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Chen ZQ, Yang RJ, Zhu CW, Li Y, Yan R, Wan JB. Chemical Isotope Labeling and Dual-Filtering Strategy for Comprehensive Profiling of Urinary Glucuronide Conjugates. Anal Chem 2024; 96:13576-13587. [PMID: 39102235 PMCID: PMC11339728 DOI: 10.1021/acs.analchem.4c02339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 07/26/2024] [Accepted: 07/29/2024] [Indexed: 08/06/2024]
Abstract
Glucuronidation, a crucial process in phase II metabolism, plays a vital role in the detoxification and elimination of endogenous substances and xenobiotics. A comprehensive and confident profiling of glucuronate-conjugated metabolites is imperative to understanding their roles in physiological and pathological processes. In this study, a chemical isotope labeling and dual-filtering strategy was developed for global profiling of glucuronide metabolites in biological samples. N,N-Dimethyl ethylenediamine (DMED-d0) and its deuterated counterpart DMED-d6 were used to label carboxylic acids through an amidation reaction. First, carboxyl-containing compounds were extracted based on a characteristic mass difference (Δm/z, 6.037 Da) observed in MS between light- and heavy-labeled metabolites (filter I). Subsequently, within the pool of carboxyl-containing compounds, glucuronides were identified using two pairs of diagnostic ions (m/z 247.1294/253.1665 and 229.1188/235.1559 for DMED-d0/DMED-d6-labeled glucuronides) originating from the fragmentation of the derivatized glucuronic acid group in MS/MS (filter II). Compared with non-derivatization, DEMD labeling significantly enhanced the detection sensitivity of glucuronides, as evidenced by a 3- to 55-fold decrease in limits of detection for representative standards. The strategy was applied to profiling glucuronide metabolites in urine samples from colorectal cancer (CRC) patients. A total of 685 features were screened as potential glucuronides, among which 181 were annotated, mainly including glucuronides derived from lipids, organic oxygen, and phenylpropanoids. Enzymatic biosynthesis was employed to accurately identify unknown glucuronides without standards, demonstrating the reliability of the dual-filtering strategy. Our strategy exhibits great potential for profiling the glucuronide metabolome with high coverage and confidence to reveal changes in CRC and other diseases.
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Affiliation(s)
- Zhi-Qiang Chen
- State
Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University
of Macau, Taipa Macao SAR, China
| | - Ru-Jie Yang
- State
Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University
of Macau, Taipa Macao SAR, China
| | - Chao-Wei Zhu
- Shenzhen
People’s Hospital, Shenzhen, Guangdong 518000, China
| | - Yang Li
- Shenzhen
People’s Hospital, Shenzhen, Guangdong 518000, China
| | - Ru Yan
- State
Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University
of Macau, Taipa Macao SAR, China
| | - Jian-Bo Wan
- State
Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University
of Macau, Taipa Macao SAR, China
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Shao X, Steiner R, Peterson AL. Newborn screening for lipid disorders. Curr Opin Lipidol 2024; 35:149-156. [PMID: 38408035 DOI: 10.1097/mol.0000000000000928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW Newborn screening is one of the most successful public health programs of the last century and offers unparalleled access to universal screening for a variety of metabolic and other disorders. Interest in development of newborn screening for lipid disorders has intensified in recent years. Screening newborns for lipid disorders has important implications for the health of the newborn as well as their relatives, and in the case of more common lipid disorders like familial hypercholesterolemia, could have important public health implications. RECENT FINDINGS Recent studies have demonstrated feasibility of measuring biomarkers for heterozygous familial hypercholesterolemia from newborn screening dried blood spot specimens. Another lipid disorder, cerebrotendinous xanthomatosis, is currently amenable to newborn screening utilizing currently available assays. New research in next-generation sequencing as a primary screen in newborns will also identify both common and rare lipid disorders in newborns. SUMMARY Historically, newborn screening for lipid disorders was not done for many reasons, but new research has developed testing methods that may successfully identify common and rare lipid disorders. This will impact the health of the newborn but could also impact family members and public health.
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Affiliation(s)
- Xiangqiang Shao
- Department of Pediatrics, Division of Genetics and Metabolism
| | - Robert Steiner
- Department of Pediatrics, Division of Genetics and Metabolism
| | - Amy L Peterson
- Department of Pediatrics, Division of Pediatric Cardiology, University of Wisconsin School of Medicine and Public Health. Madison, Wisconsin, USA
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Stenton SL, Campagna M, Philippakis A, O'Donnell-Luria A, Gelb MH. First-Tier Next Generation Sequencing for Newborn Screening: An Important Role for Biochemical Second-Tier Testing. GENETICS IN MEDICINE OPEN 2023; 1:100821. [PMID: 39238532 PMCID: PMC11377026 DOI: 10.1016/j.gimo.2023.100821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/07/2024]
Abstract
There is discussion of expanding newborn screening (NBS) through the use of genomic sequence data; yet, challenges remain in the interpretation of DNA variants. Population-level DNA variant databases are available, and it is possible to estimate the number of newborns who would be flagged as having a risk for a genetic disease (including rare variants of unknown significance, VUS) via next-generation sequencing (NGS) positive. Estimates of the number of newborns screened as NGS positive for monogenic recessive diseases were obtained by analysis of the Genome Aggregation Database (gnomAD). For a collection of diseases for which there is interest in NBS, we provided 2 estimates for the expected number of newborns screened as NGS positive. For a set of lysosomal storage diseases, we estimated that 100 to approximately 600 NGS screen positives would be found per disease per year in a large NBS laboratory (California), and this figure may be expected to rise to a limit of about 1000 if we account for the fact that gnomAD does not contain all worldwide variants. The number of positives would drop 2.5- to 10-fold if the 10 VUS with highest allele frequency were biochemically annotated as benign. It is proposed that a second-tier biochemical assay using the same dried blood spot could be carried out as a filter and as part of NBS to reduce the number of high-risk NGS positive newborns to a manageable number.
