinated axons was widespread and the disease does not belong to the leukodystrophies. Cortical lamination disturbances were present indicating that the disease develops as early as the sixth fetal month. Abnormal arborization of Purkinje cells with swelling of dendrites was present and thought not to be identical with the Purkinje cell abnormalities seen in amaurotic idiocy. The difference in severity of the copper deficiency in 2 patients is compared with the situation in "brindled" and "blotchy" mutant mice. Troost D, van Rossum A, Straks W, Willemse J. Menkes' kinky hair disease. II. A clinicopathological report of three cases. Brain Dev 1982;4: 115-26
In 1962, Menkes et a1 [1] described a sexlinked recessive heredodegenerative disorder characterized by mental retardation, retardation of growth, peculiar hair growth, focal cerebral degeneration and also cerebellar degeneration. Several clinicopathological and biochemical reports have been published since [2-7]. Danks et al [8] suggested that the patients, From the Department of Neuropathology - Neurological Clinic (DT, AvR), Department of Child Neurology (JW), Pathological Institute (WS); University of Utrecht, Utrecht, The Netherlands. Received for publication: July 29, 1981. Accepted for publication: January 22, 1982.
Key words: Menkes' disease. kinky hair disease. Xchromosome-linked copper malabsorption (X. cLeM). Purkinje cell. Correspondence address: Dr. Dirk Troost, Department of Neuropathology - Neurological Clinic, Nicolaas Beetsstraat 24, Utrecht, The Netherlands.
described by Menkes et al [1], suffered from copper deficiency resulting from impaired intestinal absorption of alimentary copper. Purpura et al [9], Hirano et al [10] and Iwata et al [11, 12] studied in particular the pathology of the diseased areas of the cerebral cortex, cerebellum and thalamus. Thus, far 20 case reports, including pathological findings, have been reported. In this paper we want to add three more case reports. These are of special interest, because of the sequence of ages they present. The combined reports presented an opportunity to study the development of the pathological features of the disease. Some of the pathological findings in these cases were not described for Menkes' disease before. Materials and Methods The brains of these boys of respective ages of 7 months, 57 months and 27 months were examined. After removal of parts of the right
frontal lobe and small parts of the basal ganglia and cerebellum for histochemistry and EM studies the three brains were fixed in 5% neutral buffered formaldehyde for at least 6 weeks. In all cases, paraffin, large celloidin and frozen sections were made for light microscopic studies and stained by the routine neuropathologic staining methods. Biopsies of the sural nerve , soleus muscle and jejunum were obtained during the life of patient 2 for electron microscopical study. Patient 1
Clinical Features Patient 1 was a male born on September 28, 1971 . Pregnancy and birth were uneventful. The birth weight was 3,000 gm. He was the sixth child of seven. At the age of 2 months he was admitted to a hospital, because of a generalized epileptic fit. In the course of the following months his mental and motor development appeared to be retarded . Focal neurological symptoms were not noted. On angiography generalized tortuosity of the cerebral vessels was found and considered to be related to a vascular disease. Extensive laboratory studies, including metabolic errors (copper excluded!), were negative. At the age of 7 months he died , some hours after admittance for pneumococcal meningitis. Autopsy Report (abstract) The significant findings were chronic bronchitis and an adrenal hemorrhage.
Neuropathological Findings The brain weighed 700 gm (normal weight for
the age = 767 gm [3]). The cisterns at the base of the brain were filled with creamy pus (which covered the blood vessels.) The cerebellum was hypoplastic in the medio-basal region and there was a basal retrocerebellar cyst. The aquaductus Sylvii was enlarged. There was no hydrocephalus.
Microscopy The entire leptomeninx showed the features of pyogenic meningitis. There was edema in the cortex. The nerve cells were normal. In the temporal and occipital lobes, there were light lamination .disturbances, sometimes with almost an allocortical structure (Fig 1). In these 116 Brain & Development, Vol 4. No 2, 1982
areas the cortex was very thin and consisted of four or five layers. In the deeper layers of such areas there were nerve .cells with abnormal polarity. In these regions there were also nerve cells scattered within the white matter and clusters of heterotopic nerve cells were also seen in the white matter. Lipid droplets and lipid laden macrophages were present around arterioles and veins in the subcortical white matter. The myelinization of the brain was normal for the age of 7 months. The corpus striatum was normal, except for the presence of a few calcospherites. In the thalamus there was a diffuse loss of nerve cells with many ghost cells and a light fibrillary gliosis. There were no lesions in the mesencephalon, pons or medulla oblongata, except for lipid droplets and lipid laden macrophages around arterioles and veins in the white matter. The cerebellum had a thin molecular layer still with a external granular layer. Some Purkinje cells in the molecular layer were heterotopic and others had double nuclei: (Fig 2). Swollen dendrites of Purkinje cells were clearly visible , but not in abundance. The weeping willow, or arcuate phenomenon was already present. There was occasional somal sprouting present. The Purkinje cell layer was irregular. The internal granular layer was atrophic. Axonal torpedoes of Purkinje cells were seldom seen. In the white matter of the cerebellum there was diffuse macroglial and microglial proliferation and the lipids described above. The nucleus dentatus was normal, except for the gliosis seen elsewhere in the white matter. Patient 2
Clinical Features Patient II was a male, the younger brother of patient I, the youngest child of seven, and born by normal delivery after a normal pregnancy. At birth he weighed 2,500 gm and was 49 cm in length. At the age of 2 weeks hypothermia was observed and he developed epileptic seizures, at first right-sided, in the following six weeks. Motor and mental development were normal initially, but from the age of 2 months his motor and mental states regressed rapidly to the neonatal level. A decerebrate state developed. Notwith-
Fig 1 Thin cortex with nerve cell loss in the third or fourth layer and a zone of irregularly placed neurons beneath it. KlUver x 30. Patient 1.
