Further studies on a patient with iminodipeptiduria: a probable case of prolidase deficiency

Quantitative analysis of the natural history of prolidase deficiency: description of 17 families and systematic review of published cases

PURPOSE

Prolidase deficiency is a rare inborn error of metabolism causing ulcers and other skin disorders, splenomegaly, developmental delay, and recurrent infections. Most of the literature is constituted of isolated case reports. We aim to provide a quantitative description of the natural history of the condition by describing 19 affected individuals and reviewing the literature.

METHODS

Nineteen patients were phenotyped per local institutional procedures. A systematic review following PRISMA criteria identified 132 articles describing 161 patients. Main outcome analyses were performed for manifestation frequency, diagnostic delay, overall survival, symptom-free survival, and ulcer-free survival.

RESULTS

Our cohort presented a wide variability of severity. Autoimmune disorders were found in 6/19, including Crohn disease, systemic lupus erythematosus, and arthritis. Another immune finding was hemophagocytic lymphohistiocytosis (HLH). Half of published patients were symptomatic by age 4 and had a delayed diagnosis (mean delay 11.6 years). Ulcers were present initially in only 30% of cases, with a median age of onset at 12 years old.

CONCLUSION

Prolidase deficiency has a broad range of manifestations. Symptoms at onset may be nonspecific, likely contributing to the diagnostic delay. Testing for this disorder should be considered in any child with unexplained autoimmunity, lower extremity ulcers, splenomegaly, or HLH.

PROLIDASE: A Review from Discovery to its Role in Health and Disease

Prolidase (peptidase D), encoded by the PEPD gene, is a ubiquitously expressed cytosolic metalloproteinase, the only enzyme capable of cleaving imidodipeptides containing C-terminal proline or hydroxyproline. Prolidase catalyzes the rate-limiting step during collagen recycling and is essential in protein metabolism, collagen turnover, and matrix remodeling. Prolidase, therefore plays a crucial role in several physiological processes such as wound healing, inflammation, angiogenesis, cell proliferation, and carcinogenesis. Accordingly, mutations leading to loss of prolidase catalytic activity result in prolidase deficiency a rare autosomal recessive metabolic disorder characterized by defective wound healing. In addition, alterations in prolidase enzyme activity have been documented in numerous pathological conditions, making prolidase a useful biochemical marker to measure disease severity. Furthermore, recent studies underscore the importance of a non-enzymatic role of prolidase in cell regulation and infectious disease. This review aims to provide comprehensive information on prolidase, from its discovery to its role in health and disease, while addressing the current knowledge gaps.

Prolidase is a critical enzyme for complete gliadin digestion in Tenebrio molitor larvae

Prolidase is a proline-specific metallopeptidase that cleaves imidodipeptides with C-terminal Pro residue. Prolidase was purified and characterized from the Tenebrio molitor larval midgut. The enzyme was localized in the soluble fraction of posterior midgut tissues, corresponding to a predicted cytoplasmic localization of prolidase according to the structure of the mRNA transcript. Expression of genes encoding prolidase and the major digestive proline-specific peptidase (PSP)-dipeptidyl peptidase 4-were similar. The pH optimum of T. molitor prolidase was 7.5, and the enzyme was inhibited by Z-Pro, indicating that it belongs to type I prolidases. In mammals, prolidase is particularly important in the catabolism of a proline-rich protein-collagen. We propose that T. molitor larval prolidase is a critical enzyme for the final stages of digestion of dietary proline-rich gliadins, providing hydrolysis of imidodipeptides in the cytoplasm of midgut epithelial cells. We propose that the products of hydrolysis are absorbed from the luminal contents by peptide transporters, which we have annotated in the T. molitor larval gut transcriptome. The origin of prolidase substrates in the insect midgut is discussed in the context of overall success of grain feeding insects.

