1
Glycogen Storage Disease type IV and early Implantation Defect: early
2
Trophoblastic Involvement associated with a new GBE1 Mutation
3
Linda Dainese1, Nicolas Adam1, Sabah Boudjemaa1, Kamel Hadid1, Jonathan Rosenblatt2,
4
Jean-Marie Jouannic2, Delphine Heron3, Roseline Froissart4, Aurore Coulomb1
5 6
1-
7 8
Trousseau – AP-HP, Paris, France ; 2-
9 10
13
Service de gynécologie Obstétrique, Diagnostic anténatal, médecine fœtale et échographie, Hôpital d’Enfants Armand Trousseau – AP-HP, Paris, France ;
3-
11 12
Service d’Anatomie et Cytologie Pathologiques– Hôpital d’Enfants Armand
Département de génétique et cytogénétique, Unité Fonctionnelle de génétique médicale, Groupe hospitalier Pitié-Salpêtrière, 75013 Paris, France ;
4-
Laboratoire des Maladies Héréditaires du Métabolisme, Centre de Biologie Est, Hospices Civils de Lyon, 69677 BRON, France ;
14 15 16
E-mail adresses :
17
Kamel Hadid: [email protected]
18
Sabah Boudjemaa: [email protected]
19
Jonathan Rosenblatt: [email protected]
20
Jean-Marie Jouannic: [email protected]
21
Delphine Heron: [email protected]
22
Roseline Froissart: [email protected]
23
Aurore Coulomb: [email protected]
Nicolas Adam: [email protected]
24 25 26
Running head: Dainese et al. GSD type IV: a new GBE1 Mutation
27
Corresponding author:
28
Linda Dainese, MD
29
Service d’Anatomie et Cytologie Pathologiques– Hôpital d’Enfants Armand Trousseau
30
26 avenue du Dr Arnold Netter
31
75 012 Paris, France
32
[email protected]
33
Fax +33 (0) 1 44 73 62 82
34
tel +33 (0) 1 44 73 61 82
35 36 37
38
Abstract
39
A 29-year-old primigravida presented with a spontaneous miscarriage at 8 weeks of gestation
40
(WG). There was no consanguinity in the family. Aspiration was performed. Pathological
41
examination showed immature villi with numerous slightly yellow intracytoplasmic
42
inclusions within the early implantation stage cytotrophoblastic cells. Inclusions were
43
periodic-acid-Schiff and Alcian blue positive and partially positive with periodic-acid-Schiff
44
with amylase. Diagnosis of Glycogen Storage Disease type IV (GSD IV) was made.
45
Genetic analysis of Glycogen Branching Enzyme 1 gene (GBE1) was performed in parents
46
and showed a novel deletion of one nucleotide c.1937delT affecting the mother and a
47
mutation affecting a consensus splice site c.691+2T>C in the father.
48
At subsequent pregnancy, genetic counseling with GBE1 gene analysis was performed on
49
throphoblastic biopsy and showed a mutated allele c.1937delT inherited from the mother. The
50
mother gave birth to a healthy unaffected female newborn.
51
Our findings demonstrate that GSD IV may affect early pregnancies leading to trophoblastic
52
damage and early fetal loss. Diagnosis canaccurately be made on pathological examination
53
and should be further documented by genetic analysis.
54 55
56 57 58 59 60 61
Key words: Early Implantation , GBE1, Genetic, GSD4, Pathology, Trophoblast
62
Introduction
63
GSD IV (Andersen Disease, Amylopectinosis, OMIM: 232500) is a rare, severe, inherited
64
disease that represents 3% of all glycogen storage disease, caused by a genetic defect in the
65
glycogen-branching-enzyme leading to the accumulation in different human tissue of
66
insoluble abnormal glycogen with fewer branching points (polyglucosan-like). This
67
accumulation induces tissue damages. Clinically, this disease is very heterogeneous
68
depending on the tissues involved. It may affect liver, central nervous system, skeletal
69
muscles or heart [1-4]. In its most severe form, neuromuscular involvement is characterized
70
by fetal akinesia, arthrogyrosis, and pulmonary hypoplasia leading to death in the perinatal
71
period. Placental involvement in these severe forms has been reported at 25 and 35 WG [2].
