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. 2015 Jun 4;1(1):e7.
doi: 10.1212/NXG.0000000000000007. eCollection 2015 Jun.

PFKM gene defect and glycogen storage disease GSDVII with misleading enzyme histochemistry

Mari Auranen  1 , Johanna Palmio  1 , Emil Ylikallio  1 , Sanna Huovinen  1 , Anders Paetau  1 , Satu Sandell  1 , Hannu Haapasalo  1 , Kati Viitaniemi  1 , Päivi Piirilä  1 , Henna Tyynismaa  1 , Bjarne Udd  1
Affiliations

PFKM gene defect and glycogen storage disease GSDVII with misleading enzyme histochemistry

Mari Auranen et al. Neurol Genet. .

Abstract

Objective: To elaborate the diagnostic methods used as "gold standard" in one of the most common glycogen storage diseases (GSDs), Tarui disease (GSDVII).

Methods: Two siblings with disease suggestive of GSD underwent thorough clinical analysis, including muscle biopsy, muscle MRI, exercise tests, laboratory examinations, and whole-exome sequencing (WES).

Results: Both siblings had juvenile-onset exercise intolerance with cramping and infrequent myoglobinuria. Muscle biopsy showed extralysosomal glycogen accumulation, but because of normal phosphofructokinase histochemistry, GSDVII was thought to be excluded. However, WES revealed a causative homozygous PFKM gene defect, R39Q, in both siblings, establishing the diagnosis of GSDVII, which was confirmed by very low residual phosphofructo-1-kinase (PFK) enzyme activity in biochemical studies.

Conclusions: We suggest that in patients with suspicion of GSD and extralysosomal glycogen accumulation, biochemical activity assay of PFK followed by molecular genetics should be performed even when enzyme histochemistry is normal.

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Figures

Figure 1
Figure 1. Tibialis anterior muscle biopsy of P1
(A) Increased fiber size variation, ring fibers, slight endomysial fibrosis, and prominent clear mainly subsarcolemmal blebs. Hematoxylin and eosin staining, ×200. (B) Enhancement of subsarcolemmal and partly intermyofibrillar periodic acid–Schiff (PAS) positivity. PAS staining ×200. (C) Histochemical staining for phosphosphofructokinase shows preserved staining and activity ×200. (D) A single cytochrome c oxidase (COX)-negative fiber was observed in COX-succinate dehydrogenase (SDH) staining located at the center. COX-SDH ×100. (E) Subsarcolemmal and some intermyofibrillar blebs in toluidine blue staining, plastic section ×400. (F) Verified accumulation of subsarcolemmal glycogen in electron microscopy ×3,950.
Figure 2
Figure 2. Vastus lateralis biopsy of P2
(A) Vastus lateralis muscle cryostat section hematoxylin and eosin (H&E) staining shows basophilic subsarcolemmal aggregate in one muscle fiber and one fiber with a small rimmed vacuole. H&E staining ×100. (B) Periodic acid–Schiff (PAS) staining ×100 reveals some otherwise pale fibers with prominent accumulates of PAS-positive polyglucosan material, evident also in (C) PAS semithin sections ×200. (D) Immunohistochemical staining for phosphosphofructokinase shows no reduction in sarcolemmal or cytoplasmic expression. However, abnormal cytoplasmic phosphofructo-1-kinase–positive aggregates are observed in some fibers. These accumulations are unlike normal glycogen positive for (E) p62, (F) ubiquitin, (G) valosin-containing protein, and (H) desmin immunohistochemistry and negative for (I) myotilin, findings consistent with polyglucosan aggregates. (J) In these fiber regions, rimmed vacuolar pathology with accumulation of light chain 3b–positive material is also seen (original magnification ×100 in panels E–J).
Figure 3
Figure 3. Homozygous c.329G→A nucleotide change in the PFKM gene in both patients
Chromatograms show the presence of the PFKM c.329G→A mutation in the patient genomic DNA but not in the normal control sample.
See this image and copyright information in PMC

References

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