Parkinsonism-dementia Complex Of Guam Research Articles

BMAA selectively injures motor neurons via AMPA/kainate receptor activation

The toxin beta-methylamino- l-alanine (BMAA) has been proposed to contribute to amyotrophic lateral sclerosis–Parkinsonism Dementia Complex of Guam (ALS/PDC) based on its ability to induce a similar disease phenotype in primates and its presence in cycad seeds, which constituted a dietary item in afflicted populations. Concerns about the apparent low potency of this toxin in relation to estimated levels of human ingestion led to a slowing of BMAA research. However, recent reports identifying potential new routes of exposure compel a re-examination of the BMAA/cycad hypothesis. BMAA was found to induce selective motor neuron (MN) loss in dissociated mixed spinal cord cultures at concentrations (∼ 30 μM) significantly lower than those previously found to induce widespread neuronal degeneration. The glutamate receptor antagonist NBQX prevented BMAA-induced death, implicating excitotoxic activation of AMPA/kainate receptors. Using microfluorimetric techniques, we further found that BMAA induced preferential [Ca 2+] i rises and selective reactive oxygen species (ROS) generation in MNs with minimal effect on other spinal neurons. Cycad seed extracts also triggered preferential AMPA/kainate-receptor-dependent MN injury, consistent with the idea that BMAA is a crucial toxic component in this plant. Present findings support the hypothesis that BMAA may contribute to the selective MN loss in ALS/PDC.

Characterization of tau pathologies in gray and white matter of Guam parkinsonism-dementia complex

Guam parkinsonism-dementia complex (PDC) is a neurodegenerative tauopathy in ethnic Chamorro residents of the Mariana Islands that manifests clinically with parkinsonism as well as dementia and is characterized neuropathologically by prominent cortical neuron loss in association with extensive telencephalic neurofibrillary tau pathology. To further characterize cortical gray and white matter tau, alpha-synuclein and lipid peroxidation pathologies in Guam PDC, we examined the brains of 17 Chamorro PDC and control subjects using biochemical and immunohistological techniques. We observed insoluble tau pathology in both gray and white matter of PDC and Guam control cases, with frontal and temporal lobes being most severely affected. Using phosphorylation dependent anti-tau antibodies, abundant tau inclusions were detected by immunohistochemistry in both neuronal and glial cells of the neocortex, while less alpha-synuclein pathology was observed in more limited brain regions. Further, in sharp contrast to Alzheimer's disease (AD), levels of the lipid peroxidation product 8, 12-iso-iPF(2alpha)-VI isoprostane were not elevated in Guam PDC brains relative to controls. Thus, although the tau pathologies of Guam PDC share similarities with AD, the composite Guam PDC neuropathology profile of tau, alpha-synuclein and 8, 12-iso-iPF(2alpha)-VI isoprostane reported here more closely resembles that seen in other tauopathies including frontotemporal dementias (FTDs), which may imply that Guam PDC and FTD tauopathies share underlying mechanisms of neurodegeneration.

Thrombin and Prothrombin Are Expressed by Neurons and Glial Cells and Accumulate in Neurofibrillary Tangles in Alzheimer Disease Brain

Thrombin is a serine protease that is generated by proteolytic cleavage of its precursor, prothrombin. We previously showed that thrombin proteolyses the microtubule-associated protein tau and that phosphorylation of tau inhibits this process. To characterize further the role of thrombin in the brain, we investigated prothrombin and thrombin expression in cultured brain cells and in brains of control, Alzheimer disease (AD) and parkinsonism-dementia complex of Guam (PDCG). We show by reverse transcriptase-polymerase chain reaction that prothrombin mRNA is expressed in brain tissues, neuroblastoma cells, and cultured human astrocytes, oligodendrocytes, and microglial cells. We also show by immunohistochemistry that the proteins prothrombin and thrombin are present in brain using specific monoclonal and polyclonal antibodies for both proteins. All antibodies stained residual serum in blood vessels, as well as normal pyramidal neurons and their processes, and some astrocytes. Additionally, in AD and PDCG cases, all antibodies stained extra- and intracellular neurofibrillary tangles (NFTs), senile plaques, and reactive microglial cells. The ubiquitous expression of prothrombin and thrombin in brain cells suggests that thrombin plays an important physiological role in normal brain. The accumulation of thrombin and prothrombin in NFTs supports the hypothesis that thrombin may be involved in tau proteolysis and that failure to metabolize tau may lead to its aggregation in neurodegenerative diseases.

