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Košir M, Možina H, Podbregar M. Skeletal muscle oxygenation during cardiopulmonary resuscitation as a predictor of return of spontaneous circulation: a pilot study. Eur J Med Res 2023; 28:418. [PMID: 37821950 PMCID: PMC10566100 DOI: 10.1186/s40001-023-01393-z] [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: 07/26/2022] [Accepted: 09/23/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) provides regional tissue oxygenation (rSO2) even in pulseless states, such as out-of-hospital cardiac arrest (OHCA). Brain rSO2 seems to be important predictor of return of spontaneous circulation (ROSC) during cardiopulmonary resuscitation (CPR). Aim of our study was to explore feasibility for monitoring and detecting changes of skeletal muscle rSO2 during resuscitation. METHODS Skeletal muscle and brain rSO2 were measured by NIRS (SenSmart Model X-100, Nonin, USA) during CPR in adult patient with OHCA. Start (basal) rSO2, maximal during CPR (maximal) and difference between maximal-minimal rSO2 (delta-rSO2), were recorded. Patients were divided into ROSC and NO-ROSC group. RESULTS 20 patients [age: 66.0ys (60.5-79.5), 65% male] with OHCA [50% witnessed, 70% BLS, time to ALS 13.5 min (11.0-19.0)] were finally analyzed. ROSC was confirmed in 5 (25%) patients. Basal and maximal skeletal muscle rSO2 were higher in ROSC compared to NO-ROSC group [49.0% (39.7-53.7) vs. 15.0% (12.0-25.2), P = 0.006; 76.0% (52.7-80.5) vs. 34.0% (18.0-49.5), P = 0.005, respectively]. There was non-linear cubic relationship between time of collapse and basal skeletal muscle rSO2 in witnessed OHCA and without BLS (F-ratio = 9.7713, P = 0.0261). There was correlation between maximal skeletal muscle and brain rSO2 (n = 18, rho: 0.578, P = 0.0121). CONCLUSIONS Recording of skeletal muscle rSO2 during CPR in patients with OHCA is feasible. Basal and maximal skeletal muscle rSO2 were higher in ROSC compared to NO-ROSC group. Clinical trial registration number ClinicalTrials.gov, NCT04058925, registered on: 16th August 2019. URL of trial registry record: https://www. CLINICALTRIALS gov/ct2/show/NCT04058925?titles=Tissue+Oxygenation+During+Cardiopulmonary+Resuscitation+as+a+Predictor+of+Return+of+Spontaneous+Circulation&draw=2&rank=1 .
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Affiliation(s)
- Miha Košir
- Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, 1000, Ljubljana, Slovenia
- Unit SNMP, Community Health Centre Ljubljana, Bohoričeva Ulica 4, 1000, Ljubljana, Slovenia
| | - Hugon Možina
- Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, 1000, Ljubljana, Slovenia
- Emergency Department, University Medical Center Ljubljana, Zaloška Cesta 4, 1000, Ljubljana, Slovenia
| | - Matej Podbregar
- Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, 1000, Ljubljana, Slovenia.
- Department for Internal Intensive Care, General Hospital Celje, Oblakova Ulica 5, 3000, Celje, Slovenia.
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2
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Ranganath L, Khedr M, Milan AM, Davison AS, Norman BP, Janssen MCH, Lock E, Bou‐Gharios G, Gallagher JA. Increased prevalence of Parkinson's disease in alkaptonuria. JIMD Rep 2023; 64:282-292. [PMID: 37404676 PMCID: PMC10315388 DOI: 10.1002/jmd2.12367] [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: 03/30/2023] [Accepted: 04/27/2023] [Indexed: 07/06/2023] Open
Abstract
Amongst a cohort of 88 alkaptonuria (AKU) patients attending the United Kingdom National Alkaptonuria Centre (NAC), four unrelated patients had co-existing Parkinson's disease (PD). Two of the NAC patients developed PD before receiving nitisinone (NIT) while the other two developed overt PD during NIT therapy. NIT lowers redox-active homogentisic acid (HGA) and profoundly increases tyrosine (TYR). A further unpublished case of a Dutch patient with AKU and PD on deep brain stimulation is included in this report. A Pubmed search revealed a further five AKU patients with PD, all without NIT usage. The prevalence of PD in AKU in the NAC appears to be nearly 20-times higher than in the non-AKU population (p < 0.001) even when adjusted for age. We propose that life-long exposure to redox-active HGA may account for the higher prevalence of PD in AKU. Furthermore, the appearance of PD in AKU patients during NIT therapy may be due to unmasking dopamine deficiency in susceptible individuals, as a result of the tyrosinaemia during NIT therapy inhibiting the rate-limiting brain tyrosine hydroxylase.
