Analysis of diagnosis and treatment of Lesch-Nyhan syndrome / 中华泌尿外科杂志

Objective:To explore the etiology, clinical diagnosis and treatment strategy of Lesch Nyhan syndrome.Methods:We retrospectively analyzed 2 patients with severe dyskinesia, mental retardation and complicated renal calculi who were admitted to the first people's Hospital of Zhengzhou in August 2019. Case 1, male, 9 years old, had multiple urinary calculi for 1 year. The patient came to the local hospital because double multiple kidney stones and bladder stonesa year ago. The patient had been treated with transurethral holmium laser lithotripsy for bladder stones. The results of infrared spectrum showed that the bladder stone was anhydrous uric acid stone. A week ago, color Doppler ultrasound showed multiple kidney stones and bladder stones. The patient was underdeveloped, mentally retarded and had a full-term cesarean section. There was no history of hypoxia, asphyxia and rescue of the patient. He had the following clinical manifestations: In the waking state, he was no language response to any stimulation. The nasolabial fold on the right was shallow and the corner of the mouth was oblique to the left. He lost the large movements such as lifting head, sitting alone, standing. The trunk showed torsion spasticity, limb muscle strength 2-3, limbs showing spastic hypertonia, limb joints stiff, hands showing fist-like, no involuntary movement and muscle fasciculation. The biceps reflex and knee tendon reflex were not elicited, and the pathological reflex was positive. Serum uric acid was 517 μmol/L. The Case 2 came from the same family, male, 6 years old, had the similar symptoms to his elder brother case 1. The family members complained on behalf of the child about intermittent fever for more than 2 years. The imaging examination of case 2 revealed kidney stones. Serum uric acid was 373 μmol/L. Whole Exome Sequencing and Sanger Sequencing were used to find the genetic causes of the two siblings. The NCBI-Homologene database was used to find the homologous sequence of the human HPRT1 gene, and the human HPRT1 gene sequence was compared with other species to analyze the protein conservation. The online website PredictProtein (http: //www.predactprotein) was used to predict the two-dimensional structure of the HPRT1 gene. The reported cases were summarized and same with the treatment plan.Results:A De novo mutation [c.571T>G(p.Tyr191Asp)] was found in the HPRT1 gene of the child, which was inherited from the mother. Lesch Nyhan syndrome can be diagnosed by the results of gene examination combined with clinical manifestations. The amino acid Tyr at the 191 position and the amino acids before and after it were highly conserved. Amino acid 191 was involved in the β-strand of the protein. We treated the patients with the lowest dose of allopurinol and children's conventional dose of potassium sodium bicitrate granules, and low purine diet. After 3 months of treatment, the serum uric acid was decreased, and the urinary calculi did not increase significantly.Conclusions:Combining with the clinical manifestations of children, HPRT1 gene might be the cause of pediatric disease and the two siblings could be diagnosed as Lesch-Nyhan syndrome. For such patients, the lowest dose of allopurinol and children's conventional dose of potassium sodium hydrogen citrate granule combined with diet could be more effective.

Lesch-Nyhan Disease and Its Variants: Phenotypic and Mutation Spectrum of Hypoxanthine-Guanine Phosphoribosyltransferase Deficiency in Argentine Patients

Abstract Hypoxanthine-guanine phosphoribosyltransferase (HPRT) deficiency is a disorder of purine metabolism responsible for Lesch-Nyhan Disease (LND) and its variants, HPRT-related hyperuricemia with neurologic dysfunction (HND) and HPRT-related hyperuricemia (HRH). The objective of this study was to characterize a cohort of Argentine patients with HPRT deficiency diagnosed in a single center. Results: Twenty nine patients were studied, including 12 LND, 15 HND and 2 HRH. The average onset age was 0.64 years for LND with motor delay as the main manifestation, 8.84 years for HND and 2.5 years for HRH; nephrological manifestations predominated as presenting features in these variants. The average diagnosis age was 3.58 years for LND, 17.21 years for HND and 2.5 years for HRH. Clinical heterogeneity was more evident in HND, even in members of the same family. All patients presented hyperuricemia and no detectable HPRT activity in erythrocyte lysate. The molecular study allowed to identify 9 different mutations in HPRT1 gene from 24 patients (11 independent pedigrees) and to establish genotype-phenotype correlation. In conclusion, this study describes the genotypic/phenotypic spectrum of HPRT deficiency in Argentine patients and highlights the need to increase awareness about the suspicion of these diseases, especially the LND variants with high clinical heterogeneity.

