Four cases in a box

Case 1: at the age of 24 years

old…• Started complaining of pain in several joints

• Generalized fatigue developed over the course of several years

• No fever, no weight loss

• A presumed diagnosis of seronegative rheumatoidarthritis was made

• Apparently, one sister had the same complaints

• Is Turkish from origin, no consanguinity, alreadyfor several years in Belgium

• No job, normal developmental milestones

In 2009 (age 30 yrs) outpatient

clinic of hematology• Referral reason: unexplained splenomegaly

Biochemistry over the past years

- Anti-cyclic citrullinated peptide negative

- HLA B27 negative

- RF negative

- ANF negative

- CRP normal

- Ferritine level normal

- Platelets 92.000

Ultrasound of the knee

Synovial proliferation at the suprapatellar

recessus bilateral, right more than left

knee: suggestive of bilateral arthritis

Although clinically not very prominent

Summary case 1

• Young man of Turkish origin

• Chronic complaints of fatigue and joint

pain

• Splenomegaly and thrombocytopenia

• PAS-positive macrophages on bone

marrow biopsy

• Grocott stain positive: Histoplasma ?

•14 year old boy

•Not doing very well in school

•Complains of strange nagging,

burning sensation in hands/feet

•Extensive medical investigation

by paediatrician-rheumatologist:

no medical reason for boy’s

complaints

Case 2

•At age 25 yrs macroalbuminuria is established and angiokeratoma are found on the buttocks

•Renal biopsy shows PAS-positive material in endothelial cells

.

Renal biopsy

Conclusion case 2

• Young man with atypical pains in hand

and feet

• Proteinuria

• PAS-positive material in mainly podocytes

Case report 3: pain, growth

retardation• Boy aged 10, normal cognitive

development

• Last few years: occasionally

complaining of recurrent pain in belly

(left sided)

• Growth curve shifting (from P50 at age 7

to P10 at age 10)

• Taking a rest on the couch after coming

home from school

• Physical examination shows small-for-

age, lean child with enlarged spleen

• Blood testing reveals mild anaemia and

thrombocytopenia and slightly increased

liver enzymes

• Lost to follow up

• Presents at the age of 22 with pain in the lower back

• Treated for suspected osteomyelitis

• Massive enlargement of the spleen, biopsy: PAS-positive

materialParameter Value Reference

ESR 115 mm 0-15

CRP 50 mg/l <5.0

Hgb 13.8 g/dl 13.1-17.2

Wbc 14.6 x 10**9/l 3.9-9.5

Platelets 161 x 10**9/l 150-450

Hemokulturen steriel

Calcium 8 mg/dl 8.5-10

Fosfor 3.2 mg/dl 2.3-4.7

ALT 25 U/l 10-37

Alkfos 284 U/l 42-104

Gamma GT 16 U/l 10-49

Acid phosphatase staining

PAS staining in bone

marrow

Conclusion case 3

• Young man with pain in the back

• Splenomegaly

• PAS-positive material in the spleen and

bone marrow

Case report 4: muscle weakness• 17 year old boy, normal cognitive

development

• No special family history

• Multiple lower respiratory tract infections over last couple of years

• Stumbling often, avoiding sports

• Increasing difficulty descending & climbing stairs

• Moderate kyphoscoliosis

• Multiple consultations with various medical specialist (no diagnosis other than kyphoscoliosis)

• At age 20 years: unable to work full time > referral to rheumatologist in university hospital

• Full routine blood & urine testing shows significantly increased (10x) creatin kinase(CK) level

• Muscle biopsy: vacuoles in muscle fibers & loss of fibers

• PAS positive material

Conclusion case 4

• Young man with progressive muscle

weakness

• Raised CK-level

• PAS-positive material in muscle biopsy

PAS-positive material

• PAS staining is mainly used for staining structures containing a high proportion of

carbohydrate macromolecules (glycogen, glycoprotein, proteoglycans), typically

found in e.g. connective tissues, mucus, the glycocalyx, and basal laminae.

PAS staining can be used to assist in the diagnosis of several medical conditions:

• lysosomal storage disease (in macrophages !!!!)

