http://jcn.sagepub.com/Journal of Child Neurology

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 DOI: 10.1177/0883073812448459

2013 28: 470 originally published online 25 July 2012J Child NeurolBermejo, Elena Martín Hernández, M Josep Coll Rosell, Laura Gort and Montserrat Milá

María J Martínez González, Jesús Eiris Puñal, Alfonso Verdú Pérez, M Mar García González, Antonio Martínez María S. Pérez-Poyato, Mercé Pineda Marfa, Isidre Ferrer Abizanda, Laia Rodriguez-Revenga, Victoria Cusí Sánchez,

Spanish PatientsLate Infantile Neuronal Ceroid Lipofuscinosis: Mutations in the CLN2 Gene and Clinical Course in

  

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Original Article

Late Infantile Neuronal CeroidLipofuscinosis: Mutations in the CLN2 Geneand Clinical Course in Spanish Patients

Marıa S. Perez-Poyato, MD1, Merce Pineda Marfa, MD, PhD1,2,Isidre Ferrer Abizanda, MD, PhD3, Laia Rodriguez-Revenga, BS, PhD2,4,Victoria Cusı Sanchez, MD, PhD5, Marıa J Martınez Gonzalez, MD6,Jesus Eiris Punal, MD7, Alfonso Verdu Perez, MD, PhD8,M Mar Garcıa Gonzalez, MD9, Antonio Martınez Bermejo, MD, PhD10,Elena Martın Hernandez, MD, PhD11, M Josep Coll Rosell, PhD12,Laura Gort, PhD2,12, and Montserrat Mila, BS, PhD2,4

AbstractLate infantile neuronal ceroid lipofuscinosis (Jansky-Bielchowsky disease) is a rare disease caused by mutations in the CLN2 gene.The authors report the clinical outcome and correlate with genotype in 12 Spanish patients with this disease. Psychomotorregression, epilepsy, and other clinical symptoms/signs were assessed. Age at onset of clinical symptoms ranged from 18 monthsto 3.7 years, and they included delayed speech and simple febrile seizures followed by epilepsy. Partial seizures and myoclonicjerks occurred at an earlier age (median 3.4 and 3.7 years, respectively) than ataxia and cognitive decline (median 4 years). Clinicalregression was initiated by loss of sentences (median 3.7 years) followed by loss of walking ability and absence of language (median4.5 years). Patients showed blindness and lost sitting ability at similar age (median 5 years). The authors report 4 novel mutationsin the CLN2 gene. This study provides detailed information about the natural history of this disease.

Keywordsclinical outcome, CLN2 gene, Jansky-Bielschowsky disease, late infantile neuronal ceroid lipofuscinosis, tripeptidyl peptidase 1

Received February 24, 2012. Accepted for publication April 22, 2012.

Neuronal ceroid lipofuscinosis is one of the most

common groups of progressive neurodegenerative diseases

in childhood.1 Late infantile neuronal ceroid lipofuscinosis

(Jansky-Bielchowsky disease) is the second most frequent

form of the 8 neuronal ceroid lipofuscinosis lysosomal storage

disorders2 all of which are genetically determined diseases.3

1 Department of Pediatric Neurology, Hospital Sant Joan de Deu, Esplugues de Llobregat, Barcelona, Spain2 Centre for Biomedical Research on Rare Diseases (CIBER-ER), Instituto de Salud Carlos III, Spain3 Institute of Neuropathology, Service of Anatomical Pathology, IDIBELL-Hospital Universitari de Bellvitge, Barcelona, CIBERNED, Spain4 Biochemical and Molecular Genetics Department, IDIBAPS, Hospital Clınic, Universitat de Barcelona, Spain5 Service of Anatomical Pathology, Hospital Sant Joan de Deu, Esplugues de Llobregat, Barcelona, Spain6 Department of Pediatric Neurology, Hospital Cruces, Baracaldo, Bizkaia, Spain7 Department of Pediatric Neurology, Hospital Clınico Santiago de Compostela, Spain8 Department of Pediatric Neurology, Hospital Virgen de la Salud, Toledo, Spain9 Department of Pediatric Neurology, Hospital de Figueras, Girona, Spain10 Department of Pediatric Neurology, Hospital La Paz, Madrid, Spain11 Department of Pediatric Neurology, Pediatric Unit of rare disease, Hospital 12 de Octubre, Madrid, Spain12 Biochemical and Molecular Genetics Department, Inborn Errors of Metabolism (IBC), Hospital Clınic, Barcelona, Spain

