1
|
Moirangthem A, Saxena D, Masih S, Shambhavi A, Nilay M, Phadke SR. Variable neurological phenotypes of homocystinuria caused by biallelic methylenetetrahydrofolate reductase variants. Clin Dysmorphol 2022; 31:59-65. [PMID: 34845156 DOI: 10.1097/mcd.0000000000000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Inherited methylenetetrahydrofolate reductase (MTHFR) deficiency is associated with a wide spectrum of disorders including homocystinuria. This study aims to describe the neurological phenotypes and molecular profiles of patients with homocystinuria caused by biallelic variants in MTHFR. We report six subjects with MTHFR deficiency who presented with variable neurological phenotypes which could be viewed as a continuous spectrum. Fatal infantile encephalopathy was observed in one family, whereas another patient presented at 27 years with acute leukoencephalopathy and recovered within 3 months. Intermediate forms presenting as complicated hereditary spastic paraparesis of variable severity were observed in four subjects. Clinical and molecular information of the 207 cases reported in literature were also retrieved and analyzed. We categorized all subjects into three categories - severe, intermediate and mild forms according to the clinical presentation. In addition, a total of 286 disease-causing variations reported to date were analyzed. These included seven disease-causing variants reported in this study of which one is novel. Some genotype-phenotype correlation could be seen which corroborated with previous observations. However, inter- and intrafamilial variability was also noted. Treatment with betaine, B12 and folic acid was started in four subjects with variable outcomes.
Collapse
Affiliation(s)
- Amita Moirangthem
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | | | | | | | | | | |
Collapse
|
2
|
Sudheer P, Agarwal A, Garg A, Padma Srivastava MV, Vishnu VY. MTHFR Deficiency: A Potentially Treatable Cause of Adult-Onset Hereditary Spastic Paraparesis. Ann Indian Acad Neurol 2022; 25:300-301. [PMID: 35693677 PMCID: PMC9175398 DOI: 10.4103/aian.aian_340_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/26/2021] [Accepted: 08/06/2021] [Indexed: 12/02/2022] Open
Affiliation(s)
- Pachipala Sudheer
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ayush Agarwal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | | | | |
Collapse
|
3
|
Marelli C, Lavigne C, Stepien KM, Janssen MCH, Feillet F, Kožich V, Jesina P, Schule R, Kessler C, Redonnet-Vernhet I, Regnier A, Burda P, Baumgartner M, Benoist JF, Huemer M, Mochel F. Clinical and molecular characterization of adult patients with late-onset MTHFR deficiency. J Inherit Metab Dis 2021; 44:777-786. [PMID: 33089527 DOI: 10.1002/jimd.12323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 10/13/2020] [Accepted: 10/20/2020] [Indexed: 11/07/2022]
Abstract
5,10-Methylenetetrahydrofolate reductase (MTHFR) deficiency usually presents as a severe neonatal disease. This study aimed to characterize natural history, biological and molecular data, and response to treatment of patients with late-onset MTHFR deficiency. The patients were identified through the European Network and Registry for Homocystinuria and Methylation Defects and the Adult group of the French Society for Inherited Metabolic Diseases; data were retrospectively colleted. To identify juvenile to adult-onset forms of the disease, we included patients with a diagnosis established after the age of 10 years. We included 14 patients (median age at diagnosis: 32 years; range: 11-54). At onset (median age: 20 years; range 9-38), they presented with walking difficulties (n = 8), cognitive decline (n = 3) and/or seizures (n = 3), sometimes associated with mild mental retardation (n = 6). During the disease course, symptoms were almost exclusively neurological with cognitive dysfunction (93%), gait disorders (86%), epilepsy (71%), psychiatric symptoms (57%), polyneuropathy (43%), and visual deficit (43%). Mean diagnostic delay was 14 years. Vascular events were observed in 28% and obesity in 36% of the patients. One patient remained asymptomatic at the age of 55 years. Upon treatment, median total homocysteine decreased (from 183 μmol/L, range 69-266, to 90 μmol/L, range 20-142) and symptoms improved (n = 9) or stabilized (n = 4). Missense pathogenic variants in the C-terminal regulatory domain of the protein were over-represented compared to early-onset cases. Residual MTHFR enzymatic activity in skin fibroblasts (n = 4) was rather high (17%-58%). This series of patients with late-onset MTHFR deficiency underlines the still unmet need of a prompt diagnosis of this treatable disease.
