FOUNDATION MODULE

LYSOSOMAL STORAGE DISEASES- SPHINGOLIPIDOSIS

PRE-READING MATERIAL

LEARNING OBJECTIVES

 Describe the biochemical basis of following lysosomal disorders:

 Pompes disease
 Gaucher disease
 Fabry disease
 Nieman-Pick disease
 Correlate the metabolic abnormalities observed in the given lysosomal disorders with their clinic-
pathological presentation.
 Enumerate the available screening and laboratory diagnostic methods for the given. Lysosomal
storage disorders
 Illustrate the structure of cholesterol with the help of a diagram
 Enumerate various forms of cholesterol.
 Relate the various functions of cholesterol with the biomedical importance.

INTRODUCTION

Lysosomal storage diseases (LSDs) are inborn errors of metabolism i.e metabolic disorders due to
congenital enzyme deficiencies. These are characterized by the accumulation of substrates in
various organs' cells during degradation of glycosphingolipids due to the defective functioning of
lysosomes. They cause dysfunction of those organs where they accumulate and contribute to great
morbidity and mortality.

Sphingolipids are primarily membrane lipids. The synthesis of these lipids is required when cells are
formed. As essential components of membranes that play vital roles in a variety of signaling
cascades, SLs not only have structural functions but also play other vital roles in cellular
homeostasis, adhesion, signaling, senescence, development, and death . SLs are also involved in the
pathology of several immune and neurological diseases . Depending on the head groups,
sphingolipids can be classified into phosphosphingolipids (e.g., sphingomyelin (SM)) and
glycosphingolipids (GSLs). SMs are highly abundant in the myelin sheath surrounding the axonal
regions of neural cells

When cells such as red and white blood cells become senescent, they are removed from the
circulation. Their membrane components are sequentially biodegraded by hydrolytic enzymes
located in lysosomes within phagocytic cells. As the brain develops and synapses are formed, the
structures of sphingolipids may be simplified or their quantity reduced. Both of these processes
require sequential activity of a series of sphingolipid hydrolases. Deleterious mutations occasionally
occur in genes that code for sphingolipid catabolizing enzymes that cause a reduction of their
catalytic activity. When such an alteration occurs, there is an accumulation of a lipid that normally
would be completely degraded. The accumulation can be rapid or slow depending largely on the
nature of the mutation and its effect on the activity of the enzyme. sphingolipidoses have an
incidence of approximately 1 in 10,000 individuals.

CLINICAL PRESENTATIONS

Clinical presentations of these cases vary, depending on each type of enzyme defect. All the patients
appeared healthy at birth, and symptoms appear at around 1 or 2 years. Clinical features,
radiological findings, and especially enzyme assays have allowed us to establish a definitive
diagnosis in these cases. These cases highlight that abnormal clinical symptom, such as growth
failure, coarse facial features, and joint problems, are key points for further investigation.

Most LSDs have an autosomal recessive pattern of inheritance. Two have an X-linked inheritance
pattern: Hunter disease, Fabry disease. The last decade has observed tremendous advances in
understanding many of these conditions. Enzyme testing is usually the initial diagnostic test, but
genetic analysis of the gene mutations adds precision.

BIOCHEMICAL BASIS OF LSDS:

Lysosomes have luminal proteins and structural proteins which includes amino acid and lipid
transporters, ion-channels like calcium channels, membrane catabolic enzymes, trafficking and
fusion machinery and lysosomal associated proteins.

Abnormalities in these can interfere with lysosomal functions and result in LSDs. Lysosomes
communicate with the endoplasmic reticulum, mitochondria, peroxisomes to exchange content. The
lysosomal enzymes and other proteins are synthesized in the ribosomes and transported to the
endoplasmic reticulum (ER), where they are folded and attain a three-dimensional form.

Stepwise enzymatic reactions catalyze the degradation of these compounds. A deficient enzyme or
accessory protein will prevent the forward reaction and lead to substrate accumulation. The
accumulated compounds are excreted and form the basis for measurement in the urine. Common
features in sphingolipidosis include:

(1) Complex lipids containing ceramide accumulate in cells, particularly neurons, causing
neurodegeneration and shortening the life span.

(2) The rate of synthesis of the stored lipid is normal.

(3) The enzymatic defect is in the lysosomal degradation pathway of sphingolipids.

MANIFESTATIONS

Although single gene defects typically result in substrate accumulation, the precise underlying
pathophysiologic mechanisms that lead to clinical symptoms are not entirely clear. The distribution
of accumulating material correlates with which organs are affected. Cells of the mononuclear
phagocyte system are especially rich in lysosomes and thus are frequently affected by lysosomal
storage diseases.
Neurons and glia are commonly affected, likely because of the relative paucity of cell turnover in the
central nervous system, yet non-neuronopathic forms of lysosomal storage disease exist. Lysosomal
storage diseases may result in a severe neurodegenerative phenotype. Milder (typically later-onset
or adult-onset) phenotypes have been identified and are generally related to the degree of residual
enzyme activity.