Corresponding Author:

Montserrat Mila Recasens, PhD, Biochemical and Molecular Genetics Department, IDIBAPS, Hospital Clinic, Universitat de Barcelona, Centre for Biomedical

Research on Rare Diseases (CIBER-ER), Instituto de Salud Carlos III, Carrer Villarroel, 170, Barcelona 08036, Spain.

Email: MMILA@clinic.ub.es

Journal of Child Neurology28(4) 470-478ª The Author(s) 2012Reprints and permission:sagepub.com/journalsPermissions.navDOI: 10.1177/0883073812448459jcn.sagepub.com

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Eight causal genes, CLN10/CTSD, CLN1/PPT, CLN2/TTP1, CLN3, CLN5, CLN6, CLN7/MFSD8, CLN8, have

been identified in childhood (http://www.ucl.ac.uk/ncl/

mutation.shtml).

Late infantile neuronal ceroid lipofuscinosis is rare with an

incidence of 0.46 per 100 000 live births in West Germany4 and

an estimated prevalence of 0.6 to 0.7 per 1 000 000 in Northern

Europe.5 It is caused by mutations in the CLN2 gene, located

on chromosome 11q15,6 which encodes the lysosomal

enzyme tripeptidyl peptidase 1.7 Ultrastructural examination

of late infantile neuronal ceroid lipofuscinosis storage bodies

reveals curvilinear bodies (CV) in cells of affected individu-

als.8 Clinically, late infantile neuronal ceroid lipofuscinosis

is characterized by epilepsy at the age of 2 to 4 years, which

may be manifested by partial or secondary generalized sei-

zures as well as generalized tonic-clonic or absence seizures,

but myoclonus is the most characteristic feature. Sometimes

delayed speech may precede epilepsy. Regression of acquired

skills becomes evident soon thereafter, followed by ataxia,

extrapyramidal, and pyramidal signs. Visual failure leads to

blindness by 5 or 6 years of age. The patients usually die

between 6 and 15 years of age.9,10

Mutations in the CLN2 gene may give rise not only to clas-

sical late-infantile but also to juvenile onset of the disease with

a milder clinical course.3,11–15 Furthermore, patients with onset

of the disease in the first year of life have been reported.16,17

Two common mutations, the splicing mutation c.509-1G>A

and the nonsense mutation c.622 C>T, account for approxi-

mately 60% to 78% of patients with late infantile neuronal cer-

oid lipofuscinosis.18,19

The clinical features of late infantile neuronal ceroid lipo-

fuscinosis are clearly defined and the progressive deteriorating

course of late infantile neuronal ceroid lipofuscinosis has been

assessed by clinical rating scores (modified Hamburg Late

Infantile Neuronal Ceroid Lipofuscinosis Scale, Weill Cornell

Late Infantile Neuronal Ceroid Lipofuscinosis Scale).20,21 In

this study, we report the clinical outcome and correlate with

genotype in 12 Spanish patients with late infantile neuronal

ceroid lipofuscinosis.

Patients and Methods

From 1979 to 2011, a total of 12 Spanish patients (8 males, 4 females)

with a mean age of 7.4 years (range 4-14) from 10 unrelated families

were diagnosed with late infantile neuronal ceroid lipofuscinosis. The

study was approved by the Ethics Committee of Hospital Sant Joan de

Deu in Barcelona, which was the reference hospital for the study.

Written informed consent was obtained from all patients, parents, or

legal guardians.

