Original Paper
Received: December 23, 2002
Accepted: May 9, 2003

Eur Neurol 2003;50:100–105
DOI: 10.1159/000072507

A Novel GFAP Mutation and
Disseminated White Matter Lesions:
Adult Alexander Disease?
Knut Brockmann a Moritz Meins b Angelika Taubert c Ralf Trappe b
Martin Grond c Folker Hanefeld a
Departments of a Pediatrics and Neuropediatrics and b Human Genetics, University of Göttingen, Göttingen, and
c Department of Neurology, Community Hospital, Siegen, Germany

Key Words
Alexander disease W Glial fibrillary acidic protein W Adult
onset W Multiple sclerosis

is actually afflicted with Alexander disease. Mutation
analysis of GFAP should be considered in patients with
remitting neurological deficits, disseminated white matter lesions and absence of inflammatory CSF changes.
Copyright © 2003 S. Karger AG, Basel

Abstract
The recent discovery of heterozygous de novo mutations
in the glial fibrillary acidic protein (GFAP) gene as the
cause of infantile and juvenile Alexander disease has
shed new light on the long-standing debate whether the
adult subtype has the same etiology as infantile and
juvenile Alexander disease. A 40-year-old man presented with subacute left hemiplegia and ataxia. Cranial MRI
revealed disseminated patchy white matter changes involving the corpus callosum, basal ganglia and brainstem. CSF investigation demonstrated elevated total
protein but was otherwise normal. Mutation analysis of
the GFAP gene was performed in the patient, his mother
and healthy brother. A novel heterozygous mutation in
exon 4, 681G→C, predicting an amino acid substitution
E223Q in the rod region of GFAP was detected in the
patient and his mother but not in his healthy brother or
150 control chromosomes. We conclude that the patient
K.B. and M.M. contributed equally to this work.

ABC

© 2003 S. Karger AG, Basel
0014–3022/03/0502–0100$19.50/0

Fax + 41 61 306 12 34
E-Mail karger@karger.ch
www.karger.com

Accessible online at:
www.karger.com/ene

Introduction

Alexander disease, originally described in 1949 [1], is a
rare, fatal disease of the central nervous system due to a
dysfunction of astrocytes [2]. Three major subtypes have
been delineated based on the age of onset. The most common infantile form presents as a megalencephalic leukoencephalopathy with rapid progression usually leading
to death within few years [3]. The juvenile type is characterized by a slowly progressive brainstem dysfunction [4].
Adult-onset Alexander disease has been reported rarely
and with the most variable phenotypes. Several familial
cases exhibited palatal myoclonus, cerebellar ataxia and
ocular motor abnormalities [5, 6]. In some patients, clinical features mimicked the juvenile subtype, though with a
later onset and a more protracted course. Others presented with clinical symptoms resembling multiple sclerosis
[7, 8].

Knut Brockmann
Department of Pediatrics and Neuropediatrics, University of Göttingen
Robert-Koch-Strasse 40
DE–37075 Göttingen (Germany)
Tel. +49 551 39 6210, Fax +49 551 39 6252, E-Mail kbrock@med.uni-goettingen.de

Alexander disease is pathologically characterized by
demyelination, astrocytosis and the presence of countless
Rosenthal fibers throughout the brain, predominantly in
subpial, subependymal and perivascular regions. Rosenthal fibers are cytoplasmatic inclusions containing glial
fibrillary acidic protein (GFAP) and small heat shock proteins [9]. Messing et al. [10] observed inclusion bodies
indistinguishable from Rosenthal fibers in fatal GFAP
transgenic mice, who showed overexpression of human
GFAP in astrocytes. This finding pointed to GFAP as a
candidate gene in Alexander disease.
Recently, de novo heterozygous GFAP mutations have
been detected in infantile cases with a histopathologically
verified diagnosis of Alexander disease [11]. A genotypephenotype correlation has been demonstrated [12]. Mutations were observed predominantly in exons 1 and 4, clustering around 2 hot spots. Subsequently, GFAP mutations
have been shown in adult members of a family with autosomal dominant palatal myoclonus and spinal cord atrophy [13] and in patients with juvenile onset of disease [14,
15].
Here, we report an adult male with clinical symptoms
resembling multiple sclerosis, disseminated white matter
lesions on MRI and a novel GFAP mutation.

