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<meta name="robots" content="INDEX,FOLLOW,NOARCHIVE" /><meta name="citation_inbook_title" content="GeneReviews® [Internet]" /><meta name="citation_title" content="Progressive Myoclonic Epilepsy Type 1" /><meta name="citation_publisher" content="University of Washington, Seattle" /><meta name="citation_date" content="2020/07/02" /><meta name="citation_author" content="Anna-Elina Lehesjoki" /><meta name="citation_author" content="Reetta Kälviäinen" /><meta name="citation_pmid" content="20301321" /><meta name="citation_fulltext_html_url" content="https://www.ncbi.nlm.nih.gov/books/NBK1142/" /><meta name="citation_keywords" content="EPM1" /><meta name="citation_keywords" content="Unverricht-Lundborg Disease (ULD)" /><meta name="citation_keywords" content="EPM1" /><meta name="citation_keywords" content="Unverricht-Lundborg Disease (ULD)" /><meta name="citation_keywords" content="Cystatin-B" /><meta name="citation_keywords" content="CSTB" /><meta name="citation_keywords" content="Progressive Myoclonic Epilepsy Type 1" /><link rel="schema.DC" href="http://purl.org/DC/elements/1.0/" /><meta name="DC.Title" content="Progressive Myoclonic Epilepsy Type 1" /><meta name="DC.Type" content="Text" /><meta name="DC.Publisher" content="University of Washington, Seattle" /><meta name="DC.Contributor" content="Anna-Elina Lehesjoki" /><meta name="DC.Contributor" content="Reetta Kälviäinen" /><meta name="DC.Date" content="2020/07/02" /><meta name="DC.Identifier" content="https://www.ncbi.nlm.nih.gov/books/NBK1142/" /><meta name="description" content="Progressive myoclonic epilepsy type 1(EPM1) is a neurodegenerative disorder characterized by onset from age six to 15 years, stimulus-sensitive myoclonus, and tonic-clonic epileptic seizures. Some years after the onset, ataxia, incoordination, intentional tremor, and dysarthria develop. Individuals with EPM1 are cognitively mostly within the normal range, but show emotional lability and depression. The epileptic seizures are usually well controlled by anti-seizure medication, but the myoclonic jerks are progressive, action activated, and treatment resistant, and can be severely disabling." /><meta name="og:title" content="Progressive Myoclonic Epilepsy Type 1" /><meta name="og:type" content="book" /><meta name="og:description" content="Progressive myoclonic epilepsy type 1(EPM1) is a neurodegenerative disorder characterized by onset from age six to 15 years, stimulus-sensitive myoclonus, and tonic-clonic epileptic seizures. Some years after the onset, ataxia, incoordination, intentional tremor, and dysarthria develop. Individuals with EPM1 are cognitively mostly within the normal range, but show emotional lability and depression. 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<div class="pre-content"><div><div class="bk_prnt"><p class="small">NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.</p><p>Adam MP, Feldman J, Mirzaa GM, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2025. </p></div><div class="iconblock clearfix whole_rhythm no_top_margin bk_noprnt"><a class="img_link icnblk_img" title="All GeneReviews" href="/books/n/gene/"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-gene-lrg.png" alt="Cover of GeneReviews®" height="100px" width="80px" /></a><div class="icnblk_cntnt eight_col"><h2>GeneReviews<sup>®</sup> [Internet].</h2><a data-jig="ncbitoggler" href="#__NBK1142_dtls__">Show details</a><div style="display:none" class="ui-widget" id="__NBK1142_dtls__"><div>Adam MP, Feldman J, Mirzaa GM, et al., editors.</div><div>Seattle (WA): <a href="http://www.washington.edu" ref="pagearea=page-banner&targetsite=external&targetcat=link&targettype=publisher">University of Washington, Seattle</a>; 1993-2025.</div></div><div class="half_rhythm"><ul class="inline_list"><li style="margin-right:1em"><a class="bk_cntns" href="/books/n/gene/">GeneReviews by Title</a></li></ul></div><div class="bk_noprnt"><form method="get" action="/books/n/gene/" id="bk_srch"><div class="bk_search"><label for="bk_term" class="offscreen_noflow">Search term</label><input type="text" title="Search GeneReviews" id="bk_term" name="term" value="" data-jig="ncbiclearbutton" /> <input type="submit" class="jig-ncbibutton" value="Search GeneReviews" submit="false" style="padding: 0.1em 0.4em;" /></div></form><div><ul class="inline_list"><li><a href="/books/n/gene/advanced/">GeneReviews Advanced Search</a></li><li style="margin-left:.5em"><a href="/books/n/gene/helpadvsearch/">Help</a></li></ul></div></div></div><div class="icnblk_cntnt two_col"><div class="pagination bk_noprnt"><a class="active page_link prev" href="/books/n/gene/primrose/" title="Previous page in this title">< Prev</a><a class="active page_link next" href="/books/n/gene/lafora/" title="Next page in this title">Next ></a></div></div></div></div></div>
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<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/CreativeWork"><div class="meta-content fm-sec"><h1 id="_NBK1142_"><span class="title" itemprop="name">Progressive Myoclonic Epilepsy Type 1</span></h1><div itemprop="alternativeHeadline" class="subtitle whole_rhythm">Synonyms: EPM1, Unverricht-Lundborg Disease (ULD)</div><p class="contrib-group"><span itemprop="author">Anna-Elina Lehesjoki</span>, MD, PhD and <span itemprop="author">Reetta Kälviäinen</span>, MD, PhD.</p><a data-jig="ncbitoggler" href="#__NBK1142_ai__" style="border:0;text-decoration:none">Author Information and Affiliations</a><div style="display:none" class="ui-widget" id="__NBK1142_ai__"><div class="contrib half_rhythm"><span itemprop="author">Anna-Elina Lehesjoki</span>, MD, PhD<div class="affiliation small">Folkhälsan Research Center and University of Helsinki<br />Helsinki, Finland<div><span class="email-label">Email: </span><a href="mailto:dev@null" data-email="if.iknisleh@ikojsehel.anile-anna" class="oemail">if.iknisleh@ikojsehel.anile-anna</a></div></div></div><div class="contrib half_rhythm"><span itemprop="author">Reetta Kälviäinen</span>, MD, PhD<div class="affiliation small">Kuopio Epilepsy Center<br />Kuopio University Hospital<br />Member, EpiCARE ERN<br />University of Eastern Finland<br />Kuopio, Finland<div><span class="email-label">Email: </span><a href="mailto:dev@null" data-email="if.huk@neniaivlak.atteer" class="oemail">if.huk@neniaivlak.atteer</a></div></div></div></div><p class="small">Initial Posting: <span itemprop="datePublished">June 24, 2004</span>; Last Update: <span itemprop="dateModified">July 2, 2020</span>.</p><p><em>Estimated reading time: 19 minutes</em></p></div><div class="jig-ncbiinpagenav body-content whole_rhythm" data-jigconfig="allHeadingLevels: ['h2'],smoothScroll: false" itemprop="text"><div id="epm1.Summary" itemprop="description"><h2 id="_epm1_Summary_">Summary</h2><div><h4 class="inline">Clinical characteristics.</h4><p>Progressive myoclonic epilepsy type 1(EPM1) is a neurodegenerative disorder characterized by onset from age six to 15 years, stimulus-sensitive myoclonus, and tonic-clonic epileptic seizures. Some years after the onset, ataxia, incoordination, intentional tremor, and dysarthria develop. Individuals with EPM1 are cognitively mostly within the normal range, but show emotional lability and depression. The epileptic seizures are usually well controlled by anti-seizure medication, but the myoclonic jerks are progressive, action activated, and treatment resistant, and can be severely disabling.</p></div><div><h4 class="inline">Diagnosis/testing.</h4><p>The diagnosis of EPM1 is established in a <a class="def" href="/books/n/gene/glossary/def-item/proband/">proband</a> with suggestive findings and either <a class="def" href="/books/n/gene/glossary/def-item/biallelic/">biallelic</a> abnormal CCC-CGC-CCC-GCG dodecamer repeat expansions in <i>CSTB</i> or compound heterozygosity for a <i>CSTB</i> dodecamer repeat expansion and a <i>CSTB</i> sequence variant (i.e., <a class="def" href="/books/n/gene/glossary/def-item/single-nucleotide-variant/">single-nucleotide variant</a> or <a class="def" href="/books/n/gene/glossary/def-item/indel/">indel</a>) identified by <a class="def" href="/books/n/gene/glossary/def-item/molecular-genetic-testing/">molecular genetic testing</a>.</p></div><div><h4 class="inline">Management.</h4><p><i>Treatment of manifestations:</i> Symptomatic pharmacologic and rehabilitative management, including psychosocial support, are the mainstay of care; valproic acid, the first drug of choice, diminishes myoclonus and the frequency of generalized seizures; clonazepam, approved by FDA for the treatment of myoclonic seizures, is an add-on therapy; high-dose piracetam is used to treat myoclonus; levetiracetam, brivaracetam, and perampanel appear to be effective for both myoclonus and generalized seizures. Topiramate and zonisamide may also be used as add-on therapy.</p><p><i>Surveillance:</i> Lifelong clinical follow up including evaluation of drug treatment and rehabilitation.</p><p><i>Agents/circumstances to avoid:</i> Phenytoin aggravates neurologic symptoms or even accelerates cerebellar degeneration; sodium channel blockers (carbamazepine, oxcarbazepine), GABAergic drugs (tiagabine, vigabatrin), and gabapentin and pregabalin may aggravate myoclonus and myoclonic seizures.</p></div><div><h4 class="inline">Genetic counseling.</h4><p>EPM1 is inherited in an <a class="def" href="/books/n/gene/glossary/def-item/autosomal-recessive/">autosomal recessive</a> manner. At conception, each sib of an affected individual has a 25% chance of being affected, a 50% chance of being an asymptomatic <a class="def" href="/books/n/gene/glossary/def-item/carrier/">carrier</a>, and a 25% chance of being unaffected and not a carrier. Once both <i>CSTB</i> pathogenic variants in a family are known, <a class="def" href="/books/n/gene/glossary/def-item/carrier-testing/">carrier testing</a> for at-risk relatives, <a class="def" href="/books/n/gene/glossary/def-item/prenatal-testing/">prenatal testing</a> for pregnancies at increased risk, and <a class="def" href="/books/n/gene/glossary/def-item/preimplantation-genetic-testing/">preimplantation genetic testing</a> are possible.</p></div></div><div id="epm1.Diagnosis"><h2 id="_epm1_Diagnosis_">Diagnosis</h2><div id="epm1.Suggestive_Findings"><h3>Suggestive Findings</h3><p>The diagnosis of progressive myoclonic epilepsy type 1 (EPM1) <b>is suspected</b> in a previously healthy child age six to 15 years who manifests the following:</p><ul><li class="half_rhythm"><div>Involuntary, action-activated myoclonic jerks AND/OR generalized tonic-clonic seizures</div></li><li class="half_rhythm"><div>Photosensitive, generalized spike-and-wave and polyspike-and-wave paroxysms on EEG</div></li><li class="half_rhythm"><div>Abnormal EEG (always abnormal, even before the onset of manifestations). The background activity is labile and may be slower than normal. Photosensitivity is marked.</div></li><li class="half_rhythm"><div>A gradual worsening of the neurologic manifestations (myoclonus and ataxia), difficulties running, playing sports, using stairs</div></li><li class="half_rhythm"><div>Normal brain MRI</div></li></ul></div><div id="epm1.Establishing_the_Diagnosis"><h3>Establishing the Diagnosis</h3><p>The diagnosis of EPM1 disease <b>is established</b> in a <a class="def" href="/books/n/gene/glossary/def-item/proband/">proband</a> with suggestive findings and either <a class="def" href="/books/n/gene/glossary/def-item/biallelic/">biallelic</a> abnormal CCC-CGC-CCC-GCG dodecamer repeat expansions in <i>CSTB</i> or compound heterozygosity for a <i>CSTB</i> dodecamer repeat expansion and a <i>CSTB</i> sequence variant (i.e., <a class="def" href="/books/n/gene/glossary/def-item/single-nucleotide-variant/">single-nucleotide variant</a> or <a class="def" href="/books/n/gene/glossary/def-item/indel/">indel</a>) identified by <a class="def" href="/books/n/gene/glossary/def-item/molecular-genetic-testing/">molecular genetic testing</a> (see <a href="/books/NBK1142/table/epm1.T.molecular_genetic_testing_used_in/?report=objectonly" target="object" rid-ob="figobepm1Tmoleculargenetictestingusedin">Table 1</a>).</p><p>Note: Pathogenic dodecamer repeat expansions in <i>CSTB</i>
