J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.49.1.77 on 1 January 1986. Downloaded from

Journal ofNeurology, Neurosurgery, and Psychiatry 1986;49:77-86

Neonatal

PATRICK AUBOURG,* JACQUES SCOTTO,t FRANCIS ROCCHICCIOLI,§ DELPHINE. FELDMANN-PAUTRAT,l OLIVIER ROBAINt

From Service de Neuropediatrie, * and INSERM U 154, t Hopital Saint-Vincent-de-Paul, Paris, INSERM U 56, Hopital Bicetre, Bicetre, t Departement de Biochimie (INSERM U 75), Faculte de Medecine Necker-Enfants Malades, Paris§ Laboratoire de Biochimie, Hopital Trousseau, Parisl France

SUMMARY Nine cases of neonatal adrenoleukodystrophy are described. All patients had abnor- mal facial features, moderate to severe , , and retinitis pigmentosa. The clinical course was rapidly progressive in six cases and more protracted in three others. Biological signs of adrenal insufficiency were present in five cases. CT scan showed a demyelinating process in four patients. Trilamellar inclusions were found in the liver of four cases and dark and complex lipidic inclusions in three other cases. In the three necropsied patients there was severe alteration of the white matter involving particularly the cerebellum in two cases. Gyral and cytoarchitec- tonic disturbances were absent in all three cases. Increased plasma levels of very long chain fatty acids (8/8), (7/8) and bile fluid trihydroxycoprostanic acid (2/4) confirmed the deficiency of multiple peroxisomal enzymes. Clinical, histopathological and biochemical findings of these nine cases are compared to those reported in other neolatal adrenoleukodystrophy cases Protected by copyright. and to those of other neonatal peroxisomal disorders, that is cerebro-hepato-renal syndrome of Zellweger and infantile Refsum's .

Childhood adrenoleukodystrophy has been recog- respect to age of onset, occurrence of retinal pig- nised for over half century as a neurodegenerative mentary degeneration and liver involvment. disorder.' 2 Adrenomyeloneuropathy represents Benke et a16 have drawn attention to the ressemb- probably a phenotypic adult variant of the same dis- lance between cerebro-hepato-renal syndrome and ease.3 Adrenoleukodystrophy and adrenomyelo- neonatal adrenoleukodystrophy, and Goldfischer"5 neuropathy are frequently observed in the same postulated that both form a closely related group of kindred and have an X-linked mode of inheritance. peroxisomal disorders. Evidence to support this Neonatal forms have also been described.4'3 It is view came from the lack of hepatic in obvious now that childhood adrenoleukodystrophy both disorders" 1216 and increased plasma and cul- and neonatal adrenoleukodystrophy are two differ- tured skin fibroblasts very long chain fatty acids http://jnnp.bmj.com/ ent .'4 '5 Neonatal adrenoleukodystrophy -reflecting impaired a-oxidation of those subs- appears to be autosomal recessive and has never trates.' 17 Recently, Poulos et al'8 have pointed out been observed in the same kindred with childhood that infantile Refsum's disease'920 may also be a adrenoleukodystrophy and adrenomyeloneuro- possible variant of Zellweger's syndrome. Those pathy. Neonatal adrenoleukodystrophy differs finding raise the question of whether neonatal sharply from childhood adrenoleukodystrophy with adrenoleukodystrophy and cerebro-hepato-renal syndrome are phenotypic variants of a specific enzyme deficiency or separate disease springing on September 24, 2021 by guest. from different mutations. We report the clinical observations and biochemi- cal findings of nine cases of neonatal Address for reprint requests: Dr P Aubourg, Service de adrenoleukodystrophy and the histopathological Neuropddiatrie H6pital Saint Vincent-de-Paul, 74 Avenue Denfert-Rochereau, 75674, Paris Cedex, France. data of three of them, which may throw some light upon this still confused area of peroxisomal disor- Received 26 February 1985. Accepted 22 April 1985 ders. 77 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.49.1.77 on 1 January 1986. Downloaded from

