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Hsu RH, Lee NC, Chen HA, Hwu WL, Chang TM, Chien YH. Late-onset symptomatic hyperprolactinemia in 6-pyruvoyl-tetrahydropterin synthase deficiency. Orphanet J Rare Dis 2023; 18:351. [PMID: 37950276 PMCID: PMC10636984 DOI: 10.1186/s13023-023-02963-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/28/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Tetrahydrobiopterin (BH4) deficiency caused by 6-pyruvoyl-tetrahydropterin synthase (PTPS) deficiency is a rare disorder that is one of the major causes of hyperphenylalaninemia in Taiwan. METHODS In this study, we reviewed the clinical courses of 12 adolescent and adult patients (7 females and 5 males) with PTPS deficiency. RESULTS The patients were treated shortly after diagnosis through newborn screening with a combination of BH4, levodopa/carbidopa, and 5-OH-tryptophan. Their plasma phenylalanine and tyrosine levels were well controlled, and their prolactin levels were also decreased after treatment. However, their prolactin levels gradually rose as they grew into puberty, and at a current age of 27.5 [interquartile range (IQR 7.9)] years, five of the 12 patients had either highly elevated prolactin levels (> 100 ng/mL in one male patient, normal reference values, male < 11 ng/mL, female < 17 ng/mL) or symptoms, including irregular menstruation, amenorrhea, and breast swelling (in four female patients). The dosage of levodopa in these five patients (14.3 (IQR 3.0) mg/kg/day) was slightly higher than that in the other patients (p = 0.05). Magnetic resonance imaging studies did not reveal an increase in the size of the anterior pituitary gland, although a Rathke cleft cyst was found in one patient. Two patients received cabergoline treatment, which promptly lowered prolactin levels and relieved symptoms. CONCLUSIONS Hyperprolactinemia is common in female patients with PTPS deficiency, especially after puberty. A long-acting dopamine agonist, such as cabergoline, may be a necessary adjunctive treatment for most patients with BH4 deficiency.
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Affiliation(s)
- Rai-Hseng Hsu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medical Genetics, National Taiwan University Hospital, 8 Chung-Shan South Road, Taipei, 10041, Taiwan
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ni-Chung Lee
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medical Genetics, National Taiwan University Hospital, 8 Chung-Shan South Road, Taipei, 10041, Taiwan
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hui-An Chen
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medical Genetics, National Taiwan University Hospital, 8 Chung-Shan South Road, Taipei, 10041, Taiwan
| | - Wuh-Liang Hwu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medical Genetics, National Taiwan University Hospital, 8 Chung-Shan South Road, Taipei, 10041, Taiwan
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei, Taiwan
- Center for Precision Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Tung-Ming Chang
- Department of Pediatric Neurology, Changhua Christian Children's Hospital, Changhua, Taiwan
- Department of Biological Science and Technology, College of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Yin-Hsiu Chien
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan.
- Department of Medical Genetics, National Taiwan University Hospital, 8 Chung-Shan South Road, Taipei, 10041, Taiwan.
- Department of Pediatrics, National Taiwan University College of Medicine, Taipei, Taiwan.
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Gottschalk CG, Whelan R, Peterson D, Roy A. Detection of Elevated Level of Tetrahydrobiopterin in Serum Samples of ME/CFS Patients with Orthostatic Intolerance: A Pilot Study. Int J Mol Sci 2023; 24:ijms24108713. [PMID: 37240059 DOI: 10.3390/ijms24108713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/02/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
Myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS) is a multisystem chronic illness characterized by severe muscle fatigue, pain, dizziness, and brain fog. Many patients with ME/CFS experience orthostatic intolerance (OI), which is characterized by frequent dizziness, light-headedness, and feeling faint while maintaining an upright posture. Despite intense investigation, the molecular mechanism of this debilitating condition is still unknown. OI is often manifested by cardiovascular alterations, such as reduced cerebral blood flow, reduced blood pressure, and diminished heart rate. The bioavailability of tetrahydrobiopterin (BH4), an essential cofactor of endothelial nitric oxide synthase (eNOS) enzyme, is tightly coupled with cardiovascular health and circulation. To explore the role of BH4 in ME/CFS, serum samples of CFS patients (n = 32), CFS patients with OI only (n = 10; CFS + OI), and CFS patients with both OI and small fiber polyneuropathy (n = 12; CFS + OI + SFN) were subjected to BH4 ELISA. Interestingly, our results revealed that the BH4 expression is significantly high in CFS, CFS + OI, and CFS + OI + SFN patients compared to age-/gender-matched controls. Finally, a ROS production assay in cultured microglial cells followed by Pearson correlation statistics indicated that the elevated BH4 in serum samples of CFS + OI patients might be associated with the oxidative stress response. These findings suggest that the regulation of BH4 metabolism could be a promising target for understanding the molecular mechanism of CFS and CFS with OI.