,
Fig 2 Purkinje cell in molecular layer. H-E x 315. Patient 1.
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standing frequent epileptic seizures of several types (tonic-clonic seizures, infantile spasms, epileptic states) the patient was stationary until death of pneumonia at the age of 57 months. Skeletal Muscle Biopsy A biopsy of the soleus muscle showed normally arranged myofilaments. A- and I-bands as well as the Z-membrane were normally demarcated. Some glycogen was present. Most of the mitochondria were enlarged and had irregular cristae arranged in a disorderly pattern (Fig 3). Mitochondria in surrounding connective tissue showed no abnormalities.
Peripheral Nerve Biopsy A biopsy of the sural nerve showed normal axonal structures and an intact myelin sheath. In the cytoplasm of the Schwann cell the number of lysosomes seemed to be increased. Jejunal Biopsy A jejunal biopsy showed normal microvilli. The epithelial lining showed no abnormalities, especially the mitochondria had a normal appearance. Autopsy Report (abstract) The only significant findings were liver congestion and chronic bronchitis.
Fig 3 Enlarged mitochondria with irregular cristae, arranged in a disorderly pattern. Patient 1.
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x
35,000.
Neuropathological Findings The brain weighed 882 gm (normal weight for the age = 1,216 gm [14 D. There was diffuse atrophy of the entire brain. The vessels were macroscopically normal. The left superior temporal gyrus was partly necrotic. The cerebellum was hypoplastic in the medio-basal region (Fig 4) and there was a basal retrocerebellar cyst. The corpus callosum was also hypoplastic. There was a hydrocephalus, but no obstructions were noted. There was severe atrophy of the thalamus on both sides. Microscopy There were no abnormalities in the leptomeninges of the cerebral hemispheres. The cortex showed normal lamination, but was still columnar. There was no degeneration of nerve cells. There was patchy edema of the deeper cortical layers. In the gyrus temporalis superior of the left temporal lobe there was a necrotic area. In both cortical parieto-occipital regions there were slight abbe rations in the normal lamination. More remarkable was the loss of nerve cells in the third and fourth layers and the reversal of polarity of nerve cells in the fifth and sixth cortical layers without reactive gliosis. In the subcortical white matter and within the centrum semiovale there were excessive numbers of heterotopic nerve cells. Glial nodules were found diffusely through the white and gray matter. Many thin-walled vessels were found in the
centrum semiovale and within the corpus striatum and there was a small capillary hemangioma in the left hemisphere. There were no lesions in the vessel walls. The internal, external and extreme capsules were normal. There was diffuse demyelinization in the centrum semiovale and the temporal and occipital lobes. Neither neutral lipids nor metachromasia were observed. The optic tract was normally myelinated. In the corpus striatum there was diffuse gliosis, but no obvious nerve cell loss. The thalamus was severely atrophied. There was loss of neurons, fibrous gliosis, myelin pallor and calcospherites, but the nuclei of the pars intralamellaris and pars paraventricularis were preserved. The nuclei of the pars lateralis and pars posterior were affected with the exception of the medial part of the pulvinar. The formatio anterior and the nucleus dorsalis superficialis were spared. The brain stem nuclei and tracts were grossly normal, but there was diffuse fibrillary gliosis and hypomyelinization. In the cerebellum there were too many thinwalled vessels within the leptomeninx. The molecular layer was very thin. Dendritical swelling of Purkinje cells was clearly visible in the molecular layer. On silver staining the following dendritical abberations were observed; abnormal arborization , swollen dendrites, weeping willow formation and Medusa head formation, with
Fig 4 Hypoplastic cerebellum. Patient 2.
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Fig 5 Purkinje cell with Medusa head formation . Bodian x 500. Patient 2.
Fig 6 Weeping willow formation of cerebellar, molecular layer. Bodian x 500. Patient 2.
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pseudonuclei (Figs 5 and 6). Some asteroid bodies were seen. There was some loss of Purkinje cells and empty baskets were seen. There was vacuolar degeneration of Purkinje cells (Fig 7), dumbbell formation of nuclei and double nucleated Purkinje cells were present. Somal sprouting was abundant. Some Purkinje cells had axonal torpedoes and abnormal axonal sprouting. There was proliferation of Bergmann glia. The Purkinje cell layer was slightly irregular and several heterotopic Purkinje cells were found in the molecular and granular layers. There were fewer myelinated fibers than expected in the cerebellar folia and a mild gliosis was present. The nucleus dentatus showed no obvious nerve cell loss or degeneration, and only a diffuse gliosis. Patient 3 Clinical Features Patient 3 was a boy with a birth weight of
Fig 7
Vacuolar degeneration of Purkinje cell. Wei!
x
2,800 gm and a length of 47 cm. Pregnancy and delivery were uneventful. Brushy hair was noticed. The child appeared to be severely retarded, mental development not exceeding the neonatal level. The patient died of pneumonia at the age of 27 months. Autopsy Report (abstract) The main fmdings were bronchitis, bronchopneumonia and chronic tonsillitis. There were no abnormalities of the vessels. Neuropathological Findings Brain weight after fixation was 910 gm (normal = 1,034 gm [14]). The brain was soft and there were some autolytic changes. The cerebellum was hypoplastic in the medio-basal region and there was a basal infratentorial cyst. There was slight enlargement of all four ventricles, but no obstructions were noted. The corpus callosum and thalamus were hypoplastic. The white matter in the centrum semiovale was diminished in bulk.
