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Williams M, Menkovic I, Reitnauer P, Gilbert E, Koeberl D, Young SP, Stiles AR. Critical sample collection delayed? Urine organic acid analysis can still save the day! A new case of HMG-CoA synthase deficiency. Mol Genet Metab Rep 2024; 38:101062. [PMID: 38469099 PMCID: PMC10926198 DOI: 10.1016/j.ymgmr.2024.101062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/25/2024] [Accepted: 01/26/2024] [Indexed: 03/13/2024] Open
Abstract
Mitochondrial 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) synthase (mHS) deficiency is an autosomal recessive disorder of ketone body synthesis caused by biallelic pathogenic variants in HMGCS2. Clinical symptoms are precipitated by prolonged fasting and/or intercurrent illness with onset before the first year of life. Clinically, patients may present with hypo-/ non-ketotic hypoglycemia, metabolic acidosis, hyperammonemia, lethargy, hepatomegaly, and encephalopathy. During periods of decompensation, elevations of 4-hydroxy-6-methyl-2-pyrone (4-HMP), several hydroxylated hexanoic and hexenoic acid species, and medium-chain dicarboxylic acids in the absence of significant ketonuria may be observed in the urine organic acid profile. Abnormalities may also be observed in plasma which includes elevated acetylcarnitine (C2) and 3-hydroxybutyryl/3-hydroxyisobutyryl (C4-OH) carnitine. We report a patient who presented to the ED at 13 months of age with an undetectable point-of-care blood glucose level. Continuous infusion of dextrose-containing intravenous (IV) fluids were required to correct the hypoglycemia and routine chemistries were notable for an anion gap metabolic acidosis, transaminasemia, and elevated creatine kinase and lactate dehydrogenase. Urine and blood ketones were undetectable. Qualitative assessment of urine organic acids collected ∼46 and ∼ 99 h post-admission were significant for mild elevations of 4-HMP and hydroxy-hexanoic and hydroxy-hexenoic acid species with a notable absence of ketones. Previously, biochemical abnormalities in urine have been shown to normalize in as few as 27 h after treatment giving providers a narrow window with which to obtain a critical sample. Direct communication of laboratory findings to the ordering provider guided the molecular testing and assisted in results interpretation to confirm the molecular diagnosis. Our case emphasizes the importance of collecting samples for biochemical analysis even if the critical period has been missed and acute metabolic decompensation seems to be resolved, as residual abnormalities observed in our patient greatly narrowed the differential diagnosis.
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Affiliation(s)
- Monika Williams
- Department of Pediatrics, Division of Pediatric Genetics and Metabolism, UNC, Chapel Hill, NC, USA
| | - Iskren Menkovic
- Biochemical Genetics Laboratory, Duke University Health System, Durham, NC, USA
| | - Pamela Reitnauer
- Pediatric Teaching Program & Pediatric Medical Genetics, Cone Health, Greensboro, NC, USA
| | - Eileen Gilbert
- Biochemical Genetics Laboratory, Duke University Health System, Durham, NC, USA
| | - Dwight Koeberl
- Biochemical Genetics Laboratory, Duke University Health System, Durham, NC, USA
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Sarah P. Young
- Biochemical Genetics Laboratory, Duke University Health System, Durham, NC, USA
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Ashlee R. Stiles
- Biochemical Genetics Laboratory, Duke University Health System, Durham, NC, USA
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
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Niehaus AD, Cooper H, Lee CU. Mitochondrial HMG-CoA Synthase Deficiency: A Cyclic Vomiting Mimic Without Reliable Biochemical Markers. J Investig Med High Impact Case Rep 2024; 12:23247096241267154. [PMID: 39143735 PMCID: PMC11325301 DOI: 10.1177/23247096241267154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/14/2024] [Accepted: 06/22/2024] [Indexed: 08/16/2024] Open
Abstract
