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全 娇, 刘 小, 胡 可, 侯 茜. [Enteral nutrition support for lysinuric protein intolerance: a case report and literature review]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:1270-1275. [PMID: 38112146 PMCID: PMC10731975 DOI: 10.7499/j.issn.1008-8830.2306148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 11/09/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVES To summarize the clinical characteristics and nutrition therapy for children with lysinuric protein intolerance (LPI). METHODS The clinical manifestations, laboratory test results and enteral nutrition treatment in a girl with LPI diagnosed in Xiangya Hospital, Central South University were retrospective analyzed. Additionally, the data of the children with LPI reported in China and overseas were reviewed. RESULTS A case of 4-year-old girl was presented, who exhibited significant gastrointestinal symptoms, such as chronic abdominal distension, prolonged diarrhea, recurrent pneumonia, and limited growth. She had a poor response to anti-infection treatment. After receiving enteral nutrition therapy, she did not experience any gastrointestinal discomfort, and there were improvements in the levels of hemoglobin, albumin, and blood ammonia. Unfortunately, due to serious illness, she declined further treatment and later passed away. A total of 92 cases of pediatric patients with LPI have been reported to date, including one case reported in this study. Most children with LPI experienced disease onset after weaning or introduction of complementary foods, presenting with severe digestive system symptoms, malnutrition, and growth retardation. It is noteworthy that only 50% (46/92) of these cases received nutritional therapy, which effectively improved their nutritional status. Among the 92 children, 8 (9%) died, and long-term follow-up data were lacking in other reports. CONCLUSIONS LPI often involves the digestive system and may result in growth restriction with a poor prognosis. Nutritional therapy plays a crucial role in the comprehensive treatment of LPI.
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Ziegler SG, Kim J, Ehmsen JT, Vernon HJ. Inborn errors of amino acid metabolism - from underlying pathophysiology to therapeutic advances. Dis Model Mech 2023; 16:dmm050233. [PMID: 37994477 PMCID: PMC10690057 DOI: 10.1242/dmm.050233] [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: 04/06/2023] [Accepted: 10/19/2023] [Indexed: 11/24/2023] Open
Abstract
Amino acids are organic molecules that serve as basic substrates for protein synthesis and have additional key roles in a diverse array of cellular functions, including cell signaling, gene expression, energy production and molecular biosynthesis. Genetic defects in the synthesis, catabolism or transport of amino acids underlie a diverse class of diseases known as inborn errors of amino acid metabolism. Individually, these disorders are rare, but collectively, they represent an important group of potentially treatable disorders. In this Clinical Puzzle, we discuss the pathophysiology, clinical features and management of three disorders that showcase the diverse clinical presentations of disorders of amino acid metabolism: phenylketonuria, lysinuric protein intolerance and homocystinuria due to cystathionine β-synthase (CBS) deficiency. Understanding the biochemical perturbations caused by defects in amino acid metabolism will contribute to ongoing development of diagnostic and management strategies aimed at improving the morbidity and mortality associated with this diverse group of disorders.
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Affiliation(s)
- Shira G. Ziegler
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Jiyoung Kim
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Jeffrey T. Ehmsen
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Hilary J. Vernon
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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Lokuhewage C, Pathiraja H, Madawala P, Bandara S, Mettananda S. Lysinuric protein intolerance presenting as pancytopenia and splenomegaly mimicking acute leukaemia: a case report. BMC Pediatr 2023; 23:382. [PMID: 37528333 PMCID: PMC10391768 DOI: 10.1186/s12887-023-04207-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 07/21/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Lysinuric protein intolerance is a rare inherited metabolic disease due to autosomal recessive mutations of the SLC7A7 gene. The affected patients commonly present with protein-rich food intolerance, failure to thrive, hepatosplenomegaly, muscle hypotonia and lung involvement due to impaired intestinal absorption and excessive urinary excretion of dibasic amino acids. Presentation with splenomegaly and cytopenia without other features has not been reported. Here we report a Sri Lankan girl with lysinuric protein intolerance presenting with pancytopenia and splenomegaly mimicking acute leukaemia. CASE PRESENTATION Two years and six months old Sri Lankan girl presented with persistent pancytopenia following a viral illness. She was asymptomatic without vomiting, diarrhoea, abdominal pain or irritability. Physical examination revealed pallor and isolated firm splenomegaly of 2 cm. Growth parameters and other system examinations were normal. Full blood count revealed anaemia, leukopenia and thrombocytopenia. The blood picture showed a mixture of hypochromic microcytic and normochromic normocytic red cells with occasional pencil cells and macrocytes. Bone marrow examination was normal except for occasional megaloblasts; however, serum vitamin B12 and red blood cell folate were normal. The metabolic screen showed a high anion gap compensated metabolic acidosis, high lactate and ketosis. Genetic mutation analysis using whole exome sequencing revealed compound heterozygous variants of the SLC7A7 gene, confirming the diagnosis of lysinuric protein intolerance. CONCLUSION We report a child with lysinuric protein intolerance presenting with pancytopenia and splenomegaly without other disease features. This case report adds to the heterogenic presentations of lysinuric protein intolerance, which is considered a multifaceted disease.
