Abstract
Considerable research has focused on patients with trinucleotide (CGG) repeat expansions in the fragile X mental retardation 1 (FMR1) gene that fall within either the full mutation (>200 repeats) or premutation range (55–200 repeats). Recent interest in individuals with gray zone expansions (41–54 CGG repeats) has grown due to reported phenotypes that are similar to those observed in premutation carriers, including neurological, molecular, and cognitive signs. The purpose of this manuscript is to describe a series of adults with FMR1 alleles in the gray zone presenting with movement disorders or memory loss. Gray zone carriers ascertained in large FMR1 screening studies were identified and their clinical phenotypes studied. Thirty-one gray zone allele carriers were included, with mean age of symptom onset of 53 years in patients with movement disorders and 57 years in those with memory loss. Four patients were chosen for illustrative case reports and had the following diagnoses: early-onset Parkinson disease (PD), atypical parkinsonism, dementia, and atypical essential tremor. Some gray zone carriers presenting with parkinsonism had typical features, including bradykinesia, rigidity, and a positive response to dopaminergic medication. These patients had a higher prevalence of peripheral neuropathy and psychiatric complaints than would be expected. The patients seen in memory clinics had standard presentations of cognitive impairment with no apparent differences. Further studies are necessary to determine the associations between FMR1 expansions in the gray zone and various phenotypes of neurological dysfunction.
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Hagerman RJ, Leehey M, Heinrichs W, et al. Intention tremor, parkinsonism, and generalized brain atrophy in male carriers of fragile X. Neurology. 2001;57:127–30.
Greco CM, Hagerman RJ, Tassone F, et al. Neuronal intranuclear inclusions in a new cerebellar tremor/ataxia syndrome among fragile X carriers. Brain. 2002;125:1760–71.
Sevin M, Kutalik Z, Bergman S, et al. Penetrance of marked cognitive impairment in older male carriers of the FMR1 gene premutation. J Med Genet. 2009;46:818–24.
Schwartz CE, Dean J, Howard-Peebles PN, et al. Obstetrical and gynecological complications in fragile X carriers: a multicenter study. Am J Med Genet. 1994;51:400–2.
Hall DA, Howard K, Hagerman RJ, Leehey MA. Parkinsonism in FMR1 premutation carriers may be indistinguishable from Parkinson disease. Parkinsonism Relat Disord. 2009;15:156–9.
Tassone F, Hagerman RJ, Taylor AK, Gane L, Godfrey TE, Hagerman PJ. Elevated levels of FMR1 mRNA in carrier males: a new mechanism of involvement in the fragile X syndrome. Am J Hum Genet. 2000;66:6–15.
Monaghan KG, Lyon E, Spector EB, American College of Medical G, Genomics. ACMG standards and guidelines for fragile X testing: a revision to the disease-specific supplements to the standards and guidelines for clinical genetics Laboratories of the American College of Medical Genetics and Genomics. Genet Med: Off J Am Coll Med Genet. 2013;15:575–86.
Tassone F, Iong KP, Tong TH, et al. FMR1 CGG allele size and prevalence ascertained through newborn screening in the United States. Genome Med. 2012;4:100.
Grigsby J, Brega AG, Leehey MA, et al. Impairment of executive cognitive functioning in males with fragile X-associated tremor/ataxia syndrome. Mov Disord: Off J Mov Disord Soc. 2007;22:645–50.
Loesch DZ, Godler DE, Evans A, et al. Evidence for the toxicity of bidirectional transcripts and mitochondrial dysfunction in blood associated with small CGG expansions in the FMR1 gene in patients with parkinsonism. Genet Med. 2011;13:392–9.
Loesch DZ, Godler DE, Khaniani M, et al. Linking the FMR1 alleles with small CGG expansions with neurodevelopmental disorders: preliminary data suggest an involvement of epigenetic mechanisms. Am J Med Genet A. 2009;149A:2306–10.
Nolin SL, Sah S, Glicksman A, et al. Fragile X AGG analysis provides new risk predictions for 45-69 repeat alleles. Am J Med Genet A. 2013;161A:771–8.
Hall DA, Berry-Kravis E, Zhang W, et al. FMR1 gray-zone alleles: association with Parkinson’s disease in women? Mov Disord. 2011;26:1900–6.
Hall DA, Tassone F, Klepitskaya O, Leehey M. Fragile X-associated tremor ataxia syndrome in FMR1 gray zone allele carriers. Mov Disord. 2012;27:296–300.
Liu Y, Winarni TI, Zhang L, Tassone F, Hagerman RJ. Fragile X-associated tremor/ataxia syndrome (FXTAS) in grey zone carriers. Clin Genet. 2013;84:74–7.
Hall DA, Jennings D, Seibyl J, Tassone F, Marek K. FMR1 gene expansion and scans without evidence of dopaminergic deficits in parkinsonism patients. Parkinsonism Relat Disord. 2010;16:608–11.
Hall DA, Bennett DA, Filley CM, et al. Fragile X gene expansions are not associated with dementia. Neurobiol Aging. 2014;35:2637–8.
