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Original article
Clinical course and endocrine dysfunction in X-linked adrenoleukodystrophy: A case series
Evolución clínica y disfunción endocrina en la adrenoleucodistrofia ligada al cromosoma X: una serie de casos
Tânia Matosa,
Corresponding author
tania.loureiro.matos@gmail.com

Corresponding author.
, Cristiana Costaa, Alexandra Novais Araújoa, Sónia do Valea,b
a Endocrinology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, EPE, Lisbon, Portugal
b Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">X-linked adrenoleukodystrophy &#40;X-ALD&#41; is the most frequent peroxisomal disorder&#44; with an estimated incidence of 1 in 16&#44;800 new-borns &#40;male and female&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1&#44;2</span></a> It is caused by mutations in the ABCD1 gene&#44; resulting in the absence or dysfunction of adrenoleukodystrophy protein &#40;ALDP&#41;&#44; a peroxisomal transmembrane protein involved in the transmembrane transport of very-long-chain fatty acids &#40;VLCFA&#41;&#46; This disorder is characterized by an impaired peroxisomal beta-oxidation of VLCFA&#44; leading to their accumulation in plasma and in all tissues&#44; particularly affecting the nervous tissue and adrenal cortex&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The exact pathophysiological mechanisms by which the excess of VLCFA leads to tissue damage and why specific cell types are uniquely vulnerable are not fully understood&#46; However&#44; direct VLCFA cytotoxicity and the induction of oxidative stress are both known to play a role&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#44;5&#8211;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The clinical manifestations are highly variable and there is no correlation between genotype and phenotype&#44; even within individual families&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> Phenotypes in men range from asymptomatic and pre-symptomatic patients&#44; Addison-Only &#40;ADO&#41; and Adrenomyeloneuropathy &#40;AMN&#41; to the cerebral form of X-ALD &#40;CALD&#41;&#44; including childhood&#44; adolescent and adult forms&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> However&#44; phenotypes are not static&#44; and X-ALD is considered a progressive disease and the risk of presenting symptoms increases with age&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Women with X-ALD are also affected and are not just carriers&#46; More than 80&#37; of women with X-ALD develop myelopathy or peripheral neuropathy after the age of 60 years&#44; although adrenal insufficiency or cerebral involvement are very rare&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Most X-ALD reports have focused on the neurological manifestations of this metabolic disease&#46; However&#44; endocrine dysfunction is common&#44; and the first manifestation in male patients is usually adrenal insufficiency&#46; Almost all males with X-ALD develop adrenal insufficiency in the course of their life and about 80&#37; before adulthood&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> Gonadal dysfunction may also be present in X-ALD&#44; although it is not always clinically apparent&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In this study&#44; we describe the clinical and biochemical features&#44; together with the clinical course of 10 X-ALD patients&#44; focusing not only on the neurological alterations&#44; but also on the endocrine dysfunctions associated with X-ALD&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">We performed a retrospective study&#44; including 10 patients diagnosed with X-ALD and followed up at the Endocrinology Department of Hospital de Santa Maria&#44; Centro Hospitalar Universit&#225;rio Lisboa Norte &#40;Lisbon&#44; Portugal&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Information was collected through their medical records&#44; including demographics&#44; endocrine and neurological findings&#44; neuroimaging and biochemical data&#44; treatment and disease progression&#46; The data collected included gender&#44; X-ALD phenotype&#44; date of birth and current age&#47;date of death&#44; age at diagnosis&#44; brain MRI data and testosterone levels&#44; phenotype evolution&#44; comorbidities&#44; treatment schemes and family history&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">X-ALD presentation and clinical course</span><p id="par0045" class="elsevierStylePara elsevierViewall">This retrospective study included a total of 10 male patients with a mean age of 19&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;1 years &#40;range&#58; 6&#8211;64 years&#41; at diagnosis who were followed up on average for 24&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;1 years&#46; The patients belong to 7 different families&#44; and all of them except two had a positive family history for X-ALD &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">At diagnosis&#44; all the patients presented adrenal insufficiency&#44; 8 of them with ADO phenotype and the remaining 2 with AMN phenotype&#46; The patients presenting with ADO phenotype had a mean age of 12&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;5 years&#44; whereas those who presented with AMN phenotype had a mean age of 46&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&#46;7 years &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the