Ubiquilin-2 Gene Mutation Presenting with Adult-Onset Ataxia and Spasticity: Report Of A Novel Phenotype Case - European Medical Journal

Ubiquilin-2 Gene Mutation Presenting with Adult-Onset Ataxia and Spasticity: Report Of A Novel Phenotype Case

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*Thomai Stardeli,1 Theodora Afrantou,1 Georgia Xiromerisiou,2 Maria Karatzikou,1 Sofia Kitmeridou,1 Maria Dimitriou,1 Aggeliki – Stiliani Sintila,1 Nikolaos Grigoriadis1

The authors have declared no conflicts of interest.


The authors would like to thank all patients and families.

EMJ Neurol. ;8[1]:58-59. Abstract Review No: AR12.
Amyotrophic lateral sclerosis (ALS), ataxia, spasticity, ubiquilin-2 (UBQLN2).

Each article is made available under the terms of the Creative Commons Attribution-Non Commercial 4.0 License.


UBQLN2 is a member of the ubiquitin-like protein family and plays a critical role in protein clearance pathways including the ubiquitin–proteasome system.1,2 It also functions to modulate autophagy, cell signalling, cell-cycle progression, and cytoskeletal association.2 UBQLN2 mutations cause a small subset of amyotrophic lateral sclerosis (ALS), and ALS-frontotemporal dementia (ALS–FTD) cases.3-6 More widespread is the presence of UBQLN2-positive inclusions in the affected neurons of some familial and sporadic ALS and ALS-FTD cases, indicating a pathogenic role for UBQLN2 in these diseases.1,5-8


A 35-year-old female with normal developmental milestones and an unremarkable personal and family history presented with oscillopsia, dizziness, and unstable gait with subacute onset and gradual progression.

The neurological examination revealed mild cognitive impairment, diplopia, dysarthric speech, marked tremor, limb and gait ataxia, along with evident spasticity. In the first 2 years, the patient deteriorated, evolving difficulty in swallowing thin liquids as well as urinary incontinence, fasciculations, and required bilateral assistance for walking.

Blood examinations were notable for iron deficiency anaemia. Cerebrospinal fluid analysis was normal and examination for autoimmune and metabolic diseases was insignificant. Brain and spinal cord MRI scans were normal initially and on follow-up, while the electroencephalographic examination recorded mild diffuse slowness with rare lateralised epileptiform discharges on the right hemisphere without deterioration. A wide panel for antibodies causative of autoimmune and paraneoplastic encephalomyelitis was negative, as well as investigation for underlying malignancy with full body CT and PET scan. Genetic testing for common modalities causing ataxia and/or spasticity showed no pathology. Needle electromyography was consistent with mild denervation in the first dorsal interosseous muscle of the right hand. The patient received first-line immunotherapies, with no amelioration of signs and symptoms.

Whole exome sequencing was performed, revealing a mutation in the UBQLN2 gene in X-chromosome [c.1019G>T (p.Ser340Ile)]. Genetic testing was performed for the patient’s parents, revealing the same mutation in her father, who is asymptomatic at the age of 65 with the same neurophysiologic findings in needle electromyography.

Following the initial deterioration, the patient had a stable disease course at 5-years follow-up and is receiving symptomatic treatment for tremor and spasticity.


Studies have revealed that UBQLN2 plays a pathogenic role in X-linked ALS with or without FTD.3,5-7 The course of familial ALS is slower than that of sporadic cases.9 UBQLN2 mutations have been associated with ALS with onset from third to seventh decade, with spasticity, muscle weakness, dysphagia, and dysarthria. Women tend to manifest milder phenotypes, with late onset and decreased penetrance.3,9,10


Here is presented a case with clinical features of predominant ataxia with evident spasticity but without muscle weakness, and with stable disease course after the initial progression after a 5-year follow-up. This phenotype has not previously been documented in association with a mutation in the UBQLN2 gene.

Walters KJ et al. Structural studies of the interaction between ubiquitin family proteins and proteasome subunit S5a. Biochemistry. 2002;41(6):1767-77. Zhang KY et al. Ubiquilin 2: a component of the ubiquitin–proteasome system with an emerging role in   neurodegeneration. Int J Biochem Cell Bio. 2014;50:123-6. Deng HX et al. Mutations in UBQLN2 cause dominant X-linked juvenile and adult-onset ALS and ALS/dementia. Nature. 2011;477(7363):211-5. Alexander EJ et al. Ubiquilin 2 modulates ALS/FTD-linked FUS–RNA complex dynamics and stress granule formation. Proc Natl Acad Sci. 2018;115(49):E11485-94. Chang L, Monteiro MJ. Defective proteasome delivery of polyubiquitinated proteins by ubiquilin-2 proteins containing ALS mutations. PLoS One. 2015;10(6):e0130162. Daoud H, Rouleau GA. Motor neuron disease: a role for ubiquilin 2 mutations in neurodegeneration. Nat Rev Neurol. 2011;7(11):599. Gellera C et al. Ubiquilin 2 mutations in Italian patients with amyotrophic lateral sclerosis and frontotemporal dementia. J Neurol Neurosurg Psychiatry. 2013;84(2):183-7. Osaka M et al. Disturbance of proteasomal and autophagic protein degradation pathways by amyotrophic lateral sclerosis-linked mutations in ubiquilin 2. Biochem Biophys Res Commun. 2016;472(2):324-31. Li HF, Wu ZY. Genotype-phenotype correlations of amyotrophic lateral sclerosis. Transl Neurodegener. 2016;5(1);3. Fahed AC et al. UBQLN2 mutation causing heterogeneous X-linked dominant neurodegeneration. Ann Neurol.2014;75(5):793-8.

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