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Affiliation(s)
| | | | | | | | - Sachith Mettananda
- Colombo North Teaching Hospital, Ragama, Sri Lanka.
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Thalagolla Road, Ragama, 11010, Sri Lanka.
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Akyol Ş, Yılmaz Ş, Tüfekçi Ö, Arslan N, Ören H. A complication of lysinuric protein intolerance: Intermittent haemophagocytic lymphohistiocytosis. J Paediatr Child Health 2022; 58:2300-2301. [PMID: 35938785 DOI: 10.1111/jpc.16158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/17/2022] [Accepted: 07/26/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Şefika Akyol
- Department of Pediatric Hematology, Dokuz Eylül University, Faculty of Medicine, İzmir, Turkey
| | - Şebnem Yılmaz
- Department of Pediatric Hematology, Dokuz Eylül University, Faculty of Medicine, İzmir, Turkey
| | - Özlem Tüfekçi
- Department of Pediatric Hematology, Dokuz Eylül University, Faculty of Medicine, İzmir, Turkey
| | - Nur Arslan
- Department of Pediatric Metabolic Diseases, Dokuz Eylül University, Faculty of Medicine, İzmir, Turkey
| | - Hale Ören
- Department of Pediatric Hematology, Dokuz Eylül University, Faculty of Medicine, İzmir, Turkey
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Association of rare variants in genes of immune regulation with pediatric autoimmune CNS diseases. J Neurol 2022; 269:6512-6529. [PMID: 35960392 PMCID: PMC9372976 DOI: 10.1007/s00415-022-11325-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 11/27/2022]
Abstract
Background There is a gap in the literature regarding genetic underpinnings of pediatric autoimmune CNS diseases. This study explored rare gene variants implicated in immune dysregulation within these disorders. Methods This was a single-center observational study of children with inflammatory CNS disorder who had genetic testing through next generation focused exome sequencing targeting 155 genes associated with innate or adaptive immunity. For in silico prediction of functional effects of single-nucleotide variants, Polymorphism Phenotyping v2, and Sorting Intolerant from Tolerant were used, and Combined Annotation Dependent Depletion (CADD) scores were calculated. Identified genes were analyzed using Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis. Results Of 54 patients, 42 (77.8%) carried variant(s), among which 12 (22.2%) had 3–8 variants. Eighty-eight unique single-nucleotide variants of 55 genes were identified. The most variants were detected in UNC13D, LRBA, LYST, NOD2, DOCK8, RNASEH2A, STAT5B, and AIRE. The majority of variants (62, 70.4%) had CADD > 10. KEGG pathway analysis revealed seven genes associated with primary immunodeficiency (Benjamini 1.40E − 06), six genes with NOD-like receptor signaling (Benjamini 4.10E − 04), five genes with Inflammatory Bowel Disease (Benjamini 9.80E − 03), and five genes with NF-kappa B signaling pathway (Benjamini 1.90E − 02). Discussion We observed a high rate of identification of rare and low-frequency variants in immune regulatory genes in pediatric neuroinflammatory CNS disorders. We identified 88 unique single-nucleotide variants of 55 genes with pathway analysis revealing an enrichment of NOD2-receptor signaling, consistent with involvement of the pathway within other autoinflammatory conditions and warranting further investigation. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-022-11325-2.
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Contreras JL, Ladino MA, Aránguiz K, Mendez GP, Coban-Akdemir Z, Yuan B, Gibbs RA, Burrage LC, Lupski JR, Chinn IK, Vogel TP, Orange JS, Poli MC. Immune Dysregulation Mimicking Systemic Lupus Erythematosus in a Patient With Lysinuric Protein Intolerance: Case Report and Review of the Literature. Front Pediatr 2021; 9:673957. [PMID: 34095032 PMCID: PMC8172984 DOI: 10.3389/fped.2021.673957] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/14/2021] [Indexed: 12/14/2022] Open
Abstract
Lysinuric protein intolerance (LPI) is an inborn error of metabolism caused by defective transport of cationic amino acids in epithelial cells of intestines, kidneys and other tissues as well as non-epithelial cells including macrophages. LPI is caused by biallelic, pathogenic variants in SLC7A7. The clinical phenotype of LPI includes failure to thrive and multi-system disease including hematologic, neurologic, pulmonary and renal manifestations. Individual presentations are extremely variable, often leading to misdiagnosis or delayed diagnosis. Here we describe a patient that clinically presented with immune dysregulation in the setting of early-onset systemic lupus erythematosus (SLE), including renal involvement, in whom an LPI diagnosis was suspected post-mortem based on exome sequencing analysis. A review of the literature was performed to provide an overview of the clinical spectrum and immune mechanisms involved in this disease. The precise mechanism by which ineffective amino acid transport triggers systemic inflammatory features is not yet understood. However, LPI should be considered in the differential diagnosis of early-onset SLE, particularly in the absence of response to immunosuppressive therapy.
