Clinical and Pathologic Features of Families with LRRK2-Associated Parkinson’S Disease

J Neural Transm (2006) [Suppl] 70: 221–229 # Springer-Verlag 2006

Clinical and pathologic features of families with LRRK2-associated Parkinson’s disease

N. R. Whaley1, R. J. Uitti1, D. W. Dickson2, M. J. Farrer2, and Z. K. Wszolek1 1 Department of Neurology, and 2 Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA

Summary. The etiology for Parkinson’s dis- inclusions containing protein aggregates, and ease (PD) remains unknown. Genetic causes the loss of dopaminergic neurons in the pars have been identified with several distinct compacta of the substantia nigra (SN). PD mutations. Recently, 9 mutations involving affects 1% of individuals aged 65 years or a novel gene, leucine-rich repeat kinase 2 older, a prevalence second only to Alzheimer’s (LRRK2), have been identified as the cause disease among neurodegenerative disorders. of autosomal dominant PD in kindreds, with The etiology of idiopathic PD is unknown. some of them previously linked to the PARK8 However, genetic causes have now been iden- locus on chromosome 12. LRRK2 mutations tified with several distinct mutations (Eriksen are relatively common genetic causes of fa- et al., 2005). milial and sporadic PD. In addition, these Recently, 9 mutations involving a novel mutations have been identified in diverse pop- gene, leucine-rich repeat kinase 2 (LRRK2), ulations. The clinical and pathologic features have been identified as the cause of autoso- of LRRK2-associated PD are indistinguish- mal dominant PD in kindreds, with some of able from idiopathic PD; however, consider- them previously linked to the PARK8 locus able clinical and pathologic variability exists on chromosome 12 (Paisan-Ruiz et al., 2004; even among kindreds. This short review Zimprich et al., 2004a, b; Di Fonzo et al., highlights the clinical and pathologic features 2005; Gilks et al., 2005; Kachergus et al., in LRRK2-associated parkinsonism. 2005; Nichols et al., 2005). The LRRK2 gene encodes LRRK2, a large protein comprising Abbreviations 2,527 amino acids and belonging to the ROCO group within the Ras=GTPase super- 18F-dopa 18F-6-fluoro-L-dopa, LB Lewy family (Zimprich et al., 2004a). The function bodies, LRRK2 leucine-rich repeat kinase 2, of LRRK2 protein is currently unknown. PD Parkinson’s disease, PET positron emis- In this review, we describe the clinical and sion tomography, SN substantia nigra. pathologic features in families with LRRK2- Introduction associated PD.

Parkinson’s disease (PD) is typiﬁed clinically Sagamihara Family by bradykinesia, rigidity, postural instability, and rest tremor and pathologically by both the In 2002, Funayama et al. (2002) identiﬁed a presence of Lewy bodies (LB), eosinophilic novel locus, PARK8, on chromosome 12q12 2 .R hlye al. et Whaley R. N. 222

Table 1. Clinical and pathologic features of families with LRRK2-associated Parkinson’s disease

Feature Family 3 Unrelated Family 111 English patients Sagamihara family Family D (Wszolek Family A (Wszolek (Gilks et al., 2005) (Funayama et al., 2002) et al., 1995, 2004) et al., 1997)

Ancestral origin Japan USA Canada, Germany UK USA y Mutation, substitution 6059T>C, I2020T 4321C>T, R1441C 5096A>G, Y1699C 6055G>A, G2019S 6055G>A, G2019S Gene domain MAPKKK Roc COR MAPKKK MAPKKK No. affected 47 22 16 NA 2 Average age at onset, y 54 65 53 NA 68 Additional features None SnGP D, A, Dys NA D, RLS, OH No. of autopsies; 4; ‘‘pure’’ ND 4; ND in all, 3; ND in all, LB 3; ND and LB in all, 1; ND, LB in SN, pathologic features LB in brainstem in limbic cortex in 1, LB in limbic cortices brainstem, amygdala, in 1, widespread ubiquitin inclusions in 2, SP and NFT in 1 and basal nucleus in 1, tau in 1 in 2, anterior horn of Meynert axonal spheroids in 1

