国内首批使用酶替代疗法的婴儿型庞贝病1例护理

<正>庞贝病(Pompe disease)也称为糖原贮积病Ⅱ型(glycogen storage disease typeⅡ,GSDⅡ)或酸性α-葡糖苷酶缺乏症(acid-α-glucosidase deficiency)。病因是由于酸性α-葡糖苷酶(acid-α-glucosidase,GAA)基因突变,溶酶体内GAA活性缺乏或显著降低,糖原不能被降解而沉积在骨骼肌、心肌和平滑肌等细胞的溶酶体内,导致溶酶体肿胀、细胞破坏及脏器功能损害,并引     

婴儿型庞贝病1例护理

庞贝病(又称为糖原累积病Ⅱ型)是一种常染色体隐性遗传病,其特征是溶酶体酸性α-葡糖苷酶(acid alpha-glucosidase,GAA)基因突变导致GAA酶活性降低或缺乏,糖原不能分解而贮积在各种组织的溶酶体内,导致心肌、呼吸肌及骨骼肌等进行性损害,以及各种神经功能损害[1]。根据临床症状出现的时间,该病可分成婴儿型庞贝病(infantile-onset Pompe disease,IOPD)和晚发型庞贝病(late-onset Pompe disease,LOPD)。IOPD患儿病情进展迅速,绝大多数患儿表现为肥厚性心肌病、心脏肿大、肌肉无力及呼吸功能不全,若无有效治疗,常于1岁左右死于心力衰竭及呼吸衰竭[2]。     

有机磷中毒致迟发性神经肌肉病变20例

有机磷农药种类繁多,使用日益广泛,时有中毒发生,迟发性神经肌病明显增加。近年来本院收治有机磷农药中毒致迟发性神经肌病20例,其中6例做肌电图检查示神经原性肌萎缩,2例肌肉活检组化病理示肌纤维萎缩和坏死,部分肌纤维代偿性肥大,电镜示肌原纤维和线粒体轻度变性,糖原颗粒减少。现报告如下。     

糖原累积病Ⅱ型1例并文献复习

目的：探讨糖原累积病Ⅱ型（glycogen storage disease type Ⅱ,GSD-Ⅱ）的临床诊断与治疗。方法：对收治的1例GSD-Ⅱ的临床资料进行分析,并结合国内外文献复习。结果与结论：该例患者为年青女性,以四肢进行性乏力为主要表现。肌电图示肌源性损害。骨骼肌光镜下特征性病理改变：大量肌纤维胞浆内可见大小不一的空泡,内有糖原堆积。电镜下见肌纤维结构紊乱,肌膜下、肌纤维间见大量糖原聚集。GSD-Ⅱ属于常染色体隐性遗传病,缺乏特异性体征,最后诊断依靠酶的测定及基因诊断,但目前国内尚未普及,故肌肉活检结果有重要诊断价值。对于该病的治疗主要采取加强护肝、控制感染、辅助呼吸等对症支持治疗。     

1例糖原贮积病Ⅱ型合并妊娠患者的护理体会

糖原贮积病Ⅱ 型(glycogen storage disease type Ⅱ,GSD Ⅱ,MIM 232300)也称为酸性α-葡糖苷酶缺乏症(acid-α—glucosi-dase deficiency).1932年荷兰病理学家Pompe首次报道本病,故常称为庞贝病(Pompe病)oGGSD Ⅱ是一种罕见的常染色体隐性遗传的进展性溶酶体贮积病,是目前所知惟一属于溶酶体贮积病的糖原贮积病[1].以进行性加重的骨骼肌萎缩、无力为特征,患者预后不良[2].近期,我院神经内科收治了1例糖原贮积病Ⅱ型合并妊娠的患者,根据实施治疗及护理,患者顺利产子并出院,为全国罕见糖原贮积病Ⅱ型生产病例,可借鉴的护理经验极为缺乏.本文将我院此例患者的护理过程进行总结,现将护理经验报道如下.     

