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Mabondzo A, van de Kamp J, Mercimek-Andrews S. Dodecyl creatine ester therapy: from promise to reality. Cell Mol Life Sci 2024; 81:186. [PMID: 38632116 PMCID: PMC11024018 DOI: 10.1007/s00018-024-05218-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 01/18/2024] [Revised: 02/26/2024] [Accepted: 03/05/2024] [Indexed: 04/19/2024]
Abstract
Pathogenic variants in SLC6A8, the gene which encodes creatine transporter SLC6A8, prevent creatine uptake in the brain and result in a variable degree of intellectual disability, behavioral disorders (e.g., autism spectrum disorder), epilepsy, and severe speech and language delay. There are no treatments to improve neurodevelopmental outcomes for creatine transporter deficiency (CTD). In this spotlight, we summarize recent advances in innovative molecules to treat CTD, with a focus on dodecyl creatine ester, the most promising drug candidate.
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Affiliation(s)
- Aloïse Mabondzo
- Paris Saclay University, CEA, Medicines and Healthcare Technologies Department (MTS), SPI, Neurovascular Unit Research and Therapeutic Innovation Laboratory, 91191, Gif-sur-Yvette cedex, France.
| | - Jiddeke van de Kamp
- Department of Human Genetics, Amsterdam UMC, Vrije Universtiteit Amsterdam, Amsterdam, The Netherlands
| | - Saadet Mercimek-Andrews
- Department of Medical Genetics, Faculty of Medicine and Dentistry, Neurosciences and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
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2
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Mejdahl Nielsen M, Petersen ET, Fenger CD, Ørngreen MC, Siebner HR, Boer VO, Považan M, Lund A, Grønborg SW, Hammer TB. X-linked creatine transporter (SLC6A8) deficiency in females: Difficult to recognize, but a potentially treatable disease. Mol Genet Metab 2023; 140:107694. [PMID: 37708665 DOI: 10.1016/j.ymgme.2023.107694] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 03/24/2023] [Revised: 08/29/2023] [Accepted: 08/29/2023] [Indexed: 09/16/2023]
Abstract
Creatine transporter deficiency (CTD), caused by pathogenic variants in SLC6A8, is the second most common cause of X-linked intellectual disability. Symptoms include intellectual disability, epilepsy, and behavioral disorders and are caused by reduced cerebral creatine levels. Targeted treatment with oral supplementation is available, however the treatment efficacy is still being investigated. There are clinical and theoretical indications that heterozygous females with CTD respond better to supplementation treatment than hemizygous males. Unfortunately, heterozygous females with CTD often have more subtle and uncharacteristic clinical and biochemical phenotypes, rendering diagnosis more difficult. We report a new female case who presented with learning disabilities and seizures. After determining the diagnosis with molecular genetic testing confirmed by proton magnetic resonance spectroscopy (1H-MRS), the patient was treated with supplementation treatment including creatine, arginine, and glycine. After 28 months of treatment, the patient showed prominent clinical improvement and increased creatine levels in the brain. Furthermore, we provide a review of the 32 female cases reported in the current literature including a description of phenotypes, genotypes, diagnostic approaches, and effects of supplementation treatment. Based on this, we find that supplementation treatment should be tested in heterozygous female patients with CTD, and a prospective treatment underlines the importance of diagnosing these patients. The diagnosis should be suspected in a broad clinical spectrum of female patients and can only be made by molecular genetic testing. 1H-MRS of cerebral creatine levels is essential for establishing the diagnosis in females, and especially valuable when assessing variants of unknown significance.
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Affiliation(s)
- Malene Mejdahl Nielsen
- Department of Clinical Genetics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Esben Thade Petersen
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark; Section for Magnetic Resonance, Department of Health Technology, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Christina Dühring Fenger
- Epilepsy Genetics and Personalized Medicine, Danish Epilepsy Centre, Denmark; Amplexa Genetics, Odense, Denmark
| | - Mette Cathrine Ørngreen
- Center for Inherited Metabolic Diseases, Departments of Pediatrics and Clinical Genetics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; European Reference Network for Rare Hereditary Metabolic Disorders (MetabERN) - Project ID No 739543, Denmark
| | - Hartwig Roman Siebner
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark; Department of Neurology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Vincent Oltman Boer
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Michal Považan
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Allan Lund
- Center for Inherited Metabolic Diseases, Departments of Pediatrics and Clinical Genetics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; European Reference Network for Rare Hereditary Metabolic Disorders (MetabERN) - Project ID No 739543, Denmark
| | - Sabine Weller Grønborg
- Center for Inherited Metabolic Diseases, Departments of Pediatrics and Clinical Genetics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; European Reference Network for Rare Hereditary Metabolic Disorders (MetabERN) - Project ID No 739543, Denmark
| | - Trine Bjørg Hammer
- Department of Clinical Genetics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Epilepsy Genetics and Personalized Medicine, Danish Epilepsy Centre, Denmark
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Fernandes-Pires G, Braissant O. Current and potential new treatment strategies for creatine deficiency syndromes. Mol Genet Metab 2022; 135:15-26. [PMID: 34972654 DOI: 10.1016/j.ymgme.2021.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 08/13/2021] [Revised: 12/14/2021] [Accepted: 12/14/2021] [Indexed: 12/16/2022]
Abstract
Creatine deficiency syndromes (CDS) are inherited metabolic disorders caused by mutations in GATM, GAMT and SLC6A8 and mainly affect central nervous system (CNS). AGAT- and GAMT-deficient patients lack the functional brain endogenous creatine (Cr) synthesis pathway but express the Cr transporter SLC6A8 at blood-brain barrier (BBB), and can thus be treated by oral supplementation of high doses of Cr. For Cr transporter deficiency (SLC6A8 deficiency or CTD), current treatment strategies benefit one-third of patients. However, as their phenotype is not completely reversed, and for the other two-thirds of CTD patients, the development of novel more effective therapies is needed. This article aims to review the current knowledge on Cr metabolism and CDS clinical aspects, highlighting their current treatment possibilities and the most recent research perspectives on CDS potential therapeutics designed, in particular, to bring new options for the treatment of CTD.
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Affiliation(s)
- Gabriella Fernandes-Pires
- Service of Clinical Chemistry, University of Lausanne and Lausanne University Hospital, Lausanne, Switzerland
| | - Olivier Braissant
- Service of Clinical Chemistry, University of Lausanne and Lausanne University Hospital, Lausanne, Switzerland.
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Abstract
INTRODUCTION Stroke-like episodes (SLEs) are typical cerebral manifestations of certain mitochondrial disorders (MIDs). They are characterised by a vasogenic edema in a non-vascular distribution. PATIENTS CONCERNS:: none DIAGNOSIS:: SLEs show up on cerebral MRI as stroke-like lesions (SLLs), characterised by vasogenic edema in a non-vascular distribution. SLLs expand in the acute stage and regress during the chronic stage. They show hyperperfusion in the acute stage and hypoperfusion in the chronic stage. INTERVENTIONS SLLs respond favorably to antiseizure drugs, to No-precursors, steroids, the ketogenic diet, and antioxidants. OUTCOME SLLs end up as normal tissue, white matter lesion, grey matter lesion, cyst, laminar cortical necrosis, or the toenail sign. CONCLUSIONS SLLs are a frequent manifestation of MIDs. They undergo dynamic changes in the acute and chronic stage. They need to be differentiated from ischemic stroke as they are differentially treated.
