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Presenting symptoms of GBA-related Parkinson's disease
Parkinsonism and Related Disorders xxx (2015) 1e4
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Short communication
Presenting symptoms of GBA-related Parkinson's disease Nikola Kresojevi c a, Milena Jankovi c a, Igor Petrovi c a, Kishore R. Kumar c, a a cic , Ivana Novakovi c b, Marina Svetel a, Natasa Dragasevi c , Valerija Dobri c e, Vladimir S. Kosti c a, * Christine Klein d, Tatjana Pekmezovi a
Institute of Neurology CCS, School of Medicine, University of Belgrade, Belgrade, Serbia Institute for Human Genetics, School of Medicine, University of Belgrade, Belgrade, Serbia c Department of Neurogenetics, Kolling Institute of Medical Research, Royal North Shore Hospital, University of Sydney, St Leonards, NSW, Australia d Institute of Neurogenetics, University of Luebeck, Luebeck, Germany e Institute of Epidemiology, School of Medicine, University of Belgrade, Belgrade, Serbia b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 November 2014 Received in revised form 11 April 2015 Accepted 14 April 2015
Background: Mutations in the Glucocerebrosidase gene (GBA) are associated with Parkinson's disease (PD). It has been shown that GBA-related PD (PD-GBA) patients had an earlier age at PD onset and more prevalent non-motor symptoms when compared to “sporadic” PD patients without such mutations (sPD). Aim: To explore whether presenting symptoms differ between PD-GBA and sPD patients. Methods: Demographic and clinical features (including presenting symptoms) were collected for 578 PD patients. Sequence analysis was performed for exons 8e11 of the GBA gene for all participants. Results: 39 PD patients (6.7%) with GBA mutations were compared to 539 PD patients without them. Although no statistically significant differences were found regarding the presenting symptoms, we observed that pain was more frequently reported as an initial problem in the PD-GBA (10.3%) than in the sPD group (3.0%) (chi square p ¼ 0.039; logistic regression analysis OR ¼ 3.74; p ¼ 0.024). Conclusions: Overall, the presenting symptoms were similar in PD-GBA and sPD patients, with the exception that pain might be more frequent in PD-GBA. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Pain Glucocerebrosidase Parkinson's disease Presenting symptom
1. Introduction Both homo- and heterozygous mutations in the Glucocerebrosidase gene (GBA) are associated with Parkinson's disease (PD), and represent the most robust known genetic susceptibility factor identified in PD [1]. In a large multicenter study, the odds ratio for any GBA mutation in PD patients versus controls was 5.43 across centers [2]. The PD phenotype in homozygous and heterozygous GBA mutation carriers is similar [1]. Clinically, GBA mutation carriers have an earlier age at PD onset (between 1.7 and 6.0 years earlier than PD patients without mutations) [1] and more likely have a positive family history for PD, but also more prevalent non-motor symptoms (NMS) such as cognitive and olfactory impairment, neuropsychiatric (depression, apathy, anxiety), autonomic and sleep
* Corresponding author. Neurology Clinic CCS, School of Medicine, University of Belgrade, Dr. Suboti ca 6, 11000 Belgrade, Serbia. E-mail address: [email protected] (V.S. Kosti c).
