Identification of long chain dicarboxylic acids in the serum of two patients with Reye's syndrome

Large-Scale Implementation and Flaw Investigation of Human Serum Suspect Screening Analysis for Industrial Chemicals

Non-targeted analysis (NTA), including both suspect screening analysis (SSA) and unknown compound analysis, has gained increasing popularity in various fields for its capability in identifying new compounds of interests. Current major challenges for NTA SSA are that (1) tremendous effort and resources are needed for large-scale identification and confirmation of suspect chemicals and (2) suspect chemicals generally show low matching rates during identification and confirmation processes. To narrow the gap between these challenges and smooth implementation of NTA SSA methodology in the biomonitoring field, we present a thorough SSA workflow for the large-scale screen, identification, and confirmation of industrial chemicals that may pose adverse health effects in pregnant women and newborns. The workflow was established in a study of 30 paired maternal and umbilical cord serum samples collected at delivery in the San Francisco Bay area. By analyzing LC-HRMS and MS/MS data, together with the assistance of a combination of resources including online MS/MS spectra libraries, online in silico fragmentation tools, and the EPA CompTox Chemicals Dashboard, we confirmed the identities of 17 chemicals, among which monoethylhexyl phthalate, 4-nitrophenol, tridecanedioic acid, and octadecanedioic acid are especially interesting due to possible toxicities and their high-volume use in industrial manufacturing. Similar to other previous studies in the SSA field, the suspect compounds show relatively low MS/MS identification (16%) and standard confirmation (8%) rates. Therefore, we also investigated origins of false positive features and unidentifiable suspected features, as well as technical obstacles encountered during the confirmation process, which would promote a better understanding of the flaw of low confirmation rate and encourage gaining more effective tools for tackling this issue in NTA SSA.

Aspirin and Reye syndrome: a review of the evidence

Reye syndrome is an extremely rare but severe and often fatal disease. Death occurs in about 30-40% of cases from brainstem dysfunction. The disease typically is preceded by a viral infection with an intermediate disease-free interval of 3-5 days. The biochemical explanation for Reye-like symptoms is a generalized disturbance in mitochondrial metabolism, eventually resulting in metabolic failure in the liver and other tissues. The etiology of 'classical' Reye syndrome is unknown. Hypothetically, the syndrome may result from an unusual response to the preceding viral infection, which is determined by host genetic factors but can be modified by a variety of exogenous agents. Thus, several infections and diseases might present clinically with Reye-like symptoms. Exogenous agents involve a number of toxins, drugs (including aspirin [acetylsalicylic acid]), and other chemicals. The 'rise and fall' in the incidence of Reye syndrome is still poorly understood and unexplained. With a few exceptions, there were probably no new Reye-like diseases reported during the last 10 years that could not be explained by an inherited disorder of metabolism or a misdiagnosis. This may reflect scientific progress in the better understanding of cellular and molecular dysfunctions as disease-determining factors. Alternatively, the immune response to and the virulence of a virus might have changed by alteration of its genetic code. The suggestion of a defined cause-effect relationship between aspirin intake and Reye syndrome in children is not supported by sufficient facts. Clearly, no drug treatment is without side effects. Thus, a balanced view of whether treatment with a certain drug is justified in terms of the benefit/risk ratio is always necessary. Aspirin is no exception.

Abnormal fatty acid metabolism in childhood spinal muscular atrophy

Our previous experience with abnormal fatty acid metabolism in several children with spinal muscular atrophy (SMA) prompted evaluation of fatty acid metabolism in a larger cohort. Thirty-three infants with severe infantile SMA were shown to have a significantly increased ratio of dodecanoic to tetradecanoic acid in plasma compared with normal infants and 6 infants affected with equally debilitating, non-SMA denervating disorders. Seventeen children with milder forms of SMA had normal fatty acid profiles. In addition, all 5 infants with severe SMA evaluated in a fasting state developed a distinctive and marked dicarboxylic aciduria, including saturated, unsaturated, and 3-hydroxy forms, comparable in severity with the dicarboxylic aciduria of children with primary defects of mitochondrial fatty acid beta-oxidation. Nine children with chronic SMA and 23 control patients did not develop an abnormal dicarboxylic aciduria during fasting. No known disorder of fatty acid metabolism explains all of the abnormalities we find in SMA. Our data suggest, however, that the abnormalities are not a consequence of SMA-related immobility, systemic illness, muscle denervation, or muscle atrophy. These abnormalities in fatty acid metabolism may be caused by changes in cellular physiology related to the molecular defects of the SMA-pathogenic survival motor neuron gene or neighboring genes.