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MESH Headings
- Acidosis, Lactic/diagnosis
- Anticonvulsants/therapeutic use
- Antioxidants/therapeutic use
- Asian People/ethnology
- Brain Diseases, Metabolic, Inborn/complications
- Brain Diseases, Metabolic, Inborn/diagnosis
- Brain Diseases, Metabolic, Inborn/drug therapy
- Brain Edema/diagnostic imaging
- Child
- DNA, Mitochondrial/genetics
- Diagnosis, Differential
- Diet, Ketogenic/adverse effects
- Diet, Ketogenic/methods
- Encephalitis/diagnosis
- Encephalitis/drug therapy
- Humans
- MELAS Syndrome/diagnostic imaging
- MELAS Syndrome/drug therapy
- MELAS Syndrome/genetics
- MELAS Syndrome/pathology
- Magnetic Resonance Imaging
- Male
- Mitochondrial Diseases/complications
- Mitochondrial Encephalomyopathies/diagnosis
- Oxidative Phosphorylation/drug effects
- Stroke/classification
- Stroke/drug therapy
- Stroke/pathology
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5
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Gorshkov K, Wang AQ, Sun W, Fisher E, Frigeni M, Singleton M, Thorne N, Class B, Huang W, Longo N, Do MT, Ottinger EA, Xu X, Zheng W. Phosphocyclocreatine is the dominant form of cyclocreatine in control and creatine transporter deficiency patient fibroblasts. Pharmacol Res Perspect 2019; 7:e00525. [PMID: 31859463 PMCID: PMC6924099 DOI: 10.1002/prp2.525] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/20/2019] [Accepted: 08/29/2019] [Indexed: 12/26/2022] Open
Abstract
Creatine transporter deficiency (CTD) is a metabolic disorder resulting in cognitive, motor, and behavioral deficits. Cyclocreatine (cCr), a creatine analog, has been explored as a therapeutic strategy for the treatment of CTD. We developed a rapid, selective, and accurate HILIC ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method to simultaneously quantify the intracellular concentrations of cCr, creatine (Cr), creatine-d3 (Cr-d3), phosphocyclocreatine (pcCr), and phosphocreatine (pCr). Using HILIC-UPLC-MS/MS, we measured cCr and Cr-d3 uptake and their conversion to the phosphorylated forms in primary human control and CTD fibroblasts. Altogether, the data demonstrate that cCr enters cells and its dominant intracellular form is pcCr in both control and CTD patient cells. Therefore, cCr may replace creatine as a therapeutic strategy for the treatment of CTD.
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Affiliation(s)
- Kirill Gorshkov
- National Center for Advancing Translational SciencesNational Institutes of HealthBethesdaMDUSA
| | - Amy Q. Wang
- National Center for Advancing Translational SciencesNational Institutes of HealthBethesdaMDUSA
| | - Wei Sun
- National Center for Advancing Translational SciencesNational Institutes of HealthBethesdaMDUSA
| | - Ethan Fisher
- National Center for Advancing Translational SciencesNational Institutes of HealthBethesdaMDUSA
| | - Marta Frigeni
- Division of Medical GeneticsDepartment of PediatricsUniversity of UtahSalt Lake CityUTUSA
| | - Marc Singleton
- National Center for Advancing Translational SciencesNational Institutes of HealthBethesdaMDUSA
| | - Natasha Thorne
- National Center for Advancing Translational SciencesNational Institutes of HealthBethesdaMDUSA
| | - Bradley Class
- National Center for Advancing Translational SciencesNational Institutes of HealthBethesdaMDUSA
| | - Wenwei Huang
- National Center for Advancing Translational SciencesNational Institutes of HealthBethesdaMDUSA
| | - Nicola Longo
- Division of Medical GeneticsDepartment of PediatricsUniversity of UtahSalt Lake CityUTUSA
- Associated Regional and University Pathologists (ARUP) LaboratoriesSalt Lake CityUTUSA
| | | | - Elizabeth A. Ottinger
- National Center for Advancing Translational SciencesNational Institutes of HealthBethesdaMDUSA
| | - Xin Xu
- National Center for Advancing Translational SciencesNational Institutes of HealthBethesdaMDUSA
| | - Wei Zheng
- National Center for Advancing Translational SciencesNational Institutes of HealthBethesdaMDUSA
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6
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Pope S, Artuch R, Heales S, Rahman S. Cerebral folate deficiency: Analytical tests and differential diagnosis. J Inherit Metab Dis 2019; 42:655-672. [PMID: 30916789 DOI: 10.1002/jimd.12092] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/19/2019] [Accepted: 03/25/2019] [Indexed: 11/07/2022]
Abstract
Cerebral folate deficiency is typically defined as a deficiency of the major folate species 5-methyltetrahydrofolate in the cerebrospinal fluid (CSF) in the presence of normal peripheral total folate levels. However, it should be noted that cerebral folate deficiency is also often used to describe conditions where CSF 5-MTHF is low, in the presence of low or undefined peripheral folate levels. Known defects of folate transport are deficiency of the proton coupled folate transporter, associated with systemic as well as cerebral folate deficiency, and deficiency of the folate receptor alpha, leading to an isolated cerebral folate deficiency associated with intractable seizures, developmental delay and/or regression, progressive ataxia and choreoathetoid movement disorders. Inborn errors of folate metabolism include deficiencies of the enzymes methylenetetrahydrofolate reductase, dihydrofolate reductase and 5,10-methenyltetrahydrofolate synthetase. Cerebral folate deficiency is potentially a treatable condition and so prompt recognition of these inborn errors and initiation of appropriate therapy is of paramount importance. Secondary cerebral folate deficiency may be observed in other inherited metabolic diseases, including disorders of the mitochondrial oxidative phosphorylation system, serine deficiency, and pyridoxine dependent epilepsy. Other secondary causes of cerebral folate deficiency include the effects of drugs, immune response activation, toxic insults and oxidative stress. This review describes the absorption, transport and metabolism of folate within the body; analytical methods to measure folate species in blood, plasma and CSF; inherited and acquired causes of cerebral folate deficiency; and possible treatment options in those patients found to have cerebral folate deficiency.
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Affiliation(s)
- Simon Pope
- Neurometabolic Unit, National Hospital for Neurology, London, UK
| | - Rafael Artuch
- Clinical Biochemistry Department, Institut de Recerca Sant Joan de Déu and CIBERER, ISCIII, Barcelona, Spain
| | - Simon Heales
- Neurometabolic Unit, National Hospital for Neurology, London, UK
- Department of Chemical Pathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Mitochondrial Research Group, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Shamima Rahman
- Mitochondrial Research Group, UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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7
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Boyer M, Sowa M, Di Meo I, Eftekharian S, Steenari MR, Tiranti V, Abdenur JE. Response to medical and a novel dietary treatment in newborn screen identified patients with ethylmalonic encephalopathy. Mol Genet Metab 2018. [PMID: 29526615 DOI: 10.1016/j.ymgme.2018.02.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [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] [Indexed: 11/16/2022]
Abstract
Ethylmalonic encephalopathy (EE) is a devastating neurodegenerative disease caused by mutations in the ETHE1 gene critical for hydrogen sulfide (H2S) detoxification. Patients present in infancy with hypotonia, developmental delay, diarrhea, orthostatic acrocyanosis and petechiae. Biochemical findings include elevated C4, C5 acylcarnitines and lactic and ethylmalonic acid (EMA) in body fluids. Current treatment modalities include metronidazole and N-acetylcysteine (NAC) to lower the production and promote detoxification of toxic H2S. Patients are typically identified after the onset of clinical symptoms and there is limited information about long term response to treatment. We report the findings of two unrelated patients with EE, identified through newborn screening, who were managed with conventional treatment (NAC, metronidazole alternated with neomycin) and in patient 2, a novel dietary treatment restricting sulfur containing amino acids. Pathogenic mutations were confirmed in the ETHE1 gene (homozygous splice site mutation in patient 1, c.505 + 1G > A; compound heterozygous mutations in patient 2, c.131_132delAG + c.566delG). Both patients were started on metronidazole and NAC by 10 weeks of age and treated for 23 months. Patient 1 did not accept the metabolic formula due to palatability and parental refusal for gastrostomy tube placement. She demonstrated improved biomarkers (EMA, lactic acid and thiosulfate) and an attenuated clinical course. Patient 2 was started on a low methionine and cysteine diet at 8 months of age utilizing SOD Anamix® Early Years, (Nutricia). Baseline EMA levels were (642 mg/g Cr; n = 2) and decreased with medical treatment by 38% to a mean of 399 (n = 4, SD = 71, p 0.0013). With dietary treatment EMA levels were further reduced by 42% to a mean of 233 (n = 8, SD = 52, p 0.0030). Lactic acid, thiosulfates and clinical outcomes were also improved. Our long-term follow-up confirms previous reports of clinical improvement with NAC and metronidazole treatment. Additionally, our studies suggest that a diet restricted in sulfur-containing amino acids results in further improvement in clinical outcomes and biochemical markers.
