1
|
Ramachandran PS, Okaty BW, Riehs M, Wapniarski A, Hershey D, Harb H, Zia M, Haas EA, Alexandrescu S, Sleeper LA, Vargas SO, Gorman MP, Campman S, Mena OJ, Levert K, Hyland K, Goldstein RD, Wilson MR, Haynes RL. Multiomic Analysis of Neuroinflammation and Occult Infection in Sudden Infant Death Syndrome. JAMA Neurol 2024; 81:240-247. [PMID: 38285456 PMCID: PMC10825787 DOI: 10.1001/jamaneurol.2023.5387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/10/2023] [Indexed: 01/30/2024]
Abstract
Importance Antemortem infection is a risk factor for sudden infant death syndrome (SIDS)-the leading postneonatal cause of infant mortality in the developed world. Manifestations of infection and inflammation are not always apparent in clinical settings or by standard autopsy; thus, enhanced resolution approaches are needed. Objective To ascertain whether a subset of SIDS cases is associated with neuroinflammation and occult infection. Design, Setting, and Participants In this case-control study, postmortem fluids from SIDS cases and controls collected between July 2011 and November 2018 were screened for elevated inflammatory markers, specifically cerebrospinal fluid (CSF) neopterin and CSF and serum cytokines. CSF, liver, and brain tissue from SIDS cases with elevated CSF neopterin were subjected to metagenomic next-generation sequencing (mNGS) to probe for infectious pathogens. Brainstem tissue from a subset of these cases was analyzed by single-nucleus RNA sequencing (snRNAseq) to measure cell type-specific gene expression associated with neuroinflammation and infection. All tissue and fluid analyses were performed from April 2019 to January 2023 in a pathology research laboratory. Included was autopsy material from infants dying of SIDS and age-matched controls dying of known causes. Exposures There were no interventions or exposures. Main Outcomes and Measures CSF neopterin levels were measured by high-performance liquid chromatography. Cytokines were measured by multiplex fluorometric assay. mNGS was performed on liver, CSF, brain, and brainstem tissue. snRNAseq was performed on brainstem tissue. Results A cohort of 71 SIDS cases (mean [SD] age, 55.2 [11.4] postconceptional weeks; 42 male [59.2%]) and 20 controls (mean [SD] age, 63.2 [16.9] postconceptional weeks; 11 male [55.0%]) had CSF and/or serum available. CSF neopterin was screened in 64 SIDS cases and 15 controls, with no exclusions. Tissues from 6 SIDS cases were further analyzed. For CSF neopterin measures, SIDS samples were from infants with mean (SD) age of 54.5 (11.3) postconceptional weeks (38 male [59.4%]) and control samples were from infants with mean (SD) age of 61.5 (17.4) postconceptional weeks (7 male [46.7%]). A total of 6 SIDS cases (9.3%) with high CSF neopterin were identified, suggestive of neuroinflammation. mNGS detected human parechovirus 3 (HPeV3) in tissue and CSF from 1 of these 6 cases. snRNAseq of HPeV3-positive brainstem tissue (medulla) revealed dramatic enrichment of transcripts for genes with predominately inflammatory functions compared with 3 age-matched SIDS cases with normal CSF neopterin levels. Conclusions and Relevance Next-generation molecular tools in autopsy tissue provide novel insight into pathogens that go unrecognized by normal autopsy methodology, including in infants dying suddenly and unexpectedly.
Collapse
Affiliation(s)
- Prashanth S. Ramachandran
- Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco
- The Peter Doherty Institute for Immunity and Infection, University of Melbourne, Melbourne, Victoria, Australia
- The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
- Now with St Vincent’s Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Benjamin W. Okaty
- Department of Genetics, Harvard Medical School, Boston, Massachusetts
| | - Molly Riehs
- Department of Pathology, Boston Children’s Hospital, Boston, Massachusetts
| | - Anne Wapniarski
- Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco
| | - Daniel Hershey
- Department of Pediatrics, Division of Pediatric Hospital Medicine, University of California San Diego, Rady Childrens Hospital, San Diego
| | - Hani Harb
- Department of Immunology, Boston Children’s Hospital, Boston, Massachusetts
- Now with Institute for Medical Microbiology and Virology, Technical University Dresden, Germany
| | - Maham Zia
- Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco
| | - Elisabeth A. Haas
- Department of Research, Rady Children’s Hospital, San Diego, California
| | - Sanda Alexandrescu
- Department of Pathology, Boston Children’s Hospital, Boston, Massachusetts
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Sara O. Vargas
- Department of Pathology, Boston Children’s Hospital, Boston, Massachusetts
| | - Mark P. Gorman
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Steven Campman
- San Diego County Medical Examiner Office, San Diego, California
| | - Othon J. Mena
- San Diego County Medical Examiner Office, San Diego, California
- Now with Ventura County Medical Examiner Office, Ventura, California
| | - Keith Levert
- Medical Neurogenetics Laboratories, a Labcorp company, Atlanta, Georgia
| | - Keith Hyland
- Medical Neurogenetics Laboratories, a Labcorp company, Atlanta, Georgia
| | - Richard D. Goldstein
- Robert’s Program on Sudden Unexpected Death in Pediatrics, Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Michael R. Wilson
- Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco
| | - Robin L. Haynes
- Department of Pathology, Boston Children’s Hospital, Boston, Massachusetts
| |
Collapse
|
2
|
Pan LA, Segreti AM, Wrobleski J, Shaw A, Hyland K, Hughes M, Finegold DN, Naviaux RK, Brent DA, Vockley J, Peters DG. Metabolomic disorders: confirmed presence of potentially treatable abnormalities in patients with treatment refractory depression and suicidal behavior. Psychol Med 2023; 53:6046-6054. [PMID: 36330595 PMCID: PMC10520591 DOI: 10.1017/s0033291722003233] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 09/13/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Refractory depression is a devastating condition with significant morbidity, mortality, and societal cost. Approximately 15% of patients with major depressive disorder are refractory to currently available treatments. We hypothesized metabolic abnormalities contributing to treatment refractory depression are associated with distinct findings identifiable in the cerebrospinal fluid (CSF). Our hypothesis was confirmed by a previous small case-controlled study. Here we present a second, larger replication study. METHODS We conducted a case-controlled, targeted, metabolomic evaluation of 141 adolescent and adult patients with well-characterized history of depression refractory to three maximum-dose, adequate-duration medication treatments, and 36 healthy controls. Plasma, urine, and CSF metabolic profiling were performed by coupled gas chromatography/mass spectrometry, and high-performance liquid chromatography, electrospray ionization, tandem mass spectrometry. RESULTS Abnormalities were identified in 67 of 141 treatment refractory depression participants. The CSF abnormalities included: low cerebral folate (n = 20), low tetrahydrobiopterin intermediates (n = 11), and borderline low-tetrahydrobiopterin intermediates (n = 20). Serum abnormalities included abnormal acylcarnitine profile (n = 12) and abnormal serum amino acids (n = 20). Eighteen patients presented with two or more abnormal metabolic findings. Sixteen patients with cerebral folate deficiency and seven with low tetrahydrobiopterin intermediates in CSF showed improvement in depression symptom inventories after treatment with folinic acid and sapropterin, respectively. No healthy controls had a metabolite abnormality. CONCLUSIONS Examination of metabolic disorders in treatment refractory depression identified an unexpectedly large proportion of patients with potentially treatable abnormalities. The etiology of these abnormalities and their potential roles in pathogenesis remain to be determined.
Collapse
Affiliation(s)
- Lisa A Pan
- University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, USA
- New Hope Molecular, Pittsburgh, PA 15228, USA
- University of Pittsburgh, Graduate School of Public Health, Pittsburgh, PA 15261, USA
- Panomics Mental Health Initiative, Pittsburgh, PA 15228, USA
| | | | - Joseph Wrobleski
- University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, USA
| | - Annie Shaw
- University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, USA
| | - Keith Hyland
- Medical Neurogenetics Laboratory, Atlanta, Georgia 30342, USA
| | - Marion Hughes
- University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, USA
| | - David N Finegold
- New Hope Molecular, Pittsburgh, PA 15228, USA
- University of Pittsburgh, Graduate School of Public Health, Pittsburgh, PA 15261, USA
- Panomics Mental Health Initiative, Pittsburgh, PA 15228, USA
| | - Robert K Naviaux
- University of California at San Diego, School of Medicine, San Diego, California 92103, USA
| | - David A Brent
- University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, USA
| | - Jerry Vockley
- University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, USA
| | - David G Peters
- University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, USA
- Panomics Mental Health Initiative, Pittsburgh, PA 15228, USA
- Magee-Womens Research Institute, Pittsburgh, PA 15213, USA
| |
Collapse
|
3
|
Champagne M, Horvath GA, Perreault S, Gauthier J, Hyland K, Soucy J, Mitchell GA. Intermittent neurologic decompensation: An underrecognized presentation of tyrosine hydroxylase deficiency. JIMD Rep 2022; 63:400-406. [PMID: 36101825 PMCID: PMC9458604 DOI: 10.1002/jmd2.12306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 05/15/2022] [Accepted: 05/17/2022] [Indexed: 12/04/2022] Open
Abstract
Tyrosine hydroxylase deficiency (THD) is a treatable inborn error of dopamine biosynthesis caused by mutations in TH. Two presentations are described. Type A, milder, presents after 12 months of age with progressive hypokinesis and rigidity. Type B presents before 12 months as a progressive complex encephalopathy. We report a girl with mild THD who had recurrent episodes of neurological decompensations. Before the first episode, she had normal development except for mild head tremor. Episodes occurred at 12, 19, and 25 months of age. After viral infections or vaccination, she developed lethargy, worsened tremor, language, and motor regression including severe axial hypotonia, recuperating over several weeks of intensive rehabilitation but with residual tremor and mild lower limb spasticity. Basal ganglia imaging was normal. Exome sequencing revealed two missense variants of uncertain significance in TH: c.1147G>T and c.1084G>A. Both have low gnomAD allele frequencies and in silico, are predicted to be deleterious. Cerebrospinal fluid analysis showed low homovanillic acid (HVA, 160 nmol/L, reference 233–938) and low HVA/5‐hydroxyindolacetic acid molar ratio (1.07, reference .5–3.5). She responded rapidly to L‐Dopa/carbidopa without further episodes. Literature review revealed four other THD patients who had a total of seven episodes of marked hypotonia and motor regression following infections, occurring between ages 12 months and 6 years. All improved with L‐Dopa/carbidopa treatment. Intermittent THD is treatable, important for genetic counseling, and should be considered after even a single episode of marked hypotonia with recuperation over weeks, especially in patients with preexisting tremor, dystonia, or rigidity.
Collapse
Affiliation(s)
- Marjolaine Champagne
- Division of Medical Genetics, Department of Pediatrics, Molecular Diagnostic Laboratory, Centre Hospitalier Universitaire Sainte‐Justine Université de Montréal Montréal Québec Canada
| | - Gabriella A. Horvath
- Division of Biochemical Diseases, Department of Pediatrics BC Children's Hospital Vancouver British Columbia Canada
| | - Sébastien Perreault
- Division of Child Neurology, Department of Pediatrics Centre Hospitalier Universitaire Sainte‐Justine Montréal Québec Canada
| | - Julie Gauthier
- Division of Medical Genetics, Department of Pediatrics, Molecular Diagnostic Laboratory, Centre Hospitalier Universitaire Sainte‐Justine Université de Montréal Montréal Québec Canada
- Integrated Centre for Pediatric Clinical Genomics, Centre Hospitalier Universitaire Sainte‐Justine Montréal Québec Canada
| | - Keith Hyland
- MNG Laboratories (Medical Neurogenetics, LLC.), MNG, a Wholly Owned Subsidiary of Laboratory Corporation of America Holdings San Diego California USA
| | - Jean‐François Soucy
- Division of Medical Genetics, Department of Pediatrics, Molecular Diagnostic Laboratory, Centre Hospitalier Universitaire Sainte‐Justine Université de Montréal Montréal Québec Canada
- Integrated Centre for Pediatric Clinical Genomics, Centre Hospitalier Universitaire Sainte‐Justine Montréal Québec Canada
| | - Grant A. Mitchell
- Division of Medical Genetics, Department of Pediatrics, Molecular Diagnostic Laboratory, Centre Hospitalier Universitaire Sainte‐Justine Université de Montréal Montréal Québec Canada
- Integrated Centre for Pediatric Clinical Genomics, Centre Hospitalier Universitaire Sainte‐Justine Montréal Québec Canada
| |
Collapse
|
4
|
Rubach MP, Mukemba JP, Florence SM, Lopansri BK, Hyland K, Simmons RA, Langelier C, Nakielny S, DeRisi JL, Yeo TW, Anstey NM, Weinberg JB, Mwaikambo ED, Granger DL. Cerebrospinal Fluid Pterins, Pterin-Dependent Neurotransmitters, and Mortality in Pediatric Cerebral Malaria. J Infect Dis 2021; 224:1432-1441. [PMID: 33617646 PMCID: PMC8682765 DOI: 10.1093/infdis/jiab086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 02/10/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cerebral malaria (CM) pathogenesis remains incompletely understood. Having shown low systemic levels of tetrahydrobiopterin (BH4), an enzymatic cofactor for neurotransmitter synthesis, we hypothesized that BH4 and BH4-dependent neurotransmitters would likewise be low in cerebrospinal fluid (CSF) in CM. METHODS We prospectively enrolled Tanzanian children with CM and children with nonmalaria central nervous system conditions (NMCs). We measured CSF levels of BH4, neopterin, and BH4-dependent neurotransmitter metabolites, 3-O-methyldopa, homovanillic acid, and 5-hydroxyindoleacetate, and we derived age-adjusted z-scores using published reference ranges. RESULTS Cerebrospinal fluid BH4 was elevated in CM (n = 49) compared with NMC (n = 51) (z-score 0.75 vs -0.08; P < .001). Neopterin was increased in CM (z-score 4.05 vs 0.09; P < .001), and a cutoff at the upper limit of normal (60 nmol/L) was 100% sensitive for CM. Neurotransmitter metabolite levels were overall preserved. A higher CSF BH4/BH2 ratio was associated with increased odds of survival (odds ratio, 2.94; 95% confidence interval, 1.03-8.33; P = .043). CONCLUSION Despite low systemic BH4, CSF BH4 was elevated and associated with increased odds of survival in CM. Coma in malaria is not explained by deficiency of BH4-dependent neurotransmitters. Elevated CSF neopterin was 100% sensitive for CM diagnosis and warrants further assessment of its clinical utility for ruling out CM in malaria-endemic areas.