Tau-Positive Fine Granules in the Cerebral White Matter: A Novel Finding Among the Tauopathies Exclusive to Parkinsonism-Dementia Complex of Guam

We examined the autopsied brains of cases of 6 types of tauopathy: parkinsonism-dementia complex of Guam (PDC), corticobasal degeneration (CBD), progressive supranuclear palsy (PSP), Pick disease, Alzheimer disease (AD), and myotonic dystrophy together with Guamanian controls. Light microscopy sections of these brains were examined using anti-tau antibodies. Tau-positive fine granules (TFGs) were globe-shaped, and 3 to 6 mum in diameter, were observed predominantly in the frontal white matter in 30 of the 35 patients with PDC. However, no TFGs were found in association with PSP, myotonic dystrophy, Pick disease, AD, or CBD. Western blot analysis of frozen brain tissue taken from the PDC cases revealed that the frontal cortex was hyperphosphorylated and contained 6 tau isoforms (3R+4R tau). However, in the present study, it was revealed that the novel TFGs in the white matter of patients with PDC was composed of 4R tau. Western blot analysis of sarkosyl-insoluble tau from the white matter of the PDC cases showed 2 major bands of 60 and 64 kDa and one minor band of 67 kDa. After dephosphorylation, these bands resolved into one major band of 4-repeat (4R) tau isoform and 3 minor bands of 3-repeat (3R) and 4R tau isoforms. Moreover, the TFGs observed in cases in which the number of neurofibrillary tangles (NFTs) was higher than the threshold level were not correlated with the presence of cortical NFTs. In conclusion, these novel TFGs were found almost exclusively in PDC brains and could therefore be considered as a characteristic neuropathologic marker of this particular tauopathy. The TFGs were hyperphosphorylated tau-positive structures that may be formed by a different mechanism from that used to produce cortical NFTs.

The nature of the parkinsonism-dementia complex and amyotrophic lateral sclerosis of Guam and magnesium deficiency

The parkinsonism-dementia complex (PDC) and amyotrophic lateral sclerosis (ALS) were the fatal neurological diseases, showing very high incidence during 1950–1970 and dramatic decrease after 1970 on Guam. Through the research, the present author insisted that; (1) NFTs in Guam ALS patients are merely a background feature widely dispersed in the population, (2) Guam ALS and PDC are basically different diseases, and (3) Guam ALS occurs initially as classic ALS. As pathogeneses of the diseases, intake of low calcium (Ca) and magnesium (Mg) and high aluminum water and of some plant excitatory neurotoxin has been speculated. To elucidate the pathogenesis, the author performed an experiment exposing rats to low Ca and/or Mg intake for two generations, so as to follow the actual way of human living on the island, since several generations live continuously in the same environment. The study indicates that continuous low Mg intake for two generations induces exclusive loss of dopaminergic neurons in in rats, and may support the Mg hypothesis in the pathogenesis of PDC of Guam.

Tau and α-Synuclein Inclusions in a Case of Familial Frontotemporal Dementia and Progressive Aphasia

Recent studies have shown that neurofibrillary tangles are frequently accompanied by alpha-synuclein inclusions in sporadic and familial Alzheimer disease, in Down syndrome, in progressive supranuclear palsy, and Parkinsonism dementia complex of Guam. Here we report the cases of 2 brothers with familial progressive aphasia who developed features of frontotemporal dementia with predominant tau pathology but also alpha-synuclein pathology. The 2 patients' brains revealed abundant tau pathology in the hippocampus and basal ganglia, whereas tau and alpha-synuclein aggregates coexisted only in the nucleus basalis of Meynert, the only region where alpha-synuclein was present. In this brain region, abundant Lewy bodies, Lewy neurites, and tau inclusions were found; the pathology was more abundant in the older than in the younger brother. Sarkosyl-insoluble tau extracted from brains of the 2 patients showed the presence of tau filaments that contained 3 major tau bands of 60, 64, and 68 kDa on Western blot analysis. These bands contained mainly tau with 3 and 4 repeats and no amino-terminal inserts and tau with 4 repeats and one amino-terminal insert. No mutations were identified in the tau, alpha-synuclein, beta-synuclein, or parkin genes. We think that this is the first report showing a specific colocalization of neurofibrillary tangles and Lewy bodies in a family with progressive aphasia.

