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Wang MW, Wu CJ, Zhang ZQ. Neurological and imaging phenotypes of adults with untreated phenylketonuria: new cases and literature review. J Neurol 2023:10.1007/s00415-023-11760-9. [PMID: 37162580 DOI: 10.1007/s00415-023-11760-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVES Phenylketonuria (PKU) is the most prevalent congenital disease of amino acid metabolism. Neurological manifestations usually complicate PKU in untreated adult patients. This study describes neurological and imaging phenotypes of adult patients with untreated PKU. METHODS We investigated a cohort of 320 unrelated adult patients with suspected genetic leukoencephalopathies using whole-exome sequencing (WES). We analyzed the phenotypic features of adult PKU patients in our cohort and summarized cases reported in the literature. RESULTS We identified 10 patients in our cohort and 12 patients in the literature, who presented with neurological manifestations and were diagnosed with PKU in adulthood. Approximately 60% of these patients had onset of clinical features in adulthood. The most common neurological symptoms of patients presenting in adulthood were cognitive disturbance and spastic paralysis, followed by vision loss, cerebellar ataxia, weakness of limbs, and seizure. This differed from that of patients presenting with PKU features in childhood, who consistently had mental retardation with various neurological complications emerging during a broad age range. Imaging findings were similar between patients presenting with clinical features in childhood compared with adulthood, comprising symmetric periventricular white matter hyperintense on T2-weighted imaging and diffusion-weighted imaging predominantly in the parietal and occipital lobes. Also, normal brain imaging and diffuse leukoencephalopathies were observed in both patient groups. CONCLUSION PKU with clinical features presenting in adulthood is an atypical subtype and should be considered during diagnosis of adults with neurological symptoms and leukoencephalopathy. DWI seems to be most helpful to distinguish patients with PKU. Additionally, we demonstrate that PKU constitutes a part (3.1%) of adult genetic leukoencephalopathies.
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Affiliation(s)
- Meng-Wen Wang
- Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China
| | - Chu-Jun Wu
- Department of Neurology, Beijing Tiantan Hospital, National Clinical Research Center for Neurological Diseases, Capital Medical University, No.119 South 4Th Ring West Road, Fengtai District, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China
| | - Zai-Qiang Zhang
- Department of Neurology, Beijing Tiantan Hospital, National Clinical Research Center for Neurological Diseases, Capital Medical University, No.119 South 4Th Ring West Road, Fengtai District, Beijing, 100070, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China.
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Yıldız Y, Sivri HS. Maternal phenylketonuria in Turkey: outcomes of 71 pregnancies and issues in management. Eur J Pediatr 2019; 178:1005-1011. [PMID: 31053953 DOI: 10.1007/s00431-019-03387-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/10/2019] [Accepted: 04/16/2019] [Indexed: 12/30/2022]
Abstract
Untreated phenylketonuria (PKU) in pregnancy causes a severe embryopathy called maternal PKU syndrome. Here, we aimed to assess management issues and pregnancy outcomes in the first published series of PKU pregnancies from the developing world. Data were collected retrospectively in a single center from 71 pregnancies and 45 live births of 32 women with PKU, 11 of whom were diagnosed in adulthood after having an affected child. Microcephaly, intellectual disability, and dysmorphic facies were more prevalent in offspring of untreated than treated pregnancies with classical PKU (100% vs. 0%, 91% vs. 0%, and 73% vs. 23% with p < 0.001, p < 0.001, and p = 0.037, respectively). In treated pregnancies, phenylalanine levels were higher during weeks 6-14 than other periods of gestation (4.38 vs. 3.93, 2.00 and 2.28 mg/dl; p < 0.05). Poor compliance correlated with higher phenylalanine levels (ρ = - 0.64, p = 0.019) and fluctuations (ρ = - 0.66, p = 0.014).Conclusion: More frequent phenylalanine measurements during late first trimester are crucial to improve outcomes in treated pregnancies. In order to prevent untreated pregnancies via detecting undiagnosed adults, countries where significantly many women of childbearing age were not screened as newborns may consider pre-pregnancy PKU screening. Microcephaly in the newborn should prompt screening for PKU in the mother. What Is Known •Untreated phenylketonuria during pregnancy causes maternal phenylketonuria syndrome in the newborn. •Effective treatment throughout pregnancy can prevent adverse fetal outcomes. What Is New: •Metabolic control is related to frequency of follow-up and worsens during late first trimester. Closer follow-up during this period may improve metabolic control. •In order to prevent untreated pregnancies, pre-pregnancy phenylketonuria screening may be considered if many women of childbearing age were not screened as newborns.
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Affiliation(s)
- Yılmaz Yıldız
- Division of Pediatric Metabolism, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
| | - Hatice Serap Sivri
- Division of Pediatric Metabolism, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Watson JN, Seagraves NJ. RNA-Seq analysis in an avian model of maternal phenylketonuria. Mol Genet Metab 2019; 126:23-29. [PMID: 30600150 DOI: 10.1016/j.ymgme.2018.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 09/03/2018] [Accepted: 09/03/2018] [Indexed: 01/28/2023]
Abstract
Cardiac malformations (CVMs) are a leading cause of infant morbidity and mortality. CVMs are particularly prevalent when the developing fetus is exposed to high levels of phenylalanine in-utero in mothers with Phenylketonuria. Yet, elucidating the underlying molecular mechanism leading to CVMs has proven difficult. In this study we used RNA-Seq to investigate an avian model of MPKU and establish differential gene expression (DEG) characteristics of the early developmental stages HH10, 12, and 14. In total, we identified 633 significantly differentially expressed genes across stages HH10, 12, and 14. As expected, functional annotation of significant DEGs identified associations seen in clinical phenotypes of MPKU including CVMs, congenital heart defects, craniofacial anomalies, central nervous system defects, and growth anomalies. Additionally, there was an overrepresentation of genes involved in cardiac muscle contraction, adrenergic signaling in cardiomyocytes, migration, proliferation, metabolism, and cell survival. Strikingly, we identified significant changes in expression with multiple genes involved in Retinoic Acid (RA) metabolism and downstream targets. Using qRTPCR, we validated these findings and identified a total of 42 genes within the RA pathway that are differentially expressed. Here, we report the first elucidation of the molecular mechanisms of cardiovascular malformations in MPKU conducted at early developmental timepoints. We provide evidence suggesting a link between PHE exposure and the alteration of RA pathway. These results are promising and offer novel findings associated with congenital heart defects in MPKU.
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Affiliation(s)
- Jamie N Watson
- Department of Biology, University of Central Oklahoma, Edmond, OK, USA.
| | - Nikki J Seagraves
- Department of Biology, University of Central Oklahoma, Edmond, OK, USA.
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van Vliet D, van Wegberg AMJ, Ahring K, Bik-Multanowski M, Blau N, Bulut FD, Casas K, Didycz B, Djordjevic M, Federico A, Feillet F, Gizewska M, Gramer G, Hertecant JL, Hollak CEM, Jørgensen JV, Karall D, Landau Y, Leuzzi V, Mathisen P, Moseley K, Mungan NÖ, Nardecchia F, Õunap K, Powell KK, Ramachandran R, Rutsch F, Setoodeh A, Stojiljkovic M, Trefz FK, Usurelu N, Wilson C, van Karnebeek CD, Hanley WB, van Spronsen FJ. Can untreated PKU patients escape from intellectual disability? A systematic review. Orphanet J Rare Dis 2018; 13:149. [PMID: 30157945 PMCID: PMC6116368 DOI: 10.1186/s13023-018-0890-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 08/12/2018] [Indexed: 12/19/2022] Open
Abstract
Background Phenylketonuria (PKU) is often considered as the classical example of a genetic disorder in which severe symptoms can nowadays successfully be prevented by early diagnosis and treatment. In contrast, untreated or late-treated PKU is known to result in severe intellectual disability, seizures, and behavioral disturbances. Rarely, however, untreated or late-diagnosed PKU patients with high plasma phenylalanine concentrations have been reported to escape from intellectual disability. The present study aimed to review published cases of such PKU patients. Methods To this purpose, we conducted a literature search in PubMed and EMBASE up to 8th of September 2017 to identify cases with 1) PKU diagnosis and start of treatment after 7 years of age; 2) untreated plasma phenylalanine concentrations ≥1200 μmol/l; and 3) IQ ≥80. Literature search, checking reference lists, selection of articles, and extraction of data were performed by two independent researchers. Results In total, we identified 59 published cases of patients with late-diagnosed PKU and unexpected favorable outcome who met the inclusion criteria. Although all investigated patients had intellectual functioning within the normal range, at least 19 showed other neurological, psychological, and/or behavioral symptoms. Conclusions Based on the present findings, the classical symptomatology of untreated or late-treated PKU may need to be rewritten, not only in the sense that intellectual dysfunction is not obligatory, but also in the sense that intellectual functioning does not (re)present the full picture of brain damage due to high plasma phenylalanine concentrations. Further identification of such patients and additional analyses are necessary to better understand these differences between PKU patients. Electronic supplementary material The online version of this article (10.1186/s13023-018-0890-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Danique van Vliet
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, 9700, RB, Groningen, The Netherlands
| | - Annemiek M J van Wegberg
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, 9700, RB, Groningen, The Netherlands.,Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kirsten Ahring
- Department of PKU, Kennedy Center, Copenhagen University Hospital, Glostrup, Denmark
| | | | - Nenad Blau
- Dietmar-Hopp Metabolic Center, University Children's Hospital, Heidelberg, Germany
| | - Fatma D Bulut
- Department of Pediatrics, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Kari Casas
- Medical Genetics, Sanford Health, Fargo, ND, USA
| | - Bozena Didycz
- University Children's Hospital, Jagiellonian University, Krakow, Poland
| | - Maja Djordjevic
- Mother and Child Health Care Institute of Serbia Dr Vukan Cupic, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Antonio Federico
- Department of Medical, Surgical and Neurological Sciences, Medical School, University of Siena, Policlinico Santa Maria Alle Scotte, Siena, Italy
| | - François Feillet
- Department of Pediatrics, Hôpital d'Enfants Brabois, CHU Nancy, Vandoeuvre les Nancy, France
| | - Maria Gizewska
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, Szczecin, Poland
| | - Gwendolyn Gramer
- Department of General Pediatrics, Division of Neuropediatrics and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jozef L Hertecant
- Department of Pediatrics, Tawam Hospital, Al-Ain, United Arab Emirates
| | - Carla E M Hollak
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Academic Medical Center, Amsterdam, Netherlands
| | - Jens V Jørgensen
- Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | - Daniela Karall
- Clinic for Pediatrics, Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Yuval Landau
- Metabolic Disease Unit, Sheba Medical Center, Edmond and Lily Safra Children's Hospital, Tel Aviv, Israel
| | - Vincenzo Leuzzi
- Department of Pediatrics, Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Per Mathisen
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Kathryn Moseley
- Genetics Division, Department of Pediatrics, Keck School of Medicine, University of Southern California, California, Los Angeles, USA
| | - Neslihan Ö Mungan
- Department of Pediatrics, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Francesca Nardecchia
- Department of Pediatrics, Child Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Katrin Õunap
- Department of Clinical Genetics, United Laboratories, Tartu University Hospital and Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Kimberly K Powell
- Department of Genetics and Metabolism, Chapel Hill hospital, University of North Carolina, Chapel Hill, USA
| | - Radha Ramachandran
- Department of Chemical Pathology and Metabolic Medicine, Guys and St Thomas' Hospitals NHS foundation trust, London, UK
| | - Frank Rutsch
- Department of General Pediatrics, Muenster University Children's Hospital, Muenster, Germany
| | - Aria Setoodeh
- Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran
| | - Maja Stojiljkovic
- Institute of Molecular Genetics and Genetic Engineering, University of Belgrade, Belgrade, Serbia
| | - Fritz K Trefz
- Dietmar-Hopp Metabolic Center, University Children's Hospital, Heidelberg, Germany
| | - Natalia Usurelu
- Institute of Mother and Child, Centre of Reproductive Health and Medical Genetics, Chisinau, Moldova
| | - Callum Wilson
- Newborn Metabolic Screening Unit, LabPlus, Auckland City Hospital, Auckland, New Zealand
| | - Clara D van Karnebeek
- Departments of Pediatrics and Clinical Genetics, Academic Medical Centre, Emma Children's Hospital, Amsterdam, The Netherlands.,Department of Pediatrics, Centre for Molecular Medicine and Therapeutics, University of British Columbia, Vancouver, Canada
| | - William B Hanley
- Clinical and Biochemical Genetics, Department of Pediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Canada
| | - Francjan J van Spronsen
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, 9700, RB, Groningen, The Netherlands.
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Resta R. Generation n + 1: Projected numbers of babies born to women with PKU compared to babies with PKU in the United States in 2009. Am J Med Genet A 2012; 158A:1118-23. [PMID: 22495780 DOI: 10.1002/ajmg.a.35312] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Accepted: 01/16/2012] [Indexed: 11/06/2022]
Abstract
Newborn PKU screening has been available since the mid-1960s, and the first group of screened babies is now a complete reproductive cohort (age 15-44). Untreated maternal PKU (MPKU) often results in significant developmental and physical disabilities in exposed fetuses, and could potentially offset some or all of the benefits produced by newborn PKU screening and dietary treatment. Based on the age distribution of the United States population in 2009, and using different estimates of PKU frequency (1/10,000; 1/15,000; 1/20,000), the projected number of babies born to women with PKU was compared to the projected number of babies born with PKU. In 2009, there were about 62,000,000 women age 15-44, with a fertility rate of 66.7 births/1,000 women. Of these women, depending on the incidence of PKU, 3,097-6,195 were estimated to have PKU, and they would have delivered 207-413 babies. In that same year, the number of births was 4,118,055, which would have resulted in 206-412 babies with PKU. Thus, in the United States, at all estimates of PKU frequency, the number of babies exposed to MPKU is equal to the number of babies born with PKU. This ratio varies with the fertility rate but is not dependent on the incidence of PKU. The benefits of newborn PKU screening and treatment could be significantly curtailed if adequate resources, education, and funding are not available to follow and monitor women with MPKU and their babies.
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Affiliation(s)
- Robert Resta
- Hereditary Cancer Clinic, Swedish Medical Center, Seattle, Washington 98104, USA.
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