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Affiliation(s)
- Sarah L Stenton
- Broad Institute of MIT and Harvard, Cambridge, MA
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA
| | | | | | - Anne O'Donnell-Luria
- Broad Institute of MIT and Harvard, Cambridge, MA
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA
| | - Michael H Gelb
- Department of Chemistry, University of Washington, Seattle, WA
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Brlek P, Bulić L, Glavaš Weinberger D, Bošnjak J, Pavlović T, Tomić S, Krivdić Dupan Z, Borić I, Primorac D. Successful Treatment of a Rare Cholesterol Homeostasis Disorder Due to CYP27A1 Gene Mutation with Chenodeoxycholic Acid Therapy. Biomedicines 2023; 11:biomedicines11051430. [PMID: 37239101 DOI: 10.3390/biomedicines11051430] [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: 03/31/2023] [Revised: 05/05/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is a genetic disorder of the cholesterol metabolic pathway, most often associated with variants in the CYP27A1 gene. The dysregulation of cholesterol metabolism results in the accumulation of metabolites such as cholestanol, which has a predilection for neuronal tissue and tendons. The condition is treatable with chenodeoxycholic acid (CDCA), which halts the production of these metabolites. We present two adult brothers, without diagnosis, suffering from ataxia, general muscle weakness and cognitive deficits. Both brothers suffered from early onset cataracts, watery stools and thoracic kyphoscoliosis. Magnetic resonance imaging revealed hyperintense alterations in the central nervous system and intratendinous xanthomas in the Achilles tendons. A biochemical analysis showed elevated levels of cholestanol, lathosterol and 7-dehydrocholesterol. Their family history was negative for neurological and metabolic disorders. Genetic testing revealed a pathogenic CYP27A1 variant (c.1184+1G>A) in both brothers, confirming the diagnosis. The patients were started on CDCA therapy and have shown significant improvement at their follow-up examinations. Early diagnosis and treatment initiation in CTX patients is of great importance, as the significant reversal of disease progression can be achieved. For this reason, clinical genetic testing is necessary when it comes to patients with an onset of cataracts, chronic diarrhea, and neurological symptoms in early childhood.
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Affiliation(s)
- Petar Brlek
- St. Catherine Specialty Hospital, 10000 Zagreb, Croatia
| | - Luka Bulić
- St. Catherine Specialty Hospital, 10000 Zagreb, Croatia
| | | | | | - Tomislav Pavlović
- St. Catherine Specialty Hospital, 10000 Zagreb, Croatia
- Department of Health Studies, University of Split, 21000 Split, Croatia
- School of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
| | - Svetlana Tomić
- School of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- University Hospital Centre, 31000 Osijek, Croatia
| | - Zdravka Krivdić Dupan
- School of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- University Hospital Centre, 31000 Osijek, Croatia
| | - Igor Borić
- St. Catherine Specialty Hospital, 10000 Zagreb, Croatia
| | - Dragan Primorac
- St. Catherine Specialty Hospital, 10000 Zagreb, Croatia
- School of Medicine, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Medical School, University of Split, 21000 Split, Croatia
- Department of Biochemistry & Molecular Biology, The Pennsylvania State University, State College, PA 16802, USA
- The Henry C. Lee College of Criminal Justice and Forensic Sciences, University of New Haven, West Haven, CT 06516, USA
- Medical School REGIOMED, 96450 Coburg, Germany
- Medical School, University of Rijeka, 51000 Rijeka, Croatia
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia
- Medical School, University of Mostar, 88000 Mostar, Bosnia and Herzegovina
- National Forensic Sciences University, Gujarat 382007, India
- University Hospital Centre Zagreb, 10000 Zagreb, Croatia
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5
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Pramparo T, Steiner RD, Rodems S, Jenkinson C. Allelic prevalence and geographic distribution of cerebrotendinous xanthomatosis. Orphanet J Rare Dis 2023; 18:13. [PMID: 36650582 PMCID: PMC9843874 DOI: 10.1186/s13023-022-02578-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/20/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Cerebrotendinous xanthomatosis (CTX) is a rare recessive genetic disease characterized by disruption of bile acid synthesis due to inactivation of the CYP27A1 gene. Treatment is available in the form of bile acid replacement. CTX is likely underdiagnosed, and prevalence estimates based on case diagnosis are probably inaccurate. Large population-based genomic databases are a valuable resource to estimate prevalence of rare recessive diseases as an orthogonal unbiased approach building upon traditional epidemiological studies. METHODS We leveraged the Hardy-Weinberg principle and allele frequencies from gnomAD to calculate CTX prevalence. ClinVar and HGMD were used to identify high-confidence pathogenic missense variants and to calculate a disease-specific cutoff. Variant pathogenicity was also assessed by the VarSome implementation of the ACMG/AMP algorithm and the REVEL in silico predictor. RESULTS CTX prevalence estimates were highest in Asians (1:44,407-93,084) and lowest in the Finnish population (1:3,388,767). Intermediate estimates were found in Europeans, Americans, and Africans/African Americans (1:70,795-233,597). The REVEL-predicted pathogenic variants accounted for a greater increase in prevalence estimates for Europeans, Americans, and Africans/African Americans compared with Asians. We identified the most frequent alleles designated pathogenic in ClinVar (p.Gly472Ala, p.Arg395Cys), labeled pathogenic based on sequence consequence (p.Met1?), and predicted to be pathogenic by REVEL (p.Met383Lys, p.Arg448His) across populations. Also, we provide a prospective geographic map of estimated disease distribution based on CYP27A1 variation queries performed by healthcare providers from selected specialties. CONCLUSIONS Prevalence estimates calculated herein support and expand upon existing evidence indicating underdiagnosis of CTX, suggesting that improved detection strategies are needed. Increased awareness of CTX is important for early diagnosis, which is essential for patients as early treatment significantly slows or prevents disease progression.
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Affiliation(s)
- Tiziano Pramparo
- Travere Therapeutics, Inc., 3611 Valley Centre Dr Suite 300, San Diego, CA, 92130, USA.
| | - Robert D. Steiner
- grid.14003.360000 0001 2167 3675Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 USA
| | - Steve Rodems
- Travere Therapeutics, Inc., 3611 Valley Centre Dr Suite 300, San Diego, CA 92130 USA
| | - Celia Jenkinson
- Travere Therapeutics, Inc., 3611 Valley Centre Dr Suite 300, San Diego, CA 92130 USA
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Vaz FM, Jamal Y, Barto R, Gelb MH, DeBarber AE, Wevers RA, Nelen MR, Verrips A, Bootsma AH, Bouva MJ, Kleise N, van der Zee W, He T, Salomons GS, Huidekoper HH. Newborn screening for Cerebrotendinous Xanthomatosis: A retrospective biomarker study using both flow-injection and UPLC-MS/MS analysis in 20,000 newborns. Clin Chim Acta 2023; 539:170-174. [PMID: 36529270 PMCID: PMC10387442 DOI: 10.1016/j.cca.2022.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Cerebrotendinous Xanthomatosis (CTX) is a treatable disorder of bile acid synthesis caused by deficiency of 27-sterol hydroxylase -encoded by CYP27A1- leading to gastrointestinal and progressive neuropsychiatric symptoms. Biochemically, CTX is characterized by accumulation of the bile alcohol cholestanetetrol glucuronide (GlcA-tetrol) and the deficiency of tauro-chenodeoxycholic acid (t-CDCA) and tauro-trihydroxycholestanoic acid (t-THCA). MATERIALS AND METHODS To ascertain the feasibility of CTX newborn screening (NBS) we performed a study with deidentified Dutch dried blood spots using reagents and equipment that is frequently used in NBS laboratories. 20,076 deidentified newborn blood spots were subjected to flow-injection (FIA)-MS/MS and UPLC-MS/MS analysis to determine the concentration of GlcA-tetrol and calculate the GlcA-tetrol/t-CDCA and t-THCA/GlcA-tetrol ratios. RESULTS Using UPLC-MS/MS analysis both GlcA-tetrol concentration and/or metabolite ratios GlcA-tetrol/t-CDCA proved to be informative biomarkers; newborn DBS results did not overlap with those of the CTX patients. For FIA-MS/MS, GlcA-tetrol also was an excellent marker but when using the combination of the GlcA-tetrol/t-CDCA and t-THCA/GlcA-tetrol ratios also did not yield any screen positives. CONCLUSION Newborn screening for CTX using only metabolite ratios following the measurement of three CTX biomarkers is possible using either FIA-MS/MS or UPLC-MS/MS, which paves the way for introduction of CTX NBS.
