The clinical features of patients with 3-PGDH defi- ciency and the response to treatment with amino acid supplementation indicate important functions of serine and glycine in brain metabolism. Little is known about the function of serine in human brain metabolism, but data from in vitro studies indicate important func- t ion~. ' , '~ Glycine is known for its neurotransmitter functions.".12 It is therefore not surprising that severe neurological impairment is present in patients with de- ficiencies of both serine and glycine. The importance of diagnosing serine biosynthesis defects in patients with congenital microcephaly and seizures was recently reported.I3

In conclusion, our results indicate beneficial effects of amino acid supplementation with both L-serine and glycine in the treatment of 3-PGDH deficiency.

Familial Spinocerebellar Ataxia with Cerebellar Atrophy, Peripheral Neuropathy, and Elevated Level of Serum Creatine Kinase, ?-Globulin, and a-Fetoprotein Mitsunori Watanabe, MD, PhD,*t Yoshiro Sugai, MD, PhD," Patrick Concannon, PhD,$ Michel Koenig, MD, PhD,$ Michele Schmitt, PhD,§ Madoka Sato, MD, PhD," Masami Shizuka, MD,t Kazuyuki Mizushima, MDt Yoshio Ikeda, MD,t Yasushi Tornidokoro, MD,? Koichi Okamoto, MD, PhD,t and Mikio Shoji, MD, PhDt

We thank Dr M. S. van der Knaap for reviewing MRI scans.

References 1. Jaeken J, Detheux M, Van Maldergem L, et al. 3-Phospho-

glycerate dehydrogenase deficiency: an inborn error of serine biosynthesis. Arch Dis Child 1996;74:542-545

2. Gregory DM, Sovetts D, Clow CL, Scriver CR. Plasma free amino acids values in normal children and adolescents. Metab- olism 1986;35:967-969

3. Araki A, Sako Y. Determination of free and total homocysteine in human plasma by high performance liquid chromography with fluorescence detection. J Chromatogr Biomed Appl 1987; 422:43-52

4. de Koning TJ, Duran M, Dorland L, et al. Maternal 3-methylglutaconic aciduria associated with abnormalities in offspring. Lancet 1996;348:887-888

5. Walsh R, Conway H, Roche G, et al. 3-Methylglutaconic aci- duria in pregnancy. Lancet 1997;349:776

6. Smith QR, Momma S, Aoyagi M, Rapoport SI. Kinetics of neutral amino acid transport across the blood-brain barrier. J Neurochem 1987;49:1651-1658

7. Clayton PT, Smith I, Harding B, et al. Subacute combined degeneration of the cord, dementia and parkinsonism due to an inborn error of folate metabolism. J Neurol Neurosurg Psychi- atry 1986;49:920-927

8. Hyland K, Smith I, Bottiglieri T, et al. Demyelination and de- creased S-adenosylmethionine in 5,lO-methylenetetrahydrofolate reductase deficiency. Neurology 1988;38:459-462

9. Kanai Y. Family of neutral and acidic amino acid transporters: molecular biology, physiology and medical implications. Curr Opin Cell Biol 1997;9:565-572

10. Savoca R, Ziegler U, Sonderegger P. Effects of L-serine on neu- rons in vitro. J Neurosci Methods 1995;61:159-167

11. Betz H. Glycine receptors: heterogeneous and widespread in the mammalian brain. Trends Neurosci 1991;14:458-461 Lipton SA, Rosenberg PA. Excitatory amino acids as a final

common pathway for neurologic disorders. N Engl J Med 1994;330:613- 622

13. Walter JH. Two "new" treatable inherited biosynthetic disor- ders. Lancet 1996;348:558-559 (Commentary)

12.

Here, we report a familial spinocerebellar ataxia (FSCA), which has clinical features similar to Friedreich's ataxia, an ataxia with isolated vitamin E deficiency, and ataxia telangiectasia. However, the serum levels of creatine ki- nase, y-globulin, and a-fetoprotein were elevated, and biochemical and genetic analyses ruled out diagnosis of these three ataxias as well as other FSCAs. Thus, this family is thought to have a new type of FSCA.

