1
|
Brahmane NA, Sharath HV, Seth NH, Khan AF. Effects of a Tailored Pediatric Rehabilitation Protocol on Children With Neurometabolic Disorder: A Case Report. Cureus 2024; 16:e57115. [PMID: 38681474 PMCID: PMC11055611 DOI: 10.7759/cureus.57115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/28/2024] [Indexed: 05/01/2024] Open
Abstract
Neurometabolic disorders encompass a diverse group of conditions characterized by inborn errors of metabolism, affecting various aspects of neurological function. This case report focuses on an 11-year-old male child with a neurometabolic disorder who presents with walking difficulties, speech impairment, and neurological symptoms. The background emphasizes the heterogeneity of neurometabolic disorders, their genetic and clinical complexity, and the need for tailored interventions to address specific manifestations. The primary aim of this study is to implement a comprehensive physiotherapy intervention plan for an 11-year-old male child with a neurometabolic disorder, targeting the improvement of gait abnormalities, regaining developmental milestones, and addressing associated challenges such as fatigue. The physiotherapy intervention plan employs a multifaceted approach, incorporating principles of neuroplasticity, motor learning, and adaptive strategies. A comprehensive gait training protocol involves proper orthotic fitting, forearm support walker training, treadmill exercises, and parallel bar training. Developmental milestones are addressed through motor and fine motor skill exercises. Coping strategies and energy conservation techniques are integrated to manage fatigue. The study utilizes outcome measures, including the Gross Motor Function Measure, Manual Ability Classification System, and Functional Independence Measure, to assess the impact of the intervention on the patient's functional abilities. Preliminary findings suggest promising improvements in gait, motor skills, and overall functional independence following the implemented physiotherapy intervention. The study underscores the potential effectiveness of a tailored approach rooted in neuroplasticity and motor learning principles for individuals with neurometabolic disorders. The patient-centered care model, encompassing coping strategies and energy conservation techniques, contributes to holistic well-being. While specific literature on these interventions in neurometabolic disorders is limited, the study provides valuable insights and calls for further research to refine and expand tailored therapeutic approaches in this challenging clinical context.
Collapse
Affiliation(s)
- Neha A Brahmane
- Department of Paediatric Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - H V Sharath
- Department of Paediatric Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Nikita H Seth
- Department of Neurophysiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Arasha F Khan
- Department of Paediatric Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| |
Collapse
|
2
|
Doshi HP, Vachharajani HH, Tchan MC, Nasreddine MA, Billmore KE. Metabolic crisis in maple syrup urine disease: an unusual complication of a rare disease: a case report. Anaesth Intensive Care 2024; 52:64-68. [PMID: 37994838 DOI: 10.1177/0310057x231183981] [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] [Indexed: 11/24/2023]
Abstract
A 19-year-old woman with known maple syrup urine disease presented to hospital with metabolic crisis in the setting of influenza type A infection and intractable vomiting, rapidly progressing to acute cerebral oedema manifesting as refractory seizures and decreased level of consciousness needing emergency intubation and mechanical ventilation, continuous veno-venous haemodiafiltration and thiopentone coma. A computed tomography scan and magnetic resonance imaging of the brain demonstrated classic signs of cerebral oedema secondary to a metabolic crisis from the metabolic disorder. Her management posed multiple challenges to all teams involved due to lack of familiarity and experience in managing this clinical scenario in the adult intensive care setting.