Síndrome de Lesch-Nyhan y automutilación oral. Reporte de un caso / Oral self-mutilation in Lesch-Nyhan Syndrome. Case Report

Resumen: Introducción: El síndrome de Lesch-Nyhan (SLN) es un trastorno hereditario recesivo relacionado con el cromosoma X, causado por la deficiencia de la enzima hipoxantina-guanina fosforribosil transferasa (HPRT). La automutilación compulsiva y distonía ocurre antes del año de edad y se expresa con mordeduras persistentes en la mucosa oral, labios, lengua, dedos y hombros. La intervención odontológica realizada en la mayoría de estos pacientes es la extracción dental múltiple para prevenir lesiones graves secundarias. Objetivo: presentar un caso clínico de SLN y describir el manejo odonto-pediátrico en pacientes con conducta automutilatoria. Caso clínico: Paciente varón, 7 años de edad, portador de SLN. Fue referido a la Unidad de Odontología desde el Departamento de Neurología Pediátrica para la evaluación y manejo de heridas autoinfligidas en dedos, labios y mejillas asociadas a una pérdida de peso y disminución de la ingesta de alimentos. El procedimiento quirúrgico consistió en extracciones dentales múltiples, y remodelación quirúrgica de las crestas alveolares residuales, bajo anestesia general. Al segundo mes posquirúrgico el paciente fue dado de alta definitivamente, con un adecuado estado nutricional y sin signos de automutilación en manos ni en cavidad oral. Conclusio nes: A pesar, que el SLN es infrecuente, es esencial saber cómo proceder para dar la mejor calidad de vida a los pacientes y sus familias. Las extracciones tempranas del diente, como fase inicial en casos severos, parecen ser la alternativa más útil para minimizar el daño y el dolor por la automutilación.

Abstract: Introduction: Lesch-Nyhan syndrome (LNS) is an inherited recessive X-related disorder caused by the deficiency of the enzyme hypoxanthin-guanine phosphorribosyl transferase (HPRT). Compul sive self-mutilation and dystonia occurs before the first year of age and is expressed by persistent bites on the oral mucosa, lips, tongue, fingers, and shoulders. The dental intervention performed on most of these patients is multiple tooth extraction to prevent serious secondary lesions. Objective: To present a clinical case of LNS and describe pediatric dentistry management in patients with self-mutilating behavior. Clinical case: Male patient, 7 years old, LNS carrier. He was referred to the Dental Unit from the Department of Pediatric Neurology for evaluation and management of self-inflicted wounds on fingers, lips and cheeks associated with weight loss and decreased food intake. The surgical procedure consisted of multiple extractions, surgical remodeling of the residual alveolar ridges under general anesthesia. In the second postoperative month, the patient was discharged definitively, with an adequate nutritional status and no signs of self-mutilation in hands or oral cavity. Conclusions: Although LNS is rare, it is essential to know how to proceed in order to provide the best quality of life for patients and their families. Early tooth extractions, as an initial phase in severe cases, seem to be the most useful alternative to minimize damage.

Lesch-Nyhan syndrome in a Chinese family with mutation in the HGPRT gene / 中国生化药物杂志

Lesch-Nyhan syndrome(LNS) is a congenital X-linked recessive inherited disorder caused by mutations in the hypoxanthine guanine phosphoribosyl transferase (HPRT) gene.A deficiency of the HPRT enzyme is responsible for the disease.The main clinical manifestation includes hyperuricemia, juvenile-onset gouty arthritis and neurological developmental disorders.Studies have reported there are more than 400 HPRT gene mutation sites, but the incidence of LNS in the Chinese population is extremely low.Here we report a 16-year-old male patient who suffered neurological dysfunction at an early age and gouty arthritis in his youth.DNA of patient and his family members were extracted from peripheral blood lymphocytes.The coding region and the intron-exon boundaries of HPRT gene were sequenced by standard methods.We found a mutation in exon 3 of the HPRT gene of the patient and his mother (Exon3:c.143G>A), which resulted in an arginine to histidine (p.R48H) substitution in the encoded protein.No activity of the enzyme HPRT was detected in the erythrocytes.The same mutation was reported in several European families, but was found in Chinese family for the first time.Clinicians in China have poor experience in diagnosing LNS case, due to the low incidence in China.Therefore LNS screening for infants or adolescents with hyperuricemia, gouty arthritis and neurological dysfunction should be performed.

