【作者】 朴钟源；

【导师】 江新梅；

【作者基本信息】 吉林大学 ， 神经病学， 2009， 博士

【摘要】 伴有耳聋的桥脑延髓麻痹,又称为Brown-Vialleto-Van Laere综合征(BVVL综合征)、延髓遗传性运动神经病Ⅰ型(Bulbar hereditary motor neuropathy typeⅠ),是一种非常罕见的运动神经元病的特殊类型。本文报告了BVVL的临床、组织病理(包括中枢神经系统、周围神经系统、肌肉及皮肤)、TDP-43等蛋白表达、与SCAs部分亚型及SBMA基因鉴别诊断的分子生物学研究。临床研究发现BVVL表现为耳聋起病、进行性面神经及第九至第十二对脑神经受累、上/下运动神经元受累为其临床三组征;中枢神经系统病理以蜗神经核为主的脑干神经核团、脊髓前角运动神经元丢失伴胶质增生及脊髓小脑束等传导束髓鞘丢失等为病理特征,周围神经改变较轻,全身骨骼肌呈神经源性肌萎缩的改变,皮肤神经纤维分布明显减少,免疫组化研究未见TDP-43、泛素、tau、α共核蛋白等核内及胞浆内阳性包涵体;基因检测未见SCAs及SBMA的异常条带的产生。伴有耳聋的桥脑延髓麻痹的研究填补了我国在这种罕见的特殊神经变性疾病在临床、病理和分子生物学等方面研究的空白,为进一步从临床、病理及分子生物学研究伴有耳聋的桥脑延髓麻痹提供了基础。更多还原

