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Deficiency of arylsulfatase B in 2 brothers aged 40 and 38 years.

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Deficiency of Arylsulfatase B
in 2 Brothers Aged 40 and 38 Years
(Maroteaux-Lamy Syndrome, Type B)
H. Pilz, MD, K. von Figura, MD, and H. H. Goebel, MD
Two brothers, aged 40 and 38 years, suffered from dysplastic features, coarse facies, bone and skeletal abnormalities, deformities of spine, and joint impairments. Body heights were 168 and 164 cm, respectively. Enlargement
of liver and spleen, cardiac insufficiency, marked corneal clouding, and hernias were absent. Both patients had signs
iof cervical and lumbar radiculopathy and cervical myelopathy (tetraspastic syndrome).
Vacuoles, acid phosphatase-positive granules, and metachromatic inclusions were found in peripheral lymphozytes; granulocytes and monocytes contained azurophilic hypergranulation. By electron microscopy, clear
membrane-bound vacuoles were noted in lymphocytes (but not in neutrophils), fibroblasts, Schwann cells, mural
:ells of the vasculature, and epidermal cells.
Leukocytes, urine, and cultured skin fibroblasts revealed a deficiency of arylsulfatase B (N-acetylgalactosamine
$-sulfate sulfatase). The 6-year-old daughter of one of the patients has an intermediate level of this enzyme.
Fibroblasts exhibited a constant intracellular accumulation of 35S-labeledmucopolysaccharides. The urine of one of
he brothers showed an abnormal mucopolysacchariduria; in both, the presence of urinary dermatan sulfate could
he demonstrated. These findings conform to the mild B variant of Maroteaux-Lamy syndrome with high longevity.
Pilz H , von Figura K, Goebel H H : Deficiency of arylsulfatase B in 2 brothers aged 40 and 38 years
(Maroteaux-Lamy syndrome, type B) Ann Neurol 6.315-325, 1979
The autosomal recessively inherited MaroteauxLamy syndrome (MLS) is a recently discovered
nucopolysaccharidosis. These storage diseases are
commonly marked by intracellular accretion and en!lanced urinary excretion of acid mucopolysac4:harides. The syndrome was differentiated from
other mucopolysaccharidoses in the mid-1960s [30,
.\ 11 on clinical and biochemical grounds. Its clinical
characteristics include retarded growth, osseous deformities, enlargement of the liver and possibly the
spleen, cardiac abnormalities, corneal clouding, and
coarse facies. Mental deficiency is absent. Its chief
4.haracteristic is urinary excretion of dermatan sult ate.
One of the first descriptions of MLS was probably
iurnished by the neurologist Nonne [ 341. After sevcral investigators indicated heterogeneity of MLS
14 1, 481 based o n radiological findings, the patients'
>,ize,and longevity, McKusick [33] suggested sep;rating a severe form (mucopolysaccharidosis type
VIA) from a mild variant (type VIB). The distinct
nature of MLS was confirmed by the demonstration of a specific corrective factor in this condi-
I'rom the Department of Neurology, University of Hamburg, the
1 >epartment of Physiological Chemistry, University of Minster,
. nd the Department of Neuropathology, University of Gottingen,
I ederal Republic of Germany.
tion [2] and by disclosure of a deficiency of arylsulfatase B (N-acetylgalactosamine 4-sulfate sulfatase)
We have examined 2 brothers, 40 and 38 years old,
who exhibited the somatic features of mucopolysaccharidosis and proved to have a deficiency of arylsulfatase B in fibroblasts, leukocytes, and urine. This
paper describes the findings in these 2 patients.
Case Reports
Consanguinity of the parents is not known. However, both
came from closely adjacent towns. The family history is
unremarkable. The father measured 178 cm in height, the
mother, 165 cm.
