Sensitivity to Parietaria officinalis and Parietaria judaica pollen allergens in a Spanish population

To investigate the biological activity of P. judaica and P. officinalis allergen preparations, 36 Spanish patients were included in a biological standardization (BS) trial. For both species the concentration corresponding to 1000 biological units/ml (BU/ml) was found to be about 2 micrograms dry weight/ml (d.w./ml). The allergenic activity per microgram d.w. was about the same as reported for other important weed pollen extracts. The physico-chemical and immunological properties of the purified Parietaria judaica and Parietaria officinalis pollen allergen preparations used for biological standardization were investigated. The protein content was determined to 38% and 23% for P. judaica and P. officinalis respectively, while the carbohydrate content was 25% in both weed preparations. More than 40 antigens and at least 10 different allergens were detected by crossed immuno electrophoresis/crossed radio immunoelectrophoresis (CIE/CRIE) analyses. SDS-gPAGE followed by electroblotting showed important allergens between 10,000 and 75,000 d for both species. The crossreactivity as measured by skin prick test, RAST and CRIE was high.

Diagnosis and immunotherapy of mould allergy. V. Clinical efficacy and side effects of immunotherapy with Cladosporium herbarum

A placebo-controlled, double-blind study of immunotherapy with the mould species Cladosporium was performed in 22 adult asthmatics. The diagnosis of Cladosporium allergy was based on a combination of bronchial provocation test and daily symptom score in the Cladosporium season. An aqueous preparation of a potent, biologically standardized and purified extract was used in a clustered dose-increase regimen. The clinical efficacy was evaluated by a combination of symptoms (asthma score + peak flow) and consumption of antiasthmatic medication. The mean changes in symptoms and medication consumption over a 10-week registration period (peak Cladosporium season) in 1982 after 5-7 months of immunotherapy were compared with the corresponding 1981 pretreatment 10-week period. A significant (P = 0.03) difference in terms of "improved", "unchanged" and "deteriorated" patients in favour of Cladosporium treatment was found. Approximately 80% in the Cladosporium group showed improved/unchanged symptoms contrary to 30% of the placebo treated. Side effects were observed frequently but only in the Cladosporium-treated. About 70% experienced a large local reaction and 100% had episodes of asthma during dose-increase phase. Only a few severe systemic reactions occurred. Based on the clinical efficacy of the treatment we consider immunotherapy with Cladosporium feasible for highly specialized clinics.

Clinical history, skin prick test and RAST in the diagnosis of birch and timothy pollinosis

The diagnostic efficacy of clinical history (CH), skin prick test (SPT) and RAST was estimated in relation to nasal and conjunctival provocation tests (NPT, CPT) in 69 patients with seasonal rhinoconjunctivitis. The extracts used were freeze-dried, and biologically standardized birch and timothy allergen preparations matched to the extracts on Phadebas RAST discs. Based on single determinations the sensitivity, specificity and predictive values were calculated. There were highly significant (P less than 0.001) correlations between all parameters: NPT, CPT, CH, SPT and RAST. For birch the combination of SPT and RAST made the PTs superfluous as both sensitivity and specificity then reached 100%. With timothy the sensitivity was 97% and with the addition of CH 100%. However, the specificity was only 79% through combining CH, SPT and RAST. The present study using the same standardized allergen preparation in all tests showed a good correlation between indirect test results and provocation tests.

Oral immunotherapy of children with rhinoconjunctivitis due to birch pollen allergy. A double blind study

Thirty children with rhinoconjunctivitis due to birch pollinosis were treated in a double blind manner for 10 months with enteric-coated capsules containing either a birch pollen preparation (n = 14) with doses up to 1.4 X 10(6) biologic units per day or placebo (n = 16). Compared with the placebo group the actively treated children had less symptoms during the birch pollen season after 3 months of therapy (P = 0.035). Skin prick reactions decreased significantly more in the active group than in the placebo group after 10 months (P = 0.01). Conjunctival sensitivity was lower in the active group than in the placebo group after 3 months of treatment (P = 0.01) but not after 10 months. Compared with the placebo group the treated children more often increased their levels of IgG (P = 0.007) and pre-seasonal IgE (P = 0.001) against birch. There was a seasonal increase of IgE antibody level against birch in the placebo but not in the treatment group (P less than 0.001). None of the treated children developed asthma, compared with five of the untreated children. No general reactions occurred and few side effects were seen during the treatment period. We conclude that in children with birch pollinosis oral immunotherapy with high doses of a biologically potent preparation in enteric-coated capsules is effective, easy to perform, economic and safe.

