SUPPLEMENTARY MATERIAL
Patient 1
Female, born to nonconsanguineous parents, with uneventful pregnancy and delivery, presenting congenital clubfeet. Neurologic development initially described as normal. At the age of three, she was noted to present bone deformities including short neck, thoracic kyphosis, lumbar scoliosis, and genu valgum. At the age of seven she presented learning disability. She also developed dysarthria at the age of 17 and dysphagia at 20. Skeletal deformities progressed, especially in the hips, and she was submitted to bilateral hip arthroplasty at the age of 19, without functional outcome and being then confined to a wheelchair.
She was referred at the age of eight from the orthopedist with a diagnosis of Morquio disease. A residual activity of β-gal in fibroblasts resulted 15 nmol/h/mg protein (RV 394-1440). Later on, molecular analysis of theGLB1 gene revealed compound heterozygosity for p.T384S and p.T500A mutations.
A skeletal survey revealed gibbus deformity, irregularity and beaking of the vertebral bodies (especially L1), dysplasia of the femoral head, and irregularity of the acetabular roof. There was also a bone bar from T10 to L3 (fig. 1). At the age of 31 years an abdominal ultrasound showed chronic choledocolithiasis and right nephrolithiasis, an echocardiogram was normal, and ophthalmologic evaluation showed only strabismus, without corneal or fundoscopic changes.
In the last physical evaluation at the age of 31 she presented short stature and spinal deformities. There was no visceromegaly. Neurologic evaluation was compromised due to skeletal deformities, tendon retractions, and pain, but she presented with pyramidal signs as increased reflexes and pseudo Babinsky. Extapyramidal signs such as symmetric facial dystonia, limb dystonia, and grimacing face were present. She also had generalized muscle atrophy, dysarthria, dysphagia, abnormal eye movements with saccadic intrusions, and severe impairment of the activities of daily living. She presents with anarthria but cognition is apparently preserved.
Patient 2
Male, born to nonconsanguineous parents of mixed Brazilian and Spanish ancestry, the product of a dizygotic uneventful pregnancy. Delivery was by caesarean section and complicated by amniotic fluid aspiration. He presented with neuromotor delay while the twin brother presented normal neurologic and somatic developments.
At the age of two and half years he was first noted to present gait instability and bone changes which progressed to short stature, chest deformity, kyphoscoliosis, and cubitus valgus. He was referred at the age of eight to investigate spondyloepiphyseal dysplasia presenting a normal toluidine blue test and a glycosaminoglycans chromatography. At this age, cognition was considered normal by the relatives.
A residual activity of β-gal in leukocytes resulted 6 nmol/h/mg protein (RV 78-280) and molecular analysis of the GLB1 gene revealed compound heterozygosity for p.R59H and p.T500A, the former associated to the IVS12+8T>C polymorphism.
He evaluated with gait deterioration. At the age of 14 he was submitted to spine surgery due to lumbar spondylolysthesis. At the age of 22 he presented with dysphagia and a progressive spastic tetraplegia was noted at the age of 30.
A skeletal survey showed platyspondyly, irregularity and beaking of the vertebral bodies, dysplasia of the femoral head, and irregularity of the acetabular roof. A spine CT also showed abnormal rotation of the cervical portion, enlarged C1, narrowing of the medullary canal, os odontoideum, and spondylolysthesis C2-C3 (fig. 1). Abdominal ultrasound, echocardiogram, and ophthalmologic evaluation resulted normal at the age of 31 years.
At the age of 32 he presents no visceromegaly. Examination revealed cutis verticis gyrata. Neurologic evaluation was compromised due to skeletal deformities and pain, but he presented with pyramidal syndrome comprising increased reflexes, spasticity, and clonus. Extapyramidal signs were severe facial dystonia, mild limb dystonia, and grimacing face. Generalized muscle atrophy, dysarthria, dysphagia, abnormal eye movements with saccadic intrusions were also noted and severe impairment of the activities of daily living was evident. Cognition was apparently preserved.
Patient 3
Born to nonconsanguineous parents and sister of patient 4. Pregnancy and delivery were uneventful and she had a normal somatic and neurologic development until the age of 7 years, when speech deterioration associated to loss of fine motor skills was noted. These symptoms progressed and were latter combined to gait disorder and fluctuating mental abilities which finally resulted in severe cognitive impairment. At the age of 16 she also developed enuresis and was no longer able to walk at the age of 17.
At the age of 18 she developed a severe anorexia resulting in a loss of 28 kg within few months, and bone abnormalities mainly in the hips became evident. At the age of 22 years she developed angiokeratomas on knees, elbows, and pelvis.
A residual activity of β-gal resulted 3.3 nmol/h/mg protein (RV 78-280) in leukocytes and 28 nmol/h/mg protein (RV 394–1440) in fibroblasts, with normal neuroaminidase activity (4.9 nmol/h/mg protein for a RV 1.02-5.9). Molecular analysis of GLB1 gene revealed compound heterozygosity for p.R59H and p.R201H, the former associated to the IVS12+8T>C polymorphism.
