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Abstract Introduction: Glutaric Aciduria Type 1 (GA-1) is produced by the enzymatic deficiency of glutaryl-CoA-dehydrogenase (GCDH), leading to the accumulation of glutaric acid (GA). 90% of patients without early treatment present acute encephalopathic crisis (AEC), followed by disabling neurological symptoms. The treatment consists of a low lysine (Lys) diet, protein substitute lys-free, tryptophan-reduced (PS) and L-carnitine. Objectives: Describe the clinical and nutritional evolution of a cohort of GA-1 patients at a national referral center in Chile. Methodology: Retrospective study of 24 patients diagnosed with GA-1 between 1998-2020 and referred to the Institute of Nutrition and Food Technology (INTA) of University of Chile. Results: Age at diagnosis was 19±27 months; 10/24 presented AEC and neurological sequelae. The cases without AEC (14/24) 8 presented neurological compromise: psychomotor development delay, abnormal movements and pyramidal syndrome. Nutritional evaluation: 12/24 were malnourished by deficiency, <6 years old group (12/24): 11 cases were found to have Lys and PS, ≥6 years old (12/24): 9/12 did not receive PS. All had normal free carnitine levels. Conclusion: GA-1 has variable symptoms with neurological involvement AEC or insidious start. Is essential to maintain a long-term follow-up and consider its inclusion in neonatal screening programs.
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Introduction@#Glutaric Aciduria Type 1 (GA1) is an inborn error of metabolism included in the expanded newborn screening of the Philippines. This inborn error of metabolism is caused by glutaryl-CoA dehydrogenase deficiency which is important in the catabolism of lysine, hydroxylysine and tryptophan. @*Objective@#This paper aimed to present the baseline data of patients with GA1 in the Philippines by describing the clinical, biochemical, and radiologic characteristics of Filipino patients with biochemically-confirmed GA1 seen at the Philippine General Hospital from January 2010 to December 2017. The cases of this condition have been increasing and are expected to increase even more with the full coverage of the expanded newborn screening. @*Methods@#This study was a review of the medical records of the GA1 patients managed by the Division of Clinical Genetics, Department of Pediatrics of the Philippine General Hospital (PGH). Biochemical parameters, developmental assessment, neurologic assessment, and radiologic features of the patients were reviewed and analyzed. @*Results@#There were a total of 7 patients with GA1 at the PGH from January 2010 to December 2017. Of the 7 patients, 4 were diagnosed by expanded newborn screening (ENBS) and 3 patients had disease onset prior to diagnosis. Clinical features noted in screened patients include global developmental delay (75%), seizures (50%), dystonia (50%), truncal hypotonia (25%) and macrocephaly (25%). In unscreened patients, macrocephaly was present in 66.67 %, while the other clinical features were present in all of them. Four of the 7 patients had infection and one had vaccination, which may have led to a metabolic crisis and subsequent onset of symptoms. The plasma levels of glutarylcarnitine (C5DC) range from 2.81 to 4.58 umol/L. Grossly elevated urinary excretion of glutarylcarnitine were noted in all patients. Urinary glutaconic acid and 3-hydroxyglutaric acid were also detected in all patients. Both striatal and extra-striatal abnormalities were present in screened and unscreened patients on neuroimaging. The most common being the widening of the sylvian fissure, cerebral atrophy, and white matter abnormalities. @*Conclusion@#Although newborn screening of GA1 and initiation of early management of this condition have been seen important, it is still prudent to continue the appropriate management and to provide timely aggressive emergency treatment in order to improve outcome of patients with GA1. With the recent Philippine Health Insurance (PhilHealth) coverage of the expanded newborn screening, it is expected that physicians will encounter more of the metabolic disorders, including GA1. Hence, it is important that physicians be more aware of the presenting signs and symptoms of this disorder, as well as its management, which can further improve the neurologic and developmental outcomes of these patients.
Subject(s)
Neonatal ScreeningABSTRACT
Objective@#To screen for potential variants of GCDH gene in 3 patients clinically diagnosed as glutaric aciduria type Ⅰ.@*Methods@#GCDH gene variants was detected by Sanger sequencing among the three children and their family members.@*Results@#Sanger sequencing showed that patient 1 carried compound heterozygosity variants of c. 532G>A (p.Gly178Arg) and c. 655G>A (p.Ala219Thr) of the GCDH gene, while his father and mother respectively carried heterozygous c. 532G>A(p.Gly178Arg) and c. 655G>A (p.Ala219Thr) variants. Patient 2 carried c. 532G>A (p.Gly178Arg) and a novel c. 1060G>T (p.Gly354Cys) compound heterozygous variant, while his father and mother respectively carried heterozygous c. 532G>A (p.Gly178Arg) and c. 1060G>T (p.Gly354Cys) variant. Patient 3 carried homozygous c. 532G>A (p.Gly178Arg) variant of the GCDH gene, for which both of his parents were heterozygous carriers.@*Conclusion@#The GCDH gene variant probably underlie the glutaric aciduria type Ⅰ among the 3 patients. Identifcation of the novel variant has enriched the spectrum of GCDH gene variants.