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Affiliation(s)
- Carl Gunnar Gottschalk
- Simmaron Research Institute, 948 Incline Way, Incline Village, NV 89451, USA
- Simmaron Research and Development Laboratory, Chemistry Building, University of Wisconsin-Milwaukee, 3210 N Cramer Street, Suite # 214, Milwaukee, WI 53211, USA
| | - Ryan Whelan
- Simmaron Research Institute, 948 Incline Way, Incline Village, NV 89451, USA
| | - Daniel Peterson
- Simmaron Research Institute, 948 Incline Way, Incline Village, NV 89451, USA
- Sierra Internal Medicine, 920 Incline Way, Incline Village, NV 89451, USA
| | - Avik Roy
- Simmaron Research Institute, 948 Incline Way, Incline Village, NV 89451, USA
- Simmaron Research and Development Laboratory, Chemistry Building, University of Wisconsin-Milwaukee, 3210 N Cramer Street, Suite # 214, Milwaukee, WI 53211, USA
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3
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Manzoni F, Salvatici E, Burlina A, Andrews A, Pasquali M, Longo N. Retrospective analysis of 19 patients with 6-Pyruvoyl Tetrahydropterin Synthase Deficiency: Prolactin levels inversely correlate with growth. Mol Genet Metab 2020; 131:380-389. [PMID: 33234470 PMCID: PMC7749858 DOI: 10.1016/j.ymgme.2020.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pyruvoyl Tetrahydropterin Synthase (PTPS) Deficiency is the most common form of BH4 deficiency resulting in hyperphenylalaninemia. It can have variable clinical severity and there is limited information on the clinical presentation, natural history and effectiveness of newborn screening for this condition. METHODS Retrospective data (growth and clinical parameters, biochemical and genetic testing results, treatment) were collected from 19 patients with PTPS deficiency in different centers, to evaluate biochemical and clinical outcomes. Descriptive statistics was used for qualitative variables, while linear regression analysis was used to correlate quantitative variables. RESULTS Patients with PTPS deficiency had an increased incidence of prematurity (4/18) with an average gestational age only mildly reduced (37.8 ± 2.4 weeks) and low birth weight (-1.14 ± 0.97 SD below that predicted for gestational age). With time, weight and height approached normal. VALUES All patients were identified by newborn screening for an elevated phenylalanine level. However, phenylalanine levels were normal in two whose testing was performed at or before 24 h of age. Sapropterin dihydrochloride treatment normalized phenylalanine levels. Molecular testing identified novel variants in the PTS gene, some of which present in more than one affected family. The neurotransmitter derivatives 5-hydroxyindoleacetic acid (5HIAA) and homovanillic acid (HVA) in the CSF were decreased in most cases except in 2 families with the peripheral form of PTPS deficiency. With time, HVA and 5HIAA became abnormally low in two of these patients requiring therapy. Prolactin (whose secretion is inhibited by dopamine) levels were elevated in several patients with PTPS deficiency and inversely correlated with the z-scores for height (p < 0.01) and weight (p < 0.05). Most patients with PTPS deficiency had delayed development early in life, improving around school age with IQs mostly in the normal range, with a small decline in older individuals. From a neurological standpoint, most patients had normal brain MRI and minor EEG anomalies, although some had persistent neurological symptoms. DISCUSSION Patients with PTPS deficiency have not only an increased incidence of prematurity, but also decreased birth weight when corrected for gestational age. Hyperphenylalaninemia can be absent in the first day of life. Therapy with sapropterin dihydrochloride normalizes phenylalanine levels and neurotransmitter precursors can improve CSF neurotransmitter metabolites levels. Insufficient dopaminergic stimulation (as seen from elevated prolactin) might result in decreased height in patients with PTPS deficiency. Despite early delays in development, many patients can achieve independence in adult life, with usually normal neuroimaging and EEG.
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Affiliation(s)
- Francesca Manzoni
- Division of Medical Genetics/Pediatrics, University of Utah, Salt Lake City, UT, USA; Clinical Department of Neuropsychiatry, San Paolo Hospital, University of Milan, Milan, Italy; Division of Inherited Metabolic Diseases, Department of Diagnostic Services, University Hospital, Padua, Italy
| | - Elisabetta Salvatici
- Clinical Department of Pediatrics, San Paolo Hospital, University of Milan, Milan, Italy
| | - Alberto Burlina
- Division of Inherited Metabolic Diseases, Department of Diagnostic Services, University Hospital, Padua, Italy
| | - Ashley Andrews
- Division of Medical Genetics/Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Marzia Pasquali
- Division of Medical Genetics/Pediatrics, University of Utah, Salt Lake City, UT, USA; ARUP Laboratories, Salt Lake City, UT, USA; Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Nicola Longo
- Division of Medical Genetics/Pediatrics, University of Utah, Salt Lake City, UT, USA; ARUP Laboratories, Salt Lake City, UT, USA; Department of Pathology, University of Utah, Salt Lake City, UT, USA..
