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Baker PR. Recognizing and Managing a Metabolic Crisis. Pediatr Clin North Am 2023; 70:979-993. [PMID: 37704355 DOI: 10.1016/j.pcl.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
In some relatively common inborn errors of metabolism there can be the accumulation of toxic compounds including ammonia and organic acids such as lactate and ketoacids, as well as energy deficits at the cellular level. The clinical presentation is often referred to as a metabolic emergency or crisis. Fasting and illness can result in encephalopathy within hours, and without appropriate recognition and intervention, the outcome may be permanent disability or death. This review outlines easy and readily available means of recognizing and diagnosing a metabolic emergency as well as general guidelines for management. Disease-specific interventions focus on parenteral nutrition to reverse catabolism, toxin removal strategies, and vitamin/nutrition supplementation.
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Affiliation(s)
- Peter R Baker
- University of Colorado, Children's Hospital Colorado, 13123 East 16th Avenue, Box 300, Aurora, CO 80045, USA.
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2
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Moran E, McEvoy MT, Brackett J, Chawla R. Undifferentiated Shock in a 2-month-old Girl. Pediatr Rev 2023; 44:517-520. [PMID: 37653131 DOI: 10.1542/pir.2021-005297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Affiliation(s)
- Elizabeth Moran
- Texas Children's Hospital, Houston, TX
- Baylor College of Medicine, Houston, TX
| | - Matthew T McEvoy
- Texas Children's Hospital, Houston, TX
- Baylor College of Medicine, Houston, TX
| | - Julienne Brackett
- Texas Children's Hospital, Houston, TX
- Baylor College of Medicine, Houston, TX
| | - Rolly Chawla
- Texas Children's Hospital, Houston, TX
- Baylor College of Medicine, Houston, TX
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3
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Diagnosis and Management of Inborn Errors of Metabolism in Adult Patients in the Emergency Department. Diagnostics (Basel) 2021; 11:diagnostics11112148. [PMID: 34829496 PMCID: PMC8621113 DOI: 10.3390/diagnostics11112148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 12/30/2022] Open
Abstract
Inborn errors of metabolism (IEM) constitute an important group of conditions characterized by an altered metabolic pathway. There are numerous guidelines for the diagnosis and management of IEMs in the pediatric population but not for adults. Given the increasing frequency of this group of conditions in adulthood, other clinicians in addition to pediatricians should be aware of them and learn to identify their characteristic manifestations. Early recognition and implementation of an appropriate therapeutic approach would improve the clinical outcome of many of these patients. This review presents when and how to investigate a metabolic disorder with the aim of encouraging physicians not to overlook a treatable disorder.
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Abdel Maksoud M, ELsayed SM, Shatla RH, Imam AA, Elsayed RM, Mosabah AA, Sherif AM. Frequency of inborn errors of metabolism screening for children with unexplained acute encephalopathy at an emergency department. Neuropsychiatr Dis Treat 2018; 14:1715-1720. [PMID: 29988750 PMCID: PMC6029674 DOI: 10.2147/ndt.s165833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Our study aimed to estimate the frequency of inborn errors of metabolism (IEMs) in patients presenting with acute encephalopathy-like picture at an emergency department (ED). SUBJECTS AND METHODS Our study was a prospective observational study conducted on 30 patients admitted to the pediatric ED with unexplained acute encephalopathy. The study included 30 children with an age ranging from 1 month to 5 years. All patients were subjected to full history taking, thorough clinical examination, and laboratory investigations including serum ammonia, serum lactate, arterial blood gases, tandem mass spectroscopy, organic acid of urine, cerebrospinal fluid examination to exclude central nervous system infection plus the routine laboratory tests (kidney functions, liver functions, random blood glucose, complete blood picture), and brain imaging computed tomography and/or magnetic resonance imaging brain. RESULTS Thirty children presented with acute encephalopathy at the ED. All were screened for suspected IEMs. Ten (33.3%) of them was positive in the initial screening test. There were four (13.3%) patients with possible mitochondrial diseases, four (13.3%) patients with possible organic acidemia, one (3.3%) patient with possible urea cycle defect, and one (3.3%) patient with possible nonketotic hyperglycinemia. CONCLUSION Any case of unexplained acute encephalopathy presenting to the ED should be investigated for suspected IEM, especially in high-risk families, as early interventions will lead to improved outcome.
