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Yazıcı H, Ak G, Çelik MY, Erdem F, Yanbolu AY, Er E, Bozacı AE, Güvenç MS, Aykut A, Durmaz A, Canda E, Uçar SK, Çoker M. Experience with carnitine palmitoyltransferase II deficiency: diagnostic challenges in the myopathic form. J Pediatr Endocrinol Metab 2024; 37:33-41. [PMID: 37925743 DOI: 10.1515/jpem-2023-0298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/20/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVES Carnitine palmitoyltransferase II (CPT II) deficiency is an autosomal recessive disorder of long-chain fatty acid oxidation. Three clinical phenotypes, lethal neonatal form, severe infantile hepatocardiomuscular form, and myopathic form, have been described in CPT II deficiency. The myopathic form is usually mild and can manifest from infancy to adulthood, characterised by recurrent rhabdomyolysis episodes. The study aimed to investigate the clinical features, biochemical, histopathological, and genetic findings of 13 patients diagnosed with the myopathic form of CPT II deficiency at Ege University Hospital. METHODS A retrospective study was conducted with 13 patients with the myopathic form of CPT II deficiency. Our study considered demographic data, triggers of recurrent rhabdomyolysis attacks, biochemical metabolic screening, and molecular analysis. RESULTS Ten patients were examined for rhabdomyolysis of unknown causes. Two patients were diagnosed during family screening, and one was diagnosed during investigations due to increased liver function tests. Acylcarnitine profiles were normal in five patients during rhabdomyolysis. Genetic studies have identified a c.338C>T (p.Ser113Leu) variant homozygous in 10 patients. One patient showed a novel frameshift variant compound heterozygous with c.338C>T (p.Ser113Leu). CONCLUSIONS Plasma acylcarnitine analysis should be preferred as it is superior to DBS acylcarnitine analysis in diagnosing CPT II deficiency. Even if plasma acylcarnitine analysis is impossible, CPT2 gene analysis should be performed. Our study emphasizes that CPT II deficiency should be considered in the differential diagnosis of recurrent rhabdomyolysis, even if typical acylcarnitine elevation does not accompany it.
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Affiliation(s)
- Havva Yazıcı
- Department of Inborn Errors of Metabolism, Ege University Faculty of Medicine, Izmir, Türkiye
| | - Gunes Ak
- Department of Clinical Biochemistry, Ege University Faculty of Medicine, Izmir, Türkiye
| | - Merve Yoldas Çelik
- Department of Inborn Errors of Metabolism, Ege University Faculty of Medicine, Izmir, Türkiye
| | - Fehime Erdem
- Department of Inborn Errors of Metabolism, Ege University Faculty of Medicine, Izmir, Türkiye
| | - Ayse Yuksel Yanbolu
- Department of Inborn Errors of Metabolism, Ege University Faculty of Medicine, Izmir, Türkiye
| | - Esra Er
- Department of Inborn Errors of Metabolism, Ege University Faculty of Medicine, Izmir, Türkiye
| | - Ayse Ergül Bozacı
- Department of Inborn Errors of Metabolism, Ege University Faculty of Medicine, Izmir, Türkiye
| | - Merve Saka Güvenç
- Department of Medical Genetics, Tepecik Training and Research Hospital, Izmir, Türkiye
| | - Ayca Aykut
- Department of Medical Genetics, Ege University Faculty of Medicine, Izmir, Türkiye
| | - Asude Durmaz
- Department of Medical Genetics, Ege University Faculty of Medicine, Izmir, Türkiye
| | - Ebru Canda
- Department of Inborn Errors of Metabolism, Ege University Faculty of Medicine, Izmir, Türkiye
| | - Sema Kalkan Uçar
- Department of Inborn Errors of Metabolism, Ege University Faculty of Medicine, Izmir, Türkiye
| | - Mahmut Çoker
- Department of Inborn Errors of Metabolism, Ege University Faculty of Medicine, Izmir, Türkiye
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Arana C, Del Carpio J, Fayos L, Ars E, Ayasreh N, Guirado L, Bover J. Acute Renal Failure Secondary to an Unusual Familial Metabolic Myopathy. Nephron Clin Pract 2021; 145:199-204. [PMID: 33423032 DOI: 10.1159/000512666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/29/2020] [Indexed: 11/19/2022] Open
Abstract
Rhabdomyolysis is a major cause of acute kidney failure. The etiology is diverse, from full-blown crush syndrome to less frequent causes, such as metabolic myopathy. We describe the case of a 35-year-old male with a history of intermittent myalgias who was admitted to hospital with acute renal failure secondary to rhabdomyolysis. Moderate to intense diffuse uptake of technetium-99m was seen in soft tissues at scintigraphy. The diagnosis of metabolic myopathy was confirmed after careful workup and genetic testing.