Data from each patient were collected from the patient’s medical

record and completed by information provided by the physicians in

charge and parents. The review of the medical records and the inter-

views was conducted by a single investigator. Data were entered into

a database previously reported22 with 50 items that included age at

diagnosis; initial symptom; age at regression of acquired skills;

type of seizures (myoclonic, myoclonic-atonic, partial, generalized

tonic-clonic, secondarily generalized, atypical absence); main signs

and symptoms; electroencephalographic findings; ophthalmologic

data; electroretinographic findings; visual evoked potentials;

enzymatic assays (tripeptidyl peptidase 1); ultrastructural data and

molecular studies.

Neurophysiological (electroretinography, visual evoked potentials),

neuroimaging (brain magnetic resonance imaging [MRI], computed

tomography scanner), and ophthalmologic studies were available for all

patients. Electroretinography was performed in 9 patients at least once

during the course of the disease. Visual evoked potentials were per-

formed in 7 patients and ophthalmologic evaluations in 11. All patients

underwent neuroimaging studies.

Electron microscope examinations of biopsied tissues were the

main morphological diagnostic technique being obtained according

to routine methods. The histologic examination of biopsy samples was

carried out in 9 patients, including biopsies of the skin (4 patients),

conjunctiva (2 patients), appendix (2 patients), and muscle (1 patient).

The tissue samples were fixed in 2.5% glutaraldehyde in phosphate

buffer, postfixed in 1% osmium tetroxide, dehydrated through graded

ethanol and embedded in epoxy resin. Semithin sections were stained

with toluidine blue and selected ultra-thin sections with uranyl acetate

and lead citrate.

Tripeptidyl peptidase 1 activity was measured in samples of leuko-

cytes or fibroblasts of 8 patients. The fluorometric enzymatic analy-

ses were performed using Ala-Ala-Phe-7-amido-4-metilcoumarina

(Sigma, Spain) as substrate. Protein measurement was performed

according to the method of Lowry et al (1951).23

Molecular genetics studies were carried out in 9 patients. DNA was

not available in 3 patients, as 1 patient died before genetic studies

were available (case 1) and 1 family did not approve this study (cases

4a and 4b). DNA extraction from whole blood was performed using

an automatic MagnaPure system (Roche Diagnostics, Spain) accord-

ing to the manufacturer’s instructions. The presence of mutations

was assessed by direct sequencing of the 13 exons of the CLN2 gene

using the BigDye Terminator v3.1 Cycle Sequencing Kit (Applied

Biosystems, Foster City, CA) and an ABI3130 automatic sequencer

(Applied Biosystems).

The primary endpoints of the study were the assessment of

psychomotor regression (time to reach regression of acquired skills),

epilepsy (age at onset of seizures), and the age at onset of main clin-

ical symptoms/signs of the disease. Nonparametrical survival esti-

mation was performed by means of a Kaplan-Meier analysis. The

time variable was computed as the time interval from birth to the

onset of psychomotor regression, epilepsy, and clinical symptoms/

signs of the disease. In the absence of this information, the follow-

up time was censured at the last visit. Data were analyzed with the

Statistical Package for the Social Sciences (SPSS) computer program

(version 17.0).

Results

Enzymatic, Molecular Studies, and UltrastructuralFindings

Partial deficiency of tripeptidyl peptidase 1 activity was found

in 8 patients, 6 of them also showed mutations in the CLN2

gene (cases 5, 6, 7, 8a, 8b, and 9). In the remaining 4 patients,

data on tripeptidyl peptidase 1 activity were not assessed; 3 of

these patients belonged to 3 unrelated families harboring muta-

tions in the CLN2 gene (cases 2, 3, and 10) and in the remaining

patient the diagnosis was made by a typical clinical course

Perez-Poyato et al 471

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compatible with late infantile neuronal ceroid lipofuscinosis

and ultrastructural studies that showed curvilinear bodies

inclusions (case 1).