Inflammation and the Degenerative Diseases of Aging

Chronic inflammation is associated with a broad spectrum of neurodegenerative diseases of aging. Included are such disorders as Alzheimer's disease (AD), Parkinson's disease (PD), amyotrophic lateral sclerosis, the Parkinson-dementia complex of Guam, all of the tauopathies, and age-related macular degeneration. Also included are such peripheral conditions as osteoarthritis, rheumatoid arthritis, atherosclerosis, and myocardial infarction. Inflammation is a two-edged sword. In acute situations, or at low levels, it deals with the abnormality and promotes healing. When chronically sustained at high levels, it can seriously damage viable host tissue. We describe this latter phenomenon as autotoxicity to distinguish it from autoimmunity. The latter involves a lymphocyte-directed attack against self proteins. Autotoxicity, on the other hand, is determined by the concentration and degree of activation of tissue-based monocytic phagocytes. Microglial cells are the brain representatives of the monocyte phagocytic system. Biochemically, the intensity of their activation is related to a spectrum of inflammatory mediators generated by a variety of local cells. The known spectrum includes, but is not limited to, prostaglandins, pentraxins, complement components, anaphylotoxins, cytokines, chemokines, proteases, protease inhibitors, adhesion molecules, and free radicals. This spectrum offers a huge variety of targets for new anti-inflammatory agents. It has been suggested, largely on the basis of transgenic mouse models, that stimulating inflammation rather than inhibiting it can be beneficial in such diseases as AD. If this were the case, administration of NSAIDs, or other anti-inflammatory drugs, would be expected to exacerbate conditions such as AD, PD, and atherosclerosis. However, epidemiological evidence overwhelmingly demonstrates that the reverse is true. This indicates that, at least in these diseases, the inflammation is harmful. So far, advantage has not been taken of opportunities indicated by these epidemiological studies to treat AD and PD with appropriate anti-inflammatory agents. Based on this evidence, classical NSAIDs are the most logical choice. Dosage, though, must be sufficient to combat the inflammation. Analysis of mRNA levels of inflammatory mediators indicates that the intensity of inflammation is considerably higher in AD hippocampus and in PD substantia nigra than in osteoarthritic joints. Thus, full therapeutic doses of NSAIDs, or combinations of anti-inflammatory agents, are needed to achieve the suggested neurological benefits.

Genome-Wide Analysis of the Parkinsonism-Dementia Complex of Guam

Parkinsonism-dementia complex (PDC) is a neurofibrillary tangle degeneration involving the deposition of Alzheimer-type tau, predominantly in the mesial temporal cortex, brainstem, and basal ganglia. It occurs in focal geographic isolates, including Guam and the Kii peninsula of Japan. The familial clustering of the disease has suggested that a genetic factor could be important in its etiology. To determine whether a genetic locus could be identified, linked, or associated with PDC. We performed a genome-wide association study of 22 Guamanian PDC and 19 control subjects using 834 microsatellite markers with an approximate genome-wide marker density of 4.4 centimorgans. Two-point association analysis identified 17 markers (P<.015). Each of these markers then underwent conventional linkage analysis in 5 families with PDC. One marker, D20S103, generated a logarithm of odds score of greater than 1.5. Multipoint association analysis also highlighted 2 other areas on chromosome 14q (adjacent to D14S592, 59.2 megabases [M]) and chromosome 20 (adjacent to D20S470, 17.4 M) with multipoint association logarithm of the odds scores of greater than 2. The areas around D20S103, D14S592, and D20S470 were further analyzed by association using additional microsatellite markers and by conventional linkage analysis. This did not provide further evidence for the role of these areas in PDC. This study has not identified a single gene locus for PDC, confirming the impression of a geographic disease isolate with a complex genetic, a genetic/environmental etiology, or a purely environmental etiology.

