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Batllori M, Molero-Luis M, Ormazabal A, Montero R, Sierra C, Ribes A, Montoya J, Ruiz-Pesini E, O'Callaghan M, Pias L, Nascimento A, Palau F, Armstrong J, Yubero D, Ortigoza-Escobar JD, García-Cazorla A, Artuch R. Cerebrospinal fluid monoamines, pterins, and folate in patients with mitochondrial diseases: systematic review and hospital experience. J Inherit Metab Dis 2018; 41:1147-1158. [PMID: 29974349 DOI: 10.1007/s10545-018-0224-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/18/2018] [Accepted: 06/20/2018] [Indexed: 10/28/2022]
Abstract
Mitochondrial diseases are a group of genetic disorders leading to the dysfunction of mitochondrial energy metabolism pathways. We aimed to assess the clinical phenotype and the biochemical cerebrospinal fluid (CSF) biogenic amine profiles of patients with different diagnoses of genetic mitochondrial diseases. We recruited 29 patients with genetically confirmed mitochondrial diseases harboring mutations in either nuclear or mitochondrial DNA (mtDNA) genes. Signs and symptoms of impaired neurotransmission and neuroradiological data were recorded. CSF monoamines, pterins, and 5-methyltetrahydrofolate (5MTHF) concentrations were analyzed using high-performance liquid chromatography with electrochemical and fluorescence detection procedures. The mtDNA mutations were studied by Sanger sequencing, Southern blot, and real-time PCR, and nuclear DNA was assessed either by Sanger or next-generation sequencing. Five out of 29 cases showed predominant dopaminergic signs not attributable to basal ganglia involvement, harboring mutations in different nuclear genes. A chi-square test showed a statistically significant association between high homovanillic acid (HVA) values and low CSF 5-MTHF values (chi-square = 10.916; p = 0.001). Seven out of the eight patients with high CSF HVA values showed cerebral folate deficiency. Five of them harbored mtDNA deletions associated with Kearns-Sayre syndrome (KSS), one had a mitochondrial point mutation at the mtDNA ATPase6 gene, and one had a POLG mutation. In conclusion, dopamine deficiency clinical signs were present in some patients with mitochondrial diseases with different genetic backgrounds. High CSF HVA values, together with a severe cerebral folate deficiency, were observed in KSS patients and in other mtDNA mutation syndromes.
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Affiliation(s)
- Marta Batllori
- Clinical Biochemistry, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Marta Molero-Luis
- Clinical Biochemistry, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Aida Ormazabal
- Clinical Biochemistry, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
- CIBERER, Instituto de Salud Carlos III, Barcelona, Spain
| | - Raquel Montero
- Clinical Biochemistry, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
- CIBERER, Instituto de Salud Carlos III, Barcelona, Spain
| | - Cristina Sierra
- Clinical Biochemistry, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Antonia Ribes
- CIBERER, Instituto de Salud Carlos III, Barcelona, Spain
- Institut de Bioquímica Clínica-Corporació Sanitaria Clínic, Barcelona, Spain
| | - Julio Montoya
- CIBERER, Instituto de Salud Carlos III, Barcelona, Spain
- Biochemistry, Cellular and Molecular Biology Department, Universidad de Zaragoza, Zaragoza, Spain
| | - Eduardo Ruiz-Pesini
- CIBERER, Instituto de Salud Carlos III, Barcelona, Spain
- Biochemistry, Cellular and Molecular Biology Department, Universidad de Zaragoza, Zaragoza, Spain
| | - Mar O'Callaghan
- CIBERER, Instituto de Salud Carlos III, Barcelona, Spain
- Pediatric Neurology, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Leticia Pias
- Pediatric Neurology, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Andrés Nascimento
- CIBERER, Instituto de Salud Carlos III, Barcelona, Spain
- Pediatric Neurology, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Francesc Palau
- CIBERER, Instituto de Salud Carlos III, Barcelona, Spain
- Genetics Department, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Judith Armstrong
- CIBERER, Instituto de Salud Carlos III, Barcelona, Spain
- Genetics Department, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Delia Yubero
- CIBERER, Instituto de Salud Carlos III, Barcelona, Spain
- Genetics Department, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | | | - Angels García-Cazorla
- CIBERER, Instituto de Salud Carlos III, Barcelona, Spain
- Pediatric Neurology, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Rafael Artuch
- Clinical Biochemistry, Institut de Recerca Sant Joan de Déu, Barcelona, Spain.
