Chorea-Acanthocytosis Genotype in the Original Critchley Kentucky Neuroacanthocytosis Kindred

OBSERVATION Chorea-Acanthocytosis Genotype in the Original Critchley Kentucky Neuroacanthocytosis Kindred

Antonio Velayos-Baeza, PhD; Elke Holinski-Feder, MD, PhD; Birgit Neitzel; Benedikt Bader, MD; Edmund M. R. Critchley, DM(Oxon), FRCP; Anthony P. Monaco, MD, PhD; Adrian Danek, MD; Ruth H. Walker, MB, ChB, PhD

Objective: To determine the molecular nature of the neu- Main Outcome Measures: Mutations in the VPS13A rological disease in the seminal family reported by Critch- gene. ley et al in the 1960s, characterized by a hyperkinetic move- ment disorder and the appearance of acanthocytosis on peripheral blood smear. The eponym Levine-Critchley syn- Results: A mutation was identified in the VPS13A drome, subsequently termed neuroacanthocytosis, has been gene, responsible for autosomal recessive chorea- applied to symptomatically similar, but genetically distinct, acanthocytosis. Haplotype reconstruction suggested that disorders, resulting in clinical and diagnostic confusion. this mutation was homozygous in the proband.

Design: DNA analysis. Conclusion: These findings strongly support the diag- Setting: Molecular biology research laboratories. nosis of chorea-acanthocytosis as the disorder described in the original report. Participants: First- and second-degree relatives of the original Critchley et al proband from Kentucky. Arch Neurol. 2011;68(10):1330-1333

EUROACANTHOCYTOSIS X-linked McLeod syndrome,8 autosomal (NA) is an umbrella term recessive pantothenate kinase–associ- for a genetically and phe- ated neurodegeneration,9 and autosomal notypically heteroge- dominant Huntington disease–like 2.10 neous group of neuro- Chorea-acanthocytosis and McLeod syn- logicalN conditions that occur together with drome are considered the “core” NA spiny red blood cells known as acantho- syndromes, as acanthocytosis is a fre- cytes. Some of the earliest cases of NA re- quent finding in both disorders, while it ported in the Western literature were given is only occasionally seen in Huntington the eponym Levine-Critchley syndrome in disease–like 210 and pantothenate kinase– Author Affiliations: The recognition of the work of Irvine Levine, associated neurodegeneration.9 Wellcome Trust Centre for MD, and Edmund Critchley, DM(Oxon), From the literature, all of the Critchley Human Genetics, Oxford FRCP. In the 1960s, these authors inde- et al cases2,3 appear to have a phenotype (Drs Velayos-Baeza and pendently reported a neurological condi- identical to that seen in patients in whom Monaco), and University of tion characterized by acanthocytes and a molecular diagnosis of ChAc has been con- Central Lancashire, Preston 4,5,11 (Dr Critchley), England; normolipoproteinemia in patients from 3 firmed, but the same does not apply to 1 Medizinisch Genetisches different families from New England, Ken- the New England family described by Zentrum (Dr Holinski-Feder tucky,2 and the United Kingdom.3 Levine,1 and no assumption can be made in and Ms Neitzel) and Advances in molecular medicine have this regard without genetic testing. Neurologische Klinik led to the recognition of several different A nephew of the proband from the origi- und Poliklinik, disorders covered by the term neuroacan- nal Critchley et al Kentucky pedigree con- Ludwig-Maximilians-Universita¨t thocytosis4,5 and have made contempo- tacted one of us (R.H.W.) via the Internet, (Drs Bader and Danek), rary use of this ambiguous term obsolete, expressing an interest on behalf of the fam- Munich, Germany; and apart from as a descriptor for a group of ily in participating in any further research Department of Neurology, James J. Peters Veterans Affairs hyperkinetic disorders in which acantho- on the disorder affecting his uncle. Samples Medical Center, Bronx, and cytosis may be seen. The main NA syn- were obtained from several surviving fam- Mount Sinai School of dromes are defined by at least 4 geneti- ily members allowing us to determine the Medicine, New York, cally distinct conditions: autosomal molecular nature of the neurological dis- New York (Dr Walker). recessive chorea-acanthocytosis (ChAc),6,7 ease in this seminal NA family.