72
Only one report described placental polyglucosan-bodies accumulation in a third trimester
73
placenta [2]. This accumulation has never been reported in the first trimester. The aim of this
74
study is to report pathological and genetic data of a GSD IV on first trimester pregnancy
75
miscarriage.
76 77 78
Clinical observation
79
A 29-year-old healthy primigravida patient presented a spontaneous gestation. This patient
80
had no medical history. There was no consanguinity in the family. Beta-HCG level was
81
within the normal range. The first trimester ultrasound was performed at 8 WG and showed a
82
40 mm ovular cavity containing two embryos measuring 19 mm and 19,2 mm without any
83
inter amniotic membrane, corresponding to a monochorial monoamniotic twin pregnancy. No
84
cardiac activity was observed in both embryos. Endo uterine aspiration was then performed
85
and the aspiration material was sent to our pathological department. Beta-HCG level
86
performed following the aspiration was within the normal range (16 UI/l).
87
Pathological findings
88
Aspirated material weighted 53 g and didn’t show embryonic structures on gross examination.
89
Three tissue blocks were performed according to the institutional protocol. Three additional
90
blocks were performed in a second run. Hematoxylin-Eosin-saffron (HES), Periodic-acid-
91
schiff (PAS), PAS-amylase and Alcian Blue stains were performed. Microscopic analysis
92
showed immature villi lined by two layers of cytotrophoblastic and syncythiotrophoblastic
93
cells. Extravillous trophoblastic cells located in the intervillous space, corresponding to the
94
anchoring villi and cytotrophoblastic cells from the floor of the placenta were overloaded by
95
intracytoplasmic inclusions (Figure 1A). These inclusions were of variable size, giving a
96
signet ring cell appearance as it is observed in carcinoma. This trophoblastic cell population
97
corresponds to the early implantation stage present between 6 to 12 weeks from the last
98
menstrual period. The invasive intermediate trophoblast which permeates the endometrium in
99
the implantation site was also affected by the storage (Figure 1B).
100
Some endovascular trophoblastic cells derived from the cytotrophoblastic shell forming plugs
101
within uterine arteries also showed polyglucosan accumulation (Figure 1C). These inclusions
102
were rarely observed within the villous trophoblast, both cyto and syncythiotrophoblastic cells.
103
Interestingly, polyclusosan inclusions were not observed in embryonic cells. Liver, muscle
104
and central nervous system cells couldn’t be observed at this early stage of development
105
(Figure 1D). Theses inclusions were slightly yellow on HE stains and didn’t show Malt cross
106
reaction under polarized light (Figure 1A, 1B, 1C) and were usually unique and of different
107
size within trophoblastic cells or rarely multiple within the same cell. Large amount of
108
vacuolated extravillous trophoblast within the intervillous space was associated with necrosis.
109
Vacuoles were stained purple with PAS, partially stained with PAS-amylase and were slightly
110
stained in blue with Alcian Blue (Figure 2). These findings were consistent with a
111
polyglucosan-like composition of the vacuoles and we concluded to a GSD IV involving the
112
early implantation stage trophoblast.. Neither enzymatic assay nor molecular analysis could
113
be performed on the pregnancy loss material because of lack of frozen tissue.
114
GBE1 mutations testing
115
A constitutional genetic analysis was performed on both parents after informed consent.
116
Genomic DNA was extracted from parents' leucocytes using standard procedures. All 16
117
exons and the intron boundaries of the GBE1 gene were amplified by PCR and sequenced in
118
both directions using the BigDye Terminator Cycle Sequencing Kit v3.1 (Applied Biosystems)
119
and an ABI PRISM 3730xl DNA analyzer (Applied Biosystems), according to the
120
manufacturer’s instructions.
121
Both parents were found to be carriers for a single mutation on the GBE1 gene. The mother
122
was heterozygous for the novel mutation c.1937delT which results in a frameshift beginning
123
at amino acid Phe in postion 646 and a premature stop codon 4 amino acids downstream
124
(p.Phe646Sfs*5). The father was heterozygous for the mutation c.691+2T>C located in a
125
consensus splice site. This mutation has previously been described [5].
126
Follow-up
127
The patient had a second single gestation. Trophoblast biopsy performed at 12 GW for genetic
128
analysis showed only the mutation inherited from the mother (c.1937delT). The pregnancy
129
evolved normally and the mother gave birth to a healthy 3260 gr and 48 cm girl at 39 WG.
