ENZYME
INDUCTION
IN
A
CASE
OF
GLYCOGEN
STORAGE
DISEASE
Shimon W. Moses, M.D., Stanley Levin, MB.B.Ch., Reuben Chayoth, M.Sc., and
Kurt Steinitz, M.D.*
Pediatric Research Department, Kaplan Hospital, Rehovoth, affiliated to the Hebrew University-Hadassa
Medical School, Jerusalem and Department of Clinical Pathology, Tel-Aviv University School of Medicine,
Beilinson Hospital, Petah-Tikva, Israel
(Received November 1, 1965; accepted for publication February 3, 1966.)
This work va.s supported in part by a research grant of the National institutes of Health No.
AM-09302-01.
PRESENT ADDRESS: (S.W.M.) Head of Ped. Dept. “B” hospital of the Negev, Beer Sheva, Israel.
PEDIATRICS, Vol. 38, No. 1, Ji1ily, 196
111
I
NCREASING INTEREST in the biochemical disorders found in glycogen storagedis-ease (G.S.D.) has led to the discovery of en-zymatic defects at virtually all the major steps in the metabolism of glycogen. The
majority of these defects involve glycogen breakdown and result in abnormal
glyco-gen storage, whereas deficiency of one en-zyme, that of glycogen-UDPG-1,4-trans
glycocylase, affects glycogen synthesis and results in glycogen depletionl (Table I). Our understanding of this disease, however, is as yet incomplete, since cases of G.S.D.
have been reported in which no enzymatic defect could be demonstrated.3’6 On the
other hand, several cases of G.S.D. with presumably double enzymatic deficiencies are on 18 Cases of siblings with
dissimilar enzyme deficiencies have also been reported.6’9’
The incidence of G.S.D. of the liver has
been estimated by Hers not to exceed 1 : 10,000 live births. Ockerman calculated the incidence of G.S.D. (all types) in Swe-den to range between 1 : 1 19,000 live birth (maximum) and 1:246,000 (minimum)) An
unusually high incidence of type III G.S.D. has been reported from Israel among chil-dren of Jewish immigrants from North Africa. A detailed report on these cases will be presented elsewhere.
The occurrence of apparent double
en-zyne deficiencies is much rarer and a
re-aDeceased.
cent report reviews some 13 cases.21 The
genetic explanation for the occurrence of these double enzymatic defects could be on the basis of a structural gene defect, or a regulatory gene abnormality. The concept
of one gene-one polypeptide presupposes
multiple point mutations to occur at different structural gene loci. The chance of such multiple structural mutations having
occurred independently in the same
mdi-vidium as an unrelated random eventgov-erned by the laws of probability would be infinitely small. On the other hand it is
difficult to explain the double enzyme deficiencies on the basis of a regulator gene defect in line with tle “operator gene
con-cept” of Jacob and M22 The concept
of one regulator gene controlling adjacent genes aligned in a sequential linear
ar-rangement, imposes restrictions on the
number of combinations of multiple
en-zyme deficiencies that can result from a
regulatory gene disorder.2’
Another explanation for the relatively
fre-(Illent occurrence of double enzyme defects found in this disease is presented by
Auerbach2’ who suggests alternate tran-scription of mRNA from two strands of a DNA pair in “copy choice” fashion. In view of the opposite polarity of each DNA strand, such “copy choice” transcription is
difficult to envision. Furthermore, no exper-imental support for this hypothesis has been
presented.
Type Synonym Organ affected Enzyme defect
I Von Gierke’s Liver, kidney ( ilucose-6-phospliatase
II Pompe’s Cardiac type, glycogen iii many tissues a-I,4 glucosidase
III Con’s Limit dextrinosis
A B
C
Muscle, liver Liver Muscle
Amylo-l ,6-glucosidase
IV Ahldersen’s Liver, lIES. .\nivlo-1 ,4-1 ,6-tra osgiucosidase
V Mc Anile’s Muscle Muscle itispitricise
VI
-hers’ Lewis’ Tarui2
tTndefined types
Liver Liver Muscle
Liver mid other organs
Liver phosphorylase
UI)P( -glycogeii transglucosi(lase Phosphofructokinase
No enzyme deficiency demolistrated
TABLE I
TYPES OF GLYCOGEN STORAGE DISEASE
of these deficiencies could be based on
Lin’s recent evidence in microorganisms of a regulatory system exerting distant control of protein synthesis at various unrelated
gene loci.”
