- Open Access
Immunoreactivity of valosin-containing protein in sporadic amyotrophic lateral sclerosis and in a case of its novel mutant
- Takashi Ayaki1,
- Hidefumi Ito1Email author,
- Hiroko Fukushima2,
- Takeshi Inoue2,
- Takayuki Kondo3, 4,
- Akito Ikemoto5,
- Takeshi Asano4,
- Akemi Shodai4,
- Takuji Fujita6,
- Satoshi Fukui7,
- Hiroyuki Morino8,
- Satoshi Nakano9,
- Hirofumi Kusaka10,
- Hirofumi Yamashita4,
- Masafumi Ihara11,
- Riki Matsumoto4, 12,
- Jun Kawamata13,
- Makoto Urushitani4,
- Hideshi Kawakami8 and
- Ryosuke Takahashi4
© Ayaki et al.; licensee BioMed Central. 2014
Received: 28 October 2014
Accepted: 27 November 2014
Published: 10 December 2014
Mutations in the valosin-containing protein (VCP) gene were first found to cause inclusion- body myopathy with early-onset Paget disease and frontotemporal dementia (IBMPFD). Mutations in the VCP gene were later reported to occur in familial amyotrophic lateral sclerosis (ALS). But the role of VCP in the neurodegenerative processes that occur in ALS remains unknown. The purpose of the present study was to elucidate the role of VCP in the neurodegeneration seen in sporadic and VCP mutant ALS.
Immunohistochemistry demonstrated that the frequency of distinct VCP-positive nuclei of spinal motor neurons of patients with sporadic ALS (SALS) and the ALS with VCP novel mutation (ALS-VCP, M158V) was increased, compared with that of the control cases. No VCP-positive inclusion bodies were observed in SALS patients, a ALS-VCP patient or in control subjects. Neuropathologic examination of the ALS-VCP case showed loss of motor neurons, the presence of Bunina bodies, and degeneration of the corticospinal tracts. Bunina bodies detected in this case were confirmed to show immunohistochemical and ultrastructural features similar to those previously described. Furthermore, neuronal intracytoplasmic inclusions immunopositive for TAR DNA-binding protein 43 kDa (TDP-43), phosphorylated TDP-43, ubiquitin (Ub), p62, and optineurin were identified in the spinal and medullary motoneurons, but not in the neocortex. Gene analysis of this ALS-VCP patient confirmed the de novo mutation of M158V, which was not found in control cases; and bioinformatics using several in silico analyses showed possible damage to the structure of VCP. Immunocytochemical study of cultured cells showed increased cytoplasmic translocation of TDP-43 in cells transfected with several mutant VCP including our patient’s compared with wild-type VCP.
These findings support the idea that VCP is associated with the pathomechanism of SALS and familial ALS with a VCP mutation, presumably acting through a dominant-negative mechanism.
Valosin-containing protein (VCP) is a ubiquitous member of the AAA-ATPase supergene family. VCP is known to play an important role in cellular activities including ubiquitin (Ub) -dependent protein degradation , chromatin-associated protein degradation , messenger ribonucleic acid (mRNA) metabolism , autophagy , anti-apoptotic function , and post-mitotic Golgi apparatus reassembly . Mutations in the VCP gene were first found to cause inclusion-body myopathy with early-onset Paget disease and frontotemporal dementia (IBMPFD) ,. IBMPFD is an autosomal dominantly inherited disorder with variable penetrance of 3 predominant phenotypic features, i.e., myopathy, Paget disease of bone, and frontotemporal dementia (FTD) . The penetrance of the gene is 82% for myopathy, 49% for Paget’s disease, and 30% for FTD . IBMPFD patients with VCP mutations can develop disorders in other organ systems including sphincters , cardiac muscles , auditory system , and liver , as well as in visuoconstructive ability . Neurodegenerative diseases associated with a VCP mutation encompass scapuloperoneal muscular dystrophy and dropped head syndrome , Parkinson’s disease -, hereditary spastic paraplegia , and cerebellar ataxia . In addition to mutations in VCP,, mutations in Heterogeneous Nuclear Ribonucleoprotein A2B1 (HNRNPA2B1) and Heterogeneous Nuclear Ribonucleoprotein A1 (HNRNPA1)  have been identified in families with IBMPFD. Given these observations, the name of multisystem proteinopathy (MSP) has been proposed, using the nomenclature of MSP1 for IBMPFD caused by a VCP mutation, MSP2 for IBMPFD related to an HNRNPA2B1 mutation, MSP3 for IBMPFD related to an HNRNPA1 mutation, and MSP4 for IBMPFD due to some unidentified gene . Clinically, 37.7% patients of IBMPFD with a VCP mutation (MSP1) develop FTD . FTD cases with a VCP mutation (MSP1) present with TAR DNA-binding protein 43 kDa (TDP-43) and ubiquitin-positive short dystrophic neurites and frequently lentiform neuronal intranuclear inclusions in their neocortex -. On the other hand, only rare VCP-positive neuronal intranuclear inclusions are detected, and those that are detected lack the characteristic lentiform morphology . This finding suggests that TDP-43 and ubiquitin positive-inclusions do not contain VCP and supports the idea that VCP gene mutations in IBMPFD produce a dominant-negative loss of VCP function ,.
