Archives of Disease in Childhood 1994; 71: 123-127 123 Carbohydrate deficient glycoprotein syndrome type II: a deficiency in Golgi localised Arch Dis Child: first published as 10.1136/adc.71.2.123 on 1 August 1994. Downloaded from N-acetyl-glucosaminyltransferase II J Jaeken, H Schachter, H Carchon, P De Cock, B Coddeville, G Spik Abstract Case report The carbohydrate deficient glycoprotein The patient, a Belgian boy, was born in 1983 (CDG) syndromes are a family of genetic after a normal pregnancy and delivery. His multisystemic disorders with severe birth weight was 3250 g, length 50 cm, and nervous system involvement. This report head circumference 35 cm. He had a younger is on a child with a CDG syndrome that healthy brother; the parents were not related. differs from the classical picture but is The father's height was on the 3rd centile and very similar to a patient reported in head circumference on the 90th centile; he 1991. Both these patients are therefore showed some facial dysmorphism with a short designated CDG syndrome type II. neck but was otherwise normal. From birth Compared with type I patients they have the patient was hypotonic. He showed a more severe psychomotor retardation dysmorphic features: a hook nose, large but no peripheral neuropathy nor cere- dysplastic ears in oblique position, thin lips, bellar hypoplasia. The serum transferrin prognathia of the maxilla, short neck, isoform pattern obtained by isoelec- proximal implantation of the thumbs, and tric focusing showed disialotransferrin irregular position of the toes. There was a as the major fraction. The serum cardiac murmur due to a small ventricular disialotransferrin, studied in the present septal defect. Psychomotor development was patient, contained two moles of trun- severely retarded: visual contact appeared cated monoantennary Sialyl-Gal-GlcNAc- around 16 months (but remained poor), he Man(al-+3)[Man(cl-+6)]Man(,B1-4)GlcN could sit without support at 2-5 years, reach Ac(B1-+4)GlcNAc-Asn per mole of trans- for an object at 4-5 years, and take a few steps ferrin. A profoundly deficient activity of without support at 7 years. At the age of 10 the Golgi enzyme N-acetylglucosaminyl- years his speech was limited to a few mono- transferase II (EC 2.4.1.143) was demon- tonous sounds. Growth was normal until the strated in fibroblasts. age of 2 years but then progressively slowed (Arch Dis Child 1994; 71: 123-127) down; at 10 years his height was 114 cm (3rd http://adc.bmj.com/ centile 125 cm, weight 18 kg (3rd centile 23 kg), and his head circumference has remained Carbohydrate deficient glycoprotein (CDG) between the 25th and 50th centiles. From the syndromes are genetic multisystemic diseases first weeks he suffered from gastrointestinal first reported in 1980 by Jaeken et al. They are problems (regurgitation due to volvulus of characterised by a deficiency in the carbo- the stomach, and obstipation) as well as hydrate moiety of secretory glycoproteins, from frequent infections particularly of the on October 2, 2021 by guest. Protected copyright. lysosomal enzymes, and probably also upper airways. Epilepsy developed at the membranous glycoproteins (for reviews see age of 6 years and was only partially con- Department of Paediatrics, University Jaeken et al 1-3). The nervous system is always trolled by methylphenobarbitone and sodium Hospital Gasthuisberg, moderately to severely affected and most other valproate. He showed a striking stereotypic Herestraat 49, B-3000 organs are involved to a variable degree. A behaviour: hand-mouth and handwashing Leuven, Belgium reliable diagnostic test is isoelectric of head on J Jaeken focusing movements, turning, knocking his H Carchon serum transferrin showing a cathodal shift as a cheeks, and rocking. After the age of 1 year P De Cock consequence of the partial sialic acid other morphological characteristics were deficiency.4 5 The primary defect has yet to be noted: a midfrontal capillary haemangioma, Department of Biochemistry determined. Recently we have reported on a gum hypertrophy and unusually large teeth, Research, The CDG syndrome in an Iranian girl with thoracolumbar kyphoscoliosis, hollowed Hospital for Sick distinctive clinical and biochemical features.6 breast, hypotrophic distal limbs, and flat feet. Children, Toronto, Ontario, Canada Here we describe a Belgian boy with Deep tendon reflexes were normal. The H Schachter remarkably similar findings. These two following diagnoses have been put forward patients represent a separate variant of CDG successively: Holt-Oram syndrome, tri- Laboratory of Biological Chemistry, syndrome designated type II as opposed to chorhinophalangeal syndrome (in the first University of Sciences the 'classic' type I. We have demon- years his hair was sparse and thin), and and Technologies, strated that the activity of UDP-GlcNAc:cx6- Smith-Lemli-Opitz syndrome. The correct Villeneuve d'Ascq, France D-mannoside 1 -+2-N-acetylglucosaminyl- diagnosis was finally made at 9 5 years when, B Coddeville transferase II (GnT II; EC 2.4.1.143) is on occasion of a gum bleeding, investigation G Spik severely decreased in patient fibroblasts thus of the coagulation revealed the typical Correspondence to: identifying this disease as a Golgi disorder. A coagulopathy of CDG syndrome.8 Clinical Dr Jaeken. short report on this patient has been published examination at that time also showed small Accepted 24 February 1994 elsewhere.7 testes (1 ml). 