Scientific Letter
Leucoencephalopathy with brain stem and spinal cord involvement and lactate elevation: Report of two new cases
Leucoencefalopatía con afectación de troncoencéfalo y médula espinal y elevación de lactato: presentación de 2 nuevos casos
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Navarro Vázquez, L. Maestre Martínez, E. Lozano Setién, F. Menor Serrano" "autores" => array:4 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "Navarro Vázquez" "email" => array:1 [ 0 => "inmanavarro@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L." "apellidos" => "Maestre Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Lozano Setién" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "F." "apellidos" => "Menor Serrano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Pediatría, Hospital General de Almansa, Almansa, Albacete, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radiología, Complejo Hospitalario Universitario de Albacete, Albacete, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Radiología Infantil, Hospital Universitari i Politècnic La Fe, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Leucoencefalopatía con afectación de troncoencéfalo y médula espinal y elevación de lactato: presentación de 2 nuevos casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 827 "Ancho" => 1950 "Tamanyo" => 138805 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transversal T2-weighted images showing extensive involvement of the periventricular, deep and cerebellar white matter (white asterisks). Involvement of the corpus callosum (black asterisks) and the corticospinal tract, from the posterior limb of the internal capsule and pyramidal tracts in the brainstem (black arrows). Abnormal signal intensity in the thalamus and medial lemniscus in the brainstem (white arrows). Trigeminal nerve trajectory involvement (white arrow head).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Leucoencephalopathy with brain stem and spinal cord involvement and lactate elevation is a rare disease that affects the white matter of the brain of which fewer than a hundred cases have been described. The onset of symptoms usually occurs during childhood or adolescence and is characterised by slowly progressing cerebellar ataxia, spasticity and dysfunction of the dorsal column of the spinal cord. Its diagnosis is based on the abnormalities found in magnetic resonance imaging (MRI) and spectroscopy. It follows a pattern of autosomal recessive inheritance and caused by mutations in the DARS2 gene.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the cases of two female twins aged 14 months, born preterm at 32 weeks’ gestation to consanguineous parents, and referred for evaluation due to failure to thrive. They were followed up in the clinic, exhibiting mild psychomotor delay at age 9 months. At 14 months they were admitted for evaluation of severe malnutrition. The neurological assessment revealed psychomotor regression with absence of sitting and turning, irregular eye focusing and tracking, and little interest in objects. A metabolic and nutritional screening was performed, revealing a mild elevation of lactate in blood. The findings of brain and spinal cord MRI were compatible with severe, uniform diffuse involvement of the periventricular, centrum semiovale, and cerebellar peduncle white matter. There was involvement of the posterior and anterior regions of the corpus callosum, the corticospinal tracts from the posterior limb of the internal capsule through the brain stem to the lateral corticospinal tracts in the spinal cord and of the ascending tracts from the dorsal columns of the cervical spinal cord and medial lemniscus of the brain stem to the thalamus and corona radiata (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). We performed a magnetic resonance spectroscopic imaging (MRSI) scan that revealed a decreased N-acetyl aspartate/creatine ratio and lactate elevation. The disease progressed slowly in both twins, with gradual neurological deterioration and recurrent respiratory infections leading to their death at age 2 years.