Mutations in the VCP gene were later reported to occur in familial amyotrophic lateral sclerosis (ALS) . A recent study with a large data set of patients with VCP mutations showed that 8.9% of these patients developed ALS . Features of ALS with VCP mutations (ALS-VCP) are similar to those of sporadic ALS (SALS), including bulbar signs, spasticity, hyperreflexia, fasciculations, and electrophysiological evidence of lower motor neuron involvement such as denervation and reinnervation . The neuropathology of ALS-VCP has been briefly described in 2 cases to date ,. Both reports described TDP-43-positive intracytoplasmic inclusions in the motor neurons. These facts suggest that the neuropathologic features of ALS-VCP could be similar to those of SALS and that SALS would share its pathogenic role with ALS-VCP cases through dysfunction of VCP. To confirm this hypothesis, it is of importance to elucidate detailed pathological features of ALS-VCP and to compare them with those of SALS. However, specific inclusion pathology including their immunohistochemical properties and distributions, as well as detailed cytopathology of motor and non-motor neurons and glial cells, remain to be explored.
VCP immunoreactivity has been observed in Lewy bodies in Parkinson’s disease and dementia with Lewy bodies, in neuronal nuclear inclusions in polyglutamine diseases and intranuclear inclusion body disease, in Marinesco bodies , and in epidermal cells from patients with SALS . VCP-positive nuclei have also been reported in neocortical neurons  and in muscle cells  from IBMPFD cases with a VCP mutation (MSP1). However, the distribution of VCP in ALS-VCP cases is unknown. Moreover, it remains to be investigated whether a VCP mutation leads to VCP-positive inclusions in the ALS phenotype, and whether VCP-positive structures are present in the motor neurons of SALS patients.
To elucidate the role of VCP in neurodegenerative processes in ALS, in the present study we examined the neuropathology of a patient with ALS and Paget disease of bone with a novel VCP mutation, as well as the immunohistochemical localization of VCP in SALS cases and in the ALS-VCP patient.
Materials and methods
VCP immunohistochemistry in ALS
Clinical findings of patients with amyotrophic lateral sclerosis and of control subjects
Age at death (years)
Postmortem delay (hours)
Duration of illness (months)
Percentage of VCP-positive nuclei
Chronic lymphocitic leukemia
For VCP immunohistochemistry, formalin-fixed, paraffin-embedded 6-μm-thick sections were deparaffinized and immunostained for VCP. We applied 2 distinct primary antibodies for VCP(mouse monoclonal [Cat. No. ab11433], Abcam plc, Cambridge, UK; 1:500; and rabbit polyclonal [Cat. No. AP6920b], Abgent, San Diego, California, USA; 1:75). Bound antibodies were detected with the appropriate VECTASTAIN Elite ABC Kit (Vector Laboratories, Burlingame, California, USA). We assessed staining specificity by replacing the primary antibodies with an appropriate amount of phosphate-buffered saline solution containing 3% bovine serum albumin. No deposits of reaction products were seen in the sections thus treated. Procedures involving the use of human material were performed in accordance with ethical guidelines set by Kyoto University.
For quantitative study of VCP-positive nuclei of the motor neurons, we obtained 3 distinct sections from each case, taken at an interval of 30 μm, to avoid counting the same nucleus twice. All observations were made by 2 examiners who had no information regarding the clinical history and condition of the individual providing the spinal specimen. Only anterior horn cells (AHCs) with a distinct nucleus and nucleolus were counted. The frequency of VCP-positive motor neurons in the lumbar cord was compared between control patients and SALS patients by the nonparametric Mann–Whitney U test using Prism software (GraphPad, La Jolla, USA).
