01:11:37
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[00:00:00] Dr Francesca Fumagalli: Good day everybody. I welcome you to the Webinar- Spot the early signs of MLD I have a few housekeeping slides so please do not take any screenshot of the presentation you will see today and, whenever you want, you can add your question to the question panel on the right upper part of your screen. I will introduce myself. I am Dr francesca Fumagalli, a neurologist of San Raffaele Hospital in Milan, and with me there is Alejandra Darling that can introduce herself.
[00:01:24] Dr Alejandra Darling: Hello, good morning. My name is Alejandra Darling. I am a paediatric neurologist from the hospital San Juan De Deu in Barcelona. Thank you.
[00:01:36] Dr Francesca Fumagalli: So I thank you, the organizers, for inviting me introducing the first webinar on Early Science of MLD. We will go in detail understanding the first symptoms, signs of MLD, and we will do that together with some cases presentations, and we will discuss them together. Before starting, a very short introduction on MLD for those who are not so expert on that. It is a lysosomal storage disorder caused by the deficiency of arylsulfatase A, a lysosomal enzyme that, if lacking, causes accumulation of sulfatase both in central and peripheral nervous system. According to the age of onset of first symptoms, we can distinguish different variants, and the most severe are the variants with the earliest onset, so the late infantile and early juvenile variants with an onset respectively below 30 months and between 30 months and seven years old. Depending on the residual ARSA activity and the severity of the mutation, we can have an earlier onset and most rapid disease course leading to the progressive deterioration and decline of both motor and cognitive function, leading to an early fatal outcome. We will go in depth in the early clinical symptoms because now, the disease can be treated. There is a treatment that is ARSA cells that can be used in early onset form in a pre- symptomatic phase, and in the early juvenile form also in the early symptomatic phase so it is very important that we can detect and recognize the disease as soon as possible. But, this is a very great challenge. In fact, the first symptoms and signs of the disease are very subtle and nonspecific. As we have said, it depends on the age of onset. So the onset of the late infantile form is prevalently characterized by motor symptoms, delayed milestones and gait abnormalities, while the juvenile form are also characterized by cognitive and behavioral changes, while the late onset variants are first characterized by cognitive and psychiatric symptoms. The fact that these symptoms are so subtle and non- specific leads to a delay in the diagnosis of the disease of months or years. As you can see in these pictures, there is a lag time between the first symptoms and the first medical consult because of many reasons, going from 4 weeks to even 24 weeks. Sometimes, the specialist that is consulted is not the right one, so not a specialty that they can think to a disease. So sometimes due to gait impairment or abnormal feet posture, an orthopedist is consulted for example, in the juvenile form, the first one that is consulted is a psychologist because of behavioral changes. And in fact the misdiagnosis or developmental delay for late infantile variants and problems of inattention and hyperactivity in the juvenile form And you can notice how long is the time frame between the first symptoms and diagnosis. Too long to assure to these patients a good treatment and a good outcome. We go now to the late infantile variant, with an onset below 30 months. These children have a normal motor development in the first months of life, and then go through a stagnation of their motor development, followed by a rapid progression. We should be able to detect these children in the phase of stagnation or even earlier, particularly if we have an older sibling affected. This paper clearly underlines how the developmental delay precedes the motor regression. And in fact, this delay can be detected between 9 and 12 months, I would say, so that the milestone that should be reached at that age starts to be delayed or never achieved, such as pulling to stand, standing alone, or walking alone. If a child is seen by a neurologist at that time, you can already see some clear neurological signs, very subtle signs of hypotonia, signs of ataxia, or mild muscle weakness, particularly at the lower limb.
[00:07:20] Dr Francesca Fumagalli: And if the patient is seen later, signs become more evident, more clear. And I'll show you some videos to explain to you better what I'm saying. You see this child that has been seen around 12 months because of a familial history. He's not yet able to walk independently, and the neurologist noticed some signs of hypotonia, axial hypotonia, and limb hypotonia. You can also appreciate, for example, faint reflexes at that time. Again, another child not yet able to walk at 15 months old. The majority of neurologists would say that it is normal at that age, still normal. But if you visit him, you can notice something additional, so some higher degree of imbalance with respect to peers, and hypotonia again. In the next months, so between 18 and 24 months, children are sometimes still able to walk independently, what we call GMFC level 1. But the majority of them are not yet able, or no more able to walk independently, so what we call GMFC level 2.
