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MPS Reference
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“We hope that when the paediatrician sees the physical findings, and if the radiologist gets some X-rays, [that] they can say that these vertebrae don’t look normal [and] we need to send this child to the geneticist”. – Dr Paul Harmatz

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Joint manifestations are often among the first signs of MPS

Rheumatologists’ suspicion of MPS is essential for accurate and timely diagnosis

Bone- and joint-related features are common from a very early stage of disease in patients with most types of mucopolysaccharidosis (MPS) disorders. Patients with these types of musculoskeletal manifestations often present to a rheumatologist – and often before MPS is diagnosed.1

Delayed diagnosis can lead to

  • Severe multisystemic complications1,3
  • Irreversible or end-organ damage1
  • Delayed treatment2
  • Lack of access to disease-specific management, with concomitant increase in risk of surgical mortality1,6,1,5,-8

Watch key opinion leader Dr Offiah talk about variability in phenotype and disease progression.

Signs and symptoms are unpredictable and clinically heterogeneous across and within MPS disorders, making diagnosis challenging. Patients may exhibit non-classical and/or classical signs of MPS, as well as rapidly or slowly progressing disease.2-4

Suspect, refer and rule out MPS

Because of early and ongoing joint involvement, rheumatology has opportunities to positively impact the lives of patients and families living with MPS through early identification, which can enable disease-specific management and access to available therapies. To expedite early intervention, be aware of signs and symptoms, including the following:

  • Joint stiffness or laxity6,9
  • Joint involvement in the absence of inflammation10
  • Progressive loss of joint mobility5
  • Carpal tunnel syndrome10
  • Bone abnormalities10
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Rheumatologic involvement is uniformly progressive, with incidence and severity increasing over time. Although patients with MPS typically present with a wide range or cluster of symptoms, isolated symptoms may be sufficient to merit referral to a geneticist or metabolic centre.1,11

Signs and symptoms may be subtle or overt. Common bone and joint features suggestive of MPS include1:

  • Early joint involvement without classic inflammatory features or erosive bone lesions
  • “Claw hand”
  • Spinal deformity (subtle or overt gibbus, scoliosis, kyphosis, lordosis)
  • Radiologic evidence of dysostosis multiplex

Additional signs and symptoms that may be present can be seen in the table below.

Musculoskeletal-manifestations-of-MPS_AMc

Not all joint problems present similarly across all MPS types.

  • Skeletal dysplasia of patients with MPS IV is distinct from the dysostosis multiplex seen in other MPS types.6
  • Ligamentous laxity/joint hypermobility associated with MPS IV is also unique; in other MPS types, joint involvement typically presents with decreased mobility and stiffness.6

MPS is mistakenly considered a childhood disease; however, patients with slow-progressing MPS may present and should trigger suspicion at any age.6,9

  • Joint disease with or without inflammation is a key feature of slowly progressing MPS.6,9
  • Rheumatologists should consider an MPS referral in patients with any of the following:
    • Oligoarticular juvenile idiopathic arthritis who do not respond to anti-inflammatory therapy (e.g. non-steroidal anti-inflammatory drugs)10,7
    • Family history of similarly affected siblings2,7
    • MRI findings of proliferative synovitis without erosions7
    • Joint pain and contractures without systemic and local signs of inflammation6

Stiffness and contractures may affect any joint but are often observed at phalangeal joints.6

  • The characteristic “claw hand” deformity develops when interphalangeal joints of the hands are affected.6
    • Patients with MPS are more likely to have distal interphalangeal joint involvement.6
    • Patients with inflammatory arthritis are more likely to have proximal interphalangeal or metacarpophalangeal joint involvement.6
  • Because carpal tunnel syndrome is uncommon in childhood, its occurrence in a child should prompt suspicion of MPS.6

Take a deep dive into signs and symptoms that should elevate your suspicion of MPS

Presentation and disease progression are unpredictable, multisystemic, and variable across and within MPS disorders, making diagnosis challenging.1

Delayed diagnosis is common, and it can have devastating consequences for your patients. Early identification of signs and symptoms across systems can be critical to early and accurate diagnosis. Become familiar with the diverse signs and symptoms of MPS that may present in your practice.2,5

Discover the signs and symptoms of MPS

A more common joint condition or MPS?

