Branching enzyme-deficiency glycogenosis: studies in therapy.
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A 3 year old boy developed an unusually mild form of glycogen storage disease type IV. Metabolic investigations showed severe abnormalities of fatty acid and carnitine metabolism. A muscle carnitine deficiency was found. Treatment with L-carnitine orally led to a notable improvement in muscle strength.
Hepatomegaly, the presenting feature of type IV glycogen storage disease at 20 months of age, regressed during childhood. The patient remained asymptomatic until 12 years of age when, after an episode of shock, septicaemia, and spontaneous peritonitis, liver transplantation was successfully performed.
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Two cases of type III glycogen storage disease are reported in adults; the occurrence of cirrhosis in one case illustrates the potential development of chronic liver disease in this condition. The other was the oldest patient with this condition found in a review of published reports. Electron microscopy of peripheral blood leucocytes to demonstrate excess glycogen was found to be a quick and useful aid to diagnosis. Histology of these adult cases showed a distribution of hepatocyte vacuolation which has not been previously recorded.
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Glucose carbon recycling, endogenous glucose production, and glucose turnover rates were measured, by stable isotope methodology, in five patients with glycogen storage disease type I (GSD-I), two patients with glycogen storage disease type III (GSD-III), and three control children. A primed-constant infusion of D-[U-13C]glucose was administered nasogastrically to fasted subjects. The isotopic enrichments and 13C isotopomer distribution of plasma glucose were measured by chemical ionization gas chromatography mass spectroscopy. In response to increasing rates of glucose infusion, endogenous glucose production decreased, whereas the rate of glucose appearance or total glucose flux increased. Recycling of infused D-[U-13C]-glucose, calculated from changes in the isotopomer distribution of plasma [13C]glucose, was not detectable in GSD-I but reached 50% in GSD-III. In GSD-I the gluconeogenic pool was found to be highly labeled and recycled, whereas plasma glucose was diluted but not recycled. It is suggested that in GSD-I dilution of plasma glucose is due to release of glucose from branch points in glycogen. We propose that studies of the extent of glucose recycling and of isotopic enrichment of gluconeogenic precursors can be used as a noninvasive test for diagnosis of GSD-I and other defects in glucose production.
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During constant work-rate exercise above the lactic acidosis threshold, oxygen consumption fails to plateau by 3 minutes, but continues to rise slowly. This slow component correlates closely with the rise in lactate in normal subjects. We investigated if oxygen consumption during constant work-rate exercise could rise after 3 minutes in the absence of a rise in lactate. We studied five patients with McArdle's disease, one patient with phosphofructokinase deficiency and six normal subjects. Subjects performed two 6-minute duration constant work-rate exercise tests at 40 and 70% of peak oxygen consumption. During low-intensity exercise, oxygen consumption reached steady state by 3 minutes in both groups. Lactate rose slightly in control subjects but not in patients. During high-intensity exercise, oxygen consumption rose from the third to the sixth minute by 144 (21-607) ml/minute (median and range) in control subjects and by 142 (73-306) ml/minute in patients (p = not significant, Mann-Whitney U test). Over the same period, lactate (geometric mean and range) rose from 2.68 (1.10-5.00) to 5.39 (2.70-10.00) mmol/L in control subjects, but did not rise in patients (1.20 [0.64-1.60] to 0.70 [0.57-1.20] mmol/L). We conclude that the slow component of oxygen consumption during heavy exercise is not dependent on lactic acidosis.
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1. In order to reduce the time interval between amniocentesis and prenatal diagnosis of Pompe's disease microchemical techniques were used for assay of acid alpha-1,4-glucosidase activities in cultured amniotic fluid cells. 2. Microtechniques used on homogenates of cultured amniotic fluid cells enabled the waiting period to be reduced to 2-3 weeks. 3. When dissected lyophilized groups of 200-300 cultured cells were analyzed, a prenatal diagnosis was possible at about 10 days after amniocentesis. 4. The acid alpha-1,4-glucosidase activity in the amniotic fluid supernatant is not informative in prenatal diagnosis of Pompe's disease. 5. Conditions of cell cultivation such as length of time in culture were found to influence markedly the acid alpha-1,4-glucosidase activity in cultured amniotic fluid cells. 6. For a reliable prenatal diagnosis of metabolic disorders primary cultures of control amniotic fluid cells should be used and the analytical results from the pregnancy at risk should be compared with primary cultures of control amniotic fluid cells and with those in cultured fibroblasts from heterozygous carriers, and an affected sibling from the particular family.