Sandbox:Vellayat

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vellayat Ali M.B.B.S[2]

Type of respiratory failure	Causes/Etiology		Onset	Clinical manifestations						Investigations		Gold standard	Other features
				Symptoms					Physical exam
				Dyspnea	Cough	Sputum production	Fever	Others		Chest X-ray	Labs
Hypoxic respiratory failure (Type 1 respiratory failure)	Cardiogenic pulmonary edema	Acute decompensated heart failure	Acute	+	+ with frothy expectoration	-	+/-	Cough with pink frothy expectoration Dyspnea Increased pulse rate	Wheezing Crackles Leg edema in both legs Obtundation	Cardiomegaly and interstitial edema in chest radiograph	ST and T waves abnormalities in ECG SaO2 <90%	Clinical diagnosis	High levels of BNP and pro-BNP
	Non cardiogenic pulmonary edema	Adult respiratory distress syndrome (ARDS)	Acute	+	+/-	+/-	+/-	Cyanosis	Tachypnea Tachycardia Diffuse crackles	Diffuse, bilateral, alveolar infiltrates without cardiomegaly	Hypoxemia with acute respiratory alkalosis in arterial blood gases Alveolar infiltrates in chest X-Ray Bilateral opacities in CT	Clinical diagnosis	According to Berlin definition: One week of new or worse respiratory symptoms or clinical insult Symptoms can not be explained by cardiac disease Bilateral opacities in chest X-Ray or CT Compromised oxygenation
		High-Altitude Pulmonary edema (HAPE)	Acute	+	+ with frothy expectoration		+	Chest tightness Decreased exercise performance	Wheezing	Patchy alveolar infiltrates, predominantly in the right central hemithorax, which become more confluent and bilateral as the illness progresses	High levels of white blood cell count Decreased of oxygen saturation	Clinical diagnosis	Occurrs over 2500 m Descent is mandatory in >4000 m
		Neurogenic pulmonary edema	Acute	+			+/-	Dyspnea Hemoptysis	Rales Bilateral crackles		Leukocytosis Bilateral hyperdense infiltration in chest X-Ray PaO2/FiO2 ratio <200	PaO2/FiO2 ratio <200 Bilateral infiltration No left atrial hypertension CNS injury No evidence of other causes of ARDS	Major causes of NPE are epileptic seizures, cerebral hemorrhages and brain injury
		Pulmonary embolism	Acute, subacute, Chronic	+	+			Dyspnea Chest pain Cough Orthopnea	Wheezing Tachypnea Edema Decreased breath sounds Tachycardia		Leukocytosis, elevated erythrocyte sedimentation and lactic acid in complete blood count Hypoxemia in arterial blood gas D-dimer to rule out other diseases Hamptom and Westermark sign in chest X-Ray Tachycardia and abnormalities in ST-segment and T waves are observed in ECG	Computed tomography pulmonary angiogram (CTPA) or catheter based pulmonary angiography	Venous thromboembolism(VTE)
	Pneumonia		Acute	+	+	+	+	Productive cough Chest pain Fever	Egophony Crackles Tactile fremitus		Leukocytosis Infiltration in chest X-Ray Optional microbiological test	Clinical manifestations and infiltration chest X-Ray with or without microbiological test	Community-acquired pneumonia Hospital-acquired pneumonia Healthcare-associated pneumonia Ventilator-associated pneumonia Aspiration pneumonia
	Idiopatic chronic lung fibrosis		Chronic	+	+	-		Dyspnea Non-productive cough	Clubbing of the digits Crackles		Reticular or nodular pattern in chest X-Ray Nodules and bilateral hiliar adenopathy in CT	Lung biopsy when Lab, imaging and PFT do not allow to do the diagnosis	Reduced FEV1 and FVC in spirometry
Hypercapnic respiratory failure (Type 2 respiratory failure)	COPD		Acute Chronic Acute-on-chronic	+	+	+	+/-	Dyspnea Cough with/without sputum Exercise intolerance Acute exacerbations may affect CNS, ranging from irritability to decreased responsiveness. CNS symptoms may be the only manifestation in elderly with baseline hypercapnia.2	Clubbing Tachypnea Barrel shaped chest Decreased breath sounds with prolonged expiration Rhonchi and Wheeze Use of accessory respiratory muscles Increased JVP, peripheral edema may manifest with right ventricular overload during an acute exacerbation.1		Chest X-ray: hyperinflation, flattened diaphragm, rapid tapering of vascular markings  PFTs: (FEV1/FVC) <70% of predicted    ABGs: Mild to moderate hypoxemia, hypercapnia with progression of disease, pH is around normal. < 7.3 points to respiratory acidosis
	Severe Asthma/Status Asthmaticus		Acute	+	-		-				PEF <40 percent predicted or personal best Pulse oximetry Chest X-ray: not required in acute conditions, may show hyperinflatio
	Drug Overdose		Acute	+		-	-
	Myasthenic crisis		Acute	+	+/-	+/-	+/-
	Guillain-Barré syndrome		Acute	+	-	-	+/-
Perioperative respiratory failure (Type 3 respiratory failure)	Post-operative atelectasis		Acute					Asyptomatic or increase work of breathing	Skin or lips blue Tachypnea Tachycardia		Bronchoscopy CT and chest X-Ray PaO2/FiO2 <300 mmHg	Clinical diagnosis with supportive test	Obstructive Non Obstructive
Type 4 respiratory failure	Shock		Acute					Oliguria Abnormal mental status Clammy skin Cool extremities	Hypotension Tachycardia Tachypnea Rales Gallop rythm		Electrocardigogram with isquemic abnormalities Visible congestion in chest X-Ray High levels of nitrogen Increased levels of lactic acid Low levels of Bicarbonate Echocardiography to identify any dysfunction	Clinical diagnosis with supportive test	Cardiac index decreased Troponin leves, chemestry screen, complete blood count Cardiogenic shock Septic shock Hypovolemic shock

