Tuesday, July 28, 2020

Necrotizing encephalopathy

 A Missouri toddler is battling a rare brain disease and is in critical condition after contracting the flu.

Earlier this month 2-year-old Layla Thomas began exhibiting flu-like symptoms but, out of nowhere, Layla’s condition took a turn for the worse and on March 18 she was rushed to the hospital with a 107-degree fever, according to a GoFundMe page set up to cover her medical expenses.

Upon her arrival at the hospital, the small child tested positive for Influenza A and was diagnosed with necrotizing encephalopathy — a rare disease characterized by brain damage that usually follows an acute febrile disease, mostly viral infections.

According to the GoFundMe, little Layla’s condition is “extremely severe” and doctors haven’t seen a case like hers in over 10 years.

Until recently the rare brain disease was thought to only affect children of Asian descent as most of the reported cases were found in Taiwan and Japan, according to an article in the Journal of Clinical Imaging Science. Cases have since occurred in other parts of the world, however, the disease remains very uncommon.

Since being admitted, Layla has had blood transfusions and has been in an induced coma.

“The doctors have given her a 50/50 chance of survival but only time will tell what her outcome will be,” the GoFundMe says.


However, her family is hopeful Layla will beat the odds as she’s “showing signs of improvement every day.”

Layla’s aunt Jessica Kile opened up about the drastic series of events to KMOV St. Louis saying, “She had just a runny nose, maybe a little cough but nothing out of the ordinary that we haven’t seen before.”

“They had her hooked up to everything imaginable,” Kile told the outlet. “She’s completely unresponsive and is making small eye movements.”

Layla’s god grandmother also spoke out about the toddler’s condition on Facebook.

 “Please help my grand goddaughter in any way you can. Thank you to all of you that are praying, sending good vibes and positive thoughts for this sweet baby,” Nancy Lynn wrote on Facebook alongside a series of photos of the little girl.

According to the GoFundMe page, Layla will be in the hospital for at least a few months. “Her parents, grandparents, family and friends have been by her side 24/7.”

Dr. Rachel Orschlen, who specializes in infectious diseases told KMOV that “we are still seeing a high number of flu cases in the St. Louis area.”

Dr. Orschlen is urging parents to be aware of early-warning signs like sleepiness, seizures and los of appetite as they could all lead to Layla’s condition.

“Even with appropriate anti-viral treatments some of these severe complications can result in permanent disability or even death,” Dr. Orschlen told KMOV.

Italian gene therapy for metachromatic leukodystrophy

A family in Phoenix is desperately seeking help to afford a special treatment overseas after two of their daughters were diagnosed with an aggressive and debilitating brain disease that could ultimately kill them both one day.

Earlier this year, Dave and Kendra Riley's world was flipped upside down when they discovered that their 2-year-old daughter, Olivia, had a "highly progressive and rare genetic brain disease" called Metachromatic Leukodystrophy (MLD), according to a GoFundMe page set up on the family's behalf.

Months later, as Olivia's condition worsened to the point where she can no longer walk or talk, things became even more heartbreaking for the family after they welcomed their third daughter, Keira, and learned that she also has MLD.

As their days with Olivia become "limited," Dave, Kendra and their eldest daughter Eva, 5, now find themselves in a race against time to raise enough money by the end of July so that they can afford a special gene therapy treatment — only available in Milan, Italy — that could potentially save Keira's life.

"We have so much hope for Keira because of this treatment and want to do everything we can to give Eva (and ourselves) as many happy memories as we can with her sisters," the parents wrote on the GoFundMe. "Please help us raise enough funds to give our Keira the chance at a normal life; to save her life from the horrible disease that is MLD."

Dave and Kendra Riley. Two of their three daughters, Olivia (2 years old) and Keira (5 months old), have been diagnosed with Metachromatic Leukodystrophy (MLD)

Dave and Kendra first noticed something seemed wrong with Olivia in November 2019, according to the GoFundMe.

"Olivia began having difficulties walking, would tilt her head and we then noticed a vibration in the irises of her eye," Kendra explained. "Concerned, we took her to our pediatrician who suggested starting PT and going to an ophthalmologist."

The ophthalmologist ordered an MRI, and in the meantime, the Phoenix parents welcomed their third daughter, whom Kendra said was "perfectly healthy" at birth on Jan. 9.

But Olivia's condition continued to get worse, and Dave and Kendra were faced with even more of a challenge in getting her adequate medical attention due to the coronavirus pandemic.

After finally getting an MRI, which showed "vanishing white matter in her brain," and seeking out multiple opinions from neurologists, a genetic test confirmed that Olivia had MLD.

According to the U.S. National Library of Medicine, MLD is a genetic disorder that affects cells in the nervous system which produce myelin, the substance that insulates and protects nerves.

The disease causes a progressive loss of brain functions and motor skills, such as the ability to walk and speak. It also can lead to loss of sensation in the hands and feet, seizures, paralysis, blindness and hearing loss and eventually cause one to become unresponsive due to a "lost awareness of their surroundings."

In Olivia's case, because it presented so early, doctors have said she is not expected to live past 4 to 6-years-old, according to the GoFundMe.

"Dave and I were devastated. How could this happen to our sweet Livvy?" Kendra wrote, noting that she and Dave even had genetic testing done before they started having kids and were cleared from MLD. "Unfortunately, our form of MLD is so rare that they don’t even test for it, they only test for the five most common mutations."

Kendra and Dave eventually learned that they both carry the genetic mutation, which presents their kids with a 25 percent chance of developing MLD, so they immediately had testing done on Keira and Eva.

As they awaited the girls' results, the parents continued to take weekly trips with Olivia to Iowa, where she has been receiving treatment and medicine through a port.

