Au Professeur Marco Fraccaro
En réunissant ce symposium, vous avez fait preuve de la même
imagination qu'Alexandre Dumas donnant une suite aux "Trois Mousquetaires". Et
cous avez, comme lui, fait preuve dune souveraine indifférence pour le
quantitatif puisque comme chacun sait, les trois mousquetaires étaient quatre,
et que noun sommes ici, grace à vous, plus de deux cents !
Que savons-nous de la trisomie 21, après vingt ans de recherche ?
Quel sujet de meditation et d'inquiètude aussi ! Certes, nous avons appris
bien des chosen, et même à reconnaître la maladie chez des enfants très
jeunes, encore au ventre de leur mère. Mais si ce pouvoir nouveau a suscité
chez certains la tentation d'éliminer les malades extrêmement jeunes, cette
connaissance n'a fait en aucun cas régresser la maladie.
Et c'est pourtant la maladie qu'il fact vaincre, et les patients qu il
faut guérir !
Twenty years after the description of the chromosomal basis of the
disease (Lejeune et al. 1959), the main question remains unanswered: "what is
the actual cause of mental deficiency in trisomy 21 ?"
Sure enough, the first hypothesis of a genic dosage effect (Lejeune
1963) has been followed by a considerable amount of information. For instance,
the gene of superoxide dismutase A (Tan et al. 1973; Sinet et al. 1976 a) has
been localized in the region of the bands q2.21 of chromosome 21. Hence, the
excess of superoxide dismutase A in trisomic 21 patients (Sichitiu et al. 1974;
Sinet et al. 1974) shows the convergence of biochemical, cytogenetic, and
The shift of the oxygen metabolism is complicated by the fact that
glutathione peroxidase (nonlocated in the 21) is also elevated (Sinet et al.
1976 b). More recently, it was demonstrated that the oxygen metabolism
disturbance must have some relationship with the mental retardation (Sinet et
al. 1979): a positive correlation is observed between glutathione peroxidase
activity and the IQ.
Obviously SODA excess could transform O2- to rapidly into
H202 and partially deprive the organism of O2 and increase the amount of toxic
H202. On the other side, glutathione peroxidase elevation could dispose of the
excess of H202 by transforming it in H20. This protective effect seems
plausible, but it is entirely unknown how scavenging too much of the superoxide
ion 02 could be deleterious.
Before trying to discuss this difficult question, it seems appropriate
to ask ourselves whether the anatomoclinical method could reveal some hint,
some heuristic models. The goal is to figure out where a link between mental
deficiency and trisomy 21 should be sought.
No doubt the tiny 21 contains many genes and some, if not all of them,
could exhibit a dosage effect. Truly, such a search could seem entirely
hopeless at first glance, but I shall try to show that methodological
reflection could tell us that some specific observations are to be
A General Outlook of Metabolic Disturbancies Leading to
Mental Retardation: Possible Central Role of the one Carbon
In a few preceding papers (Lejeune 1977, 1978), a general
representation of the chemical reactions going on inside the neurons was
presented in the form of a pseudo-pascalian machine. If the genetic diseases
actually known are reported on such a scheme, it becomes possible to state the
dynamic effect of each disturbance.
Curiously, the blocks are not located randomly on the machine but
cluster clearly in two regions: one is related to manufacture and disposal of
insulating substances, protecting the nervous network from short circuits. The
other is related to the production of the constitutive elements of the
membranes (glycoproteins and mucopolysaccharides).
As already discussed (Lejeune 1978), such a clustering is expected if
we consider that membrane efficiency on the one hand and reliable circuitry on
the other hand are two prerequisites for an engine able to simulate some of the
functions of the mind. Here, the analogy with computer is too obvious to be
However, a third group of points remains, rather scattered on the
machine and apparently entirely unrelated. This heteroclite sample includes,
for example: phenylketonuria, tyrosinosis, hypothyroidism, maple sirup disease,
homocystinuria, histidinemia, carnosinuria, hyperprolinemia (I and II),
hyperhydroxyprolinemia, iminodipeptiduria, nonketotic hyperglycinemia,
sarcasinemia, hypoxanthine-guanine phosphoribosyltransferase deficiency,
Interestingly enough, inspection of the machine shows that all these
various conditions could have a common consequence, a disturbance of the one
carbon cycle. A simplified, so to speak, diagram of the machine will
demonstrate this overall impression (Fig. l ).