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Affiliation(s)
- Lakshminarayan Ranganath
- Department of Clinical Biochemistry and Metabolic MedicineRoyal Liverpool University HospitalLiverpoolUK
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical SciencesUniversity of LiverpoolLiverpoolUK
| | - Milad Khedr
- Department of Clinical Biochemistry and Metabolic MedicineRoyal Liverpool University HospitalLiverpoolUK
| | - Anna M. Milan
- Department of Clinical Biochemistry and Metabolic MedicineRoyal Liverpool University HospitalLiverpoolUK
| | - Andrew S. Davison
- Department of Clinical Biochemistry and Metabolic MedicineRoyal Liverpool University HospitalLiverpoolUK
| | - Brendan P. Norman
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical SciencesUniversity of LiverpoolLiverpoolUK
| | - Mirian C. H. Janssen
- Departments of Internal Medicine & PediatricsRadboud University Nijmegen Medical CentreNijmegenNetherlands
| | - Edward Lock
- School of Pharmacy and Biomolecular SciencesLiverpool John Moores UniversityLiverpoolUK
| | - George Bou‐Gharios
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical SciencesUniversity of LiverpoolLiverpoolUK
| | - James A. Gallagher
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical SciencesUniversity of LiverpoolLiverpoolUK
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3
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Davison AS, Luangrath E, Selvi E, Ranganath LR. Fatal acute haemolysis and methaemoglobinaemia in a man with renal failure and Alkaptonuria - Is nitisinone the solution? Mol Genet Metab Rep 2020; 23:100588. [PMID: 32322505 PMCID: PMC7171525 DOI: 10.1016/j.ymgmr.2020.100588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/08/2020] [Accepted: 04/08/2020] [Indexed: 02/02/2023] Open
Abstract
Haemolysis and methaemoglobinaemia (MetHb) are rare metabolic complications that can occur in Alkaptonuria (AKU), for which there is no curative treatment. Presented is a case of a man who had AKU, and serves as a reminder of life-threatening complications that can occur with haemolysis and MetHb. This case presents an opportunity to revisit important considerations relating to the investigation and treatment of haemolysis and MetHb with a view to raising awareness, and in doing so hopefully reducing the uniformly fatal outcome. Additionally it is proposed that treatment of haemolysis and MetHb with nitisinone is considered as a potentially lifesaving treatment as it is believed that reducing the concentration of circulating homogentisic acid will reduce oxidative stress.
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Affiliation(s)
- A S Davison
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, UK.,Musculoskeletal Biology I, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - E Luangrath
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, UK
| | - E Selvi
- Department of Rheumatology, University of Siena, Italy
| | - L R Ranganath
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, UK.,Musculoskeletal Biology I, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
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4
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Freeman AR, Wills SM. Fatal methemoglobinemia complicating alkaptonuria (ochronosis): a rare presentation. Forensic Sci Med Pathol 2018; 14:236-240. [PMID: 29572623 DOI: 10.1007/s12024-018-9965-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2018] [Indexed: 11/27/2022]
Abstract
A 61-year-old female died in hospital with multiple organ failure 4 weeks following presentation with acute kidney injury, hemolytic anemia and methemoglobinemia. At autopsy, brown to black discoloration of cartilages was observed. Histology revealed brown pigmentation of the hyaline cartilage, with focal full-thickness erosion of the articular hyaline cartilage, characteristic of alkaptonuria (ochronosis). Although alkaptonuria is rarely fatal, this case illustrates a rare acute fatal complication. Accumulation of circulating homgentisic acid secondary to acute derangement of renal function is believed to have overwhelmed the endogenous antioxidant processes, resulting in hemolysis and methemoglobinemia, which were refractory to treatment. Small numbers of cases have previously been reported in the literature in patients known to suffer with the disease, all of which were preceded by acute kidney injury. Whilst the clinical diagnosis of alkaptonuria may be challenging, the autopsy findings of this rare condition are striking and this case illustrates the utility of the autopsy, albeit retrospectively, in arriving at a diagnosis. To our knowledge this is the first reported case where previously undiagnosed alkaptonuria has presented with methemoglobinemia.
