Skin manifestations of Fabry disease

Department-related tasks and organ-targeted therapy in Fabry disease: an interdisciplinary challenge

Fabry disease is a rare X-linked storage disorder leading to an accumulation of globotriaosylceramides in all cells carrying lysosomes. As the accumulation occurs in most organs, different medical specialties are involved in the diagnostics and therapy of Fabry disease. With this review of the 3 main specialties (cardiology, nephrology, and neurology) and, in addition, the adjacent specialties (ophthalmology and dermatology), we aim to discuss the division-related responsibilities and want to suggest an organ-related additional therapy besides enzyme replacement therapy.

A study on serum IgE and clinical symptomatology of atopy in patients suffering from the lysosomal storage disorder Fabry disease

BACKGROUND

Lysosomal storage disorders may impair intracellular lysosomal processing of antigen with consequences for antibody production [e.g. immunoglobulin E (IgE)] and atopic disease status.

AIMS

Serum concentration of total IgE as well as clinical symptoms of atopic disorders as an indirect consequence of lysosomal impairment of antigen processing were studied in male and female Fabry disease (FD) patients with and without replacement of the missing lysosomal enzyme, alpha-galactosidase A (alpha-Gal A).

METHODS

Observational study in 31 adult FD patients with measurements of total serum IgE concentration. Questionnaire-derived data were obtained for atopic eczema (AE) skin lesions, allergic rhinoconjunctivitis (RCA) and allergic asthma (AA) at present or in the past.

RESULTS

Among 12 FD males under enzyme replacement therapy (ERT), 2 showed total IgE concentrations above 100 kU/L. Clinical symptoms for AA were found in 2, RCA and AE in 1, respectively. Among 10 FD females under ERT, 4 showed total IgE concentrations above 100 kU/L. Clinical symptoms for AA were found in 4, RCA in 2 and AE in 2. Among 9 females without ERT, 2 showed total IgE concentrations above 100 kU/L. Clinical symptoms for AA were found in 2, RCA in 2 and AE in none.

CONCLUSIONS

FD patients may demonstrate an increased total serum IgE concentration and may show symptoms of atopic disorders (AA, RCA, AE) in a prevalence rate comparable to international experience for individuals without FD. There was no difference between patients with and without ERT. Lack of detection of AE in females without ERT is suggested to be caused by the small sample size. FD patients without any alpha-Gal A activity prior to initiation of ERT should be in the focus of future studies.

Fabry disease: case report with emphasis on enzyme replacement therapy and possible future therapeutic options

A 38-year-old male Caucasian with Fabry disease presented with angiokeratomas and tortuous conjunctival and retinal vessels. Additionally, the patient showed characteristic skin lesions of psoriasis and seborrheic dermatitis. His past medical history revealed anhidrosis, acral paresthesias, myocardial infarction, phlebothrombosis, hypertension, antithrombin III deficiency, factor V Leiden disease, chronic obstructive lung disease, tinnitus, diarrhea, recurrent abdominal pain, headache, and depressive mood. He was treated with intravenous substitution of the deficient enzyme alpha-galactosidase A. Possible future options in treatment of Fabry disease are discussed.

Relationship between functional loss before hospital admission and mortality in elderly persons with medical illness

OBJECTIVE

This hospital-based prospective study tests the hypothesis that, in a large group of hospitalized elderly patients, those who report functional decline between pre-illness baseline and hospital admission have a higher risk of death.

METHODS

Nine hundred fifty elderly ambulant patients (F = 69.3%; mean age 78.3 +/- 8.5 years) were consecutively admitted to a geriatric ward (Poliambulanza Hospital, Brescia, Italy) during a 15-month period. Number and severity of somatic diseases, Charlson Index score, APACHE II score, level of serum albumin, cognitive status (by Mini-Mental State Examination), and depression score (by Geriatric Depression Scale), were assessed on admission and evaluated as potential prognostic factors. Functional status (by Barthel Index) was assessed by self-report on admission. Preadmission function was also assessed by self-report at the time of admission. Impairment of function due to an acute event is measured as the difference between performances on admission and 2 weeks before the acute event. Six-month survival was the main outcome variable.

RESULTS

Factors related to mortality in bivariate analysis were: male sex, age over 80, cancer, congestive heart failure, pulmonary diseases, elevated Charlson Index score, and (independently) dementia (Mini-Mental State Examination < 18), APACHE-Acute Physiology Score , albumin level <3.5 g/dL, and anemia. After controlling for these variables and for Barthel Index score 2 weeks before the acute event, change in function due to the acute disease is independently related to 6-month mortality (minor functional change [<30 Barthel Index Point] relative risk: 1.3, 95% confidence interval, 0.6-3.0 and major functional change [major functional decrement] relative risk: 2.8, 95% confidence interval, 1.3-5.7).

CONCLUSIONS

Disease-induced disability may reflect a condition of biological inability to react to acute diseases (i.e., frailty), and should be assessed as a relevant prognostic indicator.

Fabry disease: recognition and management of cutaneous manifestations

Fabry disease (angiokeratoma corporis diffusum universale) is a rare, X chromosome-linked lysosomal storage disease. The deficient enzyme, alpha-galactosidase A (alpha-gal A), is responsible for the accumulation of neutral glycosphingolipids within vascular endothelial lysosomes of various organs, including skin, kidneys, heart, and brain. The disease manifests primarily in affected hemizygous men and to some extent in heterozygous women ('carriers'). The diagnosis of Fabry disease is made in hemizygous males after the detection of the presence of angiokeratomas, irregularities in sweating, edema, scant body hair, painful sensations, and of cardiovascular, gastrointestinal, renal, ophthalmologic, phlebologic, and respiratory involvement. A deficiency of alpha-gal A in serum, leukocytes, tears, tissue specimens, or cultured skin fibroblasts further supports the diagnosis in male patients. Since heterozygous women show angiokeratomas in only about 30% of cases and may have alpha-gal A levels within normal range, genetic analysis is recommended. Current treatment of angiokeratomas of Fabry disease is based mainly on the use of laser systems, including variable pulse width 532nm Neodymium:Yttrium-Aluminum-Garnet (Nd:YAG) laser, 578nm copper vapor laser, and flashlamp-pumped dye laser. When cutaneous and mucous glands are affected, restrictions may be required with regard to the time spent in a warm climate and the amount time spent working or on sporting activities, and may necessitate the use of topical and systemic antiperspirant agents, and topical application of artificial lacrimal fluid and saliva, respectively. For the future, new treatment modalities, including enzyme replacement therapy, substrate deprivation strategies, and gene therapy offer extraordinary options for the cutaneous and visceral lesions in patients with Fabry disease.