1
|
Tsykunova G, Kristensen E, Stray-Pedersen A, Bruserud Ø, Sørensen IW, Bruserud Ø, Tvedt THA. Adult presentation of ornithine transcarbamylase deficiency: a possible cause of hyperammonemia after high-dose chemotherapy and stem cell transplantation. Hematology 2023; 28:2265187. [PMID: 38078487 DOI: 10.1080/16078454.2023.2265187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 09/26/2023] [Indexed: 12/18/2023] Open
Abstract
Hyperammonemia is a rare and often fatal complication following the conditioning therapy in autologous and allogeneic stem cell transplant recipients. It is characterized by anorexia, vomiting, lethargy and coma without any other apparent cause. The diagnosis is often delayed because symptoms can be subtle and ammonia is usually not included among the routine analyzes. Previous reports have not identified the molecular mechanisms behind hyperammonemia in stem cell transplant recipients. Urea cycle disorders (UCDs) are inborn errors of metabolism leading to hyperammonemia that usually presents in early childhood, whereas first presentation in adults is less common. Here we describe an adult woman with hyperammonemia following autologous stem cell transplantation for multiple myeloma. No apparent cause of hyperammonemia was identified, including portosystemic shunting, liver dysfunction or recent hyperammonemia-inducing chemotherapy. Hyperammonemia, normal blood glucose as well as anion gap and a previous history of two male newborns that died early after birth, prompted biochemical and genetic investigations for a UCD. A heterozygous variant in the X-linked gene encoding ornithine transcarbamylase (OTC) was identified and was regarded as a cause of UCD. The patient improved after treatment with nitrogen scavengers and high caloric intake according to a UCD protocol. This case report suggests that UCD should be considered as a possible cause of hyperammonemia following stem cell transplantation.
Collapse
Affiliation(s)
- Galina Tsykunova
- Department of Medicine Haukeland University Hospital, Bergen, Norway
| | - Erle Kristensen
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Asbjørg Stray-Pedersen
- The National Unit for Newborn Screening, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Øyvind Bruserud
- Department of Anesthesiology and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Ida Wiig Sørensen
- Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway
| | - Øystein Bruserud
- Department of Medicine Haukeland University Hospital, Bergen, Norway
- Section for Hematology, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Tor Henrik Anderson Tvedt
- Department of Medicine Haukeland University Hospital, Bergen, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
2
|
Ivnitsky JJ, Schäfer TV, Rejniuk VL, Vakunenkova OA. Secondary Dysfunction of the Intestinal Barrier in the Pathogenesis of Complications of Acute Poisoning. J EVOL BIOCHEM PHYS+ 2022; 58:1075-1098. [PMID: 36061072 PMCID: PMC9420239 DOI: 10.1134/s0022093022040123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 11/22/2022]
Abstract
The last decade has been marked by an exponential increase
in the number of publications on the physiological role of the normal
human gut microbiota. The idea of a symbiotic relationship between
the human organism and normal microbiota of its gastrointestinal
tract has been firmly established as an integral part of the current
biomedical paradigm. However, the type of this symbiosis varies
from mutualism to parasitism and depends on the functional state
of the host organism. Damage caused to the organism by external
agents can lead to the emergence of conditionally pathogenic properties
in the normal gut microbiota, mediated by humoral factors and affecting
the outcome of exogenous exposure. Among the substances produced
by symbiotic microbiota, there are an indefinite number of compounds
with systemic toxicity. Some occur in the intestinal chyme in potentially
lethal amounts in the case they enter the bloodstream quickly. The quick
entry of potential toxicants is prevented by the intestinal barrier
(IB), a set of structural elements separating the intestinal chyme
from the blood. Hypothetically, severe damage to the IB caused by
exogenous toxicants can trigger a leakage and subsequent systemic
redistribution of toxic substances of bacterial origin. Until recently,
the impact of such a redistribution on the outcome of acute exogenous
poisoning remained outside the view of toxicology. The present review
addresses causal relationships between the secondary dysfunction
of the IB and complications of acute poisoning. We characterize
acute systemic toxicity of such waste products of the normal gut microflora
as ammonia and endotoxins, and demonstrate their involvement in
the formation of such complications of acute poisoning as shock,
sepsis, cerebral insufficiency and secondary lung injuries. The
principles of assessing the functional state of the IB and the approaches
to its protection in acute poisoning are briefly considered.
