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Rintz E, Banacki M, Ziemian M, Kobus B, Wegrzyn G. Causes of death in mucopolysaccharidoses. Mol Genet Metab 2024; 142:108507. [PMID: 38815294 DOI: 10.1016/j.ymgme.2024.108507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024]
Abstract
Mucopolysaccharidoses are inherited metabolic diseases caused by mutations in genes encoding enzymes required for degradation of glycosaminoglycans. A lack or severe impairment of activity of these enzymes cause accumulation of GAGs which is the primary biochemical defect. Depending on the kind of the deficient enzyme, there are 12 types and subtypes of MPS distinguished. Despite the common primary metabolic deficit (inefficient GAG degradation), the course and symptoms of various MPS types can be different, though majority of the diseases from the group are characterized by severe symptoms and significantly shortened live span. Here, we analysed the frequency of specific, direct causes of death of patients with different MPS types, the subject which was not investigated comprehensively to date. We examined a total of 1317 cases of death among MPS patients, including 393 cases of MPS I, 418 cases of MPS II, 232 cases of MPS III, 45 cases of MPS IV, 208 cases of MPS VI, and 22 cases of MPS VII. Our analyses indicated that the most frequent causes of death differ significantly between MPS types, with cardiovascular and respiratory failures being predominant in MPS I, MPS II, and MPS VI, neurological deficits in MPS III, respiratory issues in MPS IV, and hydrops fetalis in MPS VII. Results of such studies suggest what specific clinical problems should be considered with the highest priority in specific MPS types, apart from attempts to correct the primary causes of the diseases, to improve the quality of life of patients and to prolong their lives.
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Affiliation(s)
- Estera Rintz
- Department of Molecular Biology, Faculty of Biology, University of Gdansk, Wita Stwosza, 59, 80-308 Gdansk, Poland.
| | - Marcin Banacki
- Department of Molecular Biology, Faculty of Biology, University of Gdansk, Wita Stwosza, 59, 80-308 Gdansk, Poland
| | - Maja Ziemian
- Department of Molecular Biology, Faculty of Biology, University of Gdansk, Wita Stwosza, 59, 80-308 Gdansk, Poland
| | - Barbara Kobus
- Department of Molecular Biology, Faculty of Biology, University of Gdansk, Wita Stwosza, 59, 80-308 Gdansk, Poland
| | - Grzegorz Wegrzyn
- Department of Molecular Biology, Faculty of Biology, University of Gdansk, Wita Stwosza, 59, 80-308 Gdansk, Poland
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2
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Mandolfo O, Parker H, Aguado È, Ishikawa Learmonth Y, Liao AY, O'Leary C, Ellison S, Forte G, Taylor J, Wood S, Searle R, Holley RJ, Boutin H, Bigger BW. Systemic immune challenge exacerbates neurodegeneration in a model of neurological lysosomal disease. EMBO Mol Med 2024; 16:1579-1602. [PMID: 38890537 PMCID: PMC11251277 DOI: 10.1038/s44321-024-00092-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 05/30/2024] [Accepted: 06/04/2024] [Indexed: 06/20/2024] Open
Abstract
Mucopolysaccharidosis type IIIA (MPS IIIA) is a rare paediatric lysosomal storage disorder, caused by the progressive accumulation of heparan sulphate, resulting in neurocognitive decline and behavioural abnormalities. Anecdotal reports from paediatricians indicate a more severe neurodegeneration in MPS IIIA patients, following infection, suggesting inflammation as a potential driver of neuropathology. To test this hypothesis, we performed acute studies in which WT and MPS IIIA mice were challenged with the TLR3-dependent viral mimetic poly(I:C). The challenge with an acute high poly(I:C) dose exacerbated systemic and brain cytokine expression, especially IL-1β in the hippocampus. This was accompanied by an increase in caspase-1 activity within the brain of MPS IIIA mice with concomitant loss of hippocampal GFAP and NeuN expression. Similar levels of cell damage, together with exacerbation of gliosis, were also observed in MPS IIIA mice following low chronic poly(I:C) dosing. While further investigation is warranted to fully understand the extent of IL-1β involvement in MPS IIIA exacerbated neurodegeneration, our data robustly reinforces our previous findings, indicating IL-1β as a pivotal catalyst for neuropathological processes in MPS IIIA.
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Affiliation(s)
- Oriana Mandolfo
- Division of Cell Matrix Biology and Regenerative Medicine, Faculty of Biology, Medicine and Health, University of Manchester, 3.721 Stopford Building, Manchester, UK
| | - Helen Parker
- Division of Cell Matrix Biology and Regenerative Medicine, Faculty of Biology, Medicine and Health, University of Manchester, 3.721 Stopford Building, Manchester, UK
- Lydia Becker Institute of Immunology and Inflammation, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Èlia Aguado
- Division of Cell Matrix Biology and Regenerative Medicine, Faculty of Biology, Medicine and Health, University of Manchester, 3.721 Stopford Building, Manchester, UK
| | - Yuko Ishikawa Learmonth
- Division of Cell Matrix Biology and Regenerative Medicine, Faculty of Biology, Medicine and Health, University of Manchester, 3.721 Stopford Building, Manchester, UK
| | - Ai Yin Liao
- Division of Cell Matrix Biology and Regenerative Medicine, Faculty of Biology, Medicine and Health, University of Manchester, 3.721 Stopford Building, Manchester, UK
| | - Claire O'Leary
- Division of Cell Matrix Biology and Regenerative Medicine, Faculty of Biology, Medicine and Health, University of Manchester, 3.721 Stopford Building, Manchester, UK
| | - Stuart Ellison
- Division of Cell Matrix Biology and Regenerative Medicine, Faculty of Biology, Medicine and Health, University of Manchester, 3.721 Stopford Building, Manchester, UK
| | - Gabriella Forte
- Division of Cell Matrix Biology and Regenerative Medicine, Faculty of Biology, Medicine and Health, University of Manchester, 3.721 Stopford Building, Manchester, UK
| | - Jessica Taylor
- Division of Cell Matrix Biology and Regenerative Medicine, Faculty of Biology, Medicine and Health, University of Manchester, 3.721 Stopford Building, Manchester, UK
| | - Shaun Wood
- Division of Cell Matrix Biology and Regenerative Medicine, Faculty of Biology, Medicine and Health, University of Manchester, 3.721 Stopford Building, Manchester, UK
- Centre for Regenerative Medicine, Institute for Regeneration and Repair, The University of Edinburgh, Edinburgh, UK
| | - Rachel Searle
- Division of Cell Matrix Biology and Regenerative Medicine, Faculty of Biology, Medicine and Health, University of Manchester, 3.721 Stopford Building, Manchester, UK
- Centre for Regenerative Medicine, Institute for Regeneration and Repair, The University of Edinburgh, Edinburgh, UK
| | - Rebecca J Holley
- Division of Cell Matrix Biology and Regenerative Medicine, Faculty of Biology, Medicine and Health, University of Manchester, 3.721 Stopford Building, Manchester, UK
| | - Hervé Boutin
- Division of Neuroscience & Experimental Psychology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
- INSERM, UMR 1253, iBrain, Université de Tours, Tours, France
| | - Brian W Bigger
- Division of Cell Matrix Biology and Regenerative Medicine, Faculty of Biology, Medicine and Health, University of Manchester, 3.721 Stopford Building, Manchester, UK.
- Centre for Regenerative Medicine, Institute for Regeneration and Repair, The University of Edinburgh, Edinburgh, UK.
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Paget TL, Larcombe AN, Pinniger GJ, Tsioutsias I, Schneider JP, Parkinson-Lawrence EJ, Orgeig S. Mucopolysaccharidosis (MPS IIIA) mice have increased lung compliance and airway resistance, decreased diaphragm strength, and no change in alveolar structure. Am J Physiol Lung Cell Mol Physiol 2024; 326:L713-L726. [PMID: 38469649 DOI: 10.1152/ajplung.00445.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 12/18/2023] [Accepted: 01/18/2024] [Indexed: 03/13/2024] Open
Abstract
Mucopolysaccharidosis type IIIA (MPS IIIA) is characterized by neurological and skeletal pathologies caused by reduced activity of the lysosomal hydrolase, sulfamidase, and the subsequent primary accumulation of undegraded heparan sulfate (HS). Respiratory pathology is considered secondary in MPS IIIA and the mechanisms are not well understood. Changes in the amount, metabolism, and function of pulmonary surfactant, the substance that regulates alveolar interfacial surface tension and modulates lung compliance and elastance, have been reported in MPS IIIA mice. Here we investigated changes in lung function in 20-wk-old control and MPS IIIA mice with a closed and open thoracic cage, diaphragm contractile properties, and potential parenchymal remodeling. MPS IIIA mice had increased compliance and airway resistance and reduced tissue damping and elastance compared with control mice. The chest wall impacted lung function as observed by an increase in airway resistance and a decrease in peripheral energy dissipation in the open compared with the closed thoracic cage state in MPS IIIA mice. Diaphragm contractile forces showed a decrease in peak twitch force, maximum specific force, and the force-frequency relationship but no change in muscle fiber cross-sectional area in MPS IIIA mice compared with control mice. Design-based stereology did not reveal any parenchymal remodeling or destruction of alveolar septa in the MPS IIIA mouse lung. In conclusion, the increased storage of HS which leads to biochemical and biophysical changes in pulmonary surfactant also affects lung and diaphragm function, but has no impact on lung or diaphragm structure at this stage of the disease.NEW & NOTEWORTHY Heparan sulfate storage in the lungs of mucopolysaccharidosis type IIIA (MPS IIIA) mice leads to changes in lung function consistent with those of an obstructive lung disease and includes an increase in lung compliance and airway resistance and a decrease in tissue elastance. In addition, diaphragm muscle contractile strength is reduced, potentially further contributing to lung function impairment. However, no changes in parenchymal lung structure were observed in mice at 20 wk of age.
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Affiliation(s)
- Tamara L Paget
- Mechanisms in Cell Biology and Diseases Research Concentration, Clinical & Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Alexander N Larcombe
- Respiratory Environmental Health, Wal-yan Respiratory Research Centre, Telethon Kids Institute, Perth, Western Australia, Australia
- Occupation, Environment & Safety, School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Gavin J Pinniger
- School of Human Sciences, The University of Western Australia, Crawley, Western Australia, Australia
| | - Irene Tsioutsias
- School of Human Sciences, The University of Western Australia, Crawley, Western Australia, Australia
| | - Jan Philipp Schneider
- Hannover Medical School, Institute of Functional and Applied Anatomy, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Emma J Parkinson-Lawrence
- Mechanisms in Cell Biology and Diseases Research Concentration, Clinical & Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Sandra Orgeig
- Mechanisms in Cell Biology and Diseases Research Concentration, Clinical & Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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Montanari C, Tagi VM, D’Auria E, Guaia V, Di Gallo A, Ghezzi M, Verduci E, Fiori L, Zuccotti G. Lung Diseases and Rare Disorders: Is It a Lysosomal Storage Disease? Differential Diagnosis, Pathogenetic Mechanisms and Management. CHILDREN (BASEL, SWITZERLAND) 2024; 11:668. [PMID: 38929247 PMCID: PMC11201433 DOI: 10.3390/children11060668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/14/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024]
Abstract
Pulmonologists may be involved in managing pulmonary diseases in children with complex clinical pictures without a diagnosis. Moreover, they are routinely involved in the multidisciplinary care of children with rare diseases, at baseline and during follow-up, for lung function monitoring. Lysosomal storage diseases (LSDs) are a group of genetic diseases characterised by a specific lysosomal enzyme deficiency. Despite varying pathogen and organ involvement, they are linked by the pathological accumulation of exceeding substrates, leading to cellular toxicity and subsequent organ damage. Less severe forms of LSDs can manifest during childhood or later in life, sometimes being underdiagnosed. Respiratory impairment may stem from different pathogenetic mechanisms, depending on substrate storage in bones, with skeletal deformity and restrictive pattern, in bronchi, with obstructive pattern, in lung interstitium, with altered alveolar gas exchange, and in muscles, with hypotonia. This narrative review aims to outline different pulmonary clinical findings and a diagnostic approach based on key elements for differential diagnosis in some treatable LSDs like Gaucher disease, Acid Sphingomyelinase deficiency, Pompe disease and Mucopolysaccharidosis. Alongside their respiratory clinical aspects, which might overlap, we will describe radiological findings, lung functional patterns and associated symptoms to guide pediatric pulmonologists in differential diagnosis. The second part of the paper will address follow-up and management specifics. Recent evidence suggests that new therapeutic strategies play a substantial role in preventing lung involvement in early-treated patients and enhancing lung function and radiological signs in others. Timely diagnosis, driven by clinical suspicion and diagnostic workup, can help in treating LSDs effectively.
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Affiliation(s)
- Chiara Montanari
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (C.M.); (V.M.T.); (E.D.); (V.G.); (A.D.G.); (M.G.); (L.F.); (G.Z.)
- Department of Biomedical and Clinical Science, University of Milan, 20157 Milan, Italy
| | - Veronica Maria Tagi
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (C.M.); (V.M.T.); (E.D.); (V.G.); (A.D.G.); (M.G.); (L.F.); (G.Z.)
- Department of Biomedical and Clinical Science, University of Milan, 20157 Milan, Italy
| | - Enza D’Auria
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (C.M.); (V.M.T.); (E.D.); (V.G.); (A.D.G.); (M.G.); (L.F.); (G.Z.)
- Department of Biomedical and Clinical Science, University of Milan, 20157 Milan, Italy
| | - Vincenzo Guaia
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (C.M.); (V.M.T.); (E.D.); (V.G.); (A.D.G.); (M.G.); (L.F.); (G.Z.)
| | - Anna Di Gallo
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (C.M.); (V.M.T.); (E.D.); (V.G.); (A.D.G.); (M.G.); (L.F.); (G.Z.)
| | - Michele Ghezzi
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (C.M.); (V.M.T.); (E.D.); (V.G.); (A.D.G.); (M.G.); (L.F.); (G.Z.)
| | - Elvira Verduci
- Department of Health Sciences, University of Milan, 20146 Milan, Italy
- Metabolic Diseases Unit, Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy
| | - Laura Fiori
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (C.M.); (V.M.T.); (E.D.); (V.G.); (A.D.G.); (M.G.); (L.F.); (G.Z.)
| | - Gianvincenzo Zuccotti
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (C.M.); (V.M.T.); (E.D.); (V.G.); (A.D.G.); (M.G.); (L.F.); (G.Z.)