Increasing evidence has recently been
presented to show that hormones are im-plicated in the regulation of protein synthe-515. Insulin, corticosteroids, estrogens,
an-drogens, thyroid, and growth hormones have been shown to stimulate incorporation of amino acids into protein.’4
Karlson observed that ecdyson, a steroid hormone capable of initiating metamor-phosis in insects, acts by inducing RNA synthesis in “Puffs” of giant polytene
chromosomes.’5 This indicates that hormon-al action on genetic material is not limited to mammalian systems only. The primary site of action is believed to be at the level of the DNA-protein complex, where mRNA
is 24 Hormonal regulation of
protein biosynthesis has been observed to be an important factor in induction and suppression of adaptive enzymes in mam-malian systems.’6 Alterations in enzyme ac-tivity thus caused seem to have a significant
role in controlling directions and activity rates of metabolic pathways.27
Glucose-6-phosphatase is one of the four key enzymes involved in the homeostatic control of gluconeogenesis.2830 These
en-zymes which catalyze one-way reactions have been shown to have the lowest activity
in the entire pathway, aiid have therefore been considered to be rate limiting in
Glucose-fi-phosphatase serves as one cx-ample of an adaptive enzyme, being
stimu-lated by corticosteroids and suppressed by
iiisulin.” The evidence to indicate that
these hormones affect de novo enzyme biosynthesis is based on the following
ob-servations. The hormonal effect can be blocked by (a) ethionine which has been shown to interfere with protein biosynthe-sis; by (b) actinomycin which is a powerful inhibitor of DNA directed RNA synthesis;
and by (c) puromycin which specifically in-hibits protein synthesis at the ribosomal
3 1 Furthermore, corticosteroids have
been shown to increase the amount of
he-patic RNA, stimulate RNA polymerase ac-tivity, and mRNA synthesis in rat liver
nuclei, and enhance incorporation of radio-active precursors into RNA.”35
Corticosteroids (Triamcinolone) have
been shown by Weber and others to induce glucose-6-phosphatase activity in normal rat
livers when given in pharmaceutical
dos-ages, a marked response being noted after 3 days administration.21
In type III G.S.D. due to
amylo-1,6-glucosidase deficiency abnormally low values of glucose-6-phosphatase have been frequently encountered, both in cases ported in the literaturelh1lti and in our own
noto-riously unstable in vitro, therefore the dem-onstration of lack of activity may
some-times be due to technical difficulties, such
as improper preservation and handling of
tissue.
However, with special precautions to
prevent loss of activity, low glucose-6-phosphatase was repeatedly found in sev-eral of our cases of amylo-i, 6-glucosidase deficiency. It seemed to be of major
impor-tance to find out whether
glucose-6-phosphatase activity could be induced in such cases. Since if a structural genetic de-feet was involved, no induction was to be
cx-pected whereas if low enzyme activity was
the result of abnormal control affecting reg-ulation of enzyme synthesis, hormonal in-duction may indeed be possible.
In the following presentation the
indu-cive effect of steroids oii the activity of glu-cose-6-phosphatase in a case of type III G.S.D. is demonstrated.
CASE REPORT
J. E., 1-year-old female, was born to healthy
related Jewish parents in Morocco. She is one of
seven healthy siblings. Three other siblings died in
Morocco at an early age from unknown causes.
No other cases with signs and symptoms similar
to the proband are known in the family.
From an early age this child has suffered from
repeated infections, has been a poor eater, and
has grown slowly. At the age of lh years she was
hospitalized in Morocco because of a large
ab-domen and failure to thrive. The parents were not
informed of any particular disease, but some form
of electrotherapy was suggested.
