Heterozygous mutations in HSD17B4

cause juvenile peroxisomal D-bifunctional

protein deficiency

David J. Amor, MBBS, ABSTRACT

PhD Objective: To determine the genetic cause of slowly progressive cerebellar ataxia, sensorineural
Ashley P.L. Marsh, BSc deafness, and hypergonadotropic hypogonadism in 5 patients from 3 different families.
Elsdon Storey, MBBS,
Methods: The patients comprised 2 sib pairs and 1 sporadic patient. Clinical assessment included
DPhil
history, physical examination, and brain MRI. Linkage analysis was performed separately on the 2
Rick Tankard, BSc
sets of sib pairs using single nucleotide polymorphism microarrays, followed by analysis of the
Greta Gillies, MSci
intersection of the regions. Exome sequencing was performed on 1 affected patient with variant
Martin B. Delatycki,
filtering and prioritization undertaken using these intersected regions.
MBBS, PhD
Kate Pope, BSc (Nursing) Results: Using a combination of sequencing technologies, we identified compound heterozygous
Catherine Bromhead, BSc mutations in HSD17B4 in all 5 affected patients. In all 3 families, peroxisomal D-bifunctional
Richard J. Leventer, protein (DBP) deficiency was caused by compound heterozygosity for 1 nonsense/deletion muta-
MBBS, PhD tion and 1 missense mutation.
Melanie Bahlo, PhD Conclusions: We describe 5 patients with juvenile DBP deficiency from 3 different families, bring-
Paul J. Lockhart, PhD ing the total number of reported patients to 14, from 8 families. This report broadens and consol-
idates the phenotype associated with juvenile DBP deficiency. Neurol Genet 2016;2:e114; doi:
10.1212/NXG.0000000000000114
Correspondence to Dr. Lockhart:
[email protected]
GLOSSARY
CoA 5 coenzyme A; DBP 5 D-bifunctional protein; FSH 5 follicle-stimulating hormone; LH 5 luteinizing hormone; MPS 5
massively parallel sequencing; SNP 5 single nucleotide polymorphism; VLCFA 5 very long-chain fatty acid.

Peroxisomal D-bifunctional protein (DBP) deficiency is an autosomal recessive disorder that

compromises peroxisomal fatty acid oxidation. DBP is crucial to the b-oxidation of fatty acids
in the peroxisome, catalyzing the second and third steps of this process which are performed,
respectively, by a 2-enoyl-coenzyme A (CoA) hydratase unit and a 3-hydroxyacyl-CoA dehy-
drogenase unit.1 DBP deficiency is typically associated with a severe clinical presentation com-
prising neonatal hypotonia, seizures, and severely impaired psychomotor development.1
Dysmorphism, loss of hearing and vision, and CNS abnormalities also commonly occur.
Infant onset DBP deficiency has been classified into 3 subgroups based on the relative impair-
ment of the 2 DBP functions.2 Type I deficiency represents a total deficiency of both the
hydratase and hydroxyacyl-CoA dehydrogenase activities. Type II is an isolated deficiency of
the hydratase activity, and type III is an isolated deficiency of the hydroxyacyl-CoA dehydro-
genase activity. The 3 subgroups share a similar spectrum of clinical features but differ in
severity: nearly all infants with type I deficiency die in the first year of life, whereas those with
types II and III often survive beyond 10 years.1
Recently, a less severe form of DBP has been described in 5 families3–7 and designated
juvenile DBP deficiency,5 or alternatively DBP deficiency type IV6 or multifunctional protein

From the Murdoch Childrens Research Institute (D.J.A., A.P.L.M., G.G., M.B.D., K.P., R.J.L., P.J.L.), Royal Children’s Hospital (D.J.A., M.B.
D., R.J.L.), Parkville; Department of Paediatrics (D.J.A., A.P.L.M., M.B.D., C.B., R.J.L., P.J.L.), Department of Medical Biology (R.T., M.B.),
The University of Melbourne; Department of Medicine (Neuroscience) (E.S.), Central Clinical School, Monash University; and Population Health
and Immunity Division (R.T., M.B.), The Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, Victoria, Australia.
Funding information and disclosures are provided at the end of the article. Go to Neurology.org/ng for full disclosure forms. The Article Processing
Charge was paid by the authors.
This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC
BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used
commercially.