Clinical and immunological effects of oral immunotherapy with a standardized birch pollen extract

Oral immunotherapy (IT) was evaluated in a pilot study in two centres in children aged 8-15 years with allergic rhinoconjunctivitis. High doses (up to 20 X 10(6) BU monthly) of a defined freeze-dried birch pollen extract administered in enteric-coated gelatine capsules were given either daily for seven consecutive days every month or once weekly. Symptom scores, as assessed by sneezing, dripping and blockage of the nose, and redness, itching and swelling of the eyes, were significantly lower in treated patients compared to untreated, or placebo treated controls after 3 to 5 months of therapy. In all the 16 treated, but only in three of eight untreated patients, the scores were lower during the pollen season 1982 than during the pollen season preceding the treatment period, despite comparable pollen counts during the two seasons. One year after beginning treatment the reactivity in conjunctival provocation tests was decreased about 10-fold (P less than 0.001) in the patients receiving more than 2 X 10(5) BU monthly compared to about two-fold in patients receiving lower doses, or placebo. Increased levels of IgE antibodies directed against birch pollen were recorded in the serum and saliva of most patients after 3-4 months of active IT. In contrast, IgG antibody responses were poor in most of the patients. Side effects, particularly from the gastrointestinal tract, appeared in all treated children. In one of them a systemic reaction occurred during IT. The study indicates that properly performed oral IT with a potent birch allergen extract in enteric-coated capsules may be effective.

Cross-reactivity between deciduous trees during immunotherapy. I. In vivo results

Thirty-nine children with rhinoconjunctivitis due to birch pollinosis were given immunotherapy for 3 years with a potent, purified pollen preparation made from either birch alone or from a mixture of birch, alder and hazel. The therapy was evaluated with self-evaluation after each season, daily symptom score during the season, conjunctival provocation test and skin-prick test. All children but one considered that their condition had been improved by the treatment. Symptom scores decreased slightly more in the group treated with the mixture than in the group treated with birch only due to symptoms decreasing faster in the mixture treated group after each pollen peak (P less than 0.001). The sensitivity of the conjunctiva and the skin decreased significantly in both groups but without any significant differences between the groups. After 3 years the conjunctival sensitivity correlated strongly to eye symptoms during the season. Immunotherapy with a mixture of birch, alder and hazel appears to be at least as effective as a preparation made from birch only when treating birch pollinosis even in a region where birch is totally dominating among the pollens from deciduous trees.

IgG and IgE antibody patterns after immunotherapy with monomethoxy polyethyleneglycol modified honey bee venom

Antibody responses to honey bee venom (HBV) were studied in 13 patients during a 4-month course of immunotherapy with monomethoxy polyethyleneglycol (mPEG) modified venom. There was a rise of HBV-specific IgG antibodies as measured by IgG-RAST in all patients and a slight decrease of IgE antibody in most of them. The IgG-antibody responses during mPEG-HBV treatment as examined by crossed radioimmunoelectrophoresis were directed to phospholipase A, hyaluronidase, acid phosphatase and to another allergen, antigen 1. Thus, despite a high degree of mPEG-modification of HBV, the immunogenicity of the most important HBV allergens was retained.

A double-blind, multicenter immunotherapy trial in children, using a purified and standardized Cladosporium herbarum preparation. II. In vitro results

This double-blind immunotherapy trial in children, using a purified and standardized Cladosporium herbarum allergen preparation, has shown that children with mould asthma and/or rhinoconjunctivitis, responded to immunotherapy with a decrease in specific IgE and a significant increase in specific IgG. There was a marked increase in the ratio specific IgG/specific IgE as a result of active treatment. IgE-CRIE radiostaining patterns showed no pronounced changes after 10 months' active treatment and no "new sensitivities" could be detected in the studied patients. IgG-CRIE radiostaining, primarily directed towards the important allergens, was significantly increased in the active group and particularly towards Ag-12 (partially identical to a previously described major allergen in Cladosporium herbarum, Ag-54). Children treated with histamine placebo showed no change in antibody patterns during 10 months of treatment.

