Matthias Loumlhle MDDerralynn Hughes MDAlan MilliganLinda RichfieldHeinz Reichmann MD

PhDAtul Mehta MDAnthony HV Schapira

DSc FMedSci

Correspondence toDr Loumlhlematthiasloehleuniklinikum-dresdende

Supplemental dataat Neurologyorg

Clinical prodromes of neurodegenerationin Anderson-Fabry disease

ABSTRACT

Objective To estimate the prevalence of prodromal clinical features of neurodegeneration inpatients with Anderson-Fabry disease (AFD) in comparison to age-matched controls

Methods This is a single-center prospective cross-sectional study in 167 participants(60 heterozygous females and 50 hemizygous males with genetically confirmed AFD 57 age-matched controls) using a clinical screening program consisting of structured interview quantita-tive tests of motor function and assessments of cognition depression olfaction orthostaticintolerance pain REM sleep behavior disorder and daytime sleepiness

Results In comparison to age-matched controls (mean age 483 years) patients with AFD (meanage 490 years) showed slower gait and transfer speed poorer fine manual dexterity and lowerhand speed which was independent of focal symptoms due to cerebrovascular disease Patientswith AFD were more severely affected by depression pain and daytime sleepiness and had a lowerquality of life Thesemotor and nonmotormanifestations significantly correlatedwith clinical diseaseseverity However patients with AFD did not reveal extrapyramidal motor features or signs of sig-nificant cognitive impairment hyposmia orthostatic intolerance or REM sleep behavior disorderwhich commonly precede later neurodegenerative disease In our cohort there were no differencesin neurologic manifestations of AFD between heterozygous females and hemizygous males

Conclusions Aside from cerebrovascular manifestations and small fiber neuropathy AFD resultsin a distinct neurologic phenotype comprising poorer motor performance and specific nonmotorfeatures In contrast to functional loss of glucocerebrosidase in Gaucher disease a-galactosidasedeficiency in AFD is not associated with a typical cluster of clinical features prodromal forneurodegenerative diseases such as Parkinson disease Neurologyreg 2015841454ndash1464

GLOSSARYa-Gal 5 a-galactosidase A AFD 5 Anderson-Fabry disease ALP 5 autophagy-lysosomal pathway BDI 5 Beck DepressionInventory BPI5 Brief Pain Inventory ERT5 enzyme replacement therapy ESS5 Epworth Sleepiness Scale GD5 Gaucherdisease MDS-UPDRS 5 Movement Disorders Societyndashrevised version of the Unified Parkinsonrsquos Disease Rating ScaleMMSE 5 Mini-Mental State Examination MoCA 5 Montreal Cognitive Assessment MSSI 5 Mainz Severity Score IndexNIHSS 5 NIH Stroke Scale PD 5 Parkinson disease RBD 5 REM sleep behavior disorder RBDSQ 5 REM Sleep BehaviorDisorder Screening Questionnaire SF-36 5 36-item Short-Form health survey SS-16 5 Sniffinrsquo Sticks 16-item smellidentification test

Anderson-Fabry disease (AFD) is a rare X-linked lysosomal storage disorder resulting in defi-ciency of the lysosomal enzyme a-galactosidase A (a-Gal)1 and progressive accumulation ofundegraded glycosphingolipids in various tissues Neurologic manifestations of AFD includesmall fiber neuropathy associated with pain and reduced temperature sensation2 and prematurecerebrovascular events3 which are attributed to complex vasculopathy secondary to progressiveglycosphingolipid accumulation in vessels and to cardiac involvement

Neuropathologic studies have shown that glycosphingolipid storage in AFD is not restrictedto the vasculature but also present in neurons of brain regions known to be affected in

From the Department of Clinical Neuroscience Institute of Neurology (ML AHVS) and the Lysosomal Storage Disorders Unit Departmentof Haematology (DH AM LR AM) University College London UK and the Department of Neurology (ML HR) Dresden Universityof Technology Germany

Go to Neurologyorg for full disclosures Funding information and disclosures deemed relevant by the authors if any are provided at the end of the articleThe Article Processing charge was paid by RCUK

This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use distribution andreproduction in any medium provided the original work is properly cited

1454 copy 2015 American Academy of Neurology

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

neurodegenerative diseases such as the dorsalmotor nucleus of the vagus substantianigra and neocortex45 Moreover disrup-tion of the autophagy-lysosomal pathway(ALP) and focused presence of phosphorylateda-synuclein-containing lesions in the pons havebeen recently demonstrated in a-Gal-deficientmice6 Although Gaucher disease (GD) anotherlysosomal storage disorder has been shown tobe associated with at least a fivefold risk forParkinson disease (PD)7 and case reports havedescribed L-dopa-responsive parkinsonism in pa-tients with AFD89 the prevalence of prodromesof neurodegeneration has not been examined inthis rare disease

We report the results of a prospective cross-sectional study investigating the clinical signifi-cance of neuronal glycosphingolipid storage inAFD by examining prodromal features of neu-rodegeneration in a large cohort of patients andage-matched controls We hypothesized thatneuronal glycosphingolipid storage and ALPdisruption in AFD would result in clinicalmanifestations similar to those seen in GDpatients and carriers10

METHODS Standard protocol approvals registrationsand patient consents This prospective cross-sectional studyhad ethical approval from the North West London Research

Ethics Committee (REC number 10H072021) Written

informed consent was obtained from all participants

Participants A total of 110 patients with AFD (60 heterozy-

gous females 50 hemizygous males) were recruited between April

2011 and February 2012 from the Lysosomal Storage Disorders

Unit at the Royal Free London Hospital Diagnosis was confirmed

by molecular genetic analysis in all patients except one female

(genetic data available on request) Fifty-seven controls matched

to patients for age and ethnicity were identified from volunteers

and nonmedical staff at the hospital Controls were required to

have a negative family history for lysosomal storage disorders and

had no clinical signs of AFD Neither patients nor controls had

been diagnosed with neurodegenerative diseases in the past

Procedures Test procedures were performed identically in pa-

tients and controls All participants were assessed by the same

movement disorders specialist (ML) and underwent a structured

interview and detailed clinical screening for motor and nonmotor

prodromes of neurodegenerative diseases as explained below Dis-

ease severity in patients with AFD was rated with the Mainz

Severity Score Index (MSSI)11 The presence of white matter

abnormalities lacuna and territorial infarctions on latest cerebral

MRI scans was used to document cerebrovascular sequelae of

AFD Renal involvement was assessed by serum creatinine serum

urea glomerular filtration rate estimated by 51Cr-EDTA clear-

ance and presence of proteinuria Cardiac manifestations were

assessed by the interventricular septal diameter measured by the

latest transthoracic echocardiography

Evaluation of motor function Three tests were performed for

quantitative assessment of motor function (1) the Timed Up and

Go which is a basic measure of gait and transfer speed12 (2) the

Purdue Pegboard a test of fine manual dexterity motor speed

and finger-eye coordination13 and (3) a shortened 30-second

version of the alternate tap test used for the assessment of

motor speed in the hands with a moderate requirement of

coordination and accuracy14 Extrapyramidal motor symptoms

were evaluated with the activities of daily living and motor

subscales of the Movement Disorders Societyndashrevised version of

the Unified Parkinsonrsquos Disease Rating Scale (MDS-UPDRS

parts II and III)15 The NIH Stroke Scale (NIHSS) a graded

neurologic examination rating speech and language cognition

visual field deficits motor and sensory impairments and ataxia

was used to identify potential focal neurologic deficits due to

cerebrovascular disease16

Evaluation of nonmotor function and quality of life Cog-nitive function was assessed with the Mini-Mental State

Examination (MMSE)17 and the Montreal Cognitive Assessment

(MoCA)18 The MoCA has been shown to be more sensitive for

the detection of mild cognitive impairment or dementia in PD

than other scales with optimal cut-off scores of 26 indicating

mild cognitive impairment and 21 dementia19 Depressive

symptoms were evaluated with the Beck Depression Inventory

(BDI) II20 Olfactory function was assessed with the 16-item smell

identification test from Sniffinrsquo Sticks (SS-16 Burghart Messtechnik

Wedel Germany) Individuals with anatomical upper airway

abnormalities respiratory tract infections or a history of traumatic

head injury were excluded from the analysis Hyposmia was

diagnosed at SS-16 scores 11 which in the UK population have

shown to provide a PD probability of $5021 Resting blood

pressure and heart rate were taken after participants had been

resting for 5 minutes in supine position and 2 minutes after

standing up to check for signs of orthostatic intolerance Drops of

$20 mm Hg in systolic blood pressure were considered to be

clinically significant Pain was quantified with the Brief Pain

Inventory (BPI) which measures intensity of pain and the

interference of pain with the participantrsquos life22 Features of REM

sleep behavior disorder (RBD) were identified with the REM Sleep

Behavior Disorder Screening Questionnaire (RBDSQ) which was

considered positive at scores of $523 Daytime sleepiness was

screened for with the Epworth Sleepiness Scale (ESS) with ESS

values 10 points indicating significant sleepiness24 Quality of life

was assessed with the EQ-5D-5L25 and the 36-item Short-Form

health survey (SF-36)26

Statistical analyses Statistical analyses were performed with

SPSS software version 210 (SPSS Chicago IL) Since we

expected sex differences due to X-linked inheritance in AFD sta-

tistical comparisons were initially carried out separately for female

and male participants with the unpaired t test or Mann-WhitneyUtest (continuous variables) and the x2 or Fisher exact test (discrete

variables) as appropriate For comparison of continuous variables

between all participants we used a general linear model with disease

and sex as fixed factors and age as covariate which was valid in all

outcome parameters The Spearman correlation was used to assess

the association of clinical outcomes and theMSSI Pairwise deletion

was used for missing data Unless stated otherwise values are

displayed as unadjusted means 6 SD Two-sided p values 005

were deemed statistically significant

RESULTS Study participants A total of 110 patientswith AFD (60 heterozygous females 50 hemizygousmales) and 57 controls (29 female 28 male) were

Neurology 84 April 7 2015 1455

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

included in our cross-sectional study Mean age agerange and ethnic background were similar betweenpatients and controls (table 1) Patients with AFDwere less likely to have university education and tobe employed and more likely to be medically retiredthan controls Hyperlipidemia and hypertension hadbeen diagnosed more often in patients whereas othercardiovascular risk factors were similar between groupsCerebrovascular events were more often reported bypatients with AFD of whom 136 reported TIAs orstrokes in the past Antidepressants were morefrequently found in the concomitant medication ofpatients with AFD whereas other CNS medicationswere not different

Disease characteristics in patients with AFD Female andmale patients with AFD examined in this study hadbeen diagnosed a mean of 96 and 118 years agorespectively (table e-1 on the Neurologyreg Web siteat Neurologyorg) Male patients were less likely tohave a positive family history for AFD at the time ofdiagnosis than their female counterparts indicatingthat diagnosis in male patients had been made morefrequently following prior organ involvement

Clinical disease severity rated with the MSSI washigher in male than in female patients In keeping withhigher disease severity male patients with AFD weretreated more often with enzyme replacement therapy(ERT) which had been initiated in 88 of maleand 60 of female patients The difference in totalMSSI scores between sexes was due to higher renaland cardiac subscores in male participants whereasgeneral and neurologic MSSI subscores as well as thepoint distribution in individual components of theneurologic subscore were not different Accordinglymale patients showed more pronounced renal and car-diac involvement on laboratory markers of renal func-tion and transthoracic echocardiography respectivelywhereas cerebral MRI reports did not indicate signifi-cant differences in cerebrovascular manifestationsbetween female and male patients

Structured interview All participants were interviewedfor motor and nonmotor symptoms frequentlyobserved in neurodegenerative diseases (table e-2)In brief patients with AFD did not report extrapy-ramidal motor features more often than controlsWhen asked for nonmotor symptoms patients morefrequently noted orthostatic problems urinary dys-function constipation depression neuropathic painand impaired hearing whereas hyposmia visual dis-turbances and sleep problems were not reported dif-ferently in patients and controls

Motor function Quantitative assessments of motorfunction in patients with AFD demonstrated lowergait and transfer speed on the Timed Up and Go testand poorer fine manual dexterity and hand speed on

the Purdue Pegboard and the alternate tap testrespectively (table 2 and figure 1) Interestingly theseimpairments were still evident when we used theNIHSS as covariate instead of age in order to correctfor potential focal neurologic deficits due to cerebrovas-cular disease (results not shown) Evaluation of extrapy-ramidal motor function with the MDS-UPDRS parts IIand III revealed higher scores in patients with AFDcompared to controls indicating more impairment inmotor experiences of daily living and extrapyramidalmotor function Evaluation of extrapyramidalsymptoms demonstrated more asymmetric motorslowing and a trend for more postural instability inpatients with AFD whereas frequencies of tremorrigidity and reduced arm swing during gait weresimilar between groups (figure 2) Assessment for focalneurologic deficits with the NIHSS demonstrated verylow scores in all groups although mean NIHSS scoreswere slightly higher in patients with AFD as expected ina disease with known potential cerebrovascularmanifestations

Motor function worsened with increasing agewhich we used as covariate in our statistical modelFemale participants performed better on the PurduePegboard test whereas male participants performedbetter on the alternate tap test otherwise there wereno significant differences between sexes Importantlywe did not observe a combined effect of disease andsex on motor function arguing for similar diseaseeffects in female and male patients with AFD

Nonmotor function and quality of life Evaluation withMMSE and MoCA did not reveal significant cogni-tive deficits in patients with AFD although meanMoCA scores were slightly lower than in controls (fig-ure 1) due to reduced performance in abstraction anddelayed recall (table 3) Depressive symptoms on theBDI were more frequent and severe in patients withAFD who had significant and severe depression in268 and 82 of cases respectively Testing withthe SS-16 did not show differences in olfactoryfunction between patients and controls which wasalso illustrated by similarly low frequencies ofhyposmia in all groups During orthostatic challengepatients with AFD did not show more evidence fororthostatic hypotension than age-matched controlsBPI assessments revealed higher severity and functionalinterference of pain in patients with AFD than in age-matched controls which upon visual inspection of thequestionnaires was frequently due to a combination ofjoint problems and neuropathic pain Evaluation withthe ESS revealed significantly higher scores for daytimesleepiness in patients whereas screening with theRBDSQ provided no evidence for a higher frequencyof RBD in AFD Although most patients were treatedwith ERT both female and male patients with AFD had

1456 Neurology 84 April 7 2015

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

included in our cross-sectional study Mean age agerange and ethnic background were similar betweenpatients and controls (table 1) Patients with AFDwere less likely to have university education and tobe employed and more likely to be medically retiredthan controls Hyperlipidemia and hypertension hadbeen diagnosed more often in patients whereas othercardiovascular risk factors were similar between groupsCerebrovascular events were more often reported bypatients with AFD of whom 136 reported TIAs orstrokes in the past Antidepressants were morefrequently found in the concomitant medication ofpatients with AFD whereas other CNS medicationswere not different

Disease characteristics in patients with AFD Female andmale patients with AFD examined in this study hadbeen diagnosed a mean of 96 and 118 years agorespectively (table e-1 on the Neurologyreg Web siteat Neurologyorg) Male patients were less likely tohave a positive family history for AFD at the time ofdiagnosis than their female counterparts indicatingthat diagnosis in male patients had been made morefrequently following prior organ involvement

Clinical disease severity rated with the MSSI washigher in male than in female patients In keeping withhigher disease severity male patients with AFD weretreated more often with enzyme replacement therapy(ERT) which had been initiated in 88 of maleand 60 of female patients The difference in totalMSSI scores between sexes was due to higher renaland cardiac subscores in male participants whereasgeneral and neurologic MSSI subscores as well as thepoint distribution in individual components of theneurologic subscore were not different Accordinglymale patients showed more pronounced renal and car-diac involvement on laboratory markers of renal func-tion and transthoracic echocardiography respectivelywhereas cerebral MRI reports did not indicate signifi-cant differences in cerebrovascular manifestationsbetween female and male patients

Structured interview All participants were interviewedfor motor and nonmotor symptoms frequentlyobserved in neurodegenerative diseases (table e-2)In brief patients with AFD did not report extrapy-ramidal motor features more often than controlsWhen asked for nonmotor symptoms patients morefrequently noted orthostatic problems urinary dys-function constipation depression neuropathic painand impaired hearing whereas hyposmia visual dis-turbances and sleep problems were not reported dif-ferently in patients and controls

