Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
For the autosomal recessive, neonatal onset disease, see nificantly higher incidence in any specific ethnic groups.
Neonatal adrenoleukodystrophy
1
2 5 TREATMENT
where plasma VLCFA measurement is not always con- typically avoid the most severe manifestations of the dis-
clusive (some female carriers will have normal VLCFA ease, but often become symptomatic later in life.[1] Al-
in plasma),[5] molecular analysis is preferred, particularly though, the detection of an ABCD1 mutation identifies an
in cases where the mutation in the family is known.[1][3] individual who is affected with a form of ALD, however
Although the clinical phenotype is highly variable among there is no genotype - phenotype correlation.[12] Within a
affected males, the elevations of VLCFA are present in family, there will often be several different phenotypes,
all males with an ABCD1 mutation.[3] despite the presence of the same causative mutation. In
Because the characteristic elevations associated with one case, a family with six affected members displayed
five different phenotypes.[1] There are no common mu-
ALD are present at birth, well before any symptoms are
apparent, there have been methods developed[6][7] in the tations that cause ALD, most are private or familial. Al-
most 600[3] different mutations have been identified, ap-
interests of including it in newborn screening programs.[8]
One of the difficulties with ALD as a disease included proximately half are missense mutations, one quarter are
frameshifts, with in-frame deletions and splicing defects
in universal newborn screening is the difficulty in pre-
dicting the eventual phenotype that an individual will ex- making up the remainder.[1] The incidence of new muta-
press. The accepted treatment for affected boys present- tions in ALD (those occurring spontaneously, rather than
ing with the cerebral childhood form of the disease is a being inherited from a carrier parent) is estimated at ap-
bone marrow transplant, a procedure which carries signif- proximately 4.1%, with the possibility that these are due
icant risks.[2][9] However, because most affected males to germline mosaicism.[3]
will demonstrate adrenal insufficiency, early discovery
and treatment of this symptom could potentially prevent
complications and allow these patients to be monitored 4 Pathogenesis
for other treatment in the future, depending on the pro-
gression of their disease.[8] The exact cause for the varied collection of symptoms
The Loes score is a rating of the severity of abnormal- found in the different ALD phenotypes is not clear. The
ities in the brain found on MRI. It ranges from 0 to 34, white matter of the brain, the Leydig cells of the testes
based on a point system derived from the location and ex- and the adrenal cortex are the most severely affected
[1]
tent of disease and the presence of atrophy in the brain, systems. The excess VLCFA can be detected in al-
either localized to specific points or generally through- most all tissues of the body, despite the localization of
[1]
out the brain. A Loes score of 0.5 or less is classified symptoms. Successful treatment of the demyelination
as normal, while a Loes score of 14 or greater is consid- process that affects the brain with either stem cell trans-
ered severe. It was developed by neuroradiologist Daniel plant or gene therapy does not immediately normalize
[9]
J. Loes MD and is an important tool in assessing disease the VLCFA levels in body tissues. The levels of VL-
progression and the effectiveness of therapy. [10] CFA can be normalized by treatment with Lorenzo’s oil,
but this does not alter the progression of the disease.[2]
It is unclear whether the accumulation of VLCFA is as-
sociated with the pathogenesis of the disease in a spe-
3 Genetics cific way, or if it is a biochemical phenotype, useful for
identification.[1]
Xq28
ABCD1 gene in
X-chromosome 5 Treatment
Xq21.31
Xp22.32
Xp11.22
Xp22.12
Xp21.1
Xq13.2
Xq22.2
Xq27.1
Xq25
Xp21.3
Xq27.3
Xq26.2
Xq12
Xq23
7 See also
5.2 Transplant
• Lorenzo’s Oil
While dietary therapy has been shown to be effective
to normalize the very-long chain fatty acid concentra-
tions in the plasma of individuals with ALD, allogeneic
hematopoietic stem cell transplants are the only treatment 8 References
that can stop the demyelination that is the hallmark of
the cerebral forms of the disease.[9] In order to be ef- [1] Moser, Hugo W.; Smith, Kirby D.; Watkins, Paul A.;
fective, the transplant must be done at an early stage of Powers, James; Moser, Ann (2001). “131. X-Linked
the disease; if the demyelination has progressed, trans- Adrenoleukodystrophy”. In Scriver, C.W.; Beaudet, A.L.;
Sly, W.S.; Valle, D.; Childs, B.; Kinzler, K.W.; Vogel-
plant can worsen the outcome, and increase the rate of de-
stein, B. Metabolic and Molecular Bases of Inherited Dis-
cline. While transplants have been shown to be effective ease. 2 (8th ed.). New York: McGraw Hill. ISBN 0-07-
at halting the demyelination process in those presenting 136320-3.
with the childhood cerebral form of ALD, follow-up of
these patients has shown that it does not improve adrenal [2] Berger, J.; Gärtner, J. (2006). “X-linked adrenoleukodys-
function.[14] trophy: Clinical, biochemical and pathogenetic
aspects”. Biochimica et Biophysica Acta (BBA) -
Molecular Cell Research. 1763 (12): 1721–32.
doi:10.1016/j.bbamcr.2006.07.010. PMID 16949688.
