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Intermediate C9orf72 alleles in neurological disorders: does size really matter?
  1. Adeline S L Ng1,
  2. Eng-King Tan2,3
  1. 1 Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore
  2. 2 Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore
  3. 3 Neuroscience and Behavioural Disorders, Duke-NUS Graduate Medical School, Singapore
  1. Correspondence to Dr Eng-King Tan, Department of Neurology, Singapore General Hospital, Block 1 Level 3, Outram Road, Singapore 169108, Singapore; gnrtek{at}


C9orf72 repeat expansions is a major cause of familial frontotemporal dementia (FTD) and amyotrophic lateral sclerosis (ALS) worldwide. Sizes of <20 hexanucleotide repeats are observed in controls, while up to thousands associate with disease. Intermediate C9orf72 repeat lengths, however, remain uncertain. We systematically reviewed the role of intermediate C9orf72 alleles in C9orf72-related neurological disorders. We identified 49 studies with adequate available data on normal or intermediate C9orf72 repeat length, involving subjects with FTD, ALS, Parkinson’s disease (PD), atypical parkinsonism, Alzheimer’s disease (AD) and other aetiologies. We found that, overall, normal or intermediate C9orf72 repeat lengths are not associated with higher disease risk across these disorders, but intermediate allele sizes appear to associate more frequently with neuropsychiatric phenotypes. Intermediate sizes were detected in subjects with personal or family history of FTD and/or psychiatric illness, parkinsonism complicated by psychosis and rarely in psychiatric cohorts. Length of the hexanucleotide repeat may be influenced by ethnicity (with Asian controls displaying shorter normal repeat lengths compared with Caucasians) and underlying haplotype, with more patients and controls carrying the ‘risk’ haplotype rs3849942 displaying intermediate alleles. There is some evidence that intermediate alleles display increased methylation levels and affect normal transcriptional activity of the C9orf72 promoter, but the ‘critical’ repeat size required for initiation of neurodegeneration remains unknown and requires further study. In common neurological diseases, intermediate C9orf72 repeats do not influence disease risk but may associate with higher frequency of neuropsychiatric symptoms. This has important clinical relevance as intermediate carriers pose a challenge for genetic counselling.

  • intermediate alleles
  • clinical genetics
  • genetics
  • repeat expansions

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  • Contributors A SL Ng conducted the literature search and drafting of the manuscript. EK Tan revised the manuscript for intellectual content and provided the outline for the draft. A SL Ng and EK Tan drafted and approved the manuscript.

  • Funding A SL Ng is supported by the Singapore Ministry of Health’s National Medical Research Council (NIG grant) and the SingHealth Foundation Award (PRISM grant). EK Tan is supported by the Singapore Ministry of Health’s National Medical Research Council (STaR and Parkinson’s Disease TCR grants).

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

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