Motor function Quantitative assessments of motorfunction in patients with AFD demonstrated lowergait and transfer speed on the Timed Up and Go testand poorer fine manual dexterity and hand speed on

the Purdue Pegboard and the alternate tap testrespectively (table 2 and figure 1) Interestingly theseimpairments were still evident when we used theNIHSS as covariate instead of age in order to correctfor potential focal neurologic deficits due to cerebrovas-cular disease (results not shown) Evaluation of extrapy-ramidal motor function with the MDS-UPDRS parts IIand III revealed higher scores in patients with AFDcompared to controls indicating more impairment inmotor experiences of daily living and extrapyramidalmotor function Evaluation of extrapyramidalsymptoms demonstrated more asymmetric motorslowing and a trend for more postural instability inpatients with AFD whereas frequencies of tremorrigidity and reduced arm swing during gait weresimilar between groups (figure 2) Assessment for focalneurologic deficits with the NIHSS demonstrated verylow scores in all groups although mean NIHSS scoreswere slightly higher in patients with AFD as expected ina disease with known potential cerebrovascularmanifestations

Motor function worsened with increasing agewhich we used as covariate in our statistical modelFemale participants performed better on the PurduePegboard test whereas male participants performedbetter on the alternate tap test otherwise there wereno significant differences between sexes Importantlywe did not observe a combined effect of disease andsex on motor function arguing for similar diseaseeffects in female and male patients with AFD

Nonmotor function and quality of life Evaluation withMMSE and MoCA did not reveal significant cogni-tive deficits in patients with AFD although meanMoCA scores were slightly lower than in controls (fig-ure 1) due to reduced performance in abstraction anddelayed recall (table 3) Depressive symptoms on theBDI were more frequent and severe in patients withAFD who had significant and severe depression in268 and 82 of cases respectively Testing withthe SS-16 did not show differences in olfactoryfunction between patients and controls which wasalso illustrated by similarly low frequencies ofhyposmia in all groups During orthostatic challengepatients with AFD did not show more evidence fororthostatic hypotension than age-matched controlsBPI assessments revealed higher severity and functionalinterference of pain in patients with AFD than in age-matched controls which upon visual inspection of thequestionnaires was frequently due to a combination ofjoint problems and neuropathic pain Evaluation withthe ESS revealed significantly higher scores for daytimesleepiness in patients whereas screening with theRBDSQ provided no evidence for a higher frequencyof RBD in AFD Although most patients were treatedwith ERT both female and male patients with AFD had

1456 Neurology 84 April 7 2015

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Table 1 Demographic data of patients with Anderson-Fabry disease and age-matched controls

Female controls Female patients Male controls Male patients All controls All patients p Valuesa

No of participants 29 60 28 50 57 110

Age y

Mean (SD) 475 (179) 478 (161) 491 (171) 505 (159) 483 (174) 490 (160)

Minndashmax 216ndash882 173ndash844 237ndash863 190ndash812 216ndash882 173ndash844

Ethnic groups n ()

White 26 (897) 59 (983) 27 (964) 50 (1000) 53 (930) 109 (991)

Asian 2 (69) 1 (17) 1 (36) 0 (00) 3 (53) 1 (09)

Black 0 (00) 0 (00) 0 (00) 0 (00) 0 (00) 0 (00)

Mixed 1 (34) 0 (00) 0 (00) 0 (00) 1 (18) 0 (00)

School education y n ()

gt12 21 (724) 22 (367)b 23 (821) 24 (480)b 44 (772) 46 (418) 005b

12 (A-Levels) 4 (138) 10 (167) 2 (71) 3 (60) 6 (105) 13 (118)

11 (GCSE) 3 (103) 15 (250) 0 (00) 13 (260)b 3 (53) 28 (255) 005b

lt11 1 (34) 13 (217)b 3 (107) 10 (200) 4 (70) 23 (209) 005b

Profession n ()

Studying 5 (172) 4 (67) 1 (36) 2 (40) 6 (105) 6 (55)

Employed 20 (690) 35 (583) 22 (786) 29 (580) 42 (737) 64 (582) 005b

Housewife 0 (00) 5 (83) NA NA 0 (00) 5 (45)

Pensioned 4 (138) 10 (167) 5 (179) 9 (180) 9 (158) 19 (173)

Medically retired 0 (00) 4 (67) 0 (00) 5 (100) 0 (00) 9 (82) 005b

Unemployed 0 (00) 2 (33) 0 (00) 5 (100) 0 (00) 7 (64)

Cardiovascular risk factors

Adipositas n () 4 (138) 12 (200) 5 (179) 9 (180) 9 (158) 21 (191)

Body mass index kgm2 mean (SD) 253 (42) 259 (47) 269 (41) 257 (51) 261 (42) 258 (49)

Diabetes mellitus type 2 n () 1 (34) 2 (33) 1 (36) 4 (80) 2 (35) 6 (55)

Hyperlipidemia n () 3 (103) 22 (367)c 4 (143) 19 (380)c 7 (123) 41 (373) 0001c

Hypertension n () 3 (103) 17 (283) 4 (143) 16 (320) 7 (123) 33 (300) 0011c

Smoking n () 4 (138) 9 (150) 4 (143) 10 (200) 8 (140) 19 (173)

Pack-years in smokers mean (SD) 189 (166) 126 (161) 105 (117) 164 (118) 147 (141) 146 (124)

Cerebrovascular events n ()

None 28 (966) 50 (833) 28 (1000) 45 (900) 56 (982) 95 (864) 0013c

TIA 0 (00) 5 (83) 0 (00) 2 (40) 0 (00) 7 (64)

Stroke 1 (34) 5 (83) 0 (00) 3 (60) 1 (18) 8 (73)

Concomitant CNS medications n ()

Antidepressants 0 (00) 9 (150)d 0 (00) 4 (80) 0 (00) 13 (118) 0005d

Antiparkinsonian agents 0 (00) 0 (00) 0 (00) 0 (00) 0 (00) 0 (00)

Dopamine antagonists 1 (34) 0 (00) 0 (00) 1 (20) 1 (18) 1 (09)

Neuroleptics 0 (00) 0 (00) 0 (00) 2 (40) 0 (00) 2 (18)

Abbreviations GCSE 5 General Certificate of Secondary Education NA 5 not applicableNonsignificant p values were omitted for clarity Significant differences within female and male participants with p 005 additionally indicated bycPearson x2 test dFisher exact test or bZ test Means are provided as unadjusted meansap Values for comparisons between patients with Anderson-Fabry disease and age-matched controlsbx2 test for equality of 2 proportions (Z test)c Pearson x2 testd Fisher exact test

Neurology 84 April 7 2015 1457

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Table 2 Motor function and focal neurologic symptoms in patients with Anderson-Fabry disease and age-matched controls

Female controls Female patients Male controls Male patients All controls All patients

F and p values after GLM analysis

Disease Other factors

No of participants 29 60 28 50 57 110

Right-handedness n () 24 (828) 48 (800) 26 (929) 44 (880) 50 (877) 92 (836)

Quantitative tests of motor function

Timed Up and Go s mean (SD) 72 (16) 87 (29)a 72 (11) 88 (61)a 72 (14) 88 (46) F 5 58 p 5 0018 Age F 5 84 p 5 0004

Purdue Pegboard test pegs30 s mean (SD)

Dominant hand 164 (26) 150 (23)a 153 (23) 141 (25)a 159 (25) 146 (24) F 5 132 p 0001 Age F 5 571 p 0001 sex F 5 54 p 5 0021

Nondominant hand 150 (24) 140 (22) 146 (23) 137 (21) 148 (24) 139 (22) F 5 74 p 5 0007 Age F 5 651 p 0001

Alternate tap test taps30 s mean (SD)

Dominant hand 1149 (171) 1052 (227) 1236 (139) 1132 (220)a 1191 (161) 1089 (226) F 5 92 p 5 0003 Age F 5 142 p 0001 sex F 5 80 p 5 0005

Nondominant hand 1051 (171) 964 (178) 1110 (161) 1018 (169)a 1080 (167) 989 (175) F 5 104 p 5 0002 Age F 5 151 p 0001 sex F 5 54 p 5 0021

Extrapyramidal function mean (SD)

MDS-UPDRS part II (M-EDL) 09 (18) 28 (45) 09 (16) 24 (62) 09 (17) 26 (53) F 5 55 p 5 0021 Age F 5 56 p 5 0019

MDS-UPDRS part III (motor examination) 33 (52) 56 (61) 42 (36) 60 (60) 37 (39) 58 (60) F 5 56 p 5 0019 Age F 5 330 p 0001

Focal neurologic deficits mean (SD)

NIHSS score mean (SD) 0 (0) 028 (085)a 004 (019) 020 (078) 002 (013) 025 (082) F 5 41 p 5 0046

Neurologic deficit NIHSS Dagger1 n () 0 (0) 9 (150)b 1 (36) 5 (100) 1 (18) 14 (127) (0019)

Abbreviations GLM5 general linear model M-EDL5motor experiences of daily living MDS-UPDRS5Movement Disorder Societyndashsponsored new version of the Unified Parkinsonrsquos Disease Rating Scale NIHSS5

NIH Stroke ScaleStatistical comparison between controls and patients was performed with a GLM using disease and sex as fixed factors and age as covariate Additional statistical comparison within female and male participantswas performed with Fisher exact test or Mann-Whitney test as appropriate ap 005 within same sex with Mann-Whitney U test bp 005 within same sex with Fisher exact test Values in parentheses representgroup analysis of NIHSS ordinal data performed with x2 test instead of GLM Means are provided as unadjusted means Nonsignificant p values have been omitted for clarity

1458

Neurology

84

April7

2015

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a markedly reduced quality of life as documented by theEQ-5D-VAS and the SF-36 total scores (table 3)

Similar to motor function age also affected sev-eral nonmotor outcomes in patients and controls(table 3) Higher age was associated with cognitivedecline on the MMSE and MoCA a reduction ofolfactory function on the SS-16 a lower drop ofblood pressure and reduced compensatory increaseof heart rate upon standing up higher pain severityand interference indices on the BPI more daytime

sleepiness on the ESS and a lower quality of life onboth EQ-5D-VAS and SF-36 (not shown) Sexeffects were only identified during olfactory testingwhere female participants performed significantlybetter than male participants (table 3) In keepingwith our observations on motor function we did notidentify any differences in nonmotor outcomesbetween female and male patients with AFD againindicating that the disease similarly affected bothsexes

Figure 1 Motor and nonmotor outcomes in patients with Anderson-Fabry disease (red circles) and age-matched controls (blue circles)

Black bars indicate unadjusted mean values N 5 110 and n 5 57 for patients with Anderson-Fabry disease (AFD) and age-matched controls respectivelyp 005 p 001 p 0001 in comparison to age-matched controls with a general linear model using disease and sex as fixed factors and age ascovariate Only disease effects are shown BDI 5 Beck Depression Inventory BPI 5 Brief Pain Inventory ESS 5 Epworth Sleepiness Scale MCI 5 mildcognitive impairment MoCA 5 Montreal Cognitive Assessment RBD 5 REM sleep behavior disorder RBDSQ 5 REM Sleep Behavior Disorder ScreeningQuestionnaire SS-16 5 16-item smell identification test from Sniffinrsquo Sticks

Neurology 84 April 7 2015 1459

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Correlation of study outcomes with disease severity Inorder to assess whether neurologic symptoms wouldalso correlate with disease severity in AFD we per-formed bivariate correlations of all outcome parame-ters with the MMSI (table e-3) Significant andmoderate correlations were found for all motor scalesdepression (BDI-II) pain (BPI) and quality of life(EuroQoL Visual Analogue Scale SF-36 score)

DISCUSSION We report a prospective cross-sectionalstudy on prodromal symptoms of neurodegeneration ina large cohort of patients with AFD aiming to evaluatethe clinical relevance of neuronal glycosphingolipidaccumulation in this rare disease We found that

AFD is associated with impaired motor function andvarious nonmotor symptoms but unlike GD doesnot lead to a pattern of extrapyramidal symptomssignificant cognitive problems hyposmia or RBDcommonly preceding neurodegenerative diseases inparticular PD27 and dementia with Lewy bodies28

Aside from cardinal neurologic manifestationssuch as stroke29 and small fiber neuropathy2 previousstudies have described depression30 pain31 and day-time sleepiness32 in 46 53 and 68 of patientswith AFD respectively Our study was able to repro-duce these findings but prevalence of these nonmo-tor symptoms was lower in our cohort possibly dueto ongoing symptomatic treatment or ERT in themajority of cases Nevertheless it is noteworthy that4 out of 9 severely depressed patients did not receivetreatment with antidepressants reemphasizing theneed for recognition of depressive symptoms in thisdisease AFD was not associated with cognitiveimpairment or autonomic dysfunction which is inkeeping with previous smaller studies33ndash35 Moreoverwe were able to show that AFD does not result inhyposmia or RBD which are prodromal for later neu-rodegenerative disease

In addition our study suggests that AFD does notlead to extrapyramidal symptoms or parkinsonianmotor features but instead is associated with motorimpairments during gait and transfer and poorer finemanual dexterity and hand speed These deficits inmotor function correlated to clinical disease severitysimilar to depression and pain which emphasizes thatmotor impairments are an integral part of the diseaseThe pathophysiologic reasons for poorer motor per-formance in AFD cannot be answered by our clinicalstudy and remain to be elucidated Although cerebro-vascular manifestations of AFD may lead to motorimpairment it must be noted that frequency and bur-den of cerebrovascular symptoms in our AFD cohortwas very low and that disease effects on motor func-tion were still evident when results were correctedfor the presence of focal neurologic deficits Noneof our patients complained about sensory losswhich is in agreement with previous neurophysiologicstudies demonstrating that small fiber dysfunctionpredominates in the disease2 and argues againstperipheral neuropathy as the main reason forimpaired motor function Interestingly former neu-ropathologic studies have shown that glycosphingo-lipid accumulation in AFD is not limited to thevasculature but can be found in neurons of variousbrain regions in particular the brainstem45 Recentlya study has demonstrated ALP disruption and focusedpresence of phosphorylated a-synuclein-containinglesions in the pons of a-Gal-deficient mice whichwere colocalized with large axonal spheroids indicat-ing axonal degeneration6 We therefore speculate that

Figure 2 Extrapyramidal motor symptoms in patients with Anderson-Fabrydisease (red bars) and age-matched controls (blue bars)

N 5 110 and n 5 57 for patients with Anderson-Fabry disease (AFD) and age-matchedcontrols respectively Symptoms were assessed during clinical evaluation with the Move-ment Disorders Societyndashrevised version of the Unified Parkinsonrsquos Disease Rating Scale(MDS-UPDRS) Postural instability was evaluated with the pull test Motor asymmetry wasdefined as right-minus-left difference score$2 on side-specific MDS-UPDRS items Fisherexact test Pearson x2 test

1460 Neurology 84 April 7 2015

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Table 3 Nonmotor function and quality of life in patients with Anderson-Fabry disease and age-matched controls

Femalecontrols

Femalepatients

Malecontrols

Malepatients

Allcontrols All patients

F and p values after GLM analysis for

Disease Other factors

No of participants 29 60 28 50 57 110

Autonomic function (orthostatic challenge)

BP change at 2 minutes mm Hg mean (SD) 256 (111) 244 (106) 239 (141) 04 (119) 248 (126) 222 (114) Age F 5 50 p 5 0026

HR change at 2 minutes (1min) mean (SD) 92 (91) 111 (92) 86 (70) 100 (65) 89 (80) 106 (80) Age F 5 268 p 0001

Significant BP drop (gt20 mm Hg) n () 2 (69) 4 (74) 4 (143) 2 (43) 6 (105) 6 (60)

Cognition

MMSE

Total score (0ndash30) mean (SD) 287 (15) 283 (20) 290 (13) 285 (15) 288 (14) 284 (18) Age F 5 171 p 0001

Dementia (lt24 points) n () 0 (0) 2 (33) 0 (0) 0 (0) 0 (0) 2 (12)

MoCA

Visuospatial and executive mean (SD) 45 (07) 42 (10) 46 (07) 43 (08) 45 (07) 43 (09) Age F 5 173 p 0001

Naming mean (SD) 30 (02) 30 (02) 30 (0) 30 (01) 30 (02) 30 (02)

