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Consiglieri G, Tucci F, De Pellegrin M, Guerrini B, Cattoni A, Risca G, Scarparo S, Sarzana M, Pontesilli S, Mellone R, Gasperini S, Galimberti S, Silvani P, Filisetti C, Darin S, Forni G, Miglietta S, Santi L, Facchini M, Corti A, Fumagalli F, Cicalese MP, Calbi V, Migliavacca M, Barzaghi F, Ferrua F, Gallo V, Recupero S, Canarutto D, Doglio M, Tedesco L, Volpi N, Rovelli A, la Marca G, Valsecchi MG, Zancan S, Ciceri F, Naldini L, Baldoli C, Parini R, Gentner B, Aiuti A, Bernardo ME. Early skeletal outcomes after hematopoietic stem and progenitor cell gene therapy for Hurler syndrome. Sci Transl Med 2024; 16:eadi8214. [PMID: 38691622 DOI: 10.1126/scitranslmed.adi8214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 04/10/2024] [Indexed: 05/03/2024]
Abstract
Mucopolysaccharidosis type I Hurler (MPSIH) is characterized by severe and progressive skeletal dysplasia that is not fully addressed by allogeneic hematopoietic stem cell transplantation (HSCT). Autologous hematopoietic stem progenitor cell-gene therapy (HSPC-GT) provides superior metabolic correction in patients with MPSIH compared with HSCT; however, its ability to affect skeletal manifestations is unknown. Eight patients with MPSIH (mean age at treatment: 1.9 years) received lentiviral-based HSPC-GT in a phase 1/2 clinical trial (NCT03488394). Clinical (growth, measures of kyphosis and genu velgum), functional (motor function, joint range of motion), and radiological [acetabular index (AI), migration percentage (MP) in hip x-rays and MRIs and spine MRI score] parameters of skeletal dysplasia were evaluated at baseline and multiple time points up to 4 years after treatment. Specific skeletal measures were retrospectively compared with an external cohort of HSCT-treated patients. At a median follow-up of 3.78 years after HSPC-GT, all patients treated with HSPC-GT exhibited longitudinal growth within WHO reference ranges and a median height gain greater than that observed in patients treated with HSCT after 3-year follow-up. Patients receiving HSPC-GT experienced complete and earlier normalization of joint mobility compared with patients treated with HSCT. Mean AI and MP showed progressive decreases after HSPC-GT, suggesting a reduction in acetabular dysplasia. Typical spine alterations measured through a spine MRI score stabilized after HSPC-GT. Clinical, functional, and radiological measures suggested an early beneficial effect of HSPC-GT on MPSIH-typical skeletal features. Longer follow-up is needed to draw definitive conclusions on HSPC-GT's impact on MPSIH skeletal dysplasia.
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Affiliation(s)
- Giulia Consiglieri
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Francesca Tucci
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | | | | | - Alessandro Cattoni
- Paediatrics, IRCCS San Gerardo dei Tintori Foundation, 20900 Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Giulia Risca
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, 20854 Vedano al Lambro, Italy
| | - Stefano Scarparo
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Marina Sarzana
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Silvia Pontesilli
- Neuroradiology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Renata Mellone
- Radiology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Serena Gasperini
- Paediatrics, IRCCS San Gerardo dei Tintori Foundation, 20900 Monza, Italy
| | - Stefania Galimberti
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, 20854 Vedano al Lambro, Italy
- Units of Neurology and Neurophysiology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Paolo Silvani
- Anesthesia and Critical Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Chiara Filisetti
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
- "Vita-Salute" San Raffaele University, 20132 Milan, Italy
| | - Silvia Darin
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Giulia Forni
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, 50134 Florence, Italy
| | - Simona Miglietta
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Ludovica Santi
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Marcella Facchini
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Ambra Corti
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Francesca Fumagalli
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Maria Pia Cicalese
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
- "Vita-Salute" San Raffaele University, 20132 Milan, Italy
| | - Valeria Calbi
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Maddalena Migliavacca
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Federica Barzaghi
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Francesca Ferrua
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Vera Gallo
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Salvatore Recupero
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Daniele Canarutto
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Matteo Doglio
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Lucia Tedesco
- Paediatrics, IRCCS San Gerardo dei Tintori Foundation, 20900 Monza, Italy
| | - Nicola Volpi
- Department of Life Sciences, University of Modena and Reggio Emilia, Laboratory of Biochemistry and Glycobiology, 41125 Modena, Italy
| | - Attilio Rovelli
- Paediatrics, IRCCS San Gerardo dei Tintori Foundation, 20900 Monza, Italy
| | - Giancarlo la Marca
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, 50134 Florence, Italy
- Newborn Screening, Clinical Chemistry and Pharmacology Laboratory, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Maria Grazia Valsecchi
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, 20854 Vedano al Lambro, Italy
- Biostatistics and Clinical Epidemiology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Stefano Zancan
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Fabio Ciceri
- "Vita-Salute" San Raffaele University, 20132 Milan, Italy
- Department of Haematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Luigi Naldini
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
- "Vita-Salute" San Raffaele University, 20132 Milan, Italy
| | - Cristina Baldoli
- Neuroradiology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Rossella Parini
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
| | - Bernhard Gentner
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
- Ludwig Institute for Cancer Research and Department of Oncology, University of Lausanne (UNIL) and Lausanne University Hospital (CHUV), 1015 Lausanne, Switzerland
| | - Alessandro Aiuti
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
- "Vita-Salute" San Raffaele University, 20132 Milan, Italy
| | - Maria Ester Bernardo
- Pediatric Immunohematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), 20132 Milan, Italy
- "Vita-Salute" San Raffaele University, 20132 Milan, Italy
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Miller BS, Fung EB, White KK, Lund TC, Harmatz P, Orchard PJ, Whitley CB, Polgreen LE. Persistent bone and joint disease despite current treatments for mucopolysaccharidosis types I, II, and VI: Data from a 10-year prospective study. J Inherit Metab Dis 2023; 46:695-704. [PMID: 36840680 PMCID: PMC10824391 DOI: 10.1002/jimd.12598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 02/02/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023]
Abstract
The mucopolysaccharidosis (MPS) disorders have many potential new therapies on the horizon. Thus, historic control data on disease progression and variability are urgently needed. We conducted a 10-year prospective observational study of 55 children with MPS IH (N = 23), MPS IA (N = 10), non-neuronopathic MPS II (N = 13), and MPS VI (N = 9) to systematically evaluate bone and joint disease. Annual measurements included height, weight, and goniometry. Mixed effects modeling was used to evaluate changes over time. All participants had been treated with hematopoietic cell transplantation and/or enzyme replacement therapy. Height z-score decreased over time in MPS IH, MPS II, and MPS VI, but not MPS IA. Adult heights were 136 ± 10 cm in MPS IH, 161 ± 11 cm in MPS IA, 161 ± 14 cm in MPS II, and 128 ± 15 cm in MPS VI. Adult average BMI percentiles were high: 75 ± 30%ile in MPS IH, 71 ± 37%ile in MPS IA, 71 ± 25%ile in MPS II, and 60 ± 42%ile in MPS VI. Every participant had joint contractures of the shoulders, elbows, hips, and/or knees. Joint contractures remained stable over time. In conclusion, despite current treatments for MPS I, II, and VI, short stature and joint contractures persist. The elevation in average BMI may be related, in part, to physical inactivity due to the ongoing bone and joint disease. Data from this longitudinal historical control study may be used to expedite testing of experimental bone and joint directed therapies and to highlight the need for weight management as part of routine clinical care for patients with MPS.
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Affiliation(s)
- Bradley S Miller
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ellen B Fung
- Divisions of Hematology and Gastroenterology, University of California, San Francisco Benioff Children's Hospital, Oakland, California, USA
| | - Klane K White
- Department of Orthopedics, University of Colorado, Denver, Colorado, USA
| | | | - Paul Harmatz
- Divisions of Hematology and Gastroenterology, University of California, San Francisco Benioff Children's Hospital, Oakland, California, USA
| | - Paul J Orchard
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chester B Whitley
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lynda E Polgreen
- Institute for Translational Genomics and Population Sciences, The Lundquist Institute, and Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California, USA
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MPSI Manifestations and Treatment Outcome: Skeletal Focus. Int J Mol Sci 2022; 23:ijms231911168. [PMID: 36232472 PMCID: PMC9569890 DOI: 10.3390/ijms231911168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/16/2022] [Accepted: 09/17/2022] [Indexed: 11/23/2022] Open
Abstract
Mucopolysaccharidosis type I (MPSI) (OMIM #252800) is an autosomal recessive disorder caused by pathogenic variants in the IDUA gene encoding for the lysosomal alpha-L-iduronidase enzyme. The deficiency of this enzyme causes systemic accumulation of glycosaminoglycans (GAGs). Although disease manifestations are typically not apparent at birth, they can present early in life, are progressive, and include a wide spectrum of phenotypic findings. Among these, the storage of GAGs within the lysosomes disrupts cell function and metabolism in the cartilage, thus impairing normal bone development and ossification. Skeletal manifestations of MPSI are often refractory to treatment and severely affect patients’ quality of life. This review discusses the pathological and molecular processes leading to impaired endochondral ossification in MPSI patients and the limitations of current therapeutic approaches. Understanding the underlying mechanisms responsible for the skeletal phenotype in MPSI patients is crucial, as it could lead to the development of new therapeutic strategies targeting the skeletal abnormalities of MPSI in the early stages of the disease.
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Maier S, Zivicnjak M, Grigull L, Hennermann JB, Aries C, Maecker‐Kolhoff B, Sauer M, Das AM, Beier R. Predictors of growth patterns in children with mucopolysaccharidosis I after haematopoietic stem cell transplantation. JIMD Rep 2022; 63:371-378. [PMID: 35822096 PMCID: PMC9259397 DOI: 10.1002/jmd2.12291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 03/31/2022] [Accepted: 04/11/2022] [Indexed: 12/15/2022] Open
Abstract
Mucopolysaccharidosis type I (MPS I) is an autosomal‐recessive metabolic disorder caused by an enzyme deficiency of lysosomal alpha‐l‐iduronidase (IDUA). Haematopoietic stem cell transplantation (HSCT) is the therapeutic option of choice in MPS I patients younger than 2.5 years, which has a positive impact on neurocognitive development. However, impaired growth remains a problem. In this monocentric study, 14 patients with MPS I (mean age 1.72 years, range 0.81–3.08) were monitored according to a standardised follow‐up program after successful allogeneic HSCT. A detailed anthropometric program was carried out to identify growth patterns and to determine predictors of growth in these children. All patients are alive and in outpatient care (mean follow‐up 8.1 years, range 0.1–16.0). Progressively lower standard deviation scores (SDS) were observed for body length (mean SDS −1.61; −4.58 – 3.29), weight (−0.56; −3.19 – 2.95), sitting height (−3.28; −7.37 – 0.26), leg length (−1.64; −3.88 – 1.49) and head circumference (0.91; −2.52 – 6.09). Already at the age of 24 months, significant disproportions were detected being associated with increasing deterioration in growth for age. Younger age at HSCT, lower counts for haemoglobin and platelets, lower potassium, higher donor‐derived chimerism, higher counts for leukocytes and recruitment of a matched unrelated donor (MUD) positively correlated with body length (p ≤ 0.05). In conclusion, this study characterised predictors and aspects of growth patterns in children with MPS I after HSCT, underlining that early HSCT of MUD is essential for slowing body disproportion.
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Affiliation(s)
- Stefanie Maier
- Department of Paediatric Haematology and Oncology Hannover Medical School Hannover Germany
| | - Miroslav Zivicnjak
- Department of Paediatric Kidney Liver and Metabolic Diseases at Hannover Medical School Hannover Germany
| | - Lorenz Grigull
- Rare Disease Centre, Bonn University Medical Centre Bonn Germany
| | - Julia B. Hennermann
- Villa Metabolica, Department of Paediatric and Adolescent Medicine University Medical Centre Mainz Germany
| | - Charlotte Aries
- Department of Paediatrics Hamburg‐Eppendorf University Medical Centre Hamburg Germany
| | - Britta Maecker‐Kolhoff
- Department of Paediatric Haematology and Oncology Hannover Medical School Hannover Germany
| | - Martin Sauer
- Department of Paediatric Haematology and Oncology Hannover Medical School Hannover Germany
| | - Anibh M. Das
- Department of Paediatric Kidney Liver and Metabolic Diseases at Hannover Medical School Hannover Germany
| | - Rita Beier
- Department of Paediatric Haematology and Oncology Hannover Medical School Hannover Germany
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Stepien KM, Bentley A, Chen C, Dhemech MW, Gee E, Orton P, Pringle C, Rajan J, Saxena A, Tol G, Gadepalli C. Non-cardiac Manifestations in Adult Patients With Mucopolysaccharidosis. Front Cardiovasc Med 2022; 9:839391. [PMID: 35321113 PMCID: PMC8935042 DOI: 10.3389/fcvm.2022.839391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/10/2022] [Indexed: 12/12/2022] Open
Abstract
Mucopolysaccharidoses (MPS) are a heterogeneous group of disorders that results in the absence or deficiency of lysosomal enzymes, leading to an inappropriate storage of glycosaminoglycans (GAGs) in various tissues of the body such as bones, cartilage, heart valves, arteries, upper airways, cornea, teeth, liver and nervous system. Clinical manifestations can become progressively exacerbated with age and affect their quality of life. Developments in advanced supportive treatment options such as enzyme replacement therapy (ERT), hematopoietic stem cell transplantation (HSCT) may have improved patients' life span. Adult MPS patients require specialist clinical surveillance long-term. In many cases, in addition to the MPS-related health problems, they may develop age-related complications. Considering the complexity of their clinical manifestations and lack of guidelines on the management of adult MPS disorders, multispecialty and multidisciplinary teams' care is essential to diagnose and treat health problems that are likely to be encountered. This review presents non-cardiac clinical manifestations, their pathophysiology, management and long-term outcomes in adult MPS patients.