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<b>cannot be detected</b> by sequence-based multigene panels, <a class="def" href="/books/n/gene/glossary/def-item/exome-sequencing/">exome sequencing</a>, or <a class="def" href="/books/n/gene/glossary/def-item/genome-sequencing/">genome sequencing</a>.</p><p>
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<b>Repeat sizes</b>
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</p><ul><li class="half_rhythm"><div><b>Normal.</b> 2 to 3 dodecamer repeats</div></li><li class="half_rhythm"><div><b>Uncertain significance.</b> 12-17 dodecamer repeats (unstable, but not clinically characterized)</div></li><li class="half_rhythm"><div><b>Pathogenic (full <a class="def" href="/books/n/gene/glossary/def-item/penetrance/">penetrance</a>).</b> ≥30 dodecamer repeats</div></li></ul><p>Note: The dodecamer repeat sequence is CCC-CGC-CCC-GCG. Repeats of 4-11 and 18-29 have not been observed.</p><p><b>Molecular genetic testing</b> relies on targeted analysis to characterize the number of <i>CSTB</i> CCC-CGC-CCC-GCG dodecamer repeats (see <a href="/books/NBK1142/table/epm1.T.methods_to_characterize_cstb_cccc/?report=objectonly" target="object" rid-ob="figobepm1Tmethodstocharacterizecstbcccc">Table 7</a>).</p><div id="epm1.T.molecular_genetic_testing_used_in" class="table"><h3><span class="label">Table 1. </span></h3><div class="caption"><p>Molecular Genetic Testing Used in Progressive Myoclonic Epilepsy Type 1</p></div><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK1142/table/epm1.T.molecular_genetic_testing_used_in/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__epm1.T.molecular_genetic_testing_used_in_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_epm1.T.molecular_genetic_testing_used_in_1_1_1_1" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Gene <sup>1</sup></th><th id="hd_h_epm1.T.molecular_genetic_testing_used_in_1_1_1_2" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Method <sup>2, 3</sup></th><th id="hd_h_epm1.T.molecular_genetic_testing_used_in_1_1_1_3" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Proportion of Probands with a Pathogenic Variant Detectable by Method</th></tr></thead><tbody><tr><td headers="hd_h_epm1.T.molecular_genetic_testing_used_in_1_1_1_1" rowspan="2" scope="row" colspan="1" style="text-align:left;vertical-align:middle;">
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<i>CSTB</i>
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</td><td headers="hd_h_epm1.T.molecular_genetic_testing_used_in_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Targeted analysis for the dodecamer expansion</td><td headers="hd_h_epm1.T.molecular_genetic_testing_used_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">~90% <sup>4, 5</sup></td></tr><tr><td headers="hd_h_epm1.T.molecular_genetic_testing_used_in_1_1_1_2" colspan="1" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">Sequence analysis <sup>6</sup></td><td headers="hd_h_epm1.T.molecular_genetic_testing_used_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">~10% <sup>4</sup></td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt>1. </dt><dd><div id="epm1.TF.1.1"><p class="no_margin">See <a href="/books/NBK1142/#epm1.molgen.TA">Table A. Genes and Databases</a> for <a class="def" href="/books/n/gene/glossary/def-item/chromosome/">chromosome</a> <a class="def" href="/books/n/gene/glossary/def-item/locus/">locus</a> and protein.</p></div></dd><dt>2. </dt><dd><div id="epm1.TF.1.2"><p class="no_margin">See <a href="/books/NBK1142/table/epm1.T.methods_to_characterize_cstb_cccc/?report=objectonly" target="object" rid-ob="figobepm1Tmethodstocharacterizecstbcccc">Table 7</a> for specific methods to characterize the number of dodecamer (CCC-CGC-CCC-GCG) repeats in <i>CSTB</i>.</p></div></dd><dt>3. </dt><dd><div id="epm1.TF.1.3"><p class="no_margin">Sequence-based multigene panels, <a class="def" href="/books/n/gene/glossary/def-item/exome-sequencing/">exome sequencing</a>, and <a class="def" href="/books/n/gene/glossary/def-item/genome-sequencing/">genome sequencing</a> cannot detect pathogenic repeat expansions in this <a class="def" href="/books/n/gene/glossary/def-item/gene/">gene</a>.</p></div></dd><dt>4. </dt><dd><div id="epm1.TF.1.4"><p class="no_margin">Sequence analysis detects variants that are benign, <a class="def" href="/books/n/gene/glossary/def-item/likely-benign/">likely benign</a>, of <a class="def" href="/books/n/gene/glossary/def-item/uncertain-significance/">uncertain significance</a>, <a class="def" href="/books/n/gene/glossary/def-item/likely-pathogenic/">likely pathogenic</a>, or pathogenic. Variants may include small intragenic deletions/insertions and <a class="def" href="/books/n/gene/glossary/def-item/missense/">missense</a>, <a class="def" href="/books/n/gene/glossary/def-item/nonsense-variant/">nonsense</a>, and <a class="def" href="/books/n/gene/glossary/def-item/splice-site/">splice site</a> variants; typically, <a class="def" href="/books/n/gene/glossary/def-item/exon/">exon</a> or whole-<a class="def" href="/books/n/gene/glossary/def-item/gene/">gene</a> deletions/duplications are not detected. For issues to consider in interpretation of <a class="def" href="/books/n/gene/glossary/def-item/sequence-analysis/">sequence analysis</a> results, click <a href="/books/n/gene/app2/">here</a>.</p></div></dd><dt>5. </dt><dd><div id="epm1.TF.1.5"><p class="no_margin"><a class="bk_pop" href="#epm1.REF.lalioti.1997.847">Lalioti et al [1997]</a>, <a class="bk_pop" href="#epm1.REF.joensuu.2008.557">Joensuu et al [2008]</a></p></div></dd><dt>6. </dt><dd><div id="epm1.TF.1.6"><p class="no_margin">~99% in Finnish individuals [<a class="bk_pop" href="#epm1.REF.joensuu.2008.557">Joensuu et al 2008</a>]</p></div></dd></dl></div></div></div></div></div><div id="epm1.Clinical_Characteristics"><h2 id="_epm1_Clinical_Characteristics_">Clinical Characteristics</h2><div id="epm1.Clinical_Description"><h3>Clinical Description</h3><p>In more than half of individuals with progressive myoclonic epilepsy type 1 (EPM1) the first manifestation is involuntary myoclonic jerks [<a class="bk_pop" href="#epm1.REF.k_lvi_inen.2008.549">Kälviäinen et al 2008</a>, <a class="bk_pop" href="#epm1.REF.hypp_nen.2015.1529">Hyppönen et al 2015</a>]. The myoclonic jerks are action activated and stimulus sensitive and may be provoked by light, physical exertion, and stress. They occur predominantly in the proximal muscles of the extremities and are asynchronous; they may be focal or multifocal and may generalize to a series of myoclonic seizures or even status myoclonicus (continuous myoclonic jerks involving a semi-loss of consciousness).</p><p>During the first five to ten years, the symptoms/myoclonic jerks characteristically progress and about one third of affected individuals become severely incapacitated (wheelchair bound). Although the myoclonic jerks are disabling and resistant to therapy, the individual usually learns to tolerate them over time, if psychosocial support is good and depression not too severe.</p><p>In almost half of individuals, the first manifestation is tonic-clonic seizures. There may also be absence, psychomotor, and/or focal motor seizures. Epileptic seizures, infrequent in the early stages of the disease, often increase in frequency during the ensuing three to seven years. Later they may cease entirely with appropriate anti-seizure medication. In rare cases, tonic-clonic seizures do not occur.</p><p>Neurologic findings initially appear normal; however, experienced observers usually note recurrent, almost imperceptible myoclonus, especially in response to photic stimuli or other stimuli (threat, clapping of hands, nose tapping, reflexes) or to action (movements made during neurologic examination) or to cognitive stimuli (task demanding cognitive and psychomotor processing). Some years after the onset, ataxia, incoordination, intentional tremor, and dysarthria develop.</p><p>Cognitive performance, especially memory, is mostly within the normal range. However, affected individuals may exhibit poor performance in time-limited tests dependent on motor functions.</p><p>The disease course is inevitably progressive; however, the rate of deterioration – especially in terms of walking capacity – appears to vary even within the same family. Generalized tonic-clonic seizures are usually controlled with treatment, but myoclonic jerks may become severe, appear in series, and inhibit normal activities [<a class="bk_pop" href="#epm1.REF.magaudda.2006.860">Magaudda et al 2006</a>, <a class="bk_pop" href="#epm1.REF.hypp_nen.2015.1529">Hyppönen et al 2015</a>]. Myoclonic jerks may also be subcortical in origin and therefore difficult to control [<a class="bk_pop" href="#epm1.REF.danner.2009.81">Danner et al 2009</a>]. The individual becomes depressed and progression ensues. Education is often interrupted because of emotional, social, and intellectual problems.</p><p>In the past, life span was shortened; many individuals died eight to 15 years after the onset of disease, usually before age 30 years. With better pharmacologic, physiotherapeutic, and psychosocial supportive treatment, life expectancy is comparable to controls up to age 40 years, but is poorer over the long term. Death occurs mainly due to respiratory infections [R Kälviäinen, personal communication].</p></div><div id="epm1.GenotypePhenotype_Correlations"><h3>Genotype-Phenotype Correlations</h3><p>Individuals with pathogenic variants in <i>CSTB</i> usually develop similar disease manifestations. There is evidence that correlation exists between the length of the expanded dodecamer repeat and the age of onset or disease severity [<a class="bk_pop" href="#epm1.REF.hypp_nen.2015.1529">Hyppönen et al 2015</a>]. However, disease severity also varies among affected individuals within a family with apparently similar repeat-size expansions.</p><p>Moreover, EPM1 resulting from compound heterozygosity for a dodecamer repeat expansion and a sequence variant (i.e., <a class="def" href="/books/n/gene/glossary/def-item/single-nucleotide-variant/">single-nucleotide variant</a> or <a class="def" href="/books/n/gene/glossary/def-item/indel/">indel</a>) often presents with earlier age of onset, more severe myoclonus, and seizures that may be drug resistant [<a class="bk_pop" href="#epm1.REF.koskenkorva.2011.515">Koskenkorva et al 2011</a>, <a class="bk_pop" href="#epm1.REF.canafoglia.2012.2120">Canafoglia et al 2012</a>]. It has been also suggested that compound heterozygosity causes a more severe EPM1 <a class="def" href="/books/n/gene/glossary/def-item/phenotype/">phenotype</a> in affected males than females, but the numbers are small [<a class="bk_pop" href="#epm1.REF.assenza.2017.e31">Assenza et al 2017</a>].