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Arhip L, Brox-Torrecilla N, Romero I, Motilla M, Serrano-Moreno C, Miguélez M, Cuerda C. Late-onset methylmalonic acidemia and homocysteinemia (cblC disease): systematic review. Orphanet J Rare Dis 2024; 19:20. [PMID: 38245797 PMCID: PMC10799514 DOI: 10.1186/s13023-024-03021-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 01/11/2024] [Indexed: 01/22/2024] Open
Abstract
INTRODUCTION Combined methylmalonic acidemia and homocystinuria, cblC type is an inborn error of intracellular cobalamin metabolism and the most common one. The age of onset ranges from prenatal to adult. The disease is characterised by an elevation of methylmalonic acid (MMA) and homocysteine and a decreased production of methionine. The aim is to review existing scientific literature of all late onset cblC patients in terms of clinical symptoms, diagnosis, and outcome. METHODS A bibliographic database search was undertaken in PubMed (MEDLINE) complemented by a reference list search. We combined search terms regarding cblC disease and late onset. Two review authors performed the study selection, data extraction and quality assessment. RESULTS Of the sixty-five articles included in this systematic review, we collected a total of 199 patients. The most frequent clinical symptoms were neuropathy/myelopathy, encephalopathy, psychiatric symptoms, thrombotic microangiopathy, seizures, kidney disease, mild to severe pulmonary hypertension with heart failure and thrombotic phenomena. There were different forms of supplementation used in the different studies collected and, within these studies, some patients received several treatments sequentially and/or concomitantly. The general outcome was: 64 patients recovered, 78 patients improved, 4 patients did not improve, or the disease progressed, and 12 patients died. CONCLUSIONS Most scientific literature regarding the late onset cblC disease comes from case reports and case series. In most cases treatment initiation led to an improvement and even recovery of some patients. The lack of complete recovery underlines the necessity for increased vigilance in unclear clinical symptoms for cblC disease.
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Affiliation(s)
- Loredana Arhip
- Unidad de Nutrición Clínica y Dietética, Hospital General Universitario Gregorio Marañón, Calle del Doctor Esquerdo 46, 28007, Madrid, Spain.
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
| | | | | | - Marta Motilla
- Unidad de Nutrición Clínica y Dietética, Hospital General Universitario Gregorio Marañón, Calle del Doctor Esquerdo 46, 28007, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Clara Serrano-Moreno
- Unidad de Nutrición Clínica y Dietética, Hospital General Universitario Gregorio Marañón, Calle del Doctor Esquerdo 46, 28007, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - María Miguélez
- Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Cristina Cuerda
- Unidad de Nutrición Clínica y Dietética, Hospital General Universitario Gregorio Marañón, Calle del Doctor Esquerdo 46, 28007, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Universidad Complutense Madrid, Madrid, Spain
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2
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Mathew AR, Di Matteo G, La Rosa P, Barbati SA, Mannina L, Moreno S, Tata AM, Cavallucci V, Fidaleo M. Vitamin B12 Deficiency and the Nervous System: Beyond Metabolic Decompensation-Comparing Biological Models and Gaining New Insights into Molecular and Cellular Mechanisms. Int J Mol Sci 2024; 25:590. [PMID: 38203763 PMCID: PMC10778862 DOI: 10.3390/ijms25010590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/16/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
Vitamin B12 (VitB12) is a micronutrient and acts as a cofactor for fundamental biochemical reactions: the synthesis of succinyl-CoA from methylmalonyl-CoA and biotin, and the synthesis of methionine from folic acid and homocysteine. VitB12 deficiency can determine a wide range of diseases, including nervous system impairments. Although clinical evidence shows a direct role of VitB12 in neuronal homeostasis, the molecular mechanisms are yet to be characterized in depth. Earlier investigations focused on exploring the biochemical shifts resulting from a deficiency in the function of VitB12 as a coenzyme, while more recent studies propose a broader mechanism, encompassing changes at the molecular/cellular levels. Here, we explore existing study models employed to investigate the role of VitB12 in the nervous system, including the challenges inherent in replicating deficiency/supplementation in experimental settings. Moreover, we discuss the potential biochemical alterations and ensuing mechanisms that might be modified at the molecular/cellular level (such as epigenetic modifications or changes in lysosomal activity). We also address the role of VitB12 deficiency in initiating processes that contribute to nervous system deterioration, including ROS accumulation, inflammation, and demyelination. Consequently, a complex biological landscape emerges, requiring further investigative efforts to grasp the intricacies involved and identify potential therapeutic targets.
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Affiliation(s)
- Aimee Rachel Mathew
- Department of Biology and Biotechnologies “Charles Darwin”, Sapienza University of Rome, 00185 Rome, Italy; (A.R.M.); (A.M.T.)
| | - Giacomo Di Matteo
- Department of Chemistry and Technology of Drugs, Sapienza University of Rome, 00185 Rome, Italy; (G.D.M.); (L.M.)
| | - Piergiorgio La Rosa
- Division of Neuroscience, Department of Psychology, Sapienza University of Rome, 00185 Rome, Italy;
- European Center for Brain Research, IRCCS Fondazione Santa Lucia, 00179 Rome, Italy
| | - Saviana Antonella Barbati
- Departmental Faculty of Medicine and Surgery, UniCamillus-Saint Camillus International University of Health Sciences, 00131 Rome, Italy;
| | - Luisa Mannina
- Department of Chemistry and Technology of Drugs, Sapienza University of Rome, 00185 Rome, Italy; (G.D.M.); (L.M.)
| | - Sandra Moreno
- Department of Science, University Roma Tre, 00146 Rome, Italy;
- Laboratory of Neurodevelopment, Neurogenetics and Neuromolecular Biology, IRCCS Fondazione Santa Lucia, 00179 Rome, Italy
| | - Ada Maria Tata
- Department of Biology and Biotechnologies “Charles Darwin”, Sapienza University of Rome, 00185 Rome, Italy; (A.R.M.); (A.M.T.)
- Research Centre of Neurobiology “Daniel Bovet”, Sapienza University of Rome, 00185 Rome, Italy
| | - Virve Cavallucci
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Marco Fidaleo
- Department of Biology and Biotechnologies “Charles Darwin”, Sapienza University of Rome, 00185 Rome, Italy; (A.R.M.); (A.M.T.)
- Research Center for Nanotechnology Applied to Engineering (CNIS), Sapienza University of Rome, 00185 Rome, Italy
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3
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Wais T, Ibarra KP, Sudarshana DM, Eswarappa M, Park M, Gallagher RC, Tsui B, Teixeira S, Josephson SA, Richie M. 41-Year-Old Male with Sub-Acute Encephalopathy, Seizures, and End Stage Renal Disease: A Unifying Diagnosis and Response to Therapy. Neurohospitalist 2024; 14:69-73. [PMID: 38235033 PMCID: PMC10790610 DOI: 10.1177/19418744231193490] [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: 01/19/2024] Open
Abstract
We describe a case of a 41-year-old male with a history of end-stage renal disease, hypertension, epilepsy, ischemic stroke, and traumatic brain injury transferred to our tertiary care center for subacute, progressive cognitive impairment. He was found to have disproportionate brain atrophy, focal seizures, and refractory hypertension. Given suspicion for an underlying genetic etiology, a genetic panel for progressive renal disease was sent, revealing two known pathogenic variants in a gene for a cobalamin metabolism disorder, Cobalamin C deficiency. He was started on targeted metabolic supplementation with subsequent improvement in his cognition. Our case highlights the crucial need to expand diagnostic workup to include genetic and metabolic causes in patients with neurologic disease, atypical features, relevant family history and multi-organ dysfunction.
