ALS10 is clinically indistinguishable from other types of sporadic or familial ALS. Affected individuals may claim muscle weakness, often limited one arm or leg, or present with dysarthria and dysphagia, symptoms characteristic of bulbar palsy. In this regard, spinal-onset ALS10 seems to be more common than bulbar-onset ALS10 [1]. But as the disease progresses, most ALS10 patients lose muscle strength in all four limbs and many develop bulbar palsy, independent of the site of onset [2]. Muscle weakness is followed by atrophy, and fasciculations are very common, too [3]. Fasciculations of the tongue are often observed and patients may eventually show tongue amyotrophy.

Besides those lower motor neuron signs, ALS patients may show distinct symptoms of upper motor neuron disease. Hyperreflexia and an increase of muscle tone are most characteristic and may be detected in muscles of face, larynx and pharynx (bulbar region), neck, arms, and diaphragm (cervical region), abdomen and back (thoracic region), and legs (lumbosacral region). The fact that hyperreflexia may be detected in regions of muscle atrophy is considered to be highly indicative of ALS [3]. In some ALS10 patients, lower motor neuron signs predominate the clinical presentation [1].

The patients' sensibility is usually unaltered. Accordingly, electrophysiological studies typically reveal abnormal spontaneous activity (e.g., fibrillations, fasciculations, and positive sharp waves) as well as enlongated, large motor unit potentials and reduced motor unit recruitment, but normal amplitudes of action potentials of sensory nerves [2] [4].

ALS10 may be associated with frontotemporal dementia [5]. While some authors state that few such cases have been reported to date [6], others consider dementia to be a common feature in ALS10 patients [7]. In isolated cases, ALS10 has been reported to be associated with parkinsonism or Parkinson's disease [8].

• Malnutrition

  Malnutrition Malnutrition is another common problem in patients with ALS. This can be caused either by the patient not eating sufficiently or mechanical problems with swallowing. [pharmaceutical-journal.com]

  Many people with ALS experience malnutrition because of reduced food intake due to dysphagia and an increase in their body's energy demands (metabolism) due to prolonged illness. [icdlist.com]

  In some cases, death may occur due to malnutrition and dehydration, according to The Muscular Dystrophy Association (MDA). This may happen because the muscles that control swallowing no longer function properly. [livescience.com]

  Eating problems People with ALS can develop malnutrition and dehydration from damage to the muscles that control swallowing. They are also at higher risk of getting food, liquids or saliva into the lungs, which can cause pneumonia. [mayoclinic.org]

• Pathologist

  Assay Assay and technical information Invitae is a College of American Pathologists (CAP)-accredited and Clinical Laboratory Improvement Amendments (CLIA)-certified clinical diagnostic laboratory performing full-gene sequencing and deletion/duplication [invitae.com]

  Standard Therapies Treatment The treatment of amyotrophic lateral sclerosis generally requires a team approach and should include physicians, physical therapists, speech pathologists, pulmonary therapists, medical social workers, and nurses. [rarediseases.org]

  Given the progressive nature of the neurodegenerative diseases, speech-language pathologists must be aware of appropriate augmentative and alternative communication equipment at the early stage of the disease course. [jkslp.org]

  Speech and swallowing difficulties can be minimized or delayed through training provided by a speech-language pathologist. This specialist can also provide advice on communication aids, including computer-assisted devices and simpler word boards. [medical-dictionary.thefreedictionary.com]

  Speech pathologists can also assist patients who have problems in swallowing. [aafp.org]

• Camping

  Logged First HfxTC, teams in training camps are allowed to put pads and make tackles. Second, Tovell was early in training camp and played in the 2 pre-season games. [forums.cfl.ca]

  Pagina 311 - The results indicated the absence of any significant change in the content of cAMP and cGMP in the first minutes to hours after activation of the lymphocytes by the polyanion (Figure 17). ‎ [books.google.ro]

• Dysphagia

  Affected individuals may develop slurred speech (dysarthria) and, later, difficulty chewing or swallowing (dysphagia). [icdlist.com]

  TNFRSF1A C9orf72 HLA-DRB1 For most patients with ALS, the initial signs and symptoms are dysarthria or dysphagia. asymmetric limb weakness. muscle atrophy and weight loss. [journals.lww.com]

  […] management, which may increase survival and improve quality of life, should be emphasized. 2 Noninvasive ventilation is effective in prolonging survival, slowing the rate of decline in forced vital capacity, and enhancing quality of life. 3,4 Because dysphagia [nejm.org]

