GM1 Gangliosidosis
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Transcript GM1 Gangliosidosis
An Infant with Neuro-regression
Dr. KF Huen
TKOH
History
F / 12 months
FT NSD at UCH with BW 2.655 kg
Uneventful perinatal course
No consanguinity
Father - Chinese
Mother - Chinese + Thai
No family history of metabolic disease or
sudden/early infant death
History
Presented with clinical sepsis in neonatal period
No positive bacterial or viral culture
Noted ↑ ALP up to 1350 U/L (< 281 U/L) with
bone isoenzyme predominant
Calcium and phosphate normal
Skeletal survey – no evidence of rickets or
previous fracture
ALP gradually ↓ with serial monitoring,
normalized at 3m
History
Noted hypotonia and developmental delay at 6
months of age
Head lag, not able to roll over or sit, no reach out
Plain CT brain – unremarkable
Urine metabolic screen – negative
Physiotherapy arranged for early training, slight
improvement in development
History
At 9 months of age, better head control, able to sit with
curve back with support and able to reach out
Noted neuro-regression at 11 months of age, head
control lost, not able to sit with support, not able to
reach out and no visual fixation and follow
More easy choking on oral feeding
Assessment in CAC at 12 months – significant global
delay (mental age = 1 month)
Examination
HC 90-97 %
BW 50-75 %
BH 50-75%
Hypotonia with head lag
Paucity of anti-gravity movement
Coarse facial features – frontal bossing, flat nasal
bridge, hypertelorism, thick lips and gum
hypertrophy
Examination
No cataract or corneal clouding
No fix and follow
Abdomen – hepatosplenomegaly
CVS – unremarkable
Chest – unremarkable
Hypotonia
Coarse Facial Features
Extensive Mongolian Spots
Investigations
CBP – atypical lymphocytosis with a number of
lymphocytes with prominent cytoplasmic
vacuolation
LFT – ALP 522 (< 281 U/L), ALT 39 (< 33
U/L)
Skeletal survey – ovoid shaped vertebral bodies,
anterior beaking of T12 and especially L1 with
kyphosis, thickened skull vault, normal pituitary
fossa
Cytoplasmic Vacuolation
Vacuolated
lymphocytes
Lymphocytes with multiple medium-sized vacuoles (top left).
Some contained a large azurophilic granule (bottom left).
Majority of eosinophilic granulocytes were pale. Many contained large
granules unevenly distributed within the cytoplasm (right).
Although abnormally vacuolated lymphocytes may be observed in
infantile sialic acid storage disease, mannosidosis and GM1gangliosidosis,
the eosinophilic anomaly in addition is specific for GM1-gangliosidosis
type I (Giltzemann et al, 1985).
Two-dimensional glycosaminoglycan
electrophoresis of the patient’s urine
Presence of chondroitin
sulphate (CS), heparan
sulphate (HS) and
keratan sulphate (KS).
The presence of KS is
abnormal and is seen
in patients with
mucopolysaccharidosis
type IV (Morquio
syndrome) and GM1gangliosidosis.
