Journal of Perinatology (2012) 32, 810–813 r 2012 Nature America, Inc. All rights reserved. 0743-8346/12 www.nature.com/jp PERINATAL/NEONATAL CASE PRESENTATION Neonatal presentation of lethal neuromuscular glycogen storage type IV

LF Escobar1,2, S Wagner1, M Tucker1,3 and J Wareham2 1Medical Genetics and Neurodevelopmental Pediatric Center-Peyton Manning Children Hospital, Indianapolis, IN, USA; 2Section of Neonatology-St Vincent Women’s Hospital, Indianapolis, IN, USA and 3Center for Prenatal Diagnosis-St Vincent Women’s Hospital, Indianapolis, IN, USA

presentation of GSD IV, which resembles spinal muscular atrophy A total of 11 types of glycogen storage disorders have been recognized with type 1 (SMA1) in the newborn.6 The presentation of GSD IV variable clinical presentations. Type IV, also known as Andersen disease, resembling SMA1 is considered a severe neuromuscular subtype represents a rare subtype that can induce severe clinical findings early in of GSD IV. life. We report on a patient with early fetal onset of symptoms with severe We report on case of an unusual presentation of GSD IV neuromuscular findings at birth. The was further complicated by neuromuscular type with a severe lethal phenotype in the neonatal polyhydramnios and depressed fetal movement. At birth severe period. The condition appears to be caused by a previously was noticed requiring active resuscitation and then mechanical ventilation. unrecognized mutation in the GBE1 gene. We did not recognize a His lack of expected course for hypoxic ischemic encephalopathy prompted second mutation, suggesting the possibility of homozygosity for the genetic testing, including a muscle biopsy, which confirmed the diagnosis new mutation, consanguinity or uniparental disomy. We review of glycogen storage disease IV (GSD IV). Mutation analysis of the glycogen additional published cases, and discuss the need for awareness branching enzyme 1 gene demonstrated a previously unrecognized that severe neonatal hypotonia with a lack of spontaneous mutation. We review recent information on early presentation of GSD IV movement may represent GSD IV, neuromuscular type.7 with particular interest in the presentation of the neonatal lethal neuromuscular form of this rare disorder. Journal of Perinatology (2012) 32, 810–813; doi:10.1038/jp.2011.178 Patient summary Keywords: glycogen storage disease; hypotonia; fetal akinesia; Andersen syndrome We report on male patient born at 35 weeks gestation to a 30-year-old primigravida mother after a pregnancy complicated by polyhydramnios, perinatal depression and a vague history of recent decrease fetal movement. The birth weight was 2.300 kg Introduction (28 percentile), the length was 46 cm (47.2 percentile) and the Glycogen storage disease IV (GSD IV or Andersen disease) accounts head circumference was 31 cm (36 percentile). Upon delivery, the for only 3/1000 of all GSD’s and 1 in 7 60 000 to 9 60 000 live child exhibited severe hypotonia with no spontaneous movement, births.1 It is an autosomal recessive metabolic disorder caused by bradycardia and apnea. Apgar scores were 0, 1 and 1 at 1, 5 mutations in the glycogen branching enzyme gene (GBE1). The and 10 min, respectively. Resucitation including CPR, intubation, glycogen branching enzyme is vital for glycogen synthesis, and multiple doses of epinephrine and volume expansion lasted when deficient results in the accumulation of amylopectin-like 18 min. Once heart rate stabilized the infant was transferred to configurations of glycogen in the liver, heart, muscle, nervous the NICU and was placed on mechanical ventilation. system and skin.2 GBE1 is located at chromosome 3p14 and Upon clinical examination, the patient showed marked encodes for a 702 amino-acid protein.1,3–5 GSD IV usually presents hypotonia and poor response to stimuli. There was decreased in the first year of life with features of hepatic failure and muscle mass with no peripheral reflexes, normocephaly with a soft portal hypertension, normally causing death by the age of 2 to 4.3 open anterior fontanel, normal fundoscopy, patent nares, a normal Few cases have been reported in the literature of the early severe oral cavity, clear breath sounds, a regular heart rate and good pulses. The abdomen was soft and symmetric, displaying no Correspondence: Dr LF Escobar, Medical Genetics/Neonatology, Peyton Manning Children’s organomegaly. However, there was anterior displacement of the Hospital, 8402 Harcourt Road, #300, Indianapolis, IN 46260, USA. E-mail: [email protected] anal ampulla, which was also hypotrophic with decreased anal Received 27 September 2011; revised 1 November 2011; accepted 2 November 2011 folds, suggestive of decreased muscle mass. Neonatal presentation of lethal neuromuscular GSD IV LF Escobar et al 811