Amyotrophic lateral sclerosis and parkinsonism-dementia complex of Guam: changing incidence rates during the past 60 years.

In the 1950s, the incidence of amyotrophic lateral sclerosis (ALS, or Lytico) and parkinsonism-dementia complex (PDC, or Bodig) on the island of Guam was much higher than anywhere else in the world. From the late 1960s to the early 1980s, the incidence of both disorders has decreased. The objective of the present study was to ascertain whether the decreasing incidence continued until the end of the century (1999). The average annual incidence of ALS and PDC was calculated for each 5-year period from 1940 to 1999, utilizing registration records of all ALS and PDC cases on Guam during that period. The results of this study confirmed that the incidence of ALS declined steadily during the past 40 years. The incidence of PDC also declined until the late 1980s but, unlike ALS, showed a slight increase from 1980 to 1999. The rapid decrease in incidence is not likely to be due to genetic factors. Instead, it is most likely to be the results of radical socioeconomic, ethnographic, and ecologic changes brought about by the rapid westernization of Guam.

Concentrations of Cd, Co, Cu, Fe, Mn, Rb, V, and Zn in formalin-fixed brain tissue in amyotrophic lateral sclerosis and Parkinsonism-dementia complex of Guam determined by High-resolution ICP-MS.

Amyotrophic lateral sclerosis (ALS) and parkinsonism-dementia complex (PDC) are neurodegenerative disorders that occurred with extremely high frequency among the native population on Guam, especially in the 1950s and 1960s, but have substantially declined over the last half-century. The etiology of these diseases is unknown, but the most plausible hypothesis centers on imbalances in essential and toxic metals. We have determined the concentrations of Cd, Co, Cu, Fe, Mn, Rb, V, and Zn in formalin-fixed brain tissue collected during the period 1979-1983 from eight Guamanian patients with ALS, four with PDC, and five control subjects using high-resolution inductively coupled plasma-mass spectrometry. The concentrations of Cd are markedly and significantly elevated both in gray and white matter in ALS, but not in PDC patients. The concentrations of Zn are elevated for both patient groups, in both gray and white matter, but only the difference in gray matter for PDC is significant. For the other metals, no significant differences are found.

ALS and PDC of Guam: forty-year follow-up.

It was noticed in the mid-1950s that the incidence of ALS and parkinsonism--dementia complex (PDC) were much higher on Guam than anywhere else in the world. In 1958, a registry of patients and controls was established to ascertain the familial and genetic aspects of these diseases. Patients and individually matched controls and their relatives were registered from 1958 to 1963. The registry was updated and analyzed in 1998 through 1999. To ascertain whether first-degree relatives of patients had a higher risk for developing ALS or PDC than relatives of controls. During the period of 1958 to 1963, 126 new patients and 126 individually matched controls and their respective first-degree relatives and spouses were evaluated neurologically and registered. Forty years later, the number of new cases among the patient and control relatives were compared to an expected number of new cases based on the age- and sex-specific incidence of ALS and PDC in the population at large. From 1958 to 1999, there were 102 new ALS or PDC cases among relatives of patients and 33 among relatives of controls. These values were compared with the derived expected values. There were more observed than expected new cases among patients' relatives, and less observed cases than expected among the controls' relatives. Relatives of patients with ALS or PDC have significantly higher risks for developing the disease than the Guamanian population, whereas relatives of controls have significantly lower risks.

The parkinsonism dementia complex of Guam and flying foxes

This article was written by Huw Morris as a commentary on our interview with Oliver Sacks and Paul Cox which you can find at www.acnr.co.uk/2021/01/dementia-complex-of-guam/. Huw spent some time in Guam and is able to rely on his own experiences and local knowledge and contacts to provide the interesting counterpoint that forms his commentary.

Cholinergic deficits in the brains of patients with parkinsonism-dementia complex of Guam.