disturbances, when compared to PD patients without such mutations [3]. Moreover, those with severe GBA mutations (e.g., L444P) were found to be predisposed to an earlier age at PD onset and more commonly exhibited cognitive impairment [4]. NMS may be a presenting complaint in PD. In a study on 433 cases of pathologically proven PD, 21% of them presented with NMS, with pain being the most frequent finding (15%) [5]. The aim of this study was to explore whether presenting symptoms differ between PD patients with (PD-GBA) and without GBA mutations (sPD). 2. Patients and methods 2.1. Patients Consecutive, unrelated PD patients were recruited at the Institute of Neurology, School of Medicine, University of Belgrade (Serbia). The diagnosis of PD was based on the UK Brain Bank Criteria, with the exception that a positive family history was
http://dx.doi.org/10.1016/j.parkreldis.2015.04.028 1353-8020/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: N. Kresojevic, et al., Presenting symptoms of GBA-related Parkinson's disease, Parkinsonism and Related Disorders (2015), http://dx.doi.org/10.1016/j.parkreldis.2015.04.028
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among the exclusion criteria. All patients were examined by a movement disorders specialist (VSK, MS, IP, ND). The study was approved by the institutional ethical committee and a written informed consent was obtained from each subject. Patients were asked to recollect their experiences for two years prior to establishing the diagnosis of PD. Next, a systematic review was performed of all available medical charts, including notes of the primary care physicians over a same period considering the presenting symptom(s). Similar to the methodology used by O'Sullivan et al. [5], the included symptoms were those retrospectively considered by VSK, MS, IP and ND to be associated with PD. Only those PD patients whose reported symptoms were consistent with the data obtained from the charts were included in subsequent analyses. If more than one initial symptom was reported, we investigated further to identify the dominant one which was analyzed. Other clinical and demographic features were also collected, including family history, age, age at onset, disease duration, and initially affected part of the body. 2.2. Methods Sequence analysis was performed for exons 8e11 of the GBA gene. Primers used for the amplification of exons 8 and 9 were specific to the functional gene (GBA) rather than the pseudogene (GBAP). Exons 10 and 11 were amplified using nested PCR with partially mismatched primers to avoid co-amplification of the GBAP. Subjects identified with the D409H mutation were also sequenced for H255Q. A part of these results has been previously published with a detailed methodological description (see: Kumar et al. [6]). 2.3. Statistical analysis Continuous variables were compared using Student's t test or ManneWhitney U test. Categorical variables were compared using a Chi-square test or Fisher's exact test. As a measure of effect size, odds ratio (OR) with corresponding 95% confidence interval (95% CI) was calculated by using logistic regression analysis. The probability level of 0.05 was considered statistically significant. For statistical analysis the SPSS 17.0 statistical software package (SPSS Inc. Chicago, IL, USA) was used. 3. Results Out of 578 included PD patients, 39 (6.7%) had mutations in GBA, while in 539 no mutations were detected in exons 8e11. One
patient was homozygous for the N370S mutation and one was a compound heterozygote (N370S/D409H), while in 37 PD patients the following heterozygous mutations were identified: N370S (12 patients), D409H (11 patients), RecNciI (4 patients), L444P (two patients), R463C (two patients), R463H (two patients), and D380V, E388K, N392S and P391L in one patient each. All carriers of the D409H were found to carry the [D409H; H255Q] double-mutant allele (Table 2). No statistically significant differences were found regarding sex distribution, age, age at onset, disease duration, and family history for PD between mutation carriers (PD-GBA) and non-carriers (sPD) (Table 1). Regardless of the GBA status, the arm/shoulder region was initially affected in the majority of patients (68.4% and 75.6% of PDGBA and sPD patients, respectively). These two groups did not differ either regarding the first affected site, or the reported presenting symptoms (Table 1). However, pain was more frequently reported as an initial symptom in the PD-GBA (10.3%) than in the sPD group (3.0%) (p ¼ 0.039). These results were confirmed by logistic regression analysis (OR ¼ 3.74; p ¼ 0.024). In all four PD-GBA patients presenting with pain and in 14 out of 16 sPD patients with pain as an initial symptom, it was localized in an arm (predominantly the shoulder region) ipsilateral to the side of PD onset. The two remaining sPD patients reported leg pain as a presenting symptom. Out of four PD-GBA patients that reported shoulder pain as initial symptom, three were D409H heterozygotes, and one a R463H heterozygote. 4. Discussion The most significant result of our study is that presenting symptoms of PD are similar in GBA carriers and non-carriers for all parameters studied except for pain. The most common presenting symptoms of PD in our study were, regardless of the GBA status, cardinal motor symptoms of PD (Table 1). Tremor was the presenting symptom in 43.6% and 50.5%, bradykinesia in 25.6% and 27.6%, and rigidity in 15.4% and 13.5% of PD-GBA and sPD patients, respectively. Pain as a presenting symptom (in this study almost exclusively shoulder pain) was significantly more frequent in PD-GBA (10.3%) than in sPD patients (3%) (Table 1). A similar prevalence of pain as presenting symptom in GBA mutation carriers (9.86%) was reported in a previous study, although without a statistically significant difference when comparing its frequency to that in non-carriers (6.07%) [7]. We found less pain as initial symptom in both
Table 1 Demographic and clinical features of patients with Parkinson's disease with (n ¼ 39; PD-GBA) and without GBA mutation (n ¼ 539; sPD).
