Wolman disease …

Neurogenetic Disorders

Updated 08.27.2023
Released 04.28.1997
Expires For CME 08.27.2026

Wolman disease

Authors: Kimberly A Chapman MD PhD, Christina Grant MD PhD, Seth I Berger MD PhD

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Editor: AHM M Huq MD PhD

Wolman disease

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Introduction

Overview

The etiology of lysosomal acid lipase deficiency, which is known as Wolman disease in its most severe form and historically as cholesteryl storage disease in its milder form, is the deficient activity of acid lipase (E.C. 3.1.1.13), a hydrolase that cleaves cholesteryl esters and triglycerides under acid conditions, with an autosomal recessive mode of inheritance. It has been referred to as lysosomal acid lipase, acid lipase, or acid esterase. The abnormal accumulation of cholesteryl esters and triglycerides is the biological basis of lysosomal acid lipase deficiency. Due to apparently complete absence of enzyme activity in the most severe form, Wolman disease, the accumulation in that disorder is more severe and affects a larger variety of tissues, whereas the slight residual enzyme activity in the milder cholesteryl ester storage disease offers some protection. The incidence of both conditions can be diminished by genetic counseling, familial carrier testing, and preimplantation genetic diagnostics. The demonstration of deficient acid lipase activity or molecular diagnosis can serve as the definitive diagnostic tests. Intravenous enzyme replacement therapy has emerged as a therapeutic option with some success.

Key points

	• Wolman disease was first described in Iranian-Jewish children. It is the infantile form of autosomal recessive lysosomal acid lipase deficiency.
	• Characteristically, Wolman disease presents in early infancy with diarrhea, massive hepatosplenomegaly, failure to thrive, and calcification of adrenal glands.
	• Without treatment, hepatic failure followed by death occurs within the first year of life.
	• Milder lysosomal acid lipase deficiency, historically described as cholesteryl ester storage disease, is characterized by hepatic steatosis and dyslipidemia.
	• Enzyme replacement therapy has emerged as a therapeutic option.

Historical note and terminology

In 1956, Abramov and colleagues described an infant with abdominal distension, hepatosplenomegaly, and massive calcification of the adrenal gland who died at 3 months of age (01). In 1961, Wolman and colleagues reported the same clinical findings in two siblings of the first patient and also demonstrated that the accumulated lipids consisted mainly of cholesterol esters and triglycerides (77). The name "Wolman disease" was introduced by Crocker and colleagues in 1965 (22). In 1969, Patrick and Lake demonstrated a deficient activity of a lysosomal acid lipase catalyzing the hydrolysis of cholesterol ester and triglycerides in the liver and spleen of patients with Wolman disease (58), and this led to diagnostic assays in cultured fibroblasts (21) and lymphocytes (19). Anderson and Sando cloned human lysosomal acid lipase in 1991 (04). The crystal structure has been described (62).

Defective activity of lysosomal acid lipase is also a feature in cholesteryl ester storage disease (09), a somewhat milder disorder characterized by hepatomegaly and hyperlipoproteinemia that is compatible with survival to the second decade or adulthood. It is now clear that Wolman disease and cholesteryl ester storage disease are allelic and describe a continuum of lysosomal acid lipase deficiency. A variety of mutations in the gene that encode lysosomal acid lipase have been reported for both disorders (02; 56; 55; 49; 07).

In 2015, a phase 3 trial of sebelipase alfa, a recombinant human enzyme replacement therapy, demonstrated that this therapeutic option could result in the reduction of several measures of disease severity in children and adults (15). This drug has since been approved for use both in Europe and by the FDA in the United States (57). Follow-up studies demonstrate that sebelipase alfa is well tolerated and can improve lipid levels and liver function long-term (16).

Clinical manifestations

Presentation and course

	•Wolman is the severe form and cholesteryl ester storage disease is the milder form of lysosomal acid lipase deficiency.
	•Adrenal calcifications are a characteristic radiological finding.

The most severe form of lysosomal acid lipase deficiency, Wolman disease has a striking and consistent clinical presentation. The disease has its clinical onset in the first few weeks of life, with persistent vomiting and abdominal distension as the most frequent initial symptoms. Increasing vomiting, diarrhea, abdominal distension associated with hepatosplenomegaly, anemia, and inanition are the predominant abnormalities. Adrenal gland calcification is a characteristic radiological finding (79). Primary adrenal insufficiency in children is an uncommon but potentially lethal condition. In a study that included 55 girls and 48 boys with primary adrenal insufficiency who attended one hospital department between September 1981 and September 2001, Wolman disease was diagnosed in three patients in two different consanguineous families (59). Wolman disease should also be considered if fetal hepatomegaly or bilateral adrenal echogenicity suggestive of diffuse calcification are noted on prenatal ultrasound examination (12).

Without treatment, death usually occurs by the age of 3 to 6 months, but it has been as protracted as 14 months (08). Ben-Haroush and colleagues report a case of isolated fetal ascites diagnosed at 32 weeks’ gestation, with negative work-up for immune and nonimmune hydrops fetalis and congenital infections and malformations (10). After delivery, the diagnosis of Wolman disease was established. This suggests that Wolman disease should be considered in cases of isolated fetal ascites.