[00:08:55] Dr Francesca Fumagalli: So we are still in a time window that neurology would wait to see what happens if the child improves, but we cannot lose time. And visiting the child, we can notice that the reflexes start to become brisk. There are some mild signs of spasticity in the lower limb. You can experience clonus for example. So same signs of central nervous system involvement and abnormal feet posture. Abnormal feet are also reported by parents in many, many cases, the parents report abnormal posture of fee, the intra- rotation of feet, foot drop, and so on. Here you see a patient at this age. This is a child nine months old. He can stand, but lower limbs are weak. The knees are hyperextended. There are also some signs of spasticity. The standing and walking gets broad- based. The second child, 20 months, 22 months old, already started to walk independently, but now, 22 months, he's still unsteady. He searched for support, external support, and there is a high risk of falling down. And parents reported my child falls down more frequently than other kids. The third one is similar. I hope you can see it. Retro curved, what we call retro curved knees, broad base, unbalance, and hypotonia. And we are 25 months old, so a time when children should walk properly. Trying to go to the next slide. I want to underline another signs of the disease that sometimes occur even earlier respect to neurological regression or neurological symptoms. It is involvement of high cranial nerves. So there is an onset of sudden strabismus. And if you perform a brain MRI at that point, you can notice enhancements of cranial nerve. You have to perform the brain MR with gadolinium. And it is a very, very pathognomonic sign. And it occurs very early in the disease progression. Moving to the early juvenile forms, the onset occurs a little bit later. And the first phase is a little bit slower. again very rapid. So we should detect patients before the phase of rapid progression. This slide summarizes symptoms occurring first in the early juvenile forms is a mixture of gross motor symptoms, fine motor impairment, cognitive and behavioral abnormalities. And some times behavioral abnormalities occur earlier compaired to motor symptoms. Parents report fatigability, abnormal feet posture, stiffness of leg, but also tremors. So patients are children that are going to kindergarten and their way of drawing or initial writing is worsening. The teachers report low attention and agressive behavior. For example, the child starts again to put objects in the mouth. Or a child that has reached toilet training comes back and start to have problems during school accidents. I'll try to show you some videos. This is a child that is 4 to 5 years old. You see on balance a child at this age should be able to climb stairs better than that. While this child needs to the support to help him climb stairs
[00:13:44] Dr Francesca Fumagalli: Or for example, impairment in fine motor skills can be noticed at that time. Don't forget that the child can even have seizures. Strabismus can be observed also in the early juvenile. And we can also say something about gallbladder abnormalities. There are other non-neurological signs I will speak later. It is important to remember that the peripheral nervous system involvement, central nervous system involvement and behavioral symptoms can be superimposed.
[00:14:19] Dr Francesca Fumagalli: If I notice peripheral nervous system symptoms and signs, I should search for central nervous system signs that can even be superimposed and mask each other. For example, reflexes can be both absent or brisk depending on the prevalence of peripheral central nervous system involvement. But we have also to ask ourselves and ask to parents if there are behavioral problems attention deficit, problem in fine motor skills and other cognitive symptoms. It is important to check all the three areas. This is the gallbladder involvement that can manifest even before neurological symptoms like a sludge, like wall thickening or polyposis. If as a pediatrician you see a child with gallbladder abnormalities, please check if there are neurological symptoms. Ask, collect clinical history regarding possible cognitive abnormalities and behavioral problems. I skipped some slides because you will see additional topics on that in the next webinar. I just want to say that sometimes brain MRIs are still normal up to 18- 24 months, so think to MLD even if MRI is still reported normal. Please consider MLD in case of only peripheral nervous system signs and in case of a decline occurring after infections that can be confused with Guillain- Barré syndrome because there are tests that can make you think into Guillain- Barré, so the clinical history with the post- infective decline, and the enhancement of the cranial nerve and the nerve roots of the cauda equina and also increase of protein level of the spinal fluid. Now I will present you a few cases that can help describing what I've shown you before. This is a case of two siblings. Paul was born in May 2014. The first milestones are ok. He had control, sitting ok on borderline around 8- 9 months. He can not crawling but shuffling on his bottom. He was able to pull to stand at 10- 11 months. It is normal and cruising. But parents start to be concerned about him at 18 months because he was not yet able to walk without support. Time passed because pediatrician was not worried about that, waiting to see if he will impove in the next months But at 27 months, the child is not yet able to walk independently and some exams are performed. As I showed you before, MRI was reported normal, while