</p><p>Recently, <a class="def" href="/books/n/gene/glossary/def-item/homozygous/">homozygous</a> stop-codon and frameshift pathogenic variants in <i>CSTB</i> were associated with infantile-onset progressive disorders with unexplained severe developmental delay, microcephaly, and hypomyelination [<a class="bk_pop" href="#epm1.REF.mancini.2016.877">Mancini et al 2016</a>, <a class="bk_pop" href="#epm1.REF.obrien.2017.775">O'Brien et al 2017</a>).</p></div><div id="epm1.Nomenclature"><h3>Nomenclature</h3><p>Progressive myoclonic epilepsy type 1 (EPM1) was originally referred to as Baltic myoclonus (or Baltic myoclonic epilepsy) and Mediterranean myoclonus. EPM1 is known to occur worldwide, and thus these toponyms are misleading and should no longer be used.</p></div><div id="epm1.Prevalence"><h3>Prevalence</h3><p>EPM1 has the highest incidence among the progressive myoclonic epilepsies (PMEs), a term that includes a large and varied group of diseases characterized by stimulus-sensitive myoclonus, epilepsy, and progressive neurologic deterioration.</p><p>EPM1 occurs worldwide. Prevalence is increased in certain populations:</p><ul><li class="half_rhythm"><div>The North African countries of Tunisia, Algeria, and Morocco, where exact prevalence figures are not available</div></li><li class="half_rhythm"><div>Finland, where its prevalence (2:100,000) is higher than anywhere else in the world [R Kälviäinen, personal communication]. The incidence in Finland is estimated at 1:20,000 births.</div></li></ul></div></div><div id="epm1.Genetically_Related_Allelic_Disorde"><h2 id="_epm1_Genetically_Related_Allelic_Disorde_">Genetically Related (Allelic) Disorders</h2><p>No phenotypes other than those discussed in this <i>GeneReview</i> are known to be associated with <a class="def" href="/books/n/gene/glossary/def-item/germline/">germline</a> pathogenic variants in <i>CSTB</i>.</p></div><div id="epm1.Differential_Diagnosis"><h2 id="_epm1_Differential_Diagnosis_">Differential Diagnosis</h2><p>At the onset of progressive myoclonic epilepsy type 1 (EPM1), juvenile myoclonic epilepsy (JME) (OMIM <a href="https://omim.org/phenotypicSeries/PS254770" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">PS254770</a>) – which has a more favorable outcome – should be considered as a diagnostic alternative. Individuals with JME have a normal neurologic examination and undisturbed background of the EEG.</p><p>Other disorders to consider in the differential diagnosis of EPM1 are summarized in <a href="/books/NBK1142/table/epm1.T.genes_of_interest_in_the_differen/?report=objectonly" target="object" rid-ob="figobepm1Tgenesofinterestinthedifferen">Table 2</a>.</p><div id="epm1.T.genes_of_interest_in_the_differen" class="table"><h3><span class="label">Table 2. </span></h3><div class="caption"><p>Genes of Interest in the Differential Diagnosis of Progressive Myoclonic Epilepsy Type 1</p></div><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK1142/table/epm1.T.genes_of_interest_in_the_differen/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__epm1.T.genes_of_interest_in_the_differen_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_1" rowspan="2" scope="col" colspan="1" headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_1" style="text-align:left;vertical-align:middle;">Gene(s)</th><th id="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_2" rowspan="2" scope="col" colspan="1" headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_2" style="text-align:left;vertical-align:middle;">Disorder</th><th id="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_3" rowspan="2" scope="col" colspan="1" headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_3" style="text-align:left;vertical-align:middle;">MOI</th><th id="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_4" colspan="2" scope="colgroup" rowspan="1" style="text-align:left;vertical-align:middle;">Clinical Characteristics of Differential Diagnosis Disorder</th></tr><tr><th headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_4" id="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_2_1" colspan="1" scope="colgroup" rowspan="1" style="text-align:left;vertical-align:middle;">Overlapping w/EPM1</th><th headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_4" id="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_2_2" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Distinguishing from EPM1</th></tr></thead><tbody><tr><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
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<i>EPM2A</i>
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<br />
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<i>NHLRC1</i>
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</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
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<a href="/books/n/gene/lafora/">PME, Lafora type</a>
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</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">AR</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_4 hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
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<ul><li class="half_rhythm"><div>PME</div></li><li class="half_rhythm"><div>Focal occipital seizures & fragmentary, symmetric, or generalized myoclonus beginning in previously healthy individuals</div></li></ul>
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</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_4 hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
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<ul><li class="half_rhythm"><div>Later onset (age 8-19 yrs); rapid disease progression; death ~10 yrs after diagnosis</div></li><li class="half_rhythm"><div>Prior to the availability of <a class="def" href="/books/n/gene/glossary/def-item/molecular-genetic-testing/">molecular genetic testing</a>, histologic findings on skin biopsy established the diagnosis.</div></li></ul>
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</td></tr><tr><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
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<i>GOSR2</i>
|
||
</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">EPM6 (OMIM <a href="https://omim.org/entry/614018" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">614018</a>)</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">AR</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_4 hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<ul><li class="half_rhythm"><div>Early-onset ataxia (average age 2 yrs) followed by action myoclonus & seizures later in childhood</div></li><li class="half_rhythm"><div>Independent ambulation lost in 2nd decade</div></li></ul>
|
||
</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_4 hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Earlier onset; scoliosis (develops by adolescence)</td></tr><tr><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<i>KCNC1</i>
|
||
</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">EPM7 (OMIM <a href="https://omim.org/entry/616187" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">616187</a>)</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">AD</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_4 hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<ul><li class="half_rhythm"><div>Resembles EPM1 at disease onset <sup>1</sup></div></li><li class="half_rhythm"><div>Presents at age 6-15 yrs w/myoclonus (sometimes reported as tremor)</div></li><li class="half_rhythm"><div>The later disease course is characterized by moderate-to-severe incapacitating myoclonus, infrequent tonic-clonic seizures, ataxia, & mild (if any) cognitive decline.</div></li></ul>
|
||
</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_4 hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">EPM7 & EPM1 have a remarkably similar clinical presentation. EPM7 may have a somewhat more severe progression than EPM1 in its early phases.</td></tr><tr><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<i>MT-TF</i>
|
||
<br />
|
||
<i>MT-TI</i>
|
||
<br />
|
||
<i>MT-TK</i>
|
||
<br />
|
||
<i>MT-TL1</i>
|
||
<br />
|
||
<i>MT-TP</i>
|
||
</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<a href="/books/n/gene/merrf/">MERRF</a>
|
||
</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Mat</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_4 hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<ul><li class="half_rhythm"><div>PME</div></li><li class="half_rhythm"><div>Onset usually in childhood, after normal early development</div></li></ul>
|
||
</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_4 hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<ul><li class="half_rhythm"><div>Brain MRI often shows brain atrophy & basal ganglia calcification.</div></li><li class="half_rhythm"><div>Muscle biopsy typically shows RRF.</div></li></ul>
|
||
</td></tr><tr><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<i>SCARB2</i>
|
||
</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<a href="/books/n/gene/amrf/">Action myoclonus - renal failure syndrome</a>
|
||
</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">AR</td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_4 hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Typically presents at ages 15-25 yrs; may present w/neurologic symptoms (e.g., tremor, action myoclonus, seizures, ataxia) <sup>2</sup></td><td headers="hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_1_4 hd_h_epm1.T.genes_of_interest_in_the_differen_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">May present w/proteinuria that progresses to renal failure</td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_margin">AD = <a class="def" href="/books/n/gene/glossary/def-item/autosomal-dominant/">autosomal dominant</a>; AR = <a class="def" href="/books/n/gene/glossary/def-item/autosomal-recessive/">autosomal recessive</a>; Mat = maternal; MERRF = myoclonic epilepsy with ragged red fibers; MOI = <a class="def" href="/books/n/gene/glossary/def-item/mode-of-inheritance/">mode of inheritance</a>; PME = progressive myoclonic epilepsy; RRF = ragged red fibers</p></div></dd><dt>1. </dt><dd><div id="epm1.TF.2.1"><p class="no_margin">
|
||
<a class="bk_pop" href="#epm1.REF.muona.2015.39">Muona et al [2015]</a>
|
||
