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Kim YA, Kim SH, Cheon CK, Kim YM. A Rare Cause of Life-Threatening Ketoacidosis: Novel Compound Heterozygous OXCT1 Mutations Causing Succinyl-CoA:3-Ketoacid CoA Transferase Deficiency. Yonsei Med J 2019; 60:308-311. [PMID: 30799594 PMCID: PMC6391521 DOI: 10.3349/ymj.2019.60.3.308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 01/02/2019] [Accepted: 01/06/2019] [Indexed: 12/21/2022] Open
Abstract
Succinyl-CoA:3-ketoacid CoA transferase (SCOT) deficiency is a rare inborn error of ketone body utilization, characterized by episodic or permanent ketosis. SCOT deficiency is caused by mutations in the OXCT1 gene, which is mapped to 5p13 and consists of 17 exons. A 12-month-old girl presented with severe ketoacidosis and was treated with continuous renal replacement therapy. She had two previously unrecognized mild-form episodes of ketoacidosis followed by febrile illness. While high levels of ketone bodies were found in her blood and urine, other laboratory investigations, including serum glucose, were unremarkable. We identified novel compound heterozygous mutations in OXCT1:c.1118T>G (p.Ile373Ser) and a large deletion ranging from exon 8 to 16 through targeted exome sequencing and microarray analysis. This is the first Korean case of SCOT deficiency caused by novel mutations in OXCT1, resulting in life-threatening ketoacidosis. In patients with unexplained episodic ketosis, or high anion gap metabolic acidosis in infancy, an inherited disorder in ketone body metabolism should be suspected.
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Affiliation(s)
- Young A Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Seong Heon Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Chong Kun Cheon
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Yoo Mi Kim
- Department of Pediatrics, Chungnam National University Hospital, College of Medicine, Chungnam National University, Daejeon, Korea.
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Sasai H, Aoyama Y, Otsuka H, Abdelkreem E, Naiki Y, Kubota M, Sekine Y, Itoh M, Nakama M, Ohnishi H, Fujiki R, Ohara O, Fukao T. Heterozygous carriers of succinyl-CoA:3-oxoacid CoA transferase deficiency can develop severe ketoacidosis. J Inherit Metab Dis 2017; 40:845-852. [PMID: 28695376 DOI: 10.1007/s10545-017-0065-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 06/07/2017] [Accepted: 06/08/2017] [Indexed: 02/05/2023]
Abstract
Succinyl-CoA:3-oxoacid CoA transferase (SCOT, gene symbol OXCT1) deficiency is an autosomal recessive disorder in ketone body utilization that results in severe recurrent ketoacidotic episodes in infancy, including neonatal periods. More than 30 patients with this disorder have been reported and to our knowledge, their heterozygous parents and siblings have had no apparent ketoacidotic episodes. Over 5 years (2008-2012), we investigated several patients that presented with severe ketoacidosis and identified a heterozygous OXCT1 mutation in four of these cases (Case1 p.R281C, Case2 p.T435N, Case3 p.W213*, Case4 c.493delG). To confirm their heterozygous state, we performed a multiplex ligation-dependent probe amplification analysis on the OXCT1 gene which excluded the presence of large deletions or insertions in another allele. A sequencing analysis of subcloned full-length SCOT cDNA showed that wild-type cDNA clones were present at reasonable rates to mutant cDNA clones. Over the following 2 years (2013-2014), we analyzed OXCT1 mutations in six more patients presenting with severe ketoacidosis (blood pH ≦7.25 and total ketone body ≧10 mmol/L) with non-specific urinary organic acid profiles. Of these, a heterozygous OXCT1 mutation was found in two cases (Case5 p.G391D, Case6 p.R281C). Moreover, transient expression analysis revealed R281C and T435N mutants to be temperature-sensitive. This characteristic may be important because most patients developed ketoacidosis during infections. Our data indicate that heterozygous carriers of OXCT1 mutations can develop severe ketoacidotic episodes in conjunction with ketogenic stresses.