Patients with parkinsonism-dementia complex (PDC) of Guam showed moderate loss of choline acetyl transferase activity in the midfrontal and inferior parietal cortex, and severe loss in the superior temporal cortex. This deficit was similar to that seen in Alzheimer's disease and less severe than Lewy body disease. Thus, cholinergic deficits in the neocortex might contribute to some of the cognitive alterations in PDC of Guam.

Induction of complement C9 messenger RNAs in human neuronal cells by inflammatory stimuli: relevance to neurodegenerative disorders.

Neurons express proteins of the classical complement pathway, including C9. Both the mRNA and protein levels for C9 are sharply upregulated in brain areas affected by Alzheimer's disease (AD). Since little is known about the signals that are responsible for this upregulation, we evaluated in human SH-SY5Y neuroblastoma cells the factors which stimulate C9 production. Interferon-gamma, phorbol myristate acetate and interleukin-6 all stimulated C9 mRNA expression but the inflammatory cytokines tumor necrosis factor-alpha, interleukin-1 beta, as well as the anaphylatoxin C5a and the bacterial lipopolysaccharide, were ineffective. Immunohistochemical analysis of postmortem human brains for C9 protein demonstrated its presence in many cortical pyramidal neurons in AD, Down's syndrome, the parkinsonism dementia complex of Guam and pallido-ponto-nigral degeneration, as well as in thalamic neurons of progressive supranuclear palsy and ballooned neurons of Pick's disease. Since C9 is required for the membrane attack complex of complement to become functional, interfering with signaling pathways that stimulate its production could offer new therapeutic strategies for treating various neurodegenerative disorders.

Influence of Apolipoprotein E3 on the Production of Paired Helical Filament in Guamanian Parkinsonism‐dementia Complex/Amyotrophic Lateral Sclerosis and Alzheimer's Disease

Background: Neuropathologically, Guamanian parkinsonism‐dementia complex (PDC) and amyotrophic lateral sclerosis (ALS) are characterized by neuronal loss and neurofibrillary tangles (NFTs). The NFTs are principally composed of paired helical filaments (PHFs) consisting of hyperphosphorylated tau and have been shown to be histopathologically similar to those in Alzheimer's disease (AD). Recent biochemical studies have suggested that the binding of apolipoprotein E3 (ApoE3) to tau may interfere with the hyperphosphorylation of tau, thus resulting in neuroprotective effects. Methods: In order to clarify the influence of ApoE3 on the production of PHFs in various pathological conditions, the ɛ3 allele frequency in patients with Guamanian PDC and ALS, as well as AD, was examined. Results: The results obtained in this study showed no significant differences between these affected groups and each of the controls in terms of the frequency of the ApoE3 allele. Conclusion: Although ApoE3 has been implicated in the production of PHFs, the present study suggests that ApoE3 may not have a strong inhibitory effect on the production of NFTs in these affected patients.

Tauopathies--a new class of neurodegenerative diseases

Recently it was shown by several research groups that mutations in the gene encoding for the tau protein associated with microtubuli on chromosome 17 caused a distinct form of dementia named frontotemporal dementia and parkinsonism (FTDP-17). This disease includes familial asymmetrical frontal and, in the further course, frontotemporal dementia, parkinsonism, which is often initially sensitive to levodopa, signs of upper motor neuron degeneration, and, less commonly, amyotrophy. Tau is an intracellular protein of the cytoskeleton, which is responsible for the arrangement and stabilization of microtubuli. The discovery of mutations in the tau gene causing a distinct neurodegenerative disease in humans has firmly established the importance of the tau gene for neurodegenerative processes, not only in tauopathies but also in other degenerative disorders with tau pathology, such as corticobasal degeneration, supranuclear progressive paralysis, amyotropic lateral sclerosis, parkinsonism-dementia complex of Guam, and Alzheimer's disease. Our experience with patients suffering from PTDP-17 shows that its phenotype varies more than was described in the first consensus conferences. In the future, it will be important to designate the diagnostic gold standard not by clinical description, but etiologic classification.

