lNTRODUCTlON

Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive lipid deposition disorder characterized by systemic signs and neurological dysfunction[1]. CTX is a treatable genetic metabolic disease,and early diagnosis and treatment can delay the progression of the disease to a considerable extent[2].We report a case of CTX caused by mutations at two sites in

. This case report will help clinicians to better understand CTX and its presentation, leading to early diagnosis and treatment,thereby improving the quality of life of patients.

CASE PRESENTATlON

Chief complaints

A 38-year-old male was admitted to our hospital with a history of unabating postural instability and difficulty in walking for more than 30 years.

History of present illness

The patient was first brought for treatment at the age of 5 years. Clinical documentation at that time reported that the patient had exhibited unabating postural instability and difficulty in walking that did not improve with rest. He also exhibited cognitive impairment and irritability.

History of past illness

Since childhood, the patient experienced frequent episodes of chronic diarrhea lasting multiple weeks.At the age of 11 years, the patient underwent bilateral cataract surgery. At the age of 36 years, the patient presented with bilateral masses on the Achilles tendons coupled with thickening of the Achilles tendons.

合金中加入Cu元素后，Cu會(huì)以顆粒狀化合物形式存在于鋁基體之中或者固溶于鋁基體，顯著提高鋁合金的強(qiáng)度和硬度，但會(huì)使鋁合金的伸長(zhǎng)率有所降低；Cu在Al-Si合金中會(huì)形成強(qiáng)化相 Al2Cu 及 Al4Mg6Cu4Si4，這兩種強(qiáng)化相有助于提高合金的強(qiáng)度[6].在Si，Mg，Mn三種元素的質(zhì)量分?jǐn)?shù)分別為10%，0.1%，0.1%的條件下，鑄態(tài)下不同Cu含量的合金顯微組織如圖7所示.由圖7可知，隨著Cu含量的增加，條片狀Si相減少，細(xì)化程度得到明顯改善，分布逐漸變得不均勻，大部分Si相呈現(xiàn)聚集傾向.

Personal and family history

The patient had no specific personal and family medical history.

精工是世界上唯一一家能夠用單體表殼制造潛水表的制造商。整體式結(jié)構(gòu)非常有價(jià)值，專為70年代末制作的水肺潛水表而設(shè)計(jì)（例如，最初的PloProf也采用整體式表殼），它代表著令人難以置信的特點(diǎn)---沒(méi)有密封件（除了從表盤側(cè)面外無(wú)法進(jìn)入機(jī)心），完美的密封性和獨(dú)特的設(shè)計(jì)。SLA025就繼承了偉大原型的這一特點(diǎn)：采用厚重的單體不銹鋼表殼，表徑44.8毫米，厚15.7毫米 - 與原型相比略大一些。此外，該表殼還具有超硬涂層，具有更好的防刮性；而4點(diǎn)鐘位置的表冠是典型的向原型致敬設(shè)計(jì)。

Physical examination

（四）強(qiáng)化生態(tài)環(huán)境保護(hù)能力保障體系。增強(qiáng)科技支撐，開展大氣污染成因與治理、水體污染控制與治理、土壤污染防治等重點(diǎn)領(lǐng)域科技攻關(guān)，

Laboratory examinations

The main cause of CTX is sterol 27-hydroxylase deficiency caused by the mutation of

[3].

encodes sterol 27-hydroxylase and is the only gene known to be associated with CTX[4]. Sterol 27-hydroxylase is involved in the biosynthesis of primary bile acids, including cholic acid and CDCA[5]. Sterol 27-hydroxylase deficiency obstructs the synthesis of primary bile acids, which causes the accumulation of bile acid synthesis pathway intermediates and derivative metabolites such as cholesterol and cholestanol. These substances are easily deposited in various lipophilic tissues, and therefore, they are more common in the brain, lens, and tendons[6]. They can negatively influence the function of cellular calcium channels, destroy the stability of cell membranes, and initiate the apoptosis pathway[7].

Imaging examinations

Based on the patient's medical history, clinical manifestations, auxiliary examinations and gene sequencing results, the diagnosis of CTX was confirmed.

