Cuando las enfermedades metabólicas se confunden con las inflamatorias

The presence of distal extremity pain and muscle weakness in patients usually triggers the search for rheumatic diseases without giving thought to non-rheumatologic etiologies. Approaching these symptoms with a broad differential diagnosis including non-rheumatologic entities may lead to earlier diagnosis of metabolic diseases, thus decreasing cost and aiding in earlier initiation of appropriate therapy. Aim: To present 2 cases of patients who, after years of rheumatologic work up for arthralgia and muscle weakness, were found to have inherited metabolic diseases. Rheumatologists and immunologists may be the first to encounter patients with Fabry and Pompe disease. If these disorders are not considered in the differential diagnosis, we will miss the opportunity for early institution of therapy.La presencia de dolor distal en las extremidades y debilidad muscular lleva en muchos pacientes a la búsqueda de enfermedades reumatológicas sin contemplar la posibilidad de otras entidades no inflamatorias. Un acercamiento al diagnóstico del dolor distal y la debilidad muscular desde múltiples enfoques puede resultar en el arribo al diagnóstico en forma temprana, disminuyendo los costos para el sistema y ofreciendo una posibilidad terapáutica precoz. Presentamos dos pacientes con artralgias y debilidad muscular, que luego de años de seguimiento y estudios en búsqueda de enfermedades reumáticas, se les realizó diagnóstico de errores congénitos del metabolismo. Los reumatólogos e inmunólogos pueden ser los primeros especialistas en enfrentar pacientes con enfermedad de Fabry y Pompe. Si estas enfermedades no son consideradas dentro del diagnóstico diferencial, se estará perdiendo la posibilidad de iniciar un tratamiento específico que puede modificar la evolución natural de la enfermedad

Fabry disease and COVID-19: International expert recommendations for management based on real-world experience

The rapid spread of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 has raised questions about Fabry disease (FD) as an independent risk factor for severe COVID-19 symptoms. Available real-world data on 22 patients from an international group of healthcare providers reveals that most patients with FD experience mild-to-moderate COVID-19 symptoms with an additional complication of Fabry pain crises and transient worsening of kidney function in some cases; however, two patients over the age of 55 years with renal or cardiac disease experienced critical COVID-19 complications. These outcomes support the theory that pre-existent tissue injury and inflammation may predispose patients with more advanced FD to a more severe course of COVID-19, while less advanced FD patients do not appear to be more susceptible than the general population. Given these observed risk factors, it is best to reinforce all recommended safety precautions for individuals with advanced FD. Diagnosis of FD should not preclude providing full therapeutic and organ support as needed for patients with FD and severe or critical COVID-19, although a FD-specific safety profile review should always be conducted prior to initiating COVID-19-specific therapies. Continued specific FD therapy with enzyme replacement therapy, chaperone therapy, dialysis, renin–angiotensin blockers or participation to clinical trials during the pandemic is recommended as FD progression will only increase susceptibility to infection. In order to compile outcome data and inform best practices, an international registry for patients affected by Fabry and infected by COVID-19 should be established

Early diagnosis of peripheral nervous system involvement in Fabry disease and treatment of neuropathic pain: the report of an expert panel