After 2 weeks without spontaneous movement even while indicated normal ranges for the glycogen content (patient: weaning sedation, rare causes of severe neuromuscular dysfunction 0.2%, control: 0.94±0.55%) and alpha glucosidase activity other than hypoxic ischemic encephalopathy were considered. A (patient: 0.59 mmol minÀ1 per gram tissue, control: chest X-ray showed mild atelectasis in the right upper lobe and left 0.42± mmol minÀ1 per gram tissue) in the muscle sample posteromedial lung base. A head MRI demonstrated a prominent possibly due to the early stages of disease, whereas the branching fluid collection posterior to the cerebellar hemisphere, indicating enzyme activity was measured in the very low deficiency the presence of a mega cisternal magna. A complete spinal MRI range (patient: 0.3 mmol minÀ1 per gram tissue, control: noted an unremarkable spinal cord. Testing for both SMA1 and 32±10 mmol minÀ1 per gram tissue). A deficiency in the congenital muscular dystrophy (DM1) was negative. A comparative glycogen-branching enzyme suggested GSD IV. genomic hybridization was normal with no copy number variants Following the above studies, we obtained a skin biopsy to of clinical significance. A urine amino-acid screening showed sequence the GBE1 gene known to cause glycogen storage disorder non-specific elevations of cystine, ornithine, lysine and arginine. type IV. Sequencing found a previously unreported mutation A second amino-acid screening and a urine screening found 18 consisting of a single amino-acid substitution (c.1236 þ 1 G>A). amino acids with elevated levels and 29 organic acids with higher Following two sudden cardiac crises, the patient died at age 117 than normal levels. Neither of these analyses indicated a clear days (3.8 months) of age. Maternal testing showed mother to be pathologic pattern. positive for the same mutation, and paternal testing was not Due to the unclear etiology of the severe muscle symptoms we possible. did a muscle biopsy. The biopsy showed significantly atrophic muscle fibers and an increased density of the nuclei. Central nuclei were observed in scattered fibers, and basophilic, pale and even Discussion degenerating fibers were also observed. Additionally, the muscle GSD IV is a rare metabolic disorder, where there is a deficiency in biopsy showed numerous inclusions staining positively for periodic the glycogen branching storage enzyme. The normal form of the acid schiff (PAS). The PAS-positive inclusions were also observed to glycogen branching enzyme catalyzes the movement of glucose be resistant to diastase digestions (Figure 1). These findings were molecules from the end of a glycogen chain to an alpha-1,6 indicative of a glycogen storage disorder. position on the chain, forming an alpha-1,6 glycosidic bond Subsequently, we undertook enzymatic studies testing for between two glucose molecules. A deficiency in this enzyme GSD type II and GSD type IV. The glycogen storage investigation results in a glycogen chain with fewer branching points and

Figure 1 Periodic acid schiff (PAS) staining of quadriceps muscle biopsies from a control patient (a) and patient affected by glycogen storage disorder type IV (b). Diastase treated, PAS stained section of quadriceps muscle biopsies from control tissue (c), and tissue of a patient diagnosed with glycogen storage disorder type IV (d).

Journal of Perinatology Neonatal presentation of lethal neuromuscular GSD IV LF Escobar et al 812