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 I

1 273 4 5 6 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 II

1 2 3 4 5 III B C A T G T A A T A G C T C T A C G A A G A A A T T A T C T T C C

Male Neurological illness

Female Acanthocytosis

Deceased Friedreich ataxia-resembling disorder Control

Original proband Family members first tested (whole-gene mutation screening) Additional family members analyzed II-29 Analyzed family members carrying mutation c.7867C > T (heterozygous) Black Data as in original article2 Blue New data, not in original article2 C A T G T A A T A G C T C T A C G A A G A A A T T A T C T T C C His Val Ile Ala Leu Arg Arg Asn Tyr Leu Pro T Stop

Figure. Updated pedigree for the Kentucky family and their mutation. A, Information about all family members examined by Critchley et al (original Figures 4 and 6 from Critchley et al2), with new data shown in blue. The proband and family members tested in the present work are indicated. B, Chromatograms obtained after sequencing exon 56 of the VPS13A gene in an unaffected individual (control) and in the Kentucky family member II-29 showing the CϾT transition at position c.7867 (p.R2623X) detected in this family. Identical chromatograms showing this mutation in heterozygosis were obtained for family members carrying haplotype 1 (eTable 3 and eFigure, http://www.archneurol.com) as well as for “proband 23”11 and her father.

METHODS (II-6, II-29, II-30, II-31, and II-32) of an affected individual would be a heterozygous carrier of a VPS13A mu- To determine whether the original condition reported for this tant allele. Blood samples were collected from family mem- family was indeed ChAc, we screened the causative gene, bers II-29, II-30, II-31 (presumably heterozygous), II-7 VPS13A, for mutations.11 The study was approved by the rel- (probably heterozygous), and I-8 (50% probability of being evant institutional review boards. Consent was obtained and heterozygous). After DNA amplification and sequenc- DNA was isolated from blood (Nucleon BACC2 kit; Tepnel Life ing, a nonsense mutation in exon 56 of the VPS13A gene Sciences, Manchester, England) or saliva (Oragene OG-500; (c.7867CϾT; p.R2623X) was found in family member DNA Genotek, Kanata, Ontario, Canada) samples from the ap- II-7. We then checked for this mutation in the other 4 propriate family members. For the initial mutation screening, available samples and found this mutation in all indi- all translated exons plus flanking regions were amplified by poly- viduals (Figure, B). This mutation has previously been merase chain reaction and sequenced using standard proto- described in a patient with ChAc (“proband 23”), re- cols. For genotyping, 10 polymorphic microsatellite markers 11 on chromosome 9 flanking the VPS13A gene and single- ported as compound heterozygous. nucleotide polymorphism rs10869920 (c.9077-133, intron 67) A second change was also detected in all 5 analyzed were analyzed (eTable 1, http://www.archneurol.com). Hap- samples in the amplified flanking region of exon 68 lotypes were constructed manually by minimization of recom- (c.9077-262CϾT, in intron 67). This change does not bination events between markers and confirmed using Mer- appear as a single-nucleotide polymorphism in any da- lin.12 Original medical records from the initial evaluation of the tabase and we could not detect it in 180 control chro- proband at the University of Kentucky, Lexington, were re- mosomes. However, its location in an intronic position viewed for additional information. far away from the splicing consensus sequences sug- gests that it probably does not have any pathogenic effect. RESULTS To have a clearer genetic picture for this family, additional (saliva) samples from other available poten- Part A of the Figure shows the updated pedigree of the tially informative members were collected (Figure, A) to Kentucky family reported by Critchley et al.2 The pro- perform genotyping. These samples were examined for band’s only surviving sibling (I-8 in the Figure), now aged the 2 changes mentioned earlier. Blood samples were ob- 78 years, has features consistent with Parkinson dis- tained from both parents of proband 23. This family trio ease. No family members were affected outside the pro- was analyzed as described earlier and additionally for the band’s generation. If the underlying disease in this fam- 2 mutations previously reported (c.7867CϾT and ily is autosomal recessive ChAc, any direct descendant c.1208_1211del),11 which we found were from paternal

