Huntington Disease Clinical Presentation

Huntington disease mutation carriers who have yet to develop clinical symptoms are most concerned with internal and relational issues (social, emotional, and self concerns) that are associated with the disease. These concerns remain throughout and do not increase in the subsequent stages of HD. Patients with HD stages 1-5 are most concerned with physical and functional issues caused by HD, with these concerns increasing as the disease progresses. Patients with early HD (stages 1 and 2) have increasing concerns about cognitive issues, and these concerns remain constant during moderate HD (stages 3 and 4). Patients with late-stage HD (stage 5) have a lack of cognitive concerns, presumably due to impaired insight.^[13]

The clinical features of Huntington disease (HD) include a movement disorder, a cognitive disorder, and a behavioral disorder. Patients may present with one or all disorders in varying degrees.

• Chorea (derived from the Greek word meaning to dance) is the most common movement disorder seen in HD.

  • Initially, mild chorea may pass for fidgetiness. Severe chorea may appear as uncontrollable flailing of the extremities (ie, ballism), which interferes with function.
  • As the disease progresses, chorea coexists with and gradually is replaced by dystonia and parkinsonian features, such as bradykinesia, rigidity, and postural instability, which are usually more disabling than the choreic syndrome per se.
  • In advanced disease, patients develop an akinetic-rigid syndrome, with minimal or no chorea. Other late features are spasticity, clonus, and extensor plantar responses.
  • Dysarthria and dysphagia are common. Abnormal eye movements may be seen early in the disease. Other movement disorders, such as tics and myoclonus, may be seen in patients with HD.
  • Juvenile HD (Westphal variant), defined as having an age of onset of younger than 20 years, is characterized by parkinsonian features, dystonia, long-tract signs, dementia, epilepsy, and mild or even absent chorea.
• Cognitive decline is characteristic of HD, but the rate of progression among individual patients can vary considerably. Dementia and the psychiatric features of HD are perhaps the earliest and most important indicators of functional impairment.

  • The dementia syndrome associated with HD includes early onset behavioral changes, such as irritability, untidiness, and loss of interest. Slowing of cognition, impairment of intellectual function, and memory disturbances are seen later. This pattern corresponds well to the syndrome of subcortical dementia, and it has been suggested to reflect dysfunction of frontal-subcortical neuronal circuitry. (The so-called cortical dementias primarily involve the cerebral cortex and are associated with aphasia, agnosia, apraxia, and severe amnesia.)
  • Early stages of HD are characterized by deficits in short-term memory, followed by motor dysfunction and a variety of cognitive changes in the intermediate stages of dementia. These deficits include diminished verbal fluency, problems with attention, executive function, visuospatial processing, and abstract reasoning. Language skills become affected in the final stages of the illness, resulting in a marked word-retrieval deficit.
• The behavioral disorder of HD is represented most commonly by affective illness.

  • Depression is more prevalent, with a small percentage of patients experiencing episodic bouts of mania characteristic of bipolar disorder.
  • Patients with HD and persons at risk for HD may have an increased rate of suicide.
  • Patients with HD also can develop psychosis, obsessive-compulsive symptoms, sexual and sleep disorders, and changes in personality.

Most patients with HD have a mixed pattern of neurological and psychiatric abnormalities. Understanding of the clinical signs must take into account the fact that signs change during the course of the illness and that different patterns may be observed, depending on the age of onset.

• Chorea is a characteristic feature of HD and, until recently, the disorder commonly was called Huntington chorea. Chorea, as defined by the World Federation of Neurology, is a state of excessive, spontaneous movements, irregularly timed, randomly distributed, and abrupt. Severity of chorea may vary from restlessness with mild intermittent exaggeration of gesture and expression, fidgeting movements of the hands, and unstable dancelike gait to a continuous flow of disabling violent movements. Chorea in cases of HD usually is generalized.

  • Patients may incorporate involuntary choreiform movements into apparently purposeful gestures, a phenomenon referred to as parakinesia.
  • Ballism is characterized by large amplitude, usually proximal, flinging movements of a limb or body part. Ballism is considered to be a severe form of chorea by most authors.
  • Chorea may coexist with slower, distal, writhing, sinuous movements called athetosis; it then is described as choreoathetosis.
  • Chorea is less prominent in juvenile HD and in advanced stages of the illness.
• Bradykinesia and akinesia are frequent features of HD and may explain some of the abnormalities of voluntary movement observed clinically.

  • Bradykinesia may be a major source of disability of voluntary movement, though it commonly is overshadowed by the hyperkinetic movement disorder.
  • Other parkinsonian signs, such as rigidity and postural instability, may be seen. Patients may become akinetic and rigid in the terminal stages of the illness.
• Dystonia is defined as a syndrome of sustained muscle contractions, frequently causing twisting and repetitive movements or abnormal postures.

  • Mild dystonia, in combination with chorea, may give the writhing appearance of choreoathetosis.
  • Sustained dystonic posturing may result in contractures, immobility, and breakdown of skin.
  • Dystonia may be prominent in juvenile HD.
• Eye movement abnormalities can be seen early in the disease.