Watanabe M, Sugai Y, Concannon P, Koenig M, Schmitt M, Sat0 M, Shizuka M, Mizushima K, Ikeda Y, Tomidokoro Y, Okamoto K, Shoji M.

Familial spinocerebellar ataxia with cerebellar atrophy, peripheral neuropathy, and elevated level

of serum creatine kinase, y-globulin, and a-fetoprotein. Ann Neurol 1998;44:265-269

Familial spinocerebellar ataxias (FSCAs) consist of ge- netically heterogenous subgroups. Friedreich's ataxia (FA), ataxia with isolated vitamin E deficiency (AVED), and ataxia telangiectasia (AT) are representa- tive diseases with an autosomal recessive trait. The genes responsible for these FSCAs were recently

Here, we present a new type of FSCA that

From 'Department of Neurology, Sawatari Spa Hospital, Gunma Medical Association, Agatsumagun, and Departments of tNeurol- ogy and "Dermatology, Gunma University School of Medicine, Mae- bashi, Gunma, Japan; $Virginia Mason Research Center, University of Washington School of Medicine, Seattle, WA; and $Insticut de Gknktique et de Biologie Molkculaire et Cellulaire, Illkirch, France.

Received Sep 2, 1997, and in revised form Feb 18, 1998. Accepted for publication Feb 18, 1998.

Address correspondence to Dr Watanabe, Department of Neurol- ogy, Gunma University School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-851 1, Japan.

Copyright 0 1998 by the American Neurological Association 265

has clinical characteristics common with FA, AVED, and ataxia telangiectasia, and document its biochemical and genetic characteristics as well as clinical features.

Patient Histories The Table demonstrates the main clinical features and results of laboratory investigations of the 4 patients examined.

Patient I The parents of Patient 1 (proband, Subject 11-6 in Fig 1A) were first cousins and had no neurological symptoms. The mother, age 68 years, was healthy, but the father had died of hepatocellular carcinoma at age 65. Other relatives similarly had no neurological disorders.

The serum levels of creatine kinase (CK), IgG, and a-fetoprotein (AFP), for Patient 1, were elevated, in contrast with the normal levels of serum vitamin E, cholestanol, lac- tate, pyruvate, phytanic acids and very-long-chain fatty acids, and 10 lysosomal enzymes in leukocytes (see Table). No ab- normalities such as acanthocytes or vacuolation in the lym- phocytes were discerned in the peripheral blood. The CD4/ CD8 ratio (0.57) was a little lower than normal. Analyses of amino acids showed normal patterns both in plasma and in urine. The findings of standard urine tests were normal.

Microscopic analysis of specimens from his biceps dis- closed no abnormalities. Notably absent were ragged-red fi- bers and autofluorescent materials such as ceroid. Ceroid-like structures were not revealed through staining with oil red 0 and periodic acid-Schiff, and cytochrome c oxidase stain- ing produced a normal result. Moreover, the activities of mitochondria1 enzymes (cytochrome c oxidase, succinate- cytochrome c reductase, rotenone-sensitive NADH-cyto- chrome c reductase, NADH dehydrogenase, succinate dehy- drogenase, and citrate synthase) were normal in his muscle samples. The cultured fibroblasts were normally positive for cytochrome c oxidase and showed no ceroid-like materials stained by oil red 0 or periodic acid-Schiff. They indicated a normal survival curve after exposure to x rays.

The presence of spontaneous chromosomal abnormalities was examined by the G-banding method in peripheral lym- phocytes, revealing no numerical or structural aberrations, especially abnormalities of chromosomes 7 and 14. In addition, structural abnormalities were not induced by stim- ulation of mitomycin C.

Electrocardiogram (ECG) findings were normal, and the abdominal computed tomogram (CT) indicated no abnor- malities including hepatosplenomegaly. His brain CT and magnetic resonance image (MRI) revealed mild cerebellar at- rophy and a dilated fourth ventricle, but brainstem and ce- rebrum were normal (Fig 2A).