130
Discussion
131
We report a new GSD IV form affecting trophoblastic cells from the early implantation
132
stageleading to a first trimester miscarriage of a monochorial monoamniotic twin pregnancy
133
at 8 weeks of gestation, associated with a c691+2T>C in the mother and a 1967delT in the
134
father.
135
This huge amount of accumulation within extravillous trophoblastic cells in the intervillous
136
space with necrosis should not be misdiagnosed as a placental metastasis of a signet ring cell
137
carcinoma. Placental metastasis are exceptional and are reported for maternal melanoma,
138
cervical carcinoma, lymphoma, leukemia, thyroid, breast and lung carcinomas. Signet ring
139
cell carcinoma metastasis has never been reported in the placenta [6]. The trophoblastic
140
accumulation within the intervillous space should not be misinterpreted as gestational
141
trophoblastic disease ormassive chronic intervillositis.
142
This accumulation within the extravillous trophoblast at the early implantation stage and the
143
defect in the vascular remodeling induced by the invasion intermediate trophoblast are
144
probably responsible for a defect in the next step of the early implantation stage leading to the
145
arrest of the gestation at 8 GW.
146
Interestingly, amylopectin-like accumulation was observed in all trophoblastic cells,
147
consistent with the homozygous status of this twin pregnancy.
148
There were no inclusions in the embryonic tissue present within this miscarriage. No liver,
149
muscle or nervous tissues were present because of the early stage of development The only
150
embryonal cells observed were undifferentiated mesenchymal cells and somites.
151
GSD IV is caused by lower or absent activity of the glycogen branching enzyme, leading to
152
the accumulation of insoluble abnormal glycogen with fewer branching points. In our case,
153
the large amount of storage cells is probably related to a totally deficient glycogen branching
154
enzyme activity.
155
In its classical form, GSD IV begins within the first month of life by liver dysfunction leading
156
to cirrhosis and portal hypertension, and causing death in the first years of life. This classical
157
hepatic form is typically associated with growth retardation and hypotonia. In some cases,
158
hypertrophic cardiomyopathy is also described [7]. Liver biopsy shows amphophilic
159
intracytoplasmic inclusions staining intensely with PAS, partially resistant to diastase and
160
positive with Colloidal iron stain [8]. Differential diagnosis of the hepatic form includes other
161
glycogen storage diseases, GSD III, Lafora disease, mitochondrial depletion syndromes. The
162
diagnosis of GSD IV is usually made on pathological examination of liver biopsy showing
163
exactly the same inclusions as in our case.
164
The fatal perinatal neuromuscular form presents with fetal akinesia deformation sequence
165
(FADS), arthrogryposis, polyhydramnios, fetal hydrops and neonatal hypotonia. Death
166
usually occurs between 4 weeks and 4 months. Pathology shows typical neuronal and
167
muscular PAS positive and diastase resistant inclusions [9]. Differential diagnosis includes
168
spinal muscular atrophy, Pompe disease, Zellweger syndrome and congenital disorders of the
169
glycosylation but the pathological examination showing the typical inclusions in neuronal or
170
muscular cells will prompt the pathologist to the diagnosis [1]. Cases with non-progressive
171
hepatic and congenital non-progressive muscular forms have also been described [8,10]. A
172
late onset form also exists, known as Adult Polyglucosan Body Disease (APBD).
173
In this form, neurological symptoms are predominant; they begin in the fourth to sixth decade
174
and are characterized by progressive bladder dysfunction, often followed by motor and
175
sensory deficits and mild cognitive impairment in about half of the patients. Pathology will
176
show typical neuron and astrocyte inclusions of polyglucosan-like bodies [4].
177
GSD IV may affect several organs and can be difficult to classify. In the progressive hepatic
178
form, hepatic transplantation remains the only effective treatment of GSD IV. In some cases,
179
extra hepatic resorption of amylopectine has been demonstrated after liver transplantation.
180
The mechanism of this resorption remains unknown but is attributed to cell migration from
181
the donor liver to the recipient heart [11,12,13]. Development of a mouse model that
182
recapitulates symptomatology of GSD IV opens the field for new therapeutic innovations.
