Brain & Development 31 (2009) 499502 www.elsevier.

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Review article

Towards understanding the neuronal ceroid lipofuscinoses

Alfried Kohlschu tter *, Angela Schulz
Childrens Hospital, University Medical Center Eppendorf, Hamburg, Germany Received 4 November 2008; accepted 10 December 2008

Abstract The neuronal ceroid lipofuscinoses (NCLs) are a group of genetic progressive brain diseases of children and young adults, characterized by a decline of mental and other capacities, epilepsy, and visual loss through retinal degeneration. The common pathology of NCLs is that of a storage disorder with accumulation of an autouorescent material, ceroid lipofuscin, in combination with the degeneration of neuronal cells. At least 10 genetically distinct NCLs, designated CLN1 to CLN10, are presently known. Several NCLs exhibit a widely variable clinical picture, depending on the severity of the individual mutation. Some NCLs are not particularly rare. With increasing awareness of these disorders and better diagnostic techniques available, the number of recognized patients is rising. This overview briey summarizes recent developments (or quotes corresponding literature) that are important to understand, diagnose, and manage patients suering from one of these incurable disorders. 2008 Elsevier B.V. All rights reserved.
Keywords: Dementia; Retinopathy; Lysosomal storage disorder; Neurodegeneration

1. Introduction The neuronal ceroid lipofuscinoses (NCLs) are a heterogeneous group of genetic degenerative brain diseases characterized by a progressive decline of mental and motor capacities, epilepsy, and visual loss through retinal degeneration. NCLs can aect humans from birth to young adulthood. Some representatives of this group are not extremely rare. With increasing awareness of these disorders and better diagnostic techniques, the number of recognized patients is rising. The number of established NCL disease entities has also risen to a number of presently at least 10 dierent disorders (Table 1). While the NCLs are now classied according to the designation of the mutated gene, Table 1 lists the single disorders in order of the age at which they typically become

* Corresponding author. Tel.: +49 40 42803 6391; fax: +49 40 42803 5137. E-mail address: kohlschuetter@uke.uni-hamburg.de (A. Kohlschutter).

manifest. It must be noted, however, that genetic variants with mild mutations can have a signicantly later onset than their classical forms. For physicians as for basic scientists, it is practical to look upon the dierent types of NCL as a group of disorders as they have many things in common. Clinically, they are progressive neurological diseases characterized almost always by a combination of retinopathy, dementia, and epilepsy. Their pathology is that of a storage disorder with accumulation of a material termed ceroid lipofuscin in combination with the degeneration of neuronal cells. The purpose of this short overview is not to review the NCLs, for which comprehensive accounts exist [1,2], but to give a report on progress in the NCLs that is of importance when confronted with patients suspected or proven to suer from such a disease. Readers more interested in basic mechanisms are referred to recent reviews [3]. In the following, the single NCLs are dealt with in the order of their genetic designation CLN1 to CLN10.

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A. Kohlschutter, A. Schulz / Brain & Development 31 (2009) 499502

Table 1 Classication of neuronal ceroid lipofuscinoses. Age at manifestation Congenital or later Infantile or later Late infantile or later Designation CLN10 CLN1 CLN2 CLN5 CLN6 CLN7 CLN8 CLN3 CLN9 CLN4 Chromosomal location 11p15 1p32 11p15 13q22 15q21 4q28 8p23 16p12 Product CDa PPT1a TPP1a Partially soluble protein Membrane protein Membrane protein Membrane protein Membrane protein

Juvenile Adult
a

Lysosomal enzymes, CD, cathepsin D; PPT1, palmitoylprotein thioesterase 1; TPP1, tripeptidylpeptidase 1.

2. The single NCL disorders CLN1. The classical infantile NCL (INCL) manifests itself in the second half of the rst year of life and progresses dramatically with seizures, mental decay, loss of vision, and brain atrophy. Some mutations cause manifestation at any age, including adulthood [4]. The underlying defect is the lack of activity of the lysosomal palmitoylthioesterase 1 (PPT1) which can be used for diagnosis. As the enzyme cleaves fatty acid thioesters in plasma membranes, it was suggested that the drug cysteamine, a simple aminothiol used in the treatment of cystinosis, may have utility in the treatment of CLN1. In vitro studies, however, have cast doubt on this concept [5]. Experimental treatment with injection of human fetal neuronal stem cells [6] has been performed but cannot yet be evaluated. CLN2. Classical late infantile NCL starts around the third year of life with seizures and a standstill of mental development while the retinopathy frequently is not prominent early in the course and may be missed after progression to more generalized decits. The basic defect is the lack of activity of the lysosomal tripeptidylpeptidase 1 (PPT1), which can be used for diagnosis. An experimental treatment approach uses intracerebral injection of viral vectors containing normal coding segments of the CLN2 gene. In a mouse model of CLN2, this procedure resulted in cerebral enzyme expression, reduced brain pathology and increased survival. A small number of human patients have recently been treated in the same way [7]. Intraventricular enzyme replacement in a mouse model improved the disease phenotype [8]. Experimental treatment with human fetal neuronal stem cells [6] is also being performed. CLN3. Classical juvenile NCL on the basis of a CLN3 mutation starts at the age of four to six years with a progressive loss of vision due to retinal degeneration. After several years, dementia, epilepsy, and motor disturbances ensue. The diagnostic hallmark of this frequent NCL type are conspicuous vacuoles in the cytoplasm of lymphocytes which are detectable on a reg-