Clinical features of the ALS patient with a VCP mutation
His extremities gradually became weaker, resulting in a bedridden condition. Shortly after he developed a fracture of the right femoral bone, he died of respiratory failure at the age of 41. Throughout the clinical course he did not develop any cognitive decline or mood disorder, Parkinsonism, spastic paraplegia, cerebellar ataxia or decubitus ulcer. Also, the patient did not have any abnormalities in cardiac, hepatic, visual, auditory, sensory or autonomic systems. No frozen brain tissue was available.
Genetic analysis of VCP, Cu/Zn superoxide dismutase 1 (SOD1), TDP-43, fused in sarcoma (FUS), Charged multivesicular body protein 2b (CHMP2B), angiogenin, Sequestosome 1 (SQSTM1), and chromosome 9 open reading frame 72 (C9ORF72) was approved by either the Kyoto University Graduate School of Medicine Ethical Committee or Hiroshima University Ethical Committee, and written informed consent was obtained from the above patient prior to his demise. DNA was extracted from a blood sample; and by using previously reported primers, we amplified the exons of each gene and sequenced them on anABI310 sequencer (Applied Biosystem, Foster City, California, USA). To detect C9ORF72 expansion, we performed a repeat-primed polymerase chain reaction, as reported previously . As a result we identified a novel heterozygous M158V mutation in the VCP gene (Figure 1b). This mutation was not present in the 1000 Genomes project (http://www.1000genomes.org/), dbSNP (http://www.ncbi.nlm.nih.gov/SNP/) or in the Human Genetic Variation Browser (includes genetic variations determined by exome sequencing of 1,208 Japanese individuals and genotyping data of common variations obtained from a cohort of 3,248 individuals [http://www.genome.med.kyoto-u.ac.jp/SnpDB/]). The other genes were normal. Conservation analysis of the mutated amino acid by using National Center for Biotechnology (NCBI) HomoloGene demonstrated conservation among species at the mutation site (Figure 1c). The mutation site in this case (amino acid 158 in VCP) was located near the reported mutation sites (amino acids 155  and 159  in VCP) within the same domain (Figure 1d). In Figure 1d, mutation sites in VCP gene associated with ALS and IBMPFD are also listed from the literature ,,-,,,,-.
His parents were still alive and not affected with ALS or any other neurodegenerative diseases. His father was 73 years of age and had been diagnosed with prostate cancer, whereas his mother was 71 years old and healthy. Neither parent carried the VCP mutation identified in the proband. Haplotype analysis using 15 short tandem repeat markers supported their genetic kinship, confirming that the mutation occurred de novo in the present case. No sample from the patient’s brother was available.
For neuropathologic examinations, formalin-fixed, paraffin-embedded 6-μm-thick sections were deparaffinized and stained with hematoxylin and eosin (H&E) or used for Klüver-Barrera (KB) staining. For immunohistochemistry, after antigen retrieval by heat/autoclaving (10 min at 121°C in 10 mM anhydrous citric acid buffer, pH 6.0), the sections were immunostained as described above.
The antigens recognized by the primary antibodies used in this study were the following: TDP-43(rabbit polyclonal [Cat No. 10782-2-AP], ProteinTec Group Inc., Chicago, Illinois, USA; 1:200), phosphorylated TDP-43 (mouse monoclonal [Cat No. TIP-PDT-M01], Cosmo Bio Co., Ltd., Tokyo, Japan; 1:2000), trans-Golgi-network (sheep polyclonal [Cat No. 610832], Novus Biologicals, Inc, Littleton, Colorado, USA; 1:250), VCP(mouse monoclonal [Cat No. ab11433], Abcam plc, Cambridge, UK; 1:500; rabbit polyclonal [Cat No. AP6920b], Abgent, San Diego, California, USA; 1:75), FUS(rabbit polyclonal [Cat No. HPA008784], Sigma-Aldrich Inc., St. Louis, Missouri, USA; 1:100), CD68 (mouse monoclonal [Cat No. M0814], DAKO, Glostrup, Denmark; 1:100), p62(mouse monoclonal [Cat No. 610832], Becton Dickinson and Company, Franklin Lakes, New Jersey, USA; 1:700), ubiquitin(rabbit polyclonal [Cat No. U5379], Sigma-Aldrich Inc., St. Louis, Missouri, USA; 1:100), and optineurin (rabbit polyclonal [Cat No. 100000], Cayman Chemical Company, Ann Arbor, Michigan, USA; 1:200).