"So far, we have not seen a difference but we are hopeful that it will slow the disease down so we have more time with her," Kendra wrote. "Olivia has lost her vocabulary, cannot pronounce most words, and experiences some form of pain (from moderate to severe) on a daily basis."
By June 19, results confirmed that Eva was a carrier for the disease like her parents, and will be unaffected by it, but her little sister had both mutated copies of the gene and MLD, according to the GoFundMe.

"Hearing that not one but two of my daughters’ lives will be cut short from this awful disease is too much to bare," Kendra wrote.

The parents said they immediately reached out to resources for MLD-affected families after the heartbreaking news and learned of "a cutting edge treatment option" called gene therapy, which could potentially give Keira the chance for "a normal life."

Unfortunately, the treatment is only available in Milan, and because the clinical trial was fully enrolled, Dave and Kendra said they would have to pay out of pocket for the family to move to Italy for five months.

Additionally, Dave and Kendra explained that if they were to temporarily move to Europe, they would also have to transfer Olivia's treatments there and make sure that their insurance will cover them.

"It will cost upwards of $500,000 for the treatment, lodging, travel and expenses for our girls’ day to day care," Kendra explained. "This does not include the trips we will need to take back to Italy every 6 months for Keira’s check-ups. Dave and I will also not be able to sustain a stable income while we spend this time with our girls."

With no other options, Dave's sister Nina Riley set up the GoFundMe on behalf of the family on June 25. Since then, they have raised over $171,000. A tax-deductible fundraising page was also set up on the Armer Foundation for Kids website.

"Your support will not only help save our daughter’s life but further the advancement of gene therapy, which has the potential to cure hundreds of rare diseases," Kendra wrote on the GoFundMe. "We could not thank you enough for any help or support during this time."

My advocacy for gene therapy dates back to July 5, 2012. That was the day a neurologist at Children’s Hospital of Philadelphia explained how my 2-year-old daughter, Cal, had late infantile-onset metachromatic leukodystrophy (MLD). It is caused by a single faulty gene that she inherited from both my husband and me. The genetics counselor explained that Cal had won the worst sort of lottery: MLD affects 1 in 100,000 children.

This genetic error causes fats known as sulfatides to accumulate in Cal’s cells. As they build up in cells that make myelin, the substance that insulates and protects nerves, they destroy tissue throughout the brain, spinal cord, and other parts of the nervous system.

At the time, there was no cure for MLD, and Cal was not expected to live beyond the age of 6.

A few days after the one-year anniversary of Cal’s diagnosis, Dr. Alessandra Biffi and her colleagues at the San Raffaele Scientific Institute in Milan, Italy, published a report in Science magazine about a revolutionary gene therapy for MLD. Biffi’s team had hoped the therapy would lead to a milder form of the disease. But some of the children who underwent the treatment were not developing MLD at all — a miracle to them and their families.

Cal once ran and read books and ate macaroni on her own. By the time we learned of the Italians’ breakthrough, she had stopped talking, could not see, and was essentially paralyzed. She gets nourishment through a feeding tube, and receives hospice care.

To help us cope with our grief, friends and neighbors started hosting bake sales to raise funds for fighting MLD. The first event raised $9,000. We weren’t sure what to do with it. Dr. Amy Waldman, Cal’s neurologist at Children’s Hospital of Philadelphia, made a suggestion that would change all of our lives. After reading the report by Biffi and her colleagues, she recommended that we help families get to Milan for the ongoing MLD gene therapy trial there.

Gene therapy works only to prevent the disease. Once symptoms appear, it can’t reverse the damage to the brain and central nervous system. “So how can we help other people’s children when Cal couldn’t be saved?” I asked Waldman. She explained that, since there is no newborn screening test for MLD, the birth of a child with the condition is a signal to test any other children the parents have later. So every child eligible for the gene therapy trial is a younger sibling of a child living with MLD.

A year later, when Cecelia Price from Omaha, Neb., was diagnosed with MLD because of her older sister’s diagnosis, the foundation we started was able to help send her to Milan to take part in the trial. Since then, we have sent 10 children to Italy: five from the U.S., two from the United Kingdom, one from Australia, one from Ireland, and one from Switzerland. Some of them now play baseball and soccer, attend school, and lead remarkably healthy lives. These children, who have outlived their siblings with MLD, became our investments in a miracle.


Sessa M, Lorioli L, Fumagalli F, et al. Lentiviral haemopoietic stem-cell gene therapy in early-onset metachromatic leukodystrophy: an ad-hoc analysis of a non-randomised, open-label, phase 1/2 trial. Lancet. 2016;388(10043):476-487. doi:10.1016/S0140-6736(16)30374-9


Background: Metachromatic leukodystrophy (a deficiency of arylsulfatase A [ARSA]) is a fatal demyelinating lysosomal disease with no approved treatment. We aimed to assess the long-term outcomes in a cohort of patients with early-onset metachromatic leukodystrophy who underwent haemopoietic stem-cell gene therapy (HSC-GT).

Methods: This is an ad-hoc analysis of data from an ongoing, non-randomised, open-label, single-arm phase 1/2 trial, in which we enrolled patients with a molecular and biochemical diagnosis of metachromatic leukodystrophy (presymptomatic late-infantile or early-juvenile disease or early-symptomatic early-juvenile disease) at the Paediatric Clinical Research Unit, Ospedale San Raffaele, in Milan. Trial participants received HSC-GT, which consisted of the infusion of autologous HSCs transduced with a lentiviral vector encoding ARSA cDNA, after exposure-targeted busulfan conditioning. The primary endpoints of the trial are safety (toxicity, absence of engraftment failure or delayed haematological reconstitution, and safety of lentiviral vector-tranduced cell infusion) and efficacy (improvement in Gross Motor Function Measure [GMFM] score relative to untreated historical controls, and ARSA activity, 24 months post-treatment) of HSC-GT. For this ad-hoc analysis, we assessed safety and efficacy outcomes in all patients who had received treatment and been followed up for at least 18 months post-treatment on June 1, 2015. This trial is registered with ClinicalTrials.gov, number NCT01560182.