A Case of Lesch-Nyhan Syndrome Manifesting Only Chronic Gouty Arthritis without Neurologic Symptom

Deficiency of hypoxanthine-guanine phosphoribosyltransferase is a purine nucleotide disorder and is the most common genetic cause of uric acid overproduction. This disease has a wide range of spectrum with regard to neurological features depending on the extent of the enzymatic deficiency. Complete deficiency of hypoxanthine-guanine phosphoribosyltransferase, called Lesch-Nyhan syndrome, is presented with hyperuricemia and characteristic neurological manifestation and self-mutilation. Partial hypoxanthine-guanine phosphoribosyltransferase--deficient patients are presented with a various intensities of the aforementioned symptoms, from almost normal neurologic manifestation to a severe form along with hyperuricemia. We report a twenty-year-old man with complete hypoxanthine-guanine phosphoribosyltransferase mutation and Lesch-Nyhan sydrome, who manifested gouty arthritis without neurologic symptom.

A Case of Lesch-Nyhan Disease Manifesting Gouty Arthritis without Self-mutilation / 대한신장학회지

Lesch-Nyhan disease is a very rare X-linked recessive disorder characterized by mental retardation, spasticity resembling cerebral palsy, choreoathetosis, self-mutilation and hyperuricemia. Self-mutilative behavior is a hallmark of the disease. The underlying defect is a deficiency of hypoxanthine-guanine phosphoribosyltransferase (HPRT). We report on a fourteen-year-old boy, who manifested gouty arthritis and mild renal insufficiency with Lesch-Nyhan disease, lacking self-mutilative behavior in spite of undetectable HPRT activity. Though there were several reports about some cases of Lesch-Nyhan disease in the past Korean literature, the cases were classic forms with definite neurological manifestation. As far as we know, this is the first case of Lesch-Nyhan disease without self-mutilation in Korea.

General Anesthesia for Extracorporeal Shockwave Lithotripsyin Child with Lesch-Nyhan Syndrome / 영남의대학술지

Lesch-Nyhan syndrome is an inborn error of purine metabolism resulting from hypoxanthine-guanine-phosphoribosyltransferase (HGPRT) deficiency and leading to excess purine production and uric acid over-production. It is a very rare X-linked recessive disorder, characterized by movement disorder, cognitive deficits, and self-injurious behavior. However, because of the high incidence of calculi, patients may present for surgery of urinary tract, and have increased risk of difficult intubation, aspiration pneumonia, renal insufficiency or sudden death. We report the case of a 5-year-old boy with Lesch-Nyhan syndrome who underwent successive extracorporeal shockwave lithotripsy under general anesthesia.

Anesthetic Experience of Percutaneous Nephrolithotomy for Renal Calculi in a Patient with Lesch-Nyhan Syndrome: A case report / 대한마취과학회지

Lesch-Nyhan syndrome (LNS) is a rare, X-linked recessive inherited disorder caused by a deficiency of the enzyme hypoxanthine-guanine-phophoribosyltransferase, leading to excessive purine production and elevation of uric acid. Clinical manifestations include mental retardation, spasticity, choreathetosis, compulsive self-mutilation, renal calculi followed by obstructive nephropathy, and arthritis. Patient with LNS may have increased risk of aspiration pneumonia, acute renal failure and unexpected sudden death. We accomplished successful general anesthesia in a case of LNS requiring percutaneous nephrolithotomy due to renal calculi.

