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Chapter 8: Enzyme and Collagen Disorders
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. Why does a newborn with a genetic enzyme deficiency have a normal phenotype at birth?
A. Metabolism during prenatal life is too slow to require full enzyme activity.
B. The deficient enzyme’s activity was performed by maternal enzymes before birth.
C. During the fetal phase of life, the newborn was not exposed to the protein that the
enzyme is responsible for degrading.
D. Although the newborn cannot synthesize the enzyme after birth, the initially stored
enzyme performs its functions until the level is fully depleted.
____ 2. What is the expected result of a deficiency in the enzyme phenylalanine hydroxylase (PAH)?
A. High levels of phenylalanine; low levels of tyrosine
B. High levels of phenylalanine; high levels of tyrosine
C. Low levels of phenylalanine; low levels of tyrosine
D. Low levels of phenylalanine; high levels of tyrosine
____ 5. What is the expected outcome of pregnancy for women with phenylketonuria when the blood levels
of phenylalanine are high throughout the pregnancy?
A. Most births are postmature
B. High incidence of infertility
C. Infant develops phenylketonuria
D. High incidence of cardiovascular birth defects
____ 9. Which assessment finding in a 6-month-old child suggests a possible lysosomal storage disease?
A. Enlarged, palpable liver
B. Weight in the 95th percentile
C. Does not yet say “mama” or “dada”
D. Skin tone appears slightly lighter than that of either parent
____ 10. Which therapeutic option has been found beneficial for patients with type I Gaucher disease?
A. Daily ingestion of oral sapropterin dihydrochloride (Kuvan)
B. Intravenous enzyme replacement with alpha-L iduronidase
C. Weekly phlebotomy with removal of excess red blood cells
D. Intravenous enzyme replacement with imiglucerase (Cerezyme)
____ 11. How are the two mucopolysaccharide disorders Hurler Syndrome and Hunter Syndrome different?
A. Hurler syndrome is an autosomal dominant disorder, and Hunter syndrome is
autosomal recessive.
B. Hunter syndrome is an autosomal dominant disorder, and Hurler syndrome is
autosomal recessive.
C. Individuals with Hurler syndrome become cognitively impaired in early childhood,
whereas those with Hunter syndrome often retain intellectual ability until later in
life.
D. Individuals with Hunter syndrome become cognitively impaired in early
childhood, whereas those with Hurler syndrome often retain intellectual ability
until later in life.
____ 12. Which enzyme is deficient in individuals with Hurler syndrome?
A. Alpha-L iduronidase
B. Beta glucosidase
C. Iduronate sulfatase
D. Phenylalanine hydroxylase
____ 13. If a man with Fabry disease has children with a woman who is a carrier for the disorder, what is the
expected risk pattern?
A. All sons will be unaffected; all daughters will be carriers.
B. Sons have a 50% risk for being affected; all daughters will either be affected or
carriers.
C. Daughters have a 50% risk for being affected; all sons will either be affected or
carriers.
D. Each child of either gender has a 50% risk of being a carrier, a 25% risk of having
the disease, and a 25% risk of neither being a carrier nor having the disease.
____ 14. Two 4-year-olds (Charlie and Lisa) have mucopolysaccharidosis I (MPSI). Charlie has severe
dysmorphic features and many skeletal anomalies. Lisa has only mildly coarse features and slight
developmental delay. What is the best explanation for these differences?
A. Skewed X inactivation allowed more paternal X expression for Lisa and more
maternal X expression for Charlie.
B. Lisa’s mother had better prenatal care, including good diet, exercise, and vitamins
than Charlie’s mother.
C. It is likely that Lisa has been misdiagnosed and really has MPSII.
D. The disorder has wide variability in expression of severity.
____ 15. A woman who is a carrier for Fabry disease has children with a man who does not have the disorder.
Their son has the disease and their daughter also has some symptoms of Fabry disease even though
she could only have inherited one affected allele. What is the explanation for the daughter having
some symptoms of Fabry disease?