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Affiliation(s)
| | - Mabel A. Ladino
- Universidad de Chile, Reumatóloga Pediátrica Hospital San Juan de Dios, Santiago, Chile
| | - Katherine Aránguiz
- Unidad de Inmunología y Reumatología Hospital Luis Calvo Mackenna, Providencia, Chile
| | - Gonzalo P. Mendez
- Patológo Renal, Departamento de Anatomía Patológica, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Zeynep Coban-Akdemir
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Bo Yuan
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA, United States
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, United States
| | - Richard A. Gibbs
- Sequencing Center, Baylor College of Medicine, Houston, TX, United States
| | - Lindsay C. Burrage
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
- Texas Children's Hospital, Houston, TX, United States
| | - James R. Lupski
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
- Sequencing Center, Baylor College of Medicine, Houston, TX, United States
- Texas Children's Hospital, Houston, TX, United States
| | - Ivan K. Chinn
- Texas Children's Hospital, Houston, TX, United States
- Department of Pediatrics, Division of Allergy, Immunology and Retrovirology, Baylor College of Medicine, Houston, TX, United States
| | - Tiphanie P. Vogel
- Texas Children's Hospital, Houston, TX, United States
- Department of Pediatrics, Division of Rheumatology, Baylor College of Medicine, Houston, TX, United States
| | - Jordan S. Orange
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University, New York, NY, United States
| | - M. Cecilia Poli
- Facultad de Medicina Universidad del Desarrollo-Clínica Alemana, Santiago, Chile
- Department of Pediatrics, Division of Allergy, Immunology and Retrovirology, Baylor College of Medicine, Houston, TX, United States
- Unidad de Inmunología y Reumatología, Hospital Roberto del Río, Santiago, Chile
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Al-Qattan S, Malcolmson C, Mercimek-Andrews S. Lysinuric protein intolerance mimicking N-acetylglutamate synthase deficiency in a nine-year-old boy. Mol Genet Metab Rep 2021; 27:100741. [PMID: 33763330 PMCID: PMC7973239 DOI: 10.1016/j.ymgmr.2021.100741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 12/01/2022] Open
Abstract
We report a 9-year-old boy with lysinuric protein intolerance (LPI). He had developmental delay, short stature, failure to thrive, high-protein food aversion, hypothyroidism, growth hormone deficiency, features of hemophagocytic lymphohistiocytosis (HLH), decreased bone mineral density and multiple thoracic spine compression fractures on X-ray. LPI was suspected, but urine amino acid profile and normal orotic acid did not suggest biochemical diagnosis of LPI. Targeted next generation sequencing panel for HLH (including SLC7A7) was organized. Due to elevated glutamine in plasma amino acid analysis, a metabolic consultation was initiated and his asymptomatic post-prandial ammonia was 295 μmol/L. We then suspected n-acetylglutamate synthase or carbamoyl-phosphate synthase I deficiency due to marked hyperammonemia, elevated glutamine level, normal orotic acid, and normalization of ammonia at 2 h of carglumic acid (200 mg/kg/d). His targeted next generation sequencing panel for HLH revealed homozygous pathogenic variant in SLC7A7 ((NM_001126106.2): c.726G>A (p.Trp242*)) and confirmed the diagnosis of LPI. We emphasize the importance of genetic investigations in the diagnosis of LPI. LPI associated hyperammonemia responds to carbaglumic acid. Protein aversion, and failure to thrive should warrant for ammonia measurement. Multisystem disease should include LPI into the differential diagnosis even in the absence of typical biochemical features.
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Affiliation(s)
- Sarah Al-Qattan
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Caroline Malcolmson
- Division of Hematology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Saadet Mercimek-Andrews
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medical Genetics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
- Corresponding author at: Department of Medical Genetics, University of Alberta, Stollery Children's Hospital, Alberta Health Services, 8-39 Medical Sciences Building, 8613 – 114 Street, Edmonton, Alberta T6G 2H7, Canada.
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