12414aeken, Schachter, Carchon, De Cock, Coddeville, Spik Laboratory investigations FIBROBLAST CULTURE AND ENZYME Normal results were obtained for peripheral EXTRACTION blood indices and for serum electrolytes, Fibroblasts were grown in 100 mm tissue creatinine, uric acid, amino acids, albumin, culture dishes to a confluent monolayer (about Arch Dis Child: first published as 10.1136/adc.71.2.123 on 1 August 1994. Downloaded from cholesterol, alkaline phosphatase, glutamic 106 cells/dish) in alpha minimal essential pyruvic transaminase, -y-glutamyltransami- medium (a-MEM) containing glucose, 1 0% nase, IgA, IgM, transferrin, ceruloplasmin, fetal calf serum, antibiotics, and amphotericin. creatine kinase, arylsulphatase A activity, The medium was removed, the cells were coagulation factor VIII and X activities, von washed with citrate saline EDTA (0.2%), Willebrand factor antigen, ristocetin cofactor, trypsin was added to the dish, followed by 5 ml fibrinogen, complement factors C 1 q, C3c, at-MEM/1 0% fetal calf serum when the cells C4, C5, and C 1 esterase inhibitor, follicle were rounded up. The cells were rinsed with stimulating hormone, luteinising hormone, the same solution and centrifuged at 1000 rpm prolactin, growth hormone, free thyroxine, for 5 minutes. The cells were washed with 5 ml total triiodothyronine, thyroid stimulating phosphate buffered saline (PBS), centrifuged hormone, insulin, and cortisol. at 1000 rpm for 5 minutes, the PBS was Lowered serum values were found for a large removed, and the cell pellets were frozen at number of glycoproteins (table). There was an -70°C. The enzyme extract was prepared by increase of serum glutamic oxaloacetic trans- dissolving the frozen pellets in an equal volume aminase: 80-160 U/l (normal range <40), of ofice cold 0 1 M 2-[N-morpholino] ethanesul- complement factor C3d: 622% (0-6-3 1), and fonic acid (MES), pH 6-5, 1% Triton ofthe activated partial thromboplastin time: 71 X-100, 0-2 M sodium chloride (NaCl), and seconds (24-38). There was a decrease of the 0-02% sodium azide. Protein concentrations thrombin time: 15 seconds (18-24), serum were determined on the Triton extracts with iron: 7-5 jimol/ (14-3-21-5), total thyroxine: the BCA Protein Assay Reagent (Pierce) using 51 5 nmol/I (70-8-154), reverse triiodo- bovine serum albumin as standard. thyronine: 0-20 nmol/l (0-31-0-77), and 25- hydroxyvitamin D: 12-5 nmol/l (17-5-149-8). Routine urine analysis and concentration of ENZYME ASSAYS cerebrospinal fluid protein were normal. GnT I (Uridine diphosphate (UDP)-GkNAc:a3- In lymphocytes activities of the lysosomal D-mannoside ,3-1,2-N-acetylglucosaminyltrans- enzymes arylsulphatase A, cx-L-fucosidase, ferase I; EC 2. 4. 1. 101) P-galactosidase, a-glucosidase, 3-glucuroni- The reaction mixture in the enzyme assay'5 dase, N-acetyl r-hexosaminidase, and oa-man- contained, in a total volume of 0-020 ml, 0-25 nosidase were normal. Chromosomal analysis mM M3-octyl (Mano1t-6[Mana1-+3]ManI- in lymphocytes and fibroblasts was normal. It octyl, synthesised in the laboratory of Professor has to be noted that lymphocyte culture was H Paulsen, Hamburg, Germany), 0 1 M MES, successful only at the seventh attempt. pH 6-5, 0-1 M NaCl, 20 mM manganese Radiological examination of the skeleton chloride, 0 5 mM UDP- [3H]GlcNAc (10 000 http://adc.bmj.com/ showed osteopenia, luxation of the left radius, disintegrations/minute (dpm)/nmol), 0-25% bilateral coxa valga, gracile long bones, and Triton X-100, 10 mM AMP, 0-2 M GlcNAc, hemivertebra of C6. Electromyography, nerve 002% sodium azide, and enzyme extract conduction velocity, and evoked potentials (0-1-0-3 mg). After incubation at 370C for gave normal results. On ophthalmological 30-60 minutes, the reaction was stopped with examination there were somewhat pale and 0 5 ml water and frozen at -70°C. Product hazy papillae at 9 years and decreased formation was assayed by adsorption to on October 2, 2021 by guest. Protected copyright. amplitude of the electroretinogram. Sep-Pak C18 reverse phase cartridges (Waters), Electroencephalography showed a slow