Collapse
Affiliation(s)
- Matthew P Rubach
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Jackson P Mukemba
- Department of Pediatrics, Hubert Kairuki Memorial University, Dar es Salaam, United Republic of Tanzania
| | - Salvatore M Florence
- Department of Pediatrics, Hubert Kairuki Memorial University, Dar es Salaam, United Republic of Tanzania
| | - Bert K Lopansri
- Department of Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
- Department of Medicine, University of Utah School of Medicine and VA Medical Center, Salt Lake City, Utah, USA
| | - Keith Hyland
- Medical Neurogenetics Laboratories, Atlanta, Georgia, USA
| | - Ryan A Simmons
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Biostatistics, Duke University, Durham, North Carolina, USA
| | - Charles Langelier
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, California, USA
- Chan Zuckerberg Biohub, San Francisco, California, USA
| | - Sara Nakielny
- Chan Zuckerberg Biohub, San Francisco, California, USA
| | - Joseph L DeRisi
- Chan Zuckerberg Biohub, San Francisco, California, USA
- Department of Biochemistry and Biophysics, University of California San Francisco, San Francisco, California, USA
| | - Tsin W Yeo
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - J Brice Weinberg
- Department of Medicine, Duke University and VA Medical Centers, Durham, North Carolina, USA
| | - Esther D Mwaikambo
- Department of Pediatrics, Hubert Kairuki Memorial University, Dar es Salaam, United Republic of Tanzania
| | - Donald L Granger
- Department of Medicine, University of Utah School of Medicine and VA Medical Center, Salt Lake City, Utah, USA
| |
Collapse
|
5
|
Himmelreich N, Montioli R, Bertoldi M, Carducci C, Leuzzi V, Gemperle C, Berner T, Hyland K, Thöny B, Hoffmann GF, Voltattorni CB, Blau N. Corrigendum to "Aromatic amino acid decarboxylase deficiency: Molecular and metabolic basis and therapeutic outlook" [Mol Genet Metab. 2019 May;127(1):12-22]. Mol Genet Metab 2021; 134:216. [PMID: 34244047 DOI: 10.1016/j.ymgme.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Nastassja Himmelreich
- Dietmar-Hopp Metabolic Center and Centre for Pediatrics and Adolescent Medicine, University Children's Hospital, Heidelberg, Germany
| | - Riccardo Montioli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Mariarita Bertoldi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Carla Carducci
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Vincenzo Leuzzi
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Corinne Gemperle
- Department of Pediatrics, Divisions of Metabolism and of Clinical Chemistry and Biochemistry, University of Zürich, Zürich, Switzerland
| | - Todd Berner
- Global Medical Affairs, PTC Therapeutics, South Plainfield, NJ, USA
| | - Keith Hyland
- Medical Neurogenetics Laboratories, Atlanta, GA, USA
| | - Beat Thöny
- Department of Pediatrics, Divisions of Metabolism and of Clinical Chemistry and Biochemistry, University of Zürich, Zürich, Switzerland
| | - Georg F Hoffmann
- Dietmar-Hopp Metabolic Center and Centre for Pediatrics and Adolescent Medicine, University Children's Hospital, Heidelberg, Germany
| | - Carla B Voltattorni
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy.
| | - Nenad Blau
- Dietmar-Hopp Metabolic Center and Centre for Pediatrics and Adolescent Medicine, University Children's Hospital, Heidelberg, Germany.
| |
Collapse
|
6
|
Engelke UF, van Outersterp RE, Merx J, van Geenen FA, van Rooij A, Berden G, Huigen MC, Kluijtmans LA, Peters TM, Al-Shekaili HH, Leavitt BR, de Vrieze E, Broekman S, van Wijk E, Tseng LA, Kulkarni P, Rutjes FP, Mecinović J, Struys EA, Jansen LA, Gospe SM, Mercimek-Andrews S, Hyland K, Willemsen MA, Bok LA, van Karnebeek CD, Wevers RA, Boltje TJ, Oomens J, Martens J, Coene KL. Untargeted metabolomics and infrared ion spectroscopy identify biomarkers for pyridoxine-dependent epilepsy. J Clin Invest 2021; 131:e148272. [PMID: 34138754 DOI: 10.1172/jci148272] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/16/2021] [Indexed: 12/30/2022] Open
Abstract
BackgroundPyridoxine-dependent epilepsy (PDE-ALDH7A1) is an inborn error of lysine catabolism that presents with refractory epilepsy in newborns. Biallelic ALDH7A1 variants lead to deficiency of α-aminoadipic semialdehyde dehydrogenase/antiquitin, resulting in accumulation of piperideine-6-carboxylate (P6C), and secondary deficiency of the important cofactor pyridoxal-5'-phosphate (PLP, active vitamin B6) through its complexation with P6C. Vitamin B6 supplementation resolves epilepsy in patients, but intellectual disability may still develop. Early diagnosis and treatment, preferably based on newborn screening, could optimize long-term clinical outcome. However, no suitable PDE-ALDH7A1 newborn screening biomarkers are currently available.MethodsWe combined the innovative analytical methods untargeted metabolomics and infrared ion spectroscopy to discover and identify biomarkers in plasma that would allow for PDE-ALDH7A1 diagnosis in newborn screening.ResultsWe identified 2S,6S-/2S,6R-oxopropylpiperidine-2-carboxylic acid (2-OPP) as a PDE-ALDH7A1 biomarker, and confirmed 6-oxopiperidine-2-carboxylic acid (6-oxoPIP) as a biomarker. The suitability of 2-OPP as a potential PDE-ALDH7A1 newborn screening biomarker in dried bloodspots was shown. Additionally, we found that 2-OPP accumulates in brain tissue of patients and Aldh7a1-knockout mice, and induced epilepsy-like behavior in a zebrafish model system.ConclusionThis study has opened the way to newborn screening for PDE-ALDH7A1. We speculate that 2-OPP may contribute to ongoing neurotoxicity, also in treated PDE-ALDH7A1 patients. As 2-OPP formation appears to increase upon ketosis, we emphasize the importance of avoiding catabolism in PDE-ALDH7A1 patients.FundingSociety for Inborn Errors of Metabolism for Netherlands and Belgium (ESN), United for Metabolic Diseases (UMD), Stofwisselkracht, Radboud University, Canadian Institutes of Health Research, Dutch Research Council (NWO), and the European Research Council (ERC).
Collapse
Affiliation(s)
- Udo Fh Engelke
- Translational Metabolic Laboratory, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Jona Merx
- Institute for Molecules and Materials, Synthetic Organic Chemistry, Radboud University, Nijmegen, Netherlands
| | | | - Arno van Rooij
- Translational Metabolic Laboratory, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Giel Berden
- Institute for Molecules and Materials, FELIX Laboratory and
| | - Marleen Cdg Huigen
- Translational Metabolic Laboratory, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Leo Aj Kluijtmans
- Translational Metabolic Laboratory, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Tessa Ma Peters
- Translational Metabolic Laboratory, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hilal H Al-Shekaili
- Centre for Molecular Medicine and Therapeutics, British Columbia Children's Hospital Research Institute, Department of Medical Genetics, University of British Columbia Vancouver, British Columbia, Canada
| | - Blair R Leavitt
- Centre for Molecular Medicine and Therapeutics, British Columbia Children's Hospital Research Institute, Department of Medical Genetics, University of British Columbia Vancouver, British Columbia, Canada
| | - Erik de Vrieze
- Department of Otorhinolaryngology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Sanne Broekman
- Department of Otorhinolaryngology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Erwin van Wijk
- Department of Otorhinolaryngology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, Netherlands
| | - Laura A Tseng
- Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Purva Kulkarni
- Translational Metabolic Laboratory, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Floris Pjt Rutjes
- Institute for Molecules and Materials, Synthetic Organic Chemistry, Radboud University, Nijmegen, Netherlands
| | - Jasmin Mecinović
- Institute for Molecules and Materials, Synthetic Organic Chemistry, Radboud University, Nijmegen, Netherlands.,Department of Physics, Chemistry and Pharmacy, University of Southern Denmark, Odense, Denmark
| | - Eduard A Struys
- Department of Clinical Chemistry, Amsterdam University Medical Centers, location VU Medical Centre, Amsterdam, Netherlands
| | - Laura A Jansen
- Division of Pediatric Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sidney M Gospe
- Departments of Neurology and Pediatrics, University of Washington, Seattle, Washington, USA.,Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Saadet Mercimek-Andrews
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Medical Genetics, University of Alberta, Edmonton, Alberta, Canada
| | - Keith Hyland
- Medical Neurogenetics Laboratories, Atlanta, Georgia, USA
| | - Michèl Aap Willemsen
- Department of Pediatric Neurology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Levinus A Bok
- Department of Pediatrics, Máxima Medical Centre, Veldhoven, Netherlands
| | - Clara Dm van Karnebeek
- Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Department of Pediatrics-Metabolic Diseases, Radboud Center for Mitochondrial Medicine, Radboud University Medical Center, Nijmegen, Netherlands.,United for Metabolic Diseases (UMD), Netherlands
| | - Ron A Wevers
- Translational Metabolic Laboratory, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Thomas J Boltje
- Institute for Molecules and Materials, Synthetic Organic Chemistry, Radboud University, Nijmegen, Netherlands
| | - Jos Oomens
- Institute for Molecules and Materials, FELIX Laboratory and.,Van't Hoff Institute for Molecular Sciences, University of Amsterdam, Amsterdam, Netherlands
| | | | - Karlien Lm Coene
- Translational Metabolic Laboratory, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| |
Collapse
|
7
|
Tristán-Noguero A, Borràs E, Molero-Luis M, Wassenberg T, Peters T, Verbeek MM, Willemsen M, Opladen T, Jeltsch K, Pons R, Thony B, Horvath G, Yapici Z, Friedman J, Hyland K, Agosta GE, López-Laso E, Artuch R, Sabidó E, García-Cazorla À. Novel Protein Biomarkers of Monoamine Metabolism Defects Correlate with Disease Severity. Mov Disord 2020; 36:690-703. [PMID: 33152132 DOI: 10.1002/mds.28362] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Genetic defects of monoamine neurotransmitters are rare neurological diseases amenable to treatment with variable response. They are major causes of early parkinsonism and other spectrum of movement disorders including dopa-responsive dystonia. OBJECTIVES The objective of this study was to conduct proteomic studies in cerebrospinal fluid (CSF) samples of patients with monoamine defects to detect biomarkers involved in pathophysiology, clinical phenotypes, and treatment response. METHODS A total of 90 patients from diverse centers of the International Working Group on Neurotransmitter Related Disorders were included in the study (37 untreated before CSF collection, 48 treated and 5 unknown at the collection time). Clinical and molecular metadata were related to the protein abundances in the CSF. RESULTS Concentrations of 4 proteins were significantly altered, detected by mass spectrometry, and confirmed by immunoassays. First, decreased levels of apolipoprotein D were found in severe cases of aromatic L-amino acid decarboxylase deficiency. Second, low levels of apolipoprotein H were observed in patients with the severe phenotype of tyrosine hydroxylase deficiency, whereas increased concentrations of oligodendrocyte myelin glycoprotein were found in the same subset of patients with tyrosine hydroxylase deficiency. Third, decreased levels of collagen6A3 were observed in treated patients with tetrahydrobiopterin deficiency. CONCLUSION This study with the largest cohort of patients with monoamine defects studied so far reports the proteomic characterization of CSF and identifies 4 novel biomarkers that bring new insights into the consequences of early dopaminergic deprivation in the developing brain. They open new possibilities to understand their role in the pathophysiology of these disorders, and they may serve as potential predictors of disease severity and therapies. © 2020 International Parkinson and Movement Disorder Society.
Collapse
Affiliation(s)
- Alba Tristán-Noguero
- Synaptic Metabolism Laboratory, Sant Joan de Déu Foundation, Research Pediatric Institute (IPR), Sant Joan de Déu Hospital, Barcelona, Spain
| | - Eva Borràs
- Proteomics Unit, Center for Genomics Regulation, Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Marta Molero-Luis
- Department of Clinical Biochemistry, IPR and CIBERER-ISCIII, Sant Joan de Déu Hospital, Barcelona, Spain
| | - Tessa Wassenberg
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands
| | - Tessa Peters
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands
| | - Marcel M Verbeek
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands.,Department of Pediatric Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands
| | - Michel Willemsen
- Department Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Thomas Opladen
- Division of Neuropediatrics & Metabolic Medicine, University Children's Hospital, Heidelberg, Germany
| | - Kathrin Jeltsch
- Division of Neuropediatrics & Metabolic Medicine, University Children's Hospital, Heidelberg, Germany
| | - Roser Pons
- First Department of Pediatrics, Pediatric Neurology Unit, Agia Sofia Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Beat Thony
- Division of Metabolism and Children's Research Centre, University Children's Hospital, Zurich, Switzerland
| | - Gabriella Horvath
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Zuhal Yapici
- Division of Child Neurology, Department of Neurology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Jennifer Friedman
- Departments of Neuroscience and Pediatrics, University of California, San Diego, California, USA.,Rady Children's Hospital and Rady Children's Institute for Genomic Medicine, San Diego, California, USA
| | - Keith Hyland
- Medical Neurogenetics, LLC, Atlanta, Georgia, USA
| | | | - Eduardo López-Laso
- Pediatric Neurology Unit, Department of Pediatrics, University Hospital Reina Sofía, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), and CIBERER, Córdoba, Spain
| | - Rafael Artuch
- Department of Clinical Biochemistry, IPR and CIBERER-ISCIII, Sant Joan de Déu Hospital, Barcelona, Spain
| | - Eduard Sabidó
- Proteomics Unit, Center for Genomics Regulation, Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Àngels García-Cazorla
- Synaptic Metabolism Laboratory, Sant Joan de Déu Foundation, Research Pediatric Institute (IPR), Sant Joan de Déu Hospital, Barcelona, Spain.,Neurometabolic Unit, Neurology Department, IPR, CIBER ("Centro de investigación Biomédica en Red") of Rare Diseases and Carlos III Healthcare Institute (CIBERER-ISCIII), European Reference Network for Hereditary Metabolic Disorders (MetabERN), Sant Joan de Déu Hospital, Barcelona, Spain
| |
Collapse
|
8
|
Abstract
BACKGROUND Aromatic l-amino acid decarboxylase (AADC) deficiency is an autosomal recessive metabolic disorder that results from disease-causing pathogenic variants of the dopa decarboxylase (DDC) gene. Loss of dopamine and serotonin production in the brain from infancy prevents achievement of motor developmental milestones. METHODS We retrospectively evaluated data obtained from requests to Medical Neurogenetics Laboratories for analyses of neurotransmitter metabolites in the cerebrospinal fluid, AADC enzyme activity in plasma, and/or Sanger sequencing of the DDC gene. Our primary objective was to estimate the prevalence of AADC deficiency in an at-risk population. RESULTS Approximately 20,000 cerebrospinal fluid samples were received with a request for neurotransmitter metabolite analysis in the eight-year study period; 22 samples tested positive for AADC deficiency based on decreased concentrations of 5-hydroxyindoleacetic acid and homovanillic acid, and increased 3-O-methyldopa, establishing an estimated prevalence of approximately 0.112%, or 1:900. Of the 81 requests received for plasma AADC enzyme analysis, 25 samples had very low plasma AADC activity consistent with AADC deficiency, resulting in identification of nine additional cases. A total of five additional patients were identified by Sanger sequencing as the primary request leading to the diagnosis of AADC deficiency. CONCLUSIONS Overall, these analyses identified 36 new cases of AADC deficiency. Sequencing findings showed substantial diversity with identification of 26 different DDC gene variants; five had not previously been associated with AADC deficiency. The results of the present study align with the emerging literature and understanding of the epidemiology and genetics of AADC deficiency.