Skeletal Survey – dysostosis multiplex
Thickened calvarium; enlarged sella
Flattening, beaking and kyphosis
Flaring of ilia of pelvis;
acetabular dysplasia
Coarse thickening of
phalanges and metacarpals;
Bullet-shaped appearance
Investigations
Echo – no cardiomyopathy, normal LV function
Ophthalmologic exam – bilateral cherry red spots
ENT exam – both vocal cords smooth and
mobile, bilateral moderate-severe sensorineural
hearing deficit, bilateral flat tympanometry
Speech therapist assessment – impaired
swallowing but normal vocal cord function
MRI brain – gross delay in myelination process
MRI brain
Investigations
Urine metabolic screen – negative for
mucopolysaccharide (by electrophoresis)
Urine oligosaccharide pattern (TLC) compatible
with GM1 gangliosidosis
TLC - Heavily staining bands around zones of penta-saccharide,
octa-saccharide, and oligosaccharides with longer sugar chains
TTN
TTN
GM1
TTN
Investigations
Leucocytes for enzyme assay –
Hexosaminidase A & B activity normal (GM2
gangliosidosis – Tay-Sachs, Sandhoff)
α-galactosidase activity normal (Fabry, Schindler)
Deficient β-galactosidase activity 0.10 (1.0 – 6.0
nmol/min/mg protein)
Investigations
β-galactosidase (GLB1) gene mutation analysis
Index: compound heterozygous for
c.495-7delTCT and c.1734G>T
Mother: heterozygous for c.1734G>T
Father: mutation not detected
Diagnosis
GM1 gangliosidosis
Complications
GERD and aspiration
Developed repeated
episodes of cough,
noisy breathing and
vomiting
Required continuous
naso-gastric tube
feeding
Complications
Seizure
Developed repeated episodes of apnoea &
desaturation and generalised tonic clonic
convulsion
EEG – epileptic tendency
Required phenobarbitone, phenytoin and
clobazam for seizure control
Complications
Spasticity
Spasticity over extremeties and tight Achilles
tendons
Required physiotherapy and nocturnal anklefoot orthosis
Progress
Parents preferred naso-gastric tube feeding than
gastrostomy feeding
Experienced few episodes of gastro-esophageal
reflux and aspiration
At 18 months of age, developed aspiration
pneumonia and hence respiratory failure, finally
succumbed
Review
GM1 gangliosidosis
Background
Autosomal recessive lysosomal storage disorder
characterized by the generalized accumulation of
GM1 ganglioside, oligosaccharides, and the
mucopolysaccharide keratan sulfate and their
derivatives
Deficiency of the lysosomal hydrolase, acid βgalactosidase (GLB1), causes GM1 gangliosidosis
and Morquio disease type B (ie.
mucopolysaccharidosis type IVB).
Background
Three clinical subtypes classified by age of onset:
Infantile (type 1)
Combines the features of a neurolipidosis (neurodegeneration,
macular cherry-red spots) with those of a mucopolysaccharidosis
(visceromegaly, dysostosis multiplex, coarse facial features)
Most frequently presents in early infancy and may be evident at birth
Juvenile (type 2)
Slightly later age of onset and clinical variability in the classic physical
features
Adult (type 3)
Normal early neurologic development with no physical stigmata and
subsequent development of a slowly progressive dementia with
parkinsonian features, extrapyramidal disease and dystonia
Pathophysiology
Acid β-galactosidase is a lysosomal hydrolase that catalyzes the removal
of the terminal β-linked galactose from glycoconjugates (eg. GM1
ganglioside), generating GM2 ganglioside
Degrades other β-galactose-containing glycoconjugates, such as
keratan sulfate
Deficiency of acid β-galactosidase results in the accumulation of
glycoconjugates in body tissues and their excretion in urine
GM1 ganglioside and its derivative asialo-GM1 ganglioside (GA1),
glycoprotein-derived oligosaccharides, and keratan sulfate are found at
elevated intracellular concentrations
Gangliosides are normal components of cell membranes, particularly
neurons, and GM1 is the major ganglioside in the vertebrate brain
Accumulation of toxic asialo- and lyso-compound GM1 ganglioside
derivatives is believed to be neuropathic
Epidemiology
Frequency
Rare disorder, incidence not widely available
High incidence of 1 per 3700 live births in Malta
Race
Found in all race, large number of Japanese patients
with adult form has been reported
Sex
Autosomal recessive traits, equal sex distributions
Clinical Course
Infantile form (type 1)
Juvenile form (type 2)
Typically presents between birth and age 6 months with progressive organomegaly,
dysostosis multiplex, facial coarsening, and rapid neurologic deterioration within
the first year of life
Death usually occurs during the second year of life because of aspiration
pneumonia and cardiopulmonary failure
Typically presents at age 1-2 years with progressive psychomotor retardation
Little visceromegaly and milder skeletal disease
Death usually occurs before the second decade of life
Adult form (type 3)
Typically presents during childhood or adolescence as a slowly progressive
dementia with prominent parkinsonian features and extrapyramidal disease,
particularly dystonia.