Alpha-synuclein inclusions in amygdala in the brains of patients with the parkinsonism-dementia complex of Guam.

We investigated by immunohistochemistry the deposition of alpha-synuclein in the brains of deceased patients with the parkinsonism-dementia complex (PDC) of Guam. Five of 13 PDC brains showed numerous alpha-synuclein positive neuronal inclusions and abnormal neurites, chiefly in the amygdala. Similar alpha-synuclein positive lesions were observed, although to a lesser extent, in the entorhinal cortex and the dorsal vagal nucleus. No alpha-synuclein positive inclusions were observed in motor cortex or locus coeruleus, and only a small number of positive inclusions were found in the Sommer's sector, temporal cortex, or substantia nigra. Some of the alpha-synuclein positive inclusions were reminiscent of cortical Lewy bodies (LB), but many of those in the amygdala coexisted with tau-positive pretangles and/or neurofibrillary tangles (NFT) within the same neurons. In these neurons, tau-positive shells encapsulated alpha-synuclein positive central cores or irregularly shaped alpha-synuclein-positive deposition intermingled with pretangles/NFT. Thus, the present study suggests that a common mechanism may govern aggregation of alpha-synuclein and tau in the amygdala, and that aggregation of alpha-synuclein may play some role in the neurodegenerative process of a tauopathy (i.e. PDC) in which Abeta deposition is virtually absent.

Casein kinase 1 delta is associated with pathological accumulation of tau in several neurodegenerative diseases

The distribution of casein kinase 1 δ (Ckiδ) was studied by immunohistochemistry and correlated with other pathological hallmarks in Alzheimer’s disease (AD), Down syndrome (DS), progressive supranuclear palsy (PSP), parkinsonism dementia complex of Guam (PDC), Pick’s disease (PiD), pallido-ponto-nigral degeneration (PPND), Parkinson’s disease (PD), dementia with Lewy bodies (DLB), amyotrophic lateral sclerosis (ALS), and elderly controls. Ckiδ was found to be associated generally with granulovacuolar bodies and tau-containing neurofibrillary tangles in AD, DS, PSP, PDC, PPND, and controls, and Pick bodies and ballooned neurons in PiD. It was not associated with tau-containing inclusions in astroglia and oligodendroglia in PPND, PSP, and PDC. It was also not associated with tau-negative Lewy bodies in PD and DLB, Hirano bodies in PDC, Marinesco bodies in PD, AD, and controls and “skein”-like inclusions in anterior motor neurons in ALS. The colocalization of the kinase Ckiδ and its apparent substrate tau suggests a function for Ckiδ in the abnormal processing of tau.

Aβ42-Carboxy-Terminal-like Immunoreactivity Is Associated with Intracellular Neurofibrillary Tangles and Pick Bodies

Co-occurrence of neurofibrillary tangles (NFTs) and β-amyloid (Aβ)-containing plaques is the pathological hallmark of Alzheimer's disease (AD). Much research has been carried out to elucidate the possible interactions of these two characteristic lesions. Here we show by immunohistochemistry that an Aβ42-carboxy-terminal-like epitope (tAβ42) is associated with NFTs at an early, intraneuronal stage. The NFTs immunoreactive for tAβ42 were also positive for tau2. tAβ42 NFTs occurred even in cases without plaques or any other form of extracellular Aβ deposits. NFTs were tAβ42 immunoreactive under all tangle forming conditions studied: AD, the parkinsonism dementia complex of Guam, progressive supranuclear palsy, and elderly controls. In Pick disease, which is another “tauopathy” Pick bodies and ballooned neurons were found to be immunoreactive for tAβ42. Appearance of an epitope of Aβ in neurons at such an early stage of tangle formation and in Pick bodies may indicate a direct connection of Aβ42 and cytoskeletal disarrangement, although cross-reactivity with other epitopes cannot be ruled out.