Attention mean (SD) 54 (07) 54 (09) 58 (06) 58 (05) 56 (07) 56 (08) Age F 5 77 p 5 0006 sex F 5 100 p 5 0002

Language mean (SD) 24 (07) 21 (09) 24 (07) 23 (08) 24 (07) 22 (09)

Abstraction mean (SD) 18 (04) 18 (04) 20 (00) 18 (04)a 19 (03) 18 (04) F 5 61 p 5 0014

Delayed recall mean (SD) 44 (10) 38 (15)b 42 (08) 38 (12) 43 (09) 38 (14) F 5 63 p 5 0013 Age F 5 253 p 0001

Orientation mean (SD) 59 (03) 59 (03) 59 (03) 59 (03) 59 (03) 59 (03)

Total score (0ndash30) mean (SD) 276 (23) 266 (28) 280 (16) 273 (20) 278 (20) 269 (25) F 5 50 p 5 0027 Age F 5 261 p 0001

MCI (lt26 points) n () 4 (138) 15 (250) 2 (71) 8 (160) 6 (105) 23 (209) (p 5 0093c)

Dementia (lt21 points) n () 1 (34) 3 (50) 0 (0) 0 (0) 1 (18) 3 (27)

Depression

BDI-II

Total score mean (SD) 38 (47) 113 (111)a 32 (35) 80 (86)a 35 (41) 98 (102) F 5 187 p 0001

Depression (gt13 points) n () 2 (69) 19 (317)c 0 (0) 10 (200)d 2 (35) 29 (268) (p 0001c)

Severe depression (Dagger30 points) n () 0 (0) 5 (83) 0 (0) 4 (82) 0 (0) 9 (82) (p 5 0028c)

Olfaction

SS-16

Total score (0ndash16) mean (SD) 135 (15) 135 (17) 127 (21) 129 (15) 131 (18) 132 (16) Age F 5 45 p 5 0035 sex F 5 56 p 5 002

Hyposmia (lt11 points) n () 1 (34) 3 (53) 2 (74) 2 (42) 3 (54) 5 (48)

Continued

Neurology

84

April7

2015

1461

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Table 3 Continued

Femalecontrols

Femalepatients

Malecontrols

Malepatients

Allcontrols All patients

F and p values after GLM analysis for

Disease Other factors

Pain

BPI

Pain severity index (0ndash10) mean (SD) 09 (16) 22 (24)b 07 (14) 15 (22)a 08 (15) 19 (23) F 5 98 p 5 0002 Age F 5 96 p 5 0002

Function interference index (0ndash10) mean (SD) 06 (12) 19 (25)b 06 (14) 15 (26)a 06 (13) 17 (25) F 5 91 p 5 0003 Age F 5 48 p 5 003

Sleep

RBDSQ

Total score mean (SD) 25 (20) 32 (28) 26 (19) 28 (27) 25 (19) 30 (28) Age F 5 67 p 5 001

RBD (Dagger5 points) n () 5 (172) 16 (267) 3 (107) 13 (265) 8 (140) 29 (266)

ESS

Total score (0ndash24) mean (SD) 56 (39) 74 (51) 47 (44) 71 (48)b 51 (42) 72 (50) F 5 70 p 5 0009 Age F 5 57 p 5 0018

Significant sleepiness (Dagger10 points) n () 5 (172) 16 (267) 6 (214) 12 (245) 11 (193) 28 (257)

Quality of life

EuroQol Visual Analogue Scale (0ndash100) mean (SD) 856 (198) 768 (190)a 839 (116) 726 (201)b 848 (161) 749 (195) F 5 109 p 5 0001 Age F 5 89 p 5 0003

SF-36 total score (0ndash100) mean (SD) 846 (125) 628 (244)a 863 (120) 682 (239)a 854 (122) 652 (242) F 5 344 p 0001 Age F 5 113 p 5 0001

Abbreviations BDI 5 Beck Depression Inventory BP 5 blood pressure BPI 5 Brief Pain Inventory ESS 5 Epworth Sleepiness Scale GLM 5 general linear model HR 5 heart rate MCI 5 mild cognitive impairmentMMSE 5 Mini-Mental State Examination MoCA 5 Montreal Cognitive Assessment RBD 5 REM sleep behavior disorder RBDSQ 5 REM Sleep Behavior Disorder Screening Questionnaire SF-36 5 Short FormHealth Survey SS-16 5 Sniffinrsquo Sticks 16-item smell identification testStatistical comparison between controls and patients was performed with a GLM using disease and sex as fixed factors and age as covariate Additional statistical comparison within female and male participantswas performed with the x2 test Fisher exact test or Mann-Whitney U test ap 001 bp 005 within same sex with Mann-Whitney U test cp 005 within same sex with x2 test dp 005 within same sex withFisher exact test Values in parentheses represent p values derived from group analysis of MCI and depression rates performed with x2 test instead of GLM Means are provided as unadjusted means Nonsignificantp values have been omitted for clarity

1462

Neurology

84

April7

2015

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

neuronal glycosphingolipid storage and ALP disrup-tion in AFD lead to focused brainstem pathologywhich results in a distinct clinical phenotype withmild motor impairment and nonmotor symptomssuch as depression pain daytime sleepiness andhearing loss but is not associated with cardinal clin-ical prodromes of neurodegenerative diseases such asparkinsonian motor signs and impairments of cogni-tion and olfaction that are found in GD10 Howeverwe would not completely rule out a contribution ofa-Gal deficiency to the development of neurodegen-erative disease based on the lack of clinical prodromesespecially as neuropathologic brainstem involvementhas also been demonstrated in presymptomatic stagesof PD36

Another interesting observation of our study is thesimilarity of neurologic manifestations in female andmale patients with AFD which is in keeping withother studies showing significant organ involvementin female heterozygotes despite X-chromosomalinheritance37 Skewed inactivation of the X-chromo-some was suspected to explain disease manifestations infemale patients which is supported by recent researchdemonstrating correlations between X-inactivation andclinical disease severity in female patients38 Molecularinterference by the mutant enzyme protein exertinga dominant negative effect on the normal gene pro-duct has also been suggested39 but this explanatorytheory remains to be proven While the reasons forsex parity of disease manifestations in AFD remain tobe elucidated our study should raise physiciansrsquoawareness for symptoms in female patients withAFD who are often considered as carriers of butnot patients with the disease

Strengths of our study in this rare disease includeits size range and complexity of clinical testing andthe use of age-matched controls to enhance externalvalidity of the results Due to its observational andcross-sectional design our study has some limitationswhich may have influenced its outcome First themajority of patients in our AFD cohort were treatedwith ERT which may have partly altered the naturalphenotype of the disease and explain lower severity ofperipheral nonmotor symptoms such as pain How-ever ERT is unlikely to influence neurologic symp-toms caused by central manifestations of AFD suchas motor features hyposmia or RBD since it cannotcross the bloodndashbrain barrier Secondly it must beacknowledged that blinded examination was not possi-ble due to facial stigmata and skin manifestations inAFD which may have subconsciously influenced ourassessments although we applied well-established andhighly standardized clinical tests to minimize observerbias Third sex comparison in our study may notentirely reflect natural conditions in AFD carriers sinceour cohort was recruited from a university-based

specialty center in which more severely affected femalepatients may be overrepresented Moreover patientsrsquoperception of having AFD may have contributed toworse outcomes on questionnaires in comparison tocontrols

Taken together our study argues for a distinctneurologic phenotype in AFD that lacks classical pro-dromal features of neurodegeneration that have beendemonstrated in GD Unlike functional loss of gluco-cerebrosidase in GD which has been shown to beinvolved in accumulation of a-synuclein and resultsin neurotoxicity40 AFD-linked deficiency of a-Gal isapparently not associated with neurodegeneration onthe clinical level

AUTHOR CONTRIBUTIONSM Loumlhle design and conceptualization of the study analysis and inter-

pretation of the data drafting and revising the manuscript for intellectual

content D Hughes revising the manuscript for intellectual content

A Milligan revising the manuscript for intellectual content L Richfield

revising the manuscript for intellectual content H Reichmann revising

the manuscript for intellectual content A Mehta revising the manu-

script for intellectual content A Schapira design and conceptualization

of the study interpretation of the data revising the manuscript for intel-

lectual content

ACKNOWLEDGMENTThe authors thank the patients and controls for their participation and

Junibelle Cooke Anna Fernandez-Saranillo Patricia Pilgrim and Mark

McKie members of the Lysosomal Storage Disorder Unit at the Royal

Free Hospital who helped with recruitment for this study M Loumlhle

thanks Alisdair McNeill Christos Proukakis and Alexander Storch for

discussions

STUDY FUNDINGSupported by the NIHR UCLH Biomedical Research Centre and UCLH

BRC award to AHV Schapira AHV Schapira is a NIHR Senior

Investigator

DISCLOSUREM Loumlhle was supported by a seed grant of the Center for Regenerative

Therapies Dresden and has received honoraria for presentations from

Boehringer Ingelheim GlaxoSmithKline MEDA Pharma and UCB

D Hughes has received travel and research grants and honoraria

for speaking and advisory boards from Amicus Genzyme (Sanofi) and

Shire A Milligan has received travel grants from Genzyme (Sanofi) and

Shire L Richfield has received travel grants from Genzyme (Sanofi)

and Shire H Reichmann was acting on Advisory Boards and gave lec-

tures and has received research grants from Abbott Abbvie Bayer Health

Care Boehringer Ingelheim Brittania Cephalon Desitin GSK Lund-

beck Medtronic Merck-Serono Novartis Orion Pfizer TEVA UCB

and Valeant A Mehta has received travel and research grants and

honoraria for speaking and advisory boards from Genzyme (Sanofi) and

Shire A Schapira is a NIHR Senior Investigator He has received

honoraria for educational symposia and consultancy from Boehringer

Ingelheim Teva-Lundbeck UCB Merz Merck Orion and Novartis

Go to Neurologyorg for full disclosures

Received September 13 2014 Accepted in final formDecember 22 2014

REFERENCES1 Brady RO Gal AE Bradley RM Martensson E

Warshaw AL Laster L Enzymatic defect in Fabryrsquos dis-

ease ceramidetrihexosidase deficiency N Engl J Med

19672761163ndash1167

Neurology 84 April 7 2015 1463

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Table 2 Motor function and focal neurologic symptoms in patients with Anderson-Fabry disease and age-matched controls

Female controls Female patients Male controls Male patients All controls All patients

F and p values after GLM analysis

Disease Other factors

No of participants 29 60 28 50 57 110

Right-handedness n () 24 (828) 48 (800) 26 (929) 44 (880) 50 (877) 92 (836)

Quantitative tests of motor function

Timed Up and Go s mean (SD) 72 (16) 87 (29)a 72 (11) 88 (61)a 72 (14) 88 (46) F 5 58 p 5 0018 Age F 5 84 p 5 0004

Purdue Pegboard test pegs30 s mean (SD)

Dominant hand 164 (26) 150 (23)a 153 (23) 141 (25)a 159 (25) 146 (24) F 5 132 p 0001 Age F 5 571 p 0001 sex F 5 54 p 5 0021

Nondominant hand 150 (24) 140 (22) 146 (23) 137 (21) 148 (24) 139 (22) F 5 74 p 5 0007 Age F 5 651 p 0001

Alternate tap test taps30 s mean (SD)

Dominant hand 1149 (171) 1052 (227) 1236 (139) 1132 (220)a 1191 (161) 1089 (226) F 5 92 p 5 0003 Age F 5 142 p 0001 sex F 5 80 p 5 0005

Nondominant hand 1051 (171) 964 (178) 1110 (161) 1018 (169)a 1080 (167) 989 (175) F 5 104 p 5 0002 Age F 5 151 p 0001 sex F 5 54 p 5 0021

Extrapyramidal function mean (SD)

MDS-UPDRS part II (M-EDL) 09 (18) 28 (45) 09 (16) 24 (62) 09 (17) 26 (53) F 5 55 p 5 0021 Age F 5 56 p 5 0019

MDS-UPDRS part III (motor examination) 33 (52) 56 (61) 42 (36) 60 (60) 37 (39) 58 (60) F 5 56 p 5 0019 Age F 5 330 p 0001

Focal neurologic deficits mean (SD)

NIHSS score mean (SD) 0 (0) 028 (085)a 004 (019) 020 (078) 002 (013) 025 (082) F 5 41 p 5 0046

Neurologic deficit NIHSS Dagger1 n () 0 (0) 9 (150)b 1 (36) 5 (100) 1 (18) 14 (127) (0019)

Abbreviations GLM5 general linear model M-EDL5motor experiences of daily living MDS-UPDRS5Movement Disorder Societyndashsponsored new version of the Unified Parkinsonrsquos Disease Rating Scale NIHSS5

NIH Stroke ScaleStatistical comparison between controls and patients was performed with a GLM using disease and sex as fixed factors and age as covariate Additional statistical comparison within female and male participantswas performed with Fisher exact test or Mann-Whitney test as appropriate ap 005 within same sex with Mann-Whitney U test bp 005 within same sex with Fisher exact test Values in parentheses representgroup analysis of NIHSS ordinal data performed with x2 test instead of GLM Means are provided as unadjusted means Nonsignificant p values have been omitted for clarity

1458

Neurology

84

April7

2015

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

a markedly reduced quality of life as documented by theEQ-5D-VAS and the SF-36 total scores (table 3)

Similar to motor function age also affected sev-eral nonmotor outcomes in patients and controls(table 3) Higher age was associated with cognitivedecline on the MMSE and MoCA a reduction ofolfactory function on the SS-16 a lower drop ofblood pressure and reduced compensatory increaseof heart rate upon standing up higher pain severityand interference indices on the BPI more daytime

sleepiness on the ESS and a lower quality of life onboth EQ-5D-VAS and SF-36 (not shown) Sexeffects were only identified during olfactory testingwhere female participants performed significantlybetter than male participants (table 3) In keepingwith our observations on motor function we did notidentify any differences in nonmotor outcomesbetween female and male patients with AFD againindicating that the disease similarly affected bothsexes

Figure 1 Motor and nonmotor outcomes in patients with Anderson-Fabry disease (red circles) and age-matched controls (blue circles)

Black bars indicate unadjusted mean values N 5 110 and n 5 57 for patients with Anderson-Fabry disease (AFD) and age-matched controls respectivelyp 005 p 001 p 0001 in comparison to age-matched controls with a general linear model using disease and sex as fixed factors and age ascovariate Only disease effects are shown BDI 5 Beck Depression Inventory BPI 5 Brief Pain Inventory ESS 5 Epworth Sleepiness Scale MCI 5 mildcognitive impairment MoCA 5 Montreal Cognitive Assessment RBD 5 REM sleep behavior disorder RBDSQ 5 REM Sleep Behavior Disorder ScreeningQuestionnaire SS-16 5 16-item smell identification test from Sniffinrsquo Sticks

Neurology 84 April 7 2015 1459

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Correlation of study outcomes with disease severity Inorder to assess whether neurologic symptoms wouldalso correlate with disease severity in AFD we per-formed bivariate correlations of all outcome parame-ters with the MMSI (table e-3) Significant andmoderate correlations were found for all motor scalesdepression (BDI-II) pain (BPI) and quality of life(EuroQoL Visual Analogue Scale SF-36 score)

DISCUSSION We report a prospective cross-sectionalstudy on prodromal symptoms of neurodegeneration ina large cohort of patients with AFD aiming to evaluatethe clinical relevance of neuronal glycosphingolipidaccumulation in this rare disease We found that

AFD is associated with impaired motor function andvarious nonmotor symptoms but unlike GD doesnot lead to a pattern of extrapyramidal symptomssignificant cognitive problems hyposmia or RBDcommonly preceding neurodegenerative diseases inparticular PD27 and dementia with Lewy bodies28

Aside from cardinal neurologic manifestationssuch as stroke29 and small fiber neuropathy2 previousstudies have described depression30 pain31 and day-time sleepiness32 in 46 53 and 68 of patientswith AFD respectively Our study was able to repro-duce these findings but prevalence of these nonmo-tor symptoms was lower in our cohort possibly dueto ongoing symptomatic treatment or ERT in themajority of cases Nevertheless it is noteworthy that4 out of 9 severely depressed patients did not receivetreatment with antidepressants reemphasizing theneed for recognition of depressive symptoms in thisdisease AFD was not associated with cognitiveimpairment or autonomic dysfunction which is inkeeping with previous smaller studies33ndash35 Moreoverwe were able to show that AFD does not result inhyposmia or RBD which are prodromal for later neu-rodegenerative disease