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Affiliation(s)
- Tameena Wais
- Department of Neurology, University of Arizona, Tucson, AZ, USA
| | - Karen P. Ibarra
- Department of Neurology and the Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Dattanand M. Sudarshana
- Department of Neurology and the Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Meghana Eswarappa
- Division of Nephrology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Meyeon Park
- Division of Nephrology, Department of Medicine, University of California, San Francisco, CA, USA
| | | | - Brian Tsui
- Department of Radiology, University of California, San Francisco, CA, USA
| | - Stephanie Teixeira
- Department of Radiology, University of California, San Francisco, CA, USA
| | - S. Andrew Josephson
- Department of Neurology and the Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Megan Richie
- Department of Neurology and the Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
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4
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Wang S, Wang X, Xi J, Yang W, Zhu M. Case Report: A Case of Adult Methylmalonic Acidemia With Bilateral Cerebellar Lesions Caused by a New Mutation in MMACHC Gene. Front Neurol 2022; 13:935604. [PMID: 35865640 PMCID: PMC9294225 DOI: 10.3389/fneur.2022.935604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/09/2022] [Indexed: 11/13/2022] Open
Abstract
Methylmalonic acidemia is a severe heterogeneous disorder of methylmalonate and cobalamin (Cbl; vitamin B12) metabolism with poor prognosis. Around 90% of reported patients with methylmalonic acidemia (MMA) are severe infantile early onset, while cases with late-onset MMA have been rarely reported. Few reported late-onset MMA patients presented with atypical clinical symptoms, therefore, often misdiagnosed if without family history. Herein, we report a 29-year-old female who was admitted to our hospital due to symptoms manifested as encephalitis. The brain MRI showed symmetrical bilateral cerebellar lesions with Gd enhancement. Laboratory tests showed significantly elevated levels of homocysteine and methylmalonic acid. A genetic analysis identified a novel homozygous mutation (c.484G>A; p.Gly162 Arg) in the MMACHC gene. The patient was diagnosed with MMA, and her symptoms improved dramatically with intramuscular adenosine cobalamin treatment. In conclusion, for patients with symmetrical lesions in the brain, the possibility of metabolic diseases should be considered, detailed medical and family history should be collected, and metabolic screening tests as well as gene tests are necessary for correct diagnosis. The mutation diversity in MMACHC gene is an important factor leading to the heterogeneity of clinical manifestations of patients with MMA.
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Affiliation(s)
- Shengnan Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Xu Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Jianxin Xi
- Clinical College, Jilin University, Changchun, China
| | - Wenzhuo Yang
- Clinical College, Jilin University, Changchun, China
| | - Mingqin Zhu
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
- *Correspondence: Mingqin Zhu
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5
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Efficient mass spectrometric characterization and classification of methylmalonic aciduria subtypes through urinary and blood metabolic profiles fusion. Microchem J 2022. [DOI: 10.1016/j.microc.2022.107754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Wiedemann A, Oussalah A, Lamireau N, Théron M, Julien M, Mergnac JP, Augay B, Deniaud P, Alix T, Frayssinoux M, Feillet F, Guéant JL. Clinical, phenotypic and genetic landscape of case reports with genetically proven inherited disorders of vitamin B 12 metabolism: A meta-analysis. Cell Rep Med 2022; 3:100670. [PMID: 35764087 PMCID: PMC9381384 DOI: 10.1016/j.xcrm.2022.100670] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/22/2021] [Accepted: 06/02/2022] [Indexed: 10/31/2022]
Abstract
Inherited disorders of B12 metabolism produce a broad spectrum of manifestations, with limited knowledge of the influence of age and the function of related genes. We report a meta-analysis on 824 patients with a genetically proven diagnosis of an inherited disorder of vitamin B12 metabolism. Gene clusters and age categories are associated with patients' manifestations. The "cytoplasmic transport" cluster is associated with neurological and ophthalmological manifestations, the "mitochondrion" cluster with hypotonia, acute metabolic decompensation, and death, and the "B12 availability" and "remethylation" clusters with anemia and cytopenia. Hypotonia, EEG abnormalities, nystagmus, and strabismus are predominant in the younger patients, while neurological manifestations, such as walking difficulties, peripheral neuropathy, pyramidal syndrome, cerebral atrophy, psychiatric disorders, and thromboembolic manifestations, are predominant in the older patients. These results should prompt systematic checking of markers of vitamin B12 status, including homocysteine and methylmalonic acid, when usual causes of these manifestations are discarded in adult patients.
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Affiliation(s)
- Arnaud Wiedemann
- Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, University of Lorraine, INSERM UMR_S 1256, 54000 Nancy, France; Department of Pediatrics, University Hospital of Nancy, 54000 Nancy, France; Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, 54000 Nancy, France
| | - Abderrahim Oussalah
- Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, University of Lorraine, INSERM UMR_S 1256, 54000 Nancy, France; Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, 54000 Nancy, France; Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, 54000 Nancy, France
| | - Nathalie Lamireau
- Department of Pediatrics, University Hospital of Nancy, 54000 Nancy, France
| | - Maurane Théron
- Department of Pediatrics, University Hospital of Nancy, 54000 Nancy, France
| | - Melissa Julien
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, 54000 Nancy, France
| | | | - Baptiste Augay
- Department of Pediatrics, University Hospital of Nancy, 54000 Nancy, France
| | - Pauline Deniaud
- Department of Pediatrics, University Hospital of Nancy, 54000 Nancy, France
| | - Tom Alix
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, 54000 Nancy, France
| | - Marine Frayssinoux
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, 54000 Nancy, France
| | - François Feillet
- Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, University of Lorraine, INSERM UMR_S 1256, 54000 Nancy, France; Department of Pediatrics, University Hospital of Nancy, 54000 Nancy, France; Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, 54000 Nancy, France
| | - Jean-Louis Guéant
- Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, University of Lorraine, INSERM UMR_S 1256, 54000 Nancy, France; Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, 54000 Nancy, France; Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, Nutrition, and Metabolism, University Hospital of Nancy, 54000 Nancy, France.
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7
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Kalantari S, Brezzi B, Bracciamà V, Barreca A, Nozza P, Vaisitti T, Amoroso A, Deaglio S, Manganaro M, Porta F, Spada M. Adult-onset CblC deficiency: a challenging diagnosis involving different adult clinical specialists. Orphanet J Rare Dis 2022; 17:33. [PMID: 35109910 PMCID: PMC8812048 DOI: 10.1186/s13023-022-02179-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/16/2022] [Indexed: 12/13/2022] Open
Abstract
Background Methylmalonic aciduria and homocystinuria, CblC type (OMIM #277400) is the most common disorder of cobalamin intracellular metabolism, an autosomal recessive disease, whose biochemical hallmarks are hyperhomocysteinemia, methylmalonic aciduria and low plasma methionine. Despite being a well-recognized disease for pediatricians, there is scarce awareness of its adult presentation. A thorough analysis and discussion of cobalamin C defect presentation in adult patients has never been extensively performed. This article reviews the published data and adds a new case of the latest onset of symptoms ever described for the disease.
Results We present the emblematic case of a 45-year-old male, describing the diagnostic odyssey he ventured through to get to the appropriate treatment and molecular diagnosis. Furthermore, available clinical, biochemical and molecular data from 22 reports on cases and case series were collected, resulting in 45 adult-onset CblC cases, including our own. We describe the onset of the disease in adulthood, encompassing neurological, psychiatric, renal, ophthalmic and thromboembolic symptoms. In all cases treatment with intramuscular hydroxycobalamin was effective in reversing symptoms. From a molecular point of view adult patients are usually compound heterozygous carriers of a truncating and a non-truncating variant in the MMACHC gene. Conclusion Adult onset CblC disease is a rare disorder whose diagnosis can be delayed due to poor awareness regarding its presenting insidious symptoms and biochemical hallmarks. To avoid misdiagnosis, we suggest that adult onset CblC deficiency is acknowledged as a separate entity from pediatric late onset cases, and that the disease is considered in the differential diagnosis in adult patients with atypical hemolytic uremic syndromes and/or slow unexplained decline in renal function and/or idiopathic neuropathies, spinal cord degenerations, ataxias and/or recurrent thrombosis and/or visual field defects, maculopathy and optic disc atrophy. Plasma homocysteine measurement should be the first line for differential diagnosis when the disease is suspected. To further aid diagnosis, it is important that genes belonging to the intracellular cobalamin pathway are included within gene panels routinely tested for atypical hemolytic uremic syndrome and chronic kidney disorders. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02179-y.