- CIBERER, Instituto de Salud Carlos III, Barcelona, Spain.
- Clinical Biochemistry Department, IRSJD and CIBERER, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu, 2., 08950, Esplugues de Llobregat, Barcelona, Spain.
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Abstract
Vitamin-dependent epilepsies and multiple metabolic epilepsies are amenable to treatment that markedly improves the disease course. Knowledge of these amenably treatable severe pediatric epilepsies allows for early identification, testing, and treatment. These disorders present with various phenotypes, including early onset epileptic encephalopathy (refractory neonatal seizures, early myoclonic encephalopathy, and early infantile epileptic encephalopathy), infantile spasms, or mixed generalized seizure types in infancy, childhood, or even adolescence and adulthood. The disorders are presented as vitamin responsive epilepsies such as pyridoxine, pyridoxal-5-phosphate, folinic acid, and biotin; transportopathies like GLUT-1, cerebral folate deficiency, and biotin thiamine responsive disorder; amino and organic acidopathies including serine synthesis defects, creatine synthesis disorders, molybdenum cofactor deficiency, and cobalamin deficiencies; mitochondrial disorders; urea cycle disorders; neurotransmitter defects; and disorders of glucose homeostasis. In each case, targeted intervention directed toward the underlying metabolic pathophysiology affords for the opportunity to significantly effect the outcome and prognosis of an otherwise severe pediatric epilepsy.
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Affiliation(s)
- Phillip L Pearl
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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Quijada-Fraile P, O'Callaghan M, Martín-Hernández E, Montero R, Garcia-Cazorla À, de Aragón AM, Muchart J, Málaga I, Pardo R, García-Gonzalez P, Jou C, Montoya J, Emperador S, Ruiz-Pesini E, Arenas J, Martin MA, Ormazabal A, Pineda M, García-Silva MT, Artuch R. Follow-up of folinic acid supplementation for patients with cerebral folate deficiency and Kearns-Sayre syndrome. Orphanet J Rare Dis 2014; 9:217. [PMID: 25539952 PMCID: PMC4302586 DOI: 10.1186/s13023-014-0217-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 12/18/2014] [Indexed: 01/09/2023] Open
Abstract
Background Kearns-Sayre syndrome (KSS) is a mitochondrial DNA deletion syndrome that presents with profound cerebral folate deficiency and other features. Preliminary data support the notion that folinic acid therapy might be useful in the treatment of KSS patients. Our aim was to assess the clinical and neuroimaging outcomes of KSS patients receiving folinic acid therapy. Methods Patients: We recruited eight patients with diagnoses of KSS. Four cases were treated at 12 de Octubre Hospital, and the other two cases were treated at Sant Joan de Déu Hospital. Two patients refused to participate in the treatment protocol. Methods: Clinical, biochemical and neuroimaging data (magnetic resonance imaging or computed tomography scan) were collected in baseline conditions and at different time points after the initiation of therapy. Cerebrospinal fluid 5-methyltetrahydrofolate levels were analysed with HPLC and fluorescence detection. Large-scale mitochondrial DNA deletions were analysed by Southern blot. Treatment protocol: The follow-up periods ranged from one to eight years. Cases 1–4 received oral folinic acid at a dose of 1 mg/kg/day, and cases 6 and 8 received 3 mg/kg/day. Results No adverse effects of folinic acid treatment were observed. Cerebral 5-methyltetrahydrofolate deficiencies were observed in all cases in the baseline conditions. Moreover, all three patients who accepted lumbar puncture after folinic acid therapy exhibited