Male:female ratio Age (years)* Age at onset (years)* Disease duration (years)* Family history# Presenting symptom Slowness of movements/bradykinesia# Muscle stiffness/rigidity# Tremor# Pain# Writing difficulties# Gait problems# Localization of presenting symptom Arm (including shoulder) Leg Arm and leg
PD-GBA
na
sPD
na
p
OR
95% CI
p
21:18 61.0 ± 9.6 53.1 ± 9.6 7.9 ± 6.1 9 (23.7%)
39 39 37 37 38
337:202 60.7 ± 10.4 53.5 ± 10.9 7.1 ± 5.7 91 (17.7%)
539 539 539 539 513
0.281 0.856 0.852 0.443 0.359
0.70 1.00 1.00 0.98 1.44
0.36-1.34 0.97e1.04 0.97e1.03 0.93e1.03 0.66e3.14
0.283 0.842 0.838 0.420 0.361
10 (25.6%) 6 (15.4%) 17 (43.6%) 4 (10.3%) 0 (0.0%) 2 (5.1%)
39 39 39 39 39 39
149 (27.6%) 73 (13.5%) 272 (50.5%) 16 (3.0%) 7 (1.3%) 22 (4.1%)
539 539 539 539 539 539
0.786 0.746 0.407 0.039 1.000 0.672
0.90 1.16 0.76 3.74 0.60 1.27
0.43-1.90 0.47e2.87 0.39e1.46 1.18e11.77 0.07e13.11 0.29e5.61
0.787 0.747 0.408 0.024 0.484 0.752
26 (68.4%) 5 (13.2%) 7 (18.4%)
38 38 38
403 (75.6%) 59 (11.1%) 71 (13.3%)
533 533 533
0.322 0.693 0.376
0.70 1.22 1.47
0.34e1.42 0.46-3.24 0.62e3.46
0.324 0.694 0.379
GBA: glucocerebrosidase; PD: Parkinson's disease; na: number of patients with reliable information; * values present means ± SDs; # values present number of patients with a percentage in parenthesis; OR: odds ratio; CI: confidence interval; p : p for parametric and non-parametric tests.
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Table 2 Detected mutations in GBA gene. Variant namea Heterozygous mutations N370S D380V E388K P391L N392S [D409H; H255Q]b RecNciI (L444Pþ A456Pþ V460V)
L444P R463C R463H Homozygous mutations N370S/N370S N370S/[D409H; H255Q] a b
c.DNA nucleotide change c.1226A>G c.1256A>T c.1279G>A c.1289C>T c.1292A>G c.1342G>C c.882T>G c.1448T>C c.1483G>C c.1497G>C c.1448T>C c.1504C>T c.1505G>A c.1226A>G/c.1226A>G c.1226A>G/c.1342G>C
Exon 9 9 9 9 9 9 10
10 10 10 9 9
Protein amino acid change
Number of patients
p.Asn409Ser p.Asp419Val p.Glu427Lys p.Pro430Leu p.Asn431Ser p.Asp448His p.His294Gln p.Leu483Pro p.Ala495Pro p.Val499Val p.Leu483Pro p.Arg502Cys p.Arg502His
12 1 1 1 1 11
p.Asn409Ser/p.Asn409Ser p.Asn409Ser/p.Asp448His
4
2 2 2 1 1
Variant names follow the common nomenclature and apply to the processed protein, not including the 39-residue signal peptide. Double-mutant allele.
investigated PD groups than O'Sullivan and colleagues who found pain in 15% of PD patients [5]. Inconsistency of pain frequency as initial symptom in PD is probably due to methodological approach, primarily on taking pain in analysis as one of presenting symptoms or as the dominant initial symptom. In another study, unexplained pain was more frequently reported by PD-GBA patients (58%) when compared to non-carriers (10%) [8]. Pain is one of the most common premotor symptoms in PD, and Winkler et al. [9] included pain, among several other NMS, in a PD risk score developed to identify individuals at risk to develop motor symptoms of PD later in life. Frozen shoulder, defined as a painful syndrome with restriction of movements in the shoulder in the absence of a joint abnormality, was one of the most common musculoskeletal conditions in PD, and may be a presenting symptom of PD. Patients with PD were 21 times more likely to have shoulder pain when compared to those without PD, with prior injury, muscle cramps and tightness that might be related to shoulder pain in PD [10]. Our data are also in agreement with the notion of a possible genetic contribution to pain in PD. Namely, besides variants within the SCN9A, FAAH and COMT genes [11], we raise the hypothesis that the GBA mutations might also be associated with a risk of developing pain in PD. Besides its retrospective approach, there are several other limitations of our study. First, although we tested a large number of PD patients, only 39 (6.7%) were mutation carriers and only 4 presented with pain. Therefore, it would be impossible to make meaningful phenotype/genotype correlations due to a small number of patients. Also, we analyzed only GBA exons 8e11, which may have led to an underestimation of the true mutation frequency. Due to the same reason, some of the control subjects could still have
Nikola Kresojevi c Milena Jankovi c Igor Petrovi c Natasa Dragasevi c Valerija Dobri ci c Ivana Novakovi c Marina Svetel Christine Klein Kishore R Kumar Tatjana Pekmezovi c Vladimir S. Kosti c
1 1 1 1 1 1 1 1 1 1 1
GBA mutations. With the methodological approach we used, a potential recall bias is highly possible (i.e. only 3% of sPD group reported pain). Finally, although retrospective questioning and chart review were far from adequate to assess the real clinical presentation, we believe that our data are still valuable since all these limitations equally affect both groups of patients (PD-GBA and sPD). Our results suggest that PD patients with GBA mutations may have more frequently pain (e.g., shoulder pain) as an initial symptom when compared with PD patients without such mutations. Knowledge on the nature, time of onset, prevalence and progression of both motor and non-motor symptoms in this particular form of PD may be important for a more accurate prognosis and for evaluation of therapeutic strategies [3,5]. Financial disclosures/conflict of interest The authors do not have any conflict of interest. Funding sources for the study The Ministry of Education and Science, Republic of Serbia (project #ON175090 (to VK)). Authors' roles (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.