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Multiple acyl-CoA dehydrogenase deficiency,also known as glutaric aciduria typeⅡ,is an autosomal recessive inherited metabolic disease. It is a mitochondrial electron transport chain and fatty acid metabolism disorder caused by a defect of electron transfer flavoprotein(ETF)or ETF dehydrogenase(ETFDH),resulting in the damage to multiple organs such as myocardia,liver,brain and skeletal muscle. The clinical diagnosis of multiple acyl-CoA dehydrogenase deficiency is difficult due to the lack of specific symptoms and signs of the patients. To make a definitive diagnosis,blood aminoacids and acylcarnitine profiles,urinary organic acids profiles and gene analysis are necessary. According to the response to ribo-flavin(or vitamin B2),multiple acyl-CoA dehydrogenase deficiency could be divided into riboflavin-responsive form and riboflavin-unresponsive form. The riboflavin-responsive form is usually observed in the late-onset cases with good outcome.The patients of riboflavin-unresponsive form usually have early-onset with severe diseases. Bezafibrate, L-carnitine,coenzyme Q10,sodium-D,L-3-hydroxybutyrate and low-fat die should be considered for the treatment. Some patients with riboflavin-unresponsive form show poor outcome.
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Objective To explore the excitotoxic role of NMDA receptors in striatal neurons in glutaric aciduria type I (GA1). Methods A GA1 cell model was established by lentivirus-mediated shRNA to GCDH and excessive intake of lysine. The expression levels of NMDA receptors were determined by Western blotting. The striatal neurons were preprocessed by MK801(a NMDA receptor antagonist), then infected with lentivirus and cultured in high concentration lysine. Cell viability was measured using MTT. Apoptosis was assessed using Hoechst33342 staining. Results Compared with the control group, the expression of NR2B protein in the experimental group was increased, and there was statistical difference (P<0.001). The differentces in the cell viability and normal nuclear proportion among experimental group, control group, and MK-801 pretreatment group were statistically significant (P<0.01). The cell viability and normal nucleus proportion in experimental group were significantly lower than those in control group while they were significantly higher in MK-801 pretreated group than those in the experiment group but still significantly lower than those in control group (P all <0.05). Conclusion The accumulation of metabolites in GA 1 played a toxic role in striatal neurons through NMDR receptors.
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Objective To explore the excitotoxic role of NMDA receptors in striatal neurons in glutaric aciduria type I (GA1). Methods A GA1 cell model was established by lentivirus-mediated shRNA to GCDH and excessive intake of lysine. The expression levels of NMDA receptors were determined by Western blotting. The striatal neurons were preprocessed by MK801(a NMDA receptor antagonist), then infected with lentivirus and cultured in high concentration lysine. Cell viability was measured using MTT. Apoptosis was assessed using Hoechst33342 staining. Results Compared with the control group, the expression of NR2B protein in the experimental group was increased, and there was statistical difference (P<0.001). The differentces in the cell viability and normal nuclear proportion among experimental group, control group, and MK-801 pretreatment group were statistically significant (P<0.01). The cell viability and normal nucleus proportion in experimental group were significantly lower than those in control group while they were significantly higher in MK-801 pretreated group than those in the experiment group but still significantly lower than those in control group (P all <0.05). Conclusion The accumulation of metabolites in GA 1 played a toxic role in striatal neurons through NMDR receptors.
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Objective To investigate the clinical features,magnetic resonance imaging (MRI),treatment,and follow-up of patients with glutaric aciduria type Ⅰ (GA-1).Methods Four pediatric patients with GA-1 diagnosed in our hospital were included in this study.They were treated with special diets and carnitine supplements.MRI and tandem mass spectrometry (MS/MS) were performed,and the mental development indices were measured.Results GA-1 was confirmed 2 months,13 months,4 months,and 7 months after birth.Seizure had been observed before the disease diagnosis in three patients and disappeared after treatment.In all four patients,T2-weighted brain MRI showed frontotemporal atrophy or hypoplasia and enlarged subarachnoid space in the sylvian fissures and anterior to the temporal lobes.Diffusion weighted imaging revealed high-density lesions over both the putamen and globus pallidus.The patients were followed up for 4 to 5 years.Plasma amino acids and acylcamitine profile were monitored every 3-5 months.The mean C5DC level and C5DC/C8 were kept the higher limits of the normal ranges,especially in case 3.During the follow-up,the body weight was at-2 SD-0 and the height at-1 SD-0.Intellectual development test showed that case 1 and case 4 had mildly abnormal intelligence,whereas case 2 and case 3 had extremely severe intellectual disability.Gene test confirmed the presence of gene mutations in all four cases,including IVS10-2A ＞ C homozygous mutation in cases 1,3,and 4 and [IVS10-2A ＞ C] + [c.245G ＞c(p.Arg82Pro)] hybrid mutation in case 2.Two female children were smoothly enrolled by local kindergarten,while two male children were unable to walk alone due to delayed motor development and spastic paralysis.Conclusions The phenotype of GA-1 patients is not remarkably correlated with its genotype correlation.Newborn screening is essential for identifying GA-1 patients.
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Objective To investigate the clinical characteristics of Kennedy disease with secondary mitochondrial dysfunction and glutaric aciduria typeⅡ.Methods The clinical data of 1 case Kennedy disease with secondary mitochondrial dysfunction and glutaric aciduria typeⅡwas retrospectively analyzed.Results The patient presented muscle weakness in proximal limbs, fasciculation, bulbar palsy, amyotrophy, postural tremor, sensory disturbance, gynaecomastia, impotency.The level of serum creatine kinase and urinary glutaric acid were elevated. Electromyogram and nerve and muscle biopsy supported mixed damage in peripheral nerves, as well as neurogenic and secondary myogenic pathologic changes in muscles.Gene sequencing indicated trinucleotide CAG repeated amplification for 47 times in chromosome X.Diabetes was diagnosed at 7 years after onset.Conclusions The pathogenesis of Kennedy disease is very complex, which may involve myogenic factor.The treatment to the secondary mitochondrial and lipid metabolic disturbance in muscle can improve the muscle weakness to a certain extent.
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La aciduria glutárica tipo I se produce por deficiencia de la enzima glutaril-CoA deshidrogenasa involucrada en el catabolismo de la L-lisina, L-hidroxilisina y L-triptófano lo que ocasiona acumulación de los ácidos glutárico y 3 hidroxiglutárico responsables del compromiso neurológico severo característico de esta enfermedad. La sospecha y diagnóstico de las enfermedades metabólicas constituyen un reto para el personal de salud dada su baja incidencia. En el caso de la aciduria glutárica tipo I se trata de una enfermedad para la cual se poseen los recursos técnicos para el diagnóstico y tratamiento nutricional, su instauración previa a la aparición de encefalopatía aguda, que ocasionan daños irreversibles en el sistema nervioso central, mejora el pronóstico y disminuye el grado de discapacidad. En esta publicación se reportan 5 casos con diagnóstico clínico y bioquímico de aciduria glutárica tipo I que ilustran el espectro clínico y el proceso diagnóstico y de tratamiento en el medio colombiano. Los pacientes se encuentran en seguimiento por los servicios de Neuropediatría.
Glutaric aciduria type i is a disorder resulting trom the deficiency ot the glutaryl-CoA dehydrogenase, enzyme involved in the catabolism ot L-lysine, L-hydroxy-lysine y L-tryptophan causing the accumulation ot its derivatives glutaric acid and 3-hydroxy-glutaric acid which are responsible tor the severe neurological involvement observed in this disease. The diagnosis ot metabolic disorders represents a challenge tor health-care services given its low incidence. Glutaric aciduria type I is a disease tor which there are available technical resources tor diagnosis as well as the nutritional therapy that when set prior to acute encephalopathy, who results in irreversible damage ot central nervous system, can improve the prognosis and decrease the disability ot patients. This publication report 5 cases with clinical and biochemical diagnosis ot glutaric aciduria type i that show the clinical spectrum the diagnostic and treatment approach ot this pathology in Colombia. All the patients are being followed by neuropediatrics services.
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In previous study,glutaric acid (GA) induced apoptosis of primary striatal neuron in vitro.In order to investigate the neurotoxic effects of GA on neonatal rat corpus striatum and the possible mechanism,34 male pups were randomly assigned to NS group,low dose GA (LGA,5 μmol GA/g body weight) group and high dose GA (HGA,10 μmol GA/g body weight) group.These pups were subcutaneously administered with three injections from postnatal day 3 to 22 at 7:30 am,15:00 pm and 22:30 pm and killed 12 h after the last injection.Microscopic pathology in corpus striatum was evaluated by HE staining.The apoptotic cells were identified by TUNEL staining.The transcript levels of caspase-3,8,9,Bax,Bcl-2 were detected by using real-time PCR and the protein levels of procaspase-3 and the active fraction were evaluated by Westem blotting.In LGA and HGA groups,ventricle collapse,cortical atrophy by a macroscope and interstitial edema,vacuolations,widened perivascular space of bilateral striatum by a microscope were observed.TUNEL assay revealed that the apoptotic cells were increased in LGA and HGA groups.The transcript of caspase-3 was up-regulated to 2.5 fold,accompanied by the up-regulation of caspase-9,Bax and down-regulation of Bcl-2.The protein levels ofprocaspase-3 and the active fraction were up-regulated in LGA and HGA groups.The rat model for GA Ⅰ showed mitochondrial apoptotic pathway may be involved in the GA-induced striatal lesion.Further studies should be taken to investigate the underlying mechanisms.
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Glutaric aciduria type Ⅰ is an autosomal recessive disorder resulting from glutaryl-CoA dehydrogenase(GCDH) deflciency.Untreated patients commonly present with severe striatal degeneration and extrapyramidal sequelae during encephalopathic crises.GCDH deficiency leads to accumulation of glutaric acid and 3-hydroxyglutaric acid in tissues and body fluids (especially in brain),which are neurotoxic.There is no correlation between residual enzyme activity caused by mutations in GCDH and phenotype.The pathogenesis of glutaric aciduria type Ⅰ is complicated.Previous studies have demonstrated that glutaric and 3-hydroxyglutaric acids are synthesized in central nervous system and trapped because of limiting transport across the blood-brain barrier.The studies on metabolite-mediated neurotoxicity mainly focus on excitotoxicity,impairment of energy metabolism and oxidative stress.In addition,activation of astrocyte,vascular derangements,inflammatory processes may be a synergism of neurotoxicity.
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Introduccion: la aciduria glutarica tipo II, o deficiencia multiple de acil-CoA deshidrogenasas,es un trastorno causado por deficiencia de la flavoproteina de transferencia de electrones,de su oxidorreductasa o de ambas; se trata de una enfermedad metabolica autosomica recesiva, caracterizada por acidosis, hipoglicemia, aciduria organica, olor a pies sudados y malformaciones en cerebro y riñones. Objetivo: analizar las tasas de oxidacion de sustratos tritiados por fibroblastos de pacientescon aciduria glutarica tipo II. Materiales y metodos: se incubaron fibroblastos de dos pacientes con aciduria glutarica tipoII y de 20 controles en presencia de acidos palmitico y miristico tritiados. Resultados: se encontro muy deprimida (16%-18%) la oxidacion de los sustratos tritiados porlos fibroblastos procedentes de pacientes con aciduria glutarica tipo II en comparacion con los controles. Conclusion: la prueba estudiada permite la confirmacion in vitro del diagnostico de aciduriaglutarica tipo II.
Introduction: Glutaric aciduria type II (GA II), or multiple acyl-CoA dehydrogenase deficiency, is a disorder caused by deficiency of either electron transport flavoprotein or electron transport flavoprotein oxyreductase. It is an autsomal recessive metabolic disease, characterized by acidosis, hypoglycemia, organic aciduria, sweat-sock odour, and malformations in brain and kidneys. Objective: To analyse the oxidation rate of tritiated substrates by fibroblasts of patients with GA II. Materials and methods: Fibroblasts of two patients with GA II were incubated with tritiated palmitic and myristic acids. Results: Oxidation of tritiated substrates by fibroblasts of patients with GA II was very depressed (16%-18%) in comparison with controls. Conclusion: Diagnosis of GA II may be confirmed in vitro by the studied test.
Subject(s)
Humans , Acetyl Coenzyme A , Fatty Acids , Oxidoreductases/deficiencyABSTRACT
Glutaric aciduria type I (GA I) is an autosomal recessive disorder caused by a deficiency of glutaryl-CoA dehydrogenase. Although over 400 patients confirmed as GA I have been reported, reports from the Asian population had contributed to the minor proportion. We recently diagnosed two cases of GA I confirmed with mutational analysis. Here, we present their rather atypical clinical presentations with genetic characteristics for the first time in Korea. Profound developmental delay from birth, association of hearing loss, and neurological improvement after surgical intervention, were considered to be different clinical features from most reported cases. One patient was a compound heterozygote for p.Ser139Leu and p.Asp220Tyr, and the other for p.Ser139Leu and Glu160X. The mutations of the two alleles (p.Asp220Tyr and p.Glu160X) were novel and reports of p.Ser139Leu were rare both in Western and other Asian populations. These might suggest different genetic spectrum of Korean GA I patients.
ABSTRACT
Glutaric aciduria type 1 is an inborn error of lysine, hydroxylysine, and tryptophan metabolism caused by deficiency of glutaryl-coenzyme A dehydrogenase. The disease often appears in infancy with encephalopathy episode that results in acute basal ganglia and white matter degeneration. The majority of patients develop a dystonic-dyskinetic syndrome. This reports 6year-old boy who had been done previous gastrostomy due to swallowing difficulty underwent bilateral pallidotomy with intraoperative electromyography(EMG) monitoring for disabling dystonia. Intraoperative EMG was used to assess stimulation thresholds required for capsular responses and muscle tone. Surface EMG electrodes were placed on the face and cricopharyngeal muscles. Exact target were directly modified according to MRI-visualized anatomy. EMG response was consistently seen prior to visual observation of muscle activity. The surgery improved dystonic symptoms without swallowing difficulty.
Subject(s)
Humans , Male , Basal Ganglia , Deglutition , Dystonia , Electrodes , Gastrostomy , Glutaryl-CoA Dehydrogenase , Hydroxylysine , Lysine , Metabolism , Muscles , Pallidotomy , TryptophanABSTRACT
Glutaric aciduria type 1(GA1) is an autosomal recessive disorder of the lysine, hydroxylysine and tryptophan metabolism caused by the deficiency of mitochondrial glutaryl-CoA dehydrogenase. This disease is characterized by macrocephaly at birth or shortly after birth and various neurologic symptoms. Between the first weeks and the 4-5th year of life, intercurrent illness such as viral infections, gastroenteritis, or even routine immunizations can trigger acute encephalopathy, causing injury to caudate nucleus and putamen. But intellectual functions are well preserved until late in the disease course. We report a one-month-old male infant with macrocephaly and hypotonia. In brain MRI, there was frontotemporal atrophy(widening of sylvian cistern). In metabolic investigation, there were high glutarylcarnitine level in tandem mass spectrometry and high glutarate in urine organic acid analysis, GA1 was confirmed by absent glutaryl-CoA dehydrogenase activity in fibroblast culture. He was managed with lysine free milk and carnitine and riboflavin. He developed well without a metabolic crisis. If there is macrocephaly in an infant with neuroradiologic sign of frontotemporal atrophy, GA1 should have a high priority in the differential diagnosis. Because current therapy can prevent brain degeneration in more than 90% of affected infants who are treated prospectively, recognition of this disorder before the brain has been injured is essential for treatment.
Subject(s)
Humans , Infant , Male , Atrophy , Brain , Carnitine , Caudate Nucleus , Diagnosis, Differential , Fibroblasts , Gastroenteritis , Glutaryl-CoA Dehydrogenase , Hydroxylysine , Immunization , Lysine , Megalencephaly , Magnetic Resonance Imaging , Metabolism , Milk , Muscle Hypotonia , Neurologic Manifestations , Parturition , Putamen , Riboflavin , Tandem Mass Spectrometry , TryptophanABSTRACT
Glutaric aciduria(type 1) is characterized clinically by progressive dystonia and dyskinesia in childhood, pathologically by degeneration of caudate and putamen, biochemically by tissue deficiency of glutaryl-CoA dehydrogenase(GCDH), and is transmitted as an autosomal recessive traits. Mutations of the GCDH gene on chromosome 19 have been implicated in the causation of glutaric aciduria(type 1). Macrocephaly in infancy and crossing of percentiles for head circumference are real clues to early diagnosis. Acute neuroregression of dystonia following an initial phase of normal or almost normal development is a common mode of presentation, at times preceded by seizures. We experienced a case of glutaric aciduria(type 1) in a 13-month old girl. She was admitted due to development delay and choreoasthetoid movememt that developed after generalized tonic-clonic type seizures. She was diagnosed as having glutaric aciduria(type 1) based on brain MRI and urine organic acid analysis finding.