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      Lafora Disease during a Seven-Year Period, Bosnian and Herzegovinian experience

      case-report

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          Abstract

          Lafora progressive myoclonus epilepsy (Lafora disease, LD) is a fatal autosomal recessive neurodegenerative disorder (with an onset in teenage years in previously normal adolescents). This paper represents a view of a patient diagnosed with Lafora progressive myoclonus epilepsy, over a course of seven years. A description of the initial manifestation of symptoms, doctors' attempts to combat the symptoms with drug treatment, further attempts towards reaching the correct diagnosis, the final confirmation of the Lafora diagnosis (mutation in the NHLRC1 gene), and the current state of the patient is presented. The absence of a positive family history, the lack of staff specialized in dealing with this or similar pathology, and the diagnostic inability to characterize this type of disorder in Bosnia and Herzegovina have led to a fair delay in diagnosing and beginning of an adequate pharmacological treatment. Overall, recent identification of LD cases in Bosnia and Herzegovina warrants an establishment of a Centre for Genetic Testing in order to ensure more humane counseling of an entire family whose family member(s) might be diagnosed with this devastating and currently an incurable disorder.

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          Typical progression of myoclonic epilepsy of the Lafora type: a case report.

          A 20-year-old woman presented to a specialist epilepsy center with a 3-year history of drug-resistant epileptic seizures, progressive myoclonus, ataxia, and cognitive decline. Neurological examination, neuropsychological testing, electrophysiological studies, skin biopsy, MRI, genetic testing, and autopsy. Lafora disease (EPM2), resulting from a homozygous missense mutation in EPM2B (NHLRC1; c205C>G; Pro69Ala). Symptomatic treatment with conventional antiepileptic and antimyoclonic drugs.
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            The phosphatase activity of laforin is dispensable to rescue Epm2a-/- mice from Lafora disease.

            Lafora progressive myoclonus epilepsy (Lafora disease) is a fatal autosomal recessive neurodegenerative disorder characterized by the presence of glycogen-like intracellular inclusions called Lafora bodies. The vast majority of patients carry mutations in either the EPM2A or EPM2B genes, encoding laforin, a glucan phosphatase, and malin, an E3 ubiquitin ligase, respectively. Although the precise physiological role of these proteins is not fully understood, work in past years has established a link between glycogen synthesis, Lafora bodies formation and Lafora disease development. To determine the role of the phosphatase activity of laforin in disease development we generated two Epm2a(-/-) mouse lines expressing either wild-type laforin or a mutant (C265S) laforin lacking only the phosphatase activity. Our results demonstrate that expression of either transgene blocks formation of Lafora bodies and restores the impairment in macroautophagy, preventing the development of Lafora bodies in Epm2a(-/-) mice. These data indicate that the critical pathogenic process is the control of abnormal glycogen accumulation through intracellular proteolytic systems by the laforin-malin complex, and not glycogen dephosphorylation by laforin. Understanding which is the essential process leading to Lafora disease pathogenesis represents a critical conceptual advance that should facilitate development of appropriate therapeutics.
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              Unusual Course of Lafora Disease

              Summary A 42‐year‐old male was admitted for refractory status epilepticus. At the age of 25, he had been diagnosed with juvenile myoclonic epilepsy. He had a stable clinical course for over a decade until a recent deterioration of behavior and epilepsy. After exclusion of acquired disorders, diagnostic work‐up included application of next‐generation sequencing (NGS), with a gene panel targeting progressive myoclonic epilepsies. This resulted in the diagnosis Lafora disease resulting from compound heterozygous NHLRC1 pathogenic variants. Although these pathogenic variants may be associated with a variable phenotype, including both severe and mild clinical course, the clinical presentation of our patient at this age is very unusual for Lafora disease. Our case expands the phenotype spectrum of Lafora disease resulting from pathogenic NHLRC1 variants and illustrates the value of using NGS in clinical practice to lead to a rapid diagnosis and guide therapeutic options.
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                Author and article information

                Journal
                Iran J Child Neurol
                Iran J Child Neurol
                IJCN
                Iranian Journal of Child Neurology
                Shahid Beheshti University of Medical Sciences (Tehran, Iran )
                1735-4668
                2008-0700
                Winter 2019
                : 13
                : 1
                : 115-120
                Affiliations
                [1 ]Health Care Centre, Maglaj, Bosnia and Herzegovina
                [2 ]Department of Pharmacology, School of Medicine, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina
                [3 ]Department of Cardiology, Pediatric Clinic, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
                [4 ]PhD Student, Faculty of Medicine, University of Tuzla, Tuzla, Bosnia and Herzegovina
                Author notes
                Corresponding Author: Begic E. MD, MA, Health Care Centre, Maglaj, Bosnia and Herzegovina. Email: edinbegic90@gmail.com
                Article
                ijcn-13-115
                6296693
                30598679
                afdf0fa7-6ccf-4ba2-94bb-d38fdc416b5f

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License, ( http://creativecommons.org/licenses/by/3.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 13 February 2017
                : 5 July 2017
                : 5 May 2018
                Categories
                Case Report

                progressive myoclonus epilepsy,lafora disease,nhlrc1 mutation

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