PMC9642335_01
Imaging examination of patient 1. Head magnetic resonance imaging (MRI) in November 2019 showed high-signal intensity in the left temporal, parietal, and occipital lobes on T2-weighted imaging, diffusion-weighted imaging (DWI), and T2 fluid-attenuated inversion recovery (FLAIR) sequences [(A1-A5), (B1-B5), and (C1-C5); red arrows]. MRI in December 2019 showed high-signal intensity in the left temporal, parietal, and occipital lobes on T2-weighted imaging, magnetic resonance spectroscopy, and T2 FLAIR sequences [(A6-A10), (B6), and (C6-C10); red arrows]. Head MRI in August 2020 revealed that the high-intensity signal on the left temporal, parietal, and occipital lobes on T2-weighted imaging, DWI, and T2 FLAIR sequences had disappeared [(D1-D5), (E1-E5), and (F1-F5)]. Head MRI in December 2021 showed bilateral and relatively symmetrical ribbon signs with high-intensity signals along the corticomedullary junction of the frontotemporal-parietal lobes on DWI [(D6-D10), (E6-E10), and (F6-F10); red arrows].
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F1
Her old sister (patient 2, II-1) had symptoms that included recurrent headache with blurred vision and progressive contralateral limb numbness and weakness (Supplementary Figure 1). T1 and T2 signal shadows. T2 FLAIR showed a slightly elevated signal, while diffusion was limited on the DWI sequence (Figures 1D6-D10,E6-E10,F6-F10).
Imaging examination of patient 2. Head magnetic resonance imaging (MRI) in November 2019 showed bilateral and relatively symmetrical ribbon signs with high-intensity signals along the corticomedullary junction of the frontotemporal-parietal lobes and corpus callosum on T2-weighted imaging, diffusion-weighted imaging (DWI), and T2 fluid-attenuated inversion recovery (FLAIR) sequence [(A1-A5), (B1-B5), and (C1-C5); red arrows]. Head MRI in August 2020 [(D1-D5), (E1-E5), and (F1-F5); red arrows] and December 2021 [(G1-G5), (H1-H5), and (I1-I5); red arrows] showed the same high signal along the corticomedullary junction of the frontotemporal-parietal lobes and corpus callosum on T2-weighted imaging, DWI, and T2 FLAIR sequences as were observed in November 2019.
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F2
MRI on 5 December 2019, which showed extensive and slightly elongated T1 shadows, as well as a slightly elongated T2 signal shadow, bilaterally in the frontal, temporal, parietal, and occipital cortices and corpus callosum. Moreover, T2 FLAIR and DWI signals were high (Figures 2A1-A5,B1-B5,C1-C5). T1 and slightly elongated T2 signals in the corticomedullary junction and corpus callosum of both cerebral hemispheres. T2 FLAIR showed a high signal, and the apparent diffusion coefficient slightly decreased; no enhancement was observed in the lesions (Figures 2D1-D5,E1-E5,F1-F5). T1 and T2 signal shadows. T2 FLAIR showed a slightly elevated signal, while diffusion was limited on the DWI sequence (Figures 1D6-D10,E6-E10,F6-F10). Brain MRI in December 2021 revealed minimal change from August 2020 (Figures 2G1-G5,H1-H5,I1-I5).
Pathological examination. (A) Hematoxylin and eosin staining shows eosinophilic inclusion bodies in some skin fibroblasts (100x, yellow arrow). (B) Anti-ubiquitin immunohistochemical staining. Inclusion bodies are visible in the nuclei of some skin sweat gland cells (100x, green arrow). (C) Anti-P62 immunohistochemical staining. Inclusion bodies are observed in the nuclei of some sweat gland cells (100x, yellow arrow). (D) Anti-SUMO1 immunohistochemical staining. Inclusion bodies are visible in the nuclei of some sweat gland cells (100x, yellow arrow). (E,F) Electron microscopy revealed a circular inclusion body structure in the nucleus of a sweat gland cell (15,000x and 30,000x, respectively; red arrows).
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PMC9642335_02_fneur-13-1013213-g0003.jpg
F3
MRI on 5 December 2019, which showed extensive and slightly elongated T1 shadows, as well as a slightly elongated T2 signal shadow, bilaterally in the frontal, temporal, parietal, and occipital cortices and corpus callosum. Moreover, T2 FLAIR and DWI signals were high (Figures 2A1-A5,B1-B5,C1-C5). T1 and slightly elongated T2 signals in the corticomedullary junction and corpus callosum of both cerebral hemispheres. T2 FLAIR showed a high signal, and the apparent diffusion coefficient slightly decreased; no enhancement was observed in the lesions (Figures 2D1-D5,E1-E5,F1-F5). Light and electron microscopy showed eosinophilic, ubiquitin-positive, p62-positive, and SUMO-1-positive intranuclear inclusions in the adipocytes, fibroblasts, and sweat gland cells in both patients (Figures 3A-F). T1 and T2 signal shadows. T2 FLAIR showed a slightly elevated signal, while diffusion was limited on the DWI sequence (Figures 1D6-D10,E6-E10,F6-F10). Brain MRI in December 2021 revealed minimal change from August 2020 (Figures 2G1-G5,H1-H5,I1-I5).