In the case with the VCP mutation, the sample from formalin-fixed medulla was fixed in 2% glutaraldehyde with phosphate buffer (pH 7.4). After fixation, sections were cut into pieces about 1 mm thick, postfixed with 1% osmium tetroxide for 2 h, dehydrated, and embedded in epoxy resin. Each block was then cut into semithin sections about 1 μm in thickness and stained with toluidine blue. Appropriate regions were subsequently cut into ultrathin sections and stained with uranyl acetate and lead citrate for electron microscopy.
The effect of the newly detected missense mutation (M158V) and previously reported mutations of 2 autopsied ALS-VCP cases (R155H and R159H) was analyzed with Mutation Taster (http://www.mutationtaster.org), Sorting Intolerant From Tolerant (SIFT, http://sift.bii.a-star.edu.sg/), and PolyPhen-2 (http://genetics.bwh.harvard.edu/pph/).
Vectors for in vitro analysis
To assess the functional importance of the novel mutation identified in this study, we created vectors (pcDNA3) expressing wild-type (WT) VCP and mutant VCPs (R155H, M158V, R159H and A232E) tagged with FLAG at their N-terminus.
SH-SY5Y and human embryonic kidney 293 T (HEK293T) cells were grown in Dulbecco’s Modified Eagle Medium (DMEM) supplemented with 10% fetal bovine serum, 1% non-essential amino acids, and 1% penicillin-streptomycin-L glutamine sodium.
To generate FLAG-tagged VCP, we obtained WT VCP complementary deoxyribonucleic acid (cDNA) from a cDNA library and generated sequence variants, including R155H (464G > A), M158V (472A > G), R159H (476 G > A) and A232E (695C > A). WT and mutant VCPs were generated by PCR with primer pairs used to change the nucleotides and then inserted into the Not I/BamH I cloning site of the pcDNA3 vector. All constructs were verified by using the 3130xl Genetic Analyzer (Life Technologies, Carlsbad, California, USA. Cultured cells were transfected with the vector by using a FuGene HD transfection kit (Roche, Basel, Switzerland) according to the manufacturer’s protocol.
Cells were lysed in lysis buffer containing 10 mM Tris–HCl (pH 7.6), 150 mM NaCl, 1% Triton X-100, 1% sodium deoxycholate (Na-DOC), 0.1% sodium dodecyl sulfate (SDS), and a protease inhibitor cocktail (Complete EDTA-free protease inhibitor; Nacalai Tesque). Nuclei and membrane fractions were removed by centrifugation. Lysates were separated by SDS-poly-acrylamide gel electrophoresis (SDS-PAGE), and proteins were then transferred to a polyvinylidene difluoride (PVDF) membrane. The membrane was incubated with the appropriate primary antibody, followed by incubation with horseradish peroxidase (HRP)-conjugated anti-rabbit or anti-mouse IgG (Santa Cruz Biotechnology Inc, Dallas, Texas, USA) secondary antibody. Immunoreactive proteins were visualized by using the Pierce ECL Western Blotting Substrate (Thermo Scientific Pierce, Kanagawa, Japan) and an LAS3000 scanning system (Fuji Film, Tokyo, Japan). The following primary antibodies were used in the immunoblot analysis: anti-VCP (rabbit polyclonal [Cat No. AP6920b], Abgent, San Diego, California, USA; 1:200) and anti-β-actin (mouse monoclonal [Cat No. A5441], Sigma-Aldrich Inc., St. Louis, Missouri, USA; 1:2,000).