electromyography showed clear signs of demyelinating peripheral neuropathy. Again, no other tests are conducted up to when, a few months later, the child starts to decline very fast, losing speech and having a clear motor decline. And even swallowing difficulties usually occur later in the disease course. So we are entering the phase of rapid progression. It is December 2016 when a brain MRI is repeated, showing signs of leukodystrophy. And the diagnosis of MLD occurs very late, 32 months old. But what happens in the meantime? The mother is pregnant and gives birth to another child, John, in March 2016, when the diagnosis is not yet available for Paul. And when the diagnosis of Paul is done, John is 10 months old. John is referred to a treatment center to evaluate him for gene therapy. At the time of first evaluation at our center, he is 12 months old. The first milestones were okay. He was able to pull to stand, in the WHO range of normal values, some signs of hypotonia, very mild have been seen. And occasionally he walks on his tiptoes. Patellar reflexes are braced, while ankle reflexes faint. The brain MRI is still normal. As this is the video I showed you before, you can still say that it is in range for the milestones on development. There are many children not yet walking at that time. We probably could detect very minor signs of neurological examination, because we know the familiar history. We decided to treat this patient because we feel we are still before the phase of rapid decline, even if probably we were very close to disease onset. I'm not showing the outcome of gene therapy of this patient, but I can say that the outcomes were very good. This child is now going to primary school, still walking independently with good cognitive function. This is a second case of a child with a very long delay in diagnosis. Again the motor milestones are reached accordingly to their age. This child was even able to reach independent walking around 11 months. And also, the cognitive development was OK. Even early, the child was able to speak in sentences at 18 months. But the parents report the child was a really weak child going through multiple infections between the first and the second year. When going through infection, the child needs to be hospitalized and was described as very weak with some step down in her motor capabilities. And then after infection, the child seems to recover. performed around 20 months.
[00:21:58] Dr Francesca Fumagalli: And the child was described as hypotonic. But no additional exams were performed. Up to 22 months, during another hospitalization for infection, the child started to complain for leg pain and suddenly stopped walking around 24 months. Really, suddenly, really acute symptoms. So the patient was seen by an orthopedic, the wrong specialist, that said that his evaluation was normal. And finally, a pediatric neurologist recorded his general muscle weakness. The child was no more able to sit unassisted, complain muscle pain, and deep tendon reflexes were absent. So this neurologist thought to perform a nerve conduction velocity study detecting peripheral demyelinating process. The cerebrospinal fluid was analyzed. So a lumbar puncture was done with an increased level of protein. Glucosal cells were normal. And this neurologist concluded for a Guillain-Barré syndrome, as I described above, and treated the child with a high dose of intravenous immunoglobulin. Because at the beginning, the child seems to recover, some cycles of immunoglobulin were repeated for six months. But after the first transient improvement, no more improvement was seen. And the neurologist decided to perform also a spine MRI, noticing enhancement of nerve root at the lumbar level.
[00:23:59] Dr Francesca Fumagalli: So again, a wrong diagnosis of chronic inflammatory disease. In the meantime, however, some additional metabolic tests were performed, noticing a low level of enzyme activity. The tests were completed with a brain MRI showing widespread white matter abnormalities compatible with a leukodystrophy, and leading to the diagnosis of MLD. So this is a case to remember, to think to metachromatic leukodystrophy in case of a sudden decline after infection, signs of peripheral neuropathy, and conduction velocity studies and enhancement of cranial nerve and cranial root in an MRI with gadolinium. Please complete with a brain MR in this case to check if central nervous system signs are present. The last case I want to present is a case of an older child. Then the parents noticed some strange gait pattern at two years and 10 months or later. They asked the opinion of an orthopedic that described femoral antiversion. Then the child was conducted to the emergency room to an acute diplopia. But this happened during COVID pandemic. No exams were performed. And she was come back home. The family pediatrician tried to use steroids to cure strabismus . With the recovery of symptoms, another episode of strabismus occur, the ophthalmologist only prescribed glasses, and again, the pediatrician used steroids with good recovery. But later on, the parents noticed that the gait pattern was worsening. There was still clumsiness, and tender to fall down. Again, they bring the child to an orthopedic, confirming femoral antiversion. Only six months later, due to a worsening, a father, a different orthopedic noticed neurological signs and suggested neurological consultation. At that time, the neurologist seems to propose to the family physical therapy. This is the child between 5 and five and a half years old with this intrarotation, particularly of the right feet, and a little bit clumsy in respect to peers.