MPS joint disorders can mimic, and thus be confused with, more common rheumatologic conditions.6 Because appropriately managing MPS can have a life-changing impact, early and accurate diagnosis is critical. If there is any suspicion of MPS, refer to a geneticist or local metabolic centre.1

Differential-diagnoses-to-rule-out-MPS-110_AMc
Rheumatologists should include MPS in the differential diagnosis for all patients with either joint contracture or laxity with or without inflammation.1,6,10
When in doubt over differential diagnoses, refer to rule out MPS

How else might you see MPS?

Patterns of signs and symptoms warrant a high suspicion of MPS

Regardless of the clinical setting, there are overt and generally observable signs that should raise your suspicion. Upon further examination, additional symptomatology may be discovered through specialty-specific targeted clinical assessments, laboratory findings and patient history. This division is illustrated below.

Signs and symptoms of MPS1,-4,10,12-24

Musculoskeletal

General features

  • Abnormal gait
  • Bone dysplasia
  • Claw hands
  • Coarse facial features
  • Joint pain
  • Macrocephaly
  • Pectus carinatum
  • Reduced endurance/exercise intolerance
  • Short stature/growth retardationa

Features revealed by specialty–specific assessment

  • Abnormal gait
  • Bone deformities
  • Dysostosis multiplex
  • Genu valgum
  • Joint involvement (contractures, joint laxity) without inflammation
  • Spinal subluxation

Rheumatological

General features

  • Decreased joint mobility
  • Hip stiffness and pain
  • Joint pain
  • Joint stiffness or laxity

Features revealed by specialty–specific assessment

  • Carpal tunnel syndrome
  • Joint involvement without joint swelling or erosive bone lesions

Ear, Nose, and Throat

General features

  • Conductive and/or sensorineural hearing loss
  • Enlarged tongue
  • Recurrent otitis media

Features revealed by specialty-specific assessment

  • Abnormal epiglottis
  • Depressed nasal bridge
  • Hypertrophic adenoids
  • Hypertrophic tonsils
  • Middle ear mucus
  • Narrowing of supraglottic and infraglottic airway
  • Ossicular malformation
  • Recurrent and excessive rhinorrhea
  • Recurrent otitis media
  • Tracheal thickening/compression
  • Tubular obstruction
  • Tympanic membrane thickening

Ophthalmological

General features

  • Cataracts
  • Diffuse corneal clouding
  • Glaucoma

Features revealed by specialty-specific assessment

  • Amblyopia
  • Corneal clouding with characteristic “ground glass” appearance
  • High hyperopia
  • Hypertelorism
  • Optic nerve abnormalities (swelling and atrophy)
  • Peripheral vascularisation of the cornea
  • Progressive pseudo-exophthalmos
  • Reduction in visual acuity
  • Retinopathy
  • Strabismus

Neurological

General features

  • Behavioural abnormalities (typically not present in MPS IVA and VI)
  • Developmental delay (typically not present in MPS IVA and VI)
  • Hearing impairment
  • Seizures (typically not present in MPS IVA and VI)

Features revealed by specialty-specific assessment

  • Arachnoid cysts (typically not present in MPS IVA and VI)
  • Brain atrophy (typically not present in MPS IVA and VI)
  • Carpal tunnel syndrome
  • Cervical cord compression/myelopathy/subluxation
  • Enlarged perivascular space
  • Hydrocephalus
  • Odontoid dysplasia
  • Pachymeningitis cervicalis
  • Papilledema/optic atrophy
  • Sensorineural deafness
  • Signal-intensity abnormalities
  • Spinal canal stenosis
  • Ventriculomegaly

Cardiovascular

General features

  • Reduced endurance/exercise intolerance

Features revealed by specialty-specific assessment

  • Pulmonary hypertension
  • Thickened, regurgitant or stenotic mitral or aortic valves in presence of left ventricular hypertrophy
  • Tricuspid regurgitation