• staining macrophages in Whipple's disease, leishmaniasis, histoplasmosis

• It can be used to diagnose α1-antitrypsin deficiency if periportal liver hepatocytes

stain positive.

• Some rare diseases: alveolar soft part sarcoma, erythroleukemia, mycosis fungoides,

Sezary syndrome

Lysosomes

Lysosomal Storage Diseases• > 50 genetic disorders

• Caused by deficiencies in genes encoding for lysosomal enzymes

• All LSD’s jointly affects an estimated 1:7500 newborns

• Wide spectrum of symptoms, signs and severity

Normal cell

Affected cell

Summary case 1

• Young man of Turkish origin

• Chronic complaints of fatigue and joint

pain

• Splenomegaly and thrombocytopenia

• PAS-positive macrophages on bone

marrow biopsy

• Grocott stain positive: Histoplasma ?

Disorders of sphingolipid metabolism

• Glycosphingolipids are formed in the Golgi apparatus by

sequential addition of monosaccharides to ceramide

• Sphingolipids are then transported and inserted in the

plasma membrane where they play a structural and

functional role.

• They are hydrolysed stepwise in the lysosome.

• Sphingolipidoses: a subgroup of lysosomal storage

disorders in which sphingolipids accumulate in one or

several organs as the result of a primary deficiency in

enzymes or activator proteins involved in their

degradative pathway.

Niemann-Pick type B/IS (n=3)Acid sfingomyelinase

Hepatosplenomegaly, decreased diffusion capacity

ing the lung, hyperlipidemia

D/ CE, radiology, APO (EM), enzyme activity, DNA

Globotriaosylceramide (Gb3)

Gal, galactose; Glc, glucose

Reproduced from Beck & Ries, Fabry disease: clinical manifestations, diagnosis and therapy. Oxford: OCC Europe Ltd;

2001 with permission

Gb3 is broken down into galactose and lactosylceramide

by the enzyme a-galactosidase A

Structure of Gb3

Fabry’s disease

Alpha-galactosidase A def. (X-linked dominant)

Cardiovascular symptoms (young stroke)

Renal failure (proteinuria NTx)

Neuropathic pain in hands and feet

Angiokeratoma

Hypertrophic cardiomyopathy

Adapted from Ries et al., Eur J Pediatr 2003;162:767–72 with permission. © Springer

Clinical findings in young male and female patients with

Fabry disease

Courtesy of Dr Jarl Ahlmén, Skövde, Sweden

Glomerular podocytes appear

enlarged and vacuolated

Lamellar myeloid bodies are

evident in different regions of

the glomerulus

Electron micrographs showing

podocytes

diseasePR intervals are short, there is

marked left ventricular hypertrophy and prominent ST depressions and

T-wave inversions

Magnetic resonance image showing the

characteristic symmetrical high signal in the

posterior thalamus in a patient with Fabry disease

Multiple hyperintensities in the white matter of the brain

in a woman with Fabry disease

AxialSagittal

T2-weighted magnetic resonance images of the brain of a 58-year-old

woman with Fabry disease showing multiple hyperintensities in the

central and subcortical white matter

Typical distribution of angiokeratomas on the skin of a

patient with Fabry disease

Increased vessel tortuosity in the

conjunctiva and retina of the eye

Conjunctiva Retina

Gaucher’s disease

galactose galactose glucose ceramide

a- galactosidase (Fabry disease )

- glucosidase (Gaucher disease)

galactocerebrosidase (Krabbe disease)

Gaucher’s disease (n=10)

Type I = adult, non-neuronopathic

Glucocerebrosidase-mutation

Storage of glucocerebroside in liver, spleen and

bone marrow

S/ Hepatosplenomegaly, anemia, trombocytopenia,

bone crises

R/ 1) Enzyme replacement (Cerezyme)

2) Substrate reduction (Zavesca)

Gaucher disease: autosomal recessive disorder

Check brothers and sisters!

Gaucher disease: different compartments are affected

Compression fracture

Pathologicfracture

Erlenmeyer deformation

Osteonecrosis/Osteopenia

Anaemia / Thrombocytopenia

Growth pain

Splenomegaly

Hepatomegaly

Growth retardation

Bone crisis

Cox TM, Schofield JP. Bailliere’s Clin Haematol. 1997;10:657-689.

Gaucher disease: clinical manifestations

Enlarged macrophage (Gaucher cell)

Infiltration of macrophages

in bone marrowNormal Homogeneous Heterogeneous

Hepatomegaly

Splenomegaly

Anaemia / Thrombocytopenia

Hepatosplenomegaly

Bone involvement: most debilitating

aspect of Gaucher disease

Erlenmeyer flask deformity

Osteopenia

Type II glycogenosis (Pompe)

Lysosomal alpha-glucosidase

R/ Myozyme (ERT)

Pathogenesis of Pompe

Disease

• GAA enzyme

essential for

degradation of

lysosomal

glycogen

• Inherited

enzyme

deficiency

results in

glycogen

accumulation

and lysosomal

distention

INTRODUCTION

Glycogen Accumulation Leads to Muscle

Tissue Destruction

INTRODUCTION

Electron microscopy in skeletal muscle of infantile patient. Magnification 6500x. Image courtesy of Genzyme Pathology.

Residual GAA activity is generally inversely correlated with disease severity

Infantile-onset Late-onset<1% of normal <40% of normal

Hirschhorn R, et al. In: The Metabolic and Molecular Bases of Inherited Disease. 2001:3389-3420.

PATHOLOGY

INFANTILE-ONSET* LATE-ONSET100%

0%

CL

INIC

AL

S

TA

TU

S RE

SID

UA

L G

AA

AC

TIV

ITY

(SK

IN F

IBR

OB

LA

ST

S)

501AGE (YEARS)

*CARDIOMYOPATHY

0%

100%

40%

Pompe Disease

Infantile onset < 12 months Late onset > 12 months

Head lag

Enlarged tongue

Respiratory

insufficiency

Delayed motor

development

Muscle weakness

Organomegaly

Cardiomegaly/

cardiomyopathy

Morning headacheDaytime somnolence

Shortness of breath/

sleep apnea

Scapular winging

Scoliosis

Low back pain

Muscle weakness

Hirschhorn R et al. In: The Metabolic and Molecular Bases of Inherited Disease. 2001:3389-3420.

Respiratory

insufficiency

Gait abnormality

Pompe Disease:

Typical Progression in Late Onset Cases

Skeletal Muscle Weakness Respiratory Muscle Weakness

Loss of Independent AmbulationRespiratory Failure (ventilator use)

Mucopolysaccharidosis (7 types)

MPS1 Hurler-Scheie

60

Umbilical hernia

Airway obstruction

Scoliosis

Lordosis

Hepatosplenomegaly

Growth retardation

Tip foot

Corneal clouding

Valvular disease/cardiomyopaty

Movement restrictions

“Claw hand”

Neufeld EF, Muenzer J. In: Scriver C,Beaudet A, Sly W, Valle D, eds.

The Metabolic and Molecular Bases of Inherited Disease. New York: McGraw Hill; 2001:3421-3452.

Dysostosis multiplex

MPS I (Hurler-Scheie)

Movement restriction in

the shoulder

Attenuated MPS I (Scheie): delayed

or missed diagnosis quite common

Severe, bilateral corneal clouding

Joint movement restrictions, like claw hand or trigger fingers

(Near) normal appearance

PAS-positive material: not always

infectionDisease Cell type Symptoms

Fabry Vascular endothelium

• Early onset: acroparesthesia,

angiokeratoma, cornea verticillata,

• Late complications: cardiac,

renal and CNS events

Gaucher Macrophages

• Haematological: pancytopenia

• Visceral: hepatosplenomegaly

• Skeletal: bone crises

Pompe Muscle cells

Muscle weakness, respiratory

insufficiency, cardiomegaly

(infantile onset)

MPS I

(Hurler-

Scheie)

Connective tissueJoint stiffness, claw hand,

umbilical hernia, dysostosis

multiplex