Although he has received 450 mg of tocopherol acetate, 104 mg of benfotiamine hydrochloride, 75 mg of pyridoxine hydrochloride, and 750 pg of hydroxocobalamin hydro- chloride per day for 2 years, his symptoms remains gradually progressive.

Patient 2 Patient 2 (Subject 11-3, see Fig lA), an older sister of the proband, developed an unsteady gait at age 19 and presented at a certain hospital. After diagnosis of FSCA, she underwent

sural nerve biopsy. The findings demonstrated severe loss of the myelinated fibers, in particular large myelinated fibers, but no onion bulb formation (data not shown). At age 28, the findings of her ultracardiosonography were normal. However, her symptoms gradually progressed and she be- came wheelchair bound, so she visited our hospital at age 33. As shown in the Table, there were elevated levels of serum CK, IgG, IgA, IgM, and AFP, and mild impairment of glu- cose tolerance. Her brain CT and MRI scans showed a di- lated fourth ventricle, moderate atrophy of the cerebellar hemispheres and vermis, and preservation of brainstem and cerebrum (data not shown).

Patient 3 Patient 3 (Subject 11-2, see Fig lA), an older sister of Patient 2, developed truncal ataxia at age 19 years. At the age of 21, she was admitted to a certain hospital and was diagnosed as having FSCA. During her admission, the findings of cere- brospinal fluids and ultracardiosonography were normal. The results of the conduction velocity study of the median nerve showed decreased amplitude in both motor and sensory ac- tion potentials, whereas in the tibial nerve, no action poten- tials of the sensory nerve were detected, and motor conduc- tion velocity was decreased. After gradual deterioration of her symptoms, at age 33 and wheelchair bound, she presented at our hospital. She had mild elevation of serum CK, IgG, IgA, and AFP levels, and mildly impaired glucose tolerance, de- spite the normal level of serum vitamin E (see Table). The findings of ECG were normal, and no abnormalities includ- ing hepatosplenomegaly were observed by abdominal CT. Her brain CT and MRI scans showed a dilated fourth ven- tricle, severe atrophy of the cerebellar hemispheres and ver- mis, and preservation of brainstem and cerebrum (see Fig 2B).

Patient 4 Patient 4 (Subject 11-1, see Fig lA), an older brother of Pa- tient 3, developed cerebellar signs at age 20 years and pre- sented at a certain hospital at the age of 28 years. The clin- ical characteristics at that time are shown in the Table. ECG findings were normal. With regard to the study of both me- dian and tibial nerve conduction velocity, sensory action po- tentials could not be identified, and the velocity of the motor nerve was decreased with severely reduced amplitude. There- after, his symptoms have gradually worsened, and at present, at age 43, his mobility is reduced to crawling. However, he shows no symptoms of impaired mentality, dysphagia, pneu- monia, or respiratory or heart failure.

Genetic Analysis With informed consent, blood samples were obtained from all family members available (Subjects 1-1, 11-1, 11-2, 11-3, and 11-6; see Fig lA), and genomic DNA was isolated by a standard phenoUchloroform method. For Patient 1 (Subject 11-6), gene analyses for spinocerebellar ataxia types 1, 2, 3, 6, and 7 and hereditary dentatorubropallidoluysian atrophy were conducted.'-'' Diagnosis of these FSCAs was pre- cluded because there were no expansions of the CAG repeat in (he open reading frame of each gene. Moreover, no mi- tochondrial DNA mutations of A8344G, T8356C, T8993C, T8993G, A3243G, and T3271C were detected in Patient 3 (Subject 11-2).

