1
|
Denk CH, Kunzmann J, Maieron A, Wöhrer A, Quinot V, Oberndorfer S. Histopathological examination of characteristic brain MRI findings in acute hyperammonemic encephalopathy: A case report and review of the literature. Neuroradiol J 2023:19714009231212370. [PMID: 37915221 DOI: 10.1177/19714009231212370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
INTRODUCTION Acute hyperammonemic encephalopathy is associated with distinct brain MRI findings, namely, hyperintensity in T2-weighted sequences as well as restricted diffusion in diffusion-weighted imaging with accentuation in the insular cortex and cingulate gyrus. The pathophysiology and the histopathological correlates of these characteristic MRI findings are largely unknown. CASE REPORT We present a 57-year-old male with a history of chronic alcohol abuse, liver cirrhosis and portal hypertension, and a clinical syndrome (variceal bleeding, depression of consciousness, seizures), elevated plasma ammonia levels, and characteristic brain MRI abnormalities suggestive of acute hyperammonemic encephalopathy. A postmortem histopathological examination revealed extensive hypoxic ischemic encephalopathy without evidence for metabolic encephalopathy. No episodes of prolonged cerebral hypoxemia were documented throughout the course of the disease. We conducted a review of the literature, which exhibited no reports of hyperammonemic encephalopathy in association with characteristic brain MRI findings and a consecutive histopathological examination. CONCLUSION This is the first report of a patient with acute hyperammonemic encephalopathy together with characteristic brain MRI findings and a histopathological correlation. Although characteristic MRI findings of acute hyperammonemic encephalopathy were present, a histopathological examination revealed only hypoxic pathology without signs of metabolic encephalopathy.
Collapse
Affiliation(s)
- C H Denk
- Department of Neurology, University Hospital St. Pölten, Karl Landsteiner Private University of Health Sciences (KLPU), Austria
| | - J Kunzmann
- Department of Radiology, University Hospital St. Pölten, Karl Landsteiner Private University of Health Sciences (KLPU), Austria
| | - A Maieron
- Department of Gastroenterology, University Hospital St. Pölten, Karl Landsteiner Private University of Health Sciences (KLPU), Austria
| | - A Wöhrer
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Austria
| | - V Quinot
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Austria
| | - S Oberndorfer
- Department of Neurology, University Hospital St. Pölten, Karl Landsteiner Private University of Health Sciences (KLPU), Austria
- Karl Landsteiner Institute for Clinical Neurology and Neuropsychology, Austria
| |
Collapse
|
2
|
A complex case of delayed diagnosis of ornithine transcarbamylase deficiency in an adult patient with multiple comorbidities. Mol Genet Metab Rep 2022; 33:100916. [PMID: 36620385 PMCID: PMC9817481 DOI: 10.1016/j.ymgmr.2022.100916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 01/11/2023] Open
Abstract
We report the case of a medically complex African American adult female with ornithine transcarbamylase (OTC) deficiency diagnosed after lifelong protein aversion and new onset of chronic vomiting and abdominal pain with intermittent lethargy and confusion. Symptomatology was crucial to diagnosis as genetic testing did not identify any pathogenic variants in OTC; however, the patient's diagnosis was delayed despite her having longstanding symptoms of a urea cycle disorder (UCD). Her symptoms improved after treatment with a modified protein-restricted diet, long-term nitrogen-scavenger therapy, and supplemental L-citrulline. Adherence to her UCD management regimen remained a challenge due to her underlying frailty and other medical conditions, which included primary renal impairment (further exasperated by type 2 diabetes mellitus) and decreased left-ventricular function. She passed away 3 years after her OTC deficiency diagnosis due to complications of congestive heart failure. Her OTC deficiency did not have a major impact on her final illness, and appropriate OTC deficiency management was provided until the decision was made to withdraw medical care.