- Department of Biomedical and Clinical Science, University of Milan, 20157 Milan, Italy
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5
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Catalano F, Vlaar EC, Dammou Z, Katsavelis D, Huizer TF, Zundo G, Hoogeveen-Westerveld M, Oussoren E, van den Hout HJ, Schaaf G, Pike-Overzet K, Staal FJ, van der Ploeg AT, Pijnappel WP. Lentiviral Gene Therapy for Mucopolysaccharidosis II with Tagged Iduronate 2-Sulfatase Prevents Life-Threatening Pathology in Peripheral Tissues But Fails to Correct Cartilage. Hum Gene Ther 2024; 35:256-268. [PMID: 38085235 PMCID: PMC11044872 DOI: 10.1089/hum.2023.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/01/2023] [Indexed: 02/03/2024] Open
Abstract
Deficiency of iduronate 2-sulfatase (IDS) causes Mucopolysaccharidosis type II (MPS II), a lysosomal storage disorder characterized by systemic accumulation of glycosaminoglycans (GAGs), leading to a devastating cognitive decline and life-threatening respiratory and cardiac complications. We previously found that hematopoietic stem and progenitor cell-mediated lentiviral gene therapy (HSPC-LVGT) employing tagged IDS with insulin-like growth factor 2 (IGF2) or ApoE2, but not receptor-associated protein minimal peptide (RAP12x2), efficiently prevented brain pathology in a murine model of MPS II. In this study, we report on the effects of HSPC-LVGT on peripheral pathology and we analyzed IDS biodistribution. We found that HSPC-LVGT with all vectors completely corrected GAG accumulation and lysosomal pathology in liver, spleen, kidney, tracheal mucosa, and heart valves. Full correction of tunica media of the great heart vessels was achieved only with IDS.IGF2co gene therapy, while the other vectors provided near complete (IDS.ApoE2co) or no (IDSco and IDS.RAP12x2co) correction. In contrast, tracheal, epiphyseal, and articular cartilage remained largely uncorrected by all vectors tested. These efficacies were closely matched by IDS protein levels following HSPC-LVGT. Our results demonstrate the capability of HSPC-LVGT to correct pathology in tissues of high clinical relevance, including those of the heart and respiratory system, while challenges remain for the correction of cartilage pathology.
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Affiliation(s)
- Fabio Catalano
- Department of Clinical Genetics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Eva C. Vlaar
- Department of Clinical Genetics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Zina Dammou
- Department of Clinical Genetics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Drosos Katsavelis
- Department of Clinical Genetics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Tessa F. Huizer
- Department of Clinical Genetics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Giacomo Zundo
- Department of Clinical Genetics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marianne Hoogeveen-Westerveld
- Department of Clinical Genetics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Esmeralda Oussoren
- Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Hannerieke J.M.P. van den Hout
- Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Gerben Schaaf
- Department of Clinical Genetics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Karin Pike-Overzet
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frank J.T. Staal
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Ans T. van der Ploeg
- Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - W.W.M. Pim Pijnappel
- Department of Clinical Genetics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Mayhew D, Palmer K, Wilson I, Watson S, Stepien KM, Jenkins P, Gadepalli C. Airway and Anaesthetic Management of Adult Patients with Mucopolysaccharidoses Undergoing Cardiac Surgery. J Clin Med 2024; 13:1366. [PMID: 38592237 PMCID: PMC10932343 DOI: 10.3390/jcm13051366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/13/2024] [Accepted: 02/23/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Mucopolysaccharidoses (MPSs) are rare congenital lysosomal storage disorders due to a deficiency of enzymes metabolising glycosaminoglycans, leading to their accumulation in tissues. This multisystem disease often requires surgical intervention, including valvular cardiac surgery. Adult MPSs have complex airways making anaesthesia risky. Methods: We report novel three-dimensional (3D) modelling airway assessments and multidisciplinary peri-operative airway management. Results: Five MPS adults underwent cardiac surgery at the national MPS cardiac centre (type I = 4, type II = 1; ages 20, 24, 33, 35, 37 years; two males, three females). All had complex airway abnormalities. Assessments involved examination, nasendoscopy, imaging, functional studies, 3D reconstruction, virtual endoscopy, virtual reality and simulation using computerised, physical modelling. Awake oral fibre-optic intubation was achieved via airway conduit. Staged extubation was performed on the first post-operative day under laryngo-tracheoscopic guidance. The post-operative period involved chest physiotherapy and occupational therapy. All patients had safe intubation, ventilation and extubation. Four had good cardiac surgical outcomes, one (MPS type I; age 35 years) was inoperable due to endocarditis. None had post-operative airway complications. Conclusions: Expertise from cardiovascular-heart team, multidisciplinary airway management, use of novel techniques is vital. Traditional airway assessments are insufficient, so ENT input, radiology and computerised methods to assess and simulate the airway in 3D by collaboration with clinical engineering is essential.
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Affiliation(s)
- David Mayhew
- Department of Anaesthesia, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK; (D.M.); (K.P.)
| | - Kenneth Palmer
- Department of Anaesthesia, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK; (D.M.); (K.P.)
| | - Ian Wilson
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK;
| | - Stuart Watson
- Medical Physics Department, Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Manchester M6 8HD, UK;
| | - Karolina M. Stepien
- Adult Inherited Metabolic Department, Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Manchester M6 8HD, UK;
| | - Petra Jenkins
- Adult Congenital Heart Disease Centre, Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK;
| | - Chaitanya Gadepalli
- Ear Nose and Throat Department, Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Manchester M6 8HD, UK
- School of Medical Education, The University of Manchester, Manchester M14 4PX, UK
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7
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Rossi A, Basilicata S, Borrelli M, Ferreira CR, Blau N, Santamaria F. Clinical and biochemical footprints of inherited metabolic diseases. XIII. Respiratory manifestations. Mol Genet Metab 2023; 140:107655. [PMID: 37517329 DOI: 10.1016/j.ymgme.2023.107655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/17/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
At any age, respiratory manifestations are a major cause of increased morbidity and mortality of inherited metabolic diseases (IMDs). Type and severity are extremely variable, this depending on the type of the underlying disorder. Symptoms and signs originating from upper or lower airways and/or thoracic wall and/or respiratory muscles involvement can occur either at presentation or in the late clinical course. Acute respiratory symptoms can trigger metabolic decompensation which, in turn, makes airway symptoms worse, creating a vicious circle. We have identified 181 IMDs associated with various types of respiratory symptoms which were classified into seven groups according to the type of clinical manifestations affecting the respiratory system: (i) respiratory failure, (ii) restrictive lung disease, (iii) interstitial lung disease, (iv) lower airway disease, (v) upper airway obstruction, (vi) apnea, and (vii) other. We also provided a list of investigations to be performed based on the respiratory phenotypes and indicated the therapeutic strategies currently available for IMD-associated airway disease. This represents the thirteenth issue in a series of educational summaries providing a comprehensive and updated list of metabolic differential diagnoses according to system involvement.
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Affiliation(s)
- Alessandro Rossi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Simona Basilicata
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Melissa Borrelli
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Carlos R Ferreira
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Nenad Blau
- Division of Metabolism, University Children's Hospital, Zürich, Switzerland.
| | - Francesca Santamaria
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.
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Pierzynowska K, Deresz P, Węgrzyn G, Gaffke L. Dysregulation of genes coding for proteins involved in metabolic processes in mucopolysaccharidoses, evidenced by a transcriptomic approach. Metab Brain Dis 2023; 38:2133-2144. [PMID: 37195412 PMCID: PMC10349023 DOI: 10.1007/s11011-023-01231-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 05/07/2023] [Indexed: 05/18/2023]
Abstract
Mucopolysaccharidoses (MPS) are a group of lysosomal storage diseases (LSD) caused by mutations in genes coding for enzymes responsible for degradation of glycosaminoglycans (GAGs). Most types of these severe disorders are characterized by neuronopathic phenotypes. Although lysosomal accumulation of GAGs is the primary metabolic defect in MPS, secondary alterations in biochemical processes are considerable and influence the course of the disease. Early hypothesis suggested that these secondary changes might be due to lysosomal storage-mediated impairment of activities of other enzymes, and subsequent accumulation of various compounds in cells. However, recent studies indicated that expression of hundreds of genes is changed in MPS cells. Therefore, we asked whether metabolic effects observed in MPS are caused primarily by GAG-mediated inhibition of specific biochemical reactions or appear as results of dysregulation of expression of genes coding for proteins involved in metabolic processes. Transcriptomic analyses of 11 types of MPS (using RNA isolated from patient-derived fibroblasts), performed in this study, showed that a battery of the above mentioned genes is dysregulated in MPS cells. Some biochemical pathways might be especially affected by changes in expression of many genes, including GAG metabolism and sphingolipid metabolism which is especially interesting as secondary accumulation of various sphingolipids is one of the best known additional (while significantly enhancing neuropathological effects) metabolic defects in MPS. We conclude that severe metabolic disturbances, observed in MPS cells, can partially arise from changes in the expression of many genes coding for proteins involved in metabolic processes.
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Affiliation(s)
- Karolina Pierzynowska
- Department of Molecular Biology, Faculty of Biology, University of Gdansk, Wita Stwosza 59, 80-308, Gdansk, Poland
| | - Patrycja Deresz
- Department of Molecular Biology, Faculty of Biology, University of Gdansk, Wita Stwosza 59, 80-308, Gdansk, Poland
| | - Grzegorz Węgrzyn
- Department of Molecular Biology, Faculty of Biology, University of Gdansk, Wita Stwosza 59, 80-308, Gdansk, Poland
| | - Lidia Gaffke
- Department of Molecular Biology, Faculty of Biology, University of Gdansk, Wita Stwosza 59, 80-308, Gdansk, Poland.
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9
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Piotto M, Gambadauro A, Rocchi A, Lelii M, Madini B, Cerrato L, Chironi F, Belhaj Y, Patria MF. Pediatric Sleep Respiratory Disorders: A Narrative Review of Epidemiology and Risk Factors. CHILDREN (BASEL, SWITZERLAND) 2023; 10:955. [PMID: 37371187 DOI: 10.3390/children10060955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/09/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023]
Abstract
Sleep is a fundamental biological necessity, the lack of which has severe repercussions on the mental and physical well-being in individuals of all ages. The phrase "sleep-disordered breathing (SDB)" indicates a wide array of conditions characterized by snoring and/or respiratory distress due to increased upper airway resistance and pharyngeal collapsibility; these range from primary snoring to obstructive sleep apnea (OSA) and occur in all age groups. In the general pediatric population, the prevalence of OSA varies between 2% and 5%, but in some particular clinical conditions, it can be much higher. While adenotonsillar hypertrophy ("classic phenotype") is the main cause of OSA in preschool age (3-5 years), obesity ("adult phenotype") is the most common cause in adolescence. There is also a "congenital-structural" phenotype that is characterized by a high prevalence of OSA, appearing from the earliest ages of life, supported by morpho-structural abnormalities or craniofacial changes and associated with genetic syndromes such as Pierre Robin syndrome, Prader-Willi, achondroplasia, and Down syndrome. Neuromuscular disorders and lysosomal storage disorders are also frequently accompanied by a high prevalence of OSA in all life ages. Early recognition and proper treatment are crucial to avoid major neuro-cognitive, cardiovascular, and metabolic morbidities.
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Affiliation(s)
- Marta Piotto
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Antonella Gambadauro
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Alessia Rocchi
- Pediatric Emergency Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Mara Lelii
- Pediatria Pneumoinfettivologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Barbara Madini
- Pediatria Pneumoinfettivologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Lucia Cerrato
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Federica Chironi
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Youssra Belhaj
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Maria Francesca Patria
- Pediatria Pneumoinfettivologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
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Endoscopic and Image Analysis of the Airway in Patients with Mucopolysaccharidosis Type IVA. J Pers Med 2023; 13:jpm13030494. [PMID: 36983675 PMCID: PMC10059844 DOI: 10.3390/jpm13030494] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/05/2023] [Accepted: 03/07/2023] [Indexed: 03/12/2023] Open
Abstract
Mucopolysaccharidosis (MPS) is a hereditary disorder arising from lysosomal enzymes deficiency, with glycosaminoglycans (GAGs) storage in connective tissues and bones, which may compromise the airway. This retrospective study evaluated patients with MPS type IVA with airway obstruction detected via endoscopy and imaging modalities and the effects of surgical interventions based on symptoms. The data of 15 MPS type IVA patients (10 males, 5 females, mean age 17.8 years) were reviewed in detail. Fiberoptic bronchoscopy (FB) was used to distinguish adenotonsillar hypertrophy, prolapsed soft palate, secondary laryngomalacia, vocal cord granulation, cricoid thickness, tracheal stenosis, shape of tracheal lumen, nodular deposition, tracheal kinking, tracheomalacia with rigid tracheal wall, and bronchial collapse. Computed tomography (CT) helped to measure the deformed sternal angle, the cross-sectional area of the trachea, and its narrowest/widest ratio (NW ratio), while angiography with 3D reconstruction delineated tracheal torsion, kinking, or framework damage and external vascular compression of the trachea. The NW ratio correlated negatively with age (p < 0.01), showing that airway obstruction progressed gradually. Various types of airway surgery were performed to correct the respiratory dysfunction. MPS type IVA challenges the management of multifactorial airway obstruction. Preoperative airway evaluation with both FB and CT is strongly suggested to assess both intraluminal and extraluminal factors causing airway obstruction.
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11
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Numan A, Alruwaili AN, Ali R, Alsharari H, Alanazi M, Alazmi NN, Alsaati AA. Mucopolysaccharidosis Type VI with Recurrent Chest Infection. Cureus 2023; 15:e35229. [PMID: 36968901 PMCID: PMC10032617 DOI: 10.7759/cureus.35229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 02/22/2023] Open
Abstract
Mucopolysaccharidosis type VI (Maroteaux-Lamy syndrome) is a progressive multi-systemic autosomal recessive disease resulting from a deficiency of arylsulfatase B (N-acetylgalactosamine-4-sulfatase). Here we report the case of a three-year-old male child born full-term via normal vaginal delivery. He had frequent admissions due to a chest infection that started at two months of age. At the age of 23 months, he was admitted after complaining of shortness of breath (SOB) due to asthma and aspiration pneumonia; additionally, dysmorphic features were noticed (single palmar crease, short round toes, coarse facial features such as a flat nose, big lips). A genetic study showed mucopolysaccharidosis VI (MPS VI). At three years of age, he was complaining of cough and SOB. Examination showed wheezing all over the chest, normal first and second heart sounds (S1 and S2), a murmur with no clicks, hepatosplenomegaly, and a palpable left kidney. However, the central nervous system (CNS) and eye examinations were normal. Echocardiography revealed a thickened bicuspid aortic valve, mild aortic regurgitation, and mitral regurgitation. Therefore, the patient presented with different clinical symptoms of MPS VI. It is important to increase the physicians' awareness about MPS by focusing on increasing the probability of MPS as a differential diagnosis whenever patients present with abnormal appearance, limb deformities, and recurrent unexplained infections; hence, making early diagnosis and treatment decisions, leading to a slowing down of the progression of the disease and enhancing the patient's quality of life.