183
However, microscopic analysis of the mutated mice’s endometrium and placental tissues has
184
not been performed [14].
185
In conclusion, these findings extend the field of the phenotypic manifestations of GSD IV in
186
early implantation stage trophoblastic cells. A GSD IV diagnosis on early miscarriage
187
material is possible on pathological examination and should be confirmed by enzymatic and
188
genetic analysis of both miscarriage material and parents.
189
190 191 192 193 194 195 196 197
References 1. Magoulas PL, El-Hattab AW. Glycogen Storage Disease Type IV. Gene Review
2013; [Internet]. 2. Konstantinidou AE, Anninos H, Dertinger S, et al. Placental involvement in
glycogen storage disease type IV. Placenta 2008; 29:378-81. 3. L'herminé-Coulomb A, Beuzen F, Bouvier R, et al. Fetal type IV glycogen storage
198
disease: clinical, enzymatic, and genetic data of a pure muscular form with
199
variable and early antenatal manifestations in the same family. Am J Med Genet
200
2005; 139A:118-22.
201 202 203
4. Dainese L, Monin ML, Demeret S, et al. Abnormal glycogen in astrocytes is
sufficient to cause adult polyglucosan body disease. Gene 2013; 515: 376-379. 5. Fernandez C, Halbert C, De Paula AM, et al. Non-lethal neonatal neuromuscular
204
variant of glycogenosis type IV with novel GBE1 mutations. Muscle Nerve 2010;
205
41(2):269-71.
206
6. Dessolle L, Dalmon C, Roche B, et al. Placental metastases from maternal
207
malignancies: review of the literature. J Gynecol Obstet Biol Reprod 2007; 36:
208
344-53.
209
7. Aksu T, Colak A, Tufekcioglu O. Cardiac Involvement in Glycogen Storage
210
Disease Type IV: Two Cases and the Two Ends of a Spectrum. Case Rep Med
211
2012;764286.
212
8. Magoulas PL, El-Hattab AW, Roy A, et al. Diffuse reticuloendothelial system
213
involvement in type IV glycogen storage disease with a novel GBE1 mutation: a
214
case report and review. Hum. Pathol 2012; 43:943-51.
215
9. Lamperti C, Salani S, Lucchiari S, et al. Neuropathological study of skeletal
216
muscle, heart, liver, and brain in a neonatal form of glycogen storage disease type
217
IV associated with a new mutation in GBE1 gene. J Inherit Metab Dis 2009;
218
32:161-8.
219 220 221
10. Burrow TA, Hopkin RJ, Bove KE, et al. Non-lethal congenital hypotonia due to
glycogen storage disease type IV. Am J Med Genet 2006; 140:878-82. 11. Davis MK, Weinstein DA. Liver transplantation in children with glycogen storage
222
disease: controversies and evaluation of the risk/benefit of this procedure. Pediatr
223
Transplant 2008; 12:137-45.
224 225 226 227 228
12. Matern D, Starzl TE, Arnaout W, et al. Liver transplantation for glycogen storage
disease types I, III, and IV.Eur J Pediatr 1999; 158: 43-8. 13. Oldfors A, Dimauro S. New insights in the field of muscle glycogenoses. Curr
Opin Neurol. 2013; 26:544-53. 14. Akman HO, Sheiko T, Tay SK, et al. Generation of a novel mouse model that
229
recapitulates early and adult onset glycogenosis type IV. Hum Mol Genet 2011;
230
20:4430-9.
231
232
Figure legends:
233 234
Figure 1: Immature villi lined by two layers of cytotrophoblastic and syncythiotrophoblastic
235
cells. Extravillous trophoblastic cells located in the intervillous space (anchoring villi) and
236
cytotrophoblastic cells from the floor of the placenta overloaded by intracytoplasmic
237
inclusions (Figure 1A, HES X 10). Invasive intermediate trophoblast affected by the storage
238
(Figure 1B, HES X20). Endovascular trophoblastic cells forming plugs within uterine arteries
239
showing polyglucosan accumulation (Figure 1C, HES X 20).
240
Embryonal undifferentiated mesenchymal cells without polyglucosan accumulation (Figure
241
1D, HES X 20).
242
Figure 2: Vacuoles stained purple with PAS (Figure 2A, HES X20) and slightly stained in
243
blue with Alcian Blue (Figure 2B, HES X20).