Table 1 Features of patients with the lethal GSD IV reported in the literature IV (Table 1). Maruyama et al.10 report a case of GSD IV with hydrops fetalis, which was postnatally attributed to chylothorax. Number of patients Percentage Our (N ¼ 29) (%) patient Hydrops fetalis may be the result of decreased movement resulting from hypotonia that hinders lymphatic drainage.9 Prenatal symptoms At birth, our patient presented with severe hypotonia, poor Polyhydramnios 18/29 62 + response to stimuli and very little spontaneous movement. Hydrops fetalis 11/29 41 Eighty-five percent of live born infants diagnosed with the lethal Decreased fetal movement 15/29 52 + neonatal neuromuscular form of GSD IV, including our case, Postnatal symptoms presented with hypotonia at birth. This is one of the hallmark of Neuromuscular findings 19/29 66 + glycogen storage disorder type IV, resulting from the accumulation Respiratory findings 22/29 76 + of the improperly branching glycogen in neuronal and skeletal 9,11 Cardiac findings 10/29 34 muscle tissues. Seventy-six percent of cases, including our case, Other dysmorphic features 6/29 21 required immediate intubation and mechanical ventilation, a PAS-positive deposits 24/29 83 + direct result of muscle dysfunction and poor respiratory effort. Decreased glycogen branching 18/29 62 + In addition to respiratory findings, cardiac dysfunction, likely due enzyme activity to the accumulation of abnormal glycogen in the myocardial Mutation in branching 11/29 38 + tissues was seen (Table 1). Two cases had cardiomyopathy as a enzyme gene significant cardiac finding.7,12 Dysmorphic features were also Mortality rate 29/29 100 + reported following birth in 21% of the cases (Table 1), including a Abbreviations: GSD IV, glycogen storage disease type IV; PAS, periodic acid schiff. cleft palate in one case and features resembling Crouzon syndrome in another case.1,13 All 29 reported patients with neuromuscular neonatal GSD IV died, with the longest living patient surviving to longer outer chains.8 This abnormally branching glycogen, 28 months.13 All patients’ deaths were linked to complications due often referred as amylopectin, accumulates in all tissues disrupting to muscle weakness, most frequently involving myocardial and the integrity of the muscle fibers.9 skeletal muscle and resulting in cardiac and respiratory failure.9 In GSD IV there is considerable variation in clinical presentation Enzymatic assays and staining for glycogen deposits are and course making it difficult to diagnose. GSD IV can present required to make a conclusive diagnosis of glycogen storage as a progressive form leading to liver failure by the age of five, a disorder type IV. In suspected cases of GSD IV, an enzyme activity milder non-progressive hepatic form, a variant with multi-system assay should be performed to determine the activity of the glycogen involvement, a juvenile form with the amylopectin-like glycogen branching enzyme. From all patients reviewed, 18 of 29 cases but normal glycogen branching enzyme functioning and lastly the had enzyme assay performed and all had decreased glycogen lethal neonatal neuromuscular presentation. The lethal neonatal branching enzyme activity. The decrease in enzyme activity in form can be associated with complicated by these cases was most often demonstrated in fibroblasts (others did polyhydramnios, hydrops fetalis and limited fetal movement not specify tissue source).4,9,11,13–15 Other tissues reported to have secondary to severe myopathy, hypotonia and poor fetal growth. decreased branching enzyme activity include the central nervous The 29 published and documented cases of fatal congenital system, white blood cells, epidermis and muscle. In all, 24 of the GSD IV and their clinical findings are summarized in Table 1. 29 cases had PAS testing and all had PAS þ inclusions in various The case discussed here presented with severe findings that muscle tissues. This indicates a significant increase in glycogen were not specific to but consistent with GSD IV. Our patient was storage in muscle fibers. Additionally, our patient’s muscle biopsy delivered after a pregnancy complicated with polyhydramnios and was stained with diastase and found to be resistant to diastase possibly depressed fetal movement. The majority of confirmed cases digestion, also suggesting an abnormal glycogen structure. of GSD IV in the literature presented with polyhydramnios during In all, 11 of the 29 cases had sequencing the GBE gene and the fetal period (Table 1), most often occurring during the third reported at least one mutation in the gene. Sequencing on our trimester. In addition to polyhydramnios, our patient presented patient identified a single mutation consisting of an amino-acid with decreased fetal movement late in the pregnancy. Half of the substitution c.1236 þ 1 G>A. This mutation has not been documented cases report decreased fetal movement (Table 1). Both previously reported. Although the exact impact of this novel the polyhydramnios and decreased fetal movement are likely to be mutation is unknown, it is similar to previously reported GBE1 a result of the accumulation of the amylopectin-like glycogen in gene mutations. This particular variant disrupts a GT splice site. the skeletal muscles, causing hypotonia. The muscle weakness Akman and Konstanidou, both report on a novel splice site likely prevents proper swallowing, inducing polyhydramnios. mutation at the intron exon boundary of exon 11, which likely Hydrops fetalis has also been seen in patients diagnosed with GSD caused mRNA instability or abnormal splicing.1 Multiple cases of

Journal of Perinatology Neonatal presentation of lethal neuromuscular GSD IV LF Escobar et al 813

