1
|
Martin SJ, Davidson A, Murdoch S, Selvarajah J. A treatable inborn error of metabolism presenting in the sixth decade. BMJ Case Rep 2024; 17:e256053. [PMID: 38383131 PMCID: PMC10882449 DOI: 10.1136/bcr-2023-256053] [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: 02/23/2024] Open
Abstract
Phenylketonuria (PKU) is an inborn error of amino acid metabolism. If untreated, PKU can result in global developmental delay, learning difficulties or seizures. For that reason, PKU is included in the UK neonatal screening programme. We describe a patient in his sixth decade presenting with progressive cognitive decline and spasticity, in whom a diagnosis of PKU was eventually reached. We note that although we currently have a robust neonatal screening programme, this has not always been the case. Patients born before 1969 were not screened, and tests used in early screening programmes were less sensitive than those used today. This case serves as a reminder that inherited metabolic disorders may present in later life and may mimic the neurocognitive and radiological picture of other white matter syndromes.
Collapse
Affiliation(s)
- Sarah-Jane Martin
- NHS Greater Glasgow and Clyde, Institute of Neurological Sciences, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Amy Davidson
- NHS Greater Glasgow and Clyde, Institute of Neurological Sciences, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Sheena Murdoch
- Department of Neurology, Raigmore Hospital, Inverness, UK
| | - Johann Selvarajah
- NHS Greater Glasgow and Clyde, Institute of Neurological Sciences, Glasgow, UK
- University of Glasgow, Glasgow, UK
| |
Collapse
|
2
|
Pasquetti D, Gazzellone A, Rossi S, Orteschi D, L’Erario FF, Concolino P, Minucci A, Dionisi-Vici C, Genuardi M, Silvestri G, Chiurazzi P. Triple Genetic Diagnosis in a Patient with Late-Onset Leukodystrophy and Mild Intellectual Disability. Int J Mol Sci 2023; 25:495. [PMID: 38203665 PMCID: PMC10778870 DOI: 10.3390/ijms25010495] [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: 11/27/2023] [Revised: 12/20/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
We describe the complex case of a 44-year-old man with polycystic kidney disease, mild cognitive impairment, and tremors in the upper limbs. Brain MRI showed lesions compatible with leukodystrophy. The diagnostic process, which included clinical exome sequencing (CES) and chromosomal microarray analysis (CMA), revealed a triple diagnosis: autosomal dominant polycystic kidney disease (ADPKD) due to a pathogenic variant, c.2152C>T-p.(Gln718Ter), in the PKD1 gene; late-onset phenylketonuria due to the presence of two missense variants, c.842C>T-p.(Pro281Leu) and c.143T>C-p.(Leu48Ser) in the PAH gene; and a 915 Kb duplication on chromosome 15. Few patients with multiple concurrent genetic diagnoses are reported in the literature; in this ADPKD patient, genome-wide analysis allowed for the diagnosis of adult-onset phenylketonuria (which would have otherwise gone unnoticed) and a 15q11.2 duplication responsible for cognitive and behavioral impairment with incomplete penetrance. This case underlines the importance of clinical genetics for interpreting complex results obtained by genome-wide techniques, and for diagnosing concurrent late-onset monogenic conditions.
Collapse
Affiliation(s)
- Domizia Pasquetti
- Section of Genomic Medicine, Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Medical Genetics Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Annalisa Gazzellone
- Section of Genomic Medicine, Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Medical Genetics Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Salvatore Rossi
- Department of Neurosciences, Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Neurology Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Daniela Orteschi
- Section of Genomic Medicine, Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Medical Genetics Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Federica Francesca L’Erario
- Section of Genomic Medicine, Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Medical Genetics Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Paola Concolino
- Departmental Unit of Molecular and Genomic Diagnostics, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Angelo Minucci
- Departmental Unit of Molecular and Genomic Diagnostics, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolic Diseases, Bambino Gesù Children’s Hospital IRCCS, 00165 Rome, Italy
| | - Maurizio Genuardi
- Section of Genomic Medicine, Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Medical Genetics Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Gabriella Silvestri
- Department of Neurosciences, Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Neurology Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Pietro Chiurazzi
- Section of Genomic Medicine, Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Medical Genetics Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| |
Collapse
|
3
|
