[Type I Gaucher's disease. Report of 2 affected families].

Gaucher's disease (GD) is the most common lisosomic deposit disorders which is caused by an inherited deficit of the glucocerebrosidase enzyme. The most common for in the adult is type I and the clinical manifestations include liver and spleen enlargement, thrombocytopenia, and skeletal changes. Four patients with GD type I are here reported. They belonged to two different families and these underwent enzyme and genetic investigations. Eight healthy carriers were identified and the genetic counsel was given. The most relevant clinical manifestations included liver and spleen enlargement (3/4), thrombocytopenia (3/4), skeletal changes (2/4) and pulmonary involvement (1/4). Diagnosis was achieved by the demonstration of a decrease in the leukocyte enzymatic activity in the four patients. The mutation observed most frequently (66%) was N370S. The patient with pulmonary involvement has been under substitutive enzyme therapy for 9 months by means of alglucerase infusions (placental derivative of glucocerebrosidase), and an improvement in pulmonary function testing has been observed.

    Gaucher's disease (GD)
    DIAGNOSIS

 is the most common

    lisosomic deposit disorders
    DIAGNOSIS

 which is caused by an

    inherited deficit of the glucocerebrosidase enzyme
    GENETICS

. The most common for in the

    adult
    AGE

 is

    type I
    DIAGNOSIS

 and the clinical manifestations include

    liver and spleen enlargement
    SYMPTOMS

,

    thrombocytopenia
    BIOCHEMICAL

, and

    skeletal changes
    SYMPTOMS

. Four patients with

    GD type I
    DIAGNOSIS

 are here reported. They belonged to two different families and these underwent

    enzyme and genetic investigations
    PARACLINICAL

. Eight healthy carriers were identified and the

    genetic counsel
    MEDICATION

 was given. The most relevant clinical manifestations included

    liver and spleen enlargement
    SYMPTOMS

 (3/4),

    thrombocytopenia
    BIOCHEMICAL

 (3/4),

    skeletal changes
    SYMPTOMS

 (2/4) and

    pulmonary involvement
    SYMPTOMS

 (1/4). Diagnosis was achieved by the demonstration of a

    decrease in the leukocyte enzymatic activity
    BIOCHEMICAL

 in the four patients. The mutation observed most frequently (66%) was N370S. The patient with

    pulmonary involvement
    SYMPTOMS

 has been

    under substitutive enzyme therapy for 9 months
    MEDICATION

    by means of alglucerase infusions (placental derivative of glucocerebrosidase)
    MEDICATION

, and an

    improvement in pulmonary function testing
    SYMPTOMS

 has been observed.

Gaucher's disease (GD)
lisosomic deposit disorders
type I
GD type I


[Enzyme therapy in children with severe forms of Gaucher's disease].

The enzyme therapy with Ceredase in patients with Gaucher's disease is at present probably the most expensive treatment in the whole world. One-year treatment of an adult patient with Gaucher's disease costs more than 7 million crowns. Indications for treatment in individual patients as well as financial provisions are so far problematic in the Czech Republic. From a total of 28 patients of varying age with Gaucher's disease diagnosed by the authors Ceredase was administered to two boys with a severe course of the disease. Within one year of treatment the health status of both children improved, growth became normal, the spleen diminished in size by 20-35%, haematological manifestations of hypersplenism are receding, there was a 32-46% decline of the activity of serum chitotriosidase and biochemical parameters of the disease improved.

The

    enzyme therapy with Ceredase
    MEDICATION

 in patients with

    Gaucher's disease
    DIAGNOSIS

 is at present probably the most expensive treatment in the whole world.

    One-year treatment
    MEDICATION

 of an

    adult
    AGE

 patient with

    Gaucher's disease
    DIAGNOSIS

 costs more than 7 million

    crowns
    MEDICATION

. Indications for treatment in individual patients as well as financial provisions are so far problematic in the

    Czech Republic
    ETHNICITY

. From a total of 28 patients of

    varying age
    AGE

 with

    Gaucher's disease
    DIAGNOSIS

 diagnosed by the authors

    Ceredase
    MEDICATION

 was administered to two

    boys
    GENDER

 with a

    severe course of the disease
    DIAGNOSIS

. Within one year of treatment the

    health status of
    SYMPTOMS

 both

    children
    AGE

    improved
    SYMPTOMS

,

    growth became normal
    SYMPTOMS

,

    the spleen diminished in size by 20-35%
    SYMPTOMS

,

    haematological manifestations of hypersplenism are receding
    BIOCHEMICAL

,

    there was a 32-46% decline of the activity of serum chitotriosidase
    BIOCHEMICAL

 and

    biochemical parameters of the disease improved
    BIOCHEMICAL

.

enzyme therapy with Ceredase
One-year treatment
crowns
Ceredase

Gaucher's disease
Gaucher's disease
Gaucher's disease
severe course of the disease

health status of
improved
growth became normal
the spleen diminished in size by 20-35%


Novel insertion mutation in a non-Jewish Caucasian type 1 Gaucher disease patient.

Gaucher disease is the most prevalent lysosomal storage disorder. It is autosomalrecessive, resulting in lysosomal glucocerebrosidase deficiency. Three clinical forms of Gaucher disease have been described: type 1 (nonneuronopathic), type 2 (acute neuronopathic), and type 3 (subacute neuronopathic). We performed PCR-thermal cycle sequence analysis of glucocerebrosidase genomic DNA and identified a novel mutation in a non-Jewish type 1 Gaucher disease patient. It is a C insertion in exon 3 at cDNA nucleotide position 122 and genomic nucleotide position 1626. This mutation causes a frameshift and, subsequently, four of the five codons immediately downstream of the insertion were changed while the sixth was converted to a stop codon, resulting in premature termination of protein translation. The 122CC insertion abolishes a Cac81 restriction endonuclease cleavage site, allowing a convenient and reliable method for detection using RFLP analysis of PCR-amplified glucocerebrosidase genomic DNA. The mutation in the other Gaucher allele was found to be an A-->G substitution at glucocerebrosidase cDNA nucleotide position 1226 that so far has only been reported among type 1 Gaucher disease patients. Since mutation 122CC causes a frameshift and early termination of protein translation, it most likely results in a meaningless transcript and subsequently no residual glucocerebrosidase enzyme activity. We speculate that mutation 122CC may result in a worse prognosis than mutations associated with partial activity. When present in the homozygous form, it could be a lethal allele similar to what has been postulated for the other known insertion mutation, 84GG. Our patient, who is a compound heterozygote 122CC/1226G, has moderately severe type 1 Gaucher disease. Her clinical response to Ceredase therapy that began 31 months ago has been favorable, though incomplete.

    Gaucher disease
    DIAGNOSIS

 is the most prevalent

    lysosomal storage disorder
    DIAGNOSIS

. It is

    autosomalrecessive
    GENETICS

, resulting in

    lysosomal glucocerebrosidase deficiency
    BIOCHEMICAL

. Three clinical forms of

    Gaucher disease
    DIAGNOSIS

 have been described:

    type 1 (nonneuronopathic)
    DIAGNOSIS

,

    type 2 (acute neuronopathic)
    DIAGNOSIS

, and

    type 3 (subacute neuronopathic)
    DIAGNOSIS

. We performed

    PCR-thermal cycle sequence analysis of glucocerebrosidase genomic DNA
    PARACLINICAL

 and identified a

    novel mutation
    GENETICS

 in a

    non-Jewish
    ETHNICITY

    type 1 Gaucher disease
    DIAGNOSIS

 patient. It

    is a C insertion in exon 3 at cDNA nucleotide position 122 and genomic nucleotide position 1626
    GENETICS

. This

    mutation causes a frameshift and, subsequently, four of the five codons immediately downstream of the insertion were changed while the sixth was converted to a stop codon
    GENETICS

, resulting in

    premature termination of protein translation
    GENETICS

. The

    122CC insertion abolishes a Cac81 restriction endonuclease cleavage site
    GENETICS

, allowing a convenient and reliable method for detection using

    RFLP analysis of PCR-amplified glucocerebrosidase genomic DNA
    PARACLINICAL

. The

    mutation in the other Gaucher allele was found to be an A-->G substitution at glucocerebrosidase cDNA nucleotide position 1226
    GENETICS

 that so far has only been reported among

    type 1 Gaucher disease
    DIAGNOSIS

 patients. Since

    mutation 122CC causes a frameshift and early termination of protein translation
    GENETICS

, it most likely results in a

    meaningless transcript
    GENETICS

 and subsequently

    no residual glucocerebrosidase enzyme activity
    NEG_FINDINGS

. We speculate that

    mutation 122CC
    GENETICS

 may result in a worse prognosis than mutations associated with

    partial activity
    BIOCHEMICAL

. When

    present in the homozygous form
    GENETICS

, it could be a

    lethal allele
    GENETICS

 similar to what has been postulated for the other known

    insertion mutation, 84GG
    GENETICS

. Our patient, who is a

    compound heterozygote 122CC/1226G
    GENETICS

, has

    moderately severe type 1 Gaucher disease
    DIAGNOSIS

.

    Her
    GENDER

 clinical response to

    Ceredase therapy
    MEDICATION

 that began 31 months ago has been favorable, though incomplete.

lysosomal glucocerebrosidase deficiency
partial activity


Pulmonary involvement in adult Gaucher's disease: high resolution CT appearance.

High resolution CT findings of pulmonary involvement are described in a patient with adult type Gaucher's disease. Although the reticular pattern on the chest radiograph was typical, appearance of pulmonary involvement on high resolution CT has not been demonstrated in the literature. High resolution CT demonstrated interlobular septal and intralobular interstitial thickening, irregular interfaces at the pleural surfaces and ground-glass appearance, corresponding to both the alveolar and the interstitial components of the pulmonary involvement.

    High resolution CT
    PARACLINICAL

 findings of

    pulmonary involvement
    SYMPTOMS

 are described in a patient with

    adult type Gaucher's disease
    DIAGNOSIS

. Although the

    reticular pattern on the chest radiograph
    SYMPTOMS

 was typical, appearance of

    pulmonary involvement
    SYMPTOMS

 on

    high resolution CT
    PARACLINICAL

 has not been demonstrated in the literature.

    High resolution CT
    PARACLINICAL

 demonstrated

    interlobular septal and intralobular interstitial thickening
    SYMPTOMS

,

    irregular interfaces at the pleural surfaces
    SYMPTOMS

 and

    ground-glass appearance, corresponding to both the alveolar and the interstitial components of the pulmonary involvement
    SYMPTOMS

.


Pseudo-Gaucher's cells in association with common acute lymphoblastic leukemia.

Gaucher-like cells were found in the bone marrow and liver of an Omani teenager who had common acute lymphoblastic leukemia (cALL) confirmed on peripheral blood analysis by the presence of CD10 antigen. Leukocytic or fibroblastic beta-glucocerebrosidase enzyme activity was not measured, but other biochemical data and features of bone marrow on electron microscopy were not indicative of genuine type 1 Gaucher's disease. To our knowledge, this is the first report of pseudo-Gaucher's cells in association with cALL.

    Gaucher-like cells were found in the bone marrow and liver
    MICROSCOPIC

 of an

    Omani
    ETHNICITY

    teenager
    AGE

 who had

    common acute lymphoblastic leukemia (cALL)
    DIAGNOSIS

 confirmed on

    peripheral blood analysis
    PARACLINICAL

 by the

    presence of CD10 antigen
    BIOCHEMICAL

.

    Leukocytic or fibroblastic beta-glucocerebrosidase enzyme activity was not measured
    NEG_FINDINGS

, but other biochemical data and features of bone marrow on

    electron microscopy
    PARACLINICAL

    were not indicative of genuine type 1 Gaucher's disease
    NEG_FINDINGS

. To our knowledge, this is the first report of

    pseudo-Gaucher's cells in association with cALL
    MICROSCOPIC

.


Dental observations in Gaucher's disease: review of the literature and two case reports with 13- and 60-year follow-ups.