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Affiliation(s)
- Karolina M. Stepien
- Adult Inherited Metabolic Diseases, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Andrew Bentley
- Northwest Ventilation Unit and Sleep Department, Wythenshawe Hospital, Manchester University National Health Service Foundation Trust, Manchester, United Kingdom
- Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
- Intensive Care & Respiratory Medicine, Manchester University National Health Service Foundation Trust, Manchester, United Kingdom
| | - Cliff Chen
- Clinical Neuropsychology, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - M. Wahab Dhemech
- Northwest Ventilation Unit and Sleep Department, Wythenshawe Hospital, Manchester University National Health Service Foundation Trust, Manchester, United Kingdom
| | - Edward Gee
- Trauma and Orthopaedic Surgery, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Peter Orton
- Trauma and Orthopaedic Surgery, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Catherine Pringle
- Neurosurgery, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Jonathan Rajan
- Manchester and Salford Pain Centre, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Ankur Saxena
- Neurosurgery, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Govind Tol
- Anaesthetics Department, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Chaitanya Gadepalli
- Ear, Nose and Throat, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
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Roth J, Inbar-Feigenberg M, Raiman J, Bisch M, Chakraborty P, Mitchell J, Di Geso L. Ultrasound findings of finger, wrist and knee joints in Mucopolysaccharidosis Type I. Mol Genet Metab 2021; 133:289-296. [PMID: 34090760 DOI: 10.1016/j.ymgme.2021.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/19/2021] [Accepted: 05/25/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Musculoskeletal findings in MPS can progress after enzyme replacement. Our aim was to examine synovial recesses, tendons, retinacula and pulleys using ultrasonography for structural and inflammatory changes. MATERIAL AND METHODS The wrist, metacarpophalangeal (MCP), proximal and distal interphalangeal (PIP and DIP) joints, the finger flexor tendons and the knee including entheses of quadriceps and patella tendons were assessed clinically. Ultrasonography of the various synovial recesses of the wrist as well as the extensor retinaculum, carpal tunnel, MCP, PIP and DIP joints of the second finger, extensor and flexor tendons, A1-5 pulleys and the knee joint including relevant entheses followed. Significance of differences between patient values and available normative data were assessed using t-tests. RESULTS Ultrasonography showed significant abnormal intraarticular material in the wrist without a clear distribution to synovial recesses and without effusions. Doppler signals were found in a perisynovial distribution and not intrasynovial as expected in in inflammatory arthritis. Findings were similar in the knee but not the fingers. Flexor and extensor tendons were also mostly normal in their structure but significant thickening of retinaculae and the flexor tendon pulleys was seen (p<0.0001 compared to normal). CONCLUSION MPS I patients showed intraarticular deposition of abnormal material in the wrist and knee but not in the finger joints where significant thickening of retinaculae/pulleys controlling tendon position was dominant. No ultrasound findings of inflammatory pathology were demonstrated but rather a secondary reaction to abnormal deposition and direct damage of GAG.
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Affiliation(s)
- Johannes Roth
- Division of Pediatric Dermatology and Rheumatology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.
| | - Michal Inbar-Feigenberg
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Julian Raiman
- Department of Inherited Metabolic Disease, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, UK
| | - Marg Bisch
- Division of Pediatric Dermatology and Rheumatology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Pranesh Chakraborty
- Newborn Screening Ontario and Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - John Mitchell
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Luca Di Geso
- Ospedale Provinciale Madonna del Soccorso, Department of Internal Medicine, San Benedetto del Tronto, Marche, Italy
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van der Veer EL, Gielis WP, Weinans H, Beek EJ, van Hasselt PM, Sakkers RJB. Quantifying the Effects of Hip Surgery on the Sphericity of the Femoral Head in Patients with Mucopolysaccharidosis Type I. J Bone Joint Surg Am 2021; 103:489-496. [PMID: 33443965 DOI: 10.2106/jbjs.20.00515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The introduction of stem cell transplantation has improved life expectancy and cognitive outcome in patients with mucopolysaccharidosis I, but this condition remains associated with substantial residual disease in several parts of the body. Many patients have hip dysplasia with progressive medial flattening of the femoral head. Quantitative evidence on the effect of surgery on remodeling to sphericity of flattened femoral heads is lacking. In the present study, we used statistical shape modeling to quantify the effect of hip surgery on the sphericity of the femoral head in patients with mucopolysaccharidosis I. METHODS We performed a retrospective case control study involving a series of 23 patients with hip dysplasia due to mucopolysaccharidosis I. Surgery was not offered to the first 11 children (control group). Following a change in treatment protocol, the next 12 children underwent bilateral proximal femoral varus derotation osteotomy and Pemberton osteotomy for the treatment of acetabular dysplasia with progressive femoral head flattening (surgery group). The surgery and control groups were compared with a reference group of patients with normal hips. Statistical shape modeling was used to quantify the shape of the femoral head (i.e., flattening and/or roundness of the epiphysis). RESULTS The mean age at the time of stem cell transplantation in the surgery and control groups was comparable (1.2 years). The mean age at the time of surgical intervention was 5.5 years, and mean duration of postoperative follow-up was 3.3 years. Statistical shape modeling showed variations within the total group in terms of medial indentation, width, height, and sphericity of the femoral heads. In contrast to the progressive femoral head flattening in the control group, the surgery group showed improvement of the sphericity of the femoral head after surgery. The overall shape characteristics of the femoral head in the surgery group were similar to those of the reference group of patients with normal hips. CONCLUSIONS To our knowledge, this is the first study in patients with mucopolysaccharidosis I that has shown quantitative remodeling of the dysplastic, flattened femoral head to normal sphericity after increasing containment of the femoral head. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Eline L van der Veer
- Departments of Orthopedic Surgery (E.L.v.d.V., H.W., and R.J.B.S.), Radiology (E.J.B.), and Pediatrics (P.M.v.H.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - Willem Paul Gielis
- Departments of Orthopedic Surgery (E.L.v.d.V., H.W., and R.J.B.S.), Radiology (E.J.B.), and Pediatrics (P.M.v.H.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - Harry Weinans
- Departments of Orthopedic Surgery (E.L.v.d.V., H.W., and R.J.B.S.), Radiology (E.J.B.), and Pediatrics (P.M.v.H.), University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Biomechanical Engineering, Technical University Delft, Delft, the Netherlands
| | - Erik J Beek
- Departments of Orthopedic Surgery (E.L.v.d.V., H.W., and R.J.B.S.), Radiology (E.J.B.), and Pediatrics (P.M.v.H.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter M van Hasselt
- Departments of Orthopedic Surgery (E.L.v.d.V., H.W., and R.J.B.S.), Radiology (E.J.B.), and Pediatrics (P.M.v.H.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ralph J B Sakkers
- Departments of Orthopedic Surgery (E.L.v.d.V., H.W., and R.J.B.S.), Radiology (E.J.B.), and Pediatrics (P.M.v.H.), University Medical Center Utrecht, Utrecht, the Netherlands
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Oussoren E, Wagenmakers MAEM, Link B, van der Meijden JC, Pijnappel WWMP, Ruijter GJG, Langeveld M, van der Ploeg AT. Hip disease in Mucopolysaccharidoses and Mucolipidoses: A review of mechanisms, interventions and future perspectives. Bone 2021; 143:115729. [PMID: 33130340 DOI: 10.1016/j.bone.2020.115729] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 11/20/2022]
Abstract
The hips are frequently involved in inheritable diseases which affect the bones. The clinical and radiological presentation of these diseases may be very similar to common hip disorders as developmental dysplasia of the hip, osteoarthritis and avascular necrosis, so the diagnosis may be easily overlooked and treatment may be suboptimal. Mucopolysaccharidosis (MPS) and Mucolipidosis (ML II and III) are lysosomal storage disorders with multisystemic involvement. Characteristic skeletal abnormalities, known as dysostosis multiplex, are common in MPS and ML and originate from intra-lysosomal storage of glycosaminoglycans in cells of the cartilage, bones and ligaments. The hip joint is severely affected in MPS and ML. Hip pathology results in limitations in mobility and pain from young age, and negatively affects quality of life. In order to better understand the underlying process that causes hip disease in MPS and ML, this review first describes the normal physiological (embryonic) hip joint development, including the interplay between the acetabulum and the femoral head. In the second part the factors contributing to altered hip morphology and function in MPS and ML are discussed, such as abnormal development of the pelvic- and femoral bones (which results in altered biomechanical forces) and inflammation. In the last part of this review therapeutic options and future perspectives are addressed.
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Affiliation(s)
- Esmee Oussoren
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Margreet A E M Wagenmakers
- Department of Internal Medicine, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Bianca Link
- Division of Metabolism, Connective Tissue Unit, University Children's Hospital Zurich, Zurich, Switzerland.
| | - Jan C van der Meijden
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - W W M Pim Pijnappel
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Clinical Genetics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - George J G Ruijter
- Department of Clinical Genetics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Mirjam Langeveld
- Department of Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Ans T van der Ploeg
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Clinical Genetics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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9
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Hampe CS, Wesley J, Lund TC, Orchard PJ, Polgreen LE, Eisengart JB, McLoon LK, Cureoglu S, Schachern P, McIvor RS. Mucopolysaccharidosis Type I: Current Treatments, Limitations, and Prospects for Improvement. Biomolecules 2021; 11:189. [PMID: 33572941 PMCID: PMC7911293 DOI: 10.3390/biom11020189] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 12/16/2022] Open
Abstract
Mucopolysaccharidosis type I (MPS I) is a lysosomal disease, caused by a deficiency of the enzyme alpha-L-iduronidase (IDUA). IDUA catalyzes the degradation of the glycosaminoglycans dermatan and heparan sulfate (DS and HS, respectively). Lack of the enzyme leads to pathologic accumulation of undegraded HS and DS with subsequent disease manifestations in multiple organs. The disease can be divided into severe (Hurler syndrome) and attenuated (Hurler-Scheie, Scheie) forms. Currently approved treatments consist of enzyme replacement therapy (ERT) and/or hematopoietic stem cell transplantation (HSCT). Patients with attenuated disease are often treated with ERT alone, while the recommended therapy for patients with Hurler syndrome consists of HSCT. While these treatments significantly improve disease manifestations and prolong life, a considerable burden of disease remains. Notably, treatment can partially prevent, but not significantly improve, clinical manifestations, necessitating early diagnosis of disease and commencement of treatment. This review discusses these standard therapies and their impact on common disease manifestations in patients with MPS I. Where relevant, results of animal models of MPS I will be included. Finally, we highlight alternative and emerging treatments for the most common disease manifestations.
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Affiliation(s)
| | | | - Troy C. Lund
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA; (T.C.L.); (P.J.O.); (J.B.E.)
| | - Paul J. Orchard
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA; (T.C.L.); (P.J.O.); (J.B.E.)
| | - Lynda E. Polgreen
- The Lundquist Institute at Harbor, UCLA Medical Center, Torrance, CA 90502, USA;
| | - Julie B. Eisengart
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA; (T.C.L.); (P.J.O.); (J.B.E.)
| | - Linda K. McLoon
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Sebahattin Cureoglu
- Department of Otolaryngology, Head and Neck Surgery, University of Minnesota, Minneapolis, MN 55455, USA; (S.C.); (P.S.)
| | - Patricia Schachern
- Department of Otolaryngology, Head and Neck Surgery, University of Minnesota, Minneapolis, MN 55455, USA; (S.C.); (P.S.)
| | - R. Scott McIvor
- Immusoft Corp, Minneapolis, MN 55413, USA;
- Department of Genetics, Cell Biology and Development and Center for Genome Engineering, University of Minnesota, Minneapolis, MN 55455, USA
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10
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Jiang Z, Byers S, Casal ML, Smith LJ. Failures of Endochondral Ossification in the Mucopolysaccharidoses. Curr Osteoporos Rep 2020; 18:759-773. [PMID: 33064251 PMCID: PMC7736118 DOI: 10.1007/s11914-020-00626-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW The mucopolysaccharidoses (MPS) are a group of inherited lysosomal storage disorders characterized by abnormal accumulation of glycosaminoglycans (GAGs) in cells and tissues. MPS patients frequently exhibit failures of endochondral ossification during postnatal growth leading to skeletal deformity and short stature. In this review, we outline the current understanding of the cellular and molecular mechanisms underlying failures of endochondral ossification in MPS and discuss associated treatment challenges and opportunities. RECENT FINDINGS Studies in MPS patients and animal models have demonstrated that skeletal cells and tissues exhibit significantly elevated GAG storage from early in postnatal life and that this is associated with impaired cartilage-to-bone conversion in primary and secondary ossification centers, and growth plate dysfunction. Recent studies have begun to elucidate the underlying cellular and molecular mechanisms, including impaired chondrocyte proliferation and hypertrophy, diminished growth factor signaling, disrupted cell cycle progression, impaired autophagy, and increased cell stress and apoptosis. Current treatments such as hematopoietic stem cell transplantation and enzyme replacement therapy fail to normalize endochondral ossification in MPS. Emerging treatments including gene therapy and small molecule-based approaches hold significant promise in this regard. Failures of endochondral ossification contribute to skeletal deformity and short stature in MPS patients, increasing mortality and reducing quality of life. Early intervention is crucial for effective treatment, and there is a critical need for new approaches that normalize endochondral ossification by directly targeting affected cells and signaling pathways.
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Affiliation(s)
- Zhirui Jiang
- Department of Orthopedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, 371 Stemmler Hall, 3450 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Sharon Byers
- Genetics and Molecular Pathology, SA Pathology, Adelaide, SA, Australia
- Paediatrics, The University of Adelaide, Adelaide, SA, Australia
- Genetics and Evolution, The University of Adelaide, Adelaide, SA, Australia
| | - Margret L Casal
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lachlan J Smith
- Department of Orthopedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, 371 Stemmler Hall, 3450 Hamilton Walk, Philadelphia, PA, 19104, USA.
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11
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Nath SC, Harper L, Rancourt DE. Cell-Based Therapy Manufacturing in Stirred Suspension Bioreactor: Thoughts for cGMP Compliance. Front Bioeng Biotechnol 2020; 8:599674. [PMID: 33324625 PMCID: PMC7726241 DOI: 10.3389/fbioe.2020.599674] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/30/2020] [Indexed: 12/23/2022] Open
Abstract
Cell-based therapy (CBT) is attracting much attention to treat incurable diseases. In recent years, several clinical trials have been conducted using human pluripotent stem cells (hPSCs), and other potential therapeutic cells. Various private- and government-funded organizations are investing in finding permanent cures for diseases that are difficult or expensive to treat over a lifespan, such as age-related macular degeneration, Parkinson’s disease, or diabetes, etc. Clinical-grade cell manufacturing requiring current good manufacturing practices (cGMP) has therefore become an important issue to make safe and effective CBT products. Current cell production practices are adopted from conventional antibody or protein production in the pharmaceutical industry, wherein cells are used as a vector to produce the desired products. With CBT, however, the “cells are the final products” and sensitive to physico- chemical parameters and storage conditions anywhere between isolation and patient administration. In addition, the manufacturing of cellular products involves multi-stage processing, including cell isolation, genetic modification, PSC derivation, expansion, differentiation, purification, characterization, cryopreservation, etc. Posing a high risk of product contamination, these can be time- and cost- prohibitive due to maintenance of cGMP. The growing demand of CBT needs integrated manufacturing systems that can provide a more simple and cost-effective platform. Here, we discuss the current methods and limitations of CBT, based upon experience with biologics production. We review current cell manufacturing integration, automation and provide an overview of some important considerations and best cGMP practices. Finally, we propose how multi-stage cell processing can be integrated into a single bioreactor, in order to develop streamlined cGMP-compliant cell processing systems.