Mutations in the CLN2 gene were present in 10 cases (8

unrelated) (Table 2). The nonsense mutation c.622 C>T leading

to R208stop accounted for 20% of the CLN2 mutated chromo-

somes and the splicing mutation (IVS5-1G>C) for a 6%.

Electron microscopy examination of biopsies revealed the

presence of membrane-bound curvilinear inclusions in various

cell types including endothelial cells, pericytes, smooth muscle

cells, fibroblasts, Schwann cells, and glands depending on the

tissue available for study. Curvilinear inclusions in fibroblast in

a case of late infantile neuronal ceroid lipofuscinosis are shown

in Figure 1.

Individualized clinical, enzymatic, and ultrastructural data

are shown in Table 1.

Regression of Acquired Skills

As shown in Table 3, at the time of the study all patients had

lost the ability to speak in full sentences at a median age of

3.7 years (95% CI 3.1-4.3). Loss of walking ability and com-

plete absence of language appeared in 92% of patients at a

median age of 4.5 years (95% CI 4.3-4.6 vs 95% CI 4.1-4.8).

The median age at which patients became wheelchair bound

was quite similar to that which they lost their sitting ability,

purposeful hand use and urinary sphincter control. Dysphagia

was observed at a median age of 5.4 years (95% CI 4.4-6.3).

Kaplan-Meier estimates of the age of the patients at the time

of regression of acquired skills are shown in Figure 2A.

Epilepsy

Myoclonic jerks were observed in all patients at a median age

of 3.7 years (95% CI 3.4-4) and partial seizures with secondary

generalization were reported in 83% of patients at a median of

3.4 years (95% CI 2.9-3.8). Myoclonic-atonic seizures were

observed in 75% of patients at a median age of 4.1years

(95% CI 3.5-4.7) and generalized tonic-clonic seizures

appeared in 58% of patients at a median age of 4 years (95%CI 3.3-4.6). Continuous myoclonus was observed in 92% of

patients at a median of 4.7 years (95% CI 4.2-5.2). Kaplan-

Meier estimates of the age of the patients at the time of appear-

ance of seizures are shown in Figure 2B.

Clinical Signs and Symptoms

The presenting symptoms included seizures (6 patients), delayed

speech (5 patients), and clumsiness (1 patient); they were

observed between 18 months and 3.7 years of age (mean 2.2

years). Initial seizures were partial status epilepticus (case 4a),

partial (case 4b) and simple febrile (case 5) that were followed

by myoclonic-atonic seizures (cases 1, 9), myoclonic jerks

(case 2), and generalized seizures (case 5) (Table 1).

All patients developed ataxia at a median age of 4 years

(95% CI 3.9-4.1), and cognitive decline was observed in 92%of patients at a similar age (median 4 years, 95% CI 3.5-4.4)

whereas visual failure appeared at an earlier age (median 3.8

years, 95% CI 3.2-4.4). Tremor occurred in 92% of patients

earlier than both spasticity (median age 4.9 years; 95% CI

3.8 - 5.9) and blindness (median age 5.1 years; 95% CI 4.6-

5.6). Kaplan-Meier estimates of the age of the patients at the

time of appearance of clinical signs and symptoms are shown

in Figure 2C.

The MRI abnormalities in a patient with late infantile neu-

ronal ceroid lipofuscinosis are shown in Figure 3.

Discussion

Late infantile neuronal ceroid lipofuscinosis occurs worldwide

and it seems to be less frequent compared to the juvenile form

in Spain.22 The main clinical features and ultrastructural data of

this disease have been previously described.8,24 However, there

have been no reports of the rate of disease progression and its

correlation with mutations in the CLN2 gene in our country.