phenotype evolution of the 10 patients included&#46; Throughout the follow-up&#44; 4 additional patients also developed AMN&#44; on average about 25&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;4 years after the initial diagnosis&#44; ranging from 16 to 32 years&#46; Overall&#44; AMN was diagnosed at a mean age of 39&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;9 years&#46; Two patients also presented the adult form of CALD at 75 and 30 years&#44; 11 and 17 years after the initial diagnosis&#44; respectively&#46; The first patient died two months after this diagnosis and the second one remains in follow-up&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">A single total testosterone determination was available in 8 of the patients studied&#46; Testosterone levels were within the normal range in all the patients tested&#44; with an average of 430&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>120&#46;9<span class="elsevierStyleHsp" style=""></span>ng&#47;dL &#40;reference range&#58; 240&#8211;830<span class="elsevierStyleHsp" style=""></span>ng&#47;dL&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Two patients were also diagnosed with hypothyroidism&#44; both of whose antithyroid peroxidase and antithyroglobulin antibodies were within the normal range&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">As for neurological manifestations&#44; all six patients with AMN presented spastic paraparesis and sensitive peripheral neuropathy&#44; 5 mood disorders&#44; 4 sphincter disturbances and 2 sexual dysfunction &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">All the AMN patients exhibited slight brain MRI abnormalities&#44; presenting with T2 and moderate hyperintensity &#40;FLAIR&#41; in the internal capsule area&#46; In the CALD patients&#44; patient number 7s brain MRI showed an increased signal on T2 and FLAIR sequences in the corpus callosum&#44; pyramidal tracts within the brainstem&#44; pons and internal capsules&#44; together with enhancement on T1 sequences after intravenous gadolinium administration&#46; Unfortunately&#44; the brain MRI of patient 6 was not available&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Family history</span><p id="par0080" class="elsevierStylePara elsevierViewall">As was mentioned above&#44; the ten patients belonged to seven different families&#44; marked from 1 to 7 on <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Family 1 is comprised of two brothers&#44; currently aged 51 and 63 years&#44; both of whom presented adrenal insufficiency at the age of six and who developed AMN by the ages of 36 and 38 years&#44; respectively&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Family 2 included two brothers and one maternal cousin&#44; now aged 34&#44; 41 and 45 years&#46; All of them presented adrenal insufficiency at the ages of 13&#44; 14 and 18 years&#44; respectively&#46; Only the third was diagnosed with AMN by the age of 40&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Family 4 is represented by one 39-year-old patient&#44; diagnosed with adrenal insufficiency at the age of 13 years and who developed both AMN and cerebral involvement at the age of 29&#46; Although he remained clinically stable for several years&#44; he has presented clinical and imaging signs of disease progression for the last 2 years&#46; His family history includes a brother with X-ALD who died with CALD at the age of 33 years&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Patients 6 and 8 represent families 3 and 5&#46; The family history of the former revealed 3 brothers diagnosed with X-ALD&#44; and the latter a maternal grandfather also diagnosed with X-ALD&#46; However&#44; information about phenotypes and clinical course was unavailable in their clinical records&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">X-ALD treatment</span><p id="par0105" class="elsevierStylePara elsevierViewall">A VLCFA-restricted diet was recommended for all of the patients accompanied&#46; Lorenzo&#39;s oil was used by 3 patients&#44; 2 with ADO phenotype and 1 with AMN &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Hydrocortisone was used in 9 patients at an average daily dose of about 19&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#46; One patient was medicated with 7&#46;5<span class="elsevierStyleHsp" style=""></span>mg of prednisolone per day&#46; Six patients were medicated with fludrocortisone at an average daily dose of approximately 0&#46;08<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;03<span class="elsevierStyleHsp" style=""></span>mcg &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Allogeneic haematopoietic stem cell transplantation &#40;HSCT&#41; was not performed in any of the patients with CALD&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">X-ALD has traditionally been classified in different phenotypes&#44; including ADO&#44; AMN&#44; childhood&#44; adolescent or adult CALD and asymptomatic carriers&#46; However&#44; X-ALD is a progressive disease and the risk of having symptoms increases with age&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#44;6&#44;9</span></a> New-born screening for X-ALD permits the detection of the disease prior to the development of clinical manifestations and has already been implemented by several countries&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">7</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Typically&#44; patients