Case Report
A 40-year-old man presented with subacute left hemiplegia. He
was the first of 2 sons of nonconsanguineous parents. His father had
died from stroke at the age of 68 years. His 65-year-old mother exhibited symptoms of a mild, chronic impairment of intellectual function
along with a change of personality, apparent for 3 years. She declined
clinical and neuroradiological examination. His younger brother was
healthy. The patient’s early motor and mental development was normal but slower than in his brother. He had been stuttering since
childhood. He attended a regular school but did not pass the final
examination. He had no professional training and was occupied as a
road laborer. Arterial hypertension and diabetes mellitus had been
treated for 10 years. An intermittent abuse of alcohol was reported by
his relatives. The left hemiparesis showed an insidious onset and
slowly worsened over a period of 5 weeks. A further deterioration led
to admission to the hospital.
On neurological examination, he was fully orientated and friendly, though slowed in his performance. He was stuttering, had a spastic
and cerebellar dysarthria and showed weakness of the lower face on
the left side. Funduscopy revealed retinal signs of hypertension. Cranial nerves were otherwise normal. No palatal myoclonus was
observed. There was spastic hemiplegia of the left side with exaggerated reflexes and clonus of the lower limb. Ataxia with unsteadiness
of gait was noted. A general physical examination showed no significant abnormalities except for arterial hypertension. Twenty-fourhour ambulatory blood pressure monitoring revealed systolic values
up to 200 mm Hg and diastolic values up to 125 mm Hg.

GFAP Mutation and Adult Alexander
Disease

Investigation of CSF disclosed normal values for cell count and
glucose. Total protein was increased to 72 mg/dl (normal, 15–45); no
oligoclonal bands were detected. The Treponema pallidum hemagglutination assay was nonreactive, and antibodies to Borrelia burgdorferi were negative.
EEG, visual-evoked responses and brainstem auditory-evoked
responses were normal. Nerve conduction velocities revealed a mild
demyelinating motor and sensory neuropathy in the lower limbs,
associated with his diabetes. Doppler ultrasonography of carotid and
vertebral-basilar arteries showed no abnormalities.
Cranial MRI (fig. 1) revealed disseminated patchy T2-weighted
hyperintensities in supratentorial white matter predominantly in
periventricular regions as well as in basal ganglia. A large confluent
lesion of the corpus callosum and streaky and patchy lesions of the
pons were detected. Virchow-Robin spaces were widened in the
white matter and basal ganglia, and the inner and outer CSF spaces
were moderately enlarged.
Subsequently, the patient’s hemiplegia resolved slowly over a
period of several months, leaving him with a mild residual weakness.
Since then, his motor impairment as well as his incoordination have
followed a fluctuating course.

Methods
EDTA blood samples were collected from the patient, his mother
and brother after informed consent. No other relatives were available
for mutation analysis. DNA was extracted from blood leukocytes by
standard methods. Mutation analysis was performed as described
earlier [16]. Basically, the complete coding exons of the GFAP gene
were amplified by polymerase chain reaction (PCR), which was carried out in 50-Ìl reactions with 100 ng of patient DNA, 20 pmol of
each primer, 25 Ìl of HotStar Taq master mix (Qiagen) in water,
using the following PCR protocol (95 ° C for 15 min; 35 cycles at
95 ° C for 20 s, 56 ° C for 30 s, 72 ° C for 45 s, followed by a final
elongation at 72 ° C for 10 min). Amplification products were tested
by agarose gel electrophoresis and purified. PCR products were
sequenced directly using the ET dye terminator kit and a MegaBace500 sequencer (Amersham-Pharmacia), according to the manufacturers’ instructions. After sequence evaluation, the detected mutation was confirmed by restriction digestion of the amplicon with the
restriction enzyme BsgI (New England Biolabs).

