From the Paediatric Department, University Hospital, Copenhagen, the Neuropatho- logical Laboratory, Kommunehospitalet, Copenhagen and the Biochemical Research

Laboratory, Kolonien Fidadelfia, Dianalund, Denmark.

HEREDITARY PROGRESSIVE CEREBRAL LEUCODYSTROPHY

ERIK HANSEN, STEEN OLSEN and C. MUNK PLUM

Hereditary progressive cerebral leucodystrophy is the designation introduced by Bielschowsky & Henneberg (1928) for those disease groups which may be regarded as hereditary abiotrophies, the terminal stage of which is widespread and elective destruction of the white matter of the entire cerebrum.

Even since Pelizaeus (1885) described five cases of hereditary disease of the CNS, quite a number of case reports and reviews have appeared in the literature. Classifications of the leucodystrophies have been pro- posed by several authors, for example Krabbe (1947), Einarson, Nee1 & Sfromgren (1944) , Poser & van Bogaert (1956) and Greenfield (1958) . These classifications are established on a clinical, genetic, pathological or histochemical basis. A s intensive histochemical, electron-microscopic and neurochemical studies have been made in recent years, and as other current studies will undoubtedly yield further results, the above clas- sifications must be regarded as merely provisional.

Poser (1961) proposed the theory in 1957 that the leucodystrophies should really be regarded as “dysmyelinating diseases”, in contrast to true demyelinating diseases such as multiple sclerosis, diffuse sclerosis of the Schilder (1912) type, Balo’s disease and Devic’s disease. The leucodystrophies appear to be characterized by a disturbance of myelin anabolism, which may be regarded as the end result of an “inborn error of metabolism”. On this view the leucodystrophies would be closely related to the lipidoses; such a relationship was suggested by Wicke (1939) , Norman (1947) and Einarson (1951) , and later developed by Poser (1961) , who quotes the recent neurochemical studies of Diezel (1955) and Edgar (1957), for example, as bearing out this relationship.

On the basis of our present knowledge, therefore, it would appear that the leucodystrophies and the lipidoses should be classified together.

It would be of value in clinical studies to classify this large collective

This- investigation was supported by a PHS research grant B-2408 from the National Institute of Neurological Diseases and Blindness, IJ. S. Public Hcalth Service.

209

group according to time of origin of the disease, age at onset of the various symptoms, course of the disease, and so on. This classification has therefore been made in Table 1, which also shows the most im- portant pathological, histochemical and neurochemical characteristics.

Other syndromes can probably be added to this group: e.g. the Lau- rence-Moon-Biedl syndrome and other cases of retinitis pigmentosa, with accompanying symptoms of degenerative disease of the CNS, dc- scribed (according to Ford (1961) ) by Stewart and Claws, for example, and (likewise according to Ford ( 1961) ) cases of macular degeneration.

The following case of a boy who was studied from the age of 3 years until death at not quite 6 years, may be of some intercst, as a contribu- tion to the investigation of those progressive diseases of the CNS which present in childhood.

CASE REPORT

Jan V. L., paediatric department, University Hospital, record no. 118/59 : horn Jan. 1954. Parents healthy. Mother born 1915, father born 1917. No cases of nerve disease in the families of the parents. The patient is the third child of three. The first was a girl, born in July 1946, admitted to the paediatric department of the University Hospital (record no. 658/49), and dying in the neurosurgical department of the Uni- versity Hospital, August 1949. A brain autopsy was performed by Dr. Erna Cbristen- sen on this sister of the prcsent patient, and showed progressive cerebral meta- chromatic leucodystrophy. This sister of the patient is included in Dr. Erna Chris- tensen’s unpublished material of leucodystrophies, but it may be stated here briefly that her condition presented at the age of 15 months, and lasted for not quite two gears. I t was characterized clinically by rapidly progressive tetraplegia with disturb- anccs of coordination, and dementia.

With regard to the present patient, he was born at term, delivery was normal and the neonatal period was likewise normal. Birth weight was 4200g. Motor dc- velopment was slightly retarded, the patient walking at the age of 20 months. Mental development is reported to have been normal. There was a slight motor impairment in walking at the age of about 2% years, gait became slow and un- certain, the patient fell a great deal and there was intention tremor of the upper extremities. EEG, roentgenogram of the skull and ophthalmoscopic examination revealed nothing abnormal. At the age of three years (Fig. 1) his gait was straddling and there was talipes equinti-varus. The diagnosis of cerebral palsy, paraplegia spastica? was made at the ITniversity Hospital, paediatric department, where it was not known that he was a brother to the above patient (different surnames). His condition deteriorated rapidly during the next year, and when admitted to the paediatric department of the University Hospital a t the age of 3% years he could not hold his head erect or stand or sit without support, was plaintive and wbimper- ing, unable to speak, and could take only liquid nourishment. It is doubtful whether he understood any remarks made to him. The spasticity of the lower limbs was now very pronounced, with considerable spasticity of the upper limbs as well. Pneumoeneephalography (Fig. 2) was performed during this hospitalization, and showed a slight dilatation of the ventricular system. The diagnosis was now altered to progressive leucodystrophy.