Spurious Elevation of Multiple Urine Amino Acids by Ion-Exchange Chromatography in Patients with Prolidase Deficiency

The enzyme prolidase cleaves dipeptides where the C-terminal amino acid corresponds to proline or hydroxyproline. As a consequence, a deficiency of this enzyme leads to accumulation of these dipeptides, which correspondingly are found to be elevated in urine. In fact, the absence of dipeptiduria is sufficient to rule out a diagnosis of prolidase deficiency. However, given the fact that these dipeptides elute at the same position as more common amino acids, the analyzer's software will instead call an elevation of these corresponding amino acids. Thus, an elevation of glycylproline, aspartylproline, glutamylproline, threonylproline and serylproline, valylproline, leucylproline, isoleucylproline, alanylproline, phenylalanylproline, and lysylproline will instead be interpreted as an elevation of leucine, citrulline, methionine, isoleucine, beta-aminoisobutyric acid, gamma-aminobutyric acid, ethanolamine, tyrosine, histidine, and anserine/carnosine, respectively. This particular profile of elevated amino acids, however, can easily be overlooked. We hope that the recognition of this characteristic pattern of falsely elevated urinary amino acids will aid in the recognition of prolidase deficiency.

Absorption of hydroxyproline-containing peptides in vascularly perfused rat small intestine in situ

To assess the digestion and assimilation of gelatin and gelatin hydrolysates, the in situ absorption of typical hydroxyproline-containing dipeptides, Pro-Hyp, Hyp-Gly, Ser-Hyp Ala-Hyp, and pentadecapeptide, (Pro-Hyp-Gly)(5), was investigated in the rat small intestine. During vascular perfusion after the injection of Hyp-Gly, Pro-Hyp and (Pro-Hyp-Gly)(5) into the jejunum, peptide-form Hyp but not free-Hyp gradually increased in the perfusate. In contrast, in the case of Ser-Hyp and Ala-Hyp, both free- and peptide-form Hyp rapidly increased. The presence of these dipeptides and the pentadecapeptide in the perfusates was confirmed by liquid chromatography-tandem mass spectrometry (LC-MS/MS), using multiple reaction monitoring (MRM). Some digestive and absorbed forms from (Pro-Hyp-Gly)(5) were identified as Gly-(Pro-Hyp-Gly)(4), (Pro-Hyp-Gly)(4), Gly-(Pro-Hyp-Gly)(3), (Pro-Hyp-Gly)(3), Gly-(Pro-Hyp-Gly)(2), and (Pro-Hyp-Gly)(2) by MALDI-TOF/MS. The dipeptide hydrolase activity in intestinal mucosa toward Pro-Hyp and Hyp-Gly was extremely low, while Ser-Hyp and Ala-Hyp were substantially hydrolyzed in the cytosol. These results suggest that Hyp-peptides were resistant to intracellular hydrolysis and that a significant amount of these peptides was transported across the intestinal wall and may enter the portal circulation in an intact form.

Characterization of prolidase I and II purified from normal human erythrocytes: comparison with prolidase in erythrocytes from a patient with prolidase deficiency

The effect of various sulfur-containing amino acids on the activities of prolidase isoenzymes I and II isolated from erythrocytes of healthy individuals, and erythrocyte lysates from a patient with prolidase deficiency was investigated. The activity of prolidase I against glycylproline was strongly enhanced by D: -methionine. L: -Methionine and D: ,L: -methionine slightly enhanced the activity at low concentration, but N-acetyl-L: -methionine had no effect. D: -Ethionine, L: -ethionine, and D: ,L: -ethionine also enhanced the activity of prolidase I. D: ,L: -Homocysteine enhanced the activity at low concentration, but inhibited the activity at 50 mM: . The activity of prolidase II against methionylproline was enhanced by D: -methionine, D: ,L: -methionine, and L: -methionine, but N-acetyl-L: -methionine had no effect. D: -Ethionine and D: ,L: -ethionine strongly enhanced the activity of prolidase II compared with L: -ethionine; D: ,L: -homocysteine weakly enhanced the activity. D: ,L: -Homocysteine-thiolactone inhibited the activities of prolidase I and II in a concentration-dependent manner. The effect of various sulfur-containing amino acids on prolidase activity against methionylproline in erythrocyte lysates from a patient with prolidase deficiency was almost the same as that on prolidase II. The kinetics of the activities of prolidase I, II, and patient prolidase were also studied. Their K (m) values were changed by adding sulfur-containing amino acids, but V (max) values were unchanged.