266 Annals of Neurology Vol 44 No 2 August 1998

Table. Clinical characteristics and Results of Blood and Biochemical Examinations -

Clinical Characteristics

Sex Present age (yr) Age at onset (yr) Intellectual disturbance Truncal ataxia Limb ataxia Cerebellar dysarrhria Horizontal gaze nystagmus Saccadic eye movement Ophthalmoparesis Ocular motor apraxia Visual disturbance Findings of ocular fundus Telangiectasia over the bulbar conjunctiva Areflexia Plantar response Decreased vibration sense in all the limbs Impaired joint position sense in the lower limbs Hypoesthesia in the lower limbs Mild muscle weakness in the lower limbs I'es caws Hearing loss Epilepsy Choreoathetosis Rectal and bladder disturbance Scoliosis Cardiomegaly Low srature Microcephaly

Examinations Aspartate aminotransferase (IUIL) Alanine aminotransferase (IUIL) y-Glutamyl transpeptidase (IUIL) Total protein (gidl) Albumin (gldl) Alburniniglobulin ratio Protein fractionation (%)

Albumin a I -Globulin a,-Globulin @-Globulin y-Globulin

IgG (mgidl)

IgM (mgidl) Choline esrerase (IUiml) Erythrocyte sedimentation rate (mmihr) C-reactive protein (mgidl) Total cholesterol (mgidl) High-density lipoprotein cholesterol (mgldl) Triglyceride (mg/dl) Cholestanol (pg/ml) Creatine kinase (IUIL) Creatine kinase isozyme (%)

I$ (mgidl)

MB" MM"

Aldolase (IUiL) Vitamin E (pglml) Cernloplasmin (mgidl) a-Fetoprotein (ng/ml) Carcinoembryonic antigen (ngiml) 75 g oral glucose tolerance test Lactate (mgidl) Pyruvare (mgidl) a-Glucosidase" (nmolimg of proteinihr) P-Glucosidase' (nmolimg of proteinihr) a-Galactosidase A" (nmolimg of proteinlhr) P-Galactosidase" (nmolimg of proteinihr) a-Mannosidase" (nmol/mg of protein/hr) a-Fucosidase" (nmolimg of proteinihr) P-Glucuronidase' (nmolimg of proteinihr) @-Total hexosaminidase' (nmollmg of proreinihr) P-Hexosaminidase A" (nmollmg of proteinihr) Arylsulphatase A" (nmollmg of proteinihr) Phytanic acids (pmoliml) Vely-long-chain fatty acids

Patient 1 (11-6) Patient 2 (11-3) Patient 3 (11-2)

Male 22 20

+ + + + +

-

- ~

-

Normal + + Flexor + + - -

+ ~

- - - ~

- - ~

19 14 7 8.2 5.19 1.72

63.3 2.1 7.8 8.3 18.5 2,710 375 171 6.2 4 Negative 125 41 213 1.7 362

2 98 4.3 13.0 36.0 22 1.0 Normal 10.2 0.90 32.8 7.2 65.6 140.4 225.5 63.0 180.8 1,489.6 493.4 125.3 1.29 Normal

Female 33 19

++ ++ + + + - - -

Normal + + Flexor + + + + +

15 13 6 8.4 4.49 1.15

53.5 3.1 10.3 11.1 22.0 2,650 430 361 5.3 14 Negative 195 54 91 NE 304

4 96 6.5 NE 33.0 54 0.7 Mildly impaired NE NE NE NE NE NE NE NE NE NE NE NE NE NE

Female 35 19

++ ++ + + +

-

- - -

Normal + + Flexor + + + + + - - - -

16 16 6 7.6 4.58 1.52

60.3 3.1 10.3 10.3 16.0 1,890 458 212 6.7 5 Negative 171 50 132 1.6 166

3 94 4.1 12.5 24.6 31 1.1 Mildly impaired 6.7 0.61 33.2 6.3 78.3 135.9 226.6 55.5 143.5 1,194.8 419.1 136.8 1.22 Normal

- - - absent; 2 = present but extremely mild; + = present; ++ = marked; NE 2 not examined; MB = muscle/brain; MM = muscle/muscle.

'Activities of these enzymes were measured in patients' leukocytes.