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Affiliation(s)
- M Boyer
- Division of Metabolic Disorders, CHOC Children's Hospital, Orange, CA, United States
| | - M Sowa
- Division of Metabolic Disorders, CHOC Children's Hospital, Orange, CA, United States
| | - I Di Meo
- Unit of Molecular Neurogenetics, Foundation IRCCS Neurological Institute C. Besta, Milan, Italy
| | - S Eftekharian
- Division of Metabolic Disorders, CHOC Children's Hospital, Orange, CA, United States
| | - M R Steenari
- Division of Pediatric Neurology, CHOC Children's Hospital, Orange, CA, United States; Department of Pediatrics, University of California-Irvine, Orange, CA, United States
| | - V Tiranti
- Unit of Molecular Neurogenetics, Foundation IRCCS Neurological Institute C. Besta, Milan, Italy
| | - J E Abdenur
- Division of Metabolic Disorders, CHOC Children's Hospital, Orange, CA, United States; Department of Pediatrics, University of California-Irvine, Orange, CA, United States.
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Tonduti D, Invernizzi F, Panteghini C, Pinelli L, Battaglia S, Fazzi E, Zorzi G, Moroni I, Garavaglia B, Chiapparini L, Nardocci N. SLC19A3 related disorder: Treatment implication and clinical outcome of 2 new patients. Eur J Paediatr Neurol 2018; 22:332-335. [PMID: 29287834 DOI: 10.1016/j.ejpn.2017.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 05/31/2017] [Revised: 11/27/2017] [Accepted: 11/29/2017] [Indexed: 11/17/2022]
Abstract
Encephalopathies with neostriatal involvement constitute a heterogeneous group of acquired and genetically inherited conditions that include Bilateral Striatal Necrosis (BSN) and other Striatal Lesions (SL) (Tonduti et al). We describe two new patients suffering from BSN due to biallelic SLC19A3 mutations. In the first patient vitamin supplementation was started early on, resulting in the remission of the clinical picture, and an almost complete normalization of the neuroradiological findings. In the second one treatment was started late, compliance was irregular and the resulting clinical outcome was poor. The clinical outcome of our two patients confirms and further stresses the importance of the early administration of vitamin supplementation in all patients presenting with neostriatal lesions, or clear bilateral striatal necrosis. Patient 2 didn't present any additional episode of acute decompensation after the age of 20 years despite having completely stopped treatment. This suggests the existence of an age dependency of thiamin requirement in humans.
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Affiliation(s)
- Davide Tonduti
- Child Neurology Unit, IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Federica Invernizzi
- Molecular Neurogenetics Unit, IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Celeste Panteghini
- Molecular Neurogenetics Unit, IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Lorenzo Pinelli
- Neuroradiology Unit, Pediatric Neuroradiology Section, ASST Spedali Civili, Brescia, Italy
| | - Silvia Battaglia
- Child Neurology and Psychiatry Unit, ASST Spedali Civili - Dept. of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Elisa Fazzi
- Child Neurology and Psychiatry Unit, ASST Spedali Civili - Dept. of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Giovanna Zorzi
- Child Neurology Unit, IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Isabella Moroni
- Child Neurology Unit, IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Barbara Garavaglia
- Molecular Neurogenetics Unit, IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Luisa Chiapparini
- Neuroradiology Unit, IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Nardo Nardocci
- Child Neurology Unit, IRCCS-Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
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9
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Aydin HI. Creatine Transporter Deficiency in Two Brothers with Autism Spectrum Disorder. Indian Pediatr 2018; 55:67-68. [PMID: 29396939] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Creatine transporter deficiency (CTD) is a treatable, X-linked, inborn error of metabolism. CASE CHARACTERISTICS Two brothers with autism spectrum disorder were diagnosed with CTD at the ages of 17 and 12 years. Both were found to have a previously reported hemizygous p.408delF (c.1216_1218delTTC) deletion mutation. OUTCOME Both patients were given creatine monohydrate, L-arginine, L-glycine and S-adenosylmethionine, which partially improved the behavioral problems. MESSAGE Serum creatinine levels, creatine peak at brain MR spectroscopy or creatine/creatinine ratio in urine should be evaluated to identify CTD in children with autistic behavior and language disorders.
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MESH Headings
- Adolescent
- Arginine/therapeutic use
- Autism Spectrum Disorder/complications
- Autism Spectrum Disorder/physiopathology
- Brain Diseases, Metabolic, Inborn/complications
- Brain Diseases, Metabolic, Inborn/drug therapy
- Brain Diseases, Metabolic, Inborn/genetics
- Brain Diseases, Metabolic, Inborn/physiopathology
- Child
- Creatine/deficiency
- Creatine/genetics
- Creatine/therapeutic use
- Glycine/therapeutic use
- Humans
- Male
- Mental Retardation, X-Linked/complications
- Mental Retardation, X-Linked/drug therapy
- Mental Retardation, X-Linked/genetics
- Mental Retardation, X-Linked/physiopathology
- Nerve Tissue Proteins
- Plasma Membrane Neurotransmitter Transport Proteins/deficiency
- Plasma Membrane Neurotransmitter Transport Proteins/genetics
- S-Adenosylmethionine/therapeutic use
- Siblings
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Affiliation(s)
- Halil Ibrahim Aydin
- Department of Pediatrics, Medical Faculty, Section of Inborn Errors of Metabolism, Baskent University, Ankara, Turkey. Correspondence to: Dr Halil Ibrahim Aydin, Professor, Baskent University Medical Faculty, Department of Pediatrics, Section of Inborn Errors of Metabolism, Temel Kuguluoglu Sokak, No: 24/2, Bahçelievler, Ankara, Turkey.
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10
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Lopez-Marin L. [Metabolic approach in epileptic encephalopathies in infants]. Rev Neurol 2017; 64:S49-S53. [PMID: 28524220] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Although the overall incidence of inborn errors of metabolism is low, their early diagnosis is essential, since some of them have a specific treatment. DEVELOPMENT We review the main treatable inborn errors of metabolism that can present as early-onset epileptic encephalopathies, together with their biochemical markers and their treatment. CONCLUSIONS It is important to think about the possibility of an inborn error of metabolism with a specific therapy, since it is crucial for this to be started as soon as possible in order to prevent permanent neurological damage.
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MESH Headings
- Age of Onset
- Biotin/therapeutic use
- Brain Diseases, Metabolic/drug therapy
- Brain Diseases, Metabolic/metabolism
- Brain Diseases, Metabolic, Inborn/drug therapy
- Brain Diseases, Metabolic, Inborn/metabolism
- Brain Diseases, Metabolic, Inborn/therapy
- Child, Preschool
- Creatine/metabolism
- Diagnostic Techniques, Neurological
- Epilepsy/drug therapy
- Epilepsy/metabolism
- Fetal Diseases/genetics
- Fetal Diseases/metabolism
- Holocarboxylase Synthetase Deficiency/drug therapy
- Holocarboxylase Synthetase Deficiency/metabolism
- Humans
- Hypoxia-Ischemia, Brain/drug therapy
- Hypoxia-Ischemia, Brain/metabolism
- Infant
- Infant, Newborn
- Pyridoxaminephosphate Oxidase/deficiency
- Pyridoxaminephosphate Oxidase/metabolism
- Pyridoxine/therapeutic use
- Seizures/drug therapy
- Seizures/metabolism
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Affiliation(s)
- L Lopez-Marin
- Hospital Infantil Universitario Nino Jesus, 28009 Madrid, Espana
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11
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Kılıç M, Dedeoğlu Ö, Göçmen R, Kesici S, Yüksel D. Successful treatment of a patient with ethylmalonic encephalopathy by intravenous N-acetylcysteine. Metab Brain Dis 2017; 32:293-296. [PMID: 27830356 DOI: 10.1007/s11011-016-9928-5] [Citation(s) in RCA: 14] [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: 06/29/2016] [Accepted: 11/01/2016] [Indexed: 12/28/2022]
Abstract
Ethylmalonic encephalopathy (EE) is an autosomal recessive devastating metabolic disorder affecting the brain, gastrointestinal tract, peripheral vessels and rarely the other vascular organs. We report a 10-month-old girl who presented as a meningococcemia clinic but later diagnosed ethylmalonic encephalopathy. Molecular analyses revealed a homozygous c.554 T > G; p. L185R mutation in ETHE1 gene. She was only partially benefited from riboflavine, coenzyme Q10, metronidazole, N-acetylcysteine and symptomatic treatment and discharged from hospital with the sequela of oxygene dependance and developmental delay. We observed N-acetylcysteine 100 mg/kg/day intravenous infusion theraphy may be the most important drug especially in comatous EE patients.
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Affiliation(s)
- Mustafa Kılıç
- Metabolism Unit, Sami Ulus Children Hospital, Babur cad. No: 44 Altındağ, 06080, Ankara, Turkey.
| | - Özge Dedeoğlu
- Pediatric Neurology Unit, Sami Ulus Children Hospital, Ankara, Turkey
| | - Rahşan Göçmen
- Deparment of Radiology, Hacettepe University, Ankara, Turkey
| | - Selman Kesici
- Pediatric Intensive Care Unit, Sami Ulus Children Hospital, Ankara, Turkey
| | - Deniz Yüksel
- Pediatric Neurology Unit, Sami Ulus Children Hospital, Ankara, Turkey
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12
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Wang F, Travins J, Lin Z, Si Y, Chen Y, Powe J, Murray S, Zhu D, Artin E, Gross S, Santiago S, Steadman M, Kernytsky A, Straley K, Lu C, Pop A, Struys EA, Jansen EEW, Salomons GS, David MD, Quivoron C, Penard-Lacronique V, Regan KS, Liu W, Dang L, Yang H, Silverman L, Agresta S, Dorsch M, Biller S, Yen K, Cang Y, Su SSM, Jin S. A small molecule inhibitor of mutant IDH2 rescues cardiomyopathy in a D-2-hydroxyglutaric aciduria type II mouse model. J Inherit Metab Dis 2016; 39:807-820. [PMID: 27469509 PMCID: PMC5065612 DOI: 10.1007/s10545-016-9960-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 06/17/2016] [Accepted: 06/22/2016] [Indexed: 10/25/2022]
Abstract
D-2-hydroxyglutaric aciduria (D2HGA) type II is a rare neurometabolic disorder caused by germline gain-of-function mutations in isocitrate dehydrogenase 2 (IDH2), resulting in accumulation of D-2-hydroxyglutarate (D2HG). Patients exhibit a wide spectrum of symptoms including cardiomyopathy, epilepsy, developmental delay and limited life span. Currently, there are no effective therapeutic interventions. We generated a D2HGA type II mouse model by introducing the Idh2R140Q mutation at the native chromosomal locus. Idh2R140Q mice displayed significantly elevated 2HG levels and recapitulated multiple defects seen in patients. AGI-026, a potent, selective inhibitor of the human IDH2R140Q-mutant enzyme, suppressed 2HG production, rescued cardiomyopathy, and provided a survival benefit in Idh2R140Q mice; treatment withdrawal resulted in deterioration of cardiac function. We observed differential expression of multiple genes and metabolites that are associated with cardiomyopathy, which were largely reversed by AGI-026. These findings demonstrate the potential therapeutic benefit of an IDH2R140Q inhibitor in patients with D2HGA type II.
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Affiliation(s)
- Fang Wang
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Jeremy Travins
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Zhizhong Lin
- Oncology Business Unit, WuXi AppTec, Shanghai, China
| | - Yaguang Si
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Yue Chen
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Josh Powe
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Stuart Murray
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Dongwei Zhu
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Erin Artin
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Stefan Gross
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Stephanie Santiago
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Mya Steadman
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Andrew Kernytsky
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Kimberly Straley
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Chenming Lu
- Oncology Business Unit, WuXi AppTec, Shanghai, China
| | - Ana Pop
- Metabolic Unit, Department of Clinical Chemistry, VU University Medical Center/ Neuroscience Campus, Amsterdam, The Netherlands
| | - Eduard A Struys
- Metabolic Unit, Department of Clinical Chemistry, VU University Medical Center/ Neuroscience Campus, Amsterdam, The Netherlands
| | - Erwin E W Jansen
- Metabolic Unit, Department of Clinical Chemistry, VU University Medical Center/ Neuroscience Campus, Amsterdam, The Netherlands
| | - Gajja S Salomons
- Metabolic Unit, Department of Clinical Chemistry, VU University Medical Center/ Neuroscience Campus, Amsterdam, The Netherlands
| | - Muriel D David
- Institut National de la Santé et de la Recherche Médicale, INSERM U1170, Villejuif, France
- Institut Gustave Roussy, Villejuif, France
| | - Cyril Quivoron
- Institut National de la Santé et de la Recherche Médicale, INSERM U1170, Villejuif, France
- Institut Gustave Roussy, Villejuif, France
| | - Virginie Penard-Lacronique
- Institut National de la Santé et de la Recherche Médicale, INSERM U1170, Villejuif, France
- Institut Gustave Roussy, Villejuif, France
| | - Karen S Regan
- Regan Pathology/Toxicology Services, Ashland, OH, USA
| | - Wei Liu
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Lenny Dang
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Hua Yang
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Lee Silverman
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Samuel Agresta
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Marion Dorsch
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Scott Biller
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Katharine Yen
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Yong Cang
- Oncology Business Unit, WuXi AppTec, Shanghai, China
| | - Shin-San Michael Su
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA
| | - Shengfang Jin
- Agios Pharmaceuticals Inc., 88 Sidney Street, Cambridge, MA, 02139-4169, USA.
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13
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Mühlhausen C, Salomons GS, Lukacs Z, Struys EA, van der Knaap MS, Ullrich K, Santer R. Combined D2-/L2-hydroxyglutaric aciduria (SLC25A1 deficiency): clinical course and effects of citrate treatment. J Inherit Metab Dis 2014; 37:775-81. [PMID: 24687295 DOI: 10.1007/s10545-014-9702-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [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: 12/16/2013] [Revised: 02/24/2014] [Accepted: 03/06/2014] [Indexed: 10/25/2022]
Abstract
Combined D,L-2-hydroxyglutaric aciduria (DL-2HGA; OMIM #615182) is a rare neurometabolic disorder clinically characterized by muscular hypotonia, severe neurodevelopmental dysfunction, and intractable seizures associated with respiratory distress. Biochemically, DL-2HGA patients excrete increased amounts of D- and L-2-hydroxyglutarate (D2HG and L2HG, respectively), with predominance of D2HG, and α-ketoglutarate, and show a decrease in urinary citrate. Impaired function of the mitochondrial citrate carrier (CIC) due to pathogenic mutations within the SLC25A1 gene has been identified as the underlying molecular cause of the disease. CIC mediates efflux of the mitochondrial tricarboxylic acid (TCA) cycle intermediates citrate and isocitrate in exchange for cytosolic malate. Thus, depletion of cytosolic citrate as well as accumulation of citrate inside mitochondria have been considered to play a role in the pathophysiology of DL-2HGA. Here, we report for the first time on a patient with a genetically confirmed diagnosis of DL-2HGA and treatment with either malate or citrate. During malate treatment, urinary malate concentration increased, but beyond that, neither biochemical nor clinical alterations were observed. In contrast, treatment with citrate led to an increased urinary excretion of TCA cycle intermediates malate and succinate, and by trend to an increased concentration of urinary citrate. Furthermore, excretion of D2HG and L2HG was reduced during citrate treatment. Clinically, the patient showed stabilization with regard to frequency and severity of seizures. Treating DL-2HGA with citrate should be considered in other DL-2HGA patients, and its effects should be studied systematically.
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Affiliation(s)
- Chris Mühlhausen
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany,
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14
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Dunbar M, Jaggumantri S, Sargent M, Stockler-Ipsiroglu S, van Karnebeek CDM. Treatment of X-linked creatine transporter (SLC6A8) deficiency: systematic review of the literature and three new cases. Mol Genet Metab 2014; 112:259-74. [PMID: 24953403 DOI: 10.1016/j.ymgme.2014.05.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [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: 04/08/2014] [Revised: 05/19/2014] [Accepted: 05/19/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Creatine transporter deficiency (CTD) is an X-linked inborn error of creatine metabolism characterized by reduced intra-cerebral creatine, developmental delay/intellectual disability, (ID), behavioral disturbance, seizures, and hypotonia in individuals harboring mutations in the SLC6A8 gene. Treatment for CTD includes supplementation with creatine, either alone or in combination with creatine precursors (arginine or glycine). Unlike other disorders of creatine metabolism, the efficacy of its treatment remains controversial. METHODS We present our systematic literature review (2001-2013) comprising 7 publications (case series/reports), collectively describing 25 patients who met the inclusion criteria, and 3 additional cases treated at our institution. Definitions were established and extracted data analyzed for cognitive ability, psychiatric and behavioral disturbances, epilepsy, and cerebral proton magnetic resonance spectroscopy measurements at pre- and post-treatment. RESULTS Treatment regimens varied among the 28 cases: 2 patients received creatine-monohydrate supplementation; 7 patients received L-arginine; 2 patients received creatine-monohydrate and L-arginine; and 17 patients received a combination of creatine-monohydrate, L-arginine and glycine. Median treatment duration was 34.6 months (range 3 months-5 years). Level of evidence was IV. A total of 10 patients (36%) demonstrated response to treatment, manifested by either an increase in cerebral creatine, or improved clinical parameters. Seven of the 28 patients had quantified pre- and post-treatment creatine, and it was significantly increased post-treatment. All of the patients with increased cerebral creatine also experienced clinical improvement. In addition, the majority of patients with clinical improvement had detectable cerebral creatine prior to treatment. 90% of the patients who improved were initiated on treatment before nine years of age. CONCLUSIONS Acknowledging the limitations of this systematic review, we conclude that a proportion of CTD patients show amenability to treatment-particularly milder cases with residual brain creatine, and therefore probable residual protein function. We propose systematic screening for CTD in patients with ID, to allow early initiation of treatment, which currently comprises oral creatine, arginine and/or glycine supplementation. Standardized monitoring for safety and evaluation of treatment effects are required in all patients. This study provides effectiveness on currently available treatment, which can be used to discern effectiveness of future interventions (e.g. cyclocreatine).
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Affiliation(s)
- Mary Dunbar
- Division of Pediatric Neurology, Department of Pediatrics, BC Children's Hospital, Vancouver, Canada
| | - Sravan Jaggumantri
- Division of Biochemical Diseases, Department of Pediatrics, BC Children's Hospital, Child & Family Research Institute, University of British Columbia, Vancouver, Canada; Treatable Intellectual Disability Endeavor in British Columbia (TIDE-BC), Vancouver, Canada
| | - Michael Sargent
- Department of Radiology, BC Children's Hospital, Vancouver, Canada
| | - Sylvia Stockler-Ipsiroglu
- Division of Biochemical Diseases, Department of Pediatrics, BC Children's Hospital, Child & Family Research Institute, University of British Columbia, Vancouver, Canada; Treatable Intellectual Disability Endeavor in British Columbia (TIDE-BC), Vancouver, Canada
| | - Clara D M van Karnebeek
- Division of Biochemical Diseases, Department of Pediatrics, BC Children's Hospital, Child & Family Research Institute, University of British Columbia, Vancouver, Canada; Treatable Intellectual Disability Endeavor in British Columbia (TIDE-BC), Vancouver, Canada; Centre for Molecular Medicine and Therapeutics, Vancouver, Canada.
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15
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Mahfoud A, Domínguez CL, Rashed M, Durán M, Rodríguez T, Rodríguez D, Landa V. [D-2-hydroxyglutaric aciduria. Report of two cases]. Invest Clin 2009; 50:369-375. [PMID: 19961059] [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] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
D-2-hydroxyglutaric aciduria (D-2-HGA) is a cerebral organic aciduria characterized by the accumulation of abnormal amounts of D-2-hydroxyglutaric acid in cerebrospinal fluid, blood, and urine. The clinical phenotype varies widely from neonatal severe epileptic encephalopathy to asymptomatic. Magnetic resonance imaging of affected patients typically show signs of delayed cerebral maturation, ventricular abnormalities and the presence of sub-ependymal cysts in the first months of life. We present clinical, biochemical and brain magnetic resonance imaging data of two pediatric patients with D-2-hydroxyglutaric aciduria. One patient presented with severe early infantile-onset epileptic encephalopathy, marked hypotonia, visual deficit, developmental delay and abnormal neuroradiological findings; while the other had hypotonia and development delay. Our findings reinforce the described phenotype of this rare neurometabolic inherited disorder. The diagnostic approach is based on clinical findings and the neuroimaging pattern and is established by the detection of D-2-hydroxyglutaric acid in body fluids. We suggest considering D-2-hydroxyglutaric aciduria in the differential diagnosis of any neonate or infant with epileptic encephalopathy and CNS dysfunction of unknown origin.
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MESH Headings
- Anticonvulsants/therapeutic use
- Atrophy
- Brain/abnormalities
- Brain/pathology
- Brain Diseases, Metabolic, Inborn/complications
- Brain Diseases, Metabolic, Inborn/diagnosis
- Brain Diseases, Metabolic, Inborn/drug therapy
- Brain Diseases, Metabolic, Inborn/genetics
- Brain Diseases, Metabolic, Inborn/pathology
- Brain Diseases, Metabolic, Inborn/urine
- Carnitine/therapeutic use
- Child, Preschool
- Consanguinity
- Diagnosis, Differential
- Female
- Glutarates/urine
- Humans
- Infant
- Intellectual Disability/etiology
- Muscle Hypotonia/etiology
- Psychomotor Disorders/etiology
- Riboflavin/therapeutic use
- Spasms, Infantile/drug therapy
- Spasms, Infantile/etiology
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Affiliation(s)
- Antionieta Mahfoud
- Unidad de Errores Innatos del Metabolismo (UDEIM), Centro de Biociencias y Medicina Molecular, Instituto de Estudios Avanzados-IDEA, Caracas, Venezuela.
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16
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Manegold C, Hoffmann GF, Degen I, Ikonomidou H, Knust A, Laass MW, Pritsch M, Wilichowski E, Hörster F. Aromatic L-amino acid decarboxylase deficiency: clinical features, drug therapy and follow-up. J Inherit Metab Dis 2009; 32:371-80. [PMID: 19172410 DOI: 10.1007/s10545-009-1076-1] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [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: 10/16/2008] [Revised: 12/11/2008] [Accepted: 12/15/2008] [Indexed: 11/25/2022]
Abstract
BACKGROUND Aromatic L-amino acid decarboxylase (AADC) deficiency is a disorder of biogenic amine metabolism resulting in generalized combined deficiency of serotonin, dopamine and catecholamines. Main clinical features are developmental delay, muscular hypotonia, dystonia, oculogyric crises and additional extraneurological symptoms. Response to therapy has been variable and unsatisfactory; the overall prognosis is guarded. METHODS To gain more insight into this rare disorder we collected clinical and laboratory data of nine German patients. All patients were clinically examined by one investigator, and their responses to different drug regimes were evaluated by the patients' charts. RESULTS Symptoms were obvious from early infancy. Later, main neurological features were truncal muscular hypotonia, hypokinesia, oculogyric crises and rigor. Three patients had single seizures. All patients presented distinct extraneurological symptoms, such as hypersalivation, hyperhidrosis, nasal congestion, sleep disturbances and hypoglycaemia. In CSF all patients revealed the pattern typical of AADC with decreased concentrations of homovanillic and 5-hydroxyindoleacetic acid and elevated concentration of 3-ortho-methyldopa. Diagnosis was confirmed by measurement of AADC activity in plasma in all patients. Drug regimes consisted of vitamin B6, dopamine agonists, MAO inhibitors and anticholinergics in different combinations. No patient achieved a complete recovery from neurological symptoms, but partial improvement of mobility and mood could be achieved in some. CONCLUSION AADC deficiency is a severe neurometabolic disorder, characterized by muscular hypotonia, dystonia, oculogyric crises and additional extraneurological symptoms. Medical treatment is challenging, but a systematic trial of the different drugs is worthwhile.
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Affiliation(s)
- C Manegold
- Division of Inherited Metabolic Diseases, University Children's Hospital, Im Neuenheimer Feld 430, Heidelberg D-69120, Germany
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17
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Ruiz A, García-Villoria J, Ormazabal A, Zschocke J, Fiol M, Navarro-Sastre A, Artuch R, Vilaseca MA, Ribes A. A new fatal case of pyridox(am)ine 5'-phosphate oxidase (PNPO) deficiency. Mol Genet Metab 2008; 93:216-8. [PMID: 18024216 DOI: 10.1016/j.ymgme.2007.10.003] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Revised: 10/02/2007] [Accepted: 10/02/2007] [Indexed: 11/20/2022]
Abstract
We present a patient with severe pyridox(am)ine 5'-phosphate oxidase deficiency and homozygosity for a novel nonsense-mutation, p.A174X, in the PNPO gene who died with pyridoxal phosphate (PLP) treatment despite initial clinical recovery. He presented neonatally, with the classical clinical symptoms of the disease. Increase of urinary vanillactate was the first biochemical factor of alert. Amino acid and neurotransmitter analysis in CSF indicated reduced activity of several PLP-dependent enzymes. The diagnosis was confirmed by mutational studies. From this and the other reported patients it may be concluded that the administration of PLP should not be delayed until the complete biochemical evidence is obtained.
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Affiliation(s)
- Angeles Ruiz
- Department of Pediatrics, Hospital Son Dureta, Palma de Mallorca, Spain
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18
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Abstract
Ubiquinone (coenzyme Q10 or CoQ10) is a lipid-soluble component of virtually all cell membranes and has multiple metabolic functions. Deficiency of CoQ10 (MIM 607426) has been associated with five different clinical presentations that suggest genetic heterogeneity, which may be related to the multiple steps in CoQ10 biosynthesis. Patients with all forms of CoQ10 deficiency have shown clinical improvements after initiating oral CoQ10 supplementation. Thus, early diagnosis is of critical importance in the management of these patients. This year, the first molecular defect causing the infantile form of primary human CoQ10 deficiency has been reported. The availability of genetic testing will allow for a better understanding of the pathogenesis of this disease and early initiation of therapy (even presymptomatically in siblings of patients) in this otherwise life-threatening infantile encephalomyopathy.
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Affiliation(s)
- Catarina M. Quinzii
- Department of Neurology, Columbia University Medical Center, New York, NY 10032 USA
| | - Salvatore DiMauro
- Department of Neurology, Columbia University Medical Center, New York, NY 10032 USA
| | - Michio Hirano
- Department of Neurology, Columbia University Medical Center, New York, NY 10032 USA
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19
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Schulze A, Hoffmann GF, Bachert P, Kirsch S, Salomons GS, Verhoeven NM, Mayatepek E. Presymptomatic treatment of neonatal guanidinoacetate methyltransferase deficiency. Neurology 2006; 67:719-21. [PMID: 16924036 DOI: 10.1212/01.wnl.0000230152.25203.01] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [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: 11/15/2022] Open
Abstract
Prospective observation in a neonate with guanidinoacetate methyltransferase deficiency (GAMT-D), a severe neurometabolic disorder, revealed increased guanidinoacetate levels at birth. After 14-month treatment with creatine, high-dose ornithine, benzoate, and an arginine-restricted diet, the patient's development is normal and she does not present any symptoms of GAMT-D. The authors' observation indicates that early detection of GAMT-D is possible in the neonatal period, and presymptomatic treatment may prevent its manifestation.
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Affiliation(s)
- A Schulze
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany.
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20
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Pascual-Castroviejo I, Pascual-Pascual SI, Merinero B, Ugarte M, Garcia-Segura JM, Viaño J, Velazquez R. [Glutaric aciduria type 1 with normal evolution: follow-up of one case until adult age]. Neurologia 2005; 20:189-93. [PMID: 15891948] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
We present a patient of 20 years of age with glutaric aciduria type 1 (GA1) and normal psychomotor development. Her symptoms consisted of a few convulsions between 2.5 and 4.5 years of age. She was diagnosed at 9 years of age because of the typical alterations of GA1 that appeared in computed tomography and magnetic resonance (MR) imaging studies. Enzymatic activity in fibroblasts culture was nonexistent and glutarate excretion was elevated in the annual controls where this was investigated from the diagnosis of the disease so far. MR studies showed hyposignal in T1 of the subcortical white matter, severe dilatation of the Sylvian region and temporal fossa subarachnoid spaces, and hypoplasia of the subjacent cerebral parenchyma and of both temporal lobes. The corpus callosum and the surrounding zones appeared very enlarged and with signal changes. Spectroscopic MR showed signs of membrane instability and cellular impoverishment in subcortical white matter and basal ganglia and presence of lactic acid. Macrocephaly always maintained centiles over 98. The patient has no abnormal movements or motor disturbances, her behavior and intelligence being normal and she is able to follow studies of middle level.
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MESH Headings
- Basal Ganglia/pathology
- Brain/pathology
- Brain Chemistry
- Brain Diseases, Metabolic, Inborn/drug therapy
- Brain Diseases, Metabolic, Inborn/enzymology
- Brain Diseases, Metabolic, Inborn/genetics
- Brain Diseases, Metabolic, Inborn/pathology
- Brain Diseases, Metabolic, Inborn/urine
- Carnitine/therapeutic use
- Cells, Cultured/enzymology
- Child Development
- Child, Preschool
- Chromosomes, Human, Pair 19/genetics
- Corpus Callosum/pathology
- Female
- Fibroblasts/enzymology
- Follow-Up Studies
- Glutarates/urine
- Glutaryl-CoA Dehydrogenase
- Heterozygote
- Humans
- Intelligence
- Lactic Acid/analysis
- Magnetic Resonance Imaging
- Mutation, Missense
- Oxidoreductases Acting on CH-CH Group Donors/deficiency
- Oxidoreductases Acting on CH-CH Group Donors/genetics
- Riboflavin/therapeutic use
- Seizures/etiology
- Seizures/genetics
- Sequence Deletion
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21
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Abstract
BACKGROUND After many years of intensive investigation, enzyme-replacement therapy (ERT) has become standard treatment for patients with type 1 (non-neuronopathic) Gaucher's disease. ERT has greatly changed the clinical course of this disorder by reducing hepatosplenomegaly, by improving anaemia and thrombocytopenia, and by ameliorating skeletal damage. This example has prompted the investigation of ERT for several other metabolic disorders. The results of several of these trials have recently been published. RECENT DEVELOPMENTS In addition to Gaucher's disease, the effects of ERT in four other major metabolic storage disorders have been reported. Among these rare orphan diseases are Fabry's disease, in which the heart, kidney, gastrointestinal tract, and peripheral nerves are damaged; Pompe's disease, in which the heart, skeletal muscles, and brain are involved; Hurler's disease and Maroteaux-Lamy syndrome in which the eyes, liver, joints, and skeleton are usually affected. Responses to ERT in these four disorders have generally been encouraging although the degree and extent of benefit vary considerably. WHERE NEXT There are several critical features of ERT that require attention and amelioration. Among these are the development of severity-score indices that can be used to explicitly quantify the benefit of ERT. The benefit of this treatment has been slight in Fabry's disease and is yet to be fully shown in the other three disorders. Secondly, novel technologies need to be developed to deliver therapeutic enzymes effectively to tissues such as the cardiac muscle and kidney in Fabry's disease, skeletal muscle in patients with Pompe's disease, and to joint tissues and structures in patients with Hurler's disease and Maroteaux-Lamy syndrome. Finally, an all-encompassing concern is to devise methods to ameliorate the damage to the central and peripheral nervous systems that occurs in specific phenotypes of these disorders. In this review we descibe emerging strategies that seem to be useful in these critical regards.
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Affiliation(s)
- Roscoe O Brady
- Developmental and Metabolic Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892-1260, USA.
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22
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Michel SJ, Given CA, Robertson WC. Imaging of the brain, including diffusion-weighted imaging in methylmalonic acidemia. Pediatr Radiol 2004; 34:580-2. [PMID: 15205843 DOI: 10.1007/s00247-004-1155-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [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: 11/20/2003] [Revised: 01/20/2004] [Accepted: 01/27/2004] [Indexed: 11/25/2022]
Abstract
Methylmalonic acidemia (MMA) is a multifactorial autosomal recessive inborn error of organic acid metabolism, often presenting with neurologic findings. We report the imaging findings in a case of a child with classic neurological and laboratory findings for MMA. Imaging studies demonstrated abnormalities within the basal ganglia, particularly the globi pallidi (GP). Diffusion-weighted abnormalities seen in patients with MMA during an acute episode of metabolic acidosis and at follow-up are discussed. The authors are aware of only one prior report of serial examinations demonstrating resolution of restricted diffusion in the GP. The biochemical and pathophysiologic basis of the imaging findings of MMA are explained.
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Affiliation(s)
- Steven J Michel
- Department of Diagnostic Radiology, University of Kentucky Chandler Medical Center, Room HX-311C, 800 Rose Street, Lexington, KY 40536, USA.
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23
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Tsakiris S, Schulpis KH, Marinou K, Behrakis P. Protective effect of ?-cysteine and glutathione on the modulated suckling rat brain Na+,K+-ATPase and Mg2+-ATPase activities induced by the in vitro galactosaemia. Pharmacol Res 2004; 49:475-9. [PMID: 14998558 DOI: 10.1016/j.phrs.2003.11.006] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.1] [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] [Accepted: 11/12/2003] [Indexed: 11/22/2022]
Abstract
UNLABELLED Galactosaemia is an inborn error of galactose (Gal) metabolism characterized by irreversible brain damage. The aim of this study was to evaluate whether the antioxidants L-cysteine (Cys) and the reduced glutathione (GSH) could reverse the alterations of brain total antioxidant status (TAS) and the modulated activities of the enzymes Na+,K+ -ATPase and Mg2+ -ATPase in in vitro galactosaemia. Mixture A (mix. A: galactose-1-phosphate (Gal-1-P, 2mM) plus galactitol (Galtol, 2mM) plus Gal (4mM) = classical galactosaemia) or Mixture B (mix. B: Galtol (2mM) plus Gal (1mM) = galactokinase deficiency galactosaemia) were preincubated in the presence or absence of Cys (0.83mM) or GSH (0.83 mM) with whole brain homogenates of suckling rats at 37 degrees C for 1h. TAS and the enzyme activities were determined spectrophotometrically. The preincubation of brain homogenates with mix. A or mix. B resulted in a decrease of TAS to 30% (P < 0.01), while the presence of Cys or GSH increased TAS to 20% (P < 0.01) and 60% ( P < 0.001), respectively. The antioxidants reversed the inhibited Na+,K+ -ATPase by mix. A or mix. B and the stimulated Mg2+ -ATPase by mix. B to control values, whereas no effect was observed on the enormously activated Mg2+ -ATPase by mix. A. CONCLUSIONS (a) Gal and its derivatives may produce free radicals in the suckling rat brain, reported for first time, (b) Na+,K+ -ATPase inhibition and Mg2+ -ATPase activation are probably due to the oxidative stress from the above compounds, (c) Cys or GSH could play a protective role reversing the inhibited Na+,K+ -ATPase toward normal in in vitro galactosaemia and (d) the addition of the above antioxidants may reduce the consequences of brain Mg2+ -ATPase activation by Gal and Galtol in galactokinase deficiency galactosaemia.
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Affiliation(s)
- Stylianos Tsakiris
- Department of Experimental Physiology, University of Athens, Medical School, Athens, Greece.
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Strauss KA, Puffenberger EG, Robinson DL, Morton DH. Type I glutaric aciduria, part 1: natural history of 77 patients. Am J Med Genet C Semin Med Genet 2003; 121C:38-52. [PMID: 12888985 DOI: 10.1002/ajmg.c.20007] [Citation(s) in RCA: 242] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Type I glutaric aciduria (GA1) results from mitochondrial matrix flavoprotein glutaryl-CoA dehydrogenase deficiency and is a cause of acute striatal necrosis in infancy. We present detailed clinical, neuroradiologic, molecular, biochemical, and functional data on 77 patients with GA1 representative of a 14-year clinical experience. Microencephalic macrocephaly at birth is the earliest sign of GA1 and is associated with stretched bridging veins that can be a cause of subdural hematoma and acute retinal hemorrhage. Acute striatal necrosis during infancy is the principal cause of morbidity and mortality and leads to chronic oromotor, gastroesophageal, skeletal, and respiratory complications of dystonia. Injury to the putamen is heralded by abrupt-onset behavioral arrest. Tissue degeneration is stroke-like in pace, radiologic appearance, and irreversibility. It is uniformly symmetric, regionally selective, confined to children under 18 months of age, and occurs almost always during an infectious illness. Our knowledge of disease mechanisms, though incomplete, is sufficient to allow a rational approach to management of encephalopathic crises. Screening of asymptomatic newborns with GA1 followed by thoughtful prospective care reduces the incidence of radiologically and clinically evident basal ganglia injury from approximately 90% to 35%. Uninjured children have good developmental outcomes and thrive within Amish and non-Amish communities.