In addition our study suggests that AFD does notlead to extrapyramidal symptoms or parkinsonianmotor features but instead is associated with motorimpairments during gait and transfer and poorer finemanual dexterity and hand speed These deficits inmotor function correlated to clinical disease severitysimilar to depression and pain which emphasizes thatmotor impairments are an integral part of the diseaseThe pathophysiologic reasons for poorer motor per-formance in AFD cannot be answered by our clinicalstudy and remain to be elucidated Although cerebro-vascular manifestations of AFD may lead to motorimpairment it must be noted that frequency and bur-den of cerebrovascular symptoms in our AFD cohortwas very low and that disease effects on motor func-tion were still evident when results were correctedfor the presence of focal neurologic deficits Noneof our patients complained about sensory losswhich is in agreement with previous neurophysiologicstudies demonstrating that small fiber dysfunctionpredominates in the disease2 and argues againstperipheral neuropathy as the main reason forimpaired motor function Interestingly former neu-ropathologic studies have shown that glycosphingo-lipid accumulation in AFD is not limited to thevasculature but can be found in neurons of variousbrain regions in particular the brainstem45 Recentlya study has demonstrated ALP disruption and focusedpresence of phosphorylated a-synuclein-containinglesions in the pons of a-Gal-deficient mice whichwere colocalized with large axonal spheroids indicat-ing axonal degeneration6 We therefore speculate that

Figure 2 Extrapyramidal motor symptoms in patients with Anderson-Fabrydisease (red bars) and age-matched controls (blue bars)

N 5 110 and n 5 57 for patients with Anderson-Fabry disease (AFD) and age-matchedcontrols respectively Symptoms were assessed during clinical evaluation with the Move-ment Disorders Societyndashrevised version of the Unified Parkinsonrsquos Disease Rating Scale(MDS-UPDRS) Postural instability was evaluated with the pull test Motor asymmetry wasdefined as right-minus-left difference score$2 on side-specific MDS-UPDRS items Fisherexact test Pearson x2 test

1460 Neurology 84 April 7 2015

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Table 3 Nonmotor function and quality of life in patients with Anderson-Fabry disease and age-matched controls

Femalecontrols

Femalepatients

Malecontrols

Malepatients

Allcontrols All patients

F and p values after GLM analysis for

Disease Other factors

No of participants 29 60 28 50 57 110

Autonomic function (orthostatic challenge)

BP change at 2 minutes mm Hg mean (SD) 256 (111) 244 (106) 239 (141) 04 (119) 248 (126) 222 (114) Age F 5 50 p 5 0026

HR change at 2 minutes (1min) mean (SD) 92 (91) 111 (92) 86 (70) 100 (65) 89 (80) 106 (80) Age F 5 268 p 0001

Significant BP drop (gt20 mm Hg) n () 2 (69) 4 (74) 4 (143) 2 (43) 6 (105) 6 (60)

Cognition

MMSE

Total score (0ndash30) mean (SD) 287 (15) 283 (20) 290 (13) 285 (15) 288 (14) 284 (18) Age F 5 171 p 0001

Dementia (lt24 points) n () 0 (0) 2 (33) 0 (0) 0 (0) 0 (0) 2 (12)

MoCA

Visuospatial and executive mean (SD) 45 (07) 42 (10) 46 (07) 43 (08) 45 (07) 43 (09) Age F 5 173 p 0001

Naming mean (SD) 30 (02) 30 (02) 30 (0) 30 (01) 30 (02) 30 (02)

Attention mean (SD) 54 (07) 54 (09) 58 (06) 58 (05) 56 (07) 56 (08) Age F 5 77 p 5 0006 sex F 5 100 p 5 0002

Language mean (SD) 24 (07) 21 (09) 24 (07) 23 (08) 24 (07) 22 (09)

Abstraction mean (SD) 18 (04) 18 (04) 20 (00) 18 (04)a 19 (03) 18 (04) F 5 61 p 5 0014

Delayed recall mean (SD) 44 (10) 38 (15)b 42 (08) 38 (12) 43 (09) 38 (14) F 5 63 p 5 0013 Age F 5 253 p 0001

Orientation mean (SD) 59 (03) 59 (03) 59 (03) 59 (03) 59 (03) 59 (03)

Total score (0ndash30) mean (SD) 276 (23) 266 (28) 280 (16) 273 (20) 278 (20) 269 (25) F 5 50 p 5 0027 Age F 5 261 p 0001

MCI (lt26 points) n () 4 (138) 15 (250) 2 (71) 8 (160) 6 (105) 23 (209) (p 5 0093c)

Dementia (lt21 points) n () 1 (34) 3 (50) 0 (0) 0 (0) 1 (18) 3 (27)

Depression

BDI-II

Total score mean (SD) 38 (47) 113 (111)a 32 (35) 80 (86)a 35 (41) 98 (102) F 5 187 p 0001

Depression (gt13 points) n () 2 (69) 19 (317)c 0 (0) 10 (200)d 2 (35) 29 (268) (p 0001c)

Severe depression (Dagger30 points) n () 0 (0) 5 (83) 0 (0) 4 (82) 0 (0) 9 (82) (p 5 0028c)

Olfaction

SS-16

Total score (0ndash16) mean (SD) 135 (15) 135 (17) 127 (21) 129 (15) 131 (18) 132 (16) Age F 5 45 p 5 0035 sex F 5 56 p 5 002

Hyposmia (lt11 points) n () 1 (34) 3 (53) 2 (74) 2 (42) 3 (54) 5 (48)

Continued

Neurology

84

April7

2015

1461

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Table 3 Continued

Femalecontrols

Femalepatients

Malecontrols

Malepatients

Allcontrols All patients

F and p values after GLM analysis for

Disease Other factors

Pain

BPI

Pain severity index (0ndash10) mean (SD) 09 (16) 22 (24)b 07 (14) 15 (22)a 08 (15) 19 (23) F 5 98 p 5 0002 Age F 5 96 p 5 0002

Function interference index (0ndash10) mean (SD) 06 (12) 19 (25)b 06 (14) 15 (26)a 06 (13) 17 (25) F 5 91 p 5 0003 Age F 5 48 p 5 003

Sleep

RBDSQ

Total score mean (SD) 25 (20) 32 (28) 26 (19) 28 (27) 25 (19) 30 (28) Age F 5 67 p 5 001

RBD (Dagger5 points) n () 5 (172) 16 (267) 3 (107) 13 (265) 8 (140) 29 (266)

ESS

Total score (0ndash24) mean (SD) 56 (39) 74 (51) 47 (44) 71 (48)b 51 (42) 72 (50) F 5 70 p 5 0009 Age F 5 57 p 5 0018

Significant sleepiness (Dagger10 points) n () 5 (172) 16 (267) 6 (214) 12 (245) 11 (193) 28 (257)

Quality of life

EuroQol Visual Analogue Scale (0ndash100) mean (SD) 856 (198) 768 (190)a 839 (116) 726 (201)b 848 (161) 749 (195) F 5 109 p 5 0001 Age F 5 89 p 5 0003

SF-36 total score (0ndash100) mean (SD) 846 (125) 628 (244)a 863 (120) 682 (239)a 854 (122) 652 (242) F 5 344 p 0001 Age F 5 113 p 5 0001

Abbreviations BDI 5 Beck Depression Inventory BP 5 blood pressure BPI 5 Brief Pain Inventory ESS 5 Epworth Sleepiness Scale GLM 5 general linear model HR 5 heart rate MCI 5 mild cognitive impairmentMMSE 5 Mini-Mental State Examination MoCA 5 Montreal Cognitive Assessment RBD 5 REM sleep behavior disorder RBDSQ 5 REM Sleep Behavior Disorder Screening Questionnaire SF-36 5 Short FormHealth Survey SS-16 5 Sniffinrsquo Sticks 16-item smell identification testStatistical comparison between controls and patients was performed with a GLM using disease and sex as fixed factors and age as covariate Additional statistical comparison within female and male participantswas performed with the x2 test Fisher exact test or Mann-Whitney U test ap 001 bp 005 within same sex with Mann-Whitney U test cp 005 within same sex with x2 test dp 005 within same sex withFisher exact test Values in parentheses represent p values derived from group analysis of MCI and depression rates performed with x2 test instead of GLM Means are provided as unadjusted means Nonsignificantp values have been omitted for clarity

1462

Neurology

84

April7

2015

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

neuronal glycosphingolipid storage and ALP disrup-tion in AFD lead to focused brainstem pathologywhich results in a distinct clinical phenotype withmild motor impairment and nonmotor symptomssuch as depression pain daytime sleepiness andhearing loss but is not associated with cardinal clin-ical prodromes of neurodegenerative diseases such asparkinsonian motor signs and impairments of cogni-tion and olfaction that are found in GD10 Howeverwe would not completely rule out a contribution ofa-Gal deficiency to the development of neurodegen-erative disease based on the lack of clinical prodromesespecially as neuropathologic brainstem involvementhas also been demonstrated in presymptomatic stagesof PD36

Another interesting observation of our study is thesimilarity of neurologic manifestations in female andmale patients with AFD which is in keeping withother studies showing significant organ involvementin female heterozygotes despite X-chromosomalinheritance37 Skewed inactivation of the X-chromo-some was suspected to explain disease manifestations infemale patients which is supported by recent researchdemonstrating correlations between X-inactivation andclinical disease severity in female patients38 Molecularinterference by the mutant enzyme protein exertinga dominant negative effect on the normal gene pro-duct has also been suggested39 but this explanatorytheory remains to be proven While the reasons forsex parity of disease manifestations in AFD remain tobe elucidated our study should raise physiciansrsquoawareness for symptoms in female patients withAFD who are often considered as carriers of butnot patients with the disease

Strengths of our study in this rare disease includeits size range and complexity of clinical testing andthe use of age-matched controls to enhance externalvalidity of the results Due to its observational andcross-sectional design our study has some limitationswhich may have influenced its outcome First themajority of patients in our AFD cohort were treatedwith ERT which may have partly altered the naturalphenotype of the disease and explain lower severity ofperipheral nonmotor symptoms such as pain How-ever ERT is unlikely to influence neurologic symp-toms caused by central manifestations of AFD suchas motor features hyposmia or RBD since it cannotcross the bloodndashbrain barrier Secondly it must beacknowledged that blinded examination was not possi-ble due to facial stigmata and skin manifestations inAFD which may have subconsciously influenced ourassessments although we applied well-established andhighly standardized clinical tests to minimize observerbias Third sex comparison in our study may notentirely reflect natural conditions in AFD carriers sinceour cohort was recruited from a university-based

specialty center in which more severely affected femalepatients may be overrepresented Moreover patientsrsquoperception of having AFD may have contributed toworse outcomes on questionnaires in comparison tocontrols

Taken together our study argues for a distinctneurologic phenotype in AFD that lacks classical pro-dromal features of neurodegeneration that have beendemonstrated in GD Unlike functional loss of gluco-cerebrosidase in GD which has been shown to beinvolved in accumulation of a-synuclein and resultsin neurotoxicity40 AFD-linked deficiency of a-Gal isapparently not associated with neurodegeneration onthe clinical level

AUTHOR CONTRIBUTIONSM Loumlhle design and conceptualization of the study analysis and inter-

pretation of the data drafting and revising the manuscript for intellectual

content D Hughes revising the manuscript for intellectual content

A Milligan revising the manuscript for intellectual content L Richfield

revising the manuscript for intellectual content H Reichmann revising

the manuscript for intellectual content A Mehta revising the manu-

script for intellectual content A Schapira design and conceptualization

of the study interpretation of the data revising the manuscript for intel-

lectual content

ACKNOWLEDGMENTThe authors thank the patients and controls for their participation and

Junibelle Cooke Anna Fernandez-Saranillo Patricia Pilgrim and Mark

McKie members of the Lysosomal Storage Disorder Unit at the Royal

Free Hospital who helped with recruitment for this study M Loumlhle

thanks Alisdair McNeill Christos Proukakis and Alexander Storch for

discussions

STUDY FUNDINGSupported by the NIHR UCLH Biomedical Research Centre and UCLH

BRC award to AHV Schapira AHV Schapira is a NIHR Senior

Investigator

DISCLOSUREM Loumlhle was supported by a seed grant of the Center for Regenerative

Therapies Dresden and has received honoraria for presentations from

Boehringer Ingelheim GlaxoSmithKline MEDA Pharma and UCB

D Hughes has received travel and research grants and honoraria

for speaking and advisory boards from Amicus Genzyme (Sanofi) and

Shire A Milligan has received travel grants from Genzyme (Sanofi) and

Shire L Richfield has received travel grants from Genzyme (Sanofi)

and Shire H Reichmann was acting on Advisory Boards and gave lec-

tures and has received research grants from Abbott Abbvie Bayer Health

Care Boehringer Ingelheim Brittania Cephalon Desitin GSK Lund-

beck Medtronic Merck-Serono Novartis Orion Pfizer TEVA UCB

and Valeant A Mehta has received travel and research grants and

honoraria for speaking and advisory boards from Genzyme (Sanofi) and

Shire A Schapira is a NIHR Senior Investigator He has received

honoraria for educational symposia and consultancy from Boehringer

Ingelheim Teva-Lundbeck UCB Merz Merck Orion and Novartis

Go to Neurologyorg for full disclosures

Received September 13 2014 Accepted in final formDecember 22 2014

REFERENCES1 Brady RO Gal AE Bradley RM Martensson E

Warshaw AL Laster L Enzymatic defect in Fabryrsquos dis-

ease ceramidetrihexosidase deficiency N Engl J Med

19672761163ndash1167

Neurology 84 April 7 2015 1463

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

a markedly reduced quality of life as documented by theEQ-5D-VAS and the SF-36 total scores (table 3)

Similar to motor function age also affected sev-eral nonmotor outcomes in patients and controls(table 3) Higher age was associated with cognitivedecline on the MMSE and MoCA a reduction ofolfactory function on the SS-16 a lower drop ofblood pressure and reduced compensatory increaseof heart rate upon standing up higher pain severityand interference indices on the BPI more daytime

sleepiness on the ESS and a lower quality of life onboth EQ-5D-VAS and SF-36 (not shown) Sexeffects were only identified during olfactory testingwhere female participants performed significantlybetter than male participants (table 3) In keepingwith our observations on motor function we did notidentify any differences in nonmotor outcomesbetween female and male patients with AFD againindicating that the disease similarly affected bothsexes

Figure 1 Motor and nonmotor outcomes in patients with Anderson-Fabry disease (red circles) and age-matched controls (blue circles)

Black bars indicate unadjusted mean values N 5 110 and n 5 57 for patients with Anderson-Fabry disease (AFD) and age-matched controls respectivelyp 005 p 001 p 0001 in comparison to age-matched controls with a general linear model using disease and sex as fixed factors and age ascovariate Only disease effects are shown BDI 5 Beck Depression Inventory BPI 5 Brief Pain Inventory ESS 5 Epworth Sleepiness Scale MCI 5 mildcognitive impairment MoCA 5 Montreal Cognitive Assessment RBD 5 REM sleep behavior disorder RBDSQ 5 REM Sleep Behavior Disorder ScreeningQuestionnaire SS-16 5 16-item smell identification test from Sniffinrsquo Sticks

Neurology 84 April 7 2015 1459

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Correlation of study outcomes with disease severity Inorder to assess whether neurologic symptoms wouldalso correlate with disease severity in AFD we per-formed bivariate correlations of all outcome parame-ters with the MMSI (table e-3) Significant andmoderate correlations were found for all motor scalesdepression (BDI-II) pain (BPI) and quality of life(EuroQoL Visual Analogue Scale SF-36 score)

DISCUSSION We report a prospective cross-sectionalstudy on prodromal symptoms of neurodegeneration ina large cohort of patients with AFD aiming to evaluatethe clinical relevance of neuronal glycosphingolipidaccumulation in this rare disease We found that

AFD is associated with impaired motor function andvarious nonmotor symptoms but unlike GD doesnot lead to a pattern of extrapyramidal symptomssignificant cognitive problems hyposmia or RBDcommonly preceding neurodegenerative diseases inparticular PD27 and dementia with Lewy bodies28

