STEATOHEPATITIS AND UNSUSPECTED MICRONODULAR CIRRHOSIS

IN DORFMAN-CHANARIN SYNDROME WITH DOCUMENTED

ABHD5 MUTATION

RAMESH SRINIVASAN, MD, NEDIM HADZIC, MD, JUDITH FISCHER, MD, PHD, AND A. S. KNISELY, MD

Mutation in ABHD5 causes Dorfman-Chanarin syndrome (DCS), a multisystem triglyceride storage disorder. Ultrastructural

study of leukocytes confirmed DCS in a child homozygous for a novel ABHD5 mutation, with ichthyosis, developmental delay,

and steatohepatitis with cirrhosis, manifest only as elevated aminotranferase levels. We recommend early assessment for liver

disease in DCS. (J Pediatr 2004;144:662-5)

Dorfman-Chanarin syndrome (DCS, Mendelian Inheritance in Man 275630)1 is associated with neutral lipid (triglyceride)accumulation. The stored lipid (intracytoplasmic; extralysosomal; non–membrane-bound) occurs in droplets or vacuolesin cells stained after nonpolar solvent exposure. Such vacuoles within leukocytes constitute Jordans anomaly.2 Mutation in

both copies of ABHD5 (abhydrolase domain containing 5 [CGI-58]), a gene encoding an enzyme with an ab-hydrolase fold andesterase-lipase-thioesterase activity, causes DCS. The metabolic role of this enzyme is undetermined.3 The manifestation of DCSmost frequently seen in infancy is ichthyosis. Myopathy, steatosis, steatohepatitis, cholestasis, developmental delay or mentalretardation, sensorineural deafness, and cataracts may also occur1,4-6; severities vary. We report a girl with DCS, homozygous fora previously undescribed mutation in ABHD5 (A752C, P251H), in whom steatohepatitis progressed to unsuspected cirrhosis.

CASE REPORTA 7-year-old girl was referred for investigation of elevated serum aminotransferase

and creatine kinase values, discovered during assessment for learning difficulties. Born at38 weeks of gestation, she had collodion skin. Pregnancy was complicated by growthretardation (birth weight, 2.3 kg). Her healthy East Indian parents denied consanguinity.Extensive exfoliation in early life, with impaired thermohomeostasis, was followed bydelayed language and motor development. Some catch-up occurred, but on preschoolentry, concern prompted reevaluation.

The patient was slender (weight, 23.9 kg; height, 127.3 cm; body mass index, 14.75).Ichthyosis and erythroderma were diffuse, with fine, white scales. Hyperkeratosis wasmarked on palms and soles and at elbows, knees, and ankles. Bilateral ectropion andposterior embryotoxon were the only ocular abnormalities. The ears were normal.Attempts at histochemical demonstration of lipid within leukocyte vacuoles failed.Alanine/aspartate aminotransferase activities were elevated (306/200 IU/L, respectively;normal for both, <50), as was creatine kinase activity (618 IU/L; normal, <150).Autoantibodies and evidence of viral infection were not found. Alkaline phosphatase andgamma-glutamyl transpeptidase activities and albumin, ammonia, bilirubin, andimmunoglobulin concentrations were unremarkable. No thyroid function abnormalitywas identified. Urine and plasma amino acid screening results were normal. No evidencefor lead overload was found. Chromosomal analysis identified no abnormality.

She was referred to King’s College Hospital, where elevated aminotransferase andcreatine kinase activities were confirmed, as was absence of viral infection and autoimmune

From the Department of Child Healthand Institute of Liver Studies, King’sCollege Hospital, Denmark Hill, Lon-don, United Kingdom; and Dermato-logic Disease Projects, CentreNationalde Genotypage, Evry, France.Submitted for publication Aug 22, 2003;last revision received Dec 9, 2003;accepted Jan 12, 2004.

Reprints not available from the au-thors. Please address correspondenceto A. S. Knisely, Consultant Histopa-thologist, Institute of Liver Studies,King’s College Hospital, Denmark Hill,London SE5 9RS, United Kingdom.E-mail: alex.knisely@kcl.ac.uk.0022-3476/$ - see front matter

Copyrightª 2004 Elsevier Inc. All rightsreserved.

10.1016/j.jpeds.2004.01.036

ABHD5 Abhydrolase domain containing 5DCS Dorfman-Chanarin syndrome

NASH Nonalcoholic steatohepatitis

662

Fig 1. A, Liver biopsy. Cirrhosis is seen. Reticulin stain; original magnification 3100; bar, 250 l; B, Liver biopsy. Macrovesicular andmicrovesicular steatosis, with steatohepatitis, is found (note neutrophil leukocytes and hepatocyte damage, arrow). Hematoxylin & eosinstain; original magnification 3400; bar, 50 l.

disorder. The protease-inhibitor genotype was MM. Con-centrations of glycosylated hemoglobin (Hb) were not in-creased (HbA1c, 5.1%). Ceruloplasmin concentrations werenormal; urine and serum studies found no copper overload.Unusual long-chain fatty acids in plasma or bile acids in urinewere not detected. An acylcarnitine profile was normal.Cholesterol/triglycerides concentrations were 3.5/1.0 mmol/L, respectively. Sonography found increased diffuse hepaticreflectivity, consistent with fatty change. No abnormality wasfound in the biliary tree, major hepatic vessels, or spleen. Pure-tone audiometry revealed 60-/50-DB hearing losses (right/left, respectively), indicating bilateral sensorineural deafness.Electromyography disclosed proximal muscle weakness.

Light microscopy of skin and of liver found ichthyosisand well-developed micronodular cirrhosis (Fig 1, A). Hepaticcopper content in liver was not elevated (39 lg/g dry weight).Both microvesicular and macrovesicular steatosis involved>95% of hepatocytes, with steatohepatitis (Fig 1, B). Vacuoleswithin granulocyte, monocyte, and lymphocyte cytoplasm,abundant in Wright-Giemsa–stained blood films from thepatient (Fig 2, A) and each parent, contained fat on light andtransmission electron microscopy (Fig 2, B and C) of resin-embedded buffy-coat preparations postfixed in osmiumtetroxide.7 This confirmed Jordans anomaly and the diagnosisof DCS. The patient was prescribed hearing aids and a low-fat,

Steatohepatitis and Unsuspected Micronodular Cirrhosis in Dorfman-Chanarin Synwith Documented ABHD5 Mutation

low-protein, high-carbohydrate diet8,9 with ursodeoxycholicacid (20 mg/kg/day) and vitamin E (10 mg/kg/day). Over theensuing year, aspartate aminotransferase and creatine kinaseactivities fell to 64 and 352, respectively; lipids were un-changed.

Mutational analysis of ABHD5 (Centre National deGenotypage, Evry, France) was performed.3 The patient washomozygous for a mutation (A752C) in exon 5. This pre-viously unreported change substitutes proline for histidine atposition 251 (P251H), disrupting the ab-hydrolase fold,which is important for function.

DISCUSSIONOur patient met clinical and morphologic criteria for

DCS. We excluded ichthyotic (multiple sulfatase deficiency,ichthyosis-sclerosing cholangitis syndrome10) and degenera-tive disorders (systemic carnitine deficiency, Refsum disease,Wolman disease), in which leukocytes may be vacuolated,based on clinical and laboratory findings. Leukocyte vacuolesin ichthyosis-sclerosing cholangitis syndrome are nonlipidic[E. Jacquemin, personal communication]; clinical-biochem-istry evidence of biliary tract disease was lacking.

DCS in our patient was associated with homozygosityfor a mutation in ABHD5. Hers is the fourteenth instance of

drome663

Fig 2. A, Peripheral blood. Granulocyte cytoplasm contains optically clear vacuoles. Wright-Giemsa stain; original magnification 31000;bar, 6 l;. B, Peripheral blood, buffy coat preparation, fixed in paraformaldehyde-glutaraldehyde, postfixed in osmium tetroxide (OsO4),and embedded in resin. Gray inclusions within granulocytes (arrow) represent neutral lipid complexed with osmium. OsO4/toluidine blue,original magnification 31000; bar, 8 l; C, Peripheral blood, buffy coat preparation; transmission electron micrograph. Note that rippleddroplets of featureless osmicated neutral lipid within the granulocyte are not membrane-bound. OsO4/uranyl acetate/lead citrate, originalmagnification 316,500; bar, 1 l.

mutated ABHD5 in DCS and the ninth mutation in ABHD5described. How mutation in both copies of ABHD5 causesDCS is unclear, as is the intermediary-metabolism function ofthe protein encoded by ABHD5. Catabolism of long-chainfatty acids appears defective in DCS.4 Triglycerides are brokendown in DCS; but because released acylglycerols appear not toenter phospholipid synthesis, rapid resynthesis of triglyceridesmay mask lipolysis. How the product of ABHD5 contributesto cellular lipid storage remains obscure.

Diagnosis of Jordans anomaly by demonstration thatvacuoles within routinely stained leukocytes represent neutrallipid is possible by microscopy of buffy coat preparationspostfixed in osmium tetroxide. This should be rememberedwhen usual histochemistry gives inconclusive results in bloodfilms.

In DCS, hepatic steatosis with steatohepatitis canmove rapidly to cirrhosis. Our patient had nonalcoholicsteatohepatitis (NASH). Associated with progression inadults with NASH are older age, hyperlipidemia, diabetes,severe obesity, and elevated transaminase activity.11 Cirrhosisis exceptional in children with NASH.12 If DCS led to cir-rhosis in our patient, of note is that among reported adultrisk factors, only elevated aminotransferase activity was iden-tified. Additional pathogenetic mechanisms appear present

664 Srinivasan et al

in progression to cirrhosis in DCS. Patients with DCSshould perhaps prospectively receive vitamin E and ursodeoxy-cholic acid, thought to ameliorate NASH, and follow low-protein, low-fat, high-carbohydrate regimens reported to bebeneficial.8,9

REFERENCES1. Online Mendelian Inheritance in Man, OMIM (TM). Johns Hopkins

University, Baltimore, Md. MIM Number 275630, 25 August 2003. World

Wide Web URL: http://www.ncbi.nlm.nih.gov/omim/.

2. Jordans GHW. The familial occurrence of fat-containing vacuoles in the

leukocytes diagnosed in two brothers suffering from dystrophia musculorum

progressiva (Erb). Acta Med Scand 1953;145:419-23.

3. Lefevre C, Jobard F, Caux F, Bouadjar B, Karaduman A, Heilig R, et al.

Mutations in CGI-58, the gene encoding a new protein of the esterase/lipase/

thioesterase subfamily, in Chanarin-Dorfman syndrome. Am J Hum Genet

2001;69:1002-12.

4. Igal RA, Coleman RA. Neutral lipid storage disease: a genetic disorder

with abnormalities in the regulation of phospholipid metabolism. J Lipid Res

1998;39:31-43.

5. Srebrnik A, Brenner S, Ilie B, Messer G. Dorfman-Chanarin syndrome:

Morphologic studies and presentation of new cases. Am J Dermatopathol

1998;20:79-85.

6. Muranjan MN, Save SU, Deshmukh CT, Khubchandani SR, Bharucha

BA. Dorfman-Chanarin syndrome: a rare neutral lipid storage disease. Indian

Pediatr 2000;37:88-93.

The Journal of Pediatrics � May 2004

7. Watanabe I, Donahue S, Hoggatt N. Method for electron microscopic

studies of circulating human leukocytes and observations on their fine

structure. J Ultrastruct Res 1967;20:366-82.

8. Angelini C, Philippart M, Borrone C, Bresolin N, Cantini M, Lucke S.

Multisystem triglyceride storage disorder with impaired long-chain fatty acid

oxidation. Ann Neurol 1980;7:5-10.

9. Kakourou T, Drogari E, Christomanou H, Giannoulia A, Dacou-

Voutetakis C. Neutral lipid storage disease: Response to dietary intervention.

[letter]. Arch Dis Child 1997;77:184.

50 Years Ago in The Journal of PediatTREATMENTOF PURULENTMENINGITISWITH TE

SULFADIAZINE

Moll FC, Warmington W. J Pediatr 1954;44:541-6

It is interesting that after 50 years of intense research and kno

most significant controversies in meningitis have not changed s

antimicrobial therapy.

This series reports 31 children with purulent meningitis tre

Sulfadiazine) intended to empirically cover the most likely mi

antimicrobial use in the ambulatory setting before the diagnos

on the possibility of isolating the etiologic agent and on the p

valid today when the widespread use of antimicrobials is of univ

acquired antimicrobial resistance of common respiratory path

Neisseria meningitidis or Haemophilus influenzae were isolat

organism was detected. The absence of Streptococcus pneumon

neither H influenzae nor S pneumoniae are significant pathoge

including Latin America, S pneumoniae and N meningitidis a

influenzae continues to afflict children in the poorest areas of t

The basic concept guiding meningitis-associated antimicr

antimicrobial therapy based on local epidemiologic data to ster

by Moll and Warmington 50 years ago. Throughout the yea

chloramphenicol, sulfadiazine, ampicillin, third generation ce

resistant S pneumoniae. We foresee an escalation of antimicr

alternatives in the near future unless vaccines for H influenza

widely. For S pneumoniae, serotype coverage is expanded an

meningitides B is developed. In parallel, medical education en

Steatohepatitis and Unsuspected Micronodular Cirrhosis in Dorfman-Chanarin Synwith Documented ABHD5 Mutation

10. Baala L, Hadj-Rabia S, Hamel-Teillac D, Hadchouel M, Prost C, Leal

SM, et al. Homozygosity mapping of a locus for a novel syndromic ichthyosis

to chromosome 3q27-q28. J Invest Dermatol 2002;119:70-6.

11. Neuschwander-Tetri BA, Caldwell SH. Nonalcoholic steatohepatitis:

summary of an AASLD single topic conference. Hepatology 2003;37:1202-

19.

12. Molleston JP, White F, Teckman J, Fitzgerald JF. Obese children with

steatohepatitis can develop cirrhosis in childhood. Am J Gastroenterol

2002;97:2460-2.

ricsRRAMYCIN (OXYTETRACYCLINE) AND

wledge acquisition, Moll and Wamington show us that the

ubstantially, irrespective of the change in epidemiology and

ated with a ‘‘new’’ antimicrobial regimen (Terramycin and

croorganisms. The authors stress the concept of inadequate

is of meningitis and the negative impact that this likely has

rognosis of the meningitis episode. Both concepts are fully

ersal concern and responsible for a significant portion of the

ogens.

ed from 23 of 31 cases in this study, and in 8 children no

iae in this series is noticeable. Today in the United States,

ns in lieu of vaccination; in most of the developing world,

re the main pathogens associated with meningitis, and H

he world where vaccination has still not been implemented.

obial therapy today—prompt administration of empirical

ilize the cerebrospinal fluid within 24 hours—was promoted

rs, antimicrobials for meningitis have included penicillin,

phalosporins, and more recently, vancomycin in an era of

obial therapy to quinolones, carbapenems, and other new

e and groups A and C N meningitides are distributed more

d made more available, and a suitable alternative for N

couraging rational antimicrobial use is a worldwide need.

Marıa Elena Santolaya, MD

Hospital Luis Calvo Mackenna

Faculty of Medicine, Universidad de Chile

Santiago, Chile

YMPD77510.1016/j.jpeds.2004.02.004

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