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Affiliation(s)
- Hideo Sasai
- Department of Pediatrics, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan
| | - Yuka Aoyama
- Department of Pediatrics, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan
- Department of Biomedical Sciences, College of Life and Health Sciences, Chubu University, Kasugai, Japan
| | - Hiroki Otsuka
- Department of Pediatrics, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan
| | - Elsayed Abdelkreem
- Department of Pediatrics, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan
- Department of Pediatrics, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Yasuhiro Naiki
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | - Mitsuru Kubota
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yuji Sekine
- Department of General Pediatrics, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Masatsune Itoh
- Department of Pediatrics, Kanazawa Medical University, Kanazawa, Japan
| | - Mina Nakama
- Division of Clinical Genetics, Gifu University Hospital, Gifu, Japan
| | - Hidenori Ohnishi
- Department of Pediatrics, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan
| | - Ryoji Fujiki
- Department of Technology Development, Kazusa DNA Research Institute, Kisarazu, Japan
| | - Osamu Ohara
- Department of Technology Development, Kazusa DNA Research Institute, Kisarazu, Japan
| | - Toshiyuki Fukao
- Department of Pediatrics, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu City, Gifu, 501-1194, Japan.
- Division of Clinical Genetics, Gifu University Hospital, Gifu, Japan.
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Zheng DJ, Hooper M, Spencer-Manzon M, Pierce RW. A Case of Succinyl-CoA:3-Oxoacid CoA Transferase Deficiency Presenting with Severe Acidosis in a 14-Month-Old Female: Evidence for Pathogenicity of a Point Mutation in the OXCT1 Gene. J Pediatr Intensive Care 2017; 7:62-66. [PMID: 31073471 DOI: 10.1055/s-0037-1604270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 06/12/2017] [Indexed: 10/19/2022] Open
Abstract
We describe a case of succinyl-CoA:3-oxoacid CoA transferase (SCOT) deficiency in an otherwise healthy 14 month-old female. She presented with lethargy, tachypnea, and hyperpnea with hypoglycemia and a severe anion gap metabolic acidosis. Early management included correction of the acidosis and metabolic support with dextrose and insulin. Inborn errors of metabolism are rare outside the neonatal period. However, SCOT deficiency may present at older ages. Maintaining a high index of suspicion, immediate transfer to a pediatric intensive care unit, and prompt metabolic support are key to achieving a favorable outcome.
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Affiliation(s)
- Daniel J Zheng
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, United States
| | - Michael Hooper
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, United States
| | - Michele Spencer-Manzon
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, United States.,Department of Genetics, Yale School of Medicine, New Haven, Connecticut, United States
| | - Richard W Pierce
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, United States
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Erdol S, Ture M, Yakut T, Saglam H, Sasai H, Abdelkreem E, Otsuka H, Fukao T. A Turkish Patient With Succinyl-CoA:3-Oxoacid CoA Transferase Deficiency Mimicking Diabetic Ketoacidosis. JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2016. [DOI: 10.1177/2326409816651281] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Sahin Erdol
- Division of Metabolism, Department of Pediatrics, Uludağ University Faculty of Medicine, Görükle, Bursa, Turkey
| | - Mehmet Ture
- Department of Medical Genetics, Uludağ University, Görükle, Bursa, Turkey
| | - Tahsin Yakut
- Department of Medical Genetics, Uludağ University, Görükle, Bursa, Turkey
| | - Halil Saglam
- Division of Metabolism, Department of Pediatrics, Uludağ University Faculty of Medicine, Görükle, Bursa, Turkey
| | - Hideo Sasai
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Elsayed Abdelkreem
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Hiroki Otsuka
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Toshiyuki Fukao
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
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Hori T, Yamaguchi S, Shinkaku H, Horikawa R, Shigematsu Y, Takayanagi M, Fukao T. Inborn errors of ketone body utilization. Pediatr Int 2015; 57:41-8. [PMID: 25559898 DOI: 10.1111/ped.12585] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 12/01/2014] [Accepted: 12/15/2014] [Indexed: 11/28/2022]
Abstract
Succinyl-CoA:3-ketoacid CoA transferase (SCOT) deficiency and mitochondrial acetoacetyl-CoA thiolase (beta-ketothiolase or T2) deficiency are classified as autosomal recessive disorders of ketone body utilization characterized by intermittent ketoacidosis. Patients with mutations retaining no residual activity on analysis of expression of mutant cDNA are designated as severe genotype, and patients with at least one mutation retaining significant residual activity, as mild genotype. Permanent ketosis is a pathognomonic characteristic of SCOT-deficient patients with severe genotype. Patients with mild genotype, however, may not have permanent ketosis, although they may develop severe ketoacidotic episodes similar to patients with severe genotype. Permanent ketosis has not been reported in T2 deficiency. In T2-deficient patients with severe genotype, biochemical diagnosis is done on urinary organic acid analysis and blood acylcarnitine analysis to observe characteristic findings during both ketoacidosis and non-episodic conditions. In Japan, however, it was found that T2-deficient patients with mild genotype are common, and typical profiles were not identified on these analyses. Based on a clinical study of ketone body utilization disorders both in Japan and worldwide, we have developed guidelines for disease diagnosis and treatment. These diseases are treatable by avoiding fasting and by providing early infusion of glucose, which enable the patients to grow without sequelae.
