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Reduced folate transport to the CNS in female Rett patients

From the Division of Pediatric Neurology, Department of Pediatrics (Drs. Ramaekers, Opladen, Senderek, Häusler, and Heimann), University Hospital Aachen, Germany; Department of Clinical Chemistry (Drs. Hansen and Holm), Hillerød Sygehus, Hillerød, Denmark; Department of Clinical Chemistry (Dr. Fowler), University Children’s Hospital, Basel, Switzerland; Institute of Medical Genetics and Molecular Medicine (Dr. Maiwald), Cologne, Germany; and Division of Clinical Chemistry and Biochemistry (Dr. Blau), University Children’s Hospital, Zürich, Switzerland.

Address correspondence and reprint requests to Dr. Vincent T. Ramaekers, Division of Pediatric Neurology–Department of Pediatrics, University Hospital Aachen, Pauwelsstrasse 30, D-52074 Aachen, Germany; e-mail: vramaekers{at}ukaachen.de

Background: Previous CSF studies in Rett syndrome suggest reduced turnover of the biogenic monoamines serotonin and dopamine. Because diminished turnover may result from CNS folate depletion, the authors studied transport of folate across the blood–brain barrier.

Methods: In four patients with Rett syndrome, the authors measured CSF values of 5-methyltetrahydrofolate (5MTHF), biogenic monoamine end-metabolites, and pterins together with serum and red blood cell folate. In CSF, the overall folate binding capacity by the two soluble folate-binding proteins FBP1 and FBP2 (sFBP) was measured using a radioligand binding method for H³-labeled folate. A specific immunoreactive test (ELISA) detected sFBP1, which normally contributes to 30 to 35% of the total folate binding capacity. Genetic analysis included DNA sequencing of the MECP2, FBP1, and FBP2 genes. Empirical treatment with oral folinic acid was evaluated.

Results: Two patients without and two with mutations of the MECP2 gene had normal values for red blood cell folate, serum folate, homocysteine, and methionine. In CSF, all patients had low values for 5MTHF, neopterin, and the serotonin end-metabolite 5-hydroxyindoleacetic acid (5-HIAA). Genetic analysis of FBP1 and FBP2 genes had normal results. Compared to controls, patients with Rett syndrome had normal immunoreactive sFBP1 in CSF, whereas the total folate binding capacity was disproportionately lowered. Empirical treatment with oral folinic acid normalized 5-MHTF and 5-HIAA levels in CSF, and led to partial clinical improvement.

Conclusion: Irrespective of the MECP2 genotype, 5MTHF transfer to the CNS is reduced in Rett syndrome. Folinic acid supplementation restores 5MTHF levels and serotoninergic turnover. The lowered folate binding capacity of FBP is not explained by a defect of the FBP1 or FBP2 gene, but most likely occurs as a secondary phenomenon in Rett syndrome.

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