Patient 1
Patient 1 was born in 1936. He walked at an appropriate
age but experienced slight difficulties at 7 years. Perthes
disease was diagnosed when he was 8 or 9 years old and was
treated by application of a pelvic cast for three months. In
the ensuing years, when the disease did not progress, the
patient rode a bicycle and motorbike and played table tennis. In 1957, radiological examination revealed a thick skull
with prominent frontal bones and a normal sella, small
Accepted for publication Jan 5 , 1979.
Address reprint requests to D r Goebel, Neuropathologische Abteilung, N~~~~Klinikum, Robert-Koch-Str. 40, 3400 Gottingen,
Federal Republic of Germany.
0 3 6 4 - 5 1 3 ~ / 7 ~ / 1 0 0 3 1 5 - 1 1 ~ 0 1@
. 2 51978 by H . H . Goebel
F i g 1 . Patierit 1
316 Annals of Neurology Vol 6 No 4 October 1979
“beaked” vertebrae of the thoracic and lumbar spine, an
incompletely closed arch of the first sacral vertebra, thoracic
kyphosis, marked flattening of both femoral heads associated with several segmented cores in the epiphyseal region, and sclerosing bone transformation affecting the
acetabular roofs. There was a diminished intraarticular
space, flattening of the caput humeri, and shortening and
bowing of the humeral diaphysis but normal length of both
forearms. Carpal bones appeared deformed and parts were
small; metacarpal bones and phalanges of the hand were
stubby and short. Club feet with coarse calcaneal bones as
well as considerable degenerative changes of the elbow
joints and moderate thickening of the ribs were present.
Having successfully completed elementary and high
school, the patient studied law for four years and was then
employed at a municipal office. Since 1967, a slowly increasing weakness of his arms and legs has developed due
to mild tetraspasticity, especially of the legs. Examination
in 1971 revealed a height of 168 cm, weight of 70.2 kg,
stunting of trunk and limbs (Fig I ) , a large head, thick lips,
moderate macroglossia, saddle nose, bell-shaped thoracic
cage, sparse body hair, and protruding abdomen, but no
hernias. The liver and spleen were not enlarged.
Radiological examination (Fig 3) showed no change
compared to the roentgenographic examination in 1957.
Deformities of the spine were also present in the cervical region. Pneumomyelography revealed a normal subarachnoid space. Otological examination disclosed a mild
bilateral conductive hearing loss.
Ophthalmological examination showed small, circumscribed, and circular limbic corneal clouding of the
central parenchyma, no impairment of vision, and normal
fundi. The electroretinogram did not show pathological
potentials. He had bilateral hyperopia which upon correction gave normal vision. Results of various laboratory tests
were normal. An echoencephalogram showed a 6 mm wide
third ventricle. The Wechsler Adult Intelligence test gave a
value of 109.
A bilateral hip endoprosthesis was inserted in 1971.
Since then, his disease has not progressed.
Patient 2
Fig 3. Roentgeirograni of the thoracic spine (Patient 1)
A soft systolic cardiac murmur was heard in the apical
region, but signs of cardiac insufficiency were lacking. Expiratory and inspiratory stridor were noted. Joint mobility
was decreased in elbows, hips, and fingers. He had thoracic
scoliosis. The hands and fingers appeared stubby (Fig 2).
Deep tendon reflexes of the arms and legs were hyperac:he, especially on the right; abdominal reflexes were weak,
and ankle clonus and Babinski signs were present bilater, ~ I l y .There was hypoesthesia over the eighth cervical segnent.
The younger brother of Patient I was born in 1938. Joint
dysfunction first occurred at the age of 10 years and appeared less pronounced than that of his brother. H e
worked as a clerk and married in 1970, producing a
daughter one year later. His maximal body height was 164
cm. Since 1971 he has experienced stiffness of his legs and
numbness of his right knee and leg. In 1972, h e complained of blurred vision, increased sensitivity to light, and
orbital pain in his right eye. At hospital admission his
height was 161 cm and weight, 66.5 kg. He has dysplastic
features (Fig 4) consisting of short neck, large head (circumference 62 cm), a Hurlerlike face, thick lips, macroglossia, gaping teeth, and protruding abdomen, but no hernias. His liver was 1 fingerbreadth below the costal arch
and the spleen was of normal size.