are born asymptomatic&#44; and adrenal insufficiency is usually the first manifestation of the disease&#44; affecting up to 80&#37; of men with X-ALD&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;11</span></a> Here we have described a series of 10 X-ALD patients&#44; all presenting with adrenal insufficiency at diagnosis&#44; 80&#37; of them with ADO phenotype&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Adrenal dysfunction in X-ALD is due to primary adrenocortical insufficiency&#46; However&#44; the nature of adrenal gland toxicity and its relationship with increased VLCFA levels is poorly understood&#46; Nevertheless&#44; abnormal VLCFA accumulation in the adrenal cortex&#44; particularly evident in the zona reticularis and the zona fasciculata&#44; is believed to cause apoptosis and ultimately adrenal cortex atrophy&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#44;7&#44;13</span></a> Furthermore&#44; the incorporation of VLCFA into the adrenocortical cell membrane may also impair adrenocorticotropin &#40;ACTH&#41; receptor function&#44; and the increased esterification of cholesterol with VLCFA can lead to a relative shortage of substrate for steroidogenesis and impair cortisol secretion further&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#44;13&#44;14</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The accumulation of VLCFA has been detected in the foetal adrenal gland&#44; indicating that these alterations are already present in utero&#46; However&#44; loss of adrenal function appears to be a gradual and progressive phenomenon&#44; as subclinical abnormalities in cortisol response to ACTH stimulation usually precede frank hypocortisolism&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;13&#44;15</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Adrenal insufficiency is most commonly diagnosed between the ages of 3 and 10 years&#44; although it has been reported as early as 5 months of age&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">11&#44;13&#44;16</span></a> However&#44; in our study&#44; only two patients were diagnosed before the age of 10 years and 4 patients were even diagnosed during adulthood&#44; including one patient who was surprisingly diagnosed at the age of 64&#44; illustrating the variability in the presentation of X-ALD&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Acknowledging that Addison&#39;s disease is due to X-ALD has important implications not only for genetic counselling but also for its management&#46; It is therefore important to screen for X-ALD in male patients with primary adrenal insufficiency&#44; particularly in those diagnosed before 10 years of age&#46; Nevertheless&#44; our results underscore the need to also include VLCFA assessment in adult patients with primary adrenal insufficiency&#44; particularly in those with concomitant neurological symptoms&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">As was already mentioned&#44; X-ALD is a progressive disease&#44; and the phenotypes are not static&#46; Indeed&#44; since AMN appears later in life and will eventually affect all men with X-ALD who reach adulthood&#44; periodical neurological surveillance is recommended&#44; even in patients presenting with ADO phenotype&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#44;16&#8211;18</span></a> In our series&#44; AMN was diagnosed in half of the patients initially presenting with ADO&#46; However&#44; the progression rate was highly variable&#44; as the time between the diagnosis of adrenal insufficiency and AMN development ranged from 16 to 32 years&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">AMN is mainly diagnosed in the third and fourth decade of life&#44; and its incidence increases with age&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#8211;6</span></a> Spinal cord lesions&#44; particularly the long tracts and to a lesser extent of the peripheral neural system&#44; are observed in AMN&#44; traditionally characterised as a distal axonopathy without significant myelin changes&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">9&#44;19</span></a> Therefore&#44; AMN symptoms represent a combination of myelopathy and peripheral neuropathy&#44; gradually progressive&#44; and most patients lose unassisted ambulation by the 6th decade&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#44;17</span></a> A higher prevalence of major affective disturbance has also been reported in AMN patients&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a> In our series&#44; the clinical presentation of the six AMN patients was in line with the traditional presentation and&#44; remarkably&#44; 4 of them also presented with mood disorders&#44; although CALD was not apparent&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The cerebral form of ALD is the most rapidly progressive and devastating phenotype of X-ALD&#44; characterised by a severe inflammatory demyelination process&#44; affecting primarily the cerebral hemispheres&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">3&#44;7&#44;16&#44;21</span></a> CALD presents more frequently during childhood&#44; although it can emerge at any age and is believed to be the result of an interplay between genetic and environmental factors&#46; The onset of CALD is usually insidious and it presents in a similar fashion in children and adults&#44; although