Wang MW, Wu CJ, Zhang ZQ. Neurological and imaging phenotypes of adults with untreated phenylketonuria: new cases and literature review. J Neurol 2023:10.1007/s00415-023-11760-9. [PMID: 37162580 DOI: 10.1007/s00415-023-11760-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVES Phenylketonuria (PKU) is the most prevalent congenital disease of amino acid metabolism. Neurological manifestations usually complicate PKU in untreated adult patients. This study describes neurological and imaging phenotypes of adult patients with untreated PKU. METHODS We investigated a cohort of 320 unrelated adult patients with suspected genetic leukoencephalopathies using whole-exome sequencing (WES). We analyzed the phenotypic features of adult PKU patients in our cohort and summarized cases reported in the literature. RESULTS We identified 10 patients in our cohort and 12 patients in the literature, who presented with neurological manifestations and were diagnosed with PKU in adulthood. Approximately 60% of these patients had onset of clinical features in adulthood. The most common neurological symptoms of patients presenting in adulthood were cognitive disturbance and spastic paralysis, followed by vision loss, cerebellar ataxia, weakness of limbs, and seizure. This differed from that of patients presenting with PKU features in childhood, who consistently had mental retardation with various neurological complications emerging during a broad age range. Imaging findings were similar between patients presenting with clinical features in childhood compared with adulthood, comprising symmetric periventricular white matter hyperintense on T2-weighted imaging and diffusion-weighted imaging predominantly in the parietal and occipital lobes. Also, normal brain imaging and diffuse leukoencephalopathies were observed in both patient groups. CONCLUSION PKU with clinical features presenting in adulthood is an atypical subtype and should be considered during diagnosis of adults with neurological symptoms and leukoencephalopathy. DWI seems to be most helpful to distinguish patients with PKU. Additionally, we demonstrate that PKU constitutes a part (3.1%) of adult genetic leukoencephalopathies.
Collapse
Affiliation(s)
- Meng-Wen Wang
- Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China
| | - Chu-Jun Wu
- Department of Neurology, Beijing Tiantan Hospital, National Clinical Research Center for Neurological Diseases, Capital Medical University, No.119 South 4Th Ring West Road, Fengtai District, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China
| | - Zai-Qiang Zhang
- Department of Neurology, Beijing Tiantan Hospital, National Clinical Research Center for Neurological Diseases, Capital Medical University, No.119 South 4Th Ring West Road, Fengtai District, Beijing, 100070, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, 100070, China.
| |
Collapse
|
4
|
Merkel M, Berg D, Brüggemann N, Classen J, Mainka T, Zittel S, Muntau AC. Characterisation and differential diagnosis of neurological complications in adults with phenylketonuria: literature review and expert opinion. J Neurol 2023:10.1007/s00415-023-11703-4. [PMID: 37081197 DOI: 10.1007/s00415-023-11703-4] [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: 12/22/2022] [Revised: 03/31/2023] [Accepted: 04/01/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVE Phenylketonuria (PKU) is a rare inherited metabolic disorder characterised by elevated phenylalanine (Phe) concentrations that can exert neurotoxic effects if untreated or upon treatment discontinuation. This systematic review supported by expert opinion aims to raise awareness among the neurological community on neurological complications experienced by adults with PKU (AwPKU). METHODS The PubMed database was searched for articles on neurological signs and symptoms in AwPKU published before March 2022. In addition, two virtual advisory boards were held with a panel of seven neurologists and two metabolic physicians from Germany and Austria. Findings are supported by three illustrative patient cases. RESULTS Thirty-nine articles were included. Despite early diagnosis and treatment, neurological signs and symptoms (e.g. ataxia, brisk tendon reflexes, tremor, visual impairment) can emerge in adulthood, especially if treatment has been discontinued after childhood. In PKU, late-onset neurological deficits often co-occur with cognitive impairment and psychiatric symptoms, all of which can be completely or partially reversed through resumption of treatment. CONCLUSION Ideally, neurologists should be part of the PKU multidisciplinary team, either to bring lost to follow-up patients back to clinic or to manage symptoms in referred patients, considering that symptoms are often reversible upon regaining metabolic control. The current findings have been combined in a leaflet that will be disseminated among neurologists in Germany and Austria to create awareness.
Collapse
Affiliation(s)
- Martin Merkel
- Endokrinologikum Hamburg, Lornsenstraße 6, 22767, Hamburg, Germany.