At the age of 3 years, she was admitted to our
department for the first time because of failure
to thrive and extreme hepatomegaly. On physical
examination tile child was found to be emaciated
and suffering from nialnutrition. The abdomen was
protuberant due to an enlarged liver extending
almost to tile iliac crest. In contrast to the general
emaciation her face was rounded, quite well
padded and “doll like.” Both her weight (9.1 kg)
and her height (71 cm), were equivalent to that of
the 50th percentile of a 10-month-old female
in-fant. She showed marked psychomotor retardation,
being able to speak only a few words. She was
unable to sit without help. Results of laboratory
examinations are listed in Table II. X-ray studies
were non-contributary, with the exception of tile
bone age, which was compatible with that of a
18-month-old child. E. C. G. showed slight left
heart hypertrophy based on voltage criteria.
Ilisto-logical study of a liver needle biopsy specimen
revealed marked intracellular glycogen deposition
with beginning fibrosis (Fig. 1).
The typical clinical picture, the histological cvi-dence of marked glycogen accumulation in the liver,
and the biochemical evidence of a defect in the
conversion of glycogen to glucose, established the
diagnosis of glycogen storage disease. Amylo-1,
6-glucosidase was not assayed at this time, but in
view of the high glycogen content in erythrocytes,
a type III (Con) defect was suspected. The very
low levels of glucose-6-phosphatase suggested a partial deficiency of this enzyme as well. At this
time, therefore, a double enzyme defect was
can-sidered. At the age of 4 years the patient was
restudied at another hospital where liver and
muscle biopsies were performed following
lapar-atomy.
The present admission was at the age of 7 years.
She had been growing very slowly, but had been
relatively well, and had not had clinical attacks
of hypoglycemia. 11cr height was only 97 cm
(the equivalent of the 50th percentile for a
34-year-old child), and her weight 18 kg (the
equiva-lent of the 50th percentile for a 5-year-old child).
11cr face was cherubic, her abdomen markedlv
protuberant, and she walked with a waddle. The
liver was hard, regular, and extended 10 cm below
the costal margin. Tile rest of the physical
exami-nation was non-contnibutary. Routine laboratory
studies at this admission are shown in Table II.
SPECIAL BIOCHEMICAL STUDIES
Glycogen Analysis
Glycogen in liver and muscle was cx-tracted by the hot alkali procedure,’8 pre-cipitated with ethanol and determined with the anthrone reagent.’9’ #{176}Erythrocyte
glycogen was determined by the method
of Sidbury, et During the last hos-pitalization the anthrone method was
re-placed by the direct enzymatic
determina-tion of the precipitated glycogen with the
diazyme 43 Glycogen was
in-creased in all tissues examined.
-Amylase degradation, determined after Sidbury, et al.,4’ indicated short outer
branches (Table III).
Enzyme Studies
Glucose-6-phosphatase activities in the liver (Table IV) represent the result of
repeated examinations of liver tissue
Acetonunia
9 At the age of 4 years, fasting blood glucose levels (glucose oxidase method)
mg/i#{174} ml.
surgical biopsy. Liver homogenates
pre-pared in sucrose-EDTA were used for the determination of glucose-6-phosphatase.
The technique,6 based on phosphate release
and including two controls for unspecific phosphatases (inactivation at pH5.O and incubation with f3-glycero-phosphate)” was
used. The difference in activity between the sample containing glucose-6-phosphate and f3-glycerophosphate should be nearly identical (within 10%) to that between the
samples containing glucose-6-phosphate
be-Fic. 1. Section of liver showing enlarged liver cells
with clear cytoplasm, sharp cellular borders and
beginning fibrosis (Hematoxylin eosin X 154).
TABLE II
LABORATORY DATA IN CASE OF G.S.D. TYPE III
Test
Age
8w’ 7yr
--
-Blood
Hb
WBC
Biood smear
Reticulocytes
Prothrombin time
Fasting blood sugar9
Cholesterol
Total lipids Phospholipids
SGOT
Bilirubin
Total protein Albumin
Globulin
7-globulin
Protein electrophoresis
Plasma amino acids
Bicarbonate
Calcium Phosphorus
Alkaline phosphatase
Uric acid
P.B.I.