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Affiliation(s)
- Frédéric M Vaz
- Amsterdam UMC Location University of Amsterdam, Departments of Clinical Chemistry and Pediatrics, Laboratory Genetic Metabolic Diseases, Emma Children's Hospital, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Inborn Errors of Metabolism, Amsterdam, the Netherlands; Core Facility Metabolomics, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands; United for Metabolic Diseases, the Netherlands.
| | - Youssra Jamal
- Amsterdam UMC Location University of Amsterdam, Departments of Clinical Chemistry and Pediatrics, Laboratory Genetic Metabolic Diseases, Emma Children's Hospital, Meibergdreef 9, Amsterdam, the Netherlands
| | - Rob Barto
- Amsterdam UMC Location University of Amsterdam, Departments of Clinical Chemistry and Pediatrics, Laboratory Genetic Metabolic Diseases, Emma Children's Hospital, Meibergdreef 9, Amsterdam, the Netherlands
| | - Michael H Gelb
- Department of Chemistry, University of Washington, Seattle, WA, USA
| | - Andrea E DeBarber
- University Shared Resource and Department of Chemical Physiology and Biochemistry, Oregon Health and Science University, Portland, OR, USA
| | - Ron A Wevers
- Department of Laboratory Medicine, Translational Metabolic Laboratory, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marcel R Nelen
- Department of Human Genetics, Radboud University Medical Center, 6500 HB Nijmegen, the Netherlands
| | - Aad Verrips
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Albert H Bootsma
- Amsterdam UMC Location University of Amsterdam, Departments of Clinical Chemistry and Pediatrics, Laboratory Genetic Metabolic Diseases, Emma Children's Hospital, Meibergdreef 9, Amsterdam, the Netherlands
| | - Marelle J Bouva
- Center for Health Protection, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Nick Kleise
- PerkinElmer / Wallac Oy, Mustionkatu 6, 20750 Turku, Finland
| | | | - Tao He
- PerkinElmer / Wallac Oy, Mustionkatu 6, 20750 Turku, Finland
| | - Gajja S Salomons
- Amsterdam UMC Location University of Amsterdam, Departments of Clinical Chemistry and Pediatrics, Laboratory Genetic Metabolic Diseases, Emma Children's Hospital, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Inborn Errors of Metabolism, Amsterdam, the Netherlands; Core Facility Metabolomics, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands; United for Metabolic Diseases, the Netherlands
| | - Hidde H Huidekoper
- Department of Pediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, Rotterdam, the Netherlands; United for Metabolic Diseases, the Netherlands
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Muacevic A, Adler JR, C P, A R, A M. Cerebrotendinous Xanthomatosis: Report of Two Siblings With the Same Mutation but Variable Presentation. Cureus 2023; 15:e33378. [PMID: 36628393 PMCID: PMC9821311 DOI: 10.7759/cureus.33378] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 01/06/2023] Open
Abstract
Cerebrotendinous xanthomatosis (CTX), also known as CTX, is an extremely rare bile acid metabolic disorder caused by mutations in the cytochrome P450 family 27 subfamily A member 1 (CYP27A1) gene. This genetic disease is inherited in an autosomal recessive manner, and it affects the enzyme sterol 27-hydroxylase, which is involved in the bile acid metabolic process. It is distinguished by diarrhoea in infancy, early juvenile cataract, tendon xanthomas in adolescence, and progressive neuropsychiatric dysfunction in adulthood. So far, India has reported eight genetically confirmed cases. We present two cases of CTX among siblings in a family. The elder sibling was initially diagnosed, and after reviewing his family history and performing a thorough clinical examination, we discovered a similar manifestation in his younger sibling. Genetic testing on the siblings revealed similar mutations at exon 2 of the CYP27A1 gene. If a pathogenic mutation is discovered in a family member, prenatal and preimplantation genetic testing, as well as childhood screening, are the options. These screening strategies will prevent the onset of neuropsychiatric manifestations and disability.
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Nóbrega PR, Bernardes AM, Ribeiro RM, Vasconcelos SC, Araújo DABS, Gama VCDV, Fussiger H, Santos CDF, Dias DA, Pessoa ALS, Pinto WBVDR, Saute JAM, de Souza PVS, Braga-Neto P. Cerebrotendinous Xanthomatosis: A practice review of pathophysiology, diagnosis, and treatment. Front Neurol 2022; 13:1049850. [PMID: 36619921 PMCID: PMC9816572 DOI: 10.3389/fneur.2022.1049850] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
Cerebrotendinous Xanthomatosis represents a rare and underdiagnosed inherited neurometabolic disorder due to homozygous or compound heterozygous variants involving the CYP27A1 gene. This bile acid metabolism disorder represents a key potentially treatable neurogenetic condition due to the wide spectrum of neurological presentations in which it most commonly occurs. Cerebellar ataxia, peripheral neuropathy, spastic paraparesis, epilepsy, parkinsonism, cognitive decline, intellectual disability, and neuropsychiatric disturbances represent some of the most common neurological signs observed in this condition. Despite representing key features to increase diagnostic index suspicion, multisystemic involvement does not represent an obligatory feature and can also be under evaluated during diagnostic work-up. Chenodeoxycholic acid represents a well-known successful therapy for this inherited metabolic disease, however its unavailability in several contexts, high costs and common use in patients at late stages of disease course limit more favorable neurological outcomes for most individuals. This review article aims to discuss and highlight the most recent and updated knowledge regarding clinical, pathophysiological, neuroimaging, genetic and therapeutic aspects related to Cerebrotendinous Xanthomatosis.
