A Biomarker Out of Context: Understanding High p-tau217 in the Developing Brain

Phosphorylated tau at threonine 217 (p-tau217) is generally considered a very specific biomarker of Alzheimer's disease and tau-mediated neurodegeneration in adult patients, where its increase is strongly associated with amyloid, pathology, synaptic dysfunction, and progressive cognitive decline. However, surprisingly, some data report extremely elevated levels of p-tau217 in plasma and cerebrospinal fluid of healthy neonates and infants, i.e., without the presence of neurodegeneration, cognitive impairment, or structural brain damage. The latter paradoxical situation raises a fundamental question that might literally rewrite the interpretations about the tau phosphorylation being a strictly pathological process. This overview aims to bring together the latest clinical, biochemical, and developmental neuroscience literature to unveil the physiological function of p-tau217 during early brain development. We argue that high p-tau217 in infancy may be indicative of ongoing neurodevelopmental processes, such as axonal growth, synaptogenesis, neuronal plasticity, and cytoskeletal remodeling, rather than tau toxicity. Further, we analyze the contribution of the differential expression of tau isoforms, phosphorylation rates, clearance pathways, and BBB permeability in development that could explain the age-dependent biomarker profiles. In addition, this review compares the biology of tau in neonates and adults in a detailed manner, explaining how the context-dependent regulation of tau phosphorylation distinguishes p-tau217 as a developmental marker or a pathological marker. Grasping this difference is essential for the correct reading of tau biomarkers throughout the life span and for preventing the neurodegenerative risk in children from being wrongly diagnosed. In the end, this paradox highlights the need for biomarker frameworks that are specific to different ages and offers new understandings of tau physiology that might lead to novel therapies for tauopathies in the future.