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. 2024 Sep;296(3):234-248.
doi: 10.1111/joim.13815. Epub 2024 Jul 7.

Spinocerebellar ataxia type 4 is caused by a GGC expansion in the ZFHX3 gene and is associated with prominent dysautonomia and motor neuron signs

Martin Paucar  1   2 , Daniel Nilsson  3   4 , Martin Engvall  5   6 , José Laffita-Mesa  2   7 , Cilla Söderhäll  8 , Mikael Skorpil  5   9 , Christer Halldin  10 , Patrik Fazio  10 , Kristina Lagerstedt-Robinson  3   5 , Göran Solders  2   11 , Maria Angeria  12 , Andrea Varrone  10 , Mårten Risling  12 , Hong Jiao  13 , Inger Nennesmo  14 , Anna Wedell  5   6 , Per Svenningsson  1   2
Affiliations

Spinocerebellar ataxia type 4 is caused by a GGC expansion in the ZFHX3 gene and is associated with prominent dysautonomia and motor neuron signs

Martin Paucar et al. J Intern Med. 2024 Sep.

Abstract

Background: Spinocerebellar ataxia 4 (SCA4), characterized in 1996, features adult-onset ataxia, polyneuropathy, and linkage to chromosome 16q22.1; its underlying mutation has remained elusive.

Objective: To explore the radiological and neuropathological abnormalities in the entire neuroaxis in SCA4 and search for its mutation.

Methods: Three Swedish families with undiagnosed ataxia went through clinical, neurophysiological, and neuroimaging tests, including PET studies and genetic investigations. In four cases, neuropathological assessments of the neuroaxis were performed. Genetic testing included short read whole genome sequencing, short tandem repeat analysis with ExpansionHunter de novo, and long read sequencing.

Results: Novel features for SCA4 include dysautonomia, motor neuron affection, and abnormal eye movements. We found evidence of anticipation; neuroimaging demonstrated atrophy in the cerebellum, brainstem, and spinal cord. [18F]FDG-PET demonstrated brain hypometabolism and [11C]Flumazenil-PET reduced binding in several brain lobes, insula, thalamus, hypothalamus, and cerebellum. Moderate to severe loss of Purkinje cells in the cerebellum and of motor neurons in the anterior horns of the spinal cord along with pronounced degeneration of posterior tracts was also found. Intranuclear, mainly neuronal, inclusions positive for p62 and ubiquitin were sparse but widespread in the CNS. This finding prompted assessment for nucleotide expansions. A polyglycine stretch encoding GGC expansions in the last exon of the zink finger homeobox 3 gene was identified segregating with disease and not found in 1000 controls.

Conclusions: SCA4 is a neurodegenerative disease caused by a novel GGC expansion in the coding region of ZFHX3, and its spectrum is expanded to include dysautonomia and neuromuscular manifestations.

Keywords: ZFHX3; nucleotide expansion; polyglycine; spinocerebellar ataxia.

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References

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