Aside from cardinal neurologic manifestationssuch as stroke29 and small fiber neuropathy2 previousstudies have described depression30 pain31 and day-time sleepiness32 in 46 53 and 68 of patientswith AFD respectively Our study was able to repro-duce these findings but prevalence of these nonmo-tor symptoms was lower in our cohort possibly dueto ongoing symptomatic treatment or ERT in themajority of cases Nevertheless it is noteworthy that4 out of 9 severely depressed patients did not receivetreatment with antidepressants reemphasizing theneed for recognition of depressive symptoms in thisdisease AFD was not associated with cognitiveimpairment or autonomic dysfunction which is inkeeping with previous smaller studies33ndash35 Moreoverwe were able to show that AFD does not result inhyposmia or RBD which are prodromal for later neu-rodegenerative disease

In addition our study suggests that AFD does notlead to extrapyramidal symptoms or parkinsonianmotor features but instead is associated with motorimpairments during gait and transfer and poorer finemanual dexterity and hand speed These deficits inmotor function correlated to clinical disease severitysimilar to depression and pain which emphasizes thatmotor impairments are an integral part of the diseaseThe pathophysiologic reasons for poorer motor per-formance in AFD cannot be answered by our clinicalstudy and remain to be elucidated Although cerebro-vascular manifestations of AFD may lead to motorimpairment it must be noted that frequency and bur-den of cerebrovascular symptoms in our AFD cohortwas very low and that disease effects on motor func-tion were still evident when results were correctedfor the presence of focal neurologic deficits Noneof our patients complained about sensory losswhich is in agreement with previous neurophysiologicstudies demonstrating that small fiber dysfunctionpredominates in the disease2 and argues againstperipheral neuropathy as the main reason forimpaired motor function Interestingly former neu-ropathologic studies have shown that glycosphingo-lipid accumulation in AFD is not limited to thevasculature but can be found in neurons of variousbrain regions in particular the brainstem45 Recentlya study has demonstrated ALP disruption and focusedpresence of phosphorylated a-synuclein-containinglesions in the pons of a-Gal-deficient mice whichwere colocalized with large axonal spheroids indicat-ing axonal degeneration6 We therefore speculate that

Figure 2 Extrapyramidal motor symptoms in patients with Anderson-Fabrydisease (red bars) and age-matched controls (blue bars)

N 5 110 and n 5 57 for patients with Anderson-Fabry disease (AFD) and age-matchedcontrols respectively Symptoms were assessed during clinical evaluation with the Move-ment Disorders Societyndashrevised version of the Unified Parkinsonrsquos Disease Rating Scale(MDS-UPDRS) Postural instability was evaluated with the pull test Motor asymmetry wasdefined as right-minus-left difference score$2 on side-specific MDS-UPDRS items Fisherexact test Pearson x2 test

1460 Neurology 84 April 7 2015

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Table 3 Nonmotor function and quality of life in patients with Anderson-Fabry disease and age-matched controls

Femalecontrols

Femalepatients

Malecontrols

Malepatients

Allcontrols All patients

F and p values after GLM analysis for

Disease Other factors

No of participants 29 60 28 50 57 110

Autonomic function (orthostatic challenge)

BP change at 2 minutes mm Hg mean (SD) 256 (111) 244 (106) 239 (141) 04 (119) 248 (126) 222 (114) Age F 5 50 p 5 0026

HR change at 2 minutes (1min) mean (SD) 92 (91) 111 (92) 86 (70) 100 (65) 89 (80) 106 (80) Age F 5 268 p 0001

Significant BP drop (gt20 mm Hg) n () 2 (69) 4 (74) 4 (143) 2 (43) 6 (105) 6 (60)

Cognition

MMSE

Total score (0ndash30) mean (SD) 287 (15) 283 (20) 290 (13) 285 (15) 288 (14) 284 (18) Age F 5 171 p 0001

Dementia (lt24 points) n () 0 (0) 2 (33) 0 (0) 0 (0) 0 (0) 2 (12)

MoCA

Visuospatial and executive mean (SD) 45 (07) 42 (10) 46 (07) 43 (08) 45 (07) 43 (09) Age F 5 173 p 0001

Naming mean (SD) 30 (02) 30 (02) 30 (0) 30 (01) 30 (02) 30 (02)

Attention mean (SD) 54 (07) 54 (09) 58 (06) 58 (05) 56 (07) 56 (08) Age F 5 77 p 5 0006 sex F 5 100 p 5 0002

Language mean (SD) 24 (07) 21 (09) 24 (07) 23 (08) 24 (07) 22 (09)

Abstraction mean (SD) 18 (04) 18 (04) 20 (00) 18 (04)a 19 (03) 18 (04) F 5 61 p 5 0014

Delayed recall mean (SD) 44 (10) 38 (15)b 42 (08) 38 (12) 43 (09) 38 (14) F 5 63 p 5 0013 Age F 5 253 p 0001

Orientation mean (SD) 59 (03) 59 (03) 59 (03) 59 (03) 59 (03) 59 (03)

Total score (0ndash30) mean (SD) 276 (23) 266 (28) 280 (16) 273 (20) 278 (20) 269 (25) F 5 50 p 5 0027 Age F 5 261 p 0001

MCI (lt26 points) n () 4 (138) 15 (250) 2 (71) 8 (160) 6 (105) 23 (209) (p 5 0093c)

Dementia (lt21 points) n () 1 (34) 3 (50) 0 (0) 0 (0) 1 (18) 3 (27)

Depression

BDI-II

Total score mean (SD) 38 (47) 113 (111)a 32 (35) 80 (86)a 35 (41) 98 (102) F 5 187 p 0001

Depression (gt13 points) n () 2 (69) 19 (317)c 0 (0) 10 (200)d 2 (35) 29 (268) (p 0001c)

Severe depression (Dagger30 points) n () 0 (0) 5 (83) 0 (0) 4 (82) 0 (0) 9 (82) (p 5 0028c)

Olfaction

SS-16

Total score (0ndash16) mean (SD) 135 (15) 135 (17) 127 (21) 129 (15) 131 (18) 132 (16) Age F 5 45 p 5 0035 sex F 5 56 p 5 002

Hyposmia (lt11 points) n () 1 (34) 3 (53) 2 (74) 2 (42) 3 (54) 5 (48)

Continued

Neurology

84

April7

2015

1461

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Table 3 Continued

Femalecontrols

Femalepatients

Malecontrols

Malepatients

Allcontrols All patients

F and p values after GLM analysis for

Disease Other factors

Pain

BPI

Pain severity index (0ndash10) mean (SD) 09 (16) 22 (24)b 07 (14) 15 (22)a 08 (15) 19 (23) F 5 98 p 5 0002 Age F 5 96 p 5 0002

Function interference index (0ndash10) mean (SD) 06 (12) 19 (25)b 06 (14) 15 (26)a 06 (13) 17 (25) F 5 91 p 5 0003 Age F 5 48 p 5 003

Sleep

RBDSQ

Total score mean (SD) 25 (20) 32 (28) 26 (19) 28 (27) 25 (19) 30 (28) Age F 5 67 p 5 001

RBD (Dagger5 points) n () 5 (172) 16 (267) 3 (107) 13 (265) 8 (140) 29 (266)

ESS

Total score (0ndash24) mean (SD) 56 (39) 74 (51) 47 (44) 71 (48)b 51 (42) 72 (50) F 5 70 p 5 0009 Age F 5 57 p 5 0018

Significant sleepiness (Dagger10 points) n () 5 (172) 16 (267) 6 (214) 12 (245) 11 (193) 28 (257)

Quality of life

EuroQol Visual Analogue Scale (0ndash100) mean (SD) 856 (198) 768 (190)a 839 (116) 726 (201)b 848 (161) 749 (195) F 5 109 p 5 0001 Age F 5 89 p 5 0003

SF-36 total score (0ndash100) mean (SD) 846 (125) 628 (244)a 863 (120) 682 (239)a 854 (122) 652 (242) F 5 344 p 0001 Age F 5 113 p 5 0001

Abbreviations BDI 5 Beck Depression Inventory BP 5 blood pressure BPI 5 Brief Pain Inventory ESS 5 Epworth Sleepiness Scale GLM 5 general linear model HR 5 heart rate MCI 5 mild cognitive impairmentMMSE 5 Mini-Mental State Examination MoCA 5 Montreal Cognitive Assessment RBD 5 REM sleep behavior disorder RBDSQ 5 REM Sleep Behavior Disorder Screening Questionnaire SF-36 5 Short FormHealth Survey SS-16 5 Sniffinrsquo Sticks 16-item smell identification testStatistical comparison between controls and patients was performed with a GLM using disease and sex as fixed factors and age as covariate Additional statistical comparison within female and male participantswas performed with the x2 test Fisher exact test or Mann-Whitney U test ap 001 bp 005 within same sex with Mann-Whitney U test cp 005 within same sex with x2 test dp 005 within same sex withFisher exact test Values in parentheses represent p values derived from group analysis of MCI and depression rates performed with x2 test instead of GLM Means are provided as unadjusted means Nonsignificantp values have been omitted for clarity

1462

Neurology

84

April7

2015

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

neuronal glycosphingolipid storage and ALP disrup-tion in AFD lead to focused brainstem pathologywhich results in a distinct clinical phenotype withmild motor impairment and nonmotor symptomssuch as depression pain daytime sleepiness andhearing loss but is not associated with cardinal clin-ical prodromes of neurodegenerative diseases such asparkinsonian motor signs and impairments of cogni-tion and olfaction that are found in GD10 Howeverwe would not completely rule out a contribution ofa-Gal deficiency to the development of neurodegen-erative disease based on the lack of clinical prodromesespecially as neuropathologic brainstem involvementhas also been demonstrated in presymptomatic stagesof PD36

Another interesting observation of our study is thesimilarity of neurologic manifestations in female andmale patients with AFD which is in keeping withother studies showing significant organ involvementin female heterozygotes despite X-chromosomalinheritance37 Skewed inactivation of the X-chromo-some was suspected to explain disease manifestations infemale patients which is supported by recent researchdemonstrating correlations between X-inactivation andclinical disease severity in female patients38 Molecularinterference by the mutant enzyme protein exertinga dominant negative effect on the normal gene pro-duct has also been suggested39 but this explanatorytheory remains to be proven While the reasons forsex parity of disease manifestations in AFD remain tobe elucidated our study should raise physiciansrsquoawareness for symptoms in female patients withAFD who are often considered as carriers of butnot patients with the disease

Strengths of our study in this rare disease includeits size range and complexity of clinical testing andthe use of age-matched controls to enhance externalvalidity of the results Due to its observational andcross-sectional design our study has some limitationswhich may have influenced its outcome First themajority of patients in our AFD cohort were treatedwith ERT which may have partly altered the naturalphenotype of the disease and explain lower severity ofperipheral nonmotor symptoms such as pain How-ever ERT is unlikely to influence neurologic symp-toms caused by central manifestations of AFD suchas motor features hyposmia or RBD since it cannotcross the bloodndashbrain barrier Secondly it must beacknowledged that blinded examination was not possi-ble due to facial stigmata and skin manifestations inAFD which may have subconsciously influenced ourassessments although we applied well-established andhighly standardized clinical tests to minimize observerbias Third sex comparison in our study may notentirely reflect natural conditions in AFD carriers sinceour cohort was recruited from a university-based

specialty center in which more severely affected femalepatients may be overrepresented Moreover patientsrsquoperception of having AFD may have contributed toworse outcomes on questionnaires in comparison tocontrols

Taken together our study argues for a distinctneurologic phenotype in AFD that lacks classical pro-dromal features of neurodegeneration that have beendemonstrated in GD Unlike functional loss of gluco-cerebrosidase in GD which has been shown to beinvolved in accumulation of a-synuclein and resultsin neurotoxicity40 AFD-linked deficiency of a-Gal isapparently not associated with neurodegeneration onthe clinical level

AUTHOR CONTRIBUTIONSM Loumlhle design and conceptualization of the study analysis and inter-

pretation of the data drafting and revising the manuscript for intellectual

content D Hughes revising the manuscript for intellectual content

A Milligan revising the manuscript for intellectual content L Richfield

revising the manuscript for intellectual content H Reichmann revising

the manuscript for intellectual content A Mehta revising the manu-

script for intellectual content A Schapira design and conceptualization

of the study interpretation of the data revising the manuscript for intel-

lectual content

ACKNOWLEDGMENTThe authors thank the patients and controls for their participation and

Junibelle Cooke Anna Fernandez-Saranillo Patricia Pilgrim and Mark

McKie members of the Lysosomal Storage Disorder Unit at the Royal

Free Hospital who helped with recruitment for this study M Loumlhle

thanks Alisdair McNeill Christos Proukakis and Alexander Storch for

discussions

STUDY FUNDINGSupported by the NIHR UCLH Biomedical Research Centre and UCLH

BRC award to AHV Schapira AHV Schapira is a NIHR Senior

Investigator

DISCLOSUREM Loumlhle was supported by a seed grant of the Center for Regenerative

Therapies Dresden and has received honoraria for presentations from

Boehringer Ingelheim GlaxoSmithKline MEDA Pharma and UCB

D Hughes has received travel and research grants and honoraria

for speaking and advisory boards from Amicus Genzyme (Sanofi) and

Shire A Milligan has received travel grants from Genzyme (Sanofi) and

Shire L Richfield has received travel grants from Genzyme (Sanofi)

and Shire H Reichmann was acting on Advisory Boards and gave lec-

tures and has received research grants from Abbott Abbvie Bayer Health

Care Boehringer Ingelheim Brittania Cephalon Desitin GSK Lund-

beck Medtronic Merck-Serono Novartis Orion Pfizer TEVA UCB

and Valeant A Mehta has received travel and research grants and

honoraria for speaking and advisory boards from Genzyme (Sanofi) and

Shire A Schapira is a NIHR Senior Investigator He has received

honoraria for educational symposia and consultancy from Boehringer

Ingelheim Teva-Lundbeck UCB Merz Merck Orion and Novartis

Go to Neurologyorg for full disclosures

Received September 13 2014 Accepted in final formDecember 22 2014

REFERENCES1 Brady RO Gal AE Bradley RM Martensson E

Warshaw AL Laster L Enzymatic defect in Fabryrsquos dis-

ease ceramidetrihexosidase deficiency N Engl J Med

19672761163ndash1167

Neurology 84 April 7 2015 1463

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Correlation of study outcomes with disease severity Inorder to assess whether neurologic symptoms wouldalso correlate with disease severity in AFD we per-formed bivariate correlations of all outcome parame-ters with the MMSI (table e-3) Significant andmoderate correlations were found for all motor scalesdepression (BDI-II) pain (BPI) and quality of life(EuroQoL Visual Analogue Scale SF-36 score)

DISCUSSION We report a prospective cross-sectionalstudy on prodromal symptoms of neurodegeneration ina large cohort of patients with AFD aiming to evaluatethe clinical relevance of neuronal glycosphingolipidaccumulation in this rare disease We found that

AFD is associated with impaired motor function andvarious nonmotor symptoms but unlike GD doesnot lead to a pattern of extrapyramidal symptomssignificant cognitive problems hyposmia or RBDcommonly preceding neurodegenerative diseases inparticular PD27 and dementia with Lewy bodies28

Aside from cardinal neurologic manifestationssuch as stroke29 and small fiber neuropathy2 previousstudies have described depression30 pain31 and day-time sleepiness32 in 46 53 and 68 of patientswith AFD respectively Our study was able to repro-duce these findings but prevalence of these nonmo-tor symptoms was lower in our cohort possibly dueto ongoing symptomatic treatment or ERT in themajority of cases Nevertheless it is noteworthy that4 out of 9 severely depressed patients did not receivetreatment with antidepressants reemphasizing theneed for recognition of depressive symptoms in thisdisease AFD was not associated with cognitiveimpairment or autonomic dysfunction which is inkeeping with previous smaller studies33ndash35 Moreoverwe were able to show that AFD does not result inhyposmia or RBD which are prodromal for later neu-rodegenerative disease

