Medscape is available in 5 Language Editions – Choose your Edition here.


Type IV Glycogen Storage Disease

  • Author: Wayne E Anderson, DO, FAHS, FAAN; Chief Editor: George T Griffing, MD  more...
Updated: Apr 25, 2014


A glycogen storage disease (GSD) is the result of an enzyme defect. These enzymes normally catalyze reactions that ultimately convert glycogen compounds to glucose. Enzyme deficiency results in glycogen accumulation in tissues. In many cases, the defect has systemic consequences, but in some cases, the defect is limited to specific tissues. Most patients experience muscle symptoms such as weakness and cramps, although certain GSDs manifest as specific syndromes, such as hypoglycemic seizures or cardiomegaly.[1]

The diagram below illustrates metabolic pathways of carbohydrates.

Metabolic pathways of carbohydrates. Metabolic pathways of carbohydrates.

The following list contains a quick reference for 8 of the GSD types:

  • 0 - Glycogen synthase deficiency
  • Ia - Glucose-6-phosphatase deficiency (von Gierke disease)
  • II - Acid maltase deficiency (Pompe disease)
  • III - Debranching enzyme deficiency (Forbes-Cori disease)
  • IV - Transglucosidase deficiency (Andersen disease, amylopectinosis)
  • V - Myophosphorylase deficiency (McArdle disease)
  • VI - Phosphorylase deficiency (Hers disease)
  • VII - Phosphofructokinase deficiency (Tarui disease)

Although at least 14 unique GSDs are discussed in the literature, the 4 that cause clinically significant muscle weakness are Pompe disease (GSD type II, acid maltase deficiency), Cori disease (GSD type III, debranching enzyme deficiency), McArdle disease (GSD type V, myophosphorylase deficiency), and Tarui disease (GSD type VII, phosphofructokinase deficiency). One form, von Gierke disease (GSD type Ia, glucose-6-phosphatase deficiency), causes clinically significant end-organ disease with significant morbidity. The remaining GSDs are not benign but are less clinically significant; therefore, the physician should consider the aforementioned GSDs when initially entertaining the diagnosis of a GSD. Interestingly, GSD type 0, which is due to defective glycogen synthase, is also recognized.

These inherited enzyme defects usually present in childhood, although some, such as McArdle disease and Pompe disease, have separate adult-onset forms. In general, GSDs are inherited as autosomal-recessive conditions. Several different mutations have been reported for each disorder.

Unfortunately, no specific treatment or cure exists, although diet therapy may be highly effective at reducing clinical manifestations. In some cases, liver transplantation may abolish biochemical abnormalities. Active research continues.

Diagnosis depends on patient history and physical examination, muscle biopsy, electromyelography, ischemic forearm test, and creatine kinase level. Biochemical assay for enzyme activity is the method of definitive diagnosis.

Branching enzyme defect results in an abnormal glycogen structure that is unique to Andersen disease (GSD type IV). Clinically, hepatosplenomegaly, cirrhosis of the liver, and hepatic failure are major concerns.



Transglucosidase, which is found in all tissues, is deficient. The condition is autosomal recessive. Due to abnormal glycogen, hepatic deposition may occur and result in severe cirrhosis, hepatic failure, or neuromuscular failure. It also can present as abnormal liver function tests in its mildest presentation.

Cardiac and skeletal muscle may show PAS+ eosinophilic cytoplasmic inclusions.

Bruno and colleagues, Janecke et al, and others have demonstrated several novel mutations of the branching enzyme gene resulting in GSD IV.[2, 3, 4, 5]

Lamperti et al noted a novel mutation in an infant who died at age 1 month of cardiorespiratory failure.[6] The branching enzyme gene sequence was found to contain a homozygous nonsense mutation, p.E152X, in exon 4, that correlated with a virtual absence of branching enzyme biochemical activity in muscles and fibroblasts, as well as with a complete absence of such activity in the liver and heart.

The infant presented with symptoms consistent with congenital GSD IV, including severe hypotonia, dilatative cardiomyopathy, mild hepatopathy, and brain lateral ventricle hemorrhage. Muscle, heart, and liver specimens contained numerous vacuoles filled with PAS+ diastase-resistant materials, while electron microscopy revealed polyglucosan accumulations in all of the examined tissues. Polyglucosan was also found in vacuolated neurons.