ular blood smear (Fig. 1). The basic defect is in a membrane protein of unknown function. Hypotheses oered for the function of the CLN3 protein are focussing on its role in lysosomal metabolism, on its properties as an anti-apoptotic agent, or fatty acid desaturase, and on other mechanisms [3]. An intriguing hypothesis is based on the very high evolutionary conservation of this protein, which would qualify it as a protein absolutely necessary for survival. In contrast to this consideration is the observation that the typical patients with CLN3 defects (usually with a large deletion in the CLN3 gene) suer from one of the mildest clinical forms of NCL that manifests itself only many years of perfect health. It was therefore suggested that the CLN3 protein in the typical patients has some residual function and that a complete lack of the protein might cause much more severe phenotypes, possibly intrauterine death [9]. Humoral autoimmunity against glutamic acid decarboxylase is believed to play a role in the pathophysiology of CLN3 and has led to immunosuppressive intervention [10]. For the evaluation of any eects of new treatments, the natural variability of the clinical course must be studied more precisely [11].

Fig. 1. A vacuolated lymphocyte in a blood smear of a CLN3 patient.

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CLN4. This is a term reserved for an adult form of NCL (Kufs disease) that is still dened by clinical and neuropathological ndings alone [12]. CLN5. This variant of late infantile NCL develops symptoms somewhat later than classical CLN2. Regarded as a purely Finnish disease in the past, this type of NCL has recently been observed in the Netherlands, Colombia, Portugal, Italy [13], Afghanistan, and Pakistan. It should be considered in any exhaustive diagnostic approach to a patient with suspected NCL. The basic defect concerns a partially soluble protein, apparently localized in lysosomes, whose function seems to be related to the CLN2 and CLN1 proteins. These observations suggest that there may exist common molecular pathways underlying neuronal degeneration in various types of NCLs. CLN6. This is also a later manifesting clinical variant of classical late infantile NCL, mostly observed in India, the Iberic peninsula, in middle and South America. The CLN6 protein is a polytopic membrane protein of unknown function resident in the endoplasmic reticulum. CLN7. This Turkish variant of late infantile NCL is caused by mutations in a gene (also termed MFSD8) coding for a putative lysosomal transporter protein. The protein is expressed ubiquitously and localizes mainly to the lysosomal compartment [14]. CLN8. A disease known in Finland as Juvenile Northern Epilepsy has recently been shown to be caused by mutations in the CLN8 gene which are allelic to those causing CLN7 disease. It is characterized by a progressive epilepsy associated with dementia and diers from other juvenile NCLs in so far as the visual problems may be mild and go unnoticed. The disease was also observed in Italy, Turkey, and Israel [15]. CLN9. A juvenile NCL clinically not distinguishable from CLN3 was termed CLN9 but has resisted genetic clarication until now. Cells from CLN9 patients have shown multiple abnormalities when studied in vitro [16]. CLN10. A congenital form of CLN10 is characterized by primary microcephaly, neonatal (possibly already intrauterine) epilepsy, and death in early infancy [17]. Late-onset forms of this NCL may be seen in juveniles and adults [18]. The aected CTSD gene in NCL10 codes for cathepsin D, a lysosomal enzyme thought to be important for neuronal stability. Alterations in a macroautophagy-lysosomal degradation pathway seem to mediate neuron death in this NCL and possibly other diseases. Unclassied NCLs. Patients with clinical ndings suggestive of an NCL and electron microscopic evidence of intracellular storage material, but unable to be classied after thorough investigation, are being encountered in diagnostic institutions. Genes coding for ion channels have been suggested as candidates in such disorders [19].

Fig. 2. Diagnostic strategy in a suspected case of NCL.