Pulmonary

General features

  • Reduced endurance/exercise intolerance
  • Sleep apnoea

Features revealed by specialty-specific assessment

  • Obstructed upper and lower airways (bronchial narrowing, narrowing of supraglottic and infraglottic airway)
  • Progressive reduction in lung volume
  • Respiratory infections
  • Sleep disorders (obstructive sleep apnoea/hypopnoea syndrome and upper airway resistance syndrome)

Gastrointestinal

General features

  • Abdominal pain
  • Constipation
  • Hepatosplenomegaly
  • Hernias
  • Loose stools

Features revealed by specialty-specific assessment

  • Hepatosplenomegaly

Dental

General features

  • Abnormal buccal surfaces
  • Dentinogenesis imperfecta
  • Hypodontia
  • Pointed cusps
  • Spade-shaped incisors
  • Thin enamel

Features revealed by specialty-specific assessment

  • Abnormal buccal surfaces
  • Thin enamel

aSkeletal involvement and short stature may be less overt in some patients.

Patients with undiagnosed MPS often have joint-related signs and symptoms – which may mimic other rheumatologic disorders – and thus may present to a rheumatologist.6 Rheumatology consequently plays an essential role in identifying individuals with MPS. Appropriate patients should be referred to a geneticist or metabolic centre for definitive diagnosis and, when available, initiate management to improve outcomes.1,4,1,6
Refer to rule out MPS

