Abstract Mutations in the SPG3A gene (atlastin protein) cause approximately 10% of autosomal-dominant hereditary spastic paraplegia. Most patients with an SPG3A mutation present with a pure phenotype and early-onset disease, although complicated forms with peripheral neuropathy are also reported. We report a new heterozygous S398F mutation in exon 12 of the SPG3A gene causing a very early-onset spastic paraplegia in association with motor axonal neuropathy in a 4-year-old girl resembling diplegic cerebral palsy

Andrea Nuccitelli

Bruno Casali

Carlo Fusco

Daniele Frattini

Davide Nicoli

Elvio Della Giustina

Enrico Farnetti

Francesco Fiorentino

CiteSeerX

ARTICLE IN PRESSwww.elsevier.com/locate/braindev
Brain & Development xxx (2009) xxx–xxxCase report
Hereditary spastic paraplegia and axonal motor neuropathy
caused by a novel SPG3A de novo mutation
Carlo Fusco a,*, Daniele Frattini a, Enrico Farnetti b, Davide Nicoli b, Bruno Casali b,
Francesco Fiorentino c, Andrea Nuccitelli c, Elvio Della Giustina a
a Child Neurology Unit, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
b Molecular Biology Unit, Santa Maria Nuova, Reggio Emilia, Italy
c Molecular Biology & Cytogenetics, Genoma Laboratories, Rome, Italy
Received 24 April 2009; received in revised form 13 July 2009; accepted 16 August 2009Abstract
Mutations in the SPG3A gene (atlastin protein) cause approximately 10% of autosomal-dominant hereditary spastic paraplegia.
Most patients with an SPG3A mutation present with a pure phenotype and early-onset disease, although complicated forms with
peripheral neuropathy are also reported. We report a new heterozygous S398F mutation in exon 12 of the SPG3A gene causing a
very early-onset spastic paraplegia in association with motor axonal neuropathy in a 4-year-old girl resembling diplegic cerebral
palsy.
 2009 Elsevier B.V. All rights reserved.
Keywords: Hereditary spastic paraplegia; SPG3A; Axonal neuropathy1. Introduction
Hereditary spastic paraplegia (HSP) comprises a
group of inherited neurodegenerative disorders with
the shared characteristics of progressive weakness and
spasticity predominantly affecting the lower limb due a
length-dependent, retrograde axonopathy of corticospi-
nal motor neurons [1,2]. Traditionally, HSP are divided
into pure (uncomplicated) and complicated, depending
on the presence of other neurological features in addi-
tion to spastic paraparesis. Moreover, HSP can be inher-
ited as an autosomal dominant, recessive, or X-linked
recessive trait, and at least 41 spastic paraplegia gene0387-7604/$ - see front matter  2009 Elsevier B.V. All rights reserved.
doi:10.1016/j.braindev.2009.08.003
* Corresponding author. Address: Child Neurology Unit, Arcispe-
dale Santa Maria Nuova, Viale Risorgimento 80, 42100 Reggio Emilia,
Italy. Tel.: +39 0522295968; fax: +39 0522295046.
E-mail address: fusco.carlo@asmn.re.it (C. Fusco).
Please cite this article in press as: Fusco C et al. Hereditary spastic paraple
mutation. Brain Dev (2009), doi:10.1016/j.braindev.2009.08.003loci have been mapped [3]. Early-onset HSP SPG3A
(OMIM 182600) is caused by mutations in the gene
encoding the large oligomeric GTPase atlastin-1 protein
[4]. Mutations in SPG3A (also known as atlastin
GTPase 1 [ATL1]) cause both pure and uncomplicated
phenotypes with early onset and slow progression [5].
We report a 4-year-old girl carrying a new SPG3A
mutation with early onset and severe phenotype, compli-
cated by axonal motor neuropathy.
2. Case report
This patient was born to healthy nonconsanguineous
parents after an uncomplicated pregnancy and delivery.
Neonatal period was normal. At 6 months of life, neuro-
logical examination found signs of spasticity in the
lower limbs resembling diplegic cerebral palsy. Routine
laboratory studies and vitamin B12, apolipoprotein
and lipid profile, plasma amino acids, biotinidase andgia and axonal motor neuropathy caused by a novel SPG3A de novo
2 C. Fusco et al. / Brain & Development xxx (2009) xxx–xxx