Findings: Between April, 2010, and February, 2013, we had enrolled nine children with a diagnosis of early-onset disease (six had late-infantile disease, two had early-juvenile disease, and one had early-onset disease that could not be definitively classified). At the time of analysis all children had survived, with a median follow-up of 36 months (range 18-54). The most commonly reported adverse events were cytopenia (reported in all patients) and mucositis of different grades of severity (in five of nine patients [grade 3 in four of five patients]). No serious adverse events related to the medicinal product were reported. Stable, sustained engraftment of gene-corrected HSCs was observed (a median of 60·4% [range 14·0-95·6] lentiviral vector-positive colony-forming cells across follow-up) and the engraftment level was stable during follow-up; engraftment determinants included the duration of absolute neutropenia and the vector copy number of the medicinal product. A progressive reconstitution of ARSA activity in circulating haemopoietic cells and in the cerebrospinal fluid was documented in all patients in association with a reduction of the storage material in peripheral nerve samples in six of seven patients. Eight patients, seven of whom received treatment when presymptomatic, had prevention of disease onset or halted disease progression as per clinical and instrumental assessment, compared with historical untreated control patients with early-onset disease. GMFM scores for six patients up to the last follow-up showed that gross motor performance was similar to that of normally developing children. The extent of benefit appeared to be influenced by the interval between HSC-GT and the expected time of disease onset. Treatment resulted in protection from CNS demyelination in eight patients and, in at least three patients, amelioration of peripheral nervous system abnormalities, with signs of remyelination at both sites.

Interpretation: Our ad-hoc findings provide preliminary evidence of safety and therapeutic benefit of HSC-GT in patients with early-onset metachromatic leukodystrophy who received treatment in the presymptomatic or very early-symptomatic stage. The results of this trial will be reported when all 20 patients have achieved 3 years of follow-up.

Monday, July 27, 2020

SLC6A1 mutation

Amber Freed still remembers the life-changing devastation she felt in the summer of 2018 when she learned her young son Maxwell had been diagnosed with a disease so rare, doctors didn’t even have a name for it.

“Most of us have suffered through what we would call our lowest minute in life, like our deepest, darkest moment,” Freed, 38, tells PEOPLE. “Amplify that by exponentially 1 million times. And that’s what it feels like when your child is diagnosed with a disease that doesn’t have any name.”

Instead of sitting down and accepting the news, however, Freed took it upon herself to “fight like a mother,” raising the millions of dollars needed to fund and create a treatment all on her own, which has now been developed and is awaiting approval from the U.S. Food and Drug Administration.

“If I were doing this for myself, I would have stopped,” she says. “But I’m not doing it for myself, I’m doing it for a perfect little boy named Maxwell Freed, and I can work forever for him.”

Freed and her husband Mark, who are based in Denver, were never happier than in March 2017, when they welcomed twins Maxwell and Riley after two years of IVF treatments. 

But their joy quickly turned to concern four months later as they noticed something was wrong with Maxwell, who wasn’t matching typical milestones — like rolling over or reaching for toys — when his sister Riley was.

Despite having her initial concerns dismissed by doctors, Freed searched long and hard for an answer to her son’s struggles, and in the summer of 2018 learned the devastating diagnosis: Maxwell had SLC6A1, a neurological disease so rare, it was referred to only by its genetic location.

Freed was understandably confused by the diagnosis, which yielded zero results on a Google search and was largely unknown, save for a single article out of Denmark. Doctors couldn’t even answer whether Maxwell would live or not.

 “[They said] ‘We don’t know anything else, but hopefully you can become the expert and educate us,’” Freed recalls. “I realized that if anybody was going to cure this disease, it was going to be [my husband and I], that we had to figure this out on our own.”

With the weight of her son’s future on her shoulders, Freed quit her job as an investment analyst that same day, and soon began courting scientists to help her develop a cure, at times sending them cookies throughout the day via Uber Eats to grab their attention.

One scientist in particular — Dr. Steven Gray of the University of Texas Southwestern Medical Center — was especially tricky to pin down, so Freed hopped on a flight to Washington, D.C. and showed up at a conference she knew he’d be attending.

It was during a four-hour dinner with Gray in D.C. that Freed laid out her situation and the two teamed up, developing a plan to cure Maxwell’s disease with a carefully researched gene replacement therapy for which they would create a clinical trial themselves.

Gray warned that the process would be not only time-consuming, but costly, and that Freed should be prepared to spend anywhere between $4 and 7 million to make it work.

 “I ran by the belief that if money can solve a problem, then it’s not a problem,” she says. “I just know me as a person and I was never going to be able to live with myself had I not tried. So I said, ‘I’m all in.’”

In no time at all, Freed strapped on her fundraising boots and by the end of 2019, had raised $2 million through crowdfunding — mainly through a GoFundMe — which allowed her to fund the clinical trial and greatly expand her team.

A major breakthrough came late last year when she and her team of scientists got their hands on Chinese mice with genetics that mirrored Maxwell’s just before Christmas. Though the mice typically cost between $50,000 and $75,000 each, Freed’s tenacity paid off once again, as the scientists agreed to give her the mice for free after she got in touch.

“We’ve been able to test the gene replacement therapy in mice now, and test to make sure it’s safe,” she says. “And I think we all feel very strongly that a gene replacement therapy is safe and that we will be able to advance.”

The treatment is simple: those with the disease receive a two-hour spinal tap, where the new gene is introduced to the body through a virus that does not make humans sick. The virus then travels up through the spinal fluid into the brain, then attacks bad copies of the DNA and stacks good, working copies of the DNA to alter it permanently.

While the progress has been a huge morale booster for Freed and her family, coronavirus and the subsequent shutdown of academic labs across the country have produced major setbacks — a serious problem considering that when it comes to finding a cure for Maxwell, time is of the essence.