SH-SY5Y and HEK293T cells transfected with FLAG-conjugated WT or mutant VCP were fixed and immunostained with anti-TDP-43 or anti-FLAG, and stained with DAPI, at 48 h post-transfection. For immunofluorescence analysis of cell cultures, cultured cells were fixed with 4% PFA for 20 min, washed 3 times with PBS (2 min each), and then rendered permeable and blocked with 0.2% Triton X-100/5% goat serum in PBS for 15 min. The transfected cells were incubated with primary antibodies (anti-TDP-43 antibody, rabbit polyclonal, ProteinTech, 1:1000 and anti-FLAG M2, mouse monoclonal, Sigma-Aldrich Inc., St. Louis, Missouri, USA; 1:500, diluted in PBS containing 0.2% Triton X-100/5% goat serum) overnight and washed 3 times with PBS (5 min each). After the final wash, the cells were incubated with secondary antibodies (Alexa Fluor 488 donkey anti-rabbit IgG (H + L) or Alexa Fluor 546 donkey anti-mouse IgG (H + L), diluted in PBS containing 0.2% Triton X-100/5% goat serum) for 1 h, washed 3 times with PBS (5 min each), and mounted with Vectashield plus DAPI (Vector Laboratories, Burlingame, California, USA). Digital imaging was performed with an OLYMPUS FV-100 IX microscope (Olympus, Tokyo, Japan) using FV-10-ASW 3.1 software (Olympus). A blinded examiner counted more than 100 FLAG-tagged VCP-expressing cells from separate cultures for the presence of cytoplasmic TDP-43-positive cells. Results were analyzed by One-way ANOVA of Bonferroni’s multiple-comparison test using Prism software (GraphPad, La Jolla, USA).
Immunohistochemistry for VCP in control subjects, SALS patients, and the VCP mutant case
Two distinct anti-VCP antibodies applied in the present study gave the same results.
We also identified some neuronal (Figure 2e) and glial (Figure 2f) nuclei that were immunoreactive for VCP in the ALS case with the heterozygous M158V VCP mutation (case 18 in the Table). In the ALS-VCP case, VCP immunoreactivity in the AHCs was less robust than that in the SALS cases. No VCP-positive inclusions were detected in any of the cases investigated.
In the motor cortex and hippocampus, there was no significant immunoreactivity for VCP except for faint immunoreactivity of glial nuclei.
The frequency of VCP-positive nuclei in the lumbar cord of patients with SALS (mean ± standard deviation, 26.1 ± 31.5) was significantly higher (p < 0.05, Mann–Whitney U test) than that for the control subjects (1.8 ± 3.2%; Figure 2g). In the ALS-VCP case 7.7% of the AHC nuclei were VCP positive. On serial section analysis, there was no apparent relationship between VCP immunoreactivity and intracytoplasmic TDP-43 accumulation.
Neuropathologic examinations of the patient with M158V ALS-VCP
At autopsy of the M158V ALS-VCP patient, pneumonia, fatty liver, and atheromatous plaques of the aorta were recognized. Microscopic examination of the vertebra revealed mixed osteoclastic-osteoblastic activity and a chaotic picture of trabecular bone (“mosaic” pattern) that was compatible with Paget disease of bone(Figure 3c).
Neuropathologically, the formalin-fixed brain weighed 1,435 g. Macroscopic examination showed no evidence of cerebral atrophy (Figure 3d, e). In H&E- and KB-stained sections, the spinal anterior horns and the corticospinal tracts showed evidence of degeneration, especially in the lumbar cord (Figure 3f). Cervical and lumbar cord showed cell loss with gliosis in the anterior horns (Figure 3g). Onuf’s nucleus and Clarke’s column were preserved. H&E-stained sections revealed the presence of Bunina bodies (Figure 3h) and spheroids in the anterior horns of the cervical and lumbar cords.
Immunohistochemical investigation of the Golgi apparatus revealed characteristic fragmentation of it in the AHCs (Figure 4k), whereas non-motor neurons in the posterior horn had preserved Golgi apparatuses (Figure 4l). Using the same method reported previously , we found that in our case 61.5% (16/26) of the AHCs from 3 distinct spinal cord segments had a fragmented Golgi apparatus. In the corticospinal tracts, immunostaining for CD68 showed infiltration of CD68-positive microglia.
Betz cells were not apparently depleted. Hippocampal sclerosis was not found. In the primary motor, superior frontal, and temporal cortices, putamen, thalamus, cerebellum, and hippocampus, there were no neuronal nuclear or intracytoplasmic inclusions or GCIs found by any of the staining procedures, including p62 immunohistochemistry.
By amyloid β and AT8-immunohistochemistry, this case showed no senile plaque, but only a few isolated neurofibrillary tangles in the hippocampus and amygdala (CERAD 0, Braak-Braak stage II). Immunostaining for α-synuclein and FUS revealed no pathologies.
Bioinformatics and in vitro studies
The effect of the newly detected missense mutation on VCP protein structure was analyzed by in silico analysis using different software. In Mutation Taster (http://www.mutationtaster.org), M158V was estimated to be disease causing (probability > 0.9999), and no Single Nucleotide Polymorphism (SNP) was found in the site of mutation. The known disease-causing VCP mutations R155H and R159H were also diagnosed as disease causing (probability > 0.9999) in Mutation Taster.