ARTICLE IN PRESSvitamin E levels were normal. Brain and spinal magnetic
resonance was normal. Ophthalmologic examinations
yielded normal results. Nerve conduction velocities
(NCV) and electromyography (EMG) were normal at
6 months old. Molecular analysis excluded mutations
in MPZ, PMP22, SPAST, SPG7, KIF5A, and BSCL2.
Genomic DNA was extracted from peripheral blood
using a rapid extraction kit (Puregene Gentra System).
SPG3A was amplified by PCR and both strands
sequenced. Molecular analysis revealed a novel hetero-
zygous S398F mutation in exon 12. To confirm the
result and exclude the presence of a polymorphism, we
tested samples from the patient and her parents by
RFLP-PCR and subsequently from 200 unrelated
healthy controls. The S398F mutation was found in
the DNA of the patient only. NCV and EMG at 1
and 2 years of life showed progressive reduction of the
compound muscle action potential of the peroneal and
posterior tibial nerves with normal motor and sensory
NCV in lower and upper limbs (Table 1). Sensory nerve
conduction velocity, distal latency and amplitude poten-
tial of sural, superficial peroneal and median nerves were
normal. Electromyography of the bilateral anterior tib-
ial and gastrocnemius muscles showed chronic neuro-
genic changes. Brainstem evoked potentials showed
reduced IV and V wave amplitude. The somatosensory
evoked potential from the lower limbs showed very
small cortical potentials. The last neurologic examina-
tion, performed at 4 years old, showed markedly
increased tone, brisk tendon reflex, bilateral Babinski
signs, distal atrophy, pes cavus, and weakness in lower
limbs. The upper limbs were spared and there was no
evidence of language or cognitive impairment (coeffi-
cient of 94 was found for total IQ on Wechsler Pre-Table 1
Motor nerve conduction findings.
Age 1 year 2 years
Right peroneal
Conduction velocity 38 m/s (>36) 44 m/s (>40)
Response amplitude 0.8 mV (>2) 0.5 mV (>3)
Distal latency 2.1 ms (<3.2) 2 ms (<3.5)
Left peroneal
Conduction velocity 38 m/s (>36) 45 m/s (>40)
Response amplitude 0.9 mV (>2) 0.5 mV (>3)
Distal latency 2 ms (<3.2) 2 ms (<3.5)
Right posterior tibial
Conduction velocity 38 m/s (>35) 44 m/s (>40)
Response amplitude 1 mV (>3.5) 0.8 mV (>4)
Distal latency 2.6 ms (<3.5) 2.4 ms (<4)
Left posterior tibial
Conduction velocity 38 m/s (>35) 44 m/s (>40)
Response amplitude 0.9 mV (>3.5) 0.7 mV (>4)
Distal latency 2.6 ms (<3.5) 2.5 ms (<4)
() = normal values.
Please cite this article in press as: Fusco C et al. Hereditary spastic paraple
mutation. Brain Dev (2009), doi:10.1016/j.braindev.2009.08.003school and Primary Scale of Intelligence). No
sphincter disturbance was reported.3. Discussion
The diagnosis of HSP in sporadic case presents sev-
eral difficulties and further investigation is often
required. The onset of HSP may be subtle, with develop-
ment of leg stiffness, brisk reflex, clonus and mild distal
hypertonia in the lower limb mimicking spastic diplegic
cerebral palsy. Thereby, we first excluded cerebral palsy
because of normality of perinatal history and cerebral
magnetic resonance imaging study. Moreover, meta-
bolic conditions clinically resembling complicated HSP
including amino acids disorders, biotinidase, vitamin
B12 and vitamin E deficiency, and inherited neuropathy
were ruled out. Numerous studies have documented that
HSP syndromes are heterogeneous, but the most strik-
ing feature reported for most affected members showing
a mutation in SPG3A is the young age at onset [6]. In
fact, SPG3A mutations cause approximately 10% of
dominantly inherited, uncomplicated HSP and approxi-
mately 25% of early childhood onset of dominant HSP
[7]. The clinical features that we describe here, associ-
ated with an S398F mutation in exon 12 of SPG3A,
are a very early onset (before or at age of 6 months)
and a progressive form of spastic paraplegia of the lower
limbs associated with axonal motor neuropathy. Up to
now, SPG3A was associated with an early onset of
symptoms, mainly in the first decade [7], while our