DMD/BMD患者的dystrophin基因表达研究

目的探讨杜氏进行性肌营养不良(DMD)/贝氏进行性肌营养不良(BMD)患者的dystrophin基因突变与蛋白质表达之间的关系。方法用多重连接探针扩增(MLPA)法检测14例DMD/BMD患者dystrophin基因突变,肌肉活检观察组织的形态结构特点,免疫组织化学染色检测患者腓肠肌组织中dystrophin蛋白的表达情况。结果 14例DMD/BMD患者中有3例检出dystrophin基因缺失,其余未检出基因突变。肌肉活检结果显示,14例患者均可见肌纤维大小不一,圆形化,肌纤维明显变性、坏死,不同程度再生;部分肌纤维间可见少量炎性细胞浸润,结缔组织增生。免疫组织化学染色显示,3例未表达dystrophin基因突变患者的肌纤维膜dystrophin蛋白不同程度表达减弱,其余11例患者可见肌纤维膜dystrophin蛋白质表达完全缺失。结论 MLPA联合肌肉活检及免疫组化染色可以鉴别诊断DMD/BMD,为患者的诊治和预后提供了依据。     

活检骨骼肌对肌糖原累积病的诊断价值

目的:总结肌糖原累积病(MGSD)临床与活检骨骼肌的病理特点。方法:回顾性分析16例MGSD患者的临床和骨骼肌病理资料。结果:临床表现包括肌力下降、运动不耐受、肌痛、肌张力减低等,可合并多系统受累;血肌酸激酶不同程度升高;肌电图正常或呈肌源性/神经源性损害。活检骨骼肌病理分析:典型病理表现为细胞浆内散在不定形空泡和/或PAS染色空泡内糖原流失或蓄积;2例酸性磷酸酶活性增加;1例磷酸化酶活性缺失;电镜下可见大量糖原颗粒聚集,MGSDⅡA病患者可见双膜自噬泡、髓样小体、溶酶体聚集和糖原颗粒蓄积。结论:骨骼肌活检对MGSD诊断与鉴别诊断具有重要价值;细胞浆内糖原空泡、糖原蓄积是重要病理诊断依据,酸性磷酸酶、磷酸化酶特殊染色有助于分型诊断,指导致病基因测序;电镜下溶酶体髓磷脂样改变支持MGSDⅡA型诊断。     

痉挛性脑瘫肌肉的超微结构研究

目的　探讨痉挛性脑瘫骨骼肌纤维的病理改变特点。方法　取材于 2 5例痉挛性脑瘫的骨骼肌标本 5 4个 ,通过透射电镜观察其亚显微结构改变。结果　大体观察基本正常。光镜下有集簇性肌纤维变性、结缔组织增生 ,肌梭结构尚好。电镜下肌纤维线粒体多 ,三联管结构少、发育差 ;病变肌纤维呈细胞水肿和肌原纤维破坏的表现 ;部分肌纤维中可见肌原纤维旋涡样变结构。结论　痉挛性脑瘫的骨骼肌存在着继发性病变 ,Ⅰ型肌纤维的亚显微结构表现明显。     

10例进行性肌营养不良肌肉组织活检的电镜观察

目的 探讨进行性肌营养不良的发病机理及诊断。方法 对１０不同临床类型的进行性肌营养不良症的腓肠肌活检标本进行了光镜和电镜观察。结果 在所有的标本中肿胀肌纤维与萎缩肌纤维混合存在,大量的小泡多见于前者肌浆中,局灶性微孔肌浆膜的出现常见于该病症的早期。随病程进行,肌浆膜有片状缺失,常见肌纤维间、原纤维间、微丝间和肌浆内水肿变性,多见线粒体肿胀、嵴断裂、消失及结晶样包含物的出现,同时见到肌浆网扩张。二者同积聚的糖原常充填于肌溶灶处,在病变早期肌原纤维的微丝显出排列紊乱,相邻原纤维的Ｚ线不在一条水平线上排列,Ⅰ带变宽,肌小体增长,最后受损肌原纤维溶解,断裂和凝固性坏死,随后单核细胞入侵。结论 虽然临床上将本病症分为若干类型,但所有标本中的类型未见有特异性的超微结构改变;微孔肌浆膜的早期出现是该病的的主要特征。本文最后还     