Urine
9.7 gm/100 ml
9,500 per cm
Normal
100%
76-105 mg/100 ml
00-8 mg/100 ml
7H-1,087 mg/100 ml
16-174 units
7.6-8.1 gin/100 ml
4.7-5.2 gm/100 ml
.9 gm/100 ml
Normal
9.5-10 mg/100 ml
4.7 mg/100 nsl
4.8 B.U.
8. sg/100 1111
Intermittent
11.7 gm/100 ml
9,100 per cm
Normal
1%
9%
65-97 mg/100 ml
08- mg/100 ml
774-1,115 mg/100 all
8.16 mg/100 ml
97-700 units
0.6 mg/100 ml
7.6 gm/100 ml
5.1 gm/100 ml
.5 gm/100 ml
1.3
Normal 47 mg/100 nIl
mEq/L
10.4 mg/100 1111
5.1 mg/I00 nil
1.6 B.U.
6. mg/100 ml
3.6 ,g/100 ml
Intermittent
UCalculated per 10” leucocytes/min.
TCalculated per gram hemoglobin.
TABLE III
TISSUE GLYCOGEN CONCENTRATION AND STRUeFURE IN A CASE OF GLYCOGEN STORAGE DISEASE
TYPE III
Test
.
Liver Muscle . Erythrocytes
ivizcrogram per gm
Patient Normal Patieni Normal Patient Normal
Glycogen Concentration (gm/100
ml of wet tissue)
Length of outer branches ($
Amy-lase degradation
%)
9.5
35 .6
<5 .0’
50 .0
.5
0 .7
< .019
50.0
6 < 150
fore and after inactivation at pH 5.0. The Amylo-i, 6-glucosidase activity was
stud-mean between these two values is taken as ied by two different methods : (a) incorpora-the specific glucose-6-phosphatase ac- tion of glucose U-C14 into the branching
tivity.45 The finding of extremely low values points of glycogen;6 (b) rate of glucose re-of glucose-6-phosphatase on the first exam- leased from phosphorylase limit dextrin.6 ination, at the age of 3 years, may have Amylo-i, 6-glucosidase activity was absent been partly due to technical reasons. Re- or very low in all tissues measured (liver,
peated analysis for the specific activity at muscle, leucocytes, and erythrocytes). The the age of 4 and 7 years with special ar- minimal activity detected in some examina-rangements for immediate freezing of liver tions may have been due to analytical
limi-tissue and analysis of enzyme activity tations of the method employed. As no within 3 hours of biopsy, again showed a significant amylo-i, 6-glucosidase activity
markedly subnormal glucose-6-phosphatase could be demonstrated by both methods
activity. in any tissue, this case can be classified as
TABLE IV
A(’TIVITIE.S OF GLYIOGENOIYTIC ENZYMES IN A CASE OF GIYCOGEN STORAGE DISEASE TYPE III
Enzyme
Glucose-6-phosphatase
Amyio-i,6-glucosidANe
Amylo-1,6-glucosidase
Phosphorylase
Acid
a-14-glucosidase
Units
Mieromol/gram/min phosphate liberated
#{182}gIucoseU-C”
incorporated/gram
tissue/hr
Micromol glucose
released from
pl,osphorylase limit
dextrin/gram
tissue/hr
Micromol phosphate released from G-1-P/ gram tissue/mm
Micromol maltose
split/gram tiasue/min
Age
S 4
7
7
7
4
4
Licer Muscle Leucoryte,’ Erythrocytest
Patient
0.6 0.1
1.S
0.0
0. 1
39.0
0.9
Normal range
4-13”
6-SO”
0.4-0. 11”
15-33”
0.3-1.5” Patient
0.0
0. ii
89.0
0.13
Normal range
5-10”
0.5-0.7”
60-140”
0.03’
Patzent
0.3
0. 15
Normal range
7.35±5.33”
0.78± 0. 18 Palieni
0.08
0.036
Norma!