Gaucher's disease is a genetically determined inborn error of metabolism in which acid beta-glucosidase or one of its cofactors is absent or diminished in macrophage cells and cause an accumulation of glucosylceramide in these cells. These Gaucher cells accumulate in the organs of the reticuloendothelial system and cause varying degrees of splenomegaly, hepatomegaly, and encroachment of the marrow cavity of bones. Dental radiographs often reveal consistent bony changes that result from this encroachment. In cases where visceral signs are not apparent, dental radiographs can detect the presence of the disease. Because therapy is available, early recognition of this disorder may reduce overall morbidity. A review of the dental radiographic changes over as many as 60 years shows the effects of oral surgery procedures on bone degeneration and regeneration. The effects of mannose lectin acid beta-glucosidase, alglucerase on bone deposition are discussed. Finally, a literature review shows that the changes in the dental radiograph of patients with Gaucher's disease are very specific. Currently, this disorder and its associated molecular genetics are a prototype for research of new treatments such as allogenic bone marrow transplantation and molecularly engineered enzymes.

    Gaucher's disease
    DIAGNOSIS

 is a

    genetically determined inborn error of metabolism
    GENETICS

 in which

    acid beta-glucosidase or one of its cofactors is absent or diminished in macrophage cells
    BIOCHEMICAL

 and cause an

    accumulation of glucosylceramide in these cells
    MICROSCOPIC

.

    These Gaucher cells accumulate in the organs of the reticuloendothelial system
    MICROSCOPIC

 and cause varying degrees of

    splenomegaly
    SYMPTOMS

,

    hepatomegaly
    SYMPTOMS

, and

    encroachment of the marrow cavity of bones
    SYMPTOMS

.

    Dental radiographs
    PARACLINICAL

 often reveal

    consistent bony changes that result from this encroachment
    SYMPTOMS

. In cases where

    visceral signs are not apparent
    NEG_FINDINGS

,

    dental radiographs
    PARACLINICAL

 can detect the presence of the disease. Because therapy is available, early recognition of this disorder may reduce overall morbidity. A review of the dental radiographic changes over as many as 60 years shows the effects of

    oral surgery procedures
    MEDICATION

 on

    bone degeneration and regeneration
    SYMPTOMS

. The effects of

    mannose lectin acid beta-glucosidase, alglucerase
    MEDICATION

 on

    bone deposition
    SYMPTOMS

 are discussed. Finally, a literature review shows that the changes in the dental radiograph of patients with

    Gaucher's disease
    DIAGNOSIS

 are very specific. Currently, this disorder and its associated

    molecular genetics
    GENETICS

 are a prototype for research of new treatments such as

    allogenic bone marrow transplantation
    MEDICATION

 and

    molecularly engineered enzymes
    MEDICATION

.


Gammopathy-related crystal-storing histiocytosis, pseudo- and pseudo-pseudo-Gaucher cells. Critical commentary and mini-review.

Commenting on a case report of dermal immunocytoma with crystal-storing histiocytes, a short review is given on the phenomena related to crystallization of monoclonal immunoglobulins within plasma cells, in the extracellular space, or within the lysosomal compartment of macrophages. Paraprotein crystallization is supported by hydrophobicity, poor solubility in the cold or at acid pH, and there are few reports on structural defects of crystal-forming myeloma proteins which are supposed to promote either their crystallization or impaired intralysosomal degradation. In the hitherto known cases of crystal histiocytosis, immunoglobulins of light chain type kappa have been exclusively involved in the process of macrophage storage. Accumulation of paraprotein-related crystals in macrophages may mimic the appearance of Gaucher cells or of the so-called pseudo-Gaucher cells seen in chronic myelogeneous leukaemia. With regard to their lightmicroscopical and ultrastructural differences to both, Gaucher cells and pseudo-Gaucher cells, paraproteinaemia-related crystal-storing macrophages may be denoted as pseudo-pseudo-Gaucher cells (PPGC). Human PPGC are similar to constitutive crystal-storing histiocytes known from inbred C57 BL-6 mice. The distribution of PPGC may be limited to the realm of a plasmacytoma or immunocytoma, but there are also cases with systemic involvement of the RES similar to Gaucher disease.

Commenting on a case report of

    dermal immunocytoma with crystal-storing histiocytes
    MICROSCOPIC

, a short review is given on the phenomena related to

    crystallization of monoclonal immunoglobulins within plasma cells, in the extracellular space, or within the lysosomal compartment of macrophages
    MICROSCOPIC

.

    Paraprotein crystallization
    MICROSCOPIC

 is supported by hydrophobicity,

    poor solubility in the cold or at acid pH
    SYMPTOMS

, and there are few reports on structural defects of

    crystal-forming myeloma proteins
    MICROSCOPIC

 which are supposed to promote either their crystallization or

    impaired intralysosomal degradation
    BIOCHEMICAL

. In the hitherto known cases of

    crystal histiocytosis
    MICROSCOPIC

,

    immunoglobulins of light chain type kappa
    BIOCHEMICAL

 have been exclusively involved in the

    process of macrophage storage
    MICROSCOPIC

.

    Accumulation of paraprotein-related crystals in macrophages
    MICROSCOPIC

 may

    mimic the appearance of Gaucher cells or of the so-called pseudo-Gaucher cells
    MICROSCOPIC

 seen in

    chronic myelogeneous leukaemia
    MICROSCOPIC

. With regard to their

    lightmicroscopical and ultrastructural differences to both, Gaucher cells and pseudo-Gaucher cells
    SYMPTOMS

,

    paraproteinaemia-related crystal-storing macrophages
    MICROSCOPIC

 may be denoted as

    pseudo-pseudo-Gaucher cells (PPGC)
    MICROSCOPIC

.

    Human PPGC
    MICROSCOPIC

 are similar to

    constitutive crystal-storing histiocytes
    MICROSCOPIC

 known from inbred C57 BL-6 mice. The distribution of

    PPGC
    MICROSCOPIC

 may be limited to the realm of a

    plasmacytoma
    DIAGNOSIS

 or

    immunocytoma
    DIAGNOSIS

, but there are also cases with

    systemic involvement of the RES
    MICROSCOPIC

 similar to

    Gaucher disease
    DIAGNOSIS

.

plasmacytoma
immunocytoma
Gaucher disease


A case of type I Gaucher disease with cardiopulmonary amyloidosis and chitotriosidase deficiency.

Severe cardiopulmonary amyloidosis developed several months after a total splenectomy in a patient with type 1 Gaucher disease and led within a year to his death at 48 years of age. The autopsy findings were dominated by extensive pulmonary and cardiac amyloid infiltration. No Gaucher cells were found in the lungs. Aside from a glucocerebrosidase deficiency the patient was also deficient in chitotriosidase, an enzyme whose activity is usually greatly increased in the serum of Gaucher patients. Analysis of mutations in the glucocerebrosidase gene revealed heterozygosity for N370S and D409H mutations. The normal amount of glucocerebrosidase was found in the spleen by Western blotting. We suggest that amyloidosis should be considered in the differential diagnosis of severe cardiopulmonary disease in Gaucher patients.

    Severe cardiopulmonary amyloidosis
    DIAGNOSIS

 developed several months after a

    total splenectomy
    MEDICATION

 in a patient with

    type 1 Gaucher disease
    DIAGNOSIS

 and led within a year to

    his
    GENDER

    death
    SYMPTOMS

 at

    48 years of age
    AGE

. The

    autopsy
    PARACLINICAL

 findings were dominated by

    extensive pulmonary and cardiac amyloid infiltration
    MICROSCOPIC

.

    No Gaucher cells were found in the lungs
    NEG_FINDINGS

. Aside from a

    glucocerebrosidase deficiency
    BIOCHEMICAL

 the patient was also

    deficient in chitotriosidase, an enzyme whose activity is usually greatly increased in the serum
    BIOCHEMICAL

 of

    Gaucher patients
    MICROSCOPIC

.

    Analysis of mutations in the glucocerebrosidase gene
    PARACLINICAL

 revealed

    heterozygosity for N370S and D409H mutations
    GENETICS

. The

    normal amount of glucocerebrosidase was found in the spleen
    NEG_FINDINGS

 by

    Western blotting
    PARACLINICAL

. We suggest that

    amyloidosis
    DIAGNOSIS

 should be considered in the

    differential diagnosis
    PARACLINICAL

 of

    severe cardiopulmonary disease
    DIAGNOSIS

 in

    Gaucher
    DIAGNOSIS

 patients.

Severe cardiopulmonary amyloidosis
type 1 Gaucher disease
amyloidosis
severe cardiopulmonary disease
Gaucher


Clinical and enzyme studies in Gaucher disease.

To study the clinical and biochemical spectrum of Gaucher disease.

Assay of beta glucosidase enzyme in leucocytes in patients with splenomegaly, and in chorionic villi for prenatal diagnosis.

Hospital-based.

Of 13 cases of Gaucher disease, aged 1-6 years, 9 were identified at Delhi and 4 at Bombay.

The enzyme beta-glucosidase was 0.65 nmol/h/mg of protein or less in all the cases in Delhi, and 2.5 nmol/h/mg of protein or less in Bombay. All cases except one belonged to type 1 (hepatosplenomegaly), while one case was of type 2 (neuronopathic). Prenatal diagnosis was carried out in one family and the fetus was found to be affected.

In children with hepatosplenomegaly and increased acid phosphatase, assay of beta-glucosidase enzyme confirms the diagnosis of Gaucher disease. Diagnosis of the disease is important because enzyme replacement therapy is available and prenatal diagnosis is possible.

To study the clinical and biochemical spectrum of

    Gaucher disease
    DIAGNOSIS

.

    Assay of beta glucosidase enzyme in leucocytes
    BIOCHEMICAL

 in patients with

    splenomegaly
    BIOCHEMICAL

, and in

    chorionic villi
    PARACLINICAL

 for

    prenatal diagnosis
    PARACLINICAL

.

Of 13 cases of

    Gaucher disease
    DIAGNOSIS

,

    aged 1-6 years
    AGE

, 9 were identified at

    Delhi
    ETHNICITY

 and 4 at

    Bombay
    ETHNICITY

.

    The enzyme beta-glucosidase was 0.65 nmol/h/mg of protein or less
    BIOCHEMICAL

 in all the cases in

    Delhi
    ETHNICITY

, and

    2.5 nmol/h/mg of protein or less
    BIOCHEMICAL

 in

    Bombay
    ETHNICITY

. All cases except one belonged to

    type 1
    DIAGNOSIS

 (

    hepatosplenomegaly
    SYMPTOMS

    )
    DIAGNOSIS

, while one case was of

    type 2 (neuronopathic)
    DIAGNOSIS

.

    Prenatal diagnosis
    PARACLINICAL

 was carried out in one family and

    the fetus was found to be affected
    FAMILY

.

In

    children
    AGE

 with

    hepatosplenomegaly
    SYMPTOMS

 and

    increased acid phosphatase
    BIOCHEMICAL

,

    assay of beta-glucosidase enzyme
    PARACLINICAL

 confirms the diagnosis of

    Gaucher disease
    DIAGNOSIS

. Diagnosis of the disease is important because

    enzyme replacement therapy
    MEDICATION

 is available and

    prenatal diagnosis
    AGE

 is possible.

Gaucher disease
Gaucher disease
type 1
)
type 2 (neuronopathic)
Gaucher disease


Gaucher's disease in pregnancy.

Gaucher's disease is an autosomal recessive lysosomal storage disease, resulting from a deficiency of the enzyme glucocerebrosidase, important for the physiologic recycling of cell membrane lipids. The clinical symptoms and disease presentations of Gaucher's disease are heterogeneous, including hepatosplenomegaly, bone "crisis" and fracture, anemia, thrombocytopenia and in some forms, rapid neurological decompensation. Similarly, the genetic variability of Gaucher's disease is diverse, and in some aspects affects phenotypic expression. Type 1 Gaucher's disease, however, usually present with less severe symptoms, at more advanced age, and is particularly amenable to enzyme replacement therapy with alglucerase. In type 1 patients with Gaucher's disease reproductive age is commonly reached and childbearing frequently desired with need for appropriate prenatal diagnosis, counseling and careful obstetrical surveillance. Although pregnancy concurrent with Gaucher's disease has been reported in the medical literature, only one small series of alglucerase treated Gaucher's disease during pregnancy exists. Without treatment, pregnancy concurrent with Gaucher's disease has several risks including an increased severity of anemia and thrombocytopenia that can potentiate postpartum bleeding, significant increases in organomegaly and possibly an increased spontaneous abortion rate. It is yet to be shown whether alglucerase reduces the risk of these complications during pregnancy and whether its use has any adverse effect on fetal development.