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Affiliation(s)
- Paulo Ribeiro Nóbrega
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Brazil,Neurogenetics Unit, Department of Neurology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Anderson Moura Bernardes
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Rodrigo Mariano Ribeiro
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Sophia Costa Vasconcelos
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Brazil
| | | | | | - Helena Fussiger
- School of Medicine, Universidade Federação de Estabelecimentos de Ensino Superior em Novo Hamburgo, Novo Hamburgo, Brazil,Graduate Program in Medicine: Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | - André Luíz Santos Pessoa
- Hospital Infantil Albert Sabin, Fortaleza, Brazil,Center of Health Science, Universidade Estadual do Ceará, Fortaleza, Brazil
| | | | - Jonas Alex Morales Saute
- Graduate Program in Medicine: Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil,Medical Genetics Service and Neurology Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil,Department of Internal Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Paulo Victor Sgobbi de Souza
- Neurometabolic Unit, Division of Neuromuscular Diseases, Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, Brazil,*Correspondence: Paulo Victor Sgobbi de Souza ✉
| | - Pedro Braga-Neto
- Division of Neurology, Department of Clinical Medicine, Federal University of Ceará, Fortaleza, Brazil,Center of Health Science, Universidade Estadual do Ceará, Fortaleza, Brazil
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9
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Liquid Chromatography-Tandem Mass Spectrometry in Newborn Screening Laboratories. Int J Neonatal Screen 2022; 8:ijns8040062. [PMID: 36547379 PMCID: PMC9781967 DOI: 10.3390/ijns8040062] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 11/11/2022] [Accepted: 11/16/2022] [Indexed: 11/29/2022] Open
Abstract
Tandem mass spectrometry (MS/MS) is the most universal platform currently available for the analysis of enzymatic activities and biomarkers in dried blood spots (DBS) for applications in newborn screening (NBS). Among the MS/MS applications in NBS, the most common is flow-injection analysis (FIA-) MS/MS, where the sample is introduced as a bolus injection into the mass spectrometer without the prior fractionation of analytes. Liquid chromatography combined with MS/MS (LC-MS/MS) has been employed for second-tier tests to reduce the false-positive rate associated with several nonspecific screening markers, beginning two decades ago. More recently, LC-MS/MS has been applied to primary screening for new conditions for which FIA-MS/MS or other methods, including genomic screening, are not yet adequate. In addition to providing a list of the currently used LC-MS/MS-based assays for NBS, the authors share their experience regarding the maintenance requirements of LC-MS/MS vs. FIA-MS/MS systems. The consensus is that the maintenance of LC-MS/MS and FIA-MS/MS instrumentation is similar, and LC-MS/MS has the advantage of allowing for a larger number of diseases to be screened for in a multiplex, cost-effective fashion with a high throughput and an adequate turnaround time.
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10
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Stelten BML, Raal FJ, Marais AD, Riksen NP, Roeters van Lennep JE, Duell PB, van der Graaf M, Kluijtmans LAJ, Wevers RA, Verrips A. Cerebrotendinous xanthomatosis without neurological involvement. J Intern Med 2021; 290:1039-1047. [PMID: 33830582 DOI: 10.1111/joim.13277] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/16/2021] [Accepted: 01/20/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Cerebrotendinous xanthomatosis (CTX) is an autosomal recessively inherited inborn error of metabolism. Neurological symptoms are considered to be a clinical hallmark of untreated adult patients. We describe a 'milder CTX phenotype', without neurological involvement. METHODS We performed a retrospective patient file study in 79 genetically confirmed Dutch patients with CTX (55 patients aged ≥ 21 years) to study the clinical heterogeneity of CTX. We studied the frequency of adult patients with CTX without neurological involvement at diagnosis, in our Dutch cohort, and included a family from South Africa and patients from Italy, USA, Chile and Asia from the literature. RESULTS In total, we describe 19 adult patients with CTX from 16 independent families, without neurological symptoms at diagnosis. A relatively small percentage (21%, n = 4) had a history of cataract. The majority, 84% (n = 16), presented with tendon xanthomas as the sole or predominant feature. The majority of patients showed increased plasma cholesterol levels. No correlation was found between this 'milder phenotype', the cholestanol levels and the CYP27A1 genotype. In addition, we describe three novel mutations in the CYP27A1 gene. CONCLUSIONS This study shows the clinical heterogeneity of CTX, highlighting the existence of a 'milder phenotype', that is without neurological involvement at diagnosis. Adult patients with CTX may present with tendon xanthomas as the sole or predominant feature, mimicking familial hypercholesterolemia. It is important to realize that the absence of neurological symptoms does not rule out the development of future neurological symptoms. As CTX is a treatable disorder, early diagnosis and initiation of treatment when additional clinical signs occur is therefore essential.
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Affiliation(s)
- B M L Stelten
- From the, Department of Neurology, Catharina Hospital, Eindhoven, The Netherlands
| | - F J Raal
- The Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - A D Marais
- Chemical pathology, University of Cape Town, Cape Town, South Africa
| | - N P Riksen
- Department of Internal Medicine, Division of Vascular Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J E Roeters van Lennep
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - P B Duell
- Division of Endocrinology, Diabetes, and Clinical Nutrition, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - M van der Graaf
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L A J Kluijtmans
- Department of Laboratory Medicine, Translational Metabolic Laboratory, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R A Wevers
- Department of Laboratory Medicine, Translational Metabolic Laboratory, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A Verrips
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
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11
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Abstract
Leukodystrophies are a group of genetically determined disorders that affect development or maintenance of central nervous system myelin. Leukodystrophies have an incidence of at least 1 in 4700 live births and significant morbidity and elevated risk of early death. This report includes a discussion of the types of leukodystrophies; their prevalence, clinical presentation, symptoms, and diagnosis; and current and future treatments. Leukodystrophies can present at any age from infancy to adulthood, with variability in disease progression and clinical presentation, ranging from developmental delay to seizures to spasticity. Diagnosis is based on a combination of history, examination, and radiologic and laboratory findings, including genetic testing. Although there are few cures, there are significant opportunities for care and improvements in patient well-being. Rapid advances in imaging and diagnosis, the emergence of and requirement for timely treatments, and the addition of leukodystrophy screening to newborn screening, make an understanding of the leukodystrophies necessary for pediatricians and other care providers for children.