11例各类肌炎的病理学表现

目的：探讨各类肌炎的病理学特点，方法：对11例患各类肌炎病人的肌肉活检标本进行常规染色，特染，组织酶学染色及超微结构病理研究。结果：11例肌炎病人中感染性肌炎3例，其病理形态表现各具特征，免疫介导性肌炎8例，其病理形态的共同点是坏死肌纤维位于肌束周边，伴灶性炎细胞浸润，小血管壁增厚，结论：苏木精－伊红染色是诊断各种肌炎的主要方法，特染和组织酶学染色对诊断肌炎有辅助作用，电镜下超微结构的观察对包涵体肌炎有诊断价值。     

Adeno-associated virus-mediated transfer of human acid maltase gene results in a transient reduction of glycogen accumulation in muscle of Japanese quail with acid maltase deficiency

Glycogen storage disease type II (GSD II), Pompe's disease, is caused by the deficiency of acid alpha-D-glucosidase (GAA) in lysosome and is the most common form of GSD in Taiwan. Most cases are the infantile form. The disease is relentless and most patients die of cardiac failure and respiratory tract infection in the first year of life. At present, no treatment has been proved effective for this fatal disease. The applicability of enzyme replacement therapy is under investigation. However, high price and transient efficiency are the major problems to be solved. Accordingly, gene therapy by viral method has been conducted. In this study we constructed a plasmid that contained 5'-shortened BglII-NotI fragment human GAA cDNA, downstream of CMV promoter and bovine growth hormone polyadenylation signal, as well as AAV ITR region. When fibroblasts obtained from GSD II patients were cultured and infected with rAAV-GAA, the GAA activity of the fibroblasts increased four- to five-fold. Using acid maltase deficient (AMD) Japanese quail as the animal model, rcAAV-GAA 0.1 ml per site (1 x 10(9)-10) particles), totally 10 different sites to make 1 ml (1 x 10(1)0-11) particles), was injected into unilateral deep pectoral muscle of AMD quails. Medium (hepes) was only injected in the same way into the contralateral deep pectoral muscle to serve as control. Four days after injection, PAS staining showed disappearance of the glycogenosomes with regeneration of myocytes surrounding the intramuscular injected area as compared with the contralateral muscle of the same birds. Using anti-GAA monoclonal antibody, GAA was demonstrated on the regenerated myocytes by immunohistochemical staining and absent on the contralateral muscle of the same birds. Nevertheless, T lymphocytes infiltration was noted in both the rcAAV-GAA and hepes (medium) injected muscles and more prominent in the rcAAV-GAA-injected site. Functional evaluation demonstrated that wing flapping movement improved with wide flapping in the rAAV-GAA injected side, but not in the counterpart. Unfortunately, these histochemical and functional improvements faded away in 14 days, probably due to destruction of rcAAV by cell-mediated immunity of infiltrated T cells. Taken together, the present study suggests that rAAV can enter either human or quail cells and express and effectively reduce the glycogen accumulation in the skeletal muscle of AMD quails. These preliminary results are similar to these of low-dose rGAA replacement therapy. The mechanisms underlying the induction of cell-mediated immunity are unknown. How to elevate the number of packaged AAV, enhance the infectivity of AAV and reduce cell-mediated immunity must be solved in the future.     