315. Patient 2.
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Microscopy The cortex and white matter were diffusely edematous. A normal six-layered cortex was present. There was some patchy neuronal loss and fibrillary gliosis. There was marked fibrillary gliosis and a diffuse myelin reduction in the white matter of the right and left parietotemporal regions. The leptomeninx over the left parieto-temporal region contained too many thin-walled vessels. The same cortical lamination disturbances as in case 2 were seen. In the right temporal lobe there was a large empty cyst, surrounded by macrophages, fibrillary gliosis and calcified neurons. Degenerative changes in the thalamus were the same as described for case 2. The corpus striatum and brain stem were normal, except for a diffuse fibrillary gliosis. In the cerebellum there were too many thinwalled vessels within the leptomeninx. The molecular and granular layers were too thin. Dendritical swelling of Purkinje cells and somal sprouting was present (Fig 8). The following dendritical abbe rations were
observed; abnormal arborization, swollen dendrites, weeping willow formation and Medusa head formation with pseudonuc1ei. Discussion Lep tomeninges The large retrocerebellar arachnoidal cysts, in all three cases, were not reported before in Menkes' disease. They could have obstructed the flow of the cerebrospinal fluid and were probably responsible for the hydrocephalus in these cases [15]. Vessels Dilated thin-walled vessels were present in patients 2 and 3 and were also reported by Aguilar et al [16], Danks et al [8] and Dorn et al [18]. They were not present in patient I. O. Vuia and D. Heye [19] noted a pseudoangiomatous appearance of the leptomeninx vessels as was also found in patient III. No alterations in non-eNS arteries were demonstrated in our patients. In patients 2 and 3
Fig 8 Somal sprouting and swollen dendrite of Purkinje cell. Bodian
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x
500. Patient 3.
there were also numerous small dilated vessels in the cerebellar leptomeninx, which was not reported before in Menkes' disease (Fig 9).
present in the molecular layer. Scattered neurons were present in the white matter, sometimes in clusters. Kopp et al [4] suggested that the focal neuronal depopulation is a result of anoxia caused by vascular anomalies and a lack of cytochrome oxidase. French [5] demonstrated the lack of cytochrome oxidase. Although this is a possible explanation, focal neuronal loss in combination with reversed polarity of neurons, the presence of neurons within the molecular layer, excessive numbers of heterotopic neurons in the white matter, and cerebellar deformities is more likely to be due to a disturbance in the migration of neuroblasts.
Cortex Aguilar et al [16], Menkes et al [I] and VagnHansen et al [17] reported cystic degeneration of the gray and white matter principally in the temporal lobes. In our case 2 a small necrotic area was found in the left temporal lobe, and in case 3 some empty cystic spaces were seen in the right temporal lobe. Kopp et al [4] described neuronal loss, especially in the depth of the sulci and in the middle layers of the cortex, together with reversal of polarity of groups of neurons and no gliosis. In patient 1 there was subtotal focal neuronal loss in the cerebral cortex in the third and fourth layers. In some areas the cortex had an almost allocortical structure. In patients 2 and 3 the loss of cortical nerve cells in some places was similar, but less severe. Reversed polarity of nerve cells was noted in the deeper cortical layers, especially in areas of neuronal loss. In all three cases heterotopic neurons were
White Matter Vagn-Hansen and Reske-Nielsen and Lou [17] reported in their case C.A.T., a pronounced accumulation of neutral fat and cholesterol compounds within the glial cells and diffusely distributed in the white matter. In case 1 we observed normal myelinization for the age. Lipid droplets and lipid laden macrophages were present around the small vessels in the subcortical white matter and there were lipid
Fig 9 Small dilated vessels in cerebellar leptomeninx. H-E
x
30. Patient 3.
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droplets in and around glial cells in the subcortical white matter and the white matter of the brainstem and cerebellum. This seemed to be normal [20, 21] . Vagn-Hansen et al stated that the disease is a leucodystrophy. In our case 1 there was no obvious demyelinization, in cases 2 and 3 the myelin disturbance was of a diffuse type, not focal and there was no sudanophilic or metachromatic material ; for these reasons Menkes' disease does not belong to the leucodystrophy group. Therefore, we suppose that the myelin disturbance in Menkes disease is not the essential feature of the disease as it is in leucodystrophy. We presume that the thalamic degeneration in Menkes' kinky hair disease develops after birth, for we observed in the thalamic nuclei of case 1 many normal nerve cells adjacent or ghost cells, and the thalamic degeneration was almost complete in the other two patients, who were older. The biochemically proved differences between cases 2 and 3 [22] could not be confirmed from the pathological findings .