Neurology.org/ng © 2016 American Academy of Neurology 1

ª 2016 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

 ataxia syndrome.8 Here, we describe 5 affected C24:0/C22:0 ratio was 0.762 (reference 0.550–
individuals from 3 new families affected by 1.115) and C26:0/C22:0 ratio was 0.020 (reference
juvenile DBP deficiency and expand the pub- ,0.035). Plasma phytanic acid level was 0.1 mg/
lished phenotypic spectrum for this disorder. 100 mL (reference ,0.7). Urine bile acid profile
was normal.
Pedigree 2 includes 2 affected siblings, a male
METHODS Standard protocol approvals, registrations,
and patient consents. The study was approved by the Royal and a female, along with 3 unaffected female sib-
Children’s Hospital Human Research Ethics Committee lings born to nonconsanguineous parents of Leba-
(approval number 28097). Participants were recruited following nese descent. The male sib (II-2) presented at age
review of clinical details obtained from medical records and family 29 years with a 5-year history of progressive ataxia.
interviews. Each participant signed an informed consent docu- His workmates had noticed impaired balance and
ment before enrollment.
slurred speech, of which he was unaware. Increased
Genetic analysis. Genetic studies were performed essentially as falls and deteriorating handwriting had been noted
described previously.9 Genomic DNA isolated from the periph- for 3 years. He had not noted any visual or hearing
eral blood and single nucleotide polymorphism (SNP) genotype
impairment or sensory symptoms, and there was no
data were generated. Parametric multipoint linkage analysis was
erectile dysfunction.
performed specifying a rare recessive disease model. Genomic
DNA was analyzed by whole-exome capture (Illumina TruSeq Examination revealed a very broad-based ataxic
capture kit, San Diego, CA), and massively parallel sequencing gait with mild cerebellar dysarthria. There was bilat-
(MPS) was performed on a HiSeq2000 (Axeq Technologies, eral horizontal gaze-evoked nystagmus, but horizontal
Macrogen, Seoul, Korea). Reads were aligned to the reference saccades appeared normal. Upward saccades were hy-
genome with Novoalign, and variants were identified with pometric, and downward saccades hypermetric. Tone
SAMtools and annotated by ANNOVAR. Variants were
and power were normal in the limbs, and deep ten-
filtered in a step-wise manner against exclusion criteria
including linkage region, minor allele frequency (#0.01, don reflexes were reduced but present without
1000 Genomes10), and functional impact. Inclusion criteria enhancement. There was bilateral appendicular
included predicted damaging effects on the protein using ataxia, with notably slow and hypermetric ballistic
PolyPhen-2 and SIFT. Sanger sequence analysis of HSD17B4 tracking (“finger chase”) movements. Vibration and
was performed by PCR amplification (primer sequences pinprick perception were intact distally, but 2-point
available on request). Primary fibroblast cells were analyzed by
discrimination was clearly impaired at the great toes
Western blot as previously described11 using anti-HSD17B4
(1:1000 HPA021479; Sigma-Aldrich, St. Louis, MO) and
(2.5 cm). Brain MRI at age 25 years showed mild
anti–b-actin antibody (1:10000 A5441; Sigma-Aldrich). The cerebellar atrophy with vermal emphasis and normal
reference sequences used for HSD17B4 were NG_008182.1, brainstem and cerebrum. Audiology showed moder-
NM_000414.3, and NP_000405.1. ate high-frequency hearing loss. At follow-up assess-
ment 1 year later, his testosterone, luteinizing
RESULTS Clinical descriptions. The clinical details of hormone (LH), follicle-stimulating hormone (FSH),
5 affected individuals from 3 pedigrees are presented and sperm count were normal. He had naturally con-
in table 1 and the family pedigrees in figure 1A. ceived 2 sons and a daughter. Five years later, he
Pedigree 1, comprising 2 affected sisters of required a wheelchair for mobility outside the house.
Italian descent (II-1 and II-2), was published previ- His vibration perception threshold was well below the
ously under the designation “Cerebellar ataxia with fifth percentile for his age, but pinprick sensation
hypergonadotropic hypogonadism” (OMIM remained intact.
#605672),12 prior to the identification of The sister of the family proband (II-1) presented
HSD17B4 mutations. Briefly, the sisters, aged 57 at age 31 years with a 4-year history of dysarthria
and 63 years at the most recent follow-up, both and impaired balance, although she reported always
presented with adult-onset progressive cerebellar sensing some imbalance. She had been referred to
ataxia and secondary amenorrhea due to hypergo- an ENT specialist, who had discovered moderate
nadotropic hypogonadism. Intellect was normal, high-frequency sensorineural hearing loss (figure
peripheral sensory neuropathy was observed, and 2A). Ovarian failure had been diagnosed on investi-
there was sensorineural deafness with vestibular hy- gation for primary amenorrhea. Examination revealed
pofunction. Neurologic symptoms were observed in a mildly broad-based gait and mild cerebellar dysar-
the third decade, and secondary amenorrhea was thria. Visual smooth pursuit was normal, and imper-
described at 16 and 32 years of age, respectively. sistent horizontal gaze-evoked nystagmus was evident
Brain MRI on both sisters showed marked atrophy on right gaze (only). Saccades to target were hyper-
of the cerebellum, involving both hemispheres and metric to the right and into down gaze. Tone, power,
vermis. Additional metabolic studies were under- and reflexes were normal in the limbs. There was mild
taken in the younger sister (II-2). Plasma levels of appendicular ataxia. Vibration and pinprick percep-
very long-chain fatty acids (VLCFAs) were normal: tion and 2-point discrimination were normal at the