Cholesteryl ester storage disease has a much more variable phenotype (44). The principal and sometimes only sign, hepatomegaly, may be evident at birth or in early childhood, but may be delayed until the second decade or occasionally until adulthood (27; 44). The resultant loss of lysosomal acid lipase-derived free cholesterol leads to hypercholesterolemia in patients with cholesteryl ester storage disease, as well as premature atherosclerosis. Other clinical findings are xanthelasma and splenomegaly, which occur in about one third of the patients. Liver failure and jaundice occur occasionally. Radiologically demonstrable adrenal calcification is absent in most patients but has been reported occasionally. Drebber and colleagues describe the first case in the literature with diarrhea as a putative symptom of cholesteryl ester storage disease in adult patients. Histopathologic changes in the liver tissue and DNA sequence analysis confirmed the diagnosis of cholesteryl ester storage disease due to homozygosity for the most common cholesteryl ester storage disease mutation, a G934A splice site defect encoded by exon 8 of the lysosomal acid lipase gene (25). Bindu and colleagues describe two patients with hitherto unreported ptosis and external ophthalmoplegia associated with cholesteryl ester storage disease (11). Kathuria and colleagues report two siblings with Wolman disease presenting with intractable ascites, requiring therapeutic paracentesis, albumin infusion, and diuretics to control tense ascites. Although intractable ascites are rare in Wolman disease, it should be considered in the differential diagnosis of infantile ascites (41). There is a strong association between Wolman disease and bilateral adrenal calciﬁcations. Schreyer-Shafir and colleagues report on prenatal and postnatal findings of two fetuses with bilateral adrenal calcifications, increased nuchal translucency, increased nuchal fold, micropenis, hypogonadism, and congenital nephritic syndrome, which they consider as a new clinical entity, probably of autosomal recessive inheritance (65).

Prognosis and complications

In untreated Wolman disease, death usually occurs by 3 to 6 months of age. One patient survived to 14 months (48). Treatment with sebelipase alfa has been shown to reduce hepatomegaly and normalize transaminase levels as well as improve dyslipidemia in lysosomal acid lipase deficiency (LAL-D). In Wolman disease, enzyme replacement is correlated with longer survival than the natural history (28).

Patients with cholesteryl ester storage disease survive to the second decade or later. Two patients with a benign variant were diagnosed at 43 and 56 years of age (27). Death is due to complications of liver disease, obstructive pulmonary vascular disease (36), and anemia. Although premature arteriosclerosis is known to occur on pathological study, clinically evident coronary or cardiovascular disease has not been reported (08). However, a case series of 14 patients did demonstrate increased common carotid artery mean intima-media thickness of about the 95th percentile in several patients (60).

Hemophagocytic lymphohistiocytosis is a life-threatening condition that may be genetically determined or secondary to infections, malignancies, immune deficiencies, and rheumatologic disorders. It has been anecdotally described in three patients with Wolman disease. Taurisano and colleagues reported a patient with Wolman disease with clear-cut clinical, biochemical, and histological features indicative of hemophagocytic lymphohistiocytosis (70). They discussed the role of cholesteryl ester-induced inflammasome activation in macrophages, suggesting that Wolman disease can cause secondary hemophagocytic lymphohistiocytosis.

Clinical vignette

Wolman disease. Pregnancy and delivery were unremarkable, and birth weight was 3600 g (63). The baby was less active than normal. After 2 months, the clinical condition deteriorated, and a dilated abdomen was noted. When taken into the hospital at 3 months, the clinical condition was poor, and hepatosplenomegaly and increased bleeding tendency were observed. X-ray examinations revealed calcified adrenal glands on both sides. The spleen was increased in size. Vacuolated monocytic cells were present in the blood smear, and the bone marrow showed an infiltration of histiocytic cells with pale foamy cytoplasm. The child was severely anemic. Acid lipase activity in leukocytes was 70 units compared to 800±240 in controls and 335 and 324 in the father and mother, respectively. Inanition progressed, and the child died at 4.5 months.

Cholesteryl ester storage disease. A 2-year-old girl was noted to have hepatosplenomegaly during hospitalization due to measles (09). Although she remained generally well until 7 years of age, her height and weight had fallen progressively to or below the third percentile. Occult blood was found in the stool and she had a chronic iron deficiency anemia. She was readmitted to a hospital at 8 years of age. The abdomen was protuberant, with the liver 10 cm below the right costal margin and the spleen 8 cm below the left. Hemoglobin was 10.5 g/dL and hematocrit 35%. Radiographs of the abdomen revealed bilateral adrenal calcification. The bone marrow contained isolated large histiocytes scattered irregularly among the hematopoietic cells. A liver biopsy had similar cells in greater number. Bands of dense connective tissue extended from the portal areas into the lobules forming large and small nodules of different sizes. Many large foam cells occupied the portal areas and were also present in the lamina propria of the duodenum. Leukocyte acid lipase activity was 0.88 nmol/min per mg protein compared to 14.33 in controls and 5.49 and 6.00 in the father and mother, respectively. At a follow-up at 13 years of age, the height and weight had fallen further below the third percentile. Epistaxis was frequent, stool specimens were positive for occult blood, and chronic iron deficiency anemia required therapy. Two sisters with the same illness had died at 7 and 9 years with similar illness complicated by hepatic portal cirrhosis, epicarditis, myocarditis, and renal failure.

Biological basis

Etiology and pathogenesis

The etiology of Wolman disease and of cholesteryl storage disease is the deficient activity of acid lipase (E.C. 3.1.1.13), a hydrolase that cleaves cholesteryl esters and triglycerides under acid conditions. It has been referred to as lysosomal acid lipase, acid lipase, or acid esterase. It has been purified from many sources (31). It has a molecular weight of 41 kd. The purified enzyme hydrolyzes trioleyl glycerol, dioleoylglycerol, mono-oleoylglycerol, as well as cholesteryl oleate. The gene that encodes this enzyme has been mapped to chromosome 10q23.2-q23.3 (03). The gene structure includes 10 exons dispersed over 45 kilobases (06). Mutations in this gene have been demonstrated in both Wolman disease and in cholesteryl ester disease. Anderson and Sando reported a patient with Wolman disease with two mutations: a T-insertion after position 634, which resulted in a stop codon, and a leucine-to-proline substitution at amino acid 179 (04). Pagani and colleagues reported a tyrosine to histidine at codon 274 in a patient with cholesteryl ester storage disease and subsequently identified four other mutations in this disease, namely a proline 181 leucine transition, a leucine 273 serine transition, an A to G 3' splice site substitution that caused skipping of exon 7, and a 5' splice site mutation (G to A) that led to skipping of exon 8 (56; 55). The mutation in a rat model of Wolman disease has been identified (50).