Overview

underlying condition	Onset of respiratory failure	Physical examination	Symptoms	Labs and imaging	others
COPD	Acute Chronic Acute on chronic	Clubbing Tachypnea Barrel shaped chest Decreased breath sounds with prolonged expiration Rhonchi and Wheeze Use of accessory respiratory muscles Increased JVP, peripheral edema may manifest with right ventricular overload during an acute exacerbation.1	Dyspnea Cough with/without sputum Exercise intolerance Acute exacerbations may affect CNS, ranging from irritability to decreased responsiveness. CNS symptoms may be the only manifestation in elderly with baseline hypercapnia.2	Chest X-ray: hyperinflation, flattened diaphragm, rapid tapering of vascular markings  PFTs: (FEV1/FVC) <70% of predicted    ABGs: Mild to moderate hypoxemia, hypercapnia with progression of disease, pH is around normal, below 7.3 points to respiratory acidosis	History of smoking, cough and sputum production
Severe Asthma/Status Asthmaticus	Acute	Tachypnea Tachycardia Use of accessory respiratory muscles Unable to speak full sentences Orthopnea Pulsus paradoxus	Dyspnea Wheezing Cough Chest tightness	PEF <40 percent predicted or personal best Pulse oximetry Chest X-ray: not required in acute conditions, may show hyperinflation	Hx of Bronchial asthma Presence of Drowsiness3 and silent chest is a useful predictor of impending respiratory failure

Acute hypercapnic respiratory failure: the patient will have no, or minor, evidence of preexisting respiratory disease, and arterial blood gas tensions will show a high Paco₂, low pH, and normal bicarbonate.

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Chronic hypercapnic respiratory failure: evidence of chronic respiratory disease, high Paco₂, near normal pH, high bicarbonate.

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Acute-on-chronic hypercapnic respiratory failure: an acute deterioration in an individual with significant preexisting hypercapnic respiratory failure, high Paco₂, low pH, high bicarbonate.

Glycogen Storage Disease Type IV

Synonyms: GSD IV, Andersen Disease, Brancher deficiency; Amylopectinosis; Glycogen Branching Enzyme Deficiency, Glycogenosis IV

 

Overview:

 

Historical Perspective:  

- In 1952, B Illingworth and GT Cori observed accumulation of an abnormal glycogen (resembling amylopectin) in the liver of a patient with von Gierke’s Disease. They postulated this finding to a different type of enzymatic deficiency, and thus to a different type of glycogen storage disease.[1]

- In 1956, DH Andersen, an American pathologist and pediatrician, reported the first clinical case of the disease as "familial cirrhosis of the liver with storage of abnormal glycogen".[2]

- In 1966, BI Brown and DH Brown clearly demonstrated the deficiency of glycogen branching enzyme (alpha-1,4-glucan: alpha-1,4-glucan 6-glycosyl transferase) in a case of Type IV glycogenosis.[3]