Identification of alleles with GGC repeat expansions in the two sisters. Repeat-primed PCR and fluorescence amplicon length analysis of both patients showed GGC repeat expansions. The number of repeats was determined by comparing the length of the highest signal peak of the expanded allele (arrows) to that of the human reference gene sequence as previously described. The formula to determine repeat size was (["length of the highest signal peak of the expanded allele" bp - 185 bp] / 3 bp + 13). The assumed length of the PCR product was 185 bp in accordance with the standardized GRCh38.p13 human genome, containing the reference (GGC)9(GGA)2(GGC)2 sequence (n = 13).
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F4
MRI on 5 December 2019, which showed extensive and slightly elongated T1 shadows, as well as a slightly elongated T2 signal shadow, bilaterally in the frontal, temporal, parietal, and occipital cortices and corpus callosum. Moreover, T2 FLAIR and DWI signals were high (Figures 2A1-A5,B1-B5,C1-C5). T1 and slightly elongated T2 signals in the corticomedullary junction and corpus callosum of both cerebral hemispheres. T2 FLAIR showed a high signal, and the apparent diffusion coefficient slightly decreased; no enhancement was observed in the lesions (Figures 2D1-D5,E1-E5,F1-F5). Both sisters were also tested for the NOTCH2NLC pathogenic gene of NIID; patients 1 and 2 had 70 and 66 GGC repeats, respectively (Figure 4), suggesting NIID. T1 and T2 signal shadows. T2 FLAIR showed a slightly elevated signal, while diffusion was limited on the DWI sequence (Figures 1D6-D10,E6-E10,F6-F10). Brain MRI in December 2021 revealed minimal change from August 2020 (Figures 2G1-G5,H1-H5,I1-I5).
PMC9642335_02
Imaging examination of patient 1. Head magnetic resonance imaging (MRI) in November 2019 showed high-signal intensity in the left temporal, parietal, and occipital lobes on T2-weighted imaging, diffusion-weighted imaging (DWI), and T2 fluid-attenuated inversion recovery (FLAIR) sequences [(A1-A5), (B1-B5), and (C1-C5); red arrows]. MRI in December 2019 showed high-signal intensity in the left temporal, parietal, and occipital lobes on T2-weighted imaging, magnetic resonance spectroscopy, and T2 FLAIR sequences [(A6-A10), (B6), and (C6-C10); red arrows]. Head MRI in August 2020 revealed that the high-intensity signal on the left temporal, parietal, and occipital lobes on T2-weighted imaging, DWI, and T2 FLAIR sequences had disappeared [(D1-D5), (E1-E5), and (F1-F5)]. Head MRI in December 2021 showed bilateral and relatively symmetrical ribbon signs with high-intensity signals along the corticomedullary junction of the frontotemporal-parietal lobes on DWI [(D6-D10), (E6-E10), and (F6-F10); red arrows].
fneur-13-1013213-g0001.jpg
PMC9642335_02_fneur-13-1013213-g0001.jpg
F1
Her old sister (patient 2, II-1) had symptoms that included recurrent headache with blurred vision and progressive contralateral limb numbness and weakness (Supplementary Figure 1). T1 and T2 signal shadows. T2 FLAIR showed a slightly elevated signal, while diffusion was limited on the DWI sequence (Figures 1D6-D10,E6-E10,F6-F10).
Imaging examination of patient 2. Head magnetic resonance imaging (MRI) in November 2019 showed bilateral and relatively symmetrical ribbon signs with high-intensity signals along the corticomedullary junction of the frontotemporal-parietal lobes and corpus callosum on T2-weighted imaging, diffusion-weighted imaging (DWI), and T2 fluid-attenuated inversion recovery (FLAIR) sequence [(A1-A5), (B1-B5), and (C1-C5); red arrows]. Head MRI in August 2020 [(D1-D5), (E1-E5), and (F1-F5); red arrows] and December 2021 [(G1-G5), (H1-H5), and (I1-I5); red arrows] showed the same high signal along the corticomedullary junction of the frontotemporal-parietal lobes and corpus callosum on T2-weighted imaging, DWI, and T2 FLAIR sequences as were observed in November 2019.