    Gaucher's disease
    DIAGNOSIS

 is an

    autosomal recessive
    GENETICS

    lysosomal storage disease
    DIAGNOSIS

, resulting from a

    deficiency of the enzyme glucocerebrosidase
    BIOCHEMICAL

, important for the

    physiologic recycling of cell membrane lipids
    BIOCHEMICAL

. The clinical symptoms and disease presentations of

    Gaucher's disease
    DIAGNOSIS

 are heterogeneous, including

    hepatosplenomegaly
    SYMPTOMS

,

    bone "crisis" and fracture
    SYMPTOMS

,

    anemia
    BIOCHEMICAL

,

    thrombocytopenia
    BIOCHEMICAL

 and in some forms,

    rapid neurological decompensation
    SYMPTOMS

. Similarly, the

    genetic variability
    GENETICS

 of

    Gaucher's disease
    DIAGNOSIS

 is diverse, and in some aspects affects phenotypic expression.

    Type 1 Gaucher's disease
    DIAGNOSIS

, however, usually present with

    less severe symptoms
    SYMPTOMS

, at more

    advanced age
    AGE

, and is particularly amenable to

    enzyme replacement therapy with alglucerase
    MEDICATION

. In

    type 1
    DIAGNOSIS

 patients with

    Gaucher's disease
    DIAGNOSIS

    reproductive age
    AGE

 is commonly reached and

    childbearing
    AGE

 frequently desired with need for appropriate

    prenatal diagnosis
    MEDICATION

,

    counseling
    MEDICATION

 and

    careful obstetrical surveillance
    PARACLINICAL

. Although

    pregnancy concurrent with Gaucher's disease
    DIAGNOSIS

 has been reported in the medical literature, only one small series of

    alglucerase treated Gaucher's disease
    MEDICATION

 during

    pregnancy
    DIAGNOSIS

 exists.

    Without treatment
    NEG_FINDINGS

,

    pregnancy concurrent with Gaucher's disease
    DIAGNOSIS

 has several risks including an

    increased severity of anemia and thrombocytopenia
    BIOCHEMICAL

 that can potentiate

    postpartum bleeding
    SYMPTOMS

,

    significant increases in organomegaly
    SYMPTOMS

 and possibly an

    increased spontaneous abortion rate
    SYMPTOMS

. It is yet to be shown whether

    alglucerase
    MEDICATION

 reduces the risk of these complications during

    pregnancy
    DIAGNOSIS

 and whether its use has any adverse effect on fetal development.

hepatosplenomegaly
bone "crisis" and fracture
rapid neurological decompensation
less severe symptoms
postpartum bleeding
significant increases in organomegaly
increased spontaneous abortion rate


Osteoblastoma of the humerus associated with type-I Gaucher's disease. A case report.

We report a unique case of juxtacortical osteoblastoma of the humeral shaft, which stimulated the appearance of an extraosseous extension of Gaucher-cell deposits. The tumour was treated successfully by curettage and bone grafting. We can find no previous report of this association between osteoblastoma and Gaucher's disease.

We report a unique case of

    juxtacortical osteoblastoma of the humeral shaft
    DIAGNOSIS

, which stimulated the appearance of an

    extraosseous extension of Gaucher-cell deposits
    MICROSCOPIC

. The tumour was treated successfully by

    curettage and bone grafting
    MEDICATION

. We can find no previous report of this

    association between osteoblastoma
    DIAGNOSIS

 and

    Gaucher's disease
    DIAGNOSIS

.


Combined hereditary disorders of haemophilia B Leyden (-6 G-->A) and type 1 von Willebrand disease.

Multiple coagulation disorders are unusual. We report here a combination of haemophilia B Leyden with type 1 von Willebrand disease (vWD) affecting different members of the same family. Haemophilia B Leyden was due to a -6 G-->A mutation within the promoter of the factor IX gene and was responsible for a mild haemophilia in the father of the proband. The proband and her sister (age 4 and 6) exhibited a twofold lower level of factor IX activity (0.4 IU/ml) than the paternal grandmother (0.95 IU/ml). The differences in F IX levels in the three carriers of the same -6 G-->A mutation suggest the implication of an age-related mechanism responsible for the increase in factor IX plasma level. Haemophilia B Leyden patient and carriers suffered also from a mild von Willebrand disease. The diagnosis of this associated type 1 vWD was performed by assaying plasma von Willebrand factor together with multimer electrophoretic studies and DDAVP test. The inheritance of this vWD was investigated by haplotype analysis of the vWF gene. Individuals affected by such an association are actually asymptomatic, but per- and post-operative bleeding risk remains to be evaluated.

    Multiple coagulation disorders
    DIAGNOSIS

 are unusual. We report here a

    combination of haemophilia B Leyden with type 1 von Willebrand disease (vWD)
    DIAGNOSIS

    affecting different members of the same family
    FAMILY

.

    Haemophilia B Leyden
    DIAGNOSIS

 was due to

    a -6 G-->A mutation within the promoter of the factor IX gene
    GENETICS

 and was responsible for

    a mild haemophilia in the father of the proband
    FAMILY

. The

    proband and her sister (age 4 and 6) exhibited a twofold lower level of factor IX activity (0.4 IU/ml) than the paternal grandmother (0.95 IU/ml)
    FAMILY

. The

    differences in F IX levels
    BIOCHEMICAL

 in the three

    carriers of the same -6 G-->A mutation
    GENETICS

 suggest the implication of an age-related mechanism responsible for the

    increase in factor IX plasma level
    BIOCHEMICAL

.

    Haemophilia B Leyden
    DIAGNOSIS

 patient and carriers suffered also from a

    mild von Willebrand disease
    DIAGNOSIS

. The diagnosis of this associated

    type 1 vWD
    DIAGNOSIS

 was performed by

    assaying plasma von Willebrand factor
    PARACLINICAL

 together with

    multimer electrophoretic studies
    PARACLINICAL

 and

    DDAVP test
    PARACLINICAL

. The

    inheritance of
    GENETICS

 this

    vWD
    DIAGNOSIS

 was investigated by

    haplotype analysis of the vWF gene
    PARACLINICAL

. Individuals affected by such an association are actually

    asymptomatic
    NEG_FINDINGS

, but per- and post-operative bleeding risk remains to be evaluated.

differences in F IX levels
increase in factor IX plasma level


Use of various diagnostic methods in a patient with Gaucher disease type I.

A series of plain radiographs, bone scans, bone marrow scans, and MRIs is reported in a patient with Gaucher disease type I, in whom two episodes of acute bone crisis developed during a 6-year period of follow-up. Acute bone crisis and global indolent bone marrow displacement could both be assessed by bone marrow scintigraphy, whereas MRI could better clarify the corti-comedullary alteration after bone infarction. Thus, MRI and bone marrow scintigraphy could be used as complementary imaging methods in the management of patients with Gaucher disease.

A series of

    plain radiographs
    PARACLINICAL

,

    bone scans
    PARACLINICAL

,

    bone marrow scans
    PARACLINICAL

, and

    MRIs
    PARACLINICAL

 is reported in a patient with

    Gaucher disease type I
    DIAGNOSIS

, in whom

    two episodes of acute bone crisis
    SYMPTOMS

 developed during a 6-year period of follow-up.

    Acute bone crisis
    SYMPTOMS

 and

    global indolent bone marrow displacement
    SYMPTOMS

 could both be assessed by

    bone marrow scintigraphy
    PARACLINICAL

, whereas

    MRI
    PARACLINICAL

 could better clarify the

    corti-comedullary alteration after bone infarction
    SYMPTOMS

. Thus,

    MRI
    PARACLINICAL

 and

    bone marrow scintigraphy
    PARACLINICAL

 could be used as complementary imaging methods in the management of patients with

    Gaucher disease
    DIAGNOSIS

.


Regression of skeletal changes in type 1 Gaucher disease with enzyme replacement therapy.

A 9-year-old patient presented with an acute onset of pain of the right femur showing destructive changes with periosteal elevation mimicking osteomyelitis. Technetium-99m sulfur colloid (99mTc SC) marrow scan revealed lack of uptake in the right femoral head and the entire shaft of the right femur. Eight months following enzyme replacement therapy, radiography showed almost complete reconstitution of the femoral shaft, and 99mTc SC marrow scan uptake returned to normal.

A

    9-year-old
    AGE

 patient presented with an

    acute onset of pain of the right femur showing destructive changes with periosteal elevation
    SYMPTOMS

 mimicking

    osteomyelitis
    DIAGNOSIS

.

    Technetium-99m sulfur colloid (99mTc SC) marrow scan
    PARACLINICAL

 revealed

    lack of uptake in the right femoral head and the entire shaft of the right femur
    SYMPTOMS

. Eight months following

    enzyme replacement therapy
    MEDICATION

,

    radiography
    PARACLINICAL

 showed

    almost complete reconstitution of the femoral shaft
    SYMPTOMS

, and

    99mTc SC marrow scan uptake returned to normal
    SYMPTOMS

.


Improvement of bone disease with increased dose of glucocerebrosidase in a Gaucher disease patient who had a bone lesion presenting during low-dose enzyme replacement therapy.

In recent years, enzyme replacement therapy has been shown to be useful for the treatment of Gaucher disease. A 10 year old Japanese boy with Gaucher disease underwent splenectomy at the age of 5 years and received enzyme replacement therapy from the age of 6 years. He had avascular necrosis of the bilateral femoral heads, which was not seen at the beginning of the therapy, without deterioration of hematological variables during maintenance therapy. The enzyme dosage was increased from 20 to 120 IU/kg per month resulting in an improvement of the clinical symptoms and bone lesion. In enzyme replacement therapy, dose increase is considered to be essential for improvement in bone disease; however, it is important to watch for the development of bone lesion.

In recent years,

    enzyme replacement therapy
    MEDICATION

 has been shown to be useful for the treatment of

    Gaucher disease
    DIAGNOSIS

. A

    10 year old
    AGE

    Japanese
    ETHNICITY

    boy
    GENDER

 with

    Gaucher disease
    DIAGNOSIS

 underwent

    splenectomy
    MEDICATION

 at the

    age of 5 years
    AGE

 and

    received enzyme replacement therapy from the age of 6 years
    MEDICATION

.

    He
    GENDER

 had

    avascular necrosis of the bilateral femoral heads
    SYMPTOMS

, which was

    not seen at the beginning of the therapy
    NEG_FINDINGS

,

    without deterioration of hematological variables during maintenance therapy
    NEG_FINDINGS

.

    The enzyme dosage was increased from 20 to 120 IU/kg per month
    MEDICATION

 resulting in an

    improvement of the clinical symptoms and bone lesion
    SYMPTOMS

. In

    enzyme replacement therapy
    MEDICATION

,

    dose increase
    MEDICATION

 is considered to be essential for improvement in

    bone disease
    SYMPTOMS

; however, it is important to watch for the development of

    bone lesion
    SYMPTOMS

.


Gaucher's disease and pregnancy.

A 24-year-old primigravid woman with adult type Gaucher's disease was admitted at 28 weeks of pregnancy. She was asthenic and the abdomen was markedly protuberant due to hepatosplenomegaly. A conservative approach with close monitorization of both mother and baby was planned. On the 39th week of pregnancy a healthy female baby of 3000 g was delivered via cesarean section. Apart from mild hematological complications, the pregnancy, the delivery and the puerperium were uneventful.

A

    24-year-old
    AGE

    primigravid
    DIAGNOSIS

    woman
    GENDER

 with

    adult type Gaucher's disease
    DIAGNOSIS

 was admitted at

    28 weeks of pregnancy
    MEDICATION

.