Collapse
Affiliation(s)
- Keith Hyland
- Department of Neurochemistry, Medical Neurogenetics Laboratories, Atlanta, Georgia.
| | - Michael Reott
- Department of Neurochemistry, Medical Neurogenetics Laboratories, Atlanta, Georgia
| |
Collapse
|
9
|
Monteleone B, Hyland K. Case report: discovery of 2 gene variants for aromatic L-amino acid decarboxylase deficiency in 2 African American siblings. BMC Neurol 2020; 20:12. [PMID: 31918669 PMCID: PMC6953244 DOI: 10.1186/s12883-019-1596-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 12/30/2019] [Indexed: 11/26/2022] Open
Abstract
Background Aromatic l-amino acid decarboxylase (AADC) deficiency is a rare genetic disorder with heterogeneous phenotypic spectrum resulting from disease-causing variants in the dopa decarboxylase (DDC) gene. Consensus guidelines recommend dopamine agonists, monoamine oxidase inhibitors, and other symptomatic treatments, but most patients have an unrelenting disease course with no response to these therapies. Case presentation We describe 2 African American siblings with AADC deficiency and identify 2 DDC gene variants not previously associated with the disorder. The patients were evaluated for cognitive and neurologic impairments. Diagnosis of AADC deficiency was initially based on evaluation of urine and plasma metabolites, followed by targeted DDC gene sequencing. The first patient, a firstborn African American female, had moderate elevations of vanillactic and vanilpyruvic acids, and slight elevation of N-acetylvanilalanine in urine. The second patient, an African American female and younger sibling of the first patient, had low AADC enzyme activity and elevated 3-O-methyldopa levels in plasma. Genetic testing confirmed that both siblings possessed the same 2 DDC gene variants, which were identified as NM_000790.3: c.48C > A (p.Tyr16Ter) and NM_000790.3: c.116G > C (p.Arg39Pro). Conclusions This report describes 2 previously unknown patients with AADC deficiency and confirmed the presence of 2 DDC gene variants not previously associated with this disorder. Further research is needed to identify disease-modifying treatments for this devastating neurometabolic disorder. Gene therapy with a recombinant adeno-associated viral vector serotype 2 carrying the gene for the human AADC protein (AAV2-hAADC) is currently in clinical development.
Collapse
Affiliation(s)
- Berrin Monteleone
- NYU Langone Health Winthrop Pediatric Associates, 120 Mineola Blvd., Suite 210, Mineola, NY, 11501, USA.
| | | |
Collapse
|
10
|
Smith N, Longo N, Levert K, Hyland K, Blau N. Exploratory study of the effect of one week of orally administered CNSA-001 (sepiapterin) on CNS levels of tetrahydrobiopterin, dihydrobiopterin and monoamine neurotransmitter metabolites in healthy volunteers. Mol Genet Metab Rep 2019; 21:100500. [PMID: 31453106 PMCID: PMC6700519 DOI: 10.1016/j.ymgmr.2019.100500] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 08/02/2019] [Indexed: 12/01/2022] Open
Abstract
Tetrahydrobiopterin (BH4) is a cofactor for the enzymes tyrosine hydroxylase and tryptophan hydroxylase, the rate-limiting enzymes in the production of the neurotransmitters, dopamine and serotonin, respectively, in the central nervous system (CNS). Administration of BH4 is used clinically within the management of persons with genetic BH4 deficiencies, but the BH4 molecule does not cross the blood-brain barrier sufficiently. CNSA-001 is a pharmaceutical preparation of sepiapterin, a natural precursor of BH4 that induced larger increases in plasma BH4 compared with administration of the same doses of BH4 itself in healthy volunteers in a randomized trial. Here, we report the effects of 7 days of once-daily treatment with CNSA-001 60 mg/kg (n = 6) or placebo (n = 2) on metabolites of the BH4 synthetic pathway and on biomarkers of the serotonin (5-hydroxyindoleacetic acid [5-HIAA]) and dopamine (homovanillic acid [HVA]) pathways in cerebrospinal fluid (CSF) in subjects from this trial. There were no notable changes in any metabolite in placebo-treated subjects. Administration of CNSA-001 increased mean BH4 from 18.1 (SD 3.0) to 35.1 (10.0) nmol/L, and of dihydrobiopterin (BH2) from 2.1 (0.3) to 7.9 (1.5) nmol/L. Overall, administration of CNSA-001 had little effect on mean levels (pre- vs. post-treatment) of 5-HIAA (76.1 [SD 29.8] vs. 70.1 [23.1] nmol/L) or HVA (177.2 [66.5] vs. 184.8 [35.3]) nmol/L. One subject with low 5-HIAA and HVA at baseline responded with approximately three-fold increases in CNS levels of these metabolites after CNSA-001 treatment, with post-treatment levels within the range of those seen in other subjects. Administration of CNSA-001 60 mg/kg markedly increased levels of BH4 in the CNS of healthy volunteers, with apparently little overall effect in CNS levels of already normal key neurotransmitter metabolites. Tetrahydrobiopterin (BH4) is a cofactor of enzymes involved in production of central neurotransmitters dopamine and serotonin Healthy volunteers were randomized to receive a once daily doses of CNSA-001 (sepiapterin) or placebo for 7 days Oral CNSA-001 administration increased levels of BH4 and 7,8-dihydrobiopterin (BH2) in cerebrospinal fluid Normal base levels of metabolites of serotonin (5-HIAA) or dopamine (HVA) were unaffected Abnormally low baseline levels of 5-HIAA and HVA in one patient increased to normal ranges following CNSA-001 administration
Collapse
Affiliation(s)
- Neil Smith
- Censa Pharmaceuticals Inc., Wellesley, MA, USA
| | - Nicola Longo
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | | | | | - Nenad Blau
- Dietmar-Hopp Metabolic Center, University Children's Hospital, Heidelberg, Germany.,Division of Metabolism, University Children's Hospital, Zurich, Switzerland
| |
Collapse
|
11
|
Himmelreich N, Montioli R, Bertoldi M, Carducci C, Leuzzi V, Gemperle C, Berner T, Hyland K, Thöny B, Hoffmann GF, Voltattorni CB, Blau N. Aromatic amino acid decarboxylase deficiency: Molecular and metabolic basis and therapeutic outlook. Mol Genet Metab 2019; 127:12-22. [PMID: 30952622 DOI: 10.1016/j.ymgme.2019.03.009] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/24/2019] [Accepted: 03/25/2019] [Indexed: 12/24/2022]
Abstract
Aromatic-l-amino acid decarboxylase (AADC) deficiency is an ultra-rare inherited autosomal recessive disorder characterized by sharply reduced synthesis of dopamine as well as other neurotransmitters. Symptoms, including hypotonia and movement disorders (especially oculogyric crisis and dystonia) as well as autonomic dysfunction and behavioral disorders, vary extensively and typically emerge in the first months of life. However, diagnosis is difficult, requiring analysis of metabolites in cerebrospinal fluid, assessment of plasma AADC activity, and/or DNA sequence analysis, and is frequently delayed for years. New metabolomics techniques promise early diagnosis of AADC deficiency by detection of 3-O-methyl-dopa in serum or dried blood spots. A total of 82 dopa decarboxylase (DDC) variants in the DDC gene leading to AADC deficiency have been identified and catalogued for all known patients (n = 123). Biochemical and bioinformatics studies provided insight into the impact of many variants. c.714+4A>T, p.S250F, p.R347Q, and p.G102S are the most frequent variants (cumulative allele frequency = 57%), and c.[714+4A>T];[714+4A>T], p.[S250F];[S250F], and p.[G102S];[G102S] are the most frequent genotypes (cumulative genotype frequency = 40%). Known or predicted molecular effect was defined for 79 variants. Most patients experience an unrelenting disease course with poor or no response to conventional medical treatments, including dopamine agonists, monoamine oxidase inhibitors, and pyridoxine derivatives. The advent of gene therapy represents a potentially promising new avenue for treatment of patients with AADC deficiency. Clinical studies based on the direct infusion of engineered adeno-associated virus type 2 vectors into the putamen have demonstrated acceptable safety and tolerability and encouraging improvement in motor milestones and cognitive symptoms. The success of gene therapy in AADC deficiency treatment will depend on timely diagnosis to facilitate treatment administration before the onset of neurologic damage.
Collapse
Affiliation(s)
- Nastassja Himmelreich
- Dietmar-Hopp Metabolic Center and Centre for Pediatrics and Adolescent Medicine, University Children's Hospital, Heidelberg, Germany
| | - Riccardo Montioli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Mariarita Bertoldi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Carla Carducci
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Vincenzo Leuzzi
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Corinne Gemperle
- Department of Pediatrics, Divisions of Metabolism and of Clinical Chemistry and Biochemistry, University of Zürich, Zürich, Switzerland
| | - Todd Berner
- Global Medical Affairs, PTC Therapeutics, South Plainfield, NJ, USA
| | - Keith Hyland
- Medical Neurogenetics Laboratories, Atlanta, GA, USA
| | - Beat Thöny
- Department of Pediatrics, Divisions of Metabolism and of Clinical Chemistry and Biochemistry, University of Zürich, Zürich, Switzerland
| | - Georg F Hoffmann
- Dietmar-Hopp Metabolic Center and Centre for Pediatrics and Adolescent Medicine, University Children's Hospital, Heidelberg, Germany
| | - Carla B Voltattorni
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy.
| | - Nenad Blau
- Dietmar-Hopp Metabolic Center and Centre for Pediatrics and Adolescent Medicine, University Children's Hospital, Heidelberg, Germany.
| |
Collapse
|
12
|
Wempe MF, Kumar A, Kumar V, Choi YJ, Swanson MA, Friederich MW, Hyland K, Yue WW, Van Hove JLK, Coughlin CR. Identification of a novel biomarker for pyridoxine-dependent epilepsy: Implications for newborn screening. J Inherit Metab Dis 2019; 42:565-574. [PMID: 30663059 DOI: 10.1002/jimd.12059] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 01/11/2019] [Indexed: 11/12/2022]
Abstract
Pyridoxine-dependent epilepsy (PDE) is often characterized as an early onset epileptic encephalopathy with dramatic clinical improvement following pyridoxine supplementation. Unfortunately, not all patients present with classic neonatal seizures or respond to an initial pyridoxine trial, which can result in the under diagnosis of this treatable disorder. Restriction of lysine intake and transport is associated with improved neurologic outcomes, although treatment should be started in the first year of life to be effective. Because of the documented diagnostic delay and benefit of early treatment, we aimed to develop a newborn screening method for PDE. Previous studies have demonstrated the accumulation of Δ1 -piperideine-6-carboxylate and α-aminoadipic semialdehyde in individuals with PDE, although these metabolites are unstable at room temperature (RT) limiting their utility for newborn screening. As a result, we sought to identify a biomarker that could be applied to current newborn screening paradigms. We identified a novel metabolite, 6-oxo-pipecolate (6-oxo-PIP), which accumulates in substantial amounts in blood, plasma, urine, and cerebral spinal fluid of individuals with PDE. Using a stable isotope-labeled internal standard, we developed a nonderivatized liquid chromatography tandem mass spectrometry-based method to quantify 6-oxo-PIP. This method replicates the analytical techniques used in many laboratories and could be used with few modifications in newborn screening programs. Furthermore, 6-oxo-PIP was measurable in urine for 4 months even when stored at RT. Herein, we report a novel biomarker for PDE that is stable at RT and can be quantified using current newborn screening techniques.
Collapse
Affiliation(s)
- Michael F Wempe
- School of Pharmacy, Department of Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Amit Kumar
- School of Pharmacy, Department of Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Vijay Kumar
- School of Pharmacy, Department of Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Yu J Choi
- School of Pharmacy, Department of Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Michael A Swanson
- Department of Pediatrics, Section of Clinical Genetics and Metabolism, University of Colorado School of Medicine, Aurora, Colorado
| | - Marisa W Friederich
- Department of Pediatrics, Section of Clinical Genetics and Metabolism, University of Colorado School of Medicine, Aurora, Colorado
| | - Keith Hyland
- Medical Neurogenetics Laboratories, LLC, Atlanta, Georgia
| | - Wyatt W Yue
- Structural Genomics Consortium, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Johan L K Van Hove
- Department of Pediatrics, Section of Clinical Genetics and Metabolism, University of Colorado School of Medicine, Aurora, Colorado
| | - Curtis R Coughlin
- Department of Pediatrics, Section of Clinical Genetics and Metabolism, University of Colorado School of Medicine, Aurora, Colorado
| |
Collapse
|
13
|
Smith N, Longo N, Levert K, Hyland K, Blau N. Phase I clinical evaluation of CNSA-001 (sepiapterin), a novel pharmacological treatment for phenylketonuria and tetrahydrobiopterin deficiencies, in healthy volunteers. Mol Genet Metab 2019; 126:406-412. [PMID: 30922814 DOI: 10.1016/j.ymgme.2019.02.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 02/07/2019] [Accepted: 02/07/2019] [Indexed: 01/14/2023]
Abstract
Tetrahydrobiopterin (BH4) is the natural cofactor of aromatic amino acid hydroxylases and essential for degradation of phenylalanine and synthesis of catecholamines and serotonin. It can be synthesized either de novo from GTP or through the salvage pathway from sepiapterin. Sepiapterin, a natural precursor of BH4, is a more stable molecule and is transported more efficiently across cellular membranes, thus having potentially significant advantage over BH4 as a pharmacological agent for diseases associated with BH4-deficient conditions. We report the results of a first-in-humans, randomized, double-blind, placebo-controlled, dose-ranging, Phase I clinical trial in 83 healthy volunteers of CNSA-001, a novel formulation of sepiapterin. Single oral doses of 2.5-80 mg/kg CNSA-001 caused dose-related increases in plasma sepiapterin (mean Cmax 0.58-2.92 ng/mL) and BH4 (mean Cmax 57-312 ng/mL). Maximum plasma concentrations were achieved in about 1-2 h (sepiapterin) or about 4 h (BH4) after CNSA-001 oral intake. Increases in plasma BH4 were substantially larger in absolute terms and on a dose-for-dose basis following treatment with CNSA-001 vs. sapropterin dihydrochloride, a synthetic form of BH4. The pharmacokinetics of plasma sepiapterin and BH4 were similar before and after seven days of repeat daily dosing with CNSA-001 at 5, 20 or 60 mg/kg indicating little or no drug accumulation. Oral administration of CNSA-001 resulted in higher concentrations of sepiapterin in fasted vs. fed subjects, but overall BH4 plasma exposure following CNSA-001 intake increased by 1.7-1.8-fold in fed subjects. CNSA-001 was well tolerated, with no clear dose-relationship for adverse events (AE), no serious AE and no study discontinuations for AE. These data indicate that CNSA-001 is rapidly and efficiently converted to BH4 in humans supporting further clinical evaluation of CNSA-001 for the management of PKU, primary BH4 deficiencies and other diseases associated with deficient BH4 metabolism.
