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Platt I, Bisgin A, Kilavuz S. Ethylmalonic Encephalopathy: a literature review and two new cases of mild phenotype. Neurol Sci 2023; 44:3827-3852. [PMID: 37458841 DOI: 10.1007/s10072-023-06904-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/12/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Ethylmalonic encephalopathy (EE) is a rare intoxication-type metabolic disorder with multisystem involvement. It is caused by mutations in ETHE1, which encodes the ETHE1 enzyme in the mitochondrial matrix that plays a key role in hydrogen sulfide (H2S) detoxification acting as a sulphur dioxygenase. RESULTS This review focuses on the clinical, metabolic, genetic and neuroradiological features of 70 reported cases, including two new cases. The common manifestations of EE are psychomotor regression, hypotonia, developmental delay, petechia, pyramidal signs, chronic diarrhoea, orthostatic acrocyanosis and failure to thrive, respectively. A significant difference was found in EMA and C4 levels (p=0.003, p=0.0236) between classical and mild phenotypes. Urinary EMA, C4 and C5 levels were found to exhibit normal values in milder cases during attack-free periods. The most common ETHE1 gene homozygous state mutations were (p.R163Q) (c.488G>A), exon 4 deletion, (p.R163W)(c.487C>T), (p.Glu44ValfsTer62)(c.131_132delAG) and (p.M1I)(c.3G>T) mutations, respectively. Fifty-two patients underwent cranial MRI. Basal ganglia signal alterations were detected in 42 cases. Of the 70 cases, eight had a mild phenotype and slow neurological progression with low levels of ethylmalonic acid (EMA) and C4 acylcarnitine. The current age of alive patients in the published articles with mild phenotype was significantly higher than the classical phenotype. (p=0.002). Reducing the accumulation and inducing detoxification of sulfide is the main long-term treatment strategy for EE, including metronidazole, N-acetylcysteine (NAC), dietary modification, liver transplantation and continuous renal replacement therapy (CRRT). CONCLUSION Measuring EMA and C4 acylcarnitine during metabolic attacks is critical to diagnosing EE, allowing for early treatment initiation to prevent further encephalopathic crises. Experience with liver transplantation, diet and CRRT, is currently limited. An early multidisciplinary approach with combination therapies is vital to prevent irreversible neurological damage.
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Affiliation(s)
| | - Atil Bisgin
- Department of Medical Genetics, Cukurova University AGENTEM (Adana Genetic Diseases Diagnosis and Treatment Center), Adana, Turkey
| | - Sebile Kilavuz
- Division of Pediatric Metabolism and Nutrition, Department of Pediatrics, Marmara University Faculty of Medicine, İstanbul, Turkey.
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Gowda VK, Srinivasan VM, Jetha K, Sugumar K, Bhat M, Shivappa SK, Bhat M, Christopher R. Case Series of Ethylmalonic Encephalopathy from Southern India. J Pediatr Genet 2023; 12:213-218. [PMID: 37575639 PMCID: PMC10421674 DOI: 10.1055/s-0041-1740370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 10/22/2021] [Indexed: 10/19/2022]
Abstract
Ethylmalonic encephalopathy is a rare neurometabolic disorder with central nervous system involvement and vasculopathy. It is presented in infancy with developmental delay, acrocyanosis, petechiae, chronic diarrhea, and early death. This was a retrospective study of confirmed cases of ethylmalonic aciduria from a tertiary care hospital over a period of 5 years from January 2015 to December 2020. Case details including analysis of clinical history, investigations, and outcomes are presented. Of six cases, male-to-female ratio was 4:2. Mean age of presentation was 35.5 months (range: 14-83 months). Consanguinity, global developmental delay, failure to thrive, skin rashes, microcephaly, hypotonia, and exaggerated deep tendon reflexes were observed in all cases. Chronic diarrhea was presented in five cases. The serum levels of C4 carnitine and urinary levels of ethylmalonic acid were increased in all cases. Magnetic resonance imaging (MRI) of the brain showed heterogenous bilateral symmetrical changes in the basal ganglia in five cases, and in one case, MRI could not be done. Genetic testing in two cases showed a homozygous variant in ETHE1 gene. Four children died, while the other two cases showed a decreased in recurrent encephalopathies and diarrhea after starting metronidazole. All children had global developmental delay, failure to thrive, skin rashes, central hypotonia, increased C4 carnitine levels in the serum, and increased ethylmalonic acid in the urine. Chronic diarrhea, acrocyanosis, and basal ganglia change in the MRI of the brain also give important clues for diagnosis. Metronidazole is useful in preventing recurrent episodes of encephalopathy.
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Affiliation(s)
- Vykuntaraju K. Gowda
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Varunvenkat M. Srinivasan
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Kapil Jetha
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Kiruthiga Sugumar
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Meenakshi Bhat
- Department of Genetics, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Sanjay K. Shivappa
- Department of Pediatric Medicine, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Maya Bhat
- Department of Neuroradiology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Rita Christopher
- Department of Neurochemistry, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
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3
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Distelmaier F, Klopstock T. Neuroimaging in mitochondrial disease. HANDBOOK OF CLINICAL NEUROLOGY 2023; 194:173-185. [PMID: 36813312 DOI: 10.1016/b978-0-12-821751-1.00016-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
The anatomic complexity of the brain in combination with its high energy demands makes this organ specifically vulnerable to defects of mitochondrial oxidative phosphorylation. Therefore, neurodegeneration is a hallmark of mitochondrial diseases. The nervous system of affected individuals typically shows selective regional vulnerability leading to distinct patterns of tissue damage. A classic example is Leigh syndrome, which causes symmetric alterations of basal ganglia and brain stem. Leigh syndrome can be caused by different genetic defects (>75 known disease genes) with variable disease onset ranging from infancy to adulthood. Other mitochondrial diseases are characterized by focal brain lesions, which is a core feature of MELAS syndrome (mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes). Apart from gray matter, also white matter can be affected by mitochondrial dysfunction. White matter lesions vary depending on the underlying genetic defect and may progress into cystic cavities. In view of the recognizable patterns of brain damage in mitochondrial diseases, neuroimaging techniques play a key role in diagnostic work-up. In the clinical setting, magnetic resonance imaging (MRI) and MR spectroscopy (MRS) are the mainstay of diagnostic work-up. Apart from visualization of brain anatomy, MRS allows the detection of metabolites such as lactate, which is of specific interest in the context of mitochondrial dysfunction. However, it is important to note that findings like symmetric basal ganglia lesions on MRI or a lactate peak on MRS are not specific, and that there is a broad range of disorders that can mimic mitochondrial diseases on neuroimaging. In this chapter, we will review the spectrum of neuroimaging findings in mitochondrial diseases and discuss important differential diagnoses. Moreover, we will give an outlook on novel biomedical imaging tools that may provide interesting insights into mitochondrial disease pathophysiology.
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Affiliation(s)
- Felix Distelmaier
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.
| | - Thomas Klopstock
- Department of Neurology, Friedrich-Baur-Institute, University Hospital, Ludwig-Maximilians-Universität (LMU) München, Munich, Germany; German Center for Neurodegenerative Diseases (DZNE), Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Munich, Germany; German Network for mitochondrial disorders (mitoNET), Munich, Germany
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4
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Viscomi C, Zeviani M. Experimental therapy for mitochondrial diseases. HANDBOOK OF CLINICAL NEUROLOGY 2023; 194:259-277. [PMID: 36813318 DOI: 10.1016/b978-0-12-821751-1.00013-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Mitochondrial diseases are extremely heterogeneous genetic disorders due to faulty oxidative phosphorylation (OxPhos). No cure is currently available for these conditions, beside supportive interventions aimed at relieving complications. Mitochondria are under a double genetic control carried out by the mitochondrial DNA (mtDNA) and by nuclear DNA. Thus, not surprisingly, mutations in either genome can cause mitochondrial disease. Although mitochondria are usually associated with respiration and ATP synthesis, they play fundamental roles in a large number of other biochemical, signaling, and execution pathways, each being a potential target for therapeutic interventions. These can be classified as general therapies, i.e., potentially applicable to a number of different mitochondrial conditions, or therapies tailored to a single disease, i.e., personalized approaches, such as gene therapy, cell therapy, and organ replacement. Mitochondrial medicine is a particularly lively research field, and the last few years witnessed a steady increase in the number of clinical applications. This chapter will present the most recent therapeutic attempts emerged from preclinical work and an update of the currently ongoing clinical applications. We think that we are starting a new era in which the etiologic treatment of these conditions is becoming a realistic option.
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Affiliation(s)
- Carlo Viscomi
- Department of Biomedical Sciences, University of Padova, Padova, Italy.
| | - Massimo Zeviani
- Department of Neurosciences, University of Padova, Padova, Italy; Venetian Institute of Molecular Medicine, Padova, Italy.
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Abstract
Leigh syndrome, or subacute necrotizing encephalomyelopathy, was initially recognized as a neuropathological entity in 1951. Bilateral symmetrical lesions, typically extending from the basal ganglia and thalamus through brainstem structures to the posterior columns of the spinal cord, are characterized microscopically by capillary proliferation, gliosis, severe neuronal loss, and relative preservation of astrocytes. Leigh syndrome is a pan-ethnic disorder usually with onset in infancy or early childhood, but late-onset forms occur, including in adult life. Over the last six decades it has emerged that this complex neurodegenerative disorder encompasses more than 100 separate monogenic disorders associated with enormous clinical and biochemical heterogeneity. This chapter discusses clinical, biochemical and neuropathological aspects of the disorder, and postulated pathomechanisms. Known genetic causes, including defects of 16 mitochondrial DNA (mtDNA) genes and approaching 100 nuclear genes, are categorized into disorders of subunits and assembly factors of the five oxidative phosphorylation enzymes, disorders of pyruvate metabolism and vitamin and cofactor transport and metabolism, disorders of mtDNA maintenance, and defects of mitochondrial gene expression, protein quality control, lipid remodeling, dynamics, and toxicity. An approach to diagnosis is presented, together with known treatable causes and an overview of current supportive management options and emerging therapies on the horizon.
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Affiliation(s)
- Shamima Rahman
- Genetics and Genomic Medicine Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Metabolic Medicine Department, Great Ormond Street Hospital for Children, London, United Kingdom.