complete recoveries of their decreased basal cerebrospinal fluid 5-methyltetrahydrofolate levels to normal values. Two cases neurologically improved after folinic therapy. Disease worsened in the other patients. Post-treatment neuroimaging was performed for the 6 cases that received folinic acid therapy. One patient exhibited improvements in white matter abnormalities. The remaining patients displayed progressions in subcortical cerebral white matter, the cerebellum and cerebral atrophy. Conclusions Four patients exhibited clinical and radiological progression of the disease following folinic acid treatment. Only one patient who was treated in an early stage of the disease exhibited both neurological and radiological improvements following elevated doses of folinic acid, and an additional patient experienced neurological improvement. Early treatment with high-dose folinic acid therapy seems to be advisable for the treatment of KSS. Trial registration EudracT2007-00-6748-23 Electronic supplementary material The online version of this article (doi:10.1186/s13023-014-0217-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pilar Quijada-Fraile
- Unidad de Enfermedades Mitocondriales-Enfermedades Metabólicas Hereditarias. Dpto. de Pediatría y Radiología, Hospital 12 de Octubre, Madrid, Spain.
| | - Mar O'Callaghan
- Pediatric Neurology, Clinical Biochemistry, Histopathology and Radiology Departments, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu, 2., Esplugues, Barcelona, 08950, Spain.
| | - Elena Martín-Hernández
- Unidad de Enfermedades Mitocondriales-Enfermedades Metabólicas Hereditarias. Dpto. de Pediatría y Radiología, Hospital 12 de Octubre, Madrid, Spain.
| | - Raquel Montero
- Centre For research in rare diseases (CIBERER), Institut de Salud Carlos III, Madrid, Spain. .,Pediatric Neurology, Clinical Biochemistry, Histopathology and Radiology Departments, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu, 2., Esplugues, Barcelona, 08950, Spain.
| | - Àngels Garcia-Cazorla
- Centre For research in rare diseases (CIBERER), Institut de Salud Carlos III, Madrid, Spain. .,Pediatric Neurology, Clinical Biochemistry, Histopathology and Radiology Departments, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu, 2., Esplugues, Barcelona, 08950, Spain.
| | - Ana Martínez de Aragón
- Unidad de Enfermedades Mitocondriales-Enfermedades Metabólicas Hereditarias. Dpto. de Pediatría y Radiología, Hospital 12 de Octubre, Madrid, Spain.
| | - Jordi Muchart
- Pediatric Neurology, Clinical Biochemistry, Histopathology and Radiology Departments, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu, 2., Esplugues, Barcelona, 08950, Spain.
| | - Ignacio Málaga
- Servicio de Pediatría, Hospital Universitario Central de Asturias, Oviedo, Spain.
| | - Rafael Pardo
- Servicios de Pediatría y Radiología, Hospital de Cabueñes, Asturias, Spain.
| | | | - Cristina Jou
- Pediatric Neurology, Clinical Biochemistry, Histopathology and Radiology Departments, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu, 2., Esplugues, Barcelona, 08950, Spain.
| | - Julio Montoya
- Centre For research in rare diseases (CIBERER), Institut de Salud Carlos III, Madrid, Spain. .,Departamento de Bioquímica, Biología Molecular y Celular, Universidad de Zaragoza, Instituto Aragonés de Ciencias de la Salud, Zaragoza, Spain.
| | - Sonia Emperador
- Departamento de Bioquímica, Biología Molecular y Celular, Universidad de Zaragoza, Instituto Aragonés de Ciencias de la Salud, Zaragoza, Spain.
| | - Eduardo Ruiz-Pesini
- Centre For research in rare diseases (CIBERER), Institut de Salud Carlos III, Madrid, Spain. .,Departamento de Bioquímica, Biología Molecular y Celular, Universidad de Zaragoza, Instituto Aragonés de Ciencias de la Salud, Zaragoza, Spain.