For the now-3-year-old Maxwell, the therapy needs to be administered before his disease develops into a debilitating form of epilepsy that could lead to irreversible brain damage – something his mom calls “a death sentence.” The epilepsy typically begins between the ages of 3 and 4.

“There’s labs that are open in Europe we can work with. We have other ways of making this happen this year,” Freed says. “We just need to raise more money.”

The gene replacement therapy must be approved by the FDA before it can be used on Maxwell – and even if it is approved, Freed says she still needs to raise another $2 million to actually make the drug and pay for the clinical trial.

Still, it's all worth it for the little boy she calls "the most loving child in the entire world."

“What we went through is just so horrifying and I never want this to happen to another family,” she says. “My dream is that in five years, this gene is on a newborn testing panel and doctors can come in and say to you, ‘This beautiful little baby you just had has been diagnosed with this horrible, rare disease, but they are going to have gene replacement therapy before you leave the hospital. And this is a once-and-done procedure and your baby will live a perfectly normal life. This is just a chapter in your book.'”


Courtesy of my daughter

Sunday, July 26, 2020

Intracerebroventricular cerliponase alfa for neuronal ceroid lipofuscinosis type 2 disease: Clinical practice considerations

de Los Reyes E, Lehwald L, Augustine EF, et al. Intracerebroventricular Cerliponase Alfa for Neuronal Ceroid Lipofuscinosis Type 2 Disease: Clinical Practice Considerations From US Clinics [published online ahead of print, 2020 May 4]. Pediatr Neurol. 2020;S0887-8994(20)30149-1. doi:10.1016/j.pediatrneurol.2020.04.018


Background: Neuronal ceroid lipofuscinosis type 2 or CLN2 disease is a rare, autosomal recessive, neurodegenerative lysosomal storage disorder caused by tripeptidyl peptidase 1 deficiency. Cerliponase alfa, a recombinant human tripeptidyl peptidase 1 enzyme, is the first and only approved treatment for CLN2 disease and the first approved enzyme replacement therapy administered via intracerebroventricular infusion.

Methods: A meeting of health care professionals from US institutions with experience in cerliponase alfa treatment of children with CLN2 disease was held in November 2018. Key common practices were identified, and later refined during the drafting of this article, that facilitate safe chronic administration of cerliponase alfa.

Results: Key practices include developing a multidisciplinary team of clinicians, pharmacists, and coordinators, and institution-specific processes. Infection risk may be reduced through strict aseptic techniques and minimizing connections and disconnections during infusion. The impact of intracerebroventricular device design on port needle stability during extended intracerebroventricular infusion is a critical consideration in device selection. Monitoring for central nervous system infection is performed at each patient contact, but with flexibility in the degree of monitoring. Although few institutions had experienced positive cerebrospinal fluid test results, the response to a positive cerebrospinal fluid culture should be determined on a case-by-case basis, and the intracerebroventricular device should be removed if cerebrospinal fluid infection is confirmed.

Conclusions: The key common practices and flexible practices used by institutions with cerliponase alfa experience may assist other institutions in process development. Continued sharing of experiences will be essential for developing standards and patient care guidelines.

Trofinetide in the treatment of fragile X syndrome

Berry-Kravis E, Horrigan JP, Tartaglia N, et al. A Double-Blind, Randomized, Placebo-Controlled Clinical Study of Trofinetide in the Treatment of Fragile X Syndrome [published online ahead of print, 2020 May 23]. Pediatr Neurol. 2020;S0887-8994(20)30150-8. doi:10.1016/j.pediatrneurol.2020.04.019


Background: We analyze the safety and tolerability of trofinetide and provide a preliminary evaluation of its efficacy in adolescent and adult males with fragile X syndrome.

Methods: This study was an exploratory, phase 2, multicenter, double-blind, placebo-controlled, parallel group study of the safety and tolerability of orally administered trofinetide in 72 adolescent and adult males with fragile X syndrome. Subjects were randomly assigned in a 1:1:1 ratio to 35 or 70 mg/kg twice daily trofinetide or placebo for 28 days. Safety assessments included adverse events, clinical laboratory tests, vital signs, electrocardiograms, physical examinations, and concomitant medications. Efficacy measurements were categorized into four efficacy domains, which related to clinically relevant phenotypic dimensions of impairment associated with fragile X syndrome.

Results: Both 35 and 70 mg/kg dose levels of trofinetide were well tolerated and appeared to be generally safe. Trofinetide at the 70 mg/kg dose level demonstrated efficacy compared with placebo based on prespecified criteria. On the basis of a permutation test, the probability of a false-positive outcome for the achieved prespecified success was 0.045. In the group analysis, improvement from treatment baseline was demonstrated on three fragile X syndrome-specific outcome measures.

Conclusions: Trofinetide was well tolerated in adolescent and adult males with fragile X syndrome. Despite the relatively short duration of the study, a consistent signal of efficacy at the higher dose was observed in both caregiver and clinician assessments, based on a novel analytical model incorporating evaluation of multiple key symptom areas of fragile X syndrome. This finding suggests a potential for trofinetide treatment to provide clinically meaningful improvement in core fragile X syndrome symptoms.

Friday, July 17, 2020

WWOX epileptic encephalopathy

Inspired by a patient

Tarta-Arsene O, Barca D, Craiu D, Iliescu C. Practical clues for diagnosing WWOX encephalopathy. Epileptic Disord. 2017;19(3):357-361. doi:10.1684/epd.2017.0924

The WW domain-containing oxidoreductase gene is implicated in autosomal recessive disorders of the central nervous system, expressed either as spinocerebellar ataxia or as a severe form with early-infantile epileptic encephalopathy. Here, we describe the electroclinical evolution of these disorders, adding new diagnostic clues based on a case study. The patient, a boy with early-onset epilepsy, presented with profound global developmental delay, persistent hypsarrhythmia, and epileptic spasms, associated with progressive cerebral atrophy without microcephaly. Metabolic disease was excluded. Whole-exome sequencing showed mutations in the WW domain-containing oxidoreductase gene. Our findings extend the phenotypic traits of this aggressive epileptic encephalopathy, with persistent epileptic spasms and hypsarhythmia as a part of the electroclinical phenotype, demonstrating that microcephaly is not mandatory for diagnosis, even when associated with progressive cerebral atrophy. These mutations might be more frequent than expected among early-onset epileptic encephalopathies. We present practical clues for the diagnosis of WWOX encephalopathy in order to avoid unnecessary investigations and ensure appropriate genetic counselling for the families.

