Extract: A new variant of glucose phosphate isomerase (GPI) deficiency (type Nordhorn) associated with congenital nonspherocytic hemolytic anemia is described. The propositus, an 18-month-old boy of German origin, has suffered since birth from a severe to moderate macrocytic anemia, which is characterized by low mean corpuscular hemoglobin concentration (28%), high reticulocytosis (45—60%), normal osmotic fragility, type I autohemolysis, and short erythrocyte life-span (51Cr t1/2 = 2 days). With the exception of GPI, the activities of most erythrocyte enzymes are increased. GPI activity is decreased to 22% of the normal. The father and mother exhibit GPI activities between 36% and 47% of normal. No difference is demonstrable between the enzyme of the propositus and normal subjects concerning Michaelis-Menten constant for fructose 6-phosphate, pH optimum, and thermal optimum. The stability of the enzyme is decreased in the propositus and in all affected maternal relatives. The enzyme of the paternal relatives is stable. On starch-gel electrophoresis the enzyme of the father is normal (three bands). In the hemolysate of the mother a fourth cathodally migrating band is demonstrable in addition to the three normal bands. The propositus exhibits only one band with a cathodal mobility of 132% of the main band of normal subjects. It is suggested that the propositus is double heterozygous for two abnormal alleles. The heterozygote mother contributes an allele which produces a thermolabile enzyme of decreased activity and abnormal electrophoretic mobility, whereas the father contributes an allele without enzymatic activity.The enzyme defect is also manifest in the leukocytes of the propositus (39% of normal activity). The thermolability is evident in the leukolysates of the propositus and in those of his mother.When erythrocyte glucose consumption and lactate formation are compared with nonenzymopenic, reticulocyte-rich blood, which has no metabolic defect, the rate of glycolysis is markedly impaired in the propositus. Glucose 6-phosphate, the substrate before the defect, accumulates fourfold and probably inhibits hexokinase, and consequently glycolysis. Compared with erythrocyte populations of similar mean cell age, the concentrations of ATP and 2,3-diphosphoglycerate are decreased. After separation of young from old cells the defect becomes more evident in the older population. Premature inactivation of the enzyme during maturation is suggested.Speculation: Many so-called “homozygous states” of inherited enzyme defect: could be double heterozygous as well. Double heterozygosity may partially explain the clinical heterogeneity of the “homozygous” manifestation, and the lack of correlation between residual enzyme activity and clinical expression in many inborn errors of metabolism. In double heterozygotes with glucose phosphate isomerase deficiency, a premature inactivation of the enzyme during maturation of the erythrocytes may be the reason for metabolic impairment of the celIs, followed by premature hemolysis.
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