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References:  1. Lehman TJA, Miller N, Norquist B, Underhill L, Keutzer J. Diagnosis of the mucopolysaccharidoses. Rheumatology. 2011;50(suppl 5):v41-v48.  2. Hendriksz C. Improved diagnostic procedures in attenuated mucopolysaccharidosis. Br J Hosp Med. 2011;72(2):91-95.  3. Hendriksz CJ, Berger KI, Giugliani R, et al. International guidelines for the management and treatment of Morquio A syndrome. Am J Med Genet Part A. 2014;9999A:1-15. doi:10.1002/ajmg.a.36833.  4. Lachman RS, Burton BK, Clarke LA, et al. Mucopolysaccharidosis IVA (Morquio A syndrome) and VI (Maroteaux-Lamy syndrome): under-recognized and challenging to diagnose. Skeletal Radiol. 2014;43(3):359-369. doi:10.1007/s00256-013-1797-y.  5. Clarke LA. Pathogenesis of skeletal and connective tissue involvement in the mucopolysaccharidoses: glycosaminoglycan storage is merely the instigator. Rheumatology (Oxford). 2011;50(suppl 5):v13-18. doi:10.1093/rheumatology/ker395.  6. Morishita K, Petty RE. Musculoskeletal manifestations of mucopolysaccharidoses. Rheumatology. 2011;50(suppl 5):v19-v25. doi:10.1093/rheumatology/ker397.  7. Muenzer J, Beck M, Eng CM, et al. Long-term, open-labeled extension study of idursulfase in the treatment of Hunter syndrome. Genet Med. 2011;13(2):95-101. doi:10.1097/GIM.0b013e3181fea459.  8. Spinello CM, Novello LM, Pitino S, et al. Anesthetic management in mucopolysaccharidoses. ISRN Anesthesiol. 2013;2013:1-10. doi:10.1155/2013/791983.  9. Lampe C, Bosserhoff AK, Burton BK, et al. Long-term experience with enzyme replacement therapy (ERT) in MPS II patients with a severe phenotype: an international case series. J Inherit Metab Dis. 2014;37(5):823-829. doi:10.1007/s10545-014-9686-7.  10. Cimaz R, Coppa GV, Koné-Paut I, et al. Joint contractures in the absence of inflammation may indicate mucopolysaccharidosis [hypothesis]. Pediatr Rheumatol Online J. 2009;7:18. doi:10.1186/1546-0096-7-18.  11. Wood T, Bodamer OA, Burin MG, et al. Expert recommendations for the laboratory diagnosis of MPS VI. Mol Genet Metab. 2012;106(1):73-82. doi:10.1016/j.ymgme.2012.02.005.  12. Muenzer J. The mucopolysaccharidoses: a heterogeneous group of disorders with variable pediatric presentations. J Pediatr. 2004;144(suppl 5):S27-S34.  13. Thümler A, Miebach E, Lampe C, et al. Clinical characteristics of adults with slowly progressing mucopolysaccharidosis VI: a case series. J Inherit Metab Dis. 2012;35(6):1071-1079. doi:10.1007/s10545-012-9474-1.  14. Montaño AM, Tomatsu S, Gottesman GS, Smith M, Orii T. International Morquio A Registry: clinical manifestation and natural course of Morquio A disease. J Inherit Metab Dis. 2007;30(2):165-174. doi:10.1007/s10545-007-0529-7.  15. Kinirons MJ, Nelson J. Dental findings in mucopolysaccharidosis type IV A (Morquio’s disease type A). Oral Surg Oral Med Oral Pathol. 1990;70(2):176-179.  16. Lachman R, Martin KW, Castro S, Basto MA, Adams A, Teles EL. Radiologic and neuroradiologic findings in the mucopolysaccharidoses. J Pediatr Rehabil Med. 2010;3(2):109-118. doi:10.3233/PRM-2010-0115.  17. Fahnehjelm KT, Ashworth JL, Pitz S, et al. Clinical guidelines for diagnosing and managing ocular manifestations in children with mucopolysaccharidosis. Acta Ophthalmol. 2012;90(7):595-602. doi:10.1111/j.1755-3768.2011.02280.x.  18. Zafeiriou DI, Batzios SP. Brain and spinal MR imaging findings in mucopolysaccharidoses: a review. AJNR Am J Neuroradiol. 2013;34(1):5-13. doi:10.3174/ajnr.A2832.  19. Braunlin EA, Harmatz PR, Scarpa M, et al. Cardiac disease in patients with mucopolysaccharidosis: presentation, diagnosis and management. J Inherit Metab Dis. 2011;34(6):1183-1197. doi:10.1007/s10545-011-9359-8.  20 Braunlin E, Orchard PJ, Whitley CB, Schroeder L, Reed RC, Manivel JC. Unexpected coronary artery findings in mucopolysaccharidosis. Report of four cases and literature review. Cardiovasc Pathol. 2014;23(3):145-151. doi:10.1016/j.carpath.2014.01.001.  21. Mesolella M, Cimmino M, Cantone E, et al. Management of otolaryngological manifestations in mucopolysaccharidoses: our experience. Acta Otorhinolaryngol Ital. 2013;33(4):267-272.  22. Berger KI, Fagondes SC, Giugliani R, et al. Respiratory and sleep disorders in mucopolysaccharidosis. J Inherit Metab Dis. 2013;36(2):201-210. doi:10.1007/s10545-012-9555-1.  23. Martins AM, Dualibi AP, Norato D, et al. Guidelines for the management of mucopolysaccharidosis type I. J Pediatr. 2009;155(4)(suppl 2):S32-S46. doi:10.1016/j.jpeds.2009.07.005.  24. Clarke LA, Winchester B, Giugliani R, Tylki-Szymańska A, Amartino H. Biomarkers for the mucopolysaccharidoses: discovery and clinical utility. Mol Genet Metab. 2012;106(4):396-402. doi:10.1016/j.ymgme.2012.05.003.  25. Data on file. Biomarin Pharmaceutical, Inc.  26. Drummond JC, Krane EJ, Tomatsu S, Theroux MC, Lee RR. Paraplegia after epidural-general anesthesia in a Morquio patient with moderate thoracic spinal stenosis. Can J Anesth. 2015;62(1):45-49. doi:10.1007/s12630-014-0247-1.  27. Sharkia R, Mahajnah M, Zalan A, Sourlis C, Bauer P, Schöls L. Sanfilippo type A: new clinical manifestations and neuro-imaging findings in patients from the same family in Israel: a case report. J Med Case Rep. 2014;8:78. doi:10.1186/1752-1947-8-78.