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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282XOn-line version ISSN 1678-4227

Arq. Neuro-Psiquiatr. vol.59 no.3B São Paulo Sept. 2001

http://dx.doi.org/10.1590/S0004-282X2001000500025 

HEREDITARY SPASTIC PARAPLEGIA ASSOCIATED WITH THIN CORPUS CALLOSUM

 

Hélio A. Ghizoni Teive1, Fabio Massaiti Iwamoto2, Marcus Vinícius Della Coletta2, Carlos Henrique Camargo2, Ruth Danielle Bezerra2, Guilberto Minguetti3, Lineu Cesar Werneck4

 

 

ABSTRACT - Autosomal recessive hereditary spastic paraplegia (AR-HSP) associated with thin corpus callosum was recently described in Japan, and most families were linked to chromosome 15q13-15. We report two patients from two different Brazilian families with progressive gait disturbance starting at the second decade of life, spastic paraparesis, and mental deterioration. One patient presented cerebellar ataxia. Magnetic resonance imaging (MRI) of the head of both patients showed a thin corpus callosum. AR-HSP with a thin corpus callosum is a rare disorder, mainly described in Japanese patients. We found only 4 Caucasian families with AR-HSP with thin corpus callosum described in the literature. Further studies including additional Caucasian families of AR-HSP with thin corpus callosum are required to delineate the genetic profile of this syndrome in occidental countries.

KEY WORDS: hereditary spastic paraplegia, corpus callosum, MRI.

 

Paraplegia espástica hereditária associada a hipoplasia de corpo caloso

RESUMO - A paraplegia espástica hereditária autossômica recessiva (PEH-AR) associada com hipoplasia de corpo caloso foi inicialmente descrita no Japão. Estudos de ligação genética mostram que a maioria das famílias estão relacionadas ao cromossomo 15q13-15. Relatamos dois pacientes de famílias brasileiras, não relacionadas, com distúrbio de marcha com início na segunda década de vida, paraparesia espástica e comprometimento das funções cognitivas. Um dos pacientes apresentava ataxia cerebelar. A ressonância magnética de encéfalo de ambos os pacientes mostrou hipoplasia de corpo caloso. PEH-AR associada com hipoplasia de corpo caloso é uma condição rara, descrita principalmente em pacientes do Japão. Encontramos apenas 4 famílias caucasianas com PEH-AR e hipoplasia de corpo caloso. Mais estudos com famílias caucasianas são necessários para delinear o perfil genético dessa síndrome em países ocidentais.

PALAVRAS-CHAVE: paraplegia espástica hereditária, corpo caloso, ressonância magnética.

 

 

Hereditary spastic paraplegia (HSP) is a heterogeneous group of genetic neurodegenerative disorders characterized by progressive spasticity of the lower limbs. In 1981, Harding1 suggested clinical criteria for classifying HSP into pure and complicated forms. Pure HSP patients present with family history, progressive gait disturbance, spasticity of lower limbs, hiperreflexia, and extensor plantar responses. In complicated HSP the spastic paraparesis is only one feature of a much more complex phenotype. Complicated HSP has been associated with many conditions including mental retardation or deterioration, optic atrophy, retinopathy, extrapyramidal disease, amyotrophy, ataxia and cerebellar signs, deafness, icthyosis, and peripheral neuropathy2. HSP is also genetically heterogeneous and autosomal dominant, autosomal recessive, and X-linked mode of inheritance have been described2. Recently, a new form of complicated autosomal recessive HSP (AR-HSP) associated with thin corpus callosum was described in Japan3,4. Because few cases were reported in Caucasian population, herein we present two patients from two different families with HSP and thin corpus callosum.

 

CASES

Patient 1. A 18-year-old Caucasian girl presented a 4-year history of frequent falls, gait disturbance, progressive muscular weakness, and pain in the lower limbs. She had normal achievement of motor milestones. There was no family history and her parents were unrelated. General physical examination was normal. On neurological examination, she presented mild dysarthria, muscular strength in the lower limbs grade IV/V (Medical Research Council), spasticity in the lower limbs, patellar and ankle deep tendon reflexes grade +++/IV, left extensor cutaneous plantar response, and spastic gait. Sensation and coordination was normal. Ophthalmological examination was normal. Complete blood count, glucose, electrolytes, thyroid function tests, serum vitamin B12, and cerebrospinal fluid analysis were normal. Serum HTLV-1 antibody assay was negative. Needle electromyography showed active denervation in anterior tibial, and first dorsal interosseous of the right foot. Nerve conduction studies were normal. MRI of the head showed a dysgenesis of corpus callosum (thin corpus callosum) (Fig 1). Electroencephalogram showed diffuse slowing of background rhythm.