A double-blind, multicenter immunotherapy trial in children, using a purified and standardized Cladosporium herbarum preparation. I. Clinical results

A double-blind histamine placebo controlled immunotherapy trial was performed to investigate the clinical effect of a purified and standardized Cladosporium herbarum allergen preparation. Thirty children with a clinical history suggesting mould-induced asthma and/or rhinoconjunctivitis were included. The diagnosis was confirmed by positive skin prick test and Phadebas RAST as well as positive bronchial and/or conjunctival provocation test to Cladosporium herbarum. Immunotherapy was given for 10 months in a double-blind manner to randomized groups with either Pharmalgen/Cladosporium herbarum preparation or histamine placebo. Allergic side effects to injections were common, especially during the peak of the mould season (July-September in Scandinavia). In the active group, 13/16 patients experienced general reactions during the first 10 months of treatment. After 6 months of treatment, eye, nose and bronchial symptom scores and peak expiratory flow rates were similar for the groups, maybe because most of the children were also sensitive to many other allergens, including Alternaria alternata. However, medication scores were significantly lower in the treated group (P less than 0.01). Bronchial (P less than 0.01) and conjunctival sensitivity (P = 0.01) were significantly reduced in the Cladosporium-treated group but not in the placebo group after 10 months of treatment. This is the first double-blind clinical trial showing the clinical efficacy of immunotherapy in children with mould-induced asthma.

A preliminary study of immunotherapy with a monomethoxy polyethylene glycol modified honey bee venom preparation

Monomethoxy polyethylene glycol (mPEG) modified honey bee venom (HBV) immunotherapy (IT) has been studied in 14 patients allergic to honey bee venom. Doses could be increased more rapidly and higher doses were reached compared to regular venom immunotherapy. No general side effects were seen, although large local swellings were found somewhat more often than with regular HBV. Most patients could easily be switched from the modified to the unmodified venom. Eight patients experienced and tolerated field stings. Skin testing showed a decreased allergenicity of the mPEG-HBV. The mean HBV-specific IgE level was below pre-treatment level already after only 6 weeks of IT. The HBV-specific IgG response was very good.

Diagnosis and immunotherapy of mould allergy. III. Diagnosis of Cladosporium allergy by means of symptom score, bronchial provocation test, skin prick test, RAST, CRIE and histamine release

Thirty-three adult asthmatic patients suspected of mould allergy were investigated by in vivo and in vitro tests in order to establish a specific diagnosis of asthma caused by the mould species Cladosporium. The patients were evaluated by daily symptom scores in the peak Cladosporium season, bronchial provocation test (BPT), skin prick test (SPT), RAST, histamine release from basophil granulocytes (HIST), and crossed radioimmunoelectrophoresis (CRIE), and the results were scored as negative (score 0), equivocal (score 1) or positive (score 2). Based on daily symptom scores and the result of BPT the patients were classified as being manifest allergic (asthma) to Cladosporium (positive allergy), inconclusive or negative. Positive allergy was defined as asthma symptoms oscillating with the spore concentration and a BPT score 2 (positive at allergen concentration less than 10,000 BU). Negative allergy was defined as no asthma symptoms and a negative BPT (score 0) and inconclusive in the case of symptoms and BPT sum of score 1-3. According to the classification a final diagnosis (positive or negative) could be established in 85% of the patients. "False positive" tests were found: for BPT in 27%, SPT 18%, RAST 0%, HIST 18%, and CRIE 0%. The corresponding figures for "false negative" were: BPT 0%, SPT 0%, RAST 27%, HIST 18%, and CRIE 23%. The relative risk of being allergic in spite of a negative test result was 0% for BPT and SPT, and 25-30% with RAST, HIST, and CRIE. In the case of positive test the risk was 90-100%. Excluding BPT, SPT was found to be the optimal single test to predict/rule out clinical allergy. A stepwise combination of positive SPT and positive RAST was found exclusively in patients clinically evaluated as positive, and does not call for an additional BPT. Using a potent allergenic extract a negative SPT excluded clinically important allergy. The primary conclusion of the study, however, is that the final diagnosis of Cladosporium asthma could not be based on a positive BPT alone (due to "false positive"), but only on a combination of clinical symptoms during the spore season and a positive BPT.