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Financial disclosures of all authors (for the preceding 12 months) Nikola Kresojevi c, Melena Jankovi c, Natasa Dragasevi c, Ivana Novakovi c and Tatjana Pekmezovic report no disclosures. Kishore Kumar is supported by a Douglas Piper Fellowship from the Royal North Shore Hospital Scholarship Program, and a National Health and Medical Research Council (NHMRC) Early Career Fellowship. Igor Petrovi c received honoraria for lectures for Boehringer Ingelheim and GlaxoSmithKline. Marina Svetel received honoraria for lectures for GlaxoSmithKline, Novartis and Boeringer/Ingelheim. Christine Klein is Medical advisor to Centogene; the recipient of a career development award from the Hermann and Lilly Schilling Foundation and receives grants from the BMBF; the German Research Foundation; the European Community (FP7); intramural funds from the University of Luebeck. Vladimir Kosti c is a member of Regional South-Eastern European Advisory Board of Boehringer Ingelheim and received honoraria for lectures for Novartis, Boehringer Ingelheim, Libra (Merck), Lundbeck and GlaxoSmithKline. Acknowledgment This study was supported by a grant from the Ministry of Education and Science, Republic of Serbia (projects #ON175090 to VK).
References [1] E. Sidransky, G. Lopez, The link between the GBA gene and parkinsonism, Lancet Neurol. 11 (2012) 986e998. [2] E. Sidransky, M. Nalls, J. Aasly, J. Aharon-Peretz, G. Annesi, E.R. Barbosa, et al., Multicenter analysis of Glucocerebrosidase mutations in Parkinson's disease, N. Engl. J. Med. 361 (17) (2009) 1651e1661. [3] K. Brockmann, K. Srulijes, A.K. Hauser, C. Schulte, I. Csoti, T. Gasser, et al., GBAassociated PD presents with nonmotor characteristics, Neurology 77 (3) (2011) 276e280. [4] Z. Gan-Or, N. Giladi, A. Orr-Urtreger, Differential phenotype in Parkinson's disease patients with severe versus mild GBA mutations, Brain 132 (2009) e125. [5] S.S. O'Sullivan, D.R. Williams, D.A. Gallagher, L.A. Massey, L. Silveira-Moriyama, A.J. Lees, Nonmotor symptoms as presenting complaints in Parkinson's disease: a clinicopathological study, Mov. Disord. 23 (2008) 101e106. €bel, N. Kresojevi [6] K.R. Kumar, A. Ramirez, A. Go c, M. Svetel, K. Lohmann, et al., Glucocerebrosidase mutations in a Serbian Parkinson's disease population, Eur. J. Neurol. 20 (2013) 402e405. [7] Z. Gan-Or, N. Giladi, U. Rozovski, C. Shifrin, S. Rosner, T. Gurevich, et al., Genotype-phenotype correlations between GBA mutations and Parkinson disease risk and onset, Neurology 70 (2008) 2277e2283. [8] A. McNeill, R. Duran, D.A. Hughes, A. Mehta, A.H. Schapira, A clinical and family history study of Parkinson's disease in heterozygous glucocerebrosidase mutation carriers, J. Neurol. Neurosurg. Psychiatry 83 (2012) 853e854. [9] J. Winkler, R. Ehret, T. Büttner, U. Dillmann, W. Fogel, M. Sabolek, et al., Parkinson's disease risk score: moving to a premotor diagnosis, J. Neurol. 258 (2011) S311eS315. [10] M. Madden, D. Hall, Shoulder pain in Parkinson's disease: a case-control study, Mov. Disord. 25 (2010) 1105e1106. [11] L. Greenbaum, I. Tegeder, Y. Barhum, E. Melamed, Y. Roditi, R. Djaldetti, Contribution of genetic variants to pain susceptibility in Parkinson disease, Eur. J. Pain 16 (2012) 1243e1250.
