Term | Definition |
Mitochondria targeting signal | N-terminal amphipathic helix |
Nucleus targeting signal | internal basic AA di-peptide |
ER targeting signal | N-terminal hydrophobic peptide; binds signal recongnition particle (SRP) with co-translational import followed by cleavage |
Lysosome targeting signal | Mannose-6-P (M6P) added post-translationally |
Peroxisome targeting signal | C-terminal -SKL
near N-terminal -RLX5H/QL |
size of mitochondrial genome | 16,659 bp |
mutation rate of mitocchondrial genome | 7-10X nuclear |
copies of mt in cel | 100-1000s |
mtDNA genes | 37 genes (13 resp chain protein, 2 rRNAs, 22 tRNAs) |
NuDNA mito-assoc genes | >300 genes (resp chain, mtDNA replication, expression, and repair, antioxidant defense, FE homeostasis) |
Mitochondrial disease incidence | 1/5000-8000 |
Mito disease mutations in | nuclear and mt DNA |
mito disease | affects tissue with high energy demands |
heteroplasmy | threshold effect |
Mito disease CNS | hypotonia, ataxia, IDD, seizures, migraines, dementia, snhl |
Mito disease eyes | RP, optic atrophy, nystagmus, ophthalmoplegia |
Mito disease muscle | weakness, exercise intolerance, red ragged fibers |
Mito disease cardiac | HCM, arrhythmias, heart block |
Mito disease hematologic | macrocytic anemia, pancytopenia |
Mito disease endocrine | diabetes mellitus, diabetes insipidus, exocrine pancreatic dysfunction, short staturem |
Mito disease GI | dysfx, intestinal psuedo-obstruction |
Mito disease liver | dysfx, failure |
Mito disease renal | RTA, Fanconi syndrome |
Mt disorders of OxPhos | 80-90% pts have nuclear defects (e- transport chain)
AR inheritance |
Mt disorders of Resp chain assembly factors | mutation in nuc genes
ACAD9 (complex 1)
SURF1 (complex IV)
SCO1&2 (Cu++ homeostasis, complex assembly) |
Mt neurogastrointestinal encephalomyopathy (MNGIE) | AR
defect in TYMP gene (nuclear) |
CoQ synthesis defects | 5 nuclear genes |
Leigh syndrome | onset late infancy with regression
MRI abnormal with white matter and basal ganglia changes
+/- increase in serum lactate |
Leigh syndrome | heterogeneous with nuclear & mt mutations
~50% SURF1 (inv assembly cyt oxidase, comple IV)
PDH mutations
Complex I,II,IV def
NARP mt DNA mut
mt DNA depletion |
Mitochondrial depletion syndrome | AR
decrease in ratio mt/nuclear DNA |
Genes that cause Mito depletion syndrome | POLG1
TK2
DGUOK
TWINKLE
others |
Mito depletion syndrome clinical presentation | hepatic failure
decrease glucose
CNS involvement |
LHON | adult onset optic neuropathy;
mostly hmp missense mutations |
NARP | Neuropathy, ataxia and RP;
mostly heteroplasmic missense mutations in ATP synthase (Complex V) |
Maternally inherited deafness | point mutations in MT-rRNA; also associated with susceptibility to aminoglycoside ototoxicity |
mt tRNA mutations cause | MERRF
MELAS |
heteroplasmic point muts in mt tRNA(lys) | MERRF (~80%): myoclonic epilepsy with red ragged fibers |
heteroplasmic point muts in mt tRNA(leu) | MELAS (most): myoclonic epilepsy with lactic acidosis and stroke |
mt tRNA mutations pathogenesis | inability to translate several mt proteins and lack of nl processing of transcripts |
MELAS presentation and genetics | episodes of metabolic decompensation assoc/ w/ high risk for stroke;
acute rx to Arg;
3243A>G tRNA(Leu) 80%
3271T>C tRNA(Leu)7%
heteroplasmic |