A. The girl must have a different father than her brother.
B. The daughter is seeking the same attention that is given to her brother.
C. The inactivation of one X chromosome in female cells is a totally random event.
D. In addition to inheriting one affected allele, the daughter has developed a somatic
mutation.
____ 16. What is the pathologic basis of Fabry disease?
A. Increased degradation of globotriaosylceramide
B. Increased accumulation of globotriaosylceramide
C. Deficiency in the number of liver lysosomes
D. Excessive number of liver lysosomes
____ 17. Which manifestation in a teenage boy whose mother is a carrier for Fabry disease suggests the boy
may have the disorder?
A. Hearing is hyperacute.
B. Opacity is present in both eyes.
C. Fasting blood glucose level is elevated.
D. Growth spurt results in a height 6 inches taller than his siblings.
____ 18. Couples from which ethnic group would derive the greatest benefit from genetic testing for
Tay-Sachs disease?
A. Ashkenazi Jews
B. Asian Americans
C. French Canadians from Quebec
D. Individuals of Mediterranean descent
____ 19. Which clinical manifestation in a 6-month-old infant is most diagnostic for Tay-Sachs disease?
A. Anemia and bruising
B. Enlarged liver and spleen
C. Cherry red spot on the retina
D. Progressive cognitive impairment
____ 20. Which substance fails to form normally in individuals with Marfan syndrome?
A. Elastin
B. Glycogen
C. Collagen
D. Fibrillin
____ 21. A son with osteogenesis imperfecta is born to parents with no family history of the disease. What is
the most likely explanation for the son’s disorder?
A. The son is not biologically related to the father.
B. The son is not biologically related to the mother.
C. The gamete of one parent had a spontaneous mutation.
D. The son’s DNA underwent a spontaneous mutation during the second trimester of
pregnancy.
____ 22. Which manifestation is most common among individuals with osteogenesis imperfecta type I?
A. Short stature
B. Premature birth
C. Skull deformities
D. Blue-tinged sclerae
____ 23. What is the most common cause of death among individuals with vascular Ehlers-Danlos
(Ehlers-Danlos type IV)?
A. Respiratory impairment from kyphosis
B. Skin cancer (melanoma)
C. Intestinal rupture
D. Liver failure
Chapter 8: Enzyme and Collagen Disorders
Answer Section
MULTIPLE CHOICE
1. ANS: B
The newborn with a genetic enzyme deficiency does not have symptoms of the deficiency at birth.
The reason that symptoms often are not apparent in the newborn is that the maternal enzymes cross
the placenta and perform their specific functions in the cells of the fetus. When the child is born, its
access to effective maternal enzymes stops and the enzyme deficiency begins to affect the child’s
metabolism.
PTS: 1
2. ANS: A
The phenylalanine hydroxylase (PAH) is responsible for converting the amino acid phenylalanine
into tyrosine. The result of a deficiency of PAH is an excess of phenylalanine and a deficiency of
tyrosine.
PTS: 1
3. ANS: D
When the level of phenylalanine is not managed, brain dysfunction results in severe cognitive
deficiencies and diminished motor skills. Growth retardation is present, and the skin, eyes, and hair
color are lighter than those of parents or unaffected siblings, rather than increased pigmentation. The
urine contains large amounts of phenylalanine, but urine volume is not increased above normal.
Bone density is not affected by the disorder.
PTS: 1
4. ANS: C
Executive functions are those behavioral functions associated with prefrontal lobe brain activity and
include problem-solving, impulse control, planning, and goal-directed actions. Learning names,
hopping, and counting are not related to problem-solving, impulse control, planning, or goal-directed
activities.
PTS: 1
5. ANS: D
With increasing life spans and cognition among people with PKU, a newer issue is the problem of an
increased incidence of a variety of health problems and birth defects among infants born to PKU
mothers. The infants do not have PKU; however, abnormal blood levels of amino acids, especially
during embryonic life, result in a wide variety of birth defects, most commonly of the cardiovascular
system. The best pregnancy outcomes for PKU mothers are achieved when phenylalanine levels are
well controlled before as well as during pregnancy.