Please cite this article in press as: N. Kresojevic, et al., Presenting symptoms of GBA-related Parkinson's disease, Parkinsonism and Related Disorders (2015), http://dx.doi.org/10.1016/j.parkreldis.2015.04.028
Contents lists available at ScienceDirect
Parkinsonism and Related Disorders journal homepage: www.elsevier.com/locate/parkreldis
Short communication
Presenting symptoms of GBA-related Parkinson's disease Nikola Kresojevi c a, Milena Jankovi c a, Igor Petrovi c a, Kishore R. Kumar c, a a cic , Ivana Novakovi c b, Marina Svetel a, Natasa Dragasevi c , Valerija Dobri c e, Vladimir S. Kosti c a, * Christine Klein d, Tatjana Pekmezovi a
Institute of Neurology CCS, School of Medicine, University of Belgrade, Belgrade, Serbia Institute for Human Genetics, School of Medicine, University of Belgrade, Belgrade, Serbia c Department of Neurogenetics, Kolling Institute of Medical Research, Royal North Shore Hospital, University of Sydney, St Leonards, NSW, Australia d Institute of Neurogenetics, University of Luebeck, Luebeck, Germany e Institute of Epidemiology, School of Medicine, University of Belgrade, Belgrade, Serbia b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 November 2014 Received in revised form 11 April 2015 Accepted 14 April 2015
Background: Mutations in the Glucocerebrosidase gene (GBA) are associated with Parkinson's disease (PD). It has been shown that GBA-related PD (PD-GBA) patients had an earlier age at PD onset and more prevalent non-motor symptoms when compared to “sporadic” PD patients without such mutations (sPD). Aim: To explore whether presenting symptoms differ between PD-GBA and sPD patients. Methods: Demographic and clinical features (including presenting symptoms) were collected for 578 PD patients. Sequence analysis was performed for exons 8e11 of the GBA gene for all participants. Results: 39 PD patients (6.7%) with GBA mutations were compared to 539 PD patients without them. Although no statistically significant differences were found regarding the presenting symptoms, we observed that pain was more frequently reported as an initial problem in the PD-GBA (10.3%) than in the sPD group (3.0%) (chi square p ¼ 0.039; logistic regression analysis OR ¼ 3.74; p ¼ 0.024). Conclusions: Overall, the presenting symptoms were similar in PD-GBA and sPD patients, with the exception that pain might be more frequent in PD-GBA. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Pain Glucocerebrosidase Parkinson's disease Presenting symptom
1. Introduction Both homo- and heterozygous mutations in the Glucocerebrosidase gene (GBA) are associated with Parkinson's disease (PD), and represent the most robust known genetic susceptibility factor identified in PD [1]. In a large multicenter study, the odds ratio for any GBA mutation in PD patients versus controls was 5.43 across centers [2]. The PD phenotype in homozygous and heterozygous GBA mutation carriers is similar [1]. Clinically, GBA mutation carriers have an earlier age at PD onset (between 1.7 and 6.0 years earlier than PD patients without mutations) [1] and more likely have a positive family history for PD, but also more prevalent non-motor symptoms (NMS) such as cognitive and olfactory impairment, neuropsychiatric (depression, apathy, anxiety), autonomic and sleep
* Corresponding author. Neurology Clinic CCS, School of Medicine, University of Belgrade, Dr. Suboti ca 6, 11000 Belgrade, Serbia. E-mail address: [email protected] (V.S. Kosti c).