Collapse
Affiliation(s)
- Hemang P Doshi
- Department of Intensive Care Services, Westmead Hospital, Sydney, Australia
| | | | - Michael C Tchan
- Department of Genetic Medicine, Westmead Hospital, Sydney, Australia
| | | | - Kate E Billmore
- Department of Genetic Medicine, Westmead Hospital, Sydney, Australia
| |
Collapse
|
3
|
Yuzkan S, Emecen Sanli M, Balci M, Cennetoglu P, Kafadar I, Kocak B. Use of Thalamus L-Sign to Differentiate Periventricular Leukomalacia From Neurometabolic Disorders. J Child Neurol 2023; 38:446-453. [PMID: 37128731 DOI: 10.1177/08830738231168973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
PURPOSE To assess the diagnostic value of the thalamus L-sign on magnetic resonance imaging (MRI) in distinguishing between periventricular leukomalacia and neurometabolic disorders in pediatric patients. METHODS In this retrospective study, clinical and imaging information was collected from 50 children with periventricular leukomalacia and 52 children with neurometabolic disorders. MRI was used to evaluate the L-sign of the thalamus (ie, injury to the posterolateral thalamus) and the lobar distribution of signal intensity changes. Age, sex, gestational age, and level of Gross Motor Function Classification System (only for periventricular leukomalacia) constituted the clinical parameters. Statistical evaluation of group differences for imaging and clinical variables were conducted using univariable statistical methods. The intra- and inter-observer agreement was evaluated using Cohen's kappa. Univariable or multivariable logistic regression was employed for selection of variables, determining independent predictors, and modeling. RESULTS The thalamus L-sign was observed in 70% (35/50) of patients in the periventricular leukomalacia group, but in none of the patients with neurometabolic disorder (P < .001). The gestational age between groups varied significantly (P < .001). Involvement of frontal, parietal, and occipital lobes differed significantly between groups (P < .001). In the logistic regression, the best model included negative thalamus L-sign and gestational age, yielding an area under the curve, accuracy, sensitivity, specificity, and precision values of 0.995, 96.1%, 96%, 96.2%, and 96%, respectively. Both the lack of thalamus L-sign and gestational age were independent predictors (P < .001). CONCLUSIONS The thalamus L-sign and gestational age may be useful in distinguishing between periventricular leukomalacia and neurometabolic disorders.
Collapse
Affiliation(s)
- Sabahattin Yuzkan
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, Istanbul, Turkey
| | - Merve Emecen Sanli
- Department of Pediatric Inherited Metabolic Diseases, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, Istanbul, Turkey
| | - Merve Balci
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, Istanbul, Turkey
| | - Pakize Cennetoglu
- Department of Pediatric Neurology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, Istanbul, Turkey
| | - Ihsan Kafadar
- Department of Pediatric Neurology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, Istanbul, Turkey
| | - Burak Kocak
- Department of Radiology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Basaksehir, Istanbul, Turkey
| |
Collapse
|
4
|
Kempińska W, Korta K, Marchaj M, Paprocka J. Microcephaly in Neurometabolic Diseases. CHILDREN (BASEL, SWITZERLAND) 2022; 9:97. [PMID: 35053723 PMCID: PMC8774396 DOI: 10.3390/children9010097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/31/2021] [Accepted: 12/31/2021] [Indexed: 12/18/2022]
Abstract
Neurometabolic disorders are an important group of diseases that mostly occur in neonates and infants. They are mainly due to the lack or dysfunction of an enzyme or cofactors necessary for a specific biochemical reaction, which leads to a deficiency of essential metabolites in the brain. This, in turn, can cause certain neurometabolic diseases. Disruption of metabolic pathways, and the inhibition at earlier stages, may lead to the storage of reaction intermediates, which are often toxic to the developing brain. Symptoms are caused by the progressive deterioration of mental, motor, and perceptual functions. The authors review the diseases with microcephaly, which may be one of the most visible signs of neurometabolic disorders.
Collapse
Affiliation(s)
| | | | | | - Justyna Paprocka
- Students’ Scientific Society, Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland; (W.K.); (K.K.); (M.M.)
| |
Collapse
|
5
|
Wassenberg T, Geurtz BPH, Monnens L, Wevers RA, Willemsen MA, Verbeek MM. Blood, urine and cerebrospinal fluid analysis in TH and AADC deficiency and the effect of treatment. Mol Genet Metab Rep 2021; 27:100762. [PMID: 33996491 PMCID: PMC8093927 DOI: 10.1016/j.ymgmr.2021.100762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 12/03/2022] Open
Abstract
Background Aromatic L-amino acid decarboxylase (AADC) deficiency and tyrosine hydroxylase (TH) deficiency are rare inherited disorders of monoamine neurotransmitter synthesis which are typically diagnosed using cerebrospinal fluid examination of monoamine neurotransmitter metabolites. Until now, it has not been systematically studied whether analysis of monamine neurotransmitter metabolites in blood or urine has diagnostic value as compared to cerebrospinal fluid examination, or whether monoamine neurotransmitter metabolites in these peripheral body fluids is useful to monitor treatment efficacy. Methods Assessment, both by literature review and retrospective analysis of our local university hospital database, of monoamine neurotransmitter metabolites in urine, blood and cerebrospinal fluid, and serum prolactin levels, before and during treatment in patients with AADC and TH deficiency. Results In AADC deficiency, 3-O-methyldopa