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4
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Opladen T, López-Laso E, Cortès-Saladelafont E, Pearson TS, Sivri HS, Yildiz Y, Assmann B, Kurian MA, Leuzzi V, Heales S, Pope S, Porta F, García-Cazorla A, Honzík T, Pons R, Regal L, Goez H, Artuch R, Hoffmann GF, Horvath G, Thöny B, Scholl-Bürgi S, Burlina A, Verbeek MM, Mastrangelo M, Friedman J, Wassenberg T, Jeltsch K, Kulhánek J, Kuseyri Hübschmann O. Consensus guideline for the diagnosis and treatment of tetrahydrobiopterin (BH 4) deficiencies. Orphanet J Rare Dis 2020; 15:126. [PMID: 32456656 PMCID: PMC7251883 DOI: 10.1186/s13023-020-01379-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/07/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Tetrahydrobiopterin (BH4) deficiencies comprise a group of six rare neurometabolic disorders characterized by insufficient synthesis of the monoamine neurotransmitters dopamine and serotonin due to a disturbance of BH4 biosynthesis or recycling. Hyperphenylalaninemia (HPA) is the first diagnostic hallmark for most BH4 deficiencies, apart from autosomal dominant guanosine triphosphate cyclohydrolase I deficiency and sepiapterin reductase deficiency. Early supplementation of neurotransmitter precursors and where appropriate, treatment of HPA results in significant improvement of motor and cognitive function. Management approaches differ across the world and therefore these guidelines have been developed aiming to harmonize and optimize patient care. Representatives of the International Working Group on Neurotransmitter related Disorders (iNTD) developed the guidelines according to the SIGN (Scottish Intercollegiate Guidelines Network) methodology by evaluating all available evidence for the diagnosis and treatment of BH4 deficiencies. CONCLUSION Although the total body of evidence in the literature was mainly rated as low or very low, these consensus guidelines will help to harmonize clinical practice and to standardize and improve care for BH4 deficient patients.
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Affiliation(s)
- Thomas Opladen
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany.
| | - Eduardo López-Laso
- Pediatric Neurology Unit, Department of Pediatrics, University Hospital Reina Sofía, IMIBIC and CIBERER, Córdoba, Spain
| | - Elisenda Cortès-Saladelafont
- Inborn errors of metabolism Unit, Institut de Recerca Sant Joan de Déu and CIBERER-ISCIII, Barcelona, Spain
- Unit of Pediatric Neurology and Metabolic Disorders, Department of Pediatrics, Hospital Germans Trias i Pujol, and Faculty of Medicine, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Toni S Pearson
- Department of Neurology, Washington University School of Medicine, St. Louis, USA
| | - H Serap Sivri
- Department of Pediatrics, Section of Metabolism, Hacettepe University, Faculty of Medicine, 06100, Ankara, Turkey
| | - Yilmaz Yildiz
- Department of Pediatrics, Section of Metabolism, Hacettepe University, Faculty of Medicine, 06100, Ankara, Turkey
| | - Birgit Assmann
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany
| | - Manju A Kurian
- Developmental Neurosciences, UCL Great Ormond Street-Institute of Child Health, London, UK
- Department of Neurology, Great Ormond Street Hospital, London, UK
| | - Vincenzo Leuzzi
- Unit of Child Neurology and Psychiatry, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Simon Heales
- Neurometabolic Unit, National Hospital, Queen Square, London, UK
| | - Simon Pope
- Neurometabolic Unit, National Hospital, Queen Square, London, UK
| | - Francesco Porta
- Department of Pediatrics, AOU Città della Salute e della Scienza, Torino, Italy
| | - Angeles García-Cazorla
- Inborn errors of metabolism Unit, Institut de Recerca Sant Joan de Déu and CIBERER-ISCIII, Barcelona, Spain
| | - Tomáš Honzík
- Department of Paediatrics and Adolescent Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Roser Pons
- First Department of Pediatrics of the University of Athens, Aghia Sofia Hospital, Athens, Greece
| | - Luc Regal
- Department of Pediatric, Pediatric Neurology and Metabolism Unit, UZ Brussel, Brussels, Belgium
| | - Helly Goez
- Department of Pediatrics, University of Alberta Glenrose Rehabilitation Hospital, Edmonton, Canada
| | - Rafael Artuch
- Clinical biochemistry department, Institut de Recerca Sant Joan de Déu, CIBERER and MetabERN Hospital Sant Joan de Déu, Barcelona, Spain
| | - Georg F Hoffmann
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany
| | - Gabriella Horvath
- Department of Pediatrics, Division of Biochemical Genetics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Beat Thöny
- Division of Metabolism, University Children's Hospital Zurich, Zürich, Switzerland
| | - Sabine Scholl-Bürgi
- Clinic for Pediatrics I, Medical University of Innsbruck, Anichstr 35, Innsbruck, Austria
| | - Alberto Burlina
