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Pelizaeus-Merzbacher Disease Differential Diagnoses

  • Author: Jasvinder Chawla, MD, MBA; Chief Editor: Selim R Benbadis, MD  more...
 
Updated: Jul 11, 2016
 
 

Diagnostic Considerations

Gene defects other than those found in Pelizaeus-Merzbacher disease can cause a Pelizaeus-Merzbacher disease–like syndrome. In particular, these include mutations that affect the GJA12 gene on chromosome 1.[11] SOX10 mutations cause severe peripheral and central dysmyelination and dysmorphic facial abnormalities.

Salla disease, caused by defects in a lysosomal transporter protein for sialic acid (N -acetyl neuraminic acid), may manifest with nystagmus in the first months of life, as well as hypotonia and cognitive impairment. Children with severe impairment do not ambulate or acquire language but do typically learn to walk and speak and can have a normal life expectancy. MRI reveals arrested or delayed myelination.

Lazzarini described a Pelizaeus-Merzbacher disease–like disorder, observed in a single family, in which the condition was linked to Xq28.[12] However, MRI data have not been obtained on members of this family.

Other leukodystrophies, such as metachromatic leukodystrophy, adrenoleukodystrophy, Krabbe disease, Cockayne disease, and Canavan disease, do not typically cause nystagmus. MRI scans in these diseases usually reveal a disease-based regional predilection for associated abnormalities (eg, occipital white matter in adrenoleukodystrophy, frontal white matter in metachromatic leukodystrophy). Peripheral nerve conduction and evoked potential test results are usually abnormal.

Infants with merosin deficiency have a dramatically increased T2 signal in the cerebral white matter, but the presence of severe weakness and hypotonia and the absence of nystagmus should direct the clinician toward consideration of myopathy. A fatal X-linked syndrome of ataxia, blindness, deafness, and mental retardation has been described and is linked to Xq21-24, but MRI does not reveal a pattern of leukodystrophy. Mutations in the PLP1 coding regions have been excluded in this disorder.

Mutations in the cell adhesion molecule gene L1CAM at Xq28 cause X-linked spastic paraplegia type 1 (SPG1). This disorder is associated with mental retardation and adducted thumbs and is allelic to mental retardation, aphasia, shuffling gait, and adducted thumbs (MASA) syndrome and X-linked hydrocephalus. MRI scans of these disorders may reveal enlarged ventricles or agenesis of the corpus callosum but do not reveal leukodystrophy.

Conditions to consider in the differential diagnosis of Pelizaeus-Merzbacher disease include the following:

  • Alexander disease – Reportedly caused by mutations in glial fibrillary acid protein
  • Adrenoleukodystrophy
  • Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)
  • Canavan disease
  • Cockayne disease
  • Congenital muscular dystrophy due to merosin deficiency
  • Congenital nystagmus
  • Familial spastic paraplegia
  • Krabbe disease (globoid cell leukodystrophy)
  • Metachromatic leukodystrophy
  • Pelizaeus-Merzbacher–like disease
  • Salla disease (sialic aciduria)
  • Sjögren-Larsson syndrome
  • SOX10 mutation syndrome
  • Spastic paraplegia type 1
  • X-linked ataxia, deafness, blindness, and mental retardation
  • Multiple sclerosis
  • Parkinson disease
  • Parkinson-plus syndromes
  • Peroxisomal disorders
  • Progressive supranuclear palsy
  • Striatonigral degeneration
  • Temporal lobe epilepsy
  • Tonic-clonic seizures
  • Wilson disease

Differential Diagnoses

 
 
Contributor Information and Disclosures
Author

Jasvinder Chawla, MD, MBA Chief of Neurology, Hines Veterans Affairs Hospital; Professor of Neurology, Loyola University Medical Center

Jasvinder Chawla, MD, MBA is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Clinical Neurophysiology Society, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cyberonics; Eisai; Lundbeck; Sunovion; UCB; Upsher-Smith<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cyberonics; Eisai; Glaxo Smith Kline; Lundbeck; Sunovion; UCB<br/>Received research grant from: Cyberonics; Lundbeck; Sepracor; Sunovion; UCB; Upsher-Smith.

Acknowledgements

Nestor Galvez-Jimenez, MD, MSc, MHA Chairman, Department of Neurology, Program Director, Movement Disorders, Department of Neurology, Division of Medicine, Cleveland Clinic Florida

Nestor Galvez-Jimenez, MD, MSc, MHA is a member of the following medical societies: American Academy of Neurology, American College of Physicians, and Movement Disorders Society

Disclosure: Nothing to disclose.

Stephen T Gancher, MD Adjunct Associate Professor, Department of Neurology, Oregon Health Sciences University

Stephen T Gancher, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, and Movement Disorders Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Acknowledgments

The author is extremely grateful to patients with Pelizaeus-Merzbacher disease and their families for their help and support of Pelizaeus-Merzbacher disease research and to the Pelizaeus-Merzbacher Disease Foundation, the National Institutes of Health, and the Children's Research Center of Michigan for financial support.