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Affiliation(s)
- Suman C Nath
- Department of Biochemistry & Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lane Harper
- Department of Biochemistry & Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Derrick E Rancourt
- Department of Biochemistry & Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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12
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Hampe CS, Eisengart JB, Lund TC, Orchard PJ, Swietlicka M, Wesley J, McIvor RS. Mucopolysaccharidosis Type I: A Review of the Natural History and Molecular Pathology. Cells 2020; 9:cells9081838. [PMID: 32764324 PMCID: PMC7463646 DOI: 10.3390/cells9081838] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 07/31/2020] [Accepted: 08/02/2020] [Indexed: 12/14/2022] Open
Abstract
Mucopolysaccharidosis type I (MPS I) is a rare autosomal recessive inherited disease, caused by deficiency of the enzyme α-L-iduronidase, resulting in accumulation of the glycosaminoglycans (GAGs) dermatan and heparan sulfate in organs and tissues. If untreated, patients with the severe phenotype die within the first decade of life. Early diagnosis is crucial to prevent the development of fatal disease manifestations, prominently cardiac and respiratory disease, as well as cognitive impairment. However, the initial symptoms are nonspecific and impede early diagnosis. This review discusses common phenotypic manifestations in the order in which they develop. Similarities and differences in the three animal models for MPS I are highlighted. Earliest symptoms, which present during the first 6 months of life, include hernias, coarse facial features, recurrent rhinitis and/or upper airway obstructions in the absence of infection, and thoracolumbar kyphosis. During the next 6 months, loss of hearing, corneal clouding, and further musculoskeletal dysplasias develop. Finally, late manifestations including lower airway obstructions and cognitive decline emerge. Cardiac symptoms are common in MPS I and can develop in infancy. The underlying pathogenesis is in the intra- and extracellular accumulation of partially degraded GAGs and infiltration of cells with enlarged lysosomes causing tissue expansion and bone deformities. These interfere with the proper arrangement of collagen fibrils, disrupt nerve fibers, and cause devastating secondary pathophysiological cascades including inflammation, oxidative stress, and other disruptions to intracellular and extracellular homeostasis. A greater understanding of the natural history of MPS I will allow early diagnosis and timely management of the disease facilitating better treatment outcomes.
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Affiliation(s)
- Christiane S. Hampe
- Immusoft Corp, Seattle, WA 98103, USA; (M.S.); (J.W.)
- Correspondence: ; Tel.: +1-206-554-9181
| | - Julie B. Eisengart
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA; (J.B.E.); (T.C.L.); (P.J.O.)
| | - Troy C. Lund
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA; (J.B.E.); (T.C.L.); (P.J.O.)
| | - Paul J. Orchard
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA; (J.B.E.); (T.C.L.); (P.J.O.)
| | | | - Jacob Wesley
- Immusoft Corp, Seattle, WA 98103, USA; (M.S.); (J.W.)
| | - R. Scott McIvor
- Immusoft Corp, Minneapolis, MN 55413, USA; or
- Department of Genetics, Cell Biology and Development and Center for Genome Engineering, University of Minnesota, Minneapolis, MN 55413, USA
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13
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Wang Z, Xu Y, Jiang E, Wang J, Tomatsu S, Shen K. Pathophysiology of Hip Disorders in Patients with Mucopolysaccharidosis IVA. Diagnostics (Basel) 2020; 10:E264. [PMID: 32365519 PMCID: PMC7277472 DOI: 10.3390/diagnostics10050264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 01/12/2023] Open
Abstract
Patients with mucopolysaccharidoses IVA (MPS IVA) have a progressive accumulation of the specific glycosaminoglycans (GAGs): chondroitin-6-sulfate (C6S) and keratan sulfate (KS), leading to the degeneration of the cartilage matrix and its connective tissue perturbing the regular microarchitecture of cartilage and successively distorting bone ossification and growth. Impaired cartilage quality and poor bone mineralization lead to serious hip disorders in MPS IVA patients. Although hip dysplasia is seen widely in musculoskeletal abnormality of this disorder, the pathophysiology of the hip bone and cartilage morphology in these patients remains unclear. Until now, no systemic study of the hip joints in MPS IVA has been reported by using the combined images of plain film radiographs (PFR) and Magnetic Resonance Imaging (MRI). This study aimed to assess the bony and cartilaginous features of hip joints and to explore the potentially related factors of femoral head osteonecrosis (FHN) and hip subluxation/dislocation in patients with MPS IVA. Hip joints in MPS IVA patients were retrospectively reviewed, based on the findings of PFR and MRI data from 2014 to 2019. Demographic information was also collected and analyzed with imaging measurements. A total of 19 patients (eight boys and 11 girls) were recruited, and 38 hip joints in these patients were examined. Eleven patients (57.9%) had FHN. FHN patients were statistically compared with those without FHN. Correlations between cartilaginous femoral head coverage (CFHC) and acetabular index (AI), cartilaginous AI (CAI), or neck-shaft angle (NSA) were investigated in patients with hip subluxation or dislocation. The greater cartilaginous coverage of the hips than their osseous inherency was observed. Significant correlation was observed between CFHC and AI (r =-0.351, p = 0.049) or CAI (r =-0.381, p = 0.032). Severe subluxations or dislocations were more likely to be present in those with more dysplastic bony and cartilaginous hips. In conclusion, our study provides the first systemic description of bony and cartilaginous characteristics in the hip morphology of MPS IVA patients. We have demonstrated that plain radiography alone leads to a misunderstanding of hip morphology and that MRI measurements with PFR are an essential tool to evaluate the 'true' characterization of hips for MPS IVA patients.
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Affiliation(s)
- Zhigang Wang
- Department of Pediatric Orthopedics, Shanghai Children’s Medical Center affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Yunlan Xu
- Department of Pediatric Orthopedics, Shanghai Children’s Medical Center affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Enze Jiang
- Department of Pediatric Orthopedics, Shanghai Children’s Medical Center affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Jianmin Wang
- Department of Hematology/Oncology, Shanghai Children’s Medical Center affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Shunji Tomatsu
- Departments of Orthopedics and BioMedical, Skeletal Dysplasia, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA
| | - Kaiying Shen
- Department of Pediatric Orthopedics, Shanghai Children’s Medical Center affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
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14
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Remondino RG, Tello CA, Noel M, Wilson AF, Galaretto E, Bersusky E, Piantoni L. Clinical Manifestations and Surgical Management of Spinal Lesions in Patients With Mucopolysaccharidosis: A Report of 52 Cases. Spine Deform 2019; 7:298-303. [PMID: 30660225 DOI: 10.1016/j.jspd.2018.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 06/26/2018] [Accepted: 07/16/2018] [Indexed: 11/28/2022]
Abstract
STUDY DESIGN Descriptive retrospective cohort of 52 pediatric patients with mucopolysaccharidosis (MPS) and spinal cord disease and surgical outcomes in a reference hospital. OBJECTIVES To describe clinical manifestations and surgical management and outcomes of spinal lesions. METHODS All medical records of 52 patients with mucopolysaccharidosis (I, II, III, IV, and VI) diagnosed between 1992 and 2011 were identified and followed at a single spine center of a pediatric hospital. Demographic, clinical manifestations, spinal cord lesions, and surgical management were the focus of the descriptive report. RESULTS A total of 52 patients (32 males and 20 females), mean age at diagnosis of 8 ± 4 years (range 1-19), and with a mean follow-up of 11 ± 8 years were identified. Forty-three had cervical disease (the most frequent affection found was odontoid hypoplasia followed by atlantoaxial instability) and 14 patients had thoracolumbar kyphosis. Twenty-one patients presented neurologic compromise before surgery (quadriparesis as the most frequent manifestation), with the progression of neurologic impairment being the most common surgical indication. Surgery was performed in 38 patients (25 cervical and 13 thoracolumbar). Of the 21 patients with preoperative neurologic deficit, 6 patients showed neurologic improvement. The most common surgical complication found was proximal junctional kyphosis. CONCLUSION This is the largest series published of mucopolysaccharidosis pediatric patients with a surgically treated spinal condition. We recommend early spinal cord decompression in mucopolysaccharidosis spine pathology to prevent or potentially reverse neurologic impairment. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Rodrigo G Remondino
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, CABA, Buenos Aires, Argentina.
| | - Carlos A Tello
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, CABA, Buenos Aires, Argentina
| | - Mariano Noel
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, CABA, Buenos Aires, Argentina
| | - Alejandra Francheri Wilson
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, CABA, Buenos Aires, Argentina
| | - Eduardo Galaretto
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, CABA, Buenos Aires, Argentina
| | - Ernesto Bersusky
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, CABA, Buenos Aires, Argentina
| | - Lucas Piantoni
- Servicio de Patología Espinal, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, CABA, Buenos Aires, Argentina
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15
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Taylor M, Khan S, Stapleton M, Wang J, Chen J, Wynn R, Yabe H, Chinen Y, Boelens JJ, Mason RW, Kubaski F, Horovitz DDG, Barth AL, Serafini M, Bernardo ME, Kobayashi H, Orii KE, Suzuki Y, Orii T, Tomatsu S. Hematopoietic Stem Cell Transplantation for Mucopolysaccharidoses: Past, Present, and Future. Biol Blood Marrow Transplant 2019; 25:e226-e246. [PMID: 30772512 DOI: 10.1016/j.bbmt.2019.02.012] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/11/2019] [Indexed: 12/16/2022]
Abstract
Allogenic hematopoietic stem cell transplantation (HSCT) has proven to be a viable treatment option for a selected group of patients with mucopolysaccharidoses (MPS), including those with MPS types I, II, IVA, VI, and VII. Early diagnosis and timely referral to an expert in MPS are critical, followed by a complete examination and evaluation by a multidisciplinary team, including a transplantation physician. Treatment recommendations for MPS are based on multiple biological, sociological, and financial factors, including type of MPS, clinical severity, prognosis, present clinical signs and symptoms (disease stage), age at onset, rate of progression, family factors and expectations, financial burden, feasibility, availability, risks and benefits of available therapies such as HSCT, enzyme replacement therapy (ERT), surgical interventions, and other supportive care. International collaboration and data review are critical to evaluating the therapeutic efficacy and adverse effects of HSCT for MPS. Collaborative efforts to assess HSCT for MPS have been ongoing since the first attempt at HSCT in a patient with MPS reported in 1981. The accumulation of data since then has made it possible to identify early outcomes (ie, transplantation outcomes) and long-term disease-specific outcomes resulting from HSCT. The recent identification of predictive factors and the development of innovative regimens have significantly improved the outcomes of both engraftment failure and transplantation-related mortality. Assessment of long-term outcomes has considered a variety of factors, including type of MPS, type of graft, age at transplantation, and stage of disease progression, among others. Studies on long-term outcomes are considered a key factor in the use of HSCT in patients with MPS. These studies have shown the effects and limitations of HSCT on improving disease manifestations and quality of life. In this review, we summarize the efficacy, side effects, risks, and cost of HSCT for each type of MPS.
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Affiliation(s)
- Madeleine Taylor
- Department of Biomedical, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; Deparment of Biological Science, University of Delaware, Newark, Delaware
| | - Shaukat Khan
- Department of Biomedical, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Molly Stapleton
- Department of Biomedical, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; Deparment of Biological Science, University of Delaware, Newark, Delaware
| | - Jianmin Wang
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Chen
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Robert Wynn
- Department of Paediatric Haematology and Cell Therapy, University of Manchester, Manchester, United Kingdom
| | - Hiromasa Yabe
- Department of Cell Transplantation and Regenerative Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Yasutsugu Chinen
- Department of Pediatrics, Faculty of Medicine, University of the Ryukyus, Nishihara, Japan
| | - Jaap Jan Boelens
- Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert W Mason
- Department of Biomedical, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; Deparment of Biological Science, University of Delaware, Newark, Delaware
| | - Francyne Kubaski
- Medical Genetics Service, Hospital de ClÃnicas de Porto Alegre (HCPA), Department of Genetics and Molecular Biology- Program Partnership Graduate in Genetics and Molecular Biology (PPGBM), Federal University of Rio Grande do Sul (UFRGS), and National Institute of Populational Medical Genetics (INAGEMP), Porto Alegre, Brazil
| | - Dafne D G Horovitz
- Medical Genetics Department, National Institute of Women, Children, and Adolescent Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Anneliese L Barth
- Medical Genetics Department, National Institute of Women, Children, and Adolescent Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Marta Serafini
- Department of Pediatrics, Dulbecco Telethon Institute, University of Milano-Bicocca, Monza, Italy
| | - Maria Ester Bernardo
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, San Raffaele-Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Hironori Kobayashi
- Department of Pediatrics, Shimane University Faculty of Medicine, Shimane, Japan
| | - Kenji E Orii
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Yasuyuki Suzuki
- Medical Education Development Center, Gifu University, Gifu, Japan
| | - Tadao Orii
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Shunji Tomatsu
- Department of Biomedical, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; Department of Pediatrics, Shimane University Faculty of Medicine, Shimane, Japan; Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan; Department of Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania.