Disorders caused by mtDNA del and/or dup | Diabetes and deafness; Pearson syndrome (anemia, 2ndary marrow failure, lactic acidosis, exoncrine pancreatic failure, RTA);
CPEO (chronic progressive external ophthalmoplegia);Kearns-Sayre (PEO,cardiac conduction block,RP,ataxia,lacticacidosis,sporadic) |
Lab diagnosis of mt disorders | increase ratio of lactate to pyruvate or vice versa(peripheral, CNS);
inrease of alanine;
Brain MRI;
Muscle and/or liver biopsy;
OxPhos analysis (+enzyme assays)
Molecular testing (mt/nuclear DNA, exome) |
Treatment of mitochondrial disorders | symptomatic for involved organs;
carnitine, coenzyme Q10, riboflavin (comp 1 and 2), antioxidants (vit C, K deravitives)
L-arg for MELAS to reduce stroke risk;
diet manipulation |
Congenital Disorders of Glycosylation (CDG) clinical spectrum | CNS, eye, skeletal, skin, clotting, immune system, endocrine, GI, liver, and more |
Classes of Glycosylation Disorders | N-glycosylation defects (17)
O-glycosylation defects (17)
Lipid glycosylation defects (3+)
Golgi COG (component of oligomeric Golgi) complex proteins (6)
dolichol synthesis or recycling (6) |
N-glycosylation defects | amide linkage to Aspargine
N-glycan assembly ER or cytosol; sugars transferred en bloc from dolichol; processing in ER or Golgi
~50% of all known proteins have 1+ N-gly site |
O-glycosylation defects | linkage through -OH on Ser or Thr; transfer single sugars onto growing glycan backbone
includes ABO blood grps, exostoses 1&2 proteins; proteoglycans (with skeletal & connective tissue sx), some congenital muscular dystrophies (POMT1&2, Fukutin, etc.) |
Classical PMM2-CDG (Ia) presentation | Multisystem disorder: 1.hypotonia, IDD, szs, ataxia (cerebellar hypoplasia) 2. RP,strabismus 3.liver disease, coagulopathy 4.FTT, inverted nipples, lipodystrophy 5.death <1yrs to adulthood w/ range of cognitive skills |
Classical PMM2-CDG (Ia) genetics | most common CDG (60-70% of pts)
AR
phosphomannomutase 2 def
abnormal transferrin isoelectric focusing |
MPI-CDG (1b)
Mannose-6-phosphate isomerase def | hepatic/GI symptoms with vomiting, GI bleeding, protein loss enteropathy, liver disease, coagulopathy, hepatic fibrosis
minimal neurologic involvement
treatment: oral mannose |
SRD5A3-CDG (Iq)
Steroid 5-a-3 reductase deficiency | dolichol synthesis defect
1st symptoms at 6 mo - 12 yrs
severe IDD, ataxia, cerebellar hypoplasia
eye: COLOBOMA, optic atrophy, cataracts, glaucoma, micro-ophthalmia
heart defects, liver dysfx, ICTHYOSIS |
CDG diagnosis | transferrin isoelectric focusing (N-linked only)
mass spec protein(Tf, apoCIII,...) and urine (N and O linked disorders)
false positives (in <30 day old): galactosemia, HFI, recent EtOH use, liver dis, hemolytic uremic syn, Tf prot polymorphisms |
Lysosomes | cytoplasmic organelles that contain ~50 acidic degradative enzymes |
Lysosomal storage disorders | accum of macromolecules usually degraded
stored material may cause enlargement of organs and may be visualized in membrane bound vesicles by EM |
Lysosomal storage disorders (inheritance) | all are recessive
most are autosomal |
LSDs (progression) | normal at birth; as material accumulates there is a plateau and then regression: progressive and often fatal; there are milder forms |
LSD classes | 1.Mucopolysaccharidoses 2.Sphingolipidoses 3.Transport disorders 4.Mucolipidoses 5.Glycoprotein 6.Neutral Lipid 7.Glycogen Storage |
