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Gold JI, Madhavan S, Park J, Zouk H, Perez E, Strong A, Drivas TG, Karaa A, Yudkoff M, Rader D, Green RC, Gold NB. Phenotypes of undiagnosed adults with actionable OTC and GLA variants. HGG ADVANCES 2023; 4:100226. [PMID: 37593415 PMCID: PMC10428110 DOI: 10.1016/j.xhgg.2023.100226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/21/2023] [Indexed: 08/19/2023] Open
Abstract
Inherited metabolic disorders (IMDs) are variably expressive, complicating identification of affected individuals. A genotype-first approach can identify individuals at risk for morbidity and mortality from undiagnosed IMDs and can lead to protocols that improve clinical detection, counseling, and management. Using data from 57,340 participants in two hospital biobanks, we assessed the frequency and phenotypes of individuals with pathogenic/likely pathogenic variants (PLPVs) in two IMD genes: GLA, associated with Fabry disease, and OTC, associated with ornithine transcarbamylase deficiency. Approximately 1 in 19,100 participants harbored an undiagnosed PLPV in GLA or OTC. We identified three individuals (2 male, 1 female) with PLPVs in GLA, all of whom were undiagnosed, and three individuals (3 female) with PLPVs in OTC, two of whom were undiagnosed. All three individuals with PLPVs in GLA (100%) had symptoms suggestive of mild Fabry disease, and one individual (14.2%) had an ischemic stroke at age 33, likely indicating the presence of classic disease. No individuals with PLPVs in OTC had documented hyperammonemia despite exposure to catabolic states, but all (100%) had chronic symptoms suggestive of attenuated disease, including mood disorders and migraines. Our findings suggest that GLA and OTC variants identified via a genotype-first approach are of high penetrance and that population screening of these genes can be used to facilitate stepwise phenotyping and appropriate care.
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Affiliation(s)
- Jessica I. Gold
- Division of Human Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia; Philadelphia, PA, USA
| | - Sarina Madhavan
- Harvard Medical School, Boston, MA, USA
- Harvard Business School, Cambridge, MA, USA
| | - Joseph Park
- Department of Genetics, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Hana Zouk
- Harvard Medical School, Boston, MA, USA
- Laboratory for Molecular Medicine, Mass General Brigham Personalized Medicine, Cambridge MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Emma Perez
- Mass General Brigham Personalized Medicine, Cambridge MA, USA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Alanna Strong
- Division of Human Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia; Philadelphia, PA, USA
- Division of Human Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Applied Genomics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Theodore G. Drivas
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Amel Karaa
- Massachusetts General Hospital for Children, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Marc Yudkoff
- Division of Human Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia; Philadelphia, PA, USA
- Division of Human Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel Rader
- Department of Genetics, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Regeneron Genetics Center
- Division of Human Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia; Philadelphia, PA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard Business School, Cambridge, MA, USA
- Department of Genetics, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Laboratory for Molecular Medicine, Mass General Brigham Personalized Medicine, Cambridge MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Mass General Brigham Personalized Medicine, Cambridge MA, USA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Human Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Applied Genomics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Massachusetts General Hospital for Children, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Broad Institute, Boston, MA, USA
- Ariadne Labs, Boston, MA, USA
| | - Penn Medicine BioBank
- Division of Human Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia; Philadelphia, PA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard Business School, Cambridge, MA, USA
- Department of Genetics, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Laboratory for Molecular Medicine, Mass General Brigham Personalized Medicine, Cambridge MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Mass General Brigham Personalized Medicine, Cambridge MA, USA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Human Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Applied Genomics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Massachusetts General Hospital for Children, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Broad Institute, Boston, MA, USA
- Ariadne Labs, Boston, MA, USA
| | - Robert C. Green
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Broad Institute, Boston, MA, USA
- Ariadne Labs, Boston, MA, USA
| | - Nina B. Gold
- Massachusetts General Hospital for Children, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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2
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Whitehead MT, Lai LM, Blüml S. Clinical 1H MRS in childhood neurometabolic diseases — part 2: MRS signatures. Neuroradiology 2022; 64:1111-1126. [DOI: 10.1007/s00234-022-02918-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/10/2022] [Indexed: 12/23/2022]
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Sen K, Whitehead M, Castillo Pinto C, Caldovic L, Gropman A. Fifteen years of urea cycle disorders brain research: Looking back, looking forward. Anal Biochem 2022; 636:114343. [PMID: 34637785 PMCID: PMC8671367 DOI: 10.1016/j.ab.2021.114343] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/13/2021] [Accepted: 08/17/2021] [Indexed: 01/03/2023]
Abstract
Urea cycle disorders (UCD) are inherited diseases resulting from deficiency in one of six enzymes or two carriers that are required to remove ammonia from the body. UCD may be associated with neurological damage encompassing a spectrum from asymptomatic/mild to severe encephalopathy, which results in most cases from Hyperammonemia (HA) and elevation of other neurotoxic intermediates of metabolism. Electroencephalography (EEG), Magnetic resonance imaging (MRI) and Proton Magnetic resonance spectroscopy (MRS) are noninvasive measures of brain function and structure that can be used during HA to guide management and provide prognostic information, in addition to being research tools to understand the pathophysiology of UCD associated brain injury. The Urea Cycle Rare disorders Consortium (UCDC) has been invested in research to understand the immediate and downstream effects of hyperammonemia (HA) on brain using electroencephalogram (EEG) and multimodal brain MRI to establish early patterns of brain injury and to track recovery and prognosis. This review highlights the evolving knowledge about the impact of UCD and HA in particular on neurological injury and recovery and use of EEG and MRI to study and evaluate prognostic factors for risk and recovery. It recognizes the work of others and discusses the UCDC's prior work and future research priorities.