Iacomino M, Baldassari S, Tochigi Y, et al. Loss of Wwox Perturbs Neuronal Migration and Impairs Early Cortical Development. Front Neurosci. 2020;14:644. Published 2020 Jun 11. doi:10.3389/fnins.2020.00644

Mutations in the WWOX gene cause a broad range of ultra-rare neurodevelopmental and brain degenerative disorders, associated with a high likelihood of premature death in animal models as well as in humans. The encoded Wwox protein is a WW domain-containing oxidoreductase that participates in crucial biological processes including tumor suppression, cell growth/differentiation and regulation of steroid metabolism, while its role in neural development is less understood. We analyzed the exomes of a family affected with multiple pre- and postnatal anomalies, including cerebellar vermis hypoplasia, severe neurodevelopmental impairment and refractory epilepsy, and identified a segregating homozygous WWOX mutation leading to a premature stop codon. Abnormal cerebral cortex development due to a defective architecture of granular and molecular cell layers was found in the developing brain of a WWOX-deficient human fetus from this family. A similar disorganization of cortical layers was identified in lde/lde rats (carrying a homozygous truncating mutation which disrupts the active Wwox C-terminal domain) investigated at perinatal stages. Transcriptomic analyses of Wwox-depleted human neural progenitor cells showed an impaired expression of a number of neuronal migration-related genes encoding for tubulins, kinesins and associated proteins. These findings indicate that loss of Wwox may affect different cytoskeleton components and alter prenatal cortical development, highlighting a regulatory role of the WWOX gene in migrating neurons across different species.

Kośla K, Kałuzińska Ż, Bednarek AK. The WWOX gene in brain development and pathology [published online ahead of print, 2020 May 9]. Exp Biol Med (Maywood). 2020;1535370220924618. doi:10.1177/1535370220924618

WW domain-containing oxidoreductase encoded by the WWOX gene is a transcription regulator and a key player in a number of cellular and biological processes such as tumor suppression, cell proliferation, apoptosis induction, steroid metabolism, and central nervous system development. This review provides a comprehensive summary of currently known roles and discusses the importance of WWOX gene for CNS development and functioning.

Weisz-Hubshman M, Meirson H, Michaelson-Cohen R, et al. Novel WWOX deleterious variants cause early infantile epileptic encephalopathy, severe developmental delay and dysmorphism among Yemenite Jews. Eur J Paediatr Neurol. 2019;23(3):418-426. doi:10.1016/j.ejpn.2019.02.003

The human WW Domain Containing Oxidoreductase (WWOX) gene was originally described as a tumor suppressor gene. However, recent reports have demonstrated its cardinal role in the pathogenesis of central nervous systems disorders such as epileptic encephalopathy, intellectual disability, and spinocerebellar ataxia. We report on six patients from three unrelated families of full or partial Yemenite Jewish ancestry exhibiting early infantile epileptic encephalopathy and profound developmental delay. Importantly, four patients demonstrated facial dysmorphism. Exome sequencing revealed that four of the patients were homozygous for a novel WWOX c.517-2A > G splice-site variant and two were compound heterozygous for this variant and a novel c.689A > C, p.Gln230Pro missense variant. Complementary DNA sequencing demonstrated that the WWOX c.517-2A > G splice-site variant causes skipping of exon six. A carrier rate of 1:177 was found among Yemenite Jews. We provide the first detailed description of patients harboring a splice-site variant in the WWOX gene and propose that the clinical synopsis of WWOX related epileptic encephalopathy should be broadened to include facial dysmorphism. The increased frequency of the c.517-2A > G splice-site variant among Yemenite Jews coupled with the severity of the phenotype makes it a candidate for inclusion in expanded preconception screening programs.

Yang C, Zhang Y, Song Z, Yi Z, Li F. Novel compound heterozygous mutations in the WWOX gene cause early infantile epileptic encephalopathy. Int J Dev Neurosci. 2019;79:45-48. doi:10.1016/j.ijdevneu.2019.10.003

Defects of WW domain-containing oxidoreductase (WWOX) has been associated with autosomal recessive spinocerebellar ataxia type 12 (SCAR12) and severe early-onset epileptic encephalopathy. The mutations in this gene can lead to global developmental delay, acquired microcephaly, and epilepsy. We report an infant with an autosomal recessive severe early-onset epileptic encephalopathy. Whole exome sequencing analysis was applied to the patient. Novel compound heterozygous mutations in the WWOX gene, c.173-2A > G and c.775 T > C (p.Ser259Pro), were identified. The present study expands our knowledge of WWOX mutations and related phenotypes, and provides new information on the genetic defects associated with this disease for clinical diagnosis.

Serin HM, Simsek E, Isik E, Gokben S. WWOX-associated encephalopathies: identification of the phenotypic spectrum and the resulting genotype-phenotype correlation. Neurol Sci. 2018;39(11):1977-1980. doi:10.1007/s10072-018-3528-6

Epileptic encephalopathies are a group of disorders in which epileptiform abnormalities cause progressive deterioration in cerebral function. Genetic causes have been described in several of the epileptic encephalopathies, and many previously unknown genes have been identified. WW domain-containing oxidoreductase (WWOX) has recently been implicated in autosomal recessive spinocerebellar ataxia type 12 (SCAR12) and severe early-onset epileptic encephalopathy. With whole-exome sequencing, we identified a homozygous WWOX missense mutation, p.Leu239Arg, in a girl from a consanguineous family with psychomotor developmental delay, acquired microcephaly, and epileptic seizures. WWOX-related epileptic encephalopathy is a rare condition but it should be considered in cases having early epileptic spasms and parental consanguinity.

