Concerning the Cases Previously Reported in the Literature

Appendix e-1

Genealogical results

A genealogical link was established with all the subjects carrying the PSEN1 Met146Leu mutation reported in the literature. The reconstituted N-TO kindred plus the Naples family and the Australian family comprises 148 affected individuals and 19 obligate carriers from the 17th century onwards.

The link between the N Family and the Australian family 20 was established to originate to 1895. The subject linking the two families was the woman I-1 20 as the founder and deceased at age 39 due to kidney disease. We found transcription of her birth in the Official State Archives of Nicastro (now Lamezia Terme) and the records show she was born in Cairo on March 29th, 1895 from Calabrian parents. Her father emigrated, from the place of origin of the N family, to work on the Suez Canal in 1894. The family was in descent of the common ancestor of the N family (#4403 born in 1715 and deceased at age 43 years).

Concerning the cases previously reported in the literature,

In 199514, three EOFAD Italian families were reported segregating Met146Leu, suggesting a founder effect in common with the N and TO families. One of them was the Tuscan branch of the N family (descending from #228); the reported FLO11 was identified as the Naples family. Clinical documents of the remaining third family were not available, therefore it has not been identified.

In 199515 it was indicated that one of the reported families was a branch of the FAD4 kindred (namely the N family). In 199916 it was confirmed that all PSEN1 Met146Leu persons identified belonged to branches of the TO family. In 200118 a screening for PSEN1 mutations was performed on a set of early onset FAD among which two were patients belonging to the TO family. Similarly, in 200117 patients belonging to the FJ01 family were decsribed that also belonged to the TO family. In 200519 a member of the German branch of the N Family was reported; he had also been examined in our centre.

Molecular link

We performed a genetic analysis to link the Naples family to the N-TO family into a common pedigree, since we were not able to do so using genealogy.

Had the Met146Leu mutation occurred from a common founder, alleles at nearby markers would be located on chromosomes carrying the variation.

The patients studied resulted homozygous for the D14S1002 and D14S1028 markers sharing the same 1-1 haplotype, and were heterozygous for the D14S77 marker, sharing the 1 allele. The two patients (#133611, #16056) belonging to Naples and TO families were heterozygous for the D14S1377, while the N family patient (#1193) was homozygous. All genotyped patients were homozygous for D14S999. As for D14S1377, for the marker D14S53 the patients belonging to the Naples and TO families were heterozygous while the N family patient was homozygous.

None of the controls had the same the haplotype identified in the subjects from N and Naples family.

Therefore, a common shared DNA haplotype was found, thus suggesting that the Met146Leu mutation occurred in a common ancestor.

However, it is remarkable that members of the N and Naples families carried at least one allele with an identical number of repeats in five out of the six microsatellites tested, while patient #16056, belonging to the TO family, already linked to the N family3, showed an allelic pattern for the D14S53 marker which was different from that of the other families. This microsatellite marker is the marker most distant from PSEN1 gene and it is possible that a single recombination event occurred in this region. Unfortunately, we cannot estimate the exact number of generations separating them from the common founder due to the limited number of Naples family members available.

Naples family

Family history reported that the Naples family probably originated in Calabria even if no member knew exactly the site of origin. However, the apparent origin was in 1885 in the town of TdG near Naples, where an ancestor was traced back by historical documents belonging to the family.

The reconstructed pedigree comprises 38 persons over 6 generations, among which 7 idividuals were affected over four generations (one personal examination, four by history and two by medical records). Age of onset was 40.9+5.2; age of death 47.0+4.1 years; duration 6.8+6.4 years (3-18 years); segregation ratio 0.54; sex ratio M:F 1:1.

Proband (#133611, IV-1) first presented the disease at the age of 40 years showing memory loss, difficulties in attention and planning, spatial orientation impairment, mild reduction of spontaneous language and meaning. Moreover, he manifested hilarity and inappropriate social behaviour; insight was partial at onset. Neurological examination evidenced primitive reflexes and diffuse hyper-reflexia.

A complete neuropsychological evaluation was performed at the age of 42 years and periodically repeated every 18 months. The first examination (table E-1) evidenced moderate impairment in short and long verbal and visuo-spatial memory and constructional apraxia. He was autonomous in basic and instrumental activities of daily living, able to work, even at a reduced rate, to use the computer and mobile telephone and to drive is own car. The MMSE revealed topographical disorientation, but, at least at the beginning, he was never lost. The Neuropsychiatic Inventory (NPI) evidenced only moderate apathy and irritability. The Frontal Behaviour Inventory (FBI) evidenced moderate apathy, inflexibility, irritability, loss of insight and mild excessive jocularity.