Results

A novel heterozygous missense mutation in exon 4,
681G→C, was detected in the patient (fig. 2). The mutation creates a new recognition site for the restriction
enzyme BsgI, thus allowing detection of the mutation by
restriction analysis of the respective exon. Cosegregation
in the family and prevalence within a control cohort were
analyzed by restriction digestion with BsgI. The identical
mutation 681G→C was found in the mother of the index
patient but was not observed in his brother or in more
than 150 control chromosomes of an ethnically matched

Eur Neurol 2003;50:100–105

101

Fig. 1. Axial (a–c) and sagittal (d, e) T2-weighted MR images demonstrate disseminated patchy lesions throughout

the white matter and basal ganglia along with enlarged Virchow-Robin spaces. The corpus callosum is affected by a
large confluent symmetrical lesion (a, d, e). Patchy and streaky lesions of the pons are shown in c, d and e.

control group without neurological diseases (fig. 3). Mutation analysis was not possible in the father, as he had
deceased earlier.

Discussion

The recent discovery of mutations in the GFAP gene as
the cause of infantile and juvenile Alexander disease has
shed new light on the long-standing debate whether the
presence of excess Rosenthal fibers in adult patients
points to an adult subtype of Alexander disease or reflects
a nonspecific histopathological pattern [17, 18].

102

Eur Neurol 2003;50:100–105

In the patient reported here, the similarities of the clinical course and the brainstem involvement with the cases
described by Seil et al. [7] and Spalke and Mennel [8] led
to a search for a GFAP mutation. A novel heterozygous
mutation 681G→C in the GFAP gene was found. The
same mutation was detected in his mother, who declined
a detailed investigation. The comparatively mild clinical
course may be adequate for a mutation predicting the
exchange of glutamic acid to glutamine (E223Q). Glutamic acid at position 223 is located 16 amino acids from
R239 known to be a mutation hot spot in infantile Alexander disease and is perfectly conserved throughout evolution in mammals (human, mouse, rat and cow). Even in

Brockmann/Meins/Taubert/Trappe/Grond/
Hanefeld

3

Fig. 2. PCR and direct sequencing of exon 4 for the

2

index patient shows heterozygosity for the mutation
681G→C (upper electropherogram), compared to the
normal sequence (wild type, below). Nucleotide numbering refers to the published cDNA sequence, as used by
Brenner et al. [11].
Fig. 3. Analysis of exon 4 for the index patient and his
family by restriction digestion. The mutation 681G→C
creates a new BsgI site, 2 fragments of 243 and 139 bp are
found instead of the 382-bp fragment. The index patient
and his mother carry the mutation (characterized as
filled symbols in the overlying pedigree) but not his
younger brother (marked with an open symbol). M =
Molecular size marker; C = control.

more distant species like the zebrafish and carp, aspartic
acid is found in this position, thus preserving acidity
and charge at this position. In contrast, the mutation
681G→C leads to replacement of an acidic amino acid by
its own neutral amide. Further evidence for the pathogenicity of this mutation derives from the fact that the
exchange was neither found in the healthy brother nor in
150 control chromosomes.
To our knowledge, there has been only one report yet
of a GFAP mutation in a condition compatible with adult
Alexander disease. Autosomal dominantly transmitted
GFAP mutations have been demonstrated in 3 adult
members of a family who presented with palatal myoclonus, pyramidal tract signs, cerebellar signs and marked
atrophy of the medulla oblongata and spinal cord [13].
These clinical and neuroradiological features were almost
identical with those in two families previously reported to
have histopathological characteristics of Alexander disease with adult onset [5, 6]. Schwankhaus et al. [6] demonstrated widespread Rosenthal fiber deposition associated
with demyelination in 1 adult patient presenting with
familial palatal myoclonus, spastic paraparesis and cerebellar ataxia. This female was the daughter of the first