Tau Pathology Generated by Overexpression of Tau

Neurofibrillary changes of abnormally hyperphosphorylated tau are the key lesion in Alzheimer’s disease (AD) and a number of other tauopathies. Recent developments in the field of autosomal dominantly inherited dementias, in particular the frontotemporal dementias and Parkinsonism linked to chromosome 17 (FTDP-17) group, have shown that abnormalities in the tau gene result in neurofibrillary degeneration and cell death. Clinically this disorder presents with behavioral abnormalities, which are followed by dementia and, depending on the affected areas, by motor dysfunction. The location of the lesions does not seem to depend so much on the type of mutation as on the individual’s genetic background and may vary even in the same family with the identical mutation. For instance, in one family with a P 301 S mutation in exon 10 of tau, the father presented with frontotemporal dementia, whereas the son had corticobasal degeneration. 1 FTDP-17 is associated with both exonic and intronic mutations of the tau gene. The microtubule-associated protein (MAP) tau is a family of six proteins derived by alternative mRNA splicing 2,3 from a single gene located on chromosome 17. These molecular isoforms of tau differ in whether they contain three or four tubulin binding domains/repeats of 31 or 32 amino acids each near the C-terminal end and no, one, or two inserts of 29 amino acids each at the N-terminal end of the molecule. There are nine missense mutations on tau exons 9 to 13; all but three are on exon 10. 4-7 Exon 10 codes for the additional insert of the three 4-repeat tau isoforms. The resulting mutated taus possess an altered conformation 8 and a somewhat reduced ability to bind to and assemble microtubules. 9,10 In addition to the exonic mutations, mutations at several sites have been found in the predicted stem loop structure in the 5′ splice site to exon 10. These intronic mutations and certain mutations in exon 10 that are close to the stem loop, and thus able to disrupt it, lead to two- to sixfold higher proportion of tau mRNA containing exon 10 than in control brains. 5 The tau protein resulting from intronic mutations is normal, but the ratio of 4-repeat to 3-repeat isoforms is increased. Presently it is believed that due to the increased proportion of 4-repeat tau in the case of intronic mutations and the compromised biological activity of the tau with missense mutations, excess tau is not bound to the microtubules, which can then be hyperphosphorylated and would lead to neurofibrillary degeneration. In contrast to the FTDP-17 group of diseases, no mutations in the tau gene have been reported in AD at the time of writing this Commentary. In more than 90% of the AD patients the disease occurs sporadically above 60 years of age. In less than 5% of the cases the disease segregates with mutations in the amyloid precursor protein (APP), presenilin-1 (PS-1), or presenilin-2 (PS-2) genes. 11 Frameshift mutations of APP and ubiquitin at the level of transcription have been reported to be associated with sporadic and familial AD and Down’s syndrome. 12 The occurrence of the apolipoprotein E4 allele 13 and, most recently, mutations in the β2 macroglobulin gene 14 have been reported to be risk factors for the development of the late onset, sporadic AD. AD has two prominent neuropathological lesions, the extracellular deposits of the amyloid β peptide (Aβ) as plaques and the intraneuronal paired helical filaments (PHF) of abnormally hyperphosphorylated tau, which accumulate in the neuronal cell body as neurofibrillary tangles, in the neuropil (the so-called neuropil threads), 15 and in the dystrophic neurites surrounding the neuritic plaques. The direct relationship, if any, between the tangles and β-amyloid is not yet understood. At the one extreme, in the normal aged brain there is the significant β-amyloid accumulation and minimal neurofibrillary degeneration, whereas in the early onset familial AD with mutations in the β-APP or presenilin gene, massive β-amyloid deposits, tau hyperphosphorylation, and tangle formation are always seen. The other extreme situation is represented by extensive neurofibrillary degeneration and minimal β-amyloidosis. These include tauopathies like the tangle-predominant form of senile dementia (tangle-only dementia), Guam Parkinsonism dementia complex, dementia with argyrophilic grains, Nieman Pick’s disease type C, subacute sclerosing panencephalitis, Pick’s disease, and the dementia group with mutations in the tau gene. 16 Although at present the exact role of PHF and β-amyloid in the pathogenesis of AD is not established, there is growing evidence from a number of laboratories that the intellectual deterioration in AD patients is associated with neurofibrillary degeneration. 17-20 A third and well characterized phenomenon is synaptic loss and cell death exceeding 50% in certain areas of the brain. 21,22