H e had a soft systolic cardiac murmur at the apical region
but no signs of cardiac insufficiency. Blood pressure was
within normal range. He had hyperlordosis and scoliosis of
the thoracic and lumbar spine (Fig 5 ) and claw hands. Mobility was impaired in shoulder, elbow, hip, knee, and
finger joints. Hearing was normal. Mild tetraspasticity was
associated with increased stretch reflexes, more active on
the right side. Hypoesthesia of the seventh and eighth cervical segments on the right and of the first sacral segments
bilaterally was present. Psychological testing gave normal
Ophthalmologically, papillitis was present on the right.
The fundi were otherwise normal. He had bilateral microophthalmia but no corneal clouding.
Radiological examinations revealed a thick skull, synchondrosis sphenopetrosa, a dilated pneumatic sinus of the
dorsum sellae, and no abnormalities in the craniocervical
region, but a narrowed cervical spinal canal. His dysplastic
bone and joint features (Fig 6 ) were less marked than those
of his brother. There was mottled atrophy of the knee
joints and spondplolisthesis with fusion at the fifth
lumbar-first sacral vertebrae. Lumbar myelography using
the aqueous contrast medium Dimer-X revealed a block in
the presacral region.
Blood and serum values were normal. A lumbar spinal
tap revealed 14 lymphocytes per cubic millimeter and a
Pilz et al: Type B Maroteaux-Lamy Syndrome
protein value of 143 mg per deciliter; a suboccipital spinal
tap gave 0 cells per cubic millimeter and a protein of 20
mg per deciliter. Laminectomy revealed extensive protrusion of disc material at the fifth lumbar-first sacral vertebrae and between rhe first and second sacral vertebrae (lumbarization of the sacral vertebra). Neurological deficits i n
the sacral root areas remained postoperatively, but the
papilliris subsided, resulting in partial optic atrophy on the
right. T h e electroretinogram gave a normal wave pattern.
Because of his lesions, he has noticed increased shortening of his skeletal axis over the last three years that has
required adjustment of his walking aids.
318 Annals o f Neurology
Vol 6
No 4
October 1079
cell and granulocyte layer. These lymphocytes were then
washed in phosphate-buffered saline and again centrifuged
until a pellet formed. The pellet was fixed in a cacodylatebuffered glutaraldehyde, washed in buffer, postfixed in
osmium tetroxide, and embedded for electron microscopy
as outlined for the skin biopsy. Blood smears from both
patients were air dried and stained with the Pappenheim
and toluidine blue techniques. Acid phosphatase activity
[37] was also histochemically demonstrated in the blood
film (Patient 1).
Biochemical Studies
F i g 6 , Roentgeriograms of the thorax (A)and pelcis ( B ) of Patient 2.
Morphological Studies
A skin punch biopsy taken from Patient 2 was immediately
fixed in cacodylate-buffered glutaraldehyde, washed in the
same buffer, and postfixed in osmium tetroxide. En bloc
staining with a 0.5%) solution of uranyl acetate in 70%
ethanol and further dehydration in increasing concentrations of ethanol was followed by embedding in Araldite.
Toluidine blue-stained sections 1 p thick enabled us to
select suitable areas for ultrathin sections, which were further stained with lead citrate.