A amyotrophy; D dementia; Dyst dystonia; LB Lewy bodies; NA not available; ND nigral degeneration; NFT neurofibrillary tangles; OH orthostatic hypotension; RLS restless legs syndrome; SN substantia nigra; SnGP supranuclear gaze palsy; SP senile plaques. Only LRRK2 families with previously y published postmortem neuropathologic examinations are included. Official LRRK2 gene=protein nomenclature derived from GenBank Accession: AY792511 Features of LRRK2 Families 223 that cosegregates with autosomal dominant now includes 208 family members with 16 parkinsonism in a family from Sagamihara, affected individuals. Japan, consisting of 31 individuals from 4 Recently, 5 members from Family A and generations. Recently, the presence of a 10 from Family D were examined using pos- LRRK2 mutation, 6059T>C (I2020T), was itron emission tomography (PET) (Adams confirmed in 19 affected members of this et al., 2005). The PET findings in these pa- family (Funayama et al., 2005). tients with autosomal dominant parkinsonism were indistinguishable from those typical of Clinical features idiopathic PD. The findings on PET included reductions in 18F-6-fluoro-L-dopa (18F-dopa) The mean age of affected family members at uptake, binding of 11C-(þ=)a-dihydrotetrabe- onset of symptoms was 51 years. The disease nazine to the vesicular monoamine transporter, affected men and women equally. The parkin- and binding of 11C-d-threo-methylphenidate sonian features were unilateral at onset and to the dopamine transporter; intact postsy- responded favorably to dopaminergic agents. naptic dopamine D2 receptors; and dopa- All affected members had the constellation of minergic neuron dysfunction involving the rest tremor, bradykinesia, rigidity, and postur- putamen with sparing of the caudate nucleus. al instability. No dementia or other neurologic features were reported. Clinical features of Family D Pathologic features The clinical features included all 4 cardinal signs of PD – rigidity, bradykinesia, asym- Postmortem examination performed on 4 af- metric rest tremor, and postural instability. fected members revealed pure nigral degen- Nine individuals were treated with levodopa eration with the absence of LB (Table 1). and responded favorably. The average age of symptom onset was 65 years (range, Family D (Western Nebraska) 48–78 years). The first sign of PD was bra- and Family A (German–Canadian) dykinesia in 9 patients and resting tremor in 6 patients. One patient had both bradykinesia Zimprich et al. (2004b) searched for the and resting tremor. This information was not PARK8 locus in 167 individuals (84 affected available for 6 patients from older gener- and 83 unaffected) derived from 21 Caucasian ations. No additional clinical features such as families with autosomal dominant PD. pyramidal, cerebellar, sensory, ocular, or auto- Significant linkage to the PARK8 locus was ob- nomic dysfunction were identified. However, served in 2 large families previously described 1 affected family member with PD subse- clinically and pathologically by Wszolek quently developed supranuclear gaze palsy at et al. (1995, 1997, 2004) and referred to as the age of 83 years, 5 years after onset of her Family D (Western Nebraska) and Family A motor symptoms. She died 6 years later. She (German–Canadian). Zimprich et al. (2004a) remained responsive to levodopa therapy until first identified the LRRK2 mutation for her death. Family D (4321C>T [R1441C]) followed > shortly by that for Family A (5096A G Pathologic features of Family D [Y1699C]) in April 2004. Both families are Caucasian with Family D probably of Four autopsies of affected Family D members English extraction and Family A of German were performed (Wszolek et al., 2004). All origin. At present, the Family D pedigree 4 had neuronal loss and gliosis in the SN. includes 190 family members with 22 af- LB were seen in 2 individuals, which was fected individuals. The Family A pedigree limited to the SN in 1 case and with more 224 N. R. Whaley et al. widespread, general distribution in the other. ently unrelated kindreds from the Basque No distinctive pathology was identified in the region of Spain. In addition, they described third case. The fourth subject who presented Family PL, a British pedigree comprising 22 with PD and supranuclear gaze palsy had members, 12 of whom were affected and found tau-positive neurofibrillary tangle pathology to have an autosomal dominant parkinsonism without LB (Table 1). caused by a different LRRK2 mutation.

