Usefulness of α-synuclein as a Marker for Early Diagnosis of Parkinson's Disease in Skin Biopsy.
Study Details
Study Description
Brief Summary
Parkinson's disease (PD) is a degenerative disease that can be difficult to diagnose. The clinicopathological studies had demonstrated a 76% accuracy in the clinical diagnosis of PD.
At the beginning of PD is difficult for the clinician to distinguish from Parkinsonism Plus Syndromes (PPS) due to the similarity of symptoms and the lack of specific diagnostic tests.
Specific biomarkers to help improve the accuracy of diagnosis and to separate these two entities are highly needed
The histological hallmark for definite diagnosis of PD is the presence of fibrillar aggregates of phosphorylated alpha-synuclein called Lewy bodies (LBs) and Lewy neurites. Previous autopsy-based studies have revealed that alpha-synuclein is deposited in the peripheral autonomic nervous system including the enteric nervous system of the alimentary tract, cardiac plexus, adrenal medulla and skin.
For this reason, in patients with parkinsonism, an alternative tool could be to demonstrate alpha-synuclein fibrillar aggregates in the skin, allowing early and appropriate diagnosis.
| Condition or Disease | Intervention/Treatment | Phase |
|---|---|---|
|
Detailed Description
Parkinsonism, the syndrome, is a common movement disorder, and Parkinson's disease, the most common cause of parkinsonism, is the second most prevalent neurodegenerative disease after Alzheimer's disease.
The clinical diagnosis of PD is based on the presence of the four common features: tremor when the limb is at rest, resistance to passive movement of the joints (rigidity), slowness and paucity of movement (bradykinesia and akinesia) and postural abnormalities.
Approximately 25 percent of patients who received an initial clinical diagnosis of PD are found to have parkinsonism as part of another disorder, such as one of the so-called Parkinsonism-Plus Syndromes (PPS) The number and complexity of PPS seem to be increasing. This, along with the lack of diagnostic tests, makes it difficult for the clinician to distinguish between disease types.
Some characteristic clinical features are used for the differential diagnosis, this manifestations include early and severe postural instability, falls in the first year of onset, abnormal eye movements, autonomic dysfunction, cerebellar signs and upper motor neuron signs. The PPS respond poorly to antiparkinsonian medications and have a worse prognosis than does PD. In spite of these suggestive features, not all PD patients have the same progression, in some cases it is impossible to separate typical PD from PPS, especially at the early stage. In this context, biological markers must be of great usefulness for the differential diagnosis of these entities.
Some reports have described early features of PD such as (SPECT) imaging of the dopamine transporter that demonstrated the reduction of dopamine transporter in the striatum body at the early stage of PD and degeneration of the cardiac sympathetic nerve at the beginning of the disease process of PD; this occurs before neuronal cell loss is present in the dorsal vagal nucleus; This fact accounts for reduced cardiac uptake of meta-iodobenzylguanidine (MIBG), a physiological analog of norepinephrine. However, these diagnostic methods are not often performed. Therefore, more sensitive methods are needed to help improve the accuracy of diagnosis of PD.
Study Design
Arms and Interventions
| Arm | Intervention/Treatment |
|---|---|
| PD Parkinson´s Disrease We are studying the presence of alpha-synuclein in the epidermis and dermis besides the end nerve terminal. We have several reports until now, and we are following the study because we wish to convince the academic and scientific society over the utility of this study to be close to the molecular diagnosis of this kind of disease. |
Procedure: Biopsy of skin
Under local anesthesia with 1% xylocaine, 4-mm punch biopsies with 3-mm depth, including the dermis and subcutaneous fat tissue, will undergone from two regions, neck and lower back.
|
| AP Atypical Parkinsonism with neurodegenerative disease (proteinopathies) and secondary AP. |
|
| Control group Subjects without neurodegenerative disease and apparently good health status with an age that matches the problems groups |
Outcome Measures
Primary Outcome Measures
- Demonstrate the Presence of Alpha-Synuclein Inclusions in the Skin of Parkinson's Disease and Compare With an Atypical Parkinsonism Group and With a Healthy Control Group. [An average of seven days.]
The presence in the brain of a-synuclein containing Lewy neurites, or bodies, is the histological hallmark of Parkinson's disease (PD). The discovery of alpha-synuclein aggregates in nerve endings of the heart, digestive tract, and skin has lent support to the concept of PD as a systemic disease. First, our goal was to demonstrate the presence of alpha-synuclein inclusions in the skin of PD patients. Second, to detect quantitative differences (measures in the percentage of presence in the skin´s cells) between patients with PD, atypical parkinsonism (AP), compared with an apparent healthy group.