In SIFT (http://sift.bii.a-star.edu.sg/) the M158V mutation, as well as the known mutation R155H, was not tolerated (p = 0.00), meaning that the mutation is deleterious. On the other hand, the known mutation R159H ,, was tolerated (p = 0.07, in tolerant threshold <0.05), although the p-value was near the threshold. Polyphen-2 (http://genetics.bwh.harvard.edu/pph/) analysis showed possible damage to the structure by M158V, as indicated by a Position-Specific Independent Counts (PSIC) value of 0.896 (sensitivity: 0.82; specificity: 0.94), R155H was analyzed to be possibly damaging with a score with PSIC value 0.849 (sensitivity: 0.83; specificity: 0.93); although R159H ,which is indeed a disease-causing mutation, was predicted to be benign with a score of PSIC value 0.1 (sensitivity: 0.93; specificity: 0.85). Taken together, in silico analysis strongly suggested that out novel mutation M158V is pathogenic.
In the present study, we provided detailed neuropathology of an ALS case with the novel M158V VCP mutation, focusing on the similarity and difference to sporadic ALS. In addition, for the first time we demonstrated that the frequency of AHCs with VCP-immunoreactive cytoplasm and nucleus was increased in SALS patients as well as in this mutant case as compared with that in the controls.
Besides concomitant Paget disease of bone, the neurological manifestations and neuropathologic findings of our novel ALS-VCP patient were indistinguishable from those of the SALS patients. To date, 2 autopsied ALS-VCP cases with distinct mutations have been reported ,. Clinically, both cases were diagnosed as ALS without symptoms of FTD. The initial patient was associated with an R155H VCP mutation. Because of the limitation of specimen availability, neuropathologic examinations of this case were confined to brainstem and spinal cord motor neurons, revealing the loss of these neurons and the presence of Bunina bodies and TDP-43-positive cytoplasmic inclusions with concomitant loss of nuclear staining in the surviving motor neurons . The disease of the second autopsied ALS-VCP patient was associated with an R159H VCP mutation. Neuropathologic description of this case was also limited, literally describing the presence of p62-, ubiquitin-, and TDP-43-positive inclusions. Additionally, they indicated a few p62- and ubiquitin-positive inclusions in the neurons of the hippocampal granular layer and frontotemporal lobes . Although neocortical inclusion pathology was not apparent in our novel ALS-VCP case, the patient exhibited otherwise similar neuropathologic findings as reported in the previous 2 cases. Furthermore, we demonstrated that in our mutant case TDP-43 was co-localized with ubiquitin, p62, and optineurin, but not with VCP, in the cytoplasmic inclusions in the AHCs. TDP-43-positive GCIs were obviously present. The lack of VCP immunoreactivity in the TDP-43-positive inclusions may imply that the M158V mutant VCP would have lost ability to associate with aggregated TDP-43. In addition, we disclosed that the Bunina bodies in our ALS-VCP patient showed immunohistochemical and ultrastructural properties indistinguishable from those observed in SALS patients. Furthermore, we identified fragmented Golgi apparatuses in our mutant case. This finding is noteworthy, because several reports have described that the Golgi apparatus is frequently fragmented in the AHCs of patients with SALS -. It is plausible that VCP dysfunction led to vulnerability of the Golgi apparatus in the present case, because VCP plays an important role in assembly of the Golgi apparatus membrane . Taken together, our observations on the neuropathology of the present ALS-VCP case resembled considerably those on that of SALS, supporting the idea that VCP would underlie the pathomechanism of SALS.
Patients with FTD in IBMPFD associated with a VCP mutation are known to show lentiform intranuclear inclusions in the neurons of their neocortex -; however, the present case showed no such inclusions there. One possibility for this discrepancy would be the presence of modifier genes. Kimonis et al. evaluated modifier genes in a database of 231 members of 15 original families with IBMPFD and suggested a potential link between the APOE 4 genotype and FTD . Alternatively, the mutation site might influence the phenotype. Recently, a study using a large data set of patients with VCP mutations suggested that several mutations (R155C, A232E) are correlated with a severe phenotype and reduced survival; although the precise genotypic correlation with respect to VCP mutation has not been elucidated yet, because some groups of mutations were very small in number .