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16
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Kuiper GA, Langereis EJ, Breyer S, Carbone M, Castelein RM, Eastwood DM, Garin C, Guffon N, van Hasselt PM, Hensman P, Jones SA, Kenis V, Kruyt M, van der Lee JH, Mackenzie WG, Orchard PJ, Oxborrow N, Parini R, Robinson A, Schubert Hjalmarsson E, White KK, Wijburg FA. Treatment of thoracolumbar kyphosis in patients with mucopolysaccharidosis type I: results of an international consensus procedure. Orphanet J Rare Dis 2019; 14:17. [PMID: 30658664 PMCID: PMC6339313 DOI: 10.1186/s13023-019-0997-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 01/08/2019] [Indexed: 01/28/2023] Open
Abstract
Background In all patients with mucopolysaccharidosis type I (MPS I), skeletal disease (dysostosis multiplex) is a prominent, debilitating, condition related complication that may impact strongly on activities of daily living. Unfortunately, it is not alleviated by treatment with hematopoietic cell transplantation (HCT) or enzyme replacement therapy (ERT). Although early kyphosis is one of the key features of dysostosis multiplex, there is no international consensus on the optimal management. Therefore, an international consensus procedure was organized with the aim to develop the first clinical practice guideline for the management of thoracolumbar kyphosis in MPS I patients. Methods A literature review was conducted to identify all available information about kyphosis and related surgery in MPS I patients. Subsequently, a modified Delphi procedure was used to develop consensus statements. The expert panel included 10 spinal orthopedic surgeons, 6 pediatricians and 3 physiotherapists, all experienced in MPS I. The procedure consisted of 2 written rounds, a face-to-face meeting and a final written round. The first 2 rounds contained case histories, general questions and draft statements. During the face-to-face meeting consensus statements were developed. In the final round, the panel had the opportunity to anonymously express their opinion about the proposed statements. Results Eighteen case series and case reports were retrieved from literature reporting on different surgical approaches and timing of thoracolumbar kyphosis surgery in MPS I. During the face-to-face meeting 16 statements were discussed and revised. Consensus was reached on all statements. Conclusion This international consensus procedure resulted in the first clinical practice guideline for the management of thoracolumbar kyphosis in MPS I patients, focusing on the goals and timing of surgery, as well as the optimal surgical approach, the utility of bracing and required additional assessments (e.g. radiographs). Most importantly, it was concluded that the decision for surgery depends not only on the kyphotic angle, but also on additional factors such as the progression of the deformity and its flexibility, the presence of symptoms, growth potential and comorbidities. The eventual goal of treatment is the maintenance or improvement of quality of life. Further international collaborative research related to long-term outcome of kyphosis surgery in MPS I is essential as prognostic information is lacking. Electronic supplementary material The online version of this article (10.1186/s13023-019-0997-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gé-Ann Kuiper
- Amsterdam UMC, University of Amsterdam, Pediatric Metabolic Diseases, Emma Children's Hospital and Amsterdam Lysosome Center "Sphinx", Meibergdreef 9, Amsterdam, Netherlands
| | - Eveline J Langereis
- Amsterdam UMC, University of Amsterdam, Pediatric Metabolic Diseases, Emma Children's Hospital and Amsterdam Lysosome Center "Sphinx", Meibergdreef 9, Amsterdam, Netherlands
| | - Sandra Breyer
- Department of Pediatric Orthopedics, Altonaer Children's Hospital, Bleickenallee 38, 22763, Hamburg, Germany
| | - Marco Carbone
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - René M Castelein
- Department of Orthopedic Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Deborah M Eastwood
- Department of Orthopaedic Surgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, United Kingdom
| | - Christophe Garin
- Department of Paediatric Orthopaedics, Hôpital Femme-Mère-Enfant, Université Lyon 1, 69500, Lyon, Bron, France
| | - Nathalie Guffon
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hôpital Femme Mère Enfant, 69500, Lyon, Bron, France
| | - Peter M van Hasselt
- Department of Metabolic Diseases, Wilhelmina Children's Hospital, University Medical Center Utrecht, P.O. Box 85090, 3508, AB, Utrecht, the Netherlands
| | - Pauline Hensman
- Willink Biochemicals Genetics Unit, St Mary's Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, United Kingdom
| | - Simon A Jones
- Willink Biochemicals Genetics Unit, St Mary's Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, United Kingdom
| | - Vladimir Kenis
- Department of Foot and Ankle Surgery, Neuroorthopaedics and Skeletal dysplasias, The H. Turner institute for Children's Orthopedics, Saint-Petersburg, Russia
| | - Moyo Kruyt
- Department of Orthopedic Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Johanna H van der Lee
- Amsterdam UMC, University of Amsterdam, Pediatric Clinical Research Office, Meibergdreef 9, Amsterdam, Netherlands
| | | | - Paul J Orchard
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Neil Oxborrow
- Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, United Kingdom
| | - Rossella Parini
- Rare Metabolic Diseases Unit, Paediatric Clinic, MBBM Foundation, San Gerardo University Hospital, Via Pergolesi 33, 20900, Monza, Italy
| | - Amy Robinson
- Willink Biochemicals Genetics Unit, St Mary's Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, United Kingdom
| | - Elke Schubert Hjalmarsson
- Department of Physiotherapy, Queen Silvia's Children's Hospital, Rondvägen 10, 416 85, Göteborg, Sweden
| | - Klane K White
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Frits A Wijburg
- Amsterdam UMC, University of Amsterdam, Pediatric Metabolic Diseases, Emma Children's Hospital and Amsterdam Lysosome Center "Sphinx", Meibergdreef 9, Amsterdam, Netherlands.
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Abstract
BACKGROUND Hip dysplasia is common in mucopolysaccharidosis type-1H (MPS-1H) patients, but its morphology is not completely understood. No magnetic resonance imaging (MRI)-based studies have been reported in the literature. The purpose of this study was to improve knowledge of hip dysplasia pathology by describing the hip morphology of these patients in MRI scans, plain radiographs, and arthrograms. METHODS We performed a retrospective chart review of 18 MPS-1H patients. Supine anteroposterior pelvic radiographs of 36 hips and MRI scans of 18 hips were analyzed. Six arthrographs were also available. RESULTS Plain radiographs were available for 18 patients. The mean age was 6.0 (SD=3.8) years. The mean acetabular index (AI) was 36.2 degrees (SD=5.8), and the mean migration percentage was 59.0% (SD=17.2). MRI data were available for 9 patients. The MRI findings were compared with the radiographs of the same patient. The mean AI (39.3 degrees, SD=5.8) was confirmed by the MRI findings (39.1 degrees, SD=5.5). The migration percentage was lower in the MRI scans than in the radiographs. Radiologically, the center-edge angle was negative in all patients, with a mean of -16.8 degrees (SD=7.9), and the MRI images produced a more negative value (-19.6 degrees, SD=7.6). The soft tissue coverage of the femoral head was described with the inclusion of the cartilaginous roof and labrum. The cartilaginous AI was 22.4 degrees (SD=7.5), and the labral AI was 13.5 degrees (SD=6.7). All 6 arthrograms revealed stability during dynamic testing. CONCLUSIONS This study provides the first description of hip morphology in MPS-1H patients through MRI-based data. The cartilaginous coverage of the hip was increased compared with that of healthy children. The use of radiography alone may lead to a misunderstanding of hip morphology. MRI and arthrogram is highly recommended if surgery is considered.
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18
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Crostelli M, Mazza O, Mariani M, Mascello D, Iorio C. Spine challenges in mucopolysaccharidosis. INTERNATIONAL ORTHOPAEDICS 2018; 43:159-167. [PMID: 30218179 DOI: 10.1007/s00264-018-4143-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 09/03/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Mucopolysaccharidosis (MPS) are rare inherited metabolic diseases, causing lysosomal storage of mucopolysaccharides; clinical presentation involves skeletal system and particularly the spine. Anomalies include developing kyphosis at thoracolumbar junction, that can causes nervous symptoms, and dens hypoplasia with associated atlantoaxial subluxation that can cause myelopathy. We present our experience in the treatment of spine pathology in MPS. METHODS Medical treatments of MPS seem to have little impact on spine disease: treatment of cervical instability often includes surgical decompression and stabilization, as in patient MPS1 that we present, while thoracic lumbar kyphosis is treated by bracing and, in severe cases, with surgery. Bracing is more effective in kyphosis under 40° Cobb. Our surgical cases with thoracic lumbar kyphosis over 40° Cobb, treatment include the first one ever described by only posterior approach with vertebrectomy in MPS and a case of lateral costo-transverse approach instrumented correction. RESULTS Surgical patients had no major complications after surgery and CT scan at follow-up showed complete fusion without loss of correction, even if in a cervical case we used an adult rigid instrumentation in a four year-and-six month-old girl (11 years follow-up) and in thoracic lumbar kyphosis case treated by vertebrectomy due to diminutive anatomy we positioned interbody cage in suboptimal position. CONCLUSIONS Bracing is a viable treatment strategy in thoracic lumbar kyphosis and can obtain good clinical results at medium terms follow-up even if kyphosis deformity remains in radiographs. Surgical treatment is effective in severe evolving cases both at cervical and thoracic lumbar level, main difficulties arose from unavailability of dedicated instrumentation in very young patient, as even smallest devices available are often too big.
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Affiliation(s)
- Marco Crostelli
- Spine Surgery Unit, Surgery and Transplantations Department, Ospedale Pediatrico Bambino Gesù, Rome, Italy.
| | - Osvaldo Mazza
- Spine Surgery Unit, Surgery and Transplantations Department, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Massimo Mariani
- Spine Surgery Unit, Surgery and Transplantations Department, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Dario Mascello
- Spine Surgery Unit, Surgery and Transplantations Department, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Carlo Iorio
- Spine Surgery Unit, Surgery and Transplantations Department, Ospedale Pediatrico Bambino Gesù, Rome, Italy
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19
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Surgical Management of Progressive Thoracolumbar Kyphosis in Mucopolysaccharidosis: Is a Posterior-only Approach Safe and Effective? J Pediatr Orthop 2018; 38:354-359. [PMID: 27403916 DOI: 10.1097/bpo.0000000000000826] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND According to the current literature, the recommended surgical treatment is circumferential spinal fusion, including both anterior and posterior procedures, for progressive thoracolumbar kyphosis in mucopolysaccharidosis (MPS). The purpose of this study was to report our experience with the posterior-only approach and instrumented fusion for MPS kyphosis. METHODS Six consecutive patients with MPS and thoracolumbar junctional kyphosis managed with the posterior-only approach were included. Demographic data, the type of MPS, medical comorbidities, and accompanying clinical manifestations were recorded. Measurements recorded on radiographs for the study included the presence of any coronal-plane deformity, fusion levels, changes in the local kyphosis angle (LKA), proximal and distal junctional kyphosis angles, and the apical vertebral wedge angle. RESULTS The average age at the time of surgery was 6.6 (range, 4 to 12) years. The average follow-up duration was 52.6 (range, 44 to 64) months. The mean preoperative LKA of 63.1±15.8 (range, 48 to 92) degrees decreased to a mean of 16.6±8.4 (range, 5 to 30) degrees immediately after surgery. At the latest follow-up, the mean LKA was 19.6±8.8 (range, 8 to 34) degrees. Apical vertebral listhesis was reduced in all patients with surgical correction. The average apical vertebral wedge angle of 15 (range, 11 to 19) degrees at the early postoperative period decreased to 4.6 (range, 2 to 7) degrees at the latest follow-up. Adjacent-segment problems occurred in 2 patients. There were no neurological complications or implant failures in any of the patients. CONCLUSIONS Posterior-only corrective techniques and instrumented fusion with pedicle screws for progressive thoracolumbar junctional kyphosis in MPS patients are safe and effective methods. Its results are comparable to those achieved with conventional circumferential fusion. However, patients should be monitored closely for adjacent-segment problems. LEVEL OF EVIDENCE Level IV-retrospective case series.
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20
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Differences in maxillomandibular morphology among patients with mucopolysaccharidoses I, II, III, IV and VI: a retrospective MRI study. Clin Oral Investig 2017; 22:1541-1549. [PMID: 29046964 DOI: 10.1007/s00784-017-2240-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 10/05/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The aims of this study were to analyze the maxillomandibular morphology of patients with mucopolysaccharidosis (MPS) type I, II, III, IVa and VI and to evaluate the craniofacial effect of hematopoietic stem cell transplantation (HCST) in MPS I. MATERIALS AND METHODS One hundred head magnetic resonance images were retrospectively analyzed from 41 MPS and 27 control individuals. The width, height and length of the maxilla and mandible were plotted against age and the means of controls, MPS I, MPS II and MPS III were statistically compared. To determine the effect of HSCT in MPS I, jaw morphology was compared between MPS I patients with full donor chimerism versus patients with mixed/no donor chimerism. RESULTS Maxillary dimensions were not statistically different between the MPS types. The height and length of the mandible were clearly smaller in MPS I as compared to those in controls, MPS II and MPS III. This was associated with progressive resorption of the mandibular condyles in MPS I, which was also observed in MPS II and VI, but not in MPS III or IVa. Whereas the success of HCST did not affect these changes, mandibular width was significantly smaller in MPS I individuals with full donor chimerism. CONCLUSION MPS I individuals have a smaller mandible as compared to control, MPS II and MPS III individuals due to progressive condylar degeneration. These abnormalities are also evident following successful HSCT. CLINICAL RELEVANCE Clinicians should be aware of specific differences in mandibular morphology and condylar involvement among the MPS subtypes.
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21
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Kuiper GA, van Hasselt PM, Boelens JJ, Wijburg FA, Langereis EJ. Incomplete biomarker response in mucopolysaccharidosis type I after successful hematopoietic cell transplantation. Mol Genet Metab 2017; 122:86-91. [PMID: 28684085 DOI: 10.1016/j.ymgme.2017.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/14/2017] [Accepted: 05/14/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Residual disease, primarily involving musculoskeletal tissue, is a common problem in patients with neuronopathic mucopolysaccharidosis type I (MPS I, Hurler or severe Hurler-Scheie phenotype) after a successful hematopoietic cell transplantation (HCT). The concentration of the GAG derived biomarkers heparan sulfate (HS) and dermatan sulfate (DS), may reflect residual disease and is used for monitoring biochemical response to therapies. This study investigates the response of HS and DS in blood and urine to HCT in MPS I patients. METHODS In 143 blood- and urine samples of 17 neuronophatic MPS I patients, collected prior and post successful HCT, the concentration of the disaccharides derived after full enzymatic digestion of HS and DS were analyzed by multiplex liquid chromatography tandem-mass spectrometry (LC-MS/MS). RESULTS Median follow up after HCT was 2.4years (range 0-11years). HCT led to a rapid decrease of both HS and DS. However, only 38% of the patients reached normal HS levels in blood and even less patients (6%) reached normal DS levels. In none of the patients normalization of HS or DS was observed in urine. CONCLUSIONS Biomarker response after HCT is incomplete, which may reflect residual disease activity. Novel therapeutic strategies should aim for full metabolic correction to minimize clinical manifestations.
