Incidencia de la enfermedad de Fabry en pacientes con enfermedad renal crónica atendidos en tres centros de salud del departamento de Atlántico, Colombia. 2017-2018

Introducción: la enfermedad de Fabry es un defecto lisosomal caracterizado por una alteración de la enzima alfa-galactosidasa y que produce el acúmulo de glucoesfingolípidos en diferentes tejidos. Este defecto enzimático está ligado al cromosoma X y por ende es más frecuente en hombres. Sus manifestaciones clínicas varían de acuerdo al grupo etario afectado e incluyen lesiones en piel, anhidrosis, opacidades corneales, crisis de dolor, daño renal, entre otros. Objetivo: calcular la incidencia de enfermedad de Fabry en pacientes con diagnóstico de enfermedad renal crónica (ERC). Materiales y métodos: estudio ambispectivo realizado en los pacientes con diagnóstico de ERC que asistían a controles médicos en tres centros de prevención renal ubicados en el departamento del Atlántico, Colombia, y que además cumplían los criterios de inclusión y exclusión. Se revisaron las historias clínicas y se tomaron muestras para confirmar la presencia de enfermedad de Fray. Resultados: se identificaron 471 pacientes con ERC y se estableció una incidencia global de 21,23 casos por cada 1.000 habitantes para baja actividad de la alfa-galactosidasa. Sin embargo, solo en el 20% se confirmó la presencia de enfermedad de Fray mediante pruebas genéticas. Conclusiones: la incidencia de la enfermedad de Fabry en la población estudiada es mayor a la reportada en otras cohortes y además fue más frecuente en el sexo femenino.

Introduction: Fabry's disease consists of a lysosomal defect linked to the X chromosome that produces the accumulation of glycosphingolipids in different tissues. The clinical manifestations depend on the age of presentation, and includes skin lesions, acroparesthesia, pain crisis, anhidrosis, corneal opacities and hearing loss, among others. Objectives: Calculate the incidence of Fabry disease in patients diagnosed with chronic kidney disease Methodology: An ambispective study was designed, including all patients diagnosed with chronic kidney disease under medical control in three renal prevention centers located in the department of Atlántico, and which also met the inclusion and exclusion criteria. Subsequently, the review of the medical records and the sampling were carried out. Results: A total of 471 patients with chronic kidney disease were identified, with an overall incidence of 21.23 cases per 1000 people. However, only 20% were confirmed by genetic tests. Conclusions: The incidence of Fabry disease in the population studied is greater than that reported in other cohorts. In addition, it is more frequent in the female sex.

Unexpectedly High Prevalence of Low Alpha-Galactosidase A Enzyme Activity in Patients with Focal Segmental Glomerulosclerosis

OBJECTIVES: Fabry disease (FD) is a rare disease associated with sphingolipid accumulation. Sphingolipids are components of plasma membranes that are important in podocyte function and accumulate in various glomerular diseases such as focal segmental glomerulosclerosis (FSGS). Both FD and FSGS can cause podocyte damage and are classified as podocytopathies. In this respect, FD and FSGS share the same pathophysiologic pathways. Previous screening studies have shown that a significant proportion of end-stage renal disease (ESRD) patients receiving hemodialysis (HD) have unsuspected FD, and the prevalence of low alpha-galactosidase A (αGLA) enzyme activity in these patients is higher than that in the normal population. We aimed to compare αGLA enzyme activity in patients with biopsy-proven FSGS and ESRD receiving HD. METHODS: The records of 232 patients [62 FSGS (F/M: 33/29); 170 HD (M/F: 93/79)] were evaluated retrospectively. The screening was performed based on the αGLA enzyme activity on a dried blood spot, with the confirmation of plasma LysoGb3 levels, and the known GLA mutations were tested in patients with low enzyme activities. The two groups were compared using these parameters. RESULTS: The mean level of αGLA enzyme activity was found to be lower in FSGS patients than in the HD group (2.88±1.2 μmol/L/h versus 3.79±1.9 μmol/L/h, p<0.001). There was no significant relationship between the two groups with regard to the plasma LysoGb3 levels (2.2±1.22 ng/ml versus 1.7±0.66 ng/ml, p: 0.4). In the analysis of GLA mutations, a D313Y mutation [C(937G>T) in exon p] was found in one patient from the FSGS group. CONCLUSIONS: We found that αGAL activity in patients with FSGS is lower than that in patients undergoing HD. The low enzyme activity in patients with FSGS may be explained by considering the similar pathogenesis of FSGS and FD, which may also lead to sphingolipid deposition and podocyte injury.