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Affiliation(s)
- Kuntal Sen
- Division of Neurogenetics and Neurodevelopmental Pediatrics, Children's National Hospital, Washington D.C., United States
| | - Matthew Whitehead
- Division of Radiology, Children's National Hospital, Washington D.C., United States
| | | | - Ljubica Caldovic
- Childrens' Research Institute, Children's National Hospital, Washington D.C., United States
| | - Andrea Gropman
- Division of Neurogenetics and Neurodevelopmental Pediatrics, Children's National Hospital, Washington D.C., United States.
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Eskander PN, Romani SS. Transient Cortical Blindness in a Toddler With Heterozygous Ornithine Transcarbamylase Deficiency. Cureus 2021; 13:e20046. [PMID: 34987927 PMCID: PMC8717935 DOI: 10.7759/cureus.20046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 11/11/2022] Open
Abstract
Ornithine transcarbamylase (OTC) deficiency is an incredibly rare disease in the subgroup of urea cycle disorders. Although typically seen in the neonate shortly after initiating high protein feeds (human breastmilk or infant formula), patients with partial/heterozygous deficiencies can often be diagnosed later in life with unique sequelae. One such manifestation is sudden, transient vision loss shortly after an initial episode of hyperammonemia in a patient without a known diagnosis of OTC deficiency. Only two such occurrences are documented in academic literature and both share many similar presenting features hinting that a hidden, but the consistent pathophysiologic mechanism of this disease is at play. Scarce research is available to propose a concise explanation; however, recent advancements in the literature point toward the brain’s inability to uptake glucose and convert it into glutamate in patients with partial OTC deficiency as a likely explanation.
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Meyers SP. Intracranial Abnormalities with Diffusion Restriction. Magn Reson Imaging Clin N Am 2021; 29:137-161. [PMID: 33902900 DOI: 10.1016/j.mric.2021.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Multiple pathologic conditions can cause changes in the random movement of water, which can be detected with diffusion-weighted imaging (DWI). DWI plays a powerful clinical role in detecting restricted diffusion associated with acute brain infarction. Other disorders can also result in restricted diffusion. This article focuses on showing examples of common and uncommon disorders that have restricted diffusion secondary to cytotoxic and/or intramyelinic edema. These disorders include ischemia, infection, noninfectious demyelinating diseases, genetic mutations affecting metabolism, acquired metabolic disorders, toxic or drug exposures, neoplasms and tumorlike lesions, radiation treatment, trauma, and denervation.
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Affiliation(s)
- Steven P Meyers
- Department of Radiology/Imaging Sciences, University of Rochester Medical Center, University Medical Imaging, 4901 Lac de Ville Boulevard, Building D - Suite 140, Rochester, NY 14618, USA.
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Sen K, Anderson AA, Whitehead MT, Gropman AL. Review of Multi-Modal Imaging in Urea Cycle Disorders: The Old, the New, the Borrowed, and the Blue. Front Neurol 2021; 12:632307. [PMID: 33995244 PMCID: PMC8113618 DOI: 10.3389/fneur.2021.632307] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/26/2021] [Indexed: 12/16/2022] Open
Abstract
The urea cycle disorders (UCD) are rare genetic disorder due to a deficiency of one of six enzymes or two transport proteins that act to remove waste nitrogen in form of ammonia from the body. In this review, we focus on neuroimaging studies in OTCD and Arginase deficiency, two of the UCD we have extensively studied. Ornithine transcarbamylase deficiency (OTCD) is the most common of these, and X-linked. Hyperammonemia (HA) in OTCD is due to deficient protein handling. Cognitive impairments and neurobehavioral disorders have emerged as the major sequelae in Arginase deficiency and OTCD, especially in relation to executive function and working memory, impacting pre-frontal cortex (PFC). Clinical management focuses on neuroprotection from HA, as well as neurotoxicity from other known and yet unclassified metabolites. Prevention and mitigation of neurological injury is a major challenge and research focus. Given the impact of HA on neurocognitive function of UCD, neuroimaging modalities, especially multi-modality imaging platforms, can bring a wealth of information to understand the neurocognitive function and biomarkers. Such information can further improve clinical decision making, and result in better therapeutic interventions. In vivo investigations of the affected brain using multimodal neuroimaging combined with clinical and behavioral phenotyping hold promise. MR Spectroscopy has already proven as a tool to study biochemical aberrations such as elevated glutamine surrounding HA as well as to diagnose partial UCD. Functional Near Infrared Spectroscopy (fNIRS), which assesses local changes in cerebral hemodynamic levels of cortical regions, is emerging as a non-invasive technique and will serve as a surrogate to fMRI with better portability. Here we review two decades of our research using non-invasive imaging and how it has contributed to an understanding of the cognitive effects of this group of genetic conditions.