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Affiliation(s)
- Gé-Ann Kuiper
- Department of Pediatric Metabolic Diseases, Emma Children's Hospital and Amsterdam Lysosome Center 'Sphinx', Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter M van Hasselt
- Department of Pediatric Metabolic Diseases, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Jaap Jan Boelens
- Department of Pediatrics, Blood and Marrow Transplantation Program, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Frits A Wijburg
- Department of Pediatric Metabolic Diseases, Emma Children's Hospital and Amsterdam Lysosome Center 'Sphinx', Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Eveline J Langereis
- Department of Pediatric Metabolic Diseases, Emma Children's Hospital and Amsterdam Lysosome Center 'Sphinx', Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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22
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Oussoren E, Bessems JHJM, Pollet V, van der Meijden JC, van der Giessen LJ, Plug I, Devos AS, Ruijter GJG, van der Ploeg AT, Langeveld M. A long term follow-up study of the development of hip disease in Mucopolysaccharidosis type VI. Mol Genet Metab 2017; 121:241-251. [PMID: 28552677 DOI: 10.1016/j.ymgme.2017.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 05/05/2017] [Accepted: 05/05/2017] [Indexed: 12/11/2022]
Abstract
Hip problems in Mucopolysaccharidosis type VI (MPS VI) lead to severe disability. Lack of data on the course of hip disease in MPS VI make decisions regarding necessity, timing and type of surgical intervention difficult. We therefore studied the development of hip pathology in MPS VI patients over time. Data were collected as part of a prospective follow-up study. Standardized supine AP pelvis and frog leg lateral radiographs of both hips were performed yearly or every 2years. Image assessment was performed quantitatively (angle measurements) and qualitatively (hip morphology). Clinical burden of hip disease was evaluated by physical examination, six minute walking test (6MWT) and a questionnaire assessing pain, wheelchair-dependency and walking distance. A total of 157 pelvic radiographs of 14 ERT treated MPS VI patients were evaluated. Age at first image ranged from 2.0 to 21.1years. Median follow up duration was 6.8years. In all patients, even in the youngest, the acetabulum and os ilium were dysplastic. Coverage of the femoral head by the acetabulum improved over time, but remained insufficient. While the femoral head appeared normal in the radiographs at young age, the ossification pattern became abnormal in all patients over time. In all patients the distance covered in the 6MWT was reduced (median Z scores -3.3). Twelve patients had a waddling gait. Four patients were partially wheelchair-dependent and ten patients had limitations in their maximum walking distance. In conclusion, clinically significant hip abnormalities develop in all MPS VI patients from very early in life, starting with deformities of the os ilium and acetabulum. Femoral head abnormalities occur later, most likely due to altered mechanical forces in combination with epiphyseal abnormalities due to glycosaminoglycan storage. The final shape and angle of the femoral head differs significantly between individual MPS VI patients and is difficult to predict.
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Affiliation(s)
- Esmee Oussoren
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Johannes H J M Bessems
- Department of Paediatric Orthopaedics, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Virginie Pollet
- Department of Paediatric Orthopaedics, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Jan C van der Meijden
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Lianne J van der Giessen
- Department of Paediatric Physiotherapy, Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands.
| | - Iris Plug
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Annick S Devos
- Department of Radiology, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - George J G Ruijter
- Department of Clinical Genetics, Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Ans T van der Ploeg
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Mirjam Langeveld
- Center for Lysosomal and Metabolic Diseases, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Endocrinology and Metabolism, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Substrate Deprivation Therapy to Reduce Glycosaminoglycan Synthesis Improves Aspects of Neurological and Skeletal Pathology in MPS I Mice. Diseases 2017; 5:diseases5010005. [PMID: 28933358 PMCID: PMC5456338 DOI: 10.3390/diseases5010005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 02/14/2017] [Accepted: 02/21/2017] [Indexed: 12/17/2022] Open
Abstract
Mucopolysaccharidosis type I (MPS I) is the most common form of the MPS group of genetic diseases. MPS I results from a deficiency in the lysosomal enzyme α-l-iduronidase, leading to accumulation of undegraded heparan and dermatan sulphate glycosaminoglycan (GAG) chains in patient cells. MPS children suffer from multiple organ failure and die in their teens to early twenties. In particular, MPS I children also suffer from profound mental retardation and skeletal disease that restricts growth and movement. Neither brain nor skeletal disease is adequately treated by current therapy approaches. To overcome these barriers to effective therapy we have developed and tested a treatment called substrate deprivation therapy (SDT). MPS I knockout mice were treated with weekly intravenous injections of 1 mg/kg rhodamine B for six months to assess the efficacy of SDT. Mice were assessed using biochemistry, micro-CT and a battery of behaviour tests to determine the outcome of treatment. A reduction in female bodyweight gain was observed with the treatment as well as a decrease in lung GAG. Behavioural studies showed slight improvements in inverted grid and significant improvements in learning ability for female MPS I mice treated with rhodamine B. Skeletal disease also improved with a reduction in bone mineral volume observed. Overall, rhodamine B is safe to administer to MPS I knockout mice where it had an effect on improving aspects of neurological and skeletal disease symptoms and may therefore provide a potential therapy or adjunct therapy for MPS I patients.
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24
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Schmidt M, Breyer S, Löbel U, Yarar S, Stücker R, Ullrich K, Müller I, Muschol N. Musculoskeletal manifestations in mucopolysaccharidosis type I (Hurler syndrome) following hematopoietic stem cell transplantation. Orphanet J Rare Dis 2016; 11:93. [PMID: 27392569 PMCID: PMC4938899 DOI: 10.1186/s13023-016-0470-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 06/17/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) is the treatment of choice for young Hurler patients. Despite halting of neurocognitive decline and improvement of life expectancy, the beneficial effect on the skeletal system is limited. As orthopedic complications are one of the most disabling factors following HSCT, this points to the need for new treatment strategies. The study summarizes musculoskeletal manifestations in 19 transplanted Hurler patients. METHODS Data were obtained retrospectively. Patients' charts for physical examinations of the joint range of motion (JROM) of shoulders, elbows, hips and knees were reviewed. Radiographic evaluations of thorax, spine, pelvis and hands were performed. MRI scans of the craniocervical junction were analyzed to determine odontoid hypoplasia and the prevalence of craniocervical stenosis. RESULTS Nineteen Hurler patients (10 females, 9 males) with an average age of 8.1 years (range 2.5-23.8) at the latest follow-up, who underwent allogenic HSCT between 1991 and 2012, were assessed after an average follow-up period of 6.4 years (range 0.7-22.5). Seventeen patients achieved long-term engraftment, two developed graft failures. The majority of patients showed a steady state or improvements in the mobility of knees (31 %/63 %), hips (47 %/40 %) and elbows (56 %/38 %). However, shoulder abduction was impaired in ¾ of patients and showed the highest rate of progression (31 %). In patients with graft failure, progressive restrictions in JROM were noted. Assessments of the craniocervical junction by MRI showed stable or improved diameters in 67 % of patients. Correction or stabilization of odontoid hypoplasia was found in 64 %. However thoracolumbar kyphosis, scoliosis, hip dysplasia and genua valga were progressive despite HSCT. At the last follow up, 47 % of patients were partially wheelchair dependent, 10 % wheelchair bound and 25 % regularly experienced pain in the spine, hips and lower extremities due to orthopedic problems. CONCLUSION Joint mobility, odontoid hypoplasia and craniocervical stenosis might stabilize or even improve in Hurler patients following HSCT. However, despite the beneficial effects on some musculoskeletal manifestations, skeletal complications are frequently observed and the overall burden of orthopedic disease is significant. Frequent multi-disciplinary follow-up in a specialized center are essential. Novel therapeutic approaches (e.g. anti-inflammatory drugs) are needed to improve musculoskeletal outcomes.
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Affiliation(s)
- Mona Schmidt
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Sandra Breyer
- Department of Pediatric Orthopedics, Altonaer Children's Hospital, Bleickenallee 38, 22763, Hamburg, Germany
| | - Ulrike Löbel
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Sinef Yarar
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Ralf Stücker
- Department of Pediatric Orthopedics, Altonaer Children's Hospital, Bleickenallee 38, 22763, Hamburg, Germany
| | - Kurt Ullrich
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Ingo Müller
- Clinic of Pediatric Hematology and Oncology, Division for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Nicole Muschol
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Kingma SDK, Wagemans T, IJlst L, Bronckers ALJJ, van Kuppevelt TH, Everts V, Wijburg FA, van Vlies N. Altered interaction and distribution of glycosaminoglycans and growth factors in mucopolysaccharidosis type I bone disease. Bone 2016; 88:92-100. [PMID: 27105565 DOI: 10.1016/j.bone.2016.01.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 12/28/2015] [Accepted: 01/19/2016] [Indexed: 10/21/2022]
Abstract
The mucopolysaccharidoses (MPSs) comprise a group of lysosomal storage disorders characterized by deficient degradation and subsequent accumulation of glycosaminoglycans (GAGs). Progressive bone and joint disease are a major cause of morbidity, and current therapeutic strategies have limited effect on these symptoms. By elucidating pathophysiological mechanisms underlying bone disease, new therapeutic targets may be identified. Longitudinal growth is regulated by interaction between GAGs and growth factors. Because GAGs accumulate in the MPSs, we hypothesized that altered interaction between growth factors and GAGs contribute to the pathogenesis of MPS bone disease. In this study, binding between GAGs from MPS I chondrocytes and fibroblast growth factor 2 (FGF2) was not significantly different from binding of FGF2 to GAGs from control chondrocytes. FGF2 signaling, however, was increased in MPS I chondrocytes after incubation with FGF2, as compared to control chondrocytes. Using bone cultures, we demonstrated decreased growth of WT mouse bones after incubation with FGF2, but no effect on MPS I bone growth. However, MPS I bones showed decreased growth in the presence of GAGs from MPS I chondrocytes. Finally, we demonstrate altered GAG distribution in MPS I chondrocytes, and altered GAG, FGF2 and Indian hedgehog distribution in growth plates from MPS I mice. In summary, our results suggest that altered interaction and distribution of growth factors and accumulated GAGs may contribute to the pathogenesis of MPS bone disease. In the future, targeting growth factor regulation or the interaction between in growth factors and GAGs might be a promising therapeutic strategy for MPS bone disease.
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Affiliation(s)
- Sandra D K Kingma
- Laboratory of Genetic Metabolic Diseases, Department of Clinical Chemistry and Pediatrics, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands; Department of Pediatrics and Amsterdam Lysosome Centre "Sphinx", Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Tom Wagemans
- Laboratory of Genetic Metabolic Diseases, Department of Clinical Chemistry and Pediatrics, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands; Department of Pediatrics and Amsterdam Lysosome Centre "Sphinx", Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Lodewijk IJlst
- Laboratory of Genetic Metabolic Diseases, Department of Clinical Chemistry and Pediatrics, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Antonius L J J Bronckers
- Department of Oral Cell Biology ACTA, University of Amsterdam and VU University Amsterdam, Research Institute MOVE, Gustav Mahlerlaan 3004, 1081, LA, Amsterdam, The Netherlands.
| | - Toin H van Kuppevelt
- Toin H. van Kuppevelt: Department of Biochemistry, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Postbus 9101, 6500, HB, Nijmegen, The Netherlands.
| | - Vincent Everts
- Department of Oral Cell Biology ACTA, University of Amsterdam and VU University Amsterdam, Research Institute MOVE, Gustav Mahlerlaan 3004, 1081, LA, Amsterdam, The Netherlands.
| | - Frits A Wijburg
- Department of Pediatrics and Amsterdam Lysosome Centre "Sphinx", Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Naomi van Vlies
- Laboratory of Genetic Metabolic Diseases, Department of Clinical Chemistry and Pediatrics, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands; Department of Pediatrics and Amsterdam Lysosome Centre "Sphinx", Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
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Roberts SB, Dryden R, Tsirikos AI. Thoracolumbar kyphosis in patients with mucopolysaccharidoses: clinical outcomes and predictive radiographic factors for progression of deformity. Bone Joint J 2016; 98-B:229-37. [PMID: 26850429 DOI: 10.1302/0301-620x.98b2.36144] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Clinical and radiological data were reviewed for all patients with mucopolysaccharidoses (MPS) with thoracolumbar kyphosis managed non-operatively or operatively in our institution. METHODS In all 16 patients were included (eight female: eight male; 50% male), of whom nine had Hurler, five Morquio and two Hunter syndrome. Six patients were treated non-operatively (mean age at presentation of 6.3 years; 0.4 to 12.9); mean kyphotic progression +1.5(o)/year; mean follow-up of 3.1 years (1 to 5.1) and ten patients operatively (mean age at presentation of 4.7 years; 0.9 to 14.4); mean kyphotic progression 10.8(o)/year; mean follow-up of 8.2 years; 4.8 to 11.8) by circumferential arthrodesis with posterior instrumentation in patients with flexible deformities (n = 6). RESULTS In the surgical group (mean age at surgery of 6.6 years; 2.4 to 16.8); mean post-operative follow-up of 6.3 years (3.5 to 10.3), mean pre-operative thoracolumbar kyphosis of 74.3(o) (42(o) to 110(o)) was corrected to mean of 28.6(o) (0(o) to 65(o)) post-operatively, relating to a mean deformity correction of 66.9% (31% to 100%). Surgical complications included a deep wound infection treated by early debridement, apical non-union treated by posterior re-grafting, and stable adjacent segment spondylolisthesis managed non-operatively. Thoracolumbar kyphosis > +38(o) at initial presentation was identified as predicting progressively severe deformity with 90% sensitivity and 83% specificity. DISCUSSION This study demonstrates that severe thoracolumbar kyphosis in patients with MPS can be effectively treated by circumferential arthrodesis. Severity of kyphosis at initial presentation may predict progression of thoracolumbar deformity. Patients with MPS may be particularly susceptible to post-operative complications due to the underlying connective tissue disorder and inherent immunological compromise. TAKE HOME MESSAGE Clinical and radiological data were reviewed for all patients with mucopolysaccharidoses with thoracolumbar kyphosis managed non-operatively or operatively in our institution.
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Affiliation(s)
- S B Roberts
- Royal Hospital for Sick Children, Sciennes Road, Edinburgh, EH9 1LF, UK
| | - R Dryden
- Royal Hospital for Sick Children, Sciennes Road, Edinburgh, EH9 1LF, UK
| | - A I Tsirikos
- Scottish National Spine Deformity Centre, Royal Hospital for Sick Children, Sciennes Road, Edinburgh, EH9 1LF, UK
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Abstract
BACKGROUND The purpose of this study is to describe the natural history of hip morphology in patients with mucopolysaccharidoses (MPS) I and MPS II. METHODOLOGY This is a retrospective radiographic analysis of 88 hips in 44 children with MPS I and II. Radiographs were examined to determine hip migration, femoral head sphericity, and acetabular dysplasia at different ages throughout childhood. In individual hips, change in morphology and rate of change were analyzed. RESULTS There was a high rate of hip migration and femoral head dysplasia in both MPS I and MPS II. Progressive migration was seen in three quarters of hips and progressive femoral head deformity in over half of hips. Acetabular dysplasia was variable, ranging from normal to severely dysplastic, but did not change with time. Overall, hips were more dysplastic in MPS I than MPS II. CONCLUSIONS Hip morphology is variable in MPS I and MPS II ranging from almost normal to severely dysplastic. Some hips do not deteriorate with time and thus surgical intervention may not be necessary in all cases. Deterioration is slow allowing time to plan a holistic approach to treatment. LEVEL OF EVIDENCE Level IV-case series.
