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FOLR1 Gene Variation With Adult-Onset Cerebral Folate Deficiency and Stable Clinical and MRI Features up to 2 Years
Carlo Manco1, Rosa Cortese1, Manfredi Alberti1
1From the Centre for Precision and Translational Medicine (C.M., R.C., S.B., N.D.S., C.B.), Department of Medicine, Surgery and Neuroscience, University of Siena; Neurology Unit (M.A.), Department of Neurology and Human Movement Sciences, University Hospital of Siena; Department of Medical, Surgical and Neurological Science (M.A.), University of Siena; and Diagnostic and Functional Neuroimaging Unit (L.M.), Department of Neurology and Human Movement Sciences, University Hospital of Siena, Italy.
Objectives:
The objective of this case report was to describe the first report of FOLR1 variants associated with adult-onset paucisymptomatic leukoencephalopathy associated with cerebral folate deficiency (CFD).
Methods:
Considering the patient's symptoms, a nonprogressive leukoencephalopathy was suspected. CSF 5-methyltetrahydrofolate levels were low (10 nmol/L, normal range 41-117). With no other identifiable causes, a genetic analysis was conducted, revealing a compound heterozygous FOLR1 variation (c.45G>T and c. 493+2T>C).
Results:
A 47-year-old man with a history of drug and alcohol abuse was admitted to the hospital for double vision and postural instability. MRI of the brain was performed, which showed bilateral leukoencephalopathy. Diffusion tensor imaging revealed a diffuse reduction in fractional anisotropy, suggesting microstructural changes. MRI of the brain and overall clinical picture were stable on subsequent serial examinations.
Discussion:
Scientific evidence supports the deleterious effect of c.45G>T and c.493+2T>C variations on the folate receptor-α (FRα) protein structure and function. The weakness of the expression and function of FRα without elimination of its function caused by specific compound heterozygous variations may explain the atypical features observed in our patient. Although rare, CFD should be considered in paucisymptomatic adult patients with stable diffuse MRI white matter changes.