Collapse
Affiliation(s)
- Neil Smith
- Censa Pharmaceuticals Inc., Wellesley, MA, USA.
| | - Nicola Longo
- Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | | | | | - Nenad Blau
- Dietmar-Hopp-Metabolic Center, University Children's Hospital, Heidelberg, Germany; Division of Metabolism, University Children's Hospital, Zurich, Switzerland.
| |
Collapse
|
14
|
Coughlin CR, Swanson MA, Spector E, Meeks NJ, Kronquist KE, Aslamy M, Wempe MF, van Karnebeek CD, Gospe SM, Aziz VG, Tsai BP, Gao H, Nagy PL, Hyland K, van Dooren SJ, Salomons GS, Van Hove JL. The genotypic spectrum of ALDH7A1 mutations resulting in pyridoxine dependent epilepsy: A common epileptic encephalopathy. J Inherit Metab Dis 2019; 42:353-361. [PMID: 30043187 PMCID: PMC6345606 DOI: 10.1002/jimd.12045] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pyridoxine dependent epilepsy (PDE) is a treatable epileptic encephalopathy characterized by a positive response to pharmacologic doses of pyridoxine. Despite seizure control, at least 75% of individuals have intellectual disability and developmental delay. Current treatment paradigms have resulted in improved cognitive outcomes emphasizing the importance of an early diagnosis. As genetic testing is increasingly accepted as first tier testing for epileptic encephalopathies, we aimed to provide a comprehensive overview of ALDH7A1 mutations that cause PDE. The genotypes, ethnic origin and reported gender was collected from 185 subjects with a diagnosis of PDE. The population frequency for the variants in this report and the existing literature were reviewed in the Genome Aggregation Database (gnomAD). Novel variants identified in population databases were also evaluated through in silico prediction software and select variants were over-expressed in an E.coli-based expression system to measure α-aminoadipic semialdehyde dehydrogenase activity and production of α-aminoadipic acid. This study adds 47 novel variants to the literature resulting in a total of 165 reported pathogenic variants. Based on this report, in silico predictions, and general population data, we estimate an incidence of approximately 1:64,352 live births. This report provides a comprehensive overview of known ALDH7A1 mutations that cause PDE, and suggests that PDE may be more common than initially estimated. Due to the relative high frequency of the disease, the likelihood of under-diagnosis given the wide clinical spectrum and limited awareness among clinicians as well as the cognitive improvement noted with early treatment, newborn screening for PDE may be warranted.
Collapse
Affiliation(s)
- Curtis R. Coughlin
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
- These authors contributed equally to the manuscript
- Correspondence: Curtis Coughlin II,
| | - Michael A. Swanson
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
- These authors contributed equally to the manuscript
| | - Elaine Spector
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
- Molecular Genetics Laboratory, Department of Pathology and Laboratory Medicine, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Naomi J.L. Meeks
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
- Molecular Genetics Laboratory, Department of Pathology and Laboratory Medicine, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Kathryn E. Kronquist
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
- Molecular Genetics Laboratory, Department of Pathology and Laboratory Medicine, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Mezhgan Aslamy
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael F. Wempe
- School of Pharmacy, Department of Pharmaceutical Sciences, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Clara D.M. van Karnebeek
- Department of Pediatrics and Clinical Genetics, Academic Medical Centre, 1105 AZ Amsterdam, The Netherlands
- Department of Pediatrics, Centre for Molecular Medicine and Therapeutics, University of British Columbia, Vancouver BC V5Z4H4, Canada
| | - Sidney M. Gospe
- Division of Pediatric Neurology, Departments of Neurology and Pediatrics, University of Washington, Seattle, WA, USA
- Seattle Children’s Research Institute, Seattle, WA, USA
| | | | | | - Hanlin Gao
- Fulgent Genetics, Temple City, CA, 91780, USA
| | - Peter L. Nagy
- Medical Neurogenetics Laboratories, LLC, Atlanta, GA, USA
| | - Keith Hyland
- Medical Neurogenetics Laboratories, LLC, Atlanta, GA, USA
| | - Silvy J.M. van Dooren
- Department of Clinical Chemistry, Metabolic Unit, VU University Medical Center & Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Gajja S. Salomons
- Department of Clinical Chemistry, Metabolic Unit, VU University Medical Center & Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Johan L.K. Van Hove
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
15
|
Zima L, Ceulemans S, Reiner G, Galosi S, Chen D, Sahagian M, Haas RH, Hyland K, Friedman J. Paroxysmal motor disorders: expanding phenotypes lead to coalescing genotypes. Ann Clin Transl Neurol 2018; 5:996-1010. [PMID: 30128325 PMCID: PMC6093839 DOI: 10.1002/acn3.597] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 11/07/2022] Open
Abstract
Paroxysmal movement disorders encompass varied motor phenomena. Less recognized features and wide phenotypic and genotypic heterogeneity are impediments to straightforward molecular diagnosis. We describe a family with episodic ataxia type 1, initially mis‐characterized as paroxysmal dystonia to illustrate this diagnostic challenge. We summarize clinical features in affected individuals to highlight underappreciated aspects and provide comprehensive phenotypic description of the rare familial KCNA1 mutation. Delayed diagnosis in this family is emblematic of the broader challenge of diagnosing other paroxysmal motor disorders. We summarize genotypic and phenotypic overlap and provide a suggested diagnostic algorithm for approaching patients with these conditions.
Collapse
Affiliation(s)
- Laura Zima
- University of Nebraska Medical Center Omaha Nebraska
| | - Sophia Ceulemans
- Division of Neurology Rady Children's Hospital San Diego California
| | - Gail Reiner
- Division of Neurology Rady Children's Hospital San Diego California.,Department of Neurosciences University of California San Diego San Diego California
| | - Serena Galosi
- Division of Neurology Rady Children's Hospital San Diego California.,Department of Neurosciences University of California San Diego San Diego California.,Department of Human Neuroscience Child Neurology and Psychiatry Sapienza University Rome Italy
| | - Dillon Chen
- Division of Neurology Rady Children's Hospital San Diego California.,Department of Neurosciences University of California San Diego San Diego California
| | - Michelle Sahagian
- Division of Neurology Rady Children's Hospital San Diego California.,Department of Neurosciences University of California San Diego San Diego California
| | - Richard H Haas
- Division of Neurology Rady Children's Hospital San Diego California.,Department of Pediatrics University of California San Diego San Diego California.,Department of Neurosciences University of California San Diego San Diego California
| | - Keith Hyland
- Medical Neurogenetics Laboratories Atlanta Georgia
| | - Jennifer Friedman
- Division of Neurology Rady Children's Hospital San Diego California.,Department of Pediatrics University of California San Diego San Diego California.,Department of Neurosciences University of California San Diego San Diego California.,Rady Children's Institute for Genomic Medicine San Diego California
| |
Collapse
|
16
|
Pan LA, Martin P, Zimmer T, Segreti AM, Kassiff S, McKain BW, Baca CA, Rengasamy M, Hyland K, Walano N, Steinfeld R, Hughes M, Dobrowolski SK, Pasquino M, Diler R, Perel J, Finegold DN, Peters DG, Naviaux RK, Brent DA, Vockley J. Neurometabolic Disorders: Potentially Treatable Abnormalities in Patients With Treatment-Refractory Depression and Suicidal Behavior. Am J Psychiatry 2017; 174:42-50. [PMID: 27523499 PMCID: PMC10171090 DOI: 10.1176/appi.ajp.2016.15111500] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Treatment-refractory depression is a devastating condition with significant morbidity, mortality, and societal cost. At least 15% of cases of major depressive disorder remain refractory to treatment. The authors previously identified a young adult with treatment-refractory depression and multiple suicide attempts with an associated severe deficiency of CSF tetrahydrobiopterin, a critical cofactor for monoamine neurotransmitter synthesis. Treatment with sapropterin, a tetrahydrobiopterin analogue, led to dramatic and long-lasting remission of depression. This sentinel case led the authors to hypothesize that the incidence of metabolic abnormalities contributing to treatment-refractory depression is underrecognized. METHOD The authors conducted a case-control, targeted, metabolomic evaluation of 33 adolescent and young adult patients with well-characterized histories of treatment-refractory depression (at least three maximum-dose, adequate-duration medication treatments), and 16 healthy comparison subjects. Plasma, urine, and CSF metabolic profiling were performed by coupled gas chromatography/mass spectrometry and high-performance liquid chromatography electrospray ionization tandem mass spectrometry. RESULTS CSF metabolite abnormalities were identified in 21 of the 33 participants with treatment-refractory depression. Cerebral folate deficiency (N=12) was most common, with normal serum folate levels and low CSF 5-methyltetrahydrofolate (5-MTHF) levels. All patients with cerebral folate deficiency, including one with low CSF levels of 5-MTHF and tetrahydrobiopterin intermediates, showed improvement in depression symptom inventories after treatment with folinic acid; the patient with low tetrahydrobiopterin also received sapropterin. None of the healthy comparison subjects had a metabolite abnormality. CONCLUSIONS Examination of metabolic disorders in treatment-refractory depression identified an unexpectedly large proportion of patients with potentially treatable abnormalities. The etiology of these abnormalities remains to be determined.
Collapse
Affiliation(s)
- Lisa A Pan
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - Petra Martin
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - Thomas Zimmer
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - Anna Maria Segreti
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - Sivan Kassiff
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - Brian W McKain
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - Cynthia A Baca
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - Manivel Rengasamy
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - Keith Hyland
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - Nicolette Walano
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - Robert Steinfeld
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - Marion Hughes
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - Steven K Dobrowolski
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - Michele Pasquino
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - Rasim Diler
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - James Perel
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - David N Finegold
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - David G Peters
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - Robert K Naviaux
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - David A Brent
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| | - Jerry Vockley
- From the Departments of Psychiatry, Pediatrics, Human Genetics, Pathology, and Obstetrics and Gynecology, University of Pittsburgh, School of Medicine, Pittsburgh; Medical Neurogenetics Laboratory, Atlanta; the Department of Pediatrics, University Medical Center Göttingen, Göttingen, Germany; and the Departments of Medicine, Pediatrics, and Pathology, School of Medicine, University of California, San Diego
| |
Collapse
|
17
|
Shoffner J, Trommer B, Thurm A, Farmer C, Langley WA, Soskey L, Rodriguez AN, D'Souza P, Spence SJ, Hyland K, Swedo SE. CSF concentrations of 5-methyltetrahydrofolate in a cohort of young children with autism. Neurology 2016; 86:2258-63. [PMID: 27178705 DOI: 10.1212/wnl.0000000000002766] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 03/14/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine the association between cerebral folate deficiency and autism, this study examined CSF 5-methyltetrahydrofolate (5-MTHF) concentrations in a group of young children with autism, investigated the natural variation in CSF 5-MTHF over time, and assessed the relationship between CSF 5-MTHF and symptoms. METHODS CSF was collected from 67 children with a diagnosis of DSM-IV-TR autistic disorder (age, mean ± SD 43 ± 11 months), with a second CSF sample obtained 1-3 years later on 31 of these subjects (time to follow-up, 30 ± 8 months). RESULTS At time 1, 7% (5/67) of participants had 5-MTHF <40 nmol/L. At follow-up, 23% (7/31) of participants had 5-MTHF <40 nmol/L (only one of whom had been low at time 1). A moderate correlation with a very wide confidence interval (CI) was observed between time 1 and time 2 CSF 5-MTHF measurements (Pearson r[p] = 0.38 [0.04]; 95% CI 0.02-0.64). Neither the CSF 5-MTHF levels nor changes over time correlated with the clinical features of autism. CONCLUSIONS CSF 5-MTHF levels vary significantly over time in an unpredictable fashion and do not show a significant relationship to typical clinical features of autism. Reduced CSF 5-MTHF levels are a nonspecific finding in autism. Our data do not support the use of lumbar puncture for assessment of CSF 5-MTHF in autism.
Collapse
Affiliation(s)
- John Shoffner
- From Medical Neurogenetics (J.S., W.A.L., K.H.); Georgia State University (J.S.), Atlanta; Pediatrics & Developmental Neuroscience Branch (B.T., A.T., C.F., L.S., A.N.R., P.D., S.J.S., S.E.S.), National Institute of Mental Health, National Institutes of Health, Bethesda, MD; State University of New York Downstate Medical Center (B.T.), Brooklyn; and Department of Neurology (S.J.S.), Boston Children's Hospital, MA
| | - Barbara Trommer
- From Medical Neurogenetics (J.S., W.A.L., K.H.); Georgia State University (J.S.), Atlanta; Pediatrics & Developmental Neuroscience Branch (B.T., A.T., C.F., L.S., A.N.R., P.D., S.J.S., S.E.S.), National Institute of Mental Health, National Institutes of Health, Bethesda, MD; State University of New York Downstate Medical Center (B.T.), Brooklyn; and Department of Neurology (S.J.S.), Boston Children's Hospital, MA
| | - Audrey Thurm
- From Medical Neurogenetics (J.S., W.A.L., K.H.); Georgia State University (J.S.), Atlanta; Pediatrics & Developmental Neuroscience Branch (B.T., A.T., C.F., L.S., A.N.R., P.D., S.J.S., S.E.S.), National Institute of Mental Health, National Institutes of Health, Bethesda, MD; State University of New York Downstate Medical Center (B.T.), Brooklyn; and Department of Neurology (S.J.S.), Boston Children's Hospital, MA
| | - Cristan Farmer
- From Medical Neurogenetics (J.S., W.A.L., K.H.); Georgia State University (J.S.), Atlanta; Pediatrics & Developmental Neuroscience Branch (B.T., A.T., C.F., L.S., A.N.R., P.D., S.J.S., S.E.S.), National Institute of Mental Health, National Institutes of Health, Bethesda, MD; State University of New York Downstate Medical Center (B.T.), Brooklyn; and Department of Neurology (S.J.S.), Boston Children's Hospital, MA
| | - William A Langley
- From Medical Neurogenetics (J.S., W.A.L., K.H.); Georgia State University (J.S.), Atlanta; Pediatrics & Developmental Neuroscience Branch (B.T., A.T., C.F., L.S., A.N.R., P.D., S.J.S., S.E.S.), National Institute of Mental Health, National Institutes of Health, Bethesda, MD; State University of New York Downstate Medical Center (B.T.), Brooklyn; and Department of Neurology (S.J.S.), Boston Children's Hospital, MA
| | - Laura Soskey
- From Medical Neurogenetics (J.S., W.A.L., K.H.); Georgia State University (J.S.), Atlanta; Pediatrics & Developmental Neuroscience Branch (B.T., A.T., C.F., L.S., A.N.R., P.D., S.J.S., S.E.S.), National Institute of Mental Health, National Institutes of Health, Bethesda, MD; State University of New York Downstate Medical Center (B.T.), Brooklyn; and Department of Neurology (S.J.S.), Boston Children's Hospital, MA
| | - Aldeboran N Rodriguez
- From Medical Neurogenetics (J.S., W.A.L., K.H.); Georgia State University (J.S.), Atlanta; Pediatrics & Developmental Neuroscience Branch (B.T., A.T., C.F., L.S., A.N.R., P.D., S.J.S., S.E.S.), National Institute of Mental Health, National Institutes of Health, Bethesda, MD; State University of New York Downstate Medical Center (B.T.), Brooklyn; and Department of Neurology (S.J.S.), Boston Children's Hospital, MA
| | - Precilla D'Souza
- From Medical Neurogenetics (J.S., W.A.L., K.H.); Georgia State University (J.S.), Atlanta; Pediatrics & Developmental Neuroscience Branch (B.T., A.T., C.F., L.S., A.N.R., P.D., S.J.S., S.E.S.), National Institute of Mental Health, National Institutes of Health, Bethesda, MD; State University of New York Downstate Medical Center (B.T.), Brooklyn; and Department of Neurology (S.J.S.), Boston Children's Hospital, MA
| | - Sarah J Spence
- From Medical Neurogenetics (J.S., W.A.L., K.H.); Georgia State University (J.S.), Atlanta; Pediatrics & Developmental Neuroscience Branch (B.T., A.T., C.F., L.S., A.N.R., P.D., S.J.S., S.E.S.), National Institute of Mental Health, National Institutes of Health, Bethesda, MD; State University of New York Downstate Medical Center (B.T.), Brooklyn; and Department of Neurology (S.J.S.), Boston Children's Hospital, MA
| | - Keith Hyland
- From Medical Neurogenetics (J.S., W.A.L., K.H.); Georgia State University (J.S.), Atlanta; Pediatrics & Developmental Neuroscience Branch (B.T., A.T., C.F., L.S., A.N.R., P.D., S.J.S., S.E.S.), National Institute of Mental Health, National Institutes of Health, Bethesda, MD; State University of New York Downstate Medical Center (B.T.), Brooklyn; and Department of Neurology (S.J.S.), Boston Children's Hospital, MA
| | - Susan E Swedo
- From Medical Neurogenetics (J.S., W.A.L., K.H.); Georgia State University (J.S.), Atlanta; Pediatrics & Developmental Neuroscience Branch (B.T., A.T., C.F., L.S., A.N.R., P.D., S.J.S., S.E.S.), National Institute of Mental Health, National Institutes of Health, Bethesda, MD; State University of New York Downstate Medical Center (B.T.), Brooklyn; and Department of Neurology (S.J.S.), Boston Children's Hospital, MA.