| | - Joaquín Arenas
- Centre For research in rare diseases (CIBERER), Institut de Salud Carlos III, Madrid, Spain. .,Mitochondrial Diseases Laboratory, Hospital 12 de Octubre Research Institute (i + 12), Madrid, Spain.
| | - Miguel Angel Martin
- Centre For research in rare diseases (CIBERER), Institut de Salud Carlos III, Madrid, Spain. .,Mitochondrial Diseases Laboratory, Hospital 12 de Octubre Research Institute (i + 12), Madrid, Spain.
| | - Aida Ormazabal
- Centre For research in rare diseases (CIBERER), Institut de Salud Carlos III, Madrid, Spain. .,Pediatric Neurology, Clinical Biochemistry, Histopathology and Radiology Departments, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu, 2., Esplugues, Barcelona, 08950, Spain.
| | - Mercè Pineda
- Centre For research in rare diseases (CIBERER), Institut de Salud Carlos III, Madrid, Spain. .,Pediatric Neurology, Clinical Biochemistry, Histopathology and Radiology Departments, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu, 2., Esplugues, Barcelona, 08950, Spain.
| | - María T García-Silva
- Unidad de Enfermedades Mitocondriales-Enfermedades Metabólicas Hereditarias. Dpto. de Pediatría y Radiología, Hospital 12 de Octubre, Madrid, Spain. .,Centre For research in rare diseases (CIBERER), Institut de Salud Carlos III, Madrid, Spain.
| | - Rafael Artuch
- Centre For research in rare diseases (CIBERER), Institut de Salud Carlos III, Madrid, Spain. .,Pediatric Neurology, Clinical Biochemistry, Histopathology and Radiology Departments, Hospital Sant Joan de Déu, Passeig Sant Joan de Déu, 2., Esplugues, Barcelona, 08950, Spain.
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4
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Parikh S, Goldstein A, Koenig MK, Scaglia F, Enns GM, Saneto R, Anselm I, Cohen BH, Falk MJ, Greene C, Gropman AL, Haas R, Hirano M, Morgan P, Sims K, Tarnopolsky M, Van Hove JLK, Wolfe L, DiMauro S. Diagnosis and management of mitochondrial disease: a consensus statement from the Mitochondrial Medicine Society. Genet Med 2014; 17:689-701. [PMID: 25503498 DOI: 10.1038/gim.2014.177] [Citation(s) in RCA: 327] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 11/06/2014] [Indexed: 12/13/2022] Open
Abstract
PURPOSE The purpose of this statement is to review the literature regarding mitochondrial disease and to provide recommendations for optimal diagnosis and treatment. This statement is intended for physicians who are engaged in diagnosing and treating these patients. METHODS The Writing Group members were appointed by the Mitochondrial Medicine Society. The panel included members with expertise in several different areas. The panel members utilized a comprehensive review of the literature, surveys, and the Delphi method to reach consensus. We anticipate that this statement will need to be updated as the field continues to evolve. RESULTS Consensus-based recommendations are provided for the diagnosis and treatment of mitochondrial disease. CONCLUSION The Delphi process enabled the formation of consensus-based recommendations. We hope that these recommendations will help standardize the evaluation, diagnosis, and care of patients with suspected or demonstrated mitochondrial disease.