 

 

Patient 2. A 16-year-old Caucasian boy started having progressive gait disturbance, and frequent falls at 12 years of age. He had normal achievement of motor milestones. There was history of consanguineous marriage of his parents, and there were two cousins with similar disease. Aside from bilateral pes cavus, general physical examination was otherwise normal. On neurological, he presented mild mental retardation, dysarthria, and bilateral rectus lateral paresis. He presented normal muscle bulk, spasticity in the lower limbs, muscular strength grade IV/V (Medical Research Council); brisk deep tendon reflexes in the lower limbs (grade +++/IV), bilateral extensor cutaneous plantar responses, mild coordination impairment in the upper limbs, resting and postural tremor in the upper limbs, and spastic gait. Sensation was normal. Ophthalmological examination was normal. Complete blood count, glucose, electrolytes, thyroid function tests, serum vitamin B12, and cerebrospinal fluid analysis were normal. Serum HTLV-1 antibody assay was negative. Needle electromyography and nerve conduction studies were normal. MRI of the head showed dysgenesis of the corpus callosum, mainly in the anterior limb (Fig 2).

 

 

DISCUSSION

The typical clinical picture of AR-HSP with thin corpus callosum starts at the second decade of life with gait disturbance, then spastic paraparesis and mental deterioration progresses slowly3,4. Consanguineous marriage is frequent and was present in 8 of 13 families studied by Shibasaki et al.5 Cerebellar ataxia and sensory loss in the distal parts of four extremities also occur in some patients. Other clinical features include spasticity and hiperreflexia in the upper limbs, muscle atrophy, pes cavus, impaired vibration sense, urinary disturbance, dysarthria, nystagmus, congenital cataracts, and cerebellar atrophy3-6. Disease duration influences the clinical features, since associated signs and symptoms appears as disease progresses. Because this, our patients will probably present additional neurological signs in subsequent evaluations.

In AR-HSP with thin corpus callosum, MRI of the head typically demonstrates a thin corpus callosum, which is not specific of this syndrome. Additional described findings in MRI included bilateral medial frontal atrophy, widening of the interhemispheric fissure, mild enlargement of lateral and third ventricles, reduced size of thalamus4. Whether the thin corpus callosum represents a congenital hypoplasia or a progressive atrophy remains unknown. Since the thickness of the corpus callosum did not correlate with duration from disease onset in one study, it was considered more probably a hypoplasia3.

The diagnostic criteria of autosomal recessive HSP with thin corpus callosum include the following: (1) inheritance consistent with autosomal recessive trait, (2) slowly progressive spastic paraparesis and mental impairment, (3) thinning of the corpus callosum as revealed by brain CT or MRI, and (4) exclusion of other disorders by MRI of the spine and brain as well as other laboratory tests5.

Among the autosomal recessive HSP, three loci were identified. The first described locus for AR-HSP showed pure HSP phenotype and was linked to chromosome 8p12-q13 in 4 Tunisian families7. The second locus was identified on chromosome 16q24.3 in a large consanguineous Italian family8. The gene at this 16q24 locus was called paraplegin, a nuclear-encoded mitochondrial metalloprotease. Mutations in the gene of paraplegin were shown to be responsible for both pure and complicated forms of HSP9. The third locus for AR-HSP was identified as mapping to chromosome 15q13-15 in 7 families from North America and Europe whose members showed both pure and complicated forms of the disease10. Recently, Shibasaki et al.5 showed that 10 of 13 Japanese families with AR-HSP with thin corpus callosum was linked to chromosome 15q13-15. It suggests that most AR-HSP with thin corpus callosum in Japan is linked to chromosome 15q13-15, but genetically heterogeneous. Because this, other loci of AR-HSP with thin corpus callosum remains to be discovered. Clinically and genetically, AR-HSP with thin corpus callosum was poorly studied in Caucasian population. Two Caucasian families were linked to chromosome 15q13-1510, and one kindred was linked to chromosome 1611.