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Wang G, Zhao Z, Li Y. A case report of atypical ethylmalonic encephalopathy with peripheral neuropathy. CNS Neurosci Ther 2023; 29:971-973. [PMID: 36601669 PMCID: PMC9928541 DOI: 10.1111/cns.14072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/07/2022] [Accepted: 12/09/2022] [Indexed: 01/06/2023] Open
Affiliation(s)
- Guan‐Qing Wang
- Department of Neurology, Shandong Provincial Qianfoshan Hospital, School of Clinical MedicineWeifang Medical UniversityWeifangChina
| | - Ze‐Yu Zhao
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical UniversityJinanChina,Shandong Institute of NeuroimmunologyJinanChina
| | - Yan‐Bin Li
- Department of NeurologyThe First Affiliated Hospital of Shandong First Medical UniversityJinanChina,Shandong Institute of NeuroimmunologyJinanChina
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Kožich V, Schwahn BC, Sokolová J, Křížková M, Ditroi T, Krijt J, Khalil Y, Křížek T, Vaculíková-Fantlová T, Stibůrková B, Mills P, Clayton P, Barvíková K, Blessing H, Sykut-Cegielska J, Dionisi-Vici C, Gasperini S, García-Cazorla Á, Haack TB, Honzík T, Ješina P, Kuster A, Laugwitz L, Martinelli D, Porta F, Santer R, Schwarz G, Nagy P. Human ultrarare genetic disorders of sulfur metabolism demonstrate redundancies in H 2S homeostasis. Redox Biol 2022; 58:102517. [PMID: 36306676 PMCID: PMC9615310 DOI: 10.1016/j.redox.2022.102517] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/17/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Regulation of H2S homeostasis in humans is poorly understood. Therefore, we assessed the importance of individual enzymes in synthesis and catabolism of H2S by studying patients with respective genetic defects. We analyzed sulfur compounds (including bioavailable sulfide) in 37 untreated or insufficiently treated patients with seven ultrarare enzyme deficiencies and compared them to 63 controls. Surprisingly, we observed that patients with severe deficiency in cystathionine β-synthase (CBS) or cystathionine γ-lyase (CSE) - the enzymes primarily responsible for H2S synthesis - exhibited increased and normal levels of bioavailable sulfide, respectively. However, an approximately 21-fold increase of urinary homolanthionine in CBS deficiency strongly suggests that lacking CBS activity is compensated for by an increase in CSE-dependent H2S synthesis from accumulating homocysteine, which suggests a control of H2S homeostasis in vivo. In deficiency of sulfide:quinone oxidoreductase - the first enzyme in mitochondrial H2S oxidation - we found normal H2S concentrations in a symptomatic patient and his asymptomatic sibling, and elevated levels in an asymptomatic sibling, challenging the requirement for this enzyme in catabolizing H2S under physiological conditions. Patients with ethylmalonic encephalopathy and sulfite oxidase/molybdenum cofactor deficiencies exhibited massive accumulation of thiosulfate and sulfite with formation of large amounts of S-sulfocysteine and S-sulfohomocysteine, increased renal losses of sulfur compounds and concomitant strong reduction in plasma total cysteine. Our results demonstrate the value of a comprehensive assessment of sulfur compounds in severe disorders of homocysteine/cysteine metabolism and provide evidence for redundancy and compensatory mechanisms in the maintenance of H2S homeostasis. Cystathionine γ-lyase can compensate for decreased H2S synthesis in cystathionine β-synthase deficiency. Sulfide:quinone oxidoreductase deficiency is compatible with normal H2S plasma levels under non-stressed conditions. Persulfide dioxygenase deficiency (ethylmalonic encephalopathy) causes the largest accumulation of H2S among disorders of sulfur metabolism. Excess sulfite forms S-sulfocysteine and S-sulfohomocysteine, and interferes with vitamin B6 metabolism. S-sulfocysteine correlates directly with sulfite and is a stable biomarker of sulfite accumulation.
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Affiliation(s)
- Viktor Kožich
- Department of Pediatrics and Inherited Metabolic Disorders, Charles University-First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic,Corresponding author. Department of Pediatrics and Inherited Metabolic Disorders, Charles University, Medicine and General University Hospital in Prague, Ke Karlovu 2, 128 08, Praha 2, Czech Republic.
| | - Bernd C Schwahn
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Health Innovation Manchester, Manchester, United Kingdom
| | - Jitka Sokolová
- Department of Pediatrics and Inherited Metabolic Disorders, Charles University-First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Michaela Křížková
- Department of Pediatrics and Inherited Metabolic Disorders, Charles University-First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Tamas Ditroi
- Department of Molecular Immunology and Toxicology and the National Tumor Biology Laboratory, National Institute of Oncology, Budapest, Hungary
| | - Jakub Krijt
- Department of Pediatrics and Inherited Metabolic Disorders, Charles University-First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Youssef Khalil
- Genetics & Genomic Medicine Department, UCL GOS Institute of Child Health, London, UK
| | - Tomáš Křížek
- Department of Analytical Chemistry, Faculty of Science, Charles University, Prague, Czech Republic
| | - Tereza Vaculíková-Fantlová
- Department of Pediatrics and Inherited Metabolic Disorders, Charles University-First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Blanka Stibůrková
- Department of Pediatrics and Inherited Metabolic Disorders, Charles University-First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic,Institute of Rheumatology, Prague, Czech Republic
| | - Philippa Mills
- Genetics & Genomic Medicine Department, UCL GOS Institute of Child Health, London, UK
| | - Peter Clayton
- Genetics & Genomic Medicine Department, UCL GOS Institute of Child Health, London, UK
| | - Kristýna Barvíková
- Department of Pediatrics and Inherited Metabolic Disorders, Charles University-First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Holger Blessing
- Kinder- und Jugendklinik, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Jolanta Sykut-Cegielska
- Department of Inborn Errors of Metabolism and Pediatrics, The Institute of Mother and Child, Warsaw, Poland
| | - Carlo Dionisi-Vici
- Division of Metabolism, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Serena Gasperini
- Metabolic Rare Diseases Unit, Department of Pediatrics, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Ángeles García-Cazorla
- Inborn Errors of Metabolism Unit, Institut de Recerca Sant Joan de Déu and CIBERER-ISCIII, Barcelona, Spain
| | - Tobias B Haack
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, Tübingen, Germany
| | - Tomáš Honzík
- Department of Pediatrics and Inherited Metabolic Disorders, Charles University-First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Pavel Ješina
- Department of Pediatrics and Inherited Metabolic Disorders, Charles University-First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Alice Kuster
- Center for Inborn Errors of Metabolism, Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France
| | - Lucia Laugwitz
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, Tübingen, Germany,Department of Neuropediatrics, Developmental Neurology and Social Pediatrics, University of Tübingen, Tübingen, Germany
| | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Francesco Porta
- Department of Pediatrics, Metabolic diseases, AOU Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - René Santer
- Department of Pediatrics, University Medical Centre Eppendorf, Hamburg, Germany
| | - Guenter Schwarz
- Institute of Biochemistry, Department of Chemistry, University of Cologne, Cologne, Germany,Corresponding author. Institute of Biochemistry, Department of Chemistry, University of Cologne, Zuelpicher Str. 4750674, Koeln, Germany.
| | - Peter Nagy
- Department of Molecular Immunology and Toxicology and the National Tumor Biology Laboratory, National Institute of Oncology, Budapest, Hungary,Department of Anatomy and Histology, ELKH-ÁTE Laboratory of Redox Biology, University of Veterinary Medicine, Budapest, Hungary,Chemistry Institute, University of Debrecen, Debrecen, Hungary,Corresponding author. Department of Molecular Immunology and Toxicology, National Institute of Oncology, 1122 Budapest, Ráth György u. 7-9., Hungary.
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8
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Gene Therapy for Mitochondrial Diseases: Current Status and Future Perspective. Pharmaceutics 2022; 14:pharmaceutics14061287. [PMID: 35745859 PMCID: PMC9231068 DOI: 10.3390/pharmaceutics14061287] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/09/2022] [Accepted: 06/15/2022] [Indexed: 02/06/2023] Open
Abstract
Mitochondrial diseases (MDs) are a group of severe genetic disorders caused by mutations in the nuclear or mitochondrial genome encoding proteins involved in the oxidative phosphorylation (OXPHOS) system. MDs have a wide range of symptoms, ranging from organ-specific to multisystemic dysfunctions, with different clinical outcomes. The lack of natural history information, the limits of currently available preclinical models, and the wide range of phenotypic presentations seen in MD patients have all hampered the development of effective therapies. The growing number of pre-clinical and clinical trials over the last decade has shown that gene therapy is a viable precision medicine option for treating MD. However, several obstacles must be overcome, including vector design, targeted tissue tropism and efficient delivery, transgene expression, and immunotoxicity. This manuscript offers a comprehensive overview of the state of the art of gene therapy in MD, addressing the main challenges, the most feasible solutions, and the future perspectives of the field.
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Hanaford AR, Cho YJ, Nakai H. AAV-vector based gene therapy for mitochondrial disease: progress and future perspectives. Orphanet J Rare Dis 2022; 17:217. [PMID: 35668433 PMCID: PMC9169410 DOI: 10.1186/s13023-022-02324-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/09/2022] [Indexed: 12/11/2022] Open
Abstract
Mitochondrial diseases are a group of rare, heterogeneous diseases caused by gene mutations in both nuclear and mitochondrial genomes that result in defects in mitochondrial function. They are responsible for significant morbidity and mortality as they affect multiple organ systems and particularly those with high energy-utilizing tissues, such as the nervous system, skeletal muscle, and cardiac muscle. Virtually no effective treatments exist for these patients, despite the urgent need. As the majority of these conditions are monogenic and caused by mutations in nuclear genes, gene replacement is a highly attractive therapeutic strategy. Adeno-associated virus (AAV) is a well-characterized gene replacement vector, and its safety profile and ability to transduce quiescent cells nominates it as a potential gene therapy vehicle for several mitochondrial diseases. Indeed, AAV vector-based gene replacement is currently being explored in clinical trials for one mitochondrial disease (Leber hereditary optic neuropathy) and preclinical studies have been published investigating this strategy in other mitochondrial diseases. This review summarizes the preclinical findings of AAV vector-based gene replacement therapy for mitochondrial diseases including Leigh syndrome, Barth syndrome, ethylmalonic encephalopathy, and others.
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Affiliation(s)
- Allison R Hanaford
- Center for Integrative Brain Research, Seattle Children's Reserach Institute, Seattle, WA, 98101, USA.
- Papé Family Pediatric Research Institute, Oregon Health and Science University, Portland, OR, 97239, USA.
| | - Yoon-Jae Cho
- Papé Family Pediatric Research Institute, Oregon Health and Science University, Portland, OR, 97239, USA
- Division of Pediatric Neurology, Doernbecher Children's Hospital, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Hiroyuki Nakai
- Department of Molecular and Medical Genetics, Oregon Health and Science University, Portland, OR, 97239, USA
- Department of Molecular Immunology and Microbiology, Oregon Health and Science University, Portland, OR, 97239, USA
- Division of Neuroscience, Oregon National Primate Research Center, Beaverton, OR, 97006, USA
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10
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Mitochondrial Neurodegeneration. Cells 2022; 11:cells11040637. [PMID: 35203288 PMCID: PMC8870525 DOI: 10.3390/cells11040637] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/28/2022] [Accepted: 02/06/2022] [Indexed: 01/27/2023] Open
Abstract
Mitochondria are cytoplasmic organelles, which generate energy as heat and ATP, the universal energy currency of the cell. This process is carried out by coupling electron stripping through oxidation of nutrient substrates with the formation of a proton-based electrochemical gradient across the inner mitochondrial membrane. Controlled dissipation of the gradient can lead to production of heat as well as ATP, via ADP phosphorylation. This process is known as oxidative phosphorylation, and is carried out by four multiheteromeric complexes (from I to IV) of the mitochondrial respiratory chain, carrying out the electron flow whose energy is stored as a proton-based electrochemical gradient. This gradient sustains a second reaction, operated by the mitochondrial ATP synthase, or complex V, which condensates ADP and Pi into ATP. Four complexes (CI, CIII, CIV, and CV) are composed of proteins encoded by genes present in two separate compartments: the nuclear genome and a small circular DNA found in mitochondria themselves, and are termed mitochondrial DNA (mtDNA). Mutations striking either genome can lead to mitochondrial impairment, determining infantile, childhood or adult neurodegeneration. Mitochondrial disorders are complex neurological syndromes, and are often part of a multisystem disorder. In this paper, we divide the diseases into those caused by mtDNA defects and those that are due to mutations involving nuclear genes; from a clinical point of view, we discuss pediatric disorders in comparison to juvenile or adult-onset conditions. The complementary genetic contributions controlling organellar function and the complexity of the biochemical pathways present in the mitochondria justify the extreme genetic and phenotypic heterogeneity of this new area of inborn errors of metabolism known as ‘mitochondrial medicine’.