LSD general clinical features | coarse facies; organomegaly (liver, spleen); eye abnormalities (corneal clouding, cherry red spot, optic atrophy, pigmentary retinopathy), skeletal abnormalities, non-immune hydrops |
LSD general diagnostic approach | serum lysosomal enzymes; blood smear; radiological exam; opthalmologic exam; urine mucopolysaccharides and glycoproteins, bone marrow, biochemical studies of fibroblasts +/-leukocytes; molecular; others dis specific |
Mucopolysaccharidoses general clinical presentation | 1.normal at birth 2.gradual slowing of dev > regression 3.coarses facies 4.+/- corneal clouding 5.macrosephaly, IDD 6.skeletal (dec ROM, claw hand) 7.dystosis multiplex on x-ray 8.otitis and HI 9.recurrent herniae, thickened mucous 10.late cardiac |
Hurler syndrome (MPS I) inheritance/incidence | AR (1/100,000) |
Hurler syndrome (MPS I) presentation | onset 6-12 months, death by 5-10 yrs;
milder w/o CNS (Scheie IS)
Typical MPS presentation; CORNEAL clouding |
Hurler syndrome (MPS I)diagnosis | +ve MPS spot test
enzyme assay
DNA testing |
Hurler syndrome (MPS I) treatment | HSCT transplantation with match donor (slows disease if performed early but no effect on skeletal sx, corneal clouding
ERT- improved somatic sx, no effect on CNS
(ERT before HSCT) |
Hunter syndrome (MPS II) presentations | prominent deafness
NO corneal clouding |
Hunter syndrome (MPS II) inheritance | X-linked (1/70,000-1/150,000);
20% of pts with complete gene deletion > have more severe IDD |
Hunter syndrome (MPS II) diagnosis | +ve MPS spot; enzyme assay;
females best diagnosed by DNA (may be neg for MPS spot) |
Hunter syndrome (MPS II) treatment | ERT gives improved somatic function in pts w/ milder disease (reduces visceromegaly and GAG excretion, improves joint mobility, preserves linear growth); no effect on CNS
*efficacy of HSCT not proven |
Sanfilippo syndrome (MPS III) inheritance | AR
4 distinct loci (A and B most common) |
Sanfilippo syndrome (MPS III) presentations | more CNS, less somatic features
onset usually 2-4 yrs, chronic diarrhea, insomnia, szs, aggression prominent |
Sanfilippo syndrome (MPS III) diagnosis | MPS may be + or -; enzyme assay/DNA |
Sanfilippo syndrome (MPS III) treatment | none
no benefit from HSCT |
Morquio syndrome (MPS IVA and B) | short-trunk dwarfism with nl IQ; severe odontoid hypoplasia; clinical trials with ERT |
Maroteaux-Lamy syndrome (MPS VI) | somatic sx may severe; usually nl IQ
defects in arylsulfatase B
ERT (Naglazyme) |
Sly syndrome (MPS VII) | severe infantile form; prenatal form with hyrdops/fetal ascites
defect in beta-glucuronidase |
MPS disorders other features | hydrocephalus; obstructive airway disease; difficulty with intubation; excessive secretions; atlantoaxial instability; odontoid hypoplasia; cardiac-valvular, conduction disturbances, EFE, occ cardiomyopathy; pulmonary and systemic hypertension |
Gaucher disease | most common lysosomal storage disease |
Gaucher disease (type I) | nonneuronopathic, splenomegaly, pancytopenia, bone pain/lytic bone lesions
1:400 - 1:1000 US AJ |
Gaucher disease (type II) | acute neuronopathic- rapidly progressive neurologic disease with hepatosplenomegaly
all ethnic groups |
Gaucher disease (type III) | subacute neuronpathic
later onset |
Gaucher disease (diagnostic) | "foam cells" in bone marrow, smear
enzyme assay
molecular carrier screening in AJ |
