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Li H, Yang H, Li M, Liang L, Zhu H, Chen A, Qian H. Mild hyperphenylalaninemia (hpa) presenting as orthostatic tremor: a case report. BMC Neurol 2022; 22:409. [PMCID: PMC9635091 DOI: 10.1186/s12883-022-02946-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
Orthostatic tremor (OT) is a type of postural tremor of the lower extremities that has not been described in either phenylketonuria (PKU) or hyperphenylalaninemia (HPA). Because little is known about the clinical features and therapeutic responses of OT in mild HPA, we describe a mild HPA patient who presented with OT as an initial symptom.
Case presentation
A 22-year-old male was admitted for bilateral leg tremor while standing, with symptom onset eight months prior. One month before admission, the tremor disappeared in the left leg but persisted in the right leg. Electromyography recorded from the right gastrocnemius revealed a 6–8 Hz tremor, which appeared when the patient was standing and disappeared when he was resting or walking. Blood screening showed a phenylalanine/tyrosine ratio of 2.06 and a phenylalanine level of 140 μmol/L. Urine metabolic screening was negative. Whole-exome sequencing confirmed the presence of a compound heterozygous mutation, c.158G > A and c.728G > A, in phenylalanine hydroxylase (PAH) gene. After three months of levodopa/benserazide tablets (250 mg, tid) and a low-phenylalanine diet treatment, the tremor disappeared.
Conclusions
Young-onset mild HPA is a relatively rare autosomal recessive metabolic disease, and slow OT is a rare clinical feature. Metabolic screening and genetic testing are the keys to early diagnosis and treatment. For adolescents and young adults, appropriate medication and long-term dietary therapy remain important treatments. This case expanded the disease spectrum of slow OT.
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Wiedemann A, Jeannesson É, Oussalah A, Guéant JL, Guéant-Rodriguez RM, Feillet F. [Newborn screening of phenylketonuria in France]. Med Sci (Paris) 2021; 37:468-473. [PMID: 34003092 DOI: 10.1051/medsci/2021061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Phenylketonuria is the most common inborn error of metabolism and causes irreversible mental retardation if left untreated. Its newborn screening was made possible by the technique of blood collection on filter paper developed by Robert Guthrie. Neonatal PKU screening began in France in the early 1970s. It was initially carried out by a bacteriological method, then by fluorometry, and finally, since 2020, by tandem mass spectrometry. More than 35 million newborns have been screened to date. This resulted in the diagnosis of more than 3,500 children with PKU or mild hyperphenylalaninemia. The management of these children has improved over time, in particular thanks to the techniques of biochemistry and molecular genetics which lead to an accurate diagnosis and the arrival of drug treatment by sapropterin. Thanks to this screening, which allows for early management, the prognosis of PKU has been transformed and, although neurological or behavioral problems may arise, these patients are living normally today.
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Affiliation(s)
- Arnaud Wiedemann
- Service de médecine infantile, Hôpital d'enfants, CHRU de Nancy, 54000 Nancy, France - Inserm UMR_S 1256 (NGERE, Nutrition génétique et exposition aux risques environnementaux), Faculté de médecine de Nancy, Université de Lorraine, 54000 Nancy, France
| | - Élise Jeannesson
- Inserm UMR_S 1256 (NGERE, Nutrition génétique et exposition aux risques environnementaux), Faculté de médecine de Nancy, Université de Lorraine, 54000 Nancy, France - Département de médecine moléculaire, Laboratoire de biochimie et de biologie moléculaire nutrition, CHRU de Nancy, 54000 Nancy, France
| | - Abderrahim Oussalah
- Inserm UMR_S 1256 (NGERE, Nutrition génétique et exposition aux risques environnementaux), Faculté de médecine de Nancy, Université de Lorraine, 54000 Nancy, France - Département de médecine moléculaire, Laboratoire de biochimie et de biologie moléculaire nutrition, CHRU de Nancy, 54000 Nancy, France
| | - Jean-Louis Guéant
- Inserm UMR_S 1256 (NGERE, Nutrition génétique et exposition aux risques environnementaux), Faculté de médecine de Nancy, Université de Lorraine, 54000 Nancy, France - Département de médecine moléculaire, Laboratoire de biochimie et de biologie moléculaire nutrition, CHRU de Nancy, 54000 Nancy, France