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Affiliation(s)
- Silvia Kalantari
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Brigida Brezzi
- Nephrology and Dialysis Unit, Azienda Ospedaliera "SS. Antonio e Biagio e Cesare Arrigo", Alessandria, Italy
| | | | - Antonella Barreca
- Anatomia e Istologia Patologica, Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Paolo Nozza
- S.C. Anatomia e Istologia Patologica, Azienda Ospedaliera "SS. Antonio e Biagio e Cesare Arrigo", Alessandria, Italy
| | - Tiziana Vaisitti
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Antonio Amoroso
- Department of Medical Sciences, University of Turin, Turin, Italy.,Immunogenetics and Biology of Transplantation, Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Silvia Deaglio
- Department of Medical Sciences, University of Turin, Turin, Italy.,Immunogenetics and Biology of Transplantation, Città della Salute e della Scienza University Hospital, Turin, Italy
| | - Marco Manganaro
- Nephrology and Dialysis Unit, Azienda Ospedaliera "SS. Antonio e Biagio e Cesare Arrigo", Alessandria, Italy
| | - Francesco Porta
- Department of Pediatrics, Città della Salute e della Scienza University Hospital, University of Torino, Piazza Polonia 94, 10126, Turin, Italy.
| | - Marco Spada
- Department of Pediatrics, Città della Salute e della Scienza University Hospital, University of Torino, Piazza Polonia 94, 10126, Turin, Italy
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8
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Xu B, Zhang L, Chen Q, Wang Y, Peng Y, Tang H. Case Report: A Case of Late-Onset Combined Methylmalonic Acidemia and Hyperhomocysteinemia Induced by a Vegetarian Diet. Front Pediatr 2022; 10:896177. [PMID: 35903162 PMCID: PMC9315243 DOI: 10.3389/fped.2022.896177] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
Methylmalonic acidemia is a rare autosomal recessive metabolic disease. However, because of the atypical clinical symptoms, the type of late-onset methylmalonic academia is often misdiagnosed. Especially when the blood vitamin B12 and folic acid levels are normal, it is not easy to think of this disease. Herein we report a 9-year-old girl who developed normally on a relatively balanced diet before 7 years of age. However, she presented with fatigue and attention deficit when she followed a vegetarian diet. Laboratory examination showed moderate macrocytic anemia, high levels of homocysteine, high level of propionylcarnitine/acetylcarnitine, urinary methylmalonic acid and methyl citrate. Gene mutation analysis showed c.609G > A and c.80A > G compound heterozygous mutations in the MMACHC gene, supported late-onset combined methylmalonic academia with homocysteinemia. Then treatment performed with add meat to the diet, vitamin B12, folic acid betaine and L-carnitine supplement. One week later, the child's clinical symptoms and the laboratory examinations were significantly improved.
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Affiliation(s)
- Bei Xu
- Department of Pediatrics, Baoding No. 1 Central Hospital, Baoding, China
| | - Lihong Zhang
- Department of Pediatrics, Baoding No. 1 Central Hospital, Baoding, China
| | - Qiang Chen
- Department of Emergency, Baoding No. 1 Central Hospital, Baoding, China
| | - Yajuan Wang
- Department of Pediatrics, Baoding No. 1 Central Hospital, Baoding, China
| | - Yahong Peng
- Department of Pediatrics, Baoding No. 1 Central Hospital, Baoding, China
| | - Hui Tang
- Department of Pediatrics, Baoding No. 1 Central Hospital, Baoding, China
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9
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Wei Y, Hao H. Late-onset cobalamin C disease presenting with acute cerebellar ataxia. Neurol Sci 2021; 42:4839-4842. [PMID: 34392393 DOI: 10.1007/s10072-021-05541-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/31/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Yanping Wei
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing Shuaifuyuan 1, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Honglin Hao
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing Shuaifuyuan 1, Dongcheng District, Beijing, 100730, People's Republic of China.
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10
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Sena RM, Twiss JL, Gardiner AS, Dell’Orco M, Linsenbardt DN, Perrone-Bizzozero NI. The RNA-Binding Protein HuD Regulates Alternative Splicing and Alternative Polyadenylation in the Mouse Neocortex. Molecules 2021; 26:2836. [PMID: 34064652 PMCID: PMC8151252 DOI: 10.3390/molecules26102836] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 11/18/2022] Open
Abstract
The neuronal Hu/ELAV-like proteins HuB, HuC and HuD are a class of RNA-binding proteins that are crucial for proper development and maintenance of the nervous system. These proteins bind to AU-rich elements (AREs) in the untranslated regions (3'-UTRs) of target mRNAs regulating mRNA stability, transport and translation. In addition to these cytoplasmic functions, Hu proteins have been implicated in alternative splicing and alternative polyadenylation in the nucleus. The purpose of this study was to identify transcriptome-wide effects of HuD deletion on both of these nuclear events using RNA sequencing data obtained from the neocortex of Elavl4-/- (HuD KO) mice. HuD KO affected alternative splicing of 310 genes, including 17 validated HuD targets such as Cbx3, Cspp1, Snap25 and Gria2. In addition, deletion of HuD affected polyadenylation of 53 genes, with the majority of significantly altered mRNAs shifting towards usage of proximal polyadenylation signals (PAS), resulting in shorter 3'-UTRs. None of these genes overlapped with those showing alternative splicing events. Overall, HuD KO had a greater effect on alternative splicing than polyadenylation, with many of the affected genes implicated in several neuronal functions and neuropsychiatric disorders.
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Affiliation(s)
- Rebecca M. Sena
- Department Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA; (R.M.S.); (A.S.G.); (M.D.)
| | - Jeffery L. Twiss
- Department Biological Sciences, University of South Carolina, Columbia, SC 29208, USA;
| | - Amy S. Gardiner
- Department Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA; (R.M.S.); (A.S.G.); (M.D.)
- Department Cell Biology and Physiology, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Michela Dell’Orco
- Department Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA; (R.M.S.); (A.S.G.); (M.D.)
| | - David N. Linsenbardt
- Department Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA; (R.M.S.); (A.S.G.); (M.D.)
| | - Nora I. Perrone-Bizzozero
- Department Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA; (R.M.S.); (A.S.G.); (M.D.)
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11
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Chu X, Meng L, Zhang W, Luo J, Wang Z, Yuan Y. Peripheral Nervous System Involvement in Late-Onset Cobalamin C Disease? Front Neurol 2020; 11:594905. [PMID: 33324334 PMCID: PMC7726435 DOI: 10.3389/fneur.2020.594905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Cobalamin C (cblC) has a fundamental role in both central and peripheral nervous system function at any age. Neurologic manifestations may be the earliest and often the only manifestation of hereditary or acquired cblC defect. Peripheral neuropathy remains a classical but underdiagnosed complication of cblC defect, especially in late-onset cblC disease caused by mutations in the methylmalonic aciduria type C and homocysteinemia (MMACHC) gene. So the clinical, electrophysiological, and pathological characteristics of late-onset cblC disease are not well-known. Methods: A retrospective study of patients with late-onset cblC disease was conducted at our hospital on a 3-year period. The neuropathy was confirmed by the nerve conduction study. Sural biopsies were performed in 2 patients. Results: Eight patients were identified, with a mean onset age of 16.25 ± 6.07 years. All patients had methylmalonic aciduria, homocysteinemia, compound heterozygous MMACHC gene mutations were detected in all patients, and 7/8 patients with c.482G>A mutation. One patient concomitant with homozygote c.665C>T mutation in 5,10-methylenetetrahydrofolate reductase (MTHFR) gene. All patients showed limb weakness and cognitive impairment. Five patients had possible sensorimotor axonal polyneuropathy predominantly in the distal lower limbs. Sural biopsies showed loss of myelinated and unmyelinated fibers. Electro microscopy revealed crystalline-like inclusions bodies in Schwann cells and axonal degeneration. Conclusion: Late-onset cblC disease had possible heterogeneous group of distal axonal neuropathy. c.482G>A mutation is a hot spot mutation in late-onset cblC disease.