210

TABLE Leucodystrophu

I *ge at I Ijuration ! (:linical symptoms

I i 1 first symptoms Type

Hereditary progressive cerebral leucodystrophy 1. Krabbe (1916) 4-6 months 8(4-13) Rapidly developing severe

months spasticity and mental im- pairment, opisthotonus

2. Greenfield (1933) 31 (15-30) 19 (4-43) months months

3. Scholz (1935) van Bo- 8-10(6-21) 2-9(3-21) gaert & Nussen (1936) years years Norman (1947)

4. Pelizaeus (1885) Merzhacher (1910)

P5(&43) 11 (1-24) years years

Disturbed gait, ataxia, hypertony, possihly hypo- tony, dementia, epilepsy

Deafness, aphasia. blind- ness, tremor, ataxia, spa- sticity, epilepsy

Spasticity, nystagmus, tremor, dementia

5. van Bogaert & Bertrand 11/12 ( m - 7 ) 10-11 (4/30-30) Severe hypotonia, possibly (1949) years months spasticity, “decerehrate

state”, optic nerve atrophy

Cc,ri~bro-retincil degeneration 1. Tay (1881) 4-8 months %-3 years

Sachs (1887 and 1929) Apathy, hypotonia, “Cherry red spot”

21 1

1 - lipidosis

Neuropatholugy I Seuroclieiuistry I

Diffuse demyelination with sparing of the U-fibres, presence of epitheloid cells, “globoid cells” in cerebrum and’ cerebellum. Marchi : -ve lipoid (Krabbe, 1916), PAS: pink stain of varying intensity. Sudan black: diffuse grey- ish stain (Blackwood & Cumings, 1954, and Diezel, 1959).

Remarkably selective disappearance of mye- lin, and along with this, disappearance of oligodendroglia (Greenfield), retention of oligodendroglia i n the area showing total dis- appearance of myelin (Norman, 1947, and Jervis, 1960). PAS-positive metachromasia (metachromatic material in kidney and liver, demonstrated in urine by Austin, 1957). No neutral fat, no free cholesterol.

As in no. 2. Glial insufficiency (Poser and van Bogaert, 1956) “simple storage type” (Poser, 1961). Range of decomposition pro- ducts. Metachromatic staining with basic aniline dyes (Einarson & Neel, 1938).

A s in 2 and 3, but small perivascular area with retained myelin. Extensive glial prolife- ration. Less tendency to sparing of the U- fibres. Scanty neutral fat. No metachromasia.

Status spongiosus, may be spread to the cerebral cortex.

No cholesterol esters, considerable de- crease in phospholipids, considerable in- crease in cerebrosides (Blackwood & Cumings, 1954). Decrease in cerebrosides, material in globoid cells is protein-bound cerebroside (Diezel, 1955-57).

Considerable decrease in phospholipids, decreased content of cholesterol, increas- ed content of hexosamine, considerable increase in sulphuric acid esters of cere- brosides (Svennerholm, 1960) ; strong decrease in phospholipids, cholesterol, glycolipids (cerebrosides decreased, sul- phatides increased and gangliosides nor- mal) (Jervis, 1960).

Increased neuraminic acid (Brante, 1952), decreased phospholipid, no cholesterol, increased hexosamine (Cumiugs 1957, Edgar, 1957).

General decrease of lipid content, corre- sponding to age of 2 years (Blackwood & Cumings, 1954). Glycero-phosphatide fraction missing (Seitelberger, 1957).

Considerable decrease in the various lipid fractions, the lipid content corresponds to the 6-7th foetal month (Blackwood & Cumings, 1954).

Ganglion cells throughout the entire C.N.S. lncreased occurrence of gangliosides in are swollen and have a finely granulated the brain, 6.2 mg YO against a normal “hyalinc” cytoplasm. Balloon-like swelling of value of 0.3 mg % (Klenk, 1940, and terminations of dendrites. Demyelination. Cumings, 1960). Corresponding retinal changes. Weigert-Kult- schitzsky staining in Schaffer’s modification : dark-blue granules (pre-lipid?) .