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Affiliation(s)
- Sumit Parikh
- Department of Neurology, Center for Child Neurology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Amy Goldstein
- Department of Pediatrics, Division of Child Neurology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mary Kay Koenig
- Department of Pediatrics, Division of Child and Adolescent Neurology, University of Texas Medical School at Houston, Houston, Texas, USA
| | - Fernando Scaglia
- Department of Molecular and Human Genetics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Gregory M Enns
- Department of Pediatrics, Division of Medical Genetics, Stanford University Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Russell Saneto
- Department of Neurology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.,Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Irina Anselm
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Bruce H Cohen
- Department of Pediatrics, NeuroDevelopmental Science Center, Children's Hospital Medical Center of Akron, Akron, Ohio, USA
| | - Marni J Falk
- Division of Human Genetics, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Carol Greene
- Department of Pediatrics, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Andrea L Gropman
- Department of Neurology, Children's National Medical Center and the George Washington University of the Health Sciences, Washington, DC, USA
| | - Richard Haas
- Department of Neurosciences and Pediatrics, UCSD Medical Center and Rady Children's Hospital San Diego, La Jolla, California, USA
| | - Michio Hirano
- Department of Neurology, Columbia University Medical Center, New York, New York, USA
| | - Phil Morgan
- Department of Anesthesiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Katherine Sims
- Department of Neurology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mark Tarnopolsky
- Department of Pediatrics and Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Johan L K Van Hove
- Department of Pediatrics, Clinical Genetics and Metabolism, Children's Hospital Colorado, Denver, Colorado, USA
| | - Lynne Wolfe
- National Institutes of Health, Bethesda, Maryland, USA
| | - Salvatore DiMauro
- Department of Neurology, Columbia University Medical Center, New York, New York, USA
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5
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Yu JY, Pearl PL. Metabolic causes of epileptic encephalopathy. EPILEPSY RESEARCH AND TREATMENT 2013; 2013:124934. [PMID: 23762547 PMCID: PMC3674738 DOI: 10.1155/2013/124934] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 04/16/2013] [Indexed: 12/31/2022]
Abstract
Epileptic encephalopathy can be induced by inborn metabolic defects that may be rare individually but in aggregate represent a substantial clinical portion of child neurology. These may present with various epilepsy phenotypes including refractory neonatal seizures, early myoclonic encephalopathy, early infantile epileptic encephalopathy, infantile spasms, and generalized epilepsies which in particular include myoclonic seizures. There are varying degrees of treatability, but the outcome if untreated can often be catastrophic. The importance of early recognition cannot be overemphasized. This paper provides an overview of inborn metabolic errors associated with persistent brain disturbances due to highly active clinical or electrographic ictal activity. Selected diseases are organized by the defective molecule or mechanism and categorized as small molecule disorders (involving amino and organic acids, fatty acids, neurotransmitters, urea cycle, vitamers and cofactors, and mitochondria) and large molecule disorders (including lysosomal storage disorders, peroxisomal disorders, glycosylation disorders, and leukodystrophies). Details including key clinical features, salient electrophysiological and neuroradiological findings, biochemical findings, and treatment options are summarized for prominent disorders in each category.
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Affiliation(s)
- Joe Yuezhou Yu
- Department of Neurology, Children's National Medical Center, 111 Michigan Avnue, Washington, DC 20010, USA
| | - Phillip L. Pearl
- Department of Neurology, Children's National Medical Center, 111 Michigan Avnue, Washington, DC 20010, USA
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DiMauro S, Hirano M. Pathogenesis and treatment of mitochondrial disorders. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2009; 652:139-70. [PMID: 20225024 PMCID: PMC10440730 DOI: 10.1007/978-90-481-2813-6_10] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In the past 50 years, our understanding of the biochemical and molecular causes of mitochondrial diseases, defined restrictively as disorders due to defects of the mitochondrial respiratory chain (RC), has made great strides. Mitochondrial diseases can be due to mutations in mitochondrial DNA (mtDNA) or in nuclear DNA (nDNA) and each group can be subdivided into more specific classes. Thus, mtDNA-related disorders can result from mutations in genes affecting protein synthesis in toto or mutations in protein-coding genes. Mendelian mitochondrial disorders can be attributed to mutations in genes that (i) encode subunits of the RC ("direct hits"); (ii) encode assembly proteins or RC complexes ("indirect hits"); (iii) encode factors needed for mtDNA maintenance, replication, or translation (intergenomic signaling); (iv) encode components of the mitochondrial protein import machinery; (v) control the synthesis and composition of mitochondrial membrane phospholipids; and (vi) encode proteins involved in mitochondrial dynamics.In contrast to this wealth of knowledge about etiology, our understanding of pathogenic mechanism is very limited. We discuss pathogenic factors that can influence clinical expression, especially ATP shortage and reactive oxygen radicals (ROS) excess. Therapeutic options are limited and fall into three modalities: (i) symptomatic interventions, which are palliative but crucial for day-to-day management; (ii) radical approaches aimed at correcting the biochemical or molecular error, which are interesting but still largely experimental; and (iii) pharmacological means of interfering with the pathogenic cascade of events (e.g. boosting ATP production or scavenging ROS), which are inconsistently and incompletely effective, but can be safe and helpful.