fneur-13-1013213-g0002.jpg
PMC9642335_02_fneur-13-1013213-g0002.jpg
F2
MRI on 5 December 2019, which showed extensive and slightly elongated T1 shadows, as well as a slightly elongated T2 signal shadow, bilaterally in the frontal, temporal, parietal, and occipital cortices and corpus callosum. Moreover, T2 FLAIR and DWI signals were high (Figures 2A1-A5,B1-B5,C1-C5). T1 and slightly elongated T2 signals in the corticomedullary junction and corpus callosum of both cerebral hemispheres. T2 FLAIR showed a high signal, and the apparent diffusion coefficient slightly decreased; no enhancement was observed in the lesions (Figures 2D1-D5,E1-E5,F1-F5). T1 and T2 signal shadows. T2 FLAIR showed a slightly elevated signal, while diffusion was limited on the DWI sequence (Figures 1D6-D10,E6-E10,F6-F10). Brain MRI in December 2021 revealed minimal change from August 2020 (Figures 2G1-G5,H1-H5,I1-I5).
Pathological examination. (A) Hematoxylin and eosin staining shows eosinophilic inclusion bodies in some skin fibroblasts (100x, yellow arrow). (B) Anti-ubiquitin immunohistochemical staining. Inclusion bodies are visible in the nuclei of some skin sweat gland cells (100x, green arrow). (C) Anti-P62 immunohistochemical staining. Inclusion bodies are observed in the nuclei of some sweat gland cells (100x, yellow arrow). (D) Anti-SUMO1 immunohistochemical staining. Inclusion bodies are visible in the nuclei of some sweat gland cells (100x, yellow arrow). (E,F) Electron microscopy revealed a circular inclusion body structure in the nucleus of a sweat gland cell (15,000x and 30,000x, respectively; red arrows).
fneur-13-1013213-g0003.jpg
PMC9642335_02_fneur-13-1013213-g0003.jpg
F3
MRI on 5 December 2019, which showed extensive and slightly elongated T1 shadows, as well as a slightly elongated T2 signal shadow, bilaterally in the frontal, temporal, parietal, and occipital cortices and corpus callosum. Moreover, T2 FLAIR and DWI signals were high (Figures 2A1-A5,B1-B5,C1-C5). T1 and slightly elongated T2 signals in the corticomedullary junction and corpus callosum of both cerebral hemispheres. T2 FLAIR showed a high signal, and the apparent diffusion coefficient slightly decreased; no enhancement was observed in the lesions (Figures 2D1-D5,E1-E5,F1-F5). Light and electron microscopy showed eosinophilic, ubiquitin-positive, p62-positive, and SUMO-1-positive intranuclear inclusions in the adipocytes, fibroblasts, and sweat gland cells in both patients (Figures 3A-F). T1 and T2 signal shadows. T2 FLAIR showed a slightly elevated signal, while diffusion was limited on the DWI sequence (Figures 1D6-D10,E6-E10,F6-F10). Brain MRI in December 2021 revealed minimal change from August 2020 (Figures 2G1-G5,H1-H5,I1-I5).
Identification of alleles with GGC repeat expansions in the two sisters. Repeat-primed PCR and fluorescence amplicon length analysis of both patients showed GGC repeat expansions. The number of repeats was determined by comparing the length of the highest signal peak of the expanded allele (arrows) to that of the human reference gene sequence as previously described. The formula to determine repeat size was (["length of the highest signal peak of the expanded allele" bp - 185 bp] / 3 bp + 13). The assumed length of the PCR product was 185 bp in accordance with the standardized GRCh38.p13 human genome, containing the reference (GGC)9(GGA)2(GGC)2 sequence (n = 13).
fneur-13-1013213-g0004.jpg
PMC9642335_02_fneur-13-1013213-g0004.jpg
F4
MRI on 5 December 2019, which showed extensive and slightly elongated T1 shadows, as well as a slightly elongated T2 signal shadow, bilaterally in the frontal, temporal, parietal, and occipital cortices and corpus callosum. Moreover, T2 FLAIR and DWI signals were high (Figures 2A1-A5,B1-B5,C1-C5). T1 and slightly elongated T2 signals in the corticomedullary junction and corpus callosum of both cerebral hemispheres. T2 FLAIR showed a high signal, and the apparent diffusion coefficient slightly decreased; no enhancement was observed in the lesions (Figures 2D1-D5,E1-E5,F1-F5). Both sisters were also tested for the NOTCH2NLC pathogenic gene of NIID; patients 1 and 2 had 70 and 66 GGC repeats, respectively (Figure 4), suggesting NIID. T1 and T2 signal shadows. T2 FLAIR showed a slightly elevated signal, while diffusion was limited on the DWI sequence (Figures 1D6-D10,E6-E10,F6-F10). Brain MRI in December 2021 revealed minimal change from August 2020 (Figures 2G1-G5,H1-H5,I1-I5).