Diagnosis and immunotherapy of mould allergy. I. Screening for mould allergy

In order to screen for mould allergy, extracts of five common atmospheric moulds (Cladosporium, Alternaria, Penicillium, Aspergillus and Mucor) from various manufacturers were investigated in 130 patients (5-60 years old) with clinical symptoms indicating possible mould allergy. The patients were screened by skin prick test (SPT) and radioallergosorbent test (RAST). SPT seemed to be more sensitive than RAST as a diagnostic screening procedure (80% positive reactions to one or more species compared to 50%). With a partially purified, standardized preparation of Cladosporium herbarum more positive reactions were obtained than with crude extracts without evidence of any unspecific reactions. The difference between commercial and standardized extracts is most probably a result of a variation of both the biological potency of allergenic determinants and the allergenic composition. A considerable number of negative RAST reactions with standard discs were found in patients with positive skin reactions to partially purified Cladosporium, but RAST seemed to be more sensitive than SPT with the other commercial mould extracts. Based on the screening, a very convincing tendency to IgE-reactivity to other moulds was found in patients reacting to Cladosporium, the most common cause of mould allergy. The results confirm the inadequacy of most mould extracts used in diagnostic procedures and strengthen the value of using standardized extracts.

A double blind study on immunotherapy with chemically modified honey bee venom: monomethoxy polyethylene glycol-coupled versus crude honey bee venom

24 patients with honey bee sting allergy were treated with either honey bee venom (HBV) or monomethoxy polyethylene glycol-coupled HBV (PEG-HBV) in a double blind trial. Both treatments induced a strong increase in HBV-specific IgG antibodies in most patients. Immunotherapy with PEG-HBV was much better tolerated than that with HBV. Conversely, patients on HBV did considerably better during a sting challenge with a living honey bee. Only 4 developed a large local and one a mild systemic reaction compared to 7 large local and 3 moderate to severe systemic reactions in the PEG-HBV-group. A higher maintenance dose of PEG-HBV may still be well tolerated but prove more effective at reexposure.

Blood lymphocyte proliferation response to pollen extract as a monitor of immunotherapy

In a study of immunotherapy 41 children with seasonal rhinoconjunctivitis due to deciduous tree pollen allergy were monitored by means of symptom scoring, patient self-evaluation, conjunctival provocation tests and lymphocyte proliferation in vitro to the allergen. The lymphocyte responsiveness to birch pollen decreased significantly during the first year of immunotherapy. However, neither the lymphocyte responsiveness before treatment nor changes in lymphocyte reactivity during the immunotherapy correlated with the clinical efficacy of the therapy as evaluated by changes in symptom scores, self-evaluation or conjunctival provocation test changes in the individual patients. The results indicate that lymphocyte responsiveness to an allergen cannot be used to select patients for immunotherapy, i.e. to predict whether a patient would benefit from immunotherapy or not, or to evaluate the effects of immunotherapy after beginning the treatment. However, lymphocyte proliferation response to an allergen indicates clinical sensitivity.

The precision of the conjunctival provocation test

Repeated conjunctival provocation tests (CPT) were done in 20 children with rhino-conjunctivitis due to birch pollen allergy. Compared with the first open challenge, three successive blinded CPTs were reproducible within an allergen strength difference of one 10-potency in 92% of the tests. Based on the data, a power function was constructed, making it possible to determine the number of patients needed to discriminate CPT sensitivity of a given magnitude between two populations. During the study period specific serum-IgE increased in only three of 19 patients, indicating that stimulation of IgE antibody production is not a common consequence of repeated tests. We conclude that CPT is useful in clinical research. When indicated in clinical routine, CPT is a safe and easy test with good precision.

Allergy to apple, carrot and potato in children with birch pollen allergy

Skin sensitivity to apple, carrot and potato, clinically related to birch pollinosis was investigated. Different skin test techniques using fresh fruit were compared. A simple prick test (SPT) technique with a lancet piercing the apple peel just before pricking the skin was shown to be the most practical and to give reproducible results. The allergenic activity in apple was found to be heat labile and deteriorated during storage at room temperature. Apple, carrot, potato, hazelnut and birch reactivity was transferable in Prausnitz-Küstner test like IgE antibodies. SPT reactivity to fresh material from apple, carrot and potato was investigated in 174 children of whom 128 suffered from pollen allergy. Positive SPT results were obtained almost exclusively in children who were SPT positive to a birch pollen extract. Children who noticed clinical symptoms when eating apple, raw carrot or potato were found to have a significantly larger SPT reaction than children with a negative history.