Background: Fabry disease is an inherited metabolic disorder characterized by progressive lysosomal accumulation of lipids in a variety of cell types, including neural cells. Small, unmyelinated nerve fibers are particularly affected and small fiber peripheral neuropathy often clinically manifests at young age. Peripheral pain can be chronic and/or occur as provoked attacks of excruciating pain. Manifestations of dysfunction of small autonomic fibers may include, among others, impaired sweating, gastrointestinal dysmotility, and abnormal pain perception. Patients with Fabry disease often remain undiagnosed until severe complications involving the kidney, heart, peripheral nerves and/or brain have arisen. Methods: An international expert panel convened with the goal to provide guidance to clinicians who may encounter unrecognized patients with Fabry disease on how to diagnose these patients early using simple diagnostic tests. A further aim was to offer recommendations to control neuropathic pain. Results: We describe the neuropathy in Fabry disease, focusing on peripheral small fiber dysfunction - the hallmark of early neurologic involvement in this disorder. The clinical course of peripheral pain is summarized, and the importance of medical history-taking, including family history, is highlighted. A thorough physical examination (e. g., angiokeratoma, corneal opacities) and simple non-invasive sensory perception tests could provide clues to the diagnosis of Fabry disease. Reported early clinical benefits of enzyme replacement therapy include reduction of neuropathic pain, and adequate management of residual pain to a tolerable and functional level can substantially improve the quality of life for patients. Conclusions: Our recommendations can assist in diagnosing Fabry small fiber neuropathy early, and offer clinicians guidance in controlling peripheral pain. This is particularly important since management of pain in young patients with Fabry disease appears to be inadequate

Mutations, Clinical Findings and Survival Estimates in South American Patients with X-Linked Adrenoleukodystrophy

In this study, we analyzed the ABCD1 gene in X-linked adrenoleukodystrophy (X-ALD) patients and relatives from 38 unrelated families from South America, as well as phenotypic proportions, survival estimates, and the potential effect of geographical origin in clinical characteristics

The clinical profiles of female patients with fabry disease in latin america : a fabry registry analysis of natural history data from 169 patients based on enzyme replacement therapy status

1-11Background: Fabry disease is an X-linked lysosomal storage disorder with heterogeneous clinical expression in female patients ranging from asymptomatic to severe clinical presentations as in classic males. We assessed clinical profiles and compared natural history data of female patients eventually initiated on enzyme replacement therapy (“ERT-recipients”) with those remaining untreated (“ERTnaïve”). Methods: We analyzed Fabry Registry data from 93 ERT-recipients, collected prior to ERT initiation, and 76 ERT-naïve females with classic or unclassified phenotypes from four Latin American countries and evaluated Fabry symptoms, interventricular septum thickness, left ventricular posterior wall thickness, estimated glomerular filtration rate, and severe clinical events. Results: For 169 patients with available data, median age of first Fabry symptom manifestation was 12.7 years with peripheral pain as predominant first symptom, and diagnostic delay of 10.3 years from the first reported symptom. Female patients had high symptomatic burden during natural history follow-up, with 83% reporting peripheral pain, 69%-79% cold/heat intolerance or abnormal sweating, and 32% gastrointestinal symptoms. ERT-recipients reported similar age at first symptom as ERT-naïve patients but they were older at diagnosis (median 39.2 vs 24.4 years, P < .01) and last follow-up (median 43.4 vs 28.2 years, P < .01). Reported Fabry symptom frequencies and abnormal echocardiography findings were higher in ERT-recipients. Functional renal assessments were normal and similar. Conclusions: Female patients from Latin America have notable diagnostic delays and high symptomatic burden. ERT was prescribed late in females with advanced age at diagnosis and advanced disease. There remained many female patients who had been diagnosed at younger age, had substantial Fabry manifestations, but did not receive disease-specific treatment

Guidelines for diagnosis, monitoring and treatment of Fabry disease.