丁小慧才不相信許諾是那種人，她是認(rèn)識(shí)許諾的。當(dāng)初，許諾開著一個(gè)小加工廠，想跟丁小慧的爸爸談合作，承包一個(gè)金屬零件的制作。可是，他的技術(shù)水平有限，做出來(lái)的零件并不符合規(guī)范，丁爸爸一口回絕了他。許諾很固執(zhí)，一次又一次拿著新樣品上門，每次都比上次更好一點(diǎn)。最后那次，丁小慧看他滿臉失望地下了樓，樓下一個(gè)模特般的女孩在等他，他克制著自己的失落，努力沖她笑。

Genetic testing

Based on the patient's medical history, clinical manifestations, and imaging analyses, it was unclear if CTX was involved, and gene sequencing was required to confirm the diagnosis. After informing the patient, the patient was eager to identify the underlying cause and had hopes for treatment; therefore he agreed to undergo gene sequencing analyses. Genomic DNA was extracted from the peripheral blood cells of the patient, and first-generation sequencing of the exon coding region of

revealed that the gene had a compound heterozygous mutation of c.380G＞A (Figure 3) and c.1563dupA (Figure 4).Further examination demonstrated that the mother and sister of the patient were carriers of the c.1563dupA mutation.

本研究還發(fā)現(xiàn)2015年MV野毒株組內(nèi)遺傳變異較小，而與疫苗株（A型）比較遺傳變異較大。同時(shí)也發(fā)現(xiàn)有3例麻疹患者之前接種過(guò)麻疹疫苗，由于基因測(cè)序未發(fā)現(xiàn)滬191麻疹疫苗株，且前2例患者接種疫苗到發(fā)病時(shí)間較短，可能在接種前已經(jīng)感染MV野毒株，最后1例考慮為免疫失敗。馮燕等[15]研究顯示，A基因型疫苗免疫后，對(duì)國(guó)外B、D型MV毒株侵襲的保護(hù)效果，要遠(yuǎn)遠(yuǎn)好于對(duì)我國(guó)的H1a流行株的保護(hù)。因此，MV野毒株核苷酸及氨基酸變異情況，是否會(huì)引起抗原性變化影響疫苗株保護(hù)效果，還有待進(jìn)一步研究。

FlNAL DlAGNOSlS

Magnetic resonance imaging (MRI) (Figure 2A and B) of the brain showed T2-weighted and FLAIR imaging hyperintensity in the bilateral cerebellar dentate nuclei. Electroencephalography showed abnormal slow-wave activity, composed of θ and δ waves, bilaterally in the posterior regions. MRI(Figure 2C and D) of the right ankle indicated fusiform swelling and abnormal signals in the Achilles tendons.

TREATMENT

After the diagnosis of CTX, the patient was prescribed chenodeoxycholic acid (CDCA) at 250 mg three times per day and instructed to adhere to a low-cholesterol diet.

OUTCOME AND FOLLOW-UP

利用微信公眾號(hào)開展實(shí)驗(yàn)室安全知識(shí)宣傳、安全設(shè)施使用、事故案例分析和安全文化建設(shè)，此舉突破了時(shí)空限制，可結(jié)合實(shí)驗(yàn)室實(shí)際情況和實(shí)驗(yàn)教學(xué)進(jìn)程編寫圖文并茂、針對(duì)性強(qiáng)的信息資料，及時(shí)傳送給學(xué)生，使學(xué)生能及時(shí)、持續(xù)地獲取豐富的學(xué)習(xí)內(nèi)容，激發(fā)學(xué)生的學(xué)習(xí)興趣，時(shí)時(shí)保持實(shí)驗(yàn)安全的警惕性，從而達(dá)到更好的安全教育目的，這種方式也是傳統(tǒng)的安全教育方法的有效補(bǔ)充[12]。

DlSCUSSlON

Blood lipid level examination revealed a total cholesterol concentration of 4.03 mmol/L (reference range: 2.60-5.20 mmol/L).

Currently, CTX is considered a rare disease, as are only a few hundred reported cases worldwide.However, we believe that this value is likely underestimated owing to the diversity of symptoms and the frequent delay in diagnosis. Consequently, the number of CTX cases is likely to be considerably far higher than that reported. The primary manifestations of CTX are infant-onset chronic refractory diarrhea, juvenile-onset bilateral cataracts, tendinous xanthomas, and progressive neurological dysfunction[8]. Neurophenotypes include ataxia, pyramidal tract signs, cognitive impairment, and peripheral neuropathy[8]. When the above symptoms are unexplained by common diseases at any age,the possibility of CTX should be considered, and further examinations should be performed. In the case of our patient, almost all the aforementioned symptoms occurred, although they varied in age at presentation. The constellation of symptoms observed in our patient caused us to consider CTX before other possible diseases.

