Research On Clinic Features And Transcriptome In NOTCH2NLC Gene Related Neuronal Inclusion Body Disease

Objective: Objective: Neuronal intranuclear inclusion disease(NIID)is a chronic progressive neurodegenerative disease caused by abnormal repeated GGC expansion of NOTCH2 NLC gene.There is no large sample cohort study of this disease in the world,and its pathogenesis is not yet clear.This study intends performed a comprehensive analysis from the perspectives of clinic,imaging,neuroelectrophysiological,neuropsychological assessment,gene testing and RNA sequencing in a large NIID cohort from multi-center in order to investgate the clinical features,auxiliary examination characteristics and possible pathogenic mechanism.Methods:(1)The clinical information including demographic information,first symptom and its frequency progress,main clinical symptoms from a total of 302 NOTCH2 NLC gene related NIID patients were analyzed.The clinical characteristics were summarized and the clinical phenotype of each NIID patient was confirmed according to first symptom and main clinical symptoms.(2)The results of auxiliary examination in NOTCH2 NLC gene related NIID patients were summarized and analyzed;The differences of auxiliary examination among different subtypes were analyzed;To study the relationship between genotype and phenotype in patients.(3)The differentially expressed genes of peripheral blood between NOTCH2 NLC gene related NIID patients and normal controls were analyzed by RNA sequencing and bioinformatics,and the differentially expressed genes were enriched.Results:(1)There were 135 males and 167 females in the 302 patients with NOTCH2 NLC gene related NIID cohort and the gender rate was balance(p=0.066);Paroxysmal symptoms(31.8%),cognitive impairment(27.2%),movement disorders(21.5%),autonomic dysfunction(10.9%)and muscle weakness(8.6%)were usually the initial symptoms of NIID patients,and the frequency of paroxysmal symptoms,autonomic dysfunction and cognitive impairment increased rapidly within 10 years after onset;Cognitive impairment(52.32%),urinary bladder dysfunction(48.33%),onset consciousness disorder(38.74%),tremor sample(36.42%),stroke,seizures(34.11%)for adult NIID patients the most common symptoms;According to the initial symptoms and main clinical symptoms,adult NIID could be divided into four types: dementia type(125 cases,41.4%),movement disorder type(74 cases,24.5%),muscle weakness type(31cases,10.3%)and paroxysmal symptom type(72 cases,23.8%);There are two peaks in the onset age of NIID patients,which are 30 to 35 years old for muscle weakness-dominant type patients and 55 to 65 years old for other three types patients.(2)Through the analysis of NIID patient auxiliary examination,it is found that: typical U-fibre high signal(89.22%)in DWI sequence and severe leukodystrophy(85.34%)were common in adult-onset NIID,and the positive rates were different among different subtypes(p < 0.05);90.9%of NIID showed peripheral neuropathy according to electrophysiological examinations;Patients with NIID were characterized by slight demyelinating sensorimotor polyneuropathy,some patients also showed mild axonal lesions.About 42.56% of patients had abnormal MMSE evaluation,about 86.11% of patients had abnormal Mo CA evaluation,and Mo CA was more sensitive to NIID patients;About 46.71% of the patients had impaired ability of daily living,and NPI assessment suggested that about 71.7% of the patients had mental symptoms;The SCOPA-AUT score suggested that about 94.16% of patients had autonomic dysfunction.Compared with controls,patients had more severe Aut D in total SCOPAAUT,gastrointestinal,urinary,cardiovascular,thermoregulatory,and pupillomotor domains(all p<0.01);The number of GGC repeats in NIID patients ranged from 66 to 517,and the most common number of GGC repeats ranged from 91 to 120;GGC repeat sizes were negatively correlated with age of onset(r=-0.136,p<0.05),and in the muscle weakness-dominant type(median 152.00),the number of repeats was much higher than in the other three groups(p<0.05).In NIID pedigrees,significant genetic anticipation was observed(p<0.05)without repeat instability(p=0.053)during transmission.(3)A total of 1671 differentially expressed genes were found between the NIID group and the normal control group,including 123 up-regulated genes and 1548 down-regulated genes;GO analysis showed that DEGs was significantly correlated with some biological processes,such as nucleic acid phosphodiester bond hydrolysis,disaccharide metabolic process,self proteolysis,cytoplasmic translation,immune response,gene expression;GO analysis showed that DEGs was significantly correlated with some cellular components,such as Golgi trans cisterna,Golgi medial cisterna,EMC complex,cytosol,ribonucleoprotein complex,vesicle;GO analysis showed that DEGs was significantly correlated with some molecular functions,such as exodeoxyribonuclease activity,exodeoxyribonuclease activity,producing 5’-phosphomonoesters,3’-5’ exonuclease activity;KEGG analysis showed that DEGs were significantly correlated with neurodegenerative diseases,substance metabolism,pathogen infection,ribosome and spliceosome.Reactome enrichment analysis showed that DEGs was related to energy metabolism,phosphorylation and protein translation;There were only two down-regulated genes(TUBB1 and CNIH3)between the paroxysmal symptom type and muscle weakness type group,and one up-regulated gene(CSDC2)and three down-regulated genes(ITGAE,DLD and THAP8)between the movement disorder type group and cognitive disorders type group.Conclusion:(1)NOTCH2NLC gene related NIID is not rare.The initial symptoms and its frequency progression,and main clinical symptoms of NIID patients are highly heterogeneous,and it is often misdiagnosed as other diseases.The results of this study help to extend the known clinical spectrum of NOTCH2 NLC gene related NIID.(2)The diagnosis of NIID should be combined with clinical symptoms and auxiliary examination.Head MRI and neuroelectrophysiology are important auxiliary tests for NIID,and skin biopsy and gene test are the diagnostic methods for NIID.(3)NOTCH2NLC gene related NIID may be related to ribosome,phosphorylation,and spliceosome pathway.Although the clinical manifestations of each subtype were different,their gene expression was similar,which proved that NOTCH2 NLC gene related NIID was a global disease at the expression level.