Dopa-responsive dystonia is a disorder that involves involuntary muscle contractions, tremors, and other uncontrolled movements (dystonia). The features of this condition range from mild to severe. This form of dystonia is called dopa-responsive dystonia because the signs and symptoms typically improve with sustained use of a medication known as L-Dopa.

Signs and symptoms of dopa-responsive dystonia usually appear during childhood, most commonly around age 6. The first signs of the condition are typically the development of inward- and upward-turning feet (clubfeet) and dystonia in the lower limbs. The dystonia spreads to the upper limbs over time; beginning in adolescence, the whole body is typically involved. Affected individuals may have unusual limb positioning and a lack of coordination when walking or running. Some people with this condition have sleep problems or episodes of depression more frequently than would normally be expected.

Over time, affected individuals often develop a group of movement abnormalities called parkinsonism. These abnormalities include unusually slow movement (bradykinesia), muscle rigidity, tremors, and an inability to hold the body upright and balanced (postural instability).

The movement difficulties associated with dopa-responsive dystonia usually worsen with age but stabilize around age 30. A characteristic feature of dopa-responsive dystonia is worsening of movement problems later in the day and an improvement of symptoms in the morning, after sleep (diurnal fluctuation).

Rarely, the movement problems associated with dopa-responsive dystonia do not appear until adulthood. In these adult-onset cases, parkinsonism usually develops before dystonia, and movement problems are slow to worsen and do not show diurnal fluctuations.

Mutations in the GCH1 gene are the most common cause of dopa-responsive dystonia. Less often, mutations in the TH or SPR gene cause this condition.

The GCH1 gene provides instructions for making an enzyme called GTP cyclohydrolase. This enzyme is involved in the first of three steps in the production of a molecule called tetrahydrobiopterin (BH4). The SPR gene, which provides instructions for making the sepiapterin reductase enzyme, is involved in the last step of tetrahydrobiopterin production. Tetrahydrobiopterin helps process several protein building blocks (amino acids), and is involved in the production of chemicals called neurotransmitters, which transmit signals between nerve cells in the brain. Specifically, tetrahydrobiopterin is involved in the production of two neurotransmitters called dopamine and serotonin. Among their many functions, dopamine transmits signals within the brain to produce smooth physical movements, and serotonin regulates mood, emotion, sleep, and appetite.

The protein produced from the TH gene is also involved in dopamine production. The TH gene provides instructions for making the enzyme tyrosine hydroxylase, which helps convert the amino acid tyrosine to dopamine.

Mutations in the GCH1 or SPR gene impair the production of tetrahydrobiopterin, which leads to a decrease in the amount of available dopamine. TH gene mutations result in the production of a tyrosine hydroxylase enzyme with reduced function, which leads to a decrease in dopamine production. A reduction in the amount of dopamine interferes with the brain's ability to produce smooth physical movements, resulting in the dystonia, tremor, and other movement problems associated with dopa-responsive dystonia. Sleep and mood disorders also occur in some individuals with GCH1 or SPR gene mutations; these disorders likely result from a disruption in the production of serotonin. Problems with sleep and episodes of depression are not seen in people with dopa-responsive dystonia caused by TH gene mutations, which is sometimes referred to as Segawa syndrome.

Some people with dopa-responsive dystonia do not have an identified mutation in the GCH1, TH, or SPR gene. The cause of the condition in these individuals is unknown.

Normal Function

The GCH1 gene provides instructions for making an enzyme called GTP cyclohydrolase 1. This enzyme is involved in the first of three steps in the production of a molecule called tetrahydrobiopterin (BH4). Other enzymes help carry out the second and third steps in this process.

Tetrahydrobiopterin plays a critical role in processing several protein building blocks (amino acids) in the body. For example, it works with the enzyme phenylalanine hydroxylase to convert an amino acid called phenylalanine into another amino acid, tyrosine. Tetrahydrobiopterin is also involved in reactions that produce chemicals called neurotransmitters, which transmit signals between nerve cells in the brain. Specifically, tetrahydrobiopterin is involved in the production of two neurotransmitters called dopamine and serotonin. Among their many functions, dopamine transmits signals within the brain to produce smooth physical movements, and serotonin regulates mood, emotion, sleep, and appetite. Because it helps enzymes carry out chemical reactions, tetrahydrobiopterin is known as a cofactor.

Health Conditions Related to Genetic Changes

Dopa-responsive dystonia

More than 140 mutations in the GCH1 gene have been found to cause dopa-responsive dystonia. This condition is characterized by a pattern of involuntary muscle contractions (dystonia), tremors, and other uncontrolled movements and usually responds to treatment with a medication called L-Dopa. Dopa-responsive dystonia results when one copy of the GCH1 gene is mutated in each cell. Most GCH1 gene mutations that cause this condition change single amino acids in the GTP cyclohydrolase 1 enzyme. Researchers believe that the abnormal enzyme may interfere with the activity of the normal version of GTP cyclohydrolase 1 that is produced from the copy of the gene with no mutation. As a result, the amount of working enzyme in affected individuals is reduced by 80 percent or more. A reduction in functional GTP cyclohydrolase 1 enzyme causes less dopamine and serotonin to be produced, leading to the movement problems and other characteristic features of dopa-responsive dystonia.

