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Doğruel H, Aydemir M, Yılmaz N, Sarı R. An extremely rare case of hypoglycemia with a novel mutation and review of the literature: fructose-1,6 bisphosphatase deficiency in an adult man. Ir J Med Sci 2024; 193:1267-1273. [PMID: 38273074 DOI: 10.1007/s11845-024-03614-8] [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: 12/22/2023] [Accepted: 01/16/2024] [Indexed: 01/27/2024]
Abstract
Hypoglycemia is an uncommon clinical problem among non-diabetic patients. It requires systematic evaluation to determine the etiology. It may be related to critical illness, hepatic insufficiency, renal insufficiency, cardiac insufficiency, drugs, alcohol, cortisol insufficiency, growth hormone insufficiency, insulinoma, gastric bypass surgery, and paraneoplastic (insulin-like growth factor-2-related) immune-mediated or inherited metabolic disorders. We aimed to summarize the literature and present a case who suffered from hypoglycemia throughout his life and was diagnosed with fructose-1, 6 bisphosphatase deficiency in adulthood to attract attention to the rare causes of hypoglycemia in adulthood.
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Affiliation(s)
- Hakan Doğruel
- Endocrinology and Metabolism, Antalya City Hospital, Antalya, 07080, Turkey
| | - Mustafa Aydemir
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, 07070, Turkey
| | - Nusret Yılmaz
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, 07070, Turkey.
| | - Ramazan Sarı
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, 07070, Turkey
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2
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Elghobashy M, Gama R, Sulaiman RA. Investigation and Causes of Spontaneous (Non-Diabetic) Hypoglycaemia in Adults: Pitfalls to Avoid. Diagnostics (Basel) 2023; 13:3275. [PMID: 37892096 PMCID: PMC10606153 DOI: 10.3390/diagnostics13203275] [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: 09/07/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
Although adult spontaneous (non-diabetic) hypoglycaemia is rare, its recognition is important for the preventative or curative treatment of the underlying cause. Establishing Whipple's triad-low blood glucose, neuroglycopaenia and resolution of neuroglycopaenia on increasing blood glucose levels to normal or above-is essential to verify hypoglycaemia. Awareness that hypoglycaemia may occur in severely ill patients is important for its prevention. Further investigation in such cases is unnecessary unless another cause of hypoglycaemia is suspected. Patients are often asymptomatic and normoglycaemic at review. Their history of medication, self-medication, access to hypoglycaemic drugs, alcohol use and comorbidity may provide aetiological clues. The investigation involves obtaining blood samples during symptoms for laboratory glucose measurement or provoking fasting or postprandial hypoglycaemia as directed by symptoms. If confirmed, insulin, c-peptide, proinsulin and beta-hydroxybutyrate are analysed in hypoglycaemic samples. These will classify hypoglycaemia due to non-ketotic hyperinsulinaemia, non-ketotic hypoinsulinaemia and ketotic hypoinsulinaemia, and direct investigations to identify the underlying cause. There are, however, many pitfalls that may mislabel healthy individuals as "hypoglycaemic" or misdiagnose treatable or preventable causes of spontaneous hypoglycaemia. Clinical acumen and appropriate investigations will mostly identify hypoglycaemia and its cause.
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Affiliation(s)
- Maiar Elghobashy
- Clinical Chemistry, Black Country Pathology Services, Royal Wolverhampton Trust, Wolverhampton WV10 0QP, UK; (M.E.); (R.G.)
| | - Rousseau Gama
- Clinical Chemistry, Black Country Pathology Services, Royal Wolverhampton Trust, Wolverhampton WV10 0QP, UK; (M.E.); (R.G.)
- School of Medicine and Clinical Practice, Wolverhampton University, Wolverhampton WV1 1LY, UK
| | - Raashda Ainuddin Sulaiman
- Department of Medical Genomics, Center for Genomic Medicine, King Faisal Specialist Hospital and Research Center, Riyadh 11211, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
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3
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Dieterle MP, Husari A, Prozmann SN, Wiethoff H, Stenzinger A, Röhrich M, Pfeiffer U, Kießling WR, Engel H, Sourij H, Steinberg T, Tomakidi P, Kopf S, Szendroedi J. Diffuse, Adult-Onset Nesidioblastosis/Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS): Review of the Literature of a Rare Cause of Hyperinsulinemic Hypoglycemia. Biomedicines 2023; 11:1732. [PMID: 37371827 DOI: 10.3390/biomedicines11061732] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Differential diagnosis of hypoglycemia in the non-diabetic adult patient is complex and comprises various diseases, including endogenous hyperinsulinism caused by functional β-cell disorders. The latter is also designated as nesidioblastosis or non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS). Clinically, this rare disease presents with unspecific adrenergic and neuroglycopenic symptoms and is, therefore, often overlooked. A combination of careful clinical assessment, oral glucose tolerance testing, 72 h fasting, sectional and functional imaging, and invasive insulin measurements can lead to the correct diagnosis. Due to a lack of a pathophysiological understanding of the condition, conservative treatment options are limited and mostly ineffective. Therefore, nearly all patients currently undergo surgical resection of parts or the entire pancreas. Consequently, apart from faster diagnosis, more elaborate and less invasive treatment options are needed to relieve the patients from the dangerous and devastating symptoms. Based on a case of a 23-year-old man presenting with this disease in our department, we performed an extensive review of the medical literature dealing with this condition and herein presented a comprehensive discussion of this interesting disease, including all aspects from epidemiology to therapy.
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Affiliation(s)
- Martin Philipp Dieterle
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Ayman Husari
- Department of Orthodontics, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Sophie Nicole Prozmann
- Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Hendrik Wiethoff
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Manuel Röhrich
- Department of Nuclear Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Uwe Pfeiffer
- Pfalzklinikum for Psychiatry and Neurology AdÖR, Weinstr. 100, 76889 Klingenmünster, Germany
| | | | - Helena Engel
- Cancer Immune Regulation Group, German Cancer Research Center, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Harald Sourij
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8010 Graz, Austria
- Interdisciplinary Metabolic Medicine Trials Unit, Medical University of Graz, 8010 Graz, Austria
| | - Thorsten Steinberg
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Pascal Tomakidi
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Stefan Kopf
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
| | - Julia Szendroedi
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
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Krawczyk S, Urbanska K, Biel N, Bielak MJ, Tarkowska A, Piekarski R, Prokurat AI, Pacholska M, Ben-Skowronek I. Congenital Hyperinsulinaemic Hypoglycaemia-A Review and Case Presentation. J Clin Med 2022; 11:jcm11206020. [PMID: 36294341 PMCID: PMC9604599 DOI: 10.3390/jcm11206020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/24/2022] [Accepted: 10/06/2022] [Indexed: 11/22/2022] Open
Abstract
Hyperinsulinaemic hypoglycaemia (HH) is the most common cause of persistent hypoglycaemia in infants and children with incidence estimated at 1 per 50,000 live births. Congenital hyperinsulinism (CHI) is symptomatic mostly in early infancy and the neonatal period. Symptoms range from ones that are unspecific, such as poor feeding, lethargy, irritability, apnoea and hypothermia, to more serious symptoms, such as seizures and coma. During clinical examination, newborns present cardiomyopathy and hepatomegaly. The diagnosis of CHI is based on plasma glucose levels <54 mg/dL with detectable serum insulin and C-peptide, accompanied by suppressed or low serum ketone bodies and free fatty acids. The gold standard in determining the form of HH is fluorine-18-dihydroxyphenyloalanine PET ((18)F-DOPA PET). The first-line treatment of CHI is diazoxide, although patients with homozygous or compound heterozygous recessive mutations responsible for diffuse forms of CHI remain resistant to this therapy. The second-line drug is the somatostatin analogue octreotide. Other therapeutic options include lanreotide, glucagon, acarbose, sirolimus and everolimus. Surgery is required in cases unresponsive to pharmacological treatment. Focal lesionectomy or near-total pancreatectomy is performed in focal and diffuse forms of CHI, respectively. To prove how difficult the diagnosis and management of CHI is, we present a case of a patient admitted to our hospital.