Cerebellum The weeping willow formation is caused by a loss of parallel and interneuron afferent fibers [23-25] and it begins in the seventh or eighth month of gestation [26], while the migration of neuroblasts in the cerebral hemispheres is essentially complete by the end of the sixth month [27]. It is thus probable that the defect in kinky hair disease develops before the sixth month of gestation. O. Vuia and D. Heye [19] compared the dendritic abnormalities with those of amaurotic idiocy. They stated that "in cerebellar atrophy of kinky hair disease this process exceeds by far the simple stage of dendritic proliferation, since it is characterized by an accentuated dystrophy, resembling that observed in amaurotic idiOCY" (Fig 10). In contrast to the findings in Menkes disease there is no weeping willow formation and no somal sprouting in amaurotic idiocy. Furthermore, the swelling of dendrites in amaurotic idiocy is different, in that there is normal arborization , while in Menkes' kinky hair dis-
Fig 10 Photo of Purkinie cell in original slide of the cerebellum in amaurotic idiocy, made by Bielschowsky (Biel~chowsky x 780).
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ease there is swelling of dendrites after abnonnal arborization. The aberrations seen in Menkes' disease are thought to be an abortive attempt at regeneration [28], while those in amaurotic idiocy are the result of a degenerative process [29]. The dendritic aberrations per se are not specific, as was demonstrated by Santha [30], but the abundance of these abnonnalities is probably specific for Menkes' kinky hair disease. Although the neuropathological abnormalities, found in patients 2 and 3, are similar, the copper metabolism in these patients is different, i.e., the copper deficiency is apparently less severe in patient 3 [22] . A comparable situation occurs in mottled mouse mutants [31] . The brindled (Mobr/y) mouse, the animal model for Menkes' disease [32] , dies at about 14 days post-partum as a result of copper deficiency. Another mutant, the blotchy (Moblo/y) mouse, suffers from a less severe copper deficiency [31]. It is therefore likely that patients 2 and 3 are the human equivalents of the "brindled" and "blotchy" phenotypes, respectively. Although there is a difference in the degree of copper deficiency, the features of copper deficiency will be the same.
7. 8.
9.
10. 11. 12.
13. 14 . 15.
16. 17.
Acknowledgments We are grateful to B.A. van Ketel, MD, for comment, to Miss M. Schipper for typing the manuscript, to H.W. Sakkers, neuropathology technician, for his untiring assistance and to A.P. Piso and T. Wollenberg for the photographs. References 1. Menkes JH, Alter M, Steigleder GK, Weakley DR, Sung JH. A sex-linked recessive disorder with retardation of growth, peculiar hair and focal cerebral and cerebellar degeneration. Pediatrics 1962;29:764-79. 2. Reske-Nielsen E. Kinky hair syndrome. Acta Paediatr Scand 1974;63:294-6. 3. M¢llekrr AM. Case report. Kinky hair syndrome. Acta Paediatr Scand 1974;63:289-95. 4. Kopp N, Tommasi M, Carrier H, Pialat J. Neuropathologie de la trichopoliodystrophie (maladie de Menkes). Rev Neurol (Paris) 1975;131 :77589. 5. French JH. X-chromo some-linked copper malabsorption (X-cLCM). In : Vinken PJ, Bruyn GW, eds. Handbook of clinical neurology. Vol 29. Amsterdam: North Holland, 1975 :279-304. 6. Ghatak NR, Hirano A, Poon TP and French JH. Trichopoliodystrophy II. Pathological changes in
18. 19. 20. 21. 22.
23 . 24 .
25 .
skeletal muscle and nervous system. Arch Neurol 1972;26:60-72. Williams RS, Marshall PC, Lott IT, Caviness VS Jr. The cellular pathology of Menkes steely hair syndrome. Neurology 1978;28:575-83 . Danks DM, Campbell PE, Stevens BJ, Mayne V, Cartwright E. Menkes' kinky hair syndrome. An inherited defect in copper absorption with widespread effects. Pediatrics 1972;50:188-201. Purpura DP, Hirano A, French JH. Poly dendritic Purkinje cells in X-chromo some-linked copper malabsorption : A Golgi study. Brain Res 1976; 117:125-9. Hirano A, Llena JF, French JH, Ghatak NR. Fine structure of the cerebellar cortex in Menkes kinky hair disease. Arch NeuroI1977;34:52-6 . Iwata M, Hirano A, French JH. Thalamic degeneration in X-chromo some-linked copper malabsorption. Ann Neuro11979;5 :359-66 . Iwata M, Hirano A, French HI. Degeneration of the cerebellar system in X-chromo some-linked copper malabsorption. Ann Neurol 1979;5 : 542-9 . Kissane JM. Pathology of infancy and childhood. St. Louis: CV Mosby Co, 1975 :2-5 . Blinkov SM, Gleezer Il'ya I. The human brain in figures and tables. A quantitative handbook. New York: Plenum Press, 1968. Friede RL. Retrocerebellar and basal infratentorial cysts. In : Friede RL. Developmental neuropathology. Wien·New York: Springer-Verlag, 1975;199-200. Aguilar MJ, Chadwick DL, Okuyama K, Kamoshita S. Kinky hair disease. J Neuropathol Exp NeuroI1966;25 :507-22. Vagn-Hansen PL, Reske-Nielsen E. Menkes' disease: a new leucodystrophy (?). Acta NeuropathoI1973;25:103-19. Dorn G, Neuhauser G, Heye D, Keilhorn A. Das Kinky Hair Syndrom von Menkes. Klin Pddiat 1973;185:480-9. Vuia 0, Heye D. Neuropathological aspects in Menkes' kinky hair disease (trichopoliodystrophy). Neuropiidiatrie 1974;5:329-39. Tuthill CR. Fat in the infant brain in relation to myelin, blood vessels and glia. Arch Pathol 1938;25:33646. Jellinger K, Seitelberger F, Kozik M. Perivascular accumulation of lipids in the infant human brain. Acta Neuropathol (Berl) 1971;19:331-42. Willemse J, Van den Hamer CJA, Prins HW, Jonker PL. Menkes' kinky hair disease I. Comparison of classical and unusual clinical and biochemical features in two patients. Brain Dev (Tokyo) 1982;4: 105-14. Bradley P, Berry M. The effect of reduced climbing and parallel fibre input on Purkinje cell dendritic growth. Brain Res 1976;109:133-51. Altman J. Experimental reorganization of the cerebellar cortex: VI. Effects of X-irradiation schedules that allow or prevent cell acquisition after basket cells are formed. J Comp Neurol 1976; 165:49-64. Anderson WJ, Stromberg MW. Effects of low level X-irradiation on cat cerebella at different
