Michael M. Kaback

Population-based genetic screening for reproductive counseling: the Tay-Sachs disease model.

Abstract Since 1970, more than 1.4 million individuals worldwide have been screened voluntarily to determine if they are carriers of the mutant gene for Tay-Sachs Disease (TSD). Employing both enzymatic and molecular methods (for optimal sensitivity and specificity) more than 1400 couples have been identified to be at-risk for TSD in their offspring, i.e., both parents heterozygotes. Through prenatal testing of more than 3200 pregnancies, births of over 600 infants with this uniformly fatal neurodegenerative disease have been prevented. In the United States and Canada, the incidence of TSD in the Jewish population has been reduced by more than 90%. More that 100 mutations in the hexosaminidase A gene (the TSD locus) have been identified to date. Some are associated with later onset or more chronic forms of neuronal storage disease. Two mutations cause a carrier-like “pseudo-deficiency” when enzymatic testing is used (false positives). A number of practical, social, and ethical complexities have been identified in this prototypic population-based effort. Educational and counseling components must be provided both before and after screening. Issues of privacy and confidentiality of test results must be addressed. In certain cultures insurability and employment may be involved. The public perception of the biomedical community as advocates for wide-scale testing and screening may be interpreted, in some systems, as conflicts of interest on the part of entrepreneurial scientists, clinicians, and institutions. Conclusion Many new opportunities for population-based screening will be evident in this era of genome-related discovery. Accordingly, some of the experiences with Tay-Sachs disease prevention may be instructive.

METACHROMATIC LEUKODYSTROPHY WITHOUT ARYLSULFATASE A DEFICIENCY

Summary: Two siblings of consanguinous parents were noted to have a neurologic syndrome marked by developmental delay, regression of psychomotor performance, marked spasticity and progressive central nervous system degeneration. Markedly delayed nerve conduction times and a sural nerve biopsy which demonstrated changes typical of metachromatic leukodystrophy (MLD) were evident. Impairment of sulfated glycolipid metabolism was documented by analysis of glycospingolipid in urinary sediment. In spite of these findings, activities of arylsulfatase A and cerebroside sulfatidase in white blood cells and cultured skin fibroblasts were near normal. However, when intact growing fibroblasts were loaded with 35SO4-sulfatide a clear defect in sulfatide cleavage, comparable to that seen in MLD patients, was observed. Thus, these patients represent a new form of sulfatide storage disease – MLD characterized by intact enzyme activity in cell homogenates but defective sulfolipid metabolism in vivo and in intact fibroblasts.Speculation: Since cell homogenates from these patients can cleave sulfatide in the presence of detergents while the patients themselves and their intact cells cannot, soire explanation other than decreased activity of the relevant lysosomal enzyme must be invoked to explain this storage disease. The two most plausible hypotheses are that either these patients have a defect which prevents enzyme and substrate interaction in the proper subcellular location, or that these patients are missing the putative glycoprotein ″activating factor″ necessary for sulfolipid hydrolysis in vivo.

20. Screening and prevention in Tay-Sachs disease: Origins, update, and impact

Publisher Summary This chapter discusses the screening and prevention in Tay-Sachs disease (TSD): origins, update, and impact. Like many other innovations, the education, screening, and counseling program for the prevention of TSD occurred, because of a host of factors: timing, location, events, and most important, people. With the efforts and support of the National Tay-Sachs Disease and Allied Disorders Association, an International Center has been established for the annual survey of worldwide programs involved in TSD screening and prevention. The prevention program strategies were first implemented in 1970. 50–60 infants were diagnosed with TSD each year in the United States and Canada. 90% or greater reduction in the incidence of TSD in the high-risk Jewish population has occurred, undoubtedly contributed to, in large part at least, by the education, screening, and counseling programs targeted to Jewish adults of child-bearing age. This prototype, developed for TSD prevention, has also served as a model for “disease control” in other areas as well. With recent advances in gene isolation and molecular diagnosis, it is likely that comparable efforts targeted to the “control” of other serious hereditary disorders will be mounted in the near future.

Serum pyruvate-kinase (PK) and creatine-phosphokinase (CPK) in progressive muscular dystrophies.

PK and CPK have been determined in the serum from 208 individuals including 70 normal controls (61 adults and 9 children) and 138 patients with a variety of neuromuscular disorders. In adult controls the mean activity (+/- SE) for PK is 1.2 +/- 0.05 mumol/ml/h. In normal children PK activity was about twice as high as in normal adults and decreases with increasing age. In 26 patients with Duchenne dystrophy the range of serum PK was 4.0-150.4 and in 17 individuals with the Becker type, 3.0 to 148.7. All had elevated PK and CPK levels. Eighteen of 20 patients with the facio-scapulo-humeral (FSH) from of muscular dystrophy had increased PK while only 9 had elevated CPK. Regression analyses have shown an inverse correlation between PK levels and age (or degree of disability in DMD). Kinetic and electrophoretic studies indicate that the PK isozyme found in the serum from affected patients and from heterozygotes for the DMD gene is mainly the M1 type PK, which is the only PK isozyme found in skeletal muscle and brain and the major component from myocardium.