PTS: 1
6. ANS: C
The pathologic problem in lysosomal storage diseases is that either an enzyme is not present in the
correct amounts (deficiency) or the enzyme is defective and cannot perform its functions. As a
result, degradation and elimination of potentially toxic substances does not occur, and these products
accumulate. Neither collagen nor iron are relevant to lysosomal storage diseases.
PTS: 1
7. ANS: A
Early diagnosis of type I Gaucher disease and treatment with enzyme replacement therapy can
reduce some of the severe complications of the disorder, especially hepatosplenomegaly. The
enzyme replacement therapy is expensive and must continue throughout life. Dietary management is
not appropriate for the disorder. Diabetes is not a common complication of the disease and neither is
pneumonia.
PTS: 1
8. ANS: A
Gaucher disease is the most common of the lysosomal storage diseases and occurs most often among
the Ashkenazi Jewish population (incidence approximately 1 in 450 births) compared with
non-Jewish populations (incidence approximately 1 in 40,000 to 1 in 100,000 births). It is also more
common among French Canadians in the Quebec area.
PTS: 1
9. ANS: A
The liver contains an enormous number of lysosomes. With lysosomal storage disorders, the
deficient enzyme causes products to accumulate in all lysosomes, especially those of the liver, which
greatly enlarge the organ. Weight in the 95th percentile is above average but is not suggestive of
lysosomal storage disease. Most infants do not say specific words by 6 months of age. Skin tone is
not affected by lysosomal storage diseases, and often, skin tone of infants is initially lighter than that
of parents until the child has more exposure to sunshine.
PTS: 1
10. ANS: D
Enzyme replacement therapy with imiglucerase (Cerezyme), which is infused intravenously every 2
weeks once a blood level has been achieved, can reduce liver size, spleen size, and bone pain within
a few weeks of beginning the therapy, although each patient’s response is variable. This therapy is
very expensive. Sapropterin dihydrochloride (Kuvan) is a synthetic form of a cofactor needed for
PAH activity and is used in the management of PKU, not Gaucher disease. People with type I
Gaucher disease have problems with anemia, not excess red blood cells. Alpha-L iduronidase is not
affected in Gaucher disease.
PTS: 1
11. ANS: C
The actual pathophysiology of Hunter syndrome with regard to poor degradation of
mucopolysaccharides is identical to that of Hurler syndrome. Major differences are that people with
Hunter syndrome have a slower onset of symptoms and the effect on intellectual ability is more
variable. In mild forms, loss of intellectual ability is minimal. In more severe forms, the loss of
intellectual ability is more severe but occurs much later than in Hurler syndrome. Hurler syndrome is
an autosomal recessive disorder resulting in deficient function of the enzyme alpha-L iduronidase,
and Hunter syndrome is an X-linked recessive disorder with deficient function of the enzyme
iduronate sulfatase.
PTS: 1
12. ANS: A
Hurler syndrome is an autosomal recessive disorder resulting in deficient function of the enzyme
alpha-L iduronidase. Hunter syndrome has a deficiency of iduronate sulfatase. Phenylketonuria
results from a deficiency of phenylalanine hydroxylase. Beta glucosidase is the enzyme that is
deficient in Gaucher disease.
PTS: 1
13. ANS: B
Fabry disease is an X-linked recessive disorder resulting in a deficiency of the enzyme
alpha-galactosidase. Boys do not inherit an X chromosome from their fathers, only from their
mothers. Therefore, an affected father cannot transmit the gene to his son. All daughters of an
affected father will inherit an affected gene from him. Thus they will all be at least carriers. If a
daughter also inherits an affect X chromosome from her carrier mother, she will actually have the
disorder.