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postnatal intervals: II. Changes in Purkinje cell morphology . J Comp NeuroI1977; 171:39-50 .. Zecevic N, Rakic P. Differentiation of Purkinje cells and their relationship to other components of developing cerebellar cortex in man. J Comp Neuro11970; 139:473-500. Larroche JC. Developmental pathology of the neonate. Amsterdam: Excerpta Medica, 1977. Cajal SR. Degeneration and metamorphic processes consequent on cerebellar traumatism. In: Degeneration and regeneration of the nervous system, vol 2. New York: Hofner Publishing Co, 1959:616-30. Bielschowsky M. Zur Histopathologie und Patho-
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genese der amaurotischen Idiotie mit besonderer Beriicksichtigung der zerebellaren Veranderungen. J Psychol NeuroI1920;26:123-99. 30. Santha Kv. Uber die Entwicklungsst6rungen der Purkinjeneurone. Arch Psychiatr 1930;91:374410. 31. Hunt DM. Primary defect in copper transport underlies mottled mutants in the mouse. Nature 1974;249:852-3. 32. Van den Hamer CJA, Prins HW, Nooijen JL. Menkes' disease in mottled mice and man. In: Hommes FA, ed. Models for the study ofinbom errors of metabolism. Amsterdam : Elsevier, 1979:95-102.
The neuropathologic abnormalities in three new cases of Menkes' kinky hair disease are described. Principally the three cases were the same. Hypoplasia of the cerebellum, with a basal arachnoidal cyst, was present in all three cases. The cysts were not described before in Menkes' disease. There was nerve cell loss and gliosis in the cerebral cortex, cerebellum and thalamus. The reduction of myelinated axons was widespread and the disease does not belong to the leukodystrophies. Cortical lamination disturbances were present indicating that the disease develops as early as the sixth fetal month. Abnormal arborization of Purkinje cells with swelling of dendrites was present and thought not to be identical with the Purkinje cell abnormalities seen in amaurotic idiocy. The difference in severity of the copper deficiency in 2 patients is compared with the situation in "brindled" and "blotchy" mutant mice. Troost D, van Rossum A, Straks W, Willemse J. Menkes' kinky hair disease. II. A clinicopathological report of three cases. Brain Dev 1982;4: 115-26
In 1962, Menkes et a1 [1] described a sexlinked recessive heredodegenerative disorder characterized by mental retardation, retardation of growth, peculiar hair growth, focal cerebral degeneration and also cerebellar degeneration. Several clinicopathological and biochemical reports have been published since [2-7]. Danks et al [8] suggested that the patients, From the Department of Neuropathology - Neurological Clinic (DT, AvR), Department of Child Neurology (JW), Pathological Institute (WS); University of Utrecht, Utrecht, The Netherlands. Received for publication: July 29, 1981. Accepted for publication: January 22, 1982.
Key words: Menkes' disease. kinky hair disease. Xchromosome-linked copper malabsorption (X. cLeM). Purkinje cell. Correspondence address: Dr. Dirk Troost, Department of Neuropathology - Neurological Clinic, Nicolaas Beetsstraat 24, Utrecht, The Netherlands.
described by Menkes et al [1], suffered from copper deficiency resulting from impaired intestinal absorption of alimentary copper. Purpura et al [9], Hirano et al [10] and Iwata et al [11, 12] studied in particular the pathology of the diseased areas of the cerebral cortex, cerebellum and thalamus. Thus, far 20 case reports, including pathological findings, have been reported. In this paper we want to add three more case reports. These are of special interest, because of the sequence of ages they present. The combined reports presented an opportunity to study the development of the pathological features of the disease. Some of the pathological findings in these cases were not described for Menkes' disease before. Materials and Methods The brains of these boys of respective ages of 7 months, 57 months and 27 months were examined. After removal of parts of the right
frontal lobe and small parts of the basal ganglia and cerebellum for histochemistry and EM studies the three brains were fixed in 5% neutral buffered formaldehyde for at least 6 weeks. In all cases, paraffin, large celloidin and frozen sections were made for light microscopic studies and stained by the routine neuropathologic staining methods. Biopsies of the sural nerve , soleus muscle and jejunum were obtained during the life of patient 2 for electron microscopical study. Patient 1
Clinical Features Patient 1 was a male born on September 28, 1971 . Pregnancy and birth were uneventful. The birth weight was 3,000 gm. He was the sixth child of seven. At the age of 2 months he was admitted to a hospital, because of a generalized epileptic fit. In the course of the following months his mental and motor development appeared to be retarded . Focal neurological symptoms were not noted. On angiography generalized tortuosity of the cerebral vessels was found and considered to be related to a vascular disease. Extensive laboratory studies, including metabolic errors (copper excluded!), were negative. At the age of 7 months he died , some hours after admittance for pneumococcal meningitis. Autopsy Report (abstract) The significant findings were chronic bronchitis and an adrenal hemorrhage.