Determination of prolidase activity using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry

Proline-containing peptides of the X-proline type are cleaved by the dipeptidase prolidase. The classical method of prolidase assay relied on the colorimetric estimation of the liberated proline with ninhydrin using acidic media and heat. This method, however, gave inconsistent results due to the nonspecificity of the ninhydrin color reaction. We report here a method for the detection of the liberated proline using matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry. Human sera were incubated with a mixture containing the dipeptide glycyl-proline in Tris-HCl supplemented with manganese at 37 degrees C for 24h. The samples were precipitated with trifluoroacetic acid and centrifuged. An aliquot of the supernatant was mixed with an equal volume of ferulic acid solution. An aliquot from this mixture was spotted on a stainless steel mass spectrometry grid and analyzed using MALDI-TOF mass spectrometry. The activity of the enzyme was determined by the complete disappearance of the glycyl-proline peak with the concomitant appearance of the proline peak and can be expressed in terms of the ratio of the area beneath the proline to the area beneath the glycyl-proline peak. Subjects homozygous for prolidase deficiency had a ratio ranging from 0.006 to 0.04 while obligatory heterozygotes had a ratio ranging from around 1.1 to 2.4. Normal subjects had ratios ranging from 9 to 239. Using this method we have unambiguously identified subjects with homozygous or heterozygous prolidase deficiency. In addition to the advantage of rapid sample preparation time, this method is highly specific, reproducible, and sensitive.

Characteristics of Prolidase from the Erythrocytes of Normal Humans and Patients with Prolidase Deficiency and Their Mother

Prolidases I and II were highly purified from human erythrocytes. The effects of various amino acids, MnCl2 and mercaptoethanol, on these two enzymes were investigated. Normal prolidase II was very labile in the absence of MnCl2 or mercaptoethanol. The activity of prolidase II was maintained at about 76% by pre-incubation with MnCl2; it was then activated up to 140% by treatment with mercaptoethanol for 60 minutes at 37 degrees C. Normal prolidases I and II showed the highest activity against glycylproline or methionylproline in the presence of MnCl2. The activity of prolidase I against glycylproline was enhanced strongly by glycine and MnCl2, but not activated in the absence of MnCl2. The activity of prolidase II against methionylproline was enhanced three-fold in the presence of glycine and MnCl2, but its activity against glycylproline was very low even in the presence of MnCl2. A stronger enhancement of this activity was found in normal erythrocytes, and a lower level of this activity was found in erythrocytes of patients treated with glycine, MnCl2 and mercaptoethanol compared to those treated with glycine and MnCl2. The activity of prolidase II against methionylproline in all erythrocytes, of normal humans and of patients, was strongly activated by the addition of glycine with MnCl2 but suppressed by the addition of mercaptoethanol.

Prolidase deficiency associated with pathologic myopia

Deficiency of prolidase, a key enzyme in proline metabolism, is extremely rare and is usually associated with skin lesions, recurrent infections, characteristic facies, mental retardation, and splenomegaly. These clinical features are largely due to inhibition of normal recycling of proline, which causes an alteration in the metabolism of collagen and other proline-rich proteins. The case of a 25-year-old with all the recognized characteristics of prolidase deficiency is reported. Pathologic myopia, which has not been hitherto described in association with prolidase deficiency, is added to the clinical spectrum of this rare disorder.

The use of liquid chromatography-mass spectrometry for the identification and quantification of urinary iminodipeptides in prolidase deficiency

