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PubMed1991

Plasma exchange in the treatment of Refsum's disease (heredopathia atactica polyneuritiformis).

Five cases of heredopathia atactica polyneuritiformis (HAP--Refsum's disease) were treated by serial plasma exchanges. In all patients a reduction in calorie intake and body weight had been associated with a rise in plasma phytanic acid, followed by an exacerbation of the ataxia and neuropathy. Lowering the plasma phytanic acid by plasma exchange produced a rapid clinical improvement. The main indication for plasma exchange in HAP is a severe or rapidly worsening clinical condition. A lesser indication is failure of dietary management to reduce a high plasma phytanic acid level.

Adult↗
PubMed1988

Infantile Refsum's disease: a generalized peroxisomal disorder. Case report with postmortem examination.

Infantile Refsum's disease (IRD) is a peroxisomal deficiency disease which is closely related to neonatal adrenoleukodystrophy (NALD) and the Zellweger syndrome (ZS). Recent observations suggest that NALD and ZS are separate genetic disorders but the delimitation towards IRD remains uncertain. We present here the first autopsy report of a patient who was clinically and biochemically diagnosed as having IRD, and we compare the findings with those from NALD and ZS. The main gross and microscopic findings comprised micronodular liver cirrhosis, small hypoplastic adrenals without degenerative changes, and large groups of lipid macrophages in liver, lymph nodes and certain areas of the cerebral white matter. The brain showed no malformations except for a severe hypoplasia of the cerebellar granule layer and ectopic location of the Purkinje cells in the molecular layer. A mild and diffuse reduction of axons and myelin was found in the corpus callosum and periventricular white matter, the corticospinal tracts, and the optic nerves. Large numbers of perivascular macrophages were present in the same areas but there was no active demyelination. The retina and cochlea showed severe degenerative changes. Peripheral nerves, skeletal system and kidneys were normal. Electron microscopy showed characteristic cytoplasmic inclusions with bilamellar profiles in macrophages in the liver, lymph nodes and brain but not in the adrenals. Similar inclusions were found in liver cells and astrocytes. The findings differ from ZS which shows cortical renal cysts, skeletal changes, liver changes, cerebral micropolygyria, neuronal heterotopias, and demyelination of the white matter. Cases with NALD show mild cerebral malformations, active demyelination, degenerative changes of the adrenals, liver changes, and bilamellar electromicroscopic inclusions in macrophages. Our cases thus resembled NALD but lacked active demyelination, cerebral cortical malformations and adrenal degenerative changes. Further autopsy studies will be necessary to determine whether these changes are consistent findings in IRD.

Adrenoleukodystrophy↗
PubMed1968

Absorption of chlorophyll phytol in normal man and in patients with Refsum's disease.

This study was made to determine the extent of absorption of chlorophyll phytol from the intestine of man, and the importance of chlorophyll as a source of the phytanic acid that accumulates in Refsum's disease. Uniformly (14)C-labeled pheophytin a (the Mg-free derivative of chlorophyll a) was fed to normal human subjects and to patients with Refsum's disease. Feces were collected and analyzed. In all subjects, 90-95% of the administered radioactivity was recovered in the feces, still largely in the form of pheophytin a. The phytol radioactivity recovered in the feces averaged about 95% of that in the administered material, which indicates that there had been little absorption of the phytol moiety. Similarly, after 250 g of cooked spinach had been fed to a normal subject, almost the entire phytol content was found in the feces. Less than 5% of the ingested spinach phytol was accounted for in the thoracic duct lymph of another subject. It was concluded that not more than about 5% of the ingested chlorophyll phytol is absorbed by man, whether normal or afflicted with Refsum's disease. On this basis we conclude that the major portion of the phytanic acid that accumulates in Refsum's disease could not be derived from dietary chlorophyll.

Adolescent↗
PubMed1981

Renal involvement in Refsum's disease.