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Cardelo Autero N, Cordón Martínez AM, Ramos-Fernández JM. Ethylmalonic encephalopathy: phenotype-genotype description and review of its management. NEUROLOGÍA (ENGLISH EDITION) 2021; 36:729-731. [PMID: 34274260 DOI: 10.1016/j.nrleng.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/31/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- N Cardelo Autero
- Servicio de Pediatría, Hospital Regional Universitario Materno-Infantil de Málaga, Málaga, Spain
| | - A M Cordón Martínez
- Servicio de Pediatría (lactantes), Hospital Regional Universitario Materno-Infantil de Málaga, Málaga, Spain
| | - J M Ramos-Fernández
- Sección de Neurología Pediátrica, Grupo IBIMA, Servicio de Pediatría, Hospital Regional Universitario Materno-Infantil de Málaga, Málaga, Spain.
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12
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Lim J, Shayota BJ, Lay E, Elsea SH, Bekheirnia MR, Tessier MEM, Kralik SF, Rice GM, Soler-Alfonso C, Scaglia F. Acute Strokelike Presentation and Long-term Evolution of Diffusion Restriction Pattern in Ethylmalonic Encephalopathy. J Child Neurol 2021; 36:841-852. [PMID: 33900143 DOI: 10.1177/08830738211006507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ethylmalonic encephalopathy is a rare autosomal recessive mitochondrial disorder caused by pathogenic biallelic variants in the ETHE1 gene. The phenotype of this disease has been attributed to deficiency in the mitochondrial sulfur dioxygenase leading to many downstream effects. Ethylmalonic encephalopathy classically presents with developmental regression, petechiae, acrocyanosis, and chronic diarrhea. The neurologic phenotype includes hypotonia, spastic diplegia, ataxia, and developmental delay. As more patients with this condition are described, the neurologic phenotype continues to expand. Although strokelike episodes or metabolic strokes have been studied in other mitochondrial disorders, they have not been thoroughly reported in this disorder. Herein, we describe 3 patients with ethylmalonic encephalopathy who presented clinically with strokelike episodes and strokelike abnormalities on brain magnetic resonance imaging in the setting of acute illness, and the long-term sequelae with evolution into cystic changes in one of these subjects.
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Affiliation(s)
- Jaehyung Lim
- Division of Pediatric Neurology and Developmental Neurosciences, 3989Baylor College of Medicine, Houston, TX, USA
| | - Brian J Shayota
- Department of Molecular and Human Genetics, 3989Baylor College of Medicine, Houston, TX, USA.,3984Texas Children's Hospital, Houston, TX, USA
| | - Erica Lay
- Department of Molecular and Human Genetics, 3989Baylor College of Medicine, Houston, TX, USA.,3984Texas Children's Hospital, Houston, TX, USA
| | - Sarah H Elsea
- Department of Molecular and Human Genetics, 3989Baylor College of Medicine, Houston, TX, USA
| | - Mir Reza Bekheirnia
- Department of Molecular and Human Genetics, 3989Baylor College of Medicine, Houston, TX, USA.,3984Texas Children's Hospital, Houston, TX, USA.,Renal Section, Department of Pediatrics, 3989Baylor College of Medicine, Houston, TX, USA
| | - Mary Elizabeth M Tessier
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology and Nutrition 3989Baylor College of Medicine Houston TX, USA
| | - Stephen F Kralik
- Department of Radiology, 3984Texas Children's Hospital, Houston, TX, USA
| | - Gregory M Rice
- Department of Pediatrics and the Waisman Center, 5232University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Claudia Soler-Alfonso
- Department of Molecular and Human Genetics, 3989Baylor College of Medicine, Houston, TX, USA.,3984Texas Children's Hospital, Houston, TX, USA
| | - Fernando Scaglia
- Department of Molecular and Human Genetics, 3989Baylor College of Medicine, Houston, TX, USA.,3984Texas Children's Hospital, Houston, TX, USA.,Joint 3989BCM-CUHK Center of Medical Genetics, Prince of Wales Hospital, Shatin, Hong Kong SAR
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13
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Olivieri G, Martinelli D, Longo D, Grimaldi C, Liccardo D, Di Meo I, Pietrobattista A, Sidorina A, Semeraro M, Dionisi-Vici C. Ethylmalonic encephalopathy and liver transplantation: long-term outcome of the first treated patient. Orphanet J Rare Dis 2021; 16:229. [PMID: 34011365 PMCID: PMC8136189 DOI: 10.1186/s13023-021-01867-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 05/11/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Ethylmalonic encephalopathy (EE) is a severe intoxication-type metabolic disorder with multisystem clinical features and leading to early death. In 2014, based on the promising results obtained by liver-targeted gene therapy in Ethe1-/- mouse model, we successfully attempted liver transplantation in a 9-month-old EE girl. Here we report her long-term follow-up, lasting over 6 years, with a comprehensive evaluation of clinical, instrumental and biochemical assessments. RESULTS Neurological signs initially reverted, with a clinical stabilization during the entire follow-up course. Accordingly, gross motor functions improved and then stabilized. Psychomotor evaluations documented an increasing communicative intent, the acquisition of new social skills and the capability to carry out simple orders. Neurophysiological assessments, which included EEG, VEP/ERG and BAEPs, remained unchanged. Brain MRI also stabilized, showing no further lesions and cerebral atrophy improvement. Compared to pre-transplant assessments, urinary ethylmalonic acid strikingly reduced, and plasma thiosulphate fully normalized. The child maintained good clinical conditions and never experienced metabolic crises nor epileptic seizures. CONCLUSIONS The long-term follow-up of the first EE transplanted patient demonstrates that liver transplantation stabilizes, or even improves, disease course, therefore representing a potentially elective option especially in early-diagnosed patients, such as those detected by newborn screening, before irreversible neurological damage occurs.
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Affiliation(s)
- Giorgia Olivieri
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Daniela Longo
- Neuroradiology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Chiara Grimaldi
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | - Daniela Liccardo
- Division of Hepatology and Gastroenterology, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | - Ivano Di Meo
- Unit of Medical Genetics and Neurogenetics, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Andrea Pietrobattista
- Division of Hepatology and Gastroenterology, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | - Anna Sidorina
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Michela Semeraro
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
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14
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de Moura Alvorcem L, Britto R, Cecatto C, Cristina Roginski A, Rohden F, Nathali Scholl J, Guma FCR, Figueiró F, Umpierrez Amaral A, Zanatta G, Seminotti B, Wajner M, Leipnitz G. Ethylmalonic acid impairs bioenergetics by disturbing succinate and glutamate oxidation and induces mitochondrial permeability transition pore opening in rat cerebellum. J Neurochem 2021; 158:262-281. [PMID: 33837559 DOI: 10.1111/jnc.15363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 03/04/2021] [Accepted: 04/06/2021] [Indexed: 12/01/2022]
Abstract
Tissue accumulation and high urinary excretion of ethylmalonic acid (EMA) are found in ethylmalonic encephalopathy (EE), an inherited disorder associated with cerebral and cerebellar atrophy whose pathogenesis is poorly established. The in vitro and in vivo effects of EMA on bioenergetics and redox homeostasis were investigated in rat cerebellum. For the in vitro studies, cerebellum preparations were exposed to EMA, whereas intracerebellar injection of EMA was used for the in vivo evaluation. EMA reduced state 3 and uncoupled respiration in vitro in succinate-, glutamate-, and malate-supported mitochondria, whereas decreased state 4 respiration was observed using glutamate and malate. Furthermore, mitochondria permeabilization and succinate supplementation diminished the decrease in state 3 with succinate. EMA also inhibited the activity of KGDH, an enzyme necessary for glutamate oxidation, in a mixed manner and augmented mitochondrial efflux of α-ketoglutarate. ATP levels were markedly reduced by EMA, reflecting a severe bioenergetic disruption. Docking simulations also indicated interactions between EMA and KGDH and a competition with glutamate and succinate for their mitochondrial transporters. In vitro findings also showed that EMA decreased mitochondrial membrane potential and Ca2+ retention capacity, and induced swelling in the presence of Ca2+ , which were prevented by cyclosporine A and ADP and ruthenium red, indicating mitochondrial permeability transition (MPT). Moreover, EMA, at high concentrations, mildly increased ROS levels and altered antioxidant defenses in vitro and in vivo. Our data indicate that EMA-induced impairment of glutamate and succinate oxidation and MPT may contribute to the pathogenesis of the cerebellum abnormalities in EE.
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Affiliation(s)
- Leonardo de Moura Alvorcem
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Renata Britto
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Cristiane Cecatto
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Ana Cristina Roginski
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Francieli Rohden
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Juliete Nathali Scholl
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Fátima C R Guma
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Fabrício Figueiró
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Alexandre Umpierrez Amaral
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Departamento de Ciências Biológicas, Universidade Regional Integrada do Alto Uruguai e das Missões, Erechim, RS, Brazil
| | - Geancarlo Zanatta
- Departamento de Física, Universidade Federal do Ceará, Fortaleza, CE, Brazil
| | - Bianca Seminotti
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Moacir Wajner
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Guilhian Leipnitz
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Programa de Pós-Graduação em Fisiologia, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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15
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Cardelo Autero N, Cordón Martínez AM, Ramos-Fernández JM. Ethylmalonic encephalopathy: Phenotype-genotype description and review of its management. Neurologia 2021; 36:S0213-4853(21)00009-8. [PMID: 33722452 DOI: 10.1016/j.nrl.2021.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/24/2021] [Accepted: 01/31/2021] [Indexed: 12/12/2022] Open
Affiliation(s)
- N Cardelo Autero
- Servicio de Pediatría, Hospital Regional Universitario Materno-Infantil de Málaga, Málaga, España
| | - A M Cordón Martínez
- Servicio de Pediatría (lactantes), Hospital Regional Universitario Materno-Infantil de Málaga, Málaga, España
| | - J M Ramos-Fernández
- Sección de Neurología Pediátrica, Grupo IBIMA, Servicio de Pediatría, Hospital Regional Universitario Materno-Infantil de Málaga, Málaga, España.
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16
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Tinker RJ, Lim AZ, Stefanetti RJ, McFarland R. Current and Emerging Clinical Treatment in Mitochondrial Disease. Mol Diagn Ther 2021; 25:181-206. [PMID: 33646563 PMCID: PMC7919238 DOI: 10.1007/s40291-020-00510-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2020] [Indexed: 12/11/2022]
Abstract
Primary mitochondrial disease (PMD) is a group of complex genetic disorders that arise due to pathogenic variants in nuclear or mitochondrial genomes. Although PMD is one of the most prevalent inborn errors of metabolism, it often exhibits marked phenotypic variation and can therefore be difficult to recognise. Current treatment for PMD revolves around supportive and preventive approaches, with few disease-specific therapies available. However, over the last decade there has been considerable progress in our understanding of both the genetics and pathophysiology of PMD. This has resulted in the development of a plethora of new pharmacological and non-pharmacological therapies at varying stages of development. Many of these therapies are currently undergoing clinical trials. This review summarises the latest emerging therapies that may become mainstream treatment in the coming years. It is distinct from other recent reviews in the field by comprehensively addressing both pharmacological non-pharmacological therapy from both a bench and a bedside perspective. We highlight the current and developing therapeutic landscape in novel pharmacological treatment, dietary supplementation, exercise training, device use, mitochondrial donation, tissue replacement gene therapy, hypoxic therapy and mitochondrial base editing.
