Three Cases of Levodopa–Carbidopa Responsive Nocturnal Akinesis in Male Children of an Inbred Family in Rural Baluchistan, Pakistan
7 affiliations
- 1Pakistan Society of Internal Medicine, Justice Akram Road, Lahore 54600, Pakistan
- 2Jinnah Burn and Reconstructive Surgery Center, Allama Iqbal Medical College, University of Health Sciences, Lahore 54550, Pakistan
- 3Department of Otorhinolaryngology Head & Neck Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
- 4Department of Molecular Biology, Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad 44000, Pakistan
- 5Shifa College of Pharmaceutical Sciences, Shifa Tameer-e-Millat University, Islamabad 44000, Pakistan
- 6Department of Biochemistry and Molecular Biology, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
- 7Marlene & Stewart Greenebaum Comprehensive Cancer Center, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
Abstract
After more than 9 years of follow-up, we describe three affected male siblings from a consanguineous family (PKSOK) in rural Baluchistan, Pakistan, who presented with levodopa–carbidopa responsive nocturnal akinesia associated with tyrosine hydroxylase deficiency. The affected individuals also show delayed motor milestones, mild intellectual disability, speech and psychomotor delay, without epilepsy, spasticity, cerebellar ataxia, or daytime motor weakness. The marked improvement in nocturnal motor symptoms following levodopa–carbidopa (100 mg/25 mg) treatment raised the possibility of an underlying disorder of dopamine biosynthesis. Exome sequencing of the two affected siblings (IV:16 and IV:18) revealed twenty rare (frequency < 0.001) homozygous coding variants shared between them. However, segregation analysis with the disease phenotype ruled out the potential involvement of all these twenty variants. Therefore, we extended the analysis beyond the coding region variants to non-coding variants, which revealed a homozygous variant, c.-70G>A, in the regulatory region of TH (tyrosine hydroxylase). The c.-70G>A variant has been previously reported in three studies; however, our study represents the first report in the South Asian population. Our study also expands the phenotypic spectrum of disorders associated with variants in TH and highlights the importance of considering variants in regulatory regions of TH in patients with atypical but levodopa-responsive neurological phenotypes.
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BibTeX
@article{akram2026three,
title = {{Three Cases of Levodopa–Carbidopa Responsive Nocturnal Akinesis in Male Children of an Inbred Family in Rural Baluchistan, Pakistan}},
author = {Javed Akram and Amama Ghaffar and Muhammad A. Usmani and Usman Shareef and Zubair M. Ahmed and Sheikh Riazuddin and Saima Riazuddin},
journal = {International Journal of Molecular Sciences},
year = {2026},
month = oct,
doi = {10.3390/ijms27209068},
url = {https://www.mdpi.com/1422-0067/27/20/9068},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Three Cases of Levodopa–Carbidopa Responsive Nocturnal Akinesis in Male Children of an Inbred Family in Rural Baluchistan, Pakistan
AU - Javed Akram
AU - Amama Ghaffar
AU - Muhammad A. Usmani
AU - Usman Shareef
AU - Zubair M. Ahmed
AU - Sheikh Riazuddin
AU - Saima Riazuddin
PY - 2026
DA - 2026/10/01
JO - International Journal of Molecular Sciences
DO - 10.3390/ijms27209068
UR - https://www.mdpi.com/1422-0067/27/20/9068
AB - After more than 9 years of follow-up, we describe three affected male siblings from a consanguineous family (PKSOK) in rural Baluchistan, Pakistan, who presented with levodopa–carbidopa responsive nocturnal akinesia associated with tyrosine hydroxylase deficiency. The affected individuals also show delayed motor milestones, mild intellectual disability, speech and psychomotor delay, without epilepsy, spasticity, cerebellar ataxia, or daytime motor weakness. The marked improvement in nocturnal motor symptoms following levodopa–carbidopa (100 mg/25 mg) treatment raised the possibility of an underlying disorder of dopamine biosynthesis. Exome sequencing of the two affected siblings (IV:16 and IV:18) revealed twenty rare (frequency < 0.001) homozygous coding variants shared between them. However, segregation analysis with the disease phenotype ruled out the potential involvement of all these twenty variants. Therefore, we extended the analysis beyond the coding region variants to non-coding variants, which revealed a homozygous variant, c.-70G>A, in the regulatory region of TH (tyrosine hydroxylase). The c.-70G>A variant has been previously reported in three studies; however, our study represents the first report in the South Asian population. Our study also expands the phenotypic spectrum of disorders associated with variants in TH and highlights the importance of considering variants in regulatory regions of TH in patients with atypical but levodopa-responsive neurological phenotypes.
SN - 1422-0067
ER -