It is now clear that Wolman disease and cholesteryl ester storage disease are allelic. They are distinguished by the degree of reduction of acid lipase activity. Aslanidis studied two patients, one with Wolman disease and the other with cholesteryl ester storage disease, who both had splice site mutations leading to a skipping of exon 8 (07). In the patient with the milder cholesteryl ester storage disease, 3% of the genes were spliced correctly, resulting in 3% of normal enzyme activity, whereas in the patient with Wolman disease, the defect was total, resulting in the absence of enzyme activity (07).

The abnormal accumulation of cholesteryl esters and triglycerides is the biological basis of both Wolman disease and cholesteryl ester storage disease. Due to apparently complete absence of enzyme activity in Wolman disease, the accumulation in that disorder is more severe and affects a larger variety of tissues, whereas the slight residual enzyme activity in cholesteryl ester storage disease offers some protection. The enzyme plays an important role in the cellular processing of plasma lipoproteins and contributes to the homeostatic control of lipoprotein levels in blood and to prevention of cellular lipid overloading (08). The enzyme is involved in the cellular degradation of plasma low-density lipoprotein (14). The acid lipase deficiency, thus, causes a severe disturbance in regulatory mechanisms of cholesterol metabolism. The inability to release free cholesterol results in an elevated synthesis of endogenous cholesterol, upregulation of low-density lipoprotein receptor gene expression, and increased production of apo-B containing lipoproteins (64). Fitoussi and colleagues have postulated that the adrenal calcification is secondary to the toxic effects of mildly oxidized low-density lipoprotein (29). The transport into the cell of this substance is down-regulated poorly in Wolman disease (29).

In Wolman disease, the liver is enlarged to twice normal weight, the hepatic and Kupffer cells are enlarged and vacuolated, and there is marked portal and periportal fibrosis and sometimes frank cirrhosis. The spleen is grossly enlarged. The adrenal glands are grossly and symmetrically enlarged and may each weigh 13 g compared to a normal weight of 5 g. Swollen and lipid-laden cells are most prominent in the inner zone fasciculata and the entire zona reticularis (47). The small intestine is thickened and dilated. The lamina propria and mucosa are infiltrated with foamy histiocytes. Studies of the digestive and absorptive functions in the jejunum of a 1-month-old infant with Wolman disease indicated that the absorptive defect was so severe that it virtually excluded the absorption of any form of enteral nutrition (43).

In the brain, foamy histiocytes and sudanophilic droplets are found in the leptomeninges (22), capillaries of the gray matter (77), choroid plexus, microglia, and Purkinje cells. The white matter may show a sudanophilic leukodystrophy (34). Characteristic lipid inclusions are also present in Schwann cells, oligodendrocytes, astrocytes (17), and in the ganglion cells of the plexuses of Auerbach and Meissner (40). In cholesteryl ester storage disease, the liver is enlarged with lipid droplets and variable amounts of periportal fibrosis, which in some patients progresses to micronodular cirrhosis with esophageal varices. The adrenal glands are not grossly involved. Foam cells are present in the interstitium of the lung and renal glomeruli. The nervous system is not involved. Three of four autopsied patients have shown anatomic evidence of accelerated arteriosclerosis (08).

Diagnostic workup

The demonstration of deficient lysosomal acid lipase activity is the definitive diagnostic test. The activity of this enzyme is measured in freshly prepared extracts of leukocytes or cultured skin fibroblasts. The most frequently used substrates are [1-14C]trioleyl glycerol or cholesteryl-[1-14C] oleate (21). Artificial compounds such as nitrophenyl laurate (09), methylumbelliferyl oleate (67), triphenylaminolauric acid (52), and pyrenemethyl laurate for a fluorescence-based determination have been reported (53). The natural substrates are more specific (08). More recently deficient enzyme can be identified in dried blood spots; however, confirmation should be done in leukocytes or fibroblasts or by genetic sequencing demonstrating mutations in the LIPA gene (44).

Wolman disease should be considered in any neonate with bilateral adrenal calcification, which often delineates the outline of both glands, especially if there is a family history of consanguinity or early neonatal deaths (76). Wolman feels that this finding is pathognomonic for Wolman disease and for its milder form, cholesterol ester storage disease (76). Boldrini and colleagues describe the histological and ultrastructural aspects disclosed by intestinal or liver biopsy in three cases of Wolman disease and in two cases of cholesteryl ester storage disease, emphasizing the role of morphological findings in pointing the diagnosis toward a metabolic storage disease (13). Liver section typically shows microsteatosis and macrosteatosis and cholesterol crystals in hepatocyte cytoplasm, consistent with Wolman disease. Diffuse bowel thickening with dilatation, because of infiltration of the lamina propria by foamy histiocytes, is a well-established feature of Wolman disease (54). These changes predominate in the jejunum and the ileum, the internal layers indistinguishable from the submucosa. Infiltration of the lamina propria by foamy histiocytes results in malabsorption, bowel dilatation, bowel-wall thickening, and ulceration. Nchimi and colleagues further showed the correlation between ultrasound and pathology findings; the infiltrated lamina propria became hyperechoic and indistinguishable from the adjacent submucosa (51). Shome and colleagues report a case of Wolman disease with a few atypical features such as lack of adrenal calcification and unusual morphology of vacuolated marrow macrophages (66). Prenatal diagnosis is possible by measuring acid esterase activity in cultured embryonic cells (38), or through molecular testing when a familial mutation is known. Iavarone and associates have further confirmed this finding, though mutational analysis of LIPA, the gene coding for lysosomal acid lipase, may provide a more rapid diagnosis (02).