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Affiliation(s)
- Rory J Tinker
- Wellcome Centre for Mitochondrial Research, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- Clinical and Translational Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Albert Z Lim
- Wellcome Centre for Mitochondrial Research, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- Clinical and Translational Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Renae J Stefanetti
- Wellcome Centre for Mitochondrial Research, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- Clinical and Translational Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Robert McFarland
- Wellcome Centre for Mitochondrial Research, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK.
- Clinical and Translational Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK.
- NHS Highly Specialised Service for Rare Mitochondrial Disorders for Adults and Children, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
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17
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Koňaříková E, Marković A, Korandová Z, Houštěk J, Mráček T. Current progress in the therapeutic options for mitochondrial disorders. Physiol Res 2020; 69:967-994. [PMID: 33129249 PMCID: PMC8549882 DOI: 10.33549/physiolres.934529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 10/02/2020] [Indexed: 12/20/2022] Open
Abstract
Mitochondrial disorders manifest enormous genetic and clinical heterogeneity - they can appear at any age, present with various phenotypes affecting any organ, and display any mode of inheritance. What mitochondrial diseases do have in common, is impairment of respiratory chain activity, which is responsible for more than 90% of energy production within cells. While diagnostics of mitochondrial disorders has been accelerated by introducing Next-Generation Sequencing techniques in recent years, the treatment options are still very limited. For many patients only a supportive or symptomatic therapy is available at the moment. However, decades of basic and preclinical research have uncovered potential target points and numerous compounds or interventions are now subjects of clinical trials. In this review, we focus on current and emerging therapeutic approaches towards the treatment of mitochondrial disorders. We focus on small compounds, metabolic interference, such as endurance training or ketogenic diet and also on genomic approaches.
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Affiliation(s)
- E Koňaříková
- Laboratory of Bioenergetics, Institute of Physiology Czech Acad. Sci., Prague, Czech Republic. ,
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18
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Bottani E, Lamperti C, Prigione A, Tiranti V, Persico N, Brunetti D. Therapeutic Approaches to Treat Mitochondrial Diseases: "One-Size-Fits-All" and "Precision Medicine" Strategies. Pharmaceutics 2020; 12:E1083. [PMID: 33187380 PMCID: PMC7696526 DOI: 10.3390/pharmaceutics12111083] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/08/2020] [Accepted: 11/09/2020] [Indexed: 12/11/2022] Open
Abstract
Primary mitochondrial diseases (PMD) refer to a group of severe, often inherited genetic conditions due to mutations in the mitochondrial genome or in the nuclear genes encoding for proteins involved in oxidative phosphorylation (OXPHOS). The mutations hamper the last step of aerobic metabolism, affecting the primary source of cellular ATP synthesis. Mitochondrial diseases are characterized by extremely heterogeneous symptoms, ranging from organ-specific to multisystemic dysfunction with different clinical courses. The limited information of the natural history, the limitations of currently available preclinical models, coupled with the large variability of phenotypical presentations of PMD patients, have strongly penalized the development of effective therapies. However, new therapeutic strategies have been emerging, often with promising preclinical and clinical results. Here we review the state of the art on experimental treatments for mitochondrial diseases, presenting "one-size-fits-all" approaches and precision medicine strategies. Finally, we propose novel perspective therapeutic plans, either based on preclinical studies or currently used for other genetic or metabolic diseases that could be transferred to PMD.
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Affiliation(s)
- Emanuela Bottani
- Department of Diagnostics and Public Health, Section of Pharmacology, University of Verona, 37134 Verona, Italy
| | - Costanza Lamperti
- Medical Genetics and Neurogenetics Unit, Fondazione IRCCS Istituto Neurologico C. Besta, 20126 Milan, Italy; (C.L.); (V.T.)
| | - Alessandro Prigione
- Department of General Pediatrics, Neonatology, and Pediatric Cardiology, University Clinic Düsseldorf (UKD), Heinrich Heine University (HHU), 40225 Dusseldorf, Germany;
| | - Valeria Tiranti
- Medical Genetics and Neurogenetics Unit, Fondazione IRCCS Istituto Neurologico C. Besta, 20126 Milan, Italy; (C.L.); (V.T.)
| | - Nicola Persico
- Department of Clinical Science and Community Health, University of Milan, 20122 Milan, Italy;
- Fetal Medicine and Surgery Service, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Dario Brunetti
- Medical Genetics and Neurogenetics Unit, Fondazione IRCCS Istituto Neurologico C. Besta, 20126 Milan, Italy; (C.L.); (V.T.)
- Department of Medical Biotechnology and Translational Medicine, University of Milan, 20129 Milan, Italy
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19
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Zhou GP, Qu W, Zhu ZJ, Sun LY, Wei L, Zeng ZG, Liu Y. Compromised therapeutic value of pediatric liver transplantation in ethylmalonic encephalopathy: A case report. World J Gastroenterol 2020; 26:6295-6303. [PMID: 33177801 PMCID: PMC7596645 DOI: 10.3748/wjg.v26.i40.6295] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/25/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ethylmalonic encephalopathy (EE) is a rare autosomal recessive metabolic disorder caused by impaired mitochondrial sulfur dioxygenase. Due to poor therapeutic effect of current conventional treatments, progressive psychomotor regression and neurological impairment usually contribute to early death in the first decade of life. Liver transplantation (LT) is emerging as a novel therapeutic option for EE; however, worldwide experience is still limited.
CASE SUMMARY An 18-mo-old patient with the diagnosis of EE received a living donor liver transplant in our institution, which, to our knowledge, is the first case in Asian-Pacific countries. During 20 mo of follow-up, the longitudinal metabolic evaluations revealed a wild fluctuation in urinary EMA levels, still far beyond the normal range. Urinary 2-methylsuccinic acid levels gradually restored to normal, whereas the concentrations of urinary isobutyrylglycine and plasma C4- and C5-acylcarnitines fluctuated markedly and still remained above the reference limits. Only mild amelioration of petechiae and ecchymosis was observed, and no dramatic reversion of chronic mucoid diarrhea and orthostatic acrocyanosis occurred. Although brain magnetic resonance imaging suggested a certain improvement in basal ganglia lesions, the patient still presented developmental delay and neurologic disability.
CONCLUSION LT may bring about a partial but not complete cure to EE. Given its definite role in defending against the devastating natural progression of EE, LT should still be considered for patients with EE in the absence of other superior therapeutic options. Early establishment of diagnosis and initiation of conventional treatment pre-transplant, timely LT, and continuous administration of metabolism-correcting medications post-transplant may be helpful in minimizing the neurologic impairment and maximizing the therapeutic value of LT in EE.
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Affiliation(s)
- Guang-Peng Zhou
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Wei Qu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Li-Ying Sun
- Liver Transplantation Center, Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Lin Wei
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhi-Gui Zeng
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Ying Liu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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20
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Grings M, Wajner M, Leipnitz G. Mitochondrial Dysfunction and Redox Homeostasis Impairment as Pathomechanisms of Brain Damage in Ethylmalonic Encephalopathy: Insights from Animal and Human Studies. Cell Mol Neurobiol 2020; 42:565-575. [DOI: 10.1007/s10571-020-00976-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/29/2020] [Indexed: 12/13/2022]
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21
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Identification of a novel homozygous nonsense variant in a Chinese patient with ethylmalonic encephalopathy and a genotype-phenotype spectrum review. Clin Chim Acta 2020; 509:8-17. [DOI: 10.1016/j.cca.2020.05.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 11/23/2022]
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22
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Kožich V, Stabler S. Lessons Learned from Inherited Metabolic Disorders of Sulfur-Containing Amino Acids Metabolism. J Nutr 2020; 150:2506S-2517S. [PMID: 33000152 DOI: 10.1093/jn/nxaa134] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/12/2020] [Accepted: 04/17/2020] [Indexed: 12/16/2022] Open
Abstract
The metabolism of sulfur-containing amino acids (SAAs) requires an orchestrated interplay among several dozen enzymes and transporters, and an adequate dietary intake of methionine (Met), cysteine (Cys), and B vitamins. Known human genetic disorders are due to defects in Met demethylation, homocysteine (Hcy) remethylation, or cobalamin and folate metabolism, in Hcy transsulfuration, and Cys and hydrogen sulfide (H2S) catabolism. These disorders may manifest between the newborn period and late adulthood by a combination of neuropsychiatric abnormalities, thromboembolism, megaloblastic anemia, hepatopathy, myopathy, and bone and connective tissue abnormalities. Biochemical features include metabolite deficiencies (e.g. Met, S-adenosylmethionine (AdoMet), intermediates in 1-carbon metabolism, Cys, or glutathione) and/or their accumulation (e.g. S-adenosylhomocysteine, Hcy, H2S, or sulfite). Treatment should be started as early as possible and may include a low-protein/low-Met diet with Cys-enriched amino acid supplements, pharmacological doses of B vitamins, betaine to stimulate Hcy remethylation, the provision of N-acetylcysteine or AdoMet, or experimental approaches such as liver transplantation or enzyme replacement therapy. In several disorders, patients are exposed to long-term markedly elevated Met concentrations. Although these conditions may inform on Met toxicity, interpretation is difficult due to the presence of additional metabolic changes. Two disorders seem to exhibit Met-associated toxicity in the brain. An increased risk of demyelination in patients with Met adenosyltransferase I/III (MATI/III) deficiency due to biallelic mutations in the MATIA gene has been attributed to very high blood Met concentrations (typically >800 μmol/L) and possibly also to decreased liver AdoMet synthesis. An excessively high Met concentration in some patients with cystathionine β-synthase deficiency has been associated with encephalopathy and brain edema, and direct toxicity of Met has been postulated. In summary, studies in patients with various disorders of SAA metabolism showed complex metabolic changes with distant cellular consequences, most of which are not attributable to direct Met toxicity.
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Affiliation(s)
- Viktor Kožich
- Department of Pediatrics and Adolescent Medicine, Charles University-First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Sally Stabler
- Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO, USA
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23
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Almannai M, El-Hattab AW, Ali M, Soler-Alfonso C, Scaglia F. Clinical trials in mitochondrial disorders, an update. Mol Genet Metab 2020; 131:1-13. [PMID: 33129691 PMCID: PMC7537630 DOI: 10.1016/j.ymgme.2020.10.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/02/2020] [Indexed: 12/11/2022]
Abstract
Mitochondrial disorders comprise a molecular and clinically diverse group of diseases that are associated with mitochondrial dysfunction leading to multi-organ disease. With recent advances in molecular technologies, the understanding of the pathomechanisms of a growing list of mitochondrial disorders has been greatly expanded. However, the therapeutic approaches for mitochondrial disorders have lagged behind with treatment options limited mainly to symptom specific therapies and supportive measures. There is an increasing number of clinical trials in mitochondrial disorders aiming for more specific and effective therapies. This review will cover different treatment modalities currently used in mitochondrial disorders, focusing on recent and ongoing clinical trials.