In addition our study suggests that AFD does notlead to extrapyramidal symptoms or parkinsonianmotor features but instead is associated with motorimpairments during gait and transfer and poorer finemanual dexterity and hand speed These deficits inmotor function correlated to clinical disease severitysimilar to depression and pain which emphasizes thatmotor impairments are an integral part of the diseaseThe pathophysiologic reasons for poorer motor per-formance in AFD cannot be answered by our clinicalstudy and remain to be elucidated Although cerebro-vascular manifestations of AFD may lead to motorimpairment it must be noted that frequency and bur-den of cerebrovascular symptoms in our AFD cohortwas very low and that disease effects on motor func-tion were still evident when results were correctedfor the presence of focal neurologic deficits Noneof our patients complained about sensory losswhich is in agreement with previous neurophysiologicstudies demonstrating that small fiber dysfunctionpredominates in the disease2 and argues againstperipheral neuropathy as the main reason forimpaired motor function Interestingly former neu-ropathologic studies have shown that glycosphingo-lipid accumulation in AFD is not limited to thevasculature but can be found in neurons of variousbrain regions in particular the brainstem45 Recentlya study has demonstrated ALP disruption and focusedpresence of phosphorylated a-synuclein-containinglesions in the pons of a-Gal-deficient mice whichwere colocalized with large axonal spheroids indicat-ing axonal degeneration6 We therefore speculate that

Figure 2 Extrapyramidal motor symptoms in patients with Anderson-Fabrydisease (red bars) and age-matched controls (blue bars)

N 5 110 and n 5 57 for patients with Anderson-Fabry disease (AFD) and age-matchedcontrols respectively Symptoms were assessed during clinical evaluation with the Move-ment Disorders Societyndashrevised version of the Unified Parkinsonrsquos Disease Rating Scale(MDS-UPDRS) Postural instability was evaluated with the pull test Motor asymmetry wasdefined as right-minus-left difference score$2 on side-specific MDS-UPDRS items Fisherexact test Pearson x2 test

1460 Neurology 84 April 7 2015

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Table 3 Nonmotor function and quality of life in patients with Anderson-Fabry disease and age-matched controls

Femalecontrols

Femalepatients

Malecontrols

Malepatients

Allcontrols All patients

F and p values after GLM analysis for

Disease Other factors

No of participants 29 60 28 50 57 110

Autonomic function (orthostatic challenge)

BP change at 2 minutes mm Hg mean (SD) 256 (111) 244 (106) 239 (141) 04 (119) 248 (126) 222 (114) Age F 5 50 p 5 0026

HR change at 2 minutes (1min) mean (SD) 92 (91) 111 (92) 86 (70) 100 (65) 89 (80) 106 (80) Age F 5 268 p 0001

Significant BP drop (gt20 mm Hg) n () 2 (69) 4 (74) 4 (143) 2 (43) 6 (105) 6 (60)

Cognition

MMSE

Total score (0ndash30) mean (SD) 287 (15) 283 (20) 290 (13) 285 (15) 288 (14) 284 (18) Age F 5 171 p 0001

Dementia (lt24 points) n () 0 (0) 2 (33) 0 (0) 0 (0) 0 (0) 2 (12)

MoCA

Visuospatial and executive mean (SD) 45 (07) 42 (10) 46 (07) 43 (08) 45 (07) 43 (09) Age F 5 173 p 0001

Naming mean (SD) 30 (02) 30 (02) 30 (0) 30 (01) 30 (02) 30 (02)

Attention mean (SD) 54 (07) 54 (09) 58 (06) 58 (05) 56 (07) 56 (08) Age F 5 77 p 5 0006 sex F 5 100 p 5 0002

Language mean (SD) 24 (07) 21 (09) 24 (07) 23 (08) 24 (07) 22 (09)

Abstraction mean (SD) 18 (04) 18 (04) 20 (00) 18 (04)a 19 (03) 18 (04) F 5 61 p 5 0014

Delayed recall mean (SD) 44 (10) 38 (15)b 42 (08) 38 (12) 43 (09) 38 (14) F 5 63 p 5 0013 Age F 5 253 p 0001

Orientation mean (SD) 59 (03) 59 (03) 59 (03) 59 (03) 59 (03) 59 (03)

Total score (0ndash30) mean (SD) 276 (23) 266 (28) 280 (16) 273 (20) 278 (20) 269 (25) F 5 50 p 5 0027 Age F 5 261 p 0001

MCI (lt26 points) n () 4 (138) 15 (250) 2 (71) 8 (160) 6 (105) 23 (209) (p 5 0093c)

Dementia (lt21 points) n () 1 (34) 3 (50) 0 (0) 0 (0) 1 (18) 3 (27)

Depression

BDI-II

Total score mean (SD) 38 (47) 113 (111)a 32 (35) 80 (86)a 35 (41) 98 (102) F 5 187 p 0001

Depression (gt13 points) n () 2 (69) 19 (317)c 0 (0) 10 (200)d 2 (35) 29 (268) (p 0001c)

Severe depression (Dagger30 points) n () 0 (0) 5 (83) 0 (0) 4 (82) 0 (0) 9 (82) (p 5 0028c)

Olfaction

SS-16

Total score (0ndash16) mean (SD) 135 (15) 135 (17) 127 (21) 129 (15) 131 (18) 132 (16) Age F 5 45 p 5 0035 sex F 5 56 p 5 002

Hyposmia (lt11 points) n () 1 (34) 3 (53) 2 (74) 2 (42) 3 (54) 5 (48)

Continued

Neurology

84

April7

2015

1461

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Table 3 Continued

Femalecontrols

Femalepatients

Malecontrols

Malepatients

Allcontrols All patients

F and p values after GLM analysis for

Disease Other factors

Pain

BPI

Pain severity index (0ndash10) mean (SD) 09 (16) 22 (24)b 07 (14) 15 (22)a 08 (15) 19 (23) F 5 98 p 5 0002 Age F 5 96 p 5 0002

Function interference index (0ndash10) mean (SD) 06 (12) 19 (25)b 06 (14) 15 (26)a 06 (13) 17 (25) F 5 91 p 5 0003 Age F 5 48 p 5 003

Sleep

RBDSQ

Total score mean (SD) 25 (20) 32 (28) 26 (19) 28 (27) 25 (19) 30 (28) Age F 5 67 p 5 001

RBD (Dagger5 points) n () 5 (172) 16 (267) 3 (107) 13 (265) 8 (140) 29 (266)

ESS

Total score (0ndash24) mean (SD) 56 (39) 74 (51) 47 (44) 71 (48)b 51 (42) 72 (50) F 5 70 p 5 0009 Age F 5 57 p 5 0018

Significant sleepiness (Dagger10 points) n () 5 (172) 16 (267) 6 (214) 12 (245) 11 (193) 28 (257)

Quality of life

EuroQol Visual Analogue Scale (0ndash100) mean (SD) 856 (198) 768 (190)a 839 (116) 726 (201)b 848 (161) 749 (195) F 5 109 p 5 0001 Age F 5 89 p 5 0003

SF-36 total score (0ndash100) mean (SD) 846 (125) 628 (244)a 863 (120) 682 (239)a 854 (122) 652 (242) F 5 344 p 0001 Age F 5 113 p 5 0001

Abbreviations BDI 5 Beck Depression Inventory BP 5 blood pressure BPI 5 Brief Pain Inventory ESS 5 Epworth Sleepiness Scale GLM 5 general linear model HR 5 heart rate MCI 5 mild cognitive impairmentMMSE 5 Mini-Mental State Examination MoCA 5 Montreal Cognitive Assessment RBD 5 REM sleep behavior disorder RBDSQ 5 REM Sleep Behavior Disorder Screening Questionnaire SF-36 5 Short FormHealth Survey SS-16 5 Sniffinrsquo Sticks 16-item smell identification testStatistical comparison between controls and patients was performed with a GLM using disease and sex as fixed factors and age as covariate Additional statistical comparison within female and male participantswas performed with the x2 test Fisher exact test or Mann-Whitney U test ap 001 bp 005 within same sex with Mann-Whitney U test cp 005 within same sex with x2 test dp 005 within same sex withFisher exact test Values in parentheses represent p values derived from group analysis of MCI and depression rates performed with x2 test instead of GLM Means are provided as unadjusted means Nonsignificantp values have been omitted for clarity

1462

Neurology

84

April7

2015

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

neuronal glycosphingolipid storage and ALP disrup-tion in AFD lead to focused brainstem pathologywhich results in a distinct clinical phenotype withmild motor impairment and nonmotor symptomssuch as depression pain daytime sleepiness andhearing loss but is not associated with cardinal clin-ical prodromes of neurodegenerative diseases such asparkinsonian motor signs and impairments of cogni-tion and olfaction that are found in GD10 Howeverwe would not completely rule out a contribution ofa-Gal deficiency to the development of neurodegen-erative disease based on the lack of clinical prodromesespecially as neuropathologic brainstem involvementhas also been demonstrated in presymptomatic stagesof PD36

Another interesting observation of our study is thesimilarity of neurologic manifestations in female andmale patients with AFD which is in keeping withother studies showing significant organ involvementin female heterozygotes despite X-chromosomalinheritance37 Skewed inactivation of the X-chromo-some was suspected to explain disease manifestations infemale patients which is supported by recent researchdemonstrating correlations between X-inactivation andclinical disease severity in female patients38 Molecularinterference by the mutant enzyme protein exertinga dominant negative effect on the normal gene pro-duct has also been suggested39 but this explanatorytheory remains to be proven While the reasons forsex parity of disease manifestations in AFD remain tobe elucidated our study should raise physiciansrsquoawareness for symptoms in female patients withAFD who are often considered as carriers of butnot patients with the disease

Strengths of our study in this rare disease includeits size range and complexity of clinical testing andthe use of age-matched controls to enhance externalvalidity of the results Due to its observational andcross-sectional design our study has some limitationswhich may have influenced its outcome First themajority of patients in our AFD cohort were treatedwith ERT which may have partly altered the naturalphenotype of the disease and explain lower severity ofperipheral nonmotor symptoms such as pain How-ever ERT is unlikely to influence neurologic symp-toms caused by central manifestations of AFD suchas motor features hyposmia or RBD since it cannotcross the bloodndashbrain barrier Secondly it must beacknowledged that blinded examination was not possi-ble due to facial stigmata and skin manifestations inAFD which may have subconsciously influenced ourassessments although we applied well-established andhighly standardized clinical tests to minimize observerbias Third sex comparison in our study may notentirely reflect natural conditions in AFD carriers sinceour cohort was recruited from a university-based

specialty center in which more severely affected femalepatients may be overrepresented Moreover patientsrsquoperception of having AFD may have contributed toworse outcomes on questionnaires in comparison tocontrols

Taken together our study argues for a distinctneurologic phenotype in AFD that lacks classical pro-dromal features of neurodegeneration that have beendemonstrated in GD Unlike functional loss of gluco-cerebrosidase in GD which has been shown to beinvolved in accumulation of a-synuclein and resultsin neurotoxicity40 AFD-linked deficiency of a-Gal isapparently not associated with neurodegeneration onthe clinical level

AUTHOR CONTRIBUTIONSM Loumlhle design and conceptualization of the study analysis and inter-

pretation of the data drafting and revising the manuscript for intellectual

content D Hughes revising the manuscript for intellectual content

A Milligan revising the manuscript for intellectual content L Richfield

revising the manuscript for intellectual content H Reichmann revising

the manuscript for intellectual content A Mehta revising the manu-

script for intellectual content A Schapira design and conceptualization

of the study interpretation of the data revising the manuscript for intel-

lectual content

ACKNOWLEDGMENTThe authors thank the patients and controls for their participation and

Junibelle Cooke Anna Fernandez-Saranillo Patricia Pilgrim and Mark

McKie members of the Lysosomal Storage Disorder Unit at the Royal

Free Hospital who helped with recruitment for this study M Loumlhle

thanks Alisdair McNeill Christos Proukakis and Alexander Storch for

discussions

STUDY FUNDINGSupported by the NIHR UCLH Biomedical Research Centre and UCLH

BRC award to AHV Schapira AHV Schapira is a NIHR Senior

Investigator

DISCLOSUREM Loumlhle was supported by a seed grant of the Center for Regenerative

Therapies Dresden and has received honoraria for presentations from

Boehringer Ingelheim GlaxoSmithKline MEDA Pharma and UCB

D Hughes has received travel and research grants and honoraria

for speaking and advisory boards from Amicus Genzyme (Sanofi) and

Shire A Milligan has received travel grants from Genzyme (Sanofi) and

Shire L Richfield has received travel grants from Genzyme (Sanofi)

and Shire H Reichmann was acting on Advisory Boards and gave lec-

tures and has received research grants from Abbott Abbvie Bayer Health

Care Boehringer Ingelheim Brittania Cephalon Desitin GSK Lund-

beck Medtronic Merck-Serono Novartis Orion Pfizer TEVA UCB

and Valeant A Mehta has received travel and research grants and

honoraria for speaking and advisory boards from Genzyme (Sanofi) and

Shire A Schapira is a NIHR Senior Investigator He has received

honoraria for educational symposia and consultancy from Boehringer

Ingelheim Teva-Lundbeck UCB Merz Merck Orion and Novartis

Go to Neurologyorg for full disclosures

Received September 13 2014 Accepted in final formDecember 22 2014

REFERENCES1 Brady RO Gal AE Bradley RM Martensson E

Warshaw AL Laster L Enzymatic defect in Fabryrsquos dis-

ease ceramidetrihexosidase deficiency N Engl J Med

19672761163ndash1167

Neurology 84 April 7 2015 1463

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Table 3 Nonmotor function and quality of life in patients with Anderson-Fabry disease and age-matched controls

Femalecontrols

Femalepatients

Malecontrols

Malepatients

Allcontrols All patients

F and p values after GLM analysis for

Disease Other factors

No of participants 29 60 28 50 57 110

Autonomic function (orthostatic challenge)

BP change at 2 minutes mm Hg mean (SD) 256 (111) 244 (106) 239 (141) 04 (119) 248 (126) 222 (114) Age F 5 50 p 5 0026

HR change at 2 minutes (1min) mean (SD) 92 (91) 111 (92) 86 (70) 100 (65) 89 (80) 106 (80) Age F 5 268 p 0001

Significant BP drop (gt20 mm Hg) n () 2 (69) 4 (74) 4 (143) 2 (43) 6 (105) 6 (60)

Cognition

MMSE

Total score (0ndash30) mean (SD) 287 (15) 283 (20) 290 (13) 285 (15) 288 (14) 284 (18) Age F 5 171 p 0001

Dementia (lt24 points) n () 0 (0) 2 (33) 0 (0) 0 (0) 0 (0) 2 (12)

MoCA

Visuospatial and executive mean (SD) 45 (07) 42 (10) 46 (07) 43 (08) 45 (07) 43 (09) Age F 5 173 p 0001

Naming mean (SD) 30 (02) 30 (02) 30 (0) 30 (01) 30 (02) 30 (02)

Attention mean (SD) 54 (07) 54 (09) 58 (06) 58 (05) 56 (07) 56 (08) Age F 5 77 p 5 0006 sex F 5 100 p 5 0002

Language mean (SD) 24 (07) 21 (09) 24 (07) 23 (08) 24 (07) 22 (09)

Abstraction mean (SD) 18 (04) 18 (04) 20 (00) 18 (04)a 19 (03) 18 (04) F 5 61 p 5 0014

Delayed recall mean (SD) 44 (10) 38 (15)b 42 (08) 38 (12) 43 (09) 38 (14) F 5 63 p 5 0013 Age F 5 253 p 0001

Orientation mean (SD) 59 (03) 59 (03) 59 (03) 59 (03) 59 (03) 59 (03)

Total score (0ndash30) mean (SD) 276 (23) 266 (28) 280 (16) 273 (20) 278 (20) 269 (25) F 5 50 p 5 0027 Age F 5 261 p 0001

MCI (lt26 points) n () 4 (138) 15 (250) 2 (71) 8 (160) 6 (105) 23 (209) (p 5 0093c)

Dementia (lt21 points) n () 1 (34) 3 (50) 0 (0) 0 (0) 1 (18) 3 (27)

Depression

BDI-II

Total score mean (SD) 38 (47) 113 (111)a 32 (35) 80 (86)a 35 (41) 98 (102) F 5 187 p 0001

Depression (gt13 points) n () 2 (69) 19 (317)c 0 (0) 10 (200)d 2 (35) 29 (268) (p 0001c)

Severe depression (Dagger30 points) n () 0 (0) 5 (83) 0 (0) 4 (82) 0 (0) 9 (82) (p 5 0028c)

Olfaction

SS-16

Total score (0ndash16) mean (SD) 135 (15) 135 (17) 127 (21) 129 (15) 131 (18) 132 (16) Age F 5 45 p 5 0035 sex F 5 56 p 5 002