78 Aubourg, Scouo, Rocchiccioli, Feldmann-Pautrat, Robain Table 1

General Case 1 2 3 4 Birth weight (g) 3680 3860 2960 2600 Head circwnference (cm) 38 34 35 34 Sex (MIF) F F F F Family history Parents None Parents Sister of consanguinous consanguinous case 3 Clinical features Initials symptoms At birth: At birth: At birth: At birth: Hypotonia Mild Stridor stridor Convulsions hypotonia Severe Severe Poor feeding hypotonia hypotonia Convulsions Convulsions convulsions (2 mths) (day 1) (day 9) Lethargic lethargic Clinical signs at the 1 mth 3 mth 15 day 7 mth first examination Head circumference >95th percentile >70th percentile >80th percentile >95th percentile Hypotonia ++ ++ +++ +++ Deep tendon reflexes Brisk Brisk Decreased Decreased Babinski sign + + + + Deafness + + + + Retinal pigmentary degeneration +, pale optic disks + - + Diffuse amyotrophy - + +++ +++ Hepatomegaly + + + + Clinical signs of adrenal insufficiency By 7 mths: Persistent No Neurological course decreased convulsions development deep tendon worsening skills. reflexes, after 5 mths Persistent convulsions convulsions less frequent Protected by copyright. No development skills. Worsening after 12 mths. Died at 14 mths Died at 7 mths Died at 1 mth Died at 8 mths Hypotonia: + =-mild, + + = moderate, + + + = severe. Babinski sign, Deafness, Retinal pigmentary degeneration, Hepatomegaly, Clinical sign of adrenal insufficiency: + = present, - = absent. Diffuse amyotrophy: - = absent, + = mild, + + = moderate, + + + = severe. http://jnnp.bmj.com/

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Neonatal adrenoleukodystrophy 79

5 6 7 8 9 3000 2370 3150 3100 2450 35 33 33 33 35 M M M M M Brother of None None None Parents case 3 consanguinous

1-3 month: 2-4 month: 2-4 month: At birth: Stridor Mild Poor feeding jaundice Massive Severe hyptonia Failure to failure to hyptonia hypotonia Failure to thrive thrive Absence of Convulsions thrive Impaired mild hypotonia respiratory movements (day 5) vision Impaired lethargic Deafness (4-6 mths) vision 2 mth 4 mth 9 mth 8 mth 15 day >70th percentile >50th percentile >50th percentile >50th percentile >90th percentile ++ + + ++++ Decreased Decreased Normal Normal Absent + -+ +_ + -+__ + +, pale optic disks +, pale optic disks + cataract -, pale optic disks +++ ~++ -+++ + + + +_

No Occular Blindness at Head control No development pursuit 8 mths, head at 6 mths, convulsion skills at 5 mths, control at occular head control 10 mths, pursuit with

at 7 mths, sit convulsions nystagmus Protected by copyright. with support at 20 mths at 7 mths at 9 mths. No Worsening No convulsion convulsion. after 12 mths Worsening after 12 mths Died at 4 mths Died at 14 mths Died at 26 mths Alive at 13 mths Died at 1 mth

Methods 4 and 5 had dyspnoea and inspiratory stridor from birth. Slowly progressive respiratory difficulty in cases 3 and 4 Methods used for neuropathological, adrenal gland and required temporary tracheal intubation. Patient 9 showed liver studies have been previously described.2' Liver biopsy no respiratory movements from birth and required full samples from cases 1, 2, 6, 7, 8 and 9 were examined at 2, ventilatory support until his death. On the other hand, 3, 5, 9, 8 and 1 months respectively. Two liver biopsy patients 6, 7 and 8 were in a less severe condition during samples from case 4 were studied at 20 days and 7 months. the first months of life. Facial features of patient 7 (fig 1C) The procedure used for the determination of bile acids showed some similarity to those of the patient described by

concentrations in fluids and for the analysis of very long Brown et al.'0 In all those three patients, psychomotor http://jnnp.bmj.com/ chain fatty acids and phytanic acid in the plasma have been retardation became obvious only by the age of 4-7 months, previously reported.2223 and failure to thrive and/or jaundice were the most impor- tant initial clinical problems. Vision was moderately Clinical summaries impaired up to 4-6 months. Psychomotor development stopped at 7 and 12 months respectively for patients 6 and Table 1 summarises the clinical data of the nine patients. 7, followed by a period of rapid decline. All had abnormal facial features with dolichocephaly, mongoloid slant of palpebral fissures, and anteverted nos- trils. However, the dysmorphic features and the clinical Results on September 24, 2021 by guest. course were different in the nine cases. Patients 1 and 2 (fig to be like the described by Benke 1A) appeared patient LABORATORY, RADIOLOGICAL AND et al,6 while patients 3, 4, 5 and 9 (fig IB) had small trian- gular shaped face and small eyes. All patients appeared to NEUROPHYSIOLOGICAL STUDIES be severely ill from birth. Convulsions were the most Table 2 summarises the main data in eight patients. noticeable problem for the first months of life in cases 1 Liver dysfunction was present in. three cases, mild and 2. The four other newborns showed a peculiar lack of adrenal insufficiency in five patients (1, 4, 5, 8, 9) adipose tissue and severe amyotrophy at birth. Patients 3, and CSF protein was increased in three. Elec- J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.49.1.77 on 1 January 1986. Downloaded from