    She
    GENDER

 was

    asthenic
    SYMPTOMS

 and the

    abdomen was markedly protuberant
    SYMPTOMS

 due to

    hepatosplenomegaly
    SYMPTOMS

. A

    conservative approach
    MEDICATION

 with

    close monitorization of both mother and baby
    PARACLINICAL

 was planned. On the 39th week of

    pregnancy
    MEDICATION

 a

    healthy female baby of 3000 g was delivered via cesarean section
    MEDICATION

. Apart from

    mild hematological complications
    SYMPTOMS

, the pregnancy, the delivery and the

    puerperium
    SYMPTOMS

 were

    uneventful
    NEG_FINDINGS

.

primigravid
adult type Gaucher's disease

asthenic
abdomen was markedly protuberant
hepatosplenomegaly
mild hematological complications
puerperium


Pseudotumours of hepatic imaging.

The diagnosis of liver tumours with CT depends on differential attenuation coefficients and enhancement patterns. The sensitivity of CT in defining tumours is well established but there remain a variety of conditions that mimic these patterns, presenting a 'pseudotumour' appearance. A common illustrative example is hepatic steatosis, but less well recorded are the sphingolipidoses and intrahepatic arterioportal shunts, either post-traumatic or related to venous outflow block. Alpha-1-antitrypsin deficiency and hereditary tyrosinaemia provide examples in childhood.

The diagnosis of

    liver tumours
    DIAGNOSIS

 with

    CT
    PARACLINICAL

 depends on differential attenuation coefficients and enhancement patterns. The sensitivity of

    CT
    PARACLINICAL

 in defining

    tumours
    SYMPTOMS

 is well established but there remain a variety of conditions that mimic these patterns, presenting a '

    pseudotumour' appearance
    SYMPTOMS

. A common illustrative example is

    hepatic steatosis
    DIAGNOSIS

, but less well recorded are the

    sphingolipidoses
    DIAGNOSIS

 and

    intrahepatic arterioportal shunts
    SYMPTOMS

, either

    post-traumatic
    SYMPTOMS

 or related to

    venous outflow block
    SYMPTOMS

.

    Alpha-1-antitrypsin deficiency
    BIOCHEMICAL

 and

    hereditary tyrosinaemia
    BIOCHEMICAL

 provide examples in

    childhood
    AGE

.

liver tumours
hepatic steatosis
sphingolipidoses

tumours
pseudotumour' appearance
intrahepatic arterioportal shunts
post-traumatic
venous outflow block

Alpha-1-antitrypsin deficiency
hereditary tyrosinaemia


Two new missense mutations in a non-Jewish Caucasian family with type 3 Gaucher disease.

Gaucher disease is an autosomal recessive, lysosomal storage disease caused by a deficiency of the enzyme glucocerebrosidase. The prevalence of this disorder differs significantly among various populations and is highest in some Jewish populations. More than 35 disease-producing mutations of the gene have been reported. The change of the amino acid leucine at position 444 to proline (444Leu-->Pro) is the most common mutation in non-Jewish populations, and a second mutation at amino acid 370 (370Asn-->Ser) is the most common one in Jewish populations. However, most of the mutations have been reported in very few cases or even in only one pedigree. We performed a direct DNA sequencing analysis of the complete functional glucocerebrosidase gene in a 22-year-old neuronopathic non-Jewish patient with Gaucher disease type 3 with myoclonic epilepsy and slight mental disturbances and in most members of his family. After selective amplification of the complete coding region of the patient's functional glucocerebrosidase gene, we identified two hitherto unreported mutations in exon 9 (genomic nucleotide 5224G-->C; 417Val-->Leu) and in exon 11 (genomic nucleotide 6668C-->T; 510Thr-->Ile). Each parent showed one of these mutations. Once we sequenced the complete active gene, we could rule out the existence of further mutations. Data that show that in about 15 to 25% of non-Jewish patients with Gaucher disease no mutations within the glucocerebrosidase gene are found may be due to inappropriate screening methods, mostly used for the genotyping. Until we have precise information about the frequency and distribution of single-point mutations in patients with Gaucher disease, it is necessary to analyze the complete glucocerebrosidase gene.

    Gaucher disease
    DIAGNOSIS

 is an

    autosomal recessive
    GENETICS

,

    lysosomal storage disease
    DIAGNOSIS

 caused by a

    deficiency of the enzyme glucocerebrosidase
    BIOCHEMICAL

. The prevalence of this disorder differs significantly among various populations and is highest in some

    Jewish
    ETHNICITY

 populations. More than 35

    disease-producing mutations of the gene
    GENETICS

 have been reported. The

    change of the amino acid leucine at position 444 to proline (444Leu-->Pro)
    GENETICS

 is the most common mutation in

    non-Jewish populations
    ETHNICITY

, and a

    second mutation at amino acid 370 (370Asn-->Ser)
    GENETICS

 is the most common one in

    Jewish
    ETHNICITY

 populations. However, most of the mutations have been reported in very few cases or even in only one pedigree. We performed a

    direct DNA sequencing analysis of the complete functional glucocerebrosidase gene
    PARACLINICAL

 in a

    22-year-old
    AGE

    neuronopathic
    DIAGNOSIS

    non-Jewish
    ETHNICITY

 patient with

    Gaucher disease type 3
    DIAGNOSIS

 with

    myoclonic epilepsy
    SYMPTOMS

 and

    slight mental disturbances
    SYMPTOMS

 and

    in most members of his family
    FAMILY

. After

    selective amplification of the complete coding region of the patient's functional glucocerebrosidase gene
    PARACLINICAL

, we identified

    two hitherto unreported mutations in exon 9 (genomic nucleotide 5224G-->C; 417Val-->Leu) and in exon 11 (genomic nucleotide 6668C-->T; 510Thr-->Ile)
    GENETICS

.

    Each parent showed one of these mutations
    FAMILY

. Once we

    sequenced the complete active gene
    PARACLINICAL

, we could rule out the existence of further mutations. Data that show that in about 15 to 25% of

    non-Jewish
    ETHNICITY

 patients with

    Gaucher disease
    DIAGNOSIS

    no mutations within the glucocerebrosidase gene are found
    NEG_FINDINGS

 may be due to inappropriate screening methods, mostly used for the genotyping. Until we have precise information about the frequency and distribution of

    single-point mutations
    GENETICS

 in patients with

    Gaucher disease
    DIAGNOSIS

, it is necessary to

    analyze the complete glucocerebrosidase gene
    PARACLINICAL

.

Gaucher disease
lysosomal storage disease
neuronopathic
Gaucher disease type 3
Gaucher disease
Gaucher disease

Jewish
non-Jewish populations
Jewish
non-Jewish
non-Jewish

myoclonic epilepsy
slight mental disturbances


Genotype D399N/R463C in a patient with type 3 Gaucher disease previously assigned genotype N370S/R463C.

A patient with type 3 Gaucher disease is described with a novel genotype, D399N/R463C, established by DNA sequencing. This patient was previously reported as having genotype N370S/R463C. This communication now establishes that no patients reported with mutation N370S have the neuronopathic forms of Gaucher disease and has important implications for genetic counseling.

A patient with

    type 3 Gaucher disease
    DIAGNOSIS

 is described with a

    novel genotype, D399N/R463C
    GENETICS

, established by

    DNA sequencing
    PARACLINICAL

. This patient was previously reported as having genotype N370S/R463C. This communication now establishes that no patients reported with

    mutation N370S
    GENETICS

 have the

    neuronopathic forms of Gaucher disease
    DIAGNOSIS

 and has important implications for

    genetic counseling
    MEDICATION

.

type 3 Gaucher disease
neuronopathic forms of Gaucher disease

novel genotype, D399N/R463C
mutation N370S


Scintigraphic findings on 99mTc-MDP, 99mTc-sestamibi and 99mTc-HMPAO images in Gaucher's disease.

Gaucher s disease is an autosomal recessive lysosomal storage disease characterized by the specific deficiency of glucocerebrosidase that leads to accumulation of insoluble glucocerebroside in the reticuloendothelial system, particularly the bone marrow, liver, spleen and lymph nodes. Direct scintigraphic visualization of lipid deposits in Gaucher s disease has recently been described, based on the use of the lipid-soluble xenon-133. We report here on the use of the lipophilic cationic complex technetium-99m sestamibi (99mTc-MIBI), employed as an indicator of increased cellular density and metabolic activity, to evaluate Gaucher cell infiltrates in the bone marrow; 99mTc-hexametazime (99mTc-HMPAO) was also employed, as a pure indicator of lipidic infiltration in the bone marrow. A 67-year-old patient with known type 1 Gaucher s disease presented with a painful left hip and knee and difficulty in gait subsequent to traumatic fracture of the left femoral neck that had required implant of a fixation screw-plaque. Bone scan with 99mTc-methylene diphosphonate revealed reduced uptake at the distal metaphyseal-epiphyseal femoral region. In addition, whole-body maps and spot-view acquisitions of the thighs and legs were recorded at both 30 min and 2.5 h after the injection of 99mTc-MIBI: the scintigraphic pattern clearly showed increased uptake at several sites involved by Gaucher deposits in the bone marrow (both knees, with variable intensity in different areas), matching the bone changes detected by conventional x-ray. The target to non-target ratios slowly decreased with time, from an average value of 2.25 in the early scan to an average value of 2 in the delayed scan. The lipid-soluble agent 99mTc-HMPAO exhibited a superimposable scintigraphic pattern of accumulation at the involved sites, though with lower target to non-target ratios (1.27-1.48). The results obtained in this patient suggest a potential role of 99mTc-MIBI in the scintigraphic evaluation of Gaucher s lipid deposits in the bone marrow. If the results are confirmed in other patients, this radiopharmaceutical would offer clear advantages over 133Xe because of its wider availability and greater practicality (i.v. administration of 99mTc-MIBI versus inhalation of 133Xe, and use of a single gamma camera instead of two as with 133Xe).

    Gaucher s disease
    DIAGNOSIS

 is an

    autosomal recessive
    GENETICS

    lysosomal storage disease
    DIAGNOSIS

 characterized by the specific

    deficiency of glucocerebrosidase
    BIOCHEMICAL

 that leads to

    accumulation of insoluble glucocerebroside in the reticuloendothelial system, particularly the bone marrow, liver, spleen and lymph nodes
    MICROSCOPIC

.

    Direct scintigraphic visualization of lipid deposits
    PARACLINICAL

 in

    Gaucher s disease
    DIAGNOSIS

 has recently been described, based on the use of the

    lipid-soluble xenon-133
    PARACLINICAL

. We report here on the use of the

    lipophilic cationic complex technetium-99m sestamibi (99mTc-MIBI)
    PARACLINICAL

, employed as an indicator of

    increased cellular density and metabolic activity
    MICROSCOPIC

, to evaluate

    Gaucher cell infiltrates in the bone marrow
    MICROSCOPIC

;

    99mTc-hexametazime (99mTc-HMPAO)
    PARACLINICAL

 was also employed, as a pure indicator of

    lipidic infiltration in the bone marrow
    MICROSCOPIC

. A

    67-year-old
    AGE

 patient with known

    type 1 Gaucher s disease
    DIAGNOSIS

 presented with a

    painful left hip and knee
    SYMPTOMS

 and

    difficulty in gait
    SYMPTOMS

 subsequent to

    traumatic fracture of the left femoral neck
    SYMPTOMS

 that had required

    implant of a fixation screw-plaque
    MEDICATION

.

    Bone scan with 99mTc-methylene diphosphonate
    PARACLINICAL

 revealed

    reduced uptake at the distal metaphyseal-epiphyseal femoral region
    SYMPTOMS

. In addition,

    whole-body maps and spot-view acquisitions of the thighs and legs were recorded at both 30 min and 2.5 h after the injection of 99mTc-MIBI
    PARACLINICAL

: the

    scintigraphic pattern
    PARACLINICAL

 clearly showed

    increased uptake at several sites involved by Gaucher deposits in the bone marrow (both knees, with variable intensity in different areas)
    MICROSCOPIC

, matching the

    bone changes
    SYMPTOMS

 detected by

    conventional x-ray
    PARACLINICAL

. The target

    to non-target ratios
    SYMPTOMS

 slowly decreased with time, from an average

    value of 2.25 in the early scan
    SYMPTOMS

 to an average value of 2 in the delayed scan. The

    lipid-soluble agent 99mTc-HMPAO
    PARACLINICAL

 exhibited a

    superimposable scintigraphic pattern of accumulation at the involved sites, though with lower target to non-target ratios (1.27-1.48)
    SYMPTOMS

. The results obtained in this patient suggest a potential role of

    99mTc-MIBI
    PARACLINICAL

 in the

    scintigraphic evaluation
    PARACLINICAL

 of

    Gaucher s lipid deposits in the bone marrow
    MICROSCOPIC

. If the results are confirmed in other patients, this radiopharmaceutical would offer clear advantages over 133Xe because of its wider availability and greater practicality (

    i.v. administration of 99mTc-MIBI
    MEDICATION

 versus

    inhalation of 133Xe
    PARACLINICAL

, and use of a single

    gamma camera
    PARACLINICAL

 instead of two as with

    133Xe
    PARACLINICAL

).

