Small fiber involvement in Fabry's disease [Elektronische Ressource] / vorgelegt von Lan He

Huangyi

Description

Aus der Neurologischen Klinik und Poliklinik der Universität Würzburg Direktor: Professor Dr. med. Klaus V. Toyka Small fiber involvement in Fabry’s disease Inaugural-Dissertation zur Erlangung der Doktorwürde der Medizinischen Fakultät der Universität Würzburg vorgelegt von Lan He aus Urumuqi, CHINA Würzburg, im Juni 2008 Referentin: Prof. Dr. med. C. Sommer Korreferentin: Prof. Dr. med. E. Broecker Dekan: Prof. Dr. med. M. Frosch Tag der mündlichen Prüfung: 16.01.2009 Die Promovendin ist Ärztin: Lan He Contents Abbreviations 11 Introduction…………………………………………………………………...1.1 Definition and prevalence…………………………………………………….. 11.2 Heredity and Mechanisms………………………………………………….... 21.3 Clinical manifestations………………………………………………………... 41.3.1 General clinical manifestations…………………………………………….... 41.3.2 Women and children………………………………………………………….. 51.4 Diagnosis………………………………………………………………………. 61.5 Treatment………………………………………………………………………. 71.5.1 Enzyme Replacement Therapy (ERT)…………………………………….... 71.5.2 Other treatment………………………………………………………………... 81.6 Small fiber involvement in FD and its reaction to ERT…………………….. 91.6.1 Neuropathic pain………………………………………………………………. 91.6.2 Small fiber neuropathy………………………………………………………... 101.6.3 Intraepidermal nerve fiber density (IENFD)……………………………….... 111.7 Aim of the study……………………………………………………………….. 12 2 Methods………………………………………………………………………... 132.

Sujets

• Gesundheit

Informations

• Publié par: julius-maximilians-universitat_wurzburg
• Publié le: 01 janvier 2009
• Nombre de lectures: 16
• Langue: English
• Poids de l'ouvrage: 1 Mo

Extrait

Aus der Neurologischen Klinik und Poliklinik

der Universität Würzburg

Direktor: Professor Dr. med. Klaus V. Toyka

  Small fiber involvement in Fabrys disease   



Inaugural-Dissertation

zur Erlangung der Doktorwürde 

der Medizinischen Fakultät

der Universität Würzburg

vorgelegt von

Lan He

aus Urumuqi, CHINA









Würzburg, im Juni 2008









Referentin:

Korreferentin:

Dekan:















Prof. Dr. med. C. Sommer

Prof. Dr. med. E. Broecker

Prof. Dr. med. M. Frosch



Tag der mündlichen Prüfung:16.01.2009



Die Promovendin ist Ärztin: Lan He







2

2.1

Methods...

13

15

Mechanical detection threshold for modified von Frey filaments.

15

sensations

2.3.3

16

Mechanical pain threshold for pinprick stimuli

2.3.2



2.3.4

pinprick

Stimulusresponse-functions: mechanical pain sensitivity for

15

Quantitative Sensory Testing (QST).

13

2.3.1

Thermal detection, thermal pain thresholds and paradoxical heat

Pain and depression questionnaires

Subjects

13

2.3

2.2

7

1.5.1

1.5

Treatment.

Other treatment...

1.5.2

Enzyme Replacement Therapy (ERT)....

8

1.3.2

Women and children..

General clinical manifestations....

5

1.4

7

6

Diagnosis.

Intraepidermal nerve fiber density (IENFD)....

11

1.6.3

Small fiber neuropathy...



1.7

Aim of the study..

12

9

9

1.6.2

1.6.1

10

Neuropathic pain.

Small fiber involvement in FD and its reaction to ERT..

1.6

Contents



Introduction...

1.3

Definition and prevalence..

1.1

Clinical manifestations...

Heredity and Mechanisms....

1.3.1

4



Abbreviations

1

2

1

1

1.2

4

17

Vibration detection threshold.

2.3.7

2.3.8

repetitive pinprick stimuli...

Wind-up ratio  the perceptual correlate of temporal pain summation for

2.3.5

2.3.6

16

stimuli and dynamic mechanical allodynia for stroking light touch..

17

3.6.4

43

3.6.1

3.6.2

3.6.3.2

Follow up after two years...

Skin innervation (IENFD)...

41

Extra- and transcranial Doppler sonography..

21

2.6

20





Skin biopsy...

2.7

19

2.5.1

Clinical electrophysiological examination...

19

Sympathetic skin response...

20

2.5.2

Sural nerve conduction studies

18

Pressure pain threshold.

17

2.4

2.5

Neurological examination..

19

Statistics...

3.4.1

28

Male patients...

28

Quantitative sensory testing..

26

Pain and Depressive Symptoms..

25

Skin innervation (IENFD)...

30

Female patients...

3

3.1

3.2

3.3

3.4

Neurological Symptoms and Findings.

36

3.5

3.4.2

34

3.6

32

Follow up study...

3.6.3.1

37

37

One year follow up..

QST...

3.6.3

36

Pain and Depressive Symptoms..

23

Patients demographics and clinical characteristics

Results.