80 Aubourg, Scotto, Rocchiccioli, Feldmann-Pautrat, Robain Table 2 Case no. 1 2 4 5 6 7 8 9 Transaminases Normal Normal Normal Normal Increased( x 3) Increased( X4) Increased( x4) Normal Coagulation clots Normal Normal Normal Normal Normal Decreased Normal Normal VII + X Fasting blood Low Normal Low Normal ND Normal Normal Normal cortisol (3 mth) (6 mth) (1 mth) ACTH (pg/ml) 60 72 379 140 ND 92 183 202 CSF protein (g/l) 0-42 0-46 0-25 ND 0-71 0 33 0-25 0-27 Extinguished Yes Yes Yes Yes Yes Yes Yes Yes Electroretino- gram Electrocepha- Slow waves Slow waves Sharp waves Slow waves Left spikes Normal at Slow waves Slow waves logram 1-3 Hz 1-5 Hz 2-4 Hz 2-3 Hz slow waves 9 mth 3 Hz 1- Hz right and sharp waves bilateral asymetric 3 Hz bilateral right spikes left spikes spikes spikes spikes at 20 mth Electromyogram Polyphasic Mild Normal Normal Polyphasic Normal Normal Decreased motor unit polyphasic motor unit duration and potentials motor unit potentials amplitude of at 6 mth potentials at 6 mth motor unit at 7 mth potential at 1 mth Nerve conduction 22 m/s 21 m/s Normal 15 m/s Normal Normal Normal Normal velocity (SPE nerve) (SPE nerve) (SPI nerve) at 6 mth 21 m/s 28 m/s at 2 mth (ulnar nerve) (ulnar nerve) at 6 mth at 7 mth CT scan Mild atrophy Mild vermis Mild atrophy Oedematous Normal at Mild atrophy Normal at Oedematous at 1 mth. and and density of 4 mth at 8 mth 6 mth density of Oedematous cerebellar oedematous white matter Oedematous white mattei

density of atrophy at density of at 2 mth density of at 1 mthProtected by copyright. white matter 3 mth white matter white matter at 7 mth at 3 and 7 at 16 mth mth ND = not done. ACTH, normal <90 pg/ml. tromyography (EMG) showed polyphasic motor four patients, whereas C24: 0 levels appeaied within potentials in three patients (1, 2, 6) suggesting a the normal range in six. One patient (case 2) had neurogenic process but nerve conduction velocity only slightly increased levels of C26: 0. Phytanic acid (NCV) was decreased in two cases only (1, 2). In levels were strongly increased in two patients (6, 8) case 9, EMG showed decreased duration and amp- and slightly in five. litude of unit potentials suggestive of a myopathic Bile acids analysis from samples of duodenal fluid process. CT scan showed a demyelinating process in aspirates were performed in two patients (6, 8) and five patients (1, 4, 5, 7, 9). showed increase levels of trihydroxycoprostanic As shown in table 3, the levels of plasma C26: 0 acid. Small traces of dihydroxycoprostanic and var- fatty acid were increased in eight patients, and anic acids were found. In two other patients (cases 2 C26: 1 in seven. All but one patient had increased and 7), serum bile acids concentrations were nor- mal. C24:O/C22:0 ratios. C22:0 levels were decreased in http://jnnp.bmj.com/ Table 3 Very long chain fatty acids, and phytanic acid content in plasma (pMIl). Trihydroxycoprostanic acid content in bile or - - plasma (,uMII) C22:0 C24:0 C26:0 C26:1 C24/C22 C26/C22 Phytanic Trihydroxy acid coprostanic acid 1 20 94 57-07 6-14 2-87 2-72 0 293 5-70 ND' 2 23-62 14-60 1-31 0-319 0-618 0-055 2-39 Absent (serum)

