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Complicated Spastic Paraplegia in Patients with AP5Z1 Mutations (SPG48)

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Complicated Spastic Paraplegia in Patients with AP5Z1 Mutations (SPG48) Complicated spastic paraplegia in patients with AP5Z1 mutations (SPG48) Jennifer Hirst, PhD* ABSTRACT * Marianna Madeo, PhD Objective: Biallelic mutations in the AP5Z1 gene encoding the AP-5 z subunit have been * Katrien Smets, MD described in a small number of patients with hereditary spastic paraplegia (HSP) (SPG48); we James R. Edgar, PhD sought to define genotype–phenotype correlations in patients with homozygous or compound Ludger Schols, MD, heterozygous sequence variants predicted to be deleterious. Dr med Methods: We performed clinical, radiologic, and pathologic studies in 6 patients with biallelic Jun Li, MD, PhD mutations in AP5Z1. Anna Yarrow, BA z Tine Deconinck, MSci Results: In 4 of the 6 patients, there was complete loss of AP-5 protein. Clinical features encom- Jonathan Baets, MD, passed not only prominent spastic paraparesis but also sensory and motor neuropathy, ataxia, dysto- PhD nia, myoclonus, and parkinsonism. Skin fibroblasts from affected patients tested positive for periodic Elisabeth Van Aken, MD, acid Schiff and autofluorescent storage material, while electron microscopic analysis demonstrated PhD lamellar storage material consistent with abnormal storage of lysosomal material. Jan De Bleecker, MD, Conclusions: Our findings expand the spectrum of AP5Z1-associated neurodegenerative disorders PhD and point to clinical and pathophysiologic overlap between autosomal recessive forms of HSP and Manuel B. Datiles III, lysosomal storage disorders. Neurol Genet 2016;2:e98; doi: 10.1212/NXG.0000000000000098 MD Ricardo H. Roda, MD, GLOSSARY PhD HSP 5 hereditary spastic paraplegia; NCS 5 nerve conduction study; PAS 5 periodic acid-Schiff; PSP 5 progressive supra- 5 Joachim Liepert, MD nuclear palsy; SCA spinocerebellar ataxia. Stephan Züchner, MD, AP-5 is an adaptor protein that facilitates vesicular-mediated intracellular sorting and trafficking of PhD Caterina Mariotti, MD transmembrane cargo proteins. AP-1 and AP-2 are the cardinal members of this protein family and Peter De Jonghe, MD, assist in clathrin-based receptor-mediated endocytosis and intracellular trafficking, respectively. AP-5 PhD acts independently of clathrin in the endolysosomal system and is comprised of b5, zz5, m5, and s5 Craig Blackstone, MD, subunits. Although the identity of AP-5 cargo(es) remains unknown, this adaptor protein clearly has PhD an important role in normal physiology, evidenced by the recent identification of biallelic mutations Michael C. Kruer, MD in the z subunit (AP5Z1) in some patients with hereditary spastic paraplegia (SPG48).1–3 Recent findings indicate that 2 hereditary spastic paraplegia (HSP)-associated proteins, SPG11/ spatacsin and SPG15/spastizin, interact with AP-5,4 suggesting that common molecular mecha- Correspondence to Dr. Kruer: nisms may be at work. Patients with autosomal recessive loss-of-function SPG11 or SPG15 [email protected] *These authors contributed equally. From the Cambridge Institute for Medical Research (J.H., J.R.E.), University of Cambridge, Addenbrooke’s Hospital, UK; Children’s Health Supplemental data Research Center (M.M., A.Y.), Cancer Biology Research Center, Sanford Research, Sioux Falls; Neurogenetics Group (K.S., T.D., J.B., P.D.J.), at Neurology.org/ng Department of Molecular Genetics VIB, Antwerp, Belgium; Department of Neurology (K.S., J.B., P.D.J.), Antwerp University Hospital, Belgium; Laboratories of Neurogenetics and Neuropathology (K.S., T.D., J.B., P.D.J.), Institute Born-Bunge, University of Antwerp, Belgium; Department of Neurology (L.S., J. Liepert), Hertie Institute for Clinical Brain Research, Tübingen, Germany; German Center for Neurodegenerative Diseases (DZNE) (L.S.), Tübingen, Germany; Department of Neurology (J. Li), Vanderbilt University, Nashville, TN; Department of Ophthalmology (E.V.A.), Department of Neurology (J.D.B.), Ghent University Hospital, Belgium; National Eye Institute (M.B.D.), National Institutes of Health, Bethesda, MD; Cell Biology Section (R.H.R., C.B.), Neurogenetics Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Department of Neurology (R.H.R.