Collapse
Affiliation(s)
- Cecilia Marelli
- Expert Centre for Neurogenetic Diseases and Adult Mitochondrial and Metabolic Diseases, Univ Montpellier, CHU, Montpellier, France
- MMDN, Univ Montpellier, EPHE, INSERM, Montpellier, France
| | - Christian Lavigne
- Internal Medicine Department, Angers University Hospital, Angers, France
| | - Karolina M Stepien
- Adult Inherited Metabolic Diseases, Salford Royal NHS Foundation Trust, Salford Care Organisation, Northern Care Alliance, Salford, UK
| | - Mirian C H Janssen
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Francois Feillet
- Reference Center for Inborn Errors of Metabolism, Pediatric unit, University Hospital of Nancy, Nancy, France
- INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Faculty of Medicine of Nancy, Nancy, France
| | - Viktor Kožich
- Department of Pediatrics and Inherited Metabolic Disorders, Charles University-First Faculty of Medicine and General University Hospital in Prague, Praha 2, Czech Republic
| | - Pavel Jesina
- Department of Pediatrics and Inherited Metabolic Disorders, Charles University-First Faculty of Medicine and General University Hospital in Prague, Praha 2, Czech Republic
| | - Rebecca Schule
- Department of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Tübingen, Germany
- German Center for Neurodegenerative Diseases, Tübingen, Germany
| | - Christoph Kessler
- Department of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Tübingen, Germany
- German Center for Neurodegenerative Diseases, Tübingen, Germany
| | - Isabelle Redonnet-Vernhet
- lNSERM U1211, Université de Bordeaux, Bordeaux, France
- Laboratoire de Biochimie, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Centre de référence pour les maladies mitochondriales de l'enfant à l'adulte (CARAMMEL), Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Adeline Regnier
- Department of General Practice, Faculty of Medicine of Clermont-Ferrand, Clermont-Ferrand, France
| | - Patricie Burda
- Division of Metabolism and Children's Research Center, University Children's Hospital, Zürich, Switzerland
| | - Matthias Baumgartner
- Division of Metabolism and Children's Research Center, University Children's Hospital, Zürich, Switzerland
| | - Jean-Francois Benoist
- Biochemistry Laboratory Robert-Debré University Hospital, APHP, Paris, France
- LYPSIS2, Université Paris-Saclay, Chatenay-Malabry, France
| | - Martina Huemer
- Division of Metabolism and Children's Research Center, University Children's Hospital, Zürich, Switzerland
- Department of Paediatrics Landeskrankenhaus Bregenz, Austria
| | - Fanny Mochel
- APHP, La Pitié-Salpêtrière University Hospital, Department of Genetics, Paris, France
- Inserm U 1127, CNRS UMR 7225, Sorbonne Universités, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
- APHP, La Pitié-Salpêtrière University Hospital, Reference Center for Adult Neurometabolic diseases, Paris, France
| |
Collapse
|
4
|
Methylenetetrahydrofolate Reductase Deficiency as a Cause of Treatable Adult-onset Leukoencephalopathy and Myelopathy. Clin Neuroradiol 2020; 31:277-281. [PMID: 32880657 DOI: 10.1007/s00062-020-00947-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 07/31/2020] [Indexed: 10/23/2022]
|
5
|
Perna A, Masciullo M, Modoni A, Cellini E, Parrini E, Ricci E, Donati AM, Silvestri G. Severe 5,10‐methylenetetrahydrofolate reductase deficiency: a rare, treatable cause of complicated hereditary spastic paraplegia. Eur J Neurol 2018; 25:602-605. [DOI: 10.1111/ene.13557] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 12/18/2017] [Indexed: 12/01/2022]
Affiliation(s)
- A. Perna
- Institute of Neurology Catholic University of Sacred Heart (UCSC) Fondazione Policlinico Gemelli Rome
| | | | - A. Modoni
- Institute of Neurology Catholic University of Sacred Heart (UCSC) Fondazione Policlinico Gemelli Rome
| | - E. Cellini
- Laboratory of Neurogenetics Pediatric Neurology Unit A. Meyer Children's Hospital Florence
| | - E. Parrini
- Laboratory of Neurogenetics Pediatric Neurology Unit A. Meyer Children's Hospital Florence
| | - E. Ricci
- Institute of Neurology Catholic University of Sacred Heart (UCSC) Fondazione Policlinico Gemelli Rome
| | - A. M. Donati
- Metabolic and Neuromuscular Unit A. Meyer Children's Hospital Florence Italy
| | - G. Silvestri
- Institute of Neurology Catholic University of Sacred Heart (UCSC) Fondazione Policlinico Gemelli Rome
| |
Collapse
|
6
|
Rommer PS, Zschocke J, Fowler B, Födinger M, Konstantopoulou V, Möslinger D, Stögmann E, Suess E, Baumgartner M, Auff E, Sunder-Plassmann G. Manifestations of neurological symptoms and thromboembolism in adults with MTHFR-deficiency. J Neurol Sci 2017; 383:123-127. [DOI: 10.1016/j.jns.2017.10.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 09/25/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022]
