The routine investigation of urinary organic acids in selected paediatric patients: results over a 2 1/2-year period

Application of electrospray tandem mass spectrometry to neonatal screening

For the past 30 years, neonatal screening programs have been performed largely by using the bacterial inhibition assays developed by Dr Robert Guthrie. These programs focused on a small number of diseases such as phenylketonuria and maple syrup urine disease and involved one test for each disease. During the same period many new diseases were discovered, such as organic acidemias and fatty acid oxidation defects, and they presented a diagnostic challenge to biochemical laboratories. Different mass spectrometric approaches have been the main tools for the diagnosis; however, each has its own limitation. Recently, electrospray tandem mass spectrometry (MS/MS) has provided an alternative automated high throughput, specific, and broad-spectrum approach to screening for a relatively large number of disorders, including those covered by bacterial inhibition assays tests. By using specific scan functions, a large number of amino acids and acylcarnitines in blood spots are quantified in 2 minutes analytical time. A new scan function is described here for quantification and screening for argininosuccinic acid in blood spots, which is a key metabolite in the diagnosis of argininosuccinase deficiency. We describe the results of a 3-year tandem MS/MS-based neonatal study that was performed in our newborn population. We screened 27,624 blood spots and identified 20 cases yielding a frequency of 1:1,381. No false-negative cases were identified, but several false-positive cases were eliminated by repeat analysis by MS/MS of blood or by other means. We also used MS/MS analysis of urine or blood either for confirmation of initial positive results or for follow-up of treatment, such as in glutaric acidemia, citrullinemia, argininosuccinase deficiency, and biopterin-dependent phenylketonuria.

Limitations of 3-phenylpropionylglycine in early screening for medium-chain acyl-coenzyme A dehydrogenase deficiency

Screening for medium-chain acyl-coenzyme A dehydrogenase (MCAD) deficiency by urinary 3-phenylpropionylglycine may not be reliable in early infancy because young infants are not colonized with adult-type colonic flora. In this study we delineated the microbes that produce 3-phenylpropionic acid, the precursor of 3-phenylpropionylglycine. We found that the use of some antibiotics may alter gut flora, thereby confounding this method of screening for MCAD deficiency.

Azelaic and pimelic acids: metabolic intermediates or artefacts?

Azelaic and pimelic acids are excreted in elevated amounts in urine in disorders of mitochondrial beta-oxidation and disorders of peroxisomal beta-oxidation, for which they are of significant diagnostic value. We have detected the presence of azelaic, pimelic and even-chain-length dicarboxylic acids (adipic, suberic and sebacic acids) arising artefactually as a result of storage of small sample volumes in plastic containers. Storage of samples for organic acid analysis in glass containers is recommended.

Chromatography of urinary indole derivatives

Latest strategies are discussed for the routine chromatographic analysis of clinically important indole derivatives in urine. Analysis of 5-hydroxyindoleacetic acid and, perhaps more importantly, serotonin and 5-hydroxytryptophan remains attractive in the screening for carcinoid tumours and their differentiation. Analyses of two precursors of the skin pigment eumelanin seem to be promising in the monitoring of treatment of malignant melanoma and screening for pigmentation disorders and gallstone formation. Studies on the clinical relevance of the determination of tetrahydro-beta-carbolines and melatonin-related indoles await routine application of chromatographic methods designed to take into consideration the relative instability of these compounds. Application of GC-MS, although confined to larger and/or governmental laboratories remains attractive as a way of improving the specificity of analyses and in establishing reference methods. As for HPLC, the recent development of chromatographic and detection methods for the concurrent determination of different clinically important and metabolically related compounds from the same sample, preferably by direct injection techniques, seems to be fruitful and should be continued.