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Affiliation(s)
- Joshua L Bonkowsky
- Division of Pediatric Neurology, Department of Pediatrics, School of Medicine, University of Utah and Brain and Spine Center, Primary Children's Hospital, Salt Lake City, Utah
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12
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Stelten BML, Dotti MT, Verrips A, Elibol B, Falik-Zaccai TC, Hanman K, Mignarri A, Sithole B, Steiner RD, Verma S, Yahalom G, Zubarioglu T, Mochel F, Federico A. Expert opinion on diagnosing, treating and managing patients with cerebrotendinous xanthomatosis (CTX): a modified Delphi study. Orphanet J Rare Dis 2021; 16:353. [PMID: 34362411 PMCID: PMC8349076 DOI: 10.1186/s13023-021-01980-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/25/2021] [Indexed: 11/10/2022] Open
Abstract
Background Cerebrotendinous xanthomatosis (CTX) is a rare, chronic, progressive, neurodegenerative disorder requiring life-long care. Patients with CTX often experience a diagnostic delay. Although early diagnosis and treatment initiation can improve symptoms and prognosis, a standardised approach to diagnosis, treatment and management of patients is not yet established. Aim To assess expert opinion on best care practices for patients with CTX using a modified Delphi method. Methods A multidisciplinary group of healthcare professionals with expertise in CTX responded to a 3-round online questionnaire (n = 10 in Rounds 1 and 2; n = 9 in Round 3), containing questions relating to the diagnosis, treatment, monitoring, multidisciplinary care and prognosis of patients with CTX. Determination of consensus achievement was based on a pre-defined statistical threshold of ≥ 70% Delphi panellists selecting 1–2 (disagreement) or 5–6 (agreement) for 6-point Likert scale questions, or ≥ 70% Delphi panellists choosing the same option for ranking and proportion questions. Results Of the Round 1 (n = 22), Round 2 (n = 32) and Round 3 (n = 26) questions for which consensus was assessed, 59.1%, 21.9% and 3.8% reached consensus, respectively. Consensus agreement that genetic analyses and/or determination of serum cholestanol levels should be used to diagnose CTX, and dried bloodspot testing should facilitate detection in newborns, was reached. Age at diagnosis and early treatment initiation (at birth, where possible) were considered to have the biggest impact on treatment outcomes. All panellists agreed that chenodeoxycholic acid (CDCA) is a lifetime replacement therapy which, if initiated early, can considerably improve prognosis as it may be capable of reversing the pathophysiological process in CTX. No consensus was reached on the value of cholic acid therapy alone. Monitoring patients through testing plasma cholestanol levels and neurologic examination was recommended, although further research regarding monitoring treatment and progression of the disease is required. Neurologists and paediatricians/metabolic specialists were highlighted as key clinicians that should be included in the multidisciplinary team involved in patients’ care. Conclusions The results of this study provide a basis for standardisation of care and highlight key areas where further research is needed to inform best practices for the diagnosis, treatment and management of patients with CTX. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-01980-5.
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Affiliation(s)
- Bianca M L Stelten
- Department of Neurology, Catharina Hospital, Eindhoven, The Netherlands.
| | - Maria Teresa Dotti
- Department of Medicine, Surgery and Neurosciences, Medical School, University of Siena and UO Clinical Neurology and Neurometabolic Diseases, AOU Senese, Siena, Italy
| | - Aad Verrips
- Department of Neurology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Bülent Elibol
- Hacettepe University Medical Faculty Hospital, Ankara, Turkey
| | - Tzipora C Falik-Zaccai
- Institute of Human Genetics, Galilee Medical Center, Naharia, Israel.,The Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | | | - Andrea Mignarri
- UO Clinical Neurology and Neurometabolic Diseases, AOU Senese, Siena, Italy
| | | | - Robert D Steiner
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Marshfield Clinic Health System, Marshfield, WI, USA
| | | | - Gilad Yahalom
- Shaare Zedek Medical Center, Jerusalem, Israel.,Sheba Medical Center, Ramat Gan, Israel
| | - Tanyel Zubarioglu
- Division of Pediatric Nutrition and Metabolism, Department of Pediatrics, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Fanny Mochel
- Reference Center for Adult Neurometabolic Diseases, Department of Genetics, La Pitié-Salpêtrière University Hospital, Paris, France
| | - Antonio Federico
- Department of Medicine, Surgery and Neurosciences, Medical School, University of Siena, Siena, Italy
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13
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Höflinger P, Hauser S, Yutuc E, Hengel H, Griffiths L, Radelfahr F, Howell OW, Wang Y, Connor SL, Duell PB, DeBarber AE, Martus P, Lütjohann D, Griffiths WJ, Schöls L. Metabolic profiling in serum, cerebrospinal fluid, and brain of patients with cerebrotendinous xanthomatosis. J Lipid Res 2021; 62:100078. [PMID: 33891937 PMCID: PMC8135047 DOI: 10.1016/j.jlr.2021.100078] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 11/25/2022] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is caused by autosomal recessive loss-of-function mutations in CYP27A1, a gene encoding cytochrome p450 oxidase essential for bile acid synthesis, resulting in altered bile acid and lipid metabolism. Here, we aimed to identify metabolic aberrations that drive ongoing neurodegeneration in some patients with CTX despite chenodeoxycholic acid (CDCA) supplementation, the standard treatment in CTX. Using chromatographic separation techniques coupled to mass spectrometry, we analyzed 26 sterol metabolites in serum and cerebrospinal fluid (CSF) of patients with CTX and in one CTX brain. Comparing samples of drug naive patients to patients treated with CDCA and healthy controls, we identified 7α,12α-dihydroxycholest-4-en-3-one as the most prominently elevated metabolite in serum and CSF of drug naive patients. CDCA treatment substantially reduced or even normalized levels of all metabolites increased in untreated patients with CTX. Independent of CDCA treatment, metabolites of the 27-hydroxylation pathway were nearly absent in all patients with CTX. 27-hydroxylated metabolites accounted for ∼45% of total free sterol content in CSF of healthy controls but <2% in patients with CTX. Metabolic changes in brain tissue corresponded well with findings in CSF. Interestingly, 7α,12α-dihydroxycholest-4-en-3-one and 5α-cholestanol did not exert toxicity in neuronal cell culture. In conclusion, we propose that increased 7α,12α-dihydroxycholest-4-en-3-one and lack of 27-hydroxycholesterol may be highly sensitive metabolic biomarkers of CTX. As CDCA cannot reliably prevent disease progression despite reduction of most accumulated metabolites, supplementation of 27-hydroxylated bile acid intermediates or replacement of CYP27A1 might be required to counter neurodegeneration in patients with progressive disease despite CDCA treatment.
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Affiliation(s)
- Philip Höflinger
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany; Department of Neurology and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany; Graduate School of Cellular and Molecular Neuroscience, University of Tübingen, Tübingen, Germany
| | - Stefan Hauser
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany; Department of Neurology and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Eylan Yutuc
- Swansea University Medical School, ILS1, Swansea, Wales, United Kingdom
| | - Holger Hengel
- Department of Neurology and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Lauren Griffiths
- Swansea University Medical School, ILS1, Swansea, Wales, United Kingdom
| | - Florentine Radelfahr
- Friedrich-Baur-Institute, Department of Neurology, University Hospital, LMU Munich, Munich, Germany; German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Owain W Howell
- Swansea University Medical School, ILS1, Swansea, Wales, United Kingdom
| | - Yuqin Wang
- Swansea University Medical School, ILS1, Swansea, Wales, United Kingdom
| | - Sonja L Connor
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - P Barton Duell
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Andrea E DeBarber
- Chemical Physiology and Biochemistry Department, Oregon Health & Science University, Portland, OR, USA
| | - Peter Martus
- Institute of Clinical Epidemiology and applied Biostatistics, University of Tübingen, Tübingen, Germany
| | - Dieter Lütjohann
- Institute of Clinical Chemistry and Clinical Pharmacology, University Hospital Bonn, Bonn, Germany
| | | | - Ludger Schöls
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany; Department of Neurology and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.