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Affiliation(s)
- Tomohiro Hori
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
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Fukao T, Mitchell G, Sass JO, Hori T, Orii K, Aoyama Y. Ketone body metabolism and its defects. J Inherit Metab Dis 2014; 37:541-51. [PMID: 24706027 DOI: 10.1007/s10545-014-9704-9] [Citation(s) in RCA: 148] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Revised: 03/01/2014] [Accepted: 03/10/2014] [Indexed: 12/17/2022]
Abstract
Acetoacetate (AcAc) and 3-hydroxybutyrate (3HB), the two main ketone bodies of humans, are important vectors of energy transport from the liver to extrahepatic tissues, especially during fasting, when glucose supply is low. Blood total ketone body (TKB) levels should be evaluated in the context of clinical history, such as fasting time and ketogenic stresses. Blood TKB should also be evaluated in parallel with blood glucose and free fatty acids (FFA). The FFA/TKB ratio is especially useful for evaluation of ketone body metabolism. Defects in ketogenesis include mitochondrial HMG-CoA synthase (mHS) deficiency and HMG-CoA lyase (HL) deficiency. mHS deficiency should be considered in non-ketotic hypoglycemia if a fatty acid beta-oxidation defect is suspected, but cannot be confirmed. Patients with HL deficiency can develop hypoglycemic crises and neurological symptoms even in adolescents and adults. Succinyl-CoA-3-oxoacid CoA transferase (SCOT) deficiency and beta-ketothiolase (T2) deficiency are two defects in ketolysis. Permanent ketosis is pathognomonic for SCOT deficiency. However, patients with "mild" SCOT mutations may have nonketotic periods. T2-deficient patients with "mild" mutations may have normal blood acylcarnitine profiles even in ketoacidotic crises. T2 deficient patients cannot be detected in a reliable manner by newborn screening using acylcarnitines. We review recent data on clinical presentation, metabolite profiles and the course of these diseases in adults, including in pregnancy.
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Affiliation(s)
- Toshiyuki Fukao
- Department of Pediatrics, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan,
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Hori T, Fukao T, Murase K, Sakaguchi N, Harding CO, Kondo N. Molecular basis of two-exon skipping (exons 12 and 13) by c.1248+5g>a in OXCT1 gene: study on intermediates of OXCT1 transcripts in fibroblasts. Hum Mutat 2013; 34:473-80. [PMID: 23281106 DOI: 10.1002/humu.22258] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 11/30/2012] [Indexed: 11/09/2022]
Abstract
The molecular basis of simultaneous two-exon skipping induced by a splice-site mutation has yet to be completely explained. The splice donor site mutation c.1248+5g>a (IVS13) of the OXCT1 gene resulted predominantly in skipping of exons 12 and 13 in fibroblasts from a patient (GS23) with succinyl-CoA:3-ketoacid CoA transferase (SCOT) deficiency. We compared heteronuclear RNA (hnRNA) intermediates between controls' and GS23's fibroblasts. Our strategy was to use RT-PCR of hnRNA to detect the presence or absence of spliced exon clusters in RNA intermediates (SECRIs) comprising sequential exons. Our initial hypothesis was that a SECRI comprising exons 12 and 13 was formed first followed by skipping of this SECRI in GS23 cells. However, such a pathway was revealed to be not a major one. Hence, we compared the intron removal of SCOT transcript between controls and GS23. In controls, intron 11 was the last intron to be spliced and the removal of intron 12 was also rather slow and occurred after the removal of intron 13 in a major pathway. However, the mutation in GS23 cells resulted in retention of intron 13, thus causing the retention of introns 12 and 11. This "splicing paralysis" may be solved by skipping the whole intron 11-exon 12-intron 12-exon 13-mutated intron 13, resulting in skipping of exons 12 and 13.