|
7
|
Iida S, Nakamura M, Asayama S, Kunieda T, Kaneko S, Osaka H, Kusaka H. Rapidly progressive psychotic symptoms triggered by infection in a patient with methylenetetrahydrofolate reductase deficiency: a case report. BMC Neurol 2017; 17:47. [PMID: 28241805 PMCID: PMC5330085 DOI: 10.1186/s12883-017-0827-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 02/20/2017] [Indexed: 12/01/2022] Open
Abstract
Background Methylenetetrahydrofolate reductase (MTHFR) deficiency is a rare inborn error of metabolism inherited in autosomal recessive pattern and is associated with a wide spectrum of neurological abnormalities. Case presentation We herein describe a 15-year-old boy with MTHFR deficiency who presented with a slowly progressive decline of school performance and a spastic gait. Rapidly deteriorating psychosis and repetitive seizures triggered by a febrile infection prompted neurological investigation. He had significantly elevated total plasma homocysteine and urinary homocystine levels, as well as a decreased plasma methionine level. Brain magnetic resonance imaging (MRI) revealed leukoencephalopathy. DNA gene sequencing showed c.446_447 del GC ins TT and c.137G > A, and c.665C > T heterozygous mutations in the MTHFR gene of the patient. Oral administration of betaine drastically improved his clinical symptoms within a few months. After 8 months of treatment, his total plasma homocysteine level moderately decreased; and the plasma methionine concentration became normalized. Furthermore, the white matter lesions on MRI had disappeared. Conclusion This patient demonstrates the possibility that MTHFR deficiency should be considered in mentally retarded adolescents who display an abnormally elevated plasma level of homocysteine in association with progressive neurological dysfunction and leukoencephalopathy. Febrile infections may be an aggravating factor in patients with MTHFR deficiency.
Collapse
Affiliation(s)
- Shin Iida
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 5731010, Japan
| | - Masataka Nakamura
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 5731010, Japan.
| | - Shinya Asayama
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 5731010, Japan
| | - Takenobu Kunieda
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 5731010, Japan
| | - Satoshi Kaneko
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 5731010, Japan
| | - Hitoshi Osaka
- Department of Pediatrics, Jichi Medical School, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 3290498, Japan
| | - Hirofumi Kusaka
- Department of Neurology, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, 5731010, Japan
| |
Collapse
|
8
|
Huemer M, Diodato D, Schwahn B, Schiff M, Bandeira A, Benoist JF, Burlina A, Cerone R, Couce ML, Garcia-Cazorla A, la Marca G, Pasquini E, Vilarinho L, Weisfeld-Adams JD, Kožich V, Blom H, Baumgartner MR, Dionisi-Vici C. Guidelines for diagnosis and management of the cobalamin-related remethylation disorders cblC, cblD, cblE, cblF, cblG, cblJ and MTHFR deficiency. J Inherit Metab Dis 2017; 40:21-48. [PMID: 27905001 PMCID: PMC5203859 DOI: 10.1007/s10545-016-9991-4] [Citation(s) in RCA: 169] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 09/28/2016] [Accepted: 10/04/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Remethylation defects are rare inherited disorders in which impaired remethylation of homocysteine to methionine leads to accumulation of homocysteine and perturbation of numerous methylation reactions. OBJECTIVE To summarise clinical and biochemical characteristics of these severe disorders and to provide guidelines on diagnosis and management. DATA SOURCES Review, evaluation and discussion of the medical literature (Medline, Cochrane databases) by a panel of experts on these rare diseases following the GRADE approach. KEY RECOMMENDATIONS We strongly recommend measuring plasma total homocysteine in any patient presenting with the combination of neurological and/or visual and/or haematological symptoms, subacute spinal cord degeneration, atypical haemolytic uraemic syndrome or unexplained vascular thrombosis. We strongly recommend to initiate treatment with parenteral hydroxocobalamin without delay in any suspected remethylation disorder; it significantly improves survival and incidence of severe complications. We strongly recommend betaine treatment in individuals with MTHFR deficiency; it improves the outcome and prevents disease when given early.
