Pediatric Gaucher disease with intermediate type 2-3 phenotype associated with parkinsonian features and levodopa responsiveness

Introduction: Gaucher disease (GD) is an autosomal recessive lysosomal storage disorder caused by a deficiency of acid beta-glucosidase encoded by the GBA gene. In patients with GD, childhood onset parkinsonian features have been rarely described. Methods: Twin siblings with GD are described, including clinical follow-up and treatment response. Bone marrow, enzyme activity studies and genotyping were performed. Results: By age 9 months, symptoms at onset were thrombocytopenia and splenomegaly. By age 2, hypokinesia, bradykinesia and oculomotor apraxia were observed. By age 5 a complete rigid hypokinetic syndrome was stablished in both patients, including bradykinesia, tremor and rigidity. Treatment with imiglucerase, miglustat, ambroxol and levodopa were performed. Levodopa showed a good response with improvement in motor and non-motor skills. Foamy cells were found in the bone marrow study. Glucocerebrosidase activity was 28% and 26%. Sanger sequencing analysis identified a missense mutation and a complex allele (NP_000148: p. [(Asp448His)]; [(Leu422Profs*4)]) in compound heterozygosity in GBA gene. Conclusions: Two siblings with neuronopathic GD with an intermediate form between type 2 and 3, with a systemic and neurological phenotype are described. The complex neurological picture included a hypokineticrigid and tremor syndrome that improved with levodopa treatment. These conditions together have not been previously described in pediatric GD. We suggest that in children with parkinsonian features, lysosomal storage disorders must be considered, and a levodopa trial must be performed. Moreover, this report give support to the finding that GBA and parkinsonian features share biological pathways and highlight the importance of lysosomal mechanisms in parkinsonism pathogenesis, what might have therapeutic implications.

Automated summary

This study described two siblings with neuronopathic Gaucher disease with an intermediate form between type 2 and 3, who presented with a systemic and neurological phenotype. The complex neurological picture included a hypokinetic-rigid and tremor syndrome that improved with levodopa treatment. The findings suggest a potential link between GBA and parkinsonian features, highlighting the importance of lysosomal mechanisms in parkinsonism pathogenesis and potential therapeutic implications.