Aspirin induces short-chain free fatty acid accumulation in rats

Aspirin is used for the prophylaxis of infarction. A low dose of aspirin is effective for the prophylaxis of myocardial infarction, whereas a higher dose is necessary for that of stroke. Salicylic acid, the in vivo metabolite of aspirin, inhibits the beta-oxidation of short-chain fatty acids. Accordingly, drinking water containing 400, 800, or 1200 mg/l aspirin was given to each of eight rats for 30 days to determine the serum short-chain fatty acid levels. Analysis of variance and a post-hoc Fisher's protected least significant differences test revealed significantly increased levels (P < 0.05) of monocarboxylic acids, n-hexanoate, n-octanoate, n-decanoate, n-dodecanoate, and dicarboxylic acids, adipate (C6,) and suberate (C8): 78.7 +/- 36.2, 61.1 +/- 30.6, 215 +/- 151, 47.5 +/- 24.0, 3.64 +/- 2.09 and 1.71 +/- 1.45 micromol/l in the 800 mg/l aspirin group compared to 23.8 +/- 12.3, 20.1 +/- 9.0, 24.3 +/- 12.1, 6.3 +/- 5.6, 0.56 +/- 0.50 and 0.44 +/- 0.25 micromol/l in the control group, respectively. These levels were also increased in the 400 or 1200 mg/l aspirin groups but less so. These findings may help us to understand the aspirin toxicity in Reye's syndrome.

Beta-oxidation of long-chain fatty acids by human fibroblasts: evidence for a novel long-chain acyl-coenzyme A dehydrogenase

Fibroblasts from patients with long-chain acyl-CoA dehydrogenase deficiency were found to oxidize [1-14C]linoleate at an average rate of 60% of normal but [9,10(n)-3H]myristate at an average rate of only 37% of normal, a relationship reverse from that predicted by the chain-length specificities of the three known straight-chain mitochondrial acyl-CoA dehydrogenases. The residual long-chain beta-oxidative activity was found to be mitochondrial and associated with the accumulation of tetradecadienoate (C14:2w6) when the mutant fibroblasts were incubated with 100 mumol/L linoleate (C18:2w6) or eicosadienoate (C20:2w6). The results suggest the presence in human fibroblasts of a novel acyl-CoA dehydrogenase with activity toward 15 to 20 carbon-length fatty acids.

Glutaric aciduria type I: a common cause of episodic encephalopathy and spastic paralysis in the Amish of Lancaster County, Pennsylvania

We have diagnosed type I glutaric aciduria (GA-I) in 14 children from 7 Old Order Amish families in Lancaster County, Pennsylvania. An otherwise rare disorder, GA-I appears to be a common cause of acute encephalopathy and cerebral palsy among the Amish. The natural history of the disease, which was previously unrecognized in this population, is remarkably variable and ranges from acute infantile encephalopathy and sudden death to static extrapyramidal cerebral palsy to normal adult. Ten patients first manifested the disease between 3 and 18 months at the time of an acute infectious illness. Four of these children died in early childhood, also during acute illnesses. However, there has been little progression of the neurological disease after age 5 years in the surviving children and intellect usually has been preserved, even in children with severe spastic paralysis. When well, patients have plasma glutaric acid concentrations ranging from 4.8 to 14.2 mumol/liter (nl 0-5.6 mumol/liter) and urinary glutaric acid concentrations from 12.5 to 196 mg/g creatinine (nl 0.5-8.4 mg/g creatinine). We have found that GA-I can be diagnosed in the Amish by measurement of urinary glutaric acid concentrations using isotope-dilution gas chromatography/mass spectrometry, whereas the diagnosis can easily be missed by routine urine organic acid gas chromatography.(ABSTRACT TRUNCATED AT 250 WORDS)

Medium-chain acyl-CoA dehydrogenase deficiency: metabolic effects and therapeutic efficacy of long-term L-carnitine supplementation