[00:27:13] Dr Francesca Fumagalli: The physiotherapy was not convinced, so a push to the family and the neurologist to do some additional tests. And finally a brain MR was performed six years of age. So at least three years, if no more, after onset. And finally, the diagnosis of MLD was done. At that time, the GMFC level was defined as one, and the IQ was 83. But the neurologist waited the genetic confirmation before referring the child to San Raffaelle hospital so the treating center and the genetic test, they took four months, and when the child arrived to San Raffaelle Hospital, also cognitive function were declining, and the IQ was 68.
[00:28:16] Dr Francesca Fumagalli: At that time, the child was no more eligible to gene therapy because the threshold for treating this patient is an IQ of 85. A so low IQ means that the child was entered in the rapid phase of disease progression. yes, now I stop here and let Alejandra can hear you.
[00:28:52] Dr Alejandra Darling: You were frozen, sorry. Hello, thank you, Francesca, for this very nice, wonderful presentation. I think we all have learned a lot. Something to stress, I think I will stress this with my presentation, is this clumsy child in the early development, it's very important to, from the pediatric point of view, or the pediatric neurology, take care and give a follow- up to this clumsy child is very, very important. I have some questions, if it's okay for you. One is, regarding the proportion of patients with confirmed diagnosis with infections that was a trigger for the demyelinating peripheral or central nervous system. What is, you have a wide and deep experience, what is the proportion of patients with infection as a trigger?
[00:30:02] Dr Francesca Fumagalli: This parameter has not been studied. Particularly, there is no reason or no data to say that these children are more prone to infection. There is no immunodeficiency in these children. However, probably very subtle, very mild infection can be harder on these children. I think the infections are triggered particularly in the late infantile variant, respect to the early juvenile variant. In many cases, the infection trigger evaluations. Probably some symptoms, very subtle, were already there, but unrecognized. So when the infections come, the patient is evaluated by pediatrician, by doctors. Maybe the symptoms progress faster, become more evident, and is the time when the child starts being tested and being evaluated by specialists. But probably something could be even detected before infections.
[00:31:21] Dr Alejandra Darling: Okay, and do you have, maybe it's a weird question, but you know some leucodystrophies are also had as a trigger of head trauma. I don't know if you have experiences with MLD and head trauma as a probable trigger of the disease?
[00:31:40] Dr Francesca Fumagalli: I have no specific case on that. It can be particular white matter disease is related to head trauma. In my experience never happened. It cannot exclude it, probably. Yeah, yeah, yeah, probably head trauma can occur particularly later on maybe when a child still stand or walk a little bit, not sure, but could be studied.
[00:32:15] Dr Alejandra Darling: Okay, thank you. And I know you have a lot of experience in this and I will stress this in my cases, but I want you to develop this, the gall bladder problems, that it's so important. You have your cohorts of patients in follow- up and to share what is the proportion of patients with gall bladder abnormalities in your cohort, in your experience?
[00:32:44] Dr Francesca Fumagalli: The majority, I would say the majority, not all the patients show at a certain point gall bladder abnormalities. The majority of patients show at least wall thickening of the gall bladder. I think that in particular, the juvenile form should be studied really carefully because they can develop very early polyps and malignant degeneration. So they should be studied carefully and many times, if you see a child with motor symptoms, you can find in the clinical history for example gall bladder removal or gall bladder symptoms, is frequent, even to meet a child, for example, the child on the stairs with unbalanced climbing stairs was five years old, but he had removed gallbladder at three years old. So without any differential diagnosis, no one thinking to other disorders, metabolic disorders.
[00:34:03] Dr Alejandra Darling: Thank you. Thank you. Very, very interesting. I don't know if there are some questions in the public, in the people present here.
[00:34:17] Dr Francesca Fumagalli: We can have a session of question and answer at the end. So maybe Alejandra, you can go ahead with your presentation and your cases. So we highlight the opportunity, the possibility you have to upload the question on the question panel so that at the end of the meeting, we can answer you.