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The leucoencephalopathies comprehend a heterogeneous group of diseases that primarily affect the white matter of the brain. In 2003, van der Knaap et al. were the first to describe a novel entity, LBS-L (Leukoencephalopathy with Brainstem and Spinal cord involvement and increased Lactate), which exhibited a pattern of autosomal recessive inheritance.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In most of the described cases, the symptoms start between early childhood and adolescence, and progress gradually. The main clinical features are slowly progressing cerebellar ataxia, tremors, muscle weakness and spasticity most prominent in the lower limbs, with mild or absent cognitive deficits.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–3</span></a> The disease progresses slowly, leading to walking disability and wheelchair dependency over the years. The phenotypic spectrum of the disease is very broad, ranging from oligosymptomatic cases, usually with onset in adulthood, to cases of early onset and rapid and fatal progression.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Magnetic resonance imaging shows abnormal signal intensity at the level of the periventricular and deep white matter, selective involvement of cerebellar connections, and involvement of the entire length of the pyramidal and ascending tracts to the spinal cord and the intraparenchymal trajectories of the trigeminal nerve.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> The MRSI usually detects lactate elevation. These MRI abnormalities, along with the abnormal elevation of lactate in white matter found by MRSI, are considered characteristic of the disease.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–4</span></a>The diagnosis is confirmed by genetic testing. LBS-L is an autosomal recessive disease caused by mutations in the DARS2 gene in chromosome 1, which encodes mitochondrial aspartyl-tRNA synthetase.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> We did not perform genetic testing in our patients, as the clinical manifestations, neuroimaging findings and elevated lactate in spectroscopy were so characteristic of the disease that we deemed them sufficient to make the diagnosis. However, genetic confirmation is important not only for advancing our knowledge of the disease, but also for its potential in prenatal diagnosis. The general prognosis is better than that of most hereditary leucoencephalopathies, with the exception of cases with childhood onset. At present, there is no effective treatment for the disease. Supportive measures are all that is available: early stimulation, physical therapy, rehabilitation, anticonvulsant therapy if required, and nutrition therapy.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, we are presenting the cases of two female twins with an early diagnosis of leukoencephalopathy with brain stem and spinal cord involvement and elevated lactate, a rare metabolic disease that has been recently defined, who experienced rapid disease progression. We want to emphasise the usefulness of brain and spinal cord MRI, which revealed differential features consistent with LBS-L in both of the cases presented here, as they provide specific findings to guide the diagnosis of this disease.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Navarro Vázquez I, Maestre Martínez L, Lozano Setién E, Menor Serrano F. Leucoencefalopatía con afectación de troncoencéfalo y médula espinal y elevación de lactato: presentación de 2 nuevos casos. An Pediatr (Barc). 2016;84:291–293.