Siesling S, Zwinderman AH, van Vugt JP, Kieburtz K, Roos RA. A shortened version of the motor section of the unified Huntington’s disease rating scale. Mov Disord: Off J Mov Disord Soc. 1997;12:229–34.
Trouillas P, Takayanagi T, Hallett M, et al. International cooperative ataxia rating scale for pharmacological assessment of the cerebellar syndrome. J Neurol Sci. 1997;145:205–11.
Fahn S, Tolosa E, Marin C. Clinical rating scale for tremor. In: Jankovic J, Tolosa E, editors. Parkinson’s disease and movement disorders. Baltimore: Urban & Schwartzenberg; 1987. p. 225–34.
Louis ED, Ford B, Lee H, Andrews H. Does a screening questionnaire for essential tremor agree with the physician’s examination? Neurology. 1998;50:1351–7.
Fahn S, Elton R, Committee Mot UD. Unified Parkinson’s Disease Rating Scale. In: Fahn S, Marsden C, Calne D, Goldstein M, editors. Recent development in Parkinson’s disease. Florham Park: Macmillan Health Care Information; 1987. p. 153–64.
Gelb DJ, Oliver E, Gilman S. Diagnostic criteria for Parkinson’s disease. Arch Neurol. 1999;56:33–9.
Gilman S, Low PA, Quinn N, et al. Consensus statement on the diagnosis of multiple systems atrophy. J Neurol Sci. 1999;163:94–8.
Tolosa E, Valldeoriola F, Cruz-Sanchez F. Progressive supranuclear palsy: clinical and pathological diagnosis. Eur J Neurol. 1995;2:258–73.
Lang AE, Riley DE, Bergeron C. Cortical-basal ganglionic degeneration. In: Calne DB, editor. Neurodegeneration diseases. Philadelphia: WB Saunders; 1994. p. 877–94.
McKeith IG, Galasko D, Kosaka K, et al. Consensus guidelines for the clinical and pathological diagnosis of dementia with Lewy bodies (DLB): report of the consortium on DLB international workshop. Neurology. 1996;47:1113–24.
Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–98.
Dubois B, Slachevsky A, Litvan I, Pillon B. The FAB: a frontal assessment battery at bedside. Neurology. 2000;55:1621–6.
McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer’s disease: report of the NINCDS-ADRDA work group under the auspices of Department of Health and Human Services Task Force on Alzheimer’s disease. Neurology. 1984;34:939–44.
Bennett DA, Schneider JA, Aggarwal NT, et al. Decision rules guiding the clinical diagnosis of Alzheimer’s disease in two community-based cohort studies compared to standard practice in a clinic-based cohort study. Neuroepidemiology. 2006;27:169–76.
Hall DA, Berry-Kravis E, Zhang W, et al. FMR1 gray-zone alleles: association with Parkinson’s disease in women? Mov Disord. 2011. doi:10.1002/mds.23755.
Taylor AK, Safanda JF, Fall MZ, et al. Molecular predictors of cognitive impairment in female carriers of fragile X syndrome. JAMA. 1994;271:507–14.
Chen Y, Tassone F, Berman RF, et al. Murine hippocampal neurons expressing Fmr1 gene premutations show early developmental deficits and late degeneration. Hum Mol Genet. 2010;19:196–208.
Filipovic-Sadic S, Sah S, Chen L, et al. A novel FMR1 PCR method for the routine detection of low abundance expanded alleles and full mutations in fragile X syndrome. Clin Chem. 2010;56:399–408.
Zhang X, Zhuang X, Gan S, et al. Screening for FMR1 expanded alleles in patients with parkinsonism in mainland China. Neurosci Lett. 2012;514:16–21.
Loesch DZ, Khaniani MS, Slater HR, et al. Small CGG repeat expansion alleles of FMR1 gene are associated with parkinsonism. Clin Genet. 2009;76:471–6.
Fraint A, Vittal P, Szewka A, Bernard B, Berry-Kravis E, Hall DA. New observations in the fragile X-associated tremor/ataxia syndrome (FXTAS) phenotype. Front Genet. 2014;5:365.
Hughes RA. Peripheral neuropathy. BMJ. 2002;324:466–9.
Dyck PJ, Kratz KM, Karnes JL, et al. The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: the Rochester diabetic neuropathy study. Neurology. 1993;43:817–24.
Hagerman RJ, Leehey MA, Heinrichs W, et al. Intention tremor, parkinsonism, and generalized brain atrophy in older male carriers of fragile X. Neurology. 2001;57:127–30.
Jacquemont S, Hagerman RJ, Leehey M, et al. Fragile X premutation tremor/ataxia syndrome: molecular, clinical, and neuroimaging correlates. Am J Hum Genet. 2003;72:869.
Jacquemont S, Hagerman RJ, Leehey MA, et al. Penetrance of the fragile X-associated tremor/ataxia syndrome in a premutation carrier population. J Am Med Assoc. 2004;291:460.
Berry-Kravis E, Goetz C, Leehey MA, et al. Neuropathic features in fragile X premutation carriers. Am J Hum Genet. 2007;143A:19–26.