2 Neurology: Genetics

ª 2016 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

ª 2016 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

Table 1 Summary of clinical details of affected individuals in this study and previously reported in the literature

Current report, Current report,

Pierce et al.7 McMillan et al.6 Lines et al.5 pedigree 112 pedigree 2
Current report,
pedigree 3
4 3
MK LK 1 2 Lieber et al. 1 2 3 Demain et al. II-1 II-2 II-1 II-2 II-1

Sex, age at the last report, y F, 27 F, 16 M, 16 M, 14 M, 35 F, 39 M, 38 F, 35 F, 43 F, 64 F, 55 F, 41 M, 40 M, 33

Age at chief symptom onset, y

Hearing loss 1 (8) 1 (4) 1 (3.5) 1 (2) 1 (34) 1 (5) 1 (8) 1 (10) 1 1 (,20) 1 (20) 1 (27) 1 (30) 1 (6)

Ataxia 1 (5–10) 2 1 (11) 2 1 (,18) 1 (12) 1 (10) 1 (14) NR 1 (20) 1 (20) 1 (20) 1 (24) 1 (12)

Cognition LD NR None None LD LD ID ID ID None None None None None

Cerebellum

Dysarthria 1 2 NR NR 1 1 1 1 NR 1 1 1 1 1

Nystagmus 1 NR NR NR 1 1 1 1 NR 1 1 1 1 1

Mobility aids (age required, y) WC (,23) None WC None WC (29) Walker WC (32) None NR Walker (60) None None WC (35) None

Motor

Weakness 1 1 1 NR NR 1 2 1 NR 2 2 2 2 2

Lower extremity spasticity 1 2 NR NR NR 1 1 1 NR 2 2 2 2 2

Hyperkinesia NR NR NR NR NR 1 2 1 NR 1 2 2 2 2

Deep tendon reflexes Present Present Y NR [ Y [ Y NR Y Y Present Y Present

Plantar responses NR NR Flexor NR Flexor Extensor Extensor Flexor NR Flexor Flexor Flexor Flexor Flexor