Determinación de las constantes cinéticas de la enzima hipoxantina - guanina fosforribosiltransferasa (HGPRT) en controles normales y en una familia afectada por el Sindrome de Lesch-Nyhan / Determination of the Kinetic constants of hypoxanthine guanine phosphoribosyl transférase enzyme (HGPRT) in normal controls and in a family affected by Lesch-Nyhan’s syndrome

El sindrome de Lesch-Nyhan (SLN) es producido por una deficiencia total de la enzima Hipoxantina-Guanina fosforribosiltransferasa (HGPRT). Las madres de niños afectados por el SLN son heterocigotas obligadas ya que la enfermedad se hereda de forma recesiva ligada al cromosoma X. Una de las células utilizadas para determinar la enfermedad es el eritrocito; sin embargo, la determinación de la condición portadora de las madres con niños afectados no se puede hacer en estas células ya que presentan una actividad que cae dentro del rango considerado normal.Esto sucede porque el eritrocito deficiente en la enzima HGPRT es destruido antes de que alcance la circulación sanguínea. Aplicando los principios cinéticos de Lineweaver-Burk y mediante espectrofotometría se determino la cinética de la (HGPRT) extraída de los eritrocitos de una familia que sufre el Sindrome de Lesch-Nyhan y se compararon con la cinética de esta enzima utilizando eritrocitos de 10 individuos sanos y normales procesados de igual forma. Los dos sustratos estudiados fueron la Guanina y el Fosforribosilpirofosfato (PRPP). La Guanina en individuos normales presentó un rango de Vmax entre 1.7 a 2.8 μmol de GMP/ min/ g Hb. mientras que el rango presentado para la Km fue de 10 a 25 μM. El PRPP en los controles normales presentó un rango para la Vmax de 2 a 2.7 μmol de GMP/min/g Hb y el rango para la Km fue de 301 a 590 μM. estos valores corresponden a lo reportado por otros autores. En la familia estudiada la cual tiene dos niños que padecen el síndrome de Lesch- Nyhan, tanto el padre como la hija presentaron cinéticas que caen dentro del rango considerado normal, mientras que la madre presentó una alteración en la Km para el PRPP ( 1176 μ M ). Cuando se comparó la regresión linear de las pendientes presentadas por los controles con la presentada por la paciente portadora de la enfermedad se encontró que estadísticamente son muy diferentes, diferencia que es ocasionada por el valor elevado de la Km de esta paciente por el sustrato PRPP.

The syndrome of Lesch-Nyhan (SLN) is produced by total deficiency of the enzyme Hipoxanthine-Guanine Phosphoribosyltransferase (HGPRT). The mothers of children affected by the SLN are obliged heterocigotes since the illness is inherited from a recessive way bound to the chromosome X. One of the utilized cells to diagnostic the illness is the erythrocyte; however, the determination of the condition carrier of the mothers with affected children cannot make in these cells since they present an activity that falls inside the normal considered range. This happens because the faulty erythrocyte in the enzyme HGPRT is destroyed before it reaches the blood stream. Applying the kinetic principles of Lineweaver-Burk and by means of espectrophotometry I to carry out the kinetic of the HGPRT enzyme extracted of the erythrocytes of a family that it suffers the SLN and they were compared with the kinetics of this enzyme in erythrocytes of ten individuals health and normal. The two studied substrates were the Guanine and the phosphorybosylpirophosphate(PRPP). The Guanine in normal individuals presented a range of Vmax among 1.7 at 2.8 μmol GMP/min/gHb, while the range presented for the Km went from 10 to 25 μ M. The PRPP in the normal controls presented a range for the Vmax from 2 at 2.7μmol GMP/min/gHb and the range for the Km went from 301 to 590 μM. These ranges are similar to those reported by other authors. In the estudied family which has two children that suffer the SLN , as much the father as the daughter presented kinetic that fall inside the normal considered range, while the mother presented increased the km for the PRPP ( the value of Km for the PRPP of the mother of the children affected by the syndrome was of 1176 μ M. When we compared the pendent the normal controls with the obliged heterocigotes pendent for the PRPP substrate was statisticaly different owing to high Km value.

Three Cases of Lesch-Nyhan Syndrome: Cases report

Lesch-Nyhan syndrome is a rare X-linked recessive metabolic disorder characterized by developmental delay, hyperuricemia, choreoathetosis, spasticity, mental retardation, and compulsive self-injurious behavior. This disorder results from a complete deficiency of the purine salvage enzyme, hypoxanthine-guanine phosphoribosyltransferase (HGPRT). This syndrome is often misdiagnosed to cerebral palsy and clinical manifestations are usually related to the degree of enzyme deficiency. Complete HGPRT deficiency presents with severe specific neurologic manifestation and nephrolithiasis leading to fatal kidney damage. This report highlighted the importance of clinical awareness leading to early diagnosis and therapy for prevention of the self mutilation and renal failure, even if we couldn't inhibit the progression of neuro-psychotic symptoms.