progression appears to be slower in adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#44;7&#44;17&#44;22</span></a> Of the two patients in our series who were diagnosed with the adult form of CALD&#44; one of them passed away two months after the diagnosis&#46; However&#44; and remarkably so&#44; the other patient is still alive&#44; with mild neurological symptom progression 8 years on from the initial diagnosis&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">There is no generalised correlation between genotype and phenotype in X-ALD&#44; meaning that the clinical course is unpredictable&#44; even in individual families&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">8&#44;23</span></a> Nevertheless&#44; we found certain similarities both in age of presentation and clinical course in 3 of the families studied in our case series&#46; Therefore&#44; it cannot be ruled out that certain mutations lead to specific phenotypes or influence the age of onset of X-ALD clinical manifestations&#44; and further studies are needed to address this issue&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Male X-ALD patients may also present with hypogonadism&#44; which is most usually seen once neurological or adrenal symptoms are present&#46; Most commonly&#44; patients present with primary gonadal failure&#44; related to VLCFA accumulation on Leydig cells which seems to affect testicular function directly&#46; However&#44; androgen receptor dysfunction due to VLCFA accumulation has also been suggested&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Testosterone levels are reported to be in the lower-normal range&#44; and in a previously published study only 2&#46;5&#37; of the X-ALD patients were on testosterone replacement therapy due to primary hypogonadism&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;13&#44;24</span></a> Although men with X-ALD have higher rates of testicular dysfunction than the general population&#44; infertility rates were reportedly comparable between both&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> Furthermore&#44; erectile dysfunction&#44; a common finding among X-ALD patients&#44; usually reflects neurological impairment rather than testosterone deficiency&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">In our series&#44; none of the men with X-ALD presented with hypogonadism and no history of infertility was reported&#46; However&#44; we have only evaluated the last total testosterone determination available and it remains to be answered whether a longer follow-up period could have influenced our results&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">There is currently no curative or preventive treatment for the majority of patients with X-ALD&#46; For childhood CALD&#44; HSCT&#44; when performed in the early stages of cerebral involvement&#44; has been shown to halt the progression of neurological disease and increase disease-specific survival&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> However&#44; whether or not HSCT has any impact on the occurrence or progression on AMN of X-ALD remains to be seen&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#44;7</span></a> Autologous transplantation of genetically-modified hematopoietic stem cells is currently being explored as an alternative to HSCT&#44; although the long-term efficacy of this therapy has yet to be determined&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> In our series&#44; since the two patients with CALD were only diagnosed during adulthood&#44; HSCT was not considered&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Lorenzo&#39;s oil&#44; a mixture of oleic acid &#40;C18&#58;1&#41; and erucic acid &#40;C22&#58;1&#41;&#44; normalises plasma C26&#58;0 levels within 1 month in most patients with ALD&#46; However&#44; C26&#58;0 levels in the nervous system are not affected&#44; and in several open-label trials&#44; Lorenzo&#39;s oil failed to improve neurological or endocrine function and proved to be ineffective in halting AMN progression&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> Three patients in our series had been medicated with Lorenzo&#39;s oil&#44; one of whom progressed to AMN at the age of 40&#44; 22 years after the diagnosis of adrenal insufficiency&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The treatment of adrenal insufficiency in X-ALD is no different to that of individuals with other forms of primary adrenal insufficiency&#44; in whom glucocorticoid replacement therapy is mandatory&#46; Importantly&#44; neither allogenic nor autologous HSCT can prevent or reverse adrenal insufficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Since AI in X-ALD is an evolving process&#44; glucocorticoid replacement therapy may initially only be required during stressful times&#44; although progressively daily glucocorticoid treatment will be needed&#46; Glucocorticoid replacement requirements are generally the same as in other forms of primary AI&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#44;13&#44;16</span></a> Due to the relative sparing of the zona glomerulosa from the accumulation of VLCFA&#44; frank hypoaldosteronism with salt wasting is not frequent&#44; and mineralocorticoid function often remains intact&#46; Nevertheless&#44; screening and treatment for mineralocorticoid deficiency should always be considered&#44; since approximately between one third and one half