  • Initiation of saccadic movements is slow and uncoordinated. Patients have difficulty suppressing head movements or blinking in order to break fixation and generate saccadic movements.
  • Smooth pursuit is interrupted by saccadic intrusions.
  • Patients are unable to inhibit saccades toward a peripheral stimulus when instructed to look in the opposite direction.
• Tendon reflexes are variable in HD, ranging from reduced in some patients to pathologically brisk with clonus in other patients. The plantar response usually is flexor, but it may be extensor in advanced stages of the illness.
• Other hyperkinesias, such as tics and myoclonus, may be seen in HD.
• Dementia, depression, and other psychiatric manifestations may be seen at the time of examination as well.

The selective neuronal dysfunction and subsequent loss of neurons in the striatum, cerebral cortex, and other parts of the brain can explain the clinical picture seen in cases of HD. Several mechanisms of neuronal cell death have been proposed for HD, including excitotoxicity, oxidative stress, impaired energy metabolism, and apoptosis.

• Excitotoxicity

  • Excitotoxicity refers to the neurotoxic effect of excitatory amino acids in the presence of excessive activation of postsynaptic receptors.
  • Intrastriatal injections of kainic acid, an agonist of a subtype of glutamate receptor, produce lesions similar to those seen in HD.
  • Intrastriatal injections of quinolinic acid, an N -methyl-D-aspartate (NMDA) receptor agonist, selectively affect medium-sized GABA-ergic spiny projection neurons, sparing the striatal interneurons and closely mimicking the neuropathology seen in HD.
  • NMDA receptors are depleted in the striata of patients with HD, suggesting a role of NMDA receptor-mediated excitotoxicity, but no correlation exists between the distribution of neuronal loss and the density of such receptors.
  • The theory that reduced uptake of glutamate by glial cells may play a role in the pathogenesis of HD also has been proposed.
• Oxidative stress

  • Oxidative stress is caused by the presence of free radicals (ie, highly reactive oxygen derivatives) in large amounts. This may occur as a consequence of mitochondrial malfunction or excitotoxicity and can trigger apoptosis.
  • Striatal damage induced by quinolinic acid can be ameliorated by the administration of spin-trap agents, which reduce oxidative stress, providing indirect evidence for the involvement of free radicals in excitotoxic cell death.
• Impaired energy metabolism

  • Impaired energy metabolism reduces the threshold for glutamate toxicity and can lead to activation of excitotoxic mechanisms as well as increased production of reactive oxygen species.
  • Nuclear magnetic resonance spectroscopy studies have shown elevated lactate levels in the basal ganglia and occipital cortex of patients with HD.
  • Patients with HD have an elevated lactate-pyruvate ratio in the cerebrospinal fluid.
  • A reduction in the activity of the respiratory chain complex II and III (and less in complex IV) of mitochondria of caudate neurons in patients with HD has been reported.
  • In rats, intrastriatal injections of 3-nitroproprionic acid (3-NP), an inhibitor of succinate dehydrogenase or complex II of the respiratory chain, cause dose-dependent ATP depletion, increased lactate concentration, and neuronal loss in the striatum. Systemic injections of 3-NP into rats produce a selective loss of medium spiny neurons in the striatum.
• Apoptosis

  • Apoptosis is the programmed cell death that is activated normally in the nervous system during embryogenesis to remove supernumerary neurons as part of natural development.
  • Morphological features of apoptosis have been well characterized. Oxidative stress, excitotoxicity, and partial energy failure can lead to apoptosis.
  • A subset of neurons and glia in the neostriata of patients with HD appears to undergo apoptosis, as shown by in situ DNA nick end labeling (TUNEL) staining, but clear morphological evidence for an apoptotic process in HD is still missing.
• One theory is that expanded polyglutamine repeats cause neuronal degeneration through abnormal interactions with other proteins containing short polyglutamine tracts. Recent work suggests that polyglutamine interference with transcription of CREB binding protein (CBP), a major mediator of survival signals in mature neurons, may constitute a genetic gain of function underlying polyglutamine disorders including HD.^[14]
• The role of caspases (a class of highly specific proteases) in apoptosis involves cleavage of target proteins at different sites. In humans with HD and in animal models of HD, the intracellular accumulation of N-terminal huntingtin fragments is one of the neuropathological features. Caspases, among other proteins, cleave huntingtin within the N-terminal region. To address the question of a potential in vivo neuroprotective effect of inhibition of caspases, a YAC mouse model expressing mutant huntingtin, along with selective mutations of the caspase-3 and caspase-6 cleavage sites, was studied. Selective elimination of the caspase-6, but not caspase-3, cleavage site in mutant huntingtin resulted in protection from neuronal dysfunction and neurodegeneration in vivo. These results suggest that preventing caspase-6 cleavage of huntingtin may be of therapeutic interest.^[15]