Impact of humoral immune response on distribution and efficacy of recombinant adeno-associated virus-derived acid alpha-glucosidase in a model of glycogen storage disease type II

Glycogen storage disease type II (GSDII) is a lysosomal storage disease caused by a deficiency in acid alpha-glucosidase (GAA), and leads to cardiorespiratory failure by the age of 2 years. In this study, we investigate the impact of anti-GAA antibody formation on cross-correction of the heart, diaphragm, and hind-limb muscles from liver-directed delivery of recombinant adeno-associated virus (rAAV)5- and rAAV8-GAA vectors. GAA(-/-) mice receiving 1 x 10(12) vector genomes of rAAV5- or rAAV8-DHBV-hGAA were analyzed for anti-GAA antibody response, GAA levels, glycogen reduction, and contractile function. We demonstrate that restoration of GAA to the affected muscles is dependent on the presence or absence of the antibody response. Immune-tolerant mice had significantly increased enzyme levels in the heart and skeletal muscles, whereas immune-responsive mice had background levels of GAA in all tissues except the diaphragm. The increased levels of activity in immune-tolerant mice correlated with reduced glycogen in the heart and diaphragm and, overall, contractile function of the soleus muscle was significantly improved. These findings highlight the importance of the immune response to rAAV-encoded GAA in correcting GSDII and provide additional understanding of the approach to treatment of GSDII.     

Replacing acid alpha-glucosidase in Pompe disease: recombinant and transgenic enzymes are equipotent, but neither completely clears glycogen from type II muscle fibers.

Pompe disease (type II glycogen storage disease) is an autosomal recessive disorder caused by a deficiency of lysosomal acid alpha-glucosidase (GAA) leading to the accumulation of glycogen in the lysosomes primarily in cardiac and skeletal muscle. The recombinant human GAA (rhGAA) is currently in clinical trials for enzyme replacement therapy of Pompe disease. Both clinical data and the results of preclinical studies in our knockout model of this disease show that rhGAA is much more effective in resolving the cardiomyopathy than the skeletal muscle myopathy. By contrast, another form of human GAA--transgenic enzyme constitutively produced in liver and secreted into the bloodstream of knockout mice (Gaa-/-)--completely prevented both cardiac and skeletal muscle glycogen accumulation. In the experiments reported here, the transgenic enzyme was much less efficient when delivered to skeletal muscle after significant amounts of glycogen had already accumulated. Furthermore, the transgenic enzyme and the rhGAA have similar therapeutic effects, and both efficiently clear glycogen from cardiac muscle and type I muscle fibers, but not type II fibers. Low abundance of proteins involved in endocytosis and trafficking of lysosomal enzymes combined with increased autophagy in type II fibers may explain the resistance to therapy.     

Sustained correction of glycogen storage disease type II using adeno-associated virus serotype 1 vectors

Glycogen storage disease type II (GSDII) is caused by a lack of functional lysosomal acid alpha-glucosidase (GAA). Affected individuals store glycogen in lysosomes beginning during gestation, ultimately resulting in fatal hypertrophic cardiomyopathy and respiratory failure. We have assessed the utility of recombinant adeno-associated virus (rAAV) vectors to restore GAA activity in vivo in a mouse model of GSDII (Gaa(-/-)). A single systemic administration of a rAAV serotype 1 (rAAV1) vector to neonate animals resulted in restored cardiac GAA activity to 6.4 times the normal level (mean=641+/-190% of normal (Gaa(+/+)) levels with concomitant glycogen clearance) at 11 months postinjection. Greater than 20% of normal levels of GAA activity were also observed in the diaphragm and quadriceps muscles. Furthermore, functional correction of the soleus skeletal muscle was also observed compared to age-matched untreated Gaa(-/-) control animals. These results demonstrate that rAAV1 vectors can mediate sustained therapeutic levels of correction of both skeletal and cardiac muscles in a model of fatal cardiomyopathy and muscular dystrophy.     

Fully deleted adenovirus persistently expressing GAA accomplishes long-term skeletal muscle glycogen correction in tolerant and nontolerant GSD-II mice.