White cells of both patients were studied by electron
microscopy as follows. First, a buffy coat was prepared
from freshly drawn blood, fixed in cacodylate-buffered
glutaraldehyde, and further processed as described for the
skin biopsy. Second, 10 ml of heparinized blood was covered with an equal amount of a Ficoll-Isopaque mixture and
centrifuged. Lymphocytes were drawn with a pipette from
the interphase between the serum and the Ficoll-Isopaque
layer, which, after centrifugation, was located above the red
Arylsulfatase A and B was directly measured in the
dialyzed urine, leukocyte extracts, o r both, of the 2 patients
and the 6-year-old daughter of Patient 2, using the
chromogenic substrate p-nitrocatechol sulfate (Sigma) and
the buffer system of Baum et a1 [31. For reference purposes, acid P-galactosidase activity was determined with
the fluorescent substrate 4-methylumbelliferyl galactopyranoside (Sigma). For control purposes, these enzymes
were also studied in leukocytes and urine of several healthy
individuals (laboratory personnel) and patients who did not
have a lysosomal disorder. They were also studied in a
patient with GM,-gangliosidosis type 11, and another patient with adult-onset metachromatic leukodystrophy (Case
BII/5 in Pilz [39]). Urinary data were referred to 24
hours’ creatinine excretion.
Fibroblasts were maintained in culture as previously described [lo]. Incorporation of sodium sulfate S35 in
mucopolysaccharides and determination of intracellular
35S-labeled mucopolysaccharides was done according to
Fratantoni et a1 [ 151. Fibroblast suspensions obtained by
ten cycles of freezing and thawing of trypsinized fibroblasts
were assayed for a-L-iduronidase [ 191, iduronide sulfatase
[27], sulfamidase [251, a-N-acetylglucosaminidase [ S 11,
P-galactosidase [ 11,N-acetylglucosamine 6-sulfate sulfatase
[2a], arylsulfatase B [441, P-glucuronidase 111, P-Nacetylglucosaminidase [ l ] , and protein [ 2 3 ] .
Mucopolysaccharides were determined after dialyzing
urine for 24 hours against water by a semiquantitative precipitation test with toluidine blue (521 or by precipitation
with 1% (w/v) cetylpyridinium chloride and analysis for
uronic acids. The mucopolysaccharides precipitable with
cetylpyridinium chloride were characterized by electrophoresis o n cellulose acetate [28] o r thin-layer chromatography [22].
Blood Smears
A blood smear obtained after separation of lymphocytes from the pellet revealed lymphocytes and
mononuclear cells. In the acid phosphatase preparation, the mononuclear cells contained either faint
granular or rather strong globular activity, while a
minority of lymphocytes showed coarse, distinct,
strongly reactive granules. The toluidine blue stain
disclosed numerous distinct metachromatic (reddish)
granules in lymphocytes. A Pappenheim stain
showed abundant dark, azurophilic granules in many
Pilz et al: Type B Maroteaux-Lamy Syndrome
Elertrori-lucent z8acuole.r are pre~eiitiii niurul cells of the cutuiieous capillaries. 1 ~ 1 4 , 4 0 0 .()D ) (Putieiit 2 ) Schzrlaiin arid
fib}-oblasrircell.! of cutatieou.s tierite plexus show
menibrarze-bound z;acuoles. ( X9,020./ (All beJore 5 ('f redurtior2.t
320 Anna15 o f Yeurolog)
Vol 6
N o 4 October 1979
'Table 1. Activity of Arylsulfatase A (ASA),Arylsulfatase B (ASB), and p-Galactosidase (P-Gal) i n 2 Patients
with Maroteaux-Lamy Syndrome Compared with Normal Controls and Patients with Other Lysosomal Disorders
Subi ec t
3 58
Control 1 ( 5 5 yr)
Control 2 (44 yr)
Control 3 (32 yr)
Control 4 (46 yr)
GM,-Gangliosidosis (7 yr)
Metachromatic leukodystrophy (50 yr)
Maroteaux-Lamy syndrome
Patient 1 (40 yr)
Patient 2 (38 yr)
Daughter of Patient 2 (6 yr)
Control 5 (26 yr)
Control 6 (26 yr)
GM,-Gangliosidosis (7 yr)
Metachromatic leukodystrophy ( 5 0 yr)
Maroteaux-Lamy syndrome
Patient 1 (40 yr)
"In nanomoles of 4-methylumbelliferyl per hour per milligram of protein (P-galactosidase) or nanomoles of p-nitrocatechol per hour per
milligram of protein (arylsulfatase A and B) at 37°C.