Desai and colleagues demonstrated deficient lysosomal acid lipase activity in cultured amniocytes from an at-risk fetus prenatally (24). The affected 17-week fetus revealed massive lysosomal cholesterol and lipid accumulation in the fetal hepatocytes, adrenal cells, and syncytiotrophoblasts. The adrenal glands revealed extensive necrosis, suggesting that this might precede the calcification observed in these patients.

Lohse and colleagues have elucidated the genetic defects in 15 unrelated patients with cholesteryl ester storage disease (46). Seven were homozygotes for the prevalent human lysosomal acid lipase (hLAL) exon 8 splice junction mutation that results in incomplete exon skipping, whereas eight probands were compound heterozygotes for E8SJM and a rare mutation on the second chromosome. Combined with the reported data in the literature, their results demonstrate that compound heterozygosity for a mutation causing Wolman disease is common among patients with cholesteryl ester storage disease.

Whole gene or exon scale deletions have not been reported in the literature in association with Wolman disease. With a history of a previously affected individual in the family, electron microscopic examination of chorionic villus samples might allow prenatal diagnosis of storage diseases including Wolman disease (30). Molecular testing of chorionic villus samples or amniocytes is possible in families where the causative mutations are known.

To diagnose the deficiency of lysosomal acid lipase in Wolman disease, Hamilton and colleagues described a new method for its measurement in dried blood spots using Lalistat 2, a specific inhibitor of lysosomal acid lipase (35).

Huang and colleagues, using enzymatic and molecular analysis, report a case of Wolman disease in a Chinese infant, with a novel mutation of LIPA gene. The patient was homozygote for a novel insert mutation allele c.318 ins T, p. Phe106fsX4 in exon 4 on LIPA gene. Both parents were carriers of the mutation (37).

Management

Nearly all untreated patients with Wolman disease have died during the first 6 months of life due to a combination of malabsorption of orally administered food and liver disease. More specific therapy would require parenteral nutrition and some means to provide the normal enzyme or other means to reduce the accumulation of cholesteryl esters and triglycerides. Adrenal function would also need to be assessed and replacement therapy provided if required. Enzyme replacement therapy is approved by the FDA and in Europe, and has prolonged survival and diminished symptoms when the disease is recognized and therapy started early in infancy.

Initial work-up for all with lysosomal acid lipase deficiency following confirmation includes a comprehensive clinical examination, lipid biomarkers (eg, triglyceride levels, total cholesterol, HDL-C, non-HDL-C, and calculated LDL-C), ALT, AST, alkaline phosphatase, GGT, BUN, serum creatinine, CBC with differential, PT and INR (44).

Lipid biomarkers, hepatic tests (ie, ALT, AST, GGT, and alkaline phosphatase), BUN, and serum creatinine should be checked every 3 months up to 1 year and then every 6 to 12 months thereafter. CBC with differential, PT, and INR can be followed annually as can liver imaging. Cardiac evaluation is more important for the milder phenotypes, and timing depends on age since screening for premature atherosclerotic burden (44).

Krivit and colleagues have performed bone marrow transplantation in two patients and, as expected, corrected the lysosomal acid lipase deficiency in leukocytes, but did not otherwise alter the course of the disease (45). The rationale behind bone marrow transplantation is that a reconstituted hematopoietic system from a healthy, matched donor will contain stem cells that can produce the missing enzyme or enzymes.

The first report of a successful unrelated HLA-mismatched umbilical cord blood-derived stem cell cord blood transplant in a patient with Wolman disease resulted in restoration of normal acid lipase levels before the onset of permanent end-organ damage (68). Four years after transplantation, the patient is thriving and has normal levels of acid lipase in peripheral blood cells. The authors claim that umbilical cord stem cell transplantation can restore acid lipase levels in Wolman disease and, if performed early, can cure the disease.

Despite the gloomy prognosis, Tietge and colleagues have reported phenotypic correction of lipoid storage and growth arrest in Wolman disease after gene transfer of lysosomal acid lipase into affected fibroblasts (71).

The therapy of cholesteryl ester storage disease includes the management of liver disease and its complications and of epistaxis and gastrointestinal bleeding (09). Administration of the HMG-CoA reductase inhibitor lovastatin in a dosage of 20 mg twice daily resulted in a significant reduction of plasma cholesterol, triglycerides, and low-density lipoprotein cholesterol (32). Such therapy may also have a beneficial effect on liver and adrenal function. The combined administration of simvastatin (0.28 mg/kg each evening) and cholestyramine (0.22 g/kg twice a day) plus a low-cholesteryl diet and administration of vitamins A, D, E, and K had similar favorable effects on plasma lipoproteins in another patient (08). Assman and Seedorf reported that a patient who had chronic liver failure due to cholesteryl ester storage disease had a liver transplant and was said to be well 2 years later (42; 08). Adrenal function should be investigated and treatment initiated if basal or ACTH-stimulated cortisol is abnormal.

Du and colleagues demonstrate the feasibility of using plant-expressed, recombinant hLAL for the enzyme therapy of human Wolman disease/cholesteryl ester storage disease with general implications for other lysosomal storage diseases (26). Tolar and colleagues describe four cases of Wolman disease treated with stem cell transplant (72). Associated relatively high mortality rate (two out of four) was attributed to sinusoidal obstruction syndrome, multi-organ failure, and sepsis in the first case and hepatic failure and sepsis in the second case. Presently, there are no proven strategies to accelerate the differentiation and engraftment of donor-derived macrophages in a stem cell transplant recipient (33).