GSD IV have been reported with mutations that cause a truncated muscular form with variable and early antenatal manifestations in the same family. version of the glycogen branching enzyme that causes reduced Am J Med Genet 2005; 139A: 118–122. to no enzyme functionality.1,4,6,7,12,16–18 As GSD IV is an autosomal 6 Konstantinidou AE, Anninos H, Gyftodimou Y, Petersen MB, Karadimas C, Fotopoulos S recessive disorder, we suspect that our patient has a second et al. Neonatal neuromuscular variant of glycogen storage disease type IV: histopathological findings leading to the diagnosis. Histopathology 2006; 48: unidentifiable mutation in the GBE1 gene. Uniparental disomy, 869–886. consanguinity and a deletion could be considered as a likely 7 Janecke AR, Dertinger S, Ketelsen UP, Bereuter L, Simma B, Mu¨ller T et al. Neonatal explanation.19,20 type IV glycogen storage disease associated with ‘‘null’’ mutations in glycogen In summary, we report a previously unrecognized mutation in branching enzyme 1. J Pediatr 2004; 145: 705–709. the GBE1 gene causing a lethal neonatal neuromuscular form of 8 Van Noort G, Straks W, Van Diggelen OP, Hennekam RCM. A congenital variant of glycogenesis type IV. Padiatr Path 1993; 13: 685–698. GSD IV (Andersen disease). Clinicians in the NICU should be aware 9 Giuffre B, Parini R, Rizzuti T, Morandi L, van Diggelen OP, Bruno C et al. Severe of the role of GSD IV in the causation of severe hypotonia in the neonatal onset of glycogenesis type IV: clinical and laboratory findings leading to neonatal period, which is unresponsive to conventional therapy. diagnosis in two siblings. J Inherit Metab Disord 2004; 27: 609–619. Additionally clinicians should consider GSD IV when pregnancies 10 Maruyama K, Suzuki T, Koizumi T, Sugie H, Fukuda T, Ito M et al. Congenital form are complicated by polyhydramnios, hydrops fetalis and/or of glycogen storage disease type IV: a case report and a review of the literature. depressed fetal movement despite the rarity of the disease. Pediatr Int 2004; 46: 474–477. 11 Tang TT, Segura AD, Chen YT, Ricci LM, Franciosi RA, Splaingard ML et al. Neonatal hypotonia and cardiomyopathy secondary to type IV glycogenosis. Acta Neuropathol 1994; 87: 531–536. Conflict of interest 12 Nambu M, Kawabe K, Fukuda T, Okuno TB, Ohta S, Nonaka I et al. A neonatal form of The authors declare no conflict of interest. glycogen storage disease type IV. Neurology 2003; 61: 392–394. 13 Zellweger H, Mueller S, Ionasescu V, Schochet SS, McCormick WF. Glycogenosis IV: a new cause of infantile hypotonia. J Pediatr 1972; 80:5. Acknowledgments 14 Alegria A, Martins E, Dias M, Cunha A, Cardoso ML, Maire I. Glycogen storage disease type IV presenting as hydrops fetalis. J Inher Metab Disord 1999; 22: 330–332. We would like to thank Dr David Weaver for reviewing this manuscript and for his 15 Cox PM, Brueton LA, Murphy KW, Worthington VC, Bjelogrlic P, Lazda EJ et al. Early- excellent advice. onset fetal hydrops and muscle degeneration in siblings due to a novel variant of type IV glycogenosis. Am J Med Genet 1999; 86: 187–193. References 16 Nolte KW, Janecke AR, Vorgerd M, Weis J, Schroder JM. Congenital type IV glycogenosis: the spectrum of pleiomorphic polyglucosan bodies in muscle, nerve and spinal 1 Akman HO, Karadimas C, Gyftodimou Y, Grigoriadou M, Kokotas H, Konstantinidou A cord with two novel mutations in the GBE1 gene. Acta Neuropathol 2008; 116: et al. Prenatal diagnosis of glycogen storage disorder type IV. Prenat Diagn 2006; 26: 491–506. 951–955. 17 Raju GP, Li HC, Bali DS, Chen YT, Urion DK, Lidov HG et al. A case of congenital 2 Willot S, Marchand V, Rasquin A, Alvarez F, Martin SR. Systemic progression of type IV glycogen storage disease type IV with a novel GBE1 mutation. J Child Neurol 2008; 23: glycogen storage disease after liver transplantation. J Pediatr Gastroenterol Nutr 2010; 349–352. 51: 661–664. 18 Tay SKH, Akman HO, Chung WK, Pike MG, Muntoni F, Hays AP et al. Fatal infantile 3 Moses SW, Pavari R. The variable presentations of glycogen storage disease type IV: neuromuscular presentation of glycogen storage disease type IV. Neuromuscul Disord a review of clinical, enzymatic and molecular studies. Curr Mol Med 2002; 2: 2004; 14: 253–260. 177–188. 19 Konstantinidou AS, Anninos H, Dertinger S, Nonni A, Petersen M, Karadimas C et al. 4 Asserto A, van Diggelen OP, Diogo L, Morava E, Cassandrini D, Carreira I et al. Null Placental involvement in glycogen storage disease type IV. Placenta 2008; 29: mutations and lethal congenital form of glycogen storage disease type IV. BBRC 2007; 378–381. 361: 445–450. 20 Shin YS, Steiguber H, Klemm P, Endres W, Schwab O, Wolff G. Branching enzyme 5 L’hermine-Coulomb A, Beuzen F, Bouvier R, Rolland MO, Froissart R, Menez F et al. in erythrocytyes. Detection of type IV glycogenosis homozygotes and heterozygotes. Fetal type IV glycogen storage disease: clinical, enzymatic and genetic data of a pure J Inher Metab Disord 1988; 11(Suppl 2): 252–254.

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