</p></div></dd><dt>2. </dt><dd><div id="epm1.TF.2.2"><p class="no_margin">Action myoclonus - renal failure syndrome typically comprises a continuum of two major (and ultimately fatal) manifestations: progressive myoclonic epilepsy and renal failure; however, in some instances, the kidneys are not involved. Neurologic manifestations can appear before, simultaneously, or after the renal manifestations.</p></div></dd></dl></div></div></div></div><div id="epm1.Management"><h2 id="_epm1_Management_">Management</h2><div id="epm1.Evaluations_Following_Initial_Diagn"><h3>Evaluations Following Initial Diagnosis</h3><p>To establish the extent of disease and needs in an individual diagnosed with progressive myoclonic epilepsy type 1 (EPM1), the evaluations summarized in <a href="/books/NBK1142/table/epm1.T.recommended_evaluations_following/?report=objectonly" target="object" rid-ob="figobepm1Trecommendedevaluationsfollowing">Table 3</a> (if not performed as part of the evaluation that led to the diagnosis) are recommended.</p><div id="epm1.T.recommended_evaluations_following" class="table"><h3><span class="label">Table 3. </span></h3><div class="caption"><p>Recommended Evaluations Following Initial Diagnosis in Individuals with EPM1</p></div><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK1142/table/epm1.T.recommended_evaluations_following/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__epm1.T.recommended_evaluations_following_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_epm1.T.recommended_evaluations_following_1_1_1_1" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">System/Concern</th><th id="hd_h_epm1.T.recommended_evaluations_following_1_1_1_2" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Evaluation</th><th id="hd_h_epm1.T.recommended_evaluations_following_1_1_1_3" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Comment</th></tr></thead><tbody><tr><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_1" rowspan="3" scope="row" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Neurologic</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Neurologic assessment of myoclonus, incl myoclonus at rest, w/action, & in response to stimuli</td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Use standardized UMRS.</td></tr><tr><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_2" colspan="1" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">Seizure type & frequency</td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Obtain baseline EEG before initiation of anti-seizure therapy (when EEG is most characteristic).</td></tr><tr><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_2" colspan="1" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">Cerebellar motor dysfunction (gait & postural ataxia, dysmetria, dysdiadochokinesis, tremor, dysarthria, nystagmus, saccades & smooth pursuit)</td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Use standardized scale to establish baseline for ataxia (SARA, ICARS, or BARS).</td></tr><tr><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Musculoskeletal /</b>
|
||
<br />
|
||
<b>Activities of daily</b>
|
||
<br />
|
||
<b>living</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">By physical medicine & rehab/OT/PT</td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">To assess gross motor & fine motor skills, gait, ambulation, need for adaptive devices, need for ongoing PT/OT</td></tr><tr><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Speech</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">For those w/dysarthria: speech & language eval</td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Consider referral to speech & language pathologist.</td></tr><tr><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Cognitive</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Neuropsychologist</td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Cognitive eval to establish baseline</td></tr><tr><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Psychiatric</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Psychiatrist</td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Evaluate as needed for depression & supportive therapy.</td></tr><tr><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Development /</b>
|
||
<br />
|
||
<b>School</b>
|
||
<br />
|
||
<b>performance</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Developmental assessment</td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<ul><li class="half_rhythm"><div>To incl motor, adaptive, cognitive, & speech/language eval</div></li><li class="half_rhythm"><div>Evaluation for special education</div></li></ul>
|
||
</td></tr><tr><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Genetic</b>
|
||
<br />
|
||
<b>counseling</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">By genetics professionals <sup>1</sup></td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">To inform affected persons & their families re nature, MOI, & implications of EPM1 to facilitate medical & personal decision making</td></tr><tr><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Family support</b>
|
||
<br />
|
||
<b>& resources</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Assess:
|
||
<ul><li class="half_rhythm"><div>Use of community or <a href="#epm1.Resources">online resources</a> such as <a href="https://www.p2pusa.org/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Parent to Parent</a> and patient organizations;</div></li><li class="half_rhythm"><div>Need for social work involvement for parental support;</div></li><li class="half_rhythm"><div>Need for home nursing referral.</div></li></ul></td><td headers="hd_h_epm1.T.recommended_evaluations_following_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">To facilitate peer support for patients & families</td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_margin">BARS = Brief Ataxia Rating Scale; ICARS = International Cooperative Ataxia Rating Scale; MOI = <a class="def" href="/books/n/gene/glossary/def-item/mode-of-inheritance/">mode of inheritance</a>; OT = occupational therapist/therapy; PT = physical therapist/therapy; SARA = Scale for the Assessment and Rating of Ataxia; UMRS = Unified Myoclonus Rating Scale</p></div></dd><dt>1. </dt><dd><div id="epm1.TF.3.1"><p class="no_margin">Medical geneticist, certified genetic counselor, or certified advanced genetic nurse</p></div></dd></dl></div></div></div></div><div id="epm1.Treatment_of_Manifestations"><h3>Treatment of Manifestations</h3><div id="epm1.T.treatment_of_manifestations_in_in" class="table"><h3><span class="label">Table 4. </span></h3><div class="caption"><p>Treatment of Manifestations in Individuals with EPM1</p></div><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK1142/table/epm1.T.treatment_of_manifestations_in_in/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__epm1.T.treatment_of_manifestations_in_in_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_1" colspan="2" scope="colgroup" rowspan="1" style="text-align:left;vertical-align:middle;">Manifestation/Concern</th><th id="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_2" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Treatment</th><th id="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_3" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Considerations/Other</th></tr></thead><tbody><tr><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_1" rowspan="8" scope="row" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Myoclonus</b>
|
||
</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_1" rowspan="7" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Pharmacologic</b>
|
||
</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Valproic acid</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">First drug of choice; diminishes myoclonus & frequency of generalized seizures</td></tr><tr><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_2" colspan="1" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">Clonazepam</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">FDA-approved for treatment of myoclonic seizures; used as add-on therapy <sup>1</sup></td></tr><tr><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_2" colspan="1" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">High-dose piracetam</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Useful in treatment of myoclonus <sup>2</sup></td></tr><tr><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_2" colspan="1" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">Levetiracetam, brivaracetam, <sup>3</sup> perampanel <sup>4</sup></td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Appears effective for both myoclonus & generalized seizures</td></tr><tr><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_2" colspan="1" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">Topiramate & zonisamide</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">May be used as add-on therapies</td></tr><tr><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_2" colspan="1" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">N-acetylcysteine</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Variable results <sup>5</sup></td></tr><tr><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_2" colspan="1" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">Vagus nerve stimulation</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Reduces seizures & significantly improves cerebellar function on neurologic exam <sup>6</sup></td></tr><tr><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_1" colspan="1" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Other</b>
|
||
</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Avoid extreme stimuli (lights, noises, stress).</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;"></td></tr><tr><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_1" colspan="2" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Seizures</b>
|
||
</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Anti-seizure medication</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;"></td></tr><tr><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_1" colspan="2" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Activities of daily living (ADL)</b>
|
||
</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">PT/OT</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<ul><li class="half_rhythm"><div>PT (balance exercises, gait training, muscle strengthening) to maintain mobility & function <sup>1</sup></div></li><li class="half_rhythm"><div>OT to optimize ADL (incl use of adaptive devices, e.g., weighted eating utensils & dressing hooks)</div></li><li class="half_rhythm"><div>Consider adaptive devices to maintain/improve independence in mobility (e.g., canes, walkers, motorized chairs).</div></li><li class="half_rhythm"><div>Home adaptations to prevent falls (e.g., grab bars, raised toilet seats) & improve mobility (e.g., ramps to accommodate motorized chairs)</div></li></ul>
|
||
</td></tr><tr><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_1" colspan="2" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Developmental delay / Intellectual disability</b>
|
||
</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">See <a href="#epm1.Developmental_Delay__Intellectual_D">Developmental Delay / Intellectual Disability Management Issues</a>.</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;"></td></tr><tr><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_1" colspan="2" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Dysarthria</b>
|
||