Clinical features of Family A Clinical features of the Basque families The average age of symptomatic onset was All 4 Basque families demonstrated the cardi- 53 years (range, 35–65 years). Unilateral rest- nal clinical signs of PD with good responses ing tremor was the initial sign. Bradykinesia, to dopaminergic agents and typical levodopa- rigidity, and resting tremor were observed related complications. In general, the disease in all family members affected with PD. started with a unilateral rest tremor. Amyotrophy (muscle weakness, atrophy, and Family UGM03 was a pedigree of 62 in- fasciculations) was seen in 1 affected indi- dividuals spanning 4 generations with 9 af- vidual who also had features of PD. Demen- fected members. The mean age of onset was tia alone was observed in 2 family members 66 years (range, 50–79 years). In addition to from the German branch. Those treated rest tremor, a minority of individuals had ini- with dopaminergic agents benefited clinically tial symptoms of gait dysfunction. Dementia but later experienced dose wearing off, peak- was not observed in this family. Family dose dyskinesia, and unpredictable on–off UGM04 comprised 11 individuals spanning phenomenon. 2 generations with 3 affected members. The mean age of symptomatic onset was 62 years Pathologic features of Family A (range, 59–64 years). No dementia was observed in affected members. Other features Detailed postmortem examinations were per- reported were hyperreflexia and Babinski formed on 2 Canadian members of Family A. signs. Family UGM05 had 30 members from A single microscopic slide of brain tissue 3 generations with 8 affected individuals. (basal portion of the pons) was available for The mean age of onset was 58 years (range, examination for 1 additional affected mem- 57–60 years). In addition to rest tremor, the ber and showed no abnormalities. Results of disease began as unilateral clumsiness in most, the 2 more extensive neuropathologic exam- with foot dystonia in half the affected indivi- inations revealed severe loss of pigmented duals. Postural instability was not reported, neurons with extracellular melanin in the SN. although 1 individual had severe gait abnor- Neuronal loss and gliosis in SN with ubiqui- malities. This member also had paranoid de- tin-immunoreactive neuronal lesions were lusions that preceded dopaminergic therapy. also identified. LB were not seen in SN. This Family UGM06 was the largest of the 4 ped- subject also had Alzheimer’s disease pathol- igrees, with 106 members spanning 4 genera- ogy. The other case with clinical features of tions with 15 affected members. The mean age amyotrophy had mild motor neuron disease of symptomatic onset was 61 years (range, (Table 1). 59–64 years). No dementia was reported in the affected members. Basque Families and Family PL Clinical features of Family PL Paisan-Ruiz et al. (2004, 2005) described an autosomal dominant form of parkinsonism The clinical features of Family PL were not with a LRRK2=dardarin mutation in 4 appar- specified but were reportedly similar to the Features of LRRK2 Families 225 phenotype observed among the Basque kin- members who were not examined ranged in dreds (Paisan-Ruiz et al., 2004). age from their mid 50s to late 70s. The initial symptom in all affected members was a Pathologic features unilateral rest tremor. The member studied responded well to levodopa for 15 years after Autopsies were not performed for any of the which she developed a drug-induced on–off Basque families or for Family PL. phenomenon, which interfered with gait, and dyskinesias, which lead her to opt for a pal- Family 292 and Family 415 lidotomy. The surgery alleviated some drug- Recently, Hernandez et al. (2005) described related fluctuations and dyskinesia; however, the clinical and PET characteristics of 2 10 years later her gait dysfunction worsened, North American families with autosomal do- necessitating use of a wheelchair. minant parkinsonism, Family 292 of English Pathologic features descent and a Russian Ashkenazi Jewish family referred to as Family 415. Probands from Autopsies were not performed on members both families have a LRRK2 6055G>A of either family. (G2019S) mutation. The authors reported only abridged pedigrees for both families. LRRK2 in diverse populations

