Suvimol Hill

Replacement therapy for inherited enzyme deficiency--macrophage-targeted glucocerebrosidase for Gaucher's disease.

BACKGROUND AND METHODS Gauchers disease, the most prevalent of the sphingolipid storage disorders, is caused by a deficiency of the enzyme glucocerebrosidase (glucosylceramidase). Enzyme replacement was proposed as a therapeutic strategy for this disorder in 1966. To assess the clinical effectiveness of this approach, we infused macrophage-targeted human placental glucocerebrosidase (60 IU per kilogram of body weight every 2 weeks for 9 to 12 months) into 12 patients with type 1 Gauchers disease who had intact spleens. The frequency of infusions was increased to once a week in two patients (children) during part of the trial because they had clinically aggressive disease. RESULTS The hemoglobin concentration increased in all 12 patients, and the platelet count in 7. Serum acid phosphatase activity decreased in 10 patients during the trial, and the plasma glucocerebroside level in 9. Splenic volume decreased in all patients after six months of treatment, and hepatic volume in five. Early signs of skeletal improvements were seen in three patients. The enzyme infusions were well tolerated, and no antibody to the exogenous enzyme developed. CONCLUSIONS Intravenous administration of macrophage-targeted glucocerebrosidase produces objective clinical improvement in patients with type 1 Gauchers disease. The hematologic and visceral responses to enzyme replacement develop more rapidly than the skeletal response.

An Autoinflammatory Disease with Deficiency of the Interleukin-1–Receptor Antagonist

BACKGROUND Autoinflammatory diseases manifest inflammation without evidence of infection, high-titer autoantibodies, or autoreactive T cells. We report a disorder caused by mutations of IL1RN, which encodes the interleukin-1-receptor antagonist, with prominent involvement of skin and bone. METHODS We studied nine children from six families who had neonatal onset of sterile multifocal osteomyelitis, periostitis, and pustulosis. Response to empirical treatment with the recombinant interleukin-1-receptor antagonist anakinra in the first patient prompted us to test for the presence of mutations and changes in proteins and their function in interleukin-1-pathway genes including IL1RN. RESULTS We identified homozygous mutations of IL1RN in nine affected children, from one family from Newfoundland, Canada, three families from The Netherlands, and one consanguineous family from Lebanon. A nonconsanguineous patient from Puerto Rico was homozygous for a genomic deletion that includes IL1RN and five other interleukin-1-family members. At least three of the mutations are founder mutations; heterozygous carriers were asymptomatic, with no cytokine abnormalities in vitro. The IL1RN mutations resulted in a truncated protein that is not secreted, thereby rendering cells hyperresponsive to interleukin-1beta stimulation. Patients treated with anakinra responded rapidly. CONCLUSIONS We propose the term deficiency of the interleukin-1-receptor antagonist, or DIRA, to denote this autosomal recessive autoinflammatory disease caused by mutations affecting IL1RN. The absence of interleukin-1-receptor antagonist allows unopposed action of interleukin-1, resulting in life-threatening systemic inflammation with skin and bone involvement. (ClinicalTrials.gov number, NCT00059748.)

Hyper-IgE Syndrome with Recurrent Infections — An Autosomal Dominant Multisystem Disorder

BACKGROUND The hyper-IgE syndrome with recurrent infections is a rare immunodeficiency characterized by recurrent skin and pulmonary abscesses and extremely elevated levels of IgE in serum. Associated facial and skeletal features have been recognized, but their frequency is unknown, and the genetic basis of the hyper-IgE syndrome is poorly understood. METHODS We studied 30 patients with the hyper-IgE syndrome and 70 of their relatives. We took histories, reviewed records, performed physical and dental examinations, took anthropometric measurements, and conducted laboratory studies. RESULTS Nonimmunologic features of the hyper-IgE syndrome were present in all patients older than eight years. Seventy-two percent had the previously unrecognized feature of failure or delay of shedding of the primary teeth owing to lack of root resorption. Common findings among patients were recurrent fractures (in 57 percent of patients), hyperextensible joints (in 68 percent), and scoliosis (in 76 percent of patients 16 years of age or older). The classic triad of abscesses, pneumonia, and an elevated IgE level was identified in 77 percent of all patients and in 85 percent of those older than eight. In 6 of 23 adults (26 percent), IgE levels declined over time and came closer to or fell within the normal range. Autosomal dominant transmission of the hyper-IgE syndrome was found, but with variable expressivity. Of the 27 relatives at risk for inheriting the hyper-IgE syndrome, 10 were fully affected, 11 were unaffected, and 6 had combinations of mild immunologic, dental, and skeletal features of the hyper-IgE syndrome. CONCLUSIONS The hyper-IgE syndrome is a multisystem disorder that affects the dentition, the skeleton, connective tissue, and the immune system. It is inherited as a single-locus autosomal dominant trait with variable expressivity.

