Tay–Sachs disease is a genetic disorder that results in the destruction of nerve cells in

the brain and spinal cord.[1] The most common form is infantile Tay–Sachs disease which becomes
apparent around three to six months of age, with the baby losing the ability to turn over, sit, or crawl.
[1]
 This is then followed by seizures, hearing loss, and inability to move, with death usually occurring
by the age of four.[1] Less commonly, the disease may occur in later childhood or adulthood (juvenile
or late-onset).[1] These forms tend to be less severe,[1] but the juvenile form typically results in death
by age 15.[3]
Tay–Sachs disease is caused by a genetic mutation in the HEXA gene on chromosome 15, which
codes for a subunit of the hexosaminidase enzyme known as hexosaminidase A.[1] It is inherited from
a person's parents in an autosomal recessive manner.[1] The mutation disrupts the activity of the
enzyme, which results in the buildup of the molecule GM2 ganglioside within cells, leading to toxicity.
[1]
 Diagnosis may be supported by measuring the blood hexosaminidase A level or genetic testing.
[2]
 Tay–Sachs disease is a type of GM2 gangliosidosis and sphingolipidosis.[4]
The treatment of Tay–Sachs disease is supportive in nature.[2] This may involve multiple specialities
as well as psychosocial support for the family.[2] The disease is rare in the general population.
[1]
 In Ashkenazi Jews, French Canadians of southeastern Quebec, the Old Order
Amish of Pennsylvania, and the Cajuns of southern Louisiana, the condition is more common.[2]
[1]
 Approximately 1 in 3,600 Ashkenazi Jews at birth are affected.[2]
The disease is named after British opthalmologist Waren Tay, who in 1881 first described a
symptomatic red spot on the retina of the eye; and American neurologist Bernard Sachs, who
described in 1887 the cellular changes and noted an increased rate of disease in Ashkenazi Jews.
[5]
 Carriers of a single Tay–Sachs allele are typically normal.[2] It has been hypothesized that being a
carrier may confer protection from tuberculosis, explaining the persistence of the allele in certain
populations.[6] Researchers are looking at gene therapy or enzyme replacement therapy as possible
treatments.[2]

Contents

 1Signs and symptoms

o 1.1Infantile
o 1.2Juvenile
o 1.3Late-onset
 2Genetics
 3Pathophysiology
 4Diagnosis
 5Prevention
 6Management
 7Outcomes
 8Epidemiology
 9History
 10Society and culture
 11Research directions
o 11.1Enzyme replacement therapy
o 11.2Jacob sheep model
o 11.3Substrate reduction therapy
o 11.4Increasing β-hexosaminidase A activity
o 11.5Cord blood transplant
 12References
 13External links

Signs and symptoms[edit]

Tay–Sachs disease is typically first noticed in infants around 6 months old displaying an abnormally
strong response to sudden noises or other stimuli, known as the "startle response". There may also
be listlessness or muscle stiffness (hypertonia). The disease is classified into several forms, which
are differentiated based on the onset age of neurological symptoms.[7][8]

Infantile[edit]
Infants with Tay–Sachs disease appear to develop normally for the first six months after birth. Then,
as neurons become distended with GM2 gangliosides, a relentless deterioration of mental and
physical abilities begins. The child may become blind, deaf, unable to swallow, atrophied,
and paralytic. Death usually occurs before the age of four.[7]

Juvenile[edit]
Juvenile Tay–Sachs disease is rarer than other forms of Tay–Sachs, and usually is initially seen in
children between two and ten years old. People with Tay–Sachs disease
develop cognitive and motor skill deterioration, dysarthria, dysphagia, ataxia, and spasticity.[9] Death
usually occurs between the age of five to fifteen years.[3]

Late-onset[edit]
A rare form of this disease, known as Adult-Onset or Late-Onset Tay–Sachs disease, usually has its
first symptoms during the 30s or 40s. In contrast to the other forms, late-onset Tay–Sachs disease is
usually not fatal as the effects can stop progressing. It is frequently misdiagnosed. It is characterized
by unsteadiness of gait and progressive neurological deterioration. Symptoms of late-onset Tay–
Sachs – which typically begin to be seen in adolescence or early adulthood – include speech and
swallowing difficulties, unsteadiness of gait, spasticity, cognitive decline, and psychiatric illness,
particularly a schizophrenia-like psychosis.[10] People with late-onset Tay–Sachs may become full-
time wheelchair users in adulthood.
Until the 1970s and 1980s, when the disease's molecular genetics became known, the juvenile and
adult forms of the disease were not always recognized as variants of Tay–Sachs disease. Post-
infantile Tay–Sachs was often misdiagnosed as another neurological disorder, such as Friedreich's
ataxia.[11]

Genetics[edit]
Tay–Sachs disease is inherited in an autosomal recessive pattern.