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12
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De Vuyst R, Jalazo E, Tsujimoto TM, Lin FC, Muenzer J, Muhlebach MS. Airway Findings in Patients with Hunter Syndrome Treated with Intravenous Idursulfase. J Clin Med 2023; 12:480. [PMID: 36675409 PMCID: PMC9863383 DOI: 10.3390/jcm12020480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023] Open
Abstract
People with Hunter syndrome are known to be affected by a variety of airway pathologies. Treatment of Hunter syndrome with the enzyme replacement therapy (ERT) idursulfase is now the standard of care. However, it is not known how ERT changes the progression of airway involvement. To evaluate this, we performed a retrospective analysis of bronchoscopies performed on children with Hunter syndrome who were part of intrathecal ERT trials. Findings for airway pathology were extracted from bronchoscopy reports and analyses were performed for cross-sectional and longitudinal changes in airway disease. One-hundred and thirty bronchoscopies from 23 subjects were analyzed. Upper airway disease (adenoid hypertrophy and/or pharyngomalacia) was reported in 93% and 87% of bronchoscopies, respectively. Laryngeal abnormalities were recognized in 46% of cases. There were lower airway (tracheal and or bronchial) findings in 64% of all bronchoscopies and prevalence increased with age. Evaluations over time adjusted for repeat evaluations showed that increasing airway involvement was associated with older age (p = 0.0007) despite ongoing ERT. No association was discovered between age of intravenous ERT initiation and progression of airway disease. Individuals with Hunter syndrome who are receiving intravenous enzyme replacement therapy showed the progression of airways disease supporting the need for regular airway monitoring and intervention.
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Affiliation(s)
- Richard De Vuyst
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Elizabeth Jalazo
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Tamy Moraes Tsujimoto
- Department of Biostatistics, UNC Gillings School of Global Public Health, Chapel Hill, NC 27599, USA
| | - Feng-Chang Lin
- Department of Biostatistics, UNC Gillings School of Global Public Health, Chapel Hill, NC 27599, USA
| | - Joseph Muenzer
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Marianne S. Muhlebach
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC 27599, USA
- Marsico Lung Institute, University of North Carolina, Chapel Hill, NC 27599, USA
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13
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Mauhin W, Brassier A, London J, Subran B, Zeggane A, Besset Q, Jammal C, Montardi C, Mellot C, Strauss C, Borie R, Lidove O. Manifestations pulmonaires des maladies héréditaires du métabolisme. Rev Mal Respir 2022; 39:758-777. [DOI: 10.1016/j.rmr.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/11/2022] [Indexed: 11/05/2022]
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14
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MPSI Manifestations and Treatment Outcome: Skeletal Focus. Int J Mol Sci 2022; 23:ijms231911168. [PMID: 36232472 PMCID: PMC9569890 DOI: 10.3390/ijms231911168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/16/2022] [Accepted: 09/17/2022] [Indexed: 11/23/2022] Open
Abstract
Mucopolysaccharidosis type I (MPSI) (OMIM #252800) is an autosomal recessive disorder caused by pathogenic variants in the IDUA gene encoding for the lysosomal alpha-L-iduronidase enzyme. The deficiency of this enzyme causes systemic accumulation of glycosaminoglycans (GAGs). Although disease manifestations are typically not apparent at birth, they can present early in life, are progressive, and include a wide spectrum of phenotypic findings. Among these, the storage of GAGs within the lysosomes disrupts cell function and metabolism in the cartilage, thus impairing normal bone development and ossification. Skeletal manifestations of MPSI are often refractory to treatment and severely affect patients’ quality of life. This review discusses the pathological and molecular processes leading to impaired endochondral ossification in MPSI patients and the limitations of current therapeutic approaches. Understanding the underlying mechanisms responsible for the skeletal phenotype in MPSI patients is crucial, as it could lead to the development of new therapeutic strategies targeting the skeletal abnormalities of MPSI in the early stages of the disease.
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15
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Bernardo Figueirêdo B, Reinaux C, Fuzari H, Sarmento A, Fernandes J, Dornelas de Andrade A. Chest wall volumes, diaphragmatic mobility, and functional capacity in patients with mucopolysaccharidoses. Disabil Rehabil 2022:1-10. [PMID: 35695376 DOI: 10.1080/09638288.2022.2084777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE We investigated respiratory muscle strength, diaphragm mobility, lung function, functional capacity, quality of life, body composition, breathing pattern, and chest wall (VT,CW) and compartmental volumes of Mucopolysaccharidosis (MPS) patients and compared these variables with matched healthy individuals. METHODS A cross-sectional study with data analyzed separately according to age group. A total of 68 individuals (34 MPS and 34 matched-healthy subjects) were included. Six-minute walking test assessed functional capacity and ultrasound assessed diaphragm mobility during quiet spontaneous breathing (QB). Optoelectronic plethysmography assessed VT,CW and breathing pattern during QB in two different positions: seated and supine (45° trunk inclination). RESULTS Body composition, lung function, respiratory muscle strength, and functional capacity were reduced in MPS (all p < 0.01). Diaphragm mobility was only reduced in adolescents (p = 0.01) and correlated with body composition and breathing pattern. Upper chest wall compartmental volumes were significantly lower in MPS, while abdominal volume only differed significantly in adolescents. Percentage contribution (%) of upper ribcage compartments to tidal volume was reduced in MPS children, whereas %AB was significantly increased compared with healthy subjects. CONCLUSION Lung function, respiratory muscle strength, functional capacity, diaphragm mobility, and quality of life are reduced in MPS compared with matched healthy subjects. VT,CW was mainly reduced due to pulmonary and abdominal ribcage impairment. Implications for RehabilitationReduction in respiratory muscle strength, functional capacity, diaphragm excursion and low lung volumes were found in individuals with Mucopolysaccharidoses (MPS).Chest wall volumes and the upper chest wall compartmental volumes during quiet spontaneous breathing are reduced in MPS.Assessment and monitoring of the respiratory system for individuals with MPS should be performed periodically through standardized assessments to enable identification of changes and early intervention by rehabilitation protocols.This study may provide the necessary basis for carrying out respiratoty rehabilitation protocols that can improving chest wall mechanics with breathing exercise in this group.
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Affiliation(s)
- Bárbara Bernardo Figueirêdo
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Brazil.,Laboratory of Immunopathology Keizo Asami (LIKA), Federal University of Pernambuco, Recife, Brazil
| | - Cyda Reinaux
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Brazil
| | - Helen Fuzari
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Brazil
| | - António Sarmento
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Brazil
| | - Juliana Fernandes
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Brazil
| | - Armèle Dornelas de Andrade
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Brazil.,Laboratory of Immunopathology Keizo Asami (LIKA), Federal University of Pernambuco, Recife, Brazil
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16
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Wiśniewska K, Wolski J, Gaffke L, Cyske Z, Pierzynowska K, Węgrzyn G. Misdiagnosis in mucopolysaccharidoses. J Appl Genet 2022; 63:475-495. [PMID: 35562626 DOI: 10.1007/s13353-022-00703-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/02/2022] [Accepted: 05/05/2022] [Indexed: 02/05/2023]
Abstract
Mucopolysaccharidosis (MPS) is a group of 13 hereditary metabolic diseases identified in humans (or 14 diseases if considering one MPS type described to date only in mice) in which an enzymatic defect results in the accumulation of glycosaminoglycans (GAG) in the lysosomes of cells. First of all, as a result of GAG storage, the proper functioning of the lysosome is disturbed; then, the cells, and finally, tissue, organs, and the whole organism malfunctions are observed. Due to the rarity, heterogeneity, and multi-systemic and progressive nature of MPS, they present a major diagnostic challenge. Due to the wide variation in symptoms and their similarity to other diseases, MPS is often misdiagnosed, usually as neurological diseases (like autism spectrum disorders, psychomotor hyperactivity, and intellectual disability) or rheumatology and orthopedic disorders (like juvenile idiopathic arthritis, Perthes disease, rickets, and muscular dystrophy). In this review article, we present the problems associated with the possibility of misdiagnosing MPS, discuss what diseases they can be confused with, and suggest ways to reduce these problems in the future.
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Affiliation(s)
- Karolina Wiśniewska
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308, Gdańsk, Poland
| | - Jakub Wolski
- Psychiatry Ward, 7th Navy Hospital in Gdańsk, Polanki 117, 80-305, Gdańsk, Poland
| | - Lidia Gaffke
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308, Gdańsk, Poland
| | - Zuzanna Cyske
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308, Gdańsk, Poland
| | - Karolina Pierzynowska
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308, Gdańsk, Poland
| | - Grzegorz Węgrzyn
- Department of Molecular Biology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308, Gdańsk, Poland.
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17
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Cross B, Stepien KM, Gadepalli C, Kharabish A, Woolfson P, Tol G, Jenkins P. Pre-operative Considerations in Adult Mucopolysaccharidosis Patients Planned for Cardiac Intervention. Front Cardiovasc Med 2022; 9:851016. [PMID: 35445089 PMCID: PMC9013828 DOI: 10.3389/fcvm.2022.851016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/28/2022] [Indexed: 11/15/2022] Open
Abstract
Mucopolysaccharidoses (MPS) are rare lysosomal storage diseases characterized by multiorgan involvement and shortened longevity. Due to advances in therapies such as enzyme replacement therapy and haematopoietic stem cell therapy, life expectancy has increased posing newer challenges to patients and health professionals. One such challenge is cardiovascular manifestations of MPS, which can be life limiting and cause reduction in quality of life. Any cardiovascular intervention mandates comprehensive, multi-systemic work-up by specialist teams to optimize outcome. We highlight the importance of multidisciplinary evaluation of adult MPS patients requiring cardiovascular intervention. Clinical assessments and investigations are discussed, with a focus on the cardiac, anesthetic, airway, respiratory, radiological and psychosocial factors.
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Affiliation(s)
- Benjamin Cross
- Adult Congenital Heart Disease Department, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Karolina M. Stepien
- Adult Inherited Metabolic Diseases Department, Salford Royal NHS Foundation Trust, Salford, United Kingdom
- *Correspondence: Karolina M. Stepien
| | - Chaitanya Gadepalli
- Ear Nose and Throat Department, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Ahmed Kharabish
- Radiology Department, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Radiology Department, Cairo University, Giza, Egypt
| | - Peter Woolfson
- Cardiology Department, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Govind Tol
- Anaesthetics Department, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Petra Jenkins
- Adult Congenital Heart Disease Department, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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18
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Stepien KM, Bentley A, Chen C, Dhemech MW, Gee E, Orton P, Pringle C, Rajan J, Saxena A, Tol G, Gadepalli C. Non-cardiac Manifestations in Adult Patients With Mucopolysaccharidosis. Front Cardiovasc Med 2022; 9:839391. [PMID: 35321113 PMCID: PMC8935042 DOI: 10.3389/fcvm.2022.839391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/10/2022] [Indexed: 12/12/2022] Open
Abstract
Mucopolysaccharidoses (MPS) are a heterogeneous group of disorders that results in the absence or deficiency of lysosomal enzymes, leading to an inappropriate storage of glycosaminoglycans (GAGs) in various tissues of the body such as bones, cartilage, heart valves, arteries, upper airways, cornea, teeth, liver and nervous system. Clinical manifestations can become progressively exacerbated with age and affect their quality of life. Developments in advanced supportive treatment options such as enzyme replacement therapy (ERT), hematopoietic stem cell transplantation (HSCT) may have improved patients' life span. Adult MPS patients require specialist clinical surveillance long-term. In many cases, in addition to the MPS-related health problems, they may develop age-related complications. Considering the complexity of their clinical manifestations and lack of guidelines on the management of adult MPS disorders, multispecialty and multidisciplinary teams' care is essential to diagnose and treat health problems that are likely to be encountered. This review presents non-cardiac clinical manifestations, their pathophysiology, management and long-term outcomes in adult MPS patients.
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Affiliation(s)
- Karolina M. Stepien
- Adult Inherited Metabolic Diseases, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Andrew Bentley
- Northwest Ventilation Unit and Sleep Department, Wythenshawe Hospital, Manchester University National Health Service Foundation Trust, Manchester, United Kingdom
- Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
- Intensive Care & Respiratory Medicine, Manchester University National Health Service Foundation Trust, Manchester, United Kingdom
| | - Cliff Chen
- Clinical Neuropsychology, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - M. Wahab Dhemech
- Northwest Ventilation Unit and Sleep Department, Wythenshawe Hospital, Manchester University National Health Service Foundation Trust, Manchester, United Kingdom
| | - Edward Gee
- Trauma and Orthopaedic Surgery, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Peter Orton
- Trauma and Orthopaedic Surgery, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Catherine Pringle
- Neurosurgery, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Jonathan Rajan
- Manchester and Salford Pain Centre, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Ankur Saxena
- Neurosurgery, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Govind Tol
- Anaesthetics Department, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Chaitanya Gadepalli
- Ear, Nose and Throat, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
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Tomita K, Okamoto S, Seto T, Hamazaki T, So S, Yamamoto T, Tanizawa K, Sonoda H, Sato Y. Divergent developmental trajectories in two siblings with neuropathic mucopolysaccharidosis type II (Hunter syndrome) receiving conventional and novel enzyme replacement therapies: A case report. JIMD Rep 2021; 62:9-14. [PMID: 34765392 PMCID: PMC8574176 DOI: 10.1002/jmd2.12239] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 01/20/2023] Open
Abstract
Mucopolysaccharidosis type II (MPS II; Hunter syndrome) is an X-linked recessive lysosomal storage disease caused by a mutation in the IDS gene and characterized by systemic accumulations of glycosaminoglycans. Its somatic symptoms can be relieved by enzyme replacement therapy (ERT) with idursulfase, but because the enzyme cannot cross the blood-brain-barrier (BBB), it does not address the progressive neurodegeneration and subsequent central nervous system (CNS) manifestations seen in patients with neuropathic MPS-II. However, pabinafusp alfa, a human iduronate-2-sulfatase (IDS) fused with a BBB-crossing anti-transferrin receptor antibody, has been shown to be efficacious against both the somatic and CNS symptoms of MPS II. We report two cases of MPS-II in Japanese siblings sharing the same G140V mutation in the IDS gene, who showed markedly contrasting developmental trajectories following enzyme replacement therapy (ERT). Sibling 1 was diagnosed at 2 years of age, started undergoing conventional ERT shortly afterward, and scored a developmental quotient (DQ) of 53 on the Kyoto Scale of Psychological Development (KSPD) at 4 years of age. Sibling 2 was diagnosed prenatally and received conventional ERT from the age of 1 month through 1 year and 11 months, when he switched to pabinafusp alpha. He attained a DQ of 104 at age 3 years and 11 months, along with significant declines in heparan sulfate concentrations in the cerebrospinal fluid. This marked difference in neurocognitive development highlights the importance of early initiation of ERT with a BBB-penetrating enzyme in patients with neuropathic MPS-II.
