Glycogen storage disease type IV, also known as Glycogen branching enzyme deficiency, Andersen's disease or amylopectinosis is a rare inherited metabolic disorder.
Clinically there are many variations in presentation. As soon as the disease begins, there is accumulation of the long un-branched chains mainly in the liver tissues causing hepatomegaly. This leads to derangement in the normal functioning of the liver. Cirrhosis may be further seen as a consequence of continued metabolic disorder. Jaundice is visible and progressive in nature. Splenomegaly is seen in most of the individuals.
Rarely does the disease affect the peripheral nerves; when it does, neuromuscular symptoms are evident. It leads to hypotonia, gait disturbances and lumbar lordosis. Waddling gait causes difficulty in walking. Hepatic failure ensues and hence, there is failure to thrive seen in infants.
Cardiac manifestations like cardiomegaly might be seen in few individuals.
distress Hypertrophic cardiomyopathy rather than dilated cardiomyopathy 10 genes 1 Zellweger spectrum disorder AR Profound hypotonia Respiratory distress Rhizomelic chondrodysplasia punctata & biochemical peroxisomal abnormalities 40 genes 2 Congenital [ncbi.nlm.nih.gov]
Some signs and symptoms associated with Andersen's Disease include: Breathing difficulties Productive cough with bloody sputum Variations in skin tone and color Weakness and exhaustion; inability to perform physical activities Decreased muscle mass Neuromuscular [dovemed.com]
Failure to Thrive
Such signs typically include failure to thrive – slow growth and failure to gain weight at the expected rate. There may be an abnormally large liver and spleen. [agsd.org.uk]
The first indication of a problem is a failure to thrive. The rate of growth and mental progress of the baby stops at a certain point and does not continue normally. [agsdus.org]
Symptoms of GSD 4 usually begin in infancy and typically include failure to thrive; enlarged liver and spleen (hepatosplenomegaly); and in many cases, progressive liver cirrhosis and liver failure. [diseaseinfosearch.org]
The clinical presentation of the classic form of Andersen disease usually occurs in the first few months of life and is characterized by hepatosplenomegaly and failure to thrive. [themedicalbiochemistrypage.org]
The classical clinical presentation for GSD IV is hepatomegaly with failure to thrive, followed by progressive liver failure and death by the age of 5 years. 1 Variable expression of GSD IV has been reported. 2-4 A patient, diagnosed at the age of 2 years [adc.bmj.com]
Liver, Gall & Pancreas
In the non-progressive hepatic type, hepatomegaly and liver disease are usually evident in early childhood, but affected individuals typically do not develop cirrhosis. [ghr.nlm.nih.gov]
In the less common non-progressive hepatic subtype, presentation can be in childhood with hepatomegaly, liver dysfunction, myopathy, and hypotonia. [ncbi.nlm.nih.gov]
In addition, assay for branching enzyme deficiency in muscle, leukocytes, erythrocytes, or fibroblasts can be carried out to determine the exact defect resulting in the hepatomegaly. [themedicalbiochemistrypage.org]
As soon as the disease begins, there is accumulation of the long un-branched chains mainly in the liver tissues causing hepatomegaly. This leads to derangement in the normal functioning of the liver. [symptoma.com]
Glycogen Disease of the Liver Leads to hepatomegaly Types: 1, 3, 4, 6 Glycogen Disease of the Muscle Exercise intolerance and muscle weakness Types: 5 and 7 Glycogen storage disease Type Ia (von Gierke Disease) G-6-Pase deficiency Findings: (same as Ib [quizlet.com]
Liver dysfunction, myopathy, and hypotonia in childhood Childhood neuromuscular subtype. [ncbi.nlm.nih.gov]
Nota bene: Liver biopsy may be needed to determine the cause of progressive liver dysfunction. [humpath.com]
Liver transplantation was discounted because there was only a mild synthetic liver dysfunction (measured by albumin level and prothrombin time) with slight increases in aminotransferase activities. [adc.bmj.com]