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Affiliation(s)
- Amanda R Freeman
- SA Pathology, Frome Rd, Adelaide, South Australia, 5000, Australia
| | - Stephen M Wills
- Forensic Science SA, GPO Box 2790, Adelaide, SA, 5001, Australia. .,The University of Adelaide, Adelaide, South Australia, 5005, Australia.
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5
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Kovač P, Miš K, Pirkmajer S, Marš T, Klokočovnik T, Kotnik G, Podbregar E, Podbregar M. How to Measure Tissue Oxygenation Using Near-Infrared Spectroscopy in a Patient With Alkaptonuria. J Cardiothorac Vasc Anesth 2018; 32:2708-2711. [PMID: 29459112 DOI: 10.1053/j.jvca.2018.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Petra Kovač
- Clinical Department for Anesthesiology and Surgical Intensive Care Unit, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Katarina Miš
- Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Sergej Pirkmajer
- Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tomaž Marš
- Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tomislav Klokočovnik
- Clinical Department for Cardiovascular Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Gloria Kotnik
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Eva Podbregar
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Matej Podbregar
- Clinical Department for Anesthesiology and Surgical Intensive Care Unit, University Medical Centre Ljubljana, Ljubljana, Slovenia; Institute of Pathophysiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
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6
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Davison AS, Milan AM, Gallagher JA, Ranganath LR. Acute fatal metabolic complications in alkaptonuria. J Inherit Metab Dis 2016; 39:203-10. [PMID: 26596578 DOI: 10.1007/s10545-015-9902-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 11/02/2015] [Accepted: 11/09/2015] [Indexed: 10/22/2022]
Abstract
Alkaptonuria (AKU) is a rare inherited metabolic disorder of tyrosine metabolism that results from a defect in an enzyme called homogentisate 1,2-dioxygenase. The result of this is that homogentisic acid (HGA) accumulates in the body. HGA is central to the pathophysiology of this disease and the consequences observed; these include spondyloarthropathy, rupture of ligaments/muscle/tendons, valvular heart disease including aortic stenosis and renal stones. While AKU is considered to be a chronic progressive disorder, it is clear from published case reports that fatal acute metabolic complications can also occur. These include oxidative haemolysis and methaemoglobinaemia. The exact mechanisms underlying the latter are not clear, but it is proposed that disordered metabolism within the red blood cell is responsible for favouring a pro-oxidant environment that leads to the life threatening complications observed. Herein the role of red blood cell in maintaining the redox state of the body is reviewed in the context of AKU. In addition previously reported therapeutic strategies are discussed, specifically with respect to why reported treatments had little therapeutic effect. The potential use of nitisinone for the management of patients suffering from the acute metabolic decompensation in AKU is proposed as an alternative strategy.
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Affiliation(s)
- A S Davison
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, L7 8XP, UK.
- Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, L69 3GA, UK.