range
0.24±0.166k
0 20 40 60 80 00 20 TIME IN MINUTES GALACTOSE TOLERANCE TEST
GLUCAGON TEST
TIME IN MINUTES
FIG. 2. Plasma glucose, lactic acid, and free fatty
acid levels after i.v. galactose infusion (1 gm/kg body weight).
type III A. In type III B the muscle glucose
incorporating activity persists, and glucose liberation from limit dextrin is deficient.4#{176} According to present concepts, debrancher enzyme deficiency characterizes a group of
biochemically and probably genetically different subtypes, since recent evidence
indicates that phosphorylase limit dextrin has first to be transformed into a new poly-saccharide, containing only one glucosyl unit at the 1, 6 branch point 4748
This has resulted in the finding of further
enzyme The new oligo-i,
4-1, 4-glucantransferase, which can not be separated biochemically from amylo-1, 6-glucosidase,51 has been found to remain
active in some rare cases of debrancher
de-ficiency, and 4 new combinations have been
reported so
Phosphorylase and acid alpha-i, 4-glu-cosidase were determined according to
Hers6 and found to be normal.
Loading Tests
Indirect evidence for amylo-1, 6-gluco-sidase deficiency was obtained by a normal galactose test
(
1.0 gm galactose/kg body weight i.v.) resulted in a rise of glucosefrom 72 to 156 mg/100 ml after 30 minutes
with a concomitant fall of free fatty acids from 1835 to 695 micromol/liter plasma, and a rise in lactic acid (see Fig. 2). The normal
rise in glucose after galactose administra-tion indicates that the low levels of
glucose-6-phosphatase activity found repeatedly did not cause any functional impairment in the
conversion of galactose to glucose. In
con-5 trast, administration of glucagon (0.1 mgI
!
kg) after a 12-hour fast resulted in no risein glucose, and no rise in lactate levels. This : flat curve was abruptly altered when the
patient ate a banana 5 minutes before
termi-nation of the test (Fig. 3).
The steady drop in free fatty acids after glucagon may often be observed in cases in which there is no rise whatsoever in blood glucose. This decrease which is probably induced by the release of a small quantity of glucose not sufficient to cause an increase
in blood sugar, does not diminish the value of an otherwise typical glucagon test.
Hormone Studies
INSULIN LIKE ACTIVITY was nicasured by
glucose utilisation of rat diaphragm by a method described by Valiance Oven. The results obtained show markedly lower values than a normal control (Table 5).
HUMAN GROWTH HORMONE levels were measured as described by Laron5’ after 2 units of insulin administration. The values
Fic. 3. Plasma glucose, lactic acid, and free fatty
acid levels after intramuscular glucagon
w
z
4
Insulin -like activity (rug glinose mg
Steroiuls
Plasma cortisol and corticuoteroids (lug #{182})
hefore ACT!! after ACT!!
Urine
17 ketosteroids (mg,tday) before ACTII 17 OIICS (mg/day)
before ACT!!
after ACTII
I
.
17± 11.01 -1.0:110.17i0.0-J; s-0 50.0-37.7
0.3 0.5-L0
3.1 ‘3.0-10.0
incomplete collection
obtained indicated normal growth hormone reserves.
THYROID ACTIVITY as indicated by P.B.I.
levels showed normal values.
STEROID METABOLISM: Plasma cortisol
aiul corticosteroids and urine 17 Keto and 17 hydroxy corticosteroids were determined before and after ACTH infusion. ‘ Plasma
cortisol and corticosteroid levels which were high normal, showed a normal rise following ACTH administration. Urine 17 Keto- and 17 hydroxy-corticoids values were
low normal, and showed little rise after ACTH a(lministration, probably due to
in-complete urine collection.
