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Habib A, Azize NAA, Rahman SA, Yakob Y, Suberamaniam V, Nazri MIBA, Abdullah Sani H, Ch'ng GS, Yin LH, Olpin S, Lock-Hock N. Novel mutations associated with carnitine-acylcarnitine translocase and carnitine palmitoyl transferase 2 deficiencies in Malaysia. Clin Biochem 2021; 98:48-53. [PMID: 34626609 DOI: 10.1016/j.clinbiochem.2021.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/17/2021] [Accepted: 10/04/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Carnitine-acylcarnitine Translocase (CACT) deficiency (OMIM 212138) and carnitine palmitoyl transferase 2 (CPT2) deficiency (OMIM 60065050) are rare inherited disorders of mitochondrial long chain fatty acid oxidation. The aim of our study is to review the clinical, biochemical and molecular characteristics in children diagnosed with CACT and CPT2 deficiencies in Malaysia. DESIGN AND METHODS This is a retrospective study. We reviewed medical records of six patients diagnosed with CACT and CPT2 deficiencies. They were identified from a selective high-risk screening of 50,579 patients from January 2010 until Jun 2020. RESULTS All six patients had either elevation of the long chain acylcarnitines and/or an elevated (C16 + C18:1)/C2 acylcarnitine ratio. SLC25A20 gene sequencing of patient 1 and 6 showed a homozygous splice site mutation at c.199-10 T > G in intron 2. Two novel mutations at c.109C > T p. (Arg37*) in exon 2 and at c.706C > T p. (Arg236*) in exon 7 of SLC25A20 gene were found in patient 2. Patient 3 and 4 (siblings) exhibited a compound heterozygous mutation at c.638A > G p. (Asp213Gly) and novel mutation c.1073 T > G p. (Leu358Arg) in exon 4 of CPT2 gene. A significant combined prevalence at 0.01% of CACT and CPT2 deficiencies was found in the symptomatic Malaysian patients. CONCLUSIONS The use of the (C16 + C18:1)/C2 acylcarnitine ratio in dried blood spot in our experience improves the diagnostic specificity for CACT/CPT2 deficiencies over long chain acylcarnitine (C16 and C18:1) alone. DNA sequencing for both genes aids in confirming the diagnosis.
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Affiliation(s)
- Anasufiza Habib
- Biochemistry Unit, Specialised Diagnostic Centre, Institute for Medical Research, National Institute of Health, Kuala Lumpur, Malaysia, Ministry of Health Malaysia.
| | - Nor Azimah Abdul Azize
- Molecular Diagnostic Unit, Specialised Diagnostic Centre, Institute for Medical Research, National Institute of Health, Kuala Lumpur, Malaysia, Ministry of Health Malaysia
| | - Salina Abd Rahman
- Inborn Errors of Metabolism & Genetics Unit, Nutrition, Metabolic & Cardiovascular Research Centre, Institute for Medical Research, National Institutes of Health, Selangor, Malaysia, Ministry of Health Malaysia
| | - Yusnita Yakob
- Molecular Diagnostic Unit, Specialised Diagnostic Centre, Institute for Medical Research, National Institute of Health, Kuala Lumpur, Malaysia, Ministry of Health Malaysia
| | - Vengadeshwaran Suberamaniam
- Molecular Diagnostic Unit, Specialised Diagnostic Centre, Institute for Medical Research, National Institute of Health, Kuala Lumpur, Malaysia, Ministry of Health Malaysia
| | - Muhammad Irfan Bukhari Ahmad Nazri
- Biochemistry Unit, Specialised Diagnostic Centre, Institute for Medical Research, National Institute of Health, Kuala Lumpur, Malaysia, Ministry of Health Malaysia
| | - Huzaimah Abdullah Sani
- Department of Pathology, Women and Children's Hospital, Kuala Lumpur, Malaysia, Ministry of Health Malaysia
| | - Gaik-Siew Ch'ng
- Department of Genetic, Penang Hospital, Penang, Malaysia, Ministry of Health Malaysia
| | - Leong Huey Yin
- Department of Genetic, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia, Ministry of Health Malaysia
| | - Simon Olpin
- Department of Clinical Chemistry, Sheffield Children's Hospital, Sheffield, United Kingdom
| | - Ngu Lock-Hock
- Department of Genetic, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia, Ministry of Health Malaysia
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Bo R, Musha I, Yamada K, Kobayashi H, Hasegawa Y, Awano H, Arao M, Kikuchi T, Taketani T, Ohtake A, Yamaguchi S, Iijima K. Need for strict clinical management of patients with carnitine palmitoyltransferase II deficiency: Experience with two cases detected by expanded newborn screening. Mol Genet Metab Rep 2020; 24:100611. [PMID: 32489884 PMCID: PMC7260588 DOI: 10.1016/j.ymgmr.2020.100611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 12/31/2022] Open
Abstract
In Japan, carnitine palmitoyltransferase II (CPTII) deficiency has been included as one of the primary target diseases in the expanded newborn mass screening program since 2018. However, many cases of the severe infantile hepatocardiomuscular form of CPTII deficiency showed severe neurodevelopmental delay or sudden death, which indicated that management of CPTII deficiency in the acute phase remains to be studied in detail. Herein, we discuss two cases diagnosed by newborn mass screening. Patient 1 was under strict clinical management from the neonatal period, with >20 admissions in 14 months, while Patient 2 was managed using a relatively relaxed approach, with only 2 admissions in the same period. Patient 1 showed normal development; however, Patient 2 expired at the age of 1 year 2 months. To develop strategies for preventing sudden deaths in patients with CPTII deficiency, this retrospective study focused on detailed clinical management practices and biochemical findings during the acute phase. We also investigated the correlation between conventional biomarkers (such as creatine kinase) and long-chain acylcarnitines. We propose that strict monitoring and immediate medical attention, even in case of slight fever or minor abdominal symptoms, can help prevent sudden death in patients with CPTII deficiency. Considering the higher morbidity rate of such patients, strict and acute management of CPTII deficiency cannot be overemphasized.