  Symptoms include progressive weakness, atrophy, fasciculation, dysphagia, and eventual paralysis of respiratory function. [patientslikeme.com]

• Abdominal Pain

  (atrophy, fibrosis, and/or sclerosis) Diagnostic criteria for acute pancreatitis 2, 8 : Characteristic upper abdominal pain Elevated levels of pancreatic enzymes Findings of ultrasonography, CT, MRI Identification of a heterozygous pathogenic variant [centogene.com]

  The most common side effects of riluzole are weakness, dizziness, diarrhoea and abdominal pain [11]. Riluzole may cause liver damage, and should be used with caution in patients with a history of abnormal hepatic function. [pharmaceutical-journal.com]

• Diarrhea

  One of them presented also with typical systemic signs of CTX, including chronic diarrhea, juvenile bilateral cataracts and early-onset premenopausal osteopenia (unpublished data). [scielo.br]

• Muscle Weakness

  Spasticity and muscle cramps may be resolved by muscle relaxants like quinine, levetiracetam, baclofen, or dantrolene. Weakness of the respiratory muscles requires ventilatory assistance. [symptoma.com]

  Spasticity is usually accompanied by HYPERREFLEXIA and variable degrees of MUSCLE WEAKNESS. [ncbi.nlm.nih.gov]

  Symptoms include: Difficulty breathing Difficulty swallowing Choking easily Drooling Gagging Head drop due to weakness of the neck muscles Muscle cramps Muscle contractions called fasciculations Muscle weakness that slowly gets worse Commonly involves [checkorphan.org]

  Over time, muscle weakness causes affected individuals to lose the use of their hands and arms. Breathing becomes difficult because the muscles of the respiratory system weaken. [icdlist.com]

• Muscular Atrophy

  G12 Spinal muscular atrophy and related syndromes G12.0 Infantile spinal muscular atrophy, type I [Werdnig-Hoffman] G12.1 Other inherited spinal muscular atrophy Inclusion term(s): Adult form spinal muscular atrophy Childhood form, type II spinal muscular [icd10coded.com]

  […] lateral sclerosis G12.24 Familial motor neuron disease G12.25 Progressive spinal muscle atrophy G12.29 Other motor neuron disease G12.8 Other spinal muscular atrophies and related syndromes G12.9 Spinal muscular atrophy, unspecified G13 Systemic atrophies [icd10data.com]

  또는 본 임상시험에 참여하는 동안 파트너가 임신하는 것을 막기 위하여 적절한 피임방법을 사용하는데 동의하지 않는 남성 환자 14) 운동신경원질환중 상위운동신경원징후만 나타나는 PLS(primary lateral sclerosis)나 하위운동신경원징후만 나타나는 PMA(progressive muscular atrophy)환자 15) 출혈성 경향이 있는 자 16) 악성종양이 있는 자 17) 인공호흡기 또는 기관절개술 및 위루술을 시행된 환자 18 [cris.nih.go.kr]

  […] docId=2354988&cid=51362&categoryId=51362 의료비지원관련(산정특례) 170 G12.8 기타 척수성 근위축 및 관련 증후군 Other spinal muscular atrophies and related syndromes V123 ● 의료비(급여부분) ● 간병비 ● 호흡보조기 또는 기침유발기 ● 보장구 구입비 [enif.kr]

  It includes a number of overlapping syndromes, such as pseudobulbar palsy, progressive bulbar palsy, progressive muscular atrophy, and primary lateral sclerosis. [unboundmedicine.com]

• Dysarthria

  TNFRSF1A C9orf72 HLA-DRB1 For most patients with ALS, the initial signs and symptoms are dysarthria or dysphagia. asymmetric limb weakness. muscle atrophy and weight loss. [journals.lww.com]

  Affected individuals may claim muscle weakness, often limited one arm or leg, or present with dysarthria and dysphagia, symptoms characteristic of bulbar palsy. In this regard, spinal-onset ALS10 seems to be more common than bulbar-onset ALS10. [symptoma.com]

  Patients then develop motor neuron degeneration leading to facial muscle spasticity, spastic dysarthria, and spastic gait. Some patients are reported to have uncontrolled laughter and weeping (pseudobulbar syndrome). [orpha.net]

  This review discusses the characteristics of dysarthria and symptom management for these conditions. [jkslp.org]