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Affiliation(s)
- Kazuyoshi Tomita
- Department of PediatricsOsaka City University Graduate School of MedicineJapan
| | - Shungo Okamoto
- Department of PediatricsOsaka City University Graduate School of MedicineJapan
| | - Toshiyuki Seto
- Department of PediatricsOsaka City University Graduate School of MedicineJapan
| | - Takashi Hamazaki
- Department of PediatricsOsaka City University Graduate School of MedicineJapan
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20
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Hyo-Mental Angle and Distance: An Important Adjunct in Airway Assessment of Adult Mucopolysaccharidosis. J Clin Med 2021; 10:jcm10214924. [PMID: 34768446 PMCID: PMC8584402 DOI: 10.3390/jcm10214924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Mucopolysaccharidosis (MPS) is a rare congenital lysosomal storage disorder with complex airways. High anterior larynx is assessed by thyromental distance (TMD) nasendoscopy. A simpler method to assess this hyoid bone is described. The distance between the central-hyoid and symphysis of the mandible (hyo-mental distance; HMD) and inclination of this line to the horizontal axis (hyo-mental angle; HMA) in neutrally positioned patients is investigated. Methods: HMA, HMD in MPS, and non-MPS were compared, and their correlation with height and weight were assessed. Results: 50 adult MPS patients (M = 32, F = 18, age range = 19–66 years; mean BMI = 26.8 kg/m2) of MPS I, II, III, IV, and VI were compared with 50 non-MPS (M = 25, F = 25; age range = 22–84 years; mean BMI = 26.5 kg/m2). Mean HMA in MPS was 25.72° (−10 to +50) versus 2.42° (−35 to +28) in non-MPS. Mean HMD was 46.5 (25.7–66) millimeters in MPS versus 41.8 (27–60.3) in non-MPS. HMA versus height and weight showed a moderate correlation (r = −0.4, p < 0.05) in MPS and no significant correlation (r < 0.4, p > 0.05) in non-MPS. HMD versus height and weight showed no correlation (r < 0.4, p > 0.05) in both groups. Conclusions: HMA seems more acute in MPS despite nearly the same HMD as non-MPS, signifying a high larynx, which may be missed by TMD.
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21
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Paget TL, Parkinson-Lawrence EJ, Orgeig S. The role of surfactant and distal lung dysfunction in the pathology of lysosomal storage diseases. CURRENT OPINION IN PHYSIOLOGY 2021. [DOI: 10.1016/j.cophys.2021.100467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Airway Abnormalities in Adult Mucopolysaccharidosis and Development of Salford Mucopolysaccharidosis Airway Score. J Clin Med 2021; 10:jcm10153275. [PMID: 34362059 PMCID: PMC8347638 DOI: 10.3390/jcm10153275] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/15/2021] [Accepted: 07/21/2021] [Indexed: 12/14/2022] Open
Abstract
(1) Background: Mucopolysaccharidoses (MPS) are a heterogeneous group of lysosomal storage disorders caused by the absence of enzymes required for degradation of glycosaminoglycans (GAGs). GAGs deposition in tissues leads to progressive airway narrowing and/or tortuosity. Increased longevity of patients has posed newer problems, especially the airway. This study aims to characterise various airway abnormalities in adult MPS from a regional centre and proposes a method to quantify the severity of the airway disease. (2) Methods: Retrospective analysis by case notes review, clinical examination, endoscopy, cross-sectional imaging, 3-dimensional reconstruction, and physiological investigations were used to assess the airway abnormalities. Quantitative assessment of the airway severity was performed a validated questionnaire of 15 parameters to derive Salford Mucopolysaccharidosis Airway Score (SMAS). (3) Results: Thirty-one adult MPS patients (21M/ 9F; median 26.7 years; range 19–42 years) were reviewed. There were 9 MPS I, 12 MPS II, 2 MPS III, 5 MPS IV, 2 MPS VI, and 1 MPS VII. Airway abnormalities in each MPS type are described. Patients scoring more than 35 on SMAS had some form of airway intervention. The area under curve of 0.9 was noted at a score of 25, so SMAS more than 25 may predict a difficult airway and potential to have complications. Pearson’s correlation between SMAS and height, weight, BMI were poor (p < 0.05). (4) Conclusions: Airway abnormalities in adult MPS are varied and complex. Assessment of the airway should be holistic and include multiple parameters. An objective multidimensional score such as SMAS may help to predict and manage difficult airways warranting further investigation and validation.
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Differences in MPS I and MPS II Disease Manifestations. Int J Mol Sci 2021; 22:ijms22157888. [PMID: 34360653 PMCID: PMC8345985 DOI: 10.3390/ijms22157888] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/15/2021] [Accepted: 07/16/2021] [Indexed: 02/06/2023] Open
Abstract
Mucopolysaccharidosis (MPS) type I and II are two closely related lysosomal storage diseases associated with disrupted glycosaminoglycan catabolism. In MPS II, the first step of degradation of heparan sulfate (HS) and dermatan sulfate (DS) is blocked by a deficiency in the lysosomal enzyme iduronate 2-sulfatase (IDS), while, in MPS I, blockage of the second step is caused by a deficiency in iduronidase (IDUA). The subsequent accumulation of HS and DS causes lysosomal hypertrophy and an increase in the number of lysosomes in cells, and impacts cellular functions, like cell adhesion, endocytosis, intracellular trafficking of different molecules, intracellular ionic balance, and inflammation. Characteristic phenotypical manifestations of both MPS I and II include skeletal disease, reflected in short stature, inguinal and umbilical hernias, hydrocephalus, hearing loss, coarse facial features, protruded abdomen with hepatosplenomegaly, and neurological involvement with varying functional concerns. However, a few manifestations are disease-specific, including corneal clouding in MPS I, epidermal manifestations in MPS II, and differences in the severity and nature of behavioral concerns. These phenotypic differences appear to be related to different ratios between DS and HS, and their sulfation levels. MPS I is characterized by higher DS/HS levels and lower sulfation levels, while HS levels dominate over DS levels in MPS II and sulfation levels are higher. The high presence of DS in the cornea and its involvement in the arrangement of collagen fibrils potentially causes corneal clouding to be prevalent in MPS I, but not in MPS II. The differences in neurological involvement may be due to the increased HS levels in MPS II, because of the involvement of HS in neuronal development. Current treatment options for patients with MPS II are often restricted to enzyme replacement therapy (ERT). While ERT has beneficial effects on respiratory and cardiopulmonary function and extends the lifespan of the patients, it does not significantly affect CNS manifestations, probably because the enzyme cannot pass the blood-brain barrier at sufficient levels. Many experimental therapies, therefore, aim at delivery of IDS to the CNS in an attempt to prevent neurocognitive decline in the patients.
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Ademhan Tural D, Emiralioglu N, Dogru D, Ozsezen B, Ipek OF, Sunman B, Nayir Buyuksahin H, Guzelkas I, Ciki K, Kilic K, Vardar Yagli N, Yalcin E, Kiper N, Sivri S, Ozcelik U. Evaluation of sleep-disordered breathing and its relationship with respiratory parameters in children with mucopolysaccharidosis Type IVA and VI. Am J Med Genet A 2021; 185:2306-2314. [PMID: 33960649 DOI: 10.1002/ajmg.a.62229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 03/19/2021] [Accepted: 04/02/2021] [Indexed: 11/08/2022]
Abstract
The aims of the study were to evaluate the prevalence of sleep-disordered breathing (SDB) by using polysomnography (PSG) in children with MPS IVA and MPS VI who underwent enzyme replacement therapy (ERT) and to analyze the effect on SDB of having upper airway surgery, pulmonary functions, and exercise capacity. A retrospective cross-sectional study was conducted on patients with MPS IVA (n:17) and MPS VI (n:11) aged under 19 years who underwent polysomnography. Descriptive and nonparametric analyses were performed for demographic, PSG, pulmonary function and exercise capacity variables. The frequency of sleep apnea in the study sample was 85.7% (24/28). Four patients (14.3%) had no sleep apnea, 15 (53.6%) had mild, and nine (32.1%) had moderate-to-severe sleep apnea. Two patients (7.1%) had central sleep apnea and 22 had obstructive sleep apnea (OSA) (78.6%). Forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were negatively correlated to apnea-hypopnea index (AHI) (r = -0.594, p = .009; r = -0.636, p = .005, respectively). Despite ERT and previous upper airway surgery, the prevalence of OSA was high in patients with MPS IVA-MPS IV, emphasizing the importance of PSG screening for sleep disorders. Pulmonary function tests may be useful for predicting sleep apnea in patients with MPS IVA and MPS VI.
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Affiliation(s)
- Dilber Ademhan Tural
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Nagehan Emiralioglu
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Deniz Dogru
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Beste Ozsezen
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Omer Faruk Ipek
- Department of Pediatrics, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Birce Sunman
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Halime Nayir Buyuksahin
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Ismail Guzelkas
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Kismet Ciki
- Department of Pediatric Metabolism, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Kubra Kilic
- Department of Physical Therapy and Rehabilitation, Faculty of Medical Sciences, Hacettepe University, Ankara, Turkey
| | - Naciye Vardar Yagli
- Department of Physical Therapy and Rehabilitation, Faculty of Medical Sciences, Hacettepe University, Ankara, Turkey
| | - Ebru Yalcin
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Nural Kiper
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Serap Sivri
- Department of Pediatric Metabolism, Ihsan Dogramaci Children's Hospital, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ugur Ozcelik
- Department of Pediatric Pulmonology, School of Medicine, Hacettepe University, Ihsan Dogramaci Children's Hospital, Ankara, Turkey
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25
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Paget TL, Parkinson-Lawrence EJ, Trim PJ, Autilio C, Panchal MH, Koster G, Echaide M, Snel MF, Postle AD, Morrison JL, Pérez-Gil J, Orgeig S. Increased Alveolar Heparan Sulphate and Reduced Pulmonary Surfactant Amount and Function in the Mucopolysaccharidosis IIIA Mouse. Cells 2021; 10:849. [PMID: 33918094 PMCID: PMC8070179 DOI: 10.3390/cells10040849] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 02/07/2023] Open
Abstract
Mucopolysaccharidosis IIIA (MPS IIIA) is a lysosomal storage disease with significant neurological and skeletal pathologies. Respiratory dysfunction is a secondary pathology contributing to mortality in MPS IIIA patients. Pulmonary surfactant is crucial to optimal lung function and has not been investigated in MPS IIIA. We measured heparan sulphate (HS), lipids and surfactant proteins (SP) in pulmonary tissue and bronchoalveolar lavage fluid (BALF), and surfactant activity in healthy and diseased mice (20 weeks of age). Heparan sulphate, ganglioside GM3 and bis(monoacylglycero)phosphate (BMP) were increased in MPS IIIA lung tissue. There was an increase in HS and a decrease in BMP and cholesteryl esters (CE) in MPS IIIA BALF. Phospholipid composition remained unchanged, but BALF total phospholipids were reduced (49.70%) in MPS IIIA. There was a reduction in SP-A, -C and -D mRNA, SP-D protein in tissue and SP-A, -C and -D protein in BALF of MPS IIIA mice. Captive bubble surfactometry showed an increase in minimum and maximum surface tension and percent surface area compression, as well as a higher compressibility and hysteresis in MPS IIIA surfactant upon dynamic cycling. Collectively these biochemical and biophysical changes in alveolar surfactant are likely to be detrimental to lung function in MPS IIIA.
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Affiliation(s)
- Tamara L. Paget
- Mechanisms in Cell Biology and Disease Group, UniSA Clinical and Health Sciences, University of South Australia, Adelaide, SA 5000, Australia; (T.L.P.); (E.J.P.-L.)
| | - Emma J. Parkinson-Lawrence
- Mechanisms in Cell Biology and Disease Group, UniSA Clinical and Health Sciences, University of South Australia, Adelaide, SA 5000, Australia; (T.L.P.); (E.J.P.-L.)
| | - Paul J. Trim
- Proteomics, Metabolomics and MS-Imaging Core Facility, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia; (P.J.T.); (M.F.S.)
| | - Chiara Autilio
- Department of Biochemistry, Faculty of Biology and Research Institute Hospital 12 de Octubre (Imas12), Complutense University, 28003 Madrid, Spain; (C.A.); (M.E.); (J.P.-G.)
| | - Madhuriben H. Panchal
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK; (M.H.P.); (G.K.); (A.D.P.)
| | - Grielof Koster
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK; (M.H.P.); (G.K.); (A.D.P.)
| | - Mercedes Echaide
- Department of Biochemistry, Faculty of Biology and Research Institute Hospital 12 de Octubre (Imas12), Complutense University, 28003 Madrid, Spain; (C.A.); (M.E.); (J.P.-G.)
| | - Marten F. Snel
- Proteomics, Metabolomics and MS-Imaging Core Facility, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia; (P.J.T.); (M.F.S.)
| | - Anthony D. Postle
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK; (M.H.P.); (G.K.); (A.D.P.)
| | - Janna L. Morrison
- Early Origins Adult Health Research Group, Health and Biomedical Innovation, UniSA Clinical and Health Sciences, University of South Australia, Adelaide, SA 5000, Australia;
| | - Jésus Pérez-Gil
- Department of Biochemistry, Faculty of Biology and Research Institute Hospital 12 de Octubre (Imas12), Complutense University, 28003 Madrid, Spain; (C.A.); (M.E.); (J.P.-G.)
| | - Sandra Orgeig
- Mechanisms in Cell Biology and Disease Group, UniSA Clinical and Health Sciences, University of South Australia, Adelaide, SA 5000, Australia; (T.L.P.); (E.J.P.-L.)