Collapse
Affiliation(s)
- Ju. Ju. Ivnitsky
- Golikov Research Clinical Center of Toxicology, Federal Medical Biological Agency, St. Petersburg, Russia
| | - T. V. Schäfer
- State Scientific Research Test Institute of Military Medicine, Ministry of Defense of the Russian Federation, St. Petersburg, Russia
| | - V. L. Rejniuk
- Golikov Research Clinical Center of Toxicology, Federal Medical Biological Agency, St. Petersburg, Russia
| | - O. A. Vakunenkova
- Golikov Research Clinical Center of Toxicology, Federal Medical Biological Agency, St. Petersburg, Russia
| |
Collapse
|
3
|
Kamel AY, Emtiazjoo AM, Adkins L, Shahmohammadi A, Alnuaimat H, Pelaez A, Machuca T, Pipkin M, Lee HW, Weiner ID, Chandrashekaran S. Hyperammonemia After Lung Transplantation: Systematic Review and a Mini Case Series. Transpl Int 2022; 35:10433. [PMID: 35620675 PMCID: PMC9128545 DOI: 10.3389/ti.2022.10433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/18/2022] [Indexed: 11/21/2022]
Abstract
Background: Hyperammonemia after lung transplantation (HALT) is a rare but serious complication with high mortality. This systematic review delineates possible etiologies of HALT and highlights successful strategies used to manage this fatal complication. Methods: Seven biomedical databases and grey literature sources were searched using keywords relevant to hyperammonemia and lung transplantation for publications between 1995 and 2020. Additionally, we retrospectively analyzed HALT cases managed at our institution between January 2016 and August 2018. Results: The systematic review resulted in 18 studies with 40 individual cases. The mean peak ammonia level was 769 μmol/L at a mean of 14.1 days post-transplant. The mortality due to HALT was 57.5%. In our cohort of 120 lung transplants performed, four cases of HALT were identified. The mean peak ammonia level was 180.5 μmol/L at a mean of 11 days after transplantation. HALT in all four patients was successfully treated using a multimodal approach with an overall mortality of 25%. Conclusion: The incidence of HALT (3.3%) in our institution is comparable to prior reports. Nonetheless, ammonia levels in our cohort were not as high as previously reported and peaked earlier. We attributed these significant differences to early recognition and prompt institution of multimodal treatment approach.
Collapse
Affiliation(s)
- Amir Y. Kamel
- Department of Pharmacy, UF Health Shands Hospital, College of Pharmacy, University of Florida, Gainesville, FL, United States
- *Correspondence: Amir Y. Kamel,
| | - Amir M. Emtiazjoo
- Division of Pulmonary, Critical Care and Sleep Medicine, UF Lung Transplant Program, College of Medicine, University of Florida Health Hospital, Gainesville, FL, United States
| | - Lauren Adkins
- College of Pharmacy Liaison Librarian, Health Science Center Libraries, Gainesville, FL, United States
| | - Abbas Shahmohammadi
- Division of Pulmonary, Critical Care and Sleep Medicine, UF Lung Transplant Program, College of Medicine, University of Florida Health Hospital, Gainesville, FL, United States
| | - Hassan Alnuaimat
- Division of Pulmonary, Critical Care and Sleep Medicine, UF Lung Transplant Program, College of Medicine, University of Florida Health Hospital, Gainesville, FL, United States
| | - Andres Pelaez
- Division of Pulmonary, Critical Care and Sleep Medicine, UF Lung Transplant Program, College of Medicine, University of Florida Health Hospital, Gainesville, FL, United States
| | - Tiago Machuca
- Division of Cardiothoracic Surgery, UF Lung Transplant Program, University of Florida Health Hospital, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Mauricio Pipkin
- Division of Cardiothoracic Surgery, UF Lung Transplant Program, University of Florida Health Hospital, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Hyun-wook Lee
- Division of Nephrology, Hypertension and Renal Transplantation, College of Medicine, University of Florida, Gainesville, FL, United States
| | - I. David Weiner
- Division of Nephrology, Hypertension and Renal Transplantation, College of Medicine, University of Florida, Gainesville, FL, United States
- North Florida/South Georgia Veterans Health System, Gainesville, FL, United States
| | - Satish Chandrashekaran
- Division of Pulmonary, Critical Care and Sleep Medicine, UF Lung Transplant Program, College of Medicine, University of Florida Health Hospital, Gainesville, FL, United States
| |
Collapse
|
4
|
Fleming D, Cunningham SA, Patel R. Contribution of Uremia to Ureaplasma-Induced Hyperammonemia. Microbiol Spectr 2022; 10:e0194221. [PMID: 35171026 PMCID: PMC8849080 DOI: 10.1128/spectrum.01942-21] [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: 10/19/2021] [Accepted: 01/16/2022] [Indexed: 12/14/2022] Open
Abstract
Lung transplant recipients (LTRs) are vulnerable to hyperammonemia syndrome (HS) in the early postoperative period, a condition typically unresponsive to nonantibiotic interventions. HS in LTRs is strongly correlated with Ureaplasma infection of the respiratory tract, although it is not well understood what makes LTRs preferentially susceptible to HS compared to other immunocompromised hosts. Ureaplasma species harbor highly active ureases, and postoperative LTRs commonly experience uremia. We hypothesized that uremia could be a potentiating comorbidity, providing increased substrate for ureaplasmal ureases. Using a novel dialyzed flow system, the ammonia-producing capacities of four isolates of Ureaplasma parvum and six isolates of Ureaplasma urealyticum in media formulations relating to normal and uremic host conditions were tested. For all isolates, growth under simulated uremic conditions resulted in increased ammonia production over 24 h, despite similar endpoint bacterial quantities. Further, transcripts of ureC (from the ureaplasmal urease gene cluster) from U. urealyticum IDRL-10763 and ATCC-27816 rose at similar rates under uremic and nonuremic conditions, with similar endpoint populations under the two conditions (despite markedly increased ammonia concentrations under uremic conditions), indicating that the difference in ammonia production by these isolates is due to increased urease activity, not expression. Lastly, uremic mice infected with an Escherichia coli strain harboring a U. urealyticum serovar 8 gene cluster exhibited higher blood ammonia levels compared to nonuremic mice infected with the same strain. Taken together, these data show that U. urealyticum and U. parvum produce more ammonia under uremic conditions compared to nonuremic conditions. This implies that uremia is a plausible contributing factor to Ureaplasma-induced HS in LTRs. IMPORTANCE Ureaplasma-induced hyperammonemia syndrome is a deadly complication affecting around 4% of lung transplant recipients and, to a lesser extent, other solid organ transplant patients. Understanding the underlying mechanisms will inform patient management, potentially decreasing mortality and morbidity. Here, it is shown that uremia is a plausible contributing factor to the pathophysiology of the condition.
