Dear Editor,In the present study, we delineate the molecular pathways underlying atypical progressions of Gaucher disease (GD) that lead to unresponsiveness to enzyme replacement therapy (ERT). Specifically, we observed the accumulation of dense substrates (e.g., glucosylsphingosine [Lyso-Gb1]), which was associated with alterations in complement activity, autophagy metabolism, macrophage polarization and TGF-β signaling and subsequent endothelialto-mesenchymal transition (EndMT) and fibrosis. We also describe the potential therapeutic role of ambroxol, a chemical chaperone in GD, and highlight the need for a multi-functional therapeutic approach in managing GD cases with atypical progression.GD is caused by the deficiency of glucocerebrosidase (GCase) encoded by the glucocerebrosidase1 gene, which leads to the accumulation of glucosylceramide and Lyso-Gb1 in the lysosome. Specifically, Lyso-Gb1 plays important pathogenic roles in GD such as inflammation, impairment of cytoplasmic division, alteration of immune regulation and neurotoxicity. 1-3 GD can be categorized according to the degree of neurologic involvement: non-neuropathic (GD1), acute neuronopathic (GD2) and chronic neuronopathic (GD3). Since the advent of ERT, the clinical outcomes of patients with GD have improved remarkably; however, despite ERT, most GD2/3 patients as well as some GD1 patients show atypical manifestations such as lymphadenopathy, multiple myeloma, lymphoma, neurological deterioration and increases in Lyso-Gb1 levels. 4 The molecular mechanism underlying atypical responses to ERT is poorly understood.We evaluated the histological features of lymph nodes from three patients with GD, including submandibular lymph node from Pt1 (GD1, G85E/F252I), stomach lymph node from Pt2 (GD1, R87W/R296Q) and mesenteric lymph node from Pt3 (GD3, L483P/L483P) (Table S1). Despite 5 years of ERT, Pt3 died from progressiveThis is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.