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Affiliation(s)
- Sylwia Krawczyk
- Department of Paediatric Endocrinology and Diabetology, Medical University of Lublin, 20-093 Lublin, Poland
| | - Karolina Urbanska
- Department of Paediatric Endocrinology and Diabetology, Medical University of Lublin, 20-093 Lublin, Poland
| | - Natalia Biel
- Department of Paediatric Endocrinology and Diabetology, Medical University of Lublin, 20-093 Lublin, Poland
| | - Michal Jakub Bielak
- Department of Paediatric Endocrinology and Diabetology, Medical University of Lublin, 20-093 Lublin, Poland
| | - Agata Tarkowska
- Department of Neonate and Infant Pathology, Medical University of Lublin, 20-093 Lublin, Poland
| | - Robert Piekarski
- Department of Paediatric Endocrinology and Diabetology, Medical University of Lublin, 20-093 Lublin, Poland
| | - Andrzej Igor Prokurat
- Department of Paediatric Surgery, Regional Children’s Hospital in Bydgoszcz, 85-667 Bydgoszcz, Poland
| | - Malgorzata Pacholska
- Department of Paediatric Surgery, Regional Children’s Hospital in Bydgoszcz, 85-667 Bydgoszcz, Poland
| | - Iwona Ben-Skowronek
- Department of Paediatric Endocrinology and Diabetology, Medical University of Lublin, 20-093 Lublin, Poland
- Correspondence:
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Sulaiman RA, Alali A, Hosaini S, Hussein M, Pasha F, Albogami M, Aamir Sheikh A, AlSayed M, Al-Owain M. Emergency management of critically ill adult patients with inherited metabolic disorders. Am J Emerg Med 2022; 55:138-142. [DOI: 10.1016/j.ajem.2022.02.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 02/09/2022] [Accepted: 02/24/2022] [Indexed: 10/18/2022] Open
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Mukherjee S, Ray SK. Inborn Errors of Metabolism Screening in Neonates: Current Perspective with Diagnosis and Therapy. Curr Pediatr Rev 2022; 18:274-285. [PMID: 35379134 DOI: 10.2174/1573396318666220404194452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 01/24/2022] [Accepted: 02/14/2022] [Indexed: 11/22/2022]
Abstract
Inborn errors of metabolism (IEMs) are rare hereditary or acquired disorders resulting from an enzymatic deformity in biochemical and metabolic pathways influencing proteins, fats, carbohydrate metabolism, or hampered some organelle function. Even though individual IEMs are uncommon, together, they represent a diverse class of genetic diseases, with new issues and disease mechanisms being portrayed consistently. IEM includes the extraordinary multifaceted nature of the fundamental pathophysiology, biochemical diagnosis, molecular level investigation, and complex therapeutic choices. However, due to the molecular, biochemical, and clinical heterogeneity of IEM, screening alone will not detect and diagnose all illnesses included in newborn screening programs. Early diagnosis prevents the emergence of severe clinical symptoms in the majority of IEM cases, lowering morbidity and death. The appearance of IEM disease can vary from neonates to adult people, with the more serious conditions showing up in juvenile stages along with significant morbidity as well as mortality. Advances in understanding the physiological, biochemical, and molecular etiologies of numerous IEMs by means of modalities, for instance, the latest molecular-genetic technologies, genome engineering knowledge, entire exome sequencing, and metabolomics, have prompted remarkable advancement in detection and treatment in modern times. In this review, we analyze the biochemical basis of IEMs, clinical manifestations, the present status of screening, ongoing advances, and efficiency of diagnosis in treatment for IEMs, along with prospects for further exploration as well as innovation.
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Affiliation(s)
- Sukhes Mukherjee
- Department of Biochemistry, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh-462020, India
| | - Suman Kumar Ray
- Independent Researcher, Bhopal, Madhya Pradesh-462020, India
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Selected 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors. A look into their use and potential in pre-diabetes and type 2 diabetes. Endocr Regul 2021; 55:182-192. [PMID: 34523296 DOI: 10.2478/enr-2021-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objectives. This review assesses the comparative safety and efficacy of selected 3-hydroxy-3-methylglutaric acid coenzyme A inhibitors (statins, cinnamic acids. 3-hydroxy-3-methyl glutaric acid) on the pre-onset type 2 diabetes (PT2D) and post-onset type 2 diabetes (T2D)-related cluster of seven features (central obesity, hyperglycemia, hypertension, dyslipidemia, pro-thrombosis, oxidation and inflammation). Methods. Google scholar and PubMed were searched for statin*, flaxseed lignan complex (FLC), cinnamic acid (CA)*, and 3-hydroxy-3-methylglutaric acid (HMGA) in conjunction with each of PT2D, T2D and the cluster of seven. An introduction was followed by findings or absence thereof on the impacts of each of statins, FLC, CAs and HMGA on each member of the cluster of seven. Results. Pravastatin manages three features in PT2D, while a number of the statins improve five in T2D. FLC is negative in PT2D but controls four in T2D; it is not clear if the CAs and HMGA in FLC play a role in this success. CAs have potential in six and HMGA has potential in three of the cluster of seven though yet CAs and HMGA are untested in PT2D and T2D in humans. There are safety concerns with some statins and HMGA but FLC and CAs appear safe in the doses and durations tested. Conclusions. Selected statins, FLC, CAs and HMGA can manage or have a potential to manage at least three features of the cluster of seven. Most of the literature-stated concerns are with select statins but there are concerns (one actual and two potential) with HMGA.