Neuropathological Findings The brain weighed 700 gm (normal weight for
the age = 767 gm [3]). The cisterns at the base of the brain were filled with creamy pus (which covered the blood vessels.) The cerebellum was hypoplastic in the medio-basal region and there was a basal retrocerebellar cyst. The aquaductus Sylvii was enlarged. There was no hydrocephalus.
Microscopy The entire leptomeninx showed the features of pyogenic meningitis. There was edema in the cortex. The nerve cells were normal. In the temporal and occipital lobes, there were light lamination .disturbances, sometimes with almost an allocortical structure (Fig 1). In these 116 Brain & Development, Vol 4. No 2, 1982
areas the cortex was very thin and consisted of four or five layers. In the deeper layers of such areas there were nerve .cells with abnormal polarity. In these regions there were also nerve cells scattered within the white matter and clusters of heterotopic nerve cells were also seen in the white matter. Lipid droplets and lipid laden macrophages were present around arterioles and veins in the subcortical white matter. The myelinization of the brain was normal for the age of 7 months. The corpus striatum was normal, except for the presence of a few calcospherites. In the thalamus there was a diffuse loss of nerve cells with many ghost cells and a light fibrillary gliosis. There were no lesions in the mesencephalon, pons or medulla oblongata, except for lipid droplets and lipid laden macrophages around arterioles and veins in the white matter. The cerebellum had a thin molecular layer still with a external granular layer. Some Purkinje cells in the molecular layer were heterotopic and others had double nuclei: (Fig 2). Swollen dendrites of Purkinje cells were clearly visible , but not in abundance. The weeping willow, or arcuate phenomenon was already present. There was occasional somal sprouting present. The Purkinje cell layer was irregular. The internal granular layer was atrophic. Axonal torpedoes of Purkinje cells were seldom seen. In the white matter of the cerebellum there was diffuse macroglial and microglial proliferation and the lipids described above. The nucleus dentatus was normal, except for the gliosis seen elsewhere in the white matter. Patient 2
Clinical Features Patient II was a male, the younger brother of patient I, the youngest child of seven, and born by normal delivery after a normal pregnancy. At birth he weighed 2,500 gm and was 49 cm in length. At the age of 2 weeks hypothermia was observed and he developed epileptic seizures, at first right-sided, in the following six weeks. Motor and mental development were normal initially, but from the age of 2 months his motor and mental states regressed rapidly to the neonatal level. A decerebrate state developed. Notwith-
Fig 1 Thin cortex with nerve cell loss in the third or fourth layer and a zone of irregularly placed neurons beneath it. KlUver x 30. Patient 1.
,
Fig 2 Purkinje cell in molecular layer. H-E x 315. Patient 1.
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standing frequent epileptic seizures of several types (tonic-clonic seizures, infantile spasms, epileptic states) the patient was stationary until death of pneumonia at the age of 57 months. Skeletal Muscle Biopsy A biopsy of the soleus muscle showed normally arranged myofilaments. A- and I-bands as well as the Z-membrane were normally demarcated. Some glycogen was present. Most of the mitochondria were enlarged and had irregular cristae arranged in a disorderly pattern (Fig 3). Mitochondria in surrounding connective tissue showed no abnormalities.
Peripheral Nerve Biopsy A biopsy of the sural nerve showed normal axonal structures and an intact myelin sheath. In the cytoplasm of the Schwann cell the number of lysosomes seemed to be increased. Jejunal Biopsy A jejunal biopsy showed normal microvilli. The epithelial lining showed no abnormalities, especially the mitochondria had a normal appearance. Autopsy Report (abstract) The only significant findings were liver congestion and chronic bronchitis.
Fig 3 Enlarged mitochondria with irregular cristae, arranged in a disorderly pattern. Patient 1.
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x
35,000.