14 ACTA NEIlROl.. SC.AND. 37, 3

Age at Duration Type first symptoms

2. Bielschowsky (1914)

Clinical symptoms

3. Spielmeyer (1908) Vogt (1905) Sjogren (1931)

4. Kufs (1925)

Gaucher’s disease 1. Infantile

2. Juvenile

Eand-Schiiller-Christian Disease (1919)

Niemann-Pick’s Disease Niemann (1914) Bielschowsky (1927)

Hurler’s Syndrome Ford (1961)

3-4 years

5-6(3-10) years

15-25years

0-1 year

3-7 years

Childhood

2-6 months

Infantile Juvenile

about 4-5 years

10-15 years

Very slow progression

Up to one year

Up to one year

-

Maximum 2-4 years

Rarely over 10 years

Epilepsy, optic atrophy, ataxia, dementia

Epilepsy, impaired vision, dementia, hypo- or hyper- kinaesia, spasticity, pos- sibly retinitis pigmentosa

Spino-ponto-cerebellar symptoms, convulsions, late dementia

Hepatosplenomegaly, apathy-dementia, spastic- ity-opisthotonus

See above

Diabetes insipidus, exoph- thalmus, “Landkartenkra- nium”, possibly spasticity and ataxia

Ijepatosplenomegaly, skin changes, gastro-intestinal symptoms, mental impair- ment, possibly bypotony and nystagmus

Dwarfing and dementia

Lipogranulomatosis 0-4months Up to 2 years Refusal to eat, tumors of joints and liver, develop- ing dementia

Ford (1961)

Znfantile dementia, Heller 2-4 years Ford (1961) ?

Emotional instability, anxiety, dementia

213

1 (cant.) - lipidosis

I Nruropathology I h’eurochernistry

I Ganglion cell changes corresponding to Tay- Sacb’s disease + considerably degenerative changes in the cerebellum. No staining with Schaffer’s modification, but with Haidenhain- Spielmeyer’s method (iron haematoxylin) . Ganglion cell changes and degenerative Increased amount of ganglioside (Diezel, changes in the deep layers of the cerebral 1957). cortex, neostriatum and cerebellar cortex, rods and- cnnes affected (Greenfield, Holmes, 1925).

Unknown.

As under 3.

Changes as in cerebro-retinal degeneration. PAS-positive, no neutral fat, metachromasia with thionin.

See above.

In rare cases, multiple demyelination with fat-filled microglia phagocytes and giant glial cells, axis cylinder destruction. Tuber cine- reum severely affected (Davison, 1933).

Changes as in cerebro-retinal degeneration, hut rarely affection of C.N.S.

Swelling of neurones with granular content, rare areas of demyelination.

Granulomatous masses with “foam cells” among the nerve cells of cerebrum, medulla spinalis and ganglia.

Changes as in cerebro-retinal degeneration.

Slight increase in ganglioside in cortex (Cumings, 1957).

Increased amounts of cerebrosides (Thannhauser, 1953, Cumings, 1960).

Increased cholesterol (Thannhauser, 1953).

Increased sphingomyelin. gangliosides, total phospholipids and cholesterol (Klink, 1940, Thannhauser, 1952, Cumings, 1960.

Deposition of mucopolysaccharides and glycolipids, presumably in the tissues (Uzman, 1955). Increased amount of ganglioside in the cerehral cortex (Brante, 1952).

Lipo-glyco-peptide complex.

L’nknown.

14‘

214

Fig. 1. Jan V. L., 3 years old.

F i g . 2. Pneumoencephalography performed when Jan V. L. was 3?4 years old.

215

Fig. 3. Pncumoencephalography performed when Jan V. L. was 4 years 10 months old.

During the next six months his condition deteriorated further and he could now only swallow liquids. Mentally he was apathetic and disinterested, and difficult to con- tact. On readmission to the paediatric department of the University Hospital a t the age of four years, there were frequent attacks of general convulsions. The EEG was now extremely abnormal, and pneumoeneephalography (Fig. 3) showed severe eor- tical atrophy and a very dilated ventricular system.