- Asklepios Campus Hamburg, Semmelweis University, Hamburg, Germany.
| | - Daniela Berg
- Department of Neurology, Christian-Albrechts University, Kiel, Germany
| | | | - Joseph Classen
- Department of Neurology, Leipzig University Medical Center, Leipzig, Germany
| | - Tina Mainka
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
- Berlin Institute of Health at Charité Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
| | - Simone Zittel
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ania C Muntau
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
5
|
Ayasli A, Ogul H, Onbas O. Advanced MR imaging features of uncontrolled phenylketonuria in an adult patient. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:99-100. [PMID: 36918013 PMCID: PMC10014196 DOI: 10.1055/s-0043-1761293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Affiliation(s)
- Alper Ayasli
- Duzce University, Medical Faculty, Department of Neurology, Duzce, Turkey
| | - Hayri Ogul
- Duzce University, Medical Faculty, Department of Radiology, Duzce, Turkey
| | - Omer Onbas
- Duzce University, Medical Faculty, Department of Radiology, Duzce, Turkey
| |
Collapse
|
6
|
Borges AC, Broersen K, Leandro P, Fernandes TG. Engineering Organoids for in vitro Modeling of Phenylketonuria. Front Mol Neurosci 2022; 14:787242. [PMID: 35082602 PMCID: PMC8784555 DOI: 10.3389/fnmol.2021.787242] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/29/2021] [Indexed: 12/15/2022] Open
Abstract
Phenylketonuria is a recessive genetic disorder of amino-acid metabolism, where impaired phenylalanine hydroxylase function leads to the accumulation of neurotoxic phenylalanine levels in the brain. Severe cognitive and neuronal impairment are observed in untreated/late-diagnosed patients, and even early treated ones are not safe from life-long sequelae. Despite the wealth of knowledge acquired from available disease models, the chronic effect of Phenylketonuria in the brain is still poorly understood and the consequences to the aging brain remain an open question. Thus, there is the need for better predictive models, able to recapitulate specific mechanisms of this disease. Human induced pluripotent stem cells (hiPSCs), with their ability to differentiate and self-organize in multiple tissues, might provide a new exciting in vitro platform to model specific PKU-derived neuronal impairment. In this review, we gather what is known about the impact of phenylalanine in the brain of patients and highlight where hiPSC-derived organoids could contribute to the understanding of this disease.
Collapse
Affiliation(s)
- Alice C. Borges
- Department of Bioengineering and iBB – Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
- Associate Laboratory i4HB – Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - Kerensa Broersen
- Department of Applied Stem Cell Technologies, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, Netherlands
| | - Paula Leandro
- Faculty of Pharmacy, iMed.ULisboa - Research Institute for Medicines, Universidade de Lisboa, Lisbon, Portugal
| | - Tiago G. Fernandes
- Department of Bioengineering and iBB – Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
- Associate Laboratory i4HB – Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
- *Correspondence: Tiago G. Fernandes,
| |
Collapse
|
7
|
Santos BBD, Oliveira BMD, Monteiro VCL, Poloni S, Tonon T, Schwartz IVD. Brazilian Food Reference Guide for Phenylalanine Content: A Study Based on the Perception of PKU Patients and Health Providers. JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2022. [DOI: 10.1590/2326-4594-jiems-2022-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
| | | | | | | | | | - Ida V. D. Schwartz
- Universidade Federal do Rio Grande do Sul, Brazil; Hospital de Clínicas de Porto Alegre, Brazil; Universidade Federal do Rio Grande do Sul, Brazil; Hospital de Clínicas de Porto Alegre, Brazil
| |
Collapse
|
8
|
Serdari AE, Zompola C, Evangeliou A. Delayed phenylketonuria diagnosis: a challenging case in child psychiatry. J Pediatr Endocrinol Metab 2021; 34:127-130. [PMID: 33185574 DOI: 10.1515/jpem-2020-0243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/27/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Phenylalanine hydroxylase deficiency is an autosomal recessive inborn error of phenylalanine metabolism. WHAT IS NEW? Εven in cases with negative newborn screening for inborn errors of metabolism, the possibility of a metabolic disorder including PKU should be considered in any child presenting symptoms of developmental disorders. Late diagnosed PKU patients require a more specialized and individualized management than if they were early treatment cases. CASE PRESENTATION We discuss a case of a child with typical autistic symptomatology, in whom years later a diagnosis of phenylketonuria was set, even neonatal screening was negative. Τhe patient was placed on a phenylalanine-restricted diet. After a period of clinical improvement, severe behavioral problems with aggressiveness and anxiety were presented. Less restrictive diet ameliorated the symptomatology. CONCLUSION This case highlights the major medical importance of adequate newborn screening policy, in order to avoid missed diagnosed cases. PKU may be presented as autism spectrum disorder. Dietary management needs individualized attentive monitoring.
Collapse
Affiliation(s)
- Aspasia E Serdari
- Department of Child and Adolescent Psychiatry, Democritus University of Thrace, Medical School, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Christina Zompola
- Second Department of Neurology, Attikon Hospital, University of Athens, School of Medicine, Athens, Greece
| | - Athanasios Evangeliou
- Fourth Pediatric Department, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| |
Collapse
|