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Table of Contents
CASE REPORT
Year : 2013  |  Volume : 16  |  Issue : 2  |  Page : 279-281
 

Unusually prominent horizontal gaze palsy in a case of Niemann-Pick type C disease


RG Chamaria Medical Research Institute, Institute of Neurosciences, Kolkata, India

Date of Submission22-Nov-2012
Date of Decision09-Dec-2012
Date of Acceptance01-Feb-2013
Date of Web Publication24-May-2013

Correspondence Address:
Hrishikesh Kumar
Institute of Neurosciences, 185/1, AJC Bose Road, Kolkata - 700 017
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-2327.112498

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   Abstract 

Niemann-Pick Type C disease (NPC) is a rare inherited metabolic disorder characterized by lipid accumulation and systemic manifestations due to multiple organ involvement. Only a few cases of NPC have been reported so far from India. Varying presentations and often lack of access to complex diagnostic tests have leaded to initial misdiagnosis on few occasions. We here report a provisionally diagnosed case of NPC with prominent horizontal gaze palsy along with characteristic vertical gaze palsy and normal findings on microscopic examination of skin biopsy specimen.


Keywords: Niemann-Pick Type C disease, gaze palsy, sea blue histiocyte


How to cite this article:
Paul P, Mondal B, Mukherjee AK, Paul M, Kumar H. Unusually prominent horizontal gaze palsy in a case of Niemann-Pick type C disease. Ann Indian Acad Neurol 2013;16:279-81

How to cite this URL:
Paul P, Mondal B, Mukherjee AK, Paul M, Kumar H. Unusually prominent horizontal gaze palsy in a case of Niemann-Pick type C disease. Ann Indian Acad Neurol [serial online] 2013 [cited 2019 Aug 21];16:279-81. Available from: http://www.annalsofian.org/text.asp?2013/16/2/279/112498



   Introduction Top


Niemann-Pick Type C disease (NPC) is a lysosomal storage disorder due to defect in intracellular cholesterol trafficking and consequent accumulation and sequestration resulting in neuro-visceral complications. The wide spectrum of manifestations along with difficult diagnostic protocol warrants need for increased awareness about this rare condition. We here report a case of juvenile onset neuropsychiatric symptoms with bone marrow findings of sea blue histiocytosis suggestive of the diagnosis of NPC.


   Case Report Top


A 27-year-old lady, product of non-consanguineous marriage with uncomplicated birth history was apparently normal until 11 years of age. Symptoms started with worsening of school performance. The parents observed abnormal behavior in the form of restlessness, hallucinations, unprovoked episodes of screaming and crying, and decreased social interaction. Simultaneously, there was gradual onset of neurological symptoms accompanied by cognitive decline. The patient developed involuntary movements and abnormal posturing of limbs. Gradually progressive dysarthria and difficulty in walking due to clumsiness and impaired coordination interfered with patient's ability to lead an independent life.

Family history records death of elder sibling of the patient at age of 28 years due to chronic disease. He had symptoms of progressive motor and cognitive decline and was diagnosed to have storage disorder following bone marrow examination. Unfortunately, clinical data in details was not available.

On examination, patient was conscious and oriented and the vitals were stable and initial survey revealed presence of generalized choreiform movements. Eye movement abnormality included both horizontal and down-gaze palsy [Video 1]. Other findings included generalized dystonia with prominent tongue and limb dystonia [Video 2]. Gait was characterized by short steppage, wide based with variable stride length [Video 3]. Deep tendon reflexes were brisk in all four limbs.










Routine investigations were unremarkable. Complete blood counts including platelet count were normal and there was no evidence of organomegaly on ultrasound imaging. Magnetic resonance imaging of brain showed cortical atrophy, ex-vacuo dilatation of ventricles and prominence of sulci and gyri [Figure 1]. The infra-tentorial structures were relatively spared except for mild cerebellar atrophy. Bone marrow aspiration cytology demonstrated sea blue histiocytes implying lysosomal storage disorder [Figure 2], [Figure 3]. No abnormality was seen on microscopic examination of skin biopsy specimen. Considering progressive neurodegenerative features along with characteristic bone marrow findings a provisional diagnosis of juvenile onset NPC was considered.
Figure 1: T1 - weighted axial MRI - scan of the brain showing cortical atrophy and ex - vacuo dilatation of lateral ventricles

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Figure 2: High power view of bone marrow aspirate smear, showing normal cellularity with normoblastic maturation and presence of sea blue histiocyte (marked with arrow) which is characteristic of Niemann - Pick disease

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Figure 3: Higher magnification photomicrograph of sea blue histiocyte: The cell is around 25 - 30 microns in size with a relatively small nucleus and vacuolated blue colour cytoplasm

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   Discussion Top


NPC observes marked clinical heterogeneity varying from neonatal fatality and isolated hepatosplenomegaly in juvenile forms, to adult onset chronic neurodegenerative features. However, no evidence of organomegaly was noted in our case. Similar finding of absent visceromegaly have been documented in adult onset NPC. [1] While organomegaly due to lipid storage may be absent in up to 15% of all patients, [2] possible regression of systemic signs with age [2] could also explain our findings in juvenile onset type.