Gaucher s disease
lysosomal storage disease
Gaucher s disease
type 1 Gaucher s disease

implant of a fixation screw-plaque
i.v. administration of 99mTc-MIBI


Gaucher disease: studies of phenotype, molecular diagnosis and treatment.

This report summarizes the results on 39 patients with Gaucher disease who have been genotyped, evaluated, and/or followed at this center. Mutation analysis for 4 common mutations; N370S, L444P, 84gg and IVS2 (+1), was performed for all patients. Mutation analysis identified both mutant alleles in 69% and at least one mutant allele in 90% of all chromosomes. This study group of 39 patients included 32 type 1, four type 2 and three type 3 patients. We include the details of the clinical course of two patients with Gaucher disease treated with enzyme replacement therapy (ERT). One patient with chronic neuronopathic Gaucher disease has been treated with enzyme replacement therapy (ERT) at a dose of 60 U/kg every 2 weeks since 2.5 years of age and has shown no progression of neurologic involvement. A second patient with non-neuronopathic Gaucher disease has demonstrated an unusually delayed response to ERT. No clinical response was noted following 17 months of treatment at 60 U/kg every 2 weeks. Only after the dose was increased to 60 U/kg every week was a clinical response evident. Response to treatment at 15 U/kg every 2 weeks was variable in the four type 1 patients treated at the lower dose. In two of these patients with identical genotypes, one patient demonstrated a positive clinical response to low dose treatment while the other patient did not.

This report summarizes the results on 39 patients with

    Gaucher disease
    DIAGNOSIS

 who have been genotyped, evaluated, and/or followed at this center.

    Mutation analysis for 4 common mutations; N370S, L444P, 84gg and IVS2 (+1)
    PARACLINICAL

, was performed for all patients.

    Mutation analysis
    PARACLINICAL

    identified both mutant alleles in 69% and at least one mutant allele in 90% of all chromosomes
    GENETICS

. This study group of 39 patients included 32

    type 1
    DIAGNOSIS

, four

    type 2
    DIAGNOSIS

 and three

    type 3
    DIAGNOSIS

 patients. We include the details of the clinical course of two patients with

    Gaucher disease
    DIAGNOSIS

 treated with

    enzyme replacement therapy (ERT)
    MEDICATION

. One patient with

    chronic neuronopathic Gaucher disease
    DIAGNOSIS

 has been

    treated with enzyme replacement therapy (ERT) at a dose of 60 U/kg every 2 weeks
    MEDICATION

    since 2.5 years of age
    AGE

 and has shown

    no progression of neurologic involvement
    NEG_FINDINGS

. A second patient with

    non-neuronopathic Gaucher disease
    DIAGNOSIS

 has demonstrated an

    unusually delayed response to ERT
    NEG_FINDINGS

.

    No clinical response was noted
    NEG_FINDINGS

 following

    17 months of treatment at 60 U/kg every 2 weeks
    MEDICATION

. Only after the

    dose was increased to 60 U/kg every week
    MEDICATION

 was a

    clinical response
    SYMPTOMS

 evident. Response to

    treatment at 15 U/kg every 2 weeks
    MEDICATION

 was variable in the four

    type 1
    DIAGNOSIS

 patients treated at the

    lower dose
    MEDICATION

. In two of these patients with identical genotypes, one patient demonstrated a

    positive clinical response to low dose treatment
    SYMPTOMS

 while the other patient did not.

Gaucher disease
type 1
type 2
type 3
Gaucher disease
chronic neuronopathic Gaucher disease
non-neuronopathic Gaucher disease
type 1


Bone involvement in Gaucher's disease: 'bone crisis' or disease complication?

Bone involvement can represent the inaugural symptom of Gaucher's disease (GD). Here, we report the case of a 68-year old man diagnosed as having GD since 1963. In June 1994 the patient was referred to our Rheumatology Unit because of a long-lasting coxalgia on the left hip and progressive walking impairment following traumatic fracture of the left femur. Multicystic osseous changes at standard X-ray and hyper-gamma-globulinemia with an elevated ESR (122 mm, 1st hour) suggested the diagnosis of either osteonecrosis of the femoral head or multiple myeloma. On bone marrow biopsy examination, Gaucher's cell infiltrates were detected and an increased uptake in the distal left femur and proximal tibia were demonstrated by lipophilic tracer scan (99mTc-Sestamibi). Subsequently, the patient suffered another femoral fracture at a site of Gaucher's infiltrates previously documented by bone scan. We conclude that in patients with GD, 99mTc-Sestamibi bone scan can selectively evaluate the presence of bone lipid deposits, and could indirectly differentiate this bone condition from other serious skeletal complications of the disease.

    Bone involvement
    SYMPTOMS

 can represent the inaugural symptom of

    Gaucher's disease (GD)
    DIAGNOSIS

. Here, we report the case of a

    68-year old
    AGE

    man
    GENDER

 diagnosed as having

    GD
    DIAGNOSIS

 since 1963. In June 1994 the patient was referred to our Rheumatology Unit because of a

    long-lasting coxalgia on the left hip
    SYMPTOMS

 and

    progressive walking impairment
    SYMPTOMS

 following

    traumatic fracture of the left femur
    SYMPTOMS

.

    Multicystic osseous changes
    SYMPTOMS

 at

    standard X-ray
    PARACLINICAL

 and

    hyper-gamma-globulinemia
    BIOCHEMICAL

 with an

    elevated ESR (122 mm, 1st hour)
    BIOCHEMICAL

 suggested the diagnosis of either

    osteonecrosis of the femoral head
    DIAGNOSIS

 or

    multiple myeloma
    DIAGNOSIS

. On

    bone marrow biopsy examination
    PARACLINICAL

,

    Gaucher's cell infiltrates
    MICROSCOPIC

    were detected
    MICROSCOPIC

 and an

    increased uptake in the distal left femur and proximal tibia
    SYMPTOMS

 were demonstrated by

    lipophilic tracer scan (99mTc-Sestamibi)
    PARACLINICAL

. Subsequently, the patient suffered

    another femoral fracture at a site of Gaucher's infiltrates
    SYMPTOMS

 previously documented by

    bone scan
    PARACLINICAL

. We conclude that in patients with

    GD
    DIAGNOSIS

,

    99mTc-Sestamibi bone scan
    PARACLINICAL

 can selectively evaluate the presence of

    bone lipid deposits
    MICROSCOPIC

, and could indirectly differentiate this bone condition from other

    serious skeletal complications
    SYMPTOMS

 of the disease.

Gaucher's disease (GD)
GD
osteonecrosis of the femoral head
multiple myeloma
GD

hyper-gamma-globulinemia
elevated ESR (122 mm, 1st hour)


The clinical, molecular, and pathological characterisation of a family with two cases of lethal perinatal type 2 Gaucher disease.

It has recently been emphasised that a subset of patients with type 2 Gaucher disease die in the neonatal period. This report describes an Afghani family with two conceptuses having severe, prenatally detected Gaucher disease. Mutational analysis showed that the family carried a known complex allele which included mutations at amino acids L444P, A456P, and V460V. Although glucocerebrosidase RNA was present, an affected fetus had virtually no glucocerebrosidase cross reactive material on western analyses. The severe clinical course and pathology observed in these patients resemble that of the null allele Gaucher mouse, and suggest that the absence of glucocerebrosidase activity results in early death.

It has recently been emphasised that a subset of patients with

    type 2 Gaucher disease
    DIAGNOSIS

 die in the

    neonatal
    AGE

    period
    AGE

. This report describes an

    Afghani
    ETHNICITY

    family with two conceptuses having severe, prenatally detected
    FAMILY

    Gaucher disease
    DIAGNOSIS

.

    Mutational analysis
    PARACLINICAL

 showed that the family carried a known complex allele which included mutations at amino acids L444P, A456P, and V460V. Although

    glucocerebrosidase RNA was present
    BIOCHEMICAL

, an affected fetus had

    virtually no glucocerebrosidase cross reactive material on western analyses
    NEG_FINDINGS

. The

    severe clinical course and pathology
    SYMPTOMS

 observed in these patients resemble that of the

    null allele Gaucher mouse
    GENETICS

, and suggest that the

    absence of glucocerebrosidase activity
    BIOCHEMICAL

 results in

    early death
    SYMPTOMS

.

glucocerebrosidase RNA was present
absence of glucocerebrosidase activity

severe clinical course and pathology
early death


[Acute interstitial nephritis. Role of ceftazidime].

A 22-year-old man treated with ceftazidime-amikacine for a Pseudomonas aeruginosa pneumonia, experienced two days later allergic symptoms, acute renal failure and urinary sediment abnormalities. The renal biopsy showed an acute interstitial nephritis. Basophils stimulation test was positive for ceftazidime. Early diagnosis and discontinuation of the suspected agent is essential to allow rapid and complete recovery of renal function.

A

    22-year-old
    AGE

    man
    GENDER

    treated with ceftazidime-amikacine
    MEDICATION

 for a

    Pseudomonas aeruginosa pneumonia
    DIAGNOSIS

, experienced two days later

    allergic symptoms
    SYMPTOMS

,

    acute renal failure
    SYMPTOMS

 and

    urinary sediment abnormalities
    SYMPTOMS

. The

    renal biopsy
    PARACLINICAL

 showed an

    acute interstitial nephritis
    DIAGNOSIS

.

    Basophils stimulation test was positive for ceftazidime
    PARACLINICAL

. Early diagnosis and

    discontinuation of
    MEDICATION

 the suspected agent is essential to allow rapid and

    complete recovery of renal function
    SYMPTOMS

.

treated with ceftazidime-amikacine
discontinuation of

Pseudomonas aeruginosa pneumonia
acute interstitial nephritis

allergic symptoms
acute renal failure
urinary sediment abnormalities
complete recovery of renal function


Oculomotor apraxia in a case of Gaucher's disease with homozygous T1448C mutation.

We report a 10-month-old male infant with Type 2 Gaucher's disease. In addition to gradual arrest of neurological development, laryngospasm, opisthotonus, and limb rigidity, he presented characteristic oculomotor apraxia. History taking revealed that he had had abnormal horizontal gaze and had to turn his head to follow an object instead of moving the eyes alone. His eyes were in a divergent position while he was in a deep coma; however, when consciousness improved, he could open eyes with neutral eye position. Due to the impairment of reflex saccades, the doll's eye phenomenon was not reliable in evaluating the brainstem function when he was in the comatose stage. His leukocyte glucocerebrosidase activity was very low, but the typical Gaucher cell was absent in the sample of bone marrow aspiration. Molecular analysis by amplification refractory mutation system (ARMS) screening proved that he was a homozygote for T1448C mutation. To our knowledge, the T1448C gene frequency of Chinese Gaucher's disease is high. Thus, the ARMS screening method is applicable for further genetic diagnosis of Chinese Gaucher patients. Finally, this successful genetic diagnosis makes it possible in the future to perform prenatal diagnosis.

We report a

    10-month-old
    AGE

    male
    GENDER

    infant
    AGE

 with

    Type 2 Gaucher's disease
    DIAGNOSIS

. In addition to

    gradual arrest of neurological development
    SYMPTOMS

,

    laryngospasm
    SYMPTOMS

,

    opisthotonus
    SYMPTOMS

, and

    limb rigidity
    SYMPTOMS

,

    he
    GENDER

 presented characteristic

    oculomotor apraxia
    SYMPTOMS

.

