Infantile gangliosidoses: Mapping a timeline of clinical changes.

BACKGROUND: Infantile gangliosidoses include GM1 gangliosidosis and GM2 gangliosidosis (Tay-Sachs disease, Sandhoff disease). To date, natural history studies in infantile GM2 (iGM2) have been retrospective and conducted through surveys. Compared to iGM2, there is even less natural history information available on infantile GM1 disease (iGM1). There are no approved treatments for infantile gangliosidoses. Substrate reduction therapy using miglustat has been tried, but is limited by gastrointestinal side effects. Development of effective treatments will require identification of meaningful outcomes in the setting of rapidly progressive and fatal diseases. OBJECTIVES: This study aimed to establish a timeline of clinical changes occurring in infantile gangliosidoses, prospectively, to: 1) characterize the natural history of these diseases; 2) improve planning of clinical care; and 3) identify meaningful future treatment outcome measures. METHODS: Patients were evaluated prospectively through ongoing clinical care. RESULTS: Twenty-three patients were evaluated: 8 infantile GM1, 9 infantile Tay-Sachs disease, 6 infantile Sandhoff disease. Common patterns of clinical change included: hypotonia before 6months of age; severe motor skill impairment within first year of life; seizures; dysphagia and feeding-tube placement before 18months of age. Neurodevelopmental testing scores reached the floor of the testing scale by 20 to 28months of age. Vertebral beaking, kyphosis, and scoliosis were unique to patients with infantile GM1. Chest physiotherapy was associated with increased survival in iGM1 (p=0.0056). Miglustat combined with a low-carbohydrate ketogenic diet (the Syner-G regimen) in patients who received a feeding-tube was associated with increased survival in infantile GM1 (p=0.025). CONCLUSIONS: This is the first prospective study of the natural history of infantile gangliosidoses and the very first natural history of infantile GM1. The homogeneity of the infantile gangliosidoses phenotype as demonstrated by the clinical events timeline in this study provides promising secondary outcome measure candidates. This study indicates that overall survival is a meaningful primary outcome measure for future clinical trials due to reliable timing and early occurrence of this event. Combination therapy approaches, instead of monotherapy approaches, will likely be the best way to optimize clinical outcomes. Combination therapy approaches include palliative therapies (e.g., chest physiotherapy) along with treatments that address the underlying disease pathology (e.g. miglustat or future gene therapies).

Adult GM1-gangliosidosis: clinical patterns and rectal biopsy.

We studied a family with adult GM1-gangliosidosis. The proband, aged 38, had slowly progressive extrapyramidal signs with prominent dystonia, starting at about age 19. Two other patients, aged 45 and 43, had occasional slight dystonia, but led normal social lives because of mildness of their symptoms. Rectal biopsy of the proband showed histiocytic infiltration and membranous cytoplasmic bodies in the autonomic neurons. This family shows the clinical heterogeneity in adult GM1-gangliosidosis.

A case of chronic GM1 gangliosidosis presenting as dystonia: clinical and biochemical studies.

Clinical and biochemical studies are reported on a 32-year-old man with GM1 gangliosidosis who presented with a slowly progressive dystonia that began when he was aged 7 years and eventually became almost totally incapacitating at the age of 35. There was only mild intellectual deterioration, but myoclonus, seizures and macular cherry-red spots were never observed. Proton-density and T2-weighted MRI scans showed symmetrical hyperintense lesions of both putamina. No increase of GM1 ganglioside was found in plasma or cerebrospinal fluid, and the metabolism of GM1 ganglioside in cultured skin fibroblasts from the patient was also almost normal, although the residual activity of GM1 ganglioside beta-galactosidase activity was only 10% of normal. These findings suggest that impaired GM1 ganglioside metabolism is not present systemically as it is in the infantile and juvenile types of the disorder, but is mainly confined to the central nervous system in chronic GM1 gangliosidosis.

Corneal clouding in GM1-generalized gangliosidosis.

Corneal clouding is added to the list of clinical and chemical abnormalities which occur both in GM1-generalized gangliosidosis and in Hurler's syndrome (and some other mucopolysaccharidoses). The parents of our patient were first cousin Yemeni and had partial beta-galactosidase deficiency in their leucocytes and cultured fibroblasts.

Clinical and biochemical pathophysiology of ataxia in the sphingolipidoses.

The sphingolipidoses are best defined as lysosomal storage disorders. Their manifestations can be explained on the basis of a few key principles that should all be verified before making a diagnosis. A genetic mutation may reduce the activity of a lysosomal hydrolase. Mutations of the hydrolases, respecting the active site, would not compromise their activity as tested in vitro but might interfere with the lysosomal functions. The undegraded substrates accumulate in the tissues where they are normally synthesized or taken up. The site and rate of storage define the clinical expression of the defect, which may include ataxia. Detailed, comprehensive, multidisciplinary studies emphasize the great complexity of the lysosomal storage disorders and the nonspecificity of single clinical, pathological, ultrastructural, or biochemical criteria. The possibility of inducing storage by chemical means points to aspects of the lysosomal physiology that have been neglected so far but that might also have genetic expression. Lysosomal hydrolases function in a controlled environment dependent on the lysosomal membrane, pH, and hypothetical dispersing agents. Any of these factors conceivably may be genetically impaired and give rise to apparently nonspecific storage.

Oculomotor abnormalities in chronic GM2 gangliosidosis.

The clinical and electro-oculographic eye abnormalities in chronic GM2 gangliosidosis have been described. The most prominent oculomotor disturbances in our patients involved the pursuit system. This was evident during performance of eye tracking and vestibulo-ocular reflex suppression. Saccadic eye movements were dysmetric but were normal in velocity. These findings point to disturbances of cerebellar oculomotor control. While the oculomotor defects are nonspecific in this chronic form of beta-hexosaminidase A deficiency, they broaden the spectrum of clinical features considered to be typical ocular manifestations in many storage diseases. Disturbances in the oculomotor system may be the only ocular sign of chronic GM2 gangliosidosis.

[Three siblings with type 3 GM1-gangliosidosis--pathophysiology of dystonia and MRI findings].

GM1-gangliosidosis is a rare neurovisceral storage disease caused by an inherited deficiency of acid beta-galactosidase. The characteristic neurological feature of type 3 (adult or chronic) GM1-gangliosidosis is usually a slowly progressive dystonia with dysarthria due to predominant involvement of basal ganglia. About 20 adult patients with this disorder have been reported in the literature. However, there are no reports of 3 brothers with type 3 GM1-gangliosidosis, and MRI findings. Case 1 (proband): A 28-year-old man was hospitalized because of facial grimace, dysarthria, and generalized dystonia. He was born after normal pregnancy and delivery. His development was normal until 3 years of age when the difficulties of speaking and walking were noticed by his parents. These neurological abnormalities progressed slowly and facial grimace and dystonic movements occurred 7 years later. He could not walk at 22 years of age. On admission, he was bedridden with marked scoliosis and subluxation of the mandibule. The communication was possible only by pointing the words written on the board. Case 2: A 33-year-old man, elder brother of case 1, showed the similar neurological features and clinical course. Slit-lamp examination revealed corneal opacities which were located in the deep stroma. Case 3: A 33-year-old man, elder brother of case 1 or case 2. At age 10-11, he noted similar symptoms as case 1 or case 2. The severity of dystonia was milder than his brothers. A diagnosis of GM1-gangliosidosis in three patients was made on the basis of the following data.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperpigmented macules and patches in a patient with GM1 type 1 gangliosidosis.

We report a case of a 10-month-old male infant with GM1 type 1 gangliosidosis who also had hyperpigmented macules and patches. Light and electron microscopic findings correlated with previously published reports on findings in skin biopsy specimens of patients with lipid storage disorders. The hyperpigmented macules are most likely mongolian spots. A differential diagnosis of these lesions is discussed.

Angiokeratoma corporis diffusum in GM1 gangliosidosis, type 1.

A patient with severe deficiency of beta-galactosidase, who developed skin lesions of angiokeratoma corporis diffusum between the 3rd and 10th month of life, is described. The activity of other lysosomal enzymes, including alpha-neuraminidase, was normal. The first signs of the disease were noticed during the first month of life. By 3 months coarseness of the face and psychomotor retardation were present. In addition to angiokeratoma, he had large mongolian spots and several scattered slate-blue spots of pigmentation over his body. With the exception of the skin lesions, the other clinical signs and the course of the psychomotor deterioration were within the clinical picture of GM1 gangliosidosis, Type 1. Angiokeratoma, a manifestation of several lysosomal disorders, may appear in GM1 gangliosidosis during the first year of life.

Conjunctival eye signs in GM1 type 1 gangliosidosis.

Two cases of GM1 type 1 gangliosidosis demonstrated microvascular abnormalities of the conjunctiva, as well as skin abnormalities in one case. This abnormality was studied by light and electron microscopy of a conjunctival biopsy; cytoplasmic vesicles were noted in the endothelial cells, producing a mechanical narrowing of the lumen. This storage material is similar to that seen in the fibroblasts of skin and of visceral organs in GM1 gangliosidosis, as well as to the material described in the systemic mucopolysaccharidoses. The material probably represents a keratan sulfate-like material. The conjunctiva provides a ready source for biopsy and diagnostic evaluation.

Post-partum psychosis in adult GM2 gangliosidosis. A case report.

Adult hexosaminidase A deficiency is a form of GM2 gangliosidosis with autosomal recessive inheritance. Only 35 cases (mostly among Ashkenazic Jews) have been reported worldwide. Symptoms include, in a third of the cases, psychosis. A 27-year-old sufferer with no prior psychiatric history, developed a post-partum psychosis, with affective and hebephrenic components, 3 days following her first delivery. She responded to lithium within 10 days of initiating treatment; the full episode lasted 1 month. We conclude that lithium is the preferred treatment for psychosis in such adult patients, especially in light of possible long-term neurological deterioration caused by phenothiazines. Ashkenazic Jews with atypical neurological syndromes presenting with psychosis should be tested for hexosaminidase A deficiency.

Generalized gangliosidosis type II (juvenile GM1 gangliosidosis). A pathological, histochemical and ultrastructural study.

Pathological, histochemical and ultrastructural studies on 3 siblings with GM1 gangliosidosis type II are reported. These studies support a biochemical defect with profound deficiency of beta-galactosidases which results in widespread accumulation of the GM1 ganglioside and its asialo derivative in brain and to a lesser extent in viscera, as well as in storage of a keratan sulphate-like mucopolysaccharide. Striking valvular changes in the heart without myocardial involvement were seen in all cases. The histochemical and ultrastructural changes are similar to those seen in GM1 gangliosidosis type I, though less severe. Autosomal recessive inheritance without apparent ethnic predilection seems likely.

Report of an infant with GM1 gangliosidosis type I and extensive and unusual mongolian spots.

An infant with GM1 gangliosidosis was found to have an eruption at birth consisting of extensive and unusual slate blue macules resembling mongolian spots. All areas of skin were involved except face, scalp, palms, and soles. A biopsy of a macule obtained at 5 months of age demonstrated melanocytic cells in the dermis consistent with monogolian spot but also a perivascular histiocytic infiltrate. At 8 months of age, absence of beta-galactosidase activity was documented in both peripheral leukocytes and skin fibroblasts confirming the diagnosis of GM1 gangliosidosis. The dermal histiocytic cells noted on skin biopsy were interpreted as a manifestation of this storage disease. The coexistence of the hyperpigmented lesions and the heritable enzyme defect was believed to be coincidental.

Infantile GM1-gangliosidosis with marked manifestation of lungs.

GM1-gangliosidosis is a disease characterized by abnormal accumulation of GM1-ganglioside in the brain and viscera. The disease is characterized by clinical findings similar to Hurler's disease and pathologic features resembling Niemann-Pick's disease but with involvement of the glomerular epithelium. A 14-month-old boy, clinically diagnosed as GM1-gangliosidosis, died of respiratory insufficiency and was autopsied except for the brain. Biochemically, marked increase of GM1-ganglioside in the viscera was demonstrated. Pathologically, the foam cells were present in the viscera. Some parts of the cytoplasmic vacuoles in the lungs and spleen contained osmiophilic fibrillar material electron-microscopically. This case was characterized by marked accumulation of foam cells in the pulmonary alveolar spaces.