General Neurological Symptoms and Findings..

23

4.3.3

Neuropathic pain and other manifestations.

QST and skin biopsy as early diagnostic methods

61

Female patients and concomitant diseases

4.4

4.5

62

Skin innervation (IENFD) and proximal regeneration

Response of peripheral nervous system to ERT and the role of renal

4.3

4.3.1

QST follow up...

59

60

4.3.2

Summary.

References



Acknowledgements









62

Conclusion...

4.6

64

66

74

..

Appendix.

51

Neuropathic pain, pain related disability, and depression.

4.1.2

52

50

50

Small fiber involvement and the role of renal function..

4.1.1

4.2

55

Hypohidrosis, auditory impairment, and CNS symptoms.

Curriculum Vitae

QST and small fiber function.

4.1.3

54

Skin innervation (IENFD) in FD......................

3.8

Patients free from neurological complains..

3.7.4



Female patients...

47

48

3.7.3

4

Correlations..

Discussion..

4.1

48



49

Children with FD..

56

function.

57

Subgroup analysis..

44

3.7



3.7.2

Patients with normal and patients with impaired renal function...

44

3.7.1

List of Abbreviations   FD Fabrys disease

α-GAL

GL- 3 

ERT

NPSI

GCPS

CES-D

QST

CDT

WDT

TSL

PHS

CPT

HPT

MDT

MPT

MPS

DMA

WUR

VDT

PPT

SNAP

NCS

SSR

IENFD   

α-galactosidase A

Globotrioacylceramide

Enzyme replacement therapy

Neuropathic Pain Symptom Inventory

Graded Chronic Pain Scale

Center for Epidemiologic Studies Depression Scale

Quantitative sensory testing

Cold detection threshold

Warm detection threshold

Thermal sensory limen

Paradoxical heat sensations

Cold pain threshold

Heat pain threshold

Mechanical detection threshold

Mechanical pain threshold

Mechanical pain sensitivity

Dynamic mechanical allodynia

Wind-up ratio

Vibration detection threshold

Pressure pain threshold

Sensory nerve action potential

Nerve conduction studies

Sympathetic skin response

Intraepidermal nerve fiber density

1. Introduction



1.1 Definition and prevalence



Fabrys disease (FD) is a rare inherited X-linked lysosomal storage disease

caused by deficient or absent activity of the enzymeα-galactosidase A

(alpha-D-galactoside galactohydrolase (α-GAL); EC 3.2.1.22) due to mutations

in the GLA-gene. The enzymatic defect leads to the systemic accumulation of

glycosphingolipids, mainly globotrioacylceramide (GL-3) in a wide variety of

tissues including vascular endothelium, renal glomeruli and tubules, dorsal root

ganglia, cardiac myocytes, conducting tissue and valves, cornea, and skin 1 .



The German dermatologist, Johannes Fabry and the English dermatologist,

William Anderson, independently described the first patients with FD in 1898 2,3 ,

and therefore the disease is also known as Mobus Anderson-Fabry.



FD is a X-linked rare hereditary disorder which affects more males than females:

It is estimated that 1 in 40,000 4  males has FD, whereas the estimated

prevalence in the general population is 1 in 117,000 people 5 . In recent years,

more researches have revealed that this disorder is probably underdiagnosed.

In a screen of 37,104 newborns forα-galactosidase A, the incidence of FD was

found to be 1:4600 6 . In urinary screenings of patients who were undergoing

hemodialysis to treat end-stage renal disease, 1.2% were shown to have FD 7 .

With patients who had cryptogenic stroke or hypertrophic cardiomyopathy, the

prevelance was also relatively high 8-10 .











1 --

1.3 Heredity and Mechanisms



The GLA-gene is located on the X chromosome, which means a male patient

will only pass his X chromosome on to his daughters. His daughters may not

have FD but be only Fabry carriers, because the daughters other X

chromosome will likely carry a healthy gene that is capable of makingα-GAL.

On the other hand, if a mother carries the Fabry gene, there is a 50% chance

that she will pass the gene on to her sons or daughters. Her sons who inherit

the gene will have FD. Her daughters who inherit the gene will be carriers, but

may also be affected by FD, see below.



The 12-kilobase long GLA-gene is located at Xq22 on the long arm of the X

chromosome; it has seven exons 11 , and encodes a 55-kDa precursor

glycoprotein which is then proteolytically cleaved to the mature 51-kDaα-GAL

12 .α-GAL is a homodimeric glycoprotein consisting of 2 identical 49-kDa

subunits; each monomer is composed of two domains (Fig 1.), and domain 1

contains the active site. After binding a galactosylated substrate (primarily

globotriaosylceramide),α-GAL cleaves the glycosidic linkage and removes the

13 galactose from the glycolipids during the catabolism of macromolecules .



Mutations in the GLA-gene leads to absent or deficient synthesis ofα-GAL with

two corresponding general phenotypes. The classic (or severe) phenotype

shows noαactivity detectable in the tissues and has symptoms affecting-GAL

multiple organ systems, and the mild phenotype shows some residualα-GAL

activity and has symptoms generally restricted to cardiac or renal anomalies 14 .



- 2 -