【Abstract】 Pontobulbar palsy with deafness (MIM 211530),also called bulbar hereditary neuropathy typed I ,is a rare neurodegeneration which was first described by Brown in 1894 and subsequently by Vialetto and Van Laere in 1936 and 1966 respectively , therefore, it is also named as Brown-Vialetto-Van Laere syndrome (BVVL). The etiopathogenesis is still unknown,and genetic transmission as well as autoimmune origin has been considered. Fifty-eight cases of BVVL have been reported in the world until 2008,and half of them are sporadic.BVVL is commonly considered as a special subtype of motor neuron disease, characterized by sensorineural deafness followed or accompanied by progressive pontobulbar palsy,usually involving the motor component of the seven and the ninth to the twelfth cranial nerves, besides upper and lower motor neuropathy .The age of onset of the first symptom varies ranging from infancy to the third decade, but usually from late childhood to early adulthood. Several neuropathological findings revealed mainly confined to the brainstem and spinal cord,especially in the cochlear nerve nuclei,in most lower cranial nerve nuclei and in the anterior horns of the spinal cord which marked neuronal atrophy and reduction in the number of nerve cells with gliosis. Until now, there is no report about the research of immunohistology on this scare neurodegenerative disease in the world. The diagnosis of BVVL is according to the clinical manifestations and neuropathological findings.This paper is mainly located autopsy of a male who developed progressive bilateral sensorineural deafness followed by unsteadiness of gait, muscle atrophy, bilateral facial nerve palsy, abnormality of horizontal eye movements, bulbar palsy and external ophthalmoplegia. The research is involved of the clinical study, neuropathology (including central nervous system, peripheral nervous system, muscles and skins) and molecular biology, and the method is including histopathology, immunohistochemistry and genetic tests for SCA1, SCA3/MJD, SCA6, SCA7, SCA12, SCA17, DRPLA and Kennedy disease.Materials and Methods:The persons in this study were divided into three groups: Experiment BVVL group (Pontobulbar palsy with deafness), control neuropathological group (the patient with no abnormality in nervous system) and control genetic test group (the patients with SCAs). The autopsy was performed after the BVVL patient died after 1 hour and the person of control neuropathological group died after 10 hours , we observed the tissues of cerebrum, cerebellum, brainstem, spinal cord, sural nerve, sciatic nerve, biceps brachii muscle, quadriceps femoris, gastrocnemius muscle,and tibialis anterior muscle , extraocular muscles and diaphragmatic muscle as well as skins of upper arm, elbow, wrist, upper leg and distal leg from BVVL and cerebrum, cerebellum, brainstem, spinal cord from control neuropathological group ,which were removed at necropsy by microscopy. Monoclonal antibody was used to check for TDP-43, UBQ、AT8、NACP、NeuN、MAP2、Calbindin-D-28K、NF、GFAP by immunohistochemistry of central nervous system samples from BVVL patient. At the same time, we observed the ultrastructure of sural nerve by electron microscopy. DNA was extracted from BVVL patient’s frozen brain and from control genetic test person’s venous blood , and the products amplified by polymerase chain reaction (PCR) method were purified to test whether there exist abnormality of bands.Results:Experimental group of patient developed progressive sensorineural deafness as the initial symptom, followed by unsteadiness of gait, muscle atrophy, bilateral facial nerve palsy, abnormality of horizontal eye movements, bulbar palsy and external ophthalmoplegia, and was diagnosed of pontobulbar palsy with deafness (BVVL) according to clinical manifestations.Light microscopic examination revealed that the main neuropathological changes in the central nervous system of BVVL were located in the spinal cord and brain stem. In the spinal cord, severely atrophic with obvious neuronal loss and heavy gliosis were shown in the anterior horns and myelin sheathes in the anterior column and lateral column showed severe loss, especially in the spinocerebellar tract while the posterior column was intact. Mild neuronal dropout was present in the Clarke columns. In the brain stem, there was severe neuronal loss with gliosis in the dorsal cochlear nucleus, mild to moderate neuronal loss in hypoglossal nucleus and moderate neuronal loss in locus ceruleus. There was slight neuronal loss with gliosis in infra and medial vestibular nuclei. Gliosis was present in the inferior colliculus, the medulla oblongata tegmentum, dorsal nucleus of vagus nerve, pontine tegmentum and periaqueduct gray matter. In the cerebellum, mild to moderate neuronal loss with Bergmann gliosis in Purkinje cell layer was revealed. Axonal torpedoes were present in the vermis. Grumose degeneration was recognized in dentate nucleus. Besides, massive corpora amylacea was deposited in the central nervous system.No TDP-43-positive, ubiquitin-positive, tau-positive orα-synucleinin-pos- itive tranueronal or intracytoplasmic inclusion nor senile plaques were seen in the immunohistochemistry within the central nervous system of BVVL. The large diameter myelinated fibers of the sural nerves were reduced and there were no corpora amylacea in the peripheral nervous system. Heavy amyotrophy was neurogenic mainly and widespread such as in the oculorotatory muscles, biceps brachii, anterior tibial muscle, gastrocnemius, quadriceps femoris, diaphragmatic muscle and so on. The pathological find reveals that there are few fibers remaining in the skins of BVVL.The PCR results indicated that no mutation of SCA1, SCA3/MJD, SCA6, SCA7, SCA12, SCA17,DRPLA and Kennedy disease has occurred in BVVL gene.Conclusion:Experimental group of pontobulbar palsy with deafness (BVVL) is a forty year old male with course of disease of 22 years, whose clinical features were characteristic: progressive sensorineural deafness as the initial symptom, followed by bilateral facial nerve palsy, bulbar palsy, upper and lower motor neuropathy as well as unsteadiness of gait and abnormality of horizontal eye movements.The neuropathological lesions are mainly located in auditory-vestibular path, brainstem and spinal cord, including the severe neuronal loss in cochlear nuclei, anterior horn of spinal cord as well as the degeneration of spinocerebellar tracts and the change in cerebellum is slight. The pathological characteristic of auditory- vestibular path is prominent in the dorsal cochlear nuclei with slight in inferior colliculus and normal in temporal lobe .The lesions of spinal cord is heavier in the upper segment than in the lower segment. Another feature in our study is that quite a lot of corpora amylacea deposits in the central nervous system. Immun- ohistochemical analysis indicated that there are no TDP-43-positive, ubiquitin- positive, tau-positive orα-synucleinin-positive tranueronal or intracytopl- asmic inclusion in the central nervous system of BVVL which suggests that BVVL is different from ALS in pathogenesis and neuropathology though both of them belong to the motor neuron disease. In addition, corpora amylacea is ubiquitin- positive, tau-positive andα-synucleinin-positive but TDP - 43 -negative.The lesions of peripheral nervous system is quite slight. And all the muscles including the limbs,trunk and face are severe neurogenic atrophy. The pathological study of skins reveals that BVVL induce the small fiber sensory neuropathy.Genetic tests show that BVVL is different from SCA1, SCA3/MJD, SCA6, SCA7, SCA12,SCA17,DRPLA and Kennedy disease though they are overlapped in clinical manifestations.Characteristic and innovation of this study:There are some studies about BVVL correlated neuropathology, but they are limited to the research of histology, whereas, this study is characterized by:(1)First reporting about BVVL patients on immunohistochemistry of TDP-43,UBQ,AT8,NACP,NeuN,MAP2,Calbindin-D-28K,NF and GFAP,and indicating that BVVL is different from the neurodegenerative diseases such as ALS,SBMA,α-synucleinopathy,tauopathy,MSA and so on .(2)First obtaining the data of BVVL patient’s skin from autopsy and proving that BVVL can induce Small-fiber neuropathy though the patient had no manifestation of sensory disturbance .(3)First finding BVVL patient with quite a lot of corpora amylacea depositing in the central nervous system .(4)First studying in Asia on clinical and neuropathological features of BVVL and indicating that the degeneration including cochlear nuclei, anterior horns and spinocerebellar tract of spinal cord results in the deafness, neurogenic amyotrophy and gait ataxia clinically.(5)First studying in Asia on gene tests of BVVL and indicating that there is no genetic mutation of SCA1、SCA2、SCA3/MJD、SCA6、SCA7、SCA12、SCA17、DRPLA and SBMA, which manifests that BVVL is the different molecular biological entity from the above diseases.更多还原