4 7 04 19-28 13-54 8-71 2-73 1-92 12-34 ND' on September 24, 2021 by guest. 5 40-72 53-76 14-43 6-08 1-32 0-354 18-31 ND' 6 7-54 12-85 4-11 3-76 1-70 0545 136-37 952 (bile) 17% of total bile acids 7 12-16 17-64 6-29 3-81 1 45 0-517 449 Absent (serum) 8 10-17 11-10 6-22 4-12 1-09 0-611 32-75 377 (bile) 13% of total bile acids 9 27-70 33-62 2-85 4-12 1-21 0-102 8-66 ND' Controls2 38-2± 27-4 0-35 0-2 0-68 0-011± 2-09 n= 40 19-0 ±16-2 ±0-19 ±0.1 ±0-20 0-007 ±1-35 1: not done, 2: mean ±SD. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.49.1.77 on 1 January 1986. Downloaded from

Neonatal adrenoleukodystrophy 81 rovilli were sometimes dilated and their lumen was filled with deposits of loose membranous material. In the second liver sample of case 4, the homogene- ous bodies and the dilatation of bile canaliculi could no longer be found but the steatosis was more marked. Lipid vacuoles have an unusual pattern and were divided in compartments by a ribbon-like mat- erial of interconnecting membranes (fig 3). In hepatocytes this material appeared to result from clustering of altered smooth membranes (fig 4). No trilamellar inclusions were found in those 4 cases. In cases 6, 7, 8 and 9, mesenchymal cells con- tained ovoid or spindle-shaped inclusions with irregular outlines and some spike-like protusions. Their light or dense matrix was filled with globules of various densities and rectilinear lamellae showing a trilamellar structure (fig 5a). Hepatocytes also Fig 2 Case 4. First liver biopsy, parenchymal liver cells. included heterogeneous dense bodies and trilamel- Cluster ofjet-black bodies located near a dilated bile lar structures (fig 5b). Lipid vacuoles identical to canaliculus (uranyl acetate and lead citrate, x10,000). those encountered in cases 1, 2, and 4 were scanty. Peroxidatic activity of catalase in peroxisomes was studied in case 8: no activity could be detected. Liver biopsy However, the hepatocytic cytoplasm of all the liver Ultrastructural findings were nearly similar in cases samples showed the presence of microbodies whose 1, 2, and 4. The main ultrastructural change in these structure looked like peroxisomes. Their number Protected by copyright. cases was the presence of peculiar cytoplasmic dense and size were strikingly decreased (fewer than 50 bodies (fig 2). These jet-black structures were found microbodies per hepatocyte), and they were even to have irregular, angular outlines and a distinct absent in case 8. In all our cases, the mitochondria limiting membrane with a cleft-like space separating were morphologically normal. them from the surrounding cytoplasm. These spaces were probably due to technical artefacts related to Neuropathological study the hardness of their structure. The dark bodies Brain. The brain weight was increased in two of were generally located in the hepatocytes near bile canaliculi but were also found in some duct and mesenchymal cells. Bile canaliculi with loss of mic- http://jnnp.bmj.com/ on September 24, 2021 by guest.

A17 -:::r, .2 Fig 4 Case 4. Second liver biopsy. Exfoliated membranes Fig 3 Case 4. Second liver biopsy. In a parenchymal ofthe smooth endoplasmic reticulum appear in the hepatic cell, a lipid vacuole is divided in compartments by a cytoplasm ofa hepatocyte. Isolated dark bodies, numerous ribbon like membranous material (uranyl acetate and lead in thefirst biopsy are stil occasionallyfound (uranyl acetate citrate, xI0,000). and lead citrate, x30,000). J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.49.1.77 on 1 January 1986. Downloaded from