"In nanomoles of 4-methylumbelliferyl per hour per milligram of creatinine in a 24-hour urine sample (P-galactosidase) or nanomoles of
p-nitrocatechol per hour per milligram of creatinine in a 24-hour urine sample.
granulocytes and only very small single or multiple
vacuoles in lymphocytes.
Electron Microscopy of Lymphocytes
ple cytoplasmic electron-lucent vacuoles (Fig 7B).
They often appeared in clusters and compartmentalized. Vacuoles frequently coalesced.
Opening of vacuoles to the extracellular space due
to rupture of membranes was probably of artificial
origin. The vacuoles were surrounded by trilaminar
membranes. They were usually empty, but several
contained faintly electron dense reticular or granular
debris irregularly distributed over the vacuolar plane.
A few membranous profiles were also encountered in
such a vacuole. These membranes lacked any particular arrangement into stacks, whorls, or fingerprint
patterns. Similar vacuoles were present in mural cells
of the vasculature (Fig 7C) and in epithelial cells of
the basal cords of the epidermis. These vacuoles also
were electron lucent, with some finely granular and
reticular debris scattered inside. An occasional
Schwann cell contained a clear vacuole in addition to
membranous residual bodies that probably represented pi-granules (Fig 7D). Compared with the frequency of such vacuoles in fibroblasts (Fig 7D),
Schwann cells only rarely showed these inclusions.
O n electron microscopic examination the white
blood cells were well preserved. They consisted
chiefly of lymphocytes with a few thrombocytes and
granulocytes admixed. The majority of lymphocytes
had unremarkable nuclei, organelles, and cytoplasm.
However, several lymphocytes showed a few or a
cluster of round or oval membrane-bound vacuoles
(Fig 7A) that themselves contained a finely reticular
(Fig 7A, inset) or granular, amorphous material without any additional fine structural details. These vacuoles tended to be located in certain compartments
of the cytoplasm rather than being randomly dispersed in the cell sap. The granules generally were
the size of the mitochondria, with only slight variations in diameter. An occasional membrane-bound
body harbored a granular matrix and electron-lucent
droplets, probably lipofuscin. Cells that were
identified as thrombocytes or granulocytes because
of their cytoplasmic content did not have such
membrane-bound vacuoles.
Biochemical Assays
Skin Biopsy
The skin punch biopsy from Patient 2 revealed
numerous fibroblasts that contained single or multi-
As indicated in Table 1, arylsulfatase B activity was
decreased in leukocytes and urine of both patients
compared with controls. However, residual arylsulfatase B activities were still present in the patients'
Pilz et al: Type B Maroteaux-Lamy Syndrome
7 able 2 Artumu/alton of Intrta-ellular "S-labeled
.Mucopol~ra(charzdei I W Cufttzated Fthroblactc
durzng Incuhatimn tn the Preience of 35S0,
uwd after a Chair for 24 Hourr
In tracellular
(cprnirng protein)
Patient 2
1 19,500
4 39,200
Chase 24
5 1,800
5 0,300
14,5 00
specimens. Leukocyte arylsulfatase B activity in the
daughter of Patient 2, an obligate heterozygous carrier, was in the intermediate range between values
in the patients and controls. P-Galactosidase activities of both MLS patients were normal.
Fibroblasts were cultured from a skin biopsy of
Patient 2. Incorporation of 3;'S04 during a 72-hour
incubation period revealed a constant intracellular
accumulation of 35S-labeled mucopolysaccharides.