Gaucher disease genetics | GBA (glucoside-b acid) on chr 1
protective allele against CNS: N370S
L444P usually type II or III |
Gaucher disease treatment | splenectomy
ERT for type I (no effect on type II
substrate reduction therapy (miglustat; D-glu analog) |
Tay Sachs disease (GM2 gangliosidosis) incidence | AR
~1/100,000 general population
~1/4000 in AJ
increased incidence in French Canadians |
Tay Sachs presentation | classic infantile:
onset 6-12 mos
loss of milestones, hyperacusis, apathy,
cherry red spot
later onset of szs, blindness, spasticity
death by 2-5
milder juvenile and adult forms |
Cherry red spot seen in | Tay Sachs
Sandhoff
Sialidase deficiency
Niemann-Pick disease type A
GM1 gangliosidosis |
Tay Sachs molecular defect | hexoseaminidase A (HEXA) |
Sandhoff disease molecular defect | hexoseaminidase B (HEXB) |
Tay Sachs/Sandhoff diagnosis | enzyme assay
molecular testing |
treatment | none |
Tay Sachs + CNS involvement | Sandhoff disease |
Fabry disease inheritance | X-linked
1/40,000-60,000 males |
Fabry presentation (males) | median age 9 yrs
peripheral neuropathy, acroparesthesias (painful sensation), angiokeratomas, lens/corneal opacities, late renal and cardiovascular disease,chronic lung disease with fibrosis
accounts for 1% chr renal failure and 5% cryptogenic stroke |
Fabry presentation (females) | median age 13 yrs
fatigue, stroke, ~10% females develop renal failure, can be detected by slit lamp |
Fabry diagnosis | enzyme assay (may miss females)
heterogeneous mutation analysis (DNA testing best for females) |
Fabry treatment | dilantin/tegretol for neuropathy; renal transplant; ERT - may decrease pain, GI sx, slow renal disease, does not decrease proteinuria |
Krabbe disease (Globoid Cell Leukodystrophy) | onset <6 mos, hypotonia, irritability, optic atrophy, occ, macrocephaly, elevated CSF prot; leukodystrophy on MRI |
Krabbe disease diagnosis | enzyme assay
molecular testing of GALC gene
pseudodeficiency can complicate prenatal dx and requires sulfatide loading assay |
Krabbe disease gene | GALC
galactosylceramidase |
Krabbe disease treatment | HSCT has some efficacy in later onset or if performed very early in infantile cases |
Lysosomal proceesing defects | I-cell disease (Mucolipidosis II)
Multiple sulfatase deficiency |
I cell disease (MLII) gene/inheritance | AR
defect in targeting enzymes to lysosome via mannose-6-P (1st step in 2 step Golgi rxn)
*MLIII is allelic, milder variant |
I cell dis presentation | like Hurler
may see neonatal or prenatal onset |
I cell dis diagnosis | increase plasma activity multiple lysosomal enzymes with deficient activity in fibroblasts
-ve MPS spot |
I cell dis treatment | none |
Lysosomal transport disorders | defect in transport of lysosomal degradation products out of lysosomes |
Lysosomal transport disorders examples | cystinosis
sailic acid storage disease (infantile and adult forms)
Niemann-Pick type C (NPC) disease |
Niemann-Pick type C genetics | AR
1/150,000
NPC1 (95%) and NPC2 (~5%): these play role in intracellular cholesterol trafficking |
Niemann-Pick type C presentation | infantile form with neonatal jaundice
later onset forms with ataxia and progressive dementia, psychosis |
Niemann-Pick type C diagnosis | nl sphingomyelinase
abn lysosomal accumulation of unesterified cholesterol |
Niemann-Pick type C treatment | clinical trials with drugs to increase cholesterol removal from cells |