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Affiliation(s)
- Salvatore DiMauro
- Department of Neurology, Columbia University Medical Center, 3-313 Russ Berrie Medical Science Pavilion, New York, NY 10032, USA.
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Abstract
Folate is a water-soluble vitamin of the B complex group, and is required for optimal health, growth, and development. In humans, it cannot be synthesized de novo. As a cofactor or coenzyme, folate plays key biological roles in a variety of physiologic processes: maintenance and repair of the genome, regulation of gene expression, amino-acid metabolism, neurotransmitter synthesis, and the formation of myelin. Dietary folates must undergo multiple, tightly regulated absorption and metabolic processes before their cellular utilization occurs. Clinical conditions associated with abnormal body folate status are very diverse. They range from genetic syndromes defined prior to conception, to malformations that develop during embryogenesis (neural tube defects), to disorders that are postnatally acquired and progressive (e.g., cerebral folate deficiency, or folinic acid-responsive seizures). Central nervous system folate deficiency or impaired availability can occur in the settings of normal or decreased systemic folate levels. Because the majority of patients respond to treatment with folinic acid, pediatric neurologists should remain vigilant to the possibility of deficiencies of folate in patients with unexplained neurologic disorders. The deleterious outcomes of untreated patients underscore the importance of making an early diagnosis.
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Affiliation(s)
- Aleksandra Djukic
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
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Abstract
Therapy for mitochondrial diseases is woefully inadequate. However, lack of a cure does not equate with lack of treatment. Palliative therapy is dictated by good medical practice and includes anticonvulsant medication, control of endocrine dysfunction, and surgical procedures. Removal of noxious metabolites is centered on combating lactic acidosis, but extends to other metabolites. Attempts to bypass blocks in the respiratory chain by administration of electron acceptors have not been successful, but this may be amenable to genetic engineering. Administration of metabolites and cofactors is the mainstay of real-life therapy and is especially important in disorders due to primary deficiencies of specific compounds, such as carnitine or coenzyme Q10 (CoQ10). There is increasing interest in the administration of reactive oxygen radicals (ROS) scavengers, both in primary mitochondrial diseases and in neurodegenerative diseases. Gene therapy is a challenge because of polyplasmy and heteroplasmy, but novel experimental approaches are being pursued. One important strategy is to decrease the ratio of mutant to wild-type mitochondrial genomes ("gene shifting") by different means: (1) converting mutated mitochondrial DNA (mtDNA) genes into normal nuclear DNA genes ("allotopic expression"); (2) importing cognate genes from other species ("xenotopic expression"); (3) correcting mtDNA mutations by importing specific restriction endonucleases; (4) selecting for respiratory function; and (5) inducing muscle regeneration. Germline therapy raises ethical problems but is being considered for prevention of maternal transmission of mtDNA mutations. Preventive therapy through genetic counseling and prenatal diagnosis is becoming increasingly important for nuclear DNA-related disorders.
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Affiliation(s)
- Salvatore DiMauro
- Department of Neurology, Columbia University Medical Center, 4-420 College of Physicians and Surgeons, 630 West 168th Street, New York, New York 10032, USA.