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Affiliation(s)
- Carolt Arana
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, Spain,
| | - Jacqueline Del Carpio
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, Spain.,Department of Nephrology, Arnau de Villanova Hospital, Lleida, Spain
| | - Leonor Fayos
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, Spain
| | - Elisabet Ars
- Molecular Biology Laboratory, Fundació Puigvert, Instituto de Investigaciones Biomédicas Sant Pau (IIB-Sant Pau), Universitat Autònoma de Barcelona, REDinREN, Instituto de Investigación Carlos III, Barcelona, Spain
| | - Nadia Ayasreh
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, Spain
| | - Lluís Guirado
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, Spain
| | - Jordi Bover
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, Spain
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Abstract
Pediatric rhabdomyolysis is a common diagnosis that pediatricians need to be able to recognize because prompt treatment can prevent potential complications, such as acute kidney injury. The triggers for rhabdomyolysis are extensive, with viruses being the most common cause in pediatric patients. The pathophysiology behind rhabdomyolysis is complex and still being researched, but having a firm understanding of the cascade that results when muscle injury occurs is essential for proper management. Guidelines for managing pediatric rhabdomyolysis currently do not exist, but this article aims to review the available literature and give clinicians a general approach to aid in history taking, physical examination, diagnosis, acute management, follow-up, and prevention.
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Affiliation(s)
- Heidi S Szugye
- Cleveland Clinic Children's, Cleveland Clinic Lerner College of Medicine, Cleveland, OH
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Cortés R, Kleinsteuber K, Vargas CP, de Los Ángeles Avaria M. Rabdomiólisis metabólica: actualización. REVISTA MÉDICA CLÍNICA LAS CONDES 2018. [DOI: 10.1016/j.rmclc.2018.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Cucchiari D, Colombo I, Amato O, Podestà MA, Reggiani F, Valentino R, Faravelli I, Testolin S, Moggio M, Badalamenti S. Exertional rhabdomyolysis leading to acute kidney injury: when genetic defects are diagnosed in adult life. CEN Case Rep 2017; 7:62-65. [PMID: 29234986 DOI: 10.1007/s13730-017-0292-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 12/06/2017] [Indexed: 01/04/2023] Open
Abstract
Rhabdomyolysis is a common cause of acute kidney injury (AKI) that is usually triggered by trauma. However, less common causes of rhabdomyolysis may precipitate AKI as well, possibly representing a diagnostic challenge even for the experienced nephrologist. Genetic defects of muscle metabolism represent one of these causes and can be overlooked in adults, since these diseases usually become apparent in childhood. We present here a case in which an adult patient with severe exertional rhabdomyolysis leading to AKI was finally diagnosed with a genetic defect of lipid metabolism. A 41-year-old patient was brought to our attention because of AKI and pigmenturia after strenuous physical effort. At admission, the patient was over-hydrated with a weight increase of 3 kg in few days. Laboratory examination showed creatinine of 8.7 mg/dl, along with increased myoglobin and CPK. Urinalysis was positive for haemoglobin and proteins, while urinary sediment analysis did not demonstrate any red blood cell but rather "muddy-brown" casts and tubular cells. Urine output was forced and the patient completely recovered renal function. Genetic analysis later demonstrated the presence of a common mutation of Carnitine Palmitoyl-Transferase II (CPTII). When facing rhabdomyolysis of obscure origin, nephrologists must keep in mind the possibility that even adult patients may have a genetic defect of energy metabolism. In these cases, patients usually experience rhabdomyolysis during exertion, fasting, or infection. CPTII deficiency often has a subtle presentation and might be unrecognized until AKI develops. Therefore, it is important to consider a genetic defect of muscle metabolism even in adult patients when a history of rhabdomyolysis of unclear origin is present.