The MMSE score decreased to 19.9/30 after 12 months and to 17.9/30 after 18 months: during this period the patient had a progressive global cognitive decline with increasing difficulties in planning; topographical disorientation increased, while spontaneous speech was maintained even with more repetitions and mild logopenia. Instrumental activities were progressively reduced, but basic activities were still maintained. More apathy, withdrawal, lack of motivation and initiatives were detected.

After 18 months NPI evidenced the worsening of apathy and irritability with mild euphoria. FBI score evidenced increased behavioral frontal symptoms, in particular more emotional flatness, perseveration, inflexibility, disorganization and loss of insight.

After 18 months, he continued to work, even at very low pace due to progressive loss of attention and concentration. Seizure or movement impairment were never reported.

18-FDG PET, performed at age of 44 years evidenced a clear severe metabolic deficit in the temporoparietal, superior parietal and posterior cingulate cortices. Slight hypometabolism was evident in the mesial temporal and prefrontal cortex. Brain MRI was normal.

He was diagnosed with familial AD caused by a PSEN1-Met146Leu (ATG/CTG) at the Neurology Department of the University of Florence.

Naples Family –other affected subjects

Family history revealed six familial members affected by dementia over four generations.

The proband’s greatgrandfather (I-3) (born in 1885) was diagnosed with Progressive Palsy with normal CSF; he suffered epileptic seizures and died at age 49. He had two sisters and five brothers; two of them died at 50 and one at 59 for unknown reasons. The proband’s greatgrandfather was a seaman and travelled overseas for many years. The grandchildren recalled from their grandmother’s memories that, at home, at the age of 46 years, he presented a severe and rapidly progressive cognitive decline with topographical disorientation, memory loss and eating difficulties. Bedridden, he died at only 49 years old.

The maternal grandmother (II-2) was diagnosed with AD at 42 and died at 46. She developed generalized epileptic seizures. The youngest of four siblings, she started at age 41 years she began to show rapid cognitive impairment with memory loss and episodes of topographical disorientation. She had early behavioral disorders, such apathy, withdrawal, loss of interest, lack of motivation and initiative, but never had at any stage of the disease restlessness, agitation or aggression. After a period of wandering and pacing around the house, she presented movement impairment with shuffling gait and camptocormia. Bedridden, she was quiet with sporadic laughing episodes. She died at the age of 46 years.

Her brother (II-5) was diagnosed with Pick disease due to a clinical picture of disinhibition and lack of critique and judgment; moreover he presented epilepsy; clinical onset was at 46 and death at 52. He also underwent CSF examination, which was normal. He started to present the first symptoms of memory impairment and topographical disorientation at the age of 47 years. As a medical doctor, he was anosognosic and refused the diagnosis of dementia being convinced that he was affected by “brain cancer”. He consulted with many neurologists around Europe and was diagnosed in Sweden as being affected by Pick disease. Back home, he was depressed with irritability, depression, restlessness, agitation with physical and verbal outbursts against his children. Later, he showed movement disorders with shuffling gait and camptocormia. He was confined to a Psychiatric Hospital because of increasing physically aggressive behavior, sleep disorders, screaming and yelling. He died at the age of 52 years.

Dementia started in the proband’s mother (III-2) at the age of 38 years: she initially manifested progressive memory loss. Three-four months later, she had a severe episode of topographical disorientation and, as a consequence she left home while unattended by a caregiver; at home she presented wandering and pacing around the house and progressive decline in spontaneous speech culminating in aphasia. The clinical picture rapidly evolved into a state of complete dementia with apraxia and planning difficulties, in absence of behavioural disturbances. No seizures were evident. Insight was maintained at onset. Movement disorders were similar to those of her relatives, but started at a later age. CT showed ventricular enlargement. She was diagnosed with AD and died at 41 years.

A maternal uncle (III-5) developed dementia without behavioural disturbances; he first presented the disease at age 44 with memory loss, reduction in spatial orientation reduction and dysexecutive symptoms, mainly in planning. Later he started to present behavioral disturbances, even at a less advanced stage as compared to those in his relatives, mainly presenting with wandering and aggressive reaction to sound and conversation around him. He was also a heavy cigarette smoker with a compulsory behavior. He was diagnosed by molecular screening with FAD Met146Leu. Movement impairment began in the final stage of the disease; the patient died at age 47.

A maternal cousin (III-8) was diagnosed as AD with onset at age 45; in contrast to other family members the disease was characterized by a long duration since patient is still alive at age 56, although in a severe stage and bedridden. After her divorce, she began to be severely depressed with apathy, withdrawal, loss of interest, lack of motivation and initiative. Later, she presented with memory loss and topographical disorientation. The duration of the disease was in this case longer than that of her relative group, being still alive after 11 years, although bedridden since the age of 50. Until the age of 54 she was still able to smile at the relatives, but later she was in a final stage with parenteral nutrition.

Corresponding author: A.C. Bruni MD, e-mail