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©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 and maternal origin, respectively. Haplotypes were con- cidental. The presence of acanthocytosis in confirmed structed with these data (eTable 2) and for all analyzed or deduced heterozygotes I-1, I-6, and II-7 in the origi- individuals and all family members for whom they could nal report2 is intriguing. Heterozygotes have not been be deduced (eTable 3 and eFigure). routinely examined using a standard protocol for the Medical records from the evaluation of the proband presence of hematological abnormalities, and indeed, at the University of Kentucky in the 1960s confirmed the the detection of acanthocytes is often problematic even presence of marked dysarthria, dysphagia, weight loss, in affected subjects; thus, the effect of a single mutation hypotonia, areflexia, distal sensory loss, chorea, dysto- on erythrocyte membranes remains an unanswered nia, and severe tongue biting. Basal ganglia atrophy was question. found on pneumoencephalogram, and acanthocytosis was Genetic and phenotypic heterogeneity in the early found on peripheral blood smear. cases of NA has resulted in clinical and diagnostic confusion, which has been resolved in part by the use of molecular methods.5 Molecular confirmation of the COMMENT diagnosis in one of the original families supports the concept that the term Levine-Critchley syndrome Identification of a disease-associated nonsense mutation described, at least in part, what is now recognized as in the VPS13A gene strongly supports the diagnosis of ChAc. The disorder in Dr Levine’s family appears to autosomal recessive ChAc in this family. This diagnosis have been inherited in an autosomal dominant manner, is also entirely concordant with the clinical phenotype which would exclude the diagnosis of ChAc. However, as initially reported2 and confirmed in the medical rec- this assumption must be qualified by noting that indi- ords. The genotyping analyses showed that the detected viduals termed affected possessed a variety of neurologi- nonsense mutation and the additional change in intron cal signs with variable presence of acanthocytosis.1 67 were part of haplotypes 1 and D in the Kentucky and Genetic studies of this family (reported as the “Goode proband 23 families, respectively, and that these 2 hap- family of New England”14) would complete the molecu- lotypes shared the same alleles in the region harboring lar identification of the eponymous disorder. the VPS13A gene (eTable 2). Recurrent VPS13A mutations are not typical but have occasionally been re- Accepted for Publication: January 10, 2011. ported.13 The explanation for the same mutation arising Correspondence: Ruth H. Walker, MB, ChB, PhD, De- independently 2 or more times can be found in particular partment of Neurology (127), James J. Peters Veterans sequences that could be especially vulnerable to chemi- Affairs Medical Center, Bronx, NY 10468 (ruth.walker cal change or DNA replication errors.11 However, a founder @mssm.edu). effect is the most probable explanation for recurrent mu- Author Contributions: Dr Walker had full access to all tations, in particular when a geographical connection can of the data in the study and takes responsibility for the be established between 2 given pedigrees.13 The shared mu- integrity of the data and the accuracy of the data analy- tation was found on the paternal side of the family of pro- sis. Study concept and design: Velayos-Baeza, Danek, and band 23, which can be traced back to Kentucky ancestry, Walker. Acquisition of data: Velayos-Baeza, Holinski- although a direct link between the families could not be Feder, Neitzel, Bader, Critchley, Danek, and Walker. confirmed. The genotyping data mentioned earlier prac- Analysis and interpretation of data: Velayos-Baeza, Holinski- tically confirm that both families have inherited a com- Feder, Neitzel, Monaco, Danek, and Walker. Drafting of mon ancestral allele. the manuscript: Velayos-Baeza and Walker. Critical revi- Haplotype combinations 1-2, 1-3, and 2-3 detected/ sion of the manuscript for important intellectual content: deduced in the proband’s siblings I-8, I-1, and I-7, and Velayos-Baeza, Holinski-Feder, Neitzel, Bader, Critch- 1-6 in the proband’s half-sibling I-12, indicate the pres- ley, Monaco, and Danek. Obtained funding: Velayos- ence of only 3 different haplotypes (1, 2, and 3) in the Baeza, Bader, and Monaco. Administrative, technical, and proband’s parents (0-1 and 0-2) and that haplotype 1 was material support: Velayos-Baeza, Holinski-Feder, Neitzel, present in the proband’s father (0-2) (eTable 3 and eFig- Bader, Monaco, Danek, and Walker. Study supervision: ure). Therefore, the only possible haplotype combina- Velayos-Baeza, Holinski-Feder, Monaco, and Walker. tions for 0-1/0-2 are (1) 1-2/1-3 or (2) 1-3/1-2, which im- Financial Disclosure: None reported. ply that the proband (I-10) and his affected siblings (I-2, Funding/Support: This work was supported by a grant I-4, I-5, and I-9) were homozygous for the c.7867CϾT from the Advocacy for Neuroacanthocytosis Patients (the mutation (for haplotype 1, assuming no recombina- Mary Kinross Charitable Trust and the Chaney family) tion). Strictly speaking, 2 more haplotype combinations (Drs Velayos-Baeza and Monaco) and grant 075491/ could be possible: (3) 2-3/1-2 and (4) 2-3/1-3. How- Z/04 from the Wellcome Trust (Drs Velayos-Baeza and ever, they can be dismissed on the basis that a second Monaco). unidentified mutation would then need to be associated Online-Only Material: The eTables and eFigure are avail- with haplotype 3 (3) or 2 (4) and, therefore, individuals able at http://www.archneurol.com. I-1 (3) or I-8 (4) would have been affected. Moreover, Additional Contributions: We thank the family for their none of these 2 haplotypes were found in 3 direct de- participation in this study, especially C. S., who initi- scendants of the affected family member I-9. ated the study and coordinated all sampling, and Di- To our knowledge, there are no reports of neurologi- anna Ross, BS, MT (ASCP), for assistance with phle- cal disease in confirmed VPS13A heterozygotes; thus, botomy. We also thank Franca Cambi, MD, of the we suspect that Parkinson disease in sibling I-8 is coin- University of Kentucky, Lexington, for assistance in ob-

