Pathologic findings of multiple sulfatase deficiency reflect the pattern of enzyme deficiencies

Multiple sulfatase deficiency is a rare metabolic storage disorder that manifests in childhood. It is probably an autosomal-recessive inherited condition, the gene for which has not yet been identified. Clinical features include mental deficiency and a dysmorphic appearance reminiscent of a mucopolysaccharidosis. Unlike most storage disorders, there are multiple deficient enzymes; all are sulfatases, hence the name of the disorder. Biochemical testing reveals accumulation of glycosaminoglycans, sulfatides, and gangliosides in the brain and other tissues of affected patients. In previous accounts of postmortem examinations, white matter histologic and biochemical pathologic findings similar to metachromatic leukodystrophy have been reported. Ganglioside accumulation, secondary to interference with degradative enzyme activity by the accumulating glycosaminoglycans also has been demonstrated. The authors report a case of multiple sulfatase deficiency with only mild deficiencies of the arylsulfatases but with severe deficiencies of iduronate sulfatase and heparan sulfamidase. Pathologic changes were more in keeping with a mucopolysaccharidosis, with minimal white matter changes and deposition of metachromatic material. The authors postulate that the mild leukodystrophic changes but striking features similar to a mucopolysaccharidosis are reflections of the pattern of enzyme deficiency. The pathology of multiple sulfatase deficiency therefore represents an overlap between a leukodystrophy and a mucopolysaccharidosis, with the relative contribution of each pattern apparently depending on the pattern of enzyme deficiency encountered in each patient.