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Cole PD, Kamen BA. Delayed neurotoxicity associated with therapy for children with acute lymphoblastic leukemia. ACTA ACUST UNITED AC 2006; 12:174-83. [PMID: 17061283 DOI: 10.1002/mrdd.20113] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Most children diagnosed today with acute lymphoblastic leukemia (ALL) will be cured. However, treatment entails risk of neurotoxicity, causing deficits in neurocognitive function that can persist in the years after treatment is completed. Many of the components of leukemia therapy can contribute to adverse neurologic sequelae, including craniospinal irradiation, nucleoside analogs, corticosteroids, and antifolates. In this review, we describe the characteristic radiographic findings and neurocognitive deficits seen among survivors of childhood ALL. We summarize what is known about the pathophysiology of delayed treatment-related neurotoxicity, with a focus on the toxicity resulting from pharmacologic disruption of folate physiology within the central nervous system. Finally, we suggest testable strategies to ameliorate the symptoms of treatment-related neurotoxicity or decrease its incidence.
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Affiliation(s)
- Peter D Cole
- Department of Pediatrics and Pharmacology, Robert Wood Johnson Medical School/UMDNJ, The Cancer Institute of New Jersey, New Brunswick, New Jersey 08901, USA.
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Pineda M, Ormazabal A, López-Gallardo E, Nascimento A, Solano A, Herrero MD, Vilaseca MA, Briones P, Ibáñez L, Montoya J, Artuch R. Cerebral folate deficiency and leukoencephalopathy caused by a mitochondrial DNA deletion. Ann Neurol 2005; 59:394-8. [PMID: 16365882 DOI: 10.1002/ana.20746] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Our aim was to describe a child with an incomplete form of Kearns-Sayre syndrome who presented profound cerebrospinal fluid (CSF) folate deficiency and his response to folinic acid supplementation METHODS CSF 5-methyltetrahydrofolate was analyzed by HPLC with fluorescence detection and mitochondrial DNA deletions by southern blot hybridization. RESULTS Cranial magnetic resonance imaging showed a leukoencephalopathy. Profound CSF 5-methyltetrahydrofolate deficiency was observed with normal blood folate values and decreased CSF/serum folate ratio, suggesting a transport defect across the blood-brain barrier. Folinic acid treatment was established, and after 1 year clinical response to folinic supplementation was remarkable, with almost normal white matter image. INTERPRETATION The clinical response after folinic therapy highlights the need for the study of cerebral folate deficiency in patients with mitochondrial disorders and white matter lesions.
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Affiliation(s)
- Merce Pineda
- Servicios de Neuropediatría, Bioquímica y Endocrinología, Hospital Sant Joan de Déu, Clínic, Barcelona, Spain.
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11
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Tanji K, Schon EA, DiMauro S, Bonilla E. Kearns-sayre syndrome: oncocytic transformation of choroid plexus epithelium. J Neurol Sci 2000; 178:29-36. [PMID: 11018246 DOI: 10.1016/s0022-510x(00)00354-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Kearns-Sayre syndrome (KSS) is a sporadic multisystem disorder due to a defect of oxidative phosphorylation and associated with clonally-expanded rearrangements of mitochondrial DNA (mtDNA) deletions (Delta-mtDNAs) and/or duplications (dup-mtDNAs). To gain further insight into the pathogenesis of CNS dysfunction in KSS, we studied the choroid plexus from two autoptic cases using in situ hybridization (ISH) of mtDNA, and immunohistochemistry to detect mtDNA and nuclear DNA-encoded subunits of the respiratory chain. Neuropathological examination of both cases showed oncocytic transformation of choroid plexus epithelial cells. In the same cells, ISH demonstrated that the predominant species of mtDNA were Delta-mtDNAs, and immunohistochemistry showed a decreased expression of mtDNA-encoded proteins. We suggest that mitochondrial abnormalities due to the presence of abundant Delta-mtDNAs in the choroid plexus play an important role in causing the increased cerebrospinal fluid (CSF) protein and reduced folic-acid levels that are characteristic of KSS.