- U.O.C. Malattie Metaboliche Ereditarie, Dipartimento della Salute della Donna e del Bambino, Azienda Ospedaliera Universitaria di Padova - Campus Biomedico Pietro d'Abano, Padova, Italy
| | - Marcel M Verbeek
- Departments of Neurology and Laboratory Medicine, Alzheimer Centre, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Mario Mastrangelo
- Unit of Child Neurology and Psychiatry, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Jennifer Friedman
- UCSD Departments of Neuroscience and Pediatrics, Rady Children's Hospital Division of Neurology; Rady Children's Institute for Genomic Medicine, San Diego, USA
| | - Tessa Wassenberg
- Department of Pediatric, Pediatric Neurology and Metabolism Unit, UZ Brussel, Brussels, Belgium
| | - Kathrin Jeltsch
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany
| | - Jan Kulhánek
- Department of Paediatrics and Adolescent Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.
| | - Oya Kuseyri Hübschmann
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany
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5
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Porta F, Ponzone A, Spada M. Short prolactin profile for monitoring treatment in BH4 deficiency. Eur J Paediatr Neurol 2015; 19:360-3. [PMID: 25707872 DOI: 10.1016/j.ejpn.2015.01.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 01/22/2015] [Accepted: 01/28/2015] [Indexed: 10/24/2022]
Abstract
Tetrahydrobiopterin (BH4) deficiency causes hyperphenylalaninemia and impaired synthesis of serotonin and dopamine, leading to brain degeneration and early death if left untreated. Replacement therapy with neurotransmitters precursors is the cornerstone of treatment, relying on 5-hydroxytryptophan and L-dopa administration. Effective restoration of dopaminergic activity is thickened, like in Parkinson's disease, by the pulsatile pharmacokinetic profile of L-dopa. Monitoring of L-dopa therapy in BH4 deficiency is generally based upon clinical observation and periodical measurement of homovanillic acid (HVA) concentration in the cerebrospinal fluid (CSF). According to the finding that dopamine is the natural inhibitor of prolactin (PRL) incretion, we introduced the use of peripheral PRL measurement as an index of dopaminergic homeostasis, so avoiding the need of repeated lumbar punctures in patients with BH4 deficiency. As a single PRL evaluation can be misleading, due to the dependency of PRL fluctuations on L-dopa administration schedule, here we show that a short PRL profile is suitable for monitoring these patients. Together with the assessment of patients' clinical symptoms, this standardized tool will ensure an objective non-invasive reference to the management of dopaminergic replacement therapy in BH4 deficiency, even in patients treated with dopamine agonists.
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Affiliation(s)
- Francesco Porta
- Department of Pediatrics, University of Torino, Piazza Polonia 94, 10126, Torino, Italy.
| | - Alberto Ponzone
- Department of Pediatrics, University of Torino, Piazza Polonia 94, 10126, Torino, Italy.
| | - Marco Spada
- Department of Pediatrics, University of Torino, Piazza Polonia 94, 10126, Torino, Italy.
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Rupprecht CE, Willoughby R, Slate D. Current and future trends in the prevention, treatment and control of rabies. Expert Rev Anti Infect Ther 2014; 4:1021-38. [PMID: 17181418 DOI: 10.1586/14787210.4.6.1021] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Rabies remains a global zoonosis of major public health, agricultural and economic significance. Dogs are the major animal reservoirs in developing regions, wildlife maintain cycles of infection even in developed countries and new viral etiological agents continue to emerge. Nearly all human rabies cases are related directly to animal bite and thus, primary disease prevention requires minimization of suspected exposures. Once exposure occurs, modern prophylaxis entails immediate wound care, local infiltration of rabies immune globulin and parenteral administration of modern cell culture vaccines in multiple doses. Pre-exposure vaccination should occur in selected population groups at risk of occupational exposure. Historically, survival from fatal rabies by at least five human patients, vaccinated prior to the onset of clinical signs, signaled initial optimism as to the theoretical utility of medical intervention. Recently, the heroic recovery of an unvaccinated teenager from clinical rabies offers hope of future specific therapy. Canine rabies elimination is the key towards ultimate reduction of the disease burden, as first illustrated in developed countries. Implementation of oral vaccination in free-ranging carnivore hosts demonstrates the feasibility of disease abatement in particular wildlife populations, such as demonstrated in Europe and North America, with an enhanced need for application to developing countries in the Americas, Africa and Eurasia.