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Affiliation(s)
- David Cucchiari
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, 20089, Milan, Italy.
| | - Irene Colombo
- Neuromuscular Unit, Department of Neuroscience, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Ottavia Amato
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Manuel Alfredo Podestà
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Francesco Reggiani
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Rossella Valentino
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Irene Faravelli
- Neuromuscular Unit, Department of Neuroscience, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Silvia Testolin
- Neuromuscular Unit, Department of Neuroscience, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Maurizio Moggio
- Neuromuscular Unit, Department of Neuroscience, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Salvatore Badalamenti
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, 20089, Milan, Italy
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Du SH, Zhang F, Yu YG, Chen CX, Wang HJ, Li DR. Sudden infant death from neonate carnitine palmitoyl transferase II deficiency. Forensic Sci Int 2017; 278:e41-e44. [PMID: 28739175 DOI: 10.1016/j.forsciint.2017.06.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/18/2017] [Accepted: 06/19/2017] [Indexed: 12/30/2022]
Abstract
A full-term female baby born to parents who gave birth three years prior to a girl who survived only 31h postpartum died 36h after birth. An autopsy showed that the heart was markedly hypertrophic (32g). Microscopically, the myocardium, liver and kidney cells exhibited extensive vacuolar degeneration. Sudan III staining was positive in cardiac muscle, liver and kidney tissue. Tandem mass spectrometry analysis revealed that the deceased patient had a carnitine palmitoyl transferase II (CPT2) deficiency or a carnitine-acylcarnitine translocase deficiency. Genetic testing of the parents revealed heterozygous CPT2 mutations, indicating that their offspring would have a 25% chance of having a CPT2 deficiency. Therefore, we speculated that CPT2 deficiency might be the cause of death based on the results of staining, tandem mass spectrometry analysis and parental genetic testing.
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Affiliation(s)
- Si-Hao Du
- Department of Forensic Pathology, School of Forensic Medicine, Southern Medical University, Guangzhou, China.
| | - Fu Zhang
- Key Laboratory of Forensic Pathology, Ministry of Public Security, People's Republic of China, Guangzhou, China.
| | - Yan-Geng Yu
- Key Laboratory of Forensic Pathology, Ministry of Public Security, People's Republic of China, Guangzhou, China.
| | - Chuan-Xiang Chen
- Department of Forensic Pathology, School of Forensic Medicine, Southern Medical University, Guangzhou, China.
| | - Hui-Jun Wang
- Department of Forensic Pathology, School of Forensic Medicine, Southern Medical University, Guangzhou, China.
| | - Dong-Ri Li
- Department of Forensic Pathology, School of Forensic Medicine, Southern Medical University, Guangzhou, China.
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Melek E, Bulut FD, Atmış B, Yılmaz BŞ, Bayazıt AK, Mungan NÖ. An ignored cause of red urine in children: rhabdomyolysis due to carnitine palmitoyltransferase II (CPT-II) deficiency. J Pediatr Endocrinol Metab 2017; 30:237-239. [PMID: 28085674 DOI: 10.1515/jpem-2016-0324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 11/17/2016] [Indexed: 11/15/2022]
Abstract
Carnitine palmitoyltransferase II (CPT-II) deficiency is an autosomal recessively inherited disorder involving the β-oxidation of long-chain fatty acids, which leads to rhabdomyolysis and subsequent acute renal failure. The clinical phenotype varies from a severe infantile form to a milder muscle form. Here, we report a 9-year-old boy referred to our hospital for the investigation of hematuria with a 2-day history of dark urine and malaise. As no erythrocytes in the microscopic examination of the urine and hemoglobinuria were present, myoglobinuria due to rhabdomyolysis was the most probable cause of dark urine. After excluding the other causes of rhabdomyolysis, with the help of metabolic investigations, the patient was suspected to have CPT-II deficiency, the most common cause of metabolic rhabdomyolysis. Our aim in presenting this case is to emphasize considering rhabdomyolysis in the differential diagnosis of dark urine in order to prevent recurrent rhabdomyolysis and renal injury.
