Amyotrophic Lateral Sclerosis

Amyotrophic Lateral Sclerosis is a topic covered in the 5-Minute Clinical Consult.

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Basics

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease of the brain and spinal cord. Characterized by loss of upper and lower motor neurons (UMNs/LMNs), its progression is relentless and is currently incurable.

Description

  • Average survival ranges from 2 to 5 years from the time of diagnosis.
  • >50% live >3 years, 25% live >5 years, 10% live >10 years, 5% live up to 20 years
  • Sporadic ALS form is 90–95% of all cases. It includes a number of overlapping syndromes, such as pseudobulbar palsy, progressive bulbar palsy, progressive muscular atrophy, and primary lateral sclerosis.
  • Familial ALS (FALS) is most commonly inherited as an autosomal dominant condition and less so as an autosomal recessive disease. This is clinically similar to sporadic ALS but probably represents a distinct entity pathologically and biochemically.
  • Guam ALS and Parkinson-dementia complex are ALS-like syndromes often, but not always, associated with Parkinson syndrome and dementia. Guam ALS is prevalent among the Chamorro Indians of Guam and rare in the United States.
  • System(s) affected: nervous
  • Synonym(s): motor neuron disease (MND); Lou Gehrig disease; Charcot disease; ALS
ALERT
  • Infantile and juvenile spinal muscular atrophies are conditions distinct from ALS, both clinically and pathologically.
  • Symptoms of ALS may inappropriately be attributed to age.
Pregnancy Considerations
  • Uncommon among affected individuals
  • If pregnancy did occur, the only foreseeable difficulties would be related to weakness.

Epidemiology

Incidence
  • In United States, 5,000 newly diagnosed per year
  • Rate = 2 to 5/100,000 per year

Prevalence
  • Estimated 20,000 Americans may have the disease at any given time without socioeconomic boundaries.
  • ALS is more common among white males, non-Hispanics, and persons aged 60 to 69 years (1).
  • Predominant age: 40 to 70 years, average age 55 years old
  • Predominant sex: male > female in sporadic ALS:
    • After 70 years: male = female

Etiology and Pathophysiology

  • Sporadic ALS: Unknown cause, but elevated levels of glutamate have been found in serum and CSF.
  • FALS: neurodegenerative disease passed on directly or indirectly by skipping generation (2)
  • Guam ALS and Parkinson-dementia complex: possible relationship to ingestion of the cycad nut or to some other environmental toxin
  • Degeneration of the UMNs/LMNs with gliosis replacing lost neurons; leads to spinal cord atrophy, thin ventral roots, and loss of large myelinated fibers in motor nerves
  • Progressive weakness of both skeletal and smooth muscles that leads to progressive loss of function related to movement, speech, swallowing, and breathing

Genetics
  • FALS, most common (5–10% of cases); can be autosomal dominant or autosomal recessive; X-linked dominant cases have been reported. 50–60% of FALS will have a detectable known genetic mutation.
  • C9orf72 repeat expansions found in 2011 in 30–40% of FALS
  • Gene locus has been localized to the long arm of chromosome 21 at position 22.11 and encodes the superoxide dismutase (SOD1) enzyme. This accounts for 15–20% of FALS cases.
  • FIG4 gene accounts for 3% of FALS.
  • Mutation in the gene encoding fused in sarcoma (FUS) was identified in FALS type 6.
  • Mutations in the angiogenin gene (ANG) have been discovered to be associated with sporadic ALS.
  • Mutations encoding a TAR DNA-binding protein (TARDBP), TDP-43, which helps regulate transcription and alternative splicing, have also been identified in FALS and sporadic ALS.
  • Overall, 22 mutations have been reported with current research continuing to discover new genes associated with ALS.

Risk Factors

  • Family history
  • Age >40 years and <70 years
  • Smoking
  • Military personnel, due to environmental exposures

General Prevention

Genetic counseling is advised if there is a family history of ALS; however, sporadic ALS is not associated with genetic transmission.

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Citation

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TY - ELEC T1 - Amyotrophic Lateral Sclerosis ID - 117524 Y1 - 2019 PB - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117524/all/Amyotrophic_Lateral_Sclerosis ER -