The Challenge of Diagnosis and Indication for Treatment in Fabry Disease

Abstract Fabry disease, caused by deficient alpha-galactosidase A lysosomal enzyme activity, remains challenging to health-care professionals. Laboratory diagnosis in males is carried out by determination of alpha-galactosidase A activity; for females, enzymatic activity determination fails to detect the disease in about two-thirds of the patients, and only the identification of a pathogenic mutation in the GLA gene allows for a definite diagnosis. The hurdle to be overcome in this field is to determine whether a mutation that has never been described determines a ''classic'' or ''nonclassic'' phenotype, because this will have an impact on the decision-making for treatment initiation. Besides the enzymatic determination and GLA gene mutation determination, researchers are still searching for a good biomarker, and it seems that plasma lyso-Gb3 is a useful tool that correlates to the degree of substrate storage in organs. The ideal time for treatment initiation for children and nonclassic phenotype remains unclear.

Anderson-Fabry Disease: A Rare Disease That Mimics Common Cardiac, Neurological, Renal, and Other Disorders: Approach for the Differential Diagnosis and Follow-Up

Abstract Anderson-Fabry disease (AFD) is a rare inherited X-linked disease, caused by mutations of the gene encoding the α-galactosidase A enzyme, that leads to a deficiency or absence of its activity with consequent accumulation of globotriaosylceramide (Gb3) and other glycosphingolipids in the lysosomes of several cells types in the organism, mainly the endothelial, nervous system, cardiac, and renal cells. Its heterogeneous and nonspecific presentation, similar to other common pathologies, delays the diagnosis and leads to incorrect therapy. In the presence of attenuated phenotypes with predominant involvement of an organ, it is even harder to identify patients with AFD. It is highly important to be aware of this diagnosis, since enzyme replacement therapy is currently available. This review aims to approach the clinical manifestations of AFD and the phenotypes related to the differential diagnosis for each manifestation and the frequency of follow-up recommended.

Two Cases of Fabry Disease in Women with Proteinuria Diagnosed by Molecular Analysis of the alpha-Galactosidase A Gene and Kidney Biopsy / 대한내과학회지

Fabry disease is an X-linked lysosomal storage disorder caused by alpha-galactosidase A deficiency, which results in the intracellular accumulation of globotriaosylceramide and leads to severe painful neuropathy with progressive renal, cardiovascular, and cerebrovascular dysfunction and early death. We report 52- and 55-year-old women with proteinuria and hematuria that were proven to be due to Fabry disease. A gene analysis using PCR direct sequencing confirmed a missense mutation of the GLA (alpha-galactosidase A) gene. Electron microscopy of a kidney biopsy showed lamella inclusion bodies, which are typical findings of Fabry disease. The patients were treated with enzyme replacement therapy as outpatients. They had a reduction in proteinuria and normal renal function.

Enfermedad de Fabry Descripción de un caso y su evolución en terapia de reemplazo enzimático / Fabry disease Description of a case and its evolution with enzyme replacement therapy

La enfermedad de Fabry es un trastorno hereditario de depósito lisosomal progresivo y multisistémico del catabolismo de los glicoesfingolípidos, ligado al cromosoma X, que es causado por un defecto en el gen que cataliza la enzima lisosomal alfa-galactosidasa A (alfa-GAL A), y origina el depósito intracelular, especialmente de globotriaosil-ceramida (Gb-3), en el endotelio vascular y otros tejidos. La deficiencia parcial o total de la actividad de la enzima lisosomal conduce a la incapacidad de catabolizar ciertos glicoesfingolípidos causando el daño principal, es decir, el depósito intralisosomal de sustrato Gb-3 en diferentes tipos de células. En particular, son afectadas progresivamente las células vasculares endoteliales, lo cual puede causar isquemia tisular e infarto. Es una enfermedad progresiva que causa manifestaciones derivadas de la disfunción del órgano afectado por los depósitos, principalmente riñón, corazón, sistema nervioso, tracto gastrointestinal y piel, aunque puede participar cualquier órgano y sistema de la economía. Antes de la disponibilidad de la terapia de reemplazo enzimático, el tratamiento para esta enfermedad consistía principalmente de cuidados sintomáticos y medidas correctivas no específicas. Se describen las características clínicas y la evolución de un hombre de 47 años con enfermedad de Fabry en terapia de reemplazo enzimático. (ActaMed Colomb 2014; 39: 202-206).