Enzyme Therapy in Type 1 Gaucher Disease: Comparative Efficacy of Mannose-Terminated Glucocerebrosidase from Natural and Recombinant Sources

Gaucher disease, an inborn error of glycosphingolipid metabolism, is the most frequent lysosomal storage disease [1]. Non-neuronopathic or type 1 disease is the most common variant and the most prevalent genetic disease among Ashkenazi Jews [2, 3]. Various point mutations, deletions, and insertions within the glucocerebrosidase (acid -glucosidase, EC 3.2.1.45) locus at chromosome 1q21 result in a deficiency of this lysosomal enzyme [4, 5]. The subsequent accumulation of glucocerebroside (glucosylceramide) in cells of monocyte-macrophage lineage leads to the visceral manifestations of anemia, thrombocytopenia, hepatosplenomegaly, skeletal disease, and, less frequently, primary lung involvement [1]. Gaucher disease has become a prototype genetic disease for the development of prenatal diagnosis [6], genotype-phenotype correlations [2, 7, 8], and effective therapy [9-13]. On the basis of the clear efficacy of targeted enzyme therapy [10], recent studies [9, 12, 14, 15] in more than 90 patients have established that regular infusions of enzyme purified from placenta (alglucerase [Ceredase; Genzyme Corp., Cambridge, Massachusetts]) lead to regression of the clinical manifestations of Gaucher disease. In addition, antibody-mediated and non-antibody-mediated adverse events have occurred in only 5% to 7% of treated patients [15, 16]. Ceredase is a commercial form of placenta glucocerebrosidase that has been modified for targeting mannose receptor sites on macrophages and other cells [17, 18]. A theoretical limitation to the use of Ceredase is the remote possibility of infective contaminants in the preparation from human placenta. A practical limitation is the finite availability of acceptable placentae. For each patient, approximately 10 to 12 tons of placentae or about 50 000 per year are needed as source material for Ceredase. Enzyme produced by heterologous expression of human complementary DNA (cDNA) for glucocerebrosidase in eukaryotic cells could eliminate both of these limitations. To determine the efficacy of recombinant glucocerebrosidase, we did a randomized, double-blind, parallel trial with mannose-terminated glucocerebrosidase (alglucerase, Ceredase) from human placenta and the human enzyme that is produced in Chinese hamster ovary cells and deglycosylated to expose mannose residues in the oligosaccharide chains (imiglucerase, Cerezyme [Genzyme Corp.]). Methods Thirty patients with non-neuronopathic type 1 Gaucher disease were entered into the trial after consent was obtained. Deficiency of glucocerebrosidase (5% to 15% of mean normal activities) was shown by natural or artificial substrates in peripheral blood mononuclear cells, cultured skill fibroblasts, or lymphoblastoid cell lines obtained from each patient [19, 20]. Inclusion criteria for the study were as follows: 1) enzymatically confirmed glucocerebrosidase deficiency; 2) patient age between 2 and 75 years; 3) an intact, enlarged spleen; 4) a hemoglobin level at least 10 g/L less than the lower limit of normal; and 5) in women, a willingness to avoid pregnancy during the trial. Exclusion criteria were as follows: 1) inability to comply with study requirements; 2) previous receipt of any form of glucocerebrosidase; 3) total splenectomy; 4) a concurrent major medical disorder, such as active infectious disease or substance abuse; and 5) positive serologic response to hepatitis B surface antigen or human immunodeficiency virus (HIV) type 1, or both. The patients had moderate to severe Gaucher disease. The study was a double-blind, parallel trial with random assignment to Ceredase or Cerezyme. We categorized randomization into three groups according to patient age: 1) younger than 12 years; 2) 12 to 17 years; and 3) older than 17 years. In each study center, patients were independently randomly assigned in blocks by age and were assigned study numbers. All study personnel except the pharmacist at each institution were blinded to the allocated treatment. No children younger than 12 years were enrolled in the study. Of the 30 patients enrolled, 17 were male and 13 were female (age range, 12 to 69 years). Of the 7 patients between 12 and 17 years of age, 4 received Ceredase and 3 received Cerezyme. Twenty-three patients older than 17 years were enrolled; 11 of them received Ceredase and 12 received Cerezyme. The groups of patients treated with Ceredase or Cerezyme did not differ in sex distribution, age, weight, or height. All patients received Cerezyme or Ceredase at a dose of 60 U/kg body weight once every 2 weeks for 9 months. Complete hematologic and clinical chemistry data were available for this period. At this dose, complete data for hepatic and splenic volumes were available for all patients for the first 6 months. Hepatic and splenic volumes were evaluated in the 16 patients from the Mt. Sinai School of Medicine at 9 months, just before a dose-reduction study began. The