1. ADDISON IN X-LINK ADRENOLEUKODYSTROPHY (X- ALD): Phenotype and genotype of 12 cases Nguyen Ngoc Khanh 1, Vu Chi Dung 1 ， Shimozawa N 2. ， Bui Phuong Thao 1, Can Thi Bich Ngoc 1 ， Nguyen Thi Hoan 1 ， Nguyen Phu Dat 1, Le Thi Kim Ngoc 1 1 Vietnam National Hospital of Pediatrics, Hanoi, Vietnam 2 Division of Genomics Research Life Science Research Center, Department of Pediatrics, Gifu University School of Medicine, Gifu, Japan

2. BACKGROUND X-linked adrenoleukodystrophy (X-ALD): peroxisomal disorder affecting adrenal cortex & central nervous system. Rare disease: in males (USA): 1/21,000 Symptoms: often in males –Addison: hyperpigmentation, anxious. –Progressive neurologic deficit: cognitive deficit, visual deficit, hearing deficit, motor dysfunction… –May be in females: often over 30 years old with increased deep tendon reflexes and distal sensory changes in lower extremities…

3. BACKGROUND Variant phenotypes: 4 types: Cerebral inflammatory ALD, Adrenomyeloneuropathy: AMN, Addison – only, Asymtomatic. Broad phenotype: from childhood cerebral form characterized by rapid progression to a vegetative state or death within 1–2 years (31–35%), to slowly progressive adrenomyeloneuropathy (AMN) in adults (40–46%)

4. Moser HW et al. (2007) X-linked adrenoleukodystrophy Nat Clin Pract Neurol 3: 140–151 doi:10.1038/ncpneuro0421 X-linked adrenoleukodystrophy phenotypes in males THẢO LUẬN

5. Moser HW et al. (2007) X-linked adrenoleukodystrophy Nat Clin Pract Neurol 3: 140–151 doi:10.1038/ncpneuro0421

6. BACKGROUND The gene that is defective in X-ALD was mapped to Xq28 in 1981 & was isolated & cloned in 1993. This gene is now referred to as ABCD1. It is composed of 10 exons, it codes for a messenger RNA of 4.3 kb, & a protein of 745 amino acids that is now referred to as adrenoleukodystrophy protein (ALDP).

7. BACKGROUND Definitive Diagnosis: –Plasma VLCFA profiles. –Mutations analysis of ABCD1 gene

8. AIMS To describe clinical, laboratory & cerebral MRI characteristics of Vietnamese patients with X- ALD To identify mutations of ABCD1 in these cases

9. PATIENTS & METHODS 12 cases from 10 unrelated families Case series study Clinical & imagine at NHP, Hanoi, Vietmam Extraction of DNA from peripheral blood leukocyte using standard procedures VLCFA profile & mutation analysis of ABCD1 at Gifu University, Japan

10. RESULTS PHENOTYPE (1): onset – diagnosis: 0.25 – 11 yrs PatientFamily history Age of onset of addison (yrs) Age of onset of neurologic symptoms (yrs) Age of diagnosis (yrs) Time onset to diagnosis (yrs) 1+5(-) until 11.510.54.5 2 (sibling of pt 1) +4795.0 3-1.7(-) until 4.74.32.6 4*+2775.0 5*-(+) age NA67.3 6-No9.59.750.25

11. RESULTS PHENOTYPE (2): onset – diagnosis: 0.25 – 11 yrs PatientFamily history Age of onset of addison (yrs) Age of onset of neurologic symptoms (yrs) Age of diagnosis (yrs) Time onset to diagnosis (yrs) 7-1.7(-) tới 4.3 tuổi4.32.6 8+38.510.67.6 9, brother of 8 +14222511 10--5,56,30,8 11+-914,65,6 12+99,39,60,3

12. RESULTS Neurologic symptoms Neurologic symptomsN Cognitive deficit (poor learning, neglect) 9/9 Attention deficit9/9 Behaves deficit7/9 Visual dysfunction6/9 Hearing dysfunction6/9 Speech difficulty6/9 Motor dysfunction6/9

13. RESULTS Adrenal function & Brain MRI PatientCortisol at 8 AM (150-600 nmol/l) ACTH (7.2 – 63.3 pg/ml) Brain MRI 150398Normal at 11 yrs 27952Marked loss of posterior white matter 34.62000Normal at 4.7 yrs 4*121134Reduced density in white part in occipital areas 5*123.81892Marked loss of posterior white matter

14. RESULTS Adrenal function & Brain MRI (2) PatientCortisol at 8 AM (150-600 nmol/l) ACTH (7.2 – 63.3 pg/ml) Brain MRI 6NA bilateral white matter lesions (Loes 14) 723NANormal at 4.3 yrs 845.910.8White matter lesion (Loes 4) 9NA

