Ultrastructural findings in maple syrup urine disease in Poll Hereford calves

Neuroimaging findings of inborn errors of metabolism: urea cycle disorders, aminoacidopathies, and organic acidopathies

Although there are many types of inborn errors of metabolism (IEMs) affecting the central nervous system, also referred to as neurometabolic disorders, individual cases are rare, and their diagnosis is often challenging. However, early diagnosis is mandatory to initiate therapy and prevent permanent long-term neurological impairment or death. The clinical course of IEMs is very diverse, with some diseases progressing to acute encephalopathy following infection or fasting while others lead to subacute or slowly progressive encephalopathy. The diagnosis of IEMs relies on biochemical and genetic tests, but neuroimaging studies also provide important clues to the correct diagnosis and enable the conditions to be distinguished from other, more common causes of encephalopathy, such as hypoxia-ischemia. Proton magnetic resonance spectroscopy (¹H-MRS) is a powerful, non-invasive method of assessing neurological abnormalities at the microscopic level and can measure in vivo brain metabolites. The present review discusses neuroimaging findings, including those of ¹H-MRS, of IEMs focusing on intoxication disorders such as urea cycle disorders, aminoacidopathies, and organic acidopathies, which can result in acute life-threatening metabolic decompensation or crisis.

Brain magnetic resonance imaging findings and radiologic review of maple syrup urine disease: Report of three cases

BACKGROUND

Maple syrup urine disease (MSUD) is a rare autosomal-recessive disorder that affects branched-chain amino acid (BCAA) metabolism and is named after the distinctive sweet odor of affected infants’ urine. This disease is characterized by the accumulation of BCAAs and corresponding branched-chain ketoacids of leucine, isoleucine, and valine in the plasma, urine, and cerebrospinal fluid. However, the mechanisms of MSUD-induced brain damage remain poorly defined. The accumulation of BCAAs in the brain inhibits the activity of pyruvate dehydrogenase and α-ketoglutarate, disrupting the citric acid cycle and consequently impacting the synthesis of amino acids, causing cerebral edema and abnormal myelination.

CASE SUMMARY

We report three neonates admitted to our hospital with the classic subtype of MSUD. All three patients, with a transient normal period, presented with poor feeding, vomiting, poor weight gain, and increasing lethargy after birth. Laboratory testing revealed metabolic acidosis. The serum tandem mass spectrometry amino acid profile showed elevated plasma levels of BCAAs (leucine, isoleucine, and valine). Brain magnetic resonance imaging (MRI) presented abnormal signals mainly involving the globus pallidus, thalamus, internal capsule, brainstem, and cerebellar white matter, which represent the typical myelinated areas in normal full-term neonates.

CONCLUSION

In our patients, MRI showed typical features, in concordance with the available literature. Early detection and timely treatment are very helpful for the prognosis of MSUD patients. Therefore, we discuss the neuroimaging features of MSUD to enhance the knowledge of pediatricians about this disease.

Loss of the Drosophila branched-chain α-ketoacid dehydrogenase complex results in neuronal dysfunction

Maple syrup urine disease (MSUD) is an inherited error in the metabolism of branched-chain amino acids (BCAAs) caused by a severe deficiency of the branched-chain α-ketoacid dehydrogenase (BCKDH) complex, which ultimately leads to neurological disorders. The limited therapies, including protein-restricted diets and liver transplants, are not as effective as they could be for the treatment of MSUD due to the current lack of molecular insights into the disease pathogenesis. To address this issue, we developed a Drosophila model of MSUD by knocking out the dDBT gene, an ortholog of the human gene encoding the dihydrolipoamide branched chain transacylase (DBT) subunit of BCKDH. The homozygous dDBT mutant larvae recapitulate an array of MSUD phenotypes, including aberrant BCAA accumulation, developmental defects, poor mobile behavior and disrupted L-glutamate homeostasis. Moreover, the dDBT mutation causes neuronal apoptosis during the developmental progression of larval brains. The genetic and functional evidence generated by in vivo depletion of dDBT expression in the eye indicates severe impairment of retinal rhabdomeres. Further, the dDBT mutant shows elevated oxidative stress and higher lipid peroxidation accumulation in the larval brain. Therefore, we conclude from in vivo evidence that the loss of dDBT results in oxidative brain damage that may lead to neuronal cell death and contribute to aspects of MSUD pathology. Importantly, when the dDBT mutants were administrated with Metformin, the aberrances in BCAA levels and motor behavior were ameliorated. This intriguing outcome strongly merits the use of the dDBT mutant as a platform for developing MSUD therapies.This article has an associated First Person interview with the joint first authors of the paper.

Correlation of MRI with the Neuropathologic Changes in Two Cats with Bromethalin Intoxication

Two cats were presented with multifocal neurological signs. One cat's signs progressed over 2 wk; the other cat progressed over 5 days. Examinations were consistent with a process involving the prosencephalon, vestibular system, and general proprioceptive/upper motor neuron systems. MRI of the brain and cervical spinal cord reveal widespread T2 hyperintensity of the white matter. Affected areas included the cerebrum, cerebral peduncles, corticospinal tracts of the pons and medulla, and the cerebellum. T2 hyperintensity was present in all funiculi of the spinal cord. Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) maps were consistent with cytotoxic or intramyelinic edema. Differential diagnosis included toxic or metabolic/degenerative leukoencephalopathies. Necropsies revealed widespread spongy degeneration of the central nervous system white matter. Toxicologic assays of liver specimens revealed desmethylbromethalin, a metabolite of bromethalin. Bromethalin is a rodenticide that causes uncoupling of oxidative phosphorylation. Antemortem diagnosis is challenging. DWI and ADC maps were instrumental in narrowing the differential diagnosis and raised the index of suspicion for bromethalin. Bromethalin intoxication should be considered in all animals with a progressive course of multifocal neurologic deficits. MRI, specifically, DWI and ADC maps, may serve as a biomarker of cytotoxic or intramyelinic edema associated with spongiform leukoencephalomyelopathy.

Inherited and acquired disorders of myelin: The underlying myelin pathology

Remyelination is a major therapeutic goal in human myelin disorders, serving to restore function to demyelinated axons and providing neuroprotection. The target disorders that might be amenable to the promotion of this repair process are diverse and increasing in number. They range primarily from those of genetic, inflammatory to toxic origin. In order to apply remyelinating strategies to these disorders, it is essential to know whether the myelin damage results from a primary attack on myelin or the oligodendrocyte or both, and whether indeed these lead to myelin breakdown and demyelination. In some disorders, myelin sheath abnormalities are prominent but demyelination does not occur. This review explores the range of human and animal disorders where myelin pathology exists and focusses on defining the myelin changes in each and their cause, to help define whether they are targets for myelin repair therapy.

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We reviewed myelin disorders of the CNS in humans and animals.

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Myelin damage results from primary attack on the oligodendrocyte or myelin sheath.

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All major categories of disease can affect CNS myelin.

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Myelin vacuolation is common, yet does not always result in demyelination.

Maple Syrup Urine Disease in a Central Indiana Hereford Herd

Maple syrup urine disease (MSUD) and further cases were identified in herd mates of a small Hereford herd in Indiana based on history, clinical signs, microscopic lesions, and biochemical and genetic testing. This aminoacidopathy has been diagnosed in polled Shorthorn, polled Hereford, and Hereford cattle in Australia, Uruguay, Argentina, and Canada and is the result of a mutation of the branched-chain alpha-ketoacid dehydrogenase complex. The Indiana index calf case was confirmed by showing the classic accumulation of ketoacids in liver that results from a defect in the E1-alpha subunit (248 C/T haplotype) in the mitochondrial branched-chainα-ketoacid dehydrogenase complex. The presence of the mutation was confirmed in the index case, the dam, and four related herd mates that represent the first confirmed cases of bovine MSUD mutation in United States cattle.

Myelin vacuolation, optic neuropathy and retinal degeneration after closantel overdosage in sheep and in a goat

Toxicity of closantel, a halogenated salicylanilide anthelmintic, is described in 11 sheep and a goat, humanely killed 4-70 days after accidental overdosage. Status spongiosis of the cerebrum and cerebellum was present, its severity decreasing with time after treatment. Ultrastructurally, vacuoles in the cerebral white matter were seen to be intramyelinic due to splitting of myelin lamellae at the intraperiod lines, indicating myelin oedema. In the optic nerves, Wallerian degeneration and eventual fibrosis and atrophy of the nerves followed myelin vacuolation. Lesions in the optic nerves were particularly advanced in the intracanalicular portion, indicating a compressive neuropathy within the optic canal. Acute retinal lesions consisted of papilloedema, necrosis of the outer retinal layers (especially the photoreceptor layer), and retinal separation in tapetal and non-tapetal areas. In more chronic cases, the outer nuclear layer was diffusely attenuated and generally reduced to a single row of cells.

Maple syrup urine disease: diffusion MRI, and proton MR spectroscopy findings

A 7-month-old boy is reported with acute metabolic crisis of maple syrup urine disease. A reversible intramyelinic type of edema was noted by diffusion MRI which completely resolved in 3 months in accordance with good clinical outcome. Proton MR spectroscopy revealed decreased NAA, and presence of methyl resonances of branched chain amino acids at 0.9 ppm, and lactic acid in the initial examination. After 3 months, NAA returned to normal, and lactic acid disappeared. The methyl resonance of branched chain amino acids, however, remained.

Production and characterization of murine models of classic and intermediate maple syrup urine disease

BACKGROUND

Maple Syrup Urine Disease (MSUD) is an inborn error of metabolism caused by a deficiency of branched-chain keto acid dehydrogenase. MSUD has several clinical phenotypes depending on the degree of enzyme deficiency. Current treatments are not satisfactory and require new approaches to combat this disease. A major hurdle in developing new treatments has been the lack of a suitable animal model.

METHODS

To create a murine model of classic MSUD, we used gene targeting and embryonic stem cell technologies to create a mouse line that lacked a functional E2 subunit gene of branched-chain keto acid dehydrogenase. To create a murine model of intermediate MSUD, we used transgenic technology to express a human E2 cDNA on the knockout background. Mice of both models were characterized at the molecular, biochemical, and whole animal levels.

RESULTS

By disrupting the E2 subunit gene of branched-chain keto acid dehydrogenase, we created a gene knockout mouse model of classic MSUD. The homozygous knockout mice lacked branched-chain keto acid dehydrogenase activity, E2 immunoreactivity, and had a 3-fold increase in circulating branched-chain amino acids. These metabolic derangements resulted in neonatal lethality. Transgenic expression of a human E2 cDNA in the liver of the E2 knockout animals produced a model of intermediate MSUD. Branched-chain keto acid dehydrogenase activity was 5-6% of normal and was sufficient to allow survival, but was insufficient to normalize circulating branched-chain amino acids levels, which were intermediate between wildtype and the classic MSUD mouse model.

CONCLUSION

These mice represent important animal models that closely approximate the phenotype of humans with the classic and intermediate forms of MSUD. These animals provide useful models to further characterize the pathogenesis of MSUD, as well as models to test novel therapeutic strategies, such as gene and cellular therapies, to treat this devastating metabolic disease.

Status spongiosus of white matter in newborn Gelbvieh-cross calves

Various forms of status spongiosus occur in neonatal cattle, the best characterized of which is due to mutations of the branched-chain alpha-keto acid dehydrogenase complex (BCKD), resulting in bovine maple syrup urine disease (MSUD, branched-chain ketoaciduria). A distinctive neurological syndrome was identified between 1998 and 2003 in 9 calves in a 250-cow stabilized Gelbvieh-Red Angus herd. Both sexes were affected (6 heifers, 3 bulls), with a low annual incidence (3 cases in 1998; no cases in 1999; 2 cases in 2000; 2 in 2001; 1 in 2002; 1 in 2003). Affected calves were born full-term, unable to stand, and had constant whole-body tremors when stimulated. Animals remained in lateral recumbency until death or euthanasia; the longest survival time was 10 days postpartum. The principal histological change in 2 affected calves was diffuse, moderately severe bilaterally symmetrical status spongiosus with Alzheimer type II cells throughout the white matter of the brain. Myelin deficits were not evident and vacuoles were due to cleaved myelin sheaths. Neither recognized mutation of MSUD was identified in the E1a subunit of BCKD in 2 affected calves, 8 dams that gave birth to affected calves, a grand-dam of 3 affected calves, or a sire of 1 calf. Amino acid analysis of serum from 1 affected calf revealed normal concentrations of branched-chain amino acids, indicating that this disease is distinct from MSUD. The genetic and biochemical basis for the disorder, provisionally named congenital status spongiosus of Gelbvieh-cross cattle, is undetermined. The pattern of inheritance was not established.

Age dependence of diffusion-weighted magnetic resonance imaging findings in maple syrup urine disease encephalopathy

A patient with maple syrup urine disease (MSUD) who developed encephalopathy twice and underwent magnetic resonance examinations, including diffusion-weighted (DW) imaging, is presented. Areas of abnormal intensity on DW images dramatically differed between the initial and second attacks, apparently attributable to the difference in myelination. Our observation demonstrates the age dependence of DW imaging findings in MSUD encephalopathy attributable to progression of myelination and would help in the proper diagnosis of MSUD encephalopathy at any age.

Leucine toxicity in a neuronal cell model with inhibited branched chain amino acid catabolism

Individuals with the inborn error of metabolism, maple syrup urine disease (MSUD), are identified by newborn screening programs and treated with protein-modified diets that allow near normal growth and development. However, regardless of cause, a protein insult leads to metabolic decompensation, resulting in brain cell damage. The mechanism responsible for the damage is not well characterized due, in part, to the lack of an appropriate experimental model system with impaired branched chain alpha-ketoacid dehydrogenase (BCKD) activity. Here, we describe the construction of a rat pheochromocytoma cell (PC12) model harboring a doxycycline-controlled BCKD-kinase transgene. When BCKD-kinase is over-expressed in these cells, the endogenous BCKD activity is decreased, blocking branched chain amino acid (BCAA) catabolism. In cells over-expressing BCKD-kinase, addition of 25 mM leucine to the medium results in cell death. This experimental cell model accurately mimics the neuronal dysfunction in maple syrup urine disease and should facilitate further understanding of the pathophysiology of this disease and neuronal cell branched chain amino acid metabolism in general.

Status spongiosis, optic neuropathy, and retinal degeneration in Helichrysum argyrosphaerum poisoning in sheep and a goat

Lesions of natural Helichrysum argyrosphaerum poisoning were studied in eight sheep and one goat. Light microscopic examination revealed widespread, bilaterally symmetrical status spongiosis of the white matter of the brain consistently present in the subependymal area adjacent to the lateral ventricles, cerebellar peduncles, and brain stem in all animals. In three animals, the ultrastructural finding of intramyelinic vacuolation due to splitting of the myelin lamellae at the intraperiod lines indicated myelin edema. There was also mild distension of perivascular and extracellular spaces in the severely affected areas. Significant changes were absent in neurons, glial cells, axons, or blood vessel walls. Myelin edema associated with degeneration and loss of axons and myelin and astrocytic gliosis was present in the intraorbital and intracranial portions of the optic nerves. In the intracanalicular portions of the nerves in three animals that were studied, more chronic lesions consisting of fibrosis and atrophy of the nerve suggested that the optic neuropathy follows compression of the nerve in the optic canal as a result of myelin edema. The toxic principle of the plant also caused a degenerative retinopathy in five animals. The essential histopathologic change was degeneration and loss of the photoreceptor outer segments predominantly in the nontapetal retina. These retinal lesions were associated with hyperplasia and hypertrophy and with migration of the pigmented epithelium, focal retinal separation, and depletion and loss of the nuclear layers.

Spongiform central nervous system myelinopathy in African dwarf goats

A novel spongiform myelinopathy of the central nervous system (CNS) of eleven African dwarf goats was examined by light and electron microscopy. Histological lesions consisted of extensive vacuolation predominantly of the white matter of the diencephalon, midbrain and cerebellar peduncles, as well as of spinal white matter. Ultrastructurally, vacuoles were shown to be intramyelinic, resulting from the splitting of the outer myelin lamellae at the intraperiod line. A few oligodendrocytes showed vacuolar degeneration of cell bodies and processes. Inflammatory reactions were absent. The observed lesions point to an unknown primary damage of oligodendroglia and central myelin. A hereditary background of the disorder is suspected as all investigated dwarf goats were half-brothers or -sisters and partly descended from the mating of adult females with their own sire.

Is demyelination a feature of maple syrup urine disease?

To determine whether disturbance of myelination is a pathophysiologic feature in patients with treated maple syrup urine disease (MSUD), neurophysiologic studies were performed in 10 MSUD patients ages 4-16 years. Afferent and efferent pathways were studied by visual evoked potentials, somatosensory evoked potentials, motor evoked potentials, stance-stabilizing reflexes, and peripheral nerve conduction velocity. Magnetic resonance imaging was used to detect possible cerebral white matter abnormalities. Visual evoked potentials were normal in all patients. There was only slight prolongation of central afferent and efferent conduction times and the long latency component of the stance-stabilizing reflexes. Peripheral nerve conduction studies revealed reduced sensory nerve conduction velocity in 3 patients. The neurophysiologic findings were not consistently correlated to the neurologic outcome of the patients. Magnetic resonance imaging did not reveal major abnormalities and demonstrated bilateral periventricular high intensity periventricular signals on T2-weighted images in 4 of 10 patients. It is concluded that dysmyelination is not a major pathophysiologic feature in patients with MSUD.

Inherited enzyme deficiencies in livestock

The biochemical basis of over 300 inherited diseases has been defined in humans, and the majority involve abnormalities in enzymes. The rate of discovery of new defects is accelerating as biochemical and molecular technologies improve. The majority of inherited defects are expressed before puberty and approximately 25% are apparent at birth. Genomes of other mammals are similar and have been subjected to similar mutation pressures; therefore, it is probable that a range of inherited defects exists in livestock similar to that in humans. Because modern livestock populations have emerged from small population bases, the range of genetic aberrations, within breeds, will be less than in the general human population. Even if there is a 10-fold difference, however, there will be a bewildering array of defects possible in each breed. Because the level of inbreeding within livestock populations is greater than in the general human population, on the other hand, the prevalence of specific defects will be higher. It is probable that a high prevalence of a lethal recessive defect could occur within a particular livestock population and escape recognition. First, livestock producers accept a relatively high neonatal mortality rate without seeking a diagnosis. Second, few if any veterinary diagnostic facilities possess either the instrumentation or the analytic skills essential for investigating the vast range of potential inborn errors of metabolism. Third, national selection programs--e.g., those employed within the dairy industry--tend to use production data from adult progeny in selection. Consequently, the programs would not detect differences in fetal or neonatal mortality rates among descendants of specific sires until a deleterious defect had been widely disseminated.(ABSTRACT TRUNCATED AT 250 WORDS)

Glutamate and gamma-aminobutyric acid neurotransmitter systems in the acute phase of maple syrup urine disease and citrullinemia encephalopathies in newborn calves

Cerebral cortex tissue was obtained at autopsy from neonatal Poll Hereford calves with clinically confirmed maple syrup urine disease (MSUD), neonatal Holstein-Friesian calves with clinically confirmed citrullinemia, and matched controls. From this, synaptosomes were prepared for studies of neurotransmitter amino acid uptake and stimulus-induced release, and synaptic plasma membranes were obtained for studies of associated postsynaptic receptor binding sites. As well as having abnormal brain tissue concentrations of the pathognomic plasma amino acids (markedly increased levels of the branched-chain compounds valine, isoleucine, and leucine in MSUD; marked elevation of citrulline levels in citrullinemia), both groups of diseased animals showed reduced brain tissue concentrations of each of the transmitter amino acids glutamate, aspartate, and gamma-aminobutyric acid (GABA). Nontransmitter amino acids were generally unaffected in either disease. Citrullinemic calves showed a marked increase in brain glutamine concentration; in calves with MSUD, the glutamine concentration was raised, but to a much lesser extent. The Na(+)-dependent synaptosomal uptake of both glutamate and GABA was markedly reduced (to less than 50% of control values in both cases) in citrullinemic calves but was unaltered in calves with MSUD. Whereas synaptosomes from normal calves showed the expected stimulus-coupled release of transmitter amino acids, especially glutamate and aspartate, and no response to stimulus of nontransmitter amino acids, there was no increased release of transmitter amino acids in response to depolarization in synaptosomes from citrullinemic calves.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrastructural findings in spongy degeneration of white matter in silver foxes (Vulpes vulpes). A naturally occurring demyelinating disease with oligodendrocyte vacuolation

Spongy degeneration of white matter in silver foxes is a naturally occurring, hereditary disorder. We report ultrastructural findings in the upper cervical cord of five perfusion-fixed foxes that were examined between 5 weeks and 2 1/4 years after the onset of clinical signs. Large cytoplasmic vacuoles in oligodendrocytes were present in the foxes examined 5, 12 and 20 weeks after the onset. Other early features of the disease were severe vacuolation of myelin sheaths, demyelination, expansion of extracellular spaces and hypertrophy of astrocytes. Evidence of partial demyelination as well as demyelination of entire internodes was found. In the later stages of the disease, the vacuolation was largely resolved but a marked astrogliosis persisted and numerous remyelinated axons were present in the gliotic areas. Vacuolation of oligodendrocytes and partial demyelination has not previously been seen together in a single disease process. The relationship between oligodendrocyte vacuolation, myelin sheath vacuolation and demyelination is discussed. It is concluded that the present condition is due to a primary damage to oligodendrocytes; however, the underlying biochemical lesion is not known.

Spongy degeneration of white matter in the central nervous system of silver foxes (Vulpes vulpes)

A disorder of central nervous white matter in Norwegian-bred silver foxes is described from the case histories of 21 clinically affected foxes. The main presenting sign of this disorder was caudal limb ataxia, which appeared between 2 1/2 and 4 months of age and progressed over the next 4-8 weeks. Only four affected foxes were allowed to live beyond this period, but they showed moderate to marked improvement. Light microscopic examination of specimens from 16 affected foxes necropsied between 3 1/2 and 6 1/2 months of age revealed lesions that were restricted to the white matter of brain and spinal cord. The lesions were characterized by a symmetrical spongy change with vacuoles of varying sizes and included significant myelin deficiency. There was a relative preservation of axons and nerve cells and no significant inflammation or vascular reaction. An astrocytic hypertrophy was usually associated with the spongy change. Ultrastructural examination of central nervous tissue from two, perfusion-fixed, 6-month-old foxes showed intramyelin vacuoles resulting from splitting of the myelin lamellae at the intraperiod line and was interpreted as indicating myelin edema. Expanded extracellular spaces and watery astrocytic processes also contributed to the vacuolar appearance. Astrocytic processes in affected areas were hypertrophic and contained abundant filaments. Although the 16 silver foxes had severe clinical signs, their lesions had features in common with the juvenile form of Canavan's disease in children and a spongy degeneration reported in Labrador Retrievers; however, the clinical course in the foxes was not uniformly progressive.

Maple syrup urine disease in calves: a clinical, pathological and biochemical study

The clinical, pathological and biochemical findings of a study of 30 Poll Hereford, Hereford, Poll Hereford cross or Hereford cross calves affected with branched chain ketoacid dehydrogenase (BCKAD) complex deficiency or maple syrup urine disease (MSUD) are presented. In breeding studies, 6 of 21 calves from obligate heterozygote matings were affected with MSUD, suggesting the disease is inherited in an autosomal recessive manner. Calves were clinically affected from birth, but there were variations in the subsequent course of progressive deterioration of central nervous system function. Concentrations of the branched chain amino acids and keto acids were elevated in pre-suckle plasma and cerebellar water content was higher in affected calves. Activity of BCKAD complex was minimal in fibroblasts cultured from an affected calf. Spongiform encephalopathy and elevated ratios of the branched to straight chain amino acids in formalin fixed cerebral tissue were found in a stillborn foetus and a 3-month-old Hereford calf. These findings suggest the disease occurs prenatally and that a delayed form may exist.

Ultrastructural findings in citrullinaemia in Holstein-Friesian calves

Ultrastructural findings in the brains and livers of four calves affected with citrullinaemia due to a hereditary deficiency of the urea cycle enzyme arginosuccinate synthetase are described. The calves were affected in the 1st week of life with severe neurological disease characterised by depression, head pressing, stupor, convulsions and coma, accompanied by marked elevation of plasma citrulline and increasing plasma ammonia levels. Lesions included mild to moderate diffuse astroglial oedema in the cerebrocortical grey matter, and mild to severe hepatocellular hydropic change. The onset of the severe neurological signs was correlated with increasing levels of plasma ammonia, and the cerebral lesions were considered consistent with a bovine hyperammonaemic encephalopathy.