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Affiliation(s)
- Ryosuke Bo
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.,Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan
| | - Ikuma Musha
- Department of Pediatrics, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Saitama 350-0495, Japan
| | - Kenji Yamada
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan
| | - Hironori Kobayashi
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan
| | - Yuki Hasegawa
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan
| | - Hiroyuki Awano
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
| | - Masato Arao
- Department of Pediatrics, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Saitama 350-0495, Japan
| | - Toru Kikuchi
- Department of Pediatrics, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Saitama 350-0495, Japan
| | - Takeshi Taketani
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan
| | - Akira Ohtake
- Department of Pediatrics, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Saitama 350-0495, Japan
| | - Seiji Yamaguchi
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
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Phowthongkum P, Ittiwut C, Shotelersuk V. Severe Hyperammonemic Encephalopathy Requiring Dialysis Aggravated by Prolonged Fasting and Intermittent High Fat Load in a Ramadan Fasting Month in a Patient with CPTII Homozygous Mutation. JIMD Rep 2017; 41:11-16. [PMID: 29159461 DOI: 10.1007/8904_2017_74] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/07/2017] [Accepted: 11/02/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Carnitine palmitoyltransferase II (CPTII) deficiency is a mitochondrial fatty acid oxidation disorder that can present antenatally as congenital brain malformations, or postnatally with lethal neonatal, severe infantile, or the most common adult myopathic forms. No case of severe hyperammonemia without liver dysfunction has been reported. CASE PRESENTATION We described a 23-year-old man who presented to the emergency department with seizures and was found to have markedly elevation of serum ammonia. Continuous renal replacement therapy was initiated with successfully decreased ammonia to a safety level. He had a prolonged history of epilepsies and encephalopathic attacks that was associated with high ammonia level. Molecular diagnosis revealed a homozygous mutation in CPTII. The plasma acylcarnitine profile was consistent with the diagnosis. Failure to produce acetyl-CoA, the precursor of urea cycle from fatty acid in prolonged fasting state in Ramadan month, worsening mitochondrial functions from circulating long chain fatty acid and valproate toxicities were believed to contribute to this critical metabolic decompensation. CONCLUSION Fatty acid oxidation disorders should be considered in the differential diagnosis of hyperammonemia even without liver dysfunction. To our knowledge, this is the first case of CPTII deficiency presented with severe hyperammonemic encephalopathy required dialysis after prolonged religious related fasting.
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Affiliation(s)
- P Phowthongkum
- Division of Medical Genetics and Genomics, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. .,Medical Genetics Center, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand.
