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The Coexistence of Multiple Sclerosis and Hereditary Spastic Paraparesis

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The Coexistence of Multiple Sclerosis and Hereditary Spastic Paraparesis Neurology International 2013; volume 5:e6 The coexistence of multiple the genes (maspardin, paraplegin, atlastin, spastin, spartin, NIPA 1, KIF5A, HSPD1, PLP1, Correspondence: I ıl Yazıcı, zmir Tepecik sclerosis and hereditary spastic LICAM, BSCL2) known to be involved in the Educatıonal and Researchş Hospıtal,İ Department paraparesis in a patient pathogenesis.8 The functions of several of of Neurology, Gazıler Street 468, Yenı ehır/Izmır, these genes are related to axonal transport or Turkey. ş I ıl Yazıcı, Nılufer Yıldırım,Ya ar Zorlu intracellular trafficking. Mostly mutations Tel. +9.0505.5238031 - Fax: +9.0232.4330756. ş E-mail: [email protected] Department of Neurology, Izmırş Tepecık spastin and atlastin genes identified in ADHSP families.3,4 Around 40% of autosomal dominant Educatıonal and Research Hospıtal, Izmir, Key words: multiple sclerosis, spastin, hereditary HSP, SPG4, is caused by mutations in the Turkey spastic paraparesis. spastin gene on chromosome 2p.6,9 HSP shares several clinical features of the progressive Conflict of interests: the authors declare no phase in Multiple Sclerosis (MS) which is a potential conflict of interests. chronic neurodegenerative disease character- Abstract ized by multiple areas of central nervous sys- Received for publication: 30 November 2012. tem (CNS) inflammation, demyelination and Revision received: 22 January 2013. Multiple sclerosis (MS) is a chronic disease axonal loss. Accepted for publication: 26 February 2013. characterized by multiple areas of central nerv- We identified a patient with clinical history This work is licensed under a Creative Commons ous system inflammation, demyelination and and investigation findings consistent with the Attribution NonCommercial 3.0 License (CC BY- axonal loss. Hereditary spastic paraparesis concurrence of both MS and HSP. Three mem- NC 3.0). (HSP) is characterized clinically by progres- bers of the family had a history likely to HSP sive spasticity and weakness of the lower limbs and three members also had a history of MS. ©Copyright I Yazıcı et al., 2013 and pathologically by retrograd axonal degen- Laboratory and radiological investigations, Licensee PAGEPress,. Italy eration of the corticospinal tracts and posteri- cognitive tests were performed. Genetic confir- Neurology International 2013; 5:e6 or columns. We identified a patient with clini- mation for spastin gene mutation has been doi:10.4081/ni.2013.e6 cal history and investigation findings consis- completed. tent with the concurrence of both MS and HSP. only Laboratory and radiological investigations, cognitive tests were performed. Genetic confir- mation for spastin gene mutation has been Case Report completed. If this coexistence is not coinci- use dence the mutation in the spastin gene may be A 34 years old male was referred to our out- a strong susceptibility locus for MS. patient clinic with one week history of tight, heavy sensation affecting his left arm and leg. Further review of his history revealed tremor at his left leg which spontaneously reverted Introduction within 24 hours aged 32 and right eye vision loss with partial resolution without any spesif- Hereditary spastic paraparesis (HSP) is a ic treatment at the age of 33. On examination, heterogeneous group of inherited disorders, he had bilateral gaze evoked nystagmus, mild with prevalence ranged from 4.3 to 9.6 cases spastic gait abnormality, left ankle clonus and per 100.000 population.1,2 HSP is characterized hipertonicity of both legs with extensor plantar clinically by progressive spasticity and weak- responses. Pinprick and vibratory sensation ness of the lower limbs and pathologically by was diminished in the feet. Laboratory tests retrograd axonal degeneration of the corti- included full blood count, electrolytes, liver cospinal tracts and posterior columns. Harding function tests, glucose, blood urea, erythrocyte (1993) divided HSP syndromes into pure and sedimentation rate, thyroid function tests, complicated types according to clinicalNon-commercial mani- immunologic study (antinuclear antibodies, festations.3,4 Pure HSP present with progres- anticardiolipin antibodies, anti-neutrophil sive gait disturbance, spasticity of lower limbs, cytoplasmic antibodies), infectious serology hiperreflexia, extensor plantar responses (syphilis, lyme disease), vit B 12, folate were added to family history.5 Complicated HSP all normal. Electromyography and nerve con- includes spasticity accompanied by muscle duction studies were normal. Visual evoked amyotrophy, optic atrophy, pigmentary responses revealed prolonged latency in the retinopathy, extrapyramidal disease, deafness, right optic pathway. Analysis