Sensory

Pinprick Y Normal Y NR Y Y NR Normal NR Normal Y Normal Normal Normal

Vibration Y Y Normal NR NR Y Y Y NR Y Y Normal Y Normal

Cranial MRI, y

Cerebellar atrophy 1 (21) 2 (,16) 1 (12) 1 1 (14) 1 (21) 1 (25) 1 (24) NR 1 (45) 1 (39) 1 (30) 1 (25) 1 (25)
Neurology: Genetics

White matter lesions 2 (23) 2 (,16) 2 (12) 2 2 (35) 1 (39) 1 (25) 2 (24) NR 2 2 2 (30) 2 2

Endocrine

Amenorrhea 1° 1° NA NA NA 1° NA 2° 1° 2° 2° 1° NA NA

Testosterone level NR NA NR NR Y NA Y NA NA NA NA NA Normal Normal

Azoospermia NA NA NR NR 1 NA NR NA NA NA NA NA 2 1

Abbreviations: [ 5 increased; Y 5 decreased; 1° 5 primary; 2° 5 secondary; ID 5 intellectual disability; LD 5 learning difficulty; NA 5 not applicable; NR 5 not recorded; WC 5 wheelchair.
3
 pinprick perception was preserved and ankle jerks
Figure 1 Compound heterozygous mutations in HSD17B4 cause juvenile
peroxisomal D-bifunctional protein deficiency
were present.
Pedigree 3 includes 1 affected individual (II-1),
a 33-year-old man born to nonconsanguineous pa-
rents of Italian ancestry. His younger brother is unaf-
fected. He presented at age 6 years with bilateral
sensorineural hearing loss, for which he has used hear-
ing aids from age 7 years. Beginning at age 14 years,
he developed a very slowly progressive cerebellar
ataxia. A decline in gait was first noted in the early
teenage years, with incoordination and occasional
falls becoming gradually more evident. There have
not been any problems with vision, or with motor
weakness or sensory disturbance. He has never had
a tremor or involuntary movements, and there is no
history of myoclonus or seizures. His cognitive devel-
opment is entirely normal. Clinical examination re-
vealed gait ataxia, dysarthria, and limb ataxia,
consistent with cerebellar disease. Although his ocular
movements have a full range, visual pursuit was sac-
cadic, with saccades being hypermetric in the hori-
zontal plane, and there was marked gaze-evoked
nystagmus, particularly on left gaze. Tongue move-
ments were slightly slow. There was no evidence of
motor weakness or sensory loss. Serial brain MRI
demonstrated progressive pancerebellar atrophy with
normal brainstem appearance. Nerve conduction
studies did not show evidence of peripheral neuropa-
thy. He was infertile due to hypergonadotropic hypo-
gonadism with elevated FSH (33.8 IU/L N 1.5–12.4)
and normal LH (7.6 IU/L N 1.7–8.6). Serum testos-
terone was at the lower end of the normal range (9.6
nmol/L N 8.3–30.2). A semen analysis showed azo-
ospermia, and a testicular biopsy revealed no sperm
and germ cell arrest. Serum phytanic acid was normal.