Neuropathological Findings The brain weighed 882 gm (normal weight for the age = 1,216 gm [14 D. There was diffuse atrophy of the entire brain. The vessels were macroscopically normal. The left superior temporal gyrus was partly necrotic. The cerebellum was hypoplastic in the medio-basal region (Fig 4) and there was a basal retrocerebellar cyst. The corpus callosum was also hypoplastic. There was a hydrocephalus, but no obstructions were noted. There was severe atrophy of the thalamus on both sides. Microscopy There were no abnormalities in the leptomeninges of the cerebral hemispheres. The cortex showed normal lamination, but was still columnar. There was no degeneration of nerve cells. There was patchy edema of the deeper cortical layers. In the gyrus temporalis superior of the left temporal lobe there was a necrotic area. In both cortical parieto-occipital regions there were slight abbe rations in the normal lamination. More remarkable was the loss of nerve cells in the third and fourth layers and the reversal of polarity of nerve cells in the fifth and sixth cortical layers without reactive gliosis. In the subcortical white matter and within the centrum semiovale there were excessive numbers of heterotopic nerve cells. Glial nodules were found diffusely through the white and gray matter. Many thin-walled vessels were found in the
centrum semiovale and within the corpus striatum and there was a small capillary hemangioma in the left hemisphere. There were no lesions in the vessel walls. The internal, external and extreme capsules were normal. There was diffuse demyelinization in the centrum semiovale and the temporal and occipital lobes. Neither neutral lipids nor metachromasia were observed. The optic tract was normally myelinated. In the corpus striatum there was diffuse gliosis, but no obvious nerve cell loss. The thalamus was severely atrophied. There was loss of neurons, fibrous gliosis, myelin pallor and calcospherites, but the nuclei of the pars intralamellaris and pars paraventricularis were preserved. The nuclei of the pars lateralis and pars posterior were affected with the exception of the medial part of the pulvinar. The formatio anterior and the nucleus dorsalis superficialis were spared. The brain stem nuclei and tracts were grossly normal, but there was diffuse fibrillary gliosis and hypomyelinization. In the cerebellum there were too many thinwalled vessels within the leptomeninx. The molecular layer was very thin. Dendritical swelling of Purkinje cells was clearly visible in the molecular layer. On silver staining the following dendritical abberations were observed; abnormal arborization , swollen dendrites, weeping willow formation and Medusa head formation, with
Fig 4 Hypoplastic cerebellum. Patient 2.
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Fig 5 Purkinje cell with Medusa head formation . Bodian x 500. Patient 2.
Fig 6 Weeping willow formation of cerebellar, molecular layer. Bodian x 500. Patient 2.
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pseudonuclei (Figs 5 and 6). Some asteroid bodies were seen. There was some loss of Purkinje cells and empty baskets were seen. There was vacuolar degeneration of Purkinje cells (Fig 7), dumbbell formation of nuclei and double nucleated Purkinje cells were present. Somal sprouting was abundant. Some Purkinje cells had axonal torpedoes and abnormal axonal sprouting. There was proliferation of Bergmann glia. The Purkinje cell layer was slightly irregular and several heterotopic Purkinje cells were found in the molecular and granular layers. There were fewer myelinated fibers than expected in the cerebellar folia and a mild gliosis was present. The nucleus dentatus showed no obvious nerve cell loss or degeneration, and only a diffuse gliosis. Patient 3 Clinical Features Patient 3 was a boy with a birth weight of
Fig 7
Vacuolar degeneration of Purkinje cell. Wei!
x
2,800 gm and a length of 47 cm. Pregnancy and delivery were uneventful. Brushy hair was noticed. The child appeared to be severely retarded, mental development not exceeding the neonatal level. The patient died of pneumonia at the age of 27 months. Autopsy Report (abstract) The main fmdings were bronchitis, bronchopneumonia and chronic tonsillitis. There were no abnormalities of the vessels. Neuropathological Findings Brain weight after fixation was 910 gm (normal = 1,034 gm [14]). The brain was soft and there were some autolytic changes. The cerebellum was hypoplastic in the medio-basal region and there was a basal infratentorial cyst. There was slight enlargement of all four ventricles, but no obstructions were noted. The corpus callosum and thalamus were hypoplastic. The white matter in the centrum semiovale was diminished in bulk.
315. Patient 2.
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Microscopy The cortex and white matter were diffusely edematous. A normal six-layered cortex was present. There was some patchy neuronal loss and fibrillary gliosis. There was marked fibrillary gliosis and a diffuse myelin reduction in the white matter of the right and left parietotemporal regions. The leptomeninx over the left parieto-temporal region contained too many thin-walled vessels. The same cortical lamination disturbances as in case 2 were seen. In the right temporal lobe there was a large empty cyst, surrounded by macrophages, fibrillary gliosis and calcified neurons. Degenerative changes in the thalamus were the same as described for case 2. The corpus striatum and brain stem were normal, except for a diffuse fibrillary gliosis. In the cerebellum there were too many thinwalled vessels within the leptomeninx. The molecular and granular layers were too thin. Dendritical swelling of Purkinje cells and somal sprouting was present (Fig 8). The following dendritical abbe rations were
observed; abnormal arborization, swollen dendrites, weeping willow formation and Medusa head formation with pseudonuc1ei. Discussion Lep tomeninges The large retrocerebellar arachnoidal cysts, in all three cases, were not reported before in Menkes' disease. They could have obstructed the flow of the cerebrospinal fluid and were probably responsible for the hydrocephalus in these cases [15]. Vessels Dilated thin-walled vessels were present in patients 2 and 3 and were also reported by Aguilar et al [16], Danks et al [8] and Dorn et al [18]. They were not present in patient I. O. Vuia and D. Heye [19] noted a pseudoangiomatous appearance of the leptomeninx vessels as was also found in patient III. No alterations in non-eNS arteries were demonstrated in our patients. In patients 2 and 3
Fig 8 Somal sprouting and swollen dendrite of Purkinje cell. Bodian
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x
500. Patient 3.
there were also numerous small dilated vessels in the cerebellar leptomeninx, which was not reported before in Menkes' disease (Fig 9).
present in the molecular layer. Scattered neurons were present in the white matter, sometimes in clusters. Kopp et al [4] suggested that the focal neuronal depopulation is a result of anoxia caused by vascular anomalies and a lack of cytochrome oxidase. French [5] demonstrated the lack of cytochrome oxidase. Although this is a possible explanation, focal neuronal loss in combination with reversed polarity of neurons, the presence of neurons within the molecular layer, excessive numbers of heterotopic neurons in the white matter, and cerebellar deformities is more likely to be due to a disturbance in the migration of neuroblasts.