Medium-chain acyl-CoA dehydrogenase deficiency is a recently described inborn error of metabolism characterized by episodes of coma and hypoketotic hypoglycaemia in response to prolonged fasting. Secondary carnitine deficiency has been documented in these patients as well as the excretion in the urine of medium-chain-length acyl carnitine esters, such as octanoylcarnitine. Based on the potential toxicity of medium-chain fatty acid metabolites and the beneficial responses of patients with other inborn errors of metabolism and secondary carnitine deficiency, oral carnitine has been proposed as treatment for children with medium-chain acyl-CoA dehydrogenase deficiency. We report the results of carefully monitored fasting challenges of an infant with this deficiency both before and after 3 months of oral carnitine therapy. Carnitine supplementation failed to prevent lethargy, vomiting, hypoglycaemia and accumulation of free fatty acids in response to fasting despite normalization of plasma carnitine levels and a marked increase in urinary excretion of acyl-carnitine esters. Potentially toxic medium-chain fatty acids accumulated in the plasma in spite of therapy. Based on this study of one patient, we stress that avoidance of fasting and prompt institution of glucose supplementation in situations when oral intake is interrupted remain the mainstays of therapy for medium-chain acyl-CoA dehydrogenase deficient patients.

Binding of straight-chain saturated dicarboxylic acids to albumin

Dicarboxylic acids are prominent features of several diseases, including Reye's syndrome. Long-chain dicarboxylic acids have profound effects on the function and structure of isolated mitochondria, suggesting that they could contribute to the mitochondrial dysfunction in Reye's syndrome. Binding of fatty acids to albumin and the intracellular fatty acid-binding proteins is important in regulating the transport and metabolism of fatty acids and protects against the toxic effects of unbound fatty acids. We studied the binding of dicarboxylic acids to defatted albumin using equilibrium dialysis to assess to what extent dicarboxylic acids are likely to be bound in the plasma of patients. Dicarboxylic acids bind weakly to albumin in a molar ratio of 3.8, 4.2, 1.6, 0.8, and 0.7 to 1 for octadecanedioic, hexadecanedioic, tetradecanedioic, dodecanedioic, and decanedioic acid, respectively. The dissociation constants for long-chain dicarboxylic acids are 100-1,000-fold larger than those of comparable monocarboxylic acids. Oleate competes with dicarboxylic acid and reduces the moles of dicarboxylic acid bound per mol of albumin to less than 1. Octanoate inhibits dicarboxylic acid binding. Our observations indicate that in Reye's syndrome, substantial concentrations of dicarboxylic acids of patients may be free and potentially toxic to mitochondria and other cellular processes.

3-Hydroxyoctanoic aciduria: identification of a new organic acid in the urine of a patient with non-ketotic hypoglycemia

A four-month-old child with non-ketotic hypoglycemia and rapidly progressive cirrhosis excreted in her urine large amounts of two unidentified organic acids in addition to a spectrum of saturated, unsaturated, and 3-hydroxy dicarboxylic acids in her urine. Gas chromatography/mass spectrometry of the trimethylsilyl derivative of one of the unknown compounds suggested the structure of 3-hydroxyoctanoic acid, which was confirmed by similar analysis of the authentic compound. The same organic acid was found in the child's plasma. The significance of 3-hydroxyoctanoic aciduria as a possible marker for a primary defect of 3-hydroxy fatty acid metabolism is discussed.

Urinary C6-C12 dicarboxylic acylcarnitines in Reye's syndrome

C6-C12 dicarboxylic acylcarnitines have been identified for the first time in urine from a 2-year-old girl presenting with Reye's syndrome. The acylcarnitines were extracted by ion-exchange chromatography and analysed, both underivatised and as methyl esters using high-resolution fast-atom-bombardment mass spectrometry and B/E-linked scanning. The acylcarnitines were quantified by capillary gas chromatography of the acids extracted after hydrolysis of the acylcarnitine esters. Dodecandioylcarnitine was present in the highest concentration (35.9 mmol/mol creatinine) which exceeded the urinary free dodecandioic acid concentration. The adipic, suberic and sebacic acylcarnitine concentrations were less than 10% of the respective free acid concentrations. It is possible that beta-oxidation of dicarboxylic acids is partially inhibited in Reye's syndrome leading to accumulation of precursor dodecandioyl CoA which is metabolised to dodecandioylcarnitine. The accumulation of these metabolic intermediates may be significant in the pathogenesis of Reye's syndrome.