Renal hemodynamic and tubular functions were measured in a patient with Refsum's disease before and after 12 weeks of twice-weekly plasmaphereses. Percutaneous renal biopsy was performed before initiation of plasmapheresis. These studies were performed to (1) define the nature of the renal lesions and the effects of phytanic acid accumulation on renal functions, and (2) assess the effects of lowering the plasma phytanic acid level on renal functions. The patient, a 39 year old woman, had lipiduria, glycosuria, cylindruria, minimal proteinuria and mild azotemia initially. Renal lesions consist of extensive vacuolization and mitochondrial changes of the tubular epithelial cells, vacuolization of the visceral epithelial cells of the glomeruli, and slight to moderate mesangial sclerosis. The impaired renal hemodynamic function and various tubular functions improved following plasmaphereses associated with reduction of plasma phytanic acid. Over-all clinical improvement was also evident.

Adult↗
PubMed1978

The fatty acid composition of skin and plasma lipids in Refsum's disease.

The fatty acid composition of the skin and plasma lipids is described in a patient severely affected by Refsum's disease whose plasma phytanic acid concentration was very high (3.1 mg/ml). In the epidermal lipids, especially in the phospholipid fraction, phytanic acid tended to replace linoleic acid and to some extent arachidonic acid. In some respects the changes in the skin in Refsum's disease resemble those of essential fatty acid deficiency.

Cholesterol↗
PubMed1979

Refsum's disease. Eye manifestations in a patient treated with low phytol low phytanic acid diet.

The cardinal eye symptoms of Refsum's disease are night blindness, retinal pigmentary degeneration and constriction of the visual fields. Similarities with or differences from retinitis pigmentosa are discussed. A 39-year-old male has had manifestations of Refsum's disease from the age of 7 years and has been on a low phytol low phytanic acid diet for the last 13 years. Peripheral ring scotomas were present. Some reduction of the visual fields has been recorded, but only in the far periphery. The central field has not been significantly constricted during a 7-year period. Very good visual functions were found within this area. All cone mechanisms were functioning at a normal level. A moderately reduced sensitivity level of the rod mechanism could be explained in a great measure by poor pupillary dilation in the dark. In this patient minimal or no progression of the visual findings was apparent. Probably an effect of treatment, there is little resemblance with ordinary retinitis pigmentosa. ERG showed moderate abnormality. Normal conducting time was found by VER. With fluorescein angiography a central area of normal appearance was sharply outlined in contrast to marked degenerations in paracentral regions.

Adult↗
PubMed1993

[Ophthalmological manifestations of infantile Refsum's disease: apropos of 3 cases].

We describe the ophthalmic manifestations of 3 cases of infantile Refsum's disease. The gravity and the aspect of the retinal disorders which we have observed by ophthalmoscopy and electroretinography were quite different from one case to another, including two siblings. We then go on to discuss the pathogeny and the genetic basis of diseases due to a deficiency of the peroxisomal biogenesis.

Adolescent↗
PubMed1969

Localization of the oxidative defect in phytanic acid degradation in patients with Refsum's disease.

The rate of oxidation of phytanic acid-U-(14)C to (14)CO(2) in three patients with Refsum's disease was less than 5% of that found in normal volunteers. In contrast, the rate of oxidation of alpha-hydroxyphytanic acid-U-(14)C and of pristanic acid-U-(14)C to (14)CO(2), studied in two patients, while somewhat less than that in normal controls, was not grossly impaired. These studies support the conclusion that the defect in phytanic acid oxidation in Refsum's disease is located in the first step of phytanic acid degradation, that is, in the alpha oxidation step leading to formation of alpha-hydroxyphytanic acid. The initial rate of disappearance of plasma free fatty acid radioactivity after intravenous injection of phytanic acid-U-(14)C (t(1/2) = 5.9 min) was slower than that seen with pristanic acid-U-(14)C (t(1/2) = 2.7 min) or palmitic acid-1-(14)C (t(1/2) = 2.5 min). There were no differences between patients and normal controls in these initial rates of free fatty acid disappearance for any of the three substrates tested. There was no detectable lipid radioactivity found in the plasma 7 days after the injection of palmitic acid-1-(14)C or pristanic acid-U-(14)C in either patients or controls. After injection of phytanic acid-U-(14)C, however, the two patients showed only a very slow decline in plasma lipid radioactivity (estimated t(1/2) = 35 days), in contrast to the normals who had no detectable radioactivity after 2 days. Incorporation of radioactivity from phytanic acid-U-(14)C into the major lipid ester classes of plasma was studied in one of the patients; triglycerides accounted for by far the largest fraction of the total present between 1 and 4 hr.