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Affiliation(s)
- Charles E Rupprecht
- Centers for Disease Control & Prevention, 1600 Clifton Road, MS G33, Atlanta, GA 30333, USA.
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7
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Aitkenhead H, Heales SJ. Establishment of paediatric age-related reference intervals for serum prolactin to aid in the diagnosis of neurometabolic conditions affecting dopamine metabolism. Ann Clin Biochem 2013; 50:156-8. [PMID: 23404929 DOI: 10.1258/acb.2012.012080] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND There are a number of inborn errors of dopamine biosynthesis for which prolactin measurement may be a useful screening tool. However, the interpretation of prolactin results is difficult as age-related paediatric reference intervals are scant especially in infancy. METHODS Serum prolactin reference intervals were calculated from the existing laboratory data using an indirect method, based on patients (n = 2369) attending a tertiary care hospital over a 10-year period. The data were log transformed and partitioned by age and sex. RESULTS The prolactin results for all age and sex stratifications show non-gaussian distributions (P < 0.0001). There are apparent age-related differences for prolactin during the first year of life with prolactin declining sharply during the first year of life and continuing to decline until five years of age when the concentrations stabilize. The sex differences are small until 13-17 years of age when prolactin is higher in girls than in boys. CONCLUSIONS This is the first published study to report age-related prolactin reference intervals spanning all paediatric age groups where the data are age partitioned in infants under one year of age using an 'indirect' approach. It is envisaged that these reference intervals will be used to aid in the selection of patients presenting with features of central dopamine deficiency for lumbar puncture. Also, these reference intervals have the potential for treatment monitoring of patients with diagnoses of inborn errors of dopamine biosynthesis.
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Affiliation(s)
- Helen Aitkenhead
- Department of Chemical Pathology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK.
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8
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Niu DM. Disorders of BH4 metabolism and the treatment of patients with 6-pyruvoyl-tetrahydropterin synthase deficiency in Taiwan. Brain Dev 2011; 33:847-55. [PMID: 21880449 DOI: 10.1016/j.braindev.2011.07.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 07/21/2011] [Indexed: 11/19/2022]
Abstract
6-Pyruvoyl-tetrahydropterin synthase (PTPS) deficiency is the most frequent form of tetrahydrobiopterin (BH4) deficiency related to hyperphenylalaninemia (HPA). PTPS deficiency may not only cause a typical phenylketonuric phenotype, but is also accompanied by various neurological signs and symptoms due to impaired synthesis of catecholamines and serotonin. The treatment of PTPS deficiency is aimed at normalizing phenylalanine levels and brain neurotransmitters. The BH4 can be administered to normalize phenylalanine (PHE) levels easily, but, owing to severe side effects, the neurotransmitters, L-DOPA and 5-hydroxytryptophan, should be administered for these patients very carefully. However, optimal dosage of the neurotransmitters for PTPS deficiency patients is difficult to be determined. Several reports have described unsatisfied outcomes in a large percentage of patients with PTPS deficiency, despite early detection and treatment. Between 1988 and 2000, 12 newborns with PTPS deficiency identified by newborn screening were referred and received early treatment at our hospital. The mean IQ score of these 12 patients was 96.7 (±9.7; range: 86-119), which is considerably higher than previous reports of other populations of PTPS-deficient patients. In this report, we reviewed the disorders of BH4 briefly and then described treatments of our PTPS-deficient patients.
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Affiliation(s)
- Dau-Ming Niu
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan.