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Affiliation(s)
- Xujun Chu
- Department of Neurology, First Hospital, Peking University, Beijing, China
| | - Lingchao Meng
- Department of Neurology, First Hospital, Peking University, Beijing, China
| | - Wei Zhang
- Department of Neurology, First Hospital, Peking University, Beijing, China
| | - Jinjun Luo
- Department of Neurology, Temple University, Philadelphia, PA, United States
| | - Zhaoxia Wang
- Department of Neurology, First Hospital, Peking University, Beijing, China
| | - Yun Yuan
- Department of Neurology, First Hospital, Peking University, Beijing, China
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Cui J, Wang Y, Zhang H, Cui X, Wang L, Zheng H. Isolated subacute combined degeneration in late-onset cobalamin C deficiency in children: Two case reports and literature review. Medicine (Baltimore) 2019; 98:e17334. [PMID: 31574870 PMCID: PMC6775410 DOI: 10.1097/md.0000000000017334] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Subacute combined degeneration (SCD) is a disease caused by decreased vitamin B12 intake or metabolic disorders. It is more common in the elderly and rarely seen in children. Here, we report 2 pediatric cases of SCD in late-onset cobalamin C (CblC) deficiency. PATIENT CONCERNS The patients complained of unsteady gait. Their physical examination showed sensory ataxia. Magnetic resonance imaging showed classic manifestations of SCD. The serum vitamin B12 level was normal, but urine methylmalonic acid and serum homocysteine levels were high. DIAGNOSIS The pathogenic gene was confirmed as MMACHC. The 2 patients each had 2 pathogenic mutations C.482 G>A and C.271dupA and C.365A>T and C.609G>A in this gene. They were diagnosed with combined methylmalonic acidemia and homocysteinemia-CblC subtype. INTERVENTIONS The patients were treated with methylcobalamin 500 μg intravenous injection daily after being admitted. After the diagnosis, levocarnitine, betaine, and vitamin B12 were added to the treatment. OUTCOMES Twelve days after treatment, the boy could walk normally, and his tendon reflex and sense of position returned to normal. The abnormal gait seemed to have become permanent in the girl and she walked with her legs raised higher than normal. LESSONS To the best of our knowledge, this is the first report of 2 cases of isolated SCD in children with late-onset CblC disorder. Doctors should consider that SCD could be an isolated symptom of CblC disorder. The earlier the treatment, the lower the likelihood of sequelae.
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Affiliation(s)
- Junling Cui
- Department of Neurosurgery, The Second Hospital of Hebei Medical University
| | - Yuanyuan Wang
- Second Department of Neurology, The Children's Hospital of Hebei Province
| | - Huifeng Zhang
- Department of Pediatrics, The Second Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xiaopu Cui
- Second Department of Neurology, The Children's Hospital of Hebei Province
| | - Lihui Wang
- Second Department of Neurology, The Children's Hospital of Hebei Province
| | - Huacheng Zheng
- Second Department of Neurology, The Children's Hospital of Hebei Province
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Peng D. Clinical practice guideline for cognitive impairment of cerebral small vessel disease. Aging Med (Milton) 2019; 2:64-73. [PMID: 31942514 PMCID: PMC6880706 DOI: 10.1002/agm2.12073] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 05/29/2019] [Indexed: 11/22/2022] Open
Abstract
Cognitive impairment of cerebral small vessel disease (CSVD) is one of the most common cognitive disorders. It has a high incidence and results in heavy social burden; thus, it is essential to provide reasonable diagnosis and treatment in clinical practice. Based on the results of clinical research and related reports, combined with the actual situation in China, we propose a diagnosis and treatment guideline for cognitive impairment of CSVD.
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Affiliation(s)
- Dantao Peng
- Department of NeurologyChina‐Japan Friendship HospitalBeijingChina
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Wang X, Yang Y, Li X, Li C, Wang C. Distinct clinical, neuroimaging and genetic profiles of late-onset cobalamin C defects (cb1C): a report of 16 Chinese cases. Orphanet J Rare Dis 2019; 14:109. [PMID: 31092259 PMCID: PMC6521494 DOI: 10.1186/s13023-019-1058-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 04/08/2019] [Indexed: 02/08/2023] Open
Abstract
Objective The importance of late-onset cobalamin C (cblC) disorder is underestimated in adults. Improved awareness on its clinical and neuroimaging features helps timely diagnosis and appropriate treatment. Methods Totally 16 late-onset cblC cases were diagnosed based on clinical, biochemical findings and MMAHC gene mutation analysis. Clinical presentations, neuroimaging features and mutational spectrum were reviewed. Results The case series included 10 males and 6 females, with average age of 22 (range 13–40) years. All the 16 patients displayed bilateral pyramidal tract signs, and most of the cases (13) had cognitive impairment. Other symptoms included psychiatric symptoms (6), epilepsy (6), peripheral nerve damage (5), ocular symptoms (4) and lower-limb thrombosis (1). The neuroimaging findings were dominated by cerebral atrophy (11/16), followed by white matter lesions (4), cerebellar lesions/atrophy (2) and spinal cord lesions (1). There were also 2 patients with normal imaging. All the MMACHC mutations were compound heterozygous, of which the most and second frequent was c.482G > A (p.R161Q; 15/16 case; allele frequency: 46.88%) and c.609G > A(p.W203X; 6/16 case; allele frequency: 18.75%). In addition, patients carrying frameshift mutations (deletion/duplication) presented more frequently with psychiatric symptoms (57.1%) and optic nerve damages (42.9%) than those carrying point mutations (22.2 and 11.1%, respectively). In contrast, peripheral nerve (44.4%) and white matter lesions (33.3%) were more frequently identified in point mutation- carriers. However, the differences did not achieve statistical significance (all p > 0.05). Conclusion Compared to the early-onset form, late-onset cblC displayed some clinical, neuroimaging and mutational profiles, which warrants particular attention in adult neurologic practice. These findings not only broaden our insights into the genotypes and phenotypes of the disease, but highlight the importance of early diagnosis and initiation of appropriate treatments. Electronic supplementary material The online version of this article (10.1186/s13023-019-1058-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xianling Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, People's Republic of China
| | - Yanhui Yang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuying Li
- Department of Neurobiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Cunjiang Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, People's Republic of China.
| | - Chaodong Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, People's Republic of China.