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14
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Abstract
PURPOSE OF REVIEW Cerebrotendinous xanthomatosis (CTX) is a rare genetic lipid storage disorder with highly pleomorphic clinical phenotype. Complications of this disease can be devastating and may include severe cognitive impairment and dementia in later stages. Disease progression can be prevented or stabilized by bile acid replacement therapy, although a subset of patients with advanced disease continue to deteriorate despite therapy. RECENT FINDINGS Delayed diagnosis of CTX continues to impede effective treatment. A clinical diagnostic algorithm for CTX was developed that can decrease the age of diagnosis of CTX. The strategy of screening children with bilateral juvenile cataracts for CTX also improved diagnosis, as this group had a 500-fold higher-rate of CTX than the general population. Improved diagnosis of CTX is critical, as patients treated early in the course of the disease have significantly better outcomes compared with those treated later. More sensitive and specific biochemical testing for CTX has been developed that is potentially more informative than blood cholestanol to assess treatment efficacy and medication compliance in CTX. SUMMARY Because we are recognizing more severe presentations of CTX in infants and children, and delayed diagnosis and treatment worsens the prognosis, CTX is an excellent candidate disorder for newborn screening using recently reported methods for newborn dried bloodspot analysis.
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Affiliation(s)
| | - P Barton Duell
- Knight Cardiovascular Institute, and Division of Endocrinology, Diabetes & Clinical Nutrition, Oregon Health & Science University, Portland, Oregon, USA
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15
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Zhang S, Li W, Zheng R, Zhao B, Zhang Y, Zhao D, Zhao C, Yan C, Zhao Y. Cerebrotendinous xanthomatosis with peripheral neuropathy: a clinical and neurophysiological study in Chinese population. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1372. [PMID: 33313117 PMCID: PMC7723652 DOI: 10.21037/atm-20-2746] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Cerebrotendinous xanthomatosis (CTX) is an inborn disorder of bile acid metabolism caused by deficiency of sterol 27-hydroxylase (CYP27A1) gene. CTX-related peripheral neuropathy has rarely been discussed in Chinese population. Here, we reported 6 CTX cases and performed a literature review focused on CTX with neuropathy to summarize its clinical and neurophysiological features. Methods All clinical data of 6 CTX cases were collected, and 21 reported Chinese CTX patients (including this study) were reviewed and summarized. Results Clinical manifestations of 6 CTX cases showed great heterogeneity. Cognitive decline, spastic paraplegia, cerebellar ataxia and advanced bulbar palsy were common neurological disorders, often accompanied by non-neurological signs like xanthomas, cataract, diarrhea and pes cavus. Dentate nuclei hyperintensity with or without hyposignal is a valuable MRI hallmark. Pooling our patients and literature review together, peripheral neuropathy was predominant sensorimotor demyelinating type in Chinese population, with an evident length dependent pattern and increased vulnerability in motor nerves. Demyelinating and axonal degeneration tend to exist in severe neuropathy. Three novel mutations including c.1055C>A; c.432T>G; c.472T>G were identified in CYP27A1 and predicted to be pathogenic. Oral CDCA therapy could ameliorate some of the existing symptoms and provide clinical stability, but it could not cease disease progression completely. Conclusions Our study broadens the phenotype and mutation spectrum of CTX. Patients with cognitive decline, spastic tetraparesis, cerebellar ataxia and bulbar palsy, should be highly suspicious of CTX even no xanthomas disclosed. Peripheral neuropathy was predominant sensorimotor demyelinating type in Chinese population, with mixed axonal and demyelinating type in severe cases. Three novel likely pathogenic mutations including c.1055C>A; c.432T>G; c.472T>G were identified in CYP27A1.
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Affiliation(s)
- Shu Zhang
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Shandong University, Jinan, China
| | - Wei Li
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Shandong University, Jinan, China
| | - Rui Zheng
- Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Bing Zhao
- Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Yongqing Zhang
- Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Dandan Zhao
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Shandong University, Jinan, China
| | - Cuiping Zhao
- Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Chuanzhu Yan
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Shandong University, Jinan, China.,Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Yuying Zhao
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Shandong University, Jinan, China
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16
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Hong X, Daiker J, Sadilek M, DeBarber AE, Chiang J, Duan J, Bootsma AH, Huidekoper HH, Vaz FM, Gelb MH. Toward newborn screening of cerebrotendinous xanthomatosis: results of a biomarker research study using 32,000 newborn dried blood spots. Genet Med 2020; 22:1606-1612. [PMID: 32523054 PMCID: PMC7529987 DOI: 10.1038/s41436-020-0846-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 12/19/2022] Open
Abstract
Purpose Cerebrotendinous xanthomatosis (CTX) is a treatable hereditary disorder caused by the deficiency of sterol 27- hydroxylase, which is encoded by the CYP27A1 gene. Different newborn screening biomarkers for CTX have been described, including 7α,12α-dihydroxy-4-cholesten-3-one ( 7α12αC4 ), 5b-cholestane-3 α, 7α,12α,25-tetrol glucuronide(GlcA-tetrol), GlcA-tetrol to tauro-chenodeoxycholic acid (t-CDCA) ratio (GlcA-tetrol/t-CDCA), and tauro- trihydroxycholestanoic acid (t-THCA) to GlcA-tetrol ratio (t-THCA/GlcA-tetrol ). We set out to evaluate these screening methods in a research study using 32,000–55,000 newborn dried blood spots (DBS). Method Metabolites were extracted from DBS with methanol containing internal standard, which was then quantified by ultra-performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS). Results The measurement of 7α12αC4 was complicated by isobaric interferences and was discontinued after 2,033 samples. A total of 55,250 newborns were screened for the GlcA-tetrol/t-CDCA ratio, 32,737 of which had quantitative data on GlcA-tetrol. Only one newborn displayed both highly elevated GlcA-tetrol and a typical CTX biochemical profile. This newborn was interpreted as a CTX-affected patient as CYP27A1 gene sequencing identified two known pathogenic variants. Conclusion The results indicate that both GlcA-tetrol and GlcA-tetrol/t-CDCA ratio are excellent CTX biomarkers suitable for newborn screening. By characterizing the relationship of GlcA-tetrol, t-CDCA, and t-THCA as secondary markers, 100% assay specificity can be achieved.
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Affiliation(s)
- Xinying Hong
- Department of Chemistry, University of Washington, Seattle, WA, USA
| | - Jessica Daiker
- Department of Chemistry, University of Washington, Seattle, WA, USA
| | - Martin Sadilek
- Department of Chemistry, University of Washington, Seattle, WA, USA
| | - Andrea E DeBarber
- Department of Chemical Physiology and Biochemistry, Oregon Health and Science University, Portland, OR, USA
| | - John Chiang
- Molecular Vision Laboratory, Hillsboro, OR, USA
| | - Jie Duan
- Molecular Vision Laboratory, Hillsboro, OR, USA
| | - Albert H Bootsma
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, location AMC, University of Amsterdam, Department of Clinical Chemistry, Amsterdam Gastroenterology & Metabolism, Amsterdam, The Netherlands
| | - Hidde H Huidekoper
- Center for Lysosomal and Metabolic Diseases, Erasmus Medical Center, Department of Pediatrics, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Frédéric M Vaz
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, location AMC, University of Amsterdam, Department of Clinical Chemistry, Amsterdam Gastroenterology & Metabolism, Amsterdam, The Netherlands
| | - Michael H Gelb
- Department of Chemistry, University of Washington, Seattle, WA, USA. .,Department of Biochemistry, University of Washington, Seattle, WA, USA.