Wednesday, July 15, 2020

Fenfluramine as treatment for Dravet syndrome

Garcia Pierce, J. and Mithal, D.S., 2020. Fenfluramine: New Treatment for Seizures in Dravet Syndrome.. Pediatric Neurology Briefs, 34, p.8. DOI: http://doi.org/10.15844/pedneurbriefs-34-8

Investigators for the FAiRE DS Study Group assessed the efficacy and safety of Fenfluramine for treating seizures in patients less than 18 y.o. with Dravet Syndrome in an international double-blind, placebo-controlled clinical trial.

Investigators for the FAiRE DS Study Group assessed the efficacy and safety of Fenfluramine for treating seizures in patients less than 18 y.o. with Dravet Syndrome in an international double-blind, placebo-controlled clinical trial. A total of 119 patients (mean age 9.0 y, 54% male) were enrolled in the study. Patients were on stable anti-epileptic drugs with poorly controlled convulsive seizures, with an average monthly convulsive seizure frequency (MCSF) of 40.3 in the prior 28 days. For a total of 14 weeks, caregivers provided participants with either placebo, Fenfluramine 0.2mg/kg/day or Fenfluramine 0.7mg/kg/day. Exclusion criteria included recent use of Stiripentol, Cannabidiol or Serotonergic medications. Importantly, patients were monitored with echocardiograms and electrocardiograms.

The study met the primary endpoint as patients saw a significant estimated decline in the MCSF relative to placebo for both Fenfluramine 0.7mg/kg/day (62.3% reduction, p>0.0001) and 0.2mg/kg/day (32.4% reduction, p=0.0209). For the higher dose of Fenfluramine, a number of secondary endpoints were met, including reduction in rescue medication use, improvements in both caregiver and investigator assessments and improvement of some behavioral measures. The high dose of Fenfluramine resulted in weight loss for patients aged 13-18 years. Adverse side-effects where reported more in both Fenfluramine groups (95%) compared to the placebo group (65%). The most common side effects were decreased appetite, diarrhea, nasopharyngitis, lethargy, and pyrexia. Fenfluramine was not associated with any cardiovascular complications.

COMMENTARY. Fenfluramine is an amphetamine derivative that was found to have anti-epileptic effects since 1980s. The medication became popular in the 1990s as an appetite suppressant but was removed from the market due to cardiovascular complications at high doses. The mechanism by which Fenfluramine treats seizures is believed to be through regulation of serotonin signaling. Invertebrate animal models with SCN1A mutations demonstrate activity at 5-HT1D and 5-HT2C receptors.

Dravet Syndrome is an epileptic encephalopathy with a significant seizure burden, often refractory to anticonvulsant treatment. In recent years, Stiripentol and Cannabidiol have been approved for the treatment of seizures in Dravet Syndrome, both having encouraging clinical trial and post-approval data. In this study 49% of patients were previously on Stiripentol and 26% were previously on Cannabidiol, indicating an ongoing need for additional treatment options.

The paper demonstrates that low dose Fenfluramine is a safe and effective add-on medication for providers to consider to significantly reduce seizure frequency in patients with Dravet Syndrome. Importantly, despite extensive monitoring, no cardiovascular risk was associated with either dose of Fenfluramine. Weight loss was a mild side effect that should be well-tolerated if a patient experiences seizure reduction. Furthermore, a separate retrospective analysis of 10 patients with Dravet Syndrome on long-term Fenfluramine (6-27 years) demonstrated better seizure control without any significant medication side effects. The promising results in this study of Fenfluramine in Dravet Syndrome raise the possibility of future studies using the medication to treat additional forms of epilepsy.

Saturday, July 11, 2020

Mutations in TOMM70, a receptor of the mitochondrial import translocase, cause neurological impairment

Inspired by a colleague's patient

Dutta D, Briere LC, Kanca O, et al. De novo mutations in TOMM70, a receptor of the mitochondrial import translocase, cause neurological impairment. Hum Mol Genet. 2020;29(9):1568-1579. doi:10.1093/hmg/ddaa081

The translocase of outer mitochondrial membrane (TOMM) complex is the entry gate for virtually all mitochondrial proteins and is essential to build the mitochondrial proteome. TOMM70 is a receptor that assists mainly in mitochondrial protein import. Here, we report two individuals with de novo variants in the C-terminal region of TOMM70. While both individuals exhibited shared symptoms including hypotonia, hyper-reflexia, ataxia, dystonia and significant white matter abnormalities, there were differences between the two individuals, most prominently the age of symptom onset. Both individuals were undiagnosed despite extensive genetics workups. Individual 1 was found to have a p.Thr607Ile variant while Individual 2 was found to have a p.Ile554Phe variant in TOMM70. To functionally assess both TOMM70 variants, we replaced the Drosophila Tom70 coding region with a Kozak-mini-GAL4 transgene using CRISPR-Cas9. Homozygous mutant animals die as pupae, but lethality is rescued by the mini-GAL4-driven expression of human UAS-TOMM70 cDNA. Both modeled variants lead to significantly less rescue indicating that they are loss-of-function alleles. Similarly, RNAi-mediated knockdown of Tom70 in the developing eye causes roughening and synaptic transmission defect, common findings in neurodegenerative and mitochondrial disorders. These phenotypes were rescued by the reference, but not the variants, of TOMM70. Altogether, our data indicate that de novo loss-of-function variants in TOMM70 result in variable white matter disease and neurological phenotypes in affected individuals.