Mutation identification and characterization. DNA

from the 2 siblings from pedigree 1 and their
(A) Pedigree structure of families with cerebellar ataxia with hypergonadotropic hypogonad-
ism. Affected individuals are represented by black symbols. DNA from individuals that was
mother were hybridized to Affymetrix Genome-
used in this study is indicated (*). Single nucleotide polymorphism arrays and linkage were wide 6.0 SNP chips. From the genotyping data,
performed on samples I-2, II-1, II-2 (family 1), and II-1 and II-2 (family 2); WES was performed we identified regions where the affected siblings
on sample II-2 (family 2). (B) A schematic representation of HSD17B4 indicating the dehy- were sharing both maternal and paternal
drogenase, hydratase, and SCP2 domains. The position and type of all compound heterozy-
gous mutations identified in the 8 families reported with juvenile peroxisomal D-bifunctional
haplotypes (IBD2 regions), thereby eliminating
protein deficiency to date (table 2) are indicated. A 5 pedigree 1, B 5 pedigree 2, C 5 pedigree candidate genes over 3 quarters of the genome. In
3, and D–H correspond to families 4–8, respectively. (C) Immunoblot analysis with an HSD17B4- addition, no copy number variants of interest
specific antibody (1:1000, HPA021479) identified a ;80 kDa full length and ;35 kDA pro-
were detected in this family.
cessed dehydrogenase domain protein in control fibroblasts (C1 and C2) that was significantly
reduced in extracts derived from affected individuals II-1 and II-2 (families 1 and 2). An antibody DNA from the 2 affected siblings from pedigree 2
directed against b-actin confirmed equivalent protein loading. FB 5 fibroblast. FB 5 fibroblast. was hybridized to Illumina Human 610-quad bead-
chips. From the genotyping data, we identified
great toes. Brain MRI performed at age 31 years IBD2 regions between the siblings which covered
showed clear pancerebellar atrophy, with normal approximately 30% of the autosome, with 40 separate
brainstem and cerebrum (figure 2B). At age 37 years, intervals. The male sib then underwent MPS, and
she reported tinnitus, mild dysphagia, and worsening variant filtering was restricted to these linkage regions.
dysarthria and ataxia. There was evidence of sensory As the suspected disease model was compound het-
neuropathy with reduced vibration perception and 2- erozygous, the filtering process only included genes
point discrimination at the great toes, although that had 2 potential causative mutations. This

4 Neurology: Genetics

ª 2016 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

 (c.680A.G;p.His227Arg) that is predicted to be
Figure 2 Loss of HSD17B4 results in sensorineural deafness and slowly
progressive cerebellar ataxia
probably damaging/deleterious. Each variant was
present in one unaffected parent, consistent with
a compound heterozygous disease model. Only one
of the 2 mutations (c.680A.G;p.His227Arg) was
present in his unaffected brother.
To determine the functional effect of mutations in
HSD17B4, Western blot analysis of primary fibro-
blasts derived from all affected members in families
1 and 2 was performed. The 736 amino acid, 79.6
kDa protein encoded by HSD17B4 includes con-
served dehydrogenase, hydratase, and SCP2 domains
(figure 1B). In control fibroblast cells, an intense
band of the expected size (approximately 80 kDa)
was detected using an anti-HSD17B4 antibody. In
addition, a band consistent with the ;35 kDA pro-
cessed dehydrogenase domain13 was also observed.
The relative abundance of both of these proteins
(A) Audiogram from patient II-2, pedigree 2 showing high-frequency sensorineural hearing
loss. (B) Brain MRI from the same patient showing marked cerebellar atrophy. PTA 5 pure- was significantly reduced in patient fibroblasts from
tone audiometry. families 1 and 2 (figure 1B).

