Huntington disease (HD) is a neurodegenerative condition that usually manifests as a triad of movement disorder, cognitive dysfunction, and behavioral or psychiatric abnormalities; however, these features can vary widely between individuals.
HD is the most prevalent inherited neurodegenerative disease affecting up to 1 in 10,000 individuals in most populations of European descent.
HD is caused by expansion of the trinucleotide CAG (polyglutamine-encoding) repeat sequence in exon 1 of the huntingtin gene (HTT) to greater than 35 repeats. The age of disease onset in HD is inversely correlated with the size of the CAG repeat expansion.
Following identification of the causative gene defect in 1993, at-risk individuals (with an affected parent) can be offered direct predictive genetic testing prior to the onset of symptoms.
The high prevalence of HD compared to genetic disorders with similar presentation means that, even without a family history, HD is the major diagnostic consideration in the choreic individual.
In the event of a negative HD test or atypical presentation, the differential diagnoses become a focus of investigation.
Any individual with an otherwise unexplained clinical presentation consistent with HD should be offered the direct genetic test for HD, since it is easily the most common inherited cause of such a presentation. The main inherited disorders with similar clinical presentation (HD phenocopies) are outlined in Table 125-1. Of these, HDL-2 and SCA17 are probably the most common HD phenocopies. For a useful algorithm for the screening of potential HD phenocopies, see Wild and Tabrizi (2007).
In the event of a negative HD test or an atypical presentation, it is most important to exclude any treatable (and/or potentially reversible) acquired causes. Wilson disease is a genetic case which is also treatable. Acquired causes of an HD presentation include (1) medication-related tardive dyskinesia or chorea following use of typical neuroleptics or the oral contraceptive pill, and L-dopa-induced dyskinesias, (2) postinfectious, for example, Sydenham chorea (poststreptococcal) or tertiary syphilis, (3) metabolic thyrotoxicosis and chorea gravidarum of pregnancy, (4) inflammatory lupus and antiphospholipid syndrome.
Table 125-1Major Genetic Differential Diagnoses |Favorite Table|Download (.pdf) Table 125-1 Major Genetic Differential Diagnoses
|Modality ||Gene Symbol ||Discriminative Clinical Characteristics |
(SCA17 or HDL-4)
|TBP ||SCA associated with prominent cerebellar ataxia, epilepsy |
|Huntington disease like-2 (HDL-2) ||JPH3 ||Often rapidly progressive dementia, usually black African ancestry (may not always be apparent) |
|Dentatorubropallidoluysian atrophy (DRPLA) ||ATN1 ||Epilepsy; often progressive myoclonic epilepsy (particularly among those with juvenile onset), higher prevalence in those of Japanese ancestry |
|SCA1-3 ||ATXN1-3 ||SCAs associated with prominent cerebellar ataxia. Optic atrophy (SCA1), childhood onset (SCA2), mixed pyramidal/extrapyramidal features (SCA3), peripheral neuropathy may be present (SCA1-3) |
|Neuroferritinopathy ||FTL ||Prominent facial dyskinesias and parkinsonism. Imaging may be characteristic |
|Huntington disease like-1 (HDL-1)...|
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