References
  1. Dhaunchak AS, Colman DR, Nave KA. Misalignment of PLP/DM20 transmembrane domains determines protein misfolding in Pelizaeus-Merzbacher disease. J Neurosci. 2011 Oct 19. 31(42):14961-71. [Medline].

  2. Wood PL, Khan MA, Smith T, Ehrmantraut G, Jin W, Cui W, et al. In vitro and in vivo plasmalogen replacement evaluations in rhizomelic chrondrodysplasia punctata and Pelizaeus-Merzbacher disease using PPI-1011, an ether lipid plasmalogen precursor. Lipids Health Dis. 2011 Oct 18. 10(1):182. [Medline].

  3. Wood PL, Smith T, Pelzer L, Goodenowe DB. Targeted metabolomic analyses of cellular models of pelizaeus-merzbacher disease reveal plasmalogen and myo-inositol solute carrier dysfunction. Lipids Health Dis. 2011 Jun 17. 10:102. [Medline]. [Full Text].

  4. Lee JA, Carvalho CM, Lupski JR. A DNA replication mechanism for generating nonrecurrent rearrangements associated with genomic disorders. Cell. 2007. 131:1235-47. [Medline]. [Full Text].

  5. McKusick V. Pelizaeus-Merzbacher disease. Online Mendelian Inheritance in Man. Available at http://www.ncbi.nlm.nih.gov/omim/312080. Accessed: 2004.

  6. van der Knaap MS, Smit LM, Barth PG, et al. Magnetic resonance imaging in classification of congenital muscular dystrophies with brain abnormalities. Ann Neurol. 1997 Jul. 42(1):50-9. [Medline].

  7. Griffiths I, Klugmann M, Anderson T, et al. Axonal swellings and degeneration in mice lacking the major proteolipid of myelin. Science. 1998 Jun 5. 280(5369):1610-3. [Medline].

  8. Wolf NI, Sistermans EA, Cundall M, et al. Three or more copies of the proteolipid protein gene PLP1 cause severe Pelizaeus-Merzbacher disease. Brain. 2005 Apr. 128(Pt 4):743-51. [Medline].

  9. Hurst S, Garbern J, Trepanier A, Gow A. Quantifying the carrier female phenotype in Pelizaeus-Merzbacher disease. Genet Med. 2006 Jun. 8(6):371-8. [Medline].

  10. Numata Y, Gotoh L, Iwaki A, Kurosawa K, Takanashi JI, Deguchi K, et al. Epidemiological, clinical, and genetic landscapes of hypomyelinating leukodystrophies. J Neurol. 2014 Feb 16. [Medline].

  11. Uhlenberg B, Schuelke M, Rüschendorf F, Ruf N, Kaindl AM, Henneke M, et al. Mutations in the gene encoding gap junction protein alpha 12 (connexin 46.6) cause Pelizaeus-Merzbacher-like disease. Am J Hum Genet. 2004 Aug. 75(2):251-60. [Medline]. [Full Text].

  12. Lazzarini A, Schwarz KO, Jiang S, et al. Pelizaeus-Merzbacher-like disease: exclusion of the proteolipid protein locus and documentation of a new locus on Xq. Neurology. 1997 Sep. 49(3):824-32. [Medline].

  13. Tanaka M, Hamano S, Sakata H, et al. Discrepancy between auditory brainstem responses, auditory steady-state responses, and auditory behavior in two patients with Pelizaeus-Merzbacher disease. Auris Nasus Larynx. 2008 Sep. 35(3):404-7. [Medline].

  14. Laukka JJ, Stanley JA, Garbern JY, Trepanier A, Hobson G, Lafleur T, et al. Neuroradiologic correlates of clinical disability and progression in the X-linked leukodystrophy Pelizaeus-Merzbacher disease. J Neurol Sci. 2013 Dec 15. 335(1-2):75-81. [Medline].

  15. Mori T, Mori K, Ito H, Goji A, Miyazaki M, Harada M, et al. Age-related changes in a patient with Pelizaeus-Merzbacher disease determined by repeated 1H-magnetic resonance spectroscopy. J Child Neurol. 2014 Feb. 29(2):283-8. [Medline].

 
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T2-weighted magnetic resonance imaging (MRI) scan of a child aged 10 months with duplication of the proteolipid protein (PLP) gene; note the high-intensity signal throughout the cerebral white matter.
T2-weighted magnetic resonance imaging (MRI) scan of a man aged 41 years with duplication of the proteolipid protein (PLP) gene; note the increased white matter signal, as well as diffuse atrophy.
T2-weighted magnetic resonance imaging (MRI) scan of a man aged 20 years with connatal Pelizaeus-Merzbacher disease due to a Pro14Leu mutation; note the severe reduction in white matter volume, as well as the increased white matter signal.
T2-weighted magnetic resonance imaging (MRI) scan of a boy aged 17 years with null mutation of the proteolipid protein (PLP) gene; note the more subtle increase in signal intensity relative to that seen in the previous images, and observe that the volume of white matter is normal.
 
 
 
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