La enfermedad de Fabry es un trastorno de almacenamiento lisosomal hereditario ligado al cromosoma X, ocasionado por el déficit de la enzima alfa galactosidasa A. El conocimiento sobre esta patología, y en particular su manejo médico, ha progresado notablemente en la última década, incluyendo el desarrollo de su tratamiento específico. La presente guía fue desarrollada por profesionales médicos de diversas especialidades involucrados en la atención de pacientes con enfermedad de Fabry. La discusión y análisis de las evidencias científicas disponibles, sumado a la experiencia de cada uno de los participantes, ha permitido desarrollar los conceptos vertidos en esta guía con el objetivo de brindar una herramienta útil para todos los profesionales que asisten a pacientes con enfermedad de Fabry.Fabry disease is an X-linked hereditary lysosomal storage disorder caused by deficiency of the enzyme alpha-galactosidase A. Knowledge about this disease, and its medical management, has made remarkable progress in the last decade, including the development of its specific treatment. This guide was developed by medical professionals from various specialties involved in the care of patients with Fabry disease. The discussion and analysis of the available scientific evidence, coupled with the experience of each of the participants, has allowed us to develop the concepts included in this guide in order to provide a useful tool for all professionals who care for patients with Fabry disease.Fil: Neumann, Pablo. Hospital Italiano de la Plata; ArgentinaFil: Antongiovanni, Norberto. Instituto de Nefrología. Pergamino; ArgentinaFil: Fainboim, Alejandro. Hospital de Niños Ricardo Gutiérrez. Buenos Aires; ArgentinaFil: Kisinovsky, Isaac. Sanatorio Urquiza. Quilmes; ArgentinaFil: Amartino, Hernan. Hospital Universitario Austral. Pilar; ArgentinaFil: Cabrera, Gustavo Javier. Grupo Médico Del Viso. Buenos Aires; ArgentinaFil: Carmona, Sergio. Instituto de Neurociencias Buenos Aires S. A.; ArgentinaFil: Ceci, Romina. Universidad Nacional de la Plata. Facultad de Ciencias Exactas. Departamento de Ciencias Biologicas. Laboratorio de Investigaciones del Sistema Inmune; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Ciceran, Alberto. Hospital General de Agudos Juan A. Fernandez. Buenos Aires; ArgentinaFil: Choua, Martin. Centro de Nefrología. Tucumán; ArgentinaFil: Doxastakis, Griselda. Instituto de Cardiología y Cirugía Cardiovascular. Posadas; ArgentinaFil: De Maio, Sonia. Hospital General de Agudos Juan A. Fernandez. Buenos Aires; ArgentinaFil: Ebner, Roberto. Hospital Británico de Buenos Aires; ArgentinaFil: Escobar, Ana Maria. Hospital Británico de Buenos Aires; ArgentinaFil: Ferrari, Gustavo. Hospital Británico de Buenos Aires; ArgentinaFil: Forrester, Mariano. Hospital Británico de Buenos Aires; ArgentinaFil: Guelbert, Norberto Bernardo. Hospital de Niños. CEMECO. Cordóba; ArgentinaFil: Luna, Paula. Hospital Aleman; ArgentinaFil: Marchesoni, Cinthia. Hospital Británico de Buenos Aires; ArgentinaFil: Masllorens, Francisca. Hospital Posadas. Haedo; ArgentinaFil: Politei, Juan. Hospital General de Agudos Juan A. Fernandez. Buenos Aires; ArgentinaFil: Reisin, Ricardo. Hospital Británico de Buenos Aires; ArgentinaFil: Ripeau, Diego. Hospital Posadas. Haedo; ArgentinaFil: Rozenfeld, Paula Adriana. Universidad Nacional de la Plata. Facultad de Ciencias Exactas. Departamento de Ciencias Biologicas. Laboratorio de Investigaciones del Sistema Inmune; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Serebrinsky, Graciela. Laboratorio de Biología y Patología Molecular. Buenos Aires; ArgentinaFil: Tarabuso, Ana Lia. Centro de Especialistas En Audición y Lenguaje. Trelew; ArgentinaFil: Tripoli, Juan. Hospital de Niños Ricardo Gutiérrez. Buenos Aires; ArgentinaFil: Consenso de médicos de Asociación de Estudios y Difusión de las Enfermedades Lisosomales.Fil: Grupo Argentino de Diagnóstico y Tratamiento de la enfermedad de Fabry

Consenso de expertos sobre recomendaciones basadas en evidencia para el diagnóstico, tratamiento y seguimiento de enfermedad de Fabry en pediatría