Fabry disease is an inherited disorder of progressive and multisystemic lysosomal storage of glycosphingolipids catabolism, X-linked, which is caused by a defect in the gene that catalyzes the lysosomal enzyme alpha-galactosidase A (alpha-GAL A), and causes the intracellular deposition, especially of globotriaosyl ceramide (Gb3) in the vascular endothelium and other tissues. Partial or total deficiency of the lysosomal enzyme activity leads to the inability to catabolize certain glycosphingolipids causing the main damage, namely the intralysosomal deposit of Gb3 substrate in different cell types. In particular, vascular endothelial cells are progressively affected, which may cause tissue ischemia and infarction. It is a progressive disease that causes manifestations derived from the dysfunction of the organ affected by the deposits, mainly kidney, heart, nervous system, gastrointestinal tract and skin, although any organ and system of the economy may be involved. Before the availability of enzyme replacement therapy, treatment for this condition consisted mainly of symptomatic care and no specific remedies. Clinical characteristics and evolution of a 47 year old man with Fabry disease on enzyme replacement therapy are described. (Acta Med Colomb 2014; 39: 202-206).

Identification and Clinical Characterization of a Novel Alpha-Galactosidase A Mutation

Abstract Fabry disease (FD) is an inborn error of metabolism characterized by deficient/absent activity of lysosomal enzyme alpha-galactosidase A, which results in systemic accumulation of glycosphingolipids and progression to renal failure, heart and cerebrovascular disease, and small-fiber peripheral neuropathy. This article describes a Brazilian family affected by FD caused by a novel mutation in exon 6 of the alpha-galactosidase A (GLA) gene (c.812G>C). Signs and symptoms identified were pain crisis, acroparesthesia, hypohidrosis, abdominal cramps and diarrhea, chronic kidney disease, cornea verticillata, left ventricular hypertrophy, and complete heart block. Headache was a common complaint and 1 of the patients presented with aseptic meningitis. The novel missense mutation in the GLA gene identified in this Brazilian family is consistent with the classic FD phenotype.

Fabry Cardiomyopathy

Fabry disease is a progressive X-linked disorder of glycosphingolipid metabolism caused by a deficiency of the alpha-galactosidase lysosomal enzyme. The partial or complete deficiency of the lysosomal enzyme leads to an accumulation of neutral glycosphingolipids in the vascular endothelium and visceral tissues throughout the body. In the heart, glycosphingolipids deposition causes progressive left ventricular hypertrophy (LVH). We report a case of Fabry disease which was suspected based upon two-dimensional echocardiographic finding of LVH. A 44-year-old man was admitted to evaluation of aggravated exertional dyspnea of two weeks duration. He had been diagnosed with end-stage renal disease of unknown etiology at age 41 followed by renal transplantation that year. He had been treated with oral immunosuppressive agents. On hospital day two, transthoracic echocardiography revealed concentric LVH. Left ventricular systolic function was preserved but diastolic dysfunction was present. Fabry disease was confirmed by demonstration of a low plasma alpha-galactosidase A (alpha-Gal A) activity. Analysis of genomic DNA showed alpha-Gal A gene mutation. The patient was diagnosed with Fabry disease.

Guía clínica: consenso para Chile en enfermedad de Fabry / Clinical guidelines: Chilean consensus in Fabry disease

Fabry's disease is an X-linked recessive inborn error of metabolism of glycosphingolipids, caused by the deficiency of the lisosomal enzyme alpha-galactosidase. It is a rare disease with an estimated incidence rate of approximately 1:80.000 to 1:117,000 births in the general population. Recently, the growing knowledge about this disease has permitted the development of enzyme replacement therapy, which has modified the prognosis and quality of life of these patients. In Chile, the real incidence is unknown, but the increase in the number of patients diagnosed during the last five years, mainly in the north of the country. This guide was prepared with the intention of establishing a consensus for the diagnosis, treatment and monitoring of the patients with Fabry disease based on the present available scientific evidence.