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8
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D'Imperio S, Monasky MM, Micaglio E, Negro G, Pappone C. Early Morning QT Prolongation During Hypoglycemia: Only a Matter of Glucose? Front Cardiovasc Med 2021; 8:688875. [PMID: 34046442 PMCID: PMC8144311 DOI: 10.3389/fcvm.2021.688875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/19/2021] [Indexed: 12/11/2022] Open
Affiliation(s)
- Sara D'Imperio
- Arrhythmology Department, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Emanuele Micaglio
- Arrhythmology Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Gabriele Negro
- Arrhythmology Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Carlo Pappone
- Arrhythmology Department, IRCCS Policlinico San Donato, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Lopes AA, Miranda AC, Maior MS, de Mello RV, Bandeira FA. Nesidioblastosis Associated with Pancreatic Heterotopia as a Differential Diagnosis of Hypoglycemia: A Literature Review and Case Report. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e922778. [PMID: 32624567 PMCID: PMC7360359 DOI: 10.12659/ajcr.922778] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patient: Male, 32-year-old Final Diagnosis: Nesidioblastosis Symptoms: Hypoglycemia Medication:— Clinical Procedure: Distal pancreatectomy • magnetic resonance image • selective arterial calcium stimulation test with hepatic venous sampling Specialty: Endocrinology and Metabolic
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Affiliation(s)
- Aline A Lopes
- Division of Endocrinology and Diabetes, Agamenon Magalhães Hospital, University of Pernambuco Medical School, Recife, PE, Brazil
| | - Ana C Miranda
- Division of Endocrinology and Diabetes, Agamenon Magalhães Hospital, University of Pernambuco Medical School, Recife, PE, Brazil
| | - Marcelo S Maior
- Department of Pathology, Federal University of Pernambuco, Recife, PE, Brazil
| | - Roberto V de Mello
- Department of Pathology, Federal University of Pernambuco, Recife, PE, Brazil
| | - Francisco A Bandeira
- Division of Endocrinology and Diabetes, Agamenon Magalhães Hospital, University of Pernambuco Medical School, Recife, PE, Brazil
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Douillard C, Jannin A, Vantyghem MC. Rare causes of hypoglycemia in adults. ANNALES D'ENDOCRINOLOGIE 2020; 81:110-117. [PMID: 32409005 DOI: 10.1016/j.ando.2020.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/02/2020] [Indexed: 12/19/2022]
Abstract
Hypoglycemia is defined by a low blood glucose level associated to clinical symptoms. Hypoglycemia may be related to treatment of diabetes, but also to drugs, alcohol, critical illness, cortisol insufficiency including hypopituitarism, insulinoma, bariatric or gastric surgery, pancreas transplantation or glucagon deficiency, or may be surreptitious. Some hypoglycemic episodes remain unexplained, and genetic, paraneoplastic and immune causes should be considered. Genetic causes may be related to endogenous hyperinsulinism and to inborn errors of metabolism (IEM). Endogenous hyperinsulinism is related to monogenic congenital hyperinsulinism, and especially to mutations of the glucokinase-activating gene or of insulin receptors, both characterised by postprandial hypoglycemia with major hyperinsulinism. In adulthood, IEM-related hypoglycemia can persist in a previously diagnosed childhood disease or may be a presenting sign. It is suggested by systemic involvement (rhabdomyolysis after fasting or exercising, heart disease, hepatomegaly), sometimes associated to a family history of hypoglycemia. The timing of hypoglycemic episodes with respect to the last meal also helps to orientate diagnosis. Fasting hypoglycemia may be related to type 0, I or III glycogen synthesis disorder, fatty acid oxidation or gluconeogenesis disorder. Postprandial hypoglycemia may be related to inherited fructose intolerance. Exercise-induced hyperinsulinism is mainly related to activating mutation of the SLC16A1 gene. Besides exceptional ectopic insulin secretion, paraneoplastic causes involve NICTH (Non-Islet-Cell Tumour Hypoglycemia), caused by Big-IGF2 secretion by a large tumour, with low blood levels of insulin, C-peptide and IGF1. Autoimmune causes involve antibodies against insulin (HIRATA syndrome), especially in case of Graves' disease, or against the insulin receptor. Medical history, timing, and insulin level orientate the diagnosis.
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Affiliation(s)
- Claire Douillard
- Endocrinology, diabetology, metabolism department, Lille university hospital, Lille, France; Lille reference centre of inborn errors of metabolism, Lille, France.
| | - Arnaud Jannin
- Endocrinology, diabetology, metabolism department, Lille university hospital, Lille, France.
| | - Marie-Christine Vantyghem
- Endocrinology, diabetology, metabolism department, Lille university hospital, Lille, France; Inserm U1190 translational research in diabetes, Lille, France; European genomic institute for diabetes EGID, Lille, France.
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11
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de Groot S, Pijl H, van der Hoeven JJM, Kroep JR. Effects of short-term fasting on cancer treatment. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2019; 38:209. [PMID: 31113478 PMCID: PMC6530042 DOI: 10.1186/s13046-019-1189-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 04/22/2019] [Indexed: 12/14/2022]
Abstract
Growing preclinical evidence shows that short-term fasting (STF) protects from toxicity while enhancing the efficacy of a variety of chemotherapeutic agents in the treatment of various tumour types. STF reinforces stress resistance of healthy cells, while tumor cells become even more sensitive to toxins, perhaps through shortage of nutrients to satisfy their needs in the context of high proliferation rates and/or loss of flexibility to respond to extreme circumstances. In humans, STF may be a feasible approach to enhance the efficacy and tolerability of chemotherapy. Clinical research evaluating the potential of STF is in its infancy. This review focuses on the molecular background, current knowledge and clinical trials evaluating the effects of STF in cancer treatment. Preliminary data show that STF is safe, but challenging in cancer patients receiving chemotherapy. Ongoing clinical trials need to unravel if STF can also diminish toxicity and increase efficacy of chemotherapeutic regimes in daily practice.
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Affiliation(s)
- Stefanie de Groot
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, 2300RC, Leiden, The Netherlands
| | - Hanno Pijl
- Department of Endocrinology, Leiden University Medical Center, P.O. Box 9600, 2300RC, Leiden, The Netherlands
| | - Jacobus J M van der Hoeven
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, 2300RC, Leiden, The Netherlands
| | - Judith R Kroep
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, 2300RC, Leiden, The Netherlands.