Our series was quite homogeneous both clinically and

pathologically whereas clinical heterogeneity in late infantile

neuronal ceroid lipofuscinosis has been previously described.25

The age at onset of the disease ranged between 18 months and

3.7 years (mean 2.2 years), similar to what has been previously

described by Topcu et al26 and other authors have reported

onset between 2 and 3.5 years27 and up to 4 years.14,28

Careful clinical assessment regarding the regression of

acquired skills allowed us to observe that it may be initiated

by the onset of loss of sentences by 3 years of age. During the

second stage of the disease, patients lost their walking ability

and showed nonverbal communication. Finally, patients lost

their sitting ability, purposeful hand use, and urinary control

sphincter and became wheelchair-bound at a median age of 5

years2 followed by dysphagia within a few months.

The initial manifestations of the disease were delayed

speech development in patients who never completely acquired

language capacity2,8,29 and simple febrile seizures followed by

Figure 1. Curvilinear inclusions in fibroblasts in one case of CLN2mutation (ultrathin section stained with uranyl acetate and lead citrate,�42 000).

472 Journal of Child Neurology 28(4)

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Tab

le1.

Clin

ical

feat

ure

s,en

zym

atic

and

ultra

stru

ctura

lst

udie

sin

Span

ish

pat

ients

with

late

infa

ntile

neu

ronal

cero

idlip

ofu

scin

osi

s.

Cas

enu

mbe

rSe

xA

ge (y)

Cons

an-

guin

ity

Pres

enting

sym

ptom

Age

atfir

stsy

mpt

om

/ag

eat

diag

nosi

s(y

)Se

izur

es(a

ge,

y/m

o)

Myo

clonu

sje

rks/

cont

inuo

usm

yocl

onu

s(a

ge,y

/mo)

Cogn

itiv

ede

clin

e(a

ge,y/

mo)

Ata

xia

(age

,y/m

o)

Oph

thal

molo

gic

findi

ngs

(age

,y/

mo)

VEP

(age

,y/

mo)

ERG

(age

,y/m

o)

Cer

ebra

l/ce

rebe

llar

atro

phy

(age

,y/m

o)

TPP

1ac

tivi

tynm

ol/h

/mg

(cont

rol)

Elec

tron

mic

rosc

opy

(bio

psie

dtiss

ue)

1M

9*Y

esSi

mpl

efe

brile

seiz

ures

2/

6M

yocl

oni

c-at

oni

c(3

y7

mo)

4y

4m

o/4

y9

mo

4y

4y

Papi

llary

pallo

r(5

y)O

ptic

nerv

eat

roph

y(7

y)

Norm

al(4

y9

mo)

Dec

reas

edam

plitud

e(4

y9

mo)

þ/þ

(5y)

ND

CV

(conj

unct

ive)

2M

10*

No

Sim

ple

febr

ilese

izur

es3.

7/

6M

yocl

oni

c-at

oni

c(4

y9

mo)

3y

10m

o/5

y6

mo

4y

3y

10m

oPa

pilla

rypa

llor

(5y

6m

o)

Gia

ntre

spons

es(5

y3

mo)

#voltag

e,(5

y3

mo)

-/þ

(3y

10m

o)

ND

CV

(app

endi

x)

3M

7*Y

esD

elay

edsp

eech

2/

7G

ener

aliz

ed/P

artial

(3y

7m

o)

3y/

5y

3y

6m

o3

y9

mo

Papi

llary

pallo

r(3

y)O

ptic

nerv

eat

roph

y(5

y)

Abo

lishe

d(5

y6

mo)

Abo

lishe

d(5

y6

mo)

-/þ

(3y

6mo)

ND

CV

(app

endi

x)

4aM

6*N

oPa

rtia

lst

atus

epile

ptic

us3.

4/

5Pa

rtia

lst

atus

epile

ptic

us3

y7

mo/4

y3

mo

3y

7m

o4

y2

mo

Papi

llary

pallo

r(5

y)D

elay

edla

tenc

y(4

y)A

bolis

hed

(4y)

þ/þ

(5y)

2.9

(125

.1)

CV

(ski

n)

4bF

8*N

oPa

rtia

lse

izur

es3

/4

Part

ialse

izur

es3

y9

mo/3

y11

mo

3y

6m

o4

yN

DN

DN

orm

al(3

y5

mo)

þ/þ

(4y)

0.8

(125

.1)

ND

5M

14*

No

Sim

ple

febr

ilese

izur

es1.