15. RESULTS Adrenal function & Brain MRI (3) BNCortisol 8 AM (150-600 nmol/l) ACTH (7.2 – 63.3 pg/ml) MRI Sọ não 102848 Cerebral atrophy, billateral white matter lesion in thalamus, corpus callosum, cerabellum (Loes: 16) 111021,89 Bilateral white matter lesion in periventricular, thalamus, corpus callosum. (Loes: 12) 1241,1172 Bilateral white matter lesion in periventricular, thalamus, corpus callosum. (Loes: 10)

16. RESULTS VLCFA Profile (1) PatientC24:0/C22:0 (1.05 ±0.16) C25:0/C22:0 (0.024 ±0.006) C26:0/C22:0 (0.012 ±0.005) 12.030.0850.109 2 (sib of pt 1) 1.780.0880.106 31.740.0590.049 4*NA 5*2.180.0920.096 61.980.171

17. RESULTS VLCFA Profile (2) PatientC24:0/C22:0 (1.05 ±0.16) C25:0/C22:0 (0.024 ±0.006) C26:0/C22:0 (0.012 ±0.005) 71.960.135 81.320.20.144 91.600.260.22 10NA 11NA 12NA

18. RESULTS Genotype Patientc.DNAMutant protein 1c.1628C>Tp.Pro543Leu 2 (sib of pt 1) c.1628C>Tp.Pro543Leu 3c.1553G>Ap.Arg518Gln 4*c.1202G>Tp.Arg401Trp 5*c.1208T>Ap.Met403Lys *Novel mutation

19. RESULTS Genotype (2) Patientc.DNAMutant protein 6*6* deletion included between IVS1+505 and IVS2+1501, containing whole exon 2 (4243bp), plus insertion of 79bp from BAP31 and 8bp from unknown origin 7*7* IVS8+28-551bp del 8c.1552 C>Tp.Arg518Trp 9 (sibling of pt 8) c.1552 C>Tp.Arg518Trp 9 different mutations including 4 *novel

20. RESULTS Genotype (3) Patientc.DNAMutant protein 10c.46-53del insG 11c.854G>Cp.R285P 12NA 9 different mutations including 4 *novel

21. CONCLUSION Onset – diagnosis: 0.25 – 11 yrs Addison in 9/12 cases; progressive neurologic dysfunction in 9/12 cases 6 cases: Addison + progressive neurologic dysfunction 3 cases: progressive neurologic dysfunction 3 cases: Addison Cognitive deficit, attention deficit were 1 st neurologic symptoms (9/9). Behave deficit, visual dysfunction, hearing dysfunction, motor dysfunction, speech difficulty were later.  Easy to misdiagnosis

22. CONCLUSION Low plasma cortisol & high ACTH levels in 7/7 Brain MRI: abnormal in 8/8 cases with neurologic symptoms. 7/8 had Loes score >10, only 1 case 8 had Loes 4.  Brain MRI: important to decide HSCT  Definitive diagnosis: Increasing of plasma VLCFA in 8/8 Nine different mutations of ABCD1 including 4 novel ones Same family & same genotype but without neurologic symptoms in older boy (pt 1)

23. T.D.H (Pt1) 11.5 years old T.Q.N (Pt2) 9 years old Pt 1 DOB: 1/1/2000 Hyperpigmentation No neurologic symptoms p.543Pro>Leu Pt 2 DOB: 22/4/2002 Hyperpigmentation Neurologic symptoms p.543Pro>Leu

24. T.D.H (Pt1) 11.0 years old T.Q.N (Pt2) 9 years old ABCD1 ex6 c.1628C>T (p.543Pro>Leu)

25. H.D.M.T (Pt 3)4.7 years old; ABCD1 ex6 c.1553G>A p.518Arg>Gln

26. N.C.H Novel mutation c.1202G>T (p.Arg401Trp) Healthy Carrier p.Arg401Trp Died at 7 years of age Died at 12 years of age I II III IV Pt 4. Pedigree of N.C.H

27. N.C.H (pt 4)

28. Pt 6. Nguyen Van Q Extent of deletion included between IVS1+505 and IVS2+1501, containing whole the exon 2 (4243bp), plus insertion of 79bp from BAP31 and 8bp from unknown origin 9.75 yrs. From 9.5 yrs of age: pain of legs, weakness, difficulties of pronunciation, poor hearing, poor vision, no hyperpigmentation.

29. Trương Xuan H 11 yrs c.1552 C>T (p.Arg518Trp) p.Arg518Trp Pt 8

30. Trương Xuan H 11 yrs VLCFA Profile Pt 8 3857: ALD control; 3860: Pt 8; 3861: Pt 9; 3769 normal control

31. Thank you very much!