Eligibility Criteria
Criteria
Inclusion Criteria:
-
Clinical diagnosis of Parkinson's Disease or Parkinson Plus Syndrome
-
Subject is a male or female between the age of 50 and 95
-
Subject will write the informed consent
Exclusion Criteria:
-
History of stroke or/and trauma
-
Signs of cerebrovascular pathology
-
Brain tumor
-
Severe unrelated neurological or physical disease
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | Hospital Central Dr. Ignacio Morones Prieto | San Luis Potosi | Mexico | 78290 |
Sponsors and Collaborators
- Universidad Autonoma de San Luis Potosí
Investigators
- Principal Investigator: Ildefonso Rodríguez-Leyva, MD, Hospital Central "Dr. Ignacio Morones Prieto"
- Study Director: Maria E Jimenez-Capdeville, PhD, Universidad Autonoma de San Luis Potosi
- Study Director: Juan P Castanedo-Cazares, MD, Hospital Dr. Ignacio Morones Prieto
- Study Chair: Erika G Chi-Ahumada, MC, Facultad de Medicina, UASLP
- Study Chair: Maria E Jimenez-Capdeville, PhD, Facultad de Medicina
- Study Chair: Robert A. Norman, MD, PhD., Independent Dermatologist
Study Documents (Full-Text)
None provided.More Information
Publications
- Gelb DJ, Oliver E, Gilman S. Diagnostic criteria for Parkinson disease. Arch Neurol. 1999 Jan;56(1):33-9. Review.
- Hughes AJ, Daniel SE, Kilford L, Lees AJ. Accuracy of clinical diagnosis of idiopathic Parkinson's disease: a clinico-pathological study of 100 cases. J Neurol Neurosurg Psychiatry. 1992 Mar;55(3):181-4.
- Ibáñez-Salazar A, Bañuelos-Hernández B, Rodríguez-Leyva I, Chi-Ahumada E, Monreal-Escalante E, Jiménez-Capdeville ME, Rosales-Mendoza S. Oxidative Stress Modifies the Levels and Phosphorylation State of Tau Protein in Human Fibroblasts. Front Neurosci. 2017 Sep 7;11:495. doi: 10.3389/fnins.2017.00495. eCollection 2017.
- Nutt JG, Wooten GF. Clinical practice. Diagnosis and initial management of Parkinson's disease. N Engl J Med. 2005 Sep 8;353(10):1021-7. Review.
- Tuite PJ, Krawczewski K. Parkinsonism: a review-of-systems approach to diagnosis. Semin Neurol. 2007 Apr;27(2):113-22. Review.
- UASLP-PD001
Study Results
Participant Flow
| Recruitment Details | Skin retro auricular biopsies were taken from 67 patients and 20 controls. The biopsies underwent immunohistochemistry (IHC) and immunofluorescence (IF) testing for a-synuclein, after which its presence was quantified as the percentage of positive cells (containing alpha-synuclein). Patients were divided into those with Parkinson's Disease (PD: 34) and those with Atypical Parkinsonism (AP: 33). AP patients included AP with neurodegenerative disease (proteinopathies) and secondary AP |
|---|---|
| Pre-assignment Detail | PD used the United Kingdom PD Society Brain Bank. Lewy body dementia (LBD) used the consortium report on the DLB international workshop. AD used the recommendations from the National Institute on Aging and Alzheimer's Association workgroups on diagnostic guidelines for AD. MSA used the Second consensus statement on the diagnosis of multiple system atrophy. PSP used the report of the NINDS-SPSP International Workshop. |
| Arm/Group Title | Parkinson Disease | Atypical Parkinsonism | Control Group |
|---|---|---|---|
| Arm/Group Description | Patients with Parkinson Disease (PD) PD is the patient initially presented asymmetric onset (with both rest and postural tremors with a frequency of between 5 and 7 Hz), rigidity, bradykinesia, postural instability, an acceptable and sustained response to levodopa, and previous and concomitant nonmotor characteristic semiology. | AP was divided into primary (neurodegenerative) and secondary (postencephalitic, vascular, drug-induced, toxic) groups. The neurodegenerative included patients with the diagnosis of Lewy body dementia (LBD) used the consortium report on the DLB international workshop. Patients with the diagnosis of AD used the recommendations from the National Institute on Aging and Alzheimer's Association workgroups on diagnostic guidelines for AD. Patients with the diagnosis of MSA used the Second consensus statement on the diagnosis of multiple system atrophy. The diagnosis PSP used the report of the NINDS-SPSP International Workshop. CBS and we included a case with a diagnosis of neurodegeneration with brain iron accumulation syndrome (NBIA). Most of these criteria are summarized in the SIC Task Force appraisal of clinical diagnostic criteria for Parkinsonian disorders. | Subjects apparently in a good state of health without antecedents of neurodegenerative diseases and not symptoms or signs of neurodegeneration (comparable with the group's problem in gender, age, and population characteristics). |