A skeletal survey showed platyspondyly, anterior beaking of the vertebrae, toracolumbar kyphosis, and irregularities of the femoroacetabular joint. At the age of 20 she was submitted to a hip CT which revealed bilateral severe dysplasia and bursitis, being submitted to an arthroplasty. At the age of 29 an abdominal ultrasound and ophthalmologic evaluation resulted normal, and an echocardiogram showed mild aortic insufficiency.
Neurologic evaluation at the age of 29 years was compromised due to skeletal deformities and pain, but she presented with pyramidal syndrome comprising increased reflexes and spasticity. Extapyramidal signs were symmetric facial dystonia, mild limb dystonia, and grimacing face. Generalized muscle atrophy and dysarthria were also present. She was not collaborative to test eye movements due to severe cognitive and behavioral impairment.
Patient 4
Brother of patient 3. Pregnancy and delivery were uneventful and early development was described as normal until the age of 7 years, when agitation, aggressive behavioral, failing school performance, dysarthria, and loss of fine motor skills were noted. At the first evaluation in the service, at the age of nine, he also presented short stature, thoracic deformity, spine rectification, and retracted shoulders. A skeletal survey showed platyspondyly, vertebral deformities, and acetabular dysplasia.
Residual activity of β-gal resulted 4.0 nmol/h/mg protein (RV 78-280) in leukocytes and the same mutations of her sister were seen in the molecular study of the GLB1 gene.
Abdominal ultrasound examination, ophthalmologic evaluation, cardiac assessment and an echocardiogram showed no alterations at the age of 26 years.
Neurologic evaluation at this age was compromised due to agitation and severe cognitive impairment. An extrapyramidal syndrome was seen and comprised symmetric facial dystonia, mild limb dystonia, and grimacing face. Muscle atrophy and dysarthria were also present. He was not collaborative to test eye movements and gait ataxia was considered due to enlarged basis. Short after that hip dysplasia progressed to a severe arthrosis and the patient became confined to a wheelchair.
Patient 5
Female, born to nonconsanguineous parents of mixed Amerindian, Afro-Brazilian, and Iberian origin including one Italian ancestor. Pregnancy complicated by placenta previa detected in the second trimester. Delivery and neonatal period were uncomplicated. Early development was considered normal, but at the age of 14 months she was noted to present thoracic and spine deformities including lumbar hyperlordosis, followed by gait disorder and frequent falls at the age of 2 years.
She was first seen in our service at the age of 9 years with a previous diagnosis of Morquio disease. She presented with short stature, short and wide trunk, scoliosis, and lumbar hyperlordosis. Activity of β-gal in leukocytes resulted 7.8 nmol/h/mg protein (RV 78-280) and molecular study of the GLB1 gene showed compound heterozygosity for the p.T500A and c.1717-1722insG mutations.
At the age of 13 years she presented an episode of temporary facial palsy of IX to XII nerves and dysarthria turned evident after recovery. At 14 years she complained of writing difficulties and had a left hip dislocation, with loss of ambulation within the next year, being submitted to hip arthrodesis and spine arthroplasty. She discontinued follow up in the service and returned at the age of 21 years showing worsening of dysarthria and development of dysphagia.
Recent evaluation at the age of 27 years revealed short stature, chest and spine deformities, and absence of visceromegalies. Neurologic evaluation was compromised due to pain or osteoarticular abnormalities, but she presented an exuberant pyramidal syndrome and an extrapyramidal syndrome characterized by symmetrical facial dystonia, grimacing face, limb dystonia, dysarthria, dysphagia, hypometric saccadic eye movements, and generalized muscle loss. Cognition was preserved and she could communicate using the cell phone keyboard.
Abdominal ultrasound examination, echocardiogram, and ophthalmologic evaluation resulted normal. Radiologic evaluation revealed right femoroacetabular dysplasia and presence of prosthesis on the left hip, besides platyspondyly, hypoplasia of the odontoid process, and anterolisthesis of C7 and T1.
Patient 6
Male, born to nonconsanguineous parents of Iberian and Amerindian origin. Pregnancy complicated by third trimester oligohydramnios followed by uncomplicated delivery and neonatal period. Somatic and neurologic development were described as initially normal, but at the age of 12 months he was noted to present right leg claudication, which progressively progressed to abnormal gait. At the age of 14 years he presented limited internal rotation of the right leg and shortening of the ischiotibial muscles. At the age of 17 he was submitted to right inguinal herniorrhaphy. Hypernasal speech, dysarthria and dysphagia were noted at the age of 19 years.
He was first evaluated in our service at the age of 7 years and clinical evaluation revealed short stature, short trunk with prominent ribs, and joint hypermobility. Activity of β-gal resulted 21 nmol/h/mg protein (RV 78-280) in leukocytes and neuraminidase 43 nmol/h/mg protein (RV 30-38) in fibroblasts. Direct sequencing of the GLB1 gene revealed the presence of the p.T500A mutation in heterozygosity, while the second mutation remained undetected.