Sarcosinemia, homocystinuria, and nonketotic glycinemia would
disequilibrate the 5-10 methylene-THF entry to the one carbon cycle as well as
the S-adenosylmethionine-methyltransferase system.
Histidinemia, and carnosinuria would deplete the formimino-THF
entries. The excessive synthesis of purines in hypaxanthine-guanine
phosphoribosyltransferase deficiency (Lesch-Nyhan disease), and Hartnup
disease, produce a relative depletion of the 10 formyl-THF.
The general result of prolinemia I and II, hyperhydroxyprolinemia, and
iminodipeptiduria is that all of then disequillbrate the glyoxylate metabolism
either by the loss of proline and hydroxyproline (iminodipeptiduria) or by a
deficiency of recuperation of glyoxylate from the catabolism of
Phenylketonuria, tyrosinosis, and maple sirup disease remain,
apparently quite distant from this system, but the fact that metabolites of
phenylalanine (Ulevitch and Kallen 1977) and of isoleucine (Hillman and Otto
1974) are strong competitive inhibitors of the serine transhydroxymethylase put
back the effect of these three diseases in the same part of the one carbon
cycle, the 5-10-methylene-THF entry. The sane effect is found in diseases
affecting the interconversions of the various forms of folate (Rows 1978).
As a very broad and very tentative hypothesis, it could be postulated
that in case of mental retardation in which there is no gross anatomic defect
of the brain, no obvious disturbance of the insulating substances, no
demonstrated abnormality of the membranes building blocks, a deficiency of the
one carbon cycle could be the most likely trouble to be looked for.
Coming back to the diagram, it can be outlined that a main stream
seems very sensitive: the recuperation of methyl from acetylcholine, the
methyltransferases, and the transformations, serine ? glycine ? glyoxal ?
?1-pyrrolin ? carboxylate (via ?-glutamic semialdehyde) to both
glutamate and proline metabolisms. A systematic analysis of trisomy 21 could be
tried, following these lines.
Fig. 1. - Simplified scheme of
the mechanisms discussed (after Lejeune 1979)
Special Pathology of Trisomic 21 Children
The Cholinergic System
To start with the acetylcholine manufacture and recuperation, a
first constatation is that trisomic 21 children are hypocholinergic. Their
hypersensitivity to atropine (Berg and Stern 1962; Harris and Goodman 1968) and
the pharmacologic sensitivity of their iris to various chalinomimetric and
cholinolytic drugs is amply established (Priest 1960). A constitutional
hypocholinergy is the simplest explanation of these findings (Bourdais 1973;
Lejeune et al.1976).
Remarkably, trisomic 21 adults are very prone to Alzheimer-like
presenile dementia (Jervis 1970) - even the ultrastructural anomaly of the
entangled neurofilaments is entirely comparable in both disease (Ellis et al.
1974) - and, as it is well-known, Alzheimer disease is also related to a
cholinergic abnormality (deficiency of acetylcholinesterase and of choline
acetyltransferase, Davies 1979).
Serine and Glycine Pathway
No obvious trouble is actually known in trisomy 21, but a few hints
are available. Compared to their healthy brothers and sisters, trisomic 21
patients have a slight but significant diminution of serine level in the blood
(Sinet 1972). They also show a slight increase of ethanolamine. It is worth
mentioning that an ethanolamine increase is found in sarcosinemia, which,
diminishes the reuptake of methyls from choline.
Glyoxylate is among the most versatile substances. Surely its
regulation is not normal in trisomy 21. For example, a tryptophan load (McCoy
1969; E. McCoy, personal communication) increases the urinary excretion of
oxalate (the end product of glyoxylate) in normal children much more than in
trisomic 21 children. Furthermore, if an artificial deficiency of vitamin B6
has been produced previously by deoxypyridoxine administration, the oxaluria
after tryptophan load becomes much more marked among trisomic 21 children than
It could very well be that glyoxylate metabolism in man could be of
a quantitative importance in the biosynthesis of nonessential aminoacids, such
as glutamate and proline as we will see later.