6/

7G

ener

aliz

ed(4

y)5

y/7

y5

y6

mo

5y

5m

oN

orm

al(6

y)N

DN

Dþ

/þ(4

y9

mo)

9,8

(403

)C

V(m

uscl

e)

6M

6*N

oD

elay

edsp

eech

2/

4Pa

rtia

l(2

y11

mo)

3y

7m

o/4

y3

y3

mo

3y

7m

oN

orm

al(3

y9

mo)

ND

Norm

al(3

y7

mo)

þ/þ

(3y

3m

o)

1.7

(223

)C

V(s

kin)

7F

11N

oD

elay

edsp

eech

2/

7G

ener

aliz

ed(3

y4

mo)

3y

10m

o/6

y4

y4

yN

orm

al(3

y4

mo)

Gia

ntre

spons

es(3

y4

mo)

Norm

al(4

y5

mo)

–/þ

(3y

4m

o)

21.2

0(7

88.9

0)C

V(s

kin)

8aM

6*N

oC

lum

sine

ss2

/6

Part

ial(3

y8

mo)

4y

3m

o/6

y4

y3

mo

4y

6m

oPe

riph

eral

pigm

enta

rycl

umpi

ng(5

y)

Norm

al(4

y6

mo)

ND

–/þ

(3y

8m

o)

4.7

(100

3.1)

CV

(conj

unct

ive)

8bF

6*N

oD

elay

edsp

eech

2/

2Pa

rtia

l(3

y5

mo)

3y

7m

o/5

y4

y10

mo

4y

Peri

pher

alpi

gmen

tary

clum

ping

(5y)

ND

ND

–/þ

(3y

5m

o)

11.3

(100

3.1)

ND

9M

7N

oSi

mpl

efe

brile

seiz

ures

2.5

/3

Myo

cloni

c-at

oni

c(2

y6

mo)

2y

6m

o/3

y6

mo

3y

6m

o4

yN

orm

al(3

y)N

DN

orm

al(3

y7

mo)

Norm

al(3

y)13

.10

(674

)N

D

10F

4N

oD

elay

edsp

eech

2/

4Pa

rtia

l(3

y3

mo)

3y

9m

o/4

y4

y3

y9

mo

Papi

llary

pallo

r(3

y10

mo)

#vo

ltag

e(3

y9

mo)

#vo

ltag

e(3

y9

mo)

–/þ

(3y

4m

o)

ND

CV

(ski

n)

Abbre

viat

ions:

CV

,cu

rvili

nea

rbodie

s;(*

),die

d;ER

G,el

ectr

ore

tinogr

aphy;

F,fe

mal

e;M

,m

ale;

ND

,not

done

or

unkn

ow

n;T

PP1,T

ripep

tidyl

pep

tidas

e1;V

EP,vi

sual

evoke

dpote

ntial

s.

473

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epilepsy as reported occasionally.12,28 An initial diagnosis of

late infantile neuronal ceroid lipofuscinosis patients may be

suspected in the presence of regression or delayed speech.

Most authors have described epilepsy, which may be mani-

fested by any type of seizures as the presenting symptom

between 2 and 4 years of age10,14,26,30–34 (median 3 years).35

The estimated median age at onset of partial seizures by age

3.4 years, followed by myoclonic jerks that occurred between

3 and 4 years of age in our patients, was similar to what pre-

viously has been reported. The clinical course of progressive

myoclonic epilepsy became evident in the series during

follow-up. Generalized tonic-clonic seizures have been

reported as the most prominent seizure type of the disease26

and may be preceded by simple febrile seizures.12,28 In con-

trast, in the series generalized tonic-clonic seizures were less

frequent. Epileptic seizures were absent in one late infantile

neuronal ceroid lipofuscinosis patient with protracted clinical

course.13 All these data suggest that the spectrum of epilepsy

in patients with late infantile neuronal ceroid lipofuscinosis

may be surprisingly broad.