| |
Collapse
|
18
|
Lim Y, Tapawan S, Pang A, Hyland K, Tay S. Secondary Cerebral Folate Deficiency Comorbidity in Neuronal Ceroid Lipofuscinosis. J Pediatr Neurol 2016. [DOI: 10.1055/s-0036-1583275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Yvonne Lim
- Division of Paediatric Neurology, Khoo Teck Puat-National University Children's Medical Institute, National University Health Systems, Singapore
| | - Sarah Tapawan
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Aileen Pang
- Division of Paediatric Neurology, Khoo Teck Puat-National University Children's Medical Institute, National University Health Systems, Singapore
| | - Keith Hyland
- Medical Neurogenetics, Atlanta, Georgia, United States
| | - Stacey Tay
- Division of Paediatric Neurology, Khoo Teck Puat-National University Children's Medical Institute, National University Health Systems, Singapore
| |
Collapse
|
19
|
Levtova A, Camuzeaux S, Laberge AM, Allard P, Brunel-Guitton C, Diadori P, Rossignol E, Hyland K, Clayton PT, Mills PB, Mitchell GA. Normal Cerebrospinal Fluid Pyridoxal 5'-Phosphate Level in a PNPO-Deficient Patient with Neonatal-Onset Epileptic Encephalopathy. JIMD Rep 2015; 22:67-75. [PMID: 25762494 DOI: 10.1007/8904_2015_413] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 01/23/2015] [Accepted: 01/26/2015] [Indexed: 12/13/2022] Open
Abstract
UNLABELLED Deficiency of pyridox(am)ine 5'-phosphate oxidase (PNPO, OMIM 610090) is a treatable autosomal recessive inborn error of metabolism. Neonatal epileptic encephalopathy and a low cerebrospinal fluid (CSF) pyridoxal 5'-phosphate level are the reported hallmarks of PNPO deficiency, but its clinical and biochemical spectra are not fully known. CASE PRESENTATION A girl born at 33 3/7 weeks of gestation developed seizures in the first hours of life. Her seizures initially responded to GABAergic agonists, but she subsequently developed a severe epileptic encephalopathy. Brain MRI and infectious and metabolic evaluations at birth, including urinary alpha-aminoadipic semialdehyde (AASA), were normal. Lumbar puncture at age 3 months showed: pyridoxal 5'-phosphate, 52 nmol/L (normal, 23-64); homovanillic acid, 392 nmol/L (normal, 450-1,132); 5-hydroxyindoleacetic acid, 341 nmol/L (normal, 179-711); and 3-ortho-methyldopa, 30 nmol/L (normal, below 300). The patient was not being treated with pyridoxine nor with pyridoxal 5'-phosphate at the time of the lumbar puncture. She died at age 14 months. A sequencing panel targeting 53 epilepsy-related genes revealed a homozygous missense mutation in PNPO (c.674G>A, p.R225H). Homozygosity was confirmed by parental testing. Expression studies of mutant p.R225H PNPO revealed greatly reduced activity. In conclusion, a normal CSF level of pyridoxal 5'-phosphate does not rule out PNPO deficiency.
Collapse
Affiliation(s)
- Alina Levtova
- Divisions of Medical Genetics (AL, AML, CBG, GM) and Neurology (PD, ER), Department of Paediatrics, Biochemical Genetics Laboratory (CBG, PA), CHU Sainte-Justine and Université de Montréal, 3175 Côte-Sainte-Catherine, Montreal, QC, Canada, H3T 1C5
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Yeo TW, Lampah DA, Kenangalem E, Tjitra E, Price RN, Weinberg JB, Hyland K, Granger DL, Anstey NM. Impaired systemic tetrahydrobiopterin bioavailability and increased dihydrobiopterin in adult falciparum malaria: association with disease severity, impaired microvascular function and increased endothelial activation. PLoS Pathog 2015; 11:e1004667. [PMID: 25764397 PMCID: PMC4357386 DOI: 10.1371/journal.ppat.1004667] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 01/07/2015] [Indexed: 12/22/2022] Open
Abstract
Tetrahydrobiopterin (BH₄) is a co-factor required for catalytic activity of nitric oxide synthase (NOS) and amino acid-monooxygenases, including phenylalanine hydroxylase. BH4 is unstable: during oxidative stress it is non-enzymatically oxidized to dihydrobiopterin (BH₂), which inhibits NOS. Depending on BH₄ availability, NOS oscillates between NO synthase and NADPH oxidase: as the BH₄/BH₂ ratio decreases, NO production falls and is replaced by superoxide. In African children and Asian adults with severe malaria, NO bioavailability decreases and plasma phenylalanine increases, together suggesting possible BH₄ deficiency. The primary three biopterin metabolites (BH₄, BH₂ and B₀ [biopterin]) and their association with disease severity have not been assessed in falciparum malaria. We measured pterin metabolites in urine of adults with severe falciparum malaria (SM; n=12), moderately-severe malaria (MSM, n=17), severe sepsis (SS; n=5) and healthy subjects (HC; n=20) as controls. In SM, urinary BH₄ was decreased (median 0.16 ¼mol/mmol creatinine) compared to MSM (median 0.27), SS (median 0.54), and HC (median 0.34)]; p<0.001. Conversely, BH₂ was increased in SM (median 0.91 ¼mol/mmol creatinine), compared to MSM (median 0.67), SS (median 0.39), and HC (median 0.52); p<0.001, suggesting increased oxidative stress and insufficient recycling of BH2 back to BH4 in severe malaria. Overall, the median BH₄/BH₂ ratio was lowest in SM [0.18 (IQR: 0.04-0.32)] compared to MSM (0.45, IQR 0.27-61), SS (1.03; IQR 0.54-2.38) and controls (0.66; IQR 0.43-1.07); p<0.001. In malaria, a lower BH₄/BH₂ ratio correlated with decreased microvascular reactivity (r=0.41; p=0.03) and increased ICAM-1 (r=-0.52; p=0.005). Decreased BH4 and increased BH₂ in severe malaria (but not in severe sepsis) uncouples NOS, leading to impaired NO bioavailability and potentially increased oxidative stress. Adjunctive therapy to regenerate BH4 may have a role in improving NO bioavailability and microvascular perfusion in severe falciparum malaria.
Collapse
Affiliation(s)
- Tsin W. Yeo
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Institute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, Singapore
| | - Daniel A. Lampah
- Menzies School of Health Research-National Institute of Health Research and Development Research Program, and District Ministry of Health, Timika, Papua, Indonesia
| | - Enny Kenangalem
- Menzies School of Health Research-National Institute of Health Research and Development Research Program, and District Ministry of Health, Timika, Papua, Indonesia
| | - Emiliana Tjitra
- National Institute of Health Research and Development, Jakarta, Indonesia
| | - Ric N. Price
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - J. Brice Weinberg
- Duke University and VA Medical Centers, Durham, North Carolina, United States of America
| | - Keith Hyland
- Medical Neurogenetics LLC, Atlanta, Georgia, United States of America
| | - Donald L. Granger
- Division of Infectious Diseases, University of Utah and Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
| | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| |
Collapse
|
21
|
Rubach MP, Mukemba J, Florence S, Lopansri BK, Hyland K, Volkheimer AD, Yeo TW, Anstey NM, Weinberg JB, Mwaikambo ED, Granger DL. Impaired systemic tetrahydrobiopterin bioavailability and increased oxidized biopterins in pediatric falciparum malaria: association with disease severity. PLoS Pathog 2015; 11:e1004655. [PMID: 25764173 PMCID: PMC4357384 DOI: 10.1371/journal.ppat.1004655] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 01/05/2015] [Indexed: 12/17/2022] Open
Abstract
Decreased bioavailability of nitric oxide (NO) is a major contributor to the pathophysiology of severe falciparum malaria. Tetrahydrobiopterin (BH4) is an enzyme cofactor required for NO synthesis from L-arginine. We hypothesized that systemic levels of BH₄ would be decreased in children with cerebral malaria, contributing to low NO bioavailability. In an observational study in Tanzania, we measured urine levels of biopterin in its various redox states (fully reduced [BH₄] and the oxidized metabolites, dihydrobiopterin [BH₂] and biopterin [B₀]) in children with uncomplicated malaria (UM, n = 55), cerebral malaria (CM, n = 45), non-malaria central nervous system conditions (NMC, n = 48), and in 111 healthy controls (HC). Median urine BH4 concentration in CM (1.10 [IQR:0.55-2.18] μmol/mmol creatinine) was significantly lower compared to each of the other three groups - UM (2.10 [IQR:1.32-3.14];p<0.001), NMC (1.52 [IQR:1.01-2.71];p = 0.002), and HC (1.60 [IQR:1.15-2.23];p = 0.005). Oxidized biopterins were increased, and the BH4:BH2 ratio markedly decreased in CM. In a multivariate logistic regression model, each Log10-unit decrease in urine BH4 was independently associated with a 3.85-fold (95% CI:1.89-7.61) increase in odds of CM (p<0.001). Low systemic BH4 levels and increased oxidized biopterins contribute to the low NO bioavailability observed in CM. Adjunctive therapy to regenerate BH4 may have a role in improving NO bioavailability and microvascular perfusion in severe falciparum malaria.
Collapse
Affiliation(s)
- Matthew P. Rubach
- Department of Medicine, Duke University and VA Medical Centers, Durham, North Carolina, United States of America
| | - Jackson Mukemba
- Department of Pediatrics, Hubert Kairuki Memorial University, Dar es Salaam, United Republic of Tanzania
| | - Salvatore Florence
- Department of Pediatrics, Hubert Kairuki Memorial University, Dar es Salaam, United Republic of Tanzania
| | - Bert K. Lopansri
- Department of Medicine, Intermountain Healthcare, Salt Lake City, Utah, United States of America
- Department of Medicine, University of Utah School of Medicine and VA Medical Center, Salt Lake City, Utah, United States of America
| | - Keith Hyland
- Neurochemistry Division, Medical Neurogenetics, Atlanta, Georgia, United States of America
| | - Alicia D. Volkheimer
- Department of Medicine, Duke University and VA Medical Centers, Durham, North Carolina, United States of America
| | - Tsin W. Yeo
- Global and Tropical Health Division, Menzies School for Health Research and Charles Darwin University, Darwin, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
- Department of Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School for Health Research and Charles Darwin University, Darwin, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - J. Brice Weinberg
- Department of Medicine, Duke University and VA Medical Centers, Durham, North Carolina, United States of America
| | - Esther D. Mwaikambo
- Department of Pediatrics, Hubert Kairuki Memorial University, Dar es Salaam, United Republic of Tanzania
| | - Donald L. Granger
- Department of Medicine, University of Utah School of Medicine and VA Medical Center, Salt Lake City, Utah, United States of America
| |
Collapse
|
22
|
Mercimek-Mahmutoglu S, Sidky S, Hyland K, Patel J, Donner EJ, Logan W, Mendoza-Londono R, Moharir M, Raiman J, Schulze A, Siriwardena K, Yoon G, Kyriakopoulou L. Prevalence of inherited neurotransmitter disorders in patients with movement disorders and epilepsy: a retrospective cohort study. Orphanet J Rare Dis 2015; 10:12. [PMID: 25758715 PMCID: PMC4342151 DOI: 10.1186/s13023-015-0234-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 01/27/2015] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Inherited neurotransmitter disorders are primary defects of neurotransmitter metabolism. The main purpose of this retrospective cohort study was to identify prevalence of inherited neurotransmitter disorders. METHODS This retrospective cohort study does not have inclusion criteria; rather included all patients who underwent cerebrospinal fluid (CSF) homovanillic and 5-hydroxyindol acetic acid measurements. Patients with CSF neurotransmitter investigations suggestive of an inherited neurotransmitter disorder and patients with normal or non-diagnostic CSF neurotransmitter investigations underwent direct sequencing of single gene disorders. RESULTS There were 154 patients between October 2004 and July 2013. Four patients were excluded due to their diagnosis prior to this study dates. Two major clinical feature categories of patients who underwent lumbar puncture were movement disorders or epilepsy in our institution. Twenty out of the 150 patients (13.3%) were diagnosed with a genetic disorder including inherited neurotransmitter disorders (6 patients) (dihydropteridine reductase, 6-pyruvoyl-tetrahydropterin synthase, guanosine triphosphate cyclohydrolase I, tyrosine hydroxylase, pyridoxine dependent epilepsy due to mutations in the ALDH7A1 gene and pyridoxamine-5-phosphate oxidase deficiencies) and non-neurotransmitter disorders (14 patients). CONCLUSION Prevalence of inherited neurotransmitter disorders was 4% in our retrospective cohort study. Eight out of the 150 patients (5.3%) had one of the treatable inherited metabolic disorders with favorable short-term neurodevelopmental outcomes, highlighting the importance of an early and specific diagnosis. Whole exome or genome sequencing might shed light to unravel underlying genetic defects of new inherited neurotransmitter disorders in near future.
Collapse
Affiliation(s)
- Saadet Mercimek-Mahmutoglu
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada. .,Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, Canada. .,Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, Genetic and Genome Biology, Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
| | - Sarah Sidky
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada.
| | | | - Jaina Patel
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada.
| | - Elizabeth J Donner
- Division of Neurology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada.
| | - William Logan
- Division of Neurology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada.
| | - Roberto Mendoza-Londono
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada.
| | - Mahendranath Moharir
- Division of Neurology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada.
| | - Julian Raiman
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada.
| | - Andreas Schulze
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada. .,Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, Canada.
| | - Komudi Siriwardena
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada.
| | - Grace Yoon
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada. .,Division of Neurology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada.
| | - Lianna Kyriakopoulou
- Biochemical Genetics Laboratory, Department of Laboratory Medicine, University of Toronto, The Hospital for Sick Children, Toronto, Canada.
| |
Collapse
|
23
|
Mercimek-Mahmutoglu S, Cordeiro D, Cruz V, Hyland K, Struys EA, Kyriakopoulou L, Mamak E. Novel therapy for pyridoxine dependent epilepsy due to ALDH7A1 genetic defect: L-arginine supplementation alternative to lysine-restricted diet. Eur J Paediatr Neurol 2014; 18:741-6. [PMID: 25127453 DOI: 10.1016/j.ejpn.2014.07.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 06/03/2014] [Accepted: 07/07/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND HYPOTHESIS Pyridoxine dependent epilepsy (PDE) due to mutations in the ALDH7A1 gene (PDE-ALDH7A1) is caused by α-aminoadipic-semialdehyde-dehydrogenase enzyme deficiency in the lysine pathway resulting in the accumulation of α-aminoadipic acid semialdehyde (α-AASA). Classical presentation is neonatal intractable seizures with a dramatic response to pyridoxine. Pyridoxine therapy does not prevent developmental delays in the majority of the patients. We hypothesized that L-arginine supplementation will decrease accumulation of α-AASA by competitive inhibition of lysine transport into the central nervous system and improve neurodevelopmental and neurocognitive functions in PDE-ALDH7A1. METHODS A 12-year-old male with PDE-ALDH7A1 was treated with l-arginine supplementation as an innovative therapy. Treatment outcome was monitored by cerebral-spinal-fluid (CSF) α-AASA measurements at baseline, 6th and 12th months of therapy. Neuropsychological assessments were performed at baseline and 12th months of therapy. RESULTS L-arginine therapy was well tolerated without side effects. CSF α-AASA was decreased 57% at 12th months of therapy. Neuropsychological assessments revealed improvements in general abilities index from 108 to 116 and improvements in verbal and motor functioning at 12th months of therapy. CONCLUSION The short-term treatment outcome of this novel L-arginine supplementation therapy for PDE-ALDH7A1 was successful for biochemical and neurocognitive improvements.
Collapse
Affiliation(s)
- Saadet Mercimek-Mahmutoglu
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada; Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.
| | - Dawn Cordeiro
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Vivian Cruz
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Eduard A Struys
- Metabolic Laboratory, Department of Clinical Chemistry, VU Medical Centre, Amsterdam, The Netherlands
| | - Lianna Kyriakopoulou
- Biochemical Genetics Laboratory, Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Eva Mamak
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada
| |
Collapse
|
24
|
D'Aco KE, Bearden D, Watkins D, Hyland K, Rosenblatt DS, Ficicioglu C. Severe 5,10-methylenetetrahydrofolate reductase deficiency and two MTHFR variants in an adolescent with progressive myoclonic epilepsy. Pediatr Neurol 2014; 51:266-70. [PMID: 25079578 DOI: 10.1016/j.pediatrneurol.2014.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Revised: 04/04/2014] [Accepted: 04/05/2014] [Indexed: 01/29/2023]
Abstract
BACKGROUND 5,10-Methylenetetrahydrofolate reductase (MTHFR) deficiency is an inborn error of the folate-recycling pathway that affects the remethylation of homocysteine to methionine. The clinical presentation of MTHFR deficiency is highly variable ranging from early neurological deterioration and death in infancy to a mild thrombophilia in adults. PATIENT AND METHODS We describe an adolescent girl with a history of mild learning disabilities who presented at age 14 years with an epilepsy syndrome initially thought to be juvenile myoclonic epilepsy. She later developed intractable epilepsy with myoclonus, leg weakness, cognitive decline, and ataxia consistent with the syndrome of progressive myoclonic epilepsy. This prompted further evaluation that revealed elevated plasma homocysteine and decreased plasma methionine. The diagnosis of MTHFR deficiency was confirmed based on extremely reduced fibroblast MTHFR activity (0.3 nmol CHO/mg prot/hr) as well as mutation analysis that revealed two variants in the MTHFR gene, a splice site mutation p (IVS5-1G>A), as well as a missense mutation (c.155 G>A; p. Arg52Gln). Therapy with folinic acid, betaine, and methionine has produced significant clinical improvement, including improved strength, less severe ataxia, and decreased seizure frequency, as well as improvements in her electroencephalography and electromyography. CONCLUSION This patient demonstrates the importance of considering MTHFR deficiency in the differential diagnosis of progressive myoclonic epilepsy because it is one of the few causes for which specific treatment is available.
Collapse
Affiliation(s)
- Kristin E D'Aco
- Department of Pediatrics, Division of Metabolism, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Bearden
- Department of Pedatrics, Division of Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Watkins
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada
| | | | - David S Rosenblatt
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada
| | - Can Ficicioglu
- Department of Pediatrics, Division of Metabolism, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
25
|
Sparks S, Wassif C, Goodwin H, Conley S, Lanham D, Kratz L, Hyland K, Gropman A, Tierney E, Porter F. Decreased cerebral spinal fluid neurotransmitter levels in Smith-Lemli-Opitz syndrome. J Inherit Metab Dis 2014; 37:415-20. [PMID: 24500076 PMCID: PMC4166510 DOI: 10.1007/s10545-013-9672-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 12/10/2013] [Accepted: 12/13/2013] [Indexed: 12/11/2022]
Abstract
Smith-Lemli-Opitz syndrome (SLOS) is an autosomal recessive, multiple congenital anomaly syndrome with cognitive impairment and a distinct behavioral phenotype that includes autistic features. SLOS is caused by a defect in 3β-hydroxysterol Δ(7)-reductase which leads to decreased cholesterol levels and elevated cholesterol precursors, specifically 7- and 8-dehydrocholesterol. However, the pathological processes contributing to the neurological abnormalities in SLOS have not been defined. In view of prior data suggesting defects in SLOS in vesicular release and given the association of altered serotonin metabolism with autism, we were interested in measuring neurotransmitter metabolite levels in SLOS to assess their potential to be used as biomarkers in therapeutic trials. We measured cerebral spinal fluid levels of serotonin and dopamine metabolites, 5-hydroxyindoleacetic acid (5HIAA) and homovanillic acid (HVA) respectively, in 21 SLOS subjects. Results were correlated with the SLOS anatomical severity score, Aberrant Behavior Checklist scores and concurrent sterol biochemistry. Cerebral spinal fluid (CSF) levels of both 5HIAA and HVA were significantly reduced in SLOS subjects. In individual patients, the levels of both 5HIAA and HVA were reduced to a similar degree. CSF neurotransmitter metabolite levels did not correlate with either CSF sterols or behavioral measures. This is the first study demonstrating decreased levels of CSF neurotransmitter metabolites in SLOS. We propose that decreased levels of neurotransmitters in SLOS are caused by a sterol-related defect in synaptic vesicle formation and that CSF 5HIAA and HVA will be useful biomarkers in development of future therapeutic trials.
Collapse
Affiliation(s)
- S.E. Sparks
- Clinical Genetics, Department of Pediatrics, Carolinas Medical Center, Charlotte, NC, USA
| | - C.A. Wassif
- Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - H. Goodwin
- Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - S.K. Conley
- Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - D.C. Lanham
- Department of Psychiatry, Kennedy Krieger Institute, Baltimore, MD, USA
| | - L.E. Kratz
- Biochemical Genetics Laboratory, Kennedy Krieger Institute, Baltimore, MD, USA
| | - K. Hyland
- Medical Neurogenetics, Atlanta, GA, USA
| | - A. Gropman
- Center for Neuroscience Research, Children's National Medical Center, Washington, DC, USA
| | - E. Tierney
- Department of Psychiatry, Kennedy Krieger Institute, Baltimore, MD, USA
| | - F.D. Porter
- Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
- Corresponding Author: Forbes D. Porter, MD, PhD, 10-CRC, Rm. 5-2571, 10 Center Dr., Bethesda, MD 20892, Phone: 301-435-4432, Fax: 301-480-5791,
| |
Collapse
|
26
|
Ng J, Zhen J, Meyer E, Erreger K, Li Y, Kakar N, Ahmad J, Thiele H, Kubisch C, Rider NL, Morton DH, Strauss KA, Puffenberger EG, D'Agnano D, Anikster Y, Carducci C, Hyland K, Rotstein M, Leuzzi V, Borck G, Reith MEA, Kurian MA. Dopamine transporter deficiency syndrome: phenotypic spectrum from infancy to adulthood. ACTA ACUST UNITED AC 2014; 137:1107-19. [PMID: 24613933 PMCID: PMC3959557 DOI: 10.1093/brain/awu022] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Dopamine transporter deficiency syndrome is an SLC6A3-related progressive infantile-onset parkinsonism-dystonia that mimics cerebral palsy. Ng et al. describe clinical features and molecular findings in a new cohort of patients. They report infants with classical disease, as well as young adults manifesting as atypical juvenile-onset parkinsonism-dystonia, thereby expanding the disease spectrum. Dopamine transporter deficiency syndrome due to SLC6A3 mutations is the first inherited dopamine ‘transportopathy’ to be described, with a classical presentation of early infantile-onset progressive parkinsonism dystonia. In this study we have identified a new cohort of patients with dopamine transporter deficiency syndrome, including, most significantly, atypical presentation later in childhood with a milder disease course. We report the detailed clinical features, molecular genetic findings and in vitro functional investigations undertaken for adult and paediatric cases. Patients presenting with parkinsonism dystonia or a neurotransmitter profile characteristic of dopamine transporter deficiency syndrome were recruited for study. SLC6A3 mutational analysis was undertaken in all patients. The functional consequences of missense variants on the dopamine transporter were evaluated by determining the effect of mutant dopamine transporter on dopamine uptake, protein expression and amphetamine-mediated dopamine efflux using an in vitro cellular heterologous expression system. We identified eight new patients from five unrelated families with dopamine transporter deficiency syndrome. The median age at diagnosis was 13 years (range 1.5–34 years). Most significantly, the case series included three adolescent males with atypical dopamine transporter deficiency syndrome of juvenile onset (outside infancy) and progressive parkinsonism dystonia. The other five patients in the cohort presented with classical infantile-onset parkinsonism dystonia, with one surviving into adulthood (currently aged 34 years) and labelled as having ‘juvenile parkinsonism’. All eight patients harboured homozygous or compound heterozygous mutations in SLC6A3, of which the majority are previously unreported variants. In vitro studies of mutant dopamine transporter demonstrated multifaceted loss of dopamine transporter function. Impaired dopamine uptake was universally present, and more severely impacted in dopamine transporter mutants causing infantile-onset rather than juvenile-onset disease. Dopamine transporter mutants also showed diminished dopamine binding affinity, reduced cell surface transporter, loss of post-translational dopamine transporter glycosylation and failure of amphetamine-mediated dopamine efflux. Our data series expands the clinical phenotypic continuum of dopamine transporter deficiency syndrome and indicates that there is a phenotypic spectrum from infancy (early onset, rapidly progressive disease) to childhood/adolescence and adulthood (later onset, slower disease progression). Genotype–phenotype analysis in this cohort suggests that higher residual dopamine transporter activity is likely to contribute to postponing disease presentation in these later-onset adult cases. Dopamine transporter deficiency syndrome remains under-recognized and our data highlights that dopamine transporter deficiency syndrome should be considered as a differential diagnosis for both infantile- and juvenile-onset movement disorders, including cerebral palsy and juvenile parkinsonism.
Collapse
Affiliation(s)
- Joanne Ng
- 1 Neurosciences Unit, UCL Institute of Child Health, London, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Affiliation(s)
- K. Hyland
- Baylor Research Institute, Dept. of Metabolic Disease, 3812 Elm Street Dallas, Texas 75226, U.S.A
| | - R. Surtees
- Institute of Child Health, 30 Guilford Street, London WC1N1EH, U. K
| |
Collapse
|
28
|
Goyal M, Fequiere PR, McGrath TM, Hyland K. Seizures with decreased levels of pyridoxal phosphate in cerebrospinal fluid. Pediatr Neurol 2013; 48:227-31. [PMID: 23419474 DOI: 10.1016/j.pediatrneurol.2012.11.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Accepted: 11/19/2012] [Indexed: 10/27/2022]
Abstract
Although pyridoxine-dependent seizures have been reported for decades, pyridoxamine phosphate oxidase deficiency has only been recently described. Pyridoxamine phosphate oxidase (PNPO) is one of a series of enzymes involved in converting pyridoxine to pyridoxal 5'-phosphate, the biologically active form of pyridoxine. PNPO deficiency is associated with decreased levels of pyridoxal 5'-phosphate in CSF, as well as epilepsy. We describe four children up to 16 years of age with intractable seizures who all had low cerebrospinal fluid (CSF) levels of pyridoxal 5'-phosphate. Only one of the four children possessed a genetic alteration, a novel homozygous variant in exon one of the PNPO gene. Three of four, however, showed at least some clinical improvement with pyridoxal 5'-phosphate supplementation. Low CSF pyridoxal 5'-phosphate levels, although considered a diagnostic biomarker for PNPO deficiency, lack specificity and may result from multiple other causes. Genetic testing and CSF evaluation, along with clinical response are all necessary for accurate diagnosis.
Collapse
Affiliation(s)
- Monisha Goyal
- Department of Pediatric Neurology, University of Alabama, Birmingham, AL 35233, USA.
| | | | | | | |
Collapse
|
29
|
Pearl PL, Hyland K, Chiles J, McGavin CL, Yu Y, Taylor D. Partial Pyridoxine Responsiveness in PNPO Deficiency. JIMD Rep 2012; 9:139-142. [PMID: 23430561 DOI: 10.1007/8904_2012_194] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 10/17/2012] [Accepted: 10/18/2012] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Autosomal-recessive pyridox(am)ine phosphate oxidase (PNPO) deficiency causes pyridoxal-5-phosphate (PLP)-dependent epilepsy. We describe partial PNPO deficiency with a transient response to pyridoxine (B6). METHODS CSF neurotransmitter metabolites, PLP, and amino acids were analyzed while the patient was receiving pyridoxine. PNPO gene sequencing was performed by standard techniques. RESULTS A full-term 3,220 g male with refractory neonatal seizures became seizure free for 6 weeks on pyridoxine (B6). Breakthrough seizures followed. These stopped upon the first dose of PLP although episodes occurred as a dose became due. An unidentified peak was detected on the chromatographic system used to measure CSF PLP. PNPO gene sequencing identified a homozygous mutation in a highly conserved area in exon 3: c.352G>A p.G118R, predicting substitution of arginine for glycine. At age 28 months the child has hypotonia and developmental delay, both mild in severity. CONCLUSIONS Transient pyridoxine responsiveness may be seen in partial PNPO deficiency. A CSF metabolite peak, likely pyridoxine phosphate, is identifiable in patients with PNPO deficiency who are taking supplemental pyridoxine. Partial B6 responsiveness is an indication for possible PNPO deficiency and trial of PLP.
Collapse
Affiliation(s)
- Phillip L Pearl
- Department of Neurology, Children's National Medical Center, George Washington University School of Medicine, Washington, DC, USA. .,Department of Neurology, Children's National Medical Center, 111 Michigan Ave, NW, Washington, DC, 20010, USA.
| | | | - J Chiles
- Medical Neurogenetics, Atlanta, GA, USA
| | - Colleen L McGavin
- Department of Neurology, Children's National Medical Center, George Washington University School of Medicine, Washington, DC, USA
| | - Yuezhou Yu
- Department of Neurology, Children's National Medical Center, George Washington University School of Medicine, Washington, DC, USA
| | | |
Collapse
|
30
|
Farook MF, DeCuypere M, Hyland K, Takumi T, LeDoux MS, Reiter LT. Altered serotonin, dopamine and norepinepherine levels in 15q duplication and Angelman syndrome mouse models. PLoS One 2012; 7:e43030. [PMID: 22916201 PMCID: PMC3420863 DOI: 10.1371/journal.pone.0043030] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 07/16/2012] [Indexed: 01/18/2023] Open
Abstract
Childhood neurodevelopmental disorders like Angelman syndrome and autism may be the result of underlying defects in neuronal plasticity and ongoing problems with synaptic signaling. Some of these defects may be due to abnormal monoamine levels in different regions of the brain. Ube3a, a gene that causes Angelman syndrome (AS) when maternally deleted and is associated with autism when maternally duplicated has recently been shown to regulate monoamine synthesis in the Drosophila brain. Therefore, we examined monoamine levels in striatum, ventral midbrain, frontal cerebral cortex, cerebellar cortex and hippocampus in Ube3a deficient and Ube3a duplication animals. We found that serotonin (5HT), a monoamine affected in autism, was elevated in the striatum and cortex of AS mice. Dopamine levels were almost uniformly elevated compared to control littermates in the striatum, midbrain and frontal cortex regardless of genotype in Ube3a deficient and Ube3a duplication animals. In the duplication 15q autism mouse model, paternal but not maternal duplication animals showed a decrease in 5HT levels when compared to their wild type littermates, in accordance with previously published data. However, maternal duplication animals show no significant changes in 5HT levels throughout the brain. These abnormal monoamine levels could be responsible for many of the behavioral abnormalities observed in both AS and autism, but further investigation is required to determine if any of these changes are purely dependent on Ube3a levels in the brain.
Collapse
Affiliation(s)
- M. Febin Farook
- Department of Neurology, UTHSC, Memphis, Tennessee, United States of America
| | - Michael DeCuypere
- Department of Neurosurgery, UTHSC, Memphis, Tennessee, United States of America
| | - Keith Hyland
- Medical Neurogenetics, LCC, Atlanta, Georgia, United States of America
| | - Toru Takumi
- Hiroshima University, School of Medicine, Hiroshima, Japan
| | - Mark S. LeDoux
- Department of Neurology, UTHSC, Memphis, Tennessee, United States of America
- Department of Anatomy and Neurobiology, UTHSC, Memphis, Tennessee, United States of America
| | - Lawrence T. Reiter
- Department of Neurology, UTHSC, Memphis, Tennessee, United States of America
- Department of Anatomy and Neurobiology, UTHSC, Memphis, Tennessee, United States of America
- Department of Pediatrics, UTHSC, Memphis, Tennessee, United States of America
| |
Collapse
|
31
|
Friedman J, Roze E, Abdenur JE, Chang R, Gasperini S, Saletti V, Wali GM, Eiroa H, Neville B, Felice A, Parascandalo R, Zafeiriou DI, Arrabal-Fernandez L, Dill P, Eichler FS, Echenne B, Gutierrez-Solana LG, Hoffmann GF, Hyland K, Kusmierska K, Tijssen MAJ, Lutz T, Mazzuca M, Penzien J, Poll-The BT, Sykut-Cegielska J, Szymanska K, Thöny B, Blau N. Sepiapterin reductase deficiency: a treatable mimic of cerebral palsy. Ann Neurol 2012; 71:520-30. [PMID: 22522443 DOI: 10.1002/ana.22685] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Sepiapterin reductase deficiency (SRD) is an under-recognized levodopa-responsive disorder. We describe clinical, biochemical, and molecular findings in a cohort of patients with this treatable condition. We aim to improve awareness of the phenotype and available diagnostic and therapeutic strategies to reduce delayed diagnosis or misdiagnosis, optimize management, and improve understanding of pathophysiologic mechanisms. METHODS Forty-three individuals with SRD were identified from 23 international medical centers. The phenotype and treatment response were assessed by chart review using a detailed standardized instrument and by literature review for cases for which records were unavailable. RESULTS In most cases, motor and language delays, axial hypotonia, dystonia, weakness, oculogyric crises, and diurnal fluctuation of symptoms with sleep benefit become evident in infancy or childhood. Average age of onset is 7 months, with delay to diagnosis of 9.1 years. Misdiagnoses of cerebral palsy (CP) are common. Most patients benefit dramatically from levodopa/carbidopa, often with further improvement with the addition of 5-hydroxytryptophan. Cerebrospinal fluid findings are distinctive. Diagnosis is confirmed by mutation analysis and/or enzyme activity measurement in cultured fibroblasts. INTERPRETATION Common, clinical findings of SRD, aside from oculogyric crises and diurnal fluctuation, are nonspecific and mimic CP with hypotonia or dystonia. Patients usually improve dramatically with treatment. Consequently, we recommend consideration of SRD not only in patients with levodopa-responsive motor disorders, but also in patients with developmental delays with axial hypotonia, and patients with unexplained or atypical presumed CP. Biochemical investigation of cerebrospinal fluid is the preferred method of initial investigation. Early diagnosis and treatment are recommended to prevent ongoing brain dysfunction.
Collapse
Affiliation(s)
- Jennifer Friedman
- Departments of Neurosciences and Pediatrics, University of California at San Diego and Rady Children's Hospital, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Starnes M, Shoffner J, Hyland K. Rapid and Dramatic Decreases of Cerebral 5-Methyltetrahydrofolate: A Treatable Form of Progressive Neurodegeneration (S28.007). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.s28.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
33
|
Vanderver A, Tonduti D, Lebon P, Blau N, Loewenstein J, Gahl W, Toro C, Hyland K. Neurotransmitter Abnormalities and Response to L-Dopa in SPG11 (P05.133). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p05.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
34
|
Langley W, Hyland K, Mylacraine L, Shoffner J. Detection of Anti-Folate Receptor Antibodies in the Serum and CSF of Cerebral Folate Deficiency Patients (P02.171). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p02.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
35
|
Mylacraine L, Langley W, Hyland K, Shoffner J. Chronic Progressive External Ophthalmoplegia and Cerebral Folate Defect in a Patient Undergoing Antiretroviral Treatment for HIV: Effects on Mitochondrial Function (P01.264). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p01.264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
36
|
O'Leary RE, Shih JC, Hyland K, Kramer N, Asher YJT, Graham JM. De novo microdeletion of Xp11.3 exclusively encompassing the monoamine oxidase A and B genes in a male infant with episodic hypotonia: a genomics approach to personalized medicine. Eur J Med Genet 2012; 55:349-53. [PMID: 22365943 DOI: 10.1016/j.ejmg.2012.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Accepted: 01/01/2012] [Indexed: 02/07/2023]
Abstract
Monoamine oxidase A and B (MAOA and MAOB) play key roles in deaminating neurotransmitters and various other biogenic amines. Patients deficient in one or both enzymes have distinct metabolic and neurologic profiles. MAOB deficient patients exhibit normal clinical characteristics and behavior, while MAOA deficient patients have borderline intellectual deficiency and impaired impulse control. Patients who lack both MAOA and MAOB have the most extreme laboratory values (urine, blood, and CSF serotonin 4-6 times normal, with elevated O-methylated amine metabolites and reduced deaminated metabolites) in addition to severe intellectual deficiency and behavioral problems. Mice lacking maoa and moab exhibit decreased proliferation of neural stem cells beginning in late gestation and persisting into adulthood. These mice show significantly increased monoamine levels, particularly serotonin, as well as anxiety-like behaviors as adults, suggesting that brain maturation in late embryonic development is adversely affected by elevated serotonin levels. We report the case of a male infant with a de novo Xp11.3 microdeletion exclusively encompassing the MAOA and MAOB genes. This newly recognized X-linked disorder is characterized by severe intellectual disability and unusual episodes of hypotonia, which resemble atonic seizures, but have no EEG correlate. A customized low dietary amine diet was implemented in an attempt to prevent the cardiovascular complications that can result from the excessive intake of these compounds. This is the second report of this deletion and the first attempt to maintain the patient's cardiovascular health through dietary manipulation. Even though a diet low in tyramine, phenylethylamine, and dopa/dopamine is necessary for long-term management, it will not rescue the abnormal monoamine profile seen in combined MAOA and MAOB deficiency. Our patient displays markedly elevated levels of serotonin in blood, serum, urine, and CSF while on this diet. Serotonin biosynthesis inhibitors like para-chlorophenylalanine and p-ethynylphenylalanine may be needed to lower serotonin levels in patients with absent monoamine oxidase enzymes.
Collapse
Affiliation(s)
- Ryan E O'Leary
- Medical Genetics Institute, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
| | | | | | | | | | | |
Collapse
|
37
|
Robinson DP, Baverstock W, Al-Jaru A, Hyland K, Khazanehdari KA. Annually recurring parthenogenesis in a zebra shark Stegostoma fasciatum. J Fish Biol 2011; 79:1376-1382. [PMID: 22026614 DOI: 10.1111/j.1095-8649.2011.03110.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
A zebra shark, Stegostoma fasciatum, held in captivity at the Burj Al Arab aquarium, produced embryos and pups in the absence of a male. A total of 15 pups were produced from eggs laid within the aquarium over a period of four consecutive years commencing 2007. Parthenogenesis was confirmed through DNA analysis for three pups sampled during the first two consecutive egg cycles and is presumed to be the method of reproduction responsible thereafter.
Collapse
Affiliation(s)
- D P Robinson
- Jumeirah Group, P. O. Box 74147, Dubai, United Arab Emirates
| | | | | | | | | |
Collapse
|
38
|
Horvath GA, Selby K, Poskitt K, Hyland K, Waters PJ, Coulter-Mackie M, Stockler-Ipsiroglu SG. Hemiplegic migraine, seizures, progressive spastic paraparesis, mood disorder, and coma in siblings with low systemic serotonin. Cephalalgia 2011; 31:1580-6. [DOI: 10.1177/0333102411420584] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Serotonin has an important role in vascular resistance and blood pressure control, and a functional serotonin transporter polymorphism has been associated with migraine. Disturbances in serotonin metabolism have been associated with autism, depression, and myoclonus related conditions, but serotonin has far more functions in the body. Familial hemiplegic migraine is a rare autosomal dominant subtype of migraine with aura in which attacks are associated with hemiparesis. Cases: We present two siblings with hemiplegic migraine, depression, progressive spastic paraparesis, myelopathy, and spinal cord atrophy. One of the sisters presented with prolonged coma after a migraine episode. Both sisters were found to have low cerebrospinal fluid serotonin metabolite (5-hydroxyindoleacetic acid), low platelet serotonin levels, and diminished serotonin transport capacity. Their clinical symptoms improved on 5-hydroxytryptophan replacement therapy. Mutational analysis of the CACNA1A and ATP1A2 genes was negative. Conclusion: This is the first time that systemic serotonin deficiency has been described in familial hemiplegic migraine. We hypothesize that the deficiency of serotonin transport may be part of a complex cellular membrane trafficking dysfunction involving not only the serotonin transporter but also other transporters and ion channels.
Collapse
Affiliation(s)
| | | | - Ken Poskitt
- British Columbia Children's Hospital, Canada
| | | | - Paula J Waters
- British Columbia Children's Hospital, Canada
- University of British Columbia, Canada
| | | | | |
Collapse
|
39
|
Veerapandiyan A, Winchester SA, Gallentine WB, Smith EC, Kansagra S, Hyland K, Mikati MA. Electroencephalographic and seizure manifestations of pyridoxal 5'-phosphate-dependent epilepsy. Epilepsy Behav 2011; 20:494-501. [PMID: 21292558 DOI: 10.1016/j.yebeh.2010.12.046] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Revised: 12/23/2010] [Accepted: 12/27/2010] [Indexed: 10/18/2022]
Abstract
We describe the electroencephalographic and clinical seizure manifestations of pyridoxal 5'-phosphate-dependent epilepsy (PLP-DE) in two patients [diagnosis confirmed by low cerebrospinal fluid (CSF) PLP, complete resolution of previously intractable seizures with PLP supplementation, negative pyridoxine-dependent epilepsy CSF biomarkers, and/or positive disease causing pyridox(am)ine 5'-phosphate oxidase gene mutation] along with a comprehensive review of the literature. One patient presented with neonatal tonic status epilepticus with subsequent generalized tonic-clonic seizures, and the second, with refractory complex partial seizures starting at 2 years of age. The pretreatment EEG revealed, interictally, burst suppression, multifocal independent sharp waves, and electrical status epilepticus in sleep. Ictally and interictally, it revealed runs of unilateral spike/slow waves. Previously reported features include burst suppression, myoclonus, tonic seizures, clonic seizures, and spasms. In the appropriate clinical scenario, the aforementioned features should raise the possibility of PLP-DE and appropriate treatment should be initiated. The first late-onset case (at 2 years) of PLP-DE is reported.