Advances in the application of biochemical tests to diseases of the liver and biliary tract: their role in diagnosis, prognosis, and the elucidation of pathogenetic mechanisms

Despite the biochemical complexity of the liver, few laboratory tests provide discriminatory diagnostic information in patients with hepatobiliary disease. Recent efforts have concentrated upon tests which assess the function of the liver, the severity of the disease state, and underlying pathological processes. Bile Acids: The emergence of facile technology and widespread application has brought the realization that these assays are not as sensitive in detecting liver disease as previously believed, although the cholate/chenate ratio may be useful in distinguishing cholestasis from chronic liver disease. The presence of unusual bile acids in serum or urine may be helpful in some cases. Drug Metabolism: A number of tests provide good evidence about liver function, hepatic blood flow and portal shunting, but the aminopyrine breath tests is the most useful, giving prognostic information in acetaminophen overdose and alcoholic liver disease. The antipyrine half-life identifies surgical cases at risk from poor hepatic function. Proteins and Immunochemical Tests: Interest has developed in plasma proteins such as prealbumin and retinol-binding protein to monitor hepatic protein synthetic function. Secretory IgA is more elevated in biliary tract disease, unlike the native protein which is increased principally in cirrhosis. Type III procollagen can be measured in serum, and correlates with the activity of collagen synthesis and the degree of fibrosis in biopsy samples. Reye's Syndrome: Biochemical tests play an essential role in diagnosis of this recently discovered disease. These will be presented and discussed.

Reye's syndrome: current concepts

Despite greater than 23 years of study, an incomplete understanding of the etiology, epidemiology and pathogenesis of Reye's syndrome persists. Better understanding of the disease has been hampered by the lack of a good animal model on which hypotheses of its pathogenesis could be tested. Human studies indicate that a primary mitochondrial injury may lead to complex metabolic disturbances that produce the observed pathophysiology. Specific directions regarding avenues for future research should pursue two lines: a good animal model still needs to be developed in which the biochemical and morphologic alterations identified in Reye's syndrome are duplicated. This model should include an antecedent viral illness but may not require aspirin exposure as an essential ingredient. With the identification of a satisfactory model, specific questions about the roles of environmental toxins or medications may be answered. Study of noncomatose cases of Reye's syndrome should continue. The specific emphasis should be to delineate what factors (NH3, free fatty acids and dicarboxylic acids) may be implicated in the pathogenesis of the CNS disease with the hopes of devising strategies for more effective treatment of encephalopathy and its attendant morbidity and mortality.

Serum dicarboxylic acids in patients with Reye syndrome

Reye syndrome resembles disorders of fatty acid metabolism. Analysis of serum free fatty acids from 18 patients with Reye syndrome revealed that dicarboxylic acids comprise as much as 55% (range 4% to 55%) of the patients' total free fatty acids; both medium- (6 to 12 carbon lengths) and long-chain (14 to 18 carbon lengths) dicarboxylic acids were identified. Long-chain dicarboxylic acids were not found in any control samples, whereas 86% +/- 4% of the serum dicarboxylic acids were long chain in 10 patients with Reye syndrome in state 3 to 4 coma and 31% +/- 8% in eight patients with a milder illness. The serum concentration of dicarboxylic acids correlated with the clinical state (P less than 0.001) and with the elevation in blood ammonia concentration (r2 = 0.8767). No long-chain dicarboxylic acids were found in the urine. The dicarboxylic acidemia in Reye syndrome may be secondary to the general mitochondrial dysfunction or could indicate that an insult to fatty acid metabolism or the stimulation of omega-oxidation is important in the pathogenesis of the illness. Measurement of serum dicarboxylic acids, especially long chain, may be important in assessing Reye syndrome and may prove useful in distinguishing this from other diseases.

Metabolic profiling with gas chromatography-mass spectrometry and its application to clinical medicine

Nowadays, metabolic profiling is widely applied in clinical medicine for the diagnosis and study of human diseases. The number of these applications and their diversity have increased rapidly in the past few years. This review summarizes recent advances in the methods for sample pretreatment and the clinical application of GC-MS to the study of uraemia, diabetes mellitus, dicarboxylic aciduria and other organic acidurias. High-resolution GC-MS is well suited to the profile analysis of metabolic disorders.

