Sphingomyelin of Red Blood Cells in Lipidosis and in Dementia of Unknown Origin in Children
Arch Dis Child: first published as 10.1136/adc.44.234.197 on 1 April 1969. Downloaded from Arch. Dis. Childh., 1969, 44, 197.
Sphingomyelin of Red Blood Cells in Lipidosis and in Dementia of Unknown Origin in Children
G. J. M. HOOGHWINKEL, H. H. VAN GELDEREN, and A. STAAL From the Laboratory of Medical Chemistry and the Departments of Paediatrics and Neurology, University of Leiden, The Netherlands
Histological and chemical examinations of biopsy no diagnosis could be made, are briefly described in specimens from cerebral tissue of children suffering Table I. Incomplete investigation made it impossible to from undiagnosed progressive brain disease are reach a diagnosis in Cases 7 and 8. The molar con- performed increasingly. Important information centrations of phospholipids in the red blood cells therapeutic have been determined as described by Hooghwinkel is provided, which, though rarely of and Niekerk (1960), Hooghwinkel and Borri (1964), value, does increase precision of diagnosis, and Hooghwinkel, Borri, and Bruyn (1966). The prognosis, and genetic advice (Cumings, 1965a, amounts of the various phospholipids of red blood b, c; Poser, 1962; Adams, 1965). This is especially cells have been expressed as molar percentages of true of the chemical investigations, and it is likely total phospholipids. Absolute values of phospho- that chernical analyses will challenge the current lipids depend a good deal on size and shape of the classifications of progressive brain disease. Amaur- otic idiocy has already proved to be more hetero- 36 copyright. 0 geneous than was thought hitherto, while supposedly -a .A a different diseases, such as Niemann-Pick's and 0 34 . -0 - - - - - +- gargoylism, have more in common than earlier ..10- classifications suggested. 0- 5 ~~~~~~~~~0 However, brain biopsy is still a procedure not q~ - to be undertaken lightly, and it would be an advan- 32 tage if comparable information could be gained by 0 .0 a less drastic method. We have been interested -C 30- --§------I------.--- http://adc.bmj.com/ in the possibility of finding abnormalities in easily °°O + 'accessible tissue, such as red blood cells, which 0~ I might correlate with abnormalities in the constitu- 28 . tion of the brain. In this paper we give the results 0 of a study of the sphingomyelin content of ery- x E throcytes in children with various types of pro- 0 26- gressive brain disease. cr
Age at Time of Physical and Case Sex Development and Investi- Family History Neurological Symptoms Ocular Symptoms No. ProgressionParny of Disease gation and Signs* (yr.) ,. ,~- 1 I F Normal till 11 yr.; then 3 Negative No recognition; severely Vision uncertain; otherwise gradual dementia mentally retarded, normal spastic tetraplegia, irregular myoclonic jerks, fine head tremor
2 M Slow till 5 yr.; then gradual 10 Negative Functioning at IQ 30 Bilateral cataract; fundus but progressive dementia (2 yr. later completely probably normal IM demented); coarse features but neither hepatomegaly nor bone abnormalities; myoclonic jerks; spastic tetraplegia; PEG, diffusely enlarged ventricles 3 F Normal till 4 mth.; then 6 Brother died from similar Completely demented; Bilateral cataract, probably rapid dementia illness, no diagnosis spastic legs; PEG, blind made synmmetrically enlarged ventricles 4 F Normal till 6 mth.; then 21 Negative Severely demented, None severe regression hyperkinesis,
convulsions, abnormal copyright. postures; PEG, cortical atrophy rt. frontal area 5 F Normal till 9 mth.; then Nearly Negative Severely demented, None rapid regression 2 primitive reflexes, spastic tetraplegia; fever of unknown cause 6 M Normal in first few mth.; 4 3 of 5 sibs mentally Severely retarded but Pigment increase then slow development retarded, with retinal motor development abnormalities and reasonable; nystagmus,
liver enlargement liver much enlarged; http://adc.bmj.com/ PEG, slight increase of ventricle size 7 F Normal till 3 mth.; then 1 .1 Negative Completely demented, None rapid dementia with spastic tetraplegia, epilepsy probably blind, frequent convulsions 8 M Normal till 6 mth.; then 1 Consanguineous parents; Retarded, loss ofcontact; Tapetoretinal rapid regression maternal brother died vision reduced, degeneration in infancy from stereotypic aimless convulsions and head movements; PEG, on October 2, 2021 by guest. Protected enlargement cerebral atrophy
9 M Normal till 7 yr.; failing 14 Insufficient data; ataxiain Ataxy, loss of co-ordina- None at school; from 9 yr. paternal family ? tion; enlargedliver increasingly atactic with and spleen; normal acid petit-mal epilepsy; phosphatase intellectual functions declined; IQ 100 at 7yr.;49at 14yr.