Friday, July 10, 2020

Emanuel syndrome

Inspired by a colleague's patient

Emanuel BS, Zackai EH, Medne L. Emanuel Syndrome. In: Adam MP, Ardinger HH, Pagon RA, et al., eds. GeneReviews®. Seattle (WA): University of Washington, Seattle; 1993.

Clinical characteristics: Emanuel syndrome is characterized by pre- and postnatal growth deficiency, microcephaly, hypotonia, severe developmental delays, ear anomalies, preauricular tags or pits, cleft or high-arched palate, congenital heart defects, kidney abnormalities, and genital abnormalities in males.

Diagnosis/testing: The diagnosis of Emanuel syndrome is established in a proband by detection of a duplication of 22q10-22q11 and duplication of 11q23-qter on a supernumerary derivative chromosome 22 [der(22)].

Management: Treatment of manifestations: Care by a multidisciplinary team is usually necessary; standard management of gastroesophageal reflux, nutrition, anal atresia (or stenosis), inguinal hernias, cardiac defects, cleft palate, hip dysplasia, other skeletal complications, hearing loss, cryptorchidism and/or micropenis, refractive errors, and strabismus or other ophthalmologic issues; ongoing physical, occupational, and speech therapies; alternative communication methods to facilitate communication. Prevention of secondary complications: Attention to the airway during sedation and/or operative procedures in an institution with pediatric anesthesiologists. Surveillance: Follow up as needed based on the extent of systemic involvement in each individual; regular developmental assessments; periodic reevaluation by a clinical geneticist.

Genetic counseling: In more than 99% of cases, one of the parents of a proband with Emanuel syndrome is a balanced carrier of a t(11;22)(q23;q11.2) and is phenotypically normal. In most cases, a carrier parent has inherited the t(11;22) from one of his or her parents. When one of the parents of a proband is a carrier of the balanced t(11;22), possible outcomes of future pregnancies of the parents include: normal chromosomes, supernumerary der(22) syndrome, balanced t(11;22) carrier, and spontaneous abortion as a result of supernumerary der(22) or another meiotic malsegregant. Risks vary depending on whether the mother or father of a proband is the balanced translocation carrier. Prenatal diagnosis for pregnancies at increased risk is possible if the chromosome abnormality has been confirmed in the family.

Xie CL, Cardenas AM. Neuroimaging findings in Emanuel Syndrome. J Radiol Case Rep. 2019;13(10):1-5. Published 2019 Oct 31. doi:10.3941/jrcr.v13i10.3625

Emanuel syndrome is a rare inherited chromosomal abnormality caused by an unbalanced translocation of chromosomes 11 and 22. Clinically, Emanuel syndrome is characterized by a wide spectrum of congenital anomalies, dysmorphisms, and developmental disability often confused with other similar syndromes. Outside of genetic testing, diagnosis remains challenging and current literature on typical radiologic findings is limited. We present classic neuroimaging findings of Emanuel syndrome consistent with prior literature including microcephaly, microretrognathia, external auditory canal stenosis, and cleft palate; and also introduce the additional maxillofacial anomaly of dysplastic middle ear ossicles, to our knowledge not previously described in the literature. Recognition of findings leading to earlier diagnosis of Emanuel syndrome may improve outcomes and quality of life for patients and their families.

Liehr T, Acquarola N, Pyle K, et al. Next generation phenotyping in Emanuel and Pallister-Killian syndrome using computer-aided facial dysmorphology analysis of 2D photos. Clin Genet. 2018;93(2):378-381. doi:10.1111/cge.13087

High throughput approaches are continuously progressing and have become a major part of clinical diagnostics. Still, the critical process of detailed phenotyping and gathering clinical information has not changed much in the last decades. Forms of next generation phenotyping (NGP) are needed to increase further the value of any kind of genetic approaches, including timely consideration of (molecular) cytogenetics during the diagnostic quest. As NGP we used in this study the facial dysmorphology novel analysis (FDNA) technology to automatically identify facial phenotypes associated with Emanuel (ES) and Pallister-Killian Syndrome (PKS) from 2D facial photos. The comparison between ES or PKS and normal individuals expressed a full separation between the cohorts. Our results show that NPG is able to help in the clinic, and could reduce the time patients spend in diagnostic odyssey. It also helps to differentiate ES or PKS from each other and other patients with small supernumerary marker chromosomes, especially in countries with no access to more sophisticated genetic approaches apart from banding cytogenetics. Inclusion of more facial pictures of patient with sSMC, like isochromosome-18p-, cat-eye-syndrome or others may contribute to higher detection rates in future.

Luo JW, Yang H, Tan ZP, et al. A clinical and molecular analysis of a patient with Emanuel syndrome. Mol Med Rep. 2017;15(3):1348-1352. doi:10.3892/mmr.2017.6107

Emanuel syndrome (ES) is the most frequent type of recurrent nonRobertsonian translocation that is characterized by numerous anomalies. Over 100 patients with ES have been described in the literature. The phenotype of this syndrome varies but often consists of facial dysmorphism, microcephaly, severe intellectual disability, developmental retardation, congenital heart disease and genital anomalies. The present study describes a 2yearold boy with multiple malformations, including facial dysmorphism, severe intellectual disability, growth retardation, congenital heart disease, cleft lip and palate, genital malformation (micropenis), amblyopia, thymic dysplasia and hearing impairment. The karyotype of the patient was 47,XY,+del(22)(q13), and the maternal karyotype was 46,XX,t(11;22)(q25;q13),9qh,15p+. Singlenucleotide polymorphismarray analysis of the proband indicated a partial duplication of chromosomes 22 and 11 at 22q11.1q11.21 and 11q23.3q25, respectively, which confirmed the diagnosis of ES. To date, no cases of ES have been reported in mainland China. The present case further emphasizes the necessity and importance of highresolution techniques for genetic diagnosis and for subsequent genetic counseling. The present study contributed to the phenotypic delineation of ES and confirmed the first ES patient in mainland China.