Marked phenotypic variability
Age at death vary greatly
Clinical Features
Neurologic findings
Developmental delay, arrest, and regression
Generalized hypotonia initially, developing into spasticity
Exaggerated startle response
Hyperreflexia
Seizures
Extrapyramidal disease (adult subtype)
Dystonia (adult subtype)
Ataxia (adult subtype)
Dementia (adult subtype)
Clinical Features
Dysmorphic features
Frontal bossing
Depressed nasal bridge
and broad nasal tip
Large low-set ears
Long philtrum
Gingival hypertrophy and
macroglossia
Coarse skin
Hirsutism
Ophthalmologic findings
Macular cherry-red spots
Optic atrophy
Corneal clouding
Clinical Features
Cardiovascular
Dilated and/or hypertrophic
cardiomyopathy
Abdomen
Hepatosplenomegaly
Inguinal hernia
Skeletal abnormalities
Lumbar gibbus deformity
and kyphoscoliosis
Dysostosis multiplex
Broad hands and feet
Brachydactyly
Joint contractures
Hydrops fetalis
Angiokeratoma corporis
diffusum
Genetics
Gene located on chromosome band 3p21.33
Cloning and sequencing of cDNA encoding human
GLB1 in 1988 by Oshima and others
Various types of mutations identified in the acid βgalactosidase gene, including missense/nonsense,
duplication/insertion and splice site abnormalities
Genotype and phenotype correlations provides a
molecular explanation for clinical variability
Amount of residual enzyme activity determines disease
subtype and severity
Genetics
Exon
Amino Acid
DNA
2
Arg49→Cys
CGC→TGC
3
Gly123→Arg
GGG→AGG
3
Duplication-stop
condon
288-310
6
Arg208→Cys
CGC→TGC
9
Tyr316→Cys
TAT→TGT
11-12
Duplication
1103-1267
14
Arg457→Ter
CGA→TGA
15
Gly494→Cys
GGT→TGT
15
Lys577→Arg
AAG→AGG
Differential Diagnoses
I-cell disease (mucolipidosis type II)
Mucolipidosis type I (α-neuraminidase deficiencysialidosis)
Mucopolysaccharidosis type IH
Galactosialidosis (combined α-neuraminidase and
β-galactosidase deficiency)
Oligosaccharidosis (eg. mannosidosis, fucosidosis,
sialidosis)
Investigations
Acid β - galactosidase activity
Diagnosis can be confirmed by measurement of acid β-galactosidase
activity in peripheral blood leukocytes
Patients with the infantile form have almost no enzyme activity, while
patients with the adult form may have residual activity of 5-10% of
reference values
Urine oligosaccharide / mucopolysaccharide pattern
Galactose-containing oligosaccharides are excreted in the urine
Complete blood picture
Vacuolation of lymphocytes may be present in patients with GM1
gangliosidosis
Investigations
Skeletal radiographs - changes characteristic of dysostosis multiplex
including thickened calvarium, J-shaped enlarged sella turcica, wide
spatula-shaped ribs, flared ilia, acetabular dysplasia and flat femoral
heads, wide wedge-shaped metacarpals, shortened long bones with
diaphyseal widening, and hypoplastic and anteriorly beaked
thoracolumbar vertebrae
CT or MRI brain - diffuse atrophy and white matter demyelination
with or without basal ganglia changes
Ultrasound of abdomen - organomegaly
Echocardiography - signs of cardiomyopathy
Electrocardiography - signs of cardiomyopathy
Electroencephalography - generalized dysrhythmia and
epileptogenic foci
Treatment
No effective medical treatment available for the underlying disorder
Symptomatic treatment for some neurologic sequelae but not alter the clinical
course significantly
Active research in the areas of enzyme replacement and gene therapy for GM1
gangliosidosis
Multidisciplinary approach
Clinical geneticist - for initial evaluation and diagnosis, to counsel families