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Kasinathan A, Sharawat IK, Sankhyan N, Vyas S, Attri S. Reversible Spastic Paraparesis. Ann Indian Acad Neurol 2019; 22:246-247. [PMID: 31007450 PMCID: PMC6472219 DOI: 10.4103/aian.aian_351_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Ananthanarayanan Kasinathan
- Department of Pediatrics, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth University, Puducherry, India
| | - Indar Kumar Sharawat
- Department of Pediatrics, Pediatric Neurology Unit, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Naveen Sankhyan
- Department of Pediatrics, Pediatric Neurology Unit, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sameer Vyas
- Department of Radio-Diagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Savita Attri
- Department of Pediatrics, Division of Pediatric Biochemistry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Hoss GRW, Poloni S, Blom HJ, Schwartz IVD. Three Main Causes of Homocystinuria: CBS, cblC and MTHFR Deficiency. What do they Have in Common? JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2019. [DOI: 10.1590/2326-4594-jiems-2019-0007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
| | - Soraia Poloni
- Universidade Federal do Rio Grande do Sul, Brazil; Hospital de Clínicas de Porto Alegre, Brazil
| | - Henk J Blom
- University Medical Centre Amsterdam, Netherlands
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Wang SJ, Yan CZ, Wen B, Zhao YY. Clinical feature and outcome of late-onset cobalamin C disease patients with neuropsychiatric presentations: a Chinese case series. Neuropsychiatr Dis Treat 2019; 15:549-555. [PMID: 30863077 PMCID: PMC6391119 DOI: 10.2147/ndt.s196924] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE The Cobalamin C (cblC) disease is an inborn error of cobalamin metabolism. Late-onset cblC disease was diagnosed in patients having overt symptoms after 4 years of age. The late-onset cblC disease patients were rare and easily misdiagnosed. This study analyzed the clinical presentations, gene mutations, and treatments of Chinese patients with late-onset cblC disease. METHODS The clinical data of 26 Han Chinese patients diagnosed with late-onset cblC disease were retrospectively analyzed. All patients underwent serum homocysteine level exam, urine concentrations of organic acids measurement, neuroimaging scans, gene analysis, and treatments evaluations. RESULTS The mean age at disease onset and diagnosis was 17.8±7.0 years. The most frequent neuropsychiatric disturbances were lower limb weakness (50%), psychiatric disturbances (46.2%), and gait instability (42.3%). The mean methylmalonic acid level in urine was 107.4±56.6 μmol/L, and mean serum total homocysteine was 105.4±41.0 μmol/L. The most common abnormal radioimaging changes were observed in the spinal cord (88%) and brain (32%). Scoliosis was detected in 85.7% of patients. The methylmalonic aciduria and homocystinuria type C protein gene analysis showed that c.482G>A (57.7%) and c.609G>A (34.6%) mutations were the most frequent genotypes. After treatments with hydroxycobalamin, betaine, folic acid, L-carnitine, and compound vitamin B, the clinical features and biochemical parameters of patients with late-onset cblC disease were found to be alleviated. CONCLUSION In our late-onset cblC disease cases, lower limb weakness, psychiatric disturbances, and gait instability were the most frequent manifestations. Patients responded well to the drug treatments with hydrocobalamin and betaine. When juvenile or adult patients with hyperhomocysteinemia present with neurological symptoms, cblC disease needs to be considered.
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Affiliation(s)
- Sheng-Jun Wang
- Department of Neurology, Qilu Hospital, Shandong University, Jinan, China,
| | - Chuan-Zhu Yan
- Department of Neurology, Qilu Hospital, Shandong University, Jinan, China,
| | - Bing Wen
- Department of Neurology, Qilu Hospital, Shandong University, Jinan, China,
| | - Yu-Ying Zhao
- Department of Neurology, Qilu Hospital, Shandong University, Jinan, China,
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18
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Wang SJ, Yan CZ, Liu YM, Zhao YY. Late-onset cobalamin C deficiency Chinese sibling patients with neuropsychiatric presentations. Metab Brain Dis 2018; 33:829-835. [PMID: 29374341 DOI: 10.1007/s11011-018-0189-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 01/17/2018] [Indexed: 01/06/2023]
Abstract
The Cobalamin C deficiency (cblC), characterized with elevated methylmalonic acidemia and homocystinuria in plasma, is an inborn error of cobalamin metabolism. The late-onset cblC siblings patients were rarely reported. In this study, we analyzed the clinical presentations and treatment outcomes of late-onset cblC in Chinese sibling patients with neuropsychiatric presentations. The clinical data of four pairs of Chinese patients were retrospectively analyzed. Serum homocysteine, urine organic acids measurements, neuroimaging exams and gene analysis were carried out in all patents. Patients were reevaluated after treatments with cobalamin, folate, betaine, L-carnitine and compound vitamin B. The mean age at disease onset was 13.7 (range 2-19) years. The neuropsychiatric disturbances including cognitive decline (3/8), psychiatric disturbances (4/8), gait instability (2/8), lower extremity weakness and numbness (3/8) and thromboembolic events (1/8). Two patients suffered nephropathy. The mean serum homocysteine when patients were diagnosed was 109.4 (range 69.5-138) μM/L. The abnormal radioimaging included scoliosis by X-ray (5/6), cerebral atrophy (4/6) and spinal cord atrophy (3/6) by MRI scan. Three pairs of siblings showed heterozygous mutations of MMACHC gene including c.482G > A (4/6), c.354G > C (2/6), c.570insT (2/6), c.445_446del (2/6) and c.656_4658del (2/6). The other two siblings showed homozygous mutation with c.452A > G in MMACHC gene. After treatments, the psychiatric symptoms were obviously relieved in all the patients. In Chinese siblings with late-onset cblC, the main clinic manifestation and abnormal radioimaging were cognitive decline and cerebral atrophy respectively. The most common gene mutation was c.482G > A of MMACHC gene. The patients responded well to the treatments.
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Affiliation(s)
- Sheng-Jun Wang
- Department of Neurology, Qilu Hospital, Shandong University, 107#,Wen Hua Xi Road, Ji'nan, 250012, People's Republic of China
| | - Chuan-Zhu Yan
- Department of Neurology, Qilu Hospital, Shandong University, 107#,Wen Hua Xi Road, Ji'nan, 250012, People's Republic of China
| | - Yi-Ming Liu
- Department of Neurology, Qilu Hospital, Shandong University, 107#,Wen Hua Xi Road, Ji'nan, 250012, People's Republic of China
| | - Yu-Ying Zhao
- Department of Neurology, Qilu Hospital, Shandong University, 107#,Wen Hua Xi Road, Ji'nan, 250012, People's Republic of China.
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Almannai M, Marom R, Divin K, Scaglia F, Sutton VR, Craigen WJ, Lee B, Burrage LC, Graham BH. Milder clinical and biochemical phenotypes associated with the c.482G>A (p.Arg161Gln) pathogenic variant in cobalamin C disease: Implications for management and screening. Mol Genet Metab 2017; 122:60-66. [PMID: 28693988 PMCID: PMC5612879 DOI: 10.1016/j.ymgme.2017.06.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 06/24/2017] [Accepted: 06/25/2017] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Cobalamin C disease is a multisystemic disease with variable manifestations and age of onset. Genotype-phenotype correlations are well-recognized in this disorder. Here, we present a large cohort of individuals with cobalamin C disease, several of whom are heterozygous for the c.482G>A pathogenic variant (p.Arg161Gln). We compared clinical characteristics of individuals with this pathogenic variant to those who do not have this variant. To our knowledge, this study represents the largest single cohort of individuals with the c.482G>A (p.Arg161Gln) pathogenic variant. METHODS A retrospective chart review of 27 individuals from 21 families with cobalamin C disease who are followed at our facility was conducted. RESULTS 13 individuals (48%) are compound heterozygous with the c.482G>A (p.Arg161Gln) on one allele and a second pathogenic variant on the other allele. Individuals with the c.482G>A (p.Arg161Gln) pathogenic variant had later onset of symptoms and easier metabolic control. Moreover, they had milder biochemical abnormalities at presentation which likely contributed to the observation that 4 individuals (31%) in this group were missed by newborn screening. CONCLUSION The c.482G>A (p.Arg161Gln) pathogenic variant is associated with milder disease. These individuals may not receive a timely diagnosis as they may not be identified on newborn screening or because of unrecognized, late onset symptoms. Despite the milder presentation, significant complications can occur, especially if treatment is delayed.
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Affiliation(s)
- Mohammed Almannai
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA
| | - Ronit Marom
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA
| | - Kristian Divin
- Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA
| | - Fernando Scaglia
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA
| | - V Reid Sutton
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA
| | - William J Craigen
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA
| | - Brendan Lee
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA
| | - Lindsay C Burrage
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA.
| | - Brett H Graham
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, TX, USA.
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Huemer M, Diodato D, Schwahn B, Schiff M, Bandeira A, Benoist JF, Burlina A, Cerone R, Couce ML, Garcia-Cazorla A, la Marca G, Pasquini E, Vilarinho L, Weisfeld-Adams JD, Kožich V, Blom H, Baumgartner MR, Dionisi-Vici C. Guidelines for diagnosis and management of the cobalamin-related remethylation disorders cblC, cblD, cblE, cblF, cblG, cblJ and MTHFR deficiency. J Inherit Metab Dis 2017; 40:21-48. [PMID: 27905001 PMCID: PMC5203859 DOI: 10.1007/s10545-016-9991-4] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 09/28/2016] [Accepted: 10/04/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Remethylation defects are rare inherited disorders in which impaired remethylation of homocysteine to methionine leads to accumulation of homocysteine and perturbation of numerous methylation reactions. OBJECTIVE To summarise clinical and biochemical characteristics of these severe disorders and to provide guidelines on diagnosis and management. DATA SOURCES Review, evaluation and discussion of the medical literature (Medline, Cochrane databases) by a panel of experts on these rare diseases following the GRADE approach. KEY RECOMMENDATIONS We strongly recommend measuring plasma total homocysteine in any patient presenting with the combination of neurological and/or visual and/or haematological symptoms, subacute spinal cord degeneration, atypical haemolytic uraemic syndrome or unexplained vascular thrombosis. We strongly recommend to initiate treatment with parenteral hydroxocobalamin without delay in any suspected remethylation disorder; it significantly improves survival and incidence of severe complications. We strongly recommend betaine treatment in individuals with MTHFR deficiency; it improves the outcome and prevents disease when given early.
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Affiliation(s)
- Martina Huemer
- Division of Metabolism and Children's Research Center, University Childrens' Hospital Zürich, Zurich, Switzerland
- radiz - Rare Disease Initiative Zürich, Clinical Research Priority Program, University of Zürich, Zurich, Switzerland
- Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria
| | - Daria Diodato
- Division of Metabolism, Bambino Gesù Children's Research Hospital, Rome, Italy
| | - Bernd Schwahn
- Willink Biochemical Genetics Unit, Saint Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Manuel Schiff
- Reference Center for Inborn Errors of Metabolism, Robert Debré University Hospital, APHP, Paris, France
- Inserm U1141, Robert Debré Hospital, Paris, France
- Université Paris-Diderot, Sorbonne Paris Cité, site Robert Debré, Paris, France
| | | | - Jean-Francois Benoist
- Reference Center for Inborn Errors of Metabolism, Robert Debré University Hospital, APHP, Paris, France
- Inserm U1141, Robert Debré Hospital, Paris, France
- Biochimie, faculté de pharmacie, Université Paris Sud, Paris, France
| | - Alberto Burlina
- Division of Inherited Metabolic Diseases, Department of Pediatrics, University Hospital Padova, Padova, Italy
| | - Roberto Cerone
- University Dept of Pediatrics, Giannina Gaslini Institute, Genoa, Italy
| | - Maria L Couce
- Congenital Metabolic Diseases Unit, Hospital Clínico Universitario de Santiago de Compostela, IDIS, CIBER, Compostela, Spain
| | - Angeles Garcia-Cazorla
- Department of Neurology, Neurometabolism Unit, and CIBERER (ISCIII), Hospital Sant Joan de Deu, Barcelona, Spain
| | - Giancarlo la Marca
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firence, Italy
| | - Elisabetta Pasquini
- Metabolic and Newborn Screening Clinical Unit, Department of Neurosciences, A. Meyer Children's University Hospital, Florence, Italy
| | - Laura Vilarinho
- Newborn Screening, Metabolism & Genetics Unit, National Institute of Health, Porto, Portugal
| | - James D Weisfeld-Adams
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
- Inherited Metabolic Diseases Clinic, Childrens Hospital Colorado, Aurora, CO, USA
| | - Viktor Kožich
- Institute of Inherited Metabolic Disorders, Charles University-First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Henk Blom
- Laboratory of Clinical Biochemistry and Metabolism, Center for Pediatrics and Adolescent Medicine University Hospital, Freiburg, Freiburg, Germany
| | - Matthias R Baumgartner
- Division of Metabolism and Children's Research Center, University Childrens' Hospital Zürich, Zurich, Switzerland.
- radiz - Rare Disease Initiative Zürich, Clinical Research Priority Program, University of Zürich, Zurich, Switzerland.
| | - Carlo Dionisi-Vici
- Division of Metabolism, Bambino Gesù Children's Research Hospital, Rome, Italy.
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Pan YC, Liu Y, Wu WQ, Xie JS. [Gene mutation analysis and prenatal diagnosis of four pedigrees with methymalonic aciduria]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016; 18:1013-1018. [PMID: 27751223 PMCID: PMC7389556 DOI: 10.7499/j.issn.1008-8830.2016.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 06/22/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To study gene mutations in four pedigrees with methymalonic aciduria, as well as the feasibility of prenatal diagnosis of methymalonic aciduria. METHODS High-throughput sequencing was performed for related genes in the peripheral blood of children or parents who were diagnosed with methymalonic aciduria to identify the loci with mutations. Then amplification primers were designed for each locus, and PCR and direct sequencing were performed to validate the sequencing in the first generation in the four pedigrees. Whether the mutations were pathogenic were determined with reference to literature review and medical history. In the pedigrees 1, 3, and 4, ultrasound-guided chorionic villi biopsy was performed at weeks 11-13 of pregnancy to perform early prenatal diagnosis. RESULTS In pedigree 1, c.656A>T and c.729-730insTT heterozygous mutations in the MUT gene were detected in the proband's father and mother, respectively. Early prenatal diagnosis showed c.656A>T and c.729-730insTT double heterozygous mutations in the fetus. The couple decided to terminate pregnancy. In pedigree 2, c.1106G>A and c.755-756insA double heterozygous mutations in the MUT gene were detected in the proband. c.1106G>A came from the father and c.755-756insA came from the mother. In pedigree 3, c.217C>T and c.609G>A double heterozygous mutations in the MMACHC gene were detected in the proband. c.217C>T came from the father and c.609G>A came from the mother. Prenatal diagnosis showed c.609G>A heterozygous mutation in the fetus. The baby was successfully delivered, and the result of umbilical cord blood testing was consistent with the prenatal diagnosis. In pedigree 4, c.609G>A and c.567dupT double heterozygous mutations in the MMACHC gene were detected in the proband. c.609G>A came from the father and c.567dupT came from the mother. Prenatal diagnosis showed c.567dupT heterozygous mutation in the fetus. The baby was successfully delivered, and the result of umbilical cord blood testing was consistent with the prenatal diagnosis. CONCLUSIONS Identification of gene mutations helps with prenatal diagnosis in pedigrees with methymalonic aciduria.
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Affiliation(s)
- Yu-Chun Pan
- Shenzhen Maternal and Child Health Care Hospital, Southern Medical University, Shenzhen, Guangdong 518000, China.