M Normal till 5 yr.; then 8 Negative Physical and neurological Except for myopia no decline ofmental examination normal; abnormalities functions without other PEG, slightly enlarged serious signs ventricles; psychologist, dementing, organic l- picture, IQ 55 (88 2 yr. before)
t TLC = thin-layer * * PEG-pneumoencephalogram. PEG = pneumoencephalogram. t TLC = thin-layer chromatography.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~chromatography. Arch Dis Child: first published as 10.1136/adc.44.234.197 on 1 April 1969. Downloaded from
Sphingomyelin of Red Blood Cells in Lipidosis and in Dementia of Unknown Origin 199 I 'Dementia of Unknown Origin
I Biopsy Sphingomyelin EEG (i% of P-lipids Diagnosis in erythrocyte) Tissue Histology Chemistry
No normal background 29-4 Brain No abnormalities Moderate decrease of Dementia ofunknown activity, periodic bursts myelinlipids in origin, with spastic ofhigh-voltage delta white matter, paraplegia and waves sphingomyelin myoclonic jerks moderately decreased in white matter, strongly decreased in grey matter Almost continuously 28 0 Brain Typical picture of Decrease ofmyelin Dementia ofunknown spike-and-wave activity amauroticidiocy; lipids; decrease of cause; probably many neuronal cells sphingomyelin agangliosidosis; and a number of content ofwhite much increased glia cells swollen matter; marked urinary excretion withPAS +ve increase of ofacid mucopoly- material gangliosides (G5 saccharides and G6) on chromatography Severe diffuse abnormalities 29-7 Brain Focal perivascular Slight decrease of Familial dementia of most prominent in rt. necrosis with myelinlipids and unknown origin hemisphere gliosis around moderate decrease these areas ofsphingomyclin Bilateral spikes and 30-1 Brain No abnormalities Decrease of Dementia ofunknown waves, sometimes sphinogomyelinin origin synchronous grey and white copyright. matter; generalized decrease ofmyelin lipids No abnormalities, but at 31-4 Rectal mucosa; No abnormalities Not done Dementia of unknown age 4 yr. cerebral activity suralis nerve origin; normal much diminished brain one Hortega glia sphingomyelin in cellinfiltration red cells Isolated theta and delta 26-3 Liver Specimen lost Almost complete Familial oculo- waves ofspikey character absence of cerebral syndrome, in rt. temporal area sphingomyelin with with visceral long fatty acid involvement; chains investigations of http://adc.bmj.com/ patient and sibs incomplete Severe generalized 29 9 Dementia ofunknown epileptic activity origin; cerebral biopsy planned Normal 26-8 Oculo-cerebral syndrome of unknown origin, low sphingomyelin in RBC, hence on October 2, 2021 by guest. Protected amauroticidiocy unlikely Slow background activity; 29-1 Lymph-node; Foam cells Cholesterol much Clinically no specific abnormalities bone-marrow; Foam cells increased; suggestive of liver Foam cells sphingomyelin only Niemann-Pick's slightly increased; disease, but normallipid chemical analysis hexose content; ofliver specimen TLCt did not against this show increase of glycolipid Diffusely abnormal; 29-7 Sural nerve Normal Dementia of unknown paroxysmal activity origin, too well to on photo-stimulation justify brain biopsy Arch Dis Child: first published as 10.1136/adc.44.234.197 on 1 April 1969. Downloaded from
200 Hooghwinkel, van Gelderen, and Staal TABLE II Molar Distribution of Phospholipids, Expressed as Percentage of Total Phospholipid, in Red Blood Cells (mean and range)
Lysophosphatidylcholine Sphingomyelin plus Phosphatidylethanolamine Phosphatidylcholine Normals.. 32 2 (30*0 - 34*0) 40 6 (37-4 - 41 7) 27-2 (24 5 - 29 5) Juvenile amaurotic idiocy .325 (30-2 - 35 5) 396 (362 - 43 1) 279 (26-0 - 29 7) Mucopolysaccharidosis 27 8 (24 6 - 29.8)* 40 6 (38s6 - 43*7) 31 5 (29*3 - 34*4) Niemann-Pick's disease 26*7 (26*6 - 26 8)l * 46*5 (44*6 -48 4) 26 3 (24 8 -27*9) Gaucher's disease. 29-1 (27 6 - 30 4)f 42 8 (41 6 - 43 3) 28*1 (28 0 - 291) Metachromatic leucodystrophy 31 8 40 1 28-0 Sudanophilic leucodystrophy .296 39 0 31-4 Controls (see text) .31 9 (27 3 - 34-6) 39 2 (37*5 - 40 8) 28-9 (26-1 - 32 3) Dementia of unknown cause .28 8 (26*3 - 31.4)* 43-0 (39 1 - 44 8) 28 1 (24 2 - 31 3)
