Objective: We examined the clinical and pathologic phenotypes of GRN mutation carriers with the pathogenic A9D (g.26C.A) missense mutation.Methods: Three patients with GRN A9D mutations were evaluated clinically and came to autopsy with subsequent neuropathologic examination.
Results:The clinical diagnoses of patients with GRN A9D mutations were amyotrophic lateral sclerosis, atypical extrapyramidal disorder, and behavioral variant frontotemporal dementia. Immunohistochemistry for TAR DNA-binding protein 43 (TDP-43) revealed variability in morphology and distribution of pathology. One patient had notable involvement of motor neurons in the spinal cord as well as type B TDP-43, whereas 2 other patients had type A TDP-43.
Conclusions:The clinical presentation of the GRN A9D missense mutation is not restricted to behavioral variant frontotemporal dementia and may include aphasia, extrapyramidal features, and, notably, amyotrophic lateral sclerosis. Mutations in the progranulin (GRN) gene are a common cause of frontotemporal lobar degeneration (FTLD), with mutations identified in up to 10% of patients with FTLD. 1-3 Behavioral variant frontotemporal dementia (bvFTD) and primary progressive aphasia are the most frequent clinical presentations, but parkinsonism, corticobasal syndrome, and amnestic syndrome suggesting Alzheimer disease have also been reported. 4 In contrast, pathology associated with GRN mutations is relatively homogeneous, and cortical atrophy tends to be most severe in frontal lobes. 5,6 Atrophy of the parietal lobe and neuronal loss in the substantia nigra occur more often than in FTLD without GRN mutations. TAR DNA-binding protein 43 (TDP-43) is the major pathologic protein in inclusions of FTLD, 7 and GRN mutation carriers have a highly consistent pattern of TDP-43 histopathology. 5,6 The combined experience of investigators at a number of centers where FTLD is regularly seen has led to a harmonized classification system for TDP-43 pathology, with GRN mutation carriers usually exhibiting type A pathology. 8 The majority of GRN mutations promote premature termination of the coding sequence, which results in haploinsufficiency due to nonsense-mediated RNA decay. 1,2 An exception is the A9D (g.26C.A) missense mutation, which results in haploinsufficiency due to loss of GRN secretion. 9 Additional missense, silent, and intronic mutations have unknown pathogenicity or have been identified in controls and are not considered pathogenic (www.molgen.ua.ac.be/ FTDMutations). A few missense mutations of unknown pathogenicity have been reported in patients with amyotrophic lateral sclerosis (ALS) and Alzheimer disease, 10,11 suggesting that GRN variants may increase risk for diseases other than FTLD. Herein, we report that the GRN A9D mutation causes clinical and pathologic heterogeneity, which includes features of ALS.