Glycogen storage disease type II (GSD-II) patients manifest symptoms of muscular dystrophy secondary to abnormal glycogen storage in cardiac and skeletal muscles. For GSD-II, we hypothesized that a fully deleted adenovirus (FDAd) vector expressing hGAA via nonviral regulatory elements (PEPCK promoter/ApoE enhancer) would facilitate long-term efficacy and decrease propensity to generate anti-hGAA antibody responses against hepatically secreted hGAA. Intravenous delivery of FDAdhGAA into GAA-tolerant or nontolerant GAA-KO mice resulted in long-term hepatic secretion of hGAA. Specifically, nontolerant mice achieved complete reversal of cardiac glycogen storage and near-complete skeletal glycogen correction for at least 180 days and tolerant mice for minimally 300 days coupled with the preservation of muscle strength. Anti-hGAA antibody levels in both mouse strains were significantly less relative to those previously generated by CMV-driven hGAA expression in nontolerant GAA-KO mice. However, plasma GAA levels decreased in nontolerant GAA-KO mice despite long-term intrahepatic GAA expression from the persistent vector. This intriguing result is discussed in light of other examples of "tolerance" induction by gene-transfer-based approaches.     

Biochemical diagnosis of hepatic glycogen storage diseases: 20 years French experience.

French experience of 242 cases of liver glycogenoses is reported. Screening tests based on serum biochemical data and glucagon tolerance tests are briefly reviewed. The diagnosis of types I glycogen storage disease (GSD) was ascertained in 73 patients' liver biopsies by measurement of glycogen content and by studying the glucose-6-phosphatase system. Liver biopsies were also required at the beginning for the diagnosis of other hepatic GSDs; later on, the possibilities of diagnosis using peripheral blood cells were investigated. Eighty-four cases of type III GSD were confirmed by measurement of debranching enzyme activity and glycogen content using either liver biopsies (78 cases) and/or erythrocytes (37 cases); enzyme determination was also performed in leukocytes and/or fibroblasts for 18 patients. Twenty-four cases of type VI GSD underwent liver biopsies, and the diagnosis could be confirmed using mononuclear or polymorphonuclear cells for 11 of these patients. Sixty-one patients were identified as type IX GSD; phosphorylase kinase deficiency was demonstrated in erythrocytes for all patients, and a liver biopsy was analyzed for 26 of these cases. From this experience, the possibilities of diagnosis of liver GSD using peripheral blood cells are emphasized.     

Correction of glycogen storage disease type II by an adeno-associated virus vector containing a muscle-specific promoter.

Glycogen storage disease type II (Pompe disease) causes death in infancy from cardiorespiratory failure due to acid alpha-glucosidase (GAA; acid maltase) deficiency. An AAV2 vector pseudotyped as AAV6 (AAV2/6 vector) transiently expressed high-level human GAA in GAA-knockout (GAA-KO) mice without reducing glycogen storage; however, in immunodeficient GAA-KO/SCID mice the AAV2/6 vector expressed high-level GAA and reduced the glycogen content of the injected muscle for 24 weeks. A CD4+/CD8+ lymphocytic infiltrate was observed in response to the AAV2/6 vector in immunocompetent GAA-KO mice. When a muscle-specific creatine kinase promoter was substituted for the CB promoter (AAV-MCKhGAApA), that AAV2/6 vector expressed high-level GAA and reduced glycogen content in immunocompetent GAA-KO mice. Muscle-restricted expression of hGAA provoked only a humoral (not cellular) immune response. Intravenous administration of a high number of particles of AAV-MCKhGAApA as AAV2/7 reduced the glycogen content of the heart and skeletal muscle and corrected individual myofibers in immunocompetent GAA-KO mice 24 weeks postinjection. In summary, persistent correction of muscle glycogen content was achieved with an AAV vector containing a muscle-specific promoter in GAA-KO mice, and this approach should be considered for muscle-targeted gene therapy in Pompe disease.     

