<%server.execute "isdev.asp"%> Atypical juvenile neuronal ceroid lipofuscinosis: A report of three cases Setty G, Saleem R, Khan A, Hussain N - J Pediatr Neurosci
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CASE REPORT
Year : 2013  |  Volume : 8  |  Issue : 2  |  Page : 117-119
 

Atypical juvenile neuronal ceroid lipofuscinosis: A report of three cases


Department of Paediatric Neurology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom

Date of Web Publication7-Sep-2013

Correspondence Address:
Gururaj Setty
Department of Paediatric Neurology, Leicester Royal Infirmary, Infirmary Road, Leicester, LE1 5WW
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1817-1745.117840

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   Abstract 

The diagnosis of juvenile neuronal ceroid lipofuscinosis (JNCL) is usually based on age of onset, initial clinical symptoms, clinical progression, and pathologic findings. Our cases manifested atypical clinical symptomatology and/or pathologic findings and therefore, represent variant forms of JNCL. Case 1 and 2 presented with slow developmental regression from the age of 4 years and became blind and wheelchair bound at around 8 years. Pathologic finding of lymphocytes showed fingerprint inclusion which was consistent with JNCL. Mutational analysis was positive for CLN5 which usually presents as variant late infantile NCL (LINCL) and more common in Finnish population. Case 3 presented with progressive visual loss from the age of 8 years. Clinical symptomatology and age of onset were similar to that of JNCL but was found to have low palmitoyl protein thioesterase, granular inclusion body, and CLN1 mutation, thus representing milder form of INCL. These three cases demonstrated phenotypic-genotypic variations. Pertinent issues relating diagnostic difficulties, ophthalmologic, neuroradiological, and laboratory aspects are discussed.


Keywords: CLN1, CLN5, granular inclusion, juvenile neuronal ceroid lipofuscinoses, visual loss


How to cite this article:
Setty G, Saleem R, Khan A, Hussain N. Atypical juvenile neuronal ceroid lipofuscinosis: A report of three cases . J Pediatr Neurosci 2013;8:117-9

How to cite this URL:
Setty G, Saleem R, Khan A, Hussain N. Atypical juvenile neuronal ceroid lipofuscinosis: A report of three cases . J Pediatr Neurosci [serial online] 2013 [cited 2019 Apr 20];8:117-9. Available from: http://www.pediatricneurosciences.com/text.asp?2013/8/2/117/117840



   Introduction Top


Neuronal ceroid lipofuscinoses (NCLs) are a group of progressive neurogenetic disorders. In 1998, Wisniewski et al. categorized the NCLs into five major groups based primarily on age, clinical presentation, histological findings, and genetic loci; infantile NCL (INCL), late infantile/early childhood NCL (LINCL), Juvenile NCL (JNCL), adult NCL and variant, LINCL (vLINCL). This classification is still widely used.

Within the last decade, mutations that cause NCL have been found in 14 human genes (CLN1, CLN2, CLN3, CLN4/DNAJC5, CLN5, CLN6, CLN7/MFSD8, CLN8, CLN10/CTSD, CLN11/GRN, CLN12/ATP13A2, CLN13/CTSF, CLN14/KCTD7, CLCN6, and SGSH). [1] Approximately 160 NCL disease causing mutations have been described.

The most common forms are infantile, late infantile, and juvenile NCLs. Infantile NCL with CLN1 mutation presents with motor disturbances (ataxia, hypotonia, spasticity), visual impairment, seizures, dementia, and familial occurrence.

Late infantile with CLN2 mutation manifests with onset between 2 and 4 years and symptoms of epilepsy, cognitive decline, ataxia, visual failure, and death in between 9 and 18 years.

Juvenile NCL, with CLN3 mutation presents with progressive visual loss, speech and cognitive decline, epilepsy, behavioral disturbances and death in the 3 rd or 4 th decade.

However, they are already reclassified on the basis of newer molecular findings, which have provided a far more overlap for the different genetic variants that have previously suggested by the clinical phenotypes. [1],[2] We report three cases with atypical JNCL and pertinent issues concerning diagnostic difficulties, ophthalmologic, neuroradiological, and laboratory findings are discussed.