Gaucher cells with defect | macrophages |
Fabry cells with defect | endothelial cells |
Tay Sachs cells with defect | neurons |
ERT for Gaucher (I, III) | Cerezyme, Vpriv |
ERT for Fabry | Fabrazyme, Replagal |
ERT for Pompe | Myozyme |
ERT for Hurler (MPSI) | Aldurazyme |
ERT for Hunter(MPSII) | Elaprase |
ERT for Maroteaux-Lamy (MPS VI) | Naglazyme |
ERT for Lysosomal acid lipase def (Wolman) | Synageva |
Other therapies for LSDs | 1.substrate reduction
2.enzyme enhancement-chaperone therapy |
substrate reduction for LSDs | Zavesca (miglustat; Gaucher and others) iminosugar analog of glucose; crosses BBB |
Perixosomes (features) | ubiquitous (except RBCs)
single membrane
no nucleic acid
several 100/cell |
Peroxisoms (function) | degredation of VLCFA
early steps of plasmalogen biosynthesis
degredation of phytanic acid
selected steps in chol biosynthesis
degradation of pipecolic acid, synthesis of bile acid intermediated, glyoxylate metabolism |
PEX proteins | biogenesis of peroxisomes (16 proteins) |
target signals for matrix Px prot | PTS1 - C terminal SKL most common
PTS2 - N-terminal
membrane unknown |
Peroxisomal disorders classes | 1.Peroxisome biogenesis disorders
2.Single enzyme defects |
Px biogenesis disorders | Zellweger syndrome spectrum;
Rhizomelic chondrodysplasia punctata (RCDP) |
Px single enzyme defects | X-linked adrenoleukodystrophy;
Refsum disease;
11 others |
Zellweger syndrome spectrum | combined developmental and metabolic disorders
overall ~1/50,000 incidence
genetically heterogeneous (12 complementation grps)
50% defects in PEX1 encoding PTS1 receptor
includes Zellweger syn, neonatal ADL, infantile Refsum dis |
Zellweger syndrome presentation | dysmorphic facies, hypotonia, seizures, IDD, neuronal heterotopias, cataracts and/or glaucoma, renal cysts, 50% with epiphyseal calcifications
early death by 6-12 months |
Zellweger syn diagnosis | all peroxisomal functions abn
no peroxisomes or ghost membranes seen by EM
biochemical then molecular |
RCDP incidence | 1/100,000 |
RCDP presentation | skeletal dysplasia, cataracts, ichthyotic skin rash, IDD, occ CHD, cleft palate |
RCDP gene | PEX7 encodes PTS2 receptor (most common cause) |
RCDP diagnosis | low plasmalogens, elevated phytanic acid |
X-linked adrenoleukodystrophy | progressive x-linked neurodegenerative disorder assoc w/ adrenal involvement |
X-linked ALD penetrance | ~1/20,000 |
X-linked ALD presentation | highly variable
childhood cerebral-childhood onset, rapid progression
adrenomyeloneuropathy (AMN) - onset 20's - 30's with spastic parparesis
adrenal only |
X-linked ALD presentation (female) | ~50% het female carriers develop mild neurological sx in adulthood
20% gait and spinal cord involvement like AMN |
X-linked ALD genetics | ABCD1 gene encodes ABC transporter in the peroxisome membrane
no geno/pheno corr (some males with sx and other assymp in same family)
defective metabolism of VLCFA |
X-linked ALD diagnosis | VLCFA
molecular esp in females |
X-linked ALD treatment | HSCT early in course for males as soon as MRI changes noted
corticosteroids for adrenal insufficiency |
X-linked ALD diagnosis | T1 MRI with gadolinium
inflammatory demyelination with perivascular infiltration |
Zellweger spectrum | increase VLCFA
decrease plasmalogens
inrease plasma pipecolic acid |
RCDP | decrease plasmalogens
VLCFA normal |