PTS: 1
14. ANS: D
There are over 100 different mutations in the gene that can cause Hurler syndrome (MPSI). This is
responsible for the wide variations in disease severity. MPS1 is an autosomal recessive disease, not
one associated with triplet repeat expansions, and prenatal care does not appear to have an impact on
disease severity. Because the gene is not on the X chromosome, skewed X inactivation is not a
plausible explanation for the difference in severity. Clinical testing for MPSI and MPSII is accurate.
Misdiagnosis is not likely.
PTS: 1
15. ANS: C
Although the girl may be seeking attention, she can have real symptoms of Fabry disease. In order to
prevent a “double dose” of alleles on the X chromosome, one X chromosome in all somatic cells of a
female is inactivated. Although Fabry disease is much more common among males, female carriers
may have significant symptoms of the disorder as a result of skewed X chromosome inactivation in
different tissues which results in greater expression of the maternal X (with the mutated allele) than
the paternal X (with the normal allele). It is possible that the son’s father is not the daughter’s father,
but the more likely explanation is the presence of greater inactivation of the father’s X chromosome
than the mother’s X chromosome. A somatic mutation does not affect the expression of this enzyme.
PTS: 1
16. ANS: B
Fabry disease is a genetic lysosomal storage disease in which there is a deficiency of the enzyme
alpha-galactosidase A (also known as ceramide trihexosidase) that results in the accumulation of
globotriaosylceramide (GL-3) within the lysosomes of many tissues and organs. It does not change
the number of lysosomes present in the liver (just their function).
PTS: 1
17. ANS: B
The onset of signs and symptoms usually begins later in childhood. At first, symptoms are related to
poor perfusion and include cold intolerance, insufficient sweating in hot environments, and pain
episodes of unknown origin. In adolescents, the symptoms worsen with opacities developing in the
eye. Deafness often occurs, not hyperacute hearing. Height is not affected or is shorter than that of
unaffected siblings. Diabetes is not commonly associated with the disorder.
PTS: 1
18. ANS: A
The incidence of Tay-Sachs disease is highest among people of Ashkenazi Jewish ethnicity
worldwide (1 in 3900 births). The incidence among all other non-Jewish populations is much less
frequent, about 1 in 320,000 births. French Canadians from Quebec have a higher incidence of
Gaucher disease than the general population, but not of Tay-Sachs disease.
PTS: 1
19. ANS: C
During the first few months of life, the infant with Tay-Sachs disease progresses normally, learning
to control the head, recognize parental faces, socially smile, and roll over. At this point normal
development slows or stops, and physical development and cognitive development regress. The
retinal cells have filled with GM2 and become pale. This makes the fovea centralis stand out as a
cherry red spot against the pale retinal background. This is a hallmark of the disease. Although
cognitive ability regresses over time, this is not limited to Tay-Sachs disease. Anemia and
hepatosplenomegaly are not common manifestations of the disorder.
PTS: 1
20. ANS: D
Marfan syndrome (MFS) is an inherited genetic connective tissue disorder in which the gene for the
glycoprotein fibrillin is mutated. The collagen and elastin produced are normal, although the recoil
strength of tissues during and after stretching is not normal because healthy fibrillin is not present to
interact with the collagen and elastin. The structure and function of glycogen are not affected by the
gene mutation that causes Marfan syndrome.
PTS: 1
21. ANS: C
There are four major types of osteogenesis imperfecta that occur as results of mutations in a gene for
type 1 collagen. All follow an autosomal dominant transmission pattern, although spontaneous
mutations are responsible about 35% of the time.
PTS: 1
22. ANS: D
The clinical manifestations of osteogenesis imperfecta type I are relatively mild and can easily be
missed because the collagen produced is normal but the amount is reduced. Usually, the person has
no increase in fractures during infancy. Fractures of long bones do occur in response to relatively
minor trauma throughout childhood, adolescence, and adulthood, although the skull is not often
involved. In women, more fractures are seen after menopause. The most common feature is the
blue-tinged coloration of the sclerae.