Cortex Aguilar et al [16], Menkes et al [I] and VagnHansen et al [17] reported cystic degeneration of the gray and white matter principally in the temporal lobes. In our case 2 a small necrotic area was found in the left temporal lobe, and in case 3 some empty cystic spaces were seen in the right temporal lobe. Kopp et al [4] described neuronal loss, especially in the depth of the sulci and in the middle layers of the cortex, together with reversal of polarity of groups of neurons and no gliosis. In patient 1 there was subtotal focal neuronal loss in the cerebral cortex in the third and fourth layers. In some areas the cortex had an almost allocortical structure. In patients 2 and 3 the loss of cortical nerve cells in some places was similar, but less severe. Reversed polarity of nerve cells was noted in the deeper cortical layers, especially in areas of neuronal loss. In all three cases heterotopic neurons were
White Matter Vagn-Hansen and Reske-Nielsen and Lou [17] reported in their case C.A.T., a pronounced accumulation of neutral fat and cholesterol compounds within the glial cells and diffusely distributed in the white matter. In case 1 we observed normal myelinization for the age. Lipid droplets and lipid laden macrophages were present around the small vessels in the subcortical white matter and there were lipid
Fig 9 Small dilated vessels in cerebellar leptomeninx. H-E
x
30. Patient 3.
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droplets in and around glial cells in the subcortical white matter and the white matter of the brainstem and cerebellum. This seemed to be normal [20, 21] . Vagn-Hansen et al stated that the disease is a leucodystrophy. In our case 1 there was no obvious demyelinization, in cases 2 and 3 the myelin disturbance was of a diffuse type, not focal and there was no sudanophilic or metachromatic material ; for these reasons Menkes' disease does not belong to the leucodystrophy group. Therefore, we suppose that the myelin disturbance in Menkes disease is not the essential feature of the disease as it is in leucodystrophy. We presume that the thalamic degeneration in Menkes' kinky hair disease develops after birth, for we observed in the thalamic nuclei of case 1 many normal nerve cells adjacent or ghost cells, and the thalamic degeneration was almost complete in the other two patients, who were older. The biochemically proved differences between cases 2 and 3 [22] could not be confirmed from the pathological findings .
Cerebellum The weeping willow formation is caused by a loss of parallel and interneuron afferent fibers [23-25] and it begins in the seventh or eighth month of gestation [26], while the migration of neuroblasts in the cerebral hemispheres is essentially complete by the end of the sixth month [27]. It is thus probable that the defect in kinky hair disease develops before the sixth month of gestation. O. Vuia and D. Heye [19] compared the dendritic abnormalities with those of amaurotic idiocy. They stated that "in cerebellar atrophy of kinky hair disease this process exceeds by far the simple stage of dendritic proliferation, since it is characterized by an accentuated dystrophy, resembling that observed in amaurotic idiOCY" (Fig 10). In contrast to the findings in Menkes disease there is no weeping willow formation and no somal sprouting in amaurotic idiocy. Furthermore, the swelling of dendrites in amaurotic idiocy is different, in that there is normal arborization , while in Menkes' kinky hair dis-
Fig 10 Photo of Purkinie cell in original slide of the cerebellum in amaurotic idiocy, made by Bielschowsky (Biel~chowsky x 780).
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ease there is swelling of dendrites after abnonnal arborization. The aberrations seen in Menkes' disease are thought to be an abortive attempt at regeneration [28], while those in amaurotic idiocy are the result of a degenerative process [29]. The dendritic aberrations per se are not specific, as was demonstrated by Santha [30], but the abundance of these abnonnalities is probably specific for Menkes' kinky hair disease. Although the neuropathological abnormalities, found in patients 2 and 3, are similar, the copper metabolism in these patients is different, i.e., the copper deficiency is apparently less severe in patient 3 [22] . A comparable situation occurs in mottled mouse mutants [31] . The brindled (Mobr/y) mouse, the animal model for Menkes' disease [32] , dies at about 14 days post-partum as a result of copper deficiency. Another mutant, the blotchy (Moblo/y) mouse, suffers from a less severe copper deficiency [31]. It is therefore likely that patients 2 and 3 are the human equivalents of the "brindled" and "blotchy" phenotypes, respectively. Although there is a difference in the degree of copper deficiency, the features of copper deficiency will be the same.
7. 8.
9.
10. 11. 12.
13. 14 . 15.
16. 17.
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genese der amaurotischen Idiotie mit besonderer Beriicksichtigung der zerebellaren Veranderungen. J Psychol NeuroI1920;26:123-99. 30. Santha Kv. Uber die Entwicklungsst6rungen der Purkinjeneurone. Arch Psychiatr 1930;91:374410. 31. Hunt DM. Primary defect in copper transport underlies mottled mutants in the mouse. Nature 1974;249:852-3. 32. Van den Hamer CJA, Prins HW, Nooijen JL. Menkes' disease in mottled mice and man. In: Hommes FA, ed. Models for the study ofinbom errors of metabolism. Amsterdam : Elsevier, 1979:95-102.