Information on the following diseases can be found in the Related Disorders section of this report:

• Von Gierke Disease
• Andersen Disease
• Hers Disease
• Glycogen Storage Disease VIII

Symptoms of Forbes disease, at least during the first 4 to 6 years of life, may be indistinguishable from another of the glycogen storage diseases, Von Gierke disease. The amount of glycogen in the liver and muscles is abnormally high and, because the liver is enlarged (hepatomegaly), the abdomen protrudes. The muscles tend to be flaccid.

A child with Forbes disease has a short stature, low blood sugar (hypoglycemia) that does not respond to the hormone glucagon, and an elevated level of fatty substances in the blood, known as hyperlipemia. Patients with Forbes disease may also have difficulty fighting infections, and may experience unusually frequent nosebleeds.

Some other individuals may have virtually no symptoms (asymptomatic) other than a protruding abdomen and an enlarged liver. These patients tend to lose these few symptoms during adolescence when their liver decreases progressively in size. Children with Forbes disease often grow slowly during childhood and puberty may be delayed, but their adult height is usually normal.
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The defective gene responsible for GSD-III has been traced to Gene Map Locus 1p21, and the disorder is transmitted as an autosomal recessive trait. It is caused by lack of a debrancher enzyme (amylo-1,6-glucosidase) which is involved in the formation of the stored form of carbohydrates (glycogen). Glycogen is stored in the liver and muscles for future energy needs when it is converted into sugar (glucose). Glucose is used as a readily available source of energy. Without the debrancher enzyme, glycogen can only be broken down partially and the structure that is left, resembling a molecule called a "limit dextrin", accumulates in liver and muscle tissues.

Human traits, including the classic genetic diseases, are the product of the interaction of two genes for that condition, one received from the father and one from the mother. In recessive disorders, the condition does not appear unless a person inherits the same defective gene for the same trait from each parent. If an individual receives one normal gene and one gene for the disease, the person will be a carrier for the disease, but usually will not show symptoms. The risk of transmitting the disease to the children of a couple, both of whom are carriers for a recessive disorder, is 25 percent. Fifty percent of their children risk being carriers of the disease, but generally will not show symptoms of the disorder. Twenty-five percent of their children may receive both normal genes, one from each parent, and will be genetically normal (for that particular trait). The risk is the same for each pregnancy.

All individuals carry 4-5 abnormal genes. Parents who are close relatives (consanguineous) have a higher chance than unrelated parents to both carry the same abnormal gene, which increases the risk to have children with a recessive genetic disorder.
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All glycogen storage diseases together affect less than 1 in 40,000 persons in the United States. Forbes disease usually begins during childhood. It affects males as often as females. Patients with this disorder reported in Israel were generally of North African heritage.

Glycogen storage diseases involve inborn errors of metabolism in which the balance between stored energy (glycogen), and available energy (sugar or glucose), is disturbed. Too much glycogen tends to be stored in the liver and muscles, and too little sugar is available in the blood.

The following diseases are similar to Forbes disease. These can be compared with Forbes Disease for a differential diagnosis:

Von Gierke disease is a more severe form of glycogen storage disease. It is a hereditary metabolic disorder caused by an inborn lack of either the enzyme glucose-6-phosphatase or the enzyme glucose-6-phosphate translocase. These enzymes are needed to convert the main carbohydrate storage material (glycogen) into sugar (glucose) which the body uses for its energy needs. A deficiency of these enzymes causes abnormal deposits of glycogen in the liver and kidney cells.

Andersen disease is a glycogen storage disease inherited through recessive genes. Symptoms of this disorder are caused by a lack of a brancher enzyme amylo transglucosidase. The lack of this enzyme causes an abnormality in the structure of the main carbohydrate storage material (glycogen). Andersen Disease is characterized by scarring of the liver (cirrhosis) which may lead to liver failure.

Hers disease is a mild genetic form of glycogen storage disease. The disorder is caused by a deficiency of the enzyme liver phosphorylase. Hers Disease is characterized by enlargement of the liver (hepatomegaly), moderately low blood sugar (hypoglycemia), elevated levels of acetone and other ketone bodies in the blood (ketosis), and moderate growth retardation. Symptoms are not always evident during childhood. Children are able to lead normal lives. In other cases, severe symptoms may be present.

Glycogen storage disease VIII is a sex-linked genetic disorder caused by a deficiency of the enzyme liver phosphorylase kinase. The disorder is characterized by slightly low blood sugar (hypoglycemia). Excess amounts of glycogen (the stored form of energy that comes from carbohydrates) are deposited in the liver, causing enlargement of the liver (hepatomegaly).

For more information on the above disorders, choose "Von Gierke," "Andersen," "Hers," and "Glycogen Storage VIII" as your search terms in the Rare Disease Database.