Glycogen Storage Disease type IV and early Implantation Defect: early
2
Trophoblastic Involvement associated with a new GBE1 Mutation
3
Linda Dainese1, Nicolas Adam1, Sabah Boudjemaa1, Kamel Hadid1, Jonathan Rosenblatt2,
4
Jean-Marie Jouannic2, Delphine Heron3, Roseline Froissart4, Aurore Coulomb1
5 6
1-
7 8
Trousseau – AP-HP, Paris, France ; 2-
9 10
13
Service de gynécologie Obstétrique, Diagnostic anténatal, médecine fœtale et échographie, Hôpital d’Enfants Armand Trousseau – AP-HP, Paris, France ;
3-
11 12
Service d’Anatomie et Cytologie Pathologiques– Hôpital d’Enfants Armand
Département de génétique et cytogénétique, Unité Fonctionnelle de génétique médicale, Groupe hospitalier Pitié-Salpêtrière, 75013 Paris, France ;
4-
Laboratoire des Maladies Héréditaires du Métabolisme, Centre de Biologie Est, Hospices Civils de Lyon, 69677 BRON, France ;
14 15 16
E-mail adresses :
17
Kamel Hadid: [email protected]
18
Sabah Boudjemaa: [email protected]
19
Jonathan Rosenblatt: [email protected]
20
Jean-Marie Jouannic: [email protected]
21
Delphine Heron: [email protected]
22
Roseline Froissart: [email protected]
23
Aurore Coulomb: [email protected]
Nicolas Adam: [email protected]
24 25 26
Running head: Dainese et al. GSD type IV: a new GBE1 Mutation
27
Corresponding author:
28
Linda Dainese, MD
29
Service d’Anatomie et Cytologie Pathologiques– Hôpital d’Enfants Armand Trousseau
30
26 avenue du Dr Arnold Netter
31
75 012 Paris, France
32
[email protected]
33
Fax +33 (0) 1 44 73 62 82
34
tel +33 (0) 1 44 73 61 82
35 36 37
38
Abstract
39
A 29-year-old primigravida presented with a spontaneous miscarriage at 8 weeks of gestation
40
(WG). There was no consanguinity in the family. Aspiration was performed. Pathological
41
examination showed immature villi with numerous slightly yellow intracytoplasmic
42
inclusions within the early implantation stage cytotrophoblastic cells. Inclusions were
43
periodic-acid-Schiff and Alcian blue positive and partially positive with periodic-acid-Schiff
44
with amylase. Diagnosis of Glycogen Storage Disease type IV (GSD IV) was made.
45
Genetic analysis of Glycogen Branching Enzyme 1 gene (GBE1) was performed in parents
46
and showed a novel deletion of one nucleotide c.1937delT affecting the mother and a
47
mutation affecting a consensus splice site c.691+2T>C in the father.
48
At subsequent pregnancy, genetic counseling with GBE1 gene analysis was performed on
49
throphoblastic biopsy and showed a mutated allele c.1937delT inherited from the mother. The
50
mother gave birth to a healthy unaffected female newborn.
51
Our findings demonstrate that GSD IV may affect early pregnancies leading to trophoblastic
52
damage and early fetal loss. Diagnosis canaccurately be made on pathological examination
53
and should be further documented by genetic analysis.
54 55
56 57 58 59 60 61
Key words: Early Implantation , GBE1, Genetic, GSD4, Pathology, Trophoblast
62
Introduction
63
GSD IV (Andersen Disease, Amylopectinosis, OMIM: 232500) is a rare, severe, inherited
64
disease that represents 3% of all glycogen storage disease, caused by a genetic defect in the
65
glycogen-branching-enzyme leading to the accumulation in different human tissue of
66
insoluble abnormal glycogen with fewer branching points (polyglucosan-like). This
67
accumulation induces tissue damages. Clinically, this disease is very heterogeneous
68
depending on the tissues involved. It may affect liver, central nervous system, skeletal
69
muscles or heart [1-4]. In its most severe form, neuromuscular involvement is characterized
70
by fetal akinesia, arthrogyrosis, and pulmonary hypoplasia leading to death in the perinatal
71
period. Placental involvement in these severe forms has been reported at 25 and 35 WG [2].