Harper’s biochemistry 32nd edition. Chapter 24, page 235, Table 24-1.
PATHOPHYSIOLOGY

Although in general the accumulation of undegraded substrate is thought to relate to the cellular
dysfunction and death that accompanies lysosomal storage diseases, the precise mechanisms
underlying this degeneration are incompletely defined. The pattern of neuronal degeneration in
subtypes of lysosomal storage diseases may be surprisingly cell-type specific. In some cases,
substrate accumulation is also associated with sequestration of important component molecules,
leading to a relative deficiency state. 

SIGNS & SYMPTOMS

Coarse facies, macroglossia, bony abnormalities (dysostosis multiplex), cardiac involvement

(arrhythmia or cardiomegaly), hepatosplenomegaly, ophthalmologic signs (corneal clouding or
macular cherry-red spot), and neurological features may lead to clinical suspicion of a lysosomal
storage disease. Symptoms are typically gradually progressive rather than episodic, as occurs with
other neurometabolic disorders. Neurological symptoms can include developmental delay,
hypotonia, epilepsy (complex partial or myoclonic), peripheral neuropathy, intellectual disability,
ataxia, and/or spasticity.

LAB DIAGNOSIS AND SCREENING:

Many sphingolipidoses share common symptoms and signs and clinicians are facing difficulties in
diagnostic process. Biochemical investigation of the nature of a possible storage product will provide
an important clue, and direct enzyme and/or molecular analysis facilitate the final diagnosis.Clinical
suspicion for a particular lysosomal storage disease (LSD) precedes the screening tests, however
clinical features are highly variable. Many LSDs have similar features between themselves and, with
other non-lysosomal inborn errors of metabolism and diligence is required. The final diagnosis of an
LSD should rest on the combined evidence from clinical, biochemical, radiological, and genetic
information.

Screening can be performed via skeletal radiography to look for evidence of dysostosis multiplex
(seen in many of the lysosomal storage diseases), abdominal ultrasonography to identify
hepatosplenomegaly, and echocardiography to evaluate for cardiac involvement. Hearing screening
results may be abnormal in some cases. Ophthalmologic consultation may be helpful in identifying
corneal clouding or cherry-red spot. A peripheral blood smear may reveal white blood cell vacuoles
(granular, fingerprint lipid whorls, zebra bodies, or autophagic vacuoles) that may provide important
diagnostic clues. Urine can be screened for elevated excretion of oligosaccharides
(oligosaccharidoses) and glycosaminoglycans (mucopolysaccharidoses). Blood chitotriosidase (an
enzymatic marker of macrophage activation) may be elevated.

Definitive testing is most efficiently performed by enzymatic activity measurement in a reference

laboratory, typically in peripheral white blood cells (although skin fibroblasts may also be used or
even necessary in some cases). For some disorders, enzyme activity can be measured in dried filter
 paper blood spots, and, occasionally, enzyme activity measurement in other tissues such as muscle
can have utility. Urine enzyme activity measurements are seldom helpful, although urine substrate
excretion can provide useful information (see screening above). In some cases, confirmatory DNA
mutation analysis may be indicated.

1. Genetic testing for the mutated genes coding for those enzymes is available and can confirm the
enzyme tests. Genetic testing is also helpful in detecting carriers and helps in family counseling.
Prenatal screening using amniocentesis and chorionic villus biopsy is available for many LSDs to help
families with genetic counseling. Newborn screening for LSDs has gained acceptance over the years.
2. Restriction fragment length polymorphism by polymerase chain reaction (RFLP-PCR) and DNA
sequencing for detecting point mutations.
3. Radiological investigations assess the end-organ damage e.g ultrasound, MRI, CT scans.
4. Urine and serum screening tests

TREATMENT/MANAGEMENT
Currently, there is no cure for sphingolipidoses. Therapies like enzyme replacement,
pharmacological chaperone, and substrate reduction therapy, which have been shown to be
efficient in non-neuronopathic LSDs, are currently evaluated in clinical trials of neuronopathic
sphingolipidoses. In the future, neural stem cell therapy and gene therapy may become an option
for these disorders.

POSSIBLE THERAPIES FOR LYSOSOMAL STORAGE DISORDERS

a. Gene therapy
b. Enzyme replacement therapy
c. Substrate reduction therapy, and
d. Pharmacological/chemical chaperone therapy
Enzyme replacement therapy and bone marrow transplantation is available for some LSDs e.g
Gaucher and Fabry diseases. Modified forms of enzyme replacement therapy using chaperones
(chemical chaperone therapy) and gene therapy is under research. LSDs are classic examples in
healthcare with dedicated centers and multi-disciplinary specialist groups.

RESOURCES

1. Lippincott’s text book of biochemistry

2. Harpers text book of biochemistry
3. Internet resources
https://www.youtube.com/watch?v=uqg3RKz7XME&ab_channel=SimpleScienceAnswers
https://www.youtube.com/watch?v=LpDk0Ut9OUI&ab_channel=HowardSachs
https://www.youtube.com/watch?v=14_Oe-FRHSI&ab_channel=Medicowesome