It has been reported that the urine of patients with prolidase deficiency contains various iminodipeptides with a carboxyl-terminal proline (hydroxyproline). These iminodipeptides have hitherto been detected indirectly by acid hydrolysis or enzymatic digestion, followed by amino acid analysis. In the present study, it was shown that X-Pro could be distinguished from Pro-X when the iminodipeptides were analysed directly by liquid chromatography coupled with atmospheric pressure ionization mass spectrometry (LC/API-MS), with scanning of the protonated molecule ions ([M+H]+). The same procedure also successfully quantified urinary iminodipeptides from patients with prolidase deficiency. A quantitative investigation of two siblings with prolidase deficiency revealed that the patient with severe clinical symptoms excreted more iminodipeptides than the other who did not have serious symptoms. LC/API-MS also revealed iminodipeptides (Gly-Hyp and Pro-Hyp) in the urine of the mother of the patients and in normal volunteers. Patients excreted much more Pro-Hyp than normal volunteers, whereas no quantitative differences were found between the mother and controls. In patients, the excretion of large quantities of X-Pro is due to their very low prolidase activity towards this type of substrate. In the erythrocytes of patients, prolidase activity towards X-Hyp was extremely low; even in the mother and normal volunteers, it was remarkably low in comparison with the activity against X-Pro.

Only prolidase I activity is present in human plasma

1. After ion exchange chromatographic separation, liver prolidase exhibits two isoforms (prolidase I and II). 2. The activity of both was explored in human and rat tissues, and in normal and cytolytic human plasma. 3. The activity of prolidase I, eluted at the lowest ionic strength, was stimulated by 24 hr of preincubation with 1 mM MnCl2, but prolidase II activity was strongly inhibited by this long preincubation. In both normal and cytolytic human plasma, chromatographic separation also disclosed that only prolidase I activity was present. 4. This isoform displayed properties resembling those of liver and kidney prolidase I. 5. To explain the absence of prolidase II activity from the plasma, we tested the possibility that its tissue distribution differed. 6. However, this was not substantiated by the distribution found, or by the location, molecular weight and behavior of human liver prolidase II after neuraminidase treatment. 7. We also explored the hypothesis that plasma proteins inhibit prolidase II activity, and found that albumin almost abolished this activity after 6 hr incubation.

Characterization of prolidase I and II from erythrocytes of a control, a patient with prolidase deficiency and her mother

Prolidase I (EC 3.4.13.9) was purified to homogeneity from the erythrocytes of a normal human (control) and the patient's mother, and prolidase II from erythrocytes of a control and the patient's mother, and prolidase from the patient's erythrocytes was also highly purified. The various properties of the patient's prolidase were compared to those of prolidase from a control and the patient's mother. Prolidase I from a control and the patient's mother had a molecular weight of about 112,000, and was composed of two subunits with an identical molecular weight of 56,000. The Km values for Gly-Pro of the control's and the patient's mother's prolidase I were 2.90 +/- 0.22 and 2.88 +/- 0.27 mM, but the Vmax values for Gly-Pro of the mother's enzyme was reduced about 30% compared to that of control enzymes (mother: 6.02 units/mg protein, control: 22.21 units/mg protein). Isoionic points of these enzymes by chromatofocusing were pH 4.6 approximately 4.7. Prolidase II from the control and the patient's mother, and the patient's prolidase had a molecular weight of about 185,000, and was composed of two subunits with an identical molecular weight of 95,000. The Km and Vmax values for various substrates of prolidase II from a control and the patient's mother, and the patient's prolidase were almost the same.

Prolidase deficiency: a case report and literature review

We describe a patient in whom chronic leg ulceration was due to prolidase deficiency. The clinical features of this condition are described and we discuss the metabolic abnormality and the treatment regimes which have been employed. We also report the further finding of erosive cystitis, which we consider should be added to the list of clinical features of prolidase deficiency.

Profiling of amino acids in body fluids and tissues by means of liquid chromatography