Collapse
Affiliation(s)
- Martina Huemer
- Division of Metabolism and Children's Research Center, University Childrens' Hospital Zürich, Zurich, Switzerland
- radiz - Rare Disease Initiative Zürich, Clinical Research Priority Program, University of Zürich, Zurich, Switzerland
- Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria
| | - Daria Diodato
- Division of Metabolism, Bambino Gesù Children's Research Hospital, Rome, Italy
| | - Bernd Schwahn
- Willink Biochemical Genetics Unit, Saint Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Manuel Schiff
- Reference Center for Inborn Errors of Metabolism, Robert Debré University Hospital, APHP, Paris, France
- Inserm U1141, Robert Debré Hospital, Paris, France
- Université Paris-Diderot, Sorbonne Paris Cité, site Robert Debré, Paris, France
| | | | - Jean-Francois Benoist
- Reference Center for Inborn Errors of Metabolism, Robert Debré University Hospital, APHP, Paris, France
- Inserm U1141, Robert Debré Hospital, Paris, France
- Biochimie, faculté de pharmacie, Université Paris Sud, Paris, France
| | - Alberto Burlina
- Division of Inherited Metabolic Diseases, Department of Pediatrics, University Hospital Padova, Padova, Italy
| | - Roberto Cerone
- University Dept of Pediatrics, Giannina Gaslini Institute, Genoa, Italy
| | - Maria L Couce
- Congenital Metabolic Diseases Unit, Hospital Clínico Universitario de Santiago de Compostela, IDIS, CIBER, Compostela, Spain
| | - Angeles Garcia-Cazorla
- Department of Neurology, Neurometabolism Unit, and CIBERER (ISCIII), Hospital Sant Joan de Deu, Barcelona, Spain
| | - Giancarlo la Marca
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firence, Italy
| | - Elisabetta Pasquini
- Metabolic and Newborn Screening Clinical Unit, Department of Neurosciences, A. Meyer Children's University Hospital, Florence, Italy
| | - Laura Vilarinho
- Newborn Screening, Metabolism & Genetics Unit, National Institute of Health, Porto, Portugal
| | - James D Weisfeld-Adams
- Section of Clinical Genetics and Metabolism, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
- Inherited Metabolic Diseases Clinic, Childrens Hospital Colorado, Aurora, CO, USA
| | - Viktor Kožich
- Institute of Inherited Metabolic Disorders, Charles University-First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Henk Blom
- Laboratory of Clinical Biochemistry and Metabolism, Center for Pediatrics and Adolescent Medicine University Hospital, Freiburg, Freiburg, Germany
| | - Matthias R Baumgartner
- Division of Metabolism and Children's Research Center, University Childrens' Hospital Zürich, Zurich, Switzerland.
- radiz - Rare Disease Initiative Zürich, Clinical Research Priority Program, University of Zürich, Zurich, Switzerland.
| | - Carlo Dionisi-Vici
- Division of Metabolism, Bambino Gesù Children's Research Hospital, Rome, Italy.