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Affiliation(s)
- Mohammed Almannai
- Section of Medical Genetics, Children's Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ayman W El-Hattab
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - May Ali
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Claudia Soler-Alfonso
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA
| | - Fernando Scaglia
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Texas Children's Hospital, Houston, TX, USA; Joint BCM-CUHK Center of Medical Genetics, Prince of Wales Hospital, Shatin, Hong Kong.
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24
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Ersoy M, Tiranti V, Zeviani M. Ethylmalonic encephalopathy: Clinical course and therapy response in an uncommon mild case with a severe ETHE1 mutation. Mol Genet Metab Rep 2020; 25:100641. [PMID: 32923369 PMCID: PMC7476058 DOI: 10.1016/j.ymgmr.2020.100641] [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: 07/01/2020] [Revised: 08/15/2020] [Accepted: 08/16/2020] [Indexed: 02/06/2023] Open
Abstract
Ethylmalonic encephalopathy (EE) is a rare metabolic disorder caused by dysfunction of ETHE1 protein, a mitochondrial dioxygenase involved in hydrogen sulfide (H2S) detoxification. EE is usually a fatal disease with a severe clinical course mainly associated with developmental delay and regression, recurrent petechiae, orthostatic acrocyanosis, and chronic diarrhoea. Treatment includes antioxidants, antibiotics that lower H2S levels and antispastic medications, which are not curative. The mutations causing absence of the ETHE1 protein, as is the case for the described patient, usually entail a severe fatal phenotype. Although there are rare reported cases with mild clinical findings, the mechanism leading to these milder cases is also unclear. Here, we describe an 11-year-old boy with an ETHE1 gene mutation who has no neurocognitive impairment but chronic diarrhoea, which is controlled by oral medical treatment, and progressive spastic paraparesis that responded to Achilles tendon lengthening.
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Key Words
- 3-MST, 3-mercaptopyruvate sulfurtransferase
- CAT, cysteine aminotransferase
- CBS, cystathionine β-synthase
- CSE, cystathionine γ-lyase
- EE, ethylmalonic encephalopathy
- EMA, ethylmalonic acid
- ETHE1 gene
- GSH, glutathione
- H2S
- H2S, hydrogen sulfide
- H2SO3, persulfide
- MTZ, metronidazole
- Mild course
- NAC, N-acetylcysteine
- SCAD, short-chain acyl-CoA dehydrogenase
- SDO, sulfur dioxygenase
- SQR, sulfide quinone oxidoreductase
- SUOX, sulfite oxidase
- TST, thiosulfate sulfur transferase
- Therapy response
- UQ, quinone
- cIII, complex III
- cIV, complex IV
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Affiliation(s)
- Melike Ersoy
- Department of Pediatrics, Division of Pediatric Metabolism, Health Sciences University, Bakirkoy Dr. Sadi Konuk Research and Education Hospital, Istanbul, Turkey
| | - Valeria Tiranti
- Molecular Pathogenesis of Mitochondrial Disorders Unit of Medical Genetics and Neurogenetics Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Massimo Zeviani
- The Clinical School, University of Padova Department of Neurosciences Veneto Institute of Molecular Medicine Via Orus 2, Padova, Italy
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25
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La Morgia C, Maresca A, Caporali L, Valentino ML, Carelli V. Mitochondrial diseases in adults. J Intern Med 2020; 287:592-608. [PMID: 32463135 DOI: 10.1111/joim.13064] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/07/2020] [Accepted: 02/21/2020] [Indexed: 02/07/2023]
Abstract
Mitochondrial medicine is a field that expanded exponentially in the last 30 years. Individually rare, mitochondrial diseases as a whole are probably the most frequent genetic disorder in adults. The complexity of their genotype-phenotype correlation, in terms of penetrance and clinical expressivity, natural history and diagnostic algorithm derives from the dual genetic determination. In fact, in addition to the about 1.500 genes encoding mitochondrial proteins that reside in the nuclear genome (nDNA), we have the 13 proteins encoded by the mitochondrial genome (mtDNA), for which 22 specific tRNAs and 2 rRNAs are also needed. Thus, besides Mendelian genetics, we need to consider all peculiarities of how mtDNA is inherited, maintained and expressed to fully understand the pathogenic mechanisms of these disorders. Yet, from the initial restriction to the narrow field of oxidative phosphorylation dysfunction, the landscape of mitochondrial functions impinging on cellular homeostasis, driving life and death, is impressively enlarged. Finally, from the clinical standpoint, starting from the neuromuscular field, where brain and skeletal muscle were the primary targets of mitochondrial dysfunction as energy-dependent tissues, after three decades virtually any subspecialty of medicine is now involved. We will summarize the key clinical pictures and pathogenic mechanisms of mitochondrial diseases in adults.
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Affiliation(s)
- C La Morgia
- From the, Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - A Maresca
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - L Caporali
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - M L Valentino
- From the, Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - V Carelli
- From the, Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
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26
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Viscomi C, Zeviani M. Strategies for fighting mitochondrial diseases. J Intern Med 2020; 287:665-684. [PMID: 32100338 DOI: 10.1111/joim.13046] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 11/10/2019] [Accepted: 01/24/2020] [Indexed: 12/19/2022]
Abstract
Mitochondrial diseases are extremely heterogeneous genetic conditions characterized by faulty oxidative phosphorylation (OXPHOS). OXPHOS deficiency can be the result of mutation in mtDNA genes, encoding either proteins (13 subunits of the mitochondrial complexes I, III, IV and V) or the tRNA and rRNA components of the in situ mtDNA translation. The remaining mitochondrial disease genes are in the nucleus, encoding proteins with a huge variety of functions, from structural subunits of the mitochondrial complexes, to factors involved in their formation and regulation, components of the mtDNA replication and expression machinery, biosynthetic enzymes for the biosynthesis or incorporation of prosthetic groups, components of the mitochondrial quality control and proteostasis, enzymes involved in the clearance of toxic compounds, factors involved in the formation of the lipid milieu, etc. These different functions represent potential targets for 'general' therapeutic interventions, as they may be adapted to a number of different mitochondrial conditions. This is in contrast with 'tailored', personalized therapeutic approaches, such as gene therapy, cell therapy and organ replacement, that can be useful only for individual conditions. This review will present the most recent concepts emerged from preclinical work and the attempts to translate them into the clinics. The common notion that mitochondrial disorders have no cure is currently challenged by a massive effort of scientists and clinicians, and we do expect that thanks to this intensive investigation work and tangible results for the development of strategies amenable to the treatment of patients with these tremendously difficult conditions are not so far away.
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Affiliation(s)
- C Viscomi
- From the, Department of Biomedical Sciences, University of Padova, Padova, Italy
| | - M Zeviani
- Department of Neurosciences, University of Padova, Padova, Italy.,Venetian Institute of Molecular Medicine, Padova, Italy
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27
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Riboflavin Deficiency-Implications for General Human Health and Inborn Errors of Metabolism. Int J Mol Sci 2020; 21:ijms21113847. [PMID: 32481712 PMCID: PMC7312377 DOI: 10.3390/ijms21113847] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 01/13/2023] Open
Abstract
As an essential vitamin, the role of riboflavin in human diet and health is increasingly being highlighted. Insufficient dietary intake of riboflavin is often reported in nutritional surveys and population studies, even in non-developing countries with abundant sources of riboflavin-rich dietary products. A latent subclinical riboflavin deficiency can result in a significant clinical phenotype when combined with inborn genetic disturbances or environmental and physiological factors like infections, exercise, diet, aging and pregnancy. Riboflavin, and more importantly its derivatives, flavin mononucleotide (FMN) and flavin adenine dinucleotide (FAD), play a crucial role in essential cellular processes including mitochondrial energy metabolism, stress responses, vitamin and cofactor biogenesis, where they function as cofactors to ensure the catalytic activity and folding/stability of flavoenzymes. Numerous inborn errors of flavin metabolism and flavoenzyme function have been described, and supplementation with riboflavin has in many cases been shown to be lifesaving or to mitigate symptoms. This review discusses the environmental, physiological and genetic factors that affect cellular riboflavin status. We describe the crucial role of riboflavin for general human health, and the clear benefits of riboflavin treatment in patients with inborn errors of metabolism.
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28
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Madaan P, Saini L, Vyas S, Attri SV, Sahu JK. Mystery Case: An infant with developmental delay, epileptic spasms, and acrocyanosis. Neurology 2020; 94:939-942. [PMID: 32366539 DOI: 10.1212/wnl.0000000000009479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Priyanka Madaan
- From the Pediatric Neurology Unit (P.M., L.S., J.K.S.) and Department of Pediatrics (S.V.A.), Advanced Pediatrics Centre, and Department of Radiodiagnosis and Imaging, Section of Neuroimaging and Interventional Radiology (S.V.), Postgraduate Institute of Medical Education and Research, Chandigarh; and Council of Scientific and Industrial Research (P.M.), New Delhi, India
| | - Lokesh Saini
- From the Pediatric Neurology Unit (P.M., L.S., J.K.S.) and Department of Pediatrics (S.V.A.), Advanced Pediatrics Centre, and Department of Radiodiagnosis and Imaging, Section of Neuroimaging and Interventional Radiology (S.V.), Postgraduate Institute of Medical Education and Research, Chandigarh; and Council of Scientific and Industrial Research (P.M.), New Delhi, India
| | - Sameer Vyas
- From the Pediatric Neurology Unit (P.M., L.S., J.K.S.) and Department of Pediatrics (S.V.A.), Advanced Pediatrics Centre, and Department of Radiodiagnosis and Imaging, Section of Neuroimaging and Interventional Radiology (S.V.), Postgraduate Institute of Medical Education and Research, Chandigarh; and Council of Scientific and Industrial Research (P.M.), New Delhi, India
| | - Savita Verma Attri
- From the Pediatric Neurology Unit (P.M., L.S., J.K.S.) and Department of Pediatrics (S.V.A.), Advanced Pediatrics Centre, and Department of Radiodiagnosis and Imaging, Section of Neuroimaging and Interventional Radiology (S.V.), Postgraduate Institute of Medical Education and Research, Chandigarh; and Council of Scientific and Industrial Research (P.M.), New Delhi, India
| | - Jitendra Kumar Sahu
- From the Pediatric Neurology Unit (P.M., L.S., J.K.S.) and Department of Pediatrics (S.V.A.), Advanced Pediatrics Centre, and Department of Radiodiagnosis and Imaging, Section of Neuroimaging and Interventional Radiology (S.V.), Postgraduate Institute of Medical Education and Research, Chandigarh; and Council of Scientific and Industrial Research (P.M.), New Delhi, India.
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29
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Chen X, Han L, Yao H. Novel Compound Heterozygous Variants of ETHE1 Causing Ethylmalonic Encephalopathy in a Chinese Patient: A Case Report. Front Genet 2020; 11:341. [PMID: 32362910 PMCID: PMC7181787 DOI: 10.3389/fgene.2020.00341] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 03/23/2020] [Indexed: 01/22/2023] Open
Abstract
Ethylmalonic encephalopathy (EE) is a very rare autosomal recessive metabolic disorder that primarily affects children. Less than one hundred EE patients have been diagnosed worldwide. The clinical manifestations include chronic diarrhea, petechiae, orthostatic acrocyanosis, psychomotor delay and regression, seizures, and hypotonia. The ETHE1 gene has been shown to be associated with EE, and genetic sequencing provides concrete evidence for diagnosis. To date, only 37 variants of ETHE1 have been reported as disease-causing in EE patients. We identified two novel ETHE1 variants, i.e., c.595+1G>T at the canonical splice site and the missense variant c.586G>C (p. D196H), in a 3-year-old Chinese boy with EE. The patient had mild symptoms with only chronic diarrhea. The typical symptoms, including spontaneous petechiae, acrocyanosis, and hypotonia, were all absent. Herein, we report on the clinical, biochemical, and genetic findings of our patient and review the phenotypes and genotypes of all patients with EE caused by ETHE1 variants with available information. This study supports the early assessment and diagnosis of EE.