The HEXA gene is located on the long (q) arm of human chromosome 15, between positions 23 and 24.

Tay–Sachs disease is an autosomal recessive genetic disorder, meaning that when both parents
are carriers, there is a 25% risk of giving birth to an affected child with each pregnancy. The affected
child would have received a mutated copy of the gene from each parent.[7]
Tay–Sachs results from mutations in the HEXA gene on chromosome 15, which encodes the alpha-
subunit of beta-N-acetylhexosaminidase A, a lysosomal enzyme. By 2000, more than 100 different
mutations had been identified in the human HEXA gene.[12] These mutations have included single
base insertions and deletions, splice phase mutations, missense mutations, and other more complex
patterns. Each of these mutations alters the gene's protein product (i.e., the enzyme), sometimes
severely inhibiting its function.[13] In recent years, population studies and pedigree analysis have
shown how such mutations arise and spread within small founder populations. Initial research
focused on several such founder populations:

 Ashkenazi Jews. A four base pair insertion in exon 11 (1278insTATC) results in an

altered reading frame for the HEXA gene. This mutation is the most prevalent mutation in the
Ashkenazi Jewish population, and leads to the infantile form of Tay–Sachs disease.[14]
 Cajuns. The same 1278insTATC mutation found among Ashkenazi Jews occurs in the Cajun
population of southern Louisiana. Researchers have traced the ancestry of carriers from
Louisiana families back to a single founder couple – not known to be Jewish – who lived in
France in the 18th century.[15]
 French Canadians. Two mutations, unrelated to the Ashkenazi/Cajun mutation, are absent in
France but common among certain French-Canadian communities living in southeastern
Quebec and Acadians from the Province of New Brunswick. Pedigree analysis suggests the
mutations were uncommon before the late 17th century.[16][17]
In the 1960s and early 1970s, when the biochemical basis of Tay–Sachs disease was first becoming
known, no mutations had been sequenced directly for genetic diseases. Researchers of that era did
not yet know how common polymorphisms would prove to be. The "Jewish Fur Trader Hypothesis,"
with its implication that a single mutation must have spread from one population into another,
reflected the knowledge at the time.[18] Subsequent research, however, has proven that a large
variety of different HEXA mutations can cause the disease. Because Tay–Sachs was one of the first
genetic disorders for which widespread genetic screening was possible, it is one of the first genetic
disorders in which the prevalence of compound heterozygosity has been demonstrated.[19]
Compound heterozygosity ultimately explains the disease's variability, including the late-onset forms.
The disease can potentially result from the inheritance of two unrelated mutations in the HEXA gene,
one from each parent. Classic infantile Tay–Sachs disease results when a child has inherited
mutations from both parents that completely stop the biodegradation of gangliosides. Late onset
forms occur due to the diverse mutation base – people with Tay–Sachs disease may technically be
heterozygotes, with two differing HEXA mutations that both inactivate, alter, or inhibit enzyme
activity. When a patient has at least one HEXA copy that still enables some level of
hexosaminidase A activity, a later onset disease form occurs. When disease occurs because of two
unrelated mutations, the patient is said to be a compound heterozygote.[20]
Heterozygous carriers (individuals who inherit one mutant allele) show abnormal enzyme activity but
manifest no disease symptoms. This phenomenon is called dominance; the biochemical reason
for wild-type alleles' dominance over nonfunctional mutant alleles in inborn errors of
metabolism comes from how enzymes function. Enzymes are protein catalysts for chemical
reactions; as catalysts, they speed up reactions without being used up in the process, so only small
enzyme quantities are required to carry out a reaction. Someone homozygous for a nonfunctional
mutation in the enzyme-encoding gene has little or no enzyme activity, so will manifest the
abnormal phenotype. A heterozygote (heterozygous individual) has at least half of the normal
enzyme activity level, due to expression of the wild-type allele. This level is normally enough to
enable normal function and thus prevent phenotypic expression.[21]

