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Heath O, Allender B, Smith J, Savva E, Spencer L, Bannister EG, Brown NJ, Evans MS, Kiss S, Rozen TH, Yaplito‐Lee J. Diagnosis and stabilisation of familial chylomicronemia syndrome in two infants presenting with hypertriglyceridemia-induced acute pancreatitis. JIMD Rep 2024; 65:239-248. [PMID: 38974610 PMCID: PMC11224501 DOI: 10.1002/jmd2.12434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 05/14/2024] [Accepted: 05/16/2024] [Indexed: 07/09/2024] Open
Abstract
Familial chylomicronemia syndrome (FCS) is a rare disorder of triglyceride (TG) metabolism caused by loss of function variants in one of five known canonical genes involved in chylomicron lipolysis and clearance-LPL, APOC2, APOA5, LMF1, and GPIHBP1. Pathogenic variants in LPL, which encodes the hydrolytic enzyme lipoprotein lipase, account for over 80%-90% of cases. FCS may present in infancy with hypertriglyceridemia-induced acute pancreatitis and is challenging to manage both acutely and in the long-term. Here, we report our experience managing two unrelated infants consecutively diagnosed with hypertriglyceridemia-induced acute pancreatitis caused by LPL deficiency. Both had elevated TGs at presentation (205 and 30 mmol/L, respectively) and molecular genetic testing confirmed each infant carried a different homozygous pathogenic variant in the LPL gene, specifically, c.987C>A (p.Tyr329Ter) and c.632C>A (p.Thr211Lys). The more severely affected infant had cutaneous xanthomata, lipemia retinalis and lipemic plasma at presentation, and required management in an intensive care setting. Acute stabilisation was achieved using insulin and heparin infusions together with the iterative implementation of a fat-restricted diet, low in long chain triglycerides (LCT) and supplemented with medium chain triglycerides (MCT). In both cases, provision of adequate caloric intake (~110-120 kcal/kg/day) was also found to be important for a sustained TG reduction during the acute phase of management. In summary, a high index of suspicion is required to diagnose FCS in infants with hypertriglyceridemia-induced acute pancreatitis, management of which can be challenging, highlighting the need for more evidence-based recommendations.
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Affiliation(s)
- Oliver Heath
- Department of Metabolic Medicine, The Royal Children's HospitalMelbourneAustralia
- Victorian Clinical Genetics Services, Murdoch Children's Research InstituteMelbourneAustralia
| | - Brooke Allender
- Department of Metabolic Medicine, The Royal Children's HospitalMelbourneAustralia
| | - Joel Smith
- Laboratory Services, The Royal Children's HospitalMelbourneAustralia
- Department of Pathology, The Royal Melbourne HospitalMelbourneAustralia
| | - Elena Savva
- Victorian Clinical Genetics Services, Murdoch Children's Research InstituteMelbourneAustralia
| | - Lucy Spencer
- Victorian Clinical Genetics Services, Murdoch Children's Research InstituteMelbourneAustralia
| | | | - Natasha J. Brown
- Victorian Clinical Genetics Services, Murdoch Children's Research InstituteMelbourneAustralia
- Department of PaediatricsUniversity of MelbourneMelbourneAustralia
| | - Maureen S. Evans
- Department of Metabolic Medicine, The Royal Children's HospitalMelbourneAustralia
| | - Sharmila Kiss
- Department of Metabolic Medicine, The Royal Children's HospitalMelbourneAustralia
| | - Thomas H. Rozen
- Department of PaediatricsUniversity of MelbourneMelbourneAustralia
- Paediatric Intensive Care Unit, The Royal Children's HospitalMelbourneAustralia
| | - Joy Yaplito‐Lee
- Department of Metabolic Medicine, The Royal Children's HospitalMelbourneAustralia
- Victorian Clinical Genetics Services, Murdoch Children's Research InstituteMelbourneAustralia
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Ain Q, Cevc M, Marusic T, Sikonja J, Sadiq F, Sustar U, Mlinaric M, Kovac J, Batool H, Khan MI, Trebusak Podkrajsek K, Bizjan BJ, Battelino T, Fras Z, Ajmal M, Groselj U. Genetic and clinical characteristics of patients with lipoprotein lipase deficiency from Slovenia and Pakistan: case series and systematic literature review. Front Endocrinol (Lausanne) 2024; 15:1387419. [PMID: 38911039 PMCID: PMC11190153 DOI: 10.3389/fendo.2024.1387419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 05/21/2024] [Indexed: 06/25/2024] Open
Abstract
Introduction Hypertriglyceridemia (HTG) is a complex disorder caused by genetic and environmental factors that frequently results from loss-of-function variants in the gene encoding lipoprotein lipase (LPL). Heterozygous patients have a range of symptoms, while homozygous LPL deficiency presents with severe symptoms including acute pancreatitis, xanthomas, and lipemia retinalis. Methods We described the clinical characteristics of three Slovenian patients (an 8-year-old female, an 18-year-old man, and a 57-year-old female) and one Pakistani patient (a 59-year-old male) with LPL deficiency. We performed next-generation sequencing (NGS) targeting all coding exons and intron-exon boundaries of the LPL gene, and Sanger sequencing for variant confirmation. In addition, we performed a systematic literature review of all cases with three identified variants and described their clinical characteristics. Results Two Slovenian patients with a heterozygous pathogenic variant NM_000237.3:c.984G>T (p.Met328Ile) were diagnosed within the first three years of life and had triglyceride (TG) values of 16 and 20 mmol/L. An asymptomatic Pakistani patient with TG values of 36.8 mmol/L until the age of 44 years, was identified as heterozygous for a pathogenic variant NM_000237.3:c.724G>A (p.Asp242Asn). His TG levels dropped to 12.7 mmol/L on dietary modifications and by using fibrates. A Slovenian patient who first suffered from pancreatitis at the age of 18 years with a TG value of 34 mmol/L was found to be homozygous for NM_000237.3:c.337T>C (p.Trp113Arg). Conclusions Patients with LPL deficiency had high TG levels at diagnosis. Homozygous patients had worse outcomes. Good diet and medication compliance can reduce severity.