Serum pyruvate-kinase (PK) and creatine-phosphokinase (CPK) in female relatives and patients with X-linked muscular dystrophies (Duchenne and Becker)

Determination of serum creatine phosphokinase (CPK) activity is often used in efforts to detect carriers of X-linked muscular dystrophies. We have recently demonstrated that another serum enzyme, pyruvate-kinase (PK) may also be of use in the diagnosis of patients affected with a variety of neuromuscular disorders. To evaluate the usefulness of this assay for carrier detection, a comparative study of serum PK and CPK activity was performed in 74 female relatives of patients affected with Duchenne (DMD) and Becker (BMD) muscular dystrophies. For obligate carriers of the DMD gene, 10 of 14 had elevated CPKs, 11 of 14 had elevated PKs and 12 of 14 had abnormal results for either of the two enzymes. Three of 16 mothers of isolated cases had increased serum CPK activity and 6 of 16 had increased PK activity (7 had elevation of at least one enzyme). These preliminary data suggest that the use of PK may enhance the capability to discriminate carriers for these X-linked recessive genes.

1. Tay-Sachs disease: From clinical description to molecular defect

Publisher Summary This chapter focuses on Tay-Sachs disease (TSD) that has served not only as a prototype of the neuronal lysosomal lipid storage disorders, but also has been the model for population-based genetic education/heterozygote screening/genetic counseling efforts in the prospective control (prevention) of genetic disease. This chapter recounts the seminal effort that has led to these achievements, and the recent molecular genetic discoveries concerning TSD and related disorders. The chapter also describes the personal experiences of those who contributed to this process. Each discovery is derived from prior contributions and reflects, in the best sense, how multiple disciplines of biomedical science contributes to a growing foundation of knowledge on which new advances are made. This relatively rare and obscure disorder has served an importance far beyond its frequency, prevalence, or medical-economic impact. The importance of TSD is best measured as a public health prototype, in the application of new genetic knowledge for the prevention and control of serious genetic disease.

Genetic screening in the Persian Jewish community: A pilot study.

Purpose: Israeli investigators have identified several relatively frequent disorders due to founder point mutations in Persian (Iranian) Jews, who, for nearly three centuries up to the Islamic Revolution of 1979, were completely isolated reproductively.Methods: Using a community-based model previously employed with Tay-Sachs disease prevention, we developed a pilot program for the Persian Jewish community of greater Los Angeles. We screened for mutations responsible for four relatively frequent autosomal recessive conditions in Persian Jews in which effective interventions are available for each: Pseudocholinesterase deficiency (butyryl cholinesterase deficiency); Congenital hypoaldosteronism (corticosterone methyl oxidase II); Autoimmune polyendocrinopathy (autoimmune regulatory element); and Hereditary Inclusion Body myopathy.Results: One thousand individuals volunteered. Mutations were assessed in saliva-derived DNA and were positive for 121/1000 butyryl cholinesterase deficiency; 92/1000 Hereditary Inclusion Body myopathy; 38/1000 corticosterone methyl oxidase II; and 37/1000 autoimmune regulatory element. Ten homozygous individuals (9 butyryl cholinesterase deficiency and 1 Hereditary Inclusion Body myopathy) and 10 “at-risk” couples (seven for butyryl cholinesterase deficiency and one each for the other three disorders) were identified. These frequencies are comparable with those in Israel and indicate an extraordinary level of inbreeding, as anticipated.Conclusions: A carefully planned effort can be delivered to an “increased risk” community if detailed attention is given to planning and organization. However, availability of an effective intervention for those found to be “at-risk” or possibly affected, is essential before embarking.

Severe subacute GM2 gangliosidosis caused by an apparently silent HEXA mutation (V324V) that results in aberrant splicing and reduced HEXA mRNA

We have characterized the molecular basis of β‐hexosaminidase A (HEX A) deficiency in a patient ascertained through an ophthalmologic examination that revealed cherry red spots on his retina. The absence of neurological deficit in this child until 3

Perspectives in Genetic Screening: Principles and Implications

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27. Future perspectives for Tay-Sachs disease

years of age indicated residual HEX A must be present. Three HEXA mutations, 10T > C (S4P) and 972T > A (V324V) on the maternal allele, and 1A > T (M1L) on the paternal allele were identified. The effects of the amino acid substitutions on HEX A expressed in COS‐7 cells were analyzed; as expected, no HEX A activity was associated with the M1L mutation but surprisingly, the S4P mutation resulted in 59% of the HEX A activity expressed by the wild type cDNA. The effect of the S4P change was much less than that of another HEXA mutation, G269S, associated with an adult onset form of GM2 gangliosidosis. This indicated that the S4P change was not the cause of disease and suggested that one of the mutations on the maternal allele, 10T > C or 972T > A, had its effect at the mRNA level. This was confirmed by Northern blot analysis that showed only 7% of the normal level of HEXA mRNA in proband fibroblasts. Analysis of the residual mRNA by RT/PCR and sequencing revealed normal transcripts from both the maternal and paternal allele, as well as a low abundance aberrant transcript from the maternal allele. Sequencing of this aberrant transcript revealed a new exon 8 donor site created by the 972T > A mutation that resulted in a 17 bp deletion and destabilization of the resulting abnormal transcript. The remaining normal mRNA produced from the 972T > A allele must account for the delayed onset of clinical symptoms in this child.