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Leukocytosis interference in clinical chemistry: Shall we still interpret test results without hematological data? J Med Biochem 2019; 39:66-71. [PMID: 32549780 DOI: 10.2478/jomb-2019-0005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 01/30/2019] [Indexed: 12/26/2022] Open
Abstract
Background Extreme leukocytosis is known to induce remarkable variations of some clinical chemistry tests, thus leading to possible clinical misinterpretation. This study aimed to define whether also moderate leukocytosis may influence the stability of glucose and blood gases. Methods Blood samples are sent to the local laboratory through a pneumatic tube system. Clinical chemistry testing is routinely performed using Lithium-heparin tubes (for glucose) and heparin blood gases syringes (for blood gas analysis). Stability of glucose (in uncentrifuged blood tubes) and blood gases (in syringes) was hence evaluated in samples maintained at room temperature. Results were also analyzed in 2 subgroups of samples with different leukocyte counts, i.e., those with leukocytes <15 × 109/L and those with leukocytes >15 × 109/L. Results An accelerated decrease of pH was observed in blood gases syringes with leukocytosis (i.e., >15 × 109/L), while no difference was noted for other blood gases parameters (PCO2, PO2). Spurious and time-dependent hypoglycemia was noted in uncentrifuged blood tubes of patients with leukocytosis. Conclusions The results of our study suggest that even modest leukocytosis (i.e., around 15 × 109/L), which is frequently encountered in clinical and laboratory practice, may be associated with significant variations of both glucose and pH. This would lead us to conclude that results of these parameters shall be accompanied by those of hematologic testing to prevent clinical misinterpretation, namely with leukocyte counts.
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13
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Szymańska E, Jóźwiak-Dzięcielewska DA, Gronek J, Niewczas M, Czarny W, Rokicki D, Gronek P. Hepatic glycogen storage diseases: pathogenesis, clinical symptoms and therapeutic management. Arch Med Sci 2019; 17:304-313. [PMID: 33747265 PMCID: PMC7959092 DOI: 10.5114/aoms.2019.83063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 12/08/2017] [Indexed: 11/22/2022] Open
Abstract
Glycogen storage diseases (GSDs) are genetically determined metabolic diseases that cause disorders of glycogen metabolism in the body. Due to the enzymatic defect at some stage of glycogenolysis/glycogenesis, excess glycogen or its pathologic forms are stored in the body tissues. The first symptoms of the disease usually appear during the first months of life and are thus the domain of pediatricians. Due to the fairly wide access of the authors to unpublished materials and research, as well as direct contact with the GSD patients, the article addresses the problem of actual diagnostic procedures for patients with the suspected diseases. Knowledge and awareness of the problem among physicians seem insufficient, and research on the diagnosis and treatment of GSD is still ongoing, resulting in a heterogeneous GSD typology and a changing way of its diagnosis and treatment.
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Affiliation(s)
- Edyta Szymańska
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, The Children’s Memorial Health Institute, Warsaw, Poland
| | | | - Joanna Gronek
- Laboratory of Genetics, Department of Gymnastics and Dance, University School of Physical Education, Poznan, Poland
| | - Marta Niewczas
- Department of Sport, Faculty of Physical Education, University of Rzeszow, Rzeszow, Poland
| | - Wojciech Czarny
- Department of Human Sciences, Faculty of Physical Education, University of Rzeszow, Rzeszow, Poland
| | - Dariusz Rokicki
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Piotr Gronek
- Laboratory of Genetics, Department of Gymnastics and Dance, University School of Physical Education, Poznan, Poland
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Morales-Alvarez MC, Ricardo-Silgado ML, Lemus HN, González-Devia D, Mendivil CO. Fructosuria and recurrent hypoglycemia in a patient with a novel c.1693T>A variant in the 3' untranslated region of the aldolase B gene. SAGE Open Med Case Rep 2019; 7:2050313X18823098. [PMID: 30675358 PMCID: PMC6330728 DOI: 10.1177/2050313x18823098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 12/13/2018] [Indexed: 11/17/2022] Open
Abstract
Hereditary fructose intolerance, caused by mutations in the ALDOB gene, is an unusual cause of hypoglycemia. ALDOB encodes the enzyme aldolase B, responsible for the hydrolysis of fructose 1-phosphate in the liver. Here, we report the case of a 33-year-old female patient who consulted due to repetitive episodes of weakness, dizziness and headache after food ingestion. An ambulatory 72-h continuous glucose monitoring revealed multiple short hypoglycemic episodes over the day. After biochemical exclusion of other endocrine causes of hypoglycemia, hereditary fructose intolerance seemed a plausible diagnosis. Repeated measurements of urinary fructose revealed pathologic fructosuria, but genetic testing for the three most common mutations in ALDOB resulted negative. We decided to perform complete Sanger sequencing of the ALDOB gene and encountered a variant consisting of a T>A substitution in position 1963 of the ALDOB transcript (c.1693T>A). This position is located within the 3′ untranslated region of exon 9, 515 nucleotides downstream the stop codon. After complete withdrawal of dietary fructose and sucrose, the patient presented no new hypoglycemic episodes.
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Affiliation(s)
| | | | | | - Deyanira González-Devia
- School of Medicine, Universidad de los Andes, Bogotá, Colombia.,Section of Endocrinology, Department of Internal Medicine, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Carlos O Mendivil
- School of Medicine, Universidad de los Andes, Bogotá, Colombia.,Section of Endocrinology, Department of Internal Medicine, Fundación Santa Fe de Bogotá, Bogotá, Colombia
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15
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Da Lozzo P, Magnolato A, Del Rizzo I, Sirchia F, Bruno I, Barbi E. When Long-Lasting Food Selectivity Leads to an Unusual Genetic Diagnosis: A Case Report. J Adolesc Health 2019; 64:137-138. [PMID: 30327278 DOI: 10.1016/j.jadohealth.2018.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/16/2018] [Accepted: 07/19/2018] [Indexed: 10/28/2022]
Abstract
Hereditary fructose intolerance is an autosomal recessive disorder of fructose metabolism caused by catalytic deficiency of aldolase B enzyme [1]. The disease is typically expressed when fructose- and sucrose-containing foods are first introduced in the diet; acute manifestations include nausea, vomiting, abdominal distress, and symptomatic hypoglycemia [1,2]. Chronic fructose ingestion eventually leads to poor feeding, growth retardation and gradual liver and/or renal failure [3,4]. Some patients may remain undiagnosed until adulthood because of a self-protective avoidance of sweet tasting food that prevents the development of acute toxicity from fructose containing food; however, these subjects may suffer intermittent symptoms throughout life, leading to potentially serious misdiagnosis [4]. We report the case of a patient with unrecognized hereditary fructose intolerance in which chronic gastrointestinal complaints, low body weight, and unexplained food avoidance were addressed as manifestations of an eating disorder during adolescence.
