Lesch-Nyhan syndrome: growth delay, testicular atrophy and a partial failure of the 11 beta-hydroxylation of steroids

The Dystonias

Dystonia is a difficult problem for both the clinician and the scientist. It is sufficiently common to be seen by almost all physicians, yet uncommon enough to prevent any physician from gaining broad experience in its diagnosis and treatment. Each case represents a difficult challenge even to the specialist. The basic scientist is faced with investigating a disorder that is without relevant animal models and which is so rare that obtaining suitable tissue for study is a major obstacle. Dystonia may be idiopathic, or associated with lesions from many sources, including a variety of rare diseases. If idiopathic, it may be genetically transmitted or sporadic. If genetically transmitted, it may be generalized or focal, with symptoms varying in different members of the same family. It may be refractory to treatment, or it may respond to any one of a number of individual drugs that have very different mechanisms of action. For idiopathic dystonias, no clear method of genetic transmission has been established and no consistent pathology identified.

Nucleotide salvage deficiencies, DNA damage and neurodegeneration

Nucleotide balance is critically important not only in replicating cells but also in quiescent cells. This is especially true in the nervous system, where there is a high demand for adenosine triphosphate (ATP) produced from mitochondria. Mitochondria are particularly prone to oxidative stress-associated DNA damage because nucleotide imbalance can lead to mitochondrial depletion due to low replication fidelity. Failure to maintain nucleotide balance due to genetic defects can result in infantile death; however there is great variability in clinical presentation for particular diseases. This review compares genetic diseases that result from defects in specific nucleotide salvage enzymes and a signaling kinase that activates nucleotide salvage after DNA damage exposure. These diseases include Lesch-Nyhan syndrome, mitochondrial depletion syndromes, and ataxia telangiectasia. Although treatment options are available to palliate symptoms of these diseases, there is no cure. The conclusions drawn from this review include the critical role of guanine nucleotides in preventing neurodegeneration, the limitations of animals as disease models, and the need to further understand nucleotide imbalances in treatment regimens. Such knowledge will hopefully guide future studies into clinical therapies for genetic diseases.

The stress response resolution assay. I. Quantitative assessment of environmental agent/condition effects on cellular stress resolution outcomes in epithelium

The events or factors that lead from normal cell function to conditions and diseases such as aging or cancer reflect complex interactions between cells and their environment. Cellular stress responses, a group of processes involved in homeostasis and adaptation to environmental change, contribute to cell survival under stress and can be resolved with damage avoidance or damage tolerance outcomes. To investigate the impact of environmental agents/conditions upon cellular stress response outcomes in epithelium, a novel quantitative assay, the "stress response resolution" (SRR) assay, was developed. The SRR assay consists of pretreatment with a test agent or vehicle followed later by a calibrated stress conditions exposure step (here, using 6-thioguanine). Pilot studies conducted with a spontaneously-immortalized murine mammary epithelial cell line pretreated with vehicle or 20 µg N-ethyl-N-nitrososurea/ml medium for 1 hr, or two hTERT-immortalized human bronchial epithelial cell lines pretreated with vehicle or 100 µM zidovudine/lamivudine for 12 days, found minimal alterations in cell morphology, survival, or cell function through 2 weeks post-exposure. However, when these pretreatments were followed 2 weeks later by exposure to calibrated stress conditions of limited duration (for 4 days), significant alterations in stress resolution were observed in pretreated cells compared with vehicle-treated control cells, with decreased damage avoidance survival outcomes in all cell lines and increased damage tolerance outcomes in two of three cell lines. These pilot study results suggest that sub-cytotoxic pretreatments with chemical mutagens have long-term adverse impact upon the ability of cells to resolve subsequent exposure to environmental stressors.

Sex and genes, part 1: sexuality and Down, Prader-Willi, and Williams syndromes

Specific genetic syndromes affect individuals' sexual development, experiences, and fertility. Individuals with specific syndromes can also display inappropriate sexual behavior resulting from vulnerabilities presented by their genetic makeup. Using clinical case studies, we discuss the specific impact that Down, Prader-Willi, and Williams syndromes can have on sexual development and behavior. Applying a biopsychosocial approach, we present the primary sexual effects, such as delayed sexual development and infertility. These genetic syndromes are also associated with challenges that are not specifically sexual in nature but that affect sexual expression, such as self-injury, mental health issues, or epilepsy. Medication side effects are also discussed. We conclude with treatment recommendations for individuals with sexual challenges, considering the unique effects of these three syndromes on sexuality.