Evaluation of Systemic Follistatin as an Adjuvant to Stimulate Muscle Repair and Improve Motor Function in Pompe Mice

Due to the lack of acid α-glucosidase (GAA) activity, Pompe mice develop glycogen storage pathology and progressive skeletal muscle dysfunction with age. Applying either gene or enzyme therapy to reconstitute GAA levels in older, symptomatic Pompe mice effectively reduces glycogen storage in skeletal muscle but provides only modest improvements in motor function. As strategies to stimulate muscle hypertrophy, such as by myostatin inhibition, have been shown to improve muscle pathology and strength in mouse models of muscular dystrophy, we sought to determine whether these benefits might be similarly realized in Pompe mice. Administration of a recombinant adeno-associated virus serotype 8 vector encoding follistatin, an inhibitor of myostatin, increased muscle mass and strength but only in Pompe mice that were treated before 10 months of age. Younger Pompe mice showed significant muscle fiber hypertrophy in response to treatment with follistatin, but maximal gains in muscle strength were achieved only when concomitant GAA administration reduced glycogen storage in the affected muscles. Despite increased grip strength, follistatin treatment failed to improve rotarod performance. These findings highlight the importance of treating Pompe skeletal muscle before pathology becomes irreversible, and suggest that adjunctive therapies may not be effective without first clearing skeletal muscle glycogen storage with GAA.     

Long-term efficacy after [E1-, polymerase-] adenovirus-mediated transfer of human acid-alpha-glucosidase gene into glycogen storage disease type II knockout mice

Glycogen storage disease type II (GSD-II) is a lethal, autosomal recessive metabolic myopathy caused by a lack of acid-alpha-glucosidase (GAA) activity in the cardiac and skeletal muscles. Absence of adequate intralysosomal GAA activity results in massive amounts of glycogen accumulation in multiple muscle groups, resulting in morbidity and mortality secondary to respiratory embarrassment and/or cardiomyopathy. In a mouse model of GSD-II, we demonstrate that infection of the murine liver with a modified adenovirus (Ad) vector encoding human GAA (hGAA) resulted in long-term persistence of the vector in liver tissues for at least 6 months. Despite both a rapid shutdown of hGAA mRNA expression from the vector, as well as the elicitation of anti-hGAA antibody responses (hGAA is a foreign antigen in this model), the hGAA secreted by the liver was taken up by all muscle groups analyzed and, remarkably, persisted in them for at least 6 months. The persistence of the protein also correlated with long-term correction of pathologic intramuscular glycogen accumulations in all muscle groups tested, but most notably the cardiac tissues, which demonstrated a significantly decreased glycogen content for at least 190 days after a single vector injection. The results suggest that gene therapy strategies may have the potential to significantly improve the clinical course for GSD-II patients.     

Muscle fiber composition in patients with traumatic cord lesion.

Muscle fiber composition and oxidative and glycolytic enzymatic activity have been studied with complete traumatic transection of the spinal cord and spastic paralysis of the lower extremities. Muscle sample were taken by means of needle biopsy from the vastus lateralis, gastrocnemius, and soleus muscles. Biopsies were also taken for comparison from the deltoid muscle. Fibers staining darkly for alkaline stable myofibrillar ATP-ase (type II) dominated or were the only fibers identified in the paralysed muscles. The deltoid muscles of the same patients had a rather even mixture of type I and II fibers. Staining pattern was reversed after acid preincubation (pH 4.3). Mean diameters in the paralysed muscles were reduced for both fiber types. All fibers stained relatively weakly for NADH-diaphorase. Succinyldehydrogenase activity was low and phosphofructokinase activity usually moderately reduced. The findings imply that neuronal influence on the muscular fibers had led to a change in the staining characteristics of the muscle fibers. Such a change migh indicate altered contractile characteristics, though the detailed nature of the observed findings in still unclear.