At the age of 5 years he was admitted once again to the paediatrie department of the University Hospital, this time because of difficulty in breathing, with excessive secretion in the upper airways. His condition was extremely poor and he had to be tube feed. There was continuous twitching and tremor in the extremities, and his temperature was periodically elevated. All extremities showed severely increased spastic tone and there was opisthotonus. Laboratory findings during this period of

216

Fig. 4. Frontal section through cerebral hemisphere.

hospitalization showed normal haemoglobin percentage, leucocytc and differential count, ESR, erythrocyte diameter and urinalysis. There was slightly elevated serum alpha1 globulin and gamma globulin, slightly elevated serum lipid, 990 mg per 100 ml, phospholipid, 260 mg per 100 ml, neutral fat, 475 mg per 100 ml, total cholesterol, 265 mg per 100 ml, free cholesterol, 61 mg per 100 ml. Spinal fluid showed 8/3 erythrocytes, 113 leucocytes and a protein value of 231 mg per 100 ml.

After three months the patient was transferred to the paediatric department, St. Joseph’s Hospital, where his condition deterioated still further, with brief clonic convulsive attacks and occasional screaming. The patient died in this department in December 1959, aged five years and eleven months.

The brain was fixed in formalin shortly after death.

PATHOLOGICAL FINDINGS

At autopsy, scattered foci of bronchipneumonia were found in the upper lobe of the right lung. A microscopic examination of the lung tissue showed no signs of specific inflammation. A macroscopic examination of the remaining abdominal and thoracic organs showed nothing abnormal.

The brain was found to be well fixed. The leptomeninges were thickened, milky, strongly oedematous. The underlying gyri were diffusely and symmetrically atro- phic, with widened sulci. The lateral fissure was very broad and pronounced, particularly the stem portion. In a frontal section through the brain (Fig.4), the ventricular system was seen to be strongly dilated symmetrically. The cortex was fairly thin throughout, uniform and of a light greyish colour. ,4 rather narrow, darker greyish line of a gelatinous nature was found lying just beneath the cortex.

21 7

Fig. 5 A. Low-power view, myelin sheath staining, showing diffuse demyelination in the white matter. The stained subcortical zone consists of material accumulated in

macrophages and glial cells (Weil).

Beneath this was the white substance, generally showing a greyish discoloration. The basal nuclei, especially the corpus striatum, showed pronounced symmetrical atrophy. The aqueduct was open and slightly distended. The undersurface of the cerebellum showed atrophy of the vermis, which lay unusually deep in relation to the tonsils. The foramen of htagendie was enlarged, measuring 16 X 10 mm. The pons appeared slightly atrophic, with flattening of the ventral surface. The atrophy was symmetrical. Otherwise, the brain stem and cerebellum showed no abnormali- ties on external examination. The cut surfaces through these organs appeared nor- mal, but the consistency of the tissue was felt to be slightly increased.

Microscopic findings. Many sections from the cerebrum showed pronounced changes in the white matter.

Sections stained by Weil’s method showed almost total demyelination, so that prac-

218

Fig. 5 B. Section of deep cortical layer with subcortical zone showing accumulation of meta-

chromatic substance in perivascular macrophages and glial cells (PAS).

tically no myelin sheaths were preserved in the areas concerned. An exception, how- ever, were several thin myelin sheaths, preserved in a zone immediately beneath thc cortex. Considerable accumulations of a coarsely grained substance were found scattered throughout the white substance in large cells, which to some extent re- sembled gemistocytes. The substance stained dark blue by Weil’s method, and showed a strong PAS-positive reaction. The axon cylinders were strongly rarified in Bodian staining. Some of the axon cylinders were of irregular calibre and were degenerat- ing. The lipid released by the process of demyelination appeared to be taken up by the cells mentioned, a number of which were possibly very enlarged astrocytes, while the others were macrophages in the Virchow-Robin perivascular spaces. These lipid-filled and PAS-positive cells occurred diffnsely in the demyelinated area, rut in especially large numbers in a narrow subcortical zone (identical with the macroscopically visible line described above).

These cells also occurred in large numbers perivascularly, as mentioned, while the intermediate areas were more scantily supplied. Preparations stained by Cajal’s method showed a n increase in the number and size of the astrocytes. A number of these seemed to be identical with the cells containing lipid, while others did not contain accumulated material. A number of the lipid-containing cells, for example all those sited perivascularly, were not impregnated by Cajal’s staining method. Using the Rortega method of staining for microglia, diffuse moderate proliferation

219

Fig. 5 C. Proliferation and hyperplasia of macroglia in the subcortical layer

(Cajal staining, Hortega’s modification).

and enlargement of the microglia elements was seen. Holzer staining showed a slight to moderate diffuse fibril gliosis in the demyelinated areas.

Table 2 describes the histochemical nature of the substances accumulated in the macrophage cells. No globoid cells were observed.