After removal of the radiosulfate, less than 11% of
the intracellular material became degraded in the
following 24 hours, whereas in control fibroblasts,
intracellular 35S-tagged mucopolysaccharides reached
a constant level within 24 hours and more than 70%
became degraded within the 24-hour chase experiment (Table 2).
The fibroblast homogenates of Patient 2 were assayed for nine lysosomal hydrolases known to be involved in the degradation of sulfated mucopolysaccharides. The activities of the following eight
enzymes were in the range of controls (the type
of mucopolysaccharidosis in which they are deficient
is given in parentheses): a-L-iduronidase (I 1, iduronide sulfatase (II), sulfamidase (IIIA), a-Nacetylglucosaminidase (IIIB), P-galactosidase (IVB),
lable 3 /litzitti o f h t n r A.liriopriltraitharide De~radzngEnzymes in Cultured Skin
Fibroblujt, of u Puttrtit I I zth Marotecrux-Lam) Syndrome<'
Patient 2
54 (28-1 1 2 )
I d u r o n i d e Lsulture sulfiatase
4. I
cu-N -Ace t y Iglucc )samini d ase
n'-Acerylgalacrosami tie -$-sulfate sulfatase
N - Acetylglucosamine 6-sulfate sulfarase
iN = 6)
6 (05 3 - 5 5 )
( N = -)
1 9 (0 9-4 5 )
(N = 1 8 )
14 4 i72-18)
( N = 6)
1,h 20 ( 2 64 -4 .o 2 0 )
(N = 1 2 )
0 9 1 (0 43-1 2 8 )
(N = 8 )
102 (60-180)
(N = 5 )
0 18 (008-0 32)
(N = 21)
2 1,480 (7,400-29,400)
(N = 9)
"Activity is exprcsscd as nanomoles of substrate split at 37°C per huur and milligrams of cell protein. Values in parentheses give the ranges
for controls.
nor derectabic.
No rim a1
Patient 1
Patient 2
Toluiilinc blue
C P C prccipitatioii
Crcati ni ne
Thin-layer chromaLography
Deriuatan sulfate
Dermatan sulfate
"Values are i n milligrams per 2.4 hours. See text for methods.
cetylpyridinium chloride.
Annals of iVeurology
Vol 6
No 4
O c t o b e r 1979
Dermatan sulfate
Dermatan sulfate
R -acetylglucosamine 6-sulfate sulfatase (VIII), pg ucuronidase (VII), and P-N-acetylglucosaminidase
(!;andhoff disease). Arylsulfatase B activity (VI) was
n o t detectable (Table 3).
Urinary mucopolysaccharides were determined in
1971 (at another laboratory) and in 1977. Mu( opolysaccharide
excretion was normal in both
tlrothers in 1971. Reinvestigation in 1977 showed
rnucopolysacchariduria in Patient 2, whereas excrelion was normal in Patient 1 (Table 4). Fractionation
i )f urinary mucopolysaccharides by cellulose acetate
r:lectrophoresis and thin-layer chromatography
,bowed only dermatan sulfate in both cases.
Patients who have somatic stigmata of a mucopolysaccharidosis without mental deficiency invoke the differential diagnosis of Scheie disease
cmucopolysaccharidosis type Is), Morquio disease
(type IV), or Maroteaux-Lamy syndrome (type VI)
(see [13, 20, 33, 40, 471 for recent reviews of
mucopolysaccharidosis). The exact type of mucopolysaccharidosis had not been determined initially
in either of our patients, who were 4 0 and 38 years
old, respectively, because previously abnormal urinary excretion of mucopolysaccharides could not be
demonstrated. Recent enzyme analyses, however,
revealed a marked arylsulfatase B deficiency in
fibroblasts, urine, and leukocytes, which together
with the urinary dermatan sulfate excretion confirms
the diagnosis of MLS [501.