| | - A M Milan
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, L7 8XP, UK
- Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, L69 3GA, UK
| | - J A Gallagher
- Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, L69 3GA, UK
| | - L R Ranganath
- Department of Clinical Biochemistry and Metabolic Medicine, Liverpool Clinical Laboratories, Royal Liverpool University Hospitals Trust, Liverpool, L7 8XP, UK
- Bone and Joint Research Group, Musculoskeletal Biology, University of Liverpool, Liverpool, L69 3GA, UK
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7
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Braconi D, Millucci L, Bernardini G, Santucci A. Oxidative stress and mechanisms of ochronosis in alkaptonuria. Free Radic Biol Med 2015; 88:70-80. [PMID: 25733348 DOI: 10.1016/j.freeradbiomed.2015.02.021] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/29/2015] [Accepted: 02/19/2015] [Indexed: 12/16/2022]
Abstract
Alkaptonuria (AKU) is a rare metabolic disease due to a deficient activity of the enzyme homogentisate 1,2-dioxygenase (HGD), involved in Phe and Tyr catabolism. Due to such a deficiency, AKU patients undergo accumulation of the metabolite homogentisic acid (HGA), which is prone to oxidation/polymerization reactions causing the production of a melanin-like pigment. Once the pigment is deposited onto connective tissues (mainly in joints, spine, and cardiac valves), a classical bluish-brown discoloration is imparted, leading to a phenomenon known as "ochronosis", the hallmark of AKU. A clarification of the molecular mechanisms for the production and deposition of the ochronotic pigment in AKU started only recently with a range of in vitro and ex vivo human models used for the study of HGA-induced effects. Thanks to redox-proteomic analyses, it was found that HGA could induce significant oxidation of a number of serum and chondrocyte proteins. Further investigations allowed highlighting how HGA-induced proteome alteration, lipid peroxidation, thiol depletion, and amyloid production could contribute to oxidative stress generation and protein oxidation in AKU. This review briefly summarizes the most recent findings on HGA-induced oxidative stress in AKU, helping in the clarification of the molecular mechanisms of ochronosis and potentially providing the basis for its pharmacological treatment. Future work should be undertaken in order to validate in vivo the results so far obtained in in vitro AKU models.
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Affiliation(s)
- Daniela Braconi
- Dipartimento di Biotecnologie, Chimica e Farmacia, Università degli Studi di Siena, Siena, Italy
| | - Lia Millucci
- Dipartimento di Biotecnologie, Chimica e Farmacia, Università degli Studi di Siena, Siena, Italy
| | - Giulia Bernardini
- Dipartimento di Biotecnologie, Chimica e Farmacia, Università degli Studi di Siena, Siena, Italy
| | - Annalisa Santucci
- Dipartimento di Biotecnologie, Chimica e Farmacia, Università degli Studi di Siena, Siena, Italy.
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8
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Bernardini G, Laschi M, Geminiani M, Braconi D, Vannuccini E, Lupetti P, Manetti F, Millucci L, Santucci A. Homogentisate 1,2 dioxygenase is expressed in brain: implications in alkaptonuria. J Inherit Metab Dis 2015; 38:807-14. [PMID: 25762405 DOI: 10.1007/s10545-015-9829-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 02/05/2015] [Accepted: 02/23/2015] [Indexed: 10/23/2022]
Abstract
Alkaptonuria is an ultra-rare autosomal recessive disease developed from the lack of homogentisate 1,2-dioxygenase (HGD) activity, causing an accumulation in connective tissues of homogentisic acid (HGA) and its oxidized derivatives in polymerized form. The deposition of ochronotic pigment has been so far attributed to homogentisic acid produced by the liver, circulating in the blood, and accumulating locally. In the present paper, we report the expression of HGD in the brain. Mouse and human brain tissues were positively tested for HGD gene expression by western blotting. Furthermore, HGD expression was confirmed in human neuronal cells that also revealed the presence of six HGD molecular species. Moreover, once cultured in HGA excess, human neuronal cells produced ochronotic pigment and amyloid. Our findings indicate that alkaptonuric brain cells produce the ochronotic pigment in loco and this may contribute to induction of neurological complications.
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Affiliation(s)
- Giulia Bernardini
- Dipartimento di Biotecnologie, Chimica e Farmacia, and Dipartimento di Scienze della Vita, Università degli Studi di Siena, via Aldo Moro 2, 53100, Siena, Italy
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9
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Isa Y, Nihei SI, Irifukuhama Y, Ikeda T, Matsumoto H, Nagata K, Harayama N, Aibara K, Kamochi M. A rare case of acquired methemoglobinemia associated with alkaptonuria. Intern Med 2014; 53:1797-800. [PMID: 25130113 DOI: 10.2169/internalmedicine.53.1938] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein present a rare case of acquired methemoglobinemia associated with alkaptonuria. Alkaptonuria is a congenital error of metabolism caused by the deficiency of homogentisic acid oxidase, which subsequently results in the accumulation of homogentisic acid (HGA) in body tissues. As renal dysfunction progresses, the level of HGA excretion in the urine decreases and the blood concentration of HGA increases. HGA oxidizes oxyhemoglobin to methemoglobin, which can induce multiple organ failure accompanied by tissue hypoxia, intravascular hemolysis and metabolic acidosis. The mortality of this disease is high when alkaptonuria is associated with the presence of methemoglobinemia; therefore, treatment should be carefully planned in such cases.