Automated profiling of urinary organic acids by dual-column gas chromatography and gas chromatography/mass spectrometry

A multi-stage screening and identification scheme for the diagnosis of inborn errors in amino acid, fatty acid, carbohydrate and intermediary metabolism is described. The method is based on a computerized analysis of data obtained with dual-column gas chromatography/FID (GC/FID) and gas chromatography/mass spectrometry (GC/MS) profiling of urinary organic acids. It involves: (1) isolation of the compounds by solvent or solid-phase extraction; (2) conversion into trimethylsilyl (TMS) or TMS-oxime derivatives; (3) GC/FID analysis on SE-52 and OV-1701 capillary columns; (4) tentative identification by comparing the methylene unit (MU) values on both columns with a user-built library of reference compounds; (5) quantitative evaluation of the excretion profile; and (6) analysis by GC/MS of samples with an abnormal profile using an automated peak identification programme.

Routine gas chromatographic/mass spectrometric analysis of urinary organic acids. Results over a three-year period

Organic acidaemias are an important part of inborn errors of metabolism. The biochemical diagnosis is based on gas chromatographic/mass spectrometric identification of urinary organic acids. Since 1973 we have used gas chromatographic analysis of the methyl esters of urinary organic acids. Mass spectral identification was performed only when an abnormal gas chromatographic profile was suspected. In 1983 we introduced routine gas chromatographic/mass spectrometric analysis organic acids. More than 1500 urine samples from 1000 children have been analysed and we encountered more than 40 abnormal profiles: 18 classical organic acidaemias (propionic, methylmalonic, isovaleric, glutaric type I and 3-hydroxy-3-methyl glutaric acidaemias); 6 aminoacidopathies with excretion of branched chain keto acids (leucinosis) or succinylacetone (tyrosinosis type I); 14 massive dicarboxylic acidurias with excretion of suberyl and hexanoyl glycine and deficiency of the medium chain acyl CoA dehydrogenase in four patients. The use of gas chromatography/mass spectrometry routinely allows the identification of abnormal metabolites excreted in small amounts: beta-methyl-crotonyl glycine indicative of biotin deficiency: gamma-hydroxybutyric acid; and 3-methyl-glutaconic + 3-methy-glutaric acid is in a 3-methyl-glutaconic aciduria type II. Abnormal profiles due to metabolites of drugs as valproate, salicylate and barbiturate can be recognized immediately. This simple gas chromatographic/mas spectrometric system can lead to diagnosis, in one day, of rare but severe diseases needing a specific and early treatment.

Urinary organic acids in succinic semialdehyde dehydrogenase deficiency: evidence of alpha-oxidation of 4-hydroxybutyric acid, interaction of succinic semialdehyde with pyruvate dehydrogenase and possible secondary inhibition of mitochondrial beta-oxidation

In addition to the previously reported abnormalities, urine extracts from three cases of succinic semialdehyde dehydrogenase deficiency have shown consistently increased amounts of 2,4-dihydroxybutyric acid, and its lactone, and 3-hydroxypropionic acid, metabolites related to the alpha-oxidation of 4-hydroxybutyric acid. Threo- and erythro-4,5-dihydroxyhexanoic acids have also been identified for the first time and probably arise from the reaction of succinic semialdehyde with an intermediate in the pyruvate dehydrogenase pathway. Adipic acid excretion is also consistently raised, suggesting secondary interference with mitochondrial beta-oxidation. The presence of these metabolites could be a source of diagnostic confusion.

Glutaric aciduria type I misdiagnosed as Leigh's encephalopathy and cerebral palsy

Two cases are reported of boys who suffer epileptic seizures only after playing video games. It is suggested that the amount of time the patient spends in front of the screen before the seizure is important, and also that video games trigger electrocortical activity far more efficiently than either television or intermittent photic stimulation.

Biochemical investigations on a patient with a defect in cytosolic acetoacetyl-CoA thiolase, associated with mental retardation

A severely mentally retarded boy with two normal siblings was persistently found to excrete elevated amounts of 3-hydroxybutyrate and acetoacetate. Enzyme analysis in cultured fibroblasts revealed a probable deficiency in cytosolic acetoacetyl-CoA thiolase which was about half the control activity with normal mitochondrial thiolase activities. Treatment with reduced dietary fat was initiated and a rapid reduction of the ketosis to biochemical normality was demonstrated. Shortly after initiating dietary treatment he presented with severe gastrointestinal problems and the histological features of colitis cystica superficialis. This appeared to respond to intravenous hydrocortisone therapy with an apparent complete recovery.