Pathophysiology[edit]
Tay–Sachs disease is caused by insufficient activity of the enzyme hexosaminidase A.
Hexosaminidase A is a vital hydrolytic enzyme, found in the lysosomes, that breaks
down sphingolipids. When hexosaminidase A is no longer functioning properly, the lipids accumulate
in the brain and interfere with normal biological processes. Hexosaminidase A specifically breaks
down fatty acid derivatives called gangliosides; these are made and biodegraded rapidly in early life
as the brain develops. Patients with and carriers of Tay–Sachs can be identified by a simple blood
test that measures hexosaminidase A activity.[7]
The hydrolysis of GM2-ganglioside requires three proteins. Two of them are subunits of
hexosaminidase A; the third is a small glycolipid transport protein, the GM2 activator protein
(GM2A), which acts as a substrate-specific cofactor for the enzyme. Deficiency in any one of these
proteins leads to ganglioside storage, primarily in the lysosomes of neurons. Tay–Sachs disease
(along with AB-variant GM2-gangliosidosis and Sandhoff disease) occurs because a mutation
inherited from both parents deactivates or inhibits this process. Most Tay–Sachs mutations probably
do not directly affect protein functional elements (e.g., the active site). Instead, they cause
incorrect folding (disrupting function) or disable intracellular transport.[22]

Diagnosis[edit]
In patients with a clinical suspicion for Tay–Sachs disease, with any age of onset, the initial testing
involves an enzyme assay to measure the activity of hexosaminidase in serum, fibroblasts,
or leukocytes. Total hexosaminidase enzyme activity is decreased in individuals with Tay–Sachs as
is the percentage of hexosaminidase A. After confirmation of decreased enzyme activity in an
individual, confirmation by molecular analysis can be pursued.[23] All patients with infantile onset Tay–
Sachs disease have a "cherry red" macula in the retina, easily observable by a physician using
an ophthalmoscope.[7][24] This red spot is a retinal area that appears red because of gangliosides in
the surrounding retinal ganglion cells. The choroidal circulation is showing through "red" in
this foveal region where all retinal ganglion cells are pushed aside to increase visual acuity. Thus,
this cherry-red spot is the only normal part of the retina; it shows up in contrast to the rest of the
retina. Microscopic analysis of the retinal neurons shows they are distended from excess ganglioside
storage.[25] Unlike other lysosomal storage diseases (e.g., Gaucher disease, Niemann–Pick disease,
and Sandhoff disease), hepatosplenomegaly (liver and spleen enlargement) is not seen in Tay–
Sachs.[26]

Prevention[edit]
Main article: Prevention of Tay–Sachs disease
Three main approaches have been used to prevent or reduce the incidence of Tay–Sachs:

 Prenatal diagnosis. If both parents are identified as carriers, prenatal genetic testing can
determine whether the fetus has inherited a defective gene copy from both parents.[27] Chorionic
villus sampling (CVS), the most common form of prenatal diagnosis, can be performed between
10 and 14 weeks of gestation. Amniocentesis is usually performed at 15–18 weeks. These
procedures have risks of miscarriage of 1% or less.[28][29]
 Preimplantation genetic diagnosis. By retrieving the mother's eggs for in vitro fertilization, it is
possible to test the embryo for the disorder prior to implantation. Healthy embryos are then
selected and transferred into the mother's womb, while unhealthy embryos are discarded. In
addition to Tay–Sachs disease, preimplantation genetic diagnosis has been used to
prevent cystic fibrosis and sickle cell anemia among other genetic disorders.[30]
 Mate selection. In Orthodox Jewish circles, the organization Dor Yeshorim carries out an
anonymous screening program so that carriers for Tay–Sachs and other genetic disorders can
avoid marrying each other.[31]

Management[edit]
As of 2010 there was no treatment that addressed the cause of Tay–Sachs disease or could slow its
progression; people receive supportive care to ease the symptoms and extend life by reducing the
chance of contracting infections.[32] Infants are given feeding tubes when they can no longer swallow.
[33]
 In late-onset Tay–Sachs, medication (e.g., lithium for depression) can sometimes control
psychiatric symptoms and seizures, although some medications (e.g., tricyclic
antidepressants, phenothiazines, haloperidol, and risperidone) are associated with significant
adverse effects.[20][34]

Outcomes[edit]
As of 2010, even with the best care, children with infantile Tay–Sachs disease usually die by the age
of 4. Children with the juvenile form are likely to die from the ages 5–15, while those with the adult
form will probably not be affected.[32]

Epidemiology[edit]
Founder effects occur when a small number of individuals from a larger population establish a new population.
In this illustration, the original population is on the left with three possible founder populations on the right. Two
of the three founder populations are genetically distinct from the original population.

