Article Text

Download PDFPDF
Late onset AMACR deficiency with metabolic stroke-like episodes and seizures
  1. Matthew J Tanti1,
  2. Melissa J Maguire1,
  3. Daniel J Warren2 and
  4. John Bamford1
  1. 1Department of Neurology, Leeds General Infirmary, Leeds, UK
  2. 2Department of Radiology, Leeds General Infirmary, Leeds, UK
  1. Correspondence to Dr Matthew J Tanti; m.tanti{at}


Alpha-methylacyl-CoA racemase (AMACR) deficiency is a rare peroxisomal disorder causing pristanic acid accumulation. Only 16 cases have been described so far. A female in her seventh decade presented with episodes of dysphasia, headache and sensory disturbance inconsistent with migraine, epilepsy or transient ischaemic attack. An MRI demonstrated unusual changes in the pons, red nuclei, thalami and white matter. Mitochondrial disease was suspected but detailed testing was negative. After eight years of symptoms, she developed a febrile encephalopathy with hemispheric dysfunction, focal convulsive seizures and coma. Her condition stabilised after one month. Lacosamide was continued for seizure prevention. The diagnosis remained elusive until whole genome sequencing revealed AMACR deficiency. Pristanic acid levels were highly elevated and dietary modification was recommended. Genetic peroxisomal disorders can present in older age; our patient is the oldest in the AMACR deficiency literature. Novel features in our case include central apnoea, dystonia and rapid eye movement behaviour disorder.

  • Neuro genetics
  • Neuroimaging

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors MJT was responsible for drafting the paper. JB was responsible for leading the project. DJW reviewed the images. MJM was responsible for guiding sections related to epilepsy. All authors reviewed the literature and the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.