Gaucher Disease or Acid Sphingomyelinase Deficiency? The Importance of Differential Diagnosis

Abstract

Background: Gaucher disease is a lysosomal storage disorder caused by functional glucocerebrosidase enzyme deficiency. Hepatosplenomegaly and hematological complications are found in both Gaucher disease and Acid Sphingomyelinase Deficiency, which is caused by acid sphingomyelinase dysfunction. The possible overlap in clinical presentation can cause diagnostic errors in differential diagnosis. For this reason, in patients with an initial clinical suspicion of Gaucher disease, we aimed to carry out a parallel screening of acid sphingomyelinase and glucocerebrosidase. Methods: Peripheral blood samples of 627 patients were collected, and enzymatic activity analysis was performed on both glucocerebrosidase and acid sphingomyelinase. The specific gene was studied in samples with null or reduced enzymatic activity. Specific molecular biomarkers helped to achieve the correct diagnosis. Results: In 98.7% of patients, normal values of glucocerebrosidase activity excluded Gaucher disease. In 8 of 627 patients (1.3%), the glucocerebrosidase enzymatic activity assay was below the normal range, so genetic GBA1 analysis confirmed the enzymatic defect. Three patients (0.5%) had normal glucocerebrosidase activity, so they were not affected by Gaucher disease, and showed decreased acid sphingomyelinase activity. SMPD1 gene mutations responsible for Acid Sphingomyelinase Deficiency were found. The levels of specific biomarkers found in these patients further strengthened the genetic data. Conclusions: Our results suggest that in the presence of typical signs and symptoms of Gaucher disease, Acid Sphingomyelinase Deficiency should be considered. For this reason, the presence of hepatosplenomegaly, thrombocytopenia, leukocytopenia, and anemia should alert clinicians to analyze both enzymes by a combined screening. Today, enzyme replacement therapy is available for the treatment of both pathologies; therefore, prompt diagnosis is essential for patients to start accurate treatment and to avoid diagnostic delay.

Keywords: ASMD; Gaucher disease; acid sphingomyelinase; acid sphingomyelinase deficiency; differential diagnosis; glucocerebrosidase.

Figure 1

Index case mutation c.1799G>A. (a) Portion of the electropherogram of the SMPD1 exon 6 in index case; homozygous c.1799G>A is indicated by the blue line. (b) Portion of sequence of SMPD1 exon 6 in patient aligned with the corresponding sequence of a healthy control (wt). In the sequence and electropherogram, blue is for cytosine, red is for thymine, yellow is for guanine and green is for adenine.

Figure 2

Index case mutation c.1171T>G. (a) Portion of the electropherogram of the SMPD1 exon 3 in index case; homozygous c.1171T>G is indicated by the blue line. (b) Portion of sequence of SMPD1 exon 3 in patient aligned with the corresponding sequence of a healthy control (wt). In the sequence and electropherogram, blue is for cytosine, red is for thymine, yellow is for guanine and green is for adenine.

Figure 3

Index case mutation c.1829_1831del. (a) Portion of the electropherogram of the SMPD1 exon 6 in index case; homozygous c.1829_1831del is indicated by the blue line. (b) Portion of sequence of SMPD1 exon 3 in patient aligned with the corresponding sequence of a healthy control (wt). Dashes are missing nucleotides present in SMPD1 wt sequence. In the sequence and electropherogram, blue is for cytosine, red is for thymine, yellow is for guanine and green is for adenine.