There are no recognized diagnostic criteria for CTX; thus, clinicians must make their diagnoses based on medical history, family history, and clinical characteristics, following which the diagnosis must be confirmed by performing blood biochemistry tests, plasma cholesterol assessment, MRI, and gene sequencing. Our patient’s gene sequencing results showed two mutation sites in

: c.380G＞A located on exon 2 and c.1563dupA located on exon 9. Among these, the mutation site c.380G＞A has been reported previously[9], but the c.1563dupA mutation is novel and yet to be reported. As our patient possesses a known pathogenic mutation in

, we are currently unable to determine whether the new gene mutation is pathogenic; further research is needed to confirm the same. In addition, the biochemical diagnosis of CTX is based on the increase in serum cholestanol and urine bile alcohols levels[4]. The typical imaging findings indicating the prevalence of CTX include T2-weighted and FLAIR imaging hyperintensity in the dentate nucleus[10]. The current case supports the inclusion of high signal intensity of the two dentate nuclei on MRI as a typical feature of CTX[11]. The typical imaging manifestations of CTX are high signal in T2 weighted imaging and FLAIR imaging of dentate nucleus.

After 1 year of treatment, the patient felt that the symptoms of weakness in both lower limbs had improved slightly, but he did not report any additional changes. The patient reported no adverse reactions to CDCA.

In CTX treatment, there is currently no clear treatment plan, and the condition can be treated symptomatically based on the different clinical manifestations. Bile acid supplements, such as CDCA, provide a source of primary bile acids, which can inhibit the synthesis of bile acids through a negative feedback mechanism, thereby prevent the accumulation of cholesterol and cholestanol[12]. Consequently, early oral bile acid supplement treatment is recommended[13]. In addition, cataract extraction is common performed in these patients, and xanthoma can be surgically removed.

Our patient was prescribed CDCA replacement therapy. At a follow-up visit 6 months posttreatment, the symptoms of the patient had improved slightly. Based on previous studies, we understand that the clinical process of CTX is progressive[14]. Saussy

[14] compared three cases of CTX and concluded that early and uninterrupted treatment can delay progression of the disease, avert nervous system involvement, and improve the quality of life of patients. Once the neurological symptoms are completely determined, the therapeutic effect will be considerably reduced.

CONCLUSlON

Herein, we reported a case where first-generation sequencing of

was performed in a patient with CTX, leading to the detection of an unreported new mutation as well as a previously reported mutation. Consequently, this case provides new data for further examination of the pathogenesis of CTX and enriches the pathogenic mutational spectrum of

. In addition, the diagnosis of our patient helped him to receive genetic counseling and guidance regarding fertility. We hope that our case report enables other clinicians to more deeply understand the diagnosis and treatment of CTX, leading to early diagnoses and treatment and improved patient prognoses.

ACKNOWLEDGEMENTS

We would like to thank the patient and the patient’s family.

FOOTNOTES

Li ZR acquired patient information and prepared the manuscript; Zhou YL prepared the Figure; Jin Q and Xie YY checked the literature and proposed the idea of publishing this case study; Meng HM reviewed and edited the manuscript; and All authors read and approved the final manuscript.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

Informed consent was obtained from the patient. The participant consented to the submission of the case report to the Journal.

Neurological examination revealed gait ataxia, increased muscle tension in both lower limbs, bilateral hyperreflexia of the Achilles and knee tendons, a bilateral positive Babinski sign, and bilateral positive ankle clonus, indicating that the pyramidal tracts were damaged bilaterally. In addition, the patient also presented with arched feet and egg-sized, hard, painless lumps in both achilles tendons (Figure 1).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

Zhao-Ran Li 0000-0002-0048-8398; Yu-Ling Zhou 0000-0002-9155-111X; Qi Jin 0000-0002-5966-9118; Yin-Yin Xie 0000-0002-8749-2831; Hong-Mei Meng 0000-0001-6418-7300.

新時(shí)代深化司法鑒定制度改革不僅為司法鑒定管理制度改革提出新要求，也為探索司法鑒定監(jiān)管模式提出了新任務(wù)。司法鑒定管理制度改革需要為司法配套措施改革提供引領(lǐng)和方向。基于時(shí)代的要求，開創(chuàng)司法鑒定監(jiān)管的新模式需要考慮以下問(wèn)題。

Ma YJ

A

我相信隨著對(duì)混合式教學(xué)模式的深入研究和使用，它巨大的網(wǎng)絡(luò)平臺(tái)優(yōu)勢(shì)一定會(huì)得到更充分的利用，收到更好的教學(xué)效果。

Ma YJ

1 Dell'Aversano Orabona G, Dato C, Oliva M, Ugga L, Dotti MT, Fratta M, Gisonni P. Multi-imaging study in a patient with cerebrotendinous xanthomatosis: radiology, clinic and pathology correlation of a rare condition.

