Prolidase deficiency: report of a second case with quantitation of the excessively excreted amino acids

Quantitative analysis of the natural history of prolidase deficiency: description of 17 families and systematic review of published cases

PURPOSE

Prolidase deficiency is a rare inborn error of metabolism causing ulcers and other skin disorders, splenomegaly, developmental delay, and recurrent infections. Most of the literature is constituted of isolated case reports. We aim to provide a quantitative description of the natural history of the condition by describing 19 affected individuals and reviewing the literature.

METHODS

Nineteen patients were phenotyped per local institutional procedures. A systematic review following PRISMA criteria identified 132 articles describing 161 patients. Main outcome analyses were performed for manifestation frequency, diagnostic delay, overall survival, symptom-free survival, and ulcer-free survival.

RESULTS

Our cohort presented a wide variability of severity. Autoimmune disorders were found in 6/19, including Crohn disease, systemic lupus erythematosus, and arthritis. Another immune finding was hemophagocytic lymphohistiocytosis (HLH). Half of published patients were symptomatic by age 4 and had a delayed diagnosis (mean delay 11.6 years). Ulcers were present initially in only 30% of cases, with a median age of onset at 12 years old.

CONCLUSION

Prolidase deficiency has a broad range of manifestations. Symptoms at onset may be nonspecific, likely contributing to the diagnostic delay. Testing for this disorder should be considered in any child with unexplained autoimmunity, lower extremity ulcers, splenomegaly, or HLH.

Prolidase deficiency breaks tolerance to lupus-associated antigens

AIM

Prolidase deficiency is a rare autosomal recessive disease in which one of the last steps of collagen metabolism, cleavage of proline-containing dipeptides, is impaired. Only about 93 patients have been reported with about 10% also having systemic lupus erythematosus (SLE).

METHODS

We studied a large extended Amish pedigree with four prolidase deficiency patients and three heterozygous individuals for lupus-associated autoimmunity. Eight unaffected Amish children served as normal controls. Prolidase genetics and enzyme activity were confirmed. Antinuclear antibodies (ANA) were determined using indirect immunofluorescence and antibodies against extractable nuclear antigens were determined by various methods, including double immunodiffusion, immunoprecipitation and multiplex bead assay. Serum C1q levels were determined by enzyme-linked immunosorbent assay.

RESULTS

Two of the four homozygous prolidase deficiency subjects had a positive ANA. One had anti-double-stranded DNA, while another had precipitating anti-Ro. By the simultaneous microbead assay, three of the four had anti-Sm and anti-chromatin. One of the three heterozygous subjects had a positive ANA and immunoprecipitation of a 75 000 molecular weight protein. The unaffected controls had normal prolidase activity and were negative for autoantibodies.

CONCLUSIONS

Prolidase deficiency may be associated with the loss of immune tolerance to lupus-associated autoantigens even without clinical SLE.

Oxidative stress in chronic otitis media

Chronic otitis media usually presents with a benign tumor-like lesion of the temporal bone known as a cholesteatoma. The role of oxidative stress in the pathogenesis of chronic otitis media and cholesteatoma has not yet been fully explored. Therefore, the aim of this study was to investigate the oxidative stress markers and antioxidant enzymes in patients with cholesteatomatous and noncholesteatomatous chronic otitis media and in healthy subjects. A prospective controlled trial was performed on cholesteatomatous and noncholesteatomatous chronic otitis media patients in a tertiary referral center in a university hospital. A total of 75 subjects, including 25 cholesteatomatous and 25 noncholesteatomatous chronic otitis media patients and 25 healthy subjects participated in this study. Serum total oxidant status (TOS) and oxidative stress index (OSI) levels were significantly increased in the patient groups with or without cholesteatoma compared with the control group. Serum total antioxidant status (TAS) levels and Paraoxonase and arylesterase activity were significantly lower in the patient groups with or without cholesteatoma compared with the control group. Serum TOS and OSI levels were lower in the noncholesteatomatous group, whereas serum TAS levels were higher compared with the cholesteatomatous group. Serum arylesterase activity was significantly lower in the noncholesteatomatous group compared with the control group. The results of this study reveal that in cholesteatoma cases, the oxidative stress and antioxidant enzyme imbalance were more significant than in cases of chronic otitis media without cholesteatoma.