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Affiliation(s)
- Kuntal Sen
- Division of Neurogenetics and Neurodevelopmental Pediatrics, Department of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, United States
| | - Afrouz A Anderson
- Department of Research, Focus Foundation, Crofton, MD, United States
| | - Matthew T Whitehead
- Department of Radiology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, United States
| | - Andrea L Gropman
- Division of Neurogenetics and Neurodevelopmental Pediatrics, Department of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, United States
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7
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McGowan M, Ferreira C, Whitehead M, Basu SK, Chang T, Gropman A. The Application of Neurodiagnostic Studies to Inform the Acute Management of a Newborn Presenting With Sarbamoyl Shosphate Synthetase 1 Deficiency. Child Neurol Open 2021; 8:2329048X20985179. [PMID: 33644249 PMCID: PMC7841664 DOI: 10.1177/2329048x20985179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 11/14/2020] [Accepted: 12/06/2020] [Indexed: 11/17/2022] Open
Abstract
Neonatal-onset urea cycle disorders (UCDs) may result in hyperammonemic (HA) encephalopathy presenting with several neurologic sequelae including seizures, coma, and death. However, no recommendations are given in how and when neurodiagnostic studies should be used to screen or assess for these neurologic complications. We present a case of carbamoyl phosphate synthetase 1 (CPS1) deficiency in a newborn female in which electroencephalogram monitoring to assess encephalopathy and seizures, and magnetic resonance imaging measurements of brain metabolites were used to guide care during her hyperammonemic crisis. Her neurologic course and response to treatment characterizes the significant neurologic impact of HA encephalopathy. Our group herein proposes a clinical neurodiagnostic pathway for managing acute HA encephalopathy.
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Affiliation(s)
- Meaghan McGowan
- University of Illinois College of Medicine, Chicago, IL,
USA
| | - Carlos Ferreira
- Medical Genomics and Metabolic Genetics Branch, National
Human Genome Research Institute, NIH, Bethesda, MD, USA
| | - Matthew Whitehead
- Neuroradiology, Children’s National Hospital, George
Washington University School of Medicine, Washington, DC, USA
| | - Sudeepta K. Basu
- Neonatology, Children’s National Hospital, George Washington
University School of Medicine, Washington, DC, USA
| | - Taeun Chang
- Neurology, Children’s National Hospital, George Washington
University School of Medicine, Washington, DC, USA
| | - Andrea Gropman
- Neurology, Children’s National Hospital, George Washington
University School of Medicine, Washington, DC, USA
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8
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Ozturk K, McKinney AM, Nascene D. Urea Cycle Disorders: A Neuroimaging Pattern Approach Using Diffusion and FLAIR MRI. J Neuroimaging 2020; 31:144-150. [PMID: 32920938 DOI: 10.1111/jon.12787] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/29/2020] [Accepted: 08/31/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND PURPOSE This study aimed to assess characteristic regions of MRI involvement utilizing diffusion weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) at urea cycle disorder (UCD) diagnosis to determine the possible association between initial MRI patterns within 10 days of the first hyperammonemia episode, serum ammonia levels, and severity of neurological outcome based on clinical follow-up of >30 days. METHODS Ten patients with UCDs (4 females; median age: 5.4 years, age range: 6 days-54 years) were included who underwent MRI during a first episode of hyperammonemia. The topographical distribution of the DWI and FLAIR abnormalities in the cerebral cortex, deep gray matter, white matter, posterior limb of internal capsule, cerebral peduncle, and cerebellum was evaluated. Possible correlations between the brain injury patterns on DWI/FLAIR images, serum ammonia levels, and severity of neurological outcome were investigated by a trend correlation. RESULTS The UCD cohort (n = 10) involved four ornithine transcarbamoylase deficiencies, four argininosuccinic aciduria, one carbomoylphosphate synthetase deficiency, and one citrullinemia type-1. The observed trend in the distribution of DWI abnormalities as the severity of neurological sequela outcome increased was with diffuse cerebral cortex or corpus striatum involvement. Patients with initial peak serum ammonia ≥450 µmol/L had a grade 2 to 4 outcome, and those with peak ammonia <450 µmol/L had a grade 0 or 1 outcome. CONCLUSIONS The presence of more severe neurological outcome could be associated with diffuse cerebral cortex or corpus striatum involvement on DWI and high serum ammonia levels in patients with UCD.
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Affiliation(s)
- Kerem Ozturk
- Department of Radiology, University of Minnesota, Minneapolis, MN
| | - Alexander M McKinney
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL
| | - David Nascene
- Department of Radiology, University of Minnesota, Minneapolis, MN
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Sen K, Whitehead MT, Gropman AL. Multimodal imaging in urea cycle-related neurological disease - What can imaging after hyperammonemia teach us? ACTA ACUST UNITED AC 2020; 5:87-95. [PMID: 33344172 PMCID: PMC7739971 DOI: 10.3233/trd-200048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Urea cycle-related brain disease may take on variable neuroimaging manifestations, ranging from normal to abnormal with or without a signature appearance. In the past, we have described the usefulness of multimodal imaging in identifying biomarkers of neuronal injury in UCD patients. In this study, we report unique findings in an adolescent male with neonatal-onset OTC deficiency after an episode of hyperammonemia. MATERIALS AND METHODS Multiplanar, multisequence MR imaging (T1WI, T2WI, T2 FLAIR, diffusion weighted images and gradient echo) of the brain was performed on seven separate occasions over the course following the acute illness; first five exams were performed within 28 days of admission and the final two exams were performed approximately 3 and 5 months later. RESULTS 1.The initial MR revealed increased signal on T2WI in the basal ganglia, claustrum and frontoparietal white matter; which remained stable over time. By the 5th exam, signal changes had developed in frontal cortex; reflecting permanent injury. 2. DTI tractography of the corticospinal tracts displayed revealed diminution of the number of projectional and commissural fibers over time. 3. Blood flow measurements demonstrated hypoperfusion on the fifth exams followed by hyperperfusion on the final two studies. 4. MR spectroscopy demonstrated that glutamine was elevated during hyperammonemia with myoinositol reduction, reflecting osmotic buffering. CONCLUSION This particular multimodal magnetic resonance neuroimaging showed novel, temporally specific manifestations over the disease course in OTC deficiency. This prospective imaging study expands our understanding of the effect of hyperammonemia on the structure and biochemistry of the nervous system.
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Affiliation(s)
- Kuntal Sen
- Division of Neurogenetics and Developmental Pediatrics, Center for Neuroscience and Behavioral Medicine, Children's National Hospital, Washington, DC, USA
| | - Matthew T Whitehead
- Department of Radiology, Children's National Hospital, Washington, DC, USA.,George Washington University of Medicine and Health Sciences, Washington, DC, USA
| | - Andrea L Gropman
- Division of Neurogenetics and Developmental Pediatrics, Center for Neuroscience and Behavioral Medicine, Children's National Hospital, Washington, DC, USA.,George Washington University of Medicine and Health Sciences, Washington, DC, USA
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10
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Petley E, Prasad M, Ojha S, Whitehouse WP. Investigating ataxia in childhood. Arch Dis Child Educ Pract Ed 2020; 105:214-221. [PMID: 31645356 DOI: 10.1136/archdischild-2018-315893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 08/12/2019] [Accepted: 09/18/2019] [Indexed: 12/17/2022]
Abstract
Ataxia is a common presentation to an acute paediatric unit and it can often be difficult to determine the cause. It is important to distinguish between serious causes, for example, brain tumours and encephalitis, and more benign causes in order to guide investigations and treatment. In this review, we describe the different types of ataxia, the causes associated with them, the examination findings and what investigations to perform in order to make a diagnosis.
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Affiliation(s)
- Emily Petley
- Academic Division of Child Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Manish Prasad
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Shalini Ojha
- Academic Division of Child Health, School of Medicine, University of Nottingham, Nottingham, UK.,Derbyshire Children's Hospital, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - William P Whitehouse
- Academic Division of Child Health, School of Medicine, University of Nottingham, Nottingham, UK .,Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Nicolas-Jilwan M, Medlej R, Sulaiman RA, AlSayed M. The neuroimaging findings of monocarboxylate transporter 1 deficiency. Neuroradiology 2020; 62:891-894. [PMID: 32318771 DOI: 10.1007/s00234-020-02435-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 04/13/2020] [Indexed: 11/26/2022]
Abstract
Monocarboxylate transporter 1 (MCT1) deficiency was first described in 2014 by Hasselt et al. as a novel genetic cause of recurrent ketoacidosis. Patients present in the first year of life with acute episodes of ketoacidosis triggered by fasting or infections. Patients with homozygous mutations are known to have a more severe phenotype with mild to moderate developmental delay and an increased prevalence of epilepsy. There is only one recent report of the neuroimaging findings of this disorder as reported by Al-Khawaga et al. (Front Pediatr. 7:299, 2019). We report the neuroimaging abnormalities in two siblings with similar clinical presentation of recurrent ketoacidosis, seizures, and developmental delay. Whole exome sequencing in the younger sibling confirmed a known pathogenic homozygous mutation in MCT1, also known as SLC16A1 gene. Brain MRI showed a similar very distinctive pattern of signal abnormality at the gray-white matter junction, basal ganglia, and thalami in both patients. Both siblings had agenesis of the corpus callosum. Knowledge of this pattern of brain involvement might contribute to an earlier diagnosis and timely management of this rare and under recognized disorder.
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Affiliation(s)
- Manal Nicolas-Jilwan
- Division of Neuroradiology, Department of Radiology, King Faisal Specialist Hospital and Research Centre, Al Zahrawi Street, Riyadh, 11211, Saudi Arabia.
| | - Rita Medlej
- Department of Endocrinology, Hotel-Dieu de France Hospital, Alfred Naccache Boulevard, Beirut, Lebanon
| | - Raashda A Sulaiman
- Department of Medical Genetics, King Faisal Specialist Hospital and Research Centre, Al Zahrawi Street, Riyadh, 11211, Saudi Arabia
| | - Moeenaldeen AlSayed
- Department of Medical Genetics, King Faisal Specialist Hospital and Research Centre, Al Zahrawi Street, Riyadh, 11211, Saudi Arabia
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Häberle J, Burlina A, Chakrapani A, Dixon M, Karall D, Lindner M, Mandel H, Martinelli D, Pintos-Morell G, Santer R, Skouma A, Servais A, Tal G, Rubio V, Huemer M, Dionisi-Vici C. Suggested guidelines for the diagnosis and management of urea cycle disorders: First revision. J Inherit Metab Dis 2019; 42:1192-1230. [PMID: 30982989 DOI: 10.1002/jimd.12100] [Citation(s) in RCA: 249] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/04/2019] [Accepted: 04/08/2019] [Indexed: 02/06/2023]
Abstract
In 2012, we published guidelines summarizing and evaluating late 2011 evidence for diagnosis and therapy of urea cycle disorders (UCDs). With 1:35 000 estimated incidence, UCDs cause hyperammonemia of neonatal (~50%) or late onset that can lead to intellectual disability or death, even while effective therapies do exist. In the 7 years that have elapsed since the first guideline was published, abundant novel information has accumulated, experience on newborn screening for some UCDs has widened, a novel hyperammonemia-causing genetic disorder has been reported, glycerol phenylbutyrate has been introduced as a treatment, and novel promising therapeutic avenues (including gene therapy) have been opened. Several factors including the impact of the first edition of these guidelines (frequently read and quoted) may have increased awareness among health professionals and patient families. However, under-recognition and delayed diagnosis of UCDs still appear widespread. It was therefore necessary to revise the original guidelines to ensure an up-to-date frame of reference for professionals and patients as well as for awareness campaigns. This was accomplished by keeping the original spirit of providing a trans-European consensus based on robust evidence (scored with GRADE methodology), involving professionals on UCDs from nine countries in preparing this consensus. We believe this revised guideline, which has been reviewed by several societies that are involved in the management of UCDs, will have a positive impact on the outcomes of patients by establishing common standards, and spreading and harmonizing good practices. It may also promote the identification of knowledge voids to be filled by future research.
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Affiliation(s)
- Johannes Häberle
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
| | - Alberto Burlina
- Division of Inborn Metabolic Disease, Department of Pediatrics, University Hospital Padua, Padova, Italy
| | - Anupam Chakrapani
- Department of Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marjorie Dixon
- Dietetics, Great Ormond Street Hospital for Children, NHS Trust, London, UK
| | - Daniela Karall
- Clinic for Pediatrics, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Lindner
- University Children's Hospital, Frankfurt am Main, Germany
| | - Hanna Mandel
- Institute of Human Genetics and metabolic disorders, Western Galilee Medical Center, Nahariya, Israel
| | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children's Hospital, Rome, Italy
| | - Guillem Pintos-Morell
- Centre for Rare Diseases, University Hospital Vall d'Hebron, Barcelona, Spain
- CIBERER_GCV08, Research Institute IGTP, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - René Santer
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anastasia Skouma
- Institute of Child Health, Agia Sofia Children's Hospital, Athens, Greece
| | - Aude Servais
- Service de Néphrologie et maladies métaboliques adulte Hôpital Necker 149, Paris, France
| | - Galit Tal
- The Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
| | - Vicente Rubio
- Instituto de Biomedicina de Valencia (IBV-CSIC), Centro de Investigación Biomédica en Red para Enfermedades Raras (CIBERER), Valencia, Spain
| | - Martina Huemer
- University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
- Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria
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Yao X, Xu C, Cao Y, Lin L, Wu H, Wang C. Early metabolic characterization of brain tissues after whole body radiation based on gas chromatography–mass spectrometry in a rat model. Biomed Chromatogr 2018; 33:e4448. [DOI: 10.1002/bmc.4448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 11/12/2018] [Accepted: 11/24/2018] [Indexed: 01/02/2023]
Affiliation(s)
- Xueting Yao
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Medical College of Soochow University, Collaborative Innovation Center of Radiological Medicine of Jiangsu Higher Education Institutions, School for Radiological and Interdisciplinary Sciences (RAD‐X)Jiangsu Provincial Key Laboratory of Radiation Medicine and Protection Suzhou P. R. China
| | - Chao Xu
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Medical College of Soochow University, Collaborative Innovation Center of Radiological Medicine of Jiangsu Higher Education Institutions, School for Radiological and Interdisciplinary Sciences (RAD‐X)Jiangsu Provincial Key Laboratory of Radiation Medicine and Protection Suzhou P. R. China
| | - Yurong Cao
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Medical College of Soochow University, Collaborative Innovation Center of Radiological Medicine of Jiangsu Higher Education Institutions, School for Radiological and Interdisciplinary Sciences (RAD‐X)Jiangsu Provincial Key Laboratory of Radiation Medicine and Protection Suzhou P. R. China
| | - Lin Lin
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Medical College of Soochow University, Collaborative Innovation Center of Radiological Medicine of Jiangsu Higher Education Institutions, School for Radiological and Interdisciplinary Sciences (RAD‐X)Jiangsu Provincial Key Laboratory of Radiation Medicine and Protection Suzhou P. R. China
| | - Hanxu Wu
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Medical College of Soochow University, Collaborative Innovation Center of Radiological Medicine of Jiangsu Higher Education Institutions, School for Radiological and Interdisciplinary Sciences (RAD‐X)Jiangsu Provincial Key Laboratory of Radiation Medicine and Protection Suzhou P. R. China
| | - Chang Wang
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Medical College of Soochow University, Collaborative Innovation Center of Radiological Medicine of Jiangsu Higher Education Institutions, School for Radiological and Interdisciplinary Sciences (RAD‐X)Jiangsu Provincial Key Laboratory of Radiation Medicine and Protection Suzhou P. R. China
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Bozinov N, Han M, Lau W, Santini V. Late diagnosis of a rare urea cycle disorder mimicking Kleine-Levin syndrome. Neurol Clin Pract 2018; 8:e43-e45. [DOI: 10.1212/cpj.0000000000000547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/11/2018] [Indexed: 11/15/2022]
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15
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Maines E, Piccoli G, Pascarella A, Colucci F, Burlina AB. Inherited hyperammonemias: a Contemporary view on pathogenesis and diagnosis. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2018.1409108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Evelina Maines
- Pediatric Unit, Provincial Centre for Rare Diseases, Department of Women’s and Children’s Health, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Giovanni Piccoli
- CIBIO - Centre for integrative biology, Università degli Studi di Trento, Italy & Dulbecco Telethon Institute, Trento, Italy
| | - Antonia Pascarella
- Division of Inherited Metabolic Diseases, Reference Centre Expanded Newborn Screening, Department of Women’s and Children’s Health, University Hospital, Padova, Italy
| | - Francesca Colucci
- Division of Inherited Metabolic Diseases, Reference Centre Expanded Newborn Screening, Department of Women’s and Children’s Health, University Hospital, Padova, Italy
| | - Alberto B. Burlina
- Division of Inherited Metabolic Diseases, Reference Centre Expanded Newborn Screening, Department of Women’s and Children’s Health, University Hospital, Padova, Italy
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16
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Bailly P, Noury JB, Timsit S, Ben Salem D. Teaching NeuroImages: Ornithine transcarbamylase deficiency revealed by a coma in a pregnant woman. Neurology 2016; 85:e146-7. [PMID: 26574542 DOI: 10.1212/wnl.0000000000002131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Pierre Bailly
- From the Services of Neurologie (P.B., J.-B.N., S.T.) and Radiologie (D.B.S.), Hôpital de la Cavale Blanche, Brest Cedex, France.
| | - Jean-Baptiste Noury
- From the Services of Neurologie (P.B., J.-B.N., S.T.) and Radiologie (D.B.S.), Hôpital de la Cavale Blanche, Brest Cedex, France
| | - Serge Timsit
- From the Services of Neurologie (P.B., J.-B.N., S.T.) and Radiologie (D.B.S.), Hôpital de la Cavale Blanche, Brest Cedex, France
| | - Douraied Ben Salem
- From the Services of Neurologie (P.B., J.-B.N., S.T.) and Radiologie (D.B.S.), Hôpital de la Cavale Blanche, Brest Cedex, France
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17
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Dahmoush HM, Melhem ER, Vossough A. Metabolic, endocrine, and other genetic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2016; 136:1221-1259. [PMID: 27430466 DOI: 10.1016/b978-0-444-53486-6.00063-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Metabolic, endocrine, and genetic diseases of the brain include a very large array of disorders caused by a wide range of underlying abnormalities and involving a variety of brain structures. Often these disorders manifest as recognizable, though sometimes overlapping, patterns on neuroimaging studies that may enable a diagnosis based on imaging or may alternatively provide enough clues to direct further diagnostic evaluation. The diagnostic workup can include various biochemical laboratory or genetic studies. In this chapter, after a brief review of normal white-matter development, we will describe a variety of leukodystrophies resulting from metabolic disorders involving the brain, including mitochondrial and respiratory chain diseases. We will then describe various acidurias, urea cycle disorders, disorders related to copper and iron metabolism, and disorders of ganglioside and mucopolysaccharide metabolism. Lastly, various other hypomyelinating and dysmyelinating leukodystrophies, including vanishing white-matter disease, megalencephalic leukoencephalopathy with subcortical cysts, and oculocerebrorenal syndrome will be presented. In the following section on endocrine disorders, we will examine various disorders of the hypothalamic-pituitary axis, including developmental, inflammatory, and neoplastic diseases. Neonatal hypoglycemia will also be briefly reviewed. In the final section, we will review a few of the common genetic phakomatoses. Throughout the text, both imaging and brief clinical features of the various disorders will be discussed.
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Affiliation(s)
- Hisham M Dahmoush
- Department of Radiology, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, USA
| | - Elias R Melhem
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, MD, USA
| | - Arastoo Vossough
- Department of Radiology, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, USA.
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18
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In Vivo NMR Studies of the Brain with Hereditary or Acquired Metabolic Disorders. Neurochem Res 2015; 40:2647-85. [PMID: 26610379 DOI: 10.1007/s11064-015-1772-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 11/10/2015] [Accepted: 11/12/2015] [Indexed: 01/09/2023]
Abstract
Metabolic disorders, whether hereditary or acquired, affect the brain, and abnormalities of the brain are related to cellular integrity; particularly in regard to neurons and astrocytes as well as interactions between them. Metabolic disturbances lead to alterations in cellular function as well as microscopic and macroscopic structural changes in the brain with diabetes, the most typical example of metabolic disorders, and a number of hereditary metabolic disorders. Alternatively, cellular dysfunction and degeneration of the brain lead to metabolic disturbances in hereditary neurological disorders with neurodegeneration. Nuclear magnetic resonance (NMR) techniques allow us to assess a range of pathophysiological changes of the brain in vivo. For example, magnetic resonance spectroscopy detects alterations in brain metabolism and energetics. Physiological magnetic resonance imaging (MRI) detects accompanying changes in cerebral blood flow related to neurovascular coupling. Diffusion and T1/T2-weighted MRI detect microscopic and macroscopic changes of the brain structure. This review summarizes current NMR findings of functional, physiological and biochemical alterations within a number of hereditary and acquired metabolic disorders in both animal models and humans. The global view of the impact of these metabolic disorders on the brain may be useful in identifying the unique and/or general patterns of abnormalities in the living brain related to the pathophysiology of the diseases, and identifying future fields of inquiry.
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19
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Zuccoli G, Yannes MP, Nardone R, Bailey A, Goldstein A. Bilateral symmetrical basal ganglia and thalamic lesions in children: an update (2015). Neuroradiology 2015; 57:973-89. [DOI: 10.1007/s00234-015-1568-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 07/15/2015] [Indexed: 01/09/2023]
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20
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Posterior fossa syndrome in a patient with an ornithine transcarbamylase deficiency. Eur J Paediatr Neurol 2015; 19:364-6. [PMID: 25687292 DOI: 10.1016/j.ejpn.2014.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 12/01/2014] [Accepted: 12/09/2014] [Indexed: 11/20/2022]
Abstract
UNLABELLED The posterior fossa syndrome (PFS) is a well-known clinical entity and mainly occurs in children. Ornithine transcarbamylase deficiency (OTC) is the most common urea cycle disorder, which occurs in an estimated 1 per 50.000 live births in Japan. Symptoms are mostly due to hyperammonemia and include nausea, vomiting, lethargia and even convulsions and coma. Common neurological symptoms at presentation of a hyperammonemia are a decreased level of consciousness, abnormal motor function or seizures. In this case we describe a girl with late onset OCT deficiency presenting with transient mutism and subsequent dysarthria, ataxia and behavioural changes. This is an exceptional report of a not yet described neurologic syndrome in OTC. SYNOPSIS Neurologic symptoms in ornithine transcarbamylase deficiency do not only occur during an episode of hyperammonemia and may present as a transient neurologic symptoms compatible with the posterior fossa syndrome.
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Abstract
MRI performed in the neonatal period has become a tool widely used by clinicians and researchers to evaluate the developing brain. MRI can provide detailed anatomical resolution, enabling identification of brain injuries due to various perinatal insults. This review will focus on the link between neonatal MRI findings and later neurodevelopmental outcomes in high-risk term infants. In particular, the role of conventional and advanced MR imaging in prognosticating outcomes in neonates with hypoxic-ischemic encephalopathy, ischemic perinatal stroke, need for extracorporeal membrane oxygenation life support, congenital heart disease, and other neonatal neurological conditions will be discussed.
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Affiliation(s)
- An N Massaro
- Department of Pediatrics, The George Washington University School of Medicine, 111 Michigan Ave, NW Washington, DC 20010.
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22
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Inborn errors of metabolism: combining clinical and radiologic clues to solve the mystery. AJR Am J Roentgenol 2014; 203:W315-27. [PMID: 25148190 DOI: 10.2214/ajr.13.11154] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Inborn errors of metabolism in children can be challenging to interpret because of the similarity of their appearances on imaging. There are important clues to the diagnosis based on clinical history, head circumference (e.g., macrocephaly), geographic distribution of lesions (e.g., subcortical vs deep white matter or frontal vs parietooccipital), and other imaging features (e.g., contrast enhancement, calcification, cysts, and cortical dysplasia). CONCLUSION In this article, we present an algorithm-based approach to diagnosing pediatric metabolic disease with a discussion of key imaging features.
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Ruder J, Legacy J, Russo G, Davis R. Neonatal citrullinemia: novel, reversible neuroimaging findings correlated with ammonia level changes. Pediatr Neurol 2014; 51:553-6. [PMID: 25266618 DOI: 10.1016/j.pediatrneurol.2014.07.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 07/06/2014] [Accepted: 07/09/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Citrullinemia type I is an autosomal recessive disorder of the urea cycle in which a patient lacks the cytosolic enzyme, argininosuccinic acid synthetase. This enzyme deficiency results in elevated levels of ammonia, glutamine, and citrulline. The accumulation of ammonia and glutamine causes neurodegenerative changes that are detectible on magnetic resonance imaging. This is the first case report of citrullinemia with repeat magnetic resonance images and electroencephalographs in the acute phase of hyperammonemia. CASE This 3800 g white boy was born at 40 weeks 4 days gestation to a 25-year-old mother. He was delivered at home to a certified midwife with no reported complications. He was doing well until day of life 4, when the mother reported he would no longer latch to feed. He was observed to have markedly elevated ammonia levels and ultimately diagnosed with citrullinemia type I. The initial magnetic resonance image was markedly abnormal. After aggressive medical management, his repeat magnetic resonance image revealed marked improvement in the acute setting. CONCLUSION Early and aggressive management of hyperammonemia can result in improved magnetic resonance imaging findings in the acute setting. It is too early to know if this will translate to an improved clinical outcome. Clinical suspicion must remain high for urea cycle disorders in neonates with magnetic resonance image changes similar to those resulting from hypoxic-ischemic injury.
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Affiliation(s)
- John Ruder
- University of Central Florida College of Medicine, Orlando, Florida.
| | - Joseph Legacy
- University of Central Florida College of Medicine, Orlando, Florida
| | - George Russo
- Pediatric Neurology, PA and the Pediatric Epilepsy Center of Central Florida, Florida
| | - Ronald Davis
- Pediatric Neurology, PA and the Pediatric Epilepsy Center of Central Florida, Florida
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Pacheco-Colón I, Fricke S, VanMeter J, Gropman AL. Advances in urea cycle neuroimaging: Proceedings from the 4th International Symposium on urea cycle disorders, Barcelona, Spain, September 2013. Mol Genet Metab 2014; 113:118-26. [PMID: 25066103 PMCID: PMC4177962 DOI: 10.1016/j.ymgme.2014.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Accepted: 05/10/2014] [Indexed: 11/20/2022]
Abstract
Our previous imaging research performed as part of a Urea Cycle Rare Disorders Consortium (UCRDC) grant, has identified specific biomarkers of neurologic injury in ornithine transcarbamylase deficiency, OTCD. While characterization of mutations can be achieved in most cases, this information does not necessarily predict the severity of the underlying neurological syndrome. The biochemical consequences of any mutation may be modified additionally by a large number of factors, including contributions of other enzymes and transport systems that mediate flux through the urea cycle, diet and other environmental factors. These factors likely vary from one patient to another, and they give rise to heterogeneity of clinical severity. Affected cognitive domains include non-verbal learning, fine motor processing, reaction time, visual memory, attention, and executive function. Deficits in these capacities may be seen in symptomatic patients, as well as asymptomatic carriers with normal IQ and correlate with variances in brain structure and function in these patients. Using neuroimaging we can identify biomarkers that reflect the downstream impact of UCDs on cognition. This manuscript is a summary of the presentation from the 4th International Consortium on urea cycle disorders held in, Barcelona, Spain, September 2, 2014.
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Affiliation(s)
| | - Stanley Fricke
- Children's National Medical, USA; George Washington University, USA
| | - John VanMeter
- Center for Functional and Molecular Imaging, Georgetown University, USA
| | - Andrea L Gropman
- Center for Functional and Molecular Imaging, Georgetown University, USA; Children's National Medical, USA; George Washington University, USA.
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Kim SH, Lee JS, Lim BC, Kim KJ, Hwang YS, Park JD, Cheon JE, Kim IO, Kim BN, Chae JH. A female carrier of ornithine carbamoyltransferase deficiency masquerading as attention deficit-hyperactivity disorder. Brain Dev 2014; 36:734-7. [PMID: 24199608 DOI: 10.1016/j.braindev.2013.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 09/24/2013] [Accepted: 09/30/2013] [Indexed: 12/20/2022]
Abstract
Many females who are heterozygous for ornithine carbamoyltransferase (OTC) deficiency are asymptomatic or intermittently symptomatic with great phenotypic variability. Therefore, the diagnosis of this condition is occasionally a challenge and is often delayed. A 12-year-old girl who was initially diagnosed as having attention deficit-hyperactivity disorder (ADHD) became comatose and developed right-sided hemiparesis during her psychiatric admission. Brain magnetic resonance imaging indicated diffuse but extensive swelling in the left hemisphere with multiple lesions suggestive of an old infarction. Repeated evaluations revealed hyperammonemia and orotic aciduria, and she was diagnosed as having an OTC deficiency. Genetic analysis revealed a heterozygous mutation of N47I in the X-linked OTC gene. Her mental status and hemiparesis improved after hyperammonemia treatment. Here, we report a rare case of a manifestating female carrier with severe symptoms of OTC deficiency masquerading as ADHD.
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Affiliation(s)
- Se Hee Kim
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, South Korea
| | - Jin Sook Lee
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, South Korea
| | - Byung Chan Lim
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, South Korea
| | - Ki Joong Kim
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, South Korea
| | - Yong Seoung Hwang
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, South Korea
| | - June Dong Park
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, South Korea
| | - Jung-Eun Cheon
- Department of Radiology, Seoul National University College of Medicine, South Korea
| | - In-One Kim
- Department of Radiology, Seoul National University College of Medicine, South Korea
| | - Boong-Nyun Kim
- Division of Child and Adolescent Psychiatry, Department of Neuropsychiatry, Seoul National University College of Medicine, South Korea
| | - Jong-Hee Chae
- Department of Pediatrics, Pediatric Clinical Neuroscience Center, Seoul National University Children's Hospital, Seoul National University College of Medicine, South Korea.
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Gunz AC, Choong K, Potter M, Miller E. Magnetic resonance imaging findings and neurodevelopmental outcomes in neonates with urea-cycle defects. Int Med Case Rep J 2013; 6:41-8. [PMID: 23983495 PMCID: PMC3751504 DOI: 10.2147/imcrj.s43513] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The urea-cycle functions to facilitate ammonia excretion, a disruption of which results in the accumulation of toxic metabolites. The neurological outcome of neonatal-onset urea-cycle defects (UCDs) is poor, and there are no good predictors of prognosis beyond ammonia levels at presentation. The role of neuroimaging in the prognosis of neonatal-onset UCDs is unclear. We describe the magnetic resonance imaging (MRI) findings of two patients with neonatal-onset UCDs (argininosuccinic aciduria and citrullinemia) at presentation and at 2-year follow-up, and present a review of the literature on neuroimaging in this age-group. We observed two potentially significant distinct patterns of cerebral involvement on MRI: (1) a central and focal pattern of involvement limited to the basal ganglia, perirolandic regions, and internal capsule; and (2) diffuse involvement of the cerebral cortex, internal capsule, basal ganglia, and variably thalami and brain stem. Patients with more diffuse findings tended to have higher serum glutamine peaks and worse neurological outcomes, while those with central involvement, aggressive acute management, and early liver transplantation tended to have better outcomes. We propose that MRI imaging of the brain may have prognostic value following presentation with neonatal UCDs, particularly in identifying patients at risk for poor outcome. The role and timing of follow-up neuroimaging is currently unclear. Further collaborative studies are necessary to evaluate whether patterns of MRI findings vary with specific UCD subtypes, and are predictive of clinical outcomes in neonatal UCDs.
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Affiliation(s)
- Anna Catherine Gunz
- Division of Critical Care, Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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Poretti A, Blaser SI, Lequin MH, Fatemi A, Meoded A, Northington FJ, Boltshauser E, Huisman TAGM. Neonatal neuroimaging findings in inborn errors of metabolism. J Magn Reson Imaging 2012; 37:294-312. [PMID: 22566357 DOI: 10.1002/jmri.23693] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 04/03/2012] [Indexed: 12/22/2022] Open
Abstract
Individually, metabolic disorders are rare, but overall they account for a significant number of neonatal disorders affecting the central nervous system. The neonatal clinical manifestations of inborn errors of metabolism (IEMs) are characterized by nonspecific systemic symptoms that may mimic more common acute neonatal disorders like sepsis, severe heart insufficiency, or neonatal hypoxic-ischemic encephalopathy. Certain IEMs presenting in the neonatal period may also be complicated by sepsis and cardiomyopathy. Early diagnosis is mandatory to prevent death and permanent long-term neurological impairments. Although neuroimaging findings are rarely specific, they play a key role in suggesting the correct diagnosis, limiting the differential diagnosis, and may consequently allow early initiation of targeted metabolic and genetic laboratory investigations and treatment. Neuroimaging may be especially helpful to distinguish metabolic disorders from other more common causes of neonatal encephalopathy, as a newborn may present with an IEM prior to the availability of the newborn screening results. It is therefore important that neonatologists, pediatric neurologists, and pediatric neuroradiologists are familiar with the neuroimaging findings of metabolic disorders presenting in the neonatal time period.
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Affiliation(s)
- Andrea Poretti
- Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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