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26
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Broomfield AA, Padidela R, Wilkinson S. Pulmonary Manifestations of Endocrine and Metabolic Diseases in Children. Pediatr Clin North Am 2021; 68:81-102. [PMID: 33228944 DOI: 10.1016/j.pcl.2020.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Advances in technology, methodology, and deep phenotyping are increasingly driving the understanding of the pathologic basis of disease. Improvements in patient identification and treatment are impacting survival. This is true in endocrinology and inborn errors of metabolism, where disease-modifying therapies are developing. Inherent to this evolution is the increasing awareness of the respiratory manifestations of these rare diseases. This review updates clinicians, stratifying diseases spirometerically; pulmonary hypertension and diseases with a predisposition to recurrent pulmonary infection are discussed. This division is artificial; many diseases have multiple pathologic effects on respiration. This review does not cover the impact of obesity.
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Affiliation(s)
- Alexander A Broomfield
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Raja Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK; Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Stuart Wilkinson
- Respiratory Department Royal Manchester Children's Hospital, Manchester University, NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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27
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Broomfield A, Sims J, Mercer J, Hensman P, Ghosh A, Tylee K, Stepien KM, Oldham A, Prathivadi Bhayankaram N, Wynn R, Wright NB, Jones SA, Wilkinson S. The evolution of pulmonary function in childhood onset Mucopolysaccharidosis type I. Mol Genet Metab 2021; 132:94-99. [PMID: 32713717 DOI: 10.1016/j.ymgme.2020.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 11/24/2022]
Abstract
Respiratory outcomes in Mucopolysaccharidosis Type I (MPS I), have mainly focused on upper airway obstruction, with the evolution of the restrictive lung disease being poorly documented. We report the long-term pulmonary function outcomes and examine the potential factors affecting these in 2 cohorts of MPS I patients, those who have undergone Haematopoietic Stem Cell Transplantation (HSCT) and those treated with Enzyme Replacement Therapy (ERT). The results were stratified using the American Thoracic Society (ATS) guidelines. 66 patients, capable of adequately performing testing, were identified by a retrospective case note review, 46 transplanted (45 Hurler, 1 Non-Hurler) and 20 having ERT (17 Non-Hurler and 3 Hurler diagnosed too late for HSCT). 5 patients died; 4 in the ERT group including the 3 Hurler patients. Overall 14% of patients required respiratory support (non-invasive ventilation (NIV) or supplemental oxygen)) at the end of follow up. Median length of follow-up was 12.2 (range = 4.9-32) years post HSCT and 14.34 (range = 3.89-20.4) years on ERT. All patients had restrictive lung disease. Cobb angle and male sex were significantly associated with more severe outcomes in the HSCT cohort, with 49% having severe to very severe disease. In the 17 Non-Hurler ERT treated patients there was no variable predictive of severity of disease with 59% having severe to very severe disease. During the course of follow up 67% of the HSCT cohort had no change or improved pulmonary function as did 52% of the ERT patients. However, direct comparison between therapeutic modalities was not possible. This initial evidence would suggest that a degree of restrictive lung disease is present in all treated paediatrically diagnosed MPS I and is still a significant cause of morbidity, though further stratification incorporating diffusing capacity for carbon monoxide (DLCO) is needed.
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Affiliation(s)
- A Broomfield
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
| | - J Sims
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - J Mercer
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - P Hensman
- Department of physiotherapy, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - A Ghosh
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - K Tylee
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - K M Stepien
- Mark Holland Metabolic Unit, Adult Inherited Metabolic Disorders, Salford Royal NHS Foundation Trust, Salford, M6 8, HD, UK
| | - A Oldham
- Mark Holland Metabolic Unit, Adult Inherited Metabolic Disorders, Salford Royal NHS Foundation Trust, Salford, M6 8, HD, UK
| | - N Prathivadi Bhayankaram
- Department of Paediatric Blood and Marrow Transplant, Royal Manchester Children's Hospital, Oxford Rd, Manchester M13 9WL, UK
| | - R Wynn
- Department of Paediatric Blood and Marrow Transplant, Royal Manchester Children's Hospital, Oxford Rd, Manchester M13 9WL, UK
| | - N B Wright
- Department of Radiology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - S A Jones
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - S Wilkinson
- Respiratory Department Royal Manchester Children's Hospital, Manchester University, NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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28
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Chazeirat T, Denamur S, Bojarski KK, Andrault PM, Sizaret D, Zhang F, Saidi A, Tardieu M, Linhardt RJ, Labarthe F, Brömme D, Samsonov SA, Lalmanach G, Lecaille F. The abnormal accumulation of heparan sulfate in patients with mucopolysaccharidosis prevents the elastolytic activity of cathepsin V. Carbohydr Polym 2020; 253:117261. [PMID: 33278943 DOI: 10.1016/j.carbpol.2020.117261] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/30/2020] [Accepted: 10/14/2020] [Indexed: 01/01/2023]
Abstract
Mucopolysaccharidosis (MPS) are rare inherited diseases characterized by accumulation of lysosomal glycosaminoglycans, including heparan sulfate (HS). Patients exhibit progressive multi-visceral dysfunction and shortened lifespan mainly due to a severe cardiac/respiratory decline. Cathepsin V (CatV) is a potent elastolytic protease implicated in extracellular matrix (ECM) remodeling. Whether CatV is inactivated by HS in lungs from MPS patients remained unknown. Herein, CatV colocalized with HS in MPS bronchial epithelial cells. HS level correlated positively with the severity of respiratory symptoms and negatively to the overall endopeptidase activity of cysteine cathepsins. HS bound tightly to CatV and impaired its activity. Withdrawal of HS by glycosidases preserved exogenous CatV activity, while addition of Surfen, a HS antagonist, restored elastolytic CatV-like activity in MPS samples. Our data suggest that the pathophysiological accumulation of HS may be deleterious for CatV-mediated ECM remodeling and for lung tissue homeostasis, thus contributing to respiratory disorders associated to MPS diseases.
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Affiliation(s)
- Thibault Chazeirat
- Université de Tours, Tours, France; INSERM, UMR 1100, Centre d'Etude des Pathologies Respiratoires (CEPR), Team "Mécanismes Protéolytiques Dans l'Inflammation", Tours, France.
| | - Sophie Denamur
- Université de Tours, Tours, France; INSERM, UMR 1100, Centre d'Etude des Pathologies Respiratoires (CEPR), Team "Mécanismes Protéolytiques Dans l'Inflammation", Tours, France; Pediatric Department, Reference Center for Inborn Errors of Metabolism ToTeM, CHRU Tours, France.
| | | | - Pierre-Marie Andrault
- Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Damien Sizaret
- Anatomical Pathology and Cytology Department, Bretonneau Hospital, CHRU Tours, France.
| | - Fuming Zhang
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA.
| | - Ahlame Saidi
- Université de Tours, Tours, France; INSERM, UMR 1100, Centre d'Etude des Pathologies Respiratoires (CEPR), Team "Mécanismes Protéolytiques Dans l'Inflammation", Tours, France.
| | - Marine Tardieu
- Pediatric Department, Reference Center for Inborn Errors of Metabolism ToTeM, CHRU Tours, France.
| | - Robert J Linhardt
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA.
| | - François Labarthe
- Pediatric Department, Reference Center for Inborn Errors of Metabolism ToTeM, CHRU Tours, France; INSERM, UMR 1069, Nutrition, Croissance et Cancer (N2C), Tours, France.
| | - Dieter Brömme
- Department of Oral Biological and Medical Sciences, University of British Columbia, Vancouver, British Columbia, Canada.
| | | | - Gilles Lalmanach
- Université de Tours, Tours, France; INSERM, UMR 1100, Centre d'Etude des Pathologies Respiratoires (CEPR), Team "Mécanismes Protéolytiques Dans l'Inflammation", Tours, France.
| | - Fabien Lecaille
- Université de Tours, Tours, France; INSERM, UMR 1100, Centre d'Etude des Pathologies Respiratoires (CEPR), Team "Mécanismes Protéolytiques Dans l'Inflammation", Tours, France.
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29
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Mohammed YM, Khan S. Advanced Techniques for Securing Airway in Mucopolysaccharidoses and the Impact of New Therapeutic Approaches. Cureus 2020; 12:e10582. [PMID: 33110718 PMCID: PMC7581216 DOI: 10.7759/cureus.10582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Airway management in patients suffering from mucopolysaccharidoses (MPS) is one of the most difficult anesthesiologic challenges. MPS is a group of rare, inherited diseases caused by the absence or malfunctioning of lysosomal enzymes needed to break down macromolecules called glycosaminoglycans (GAGs). MPS is associated with clinical symptoms and physical features, which all together contribute to the high incidence of difficulty in providing airway during surgical procedures. We used PubMed as our main database (PubMed Advanced Search Builder) to search for relevant literature. At first, we looked for the prevalence of MPS worldwide. Then, we searched for airway management complications in the MPS population using the keywords: “Mucopolysaccharidoses,” “Anesthesia complications,” and “airway management.” Another search was carried out to look for new therapeutic agents and explore their impacts on body organs. We reviewed the finalized articles to explore how anesthesiologists used different airway techniques. We discovered that video laryngoscope and I-gel aided fiber-optic intubation have been available in recent years and have been used uneventfully in several patients. We presented recommendations regarding preoperative and intraoperative preparation to avoid airway-related complications in the future. We realized that many therapy approaches had been suggested, especially after further understanding of the pathophysiology of MPS. However, more investigation needs to be conducted to determine their efficacy and explore if there is any impact on airway management.
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Affiliation(s)
- Yousef M Mohammed
- Anesthesia and Pain Management, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Medicine, Damascus University, Damascus, SYR
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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30
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Hampe CS, Eisengart JB, Lund TC, Orchard PJ, Swietlicka M, Wesley J, McIvor RS. Mucopolysaccharidosis Type I: A Review of the Natural History and Molecular Pathology. Cells 2020; 9:cells9081838. [PMID: 32764324 PMCID: PMC7463646 DOI: 10.3390/cells9081838] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 07/31/2020] [Accepted: 08/02/2020] [Indexed: 12/14/2022] Open
Abstract
Mucopolysaccharidosis type I (MPS I) is a rare autosomal recessive inherited disease, caused by deficiency of the enzyme α-L-iduronidase, resulting in accumulation of the glycosaminoglycans (GAGs) dermatan and heparan sulfate in organs and tissues. If untreated, patients with the severe phenotype die within the first decade of life. Early diagnosis is crucial to prevent the development of fatal disease manifestations, prominently cardiac and respiratory disease, as well as cognitive impairment. However, the initial symptoms are nonspecific and impede early diagnosis. This review discusses common phenotypic manifestations in the order in which they develop. Similarities and differences in the three animal models for MPS I are highlighted. Earliest symptoms, which present during the first 6 months of life, include hernias, coarse facial features, recurrent rhinitis and/or upper airway obstructions in the absence of infection, and thoracolumbar kyphosis. During the next 6 months, loss of hearing, corneal clouding, and further musculoskeletal dysplasias develop. Finally, late manifestations including lower airway obstructions and cognitive decline emerge. Cardiac symptoms are common in MPS I and can develop in infancy. The underlying pathogenesis is in the intra- and extracellular accumulation of partially degraded GAGs and infiltration of cells with enlarged lysosomes causing tissue expansion and bone deformities. These interfere with the proper arrangement of collagen fibrils, disrupt nerve fibers, and cause devastating secondary pathophysiological cascades including inflammation, oxidative stress, and other disruptions to intracellular and extracellular homeostasis. A greater understanding of the natural history of MPS I will allow early diagnosis and timely management of the disease facilitating better treatment outcomes.
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Affiliation(s)
- Christiane S. Hampe
- Immusoft Corp, Seattle, WA 98103, USA; (M.S.); (J.W.)
- Correspondence: ; Tel.: +1-206-554-9181
| | - Julie B. Eisengart
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA; (J.B.E.); (T.C.L.); (P.J.O.)
| | - Troy C. Lund
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA; (J.B.E.); (T.C.L.); (P.J.O.)
| | - Paul J. Orchard
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA; (J.B.E.); (T.C.L.); (P.J.O.)
| | | | - Jacob Wesley
- Immusoft Corp, Seattle, WA 98103, USA; (M.S.); (J.W.)
| | - R. Scott McIvor
- Immusoft Corp, Minneapolis, MN 55413, USA; or
- Department of Genetics, Cell Biology and Development and Center for Genome Engineering, University of Minnesota, Minneapolis, MN 55413, USA
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31
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Hearing Loss in Mucopolysaccharidoses: Current Knowledge and Future Directions. Diagnostics (Basel) 2020; 10:diagnostics10080554. [PMID: 32759694 PMCID: PMC7460463 DOI: 10.3390/diagnostics10080554] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/31/2020] [Accepted: 08/02/2020] [Indexed: 01/03/2023] Open
Abstract
Mucopolysaccharidoses (MPS) are a group of lysosomal storage disorders caused by a deficiency of one of the enzymes involved in the degradation of glycosaminoglycans. Hearing loss is a common clinical presentation in MPS. This paper reviews the literature on hearing loss for each of the seven recognized subtypes of MPS. Hearing loss was found to be common in MPS I, II, III, IVA, VI, and VII, and absent from MPS IVB and MPS IX. MPS VI presents primarily with conductive hearing loss, while the other subtypes (MPS I, MPS II, MPS III, MPS IVA, and MPS VII) can present with any type of hearing loss (conductive, sensorineural, or mixed hearing loss). The sensorineural component develops as the disease progresses, but there is no consensus on the etiology of the sensorineural component. Enzyme replacement therapy (ERT) is the most common therapy utilized for MPS, but the effects of ERT on hearing function have been inconclusive. This review highlights a need for more comprehensive and multidisciplinary research on hearing function that includes behavioral testing, objective testing, and temporal bone imaging. This information would allow for better understanding of the progression and etiology of hearing loss. Owing to the prevalence of hearing loss in MPS, early diagnosis of hearing loss and annual comprehensive audiological evaluations are recommended.