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MESH Headings
- Brain Diseases, Metabolic, Inborn/complications
- Brain Diseases, Metabolic, Inborn/diet therapy
- Brain Diseases, Metabolic, Inborn/drug therapy
- Brain Diseases, Metabolic, Inborn/genetics
- Chromosomes, Human, Pair 19/genetics
- Dystonia/complications
- Glutarates/urine
- Glutaryl-CoA Dehydrogenase
- Humans
- Lysine/metabolism
- Magnetic Resonance Imaging
- Mutation/genetics
- Necrosis
- Oxidoreductases Acting on CH-CH Group Donors/deficiency
- Oxidoreductases Acting on CH-CH Group Donors/genetics
- Oxidoreductases Acting on CH-CH Group Donors/metabolism
- Putamen/blood supply
- Putamen/pathology
- Tryptophan/metabolism
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Affiliation(s)
- Kevin A Strauss
- Clinic for Special Children, 535 Bunker Hill Road, Strasburg, PA 17579, USA.
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Takeuchi M, Harada M, Matsuzaki K, Hisaoka S, Nishitani H, Mori K. Magnetic resonance imaging and spectroscopy in a patient with treated methylmalonic acidemia. J Comput Assist Tomogr 2003; 27:547-51. [PMID: 12886142 DOI: 10.1097/00004728-200307000-00018] [Citation(s) in RCA: 27] [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] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Magnetic resonance imaging (MRI) and proton magnetic resonance spectroscopy (proton MRS) findings before and after carnitine therapy in a patient with methylmalonic acidemia (MMA) are evaluated. The hyperintensity on T2-weighted image and diffusion-weighted image and the decreased apparent diffusion coefficient of bilateral basal ganglia were normalized in parallel with normalization of the elevated lactate levels and the decreased N-acetyl-aspartate levels, corresponding to improvement of clinical symptoms. MRI and proton MRS may serve as a suitable, noninvasive modality for monitoring treated MMA.
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Affiliation(s)
- Mayumi Takeuchi
- Department of Radiology, University of Tokushima, 3-18-15 Kuramoto-cho, Tokushima, Japan.
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26
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Bönig H, Däublin G, Schwahn B, Wendel U. Psychotic symptoms in severe MTHFR deficiency and their successful treatment with betaine. Eur J Pediatr 2003; 162:200-201. [PMID: 12655429 DOI: 10.1007/s00431-002-1148-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2002] [Accepted: 12/04/2002] [Indexed: 10/18/2022]
Affiliation(s)
- Halvard Bönig
- Division of Paediatric Metabolic Disease, Heinrich-Heine University Medical Centre, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Gerhard Däublin
- Division of Paediatric Metabolic Disease, Heinrich-Heine University Medical Centre, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Bernd Schwahn
- Division of Paediatric Metabolic Disease, Heinrich-Heine University Medical Centre, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Udo Wendel
- Division of Paediatric Metabolic Disease, Heinrich-Heine University Medical Centre, Moorenstrasse 5, 40225, Düsseldorf, Germany.
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Ramaekers VT, Häusler M, Opladen T, Heimann G, Blau N. Psychomotor retardation, spastic paraplegia, cerebellar ataxia and dyskinesia associated with low 5-methyltetrahydrofolate in cerebrospinal fluid: a novel neurometabolic condition responding to folinic acid substitution. Neuropediatrics 2002; 33:301-8. [PMID: 12571785 DOI: 10.1055/s-2002-37082] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.8] [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] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Normal brain development and function depend on the active transport of folates across the blood-brain barrier. The folate receptor-1 (FR 1) protein is localized at the basolateral surface of the choroid plexus, which is characterized by a high binding affinity for circulating 5-methyltetrahydrofolate (5-MTHF). PATIENTS AND METHODS We report on the clinical and metabolic findings among five children with normal neurodevelopmental progress during the first four to six months followed by the acquisition of a neurological condition which includes marked irritability, decelerating head growth, psychomotor retardation, cerebellar ataxia, dyskinesias (choreoathetosis, ballism), pyramidal signs in the lower limbs and occasional seizures. After the age of six years the two oldest patients also manifested a central visual disorder. Known disorders have been ruled out by extensive investigations. Cerebrospinal fluid (CSF) analysis included determination of biogenic monoamines, pterins and 5-MTHF. RESULTS Despite normal folate levels in serum and red blood cells with normal homocysteine, analysis of CSF revealed a decline towards very low values for 5-methyltetrahydrofolate (5-MTHF), which suggested disturbed transport of folates across the blood-brain barrier. Genetic analysis of the FR 1 gene revealed normal coding sequences. Oral treatment with doses of the stable compound folinic acid (0.5-1 mg/kg/day Leucovorin(R)) resulted in clinical amelioration and normalization of 5-MTHF values in CSF. CONCLUSION Our findings identified a new condition manifesting after the age of 6 months which was accompanied by low 5-MTHF in cerebrospinal fluid and responded to oral supplements with folinic acid. However, the cause of disturbed folate transfer across the blood-brain barrier remains unknown.
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Affiliation(s)
- V T Ramaekers
- Division of Paediatric Neurology, Department of Paediatrics, University Hospital Aachen, Aachen, Germany.
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Elpeleg O, Shaag A, Ben-Shalom E, Schmid T, Bachmann C. N-acetylglutamate synthase deficiency and the treatment of hyperammonemic encephalopathy. Ann Neurol 2002; 52:845-9. [PMID: 12447942 DOI: 10.1002/ana.10406] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [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: 11/10/2022]
Abstract
Carbamylphosphate synthase is the first enzymatic reaction of the urea cycle. Its activator, N-acetylglutamate, is synthesized from acetyl-CoA and glutamate in a reaction catalyzed by N-acetylglutamate synthase (NAGS). We have identified the putative human NAGS gene and report the first mutation in this gene in a family with carbamylglutamate responsive hyperammonemia and normal activity of the urea cycle enzymes. Mutation analysis has a higher diagnostic specificity than the enzymatic assay in NAGS deficiency. A therapeutic trial with carbamylglutamate is recommended whenever hyperammonemia without an organic aciduria, increased orotate excretion, or diagnostic amino acidemia/uria is detected.
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Affiliation(s)
- Orly Elpeleg
- The Metabolic Disease Unit, Faculty of Medicine, Shaare-Zedek Medical Center, Hebrew University, Jerusalem 91031, Israel.
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29
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Yoon HR, Hahn SH, Ahn YM, Jang SH, Shin YJ, Lee EH, Ryu KH, Eun BL, Rinaldo P, Yamaguchi S. Therapeutic trial in the first three Asian cases of ethylmalonic encephalopathy: response to riboflavin. J Inherit Metab Dis 2001; 24:870-3. [PMID: 11916321 DOI: 10.1023/a:1013948409790] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [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] [Indexed: 11/12/2022]
Abstract
Three Korean girls with ethylmalonic encephalopathy, the first Asian cases, were identified. In all three cases, we observed slight improvement in motor functions, cognitive behaviours and chronic mucoid diarrhoea after treatment with riboflavin and/or coenzyme Q10 treatment. The precise pathogenesis of ethylmalonic encephalopathy has not been fully elucidated, but riboflavin treatment may be helpful.
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Affiliation(s)
- H R Yoon
- Metabolic Disease Detection Laboratory, Seoul Medical Science Institute, Korea
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