[X-linked adrenoleukodystrophy].

X-linked adrenoleukodystrophy (ALD) is a severe neurodegenerative disorder. ALD is characterized by progressive demyelination within the central and peripheral nervous system, adrenal insufficiency (Addison's disease) and accumulation of very-long-chain fatty acids (VLCFA) in plasma, fibroblasts and tissues. The overall incidence of ALD is 1:17,000 including hemizygotes and heterozygotes who are frequently symptomatic. There are two main ALD phenotypes: 1) a cerebral demyelinating form which affects boys between 5-12 years, but also 35% of adult males; 2) a form that mainly involves the spinal cord (adrenomyeloneuropathy, AMN) in adult males between 20-50 years and 50% of heterozygous women after the age of 40 years. AMN presents with progressive spastic paraparesis. Addison's disease may be the first symptom of ALD in boys and adult males. These patients are at risk to develop cerebral ALD or AMN for life. ALD results from mutations in the ABCD1 gene without correlation between genotype and phenotype. The diagnosis of ALD relies upon the measurement of plasma VLCFA levels that allows the identification of 100% affected males and of 80-95% heterozygous women. Because of these false-negative, it is therefore mandatory to search for a mutation in the ABCD1 gene in all women at risk to be heterozygous for ALD. The ABCD1 gene encodes a peroxisomal transmembrane protein (ALD protein) with the structure of an half ATP-binding cassette transporter. It is possible that ALD protein imports VLCFA or VLCFA-CoA into peroxisomes in which they are degraded by a peroxisomal beta-oxidation system. Elongation of VLCFAs is enhanced in fibroblasts from ALD patients and likely contributes to the load of VLCFA in tissues. The underlying mechanisms that lead to cerebral demyelination, axonal degeneration in spinal cord and adrenal insufficiency are unknown. The "toxic" role of VLCFA accumulation remains to be demonstrated. The mechanisms that lead to the inflammatory reaction in cerebral ALD might involve abnormal acylation of gangliosides and phospholipids by VLCFA that would result in immune reaction of brain macrophages and astrocytes bearing CD1 molecules that recognize lipid antigens. De novo mutation of ABCD1 occurs in less than 8% of ALD patients. The genetic counseling aims to identify: 1) women who are at risk to be heterozygous; 2) neurologically asymptomatic boys. It is only at this stage that allogeneic bone marrow transplantation has clinical benefit; 3) ALD patients who have Addison's disease that can lead to sudden death. Prenatal diagnosis (chorionic villus samples, cultured amniotic fluid cells) relies upon DNA based mutation detection techniques, expression of ALD protein and measurement of VLCFA levels. Allogeneic bone marrow transplantation is the only treatment that provides a permanent cure when the procedure is performed at an early stage of cerebral demyelination, i.e when the patients are asymptomatic despite abnormal brain MRI. Treatment of Addison's disease is mandatory but does not modify the course of neurological symptoms. Dietary therapy failed to halt the neurologic progression in cerebral ALD and AMN. It might have a partial preventive effect in boys treated before 6 years of age.