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Thunga C, Mitra S, Dayal D, Lal S. Carnitine-acylcarnitine translocase deficiency: a case report with autopsy. Autops Case Rep 2024; 14:e2024483. [PMID: 38628283 PMCID: PMC11021025 DOI: 10.4322/acr.2024.483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/29/2024] [Indexed: 04/19/2024]
Abstract
Fatty acid oxidation defects are a heterogeneous group of disorders related to the mitochondrial fatty acid oxidation pathway. Carnitine acylcarnitine translocase (CACT) is an enzyme responsible for the unidirectional transport of acylcarnitine across the inner mitochondrial membrane. This enzyme plays a crucial role in the oxidation of fatty acids. The autopsy pathology of the CACT deficiency is described in only a few cases. We describe the autopsy pathology of a child with CACT deficiency dominantly in the form of microvesicular steatosis of the hepatocytes, renal proximal tubular epithelia, cardiac myocytes, and rhabdomyocytes. The diagnosis was further confirmed on whole exome sequencing with compound heterozygous variants in the exon 1 (c.82G>T, p.Gly28Cys; likely pathogenic) and exon 5 (c.535G>A, p.Asp179Asn; uncertain significance) of the SLC25A20 gene. This case elucidates the histopathology of the liver and the detailed autopsy of a case of CACT deficiency from India.
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Affiliation(s)
- Chennakeshava Thunga
- Post Graduate Institute of Medical Education and Research (PGIMER), Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Chandigarh, India
| | - Suvradeep Mitra
- Post Graduate Institute of Medical Education and Research (PGIMER), Department of Histopathology, Chandigarh, India
| | - Devi Dayal
- Post Graduate Institute of Medical Education and Research (PGIMER), Department of Pediatrics, Endocrinology and Diabetes Unit, Chandigarh, India
| | - Sadhna Lal
- Post Graduate Institute of Medical Education and Research (PGIMER), Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Chandigarh, India
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Tummolo A, Melpignano L. The Reciprocal Interplay between Infections and Inherited Metabolic Disorders. Microorganisms 2023; 11:2545. [PMID: 37894204 PMCID: PMC10608884 DOI: 10.3390/microorganisms11102545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Infections represent the main cause of acute metabolic derangements and/or the worsening of the clinical course of many inherited metabolic disorders (IMDs). The basic molecular mechanisms behind the role of infections in these conditions have not been completely clarified. This review points out the different mechanisms behind the relationship between IMDs and infections, providing an overview of this still-under-investigated area. Classically, infections have been considered as the consequence of a compromised immune system due to a biochemical defect of energy production. An adjunctive pathogenetic mechanism is related to a genetically altered protein-attached glycans composition, due to congenital glycosilation defects. In addition, a dietary regimen with a reduced intake of both micro- and macronutrients can potentially compromise the ability of the immune system to deal with an infection. There is recent pre-clinical evidence showing that during infections there may be a disruption of substrates of various metabolic pathways, leading to further cellular metabolic alteration. Therefore, infective agents may affect cellular metabolic pathways, by mediation or not of an altered immune system. The data reviewed here strongly suggest that the role of infections in many types of IMDs deserves greater attention for a better management of these disorders and a more focused therapeutic approach.
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Affiliation(s)
- Albina Tummolo
- Department of Metabolic Diseases, Clinical Genetics and Diabetology, Giovanni XXIII Children Hospital, Azienda Ospedaliero-Universitaria Consorziale, 70126 Bari, Italy
| | - Livio Melpignano
- Medical Direction, Giovanni XXIII Children Hospital, Azienda Ospedaliero-Universitaria Consorziale, 70126 Bari, Italy;
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Metzler M, Burns W, Mitchell C, Napolitano S, Chaudhari BP. A case report of necrotizing enterocolitis in a moderately preterm neonate with LCHADD-A call to focus on the basics while utilizing advanced new therapies. Front Pediatr 2023; 11:1081802. [PMID: 36861082 PMCID: PMC9969157 DOI: 10.3389/fped.2023.1081802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/16/2023] [Indexed: 02/15/2023] Open
Abstract
Long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD) is an autosomal recessive condition of impaired beta-oxidation. Traditionally, treatment included restriction of dietary long-chain fatty acids via a low-fat diet and supplementation of medium chain triglycerides. In 2020, triheptanoin received FDA approval as an alternative source of medium chain fatty acids for individuals with long-chain fatty acid oxidation disorders (LC-FAOD). We present a case of a moderately preterm neonate born at 33 2/7 weeks gestational age with LCHADD who received triheptanoin and developed necrotizing enterocolitis (NEC). Prematurity is known as a major risk factor for NEC, with risk increasing with decreasing gestational age. To our knowledge, NEC has not previously been reported in patients with LCHADD or with triheptanoin use. While metabolic formula is part of the standard of care for LC-FAOD in early life, preterm neonates may benefit from more aggressive attempts to use skimmed human milk to minimize exposure to formula during the risk period for NEC during feed advancement. This risk period may be longer in neonates with LC-FAOD compared to otherwise healthy premature neonates.