A l l sections showed a moderate degree of shrinkage in the cerebral cortex. How- ever, the division into layers was maintained, and the nerve cells present were usually well preserved. The basal nuclei were reduced in size, but the cell picture was regarded as normal. In t h e hippocampus, the pyramidal cells were preserved to a certain extent, although showing a strongly degenerative character and with small shrunken pyknotic nuclei. The granular cells had disappeared extensively. Atrophy was present in the subiculum and in adjacent parts of the cortex, and the underlying white substance was diffusely demyelinated.

Several sections from the cerebellum showed a diffuse, uniform, severe atrophy of the folia, affecting all three layers. For example, the stratum moleculare was thin with relatively slight gliosis. The number of Purkinje cells was considerably decreased, so that hardly more than 10-20 per cent of the original number were present. The remainder were characterized by degenerative changes with pyknotic nuclei. There appeared to be a moderate increase in the number of Bergmann cells. The stratum granulosum was atrophic, measuring only about % of its usual width.

220

Fig. 5 D. Silver staining, showing destruction of almost all cell processes in the white matter

(Bodian).

Here too there was a thinning out of the cells. In the corpus medullarc, severe dif- fuse demyelination was seen, of quite the same character as that described in the cerebrum. The central nuclei were characterized by moderate decrease in cell numbers.

In the pons, degeneration of all the myelinated fibres was seen. The nuclei pontis had disappeared almost completely. Widespread demyelination was likewise found in the medulla oblongata, although there were more myelin sheaths preserved than in sections from higher levels. The pyramidal tracts were almost completely de- myelinated. The hypoglossal nucleus was preserved without any loss of cells. En- larged glial cells containing lipid were found scattered throughout the brain stem.

Neither the nerve cells of the cerebral cortex nor the Purkinje cells contained any abnormal amount of lipid. On the other hand, the large nerve cells of the brain stem contained a good deal of coarsely granular deposits, so that the nucleus was displaced. The staining of the substance in the cytoplasm of the nerve cells was not so intense as in the glial cells. Otherwise, the substance showed the same characteristics as in the macrophage cells of the cerebrum.

A microscopic examination of the kidney tissue showed the presence of PAS- positive deposits in the loops of Henle. A microscopic examination of the liver showed strong PAS-positive deposits in the Kuppfer cells.

221

TABLE 2 Histochemical characteristics of the substance accumulated

in macrophages and glial cells.

Yetliotl Frozen

sections (F) sections (P)

1. Haematoxylin-eosin ...................... 2. Gallocyanin-chromalin (Einarson)

(Nucleoprotein) ............................ 3. Weil’s myelin sheath staining ........ 4. “Fettrot” (neutral fa t ) .................. 5.Sudan Black B. (Mc Manris 1946)

(Lipids) ...................................... 6. Bismuth trichloride (Grundland e t

al. 1946) for cholesterol (not esters) 7. Secondary fluorescence, Phosphine

(Popper 1944) (cholester. esters) etc. 8. Primary fluorescence ..................... 9. Periodic - Schiff ...........................

10. Periodic - Schiff after acetylation ... 11. Cu-phthalocyanin (Kli iuer & Barrera

1953) (phospholipids, sphingomyelin, ganglosides) .................................

12. Hale’s method (modified by Seitel- berger e t al. 1957) (acid polysaccha- rides) ..........................................

13. Phospho-molybdanic acid (Landing et al. 1952) (choline-containing lip.)

14. Cresyl violet .................................

15. Toluidine blue ............................. 16. Feyrter’s “Mounting Staining” .......

7, .................................

P

P P F

P

P

P P P P

P

F

++ 0

+++ (t)

4

+++ ++ +++

0

++

+++ ++ + +++ +

+++

red

black-blue (red )

black-brown

brown

white white red

blue-green

blue-green

blue-green brown metachromatic metachromatic red metachromatic

The procedures in 1, 2, 3, 4, 9, 14, 15 are those described in the usual laboratory handbooks. The remaining methods are carried out by the procedure described by Pearse (1960). In all tests, tissue was used which was fixed in phosphate-buffered 4 $% formaldehyde.

EXAMINATION OF THE CEREBRAL LIPIDS

Methods and results in studies of the cerebral lipids in normal subjects have been reported previously (Plum & S. E . Hansen, 1960, S . E . Hansen, 1960).

In the present study, the analyses can be divided into two groups, the first being carried out on material fixed for 48 hours according to the method of LilZy (Tables 3 and 4) , the second being carried out on material fixed for almost 3 months in formalin (Table 5 ) .