5.3 Gene therapy
[3] Steinberg, S. J.; Moser, A. B.; Raymond, G. V.; Pagon,
R. A.; Bird, T. D.; Dolan, C. R.; Stephens, K.; Adam,
For patients where an appropriate match for a transplant
M. P. (1993). “X-Linked Adrenoleukodystrophy”. PMID
cannot be found, there have been investigations into the 20301491.
use of gene therapy. Appropriate vectors are selected
and modified to express wild type ABCD1, which is then [4] "#300100 - Adrenoleukodystrophy”. Johns Hopkins Uni-
transplanted into the patients using a similar procedure as versity. Retrieved 2012-06-27.
for a bone marrow or stem cell transplant.[9] Gene therapy
has only been tried on a small number of patients, mainly [5] Moser, A. B.; Kreiter, N.; Bezman, L.; Lu, S.;
in France. These patients were only considered for gene Raymond, G. V.; Naidu, S.; Moser, H. W. (1999).
“Plasma very long chain fatty acids in 3,000 peroxi-
therapy after there was no HLA match for a traditional
some disease patients and 29,000 controls”. Annals
transplant. In two reported cases, the gene therapy was
of Neurology. 45 (1): 100–110. doi:10.1002/1531-
successful, with a resolution of the demyelination pro- 8249(199901)45:1<100::aid-art16>3.0.co;2-u. PMID
cess up to two years after the procedure. Although the 9894883.
gene therapy was successful in resolving the neurological
symptoms, plasma VLCFA levels remained elevated.[9] [6] Sandlers, Y.; Moser, A. B.; Hubbard, W. C.; Kratz, L.
E.; Jones, R. O.; Raymond, G. V. (2012). “Combined
extraction of acyl carnitines and 26:0 lysophosphatidyl-
choline from dried blood spots: Prospective newborn
5.4 Adrenal insufficiency screening for X-linked adrenoleukodystrophy”. Molec-
ular Genetics and Metabolism. 105 (3): 416–420.
Treatment of the adrenal insufficiency that can accom- doi:10.1016/j.ymgme.2011.11.195. PMID 22197596.
pany any of the common male phenotypes of ALD does
[7] Hubbard, W. C.; Moser, A. B.; Liu, A. C.; Jones,
not resolve any of the neurological symptoms. Hormone R. O.; Steinberg, S. J.; Lorey, F.; Panny, S. R.;
replacement is standard for ALD patients demonstrating Vogt Jr, R. F.; MacAya, D.; Turgeon, C. T.; Tor-
adrenal insufficiency.[15] Adrenal insufficiency does not torelli, S.; Raymond, G. V. (2009). “Newborn screen-
resolve with successful transplant; most patients still re- ing for X-linked adrenoleukodystrophy (X-ALD): Val-
quire hormone replacement.[14] idation of a combined liquid chromatography–tandem
4 9 EXTERNAL LINKS
[8] Raymond, G. V.; Jones, R. O.; Moser, A. B. (2007). • Images of ALD at USUHS
“Newborn screening for adrenoleukodystrophy: Implica-
tions for therapy”. Molecular diagnosis & therapy. 11 (6): • Adrenoleukodystrophy at National Center for
381–384. doi:10.1007/BF03256261. PMID 18078355. Biotechnology Information
[11] Hung KL, Wang JS, Keng WT, Chen HJ, Liang
JS, Ngu LH, Lu JF (2013). “Mutational analy-
ses on X-linked adrenoleukodystrophy reveal a novel
cryptic splicing and three missense mutations in the
ABCD1 gene”. Pediatr Neurol. 49: 185–190.
doi:10.1016/j.pediatrneurol.2013.04.021.
[14] Petryk, A.; Polgreen, L. E.; Chahla, S.; Miller, W.; Or-
chard, P. J. (2012). “No evidence for the reversal of
adrenal failure after hematopoietic cell transplantation in
X-linked adrenoleukodystrophy”. Bone Marrow Trans-
plantation. 47 (10): 1377–8. doi:10.1038/bmt.2012.33.
PMID 22388279.
9 External links
• ALD Life
• European Leukodystrophy Foundation
• Fight ALD
• March of Dimes Foundation
• United Leukodystrophy Foundation
5
10.2 Images
• File:ABCD1-gene.svg Source: https://upload.wikimedia.org/wikipedia/commons/c/cc/ABCD1-gene.svg License: CC BY-SA 3.0 Con-
tributors: Own work Original artist: RicHard-59
• File:Adrenoleukodystrophy.jpg Source: https://upload.wikimedia.org/wikipedia/commons/e/ee/Adrenoleukodystrophy.jpg License:
CC BY-SA 3.0 Contributors: http://radiopaedia.org/images/318699 and http://radiopaedia.org/uploads/radio/0031/8699/T2.jpg Original
artist: Frank Gaillard