• Hyperreflexia

  The fact that hyperreflexia may be detected in regions of muscle atrophy is considered to be highly indicative of ALS. In some ALS10 patients, lower motor neuron signs predominate the clinical presentation. [symptoma.com]

  UMN manifestations can include stiffness, spasticity, hyperreflexia, and pseudobulbar affect; LMN manifestations often include weakness accompanied by muscle atrophy, fasciculations, and cramping. Limb onset occurs in 80% and bulbar onset in 20%. [ncbi.nlm.nih.gov]

  Upper motor neuron findings in ALS include hyperreflexia and spasticity. amyotrophy and fasciculations. bowel and bladder dysfunction. The most common cause of death in ALS is heart failure. liver failure. respiratory failure. [journals.lww.com]

• Paresis

  Patients suffer from paresis and atrophy of the affected muscle groups and changes of myotactic reflexes. They usually pass away within 3-5 years, although some may live for over 10 years. [rug.nl]

  Vocal difficulties associated with ALS can mimic spasmodic dysphonia (if vocal spasms predominate) or vocal fold paresis (if vocal fold weakness and flaccid symptoms predominate). [voicefoundation.org]

  Spastic paresis could be present at the beginning or in the fully developed stage of the disease. [intechopen.com]

  The D90A-homozygous mutation is associated with slowly progressive paresis in the legs that gradually spreads up to the arms, thoracic and bulbar musculature, with atypical non-motor features such as ataxia, neuralgic, aching pain, heat sensations, and [translationalneurodegeneration.biomedcentral.com]

  ALS HNRNPA1 (Heterogeneous Nuclear Ribonucleoprotein A1; 12q13.13) – 2013 AD ALS20, IBM with early-onset Paget disease without FTD type 3 DCTN1 (Dynactin 1; 2p13.1) – 2003 AD ALS, Perry syndrome, Distal hereditary motor neuronopathy with vocal paresis [scielo.br]

• Babinski Sign

  […] of UMN disease include muscle tone increase, slow movement, and hyperreflexia.8 The presence of the Babinski sign, or upward response of the plantar reflex, is also evidence of UMN dysfunction and is discovered in 30% to 50% of patients.8 Symptoms may [ajmc.com]

  sign positive) Flexor (= normal; Babinski's sign negative) Extraneous muscle activity No fasciculations/fibrillations Fasciculations and fibrillations amyotrophic lateral sclerosis (ā·mī· ·trō·fik laˑ·t ·r l skl ·rōˑ·sis), n a fatal neurological condition [medical-dictionary.thefreedictionary.com]

  All three patients had slight pyramidal signs (hyperactive reflexes, Babinski sign without increase of muscular tone). [intechopen.com]

  (From Adams et al., Principles of Neurology, 6th ed, p54) Babinski sign MedGen UID: 19708 •Concept ID: C0034935 • Finding A reflex characterized by upward movement of the great toe and an outward movement of the rest of the toes, when the sole of the [ncbi.nlm.nih.gov]

• Hyperactivity

  All three patients had slight pyramidal signs (hyperactive reflexes, Babinski sign without increase of muscular tone). [intechopen.com]

  Reflexes were hyperactive and fasciculations were observed in the right leg. Within two years, the patient became severely disabled because of generalized weakness. [aafp.org]

ALS diagnosis relies on the identification of upper motor neuron and lower motor neuron signs, to be observed in patients suffering from a progressive neurodegenerative disease that cannot be explained by other conditions. To facilitate ALS diagnosis, diagnostic criteria have been defined on various occasions [9] [10] [11]. Currently, revised El Escorial criteria are applied in most clinical trials. Those criteria are as follows [10]:

• Clinical evidence of upper motor neuron degeneration
• Clinical, electrophysiological, or neuropathological evidence of lower motor neuron degeneration
• Disease progression, spread of symptoms and signs
• Absence of electrophysiological or pathological evidence of other diseases that may explain neurological findings
• Absence of imaging evidence of other diseases that may explain neurological findings

Furthermore, the central nervous system is divided into four regions, namely the bulbar, cervical, thoracic and lumbosacral region as indicated in the previous paragraph. The presence of symptoms related to the function of any of those four regions allows for a more precise diagnosis of clinically definite, clinically probable, clinically probable if laboratory-supported, and clinically possible ALS [10]:

• Clinically definite ALS requires the presence of upper and lower motor neuron signs in at least three out of four regions
• Clinically probable ALS is diagnosed with upper and lower motor neuron signs in at least two out of four regions, and some upper motor neuron signs rostral to lower motor neuron signs
• Clinically probable if laboratory-supported ALS is defined as the presence of upper and lower motor neuron signs in one region only, or the presence of only upper motor neuron signs in one region and lower motor neuron signs in at least two regions, with lower motor signs generally being present on electromyography
• Clinically possibly ALS implies the presence of upper and lower motor neuron signs in one region only, or the presence of only upper motor neuron signs in at least two regions, or the presence of lower motor neuron signs rostral to upper motor neuron signs, if supporting laboratory results cannot be provided

A positive family history of ALS augments the certainty of diagnosis and may even justify the diagnosis of clinically definite ALS if the respective criteria are not completely fulfilled [10]. However, TARDBP mutations have also been detected in patients suffering from sporadic ALS [1] [12]. This fact highlights the importance of genetic studies and the necessity of interpreting their results in the context of anamnestic and clinical data.

Even though molecular biological analyses are not required for the diagnosis of ALS, they are necessary to determine the subtype. Indeed, the identification of sequence anomalies may accelerate the diagnostic process: If TARDBP mutations are known to cause ALS in a determined family, a more targeted approach to diagnosis becomes feasible. By contrast, the identification of TARDBP mutations in patients suffering from sporadic ALS may improve the understanding of the pathophysiology of the disease. Additionally, ALS patients known to carry mutations that possibly predispose for frontotemporal dementia or parkinsonism - as is the case with FUS mutations - may be referred for neuropsychological tests. In conclusion, genetic analyses provide both physicians and scientists with an appropriate tool to identify carriers and family members at risk, and to promote research [13] [14].

There is no cure, and disease progression can hardly be halted. Riluzole is the only pharmacological compound approved for ALS therapy; it is assumed to reduce glutamate toxicity. It has been reported to increase survival times and to delay the onset of life-threatening symptoms such as laryngospasm and respiratory paralysis, but its efficacy is very limited [15]. The application of α-tocopherol has been proposed as a complementary measure to slow down disease progression in milder cases [16]. Otherwise, only palliative treatment can be provided. In this context, ALS patients benefit from a multidisciplinary approach that aims at maintaining their ability to cope with everyday life and to communicate with their fellows for as long as possible [3] [16]:

• Bulbar palsy results in speech disturbances and swallowing difficulties and largely affects the patients' quality of life. Therefore, they should be offered support by speech therapists and nutritionists. Modern technical devices enable ALS patients to express their thoughts even if they can only provide minimal input. Also, it may be helpful to mash solid foods to facilitate their intake by dysphagic patients, but most patients eventually require a gastrostomy tube.
• Occupational and physical therapy are required to deal with limited mobility. At the same time, orthopedic devices and wheelchairs should be provided to improve mobility and autonomy.
• Spasticity and muscle cramps may be resolved by muscle relaxants like quinine, levetiracetam, baclofen, or dantrolene.
• Weakness of the respiratory muscles requires ventilatory assistance.
• Finally, ALS patients should be offered psychological support. Some patients develop depressions and have to be treated with antidepressants.

If ALS10 patients suffer from associated neurodegenerative disorders such as dementia or parkinsonism, these should be treated according to the respective guidelines. Unfortunately though, they can neither be cured at this moment.

Progressive muscle weakness and atrophy leads to respiratory paralysis and death within years of symptom onset [2]. Mean survival times cannot be provided for ALS10, but mean survival times of ALS patients in general were calculated to be three to four years [17].

In early 2008, several research groups reported ALS patients who carried mutations in the TARDBP gene [1] [2] [4] [12]. Some of those patients were diagnosed with sporadic ALS, while others had a positive family history of the disease.

The TARDBP gene encodes for TDP-43, a DNA and RNA binding protein. It has initially been characterized as a transcriptional repressor regulating HIV-1 gene expression, but has later been found to affect DNA transcription and RNA splicing with regards to other genes. For instance, it may be involved in pathological splicing of the cystic fibrosis transmembrane receptor, thereby contributing to the onset of cystic fibrosis. Furthermore, TDP-43 has been proposed to act as a scaffold for nuclear bodies, and that's possibly how this protein predisposes for ALS [18].