222

TABLE 3 Hesults of lipid analyses of cerebrum (cortex).--The control figures are cited f rom

Plum & Ransen, 1960. (The material i s fixed for 48 hours by Lilly's method). Cortex.

I Normal Controls i lob. lob. lvb.

dert. 1 Whole brain clest. 1 dext.

Cholesterol (total) . Cholesterol (free) .. Phospholipids . . . .. , . Phosphoglycerides . Sphingomyelin . .. . . Lecithin . . . .. . . .. . . .. . . Cephalin . . ... . . . . ... . . Choline-containing

phospholipid . . . . . . Cerebroside (glyco-

sphingoside) ...... Neuraminic acid .. . .

0.84 (0.81-0.86) 0178 (0.76-0.83) 3.39 (3.14-3.66) 2.83 (2.61-3.05) 0.56 (0.53-0.58) 1.36 (1.25-1.48) 1.46 (1.36-1.50)

1.92 (1.78-2.08)

1.56 (1.44-1.64) 51.5 (48-54)

0.84 0.96 1.08 0.95 0.66 0.64 0.95 0.76 2.99 3.01 3.00 3.12 2.51 2.44 2.49 2.67 0.46 0.57 0.51 0.45 1.20 1.12 1.27 1.21 1.33 1.32 1.22 1.46

1.66 1.69 1.78 1.66

1.23 1.18 1.30 1.29 56 61 50 49

TABLE 4 Hesults of lipid analyses of cerebrum (white matter).-The control figures are cited from Plum B Hansen, 1960. (The material is f ixed f o r 48 hours by Lilly's method).

White matter.

Noriiial Controls I lob. lob. (Vernale+Male) , frontalis p : r - I t%p. I oe$ital

Whole brain j dext. dext. dext. dert. i I Cholesterol (total) . Cholesterol (free) .. Phospholipids . . . .. . . Phosphoglycerides . Sphingomyelin . .... Lecithin . . . . . . . .. . . .. . . Cephalin . . . .. . . . . . .. . . Choline-containing

phospholipid . . . . . . Cerebroside (glyco-

sphingoside) ...... Neuraminic acid ....

4.13 (3.92-4.41)

6.95 (6.46-7.44) 4.32 (4.04-4.69)

4.04 (3.85-4.32)

2.64 (2.41-2.76) 1.42 (1.31-1.53) 2.89 (2.7 1-3.1 5)

4.05 (3.72-4.29)

5.46 (5.01-5.84) ( 0 1

2.16 2.26 2.38 1.94 2.06 2.06 2.29 1.78 3.42 3.52 3.22 3.20 2.74 2.83 2.65 2.68 0.68 0.69 0.57 0.52 0.90 1.10 1.00 1.06 1.84 1.73 1.65 1.62

1.58 1.79 1.57 1.58

1.96 2.10 1.96 1.72 26 14 18 18

Tables 3, 4 and 5 show the results of the analyses. The considerable differences apparent between Table 4 on the one hand and Table 5 on the other, can be explained as follows: In Table 4, the results are from studies of white substance from parts of the cerebrum showing essen-

223

TABLE 5 Results of lipid analyses of cerebrum-The material is fixed f o r about 3 months in formalin. The figures in brackets are the range of normal values in Table 3 and 4 .

Cortex ~ ~~~ ~ ~

Cholesterol (total) .... ... . ...... . .. . . Cholesterol (free) ..... . ........ . . ... . . Phospholipids . . . . . . . . . . . . . . . . . . . . . . . . . . Phosphoglycerides . . .. . . . . . . . . . .. . . . . . Sphingomyelin . . . . . . . . . . . . . . . . . . . . . . . . Lecithin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cephalin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Choline-containing phospholipid . Cerebroside (glycosphingoside) . . Neuraminic acid . . ..... ... . ...... ... . .

~

0.83 0.78 3.41 2.88 0.53 1.31 1.57 1.84 1.44

46

I Normal Controls

0.84 (0.81-0.86) 0.78 (0.76-0.83) 3.39 (3.14-3.66) 2.83 (2.61-3.05) 0.56 (0.53-0.58) 1.36 (1.25-1.48) 1.46 (1.36-1.50) 1.92 (1.78-2.08) 1.56 (1.44-1.64)

51.5 (48-54)

I Subcortex.)