[00:34:48] Dr Alejandra Darling: Perfect. Thank you. Thank you. Thank you very much, Francesca. I will continue. Maybe some information is overlap, but I think it's good to stress some of the symptoms and concepts in MLD. So as Francesca comment, metachromatic leukodystrophy is a rare metabolic condition. This is also important, is genetically determined, caused by pathogenic variants in a gene called ARSA, that codify by an enzyme called aryl sulfatase A. And this is important, and to give some context to this area of the metabolic disorders, you have this graph. You can find all the metabolic disorders that were classified recently in 2021. And we are settled in among the complex molecule disorders. And among the complex molecule disorders, we are in the group of complex molecule disorders, degradation. And this is a group that gather lysosomal storage disorder, but other group of disorders that could also have similarities to MLD. And just some basic concepts about lysosomal storage disorders, this is a simple complex part, but to remember. You know that, you all know, must know that the normal function of the cell is, is, need a healthy lysosome to go on, to degrade macromolecules because if there is a dysfunction in the lysosome, in the lysosome, we can build up different proteins, macromolecules that could, that could lead to a dysfunction in the cell and then lead to the death cell and neurodegeneration. Here at the, my right side, maybe at your left is a very nice figure from an article, but there you can find the alteration in the lysosome led to different processes in the cell that led to neurodegeneration and cell death. One of them is demyelination because it's not only neurons because other cells in the nervous systems, but also there are different mechanisms that generate this cell damage. I will go to the next one. If we go to the clinics, as Francesca told us, in MLD, we found a progressive demyelination in the central nervous system and in the peripheral nervous system. And the manifestation, the clinical manifestations is in the motor areas with regression, stagnation, and motor deterioration, but also in cognitive areas where we find language deficit, disconnection. We will see some of the symptoms later. And coming back to the cell here, we can, well, here I mentioned different processes, but we think that the main processes in MLD are demyelination, also related to neuroinflammation. And this is very nice to relate with the cases of Francesca that were differential diagnosis with other neuroinflammatory diseases. I will go to the next one. Sorry, can you go to the previous one? I don't know why. Thank you. This is just to remember why we are here, because there are many advances in research that have enabled the development of different therapeutic approaches. Hematopoietic stem cells, it's all known, but the gene therapy is rather new. And both treatments we know are most effective when given before disease onset or very early in the disease course. So, to identify pre-symptomatic patients, the newborn screening, this is very important for MLD, is becoming available in different countries and zones. But meanwhile, because this is not developing in every country, the recognition of early onset patients is vital for the treatment eligibility for these patients. And I will continue with the next one. This is what Francesca told us. Traditionally, MLD has been classified according to the age at onset with earlier forms undergoing more rapid neurological decline that later falls. But there are many variability in the progress of the disease in each of the forms of the disease. Here we can see how in this graph that I think was on the presentation of Francesca, but the early onset forms of the disease are related to a very low activity in the activity in the enzyme activity and with high accumulation of sulfatides in the different tissues. The other way around, later onset forms, we have more activity. This is very logic in biology, more activity with less sulfatides that were accumulated in the different tissues. This is a figure that Francesca had also shared. This is very nice and very graphic. And we can see in the earlier forms with delayed milestones, gait abnormalities with different variants, ataxia, lower limb abnormal position, and also ophthalmological almost motor abnormalities are at the beginning of the onset of the early forms of the disease. But the cognitive and neuropsychiatric forms of this disease are the predominant symptoms in the later forms. I will go to the next one. This is just to remember, we as a neurologist, we have different professionals that could refer these patients. Pediatricians, when we are aware of the symptoms, but also psychologists that are with toddlers of patients that have some, need some early intervention because of a delayed development. Also physiotherapists or medical rehabilitators because they could have patients with gait abnormalities. Neurologists, neuropsychiatrists, also gastroenterologists are, could be involved in the follow- up of these patients and maybe they already don't know that. And also the ophthalmologists, as we said, because strabismus and other oculomotor disorders could be a symptom. I will share two cases. Maybe this could be some typical cases. One of them maybe with some delay in the diagnosis and we have learned a lot about these two cases. One of the cases is already known by my colleague, by Francesca, we have shared this case. But I will start with the other one. So this is a girl that we have met by 12 months with motor delay and very interesting, as Francesca told us, the parents referred, because we have not seen that in the visit, some abnormal lower limb postures. So they refer some intra-rotation in both in the feet and when we ask for the history, they present a