of men with X-ALD ultimately present with impaired mineralocorticoid function&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">In our series&#44; glucocorticoid replacement therapy was initiated in all patients at diagnosis&#44; and 6 out of 10 patients were on mineralocorticoid replacement therapy &#40;60&#37;&#41;&#44; a slightly higher proportion than the reports of previous studies&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">In males with X-ALD with confirmed testicular dysfunction&#44; testosterone replacement therapy should be considered if clinically indicated&#46; However&#44; decreased libido and erectile dysfunction&#44; common findings among X-ALD patients&#44; usually reflect neurological impairment and&#47;or the presence of a chronic disease rather than a testosterone deficiency&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">12&#44;13</span></a> Similarly&#44; although erectile dysfunction was reported in two patients in our series&#44; none of the men with X-ALD presented with hypogonadism&#46; The main limitations of our study relate to its retrospective nature and limited access to clinical records&#46; Nevertheless&#44; we were able to describe the main clinical features of ten patients with a rare metabolic disease&#44; followed up for a considerable period&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">In conclusion&#44; we have described a series of 10 patients with X-ALD followed up at an Endocrinology Department&#44; all of whom presented with adrenal insufficiency and none with hypogonadism&#46; The presentation of adrenal insufficiency varied widely&#44; with a 40&#37; presentation rate during adulthood and a 60&#37; rate of mineralocorticoid deficiency&#46; Our findings reinforce the need to screen for X-ALD at any age when dealing with adrenal insufficiency&#44; as well as the importance of regular screening for mineralocorticoid deficiency in X-ALD patients&#46; Progression rate and age at presentation of neurological manifestations varied in our series&#44; which strengthens the need for a multidisciplinary approach&#44; including endocrinologists and neurologists&#44; throughout follow-up&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Data availability statement</span><p id="par0220" class="elsevierStylePara elsevierViewall">All the data generated or analysed during this study are included in this published article&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Authors&#8217; contributions</span><p id="par0225" class="elsevierStylePara elsevierViewall">All the authors contributed to the conception and design of the study&#46; Data collection and analysis were performed by TM&#46; The manuscript was written by TM and CC and SV reviewed the manuscript and provided critical input&#46; All the authors read and approved the final manuscript&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Funding</span><p id="par0230" class="elsevierStylePara elsevierViewall">There was no funding involved in the development of this article&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of interest</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "X-ALD presentation and clinical course"
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              "titulo" => "Family history"
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            0 => "X-linked adrenoleukodystrophy"
            1 => "Adrenomyeloneuropathy"
            2 => "Adrenal insufficiency"
            3 => "Very-long-chain fatty acids"
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            0 => "Adrenoleucodistrofia ligada al X"
            1 => "Adrenomieloneuropat&#237;a"
            2 => "Insuficiencia suprarrenal"
            3 => "&#193;cidos grasos de cadena muy larga"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and purpose</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">X-linked adrenoleukodystrophy &#40;X-ALD&#41; is a peroxisomal disorder affecting particularly the nervous tissue and adrenal cortex&#46; Adrenomyeloneuropathy &#40;AMN&#41; is the most frequent phenotype&#44; although adrenal insufficiency is usually the first manifestation in male patients&#46; We set out to describe the clinical and biochemical features&#44; together with the clinical course of X-ALD patients&#44; focusing particularly on endocrine dysfunction&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study of 10 male X-ALD patients followed up at the Endocrinology Department&#46; Epidemiologic data&#44; phenotype evolution&#44; endocrine and neurological findings and family history were analysed&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All the patients presented with adrenal insufficiency&#44; 4 of them during adulthood&#44; with a mean age of 19&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;1 years &#40;6&#8211;64 years&#41;&#46; Six patients had mineralocorticoid deficiency&#46; At diagnosis&#44; 8 patients had Addison-only phenotype and 2 AMN phenotype&#46; In the course of follow-up &#40;24&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;1 years&#41;&#44; 4 patients developed AMN about 25&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;4 years after the initial diagnosis and 2 patients presented the cerebral adult form 11 and 17 years after the initial diagnosis&#46; Testosterone levels were within the normal range in all patients&#46; There were 7 families&#44; and age of onset