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Affiliation(s)
- Marina Metzler
- Pediatric Residency, Nationwide Children's Hospital, Columbus, OH, United States
| | - William Burns
- Division of Genetic and Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, United States
| | - Carly Mitchell
- Division of Genetic and Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, United States
| | - Stephanie Napolitano
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States.,Department of Pediatrics, College of Medicine, Ohio State University, Columbus, OH, United States
| | - Bimal P Chaudhari
- Division of Genetic and Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, United States.,Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States.,Department of Pediatrics, College of Medicine, Ohio State University, Columbus, OH, United States.,Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, United States
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Dynamic Changes in Plasma Metabolic Profiles Reveal a Potential Metabolite Panel for Interpretation of Fatal Intoxication by Chlorpromazine or Olanzapine in Mice. Metabolites 2022; 12:metabo12121184. [PMID: 36557223 PMCID: PMC9782175 DOI: 10.3390/metabo12121184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/11/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Diagnosing the cause of fatal intoxication by antipsychotic agents is an important task in forensic practice. In the 2020 Annual Report of the American Association of Poison Control Centers, among 40 deaths caused by antipsychotics, 21 cases were diagnosed as "probably responsible", thereby indicating that more objective diagnostic tools are needed. We used liquid chromatography-mass spectrometry-based integrated metabolomics analysis to measure changes in metabolic profiles in the plasma of mice that died from fatal intoxication due to chlorpromazine (CPZ) or olanzapine (OLA). These results were used to construct a stable discriminative classification model (DCM) comprising L-acetylcarnitine, succinic acid, and propionylcarnitine between fatal intoxication caused by CPZ/OLA and cervical dislocation (control). Performance evaluation of the classification model in mice that suffered fatal intoxication showed relative specificity for different pharmacodynamic drugs and relative sensitivity in different life states (normal, intoxication, fatal intoxication). A stable level of L-acetylcarnitine and variable levels of succinic acid and propionylcarnitine between fatal-intoxication and intoxication groups revealed procedural perturbations in metabolic pathways related to fatal intoxication by CPZ/OLA. Additional stability studies revealed that decomposition of succinic acid in fatal-intoxication samples (especially in the OLA group) could weaken the prediction performance of the binary-classification model; however, levels of these three potential metabolites measured within 6 days in fresh samples kept at 4 °C revealed a good performance of our model. Our findings suggest that metabolomics analysis can be used to explore metabolic alterations during fatal intoxication due to use of antipsychotic agents and provide evidence for the cause of death.
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Schwantje M, Fuchs SA, de Boer L, Bosch AM, Cuppen I, Dekkers E, Derks TGJ, Ferdinandusse S, Ijlst L, Houtkooper RH, Maase R, van der Pol WL, de Vries MC, Verschoof‐Puite RK, Wanders RJA, Williams M, Wijburg F, Visser G. Genetic, biochemical, and clinical spectrum of patients with mitochondrial trifunctional protein deficiency identified after the introduction of newborn screening in the Netherlands. J Inherit Metab Dis 2022; 45:804-818. [PMID: 35383965 PMCID: PMC9546250 DOI: 10.1002/jimd.12502] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/23/2022] [Accepted: 04/04/2022] [Indexed: 11/24/2022]
Abstract
Long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD) is included in many newborn screening (NBS) programs. Acylcarnitine-based NBS for LCHADD not only identifies LCHADD, but also the other deficiencies of the mitochondrial trifunctional protein (MTP), a multi-enzyme complex involved in long-chain fatty acid β-oxidation. Besides LCHAD, MTP harbors two additional enzyme activities: long-chain enoyl-CoA hydratase (LCEH) and long-chain ketoacyl-CoA thiolase (LCKAT). Deficiency of one or more MTP activities causes generalized MTP deficiency (MTPD), LCHADD, LCEH deficiency (not yet reported), or LCKAT deficiency (LCKATD). To gain insight in the outcomes of MTP-deficient patients diagnosed after the introduction of NBS for LCHADD in the Netherlands, a retrospective evaluation of genetic, biochemical, and clinical characteristics of MTP-deficient patients, identified since 2007, was carried out. Thirteen patients were identified: seven with LCHADD, five with MTPD, and one with LCKATD. All LCHADD patients (one missed by NBS, clinical diagnosis) and one MTPD patient (clinical diagnosis) were alive. Four MTPD patients and one LCKATD patient developed cardiomyopathy and died within 1 month and 13 months of life, respectively. Surviving patients did not develop symptomatic hypoglycemia, but experienced reversible cardiomyopathy and rhabdomyolysis. Five LCHADD patients developed subclinical neuropathy and/or retinopathy. In conclusion, patient outcomes were highly variable, stressing the need for accurate classification of and discrimination between the MTP deficiencies to improve insight in the yield of NBS for LCHADD. NBS allowed the prevention of symptomatic hypoglycemia, but current treatment options failed to treat cardiomyopathy and prevent long-term complications. Moreover, milder patients, who might benefit from NBS, were missed due to normal acylcarnitine profiles.
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Affiliation(s)
- Marit Schwantje
- Department of Metabolic DiseasesWilhelmina Children's Hospital, University Medical Center UtrechtUtrechtThe Netherlands
- Laboratory Genetic Metabolic Diseases, and Metabolism Institute, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Sabine A. Fuchs
- Department of Metabolic DiseasesWilhelmina Children's Hospital, University Medical Center UtrechtUtrechtThe Netherlands
| | - Lonneke de Boer
- Department of Metabolic Diseases, Amalia Children's HospitalRadboud University Medical CentreNijmegenThe Netherlands
| | - Annet M. Bosch
- Department of Metabolic Diseases, Emma Children's Hospital, and Metabolism Institute, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Inge Cuppen
- Department of Neurology and NeurosurgeryWilhelmina Children's Hospital, University Medical Center UtrechtUtrechtThe Netherlands
| | - Eugenie Dekkers
- National Institute for Public Health and the Environment (RIVM) Reference Laboratory for Pre‐ and Neonatal Screening, Center for Health Protection (R.M.) and Center for Population Screening (E.D)BilthovenThe Netherlands
| | - Terry G. J. Derks
- Department of Metabolic DiseasesBeatrix Children's Hospital, University Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Sacha Ferdinandusse
- Laboratory Genetic Metabolic Diseases, and Metabolism Institute, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Lodewijk Ijlst
- Laboratory Genetic Metabolic Diseases, and Metabolism Institute, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Riekelt H. Houtkooper
- Laboratory Genetic Metabolic Diseases, and Metabolism Institute, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Rose Maase
- National Institute for Public Health and the Environment (RIVM) Reference Laboratory for Pre‐ and Neonatal Screening, Center for Health Protection (R.M.) and Center for Population Screening (E.D)BilthovenThe Netherlands
| | - W. Ludo van der Pol
- Department of Neurology and NeurosurgeryWilhelmina Children's Hospital, University Medical Center UtrechtUtrechtThe Netherlands
| | - Maaike C. de Vries
- Department of Metabolic Diseases, Amalia Children's HospitalRadboud University Medical CentreNijmegenThe Netherlands
| | - Rendelien K. Verschoof‐Puite
- Department for Vaccine Supply and Prevention ProgramsNational Institute for Public Health and the EnvironmentBilthovenThe Netherlands
| | - Ronald J. A. Wanders
- Laboratory Genetic Metabolic Diseases, and Metabolism Institute, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Monique Williams
- Department of PediatricsCenter for Lysosomal and Metabolic Diseases, Erasmus MC, University Medical Center RotterdamRotterdamNetherlands
| | - Frits Wijburg
- Department of Metabolic Diseases, Emma Children's Hospital, and Metabolism Institute, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Gepke Visser
- Department of Metabolic DiseasesWilhelmina Children's Hospital, University Medical Center UtrechtUtrechtThe Netherlands
- Laboratory Genetic Metabolic Diseases, and Metabolism Institute, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
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Ravindranath A, Sarma MS. Mitochondrial hepatopathy: Anticipated difficulties in management of fatty acid oxidation defects and urea cycle defects. World J Hepatol 2022; 14:180-194. [PMID: 35126847 PMCID: PMC8790400 DOI: 10.4254/wjh.v14.i1.180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/19/2021] [Accepted: 12/02/2021] [Indexed: 02/06/2023] Open
Abstract
Fatty acid oxidation defects (FAOD) and urea cycle defects (UCD) are among the most common metabolic liver diseases. Management of these disorders is dotted with challenges as the strategies differ based on the type and severity of the defect. In those with FAOD the cornerstone of management is avoiding hypoglycemia which in turn prevents the triggering of fatty acid oxidation. In this review, we discuss the role of carnitine supplementation, dietary interventions, newer therapies like triheptanoin, long-term treatment and approach to positive newborn screening. In UCD the general goal is to avoid excessive protein intake and indigenous protein breakdown. However, one size does not fit all and striking the right balance between avoiding hyperammonemia and preventing deficiencies of essential nutrients is a formidable task. Practical issues during the acute presentation including differential diagnosis of hyperammonemia, dietary dilemmas, the role of liver transplantation, management of the asymptomatic individual and monitoring are described in detail. A multi-disciplinary team consisting of hepatologists, metabolic specialists and dieticians is required for optimum management and improvement in quality of life for these patients.
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Affiliation(s)
- Aathira Ravindranath
- Division of Pediatric Gastroenterology, Institute of Gastrointestinal Sciences, Apollo BGS Hospitals, Mysore 570023, Karnataka, India
| | - Moinak Sen Sarma
- Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
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Li X, Shen J. One potential hotspot SLC25A20 gene variants in Chinese patients with carnitine-acylcarnitine translocase deficiency. Front Pediatr 2022; 10:1029004. [PMID: 36419912 PMCID: PMC9676358 DOI: 10.3389/fped.2022.1029004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Carnitine-acylcarnitine translocase deficiency (CACT deficiency) is a rare and life-threatening autosomal recessive disorder of mitochondrial fatty acid oxidation caused by variant of SLC25A20 gene. The most prevalent missense variant in the SLC25A20 gene in Asia was c.199-10T > G. Due to the c.199-10T > G variant, CACT deficiency is a severe phenotype. MATERIALS AND METHODS Herein, we present a neonatal case with c.199-10T > G variant in China and analyze the clinical, biochemical, and genetic aspects of 78 patients previously identified with CACT deficiency. RESULTS The patient presented with a series of severe metabolic crises that rapidly deteriorated and eventually died 3 days after delivery. The sequencing of the patient's genome indicated that he was homozygous for the c.199-10T > G variant. 30 patients were found to have the c.199-10T > G mutation, of which 23 were Chinese and 22 were afflicted by the c.199-10T > G splicing variation. In China, c.199-10T > G allele frequency was 82.6%. CONCLUSION In CACT deficiency, prompt recognition and treatment are critical. Our data suggested that c.199-10T > G may be a potential hotspot SLC25A20 gene mutation in the Chinese population. Detection of single nucleotide polymorphism is possible for high-risk patients and parents in China.
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Affiliation(s)
- Xiaoli Li
- Department of Pediatrics, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jian Shen
- Department of Pediatrics, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Altered Metabolic Flexibility in Inherited Metabolic Diseases of Mitochondrial Fatty Acid Metabolism. Int J Mol Sci 2021; 22:ijms22073799. [PMID: 33917608 PMCID: PMC8038842 DOI: 10.3390/ijms22073799] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/03/2021] [Accepted: 04/05/2021] [Indexed: 12/14/2022] Open
Abstract
In general, metabolic flexibility refers to an organism's capacity to adapt to metabolic changes due to differing energy demands. The aim of this work is to summarize and discuss recent findings regarding variables that modulate energy regulation in two different pathways of mitochondrial fatty metabolism: β-oxidation and fatty acid biosynthesis. We focus specifically on two diseases: very long-chain acyl-CoA dehydrogenase deficiency (VLCADD) and malonyl-CoA synthetase deficiency (acyl-CoA synthetase family member 3 (ACSF3)) deficiency, which are both characterized by alterations in metabolic flexibility. On the one hand, in a mouse model of VLCAD-deficient (VLCAD-/-) mice, the white skeletal muscle undergoes metabolic and morphologic transdifferentiation towards glycolytic muscle fiber types via the up-regulation of mitochondrial fatty acid biosynthesis (mtFAS). On the other hand, in ACSF3-deficient patients, fibroblasts show impaired mitochondrial respiration, reduced lipoylation, and reduced glycolytic flux, which are compensated for by an increased β-oxidation rate and the use of anaplerotic amino acids to address the energy needs. Here, we discuss a possible co-regulation by mtFAS and β-oxidation in the maintenance of energy homeostasis.
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