* Significantly lower than normal, p <0 * 01 (Wilcoxon). red blood cells, and they vary with changes in the Results ratio of total cell surface to the total cell volume; this ratio itself may be influenced by the lipid composition Table II summarizes the results of the phos- of the membrane. Thus, it is more likely that a meta- pholipid determinations, and the Figure shows bolic disturbance will manifest itself in a change in the the distribution ofthe molar percentages of sphingo- percentage distribution of the various phospholipids. myelin in the red blood cells. In general the sphingomyelin content of plasma showed the Patients with dementia of unknown origin. same trend as that of red blood cells, but less
The patients in this group either showed normal consistently. Sphingomyelin percentages were copyright. development before the illness or had shown slow abnormally low in many cases. The patients development from birth. In all, however, there was a suffering from amaurotic idiocy were exceptional, clear-cut intellectual deterioration, together usually in that in all these cases sphingomyelin values were with epileptic symptoms and other neurological symp- within normal limits. The control group, con- toms. Before a biopsy was done, extensive investiga- of with severe cerebral tions were undertaken, of blood, urine, and CSF sisting patients atrophy (including electrophoresis and cytology). Urinary ex- after brain damage, usually due to a purulent cretion of amino acids and mucopolysaccharides was meningitis many years earlier, also showed normal values. The one case of metachromatic leuco- always checked. In most cases the urine was investigated http://adc.bmj.com/ for metachromatic material and/or arylsulphatase-A. dystrophy also had normal sphingomyelin in red Pyridoxine deficiency and dependency were excluded. cells; we do not know yet if this is typical for this White blood cells and cells in CSF were examined for disease. The group of dementias of unknown abnormal granules and vacuoles. EEG's were made origin showed low sphingomyelin values in all repeatedly (Dr. K. Mechelse). Biopsy of rectal cases but one. mucosa or sural nerve was made in a few cases. It was Discussion often difficult to make a histological diagnosis from these specimens, and, at least in our laboratories, A low sphingomyelin content of red blood cells impossible to analyse biochemically such small amounts is perhaps explicable in those patients whose on October 2, 2021 by guest. Protected of tissue. disease is associated with accumulation of sphingo- If a progressive cerebral disease were present, and lipids in the central nervous system and/or other no diagnosis could be arrived at using the above- tissues. This is the case both in Hurler's disease mentioned methods, brain biopsy was planned. With (Ledeen et al., 1965; Borri, Hooghwinkel, and permission from the parents, a biopsy was taken from Edgar, 1966) and in Tay-Sachs's disease (Svenner- the prefrontal lobe by means of a small craniotomy. holm, 1962) where gangliosides are stored in the The specimens were investigated both histologically in Gaucher's disease and and biochemically. In two cases biopsy was refused brain; (Rosenberg by the parents. In one case the biopsy was postponed, Chargaff, 1958; Janse and Hooghwinkel, 1967) because of intercurrent illness. If visceral involvement where cerebrosides are accumulating in liver and was suspected we preferred to take a biopsy from the spleen; and in Niemann-Pick's disease where there liver. In Table I we summarize the relevant data of is accumulation of sphingomyelin (Hooghwinkel the 10 patients in this group of dementia of unknown and Borri, 1964). Lowered sphingomyelin con- origin. centration of red blood cells might also have been Arch Dis Child: first published as 10.1136/adc.44.234.197 on 1 April 1969. Downloaded from
Sphingomyelin of Red Blood Cells in Lipidosis and in Dementia of Unknown Origin 201 expected in metachromatic leucodystrophy, where (2) Juvenile amaurotic idiocy is most probably sulphatides are accumulating in the brain (Austin, not caused by an accumulation of sphingolipids in 1965). the brain. The only phospholipid based on sphingosine (3) Examination of red blood cell phospholipids and not glycerol, and which is therefore to be should precede more drastic diagnostic investiga- regarded as a sphingolipid, is sphingomyelin tions in childhood dementia. which normally constitutes 32% of all phospho- (4) Cerebral symptoms together with a decreased lipids in the red blood cells. The