patient reported to have histopathologically proven adultonset Alexander disease [7]. The 47-year-old man whose
symptoms began at the age of 32 had been diagnosed clinically as having multiple sclerosis. Howard et al. [5] distinguished their patients from what had been described as
adult Alexander disease, but genetic connection and
strong clinical similarities suggest that these patients suffer from the same disease presenting with variable phenotypes within one family.
Only recently has a novel missense mutation of a Gto-T transition at nucleotide 841 in the GFAP gene resulting in the substitution of arginine for leucine at amino
acid residue 276 (R276L) been detected in 2 brothers with
adult-onset spastic paresis without palatal myoclonus and
marked atrophy of the medulla oblongata and cervicothoracic cord on MRI. Autopsy in one of these cases showed
moderate numbers of Rosenthal fibers in the stratum subcallosum and hippocampal fimbria [19].
Neuroradiological features of our patient comprise
(1) disseminated patchy lesions in the white matter and
basal ganglia, (2) large confluent lesions of the corpus callosum, (3) patchy and streaky lesions of the pons and (4)
enlarged Virchow-Robin spaces in the subcortical white

GFAP Mutation and Adult Alexander
Disease

Eur Neurol 2003;50:100–105

103

matter. These findings are ambiguous and may partially
relate to the patient‘s arterial hypertension or, possibly, to
his temporary abuse of alcohol.
(1) In a prospective cohort study, white matter lesions
in periventricular and subcortical regions have been
shown to be associated with hypertension [20]. Sierra et
al. [21] found clinically silent white matter lesions in 41%
of middle-aged essential hypertensive patients. Focal lesions in basal ganglia, however, correlated with different
risk factors including age, a history of ischemic heart disease and carotid artery stenosis [22]. None of these risk
factors was present in our patient.
(2) Acquired lesions of the corpus callosum have been
reported in a variety of diseases comprising ischemic
infarcts, CADASIL, multiple sclerosis, acute disseminated encephalomyelitis and Marchiafava-Bignami disease, but are not amongst the MRI abnormalities detected
in patients with arterial hypertension [23]. In our patient,
MRI revealed large confluent symmetrical and predominantly centrally located lesions extending from the genu
to the splenium. Similar features have been reported in
Marchiafava-Bignami disease. Originally described as a
histopathological finding in heavy drinkers post mortem,
it has later been recognized to occur associated with alcoholism more often and with milder clinical symptoms
than initially presumed [24, 25]. Lesions of the corpus callosum are not part of the typical MRI features of Alexander disease. Thus, the callosal lesion in our patient may
relate to his alcohol abuse rather than to his GFAP mutation.
(3) Pontine lesions detected by MRI in subclinical central pontine myelinolysis have been described as midline,
symmetrical and of a triangular to bat wing shape [26].
The pontine lesions found in our patient do not meet
these criteria. Pontine ischemic rarefaction is associated
with an MRI pattern similar to the features of our case
and cannot be ruled out here [27]. However, neuroradiological and neuropathological brainstem abnormalities
are highly characteristic of infantile and juvenile Alexander disease [3, 28] as well as of adult cases [6–8].
(4) Enlarged Virchow-Robin spaces present a nonspecific feature and have been observed in association with
hypertension, early multiple sclerosis and various other
disorders [29].
As most cases of histopathologically proven adultonset Alexander disease have been reported when MRI
was not yet available, the spectrum of MRI abnormalities
in the adult form still has to be delineated. In our patient,
the clinical and neuroradiological features are complicated by the other risk factors which may contribute to the

104

Eur Neurol 2003;50:100–105

white matter lesions. In the presence of hypertension and
retinopathy, a cerebrovascular event unrelated with the
GFAP mutation must be considered. However, the hemiparesis in our patient showed an insidious onset and
worsened over a period of several weeks until he was
investigated. A cerebrovascular event cannot be ruled out
but does not seem to be very likely with this course. On
the other hand, a remitting course of histologically proven
Alexander disease has been described. The first adult
patient with Alexander disease reported [7] was ‘a 47year-old man... who had been diagnosed clinically as multiple sclerosis’. His symptoms began at the age of 32 with
‘a paralysis of his left arm’, which was ‘complete for 5
days, after which he slowly regained function in the arm
to the extent that only a mild residual weakness was
present’. Later in the course, he had ‘intermittent episodes
of diplopia’ and ‘intermittent episodes of a symptom
complex of difficulty in walking, impaired position sense
of the feet, and feelings of lightheadedness’ [7]. Relentless
progression of his neurological symptoms followed later.
The MRI pattern in our patient is partially consistent
with, but not specific for, hypertensive leukoencephalopathy. The large confluent symmetrical lesions of the corpus
callosum present a peculiar finding possibly related to
alcohol abuse. However, involvement of the basal ganglia
and brainstem is not convincingly explained by these risk
factors and strongly points to Alexander disease.
Our observation lends further support to the notion
that there is an adult subtype of Alexander disease. The
question posed by Messing et al. [30], ‘whether adult Alexander disease turns out to have the same etiology as infantile or juvenile Alexander disease’ can be affirmed. The
clinical and neuroradiological spectrum of adult Alexander disease still needs to be delineated. We recommend to
consider mutation analysis of the GFAP gene in adult
patients with remitting neurological signs and disseminated white matter lesions on MRI involving the basal
ganglia and brainstem but a lack of inflammatory CSF
abnormalities.