Ashkenazi Jews have a high incidence of Tay–Sachs and other lipid storage diseases. In the United
States, about 1 in 27 to 1 in 30 Ashkenazi Jews is a recessive carrier. The disease incidence is
about 1 in every 3,500 newborn among Ashkenazi Jews.[35] French Canadians and
the Cajun community of Louisiana have an occurrence similar to the Ashkenazi Jews. Irish
Americans have a 1 in 50 chance of being a carrier.[36] In the general population, the incidence of
carriers as heterozygotes is about 1 in 300.[8] The incidence is approximately 1 in 320,000 newborns
in the general population in United States.[37]
Three general classes of theories have been proposed to explain the high frequency of Tay–Sachs
carriers in the Ashkenazi Jewish population:

 Heterozygote advantage.[38] When applied to a particular allele, this theory posits that

mutation carriers have a selective advantage, perhaps in a particular environment.[39]
 Reproductive compensation. Parents who lose a child because of disease tend to
"compensate" by having additional children to replace them. This phenomenon may maintain
and possibly even increase the incidence of autosomal recessive disease.[40]
 Founder effect. This hypothesis states that the high incidence of the 1278insTATC
chromosomes[39] is the result of an elevated allele frequency[38] that existed by chance in an early
founder population.[39]
Tay–Sachs disease was one of the first genetic disorders for which epidemiology was studied using
molecular data. Studies of Tay–Sachs mutations using new molecular techniques such as linkage
disequilibrium and coalescence analysis have brought an emerging consensus among researchers
supporting the founder effect theory.[39][41][42]

History[edit]
Main article: History of Tay–Sachs disease
Waren Tay and Bernard Sachs are two physicians. They described the disease's progression and
provided differential diagnostic criteria to distinguish it from other neurological disorders with similar
symptoms.
Both Tay and Sachs reported their first cases among Ashkenazi Jewish families. Tay reported his
observations in 1881 in the first volume of the proceedings of the British Ophthalmological Society,
of which he was a founding member.[43] By 1884, he had seen three cases in a single family. Years
later, Bernard Sachs, an American neurologist, reported similar findings when he reported a case of
"arrested cerebral development" to other New York Neurological Society members.[44][45]
Sachs, who recognized that the disease had a familial basis, proposed that the disease should be
called amaurotic familial idiocy. However, its genetic basis was still poorly understood.
Although Gregor Mendel had published his article on the genetics of peas in 1865, Mendel's paper
was largely forgotten for more than a generation – not rediscovered by other scientists until 1899.
Thus, the Mendelian model for explaining Tay–Sachs was unavailable to scientists and doctors of
the time. The first edition of the Jewish Encyclopedia, published in 12 volumes between 1901 and
1906, described what was then known about the disease:[46]
It is a curious fact that amaurotic family idiocy, a rare and fatal disease of children, occurs mostly
among Jews. The largest number of cases has been observed in the United States—over thirty in
number. It was at first thought that this was an exclusively Jewish disease because most of the
cases at first reported were between Russian and Polish Jews; but recently there have been
reported cases occurring in non-Jewish children. The chief characteristics of the disease are
progressive mental and physical enfeeblement; weakness and paralysis of all the extremities; and
marasmus, associated with symmetrical changes in the macula lutea. On investigation of the
reported cases, they found that neither consanguinity nor syphilitic, alcoholic, or nervous
antecedents in the family history are factors in the etiology of the disease. No preventive measures
have as yet been discovered, and no treatment has been of benefit, all the cases having terminated
fatally.
Jewish immigration to the United States peaked in the period 1880–1924, with the immigrants
arriving from Russia and countries in Eastern Europe; this was also a period of nativism (hostility to
immigrants) in the United States. Opponents of immigration often questioned whether immigrants
from southern and eastern Europe could be assimilated into American society. Reports of Tay–
Sachs disease contributed to a perception among nativists that Jews were an inferior race.[45]
In 1969, Shintaro Okada and John S. O'Brien showed that Tay–Sachs disease was caused by an
enzyme defect; they also proved that Tay–Sachs patients could be diagnosed by an assay of
hexosaminidase A activity.[47] The further development of enzyme assays demonstrated that levels of
hexosaminidases A and B could be measured in patients and carriers, allowing the reliable detection
of heterozygotes. During the early 1970s, researchers developed protocols for newborn testing,
carrier screening, and pre-natal diagnosis.[31][48] By the end of 1979, researchers had identified three
variant forms of GM2 gangliosidosis, including Sandhoff disease and the AB variant of GM2-
gangliosidosis, accounting for false negatives in carrier testing.[49]