Dermal phospho-alpha-synuclein deposits confirm REM sleep behaviour disorder as prodromal Parkinson's disease

Kathrin Doppler, Hanna-Maria Jentschke, Lena Schulmeyer, David Vadasz, Annette Janzen, Markus Luster, Helmut Höffken, Geert Mayer, Joachim Brumberg, Jan Booij, Thomas Musacchio, Stephan Klebe, Elisabeth Sittig-Wiegand, Jens Volkmann, Claudia Sommer, Wolfgang H Oertel, Kathrin Doppler, Hanna-Maria Jentschke, Lena Schulmeyer, David Vadasz, Annette Janzen, Markus Luster, Helmut Höffken, Geert Mayer, Joachim Brumberg, Jan Booij, Thomas Musacchio, Stephan Klebe, Elisabeth Sittig-Wiegand, Jens Volkmann, Claudia Sommer, Wolfgang H Oertel

Abstract

Phosphorylated alpha-synuclein (p-alpha-syn) deposits, one of the neuropathological hallmarks of Parkinson's disease (PD), have recently been detected in dermal nerve fibres in PD patients with good specificity and sensitivity. Here, we studied whether p-alpha-syn may serve as a biomarker in patients with a high risk of developing PD, such as those with REM sleep behaviour disorder (RBD). We compared the presence and distribution of p-alpha-syn deposits in dermal nerve fibres in 18 patients with RBD, 25 patients with early PD and 20 normal controls. Skin biopsy was taken at C7, Th10, and the upper and lower leg. Presynaptic dopamine transporter imaging using FP-CIT-SPECT was performed in all patients with RBD and in 11 patients with PD. All RBD patients underwent olfactory function testing. The likelihood ratio (LR) for prodromal PD was calculated for each patient based on published research criteria. Skin serial sections were assessed by double-immunofluorescence labelling with antibodies to pSer129-alpha-syn under blinded conditions. P-alpha-syn was visualized in 10/18 patients with RBD (sensitivity of 55.6%) and in 20/25 early PD patients (sensitivity of 80%) but in none of the controls (specificity of 100%). The percentage of dermal structures innervated by p-alpha-syn-positive fibres was negatively correlated with dopamine transporter binding in the FP-CIT-SPECT (ρ = -0.377, p = 0.048), with olfactory function (ρ = -0.668, p = 0.002), and positively correlated with the total LR for RBD to present prodromal PD (ρ = 0.531, p = 0.023). Dermal p-alpha-syn can be considered a peripheral histopathological marker of synucleinopathy and can be detected in a subgroup of RBD patients presumably representing prodromal PD. Dermal p-alpha-syn is detectable in RBD patients without PD motor symptoms, thereby stratifying a patient group that is of great interest for clinical trials testing disease-modifying drugs.

Keywords: Alpha-synuclein; FP-CIT-SPECT; Parkinson’s disease; REM sleep behaviour disorder; Skin biopsy.

Conflict of interest statement

The study was funded by a grant of Internationaal Parkinson Fonds, The Netherlands, to CS, WHO and KD. K. Doppler received personal fees for educational talks from Baxter/Baxalta and for educational material from Grifols. J. Booij received grants and personal fees from GE Healthcare. T. Musacchio received non-financial support from Merz, Allergan and Medtronic. J. Volkmann received grants and personal fees from Medtronic Inc. and Boston Scientific and personal fees from St. Jude. C. Sommer received personal fees from Baxter/Baxalta, Genzyme, Grifols, Air Liquide, CSL Behring, Kedrion, Novartis, Astellas and Pfizer for educational talks and/or consultancy and grant from Kedrion grants and is funded by the European Union's Seventh Framework Programme ("ncRNAPain", grant agreement number 602133), by Deutsche Forschungsgemeinschaft and the German ministry of education and research (CMT-Net). W.H. Oertel received personal fees for educational talks and/or consultancy from Abbvie, Adamas, Bristol-Myer-Squibb, Desitin, Mundipharma, Neuropore, Novartis, Roche and UCB Pharma and grants from the Deutsche Forschungs-Gemeinschaft, the Internationaal Parkinson-Fonds The Netherlands, the Michael J. Fox Foundation, USA, the National Research Fond Luxembourg and from Novartis Pharma, Germany.