Neuropsychiatric involvement is a hallmark of this metabolic disorder. Psychosis followed by neurological manifestations as in our case has been concordant with the clinical profile of NPC patients. [3],[4] We considered motor signs like dysarthria, supranuclear gaze palsy and severe dystonia in favor of our diagnosis.

Vertical supranuclear gaze palsy (VSGP) has been described as the characteristic eye movement disorder in NPC. In our patient, in addition to down-gaze palsy, there was also absence of horizontal saccades. Increased susceptibility of neuronal cells in the rostral interstitial nuclei of the medial longitudinal fasciculus has been suggested in pathogenesis [5] of VSGP in NPC. Horizontal gaze palsy has been rarely documented for cases with NPC. Abel et al. reported a range of horizontal saccade deficits in three patients with NPC and suggested that ocular motor measures can be index of disease severity. [6] Their study observed involvement at brainstem and prefrontal levels of control of horizontal saccades. Prominent horizontal gaze palsy in the present case may be because of involvement of frontal lobe. The imaging has revealed cortical atrophy including, frontal lobe degeneration with relative sparing of infratentorial structures.

Histopathology plays a key role in diagnosis of NPC. Bone marrow aspiration cytology for our case revealed sea blue histiocytosis suggestive of lipid metabolic disorder. [7] However, histological examination from skin biopsy specimens showed no abnormality. Mere electron microscopy has been proved to be of limited significance for diagnosis of NPC. [8] The recent guidelines suggest the integrated results from filipin staining of cultured skin fibroblasts in cholesterol rich medium along with genetic mutation studies as the gold standard diagnostic tests. [9] Unfortunately, we were not able to do these tests and even so, presence of clinical scenario comparable with other diagnosed cases that have been reported, and characteristic bone marrow findings [10] leave little room for alternative diagnosis. We may explain negative skin biopsy in our case as a 'variant biochemical phenotype' that may not show typical storage pattern in fibroblasts. [2]

At present, no standard blood tests or other simple procedures are available to diagnose NPC. Varying and often delayed presentation has lead to initial misdiagnosis on few occasions. [4],[11] The sophisticated diagnostic techniques and recently approved treatment being unavailable in India, increased knowledge and better understanding of clinical profile might help in early diagnosis and secondary prevention of complications. Our case report is an attempt to document a case of NPC with unusual eye movement sign of horizontal gaze palsy in addition to the well-known vertical gaze palsy. NPC should be considered as a differential diagnosis for any young onset gradually progressive neuropsychiatric manifestations with motor and eye movement abnormalities.

 
   References Top

1.Hulette CM, Earl NL, Anthony DC, Crain BJ. Adult onset Niemann-Pick disease type C presenting with dementia and absent organomegaly. Clin Neuropathol 1992;11:293-7.  Back to cited text no. 1
    
2.Vanier MT. Niemann-Pick disease type C. Orphanet J Rare Dis 2010;5:16.  Back to cited text no. 2
    
3.Shulman LM, David NJ, Weiner WJ. Psychosis as the initial manifestation of adult-onset Niemann-Pick disease type C. Neurology 1995;45:1739-43.  Back to cited text no. 3
    
4.Praveen KS, Sinha S, Yasha TC, Muthane UB, Ravishankar S, Sangeetha S, et al. Niemann-Pick disease type C-sea-blue histiocytosis: Phenotypic and imaging observations and mini review. Ann Indian Acad Neurol 2007;10:259-62.  Back to cited text no. 4
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5.Salsano E, Umeh C, Rufa A, Pareyson D, Zee DS. Vertical supranuclear gaze palsy in Niemann-Pick type C disease. Neurol Sci 2012;33:1225-32.  Back to cited text no. 5
    
6.Abel LA, Walterfang M, Fietz M, Bowman EA, Velakoulis D. Saccades in adult Niemann-Pick disease type C reflect frontal, brainstem, and biochemical deficits. Neurology 2009;72:1083-6.  Back to cited text no. 6
    
7.Suzuki O, Abe M. Secondary sea-blue histiocytosis derived from Niemann-Pick disease. J Clin Exp Hematop 2007;47:19-21.  Back to cited text no. 7
    
8.Natowicz MR, Stoler JM, Prence EM, Liscum L. Marked heterogeneity in Niemann-Pick disease, type C. Clinical and ultrastructural findings. Clin Pediatr (Phila) 1995;34:190-7.  Back to cited text no. 8
    
9.Patterson MC, Hendriksz CJ, Walterfang M, Sedel F, Vanier MT, Wijburg F, et al. Recommendations for the diagnosis and management of Niemann-Pick disease type C: An update. Mol Genet Metab 2012;106:330-44.  Back to cited text no. 9
    
10.Xiong H, Bao XH, Zhang YH, Xu YN, Qin J, Shi HP, et al. Niemann-Pick disease type C: Analysis of 7 patients. World J Pediatr 2012;8:61-6.  Back to cited text no. 10
    
11.Lo SM, McNamara J, Seashore MR, Mistry PK. Misdiagnosis of Niemann-Pick disease type C as Gaucher disease. (published online ahead of print September 30 2010) J Inherit Metab Dis 2010.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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