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9
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Niu DM. WITHDRAWN: Disorders of BH4 metabolism and the treatment of patients with 6-pyruvoyl-tetrahydropterin synthase deficiency in Taiwan. Brain Dev 2011:S0387-7604(11)00140-9. [PMID: 21696901 DOI: 10.1016/j.braindev.2011.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 05/11/2011] [Accepted: 05/11/2011] [Indexed: 11/19/2022]
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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Affiliation(s)
- Dau-Ming Niu
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
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10
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Ogawa A, Kanazawa M, Takayanagi M, Kitani Y, Shintaku H, Kohno Y. A case of 6-pyruvoyl-tetrahydropterin synthase deficiency demonstrates a more significant correlation of L-Dopa dosage with serum prolactin levels than CSF homovanillic acid levels. Brain Dev 2008; 30:82-5. [PMID: 17590551 DOI: 10.1016/j.braindev.2007.05.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Revised: 04/06/2007] [Accepted: 05/21/2007] [Indexed: 10/23/2022]
Abstract
6-Pyruvoyl-tetrahydropterin synthase (PTPS) deficiency is a tetrahydrobiopterin (BH4) deficiency that presents as hyperphenylalaninemia. Administration of the neurotransmitter precursors L-Dopa/carbidopa and 5-hydroxytryptophan (5HTP), as well as BH4, is necessary for treatment. It has been reported that serum prolactin levels are elevated in patients with PTPS deficiency indicating that inhibition of prolactin secretion by dopamine is insufficient and is negatively correlated with the CSF level of HVA. Here, we present a case of PTPS deficiency which showed a more significant correlation of dosage of L-Dopa/carbidopa with serum prolactin levels than with CSF HVA levels. Combined treatment of BH4, L-Dopa/carbidopa, and 5HTP was started as the CSF neopterin/biopterin ratio (N/B ratio 7.54, control 0.46-1.59) and serum prolactin level (36.79 ng/ml, control <15) were elevated. The dosage of L-Dopa/carbidopa was adjusted in the range of 9.08-10.5mg/kg/day. The CSF level of HVA stayed within normal limits using these dosages of L-Dopa/carbidopa, and there was no correlation between dose given and HVA level (R=0.230, p=0.71). On the other hand, even in this relatively small dosing range, the serum prolactin level showed significant negative correlation with the dosage of L-Dopa/carbidopa (R=0.645, p=0.023). The patient did not show any neurological symptoms even when the serum prolactin level was elevated. From these results, we suggest that the serum prolactin level may be a more sensitive marker than the CSF HVA level to guide the dose adjustment of L-Dopa/carbidopa in the management of patients with PTPS deficiency.
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Affiliation(s)
- Atsushi Ogawa
- Department of Pediatrics, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan.
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11
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Parra A, Ramírez-Peredo J, Hidalgo R, Morales-Toquero A, Velásquez-Ramírez G, Ruiz-Argüelles A, Ruiz-Argüelles GJ. Altered Functional Status of the Hypothalamic Dopaminergic Tone in Patients with Chronic Graft-versus-Host Disease after Allogeneic Hematopoietic Stem Cell Transplantation: A Pilot Study. Biol Blood Marrow Transplant 2006; 12:566-72. [PMID: 16635792 DOI: 10.1016/j.bbmt.2005.12.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2005] [Accepted: 12/16/2005] [Indexed: 11/22/2022]
Abstract
We compared the functional status of the hypothalamic dopaminergic tone in patients given an allogeneic hematopoietic stem cell transplantation (allo-HSCT) with chronic graft-versus-host disease (GVHD) with that observed in patients with allo-HSCT without chronic GVHD and in healthy controls. The effect of acute dopaminergic blockade with intravenous metoclopramide on serum prolactin (PRL) concentrations was evaluated. Twenty volunteers, 20 to 52 years of age, seronegative for both hepatitis C virus and the human immunodeficiency virus, were studied: (1) 10 clinically healthy men (group 1), and (2) 9 patients with leukemia, and 1 patient with refractory aplastic anemia who underwent allo-HSCT, 5 of whom (3 men and 2 women) developed chronic GVHD (group 2), and 5 (3 men and 2 women) who did not develop chronic GVHD (group 3). Serum PRL concentrations were measured both fasting and after intravenous administration of metoclopramide (10-mg bolus). The area under the PRL curve was calculated. Patients in group 2 were older than those in groups 1 and 3 (P<.018), but their body mass index was similar. Fasting serum PRL concentrations were similar among the 3 groups; however, group 2 had higher PRL concentrations throughout the test (P<.001) and a greater area under the PRL curve than groups 1 and 3 (P<.001), without differences between the last 2 groups. The differences remained significant after adjustment for age (P<.01). Our results in a small group of patients with chronic GVHD after allo-HSCT suggest the existence of an increased functional level of their hypothalamic dopamine tone, which would favor a tendency toward a diminished endogenous production, release of pituitary PRL, or both. This could represent an adaptive mechanism aiming to maintain circulating PRL concentrations within a physiological range.