Several reports have described patients with
mucopolysaccharidosis who showed increased longevity and probably belong to the subtype described here [8, 26, 33, 40, 41, 481. Other reported
cases of late forms of mucopolysaccharidosis do not
permit an unequivocal differentiation [16, 42, 491. A
late arylsulfatase B deficiency has previously been
recorded only in a 17-year-old boy [ l l ] and a 23year-old woman [381.
Patients with MLS usually attain a height between
110 and 140 cm, while patients afflicted with Scheie
disease usually grow taller and those having Morquio
disease are considerably smaller. Having grown to
body heights of I68 cm (Patient 1) and 164 cm (Patient 2), these 2 brothers are among the tallest recorded with MLS, comparable only with the patient
of DiFerrante et a1 [ 111, who grew 163 cm tall. Based
on McKusick’s classification [ 331, the longevity of
our patients, their size, the lack of cardiac insufficiency in association with mild cardiac murmurs, the
lack of abnormality of the sella turcica, and the absence of umbilical o r inguinal hernias, of marked
hepatosplenomegaly, and of marked corneal opacities warrant the diagnosis of the mild B variant of
Neurological deficits in MLS are most frequently
caused by hydrocephalus, peripheral nerve compression (e.g., carpal tunnel syndrome), o r hypoplasia of
the odontoid processes associated with atlantoaxial
subluxation. Our patients suffered from cervical and
lumbosacral radiculopathies and a cervical myelopathy that resulted from narrowing of the spinal
canal. The second patient, who otherwise showed
less severe symptoms, experienced massive sacral
disc herniations that necessitated surgical intervention. Myelopathy without atlantoaxial subluxation
has also been described by Peterson et a1 [38].
The unilateral acute papillitis that resulted in partial optic atrophy in Patient 2 deserves emphasis. T h e
abnormality in lumbar spinal fluid, however, may
have been related to his herniated discs rather than to
an inflammatory process of the optic nerves, since the
cisternal spinal fluid gave near-normal values.
By light microscopy, blood smears from both patients showed the characteristic features observed
in other mucopolysaccharidoses [4]: vacuoles, acid
phosphatase-positive granules, and metachromatic
inclusions in lymphocytes, with azurophilic hypergranulation of granulocytes and monocytes [9, 531.
This azurophilic hypergranulation is also present in
various forms of neuronal ceroid lipofuscinoses
(NCL) [9, 531. However, there is no specific ultrastructure related to these granules in NCL [121,
and we have not encountered any fine structural
abnormalities of neutrophils. T h e electron microscopic hallmark of the mucopolysaccharidosesmembrane-bound, chiefly clear vacuoles-were present in lymphocytes but not in neutrophils. They
were encountered in many other cell types: fibroblasts, mural cells of the vasculature, Schwann cells,
and epidermal cells. Independent of the type of cell
affected, their content was uniformly watery and associated with skeins of amorphous reticular material.
The widespread vacuolization of cells in the B variant
of MLS is in agreement with that seen in other
mucopolysaccharidoses, chiefly of children [4,29] but
also of adolescents [46]. The membrane-bound vacuoles most likely represent lysosomes [4, 461, which
display a strong acid phosphatase activity that was
also seen in our smear studies of lymphocytes and
was previously documented in eccrine sweat glands
Lipofuscin granules are a regular cellular organelle
caused by wear and tear during life. They may be
formed at an early age in lysosomal diseases, such as
infantile type I1 glycogenosis [ 181. The association of
lipofuscinlike material in lymphocytes of both our
patients and within the MLS-typical vacuoles may
reflect the underlying lysosomal abnormality.
The electron lucent and finely reticular content of
the vacuolar residual bodies caused them to resemble
Pilz et al: Type B Maroteaux-Lamy Syndrome
residual bodies found in nonneuronal cells of type I1
GM, gangliosidosis [20, 361 and in lymphocytes of
juvenile NCL [43]. In the latter disorder the Iymphocytic vacuoles also contain minute fingerprint inclusions, the ultrastructural hallmark of juvenile
Stumpf and co-workers [50] were the first to determine a marked decrease of arylsulfatase B activity
in liver, kidney, spleen, and brain of 2 patients as well
as in fibroblasts of another child with MLS, while
the activities of this enzyme in 3 patients with
mucopolysaccharidoses I, 11, and 111 were normal.