Collapse
Affiliation(s)
- Derek Fleming
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Scott A. Cunningham
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
5
|
Fleming D, Karau M, Patel R. A novel bioreactor for the stable growth of Ureaplasma parvum and Ureaplasma urealyticum. J Microbiol Methods 2021; 181:106131. [PMID: 33385441 PMCID: PMC7870580 DOI: 10.1016/j.mimet.2020.106131] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/20/2020] [Accepted: 12/21/2020] [Indexed: 11/25/2022]
Abstract
Ureaplasma species, including Ureaplasma parvum and Ureaplasma urealyticum, are challenging to culture and maintain. Here, we describe a novel bioreactor for growing high-titer liquid Ureaplasma cultures in a stable manner.
Collapse
Affiliation(s)
- Derek Fleming
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America
| | - Melissa Karau
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America; Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, United States of America.
| |
Collapse
|
6
|
Hyperammonemia as a Manifestation of Mycobacterium tilburgii Infection. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2018. [DOI: 10.1097/ipc.0000000000000586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
7
|
Graetz R, Meyer R, Shehab K, Katsanis E. Successful resolution of hyperammonemia following hematopoietic cell transplantation with directed treatment of Ureaplasma parvum infection. Transpl Infect Dis 2018; 20:e12839. [PMID: 29359847 DOI: 10.1111/tid.12839] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 08/07/2017] [Accepted: 09/17/2017] [Indexed: 11/29/2022]
Abstract
Hyperammonemia following hematopoietic cell transplantation (HCT) has been characterized as idiopathic and is associated with a very high mortality. A causal relationship between Ureaplasma infection and hyperammonemia in immunocompromised lung transplant recipients has recently been described. We document the first case of hyperammonemia following HCT associated with Ureaplasma parvum. The initiation of appropriate antibiotics resulted in rapid resolution of hyperammonemic encephalopathy and eradication of the implicating organism.
Collapse
Affiliation(s)
- Riley Graetz
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA.,Banner University Medical Center, Tucson, AZ, USA
| | - Robyn Meyer
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA.,Banner University Medical Center, Tucson, AZ, USA
| | - Kareem Shehab
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA.,Banner University Medical Center, Tucson, AZ, USA
| | - Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA.,Banner University Medical Center, Tucson, AZ, USA.,University of Arizona Cancer Center, Tucson, AZ, USA
| |
Collapse
|
8
|
Ureaplasma parvum causes hyperammonemia in a pharmacologically immunocompromised murine model. Eur J Clin Microbiol Infect Dis 2016; 36:517-522. [PMID: 27796644 DOI: 10.1007/s10096-016-2827-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 10/17/2016] [Indexed: 02/05/2023]
Abstract
A relationship between hyperammonemia and Ureaplasma infection has been shown in lung transplant recipients. We have demonstrated that Ureaplasma urealyticum causes hyperammonemia in a novel immunocompromised murine model. Herein, we determined whether Ureaplasma parvum can do the same. Male C3H mice were given mycophenolate mofetil, tacrolimus, and prednisone for 7 days, and then challenged with U. parvum intratracheally (IT) and/or intraperitoneally (IP), while continuing immunosuppression over 6 days. Plasma ammonia concentrations were determined and compared using Wilcoxon rank-sum tests. Plasma ammonia concentrations of immunosuppressed mice challenged IT/IP with spent broth (median, 188 μmol/L; range, 102-340 μmol/L) were similar to those of normal (median, 226 μmol/L; range, 154-284 μmol/L, p > 0.05), uninfected immunosuppressed (median, 231 μmol/L; range, 122-340 μmol/L, p > 0.05), and U. parvum IT/IP challenged immunocompetent (median, 226 μmol/L; range, 130-330 μmol/L, p > 0.05) mice. Immunosuppressed mice challenged with U. parvum IT/IP (median 343 μmol/L; range 136-1,000 μmol/L) or IP (median 307 μmol/L; range 132-692 μmol/L) had higher plasma ammonia concentrations than those challenged IT/IP with spent broth (p < 0.001). U. parvum can cause hyperammonemia in pharmacologically immunocompromised mice.
Collapse
|