Severe Phenotype of Phosphorylase Kinase-Deficient Liver
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0031-3998/03/5406-0834 PEDIATRIC RESEARCH Vol. 54, No. 6, 2003 Copyright © 2003 International Pediatric Research Foundation, Inc. Printed in U.S.A. Severe Phenotype of Phosphorylase Kinase-Deficient Liver Glycogenosis with Mutations in the PHKG2 Gene BARBARA BURWINKEL, TERJE ROOTWELT, ELI ANNE KVITTINGEN, PRANESH K. CHAKRABORTY, AND MANFRED W. KILIMANN Institut für Physiologische Chemie, Medizinische Fakultät, Ruhr-Universität Bochum, D-44780 Bochum, Germany [B.B., M.W.K.]; Departments of Pediatrics [T.R.] and Clinical Chemistry [E.A.K.], Rikshospitalet, N-0027 Oslo, Norway; and Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada [P.K.C.] ABSTRACT Phosphorylase kinase-deficient liver glycogenosis manifests PHKG2 mutations were found (H89fs[insC], E157K, D215N, in infancy with hepatomegaly, growth retardation, and elevated W300X). Three of these mutations are novel, bringing the total plasma aminotransferases and lipids. It can be caused by muta- number of distinct human PHKG2 mutations to 11, found in 10 tions in three different genes of phosphorylase kinase subunits: patients. We conclude that liver phosphorylase kinase deficiency PHKA2, PHKB, and PHKG2. It is usually a benign condition, with a severe phenotype, with or without cirrhosis, is indeed often with complete resolution of symptoms during puberty. A often caused by PHKG2 mutations. These patients require active minority of patients displays a more severe phenotype with measures to maintain normoglycemia (raw cornstarch, nocturnal symptomatic fasting hypoglycemia and abnormal liver histology tube feeding), which may also alleviate growth retardation and that may progress to cirrhosis. Three patients with liver cirrhosis the development of abnormal liver histology. (Pediatr Res 54: in childhood analyzed previously all had PHKG2 mutations. This 834–839, 2003) suggested that this genotype may generally cause a more severe clinical manifestation, but to date PHKG2 mutations have been Abbreviations identified in only seven patients. Here, we report mutation anal- ALT, alanine transaminase ysis in three new patients with liver phosphorylase kinase defi- GSD, glycogen storage disease ciency and recurrent hypoglycemia, liver fibrosis, and lack of Phk, phosphorylase kinase (E.C. 2.7.1.38) glucagon response but no overt cirrhosis. In all three patients, XLG, X-linked liver glycogenosis GSDs (glycogenoses) are caused by genetic deficiencies of hormonal regulation of glycogen breakdown by glycogen various enzymes or transporters involved in the metabolism of phosphorylase. Phk is a heterotetrameric protein [subunit struc- ␣␥␦ glycogen or glucose. Depending on the mutant protein and its ture, ( )4]. Moreover, each subunit has tissue-specific tissue distribution, most glycogenoses manifest primarily in isoforms or splice variants. Phk deficiency is therefore genet- liver, in muscle, or in both. GSDs of the liver occur with a ically and clinically heterogeneous, occurring in several vari- collective frequency of approximately 1 in 25,000 births in ants that differ in tissue involvement and mode of inheritance Europe (1). [Table 1; reviewed by Kilimann (2)]. A glycogenosis of the Deficiency of Phk probably constitutes the largest subgroup liver can be caused by mutations in any one of three Phk genes. of liver glycogenoses (frequency, approximately 1 in 100,000 The most common are mutations of the ␣ subunit liver isoform births). Phk is a protein kinase that mediates the neural and gene, PHKA2, causing an X-linked liver-specific variant (3–6). Mutations in the gene of the ubiquitously expressed  subunit, PHKB, give rise to an autosomal-recessive glycogenosis of Received October 22, 2002; accepted May 7, 2003. Correspondence: Manfred W. Kilimann, M.D., Institut für Physiologische Chemie, Ruhr- liver and muscle (7–9), whereas mutations in the gene of the Universität Bochum, D-44780 Bochum, Germany; e-mail: manfred.kilimann@ testis/liver isoform of the ␥ subunit, PHKG2, are responsible ruhr-uni-bochum.de Present address (MWK): Department of Cell and Molecular Biology, Uppsala Univer- for an autosomal-recessive glycogenosis of liver alone (10– sity, BMC Box 596, SE-75124 Uppsala, Sweden; e-mail: [email protected] 13). Phk deficiency in these disorders can also be detected in Supported by the Deutsche Forschungsgemeinschaft and the Fonds der Chemischen erythrocytes, leukocytes, and fibroblasts, except in patients Industrie. with certain PHKA2 missense mutations (XLG subtype 2, DOI: 10.1203/01.PDR.0000088069.09275.10 834 PHOSPHORYLASE KINASE PHKG2 MUTATIONS 835 Table 1. Subtypes of Phk-deficient GSDs METHODS Mutant Inheritance Tissues affected gene Case descriptions. Patient 1, female, is the first