The mapping of AR-HSP with thin corpus callosum to the 15q13-15 locus adds this condition to a group of two disorders previously mapped to this region: agenesis of the corpus callosum with peripheral neuropathy or Andermann syndrome, and amyotrophic lateral sclerosis2. The overlapping genetic localization of the responsible genes suggests that these disorders may be allelic and could be caused by the same defective gene5.

To our knowledge, there was only 4 Caucasian families of AR-HSP with thin corpus callosum described, including one North American10, one Italian10, one Spanish4, and one Portuguese family11. In contrast, more than 20 families of AR-HSP have been described in Japan. Herein, we described two Brazilian families of European ancestry with the typical clinical and radiological features of AR-HSP with thin corpus callosum. Further studies including additional Caucasian families of AR-HSP with thin corpus callosum is required to delineate the clinical and genetic profile of this syndrome in occidental countries.

 

REFERENCES

1. Harding AE. Hereditary pure spastic paraplegia: a clinical and genetic study of 22 families. J Neurol Neurosurg Psychiatry 1981;44:871-83.         [ Links ]

2. McDermott CJ, White K, Bushby K, Shaw PJ. Hereditary spastic paraparesis: a review of new developments. J Neurol Neurosurg Psychiatry 2000;69:150-160.         [ Links ]

3. Nakamura A, Izumi K, Umehara F, et al. Familial spastic paraplegia with mental impairment and thin corpus callosum. J Neurol Sci 1995;131:35-42.         [ Links ]

4. Ueda M, Katayama Y, Kamiya T, et al. Hereditary spastic paraplegia with thin corpus callosum and thalamic involvement in Japan. Neurology 1998; 51:1751-1754.         [ Links ]

5. Shibasaki Y, Tanaka T, Iwabuchi K, et al. Linkage of autosomal recessive hereditary spastic paraplegia with mental inpairment and thin corpus callosum to chromosome 15q13-15. Ann Neurol 2000; 48:108-112.         [ Links ]

6. Yamashita I, Sasaki H, Yabe I, et al. Recessively inherited spastic paraplegia associated with ataxia, congenital cataracts, thin corpus callosum and axonal neuropathy. Acta Neurol Scand 2000;102:65-69.         [ Links ]

7. Hentati A, Pericak-Vance MA, Hung WY, et al. Linkage of  'pure' autosomal recessive familial spastic paraplegia to chromosome 8 markers and evidence of genetic locus heterogeneity. Hum Mol Genet 1994;3: 1263-1267.         [ Links ]

8. De Michele G, De Fusco M, Cavalcanti F, et al. A new locus for autosomal recessive hereditary spastic paraplegia maps to chromosome 16q24.3. Am J Hum Genet 1998;63:135-139.         [ Links ]

9. Casari G, De Fusco M, Ciarmatori S, et al. Spastic paraplegia and OXPHOS impairment caused by mutations in paraplegin, a nuclear-encoded mitochondrial metalloprotease. Cell 1998;93:973-983.         [ Links ]

10. Murillo FM, Kobayashi H, Pegoraro E, et al. Genetic localization of a new locus for recessive familial spastic paraparesis to 15q13-15. Neurology 1999;53:50-56.         [ Links ]

11. Coutinho P, Barros J, Zemmouri R, et al. Clinical heterogeneity autosomal recessive spastic paraplegia: analysis of 106 patients in 46 families. Arch Neurol 1999;56:943-949.         [ Links ]

 

 

Division of Neurology, Hospital de Clínicas of the Federal University of Paraná (UFPR), Curitiba PR, Brazil: 1Assistant Professor; 2Resident in Neurology; 3Associate Professor; 4Professor of Neurology and Chief.

Received 5 February 2001, received in final form 30 April 2001. Accepted 10 May 2001.

Dr. Hélio Teive - Serviço de Neurologia, Hospital de Clinicas UFPR ¾ Rua General Carneiro, 181 - 80069-900 Curitiba PR - Brasil. FAX: 55 41 2643606. E-mail: hagteive@mps.com.br

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