Mohr-Tranebjaerg syndrome (MTS) is an X-linked neurodegenerative recessive syndrome characterized by clinical manifestations commencing with early childhood onset hearing loss, adolescent onset progressive dystonia or ataxia, and visual impairment from early adulthood onwards and dementia from the 4th decade onward.
Prevalence is unknown. More than 91 cases (37 families) are known, but not all cases are published.
The onset of rapidly progressing prelingual or postlingual sensorineural hearing loss, the only pathognomonic symptom, occurs in early childhood (18 months). Neuropsychologic manifestations, such as personality changes, paranoia, mild intellectual deficit may emerge at concomitantly the same time. Slowly progressive movement disorder, appearing as gegenhalten (diffuse resistance to limb movement), dystonia (mostly generalized or focal) or ataxia develops from early adolescence and are associated with brisk tendon reflexes, ankle clonus and extensor plantar responses. Patients experience a reduced visual acuity, photophobia, acquired color vision defect and central scotomas from about 20 years of age, leading to legal blindness around age 30 to 40. Slowly progressive dementia develops from the 4th decade onward. In case of a contiguous gene deletion syndrome (CGS), recurrent infections may be present. Carrier females may be mildly affected with mild hearing impairment and focal dystonia.
MTS is caused by either a mutation in the TIMM8A gene (located to Xq22) or by a CGS at Xq22, resulting in deafness-dystonia peptide 1 (DDP1) deficiency. If the CGS includes the Bruton agammaglobulinemia tyrosine kinase (BTK) gene, recurrent infections secondary to this XLA are present.
A combination of hearing impairment and recurrent infections due to XLA in a male patient should elicit sequencing of the TIMM8A gene. Neuroimaging is employed to verify the presence of cerebral atrophy. In case of suspected CGS; testing for XLA is possible.
Differential diagnosis includes MELAS syndrome; mitochondrial DNA depletion syndrome (encephalomyopathic form with methylmalonic aciduria); Arts syndrome, X-linked spinocerebellar ataxia type 3 and 4; McLeod neuroacanthocytosis syndrome; Usher syndrome type 1 and 2; Wolfram syndrome; autosomal recessive nonsyndromic sensorineural deafness type DFNB and Pendred syndrome; other forms of dystonia and rarely Friedreich ataxia (see these terms).
Prenatal diagnosis may be proposed to affected couples or parents for further pregnancies.
MTS is transmitted in an X-linked recessive manner. Genetic counseling should be provided to affected families.
Treatment of MTS is symptomatic and evolves over time. Hearing aids are used with variable success. For mild hearing loss, hearing device and cochlear implants are an option whereas hearing aids with visual clues are used in cases with more severe hearing loss. Management of dystonia and ataxia includes treatment with GABA β-agonists together with psycho-motor re-education and physical therapy. Other supportive measures include therapies for deaf-blinds addressing progressive sensory deficits, such as tactile sign language. In case of secondary complications: intravenous immunoglobulin may prevent infections in XLA. Furthermore, live viral vaccines should be avoided in case of XLA. In adulthood, regular neurological evaluation (assessment for dementia and/or psychiatric manifestations) should be maintained.
Prognosis is poor. The combination of deafness and blindness severely affects communication, while the ongoing movement disorder results in an aggravating unstable gait. There is a highly variable life expectancy ranging from death in teenage years, after rapidly progressive dystonia, to living into the 60's.
Last update: April 2013