Gemfibrozil as treatment for late infantile neuronal ceroid lipofuscinosis

Inspired by a patient's mother

Kim K, Kleinman HK, Lee HJ, Pahan K. Safety and potential efficacy of gemfibrozil as a supportive treatment for children with late infantile neuronal ceroid lipofuscinosis and other lipid storage disorders. Orphanet J Rare Dis. 2017;12(1):113. Published 2017 Jun 17. doi:10.1186/s13023-017-0663-8

Neuronal Ceroid Lipofuscinosis (NCL), also known as Batten disease, is a group of genetically distinct lysosomal disorders that mainly affect the central nervous system, resulting in progressive motor and cognitive decline primarily in children. Multiple distinct genes involved in the metabolism of lipids have been identified to date with various mutations in this family of diseases. There is no cure for these diseases but some new therapeutic approaches have been tested that offer more hope than the standard palliative care. Many of the therapeutic advances require invasive procedures but some progress in slowing the disease has been found and more options can be expected in the future. We also review the literature on children with disease/conditions other than NCL for the non-invasive use, safety, and tolerability of a lipid-lowering drug, gemfibrozil, as a potential treatment for NCLs. Gemfibrozil has shown efficacy in an animal model of NCL known as CLN2 (late infantile classic juvenile) and has been shown to be safe for lowering lipids in children. Among the 200 non-NCL children found in the published literature who were treated with gemfibrozil for NCL-related problems, only 3 experienced adverse events, including 2 with muscle pain and 1 with localized linear IgA bullous dermatitis. We conclude that gemfibrozil is safe for long-term use in children, causes minimal adverse events, is well tolerated, and may delay the progression of NCLs. Gemfibrozil may potentially be an alternative to more invasive therapeutic approaches currently under investigation and has the potential to be used in combination with other therapeutic approaches.

Ghosh A, Rangasamy SB, Modi KK, Pahan K. Gemfibrozil, food and drug administration-approved lipid-lowering drug, increases longevity in mouse model of late infantile neuronal ceroid lipofuscinosis. J Neurochem. 2017;141(3):423-435. doi:10.1111/jnc.13987

Late Infantile Neuronal Ceroid Lipofuscinosis (LINCL) is a rare neurodegenerative disease caused by mutations in the Cln2 gene that leads to deficiency or loss of function of the tripeptidyl peptidase 1 (TPP1) enzyme. TPP1 deficiency is known to cause the accumulation of autofluoroscent lipid-protein pigments in brain. Similar to other neurodegenerative disorders, LINCL is also associated with neuroinflammation and neuronal damage. Despite investigations, no effective therapy is currently available for LINCL. Therefore, we administered gemfibrozil (gem), an food and drug administration (FDA)-approved lipid-lowering drug, which has been shown to stimulate lysosomal biogenesis and induce anti-inflammation, orally, at a dose of 7.5 mg/kg body wt/day to Cln2(-/-) mice. We observed that gem-fed Cln2(-/-) mice lived longer by more than 10 weeks and had better motor activity compared to vehicle (0.1% Methyl cellulose) treatment. Gem treatment lowered the burden of storage materials, increased anti-inflammatory factors like SOCS3 and IL-1Ra, up-regulated anti-apoptotic molecule like phospho-Bad, and reduced neuronal apoptosis in the brain of Cln2(-/-) mice. Collectively, this study reinforces a neuroprotective role of gem that may be of therapeutic interest in improving the quality of life in LINCL patients.

Friday, July 3, 2020

Characterization of severe and extreme behavioral problems in patients with alternating hemiplegia of childhood

Keri Wallace, Julie Uchitel, Lyndsey Prange, Joan Jasien, Melanie Bonner, Richard D’Alli, Gary Maslow and Mohamad A. Mikati.  Characterization of Severe and Extreme Behavioral Problems in Patients with Alternating Hemiplegia of Childhood.  Pediatric Neurology.  In press.

About 41% of AHC patients have severe (26%) or extreme (15%) behaviors.
Genotype, age, puberty, and degree of ID do not correlate with behavior severity.
Medication adverse events may trigger behavioral problems, including psychosis.
Efficacy of medications for behavioral control varies among individual patients.
Collaboration with mental health professionals aids in management of AHC.


Alternating Hemiplegia of Childhood (AHC) often manifests severe or extreme behavioral problems, the nature of which remain to be fully characterized.

We analyzed 39 consecutive AHC patients for occurrence of behavioral problems and categorized those by severity: mild (not requiring intervention), moderate (requiring intervention but no risk), severe (minor risk to self and/or others) and extreme (major risk). We then analyzed behavioral manifestations, concurrent morbidity, and medication responses in patients with severe or extreme symptoms.

Two patients had mild behavioral problems, 5 moderate, 10 severe, 6 extreme and 16 none. Extreme cases exhibited disruptive behaviors escalating to assaults. Triggers, when present, included peer-provocation, low frustration tolerance, limits set by others, and sleep disruption. Reversible psychotic symptoms occurred in 2 patients; in one triggered by infection and trihexyphenidyl, and in another triggered by sertraline. Of the 16 patients with severe/extreme symptoms, 13 had concurrent neuropsychiatric diagnoses. Occurrence of severe/extreme symptoms did not correlate with age, puberty, severity of intellectual disability or mutation status (p>0.05). A multidisciplinary team including mental-health professionals co-managed all patients with severe/extreme symptoms with behavioral therapy and/or medications. When considering medications prescribed to a number of patients greater than 4, medicines that demonstrated efficacy or partial efficacy in > 50% of patients were alpha-adrenergic agonists and SSRIs.

AHC patients often (41%) experience severe/extreme behavioral problems and, rarely, medication-triggered psychotic symptoms. These observations are consistent with current understanding of underlying AHC brain pathophysiology. Increasing awareness of these behavioral problems facilitates AHC management and anticipatory guidance.