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©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 taining medical records. We acknowledge the role of the 7. Ueno S, Maruki Y, Nakamura M, et al. The gene encoding a newly discovered late David Clark, MD, University of Kentucky, in origi- protein, chorein, is mutated in chorea-acanthocytosis. Nat Genet. 2001;28(2): 121-122. nally recognizing the disorder and providing the impe- 8. Ho M, Chelly J, Carter N, Danek A, Crocker P, Monaco AP. Isolation of the gene tus for reporting it. for McLeod syndrome that encodes a novel membrane transport protein. Cell. 1994;77(6):869-880. REFERENCES 9. Hayflick SJ, Westaway SK, Levinson B, et al. Genetic, clinical, and radiographic delineation of Hallervorden-Spatz syndrome. N Engl J Med. 2003;348(1): 33-40. 1. Levine IM, Estes JW, Looney JM. Hereditary neurological disease with acantho- 10. Walker RH, Rasmussen A, Rudnicki D, et al. Huntington’s disease–like 2 can pre- cytosis: a new syndrome. Arch Neurol. 1968;19(4):403-409. sent as chorea-acanthocytosis. Neurology. 2003;61(7):1002-1004. 2. Critchley EM, Clark DB, Wikler A. Acanthocytosis and neurological disorder with- 11. Dobson-Stone C, Danek A, Rampoldi L, et al. Mutational spectrum of the CHAC out betalipoproteinemia. Arch Neurol. 1968;18(2):134-140. 3. Critchley EM, Nicholson JT, Betts JJ, Weatherall DJ. Acanthocytosis, normoli- gene in patients with chorea-acanthocytosis. Eur J Hum Genet. 2002;10(11): poproteinaemia and multiple tics. Postgrad Med J. 1970;46(542):698-701. 773-781. 4. Walker RH, Jung HH, Dobson-Stone C, et al. Neurologic phenotypes associated 12. Abecasis GR, Cherny SS, Cookson WO, Cardon LR. Merlin: rapid analysis of dense with acanthocytosis. Neurology. 2007;68(2):92-98. genetic maps using sparse gene flow trees. Nat Genet. 2002;30(1):97-101. 5. Gandhi S, Hardie RJ, Lees AJ. An update on the Hardie neuroacanthocytosis series. 13. Dobson-Stone C, Velayos-Baeza A, Jansen A, et al. Identification of a VPS13A In: Walker RH, Saiki S, Danek A, eds. Neuroacanthocytosis Syndromes II. Ber- founder mutation in French Canadian families with chorea-acanthocytosis. lin, Germany: Springer-Verlag; 2008:43-51. Neurogenetics. 2005;6(3):151-158. 6. Rampoldi L, Dobson-Stone C, Rubio JP, et al. A conserved sorting-associated 14. Chitchley E. Acanthocytosis associated with tics and involuntary movements. protein is mutant in chorea-acanthocytosis. Nat Genet. 2001;28(2):119-120. Z Neurol. 1971;200(4):336-340.

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