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Affiliation(s)
| | | | - Rania H Shatla
- Pediatric Department, Ain Shams University, Cairo, Egypt
| | | | - Riad M Elsayed
- Pediatric Neurology Unit, Pediatric Department, Mansoura University, Mansoura, Dakahlia, Egypt,
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5
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Kloesel B, Holzman RS. Anesthetic Management of Patients With Inborn Errors of Metabolism. Anesth Analg 2017; 125:822-836. [DOI: 10.1213/ane.0000000000001689] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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6
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Hope S, Johannessen CH, Aanonsen NO, Strømme P. The investigation of inborn errors of metabolism as an underlying cause of idiopathic intellectual disability in adults in Norway. Eur J Neurol 2015; 23 Suppl 1:36-44. [DOI: 10.1111/ene.12884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2015] [Indexed: 12/17/2022]
Affiliation(s)
- S. Hope
- Department of Neuro Habilitation; Oslo University Hospital, Ullevål; Oslo Norway
- NORMENT; KG Jebsen Centre for Psychosis Research; Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - C. H. Johannessen
- Department of Neuro Habilitation; Oslo University Hospital, Ullevål; Oslo Norway
| | - N. O. Aanonsen
- Department of Neuro Habilitation; Oslo University Hospital, Ullevål; Oslo Norway
| | - P. Strømme
- Department of Clinical Neurosciences for Children; Women and Children′s Division; Oslo University Hospital, Ullevål; Oslo Norway
- University of Oslo; Oslo Norway
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Abstract
Although individual metabolic diseases are relatively uncommon, inherited metabolic diseases collectively represent a more common cause of disease in the neonatal period than is generally appreciated. Newborn screening is among the most successful public health programs today. Every day, newborns considered to be at risk for hypoglycemia are screened. The definition of clinically significant hypoglycemia remains among the most confused and contentious issues in neonatology. There are 2 "competing" methods of defining hypoglycemia that suggest very different levels for management: one based on metabolic-endocrinologic hormones and another that uses outcome data to determine threshold levels of risk.
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Affiliation(s)
- David H Adamkin
- Division of Neonatal Medicine, Department of Pediatrics, University of Louisville, 571 South Floyd Street, Suite 342, Louisville, KY 40202, USA.
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Abstract
An estimated 10% to 40% of children with epilepsy have treatment-resistant epilepsy. Persistent seizures have negative psychosocial, behavioral, cognitive, and financial consequences and are associated with an increased mortality rate. Accurate syndromic and etiologic diagnoses are of vital importance because they may guide medical and/or surgical decision making. Revisitation of the history to confirm the diagnosis of epilepsy and the appropriateness of medication trials to date is vital. Routine imaging should include structural magnetic resonance imaging (MRI) with an established epilepsy protocol. In the setting of a normal previous MRI, repeat imaging may be indicated and may be supplemented with other imaging modalities. The admission for prolonged inpatient video-encephalographic monitoring may lead to a revision of a pre-existing diagnosis. Laboratory evaluations should include genetic, metabolic, and infectious/inflammatory studies when indicated. In this review, we discuss the implication of seizure semiology and syndrome classification when searching for an underlying diagnosis in treatment-resistant epilepsy, and will review both basic and more advanced procedures/studies that may aid diagnosis.
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Affiliation(s)
- Karen L Skjei
- Pediatric Regional Epilepsy Program, Division of Neurology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, USA.
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Nott L, Price TJ, Pittman K, Patterson K, Fletcher J. Hyperammonemia encephalopathy: an important cause of neurological deterioration following chemotherapy. Leuk Lymphoma 2007; 48:1702-11. [PMID: 17786705 DOI: 10.1080/10428190701509822] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Idiopathic hyperammonemic encephalopathy is an uncommon but frequently fatal complication of chemotherapy. It is characterised by abrupt alteration in mental status with markedly elevated plasma ammonia levels in the absence of obvious liver disease or any other identifiable cause, and frequently results in intractable coma and death. It usually occurs in patients with haematologic malignancies during the period of neutropenia following cytoreductive therapy or bone marrow transplantation, and in solid organ malignancies treated with 5-fluorouracil. Although the aetiology of this syndrome is yet to be determined, it appears to be multi-factorial in nature. Optimal management remains to be formally established, and the critical step is increased awareness of the syndrome by measurement of plasma ammonium levels in patients with neurological symptoms, leading to early diagnosis and the prompt implementation of therapy.
