title: Age at onset as a factor in determining the phenotype of primary torsion dystonia.
abstract: BACKGROUND
  The genetic basis of most forms of primary torsion dystonia (PTD) is unknown; multiplex families are uncommon due to low penetrance. Intrafamilial, age-related, phenotypic heterogeneity was noted in 14 PTD families. The authors hypothesized that the clinical presentation of PTD was modulated by the age at onset of the dystonia, irrespective of the genotype.
  
  
  METHODS
  This hypothesis was addressed in a study of 14 PTD families and a meta-analysis of 83 published series of PTD.
  
  
  RESULTS
  In 12 families with adult-onset PTD, the index cases presented with cervical dystonia (CD); of the 22 affected relatives, 17 had CD, 2 had writer's cramp, 1 had blepharospasm, and 2 had spasmodic dysphonia. In the two other PTD families, the probands and all 10 symptomatic relatives had limb-onset dystonia at <20 years of age. There were differences between the median ages at onset of the different phenotypes (p = 0.0037). Analysis of 83 published series including 5,057 patients indicated significant differences in the mean age at onset of five phenotypes of PTD (mean age at onset; 95% CI): DYT1 dystonia (11.3 years; 10.3 to 12.2), writer's cramp (38.4; 36.9 to 39.9), CD (40.8; 40.3 to 41.3), spasmodic dysphonia (43.0; 42.2 to 43.9), and blepharospasm-oromandibular dystonia (55.7; 55.1 to 56.4).
  
  
  CONCLUSIONS
  Phenotypic variation in PTD presentation is due to the effect of age at onset modulating the expression of a genetic disorder with a caudal-to-rostral change in the site of onset.
authors.affiliation: Department of Neurology, St. Vincent's University Hospital and University College Dublin, Ireland.
authors.forename: S
authors.initials: S
authors.lastname: O'Riordan
authors.forename: D
authors.initials: D
authors.lastname: Raymond
authors.forename: T
authors.initials: T
authors.lastname: Lynch
authors.forename: R
authors.initials: R
authors.lastname: Saunders-Pullman
authors.forename: S B
authors.initials: SB
authors.lastname: Bressman
authors.forename: L
authors.initials: L
authors.lastname: Daly
authors.forename: M
authors.initials: M
authors.lastname: Hutchinson
mesh_terms: D000293:Adolescent; D000328:Adult; D017668:Age of Onset; D000368:Aged; D000369:Aged, 80 and over; D000375:Aging / Q000502:physiology*; D004422:Dystonia Musculorum Deformans / Q000453:epidemiology* / Q000235:genetics / Q000503:physiopathology; D020821:Dystonic Disorders / Q000453:epidemiology / Q000235:genetics; D005192:Family Health; D005260:Female; D020022:Genetic Predisposition to Disease / Q000235:genetics*; D005838:Genotype; D006801:Humans; D019189:Iron Metabolism Disorders / Q000150:complications / Q000378:metabolism / Q000503:physiopathology; D008297:Male; D008538:Meige Syndrome / Q000453:epidemiology / Q000235:genetics; D008875:Middle Aged; D010641:Phenotype; D011699:Putamen / Q000378:metabolism / Q000473:pathology / Q000503:physiopathology