Electroencephalographic findings in most patients showed

spikes and slow waves superimposed on irregular slow back-

ground activity on both hemispheres, mostly in the posterior

regions, during the course of the disease.36 In contrast to other

authors, polyphasic high-voltage posterior spikes when photic

stimulation was performed at low frequency were not observed

in the series.30,37,38

In the present study, visual failure appeared after the onset

of epilepsy32,35 and it has been reported at a median age of 4

years35 leading to blindness by 5 or 6 years.10,24

Ataxia was the third symptom of the disease after the onset

of epilepsy38 and visual failure in the series, and it occurred at a

similar median age as that of cognitive decline (4 years)

although it may appear earlier (median 3.5 years, range 2.5-

4.6) in patients with late infantile neuronal ceroid lipofuscino-

sis.2 Severe motor impairment with hand tremor and spasticity

was observed at advanced stages of the disease in our patients.

We were not able to apply the rating scales of disease sever-

ity (scale developed by Steinfeld et al 2002; modified Hamburg

Late Infantile Neuronal Ceroid Lipofuscinosis Scale and Weill

Cornell Late Infantile Neuronal Ceroid Lipofuscinosis Scale)20,21

Table 2. Mutations in the CLN2 gene identified in Spanish patients.

Casenumber

Nucleotidechange Mutation

Amino acid change/predictedconsequence Status Location

Number ofindividuals

with mutationin the family Reference

2 c.622C>Tc.1222-1224del

NonsenseDel 3 bp

p.R208XFrameshift after S408

CompoundHeterozygous

Exon 6Exon 8

1 Sleat et al 1997This study

3 c.17þ1G>T Splice site Homozygous Intron 1 1 Kousi et al 20095 c.880G>A Missense p.S293N

2nd mutation notfound

CompoundHeterozygous

Exon 7 1 This study

6 c.797G>Ac.1016G>A

MissenseMissense

p.R266Qp.R339Q

CompoundHeterozygous

Exon 7Exon 8

1 Mila, personalcommunication

Pal et al 20097 c.509-1G>A

c.165 C>TSplice siteMissense

p.Q56X CompoundHeterozygous

Intron 5Exon 3

1 Sleat et al 1997This study

8 c.622C>T Nonsense p.R208X Homozygous Exon 6 2 Sleat et al 19979 c.616C>T

c.1506G>CMissenseSplice site

p.R206C Compoundheterozygous

Exon 6Intron 6

1 Mole et al 1999This study

10 c.827A>T Missense p.D276V Homozygous Exon 7 1 Kohan et al 2009

Table 3. Age at the time of psychomotor regression, epilepsy, andclinical signs and symptoms.

Patients with late infantile neuronalceroid lipofuscinosis (n ¼ 12)

Age, years median No impairment(95% CI) % patients

Regression acquired skillsLoss of walking ability 4.5 (4.3-4.6) 8.3Becoming wheelchair-bound 5 (4-5.9) 16.7Loss of sitting ability 5 (4.7-5.2) 33.3Loss of purposeful hand use 5 (4.4-5.5) 25Loss sentences 3.7 (3.1-4.3) 0No language 4.5 (4.1-4.8) 8.3Dysphagia 5.4 (4.4-6.3) 25Urinary incontinence 5 (3.1-6.8) 41.7

EpilepsyMyoclonic-atonic seizures 4.1 (3.5-4.7) 25Myoclonic jerks 3.7 (3.4-4) 0Continuous myoclonus 4.7 (4.2-5.2) 8.3Partial seizures 3.4 (2.9-3.8) 16.7Generalized tonic-clonic 4 (3.3-4.6) 41.7Atypical absence seizures 4.3 (3.1-5.4) 33.3

Clinical signs and symptomsCognitive decline 4 (3.5-4.4) 8.3Visual failure 3.8 (3.2-4.4) 16.7Blindness 5.1 (4.6-5.6) 8.3Tremor 4.2 (3.4-5) 8.3Ataxia 4 (3.9-4.1) 0Spasticity 4.9 (3.8-5.9) 16.7

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Figure 2. Kaplan-Meier estimates of the age of the patients at the time of regression of acquired skills (A), epilepsy (B), and main signs andsymptoms of the disease (C) among 12 Spanish patients with late infantile neuronal ceroid lipofuscinosis.