normal perinatal period, a normal development up to 12 months. So if we continue with the history, we can show that by age two, she developed more hypotonia. The hypotonia was mainly axial, but also in lower limbs. Also we can assess by age two weakness and slight spasticity that was distal in lower limbs. Also brisk osteotendon reflexes and a babiski sign. So as a syndrome, clinical syndrome, this is also important to keep this in mind. Maybe we can assume these patients from one point of view is a complex spastic paraparesis and we have performed different studies for this different study to look for the ideology. So the first MRI that was performed by age two was informed as normal. I think is the next one. We can see the first MRI by age two. Always when we have a diagnosis, we can take a look and maybe we can see some slight alterations. We have different sequences at T1, at T2, and a flare. Maybe in T2, there's some slight hyperintensinal periventricular and posterior, but this could be assumed also by terminal areas of malignation. So was considered as normal by that time. I will continue with the other slide. Okay, so this, as I mentioned here, was a progressive motor disorder. We have performed the workup and besides the MRI, we have performed nerve conduction studies and we have found demyelinating neuropathy. So here the suspicion of an MLD was installed. Also, we have found in the study of the CSF hyperproteinorrhagia. So these all are different signs that reassure the diagnosis. So there was a high level of suspicion and I will continue. And also as a finding, we have found in plasma, some slight increase in transaminases. I will show you this then in the presentation. By age 3 and 4, hypertonia increased, spasticity in lower limbs also increased. She presented a seizure. It was an isolated seizure, an episode of disconnection, and followed with hypertonia. It was brief. We have performed an EEG. They present a mild, a very slight alteration, but we decided to treat it with levetiracetam. And by that time, age 3 and 4, it started with dysphagia, and nasogastric tube was indicated. So by that time, we have repeated, by 3 years old, sorry, we have repeated the MRI. Maybe we come back to the next one, because we can see it, but here the MRI was different. Here in the T2 imaging also in FLAIR we can see there this hyperintense signal periventricular in both sections. So this led to ask directly to the enzyme study, the ARSA activity, that was low as aspirated. But in parallel, the family had difficulties to have the genetic test. By that time, we have performed NGS and exome sequencing, including the ARSA gene and the ARSA, the genetic study was negative. And the ARSA gene was also included in this gene panel. This is also important to, because we can have cases similar to this situation. So the year, the time passed, and by age 5, now, she is present at gross motor function classification scale 5. She is wheelchair- bound. She has no language. But before that, the genetic test performed was repeated, and we have to see with, not myself, but the genetic department have to assess several times to find the mutations that one of them was a intronic mutation and difficult to find in the first exam. And then, with this reanalysis, we can confirm, we have the genetic confirmation of the MLD. This is to reinforce the biochemical diagnosis besides the genetic diagnosis because it is not the first time that we can't find the gene but we have all the biochemical data that could reassure the diagnosis. So the genetic test was performed. This was a compound heterozygous pathogenic variants in the ARSA gene. Also, the sibling, she present an older children, older sibling that was tested and was, fortunately, it was not a carrier of the two variants. This is one case. And to stress the aspect of the gall bladder, if we go back to the history of these patients, we found that in the early years of life, she presents some elevated transaminases that require a follow- up by a hepatologist. These transaminases go down for some years between age two and three.
[00:50:16] Dr Alejandra Darling: But then, I'm sorry, and also the gamma glutamyl transaminases, this is also important, in parallel, they were high, then they get low by between two and three years old, and then go up because a complication by that time and ultrasound, abdominal ultrasound was performed and we could found some, an echogenic content in the gall bladder and increased thickness of the mucosa of the wall of the gall bladder of three millimeters. And, coinciding with this high the elevation of these proteins, she has some- we will say some- complications with hematemesis and the surgeons found a perforation of the gall bladder. So by age four, a cholecystectomy was performed and, very interesting- in the pathology of the gall bladder it was found an intracholecystic papillary neoplasm. Fortunately, all the resection margins were free of lesions and in the follow- up there were no complications after the cholecystectomy. So this is one case very interesting because if we come back to the history we can see that the elevated- in this case it was the alanine transaminase and the gamma glutamyl transaminase- were elevated in early years of life. Okay, I will continue with the other one. I think I can see the arrows here now. Yes, okay, okay, this is the second case. The second case is a girl- could be the next one, I don't know why. Okay, in relation to the family history of this girl, she- the parents- were healthy, non- consanguineous family. She presents a 10-year-old healthy sister. Her grandmother presents an essential tremor- a symptom, but with no other complication, and there was no other history of neurological disease. The normal perinatal and development and early development was normal in this girl