| |
Collapse
|
9
|
Simons A, Eyskens F, Glazemakers I, van West D. Can psychiatric childhood disorders be due to inborn errors of metabolism? Eur Child Adolesc Psychiatry 2017; 26:143-154. [PMID: 27695954 PMCID: PMC5306168 DOI: 10.1007/s00787-016-0908-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 09/23/2016] [Indexed: 12/19/2022]
Abstract
Many patients who visit a centre for hereditary metabolic diseases remarkably also suffer from a child psychiatric disorder. Those child psychiatric disorders may be the first sign or manifestation of an underlying metabolic disorder. Lack of knowledge of metabolic disorders in child psychiatry may lead to diagnoses being missed. Patients therefore are also at risk for not accessing efficacious treatment and proper counselling. To search the literature for the co-occurrence of child psychiatric disorders, such as ADHD, autism, psychosis, learning disorders and eating disorders and metabolic disorders. A search of the literature was conducted by performing a broad search on PubMed, using the terms "ADHD and metabolic disorders", "autism and metabolic disorders", "psychosis and metabolic disorders", "learning disorders and metabolic disorders", and "eating disorders and metabolic disorders". Based on inclusion criteria (concerning a clear psychiatric disorder and concerning a metabolic disorder) 4441 titles and 249 abstracts were screened and resulted in 71 relevant articles. This thorough literature search provides child and adolescent psychiatrists with an overview of metabolic disorders associated with child psychiatric symptoms, their main characteristics and recommendations for further investigations.
Collapse
Affiliation(s)
- A. Simons
- Centre of Heriditary Metabolic Diseases Antwerp (CEMA), University Hospital of Antwerp (UZA), Wilrijkstraat, 2650 Edegem, Belgium ,Collaborative Antwerp Psychiatric Research Institute (CAPRI) Youth, Antwerp, Belgium ,University Child and Adolescent Psychiatry Antwerp, Lindendreef 1, 2020 Antwerp, Belgium
| | - F. Eyskens
- Centre of Heriditary Metabolic Diseases Antwerp (CEMA), University Hospital of Antwerp (UZA), Wilrijkstraat, 2650 Edegem, Belgium
| | - I. Glazemakers
- Collaborative Antwerp Psychiatric Research Institute (CAPRI) Youth, Antwerp, Belgium ,University Child and Adolescent Psychiatry Antwerp, Lindendreef 1, 2020 Antwerp, Belgium ,University of Antwerp (CAPRI), Universiteitsplein 1, 2610 Wilrijk, Belgium
| | - D. van West
- Collaborative Antwerp Psychiatric Research Institute (CAPRI) Youth, Antwerp, Belgium ,University of Brussels, Brussels, Belgium ,University Child and Adolescent Psychiatry Antwerp, Lindendreef 1, 2020 Antwerp, Belgium ,University of Antwerp (CAPRI), Universiteitsplein 1, 2610 Wilrijk, Belgium
| |
Collapse
|
10
|
Mutation Update and Review of Severe Methylenetetrahydrofolate Reductase Deficiency. Hum Mutat 2016; 37:427-38. [DOI: 10.1002/humu.22970] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 02/03/2016] [Indexed: 11/07/2022]
|
11
|
Huemer M, Mulder-Bleile R, Burda P, Froese DS, Suormala T, Zeev BB, Chinnery PF, Dionisi-Vici C, Dobbelaere D, Gökcay G, Demirkol M, Häberle J, Lossos A, Mengel E, Morris AA, Niezen-Koning KE, Plecko B, Parini R, Rokicki D, Schiff M, Schimmel M, Sewell AC, Sperl W, Spiekerkoetter U, Steinmann B, Taddeucci G, Trejo-Gabriel-Galán JM, Trefz F, Tsuji M, Vilaseca MA, von Kleist-Retzow JC, Walker V, Zeman J, Baumgartner MR, Fowler B. Clinical pattern, mutations and in vitro residual activity in 33 patients with severe 5, 10 methylenetetrahydrofolate reductase (MTHFR) deficiency. J Inherit Metab Dis 2016; 39:115-24. [PMID: 26025547 PMCID: PMC6551224 DOI: 10.1007/s10545-015-9860-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 04/28/2015] [Accepted: 04/29/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Severe methylenetetrahydrofolate reductase (MTHFR) deficiency is a rare inborn defect disturbing the remethylation of homocysteine to methionine (<200 reported cases). This retrospective study evaluates clinical, biochemical genetic and in vitro enzymatic data in a cohort of 33 patients. METHODS Clinical, biochemical and treatment data was obtained from physicians by using a questionnaire. MTHFR activity was measured in primary fibroblasts; genomic DNA was extracted from cultured fibroblasts. RESULTS Thirty-three patients (mean age at follow-up 11.4 years; four deceased; median age at first presentation 5 weeks; 17 females) were included. Patients with very low (<1.5%) mean control values of enzyme activity (n = 14) presented earlier and with a pattern of feeding problems, encephalopathy, muscular hypotonia, neurocognitive impairment, apnoea, hydrocephalus, microcephaly and epilepsy. Patients with higher (>1.7-34.8%) residual enzyme activity had mainly psychiatric symptoms, mental retardation, myelopathy, ataxia and spasticity. Treatment with various combinations of betaine, methionine, folate and cobalamin improved the biochemical and clinical phenotype. During the disease course, patients with very low enzyme activity showed a progression of feeding problems, neurological symptoms, mental retardation, and psychiatric disease while in patients with higher residual enzyme activity, myelopathy, ataxia and spasticity increased. All other symptoms remained stable or improved in both groups upon treatment as did brain imaging in some cases. No clear genotype-phenotype correlation was obvious. DISCUSSION MTHFR deficiency is a severe disease primarily affecting the central nervous system. Age at presentation and clinical pattern are correlated with residual enzyme activity. Treatment alleviates biochemical abnormalities and clinical symptoms partially.