72
Only one report described placental polyglucosan-bodies accumulation in a third trimester
73
placenta [2]. This accumulation has never been reported in the first trimester. The aim of this
74
study is to report pathological and genetic data of a GSD IV on first trimester pregnancy
75
miscarriage.
76 77 78
Clinical observation
79
A 29-year-old healthy primigravida patient presented a spontaneous gestation. This patient
80
had no medical history. There was no consanguinity in the family. Beta-HCG level was
81
within the normal range. The first trimester ultrasound was performed at 8 WG and showed a
82
40 mm ovular cavity containing two embryos measuring 19 mm and 19,2 mm without any
83
inter amniotic membrane, corresponding to a monochorial monoamniotic twin pregnancy. No
84
cardiac activity was observed in both embryos. Endo uterine aspiration was then performed
85
and the aspiration material was sent to our pathological department. Beta-HCG level
86
performed following the aspiration was within the normal range (16 UI/l).
87
Pathological findings
88
Aspirated material weighted 53 g and didn’t show embryonic structures on gross examination.
89
Three tissue blocks were performed according to the institutional protocol. Three additional
90
blocks were performed in a second run. Hematoxylin-Eosin-saffron (HES), Periodic-acid-
91
schiff (PAS), PAS-amylase and Alcian Blue stains were performed. Microscopic analysis
92
showed immature villi lined by two layers of cytotrophoblastic and syncythiotrophoblastic
93
cells. Extravillous trophoblastic cells located in the intervillous space, corresponding to the
94
anchoring villi and cytotrophoblastic cells from the floor of the placenta were overloaded by
95
intracytoplasmic inclusions (Figure 1A). These inclusions were of variable size, giving a
96
signet ring cell appearance as it is observed in carcinoma. This trophoblastic cell population
97
corresponds to the early implantation stage present between 6 to 12 weeks from the last
98
menstrual period. The invasive intermediate trophoblast which permeates the endometrium in
99
the implantation site was also affected by the storage (Figure 1B).
100
Some endovascular trophoblastic cells derived from the cytotrophoblastic shell forming plugs
101
within uterine arteries also showed polyglucosan accumulation (Figure 1C). These inclusions
102
were rarely observed within the villous trophoblast, both cyto and syncythiotrophoblastic cells.
103
Interestingly, polyclusosan inclusions were not observed in embryonic cells. Liver, muscle
104
and central nervous system cells couldn’t be observed at this early stage of development
105
(Figure 1D). Theses inclusions were slightly yellow on HE stains and didn’t show Malt cross
106
reaction under polarized light (Figure 1A, 1B, 1C) and were usually unique and of different
107
size within trophoblastic cells or rarely multiple within the same cell. Large amount of
108
vacuolated extravillous trophoblast within the intervillous space was associated with necrosis.
109
Vacuoles were stained purple with PAS, partially stained with PAS-amylase and were slightly
110
stained in blue with Alcian Blue (Figure 2). These findings were consistent with a
111
polyglucosan-like composition of the vacuoles and we concluded to a GSD IV involving the
112
early implantation stage trophoblast.. Neither enzymatic assay nor molecular analysis could
113
be performed on the pregnancy loss material because of lack of frozen tissue.
114
GBE1 mutations testing
115
A constitutional genetic analysis was performed on both parents after informed consent.
116
Genomic DNA was extracted from parents' leucocytes using standard procedures. All 16
117
exons and the intron boundaries of the GBE1 gene were amplified by PCR and sequenced in
118
both directions using the BigDye Terminator Cycle Sequencing Kit v3.1 (Applied Biosystems)
119
and an ABI PRISM 3730xl DNA analyzer (Applied Biosystems), according to the
120
manufacturer’s instructions.
121
Both parents were found to be carriers for a single mutation on the GBE1 gene. The mother
122
was heterozygous for the novel mutation c.1937delT which results in a frameshift beginning
123
at amino acid Phe in postion 646 and a premature stop codon 4 amino acids downstream
124
(p.Phe646Sfs*5). The father was heterozygous for the mutation c.691+2T>C located in a
125
consensus splice site. This mutation has previously been described [5].