 

Classification

There is no established system for the classification of GSD Type IV. The deficiency of GBE affecting the liver, the brain, the heart, and skeletal muscles leads to variable clinical presentations. Based on organ/tissue involvement, age of onset and clinical features, Andersen disease can be segregated into various forms [16] as below:

Form of Presentation	Age of  Onset	Clinical Features
Classic Hepatic Form     Neuromuscular form      A-Perinatal             B-Congenital         C-Late childhood form        D-Adult form	0-18 Mo         In utero      At birth          0-18 yrs    >18-21 yrs (any age in adulthood)	Infants present with failure to thrive, and hepatosplenomegaly. Progresses to portal hypertension, ascites, and liver failure, leading to death by 5 years of age.[17]     Prenatal symptoms include, polyhydramnios, hydrops fetalis, and decreased fetal movement; at birth severe hypotonia is observed requiring mechanical ventilation for respiratory support. [18][19] Cardiac findings like progressive cardiomyopathy may also be present.[19]  Newborns may have severe hypotonia, hyporeflexia, cardiomyopathy, depressed respiration and neuronal involvement, leading to death in early infancy. [21]     Presents in childhood at any age with myopathy as exercise intolerance, and cardiopathy as exertional dyspnea; and congestive heart failure in progressed cases. [21].   May present as isolated myopathy [23] or as Adult Polyglucosan Body Disease (APBD) [22]

Adult polyglucosan body disesase (APBD)

 

- Adult polyglucosan body disease is one of the neuromuscular variant of GSD Type IV.

- Typically, the first clinical manifestation is of urinary incontinence (secondary to neurogenic bladder), followed by gait disturbance (due to spastic paraplegia) and lower limb paresthesias (due to axonal neuropathy). [15]

Pathophysiology:

Pathogenesis:

-       Glycogen storage disease type IV is an autosomal recessive genetic disorder which results due to deficiency of glycogen branching enzyme (GBE).[4]

-       During Glycogenesis, the branching enzyme introduces branches to growing glycogen chains by transferring α-1,4-linked glucose monomers from the outer end of a chain into an α-1,6 position of the same or neighboring glycogen chain. [6]

-       Deficiency of GBE affects the branching process, yielding a polysaccharide which has fewer branching points and longer outer chains, thus resembling amylopectin. This new amylopectin-like structure is also known as polyglucosan. [7]

-       The enzyme deficiency affects all the bodily tissues; but liver, heart, skeletal muscles, and the nervous system are mostly affected.

-       The abnormally branched glycogen accumulates as intracytoplasmic non membrane-bound inclusions in hepatocytes, myocytes, and neuromuscular system; where it increases osmotic pressure within cells, causing cellular swelling and death.[8][9]

-       The altered structure also renders glycogen to become less soluble, and this is thought to lead into a foreign body reaction causing fibrosis, and finally culminating in liver failure. [10][11]

-       In skeletal muscle, accumulation leads to muscle weakness, fatigue, exercise intolerance, and muscular atrophy. [12]

-       Regarding the heart, a wide spectrum of cardiomyopathy from dilated to hypertrophic and from asymptomatic to decompensated heart failure may occur. [13]

-       Although exact mechanism is not known, glycogen deposition in the myocardium is thought to initiate signaling pathways which cause sarcomeric hypertrophy, resulting in hypertrophic cardiomyopathy.[14] 

   

Molecular Genetics:

   •     Glycogen branching enzyme is a 702 amino acid protein encoded by GBE1 gene mapped to chromosome 3p12.2 and is transmitted as an autosomal recessive trait. [21][5] HUGO Gene Nomenclature Committee https://www.genenames.org/cgi-bin/gene_symbol_report?hgnc_id=HGNC:4180 The Universal Protein Resource (UniProt) http://www.uniprot.org/uniprot/Q04446

    •       Mutations in the GBE1 are responsible for enzymatic deficiency, and so far 40 pathogenic variants have been identified in individuals with GSD IV or adult-onset polyglucosan body disease (APBD).PMID: 23285490 

CAUSES: 

The cause of GSD type IV is variable deficiency of glycogen branching enzyme. The deficiency is due to various mutations of GBE1 gene encoding the single polypeptide protein. 

Differential Diagnosis:

Comparisons may be useful for a differential diagnosis as a number of other disease conditions with clinical features may present similar to those associated with GSD Type IV.