Tetrahydrobiopterin deficiency

At least seven mutations in the GCH1 gene have been found to cause tetrahydrobiopterin deficiency. When this condition is caused by GCH1 gene mutations, it is known as GTP cyclohydrolase 1 (GTPCH1) deficiency. GTPCH1 deficiency accounts for about 4 percent of all cases of tetrahydrobiopterin deficiency.

GTPCH1 deficiency results when two copies of the GCH1 gene are mutated in each cell. Most of the mutations responsible for this condition change single amino acids in GTP cyclohydrolase 1. These mutations greatly reduce or eliminate the activity of this enzyme. Without enough GTP cyclohydrolase 1, little or no tetrahydrobiopterin is produced. As a result, this cofactor is not available to participate in chemical reactions such as the conversion of phenylalanine to tyrosine. If phenylalanine is not converted to tyrosine, it can build up to toxic levels in the blood and other tissues. Nerve cells in the brain are particularly sensitive to phenylalanine levels, which is why excessive amounts of this substance can cause brain damage.

Additionally, a reduction in GTP cyclohydrolase 1 activity disrupts the production of certain neurotransmitters in the brain. Because neurotransmitters are necessary for normal brain function, changes in the levels of these chemicals contribute to intellectual disability in people with GTPCH1 deficiency.

Tetrahydrobiopterin deficiency is more severe than dopa-responsive dystonia likely because both copies of the GCH1 gene are mutated, which leads to a more severe enzyme shortage than in dopa-responsive dystonia, in which only one copy of the gene has a mutation.

Other Names for This Gene

• DYT5
• DYT5a
• GCH
• GCH1_HUMAN
• GTP cyclohydrolase 1 (dopa-responsive dystonia)
• GTPCH1

Genomic Location

Normal Function

The SPR gene provides instructions for making the sepiapterin reductase enzyme. This enzyme is involved in the last of three steps in the production of a molecule called tetrahydrobiopterin (BH4). Other enzymes help carry out the first and second steps in this process.

The sepiapterin reductase enzyme converts a molecule called 6-pyruvoyl-tetrahydropterin to tetrahydrobiopterin. Tetrahydrobiopterin helps process several building blocks of proteins (amino acids), and is involved in the production of chemicals called neurotransmitters, which transmit signals between nerve cells in the brain. Specifically, tetrahydrobiopterin is involved in the production of two neurotransmitters called dopamine and serotonin. Among their many functions, dopamine transmits signals within the brain to produce smooth physical movements, and serotonin regulates mood, emotion, sleep, and appetite.

Health Conditions Related to Genetic Changes

Dopa-responsive dystonia

At least four mutations in the SPR gene have been found to cause dopa-responsive dystonia. This condition is characterized by a pattern of involuntary muscle contractions (dystonia), tremors, and other uncontrolled movements and usually responds to treatment with a medication called L-Dopa. Dopa-responsive dystonia can be caused by mutations in one copy or both copies of the SPR gene in each cell. These mutations lead to the production of a sepiapterin reductase enzyme with reduced or absent function.

In most parts of the body, there are alternate pathways that do not use sepiapterin reductase for the production of tetrahydrobiopterin, but these processes do not occur in the brain. Therefore, people with sepiapterin reductase deficiency have a lack of tetrahydrobiopterin in the brain, which affects the production of dopamine and serotonin. The lack of these two neurotransmitters causes the movement problems and other characteristic features of dopa-responsive dystonia.

Sepiapterin reductase deficiency

More than a dozen mutations in the SPR gene have been found to cause sepiapterin reductase deficiency, a condition characterized by progressive problems with movement. Sepiapterin reductase deficiency results when two copies of the SPR gene are mutated in each cell. These mutations include changes that replace amino acids; alter the way the gene's instructions are pieced together to produce the enzyme; or result in a shortened, nonfunctional enzyme. All these mutations lead to the production of enzymes with reduced or no function. A common mutation in affected individuals that replaces the amino acid arginine with the amino acid glycine at position 150 in the enzyme (written as Arg150Gly or R150G) prevents the production of any sepiapterin reductase.

SPR gene mutations disrupt the production of sepiapterin reductase. Most SPR gene mutations result in an enzyme with little or no function. A nonfunctional sepiapterin reductase leads to a lack of tetrahydrobiopterin and a decrease in the production of dopamine and serotonin in the brain. The shortage of these neurotransmitters causes the movement abnormalities and other features of sepiapterin reductase deficiency.