126
Follow-up
127
The patient had a second single gestation. Trophoblast biopsy performed at 12 GW for genetic
128
analysis showed only the mutation inherited from the mother (c.1937delT). The pregnancy
129
evolved normally and the mother gave birth to a healthy 3260 gr and 48 cm girl at 39 WG.
130
Discussion
131
We report a new GSD IV form affecting trophoblastic cells from the early implantation
132
stageleading to a first trimester miscarriage of a monochorial monoamniotic twin pregnancy
133
at 8 weeks of gestation, associated with a c691+2T>C in the mother and a 1967delT in the
134
father.
135
This huge amount of accumulation within extravillous trophoblastic cells in the intervillous
136
space with necrosis should not be misdiagnosed as a placental metastasis of a signet ring cell
137
carcinoma. Placental metastasis are exceptional and are reported for maternal melanoma,
138
cervical carcinoma, lymphoma, leukemia, thyroid, breast and lung carcinomas. Signet ring
139
cell carcinoma metastasis has never been reported in the placenta [6]. The trophoblastic
140
accumulation within the intervillous space should not be misinterpreted as gestational
141
trophoblastic disease ormassive chronic intervillositis.
142
This accumulation within the extravillous trophoblast at the early implantation stage and the
143
defect in the vascular remodeling induced by the invasion intermediate trophoblast are
144
probably responsible for a defect in the next step of the early implantation stage leading to the
145
arrest of the gestation at 8 GW.
146
Interestingly, amylopectin-like accumulation was observed in all trophoblastic cells,
147
consistent with the homozygous status of this twin pregnancy.
148
There were no inclusions in the embryonic tissue present within this miscarriage. No liver,
149
muscle or nervous tissues were present because of the early stage of development The only
150
embryonal cells observed were undifferentiated mesenchymal cells and somites.
151
GSD IV is caused by lower or absent activity of the glycogen branching enzyme, leading to
152
the accumulation of insoluble abnormal glycogen with fewer branching points. In our case,
153
the large amount of storage cells is probably related to a totally deficient glycogen branching
154
enzyme activity.
155
In its classical form, GSD IV begins within the first month of life by liver dysfunction leading
156
to cirrhosis and portal hypertension, and causing death in the first years of life. This classical
157
hepatic form is typically associated with growth retardation and hypotonia. In some cases,
158
hypertrophic cardiomyopathy is also described [7]. Liver biopsy shows amphophilic
159
intracytoplasmic inclusions staining intensely with PAS, partially resistant to diastase and
160
positive with Colloidal iron stain [8]. Differential diagnosis of the hepatic form includes other
161
glycogen storage diseases, GSD III, Lafora disease, mitochondrial depletion syndromes. The
162
diagnosis of GSD IV is usually made on pathological examination of liver biopsy showing
163
exactly the same inclusions as in our case.
164
The fatal perinatal neuromuscular form presents with fetal akinesia deformation sequence
165
(FADS), arthrogryposis, polyhydramnios, fetal hydrops and neonatal hypotonia. Death
166
usually occurs between 4 weeks and 4 months. Pathology shows typical neuronal and
167
muscular PAS positive and diastase resistant inclusions [9]. Differential diagnosis includes
168
spinal muscular atrophy, Pompe disease, Zellweger syndrome and congenital disorders of the
169
glycosylation but the pathological examination showing the typical inclusions in neuronal or
170
muscular cells will prompt the pathologist to the diagnosis [1]. Cases with non-progressive
171
hepatic and congenital non-progressive muscular forms have also been described [8,10]. A
172
late onset form also exists, known as Adult Polyglucosan Body Disease (APBD).
173
In this form, neurological symptoms are predominant; they begin in the fourth to sixth decade
174
and are characterized by progressive bladder dysfunction, often followed by motor and
175
sensory deficits and mild cognitive impairment in about half of the patients. Pathology will
176
show typical neuron and astrocyte inclusions of polyglucosan-like bodies [4].
177
GSD IV may affect several organs and can be difficult to classify. In the progressive hepatic
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form, hepatic transplantation remains the only effective treatment of GSD IV. In some cases,
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extra hepatic resorption of amylopectine has been demonstrated after liver transplantation.
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The mechanism of this resorption remains unknown but is attributed to cell migration from
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the donor liver to the recipient heart [11,12,13]. Development of a mouse model that
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recapitulates symptomatology of GSD IV opens the field for new therapeutic innovations.