disturbances, when compared to PD patients without such mutations [3]. Moreover, those with severe GBA mutations (e.g., L444P) were found to be predisposed to an earlier age at PD onset and more commonly exhibited cognitive impairment [4]. NMS may be a presenting complaint in PD. In a study on 433 cases of pathologically proven PD, 21% of them presented with NMS, with pain being the most frequent finding (15%) [5]. The aim of this study was to explore whether presenting symptoms differ between PD patients with (PD-GBA) and without GBA mutations (sPD). 2. Patients and methods 2.1. Patients Consecutive, unrelated PD patients were recruited at the Institute of Neurology, School of Medicine, University of Belgrade (Serbia). The diagnosis of PD was based on the UK Brain Bank Criteria, with the exception that a positive family history was
http://dx.doi.org/10.1016/j.parkreldis.2015.04.028 1353-8020/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: N. Kresojevic, et al., Presenting symptoms of GBA-related Parkinson's disease, Parkinsonism and Related Disorders (2015), http://dx.doi.org/10.1016/j.parkreldis.2015.04.028
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2
among the exclusion criteria. All patients were examined by a movement disorders specialist (VSK, MS, IP, ND). The study was approved by the institutional ethical committee and a written informed consent was obtained from each subject. Patients were asked to recollect their experiences for two years prior to establishing the diagnosis of PD. Next, a systematic review was performed of all available medical charts, including notes of the primary care physicians over a same period considering the presenting symptom(s). Similar to the methodology used by O'Sullivan et al. [5], the included symptoms were those retrospectively considered by VSK, MS, IP and ND to be associated with PD. Only those PD patients whose reported symptoms were consistent with the data obtained from the charts were included in subsequent analyses. If more than one initial symptom was reported, we investigated further to identify the dominant one which was analyzed. Other clinical and demographic features were also collected, including family history, age, age at onset, disease duration, and initially affected part of the body. 2.2. Methods Sequence analysis was performed for exons 8e11 of the GBA gene. Primers used for the amplification of exons 8 and 9 were specific to the functional gene (GBA) rather than the pseudogene (GBAP). Exons 10 and 11 were amplified using nested PCR with partially mismatched primers to avoid co-amplification of the GBAP. Subjects identified with the D409H mutation were also sequenced for H255Q. A part of these results has been previously published with a detailed methodological description (see: Kumar et al. [6]). 2.3. Statistical analysis Continuous variables were compared using Student's t test or ManneWhitney U test. Categorical variables were compared using a Chi-square test or Fisher's exact test. As a measure of effect size, odds ratio (OR) with corresponding 95% confidence interval (95% CI) was calculated by using logistic regression analysis. The probability level of 0.05 was considered statistically significant. For statistical analysis the SPSS 17.0 statistical software package (SPSS Inc. Chicago, IL, USA) was used. 3. Results Out of 578 included PD patients, 39 (6.7%) had mutations in GBA, while in 539 no mutations were detected in exons 8e11. One
patient was homozygous for the N370S mutation and one was a compound heterozygote (N370S/D409H), while in 37 PD patients the following heterozygous mutations were identified: N370S (12 patients), D409H (11 patients), RecNciI (4 patients), L444P (two patients), R463C (two patients), R463H (two patients), and D380V, E388K, N392S and P391L in one patient each. All carriers of the D409H were found to carry the [D409H; H255Q] double-mutant allele (Table 2). No statistically significant differences were found regarding sex distribution, age, age at onset, disease duration, and family history for PD between mutation carriers (PD-GBA) and non-carriers (sPD) (Table 1). Regardless of the GBA status, the arm/shoulder region was initially affected in the majority of patients (68.4% and 75.6% of PDGBA and sPD patients, respectively). These two groups did not differ either regarding the first affected site, or the reported presenting symptoms (Table 1). However, pain was more frequently reported as an initial symptom in the PD-GBA (10.3%) than in the sPD group (3.0%) (p ¼ 0.039). These results were confirmed by logistic regression analysis (OR ¼ 3.74; p ¼ 0.024). In all four PD-GBA patients presenting with pain and in 14 out of 16 sPD patients with pain as an initial symptom, it was localized in an arm (predominantly the shoulder region) ipsilateral to the side of PD onset. The two remaining sPD patients reported leg pain as a presenting symptom. Out of four PD-GBA patients that reported shoulder pain as initial symptom, three were D409H heterozygotes, and one a R463H heterozygote. 4. Discussion The most significant result of our study is that presenting symptoms of PD are similar in GBA carriers and non-carriers for all parameters studied except for pain. The most common presenting symptoms of PD in our study were, regardless of the GBA status, cardinal motor symptoms of PD (Table 1). Tremor was the presenting symptom in 43.6% and 50.5%, bradykinesia in 25.6% and 27.6%, and rigidity in 15.4% and 13.5% of PD-GBA and sPD patients, respectively. Pain as a presenting symptom (in this study almost exclusively shoulder pain) was significantly more frequent in PD-GBA (10.3%) than in sPD patients (3%) (Table 1). A similar prevalence of pain as presenting symptom in GBA mutation carriers (9.86%) was reported in a previous study, although without a statistically significant difference when comparing its frequency to that in non-carriers (6.07%) [7]. We found less pain as initial symptom in both
Table 1 Demographic and clinical features of patients with Parkinson's disease with (n ¼ 39; PD-GBA) and without GBA mutation (n ¼ 539; sPD).
