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Secondary biogenic amine deficiencies: genetic etiology, therapeutic interventions, and clinical effects

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Abstract

Monoamine neurotransmitter disorders present predominantly with neurologic features, including dystonic or dyskinetic cerebral palsy and movement disorders. Genetic conditions that lead to secondary defects in the synthesis, catabolism, transport, and metabolism of biogenic amines can lead to neurotransmitter abnormalities, which can present with similar features. Eleven patients with secondary neurotransmitter abnormalities were enrolled between 2011 and 2015. All patients underwent research-based whole exome and/or whole genome sequencing (WES/WGS). A trial of treatment with levodopa/carbidopa and 5-hydroxytryptophan was initiated. In six families with abnormal neurotransmitter profiles and neurological phenotypes, variants in known disease-causing genes (KCNJ6, SCN2A, CSTB in 2 siblings, NRNX1, KIF1A and PAK3) were identified, while one patient had a variant of uncertain significance in a candidate gene (DLG4) that may explain her phenotype. In 3 patients, no compelling candidate genes were identified. A trial of neurotransmitter replacement therapy led to improvement in motor and behavioral symptoms in all but two patients. The patient with KCNJ6 variant did not respond to L-dopa therapy, but rather experienced increased dyskinetic movements even at low dose of medication. The patient’s symptoms harboring the NRNX1 deletion remained unaltered. This study demonstrates the utility of genome-wide sequencing in further understanding the etiology and pathophysiology of neurometabolic conditions, and the potential of secondary neurotransmitter deficiencies to serve as novel therapeutic targets. As there was a largely favorable response to therapy in our case series, a careful trial of neurotransmitter replacement therapy should be considered in patients with cerebrospinal fluid (CSF) monoamines below reference range.

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Abbreviations

5HIAA:

5-Hydroxyindoleacetic acid

5HTP:

5-Hydroxytryptophan

AADC:

Aromatic amino acid decarboxylase

ACMG:

American College of Medical Geneticists

BH4 :

Tetrahydrobiopterin

DAT:

Dopamine transporter

CP:

Cerebral palsy

ERK:

Extracellular signal-regulated kinase

HVA:

Homovanillic acid

IDD:

Intellectual and developmental disabilities

IF:

Incidental finding

iNTD:

International Working Group on Neurotransmitter Related Disorders

mtDNA:

Mitochondrial DNA

NT:

Neurotransmitter

PAK:

P21-activated kinase

PD:

Parkinson’s disease

PKC:

Protein kinase C

RAF:

Rapidly accelerated fibrosarcoma

RAS:

Rat sarcoma

SERT:

Serotonin transporter

TH:

Tyrosine hydroxylase

TPH:

Tryptophan hydroxylase

VUS:

Variant of uncertain significance

WES:

Whole exome sequencing

WGS:

Whole genome sequencing

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Acknowledgements

We are indebted to all patients and their families for participation in this study; our colleagues in the Departments of Pediatrics and Medical Genetics, University of British Columbia (Canada) for clinical management of patients; and other colleagues at BC Children’s Hospital and Vancouver General Hospital contributing to the diagnoses and management of these patients.

Funding

This study is supported by funding from the B.C. Children’s Hospital Foundation (Treatable Intellectual Disability Endeavour in British Columbia: 1st Collaborative Area of Innovation www.tidebc.org); Genome BC (SOF-195 grant to CvK); BC Clinical Genomics Network (#00032 grant to CvK); Rare Diseases Foundation (microgrants to CvK & GH), Canadian Institutes of Health Research (#301221 grant to CvK, RDMM), Michael Smith Foundation for Health Research Scholar Award (to CvK), Genome Canada (ABC4DE Project to WW; RDMM); CIHR New Investigator Award (to CR); CFRI Fellowship to AM; CFRI PhD award to JL and Alberta Children’s Hospital Research Institute Foundation.

The CAUSES Study was funded by the BC Children’s Hospital Foundation (Mining for Miracles) and GenomeBC; investigators include Shelin Adam, Christele Du Souich, Alison Elliott, Anna Lehman, Jill Mwemifumbo, Tanya Nelson, Clara van Karnebeek and Jan Friedman. Bioinformatics support was provided to CAUSES by the laboratory of Wyeth Wasserman.

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Author notes

  1. Drs. Maja Tarailo-Graovac and Gabriella A. Horvath contributed equally as co-last authors.

Authors and Affiliations

  1. BC Children’s Hospital Research Institute, Vancouver, BC, Canada

    Clara D. van Karnebeek, Ingrid Blydt-Hansen, Allison M. Matthews, Magda Price, Britt Drogemoller, Casper Shyr, Jessica Lee, Aisha Ghani, Sylvia Stockler, Jan M. Friedman, Colin J. Ross & Wyeth W. Wasserman

  2. Centre for Molecular Medicine and Therapeutics, University of British Columbia, Vancouver, Canada

    Clara D. van Karnebeek, Allison M. Matthews, Magda Price & Wyeth W. Wasserman

  3. Department of Pediatrics, Amsterdam University Medical Centre, Amsterdam, the Netherlands

    Clara D. van Karnebeek

  4. Department of Pediatrics, Radboud University Medical Center, Nijmegen, the Netherlands

    Clara D. van Karnebeek

  5. United for Metabolic Diseases’, Amsterdam, the Netherlands

    Clara D. van Karnebeek

  6. Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada

    Allison M. Matthews, Magda Price, Jill Mwenifumbo, Jan M. Friedman, Anna Lehman & Wyeth W. Wasserman

  7. Department of Biochemistry, Molecular Biology, and Medical Genetics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada

    Vladimir Avramovic & Maja Tarailo-Graovac

  8. Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada

    Sylvia Stockler & Gabriella A. Horvath

  9. Adult Metabolic Diseases Clinic, Vancouver General Hospital, Vancouver, Canada

    Anna Lehman & Gabriella A. Horvath

  10. Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada

    Colin J. Ross

  11. Biochemical Genetics, BC Children’s Hospital, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada

    Gabriella A. Horvath

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  1. Clara D. van Karnebeek
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  16. Maja Tarailo-Graovac
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Consortia

CAUSES Genomic Study

Contributions

All authors made substantial contributions to the conception or design of the work (GAH, MTG, CvK) and the acquisition, analysis, or interpretation of data (MTG, IBH, AM, VA, MP, BD, CS, JL, JM, AG, SS, JMF, AL, CR, WW). GAH, MTG, IBH drafted the manuscript. CvK, JMF, AL revised it critically for important intellectual content, and all authors approved the current version to be published.

Corresponding authors

Correspondence to Maja Tarailo-Graovac or Gabriella A. Horvath.

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The authors declare no competing interests.

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Supplemental Table 3

Presenting symptoms of patients. (DOCX 16 KB)

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van Karnebeek, C.D., Blydt-Hansen, I., Matthews, A.M. et al. Secondary biogenic amine deficiencies: genetic etiology, therapeutic interventions, and clinical effects. Neurogenetics 22, 251–262 (2021). https://doi.org/10.1007/s10048-021-00652-7

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