| | - C Ittiwut
- Center of Excellence for Medical Genetics, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - V Shotelersuk
- Excellence Center for Medical Genetics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
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Tajima G, Hara K, Tsumura M, Kagawa R, Okada S, Sakura N, Maruyama S, Noguchi A, Awaya T, Ishige M, Ishige N, Musha I, Ajihara S, Ohtake A, Naito E, Hamada Y, Kono T, Asada T, Sasai H, Fukao T, Fujiki R, Ohara O, Bo R, Yamada K, Kobayashi H, Hasegawa Y, Yamaguchi S, Takayanagi M, Hata I, Shigematsu Y, Kobayashi M. Newborn screening for carnitine palmitoyltransferase II deficiency using (C16+C18:1)/C2: Evaluation of additional indices for adequate sensitivity and lower false-positivity. Mol Genet Metab 2017; 122:67-75. [PMID: 28801073 DOI: 10.1016/j.ymgme.2017.07.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Carnitine palmitoyltransferase (CPT) II deficiency is one of the most common forms of mitochondrial fatty acid oxidation disorder (FAOD). However, newborn screening (NBS) for this potentially fatal disease has not been established partly because reliable indices are not available. METHODS We diagnosed CPT II deficiency in a 7-month-old boy presenting with hypoglycemic encephalopathy, which apparently had been missed in the NBS using C16 and C18:1 concentrations as indices. By referring to his acylcarnitine profile from the NBS, we adopted the (C16+C18:1)/C2 ratio (cutoff 0.62) and C16 concentration (cutoff 3.0nmol/mL) as alternative indices for CPT II deficiency such that an analysis of a dried blood specimen collected at postnatal day five retroactively yielded the correct diagnosis. Thereafter, positive cases were assessed by measuring (1) the fatty acid oxidation ability of intact lymphocytes and/or (2) CPT II activity in the lysates of lymphocytes. The diagnoses were then further confirmed by genetic analysis. RESULTS The disease was diagnosed in seven of 21 newborns suspected of having CPT II deficiency based on NBS. We also analyzed the false-negative patient and five symptomatic patients for comparison. Values for the NBS indices of the false-negative, symptomatic patient were lower than those of the seven affected newborns. Although it was difficult to differentiate the false-negative patient from heterozygous carriers and false-positive subjects, the fatty acid oxidation ability of the lymphocytes and CPT II activity clearly confirmed the diagnosis. Among several other indices proposed previously, C14/C3 completely differentiated the seven NBS-positive patients and the false-negative patient from the heterozygous carriers and the false-positive subjects. Genetic analysis revealed 16 kinds of variant alleles. The most prevalent, detected in ten alleles in nine patients from eight families, was c.1148T>A (p.F383Y), a finding in line with those of several previous reports on Japanese patients. CONCLUSIONS These findings suggested that CPT II deficiency can be screened by using (C16+C18:1)/C2 and C16 as indices. An appropriate cutoff level is required to achieve adequate sensitivity albeit at the cost of a considerable increase in the false-positive rate, which might be reduced by using additional indices such as C14/C3.
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Affiliation(s)
- Go Tajima
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan; Division of Neonatal Screening, Research Institute, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo 157-8535, Japan.
| | - Keiichi Hara
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan; Department of Pediatrics, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, 3-1 Aoyama-cho, Kure 737-0023, Japan.
| | - Miyuki Tsumura
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Reiko Kagawa
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Satoshi Okada
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
| | - Nobuo Sakura
- Nursing House for Severe Motor and Intellectual Severities Suzugamine, 104-27 Minaga, Itsukaichi-cho, Saeki-ku, Hiroshima 731-5122, Japan.
| | - Shinsuke Maruyama
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan.
| | - Atsuko Noguchi
- Department of Pediatrics, Akita University Graduate School of Medicine, 44-2 Hasunuma, Hiroomote, Akita 010-8543, Japan.
| | - Tomonari Awaya
- Department of Pediatrics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Mika Ishige
- Department of Pediatrics and Child Health, Nihon University School of Medicine, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo 101-8309, Japan.
| | - Nobuyuki Ishige
- Division of Newborn Screening, Tokyo Health Service Association, 1-2-59 Ichiga-Sadohara, Shinjuku-ku, Tokyo 162-8460, Japan.
| | - Ikuma Musha
- Department of Pediatrics, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Saitama 350-0495, Japan.
| | - Sayaka Ajihara
- Department of Pediatrics, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Saitama 350-0495, Japan.
| | - Akira Ohtake
- Department of Pediatrics, Faculty of Medicine, Saitama Medical University, 38 Morohongo, Moroyama-cho, Saitama 350-0495, Japan.
| | - Etsuo Naito
- Department of Pediatrics, Japanese Red Cross Tokushima Hinomine Rehabilitation Center, 4-1 Shinbiraki, Chuden-cho, Komatsushima, Tokushima 773-0015, Japan.
| | - Yusuke Hamada
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka 565-0871, Japan.
| | - Tomotaka Kono
- Division of Endocrinology and Metabolism, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama 330-8777, Japan.
| | - Tomoko Asada
- Department of Pediatrics, Faculty of Medicine, University of Miyazaki Hospital, 5200 Kihara, Kiyotake-cho, Miyazaki 889-1692, Japan.
| | - Hideo Sasai
- Department of Pediatrics, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu 501-1193, Japan.
| | - Toshiyuki Fukao
- Department of Pediatrics, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu 501-1193, Japan.
| | - Ryoji Fujiki
- Department of Technology Development, Kazusa DNA Research Institute, Kisarazu, Chiba 292-0818, Japan.
| | - Osamu Ohara
- Department of Technology Development, Kazusa DNA Research Institute, Kisarazu, Chiba 292-0818, Japan.
| | - Ryosuke Bo
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan; Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.
| | - Kenji Yamada
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan.
| | - Hironori Kobayashi
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan.
| | - Yuki Hasegawa
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan.
| | - Seiji Yamaguchi
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 En-ya-cho, Izumo 693-8501, Japan.
| | - Masaki Takayanagi
- Department of Nursing, Faculty of Health Care and Medical Sport, Teikyo Heisei University, 6-19 Chiharadai-Nishi, Ichihara 290-0192, Japan.
| | - Ikue Hata
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka-Shimoaizuki, Eiheiji-cho, Fukui 910-1193, Japan.
| | - Yosuke Shigematsu
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka-Shimoaizuki, Eiheiji-cho, Fukui 910-1193, Japan.
| | - Masao Kobayashi
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
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