La enfermedad de Fabry es un error innato del catabolismo de los glucoesfingolipidos, de herencia recesiva ligada al cromosoma X, causado por la deficiencia de la enzima lisosomal alfa-galactosidasa A (alfa-gal A). Es un defecto poco frecuente, con una incidencia estimada de 1:80.000 a 1:117.000, entre la población general. Recientemente, el creciente conocimiento acerca de esta enfermedad, ha permitido el desarrollo de la terapia de reemplazo enzimático, la cual ha modificado el pronóstico y calidad de vida de los pacientes. En Chile, se desconoce la incidencia real, pero el aumento del número de pacientes diagnosticados durante los últimos cinco años, principalmente en la zona norte del país, ha generado un mayor interés por esta enfermedad. Esta guía fue elaborada con la intención de establecer un consenso para el diagnóstico, tratamiento y seguimiento de los pacientes con enfermedad de Fabry, basado en la evidencia científica, actualmente disponible.

Clinicopathological and genetic feathers of 14 Fabry nephropathy patients / 中华肾脏病杂志

Objective To elucidate the clinicopathological and hereditary characteristics in Fabry nephropathy.Methods The clinical and pathological features of 14 patients with Fabry nephropathy were collected.The activities of α-Gal A were measured in 4 probands.Screenings of GLA mutations were done in 12 patients.Results The ratio of Fabry nephropathy in the patients with renal biopsy was 0.074 ％ (14/19 005),the average diagnostic age was (30.57±9.32) years,male to female ratio was 2.5∶ 1.All the patients had proteinuria,and the median of urine total protein (UTP)was 1.71 g/24 h (0.32-4.71 g/24 h).Two of them got nephrotic proteinuria,5 of them got microscopic hematuria,4 of them got renal function insufficiency.Angiokeratomas was the most common manifestation (10/14),followed by cardiac involvement (6/14).Hypohidrosis and diseases of central neural system could also be seen in these patients.There were 9 classic phenotype,the remaining 5 were variants/renal variants.The family information was collected in 10 pedigrees,6 of them had family histories of kidney disease.Renal pathology showed vacuolization of glomerular visceral epithelial cells was the prominent feature,global and segmental glomerulosclerosis were seen in some patients by light microscopy.The myelin bodies or zebra bodies were identified in podocytes by electron microscopy,but only were found in some podocytes of 2 females.The activity of α-Gal A was decreased compared with the normal range in 4 probands.The mutations of GLA were demonstrated in 11 patients.Three novel mutations of GLA gene were identified,which were all deletion/insertion mutations with classic phenotypes.Most variants carried the mutations located in the buried/partial buried areas of α-Gal A (3/11).The classical phenotype carried GLA mutations as W162X,F169S,S201F,N272K,L310R,while variant phenotype carried GLA mutations as I91T,R112H,Q312H.Conclusions The ratio of Fabry nephropathy in patients with renal biopsy is 0.074％.Angiokeratomas and cardiac involvement are often accompanied with Fabry nephropathy.The genotypes of GLA may have close relationships with the phenotypes of Fabry nephopathy.

A Case of Fabry's Disease with Congenital Agammaglobulinemia

Fabry's disease is an X-linked lysosomal storage disorder caused by abnormalities in the alpha-galactosidase A (GLA) gene, which leads to a GLA deficiency and to the intracellular deposition of globotriaosylceramide (Gb3) within vascular endothelium and other tissues. It manifests as progressive multiple organ dysfunctions caused by the deposition of Gb3. On the other hand, congenital agammaglobulinemia is usually caused by mutations in Bruton's tyrosine kinase (Btk) gene with X-linked dominence, suppresses B cell maturation, and causes recurrent pyogenic infections. In former reports, the distance between the loci in the Xq22 region of the human X chromosome was found to be about 69 kilobases. A 23-yr-old man diagnosed with congenital agammaglobulinemia at age 5, showed typical clinical and laboratory and histopathological findings of Fabry's disease. The genetic basis of this combination of the two syndromes was studied in this patient. Here, we report a case of Fabry's disease with congenital agammaglobulinemia.