PTS: 1
23. ANS: C
Vascular Ehlers-Danlos is severe and leads to premature death. The individual has very thin, fragile
skin and short stature. Problems are associated with the thin connective tissue in mid-sized and large
arteries, as well as in the intestinal tract. All of these tissues become thinner as the child grows. The
most common causes of death are hemorrhage from arterial rupture and sepsis from intestinal
rupture, often before the age of 30.
PTS: 1
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planet itself, in proportion to the quantity of matter in each; and the
planets attract one another just as much as they attract the sun,
according to the quantity of matter.
“M. Le Verrier has mentioned for the new planet the name
Neptunus; and probably, deference to his authority as its discoverer,
will obtain general currency for this name.”
In truth, at the moment when this was uttered, the new Planet had
already been seen by Professor Challis; for, as we have said, he had
seen it in the early part of August. He had included it in the net which
he had cast among the stars for this very purpose; but employing a
slow and cautious process, he had deferred for a time that
examination of his capture which would have enabled him to detect
the object sought. As soon as he received M. Le Verrier’s paper of
August 31 on September 29, he was so much impressed with the
sagacity and clearness of the limitations of the field of observation
there laid down, that he instantly changed his plan of observation,
and noted the planet, as an object having a visible disk, on the
evening of the same day.
Not only did this law stimulate the inquiries for the Missing Planet,
and thus lead to the discovery of the Minor Planets, but it had also a
share in the discovery of Neptune. According to the law, a planet
beyond Uranus may be expected to be at the distance represented
by 388. Mr. Adams and M. Le Verrier both of them began by
assuming a distance of nearly this magnitude for the Planet which
they sought; that is, a distance more than 38 times the earth’s
distance. It was found afterwards that the distance of Neptune is only
30 times that of the earth; yet the assumption was of essential use in
obtaining the result and Mr. Airy remarks that the history of the
discovery shows the importance of using any received theory as far
as it will go, even if the theory can claim no higher merit than that of
being plausible. 51
51 Account of the Discovery of Neptune, &c., Mem. Ast. Soc., vol.
xvi. p. 414.
The rapidity with which these discoveries were made was owing in
part to the formation of star-maps, in which all known fixed stars
being represented, the existence of a new and movable star might
be recognized by comparison of the sky with the map. These maps
were first constructed by astronomers of different countries at the
suggestion of the Academy of Berlin; but they have since been
greatly extended, and now include much smaller stars than were
originally laid down.
I will mention the number of planets discovered in each year. After
the start was once made, by Hencke’s discovery of Astræa in 1845,
the same astronomer discovered Hebe in 1847; and in the same
year Mr. Hind, of London, discovered two others, Iris and Flora. The
years 1848 and 1849 each supplied one; the year 1850, three; 1851,
two; 1852 was marked by the extraordinary discovery of eight new
members of the planetary system. The year 1853 supplied four;
1854, six; 1855, four; and 1856 has already given us five. 560
I may add that it appears to follow from the best calculations that
the total mass of all these bodies is very small. Herschel reckoned
the diameters of Ceres at 35, and of Pallas at 26 miles. It has since
been calculated 53 that some of them are smaller still; Victoria having
a diameter of 9 miles, Lutetia of 8, and Atalanta of little more than 4.
It follows from this that the whole mass would probably be less than
the sixth part of our moon. Hence their perturbing effects on each
other or on other planets are null; but they are not the less disturbed
by the action of the other planets, and especially of Jupiter.
53 Bruhns, as above.
Tides.
The Tides of the Coast of Ireland have been examined with great
care by Mr. Airy. Numerous and careful observations were made with
a view, in the first instance, of determining what was to be regarded
as “the Level of the Sea;” but the results were discussed so as to
bring into view the laws and progress, on the Irish coast, of the
various inequalities of the Tides mentioned in Chap. iv. Sect. 9 of this
Book.