L-2 hydroxyglutaric aciduria: report of a Mexican-Mayan patient with the mutation c.569C>T and response to vitamin supplements and levocarnitine.

Background: L-2-hydroxyglutaric aciduria (L2HGA) is a rare inherited autosomal recessive neurometabolic disorder caused by pathogenic variants in the L2HGDH gene which encodes mitochondrial 2-hydroxyglutarate dehydrogenase. Here, we report a case of L2HGA in a Mexican-Mayan patient with a homozygous mutation at L2HGDH gene and clinical response to vitamin supplements and levocarnitine. Case report: A 17-year-old, right-handed female patient with long-term history of seizures, developmental delay and ataxia was referred to a movement disorders specialist for the evaluation of tremor. Her brain MRI showed typical findings of L2HGA. The diagnosis was corroborated with elevated levels of 2-hydroxyglutaric acid in urine and genetic test which revealed a homozygous genetic known variant c.569C>T in exon 5 of L2HGDH gene. She was treated with levocarnitine and vitamin supplements, showing improvement in tremor and gait. Discussion: To our knowledge this is the first report of a Mexican patient with L2HGA. This case adds information about a rare condition in a different ethnic group and supports the findings of other authors which encountered symptomatic improvement with the use of flavin adenine dinucleotide (and its precursor riboflavin), and levocarnitine. Highlights: We report the first case of Mexican-Mayan patient with L2HGA showing a missense homozygous mutation in L2HGDH gene, and improvement of symptoms with vitamin supplements and levocarnitine.

L-2-Hydroxyglutaric Acid Administration to Neonatal Rats Elicits Marked Neurochemical Alterations and Long-Term Neurobehavioral Disabilities Mediated by Oxidative Stress.

L-2-Hydroxyglutaric aciduria (L-2-HGA) is an inherited neurometabolic disorder caused by deficient activity of L-2-hydroxyglutarate dehydrogenase. L-2-Hydroxyglutaric acid (L-2-HG) accumulation in the brain and biological fluids is the biochemical hallmark of this disease. Patients present exclusively neurological symptoms and brain abnormalities, particularly in the cerebral cortex, basal ganglia, and cerebellum. Since the pathogenesis of this disorder is still poorly established, we investigated the short-lived effects of an intracerebroventricular injection of L-2-HG to neonatal rats on redox homeostasis in the cerebellum, which is mostly affected in this disorder. We also determined immunohistochemical landmarks of neuronal viability (NeuN), astrogliosis (S100B and GFAP), microglia activation (Iba1), and myelination (MBP and CNPase) in the cerebral cortex and striatum following L-2-HG administration. Finally, the neuromotor development and cognitive abilities were examined. L-2-HG elicited oxidative stress in the cerebellum 6 h after its injection, which was verified by increased reactive oxygen species production, lipid oxidative damage, and altered antioxidant defenses (decreased concentrations of reduced glutathione and increased glutathione peroxidase and superoxide dismutase activities). L-2-HG also decreased the content of NeuN, MBP, and CNPase, and increased S100B, GFAP, and Iba1 in the cerebral cortex and striatum at postnatal days 15 and 75, implying long-standing neuronal loss, demyelination, astrocyte reactivity, and increased inflammatory response, respectively. Finally, L-2-HG administration caused a delay in neuromotor development and a deficit of cognition in adult animals. Importantly, the antioxidant melatonin prevented L-2-HG-induced deleterious neurochemical, immunohistochemical, and behavioral effects, indicating that oxidative stress may be central to the pathogenesis of brain damage in L-2-HGA.

Experimental Evidence that In Vivo Intracerebral Administration of L-2-Hydroxyglutaric Acid to Neonatal Rats Provokes Disruption of Redox Status and Histopathological Abnormalities in the Brain.

Tissue accumulation of L-2-hydroxyglutaric acid (L-2-HG) is the biochemical hallmark of L-2-hydroxyglutaric aciduria (L-2-HGA), a rare neurometabolic inherited disease characterized by neurological symptoms and brain white matter abnormalities whose pathogenesis is not yet well established. L-2-HG was intracerebrally administered to rat pups at postnatal day 1 (P1) to induce a rise of L-2-HG levels in the central nervous system (CNS). Thereafter, we investigated whether L-2-HG in vivo administration could disturb redox homeostasis and induce brain histopathological alterations in the cerebral cortex and striatum of neonatal rats. L-2-HG markedly induced the generation of reactive oxygen species (increase of 2',7'-dichloroflurescein-DCFH-oxidation), lipid peroxidation (increase of malondialdehyde concentrations), and protein oxidation (increase of carbonyl formation and decrease of sulfhydryl content), besides decreasing the antioxidant defenses (reduced glutathione-GSH) and sulfhydryl content in the cerebral cortex. Alterations of the activities of various antioxidant enzymes were also observed in the cerebral cortex and striatum following L-2-HG administration. Furthermore, L-2-HG-induced lipid peroxidation and GSH decrease in the cerebral cortex were prevented by the antioxidant melatonin and by the classical antagonist of NMDA glutamate receptor MK-801, suggesting the involvement of reactive species and of overstimulation of NMDA receptor in these effects. Finally, L-2-HG provoked significant vacuolation and edema particularly in the cerebral cortex with less intense alterations in the striatum that were possibly associated with the unbalanced redox homeostasis caused by this metabolite. Taken together, it is presumed that these pathomechanisms may underlie the neurological symptoms and brain abnormalities observed in the affected patients.