Figures

Fig. 1
Fig. 1
Immunofluorescence staining with anti-p-alpha-syn (red) and anti-PGP9.5 (green, c). Dermal p-alpha-syn deposition was found within axons of somatosensory or autonomic nerve fibres (b) and resembled Lewy neurites that are typically found in the CNS (a). Lewy bodies as seen in CNS tissue (a, arrow) are not detectable in skin biopsies as the cell bodies of somatosensory neurons are located in the dorsal root ganglia and sympathetic ganglia. P-alpha-syn immunoreactivity forms a punctuated line within the nerve fibres. c illustrates the localization of p-alpha-syn deposition within a nerve fibre of a dermal nerve bundle. Scale bar 10 µm p-alpha-syn phosphorylated alpha-synuclein
Fig. 2
Fig. 2
Confocal photomicrographs of double-immunofluorescence with anti-p-alpha-syn (red) and anti-PGP 9.5 (axonal marker, green). P-alpha-syn -immunoreactive nerve fibres can be found in vasomotor nerve fibres around vessels (a, b), in somatosensory nerve fibres of the subepidermal plexus (c, d), in pilomotor nerve fibres of erector pilorum muscles (e, f) and in sudomotor fibres around sweat glands (g, h). Scale bar 20 µm. p-alpha-syn phosphorylated alpha-synuclein
Fig. 3
Fig. 3
Box plots illustrating skin biopsy, FP-CIT-SPECT, LR and TDI data. The box plots of the upper panels a–c illustrate the median percentage of p-alpha-syn-positive dermal nerve structures per patient (y-axis) in patients with abnormal/normal FP-CIT-SPECT (a), normosmic (TDI > 26)/hyposmic (TDI ≤ 26) patients (b) and patients fulfilling/not fulfilling the research MDS criteria of prodromal PD (x-axis) (c). In a, upper panel, PD patients are included, all other panels only represent the RBD group. The black line marks the median, the box represents the quartiles, the whiskers mark the range. Individual patient values are represented by circles. The percentage of p-alpha-syn-positive dermal structures shows a trend towards higher numbers in PD, declining from PD to RBD with abnormal, FP-CIT-SPECT (i.e. reduced specific to non-specific binding ratio) and further to RBD with normal FP-CIT-SPECT (a). P-alpha-syn deposition is not found in normosmic patients, but is high in hyposmic patients (b) and is much more abundant in patients fulfilling the MDS criteria of prodromal PD (c). The box plots of the lower images a–c compare the lowest putaminal FP-CIT-SPECT values, TDI values and the probability of prodromal PD (y-axis) in patients without (negative) and with (positive) p-alpha-syn deposition in the skin biopsy (x-axis). Putaminal FP-CIT-SPECT values tend to be lower in patients with at least one p-alpha-syn deposition (positive) vs in patients with no deposition (negative) (a). In a the punctate line indicates the lower normal value (2.0) of the FP-CIT-SPECT value. TDI values (b) are significantly lower in patients with p-alpha-syn deposits in the skin biopsy and the probability of prodromal PD is higher in patients with p-alpha-syn deposition (c). In a, lower panel, only 17 individual patient values are represented by circles as the FP-CIT-SPECT of one patient was not included into the quantitative analysis due to lack of raw data. FP-CIT-SPECT123I-2beta-carbomethoxy-3beta-(4-iodophenyl)-N-(3-fluoropropyl)-nortropane single photon emission computed tomography, p-alpha-syn phosphorylated alpha-synuclein, PD Parkinson’s disease, RBD REM sleep behaviour disorder, TDI olfactory threshold, discrimination and identification score