Antecedentes: La enfermedad de Fabry (EF) es una enfermedad rara ligada a X secundaria al depósito lisosomal de glicoesfingolípidos debido a la deficiencia de la enzima alfa galactosidasa A (α-Gal A). A pesar de su baja frecuencia, es una condición que afecta la calidad de vida de los pacientes y disminuye su esperanza de vida. Objetivo: Generar recomendaciones informadas en evidencia para el diagnóstico y tratamiento de pacientes pediátricos (menores de 8 años) con EF. Métodos: Se realizó una revisión de literatura en bases de datos y literatura gris a partir del 2010, incluyendo guías de práctica clínica, revisiones sistemáticas, estudios primarios. La calidad de evidencia se evalúo de acuerdo con el tipo de evidencia. Las recomendaciones se sometieron a consenso de expertos a través de metodología Delphi modificada. El acuerdo se definió a partir del 80%. Resultados: A partir del análisis de la evidencia recolectada, se formularon un total de 45 recomendaciones para tamización, diagnóstico y tratamiento de paciente pediátrico con enfermedad de Fabry. El panel revisor estuvo conformado por once expertos en el tema. Las recomendaciones fueron aprobadas con puntuaciones entre 82.3% y 100%. Conclusiones: Las recomendaciones resultantes del consenso de expertos permitirán la toma de decisiones clínicas y estandarización de la práctica en la atención de pacientes pediátricos con EF a nivel nacional y regional; el diagnóstico temprano y oportuno garantiza una disminución del impacto en la calidad de vida de los pacientes y sus familiares. Palabras clave: Enfermedad de Fabry, niños, diagnóstico, terapeutica, biomarcadore

Cardiac Manifestation of Fabry Disease

Although Fabry disease was identified a century ago, it is still a challenging condition to diagnose and treat. Registries data suggest that at least 10% of patients may first present with a cardiac event and that cardiac disease is 1 of the 3 major causes of morbidity and mortality in affected males and females. Cardiac involvement in Fabry disease may be expressed as left ventricular hypertrophy (LVH), coronary disease, atrioventricular conduction disturbances, arrhythmias, and valvular involvement. The exact mechanism by which hypertrophy and fibrosis in the heart occur is not fully understood. Lysosomal globotriaosylceramide accumulation in the myocardium is responsible for only 3% of the mass in the hypertrophic heart, indicating that the LVH is not a direct result of substrate infiltration. One of the most important contributions that cardiologists can make is to consider the diagnosis of Fabry disease in patients with cardiac manifestations preceding the development of LVH and conduct family screening to identify patients with early cardiac involvement which will benefit more from enzyme replacement therapy (ERT). Fabry patients without cardiac manifestations of the disease should be evaluated annually by a cardiologist specialized in Fabry disease, regardless of the indication for ERT

The Central Nervous System Involvement in Fabry Disease

Fabry disease (FD) is an X-linked, lysosomal storage disorder caused by a mutation in the alpha galactosidase (GLA) gene leading to a deficiency in α-galactosidase A enzyme (α-Gal A) activity, which in turn results in accumulation of glycosphingolipids in different cells. The 2 major clinical phenotypes are the classic severe phenotype and the milder, later onset phenotype. In severe affected males with little or no α-Gal A activity, the onset of acroparesthesias, hypohidrosis, angiokeratomas, and corneal dystrophy is typically observed in childhood or adolescence. With advancing age, progressive multisystem microvasculopathic disease culminates in renal failure, cardiomyopathy, and/or cerebrovascular disease. Patients with later onset have residual enzyme activity and lack of vascular endothelial glycolipid accumulations; thus, they do not present with the early manifestations of the classic phenotype and typically present cardiac or renal disease in the fourth to seventh decade. Although the pathogenesis of cerebral vasculopathy in FD is poorly understood, it can be hypothesized that white matter changes may reflect the pathophysiology of the disease