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Leukoencephalopathy With Predominant Infratentorial Involvement Caused by a Novel ABCD1 Mutation

Does the Spinocerebellar Variant of Adrenoleukodystrophy Exist?

Benzoni, Chiara MD*; Farina, Laura MD*; Pensato, Viviana PhD*; Marotta, Giorgio MD; Kuqo, Altin MD; Mauro, Elena MSc*; Pareyson, Davide MD*; Salsano, Ettore MD*,§

doi: 10.1097/NRL.0000000000000252
Case Report/Case Series
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Introduction: X-linked adrenoleukodystrophy (X-ALD) encompasses several clinical and neuroimaging phenotypes, including cerebral X-ALD, the most common phenotype in children, and adrenomyeloneuropathy, the most common phenotype in adults. A spinocerebellar variant of X-ALD has been described in individuals from the Far East, but the criteria for its diagnosis are unclear.

Case Report: A 35-year-old man from Albania was assessed because of a familial, slowly progressive spastic-ataxic gait associated with neurogenic bladder, sexual dysfunctions, and manic-like behavior. There was no definite clinical feature that suggested cerebellar involvement (eg, cerebellar limb ataxia, nystagmus, and dysarthria). A few months earlier, he had received a diagnosis of Addison disease. Brain magnetic resonance imaging showed a leukoencephalopathy with predominant cerebellum and brainstem involvement, and 18FDG-PET revealed marked cerebellar hypometabolism. The diagnosis of X-ALD was made because we found an increase of very long chain fatty acids, and a new ABCD1 mutation (c.1627C>T, p.Pro543Ser).

Conclusions: X-ALD should be included in the differential diagnosis of adult leukoencephalopathies with predominant involvement of infratentorial structures, that is, the cerebellum and brainstem. From a classification perspective, our patient (of white origin), like others (all of Asian origin), should be considered as suffering from a variant of adrenomyeloneuropathy rather than from spinocerebellar X-ALD. Actually, the term “spinocerebellar” or similar ones, such as “cerebello-brainstem dominant form,” should be limited to those exceptional cases, in which both the clinical and neuroimaging findings point exclusively (or at least predominantly) to the involvement of infratentorial structures.

*Fondazione IRCCS Istituto Neurologico “C. Besta”

Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano

§Neuroscience PhD Program, University of Milano-Bicocca, Monza, Italy

Department of Neurology, Neurosurgery and Psychiatry, University Hospital Mother Theresa, Tirana, Albania

The authors declare no conflict of interest.

Correspondence to: Ettore Salsano, MD, Fondazione IRCCS Istituto Neurologico “C. Besta,” via Celoria 11, 20133 Milano, Italy. E-mail: ettore.salsano@istituto-besta.it.

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