Collapse
|
40
|
Abstract
Cerebral folate deficiency (CFD) is defined as any neurological syndrome associated with a low cerebrospinal fluid (CSF) concentration of 5-methyltetrahydrofolate (5MTHF) in the presence of normal peripheral folate status. CFD has a wide clinical presentation, with reported signs and symptoms generally beginning at around 4 months of age with irritability and sleep disturbances. These can be followed by psychomotor retardation, dyskinesia, cerebellar ataxia and spastic diplegia. Other signs may include deceleration of head growth, visual disturbances and sensorineural hearing loss. Identification of CFD is achieved by determining 5MTHF concentration in CSF. Once identified, CFD can in many cases be treated by administering oral folinic acid. Supplementation with folic acid is contraindicated and, if used, may exacerbate the CSF 5MTHF deficiency. Generation of autoantibodies against the folate receptor required to transport 5MTHF into CSF and mutations in the folate receptor 1 (FOLR1) gene have been reported to be causes of CFD. However, other mechanisms are probably also involved, as CFD has been reported in Aicardi-Goutiere's and Rett syndromes and in mitochondriopathies. Several metabolic conditions and a number of widely used drugs can also lead to a decrease in the concentration of CSF 5MTHF, and these should be considered in the differential diagnosis if a low concentration of 5MTHF is found following CSF analysis.
Collapse
|
41
|
Allen GFG, Neergheen V, Oppenheim M, Fitzgerald JC, Footitt E, Hyland K, Clayton PT, Land JM, Heales SJR. Pyridoxal 5'-phosphate deficiency causes a loss of aromatic L-amino acid decarboxylase in patients and human neuroblastoma cells, implications for aromatic L-amino acid decarboxylase and vitamin B(6) deficiency states. J Neurochem 2010; 114:87-96. [PMID: 20403077 DOI: 10.1111/j.1471-4159.2010.06742.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pyridoxal 5'-phosphate, the active form of vitamin B(6), is an essential cofactor for multiple enzymes, including aromatic l-amino acid decarboxylase that catalyses the final stage in the production of the neurotransmitters dopamine and serotonin. In two patients with inherited disorders of vitamin B(6) metabolism, we observed reductions in plasma aromatic l-amino acid decarboxylase activity. In one patient, this change was related to an increase in K(m) for pyridoxal 5'-phosphate. Furthermore, pyridoxal 5'-phosphate-deficient human SH-SY5Y neuroblastoma cells were found to exhibit reduced levels of aromatic l-amino acid decarboxylase activity and protein but with no alteration in expression. Further reductions in activity and protein were observed with the addition of the vitamin B(6) antagonist 4-deoxypyridoxine, which also reduced aromatic l-amino acid decarboxylase mRNA levels. Neither pyridoxal 5'-phosphate deficiency nor the addition of 4-deoxypyridoxine affected aromatic l-amino acid decarboxylase stability over 8 h with protein synthesis inhibited. Increasing extracellular availability of pyridoxal 5'-phosphate was not found to have any significant effect on intracellular pyridoxal 5'-phosphate concentrations or on aromatic l-amino acid decarboxylase. These findings suggest that maintaining adequate pyridoxal 5'-phosphate availability may be important for optimal treatment of aromatic l-amino acid decarboxylase deficiency and l-dopa-responsive conditions.
Collapse
Affiliation(s)
- George F G Allen
- Department of Molecular Neuroscience, UCL Institute of Neurology, London WC1N 3BG, UK.
| | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Shoffner J, Hyams L, Langley GN, Cossette S, Mylacraine L, Dale J, Ollis L, Kuoch S, Bennett K, Aliberti A, Hyland K. Fever plus mitochondrial disease could be risk factors for autistic regression. J Child Neurol 2010; 25:429-34. [PMID: 19773461 DOI: 10.1177/0883073809342128] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Autistic spectrum disorders encompass etiologically heterogeneous persons, with many genetic causes. A subgroup of these individuals has mitochondrial disease. Because a variety of metabolic disorders, including mitochondrial disease show regression with fever, a retrospective chart review was performed and identified 28 patients who met diagnostic criteria for autistic spectrum disorders and mitochondrial disease. Autistic regression occurred in 60.7% (17 of 28), a statistically significant increase over the general autistic spectrum disorder population (P < .0001). Of the 17 individuals with autistic regression, 70.6% (12 of 17) regressed with fever and 29.4% (5 of 17) regressed without identifiable linkage to fever or vaccinations. None showed regression with vaccination unless a febrile response was present. Although the study is small, a subgroup of patients with mitochondrial disease may be at risk of autistic regression with fever. Although recommended vaccinations schedules are appropriate in mitochondrial disease, fever management appears important for decreasing regression risk.
Collapse
Affiliation(s)
- John Shoffner
- Medical Neurogenetics, LLC, Atlanta, Georgia 30338, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Gunasekera RS, Hyland K. In vivo regulation of phenylalanine hydroxylase in the genetic mutant hph-1 mouse model. Mol Genet Metab 2009; 98:264-72. [PMID: 19560382 DOI: 10.1016/j.ymgme.2009.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Revised: 05/18/2009] [Accepted: 05/18/2009] [Indexed: 11/27/2022]
Abstract
The hph-1 mouse has low liver activity of GTP cyclohydrolase 1, the rate limiting enzyme in the biosynthesis of tetrahydrobiopterin (BH(4)). BH(4) is the cofactor for phenylalanine hydroxylase (PAH) and in the early stages of life the hph-1 mouse is hyperphenylalaninemic. At approximately 15 days after birth the blood phenylalanine levels normalize. During this period the animals provide an in vivo model which can be used to study the regulatory effects of phenylalanine on PAH, and for related pediatric metabolic disease in humans; from birth to youth. We therefore, examined; liver PAH activity using BH(4) and 6-methyltetrahydropterin (6MPH(4)) as cofactor; PAH total enzyme concentration by Western blotting using the PH8 antibody, and PAH state of phosphorylation using the PH7 antibody from 4 to 18 days after birth. The findings were compared to the wild type animals that are not hyperphenylalaninemic during this period. PAH (6MPH(4)) activity and total protein (PH8 antibody) rose steadily in the hph-1 mice. In control mice, both activity and total protein fluctuated. The degree of phosphorylation of PAH in the mutants and the state of activation (as measured by the 6MPH(4)/BH(4) activity ratio) increased as phenylalanine levels rose, and decreased when they fell. Similar patterns were not seen in the control animals. These studies provide in vivo evidence that phenylalanine concentration regulates the activity of PAH in the hph-1 mouse and that this acts via a mechanism that includes phosphorylation of the PAH molecule. The kinetic values (K(m) and V(max)) for mouse PAH are also reported.
Collapse
Affiliation(s)
- Richard S Gunasekera
- Institute of Metabolic Disease, Baylor University Medical Center, Dallas, TX 75226, USA.
| | | |
Collapse
|
44
|
Rosenberg EH, Struys EA, Hyland K, Plecko B, Waters PJ, Mercimek-Mahmutoglu S, Stockler-Ipsiroglu S, Gallagher RC, Scharer G, Van Hove JLK, Jakobs C, Salomons GS. Mutation detection in DNA isolated from cerebrospinal fluid and urine: Clinical utility and pitfalls of multiple displacement amplification. Mol Genet Metab 2009; 97:312-4. [PMID: 19501531 DOI: 10.1016/j.ymgme.2009.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Revised: 05/01/2009] [Accepted: 05/02/2009] [Indexed: 11/15/2022]
Abstract
This study describes the use of cerebral spinal fluid (CSF) and/or urine as source of DNA for mutation analysis combined with multiple displacement amplification. The findings illustrate the opportunities and pitfalls of these methods in the search for identification of the pathogenic mutations in the case that only scarce material is available such as CSF.
Collapse
Affiliation(s)
- Efraim H Rosenberg
- Metabolic Unit, Department of Clinical Chemistry, VU University Medical Center (PK 1 X009), 1081 HV Amsterdam, The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Parikh S, Hyland K, Lachhwani DK. Vitamins, not surgery: spinal fluid testing in hemispheric epilepsy. Pediatr Neurol 2009; 40:477-9. [PMID: 19433287 DOI: 10.1016/j.pediatrneurol.2009.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Revised: 12/29/2008] [Accepted: 01/06/2009] [Indexed: 10/20/2022]
Abstract
Metabolic testing in spinal fluid is not routinely obtained in every patient with refractory epilepsy or status epilepticus. A 9-month-old girl who was referred for surgical treatment of refractory status epilepticus suggestive of a right hemispheric focus; cranial magnetic resonance imaging was unremarkable. The patient received a metabolic evaluation according to institutional protocol and was noted to have a spinal fluid peak characteristically seen in folinic acid-responsive epilepsy. Subsequent testing revealed a deleterious mutation in the ALDH7A1 gene. At last follow-up, the patient was seizure free on folinic acid and pyridoxal 5'-phosphate supplementation. Surgery was not performed. Metabolic testing in spinal fluid is strongly urged in all patients with refractory epilepsy or status epilepticus when an underlying etiology is not known.
Collapse
Affiliation(s)
- Sumit Parikh
- Centers for Pediatric Neurology & Epilepsy, Neuroscience Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
| | | | | |
Collapse
|
46
|
Gallagher RC, Van Hove JLK, Scharer G, Hyland K, Plecko B, Waters PJ, Mercimek-Mahmutoglu S, Stockler-Ipsiroglu S, Salomons GS, Rosenberg EH, Struys EA, Jakobs C. Folinic acid-responsive seizures are identical to pyridoxine-dependent epilepsy. Ann Neurol 2009; 65:550-6. [DOI: 10.1002/ana.21568] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
47
|
Willoughby RE, Opladen T, Maier T, Rhead W, Schmiedel S, Hoyer J, Drosten C, Rupprecht CE, Hyland K, Hoffmann GF. Tetrahydrobiopterin deficiency in human rabies. J Inherit Metab Dis 2009; 32:65-72. [PMID: 18949578 DOI: 10.1007/s10545-008-0949-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Revised: 07/23/2008] [Accepted: 07/25/2008] [Indexed: 12/25/2022]
Abstract
Rabies is a fatal viral encephalitis characterized by a clinically acute and progressive course. With rare exceptions, there is a discrepancy between clinical outcome and frank histological alterations in rabies. Investigators have postulated that rabies virus may modify neurotransmission through occupancy of cellular receptors or alteration of ion channels. We took advantage of these observations to improvise a successful therapy for rabies. The Milwaukee protocol ( www.mcw.edu/rabies ) was further modified to treat two German patients. We measured pterins and monoamine neurotransmitter metabolites in the CSF of patients with rabies by HPLC with electrochemical or fluorescent detection. We report loss of tetrahydrobiopterin (BH(4)) and associated pathological decrease of dopaminergic and serotoninergic neurotransmission in three successive patients with rabies. CSF levels of BH(4) and neurotransmitter metabolites increased in two patients who were supplemented. Our findings support the long-standing speculation of modified neurotransmission in the pathogenesis of rabies, but by another mechanism. Brain turnover of dopamine and serotonin is reduced following rabies-acquired BH(4) deficiency. Neuronal nitric oxide synthase is BH(4)-dependent and may also be involved, possibly causing cerebrovascular insufficiency in one patient. This work must be carefully replicated in animal models and future patients. We are cautiously optimistic at the prospect of readily available, metabolically specific, enteral therapy for rabies.
Collapse
|
48
|
|
49
|
Ormazabal A, Oppenheim M, Serrano M, García-Cazorla A, Campistol J, Ribes A, Ruiz A, Moreno J, Hyland K, Clayton P, Heales S, Artuch R. Pyridoxal 5'-phosphate values in cerebrospinal fluid: reference values and diagnosis of PNPO deficiency in paediatric patients. Mol Genet Metab 2008; 94:173-7. [PMID: 18294893 DOI: 10.1016/j.ymgme.2008.01.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Revised: 01/14/2008] [Accepted: 01/14/2008] [Indexed: 11/28/2022]
Abstract
Our aim was to establish reference values for cerebrospinal fluid (CSF) pyridoxal 5'-phosphate (PLP) in a paediatric population for the diagnosis of pyridox(am)ine 5'-phosphate oxidase (PNPO) deficiency. For reference values, CSF samples from 113 paediatric controls (age range: 1 day-18 years) from Barcelona and London were analysed. Cerebrospinal fluid PLP and biogenic amine concentrations were analysed by HPLC with fluorescence and electrochemical detection. Pyridoxal 5'-phosphate concentrations in 4 patients with PNPO deficiency were determined. A negative correlation between CSF PLP values and age of controls was observed in both populations (r=-0.503; p<0.0001 and r=-0.542; p=0.002). Reference values were stratified into 4 (Barcelona) and 3 age groups (London). For the newborn period, CSF PLP reference intervals were 32-78 and 44-89 nmol/L for the Barcelona and London centers, respectively). No correlation was observed in the different age groups between PLP values and biogenic amines metabolites. PLP values in neonates with PNPO deficiency were clearly decreased (PLP=3.6, 12.0, 14.0 and 18.0 nmol/L) compared with our reference ranges. In conclusion, reference values for CSF PLP should be stratified according to age. No association was observed between PLP values and biogenic amines metabolites. In our 4 cases with PNPO deficiency, CSF PLP values were clearly below the reference values.
Collapse
Affiliation(s)
- Aida Ormazabal
- Departments of Clinical Biochemistry and Neurology, Hospital Sant Joan de Déu and Centre for Biomedical Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Passeig Sant Joan de Déu 2, 08950, Esplugues, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Horvath GA, Stockler-Ipsiroglu SG, Salvarinova-Zivkovic R, Lillquist YP, Connolly M, Hyland K, Blau N, Rupar T, Waters PJ. Autosomal recessive GTP cyclohydrolase I deficiency without hyperphenylalaninemia: evidence of a phenotypic continuum between dominant and recessive forms. Mol Genet Metab 2008; 94:127-31. [PMID: 18276179 DOI: 10.1016/j.ymgme.2008.01.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Accepted: 01/08/2008] [Indexed: 12/29/2022]
Abstract
We describe a unique presentation of autosomal recessive (AR) GTP cyclohydrolase I (GTPCH) deficiency, with severe CNS involvement but without hyperphenylalaninemia. A male infant presented with progressive spasticity, dystonia and oculogyric episodes. Blood phenylalanine levels were persistently normal: whereas an oral phenylalanine loading test revealed impaired phenylalanine clearance. CSF neopterin and tetrahydrobiopterin (BH(4)) were low, homovanillic acid marginally low and 5-hydroxyindoleacetic acid normal. Fibroblasts showed decreased GTPCH enzyme activity. A homozygous novel mutation of GCH1, p.V206A, was identified. On treatment (BH(4), L-Dopa/Carbidopa and 5-hydroxytryptophan), motor development improved. Mutational analysis provided neonatal diagnosis of a younger brother who, after 18 months on treatment, shows normal development. AR GTPCH I deficiency can present without hyperphenylalaninemia and with normal or subtle CSF neurotransmitter profiles. Testing for GTPCH deficiency should be considered for patients with unexplained neurological symptoms and extrapyramidal movement disorder.
Collapse
Affiliation(s)
- Gabriella A Horvath
- Department of Pediatrics, BC's Children's Hospital and University of British Columbia, 4480 Oak Street, Vancouver, BC, Canada
| | | | | | | | | | | | | | | | | |
Collapse
|