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Murgasova L, Jurovcik M, Jesina P, Malinova V, Bloomfield M, Zeman J, Magner M. Otorhinolaryngological manifestations in 61 patients with mucopolysaccharidosis. Int J Pediatr Otorhinolaryngol 2020; 135:110137. [PMID: 32502916 DOI: 10.1016/j.ijporl.2020.110137] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The mucopolysaccharidoses (MPS) are inherited lysosomal storage disorders with multisystemic and highly variable clinical manifestation. ENT symptoms are common and early signs of MPS. The most common ENT diagnoses are chronic/recurrent rhinosinusitis, acute otitis media, otitis media with effusion, hearing loss and airway obstruction. METHODS A single-centre retrospective chart review of 61 patients (36 M/25F) with different MPS subtypes (MPS I (n = 15), MPS II (n = 10), MPS III (n = 17), MPS IV (n = 15) and MPS VI (n = 4)) was conducted. The age of ENT presentation and frequency of ENT symptoms, surgeries and their distribution among MPS subtypes was studied. The relationship between ENT presentation, first ENT surgery and the age of diagnosis was also evaluated. RESULTS Median age at the first ENT manifestation was 2.8 years, median age at MPS diagnosis 4.1 years. The great majority of patients (90%) manifested at least one ENT diagnosis; often before the diagnosis of MPS (75%). Chronic/recurrent rhinosinusitis was the most prevalent ENT diagnosis (77%), followed by upper airway obstruction (65%) and hearing loss (53%). Chronic/recurrent rhinosinusitis was the first ENT symptom to appear (median age 2.2 years), followed by otitis media with effusion (3.7 years) and hearing loss (4.5 years). At least one ENT surgery was performed in 57% of patients; in 69% before MPS diagnosis was established. Median age of the first ENT surgery was 4.1 years. ENT symptoms and surgical procedures were earliest present in MPS II. CONCLUSIONS Our study documents high and early occurrence of various otolaryngologic symptoms in MPS and thus highlights the role of ENT specialist in prompt diagnosis of these rare diseases and their long-term management.
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Affiliation(s)
- Lenka Murgasova
- Department of Pediatrics and Adolescent Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic; Department of ENT, Motol University Hospital and Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Michal Jurovcik
- Department of ENT, Motol University Hospital and Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Pavle Jesina
- Department of Pediatrics and Adolescent Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Vera Malinova
- Department of Pediatrics and Adolescent Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Marketa Bloomfield
- Department of Immunology, Motol University Hospital and Second Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Pediatrics, Thomayer's Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jiri Zeman
- Department of Pediatrics and Adolescent Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Martin Magner
- Department of Pediatrics and Adolescent Medicine, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Pediatrics, Thomayer's Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic.
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Sawamoto K, Álvarez González JV, Piechnik M, Otero FJ, Couce ML, Suzuki Y, Tomatsu S. Mucopolysaccharidosis IVA: Diagnosis, Treatment, and Management. Int J Mol Sci 2020; 21:E1517. [PMID: 32102177 PMCID: PMC7073202 DOI: 10.3390/ijms21041517] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 02/15/2020] [Accepted: 02/19/2020] [Indexed: 12/16/2022] Open
Abstract
Mucopolysaccharidosis type IVA (MPS IVA, or Morquio syndrome type A) is an inherited metabolic lysosomal disease caused by the deficiency of the N-acetylglucosamine-6-sulfate sulfatase enzyme. The deficiency of this enzyme accumulates the specific glycosaminoglycans (GAG), keratan sulfate, and chondroitin-6-sulfate mainly in bone, cartilage, and its extracellular matrix. GAG accumulation in these lesions leads to unique skeletal dysplasia in MPS IVA patients. Clinical, radiographic, and biochemical tests are needed to complete the diagnosis of MPS IVA since some clinical characteristics in MPS IVA are overlapped with other disorders. Early and accurate diagnosis is vital to optimizing patient management, which provides a better quality of life and prolonged life-time in MPS IVA patients. Currently, enzyme replacement therapy (ERT) and hematopoietic stem cell transplantation (HSCT) are available for patients with MPS IVA. However, ERT and HSCT do not have enough impact on bone and cartilage lesions in patients with MPS IVA. Penetrating the deficient enzyme into an avascular lesion remains an unmet challenge, and several innovative therapies are under development in a preclinical study. In this review article, we comprehensively describe the current diagnosis, treatment, and management for MPS IVA. We also illustrate developing future therapies focused on the improvement of skeletal dysplasia in MPS IVA.
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Affiliation(s)
- Kazuki Sawamoto
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA; (K.S.); (J.V.Á.G.); (M.P.)
| | | | - Matthew Piechnik
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA; (K.S.); (J.V.Á.G.); (M.P.)
- University of Delaware, Newark, DE 19716, USA
| | - Francisco J. Otero
- Department of Pharmacology, Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Santiago de Compostela, 15872 Santiago de Compostela, Spain;
| | - Maria L. Couce
- Department of Forensic Sciences, Pathology, Gynecology and Obstetrics and Pediatrics Neonatology Service, Metabolic Unit, IDIS, CIBERER, MetabERN, University Clinic Hospital of Santiago de Compostela, 15706 Santiago de Compostela, Spain;
| | - Yasuyuki Suzuki
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu 501-1193, Japan;
| | - Shunji Tomatsu
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA; (K.S.); (J.V.Á.G.); (M.P.)
- University of Delaware, Newark, DE 19716, USA
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu 501-1193, Japan;
- Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA 19107, USA
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A Case Report of a Japanese Boy with Morquio A Syndrome: Effects of Enzyme Replacement Therapy Initiated at the Age of 24 Months. Int J Mol Sci 2020; 21:ijms21030989. [PMID: 32024277 PMCID: PMC7037301 DOI: 10.3390/ijms21030989] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 01/26/2020] [Accepted: 01/27/2020] [Indexed: 12/11/2022] Open
Abstract
Background: Morquio A syndrome, mucopolysaccharidosis type IVA (MPS IVA), is a lysosomal storage disorder caused by the deficient activity of N-acetylgalactosamine-6-sulfatase (GalNac6S), due to alterations in the GALNS gene. This disorder results in marked abnormalities in bones and connective tissues, and affects multiple organs. Here, we describe the clinical course of a Japanese boy with MPS IVA who began enzyme replacement therapy (ERT) at the age of 24 months. Patient: the patient presented for kyphosis treatment at 22 months of age. An X-ray examination revealed dysostosis multiplex. Uronic acids were elevated in the urine and the keratan sulfate (KS) fraction was predominant. The leukocyte GalNac6S enzyme activity was extremely low. The patient exhibited the c.463G > A (p.Gly155Arg) mutation in GALNS. Based on these findings, his disease was diagnosed as classical (severe) Morquio A syndrome. An elosulfase alfa infusion was initiated at the age of 24 months. The patient’s body height improved from −2.5 standard deviation (SD) to −2 SD and his physical activity increased during the first 9 months on ERT. However, he gradually developed paralysis in the lower legs with declining growth velocity, which required cervical decompression surgery in the second year of the ERT. The mild mitral regurgitation, serous otitis media, and mild hearing loss did not progress during treatment. Conclusion: early initiation of the elosulfase alfa to our patient showed good effects on the visceral system and muscle strength, while its effect on bones appeared limited. Careful observation is necessary to ensure timely surgical intervention for skeletal disorders associated with neurological symptoms. Centralized and multidisciplinary management is essential to improve the prognosis of pediatric patients with MPS IVA.
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Tulebayeva A, Sharipova M, Boranbayeva R. Respiratory Dysfunction in Children and Adolescents with Mucopolysaccharidosis Types I, II, IVA, and VI. Diagnostics (Basel) 2020; 10:E63. [PMID: 31991612 PMCID: PMC7168931 DOI: 10.3390/diagnostics10020063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/17/2020] [Accepted: 01/17/2020] [Indexed: 11/28/2022] Open
Abstract
Mucopolysaccharidosis (MPS) is a rare genetic disease involving active storage of glycosaminoglycans (GAGs). Accumulation of GAGs in the connective tissues of airways leads to progressive pulmonary dysfunction. Studies conducted in Taiwan revealed mainly restrictive pulmonary dysfunction, whereas the same studies in Egypt and California revealed obstructive pulmonary dysfunction. The contradictory results and lack of studies of respiratory system in patients with MPS in Asian populations are an indication to study pulmonary impairment in patients with MPS in Kazakhstan. The prospective study of respiratory system in patients with MPS was conducted in the Scientific Centre of Paediatrics and Paediatric Surgery. Patients with MPS (n = 11) were examined for respiratory function. Different types of pulmonary dysfunction were present in MPS patients, they were mainly of a restrictive pathology. One patient with MPS II had obstructive dysfunction. Enzyme replacement therapy was provided for an average duration of four years, leading to improvements in respiratory function in two patients with total normalization in one. All observed patients had respiratory dysfunction, mainly of the restrictive type. Pulmonary impairment in patients with MPS is the main reason for death. Thus, it is necessary to follow up with pulmonary function assessments in children with MPS.
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Affiliation(s)
- Assel Tulebayeva
- Children’s diseases Department, S.D. Asfendiyarov Kazakh National Medical University, Almaty A05H2A6, Kazakhstan
| | - Maira Sharipova
- General Pediatric Department, Scientific Center of Pediatrics and Pediatric Surgery, Almaty A15E2P4, Kazakhstan; (M.S.); (R.B.)
| | - Riza Boranbayeva
- General Pediatric Department, Scientific Center of Pediatrics and Pediatric Surgery, Almaty A15E2P4, Kazakhstan; (M.S.); (R.B.)
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Pires de Mello P, Lopes Barth A, de Araujo Torres D, Pires de Mello Valente M, Dain Gandelman Horovitz D. Laryngeal, Tracheal, and Bronchial Disease in the Mucopolysaccharidoses: Endoscopic Study. Diagnostics (Basel) 2020; 10:E37. [PMID: 31936731 PMCID: PMC7169448 DOI: 10.3390/diagnostics10010037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/23/2019] [Accepted: 01/03/2020] [Indexed: 12/04/2022] Open
Abstract
Mucopolysaccharidoses (MPS) are genetically determined diseases, leading to a deficiency of enzymes in the glycosaminoglycan (GAG) degradation pathway. The accumulation of GAG occurs in connective tissue in various organs and systems of the body, including the larynx, trachea, and bronchi. Respiratory symptoms are common and severe in these patients, and respiratory disease is a frequent cause of death. A cross-sectional study with flexible bronchoscopy was conducted in 30 MPS patients (6 MPS I, 8 MPS II, 2 MPS III, 3 MPS IV-A, and 11 MPS VI). Only four patients (13.33%) had a normal airway; nine (30%) had mild to moderate disease, 12 (40%) moderate to severe, and five patients (16.67%) had severe disease. Of particular interest, neuronopathic MPS II had the largest proportion of tracheostomized patients who died due to respiratory complications; in MPS IV-A, all patients had significant tracheobronchial deformity with associated tracheomalacia, despite lacking laryngeal involvement. Laryngotracheobronchial disease (LTBD) was associated to longer disease history and was significantly more severe in older patients. Longer use of enzyme replacement therapy did not prevent the progression of LTBD, although the age of therapy introduction may be a crucial factor in lower airway involvement.
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Affiliation(s)
- Paulo Pires de Mello
- Medical Genetics Department, National Institute of Women, Children, and Adolescents Health Fernandes Figueira, Oswaldo Cruz Foundation, Rio de Janeiro 22250-020, Brazil; (A.L.B.); (D.d.A.T.); (M.P.d.M.V.); (D.D.G.H.)
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Neonatal nonviral gene editing with the CRISPR/Cas9 system improves some cardiovascular, respiratory, and bone disease features of the mucopolysaccharidosis I phenotype in mice. Gene Ther 2019; 27:74-84. [PMID: 31827259 DOI: 10.1038/s41434-019-0113-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 10/09/2019] [Accepted: 11/19/2019] [Indexed: 01/02/2023]
Abstract
Mucopolysaccharidosis type I (MPS I) is caused by deficiency of alpha-L-iduronidase (IDUA), leading to multisystemic accumulation of glycosaminoglycans (GAG). Untreated MPS I patients may die in the first decades of life, mostly due to cardiovascular and respiratory complications. We previously reported that the treatment of newborn MPS I mice with intravenous administration of lipossomal CRISPR/Cas9 complexes carrying the murine Idua gene aiming at the ROSA26 locus resulted in long-lasting IDUA activity and GAG reduction in various tissues. Following this, the present study reports the effects of gene editing in cardiovascular, respiratory, bone, and neurologic functions in MPS I mice. Bone morphology, specifically the width of zygomatic and femoral bones, showed partial improvement. Although heart valves were still thickened, cardiac mass and aortic elastin breaks were reduced, with normalization of aortic diameter. Pulmonary resistance was normalized, suggesting improvement in respiratory function. In contrast, behavioral abnormalities and neuroinflammation still persisted, suggesting deterioration of the neurological functions. The set of results shows that gene editing performed in newborn animals improved some manifestations of the MPS I disorder in bone, respiratory, and cardiovascular systems. However, further studies will be imperative to find better delivery strategies to reach "hard-to-treat" tissues to ensure better systemic and neurological effects.
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Respiratory complications of metabolic disease in the paediatric population: A review of presentation, diagnosis and therapeutic options. Paediatr Respir Rev 2019; 32:55-65. [PMID: 31101546 DOI: 10.1016/j.prrv.2019.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 04/05/2019] [Indexed: 12/21/2022]
Abstract
Inborn errors of metabolism (IEMs) whilst individually rare, as a group constitute a field which is increasingly demands on pulmonologists. With the advent of new therapies such as enzyme replacement and gene therapy, early diagnosis and treatment of these conditions can impact on long term outcome, making their timely recognition and appropriate investigation increasingly important. Conversely, with improved treatment, survival of these patients is increasing, with the emergence of previously unknown respiratory phenotypes. It is thus important that pulmonologists are aware of and appropriately monitor and manage these complications. This review aims to highlight the respiratory manifestations which can occur. It isdivided into conditions resulting primarily in obstructive airway and lung disease, restrictive lung disease such as interstitial lung disease or pulmonary alveolar proteinosis and pulmonary hypertension, whilst acknowledging that some diseases have the potential to cause all three. The review focuses on general phenotypes of IEMs, their known respiratory complications and the basic metabolic investigations which should be performed where an IEM is suspected.