A Case of Fabry Cardiomyopathy

In the absence of hypertension, hypertrophic cardiomyopathy is the most common cause of left ventricular hypertrophy (LVH). However, it has been reported that up to 3% of males with unexplained LVH have Fabry disease, an X-linked disorder of glycophospholipid metabolism that is due to a deficiency in the lysosomal enzyme alpha-galactosidase A (alpha-Gal A). A 44-year-old man was admitted to our hospital with palpitations. He had a history of chronic renal failure diagnosed at age 33 followed by kidney transplantation performed at our institution 2 years later, as well as long-standing hypohidrosis. His medications included prednisolone (5 mg daily), mycophenolate mofetil (1,000 mg, bid), and cyclosporine (150 mg, bid). On hospital day two, an echocardiogram demonstrated increased left ventricular wall thickness (septal wall thickness of 28 mm, posterior wall thickness of 20 mm). Diastolic dysfunction was noted on transmitral flow patterns and tissue Doppler imaging. The patient was found to have low plasma alpha-Gal A activity. A previously reported H46R missense mutation was detected in his alpha-Gal A gene and the patient was subsequently diagnosed with Fabry disease.

Short-Term Efficacy of Enzyme Replacement Therapy in Korean Patients with Fabry Disease

Fabrazyme has been widely used for treatment of Fabry disease since its approval by the U.S. Food and Drug Administration in 2003. This study was undertaken to assess the short-term efficacy and safety of enzyme replacement therapy (ERT) for Fabry disease in Korea. Eight male patients and three female symptomatic carriers aged 13 to 48 yr were included. Fabrazyme was administered by intravenous infusion at a dose of 1 mg/kg every 2 weeks. Plasma and urine globotriaosylceramide (GL-3) levels, serum creatinine, creatinine clearance, and 24-hr urine protein levels were measured every 3 months. Kidney biopsies, ophthalmologic exams, and pure tone audiometry were performed before and 1 yr after ERT. Kidney function, including serum creatinine, creatinine clearance, and the 24-hr urine protein level, remained stable during ERT. Plasma and urine GL-3 levels were reduced within 3 to 6 months of ERT initiation. Microvascular endothelial deposits of GL-3 were decreased from renal biopsy specimens after 1 yr of treatment. The severity of sensorineural hearing loss and tinnitus did not improve after ERT. ERT is safe and effective in stabilizing renal function and clearing microvascular endothelial GL-3 from kidney biopsy specimen in Korean patients with Fabry disease.

Prevalência da doença de fabry em pacientes portadores de doençarenal crônica submetidos à hemodiálise em Natal – RN / Prevalence of fabry disease in patients with chronic kidney disease onhemodialysis in Natal – RN, Brazil

Introdução: A Doença de Fabry é uma doença genética de depósito lisossômico caracterizada pela deficiência da enzima α-galactosidase A (ceramidatrihexosidase). Isso gera acúmulo de globotriaosilceramida (GL-3) no endotélio vascular, podendo ocasionar complicações renais, cardíacas ecerebrovasculares. Diante da terapia de reposição enzimática, torna-se essencial o diagnóstico desta doença, o que pode ser conseguido através de umrastreamento de pacientes em hemodiálise. Objetivos: O presente estudo objetivou determinar a prevalência da doença em pacientes portadores dedoença renal crônica em hemodiálise na cidade de Natal – RN, avaliando as principais co-morbidades associadas. Métodos: Foram selecionadosindivíduos do sexo masculino em hemodiálise, entre 18 e 65 anos, excluindo-se pacientes cuja etiologia da falência renal era: diabetes mellitus, lupuseritematoso sistêmico, nefropatia obstrutiva, pielonefrite crônica e doença renal policística. Uma amostra sanguínea foi coletada para avaliação da atividadeda α-galactosidase A em papel de filtro. Os pacientes com valores inferiores a 2,5μmol/L/h tiveram a atividade enzimática testada em leucócitos eresponderam a um questionário sobre as manifestações clínicas relacionadas. Resultados: Dos 191 pacientes, 16 (8,3%) cursaram com atividadeenzimática em papel de filtro inferior a 2,5μmol/L/h. Apenas um paciente (0,52%) apresentou dosagem da atividade enzimática em leucócitos inferior aovalor da normalidade, sendo compatível com Doença de Fabry. Não foram encontradas as manifestações típicas da doença neste paciente. Conclusão:Observou-se uma prevalência da Doença de Fabry de 0,52% dentre os pacientes estudados nos centros de hemodiálise de Natal – RN no ano de 2006.