Herling and colleagues studied the incidence and frequency of inherited metabolic conditions in British Columbia. GSDs are found in 2.3 children per 100,000 births per year. GSD IV is very rare.


Serious morbidities include hepatic failure, hepatosplenomegaly, and cardiomyopathy (less frequent).


In general, GSDs present in childhood. Later onset correlates with a less severe form. Liver failure may occur in the first 5 years of life due to deposition of glycogen.

Contributor Information and Disclosures

Wayne E Anderson, DO, FAHS, FAAN Assistant Professor of Internal Medicine/Neurology, College of Osteopathic Medicine of the Pacific Western University of Health Sciences; Clinical Faculty in Family Medicine, Touro University College of Osteopathic Medicine; Clinical Instructor, Departments of Neurology and Pain Management, California Pacific Medical Center

Wayne E Anderson, DO, FAHS, FAAN is a member of the following medical societies: California Medical Association, American Headache Society, San Francisco Medical Society, San Francisco Medical Society, International Headache Society, California Neurology Society, San Francisco Neurological Society, American Academy of Neurology, California Medical Association

Disclosure: Received honoraria from Teva for speaking and teaching; Received grant/research funds from Allergan for other; Received honoraria from Insys for speaking and teaching; Received honoraria from DepoMed for speaking and teaching.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Kent Wehmeier, MD Professor, Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, St Louis University School of Medicine

Kent Wehmeier, MD is a member of the following medical societies: American Society of Hypertension, Endocrine Society, International Society for Clinical Densitometry

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, International Society for Clinical Densitometry, Southern Society for Clinical Investigation, American College of Medical Practice Executives, American Association for Physician Leadership, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

  1. Froissart R, Piraud M, Boudjemline AM, Vianey-Saban C, Petit F, Hubert-Buron A, et al. Glucose-6-phosphatase deficiency. Orphanet J Rare Dis. 2011 May 20. 6:27. [Medline]. [Full Text].

  2. Bruno C, van Diggelen OP, Cassandrini D, et al. Clinical and genetic heterogeneity of branching enzyme deficiency (glycogenosis type IV). Neurology. 2004 Sep 28. 63(6):1053-8. [Medline].

  3. Janecke AR, Dertinger S, Ketelsen UP, et al. Neonatal type IV glycogen storage disease associated with "null" mutations in glycogen branching enzyme 1. J Pediatr. 2004 Nov. 145(5):705-9. [Medline].

  4. Fernandez C, Halbert C, De Paula AM, et al. Non-lethal neonatal neuromuscular variant of glycogenosis type IV with novel GBE1 mutations. Muscle Nerve. 2009 Oct 7. [Medline].

  5. Nolte KW, Janecke AR, Vorgerd M, et al. Congenital type IV glycogenosis: the spectrum of pleomorphic polyglucosan bodies in muscle, nerve, and spinal cord with two novel mutations in the GBE1 gene. Acta Neuropathol. 2008 Nov. 116(5):491-506. [Medline].

  6. Lamperti C, Salani S, Lucchiari S, et al. Neuropathological study of skeletal muscle, heart, liver, and brain in a neonatal form of glycogen storage disease type IV associated with a new mutation in GBE1 gene. J Inherit Metab Dis. 2009 Apr 8. [Medline].

  7. Sansone V, Griggs RC, Meola G. Andersen''s syndrome: a distinct periodic paralysis. Ann Neurol. 1997 Sep. 42(3):305-12. [Medline].

  8. Shen J, Liu HM, McConkie-Rosell A. Prenatal diagnosis of glycogen storage disease type IV using PCR-based DNA mutation analysis. Prenat Diagn. 1999 Sep. 19(9):837-9. [Medline].

  9. Akman HO, Karadimas C, Gyftodimou Y, Grigoriadou M, Kokotas H, Konstantinidou A. Prenatal diagnosis of glycogen storage disease type IV. Prenat Diagn. 2006 Oct. 26(10):951-5. [Medline].