3.23 3.12 6.09 3.83 2.26 1.39 2.44 3.65 4.78 1

1 White matter 1 Nortnal Controls

Cholesterol (total) . . ... .. ... . ... . ._. . Cholesterol (free) . . ... . ...... . .. ...... Phospholipids . . . . . . . . . . . . . . . . . . . . . . . . . . Phosphoglycerides . . . . . . . . . . . . . . . . . . . . Sphingomyelin . . . . . . . . . . . . . . . . . . . . . . . . Lecithin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cephalin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Choline-containing phospholipid . Cerebroside (glycosphingoside) . . Neuraminic acid .... .. .... .......... . .

2.57 2.36 4.57 3.59 0.98 1.30 1.31 2.28 3.36

11

4.13 (3.92-4.41) 4.04 (3.85-4.32)

4.32 (4.04-4.69) 6.95 (6.46-7.44)

2.64 (2.41-2.76) 1.42 (1.31-1.53) 2.89 (2.71-3.15) 4.05 (3.72-4.29) 5.46 (5.01-5.84)

( 0 )

See Table 1.

tially the same pathological changes, both macroscopically and micro- scopically; in Table 5, the analysis results originate from a tissue sample which includes the dark gelatinous subcortical zone mentioned previously. Table 5 thus gives figures for cortex just superficial to the subcortical layer mentioned, for the subcortical layer, and for the white matter just beneath the subcortical layer. This explains the gradual re- duction in the amount of lipid when going from subcortex to white matter in Table 5, and thence to the control values for white matter (Tables 5 and 4). This will be discussed further below.

DISCUSSION

A total of 15 cases of late infantile metachromatic leucodystrophy, all verified at autopsy, have been reported in the literature. Those cases (Austin, 1957 and Jefferson, 1958) in which clinical andor pathological descriptions are lacking, have not been included.

224

TABLE 6 16 verified cases of late-infantile metachromatic leucodystrophy.

I I Age in months 1 I I I 1 Author , Sex

I ~~ ~~~~~~~

Greenfield F 24 36 12 + + - - (1933) M ? 36 ? + + ? 120

(1940) Rrandberg & Sjovall F 23 28 5 + + + -

Brain & Greenfield (1950)

Leslie

Bertrand et al.

Hain & La Veck

Jervis

Hagberg et al.

(1952)

(1954)

(1958)

(1960)

(1960)

Precent case

M 20 37 15 -- + -. 150 F 24 33 9 + + - 120 F 15 33 18 + + + 200 F 26 33 7 + + - - 100 M 301 43 12(?) + + + -

M 15 30 15 + + -- -

F 18 40 22 + + + 196

F 23 66 43 + + + 208 F 20 26 4 + + + 110 M 15 39 24 + + + 110 M 18 51 33 + + -- - M 18? 48 30 + + 150 M 30 71 41 + + f 231

The clinical course of the case presented here corresponds to that of the 15 cases previously published (Table 6 ) . Late infantile metachroma- tic leucodystrophy has its onset about the age of two years, the average age being 21 months, with extreme values of 15 months and 30 months. Death occurs around the age of 3% years, with extreme values of two years two months and five years eleven months. The mean duration is 19 months, with extreme values of 4 months and 3 years 7 months. The first manifestations of disease are slight disturbances of gait, with in- coordination, often followed by hypotonia, later hypertonia, ataxia. dysarthria and nystagmus. Dementia is not an initial symptom, but appears relatively early in the course of the disease. The EEG is normal at first, later showing severe diffuse abnormality. In all 11 cases exa- mined the protein content of the spinal fluid is elevated, 100-230 mg per 100 ml. Pneumoencephalography shows increasing atrophy. Demon- stration of metachromatic material in the urine, as proposed by Austin (1957) and confirmed by Cumings ( 1960), was not carried out in these 16 cases. The final condition is characterized by severe spasticity and stupor, often with brain-stem attacks and transient rises in temperature,

225

without accompanying infections. The present patient remained in this condition throughout the last year of life.

The pathological picture in the present case corresponds completely to that in the previously published cases, with respect to the almost total demyelination in the cerebrum and cerebellum, and the degenera- tion of almost all demyelinated fibres in the pons and, to a lesser degree, in the medulla oblongata.

Greenfield (1958) emphasized that in his cases the oligodendroglia were lacking or considerably reduced in number, even in areas where the myelin was still intact, thus confirming his theory of primary glial insufficiency. The same was found by Brandberg & Sjovall (1940), Leslie (1952), Berstrand et al. (1954) and Hagberg et al. (1960), but not by Jeruis (1960), and not in the present case.