Collapse
Affiliation(s)
- Martina Huemer
- Division of Metabolism and Children's Research Center, University Childrens' Hospital Zürich, Zürich, Switzerland
- radiz - Rare Disease Initiative Zürich, Clinical Research Priority Program, University of Zürich, Zürich, Switzerland
- Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria
| | | | - Patricie Burda
- Division of Metabolism and Children's Research Center, University Childrens' Hospital Zürich, Zürich, Switzerland
| | - D Sean Froese
- Division of Metabolism and Children's Research Center, University Childrens' Hospital Zürich, Zürich, Switzerland
| | - Terttu Suormala
- Division of Metabolism and Children's Research Center, University Childrens' Hospital Zürich, Zürich, Switzerland
| | - Bruria Ben Zeev
- Edmond and Lilly Safra Pediatric Hospital, Sheba Med Center and Sackler School of Medicine Tel Aviv, Tel Aviv, Israel
| | - Patrick F Chinnery
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Carlo Dionisi-Vici
- Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Dries Dobbelaere
- Centre de Référence Maladies Héréditaires du Métabolisme de l'enfant et de l'adulte, Hôpital Jeanne de Flandre, Lille, France
| | - Gülden Gökcay
- Istanbul Medical Faculty, Children's Hospital, Pediatric Nutrition and Metabolism, Istanbul University, Istanbul, Turkey
| | - Mübeccel Demirkol
- Istanbul Medical Faculty, Children's Hospital, Pediatric Nutrition and Metabolism, Istanbul University, Istanbul, Turkey
| | - Johannes Häberle
- Division of Metabolism and Children's Research Center, University Childrens' Hospital Zürich, Zürich, Switzerland
| | - Alexander Lossos
- Villa metabolica, Center for Pediatric and Adolescent Medicine, MC Johannes-Gutenberg-University Mainz, Mainz, Germany
| | - Eugen Mengel
- Villa metabolica, Center for Pediatric and Adolescent Medicine, MC Johannes-Gutenberg-University Mainz, Mainz, Germany
| | - Andrew A Morris
- Willink Unit, Manchester Centre for Genomic Medicine, Central Manchester University Hospitals, Manchester, UK
| | - Klary E Niezen-Koning
- Laboratory Metabolic Diseases, University Medical Center Groningen, Groningen, The Netherlands
| | - Barbara Plecko
- radiz - Rare Disease Initiative Zürich, Clinical Research Priority Program, University of Zürich, Zürich, Switzerland
- Division of Child Neurology and Children's Research Center, University Children's Hospital Zürich, Zürich, Switzerland
| | - Rossella Parini
- Unit for rare metabolic diseases, Department of Pediatrics, Fondazione MBBM/San Gerardo Hospital, Monza, Italy
| | - Dariusz Rokicki
- Department of Pediatrics, Nutrition and Metabolic Diseases, The Children's Memorial Health Institute, Warsaw, Poland
| | - Manuel Schiff
- Reference Center for Inborn Errors of Metabolism, Hôpital Robert Debré, APHP, INSERM U1141 and Université Paris-Diderot, Sorbonne Paris Cité, Paris, France
| | | | - Adrian C Sewell
- Department of Paediatrics, University Children's Hospital, Frankfurt am Main, Germany
- Bioscientia Institute for Laboratory Diagnostics, Ingelheim, Germany
| | - Wolfgang Sperl
- Department of Pediatrics, Paracelsus Medical University (PMU), Salzburg, Austria
| | - Ute Spiekerkoetter
- Department of General Pediatrics and Adolescent Medicine, University Children's Hospital, Freiburg, Germany
| | - Beat Steinmann
- Division of Metabolism and Children's Research Center, University Childrens' Hospital Zürich, Zürich, Switzerland
| | - Grazia Taddeucci
- Department of Pediatrics, Section of Paediatric Neurology, University of Pisa, Pisa, Italy
| | | | - Friedrich Trefz
- Department of Pediatrics, University of Heidelberg, Heidelberg, Germany
| | - Megumi Tsuji
- Department of Neuroscience, Jikei University School of Medicine, Minato, Tokyo, Japan
| | - María Antònia Vilaseca
- Laboratori de Malalties Metabòliques Hereditàrias, Hospital Sant Joan de Déu, Barcelona, Spain
| | | | - Valerie Walker