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Fig 5 Case 6. (A). In a hepatic mesenchymal cell, inclusion with a matrix ofvariable density contains globules ofvariable density and trilamellar structures (uranyl acetate and lead citrate, x30,000). (B). Hepatocyte cell contains the same trilamellar structures and jet-black bodies which are located near a lysosome?<>,# .,ti.(uranyl;- .,:i,._.-.8 acetate and lead citrate, x30,000). the three examined cases (1, 4). No significant cal layers or in the subcortical white matter of the abnormalities of cortical cytoarchitecture were cerebral hemispheres. Each olivary nucleus was found to have normal morphology. found except in case 2 in which there was severe Protected by copyright. cortical atrophy. In all cases, there was a severe Electron microscopic study was performed upon degeneration of the white matter involving both necropsy specimens. Ultrastructural preservation of cerebral and cerebellar hemispheres while axons tissue was poor. In addition to numerous lipid drop- were preserved. In case 4, demyelination was strik- lets, histiocytic cells and astrocytes contained dark ing in the cerebellar white matter and in the tegmen- inclusions with complex lamellar profiles and irregu- tum of the brain stem (fig 6). In cas!W 1, demyelina- lar electron dense bodies. Neither trilamellar inclu- tion was also particularly important in the cerebellar sions nor mitochondrial abnormalities could be white matter with many cuffs of mononuclear cells observed. (fig 7). Heterotopic Purkinje cells were found to be Sural nerve biopsy specimen (case 1) showed a aggregated in irregular clumps in the subcortical decreased density of myelinated sheaths with pre- areas of the cerebellar cortex in cases 1 and 4 (fig 8). servation of Schwann cells and axons. No trilamellar No heterotopic neurons were observed in the corti- inclusions were found in the Schwann cells. http://jnnp.bmj.com/

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Fig 6 Case 4. Cerebellar white matter and brain stem tegmentum showing severe demyelinadion. Note the normal Fig 7 Case 1. CerebeUlar white matter: gliosis ofthe white convolution ofboth principal inferior olivary nuclei (Loyez, matter and perivascular cuffs ofmononuclear cells (H and x2-1). E, x288).4w WeX.-I; J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.49.1.77 on 1 January 1986. Downloaded from

Neonatal adrenoleukodystrophy 83 ous only after 4-6 months of age, but the elec- troretinogram was early extinguished. Elevated levels of plasma very long chain fatty acids confirmed the diagnosis. Pipecolic acid was found to be normal in the urines of three cases studied (1, 4, ,' . ;' ,'> 8) as in some other neonatal adrenoleukodystrophy cases.'2 Increased ACTI-f plasma levels suggesting an abnormal adrenal function were found in four cases, and low morning serum cortisol without rise after IV ACTH (case 1) in a fourth case. Adrenal glands were studied in one case showing atrophy and v t * ; _ ,> >E ballooned cortical cells without striated cells. The apparently normal adrenal function observed in two _ r: # cases with normal ACTH levels is not incompatible * S. with this diagnosis. Powers et a124 have shown that 8, C * . "-' . 8 x <, from fetuses (childhood - n fetal adrenal glands £ _ z *. < adrenoleukodystrophy) with abnormal fatty acids in cultured amniotic cells contain striations and lamel- i -';; zl*'',t,: w, *#Z|w ';;'h *o lae pathognomonic of adrenoleukodystrophy. How- ;, * ever, in this latter disorder, it is shown that signs of adrenal failure may be absent or of delayed onset.' 2 .. A demyelinating process was observed in three nec- **;*ii^ 0,,9 >>*e ropsied cases (1, 2, 4) and was demonstrated on CT scan in three other patients 3, 7, 9. The distinction 6z..aP.} between neonatal adrenoleukodystrophy and child- Protected by copyright. *4|'t*b; is clear but the situa- hood adrenoleukodystrophy *,,%S tion in regard to cerebro-hepato-renal syndrome and neonatal adrenoleukodystrophy is less well defined. The resemblance includes the onset of disability in Fig 8 Case 1. Heterotopic Purkinje cells in the subcortical the neonatal period, hypotonia with convulsions, white matter ofthe cerebellar cortex (Nissl, xl13). retinal pigmentary degeneration with the presence of bileaflet inclusions and increased very long chain fatty acids in the retina,25 hepatomegaly with mic- Adrenal gland study (case 1) ronodular cirrhosis and trilamellar fatty acid inclu- The adrenal glands were atrophic and weighed 2 g sions,21 26 striated adrenocorticalad21ancells'4 21 and each. The main histological features were the pres- increased very long chain fatty acids in plasma''21 27 ence of ballooned cortical cells in the zona fas- and brain.'7 However, infants with cerebro-hepato- ciculata and reticularis, and the persistence of the renal syndrome have a more severe neurologic fetal zone of the adrenal cortex. No striated cell was deficit and rarely survive beyond the fifth month.