hepatic and splenic volumes of the patients from the National Institutes of Health (NIH) were evaluated at 12 months. We did not include these data in our report. We did analyses of variance and other statistical analyses using Systat software (Systat Inc., Evanston, Illinois). In addition to physical examinations, clinical laboratory studies were done to monitor both therapeutic efficacy and potential toxic effects, including total serum acid phosphatase levels, angiotensin-converting enzyme levels, serum bilirubin levels, hemoglobin levels, platelet counts, peripheral blood leukocyte counts, and serum iron and clotting studies. At baseline and at study completion, hepatitis B surface antigen assay; HIV-1 serologic testing; serum protein electrophoresis; and complement C3, C4, and CH-50 studies were done. Hepatic and splenic volumes were estimated by computed tomography (at Mt. Sinai School of Medicine) [12, 15] or magnetic resonance imaging (at NIH) [21]. We calculated the increases over normal volumes by assuming that the hepatic and splenic masses (1 g/mL density) were 2.5% and 0.2% of body weight, respectively [22]. To avoid biasing the results because of the nearly universal weight gain in treated patients, we averaged the body weight of adults over the study period. In children (patients younger than 18 years), we calculated the hepatic and splenic volumes on the basis of body weight at each time point to allow for growth. We monitored the formation of antibodies to natural or recombinant glucocerebrosidases every 3 months by radioimmunoprecipitation assay [16]. Adverse events were monitored at each infusion. Before each infusion, we also obtained a history of intra-infusion adverse events. Ceredase was supplied as a clear liquid solution stored at 4 C, solubilized in the presence of albumin. Cerezyme was purified from culture media of Chinese hamster ovary cell clones that contained numerous copies of the human glucocerebrosidase cDNA. Carbohydrate removal to expose core mannose moieties was done by the sequential exoglycosidase treatment used to produce Ceredase. The amino acid sequences of glucocerebrosidase in Ceredase and Cerezyme were identical except for a single amino acid substitution of a histidine for a natural arginine at position 495 in the latter. The lack of effect of this amino acid change on the catalytic function of glucocerebrosidase has been documented [23]. Cerezyme was supplied as a lyophilized powder containing mannitol, sodium citrate, and polysorbate 80. Cerezyme as lyophilized powder was stored at 4 C until use. Immediately before administration, Cerezyme was reconstituted with sterile water to a concentration of 40 U/mL. Ceredase or Cerezyme stocks were diluted in 0.9% NaCl just before infusion. During the study, the patients were weighed at each infusion, and the total dose to be administered was adjusted to 60 U/kg on the basis of the current weight. A unit of enzyme activity (U) is defined as the amount of enzyme required to cleave 1 mol of p-nitrophenol--d-glucopyranoside per minute. Results Hematologic Findings The effects of Ceredase and Cerezyme infusions on hemoglobin levels by 6 and 9 months are shown in Tables 1 and 2. Neither the mean initial hemoglobin level (approximately 107 g/L) nor changes in hemoglobin levels differed between the two treatment groups. During the first 6 months of therapy, hemoglobin levels increased by a mean of 17.1 g/L. In patients with hemoglobin levels less than 120 g/L, 54% and 30% of the patients receiving Ceredase and Cerezyme, respectively, achieved this or a greater level by 6 months. Sixty-nine percent and 40%, respectively, of patients receiving Ceredase and Cerezyme achieved these levels by 9 months. The rates at which hemoglobin levels increased by 10 and 15 g/L were also similar. An average of 92 days was required for the hemoglobin level to increase 10 g/L in the Ceredase group, whereas an average of 77 days was needed in the Cerezyme group. For the Ceredase and Cerezyme groups, hemoglobin levels increased 15 g/L in 113 and 125 days, respectively. None of the above differences was significant (P > 0.2). In both treatment groups, we observed lesser degrees of response in patients with higher initial hemoglobin levels. However, this conclusion was strongly influenced by two patients who had initial hemoglobin levels less than 90 g/L and large responses to treatment, that is, an increase of more than 30 g/L during the first 6 months of therapy. Table 1. Clinical Findings from Patients with Type I Gaucher Disease Treated with Ceredase and Cerezyme* Table 2. Effects of Ceredase and Cerezyme on Hematologic Measurements All patients in the study had thrombocytopenia (mean platelet count, approximately 71.5 109/L). About half (7 of 15) of the patients in each group had increases in platelet counts of 20% and 40% or more during the 6- and 9-month treatment periods, respectively (Table 2). These responses to therapy did not differ between the Ceredase and Cerezyme groups. In each group and in the entire st