and by 6-year-old- this is very recently, in September 2023, it started with some episodes of disconnections. It was mentioned in the school, but all the her capacities of learning capacities were normal. And some months later, three months later, in December 23,, Christmas, the family, the parents, observed some clumsiness with occasional falls and by that time the parents told that we have seen those occasional falls, but they seemed that there was like something emotional or something voluntary, so they didn't pay attention at that time. Six, some months later, she started with this worsening of motor performance, with frequent falls. Upper limb tremor was all at the same time. In relation to the cognitive areas, she presents some latencies in the response, but she maintained the level to participate in class and interaction with classmates were acceptable. But at that time they went to the hospital in its own. They had performed an MRI and the diagnosis for them was a leucodystrophy and that's why it was referred to our hospital. We can see the MRI of this six- year- old girl. We can see this T1 weighted image in a coronal section and this T2 weighted image in this coronal and in also axial sections and we can see this hyper intense signal that was confluent and generalised. So continue with this, with this clinical pattern and with this MRI. Sorry, okay, I will start. Thank you. The video- okay, the video is a little bit slow. This video is before our colleagues from Milan that planned to perform the gene therapy. We have sent this video. She can run, she can walk by herself by her own- maybe the tandem walk was difficult for her. And we can see also this abnormal position, some intra-rotation of one of the legs in the gait. She presents some gait ataxia or we will say instability, with some action tremor in upper limbs. We have found also some lower limb weakness, brisk osteotendon reflexes and also a Babinski sign. We continue with the other one. So, this is the extensive workup we have performed. Just to mention, in this case, the transaminases were normal by that time. Neurographic study informed a demyelinating neuropathy also, as the previous cases. I will stress some of the tests also. The abdominal ultrasound also showed solid and vascularized content in the fundus of the body of the gallbladder. So the differential diagnosis here could be a gallbladder adenoma or a polyploid lesion. So, we continue, I press here, okay, so here the ARSA activity was performed, it was also low. A cognitive study was performed because of the clinics we have mentioned, and the total intellectual coefficient was normal, the value was 90 for a WISC- WPPSI. And I will continue here, and the genetic study confirmed the diagnosis of this MLD. And we have asked, as in Spain, the gene therapy is not yet developed, or not started yet. It's in plan to do it. We have asked to the colleagues from Milan to assess this girl, to see if she was eligible for the gene therapy, because the criteria was not so clear, because she presents a neurological deterioration. Meanwhile, in the study, we have assessed this gallbladder abnormalities, so we have decided that laparoscopic cholecystectomy before any procedure. And also, we have found a high- grade biliary intraepithelial neoplasia, it's like a carcinoma in situ, and the anatomopathology was very similar to the previous girl that was in late infantile form of the disease. So this, I will finish here with this case, then we can discuss the outcome of this girl. It's a girl that is under follow- up, but just some messages to comment, MLD is a rare metabolic disorder, but with new treatment strategies, it could change the outcome of this disease. These therapies could be effective in selected early- onset patients, neurological, and we want to stress extra- neurological symptoms must be considered, and extensive studies must be performed in this patient with some unspecific early developmental issues. And finally, clinical research is essential to address the heterogeneity of the symptoms in order to improve care and outcomes of MLD patients. As you see with the cases I have present and the cases Francesca present, the patients are highly heterogeneous in the study, in the follow-up, and ensuring the outcome. So thank you very much. I'll finish with this one.
[01:00:24] Dr Francesca Fumagalli: Thank you. Thank you, Alejandra, for presenting these very pathognomonic cases that can recall us the first symptoms and signs we can appreciate in an MLD child. I was interested to hear your point regarding the diagnosis of the first child where the NGS resulted normal. We have two questions. Do you think the NGS should be the first test to be done in these aspects of MLD? And the second one is if, on the other hand, you suggest in suspected cases to perform sulfatides, urinary sulfatides?
[01:01:23] Dr Alejandra Darling: Yes, okay, okay. So we have considered the first child as a complex paraparesis and we are used to ask for NGSs study to capture the different genes. In previous experiences we have succeeded in the diagnosis, but this intronic more difficult variants. This case I have shared, with these difficulties, is also to stress this. I think maybe if we have biochemical tools we have to use it and maybe in this case- now I have learned about this case- the first study would be the enzyme activity. But maybe by that time we don't have the nerve conduction study, maybe it was not performed yet and we started with that study. But I agree, biochemical studies are very important for these cases, metabolic cases in general and in relation to the sulfatides, they are not so easily available here. Now we can do it, but it was not so easy before. I don't know if all the centers are, if this technique is available for all the centers, I don't know.