Here, we report an individual, eventually diagnosed with HMG-CoA synthase deficiency, who presented with a cyclic vomiting phenotype. HMG-CoA synthase deficiency is a rare disorder affecting ketone body synthesis in which affected individuals typically present at a young age with hypoketotic hypoglycemia, lethargy, encephalopathy, and hepatomegaly, usually triggered by catabolism (e.g., infection or prolonged fasting). This individual presented with recurrent episodes of vomiting and lethargy, often associated with hypoglycemia or hyperglycemia, at 3 years of age. Metabolic labs revealed nonspecific abnormalities in her urine organic acids (showing mild elevation of dicarboxylic acids with relatively low excretion of ketones) and a normal acylcarnitine profile. Given her clinical presentation, as well as a normal upper gastrointestinal series, esophagogastroduodenoscopy with biopsies, and abdominal ultrasound, she was diagnosed with cyclic vomiting syndrome at 3 years of age. Molecular testing completed at 7 years of age revealed a previously reported pathogenic sequence variant (c.1016+1G>A) and a novel likely pathogenic deletion (1.57 kB deletion, including exon 1) within HMGCS2 consistent with HMG-CoA synthase deficiency. This individual's presentation, mimicking cyclic vomiting syndrome, widens the clinical spectrum of HMG-CoA synthase deficiency. In addition, this case highlights the importance of molecular genetic testing in such presentations, as this rare disorder lacks specific metabolic markers.
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Wu S, Shen L, Chen Q, Gong C, Yang Y, Wei H, Cao B, Chen Y. Clinical, Biochemical, Molecular, and Outcome Features of Mitochondrial 3-Hydroxy-3-Methylglutaryl-CoA Synthase Deficiency in 10 Chinese Patients. Front Genet 2022; 12:816779. [PMID: 35308163 PMCID: PMC8931749 DOI: 10.3389/fgene.2021.816779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Mitochondrial 3-hydroxy-3-methylglutaryl-CoA synthase deficiency (HMGCS2D) is a rare autosomal recessive metabolic disorder caused by mutations of the HMGCS2 gene. To date, no more than 60 patients have been reported throughout the world. Purpose: To analyze the clinical, biochemical, molecular, and outcome features of HMGCS2D in a case series of 10 new Chinese patients. Methods: This retrospective study includes 10 Chinese patients diagnosed with HMGCS2D. We collected and analyzed clinical data for all patients. We also reviewed clinical data for 39 cases that had been reported previously. Results: All of our patients had experienced their first metabolic crisis before 12 months old. The most common clinical manifestations were anorexia, dyspnea, and disturbance of consciousness (10/10), followed by vomiting (8/10), fever (7/10), cough (4/10), diarrhea, and seizures (3/10). Each patient (10/10) had a different degree of hepatomegaly and increased aminotransferase, severe metabolic acidosis, and hypofibrinogenemia. 9 patients presented with severe hypoglycemia and weak positives on qualitative tests of urinary ketone body. Patient 3 was the only one without hypoglycemia. Five patients had hypocalcemia, five patients had hyperammonemia, four patients had hyperuricemia, and three had hypertriglyceridemia. During the metabolic acidosis episode, we observed high dicarboxylic acid values in urine, and the elevated ratio of blood acetylcarnitine to free carnitine may have been an additional biochemical signature. However, all returned to normal during the interictal interval. Molecular analysis identified 15 variants in the HMGCS2 gene, of which 10 were novel (c.220G>A/p.E74K, c.407A>G/p.D136G, c.422T>A/p.V141D, c.719A>C/p.D240A, c.821G>A/p.R274H, c.39dupA/p.L14Tfs*59, c.1394delA/p.N465Tfs*10, c.788delT/p.L263Cfs*36, c.717T>G/p.Y239*, and c.1017-2A>G). Combining these with previous cases, the known mutation c.1201G>T/p.E401* has been found in 6/40 (15.0%) of mutated alleles in 21 Chinese patients from 20 families, while none have been found in other populations. We found that patients with biallelic truncation mutation appeared to show a more severe clinical condition through a literature review. Conclusion: This study analyzed the phenotypic and genetic features of HMGCS2D in a Chinese case series. We also expanded the HMGCS2 mutational spectrum with 10 novel variants. The c.1201G>T/p.E401* mutation was the most frequent, representing 15.0% of the mutated alleles in reported unrelated Chinese patients, and thus, it may be a hot spot mutation.