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Affiliation(s)
- Quratul Ain
- Translational Genomics Laboratory, Department of Biosciences, COMSATS University Islamabad, Islamabad, Pakistan
- Directorate of Research, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Matija Cevc
- Division of Medicine, Centre for Preventive Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tatiana Marusic
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jaka Sikonja
- Department of Endocrinology, Diabetes and Metabolic Diseases, Division of Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Fouzia Sadiq
- Directorate of Research, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Ursa Sustar
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Matej Mlinaric
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jernej Kovac
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Hijab Batool
- Department of Clinical Chemistry and Immunology, Chughtai Institute of Pathology, Lahore, Pakistan
| | - Mohammad Iqbal Khan
- Directorate of Research, Shifa Tameer-e-Millat University, Islamabad, Pakistan
- Department of Vascular Surgery, Shifa International Hospital, Islamabad, Pakistan
| | - Katarina Trebusak Podkrajsek
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Barbara Jenko Bizjan
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tadej Battelino
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Zlatko Fras
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Muhammad Ajmal
- Translational Genomics Laboratory, Department of Biosciences, COMSATS University Islamabad, Islamabad, Pakistan
| | - Urh Groselj
- Department of Endocrinology, Diabetes, and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Xia Y, Zheng W, Du T, Gong Z, Liang L, Wang R, Yang Y, Zhang K, Lu D, Chen X, Sun Y, Sun Y, Xiao B, Qiu W. Clinical profile, genetic spectrum and therapy evaluation of 19 Chinese pediatric patients with lipoprotein lipase deficiency. J Clin Lipidol 2023; 17:808-817. [PMID: 37858495 DOI: 10.1016/j.jacl.2023.09.012] [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: 02/09/2023] [Revised: 09/08/2023] [Accepted: 09/17/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Lipoprotein lipase (LPL) deficiency, the most common familial chylomicronemia syndrome (FCS), is a rare autosomal recessive disease characterized by chylomicronemia and severe hypertriglyceridemia (HTG), with limited clinical and genetic characterization. OBJECTIVE To describe the manifestations and management of 19 pediatric patients with LPL-FCS. METHODS LPL-FCS patients from 2014 to 2022 were divided into low-fat (LF), very-low-fat (VLF) and medium-chain-triglyceride (MCT) groups. Their clinical data were evaluated to investigate the effect of different diets. The genotype-phenotype relationship was assessed. Linear regression comparing long-chain triglyceride (LCT) intake and TG levels was analyzed. RESULTS Nine novel LPL variants were identified in 19 LPL-FCS pediatric patients. At baseline, eruptive xanthomas occurred in 3/19 patients, acute pancreatitis in 2/19, splenomegaly in 6/19 and hepatomegaly in 3/19. The median triglyceride (TG) level (30.3 mmol/L) was markedly increased. The MCT group and VLF group with LCT intakes <20 en% (energy percentage) had considerably lower TG levels than the LF group (both p<0.05). The LF group presented with severe HTG and significantly decreased TG levels after restricting LCT intakes to <20 en% (p<0.05). Six infants decreased TG levels to <10 mmol/L by keeping LCT intake <10 en%. TG levels and LCT intake were positively correlated in both patients under 2 years (r=0.84) and those aged 2-9 years (r=0.89). No genotype-phenotype relationship was observed. CONCLUSIONS This study broadens the clinical and genetic spectra of LPL-FCS. The primary therapy for LPL-FCS pediatric patients is restricting dietary LCTs to <10 en% or <20 en% depending on different ages. MCTs potentially provide extra energy.
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Affiliation(s)
- Yu Xia
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Wanqi Zheng
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Taozi Du
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Zizhen Gong
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Lili Liang
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Ruifang Wang
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Yi Yang
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Kaichuang Zhang
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Deyun Lu
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Xiaohong Chen
- Department of Endocrinology and Metabolism, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (Dr Chen)
| | - Yuning Sun
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu)
| | - Yu Sun
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu); Departement of Clinical Genetics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Sun, Xiao).
| | - Bing Xiao
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu); Departement of Clinical Genetics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Sun, Xiao).
| | - Wenjuan Qiu
- Department of Pediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, School of Medicine, Shanghai Institute of Pediatric Research, Shanghai Jiao Tong University, 1665 KongJiang Road, Shanghai 200092, China (Drs Xia, Zheng, Du, Gong, Liang, Wang, Yang, Zhang, Lu, Sun, Sun, Xiao, Qiu).
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