Triarncinolone was given by mouth in the
dose of 0.4 mg/kg body weight during 3 days. Glucose-6-phosphatase activity in the liver increased more than three-fold
fol-lowing this Triamcinolone administration
(
Fig. 4). Some increase of non specific phosphatase activity could he demonstrated as well. In contrast, a normal control childdid not show significant change in enzyme activity follovi ng Trialllcinolone
aclniinis-tration (Fig. 4). No change in the reaction to
glucagon was found in the patient following
Triamcinolone adniinistratioii.
DISCUSSION
Despite totil inactivity of amvlo-i, 6-glucosidase and markedly decreased
ac-tivity of glucose-6-phosphatase, the patient
did not suffer from severe clinical
hypo-TABLE V
IIOIIMONE SluInFs IN A CASE oF’ GIy’ocF:N
STousc.F; l)IsFssF ‘fvi: Ill
Patient
‘
.\orm(,lPATIENT CONTROL.
:
w I.
4 W 4
GLUCOSE -6- PHOSPHATASE ACT1V1TY BEFORE AND
AFTER TRIAMCINOLONE ADMINISTRATION
Eli
Glucose -6-phospholose J nonspecific phosphotosesFic. 4. Liver gliicose-6-phosphatase and non
spe-cific phosphatase activities in case of glycogen
storage disease tV1)e III before and after oral
tn-anicinolone administration (0.4 nlg/kg body weight
daily for 3 days), as compared to normal control.
glycemic attacks. However, on two
occa-510115 at the age of 4 years markedly low
1)lOOd glucose levels were found.
Subse-quent fasting blood sugar levels have i)een vithii-i normal limits. The I)atient did not
stiffer from severe infections. She did how-ever, show evidence of psychomotor and growth retardation. The normal growth hormone levels found suggest that some other profound metabolic disturbance must
account for the delay in physical growth and l)one development. Biochemical
dis-turl)aflces included evidence of increased
lipolysis as indicated by some degree of hyperlipidernia and recurrent acetonuria. The elevated S.G.O.T. levels may be due
to increased liver cell destruction and re-generation as suggested by 7 As
some disturbance of steroid metabolism has been suggested in this disease by various
118
and was found to have normal blood and urine steroid levels and a normal responses
to ACTH. These findings also ruled against the likelihood that the low glucose-6-phosphatase activity was secondary to sub-normal steroid levels.
A most interesting feature of this case, as in several other similar cases was the double enzyme abnormality-total absence of amylo-i, 6-glucosidase measured by two
methods and markedly subnormal levels of glucose-6-phosphatase measured on re-peated liver biopsies. The marked increase in glucose-6-phosphatase activity following
triamcinolone administration seems to be of paramount importance. In view of the experimental evidence indicating that
corti-costeroids stimulate the biosynthesis of glucose-6-phosphatase by acting on the DNA-histone complex, causing increased formation of messenger RNA, it seems rea-sonable to infer that in this case Triam-cinolone caused enzyme induction by
af-fecting the regulatory system controlling enzyme synthesis. Therefore, the
conclu-sion seems justified that the low levels found before induction were due to a regulatory
disorder and not due to a structural muta-lion at the glucose-6-phosphatase locus, since it is most unlikely to assume at our present state of knowledge that hormones can affect structural genetic defects.
Hers considered the possibility that the
low levels of glucose-6-phosphatase found in this condition reflect an adaptive change to diminished glycogenolysis.6 Our findings indicate that Triamcinolone induced
en-zyrne activity without affecting rates of glycogen breakdown, as evidenced by the
flat glucagon curve found after 3 days of
Triamcinolone administration. This finding was to be expected since glycogen
break-down could not proceed beyond the limit
dextrin stage, in view of the structural genetic block at the amylo-i, 6-glucosidase
level.
The low insulin levels found in this case may be related to deficient glycogenolysis,
resulting in diminished glucose formation which in turn will decrease the stimulus
for insulin release from the beta cell of the
pancreas.