filtering resulted in 20 candidate genes containing 40 DISCUSSION The reported phenotype of juvenile
potential causative mutations. DBP deficiency is characterized by childhood or early
Linkage regions from pedigrees 1 and 2 were then adult-onset sensorineural deafness, ataxia, and
intersected, and subsequent variant filtering and pri- hypergonadotropic hypogonadism and overlaps
oritization was undertaken using these regions. This with that of Perrault syndrome (sensorineural
analysis identified HSD17B4 as a promising candi- deafness and, in females, ovarian dysgenesis).3–7
date, with 2 mutations identified in the male sib. Here, we describe 5 patients with juvenile (type
The first variant (NM_000414(HSD17B4_v003): IV) DBP deficiency from 3 different families,
c.661C.T, p.(Leu221Phe) is a missense mutation, bringing the total number of reported patients to
absent in population databases, that is predicted to be 14, from 8 families. We previously classified the
possibly damaging/deleterious by PolyPhen-2 and family reported here as pedigree 1 as being affected
SIFT, respectively. The second variant (c.1132 by “Cerebellar ataxia with hypergonadotropic
G.T, p.Gly378*) is a nonsense mutation, most hypogonadism” (OMIM #605672)12; however, it is
likely resulting in nonsense-mediated decay or a trun- now clear that this is the same disorder as juvenile
cated protein product. The 2 variants were confirmed DBP deficiency.
by Sanger sequencing in both siblings, and each par- This report broadens and consolidates the pheno-
ent was found to carry one of the variants, consistent type associated with juvenile DBP deficiency. The 3
with a compound heterozygous disease model. cardinal manifestations of juvenile DBP deficiency
Sanger sequencing was then undertaken in the 2 are ataxia associated with cerebellar atrophy on
sisters from pedigree 1 and their unaffected mother. MRI, sensorineural deafness, and hypergonadotropic
The same 2 variants were identified in both affected hypogonadism. The disorder is slowly progressive
sisters. The first variant (c.5811 G.A) is predicted with the onset of hearing loss and ataxia typically in
to cause loss of the exon 1 donor splice site. The the first decade of life; however, symptoms may
second variant (c.293A.AG, p.Asn98Ser) is a mis- escape recognition until the second or even the third
sense mutation predicted to be damaging/deleterious. decade. Peripheral neuropathy, affecting large diame-
The mother of the sisters was sequenced and found to ter sensory fibers clinically, typically develops some
have the c.293A.AG, p.Asn98Ser variant but not years after the onset of deafness and ataxia. Ambula-
the c.5811 G.GA variant. The father was not avail- tion is progressively impaired, with some patients
able for the study. requiring the use of a wheelchair between the third
Sanger sequencing of HSD17B4 was then per- and sixth decades. Notably, our oldest patient was
formed in pedigree 3. Two variants were identified ambulant with a walker in her 60s.
in the affected male. The first variant in exon 4 Gonadal dysfunction in juvenile DBP deficiency
(c.186_187del:pIle62Metfs*12) is a 2-base pair dele- shows greater variability. Of the 8 females identified
tion (AA) causing a frameshift and a premature stop with this disorder, 5 have had primary ovarian insuf-
codon. The second variant is a missense mutation ficiency, whereas 3 have undergone spontaneous

