Case reportA case report comparing clinical, imaging and neuropsychological assessment findings in twins discordant for the VCP p.R155C mutation

•We compared MRI and neuropsychological test data in twins discordant for VCP mutation.•Affected twin revealed rapid cognitive decline in a span of 1 year.•FTD related cognitive features may precede behavioral changes in VCP disease.•Cognitive-behavioral impairment may be missed on routine neurological exam and MMSE.•Need for a dedicated screening measure to recognize the neurological impairment.

Inclusion body myopathy, Paget disease of bone and/or frontotemporal dementia is an autosomal dominant disease caused by mutations in the Valosin Containing Protein (VCP) gene. We compared clinical findings including MRI images and neuropsychological assessment data in affected and unaffected twin brothers aged 56 years from a family with the p.R155C VCP gene mutation. The affected twin presented with a 10 year history of progressive proximal muscle weakness, difficulty swallowing, gastroesophageal reflux, fecal incontinence, and peripheral neuropathy. Comprehensive neuropsychological testing revealed rapid cognitive decline in the absence of any behavioral changes in a span of 1 year. This case illustrates that frontotemporal dementia related cognitive impairment may precede behavioral changes in VCP disease as compared with predominance of behavioral impairment reported in previous studies. Our findings suggest that there is a need to establish VCP disease specific tools and normative rates of decline to detect pre-clinical cognitive impairment among affected individuals.