of CSF could not dementia, mental retardation, ichthyosis, be performed because the patient did not peripheral neuropathy, epilepsy, ataxic syn- accept lumbar punction. Cranial MRI showed drome.6 Genetically autosomal dominant, auto- multipl hyperintense lesions in the deep and somal recessive and X-linked mode of inheri- periventricular white matter on T2 weighted tance have been described.6 Autosomal domi- and FLAIR images (Figure 1). Spine MRI was nant inheritance is most commonly associated normal. The patient was treated with intra- with püre forms of the disease, whereas auto- venous methylprednisolone for 5 days and Figure 1. Axial T2 weighted and sagittal somal recessive HSP shows greater phenotypic baclofen 20 mg/d was included in the therapy. FLAIR images show hyperintense lesions variability.7 Twenty-nine different loci of HSP On neuropsychological testing show evidence in the periventricular and subcortical white have been associated with the disease, 11 of of mild cognitive deficits in verbal function matter. [Neurology International 2013; 5:e6] [page 17] Case Report and fluency. Two years later the patient had the periventricular and subcortical white mat- made to start interferon beta 1b with the dis- one more attack. Nystagmus, hypertonicity of ter. T1 weighted images following contrast ability EDSS (Extended Disability Status both legs with extensor plantar responses, showed new enhancements at the centrum Scale) score of 2.5. Currently the patient is spastic gait abnormality and sensory loss noted semiovale and corona radiata (Figure 3). He receiving interferon beta 1b and baclofen and distally from the Th 11 level. Spinal MRI treated with ıntravenous methyprednizolone had no other relapse, his disability EDSS score demonstrated an inhomogeneous lesion (1000 mg/d) for 10 days. One years later, aged is 2.0 after four years of follow up. Family his- enhancing gadolinium in the segments 40, he had a further relapse characterized by tory revealed that the patient’s mother has (Figure 2). All the findings excluding gait right gaze evoked nystagmus, a left isolated VI. been recorded with both MS and epilepsy. The abnormality and extensor plantar responses cranial nerve palsy, pyramidal signs in all his patient’s sister has also been diagnosed as MS. were improved with the methylprednisolone limbs especially on the left; brisk reflexes in The presence of same findings of HSP had treatment. Aged 39, he was readmitted with the lower limbs, stiff-legged, unsteady gait. been determined in the patient’s aunt who is weakness in his right leg and arm. Both right This episode was again treated with pulse living in another country. The aunt’s son has hip and arm flexion weakness of 4/5, increased steroid for 10 days. Thus, the patient had clin- also been diagnosed with MS. Four generation tendon reflexes in the upper and lower limbs, ical criteria of time and space dissemination of the family pedigree is shown in the Figure 4. ankle clonus with extensor plantar responses and the diagnosis of MS was additionally cor- The patient’s 21-year-old son was affected were examined. FLAIR and T2 weighted cranial roborated by the presence of Barkhof’s criteria with the same problems as his father; but he MRI at this time showed abnormal signal in for space dissemination. The decision was developed spasticity and balance difficulty by the age of 12. On neurological evaluation he presented a severe spasticity and hyperreflex- ia of the lower limbs with extensor plantar responses. Vibration and proprioception were reduced bilaterally. On detailed neuropsycho- logical examination no cognitive decline was revealed. Magnetic resonance imaging of cra- nial and spinal cord were all normal. He had beenonly clinically diagnosed as having HSP. Genetically, SPG4 locus was detected and a heterozygous one pair deletion in exon 6 (c.310_311 insA) of the spastin gene has been usefound. This mutation has been confirmed both in the patient and the son with a clinical phe- notype of püre HSP. Discussion and Conclusions Figure 3. Axial T1 weighted images show MS is an neurodegenerative, chronic disor- contrast enhancement at the centrum der which pathogenesis is thought to involve semiovale and corona radiata. an autoimmune process that occurs in geneti- Non-commercial Figure 4. Four generation of the family. Squares indicate men, circles women and diago- Figure 2. Spinal cord magnetic resonance nal arrows indicate deceased members. Filled symbols indicate spastin gene mutation in imaging: sagittal and axial T1 after the members, question marks indicate that the people definitely or probably affected with gadolinium displays contrast enhancement HSP. Half solid symbol shows epilepsy in the member. Horizontal bar above signs indi- in the lesion T10-11. cate the people with MS. Asteriks sign indicate the proband. [page 18] [Neurology
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