A Case of Lesch-Nyhan Syndrome

Lesch-Nyhan syndrome is an X-linked recessive disorder characterized by hyperuricemia, choreoathetosis, spasticity, mental retardation, and compulsive, self-injurious behavior. This disorder results from a complete deficiency of the purine salvage enzyme, hypoxanthine-guanine phosphoribosyl transferase(HPRT). We report here on a case of Lesch-Nyhan syndrome in a 1-year, 7-month-old male who presented with frequent vomiting, failure to thrive, and developmental delay. The diagnostic work-up revealed hyperuricemia, hyperuricosuria, and medullary nephrolithiasis. The HPRT activity in the erythrocytes was undetectable with a biochemical assay. We also identified de novo mutation which was a deletion of the 649th base, adenosine, in HPRT gene(649delA) by analysis of cDNA using RT-PCR technique coupled with direct sequencing.

Determinacion de la condicion heterocigota del sindrome de Lesch-Nyhan utilizando un metodo radioquimico / Heterozygous status determination of Lesch-Nyhan syndrome using a radiochemical method

El analisis de las raices de cabello procedentes de uuna mujer, madre de dos niños con diagnostico comprobado de Sindrome de Lesch-Nyhan, mediante el metodo radioquimico, sirvio para comprobar que este procedimiento es valido como herramienta para la determinacion de portadores de dicha patologia. El metodo radioquimico, permitio la visualizacion de los productos de las reacciones catalizadas por las enzimas adenina fosforribosil transferasa (APRT) e hipoxantina-guanina fosforribosil transferasa (HGPRT) y la determinacion de la actividad biologica de las enzimas en forma total o parcial. En las raices de la paciente se encontro que la enzima mostraba diferentes niveles de actividad que variaban desde valores equivalentes a los controles normales hasta aquellos considerados como ausencia absoluta de la misma. En el presente trabajo se demuestra por primera vez en Colombia, en una paciente asintomatica, su condicion heterocigota analizando la expresion fenotipica del gen de la HGPRT.

A radiochemical metod for hair root analysis to detect asymtomatic Lesh-Nyhan symdrome patient was evaluated in one woman, mother of two children with confirmed diagnostic of this syndrome. This method allows the measurement of the enzymatic reaction products using adenine phosphoribosyltransferasa (APRT) and hypoxantine-guanine phosphoribosyltranferasa(HGPRT)suggesting partial or total activity. In the patient`s hair roots were found that these enzymes had different levels of activity and grat varibility between normal activity and absolute lack of it. In this work is presented for first time in Colombia, one asymptomatic patient with a heterocigotic condition for Lesh-Nyhan symdrome using the phenotipic expression of HGPRT gene.

Molecular characterization and Prenatal Molecular Evaluation of three fetuses in four unrelated Korean families with Lesch-Nyhan syndrome

The Lesch-Nyhan syndrome which is caused by the deficiency of hypoxanthine guanine phosphoribosyltransferase is an X-linked recessive disorder characterized by hyperuricemia, choreoathetosis, mental retardation and compulsive self-injurious behavior. Clinical management of the patients with the Lesch-Nyhan syndrome is frustrating and requires burdensome medical treatment since it cripples the patient and shortens the life span by progression of neurological symptoms, but there are no cures or measures for relieving relentless natural course of the disease yet. Therefore, prenatal diagnosis of the affected fetus is important in genetic counselling for the family at high risk. In this study, four different mutations in the HPRT gene of four probands have been identified in four unrelated families; K215X, Q109X, nt.631 A, and nt.289 GT. Two mutations among them altered restriction enzyme sites; SpeI for Q109X and MaeI for nt.289 GT. Based on their molecular defects, prenatal diagnoses of 3 the fetuses were successfully made between ninth and eleventh week of gestation by polymerase chain reaction(PCR), restriction digestion and DNA sequencing using cDNA obtained from chorionic villus samples (CVS). We predicted the outcome of all fetuses prenatally. Among the three fetuses two were male and one was female according to the identification made by PCR amplification of the sex determining region of the Y chromosome(SRY) gene. Each carried a wild type allele for the corresponding mutant allele. They were also tested postnatally for the mutations to be unaffected.