Hematological findings in the Norrbottnian type of Gaucher disease

A controlled study of hematological changes was performed on 14 patients with the Norrbottnian type of Gaucher disease, seven of whom had been splenectomized at least one year before the study. Each patient had two controls matched to age, sex and habitation. Before splenectomy the patients had slight to moderate microcytic, hypochromic anemia which changed after splenectomy to macrocytic, hypochromic anemia. The splenectomized patients had a high percentage of target cells (mean frequency 33%) and a significantly increased hypo-osmotic resistance of the erythrocytes which showed a positive correlation with the number of target cells. Before removal of the spleen the patients had slight leukopenia with a relative increase of mononuclear cells and moderate thrombocytopenia. In the splenectomized patients the thrombocyte count was normal and there was moderate leukocytosis with a persistent relative increase of lymphocytes.

Increased cerebroside concentration in plasma and erythrocytes in Gaucher disease: significant differences between type I and type III

A method was developed for the determination of cerebrosides in 1 ml of plasma or 1 ml of packed erythrocytes. At least 90% of the cerebroside fraction consisted of glucosylceramide. In the erythrocytes, nothing but glucosylceramide was identified. The method was applied to plasma samples from 25 controls, 34 Gaucher Type III obligate carriers, 16 Gaucher Type III patients, 7 Gaucher Type I patients and 7 patients with myelogenous or lymphatic leukemia, as well as to erythrocyte samples from 20 controls, 6 Gaucher Type III obligate carriers, 16 Gaucher Type III patients and 6 Gaucher Type I patients. The concentration of plasma cerebroside was 11.4 +/- 4.2 (S.D.) in controls, 11.8 +/- 2.6 in Gaucher Type III carriers, 30.4 +/- 7.7 in Gaucher Type III patients and 21.8 +/- 6.7 mumol/l in Gaucher Type I patients. The Gaucher patients had significantly increased (p less than 0.001) plasma cerebroside values, while the plasma cerebroside concentration of the leukemic patients was only slightly increased, 14.7 +/- 5.7 mumol/l. In the packed erythrocyte pellet the corresponding values were: Controls 2.9 +/- 0.7, Gaucher Type III carriers 2.9 +/- 0.7, Gaucher Type III patients 9.2 +/- 2.4 and Gaucher Type I patients 6.5 +/- 2.7 mumol/l. The phospholipid concentration was the same in all the three Gaucher groups and was not significantly different from that in the controls.

Prenatal diagnosis of Gaucher disease. Assay of the beta-glucosidase activity in amniotic fluid cells cultivated in two laboratories with different cultivation conditions

Sixteen pregnancies at risk for Gaucher disease -- six with the Norrbottnian form, one with a juvenile form with a similar clinical course to the patients from Norrbotten and nine with the infantile from -- have been monitored by the assay of beta-glucosidase activity in cultivated amniotic fluid cells with natural labelled glycosylceramide as substrate. Two methods of cultivation were compared in respect of their effect on the activity of lysosomal enzymes. No significant difference was found between the two marker enzymes, beta-galactosidase and N-acetyl-beta-glucosaminidase, but the beta-glucosidase activity was significantly higher in the cells cultivated with one of the methods. In four of the pregnancies at risk, the beta-glucosidase activity in the cultivated amniotic fluid cells was less than 5% of that in the two control materials. These fetuses were regarded as affected with Gaucher disease and were aborted. Differentiation between controls and Gaucher heterozygotes was not possible in cultivated amniotic fluid cells. The diagnosis of Gaucher disease in the amniotic fluid cells was confirmed in three of the four cases by the assay of the beta-glucosidase activity in the liver nd brain of the aborted fetuses. The glucosylceramide content of the liver from two aborted fetuses was not augmented. The beta-glucosidase activity was examined in seven placentas from pregnancies at risk for Gaucher disease and found to be in agreement with that in the cultivated amniotic fluid cells.