Based on their experience with hematopoietic cell transplantation of four patients with Wolman disease, Tolar and colleagues conclude that Wolman disease can be treated with hematopoietic cell transplantation with success and that with early diagnosis and timely referral to a transplant center, hepatic and cognitive function can be preserved (72).

Sun and colleagues studied the effects of intravenous investigational enzyme therapy on survival and efficacy in Lipa knockout, lal-/- mice with advanced disease using recombinant human lysosomal acid lipase (rhLAL) (69). In the study, rhLAL extended the lifespan of lal-/- mice in a dose-dependent manner. Enzyme therapy in high doses resulted in significantly improved organ size (liver, spleen, and small intestine) and tissue histology and significant decreases in cholesterol and triglyceride in all treated groups. In the treated livers and spleens, cholesterol and triglyceride levels were reduced to below treatment initiation levels, indicating a reversal of disease manifestations, even in advanced disease, with diminished liver fibrosis and macrophage proliferation. Their results suggest that lysosomal acid lipase deficiency can be improved biochemically and histopathologically by various dosages of enzyme therapy, even in advanced disease. Valayannopoulos and colleagues reported that long-term dosing with sebelipase alfa in patients with lysosomal acid lipase deficiency is well-tolerated and produces sustained reductions in transaminases, improvements in serum lipid profile, and reduction in the hepatic fat fraction (73).

Sebelipase alpha, a recombinant human enzyme replacement therapy, showed a reduction of several measures of disease severity in children and adults (15) with good tolerance and sustained positive outcomes (16).

Outcomes

Enzyme replacement therapy can be initiated as soon as a diagnosis is confirmed and has been shown to affect disease course. Jones and colleagues performed an open-label multicenter dose-escalation study of sebelipase alfa (39). The study included children with growth failure who were symptomatic before 6 months of life. Out of the nine enrolled infants, six survived past 1 year, and five were still alive at the 2-year follow-up with improved growth and liver function. A long-term follow-up study of French patients found that of five patients with Wolman disease treated early with enzyme replacement, all had normalized growth and improved gastrointestinal symptoms, with most able to have entirely enteral nutrition support (none requiring long term parenteral nutrition), as well as 100% survival at the time of publication (23).

Multi-modal therapy combining hematopoietic stem cell transplant, enzyme replacement therapy with sebelipase alfa, and dietary restriction has been reported in patients who developed anti-drug antibodies leading to diminished effect of enzyme replacement therapy (61). Four of five patients treated this way survived, with reported improved outcomes compared to when the patients were on enzyme replacement therapy alone.

A decrease in biomarkers for atherosclerosis risk in patients treated with sebelipase alfa, irrespective of their use of lipid-lowering medication was identified (75; 16).