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Affiliation(s)
- Shengnan Wu
- Department of Endocrinology and Metabolism, Henan Key Laboratory of Children’s Genetics and Metabolic Diseases, Children’s Hospital Affiliated to Zhengzhou University, Henan Children’s Hospital, Zhengzhou Children’s Hospital, Zhengzhou, China
| | - Linghua Shen
- Department of Endocrinology and Metabolism, Henan Key Laboratory of Children’s Genetics and Metabolic Diseases, Children’s Hospital Affiliated to Zhengzhou University, Henan Children’s Hospital, Zhengzhou Children’s Hospital, Zhengzhou, China
| | - Qiong Chen
- Department of Endocrinology and Metabolism, Henan Key Laboratory of Children’s Genetics and Metabolic Diseases, Children’s Hospital Affiliated to Zhengzhou University, Henan Children’s Hospital, Zhengzhou Children’s Hospital, Zhengzhou, China
| | - Chunxiu Gong
- Department of Endocrinology, Genetics and Metabolism, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing, China
| | - Yanling Yang
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Haiyan Wei
- Department of Endocrinology and Metabolism, Henan Key Laboratory of Children’s Genetics and Metabolic Diseases, Children’s Hospital Affiliated to Zhengzhou University, Henan Children’s Hospital, Zhengzhou Children’s Hospital, Zhengzhou, China
| | - Bingyan Cao
- Department of Endocrinology, Genetics and Metabolism, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing, China
- *Correspondence: Yongxing Chen, ; Bingyan Cao,
| | - Yongxing Chen
- Department of Endocrinology and Metabolism, Henan Key Laboratory of Children’s Genetics and Metabolic Diseases, Children’s Hospital Affiliated to Zhengzhou University, Henan Children’s Hospital, Zhengzhou Children’s Hospital, Zhengzhou, China
- *Correspondence: Yongxing Chen, ; Bingyan Cao,
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Hurst IA, Calhoun A, Mehren R, Held P, Asamoa-Bonsu Y, Cathers A. Metabolic Emergency in Flight. Air Med J 2022; 41:141-146. [PMID: 35248334 DOI: 10.1016/j.amj.2021.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/21/2021] [Indexed: 11/16/2022]
Abstract
Young children with inborn errors of metabolism often present to medical care in extremis, although their symptoms can be nonspecific. Rare metabolic disorders are not always on the statewide newborn screening panels, so infants and children can present later in life with vomiting, altered mental status, seizures, coma, or death, without any indication prior of a metabolic disorder. Swift transport to a pediatric specialty center can be lifesaving and prevent neurologic damage in these patients while awaiting definitive testing for these genetic disorders. Transport of these patients is complicated because they are often critically ill yet do not respond normally to routine resuscitation. In this case, we describe the transport of a patient with a rare, undifferentiated inborn error of metabolism with a pediatric specialty flight team and the considerations made in resuscitation and treatment of this patient in flight.
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Affiliation(s)
- Irene A Hurst
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI; Division of Pediatric Emergency Medicine, University of Wisconsin-Madison, Madison, WI; School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI.