Presenting as hepatomegaly in infancy, the following glycogen metabolism disorders should be differentiated from GSD Type IV;

-GSD Type I

-GSD Type III

-GSD Type VI

-Hepatic Phosphorylase b Kinase Deficiency

Metabolic disorders presenting with muscle weakness/myopathy during infancy should also be considered;

Muscle glycogen synthase deficiency (GSD0b)

Lysosomal acid maltase deficiency (GSD II)

Glycogen debrancher deficiency (GSD III)

Muscle phosphorylase deficiency (GSD V)

Aldolase A deficiency (GSD XII)

Glycogenin-1 deficiency (GSD XV)

 

EPIDEMIOLOGY:

FREQUENCY- The frequency of all glycogen storage diseases is estimated to be 1 in 20,000 to 25,000 live births, while GSD IV is estimated to occur in 1 in 600,000 to 800,000 individuals worldwide.  NORD GHR https://ghr.nlm.nih.gov/condition/glycogen-storage-disease-type-iv#statistics

SEX- Males and females appear to be affected in relatively equal numbers [NORD] because the deficiency of glycogen-branching enzyme activity is inherited as an autosomal-recessive trait.

RACE- Familial aggregation is observed in about 30% of adult polyglucosan body disease cases especially among Ashkenazi Jewish populations. NORD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

1.Structure of glycogens and amylopectins. III. Normal and abnormal human glycogen.

ILLINGWORTH B, CORI GT.

J Biol Chem. 1952 Dec;199(2):653-60

2. Familial cirrhosis of the liver with storage of abnormal glycogen.

ANDERSEN DH

Lab Invest. 1956 Jan-Feb; 5(1):11-20.

3. Lack of an alpha-1,4-glucan: alpha-1,4-glucan 6-glycosyl transferase in a case of type IV glycogenosis.

Brown BI, Brown DH.

Proc Natl Acad Sci U S A. 1966 Aug;56(2):725-9. 

4. Hum Mol Genet. 2011 Feb 1;20(3):455-65. doi: 10.1093/hmg/ddq492. Epub 2010 Nov 12.

Glycogen-branching enzyme deficiency leads to abnormal cardiac development: novel insights into glycogen storage disease IV. Lee YC¹, Chang CJ, Bali D, Chen YT, Yan YT.

5. Acta Myol. 2011 Oct; 30(2): 96–102.

PMCID: PMC3235878 Progress and problems in muscle glycogenoses

S. Di Mauro and R. Spiegel¹ 

6. Hum Mol Genet. 2015 Oct 15;24(20):5667-76. doi: 10.1093/hmg/ddv280. Epub 2015 Jul 21. 

7. PubMed: 15019703

Tay SK, Akman HO, Chung WK, Pike MG, Muntoni F, Hays AP, Shanske S, Valberg SJ, Mickelson JR, Tanji K, DiMauro S. Fatal infantile neuromuscular presentation of glycogen storage disease type IV. Neuromuscul Disord. 2004;14:253–60. 

8. Isolation of human glycogen branching enzyme cDNAs by screening complementation in yeast.

Thon VJ, Khalil M, Cannon JF

J Biol Chem. 1993 Apr 5; 268(10):7509-13.

9. Hum Pathol. 2012 Jun;43(6):943-51. doi: 10.1016/j.humpath.2011.10.001. Epub 2012 Feb 2. 

10. DOI: 10.1056/NEJM199101033240111

11. Severe cardiopathy enzyme deficiency in branching

Serenella Servidei, M.D., Roger E. Riepe, M.D., Claire Langston, M.D.,Lloyd Y: Tani, M.D., J. Timothy Bricker, M.D., Naoma Crisp-Lindgren, M.D.,Henry Travers, M.D., Dawna Armstrong, M.D., and

Salvatore DiMauro, M.D. 

12. National Organization for Rare Disorders (NORD): rarediseases.org/rare-diseases/andersen-disease-gsd-iv/

13. http://dx.doi.org/10.1155/2012/764286

14. DOI: 10.1056/NEJMra0902923 

15. Ann Neurol. 2012 Sep;72(3):433-41. doi: 10.1002/ana.23598. Adult polyglucosan body disease: Natural History and Key Magnetic Resonance Imaging Findings.

Mochel F¹, Schiffmann R, Steenweg ME, Akman HO, Wallace M, Sedel F, Laforêt P, Levy R, Powers JM, Demeret S, Maisonobe T, Froissart R, Da Nobrega BB, Fogel BL, Natowicz MR, Lubetzki C, Durr A, Brice A, Rosenmann H, Barash V, Kakhlon O, Gomori JM, van der Knaap MS, Lossos A. 