Assay of the beta-glucosidase activity with natural labelled and artificial substrates in cultivated skin fibroblasts from homozygotes and heterozygotes with the Norrbottnian type of Gaucher disease

Fibroblasts from 13 homozygotes and 27 obligate heterozygotes with the Norrbottnian type of Gaucher disease and 17 controls were cultivated and assayed with five beta-glucosidase methods, two with D-[glucose-U-14C] glucosylceramide and three with the artificial substrate 4-methylumbelliferyl-beta-glucoside. Two marker enzymes were assayed on the same cell samples, 4-methylumbelliferyl-beta-galactosidase and N-acetyl-beta-glucosaminidase. The beta-glucosidase activity of cultured fibroblasts, as measured with all five beta-glucosidase methods, was significantly lower (P < 0.001) for Gaucher homozygotes than heterozygotes. There was no overlap between fibroblasts from Gaucher homozygotes and the others with any of the beta-glucosidase methods used. The beta-glucosidase activity was also significantly lower (P < 0.001) for Gaucher heterozygotes than controls. However, none of the five beta-glucosidase assays differentiated between all Gaucher heterozygotes and controls, as several overlaps occurred in each assay.

Assay of the beta-glucosidase activity with natural labelled and artificial substrates in leukocytes from homozygotes and heterozygotes with the Norrbottnian type (Type 3) of Gaucher disease

Leukocytes were isolated from 14 patients (7 males and 7 females ) with Gaucher disease of the Norrbottnian type (Type 3), 32 obligate heterozygotes (16 males and 16 females) for this disease and 20 controls (10 males and 10 females). After collection, the cells were transported in dry ice to the laboratory, where they were assayed. The assays were repeated after the cells had been stored for 12 months. beta-Glucosidase activity was assayed with D-[glucose-U-14C]glucosylceramide at pH 5.8 with Cutscum-Na-cholate as a detergent and 4-methylumbelliferyl-beta-glucoside at pH 4.1 with Triton-Na-taurocholate as a detergent. The activities of two marker enzymes, 4-methylumbelliferyl-beta-galactosidase and N-acetyl-beta-glucosaminidase, were assayed in aliquots of the same leukocyte samples. The activity of beta-galactosidase remained constant during storage, N-acetyl-beta-glucosaminidase increased, while beta-glucosidase decreased as assayed with the natural as well as with the artificial substrate. beta-Glucosidase activity was significantly lower in the female than in male controls and heterozygotes. When assayed with natural substrate beta-glucosidase activity in leukocytes from the male patients was 6--12% of the control mean value and 10--15% in those from the female patients. The corresponding figures found when the artificial substrate was used were 15--30% and 22--45%. The values for the heterozygotes were respectively 42--68% and 34--79% with the natural substrate, and 33--82% and 51--109% with the artificial substrate. No correlation was found between the age of the patient and the beta-glucosidase activity.

Gaucher disease--Norrbottnian type. I. General clinical description

We report follow-up studies of 22 cases of the Norrbottnian type of Gaucher disease ("type III"). The series was divided into 2 main groups of families depending on their birth province (Norrbotten, Västerbotten). The distribution and types of organ manifestations and complications were the same in both groups, each of which was considered to be genotypically homogeneous. The severity of the clinical symptoms and signs and the course of the disease differed markedly not only between families but also between siblings. Splenectomy accelerated deterioration, particularly with regard to skeletal and central nervous system manifestations. On a clinical basis it is concluded that the Norrbottnian type of Gaucher disease, which has now been diagnosed in about 40 cases, is probably due to a unique mutation which may have happened several hundred of years ago in northern Sweden.

Attempt at enzyme replacement in Gaucher disease by renal transplantation

In Gaucher disease there is a deficiency of the lysosomal enzyme, cerebroside-beta-glucosidase, as a result of which cerebroside (glucosylcereamide) accumulates in various organs. In northern Sweden 22 patients with a juvenile form of this disease have been identified. In one such patient, a girl of 10 years, we have attempted enzyme replacement by renal transplantation. After this operation the hepatic glucocerebroside content fell significantly. In another child afflicted with Gaucher disease in whom splenectomy was performed for severe splenomegaly and hypersplenism there was a progressive increase in the level of this lipid. These findings suggest that enzyme replacement was achieved by transplantation of a normal organ.

Attempt at enzyme replacement by organ transplantation: renal transplantation in Gaucher disease

Following renal transplantation, hepatic glucocerebroside deposits in a child with Gaucher disease were reduced. This suggests that enzyme replacement had been achieved.