Collapse
Key Words
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- CT, computed tomography
- Comorbid conditions
- D20W, dextrose 20% in water
- ED, emergency department
- GPB, glycerol phenylbutyrate
- Hepatic encephalopathy
- IBW, ideal body weight
- IV, intravenous
- Late onset
- NAFLD, nonalcoholic fatty liver disease
- NG, nasogastric
- OTC, ornithine transcarbamylase
- Ornithine transcarbamylase deficiency
- UCD, urea cycle disorder
- Urea cycle disorder
- X-linked inheritance
Collapse
|
3
|
New Insight in Hyperinsulinism/Hyperammonemia Syndrome by Magnetic Resonance Imaging and Spectroscopy. Brain Sci 2022; 12:brainsci12030389. [PMID: 35326344 PMCID: PMC8946637 DOI: 10.3390/brainsci12030389] [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: 01/12/2022] [Revised: 02/21/2022] [Accepted: 03/07/2022] [Indexed: 11/16/2022] Open
Abstract
Hyperinsulinism/hyperammonemia syndrome (HI/HA) is an autosomal dominant disorder caused by monoallelic activating mutations in the glutamate dehydrogenase 1 (GLUD1) gene. While hyperinsulinism may be explained by a reduction in the allosteric inhibition of GLUD1, the pathogenesis of HA in HI/HA remains uncertain; interestingly, HA in the HI/HA syndrome is not associated with acute hyperammonemic intoxication events. We obtained a brain magnetic resonance (MR) in a woman with HI/HA syndrome with chronic asymptomatic HA. On MR spectroscopy, choline and myoinositol were decreased as in other HA disorders. In contrast, distinct from other HA disorders, combined glutamate and glutamine levels were normal (not increased). This observation suggests that brain biochemistry in HI/HA may differ from that of other HA disorders. In HI/HA, ammonia overproduction may come to the expense of glutamate levels, and this seems to prevent the condensation of ammonia with glutamate to produce glutamine that is typical of the other HA disorders. The absence of combined glutamate and glutamine elevation might be correlated to the absence of acute cerebral ammonia toxicity.
Collapse
|
4
|
Sen K, Whitehead M, Castillo Pinto C, Caldovic L, Gropman A. Fifteen years of urea cycle disorders brain research: Looking back, looking forward. Anal Biochem 2022; 636:114343. [PMID: 34637785 PMCID: PMC8671367 DOI: 10.1016/j.ab.2021.114343] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/13/2021] [Accepted: 08/17/2021] [Indexed: 01/03/2023]
Abstract
Urea cycle disorders (UCD) are inherited diseases resulting from deficiency in one of six enzymes or two carriers that are required to remove ammonia from the body. UCD may be associated with neurological damage encompassing a spectrum from asymptomatic/mild to severe encephalopathy, which results in most cases from Hyperammonemia (HA) and elevation of other neurotoxic intermediates of metabolism. Electroencephalography (EEG), Magnetic resonance imaging (MRI) and Proton Magnetic resonance spectroscopy (MRS) are noninvasive measures of brain function and structure that can be used during HA to guide management and provide prognostic information, in addition to being research tools to understand the pathophysiology of UCD associated brain injury. The Urea Cycle Rare disorders Consortium (UCDC) has been invested in research to understand the immediate and downstream effects of hyperammonemia (HA) on brain using electroencephalogram (EEG) and multimodal brain MRI to establish early patterns of brain injury and to track recovery and prognosis. This review highlights the evolving knowledge about the impact of UCD and HA in particular on neurological injury and recovery and use of EEG and MRI to study and evaluate prognostic factors for risk and recovery. It recognizes the work of others and discusses the UCDC's prior work and future research priorities.
Collapse
Affiliation(s)
- Kuntal Sen
- Division of Neurogenetics and Neurodevelopmental Pediatrics, Children's National Hospital, Washington D.C., United States
| | - Matthew Whitehead
- Division of Radiology, Children's National Hospital, Washington D.C., United States
| | | | - Ljubica Caldovic
- Childrens' Research Institute, Children's National Hospital, Washington D.C., United States
| | - Andrea Gropman
- Division of Neurogenetics and Neurodevelopmental Pediatrics, Children's National Hospital, Washington D.C., United States.
| |
Collapse
|
5
|
Redant S, Empain A, Mugisha A, Kamgang P, Attou R, Honoré PM, De Bels D. Management of late onset urea cycle disorders-a remaining challenge for the intensivist? Ann Intensive Care 2021; 11:2. [PMID: 33409766 PMCID: PMC7788146 DOI: 10.1186/s13613-020-00797-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 12/26/2020] [Indexed: 12/31/2022] Open
Abstract
Background Hyperammonemia caused by a disorder of the urea cycle is a rare cause of metabolic encephalopathy that may be underdiagnosed by the adult intensivists because of its rarity. Urea cycle disorders are autosomal recessive diseases except for ornithine transcarbamylase deficiency (OTCD) that is X-linked. Optimal treatment is crucial to improve prognosis. Main body We systematically reviewed cases reported in the literature on hyperammonemia in adulthood. We used the US National Library of Medicine Pubmed search engine since 2009. The two main causes are ornithine transcarbamylase deficiency followed by type II citrullinemia. Diagnosis by the intensivist remains very challenging therefore delaying treatment and putting patients at risk of fatal cerebral edema. Treatment consists in adapted nutrition, scavenging agents and dialysis. As adults are more susceptible to hyperammonemia, emergent hemodialysis is mandatory before referral to a reference center if ammonia levels are above 200 µmol/l as the risk of cerebral edema is then above 55%. Definitive therapy in urea cycle abnormalities is liver transplantation. Conclusion Awareness of urea cycle disorders in adults intensive care units can optimize early management and accordingly dramatically improve prognosis. By preventing hyperammonemia to induce brain edema and herniation leading to death.
