Clinical and Molecular Spectrum of Glucose-6-Phosphate Isomerase Deficiency. Report of 12 New Cases

Abstract

Glucose-6-phosphate isomerase (GPI, EC 5.3.1.9) is a dimeric enzyme that catalyzes the reversible isomerization of glucose-6-phosphate to fructose-6-phosphate, the second reaction step of glycolysis. GPI deficiency, transmitted as an autosomal recessive trait, is considered the second most common erythro-enzymopathy of anaerobic glycolysis, after pyruvate kinase deficiency. Despite this, this defect may sometimes be misdiagnosed and only about 60 cases of GPI deficiency have been reported. GPI deficient patients are affected by chronic non-spherocytic hemolytic anemia of variable severity; in rare cases, intellectual disability or neuromuscular symptoms have also been reported. The gene locus encoding GPI is located on chromosome 19q13.1 and contains 18 exons. So far, about 40 causative mutations have been identified. We report the clinical, hematological and molecular characteristics of 12 GPI deficient cases (eight males, four females) from 11 families, with a median age at admission of 13 years (ranging from 1 to 51); eight of them were of Italian origin. Patients displayed moderate to severe anemia, that improves with aging. Splenectomy does not always result in the amelioration of anemia but may be considered in transfusion-dependent patients to reduce transfusion intervals. None of the patients described here displayed neurological impairment attributable to the enzyme defect. We identified 13 different mutations in the GPI gene, six of them have never been described before; the new mutations affect highly conserved residues and were not detected in 1000 Genomes and HGMD databases and were considered pathogenic by several mutation algorithms. This is the largest series of GPI deficient patients so far reported in a single study. The study confirms the great heterogeneity of the molecular defect and provides new insights on clinical and molecular aspects of this disease.

Keywords: chronic hemolytic anemias; glucose-6-phosphate isomerase deficiency; glycolysis; red cell disorders; red cell metabolism.

FIGURE 1

Age at onset of anemia (dark gray) compared with age at diagnosis (light gray) in the 12 GPI deficient patients.

FIGURE 2

Peripheral red cell morphology from a non-splenectomized (A) and from a splenectomized (B) GPI patient (May-Grünwald’s Giemsa staining). Anisopoikilocytosis with presence of rare spherocytes (arrows), stomatocytes (triangles), more evident after splenectomy, rare echinocytes (E). The increased platelet number in panel (B) is due to splenectomy, some large and vacuolated platelets are likely due to EDTA anticoagulant.

FIGURE 3

LoRRca Osmoscan curve of 6 GPI deficient patients compared with normal controls (gray area).

FIGURE 4

Schematic representation of the GPI gene and position of the mutations identified in this study.