patient developed a spastic paraplegia before or at age
of 6 months. Moreover, although SPG3A-HSP was first
considered pure and almost indistinguishable from
SPG4 HSP, except that it begins earlier, SPG3A muta-
tions associated with axonal neuropathy are reported,
usually with sensory-motor axonal neuropathy [5–9].
Ivanova et al. described SPG3A patients with axonal
predominantly motor polyneuropathy, but reduction
of sensory action potential or velocity conduction of
sural nerve was also present. In our case, the neuro-
physiological studies revealed a pure motor axonal pol-
yneuropathy in the lower limb without sensory nerve
involvement (Table 1). All of the neurophysiological
examinations performed on our patient showed reduc-
tions in potential amplitude, with normal conduction
velocities, reflecting the main axonal involvement often
observed in HSP SPG3A patients. Besides, this neuro-
physiological pattern in part differs from other reports
where an increased central conduction times were often
found for auditory and motor symptoms, but not for
somatosensory evoked potentials [7]. The clinical and
neurophysiological findings that we have described
might find an possible explanation in view of experimen-
tal literature data and in light of the localization and the
functions of human atlastin protein. In fact, atlastingia and axonal motor neuropathy caused by a novel SPG3A de novo
C. Fusco et al. / Brain & Development xxx (2009) xxx–xxx 3
ARTICLE IN PRESSGTPase 1 is predominantly localized to the central
nervous system, but it is also expressed at low levels in
peripheral tissue [4]. This protein has been implicated
in intracellular membrane trafficking, particularly at
the endoplasmatic reticulum-to-Golgi interface; atlastin
GTPase 1 is also present in growth cones and is required
for axon formation and elongation during development
[4]. In our patient, the axonal motor neuropathy and the
chronic neurogenic changes in the lower limbs could
reflect axonal loss in motor nerves, involvement of the
lower motor neurons, or both. Alternatively, axonal loss
in both motor and sensory tracts in HSP supportive of a
“dying back” process has been reported [10]. Thus, the
associated axonal peripheral motor neuropathy might
suggest an important role for atlastin GTPase 1 also in
peripheral nervous system development. Finally, very
early-onset spasticity with associated axonal motor neu-
ropathy as the earliest sign of disease is of practical
importance, as it directly points to the right diagnosis
and allows genetic counseling of this form of HSP for
any further gestation. The interindividual variability of
the genotype–phenotype correlation probably reflects
the limitations of our understanding of the relationship
between the biologic functions of the affected protein,
postulated modulator genes and environmental factors.
In conclusion, although SPG3A mutations are frequent
in young-onset spastic paraplegia we were able to show
that an S398F mutation in exon 12 of SPG3A causes a
very early onset (before or at 6 month of life) of spastic
paraplegia with associated motor axonal neuropathy.
This report further on expands the clinical spectrum of
SPG3A mutations. We finally remark that HSP with
SPG3A de novo mutations should be considered in
patients with symptoms resembling spastic diplegic cere-
bral palsy with normal neuroimaging and perinatal and
familiar history.Please cite this article in press as: Fusco C et al. Hereditary spastic paraple
mutation. Brain Dev (2009), doi:10.1016/j.braindev.2009.08.003Acknowledgements
Thanks go to Mrs. Elena Bonini and Mrs. Giuliana
Soncini for their technical assistance.
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Hereditary spastic paraplegia and axonal motor neuropathy caused by a novel SPG3A de novo mutation

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Hereditary spastic paraplegia and axonal motor neuropathy caused by a novel SPG3A de novo mutation

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