Male:female ratio Age (years)* Age at onset (years)* Disease duration (years)* Family history# Presenting symptom Slowness of movements/bradykinesia# Muscle stiffness/rigidity# Tremor# Pain# Writing difficulties# Gait problems# Localization of presenting symptom Arm (including shoulder) Leg Arm and leg
PD-GBA
na
sPD
na
p
OR
95% CI
p
21:18 61.0 ± 9.6 53.1 ± 9.6 7.9 ± 6.1 9 (23.7%)
39 39 37 37 38
337:202 60.7 ± 10.4 53.5 ± 10.9 7.1 ± 5.7 91 (17.7%)
539 539 539 539 513
0.281 0.856 0.852 0.443 0.359
0.70 1.00 1.00 0.98 1.44
0.36-1.34 0.97e1.04 0.97e1.03 0.93e1.03 0.66e3.14
0.283 0.842 0.838 0.420 0.361
10 (25.6%) 6 (15.4%) 17 (43.6%) 4 (10.3%) 0 (0.0%) 2 (5.1%)
39 39 39 39 39 39
149 (27.6%) 73 (13.5%) 272 (50.5%) 16 (3.0%) 7 (1.3%) 22 (4.1%)
539 539 539 539 539 539
0.786 0.746 0.407 0.039 1.000 0.672
0.90 1.16 0.76 3.74 0.60 1.27
0.43-1.90 0.47e2.87 0.39e1.46 1.18e11.77 0.07e13.11 0.29e5.61
0.787 0.747 0.408 0.024 0.484 0.752
26 (68.4%) 5 (13.2%) 7 (18.4%)
38 38 38
403 (75.6%) 59 (11.1%) 71 (13.3%)
533 533 533
0.322 0.693 0.376
0.70 1.22 1.47
0.34e1.42 0.46-3.24 0.62e3.46
0.324 0.694 0.379
GBA: glucocerebrosidase; PD: Parkinson's disease; na: number of patients with reliable information; * values present means ± SDs; # values present number of patients with a percentage in parenthesis; OR: odds ratio; CI: confidence interval; p : p for parametric and non-parametric tests.
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Table 2 Detected mutations in GBA gene. Variant namea Heterozygous mutations N370S D380V E388K P391L N392S [D409H; H255Q]b RecNciI (L444Pþ A456Pþ V460V)
L444P R463C R463H Homozygous mutations N370S/N370S N370S/[D409H; H255Q] a b
c.DNA nucleotide change c.1226A>G c.1256A>T c.1279G>A c.1289C>T c.1292A>G c.1342G>C c.882T>G c.1448T>C c.1483G>C c.1497G>C c.1448T>C c.1504C>T c.1505G>A c.1226A>G/c.1226A>G c.1226A>G/c.1342G>C
Exon 9 9 9 9 9 9 10
10 10 10 9 9
Protein amino acid change
Number of patients
p.Asn409Ser p.Asp419Val p.Glu427Lys p.Pro430Leu p.Asn431Ser p.Asp448His p.His294Gln p.Leu483Pro p.Ala495Pro p.Val499Val p.Leu483Pro p.Arg502Cys p.Arg502His
12 1 1 1 1 11
p.Asn409Ser/p.Asn409Ser p.Asn409Ser/p.Asp448His
4
2 2 2 1 1
Variant names follow the common nomenclature and apply to the processed protein, not including the 39-residue signal peptide. Double-mutant allele.