Acidúria L2-hidroxiglutárica: circulação do gene em cães da raça Staffordshire Bull Terrier no Brasil em 2008-2015 / L2-hydroxyglutaric aciduria: circulation of the gene in Staffordshire Bull Terrier dogs in Brazil (2008-2015)

O objetivo do trabalho foi identificar a presença no Brasil do gene mutante L2HGDH em cães da raça Staffordshire Bull Terrier (SBT). Para tanto foi feito o teste genético em 76 cães provenientes de diferentes regiões do Brasil, no período de 2008 a 2015, sendo encontrados 55 animais (72,37%) livres do gene mutante L2-HGDH ou homozigotos dominantes, e 21(27,63%) portadores do gene mutante ou heterozigotos. Não foi encontrado nenhum animal homozigoto recessivo (afetado), porém pode-se observar que o gene circula no Brasil e que cães afetados podem aparecer.(AU)

The aim of this study was to identify the presence of a mutation in the L2-hydroxyglutarate dehydrogenase (L2-HGDH) gene in Staffordshire bull terriers in Brazil. Genetic testing was done in 76 dogs from different regions of the country, from 2008 to 2015. Fifty-five dogs (72.37%) were free of the mutant gene L2HGDH or homozygous-dominant, and 21 (27.63%) were carriers for the mutant gene or heterozygous. No homozygous recessive dogs (affected) were found, however, it is worth noting that the gene circulates in Brazil and that affected dogs can appear.(AU)

Acidúrias D-2-hidroxiglutárica e L-2-hidroxiglutárica: uma revisão da literatura / D-2-hydroxyglutaric and L-2-hydroxyglutaric acidurias:a literature review

As acidúrias D-2-hidroxiglutárica (D-2-HGA) e L-2-hidroxiglutárica (L-2-HGA) são raras doenças neurometabólicas que constituem um grupo de erros inatos do metabolismo. Essas doenças são causadas pela deficiência das atividades enzimáticas da D-2-hidroxiglutarato desidrogenase na D-2-HGA do tipo I ou isocitrato desidrogenase na D-2-HGA do tipo II, e da L-2-hidroxiglutarato desidrogenase na L-2-HGA. Os principais achados clínicos nos pacientes caracterizam-se por sintomas neurológicos, como convulsões, coma e atrofia cerebral. Também ocorrem lesões cerebrais nos gânglios da base (D-2-HGA, L-2-HGA) e cerebelo (L-2-HGA). Bioquimicamente, essas acidúrias caracterizam-se por acúmulo em tecidos e elevada excreção urinária dos ácidos D-2-hidroxiglutárico (na D-2-HGA) e L-2-hidroxiglutárico (na L-2-HGA). Ainda, uma terceira variante bioquímica da acidúria, a D,L-2-hidroxiglutárica (D,L-2-HGA), é caracterizada por excreção aumentada de ambos enantiômeros do ácido 2-hidroxiglutárico. Em modelo animal, estudos de toxicidade dos ácidos D e L-2-hidroxiglutárico mostraram injúria cerebral, mas não foi elucidado o mecanismo exato causador do dano. Além disso, altos níveis dos ácidos D e L-2-hidroxiglutárico foram encontrados em tumores cerebrais. No entanto, a relação entre a acidúria e o câncer ainda precisa ser esclarecida. Tendo em vista a gravidade da doença, este trabalho teve como objetivo fazer uma revisão bibliográfica acerca do tema, enfatizando as consequências do metabolismo, principalmente para o tecido cerebral, bem como apontar possíveis abordagens terapêuticas.

The D-2-hydroxyglutaric (D-2-HGA) and L-2-hydroxyglutaric acidurias (L-2-HGA) are rare neurometabolic diseases that form a group of inborn errors of metabolism. They are caused by a deficiency on the enzyme activities of D-2-hydroxyglutarate dehydrogenase in D-2-HGA type I or isocitrate dehydrogenase in D-2-HGA type II, and L-2-hydroxyglutarate dehydrogenase in L-2-HGA. The main clinical findings in affected patients are related to neurological symptoms, such as convulsions, coma and brain atrophy. Brain injuries also occur in the basal ganglia (D-2-HGA, L-2-HGA) and cerebellum (L-2-HGA). These acidurias are biochemically characterized by the accumulation in tissues and increased urinary excretion of D-2-hydroxyglutaric acid (in D-2-HGA) and L-2-hydroxyglutaric acid (in L-2-HGA). Still, a third biochemical variant of aciduria, called D,L-2-hydroxyglutaric (D,L-2-HGA), is characterized by increased excretion of both enantiomers of 2-hydroxyglutaric acid. In an animal model, toxicity studies on D- and L-2-hydroxyglutaric acids showed brain injury, but the exact mechanism of brain damage was not elucidated. Furthermore, high levels of D- and L-2-hydroxyglutaric acids were found in brain tumors. However, the relationship between cancer and aciduria still needs to be clarified. In view of the severity of the disease, this study aimed to do a literature review on the topic, emphasizing metabolic consequences, particularly for the brain tissue, as well as to identify possible therapeutic approaches.