Ewert and colleagues report successful heart transplantation in a patient with Andersen disease and cardiomyopathy.  Consultations See the list below: Consult a hepatologist regarding liver dysfunction and management. [emedicine.medscape.com]
Cases in which there are primarily muscle, nervous system, or cardiac defects may have no sign of liver dysfunction. Blood glucose levels are tested to assess for hypoglycemia. [encyclopedia.com]
Affected fetuses have a condition called fetal akinesia deformation sequence, which causes a decrease in fetal movement and can lead to joint stiffness (arthrogryposis) after birth. [ghr.nlm.nih.gov]
The fatal perinatal neuromuscular subtype, the most severe subtype, presents in utero with fetal akinesia deformation sequence, including decreased fetal movements, polyhydramnios, and fetal hydrops. [ncbi.nlm.nih.gov]
Whole exome sequencing in foetal akinesia expands the genotype-phenotype spectrum of GBE1 glycogen storage disease mutations. Neuromuscul Disord. 2013 Feb. 23(2):165-9. [Medline]. Raju GP, Li HC, Bali DS, et al. [emedicine.medscape.com]
Fetal akinesia develops which may cause decreased movements of the fetus in utero. There is arthrogryposis (joint stiffness) and deformities seen. There will be hypotonia and muscular atrophy noticed in the infant after birth. [symptoma.com]
Chromaffinoma, Chromaffin paraganglioma, Chromaffin tumor, intra-medullary paraganglioma, Chromaffin cell tumor Pena-Shokeir-Syndrom ( 1 Files ) Erkrankung : Pena-Shokeir-Syndrom ICD 10: Q87.8 Synonyme: Pena-Shokeir-Syndrom, Type l (OMIM 208150), Fetal akinesia [orphananesthesia.eu]
Neonatal hypotonia and cardiomyopathy secondary to type IV glycogenosis. Acta Neuropathol (Berl). 1994;87:531-36. Starzl TE, et al. Chimerism after liver transplantation for type IV glycogen storage disease and type 1 Gaucher’s disease. [rarediseases.org]
This form is characterized by polyhydramnios, neonatal hypotonia, and neuronal involvement; hepatopathy is uncommon, and the babies usually die between 4 weeks and 4 months of age. [humpath.com]
Neonatal hypotonia and cardiomyopathy secondary to type IV glycogenosis. Acta Neuropathol 1994; 87 : 531–536. 12. Nambu M, Kawabe K, Fukuda T, Okuno TB, Ohta S, Nonaka I et al. A neonatal form of glycogen storage disease type IV. [nature.com]
Profound neonatal hypotonia at birth, respiratory failure, dilated cardiomyopathy, early infantile death Classic (progressive) hepatic subtype. [ncbi.nlm.nih.gov]
In congenital form, the patients have severe hypotonia, hyporeflexia, cardiomyopathy, depressed respiration and neuronal involvement[ 104, 112 - 114 ]. Liver involvement is not severe and the child dies in early infancy. [wjgnet.com]
Absent Deep Tendon Reflex
deep tendon reflexes GAA Pompe disease AR Profound hypotonia Respiratory distress Hypertrophic cardiomyopathy rather than dilated cardiomyopathy 10 genes 1 Zellweger spectrum disorder AR Profound hypotonia Respiratory distress Rhizomelic chondrodysplasia [ncbi.nlm.nih.gov]
Overlapping w/classic hepatic subtype of GSD IV Distinguishing from classic hepatic subtype of GSD IV AGL GSD III AR Hepatomegaly Liver disease Myopathy Hypoglycemia Hyperlipidemia DGUOK Deoxyguanosine kinase deficiency AR Severe hypotonia Liver disease Nystagmus [ncbi.nlm.nih.gov]
- A Complete blood count will show anemia and neutropenia.
- Blood glucose levels will depict a picture of hypoglycemia as there is excess of glycogen circulating in the body but poor amount of usable glucose.
- Liver function tests are altered due to hepatomegaly and cirrhosis of liver.
- Serum creatinine kinase levels tend to be elevated. This is the most important test done in all patients suspected of Glycogen storage diseases.
- Coagulation studies will be abnormal due to altered liver function. There will be increased tendency to bleed in patients. Altered prothrombin time will be seen.