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Affiliation(s)
- Louise Nott
- Department of Oncology, The Queen Elizabeth Hospital, Woodville, Australia
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11
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Brustolin S, Souza C, Puga AC, Refosco L, Pires R, Peres R, Giugliani R. Assessment of a Pioneer Metabolic Information Service in Brazil. Public Health Genomics 2006; 9:127-32. [PMID: 16612064 DOI: 10.1159/000091494] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The Information Service on Inborn Errors of Metabolism (SIEM), a pioneer toll-free service in both Brazil and South America, is based in Porto Alegre, Southern Brazil. SIEM has been operating since October 2001 providing support to health care professionals involved in the diagnosis and management of suspected metabolic diseases. We analyzed the demographic and clinical characteristics of the 376 consults received and followed in the first two and half years of SIEM. Our results show that the suspicion of a metabolic disease was most often associated with neurological symptoms. Among the consults, 24.4% were eventually confirmed as inborn errors of metabolism (IEM), with organic acidurias and amino acid disorders being the two most frequent diagnostic groups. Our conclusion shows this kind of service to provide helpful support to the diagnosis and acute management of IEM, especially to health professionals working in developing countries who are often far from reference centers.
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Affiliation(s)
- Silvia Brustolin
- Information Service on Inborn Errors of Metabolism (SIEM), Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
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12
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Abstract
The Oct-4 gene encodes a transcription factor that is expressed in embryonic stem (ES) cells and germ cells. Oct-4 is known to function as a transcriptional activator of genes involved in maintaining an undifferentiated totipotent state and possibly in preventing expression of genes activated during differentiation. In addition, it is a putative proto-oncogene and a critical player in the genesis of human testicular germ cell tumors. Although much effort has gone toward characterizing Oct-4, there is still little known about the molecular mechanisms and the proteins that regulate Oct-4 function. To identify cofactors that control Oct-4 function in vivo, we used a recently developed bacterial two-hybrid screening system and isolated a novel ES cell-derived cDNA encoding Ewing's sarcoma protein (EWS). EWS is a proto-oncogene and putative RNA-binding protein involved in human cancers. By using glutathione-S-transferase (GST) pull-down assays, we were able to confirm the interaction between Oct-4 and EWS in vitro, and moreover, coimmunoprecipitation and colocalization studies have shown that these proteins also associate in vivo. We have mapped the EWS-interacting region to the POU domain of Oct-4. In addition, three independent sites on EWS are involved in binding to Oct-4. In this study, we report that Oct-4 and EWS are coexpressed in the pluripotent mouse and human ES cells. Consistent with its ability to bind to and colocalize with Oct-4, ectopic expression of EWS enhances the transactivation ability of Oct-4. Moreover, a chimeric protein generated by fusion of EWS (1-295) to the GAL4 DNA-binding domain significantly increases promoter activity of a reporter containing GAL4 DNA-binding sites, suggesting the presence of a strong activation domain within EWS. Taken together, our results suggest that Oct-4-mediated transactivation is stimulated by EWS.
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MESH Headings
- Amino Acid Motifs
- Animals
- Blotting, Northern
- Blotting, Western
- COS Cells
- Cell Line
- Cell Line, Tumor
- Cell Nucleus/metabolism
- DNA, Complementary/metabolism
- DNA-Binding Proteins/biosynthesis
- Embryo, Mammalian/cytology
- Gene Expression Regulation, Neoplastic
- Gene Library
- Genes, Reporter
- Glutathione Transferase/metabolism
- Histidine/chemistry
- Humans
- Immunoprecipitation
- Mice
- NIH 3T3 Cells
- Octamer Transcription Factor-3
- Promoter Regions, Genetic
- Protein Binding
- Protein Biosynthesis
- Protein Structure, Tertiary
- Proto-Oncogene Mas
- RNA/metabolism
- RNA-Binding Protein EWS/metabolism
- RNA-Binding Protein EWS/physiology
- Stem Cells/cytology
- Transcription Factors/biosynthesis
- Transcription, Genetic
- Transcriptional Activation
- Two-Hybrid System Techniques
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Affiliation(s)
- Jungwoon Lee
- Laboratory of Molecular and Cellular Biology, Department of Life Science, Sogang University, Seoul 121-742, Korea
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13