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Meng FY, Liu XR, Fu Q. [Acute renal failure caused by rhabdomyolysis in children: a clinical analysis of 26 cases]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:193-197. [PMID: 28202119 PMCID: PMC7389469 DOI: 10.7499/j.issn.1008-8830.2017.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 11/27/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To investigate the clinical features and prognosis of acute renal failure (ARF) caused by rhabdomyolysis (RM) in children. METHODS A retrospective analysis was performed for the clinical data, laboratory examination, and prognosis of 26 RM children with ARF. RESULTS The causes for all 26 RM children with ARF were non-traumatic diseases, and the three most common causes were infection (69%), diabetes (12%), and metabolic disease (8%). In the RM children with ARF, the five most frequent clinical manifestations were fever (69%), multiple organ dysfunction syndrome (69%), convulsion (46%), oliguria or anuria (35%), and tea-colored urine (27%). All 26 children had a serum creatine kinase (CK) level of >1 000 IU/L, among whom 26 had increased aspartate aminotransferase, 25 had increased alanine aminotransferase, 25 had increased creatine kinase isoenzyme, and 23 had increased lactate dehydrogenase. Serum myoglobin (Mb) was measured in 22 children and was found to increase in all these children. The mean time for CK to decrease to below 1 000 IU/L was 10±5 d. There was no significant difference in the time to CK recovery between the 10 children who were treated with conventional treatment as well as continuous venous-venous hemofiltration and those who were not treated with blood purification (P>0.05). Of all 26 RM children with ARF, 7 were withdrawn from the treatment, and 19 had normal renal function after treatment. CONCLUSIONS ARF and multiple organ dysfunction syndrome are major complications in RM children. The major primary disease for RM children with ARF is infectious disease. CK is the major marker for the diagnosis of RM. Early diagnosis and appropriate treatment may reverse ARF and improve prognosis.
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Affiliation(s)
- Fan-Ying Meng
- Department of Nephrology, Beijing Children's Hospital Affilicated to Capital Medical University, Beijing 100045, China.
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Yoshizawa T, Omori K, Takeuchi I, Miyoshi Y, Kido H, Takahashi E, Jitsuiki K, Ishikawa K, Ohsaka H, Sugita M, Yanagawa Y. Heat stroke with bimodal rhabdomyolysis: a case report and review of the literature. J Intensive Care 2016; 4:71. [PMID: 27980788 PMCID: PMC5134258 DOI: 10.1186/s40560-016-0193-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 11/19/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Severe heat stroke tends to be complicated with rhabdomyolysis, especially in patients with exertional heat stroke. Rhabdomyolysis usually occurs in the acute phase of heat stroke. We herein report a case of heat stroke in a patient who experienced bimodal rhabdomyolysis in the acute and recovery phases. CASE PRESENTATION A 34-year-old male patient was found lying unconscious on the road after participating in a half marathon in the spring. It was a sunny day with a maximum temperature of 24.2 °C. His medical and family history was unremarkable. Upon arrival, his Glasgow Coma Scale score was 10. However, the patient's marked restlessness and confusion returned. A sedative was administered and tracheal intubation was performed. On the second day of hospitalization, a blood analysis was compatible with a diagnosis of acute hepatic failure; thus, he received fresh frozen plasma and a platelet transfusion was performed, following plasma exchange and continuous hemodiafiltration. The patient's creatinine phosphokinesis (CPK) level increased to 8832 IU/L on the fifth day of hospitalization and then showed a tendency to transiently decrease. The patient was extubated on the eighth day of hospitalization after the improvement of his laboratory data. From the ninth day of hospitalization, gradual rehabilitation was initiated. However, he felt pain in both legs and his CPK level increased again. Despite the cessation of all drugs and rehabilitation, his CPK level increased to 105,945 IU/L on the 15th day of hospitalization. Fortunately, his CPK level decreased with a fluid infusion. The patient's rehabilitation was restarted after his CPK level fell to <10,000 IU/L. On the 31st day of hospitalization, his CK level decreased to 623 IU/L and he was discharged on foot. Later, a genetic analysis revealed that he had a thermolabile genetic phenotype of carnitine palmitoyltransferase II (CPT II). CONCLUSIONS Physicians should pay special attention to the stress of rehabilitation exercises, which may cause collapsed muscles that are injured by severe heat stroke to repeatedly flare up.
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Affiliation(s)
- Toshihiko Yoshizawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Tokyo, Japan
| | - Kazuhiko Omori
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Tokyo, Japan
| | - Ikuto Takeuchi
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Tokyo, Japan
| | - Yuto Miyoshi
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Tokyo, Japan
| | | | | | - Kei Jitsuiki
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Tokyo, Japan
| | - Kouhei Ishikawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Tokyo, Japan
| | - Hiromichi Ohsaka
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Tokyo, Japan
| | | | - Youichi Yanagawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Tokyo, Japan
- 1129 Nagaoka, Izunokuni City, Shizuoka 410-2295 Japan
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