Neurology: Genetics 5

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 juvenile DBP deficiency relies on the recognition of
Table 2 Summary of genotypes observed in affected individuals in this study
and previously reported in the literature
the characteristic clinical presentation. It is therefore
likely that juvenile DBP deficiency is an underdiag-
Family Mutation 1 Mutation type Mutation 2 Mutation type nosed entity and that further cases will come to light
Pierce et al. 7
p.Tyr568* I p.Tyr217Cys III with the increased use of exome sequencing.
McMillan et al.6 p.Ala34Vala III p.Ile516Thra II In common with other disorders of peroxisomal
function, in DBP deficiency, our understanding of
Lieber et al.4 p.239_403del I p.Ala196Val III
5
the links between cellular mechanisms and disease
Lines et al. p.Pro513Thr II p.Arg543Pro II
pathogenesis is incomplete. For some reason, the cer-
Demain et al.3 p.Gly16Sera III p.Val82Phe III
ebellum is exquisitely sensitive to perturbations in
Pedigree 1 c.5811 G.GA I p.Asn98Ser III peroxisomal function and cerebellar pathologies,
Pedigree 2 p.Gly378* I p.Leu221Phe III including hypoplasia, atrophy, and demyelination,
Pedigree 3 p.Ile62Metfs*12 I p.His227Arg III are common features of peroxisomal disorders.8 It is
possible that neurodegeneration results from a combi-
Mutation types: I 5 deletion/nonsense mutation; II 5 missense mutation in hydratase unit;
III 5 missense mutation in hydroxyacyl-CoA dehydrogenase unit.
nation of both the accumulation of toxic peroxisomal
a
Previously reported in patients with neonatal presentation. metabolic substrates (e.g., VLCFAs and phytanic
acid) and deficiency of peroxisomal synthetic prod-
ucts; however, studies in knockout mice have failed to
puberty, followed some years later by premature men- correlate neurodegeneration with the level of any can-
opause; none has had children. Of the 6 males with didate metabolite.8 It has been hypothesized that per-
juvenile DBP deficiency, information about gonadal oxisome dysfunction leads to widespread molecular
function is available for only 4. From previous re- and metabolic changes within the cell, including
ports, 2 males have been described as having low tes- altered cell signaling, increased oxidative stress, and
tosterone levels,4,5 of whom 1 had a semen analysis impaired mitochondrial function, and that these in
showing azoospermia.4 We report similar findings in turn lead to altered neuronal function and neuronal
one of our affected males (pedigree 3, II:1) who had cell death.14
a testosterone level at the lower end of the normal There is a correlation between DBP subgroups
range associated with an elevated FSH level, and a tes- and genotype, with type I deficiency associated with
ticular biopsy that showed germ cell arrest. In con- nonsense and deletion mutations, type II deficiency
trast, our other affected male had normal testicular associated with missense mutations in the hydratase
function and fathered 3 children. Our data suggest unit, and type III deficiency associated with missense
that infertility is not a certain outcome for male in- mutations in the hydroxyacyl-CoA dehydrogenase
dividuals with DBP deficiency. unit.13 Analysis of the genotypes of the 8 families with
Juvenile DBP deficiency shares some features with juvenile DBP deficiency (table 2) demonstrates that
the severe neonatal forms of DBP deficiency, notably all affected individuals are compound heterozygotes,
the presence of hearing loss, cerebellar atrophy, and either for 2 missense mutations or for 1 missense
peripheral neuropathy; however, a number of features mutation and 1 nonsense/deletion mutation. Of
of neonatal onset DBP deficiency are absent from interest, 5 of the 8 families, including the 3 families
juvenile DBP deficiency, including hypotonia, seiz- reported here, are compound heterozygous for 1 non-
ures, visual loss, liver disease, and cortical malforma- sense/deletion mutation (the latter typically associ-
tions.1 Notably, all 5 of our patients had normal ated with type I DBP deficiency) and 1 missense
intelligence, although learning difficulties and intel- mutation in the hydroxyacyl-CoA dehydrogenase
lectual disability have been described in other pa- unit, making this the most common genotypic cate-
tients. The 3 siblings previously reported5 differ gory for juvenile DBP deficiency. Of the other fam-
somewhat from the other juvenile DBP patients with ilies, one is compound heterozygote for 2 missense
respect to the presence of intellectual disability (rang- mutations in the hydroxyacyl-CoA dehydrogenase
ing from mild to severe), spasticity, and white matter unit and another is compound heterozygous for 2
changes on MRI; these findings may be specific to the missense mutations in the hydratase unit. Although
combination of mutations in these siblings. it was previously suggested that juvenile DBP defi-
It is important that the routine peroxisomal ciency might be specifically associated with the pres-
screening tests (VLCFA and phytanic acid levels), ence of 1 mutation in each of the hydratase and
which are helpful in diagnosing the infantile forms hydroxyacyl-CoA dehydrogenase units,6 only 1 fam-
of DBP deficiency, have, when tested, been consis- ily has been described with this combination of muta-
tently normal in juvenile DBP deficiency,3,5,7 includ- tion types. Notably, 3 of the mutations reported in
ing both of our patients who were tested. In the juvenile DBP deficiency have previously been re-
absence of a biochemical screening test, diagnosis of ported in patients with neonatal DBP deficiency,