   Case Reports Top


Case 1

A 9-year-old Pakistani boy born to non-consanguineous parents with a normal perinatal period and early development and at 4 years, he began to show regression in motor and cognitive skills. He was unsteady and needed support, when walking at 6 and became wheelchair bound at 7 years. His speech was very slow and slurred but he had good hearing. He developed progressive visual loss and was unable to follow a bright red object at 7½ years. Interestingly, he hallucinated seeing spiders. He developed seizures, which were well controlled with valproate. Ophthalmological examination revealed dystrophic appearance of retina, attenuation of retinal vessels with a pale disc.

Serial cranial magnetic resonance imaging (MRI) showed diffuse white matter hyperintensity in T2-weighted but not in FLAIR at 5½ years and subsequently, cerebral and cerebellar atrophy at 7½ years. Electroencephalogram (EEG) showed bilateral synchronous generalized epileptiform discharges. Electroretinogram (ERG) was absent and visual evoked potential (VEP) was normal. Palmitoyl protein thioesterase (PPT) and tripeptidyl peptidase I (TPP 1) enzyme activities were within normal range. Skin and muscle biopsy for inclusion bodies were negative and blood film showed no vacuolated lymphocytes. However, ultra structural examination of lymphocytes showed rare, membrane bound, condensed storage material with fingerprint profiles. CLN5 gene mutation was positive.

At last follow-up at 11 years, he was wheelchair bound but could walk with support, had severe visual impairment and slow and slurred speech. He was totally dependent for all his daily activities.

Case 2

He was the 6-year-old brother of case 1 and his early developments were normal except for speech. He babbled at 5 months, copied noises at 8 months and only spoke with recognizable word at 2 year 7 months (his brother spoke at 18 months). He was more independent and active than his brother. He would play football (his eldest brother never ran or jumped) with other children and his expressive language had never been clear and had difficulty putting words together and had developed stammer. He was slow to learn and at 4 years, he began to have cognitive and motor regression.

Cranial MRI findings were very similar to that demonstrated on his brother's scan. At last follow-up (8 years), he had drooling saliva, he was wheel chair bound with deterioration in his speech, cognition, motor skills, and fully dependent for his needs. His visual acuity (VA) was 6/18 in each eye with normal fundi. He had developed seizures, which were controlled by valproate.

Case 3

An 11-year-10-month-old Caucasian boy with normal perinatal and neurodevelopmental history was referred to us with 3-year history of progressive visual loss and visual hallucinations. His symptoms started with difficulty in reading, worsening handwriting, and flashes of lights in both eyes (BE). He gave us a description and consistently drew figures, which he appeared to be seeing in front of his eyes. The figures had a red border with circles and lines criss-crossing the circles.

The VA at first presentation was 6/60 in BE when he was 10 years. At last follow-up at 13, VA was 6/60 in right eye (RE) and 3/60 in left eye (LE). He was able to detect colours but could not read any letters. Visual field did not show specific defect. Optic disc and neurological examinations were unremarkable at last follow-up.

VEP of BE were delayed while ERG was normal at 12 years. MRI and EEG were normal. Blood film showed no lymphocyte vacuolation. However, electron microscopy (EM) of buffy coat showed rare, membrane bound, electron dense, granular material associated with a lipid droplet in the cytoplasm of lymphocytes. PPT activity was low measuring 2.2 nmol/hr/mg protein and normal TPP-I. Molecular genetic analysis of exon 1-9 of CLN1 gene showed that he was heterozygote for p.Cys96Tyr and p.Arg151X mutations.

A diagnosis of milder form of INCL (CLN1) was made. At his last neurology follow-up at 13 years, his vision remained poor. He had developed behavioral and cognitive problems. He had not developed seizures or motor difficulties.


   Discussion Top


All our cases did not fit well with the typical clinicopathologic descriptions, therefore representing atypical variants of JNCL or vLINCL due to the late onset at 4-7 years and EM showed fingerprints, thus, overlapping considerably with juvenile NCL. [4] For case 1 and 2, similarities to vLINCL were age-at-onset, initial symptoms, and clinical progression. Differences from classic LINCL included slower clinical progression and different inclusion profile (revealed fingerprint, not typical curvilinear inclusion body). Therefore, we labeled them as variant of LINCL. In fact, CLN2 encodes for TTP-1 enzyme, therefore, normal enzyme level excluded classic LINCL (CLN2). Furthermore, these two cases had CLN5 mutation which usually presents as vLINCL and presented with typical phenotype of CLN5.

Case 3 had a different granular inclusion body. All the cases of NCL caused by mutations in CLN1 are associated with granular appearance. [5] To sum up, case 1 and 2 had early juvenile form of NCL (vLINCL) due to CLN5 and case 3 had atypical JNCL due to CLN1 mutation, reflecting phenotypical-genotypical variation.