regarding recurrence risk, and to help provide prenatal testing for future
pregnancies
Neurologist - for symptomatic therapy of multiple neurologic sequelae
Cardiologist - to evaluate for cardiomyopathy
Orthopaedic surgeon - to evaluate for dysostosis multiplex
Ophthalmologist - to evaluate for ocular stigmata
Otolaryngologist and audiologist - to assess for hearing loss
Treatment
Diet
No specific dietary modifications significantly alter the clinical
course
May require tube feeding to provide adequate intake of energy;
however, not change the disease course
some families may choose to forgo invasive alimentation
procedures
Activity
Neurologic and orthopaedic sequelae may preclude adequate
physical activity, benefit from physical and occupational therapy
Discussion
Clinical Features
Extensive Mongolian spots
This report describes three infants with generalized Mongolian spots, two
infants with GM1 gangliosidosis type 1, and one in association with Hurler
syndrome.
Mongolian spots result from entrapment of melanocytes in the dermis
because of arrested transdermal migration, which is regulated by tyrosine
kinase, from the neural crest into the epidermis.
Accumulated metabolites such as GM1 and heparan sulfate bind to tyrosine
kinase receptor which enhances nerve growth factor activity and leads to both
neurologic manifestations and aberrant neural crest migration.
Findings of generalized Mongolian spots in newborns may lead to an early
detection and early treatment before irreversible organ damage occurs.
Extensive Mongolian Spots: A Clinical Sign Merits Special Attention. Ashrafi MR,
Shabanian R, Mohammadi M, Kavusi S. Pediatr Neurol. 2006 Feb;34(2):143-145.
Clinical Features
Hyperphosphatasemia
Hyperphosphatasemia in infantile GM1 gangliosidosis: possible association with
microscopic bone marrow osteoblastosis.
Mogilner BM, Barak Y, Amitay M, Zlotogora J. J Pediatr. 1990 Nov;117(5):758-61.
Hyperphosphatasemia in GM1 gangliosidosis. Denis R, Wayenberg JL, Vermeulen M,
Hyperphosphatasemia in early diagnosed infantile GM1 gangliosidosis
presenting as transient hydrops fetalis. Denis R, Wayenberg JL, Vermeulen M, Gorus F,
Gorus F, Liebaers I, Vamos E. J Pediatr. 1992 Jan;120(1):164.
The authors report a case of unsuspected fetal storage disorder
initially diagnosed by placental examination performed because of a
transient ascites at 28 weeks of gestation. At birth mild dysmorphic
features and gradual neurological deterioration were observed. Highly
elevated alkaline phosphatase levels were repeatedly noticed.
Deficiency of beta-galactosidase was documented confirming GM1
gangliosidosis. Previous reports described the placental pathology
after positive prenatal diagnoses of lysosomal diseases. In the present
case, the postnatal diagnosis was made in view of the placental
pathologic findings. Our observation indicates the need for thorough
investigations in hydrops fetalis, in search for metabolic diseases.
Gerlo E, Lissens W, Liebaers I, Jauniaux E, Vamos E. Acta Clin Belg. 1996;51(5):320-7.
Treatment
Bone marrow transplantation
Donor bone marrow engraftment, which resulted in complete
normalization of white cell β-galactosidase levels in a patient
with presymptomatic juvenile onset GM1-gangliosidosis, did
not improve long-term clinical outcome.
Bone marrow transplantation correcting β-galactosidase activity
does not influence neurological outcome in juvenile GM1gangliosidosis.
Shield JPH, Stone J, Steward CG. J Inherit Metab Dis.
2005;28(5):797-8.
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