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Affiliation(s)
- K Tanji
- Department of Neurology, College of Physicians and Surgeons of Columbia University, New York, NY 10032, USA
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12
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Abstract
Congenital errors of folate metabolism can be related either to defective transport of folate through various cells or to defective intracellular utilization of folate due to some enzyme deficiencies. Defective transport of folate across the intestine and the blood-brain barrier was reported in the condition 'Congenital Malabsorption of Folate'. This disease is characterized by a severe megaloblastic anaemia of early appearance associated with mental retardation. Anaemia is folate-responsive, but neurological symptoms are only poorly improved because of the inability to maintain adequate levels of folate in the CSF. A familial defect of cellular uptake was described in a family with a high frequency of aplastic anaemia or leukaemia. An isolated defect in folate transport into CSF was identified in a patient suffering from a cerebellar syndrome and pyramidal tract dysfunction. Among enzyme deficiencies, some are well documented, others still putative. Methylenetetrahydrofolate reductase deficiency is the most common. The main clinical findings are neurological signs (mental retardation, seizures, rarely schizophrenic syndromes) or vascular disease, without any haematological abnormality. Low levels of folate in serum, red blood cells and CSF associated with homocystinuria are constant. Methionine synthase deficiency is characterized by a megaloblastic anaemia occurring early in life that is more or less folate-responsive and associated with mental retardation. Glutamate formiminotransferase-cyclodeaminase deficiency is responsible for massive excretion of formiminoglutamic acid but megaloblastic anaemia is not constant. The clinical findings are a more or less severe mental or physical retardation. Dihydrofolate reductase deficiency was reported in three children presenting with a megaloblastic anaemia a few days or weeks after birth, which responded to folinic acid. The possible relationship between congenital disorders such as neural tube defects or dihydropteridine reductase deficiency and disturbances of folate metabolism are discussed. Neurological symptoms present in most of these congenital disorders highlight the role of folate in the central nervous system.
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Affiliation(s)
- J Zittoun
- Service d'Hématologie Biologique, Hôpital Henri Mondor, Creteil, France
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Wevers RA, Hansen SI, van Hellenberg Hubar JL, Holm J, Høier-Madsen M, Jongen PJ. Folate deficiency in cerebrospinal fluid associated with a defect in folate binding protein in the central nervous system. J Neurol Neurosurg Psychiatry 1994; 57:223-6. [PMID: 8126512 PMCID: PMC1072457 DOI: 10.1136/jnnp.57.2.223] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
An adult male patient of Dutch ancestry has a slowly progressive neurological disease characterised by a cerebellar syndrome, distal spinal muscular atrophy, pyramidal tract dysfunction, and perceptive hearing loss. A severe folate deficiency state was found in CSF in combination with a normal serum and red cell folate state. Two unknown abnormal metabolites were present in CSF. The concentration of immunoreactive folate binding protein in CSF was unusually low, whereas the concentration of the protein measured with radioligand (3H-folate) binding was unusually high. The transfer of folate over the choroid plexus seems to be disturbed, potentially reflecting a defect in the choroid plexus folate binder.
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Affiliation(s)
- R A Wevers
- Institute of Neurology, University Hospital of Nijmegen, The Netherlands
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14
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Abstract
Mitochondrial myopathies are clinically heterogeneous disorders that can affect multiple systems besides skeletal muscle (mitochondrial encephalomyopathies or cytopathies) and are usually defined by morphological abnormalities of muscle mitochondria. There are a few distinctive syndromes, such as the Kearns-Sayre syndrome; myoclonus epilepsy with ragged-red fibers; and mitochondrial myopathy, encephalopathy, lactic acidosis, and strokelike episodes. Biochemically, mitochondrial myopathies can be divided into defects of substrate utilization, oxidation-phosphorylation coupling, and the respiratory chain. Because mitochondria have their own DNA and their own translation and transcription apparatuses, mitochondrial myopathies can be due to defects of either a nuclear or mitochondrial genome and can be transmitted by mendelian or maternal inheritance.
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