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Affiliation(s)
| | - Andrea Magnolato
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy.
| | | | - Fabio Sirchia
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Irene Bruno
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Egidio Barbi
- University of Trieste, Trieste, Italy; Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
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16
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Guerrero RB, Salazar D, Tanpaiboon P. Laboratory diagnostic approaches in metabolic disorders. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:470. [PMID: 30740401 PMCID: PMC6331366 DOI: 10.21037/atm.2018.11.05] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 10/17/2018] [Indexed: 12/30/2022]
Abstract
The diagnosis of inborn errors of metabolism (IEM) takes many forms. Due to the implementation and advances in newborn screening (NBS), the diagnosis of many IEM has become relatively easy utilizing laboratory biomarkers. For the majority of IEM, early diagnosis prevents the onset of severe clinical symptoms, thus reducing morbidity and mortality. However, due to molecular, biochemical, and clinical variability of IEM, not all disorders included in NBS programs will be detected and diagnosed by screening alone. This article provides a general overview and simplified guidelines for the diagnosis of IEM in patients with and without an acute metabolic decompensation, with early or late onset of clinical symptoms. The proper use of routine laboratory results in the initial patient assessment is also discussed, which can help guide efficient ordering of specialized laboratory tests to confirm a potential diagnosis and initiate treatment as soon as possible.
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Affiliation(s)
- Ruben Bonilla Guerrero
- Formerly Quest Diagnostics, Inc., Ruben Bonilla Guerrero, Rancho Santa Margarita, CA, USA
| | - Denise Salazar
- Quest Diagnostics, Inc., Denise Salazar and Pranoot Tanpaiboon, San Juan Capistrano, CA, USA
| | - Pranoot Tanpaiboon
- Quest Diagnostics, Inc., Denise Salazar and Pranoot Tanpaiboon, San Juan Capistrano, CA, USA
- Genetics and Metabolism, Children’s National Rare Disease Institute, Washington, DC, USA
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17
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da Silva I, da Costa Vieira R, Stella C, Loturco E, Carvalho AL, Veo C, Neto C, Silva SM, D'Amora P, Salzgeber M, Matos D, Silva CR, Oliveira JR, Rabelo I, Yamakawa P, Maciel R, Biscolla R, Chiamolera M, Fraietta R, Reis F, Mori M, Marchioni D, Carioca A, Maciel G, Tomioka R, Baracat E, Silva C, Granato C, Diaz R, Scarpellini B, Egle D, Fiegl H, Himmel I, Troi C, Nagourney R. Inborn-like errors of metabolism are determinants of breast cancer risk, clinical response and survival: a study of human biochemical individuality. Oncotarget 2018; 9:31664-31681. [PMID: 30167086 PMCID: PMC6114970 DOI: 10.18632/oncotarget.25839] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/12/2018] [Indexed: 01/16/2023] Open
Abstract
Breast cancer remains a leading cause of morbidity and mortality worldwide yet methods for early detection remain elusive. We describe the discovery and validation of biochemical signatures measured by mass spectrometry, performed upon blood samples from patients and controls that accurately identify (>95%) the presence of clinical breast cancer. Targeted quantitative MS/MS conducted upon 1225 individuals, including patients with breast and other cancers, normal controls as well as individuals with a variety of metabolic disorders provide a biochemical phenotype that accurately identifies the presence of breast cancer and predicts response and survival following the administration of neoadjuvant chemotherapy. The metabolic changes identified are consistent with inborn-like errors of metabolism and define a continuum from normal controls to elevated risk to invasive breast cancer. Similar results were observed in other adenocarcinomas but were not found in squamous cell cancers or hematologic neoplasms. The findings describe a new early detection platform for breast cancer and support a role for pre-existing, inborn-like errors of metabolism in the process of breast carcinogenesis that may also extend to other glandular malignancies. Statement of Significance: Findings provide a powerful tool for early detection and the assessment of prognosis in breast cancer and define a novel concept of breast carcinogenesis that characterizes malignant transformation as the clinical manifestation of underlying metabolic insufficiencies.
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Affiliation(s)
- Ismael da Silva
- Gynecology Department, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil.,Fleury Laboratories, São Paulo, Brazil.,Barretos Cancer Hospital (HCB), Barretos, Brazil
| | | | - Carolina Stella
- Gynecology Department, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Edson Loturco
- Department of Surgery, Urology Unit, Human Reproduction Division, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | | | - Carlos Veo
- Barretos Cancer Hospital (HCB), Barretos, Brazil
| | | | | | - Paulo D'Amora
- Gynecology Department, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Marcia Salzgeber
- Gynecology Department, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Delcio Matos
- Department of Surgery, Surgical Gastroenterology Division, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Celso R Silva
- Clinical and Experimental Oncology Department, Hematology and Hemotherapy Division, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Jose R Oliveira
- Clinical and Experimental Oncology Department, Hematology and Hemotherapy Division, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Iara Rabelo
- Clinical and Experimental Oncology Department, Hematology and Hemotherapy Division, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Patricia Yamakawa
- Clinical and Experimental Oncology Department, Hematology and Hemotherapy Division, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Rui Maciel
- Fleury Laboratories, São Paulo, Brazil.,Department of Medicine, Endocrinology Division, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Rosa Biscolla
- Department of Medicine, Endocrinology Division, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Maria Chiamolera
- Department of Medicine, Endocrinology Division, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Renato Fraietta
- Department of Surgery, Urology Unit, Human Reproduction Division, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Felipe Reis
- Biophysics Department, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Marcelo Mori
- Department of Biochemistry and Tissue Biology, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Dirce Marchioni
- Nutrition Department, School of Public Health, University of São Paulo School of Medicine (FMUSP), São Paulo, Brazil
| | - Antonio Carioca
- Nutrition Department, School of Public Health, University of São Paulo School of Medicine (FMUSP), São Paulo, Brazil
| | - Gustavo Maciel
- Fleury Laboratories, São Paulo, Brazil.,Department of Obstetrics and Gynecology, University of São Paulo School of Medicine (HCFMUSP), São Paulo, Brazil
| | - Renato Tomioka
- Department of Obstetrics and Gynecology, University of São Paulo School of Medicine (HCFMUSP), São Paulo, Brazil
| | - Edmund Baracat
- Department of Obstetrics and Gynecology, University of São Paulo School of Medicine (HCFMUSP), São Paulo, Brazil
| | - Clovis Silva
- Department of Pediatrics, Children's Hospital, University of São Paulo School of Medicine (HCFMUSP), São Paulo, Brazil
| | - Celso Granato
- Fleury Laboratories, São Paulo, Brazil.,Retrovirology Laboratory, Infectious Diseases Unit, Medicine Department, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Ricardo Diaz
- Retrovirology Laboratory, Infectious Diseases Unit, Medicine Department, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Bruno Scarpellini
- Fleury Laboratories, São Paulo, Brazil.,Retrovirology Laboratory, Infectious Diseases Unit, Medicine Department, College of Medicine of the Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Daniel Egle
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
| | - Heidi Fiegl
- Department of Gynecology, Meran Hospital, Meran, Italy
| | | | - Christina Troi
- Department of Gynecology, Brixen Hospital, Brixen, Italy
| | - Robert Nagourney
- Department of Obstetrics and Gynecology, Gynecological Oncology Unit, University of California Irvine (UCI), California, USA
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18
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Lanaspa MA, Andres-Hernando A, Orlicky DJ, Cicerchi C, Jang C, Li N, Milagres T, Kuwabara M, Wempe MF, Rabinowitz JD, Johnson RJ, Tolan DR. Ketohexokinase C blockade ameliorates fructose-induced metabolic dysfunction in fructose-sensitive mice. J Clin Invest 2018. [PMID: 29533924 DOI: 10.1172/jci94427] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Increasing evidence suggests a role for excessive intake of fructose in the Western diet as a contributor to the current epidemics of metabolic syndrome and obesity. Hereditary fructose intolerance (HFI) is a difficult and potentially lethal orphan disease associated with impaired fructose metabolism. In HFI, the deficiency of aldolase B results in the accumulation of intracellular phosphorylated fructose, leading to phosphate sequestration and depletion, increased adenosine triphosphate (ATP) turnover, and a plethora of conditions that lead to clinical manifestations such as fatty liver, hyperuricemia, Fanconi syndrome, and severe hypoglycemia. Unfortunately, there is currently no treatment for HFI, and avoiding sugar and fructose has become challenging in our society. In this report, through use of genetically modified mice and pharmacological inhibitors, we demonstrate that the absence or inhibition of ketohexokinase (Khk), an enzyme upstream of aldolase B, is sufficient to prevent hypoglycemia and liver and intestinal injury associated with HFI. Herein we provide evidence for the first time to our knowledge of a potential therapeutic approach for HFI. Mechanistically, our studies suggest that it is the inhibition of the Khk C isoform, not the A isoform, that protects animals from HFI.