Case 1 and 3 developed visual hallucinations. These rare features have been described in the literature. [6],[7] However, delayed VEP, normal ERG and fundi were also unusual and were consistent with optic nerve neuropathy.

Visual loss in CLN5 is usually due to retinal dystrophy. Ophthalmologic examination early in the course of vLINCL (CLN5) may reveal macular changes only; gradually typical signs of pan-retinal degeneration develop: Bull's eye maculopathy, diffuse pigmentary degeneration, arteriolar attenuation, and optic atrophy. ERG shows abnormal or absent record early in the course of the disorder. Case 1 (CLN5) manifested all these features. On contrast, case 3 (CLN1) showed normal ERG, delayed VEP and persistent normal fundi even at an advanced stage. These features were consistent with optic neuropathy, rather than retinal dystrophy. Normal disc may still correspond to an early stage of juvenile form of CLN1 but was quite unexpected at this advanced stage (4 years duration with VA 6/60).

Patients with CLN1 (case 1 and 2) have cerebellar atrophy at the early stage, followed by brain atrophy that is more severe in the cerebellum. [8] In contrast, patients with typical JNCL (CLN3) have cerebral atrophy at the early stage. Cerebellar atrophy usually comes later. [2],[8] White matter hyperintensity on T2 appears at an early stage. [8]

Therapy is supportive and several treatments have been attempted with no success. Polyunsaturated fatty acids have been attempted in JNCL. Vitamin E and other antioxidants including selenium has been tried with no conclusive results. [9] Bone marrow and organ transplantation has been tried without success.


   Conclusion Top


Atypical JNCL or vLINCL should be considered in any patients who present with either psychomotor decline or progressive visual loss. Early MRI may resemble leukodystrophy and ophthalmologic findings may be normal. EM of peripheral blood lymphocytes and NCL enzyme assay may facilitate early diagnosis. Children with NCL may show geno-phenotypical variations.

 
   References Top

1.Mole S. UCL NCL Resource: A gateway for Batten disease. Available from: http://www.ucl.ac.uk/index.shtml. [Last accessed on 2013 Jan 31].  Back to cited text no. 1
    
2.Worgall S, Kekatpure MV, Heier L, Ballon D, Dyke JP, Shungu D, et al. Neurological deterioration in late infantile neuronal ceroid lipofuscinosis. Neurology 2007;69:521-35.  Back to cited text no. 2
    
3.Wisniewski KE, Zhong N, Kaczmarski W, Kaczmarski A, Sklower-Brooks S, Brown WT. Studies of atypical JNCL suggest overlapping with other NCL forms. Pediatr Neurol 1998;18:36-40.  Back to cited text no. 3
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4.Wisniewski KE, Connell F, Kaczmarski W, Kaczmarski A, Siakotos A, Becerra CR, et al. Palmitoyl-protein thioesterase deficiency in a novel granular variant of LINCL. Pediatr Neurol 1998;18:119-23.  Back to cited text no. 4
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5.Bonsignore M, Tessa A, Di Rosa G, Piemonte F, Dionisi-Vici C, Simonati A, et al. Novel CLN1 mutation in two Italian sibs with late infantile neuronal ceroid lipofuscinosis. Eur J Paediatr Neurol 2006;10:154-6.  Back to cited text no. 5
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6.von Villiez T, Lagenstein I, Koepp P. Acute optical hallucinations in the juvenile neuronal ceroid lipofuscinosis (Spielmeyer-Vogt syndrome). Acta Paedopsychiatr 1981;47:19-25.  Back to cited text no. 6
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7.Lanska DJ, Lanska MJ. Visual release hallucinations in juvenile neuronal ceroid-lipofuscinosis. Pediatr Neurol 1993;9:316-7.  Back to cited text no. 7
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8.Autti T, Raininko R, Vanhanen SL, Santavuori P. MRI of neuronal ceroid lipofuscinosis. I. Cranial MRI of 30 patients with juvenile neuronal ceroid lipofuscinosis. Neuroradiology 1996;38:476-82.  Back to cited text no. 8
    
9.Santavuori P, Heiskala H, Westermarck T, Sainio K, Moren R. Experience over 17 years with antioxidant treatment in Spielmeyer-Sjögren disease. Am J Med Genet Suppl 1988;5:265-74.  Back to cited text no. 9
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   Case Reports
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