Brockmann/Meins/Taubert/Trappe/Grond/
Hanefeld

References
1 Alexander WS: Progressive fibrinoid degeneration of fibrillary astrocytes associated with
mental retardation in a hydrocephalic infant.
Brain 1949;72:373–381.
2 Borrett D, Becker LE: Alexander’s disease: A
disease of astrocytes. Brain 1985;108:367–
385.
3 Russo LS Jr, Aron A, Anderson PJ: Alexander’s
disease: A report and reappraisal. Neurology
1976;26:607–614.
4 Pridmore CL, Baraitser M, Harding B, Boyd
SG, Kendall B, Brett EM: Alexander’s disease:
Clues to diagnosis. J Child Neurol 1993;8:134–
144.
5 Howard RS, Greenwood R, Gawler J, Scaravilli F, Marsden CD, Harding AE: A familial disorder associated with palatal myoclonus, other
brainstem signs, tetraparesis, ataxia and Rosenthal fibre formation. J Neurol Neurosurg
Psychiatry 1993;56:977–981.
6 Schwankhaus JD, Parisi JE, Gulledge WR,
Chin L, Currier RD: Hereditary adult-onset
Alexander’s disease with palatal myoclonus,
spastic paraparesis, and cerebellar ataxia. Neurology 1995;45:2266–2271.
7 Seil FJ, Schochet SS Jr, Earle KM: Alexander’s
disease in an adult: Report of a case. Arch Neurol 1968;19:494–502.
8 Spalke G, Mennel HD: Alexander’s disease in
an adult: Clinicopathologic study of a case and
review of the literature. Clin Neuropathol
1982;1:106–112.
9 Head MW, Corbin E, Goldman JE: Overexpression and abnormal modification of the
stress proteins alpha B-crystallin and HSP27 in
Alexander disease. Am J Pathol 1993;143:
1743–1753.
10 Messing A, Head MW, Galles K, Galbreath EJ,
Goldman JE, Brenner M: Fatal encephalopathy with astrocyte inclusions in GFAP transgenic mice. Am J Pathol 1998;152:391–398.
11 Brenner M, Johnson AB, Boespflug-Tanguy O,
Rodriguez D, Goldman JE, Messing A: Mutations in GFAP, encoding glial fibrillary acidic
protein, are associated with Alexander disease.
Nat Genet 2001;27:117–120.