seen. Ultrastructural study was not performed. The strikingly dysmorphic facial features are http://jnnp.bmj.com/ observed in all cerebro-hepato-renal syndrome Discussion patients, which is not the case in neonatal adrenoleukodystrophy. Eventually, cerebral The criteria used for assignment of a patient to the abnormalities observed in neonatal adrenoleukodys- neonatal adrenoleukodystrophy category have been trophy as found in our cases are different from those the onset of disability in the neonatal period, encountered in cerebro-hepato-renal syndrome.21 28 involvement of adrenal cortex and cerebral white As in some neonatal adrenoleukodystrophy 7 matter and increased very long chain fatty acids in reports,5 0 we found no gyral and cytoarchitectonic on September 24, 2021 by guest. plasma, cultured skin fibroblasts, brain and adrenal disturbances in the cerebral hemispheres. Some gland.5-'0-2 3 Clinical and biological data warrant Purkinje cells were found to be present in the sub- the inclusion of our nine patients in this category. cortical white matter of the cerebellum but the All patients had in common development delay inferior olivary nuclei showed a normal morphology. from birth, craniofacial dysmorphism, moderate to Abnormalities of gyration with "micropolygyria" severe hypotonia, hepatomegaly and retinitis pig- have been reported by some authors'69 but the mentosa. Pigmentary changes in the eyes were obvi- highly characteristic disorder of neuronal migration J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.49.1.77 on 1 January 1986. Downloaded from

84 Aubourg, Scotto, Rocchiccioli, Feldmann-Pautrat, Robain which seems to be constant in all cerebro-hepato- attention between 3 and 6 months of life. For some renal syndrome patients has never been found in patients, psychomotor development stops between 1 neonatal adrenoleukodystrophy. and 2 years and is followed by a rapid decline and The situation in regard to neonatal death (refs 5-8, our cases 6 and 7). In the third adrenoleukodystrophy and infantile Refsum' s dis- group of patients, the course is more progressive. ease is more complex. The clinical features of the Some children can sit or walk alone by the age of infantile Refsum' s disease include retinitis pigmen- five years and may be still alive after the age of ten tosa, deafness, facial dysmorphia, growth and/or years.'0 13 19 32 mental retardation, peripheral neuropathy (incon- Absence of hepatic peroxisomes is considered to stant) and hepatomegaly.'9 20 29-32 Liver biopsy be an essential clue for the diagnosis of cerebro- shows mild to severe fibrosis and trilamellar inclu- hepato-renal syndrome but has been reported also sions in parenchymal and non parenchymal liver to occur in neonatal adrenoleukodystrophy'° 12 cells,'9 20 identical to those described in Peroxisomes could not be identified after histochem- adrenoleukodystrophy, neonatal adrenoleukodys- ical reaction in one of our cases. In the other cases, trophy and cerebro-hepato-renal syndrome. The microbodies whose ultrastructural appearance was clinical course of infantile Refsum' s disease is not as similar to were found in all the liver severe as in most patients with neonatal biopsy samples but peroxidatic activity of catalase adrenoleukodystrophy and some patients survive was not studied. Microbodies were detected in the beyond the tenth year. The patients described by liver of our cases, but their number and size were Brown et al'0 and Noetzel et al'3 as neonatal greatly decreased as also reported by Goldfischer adrenoleukodystrophy share the same clinical fea- et al in neonatal adrenoleukodystrophy.34 tures as the three patients previously described by Various types of inclusions have been described in one of us,'9 and seem to have followed the same the liver of neonatal adrenoleukodystrophy and protracted course, these three children being still infantile Refsum' s disease including especially alive at 7, 8, and 11 years. Increased levels of plasma trilamellar inclusions (refs 11, 19, 20, and four ofProtected by copyright. very long chain fatty acids2'33 and abnormal bile our cases). Other types of hepatic inclusions have metabolites'832 have been documented in infantile been reported as "arced lamellae in plump, spindle Refsum' s disease cases. Similarly, plasma phytanic shaped cluster",5 "packed lamellar profiles"e. The acid levels are increased in infantile Refsum's dis- dark inclusions observed in three of our cases (1, 2, ease'920 as in cerebro-hepato-renal syndrome and and 4) seem to be peculiar on account of the neonatal adrenoleukodystrophy,2' reflecting a defi- homogeneous matrix, their irregular outlines and ciency in phytanate oxidase'8 20 3' which is supposed their hardness. Their ultrastructure resembled those to be located in part in peroxisome.'82' All those observed in some cases of neonatal cholestasis35 but findings suggest that infantile Refsum's disease, signs of cholestasis were mild or absent emphasising cerebro-hepato-renal syndrome and neonatal the pecularity of this ultrastructural pattern. These adrenoleukodystrophy are closely related disorders inclusions have also some similarity with those involving multiple peroxisomal enzymes deficiency. observed in cerebro-tendinous xanthomatosis,36 a If neonatal adrenoleukodystrophy and infantile possible .'5 The second biopsy Revsum's disease are overlapping disorders, an of case 4 shows that the ultrastructure may change in attempt must be made to draw borderline between the course of time. Bile canaliculi dilatation and them. The severity of the disease in children with jet-back inclusions were less numerous in hepato- http://jnnp.bmj.com/ neonatal adrenoleukodystrophy or infantile cytes and were replaced by empty and lipid-filled Revsum's disease varies greatly and three different septate vacuoles. Those complex lipidic inclusions clinical pictures at least are encountered. In some have also been reported in lymph nodes' and patients (refs 4, 9, our cases 1 to 5 and 9), the thymus9 of neonatal adrenoleukodystrophy. If neurological disability is as severe as in cerebro- trilamellar inclusions are probably related to the hepato-renal syndrome. Those children have no accumulation of very long chain fatty acids, other intellectual development and survive rarely beyond lipidic inclusions probably contain more complex the second year of life. In other patients, the clinical lipids. The various ultrastructural findings may also on September 24, 2021 by guest. course is more progressive. Neurological develop- correspond to different phases in the evolution of ment is delayed from birth but these children may the disease. acquire some psychomotor development. Most of Cerebral pathology has not been studied in infan- them can apparently see and hold the head following tile Refsum's disease, since most patients are still the first 6 months of life. Failure to thrive, moderate alive, whereas in neonatal adrenoleukodystrophy it developmental delay, hepatomegaly, hypotonia, is mainly a demyelinating process. In neonatal decreased hearing and impaired visual acuity call for adrenoleukodystrophy the distribution of the lesions J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.49.1.77 on 1 January 1986. Downloaded from