Acidúria L2-hidroxiglutárica: circulação do gene em cães da raça Staffordshire Bull Terrier no Brasil em 2008-2015 / L2-hydroxyglutaric aciduria: circulation of the gene in Staffordshire Bull Terrier dogs in Brazil (2008-2015)

The aim of this study was to identify the presence of a mutation in the L2-hydroxyglutarate dehydrogenase (L2-HGDH) gene in Staffordshire bull terriers in Brazil. Genetic testing was done in 76 dogs from different regions of the country, from 2008 to 2015. Fifty-five dogs (72.37%) were free of the mutant gene L2HGDH or homozygous-dominant, and 21 (27.63%) were carriers for the mutant gene or heterozygous. No homozygous recessive dogs (affected) were found, however, it is worth noting that the gene circulates in Brazil and that affected dogs can appear.(AU)

O objetivo do trabalho foi identificar a presença no Brasil do gene mutante L2HGDH em cães da raça Staffordshire Bull Terrier (SBT). Para tanto foi feito o teste genético em 76 cães provenientes de diferentes regiões do Brasil, no período de 2008 a 2015, sendo encontrados 55 animais (72,37%) livres do gene mutante L2-HGDH ou homozigotos dominantes, e 21(27,63%) portadores do gene mutante ou heterozigotos. Não foi encontrado nenhum animal homozigoto recessivo (afetado), porém pode-se observar que o gene circula no Brasil e que cães afetados podem aparecer.(AU)

In vivo intracerebral administration of L-2-hydroxyglutaric acid provokes oxidative stress and histopathological alterations in striatum and cerebellum of adolescent rats.

Patients affected by L-2-hydroxyglutaric aciduria (L-2-HGA) are biochemically characterized by elevated L-2-hydroxyglutaric acid (L-2-HG) concentrations in cerebrospinal fluid, plasma, and urine due to a blockage in the conversion of L-2-HG to α-ketoglutaric acid. Neurological symptoms associated with basal ganglia and cerebelar abnormalities whose pathophysiology is still unknown are typical of this neurometabolic disorder. In the present study we evaluated the early effects (30min after injection) of an acute in vivo intrastriatal and intracerebellar L-2-HG administration on redox homeostasis in rat striatum and cerebellum, respectively. Histological analyses of these brain structures were also carried out 7 days after L-2-HG treatment (long-term effects). L-2-HG significantly decreased the concentrations of reduced (GSH) and total glutathione (tGS), as well as of glutathione peroxidase (GPx) and reductase (GR) activities, but did not change the activities of superoxide dismutase and catalase in striatum. Furthermore, the concentrations of oxidized glutathione (GSSG) and malondialdehyde (MDA), as well as 2',7'-dichlorofluorescein (DCFH) oxidation and hydrogen peroxide (H2O2) production, were increased, whereas carbonyl formation and nitrate plus nitrite concentrations were not altered by L-2-HG injection. It was also found that the melatonin, ascorbic acid plus α-tocopherol, and creatine totally prevented most of these effects, whereas N-acetylcysteine, the noncompetitive glutamate NMDA antagonist MK-801, and the nitric oxide synthase inhibitor L-NAME were not able to normalize the redox alterations elicited by L-2-HG in striatum. L-2-HG intracerebellar injection similarly provoked a decrease of antioxidant defenses (GSH, tGS, GPx, and GR) and an increase of the concentrations of GSSG, MDA, and H2O2 in cerebellum. These results strongly indicate that the major accumulating metabolite in L-2-HGA induce oxidative stress by decreasing the antioxidant defenses and enhancing reactive oxygen species in striatum and cerebellum of adolescent rats. Regarding the histopathological findings, L-2-HG caused intense vacuolation, lymphocyte and macrophage infiltrates, eosinophilic granular bodies, and necrosis in striatum. Immunohistochemistry revealed that L-2-HG treatment provoked an increase of GFAP and a decrease of NeuN immunostaining, indicating reactive astroglyosis and reduction of neuronal population, respectively, in striatum. Similar macrophage infiltrates, associated with less intense vacuolation and lymphocytic infiltration, were observed in cerebellum. However, we did not observe necrosis, eosinophilic granular bodies, and alteration of GFAP and NeuN content in L-2-HG-teated cerebellum. From the biochemical and histological findings, it is presumed that L-2-HG provokes striatal and cerebellar damage in vivo possibly through oxidative stress induction. Therefore, we postulate that antioxidants may serve as adjuvant therapy allied to the current treatment based on a protein-restricted diet and riboflavin and L-carnitine supplementation in patients affected by L-2-HGA.