Activity of prolidase isoenzymes in the rat brain: subcellular and regional distribution during development

Prolidase deficiency is characterized by chronic ulcerative dermatitis, mental retardation, and frequent infections. In the present study we examined the characteristics of rat brain prolidase isoenzymes. Prolidase isoenzymes (PD I and PD II) were isolated from the rat brain using DEAE cellulose column chromatography. PD I showed higher activity against seryl-proline and alanyl-proline, while PD II was particularly active against methionyl-proline. Prolidase activity in the whole brain and in the different brain regions showed higher activity against methionyl-proline and seryl-proline. PD II activity was highest in the hippocampus, followed by the cerebellum, cerebral cortex, caudatum, and the midbrain. The most rapid changes in the activities of PD I and PD II occurred perinatally, with a peak at three days before birth and a nadir at two days after birth, which then gradually increased until 21 days. N-benzyloxycarbonyl-l-proline inhibited PD I activity against various substrates in a dose-dependent manner. In contrast, there was no inhibition of PD II activity against methionyl-proline at low concentrations. In summary, these data suggest that maintenance of levels of proline, other amino acids and peptides containing proline in the rat brain is regulated by prolidase isoenzymes. The age-related alterations in PD I and PD II also may help to elucidate the fundation of prolidase isoenzymes in brain nervous system.

Prolidase isoenzymes in the rat: their organ distribution, developmental change and specific inhibitors

Lack of prolidase I (PD I) leads to prolidase deficiency, a disease characterized by intractable skin lesions, recurrent respiratory infections, and mental retardation. The present study was undertaken to characterize and determine the physiologic roles of different prolidase isoenzymes. Two isoforms of prolidase were isolated from rat kidney. PD I showed higher activity against seryl-proline and alanyl-proline, whereas PD II was active especially against methionyl-proline. PD I was highly concentrated in the small intestine and kidney, whereas PD II was shown not to vary in the organs examined. Expression of PD I and PD II in the small intestine were maximal within 1 wk of birth, and then rapidly declined. The changes of prolidase in the kidney and heart were found to differ slightly. N-benzyloxycarbonyl-l-proline and captopril inhibited PD I dose-dependently, but showed no inhibition of PD II at low concentrations. NiCl2 inhibited PD II much more effectively than PD I. Our findings suggest that PD I functions by way of an intestinal peptide carrier, which may also be regulated by the uptake of various iminodipeptides. Similarly, age-related alterations of prolidase isoenzymes suggest that intestinal PD II also participates in absorption of proline and other amino acids early in life.

Characterization of prolidase activity in erythrocytes from a patient with prolidase deficiency: Comparison with prolidase I and II purified from normal human erythrocytes

OBJECTIVES

The purpose of this study was to investigate the effect of various amino acids and their metabolites on the activities of prolidase I and II from human erythrocytes compared to those in a patient with prolidase deficiency.

DESIGN AND METHODS

Prolidase I and II from human erythrocytes were purified by using column chromatography. Prolidase activity against various iminodipeptides was determined by spectrophotometry using Chinard's method.

RESULTS

The activities of prolidase I and II against glycylproline and methionylproline were enhanced by glycine, L- and D-isoforms of alanine and serine and D-isoforms of valine, leucine and isoleucine. L-isoforms of branched amino acids inhibited the activity of prolidase I. On the other hand, the activity of prolidase II was enhanced by all of these L-branched amino acids. The patient's prolidase activity was also enhanced by all the L- and D-branched amino acids.

CONCLUSION

The activities of prolidase I and II against various iminodipeptides were prominently enhanced by glycine, but the effect of L-valine differed between the two enzymes. Enzymatic properties of the patient's prolidase were essentially the same as those of prolidase II.

Effects of amino acids and its metabolites on prolidase activity against various iminodipeptides in erythrocytes from normal human and a patient with prolidase deficiency

BACKGROUND

The characteristics of prolidase in erythrocytes from controls and patient with prolidase deficiency were investigated.