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurorehabilitation (J. Liepert), Kliniken Schmieder, Allensbach, Germany; Department of Human Genetics and Hussman Institute for Human Genomics (S.Z.), Miller School of Medicine, University of Miami, FL; Genetics of Neurodegenerative and Metabolic Diseases Unit (C.M.), IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy; Departments of Child Health, Neurology & Genetics (M.C.K.), University of Arizona College of Medicine, Phoenix; Program in Neuroscience (M.C.K.), Arizona State University, Tempe; and Pediatric Movement Disorders Program and Neurogenetics Research Program (M.C.K.), Barrow Neurological Institute, Phoenix Children’sHospital,AZ. Funding information and disclosures are provided at the end of the article. Go to Neurology.org/ng for full disclosure forms. The Article Processing Charge was paid by the authors. This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially. Neurology.org/ng © 2016 American Academy of Neurology 1 ª 2016 American Academy of Neurology. Unauthorized reproduction of this article is prohibited. mutations exhibit closely overlapping clinical ethanol before being embedded in EPON in beam capsules and – features, which include thin corpus callosum, cured overnight at 65°C. Ultrathin (50 70 nm) conventional sections were cut using a diamond knife mounted to a Reichart retinal abnormalities, sensory and motor neu- Ultracut S ultramicrotome. Sections were collected onto copper ropathy, mild ataxia, cognitive impairment, and grids and stained using lead citrate. They were viewed using an parkinsonism. The parkinsonism in SPG11 FEI Tecnai transmission electron microscope (Eindhoven, the and SPG15 patients can be particularly prom- Netherlands) at 80 kV. inent, with some patients presenting with juve- Standard protocol approvals, registrations, and patient nile parkinsonism responsive to dopaminergic consents. Patients were recruited into a local institutional review – therapy.5 board and/or ethics committee approved research protocols, and written informed consent for participation was obtained. We present a series of patients with homozy- gous or compound heterozygous mutations in Nonsense mutations. Patient 1. This patient, in his 70s at the AP5Z1. Most patients presented with spastic time of examination, was born to first-generation immigrant parents who hailed from the same city in Germany, but without paraparesis. Additional features included ataxia, known consanguinity. Medical history revealed macular degen- dystonia, intellectual impairment, myoclonus, eration, hypertension, and mild hearing loss that began in his late and parkinsonism. One patient presented with 50s. The patient presented for evaluation after he developed a stiff, shuffling gait at age 60, leading to frequent tripping and pure sensory and motor neuropathy. Patient- occasional falls. This gradually progressed to the point where he derived fibroblasts demonstrated an accumula- needed a walker to ambulate. He also experienced frequent tion of autofluorescent and multilamellar storage cramping of the lower limbs. As his gait problems progressed, his material. These findings expand the spectrum of family noted facial hypomimia and bradykinesia. He developed a spastic bladder and pain and numbness in both feet. AP5Z1-associated complicated hereditary spastic On examination, the patient exhibited prominent lower paraplegia. extremity spasticity with mild distal muscle weakness and mild weakness of the hip flexors. Cognition was intact. Cogwheel rigidity was evident in the upper limbs, and this increased with METHODS Skin biopsy was performed, and fibroblast cell reinforcement. He had slow rapid alternating movements, mild lines were established using standard methods. Genomic DNA dysmetria, and a coarse, low-frequency rest tremor (video 1) in was extracted from whole blood. addition to a higher-frequency kinetic tremor. Mild spastic dysar- Exome sequencing was performed after target capture using thria was evident. Sensory examination revealed loss of vibratory an Agilent SureSelect or Illumina TruSeq kit and run on an Illu- sensation in the great toes. Mild foot dystonia was seen, greater in mina HiSeq2000 or HiSeq2500 as per the manufacturer’s the left than in the right, with curling of the toes. Gait was both instructions, employing 101-bp paired-end read sequencing. spastic and parkinsonian (video 2). Reads were mapped to the reference genome using the Burrows- An EMG/NCS (nerve conduction study) was performed 2 Wheeler Aligner and processed using the Genome Analysis Tool- years prior to evaluation and showed slight slowing of tibial kit. Data for patient 1 were analyzed using bam2mpg (e-Methods and peroneal motor velocities. Needle EMG showed mild chronic at Neurology.org/ng). Missense variants were sought in public re-innervation in distal leg muscles, sparing the upper extremity, databases to determine minor allele frequencies (ExAc, EVS) thoracic paraspinal, and upper trapezius muscles. Together, these and interrogated in silico to predict the damaging effects (SIFT, findings were thought to be consistent with
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