Tremor and Other Hyperkinetic Movements

New Observations Letters

The Movement Disorder of Brain-Lung-Thyroid Syndrome Can be Responsive to Methylphenidate

Laurence Gauquelin1,2, Luan T. Tran1,2,3,4, Sylvain Chouinard5 & Geneviève Bernard1,2,3,4*

1Department of Neurology and Neurosurgery, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Canada, 2Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Canada, 3Child Health and Human Development Program, Research Institute of the McGill University Health Centre, Montreal, Canada, 4Department of Medical Genetics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, Canada, 5Centre Hospitalier Universitaire de Montréal (CHUM)-Notre-Dame, André Barbeau Movement Disorders Unit, Montreal, Canada

Keywords: Chorea, brain-lung-thyroid syndrome, NKX2-1-related disorder, psychostimulant, methylphenidate

Citation: Gauquelin L, Tran LT, Chouinard S, Bernard G. The movement disorder of brain-lung-thyroid syndrome can be responsive to methylphenidate. Tremor Other Hyperkinet Mov. 2017; 7. doi: 10.7916/D84X5M9Z

*To whom correspondence should be addressed. E-mail: genevieve.bernard@mcgill.ca

Editor: Elan D. Louis, Yale University, USA

Received: August 29, 2017 Accepted: October 9, 2017 Published: October 26, 2017

Copyright: © 2017 Gauquelin et al. This is an open-access article distributed under the terms of the Creative Commons Attribution–Noncommercial–No Derivatives License, which permits the user to copy, distribute, and transmit the work provided that the original authors and source are credited; that no commercial use is made of the work; and that the work is not altered or transformed.

Funding: This study was supported by a grant from the Réseau de Médecine Génétique Appliquée of the Fonds de recherche du Québec en Santé (FRQS).

Financial Disclosures: Dr. Gauquelin: None. Mr. Tran: None. Dr. Chouinard: speaker’s honoraria from Allergan, Merz, and Ipsen. Dr. Bernard: speaker’s honoraria from Genzyme and Actelion Pharmaceuticals; grants from Shire and Actelion Pharmaceuticals; funds to organize a conference from Fortuna Fix, Allergan, Retrophin, and Actelion Pharmaceuticals; scientific advisory boards of Actelion Pharmaceuticals, Shire, and Santhera Pharmaceuticals.

Conflicts of interest: The authors declare no conflict of interest.

Ethics Statement: All patients that appear on video have provided written informed consent; authorization for the videotaping and for publication of the videotape was provided.

Introduction

Benign hereditary chorea is a rare disorder characterized by childhood-onset, non-progressive chorea, with or without associated respiratory and thyroid dysfunction.1 It is referred to as “brain-lung-thyroid” syndrome when all three systems are involved.2 It is caused by autosomal dominant mutations in the NKX2-1 gene (previously TITF-1), on chromosome 14.3 It is a genetically heterogeneous condition, with over 30 different causative mutations identified.4

Other neurological manifestations of benign hereditary chorea and NKX2-1-related disorders include dystonia, myoclonus, tics, tremor, dysarthria, ataxia, hypotonia, and motor developmental delay. Neuropsychiatric symptoms such as attention deficit hyperactivity disorder (ADHD), have also been reported.1,5

Pharmacologic treatment of chorea and other abnormal movements in NKX2-1-related disorders has been disappointing. It typically involves levodopa or tetrabenazine; however, side effects are often limiting.5 We report and illustrate the case of a young female patient with brain-lung-thyroid syndrome and an immediate improvement of her involuntary movements with methylphenidate (Video 1).

Methods

We obtained written informed consent from the subject and legal representative under a study approved by the ethics committee of the Montreal Children’s Hospital. We performed a retrospective chart review and assessed the patient before and after methylphenidate hydrochloride ingestion.

Results

The patient was born at term following an uncomplicated pregnancy. She suffered from transient respiratory distress. She was first referred to the neurology department at 2 years of age for hypotonia and motor delay. Thyroid function tests were performed at age 2 as part of the investigations for hypotonia and revealed hypothyroidism. The patient also had asthma. Chorea was noted on examination, predominantly in the limbs, with superimposed generalized dystonia and occasional myoclonic jerks. The cranial muscles were relatively spared. The patient was found to carry a de novo heterozygous missense mutation in NKX2-1 (NM_001079668, hg19). This variant (c.626G>C, p.Arg209Pro) has not been reported in any online database (ESP, 1000g, ExAC, gnomAD). It affects a highly conserved amino acid and is located in a highly conserved region involved in DNA binding.6 dbNSFP databases provided by Annovar predict the variant to be pathogenic. It has been published as pathogenic in three individuals from one family with childhood-onset hypothyroidism and movement disorders.6

Psychostimulant medication was initiated at the age of 5 for a concomitant diagnosis of ADHD. The patient experienced a sudden and dramatic improvement of her gait and stopped using her walker. She is now 10 years old and was initially treated with methylphenidate (up to 20 mg daily), and later with controlled-release methylphenidate hydrochloride (up to 30 mg daily). The medication adjustments were made based on her ADHD symptoms and treatment impact on her appetite. She has been on the same regimen since age 8 and has not required any additional treatment for her abnormal movements. She exhibits significant reduction of her choreic movements and dystonic postures within 30 minutes after receiving her daily dose, with consequent improvement in her gait, speech, and fine motor skills. These benefits consistently last throughout the day. The patient and her parents report that the involuntary movements only become more bothersome in the evening and peak in the morning prior to methylphenidate ingestion. This is consistent with the reported duration of action (8 to 12 hours) of extended-release forms of stimulant medications.7

Discussion

The central nervous system stimulant methylphenidate is typically not considered as a treatment option for chorea or other movement disorders. However, it was previously associated with incidental improvement in two patients with benign hereditary chorea.8,9 In 1996, Friederich first reported subjective improvements of handwriting and gait in a young male patient treated with methylphenidate.8 He hypothesized that this response was the result of a reduction in stress exacerbating the chorea rather than a direct effect. The dramatic, immediate response in our patient argues against this hypothesis.