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17
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Degrassi I, Amoruso C, Giordano G, Del Puppo M, Mignarri A, Dotti MT, Naturale M, Nebbia G. Case Report: Early Treatment With Chenodeoxycholic Acid in Cerebrotendinous Xanthomatosis Presenting as Neonatal Cholestasis. Front Pediatr 2020; 8:382. [PMID: 32766184 PMCID: PMC7381104 DOI: 10.3389/fped.2020.00382] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/05/2020] [Indexed: 12/17/2022] Open
Abstract
Background: Cerebrotendinous xanthomatosis (CTX) is an inborn disorder of bile acid synthesis which causes progressive accumulation of toxic metabolites in various organs, particularly in brain and tendons. Most cases are diagnosed and treated in the second or third decade of life, when neurological involvement appears. We describe a case of CTX presenting as neonatal cholestasis. Results: The child presented cholestasis at 2 months of life. In the following months jaundice slowly disappeared, with a normalization of bilirubin and aminotransferases, respectively, at 6 and 8 months. A LC-Mass Spectrometry of the urines showed the presence of cholestanepentols glucuronide, which led to the suspicion of cerebrotendinous xanthomatosis. The diagnosis was confirmed by the dosage of cholestanol in serum and the molecular genetic analysis of the CYP27A1 gene. Therapy with chenodeoxycholic acid (CDCA) was started at 8 months and is still ongoing. The child was monitored for 13 years by dosage of serum cholestanol and urinary cholestanepentols. A strictly biochemical and neurological follow up was performed and no sign of neurological impairment was observed. Conclusions: Prompt diagnosis and treatment of CTX presenting as neonatal cholestasis may prevent further neurological impairment.
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Affiliation(s)
- Irene Degrassi
- Pediatric Intermediate Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Chiara Amoruso
- Pediatric Intermediate Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Giordano
- Mass Spectrometry Laboratory, Women's and Children' Health Department, University of Padua, Fondazione Istituto di Ricerca Pediatrica Città della Speranza, Padova, Italy
| | - Marina Del Puppo
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Andrea Mignarri
- Unit of Neurology and Neurometabolic Diseases, Departement of Neurological and Motor Sciences, University of Siena, Siena, Italy
| | - Maria Teresa Dotti
- Unit of Neurology and Neurometabolic Diseases, Departement of Neurological and Motor Sciences, University of Siena, Siena, Italy
| | - Mauro Naturale
- Mass Spectrometry Laboratory, Women's and Children' Health Department, University of Padua, Fondazione Istituto di Ricerca Pediatrica Città della Speranza, Padova, Italy
| | - Gabriella Nebbia
- Pediatric Intermediate Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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18
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Abstract
In mammalian systems "sterolomics" can be regarded as the quantitative or semi-quantitative profiling of all metabolites derived from cholesterol and its cyclic precursors. The system can be further complicated by metabolites derived from ingested phytosterols or pharmaceuticals, but this is beyond the scope of this article. "Sterolomics" can be performed on either an unbiased global format, or more usually, exploiting a targeted format. Here we discuss the different mass spectrometry-based analytical techniques used in "sterolomics" giving specific examples in the context of neurodegenerative disease and for the diagnosis of inborn errors of metabolism. We pay particular attention to the profiling of cholesterol metabolites in the bile acid biosynthesis pathways, although the analytical techniques discussed are also appropriate for analysis of hormonal steroids.
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Affiliation(s)
- William J. Griffiths
- Swansea University Medical School, ILS1 Building, Singleton Park, Swansea SA2 8PP, Wales, UK
| | - Yuqin Wang
- Swansea University Medical School, ILS1 Building, Singleton Park, Swansea SA2 8PP, Wales, UK
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19
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Stelten BM, Huidekoper HH, van de Warrenburg BP, Brilstra EH, Hollak CE, Haak H, Kluijtmans LA, Wevers RA, Verrips A. Long-term treatment effect in cerebrotendinous xanthomatosis depends on age at treatment start. Neurology 2018; 92:e83-e95. [DOI: 10.1212/wnl.0000000000006731] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 08/20/2018] [Indexed: 12/11/2022] Open
Abstract
ObjectiveTo evaluate the effect of chenodeoxycholic acid treatment on disease progression in cerebrotendinous xanthomatosis (CTX).MethodsIn this retrospective cohort study, we report the clinical long-term follow-up characteristics of 56 Dutch patients with CTX. Age at diagnosis was correlated with clinical characteristics and with the course of modified Rankin Scale (mRS) and Expanded Disability Status Scale (EDSS) scores at follow-up.ResultsMedian follow-up time was 8 years (6 months–31.5 years). Patients diagnosed and treated before the age of 24 years had a significantly better outcome at follow-up. When considering only patients with a good treatment adherence (n = 43), neurologic symptoms, if present, disappeared in all patients who were diagnosed before the age of 24 and treated since. Furthermore, treatment prevented the development of new neurologic symptoms during follow-up. In contrast, 61% of the patients diagnosed and treated after the age of 24 showed deterioration of the neurologic symptoms, with parkinsonism as a treatment-resistant feature. There was an improvement or stabilization in favor of patients diagnosed and treated before the age of 24 compared to those treated after the age of 24: 100% vs 58% for mRS scores and 100% vs 50% for EDSS scores, respectively.ConclusionsTreatment start at an early age can reverse and even prevent the development of neurologic symptoms in CTX. This study emphasizes the importance of early diagnosis in CTX and provides a rationale to include CTX in newborn screening programs.
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20
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DeBarber AE, Kalfon L, Fedida A, Fleisher Sheffer V, Ben Haroush S, Chasnyk N, Shuster Biton E, Mandel H, Jeffries K, Shinwell ES, Falik-Zaccai TC. Newborn screening for cerebrotendinous xanthomatosis is the solution for early identification and treatment. J Lipid Res 2018; 59:2214-2222. [PMID: 30135217 DOI: 10.1194/jlr.m087999] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/19/2018] [Indexed: 12/13/2022] Open
Abstract
Cerebrotendinous xanthomatosis (CTX) is a progressive metabolic leukodystrophy. Early identification and treatment from birth onward effectively provides a functional cure, but diagnosis is often delayed. We conducted a pilot study using a two-tier test for CTX to screen archived newborn dried bloodspots (DBSs) or samples collected prospectively from a high-risk Israeli newborn population. All DBS samples were analyzed with flow injection analysis (FIA)-MS/MS, and 5% of samples were analyzed with LC-MS/MS. Consecutively collected samples were analyzed to identify CTX-causing founder genetic variants common among Druze and Moroccan Jewish populations. First-tier analysis with FIA-MS/MS provided 100% sensitivity to detect CTX-positive newborn DBSs, with a low false-positive rate (0.1-0.5%). LC-MS/MS, as a second-tier test, provided 100% sensitivity to detect CTX-positive newborn DBSs with a false-positive rate of 0% (100% specificity). In addition, 5β-cholestane-3α,7α,12α,25-tetrol-3-O-β-D-glucuronide was identified as the predominant bile-alcohol disease marker present in CTX-positive newborn DBSs. In newborns identifying as Druze, a 1:30 carriership frequency was determined for the c.355delC CYP27A1 gene variant, providing an estimated disease prevalence of 1:3,600 in this population. These data support the feasibility of two-tier DBS screening for CTX in newborns and set the stage for large-scale prospective pilot studies.