References

    1. Beck A, Steer R, Brown G. The Beck depression inventory-second edition manual. San Antonio: The Psychological Corporation; 1996.
    1. Berg D, Postuma RB, Adler CH, Bloem BR, Chan P, Dubois B, Gasser T, Goetz CG, Halliday G, Joseph L, Lang AE, Liepelt-Scarfone I, Litvan I, Marek K, Obeso J, Oertel W, Olanow CW, Poewe W, Stern M, Deuschl G. MDS research criteria for prodromal Parkinson’s disease. Mov Disord. 2015;30:1600–1611. doi: 10.1002/mds.26431.
    1. Boeve BF, Silber MH, Ferman TJ, Lin SC, Benarroch EE, Schmeichel AM, Ahlskog JE, Caselli RJ, Jacobson S, Sabbagh M, Adler C, Woodruff B, Beach TG, Iranzo A, Gelpi E, Santamaria J, Tolosa E, Singer C, Mash DC, Luca C, Arnulf I, Duyckaerts C, Schenck CH, Mahowald MW, Dauvilliers Y, Graff-Radford NR, Wszolek ZK, Parisi JE, Dugger B, Murray ME, Dickson DW. Clinicopathologic correlations in 172 cases of rapid eye movement sleep behavior disorder with or without a coexisting neurologic disorder. Sleep Med. 2013;14:754–762. doi: 10.1016/j.sleep.2012.10.015.
    1. Booij J, Hemelaar TG, Speelman JD, de Bruin K, Janssen AG, van Royen EA. One-day protocol for imaging of the nigrostriatal dopaminergic pathway in Parkinson’s disease by [123I]FPCIT SPECT. J Nucl Med. 1999;40:753–761.
    1. Braak H, de Vos RA, Bohl J, Del Tredici K. Gastric alpha-synuclein immunoreactive inclusions in Meissner’s and Auerbach’s plexuses in cases staged for Parkinson’s disease-related brain pathology. Neurosci Lett. 2006;396:67–72. doi: 10.1016/j.neulet.2005.11.012.
    1. Donadio V, Incensi A, Leta V, Giannoccaro MP, Scaglione C, Martinelli P, Capellari S, Avoni P, Baruzzi A, Liguori R. Skin nerve alpha-synuclein deposits: a biomarker for idiopathic Parkinson disease. Neurology. 2014;82:1362–1369. doi: 10.1212/WNL.0000000000000316.
    1. Donadio V, Incensi A, Piccinini C, Cortelli P, Giannoccaro MP, Baruzzi A, Liguori R. Skin nerve misfolded alpha-synuclein in pure autonomic failure and Parkinson disease. Ann Neurol. 2016;79:306–316. doi: 10.1002/ana.24567.
    1. Doppler K, Ebert S, Uceyler N, Trenkwalder C, Ebentheuer J, Volkmann J, Sommer C. Cutaneous neuropathy in Parkinson’s disease: a window into brain pathology. Acta Neuropathol. 2014;128:99–109. doi: 10.1007/s00401-014-1284-0.
    1. Doppler K, Volkmann J, Sommer C. Skin biopsies in the differential diagnosis of parkinsonism: are we ready for simplified protocols? Brain. 2015;139:e5. doi: 10.1093/brain/awv251.
    1. Doppler K, Weis J, Karl K, Ebert S, Ebentheuer J, Trenkwalder C, Klebe S, Volkmann J, Sommer C. Distinctive distribution of phospho-alpha-synuclein in dermal nerves in multiple system atrophy. Mov Disord. 2015;30:1688–1692. doi: 10.1002/mds.26293.
    1. Fearnley JM, Lees AJ. Ageing and Parkinson’s disease: substantia nigra regional selectivity. Brain. 1991;114(Pt 5):2283–2301. doi: 10.1093/brain/114.5.2283.
    1. Gibbons CH, Garcia J, Wang N, Shih LC, Freeman R. The diagnostic discrimination of cutaneous alpha-synuclein deposition in Parkinson disease. Neurology. 2016;87:505–512. doi: 10.1212/WNL.0000000000002919.
    1. Goetz CG, Tilley BC, Shaftman SR, Stebbins GT, Fahn S, Martinez-Martin P, Poewe W, Sampaio C, Stern MB, Dodel R, Dubois B, Holloway R, Jankovic J, Kulisevsky J, Lang AE, Lees A, Leurgans S, LeWitt PA, Nyenhuis D, Olanow CW, Rascol O, Schrag A, Teresi JA, van Hilten JJ, LaPelle N. Movement Disorder Society-sponsored revision of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS): scale presentation and clinimetric testing results. Mov Disord. 2008;23:2129–2170. doi: 10.1002/mds.22340.
    1. Hoehn MM, Yahr MD. Parkinsonism: onset, progression and mortality. Neurology. 1967;17:427–442. doi: 10.1212/WNL.17.5.427.
    1. Hughes AJ, Daniel SE, Kilford L, Lees AJ. Accuracy of clinical diagnosis of idiopathic Parkinson’s disease: a clinico-pathological study of 100 cases. J Neurol Neurosurg Psychiatry. 1992;55:181–184. doi: 10.1136/jnnp.55.3.181.