Carbon Dioxide↗
PubMed1993

Pseudo infantile Refsum's disease: catalase-deficient peroxisomal particles with partial deficiency of plasmalogen synthesis and oxidation of fatty acids.

Zellweger syndrome, neonatal adrenoleukodystrophy, and infantile Refsum's disease are genetic disorders characterized by the virtual absence of catalase-positive peroxisomes and a general impairment of peroxisomal functions. Recent studies in these three disorders have provided morphologic evidence of peroxisomal "ghosts" of density 1.10 g/cm3 that contain membrane proteins but lack a majority of the matrix enzyme activities. We report here the biochemical studies in a female infant with clinical features of infantile Refsum's disease whose liver and fibroblasts contained cytosolic catalase but no catalase-positive peroxisomes. Oxidation of phytanic and pipecolic acids was severely impaired, whereas oxidation of very-long-chain fatty acids and dihydroxyacetone phosphate acyltransferase activity were only partially decreased. Immunoblot analysis showed that the three peroxisomal beta-oxidation enzymes (acyl-CoA oxidase, enoyl-CoA hydratase/3-hydroxyacyl-CoA dehydrogenase, and 3-ketoacyl-CoA thiolase) were detectable in liver tissues. The 3-ketoacyl-CoA thiolase was of the mature form (41 kD), in contrast with other peroxisomal disorders with multiple enzyme deficiencies. The majority of these peroxisomal enzyme activities were associated with two subcellular membrane vesicle fractions lacking catalase: one had the density of normal peroxisomes (1.17 g/cm3), the other, yet undescribed, a lower density (1.137 g/cm3). This suggests that peroxisomes (density = 1.17 g/cm3) and structures with lower density (density = 1.137 g/cm3) found in this patient's cultured skin fibroblasts, although lacking catalase, contained functional peroxisomal enzymes. This distinguishes this disorder from other disorders of peroxisome biogenesis.

Acatalasia↗
PubMed1986

[Refsum's disease. Epidemiologic, clinical and biological correlation. 6 cases].

Nine patients with symptoms and signs of Refsum's disease are reported. In 6 a systemic accumulation of phytanic acid was demonstrated, together with low phytanic acid oxidase activity in skin fibroblasts in 5 of them. In 3, no disorder of phytanic acid metabolism was demonstrated. In 3, the diagnosis was made during the pre-clinical period. The disease seems more frequent in Northern France, which agrees with the hypothesis of a genetic mutation which would have taken place in Scandinavia some centuries ago and was subsequently spread by the Vikings. The effects of a dietary treatment on serum phytanic acid levels and clinical disorders are reported. The general condition of the patients improved remarkably but only partially. The diet is unpalatable and in some patients the level of serum phytanic acid increased, due to the mobilization of body fat. Patients with very high levels of phytanic acid might be initially treated by plasmapheresis. For the same reason, the diet should supply enough calories to keep body weight unchanged, and body weight loss whatever its cause should be avoided.

Adolescent↗
PubMed1981

Diagnosis of Refsum's disease using [1-14C]phytanic acid as substrate.

The suitability of using [1-14C]phytanic acid as a substrate for the diagnosis of Refsum's disease has been examined. Normal fibroblasts cultured in medium containing low concentrations of foetal calf serum (0.5%) oxidised added [1-14C]phytanic acid to 14CO2 only slowly up to about 2 days; beyond this period a marked stimulation in oxidation was observed. Easily measurable conversion of the radiolabelled acid (from 1.5 to 5.0%) was obtained by numbers of cells at least one order of magnitude fewer than previously described. Fibroblasts from adult patients with Refsum's disease displayed about 5-10% of the normal mean activity. Small differences in residual activity were observed in the different cell lines. However, no obvious relationship was found between the degree of residual activity, the level of plasma phytanate, and the patient's clinical condition and history.

Adult↗
PubMed1971

Heredopathia atactica polyneuritiformis (Refsum's Disease): a second trial of dietary therapy in two patients.

