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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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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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Sharma K, Cummock J, Maertens P. Acute Arterial Ischemic Stroke in a Treated Child with Hunter's Syndrome: A Case Report and Review of the Literature. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0040-1722211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractEnzyme replacement therapy (ERT) has limited therapeutic effects on neurologic, skeletal, and cardiovascular pathophysiology. We report an acute right-sided flaccid hemiparesis in an 11-year-old boy with the severe neuronopathic phenotype of Hunter's syndrome who was receiving weekly idursulfase ERT. Due to his psychomotor regression and epilepsy, his presentation to the hospital was delayed. Computed tomography scan of brain showed no acute changes or hemorrhage. Stroke code was not called as patient was already outside of the time window for tissue plasminogen activator (tPA) therapy. Brain magnetic resonance imaging (MRI) showed diffuse cortical and deep atrophy consistent with his baseline neurological status and restricted diffusion in the territory of the left-middle cerebral artery (MCA) consistent with recent infarction. T1-weighted MRI revealed low signal intensity of the left insular cortex, as well as volume loss, consistent with previous undiagnosed stroke in the same vascular territory. In addition, MR angiogram (MRA) demonstrated left terminal M1 segment MCA occlusion. Echocardiogram showed aortic root dilation and moderate aortic valve insufficiency. Patient was also noted to have bacteremia related to port infection. ERT is limited by blood–brain barrier and the underlying glycosaminoglycans (GAGs) extracellular tissue accumulation which produces a proinflammatory state. GAG and bacterial lipopolysaccharide (LPS) are known to activate toll-like receptor 4 (TLR-4). GAGs released in the extracellular space of intracranial vessels induce inflammation by activating the TLR-4 pathway which is exacerbated by bacterial LPS contributing to focal arteritis. Our case suggests the importance of GAGs in the activation of the TLR-4 pathway as a cause of stroke in Hunter's syndrome.
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Affiliation(s)
- Kamal Sharma
- Division of Pediatric Critical Care, Department of Pediatrics, University of South Alabama College of Medicine, Alabama, United States
| | - Joshua Cummock
- Department of Pediatrics, University of South Alabama College of Medicine, Alabama, United States
| | - Paul Maertens
- Department of Neurology, University of South Alabama College of Medicine, Alabama, United States
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Rintz E, Gaffke L, Podlacha M, Brokowska J, Cyske Z, Węgrzyn G, Pierzynowska K. Transcriptomic Changes Related to Cellular Processes with Particular Emphasis on Cell Activation in Lysosomal Storage Diseases from the Group of Mucopolysaccharidoses. Int J Mol Sci 2020; 21:ijms21093194. [PMID: 32366041 PMCID: PMC7246638 DOI: 10.3390/ijms21093194] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 12/13/2022] Open
Abstract
Although mucopolysaccharidoses (MPS), inherited metabolic diseases from the group of lysosomal storage diseases (LSD), are monogenic disorders, recent studies indicated that their molecular mechanisms are complicated. Storage of glycosaminoglycans (GAGs), arising from a deficiency in one of the enzymes involved in the degradation of these compounds, is the primary cause of each MPS type. However, dysfunctions of various cellular organelles and disturbance of cellular processes have been reported which contribute considerably to pathomechanisms of the disease. Here, we present a complex transcriptomic analysis in which all types and subtypes of MPS were investigated, with special emphasis on genes related to cell activation processes. Complex changes in expression of these genes were found in fibroblasts of all MPS types, with number of transcripts revealing higher or lower levels (relative to control fibroblasts) between 19 and over 50, depending on MPS type. Genes in which expression was significantly affected in most MPS types code for proteins involved in following processes, classified according to Gene Ontology knowledge database: cell activation, cell growth, cell recognition, and cell division. Levels of some transcripts (including CD9, CLU, MME and others) were especially significantly changed (over five times relative to controls). Our results are discussed in the light of molecular pathomechanisms of MPS, indicating that secondary and/or tertiary changes, relative to GAG storage, might significantly modulate cellular dysfunctions and contribute to molecular mechanisms of the disease. This may influence the efficacy of various therapies and suggests why various treatments are not fully effective in improving the complex symptoms of MPS.
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