基因确诊的九例神经元核内包涵体病的临床和外周组织病理改变分析

Neuronal intranuclear inclusion disease:the clinical features and pathological findings of peripheral tissue biopsy in nine cases with genetic diagnosis

目的总结基因确诊的神经元核内包涵体病(NIID)患者的临床特点和外周组织病理改变特征。方法用重复引物聚合酶链反应方法对2018年1月至2020年2月就诊于北京大学第一医院神经内科,拟诊为NIID的患者进行NOTCH2NLC基因5′端非翻译区GGC重复扩增检测。回顾分析经基因确诊的NIID患者的临床资料和外周组织活组织检查(活检)病理改变特点,并对外周活检组织行p62和泛素的免疫组织化学和荧光染色。结果共发现9例NOTCH2NLC基因5′端非翻译区GGC重复扩增突变的NIID患者。其中5例患者为家族性(来自3个家系),其余4例为散发性。所有患者起病年龄在36~61(51.33±7.12)岁,其最常见的临床表现为发作性的人格情绪改变(8/9)、发作性意识障碍(6/9)和发作性头晕或头痛(6/9),其他症状包括认知功能障碍、癫痫发作、肢体无力、肢体感觉障碍、精神症状、震颤和排尿功能障碍等。8例患者头颅磁共振成像可见弥散加权成像皮髓质交界区高信号。9例患者行皮肤活检,均可在细胞内发现嗜酸性的核内包涵体(IIs)。IIs可出现在皮肤组织的汗腺导管上皮细胞、脂肪细胞和成纤维细胞,免疫组织化学及免疫荧光染色示p62和泛素阳性;电镜下IIs为细丝状物质缠绕沉积,边缘不具有膜结构。2例患者行肌肉活检,其中1例患者可见个别镶边空泡肌纤维,另外1例未见明显肌源性或神经源性病理改变;1例患者行腓肠神经活检示重度髓鞘性病理改变。对3例患者的肌肉或周围神经组织运用组织学、p62和泛素的免疫组织化学染色均未发现IIs,但用免疫荧光染色均发现p62和泛素异常沉积形成的IIs。结论该组患者主要为成人型NIID患者,以发作性脑病为主要临床表现。皮肤活检作为微创的病理检查对NIID具有很高的病理诊断价值,且p62和泛素的免疫荧光染色较组织学染色和免疫组织化学染色更易发现IIs的存在。

Objective To summarize the clinical features and pathological changes of peripheral tissues from patients with neuronal intranuclear inclusion disease(NIID)diagnosed by genetic tests.Methods Repeat-primed polymerase chain reaction was used to confirm the GGC repeated expansion in the 5′untranslated region of the NOTCH2NLC gene in patients with suspected NIID who had visited the Department of Neurology of Peking University First Hospital from January 2018 to February 2020.The clinical data and pathological changes of peripheral tissues from patients with genetically diagnosed NIID were collected retrospectively and analysed.Immunostaining with anti-p62 and anti-ubiquitin antibody was performed on peripheral biopsy specimens.Results Totally nine patients with NIID who had GGC repeated expansion in the NOTCH2NLC gene were found.Five patients were familial(from three faimilies),and four patients were sporadic.The age of onset was 36-61(51.33±7.12)years.The most common symptoms in this NIID group were episodic emotion and personality change(8/9),paroxysmal disturbance of consciousness(6/9)and intermitant head discomfort(6/9).Other symptoms included cognitive dysfunction,limb weakness,limb sensory disturbance,bladder dysfunction,ataxia,seizures and psychiatric symptoms.Brain magnetic resonance imaging showed high signals along the corticomedullary junction on diffusion-weighted image in eight out of nine patients.Skin biopsied samples from nine patients demonstrated the presence of eosinophilic intranuclear inclusions(IIs),appearing in the nucleus of fibroblasts,fat cells and ductal epithelial cells of sweat glands on hematoxylin-eosin staining.IIs were positive on anti-p62 and anti-ubiquitin immunostaining.Electron microscopy indicated the IIs were composed of a pile of filament materials without membrane.Muscle biopsies from two patients showed no obvious neurogenic or myogenic pathologic changes,except in one patient several rimmed vacuoles fibers were found.In one patient sural nerve biopsy showed severe demyelinating pathological changes.No IIs were found in the muscles and peripheral nerve tissue either by histological examination or by immunohistochemical staining with anti-p62 or anti-ubiquitin,while IIs were found by immunofluorescence staining with both anti-p62 and anti-ubiquitin in three patient′s tissue.Conclusions The phenotype of this NIID patient group is adult-onset NIID,with episodic encephalopathy as the main clinical manifestation.Skin biopsy has high pathological diagnostic value for NIID.The immunofluorescence staining with anti-p62 and anti-ubiquitin is easier to detect the presence of IIs than histological staining and immumohistochemical staining.