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Affiliation(s)
- Adalberto Parra
- Department of Endocrinology, Instituto Nacional de Perinatología, Mexico City, Mexico
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Roze E, Vidailhet M, Blau N, Moller LB, Doummar D, de Villemeur TB, Roubergue A. Long-term follow-up and adult outcome of 6-pyruvoyl-tetrahydropterin synthase deficiency. Mov Disord 2006; 21:263-6. [PMID: 16161143 DOI: 10.1002/mds.20699] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Little information is available on the long-term course and adult outcome of patients with 6-pyruvoyl-tetrahydropterin synthase (PTPS) deficiency. We describe the course of a 32-year-old woman with hypotonia, dystonia, choreoathetosis, mental retardation, behavioral disturbances, and incomplete puberty due to PTPS deficiency. From the age of 6 months she developed progressive hypotonia and choreoathtetoid movements despite good control of hyperphenylalaninemia. Tetrahydrobiopterin deficiency was diagnosed at age 3 years. She had a dramatic response to L-dopa, which persisted at a stable dose for 29 years. Reducing the L-dopa dose led to severe axial hypotonia and limb dystonia, and increasing it led to florid abnormal movements and behavioral disorders. This report illustrates the role of dopamine modulation in motor, psychiatric, and endocrine functions.
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Affiliation(s)
- Emmanuel Roze
- Department of Neurology, Saint-Antoine Hospital, Paris, France, and Division of Clinical Chemistry and Biochemistry, University Children's Hospital, Zurich, Switzerland.
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Ponzone A, Spada M, Ferraris S, Dianzani I, de Sanctis L. Dihydropteridine reductase deficiency in man: from biology to treatment. Med Res Rev 2004; 24:127-50. [PMID: 14705166 DOI: 10.1002/med.10055] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In 1975, dihydropteridine reductase (DHPR) deficiency was first recognized as a cause of tetrahydrobiopterin (BH(4)) deficiency, leading to hyperphenylalaninemia (HPA) and impaired biogenic amine deficiency. So far, more than 150 patients scattered worldwide have been reported and major progresses have been made in the understanding of physiopathology, screening, diagnosis, treatment, and molecular genetics of this inherited disease. Present knowledge on different aspects of DHPR deficiency, largely derived from authors' personal experience, is traced in this article.
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Hoffmann GF, Assmann B, Bräutigam C, Dionisi-Vici C, Häussler M, de Klerk JBC, Naumann M, Steenbergen-Spanjers GCH, Strassburg HM, Wevers RA. Tyrosine hydroxylase deficiency causes progressive encephalopathy and dopa-nonresponsive dystonia. Ann Neurol 2003; 54 Suppl 6:S56-65. [PMID: 12891655 DOI: 10.1002/ana.10632] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tyrosine hydroxylase (TH) is the key enzyme in the biosynthesis of the catecholamines dopamine, epinephrine, and norepinephrine. Recessively inherited deficiency of TH was recently identified and incorporated into recent concepts of genetic dystonias as the cause of recessive Dopa-responsive dystonia or Segawa's syndrome in analogy to dominantly inherited GTP cyclohydrolase I deficiency. We report four patients with TH deficiency and two with GTP cyclohydrolase I deficiency. Patients with TH deficiency suffer from progressive infantile encephalopathy dominated by motor retardation similar to a primary neuromuscular disorder, fluctuating extrapyramidal, and ocular and vegetative symptoms. Intellectual functions are mostly compromised. Prenatally disturbed brain development and postnatal growth failure were observed. Treatment with levodopa ameliorates but usually does not normalize symptoms. Compared with patients with dominantly inherited GTP cyclohydrolase I deficiency, catecholaminergic neurotransmission is severely and constantly impaired in TH deficiency. In most patients, this results not in predominating dystonia, a largely nondegenerative condition, but in a progressive often lethal neurometabolic disorder, which can be improved but not cured by L-dopa. Investigations of neurotransmitter defects by specific cerebrospinal fluid determinations should be included in the diagnostic evaluation of children with progressive infantile encephalopathy.
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Affiliation(s)
- Georg F Hoffmann
- Department of Pediatrics, University of Heidelberg, Heidelberg, Germany.