    1. Iranzo A, Fernandez-Arcos A, Tolosa E, Serradell M, Molinuevo JL, Valldeoriola F, Gelpi E, Vilaseca I, Sanchez-Valle R, Llado A, Gaig C, Santamaria J. Neurodegenerative disorder risk in idiopathic REM sleep behavior disorder: study in 174 patients. PLoS One. 2014;9:e89741. doi: 10.1371/journal.pone.0089741.
    1. Iranzo A, Lomena F, Stockner H, Valldeoriola F, Vilaseca I, Salamero M, Molinuevo JL, Serradell M, Duch J, Pavia J, Gallego J, Seppi K, Hogl B, Tolosa E, Poewe W, Santamaria J. Decreased striatal dopamine transporter uptake and substantia nigra hyperechogenicity as risk markers of synucleinopathy in patients with idiopathic rapid-eye-movement sleep behaviour disorder: a prospective study [corrected] Lancet Neurol. 2010;9:1070–1077. doi: 10.1016/S1474-4422(10)70216-7.
    1. Iranzo A, Tolosa E, Gelpi E, Molinuevo JL, Valldeoriola F, Serradell M, Sanchez-Valle R, Vilaseca I, Lomena F, Vilas D, Llado A, Gaig C, Santamaria J. Neurodegenerative disease status and post-mortem pathology in idiopathic rapid-eye-movement sleep behaviour disorder: an observational cohort study. Lancet Neurol. 2013;12:443–453. doi: 10.1016/S1474-4422(13)70056-5.
    1. Iranzo A, Valldeoriola F, Lomena F, Molinuevo JL, Serradell M, Salamero M, Cot A, Ros D, Pavia J, Santamaria J, Tolosa E. Serial dopamine transporter imaging of nigrostriatal function in patients with idiopathic rapid-eye-movement sleep behaviour disorder: a prospective study. Lancet Neurol. 2011;10:797–805. doi: 10.1016/S1474-4422(11)70152-1.
    1. Lebouvier T, Neunlist M, Varannes SB, Coron E, Drouard A, N’Guyen JM, Chaumette T, Tasselli M, Paillusson S, Flamand M, Galmiche JP, Damier P, Derkinderen P. Colonic biopsies to assess the neuropathology of Parkinson’s disease and its relationship with symptoms. PLoS One. 2010;5:e12728. doi: 10.1371/journal.pone.0012728.
    1. Mahlknecht P, Gasperi A, Willeit P, Kiechl S, Stockner H, Willeit J, Rungger G, Sawires M, Nocker M, Rastner V, Mair KJ, Hotter A, Poewe W, Seppi K. Prodromal Parkinson’s disease as defined per MDS research criteria in the general elderly community. Mov Disord. 2016;31:1405–1408. doi: 10.1002/mds.26674.
    1. Mahlknecht P, Iranzo A, Hogl B, Frauscher B, Muller C, Santamaria J, Tolosa E, Serradell M, Mitterling T, Gschliesser V, Goebel G, Brugger F, Scherfler C, Poewe W, Seppi K. Olfactory dysfunction predicts early transition to a Lewy body disease in idiopathic RBD. Neurology. 2015;84:654–658. doi: 10.1212/WNL.0000000000001265.
    1. Mahowald MW, Schenck CH. REM sleep behaviour disorder: a marker of synucleinopathy. Lancet Neurol. 2013;12:417–419. doi: 10.1016/S1474-4422(13)70078-4.
    1. Marek K, Innis R, van Dyck C, Fussell B, Early M, Eberly S, Oakes D, Seibyl J. [123I]beta-CIT SPECT imaging assessment of the rate of Parkinson’s disease progression. Neurology. 2001;57:2089–2094. doi: 10.1212/WNL.57.11.2089.
    1. American Academy of Sleep Medicine. International Classification of Sleep Disorders: Diagnostic and Coding Manual. In: Medicine. AAoS (ed). 2 edn. Westchester III
    1. Miki Y, Tomiyama M, Ueno T, Haga R, Nishijima H, Suzuki C, Mori F, Kaimori M, Baba M, Wakabayashi K. Clinical availability of skin biopsy in the diagnosis of Parkinson’s disease. Neurosci Lett. 2010;469:357–359. doi: 10.1016/j.neulet.2009.12.027.
    1. Morrish PK, Sawle GV, Brooks DJ. Clinical and [18F] dopa PET findings in early Parkinson’s disease. J Neurol Neurosurg Psychiatry. 1995;59:597–600. doi: 10.1136/jnnp.59.6.597.
    1. Nasreddine ZS, Phillips NA, Bedirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53:695–699. doi: 10.1111/j.1532-5415.2005.53221.x.
    1. Postuma RB, Gagnon JF, Vendette M, Desjardins C, Montplaisir JY. Olfaction and color vision identify impending neurodegeneration in rapid eye movement sleep behavior disorder. Ann Neurol. 2011;69:811–818. doi: 10.1002/ana.22282.