| | - Rosa-Maria Guéant-Rodriguez
- Inserm UMR_S 1256 (NGERE, Nutrition génétique et exposition aux risques environnementaux), Faculté de médecine de Nancy, Université de Lorraine, 54000 Nancy, France - Département de médecine moléculaire, Laboratoire de biochimie et de biologie moléculaire nutrition, CHRU de Nancy, 54000 Nancy, France
| | - François Feillet
- Service de médecine infantile, Hôpital d'enfants, CHRU de Nancy, 54000 Nancy, France - Inserm UMR_S 1256 (NGERE, Nutrition génétique et exposition aux risques environnementaux), Faculté de médecine de Nancy, Université de Lorraine, 54000 Nancy, France
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Jaulent P, Charriere S, Feillet F, Douillard C, Fouilhoux A, Thobois S. Neurological manifestations in adults with phenylketonuria: new cases and review of the literature. J Neurol 2019; 267:531-542. [PMID: 31701331 DOI: 10.1007/s00415-019-09608-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/24/2019] [Accepted: 10/26/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Phenylketonuria (PKU) is a rare autosomal recessive disease characterised by high plasma phenylalanine levels inducing, if untreated, serious neurological manifestations in children but also, rarely, in adults who stopped their diet. The objective of the study was to describe the neurological manifestations observed in adults with PKU. METHODS We analysed cases reported in French reference centres for inborn errors of metabolism and cases already reported in the literature. RESULTS We report 8 new cases of neurological manifestations and 22 cases in the literature, which occurred in adult PKU patients, associated with chronic or rapid increase of phenylalanine levels, mostly when strict low-phenylalanine diet was stopped early in life. Neurological symptoms consisted in cerebellar ataxia, tremor, brisk reflexes, visual loss, sensory manifestations, and/or headaches. Visual loss was more frequent in the new cases (4/8) of the present series than in the literature (4/22). These neurological complications were associated with leucopathy on brain magnetic resonance imaging (27/29). The start of a low-phenylalanine diet improved or fully reversed neurological manifestations, even in patients with late diagnosis during adulthood. CONCLUSION Neurological manifestations can complicate PKU in adult patients with elevated phenylalanine levels, after long or short period of diet discontinuation. Neurologists should be aware of this diagnosis, and measure phenylalaninemia in case of neurological symptoms associated with non-specific leucopathy on brain MRI. PKU patients should be systematically encouraged to continue their diet and their medical follow-up to avoid neurological complications.
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Affiliation(s)
- Paul Jaulent
- Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Neurologie C, 69677, Bron Cedex, France
| | - Sybil Charriere
- Hospices Civils de Lyon, Hôpital Cardiovasculaire Louis Pradel, Fédération D'endocrinologie, Maladies métaboliques, diabète Et Nutrition, Groupement Hospitalier Est, 28 avenue Doyen Lépine, 69677, Bron Cedex, France. .,INSERM U1060, Laboratoire Carmen, Université Lyon 1, INRA U1235, INSA de Lyon, 69621, Villeurbanne, France. .,CENS, Centre de Recherche en Nutrition Humaine Rhône Alpes, 69921, Oullins Cedex, France. .,Université Lyon 1 Claude Bernard, Faculté de médecine Lyon EST, 69373, Lyon, France. .,Hospices Civils de Lyon, Centre de référence Des Maladies héréditaires du métabolisme de Lyon, Groupement Hospitalier Est, 69677, Bron Cedex, France.
| | - François Feillet
- CHU de Nancy, Hôpitaux de Brabois, Centre de référence Des Maladies héréditaires du métabolisme de Nancy, 54511, Vandoeuvre-les Nancy, France
| | - Claire Douillard
- Centre Hospitalier Régional Universitaire de Lille, Hopital Claude Huriez, Service D'Endocrinologie-Diabétologie-Métabolisme, Hopital Huriez, 59037, Lille, France
| | - Alain Fouilhoux
- Hospices Civils de Lyon, Centre de référence Des Maladies héréditaires du métabolisme de Lyon, Groupement Hospitalier Est, 69677, Bron Cedex, France
| | - Stéphane Thobois
- Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Neurologie C, 69677, Bron Cedex, France.,Université Lyon 1 Claude Bernard, Faculté de médecine Lyon EST, 69373, Lyon, France.,CNRS, Institut Des Sciences Cognitives Marc Jeannerod, UMR 5229, 69675, Bron, France
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