6 Neurology: Genetics

ª 2016 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

 indicating genotypic overlap between the subtypes of Neurology and the Journal of Pediatric Genetics and has received research
support from NHMRC, FARA USA, and FARA Australia. Ms. Pope has
DBP deficiency.
received research support from NHMRC. Ms. Bromhead reports no
Juvenile DBP deficiency shares phenotypic fea- disclosures. Dr. Leventer has received research support from NHMRC
tures with Perrault syndrome and has been described and the Campbell Edwards Trust. Dr. Bahlo has served on the scientific
by some authors as a type of Perrault syndrome.3,7 advisory boards of the Macular Telangiectasia (MacTel) Consortium and
the Department of Health (Australian Government); has received travel
Perrault syndrome is an autosomal recessive syn- funding/speaker honoraria for the 7th International Conference on Ge-
drome, the cardinal features of which are sensorineu- nomics & Bio-IT APAC 2012, the International Mathematics Institute
ral hearing loss in both sexes and primary ovarian conference (Pacific Region), the Australian Statistical Society Conference,
the International Stroke Genetics Meeting, the Human Genome Meet-
insufficiency in females. Additional neurologic fea-
ing, AGTA, and the MacTel Consortium Meeting; has served on the
tures such as ataxia, neuropathy, and intellectual dis- editorial board of Statistical Applications in Genetics and Molecular Biology;
ability are present in some patients, but are not holds a patent for Method of determining response to treatment with
required for diagnosis. Apart from HSD17B4, the immunomodulatory composition Details genetic markers that predict
response to Hepatitis C treatment; has been a consultant for the MacTel
other 4 genes so far associated with Perrault syndrome
Consortium, the Human Genetics Society of Australia, the Australian
all encode mitochondrial proteins.3 Although there is Statistical Society-Institute of Mathematical Statistics, the International
obvious clinical overlap between juvenile DBP defi- Conference on Systems Biology, the Sixth Barossa Meeting, and the 8th
ciency and Perrault syndrome, we believe that the International Conference on Genomics & Bio-IT APAC; and has
received research support from NHMRC, the Australian Research Coun-
conditions are sufficiently clinically and molecularly cil (ARC), the Victorian Life Sciences Computing Initiative (VLSCI), the
distinct for juvenile DBP deficiency not to be classi- Royal Melbourne Hospital Home Lottery Research Awards, the Leuke-
fied as a subtype of Perrault syndrome. mia Foundation National Research Program, the ARC Future Fellow-
ship, ARC Linkage Grant, DEST International Science Linkages grant,
AUTHOR CONTRIBUTIONS the Human Genetics Society of Australia, the Epilepsy Society of
Australia, the Royal Statistical Society, the Institute of Mathematical
D.J.A. formulated the study, performed patient recruitment, provided
Statistics, the Biometrics Society of Australasia, the Australian Statistics
and interpreted the clinical data, and cowrote the manuscript. A.P.L.
Society, the American Society of Human Genetics, and the International
M. performed molecular analysis and revised the manuscript. E.S. con-
Genetic Epidemiology Society. Dr. Lockhart has served on the editorial
tributed to the design of the study, provided and interpreted the clinical
boards of Genetics Research International and Open Access (OA) Genetics
data, and revised the manuscript. R.T. performed bioinformatic analysis,
and has received research support from NHMRC. Go to Neurology.org/
interpreted the data, and revised the manuscript. G.G. performed molec-
ng for full disclosures.
ular analysis and revised the manuscript. M.B.D. contributed to the
design of the study, provided and interpreted the clinical data, and revised
Received July 24, 2016. Accepted in final form September 6, 2016.
the manuscript. K.P. performed patient recruitment, collected clinical
data, and revised the manuscript. C.B. performed bioinformatic analysis,
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8 Neurology: Genetics

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 Heterozygous mutations in HSD17B4 cause juvenile peroxisomal D-bifunctional
protein deficiency
David J. Amor, Ashley P.L. Marsh, Elsdon Storey, et al.
Neurol Genet 2016;2;
DOI 10.1212/NXG.0000000000000114

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