The mutation site of our case (M158V) was very close to the reported sites of mutation leading to the ALS phenotype (R155H  and R159H ). In protein feature analysis with Mutation Taster, these mutations were shown to be disease causing. (Although only the R159H mutation was analyzed as moderately damaging in SIFT and Polyphen-2, this mutation in ALS and IBMPFD was reported to occur in various cases ,,) All 3 of these sites are located within the N-terminal domain, which contains ubiquitin and cofactor-binding domains (Figure 1d) . The accumulation of p62 and OPTN in our case suggests that the autophagy system was defective in this ALS-VCP patient, because VCP -, p62 , and OPTN  play important roles in the autophagy-dependent protein clearance system. Our results and previous reports , revealed that cells transfected with mutant VCP showed abnormal TDP-43 translocation. These results support the notion that neurodegeneration in VCP mutant cases would be attributable to dysfunction of protein clearance systems, including ubiquitin-dependent protein degradation and autophagy.
We did not detect VCP-positive inclusion bodies in our case with M158V ALS-VCP. The absence of VCP inclusions in our patient is in consistent with previous findings obtained from FTD patients with VCP mutations ,,. The lack of VCP-positive inclusion bodies makes a toxic gain-of-function mechanism implausible. On the other hand, since normal VCP  and mutant VCP  are reported to form heteromeric complexes, a mutant VCP could conceivably impair the formation of properly functioning hexamers, thus having a dominant-negative effect .
Immunohistochemical investigations on the SALS cases revealed, similar to those on the ALS-VCP patient, increased frequencies of VCP-immunoreactive structures such as neuronal cytoplasm, neuronal nuclei, and glial nuclei. These findings suggest that SALS could share its pathomechanism with ALS-VCP through dysfunctional VCP. The cytoplasm of AHCs in SALS was moderately and diffusely immunoreactive for VCP. Endoplasmic reticulum (ER) stress due to accumulation of misfolded proteins , and activated autophagy  in the cytoplasm have been reported to occur in SALS cases. Considering that VCP governs protein degradation processes in both ER-associated ubiquitin-dependent protein degradation and autophagy ,, the increase in cytoplasmic VCP in SALS may reflect a process that modifies these protein degradation systems. Neuronal and glial nuclei were more frequently immunopositive for VCP in SALS cases than in the controls. VCP-positive nuclei have also been detected in the neocortical neurons  and muscle cells  in IBMPFD cases with a VCP mutation (MSP1). On the other hand, in our study the frequency of VCP-positive neuronal nuclei in the ALS-VCP case was lower than that of these nuclei in the SALS cases, presumably because of the functional loss of the M158V mutant VCP to recognize intranuclear ubiquitinated proteins. Recently, nuclear VCP has emerged as an essential regulator of genome stability through the degradation of chromatin-associated proteins . VCP is recruited at nuclear sites of damaged DNA and facilitates degradation of ubiquitinated chromatin-associated proteins to regulate DNA repair and transcription -. Notably, VCP regulates splicing pattern  and chromatin-associated proteins including RNA polymerase II subunit 1 (Rpb1) , which plays an important role in producing heterogeneous nuclear RNA (hnRNA). It is noteworthy that the alternative splicing of hnRNA is regulated by hnRNP A2/B1 and hnRNP A1 , which are the products of causative genes of MSP2 and MSP3 ,. The dysfunction of these proteins, including VCP, hnRNP A1, and hnRNP A2/B1, could play an IBMPFD (MSP) pathogenic role through disruption of RNA metabolism and transcription processes. The increase in nuclear VCP in the ALS cases observed in the present study could be associated with the process by which VCP is recruited for intranuclear protein degradation to maintain the RNA metabolism and the transcription process. Alternatively, increased intranuclear VCP accumulation in ALS implicates loss-of-function mechanism of VCP as a pathogenesis of this disorder. Yang H et al. proposed that aggregtes of polyQ-expanded Atx3 sequester VCP into protein inclusions, and leads to neurodegeneration. It could be possible that VCP is entrapped by other intranuclear protein aggregation .
Our neuropathological investigations support the idea that VCP was associated with the pathomechanism of SALS and FALS with a VCP mutation. For determination of the pathological importance of VCP in these disorders, further studies with additional cases are warranted.
This work was supported in part by a grant-in-aid for scientific research from the Japan Society for the Promotion of Science [grant number 24300132].
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