</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Speech & language therapy</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Consider alternative communication methods as needed (e.g., writing pads & digital devices).</td></tr><tr><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_1" colspan="2" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Dysphagia</b>
|
||
</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Feeding therapy programs to improve nutrition & dysphagia & reduce aspiration risk</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<ul><li class="half_rhythm"><div>Video esophagram may help define best food consistency.</div></li><li class="half_rhythm"><div>Education re strategies to mitigate aspiration</div></li><li class="half_rhythm"><div>PEG tube in advanced cases</div></li></ul>
|
||
</td></tr><tr><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_1" colspan="2" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Weight</b>
|
||
</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Nutrition assessment</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<ul><li class="half_rhythm"><div>Consider nutritional & vitamin supplementation to meet dietary needs.</div></li><li class="half_rhythm"><div>Avoid obesity, which can exacerbate difficulties w/ambulation & mobility.</div></li></ul>
|
||
</td></tr><tr><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_1" colspan="2" scope="row" rowspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Family support & resources</b>
|
||
</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Psychotherapy, peer support</td><td headers="hd_h_epm1.T.treatment_of_manifestations_in_in_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;"></td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_margin">OT = occupational therapy; PEG = percutaneous endoscopic gastrostomy; PT = physical therapy</p></div></dd><dt>1. </dt><dd><div id="epm1.TF.4.1"><p class="no_margin">
|
||
<a class="bk_pop" href="#epm1.REF.shahwan.2005.239">Shahwan et al [2005]</a>
|
||
</p></div></dd><dt>2. </dt><dd><div id="epm1.TF.4.2"><p class="no_margin">
|
||
<a class="bk_pop" href="#epm1.REF.koskiniemi.1998.344">Koskiniemi et al [1998]</a>
|
||
</p></div></dd><dt>3. </dt><dd><div id="epm1.TF.4.3"><p class="no_margin">
|
||
<a class="bk_pop" href="#epm1.REF.k_lvi_inen.2016.210">Kälviäinen et al [2016]</a>
|
||
</p></div></dd><dt>4. </dt><dd><div id="epm1.TF.4.4"><p class="no_margin">
|
||
<a class="bk_pop" href="#epm1.REF.crespel.2017.543">Crespel et al [2017]</a>
|
||
</p></div></dd><dt>5. </dt><dd><div id="epm1.TF.4.5"><p class="no_margin">
|
||
<a class="bk_pop" href="#epm1.REF.edwards.2002.1447">Edwards et al [2002]</a>
|
||
</p></div></dd><dt>6. </dt><dd><div id="epm1.TF.4.6"><p class="no_margin">
|
||
<a class="bk_pop" href="#epm1.REF.smith.2000.1046">Smith et al [2000]</a>
|
||
</p></div></dd></dl></div></div></div><div id="epm1.Developmental_Delay__Intellectual_D"><h4>Developmental Delay / Intellectual Disability Management Issues</h4><p>The following information represents typical management recommendations for school-age individuals with developmental delay / intellectual disability in the United States; standard recommendations may vary from country to country.</p><p><b>All ages.</b> Consultation with a developmental pediatrician is recommended to ensure the involvement of appropriate community, state, and educational agencies (US) and to support parents in maximizing quality of life. Some issues to consider:</p><ul><li class="half_rhythm"><div>Individualized education plan (IEP) services:</div><ul><li class="half_rhythm"><div>An IEP provides specially designed instruction and related services to children who qualify.</div></li><li class="half_rhythm"><div>IEP services will be reviewed annually to determine whether any changes are needed.</div></li><li class="half_rhythm"><div>Special education law requires that children participating in an IEP be in the least restrictive environment feasible at school and included in general education as much as possible, when and where appropriate.</div></li><li class="half_rhythm"><div>PT, OT, and speech services will be provided in the IEP to the extent that the need affects the child's access to academic material. Beyond that, private supportive therapies based on the affected individual's needs may be considered. Specific recommendations regarding type of therapy can be made by a developmental pediatrician.</div></li><li class="half_rhythm"><div>As a child enters the teen years, a transition plan should be discussed and incorporated in the IEP. For those receiving IEP services, the public school district is required to provide services until age 21.</div></li></ul></li><li class="half_rhythm"><div>A 504 plan (Section 504: a US federal statute that prohibits discrimination based on disability) can be considered for those who require accommodations or modifications such as front-of-class seating, assistive technology devices, classroom scribes, extra time between classes, modified assignments, and enlarged text.</div></li><li class="half_rhythm"><div>Developmental Disabilities Administration (DDA) enrollment is recommended. DDA is a US public agency that provides services and support to qualified individuals. Eligibility differs by state but is typically determined by diagnosis and/or associated cognitive/adaptive disabilities.</div></li><li class="half_rhythm"><div>Families with limited income and resources may also qualify for supplemental security income (SSI) for their child with a disability.</div></li></ul></div></div><div id="epm1.Surveillance"><h3>Surveillance</h3><div id="epm1.T.recommended_surveillance_for_indi" class="table"><h3><span class="label">Table 5. </span></h3><div class="caption"><p>Recommended Surveillance for Individuals with EPM1</p></div><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK1142/table/epm1.T.recommended_surveillance_for_indi/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__epm1.T.recommended_surveillance_for_indi_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_1" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">System/Concern</th><th id="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_2" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Evaluation</th><th id="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_3" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Frequency</th></tr></thead><tbody><tr><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Myoclonus</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Severity of myoclonus using UMRS</td><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_3" rowspan="2" colspan="1" style="text-align:left;vertical-align:middle;">At least annually</td></tr><tr><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Seizures</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Seizure type & frequency</td></tr><tr><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Cerebellar involvement</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Clinical eval</td><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_3" rowspan="3" colspan="1" style="text-align:left;vertical-align:middle;">Per symptom progression</td></tr><tr><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Dysarthria</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Need for alternative communication method or speech therapy</td></tr><tr><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Dysphagia</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Assess aspiration risk & feeding methods</td></tr><tr><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Weight / Nutritional status</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<ul><li class="half_rhythm"><div>Monitor BMI.</div></li><li class="half_rhythm"><div>Consult a nutritionist</div></li><li class="half_rhythm"><div>High-calorie supplementation</div></li></ul>
|
||
</td><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;"></td></tr><tr><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Activities of daily living</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Clinically to evaluate rehab plan</td><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_3" rowspan="2" colspan="1" style="text-align:left;vertical-align:middle;">At least annually</td></tr><tr><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>School performance</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Interview</td></tr><tr><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Cognitive/Psychiatric</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Evaluate mood, signs of psychosis, & cognitive complaints to identify need for pharmacologic & psychotherapeutic interventions.</td><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Per symptom progression & development of psychiatric symptoms</td></tr><tr><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<b>Family support & resources</b>
|
||
</td><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Interview</td><td headers="hd_h_epm1.T.recommended_surveillance_for_indi_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Annually</td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_margin">BMI = body mass index; UMRS = Unified Myoclonus Rating Scale</p></div></dd></dl></div></div></div></div><div id="epm1.AgentsCircumstances_to_Avoid"><h3>Agents/Circumstances to Avoid</h3><p><b>Phenytoin</b> should be avoided, as it has been found to have aggravating side effects on the associated neurologic symptoms, and may even accelerate cerebellar degeneration [<a class="bk_pop" href="#epm1.REF.eldridge.1983.838">Eldridge et al 1983</a>].</p><p><b>Sodium channel blockers</b> (carbamazepine, oxcarbazepine, phenytoin) and <b>GABAergic drugs</b> (tiagabine, vigabatrin) as well as <b>gabapentin</b> and <b>pregabalin</b> should in general be avoided as they may aggravate myoclonus and myoclonic seizures [<a class="bk_pop" href="#epm1.REF.medina.2005.307">Medina et al 2005</a>].</p></div><div id="epm1.Evaluation_of_Relatives_at_Risk"><h3>Evaluation of Relatives at Risk</h3><p><a href="#epm1.Related_Genetic_Counseling_Issues">Genetic Counseling</a> for issues related to testing of at-risk relatives for <a class="def" href="/books/n/gene/glossary/def-item/genetic-counseling/">genetic counseling</a> purposes.</p></div><div id="epm1.Therapies_Under_Investigation"><h3>Therapies Under Investigation</h3><p>Search <a href="https://clinicaltrials.gov/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">ClinicalTrials.gov</a> in the US and <a href="https://www.clinicaltrialsregister.eu/ctr-search/search" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">EU Clinical Trials Register</a> in Europe for access to information on clinical studies for a wide range of diseases and conditions. Note: There may not be clinical trials for this disorder.</p></div></div><div id="epm1.Genetic_Counseling"><h2 id="_epm1_Genetic_Counseling_">Genetic Counseling</h2><p>
|
||
<i>Genetic counseling is the process of providing individuals and families with
|
||
information on the nature, mode(s) of inheritance, and implications of genetic disorders to help them
|
||
make informed medical and personal decisions. The following section deals with genetic
|
||
risk assessment and the use of family history and genetic testing to clarify genetic
|
||
status for family members; it is not meant to address all personal, cultural, or
|
||
