Prolidase deficiency

Alternate names

Hyperimidodipeptiduria; Imidodipeptidase deficiency; Peptidase deficiency; PD

Definition

Prolidase deficiency is a rare metabolic condition characterized by skin lesions, recurrent infections, unusual facial features, variable intellectual disability, enlargement of the liver (hepatomegaly) with elevated liver enzymes, and enlargement of the spleen (splenomegaly).

Epidemiology

Prolidase deficiency is a rare disorder. Approximately 70 individuals with this disorder have been documented in the medical literature, and researchers have estimated that the condition occurs in approximately 1 in 1 million to 1 in 2 million newborns. It is more common in certain areas in northern Israel, both among members of a religious minority called the Druze and in nearby Arab Moslem populations.

Cause

Prolidase deficiency is caused by mutations in the PEPD gene. This gene provides instructions for making the enzyme prolidase, also called peptidase D. Prolidase helps divide certain dipeptides, which are molecules composed of two protein building blocks (amino acids). Specifically, prolidase divides dipeptides containing the amino acids proline or hydroxyproline. By freeing these amino acids, prolidase helps make them available for use in producing proteins that the body needs.

Prolidase is also involved in the final step of the breakdown of some proteins obtained through the diet and proteins that are no longer needed in the body. Prolidase is particularly important in the breakdown of collagens, a family of proteins that are rich in proline and hydroxyproline. Collagens are an important part of the extracellular matrix, which is the lattice of proteins and other molecules outside the cell. The extracellular matrix strengthens and supports connective tissues, such as skin, bone, cartilage, tendons, and ligaments. Collagen breakdown occurs during the maintenance (remodeling) of the extracellular matrix.

PEPD gene mutations that cause prolidase deficiency result in the loss of prolidase enzyme activity. It is not well understood how the absence of prolidase activity causes the various signs and symptoms of prolidase deficiency. Researchers have suggested that accumulation of dipeptides that have not been broken down may lead to cell death. When cells die, their contents are released into the surrounding tissue, which could cause inflammation and lead to the skin problems seen in prolidase deficiency. Impaired collagen breakdown during remodeling of the extracellular matrix may also contribute to the skin problems. The intellectual disability that occurs in prolidase deficiency might result from problems in processing neuropeptides, which are brain signaling proteins that are rich in proline. It is unclear how absence of prolidase activity results in the other features of prolidase deficiency.

Inheritance

Autosomal recessive inheritance, a 25% chance

This condition is inherited in an autosomal recessive pattern, which means both copies of the gene in each cell have mutations. The parents of an individual with an autosomal recessive condition each carry one copy of the mutated gene, but they typically do not show signs and symptoms of the condition.

Signs and symptoms

Symptoms typically present during infancy and vary greatly among affected individuals. Affected individuals may have enlargement of the spleen (splenomegaly); in some cases, both the spleen and liver are enlarged (hepatosplenomegaly). Diarrhea, vomiting, and dehydration may also occur. People with prolidase deficiency are susceptible to severe infections of the skin or ears, or potentially life-threatening respiratory tract infections. Some individuals with prolidase deficiency have chronic lung disease.

Characteristic facial features in people with prolidase deficiency include prominent eyes that are widely spaced (hypertelorism), a high forehead, a flat bridge of the nose, and a very small lower jaw and chin (micrognathia). Affected children may experience delayed development, and about 75 percent of people with prolidase deficiency have intellectual disability that may range from mild to severe.

People with prolidase deficiency often develop skin lesions, especially on their hands, feet, lower legs, and face. The severity of the skin involvement, which usually begins during childhood, may range from a mild rash to severe skin ulcers. Skin ulcers, especially on the legs, may not heal completely, resulting in complications including infection and amputation.

The severity of symptoms in prolidase deficiency varies greatly among affected individuals. Some people with this disorder do not have any symptoms. In these individuals the condition can be detected by laboratory tests such as newborn screening tests or tests offered to relatives of affected individuals.

For most diseases, symptoms will vary from person to person. People with the same disease may not have all the symptoms listed. 80%-99% of people have these symptoms

• Abnormal facial shape(Unusual facial appearance)
• Abnormality of the hip bone(Abnormality of the hips)
• Abnormality of the middle ear
• Carious teeth(Dental cavities)
• Crusting erythematous dermatitis
• Cutaneous photosensitivity
• Depressed nasal bridge(Depressed bridge of nose)
• Dry skin
• Erythema
• Hearing impairment(Deafness)
• Palmoplantar keratoderma(Thickening of palms and soles)
• Papule
• Pruritus(Itching)
• Recurrent respiratory infections(Frequent respiratory infections)
• Skin ulcer(Open skin sore)
• Thin skin

30%-79% of people have these symptoms

• Abnormal fingernail morphology(Abnormal fingernails)
• Abnormality of retinal pigmentation
• Arachnodactyly(Long slender fingers)
• Bilateral single transverse palmar creases
• Depressed nasal ridge(Flat nose)
• Generalized hirsutism(Excessive hairiness over body)
• Genu valgum(Knock knees)
• Hypertelorism(Wide-set eyes)
• Low anterior hairline(Low frontal hairline)
• Micrognathia(Little lower jaw)
• Visual impairment(Impaired vision)
• White forelock(White part of hair above forehead)

5%-29% of people have these symptoms

• Hepatomegaly(Enlarged liver)
• Hypoplasia of the zygomatic bone(Cheekbone underdevelopment)
• Intellectual disability(Mental deficiency)
• Proptosis(Bulging eye)
• Recurrent cystitis(Recurrent bladder infections)
• Reduced bone mineral density(Low solidness and mass of the bones
• Splenomegaly(Increased spleen size)

Diagnosis

The diagnosis of prolidase deficiency is based on the presence of characteristic clinical symptoms, high levels of imidodipeptides in the urine, and detection of either mutations in the PEPD gene or reduced levels of prolidase enzyme activity

Treatment

There is no cure for prolidase deficiency. Treatment is aimed at treating the specific symptoms present in each individual. A multidisciplinary team of specialists is often needed. Supportive treatment of the skin, lung, and immunologic manifestations has been helpful in some cases.

Prognosis

The long-term outlook can vary because of the large possible range of severity in each person. For example, while skin ulcers lead to amputations in some people, others continue to be symptom-free. In most cases, people with prolidase deficiency experience a reduced quality of life because of infections and chronic pulmonary (lung) complications. Life expectancy is often decreased, with infection being the most common cause of death.

NIH genetic and rare disease info

• NIH info on Prolidase deficiency

Prolidase deficiency is a rare disease.

Prolidase deficiency Resources
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