Grigsby J, Brega AG, Jacquemont S, et al. Impairment in the cognitive functioning of men with fragile X-associated tremor/ataxia syndrome (FXTAS). J Neurol Sci. 2006;248:227–33.
Grigsby J, Brega AG, Engle K, et al. Cognitive profile of fragile X premutation carriers with and without fragile X-associated tremor/ataxia syndrome. Neuropsychology. 2008;22:48–60.
Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289:3095–105.
Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:617–27.
Aziz M, Stathopulu E, Callias M, et al. Clinical features of boys with fragile X premutations and intermediate alleles. Am J Med Genet B Neuropsychiatr Genet: Off Publ Int Soc Psychiatr Genet. 2003;121B:119–27.
Renda MM, Voigt RG, Babovic-Vuksanovic D, et al. Neurodevelopmental disabilities in children with intermediate and premutation range fragile X cytosine-guanine-guanine expansions. J Child Neurol. 2014;29:326–30.
Haddad LA, Aguiar MJ, Costa SS, Mingroni-Netto RC, Vianna-Morgante AM, Pena SD. Fully mutated and gray-zone FRAXA alleles in Brazilian mentally retarded boys. Am J Med Genet. 1999;84:198–201.
Mitchell RJ, Holden JJ, Zhang C, et al. FMR1 alleles in Tasmania: a screening study of the special educational needs population. Clin Genet. 2005;67:38–46.
Crawford DC, Meadows KL, Newman JL, et al. Prevalence and phenotype consequence of FRAXA and FRAXE alleles in a large, ethnically diverse, special education-needs population. Am J Hum Genet. 1999;64:495–507.
Patsalis PC, Sismani C, Hettinger JA, et al. Frequencies of “grey-zone” and premutation-size FMR1 CGG-repeat alleles in patients with developmental disability in Cyprus and Canada. Am J Med Genet. 1999;84:195–7.
Madrigal I, Xuncla M, Tejada MI, et al. Intermediate FMR1 alleles and cognitive and/or behavioural phenotypes. Eur J Hum Genet: EJHG. 2011;19:921–3.
Jalnapurkar I, Rafika N, Tassone F, Hagerman R. Immune mediated disorders in women with a fragile X expansion and FXTAS. Am J Med Genet A. 2015;167A:190–7.
Reiss AL, Freund L, Abrams MT, Boehm C, Kazazian H. Neurobehavioral effects of the fragile X premutation in adult women: a controlled study. Am J Hum Genet. 1993;52:884–94.
Goodlin-Jones BL, Tassone F, Gane LW, Hagerman RJ. Autistic spectrum disorder and the fragile X premutation. J Dev Behav Pediatr: JDBP. 2004;25:392–8.
Hagerman R, Hagerman P. Advances in clinical and molecular understanding of the FMR1 premutation and fragile X-associated tremor/ataxia syndrome. Lancet Neurol. 2013;12:786–98.
Cornish K, Kogan C, Turk J, et al. The emerging fragile X premutation phenotype: evidence from the domain of social cognition. Brain Cogn. 2005;57:53–60.
Hessl D, Tassone F, Loesch DZ, et al. Abnormal elevation of FMR1 mRNA is associated with psychological symptoms in individuals with the fragile X premutation. Am J Med Genet B Neuropsychiatr Genet: Off Publ Int Soc Psychiatr Genet. 2005;139B:115–21.
Johnston C, Eliez S, Dyer-Friedman J, et al. Neurobehavioral phenotype in carriers of the fragile X premutation. Am J Med Genet. 2001;103:314–9.
Willemsen R, Levenga J, Oostra BA. CGG repeat in the FMR1 gene: size matters. Clin Genet. 2011;80:214–25.
Sellier C, Usdin K, Pastori C, Peschansky VJ, Tassone F, Charlet-Berguerand N. The multiple molecular facets of fragile X-associated tremor/ataxia syndrome. J Neurodev Disord. 2014;6:23.
Greco CM, Berman RF, Martin RM, et al. Neuropathology of fragile X-associated tremor/ataxia syndrome (FXTAS). Brain. 2006;129:243–55.
Soontarapornchai K, Maselli R, Fenton-Farrell G, et al. Abnormal nerve conduction features in fragile X premutation carriers. Arch Neurol. 2008;65:495–8.
Cohen S, Masyn K, Adams J, et al. Molecular and imaging correlates of the fragile X-associated tremor/ataxia syndrome. Neurology. 2006;67:1426–31.
Kenneson A, Zhang F, Hagedorn CH, Warren ST. Reduced FMRP and increased FMR1 transcription is proportionally associated with CGG repeat number in intermediate-length and premutation carriers. Hum Mol Genet. 2001;10:1449–54.
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This work was funded by R01NS052487 (DAH). We thank the patients who participated in these studies.
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Debrey, S.M., Leehey, M.A., Klepitskaya, O. et al. Clinical Phenotype of Adult Fragile X Gray Zone Allele Carriers: a Case Series. Cerebellum 15, 623–631 (2016). https://doi.org/10.1007/s12311-016-0809-6
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DOI: https://doi.org/10.1007/s12311-016-0809-6