2020 ;6 : 20190047 [PMID: 32201602 DOI: 10 .1259 /bjrcr.20190047 ]

2 Degrassi I, Amoruso C, Giordano G, Del Puppo M, Mignarri A, Dotti MT, Naturale M, Nebbia G. Case Report: Early Treatment With Chenodeoxycholic Acid in Cerebrotendinous Xanthomatosis Presenting as Neonatal Cholestasis.

2020 ; 8 : 382 [PMID: 32766184 DOI: 10 .3389 /fped.2020 .00382 ]

3 Salen G, Steiner RD. Epidemiology, diagnosis, and treatment of cerebrotendinous xanthomatosis (CTX).

2017 ; 40 : 771 -781 [PMID: 28980151 DOI: 10 .1007 /s10545 -017 -0093 -8 ]

4 Koyama S, Sekijima Y, Ogura M, Hori M, Matsuki K, Miida T, Harada-Shiba M. Cerebrotendinous Xanthomatosis:Molecular Pathogenesis, Clinical Spectrum, Diagnosis, and Disease-Modifying Treatments.

2021 ;28 : 905 -925 [PMID: 33967188 DOI: 10 .5551 /jat.RV17055 ]

5 Hong X, Daiker J, Sadilek M, DeBarber AE, Chiang J, Duan J, Bootsma AH, Huidekoper HH, Vaz FM, Gelb MH. Toward newborn screening of cerebrotendinous xanthomatosis: results of a biomarker research study using 32 ,000 newborn dried blood spots.

2020 ; 22 : 1606 -1612 [PMID: 32523054 DOI: 10 .1038 /s41436 -020 -0846 -x]

6 Parry AH, Wani AH, Bashir M, Gojwari TA. Cerebrotendinous xanthomatosis - A case report.

2019 ; 29 : 332 -334 [PMID: 31741606 DOI: 10 .4103 /ijri.IJRI_444 _18 ]

7 Baghbanian SM, Mahdavi Amiri MR, Majidi H. Cerebrotendinous xanthomatosis revisited. Pract Neurol 2021 ; 21 : 243 -245 [PMID: 33853856 DOI: 10 .1136 /practneurol-2020 -002895 ]

8 Verrips A, Dotti MT, Mignarri A, Stelten BML, Verma S, Federico A. The safety and effectiveness of chenodeoxycholic acid treatment in patients with cerebrotendinous xanthomatosis: two retrospective cohort studies.

2020 ; 41 : 943 -949 [PMID: 31863326 DOI: 10 .1007 /s10072 -019 -04169 -8 ]

9 Watts GF, Mitchell WD, Bending JJ, Reshef A, Leitersdorf E. Cerebrotendinous xanthomatosis: a family study of sterol 27 -hydroxylase mutations and pharmacotherapy. QJM 1996 ; 89 : 55 -63 [PMID: 8730343 DOI:10 .1093 /oxfordjournals.qjmed.a030138 ]

10 Mignarri A, Dotti MT, Federico A, De Stefano N, Battaglini M, Grazzini I, Galluzzi P, Monti L. The spectrum of magnetic resonance findings in cerebrotendinous xanthomatosis: redefinition and evidence of new markers of disease progression.

2017 ; 264 : 862 -874 [PMID: 28324197 DOI: 10 .1007 /s00415 -017 -8440 -0 ]

11 Cao LX, Yang M, Liu Y, Long WY, Zhao GH. Chinese patient with cerebrotendinous xanthomatosis confirmed by genetic testing: A case report and literature review.

2020 ; 8 : 5446 -5456 [PMID: 33269283 DOI:10 .12998 /wjcc.v8 .i21 .5446 ]

12 Gerrish AC, Gaba S. Case 239 : Cerebrotendinous Xanthomatosis. Radiology 2017 ; 282 : 916 -921 [PMID: 28218883 DOI:10 .1148 /radiol.2016150707 ]

13 Pierre G, Setchell K, Blyth J, Preece MA, Chakrapani A, McKiernan P. Prospective treatment of cerebrotendinous xanthomatosis with cholic acid therapy.

2008 ; 31 Suppl 2 : S241 -S245 [PMID: 19125350 DOI:10 .1007 /s10545 -008 -0815 -z]

14 Saussy K, Jain N, Murina A. Cerebrotendinous xanthomatosis: A report of 3 cases. JAAD Case Rep 2020 ; 6 : 1205 -1207[PMID: 33294542 DOI: 10 .1016 /j.jdcr.2020 .10 .012 ]