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Affiliation(s)
- Miguel A Lanaspa
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado, USA
| | - Ana Andres-Hernando
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado, USA
| | - David J Orlicky
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado, USA
| | - Christina Cicerchi
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado, USA
| | - Cholsoon Jang
- Department of Chemistry and Lewis-Sigler Institute for Integrative Genomics, Princeton University, Princeton, New Jersey, USA
| | - Nanxing Li
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado, USA
| | - Tamara Milagres
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado, USA
| | - Masanari Kuwabara
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado, USA
| | - Michael F Wempe
- Department of Pharmacology, University of Colorado, Aurora, Colorado, USA
| | - Joshua D Rabinowitz
- Department of Chemistry and Lewis-Sigler Institute for Integrative Genomics, Princeton University, Princeton, New Jersey, USA
| | - Richard J Johnson
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado, USA
| | - Dean R Tolan
- Department of Biology, Boston University, Boston, Massachusetts, USA
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19
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International practices in the dietary management of fructose 1-6 biphosphatase deficiency. Orphanet J Rare Dis 2018; 13:21. [PMID: 29370874 PMCID: PMC5785792 DOI: 10.1186/s13023-018-0760-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 01/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In fructose 1,6 bisphosphatase (FBPase) deficiency, management aims to prevent hypoglycaemia and lactic acidosis by avoiding prolonged fasting, particularly during febrile illness. Although the need for an emergency regimen to avoid metabolic decompensation is well established at times of illness, there is uncertainty about the need for other dietary management strategies such as sucrose or fructose restriction. We assessed international differences in the dietary management of FBPase deficiency. METHODS A cross-sectional questionnaire (13 questions) was emailed to all members of the Society for the Study of Inborn Errors of Metabolism (SSIEM) and a wide database of inherited metabolic disorder dietitians. RESULTS Thirty-six centres reported the dietary prescriptions of 126 patients with FBPase deficiency. Patients' age at questionnaire completion was: 1-10y, 46% (n = 58), 11-16y, 21% (n = 27), and >16y, 33% (n = 41). Diagnostic age was: <1y, 36% (n = 46); 1-10y, 59% (n = 74); 11-16y, 3% (n = 4); and >16y, 2% (n = 2). Seventy-five per cent of centres advocated dietary restrictions. This included restriction of: high sucrose foods only (n = 7 centres, 19%); fruit and sugary foods (n = 4, 11%); fruit, vegetables and sugary foods (n = 13, 36%). Twenty-five per cent of centres (n = 9), advised no dietary restrictions when patients were well. A higher percentage of patients aged >16y rather than ≤16y were prescribed dietary restrictions: patients aged 1-10y, 67% (n = 39/58), 11-16y, 63% (n = 17/27) and >16y, 85% (n = 35/41). Patients classified as having a normal fasting tolerance increased with age from 30% in 1-10y, to 36% in 11-16y, and 58% in >16y, but it was unclear if fasting tolerance was biochemically proven. Twenty centres (56%) routinely prescribed uncooked cornstarch (UCCS) to limit overnight fasting in 47 patients regardless of their actual fasting tolerance (37%). All centres advocated an emergency regimen mainly based on glucose polymer for illness management. CONCLUSIONS Although all patients were prescribed an emergency regimen for illness, use of sucrose and fructose restricted diets with UCCS supplementation varied widely. Restrictions did not relax with age. International guidelines are necessary to help direct future dietary management of FBPase deficiency.
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20
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Vukovic R, Milenkovic T, Djordjevic M, Mitrovic K, Todorovic S, Sarajlija A, Hussain K. Postprandial hyperinsulinemic hypoglycemia in a child as a late complication of esophageal reconstruction. J Pediatr Endocrinol Metab 2017; 30:791-795. [PMID: 28672750 DOI: 10.1515/jpem-2017-0139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/02/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Postprandial hyperinsulinemic hypoglycemia (PHH) is an increasingly recognized complication of gastric bypass surgery in obese adults, distinct from the "dumping syndrome". CASE PRESENTATION Upon birth, primary repair of esophageal atresia was performed, and at the age of 14 months definite esophageal reconstruction was performed. At the age of 3 years, recurrent brief episodes of symptomatic hypoglycemia started. At the age of 5.7 years the girl was admitted to our clinic and investigations indicated hyperinsulinemic hypoglycemia. Oral glucose tolerance test (OGTT) and continuous glucose monitoring results revealed frequent postprandial hypoglycemic events, which were always preceded by early postprandial hyperglycemia. It was concluded that the patient had PHH caused by a delayed and hyperinsulinemic response to carbohydrate intake as a result of esophagogastric surgery. Treatment with acarbose was titrated using flash glucose monitoring, which resulted in satisfactory glucose regulation. CONCLUSIONS This is the first described case of a child with PHH following esophageal reconstruction.