Glutamate and Proline Pathway
From experimental data already quoted (Sinet 1972), it was shown
that glutamate is significantly elevated in the blood of trisomic 21 patients
compared to their healthy sibs. This increase could be taken care of by
introduction of glutamate to the Krebs cycle, a possibility in accordance with
the fact that those with trisomy 21 excrete more urea than their normal sibs
(Jérôme et al. 1960; Sinet 1972) and possibily derive more energy from amino
acids compared to sugar than ordinarily expected.
For proline, not elevated in the blood of trisomic 21 patients, very
few experimental data are available. Nonessential amino acids are rarely
extensively studied, but three remarks are worthwhile.
Among the diseases producing disturbance of growth and morphology
comparable to trisomy 21, congenital hypothyroidism is preeminent with the
short stature, the short fingers, the broad rose and, of course, the mental
retardation. Besides trouble of combustion through FAD systems (a possible
analogy to the disturbed metabolism of O2- due to SODA in trisomy 21),
hypothyroidism implies a diminution of the synthesis of collagen from proline
and a diminution of elimination of hydroxyproline after pro-collagen or old
collagen has been disassembled during growth and the modeling process (Uitto et
Iminodipeptiduria is also very relevant here. Affected persons lack
prolidase activity and thus eliminate X-CO-NPRO and X-CO-NHYPRQ dipeptides that
they cannot cleave. Thus, they cannot recuperate the proline and OH proline
from used collagen or pro-collagen and daily loose some 40 mg of proline and
some 10 mg of hydroxyproline per kilo (Goodman et al. 1968; Jackson et al.
1975). Iminodipeptidurics have many morphological features in common with
trisomic 21 patients: the shortness of body and fingers, syndactyly between the
second and third toes, unique palmar crease, waddling gait, rough skin, and
Like those with trisomy 21, they are also very susceptible to
naso-pharynx infection. It has been postulated (Jackson et al. 1975) that this
sensitivity could be related to the fact that the C1q fraction of the
complement has a collagen-like polypeptide chain. An effect on the fixation of
other immunologic factors and a possible relation with the abnormal uptake to
serotonin (Jérôme and Kamoun 1960 and epinephrine (Jérôme and Kamoun 1970)
by the platelets of trisomic 21 patients has been discussed (Lejeune 1979).
As already mentioned, the platelets of trisomic 21 patients do not
take up serotonin as well as normals. A tentative treatment was tried to
palliate this defect. 5-Hydroxytryptophan was administered to trisomic 21
children and reported to increase their muscular tone (Coleman 1971).
Unfortunately, this medication turned out to be very toxic, producing
devastating hypsarythmia (West syndrome). These dramatic clinical results are
in accordance, possibly, with a maladjustment of the glyoxylate metabolism
Having thus followed the steps dictated by our general hypothesis,
we have effectively noted that each of then was likely to be perturbated
slightly in trisomy 21. No blockage has been noted, which was expected in a
case of excess of genetic material, but a dynamic disequilibrium is to be
suspected at each of these steps.
Homocystinuria remains, which is entirely dissimilar to trisomy 21
as already pointed out (Lejeune 1977) and, phenotypically speaking, quite the
countertype of it. If it is remembered that homocystinuria disturbs the
5-methyltransferase system that is the output of the one carbon cycle to the
manufacture of methylated neurotransmitters (acetylcholine among others), it
could very well be that the countertype aspect could be related to a
regulation, a feedback effect, on the ?1-pyrrolin carboxylate
pathway and the proline synthesis and incorporation; anyway, homocysteic acid
itself has been demonstrated stimulating the growth of the long bones (Lejeune
This general analysis of metabolic blocks known to produce mental
deficiency has focused our attention on the
choline-serine-glycine-glyoxylate-?1-pyrrolin carboxylate pathways
and their ultimate action on the one carbon cycle metabolism.
Concomitantly, a brief review of the special pathology of trisomy 21
has shown that each of these steps was possibly slightly abnormal in the
patients. A systematic investigation is clearly indicated.