and clinical course were similar in 3 of them&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The presentation of X-ALD varied widely&#44; 40&#37; of the patients presented with adrenal insufficiency in adulthood&#44; 60&#37; had mineralocorticoid deficiency&#44; and the onset and progression of neurological manifestations showed no pattern&#46; Nevertheless&#44; some similarities in the clinical course were found in some families&#46; Our findings reinforce the need for screening for X-ALD at any age when approaching adrenal insufficiency and the importance of a multidisciplinary approach between endocrinologists and neurologists&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La adrenoleucodistrofia ligada al cromosoma X &#40;X-ALD&#41; es un trastorno peroxisomal que afecta especialmente al tejido nervioso y a la corteza suprarrenal&#46; La adrenomieloneuropat&#237;a &#40;AMN&#41; es el fenotipo m&#225;s com&#250;n&#59; no obstante&#44; la insuficiencia suprarrenal generalmente es la primera manifestaci&#243;n en varones&#46; Nuestro objetivo fue describir las caracter&#237;sticas y el desarrollo cl&#237;nico de pacientes con X-ALD&#44; centr&#225;ndonos en la disfunci&#243;n endocrina&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de 10 varones con X-ALD&#46; Fueron analizados los datos epidemiol&#243;gicos&#44; evoluci&#243;n&#44; hallazgos endocrinos&#44; neurol&#243;gicos e historia familiar&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Todos los pacientes presentaron insuficiencia suprarrenal&#44; 4 durante la edad adulta&#44; con una edad media de 19&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#44;1<span class="elsevierStyleHsp" style=""></span>a&#241;os &#40;6-64 a&#241;os&#41;&#46; Seis pacientes ten&#237;an deficiencia de mineralocorticoides&#46; Al diagn&#243;stico&#44; 8 ten&#237;an insuficiencia suprarrenal aislada y 2 AMN&#46; Durante el seguimiento &#40;24&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44;1&#41;&#44; 4 desarrollaron AMN&#44; 25&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#44;4<span class="elsevierStyleHsp" style=""></span>a&#241;os despu&#233;s del diagn&#243;stico inicial y 2 presentaron la forma cerebral a los 11 y 17 a&#241;os despu&#233;s del diagn&#243;stico inicial&#46; Los niveles de testosterona estaban dentro del rango normal en todos&#46; Hab&#237;a 7 familias y la edad al diagn&#243;stico y el desarrollo cl&#237;nico fue similar en 3 de ellas&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La presentaci&#243;n del X-ALD vari&#243; ampliamente&#44; el 40&#37; presentaron insuficiencia suprarrenal en la edad adulta&#44; el 60&#37; deficiencia de mineralocorticoides y el comienzo y progreso de las manifestaciones neurol&#243;gicas no mostr&#243; ning&#250;n patr&#243;n&#46; Sin embargo&#44; unas pocas similitudes en el desarrollo cl&#237;nico fueron encontradas en algunas familias&#46; Nuestros resultados refuerzan la necesidad de excluir X-ALD a cualquier edad cuando se aborda la insuficiencia suprarrenal y la importancia de un enfoque multidisciplinar entre endocrin&#243;logos y neur&#243;logos&#46;</p></span>"
        "secciones" => array:4 [
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          1 => array:2 [
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          2 => array:2 [
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          3 => array:2 [
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      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Phenotype evolution throughout follow-up&#59; ALD&#58; adrenoleukodistrophy&#59; AMN&#58; adrenomyeloneuropathy&#44; CALD&#58; cerebral adrenoleukodistrophy&#59; &#8224;&#58; deceased&#46;</p>"
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      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1452
            "Ancho" => 2175
            "Tamanyo" => 125776
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Total testosterone level distribution among X-ALD patients &#40;last determination&#44; reference range 240&#8211;830<span class="elsevierStyleHsp" style=""></span>ng&#47;dL&#41;&#59; the grey area represents the laboratory normal reference range for men&#59; no data are available for patients 2 and 4&#59; &#8224;&#58; deceased&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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          0 => array:3 [
            "identificador" => "at1"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ADO&#58; Addison-Only&#59; AMN&#58; adrenomyeloneuropathy&#59; CALD&#58; cerebral adrenoleukodystrophy&#59; &#8220;&#43;&#8221; present&#59; &#8224;&#58; deceased</p>"
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                  """
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            ]
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        ]
        "descripcion" => array:1 [
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      3 => array:8 [
        "identificador" => "tbl0010"
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        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">&#8220;&#43;&#8221;&#58; present&#59; &#8220;&#8722;&#8221;&#58; absent&#59; &#8224;&#58; deceased&#46;</p>"
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            0 => array:1 [
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                  """
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