March 26, 2020
Years published: 1987, 1990, 2003, 2016, 2020
NORD gratefully acknowledges Sara E. Mole, PhD, MRC Laboratory for Molecular Cell Biology, University College London, for assistance in the preparation of this report.
Adult neuronal ceroid lipofuscinosis (ANCL) is a general term for several rare genetic disorders that belong to a group of progressive, degenerative neurometabolic disorders known as the neuronal ceroid lipofuscinoses (NCLs). These disorders share certain similar symptoms and are distinguished in part by the age at which such symptoms appear. Onset of ANCL is usually around the age of 30, but these disorders can occur during the teen-aged years or in people more than 50 years old. The NCLs as a group are characterized by abnormal accumulation of certain fatty, granular substances (i.e., pigmented lipids [lipopigments] ceroid and lipofuscin) within nerve cells (neurons) of the brain as well as other tissues of the body. This is accompanied by progressive deterioration (atrophy) of certain areas of the brain, neurological impairment, and other characteristic symptoms and physical findings. ANCL is sometimes called Kufs disease. Historically, Kufs disease was broken down into type A or type B. The ANCLs are caused by changes (mutations) in different genes and can have different signs and symptoms.
Before the identification of the underlying genes, the neuronal ceroid lipofuscinoses or NCLs were broken down by age of onset. Kufs disease was the name for the adult onset form. However, many researchers now feel that it is more appropriate to classify these disorders based upon the gene that is affected rather than by age of onset. Several genes that are known to cause neuronal ceroid lipofuscinoses can have the onset of symptoms in adulthood.
ANCL or Kufs disease was generally broken down into type A and type B. The signs and symptoms of these two subtypes often overlap and the distinction between the two is not always clear. Symptoms typically become worse over time. Generally, type A is associated with progressive myoclonic epilepsy (PME). PME is a condition characterized by both muscle contractions (myoclonus) and seizures (epilepsy). Some individuals experience difficulties in coordinating voluntary movements (ataxia) or difficulty speaking (dysarthria).
Type B often has similar symptoms to type A. However, individuals may also experience abnormalities of movement and coordination including ataxia and involuntary movements such as tics or tremors, including those affecting the face (facial dyskinesia). Some individuals develop a decline in intellectual and cognitive ability (dementia) and changes in behavior and other psychiatric abnormalities. Seizures are rare in type B, but can occur.
More recently, disease has been described that begins in adulthood with vision loss but may not have further symptoms.
Changes (mutations) in several different genes can cause adult neuronal ceroid lipofuscinosis. These include the CLN6 gene for type A and the CTSF gene for type B. There are also people with adult onset of neuronal ceroid lipofuscinosis due to changes in the PPT1 gene, the CLN5 gene, CTSD gene, and the GRN gene. Adult onset disease that affects vision or the heart has been found to be caused by changes in the CLN3 gene, and the MFSD8 gene. Some very specific changes in the DNAJC5 gene can also cause adult onset neuronal ceroid lipofuscinoses.
Most types of ANCL are inherited in an autosomal recessive manner. These types of diseases appear in adults whose parents were not affected by the same disease. Most genetic diseases are determined by the status of the two copies of a gene, one received from the father and one from the mother. Recessive genetic disorders occur when an individual inherits two copies of an abnormal gene for the same trait, one from each parent. If an individual inherits one normal gene and one gene for the disease, the person will be a carrier for the disease but usually will not show symptoms. The risk for two carrier parents to both pass the altered gene and have an affected child is 25% with each pregnancy. The risk to have a child who is a carrier like the parents is 50% with each pregnancy. The chance for a child to receive normal genes from both parents is 25%. The risk is the same for males and females.
One type of ANCL caused by specific alterations in the DNAJC5 gene is inherited in an autosomal dominant manner (Parry disease). This type of disease is passed down from an affected adult to their children, who have a 1 in 2 chance of being affected. Dominant genetic disorders occur when only a single copy of an abnormal gene is necessary to cause a particular disease. The abnormal gene can be inherited from either parent or can be the result of a new mutation (gene change) in the affected individual. The risk of passing the abnormal gene from an affected parent to an offspring is 50% for each pregnancy. The risk is the same for males and females.
The genes that cause ANCL produce proteins. These proteins have specific roles in the body, including breaking down proteins and other substances in the body. When a gene is altered, the protein it produces is deficient, absent or ineffective. The missing or abnormal protein can interfere with the breakdown of certain fatty, granular substances called pigmented lipids (lipopigments: ceroid and lipofuscin). These materials accumulate within nerve cells (neurons) of the brain as well as other tissues of the body and their presence can be used to help obtain a diagnosis. The faulty protein can result in progressive deterioration (atrophy) of certain areas of the brain, neurological impairment, and other characteristic symptoms and physical findings.
Adult neuronal ceroid lipofuscinoses are extremely rare disorders. The prevalence is estimated to be about 1.5 people per 9,000,000 in the general population. Prevalence is the total numbers of individuals with a disease at a given time. Studies into the incidence of ANCL have varied based on the country conducting the study. Estimates range from 1.5-7 infants per 100,000 live births. Incidence is the number of new people born with a disorder in a given year.