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Collison FT, Xie YA, Gambin T, Jhangiani S, Muzny D, Gibbs R, Lupski JR, Fishman GA, Allikmets R. Whole Exome Sequencing Identifies an Adult-Onset Case of Methylmalonic Aciduria and Homocystinuria Type C (cblC) with Non-Syndromic Bull's Eye Maculopathy. Ophthalmic Genet 2016; 36:270-5. [PMID: 25687216 PMCID: PMC4539287 DOI: 10.3109/13816810.2015.1010736] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background: Methylmalonic aciduria and homocystinuria type C (cblC), a disorder of vitamin B12 (cobalamin) metabolism caused by mutations in the MMACHC gene, presents with many systemic symptoms, including neurological, cognitive, psychiatric, and thromboembolic events. Retinal phenotypes, including maculopathy, pigmentary retinopathy, and optic atrophy are common in early onset form of the disease but are rare in adult onset forms. Materials and Methods: An adult Hispanic female presented with decreased central vision, bilateral pericentral ring scotomas and bull’s eye-appearing macular lesions at 28 years of age. Her medical history was otherwise unremarkable except for iron deficiency anemia and both urinary tract and kidney infections. Screening of the ABCA4 gene, mutations in which frequently cause bull’s eye maculopathy, was negative. Subsequently, analysis with whole exome sequencing was performed. Results: Whole exome sequencing discovered compound heterozygous mutations in MMACHC, c.G482A:p.Arg161Gln and c.270_271insA:p.Arg91Lysfs*14, which segregated with the disease in the family. The genetic diagnosis was confirmed by biochemical laboratory testing, showing highly elevated urine methylmalonic acid/creatinine and homocysteine levels, and suggesting disease management with hydroxycobalamin injections and carnitine supplementation. Conclusions: In summary, a unique case of an adult patient with bull’s eye macular lesions and no clinically relevant systemic symptoms was diagnosed with cblC by genetic screening and follow-up biochemical laboratory tests.
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Affiliation(s)
- Frederick T Collison
- a The Pangere Center for Hereditary Retinal Diseases, The Chicago Lighthouse for People Who Are Blind or Visually Impaired , Chicago , IL , USA
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Ku CA, Ng JK, Karr DJ, Reznick L, Harding CO, Weleber RG, Pennesi ME. Spectrum of ocular manifestations in cobalamin C and cobalamin A types of methylmalonic acidemia. Ophthalmic Genet 2016; 37:404-414. [DOI: 10.3109/13816810.2015.1121500] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Cristy A. Ku
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Jacqueline K. Ng
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Daniel J. Karr
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Leah Reznick
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Cary O. Harding
- Molecular and Medical Genetics, Oregon Health & Science University, Portland, Oregon, USA
| | - Richard G. Weleber
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Mark E. Pennesi
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon, USA
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24
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Weisfeld-Adams JD, McCourt EA, Diaz GA, Oliver SC. Ocular disease in the cobalamin C defect: a review of the literature and a suggested framework for clinical surveillance. Mol Genet Metab 2015; 114:537-46. [PMID: 25742969 DOI: 10.1016/j.ymgme.2015.01.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 01/28/2015] [Accepted: 01/28/2015] [Indexed: 01/23/2023]
Abstract
The association between combined methylmalonic acidemia and homocystinuria of cblC type (cobalamin C defect, cblC) and ocular disease is now well recognized, and is a significant component of morbidity and disability associated with the condition. In this review, through collation of historically reported cases of early- and late-onset cblC and previously unreported cases, we have attempted to characterize the epidemiology, clinical features, and pathomechanisms of individual ocular features of cblC. These data suggest that maculopathy and nystagmus with abnormal vision are extremely common and affect the majority of children with early-onset cblC, usually before school age; strabismus and optic atrophy are also seen at relatively high frequency. The timing of progression of macular disease may coincide with a critical period of postnatal foveal development. Maculopathy and retinal disease may be subclinical and show only partial correlation with the extent of visual deficits, and visual deterioration may be relentlessly progressive in spite of aggressive treatment of biochemical abnormalities. In later-onset forms of the disease, visual loss and ocular complications appear to be infrequent. Finally, we discuss investigational strategies in diagnosing and characterizing eye disease in individuals with cblC, explore possible therapeutic avenues that may attenuate progression and severity of eye disease, and propose a clinical surveillance guideline for monitoring progression of ocular disease in children and adults with cblC.
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Affiliation(s)
- James D Weisfeld-Adams
- Children's Hospital Colorado, Aurora, CO, USA; Division of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Emily A McCourt
- Children's Hospital Colorado, Aurora, CO, USA; Department of Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA
| | - George A Diaz
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Scott C Oliver
- Children's Hospital Colorado, Aurora, CO, USA; Department of Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA
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25
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Liu YR, Ji YF, Wang YL, Zhang BA, Fang GY, Wang JT, Sun GF, Lu H. Clinical analysis of late-onset methylmalonic acidaemia and homocystinuria, cblC type with a neuropsychiatric presentation. J Neurol Neurosurg Psychiatry 2015; 86:472-5. [PMID: 25091368 DOI: 10.1136/jnnp-2014-308203] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Yan-ru Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yang-fei Ji
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ya-li Wang
- Department of Psychiatry, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Bo-ai Zhang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Gui-yuan Fang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing-tao Wang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Gui-fang Sun
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hong Lu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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26
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Yamamoto M, Yasui K, Watanabe Y, Kowa H, Yamaguchi S, Nakashima K. [A case of late-onset cobalamin C disease (methylmalonic aciduria and homocystinuria, cobalamin C type)]. Rinsho Shinkeigaku 2015; 55:23-8. [PMID: 25672861 DOI: 10.5692/clinicalneurol.55.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report the case of an 18-year-old Japanese woman with cobalamin (cbl) C disease. She was born between non- consanguineous parents, and had easy fatigability from a childhood. At 14 years old, she developed renal failure, and had repeated psychosis during 2 years. At 16 old, she developed her gait disturbance and her symptoms fluctuated, but the cause of gait disturbance was unclear. At 18 years old, she was admitted with worsening of gait disturbance. Physical examination revealed spastic paraparesis and bilateral peroneal nerve paralyses. Homocystinuria and methylmalonic aciduria were detected, although serum vitamin B12 was within normal range. Gene mutation analysis revealed Gly147Asp (440G>A) and Trp157Ser (470G>C) in the MMACHC gene as a compound heterozygous mutation. We diagnosed her as having late-onset cbl C disease, and her gait disturbance and renal failure improved after intramuscular hydroxocobalamin administration. Although late-onset cbl C disease is rare in Japan, it an important to consider this congenital disease because symptoms are expected to improve by medical intervention.
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Affiliation(s)
- Mikie Yamamoto
- Division of Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University
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27
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Krueger JM, Piantino J, Smith CM, Angle B, Venkatesan C, Wainwright MS. A treatable metabolic cause of encephalopathy: cobalamin C deficiency in an 8-year-old male. Pediatrics 2015; 135:e202-6. [PMID: 25511120 DOI: 10.1542/peds.2013-1427] [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] [Indexed: 11/24/2022] Open
Abstract
Neurologic regression in a previously healthy child may be caused by metabolic or neurodegenerative disorders, many of which have no definitive treatment. We report a case of a previously healthy 8-year-old boy who presented with a month-long history of waxing and waning encephalopathy and acute regression, followed by seizures. Evaluation for a metabolic disorder revealed methylmalonic acidemia and hyperhomocysteinemia of the cobalamin C type due to a single, presumed homozygous pathogenic c.394 C>T mutation in the MMACHC gene. With the appropriate diet restrictions and vitamin replacement, he improved significantly and returned to his premorbid level of behavior. This case illustrates an unusual presentation of a treatable metabolic disorder and highlights the need to consider cobalamin defects in the differential diagnosis of healthy children with neurologic regression.