[01:03:03] Dr Francesca Fumagalli: I want to stress the point of sulfatides because now that a method for newborn screening has been developed to test sulfatides on DBS- dry blood spot- probably in future sulfatides on DBS could be used as a method, a rapid and easy method for screening population at risk, because it's very easy. It can be sent by mail to another center and it should be even very quick. But in the future, in the next future, it could be a good method, particularly because you know for genetic testing you need weeks, while DBS or enzyme activity can take a few hours or a few days. So please remember biochemical tests. I have a comment on the second case, because in the evaluation of a early juvenile eligibility for treatment, it is very important- and Alejandra did a very good work- to to understand how rapidly is progressing the disease maybe the onset is very recent but we have to understant how fast the disease is progressing. So checking the child multiple times, looking if the child is worsening between one visit and the other, and particularly testing cognitive functions is fundamental to confirm eligibility. So, Alejandra, I cannot remember if you have stressed how well cognitive function of this child at your first evaluation. She was doing quite well, right,
[01:05:19] Dr Alejandra Darling: totally yes, it's very important for this. I learned it from you, Francesca. This case surprised us for the rapid progression. It was an early juvenile form of the disease with very rapid progressions and I think week by week was worsening. Even something to comment here: some procedures like anesthesia or some different issues led to a regression of the motor symptom of this child. So, yes, by now, for example, this is from the onset. It will be approximately one year, one year and some months, and now she is unable to work, to walk alone. She needs a very severe dysphagia. It was something we are handling with the palliative care unit. Yes,
[01:06:21] Dr Francesca Fumagalli: So, even if juvenile, the progression could be very fast in some cases. There are maybe questions from the audience. Someone want to ask question? There is a question, probably. We have already commented regarding frequencies of gallbladder findings. I would say that even when presenting around 2- 3 years of age there could be already gallbladder wall thickening, even in the early onset forms, and can help to lead to guide the diagnosis of MLD. Alejandra, there is a question. Maybe you would know. From your experience, how common are seizure in early juvenile? Do you have any experience?
[01:07:39] Dr Alejandra Darling: My only experience was with this girl that I know. Seizures are reported in the different cases in literature. I don't know the the frequency by heart. In some revisions in our experience only one patients present seizures that were documented.
[01:07:58] Dr Francesca Fumagalli: Yeah, in general in my experience seizures are not presenting symptoms that It is difficult to make the diagnosis on first. Seizure is not all is not common as presenting symptom.
[01:08:20] Dr Alejandra Darling: There is another one, Francesca, do you want to read it? The third one:
[01:08:32] Dr Francesca Fumagalli: if I look for just one red flag for MLD, before referring what should it be? Clumsy child? I think we should at least mention two red flags, one for late infantile and one for juvenile, but for late infantile I would say developmental delay, but not developmental delay since birth. I would say a child with a normal development up to six, nine months. Nine months, normal achievement of first motor milestone followed by a stagnation, so not reaching independent walking and not reaching independent standing after a first phase normal. This is a red flag, early red flag for late infantile. Regarding juvenile form i agreed with Alejandra about clumpsy child. Please refer also patient with behavioral changes.Think to MLD also for a child that has been always good child in term of behavior, that a certain point suddenly modifies behavior. Don't think only to psychological and environmental problems.
[01:10:10] Dr Alejandra Darling: Can I take the advantage you're here, Francesca- your experience in relation to the psychiatric symptoms in adult patients, adolescent adult patients, can you share something?
[01:10:23] Dr Francesca Fumagalli: I just want to underline that usually the presentation in adult and late onset is psychiatric symptoms, psychiatric symptoms and cognitive deterioration in younger adulthood. This is the last remark regarding the late onset form. We have not to describe so much in this meeting. I think we have exceeded time. So we thank you, the audience, for attending the meeting, for joining us and participating to this first webinar on early signs of MLD, and we invite you to follow the following webinar to see other aspects: diagnostic and treatment aspects for patient with MLD. Thank you, and thank you, Alejandra, for your expertise.
[01:11:22] Dr Alejandra Darling: No, thank you, Francesca, a lot, thank you. Thank you all, bye, bye.