Clinical features Pathogenic LRRK2 mutations are relatively common and present in diverse geographic Five members from Family 292 were exam- populations. The following studies describe ined. The average age at onset of symptoms individuals with parkinsonism that is clini- was 58 years. In general, the presenting cally indistinguishable from PD. In all stud- symptom in these patients was unilateral rest- ies, the individuals with LRRK2-associated ing tremor. Rigidity and bradykinesia were parkinsonism had variable age of disease also typical among the affected members. onset, even among kindreds. A slower disease Although the occurrence of postural instabil- progression compared with idiopathic PD has ity was not reported, gait problems developed been reported (Nichols et al., 2005). Incom- 10 years after disease onset in 3 of the 5 plete age-dependent penetrance was also do- family members examined. Four of the 5 in- cumented (Di Fonzo et al., 2005; Kachergus dividuals responded well to dopaminergic et al., 2005; Nichols et al., 2005). agents. Zimprich et al. (2004a) identified 4 (9%) PET with 18F-dopa imaging was per- of 44 PD families each with a different formed on 2 affected members, 1 genetically LRRK2 mutation. These families originated unaffected sibling, and 3 next-generation fam- from Austria, Germany, and the United States. ily members. Imaging demonstrated uptake Subsequently, Kachergus et al. (2005) identi- reductions in the caudate nucleus and put- fied the commonest known LRRK2 mutation, amen of the 2 affected family members. These 6055G>A (G2019S), by sequencing multi- responses were typical but less than expected plex families with autosomal dominant par- compared with individuals of similar disease kinsonism linked to PARK8. They reported duration with idiopathic PD. No abnormal- that 7 (2.8%) of 248 affected individuals with ities were seen on PET in the family members familial PD had a G2019S LRRK2 substitu- studied. tion. These individuals were derived from One member of Family 415 was examined. families with ancestral roots in the United At onset of symptoms, she was 54 years old. States, Norway, Ireland, and Poland. Di The ages of symptomatic onset for 5 affected Fonzo et al. (2005) reported that 4 (6.6%) 226 N. R. Whaley et al. Features of LRRK2 Families 227 of 61 individuals from geographically diverse associated parkinsonism, a relatively common PD families, including some asymptomatic genetic cause of familial and sporadic PD. carriers. The frequency of a LRRK2 G2019S In general, mutations in the LRRK2 gene are mutation in familial parkinsonism was ex- associated with disease that is, for the most amined by Nichols et al. (2005). Thirty-five part, indistinguishable from idiopathic PD. (5%) of 767 affected individuals from 358 Clinically, LRRK2-associated PD is charac- multiplex families tested positive for LRRK2 terized by the presence of cardinal features 6055G>A (G2019S) mutation. of PD, responds to levodopa therapy, and The LRRK2 6055G>A (G2019S) substi- has a similar age of onset. However, addi- tution has been reported in individuals with tional signs such as dementia, pyramidal apparent idiopathic PD. Six individuals were signs, and amyotrophy have been reported. observed to have the G2019S substitution Some patients also exhibited postural tremor, among a cohort of 806 European descendants dystonia, and restless legs syndrome. The age with idiopathic PD (Kachergus et al., 2005). of symptomatic onset for LRRK2-associated Three of the 6 did not have a family history PD is variable even in kindreds, causing both of PD. Gilks et al. (2005) estimated that the early- and late-onset disease. Penetrance ap- mutation may be responsible for idiopathic pears to be incomplete and age dependent, PD in a clinic-based study where 8 (1.6%) which could explain the large range of age of 482 individuals tested positive for the of disease onset and the presence of LRRK2 6055G>A (G2019S) mutation. Three of these substitutions in asymptomatic family mem- individuals had autopsies performed (Table 1). bers (this is particularly evident for G2019S Short clinical and pathologic descriptions carriers). Disease progression with LRRK2- of an affected individual from one of our associated PD may be slower than that of families (Family 111) with the LRRK2 idiopathic PD (Nichols et al., 2005). Pathologic 6055G>A (G2019S) mutation are presented variability has been demonstrated in family in Fig. 1 and Table 1. The index case from members that have come to autopsy and in this family developed restless legs syndrome recent Brain Bank series (Wszolek et al., during the course of his illness, suggesting 2004; Zimprich et al., 2004a; Gilks et al., that restless legs syndrome may be part of the 2005; Ross et al., 2005). While nigral de- phenotype in G2019S substitution carriers. generation is universal, and LB are often reported, alternate pathologies are possible even Discussion with the same family. Most notably, tau pathology (neurofibrillary tangles) and ubiqui- This short review highlights some of the tin pathology have been described (Zimprich clinical and pathologic features in LRRK2- et al., 2004a). This variability in pathology