Questions remain about the role of dopamine in benign hereditary chorea. NKX2-1 is believed to be involved in the embryologic striatum development.10,11 Immunohistochemical studies on an affected postmortem brain revealed loss of striatal interneurons and efferent fibers.11 In addition, a recent dopaminergic neuronal imaging study found decreased dopamine receptor binding.12

Tetrabenazine is a dopamine-depleting agent that inhibits the vesicular monoamine transporter 2, whereas levodopa is a dopamine precursor converted to dopamine by striatal enzymes. Both have shown suboptimal results in the treatment of movement disorders in patients with benign hereditary chorea and NKX2-1-related disorders.5 Methylphenidate is a dopamine reuptake blocker that facilitates dopaminergic transmission. Although dopamine appears to be involved in the pathogenesis of NKX2-1-related disorders, the benefit of methylphenidate over levodopa and other dopaminergic medications remains unexplained.

This case illustrates for the first time an immediate and objective response to methylphenidate in a patient with brain-lung-thyroid syndrome. Further research is warranted to better document and explain this response. Our report supports a trial of methylphenidate to improve functional abilities in patients affected by NKX2-1-related disorders, especially given its more favorable side effect profile compared to other pharmacologic agents.

Acknowledgments

The authors wish to thank the patient and her family for their gracious participation in this research project. G.B. has received a Research Scholar Junior 1 award from the Fonds de Recherche du Québec en Santé (2012–2016) and the New Investigator Salary Award from the Canadian Institutes of Health Research (2017–2022).

References

1. Gras D, Jonard L, Roze E, Chantot-Bastaraud S, Koht J, Motte J, et al. Benign hereditary chorea: phenotype, prognosis, therapeutic outcome and long term follow-up in a large series with new mutations in the TITF1/NKX2-1 gene. J Neurol Neurosurg Psychiatry 2012;83:956–962. doi: 10.1136/jnnp-2012-302505

2. Willemsen MA, Breedveld GJ, Wouda S, Otten BJ, Yntema JL, Lammens M, et al. Brain-Thyroid-Lung syndrome: a patient with a severe multi-system disorder due to a de novo mutation in the thyroid transcription factor 1 gene. Eur J Pediatr 2005;164:28–30. doi: 10.1007/s00431-004-1559-x

3. Krude H, Schutz B, Biebermann H, von Moers A, Schnabel D, Neitzel H, et al. Choreoathetosis, hypothyroidism, and pulmonary alterations due to human NKX2-1 haploinsufficiency. J Clin Invest 2002;109:475–480. doi: 10.1172/JCI0214341

4. Peall KJ, Lumsden D, Kneen R, Madhu R, Peake D, Gibbon F, et al. Benign hereditary chorea related to NKX2.1: expansion of the genotypic and phenotypic spectrum. Dev Med Child Neurol 2014;56:642–648. doi: 10.1111/dmcn.12323

5. Peall KJ, Kurian MA. Benign Hereditary Chorea: An Update. Tremor Other Hyperkinet Mov 2015;5. doi: 10.7916/D8RJ4HM5

6. Williamson S, Kirkpatrick M, Greene S, Goudie D. A Novel Mutation of NKX2-1 Affecting 2 Generations With Hypothyroidism and Choreoathetosis: Part of the Spectrum of Brain-Thyroid-Lung Syndrome. J Child Neurol 2014;29:666–669. doi: 10.1177/0883073813518243

7. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management, Wolraich M, et al. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics 2011;128:1007–1022. doi: 10.1542/peds.2011-2654

8. Friederich RL. Benign hereditary chorea improved on stimulant therapy. Pediatr Neurol 1996;14:326–327. doi: 10.1016/0887-8994(96)00056-2

9. Devos D, Vuillaume I, de Becdelievre A, De Martinville B, Dhaenens CM, Cuvellier JC, et al. New syndromic form of benign hereditary chorea is associated with a deletion of TITF-1 and PAX-9 contiguous genes. Mov Disord 2006;21:2237–2240. doi: 10.1002/mds.21135

10. Sussel L, Marin O, Kimura S, Rubenstein JLR. Loss of Nkx2.1 homeobox gene function results in a ventral to dorsal molecular respecification within the basal telencephalon: evidence for a transformation of the pallidum into the striatum. Development 1999;126:3359–3370.

11. Kleiner-Fisman G, Calingasan N, Putt M, Chen J, Flint Beal M, Lang AE. Alterations of Striatal Neurons in Benign Hereditary Chorea. Mov Disord 2005;20:1353–1357. doi: 10.1002/mds.20577

12. Konishi T, Satoshi K, Fujimoto M, Terada T, Matsushita K, Ouchi Y, et al. Benign hereditary chorea: dopaminergic brain imaging in patients with a novel intronic NKX2.1 gene mutation. J Neurol 2013;260:207–213. doi: 10.1007/s00415-012-6618-z

Video 1. Immediate Improvement of the Involuntary Movements with Methylphenidate. The patient executed the following tasks prior to and 30 minutes after methylphenidate hydrochloride administration: running, performing rapid alternating movements, pouring water into a cup, and writing a series of loops with her dominant hand. There was a significant reduction in her choreic movements and dystonic postures, especially in the limbs. All tasks were carried out faster and with more precision after receiving her medication.

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License.

The opinions expressed within this journal do not necessarily reflect those of Tremor, its staff, its advisory Boards, or affiliates, or those of Columbia University.