Pulmonary Nontuberculous Mycobacterial Disease: Prospective Study of a Distinct Preexisting Syndrome

RATIONALE Pulmonary nontuberculous mycobacterial (PNTM) disease is increasing, but predisposing features have been elusive. OBJECTIVES To prospectively determine the morphotype, immunophenotype, and cystic fibrosis transmembrane conductance regulator genotype in a large cohort with PNTM. METHODS We prospectively enrolled 63 patients with PNTM infection, each of whom had computerized tomography, echocardiogram, pulmonary function, and flow cytometry of peripheral blood. In vitro cytokine production in response to mitogen, LPS, and cytokines was performed. Anthropometric measurements were compared with National Health and Nutrition Examination Survey (NHANES) age- and ethnicity-matched female control subjects extracted from the NHANES 2001-2002 dataset. MEASUREMENTS AND MAIN RESULTS Patients were 59.9 (+/-9.8 yr [SD]) old, and 5.4 (+/-7.9 yr) from diagnosis to enrollment. Patients were 95% female, 91% white, and 68% lifetime nonsmokers. A total of 46 were infected with Mycobacterium avium complex, M. xenopi, or M. kansasii; 17 were infected with rapidly growing mycobacteria. Female patients were significantly taller (164.7 vs. 161.0 cm; P < 0.001) and thinner (body mass index, 21.1 vs. 28.2; P < 0.001) than matched NHANES control subjects, and thinner (body mass index, 21.1 vs. 26.8; P = 0.002) than patients with disseminated nontuberculous mycobacterial infection. A total of 51% of patients had scoliosis, 11% pectus excavatum, and 9% mitral valve prolapse, all significantly more than reference populations. Stimulated cytokine production was similar to that of healthy control subjects, including the IFN-gamma/IL-12 pathway. CD4(+), CD8(+), B, and natural killer cell numbers were normal. A total of 36% of patients had mutations in the cystic fibrosis transmembrane conductance regulator gene. CONCLUSIONS Patients with PNTM infection are taller and leaner than control subjects, with high rates of scoliosis, pectus excavatum, mitral valve prolapse, and cystic fibrosis transmembrane conductance regulator mutations, but without recognized immune defects.

Controlled trial of pamidronate in children with types III and IV osteogenesis imperfecta confirms vertebral gains but not short-term functional improvement.

Bisphosphonates have been widely administered to children with OI based on observational trials. A randomized controlled trial of q3m intravenous pamidronate in children with types III and IV OI yielded positive vertebral changes in DXA and geometry after 1 year of treatment, but no further significant improvement during extended treatment. The treated group did not experience significantly decreased pain or long bone fractures or have increased motor function or muscle strength.

Localization of the gene for sclerosteosis to the van Buchem Disease-gene region on chromosome 17q12-q21

Sclerosteosis is an uncommon, autosomal recessive, progressive, sclerosing, bone dysplasia characterized by generalized osteosclerosis and hyperostosis of the skeleton, affecting mainly the skull and mandible. In most patients this causes facial paralysis and hearing loss. Other features are gigantism and hand abnormalities. In the present study, linkage analysis in two consanguineous families with sclerosteosis resulted in the assignment of the sclerosteosis gene to chromosome 17q12-q21. This region was analyzed because of the recent assignment to this chromosomal region of the gene causing van Buchem disease, a rare autosomal recessive condition with a hyperostosis similar to sclerosteosis. Because of the clinical similarities between sclerosteosis and van Buchem disease, it has previously been suggested that both conditions might be caused by mutations in the same gene. Our study now provides genetic evidence for this hypothesis.

Clinical characteristics of a cohort of 244 patients with congenital adrenal hyperplasia.