Besides genetic factors, environmental influences are assumed to play a major role in ALS pathogenesis. With regards to such environmental influences, the following have been identified and confirmed as risk factors for ALS [17]:

• Exposure to metals like lead and mercury
• Glutamate toxicity
• Exposure to pesticides
• Smoking
• Military service

ALS is the most common motor neuron disease in adults; it affects both men and women. ALS patients' mean age at symptom onset is 60 years [17]. With regards to the ALS10, symptom onset has been reported to occur at any point in time between the early fourth decade of life and old age >80 years [2] [4]. The global incidence of ALS has been estimated to 1-2.6 per 100,000 people per year, and its prevalence amounts to 6 per 100,000 inhabitants [17]. About 10% of all those cases are familial, and TARDBP mutations have been detected in several kindreds of distinct ethnic groups that didn't carry mutations in the SOD1 gene [3]. Of note, mutations in the SOD1 gene presumably account for 20% of all cases of familial ALS [3]. The frequency of TARDBP mutations in familial ALS has been estimated to be 4-5% [19]. Familial ALS is generally inherited in an autosomal dominant manner, as is the case with ALS10 [19].

Despite extensive research, the pathophysiology of ALS remains poorly understood. The death of motor neurons is the hallmark of the disease and entails muscle weakness and atrophy, but its causes could not yet be clarified. In general, it can be said that sequence anomalies, e.g., of genes like TARDBP, may be the cause of irregularities in the amino acid sequence, post-translational modification and intracellular transport of any protein, may alter their physical properties, their propensity to bind to specific targets, and their susceptibility to degradation [20]. In this context, neuronal death has been speculated to be due to the intracellular accumulation of protein aggregates which, in turn, consist of misfolded proteins or of substrates insufficiently degraded by a defective proteasome. Studies regarding the precise composition of such neuronal inclusions revealed high contents of hyperphosphorylated TDP-43 [1] [12]. As has been mentioned above, TDP-43 may indeed serve as a scaffold for protein aggregates, thereby paving the way for the accumulation of neurotoxic inclusions and triggering neurodegeneration [12] [18].

No recommendations can be given to prevent the onset of sporadic ALS, other than avoiding the risk factors mentioned above. By contrast, genetic analyses may facilitate the identification of carriers and as-of-yet asymptomatic patients in families affected by familial ALS [13]. Prenatal diagnoses may become feasible if the disease can be related to well-defined DNA sequence anomalies, but this does not yet apply to ALS10.

ALS is the most common motor neuron disease. ALS patients may be genetically predisposed to develop the disease, and distinct genes have been associated with its familial form. One of those genes is the TARDBP gene, which encodes for protein TDP-43. ALS linked to mutations in the TARDBP gene has been designated ALS10 [3] [19]. Presumably, mutations of the TARDBP gene result in the formation of cytotoxic protein aggregates within neurons, but little is actually known about the etiology and pathogenesis of ALS10 and other types of ALS, other than that it is characterized by the death of motor neurons in the cortex, brain stem, and spinal cord. The disease follows a progressive course and ultimately leads to death by respiratory failure.

Familial ALS may be associated with other neurodegenerative diseases, and this also applies to ALS10. However, the most common clinical presentation of ALS10 is that of "pure ALS", i.e., in early stages of the disease, patients experience muscle weakness, particularly in their arms or legs, or bulbar palsy associated with dysarthria and dysphagia. Over the course of the disease, they develop amyotrophy in all four limbs. Besides these lower motor neuron signs, upper motor neuron signs are characteristic of ALS: ALS patients suffer from hyperreflexia and present with an increased muscle tone, and while those complaints are initially limited to certain body regions, they spread in a similar manner to amyotrophy.

Diagnosis of ALS relies on well-defined diagnostic criteria and is mainly clinical, with the identification of ALS10 requiring additional genetic analyses. Mean survival times of ALS patients are three to four years and patients should be treated by a multidisciplinary team to preserve life quality for as long as possible, despite the fact that there is no cure for this disease.

Amyotrophic lateral sclerosis (ALS) is a progressive motor neuron disease that typically manifests in adulthood. Little is known about the causes of ALS, but at least a minor proportion of ALS patients seems to be genetically predisposed. This condition is reflected in an increased familial incidence, i.e., relatives of an ALS patient carrying certain gene defects are much more likely to develop the disease than the general population. In this context, ALS has been associated with distinct chromosome and gene anomalies. For instance, there are several families of different origin whose members present mutations in a gene called TARDPB. This particular condition has later been designated amyotrophic lateral sclerosis 10 (ALS10).

With regards to clinical presentation, diagnosis, treatment, and prognosis, ALS10 doesn't differ from classical ALS.

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