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Affiliation(s)
- Xiaohong Chen
- Department of Endocrinology and Metabolism, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lin Han
- Running Gene Inc., Beijing, China
| | - Hui Yao
- Department of Endocrinology and Metabolism, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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30
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Govindaraj P, Parayil Sankaran B, Nagappa M, Arvinda HR, Deepha S, Jessiena Ponmalar JN, Sinha S, Gayathri N, Taly AB. Child Neurology: Ethylmalonic encephalopathy. Neurology 2020; 94:e1336-e1339. [PMID: 32111695 DOI: 10.1212/wnl.0000000000009144] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Periyasamy Govindaraj
- From the Departments of Neuropathology (P.G., S.D., N.G.), Neurology (B.P.S., M.N., S.S., A.B.T.), Neuroimaging and Interventional Radiology (H.R.A.), and Neuromuscular Laboratory-Neurobiology Research Centre (P.G., B.P.S., M.N., S.D., J.N.J.P., N.G., A.B.T.), National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Bindu Parayil Sankaran
- From the Departments of Neuropathology (P.G., S.D., N.G.), Neurology (B.P.S., M.N., S.S., A.B.T.), Neuroimaging and Interventional Radiology (H.R.A.), and Neuromuscular Laboratory-Neurobiology Research Centre (P.G., B.P.S., M.N., S.D., J.N.J.P., N.G., A.B.T.), National Institute of Mental Health and Neurosciences, Bengaluru, India.
| | - Madhu Nagappa
- From the Departments of Neuropathology (P.G., S.D., N.G.), Neurology (B.P.S., M.N., S.S., A.B.T.), Neuroimaging and Interventional Radiology (H.R.A.), and Neuromuscular Laboratory-Neurobiology Research Centre (P.G., B.P.S., M.N., S.D., J.N.J.P., N.G., A.B.T.), National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Hanumanthapura R Arvinda
- From the Departments of Neuropathology (P.G., S.D., N.G.), Neurology (B.P.S., M.N., S.S., A.B.T.), Neuroimaging and Interventional Radiology (H.R.A.), and Neuromuscular Laboratory-Neurobiology Research Centre (P.G., B.P.S., M.N., S.D., J.N.J.P., N.G., A.B.T.), National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Sekar Deepha
- From the Departments of Neuropathology (P.G., S.D., N.G.), Neurology (B.P.S., M.N., S.S., A.B.T.), Neuroimaging and Interventional Radiology (H.R.A.), and Neuromuscular Laboratory-Neurobiology Research Centre (P.G., B.P.S., M.N., S.D., J.N.J.P., N.G., A.B.T.), National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - J N Jessiena Ponmalar
- From the Departments of Neuropathology (P.G., S.D., N.G.), Neurology (B.P.S., M.N., S.S., A.B.T.), Neuroimaging and Interventional Radiology (H.R.A.), and Neuromuscular Laboratory-Neurobiology Research Centre (P.G., B.P.S., M.N., S.D., J.N.J.P., N.G., A.B.T.), National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Sanjib Sinha
- From the Departments of Neuropathology (P.G., S.D., N.G.), Neurology (B.P.S., M.N., S.S., A.B.T.), Neuroimaging and Interventional Radiology (H.R.A.), and Neuromuscular Laboratory-Neurobiology Research Centre (P.G., B.P.S., M.N., S.D., J.N.J.P., N.G., A.B.T.), National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Narayanappa Gayathri
- From the Departments of Neuropathology (P.G., S.D., N.G.), Neurology (B.P.S., M.N., S.S., A.B.T.), Neuroimaging and Interventional Radiology (H.R.A.), and Neuromuscular Laboratory-Neurobiology Research Centre (P.G., B.P.S., M.N., S.D., J.N.J.P., N.G., A.B.T.), National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Arun B Taly
- From the Departments of Neuropathology (P.G., S.D., N.G.), Neurology (B.P.S., M.N., S.S., A.B.T.), Neuroimaging and Interventional Radiology (H.R.A.), and Neuromuscular Laboratory-Neurobiology Research Centre (P.G., B.P.S., M.N., S.D., J.N.J.P., N.G., A.B.T.), National Institute of Mental Health and Neurosciences, Bengaluru, India
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31
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Lim A, Thomas RH. The mitochondrial epilepsies. Eur J Paediatr Neurol 2020; 24:47-52. [PMID: 31973983 DOI: 10.1016/j.ejpn.2019.12.021] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 01/19/2023]
Abstract
Mitochondria are vital organelles within cells that undertake many important metabolic roles, the most significant of which is to generate energy to support organ function. Dysfunction of the mitochondrion can lead to a wide range of clinical features, predominantly affecting organs with a high metabolic demand such as the brain. One of the main neurological manifestations of mitochondrial disease is metabolic epilepsies. These epileptic seizures are more frequently of posterior quadrant and occipital lobe onset, more likely to present with non-convulsive status epilepticus which may last months and be more resistant to treatment from the onset. The onset of can be of any age. Childhood onset epilepsy is a major phenotypic feature in mitochondrial disorders such as Alpers-Huttenlocher syndrome, pyruvate dehydrogenase complex deficiencies, and Leigh syndrome. Meanwhile, adults with classical mitochondrial disease syndrome such as MELAS, MERFF or POLG-related disorders could present with either focal or generalised seizures. There are no specific curative treatments for mitochondrial epilepsy. Generally, the epileptic seizures should be managed by specialist neurologist with appropriate use of anticonvulsants. As a general rule, especially in disorders associated with mutation in POLG, sodium valproate is best avoided because hepato-toxicity can be fulminant and fatal.
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Affiliation(s)
- Albert Lim
- Department of Paediatrics, Great Northern Children's Hospital, Queen Victoria Rd, Newcastle-Upon-Tyne, NE1 4LP, United Kingdom; Wellcome Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle-Upon-Tyne, NE2 4HH, United Kingdom
| | - Rhys H Thomas
- Wellcome Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle-Upon-Tyne, NE2 4HH, United Kingdom; Department of Neurology, Royal Victoria Infirmary, Queen Victoria Rd, Newcastle-Upon-Tyne, NE1 4LP, United Kingdom; Institute of Neuroscience, Henry Wellcome Building, Framlington Place, Newcastle University, Newcastle-Upon-Tyne, NE2 4HH, United Kingdom.
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32
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Abstract
Epilepsy is frequently a severe and sinister symptom in primary mitochondrial diseases, a group of more than 350 different genetic disorders characterized by mitochondrial dysfunction and extreme clinical and biochemical heterogeneity. Mitochondrial epilepsy is notoriously difficult to manage, principally because the vast majority of primary mitochondrial diseases currently lack effective therapies. Treating the underlying mitochondrial disorder is likely to be a more effective strategy than using traditional antiepileptic drugs. This review, initially presented at the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures at the Francis Crick Institute in London, summarizes the currently available and emerging therapies for mitochondrial epilepsy. Potentially treatable mitochondrial diseases include disorders of coenzyme Q10 biosynthesis and a group of mitochondrial respiratory chain complex I subunit and assembly factor defects that respond to riboflavin (vitamin B2). Approaches that have been adopted in actively recruiting clinical trials include redox modulation, harnessing mitochondrial biogenesis, using rapamycin to target mitophagy, nucleoside supplementation, and gene and cell therapies. Most of the clinical trials are at an early stage (Phase 1 or 2) and none of the currently active trials is specifically targeting mitochondrial epilepsy. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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33
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Grings M, Seminotti B, Karunanidhi A, Ghaloul-Gonzalez L, Mohsen AW, Wipf P, Palmfeldt J, Vockley J, Leipnitz G. ETHE1 and MOCS1 deficiencies: Disruption of mitochondrial bioenergetics, dynamics, redox homeostasis and endoplasmic reticulum-mitochondria crosstalk in patient fibroblasts. Sci Rep 2019; 9:12651. [PMID: 31477743 PMCID: PMC6718683 DOI: 10.1038/s41598-019-49014-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 08/14/2019] [Indexed: 01/21/2023] Open
Abstract
Ethylmalonic encephalopathy protein 1 (ETHE1) and molybdenum cofactor (MoCo) deficiencies are hereditary disorders that affect the catabolism of sulfur-containing amino acids. ETHE1 deficiency is caused by mutations in the ETHE1 gene, while MoCo deficiency is due to mutations in one of three genes involved in MoCo biosynthesis (MOCS1, MOCS2 and GPHN). Patients with both disorders exhibit abnormalities of the mitochondrial respiratory chain, among other biochemical findings. However, the pathophysiology of the defects has not been elucidated. To characterize cellular derangements, mitochondrial bioenergetics, dynamics, endoplasmic reticulum (ER)-mitochondria communication, superoxide production and apoptosis were evaluated in fibroblasts from four patients with ETHE1 deficiency and one with MOCS1 deficiency. The effect of JP4-039, a promising mitochondrial-targeted antioxidant, was also tested on cells. Our data show that mitochondrial respiration was decreased in all patient cell lines. ATP depletion and increased mitochondrial mass was identified in the same cells, while variable alterations in mitochondrial fusion and fission were seen. High superoxide levels were found in all cells and were decreased by treatment with JP4-039, while the respiratory chain activity was increased by this antioxidant in cells in which it was impaired. The content of VDAC1 and IP3R, proteins involved in ER-mitochondria communication, was decreased, while DDIT3, a marker of ER stress, and apoptosis were increased in all cell lines. These data demonstrate that previously unrecognized broad disturbances of cellular function are involved in the pathophysiology of ETHE1 and MOCS1 deficiencies, and that reduction of mitochondrial superoxide by JP4-039 is a promising strategy for adjuvant therapy of these disorders.
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Affiliation(s)
- Mateus Grings
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, CEP 90035-003, Porto Alegre, RS, Brazil. .,Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, 15224, USA.
| | - Bianca Seminotti
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, CEP 90035-003, Porto Alegre, RS, Brazil.,Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, 15224, USA
| | - Anuradha Karunanidhi
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, 15224, USA
| | - Lina Ghaloul-Gonzalez
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, 15224, USA.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Al-Walid Mohsen
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, 15224, USA.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Peter Wipf
- Departments of Chemistry, Pharmaceutical Sciences and Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15260, USA
| | - Johan Palmfeldt
- Research Unit for Molecular Medicine, Aarhus University Hospital, Skejby, Denmark
| | - Jerry Vockley
- Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, 15224, USA.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Guilhian Leipnitz
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, CEP 90035-003, Porto Alegre, RS, Brazil. .,Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, 15224, USA. .,Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2600-Anexo, CEP 90035-003, Porto Alegre, RS, Brazil.