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Langereis EJ, den Os MM, Breen C, Jones SA, Knaven OC, Mercer J, Miller WP, Kelly PM, Kennedy J, Ketterl TG, O'Meara A, Orchard PJ, Lund TC, van Rijn RR, Sakkers RJ, White KK, Wijburg FA. Progression of Hip Dysplasia in Mucopolysaccharidosis Type I Hurler After Successful Hematopoietic Stem Cell Transplantation. J Bone Joint Surg Am 2016; 98:386-95. [PMID: 26935461 DOI: 10.2106/jbjs.o.00601] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Dysostosis multiplex contributes substantially to morbidity in patients with Hurler syndrome (mucopolysaccharidosis type I Hurler phenotype [MPS I-H]), even after successful hematopoietic stem cell transplantation (HSCT). One of the hallmarks of dysostosis multiplex in MPS I-H is hip dysplasia, which often requires surgical intervention. We sought to describe in detail the course of hip dysplasia in this group of patients, as assessed by radiographic analysis, and to identify potential outcome predictors. METHODS Longitudinal data were obtained from digitally scored pelvic radiographs of patients with MPS I-H using OrthoGon software for parameters including, but not limited to, the acetabular index, migration percentage, Smith ratio, and neck-shaft angle. Scoring was performed independently by two blinded observers. Additional information on genotype, enzyme replacement therapy pre-HSCT, donor chimerism, and enzyme activity post-HSCT were obtained. General trends and potential correlations were calculated with mixed-model statistics. RESULTS Fifty-two patients (192 radiographs) were included in this analysis. Intraobserver and interobserver variation analysis showed an intraclass correlation coefficient ranging from 0.78 to 1.00. Among the twenty-one patients with follow-up beyond the age of five years, the acetabular index was in the range of severe hip dysplasia in up to 86% of the patients. Severe coxa valga was seen in 91% of the patients. Lateral and superior femoral displacement were highly prevalent, with the migration percentage outside the reference range in up to 96% of the patients. Finally, anterior pelvic tilt increased with age (p = 0.001). No correlations were identified between clinical parameters and radiographic findings. CONCLUSIONS Our study shows that progressive acetabular dysplasia as well as coxa valga and hip displacement are highly prevalent and progressive over time in patients with MPS I-H, despite successful HSCT. These data may provide essential natural history determinations for the assessment of efficacy of new therapeutic strategies aimed at improving skeletal outcomes in patients with MPS I-H.
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Affiliation(s)
- Eveline J Langereis
- Department of Pediatric Metabolic Diseases, Emma Children's Hospital and Amsterdam Lysosome Center "Sphinx," Academic Medical Center, Amsterdam, the Netherlands
| | - Matthijs M den Os
- Department of Pediatric Metabolic Diseases, Emma Children's Hospital and Amsterdam Lysosome Center "Sphinx," Academic Medical Center, Amsterdam, the Netherlands
| | - Catherine Breen
- Genetic Medicine, Manchester Academic Health Science Centre, Central Manchester University Hospitals, NHS Foundation Trust, St Mary's Hospital, Manchester, United Kingdom
| | - Simon A Jones
- Genetic Medicine, Manchester Academic Health Science Centre, Central Manchester University Hospitals, NHS Foundation Trust, St Mary's Hospital, Manchester, United Kingdom
| | - Olga C Knaven
- Department of Pediatric Metabolic Diseases, Emma Children's Hospital and Amsterdam Lysosome Center "Sphinx," Academic Medical Center, Amsterdam, the Netherlands
| | - Jean Mercer
- Genetic Medicine, Manchester Academic Health Science Centre, Central Manchester University Hospitals, NHS Foundation Trust, St Mary's Hospital, Manchester, United Kingdom
| | - Weston P Miller
- Division of Pediatric Blood and Marrow Transplantation, University of Minnesota Children's Hospital, Minneapolis, Minnesota
| | - Paula M Kelly
- Department of Orthopaedic Surgery, Our Lady's Children's Hospital, Dublin, Ireland
| | - Jim Kennedy
- Department of Orthopaedic Surgery, Our Lady's Children's Hospital, Dublin, Ireland
| | - Tyler G Ketterl
- Division of Pediatric Blood and Marrow Transplantation, University of Minnesota Children's Hospital, Minneapolis, Minnesota
| | - Anne O'Meara
- National HSCT Department, Our Lady's Children's Hospital, Dublin, Ireland
| | - Paul J Orchard
- Division of Pediatric Blood and Marrow Transplantation, University of Minnesota Children's Hospital, Minneapolis, Minnesota
| | - Troy C Lund
- Division of Pediatric Blood and Marrow Transplantation, University of Minnesota Children's Hospital, Minneapolis, Minnesota
| | - Rick R van Rijn
- Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Ralph J Sakkers
- Department of Orthopaedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Klane K White
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Frits A Wijburg
- Department of Pediatric Metabolic Diseases, Emma Children's Hospital and Amsterdam Lysosome Center "Sphinx," Academic Medical Center, Amsterdam, the Netherlands
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Tomatsu S, Azario I, Sawamoto K, Pievani AS, Biondi A, Serafini M. Neonatal cellular and gene therapies for mucopolysaccharidoses: the earlier the better? J Inherit Metab Dis 2016; 39:189-202. [PMID: 26578156 PMCID: PMC4754332 DOI: 10.1007/s10545-015-9900-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 10/21/2015] [Accepted: 10/22/2015] [Indexed: 12/03/2022]
Abstract
Mucopolysaccharidoses (MPSs) are a group of lysosomal storage disorders (LSDs). The increasing interest in newborn screening procedures for LSDs underlines the need for alternative cellular and gene therapy approaches to be developed during the perinatal period, supporting the treatment of MPS patients before the onset of clinical signs and symptoms. The rationale for considering these early therapies results from the clinical experience in the treatment of MPSs and other genetic disorders. The normal or gene-corrected hematopoiesis transplanted in patients can produce the missing protein at levels sufficient to improve and/or halt the disease-related abnormalities. However, these current therapies are only partially successful, probably due to the limited efficacy of the protein provided through the hematopoiesis. An alternative explanation is that the time at which the cellular or gene therapy procedures are performed could be too late to prevent pre-existing or progressive organ damage. Considering these aspects, in the last several years, novel cellular and gene therapy approaches have been tested in different animal models at birth, a highly early stage, showing that precocious treatment is critical to prevent long-term pathological consequences. This review provides insights into the state-of-art accomplishments made with neonatal cellular and gene-based therapies and the major barriers that need to be overcome before they can be implemented in the medical community.
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Affiliation(s)
- Shunji Tomatsu
- Department of Biomedical Research, Alfred I. duPont Institute Hospital for Children, Wilmington, DE, USA.
- Skeletal Dysplasia Lab, Department of Biomedical Research, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Rd., Wilmington, DE, 19899-0269, USA.
| | - Isabella Azario
- Dulbecco Telethon Institute at Centro Ricerca M. Tettamanti, Department of Paediatrics, University of Milano-Bicocca, San Gerardo Hospital, via Pergolesi, 33, 20900, Monza, MB, Italy
| | - Kazuki Sawamoto
- Department of Biomedical Research, Alfred I. duPont Institute Hospital for Children, Wilmington, DE, USA
| | - Alice Silvia Pievani
- Dulbecco Telethon Institute at Centro Ricerca M. Tettamanti, Department of Paediatrics, University of Milano-Bicocca, San Gerardo Hospital, via Pergolesi, 33, 20900, Monza, MB, Italy
| | - Andrea Biondi
- Centro Ricerca M. Tettamanti, Department of Paediatrics, University of Milano-Bicocca, Via Pergolesi, 33, Monza, 20900, Italy
| | - Marta Serafini
- Dulbecco Telethon Institute at Centro Ricerca M. Tettamanti, Department of Paediatrics, University of Milano-Bicocca, San Gerardo Hospital, via Pergolesi, 33, 20900, Monza, MB, Italy.
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A Long-term Retrospective Evaluation of Functional and Radiographic Outcomes of Pediatric Hip Surgery in Hurler Syndrome. J Pediatr Orthop 2016; 36:25-8. [PMID: 26090987 DOI: 10.1097/bpo.0000000000000385] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND After successful hematopoietic stem cell transplantation, maintaining function and mobility have become key goals in the management of patients with Hurler syndrome, (mucopolysaccharoidosis type 1H). The aim of this study was to establish the functional and radiologic outcomes after hip surgery in patients with this condition who had reached skeletal maturity. METHODS We prospectively followed 13 mucopolysaccharoidosis type 1H patients with closed triradiate cartilages who had undergone hip surgery in a single institution (Our Lady's Children's Hospital, Crumlin) in early childhood, after successful hematopoietic stem cell transplantation. Functional assessment was performed using the Harris Hip Score. Acetabular and femoral head morphology were defined using a pelvic radiograph. RESULTS The average age at follow-up was 18.6 years (range, 13.2 to 23.8 y). The average length of follow-up from surgical intervention was 14.6 years (range, 10.3 to 21.6 y). The average Harris Hip Score at follow-up was 61.0 (range, 19 to 91). At follow-up, 4 patients were either wheelchair bound or required a walking frame to mobilize in the community. At follow-up, all hips were in-joint with an average center edge angle of 37.7 degrees (range, 0 to 63 degrees). All hips displayed characteristic medial flattening of the femoral head. Ten hips (of 26 hips) showed radiologic degenerative changes with loss of joint space <2 mm. CONCLUSIONS Despite the surgical provision of stable well-covered hips, active intervention did not prevent the development of radiologic deterioration and clinically significant hip arthritis. We recommend that pediatric hip surgery in Hurler syndrome be designed with the possibility of early hip replacement in mind. LEVEL OF EVIDENCE Level III.
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Paleopathological Study of Dwarfism-Related Skeletal Dysplasia in a Late Joseon Dynasty (South Korean) Population. PLoS One 2015; 10:e0140901. [PMID: 26488291 PMCID: PMC4619213 DOI: 10.1371/journal.pone.0140901] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 10/01/2015] [Indexed: 11/19/2022] Open
Abstract
Skeletal dysplasias related to genetic etiologies have rarely been reported for past populations. This report presents the skeletal characteristics of an individual with dwarfism-related skeletal dysplasia from South Korea. To assess abnormal deformities, morphological features, metric data, and computed tomography scans are analyzed. Differential diagnoses include achondroplasia or hypochondroplasia, chondrodysplasia, multiple epiphyseal dysplasia, thalassemia-related hemolytic anemia, and lysosomal storage disease. The diffused deformities in the upper-limb bones and several coarsened features of the craniofacial bones indicate the most likely diagnosis to have been a certain type of lysosomal storage disease. The skeletal remains of EP-III-4-No.107 from the Eunpyeong site, although incomplete and fragmented, provide important clues to the paleopathological diagnosis of skeletal dysplasias.
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Characterization of knee alignment in children with mucopolysaccharidosis types I and II and outcome of treatment with guided growth. J Child Orthop 2015; 9:227-33. [PMID: 26076735 PMCID: PMC4486501 DOI: 10.1007/s11832-015-0661-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 05/25/2015] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To describe knee alignment in children of different ages with severe mucopolysaccharidosis (MPS) I and II and the outcome of treatment with guided growth in a patient subgroup. METHODS This is a retrospective observational study of 58 knees in 29 children with severe MPS I and II. Long-leg standing radiographs were evaluated to determine mechanical axis deviation, mechanical lateral distal femoral angle and medial proximal tibial angle at different ages throughout childhood. The change in deformity in individual children over time is reported. 20 knees in 10 patients were treated with guided growth using eight-plates. Radiographic measurements were recorded at the time of plate insertion, at plate removal and at 1 year following removal. RESULTS At 8 years of age, all MPS I children and three-quarters of MPS II children had valgus knee alignment. There was deformity progression in two-thirds of MPS I knees and half of MPS II knees. Guided growth corrected the deformities. There was recurrence in most cases 1 year after plate removal. CONCLUSIONS Knee deformity is common in children with severe MPS I and II. Guided growth can be considered where there is significant and/or or progressive deformity with the aim of halting progression and correcting existing deformity and thus minimizing the risk of gross deformity. Patients should be aware of the high rate of recurrence and the need for repeat surgery.
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Molecular Genetics and Metabolism Report Long-term follow-up of post hematopoietic stem cell transplantation for Hurler syndrome: clinical, biochemical, and pathological improvements. Mol Genet Metab Rep 2015; 2:65-76. [PMID: 25709894 PMCID: PMC4335359 DOI: 10.1016/j.ymgmr.2014.12.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Mucopolysaccharidosis type I (MPS I; Hurler Syndrome) is a lysosomal storage disease caused by a deficiency of the enzyme α-L-iduronidase which affects multiple organs such as central nervous system (CNS), skeletal system, and physical appearance. Hematopoietic stem cell transplantation (HSCT) is recommended as a primary therapeutic option at an early stage of MPS I with a severe form to ameliorate CNS involvement; however, no description of pathological improvement in skeletal dysplasia has been investigated to date. We here report a 15-year-old male case with MPS I post-HSCT. This patient received successful HSCT at the age of 2 years and 1 month, followed for over 10 years. His activity of daily living including cognitive performance has been kept normal and the present height and weight are 162 cm and 55 kg. Bone deformity has been still developed, resulting in hemiepiphysiodesis of bilateral medial proximal tibia at 12 years of age and successive arthrodesis of thoraco-lumbar spine at 13 years of age; however, skeletal histopathology from surgical remnants showed substantial improvement in bone lesion with markedly reduced occurrence and cell size of vacuolated cells. After a series of surgical procedures, he became ambulant and independent in daily activity. The levels of GAGs in blood were substantially reduced. In conclusion, this long-term post-HSCT observation should shed light on a new aspect of therapeutic effect associated with skeletal pathology and GAG levels as a biomarker, indicating that HSCT is a primary choice at an early stage for not only CNS but skeletal system in combination of appropriate surgical procedures.