GFAP Mutation and Adult Alexander
Disease

12 Rodriguez D, Gauthier F, Bertini E, Bugiani
M, Brenner M, N’guyen S, Goizet C, Gelot A,
Surtees R, Pedespan JM, Hernandorena X,
Troncoso M, Uziel G, Messing A, Ponsot G,
Pham-Dinh D, Dautigny A, Boespflug-Tanguy
O: Infantile Alexander disease: Spectrum of
GFAP mutations and genotype-phenotype correlation. Am J Hum Genet 2001;69:1134–
1140.
13 Okamoto Y, Mitsuyama H, Jonosono M, Hirata K, Arimura K, Osame M, Nakagawa M:
Autosomal dominant palatal myoclonus and
spinal cord atrophy. J Neurol Sci 2002;195:71–
76.
14 Sawaishi Y, Yano T, Takaku I, Takada G:
Juvenile Alexander disease with a novel mutation in glial fibrillary acidic protein gene. Neurology 2002;580:1541–1543.
15 Gorospe JR, Naidu S, Johnson AB, Puri V,
Raymond GV, Jenkins SD, Pedersen RC, Lewis D, Knowles P, Fernandez R, De Vivo D,
van der Knaap MS, Messing A, Brenner M,
Hoffman EP: Molecular findings in symptomatic and pre-symptomatic Alexander disease
patients. Neurology 2002;58:1494–1500.
16 Meins M, Brockmann K, Yadav S, Haupt M,
Sperner J, Stephani U, Hanefeld F: Infantile
Alexander disease: A GFAP mutation in monozygotic twins and novel mutations in two other
patients. Neuropediatrics 2002;33:194–198.
17 Herndon RM, Rubinstein LJ, Freeman JM,
Mathieson G: Light and electron microscopic
observations on Rosenthal fibers in Alexander’s disease and in multiple sclerosis. J Neuropathol Exp Neurol 1970;29:524–551.
18 Riggs JE, Schochet SS Jr, Nelson J: Asymptomatic adult Alexander’s disease: Entity or nosological misconception? Neurology 1988;38:
152–154.
19 Namekawa M, Takiyama Y, Aoki Y, Takayashiki N, Sakoe K, Shimazaki H, Taguchi T,
Tanaka Y, Nishizawa M, Saito K, Matsubara
Y, Nakano I: Identification of GFAP gene mutation in hereditary adult-onset Alexander's
disease. Ann Neurol 2002;52:779–785.
20 de Leeuw FE, de Groot JC, Oudkerk M, Witteman JCM, Hofman A, van Gijn J, Breteler
MMB: Hypertension and cerebral white matter
lesions in a prospective cohort study. Brain
2002;125:765–772.

21 Sierra C, de la Sierra A, Mercader J, GomezAngelats E, Urbano-Marquez A, Coca A: Silent
cerebral white matter lesions in middle-aged
essential hypertensive patients. J Hypertens
2002;20:519–524.
22 Uehara T, Tabuchi M, Mori E: Risk factors for
silent cerebral infarcts in subcortical white
matter and basal ganglia. Stroke 1999;30:378–
382.
23 Friese SA, Bitzer M, Freudenstein D, Voigt K,
Küker W: Classification of acquired lesions of
the corpus callosum with MRI. Neuroradiology
2000;42:795–802.
24 Kawamura M, Shiota J, Yagishita T, Hirayama
K: Marchiafava-Bignami disease: Computed
tomographic scan and magnetic resonance
imaging. Ann Neurol 1985;18:103–104.
25 Ruiz-Martinez J, Martinez Perez-Balsa A, Ruibal M, Urtasun M, Villanua J, Marti Masso JF:
Marchiafava-Bignami disease with widespread
extracallosal lesions and favourable course.
Neuroradiology 1999;41:40–43.
26 Kleinschmidt-DeMasters BK, Anderson CA,
Rubinstein D: Asymptomatic pontine lesions
found by magnetic resonance imaging: Are
they central pontine myelinolysis? J Neurol Sci
1997;149:27–35.
27 Pullicino P, Ostrow P, Miller L, Snyder W,
Munschauer F: Pontine ischemic rarefaction.
Ann Neurol 1995;37:460–466.
28 van der Knaap MS, Naidu S, Breiter SN, Blaser
S, Stroink H, Springer S, Begeer JC, van Coster
R, Barth PG, Thomas NH, Valk J, Powers JM:
Alexander disease: Diagnosis with MR imaging. AJNR Am J Neuroradiol 2001;22:541–
552.
29 Heier LA, Bauer CJ, Schwartz L, Zimmerman
RD, Morgello S, Deck MDF: Large VirchowRobin spaces: MR-clinical correlation. AJNR
Am J Neuroradiol 1989;10:929–936.
30 Messing A, Goldman JE, Johnson AB, Brenner
M: Alexander disease: New insights from genetics. J Neuropathol Exp Neurol. 2001;60:
563–573.

Eur Neurol 2003;50:100–105

105

Copyright: S. Karger AG, Basel 2003. Reproduced with the permission of S. Karger AG, Basel. Further
reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright
holder.