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Ilarslan NEÇ, Gunay F, Cobanoglu N, Karaman M, Eminoglu FT. Respiratory manifestations in inherited metabolic diseases: 6-year single-center experience. Pediatr Pulmonol 2019; 54:1190-1199. [PMID: 31115165 DOI: 10.1002/ppul.24359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 04/15/2019] [Accepted: 04/28/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES We aimed to call attention to respiratory system manifestations which occur in the course of many inherited metabolic diseases (IMD), and present as the leading cause of death. MATERIALS AND METHODS We retrospectively reviewed the diagnosis, treatment, and outcome of patients evaluated at our hospital between June 2012 and June 2018 with a diagnosis of IMD and accompanying respiratory manifestations. RESULTS A total of 50 children (29 [58%] male, 21 [42%] female) with IMD and respiratory manifestations were defined. Disorders of intracellular metabolism (n = 33, 66%) formed the majority, followed by intoxication type metabolic disorders (n = 9, 18%) and energy metabolism disorders (n = 8, 16%). The most frequent respiratory symptoms were snoring (20, 40%), tachypnea (16, 32%) and wheezing (14, 28%). Physical examination findings were signs of respiratory distress (n = 28, 56%), crackles (n = 24, 48%), thoracic deformity (n = 23, 46%), decreased breath sounds (n = 17, 34%), rhonchus (n = 17, 34%), wheezing (n = 17, 34%) and stridor (n = 10, 20%). Major respiratory manifestations were chronic airway aspiration (n = 23, 46%), upper airway obstruction (n = 23, 46%), and recurrent pneumonia (n = 18, 36%). Twenty-three 23 patients (46%) experienced endotracheal intubation, 9 patients (18%) required whole-house mechanical ventilation and tonsilloadenoidectomy was performed in 7 patients (14%). Overall survival rate was 70% (n = 35) in a median follow-up period of 2.36 (0.05-5.86) years. CONCLUSIONS Respiratory system manifestations of IMD strongly relate with increased morbidity and mortality. Therefore, prompt diagnosis and correct intervention of respiratory complications with a multidisciplinary team including pediatric metabolic diseases specialists, pulmonologists, otorhinolaryngologists, physiotherapists, and anesthesiologists are crucial to prevent progression and irreversible damage.
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Affiliation(s)
| | - Fatih Gunay
- Department of Pediatrics, Cebeci Hospital, Ankara University School of Medicine, Ankara, Turkey
| | - Nazan Cobanoglu
- Department of Pediatric Pulmonology, Cebeci Hospital, Ankara University School of Medicine, Mamak, Ankara, Turkey
| | - Merve Karaman
- Department of Pediatrics, Cebeci Hospital, Ankara University School of Medicine, Ankara, Turkey
| | - Fatma Tuba Eminoglu
- Department of Pediatric Metabolism, Cebeci Hospital, Ankara University School of Medicine, Ankara, Turkey
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Kenth JJ, Thompson G, Fullwood C, Wilkinson S, Jones S, Bruce IA. The characterisation of pulmonary function in patients with mucopolysaccharidoses IVA: A longitudinal analysis. Mol Genet Metab Rep 2019; 20:100487. [PMID: 31341787 PMCID: PMC6629586 DOI: 10.1016/j.ymgmr.2019.100487] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Indexed: 11/28/2022] Open
Abstract
Introduction Mucopolysaccharidosis (MPS) type IVA is a rare, autosomal recessive lysosomal storage disease causing substrate accumulation in various organs and tissues. MPS IVA is associated with both obstructive and restrictive airway disease, with the former often resulting in sleep disordered breathing (SDB). Respiratory failure is a primary cause of death in this condition. The aim of this study was to characterise and catalogue the long-term respiratory changes in patients with MPS IVA treated with, or without, enzyme replacement therapy (ERT). Methods In this retrospective, longitudinal, repeated-measures cohort study, descriptive statistics and non-parametric correlation were performed for demographic, respiratory function and oximetry variables over a study period from January 2009 to December 2018. Composite clinical endpoints used in this study for evaluating pulmonary function included spirometry variables (FEV1, FEV1 [%Pred] FVC, FVC [%Pred] and FEV1/FVC), oximetry variables (median %Spo2, ODI 3%, mean nadir 3%, ODI 4%, mean nadir 4% and min dip SpO2 [%]) and 6MWT to assess functional exercise capacity and thus integrated cardiopulmonary function. Results Sequential spirometry and oximetry values were collected from 16 patients, of which 13/16 were ERT treated. In general, during the study period there was a global reduction in static spirometry values in all subjects, as well as cardiorespiratory function as assessed by the 6MWT, with the decline being delayed in the ERT group. Oximetry changed to a minor degree over time in the ERT group, whereas it declined in the non-ERT group. FEV1, FVC [%predicted] and ODI 3% exhibited a strong, combined positive correlation (r 0.74–95% CI 0.61 to 0.83; p < .0001). Non-invasive ventilation (NIV) and adenotonsillectomy appeared more effective in the ERT group, either improving pulmonary function or attenuating deterioration. Conclusions Whilst spirometry values showed a gradual decline across all groups, oximetry showed modest improvement in respiratory function. The amalgamation of FEV1, FVC [%predicted] and ODI 3% appeared predictive of changes in respiratory function in this study, suggestive as being composite endpoints for monitoring disease progression as well as guiding response to ERT in MPS IVA patients.
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Key Words
- 6MWT, 6-minute walk test
- AASM, American Academy of Sleep Medicine
- ADLs, Activities of daily living
- AEs, Adverse Events
- ATS, American Thoracic Society
- BTS, British Thoracic Society
- BiPAP, Bi-level non-invasive ventilation
- C6S, Chondroitin Sulphate
- CPET, Cardiopulmonary exercises testing
- ECM, Extracellular matrix
- ERT, Enzyme replacement therapy
- Enzyme replacement therapy
- FDA, Food and Drug Administration
- FEV1 [%Pred], FEV1 as a percentage of predicted
- FEV1, Forced expiratory volume in one second
- FVC, Forced vital capacity
- FVC: [%Pred], FVC as a percentage of predicted
- GAG, Glycosaminoglycan
- GALNS, Acetylgalactosamine-6-sulfatase
- KS, Keratan sulfate
- LSD, Lysosomal storage disease.
- MPS
- MPS IVA, Mucopolysaccharidosis Type IVA
- MPS, Mucopolysaccharidosis
- Med nadir 3%, Median nadir of arterial oxygen saturations 3% from baseline
- Min dip Spo2, Minimum dips in arterial oxygen saturations [%]
- Morquio syndrome
- Mucopolysaccharidosis IVA
- ODI 3%, Oxygen desaturation index; ≥ 3% arterial oxygen desaturations per hour
- OSA, Obstructive Sleep Apnea
- Respiratory changes
- Sleep disordered breathing
- Spo2, Arterial saturations
- T&A, Adenotonsillectomy
- uKS, Urinary keratan sulfate
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Affiliation(s)
- Johnny J Kenth
- Department of Anaesthesia, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,Paediatric ENT Department, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Gabrielle Thompson
- Paediatric ENT Department, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Catherine Fullwood
- Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,Centre for Biostatistics, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Stuart Wilkinson
- Department of Paediatric Respiratory Medicine, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Simon Jones
- Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,Paediatric Inborn Errors of Metabolism, Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - I A Bruce
- Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.,Paediatric ENT Department, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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Leong HY, Abdul Azize NA, Chew HB, Keng WT, Thong MK, Mohd Khalid MKN, Hung LC, Mohamed Zainudin N, Ramlee A, Md Haniffa MA, Yakob Y, Ngu LH. Clinical, biochemical and genetic profiles of patients with mucopolysaccharidosis type IVA (Morquio A syndrome) in Malaysia: the first national natural history cohort study. Orphanet J Rare Dis 2019; 14:143. [PMID: 31200731 PMCID: PMC6570902 DOI: 10.1186/s13023-019-1105-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 05/26/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Mucopolysaccharidosis IVA (MPS IVA) is an autosomal recessive lysosomal storage disease due to N-acetylgalactosamine-6-sulfatase (GALNS) deficiency. It results in accumulation of the glycosaminoglycans, keratan sulfate and chondroitin-6-sulfate, leading to skeletal and other systemic impairments. Data on MPS IVA in Asian populations are scarce. METHODS This is a multicentre descriptive case series of 21 patients comprising all MPS IVA patients in Malaysia. Mutational analysis was performed by PCR and Sanger sequencing of the GALNS gene in 17 patients. RESULTS The patients (15 females and 6 males) had a mean age (± SD) of 15.5 (± 8.1) years. Mean age at symptom onset was 2.6 (± 2.1) years and at confirmed diagnosis was 6.9 (± 4.5) years. The study cohort included patients from all the main ethnic groups in Malaysia - 57% Malay, 29% Chinese and 14% Indian. Common presenting symptoms included pectus carinatum (57%) and genu valgum (43%). Eight patients (38%) had undergone surgery, most commonly knee surgeries (29%) and cervical spine decompression (24%). Patients had limited endurance with lower mean walking distances with increasing age. GALNS gene analysis identified 18 distinct mutations comprising 13 missense, three nonsense, one small deletion and one splice site mutation. Of these, eight were novel mutations (Tyr133Ser, Glu158Valfs*12, Gly168*, Gly168Val, Trp184*, Leu271Pro, Glu320Lys, Leu508Pro). Mutations in exons 1, 5 and 9 accounted for 51% of the mutant alleles identified. CONCLUSIONS All the MPS IVA patients in this study had clinical impairments. A better understanding of the natural history and the clinical and genetic spectrum of MPS IVA in this population may assist early diagnosis, improve management and permit timely genetic counselling and prenatal diagnosis.
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Affiliation(s)
- Huey Yin Leong
- Genetics Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
| | - Nor Azimah Abdul Azize
- Unit of Molecular Diagnostics & Protein, Institute for Medical Research, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Hui Bein Chew
- Genetics Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
| | - Wee Teik Keng
- Genetics Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
| | - Meow Keong Thong
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Mohd Khairul Nizam Mohd Khalid
- Unit of Molecular Diagnostics & Protein, Institute for Medical Research, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Liang Choo Hung
- Paediatric Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Norzila Mohamed Zainudin
- Paediatric Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Azura Ramlee
- Ophthalmology Department, Hospital Selayang, Ministry of Health Malaysia, Selayang, Malaysia
| | - Muzhirah Aisha Md Haniffa
- Genetics Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
| | - Yusnita Yakob
- Unit of Molecular Diagnostics & Protein, Institute for Medical Research, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Lock Hock Ngu
- Genetics Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
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Akyol MU, Alden TD, Amartino H, Ashworth J, Belani K, Berger KI, Borgo A, Braunlin E, Eto Y, Gold JI, Jester A, Jones SA, Karsli C, Mackenzie W, Marinho DR, McFadyen A, McGill J, Mitchell JJ, Muenzer J, Okuyama T, Orchard PJ, Stevens B, Thomas S, Walker R, Wynn R, Giugliani R, Harmatz P, Hendriksz C, Scarpa M. Recommendations for the management of MPS VI: systematic evidence- and consensus-based guidance. Orphanet J Rare Dis 2019; 14:118. [PMID: 31142378 PMCID: PMC6541999 DOI: 10.1186/s13023-019-1080-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/25/2019] [Indexed: 12/14/2022] Open
Abstract
Introduction Mucopolysaccharidosis (MPS) VI or Maroteaux-Lamy syndrome (253200) is an autosomal recessive lysosomal storage disorder caused by deficiency in N-acetylgalactosamine-4-sulfatase (arylsulfatase B). The heterogeneity and progressive nature of MPS VI necessitates a multidisciplinary team approach and there is a need for robust guidance to achieve optimal management. This programme was convened to develop evidence-based, expert-agreed recommendations for the general principles of management, routine monitoring requirements and the use of medical and surgical interventions in patients with MPS VI. Methods 26 international healthcare professionals from various disciplines, all with expertise in managing MPS VI, and three patient advocates formed the Steering Committee group (SC) and contributed to the development of this guidance. Members from six Patient Advocacy Groups (PAGs) acted as advisors and attended interviews to ensure representation of the patient perspective. A modified-Delphi methodology was used to demonstrate consensus among a wider group of healthcare professionals with expertise and experience managing patients with MPS VI and the manuscript has been evaluated against the validated Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument by three independent reviewers. Results A total of 93 guidance statements were developed covering five domains: (1) general management principles; (2) recommended routine monitoring and assessments; (3) enzyme replacement therapy (ERT) and hematopoietic stem cell transplantation (HSCT); (4) interventions to support respiratory and sleep disorders; (5) anaesthetics and surgical interventions. Consensus was reached on all statements after two rounds of voting. The greatest challenges faced by patients as relayed by consultation with PAGs were deficits in endurance, dexterity, hearing, vision and respiratory function. The overall guideline AGREE II assessment score obtained for the development of the guidance was 5.3/7 (where 1 represents the lowest quality and 7 represents the highest quality of guidance). Conclusion This manuscript provides evidence- and consensus-based recommendations for the management of patients with MPS VI and is for use by healthcare professionals that manage the holistic care of patients with the intention to improve clinical- and patient-reported outcomes and enhance patient quality of life. It is recognised that the guidance provided represents a point in time and further research is required to address current knowledge and evidence gaps. Electronic supplementary material The online version of this article (10.1186/s13023-019-1080-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Tord D Alden
- Department of Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hernan Amartino
- Child Neurology Department, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Jane Ashworth
- Department of Paediatric Ophthalmology, Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Kumar Belani
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
| | - Kenneth I Berger
- Departments of Medicine and Neuroscience and Physiology, New York University School of Medicine, André Cournand Pulmonary Physiology Laboratory, Bellevue Hospital, New York, NY, USA
| | - Andrea Borgo
- Orthopaedics Clinic, Padova University Hospital, Padova, Italy
| | - Elizabeth Braunlin
- Division of Pediatric Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Yoshikatsu Eto
- Advanced Clinical Research Centre, Institute of Neurological Disorders, Kanagawa, Japan and Department of Paediatrics/Gene Therapy, Tokyo Jikei University School of Medicine, Tokyo, Japan
| | - Jeffrey I Gold
- Keck School of Medicine, Departments of Anesthesiology, Pediatrics, and Psychiatry & Behavioural Sciences, Children's Hospital Los Angeles, Department of Anesthesiology Critical Care Medicine, 4650 Sunset Boulevard, Los Angeles, CA, USA
| | - Andrea Jester
- Hand and Upper Limb Service, Department of Plastic Surgery, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Simon A Jones
- Willink Biochemical Genetic Unit, Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Cengiz Karsli
- Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, Toronto, Canada
| | - William Mackenzie
- Department of Orthopedics, Nemours/Alfred I. Dupont Hospital for Children, Wilmington, DE, USA
| | - Diane Ruschel Marinho
- Department of Ophthalmology, UFRGS, and Ophthalmology Service, HCPA, Porto Alegre, Brazil
| | | | - Jim McGill
- Department of Metabolic Medicine, Queensland Children's Hospital, Brisbane, Australia
| | - John J Mitchell
- Division of Pediatric Endocrinology, Montreal Children's Hospital, Montreal, QC, Canada
| | - Joseph Muenzer
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Torayuki Okuyama
- Department of Clinical Laboratory Medicine, National Centre for Child Health and Development, Tokyo, Japan
| | - Paul J Orchard
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | | | | | - Robert Walker
- Department of Paediatric Anaesthesia, Royal Manchester Children's Hospital, Manchester, UK
| | - Robert Wynn
- Department of Paediatric Haematology, Royal Manchester Children's Hospital, Manchester, UK
| | - Roberto Giugliani
- Department of Genetics, UFRGS, and Medical Genetics Service, HCPA, Porto Alegre, Brazil.
| | - Paul Harmatz
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Christian Hendriksz
- Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Maurizio Scarpa
- Center for Rare Diseases at Host Schmidt Kliniken, Wiesbaden, Germany and Department of Paediatrics, University of Padova, Padova, Italy
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Li J, Zhang X, Raynald, Jiang T, Li C. Surgical consideration in Hunter syndrome: a case of hydrocephalus and a case of epidural hematoma. Childs Nerv Syst 2019; 35:889-891. [PMID: 30443672 DOI: 10.1007/s00381-018-3998-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 10/31/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Hunter syndrome (HS) is a rare X-linked lysosomal storage disorder which affects multiple organ systems. Surgical intervention and general anesthesia should be used with caution because of significant airway complications. CASE REPORT Two HS patients underwent surgery with different prognosis are presented below. In the first case, symptoms of progressive disabilities on motor function, language, intelligence, and development last for 1 year in a 6-year-old boy; magnetic resonance imaging (MRI) showed severe hydrocephalus. Third ventriculostomy was performed in this patient to relieve the hydrocephalus. Unfortunately, this patient died postoperatively due to postsurgical tracheal collapse. In the second case, an 8-year-old girl was referred to our hospital with epidural hematoma because of a falling accident. Trephination surgery was performed under local anesthesia to remove the hematoma. Three days postsurgical, the patient was discharged uneventfully. CONCLUSION General anesthesia in HS patients was associated with poor prognosis due to respiratory complications. Local anesthesia and less intensified treatment should be recommended.