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Parra A, Ramírez-Peredo J, Larrea F, Cabrera V, Coutiño B, Torres I, Angeles A, Pérez-Romano B, Ruiz-Argüelles G, Ruiz-Argüelles A. Decreased dopaminergic tone and increased basal bioactive prolactin in men with human immunodeficiency virus infection. Clin Endocrinol (Oxf) 2001; 54:731-8. [PMID: 11422107 DOI: 10.1046/j.1365-2265.2001.01262.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The aims of the study were: (1) to assess dopaminergic tone in a group of HIV infected men and the bioactivity and the molecular species of their circulating PRL in comparison with healthy men and (2) to search for a correlation between serum PRL and CD4+ T lymphocytes and viral load. DESIGN In a cross-sectional study the effect of acute dopaminergic blockade with intravenous metoclopramide on serum PRL (both immunoreactive and biologically active), TSH and PRL circulating molecular isoforms was evaluated. PATIENTS Twenty untreated HIV infected men category C2 or C3, mean (SD) age 26.9 (6.3) years, were compared to 14 clinically healthy HIV-negative men, age 25.4 (2.3) years. MEASUREMENTS Under fasting conditions and following metoclopramide administration duplicate measurements of serum immunoreactive PRL, bioactive PRL (PRL dependent Nb2 lymphoma cell assay) and immunoreactive TSH were performed. The molecular species of circulating PRL were determined by immunoblot analysis, CD4+ T lymphocytes by flow cytometry and the viral load using a nucleic acid sequence-based amplification assay. RESULTS In HIV infected men fasting bioactive (but not immunoreactive) PRL was higher (P = 0.03), but the stimulated PRL (both immunoreactive and bioactive) was lower than in healthy men throughout the test (P < or = 0.01). Fasting serum TSH was similar in HIV-infected and healthy men while its response to metoclopramide was absent in the former but not in the latter (P = 0.049). A 23.5-kD PRL was the predominant circulating isoform both in patients and healthy men. Considering HIV-infected and healthy men, CD4+ T lymphocytes correlated negatively with fasting bioactive PRL (P = 0.008) and positively with the area under the PRL (both immunoreactive and bioactive) curves (P < 0.001). The viral load was negatively correlated with the area under the curve of the bioactive/immunoreactive ratio (P = 0.008). CONCLUSIONS The raised fasting bioactive PRL, the diminished response of both immunoreactive and bioactive PRL and the absent TSH response to metoclopramide in HIV infected men, suggest the existence of a decreased, but not absent dopaminergic tone. A monomeric form of PRL was the predominant circulating species, as in healthy men, and this hormone seems to be associated both with CD4+ T lymphocytes and the viral load.
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Affiliation(s)
- A Parra
- Department of Endocrinology, Instituto Nacional de Perinatología, Mexico City, Mexico.
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Dionisi-Vici C, Hoffmann GF, Leuzzi V, Hoffken H, Bräutigam C, Rizzo C, Steebergen-Spanjers GC, Smeitink JA, Wevers RA. Tyrosine hydroxylase deficiency with severe clinical course: clinical and biochemical investigations and optimization of therapy. J Pediatr 2000; 136:560-2. [PMID: 10753262 DOI: 10.1016/s0022-3476(00)90027-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Tyrosine hydroxylase deficiency was diagnosed after determination of cerebrospinal fluid neurotransmitters and DNA analysis in a child with severe axial hypotonia and hypokinesia associated with dystonic and ballistic movements. L-dopa therapy was unsuccessful, whereas a combination with selegiline, a selective monoamine oxidase-beta inhibitor, with low-dose L-dopa markedly improved the severe clinical picture.
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Affiliation(s)
- C Dionisi-Vici
- Department of Metabolism, Bambino Gesù Hospital, Rome, Italy
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Parra A, Ramírez-Peredo J, Coutiño B, Lagunes B, Marín A, Ponce de Leon S, Ruiz-Argüelles GJ. Impaired metoclopramide-induced pituitary prolactin release in men with human immunodeficiency virus infection. THE JOURNAL OF LABORATORY AND CLINICAL MEDICINE 1999; 133:70-4. [PMID: 10385484 DOI: 10.1053/lc.1999.v133.a94237] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
To investigate whether metoclopramide-induced prolactin release is impaired in HIV-infected men, we studied 10 clinically healthy HIV-negative adult men (group 1) and 10 consecutive HIV-positive adult men (group 2) with anti-HIV antibodies confirmed by Western blot analysis and a CD4 cell count from 13 to 570x10(6)/L. After a 10- to 12-hour overnight fast, three basal blood samples were obtained at 15-minute intervals (-30, -15, and 0 minutes) and thereafter at 15, 30, 60, 90, 120, 180, and 240 minutes after a 10-mg intravenous bolus of metoclopramide. Duplicate serum prolactin concentrations were measured in each sample with commercially available radioimmunoassay kits. No significant differences between groups were observed in basal prolactin levels. Group 2 had lower serum prolactin concentrations than group 1 throughout the test (P< or =.002). The area under the prolactin curve (mean +/- SD) was also lower in group 2 than in group 1 (7156+/-1433 ng/mL/240 min vs. 12430+/-2454 ng/mL/240 min, P<.0001), and the area under the prolactin curve had a significant correlation with the CD4 cell counts (r = 0.7912, P<.001). These findings suggest that the hypothalamic dopaminergic tone, although present, was clearly diminished in these HIV-positive men regardless of their clinical stage.
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Affiliation(s)
- A Parra
- Department of Endocrinology, Instituto Nacional de Perinatología, México City, Mexico
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