References

01: Abramov A, Schorr S, Wolman M. Generalized xanthomatosis with calcified adrenals. Am J Dis Child 1956;91:282-6. PMID 13301142
02: Anderson RA, Byrum RS, Coates PM, Sando GN. Mutations at the lysosomal acid cholesteryl ester hydrolase gene locus in Wolman disease. Proc Natl Acad Sci U S A 1994;91:2718-22. PMID 8146180
03: Anderson RA, Rao N, Byrum RS, et al. In situ localization of the genetic locus encoding the lysosomal acid lipase/cholesteryl esterase (LIPA) deficient in Wolman disease in chromosome 10q23.2-23.3. Genomics 1993;15:245-7. PMID 8432549
04: Anderson RA, Sando GN. Cloning and expression of cDNA encoding human lysosomal acid lipase/cholesteryl ester hydrolase. J Biol Chem 1991;266:22479-84. PMID 1718995
05: Ashfield-Watt P, Haralambos K, Edwards R, et al. Estimation of the prevalence of cholesteryl ester storage disorder in a cohort of patients with clinical features of familial hypercholesterolaemia. Ann Clin Biochem 2019;56(1):112-7. PMID 30056760
06: Aslanidis C, Klima H, Lackner KJ, Schmitz G. Genomic organization of the human lysosomal acid lipase gene (LIPA). Genomics 1994;20:329-31. PMID 8020990
07: Aslanidis C, Ries S, Fehringer P, Buchler C, Klima H, Schmitz G. Genetic and biochemical evidence that CESD and Wolman disease are distinguished by residual lysosomal acid lipase activity. Genomics 1996;33:85-93. PMID 8617513
08: Assman G, Seedorf U. Acod lipase deficiency: Wolman disease and cholesteryl ester storage disease. In: Scriver CR, Beaudet A L, Sly WS, Valle D, editors. Metabolic and Molecular Basis of Inherited Disease. 7th ed. New York: McGraw Hill, 1995:2563-87.
09: Beaudet AL, Ferry GD, Nichols BL, Rosenberg HS. Cholesterol ester storage disease: clinical, biochemical, and pathological studies. J Pediatr 1977;90:910-4. PMID 859064
10: Ben-Haroush A, Yogey Y, Levit O, Hod M, Kaplan B. Isolated fetal ascites caused by Wolman Disease. Ultrasound Obstet Gynecol 2003;21(3):297-8. PMID 12666227
11: Bindu PS, Taly AB, Christopher R, et al. Cholesterol ester storage disease with unusual neurological manifestations in two siblings: a report from South India. J Child Neurol 2007;22(12):1401-4. PMID 18174560
12: Blitz MJ, Rochelson B, Sood M, Bialer MG, Vohra N. Prenatal sonographic findings in a case of Wolman's disease. J Clin Ultrasound 2018;46(1):66-8. PMID 28374935
13: Boldrini R, Devito R, Biselli R, Filocamo M, Bosman C. Wolman disease and cholesteryl ester storage disease diagnosed by histological and ultrastructural examination of intestinal and liver biopsy. Pathol Res Pract 2004;200(3):231-40. PMID 15200275
14: Brown MS, Goldstein JL. A receptor-mediated pathway for cholesterol homeostasis. Science 1986;232:34-47. PMID 3513311
15: Burton BK, Balwani M, Feillet F, et al. A phase 3 trial of sebelipase alfa in lysosomal acid lipase deficiency. N Engl J Med 2015;373(11):1010-20. PMID 26352813
16: Burton BK, Sanchez AC, Kostyleva M, et al. Long-term sebelipase alfa treatment in children and adults with lysosomal acid lipase deficiency. J Pediatr Gastroenterol Nutr 2022;74(6):757-64. PMID 35442238
17: Byrd JC, Powers JM. Wolman's disease: ultrastructural evidence of lipid accumulation in central and peripheral nervous systems. Acta Neuropathol 1979;45:37-42. PMID 216225
18: Carter A, Brackley SM, Gao J, Mann JP. The global prevalence and genetic spectrum of lysosomal acid lipase deficiency: A rare condition that mimics NAFLD. J Hepatol 2019;70(1):142-50. PMID 30315827
19: Coates PM, Cortner JA, Hoffman GM, Brown SA. Acid lipase activity of human lymphocytes. Biochim Biophys Acta 1979;572:225-34. PMID 427176
20: Coates PM, Cortner JA, Mennuti MT, Wheeler JE. Prenatal diagnosis of Wolman disease. Am J Med Genet 1978;2:397-407. PMID 122435
21: Cortner JA, Coates PM, Swoboda E, Schnatz JD. Genetic variation of lysosomal acid lipase. Pediatr Res 1976;10:927-32. PMID 10546
22: Crocker AC, Vawter GF, Neuhauser EB, Rosowsky A. Wolman's disease: three new patients with a recently described lipidosis. Pediatrics 1965;35:627-40. PMID 14269714
23: Demaret T, Lacaille F, Wicker C, et al. Sebelipase alfa enzyme replacement therapy in Wolman disease: a nationwide cohort with up to ten years of follow-up. Orphanet J Rare Dis 2021;16(1)507. PMID 34906190
24: Desai PK, Astrin KH, Thung SN, et al. Cholesteryl ester storage disease: pathologic changes in an affected fetus. Am J Med Genet 1987;26:689-98. PMID 3565483
25: Drebber U, Anderson M, Kasper HU, Lohse P, Stolte M, Dienes HP. Severe chronic diarrhea and weight loss in cholesteryl ester storage disease: a case report. World J Gastroenterol 2005;11(15):2364-6. PMID 15818756
26: Du H, Cameron TL, Garger SJ, et al. Wolman disease/cholesteryl ester storage disease: efficacy of plant-produced human lysosomal acid lipase in mice. J Lipid Res 2008;49(8):1646-57. PMID 18413899
27: Elleder M, Ledvinova J, Cieslar P, Kuhn R. Subclinical course of cholesterol ester storage disease diagnosed in adulthood. Report on two cases with remarks on the nature of the liver storage process. Virchows Arch A 1990;416:357-65. PMID 2106753
28: Erwin AL. The role of sebelipase alfa in the treatment of lysosomal acid lipase deficiency. Therap Adv Gastroenterol 2017;10(7):553-62. PMID 28804516
29: Fitoussi G, Negre SA, Pieraggi MT, Salvayre R. New pathogenetic hypothesis for Wolman disease: possible role of oxidized low-density lipoproteins in adrenal necrosis and calcification. Biochem J 1994;301:267-73. PMID 8037680
30: Fowler DJ, Anderson G, Vellodi A, Malone M, Sebire NJ. Electron microscopy of chorionic villus samples for prenatal diagnosis of lysosomal storage disorders. Ultrastruct Pathol 2007;31(1):15-21. PMID 17455094
31: Fowler SD, Brown WJ. Lysosomal acid hydrolase. In: Borgstrom B, Brockman HL, editors. Lipases. New York: Elsevier Science, 1984:329-64.
32: Ginsberg HN, Le NA, Short MP, Ramakrishnan R, Desnick R. Suppression of apolipoprotein B production during treatment of cholesteryl ester storage disease with Lovastatin. J Clin Invest 1987;80:1692-7. PMID 3680522
33: Gramatges MM, Dvorak CC, Regula DP, Enns GM, Weinberg K, Agarwal R. Pathological evidence of Wolman's disease following hematopoietic stem cell transplantation despite correction of lysosomal acid lipase activity. Bone Marrow Transplant 2009;44(7):449-50. PMID 19308038
34: Guazzi GC, Martin JJ, Philippart M, et al. Wolman's disease. Distribution and significance of the central nervous system lesions. Pathol Eur 1968;3:266-77. PMID 5688463
35: Hamilton J, Jones I, Srivastava R, Galloway P. A new method for the measurement of lysosomal acid lipase in dried blood spots using the inhibitor Lalistat 2. Clin Chim Acta 2012;413(15-16):1207-10. PMID 22483793
36: Hill SC, Hoeg JM, Dwyer AJ, Vucich JJ, Doppelman JL. CT findings in acid lipase deficiency: Wolman's disease and cholesteryl ester storage disease. J Comput Assist Tomogr 1983;7:815-8. PMID 6886132
37: Huang YL, Sheng HY, Zhao XY, et al. Wolman disease with novel mutation of LIPA gene in a Chinese infant. Zhonghua Er Ke Za Zhi 2012;50(8):601-5. PMID 23158738
38: Iavarone A, Dolfin G, Bracco G, Zaffaroni M, Gallina MR, Bona G. First trimester prenatal diagnosis of Wolman disease. J Inherit Metab Dis 1989;12(Suppl 2):299-300. PMID 2512430
39: Jones SA, Rojas-Caro S, Quinn AG, et al. Survival in infants treated with sebelipase Alfa for lysosomal acid lipase deficiency: an open-label, multicenter, dose-escalation study. Orphanet J Rare Dis 2017;12(1):25. PMID 28179030
40: Kamoshita S, Landing BH. Distribution of lesions in myenteric plexus and gastrointestinal mucosa in lipidoses and other neurologic disorders of children. Am J Clin Pathol 1968;49:312-8. PMID 5645093