investigated PD groups than O'Sullivan and colleagues who found pain in 15% of PD patients [5]. Inconsistency of pain frequency as initial symptom in PD is probably due to methodological approach, primarily on taking pain in analysis as one of presenting symptoms or as the dominant initial symptom. In another study, unexplained pain was more frequently reported by PD-GBA patients (58%) when compared to non-carriers (10%) [8]. Pain is one of the most common premotor symptoms in PD, and Winkler et al. [9] included pain, among several other NMS, in a PD risk score developed to identify individuals at risk to develop motor symptoms of PD later in life. Frozen shoulder, defined as a painful syndrome with restriction of movements in the shoulder in the absence of a joint abnormality, was one of the most common musculoskeletal conditions in PD, and may be a presenting symptom of PD. Patients with PD were 21 times more likely to have shoulder pain when compared to those without PD, with prior injury, muscle cramps and tightness that might be related to shoulder pain in PD [10]. Our data are also in agreement with the notion of a possible genetic contribution to pain in PD. Namely, besides variants within the SCN9A, FAAH and COMT genes [11], we raise the hypothesis that the GBA mutations might also be associated with a risk of developing pain in PD. Besides its retrospective approach, there are several other limitations of our study. First, although we tested a large number of PD patients, only 39 (6.7%) were mutation carriers and only 4 presented with pain. Therefore, it would be impossible to make meaningful phenotype/genotype correlations due to a small number of patients. Also, we analyzed only GBA exons 8e11, which may have led to an underestimation of the true mutation frequency. Due to the same reason, some of the control subjects could still have
Nikola Kresojevi c Milena Jankovi c Igor Petrovi c Natasa Dragasevi c Valerija Dobri ci c Ivana Novakovi c Marina Svetel Christine Klein Kishore R Kumar Tatjana Pekmezovi c Vladimir S. Kosti c
1 1 1 1 1 1 1 1 1 1 1
GBA mutations. With the methodological approach we used, a potential recall bias is highly possible (i.e. only 3% of sPD group reported pain). Finally, although retrospective questioning and chart review were far from adequate to assess the real clinical presentation, we believe that our data are still valuable since all these limitations equally affect both groups of patients (PD-GBA and sPD). Our results suggest that PD patients with GBA mutations may have more frequently pain (e.g., shoulder pain) as an initial symptom when compared with PD patients without such mutations. Knowledge on the nature, time of onset, prevalence and progression of both motor and non-motor symptoms in this particular form of PD may be important for a more accurate prognosis and for evaluation of therapeutic strategies [3,5]. Financial disclosures/conflict of interest The authors do not have any conflict of interest. Funding sources for the study The Ministry of Education and Science, Republic of Serbia (project #ON175090 (to VK)). Authors' roles (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.
(conception and design, acquisition of data, analysis and interpretation of data), 2 (drafting (conception and design, acquisition of data), 2 (drafting the article), 3 (conception and design, acquisition of data, analysis and interpretation of data), 2 (drafting (conception and design, acquisition of data, analysis and interpretation of data), 2 (revising (conception and design, acquisition of data), 2 (revising the article), 3 (conception and design, acquisition of data), 2 (revising the article), 3 (conception and design, acquisition of data, analysis and interpretation of data), 2 (revising (conception and design, analysis and interpretation of data), 2 (revising the article), 3 (conception and design, analysis and interpretation of data), 2 (revising the article), 3 (analysis and interpretation of data), 2 (revising the article), 3 (conception and design, acquisition of data, analysis and interpretation of data), 2 (revising
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Financial disclosures of all authors (for the preceding 12 months) Nikola Kresojevi c, Melena Jankovi c, Natasa Dragasevi c, Ivana Novakovi c and Tatjana Pekmezovic report no disclosures. Kishore Kumar is supported by a Douglas Piper Fellowship from the Royal North Shore Hospital Scholarship Program, and a National Health and Medical Research Council (NHMRC) Early Career Fellowship. Igor Petrovi c received honoraria for lectures for Boehringer Ingelheim and GlaxoSmithKline. Marina Svetel received honoraria for lectures for GlaxoSmithKline, Novartis and Boeringer/Ingelheim. Christine Klein is Medical advisor to Centogene; the recipient of a career development award from the Hermann and Lilly Schilling Foundation and receives grants from the BMBF; the German Research Foundation; the European Community (FP7); intramural funds from the University of Luebeck. Vladimir Kosti c is a member of Regional South-Eastern European Advisory Board of Boehringer Ingelheim and received honoraria for lectures for Novartis, Boehringer Ingelheim, Libra (Merck), Lundbeck and GlaxoSmithKline. Acknowledgment This study was supported by a grant from the Ministry of Education and Science, Republic of Serbia (projects #ON175090 to VK).
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Please cite this article in press as: N. Kresojevic, et al., Presenting symptoms of GBA-related Parkinson's disease, Parkinsonism and Related Disorders (2015), http://dx.doi.org/10.1016/j.parkreldis.2015.04.028