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 827 "Ancho" => 1950 "Tamanyo" => 138805 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transversal T2-weighted images showing extensive involvement of the periventricular, deep and cerebellar white matter (white asterisks). Involvement of the corpus callosum (black asterisks) and the corticospinal tract, from the posterior limb of the internal capsule and pyramidal tracts in the brainstem (black arrows). Abnormal signal intensity in the thalamus and medial lemniscus in the brainstem (white arrows). Trigeminal nerve trajectory involvement (white arrow head).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 943 "Ancho" => 1950 "Tamanyo" => 198559 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Transversal T2-weighted images of the medulla oblongata and spinal cord, and sagittal T2-weighted image of the cervical spine. Involvement of the pyramidal tract in the medulla oblongata and lateral corticospinal tracts of the spinal cord (black arrows). 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 8 | 20 |
| 2024 October | 99 | 37 | 136 |
| 2024 September | 90 | 28 | 118 |
| 2024 August | 131 | 65 | 196 |
| 2024 July | 110 | 25 | 135 |
| 2024 June | 74 | 26 | 100 |
| 2024 May | 65 | 35 | 100 |
| 2024 April | 78 | 37 | 115 |
| 2024 March | 71 | 19 | 90 |
| 2024 February | 73 | 27 | 100 |
| 2024 January | 83 | 20 | 103 |
| 2023 December | 130 | 24 | 154 |
| 2023 November | 91 | 26 | 117 |
| 2023 October | 90 | 23 | 113 |
| 2023 September | 45 | 18 | 63 |
| 2023 August | 62 | 20 | 82 |
| 2023 July | 60 | 29 | 89 |
| 2023 June | 71 | 22 | 93 |
| 2023 May | 82 | 17 | 99 |
| 2023 April | 48 | 13 | 61 |
| 2023 March | 74 | 16 | 90 |
| 2023 February | 73 | 18 | 91 |
| 2023 January | 58 | 25 | 83 |
| 2022 December | 73 | 30 | 103 |
| 2022 November | 97 | 32 | 129 |
| 2022 October | 69 | 33 | 102 |
| 2022 September | 64 | 21 | 85 |
| 2022 August | 69 | 52 | 121 |
| 2022 July | 53 | 38 | 91 |
| 2022 June | 47 | 29 | 76 |
| 2022 May | 52 | 31 | 83 |
| 2022 April | 48 | 32 | 80 |
| 2022 March | 90 | 45 | 135 |
| 2022 February | 67 | 32 | 99 |
| 2022 January | 95 | 26 | 121 |
| 2021 December | 61 | 45 | 106 |
| 2021 November | 77 | 46 | 123 |
| 2021 October | 139 | 60 | 199 |
| 2021 September | 73 | 42 | 115 |
| 2021 August | 68 | 49 | 117 |
| 2021 July | 54 | 30 | 84 |
| 2021 June | 53 | 37 | 90 |
| 2021 May | 75 | 59 | 134 |
| 2021 April | 150 | 76 | 226 |
| 2021 March | 89 | 34 | 123 |
| 2021 February | 63 | 25 | 88 |
| 2021 January | 58 | 22 | 80 |
| 2020 December | 45 | 24 | 69 |
| 2020 November | 49 | 16 | 65 |
| 2020 October | 47 | 13 | 60 |
| 2020 September | 86 | 18 | 104 |
| 2020 August | 87 | 9 | 96 |
| 2020 July | 72 | 22 | 94 |
| 2020 June | 34 | 8 | 42 |
| 2020 May | 51 | 16 | 67 |
| 2020 April | 38 | 17 | 55 |
| 2020 March | 35 | 18 | 53 |
| 2020 February | 47 | 13 | 60 |
| 2020 January | 25 | 11 | 36 |
| 2019 December | 36 | 21 | 57 |
| 2019 November | 38 | 16 | 54 |
| 2019 October | 34 | 6 | 40 |
| 2019 September | 36 | 13 | 49 |
| 2019 August | 27 | 21 | 48 |
| 2019 July | 18 | 24 | 42 |
| 2019 June | 35 | 20 | 55 |
| 2019 May | 113 | 20 | 133 |
| 2019 April | 67 | 18 | 85 |
| 2019 March | 49 | 16 | 65 |
| 2019 February | 33 | 10 | 43 |
| 2019 January | 25 | 15 | 40 |
| 2018 December | 30 | 22 | 52 |
| 2018 November | 48 | 30 | 78 |
| 2018 October | 53 | 40 | 93 |
| 2018 September | 26 | 19 | 45 |
| 2018 August | 2 | 0 | 2 |
| 2018 July | 1 | 0 | 1 |
| 2018 June | 4 | 0 | 4 |
| 2018 May | 8 | 0 | 8 |
| 2018 April | 39 | 0 | 39 |
| 2018 March | 36 | 0 | 36 |
| 2018 February | 25 | 0 | 25 |
| 2018 January | 24 | 0 | 24 |
| 2017 December | 40 | 0 | 40 |
| 2017 November | 17 | 0 | 17 |
| 2017 October | 15 | 0 | 15 |
| 2017 September | 19 | 0 | 19 |
| 2017 August | 20 | 0 | 20 |
| 2017 July | 21 | 1 | 22 |
| 2017 June | 23 | 11 | 34 |
| 2017 May | 17 | 7 | 24 |
| 2017 April | 20 | 5 | 25 |
| 2017 March | 4 | 5 | 9 |
| 2017 February | 13 | 5 | 18 |
| 2017 January | 10 | 3 | 13 |
| 2016 December | 32 | 16 | 48 |
| 2016 November | 39 | 14 | 53 |
| 2016 October | 40 | 22 | 62 |
| 2016 September | 37 | 5 | 42 |
| 2016 August | 39 | 3 | 42 |
| 2016 July | 21 | 4 | 25 |
| 2016 May | 3 | 0 | 3 |
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