Hyposmia (lt11 points) n () 1 (34) 3 (53) 2 (74) 2 (42) 3 (54) 5 (48)

Continued

Neurology

84

April7

2015

1461

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Table 3 Continued

Femalecontrols

Femalepatients

Malecontrols

Malepatients

Allcontrols All patients

F and p values after GLM analysis for

Disease Other factors

Pain

BPI

Pain severity index (0ndash10) mean (SD) 09 (16) 22 (24)b 07 (14) 15 (22)a 08 (15) 19 (23) F 5 98 p 5 0002 Age F 5 96 p 5 0002

Function interference index (0ndash10) mean (SD) 06 (12) 19 (25)b 06 (14) 15 (26)a 06 (13) 17 (25) F 5 91 p 5 0003 Age F 5 48 p 5 003

Sleep

RBDSQ

Total score mean (SD) 25 (20) 32 (28) 26 (19) 28 (27) 25 (19) 30 (28) Age F 5 67 p 5 001

RBD (Dagger5 points) n () 5 (172) 16 (267) 3 (107) 13 (265) 8 (140) 29 (266)

ESS

Total score (0ndash24) mean (SD) 56 (39) 74 (51) 47 (44) 71 (48)b 51 (42) 72 (50) F 5 70 p 5 0009 Age F 5 57 p 5 0018

Significant sleepiness (Dagger10 points) n () 5 (172) 16 (267) 6 (214) 12 (245) 11 (193) 28 (257)

Quality of life

EuroQol Visual Analogue Scale (0ndash100) mean (SD) 856 (198) 768 (190)a 839 (116) 726 (201)b 848 (161) 749 (195) F 5 109 p 5 0001 Age F 5 89 p 5 0003

SF-36 total score (0ndash100) mean (SD) 846 (125) 628 (244)a 863 (120) 682 (239)a 854 (122) 652 (242) F 5 344 p 0001 Age F 5 113 p 5 0001

Abbreviations BDI 5 Beck Depression Inventory BP 5 blood pressure BPI 5 Brief Pain Inventory ESS 5 Epworth Sleepiness Scale GLM 5 general linear model HR 5 heart rate MCI 5 mild cognitive impairmentMMSE 5 Mini-Mental State Examination MoCA 5 Montreal Cognitive Assessment RBD 5 REM sleep behavior disorder RBDSQ 5 REM Sleep Behavior Disorder Screening Questionnaire SF-36 5 Short FormHealth Survey SS-16 5 Sniffinrsquo Sticks 16-item smell identification testStatistical comparison between controls and patients was performed with a GLM using disease and sex as fixed factors and age as covariate Additional statistical comparison within female and male participantswas performed with the x2 test Fisher exact test or Mann-Whitney U test ap 001 bp 005 within same sex with Mann-Whitney U test cp 005 within same sex with x2 test dp 005 within same sex withFisher exact test Values in parentheses represent p values derived from group analysis of MCI and depression rates performed with x2 test instead of GLM Means are provided as unadjusted means Nonsignificantp values have been omitted for clarity

1462

Neurology

84

April7

2015

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

neuronal glycosphingolipid storage and ALP disrup-tion in AFD lead to focused brainstem pathologywhich results in a distinct clinical phenotype withmild motor impairment and nonmotor symptomssuch as depression pain daytime sleepiness andhearing loss but is not associated with cardinal clin-ical prodromes of neurodegenerative diseases such asparkinsonian motor signs and impairments of cogni-tion and olfaction that are found in GD10 Howeverwe would not completely rule out a contribution ofa-Gal deficiency to the development of neurodegen-erative disease based on the lack of clinical prodromesespecially as neuropathologic brainstem involvementhas also been demonstrated in presymptomatic stagesof PD36

Another interesting observation of our study is thesimilarity of neurologic manifestations in female andmale patients with AFD which is in keeping withother studies showing significant organ involvementin female heterozygotes despite X-chromosomalinheritance37 Skewed inactivation of the X-chromo-some was suspected to explain disease manifestations infemale patients which is supported by recent researchdemonstrating correlations between X-inactivation andclinical disease severity in female patients38 Molecularinterference by the mutant enzyme protein exertinga dominant negative effect on the normal gene pro-duct has also been suggested39 but this explanatorytheory remains to be proven While the reasons forsex parity of disease manifestations in AFD remain tobe elucidated our study should raise physiciansrsquoawareness for symptoms in female patients withAFD who are often considered as carriers of butnot patients with the disease

Strengths of our study in this rare disease includeits size range and complexity of clinical testing andthe use of age-matched controls to enhance externalvalidity of the results Due to its observational andcross-sectional design our study has some limitationswhich may have influenced its outcome First themajority of patients in our AFD cohort were treatedwith ERT which may have partly altered the naturalphenotype of the disease and explain lower severity ofperipheral nonmotor symptoms such as pain How-ever ERT is unlikely to influence neurologic symp-toms caused by central manifestations of AFD suchas motor features hyposmia or RBD since it cannotcross the bloodndashbrain barrier Secondly it must beacknowledged that blinded examination was not possi-ble due to facial stigmata and skin manifestations inAFD which may have subconsciously influenced ourassessments although we applied well-established andhighly standardized clinical tests to minimize observerbias Third sex comparison in our study may notentirely reflect natural conditions in AFD carriers sinceour cohort was recruited from a university-based

specialty center in which more severely affected femalepatients may be overrepresented Moreover patientsrsquoperception of having AFD may have contributed toworse outcomes on questionnaires in comparison tocontrols

Taken together our study argues for a distinctneurologic phenotype in AFD that lacks classical pro-dromal features of neurodegeneration that have beendemonstrated in GD Unlike functional loss of gluco-cerebrosidase in GD which has been shown to beinvolved in accumulation of a-synuclein and resultsin neurotoxicity40 AFD-linked deficiency of a-Gal isapparently not associated with neurodegeneration onthe clinical level

AUTHOR CONTRIBUTIONSM Loumlhle design and conceptualization of the study analysis and inter-

pretation of the data drafting and revising the manuscript for intellectual

content D Hughes revising the manuscript for intellectual content

A Milligan revising the manuscript for intellectual content L Richfield

revising the manuscript for intellectual content H Reichmann revising

the manuscript for intellectual content A Mehta revising the manu-

script for intellectual content A Schapira design and conceptualization

of the study interpretation of the data revising the manuscript for intel-

lectual content

ACKNOWLEDGMENTThe authors thank the patients and controls for their participation and

Junibelle Cooke Anna Fernandez-Saranillo Patricia Pilgrim and Mark

McKie members of the Lysosomal Storage Disorder Unit at the Royal

Free Hospital who helped with recruitment for this study M Loumlhle

thanks Alisdair McNeill Christos Proukakis and Alexander Storch for

discussions

STUDY FUNDINGSupported by the NIHR UCLH Biomedical Research Centre and UCLH

BRC award to AHV Schapira AHV Schapira is a NIHR Senior

Investigator

DISCLOSUREM Loumlhle was supported by a seed grant of the Center for Regenerative

Therapies Dresden and has received honoraria for presentations from

Boehringer Ingelheim GlaxoSmithKline MEDA Pharma and UCB

D Hughes has received travel and research grants and honoraria

for speaking and advisory boards from Amicus Genzyme (Sanofi) and

Shire A Milligan has received travel grants from Genzyme (Sanofi) and

Shire L Richfield has received travel grants from Genzyme (Sanofi)

and Shire H Reichmann was acting on Advisory Boards and gave lec-

tures and has received research grants from Abbott Abbvie Bayer Health

Care Boehringer Ingelheim Brittania Cephalon Desitin GSK Lund-

beck Medtronic Merck-Serono Novartis Orion Pfizer TEVA UCB

and Valeant A Mehta has received travel and research grants and

honoraria for speaking and advisory boards from Genzyme (Sanofi) and

Shire A Schapira is a NIHR Senior Investigator He has received

honoraria for educational symposia and consultancy from Boehringer

Ingelheim Teva-Lundbeck UCB Merz Merck Orion and Novartis

Go to Neurologyorg for full disclosures

Received September 13 2014 Accepted in final formDecember 22 2014

REFERENCES1 Brady RO Gal AE Bradley RM Martensson E

Warshaw AL Laster L Enzymatic defect in Fabryrsquos dis-

ease ceramidetrihexosidase deficiency N Engl J Med

19672761163ndash1167

Neurology 84 April 7 2015 1463

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Table 3 Continued

Femalecontrols

Femalepatients

Malecontrols

Malepatients

Allcontrols All patients

F and p values after GLM analysis for

Disease Other factors

Pain

BPI

Pain severity index (0ndash10) mean (SD) 09 (16) 22 (24)b 07 (14) 15 (22)a 08 (15) 19 (23) F 5 98 p 5 0002 Age F 5 96 p 5 0002

Function interference index (0ndash10) mean (SD) 06 (12) 19 (25)b 06 (14) 15 (26)a 06 (13) 17 (25) F 5 91 p 5 0003 Age F 5 48 p 5 003

Sleep

RBDSQ

Total score mean (SD) 25 (20) 32 (28) 26 (19) 28 (27) 25 (19) 30 (28) Age F 5 67 p 5 001

RBD (Dagger5 points) n () 5 (172) 16 (267) 3 (107) 13 (265) 8 (140) 29 (266)

ESS

Total score (0ndash24) mean (SD) 56 (39) 74 (51) 47 (44) 71 (48)b 51 (42) 72 (50) F 5 70 p 5 0009 Age F 5 57 p 5 0018

Significant sleepiness (Dagger10 points) n () 5 (172) 16 (267) 6 (214) 12 (245) 11 (193) 28 (257)

Quality of life

EuroQol Visual Analogue Scale (0ndash100) mean (SD) 856 (198) 768 (190)a 839 (116) 726 (201)b 848 (161) 749 (195) F 5 109 p 5 0001 Age F 5 89 p 5 0003

SF-36 total score (0ndash100) mean (SD) 846 (125) 628 (244)a 863 (120) 682 (239)a 854 (122) 652 (242) F 5 344 p 0001 Age F 5 113 p 5 0001

Abbreviations BDI 5 Beck Depression Inventory BP 5 blood pressure BPI 5 Brief Pain Inventory ESS 5 Epworth Sleepiness Scale GLM 5 general linear model HR 5 heart rate MCI 5 mild cognitive impairmentMMSE 5 Mini-Mental State Examination MoCA 5 Montreal Cognitive Assessment RBD 5 REM sleep behavior disorder RBDSQ 5 REM Sleep Behavior Disorder Screening Questionnaire SF-36 5 Short FormHealth Survey SS-16 5 Sniffinrsquo Sticks 16-item smell identification testStatistical comparison between controls and patients was performed with a GLM using disease and sex as fixed factors and age as covariate Additional statistical comparison within female and male participantswas performed with the x2 test Fisher exact test or Mann-Whitney U test ap 001 bp 005 within same sex with Mann-Whitney U test cp 005 within same sex with x2 test dp 005 within same sex withFisher exact test Values in parentheses represent p values derived from group analysis of MCI and depression rates performed with x2 test instead of GLM Means are provided as unadjusted means Nonsignificantp values have been omitted for clarity

1462

Neurology

84

April7

2015

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

neuronal glycosphingolipid storage and ALP disrup-tion in AFD lead to focused brainstem pathologywhich results in a distinct clinical phenotype withmild motor impairment and nonmotor symptomssuch as depression pain daytime sleepiness andhearing loss but is not associated with cardinal clin-ical prodromes of neurodegenerative diseases such asparkinsonian motor signs and impairments of cogni-tion and olfaction that are found in GD10 Howeverwe would not completely rule out a contribution ofa-Gal deficiency to the development of neurodegen-erative disease based on the lack of clinical prodromesespecially as neuropathologic brainstem involvementhas also been demonstrated in presymptomatic stagesof PD36

Another interesting observation of our study is thesimilarity of neurologic manifestations in female andmale patients with AFD which is in keeping withother studies showing significant organ involvementin female heterozygotes despite X-chromosomalinheritance37 Skewed inactivation of the X-chromo-some was suspected to explain disease manifestations infemale patients which is supported by recent researchdemonstrating correlations between X-inactivation andclinical disease severity in female patients38 Molecularinterference by the mutant enzyme protein exertinga dominant negative effect on the normal gene pro-duct has also been suggested39 but this explanatorytheory remains to be proven While the reasons forsex parity of disease manifestations in AFD remain tobe elucidated our study should raise physiciansrsquoawareness for symptoms in female patients withAFD who are often considered as carriers of butnot patients with the disease

Strengths of our study in this rare disease includeits size range and complexity of clinical testing andthe use of age-matched controls to enhance externalvalidity of the results Due to its observational andcross-sectional design our study has some limitationswhich may have influenced its outcome First themajority of patients in our AFD cohort were treatedwith ERT which may have partly altered the naturalphenotype of the disease and explain lower severity ofperipheral nonmotor symptoms such as pain How-ever ERT is unlikely to influence neurologic symp-toms caused by central manifestations of AFD suchas motor features hyposmia or RBD since it cannotcross the bloodndashbrain barrier Secondly it must beacknowledged that blinded examination was not possi-ble due to facial stigmata and skin manifestations inAFD which may have subconsciously influenced ourassessments although we applied well-established andhighly standardized clinical tests to minimize observerbias Third sex comparison in our study may notentirely reflect natural conditions in AFD carriers sinceour cohort was recruited from a university-based

specialty center in which more severely affected femalepatients may be overrepresented Moreover patientsrsquoperception of having AFD may have contributed toworse outcomes on questionnaires in comparison tocontrols

Taken together our study argues for a distinctneurologic phenotype in AFD that lacks classical pro-dromal features of neurodegeneration that have beendemonstrated in GD Unlike functional loss of gluco-cerebrosidase in GD which has been shown to beinvolved in accumulation of a-synuclein and resultsin neurotoxicity40 AFD-linked deficiency of a-Gal isapparently not associated with neurodegeneration onthe clinical level

AUTHOR CONTRIBUTIONSM Loumlhle design and conceptualization of the study analysis and inter-

pretation of the data drafting and revising the manuscript for intellectual

content D Hughes revising the manuscript for intellectual content

A Milligan revising the manuscript for intellectual content L Richfield

revising the manuscript for intellectual content H Reichmann revising

the manuscript for intellectual content A Mehta revising the manu-

script for intellectual content A Schapira design and conceptualization

of the study interpretation of the data revising the manuscript for intel-

lectual content

ACKNOWLEDGMENTThe authors thank the patients and controls for their participation and

Junibelle Cooke Anna Fernandez-Saranillo Patricia Pilgrim and Mark

McKie members of the Lysosomal Storage Disorder Unit at the Royal

Free Hospital who helped with recruitment for this study M Loumlhle

thanks Alisdair McNeill Christos Proukakis and Alexander Storch for

discussions

STUDY FUNDINGSupported by the NIHR UCLH Biomedical Research Centre and UCLH

BRC award to AHV Schapira AHV Schapira is a NIHR Senior

Investigator

DISCLOSUREM Loumlhle was supported by a seed grant of the Center for Regenerative

Therapies Dresden and has received honoraria for presentations from

Boehringer Ingelheim GlaxoSmithKline MEDA Pharma and UCB

D Hughes has received travel and research grants and honoraria

for speaking and advisory boards from Amicus Genzyme (Sanofi) and

Shire A Milligan has received travel grants from Genzyme (Sanofi) and

Shire L Richfield has received travel grants from Genzyme (Sanofi)

and Shire H Reichmann was acting on Advisory Boards and gave lec-

tures and has received research grants from Abbott Abbvie Bayer Health

Care Boehringer Ingelheim Brittania Cephalon Desitin GSK Lund-

beck Medtronic Merck-Serono Novartis Orion Pfizer TEVA UCB

and Valeant A Mehta has received travel and research grants and

honoraria for speaking and advisory boards from Genzyme (Sanofi) and

Shire A Schapira is a NIHR Senior Investigator He has received

honoraria for educational symposia and consultancy from Boehringer

Ingelheim Teva-Lundbeck UCB Merz Merck Orion and Novartis

Go to Neurologyorg for full disclosures

Received September 13 2014 Accepted in final formDecember 22 2014

REFERENCES1 Brady RO Gal AE Bradley RM Martensson E

Warshaw AL Laster L Enzymatic defect in Fabryrsquos dis-

ease ceramidetrihexosidase deficiency N Engl J Med

19672761163ndash1167

Neurology 84 April 7 2015 1463

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

neuronal glycosphingolipid storage and ALP disrup-tion in AFD lead to focused brainstem pathologywhich results in a distinct clinical phenotype withmild motor impairment and nonmotor symptomssuch as depression pain daytime sleepiness andhearing loss but is not associated with cardinal clin-ical prodromes of neurodegenerative diseases such asparkinsonian motor signs and impairments of cogni-tion and olfaction that are found in GD10 Howeverwe would not completely rule out a contribution ofa-Gal deficiency to the development of neurodegen-erative disease based on the lack of clinical prodromesespecially as neuropathologic brainstem involvementhas also been demonstrated in presymptomatic stagesof PD36