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Langereis EJ, van Vlies N, Wijburg FA. Diagnosis, classification and treatment of mucopolysaccharidosis type I. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1016908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Tomatsu S, Alméciga-Díaz CJ, Montaño AM, Yabe H, Tanaka A, Dung VC, Giugliani R, Kubaski F, Mason RW, Yasuda E, Sawamoto K, Mackenzie W, Suzuki Y, Orii KE, Barrera LA, Sly WS, Orii T. Therapies for the bone in mucopolysaccharidoses. Mol Genet Metab 2015; 114:94-109. [PMID: 25537451 PMCID: PMC4312706 DOI: 10.1016/j.ymgme.2014.12.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 11/30/2014] [Accepted: 12/01/2014] [Indexed: 12/24/2022]
Abstract
Patients with mucopolysaccharidoses (MPS) have accumulation of glycosaminoglycans in multiple tissues which may cause coarse facial features, mental retardation, recurrent ear and nose infections, inguinal and umbilical hernias, hepatosplenomegaly, and skeletal deformities. Clinical features related to bone lesions may include marked short stature, cervical stenosis, pectus carinatum, small lungs, joint rigidity (but laxity for MPS IV), kyphoscoliosis, lumbar gibbus, and genu valgum. Patients with MPS are often wheelchair-bound and physical handicaps increase with age as a result of progressive skeletal dysplasia, abnormal joint mobility, and osteoarthritis, leading to 1) stenosis of the upper cervical region, 2) restrictive small lung, 3) hip dysplasia, 4) restriction of joint movement, and 5) surgical complications. Patients often need multiple orthopedic procedures including cervical decompression and fusion, carpal tunnel release, hip reconstruction and replacement, and femoral or tibial osteotomy through their lifetime. Current measures to intervene in bone disease progression are not perfect and palliative, and improved therapies are urgently required. Enzyme replacement therapy (ERT), hematopoietic stem cell transplantation (HSCT), and gene therapy are available or in development for some types of MPS. Delivery of sufficient enzyme to bone, especially avascular cartilage, to prevent or ameliorate the devastating skeletal dysplasias remains an unmet challenge. The use of an anti-inflammatory drug is also under clinical study. Therapies should start at a very early stage prior to irreversible bone lesion, and damage since the severity of skeletal dysplasia is associated with level of activity during daily life. This review illustrates a current overview of therapies and their impact for bone lesions in MPS including ERT, HSCT, gene therapy, and anti-inflammatory drugs.
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Affiliation(s)
- Shunji Tomatsu
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA; Medical Genetics Service/HCPA and Department of Genetics/UFRGS, Porto Alegre, Brazil.
| | - Carlos J Alméciga-Díaz
- Institute for the Study of Inborn Errors of Metabolism, Pontificia Universidad Javeriana, Bogotá, D.C., Colombia
| | - Adriana M Montaño
- Department of Pediatrics, Saint Louis University, St. Louis, MO, USA
| | - Hiromasa Yabe
- Department of Cell Transplantation, Tokai University School of Medicine, Isehara, Japan
| | - Akemi Tanaka
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Vu Chi Dung
- Department of Endocrinology, Metabolism & Genetics, Vietnam National Hospital of Pediatrics, Hanoi, Viet Nam
| | - Roberto Giugliani
- Medical Genetics Service/HCPA and Department of Genetics/UFRGS, Porto Alegre, Brazil
| | - Francyne Kubaski
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA; Department of Biological Sciences, University of Delaware, Newark, DE, USA
| | - Robert W Mason
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Eriko Yasuda
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Kazuki Sawamoto
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | | | - Yasuyuki Suzuki
- Medical Education Development Center, Gifu University, Japan
| | - Kenji E Orii
- Department of Pediatrics, Gifu University, Gifu, Japan
| | - Luis A Barrera
- Institute for the Study of Inborn Errors of Metabolism, Pontificia Universidad Javeriana, Bogotá, D.C., Colombia
| | - William S Sly
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University, St. Louis, MO, USA
| | - Tadao Orii
- Department of Pediatrics, Gifu University, Gifu, Japan.
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Leone A, Rigante D, Amato DZ, Casale R, Pedone L, Magarelli N, Colosimo C. Spinal involvement in mucopolysaccharidoses: a review. Childs Nerv Syst 2015; 31:203-12. [PMID: 25358811 DOI: 10.1007/s00381-014-2578-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 10/21/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Mucopolysaccharidoses (MPS) represent a group of inheritable lysosomal storage diseases caused by mutations in the genes coding for enzymes involved in catabolism of different glycosaminoglycans (GAGs). They are clinically heterogeneous multisystemic diseases, often involving the spine. Bony abnormalities of the spine included in the so-called dysostosis multiplex and GAG deposits in the dura mater and supporting ligaments can result in spinal cord compression, which can lead to compressive myelopathy. Spinal involvement is a major cause of morbidity and mortality in some MPS (e.g., MPS IVA, VI, and I), and early radiological diagnosis is critical in preventing or arresting neurological deterioration and loss of function. DISCUSSION Management of MPS, however, requires a multidisciplinary approach because of the multiorgan nature of the disease. Indeed in order to appreciate the relevance and nuances of each other's specialty, radiologists and clinicians need to have a background of common knowledge, rather than a merely compartmentalized point of view. In the interest of the management of spinal involvement in MPS, this review article aims on one hand to provide radiologists with important clinical knowledge and on the other hand to equip clinicians with relevant radiological semiotics.
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Affiliation(s)
- Antonio Leone
- Department of Radiological Sciences, Catholic University, School of Medicine, Largo A. Gemelli, 1-00168, Rome, Italy,
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Neonatal bone marrow transplantation prevents bone pathology in a mouse model of mucopolysaccharidosis type I. Blood 2014; 125:1662-71. [PMID: 25298037 DOI: 10.1182/blood-2014-06-581207] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Neonatal bone marrow transplantation (BMT) could offer a novel therapeutic opportunity for genetic disorders by providing sustainable levels of the missing protein at birth, thus preventing tissue damage. We tested this concept in mucopolysaccharidosis type I (MPS IH; Hurler syndrome), a lysosomal storage disorder caused by deficiency of α-l-iduronidase. MPS IH is characterized by a broad spectrum of clinical manifestations, including severe progressive skeletal abnormalities. Although BMT increases the life span of patients with MPS IH, musculoskeletal manifestations are only minimally responsive if the timing of BMT delays, suggesting already irreversible bone damage. In this study, we tested the hypothesis that transplanting normal BM into newborn MPS I mice soon after birth can prevent skeletal dysplasia. We observed that neonatal BMT was effective at restoring α-l-iduronidase activity and clearing elevated glycosaminoglycans in blood and multiple organs. At 37 weeks of age, we observed an almost complete normalization of all bone tissue parameters, using radiographic, microcomputed tomography, biochemical, and histological analyses. Overall, the magnitude of improvements correlated with the extent of hematopoietic engraftment. We conclude that BMT at a very early stage in life markedly reduces signs and symptoms of MPS I before they appear.
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Abstract
The mucopolysaccharidoses (MPSs) are a group of rare genetic disorders of glycosaminoglycan catabolism, caused by a deficiency of lysosomal enzymes required for GAG degradation. Incomplete breakdown of glycosaminoglycans leads to progressive accumulation of these substances in many tissues throughout the body. Different residual enzymatic activity can result in different phenotypes of the same MPS disorder, from severe to attenuated. Musculoskeletal manifestations are common across all forms of MPS. Skeletal and joint abnormalities are prominent features of many MPS disorders, particularly attenuated phenotypes. However, diagnostic delays occur frequently for patients with an MPS, especially those with more attenuated forms of disease. In the absence of appropriate treatment, these conditions are chronic, progressive and often debilitating, but treatment for many types of MPS is now available. Therefore, increasing awareness of MPS among rheumatologists is extremely important.
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Affiliation(s)
- Rolando Cimaz
- Department of Pediatrics, Rheumatology Unit, AOU Meyer Hospital, Viale Pieraccini, no. 24, 50139, Firenze, Italy,
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Urbanski G, Bekri S, Barth M, Verny C, Lavigne C. A Case of Type I Sialidosis With Osteonecrosis Revealing a New Mutation inNEU1. JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2014. [DOI: 10.1177/2326409814543468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Geoffrey Urbanski
- Internal Medicine Department, CHU Angers, Angers, France
- Grand Ouest Metabolic Disorders Competence Center, CHU Angers, Angers, France
| | | | - Magalie Barth
- Grand Ouest Metabolic Disorders Competence Center, CHU Angers, Angers, France
- Neurogenetic Disease Reference Center, CHU Angers, Angers, France
| | - Christophe Verny
- Neurogenetic Disease Reference Center, CHU Angers, Angers, France
| | - Christian Lavigne
- Internal Medicine Department, CHU Angers, Angers, France
- Grand Ouest Metabolic Disorders Competence Center, CHU Angers, Angers, France
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Hollak CEM, Wijburg FA. Treatment of lysosomal storage disorders: successes and challenges. J Inherit Metab Dis 2014; 37:587-98. [PMID: 24820227 DOI: 10.1007/s10545-014-9718-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/04/2014] [Accepted: 04/15/2014] [Indexed: 01/29/2023]
Abstract
Treatment options for a number of lysosomal storage disorders have rapidly expanded and currently include enzyme replacement therapy, substrate reduction, chaperone treatment, hematopoietic stem cell transplantation, and gene-therapy. Combination treatments are also explored. Most therapies are not curative but change the phenotypic expression of the disease. The effectiveness of treatment varies considerably between the different diseases, but also between sub-groups of patients with a specific lysosomal storage disorder. The heterogeneity of the patient populations complicates the prediction of benefits of therapy, specifically in patients with milder disease manifestations. In addition, there is a lack of data on the natural history of diseases and disease phenotypes. Initial trial data show benefits on relevant short-term endpoints, but the real world situation may reveal different outcomes. Collaborative international studies are much needed to study the long-term clinical efficacy of treatments, and to detect new complications or associated conditions of the diseases. This review summarizes the available treatment modalities for lysosomal storage disorders and the challenges associated with long term clinical care for these patients.
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Affiliation(s)
- Carla E M Hollak
- Department of Internal Medicine, Division of Endocrinology and Metabolism, SPHINX, Amsterdam Lysosome Center, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands,
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Hoch AI, Leach JK. Concise review: optimizing expansion of bone marrow mesenchymal stem/stromal cells for clinical applications. Stem Cells Transl Med 2014; 3:643-52. [PMID: 24682286 DOI: 10.5966/sctm.2013-0196] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Bone marrow-derived mesenchymal stem/stromal cells (MSCs) have demonstrated success in the clinical treatment of hematopoietic pathologies and cardiovascular disease and are the focus of treating other diseases of the musculoskeletal, digestive, integumentary, and nervous systems. However, during the requisite two-dimensional (2D) expansion to achieve a clinically relevant number of cells, MSCs exhibit profound degeneration in progenitor potency. Proliferation, multilineage potential, and colony-forming efficiency are fundamental progenitor properties that are abrogated by extensive monolayer culture. To harness the robust therapeutic potential of MSCs, a consistent, rapid, and minimally detrimental expansion method is necessary. Alternative expansion efforts have exhibited promise in the ability to preserve MSC progenitor potency better than the 2D paradigm by mimicking features of the native bone marrow niche. MSCs have been successfully expanded when stimulated by growth factors, under reduced oxygen tension, and in three-dimensional bioreactors. MSC therapeutic value can be optimized for clinical applications by combining system inputs to tailor culture parameters for recapitulating the niche with probes that nondestructively monitor progenitor potency. The purpose of this review is to explore how modulations in the 2D paradigm affect MSC progenitor properties and to highlight recent efforts in alternative expansion techniques.
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Affiliation(s)
- Allison I Hoch
- Department of Biomedical Engineering and Department of Orthopaedic Surgery, School of Medicine, University of California, Davis, Sacramento, California, USA
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Abstract
STUDY DESIGN A retrospective radiographical follow-up study of thoracolumbar deformity in 33 children with mucopolysaccharidosis 1 (Hurler syndrome). OBJECTIVE To report the severity, natural history, risk factors for progression, and results of intervention for thoracolumbar kyphosis in children with Hurler syndrome. SUMMARY OF BACKGROUND DATA Literature on the subject of thoracolumbar kyphosis in Hurler syndrome and its treatment is limited to small case series. The natural history and thus indications for intervention are unknown. METHODS Patients who had been treated with bone marrow transplantation and/or enzyme replacement therapy were followed up with erect radiographs of the spine. Mean follow-up period was 3.5 years (range, 2-12 yr). Radiographs were retrieved and analyzed retrospectively. Seven patients underwent varied forms of surgical intervention for progressive deformity, the technique and principles of which are described. RESULTS The thoracolumbar kyphosis on initial radiographs obtained at a mean age of 17 months measured 38° (95% confidence interval, 34°-42°). Fifteen of the 33 patients (45%) followed for more than 2 years developed a deformity that made a progression of more than 10°. The magnitude of the initial deformity was predictive of whether the deformity progressed (univariate analysis, P < 0.001). An initial kyphosis angle greater than 45° was predictive of progression of more than 10° with sensitivity of 67% and specificity of 88%. All patients who underwent surgical intervention had sustained improvement in the magnitude of thoracolumbar deformity. CONCLUSION Thoracolumbar kyphosis in Hurler syndrome is of variable severity with an average deformity, in our series, of 38° at a mean age of 17 months. Forty-five percent of patients developed progression of greater than 10°. Patients with an initial deformity greater than 45° seemed to be more likely to progress. Surgical interventions in the form of anterior fusion, combined anterior and posterior surgery and use of the vertical expandable prosthetic titanium rib provided good correction. LEVEL OF EVIDENCE N/A.