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Affiliation(s)
| | - Juan Piantino
- Divisions of Neurology and Ruth D. and Ken M. Davee Pediatric Neurocritical Care Program, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Craig M Smith
- Ruth D. and Ken M. Davee Pediatric Neurocritical Care Program, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Brad Angle
- Genetics, Birth Defects, and Metabolism, and
| | - Charu Venkatesan
- Divisions of Neurology and Ruth D. and Ken M. Davee Pediatric Neurocritical Care Program, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark S Wainwright
- Divisions of Neurology and Ruth D. and Ken M. Davee Pediatric Neurocritical Care Program, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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28
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Rahmandar MH, Bawcom A, Romano ME, Hamid R. Cobalamin C deficiency in an adolescent with altered mental status and anorexia. Pediatrics 2014; 134:e1709-14. [PMID: 25367534 PMCID: PMC4533284 DOI: 10.1542/peds.2013-2711] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Although cobalamin (cbl) C deficiency is the most common inherited disorder of vitamin B12 metabolism, the late-onset form of the disease can be difficult to recognize because it has a broad phenotypic spectrum. In this report, we describe an adolescent female exposed to unknown illicit substances and sexual abuse who presented with psychosis, anorexia, seizures, and ataxia. The patient's diagnosis was delayed until a metabolic workup was initiated, revealing hyperhomocysteinemia, low normal plasma methionine, and methylmalonic aciduria. Ultimately, cblC deficiency was confirmed when molecular testing showed compound heterozygosity for mutations (c.271dupA and c.482G>A) in the MMACHC gene. This diagnosis led to appropriate treatment with hydroxocobalamin, betaine, and folate, which resulted in improvement of her clinical symptoms and laboratory values. This patient demonstrates a previously unrecognized presentation of late-onset cblC deficiency. Although neuropsychiatric symptoms are common in late-onset disease, seizures and cerebellar involvement are not. Furthermore, anorexia has not been previously described in these patients. This case emphasizes that inborn errors of metabolism should be part of the differential diagnosis for a teenager presenting with altered mental status, especially when the diagnosis is challenging or neurologic symptoms are unexplained. Correct diagnosis of this condition is important because treatment is available and can result in clinical improvement.(1.)
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Affiliation(s)
| | - Amanda Bawcom
- Division of Medical Genetics and Genomic Medicine, and
| | - Mary E. Romano
- Division of Adolescent and Young Adult Health, Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt University, Nashville, Tennessee
| | - Rizwan Hamid
- Division of Medical Genetics and Genomic Medicine, and
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29
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Huemer M, Scholl-Bürgi S, Hadaya K, Kern I, Beer R, Seppi K, Fowler B, Baumgartner MR, Karall D. Three new cases of late-onset cblC defect and review of the literature illustrating when to consider inborn errors of metabolism beyond infancy. Orphanet J Rare Dis 2014; 9:161. [PMID: 25398587 PMCID: PMC4255922 DOI: 10.1186/s13023-014-0161-1] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 10/09/2014] [Indexed: 01/11/2023] Open
Abstract
Background The cblC defect is a rare inborn error of intracellular cobalamin metabolism. Biochemical hallmarks are elevated homocysteine and low methionine in plasma accompanied by methylmalonic aciduria. Due to the heterogeneous clinical picture, patients with the late-onset form of the disease (onset >12 months) come to the attention of diverse medical specialists, e.g. paediatricians, neurologists, nephrologists, psychiatrists or haematologists. The report reviews the published clinical data and adds three new cases to raise awareness for this severe but often treatable disease. Methods The Pubmed and the Cochrane databases were searched for clinical reports on cblC patients and three unreported cases are presented to illustrate the clinical spectrum. Results Reports on 58 cases (30 females, 22 males, 6 = no information) and the three new cases underlined the clinical heterogeneity of the disease. Time between first symptoms and diagnosis ranged from three months to more than 20 years. Haemolytic uraemic syndrome and pulmonary hypertension were main presenting symptoms in preschool children. In older children/adolescents, psychiatric symptoms, cognitive impairment, ataxia and myelopathy were frequently observed while thromboembolic events and glomerulopathies were almost exclusively seen in adults. Brain atrophy, white matter lesions and myelopathy were frequently encountered. The majority of patients showed marked biochemical and clinical response to treatment with parenteral hydroxocobalamin combined with oral betaine, folate, carnitine and rarely methionine. The course was less favourable in late treated or untreated patients. Conclusions The late-onset cblC defect is a rare disease and unfortunately, diagnosis is often delayed. Raising awareness for this disorder can significantly improve patients’ outcome and perspective by timely initiation of targeted treatment. Newborn screening (NBS) for the cblC defect might be of benefit especially for late-onset patients since treatment seems efficient when initiated before irreversible organ damage. In general, inborn errors of metabolisms should be considered in unexplained medical cases at any age, especially in patients with multisystemic disease. More specifically, total homocysteine in plasma and methylmalonic acid in urine/plasma should be measured in unexplained neurologic, psychiatric, renal, haematologic and thromboembolic disease.
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Affiliation(s)
- Martina Huemer
- Division of Metabolic Diseases and Children's Research Center, University Children's Hospital Zürich, Zürich, Switzerland. .,Radiz - Rare Disease Initiative Zürich, University Zürich, Zürich, Switzerland. .,Department of Pediatrics, LKH Bregenz, Bregenz, Austria.
| | - Sabine Scholl-Bürgi
- Clinic for Pediatrics I; Inherited Metabolic Disorders, Innsbruck Medical University, Innsbruck, Austria.
| | - Karine Hadaya
- Divisions of Nephrology and Transplantation, Geneva University Hospitals, Geneva, Switzerland.
| | - Ilse Kern
- Pediatric Nephrology & Metabolism, Children's Hospital, University of Geneva, Geneva, Switzerland.
| | - Ronny Beer
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria.
| | - Klaus Seppi
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria.
| | - Brian Fowler
- Division of Metabolic Diseases and Children's Research Center, University Children's Hospital Zürich, Zürich, Switzerland.
| | - Matthias R Baumgartner
- Division of Metabolic Diseases and Children's Research Center, University Children's Hospital Zürich, Zürich, Switzerland. .,Radiz - Rare Disease Initiative Zürich, University Zürich, Zürich, Switzerland.
| | - Daniela Karall
- Clinic for Pediatrics I; Inherited Metabolic Disorders, Innsbruck Medical University, Innsbruck, Austria.
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30
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Backe PH, Ytre-Arne M, Røhr AK, Brodtkorb E, Fowler B, Rootwelt H, Bjørås M, Mørkrid L. Novel Deletion Mutation Identified in a Patient with Late-Onset Combined Methylmalonic Acidemia and Homocystinuria, cblC Type. JIMD Rep 2013; 11:79-85. [PMID: 23580368 DOI: 10.1007/8904_2013_225] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Revised: 03/12/2013] [Accepted: 03/14/2013] [Indexed: 01/04/2023] Open
Abstract
Combined methylmalonic aciduria and homocystinuria, cblC type (MMACHC), is the most common inborn error of cellular vitamin B12 metabolism and is caused by mutations in the MMACHC gene. This metabolic disease results in impaired intracellular synthesis of adenosylcobalamin and methylcobalamin, coenzymes for the methylmalonyl-CoA mutase and methionine synthase enzymes, respectively. The inability to produce normal levels of these two coenzymes leads to increased concentrations of methylmalonic acid and homocysteine in plasma and urine, together with normal or decreased concentration of methionine in plasma. Here, we report a novel homozygous deletion mutation (NM_015506.2:c.392_394del) resulting in an in-frame deletion of amino acid Gln131 and late-onset disease in a 23-year-old male. The patient presented with sensory and motoric disabilities, urine and fecal incontinence, and light cognitive impairment. There was an excessive urinary excretion of methylmalonic acid and greatly elevated plasma homocysteine. The clinical symptoms and the laboratory abnormalities responded partly to treatment with hydroxycobalamin, folinic acid, methionine, and betaine. Studies on patient fibroblasts together with spectroscopic activity assays on recombinant MMACHC protein reveal that Gln131 is crucial in order to maintain enzyme activity. Furthermore, structural analyses show that Gln131 is one of only two residues making hydrogen bonds to the tail of cobalamin. Circular dichroism spectroscopy indicates that the 3D structure of the deletion mutant is folded but perturbed compared to the wild-type protein.
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Affiliation(s)
- Paul Hoff Backe
- Department of Microbiology, Oslo University Hospital and University of Oslo, 4950, 0424, Oslo, Nydalen, Norway,
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