A diagnosis of adult neuronal ceroid lipofuscinosis is based upon identification of characteristic symptoms, a detailed patient history, a thorough clinical evaluation and a variety of specialized tests. The tests used may be different based on the specific subtype of ANCL. These tests can include enzyme assays, the study of affected tissue under an electron microscope, and molecular genetic testing to identify changes in genes that can cause disease.
Clinical Testing and Workup
Enzymes assays are tests that measure the activity of specific enzymes. In some types of ANCL, reduced enzyme activity can be demonstrated on an assay. For example, ANCL caused by the CTSF gene will show reduced activity of cathepsin F, the enzyme produced by the CTSF gene, on an enzyme assay.
Some types of ANCL require that affected tissue is surgically removed and studied under an electron microscope. This can show the buildup of storage material within the affected tissue.
Molecular genetic testing or gene sequencing can confirm a diagnosis of ANCL. The aim is to detect mutations in specific genes known to cause the various subtypes.
These tests are available only at specialized laboratories.
The treatment of adult neuronal ceroid lipofuscinosis is directed toward the specific symptoms that are apparent in each individual. There are no disease-specific treatments for ANCL yet. Treatment may require the coordinated efforts of a team of specialists. General internists, metabolic geneticists, neurologists, psychiatrists, and other healthcare professionals may need to systematically and comprehensively plan treatment. Psychosocial support for the entire family is essential.
Genetic counseling is recommended for affected individuals and their families.
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Mole SE, Anderson G, Band HA, et al. Clinical challenges and future therapeutic approaches for neuronal ceroid lipofuscinosis. Lancet Neurol 2018; 18: 107–16. https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(18)30368-5/fulltext
Geraets RD, Koh S, Hastings ML, et al. Moving towards effective therapeutic strategies for neuronal ceroid lipofuscinosis. Orphanet J Rare Dis. 2016;11:40. https://ojrd.biomedcentral.com/articles/10.1186/s13023-016-0414
Berkovic SF, Staropoli JF, Carpenter S, et al. Diagnosis and misdiagnosis of adult neuronal ceroid lipofuscinosis (Kufs disease). Neurology. 2016;87:579-584. https://www.ncbi.nlm.nih.gov/pubmed/27412140
Di Fabio R, Colonnese C, Santorelli FM, Pestillo L, Pierelli F. Brain imaging in Kufs disease type B: case reports. BMC Neurol. 2015;15:102. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4491254/
Mink JW, Augustine EF, Adams HR, Marshall FJ, Kwon JM. Classification and natural history of the neuronal ceroid lipofuscinoses. J Child Neurol. 2013;28:1101-1105. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3979348/
Smith KR, Dahl HH, Canafoglia L, et al. Cathepsin F mutations cause Type B Kufs disease, an adult-onset neuronal ceroid lipofuscinosis. Hum Mol Genet. 2013;22:1417-1423. https://www.ncbi.nlm.nih.gov/pubmed/23297359
Cotman SL, Karaa A, Staropoli JF, Sims KB. Neuronal ceroid lipofuscinosis: impact of recent genetic advances and expansion of the clinicopathologic spectrum. Curr Neurol Neurosci Rep. 2013;13:366. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3774306/
Arsov T, Smith KR, Damiano J, et al. Kufs disease, the major adult form of neuronal ceroid lipofuscinosis, caused by mutations in CLN6. Am J Hum Genet. 2011;88:566-573. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146726/
Mole SE, Williams RE. Neuronal Ceroid-Lipofuscinoses. 2001 Oct 10 [Updated 2013 Aug 1]. In: Pagon RA, Bird TD, Dolan CR, et al., GeneReviews. Internet. Seattle, WA: University of Washington, Seattle; 1993-. Available at: https://www.ncbi.nlm.nih.gov/books/NBK1428/ Accessed Dec 18, 2019.
Kohlschutter A. Adult neuronal ceroid lipofuscinosis. Orphanet Encyclopedia, February 2010. Available at: https://www.orpha.net/consor/cgi-bin/OC_Exp.php?lng=EN&Expert=79262 Accessed Dec 18, 2019.
CLN4 disease.Genetics Home Reference. Reviewed: January 2017. Available at: https://ghr.nlm.nih.gov/condition/cln4-disease# Accessed Dec 18, 2019.
Adult neuronal ceroid lipofuscinosis. Genetic and Rare Disease Information Center (GARD). Last updated: 8/31/2015. Available at:
https://rarediseases.info.nih.gov/diseases/10973/adult-neuronal-ceroid-lipofuscinosis Accessed Dec 18, 2019.
McKusick VA., ed. Online Mendelian Inheritance in Man (OMIM). Baltimore. MD: The Johns Hopkins University; Entry No:204300; Last Update: 02/20/2019. Available at: https://omim.org/entry/204300 Accessed Dec 18, 2019.
McKusick VA., ed. Online Mendelian Inheritance in Man (OMIM). Baltimore. MD: The Johns Hopkins University; Entry No:162350; Last Update: 05/02/2017. Available at: https://omim.org/entry/162350 Accessed Dec 18, 2019.
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