Dopa-responsive dystonia is a childhood-onset
dystonic disorder, characterized by a dramatic response to low dose of
L-Dopa.
Dopa-responsive dystonia is mostly caused by autosomal dominant mutations in the GCH1 gene (
GTP cyclohydrolase1) and more rarely by autosomal recessive mutations in the TH (
tyrosine hydroxylase) or SPR (
sepiapterin reductase) genes. In addition, mutations in the PARK2 gene (parkin) which causes
autosomal recessive juvenile parkinsonism may present as
Dopa-responsive dystonia. In order to evaluate the relative frequency of the mutations in these genes, but also in the genes involved in the biosynthesis and recycling of BH4, and to evaluate the associated clinical spectrum, we have studied a large series of index patients (n = 64) with
Dopa-responsive dystonia, in whom
dystonia improved by at least 50% after
L-Dopa treatment. Fifty seven of these patients were classified as pure
Dopa-responsive dystonia and seven as
Dopa-responsive dystonia-plus syndromes. All patients were screened for point mutations and large rearrangements in the GCH1 gene, followed by sequencing of the TH and SPR genes, then PTS (pyruvoyl
tetrahydropterin synthase), PCBD (pterin-4a-carbinolamine dehydratase), QDPR (dihydropteridin
reductase) and PARK2 (parkin) genes. We identified 34 different heterozygous point mutations in 40 patients, and six different large deletions in seven patients in the GCH1 gene. Except for one patient with
mental retardation and a large deletion of 2.3 Mb encompassing 10 genes, all patients had stereotyped clinical features, characterized by pure
Dopa-responsive dystonia with onset in the lower limbs and an excellent response to low doses of
L-Dopa.
Dystonia started in the first decade of life in 40 patients (85%) and before the age of 1 year in one patient (2.2%). Three of the 17 negative GCH1 patients had mutations in the TH gene, two in the SPR gene and one in the PARK2 gene. No mutations in the three genes involved in the biosynthesis and recycling of BH4 were identified. The clinical presentations of patients with mutations in TH and SPR genes were strikingly more complex, characterized by
mental retardation, oculogyric crises and
parkinsonism and they were all classified as
Dopa-responsive dystonia-plus syndromes. Patient with mutation in the PARK2 gene had
Dopa-responsive dystonia with a good improvement with
L-Dopa, similar to
Dopa-responsive dystonia secondary to GCH1 mutations. Although the yield of mutations exceeds 80% in pure
Dopa-responsive dystonia and
Dopa-responsive dystonia-plus syndromes groups, the genes involved are clearly different: GCH1 in the former and TH and SPR in the later.