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Affiliation(s)
- Tomohiro Hori
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Gifu, Japan
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Clinical and molecular characterization of five patients with succinyl-CoA:3-ketoacid CoA transferase (SCOT) deficiency. Biochim Biophys Acta Mol Basis Dis 2011; 1812:619-24. [PMID: 21296660 DOI: 10.1016/j.bbadis.2011.01.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 01/26/2011] [Accepted: 01/28/2011] [Indexed: 11/21/2022]
Abstract
Succinyl-CoA:3-ketoacid CoA transferase (SCOT) deficiency is an inborn error of ketone body metabolism and causes episodic ketoacidosis. We report clinical and molecular analyses of 5 patients with SCOT deficiency. Patients GS07, GS13, and GS14 are homozygotes of S405P, L327P, and R468C, respectively. GS17 and GS18 are compound heterozygotes for S226N and A215V, and V404F and E273X, respectively. These mutations have not been reported previously. Missense mutations were further characterized by transient expression analysis of mutant cDNAs. Among 6 missense mutations, mutants L327P, R468C, and A215V retained some residual activities and their mutant proteins were detected in immunoblot analysis following expression at 37°C. They were more stable at 30°C than 37°C, indicating their temperature sensitive character. The R468C mutant is a distinct temperature sensitive mutant which retained 12% and 51% of wild-type residual activities at 37 and 30°C, respectively. The S226N mutant protein was detected but retained no residual activity. Effects of missense mutations were predicted from the tertiary structure of the SCOT molecule. Main effects of these mutations were destabilization of SCOT molecules, and some of them also affected catalytic activity. Among 5 patients, GS07 and GS18 had null mutations in both alleles and the other three patients retained some residual SCOT activities. All 5 developed a first severe ketoacidotic crisis with blood gas pH <7.1, and experienced multiple ketoacidotic decompensations (two of them had seven such episodes). In general, the outcome was good even following multiple ketoacidotic events. Permanent ketosis or ketonuria is considered a pathognomonic feature of SCOT deficiency. However, this condition depends not only on residual activity but also on environmental factors.
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Management and communication problems in a patient with succinyl-CoA transferase deficiency in pregnancy and labour. Int J Obstet Anesth 2009; 18:280-3. [PMID: 19450972 DOI: 10.1016/j.ijoa.2009.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 01/31/2009] [Accepted: 02/02/2009] [Indexed: 11/21/2022]
Abstract
Succinyl-CoA transferase deficiency is a high-risk condition that pre-disposes the sufferer to severe and life-threatening ketoacidosis. An 18-year-old woman with succinyl-CoA transferase deficiency was admitted to the delivery suite for induction of labour at 38 weeks of gestation. Her management included adequate calorie intake in order to avoid fatty acid metabolism and adequate hydration along with rigorous electrolyte balance and minimisation of physiological stress by the use of epidural analgesia. The needs of the woman's condition had to be balanced against the desire to minimise gastric volume in case emergency obstetric intervention was required.
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Marcus C, Alkén J, Eriksson J, Blom L, Gustafsson J. Insufficient ketone body use is the cause of ketotic hypoglycemia in one of a pair of homozygotic twins. J Clin Endocrinol Metab 2007; 92:4080-4. [PMID: 17684053 DOI: 10.1210/jc.2007-0661] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Childhood ketotic hypoglycemia (KH) is a disease characterized by fasting hypoglycemia and increased levels of ketone bodies. The cause is unknown. OBJECTIVE The objective of the study was to study a pair of homozygotic twin boys, one of whom had severe KH from the age of 14 months, whereas the other boy was apparently healthy. DESIGN AND RESULTS At the age of 6 yr, the boys were thoroughly investigated. During a 24-h fasting tolerance test, the twin with KH showed hypoglycemia (blood glucose 2.0 mmol/liter) after 18 h. Three h before the occurrence of hypoglycemia, he had had 10 times higher beta-hydroxybutyrate levels than his brother, who showed no signs of hypoglycemia. Their glucose production rates were normal and similar (23.3 and 21.7 micromol/kg body weight per minute in the healthy and KH twin, respectively) as well as their lipolysis rates (5.8 and 6.8 micromol/kg body weight per minute, respectively). During repeated 60-min infusions of beta-hydroxybutyrate, the plasma level of beta-hydroxybutyrate increased 5-10 times more in the twin with KH (mean 1.1 mmol/liter in the healthy and 10.8 mmol/liter in the KH twin), indicating a disturbed clearance or metabolism of beta-hydroxybutyrate. No mutations were found in genes involved in ketone body metabolism or transport. CONCLUSION In the affected boy, KH seems to be the result of a reduced capacity to use ketone bodies, leading to increased peripheral metabolism of glucose that cannot be met by hepatic glucose production. Because the boys are homozygotic twins and only one of them is affected, the ketotic hypoglycemia is most likely caused by an altered imprinting of gene(s) involved in regulating metabolic pathways.
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Affiliation(s)
- Claude Marcus
- Department for Clinical Science, Intervention and Technology (Clintec), Division of Pediatrics, Karolinska University Hospital, Huddinge, SE-141 86 Stockholm, Sweden.
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