in serum or dried blood spots was reported in 34 patients and found to be (strongly) increased in all, serotonin in serum was decreased in 7/7 patients. Serum prolactin was increased in 34/37 and normal in 3 untreated patients. In urine, dopamine was normal or increased in 21/24 patients, 5-hydroxyindoleacetic acid was decreased in 9/10 patients, and vanillactic acid was increased in 19/20 patients. No significant changes were seen in monoamine neurotransmitter metabolites after medical treatment, except for an increase of homovanillic acid in urine and cerebrospinal fluid after levodopa therapy, sometimes even in absence of a clinical response. After gene therapy, cerebrospinal fluid homovanillic acid increased in most patients (8/12), but 5-hydroxyindoleacetic acid remained unchanged in 9/12 patients. In TH deficiency, serum prolactin was increased in 12/14 and normal in the remaining untreated patients. Urinary dopamine was decreased in 2/8 patients and normal in 6. Homovanillic acid concentrations in cerebrospinal fluid increased upon levodopa treatment, even in the absence of a clear treatment response. Conclusions This study confirms that cerebrospinal fluid is the most informative body fluid to measure monoamine neurotransmitter metabolites when AADC or TH deficiency is suspected, and that routine follow-up of cerebrospinal fluid measurements to estimate treatment response is not needed. 3-O-methyldopa in dried blood spots and vanillactic acid in urine are promising peripheral biomarkers for diagnosis of AADC deficiency. However, in many patients with TH or AADC deficiency dopamine in urine is normal or increased thereby not reflecting the metabolic block. The value of serum prolactin for follow-up of AADC and TH deficiency should be further studied.
Collapse
Key Words
- 3-OMD, 3-O-methyldopa
- 5-HIAA, 5-Hydroxyindoleacetic acid
- 5-HTP, 5-Hydroxytryptophan
- AADC deficiency
- AADC, Aromatic L-amino acid decarboxylase
- Aromatic L-amino acid decarboxylase deficiency
- Biomarkers
- CSF, Cerebrospinal fluid
- HVA, Homovanillic acid
- MHPG, 3-methoxy 4-hydroxyphenylglycol
- Monoamine neurotransmitter deficiency
- TH deficiency
- TH, Tyrosine hydroxylase
- TML, Translational Metabolic Laboratory
- Tyrosine hydroxylase deficiency
- VLA, Vanillactic acid
- VMA, Vanillylmandelic acid
Collapse
Affiliation(s)
- Tessa Wassenberg
- Radboud university medical center, Department of Neurology (943), Donders Institute for Brain, Cognition and Behaviour, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.,Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Department of Pediatrics, Pediatric Neurology Unit, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Ben P H Geurtz
- Radboud university medical center, Department of Laboratory Medicine, Translational Metabolic Laboratory (830), PO Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - Leo Monnens
- Radboud university medical center, Department of Physiology (392), PO Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - Ron A Wevers
- Radboud university medical center, Department of Laboratory Medicine, Translational Metabolic Laboratory (830), PO Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - Michèl A Willemsen
- Radboud university medical center, Amalia Children's Hospital, Department of Pediatric Neurology (801), Donders Institute for Brain, Cognition and Behaviour, PO Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Marcel M Verbeek
- Radboud university medical center, Department of Neurology (943), Donders Institute for Brain, Cognition and Behaviour, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.,Radboud university medical center, Department of Laboratory Medicine, Translational Metabolic Laboratory (830), PO Box 9101, 6500 HB, Nijmegen, the Netherlands
| |
Collapse
|
6
|
Al Orf A, Waheed KB, Ali EM, Muhammad AK, Al Zahrani FM, Seth SA, Al Jubair NN, Harisi HS, Arulanantham ZJ. Inherited paediatric neurometabolic disorders, can brain magnetic resonance imaging predict? NEUROSCIENCES (RIYADH, SAUDI ARABIA) 2021; 25:392-398. [PMID: 33459289 PMCID: PMC8015596 DOI: 10.17712/nsj.2020.5.20200072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Objectives: To evaluate diagnostic capability of brain magnetic resonance imaging (MRI) in detection of inherited neurometabolic disorders. Methods: This retrospective observational study was performed in Radiology Department at our Hospital in Dhahran, from January 2013 to January 2020. We evaluated brain MRIs of children (under 5) who were referred to pediatric neurology for clinical suspicion of neuro-developmental delay and metabolic disease. Known perinatal ischemia and birth trauma cases were excluded. Imaging criteria included: (i) bilateral symmetric white matter signal abnormality, (ii) diffusion restriction affecting bilateral deep grey nuclei with or without brainstem involvement, (iii) brain atrophy or edema with abnormal white matter signal, (iv) characteristic MR spectroscopic finding. Presence of any one of these findings was considered positive for neurometabolic disease. Two neuroradiologists interpreted MRIs with substantial interobserver agreement. Diagnoses were confirmed on biochemical/ metabolic screening and genetic testing. A 2 × 2 contingency table was used for results. Chi square test was used to determine association. Results: Out of 133 cases, 72 (49 males, 90% AR) were found to have neurometabolic disorders. Sensitivity, specificity, positive and negative predictive values were calculated as 81.94% (CI, 71.11-90.02), 67.21% (CI, 54.00-78.69), 74.68% (CI, 66.96-81.11) and 75.93% (CI, 65.16-84.17) respectively. Findings were found significant (p-value=0.0001). Conclusion: Brain MRI can help to predict inherited neurometabolic disorders considering certain findings.
Collapse
Affiliation(s)
- Ali Al Orf
- Department of Radiology Department, King Fahad Military Medical Complex, Dhahran, Kingdom of Saudi Arabia
| | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Biallelic variants in HPDL, encoding 4-hydroxyphenylpyruvate dioxygenase-like protein, lead to an infantile neurodegenerative condition. Genet Med 2020; 23:524-533. [PMID: 33188300 DOI: 10.1038/s41436-020-01010-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/06/2020] [Accepted: 10/06/2020] [Indexed: 11/08/2022] Open
Abstract
PURPOSE Dioxygenases are oxidoreductase enzymes with roles in metabolic pathways necessary for aerobic life. 4-hydroxyphenylpyruvate dioxygenase-like protein (HPDL), encoded by HPDL, is an orphan paralogue of 4-hydroxyphenylpyruvate dioxygenase (HPD), an iron-dependent dioxygenase involved in tyrosine catabolism. The function and association of HPDL with human diseases remain unknown. METHODS We applied exome sequencing in a cohort of over 10,000 individuals with neurodevelopmental diseases. Effects of HPDL loss were investigated in vitro and in vivo, and through mass spectrometry analysis. Evolutionary analysis was performed to investigate the potential functional separation of HPDL from HPD. RESULTS We identified biallelic variants in HPDL in eight families displaying recessive inheritance. Knockout mice closely phenocopied humans and showed evidence of apoptosis in multiple cellular lineages within the cerebral cortex. HPDL is a single-exonic gene that likely arose from a retrotransposition event at the base of the tetrapod lineage, and unlike HPD, HPDL is mitochondria-localized. Metabolic profiling of HPDL mutant cells and mice showed no evidence of altered tyrosine metabolites, but rather notable accumulations in other metabolic pathways. CONCLUSION The mitochondrial localization, along with its disrupted metabolic profile, suggests HPDL loss in humans links to a unique neurometabolic mitochondrial infantile neurodegenerative condition.
Collapse
|
8
|
Chinopoulos C. Quantification of mitochondrial DNA from peripheral tissues: Limitations in predicting the severity of neurometabolic disorders and proposal of a novel diagnostic test. Mol Aspects Med 2019; 71:100834. [PMID: 31740079 DOI: 10.1016/j.mam.2019.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/07/2019] [Accepted: 11/12/2019] [Indexed: 11/25/2022]
Abstract
Neurometabolic disorders stem from errors in metabolic processes yielding a neurological phenotype. A subset of those disorders encompasses mitochondrial abnormalities partially due to mitochondrial DNA (mtDNA) depletion. mtDNA depletion can be attributed to inheritance, spontaneous mutations or acquired from drug-related toxicities. In the armamentarium of diagnostic procedures, mtDNA quantification is a standard for disease classification. However, alterations in mtDNA obtained from peripheral tissues such as skin fibroblasts and blood cells do not often reflect the severity of the affected organ, in this case, the brain. The purpose of this review is to highlight the pitfalls of quantitating mtDNA from peripheral -and not limited to-tissues for diagnosing patients suffering from a variety of mtDNA depletion syndromes exhibiting neurologic abnormalities. In lieu, a qualitative test of mitochondrial substrate-level phosphorylation -even from peripheral tissues-reflecting the ability of mitochondria to rely on glutaminolysis in the presence of respiratory chain defects is proposed as a novel diagnostic assessment of mitochondrial functionality.
Collapse
Affiliation(s)
- Christos Chinopoulos
- Department of Medical Biochemistry, Semmelweis University, Tuzolto St. 37-47, Budapest, 1094, Hungary.
| |
Collapse
|