Refsum disease presentation | cerebellar ataxia, polyneuropathy and RP, elevated CSF protein |
Refsum disease genetics | AR
deficiency of phytanoyl-CoA hydroxylase |
Refsum disease diagnosis | increase phytanic acid
molecular testing |
Refsum disease treatment | phytanic acid-restricted diet |
Px clinical features (suggestive) | FTT, DD
hypotonia, cerebral atrophy, decreased myelination, neuronal heterotopia
dysmophia
cataracts, glaucoma, RP
chondropdysplasia punctata,
hepatomegaly, renal cysts |
Laminopathies genes | LMNA, LMNB2, LMNB1 |
Laminopathies disorders (LMNA) | Hutchinson-Gilford progeria
Emery-Dreifuss muscular dystrophy
Mandibuloacral dyspasia
Generalized lipodystrophy
Restrictive dermopathy |
Niemann-Pick Disease, types A and B genetics/inheritance | AR
deficiency of acid sphingomyelinase
increase in AJ (carrier freq 1:60) |
Neimann-Pick dis presentation | neurodegenerative with spleen > liver
cherry red spot (~50% type A); pulmonary (type B) |
Neimann-Pick diagnosis | enzyme assay
molecular
sea blue histiocytes in marrow |
Neimann-Pick treatment | none |
GM1 gangliosidosis presentations | somatic + CNS affected
hypotonia, szs, MR
~50% have cherry red spot
milder juvenile and adult forms exist |
GM1 gangliosidosis diagnosis | foamy histiocytes in bone marrow
enzyme assay of beta-galactosidase (GLB1 gene) |
Tay Sachs serum screening | pregnancy, oral contraceptives and some illness can make test inconclusive |
Metachromatic Leukodystrophy presentation | late infantile - most pts walk, regression before age of 2; white matter changes, elevated CSF prot |
Metachromatic Leukodystrophy gene | arylsulfatase A (ARSA)
inheritance is AR |
Metachromatic Leukodystrophy diagnosis | enzyme assay
psudodeficiency (2 singl bp changes) |
Glycoprotein disorders | mannosidosis, aspartylglycosaminuria (AGU), sialidosis, fucosidosis |
Glycoprotein disorders presentation | like mild/mod MPS; fucosidosis has false + sweat test & andiokeratomas; congenital form of sialidosis with fetal ascites |
Glycoprotein disorders diagnossis | MPS spot -ve
enzyme assay
characteristic urine oligosaccharides |
AGU | common in Finland (C163S in 95% of Finnish alleles) |
Multiple sulfatase deficiency presentation | like severe MPS + ichthyosis, mild skeletal |
Multiple sulfatase def gene/inheritance | AR
SUMF1 gene (sulfatase modifying factor 1)
def of formylglycine enzyme (catalyzes posttranslational modification of conserved cys in all sulfatases)
very rare |
Multiple sulfatase def dx | +ve urine MPS,
enzyme assays
molecular |
Farber lipogranulomatosis (ceramide def) | very rare
painful deformed joints + subcutaneous nodules
IDD |
Acid lipase def (Wolman) | GI disorder with hepatosplenomegaly
FTT
adrenal Ca++
mild variant is cholesterol ester storage disease |
Schindler disease | progressive IDD, blindness, szs, hypotonia, a rare cause of neuraxonal dystrophy due to deficiency in lysosomal N-acetylgalactosaminidase |
Pycnodysostosis | skeletal dysplasia, defect in lysosomal cathepsin K |
Sphingolipid activator protein (SAPs) | small proteins that interact with some lys hydrolases to stabilize them or stimulate activity |
Other single gene Px disorders | Px beta oxidation disorders
Ether phospholipid synthetic defects (resemble RCDP)
Mevalonate kinase - classic & hyper IgD periodic fever
Catalase deficiency - oral ulcers
Glyoxylate detoxification - hyperoxaluria type I |