3. Diagnostic strategy in suspected NCL disorders An economical approach to diagnosis of a suspected NCL starts from the type of clinical manifestation (see Fig. 2). In a neonate with microcephaly and convulsions, CLN10 with cathepsin D deciency is a possibility. The enzyme deciency is detected best in cultivated skin broblasts. In young children with otherwise unexplained epilepsy and developmental standstill, CLN2 and CLN3 are the most frequent diagnoses which are detected by the respective enzyme deciencies leukocytes, broblasts, or dry blood samples. In a school child with retinopathy, CLN3 is possible, and typical vacuoles in lymphocytes (Fig. 1) will proof the diagnosis. If all tests give normal results, the more rare NCL variants CLN5, CLN6, CLN7, or CLN8 must be considered. As molecular genetic studies in the rare NCLs can be laborious, it is advisable to prove the presence of a storage disorder by electron microscopic examination of skin biopsy material or isolated blood lymphocytes before proceeding to a mutation analysis. Mutated genes to consider in dependence of the age at manifestation are listed in Table 2. 4. Treatment of NCLs NCLs are incurable. Long-term palliative treatment that takes into consideration specic aspects of the particular type of NCL in question, is of great importance to obtain the best attainable quality of life [2]. Some

Table 2 Mutated NCL genes in dependence of the age at clinical manifestation. Age at manifestation At birth <1 year 24 years School age Adulthood Mutated genes to consider CLN10 CLN1 CLN2, CLN1, CLN5, CLN6, CLN7, CLN8 CLN3, CLN1, CLN8, CLN10, (CLN9) CLN1, CLN10, (CLN4)

Genes shown fat are frequently involved; genes in parenthesis have not yet been dened.

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A. Kohlschutter, A. Schulz / Brain & Development 31 (2009) 499502 phenotypes in a mouse model of late infantile neuronal ceroid lipofuscinosis. Mol Ther 2008;16:64956. Kitzmuller C, Haines RL, Codlin S, Cutler DF, Mole SE. A function retained by the common mutant CLN3 protein is responsible for the late onset of juvenile neuronal ceroid lipofuscinosis. Hum Mol Genet 2008;17:30312. Aberg L, Talling M, Harkonen T, Lonnqvist T, Knip M, Alen R, et al. Intermittent prednisolone and autoantibodies to GAD65 in juvenile neuronal ceroid lipofuscinosis. Neurology 2008;70:121820. Marshall FJ, de Blieck EA, Mink JW, Dure L, Adams H, Messing S, et al. A clinical rating scale for Batten disease: reliable and relevant for clinical trials. Neurology 2005;65:2759. Robertson T, Tannenberg AE, Hiu J, Reimers J. 53-year-old man with rapid cognitive decline. Brain Pathol 2008;18:2924. Cannelli N, Nardocci N, Cassandrini D, Morbin M, Aiello C, Bugiani M, et al. Revelation of a novel CLN5 mutation in early juvenile neuronal ceroid lipofuscinosis. Neuropediatrics 2007;38:469. Siintola E, Topcu M, Aula N, Lohi H, Minassian BA, Paterson AD, et al. The novel neuronal ceroid lipofuscinosis gene MFSD8 encodes a putative lysosomal transporter. Am J Hum Genet 2007;81:13646. Zelnik N, Mahajna M, Iancu TC, Sharony R, Zeigler M. A novel mutation of the CLN8 gene: is there a Mediterranean phenotype? Pediatr Neurol 2007;36:4113. Schulz A, Mousallem T, Venkataramani M, Persaud-Sawin DA, Zucker A, Luberto C, et al. The CLN9 protein, a regulator of dihydroceramide synthase. J Biol Chem 2006;281:278494. Siintola E, Partanen S, Stromme P, Haapanen A, Haltia M, Maehlen J, et al. Cathepsin D deciency underlies congenital human neuronal ceroid-lipofuscinosis. Brain 2006;129:143845. Steinfeld R, Reinhardt K, Schreiber K, Hillebrand M, Kraetzner R, Bruck W, et al. Cathepsin D deciency is associated with a human neurodegenerative disorder. Am J Hum Genet 2006;78:98898. Poet M, Kornak U, Schweizer M, Zdebik AA, Scheel O, Hoelter S, et al. Lysosomal storage disease upon disruption of the neuronal chloride transport protein ClC-6. Proc Natl Acad Sci USA 2006;103:138549. Pierret C, Morrison JA, Kirk MD. Treatment of lysosomal storage disorders: focus on the neuronal ceroid-lipofuscinoses. Acta Neurobiol Exp (Wars) 2008;68:42942.

experimental therapeutic trials aiming at the prevention of neurological progression have been mentioned above. The theoretical chances of enzyme replacement, gene therapy, cell-mediated therapy and pharmacological treatments in NCLs have been reviewed [20]. As the eects of treatment in slowly progressing neurological disorders are dicult to evaluate, precise knowledge of the natural variability of the clinical course in each genetically distinct type of NCL is needed. For this purpose, an international consortium is presently working on a clinical NCL database. References
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