The needs of urgent diagnoses and the needs emerging from acute forms of diseases have directed progress in amino acid profiling to modern, rapid, automated analyses that can be done at reasonable cost. The first step in this direction was the short programmes of classical ion-exchange chromatography. At the beginning of this review we attempted to survey methods of sample preparation and sample treatment, as these are frequently neglected stages where artefacts or erroneous results may arise. There are basically the following approaches in amino acid profiling by liquid chromatographic techniques. For preliminary screening of a large number of samples in clinical routine planar procedures are the methods of choice, as they allow large numbers of samples to be handled with minimum effort and at very reasonable cost. For more precise profiling, particularly where quantitative data are essential, one can choose between some of the modern procedures for separating underivatized amino acids using modern equipment for cation-exchange chromatography, by making use of a stepped series of lithium citrate buffers with ninhydrin, o-phthalaldehyde or 4-fluoro-7-nitrobenzo-2,1,3-oxadiazole detection. Ninhydrin detection is preferred in those situations where the demands on sensitivity are not high. Where, however, only small amounts of samples are available or high sensitivity is required, one of the latter two methods is preferred. The o-phthalaldehyde procedure is not suitable for the detection of secondary amines and, if these are of interest, then diazole derivatization is to be preferred. At present, however, the ninhydrin and o-phthalaldehyde detection procedures are the most popular. The other choice is to use one of the sophisticated HPLC systems equipped with fluorescence detection and to separate amino acids as derivatives. Here o-phthalaldehyde and 4-fluoro-7-nitrobenzo-2,1,3-oxadiazole derivatives offer the most versatile possibilities. Automation and computerization have penetrated both categories of liquid column separation and are applied to automated sample delivery, automated and computerized gradient formation and quantitation of the data obtained. The tables of metabolic disorders of amino acids and the roles of different amino acids in these disorders should provide preliminary information for clinical chemists.

An autopsy case of prolidase deficiency

A 25-year-old female who suffered from longstanding incurable leg ulcers was found to have prolidase deficiency with iminodipeptiduria. On ultrastructural studies of autopsy specimens, the lamina densa of the epidermal basement membrane was found to show irregular splitting and the basement membranes of the dermal blood vessels were lamellated with interruptions. Lamellar changes and splitting of the basement membranes of the renal tubules, interstitial blood vessels and glomerular capillaries also occurred. These morphological abnormalities seem to be one of causes of the clinical symptomatology.

Clinical and biochemical characteristics of prolidase deficiency in siblings

Two brothers with recurrent skin ulcers of the lower limbs, subnormal intelligence, developmental abnormalities, and poliosis were found to excrete large quantities of several imidodipeptides in their urine. Glycylproline was the most prominent imidodipeptide excreted and was also detected in their blood. Prolidase activity was markedly deficient in red blood cells from both patients (4.1% and 3.7% of control mean) and skin fibroblasts from the one brother so examined (3.7% of control mean). A total of 20 patients with prolidase deficiency, including the two in this report, have been described in the literature. Their manifestations and various attempts at treatment are reviewed.

Prolidase and prolidase deficiency

Prolidase deficiency seems to be a rather rare metabolic disorder. However, many new cases can be detected because screening is easy to perform and enzymatic confirmation allows the differentiation from other iminodipeptidurias . Clinical symptoms are briefly reviewed, while biological considerations and prolidase properties are exhaustively described. Methods for investigating urinary iminodipeptides are given with results. Moreover, several collagen modifications observed in this disorder led us to formulate a hypothesis for their mechanism. Genetic considerations and treatment attempts are discussed.

Prolidase deficiency

The clinical and biochemical findings in a four-year-old girl with prolidase deficiency, treated with L-proline, manganese and ascorbic acid, are presented.

In-vitro responses to ascorbate and manganese in fibroblasts from a patient with prolidase deficiency and iminodipeptiduria: cell growth, prolidase activity and collagen metabolism

After successful ascorbate and manganese treatment of a female patient with prolidase deficiency and iminodipeptiduria, we attempted to explain the mechanism of action of these drugs in vitro, using them preferentially on skin fibroblasts. Since in vivo, ascorbate and manganese seemed to be responsible for both biochemical and clinical improvement, they were also expected to activate prolidase activity in vitro. Cell growth and prolidase activity were accordingly observed in fibroblast cultures supplemented with these compounds. It seemed that only ascorbate accounted for the successful in vivo response. To understand the mechanism involved, we studied collagen metabolism and found a decreased proline pool, a massive increase of rapidly degraded collagen and moderate enhancement of type III collagen and type I trimer in the patient's fibroblasts. We believe that ascorbate allowed the prolidase-deficient cells to maintain a normal collagen pool by increasing collagen synthesis. Both the massive increase in cell growth in response to ascorbate and the bad response as regards the quality of the collagen produced confirm the secondary nature of this mechanism. However, the relationship between accelerated collagen catabolism and prolidase deficiency remains unclear.