ethical issues that may arise or to substitute for consultation with a genetics
|
||
professional</i>. —ED.</p><div id="epm1.Mode_of_Inheritance"><h3>Mode of Inheritance</h3><p>Progressive myoclonic epilepsy type 1 (EPM1) is inherited in an <a class="def" href="/books/n/gene/glossary/def-item/autosomal-recessive/">autosomal recessive</a> manner.</p></div><div id="epm1.Risk_to_Family_Members"><h3>Risk to Family Members</h3><p>
|
||
<b>Parents of a <a class="def" href="/books/n/gene/glossary/def-item/proband/">proband</a></b>
|
||
</p><ul><li class="half_rhythm"><div>The parents of an affected child are obligate heterozygotes (i.e., presumed to be carriers of one <i>CSTB</i> <a class="def" href="/books/n/gene/glossary/def-item/pathogenic-variant/">pathogenic variant</a> based on family history).</div></li><li class="half_rhythm"><div>Molecular genetic testing is recommended for the parents of a <a class="def" href="/books/n/gene/glossary/def-item/proband/">proband</a> to confirm that each parent is <a class="def" href="/books/n/gene/glossary/def-item/heterozygous/">heterozygous</a> for a <i>CSTB</i> <a class="def" href="/books/n/gene/glossary/def-item/pathogenic-variant/">pathogenic variant</a> and allow reliable <a class="def" href="/books/n/gene/glossary/def-item/recurrence-risk/">recurrence risk</a> assessment. (<i>De novo</i> variants are known to occur at a low but appreciable rate in <a class="def" href="/books/n/gene/glossary/def-item/autosomal-recessive/">autosomal recessive</a> disorders [<a class="bk_pop" href="#epm1.REF.j_nsson.2017.519">Jónsson et al 2017</a>].)</div></li><li class="half_rhythm"><div>Heterozygotes (carriers) are asymptomatic and are not at risk of developing the disorder.</div></li></ul><p>
|
||
<b>Sibs of a <a class="def" href="/books/n/gene/glossary/def-item/proband/">proband</a></b>
|
||
</p><ul><li class="half_rhythm"><div>If each parent is known to be <a class="def" href="/books/n/gene/glossary/def-item/heterozygous/">heterozygous</a> for a <i>CSTB</i> <a class="def" href="/books/n/gene/glossary/def-item/pathogenic-variant/">pathogenic variant</a>, each sib of an affected individual has at conception a 25% chance of being affected, a 50% chance of being an asymptomatic <a class="def" href="/books/n/gene/glossary/def-item/carrier/">carrier</a>, and a 25% chance of being unaffected and not a carrier.</div></li><li class="half_rhythm"><div>A sib who inherits <a class="def" href="/books/n/gene/glossary/def-item/biallelic/">biallelic</a> <i>CSTB</i> pathogenic variants is likely to have clinical manifestations similar to those of the <a class="def" href="/books/n/gene/glossary/def-item/proband/">proband</a>; however, intrafamilial clinical variability may be observed (particularly if affected family members have <a class="def" href="/books/n/gene/glossary/def-item/compound-heterozygous/">compound heterozygous</a> <i>CSTB</i> pathogenic variants; see <a href="#epm1.GenotypePhenotype_Correlations">Genotype-Phenotype Correlations</a>).</div></li><li class="half_rhythm"><div>Heterozygotes (carriers) are asymptomatic and are not at risk of developing the disorder.</div></li></ul><p>
|
||
<b>Offspring of a <a class="def" href="/books/n/gene/glossary/def-item/proband/">proband</a></b>
|
||
</p><ul><li class="half_rhythm"><div>Unless an individual's reproductive partner has EPM1 or is a <a class="def" href="/books/n/gene/glossary/def-item/carrier/">carrier</a>, offspring will be obligate heterozygotes (carriers) for a <a class="def" href="/books/n/gene/glossary/def-item/pathogenic-variant/">pathogenic variant</a> in <i>CSTB</i>.</div></li><li class="half_rhythm"><div>Because of the low <a class="def" href="/books/n/gene/glossary/def-item/carrier-rate/">carrier rate</a> in the general population, the risk that an affected individual would have children with a carrier is extremely low except in certain populations (see <a href="#epm1.Prevalence">Prevalence</a>).</div></li></ul><p><b>Other family members.</b> Each sib of the <a class="def" href="/books/n/gene/glossary/def-item/proband/">proband</a>'s parents is at a 50% risk of being a <a class="def" href="/books/n/gene/glossary/def-item/carrier/">carrier</a> of a <i>CSTB</i> <a class="def" href="/books/n/gene/glossary/def-item/pathogenic-variant/">pathogenic variant</a>.</p></div><div id="epm1.Carrier_Detection"><h3>Carrier Detection</h3><p>Carrier testing for at-risk relatives requires prior identification of the <i>CSTB</i> pathogenic variants in the family.</p><p>Carrier testing for the reproductive partners of a known <a class="def" href="/books/n/gene/glossary/def-item/carrier/">carrier</a> is possible. Primarily, targeted testing for the dodecamer repeat expansion should be done, and if it remains negative, sequencing of <i>CSTB</i> should be considered.</p></div><div id="epm1.Related_Genetic_Counseling_Issues"><h3>Related Genetic Counseling Issues</h3><p>
|
||
<b>Family planning</b>
|
||
</p><ul><li class="half_rhythm"><div>The optimal time for determination of genetic risk, clarification of <a class="def" href="/books/n/gene/glossary/def-item/carrier/">carrier</a> status, and discussion of the availability of prenatal/<a class="def" href="/books/n/gene/glossary/def-item/preimplantation-genetic-testing/">preimplantation genetic testing</a> is before pregnancy.</div></li><li class="half_rhythm"><div>It is appropriate to offer <a class="def" href="/books/n/gene/glossary/def-item/genetic-counseling/">genetic counseling</a> (including discussion of potential risks to offspring and reproductive options) to young adults who are affected, are carriers, or are at risk of being carriers.</div></li></ul></div><div id="epm1.Prenatal_Testing_and_Preimplantatio"><h3>Prenatal Testing and Preimplantation Genetic Testing</h3><p>Once both <i>CSTB</i> pathogenic variants have been identified in an affected family member, <a class="def" href="/books/n/gene/glossary/def-item/prenatal-testing/">prenatal testing</a> for a pregnancy at increased risk and <a class="def" href="/books/n/gene/glossary/def-item/preimplantation-genetic-testing/">preimplantation genetic testing</a> for EPM1 are possible.</p><p>Differences in perspective may exist among medical professionals and within families regarding the use of <a class="def" href="/books/n/gene/glossary/def-item/prenatal-testing/">prenatal testing</a>. While most centers would consider use of prenatal testing to be a personal decision, discussion of these issues may be helpful.</p></div></div><div id="epm1.Resources"><h2 id="_epm1_Resources_">Resources</h2><p>
|
||
<i>GeneReviews staff has selected the following disease-specific and/or umbrella
|
||
support organizations and/or registries for the benefit of individuals with this disorder
|
||
and their families. GeneReviews is not responsible for the information provided by other
|
||
organizations. For information on selection criteria, click <a href="/books/n/gene/app4/">here</a>.</i></p>
|
||
<ul><li class="half_rhythm"><div>
|
||
<b>National Library of Medicine Genetics Home Reference</b>
|
||
</div><div>
|
||
<a href="http://ghr.nlm.nih.gov/condition/unverricht-lundborg-disease" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Unverricht-Lundborg disease</a>
|
||
</div></li><li class="half_rhythm"><div>
|
||
<b>American Epilepsy Society</b>
|
||
</div><div>
|
||
<a href="https://www.aesnet.org" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">aesnet.org</a>
|
||
</div></li><li class="half_rhythm"><div>
|
||
<b>EpiCARE: a European Reference Network for rare and complex epilepsies</b>
|
||
</div><div>
|
||
<a href="https://epi-care.eu/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">www.epi-care.eu</a>
|
||
</div></li><li class="half_rhythm"><div>
|
||
<b>Epilepsy Foundation</b>
|
||
</div><div><b>Phone:</b> 800-332-1000; 866-748-8008</div><div>
|
||
<a href="https://www.epilepsy.com/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">epilepsy.com</a>
|
||
</div></li></ul>
|
||
</div><div id="epm1.Molecular_Genetics"><h2 id="_epm1_Molecular_Genetics_">Molecular Genetics</h2><p><i>Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —</i>ED.</p><div id="epm1.molgen.TA" class="table"><h3><span class="label">Table A.</span></h3><div class="caption"><p>Progressive Myoclonic Epilepsy Type 1: Genes and Databases</p></div><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK1142/table/epm1.molgen.TA/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__epm1.molgen.TA_lrgtbl__"><table class="no_bottom_margin"><tbody><tr><th id="hd_b_epm1.molgen.TA_1_1_1_1" rowspan="1" colspan="1" style="vertical-align:top;">Gene</th><th id="hd_b_epm1.molgen.TA_1_1_1_2" rowspan="1" colspan="1" style="vertical-align:top;">Chromosome Locus</th><th id="hd_b_epm1.molgen.TA_1_1_1_3" rowspan="1" colspan="1" style="vertical-align:top;">Protein</th><th id="hd_b_epm1.molgen.TA_1_1_1_4" rowspan="1" colspan="1" style="vertical-align:top;">Locus-Specific Databases</th><th id="hd_b_epm1.molgen.TA_1_1_1_5" rowspan="1" colspan="1" style="vertical-align:top;">HGMD</th><th id="hd_b_epm1.molgen.TA_1_1_1_6" rowspan="1" colspan="1" style="vertical-align:top;">ClinVar</th></tr><tr><td headers="hd_b_epm1.molgen.TA_1_1_1_1" rowspan="1" colspan="1" style="vertical-align:top;">
|
||
<a href="/gene/1476" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=gene">
|
||
<i>CSTB</i>
|
||
</a>
|
||
</td><td headers="hd_b_epm1.molgen.TA_1_1_1_2" rowspan="1" colspan="1" style="vertical-align:top;">
|
||
<a href="https://www.ncbi.nlm.nih.gov/genome/gdv/?context=gene&acc=1476" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">21q22<wbr style="display:inline-block"></wbr>.3</a>
|
||
</td><td headers="hd_b_epm1.molgen.TA_1_1_1_3" rowspan="1" colspan="1" style="vertical-align:top;">
|
||
<a href="http://www.uniprot.org/uniprot/P04080" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Cystatin-B</a>
|
||
</td><td headers="hd_b_epm1.molgen.TA_1_1_1_4" rowspan="1" colspan="1" style="vertical-align:top;">
|
||
<a href="http://databases.lovd.nl/shared/genes/CSTB" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">CSTB database</a>
|
||
</td><td headers="hd_b_epm1.molgen.TA_1_1_1_5" rowspan="1" colspan="1" style="vertical-align:top;">
|
||
<a href="http://www.hgmd.cf.ac.uk/ac/gene.php?gene=CSTB" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">CSTB</a>
|
||
</td><td headers="hd_b_epm1.molgen.TA_1_1_1_6" rowspan="1" colspan="1" style="vertical-align:top;">
|
||
<a href="https://www.ncbi.nlm.nih.gov/clinvar/?term=CSTB[gene]" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">CSTB</a>
|
||
</td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt></dt><dd><div id="epm1.TFA.1"><p class="no_margin">Data are compiled from the following standard references: <a class="def" href="/books/n/gene/glossary/def-item/gene/">gene</a> from
|
||
<a href="http://www.genenames.org/index.html" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">HGNC</a>;
|
||
<a class="def" href="/books/n/gene/glossary/def-item/chromosome/">chromosome</a> <a class="def" href="/books/n/gene/glossary/def-item/locus/">locus</a> from
|
||
<a href="http://www.omim.org/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">OMIM</a>;
|
||
protein from <a href="http://www.uniprot.org/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">UniProt</a>.