Neonatal adrenoleukodystrophy 85 is variable, and the cerebellum may be more or other biochemical disturbances. However, some involved than the cerebral hemispheres (refs 4, 7, major discrimination allows a temporary and our cases). The severity of the involve- classification. Severe clinical outcome, and neuronal ment is more severe than in cerebro-hepato-renal migration disturbances, are always encountered in syndrome, including moderate to severe gliosis, and cerebro-hepato-renal syndrome suggesting that this perivascular cuffs of mononuclear cells. This intense disease is the consequence of a specific gene muta- inflammatory cell response occuring within the tion. At the present time, there is no definite distinc- demyelinated areas (as in childhood tion between neonatal adrenoleukodystrophy and adrenoleukodystrophy) is obvious in neonatal infantile Refsum's disease but the different clinical adrenoleukodystrophy but absent in cerebro- courses observed in these diseases suggest that there hepato-renal syndrome.2' Trilamellar inclusions are may be at least three phenotypic variants of a also found in brain macrophages478 1 1 but other specific enzyme deficiency or three different muta- complex lipid and membrane aggregate inclusions tions. Liver and brain histopathological findings are (refs 4, 9, our case 4) may be seen. As in the liver, to date unhelpful in establishing a nosological the aspect of the lipid storage in the brain is variable classification but may supply some clarification and more data are required to determine whether pending to a better understanding of peroxisomal the difference in the distribution of the lesions and function, specially outer-inner membrane transport in the morphological aspects of the inclusions are of enzymes. significant. Biochemical abnormalities reflecting impairment We thank Drs C Billard, F Despert and M Voyer for of various peroxisomal enzymes have been referral of their patients. We are indebted to Dr MM documented in neonatal adrenoleukodystrophy and Ruchoux who performed liver electron microscopy infantile Refsum' s disease as in cerebro-hepato- studies of case 7, to Dr K Diebler who performed renal syndrome including impaired oxidation of very CT scan studies, to Dr P Plouin who performed long chain fatty acids and phytanic acid (refs 10, 17, EEG records, and to J Denni and R WehrlI for Protected by copyright. 18, 21, 33, and our cases), bile synthesis defect with expert technical assistance. elevated levels of certain intermediates (refs 18, 32, 37, and our cases 6 and 8) and increased plasma and References urine pipecolic acid.'8 38 Recent studies have emphasised the role of peroxisome in the synthesis iSchaumburg HH, Powers JM, Raine CS, Suzuki K, of glycerol-ether lipids39 and the presence of a defi- Richardson EP Jr. Adrenoleukodystrophy. A clinical ciency of dihydroxyacetone phosphate (DHAP) and pathological study of 17 cases. Arch Neurol 1975;32: 577-91. acyltransferase and alkyl-DHAP synthetase404' in 2 Aubourg P, Chaussain JL, Dulac 0, Arthuis M. cerebro-hepato-renal syndrome. The presence of a Adrenoleucodystrophie chez 1'enfant. A propos de 20 deficiency in synthesis is under inves- observations. Arch Fr Pediatr 1982;39-663-9. tigation in our patients but it must probably be 3Griffin JW, Goren E, Schaumburg HH, Engel WK, assumed that neonatal adrenoleukodystrophy and Loriaux L. Adrenomyeloneuropathy: a probable var- infantile Refsum' s disease patients are also deficient iant of adrenoleukodystrophy. Neurology (Minneap) in glycerol-ether lipids synthesis. In the absence of 1977;27: 1107-13. specific biochemical abnormalities, it must be 4 Ulrich J, Herschkowitz N, Heitz P, Sigrist T, Baerlocher determined whether variable deficiency in these P. Adrenoleukodystrophy. Preliminary report of a http://jnnp.bmj.com/ connatal case. Light- and electron microscopical peroxisomal enzymes or other biochemical abnor- immunohistochemical and biochemical findings. Acta malities exist accounting for the wide clinical and Neuropath (Berl) 1978;43:77-83. histopathological spectrum encountered in these Manz HJ, Schuelein M, McCullough DC, Kishimoto Y, disorders. Eiben RM. New phenotypic variant of adrenoleukodystrophy. Pathologic, ultrastructural, Conclusions and biochemical study in two brothers. J Neurol Sci 1980;45: 245-60.