| | - Amy Calhoun
- University of Iowa Stead Family Children's Hospital, Department of Pediatrics, Division of Medical Genetics and Genomics, University of Iowa Healthcare, Iowa City, IA
| | - Ryan Mehren
- UW Med Flight, University of Wisconsin-Madison, Madison, WI
| | - Patrice Held
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI; Department of Pediatrics, University of Wisconsin-Madison, Madison, WI; Wisconsin State Laboratory of Hygiene, Madison, WI
| | - Yaw Asamoa-Bonsu
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI; Division of Pediatric Critical Care, University of Wisconsin-Madison, Madison, WI
| | - Andrew Cathers
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI; School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI; UW Med Flight, University of Wisconsin-Madison, Madison, WI
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Liu H, Zhu J, Li Q, Wang D, Wan K, Yuan Z, Zhang J, Zou L, He X, Miao J. Untargeted metabolomic analysis of urine samples for diagnosis of inherited metabolic disorders. Funct Integr Genomics 2021; 21:645-653. [PMID: 34585279 DOI: 10.1007/s10142-021-00804-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/07/2021] [Accepted: 08/27/2021] [Indexed: 11/30/2022]
Abstract
Metabolomics has become an important tool for clinical research, especially for analyzing inherited metabolic disorders (IMDs). The purpose of this study was to explore the performance of metabolomics in diagnosing IMDs using an untargeted metabolomic approach. A total of 40 urine samples were collected: 20 samples from healthy children and 20 from pediatric patients, of whom 13 had confirmed IMDs and seven had suspected IMDs. Samples were analyzed by Orbitrap mass spectrometry in positive and negative mode alternately, coupled with ultra-high liquid chromatography. Raw data were processed using Compound Discovery 2.0 ™ and then exported for partial least squares discriminant analysis (PLS-DA) by SIMCA-P 14.1. After comparing with m/zCloud and chemSpider libraries, compounds with similarity above 80% were selected and normalized for subsequent relative quantification analysis. The uncommon compounds discovered were analyzed based on the Kyoto Encyclopedia of Genes and Genomes to explore their possible metabolic pathways. All IMDs patients were successfully distinguished from controls in the PLS-DA. Untargeted metabolomics revealed a broader metabolic spectrum in patients than what is observed using routine chromatographic methods for detecting IMDs. Higher levels of certain compounds were found in all 13 confirmed IMD patients and 5 of 7 suspected IMD patients. Several potential novel markers emerged after relative quantification. Untargeted metabolomics may be able to diagnose IMDs from urine and may deepen insights into the disease by revealing changes in various compounds such as amino acids, acylcarnitines, organic acids, and nucleosides. Such analyses may identify biomarkers to improve the study and treatment of IMDs.
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Affiliation(s)
- Hao Liu
- Newborn Screening Center, Chongqing Health Center for Women and Children, Longshan Road 120th, Yubei District, Chongqing, 401147, People's Republic of China.,Center for Clinical Molecular Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Zhongshan Road 2nd, Yuzhong District, Chongqing, 400014, People's Republic of China
| | - Jiang Zhu
- Chongqing Key Laboratory of Child Nutrition and Health, Children's Hospital of Chongqing Medical University, Chongqing, 400014, People's Republic of China
| | - Qiu Li
- Chongqing Key Laboratory of Child Nutrition and Health, Children's Hospital of Chongqing Medical University, Chongqing, 400014, People's Republic of China
| | - Dongjuan Wang
- Center for Clinical Molecular Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Zhongshan Road 2nd, Yuzhong District, Chongqing, 400014, People's Republic of China
| | - Kexing Wan
- Center for Clinical Molecular Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Zhongshan Road 2nd, Yuzhong District, Chongqing, 400014, People's Republic of China
| | - Zhaojian Yuan
- Center for Clinical Molecular Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Zhongshan Road 2nd, Yuzhong District, Chongqing, 400014, People's Republic of China
| | - Juan Zhang
- Center for Clinical Molecular Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Zhongshan Road 2nd, Yuzhong District, Chongqing, 400014, People's Republic of China
| | - Lin Zou
- Center for Clinical Molecular Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Zhongshan Road 2nd, Yuzhong District, Chongqing, 400014, People's Republic of China
| | - Xiaoyan He
- Center for Clinical Molecular Medicine, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Zhongshan Road 2nd, Yuzhong District, Chongqing, 400014, People's Republic of China.
| | - Jingkun Miao
- Newborn Screening Center, Chongqing Health Center for Women and Children, Longshan Road 120th, Yubei District, Chongqing, 401147, People's Republic of China.
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