| Period Title: Overall Study | |||
| STARTED | 34 | 33 | 20 |
| COMPLETED | 34 | 33 | 20 |
| NOT COMPLETED | 0 | 0 | 0 |
Baseline Characteristics
| Arm/Group Title | Parkinson Disease | Atypical Parkinsonism | Control Group | Total |
|---|---|---|---|---|
| Arm/Group Description | Patients with Parkinson Disease: 34 Average. Age (mean SD) 66.82 (+11.4) | Participants with Atypical Parkinsonism degenerative (26) or secondary (7), total: 33 | Subjects without neurodegenerative disease and apparently good state of health (20) | Total of all reporting groups |
| Overall Participants | 34 | 33 | 20 | 87 |
| Age (Count of Participants) | ||||
| <=18 years |
0
0%
|
0
0%
|
0
0%
|
0
0%
|
| Between 18 and 65 years |
28
82.4%
|
26
78.8%
|
10
50%
|
64
73.6%
|
| >=65 years |
6
17.6%
|
7
21.2%
|
10
50%
|
23
26.4%
|
| Age (years) [Mean (Standard Deviation) ] | ||||
| Mean (Standard Deviation) [years] |
66.82
(11.4)
|
68.2
(13.5)
|
74
(7.9)
|
69.6
(10.9)
|
| Sex: Female, Male (Count of Participants) | ||||
| Female |
10
29.4%
|
11
33.3%
|
11
55%
|
32
36.8%
|
| Male |
24
70.6%
|
22
66.7%
|
9
45%
|
55
63.2%
|
| Region of Enrollment (Count of Participants) | ||||
| Mexico |
34
100%
|
33
100%
|
20
100%
|
87
100%
|
Outcome Measures
| Title | Demonstrate the Presence of Alpha-Synuclein Inclusions in the Skin of Parkinson's Disease and Compare With an Atypical Parkinsonism Group and With a Healthy Control Group. |
|---|---|
| Description | The presence in the brain of a-synuclein containing Lewy neurites, or bodies, is the histological hallmark of Parkinson's disease (PD). The discovery of alpha-synuclein aggregates in nerve endings of the heart, digestive tract, and skin has lent support to the concept of PD as a systemic disease. First, our goal was to demonstrate the presence of alpha-synuclein inclusions in the skin of PD patients. Second, to detect quantitative differences (measures in the percentage of presence in the skin´s cells) between patients with PD, atypical parkinsonism (AP), compared with an apparent healthy group. |
| Time Frame | An average of seven days. |
Outcome Measure Data
| Analysis Population Description |
|---|
| PD diagnosis is made if bradykinesia is associated with rigidity, tremor, or postural instability and unilateral onset and persistent asymmetry, excellent response to levodopa, severe levodopa-induced dyskinesia, and progression. AP are other neurodegenerative diseases with parkinsonism or related to strokes, head injuries, encephalitis, neuroleptic use, toxins, cerebral tumor, hydrocephalus. The Control group was a comparable population without parkinsonism and apparently healthy. |
| Arm/Group Title | Parkinson Disease | Atypical Parkinsonism | Control Group |
|---|---|---|---|
| Arm/Group Description | Patients with the clinical diagnosis of Parkinson Disease | Atypical parkinsonian conditions mainly comprise progressive supranuclear palsy (PSP), corticobasal degeneration (CBD), multisystem atrophy (MSA), and dementia with Lewy bodies (DLB). Apart from these sporadic neurodegenerative disorders, atypical parkinsonism has also been described in various other inherited degenerative conditions such as frontotemporal dementia (FTD), Alzheimer's disease, and Perry syndrome. Nondegenerative parkinsonisms include vascular, toxic (use of neuroleptics, exposure to manganese, carbon monoxide, etc.), and traumatic. | Apparently, healthy subjects without a family history of neurodegenerative or chronic diseases could have population characteristics comparable to the problem groups' participants. |
| Measure Participants | 34 | 33 | 20 |
| Epidermis. Alpha synuclein expresion |
57.9
|
6.9
|
0
|
| Pilosebaceus unit |
62.1
|
7.7
|
0
|
| Eccrine gland |
58.4
|
0
|
0
|
Statistical Analysis 1
| Statistical Analysis Overview | Comparison Group Selection | Parkinson Disease, Atypical Parkinsonism, Control Group |
|---|---|---|
| Comments | The patients were stratified according to the clinical diagnosis made on the basis of the clinical findings, the MRI, and the progression of the disease. Both the clinical diagnosis and the semiquantitative histological analysis were carried out independently and blind to each other. The presence of aggregates of abnormal a-synuclein, expressed as the percentage of cells with positive inclusions in each experimental group, was tested for normality with the Shapiro-Wilk test. | |
| Type of Statistical Test | Superiority | |