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because most patients had died and the remaining 3 patients

were in an advanced stage of the disease at the time the

authors undertook this study.

Only a few studies have described neuroradiologic ima-

ging in living patients with late infantile neuronal ceroid lipo-

fuscinosis, demonstrating progressive gray matter atrophy

prominent in the infratentorial regions. Brain MRI findings

in the series were similar to previous reports.31,33,39

The relationship between the absence of tripeptidyl pepti-

dase 1 activity and curvilinear bodies9,19,40 and mutations in

CLN2 gene and curvilinear bodies has been reported.3,8 The

present results confirm that mutations in the CLN2 gene are asso-

ciated with reduced tripeptidyl peptidase 1 activity in late infan-

tile neuronal ceroid lipofuscinosis, as previously reported.19

According to the present results, 2 of the CLN2 mutations iden-

tified by Sleat et al (1997)7 were less frequent (78% vs 26%)

than previously reported in other studies.18–21 This may be due

to the higher genetic heterogeneity present in the Spanish popu-

lation, which is well known in other recessive diseases.

On the other hand, in agreement with Kohan et al (2009)14

the presence of the p.D276V missense mutation was found in

homozygosis in 1 Paraguayan patient, in agreement with other

cases of Latin American origin.

In summary, the clinical progression of late infantile neuro-

nal ceroid lipofuscinosis in the study population was relatively

homogeneous. Genetic heterogeneity of late infantile neuronal

ceroid lipofuscinosis was demonstrated in the 10 families stud-

ied. The knowledge of the natural history of the disease can

provide basic information for designing health care plans and

to prepare for future clinical trials.

Acknowledgments

This work has been approved by the responsible authorities of Hospital

Sant Joan de Deu, which was the reference hospital for the study.

The authors are grateful to Drs M. Rebollo and MI. Alonso Colme-

nero and the Spanish Association of Families Affected by NCL for the

valuable support and indispensable cooperation. Statistical support

was provided by Raquel Iniesta (Fundacio Sant Joan de Deu, ISCIII

CA08/00151).

Author Contributions

MSP-P contributed to the design of the study, reviewed the medical

records, took part in the analysis and interpretation the data, wrote the

first draft, and prepared the final draft of the manuscript. She had full

access to study data and takes responsibility for the integrity of the

study. MPM contributed to the design of the study and acquisition

of data, participated in the statistical analysis, interpretation of data,

writing of the manuscript, and approved the final draft. IFA performed

histopathologic studies, contributed to analysis of data and drafting,

reviewed the manuscript for intellectual content, and approved the

final draft. LRR contributed to genetic studies and approved the final

draft. VCS performed histopathologic studies and approved the final

draft. MJMG, JEP, AVP, MMGG, AMB, and EMH provided case his-

tories for the study, acquired data, reviewed the manuscript for intel-

lectual content, and approved the final draft. MJCR and LG performed

enzymatic studies, reviewed the manuscript for intellectual content,

and approved the final draft. MMR was the principal investigator,

performed the genetic studies, contributed to the design of the study

and acquisition of data, participated in writing of the manuscript and

Figure 2 (Continued).

476 Journal of Child Neurology 28(4)

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approved the final draft. She had full access to study data and takes

responsibility for the integrity of the study, and controlled the decision

to publish.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship,

and/or publication of this article.

Ethical Approval

The study was approved by the Ethics Committee of Hospital Sant

Joan de Deu in Barcelona.

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