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Abelin Genevois K, Garin C, Solla F, Guffon N, Kohler R. Surgical management of thoracolumbar kyphosis in mucopolysaccharidosis type 1 in a reference center. J Inherit Metab Dis 2014; 37:69-78. [PMID: 23813121 DOI: 10.1007/s10545-013-9630-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 06/04/2013] [Accepted: 06/05/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Mucopolysaccharidosis (MPS) I is a rare autosomal recessive lysosomal storage disease. Thoracolumbar kyphosis is an early characteristic feature of the disease. Ossification failure in the anterosuperior quadrant of the vertebral body results in anterior dislocation. This study describes the surgical management of thoracolumbar kyphosis in MPS IH (Hurler syndrome) in a national reference center. METHODS Among 72 MPS I patients followed in our institution, we treated surgically 14 MPS IH patients with severe thoracolumbar kyphosis. The decision was made after documented deformity progression. Mean age at surgery was 8 (3.5-15) years. Sagittal imbalance of the trunk was constant. One patient underwent extended fusion for associated scoliosis. We retrospectively reviewed 13 patients who underwent selective circumferential fusion at the thoracolumbar level. RESULTS Average preoperative kyphosis was +57.5°(+30°; +90°). Surgical correction of the kyphosis was about 66 % and maintained at final follow-up. Fusion was obtained in all patients. Two patients required revision surgery consecutively to a previous posterior-only fusion, as a significant loss of correction occurred. One patient presented delayed neurologic deficit secondarily to cardiac embolism. One patient died postoperatively from cardiorespiratory failure. CONCLUSION Surgery is necessary when kyphosis is progressive despite orthopedic management, aggravating the multifactorial trunk imbalance. Regarding our experience, circumferential arthrodesis should be recommended to achieve stable correction. Surgical management requires a multidisciplinary approach due to multisystemic failure and neurological risks specific to metabolic disorders.
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Affiliation(s)
- Kariman Abelin Genevois
- Service de Chirurgie Orthopédique Pédiatrique, Hôpital Femme Mère Enfant, Université Claude Bernard Lyon I, Hospices Civils de Lyon, Lyon, France,
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Holt JB, Van Heest AE, Shah AS. Hand disorders in children with mucopolysaccharide storage diseases. J Hand Surg Am 2013; 38:2263-6. [PMID: 24206994 DOI: 10.1016/j.jhsa.2013.08.100] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 07/22/2013] [Accepted: 08/02/2013] [Indexed: 02/02/2023]
Affiliation(s)
- Joshua B Holt
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa; Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
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Langereis EJ, Borgo A, Crushell E, Harmatz PR, van Hasselt PM, Jones SA, Kelly PM, Lampe C, van der Lee JH, Odent T, Sakkers R, Scarpa M, Schafroth MU, Struijs PA, Valayannopoulos V, White KK, Wijburg FA. Treatment of hip dysplasia in patients with mucopolysaccharidosis type I after hematopoietic stem cell transplantation: results of an international consensus procedure. Orphanet J Rare Dis 2013; 8:155. [PMID: 24088413 PMCID: PMC3852175 DOI: 10.1186/1750-1172-8-155] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 09/30/2013] [Indexed: 12/01/2022] Open
Abstract
Background Mucopolysaccharidosis type I (MPS-I) is a lysosomal storage disorder characterized by progressive multi-organ disease. The standard of care for patients with the severe phenotype (Hurler syndrome, MPS I-H) is early hematopoietic stem cell transplantation (HSCT). However, skeletal disease, including hip dysplasia, is almost invariably present in MPS I-H, and appears to be particularly unresponsive to HSCT. Hip dysplasia may lead to pain and loss of ambulation, at least in a subset of patients, if left untreated. However, there is a lack of evidence to guide the development of clinical guidelines for the follow-up and treatment of hip dysplasia in patients with MPS I-H. Therefore, an international Delphi consensus procedure was initiated to construct consensus-based clinical practice guidelines in the absence of available evidence. Methods A literature review was conducted, and publications were graded according to their level of evidence. For the development of consensus guidelines, eight metabolic pediatricians and nine orthopedic surgeons with experience in the care of MPS I patients were invited to participate. Eleven case histories were assessed in two written rounds. For each case, the experts were asked if they would perform surgery, and they were asked to provide information on the aspects deemed essential or complicating in the decision-making process. In a subsequent face-to-face meeting, the results were presented and discussed. Draft consensus statements were discussed and adjusted until consensus was reached. Results Consensus was reached on seven statements. The panel concluded that early corrective surgery for MPS I-H patients with hip dysplasia should be considered. However, there was no full consensus as to whether such a procedure should be offered to all patients with hip dysplasia to prevent complications or whether a more conservative approach with surgical intervention only in those patients who develop clinically relevant symptoms due to the hip dysplasia is warranted. Conclusions This international consensus procedure led to the construction of clinical practice guidelines for hip dysplasia in transplanted MPS I-H patients. Early corrective surgery should be considered, but further research is needed to establish its efficacy and role in the treatment of hip dysplasia as seen in MPS I.
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Affiliation(s)
- Eveline J Langereis
- Department of Pediatrics and Lysosome Center 'Sphinx', Academic Medical Center, University of Amsterdam, H7-270, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Abstract
BACKGROUND Hip dysplasia is common in patients with Hurler syndrome (HS). However, its prevalence and optimal management is not yet clear because of the rarity of the disease and the prior short life span of these patients. Recent advances in the management of these children using allogeneic hematopoietic cell transplant (HCT) has significantly increased their life expectancy, with many surviving into adulthood. This review was conducted to describe the experience of a single center with hip dysplasia in HS after HCT. METHODS We performed a retrospective review of hip dysplasia in a consecutive series of patients with HS treated with HCT from 1985 to 2008. RESULTS At 4.5 (± 2.9) years after HCT all 51 children (102 hips) with HS showed acetabular dysplasia and proximal femur valgus deformity. Mean age at HCT was 1.6 ± 0.9 years. Forty hips (39%) underwent hip reconstructive osteotomies at mean age of 6.8 ± 3.1 years. Significant radiographic improvement was noted in all radiographic parameters at 5.4 ± 3.7 years after hip surgery (P<0.001). Acetabular index improved from 33.3 degrees (± 7.9) preoperative to 24.7 degrees (± 8) after surgery, lateral center edge angle improved from -5.3 degrees (± 10.9) to 35.2 degrees (± 17.8), migration index from 50.7% (± 15.7) to 9.6% (± 13.6), and femoral-neck-shaft angle from 150.9 degrees (± 5.8) to 130.8 degrees (± 12.4). Ten of the 40 hips underwent only proximal femoral varus derotation osteotomy and 30 underwent combined proximal femoral varus derotation osteotomy+pelvic osteotomy. CONCLUSIONS This study reports high prevalence of hip dysplasia (100%) in patients with HS. As significant radiographic improvement was achieved in those patients treated with surgical interventions we recommend annual orthopaedic evaluation of hips in patients with HS after HCT and intervention with reconstructive femoral and pelvic osteotomies for their hip dysplasia.
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Xing EM, Knox VW, O'Donnell PA, Sikura T, Liu Y, Wu S, Casal ML, Haskins ME, Ponder KP. The effect of neonatal gene therapy on skeletal manifestations in mucopolysaccharidosis VII dogs after a decade. Mol Genet Metab 2013; 109:183-93. [PMID: 23628461 PMCID: PMC3690974 DOI: 10.1016/j.ymgme.2013.03.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 03/17/2013] [Accepted: 03/18/2013] [Indexed: 12/27/2022]
Abstract
Mucopolysaccharidosis (MPS) VII is a lysosomal storage disease due to deficient activity of β-glucuronidase (GUSB), and results in glycosaminoglycan accumulation. Skeletal manifestations include bone dysplasia, degenerative joint disease, and growth retardation. One gene therapy approach for MPS VII involves neonatal intravenous injection of a gamma retroviral vector expressing GUSB, which results in stable expression in liver and secretion of enzyme into blood at levels predicted to be similar or higher to enzyme replacement therapy. The goal of this study was to evaluate the long-term effect of neonatal gene therapy on skeletal manifestations in MPS VII dogs. Treated MPS VII dogs could walk throughout their lives, while untreated MPS VII dogs could not stand beyond 6 months and were dead by 2 years. Luxation of the coxofemoral joint and the patella, dysplasia of the acetabulum and supracondylar ridge, deep erosions of the distal femur, and synovial hyperplasia were reduced, and the quality of articular bone was improved in treated dogs at 6 to 11 years of age compared with untreated MPS VII dogs at 2 years or less. However, treated dogs continued to have osteophyte formation, cartilage abnormalities, and an abnormal gait. Enzyme activity was found near synovial blood vessels, and there was 2% as much GUSB activity in synovial fluid as in serum. We conclude that neonatal gene therapy reduces skeletal abnormalities in MPS VII dogs, but clinically-relevant abnormalities remain. Enzyme replacement therapy will probably have similar limitations long-term.
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Affiliation(s)
- Elizabeth M Xing
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
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de Ruijter J, Maas M, Janssen A, Wijburg FA. High prevalence of femoral head necrosis in Mucopolysaccharidosis type III (Sanfilippo disease): a national, observational, cross-sectional study. Mol Genet Metab 2013; 109:49-53. [PMID: 23541797 DOI: 10.1016/j.ymgme.2013.03.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 03/07/2013] [Accepted: 03/08/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND Sanfilippo disease, or Mucopolysaccharidosis type III (MPS III), is a lysosomal storage disorder and a member of the mucopolysaccharidoses (MPSs). MPS III is clinically characterized by progressive neurodegeneration. Skeletal disease is not felt to be an important clinical component in MPS III patients, unlike in the other MPSs. We conducted radiographic studies in a relatively large group of MPS III patients and detected a high prevalence of osteonecrosis of the femoral head (ONFH). METHODS Thirty-three patients were included in the study. All the patients underwent an X-ray of the pelvis (anteroposterior view). All the X-rays were evaluated by a single, blinded radiologist using a modified Ficat classification system for ONFH (the stages ranged from 0 to IV, with increasing stages signifying more severe abnormalities). Clinical symptoms possibly related to hip disease were recorded. The patients were divided into different phenotypes based on mutational analysis and their plasma heparan sulfate (HS) levels. RESULTS In 21 of the 33 patients, the disease severity could be predicted by genotype. In 11 of the 12 remaining patients, the phenotype could be assessed via the plasma HS levels. Eight patients (24%) exhibited signs of ONFH (Ficat stage≥I), and 6 (75%) of them had bilateral changes. None of the patients with attenuated MPS III (n=14) had ONFH. In 6 of the patients with a severe phenotype, hip dysplasia was detected as an additional finding. The 7 patients with Ficat stages ≥ II reported hip pain. CONCLUSIONS Femoral head disease, which resembles ONFH, is common in patients with the severe MPS III phenotype. An evaluation of hip disease should be included in follow-up visits with MPS III patients.
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Affiliation(s)
- Jessica de Ruijter
- Department of Pediatrics, Amsterdam Lysosome Center Sphinx Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Karussis D, Petrou P, Kassis I. Clinical experience with stem cells and other cell therapies in neurological diseases. J Neurol Sci 2012; 324:1-9. [PMID: 23107343 DOI: 10.1016/j.jns.2012.09.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 09/26/2012] [Accepted: 09/27/2012] [Indexed: 12/13/2022]
Abstract
To overcome the limited capacity of the CNS for regeneration, the theoretical alternative would be to use stem cells for more effective management of chronic degenerative and inflammatory neurological conditions, and also of acute neuronal damage from injuries or cerebrovascular diseases. Although the adult brain contains small numbers of stem cells in restricted areas, this intrinsic stem cell repertoire is small and does not measurably contribute to functional recovery. Embryonic cells carrying pluripotent and self-renewal properties represent the stem cell prototype, but there are additional somatic stem cells that may be harvested and expanded from various tissues during adult life. Stem cell transplantation is based on the assumption that such cells may have the potential to regenerate or support the survival of the existing, partially damaged cells. This review summarizes the state-of-the-art and the clinical worldwide experience with the use of various types of stem cells in neurological diseases.
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Affiliation(s)
- Dimitrios Karussis
- Department of Neurology, MS Center and Laboratory of Neuroimmunology, Agnes-Ginges Center for Neurogenetics, Hadassah University Hospital, Ein Kerem, Jerusalem, Israel.
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Stoop FJ, Kruyt MC, van der Linden MH, Sakkers RJB, van Hasselt PM, Castelein RMC. Prevalence and development of orthopaedic symptoms in the dutch hurler patient population after haematopoietic stem cell transplantation. JIMD Rep 2012; 9:17-29. [PMID: 23430544 DOI: 10.1007/8904_2012_175] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 06/25/2012] [Accepted: 08/27/2012] [Indexed: 01/06/2023] Open
Abstract
Hurler syndrome (MPS-IH) is a rare autosomal recessive lysosomal storage disease. Besides a variety of other features, Hurler syndrome is characterized by a range of skeletal abnormalities known as dysostosis multiplex. Despite the successful effect of haematopoietic stem cell transplantation on the other features, dysostosis remains a disabling symptom of the disease. This study analyzed the status and development of the orthopaedic manifestations of 14 Dutch Hurler patients after stem cell transplantation.Data were obtained retrospectively by reviewing patients' charts, radiographs and MRIs. Existing methods to measure the deficiencies were modified to optimally address the dysostosis. These measurements were done by two of the authors independently. The odontoïd/body ratio, kyphotic angle, scoliotic angle and parameters for hip dysplasia and genu valgum were measured and plotted against age. The degree of progression was determined. The intraclass correlation coefficient (ICC) was calculated to determine the reliability of the measurements.All patients showed hypoplasia of the odontoïd, which significantly improved during growth. Kyphosis in the thoracolumbar area was present in 13 patients and proved to be progressive. Scoliosis was observed in eight patients. Hip dysplasia was present in all patients and showed no tendency of improvement. In all but one patient, knee valgus remained more than two standard deviations above normal.Dysostosis remains a major problem after haematopoietic stem cell transplantation in Hurler patients. Moreover, except for dens hypoplasia, it appears to be progressive and therefore surgical interventions may be necessary in the majority of these patients.
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Affiliation(s)
- F J Stoop
- Department of Orthopaedics, University Medical Center Utrecht, HP G 05.228, 85500, 3508 GA, Utrecht, The Netherlands
| | - M C Kruyt
- Department of Orthopaedics, University Medical Center Utrecht, HP G 05.228, 85500, 3508 GA, Utrecht, The Netherlands.
| | - M H van der Linden
- Department of Orthopaedics, University Medical Center Utrecht, HP G 05.228, 85500, 3508 GA, Utrecht, The Netherlands
| | - R J B Sakkers
- Department of Orthopaedics, University Medical Center Utrecht, HP G 05.228, 85500, 3508 GA, Utrecht, The Netherlands
| | - P M van Hasselt
- Department of Metabolic Diseases, Wilhelmina Children's Hospital, University Medical Center, Utrecht, The Netherlands
| | - R M C Castelein
- Department of Orthopaedics, University Medical Center Utrecht, HP G 05.228, 85500, 3508 GA, Utrecht, The Netherlands
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