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Colletti JE, Homme JL, Woodridge DP. Unsuspected neonatal killers in emergency medicine. Emerg Med Clin North Am 2004; 22:929-60. [PMID: 15474777 DOI: 10.1016/j.emc.2004.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A neonate presenting to the emergency department can present a challenge to even the most experienced clinician. This article has focused on four deceiving and potentially devastating neonatal diseases. 1. Neonatal herpes is a potentially devastating illness without pathognomonic signs or symptoms. Early recognition and therapy can reduce mortality markedly. Although no specific sign or symptom is diagnostic,the diagnosis should be strongly considered in the presence of HSV risk factors, atypical sepsis, unexplained acute hepatitis, or focal seizure activity. Acyclovir therapy should be initiated before viral dissemination or significant CNS replication occurs. 2. Pertussis is a disease in which infants are at greatest risk of death or severe complication. Neonatal pertussis often presents in an atypical manner, lacking the classic signs and symptoms such as the "whoop."More common signs and symptoms include cough, feeding difficulty,low-grade fever, emesis, increasing respiratory distress, apnea, cyanosis,and seizures. Management should include hospitalization, supportive care, and antibiotics. 3. Congenital heart defects, particularly ductal-dependent lesions, may have an initial asymptomatic period that culminates in a rapidly progressive and fatal course. A neonate with CHD presents with shock refractory to volume resuscitation or pressor support. Resuscitative efforts are ineffective unless PGE, is administered. 4. Inborn errors of metabolism often are unsuspected because of their protean and heterogeneous nature. Signs and symptoms are subtle,are nonspecific, and often mimic other, more common diseases.An elevated index of suspicion, along with application and correct interpretation of a select few laboratory tests, is the key to making a diagnosis. Therapy is relatively straightforward and focused on resuscitation followed by prevention of catabolism and correction of specifically identified abnormalities. Although these disorders are relatively uncommon, prompt diagnosis and therapy can lead to a decrease in morbidity and mortality. The key is to maintain a high index of suspicion.
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MESH Headings
- Diagnosis, Differential
- Electrocardiography
- Electroencephalography
- Emergency Medicine/methods
- Emergency Treatment/methods
- Fluorescent Antibody Technique, Direct
- Heart Defects, Congenital/diagnosis
- Heart Defects, Congenital/epidemiology
- Heart Defects, Congenital/etiology
- Heart Defects, Congenital/therapy
- Herpes Simplex/diagnosis
- Herpes Simplex/epidemiology
- Herpes Simplex/etiology
- Herpes Simplex/therapy
- Humans
- Infant Mortality
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/epidemiology
- Infant, Newborn, Diseases/etiology
- Infant, Newborn, Diseases/therapy
- Intensive Care, Neonatal/methods
- Metabolism, Inborn Errors/diagnosis
- Metabolism, Inborn Errors/epidemiology
- Metabolism, Inborn Errors/etiology
- Metabolism, Inborn Errors/therapy
- Morbidity
- Neonatal Screening
- Oximetry
- Polymerase Chain Reaction
- Resuscitation/methods
- Risk Factors
- Time Factors
- United States/epidemiology
- Whooping Cough/diagnosis
- Whooping Cough/epidemiology
- Whooping Cough/etiology
- Whooping Cough/therapy
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Affiliation(s)
- James E Colletti
- Department of Pediatric and Adolescent Medicine, Mayo Medical School, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Pardini RS, Sapien RE. Trimethylaminuria (fish odor syndrome) related to the choline concentration of infant formula. Pediatr Emerg Care 2003; 19:101-3. [PMID: 12698036 DOI: 10.1097/00006565-200304000-00010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ricci S Pardini
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
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15
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Joshi SN, Hashim J, Venugopalan P. Pattern of inborn errors of metabolism in an Omani population of the Arabian Peninsula. ANNALS OF TROPICAL PAEDIATRICS 2002; 22:93-6. [PMID: 11926058 DOI: 10.1179/027249302125000238] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
We analysed all patients < 18 years of age diagnosed with inborn errors of metabolism (IEM) in the Metabolic Division, Sultan Qaboos University Hospital, Muscat, Oman from June 1998 to December 2000. A total of 82 patients from 76 families were studied, of whom 33 (40%) were aged < 1 week at presentation. Disorders identified included different lysosomal storage disorders (22), organic acidurias (9), carbohydrate metabolic disorders (9), congenital lactic acidosis (9), urea cycle disorders (8), amino acidopathies (8), fatty acid oxidation defects (7/82) and various other miscellaneous disorders (10). Tandem mass spectrometry helped in the diagnosis of 26 (32%) cases. Parental consanguinity was twice as frequent in the study patients as in the general population. Duration of follow-up ranged from 1 to 30 months (median 15) during which time 46/56 (82%) patients with disorders amenable to specific dietary and drug therapy available in Oman were free from frequent exacerbation. Our study shows the relevance of identifying patients with IEM in Oman and the need to establish screening for the conditions identified and provide effective management protocols.
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Affiliation(s)
- S N Joshi
- Division of Genetic & Metabolic Diseases, Sultan Qaboos University Hospital, Muscat, Oman.
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