METHODS

The erythrocytes were isolated from the heparinized blood of normal human and a patient with prolidase deficiency. Effects of various amino acids and their metabolites on prolidase activity against iminodipeptides in presence of 1 mmol/l MnCl(2) were investigated.

RESULTS

Prolidase activity against glycylproline in erythrocytes from normal human was strongly enhanced by glycine, L-alanine, L-serine with MnCl(2), but the activity was strongly inhibited by L-valine, and L-leucine. However, the stereoisomers, D-leucine and D-valine enhanced the activity. The prolidase activity against methionylproline in erythrocytes from the patient with prolidase deficiency was also enhanced by glycine, L-alanine and L-serine. The activity was inhibited by l-leucine, but D-leucine and L-valine enhanced the activity against various iminodipeptides.

CONCLUSION

Prolidase activity against glycylproline in normal human erythrocytes and against methionylproline from the prolidase-deficient patient was enhanced strongly by glycine, alanine and serine with MnCl(2). However, this activity was inhibited by L-leucine, but was enhanced by D-leucine.

Prolidase deficiency: a multisystemic hereditary disorder

Prolidase deficiency is a rare hereditary disorder with a wide spectrum of clinical manifestations including skin ulcers, eczematous eruptions, characteristic facies, mental retardation, splenomegaly, and susceptibility to infections. We report two new cases of prolidase deficiency. Our patients had the typical manifestations of prolidase deficiency. One also had lupus erythematosus. Prolidase activity was either normal or half-normal in all family members. The skin disease in our patients did not respond to topical glycine/proline ointment or to oral vitamin C.

Biochemical basis of prolidase deficiency. Polypeptide and RNA phenotypes and the relation to clinical phenotypes

Cultured skin fibroblasts or lymphoblastoid cells from eight patients with clinical symptoms of prolidase deficiency were analyzed in terms of enzyme activity, presence of material crossreacting with specific antibodies, biosynthesis of the polypeptide, and mRNA corresponding to the enzyme. There are at least two enzymes that hydrolyze imidodipeptides in these cells and these two enzymes could be separated by an immunochemical procedure. The specific assay for prolidase showed that the enzyme activity was virtually absent in six cell strains and was markedly reduced in two (less than 3% of controls). The activities of the labile enzyme that did not immunoprecipitate with the anti-prolidase antibody were decreased in the cells (30-60% of controls). Cell strains with residual activities of prolidase had immunological polypeptides crossreacting with a Mr 56,000, similar to findings in the normal enzyme. The polypeptide biosynthesis in these cells and the controls was similar. Northern blot analyses revealed the presence of mRNA in the polypeptide-positive cells, yet it was absent in the polypeptide-negative cells. The substrate specificities analyzed in the partially purified enzymes from the polypeptide-positive cell strains differed, presumably due to different mutations. Thus, there seems to be a molecular heterogeneity in prolidase deficiency. There was no apparent relation between the clinical symptoms and the biochemical phenotypes, except that mental retardation was present in the polypeptide-negative patients. The activities of the labile enzyme may not be a major factor in modifying the clinical symptoms.

Profiling of amino acids in body fluids and tissues by means of liquid chromatography