41: Kathuria R, Poddar U, Ghosh J, et al. Intractable ascites as a manifestation of Wolman's disease: report of two sibs. Indian J Gastroenterol 2012;31(6):343-5. PMID 23007684
42: Kelly DR, Hoeg JM, Demosky S, Brewer HB. Characterization of plasma lipids and lipoproteins in cholesteryl ester storage disease (CESD). Am J Med Genet 1986;24:711. PMID 3740103
43: Kikuchi M, Igarashi K, Noro T, Igarashi Y, Hirooki M, Tada K. Evaluation of jejunal function in Wolman's disease. J Pediatr Gastroentrol Nutr 1991;12:65-9. PMID 2061782
44: Kohli R, Ratziu V, Fiel MI, Waldmann E, Wilson DP, Balwani M. Initial assessment and ongoing monitoring of lysosomal acid lipase deficiency in children and adults: consensus recommendations from an international collaborative working group. Mol Genet Metab 2020;129(2):59-66.** PMID 31767214
45: Krivit W, Freese D, Chan KW, Kulkarni R. Wolman disease: a review of treatment with bone marrow transplantation and consideration for the future. Bone Marrow Transplant 1992;10(Suppl 1):97-101. PMID 1521099
46: Lohse P, Maas S, Lohse P, et al. Compound heterozygosity for a Wolman mutation is frequent among patients with cholesteryl ester storage disease. J Lipid Res 2000;41(1):23-31. PMID 10627498
47: Lough J, Fawcett J, Wiegensberg B. Wolman's disease: an electron microscopic, histochemical and biochemical study. Arch Pathol 1970;89:103-10. PMID 5412920
48: Marshall WC, Ockenden BC, Fosbrooke AD, Cumings JN. Wolman's disease: a rare lipidosis with adrenal calcification. Arch Dis Child 1968;44:331-1.
49: Maslen CL, Babcock D, Illingworth DR. Occurrence of a mutation associated with Wolman disease in a family with cholesteryl ester storage disease. J Inherit Metab Dis 1995;18:620-3. PMID 8598644
50: Nakagawa H, Matsubara S, Kuriyama M, et al. Cloning of rat lysosomal acid lipase cDNA and identification of the mutation in the rat model of Wolman's disease. J Lipid Res 1995;36:2212-8. PMID 8576647
51: Nchimi A, Rausin L, Khamis J. Ultrasound appearance of bowel wall in Wolman's disease. Pediatr Radiol 2003;33(4):284-5. PMID 12709765
52: Negre A, Salvayre R, Dagan A, Borrone C, Gatt S. New spectrophotometric assays of acid lipase and their use in the diagnosis of Wolman and cholesteryl ester storage diseases. Anal Biochem 1985;145(2)398-405. PMID 4014671
53: Negre-Salvayre A, Dagan A, Gatt S, Salvayre R. Use of pyrenemethyl laurate of fluorescence-based determination of lipase activity in intact living lymphoblastoid cells and for the diagnosis of acid lipase deficiency. Biochem J 1993;294:885-91. PMID 8397511
54: Ozmen MN, Aygun N, Kilic I, et al. Wolman’s disease: ultrasonographic and computed tomographic findings. Pediatr Radiol 1992;22:541-2. PMID 1491919
55: Pagani F, Garcia R, Pariyarath R, et al. Expression of lysosomal acid lipase mutants detected in three patients with cholesteryl ester storage disease. Hum Mol Genet 1996;10:1611-7. PMID 8894696
56: Pagani F, Zagato L, Merati G, Paone G, Gridelli B, Maier JA. A histidine to tyrosine replacement in lysosomal acid lipase causes cholesteryl ester storage disease. Hum Mol Genet 1994;3:1605-9. PMID 7833918
57: Pastores GM, Hughes DA. Lysosomal acid lipase deficiency: therapeutic options. Drug Des Devel Ther 2020;14:591-601. PMID 32103901
58: Patrick AD, Lake BD. Deficiency of an acid lipase in Wolman's disease. Nature 1969;222:1067-8. PMID 5787090
59: Perry R, Kecha O, Paquette J, Huot C, Van Vliet G, Deal C. Primary adrenal insufficiency in children: twenty years experience at the Sainte-Justine Hospital, Montreal. J Clin Endocrinol Metab 2005;90(6):3243-50. PMID 15811934
60: Pisciotta L, Tozzi G, Travaglini L, et al. Molecular and clinical characterization of a series of patients with childhood-onset lysosomal acid lipase deficiency. Retrospective investigations, follow-up and detection of two novel LIPA pathogenic variants. Atherosclerosis 2017;265:124-32. PMID 28881270
61: Potter JE, Petts G, Ghosh A, et al. Enzyme replacement therapy and hematopoietic stem cell transplant: a new paradigm of treatment in Wolman disease. Orphanet J Rare Dis 2021;16(1):235. PMID 34020687
62: Rajamohan F, Reyes AR, Tu M, et al. Crystal structure of human lysosomal acid lipase and its implications in cholesteryl ester storage disease. J Lipid Res 2020;61(8):1192-202. PMID 32482718
63: Roytta M, Fagerlund AS, Toikkanen S, et al. Wolman disease: morphological, clinical and genetic studies on the first Scandinavian cases. Clin Genet 1992;42:1-7. PMID 1516222
64: Sando GN, Ma GP, Lindsley KA, Wei YP. Intercellular transport of lysosomal acids lipase mediates lipoprotein cholesteryl ester metabolism in a human vascular endothelial cell-fibroblast co-culture system. Cell Regul 1990;1:661-74. PMID 2150334
65: Schreyer-Shafir N, Sukenik-Halevy R, Tepper R, et al. Prenatal bilateral adrenal calcifications, hypogonadism, and nephrotic syndrome: beyond Wolman disease. Prenat Diagn 2014;34(6):608-11. PMID 24777844
66: Shome DK, Al-Jishi E, Greally JF, Malik N, Zainaldeen HA, Das NS. The Middle-East connection of Wolman disease. Saudi Med J 2002;23(5):597-601. PMID 12070591
67: Sloan HR, Fredrickson DS. Enzyme deficiency in cholesteryl ester storage disease. J Clin Invest 1972;51:1923-6. PMID 5032533
68: Stein J, Gartzy BZ, Dror Y, Fenig E, Zeigler M, Yaniv I. Successful treatment of Wolman disease by unrelated umbilical cord blood transplantation. Eur J of Pediatr 2007;166(7):663-6. PMID 17033804
69: Sun Y, Xu YH, Du H, et al. Reversal of advanced disease in lysosomal acid lipase deficient mice: a model for lysosomal acid lipase deficiency disease. Mol Genet Metab 2014;112(3):229-41. PMID 24837159
70: Taurisano R, Maiorana A, De Benedetti F, Dionisi-Vici C, Boldrini R, Deodato F. Wolman disease associated with hemophagocytic lymphohistiocytosis: attempts for an explanation. Eur J Pediatr 2014;173(10):1391-4. PMID 24844354
71: Tietge UJ, Sun G, Czarnecki S, et al. Phenotypic correction of lipid storage and growth arrest in Wolman disease fibroblasts by gene transfer of lysosomal acid lipase. Hum Gene Ther 2001;12:279-89. PMID 11177564
72: Tolar J, Petryk A, Khan K, et al. Long-term metabolic, endocrine, and neuropsychological outcome of hematopoietic cell transplantation for Wolman disease. Bone Marrow Transplant 2009;43(1):21-7. PMID 18776925
73: Valayannopoulos V, Malinova V, Honzík T, et al. Sebelipase alfa over 52 weeks reduces serum transaminases, liver volume and improves serum lipids in patients with lysosomal acid lipase deficiency. J Hepatol 2014;61(5):1135-42. PMID 24993530
74: Valles-Ayoub Y, Esfandiarifard S, No D, et al. Wolman disease (LIPA p.G87V) genotype frequency in people of Iranian-Jewish ancestry. Genet Test Mol Biomarkers 2011;15(6):395-8. PMID 21291321
75: Wilson DP, Friedman M, Marulkar S, Hamby T, Bruckert E. Sebelipase alfa improves atherogenic biomarkers in adults and children with lysosomal acid lipase deficiency. J Clin Lipidol 2018;12(3):604-14. PMID 29628368
76: Wolman M. Wolman disease and its treatment. Clin Pediatr (Phila) 1995;34:207-12. PMID 7789014
77: Wolman M, Sterk VV, Gatt S, Frenkel M. Primary familial xanthomatosis with involvement and calcification of the adrenals: report of two more cases in siblings of a previously described infant. Pediatrics 1961;28:742-57. PMID 14008104
78: Young EP, Patrick AD. Deficiency of acid esterase activity in Wolman's disease. Arch Dis Child 1970;45:664-8. PMID 5477680
79: Young LW, Sty JR, Babbitt DP. Radiological case of the month: Wolman disease. Am J Dis Child 1979;133:959-60. PMID 517479

Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Authors

Kimberly A Chapman MD PhD

Dr. Chapman of George Washington University and Children’s National Rare Disease Institute received honorariums from HemoShear Therapeutics as principal investigator.
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Christina Grant MD PhD

Dr. Grant of Children’s National Hospital received a consulting fee from Amicus Therapeutics and honorariums from Sanofi Genzyme for serving on an advisory committee.
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Seth I Berger MD PhD

Dr. Berger of Children’s National Health System has no relevant financial relationships to disclose.
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Editor

AHM M Huq MD PhD

Dr. Huq of Wayne State University has no relevant financial relationships to disclose.
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Former Authors

Hugo W Moser MD (original author), Tarakad S Ramachandran MD, and Arun Ramachandran MD

Patient Profile

Age range of presentation: Wolman disease: 0 to 23 months

Cholesteryl ester storage disease: 2 to 44 years
Sex preponderance: male=female
Heredity: heredity may be a factor

autosomal recessive
Population groups selectively affected: none selectively affected
Occupation groups selectively affected: none selectively affected

ICD & OMIM codes

ICD-9: Wolman disease: 272.7
ICD-10: Wolman disease: E75.5
OMIM: Wolman disease: #278000

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Wolman disease

Differential Diagnosis

Niemann-Pick disease
X-linked adrenoleukodystrophy
neonatal adrenoleukodystrophy
infantile Refsum disease
adrenal teratomas
- neuroblastoma
- ganglioneuroma
- pheochromocytoma
- glycogen storage disease
- Niemann-Pick disease type B
- mucopolysaccharidoses
- GM1 gangliosidosis
- congenital biliary cirrhosis
- familial hypercholesterolemia

Wolman disease

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Associated or underlying disorders

Diagnostic workup

Management

Outcomes

Special considerations

Pregnancy

Anesthesia

References

Contributors

Authors

Editor

Former Authors

Patient Profile

ICD & OMIM codes

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Questions or Comment?

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