16. American Journal of Medical Genetics 139A:118–122 (2005)  

17. Bao, Y., Kishnani, P., Wu, J.-Y., Chen, Y.-T. Hepatic and neuromuscular forms of glycogen storage disease type IV caused by mutations in the same glycogen-branching enzyme gene. J. Clin. Invest. 97: 941-948, 1996. 

18. Neonatal presentation of lethal neuromuscular glycogen storage disease type IV L F Escobar, S Wagner, M Tucker & J Wareham Journal of Perinatology 32, 810–813 (2012) doi:10.1038/jp.2011.178 

19. Neonatal type IV glycogen storage disease associated with “null” mutations in glycogen branching enzyme 1 Andreas R.Janecke MD Susanne Dertinger MD Uwe-Peter Ketelsen MD Lothar Bereuter MD Burkhard Simma MD Thomas Müller MD Wolfgang Vogel MD Felix A. Offner MD

https://doi.org/10.1016/j.jpeds.2004.07.024  

20. Magoulas PL, El-Hattab AW. Glycogen Storage Disease Type IV. 2013 Jan 3. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2018. Available from: https://www.ncbi.nlm.nih.gov/books/NBK115333/  

21. World J Gastroenterol. 2007 May 14; 13(18): 2541–2553.

Published online 2007 May 14. doi:  10.3748/wjg.v13.i18.2541 PMCID: PMC4146814 Glycogen storage diseases: New perspectives Hasan Özen 

22. Glycogen branching enzyme deficiency in adult polyglucosan body disease.

Bruno C, Servidei S, Shanske S, Karpati G, Carpenter S, McKee D, Barohn RJ, Hirano M, Rifai Z, DiMauro S 

Ann Neurol. 1993;33(1):88.  

23. Adult polyglucosan body myopathy.

Goebel HH, Shin YS, Gullotta F, Yokota T, Alroy J, Voit T, Haller P, Schulz A

J Neuropathol Exp Neurol. 1992 Jan; 51(1):24-35. 

24. Ann Neurol. Author manuscript; available in PMC 2015 Feb 16.

Ann Neurol. 2012 Sep; 72(3): 433–441. doi:  10.1002/ana.23598 PMCID: PMC4329926 NIHMSID: NIHMS415710

Adult Polyglucosan Body Disease: Natural History and Key Magnetic Resonance Imaging Findings

Fanny Mochel, MD, PhD,^1,2,3,4 Raphael Schiffmann, MD,⁵ Marjan E. Steenweg, MD,⁶ Hasan O. Akman, PhD,⁷ Mary Wallace, RD,⁵ Frédéric Sedel, MD, PhD,^1,3,8 Pascal Laforêt, MD,^3,9 Richard Levy, MD, PhD,^4,10,11 J. Michael Powers, MD,¹² Sophie Demeret, MD,⁸ Thierry Maisonobe, MD,¹³ Roseline Froissart, PhD,¹⁴ Bruno Barcelos Da Nobrega, MD,¹⁵ Brent L. Fogel, MD, PhD,¹⁶ Marvin R. Natowicz, MD, PhD,¹⁷ Catherine Lubetzki, MD, PhD,^1,4,8 Alexandra Durr, MD, PhD,¹² Alexis Brice, MD,^1,2,4,8 Hanna Rosenmann, PhD,¹⁸ Varda Barash, PhD,¹⁹ Or Kakhlon, PhD,¹⁸ J. Moshe Gomori, MD,²⁰ Marjo S. van der Knaap, MD, PhD,⁶ and Alexander Lossos, MD¹⁸ 

25. PMID 8274116

Glycogen-branching enzyme deficiency leads to abnormal cardiac development: novel insights into glycogen storage disease IV.

Lee YC¹, Chang CJ, Bali D, Chen YT, Yan YT.

5. Acta Myol. 2011 Oct; 30(2): 96–102.

PMCID: PMC3235878 Progress and problems in muscle glycogenoses

S. DiMauro and R. Spiegel¹ 

6. Hum Mol Genet. 2015 Oct 15;24(20):5667-76. doi: 10.1093/hmg/ddv280. Epub 2015 Jul 21. 

7. Neuromusc. Disord. 14: 253-260, 2004. [PubMed: 15019703