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jiri Zeman
- Department of Paediatrics, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Matthias R Baumgartner
- Division of Metabolism and Children's Research Center, University Childrens' Hospital Zürich, Zürich, Switzerland.
- radiz - Rare Disease Initiative Zürich, Clinical Research Priority Program, University of Zürich, Zürich, Switzerland.
| | - Brian Fowler
- Division of Metabolism and Children's Research Center, University Childrens' Hospital Zürich, Zürich, Switzerland.
- University Childrens' Hospital Basel (UKBB), Basel, Switzerland.
| |
Collapse
|
12
|
Outcomes of four patients with homocysteine remethylation disorders detected by newborn screening. Genet Med 2015; 18:162-7. [PMID: 25856670 DOI: 10.1038/gim.2015.45] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 02/23/2015] [Indexed: 01/21/2023] Open
Abstract
PURPOSE We evaluated the clinical outcome in homocysteine remethylation disorders following newborn screening (NBS) and initiation of early specific treatment. METHODS Five patients with remethylation disorders were included in this study. RESULTS Two asymptomatic patients (one with cblG and one with cblE) were identified by NBS using an approach that combines a postanalytical interpretive tool (available on the Region 4 Stork (R4S) collaborative project website, http://www.clir-r4s.org) and a second-tier test for total homocysteine determination. Both the initial screening and the second-tier test are performed on the same blood spot, with no additional patient contact, resulting in no false-positive outcomes. Two additional patients with methylenetetrahydrofolate reductase deficiency were detected by NBS using low methionine as a marker. Although already symptomatic despite the early diagnosis, the latter two patients greatly improved with treatment and their outcomes are compared with that of another patient with methylenetetrahydrofolate reductase deficiency and significant morbidity who was diagnosed clinically at 3 months of age. CONCLUSION Early detection by NBS and timely and specific treatment considerably improve at least short-term outcomes of homocysteine remethylation disorders. When a remethylation disorder is suspected, group-specific treatment could be started prior to the completion of in vitro confirmatory testing because all disorders from this group require similar intervention.
Collapse
|
13
|
Tamura A, Sasaki R, Kagawa K, Nakatani K, Osaka H, Tomimoto H. [Posterior-predominant leukoencephalopathy which was caused by methylenetetrahydrofolate reductase deficiency and successfully treated with folic acid]. Rinsho Shinkeigaku 2014; 54:200-206. [PMID: 24705833 DOI: 10.5692/clinicalneurol.54.200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
A 35-year-old woman was admitted with subacute intellectual deterioration. Laboratory studies showed elevated total homocysteine and decreased folic acid. MRI revealed leukoencephalopathy with a posterior predominance, and hyperintensity in the pyramidal tracts on T2-weighted and FLAIR images. The enzyme assay showed a deficiency of methylenetetrahydrofolate reductase (MTHFR) activity with low residual activity of 4.2% of the mean control value in cultured fibroblasts. Sequence analysis of the MTHFR gene demonstrated two homozygous missense mutations, c.677C>T (p.Ala222Val) and c.685A>C (p.Ile225Leu). c.677C>T (p.Ala222Val) is known as a common polymorphism and c.685A>C (p.Ile225Leu) is considered to be a novel polymorphism. A diagnosis of MTHFR deficiency was made. Treatment with folic acid, vitamin B12 and B6 made significant improvement of intellectual deterioration and reduction in the total homocysteine level. They also made marked resolution of leukoencephalopathy. Posterior-predominant leukoencephalopathy was found to be an excellent marker of MTHFR deficiency, and may help to establish the diagnosis.
