Two neurologic facets of CTLA4-related haploinsufficiency
Xavier Ayrignac, Radjiv Goulabchand, Eric Jeziorski, Patricia Rullier, Clarissa Carra-Dallière, Claire Lozano, Pierre Portales, Thierry Vincent, Jean François Viallard, Nicolas Menjot de Champfleur, Frédéric Rieux-Laucat, Caroline Besnard, Michel Koenig, Claire Guissart, Pierre Labauge, Philippe Guilpain, Xavier Ayrignac, Radjiv Goulabchand, Eric Jeziorski, Patricia Rullier, Clarissa Carra-Dallière, Claire Lozano, Pierre Portales, Thierry Vincent, Jean François Viallard, Nicolas Menjot de Champfleur, Frédéric Rieux-Laucat, Caroline Besnard, Michel Koenig, Claire Guissart, Pierre Labauge, Philippe Guilpain
Abstract
Objective: To describe the clinical and radiologic neurologic characteristics of patients with cytotoxic T-lymphocyte antigen-4 (CTLA4) haploinsufficiency.
Methods: Three patients from 2 families had neurologic manifestations in the context of CTLA4 haploinsufficiency. Their clinical and MRI findings are presented.
Results: A 16-year-old boy with a previous diagnosis of combined immunodeficiency presented with severe recurrent episodes of headaches, motor deficit, and seizures associated with waxing and waning gadolinium-enhancing FLAIR cortical/juxtacortical hyperintensities. His sister, who also had combined immunodeficiency, had a brain MRI when she was aged 13 years due to recent headaches and transient right hemianopsia. It revealed a gadolinium-enhancing left occipital white matter hyperintensity. Another 49-year-old woman had progressive visual loss and cerebellar ataxia in the context of recurrent pulmonary infections. All 3 patients were found to have inherited CTLA4 haploinsufficiency. Patient 1's general condition and neurologic manifestations were completely controlled with abatacept (CTLA4-Ig).
Conclusions: These cases suggest that in addition to the variable clinical penetrance and wide spectrum of CTLA4 haploinsufficiency, its neurologic spectrum is broad, ranging from recurrent tumefactive lesions to progressive deficits including cerebellar ataxia and optic atrophy with leukoencephalopathy. These phenotypes must be recognized, and should lead to a complete immunologic workup, because potentially effective targeted immunotherapy exists.
Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.
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Source: PubMed