| Comments | IHC analyses revealed intense α-synuclein positive immunostaining in PD patients, showing small nodular deposits from 1 to 2 μm in diameter in the SCL of the epidermis including the epidermal component adjacent to hair follicles, and in cells from PSUs, while control subjects presented null immunoreaction. The α-synuclein inclusions in the two groups of patients were morphologically similar but quantitatively different. These inclusions appeared to be juxtanuclear. | |
| Statistical Test of Hypothesis | p-Value | < 0.01 |
| Comments | The presence of alpha-synuclein aggregates expressed as % of cells with inclusions was tested for normality (Shapiro-Wilk test). Then, with the nonparametric Kruskal-Wallis followed by Mann-Whitney U tests (software Statistica 7.0 at 95% confidence). | |
| Method | Kruskal-Wallis | |
| Comments | The groups were analyzed with Kruskal-Wallis followed by Mann-Whitney U tests. | |
| Method of Estimation | Estimation Parameter | Median Difference (Net) |
| Estimated Value | 57.9 | |
| Confidence Interval |
(2-Sided) 95% 44.9 to 62.6 |
|
| Parameter Dispersion |
Type: Standard Deviation Value: 8.85 |
|
| Estimation Comments | The expression of the abnormal protein (alpha-synuclein) must be different between the three groups (PD, AP, and control) | |
| Other Statistical Analysis | The patients were stratified according to the clinical diagnosis based on the clinical findings, the MRI, and the progression of the disease. Both the clinical diagnosis and the semiquantitative histological analysis were carried out independently and blind to each other. The presence of aggregates of abnormal α-synuclein, expressed as the percentage of cells with positive inclusions in each experimental group, was tested for normality with the Shapiro-Wilk test. Next, the groups were analyzed with the nonparametric Kruskal-Wallis followed by Mann-Whitney U tests. One independent analysis was performed for each structure, namely the epidermis, PSU, and EG. Assessments were performed using the software Statistica 7.0 (Tulsa, OK) at 95% confidence. | |
Adverse Events
| Time Frame | The participants were aware of the possibles adverse events that they could present (pain and bleeding in the site where the biopsy was talked) during the seven days following the biopsy. | |||||
|---|---|---|---|---|---|---|
| Adverse Event Reporting Description | Three possible EA were systematically advertised to the patients: Pain in the retro-auricular area where the biopsy was taken. Bleeding in the site of the biopsy. A potential danger of infection in the place of the biopsy. All of them are graduated as AE grade 1, according to the CTCAE. No one event serious event was reported. | |||||
| Arm/Group Title | PD (n = 34) | Atypical Parkinsonism (n=33) | Control Group (n=20) | |||
| Arm/Group Description | We enrolled 34 participants who had PD. | A total of 33 patients had AP: from they 26 were found to have a neurodegenerative disease clinically (18 had a synucleinopathy-related diagnosis: MSA, LBD, and 8 had tauopathies: PSP, AD). We also included seven patients with secondary parkinsonism. | A control group (n = 20) of similar age and sex distribution to the patient population was included. There was no significant difference in either age or evolution of disease between the two groups with parkinsonism. | |||
All Cause Mortality |
||||||
| PD (n = 34) | Atypical Parkinsonism (n=33) | Control Group (n=20) | ||||
| Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | |
| Total | 0/34 (0%) | 0/33 (0%) | 0/20 (0%) | |||
Serious Adverse Events |
||||||
| PD (n = 34) | Atypical Parkinsonism (n=33) | Control Group (n=20) | ||||
| Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | |
| Total | 0/34 (0%) | 0/33 (0%) | 0/20 (0%) | |||
Other (Not Including Serious) Adverse Events |
||||||
| PD (n = 34) | Atypical Parkinsonism (n=33) | Control Group (n=20) | ||||
| Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | |
| Total | 1/34 (2.9%) | 1/33 (3%) | 0/20 (0%) | |||
| Skin and subcutaneous tissue disorders | ||||||
| Transient bleeding | 1/34 (2.9%) | 1/33 (3%) | 0/20 (0%) | |||
Limitations/Caveats
More Information
Certain Agreements
Principal Investigators are NOT employed by the organization sponsoring the study.
There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.
Results Point of Contact
| Name/Title | Ildefonso Rodriguez-Leyva |
|---|---|
| Organization | Facultad de Medicina, Universidad Autonoma de San Luis Potosi |
| Phone | +52 4442043016 |
| ildefonso.rodriguez@uaslp.mx |
- UASLP-PD001