Collapse
Affiliation(s)
- S Redant
- Department of Intensive Care, Université Libre de Bruxelles (ULB), CHU Brugmann-Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| | - A Empain
- Department of Metabolic Diseases, Hôpital universitaire des enfants reine Fabiola, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - A Mugisha
- Department of Intensive Care, Université Libre de Bruxelles (ULB), CHU Brugmann-Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| | - P Kamgang
- Department of Internal Medicine, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - R Attou
- Department of Intensive Care, Université Libre de Bruxelles (ULB), CHU Brugmann-Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| | - P M Honoré
- Department of Intensive Care, Université Libre de Bruxelles (ULB), CHU Brugmann-Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium.
| | - D De Bels
- Department of Intensive Care, Université Libre de Bruxelles (ULB), CHU Brugmann-Brugmann University Hospital, 4, Place Arthur Van Gehuchten, 1020, Brussels, Belgium
| |
Collapse
|
6
|
Nguyen HH, Khanh Nguyen N, Dung Vu C, Thu Huong Nguyen T, Nguyen NL. Late-Onset Ornithine Transcarbamylase Deficiency and Variable Phenotypes in Vietnamese Females With OTC Mutations. Front Pediatr 2020; 8:321. [PMID: 32793520 PMCID: PMC7390877 DOI: 10.3389/fped.2020.00321] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 05/18/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Ornithine transcarbamylase deficiency (OTCD) is an X- linked recessive disorder and the most common error of the urea cycle, caused by the mutations in the OTC gene. Due to X-inactivation, 15-20% of female carriers present symptoms of OTCD at late onset. Early diagnosis of OTCD by molecular analysis in females is highly desirable. The aim of the study was to identify the mutations in two unrelated Vietnamese girls suspected with OTCD and the carriers in their families for definitive diagnosis and proper counseling. Case Presentation: Two patients presented with an acute encephalopathy at the first admission. Biochemical tests revealed hyperammonemia, hyperlactatemia, elevated glutamine level, elevated transaminase, elevated urinary orotic and uracil acid levels, and disorder of prothrombin time. Brain magnetic resonance imaging indicated cerebral edema. Based on the clinical and laboratory results, the two patients were diagnosed with urea cycle disorders. Therefore, the two patients were managed by stopping feeding, with infused glucose, l-carnitine, l-arginine, and sodium benzoate, and with hemofiltration. The two patients were alert and recovered with normal blood ammonia levels after 72 h of treatment. The family history of patient 1 showed that her brother died at 4 days of age due to a coma and dyspnea, while her parents were asymptomatic. Variable phenotypes were observed in three generations of the patient 2's family, including asymptomatic (mother), affected female adults dying at the first symptom (grandmother and aunt), and affected males dying in the first week of life (uncle, cousin, and siblings). Whole-exome sequencing showed two mutations in the OTC gene, including one novel missense mutation, c.365A>T, in the patient 1 and one previously reported splicing mutation, c.717+1G>A, in the patient 2. The two mutations are evaluated as likely pathogenic and pathogenic, respectively, according to the recommendations of the American College of Medical Genetics and Genomics (ACMG). Genetic analyses in the families indicated the mothers were heterozygous. Conclusion: Clinical, biochemical, and molecular findings accurately diagnosed the two patients with late-onset OTCD. Our results explained the genetic causes and proposed the risk in the patients' families, which could be useful for genetic counseling and monitoring in prenatal diagnosis.
Collapse
Affiliation(s)
- Huy-Hoang Nguyen
- Institute of Genome Research, Vietnam Academy of Science and Technology (VAST), Hanoi, Vietnam
| | - Ngoc Khanh Nguyen
- Department of Endocrinology, Metabolism and Genetic, Center for Rare Diseases and Newborn Screening, Vietnam National Hospital of Pediatrics, Hanoi, Vietnam
| | - Chi Dung Vu
- Department of Endocrinology, Metabolism and Genetic, Center for Rare Diseases and Newborn Screening, Vietnam National Hospital of Pediatrics, Hanoi, Vietnam
| | - Thi Thu Huong Nguyen
- Institute of Genome Research, Vietnam Academy of Science and Technology (VAST), Hanoi, Vietnam.,Graduate University of Science and Technology, Vietnam Academy of Science and Technology (VAST), Hanoi, Vietnam
| | - Ngoc-Lan Nguyen
- Institute of Genome Research, Vietnam Academy of Science and Technology (VAST), Hanoi, Vietnam.,Graduate University of Science and Technology, Vietnam Academy of Science and Technology (VAST), Hanoi, Vietnam
| |
Collapse
|