Introduction: Fabry Disease is a genetic illness of lisosomic deposition characterized by the deficiency of the enzyme alpha-galactosidase A (ceramidetrihexosidase), generating an accumulation of globotriaosilceramide (GL-3) in the vascular endothelium, capable of leading to renal, cardiac andcerebrovascular complications. Faced with the therapeutic possibility of enzymatic supplementation, the diagnosis of this disease becomes essential, andcan be achieved through the screening of hemodialysis patients. Aims: The present study aimed at determining the prevalence of Fabry Disease in patientswith chronic kidney disease undergoing hemodialysis in the city of Natal, Rio Grande do Norte, Brazil, evaluating the main associated comorbidities.Methods: The sample consisted of male subjects between 18 and 65 years of age, undergoing hemodialysis, excluding patients whose etiology of renalfailure was diabetes mellitus, systemic lupus erythematosus, obstructive nephropathy, chronic pyelonephritis, or polycystic kidney disease. A blood samplewas collected for an evaluation of alpha-galactosidase A activity in filter paper. Patients with values inferior to 2.5 μmol/L/h had their enzymatic activity testedin leukocytes, and a questionnaire about related clinical manifestations was applied. Results: From 191 patients, 16 (8.3%) had an enzymatic activity infilter paper inferior to 2.5 μmol/L/h. Only one patient (0.52%) exhibited a level of enzymatic activity in leukocytes inferior to the normal value, compatible withFabry Disease. The typical manifestations of the disease were not found in this case. Conclusion: A prevalence of Fabry Disease of 0.52% was observedamong patients studied in hemodialysis centers in Natal in 2006.

A Case of Fabry Disease, Pathologically Revealed as Focal Segmental Glomerulosclerosis / 대한신장학회지

Fabry disease is an X-linked recessive lysosomal storage disease that is caused by deficient activity of the lysosomal enzyme alpha-galactosidase A. This deficiency results in progressive lysosomal accumulation of glycosphingolipid with particular globotriaosylceramide which accumulates in the heart, kidneys, and the nervous system. The classic Fabry diease affects males, who typically experience an early onset of neuropathic pain, angiokeratoma, and anhydrosis or hypohydrosis. The introduction of enzyme replacement therapy necessitates early awareness of Fabry disease and knowledge of disease- related complications. We experienced a man presenting with acroparesthesia, anhydrosis and proteinuria, who had no residual alpha-galactosidase A activity on leukocytes and mutation analysis demonstrated thiamine deletion at position 1077, exon 7 of GLA gene. He was initially diagnosed as focal segmental glomerulosclerosis without electron microscopic examination three years ago. Now he is being treated with recombinant alpha-galactosidase A via intravenous administration for 1 month.

Fabry Disease in a Family: Four Patients and Five Carriers

PURPOSE: The purpose of this study is to report the genetic diagnosis of nine cases of Fabry in one family, either as carriers or patients. METHODS: We conducted analysis of the alpha-galactosidase A gene and ophthalmologic examination of family members of a patient diagnosed with Fabry disease. RESULTS: Our patient, his brother, and two male cousins had Fabry disease; his mother, three aunts, and his female cousin were Fabry carriers. Genetic study revealed deletion mutation (1235-1236delCT) at the alpha-galactosidase A gene in all subjects. Ophthalmologic examination detected whirl-like corneal opacity in all subjects, which is a typical characteristic of Fabry disease.

A Novel Mutation in Exon 6 in a Patient with Fabry's Disease

Fabry's disease, angiokeratoma corporis diffusum, is a rare X-linked inborn error of glycosphingolipid metabolism due to the lack of the lysosomal enzyme, alpha-galactosidase A, resulting in a progressive intracellular deposition of neutral glycosphingolipids in various tissues, including the dorsal root ganglia, autonomic nervous system, vascular endothelial, and smooth muscle cells. Clinical manifestations of Fabry's disease result predominantly from the progressive deposition of globotriaocylceramide in the nervous system or vascular endothelium, and are characterized by acro-paresthesia, angiokeratoma, corneal opacity, TIA or stroke, ischemic heart disease, and renal failure. We report a case of a 19-year-old man presenting with a 12-year history of severe distal pain, acroparesthesia, short stature, and delayed puberty. An enzymatic assay disclosed substantially diminished alpha-galactosidase A activity and an electron microscopy of the peripheral nerve showed lipid inclusions which were composed of concentrically laminated, ovoid osmiophilic bodies in the perineural fibroblast and endothelial cells. These findings are typical of Fabry's disease and additional genetic study revealed deletion mutation(TTAG) at the 6th exon of the alpha-galactosidase A gene, which is a novel mutation that had never been reported in literatures. Symptomatic treatment with carbamazepine and clonazepam was tried with a good response.