|
||
For a description of databases (Locus Specific, HGMD, ClinVar) to which links are provided, click
|
||
<a href="/books/n/gene/app1/">here</a>.</p></div></dd></dl></div></div></div><div id="epm1.molgen.TB" class="table"><h3><span class="label">Table B.</span></h3><div class="caption"><p>OMIM Entries for Progressive Myoclonic Epilepsy Type 1 (<a href="/omim/254800,601145" ref="pagearea=body&targetsite=entrez&targetcat=term&targettype=omim">View All in OMIM</a>) </p></div><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK1142/table/epm1.molgen.TB/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__epm1.molgen.TB_lrgtbl__"><table><tbody><tr><td rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
||
<a href="/omim/254800" ref="pagearea=body&targetsite=entrez&targetcat=term&targettype=omim">254800</a></td><td rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">MYOCLONIC EPILEPSY OF UNVERRICHT AND LUNDBORG</td></tr><tr><td rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
||
<a href="/omim/601145" ref="pagearea=body&targetsite=entrez&targetcat=term&targettype=omim">601145</a></td><td rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">CYSTATIN B; CSTB</td></tr></tbody></table></div></div><div id="epm1.Molecular_Pathogenesis"><h3>Molecular Pathogenesis</h3><p><i>CSTB</i> encodes cystatin B, an inhibitor of several papain-family cysteine proteases, cathepsins. Cystatin B interacts with histones and cathepsin L in the nucleus where it could regulate cathepsin L activity [<a class="bk_pop" href="#epm1.REF._eru.2010.10078">Čeru et al 2010</a>].</p><p><i>Cstb</i>-deficient knockout mice display a <a class="def" href="/books/n/gene/glossary/def-item/phenotype/">phenotype</a> similar to the human disease with progressive ataxia and myoclonic seizures [<a class="bk_pop" href="#epm1.REF.pennacchio.1998.251">Pennacchio et al 1998</a>]. The mice show early microglial activation and inflammation, preceding clinical onset of myoclonus [<a class="bk_pop" href="#epm1.REF.tegelberg.2012.40">Tegelberg et al 2012</a>, <a class="bk_pop" href="#epm1.REF.okuneva.2015.400">Okuneva et al 2015</a>, <a class="bk_pop" href="#epm1.REF.okuneva.2016.298">Okuneva et al 2016</a>]. In addition, altered GABAergic signaling with subsequent loss of GABA inhibition have been reported in <i>Cstb</i>-deficient knockout mice, suggesting a mechanism for latent hyperexcitability resulting in myoclonus and seizures [<a class="bk_pop" href="#epm1.REF.franceschetti.2007.675">Franceschetti et al 2007</a>, <a class="bk_pop" href="#epm1.REF.buzzi.2012.216">Buzzi et al 2012</a>, <a class="bk_pop" href="#epm1.REF.joensuu.2014.e89321">Joensuu et al 2014</a>].</p><p>Impaired redox homeostasis has been reported as a pathophysiologic mechanism in <i>Cstb</i>-deficient knockout mice with cystatin-B-cathepsin B signaling dysregulation being a critical mechanism coupling oxidative stress to neuronal degeneration and death [<a class="bk_pop" href="#epm1.REF.lehtinen.2009.5910">Lehtinen et al 2009</a>].</p><p><b>Mechanism of disease causation.</b> Loss of function. Dodecamer repeat expansion results in a significantly reduced amount of <i>CSTB</i> <a class="def" href="/books/n/gene/glossary/def-item/mrna/">mRNA</a>: 5%-10% of the expression found in controls [<a class="bk_pop" href="#epm1.REF.joensuu.2007.185">Joensuu et al 2007</a>]. Other disease-associated variants also result in loss of cystatin-B function and some are associated with total lack of intracellular cystatin B [<a class="bk_pop" href="#epm1.REF.joensuu.2007.185">Joensuu et al 2007</a>, <a class="bk_pop" href="#epm1.REF.joensuu.2008.557">Joensuu et al 2008</a>].</p><div id="epm1.T.cstb_technical_considerations" class="table"><h3><span class="label">Table 6. </span></h3><div class="caption"><p><i>CSTB</i> Technical Considerations</p></div><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK1142/table/epm1.T.cstb_technical_considerations/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__epm1.T.cstb_technical_considerations_lrgtbl__"><table><thead><tr><th id="hd_h_epm1.T.cstb_technical_considerations_1_1_1_1" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Technical Issue</th><th id="hd_h_epm1.T.cstb_technical_considerations_1_1_1_2" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Comment [Reference]</th></tr></thead><tbody><tr><td headers="hd_h_epm1.T.cstb_technical_considerations_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Sequence of repeat</td><td headers="hd_h_epm1.T.cstb_technical_considerations_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">CCC-CGC-CCC-GCG</td></tr><tr><td headers="hd_h_epm1.T.cstb_technical_considerations_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Methods to detect expanded <a class="def" href="/books/n/gene/glossary/def-item/allele/">allele</a> (See <a href="/books/NBK1142/table/epm1.T.methods_to_characterize_cstb_cccc/?report=objectonly" target="object" rid-ob="figobepm1Tmethodstocharacterizecstbcccc">Table 7</a>.)</td><td headers="hd_h_epm1.T.cstb_technical_considerations_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Southern blotting [<a class="bk_pop" href="#epm1.REF.lalioti.1997.847">Lalioti et al 1997</a>] & <a class="def" href="/books/n/gene/glossary/def-item/pcr/">PCR</a> for expanded repeat analysis [<a class="bk_pop" href="#epm1.REF.joensuu.2007.185">Joensuu et al 2007</a>] have been described.</td></tr><tr><td headers="hd_h_epm1.T.cstb_technical_considerations_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Somatic instability</td><td headers="hd_h_epm1.T.cstb_technical_considerations_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">There is no evidence for substantial somatic instability of the expanded repeat.</td></tr><tr><td headers="hd_h_epm1.T.cstb_technical_considerations_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Germline instability</td><td headers="hd_h_epm1.T.cstb_technical_considerations_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Expanded repeats show some instability in <a class="def" href="/books/n/gene/glossary/def-item/germline/">germline</a> transmissions, w/both contractions & expansions implied. No tendency for expansion in successive generations has been reported.</td></tr></tbody></table></div></div><p><b>Methods to characterize <i>CSTB</i></b>
|
||
<b>CCC-CGC-CCC-GCG repeats.</b> Due to the technical challenges of detecting and sizing <i>CSTB</i> CCC-CGC-CCC-GCG repeat expansions, multiple methods may be needed to rule out or detect CCC-CGC-CCC-GCG repeat expansion (see <a href="/books/NBK1142/table/epm1.T.methods_to_characterize_cstb_cccc/?report=objectonly" target="object" rid-ob="figobepm1Tmethodstocharacterizecstbcccc">Table 7</a>). Repeats in the normal range (2-3) are detected by traditional <a class="def" href="/books/n/gene/glossary/def-item/pcr/">PCR</a>. However, detection of apparent homozygosity for a normal repeat by traditional PCR does not rule out the presence of an expanded repeat, thus, testing by a specific PCR method for expansion detection or Southern blotting is required.</p><div id="epm1.T.methods_to_characterize_cstb_cccc" class="table"><h3><span class="label">Table 7. </span></h3><div class="caption"><p>Methods to Characterize <i>CSTB</i> CCC-CGC-CCC-GCG Repeats</p></div><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK1142/table/epm1.T.methods_to_characterize_cstb_cccc/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__epm1.T.methods_to_characterize_cstb_cccc_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_epm1.T.methods_to_characterize_cstb_cccc_1_1_1_1" rowspan="2" scope="col" colspan="1" headers="hd_h_epm1.T.methods_to_characterize_cstb_cccc_1_1_1_1" style="text-align:left;vertical-align:middle;">Interpretation of CCC-CGC-CCC-GCG Repeat Number</th><th id="hd_h_epm1.T.methods_to_characterize_cstb_cccc_1_1_1_2" colspan="2" scope="colgroup" rowspan="1" style="text-align:left;vertical-align:middle;">Expected Results by Method</th></tr><tr><th headers="hd_h_epm1.T.methods_to_characterize_cstb_cccc_1_1_1_2" id="hd_h_epm1.T.methods_to_characterize_cstb_cccc_1_1_2_1" colspan="1" scope="colgroup" rowspan="1" style="text-align:left;vertical-align:middle;">Conventional <a class="def" href="/books/n/gene/glossary/def-item/pcr/">PCR</a></th><th headers="hd_h_epm1.T.methods_to_characterize_cstb_cccc_1_1_1_2" id="hd_h_epm1.T.methods_to_characterize_cstb_cccc_1_1_2_2" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Expanded repeat analysis <sup>1</sup></th></tr></thead><tbody><tr><td headers="hd_h_epm1.T.methods_to_characterize_cstb_cccc_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Normal: 2-3</td><td headers="hd_h_epm1.T.methods_to_characterize_cstb_cccc_1_1_1_2 hd_h_epm1.T.methods_to_characterize_cstb_cccc_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Detected <sup>2</sup></td><td headers="hd_h_epm1.T.methods_to_characterize_cstb_cccc_1_1_1_2 hd_h_epm1.T.methods_to_characterize_cstb_cccc_1_1_2_2" rowspan="2" colspan="1" style="text-align:left;vertical-align:middle;">Expansions can be detected, & repeat size can be approximated <sup>3, 4</sup></td></tr><tr><td headers="hd_h_epm1.T.methods_to_characterize_cstb_cccc_1_1_1_1" scope="row" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Pathogenic (full <a class="def" href="/books/n/gene/glossary/def-item/penetrance/">penetrance</a>): ≥30</td><td headers="hd_h_epm1.T.methods_to_characterize_cstb_cccc_1_1_1_2 hd_h_epm1.T.methods_to_characterize_cstb_cccc_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Not detected</td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt>1. </dt><dd><div id="epm1.TF.7.1"><p class="no_margin">Methods to detect and approximate the size of expanded repeats include long-range <a class="def" href="/books/n/gene/glossary/def-item/pcr/">PCR</a> sized by gel or capillary electrophoresis and Southern blotting. The upper limit of repeat size detected will vary by assay design, laboratory, sample, and/ or patient due to competition by the normal <a class="def" href="/books/n/gene/glossary/def-item/allele/">allele</a> during amplification.