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Affiliation(s)
- Andrea E DeBarber
- Physiology and Pharmacology Department, Oregon Health and Science University (OHSU), Portland, OR
| | - Limor Kalfon
- Institute of Human Genetics, Galilee Medical Center, Naharia, Israel
| | - Ayalla Fedida
- Institute of Human Genetics, Galilee Medical Center, Naharia, Israel.,Azrieli Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel; and
| | | | - Shani Ben Haroush
- Institute of Human Genetics, Galilee Medical Center, Naharia, Israel
| | - Natalia Chasnyk
- Institute of Human Genetics, Galilee Medical Center, Naharia, Israel
| | | | - Hanna Mandel
- Institute of Human Genetics, Galilee Medical Center, Naharia, Israel
| | - Krystal Jeffries
- Physiology and Pharmacology Department, Oregon Health and Science University (OHSU), Portland, OR
| | - Eric S Shinwell
- Azrieli Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel; and.,Department of Neonatology, Ziv Medical Center, Tzfat, Israel
| | - Tzipora C Falik-Zaccai
- Institute of Human Genetics, Galilee Medical Center, Naharia, Israel .,Azrieli Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel; and
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21
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Sandlers Y. The future perspective: metabolomics in laboratory medicine for inborn errors of metabolism. Transl Res 2017; 189:65-75. [PMID: 28675806 DOI: 10.1016/j.trsl.2017.06.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 06/06/2017] [Accepted: 06/08/2017] [Indexed: 12/22/2022]
Abstract
Metabolomics can be described as a simultaneous and comprehensive analysis of small molecules in a biological sample. Recent technological and bioinformatics advances have facilitated large-scale metabolomic studies in many areas, including inborn errors of metabolism (IEMs). Despite significant improvements in the diagnosis and treatment of some IEMs, it is still challenging to understand how genetic variation affects disease progression and susceptibility. In addition, a search for new more personalized therapies and a growing demand for tools to monitor the long-term metabolic effects of existing therapies set the stage for metabolomics integration in preclinical and clinical studies. While targeted metabolomics approach is a common practice in biochemical genetics laboratories for biochemical diagnosis and monitoring of IEMs, applications of untargeted metabolomics in the clinical laboratories are still in infancy, facing some challenges. It is however, expected in the future to dramatically change the scope and utility of the clinical laboratory playing a significant role in patient management. This review provides an overview of targeted and global, large-scale metabolomic studies applied to investigate various IEMs. We discuss an existing and prospective clinical applications of metabolomics in IEMs for better diagnosis and deep understanding of complex metabolic perturbations associated with the etiology of inherited metabolic disorders.
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Affiliation(s)
- Yana Sandlers
- Department of Chemistry, Cleveland State University, Cleveland, Ohio.
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Salen G, Steiner RD. Epidemiology, diagnosis, and treatment of cerebrotendinous xanthomatosis (CTX). J Inherit Metab Dis 2017; 40:771-781. [PMID: 28980151 DOI: 10.1007/s10545-017-0093-8] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/08/2017] [Accepted: 09/14/2017] [Indexed: 01/05/2023]
Abstract
Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive disorder of bile acid synthesis caused by mutations in the cytochrome P450 CYP27A1 gene that result in production of a defective sterol 27-hydroxylase enzyme. CTX is associated with abnormally high levels of cholestanol in the blood and accumulation of cholestanol and cholesterol in the brain, tendon xanthomas, and bile. Hallmark clinical manifestations of CTX include chronic diarrhea, bilateral cataracts, tendon xanthomas, and neurologic dysfunction. Although CTX is a rare disorder, it is thought to be underdiagnosed, as presenting signs and symptoms may be nonspecific with significant overlap with other more common conditions. There is marked variability in signs and symptoms, severity, and age of onset between patients. The disease course is progressive and potentially debilitating or fatal, particularly with respect to neurologic presentations that can include intellectual disability, autism, behavioral and psychiatric problems, and dementia, among others. Treatment with chenodeoxycholic acid (CDCA; chenodiol) is the current standard of care. CDCA can help restore normal sterol, bile acid, bile alcohol, and cholestanol levels. CDCA also appears to be generally effective in preventing adverse clinical manifestations of the disease from occurring or progressing if administered early enough. Improved screening and awareness of the condition may help facilitate early diagnosis and treatment.
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Affiliation(s)
- Gerald Salen
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Robert D Steiner
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Genetics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Severe Neonatal Cholestasis in Cerebrotendinous Xanthomatosis: Genetics, Immunostaining, Mass Spectrometry. J Pediatr Gastroenterol Nutr 2017; 65:561-568. [PMID: 28937538 DOI: 10.1097/mpg.0000000000001730] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Cerebrotendinous xanthomatosis (CTX) is caused by defects in sterol 27-hydroxylase (CYP27A1, encoded by CYP27A1), a key enzyme in the bile acid synthesis pathway. CTX usually presents as neurologic disease in adults or older children. The rare reports of CTX manifest as neonatal cholestasis assess the cholestasis as transient, with patient survival. Our experience differs. METHODS Homozygous or compound heterozygous CYP27A1 mutations were detected in 8 neonatal cholestasis patients by whole exome sequencing, panel sequencing, or Sanger sequencing. Their clinical and biochemical data were retrospectively reviewed. Immunostaining for CYP27A1 was conducted in liver of 4 patients. Mass spectrometry was used to analyze patients' urine samples. RESULTS All 8 infants had severe cholestasis. Five died from, or were transplanted for, liver failure; 3 cleared their jaundice eventually. Marking for CYP27A1 was weak or absent in 3 of the 4 patient specimens. Mass spectrometry of urine revealed a predominance of sulfated and doubly conjugated (sulfated-glucuronidated) bile alcohols. No patient harbored a putatively pathogenic mutation in genes other than CYP27A1 that have been implicated in cholestatic liver disease. CONCLUSIONS CTX manifest as neonatal cholestasis has a bile acid profile different from CTX manifest in later life, and thus may be overlooked. Immunostaining, mass spectrometry of urine, and genetic studies can support one another in making the diagnosis. A substantial proportion of CTX patients with severe neonatal cholestasis may die or need liver transplantation. CTX manifest in infancy as severe cholestasis warrants further investigation of biochemical diagnostic criteria and best management.
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