Patient 4 (11-1)

Male 43 20

++ ++ + + +

-

- - -

Normal + + Flexor + + + + +

-

NE NE NE NE NE NE

NE NE NE NE NE NE NE NE NE NE NE NE NE NE NE NE

NE NE NE NE NE NE NE NE NE NE NE NE NE NE NE NE NE NE NE NE NE NE

Brief Communication: Watanabe et al: Familial Spinocerebellar Ataxia 267

I

I

DllS1818

I1 DllS1819

1 2 3 4 5

Marker I 1-1 1-2 11-1 11-2 11-3 11-6 1 2 -

66 71 67 67 67 61

31 24 32 12 32 14

T D9S886 15 56 15 15 55 56

15 11 11 11 51 51 D9S2103

f DllS2179 1 13 51 15 35 15 11

A B

Fig 1. (A) Pedigree of the present family. and 0 = Male family members; and 0 = female family members; and = affected family members; diagonal = deceased; arrow = proband. (B) Results o f haploype analyses. Data from Subject 1-2 are deduced.

Fig 2. TI-weighted magnetic resonance image (repetition time 490 msec, echo time 20 msec at 1.5 r ) o f Patients 1 and 3. (A) Patient 1, 3 years afzer onset. (B) Patient 3, 1Gyears afzer onset. Patient 1 shows mild cerebellar atrophy @), in contrast with that evident in Patient 3 (B). The brainstem, however, is invariably preserved in both cases (A and B).

In addition, we examined, by our adaptation of the Southern blotting method,2 whether Patient 1 had the GAA repeat expansion in the frataxin gene, but the result was neg- ative. In Patient 1, by single-strand conformational polymor- phism analysis using our methods,6 no abnormalities were detected at exons 4 to 65 of the ATM gene, which encom- pass the entire coding region. Furthermore, to completely rule out cosegregation of the abnormalities of the frataxin and ATM genes with the affected members, haplotype anal- yses were conducted by using microsatellite markers flanking each gene (for the frataxin gene, D9S886 and D9S2103; for

the ATM gene, DllS1818, DllS1819, and DllS2179) in accordance with previous reports.327 From this use of micro- satellite markers flanking both genes, we could show some identical haplotypes but failed completely to demonstrate ho- mozygosity in any patient (see Fig 1B). Thus, linkage of this family to both the frataxin and ATM genes was excluded.

Discussion The family presented here has characteristics such as suspected autosomal recessive inheritance, juvenile on-

268 Annals of Neurology Vol 44 No 2 August 1998

set, no mental retardation, relatively benign prognosis, no brainstem symptoms, truncal and limb ataxia, mild cerebellar dysarthria, areflexia, no pyramidal signs, tel- angiectasia over the bulbar conjunctiva, cerebellar atro- phy, relatively mild sensory disturbance, and pes cavus. The levels of serum CK, y-globulin, and AFP were mildly to severely elevated, and 2 of 3 cases were ac- companied by mild impairment of glucose tolerance. Although some of these clinical symptoms, in various combinations, are observed in FA, AVED, and AT,'-' gene analyses demonstrated that the frataxin and the ATM genes are not responsible for this family's disease. Furthermore, AVED was ruled out because the level of serum vitamin E of Patients 1 and 3 was normal and tocopherol acetate was ineffective on Patient 1. In ad- dition, the diagnosis of spinocerebellar ataxia type I , 2, 3, 6, or 7 and dentatorubropallidoluysian atrophy was eliminated by the gene analyses.*-" From the clinico- pathological, biochemical, and genetic examinations, several disorders with cerebellar ataxia, especially myoc- lonus epilepsy associated with ragged-red fibers, lysoso- ma1 storage disorders, neuronal ceroid-lipofuscinosis, Nijmegen breakage syndrome," and ataxia-ocular mo- tor apraxia," were ruled out. These results, together with the fact that from the literature review we could not detect an FSCA similar to the one demonstrated by the present family, indicate that this disease is a new type of FSCA. Further study including linkage analysis is required to clone the obligatory gene, and clarify the genetic difference of the other group's FA-like FSCAs, which do not link to the frataxin gene."

This study was supported in part by The Nakabayashi Trust for ALS Research and Uehara Memorial Foundation.

We are indebted to the family studied for their cooperation and support. We also thank Drs 0 . Nikaido, I. Tajima, and J. Sugano and Mr S. Kobayashi for their kind support.

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Brief Communication: Watanabe et al: Familial Spinocerebellar Ataxia 269