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Affiliation(s)
- Jin Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Xinyan Zhang
- Emergency Department, Beijing Haidian Hospital, Beijing Haidian Section, Peking University, Beijing, 100080, China
| | - Raynald
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, 100050, China
| | - Tao Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Chunde Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.
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Molecular Pathways and Respiratory Involvement in Lysosomal Storage Diseases. Int J Mol Sci 2019; 20:ijms20020327. [PMID: 30650529 PMCID: PMC6359090 DOI: 10.3390/ijms20020327] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/10/2019] [Accepted: 01/11/2019] [Indexed: 12/25/2022] Open
Abstract
Lysosomal storage diseases (LSD) include a wide range of different disorders with variable degrees of respiratory system involvement. The purpose of this narrative review is to treat the different types of respiratory manifestations in LSD, with particular attention being paid to the main molecular pathways known so far to be involved in the pathogenesis of the disease. A literature search was conducted using the Medline/PubMed and EMBASE databases to identify studies, from 1968 through to November 2018, that investigated the respiratory manifestations and molecular pathways affected in LSD. Pulmonary involvement includes interstitial lung disease in Gaucher’s disease and Niemann-Pick disease, obstructive airway disease in Fabry disease and ventilatory disorders with chronic respiratory failure in Pompe disease due to diaphragmatic and abdominal wall muscle weakness. In mucopolysaccharidosis and mucolipidoses, respiratory symptoms usually manifest early in life and are secondary to anatomical malformations, particularly of the trachea and chest wall, and to accumulation of glycosaminoglycans in the upper and lower airways, causing, for example, obstructive sleep apnea syndrome. Although the molecular pathways involved vary, ranging from lipid to glycogen and glycosaminoglycans accumulation, some clinical manifestations and therapeutic approaches are common among diseases, suggesting that lysosomal storage and subsequent cellular toxicity are the common endpoints.
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Paget TL, Parkinson-Lawrence EJ, Orgeig S. Interstitial lung disease and surfactant dysfunction as a secondary manifestation of disease: insights from lysosomal storage disorders. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.ddmod.2019.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The mucopolysaccharidoses (MPS) are a heterogeneous group of inherited metabolic disorders, each associated with a deficiency in one of the enzymes involved in glycosaminoglycan (GAG) catabolism. Over time, GAGs accumulate in cells and tissues causing progressive damage, a variety of multi-organ clinical manifestations, and premature death. Ear, nose, and throat (ENT) disorders affect more than 90% of MPS patients and appear in the early stage of MPS; also reported are recurrent otitis media and persistent otitis media with effusion, macroglossia, adenotonsillar hypertrophy, nasal obstruction, obstructive sleep apnoea syndrome (OSAS), hearing loss, and progressive respiratory disorders. Undiagnosed MPS patients are frequently referred to otolaryngologists before the diagnosis of MPS is confirmed. Otolaryngologists thus have an early opportunity to recognize MPS and they can play an increasingly integral role in the multidisciplinary approach to the diagnosis and management of many children with MPS. The ENT commitment is therefore to suspect MPS when non-specific ENT pathologies are associated with repeated surgical treatments, unexplainable worsening of diseases despite correct treatment, and with signs, symptoms, and pathological conditions such as hepatomegaly, inguinal hernia, macrocephaly, macroglossia, coarse facial features, hydrocephalous, joint stiffness, bone deformities, valvular cardiomyopathy, carpal tunnel syndrome, and posture and visual disorders.
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Affiliation(s)
- Pier Marco Bianchi
- Surgery Department, Otorhinolaryngology Unit, Bambino Gesù Paediatric Hospital, Scientific Research Institute, P.zza S.Onofrio, 4-00165 Rome, Italy
| | - Renato Gaini
- ENT Department, S. Gerardo Hospital, Monza, Italy
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Abstract
Background Patients suffering from mucopolysaccharidosis are among the most complex from the anesthesiological point of view, especially regarding the management of the airway. The evidence base for anesthesia management is often limited to case reports and small case series. Aims To identify useful information about experience with each subtype of mucopolysaccharidosis reported in the literature and propose a guide on the best options for airway management to the anesthesiologists who take care of these patients. Methods A query of the PubMed database specific for “anesthesia” and “mucopolysaccharidosis” and a further query specific for “mucopolysaccharidosis and difficult airway management” was conducted. We looked for those items that offered practical guidance to anesthesiological management. We did not exclude case reports, especially those that reported a specific technique, because of their practical suggestions. Results We identified 15 reviews, 17 retrospective case series, 5 prospective studies, and 28 case reports that focused on airway managements in anesthesia or had practical suggestions for preoperative evaluation and risk assessment. An accurate preoperative evaluation and the need for an experienced team are emphasized in all the reviewed articles and for each type of mucopolysaccharidosis. Many suggestions on how to plan the perioperative period have been highlighted. Insertion of a laryngeal mask airway generally improves ventilation and facilitates intubation with a fiberoptic bronchoscope. Furthermore, the videolaryngoscope is very useful in making intubation easier and facilitating bronchoscope passage. Conclusions Patients with mucopolysaccharidosis are at high risk for anesthesia-related complications and require a high level of attention. However, a multidisciplinary approach, combined with expertise in the use of new techniques and new devices for airway management, makes anesthesiological management safer. Further research with prospective studies would be useful. Electronic supplementary material The online version of this article (10.1186/s13052-018-0554-1) contains supplementary material, which is available to authorized users.
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Substrate accumulation and extracellular matrix remodelling promote persistent upper airway disease in mucopolysaccharidosis patients on enzyme replacement therapy. PLoS One 2018; 13:e0203216. [PMID: 30226843 PMCID: PMC6143186 DOI: 10.1371/journal.pone.0203216] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/16/2018] [Indexed: 01/09/2023] Open
Abstract
Introduction Mucopolysaccharide diseases are a group of lysosomal storage disorders caused by deficiencies of hydrolase enzymes, leading to pathological glycosaminoglycan accumulation. A number of mucopolysaccharidosis (MPS) types are characterised by severe airway disease, the aetiology of which is poorly understood. There is ongoing evidence of significant clinical disease in the long-term despite disease modifying therapeutic strategies, including enzyme-replacement therapy (ERT). To provide a better understanding of this aspect of disease, we have characterised extracellular matrix (ECM) and inflammatory alterations in adenotonsillar tissue samples from 8 MPS patients. Methods Adenotonsillar samples from MPS I, IVA and VI ERT treated patients and from a single enzyme naïve MPS IIIA individual were compared to non-affected control samples using quantitative immunohistochemistry, qPCR and biochemical analysis. Results Significantly increased lysosomal compartment size and total sulphated glycosaminoglycan (p = 0.0007, 0.02) were identified in patient samples despite ERT. Heparan sulphate glycosaminoglycan was significantly elevated in MPS I and IIIA (p = 0.002), confirming incomplete reversal of disease. Collagen IV and laminin α-5 (p = 0.002, 0.0004) staining demonstrated increased ECM deposition within the reticular and capillary network of MPS samples. No significant change in the expression of the pro-inflammatory cytokines IL-1α, IL-6 or TNF-α was seen compared to control. Conclusion This study suggests a role for ECM remodelling contributing to the obstructive phenotype of airway disease in MPS. Current therapeutic strategies with ERT fail to normalise these pathological alterations within adenotonsillar samples. Our findings lend novel insight into the pathological cascade of events, with primarily structural rather than inflammatory changes contributing to the continuing phenotype seen in patients despite current therapeutic regimes.
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Peracha H, Sawamoto K, Averill L, Kecskemethy H, Theroux M, Thacker M, Nagao K, Pizarro C, Mackenzie W, Kobayashi H, Yamaguchi S, Suzuki Y, Orii K, Orii T, Fukao T, Tomatsu S. Molecular genetics and metabolism, special edition: Diagnosis, diagnosis and prognosis of Mucopolysaccharidosis IVA. Mol Genet Metab 2018; 125:18-37. [PMID: 29779902 PMCID: PMC6175643 DOI: 10.1016/j.ymgme.2018.05.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/09/2018] [Accepted: 05/10/2018] [Indexed: 01/03/2023]
Abstract
Mucopolysaccharidosis IVA (MPS IVA, Morquio A syndrome) is an autosomal recessive disorder caused by the deficiency of N-acetylgalactosamine-6-sulfate sulfatase. Deficiency of this enzyme leads to the accumulation of specific glycosaminoglycans (GAGs), chondroitin-6-sulfate (C6S) and keratan sulfate (KS), which are mainly synthesized in the cartilage. Therefore, the substrates are stored primarily in the cartilage and its extracellular matrix (ECM), leading to a direct impact on bone development and successive systemic skeletal spondylepiphyseal dysplasia. The skeletal-related symptoms for MPS IVA include short stature with short neck and trunk, odontoid hypoplasia, spinal cord compression, tracheal obstruction, obstructive airway, pectus carinatum, restrictive lung, kyphoscoliosis, platyspondyly, coxa valga, genu valgum, waddling gait, and laxity of joints. The degree of imbalance of growth in bone and other organs and tissues largely contributes to unique skeletal dysplasia and clinical severity. Diagnosis of MPS IVA needs clinical, radiographic, and laboratory testing to make a complete conclusion. To diagnose MPS IVA, total urinary GAG analysis which has been used is problematic since the values overlap with those in age-matched controls. Currently, urinary and blood KS and C6S, the enzyme activity of GALNS, and GALNS molecular analysis are used for diagnosis and prognosis of clinical phenotype in MPS IVA. MPS IVA can be diagnosed with unique characters although this disorder relates closely to other disorders in some characteristics. In this review article, we comprehensively describe clinical, radiographic, biochemical, and molecular diagnosis and clinical assessment tests for MPS IVA. We also compare MPS IVA to other closely related disorders to differentiate MPS IVA. Overall, imbalance of growth in MPS IVA patients underlies unique skeletal manifestations leading to a critical indicator for diagnosis.
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Affiliation(s)
- Hira Peracha
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States; Department of Biological Sciences, University of Delaware, Newark, DE, United States
| | - Kazuki Sawamoto
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States
| | - Lauren Averill
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States
| | - Heidi Kecskemethy
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States
| | - Mary Theroux
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States; Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA, United States
| | - Mihir Thacker
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States
| | - Kyoko Nagao
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States; Department of Linguistics and Cognitive Science, University of Delaware, Newark, DE, United States; College of Health Sciences, University of Delaware, Newark, DE, United States
| | - Christian Pizarro
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States
| | - William Mackenzie
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States
| | | | - Seiji Yamaguchi
- Department of Pediatrics, Shimane University, Shimane, Japan
| | - Yasuyuki Suzuki
- Medical Education Development Center, Gifu University, Japan
| | - Kenji Orii
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Tadao Orii
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Toshiyuki Fukao
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Shunji Tomatsu
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States; Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA, United States; Department of Pediatrics, Shimane University, Shimane, Japan; Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan.
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Yodoshi T, Hurt TL. Avoiding diagnostic delay for mucopolysaccharidosis IIIB: do not overlook common clues such as wheezing and otitis media. BMJ Case Rep 2018; 2018:bcr-2018-224412. [PMID: 30049674 DOI: 10.1136/bcr-2018-224412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Mucopolysaccharidosis IIIB (MPS IIIB) is an autosomal recessive lysosomal storage disorder. In comparison to Hurler syndrome (MPS I) and Hunter syndrome (MPS II), characteristic facial and physical features tend to be milder and progression of neurological symptoms may initially be slower. Obvious neurological and behavioural symptoms may not appear until age 2-6 years, but once they begin, progression is relentless, leading to death by the early 20s. Although there is currently no known cure for MPS IIIB, enzyme replacement clinical trials are showing hope for delay in the progression of symptoms. Early diagnosis is therefore necessary before neurological symptoms have progressed. In our case, MPS IIIB was diagnosed at an early age because recurrent wheezing and otitis media in conjunction with hepatomegaly were recognised as more than trivial findings. A thorough examination and a definitive proactive decision to perform a liver biopsy resulted in early diagnosis of a rare disease.
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Affiliation(s)
- Toshifumi Yodoshi
- Department of Pediatrics, Okinawa Chubu Hospital, Okinawa, Japan.,Division of Clinical Epidemiology, Jikei University Graduate School of Medicine, Tokyo, Japan
| | - Thomas L Hurt
- Department of Emergency Medicine, Mary Bridge Children's Hospital and Health Center, Tacoma, Washington, USA
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