normal values relative concentration of sphingomyelin in red found in the control group were as expected: no blood cells indicate a progressive brain disease metabolic disorder was present and therefore the associated with derangement of sphingolipid large loss of cerebral tissue is not reflected in any metabolism. change of lipid content of red blood cells. The Summary normal values in juvenile amaurotic idiocy also Sphingomyelin concentration of red blood cells, accord with the fact that in this illness no disorder measured as a percentage of phospholipid, was of sphingolipid metabolism has been demon- studied in children suffering from progressive strated. Though histological studies have brain disease of different types. Normal values suggested a storage disorder, amaurotic idiocy has were found in 12 cases of juvenile amaurotic not been thought to be a typical lipidosis. idiocy, and also in a control group of children with The other diseases listed in Table II and in the severe atrophy of the brain consequent on infection Figure are all examples of disorders of lipid storage, of CNS many years earlier. Low values were the sphingolipids accumulating in the central nervous found almost uniformly in children with muco- system and/or the visceral organs. The red polysaccharidosis (Hurler's disease), in Niemann- cells of these patients showed a decrease in sphingo- Pick's disease, and in Gaucher's disease. One myelin in nearly every case. The fact that the patient with sudanophilic leucodystrophy also group of 10 patients in whom no diagnosis could showed a slightly low value, and a normal value be made showed a similar decrease of sphingo- was obtained in one child with metachromatic copyright. myelin content of red blood cells suggests that in leucodystrophy. these patients also there was some abnormality A further group of 10 children with progressive of lipid metabolism. brain disease was studied, in whom no exact The change in sphingomyelin content of red diagnosis could be made, despite extensive investi- blood cells may be indicative of a more generalized gation which often included brain or liver biopsy. disturbance of sphingolipid metabolism. It is In 9 of these 10 patients, red blood cell sphingo- known that accumulation of various sphingolipids myelin content was decreased, suggesting an is caused by absence or deficiency of katabolic abnormality of sphingolipid metabolism. http://adc.bmj.com/ enzymes. In Gaucher's disease there is a Estimation of red blood cell sphingomyelin. deficiency of cerebrosidase (Brady, Kanfer, and content should precede more drastic investigations Shapiro, 1965); in Niemann-Pick's disease a such as brain biopsy, as it may provide an important deficiency of sphingomyelinase (Brady et al., approach to the diagnosis ofbrain disease in children. 1966), and in metachromatic leucodystrophy a We are grateful to Professor W. Luyendijk and Dr. G. deficiency of arylsulphatase (Mehl and Jatzkewitz, Th. van Beusekom, for performing the cerebral biopsies; 1965). It is suggested that in the metabolic pool to Dr. G. Th. A. M. Bots, Department of Pathology, a shortage develops of sphingosine which is the Leiden, for examining the cerebral biopsy specimens; on October 2, 2021 by guest. Protected precursor both of cerebral sphingolipids and of and to Dr. Steketee, director of the Dr. Willem v.d. Berghstichting at Noordwijk, for permission to the sphingomyelin in red blood cells. The study patients in his institution. relative deficiency of sphingomyelin may be compensated for by an increase in lecithin and REFERENCES Evidently neither demylinization nor Adams, C. W. M. (1965). Cerebral storage diseases. In Neuro- cephalin. histochemistry, p. 488. Ed. by C. W. M. Adams. Elsevier, loss of cerebral tissue by themselves result in low Amsterdam. sphingomyelin content of red blood cell mem- Austin, J. H. (1965). Mental retardation: metachromatic leuco- dystrophy. In Medical Aspects of Mental Retardation, p. 768. branes, judging by the normal values usually Ed. by C. H. Carter. C. Thomas, Springfield, Illinois. recorded in the control group. Borri, P. F., Hooghwinkel, G. J. M., and Edgar, G. W. F. (1966). Brain ganglioside pattern in three forms of amaurotic idiocy We think from the investigation described above and in gargoylism. J. 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