Two sibs with heredopathia atactica polyneuritiformis (Refsum's Disease) each had a relapse after ceasing to follow a special diet. On being placed on a very restricted low phytol, low phytanic acid diet both had marked subjective improvement, and marked objective improvement both in physical findings and in quantitative tests of strength, dexterity, and motor nerve conduction velocities, concomitant with a fall in serum phytanic acid levels. No relapse occurred in 22 months on this diet.

Ataxia↗
PubMed1979

[Clinical and biochemical follow up of Refsum's disease (author's transl)].

Within a family refered here, two sisters are presenting heredopathia atactica polyneuritiformis (Morbus Refsum) with the complete clinical, electromyographical and serological findings (increased phytanic acid level, accumulation of mono- and diphytanyl, triglycerides). In addition, some symptoms of Refsum's disease are clinically apparent in the eight year old daughter of one of the patients, but significant principal characteristics are absent (dissociation of the spinal fluid, retinopathia pigmentosa, increased phytanic acid level). The phytanic acid level in the serum of ten clinically normal blood relations (three of which are also obligatory heterozygotes) is normal. In both patients with manifest illness we found not only the usual spinal fluid changes with highly increased protein levels (gammaglobulin, IgA- and IgG-fraction) but also a remarkably large number of macrophages with vacuoles. Within almost two years of keeping to a strict diet with low phytanic acid and phytol content, both patients showed a distinct clinical improvement in parallel with a decrease of the phytanic acid level. Even a temporary increase of the phytanic acid level in one of the patients did not cause clinical relapse. Regarding the biochemical control of the course of the disease, the phytanic acid containing triglycerides proved to be a highly sensitive parameter.

Adult↗
PubMed1998

Influence of plasma phytanic acid levels in Refsum's disease on the behaviour of the erythrocyte membrane sodium-lithium countertransporter.

BACKGROUND: Abnormal behaviour of the erythrocyte membrane sodium-lithium countertransporter (SLC) is associated with plasma triglyceride concentrations. Refsum's disease is characterized by progressive neurological dysfunction and accumulation of phytanic acid, an isoprenoid fatty acid, in fat-containing tissues. METHODS: This study explored the effects of plasma phytanic acid on SLC kinetics in nine Caucasian patients with Refsum's disease and in age- and sex-matched Caucasian control subjects. RESULTS: A dose-dependent association was seen between countertransporter maximal velocity and phytanic acid content of low-density lipoprotein (LDL)-cholesterol (r = -0.61, r = -0.65 respectively; P = 0.05, P = 0.04) and high-density lipoprotein (HDL)-cholesterol (r = -0.81, -0.82 respectively; P = 0.005, P = 0.003). No significant association was seen with the sodium affinity of the transporter (r = -0.44, P = 0.20, for LDL; and -0.43, P = 0.21, for high-density lipoprotein). CONCLUSION: These findings suggest that phytanic acid may alter the behaviour of the sodium-lithium countertransporter.

Antiporters↗
PubMed1990

Heredopathia atactica polyneuritiformis (Refsum's disease).

A female patient started to develop deafness and vertigo at the age of 29. In the following years she became atactic and retinitis pigmentosa was discovered. The diagnosis of Refsum's disease was reached on the grounds of the high concentration of phytanic acid in plasma. The patient died 23 years after onset of the first symptoms. Liver, spleen and kidney showed lipofuscinosis and pigment-laden macrophages. The retina was atrophic and its pigment discontinuous. The meninges contained lipid-laden macrophages. The nerve cells in brain and spinal cord as well as the astrocytes and perivascular macrophages stored substances weakly PAS-positive and sudanophilic. The nerve cells accumulated lysosomes and residual bodies. In the astrocytes, the residual bodies were extremely polymorphous and contained inclusions with bilamellar ribbon-like structures. In the oligodendroglia the residual bodies displayed high electron density and finger print-like pattern. Peroxisomes were found in glial cells and microperoximes in neurons. The ultrastructural findings in the present case demonstrate that in terminal stages phytanic acid can reach the brain parenchyma passing through the BBB. Further autopsy studies will be necessary to determine whether these changes are consistent findings in Refsum's disease.

Central Nervous System↗