A skeletal survey showed platyspondyly, thoracic kyphosis, irregularity and beaking of the vertebrae (especially L1), asymmetrical shortening and irregularities of the femoral heads and acetabulum. Abdominal ultrasound examination revealed a horseshoe kidney. Echocardiogram and ophthalmologic evaluation resulted normal.
Neurologic evaluation at the age of 23 year was partially compromised due osteoarticular abnormalities, without signs of pyramidal and extrapyramidal syndromes, but presenting with dysarthria, dysphagia, and hypometric saccadic eye movements. Cognition and communication skills were preserved.
Patient 7
Female, born to nonconsanguineous parentes of mixed Italian and Afro-Brazilian ancestry, born after uneventful pregnancy and delivery.
At the age of three and a half years she was noted to present gait disturbance, neuromotor delay, and skeletal abnormalities (cubitus valgus, short stature, and frontal bone bulging). At the age of four parents referred slow speech.
She was first seen in our service at the age of 8 years when residual activity of β-gal resulted 9 nmol/h/mg protein (RV 72-280) in leukocytes and neuraminidase resulted 54 nmol/h/mg (RV 30-38) in fibroblasts. Molecular analysis of GLB1 gene revealed compound heterozygosity for p.G311R and p.T500A mutations. Complementary radiologic evaluation showed thoracolumbar kyphoscoliosis, platyspondyly, and irregularities of the femoroacetabular joint with bilateral femoral head flattening. Cardiac and ophthalmologic evaluation resulted normal at the age of 23 years.
At the age of 11 years she evolved with dysarthria, dystonic movements, hyperreflexia, and at 12 ½ years she no longer was able to walk independently, requiring the use of a wheelchair. An osteotomy fixation of the femoral head, bilateral knee replacement, and bilateral tenotomy of the ischiotibial muscles were performed at the age of 18 years. At this age dysphagia was evident, at 19 she no longer engaged conversations, and at 22 she needed feeding help. Nowadays, at the age of 23 years, she remains with dysphagia, sialorrhea, and recurrents pneumonias.
Neurologic evaluation was compromised due pain and skeletal deformities. She presented with pyramidal syndrome comprising alive, active reflexes; extrapyramidal signs were grimacing face, symmetric facial dystonia and limbs dystonia, diffuse muscular atrophy, dysphagia, dysarthria, abnormal eye movement with conjugate gaze palsy (vertical and horizontal). She showed apparent mild intellectual deficiency.
Patient 8
Male, born to nonconsanguineous parents with mixed Italian and Dutch ancestry. The mother referred use of carbamazepine during pregnancy, which was otherwise uneventful. He had normal somatic and neurologic development until one year of age when he was noted to present gait disturbance (mostly on right), frequent falls, lack of balance, and involution of speech and bladder control until the age of 3 years.
At the age of 5 years he was referred for evaluation in our service due to “neurologic involution syndrome”. Residual activity of β-gal was 11.7 nmol/h/mg protein (RV 394-1440) and neuraminidase 19 nmol/h/mg protein (VR: 30-38), both in fibroblasts. Direct sequencing of GLB1 gene revealed the presence of compound heterozygous mutations (p.F107L and p. L173P) besides the neutral alteration p.P152P. Abdominal ultrasound examination, cardiac and ophthalmologic evaluations showed no abnormalities. A skeletal survey showed enlargement of the sella turcica, protusion and irregularities of the vertebral bodies, acetabular irregularities and dislocation of distal epiphysis at right. An electroencephalogram showed often and progressive epileptiform disorder during sleep.
He presented with dysarthria and speech loss between seven and eight years of age, loss of ambulation at 10 years, and progressive lower limbs spasticity. At the age of 11 years he had dysphagia.
On physical examination at the age of 18 years he presented with short stature and was confined to wheelchair. Neurologic evaluation was compromised due to skeletal deformities, pain, and lack of collaboration. He presented pyramidal syndrome comprising increased tonus and cutaneous reflex-dependent speed planting in extension. Extrapyramidal signs were facial symmetric dystonia, grimacing face, limbs and axial dystonia, dysphagia and dysarthria. Eye movements evaluation was not possible due to lack of cooperation. He presented impairment of cognition and depression.
Patient 9
Female, born to nonconsanguineous parents after uneventful pregnancy and delivery. Somatic and neurologic developments were described as initially normal. The ethnic background comprises Spanish, Portuguese, German, French, and Italian ancestry.
Soon after birth karyotyping was requested due to a clinical suspicion of Down syndrome, with normal result. At the age of five years a pediatrician noticed lumbar hyperlordosis and thoracic protrusion, and at the age of seven years the family complained about short trunk and genu valgus, being diagnosed with Morquio B disease in another service.