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34
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Tam A, AlDhaheri NS, Mysore K, Tessier ME, Goss J, Fernandez LA, D'Alessandro AM, Schwoerer JS, Rice GM, Elsea SH, Scaglia F. Improved clinical outcome following liver transplant in patients with ethylmalonic encephalopathy. Am J Med Genet A 2019; 179:1015-1019. [PMID: 30864297 PMCID: PMC9873405 DOI: 10.1002/ajmg.a.61104] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/04/2019] [Accepted: 02/04/2019] [Indexed: 01/26/2023]
Abstract
Ethylmalonic encephalopathy (EE) is a rapidly progressive autosomal recessive mitochondrial disease caused by biallelic pathogenic variants in the ETHE1 gene that encodes the mitochondrial sulfur dioxygenase. It is characterized by neurodevelopmental delay and regression, pyramidal and extrapyramidal signs, recurrent petechiae, chronic diarrhea, and orthostatic acrocyanosis. Laboratory findings include elevated serum levels of lactate and C4-C5 acylcarnitines, and elevated urinary excretion of ethylmalonic acid and C4-C6 acylglycines, notably isobutyrylglycine and 2-methylbutyrylglycine. These findings are attributed to deficiency of the mitochondrial sulfur dioxygenase resulting in toxic accumulation of hydrogen sulfide metabolites in vascular endothelium and mucosal cells of the large intestine. Medical management has thus far been directed toward decreasing the accumulation of hydrogen sulfide metabolites using a combination of metronidazole and N-acetylcysteine. More recently, orthotopic liver transplant (OLT) has been reported as a new therapeutic option for EE. Here, we report two additional cases of EE who achieved psychomotor developmental improvement after 7- and 22-months following OLT. The second case serves as the longest developmental outcome follow-up reported, thus far, following OLT for EE. This report provides additional evidence to validate OLT as a promising therapeutic approach for what was considered to be a fatal disease.
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Affiliation(s)
- Allison Tam
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas,Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, Texas,Division of Medical Genetics, Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Noura Salem AlDhaheri
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas,Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, Texas,Department of Pediatrics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
| | - Krupa Mysore
- Department of Gastroenterology and Hepatology, Texas Children's Hospital, Houston, Texas
| | - Mary Elizabeth Tessier
- Department of Gastroenterology and Hepatology, Texas Children's Hospital, Houston, Texas
| | - John Goss
- Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, Texas,Division of Abdominal Transplantation, Baylor College of Medicine, Houston, Texas
| | - Luis A. Fernandez
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Anthony M. D'Alessandro
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jessica Scott Schwoerer
- Department of Pediatrics and the Waisman Center, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Gregory M. Rice
- Department of Pediatrics and the Waisman Center, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Sarah H. Elsea
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Fernando Scaglia
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas,Department of Molecular and Human Genetics, Texas Children's Hospital, Houston, Texas,BCM-CUHK Center of Medical Genetics, Prince of Wales Hospital, Hong Kong SAR
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35
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Ditrói T, Nagy A, Martinelli D, Rosta A, Kožich V, Nagy P. Comprehensive analysis of how experimental parameters affect H 2S measurements by the monobromobimane method. Free Radic Biol Med 2019; 136:146-158. [PMID: 30970274 DOI: 10.1016/j.freeradbiomed.2019.04.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 03/28/2019] [Accepted: 04/02/2019] [Indexed: 11/24/2022]
Abstract
A rapidly increasing number of studies report on widespread biological functions for endogenous hydrogen sulfide. However, the use of multiple, chemically distinct analytical methods to measure free hydrogen sulfide levels in biological samples accumulate data that are not in agreement with each other. In this work a widely appreciated technique, the monobromobimane method, was thoroughly investigated with the overall aims i) to demonstrate how results obtained by different versions of the method should be interpreted and ii) to provide an easy protocol for the community in order to obtain reliable and comparable results. We demonstrate that none of the previously published versions of the method measure free sulfide concentrations in blood serum or plasma samples due to significant interferences with the biomolecule-bound sulfide pool. On the other hand, we stress the biological relevance of these measurements in cases in which they are carefully conducted. To aid future studies, we extensively investigated the entire procedure from sample withdrawal through handling and storing of injection-ready samples until the detection protocol in order to pinpoint all parameters that can affect the final readouts. Based on our rigorous analytical investigations a set of recommendations were compiled that are necessary to ensure reliable, reproducible and comparable results in the field and a detailed standardized protocol is provided.
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Affiliation(s)
- Tamás Ditrói
- National Institute of Oncology, Department of Molecular Immunology and Toxicology, Ráth György Utca 7-9, Budapest, Hungary
| | - Attila Nagy
- National Institute of Oncology, Department of Molecular Immunology and Toxicology, Ráth György Utca 7-9, Budapest, Hungary
| | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCSS, Piazza S. Onofrio 4, Rome, I-00165, Italy
| | - András Rosta
- National Institute of Oncology, Department of Medical Oncology "A" and Hematology, Lymphoma Center, Ráth György Utca 7-9, Budapest, Hungary
| | - Viktor Kožich
- Department of Pediatrics and Adolescent Medicine, Charles University-First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Péter Nagy
- National Institute of Oncology, Department of Molecular Immunology and Toxicology, Ráth György Utca 7-9, Budapest, Hungary; Department of Medicine, Faculty of Medicine, University of Debrecen, 4012, Debrecen, Hungary.
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37
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Kitzler TM, Gupta IR, Osterman B, Poulin C, Trakadis Y, Waters PJ, Buhas DC. Acute and Chronic Management in an Atypical Case of Ethylmalonic Encephalopathy. JIMD Rep 2018; 45:57-63. [PMID: 30349987 DOI: 10.1007/8904_2018_136] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/01/2018] [Accepted: 08/17/2018] [Indexed: 12/19/2022] Open
Abstract
Ethylmalonic encephalopathy (EE) is caused by mutations in the ETHE1 gene. ETHE1 is vital for the catabolism of hydrogen sulfide (H2S). Patients with pathogenic mutations in ETHE1 have markedly increased thiosulfate, which is a reliable index of H2S levels. Accumulation of H2S is thought to cause the characteristic metabolic derangement found in EE. Recently introduced treatment strategies in EE, such as combined use of metronidazole (MNZ) and N-acetylcysteine (NAC), are aimed at lowering chronic H2S load. Experience with treatment strategies directed against acute episodes of metabolic decompensation (e.g., hemodialysis) is limited. Here we present an unusually mild, molecularly confirmed, case of EE in a 19-year-old male on chronic treatment with MNZ and NAC. During an acute episode of metabolic decompensation, we employed continuous renal replacement therapy (CRRT) to regain metabolic control. On continuous treatment with NAC and MNZ during the months preceding the acute event, plasma thiosulfate levels ranged from 1.6 to 4 μg/mL (reference range up to 2 μg/mL) and had a mean value of 2.5 μg/mL. During the acute decompensation, thiosulfate levels were 6.7 μg/mL, with hyperlactatemia and perturbed organic acid, acylglycine, and acylcarnitine profiles. CRRT decreased thiosulfate within 24 h to 1.4 μg/mL. Following discontinuation of CRRT, mean thiosulfate levels were 3.2 μg/mL (range, 2.4-3.7 μg/mL) accompanied by clinical improvement with metabolic stabilization of blood gas, acylcarnitine, organic acid, and acylglycine profiles. In conclusion, CRRT may help to regain metabolic control in patients with EE who have an acute metabolic decompensation on chronic treatment with NAC and MNZ.
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Affiliation(s)
- Thomas M Kitzler
- Department of Medical Genetics, McGill University Health Centre, Montreal, QC, Canada.
| | - Indra R Gupta
- Department of Pediatrics, Division of Nephrology, McGill University Health Centre, Montreal, QC, Canada
| | - Bradley Osterman
- Department of Pediatric Neurology, Centre Hospitalier de l'Université Laval (CHUL), Quebec City, QC, Canada
| | - Chantal Poulin
- Department of Pediatrics, Division of Neurology, McGill University Health Centre, Montreal, QC, Canada
| | - Yannis Trakadis
- Department of Medical Genetics, McGill University Health Centre, Montreal, QC, Canada
| | - Paula J Waters
- Medical Genetics Service, Department of Pediatrics, University of Sherbrooke Hospital Centre (CHUS), Sherbrooke, QC, Canada
| | - Daniela C Buhas
- Department of Medical Genetics, McGill University Health Centre, Montreal, QC, Canada
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Towards a therapy for mitochondrial disease: an update. Biochem Soc Trans 2018; 46:1247-1261. [PMID: 30301846 PMCID: PMC6195631 DOI: 10.1042/bst20180134] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 09/07/2018] [Accepted: 09/10/2018] [Indexed: 02/07/2023]
Abstract
Preclinical work aimed at developing new therapies for mitochondrial diseases has recently given new hopes and opened unexpected perspectives for the patients affected by these pathologies. In contrast, only minor progresses have been achieved so far in the translation into the clinics. Many challenges are still ahead, including the need for a better characterization of the pharmacological effects of the different approaches and the design of appropriate clinical trials with robust outcome measures for this extremely heterogeneous, rare, and complex group of disorders. In this review, we will discuss the most important achievements and the major challenges in this very dynamic research field.
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Alves CAPF, Gonçalves FG, Grieb D, Lucato LT, Goldstein AC, Zuccoli G. Neuroimaging of Mitochondrial Cytopathies. Top Magn Reson Imaging 2018; 27:219-240. [PMID: 30086109 DOI: 10.1097/rmr.0000000000000173] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Mitochondrial diseases are a complex and heterogeneous group of genetic disorders that occur as a result of either nuclear DNA or mitochondrial DNA pathogenic variants, leading to a decrease in oxidative phosphorylation and cellular energy (ATP) production. Increasing knowledge about molecular, biochemical, and genetic abnormalities related to mitochondrial dysfunction has expanded the neuroimaging phenotypes of mitochondrial disorders. As a consequence of this growing field, the imaging recognition patterns of mitochondrial cytopathies are continually evolving. In this review, we describe the main neuroimaging characteristics of pediatric mitochondrial diseases, ranging from classical to more recent and challenging features. Due to the increased knowledge about the imaging findings of mitochondrial cytopathies, the pediatric neuroradiologist plays a crucial role in the diagnosis and evaluation of these patients.
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Affiliation(s)
| | | | - Dominik Grieb
- Department of Radiology and Neuroradiology, Sana Kliniken Duisburg, Germany
| | - Leandro Tavares Lucato
- Neuroradiology Section, Hospital das Clínicas- HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Amy C Goldstein
- Division of Human Genetics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Giulio Zuccoli
- Department of Radiology, University of Pittsburgh School of Medicine, Director of Pediatric Neuroradiology, Children Hospital of Pittsburgh, Pittsburgh, PA
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40
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Emerging therapies for mitochondrial diseases. Essays Biochem 2018; 62:467-481. [PMID: 29980632 DOI: 10.1042/ebc20170114] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 05/20/2018] [Accepted: 05/23/2018] [Indexed: 12/25/2022]
Abstract
For the vast majority of patients with mitochondrial diseases, only supportive and symptomatic therapies are available. However, in the last decade, due to extraordinary advances in defining the causes and pathomechanisms of these diverse disorders, new therapies are being developed in the laboratory and are entering human clinical trials. In this review, we highlight the current use of dietary supplement and exercise therapies as well as emerging therapies that may be broadly applicable across multiple mitochondrial diseases or tailored for specific disorders. Examples of non-tailored therapeutic targets include: activation of mitochondrial biogenesis, regulation of mitophagy and mitochondrial dynamics, bypass of biochemical defects, mitochondrial replacement therapy, and hypoxia. In contrast, tailored therapies are: scavenging of toxic compounds, deoxynucleoside and deoxynucleotide treatments, cell replacement therapies, gene therapy, shifting mitochondrial DNA mutation heteroplasmy, and stabilization of mutant mitochondrial transfer RNAs.