Another interesting observation of our study is thesimilarity of neurologic manifestations in female andmale patients with AFD which is in keeping withother studies showing significant organ involvementin female heterozygotes despite X-chromosomalinheritance37 Skewed inactivation of the X-chromo-some was suspected to explain disease manifestations infemale patients which is supported by recent researchdemonstrating correlations between X-inactivation andclinical disease severity in female patients38 Molecularinterference by the mutant enzyme protein exertinga dominant negative effect on the normal gene pro-duct has also been suggested39 but this explanatorytheory remains to be proven While the reasons forsex parity of disease manifestations in AFD remain tobe elucidated our study should raise physiciansrsquoawareness for symptoms in female patients withAFD who are often considered as carriers of butnot patients with the disease

Strengths of our study in this rare disease includeits size range and complexity of clinical testing andthe use of age-matched controls to enhance externalvalidity of the results Due to its observational andcross-sectional design our study has some limitationswhich may have influenced its outcome First themajority of patients in our AFD cohort were treatedwith ERT which may have partly altered the naturalphenotype of the disease and explain lower severity ofperipheral nonmotor symptoms such as pain How-ever ERT is unlikely to influence neurologic symp-toms caused by central manifestations of AFD suchas motor features hyposmia or RBD since it cannotcross the bloodndashbrain barrier Secondly it must beacknowledged that blinded examination was not possi-ble due to facial stigmata and skin manifestations inAFD which may have subconsciously influenced ourassessments although we applied well-established andhighly standardized clinical tests to minimize observerbias Third sex comparison in our study may notentirely reflect natural conditions in AFD carriers sinceour cohort was recruited from a university-based

specialty center in which more severely affected femalepatients may be overrepresented Moreover patientsrsquoperception of having AFD may have contributed toworse outcomes on questionnaires in comparison tocontrols

Taken together our study argues for a distinctneurologic phenotype in AFD that lacks classical pro-dromal features of neurodegeneration that have beendemonstrated in GD Unlike functional loss of gluco-cerebrosidase in GD which has been shown to beinvolved in accumulation of a-synuclein and resultsin neurotoxicity40 AFD-linked deficiency of a-Gal isapparently not associated with neurodegeneration onthe clinical level

AUTHOR CONTRIBUTIONSM Loumlhle design and conceptualization of the study analysis and inter-

pretation of the data drafting and revising the manuscript for intellectual

content D Hughes revising the manuscript for intellectual content

A Milligan revising the manuscript for intellectual content L Richfield

revising the manuscript for intellectual content H Reichmann revising

the manuscript for intellectual content A Mehta revising the manu-

script for intellectual content A Schapira design and conceptualization

of the study interpretation of the data revising the manuscript for intel-

lectual content

ACKNOWLEDGMENTThe authors thank the patients and controls for their participation and

Junibelle Cooke Anna Fernandez-Saranillo Patricia Pilgrim and Mark

McKie members of the Lysosomal Storage Disorder Unit at the Royal

Free Hospital who helped with recruitment for this study M Loumlhle

thanks Alisdair McNeill Christos Proukakis and Alexander Storch for

discussions

STUDY FUNDINGSupported by the NIHR UCLH Biomedical Research Centre and UCLH

BRC award to AHV Schapira AHV Schapira is a NIHR Senior

Investigator

DISCLOSUREM Loumlhle was supported by a seed grant of the Center for Regenerative

Therapies Dresden and has received honoraria for presentations from

Boehringer Ingelheim GlaxoSmithKline MEDA Pharma and UCB

D Hughes has received travel and research grants and honoraria

for speaking and advisory boards from Amicus Genzyme (Sanofi) and

Shire A Milligan has received travel grants from Genzyme (Sanofi) and

Shire L Richfield has received travel grants from Genzyme (Sanofi)

and Shire H Reichmann was acting on Advisory Boards and gave lec-

tures and has received research grants from Abbott Abbvie Bayer Health

Care Boehringer Ingelheim Brittania Cephalon Desitin GSK Lund-

beck Medtronic Merck-Serono Novartis Orion Pfizer TEVA UCB

and Valeant A Mehta has received travel and research grants and

honoraria for speaking and advisory boards from Genzyme (Sanofi) and

Shire A Schapira is a NIHR Senior Investigator He has received

honoraria for educational symposia and consultancy from Boehringer

Ingelheim Teva-Lundbeck UCB Merz Merck Orion and Novartis

Go to Neurologyorg for full disclosures

Received September 13 2014 Accepted in final formDecember 22 2014

REFERENCES1 Brady RO Gal AE Bradley RM Martensson E

Warshaw AL Laster L Enzymatic defect in Fabryrsquos dis-

ease ceramidetrihexosidase deficiency N Engl J Med

19672761163ndash1167

Neurology 84 April 7 2015 1463

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

2 Dutsch M Marthol H Stemper B Brys M Haendl T

Hilz MJ Small fiber dysfunction predominates in Fabry

neuropathy J Clin Neurophysiol 200219575ndash586

3 Mitsias P Levine SR Cerebrovascular complications of

Fabryrsquos disease Ann Neurol 1996408ndash17

4 deVeber GA Schwarting GA Kolodny EH Kowall NW

Fabry disease immunocytochemical characterization of

neuronal involvement Ann Neurol 199231409ndash415

5 Kaye EM Kolodny EH Logigian EL Ullman MD Ner-

vous system involvement in Fabryrsquos disease clinicopatho-

logical and biochemical correlation Ann Neurol 198823

505ndash509

6 NelsonMP Tse TE OrsquoQuinn DB et al Autophagy-lysosome

pathway associated neuropathology and axonal degeneration in

the brains of alpha-galactosidase A-deficient mice Acta Neuro-

pathol Commun 2014220

7 Sidransky E Nalls MA Aasly JO et al Multicenter anal-

ysis of glucocerebrosidase mutations in Parkinsonrsquos disease

N Engl J Med 20093611651ndash1661

8 Borsini W Giuliacci G Torricelli F Pelo E Martinelli F

Scordo MR Anderson-Fabry disease with cerebrovascular

complications in two Italian families Neurol Sci 200223

49ndash53

9 Buechner S De Cristofaro MT Ramat S Borsini W Par-

kinsonism and Anderson Fabryrsquos disease a case report

Mov Disord 200621103ndash107

10 McNeill A Duran R Proukakis C et al Hyposmia and

cognitive impairment in Gaucher disease patients and car-

riers Mov Disord 201227526ndash532

11 Whybra C Kampmann C Krummenauer F et al The

Mainz Severity Score Index a new instrument for quanti-

fying the Anderson-Fabry disease phenotype and the

response of patients to enzyme replacement therapy Clin

Genet 200465299ndash307

12 Podsiadlo D Richardson S The timed ldquoUp amp Gordquo a test

of basic functional mobility for frail elderly persons J Am

Geriatr Soc 199139142ndash148

13 Desrosiers J Hebert R Bravo G Dutil E The Purdue

Pegboard Test normative data for people aged 60 and

over Disabil Rehabil 199517217ndash224

14 Nutt JG Lea ES Van Houten L Schuff RA Sexton GJ

Determinants of tapping speed in normal control sub-

jects and subjects with Parkinsonrsquos disease differing

effects of brief and continued practice Mov Disord

200015843ndash849

15 Goetz CG Tilley BC Shaftman SR et al Movement Dis-

order Society-sponsored revision of the Unified Parkinsonrsquos

Disease Rating Scale (MDS-UPDRS) scale presentation

and clinimetric testing results Mov Disord 200823

2129ndash2170

16 Goldstein LB Samsa GP Reliability of the National Insti-

tutes of Health Stroke Scale extension to non-neurologists

in the context of a clinical trial Stroke 199728307ndash310

17 Folstein MF Robins LN Helzer JE The Mini-Mental

State Examination Arch Gen Psychiatry 198340812

18 Nasreddine ZS Phillips NA Bedirian V et al The Montreal

Cognitive Assessment MoCA a brief screening tool for mild

cognitive impairment J Am Geriatr Soc 200553695ndash699

19 Dalrymple-Alford JC MacAskill MR Nakas CT et al

The MoCA well-suited screen for cognitive impairment

in Parkinson disease Neurology 2010751717ndash1725

20 Beck AT Steer RA Ball R Ranieri W Comparison of

Beck Depression Inventories IA and II in psychiatric out-

patients J Pers Assess 199667588ndash597

21 Silveira-Moriyama L Petrie A Williams DR et al The use

of a color coded probability scale to interpret smell tests in

suspected parkinsonism Mov Disord 2009241144ndash1153

22 Cleeland CS Ryan KM Pain assessment global use of the

Brief Pain Inventory Ann Acad Med Singapore 199423

129ndash138

23 Stiasny-Kolster K Mayer G Schafer S Moller JC Heinzel-

Gutenbrunner M Oertel WH The REM sleep behavior

disorder screening questionnaire a new diagnostic instru-

ment Mov Disord 2007222386ndash2393

24 Johns MW A new method for measuring daytime sleepi-

ness the Epworth Sleepiness Scale Sleep 199114540ndash545

25 Herdman M Gudex C Lloyd A et al Development and

preliminary testing of the new five-level version of EQ-5D

(EQ-5D-5L) Qual Life Res 2011201727ndash1736

26 McHorney CA Ware JE Jr Raczek AE The MOS 36-

Item Short-Form Health Survey (SF-36) II psychometric

and clinical tests of validity in measuring physical and

mental health constructs Med Care 199331247ndash263

27 Gaenslen A Wurster I Brockmann K et al Prodromal

features for Parkinsonrsquos disease baseline data from the

TREND study Eur J Neurol 201421766ndash772

28 Molano J Boeve B Ferman T et al Mild cognitive impair-

ment associated with limbic and neocortical Lewy body dis-

ease a clinicopathological study Brain 2010133540ndash556

29 Sims K Politei J Banikazemi M Lee P Stroke in Fabry

disease frequently occurs before diagnosis and in the

absence of other clinical events natural history data from

the Fabry Registry Stroke 200940788ndash794

30 Cole AL Lee PJ Hughes DA Deegan PB Waldek S

Lachmann RH Depression in adults with Fabry disease

a common and under-diagnosed problem J Inherit Metab

Dis 200730943ndash951

31 Uceyler N Ganendiran S Kramer D Sommer C Char-

acterization of pain in Fabry disease Clin J Pain 201430

915ndash920

32 Duning T Deppe M Keller S et al Excessive daytime

sleepiness is a common symptom in Fabry disease Case

Rep Neurol 2009133ndash40

33 Low M Nicholls K Tubridy N et al Neurology of Fabry

disease Intern Med J 200737436ndash447

34 Schermuly I Muller MJ Muller KM et al Neuropsychi-

atric symptoms and brain structural alterations in Fabry

disease Eur J Neurol 201118347ndash353

35 Biegstraaten M van Schaik IN Wieling W Wijburg FA

Hollak CE Autonomic neuropathy in Fabry disease a

prospective study using the Autonomic Symptom Profile

and cardiovascular autonomic function tests BMC Neurol

20101038

36 Braak H Del Tredici K Rub U de Vos RA Jansen Steur EN

Braak E Staging of brain pathology related to sporadic

Parkinsonrsquos disease Neurobiol Aging 200324197ndash211

37 WilcoxWR Oliveira JP Hopkin RJ et al Females with Fabry

disease frequently have major organ involvement lessons from

the Fabry Registry Mol Genet Metab 200893112ndash128

38 Germain DP Echevarria L Tissue-specific X chromosome

inactivation studies as a decision-making criteria for

enzyme replacement therapy in female heterozygotes for

Fabry disease Mol Genet Metab 2014111S45

39 Percy AK Kaye EM Does gender parity exist in Fabry

disease Neurology 200565508ndash509

40 Schapira AH Gegg ME Glucocerebrosidase in the path-

ogenesis and treatment of Parkinson disease Proc Natl

Acad Sci USA 20131103214ndash3215

1464 Neurology 84 April 7 2015

ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited

DOI 101212WNL00000000000014502015841454-1464 Published Online before print March 11 2015Neurology Matthias Loumlhle Derralynn Hughes Alan Milligan et al

Clinical prodromes of neurodegeneration in Anderson-Fabry disease

This information is current as of March 11 2015

rights reserved Print ISSN 0028-3878 Online ISSN 1526-632X1951 it is now a weekly with 48 issues per year Copyright copy 2015 American Academy of Neurology All

reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology

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rights reserved Print ISSN 0028-3878 Online ISSN 1526-632X1951 it is now a weekly with 48 issues per year Copyright copy 2015 American Academy of Neurology All

reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology

DOI 101212WNL00000000000014502015841454-1464 Published Online before print March 11 2015Neurology Matthias Loumlhle Derralynn Hughes Alan Milligan et al

Clinical prodromes of neurodegeneration in Anderson-Fabry disease

This information is current as of March 11 2015

rights reserved Print ISSN 0028-3878 Online ISSN 1526-632X1951 it is now a weekly with 48 issues per year Copyright copy 2015 American Academy of Neurology All

reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology

ServicesUpdated Information amp

httpnneurologyorgcontent84141454fullincluding high resolution figures can be found at

Supplementary Material

450DC1httpnneurologyorgcontentsuppl20150311WNL0000000000001Supplementary material can be found at

References httpnneurologyorgcontent84141454fullref-list-1

This article cites 40 articles 5 of which you can access for free at

Citations httpnneurologyorgcontent84141454fullotherarticles

This article has been cited by 3 HighWire-hosted articles

Subspecialty Collections

httpnneurologyorgcgicollectionprevalence_studiesPrevalence studies

httpnneurologyorgcgicollectionparkinsons_disease_parkinsonismParkinsons diseaseParkinsonism

httpnneurologyorgcgicollectionmetabolic_disease_inheritedMetabolic disease (inherited)

httpnneurologyorgcgicollectionlipidosesLipidoses

httpnneurologyorgcgicollectionall_movement_disordersAll Movement Disordersfollowing collection(s) This article along with others on similar topics appears in the

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httpwwwneurologyorgaboutabout_the_journalpermissionsits entirety can be found online atInformation about reproducing this article in parts (figurestables) or in

Reprints

httpnneurologyorgsubscribersadvertiseInformation about ordering reprints can be found online

rights reserved Print ISSN 0028-3878 Online ISSN 1526-632X1951 it is now a weekly with 48 issues per year Copyright copy 2015 American Academy of Neurology All

reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology

ServicesUpdated Information amp

httpnneurologyorgcontent84141454fullincluding high resolution figures can be found at

Supplementary Material

450DC1httpnneurologyorgcontentsuppl20150311WNL0000000000001Supplementary material can be found at

References httpnneurologyorgcontent84141454fullref-list-1

This article cites 40 articles 5 of which you can access for free at

Citations httpnneurologyorgcontent84141454fullotherarticles

This article has been cited by 3 HighWire-hosted articles

Subspecialty Collections

httpnneurologyorgcgicollectionprevalence_studiesPrevalence studies

httpnneurologyorgcgicollectionparkinsons_disease_parkinsonismParkinsons diseaseParkinsonism

httpnneurologyorgcgicollectionmetabolic_disease_inheritedMetabolic disease (inherited)

httpnneurologyorgcgicollectionlipidosesLipidoses

httpnneurologyorgcgicollectionall_movement_disordersAll Movement Disordersfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwneurologyorgaboutabout_the_journalpermissionsits entirety can be found online atInformation about reproducing this article in parts (figurestables) or in

Reprints

httpnneurologyorgsubscribersadvertiseInformation about ordering reprints can be found online

rights reserved Print ISSN 0028-3878 Online ISSN 1526-632X1951 it is now a weekly with 48 issues per year Copyright copy 2015 American Academy of Neurology All

reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology