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Rossi A, Simeoli C, Pivonello R, Salerno M, Rosano C, Brunetti B, Strisciuglio P, Colao A, Parenti G, Melis D, Derks TGJ. Endocrine involvement in hepatic glycogen storage diseases: pathophysiology and implications for care. Rev Endocr Metab Disord 2024; 25:707-725. [PMID: 38556561 PMCID: PMC11294274 DOI: 10.1007/s11154-024-09880-2] [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] [Accepted: 03/23/2024] [Indexed: 04/02/2024]
Abstract
Hepatic glycogen storage diseases constitute a group of disorders due to defects in the enzymes and transporters involved in glycogen breakdown and synthesis in the liver. Although hypoglycemia and hepatomegaly are the primary manifestations of (most of) hepatic GSDs, involvement of the endocrine system has been reported at multiple levels in individuals with hepatic GSDs. While some endocrine abnormalities (e.g., hypothalamic‑pituitary axis dysfunction in GSD I) can be direct consequence of the genetic defect itself, others (e.g., osteopenia in GSD Ib, insulin-resistance in GSD I and GSD III) may be triggered by the (dietary/medical) treatment. Being aware of the endocrine abnormalities occurring in hepatic GSDs is essential (1) to provide optimized medical care to this group of individuals and (2) to drive research aiming at understanding the disease pathophysiology. In this review, a thorough description of the endocrine manifestations in individuals with hepatic GSDs is presented, including pathophysiological and clinical implications.
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Affiliation(s)
- Alessandro Rossi
- Section of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
- Department of Translational Medicine, Section of Pediatrics, University of Naples "Federico II", Naples, Italy.
| | - Chiara Simeoli
- Dipartmento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia ed Andrologia, University of Naples "Federico II", Naples, Italy
| | - Rosario Pivonello
- Dipartmento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia ed Andrologia, University of Naples "Federico II", Naples, Italy
| | - Mariacarolina Salerno
- Department of Translational Medicine, Section of Pediatrics, University of Naples "Federico II", Naples, Italy
| | - Carmen Rosano
- Department of Translational Medicine, Section of Pediatrics, University of Naples "Federico II", Naples, Italy
| | - Barbara Brunetti
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Section of Pediatrics, University of Salerno, Baronissi, Italy
| | - Pietro Strisciuglio
- Department of Translational Medicine, Section of Pediatrics, University of Naples "Federico II", Naples, Italy
| | - Annamaria Colao
- Dipartmento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Diabetologia ed Andrologia, University of Naples "Federico II", Naples, Italy
| | - Giancarlo Parenti
- Department of Translational Medicine, Section of Pediatrics, University of Naples "Federico II", Naples, Italy
- Telethon Institute of Genetics and Medicine, Pozzuoli, Italy
| | - Daniela Melis
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Section of Pediatrics, University of Salerno, Baronissi, Italy
| | - Terry G J Derks
- Section of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Lipiński P, Tylki-Szymańska A. The Liver and Lysosomal Storage Diseases: From Pathophysiology to Clinical Presentation, Diagnostics, and Treatment. Diagnostics (Basel) 2024; 14:1299. [PMID: 38928715 PMCID: PMC11202662 DOI: 10.3390/diagnostics14121299] [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: 05/04/2024] [Revised: 06/11/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
The liver, given its role as the central metabolic organ, is involved in many inherited metabolic disorders, including lysosomal storage diseases (LSDs). The aim of this manuscript was to provide a comprehensive overview on liver involvement in LSDs, focusing on clinical manifestation and its pathomechanisms. Gaucher disease, acid sphingomyelinase deficiency, and lysosomal acid lipase deficiency were thoroughly reviewed, with hepatic manifestation being a dominant clinical phenotype. The natural history of liver disease in the above-mentioned lysosomal disorders was delineated. The importance of Niemann-Pick type C disease as a cause of cholestatic jaundice, preceding neurological manifestation, was also highlighted. Diagnostic methods and current therapeutic management of LSDs were also discussed in the context of liver involvement.
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Affiliation(s)
- Patryk Lipiński
- Institute of Clinical Sciences, Maria Skłodowska-Curie Medical Academy, 00-136 Warsaw, Poland
| | - Anna Tylki-Szymańska
- Department of Pediatrics, Nutrition and Metabolic Diseases, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland;
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Hahn JW, Lee H, Seong MW, Kang GH, Moon JS, Ko JS. Clinical and genetic spectrum of GSD type 6 in Korea. Orphanet J Rare Dis 2023; 18:132. [PMID: 37264426 DOI: 10.1186/s13023-023-02750-1] [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: 02/20/2023] [Accepted: 05/18/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Glycogen storage disease type VI (GSD VI) is a rare disease in which liver glycogen metabolism is impaired by mutations in the glycogen phosphorylase L (PYGL). This study aimed to examine the clinical features, genetic analyses, and long-term outcomes of patients with GSD VI in Korea. METHODS From January 2002 to November 2022, we retrospectively reviewed patients diagnosed with GSD VI using a gene panel at Seoul National University Hospital. We investigated the clinical profile, liver histology, molecular diagnosis, and long-term outcomes of patients with GSD VI. RESULTS Five patients were included in the study. The age at onset was 18-30 months (median, 21 months), and current age was 3.7-17 years (median, 11 years). All patients showed hepatomegaly, elevated liver transaminase activity, and hypertriglyceridaemia. Hypercholesterolaemia and fasting hypoglycaemia occurred in 60% and 40% of patients, respectively. Ten variants of PYGL were identified, of which six were novel: five missense (p.[Gly607Val], p.[Leu445Pro], p.[Gly695Glu], p.[Val828Gly], p.[Tyr158His]), and one frameshift (p.[Arg67AlafsTer34]). All patients were treated with a high-protein diet, and four also received corn starch. All patients showed improved liver function tests, hypertriglyceridaemia, hepatomegaly, and height z score. CONCLUSIONS The GSD gene panel is a useful diagnostic tool for confirming the presence of GSD VI. Genetic heterogeneity was observed in all patients with GSD VI. Increased liver enzyme levels, hypertriglyceridaemia, and height z score in patients with GSD VI improved during long-term follow-up.
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Affiliation(s)
- Jong Woo Hahn
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Gyeonggi- do, Korea
| | - Heerah Lee
- Department of Laboratory, Seoul National University College of Medicine, Seoul, Korea
| | - Moon Woo Seong
- Department of Laboratory, Seoul National University College of Medicine, Seoul, Korea
| | - Gyeong Hoon Kang
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Soo Moon
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Sung Ko
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea.
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Massese M, Tagliaferri F, Dionisi-Vici C, Maiorana A. Glycogen storage diseases with liver involvement: a literature review of GSD type 0, IV, VI, IX and XI. Orphanet J Rare Dis 2022; 17:241. [PMID: 35725468 PMCID: PMC9208159 DOI: 10.1186/s13023-022-02387-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/06/2022] [Indexed: 12/31/2022] Open
Abstract
Background Glycogen storage diseases (GSDs) with liver involvement are classified into types 0, I, III, IV, VI, IX and XI, depending on the affected enzyme. Hypoglycemia and hepatomegaly are hallmarks of disease, but muscular and renal tubular involvement, dyslipidemia and osteopenia can develop. Considering the paucity of literature available, herein we provide a narrative review of these latter forms of GSDs. Main body Diagnosis is based on clinical manifestations and laboratory test results, but molecular analysis is often necessary to distinguish the various forms, whose presentation can be similar. Compared to GSD type I and III, which are characterized by a more severe impact on metabolic and glycemic homeostasis, GSD type 0, VI, IX and XI are usually known to be responsive to the nutritional treatment for achieving a balanced metabolic homeostasis in the pediatric age. However, some patients can exhibit a more severe phenotype and an important progression of the liver and muscular disease. The effects of dietary adjustments in GSD type IV are encouraging, but data are limited. Conclusions Early diagnosis allows a good metabolic control, with improvement of quality of life and prognosis, therefore we underline the importance of building a proper knowledge among physicians about these rare conditions. Regular monitoring is necessary to restrain disease progression and complications.
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Affiliation(s)
- Miriam Massese
- Division of Metabolism, Department of Pediatric Subspecialties, Ospedale Pediatrico Bambino Gesù, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.,Center for Rare Diseases and Birth Defects, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Tagliaferri
- Division of Metabolism, Department of Pediatric Subspecialties, Ospedale Pediatrico Bambino Gesù, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.,SCDU of Pediatrics, Azienda Ospedaliero-Universitaria Maggiore Della Carità, University of Piemonte Orientale, Novara, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolism, Department of Pediatric Subspecialties, Ospedale Pediatrico Bambino Gesù, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Arianna Maiorana
- Division of Metabolism, Department of Pediatric Subspecialties, Ospedale Pediatrico Bambino Gesù, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
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Luo X, Duan Y, Fang D, Sun Y, Xiao B, Zhang H, Han L, Liang L, Gong Z, Gu X, Yu Y, Qiu W. Diagnosis and follow-up of Glycogen Storage Disease (GSD) Type VI from the largest GSD center in China. Hum Mutat 2022; 43:557-567. [PMID: 35143115 DOI: 10.1002/humu.24345] [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: 07/25/2021] [Revised: 02/03/2022] [Accepted: 02/08/2022] [Indexed: 11/10/2022]
Abstract
Glycogen storage disease (GSD) type VI is a glycogenolysis disorder caused by variants of PYGL. Knowledge about this disease is limited because only approximately 50 cases have been reported. we investigated the clinical profiles, molecular diagnosis, and treatment outcomes in patients with gsd VI from 2000 to 2021. The main initial clinical features of this cohort include hepatomegaly, short stature, elevated liver transaminases, hypertriglyceridemia, fasting hypoglycemia, and hyperuricemia. After uncooked cornstarch treatment, the stature and biochemical parameters improved significantly (P < 0.05). However, hyperuricemia recurred in most patients during adolescence. Among the 56 GSD VI patients, 54 biallelic variants and two single allelic variants of PYGL were identified, of which 43 were novel. There were two hotspot variants, c.1621-258_2178-23del and c.2467C>T p.(Gln823*), mainly in patients from Southwest and South China. c.1621-258_2178-23del is a 3.6 kb deletion that results in an out-of-frame deletion r.1621_2177del and an in-frame deletion r.1621_2265del. Our data show for the first time that long-term monitoring of uric acid is recommended for older GSD VI patients. This study also broadens the variant spectrum of PYGL and indicates that there are two hot-spot variants in China. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Xiaomei Luo
- Department of Pediatric Endocrinology and Genetics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai.,Shanghai Institute for Pediatric Research, Shanghai, China
| | - Ying Duan
- Department of Pediatric Endocrinology and Genetics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai
| | - Di Fang
- Department of Pediatric Endocrinology and Genetics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai
| | - Yu Sun
- Department of Pediatric Endocrinology and Genetics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai.,Shanghai Institute for Pediatric Research, Shanghai, China
| | - Bing Xiao
- Department of Pediatric Endocrinology and Genetics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai.,Shanghai Institute for Pediatric Research, Shanghai, China
| | - Huiwen Zhang
- Department of Pediatric Endocrinology and Genetics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai.,Shanghai Institute for Pediatric Research, Shanghai, China
| | - Lianshu Han
- Department of Pediatric Endocrinology and Genetics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai.,Shanghai Institute for Pediatric Research, Shanghai, China
| | - Lili Liang
- Department of Pediatric Endocrinology and Genetics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai.,Shanghai Institute for Pediatric Research, Shanghai, China
| | - Zhuwen Gong
- Department of Pediatric Endocrinology and Genetics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai.,Shanghai Institute for Pediatric Research, Shanghai, China
| | - Xuefan Gu
- Department of Pediatric Endocrinology and Genetics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai.,Shanghai Institute for Pediatric Research, Shanghai, China
| | - Yongguo Yu
- Department of Pediatric Endocrinology and Genetics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai.,Shanghai Institute for Pediatric Research, Shanghai, China
| | - Wenjuan Qiu
- Department of Pediatric Endocrinology and Genetics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai.,Shanghai Institute for Pediatric Research, Shanghai, China
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Grünert SC, Hannibal L, Spiekerkoetter U. The Phenotypic and Genetic Spectrum of Glycogen Storage Disease Type VI. Genes (Basel) 2021; 12:genes12081205. [PMID: 34440378 PMCID: PMC8391619 DOI: 10.3390/genes12081205] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 07/27/2021] [Accepted: 08/01/2021] [Indexed: 01/24/2023] Open
Abstract
Glycogen storage disease type VI (GSD VI) is an autosomal recessive disorder of glycogen metabolism due to mutations in the glycogen phosphorylase gene (PYGL), resulting in a deficiency of hepatic glycogen phosphorylase. We performed a systematic literature review in order to collect information on the clinical phenotypes and genotypes of all published GSD VI patients and to compare the data to those for GSD IX, a biochemically and clinically very similar disorder caused by a deficiency of phosphorylase kinase. A total of 63 genetically confirmed cases of GSD VI with clinical information were identified (median age: 5.3 years). The age at presentation ranged from 5 weeks to 38 years, with a median of 1.8 years. The main presenting symptoms were hepatomegaly and poor growth, while the most common laboratory findings at initial presentation comprised elevated activity of liver transaminases, hypertriglyceridemia, fasting hypoglycemia and postprandial hyperlactatemia. Liver biopsies (n = 37) showed an increased glycogen content in 89.2%, liver fibrosis in 32.4% and early liver cirrhosis in 10.8% of cases, respectively. No patient received a liver transplant, and one successful pregnancy was reported. Our review demonstrates that GSD VI is a disorder with broad clinical heterogeneity and a small number of patients with a severe phenotype and liver cirrhosis. Neither clinical nor laboratory findings allow for a differentiation between GSD VI and GSD IX. Early biochemical markers of disease severity or clear genotype phenotype correlations are missing. Given the overall benign and unspecific phenotype and the need for enzymatic or genetic analyses for confirmation of the diagnosis, GSD VI is likely underdiagnosed. With new treatment approaches in sight, early, pre-symptomatic diagnosis, especially with respect to hepatic cirrhosis, will become even more important.
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Affiliation(s)
- Sarah Catharina Grünert
- Department of General Paediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Centre-University of Freiburg, 79106 Freiburg, Germany;
- Correspondence: ; Tel.: +49-761-270-43000; Fax: +49-761-270-45270
| | - Luciana Hannibal
- Laboratory of Clinical Biochemistry and Metabolism, Department of General Paediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Centre-University of Freiburg, 79106 Freiburg, Germany;
| | - Ute Spiekerkoetter
- Department of General Paediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Centre-University of Freiburg, 79106 Freiburg, Germany;
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Wan J, Zhang ZC, Yang MQ, Sun XM, Yin L, Chen CQ. Minimally invasive surgery for glycogen storage disease combined with inflammatory bowel disease: A case report. World J Clin Cases 2021; 9:4342-4347. [PMID: 34141799 PMCID: PMC8173400 DOI: 10.12998/wjcc.v9.i17.4342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/22/2021] [Accepted: 03/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is rare in patients with glycogen storage disease (GSD). In GSD patients, a decrease in the number of neutrophils leads to prolonged intestinal infection, leading to the formation of chronic inflammation and eventually the development of IBD. Minimally invasive surgery for patients with IBD has been proven to reduce inflammatory responses and postoperative risks and ultimately promote rapid recovery. Herein we discuss minimally invasive surgery and the perioperative management in a patient with GSD and IBD.
CASE SUMMARY A 23-year-old male had GSD Ib associated with IBD-like disease for 10 years. Despite standard treatments, such as mesalazine, prednisone and adalimumab, the patient eventually developed colonic stenosis with incomplete ileus. After adequate assessment, the patient was treated with minimally invasive surgery and discharged in stable condition.
CONCLUSION Minimally invasive surgery for patients with IBD and GSD is safe, feasible and effective.
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Affiliation(s)
- Jian Wan
- Center for Difficult and Complicated Abdominal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Zi-Chao Zhang
- Center for Difficult and Complicated Abdominal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Mu-Qing Yang
- Center for Difficult and Complicated Abdominal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Xiao-Min Sun
- Department of Gastroenterology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Lu Yin
- Center for Difficult and Complicated Abdominal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Chun-Qiu Chen
- Center for Difficult and Complicated Abdominal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
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Grünert SC, Hannibal L, Schumann A, Rosenbaum-Fabian S, Beck-Wödl S, Haack TB, Grimmel M, Bertrand M, Spiekerkoetter U. Identification and Characterization of a Novel Splice Site Mutation Associated with Glycogen Storage Disease Type VI in Two Unrelated Turkish Families. Diagnostics (Basel) 2021; 11:diagnostics11030500. [PMID: 33809020 PMCID: PMC7998545 DOI: 10.3390/diagnostics11030500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction: Glycogen storage disease type VI (GSD VI) is a disorder of glycogen metabolism due to mutations in the PYGL gene. Patients with GSD VI usually present with hepatomegaly, recurrent hypoglycemia, and short stature. Results: We report on two non-related Turkish patients with a novel homozygous splice site variant, c.345G>A, which was shown to lead to exon 2 skipping of the PYGL-mRNA by exome and transcriptome analysis. According to an in silico analysis, deletion Arg82_Gln115del is predicted to impair protein stability and possibly AMP binding. Conclusion: GSD VI is a possibly underdiagnosed disorder, and in the era of next generation sequencing, more and more patients with variants of unknown significance in the PYGL-gene will be identified. Techniques, such as transcriptome analysis, are important tools to confirm the pathogenicity and to determine therapeutic measures based on genetic results.
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Affiliation(s)
- Sarah C. Grünert
- Department of General Paediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Centre University of Freiburg, 79106 Freiburg, Germany; (A.S.); (S.R.-F.); (U.S.)
- Correspondence: ; Tel.: +49-761-270-43000; Fax: +49-761-270-45270
| | - Luciana Hannibal
- Laboratory of Clinical Biochemistry and Metabolism, Department of General Paediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Centre-University of Freiburg, 79106 Freiburg, Germany;
| | - Anke Schumann
- Department of General Paediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Centre University of Freiburg, 79106 Freiburg, Germany; (A.S.); (S.R.-F.); (U.S.)
| | - Stefanie Rosenbaum-Fabian
- Department of General Paediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Centre University of Freiburg, 79106 Freiburg, Germany; (A.S.); (S.R.-F.); (U.S.)
| | - Stefanie Beck-Wödl
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, 72076 Tübingen, Germany; (S.B.-W.); (T.B.H.); (M.G.); (M.B.)
| | - Tobias B. Haack
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, 72076 Tübingen, Germany; (S.B.-W.); (T.B.H.); (M.G.); (M.B.)
- Center for Rare Diseases, University of Tübingen, 72076 Tübingen, Germany
| | - Mona Grimmel
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, 72076 Tübingen, Germany; (S.B.-W.); (T.B.H.); (M.G.); (M.B.)
| | - Miriam Bertrand
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, 72076 Tübingen, Germany; (S.B.-W.); (T.B.H.); (M.G.); (M.B.)
| | - Ute Spiekerkoetter
- Department of General Paediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Centre University of Freiburg, 79106 Freiburg, Germany; (A.S.); (S.R.-F.); (U.S.)
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