Delineation of the motor disorder of Lesch-Nyhan disease

Lesch-Nyhan disease (LND) is caused by deficiency of the purine salvage enzyme hypoxanthine-guanine phosphoribosyltransferase (HPRT). Affected individuals exhibit over-production of uric acid, along with a characteristic neurobehavioural syndrome that includes mental retardation, recurrent self-injurious behaviour and motor disability. Prior studies involving relatively small numbers of patients have provided different conclusions on the nature of the motor disorder. The current study includes the results of a multi-centre international prospective study of the motor disorder in the largest cohort of patients studied to date. A total of 44 patients ranging from 2 to 38 years presented a characteristic motor syndrome that involved severe action dystonia superimposed on baseline hypotonia. Although some patients also displayed other extrapyramidal or pyramidal signs, these were always less prominent than dystonia. These results are compared with a comprehensive review of 122 prior reports that included a total of 254 patients. Explanations for the differing observations available in the literature are provided, along with a summary of how the motor disorder of LND relates to current understanding of its pathophysiology involving the basal ganglia.

Medical diagnosis, management and treatment of Lesch Nyhan disease

The aim of this presentation is to inform about Lesch Nyhan Disease from the point of view of the affected boys and their families living with the condition from day to day and also to show the importance of research in treating and managing the disease (In Caring for Children with Lesch Nyhan Disease--A Guide for Parents and Professionals; McCarthy, G.T., Ed.; PUMPA and Chailey Heritage Clinical Services: East Sussex, UK, 2002).

Neurotransmitter changes in the pathophysiology of Lesch-Nyhan syndrome

The neurological symptoms of Lesch-Nyhan syndrome (LNS) are assumed to result from the neurotransmitter changes in this disorder. Among them, the dopaminergic system is believed to play a role in the self-injurious behavior through receptor supersensitivity. However, the precise mechanism underlying the dopamine supersensitivity remains unclear. An increased serotonergic action in the striatum may be crucial for the appearance of self-injurious behavior, and pharmacological evidence suggests the efficacy of serotonin agonists/antagonists for the treatment of the self-mutilation in LNS.

The importance of the measurement of ATP depletion and subsequent cell damage with an estimate of size and nature of the market for a practicable method: a review designed for technology transfer

ATP is the energy currency of cells. ATP depletion is a central process in pathogenesis, in particular ischaemia, hypoxia and hypoglycaemia. ATP depletion in cells can be indirectly measured from the increased concentrations of extracellular hypoxanthine, a central intermediate in the metabolism of ATP. Cell damage secondary to ATP depletion can also be measured from extracellular hypoxanthine. The relevant biochemistry and physiology is briefly reviewed. Since market size is needed for investment decisions that would allow technology transfer, the numbers of hypoxanthine analyses that are clinically justified from the extensive published evidence are calculated per million population from UK, Norwegian and other evidence. The concentration of oxygen in blood is measured to estimate whether mitochondrial oxidative phosphorylation is adequate. Measurements of bicarbonate are used to estimate anaerobic glycolysis. Since the indirect estimation of ATP depletion is a major objective of blood gas and acid-base analyses, the number of such analyses per million population provides a good estimate of potential market size for a more direct method of estimating ATP depletion. A method is required for the rapid, dispersed emergency analyses needed clinically. Routes for method development are indicated. Competition, risks, acceptability, consumer motivation and timetables are indicated for the development phase. There are medicolegal pressures, especially in the USA, for the proposed advances to be widely used.

Lesch-Nyhan syndrome and its pathogenesis: normal nicotinamide-adenine dinucleotide but reduced ATP concentrations that correlate with reduced poly(ADP-ribose) synthetase activity in HPRT-deficient lymphoblasts

In hypoxanthine (guanine) phosphoribosyltransferase- (HPRT; EC 2.4.2.8) deficient lymphoblasts, ATP but not nicotinamide-adenine dinucleotide coenzyme concentrations are reduced by limited nutrition. Such reduced ATP concentrations are correlated with reduced poly(ADP-ribose) synthetase (polyADPRT; EC 2.4.2.30) activity; this reduces the breakdown of nicotinamide-adenine dinucleotide coenzymes and thus explains their normal intracellular concentrations. Since reductions in poly(ADP-ribose) synthetase activity reduce DNA repair, alterations in DNA could accumulate even in non-multiplying cells such as neurons, especially in the continuously active 'respiratory centre'. Our Lesch-Nyhan patients suffered respiratory deaths between 15 and 20 years of age.