Collapse
Affiliation(s)
- Asako Tamura
- Department of Neurology, Mie University Graduate School of Medicine
| | | | | | | | | | | |
Collapse
|
14
|
Sirrs SM, Lehman A, Stockler S, van Karnebeek CDM. Treatable inborn errors of metabolism causing neurological symptoms in adults. Mol Genet Metab 2013; 110:431-8. [PMID: 24427801 DOI: 10.1016/j.ymgme.2013.10.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The identification of inborn errors of metabolism (IEM) in adults presenting with a wide range of neurological symptoms is a relatively new field in medicine. We sought to identify which treatable IEM have been diagnosed for the first time in adults and generate a protocol for metabolic screening targeting those treatable disorders. METHODS Medline/Pubmed searches of English language literature limited to the adult age group were performed. Diseases identified through this search were then compared to previously published lists of treatable IEM in both adults and children. RESULTS 85% of the treatable conditions known to cause global developmental delay or intellectual disability in children had reports where the diagnosis of that IEM was made in one or more adult patients with neurological symptoms. Screening tests in blood, urine, CSF and MRI can detect most of these treatable conditions but the diagnostic accuracy of these screening tests in adults is not clear. CONCLUSION Treatable IEM need to be considered in the differential diagnosis of neurological symptoms in patients of any age.
Collapse
|
15
|
Walterfang M, Bonnot O, Mocellin R, Velakoulis D. The neuropsychiatry of inborn errors of metabolism. J Inherit Metab Dis 2013; 36:687-702. [PMID: 23700255 DOI: 10.1007/s10545-013-9618-y] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 04/29/2013] [Accepted: 04/30/2013] [Indexed: 12/15/2022]
Abstract
A number of metabolic disorders that affect the central nervous system can present in childhood, adolescence or adulthood as a phenocopy of a major psychiatric syndrome such as psychosis, depression, anxiety or mania. An understanding and awareness of secondary syndromes in metabolic disorders is of great importance as it can lead to the early diagnosis of such disorders. Many of these metabolic disorders are progressive and may have illness-modifying treatments available. Earlier diagnosis may prevent or delay damage to the central nervous system and allow for the institution of appropriate treatment and family and genetic counselling. Metabolic disorders appear to result in neuropsychiatric illness either through disruption of late neurodevelopmental processes (metachromatic leukodystrophy, adrenoleukodystrophy, GM2 gangliosidosis, Niemann-Pick type C, cerebrotendinous xanthomatosis, neuronal ceroid lipofuscinosis, and alpha mannosidosis) or via chronic or acute disruption of excitatory/inhibitory or monoaminergic neurotransmitter systems (acute intermittent porphyria, maple syrup urine disease, urea cycle disorders, phenylketonuria and disorders of homocysteine metabolism). In this manuscript we review the evidence for neuropsychiatric illness in major metabolic disorders and discuss the possible models for how these disorders result in psychiatric symptoms. Treatment considerations are discussed, including treatment resistance, the increased propensity for side-effects and the possibility of some treatments worsening the underlying disorder.
Collapse
Affiliation(s)
- Mark Walterfang
- Melbourne Neuropsychiatry Centre, University of Melbourne and Melbourne Health, Parkville, Australia.
| | | | | | | |
Collapse
|
16
|
Urreizti R, Moya-García AA, Pino-Ángeles A, Cozar M, Langkilde A, Fanhoe U, Esteves C, Arribas J, Vilaseca MA, Pérez-Dueñas B, Pineda M, González V, Artuch R, Baldellou A, Vilarinho L, Fowler B, Ribes A, Sánchez-Jiménez F, Grinberg D, Balcells S. Molecular characterization of five patients with homocystinuria due to severe methylenetetrahydrofolate reductase deficiency. Clin Genet 2010; 78:441-8. [DOI: 10.1111/j.1399-0004.2010.01391.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|