Cerebro-hepato-renal syndrome, neonatal 6 Benke PJ, Reyes PF, Parker JC Jr. New form of on September 24, 2021 by guest. adrenoleukodystrophy and infantile Refsum' s dis- adrenoleukodystrophy. Hum Genet 1981;58: 204-8. 7 Haas JE, Johnson ES, Farrell DL. Neonatal-onset ease are peroxisomal disorders that share many clin- adrenoleukodystrophy in a girl. Ann Neurol ical, histopathological and biochemical features. In 1982; 12:449-57. the absence of specific biochemical abnormalities 8 Mobley WC, White CL, Tennekoon G, et al. Neonatal one should determine if the large clinical and his- adrenoleukodystrophy. Ann Neurol 1982; 12:204-5. topathological spectrum of these diseases is related 'Jaffe R, Crumrine P, Hashida Y, Moser HW. Neonatal to the variable deficiences in peroxisomal enzymes adrenoleukodystrophy. Clinical, pathologic, and J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.49.1.77 on 1 January 1986. Downloaded from

86 Aubourg, Scotto, Rocchiccioli, Feldmann-Pautrat, Robain biochemical delineation of a syndrome affecting both adrenoleukodystrophy. Am J Ophtalmol males and females. Am J Pathol 1982; 108: 100-11. 1983;96:488-501. 10 Brown III FR, McAdams AJ, Cummins JW, et al. 26 Mooi WJ, Dingemans KP, van den Bergh Weerman Cerebro-hepato-renal (Zellweger) syndrome and MA, Jobsis AC. Ultrastructure of the liver in the neonatal adrenoleukodystrophy: similarities in cerebro-hepato-renal syndrome of Zellweger. Ultra- phenotype and accumulation of very long chain fatty struct Pathol 1983;5: 135-44. acids. John Hopkins Med J 1982;151:344-61. 27 Bakkeren JAJM, Monnens LAH, Trijbels JMF, Maas "Partin JS, McAdams AJ. Absence of hepatic peroxi- JM. Serum very long chain fatty acid pattern in Zell- somes in neonatal onset adrenoleukodystrophy. weger syndrome. Clin Chim Acta 1984; 138:325-31. Pediatr Res 1983;17:294A. 28 Volpe JJ, Adams RD. 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