Arylsulfatase B deficiencies were also confirmed in
fibroblasts of other patients by Fluharty et a1 [14],
Shapira et a1 [44], and Beratis et a1 [6, 71, again demonstrating a residual enzyme activity of 10 to 15%.
Properties of the residual enzyme did not differ from
those of the normal enzyme. These findings suggested the basic defect in MLS to be an arylsulfatase
B deficiency. Skin fibroblasts of our second patient
did not disclose any arylsulfatase B activity when the
enzyme extract was prefractionated by column chromatography [2 11. The residual activity of this enzyme
in leukocytes, and to a lesser degree in urine, of both
our patients is probably explained by the fact that the
direct determination using the buffer system of
Baum et a1 [3] also includes partial activity of arylsulfatase A [14, 451. Conversely, Humbel [211
demonstrated residual activity of the B component
even after prefractionation of the arylsulfatases in
leukocytes of 2 patients with MLS, while DiFerrante
et al [ I 13 were unable to show any activity in urine
and fibroblasts. Kolodny and Mumford [24] as well as
Peterson et a1 [38] failed to document any such activity in skin fibroblasts by electrophoresis.
If a recessive mode of inheritance is assumed, the
daughter of our second patient is an obligate
heterozygous carrier. Even without enzyme fractionation, her arylsulfatase B activity is within
the intermediate range. However, to prove the
heterozygous state, more refined enzyme determinations ought to be performed [6, 71.
Apart from lack of arylsulfatase B deficiency,
O’Brien and co-workers [35] were able to document
that homogenates of fibroblasts fail to cleave inorganic sulfate from the nonreducing terminals of
dermatan sulfates labeled with both “SO4 and
‘‘C-N-acetylgalactosamine. They suggested that the
deficiency of N-acetylgalactosamine 4-sulfatase is the
biochemical basis for at least one type of MLS. A
similar finding was reported by Matalon et a1 [321,
who demonstrated deficiency of an enzyme specific
for 4-sulfate linkages. Investigations with highly
purified subfractions of arylsulfatase B suggested that
the Maroteaux-Lamy corrective factor may be identical to arylsulfatase B. But two components are re-
Annals of Neurology
Vol 6
No 4
October 1979
quired for sulfate release from the natural substrate, so arylsulfatase B probably is only one part of
an enzyme system necessary for degradation of dermatan sulfate [171.
Since 2 patients with the clinical signs of MLS have
shown normal activity of N-acetylgalactosamine 4sulfatase [35], we cannot exclude the possibility that
the various subtypes of MLS represent heterogenous
entities associated with different enzyme defects.
Supported by the Deutsche Forschungsgemeinschaft (Grants SFB
33 and SFB 104).
We are grateful to Ms G. Hess, Mrs Knop, and Mrs Oberschmidt
for performing the enzyme assays and to Mrs Kosswig for electron
microscopic and photographic assistance. The lymphocyte isolation for our electron microscopy studies was performed by Ms
Hundt of the Department of Microbiology, University of Giittingen.
1. Barrett AJ: Lysosomal enzymes, in Dingle JT (ed): Lysosomes.
Amsterdam, North-Holland, 1972, pp 46-135
2. Barton RW, Neufeld EF: A distinct biochemical deficit in the
Maroteaux-Lamy syndrome (mucopolysaccharidosis VI). J
Pediatr 80:114-116, 1972
2a. Basner R, Kresse H, von Eigura K: N-aceryl glucosamine
6-sulfate sulfatase from human urine. J Biol Chem 254:
1152-1158, 1979
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