1 Fig. 1. Family 1244 (LRRK2 G2019S mutation). The proband presented with gait dysfunction at the age of 68 years. Therapy with levodopa=carbidopa was initiated at the age of 78 years with good response. Subsequently, restless legs syndrome (RLS), dyskinesias, and cognitive impairment developed. Examination at 81 years revealed asymmetric rigidity, bradykinesia, and severe postural instability. No rest tremor was noted. Mini-Mental Status Examination score was 26=30 at age 81 years and 18=30 at age 82 years. Orthostatic hypotension was confirmed by autonomic studies. However, he was on combined therapy with levodopa=carbidopa, 1,500 mg=d, and pramipexole, 0.75 mg=d. He died of pneumonia at the age of 84 years. Postmortem neuropathologic examination showed transitional Lewy body disease affecting the limbic structures, with severe neuronal loss, gliosis, and axonal spheroids in the substantia nigra (a). Lewy bodies were detected in brainstem nuclei (b, c), the amygdala (d), and the basal nucleus of Meynert (e). Neuritic pathology was marked in amygdala and also present in hippocampal CA2 region (f) 228 N. R. Whaley et al. would suggest that mutations leading to mutation in idiopathic Parkinson’s disease. Lancet LRRK2 dysfunction may interfere with cellu- 365: 415–416 Hernandez DG, Paisan-Ruiz C, McInerney-Leo A, Jain lar pathways ultimately resulting in tau, ubi- S, Meyer-Lindenberg A, Evans EW, Berman KF, quitin, or a-synuclein depositions, all thought Johnson J, Auburger G, Schaffer AA, Lopez GJ, to be associated with neurodegeneration. Nussbaum RL, Singleton AB (2005) Clinical Genetic testing can now aid in the diag- and positron emission tomography of Parkinson’s nosis of PD. Future studies are needed to disease caused by LRRK2. 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Wszolek ZK, Vieregge P, Uitti RJ, Gasser T, Yasuhara Zimprich A, Muller-Myhsok B, Farrer M, Leitner P, O, Mcgeer P, Berry K, Calne DB, Vingerhoets FJG, Sharma M, Hulihan M, Lockhart P, Strongosky A, Klein C, Pfeiffer RF (1997) German–Canadian Kachergus J, Calne DB, Stoessl J, Uitti RJ, Pfeiffer family (family A) with parkinsonism, amyotrophy, RF, Trenkwalder C, Homann N, Ott E, Wenzel K, and dementia: longitudinal observations. Parkin- Asmus F, Hardy J, Wszolek Z, Gasser T (2004b) sonism Relat Disord 3: 125–173 The PARK8 locus in autosomal dominant parkin- Zimprich A, Biskup S, Leitner P, Lichtner P, sonism: conﬁrmation of linkage and further deli- Farrer M, Lincoln S, Kachergus J, Hulihan M, neation of the disease-containing interval. Am J Uitti RJ, Calne DB, Stoessl AJ, Pfeiffer RF, Hum Genet 74: 11–19 (Erratum in: Am J Hum Patenge N, Carbajal IC, Vieregge P, Asmus F, Genet 75: 534) Muller-Myhsok B, Dickson DW, Meitinger T, Strom TM, Wszolek ZK, Gasser T (2004a) Muta- Author’s address: Z. K. Wszolek, MD, Department tions in LRRK2 cause autosomal-dominant par- of Neurology, Mayo Clinic, 4500 San Pablo Road, kinsonism with pleomorphic pathology. Neuron Jacksonville, FL 32224, USA, e-mail: wszolek. 44: 601–607 [email protected]