child of X-linked recessive muscle PHKA1 healthy, distantly related Norwegian parents. A large, firm liver* (XLG1) PHKA2 abdomen was noted since birth, and hepatomegaly was ob- liver (blood cells normal; XLG2) PHKA2 served at 9 mo. Signs of hypoglycemia (somnolence, eye Autosomal recessive liver* and muscle PHKB deviation, and lack of contact) were noted repeatedly, and liver* PHKG2 muscle unidentified plasma glucose values of 1.6–2.3 mM and ketosis were deter- heart unidentified mined on fasting. Plasma triglycerides and cholesterol were * Phk deficiencies affecting the liver are also detectable in blood cells, with slightly increased (1.3–2.2 and 3.5–4.0 mM, respectively), the exception of the XLG2 group. whereas liver enzymes were markedly elevated (aspartate transaminase and ALT, 250–2000 U/L). Uric acid was repeat- edly normal. Resting lactate was normal (0.7–1.7 mM) but rose to 3.2 mM after glucose load and to 7.7 mM after galactose [glucose and galactose given orally at 2 g/kg (18)]. Liver XLG2) (3, 5). In addition, muscle-specific and heart-specific histology at 10 mo of age showed massive cytoplasmic glyco- forms of Phk deficiency are known (Table 1) (1, 2). gen storage and moderate fibrosis. In erythrocytes, Phk activity Compared with other types of liver glycogenosis, Phk defi- was low (4.8 mol P ·gHbϪ1·minϪ1; normal, 10–90) and ciency is usually a mild condition. Most patients present as i glycogen very high (449 g/g Hb; normal, 10–120). Total infants with hepatomegaly, growth retardation, and moderately phosphorylase, ␣-glucosidase, and debranching enzyme in leu- raised plasma lipids and aminotransferases. In contrast to GSD kocytes were normal, whereas the phosphorylase Ϯ AMP type I, lactic acidosis and clinically apparent hypoglycemia are activity ratio was decreased (0.15; normal ratio, 0.42–0.78). observed only in a minority. Hepatic architecture typically Two glucagon tests (0.03 mg/kg i.v.) produced no rise in remains normal, unlike GSD type III, in which fibrosis is glucose. Muscle histology, glycogen content, and Phk activity common, and unlike GSD type IV, which usually progresses to were normal. Growth has been slow, with length 3 cm below cirrhosis in childhood. The course of Phk deficiency is also the 2.5th percentile until 4 y, and length at the 10th percentile usually benign, such that hepatomegaly often recedes and and weight at the 50th percentile at8yofage. She is an active patients catch up to normal height after puberty (1, 14). Muscle girl with no signs of muscle weakness. Nocturnal gastric tube weakness may or may not be observed with any genotype. feeding (2–3mg·kgϪ1·minϪ1 of glucose polymer) was started PHKB-mutant patients can be without muscle symptoms al- at1y3moandiscontinued to date (8 y) in combination with though Phk is deficient in this tissue, whereas PHKA2-or daytime feeding of uncooked cornstarch (2 g/kg per day). The PHKG2-mutant patients may display muscle weakness in spite hypoglycemic tendency persists: at the age of 6 years a 4-h fast of normal muscle Phk activity. Growth retardation and weak- resulted in a plasma glucose of 2.3 mM. Aminotransferases ness could be the result of chronically low systemic glucose continue to be markedly elevated whereas clotting and biliru- and consequent hypoinsulinism, as in GSD I (1, 15, 16). bin are normal. The patient needs supplementation of fat- However, some patients with Phk deficiency have more soluble vitamins; without this her vitamin D levels were re- severe symptoms, and emerging data suggest a genotype- peatedly subnormal. Ultrasound at8yofageshowed marked phenotype correlation. The functional impact of PHKB muta- hepatomegaly (10 cm below costal margin) with a coarse tions, both on residual enzyme activity and clinical condition, nodular echo and a slightly enlarged spleen. Both kidneys were appears to be the mildest (7–9). PHKA2 mutations, which are of normal size (8 cm; normal range, 7–10 cm). Doppler flows most common, are usually associated with a benign disease were normal and there were no other signs of portal although more severe manifestations are also observed (3–6, hypertension. 14). PHKG2 mutations have so far been identified in only Patient 2, female, is the second child of unrelated Norwegian seven patients. These cases seem to concentrate at the other parents. The parents and brother are unaffected. She came to end of the spectrum of severity, with very low residual Phk our attention with repeated seizures from 4 mo of age. Marked activities, particularly high plasma lipids and aminotrans- hepatomegaly was noted, and hypoglycemia around 2 mM was ferases, and other abnormalities that are uncommon in Phk repeatedly determined. Plasma cholesterol and uric acid were deficiency such as frequent fasting hypoglycemia, an impaired normal, and