    1. Rothman KJ. No adjustments are needed for multiple comparisons. Epidemiology. 1990;1:43–46. doi: 10.1097/00001648-199001000-00010.
    1. Schenck CH, Montplaisir JY, Frauscher B, Hogl B, Gagnon JF, Postuma R, Sonka K, Jennum P, Partinen M, Arnulf I, Cochen de Cock V, Dauvilliers Y, Luppi PH, Heidbreder A, Mayer G, Sixel-Doring F, Trenkwalder C, Unger M, Young P, Wing YK, Ferini-Strambi L, Ferri R, Plazzi G, Zucconi M, Inoue Y, Iranzo A, Santamaria J, Bassetti C, Moller JC, Boeve BF, Lai YY, Pavlova M, Saper C, Schmidt P, Siegel JM, Singer C, St Louis E, Videnovic A, Oertel W. Rapid eye movement sleep behavior disorder: devising controlled active treatment studies for symptomatic and neuroprotective therapy—a consensus statement from the International Rapid Eye Movement Sleep Behavior Disorder Study Group. Sleep Med. 2013;14:795–806. doi: 10.1016/j.sleep.2013.02.016.
    1. Sprenger FS, Stefanova N, Gelpi E, Seppi K, Navarro-Otano J, Offner F, Vilas D, Valldeoriola F, Pont-Sunyer C, Aldecoa I, Gaig C, Gines A, Cuatrecasas M, Hogl B, Frauscher B, Iranzo A, Wenning GK, Vogel W, Tolosa E, Poewe W. Enteric nervous system alpha-synuclein immunoreactivity in idiopathic REM sleep behavior disorder. Neurology. 2015;85:1761–1768. doi: 10.1212/WNL.0000000000002126.
    1. Stiasny-Kolster K, Doerr Y, Moller JC, Hoffken H, Behr TM, Oertel WH, Mayer G. Combination of ‘idiopathic’ REM sleep behaviour disorder and olfactory dysfunction as possible indicator for alpha-synucleinopathy demonstrated by dopamine transporter FP-CIT-SPECT. Brain. 2005;128:126–137. doi: 10.1093/brain/awh322.
    1. Stiasny-Kolster K, Mayer G, Schafer S, Moller JC, Heinzel-Gutenbrunner M, Oertel WH. The REM sleep behavior disorder screening questionnaire–a new diagnostic instrument. Mov Disord. 2007;22:2386–2393. doi: 10.1002/mds.21740.
    1. Stokholm MG, Danielsen EH, Hamilton-Dutoit SJ, Borghammer P. Pathological alpha-synuclein in gastrointestinal tissues from prodromal Parkinson disease patients. Ann Neurol. 2016;79:940–949. doi: 10.1002/ana.24648.
    1. Storch A, Odin P, Trender-Gerhard I, Fuchs G, Reifschneider G, Ray Chaudhuri K, Jost WH, Ebersbach G. Non-motor Symptoms Questionnaire and Scale for Parkinson’s disease. Cross-cultural adaptation into the German language. Nervenarzt. 2010;81:980–985. doi: 10.1007/s00115-010-3010-z.
    1. Uchiyama M, Isse K, Tanaka K, Yokota N, Hamamoto M, Aida S, Ito Y, Yoshimura M, Okawa M. Incidental Lewy body disease in a patient with REM sleep behavior disorder. Neurology. 1995;45:709–712. doi: 10.1212/WNL.45.4.709.
    1. Varrone A, Dickson JC, Tossici-Bolt L, Sera T, Asenbaum S, Booij J, Kapucu OL, Kluge A, Knudsen GM, Koulibaly PM, Nobili F, Pagani M, Sabri O, Vander Borght T, Van Laere K, Tatsch K. European multicentre database of healthy controls for [123I]FP-CIT SPECT (ENC-DAT): age-related effects, gender differences and evaluation of different methods of analysis. Eur J Nucl Med Mol Imaging. 2013;40:213–227. doi: 10.1007/s00259-012-2276-8.
    1. Vilas D, Iranzo A, Tolosa E, Aldecoa I, Berenguer J, Vilaseca I, Marti C, Serradell M, Lomena F, Alos L, Gaig C, Santamaria J, Gelpi E. Assessment of alpha-synuclein in submandibular glands of patients with idiopathic rapid-eye-movement sleep behaviour disorder: a case–control study. Lancet Neurol. 2016;15:708–718. doi: 10.1016/S1474-4422(16)00080-6.
    1. Winz OH, Hellwig S, Mix M, Weber WA, Mottaghy FM, Schafer WM, Meyer PT. Image quality and data quantification in dopamine transporter SPECT: advantage of 3-dimensional OSEM reconstruction? Clin Nucl Med. 2012;37:866–871. doi: 10.1097/RLU.0b013e318251e1b3.
    1. Zange L, Noack C, Hahn K, Stenzel W, Lipp A. Phosphorylated alpha-synuclein in skin nerve fibres differentiates Parkinson’s disease from multiple system atrophy. Brain. 2015;138:2310–2321. doi: 10.1093/brain/awv138.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi