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