Clinical manifestations vary significantly according to the disease severity and the age at presentation.

N-ALD can manifest immediately after birth. However, some infants will be mildly affected. Hence diagnosis is usually delayed in these cases. Typical signs and symptoms in N-ALD include [8]:

1. Seizures, hypotonia, hearing dysfunction
2. Vision, cataracts, optic nerve dysplasia
3. Jaundice, hepatomegaly
4. Failure to thrive and facial dysmorphism (hypertelorism and flat midface)

X-ALD usually has three phenotypes, classified based on the age of presentation and the organs affected:

1. Childhood cerebral ALD, typically affect children between the age of three to ten years. The hallmark feature that characterizes this form is developmental regression. More progressive sensory and severe neurological deficits, severe disability, coma, and death are generally followed by more progressive sensory and severe neurological deficits. A small percentage of adults may present in a similar pattern to the childhood cerebral ALD. 
2. Addison disease. The adrenal gland dysfunction characterizes this form. The manifestations associated with this subtype are the result of decreased production of:
   1.  Aldosterone (hyponatremia, fatigue, hypotension, dehydration)
   2.  Cortisol (hypoglycemia and generalized weakness)
   3.  Hyperpigmentation of the skin may also occur.
3. Adrenomyeloneuropathy; the typical age of presentation is in the third decade of life. It presents a milder spectrum of ALD. Walking difficulties, unbalanced gait, and bowel/bladder sphincter dysfunction are typical manifestations.[2]  

Females who are carriers may develop milder symptoms (unbalanced gait, neuropathy, mild paresis). The adrenal glands and cerebrum are rarely involved.[9]

Typical Clinical presentation, characteristics, symptoms and signs, and suggestive family history are considered the starting point for adrenoleukodystrophy evaluation. Several states started using newborn screening tests as a screening tool to identify newborns with a potential genetic predisposition for X-ALD.[3] The driving principle behind adding X-ALD to the newborn screening is to identify newborns with the mutation to receive treatment before the symptoms appear.

Nonspecific laboratory workup may reveal an abnormal liver function and reduced response to ACTH administration. The more indicative test results will show [10]:

1. Increased VLCFA plasma concentration
2. Decrease red blood cells' plasmalogen concentration
3. Increase in the concentration of pipecolic and phytanic acid concentration in both plasma and fibroblasts

Magnetic resonance imaging (MRI) of the brain is an essential part of the evaluation; Typical findings are:

1. White matter demyelination pattern
2. Microgyria
3. Germinolytic cysts in the caudothalamic groove

Further genetic testing to identify the specific genetic mutation is recommended to confirm the diagnosis.[11]

There is no effective treatment for most of the forms of N-ALD or X-ALD. Supportive care by optimizing nutrition, occupational therapy, and respiratory support can help alleviate some of these disorders' severe consequences but typically do not significantly impact survival or long-term outcomes. Coreterosteriod and mineralocorticoid replacement therapy is the recommended therapy in those with impaired adrenal gland function. Some reports have shown that allogeneic hematopoietic cell transplant (HCT) may have beneficial effects. Favorable outcomes with HCT therapy occur in asymptomatic patients at the time of diagnosis or those with mild symptoms and CNS involvement.[12] 

Recent trials to use docosahexaenoic acid (DHA) or the induction of peroxisome proliferation were not conclusive.[13][14] Given the multiple organs affected and the multiple needs for the management of ALD patients, an interprofessional team approach (endocrinologist, neurologist, genetics, psychologist) is recommended.

The differential diagnosis for N-ALD is comprehensive and includes other genetic syndromes that present in the neonatal period with neurological signs and symptoms ( Angelman, RET syndrome, Prader Willi, hypoxic-ischemic encephalopathy, metabolic disorders, myotonic dystrophy, and others). For X-ALD; Other demyelination disorders (acute disseminated encephalomyelitis (ADEM), multiple sclerosis, specific central nervous system dysfunction) should be excluded as the evaluation, management, and prognosis for these conditions are different from ALD.

Two ongoing clinical trials to evaluate potential therapeutic interventions for ALD are actively recruiting. NCT03727555 clinical trial evaluates the use of lentiviral vector TYF-ABCD1 to correct the defective ABCD1 gene associated with ALD. Another trial, NCT03852498, aims to assess the effect of autologous CD34+ HCT on ALD.

Prognosis is poor with N-ALD and most of the other forms of X-ALD. Treatment is usually limited to symptomatic supportive management. Replacement therapy for patients with Addison disease and HCT for asymptomatic patients ( identified by newborn screen or incidental imaging) or have mild symptoms may be effective in selected cases. Severe disabilities and death are the expected outcomes on the majority of patients with N-ALD or X-ALD. 

Adrenoleukodystrophy is a peroxisome disease that affects neonates ( N-ALD) or children and adult (X-ALD) with multiple organs involvement ( commonly; the central nervous system and the adrenal glands).

• Neonatal ALD inheritance is in an autosomal recessive pattern while X-ALD follows X linked recessive (male predominance)
• Clinical presentation of patients with ALD is variable, with neurological (hypotonia, weakness, developmental regression, cognitive disabilities, severe disabilities) and adrenal insufficiency (hypotension, fatigue, hypoglycemia) been the most common clinical manifestations.
• Diagnosis of ALD requires a detailed history and physical examination, measuring VLCFA levels, brain MRI, and specific genetic testing.
• Treatment for ALD with corticosteroid replacement therapy and hematopoietic stem cell transplant ( HCT) is limited for selected cases. No effective treatment exists for the majority of cases, and management is usually supportive.
• The prognosis of ALD is unfavorable and carries a high rate of mortality and severe disabilities.
• Clinical trials are ongoing to evaluate potential gene therapy for ALD.

• Adrenoleukodystrophy is a peroxisomal disorder that has a variable clinical presentation. It has many types based on; age, organs involved, and mode of inheritance.
• A multidisciplinary team of neurologists, endocrinologists, genetics, dietician, and psychologist is recommended to coordinate the care of patients of ALD.
• Hemapotioc cell transplant (HCT), docosahexaenoic acid (DHA) fatty acid, and peroxisomal induction are possible treatments.