There does not seem to be any evidence to suggest that triamcinolone may he of therapeutic value in these cases. Steroids
have been shown to have a marked gly-cogenetic effect; in the normal rat
Triam-cinolone causes glycogen 3
Unfortunately, the size of the liver biopsy obtained following steroid administration
allowed for glucose-6-phosphatase activity analysis only and did not suffice for
gly-cogen content estimation. In view of the
glycogenic effect of Triamcinolone even in
the normal rat liver where 1)0th synthetic and breakdown pathways of glycogen meta-bolism are intact, it can he assumed that in cases with a metabolic block at the
amylo-i, 6-glucosidase level Triamcinolone
is more likely to cause further glycogen
ac-cumulation.
However, induction of glucose-6-phos-phatase activity by Triamcinolone may he
of decisive significance in evaluating cases of suspected double-enzyme deficiencies. It may serve as a diagnostic tool to differ-entiate between an enzymatic deficiency
due to a mutation of a structural gene and decreased activity due to a regulatory dis-order.
The genetic and biochemical alterations
present in G.S.D. seem to be more complex
than initially realized. Further studies on the genetic and biochemical pathology may ultimately lead to some therapeutic
appli-cations.
ADDENDUM
After completion of this manuscript a further
case of C.S.D. Type III was studied and low
values of liver Glucose-6-phosphatase were found.
Similar enzyme induction was obtained after
Tniamcinolone administration.
SUMMARY
In cases of glycogen storage disease Type
III, low levels of liver
glucose-6-phos-phatase activity have frequently been found in addition to the complete absence
the homeostatic control of gluconeogenesis.
It belongs to the group of adaptive
en-zymes, and it has been shown in rats that its
activity can be induced by steroids and suppressed by insulin. Increasing evidence is accumulating to indicate that the hor-monal control of this enzyme activity affects
de novo synthesis at the gene level. The subnormal activity of
glucose-6-phosphatase in cases of amylo-1, 6-glucosi-dase deficiency could be the result of a double enzyme deficiency due to two structural gene defects, or secondary to a
regulatory gene disorder resulting in
sup-pression of glucose-6-phosphatase biosyn-thesis. If the low levels of
glucose-6-phos-phatase activity result from a structural
gene mutation, hormonal induction of
en-zyme biosynthesis would be unlikely;
whereas, if the markedly depressed activity of this enzyme is due to abnormal control
affecting the regulation of enzyme synthesis, hormonal induction may be possible.
A case of amylo-i, 6-glucosidase type A
is presented in which, in addition to
com-plete absence of the debrancher enzyme,
exceedingly low values of liver
glucose-6-phosphatase were repeatedly demonstrated. Low insulin-like activity was found in the
patient’s plasma, but no significant
abnor-mality of steroid metabolism could be
shown. Triamcinolone administration re-sulted in fourfold increase of liver
glucose-6-phosphatase activity. This enzyme induc-tion by Triamcinolone suggests that the markedly reduced levels of glucose-6-phos-phatase activity prior to steroid
adminis-tration were due to a regulatory disorder
of enzyme biosynthesis and not to a
structural gene defect. It is suggested that
the Triamcinolone induction test can be used in similar situations as a diagnostic
tool to differentiate between a regulatory gene disorder affecting enzyme synthesis, and a structural gene defect.
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Acknowledgment
We are grateful to Mrs. Ada Rutenberg for able
technical assistance; Dr. A. Ravina, assistant chief
of Internal Medical Department, Beersheva
Hospi-tal of the Negev, for estimation of insulin like
activity; Dr. Z. Laron Rogoff Research Institute,
Beilinson Hospital for Growth Hormone assay;
Dr. G. Rumney, Head of Laboratory of Steroid
Metabolism Beilinson Hospital for steroid
determi-nations; Prof. E. Liban, Head of Department of
Pathology Kaplan Hospital for help in evaluating
the pathological material; Dr. E. Katznelson Head
of Pediatric Dept. Tel Hashomer Hospital for
per-nlission to use some of the biochemical results
ob-taifle(l during one of the earlier hospitalizations;
and Dr. C. Yagil of the Dept. of Cell Biology
Weizniann Institute of Science for fruitful