The needs of urgent diagnoses and the needs emerging from acute forms of diseases have directed progress in amino acid profiling to modern, rapid, automated analyses that can be done at reasonable cost. The first step in this direction was the short programmes of classical ion-exchange chromatography. At the beginning of this review we attempted to survey methods of sample preparation and sample treatment, as these are frequently neglected stages where artefacts or erroneous results may arise. There are basically the following approaches in amino acid profiling by liquid chromatographic techniques. For preliminary screening of a large number of samples in clinical routine planar procedures are the methods of choice, as they allow large numbers of samples to be handled with minimum effort and at very reasonable cost. For more precise profiling, particularly where quantitative data are essential, one can choose between some of the modern procedures for separating underivatized amino acids using modern equipment for cation-exchange chromatography, by making use of a stepped series of lithium citrate buffers with ninhydrin, o-phthalaldehyde or 4-fluoro-7-nitrobenzo-2,1,3-oxadiazole detection. Ninhydrin detection is preferred in those situations where the demands on sensitivity are not high. Where, however, only small amounts of samples are available or high sensitivity is required, one of the latter two methods is preferred. The o-phthalaldehyde procedure is not suitable for the detection of secondary amines and, if these are of interest, then diazole derivatization is to be preferred. At present, however, the ninhydrin and o-phthalaldehyde detection procedures are the most popular. The other choice is to use one of the sophisticated HPLC systems equipped with fluorescence detection and to separate amino acids as derivatives. Here o-phthalaldehyde and 4-fluoro-7-nitrobenzo-2,1,3-oxadiazole derivatives offer the most versatile possibilities. Automation and computerization have penetrated both categories of liquid column separation and are applied to automated sample delivery, automated and computerized gradient formation and quantitation of the data obtained. The tables of metabolic disorders of amino acids and the roles of different amino acids in these disorders should provide preliminary information for clinical chemists.

An autopsy case of prolidase deficiency

A 25-year-old female who suffered from longstanding incurable leg ulcers was found to have prolidase deficiency with iminodipeptiduria. On ultrastructural studies of autopsy specimens, the lamina densa of the epidermal basement membrane was found to show irregular splitting and the basement membranes of the dermal blood vessels were lamellated with interruptions. Lamellar changes and splitting of the basement membranes of the renal tubules, interstitial blood vessels and glomerular capillaries also occurred. These morphological abnormalities seem to be one of causes of the clinical symptomatology.

Clinical and biochemical characteristics of prolidase deficiency in siblings

Two brothers with recurrent skin ulcers of the lower limbs, subnormal intelligence, developmental abnormalities, and poliosis were found to excrete large quantities of several imidodipeptides in their urine. Glycylproline was the most prominent imidodipeptide excreted and was also detected in their blood. Prolidase activity was markedly deficient in red blood cells from both patients (4.1% and 3.7% of control mean) and skin fibroblasts from the one brother so examined (3.7% of control mean). A total of 20 patients with prolidase deficiency, including the two in this report, have been described in the literature. Their manifestations and various attempts at treatment are reviewed.

Prolidase and prolidase deficiency

Prolidase deficiency seems to be a rather rare metabolic disorder. However, many new cases can be detected because screening is easy to perform and enzymatic confirmation allows the differentiation from other iminodipeptidurias . Clinical symptoms are briefly reviewed, while biological considerations and prolidase properties are exhaustively described. Methods for investigating urinary iminodipeptides are given with results. Moreover, several collagen modifications observed in this disorder led us to formulate a hypothesis for their mechanism. Genetic considerations and treatment attempts are discussed.

Prolidase deficiency

The clinical and biochemical findings in a four-year-old girl with prolidase deficiency, treated with L-proline, manganese and ascorbic acid, are presented.

Optimal conditions for prolidase assay by proline colorimetric determination: application to iminodipeptiduria

Prolidase assay was reinvestigated by determining proline, using Chinard's method. Although several authors had previously tested this colorimetric reaction, accurate details regarding enzyme activity were not available. The need for greater sensitivity led to the introduction of several modifications: dialysis was eliminated and the substrate concentration and incubation time were changed. In addition, the reaction mixture was preincubated with Mn2+ for 24 h in order to triple prolidase activity. Color development followed at 90 degrees C, because of partial glycylproline hydrolysis at higher temperatures. The effect of several divalent cations on prolidase activity were tested with and without Mn2+. This modified assay was applied to erythrocytes, plasma and skin fibroblasts from a female patient with iminodipeptiduria.

Normal hydroxylation of proline in collagen synthesized by skin fibroblasts from a patient with prolidase deficiency

The extent of hydroxylation of proline in collagen synthesized and secreted into the culture medium by skin fibroblasts derived from a patient with prolidase deficiency has been examined and found to be normal. It would seem likely that to a considerable extent the urinary proline-containing dipeptides apparent in this condition are derived from sources other than collagen.