Hurler syndrome (252800) is caused by a deficiency of L-iduronidase, an enzyme normally expressed in most human cell types. It was demonstrated by Neufeld that exogenous L-iduronidase could be taken up by deficient cells via a targeting signal that directed the enzyme to its normal lysosomal location. Which of the following therapeutic strategies is the most realistic and efficient mode of therapy?
1.Injection with L-iduronidase purified form human liver
2.Germ line gene therapy
3.Autologous bone marrow transplant after transfection with a virus carrying the L iduronidase gene
4.Heterologous bone marrow transplant
5.Infection with a disabled adenovirus vector that carries the Liduronidase gene
All of the modes of therapy are theoretically possible, and enzyme therapy (i.e., injection of purified enzyme) has been successful in several lysosomal deficiencies, particularly those in which the central nervous system is not affected [i.e., Gaucher disease (231000)]. Unfortunately, antibodies frequently develop to the injected enzyme and limit the term of successful enzyme delivery. Heterologous bone marrow transplant, preferably from a related donor, offers the most realistic and effective therapy since the graft provides a permanent source of enzyme. Bone marrow transplants do have a 10% mortality, however, and the enzyme diffuses poorly into the central nervous system. Somatic gene therapy (i.e., delivery of enzyme to somatic cells via viral vectors or transfected tissue) is now possible; however, targeting of the gene product to appropriate tissues and organelles is still a problem. Transfected autologous bone marrow transplant (i.e., marrow from the patient) has been used in a few cases of adenosine deaminase deficiency, an immune disorder affecting lymphocytes. Germ-line gene therapy requires the insertion of functional genes into gametes or blastomeres of early embryos prior to birth. The potential for embryonic damage, lack of knowledge regarding developmental gene control, and ethical controversies regarding selective breeding or embryo experimentation make germ-line therapy unrealistic at present.