Serum lipid abnormalities in a chemical/viral mouse model for Reye's syndrome

Neonatal mice given nontoxic dermal applications of an industrial surfactant, Toximul MP8 (Tox), and subsequently infected with sublethal doses of mouse-adapted human Influenza B (Lee) virus (FluB) develop many of the biochemical features of Reye's Syndrome (RS). To determine whether these also include abnormal circulating lipid, we examined serum lipid profiles in the mouse model throughout the treatment course using Iatroscan-TH10. Following 10 days of exposure to surfactant, serum phospholipid and cholesterol levels were significantly reduced relative to control animals. These reductions were transient; however, four days following virus administration, significant differences in serum lipid were again evident. These abnormalities coincided and correlated with increased animal mortality. Animals that received combined Tox + virus treatment had significant decreases in serum total lipids relative to control animals, a reflection of a reduction in all lipid classes, including phospholipid, cholesterol, neutral glycerides (triglycerides plus diglycerides) and free fatty acids. Phospholipid (specifically phosphatidylcholine and lysophosphatidylcholine) and free fatty acid levels in the Tox + virus group were also significantly lower than those in animals that received virus alone. This study has demonstrated that suckling mice given chemical/viral treatment have the serum hypopanlipidemia but not the freefattyacidemia that are characteristic of RS.

Mass spectrometric identification of 2-hydroxy-sebacic acid in the urines of patients with neonatal adrenoleukodystrophy and Zellweger syndrome

The urines of children with neonatal adrenoleukodystrophy and Zellweger syndrome contained an excess of unusual even- and odd-numbered dicarboxylic acids with a chain length of from 5 to 15 carbon atoms, as well as 2-hydroxy-compounds, including 2-hydroxy-isocaproate, 2-hydroxy-glutarate and 2-hydroxy-sebacate. The latter product, not previously found in metabolic diseases, appears as an additional useful marker of these peroxisomal disorders.

Effect of Reye's syndrome serum on isolated chinchilla liver mitochondria

A general impairment of liver mitochondrial enzymes is central to Reye's syndrome (RS). The respiration of isolated liver mitochondria was measured after the addition of concentrated normal serum or RS serum derived from 12 patients. RS serum stimulates oxygen consumption in isolated rat liver mitochondria. This effect is due to the oxidation of uric acid by peroxisomes contaminating the preparation and a stimulation of mitochondrial respiration (1.05 +/- 0.14 nmol of O2/min X mg of protein; control 0.30 +/- 0.08 nmol O2/min X mg). The stimulation of respiration occurs in the presence of all respiratory substrates, is dependent on the amount of serum added, and represents an uncoupling of oxidative phosphorylation. RS serum reduces ATP formation by 15-76%. The uncoupling effect correlates with the amount of free fatty acid in the serum sample and resembles the effect induced by the addition of a dicarboxylic fatty acid. Dicarboxylic fatty acids, especially long-chain dicarboxylic acids, impair ATP formation. Dicarboxylic acids were found in the serum of all RS patients and comprised as much as 54% of the total serum free fatty acids. 90% of the serum dicarboxylic acids were of 16-18 carbon lengths. The amount of dicarboxylic acids in the RS serum corresponded directly with the reduction in ATP formation by the RS serum. This demonstrates that dicarboxylic acids occur in RS and may be important in the general impairment of mitochondrial function in RS and other disorders where they are present.

Urinary dicarboxylic acids in Reye syndrome

Urine from 12 patients with Reye syndrome was examined by gas-liquid chromatography for identification of organic acids. Large amounts of lactic acid, dicarboxylic acids (adipic, suberic, and sebacic), and 3-OH butyric acid were noted. The mean (+/- SD) total dicarboxylic acid concentration was 0.98 +/- 0.24 mg/mg creatinine, compared with 0.006 +/- 0.010 mg/mg creatinine in controls, n = 140; the mean in patients with Reye syndrome was higher (1.40 +/- 0.26 mg/mg creatinine, n = 8) when the samples were obtained prior to initiation of therapy, but declined rapidly after administration of hypertonic glucose, exchange transfusion, and osmotic diuretics. The total urine excretion of dicarboxylic acids plus urine ketones at the time of presentation correlated well with the plasma lactate (r2 = 0.9676) and peak blood ammonia (r2 = 0.9216) levels. Our results document the occurrence of significant dicarboxylic aciduria in Reye syndrome and indicate that fatty acid metabolism is more impaired in this disorder than previously appreciated.

Derivatization reactions in the gas—liquid chromatographic analysis of drugs in biological fluids

Alkylation, acylation, silylation and other derivatization reactions applied to the gas chromatographic analysis of drugs in biological matrices are reviewed. Reaction conditions are discussed in relation to reaction mechanisms. Detector-oriented labelling of drugs, and derivatization with chiral reagents for the separation of enantiomers are surveyed. Data on the sample clean-up, derivatization and GLC analysis of more than 300 drugs and related compounds are listed.