</p></div></dd><dt>2. </dt><dd><div id="epm1.TF.7.2"><p class="no_margin">Detection of an apparently <a class="def" href="/books/n/gene/glossary/def-item/homozygous/">homozygous</a> repeat does not rule out the presence of an expanded repeat; thus, testing by expanded repeat analysis is required to detect a repeat expansion.</p></div></dd><dt>3. </dt><dd><div id="epm1.TF.7.3"><p class="no_margin">Southern blotting [<a class="bk_pop" href="#epm1.REF.lalioti.1997.847">Lalioti et al 1997</a>] and a specific <a class="def" href="/books/n/gene/glossary/def-item/pcr/">PCR</a> protocol [<a class="bk_pop" href="#epm1.REF.joensuu.2007.185">Joensuu et al 2007</a>] for the CCC-CGC-CCC-GCG repeat expansion have been described</p></div></dd><dt>4. </dt><dd><div id="epm1.TF.7.4"><p class="no_margin">Precise sizing of repeats is not necessary as clinical utility for determining the exact repeat number has not been demonstrated.</p></div></dd></dl></div></div></div><div id="epm1.T.notable_cstb_pathogenic_variants" class="table"><h3><span class="label">Table 8. </span></h3><div class="caption"><p>Notable <i>CSTB</i> Pathogenic Variants</p></div><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK1142/table/epm1.T.notable_cstb_pathogenic_variants/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__epm1.T.notable_cstb_pathogenic_variants_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_epm1.T.notable_cstb_pathogenic_variants_1_1_1_1" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Reference Sequences</th><th id="hd_h_epm1.T.notable_cstb_pathogenic_variants_1_1_1_2" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">DNA Nucleotide Change</th><th id="hd_h_epm1.T.notable_cstb_pathogenic_variants_1_1_1_3" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Predicted Protein Change</th><th id="hd_h_epm1.T.notable_cstb_pathogenic_variants_1_1_1_4" scope="col" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Repeat Range</th></tr></thead><tbody><tr><td headers="hd_h_epm1.T.notable_cstb_pathogenic_variants_1_1_1_1" rowspan="3" scope="row" colspan="1" style="text-align:left;vertical-align:middle;">
|
||
<a href="https://www.ncbi.nlm.nih.gov/nuccore/NM_000100.4" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NM_000100<wbr style="display:inline-block"></wbr>.4</a>
|
||
</td><td headers="hd_h_epm1.T.notable_cstb_pathogenic_variants_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">c.-179_-190CCCCGCCCCGCG[2_3]</td><td headers="hd_h_epm1.T.notable_cstb_pathogenic_variants_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">--</td><td headers="hd_h_epm1.T.notable_cstb_pathogenic_variants_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Normal variants</td></tr><tr><td headers="hd_h_epm1.T.notable_cstb_pathogenic_variants_1_1_1_2" colspan="1" scope="row" rowspan="1" style="text-align:left;vertical-align:top;">c.-179_-190CCCCGCCCCGCG[12_17]</td><td headers="hd_h_epm1.T.notable_cstb_pathogenic_variants_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">--</td><td headers="hd_h_epm1.T.notable_cstb_pathogenic_variants_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Uncertain significance</td></tr><tr><td headers="hd_h_epm1.T.notable_cstb_pathogenic_variants_1_1_1_2" colspan="1" scope="row" rowspan="1" style="text-align:left;vertical-align:top;">c.-179_-190CCCCGCCCCGCG[30_?]</td><td headers="hd_h_epm1.T.notable_cstb_pathogenic_variants_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">--</td><td headers="hd_h_epm1.T.notable_cstb_pathogenic_variants_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Full-<a class="def" href="/books/n/gene/glossary/def-item/penetrance/">penetrance</a></td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_margin">Variants listed in the table have been provided by the authors. <i>GeneReviews</i> staff have not independently verified the classification of variants.</p></div></dd><dt></dt><dd><div><p class="no_margin"><i>GeneReviews</i> follows the standard naming conventions of the Human Genome Variation Society (<a href="https://varnomen.hgvs.org/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">varnomen<wbr style="display:inline-block"></wbr>.hgvs.org</a>). See <a href="/books/n/gene/app3/">Quick Reference</a> for an explanation of nomenclature.</p></div></dd></dl></div></div></div></div></div><div id="epm1.Chapter_Notes"><h2 id="_epm1_Chapter_Notes_">Chapter Notes</h2><div id="epm1.Author_History"><h3>Author History</h3><p>Reetta Kälviäinen, MD, PhD (2007-present) <br />Marja-Leena Koskiniemi, MD, PhD; University of Helsinki (2004-2007) <br />Anna-Elina Lehesjoki, MD, PhD (2004-present)</p></div><div id="epm1.Revision_History"><h3>Revision History</h3><ul><li class="half_rhythm"><div>2 July 2020 (bp) Comprehensive update posted live</div></li><li class="half_rhythm"><div>26 November 2014 (me) Comprehensive update posted live</div></li><li class="half_rhythm"><div>18 June 2009 (me) Comprehensive update posted live</div></li><li class="half_rhythm"><div>18 September 2007 (cd) Revision: <a class="def" href="/books/n/gene/glossary/def-item/sequence-analysis/">sequence analysis</a> available on a clinical basis</div></li><li class="half_rhythm"><div>12 February 2007 (me) Comprehensive update posted live</div></li><li class="half_rhythm"><div>24 June 2004 (me) Review posted live</div></li><li class="half_rhythm"><div>6 February 2004 (ael) Original submission</div></li></ul></div></div><div id="epm1.References"><h2 id="_epm1_References_">References</h2><div id="epm1.Literature_Cited"><h3>Literature Cited</h3><ul class="simple-list"><li class="half_rhythm"><div class="bk_ref" id="epm1.REF.assenza.2017.e31">Assenza G, Benvenga A, Gennaro E, Tombini M, Campana C, Assenza F, Di Pino G, Di Lazzaro V. 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Brain inflammation is accompanied by peripheral inflammation in Cstb-/- mice, a model for progressive myoclonus epilepsy. <span><span class="ref-journal">J Neuroinflammation. </span>2016;<span class="ref-vol">13</span>:298.</span> [<a href="/pmc/articles/PMC5127053/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5127053</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/27894304" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27894304</span></a>]</div></li><li class="half_rhythm"><div class="bk_ref" id="epm1.REF.pennacchio.1998.251">Pennacchio LA, Bouley DM, Higgins KM, Scott MP, Noebels JL, Myers RM. Progressive ataxia, myoclonic epilepsy and cerebellar apoptosis in cystatin B-deficient mice. <span><span class="ref-journal">Nat Genet. </span>1998;<span class="ref-vol">20</span>:251–8.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/9806543" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 9806543</span></a>]</div></li><li class="half_rhythm"><div class="bk_ref" id="epm1.REF.shahwan.2005.239">Shahwan A, Farrell M, Delanty N. Progressive myoclonic epilepsies: a review of genetic and therapeutic aspects. <span><span class="ref-journal">Lancet Neurol. </span>2005;<span class="ref-vol">4</span>:239–48.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/15778103" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15778103</span></a>]</div></li><li class="half_rhythm"><div class="bk_ref" id="epm1.REF.smith.2000.1046">Smith B, Shatz R, Elisevich K, Bespalova IN, Burmeister M. Effects of vagus nerve stimulation on progressive myoclonus epilepsy of Unverricht-Lundborg type. <span><span class="ref-journal">Epilepsia. </span>2000;<span class="ref-vol">41</span>:1046–8.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/10961635" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 10961635</span></a>]</div></li><li class="half_rhythm"><div class="bk_ref" id="epm1.REF.tegelberg.2012.40">Tegelberg S, Kopra O, Joensuu T, Cooper JD, Lehesjoki AE. Early microglial activation precedes neuronal loss in the brain of the Cstb-/- mouse model of progressive myoclonus epilepsy, EPM1. <span><span class="ref-journal">J Neuropathol Exp Neurol. </span>2012;<span class="ref-vol">71</span>:40–53.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/22157618" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22157618</span></a>]</div></li></ul></div></div><div id="bk_toc_contnr"></div></div></div>
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