The histochemical studies must be accepted with considerable reserve. They cannot be considered as specific for well-defined lipid fractions, but are included to help in characterizing the present case and to estab- lish a broader basis for comparison with the cases reported so far. A pronounced metachromatic condition is found with considerable amounts of acid polysaccharides and lipids containing carbohydrates. Finally, strongly PAS-positive deposits are found in the Kuppfer cells of the liver and in the Henle loops in the kidneys.

Brante ( 1953), by biochemical analyses, found an increased content of neuraminic acid in the white matter in two cases of metachromatic leucodystrophy. Edgar ( 1957) found increased hexosamine in the white matter, which was confirmed by Cumings (1957), who found a reduced content of phospholipid in addition. By chromatographic separation of the glycolipids, and determination of cerebrosides, gan- gliosides and sulphatides, Jervis ( 1960) and Svennerholm (Hagberg, Sourander, Svennerholm & Voss, 1960) recently found a considerable increase in the sulphatide content. Based on this, the latter proposed to classify the cases as sulphatide lipidosis, but Jervis maintains that our knowledge of sulphatide metabolism is very limited, and does not per- mit of any deductions being made.

In the present case, the lipid analyses of cortex showed no significant deviations from the values for normal material (Plum & S. E. Hansen, 1960). In the white substance, a uniform reduction has been found in the amounts of the following substances in particular, phospholipids, phosphoglycerides, choline-containing phospholipid, sphingomyelin and cerebroside, and neuraminic acid has been found. The present authors have not determined the content of hexosamine, as so far they have obtained unreliable results with formalin-fixed material.

Of interest in the present case are the investigations of the millimeter-

wide, gelatinous, sub-cortical border mentioned above. A large number of lipid-containing and PAS-positive cells were found here. These cells were also found in large numbers perivascularly. If the histochemical studies (Table 2) are considered in relation to these findings and to the biochemical analyses of tissue from this zone (Table 5 ) , an explanation is available for the processes involved. This is the last stage of the active phase, as no myelin sheaths are present, and the lipid from the myelin sheaths is taken up in the astrocytes and the perivascular macrophage elements. The chemical analyses show a reduction in lipids, but not to the same degree as in the remaining white matter. In addition there is the demonstration of strongly PAS-positive deposits in the Kuppfer cells of the liver and the loops of Henle in the kidneys, tallying with this is the demonstration by Ausfin (1958) of metachromatic material in the urine.

Metachromatic leucodystrophy can be regarded as an “inborn error of metabolism”, resulting from an enzyme defect, causing malfunction and destruction of oligodendroglia, and thereby of the myelin sheaths, or alternatively, causing incomplete incorporation of myelin in the pro- tein matrix. Earlier theories of the changes as resulting from deficiency disease or autoimmunization, must now be regarded as less probable.

While the above considerations may throw some light on the patho- genesis of the disease, no essential advance has been made in under- standing its aetiology. Further research on the leucodystrophies is necessary, all the more so because it may be reckoned that in Denmark alone today there are about 50 cases among all ages (E. Hansen, 1960).

SUMMARY

The various forms of leucodystrophy and lipidosis are mentioned, together with their clinical, pathological and neurochemical character- istics. A case of hereditary progressive cerebral leucodystrophy of the metachromatic type is reported in a boy born i January 1954 and dying in December 1959. An older sister died at the age of 3 years of the same disease. The disease presented at the age of 2 years with slight disturb- ances of gait. Severe spastic tetraplegia developed during the next 18 months, with severe dementia and frequent attacks of general convul- sions. The disease lasted 3% years. The EEG was extremely abnormal, and pneumoencephalography showed an increasing degree of dilation of the ventricular system. There was a slight rise in the serum alpha1 globulin and gamma globulin. The spinal protein was 231 mg per 100 ml.

A pathological examination showed almost complete demyelination

in the cerebrum and cerebellum, and degeneration of all myelinated fibres in the pons and medulla oblongata. No area was found with myelin still intact but oligodendroglia

missing. A histochemical examination showed a pronounced metachromatic

condition, with considerable acid polysaccharides and carbohydrate- containing lipids. There wcre strong PAS-positive deposits in the Kupp- fer cells of the liver and in the loops of Henle in the kidneys. The lipid analyses showed normal conditions in the cortex, with uniform reduc- tion of phospholipids, phosphoglycerides, cholinc-containing phospho- lipid, sphingomyelin and cerebroside in particular, as well as the occurrence of neuraminic acid in the white matter.

Subcortically there was a millimeter-wide, greyish, gelatinous zonc. which on the basis of the pathological, histochemical and biochemical studies must be regarded as the final phase of the active process.

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