Abstract
Objective
Acyl-CoA oxidase (ACOX1) deficiency is a rare disorder of peroxisomal very-long chain fatty acid oxidation. No reports detailing attempted treatment, longitudinal imaging, or neuropathology exist. We describe the natural history of clinical symptoms and brain imaging in two siblings with ACOX1 deficiency, including the younger sibling’s response to allogeneic unrelated donor hematopoietic stem cell transplantation (HSCT).
Methods
We conducted retrospective chart review to obtain clinical history, neuro-imaging, and neuropathology data. ACOX1 genotyping were performed to confirm the disease. In vitro fibroblast and neural stem cell fatty acid oxidation assays were also performed.
Results
Both patients experienced a fatal neurodegenerative course, with late-stage cerebellar and cerebral gray matter atrophy. Serial brain magnetic resonance imaging in the younger sibling indicated demyelination began in the medulla and progressed rostrally to include the white matter of the cerebellum, pons, midbrain, and eventually subcortical white matter. The successfully engrafted younger sibling had less brain inflammation, cortical atrophy, and neuronal loss on neuro-imaging and neuropathology compared to the untreated older sister. Fibroblasts and stem cells demonstrated deficient very long chain fatty acid oxidation.
Interpretation
Although HSCT did not halt the course of ACOX1 deficiency, it reduced the extent of white matter inflammation in the brain. Demyelination continued because of ongoing neuronal loss, which may be due to inability of transplant to prevent progression of gray matter disease, adverse effects of chronic corticosteroid use to control graft-versus-host disease, or intervention occurring beyond a critical point for therapeutic efficacy.
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References
Adzhubei IA, Schmidt S, Peshkin L et al (2010) A method and server for predicting damaging missense mutations. Nat Methods 7:248–249
Aubourg P, Blanche S, Jambaqué I et al (1990) Reversal of early neurologic and neuroradiologic manifestations of X-linked adrenoleukodystrophy by bone marrow transplantation. N Engl J Med 322:1860–1866
Berciano J (1982) Olivopontocerebellar atrophy. A review of 117 cases. J Neurol Sci 53:253–272
Brownell B, Oppenheimer D, Hughes J (1970) The central nervous system in motor neurone disease. J Neurol Neurosurg Psychiatry 33:338–357
Carrozzo R, Bellini C, Lucioli S et al (2008) Peroxisomal acyl-CoA-oxidase deficiency: two new cases. Am J Med Genet A 146A:1676–1681
El Hajj HI, Vluggens A, Andreoletti P et al (2012) The inflammatory response in acyl-CoA oxidase 1 deficiency (pseudoneonatal adrenoleukodystrophy). Endocrinology 153:2568–2575
Farioli-Vecchioli S, Moreno S, Cerù MP (2001) Immunocytochemical localization of acyl-CoA oxidase in the rat central nervous system. J Neurocytol 30:21–33
Ferdinandusse S, Denis S, Hogenhout EM et al (2007) Clinical, biochemical, and mutational spectrum of peroxisomal acyl-coenzyme A oxidase deficiency. Hum Mutat 28:904–912
Ferdinandusse S, Barker S, Lachlan K et al (2010) Adult peroxisomal acyl-coenzyme A oxidase deficiency with cerebellar and brainstem atrophy. J Neurol Neurosurg Psychiatry 81:310–312
Fouquet F, Zhou JM, Ralston E et al (1997) Expression of the adrenoleukodystrophy protein in the human and mouse central nervous system. Neurobiol Dis 3:271–285
Ghatak NR, Nochlin D, Peris M, Myer EC (1981) Morphology and distribution of cytoplasmic inclusions in adrenoleukodystrophy. J Neurol Sci 50:391–398
Hein S, Schönfeld P, Kahlert S, Reiser G (2008) Toxic effects of X-linked adrenoleukodystrophy-associated, very long chain fatty acids on glial cells and neurons from rat hippocampus in culture. Hum Mol Genet 17:1750–1761
Iwata NK, Kwan JY, Danielian LE et al (2011) White matter alterations differ in primary lateral sclerosis and amyotrophic lateral sclerosis. Brain 134:2642–2655
Jia Z, Moulson CL, Pei Z et al (2007) FATP4 is the principal very long-chain fatty acyl-CoA synthetase in skin fibroblasts. J Biol Chem 282:20573–20583
Kumar P, Henikoff S, Ng PC (2009) Predicting the effects of coding non-synonymous variants on protein function using the SIFT algorithm. Nat Protoc 5:1073–1081
Kurian MA, Ryan S, Besley GT et al (2004) Straight-chain acyl-CoA oxidase deficiency presenting with dysmorphia, neurodevelopmental autistic-type regression and a selective pattern of leukodystrophy. J Inherit Metab Dis 27:105–108
Loes DJ, Hite S, Moser H et al (1994) Adrenoleukodystrophy: a scoring method for brain MR observations. Am J Neuroradiol 15:1761–1766
Lowry OH, Rosebrough NJ, Farr AL, Randall RJ (1951) Protein measurement with the Folin phenol reagent. J Biol Chem 193:265–275
Miller WP, Rothman SM, Nascene D et al (2011) Outcomes after allogeneic hematopoietic cell transplantation for childhood cerebral adrenoleukodystrophy: the largest single-institution cohort report. Blood 118:1971–1978
Padovan CS, Yousry TA, Schleuning M et al (1998) Neurological and neuroradiological findings in long-term survivors of allogeneic bone marrow transplantation. Ann Neurol 43:627–633