The pathogenesis of the Lesch-Nyhan syndrome: ATP use is positively related to hypoxanthine supply to hypoxanthine guanine phosphoribosyltransferase

In order to explain features of severe hypoxanthine guanine phosphoribosyltransferase (HPRT) deficiency, the Lesch-Nyhan syndrome, a continuous supply of substrate, hypoxanthine, for the enzyme must be generated. This supply must be increased in association with increased ATP turnover. We have shown that ATP turnover continuously supplies hypoxanthine for recycling by the enzyme HPRT and that this supply increases curvilinearly with increasing ATP turnover. The effects of increasing exercise on ATP turnover were examined using a Latin square experimental design. The outputs of hypoxanthine, xanthine, urate and creatinine were measured. The data were then examined statistically.

Hypoxanthine phosphoribosyltransferase activity in tissues and hypoxanthine concentrations in plasma and CSF of the horse in comparison with other species

1. Plasma hypoxanthine and xanthine concentrations are very low in the horse and low in rat, mouse and greyhound compared to concentrations in beagles, man, sheep and rabbit. 2. Activities in erythrocytes of the main enzyme metabolizing hypoxanthine, hypoxanthine phosphori-bosyltransferase, show a similar pattern (Tax et al., 1976, Comp. Biochem. Physiol. 54B, 209-212); thus low activities have been found where plasma concentrations were low. 3. Hypoxanthine phosphoribosyltransferase activities in horse tissue other than erythrocytes are similar to those in man and rabbit with high activities in brain; this enzyme may therefore be functionally important in equine brain.

Distribution of xanthine dehydrogenase and oxidase activities in human and rabbit tissues

The activity of xanthine dehydrogenase in human postmortem tissues is surprisingly high in brain and heart; activity was found in most tissue samples, whereas many samples contained little or no oxidase activity. We have confirmed the high level of oxidase activity in liver in which tissue conversion of dehydrogenase to oxidase appears complete. We have also confirmed the virtual absence of either activity in fresh human placenta. Fresh rabbit tissues similarly show considerable dehydrogenase activity in brain and heart. In view of the stability and generalised distribution of dehydrogenase activity, our results suggest that some modification of existing ideas on the physiological and pathological roles of the enzyme may be needed.

Hypoxanthine, xanthine and uridine in body fluids, indicators of ATP depletion

Measurements of hyp, xan and urd in body fluids can provide evidence of energy, ATP, depletion in the body, in organs or in cells. Such information is clinically useful in the many diseases in which cellular energy supplies cannot be maintained like perinatal asphyxia, hydrocephalus and vascular insufficiency in brain, heart, limbs, kidneys or other organs. Similar HPLC methods using reversed-phase C18 columns and quantitation by UV absorption have been employed in a variety of centres to yield almost identical results. These have been assembled in this review to form a series of reference values. The current analytical problems are reviewed. Since concentrations of hyp and xan may alter independently situations are discussed in which separate measurements rather than their summed, total oxypurine concentrations are needed. The biochemistry and physiology underlying the use of such analyses is examined to guide sampling of the appropriate body fluid at a relevant time and to avoid oversimplified interpretation of results as well as unnecessary arguments. Specifically: (1) Intracellular concentrations of hyp and xan are inversely related to adenylate energy change and therefore to the energy currency of the cell ATP. Uridine in tissues is similarly 'controlled'. (2) There is extensive evidence that large increases in hyp, xan and urd in body fluids indicate ATP depletion. (3) Small changes in hyp probably reflect alterations of ATP turnover. (4) Xanthine arises mainly from guanine and can change independently of hyp. (5) Clinically useful information is obtainable from hyp and xan concentrations in CSF, amniotic fluid, urine and plasma. Extensive clinical correlations are reviewed. At present we are in a development phase for which HPLC is ideal but the most efficient way to perform and use such analyses in routine clinical practice remains to be established.

Lesch-Nyhan syndrome and its pathogenesis: purine concentrations in plasma and urine with metabolite profiles in CSF

Purine metabolism in the Lesch-Nyhan syndrome has been re-examined in 10 patients. Hypoxanthine and xanthine concentrations in plasma and CSF and urinary excretion have been studied, on and off allopurinol treatment, using high performance liquid chromatographic methods. Accumulation of the substrate, hypoxanthine, of the missing hypoxanthine guanine phosphoribosyltransferase (HPRT) enzyme, is more marked in urine and in CSF than in plasma. The greater increase in CSF is consistent with the most metabolically active tissue, brain, showing the most marked functional changes. The function of HPRT seems to be the recycling of hypoxanthine which is released from tissues in increasing quantities as energy use, ATP 'turnover', in the tissue increases. The existing screening method for HPRT deficiency, the ratio of the urinary concentration of urate to that of creatinine, shows overlap between the values in severe HPRT deficiency and in controls; this overlap is not found with a urinary hypoxanthine/creatinine molar concentration ratio.