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Affiliation(s)
- Yasuki Isa
- Critical Care Medicine, University Hospital of Occupational and Environmental Health, Japan
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10
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Prayson RA, Douglas EA. Pistachio green brain discolouration associated with methylene blue use: an autopsy series. Pathology 2010; 42:681-3. [DOI: 10.3109/00313025.2010.523685] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Nanda SK, Suresh DR, Vamseedhar A, Pratibha K, Arjun B. Cerebro-spinal and renal ochronosis: A rare case report. Indian J Clin Biochem 2010; 25:213-6. [PMID: 23105912 DOI: 10.1007/s12291-010-0038-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Alkaptonuria, a rare inborn error of tyrosine metabolism, characterized by the absence of homogentisic acid oxidase results in the accumulation of homogentisic acid in the body. Associated renal failure and cerebral infarction is rare and usually occurs in the later stages of the disease. We report a 55-year-old male who presented, initially with features of stroke and degenerative arthritis. He had pigmentation of sclerae, darkening of urine on long standing, abnormal renal profile, degenerative arthritis and cerebral infarction. Alkaptonuria was suspected and biochemical tests confirmed mild renal impairment, homogentisic acid in urine and homogentisic acid crystal was detected cytologically in urine sediment. Such a case of Alkaptonuric ochronosis with cerebrovascular and renal complications have been rarely reported in the previous literature.
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Affiliation(s)
- Sunil Kumar Nanda
- Department of Biochemistry, Sree Siddhartha Medical College, Sri Siddhartha University, Tumkur, India ; No-434, 11th main, Ramaiah Enclave, 8th mile, Tumkur road, Bangalore, 560073 Karnataka India
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Argiriadou H, Anastasiadis K, Antonitsis P, Kanyamimboua D, Karapanagiotidis G, Papakonstantinou C. The inability of regional oxygen saturation monitoring in a patient with alkaptonuria undergoing aortic valve replacement. J Cardiothorac Vasc Anesth 2008; 23:586-8. [PMID: 18948036 DOI: 10.1053/j.jvca.2008.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Indexed: 11/11/2022]
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Helliwell TR, Gallagher JA, Ranganath L. Alkaptonuria--a review of surgical and autopsy pathology. Histopathology 2008; 53:503-12. [PMID: 18336562 DOI: 10.1111/j.1365-2559.2008.03000.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Alkaptonuria is a rare, inherited defect of homogentisic acid 1,2-dioxygenase that leads to the widespread deposition of polymeric homogentisic acid, and clinical symptoms from degeneration of joints and the aortic valve. Pathological descriptions are few and mainly those of late-stage changes related to joint or valve failure. In this review, the macroscopic and histopathological changes in the tissues in alkaptonuria are illustrated by the detailed autopsy study of a 74-year-old female who died from disseminated ovarian carcinoma. The pathology is discussed in the context of the literature and in relation to potential pathogenic mechanisms of tissue damage. This review highlights the heterogeneity of some of the manifestations. In symptomatic patients, degenerative changes in synovial and intervertebral joints are usually well advanced, while early changes include diffuse cartilage pigmentation and chondrocyte necrosis. The initial stage of pigment deposition in the cardiovascular system may be influenced by intravascular pressure and flow disturbances, whereas more intense pigmentation affects fibrolipid components of atheromatous plaques. Pigmentation of the aortic and mitral valve cusps and valve rings is a result of intracellular and extracellular pigment deposition and is associated with calcification and clinically significant aortic stenosis.
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Affiliation(s)
- T R Helliwell
- Department of Human Anatomy and Cell Biology, University of Liverpool, Liverpool, UK.
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