CONTEXT Patients with congenital adrenal hyperplasia (CAH) often suffer from long-term complications secondary to chronic glucocorticoid therapy and suboptimal treatment regimens. OBJECTIVE The aim of the study was to describe clinical characteristics of a large cohort of pediatric and adult CAH patients. DESIGN AND SETTING We conducted a cross-sectional study of 244 CAH patients [183 classic, 61 nonclassic (NC)] included in a Natural History Study at the National Institutes of Health. MAIN OUTCOME MEASURE(S) Outcome variables of interest were height sd score, obesity, hypertensive blood pressure (BP), insulin resistance, metabolic syndrome, bone mineral density, hirsutism (females), and testicular adrenal rest (TART). RESULTS The majority had elevated or suppressed androgens, with varied treatment regimens. Mean adult height SD score was -1.0 ± 1.1 for classic vs. -0.4 ± 0.9 for NC patients (P = 0.015). Obesity was present in approximately one third of patients, across phenotypes. Elevated BP was more common in classic than NC patients (P ≤ 0.01); pediatric hypertensive BP was associated with suppressed plasma renin activity (P = 0.001). Insulin resistance was common in classic children (27%) and adults (38% classic, 20% NC); 18% of adults had metabolic syndrome. The majority (61%) had low vitamin D; 37% of adults had low bone mineral density. Hirsutism was common (32% classic; 59% NC women). TART was found in classic males (33% boys; 44% men). CONCLUSIONS Poor hormonal control and adverse outcomes are common in CAH, necessitating new treatments. Routine monitoring of classic children should include measuring BP and plasma renin activity. Osteoporosis prophylaxis and TART screening should begin during childhood. A longitudinal study is under way.

Sustained Response and Prevention of Damage Progression in Patients With Neonatal-Onset Multisystem Inflammatory Disease Treated With Anakinra: A Cohort Study to Determine Three- and Five-Year Outcomes

OBJECTIVE Blocking interleukin-1 with anakinra in patients with the autoinflammatory syndrome neonatal-onset multisystem inflammatory disease (NOMID) reduces systemic and organ-specific inflammation. However, the impact of long-term treatment has not been established. This study was undertaken to evaluate the long-term effect of anakinra on clinical and laboratory outcomes and safety in patients with NOMID. METHODS We conducted a cohort study of 26 NOMID patients ages 0.80-42.17 years who were followed up at the NIH and treated with anakinra 1-5 mg/kg/day for at least 36 months. Disease activity was assessed using daily diaries, questionnaires, and C-reactive protein level. Central nervous system (CNS) inflammation, hearing, vision, and safety were evaluated. RESULTS Sustained improvements in diary scores, parents/patients and physicians global scores of disease activity, parents/patients pain scores, and inflammatory markers were observed (all P<0.001 at 36 and 60 months). At 36 and 60 months, CNS inflammation was suppressed, with decreased cerebrospinal fluid white blood cell counts (P=0.0026 and P=0.0076, respectively), albumin levels, and opening pressures (P=0.0012 and P<0.001, respectively). Most patients showed stable or improved hearing. Cochlear enhancement on magnetic resonance imaging correlated with continued hearing loss. Visual acuity and peripheral vision were stable. Low optic nerve size correlated with poor visual field. Bony lesions progressed. Adverse events other than viral infections were rare, and all patients continued to receive the medication. CONCLUSION These findings indicate that anakinra provides sustained efficacy in the treatment of NOMID for up to 5 years, with the requirement of dose escalation. Damage progression in the CNS, ear, and eye, but not bone, is preventable. Anakinra is well tolerated overall.

Sclerosteosis Nemogenetic and pathophysiologic analysis of an American kinship

We studied an American kinship with sclerosteosis, an autosomal-recessive disorder of bone remodeling and bone overgrowth of the calvaria, skull base, and tubular bones. Unlike osteopetrosis, which is attributed to abnormal immune and osteoclast function as well as bone resorption, sclcrosteosis appears to be primarily a disorder of osteoblast (bone formation) hyperactivity. Related to cranial vascular and neural foramina1 narrowing and reduced intracranial volume, affected patients with sclerosteosis demonstrate frequent seventh nerve palsy, progressive optic and cranial neuropathics, mixed hearing loss, brainstem compression, intracranial hypertension with increased elastance, and sudden, premature death. Management should involve early childhood identification of homozygotes, monitoring and aggressive treatment of intracranial hypertension, and extensive bone removal from skull, posterior fossa, and cervical spine.