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Bulut FD, Kör D, Şeker-Yılmaz B, Gül-Mert G, Kılavuz S, Önenli-Mungan N. Turkish case of ethylmalonic encephalopathy misdiagnosed as short chain acyl-CoA dehydrogenase deficiency. Metab Brain Dis 2018; 33:977-979. [PMID: 29159724 DOI: 10.1007/s11011-017-0152-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 11/14/2017] [Indexed: 10/18/2022]
Abstract
Ethylmalonic encephalopathy is a very rare autosomal recessively inherited inborn error of metabolism; characterized by encephalopathy, recurrent petechiae without bleeding diathesis, chronic diarrhea, and orthostatic acrocyanosis. Here, we describe a case of ethylmalonic encephalopathy with late onset neurologic symptoms and a confusing family history of two deceased brothers with the wrong suspicion of short chain acyl-CoA dehydrogenase deficiency.
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Affiliation(s)
- Fatma Derya Bulut
- Department of Pediatric Metabolism and Nutrition, Çukurova University, Adana, Turkey.
| | - Deniz Kör
- Adana Numune Teaching and Research Hospital, Adana, Turkey
| | | | - Gülen Gül-Mert
- Adana Numune Teaching and Research Hospital, Adana, Turkey
| | - Sebile Kılavuz
- Department of Pediatric Metabolism and Nutrition, Çukurova University, Adana, Turkey
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Boyer M, Sowa M, Di Meo I, Eftekharian S, Steenari MR, Tiranti V, Abdenur JE. Response to medical and a novel dietary treatment in newborn screen identified patients with ethylmalonic encephalopathy. Mol Genet Metab 2018. [PMID: 29526615 DOI: 10.1016/j.ymgme.2018.02.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ethylmalonic encephalopathy (EE) is a devastating neurodegenerative disease caused by mutations in the ETHE1 gene critical for hydrogen sulfide (H2S) detoxification. Patients present in infancy with hypotonia, developmental delay, diarrhea, orthostatic acrocyanosis and petechiae. Biochemical findings include elevated C4, C5 acylcarnitines and lactic and ethylmalonic acid (EMA) in body fluids. Current treatment modalities include metronidazole and N-acetylcysteine (NAC) to lower the production and promote detoxification of toxic H2S. Patients are typically identified after the onset of clinical symptoms and there is limited information about long term response to treatment. We report the findings of two unrelated patients with EE, identified through newborn screening, who were managed with conventional treatment (NAC, metronidazole alternated with neomycin) and in patient 2, a novel dietary treatment restricting sulfur containing amino acids. Pathogenic mutations were confirmed in the ETHE1 gene (homozygous splice site mutation in patient 1, c.505 + 1G > A; compound heterozygous mutations in patient 2, c.131_132delAG + c.566delG). Both patients were started on metronidazole and NAC by 10 weeks of age and treated for 23 months. Patient 1 did not accept the metabolic formula due to palatability and parental refusal for gastrostomy tube placement. She demonstrated improved biomarkers (EMA, lactic acid and thiosulfate) and an attenuated clinical course. Patient 2 was started on a low methionine and cysteine diet at 8 months of age utilizing SOD Anamix® Early Years, (Nutricia). Baseline EMA levels were (642 mg/g Cr; n = 2) and decreased with medical treatment by 38% to a mean of 399 (n = 4, SD = 71, p 0.0013). With dietary treatment EMA levels were further reduced by 42% to a mean of 233 (n = 8, SD = 52, p 0.0030). Lactic acid, thiosulfates and clinical outcomes were also improved. Our long-term follow-up confirms previous reports of clinical improvement with NAC and metronidazole treatment. Additionally, our studies suggest that a diet restricted in sulfur-containing amino acids results in further improvement in clinical outcomes and biochemical markers.
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Affiliation(s)
- M Boyer
- Division of Metabolic Disorders, CHOC Children's Hospital, Orange, CA, United States
| | - M Sowa
- Division of Metabolic Disorders, CHOC Children's Hospital, Orange, CA, United States
| | - I Di Meo
- Unit of Molecular Neurogenetics, Foundation IRCCS Neurological Institute C. Besta, Milan, Italy
| | - S Eftekharian
- Division of Metabolic Disorders, CHOC Children's Hospital, Orange, CA, United States
| | - M R Steenari
- Division of Pediatric Neurology, CHOC Children's Hospital, Orange, CA, United States; Department of Pediatrics, University of California-Irvine, Orange, CA, United States
| | - V Tiranti
- Unit of Molecular Neurogenetics, Foundation IRCCS Neurological Institute C. Besta, Milan, Italy
| | - J E Abdenur
- Division of Metabolic Disorders, CHOC Children's Hospital, Orange, CA, United States; Department of Pediatrics, University of California-Irvine, Orange, CA, United States.
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Lehmann D, McFarland R. Overview of Approaches to Mitochondrial Disease Therapy. JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2018. [DOI: 10.1177/2326409817752960] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Diana Lehmann
- Wellcome Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Neurology, University of Halle-Wittenberg, Halle/Saale, Germany
| | - Robert McFarland
- Wellcome Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
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Toward a therapy for mitochondrial disease. Biochem Soc Trans 2017; 44:1483-1490. [PMID: 27911730 PMCID: PMC5095900 DOI: 10.1042/bst20160085] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/14/2016] [Accepted: 06/28/2016] [Indexed: 01/08/2023]
Abstract
Mitochondrial disorders are a group of genetic diseases affecting the energy-converting process of oxidative phosphorylation. The extreme variability of symptoms, organ involvement, and clinical course represent a challenge to the development of effective therapeutic interventions. However, new possibilities have recently been emerging from studies in model organisms and awaiting verification in humans. I will discuss here the most promising experimental approaches and the challenges we face to translate them into the clinics. The current clinical trials will also be briefly reviewed.
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45
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Mc Kiernan PJ. Recent advances in liver transplantation for metabolic disease. J Inherit Metab Dis 2017; 40:491-495. [PMID: 28168361 DOI: 10.1007/s10545-017-0020-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 01/18/2017] [Accepted: 01/23/2017] [Indexed: 02/07/2023]
Abstract
The indications and outcomes of liver transplantation for metabolic disease have been reviewed recently and this short review concentrates on recent developments and advances. Recently recognized metabolic causes of acute liver failure are reviewed and their implications for transplantation discussed. Newly described indications for liver transplantation in systemic metabolic diseases are described and an update is given on the role of auxiliary and domino liver transplantation.
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MESH Headings
- Amino Acid Metabolism, Inborn Errors/genetics
- Amino Acid Metabolism, Inborn Errors/surgery
- Animals
- Brain Diseases, Metabolic, Inborn/genetics
- Brain Diseases, Metabolic, Inborn/surgery
- Diabetes Mellitus, Type 1/genetics
- Diabetes Mellitus, Type 1/surgery
- Enzyme Replacement Therapy
- Epiphyses/abnormalities
- Epiphyses/surgery
- Glycine N-Methyltransferase/deficiency
- Glycine N-Methyltransferase/genetics
- Humans
- Intestinal Pseudo-Obstruction/genetics
- Intestinal Pseudo-Obstruction/surgery
- Liver Failure, Acute/surgery
- Liver Neoplasms/surgery
- Liver Transplantation/trends
- Metabolic Diseases/surgery
- Mitochondrial Encephalomyopathies/genetics
- Mitochondrial Encephalomyopathies/surgery
- Muscular Dystrophy, Oculopharyngeal
- Neoplasm Proteins/genetics
- Ophthalmoplegia/congenital
- Osteochondrodysplasias/genetics
- Osteochondrodysplasias/surgery
- Purpura/genetics
- Purpura/surgery
- Refsum Disease, Infantile/genetics
- Refsum Disease, Infantile/surgery
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Affiliation(s)
- P J Mc Kiernan
- Division of Gastroenterology/Hepatology/Nutrition Children's Hospital of Pittsburgh of UPMC, Pittsburgh Liver Research Centre, University of Pitttsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
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Kılıç M, Dedeoğlu Ö, Göçmen R, Kesici S, Yüksel D. Successful treatment of a patient with ethylmalonic encephalopathy by intravenous N-acetylcysteine. Metab Brain Dis 2017; 32:293-296. [PMID: 27830356 DOI: 10.1007/s11011-016-9928-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 11/01/2016] [Indexed: 12/28/2022]
Abstract
Ethylmalonic encephalopathy (EE) is an autosomal recessive devastating metabolic disorder affecting the brain, gastrointestinal tract, peripheral vessels and rarely the other vascular organs. We report a 10-month-old girl who presented as a meningococcemia clinic but later diagnosed ethylmalonic encephalopathy. Molecular analyses revealed a homozygous c.554 T > G; p. L185R mutation in ETHE1 gene. She was only partially benefited from riboflavine, coenzyme Q10, metronidazole, N-acetylcysteine and symptomatic treatment and discharged from hospital with the sequela of oxygene dependance and developmental delay. We observed N-acetylcysteine 100 mg/kg/day intravenous infusion theraphy may be the most important drug especially in comatous EE patients.
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Affiliation(s)
- Mustafa Kılıç
- Metabolism Unit, Sami Ulus Children Hospital, Babur cad. No: 44 Altındağ, 06080, Ankara, Turkey.
| | - Özge Dedeoğlu
- Pediatric Neurology Unit, Sami Ulus Children Hospital, Ankara, Turkey
| | - Rahşan Göçmen
- Deparment of Radiology, Hacettepe University, Ankara, Turkey
| | - Selman Kesici
- Pediatric Intensive Care Unit, Sami Ulus Children Hospital, Ankara, Turkey
| | - Deniz Yüksel
- Pediatric Neurology Unit, Sami Ulus Children Hospital, Ankara, Turkey
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Distelmaier F, Haack TB, Wortmann SB, Mayr JA, Prokisch H. Treatable mitochondrial diseases: cofactor metabolism and beyond. Brain 2016; 140:e11. [DOI: 10.1093/brain/aww303] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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48
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Abstract
Mitochondrial diseases are a group of genetic disorders that are characterized by defects in oxidative phosphorylation and caused by mutations in genes in the nuclear DNA (nDNA) and mitochondrial DNA (mtDNA) that encode structural mitochondrial proteins or proteins involved in mitochondrial function. Mitochondrial diseases are the most common group of inherited metabolic disorders and are among the most common forms of inherited neurological disorders. One of the challenges of mitochondrial diseases is the marked clinical variation seen in patients, which can delay diagnosis. However, advances in next-generation sequencing techniques have substantially improved diagnosis, particularly in children. Establishing a genetic diagnosis allows patients with mitochondrial diseases to have reproductive options, but this is more challenging for women with pathogenetic mtDNA mutations that are strictly maternally inherited. Recent advances in in vitro fertilization techniques, including mitochondrial donation, will offer a better reproductive choice for these women in the future. The treatment of patients with mitochondrial diseases remains a challenge, but guidelines are available to manage the complications of disease. Moreover, an increasing number of therapeutic options are being considered, and with the development of large cohorts of patients and biomarkers, several clinical trials are in progress.
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