- Lipid studies will show hyperlipidemia.
- Renal function tests might be done. Serum creatinine might be elevated.
- Urine tests will reveal myoglobinuria.
- Direct biochemical assay of tissues for glycogen and fat content will give a definitive diagnosis.
- Enzyme analysis of GBE1 will also confirm the diagnosis as it is a very sensitive test.
Hepatomegaly will be seen on Ultra Sonography.
Echocardiography will reveal the cardiac involvement in individuals.
Ischemic forearm test is done in all cases of muscle disorders and is an important diagnostic tool.
Genetic diagnosis 
GBE1 deficiency leads to the disorder. Biochemical genetic testing can be done by testing GBE1 activity. Placental involvement  is also seen.
Treatment of Glycogen storage disease type 4 is only palliative and not curative. There is no complete cure as it is an inherited disorder. Patients can be given appropriate diet to reduce hepatomegaly and cirrhosis and complications can be delayed. Care must be taken to give foods which will help in improving weight of the child. Deficiencies of certain fat soluble vitamins are very important as they are not absorbed in case of hepatic function alteration. Vitamin and protein supplements can take care of these nutritional deficits.
Cardiac consultation and neurological testing are extremely useful as it will help to evaluate disease prognosis.
Liver transplantation  is the treatment of choice for hepatic failure in such patients.
The infants who are affected congenitally or in the womb itself will have a bad prognosis as they cannot survive more than few months and die of hepatic failure and failure to thrive. Hypotonia will lead to disability in those who survive and hence there will be a tendency to dependency on others for life.
The milder forms like neuromuscular type have a comparatively better prognosis. Morbidity is chiefly due to hepatosplenomegaly, hepatic failure and failure to thrive seen in affected individuals.
Deficient activity of glycogen branching enzyme is the cause of Glycogen storage disease type 4. It is considered as a hereditary metabolic disorder. Andersen’s disease is an autosomal recessive disease.
There are many neuromuscular variants of this disease depending on the onset of origin. It may be evident at birth, in late childhood or adulthood.
The peri-natal variant shows symptoms usually few months after birth and is fatal to the growth of the infant.
Mutations in the GBE1 gene give rise to Glycogen storage disease type 4. The GBE1 gives instructions for the production of the glycogen branching enzyme. This enzyme is involved in the production of glycogen which is the major source of energy stored in the body.
Glycogen storage diseases in general are very few, around 2 per 1,00,000 children. Glycogen storage disease type 4 is rarer.
Glycogen branching enzyme  is deficient in all the tissues of the body in Glycogen storage disease type 4. This leads to formation of extremely long chains of glycogen which normally would be branched had the enzyme been present. The long un-branched chains have a very low solubility and get deposited in the liver. These long chains get stored in the other bodily tissues producing symptoms fatal to the neonate.
The accumulated glycogen is abnormal in structure and impairs the functioning of the organs where it gets deposited. There are 5 subtypes of Glycogen storage disease type 4 based on the severity, signs and symptoms.
The fatal perinatal neuromuscular type  is the most severe form of disease. The symptoms develop before birth itself. Symptoms like excess fluid accumulation around the fetus and in the body of the fetus are seen. Fetal akinesia develops which may cause decreased movements of the fetus in utero. There is arthrogryposis (joint stiffness) and deformities seen. There will be hypotonia and muscular atrophy noticed in the infant after birth. These infants will not survive post neonatal period due to a weakened heart  and altered breathing muscles.
The congenital muscular type of Glycogen storage disease type 4 is noticed in infants just a few months after birth. Affected infants have high grade of hypotonia which affects all the muscles of breathing. There will be weakening of the heart muscles and dilated cardiomyopathy  ensues.
The progressive hepatic type  of is the most common type of Glycogen storage disease type 4. There will be failure to thrive in infants as there is difficulty in gaining weight and associated hepatomegaly. High blood pressure in the portal veins will lead to portal hypertension and soon ascites develops. These children generally die of hepatic failure.