  10. Zingone A, Hiraiwa H, Pan CJ. Correction of glycogen storage disease type 1a in a mouse model by gene therapy. J Biol Chem. 2000 Jan 14. 275(2):828-32. [Medline].

  11. Bijvoet AG, Van Hirtum H, Vermey M. Pathological features of glycogen storage disease type II highlighted in the knockout mouse model. J Pathol. 1999 Nov. 189(3):416-24. [Medline].

  12. Ewert R, Gulijew A, Wensel R. [Glycogenosis type IV as a seldom cause of cardiomyopathy - report about a successful heart transplantation]. Z Kardiol. 1999 Oct. 88(10):850-6. [Medline].

  13. Matern D, Starzl TE, Arnaout W. Liver transplantation for glycogen storage disease types I, III, and IV. Eur J Pediatr. 1999 Dec. 158 Suppl 2:S43-8. [Medline].

  14. Amato AA. Acid maltase deficiency and related myopathies. Neurol Clin. 2000 Feb. 18(1):151-65. [Medline].

  15. Aminoff MJ. Electromyography in Clinical Practice. 3rd ed. New York, NY: Churchill Livingstone; 1998.

  16. Applegarth DA, Toone JR, Lowry RB. Incidence of inborn errors of metabolism in British Columbia, 1969-1996. Pediatrics. 2000 Jan. 105(1):e10. [Medline].

  17. Bao Y, Kishnani P, Wu JY. Hepatic and neuromuscular forms of glycogen storage disease type IV caused by mutations in the same glycogen-branching enzyme gene. J Clin Invest. 1996 Feb 15. 97(4):941-8. [Medline].

  18. Chan YJ, Lin SP, Chen BF. Glycogen storage disease type IV: a case report. Chung Hua I Hsueh Tsa Chih (Taipei). 1999 Oct. 62(10):743-7. [Medline].

  19. Chen Y. Glycogen Storage Diseases. Scriver CR, Beaudet AL, Sly WS, Valle D, eds. The Metabolic and Molecular Basis of Inherited Disease. 8th ed. New York, NY: McGraw-Hill; 2001. 1521-51.

  20. Giuffre B, Parinii R, Rizzuti T, et al. Severe neonatal onset of glycogenosis type IV: clinical and laboratory findings leading to diagnosis in two siblings. J Inherit Metab Dis. 2004. 27(5):609-19. [Medline].

  21. Goldberg T, Slonim AE. Nutrition therapy for hepatic glycogen storage diseases. J Am Diet Assoc. 1993 Dec. 93(12):1423-30. [Medline].

  22. Orho M, Bosshard NU, Buist NR. Mutations in the liver glycogen synthase gene in children with hypoglycemia due to glycogen storage disease type 0. J Clin Invest. 1998 Aug 1. 102(3):507-15. [Medline].

  23. Selby R, Starzl TE, Yunis E. Liver transplantation for type I and type IV glycogen storage disease. Eur J Pediatr. 1993. 152 Suppl 1:S71-6. [Medline].

  24. Selby R, Starzl TE, Yunis E. Liver transplantation for type IV glycogen storage disease. N Engl J Med. 1991 Jan 3. 324(1):39-42. [Medline].

  25. Smit GP, Fernandes J, Leonard JV. The long-term outcome of patients with glycogen storage diseases. J Inherit Metab Dis. 1990. 13(4):411-8. [Medline].

  26. Stevens AN, Iles RA, Morris PG. Detection of glycogen in a glycogen storage disease by 13C nuclear magnetic resonance. FEBS Lett. 1982 Dec 27. 150(2):489-93. [Medline].

  27. Takahashi T, Tandai S, Toki T, et al. KCNJ2 mutation in intractable ventricular arrhythmia with Andersen's syndrome. Pediatr Int. 2005 Apr. 47(2):220-3. [Medline].

  28. Wolfsdorf JI, Holm IA, Weinstein DA. Glycogen storage diseases. Phenotypic, genetic, and biochemical characteristics, and therapy. Endocrinol Metab Clin North Am. 1999 Dec. 28(4):801-23. [Medline].

Metabolic pathways of carbohydrates.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.