Sepiapterin reductase deficiency is more severe than dopa-responsive dystonia likely because both copies of the SPR gene are mutated, which leads to a more severe enzyme shortage than in dopa-responsive dystonia, in which only one copy of the gene has a mutation.

Other Names for This Gene

• SDR38C1
• sepiapterin reductase (7,8-dihydrobiopterin:NADP+ oxidoreductase)
• short chain dehydrogenase/reductase family 38C, member 1
• SPRE_HUMAN

Genomic Location

Normal Function

The TH gene provides instructions for making the enzyme tyrosine hydroxylase, which is important for normal functioning of the nervous system. Tyrosine hydroxylase takes part in the first step of the pathway that produces a group of hormones called catecholamines. This enzyme helps convert the protein building block (amino acid) tyrosine to a catecholamine called dopamine. Dopamine is also known as a neurotransmitter because it transmits signals between nerve cells in the brain to help control physical movement and emotional behavior. Other catecholamines called norepinephrine and epinephrine are produced from dopamine. Norepinephrine and epinephrine are involved in the autonomic nervous system, which controls involuntary body processes such as the regulation of blood pressure and body temperature.

Health Conditions Related to Genetic Changes

Dopa-responsive dystonia

More than two dozen mutations in the TH gene have been found to cause dopa-responsive dystonia. This condition is characterized by a pattern of involuntary muscle contractions (dystonia), tremors, and other uncontrolled movements and usually responds to treatment with a medication called L-Dopa. Most TH gene mutations that cause this condition change single protein building blocks (amino acids) in the tyrosine hydroxylase enzyme, resulting in a decrease in functional enzyme. A reduction in normal tyrosine hydroxylase enzyme leads to a decrease in the production of dopamine, which causes the movement problems characteristic of dopa-responsive dystonia. The amount of functional enzyme that is produced is associated with the severity of the signs and symptoms. Less functional enzyme leads to more severe symptoms.

Tyrosine hydroxylase deficiency

More than 20 mutations in the TH gene have been identified in people with tyrosine hydroxylase (TH) deficiency. These mutations result in reduced activity of the tyrosine hydroxylase enzyme. As a result, the body produces less dopamine, norepinephrine, and epinephrine. These catecholamines are necessary for normal nervous system function, and changes in their levels contribute to the abnormal movements, nervous system dysfunction, and other neurological problems seen in people with TH deficiency.

Dopa-responsive dystonia (described above) is sometimes considered a mild form of tyrosine hydroxylase deficiency. It is uncertain whether they are two separate disorders or part of the same disease spectrum.

Other disorders

Certain common TH variations (polymorphisms) modify catecholamine production, which affects the risk of developing conditions associated with regulation of the autonomic nervous system. These TH gene polymorphisms affect the extent to which blood pressure increases with stress and may increase the risk of high blood pressure (hypertension).

One TH gene polymorphism has been associated with sudden infant death syndrome (SIDS). SIDS is a major cause of death in babies younger than 1 year. It is characterized by sudden and unexplained death, usually during sleep. The polymorphism, called allele *9.3, is the most common TH gene polymorphism among people of European descent and has been identified in a larger percentage of babies who die from SIDS than in other babies. This version of the gene may affect the regulation of breathing or awakening in infants.

Other Names for This Gene

• DYT5b
• TY3H_HUMAN
• TYH
• tyrosine 3-monooxygenase

Genomic Location

When dopa-responsive dystonia is caused by mutations in the GCH1 gene, it is inherited in an autosomal dominant pattern, which means one copy of the altered gene in each cell is sufficient to cause the disorder. In some cases, an affected person inherits the mutation from one affected parent. Other cases result from new mutations in the gene and occur in people with no history of the disorder in their family.

Some people who inherit the altered GCH1 gene never develop features of dopa-responsive dystonia. (This situation is known as reduced penetrance.) It is unclear why some people with a mutated gene develop the disease and other people with a mutated gene do not. For unknown reasons, dopa-responsive dystonia caused by mutations in the GCH1 gene affects females two to four times more often than males.

When TH gene mutations are responsible for causing dopa-responsive dystonia, it is inherited in an autosomal recessive pattern, which means both copies of the gene in each cell have mutations. The parents of an individual with an autosomal recessive condition each carry one copy of the mutated gene, but they typically do not show signs and symptoms of the condition.

When dopa-responsive dystonia is caused by mutations in the SPR gene, it can have either an autosomal recessive or, less commonly, an autosomal dominant pattern of inheritance.

Dopa-responsive dystonia is estimated to affect 1 per million people worldwide. However, the disorder is likely underdiagnosed because the condition may not be identified in people with mild symptoms, or it may be misdiagnosed in people who have symptoms similar to other movement disorders.