"Le Superflu, Chose si Nécessaire"
It should be first remarked that the amino acids involved are all
nonessential, and it could be argued that nonessential products are not of an
obvious interest and that essential amino acids are much more important, as
demonstrated by phenylketonuria, (phenylalanine), Hartnup disease (tryptophan),
and maple sirup disease (leucine, isoleucine, valine), for example.
In case of genic dosage effect, I would be inclined to consider the
nonessential amino acids as the essential ones, for a very simple genetic
reason. The loss of a synthetic function (which makes a substance essential in
the food) is indeed an interesting economy made in the course of evolution.
Instead of spending energy to make a particular compound, the organism can thus
use its forces to a more interesting task, but such an economy is feasible only
if the diet can provide at the precise moment the rewired materials.
Let us consider a metabolite so important that its constant use must
be regulated with extreme precision, which cannot be stockpiled in an efficient
way, such as glucose in glycogen. Then the organism cannot indulge itself to
loose its synthesis function, under the risk of death.
It could thus very well be that the so-called nonessential building
blocks are in fact the very essential ones, and if we have retained the faculty
of their synthesis during the whole history of living systems, it is dust
because we could not afford to do otherwise.
A General Outlook
At this moment, it would be very tempting to try to relate the
disequilibrium noted in the
choline-serine-glycine-glyoxylate-?1-pyrrolin carboxylate pathway
to the shift of the oxygen metabolism due to the SODA excess and to the GSHPX
regulation. Although such a discussion has already been attempted (Lejeune
1979), it does not seem necessary to rely on such a unifying hypothesis.
Relations to the oxygen metabolism are indeed suggested by the
occurrence of many steps involving FAD-dependent reactions and the concomitant
02 ? H202 transformation. Also, the curious facial anomaly of children
suffering from compound hemoglobinopathies (Hashem. 1978), rendering newborns
rather comparable to trisomic 21 babies, points out the extreme importance of
However, so many discoveries remain to be made in this field before
acceptable models could be presented that another way of research should be
A Step-by-step Approach
Our attention being directed to metabolic pathways involving
nonessential amino acids, a very simple experiment would be to consider the
possible effect of increasing their availability by adding some of them to the
ordinary diet; an eventual effect would pinpoint a shift in their
Investigations are now in progress and it would be very premature to
derive final conclusions from the scanty data now available. Nevertheless, it
can be mentioned that the administration of 50 mg/kg/day of serine to trisomic
21 children does not produce, as expected, any unfavorable effect nor a fully
demonstrable clinical improvement. As demonstrated in a double-blind test, even
this extremely moderate alteration of the diet has a metabolic effect in
trisomic 21 children.
Compared to trisomic 21 children receiving only a placebo, the
trisomic 21 children heated with serine exhibited a significant rise (although
quite moderated) of their glutamate blood level. Such a result, in accordance
with the model discussed here, was not predicted by the conventional
Other experiments with special modification of the diet are easy to
imagine and some of them are actually in progress. It must be stressed clearly
that these laborious assays, very demanding to dedicated parents, are not to be
taken as therapeutic trials. These investigations are purely heuristics, at
least at present.
This very brief summary of the possible biochemical mechanisms
underlying the mental deficiency in trisomy 21 leads to few general
propositions for future research.
First, the one carbon cycle could be a central crossroad in most of
the severe disturbances of mental efficiency. This general statement suggested
by comparative pathogeny of various genetic diseases is possibly applicable
also to trisomy 21.
Secondly, a shift in the regulation of common, nonessential amino
acids should be looked for in trisomy 21. Again, comparative pathogeny clearly
points in that direction.
Thirdly, the relationship between these two general disequilibriums
and the perturbation of the oxygen metabolism remains to be carefully
As a conclusion, it could be ventured that future achievements in
these three areas could open new views on the general mechanisms of mental
retardation and lead some day to means of controlling directly or indirectly
these biochemical problems.
Indeed, the length of road to be covered before reaching such a goal
cannot be predicted, but to summarise the situation, I would like to quote a
famous phrase of Lyautey:
Arrivant au Maroc, il decida de fournir à la population un supplément
de ressources en étendant les palmeraies. "Mais, avant la premiere récolte de
ces palmiers-dattiers, il faudra bien vingt ans !" lui dit un spécialiste.
"Vingt ans ?" réplique Lyautey, "Alors, commençons tout de
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