The non- progressive hepatic type of Glycogen storage disease type 4 has the same features like the hepatic variant but the hepatic dysfunction is less severe. There is hypotonia and myopathy noticed in these individuals.
Prenatal diagnosis must be established and is a very important step towards prevention of complications. Molecular genetic testing can be evaluated by analysis of DNA extracted from fetal cells. Genetic counseling is a very useful tool as it is an inherited disorder and the progeny will have 25% to 50% chance of being affected. It can be avoided by testing the parents for their carrier status.
The glycogen storage diseases are enzyme deficiency diseases which are transmitted hereditarily from one generation to another. Certain enzymes are necessary for conversion of glycogen to glucose and the deficiency of one or more of these enzyme leads to excess of glycogen circulating in the body. The enzyme defect will result in consequences that will cause systemic symptoms or in certain cases limited to a few tissues.
The Glycogen storage disease type 4 is also called as Andersen’s disease or Amylopectinosis or Brancher enzyme deficiency or Polyglucosan Body Disease . The disease usually manifests in childhood owing to its inherited origin. There is no cure for this disease but following certain diet therapy, one can modify the clinical symptoms.
Glycogen storage disorder type 4 is one of the variants of the types of storage disorders. It is also called as Anderson’s disease or glycogen brancher enzyme deficiency disease. The main defect is a deficiency of glycogen branching enzyme which results in variations in the glycogen storage. The deficiency of the glycogen branching enzyme results in circulation of long un-branched glycogen chains which are low molecular weight and hence, easily get deposited at various organs.
It commonly affects the liver and abnormal liver function is seen in infants and children especially. If it affects the neonate congenitally it tends to be very fatal as there will be splenomegaly, failure to thrive and distention of abdomen. There is evidence of cardiomyopathy too in these neonates . In infants where there is neuromuscular involvement, hypotonia (decreased muscle tone) is noticed. There is also stiffness of joints in such neonates and thus, there is tendency to deformities of joints. There will be weakening of the heart and difficulty in breathing. Usually neonates suffering from this variety of disease will not survive far beyond birth.
It is an autosomal recessive type of disease and thus, inherited from the parents. There will be a chance that the next offspring may also suffer from the disease. There are many investigations which can confirm the diagnosis. Prenatal diagnosis can also be done by finding out GBE1 deficiency in the tissues or the amniotic fluid. There are significant alterations in the liver function tests and coagulation studies. Creatinine kinase levels are elevated and there will be high myoglobin levels in the urine samples. Ultra-sonography reveals an enlarged liver, ascites and splenomegaly.
Appropriate diet to reduce liver enlargement remains the most palliative form of treatment children can follow. Liver transplantation remains the main stand of treatment and if done below 2 years of age will have excellent prognosis. Regular checkups with the cardiologists and neurologists will help prevent further complications. Genetic counseling will help the parents to decide about the different aspects and difficulties faced in planning the next child.
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- Assereto S, van Diggelen OP et al. Null mutations and lethal congenital form of glycogen storage disease type IV. Biochem Biophys Res Commun. 2007 Sep 21;361(2):445-50. Epub 2007 Jul 24.
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- Lee YC, Chang CJ et al. Glycogen-branching enzyme deficiency leads to abnormal cardiac development: novel insights into glycogen storage disease IV. Hum Mol Genet. 2011 Feb 1;20(3):455-65.
- Aksu T, Colak A, Tufekcioglu O et al. Cardiac Involvement in Glycogen Storage Disease Type IV: Two Cases and the Two Ends of a Spectrum. Case Reports in Medicine, vol. 2012, Article ID 764286, 4 pages, 2012.
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- Konstantinidou AE, Anninos H et al. Placental involvement in glycogen storage disease type IV. Placenta. 2008 Apr;29(4):378-81.
- Iyer SG, Chen CL et al. Long-term results of living donor liver transplantation for glycogen storage disorders in children. Liver Transpl. 2007 Jun;13(6):848-52.
- Moses SW, Parvari R et al. The variable presentations of glycogen storage disease type IV: a review of clinical, enzymatic and molecular studies. Curr Mol Med. 2002 Mar;2(2):177-88.