    History taking
    PARACLINICAL

 revealed that

    he
    GENDER

 had had

    abnormal horizontal gaze
    SYMPTOMS

 and

    had to turn his head to follow an object instead of moving the eyes alone
    NEG_FINDINGS

. His

    eyes were in a divergent position
    SYMPTOMS

 while he was in a

    deep coma
    SYMPTOMS

; however, when

    consciousness improved
    SYMPTOMS

, he

    could open eyes with neutral eye position
    NEG_FINDINGS

. Due to the

    impairment of reflex saccades
    NEG_FINDINGS

, the

    doll's eye phenomenon was not reliable in evaluating the brainstem function
    NEG_FINDINGS

 when

    he
    GENDER

 was in the

    comatose stage
    SYMPTOMS

. His

    leukocyte glucocerebrosidase activity was very low
    BIOCHEMICAL

, but

    the typical Gaucher cell was absent in the sample of bone marrow aspiration
    MICROSCOPIC

.

    Molecular analysis by amplification refractory mutation system (ARMS) screening
    PARACLINICAL

 proved that

    he
    GENDER

 was a

    homozygote for T1448C mutation
    GENETICS

. To our knowledge, the

    T1448C gene
    GENETICS

 frequency of

    Chinese
    ETHNICITY

    Gaucher's disease
    DIAGNOSIS

 is high. Thus, the

    ARMS screening method
    PARACLINICAL

 is applicable for further genetic diagnosis of

    Chinese
    ETHNICITY

    Gaucher
    DIAGNOSIS

 patients. Finally, this successful

    genetic diagnosis
    PARACLINICAL

 makes it possible in the future to perform

    prenatal diagnosis
    MEDICATION

.

Type 2 Gaucher's disease
Gaucher's disease
Gaucher

homozygote for T1448C mutation
T1448C gene


Gaucher disease: identification of three new mutations in the Korean and Chinese (Taiwanese) populations.

Gaucher Disease type 1, the most prevalent lysosomal disease among Caucasians, is due to defects in the activity of acid beta-glucosidase. Over 40 missense, nonsense, and more complex alleles have been described, primarily in Western populations. From these results, predictive genotype/phenotype correlations have been developed and used to guide genetic counseling and therapy. Only a few mutations have been described in Japanese patients with Gaucher disease and many of these have resulted in severe phenotypes. Although rare, Gaucher Disease occurs in Korean and Chinese (Taiwanese) populations. Sequencing of RT-PCR cDNAs from five unrelated Korean and two sibling Chinese (Taiwanese) Gaucher type 1 patients identified three new Gaucher disease mutations. These disease alleles encoded V15L, G46E, and N188S substitutions leading to dysfunctional acid beta-glucosidases. The G46E was present in two Korean patients and the N188S allele was present in the Korean and Chinese (Taiwanese) populations, suggesting an ancient mutation. The commonality of these two mutations in the Korean and Chinese (Taiwanese) population indicates the need for more extensive screening for these mutations in the Gaucher populations.

    Gaucher Disease type 1
    DIAGNOSIS

, the most prevalent

    lysosomal disease
    DIAGNOSIS

 among

    Caucasians
    ETHNICITY

, is due to

    defects in the activity of acid beta-glucosidase
    BIOCHEMICAL

. Over 40

    missense, nonsense
    GENETICS

, and

    more complex alleles
    GENETICS

 have been described, primarily in

    Western
    ETHNICITY

 populations. From these results, predictive genotype/phenotype correlations have been developed and used to guide

    genetic counseling
    MEDICATION

 and therapy. Only a few mutations have been described in

    Japanese
    ETHNICITY

 patients with

    Gaucher disease
    DIAGNOSIS

 and many of these have resulted in severe phenotypes. Although rare,

    Gaucher Disease
    DIAGNOSIS

 occurs in

    Korean
    ETHNICITY

 and

    Chinese
    ETHNICITY

 (

    Taiwanese
    ETHNICITY

) populations.

    Sequencing of RT-PCR cDNAs from
    PARACLINICAL

 five unrelated

    Korean
    ETHNICITY

 and two sibling

    Chinese (Taiwanese
    ETHNICITY

)

    Gaucher type 1
    DIAGNOSIS

 patients identified three

    new Gaucher disease mutations
    GENETICS

. These

    disease alleles
    GENETICS

 encoded

    V15L, G46E, and N188S substitutions
    GENETICS

 leading to

    dysfunctional acid beta-glucosidases
    BIOCHEMICAL

. The

    G46E
    GENETICS

 was present in two

    Korean
    ETHNICITY

 patients and

    the N188S allele
    GENETICS

 was present in the

    Korean and Chinese (Taiwanese) populations
    ETHNICITY

, suggesting an

    ancient mutation
    GENETICS

. The commonality of these two mutations in the

    Korean
    ETHNICITY

 and

    Chinese (Taiwanese
    ETHNICITY

) population indicates the need for more extensive screening for these mutations in the Gaucher populations.

Gaucher Disease type 1
lysosomal disease
Gaucher disease
Gaucher Disease
Gaucher type 1

missense, nonsense
more complex alleles
new Gaucher disease mutations
disease alleles
V15L, G46E, and N188S substitutions
G46E
the N188S allele
ancient mutation


[Gaucher disease type 1, incidentally found on a periodic physical examination].

A 33-year-old man was admitted to our hospital because of thrombocytopenia found on a periodic physical examination. Splenomegaly was recognized Peripheral blood showed WBC 4,510/microliters, Hb 12.5 g/dl, and Plt 40,000/microliters. Increased serum levels of acid phosphatase and angiotensin converting enzyme were observed on laboratory tests. Bone marrow aspirate revealed Gaucher cells. Decreased beta-glucosidase activity was demonstrated in blood leukocytes, cultured blood lymphocytes, and cultured bone marrow fubroblasts from the patient. His glucocerebrosidase genotype was T1448C/C1504T (L444P/R463C). Since neurological examination and skeletal X ray results were normal, Gaucher disease type 1 was diagnosed.

A

    33-year-old
    AGE

    man
    GENDER

 was admitted to our hospital because of

    thrombocytopenia
    BIOCHEMICAL

 found on a

    periodic physical examination
    PARACLINICAL

.

    Splenomegaly
    BIOCHEMICAL

 was recognized

    Peripheral blood showed WBC 4,510/microliters, Hb 12.5 g/dl, and Plt 40,000/microliters
    BIOCHEMICAL

.

    Increased serum levels of acid phosphatase and angiotensin converting enzyme
    BIOCHEMICAL

 were observed on

    laboratory tests
    PARACLINICAL

.

    Bone marrow aspirate
    PARACLINICAL

 revealed

    Gaucher cells
    MICROSCOPIC

.

    Decreased beta-glucosidase activity was demonstrated in blood leukocytes, cultured blood lymphocytes, and cultured bone marrow fubroblasts
    BIOCHEMICAL

 from the patient.

    His
    GENDER

    glucocerebrosidase genotype was T1448C/C1504T (L444P/R463C)
    GENETICS

. Since

    neurological examination and skeletal X ray results were normal
    NEG_FINDINGS

,

    Gaucher disease type 1
    DIAGNOSIS

 was diagnosed.


Complex IgA gammopathy in Gaucher's disease.

A 55-year-old Jewish patient was simultaneously diagnosed as having Gaucher's disease and IgA multiple myeloma. Serum protein electrophoresis and immunoelectrophoresis showed two different IgA kappa type monoclonal spikes. After four years of observation, a rapid fatal course of disease developed together with expression of J chain protein and an additional IgA lambda paraprotein. Although dysproteinaemias and multiple myeloma have occasionally been reported in Gaucher's patients, such a complex gammopathy has to the best of our knowledge not yet been described.

A

    55-year-old
    AGE

    Jewish
    ETHNICITY

 patient was simultaneously diagnosed as having

    Gaucher's disease
    DIAGNOSIS

 and

    IgA multiple myeloma
    DIAGNOSIS

.

    Serum protein electrophoresis
    PARACLINICAL

 and

    immunoelectrophoresis
    PARACLINICAL

 showed

    two different IgA kappa type monoclonal spikes
    BIOCHEMICAL

. After four years of observation, a

    rapid fatal course of disease
    SYMPTOMS

 developed together with

    expression of J chain protein
    BIOCHEMICAL

 and an

    additional IgA lambda paraprotein
    BIOCHEMICAL

. Although

    dysproteinaemias
    DIAGNOSIS

 and

    multiple myeloma
    DIAGNOSIS

 have occasionally been reported in

    Gaucher's
    DIAGNOSIS

 patients, such a

    complex gammopathy
    DIAGNOSIS

 has to the best of our knowledge not yet been described.

Gaucher's disease
IgA multiple myeloma
dysproteinaemias
multiple myeloma
Gaucher's
complex gammopathy


Prenatal molecular diagnosis of Gaucher disease.

Prenatal diagnosis of Gaucher disease, the most prevalent glycolipid storage disease, is based on a reliable enzyme assay of cells from amniocentesis or chorionic villous samples. However, this method cannot differentiate among the various forms of the disease. This report details four cases of prenatal diagnosis of Gaucher disease, three of which predate the use of molecular diagnosis. DNA mutation analysis to determine the genotype was predictive of the phenotypic status of the fetus and conformed to the genotype of an affected proband where available.

    Prenatal diagnosis
    PARACLINICAL

 of

    Gaucher disease
    DIAGNOSIS

, the most prevalent

    glycolipid storage disease
    DIAGNOSIS

, is based on a

    reliable enzyme assay of cells from amniocentesis or chorionic villous samples
    PARACLINICAL

. However, this method cannot differentiate among the various forms of the disease. This report details four cases of

    prenatal diagnosis
    PARACLINICAL

 of

    Gaucher disease
    DIAGNOSIS

, three of which predate the use of

    molecular diagnosis
    PARACLINICAL

.

    DNA mutation analysis to determine the
    PARACLINICAL

 genotype was predictive of the phenotypic status of the fetus and conformed to the genotype of an affected proband where available.

Gaucher disease
glycolipid storage disease
Gaucher disease


[Repeat fracture of the femur shaft in Gaucher disease].

A case of pathologic femoral fracture in a patient with Gaucher's disease is presented. The fracture occurred at the site of bioptic trepanation performed 1 month previously. After fracture healing and removal of a Küntscher nail, pathologic fracture recurred at the same site. The paper emphasizes the value of "biological" internal fixation for the preservation of compromised blood flow in the bones of patients with Gaucher's disease.

A case of

    pathologic femoral fracture
    SYMPTOMS

 in a patient with

    Gaucher's disease
    DIAGNOSIS

 is presented. The

    fracture occurred at
    SYMPTOMS

 the site of

    bioptic trepanation
    MEDICATION

 performed 1 month previously. After

    fracture healing
    MEDICATION

 and

    removal of a Küntscher nail
    MEDICATION

,

    pathologic fracture recurred at the same
    SYMPTOMS

 site. The paper emphasizes the value of

    "biological" internal fixation
    MEDICATION

 for the

    preservation of compromised blood flow in the bones
    SYMPTOMS

 of patients with

    Gaucher's disease
    DIAGNOSIS

.

bioptic trepanation
fracture healing
removal of a Küntscher nail
"biological" internal fixation


Effects of different amino-acid substitutions in the leucine 694-proline 708 segment of recombinant von Willebrand factor.

Type 2B von Willebrand disease (vWD) is characterized by an increased affinity of von Willebrand factor (vWF) for binding to platelet glycoprotein Ib (GpIb). Most type 2B candidate mutations are clustered in the 509-695 disulphide loop but three of them (H505D, L697V and A698V) are outside this loop. We confirm here that the A698V mutation is a type 2B mutation by its expression in Cos-7 cells. As the L697V and A698V type 2B mutations both induce the presence of a valine residue in the 694-708 sequence, we created and expressed different mutated recombinant vWFs (rvWFs), in substituting the other leucine and alanine residues of this sequence (at positions 694, 701 and 706) into valine resides. V694rvWF and V706rvWF displayed decreased ristocetin-induced GpIb binding showing that it is not always the presence of a valine residue that may explain the increased affinity of type 2B vWF for GpIb. We also compared the interaction with platelets of V697rvWF and V698rvWF to those obtained with rvWFs reproducing two prevalent type 2B mutations located in the loop (R543W and V553M). We show that the two mutations located in the loop are more reactive than the two mutations identified outside the loop.

    Type 2B von Willebrand disease (vWD)
    DIAGNOSIS

 is characterized by an

    increased affinity of von Willebrand factor (vWF) for binding to platelet glycoprotein Ib (GpIb)
    BIOCHEMICAL

. Most

    type 2B candidate mutations
    GENETICS

 are

    clustered in the 509-695 disulphide loop
    GENETICS

 but three of them (

    H505D, L697V and A698V)
    GENETICS

 are outside this loop. We confirm here that the

    A698V mutation
    GENETICS

 is a

    type 2B mutation
    GENETICS

 by its expression in Cos-7 cells. As the

    L697V and A698V type 2B mutations both induce the presence of a valine residue in the 694-708 sequence
    GENETICS

, we created and expressed different mutated recombinant vWFs (rvWFs), in

    substituting the other leucine and alanine residues of this sequence (at positions 694, 701 and 706) into valine resides
    GENETICS

.

    V694rvWF
    GENETICS

 and

    V706rvWF
    GENETICS

 displayed

    decreased ristocetin-induced GpIb binding
    BIOCHEMICAL

 showing that it is not always the

    presence of a valine residue
    GENETICS

 that may explain the increased affinity of

    type 2B vWF for GpIb
    BIOCHEMICAL

. We also compared the interaction with platelets of V697rvWF and V698rvWF to those obtained with rvWFs reproducing two

    prevalent type 2B mutations located in the loop (R543W and V553M)
    GENETICS

. We show that the two

    mutations located in the
    GENETICS

 loop are more reactive than the two mutations identified outside the loop.


Cytokine mobilization of peripheral blood stem cells in patients with Gaucher disease with a view to gene therapy.

As clinical trials for gene therapy in Gaucher disease (GD) begin, questions regarding the biology of the hematopoietic stem cell in this disease remain unanswered. This study demonstrates the ability to mobilize and collect CD34+ cells in three patients with the disorder. Our RAC/FDA-approved clinical trial utilizes mobilized peripheral blood stem cells (PBSC) as the target cells for gene transfer. In this approach, a white blood cell fraction is collected by apheresis, enriched for CD34+ cells, and transduced with a retroviral vector carrying the glucocerebrosidase (GC) gene. Transduced cells from the patient with activity corrected to at least normal levels will be returned to the patient without myelosuppressive therapy. We report here the effect of cytokines in mobilizing PBSC in three patients with GD. Two (patients 1 and 2) were given granulocyte colony-stimulating factor (G-CSF) at a dose of 5 micrograms/kg/d and one (patient 3) was given 10 micrograms/kg/d for 10 days. Leukaphereses were done daily for 5 days and the products enriched for CD34+ cells using the clinical Ceprate (CellPro) column. The CD34+ cells in all fractions were monitored daily during mobilization and leukaphereses. Subset analysis for the expression of Thy-1, CD38, HLA-DR, and CD33 on the CD34+ cells was performed. An increase in CD34+ cells in the peripheral blood was noted from day 5 onward (up to a six-fold increase). Up to a 625-fold enrichment in CD34+ cells in the apheresis product was noted using the clinical Ceprate column. Totals of 1.2, 3.5, and 2.1 x 10(6) CD34+ cells/kg were collected in the three patients. A diminution in the percent of CD34+/Thy-1+ cells was noted with enrichment. In vitro retroviral transduction of the CD34-enriched cells using centrifugation promoted transduction protocol previously described (Bahnson AB et al., Centrifugal enhancement of retroviral-mediated gene transfer. Journal of Virology Methods 54:131, 1995) and modified for clinical use, demonstrated a mean transduction efficiency of 37% (range 8.3-87.1%) in clonogenic cells and up to 50% in long-term culture-initiating cells (LTC-IC) at week 6. Significantly, we have been able to achieve up to a 50-fold increase in the level of GC above deficient levels in the patients' CD34+ enriched cells when maintained in vitro in culture. The study demonstrates that up to a six-fold increase in CD34+ cells in the PB can be achieved with cytokines in patients with GD. CD34+ cells can be collected in numbers sufficient for conventional transplantation and transduced efficiently in vitro. In gene therapy trials for genetic disorders to date, myelosuppressive therapy is not advocated. The clinical trial will demonstrate whether this number of transduced CD34+ cells will be adequate for competitive engraftment of genetically corrected PBSC.

As clinical trials for

    gene therapy
    MEDICATION

 in

    Gaucher disease (GD)
    DIAGNOSIS

 begin, questions regarding the biology of the hematopoietic stem cell in this disease remain unanswered. This study demonstrates the ability to

    mobilize and collect CD34+ cells
    MEDICATION

 in three patients with the disorder. Our RAC/FDA-approved clinical trial utilizes

    mobilized peripheral blood stem cells (PBSC)
    MEDICATION

 as the target cells for

    gene transfer
    MEDICATION

. In this approach, a

    white blood cell fraction is collected by apheresis
    MICROSCOPIC

, enriched for CD34+ cells, and

    transduced with a retroviral vector carrying the glucocerebrosidase (GC) gene
    MEDICATION

. Transduced cells from the patient with

    activity corrected to at least normal levels
    BIOCHEMICAL

 will be returned to the patient

    without myelosuppressive therapy
    NEG_FINDINGS

. We report here the effect of

    cytokines in mobilizing PBSC
    MEDICATION

 in three patients with

    GD
    DIAGNOSIS

. Two (patients 1 and 2) were

    given granulocyte colony-stimulating factor (G-CSF) at a dose of 5 micrograms/kg/d
    MEDICATION

 and one (patient 3) was

    given 10 micrograms/kg/d for 10 days
    MEDICATION

.

    Leukaphereses were done daily for 5 days
    MEDICATION

 and the products

    enriched for CD34+ cells using the clinical Ceprate (CellPro) column
    MICROSCOPIC

.

    The CD34+ cells in all fractions
    BIOCHEMICAL

 were monitored daily during

    mobilization and leukaphereses
    PARACLINICAL

. Subset analysis for the expression of

    Thy-1, CD38
    BIOCHEMICAL

, HLA-DR, and

    CD33
    BIOCHEMICAL

 on the CD34+ cells was performed. An

    increase in CD34+ cells in the peripheral blood
    MICROSCOPIC

 was noted from day 5 onward (up to a six

    -fold increase
    BIOCHEMICAL

). Up to a

    625-fold enrichment in CD34+ cells in the apheresis product
    MICROSCOPIC

 was noted using the

    clinical Ceprate column
    MEDICATION

.

    Totals of 1.2, 3.5, and 2.1 x 10(6) CD34+ cells/kg were collected
    MEDICATION

 in the three patients. A

    diminution in the percent of CD34+/Thy-1+ cells
    BIOCHEMICAL

 was noted with enrichment.

    In vitro retroviral transduction of the CD34-enriched cells
    MEDICATION

 using

    centrifugation promoted transduction
    MEDICATION

 protocol previously described (Bahnson AB et al.,

    Centrifugal enhancement of retroviral-mediated gene transfer
    MEDICATION

. Journal of Virology Methods 54:131, 1995) and modified for clinical use, demonstrated a

    mean transduction efficiency of 37% (range 8.3-87.1%) in clonogenic cells and up to 50% in long-term culture-initiating cells (LTC-IC)
    MICROSCOPIC

 at week 6. Significantly, we have been able to

    achieve up to a 50-fold increase in the level of GC above deficient levels in the patients' CD34+ enriched cells when maintained in vitro in culture
    BIOCHEMICAL

. The study demonstrates that up to a

    six-fold increase in CD34+ cells in the PB
    MICROSCOPIC

 can be achieved with

    cytokines
    MEDICATION

 in patients with

    GD
    DIAGNOSIS

.

    CD34+ cells
    MEDICATION

 can be collected in numbers sufficient for

    conventional transplantation
    MEDICATION

 and transduced efficiently in vitro. In

    gene therapy
    MEDICATION

 trials for

    genetic disorders
    DIAGNOSIS

 to date,

    myelosuppressive therapy
    NEG_FINDINGS

 is not advocated. The clinical trial will demonstrate whether this number of transduced CD34+ cells will be adequate for

    competitive engraftment of genetically corrected PBSC
    MEDICATION

.

Gaucher disease (GD)
GD
GD
genetic disorders

without myelosuppressive therapy
myelosuppressive therapy


Congenital ichthyosis preceding neurologic symptoms in two sibs with type 2 Gaucher disease.

We describe 2 sibs who presented with ichthyotic skin at birth and subsequently developed neurologic manifestations of type 2 Gaucher disease. Type 2 Gaucher patients with and without ichthyosis manifest ultrastructural and biochemical abnormalities in the epidermis. The 2 patients described here clearly demonstrate that epidermal involvement in type 2 Gaucher disease may precede neurologic symptoms and substantiate the prognostic significance of early skin abnormalities in Gaucher patients. Gaucher disease should be considered in the differential diagnosis of congenital ichthyosis, even if the scaling resolves spontaneously.

We describe 2

    sibs
    FAMILY

 who presented with

    ichthyotic skin
    SYMPTOMS

 at

    birth
    AGE

 and subsequently developed

    neurologic manifestations
    SYMPTOMS

 of

    type 2 Gaucher disease
    DIAGNOSIS

.

    Type 2 Gaucher
    DIAGNOSIS

 patients with and

    without ichthyosis
    NEG_FINDINGS

 manifest

    ultrastructural and biochemical abnormalities in the epidermis
    MICROSCOPIC

. The 2 patients described here clearly demonstrate that

    epidermal involvement
    SYMPTOMS

 in

    type 2 Gaucher disease
    DIAGNOSIS

 may precede

    neurologic symptoms
    SYMPTOMS

 and substantiate the prognostic significance of

    early skin abnormalities
    SYMPTOMS

 in

    Gaucher
    DIAGNOSIS

 patients.

    Gaucher disease
    DIAGNOSIS

 should be considered in the

    differential diagnosis
    PARACLINICAL

 of

    congenital ichthyosis
    DIAGNOSIS

, even if the

    scaling resolves spontaneously
    NEG_FINDINGS

.

ichthyotic skin
neurologic manifestations
epidermal involvement
neurologic symptoms
early skin abnormalities

type 2 Gaucher disease
Type 2 Gaucher
type 2 Gaucher disease
Gaucher
Gaucher disease
congenital ichthyosis

without ichthyosis
scaling resolves spontaneously


Three unrelated Gaucher's disease patients with three novel point mutations in the glucocerebrosidase gene (P266R, D315H and A318D).

Three novel point mutations were detected in the glucocerebrosidase gene of three unrelated Gaucher's disease patients by direct sequencing of PCR products. The first is a C to G change at position 4263 in the genomic sequence (exon 7) which results in a proline to arginine change at position 266 in the mature enzyme (P266R). The second is a G to C change at position 5276 in the genomic sequence (exon 8) which results in an aspartic acid to histidine change at position 315 (D315H). The third is a C to A change at position 5286 in the genomic sequence (exon 8) which results in an alanine to aspartic acid change at position 318 (A318D). The first mutation destroys an AvaII restriction endonuclease site, the second creates a BspMI site and the third creates a BamH I site.

Three

    novel point mutations
    GENETICS

 were detected

    in the glucocerebrosidase gene
    GENETICS

 of three unrelated

    Gaucher's disease
    DIAGNOSIS

 patients by

    direct sequencing of PCR products
    PARACLINICAL

. The first is a

    C to G change at position 4263 in the genomic sequence (exon 7) which results in a proline to arginine change at position 266 in the mature enzyme (P266R)
    GENETICS

. The second is

    a G to C change at position 5276 in the genomic sequence (exon 8) which results in an aspartic acid to histidine change at position 315 (D315H)
    GENETICS

. The third is

    a C to A change at position 5286 in the genomic sequence (exon 8) which results in an alanine to aspartic acid change at position 318 (A318D)
    GENETICS

. The first mutation destroys an AvaII restriction endonuclease site, the second creates a BspMI site and the third creates a BamH I site.


Molecular diagnosis of Gaucher disease type II.

Gaucher disease is a rare autosomal recessive lysosomal storage disorder in Chinese. A mutation at nucleotide 1448C (T-to-C) of the glucocerebrosidase gene is described in type 2 Gaucher disease. This mutation creates a Bcn I site in a polymerase chain reaction (PCR) amplified fragment. This technique was applied to a Chinese infant with type 2 Gaucher disease, and homozygosity for 1448C mutation was proved. This new finding can make prenatal diagnosis and carrier detection possible in Chinese population with type 2 Gaucher disease.

    Gaucher disease
    DIAGNOSIS

 is a

    rare autosomal recessive
    GENETICS

    lysosomal storage disorder
    DIAGNOSIS

 in

    Chinese
    ETHNICITY

. A

    mutation at nucleotide 1448C (T-to-C) of the glucocerebrosidase gene
    GENETICS

 is described in

    type 2 Gaucher disease
    DIAGNOSIS

. This

    mutation creates a Bcn I site in a polymerase chain reaction (PCR) amplified fragment
    GENETICS

. This technique was applied to a

    Chinese
    ETHNICITY

    infant
    AGE

 with

    type 2 Gaucher disease
    DIAGNOSIS

, and

    homozygosity for 1448C mutation
    GENETICS

 was proved. This new finding can make

    prenatal diagnosis
    PARACLINICAL

 and carrier detection possible in

    Chinese
    ETHNICITY

 population with

    type 2 Gaucher disease
    DIAGNOSIS

.

Gaucher disease
lysosomal storage disorder
type 2 Gaucher disease
type 2 Gaucher disease
type 2 Gaucher disease


A rare G6490-->A substitution at the last nucleotide of exon 10 of the glucocerebrosidase gene in two unrelated Italian Gaucher patients.

Mutation screening of the glucocerebrosidase gene by SSCP analysis revealed an abnormal pattern of exon 10 in two unrelated Italian Gaucher patients. Direct sequencing of the mutated samples identified a G6490-->A transition. The same mutation has been described before in a Japanese patient with Gaucher disease type III. The clinical phenotype of our patients was type I in one whose second allele carried the N370S mutation and type II in the other one with a L444P mutation. In this latter the G6490-->A substitution cancels a normal Msp I site, while on the opposite chromosome the T6433-->C mutation (L444P) introduces a new Msp I site. Thus, digestion with Msp I of the amplified exon 10 is a useful method for identifying the two mutations simultaneously.

    Mutation screening of the glucocerebrosidase gene by SSCP analysis
    PARACLINICAL

 revealed an

    abnormal pattern of exon 10
    GENETICS

 in two unrelated

    Italian
    ETHNICITY

    Gaucher
    DIAGNOSIS

 patients.

    Direct sequencing of the mutated samples
    PARACLINICAL

 identified a

    G6490-->A transition
    GENETICS

. The same mutation has been described before in a

    Japanese
    ETHNICITY

 patient with

    Gaucher disease type III
    DIAGNOSIS

. The clinical phenotype of our patients was

    type I
    DIAGNOSIS

 in one whose

    second allele carried the N370S mutation
    GENETICS

 and

    type II
    DIAGNOSIS

 in the other one with a

    L444P mutation
    GENETICS

. In this latter the

    G6490-->A substitution cancels a normal Msp I site
    GENETICS

, while

    on the opposite chromosome the T6433-->C mutation (L444P) introduces a new Msp I site
    GENETICS

. Thus,

    digestion with Msp I of the amplified exon 10
    PARACLINICAL

 is a useful method for identifying the two mutations simultaneously.

Gaucher
Gaucher disease type III
type I
type II


Unusual expression of Gaucher's disease: cardiovascular calcifications in three sibs homozygous for the D409H mutation.

Three sisters suffering from an unusual form of Gaucher's disease are described. These patients had cardiovascular abnormalities consisting of calcification of the ascending aorta and of the aortic and mitral valves. Neurological findings included ophthalmoplegia and saccadic eye movements in two patients, and tonic-clonic seizures in the third. The three patients died, two of them after having undergone aortic valve replacement. Tissue was obtained from one of the sibs and fibroblast and liver beta-glucocerebrosidase activity was reduced to 4% and 11% of mean normal values. Genotype analysis indicated that the patient was homozygous for the D409H mutation. It is tempting to relate the phenotype of severe cardiac involvement to the D409H/D409H genotype, although further cases will be needed before this association can be confirmed.

Three

    sisters suffering from an unusual form of Gaucher's disease
    FAMILY

 are described. These patients had

    cardiovascular abnormalities
    SYMPTOMS

 consisting of

    calcification of the ascending aorta and of the aortic and mitral valves
    SYMPTOMS

.

    Neurological findings
    SYMPTOMS

 included

    ophthalmoplegia
    SYMPTOMS

 and

    saccadic eye movements
    SYMPTOMS

 in two patients, and

    tonic-clonic seizures
    SYMPTOMS

 in the third. The three patients

    died
    SYMPTOMS

, two of them after having

    undergone aortic valve replacement
    MEDICATION

.

    Tissue was obtained
    PARACLINICAL

 from one of the sibs and fibroblast and

    liver beta-glucocerebrosidase activity was reduced to 4% and 11% of mean normal values
    BIOCHEMICAL

.

    Genotype analysis
    PARACLINICAL

 indicated that the patient was

    homozygous for the D409H mutation
    GENETICS

. It is tempting to relate the phenotype of

    severe cardiac involvement
    SYMPTOMS

 to the

    D409H/D409H genotype
    GENETICS

, although further cases will be needed before this association can be confirmed.

homozygous for the D409H mutation
D409H/D409H genotype


Pathological findings in Gaucher disease type 2 patients following enzyme therapy.

The pathological outcomes following intravenous acid beta-glucosidase (alglucerase) infusions were compared in two siblings with Gaucher disease type 2, the acute neuronopathic variant. In case 1 enzyme infusions (four doses at 7 months) had no effect when severe progressive visceral and neuronopathic disease were present. Death from progressive disease occurred at 9 months. Case 2 was prenatally diagnosed. Enzyme infusions were initiated presymptomatically at 4 days of age and continued until death at 15.2 months. Development progressed satisfactorily, albeit at a slower than normal rate until age 10 months when progressive brain stem involvement became evident. Death occurred after slowly progressive brain stem dysfunction, but gross motor and cognitive skills were nearly normal. Postmortem light and electron microscope (EM) studies in both cases showed typical central nervous system (CNS) findings and massive infiltration of the lungs and lymph nodes by Gaucher cells. The liver, spleen, and bone marrow, except that in the temporal bone, in case 2 were normal. These studies show that enzyme therapy may slow but does not prevent the development of lethal CNS disease in Gaucher disease type 2, even when initiated presymptomatically. These findings also indicate the nonuniformity of tissue responses to enzyme therapy implying the existence of therapeutically inaccessible compartments that, in less severe variants, may create unexpected long-term disease complications.

The pathological outcomes following

    intravenous acid beta-glucosidase (alglucerase) infusions
    MEDICATION

 were compared in two siblings with

    Gaucher disease type 2, the acute neuronopathic variant
    DIAGNOSIS

. In case 1

    enzyme infusions (four doses at 7 months
    MEDICATION

)

    had no effect
    NEG_FINDINGS

 when

    severe progressive visceral and neuronopathic disease
    SYMPTOMS

 were present.

    Death from progressive disease
    SYMPTOMS

 occurred

    at 9 months
    AGE

. Case 2 was

    prenatally diagnosed
    GENETICS

.

    Enzyme infusions
    MEDICATION

 were initiated

    presymptomatically
    MEDICATION

 at

    4 days of age
    AGE

 and continued until

    death
    SYMPTOMS

    at 15.2 months
    AGE

.

    Development progressed satisfactorily
    SYMPTOMS

, albeit at a slower than normal rate until

    age 10 months
    AGE

 when

    progressive brain stem involvement
    SYMPTOMS

 became evident.

    Death
    SYMPTOMS

 occurred after

    slowly progressive brain stem dysfunction
    SYMPTOMS

, but

    gross motor and cognitive skills were nearly normal
    NEG_FINDINGS

.

    Postmortem light and electron microscope (EM) studies
    PARACLINICAL

 in both cases showed

    typical central nervous system (CNS) findings
    SYMPTOMS

 and

    massive infiltration of the lungs and lymph nodes by Gaucher cells
    MICROSCOPIC

.

    The liver, spleen, and bone marrow, except that in the temporal bone
    NEG_FINDINGS

, in case 2

    were normal
    NEG_FINDINGS

. These studies show that

    enzyme therapy
    MEDICATION

 may slow but

    does not prevent
    NEG_FINDINGS

 the development of

    lethal CNS disease
    DIAGNOSIS

 in

    Gaucher disease type 2
    DIAGNOSIS

, even when initiated

    presymptomatically
    MEDICATION

. These findings also indicate the nonuniformity of tissue responses to

    enzyme therapy
    MEDICATION

 implying the existence of therapeutically inaccessible compartments that, in less severe variants, may create

    unexpected long-term disease complications
    SYMPTOMS

.


Transtrochanteric anterior rotational osteotomy for Gaucher's disease. A case report.

Avascular necrosis of the femoral head is 1 of the skeletal manifestations of Gaucher's disease, for which hip arthroplasties are performed in many cases. Because many patients are young, total hip arthroplasty in this condition has been reported to result in aseptic loosening of the components soon after operation. Osteotomy can prevent such a problem. The authors present a successful case of a 17-year-old boy who underwent transtrochanteric anterior rotational osteotomy for avascular necrosis of the femoral head in Gaucher's disease. This procedure is an effective and safe surgical treatment for this disease if performed before the onset of significant femoral head collapse or acetabular deformity.

    Avascular necrosis of the femoral head
    DIAGNOSIS

 is 1 of the skeletal manifestations of

    Gaucher's disease
    DIAGNOSIS

, for which

    hip arthroplasties
    MEDICATION

 are performed in many cases. Because many patients are

    young
    AGE

,

    total hip arthroplasty
    MEDICATION

 in this condition has been reported to result in

    aseptic loosening of the components
    SYMPTOMS

 soon after operation.

    Osteotomy
    MEDICATION

 can prevent such a problem. The authors present a successful case of a

    17-year-old
    AGE

    boy
    GENDER

 who underwent

    transtrochanteric anterior rotational osteotomy
    MEDICATION

 for

    avascular necrosis of the femoral head
    DIAGNOSIS

 in

    Gaucher's disease
    DIAGNOSIS

. This procedure is an effective and safe

    surgical treatment
    MEDICATION

 for this disease if performed before the onset of

    significant femoral head collapse
    SYMPTOMS

 or

    acetabular deformity
    SYMPTOMS

.

Avascular necrosis of the femoral head
Gaucher's disease
avascular necrosis of the femoral head
Gaucher's disease

aseptic loosening of the components
significant femoral head collapse
acetabular deformity


Antisulfatide antibody and neuropathy in a patient with Gaucher's disease.

We report the presence of antisulfatide antibodies in a patient with type I Gaucher's disease and peripheral neuropathy. The association of Gaucher's disease with hypergammaglobulinemia and monoclonal gammopathy is well documented whereas its association with peripheral neuropathy is rare. We discuss whether antibodies directed against the sulfatide antigen are related to Gaucher's disease or are a coincidental association.

We report the

    presence of antisulfatide antibodies
    BIOCHEMICAL

 in a patient with

    type I Gaucher's disease
    DIAGNOSIS

 and

    peripheral neuropathy
    SYMPTOMS

. The association of

    Gaucher's disease
    DIAGNOSIS

 with

    hypergammaglobulinemia
    BIOCHEMICAL

 and

    monoclonal gammopathy
    BIOCHEMICAL

 is well documented whereas its association with

    peripheral neuropathy
    SYMPTOMS

 is rare. We discuss whether

    antibodies directed against the sulfatide antigen
    BIOCHEMICAL

 are related to

    Gaucher's disease
    DIAGNOSIS

 or are a coincidental association.

type I Gaucher's disease
Gaucher's disease
Gaucher's disease

peripheral neuropathy
peripheral neuropathy