Peters C, Charnas LR, Tan Y et al (2004) Cerebral X-linked adrenoleukodystrophy: the international hematopoietic cell transplantation experience from 1982 to 1999. Blood 104:881–888
Poll-The BT, Roels F, Ogier H et al (1988) A new peroxisomal disorder with enlarged peroxisomes and a specific deficiency of acyl-CoA oxidase (pseudo-neonatal adrenoleukodystrophy). Am J Hum Genet 42:422–434
Powers JM, Moser HW (1998) Peroxisomal disorders: genotype, phenotype, major neuropathologic lesions, and pathogenesis. Brain Pathol 8:101–120
Powers JM, Moser HW, Moser AB, Schaumburg HH (1982) Fetal adrenoleukodystrophy: the significance of pathologic lesions in adrenal gland and testis. Hum Pathol 13:1013–1019
Rosewich H, Waterham HR, Wanders RJ et al (2006) Pitfall in metabolic screening in a patient with fatal peroxisomal beta-oxidation defect. Neuropediatrics 37:95–98
Schaumberg HH, Powers JM, Raine CS et al (1975) Adrenoleukodystrophy. A clinical and pathological study of 17 cases. Arch Neurol 32:577–591
Schwartz PH, Bryant PJ, Fuja TJ et al (2003) Isolation and characterization of neural progenitor cells from post-mortem human cortex. J Neurosci Res 74:838–851
Shapiro E, Krivit W, Lockman L et al (2000) Long-term effect of bone-marrow transplantation for childhood-onset cerebral X-linked adrenoleukodystrophy. Lancet 356:713–718
Suzuki Y, Shimozawa N, Yajima S et al (1994) Novel subtype of peroxisomal acyl-CoA oxidase deficiency and bifunctional enzyme deficiency with detectable enzyme protein: identification by means of complementation analysis. Am J Hum Genet 54:36–43
Suzuki Y, Iai M, Kamei A et al (2002) Peroxisomal acyl CoA oxidase deficiency. J Pediatr 140:128–130
Terao S, Sobue G, Yasuda T et al (1995) Magnetic resonance imaging of the corticospinal tracts in amyotrophic lateral sclerosis. J Neurol Sci 133:66–72
van der Knaap MS, Wassmer E, Wolf NI et al (2012) MRI as diagnostic tool in early-onset peroxisomal disorders. Neurology 78:1304–1308
Wanders RJ, Schelen A, Feller N et al (1990) First prenatal diagnosis of acyl-CoA oxidase deficiency. J Inherit Metab Dis 13:371–374
Watkins PA, McGuinness MC, Raymond GV et al (1995) Distinction between peroxisomal bifunctional enzyme and acyl-CoA oxidase deficiencies. Ann Neurol 38:472–477
Zivadinov R (2005) Steroids and brain atrophy in multiple sclerosis. J Neurol Sci 233:73–81
Acknowledgments
This study was supported by CHOC Children’s (PHS). We would like to express our gratitude to Nuriel Abdenur for document typesetting and formatting, and to the Commission for Families and Children of Orange County for its support of our clinical work (RYW, JEA).
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Communicated by: Piero Rinaldo
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Supplemental Fig. 1
Microscopic neuropathology of other brain regions (H&E stains). In both patients, severe cerebellar cortical atrophy (a,b) as well as pallor of deep cerebellar white matter (c,d) and cerebral peduncles (asterisks in e,f) are present. Choroid plexus from the right atrium shows severe epithelial loss in patient 1 (g), whereas the choroid plexus from patient 2 (h) appears normal. Arrows designate the substantia nigra. Scale bars: 1 mm (all panels). (JPEG 75 kb)
Supplemental Fig. 2
Axial T2-weighted brain MR imaging from patient 2, pre-HSCT at 2.75 years of age (a-c) and 3.75 years post-HSCT at 6.5 years of age (d-f). (a) Demyelination (arrowheads) of cerebellar deep white matter and corticospinal tracts was incipient but progressed (d) to involve the cerebellar peduncles; cerebellar atrophy (asterisk) had also developed. (b,c) There were no visible supra-tentorial abnormalities just prior to transplant, but (e,f) 3.75 years later, there was marked cortical atrophy (asterisk) and non-enhancing demyelination (arrowheads) of the corpus callosum, periventricular, and subcortical white matter. (JPEG 189 kb)
Supplemental Fig. 3
Plasma VLCFA (C26:0 and C26:1) and ratios (C26:C22, C24:22) in patient 2 over his lifetime, demonstrating that all markers remained persistently elevated compared to normal reference range (dotted lines) throughout the post-transplant period despite full donor engraftment. (JPEG 195 kb)
Supplemental Fig. 4
Ultrastructural neuropathology. (a,b) The cytoplasm of macrophages contained spiculated inclusions in discrete membrane-bound aggregates that are indistinguishable from inclusions described in other peroxisomal disorders. In patient 2, inclusions were difficult to find, and when found, were present in smaller and less numerous aggregates (arrows in b). (c,d) The spicules consist of paired, parallel fibers. Scale bars: 1 um (b), 200 nm (c,d). (JPEG 79 kb)
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Wang, R.Y., Monuki, E.S., Powers, J. et al. Effects of hematopoietic stem cell transplantation on acyl-CoA oxidase deficiency: a sibling comparison study. J Inherit Metab Dis 37, 791–799 (2014). https://doi.org/10.1007/s10545-014-9698-3
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DOI: https://doi.org/10.1007/s10545-014-9698-3