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21
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Inborn Errors of Fructose Metabolism. What Can We Learn from Them? Nutrients 2017; 9:nu9040356. [PMID: 28368361 PMCID: PMC5409695 DOI: 10.3390/nu9040356] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 03/27/2017] [Accepted: 03/28/2017] [Indexed: 12/18/2022] Open
Abstract
Fructose is one of the main sweetening agents in the human diet and its ingestion is increasing globally. Dietary sugar has particular effects on those whose capacity to metabolize fructose is limited. If intolerance to carbohydrates is a frequent finding in children, inborn errors of carbohydrate metabolism are rare conditions. Three inborn errors are known in the pathway of fructose metabolism; (1) essential or benign fructosuria due to fructokinase deficiency; (2) hereditary fructose intolerance; and (3) fructose-1,6-bisphosphatase deficiency. In this review the focus is set on the description of the clinical symptoms and biochemical anomalies in the three inborn errors of metabolism. The potential toxic effects of fructose in healthy humans also are discussed. Studies conducted in patients with inborn errors of fructose metabolism helped to understand fructose metabolism and its potential toxicity in healthy human. Influence of fructose on the glycolytic pathway and on purine catabolism is the cause of hypoglycemia, lactic acidosis and hyperuricemia. The discovery that fructose-mediated generation of uric acid may have a causal role in diabetes and obesity provided new understandings into pathogenesis for these frequent diseases.
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22
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Ajala ON, Huffman DM, Ghobrial II. Glucokinase mutation-a rare cause of recurrent hypoglycemia in adults: a case report and literature review. J Community Hosp Intern Med Perspect 2016; 6:32983. [PMID: 27802864 PMCID: PMC5089152 DOI: 10.3402/jchimp.v6.32983] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/30/2016] [Indexed: 02/02/2023] Open
Abstract
Background Hypoglycemia occurs frequently in patients both in the inpatient and outpatient settings. While most hypoglycemia unrelated to diabetes treatment results from excessive endogenous insulin action, rare cases involve functional and congenital mutations in glycolytic enzymes of insulin regulation. Case A 21-year-old obese woman presented to the emergency department with complaints of repeated episodes of lethargy, syncope, dizziness, and sweating. She was referred from an outside facility on suspicion of insulinoma, with severe hypoglycemia unresponsive to repeated dextrose infusions. Her plasma glucose was 20 mg/dl at presentation, 44 mg/dl on arrival at our facility, and remained low in spite of multiple dextrose infusions. The patient had been treated for persistent hyperinsulinemic hypoglycemia of infancy at our neonatal facility and 4 years ago was diagnosed as having an activating glucokinase (GCK) mutation. She was then treated with octreotide and diazoxide with improvement in symptoms and blood glucose levels. Conclusion Improved diagnostication and management of uncommon genetic mutations as typified in this patient with an activating mutation of the GCK gene has expanded the spectrum of disease in adult medicine. This calls for improved patient information dissemination across different levels and aspects of the health care delivery system to ensure cost-effective and timely health care.
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Affiliation(s)
- Oluremi N Ajala
- Department of Internal Medicine, University of Pittsburgh Medical Center, McKeesport, PA, USA;
| | - David M Huffman
- Department of Internal Medicine, University of Tennessee College of Medicine, Chattanooga, TN, USA
| | - Ibrahim I Ghobrial
- Department of Internal Medicine, University of Pittsburgh Medical Center, McKeesport, PA, USA
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23
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Fletcher JM. Metabolic emergencies and the emergency physician. J Paediatr Child Health 2016; 52:227-30. [PMID: 27062628 DOI: 10.1111/jpc.13106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 11/28/2015] [Accepted: 12/03/2015] [Indexed: 11/30/2022]
Abstract
Fifty percent of inborn errors of metabolism are present in later childhood and adulthood, with crises commonly precipitated by minor viral illnesses or increased protein ingestion. Many physicians only consider IEM after more common conditions (such as sepsis) have been considered. In view of the large number of inborn errors, it might appear that their diagnosis requires precise knowledge of a large number of biochemical pathways and their interrelationship. As a matter of fact, an adequate diagnostic approach can be based on the proper use of only a few screening tests. A detailed history of antecedent events, together with these simple screening tests, can be diagnostic, leading to life-saving, targeted treatments for many disorders. Unrecognised, IEM can lead to significant mortality and morbidity. Advice is available 24/7 through the metabolic service based at the major paediatric hospital in each state and Starship Children's Health in New Zealand.
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Affiliation(s)
- Janice Mary Fletcher
- SA Pathology, Women's and Children's Hospital, Adelaide, Australia.,Department of Paediatrics, University of Adelaide, Adelaide, Australia
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24
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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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25
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Adolescent presentations of inborn errors of metabolism. J Adolesc Health 2015; 56:477-82. [PMID: 25907648 DOI: 10.1016/j.jadohealth.2015.01.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 01/14/2015] [Accepted: 01/15/2015] [Indexed: 12/30/2022]
Abstract
Several studies have shown that a large percentage of inborn errors of metabolism is present in adolescent patients. Individually, each diagnosis in this category of diseases is rare; therefore, there is often a significant delay in determining the etiology of a patient's complaints. These disorders can have a wide variety of multisystemic presentations, several of which overlap with more common disorders of adolescence. This review highlights the red-flag findings on history and physical examination indicating a possible inborn error of metabolism. In addition, a systematic approach for evaluating and categorizing these disorders is introduced and demonstrated through case examples. Primary care physicians play a crucial role in the early detection and prompt treatment of patients with late-onset inborn errors of metabolism.
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26
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Kato S, Nakajima Y, Awaya R, Hata I, Shigematsu Y, Saitoh S, Ito T. Pitfall in the Diagnosis of Fructose-1,6-Bisphosphatase Deficiency: Difficulty in Detecting Glycerol-3-Phosphate with Solvent Extraction in Urinary GC/MS Analysis. TOHOKU J EXP MED 2015; 237:235-9. [DOI: 10.1620/tjem.237.235] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Sayaka Kato
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences
| | - Yoko Nakajima
- Department of Pediatrics, Fujita Health University School of Medicine
| | - Risa Awaya
- Department of Pediatrics, Japanese Red Cross Nagoya Daini Hospital
| | - Ikue Hata
- Department of Pediatrics, University of Fukui Faculty of Medical Sciences
| | - Yosuke Shigematsu
- Department of Health Science, University of Fukui Faculty of Medical Sciences
| | - Shinji Saitoh
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences
| | - Tetsuya Ito
- Department of Pediatrics, Fujita Health University School of Medicine
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27
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Solano A, Lew SQ, Ing TS. Dent-Wrong disease and other rare causes of the Fanconi syndrome. Clin Kidney J 2014; 7:344-7. [PMID: 25852908 PMCID: PMC4377815 DOI: 10.1093/ckj/sfu070] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 06/10/2014] [Indexed: 12/29/2022] Open
Abstract
Dent-Wrong disease, an X-linked recessive disorder of the proximal tubules, presents with hypercalciuria, nephrocalcinosis, nephrolithiasis, renal insufficiency, low-molecular-weight proteinuria, rickets and/or osteomalacia. Dent and Friedman initially characterized the disorder in 1964 following studies of two patients with rickets who presented with hypercalciuria, hyperphosphaturia, proteinuria and aminoaciduria. Since then, extensive investigation identified two genetic mutations (CLCN5 and OCRL1) to be associated with Dent-Wrong disease. Clinical features supported by laboratory findings consistent with proximal tubule dysfunction help diagnose Dent-Wrong disease. Genetic analysis supports the diagnosis; however, these two genes can be normal in a small subset of patients. The differential diagnosis includes other forms of the Fanconi syndrome, which can be hereditary or acquired (e.g. those related to exposure to exogenous substances). Treatment is supportive with special attention to the prevention of nephrolithiasis and treatment of hypercalciuria. We review the rare forms of Fanconi syndrome with special attention to Dent-Wrong disease.