Optimal conditions for prolidase assay by proline colorimetric determination: application to iminodipeptiduria

Prolidase assay was reinvestigated by determining proline, using Chinard's method. Although several authors had previously tested this colorimetric reaction, accurate details regarding enzyme activity were not available. The need for greater sensitivity led to the introduction of several modifications: dialysis was eliminated and the substrate concentration and incubation time were changed. In addition, the reaction mixture was preincubated with Mn2+ for 24 h in order to triple prolidase activity. Color development followed at 90 degrees C, because of partial glycylproline hydrolysis at higher temperatures. The effect of several divalent cations on prolidase activity were tested with and without Mn2+. This modified assay was applied to erythrocytes, plasma and skin fibroblasts from a female patient with iminodipeptiduria.

Normal hydroxylation of proline in collagen synthesized by skin fibroblasts from a patient with prolidase deficiency

The extent of hydroxylation of proline in collagen synthesized and secreted into the culture medium by skin fibroblasts derived from a patient with prolidase deficiency has been examined and found to be normal. It would seem likely that to a considerable extent the urinary proline-containing dipeptides apparent in this condition are derived from sources other than collagen.

A case of an exceptionally high level of urinary-4-hydroxyproline containing polypeptides

The determination of total urinary-4-hydroxyproline in an adolescent showed a very high excretion of hydroxyproline containing peptides: 26.2 mmol/24 h. Estimation of total urinary 3-hydroxyproline and peptide fractionation on Biogel P 2 demonstrated unusual features. Such cases are of great interest for structural studies of the urinary polypeptides and understanding of collagen catabolism.

Prolidase deficiency with iminodipeptiduria: biochemical investigations and first results of attempted therapy

A 33-year-old female patient with chronic recurrent leg ulcerations was shown to present a massive iminodipeptiduria which seemed to be attributable to disturbance of collagen metabolism. Biochemical investigations confirmed an hereditary prolidase deficiency. A treatment was tried for the first time and showed a good biochemical result and a clinical improvement.

Fractionation and structure of several hydroxyproline-containing urinary peptides, with special reference to some 3-hydroxyproline-containing peptides

After a preliminary separation of the hydroxyproline-containing peptides on Biogel P 2, the largest peptides are fractionated on phosphocellulose and the smallest ones on QAE-Sephadex. The fractions obtained from QAE-Sephadex are subfractionated on a column of Dowex 50-M-82. The total number of hydroxyproline-containing peptides from human urine is not less than 78. Sixteen di, tri and pentapeptides have been purified, their N-terminal amino acids and amino acid compositions determined and a structure is proposed. 3 of these peptides contain 3-hydroxyproline and one of these 3 peptides probably originates from basement membrane collagen.

Iminopeptiduria, skin ulcerations, and edema in a boy with prolidase deficiency

A 12-year-old boy with recurrent skin ulceration, chronic generalized lymphedema, and mild mental retardation was found to excrete massive amounts of dipeptides, most (but not all) of which had proline or hydroxyproline as the carboxyl terminal residue. Glycylproline predominated. Prolidase deficiency was demonstrated in red blood cells and in fibroblastic cells. Prolidase activity was present in continuous lymphoid cell cultures at the same low level observed in control cells.

Prolidase deficiency: report of a second case with quantitation of the excessively excreted amino acids

The second documented case of prolidase deficiency is presented. Clinical manifestations include chronic otitis media and sinusitis, dermatitis, and splenomegaly. Prolidase is undetectable in the white blood cells of the patient and near or less than the lower range of normal in each parent. The peptide chromatographic pattern of the urine is similar to that of the previously reported patient with prolidase deficiency. The quantity of amino acids excreted in urine per 24 hours is at least three times that of the upper range of normal (of these same amino acids) for the patients age group. More than 80% of the total amino acids excreted are in peptide form. The proline-to-hydroxyproline ratio suggests that the dipeptides are the catabolic products of other proteins in addition to collagen.