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However, microscopic analysis of the mutated mice’s endometrium and placental tissues has
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not been performed [14].
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In conclusion, these findings extend the field of the phenotypic manifestations of GSD IV in
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early implantation stage trophoblastic cells. A GSD IV diagnosis on early miscarriage
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material is possible on pathological examination and should be confirmed by enzymatic and
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genetic analysis of both miscarriage material and parents.
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190 191 192 193 194 195 196 197
References 1. Magoulas PL, El-Hattab AW. Glycogen Storage Disease Type IV. Gene Review
2013; [Internet]. 2. Konstantinidou AE, Anninos H, Dertinger S, et al. Placental involvement in
glycogen storage disease type IV. Placenta 2008; 29:378-81. 3. L'herminé-Coulomb A, Beuzen F, Bouvier R, et al. Fetal type IV glycogen storage
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disease: clinical, enzymatic, and genetic data of a pure muscular form with
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variable and early antenatal manifestations in the same family. Am J Med Genet
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2005; 139A:118-22.
201 202 203
4. Dainese L, Monin ML, Demeret S, et al. Abnormal glycogen in astrocytes is
sufficient to cause adult polyglucosan body disease. Gene 2013; 515: 376-379. 5. Fernandez C, Halbert C, De Paula AM, et al. Non-lethal neonatal neuromuscular
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variant of glycogenosis type IV with novel GBE1 mutations. Muscle Nerve 2010;
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41(2):269-71.
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6. Dessolle L, Dalmon C, Roche B, et al. Placental metastases from maternal
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malignancies: review of the literature. J Gynecol Obstet Biol Reprod 2007; 36:
208
344-53.
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7. Aksu T, Colak A, Tufekcioglu O. Cardiac Involvement in Glycogen Storage
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Disease Type IV: Two Cases and the Two Ends of a Spectrum. Case Rep Med
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2012;764286.
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8. Magoulas PL, El-Hattab AW, Roy A, et al. Diffuse reticuloendothelial system
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involvement in type IV glycogen storage disease with a novel GBE1 mutation: a
214
case report and review. Hum. Pathol 2012; 43:943-51.
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9. Lamperti C, Salani S, Lucchiari S, et al. Neuropathological study of skeletal
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muscle, heart, liver, and brain in a neonatal form of glycogen storage disease type
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IV associated with a new mutation in GBE1 gene. J Inherit Metab Dis 2009;
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32:161-8.
219 220 221
10. Burrow TA, Hopkin RJ, Bove KE, et al. Non-lethal congenital hypotonia due to
glycogen storage disease type IV. Am J Med Genet 2006; 140:878-82. 11. Davis MK, Weinstein DA. Liver transplantation in children with glycogen storage
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disease: controversies and evaluation of the risk/benefit of this procedure. Pediatr
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Transplant 2008; 12:137-45.
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12. Matern D, Starzl TE, Arnaout W, et al. Liver transplantation for glycogen storage
disease types I, III, and IV.Eur J Pediatr 1999; 158: 43-8. 13. Oldfors A, Dimauro S. New insights in the field of muscle glycogenoses. Curr
Opin Neurol. 2013; 26:544-53. 14. Akman HO, Sheiko T, Tay SK, et al. Generation of a novel mouse model that
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recapitulates early and adult onset glycogenosis type IV. Hum Mol Genet 2011;
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20:4430-9.
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Figure legends:
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Figure 1: Immature villi lined by two layers of cytotrophoblastic and syncythiotrophoblastic
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cells. Extravillous trophoblastic cells located in the intervillous space (anchoring villi) and
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cytotrophoblastic cells from the floor of the placenta overloaded by intracytoplasmic
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inclusions (Figure 1A, HES X 10). Invasive intermediate trophoblast affected by the storage
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(Figure 1B, HES X20). Endovascular trophoblastic cells forming plugs within uterine arteries
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showing polyglucosan accumulation (Figure 1C, HES X 20).
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Embryonal undifferentiated mesenchymal cells without polyglucosan accumulation (Figure
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1D, HES X 20).
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Figure 2: Vacuoles stained purple with PAS (Figure 2A, HES X20) and slightly stained in
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blue with Alcian Blue (Figure 2B, HES X20).