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Affiliation(s)
- Alejandro Solano
- Division of Renal Diseases and Hypertension, Department of Medicine , The George Washington University School of Medicine and Health Sciences , Washington, DC , USA
| | - Susie Q Lew
- Division of Renal Diseases and Hypertension, Department of Medicine , The George Washington University School of Medicine and Health Sciences , Washington, DC , USA
| | - Todd S Ing
- Department of Medicine , Stritch School of Medicine, Loyola University Chicago , Maywood, IL , USA
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El-Karaksy H, Anwar G, El-Raziky M, Mogahed E, Fateen E, Gouda A, El-Mougy F, El-Hennawy A. Glycogen storage disease type III in Egyptian children: a single centre clinico-laboratory study. Arab J Gastroenterol 2014; 15:63-7. [PMID: 25097048 DOI: 10.1016/j.ajg.2014.01.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 01/09/2014] [Accepted: 01/20/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND STUDY AIMS Glycogen storage disease type III (GSD III) is an autosomal recessive disorder caused by deficiency of glycogen debrancher enzyme and is characterised by clinical variability. PATIENTS AND METHODS We herein describe the clinical and laboratory findings in 31 Egyptian patients with GSD III presenting to the Paediatric Hepatology Unit, Cairo University, Egypt. RESULTS Eighteen patients (58%) were males. Their ages ranged between 6 months to 12 years. The main presenting complaint was progressive abdominal distention in 55%. Twelve patients (38.7%) had a history of recurrent attacks of convulsions; four had an erroneous diagnosis of hypocalcaemia and epilepsy. Doll-like facies was noted in 90%. Abdominal examination of all cases revealed abdominal distention and soft hepatomegaly which had bright echogenicity by ultrasound. Hypertriglyceridaemia was present in 93.6%, hyperlactacidaemia in 51.6% and hyperuricaemia in 19.4%. Liver biopsy showed markedly distended hepatocytes with well distinct cytoplasmic boundaries and 32% had macrovesicular fatty changes. Serum creatine kinase was elevated in 64.6% of patients and correlated positively and significantly with age (r=0.7 and P=<0.001), while serum triglycerides correlated negatively with age (r=-0.4 and P=0.05). CONCLUSION Blood glucose assessment and search for hepatomegaly in an infant with recurrent seizures may prevent delay in the diagnosis. A huge soft liver reaching the left midclavicular line that appears echogenic on ultrasonography is characteristic of GSD III. A distended hepatocyte with rarified cytoplasm is pathognomonic but not diagnostic. Hypertriglyceridaemia correlates negatively with age, in contrary to CK level.
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Affiliation(s)
- Hanaa El-Karaksy
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Ghada Anwar
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mona El-Raziky
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Engy Mogahed
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ekram Fateen
- Biochemical Genetic Department, National Research Center, Cairo, Egypt
| | - Amr Gouda
- Biochemical Genetic Department, National Research Center, Cairo, Egypt
| | - Fatma El-Mougy
- Department of Chemical Pathlogy, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed El-Hennawy
- Department of Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Freeze HH, Chong JX, Bamshad MJ, Ng BG. Solving glycosylation disorders: fundamental approaches reveal complicated pathways. Am J Hum Genet 2014; 94:161-75. [PMID: 24507773 DOI: 10.1016/j.ajhg.2013.10.024] [Citation(s) in RCA: 190] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Indexed: 11/30/2022] Open
Abstract
Over 100 human genetic disorders result from mutations in glycosylation-related genes. In 2013, a new glycosylation disorder was reported every 17 days. This trend will probably continue given that at least 2% of the human genome encodes glycan-biosynthesis and -recognition proteins. Established biosynthetic pathways provide many candidate genes, but finding unanticipated mutated genes will offer new insights into glycosylation. Simple glycobiomarkers can be used in narrowing the candidates identified by exome and genome sequencing, and those can be validated by glycosylation analysis of serum or cells from affected individuals. Model organisms will expand the understanding of these mutations' impact on glycosylation and pathology. Here, we highlight some recently discovered glycosylation disorders and the barriers, breakthroughs, and surprises they presented. We predict that some glycosylation disorders might occur with greater frequency than current estimates of their prevalence. Moreover, the prevalence of some disorders differs substantially between European and African Americans.
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Affiliation(s)
- Hudson H Freeze
- Human Genetics Program, Sanford Children's Health Research Center, Sanford Burnham Medical Research Institute, La Jolla, CA 92037, USA.
| | - Jessica X Chong
- Department of Pediatrics, University of Washington, Seattle, WA 98195, USA
| | - Michael J Bamshad
- Department of Pediatrics, University of Washington, Seattle, WA 98195, USA
| | - Bobby G Ng
- Human Genetics Program, Sanford Children's Health Research Center, Sanford Burnham Medical Research Institute, La Jolla, CA 92037, USA
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Fructose-1,6-bisphosphatase deficiency: a case of a successful pregnancy by closely monitoring metabolic control. JIMD Rep 2014; 14:115-8. [PMID: 24470127 DOI: 10.1007/8904_2013_290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 11/23/2013] [Accepted: 12/16/2013] [Indexed: 04/10/2023] Open
Abstract
In patients with fructose-1,6-bisphosphatase (FBPase) deficiency, maternal and fetal neurodevelopmental abnormalities can be induced by severe hypoglycemia and lactic acidosis, which is triggered by pregnancy. The patient was a 24-year-old and primipara. Via pre-pregnancy education and management including self-monitoring of blood glucose and prompt medical intervention with glucose infusions, she never experienced hypoglycemia with impaired consciousness. She delivered a 2,406 g male infant at 38 weeks of gestation by cesarean section. No neurological abnormalities in either the mother or the child appeared during the following 2 years. This is the first report with detailed descriptions of the management of a pregnant woman with FDPase deficiency. This report suggests that for a patient with FBPase deficiency, the maternal and fetal complications can be reduced by pre-pregnancy education and self-monitoring of blood glucose to prevent hypoglycemia.
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