Diagnosis
The presence of Forbes disease is definitive if testing liver and muscle tissues (biopsies) for abnormal glycogen and debrancher enzyme is positive. White blood cells and connective tissue cells called fibroblasts can also be useful as a screen, but may not provide a definitive diagnosis.

Treatment
Forbes disease is treated by continuous glucose delivery (intravenous drip) in order to avoid low blood sugar (hypoglycemia). Frequent small servings of carbohydrates and a high protein diet are advised during the day. At night, continuous tube feeding of food solutions such as Vivonex or polyglucose (glucose) may be administered to promote normal childhood growth.

Genetic counseling is helpful for families of children with Forbes disease and other glycogen storage diseases. People with this disorder can expect to live a normal life span. However, muscle disorders may develop with age.
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Dr. Y.T. Chen at Duke University Medical Center, at the request of the Glycogen Storage Disease Association, is collecting DNA from patients with Glycogen Storage Disease Type I to form a DNA bank for GSDI. Interested patients may contact the Glycogen Storage Diseases Association for further information. The address and phone number of the organization are listed in the Resources section of this report.

McKusick VA, Ed. ONLINE MENDELIAN INHERITANCE IN MAN (OMIM). The Johns Hopkins University. Entry Number; 232400: Last Edit Date; 6/4/2002.

TEXTBOOKS
Weinstein DA, Koeberl DD, Wolfsdorf JI. Type III Glycogen Storage Disease. In: NORD Guide to Rare Disorders. Lippincott Williams & Wilkins. Philadelphia, PA. 2003:453.

Beers MH, Berkow R., eds. The Merck Manual, 17th ed. Whitehouse Station, NJ: Merck Research Laboratories; 1999:2387-89.

Berkow R., ed. The Merck Manual-Home Edition. Whitehouse Station, NJ: Merck Research Laboratories; 1997:1291-92.

Chen YT, Burchell A. Glycogen Storage Diseases. In: Scriver CR, Beaudet AL, Sly WS, et al. Eds. The Metabolic Molecular Basis of Inherited Disease. 7th ed. McGraw-Hill Companies. New York, NY; 1995:935-65.

Greene HL. Glycogen Storage Diseases. In: Bennett JC, Plum F. Eds. Cecil Textbook of Medicine. 20th ed. W.B. Saunders Co., Philadelphia, PA; 1996:1082-83.

REVIEW ARTICLES
Shen JJ, Chen YT. Molecular characterization of glycogen storage disease type III. Curr Mol Med. 2002;2:167-75.

Matern D, Starzl TE, Arnaout W, et al. Liver transplantation for glycogen storage disease types I, III, and IV. Eur J Pediatr. 1999;158 Suppl 2:S43-48.

JOURNAL ARTICLES
Lucchiari S, Donati MA, Parini R, et al. Molecular characterization and identification of six novel mutations in AGL. Hum Mutat. 2002;20:480.

OKI Y, Okubo M, Tanaka S, et al. Diabetes mellitus secondary to glycogen storage disease type III. Diabet Med. 2000;17:810-12.

Hershkovitz E, Donald A, Mullen M, et al. Blood lipids and endothelial function in glycogen storage disease type III. J Inherit Metab Dis. 1999;22:891-98.

Kiechl S, Willen J, Vogel W, et al. Reversible severe myopathy of respiratory muscles due to adult-onset type III glycogenosis. Neuromuscul Dis. 1999;9:408-10.

Kiechl S, Kohlendorfer U, Thaler C, et al. Different clinical aspects of debrancher deficiency myopathy. J Neurol Neurosurg Psychiatry. 1999;67:364-68.

Shen J, Liu HM, McConkie-Rosell A, et al. Prenatal diagnosis and carrier detection for glycogen storage disease type III using polymorphic DNA markers. Prenat Diagn. 1998;18:61-64.

FROM THE INTERNET
Sloan HR. Glycogen Storage Disease Type III. eMedicine. Last Updated; January 17, 2003. 23pp.
www.emedicine.com/ped/topic479.htm

Anderson WE. Glycogen Storage Disease Type III. eMedicine. Last Updated; December 27, 2001. 8pp.
www.wmedicine.com/med/topic909.htm

Glycogen Storage Disease Type III. Last Modified;11 Feb 1996. 2pp.
http://oxmedinfo.jr2.ox.ca.uk/Pathway/Disease/83994.htm

Glycogen Storage Disease Laboratory, Duke University Medical Center. Glycogen Storage Disease Type III. Dated; 17 Oct. 2001. 1p.
www.duke.edu/~mdfeezor/dukemedicalgenetics/gsdiii.htm