Malignant brain tumors in patients with glutaric aciduria type I

Three young patients with glutaric aciduria type I (age 6-23 years) of different ethnic origins, treated for their metabolic disease since early childhood, presented with malignant central nervous system tumors. We recommend continuing clinical follow-up, including monitoring of neurological manifestations and neuroradiological findings, in all patients with glutaric aciduria type I beyond early childhood, especially if adherence to diet is poor or the treatment was not started neonatally.

Biochemical and molecular characteristics of patients with organic acidaemias and urea cycle disorders identified through newborn screening

BACKGROUND

In recent years it has become clear that newborn screening (NBS) programmes using tandem mass spectrometry identify "patients" with "classical" inborn errors of metabolism who are asymptomatic. This observation raises issues regarding medicalization of "non-diseases," potentially unnecessary treatment and unnecessary anxiety to parents.

AIMS

This study aims to identify possible markers that may assist in predicting the need for treatment of infants with "classical" organic acidaemias (OA) and urea cycle disorders (UCD) diagnosed through NBS.

METHODS

Medical records of all patients with classical OA and UCD detected through the Victorian NBS programme from February 2002 to January 2014, or diagnosed clinically between 1990 and January 2002 were retrospectively reviewed.

RESULTS

Neonatal presentation did not always predict the need for on-going strict treatment. Blood concentrations of amino acids and acyl-carnitines and the changes thereof in follow-up samples correlated with severity in citrullinaemia-I, possibly isovaleric acidaemia but not in argininosuccinic aciduria or propionic acidaemia. Some specific mutations correlate with "attenuated" citrullinaemia-I. Gender may affect clinical outcome in propionic acidaemia.

CONCLUSIONS

Changes in blood concentration of certain metabolites (amino acids, acyl-carnitines) in the first weeks of life may be predictive of the need for treatment in some disorders but not in others. Mutation analysis may be predictive in some disorders but whether or not this should be considered as second-tier testing in NBS should be discussed separately.

Use of carglumic acid in the treatment of hyperammonaemia during metabolic decompensation of patients with propionic acidaemia

Propionic acidaemia (PA) results from propionyl-CoA carboxylase deficiency. During metabolic decompensation, the accumulation of propionyl-CoA causes secondary hyperammonaemia through N-acetylglutamate synthetase inactivation. Carglumic acid, a structural analogue of N-acetylglutamate, was given to patients with PA (n=3) during episodes of metabolic decompensation (n=8; age range: birth to 4years), in addition to high energy/low protein intake and carnitine. Plasma ammonia concentrations normalised within 6-19h. Carglumic acid was well tolerated with no side effects noted.

Amino Acid Profiles in Patients with Urea Cycle Disorders at Admission to Hospital due to Metabolic Decompensation

Urea cycle disorders (UCDs) result from inherited defects in the ammonia detoxification pathway, leading to episodes of hyperammonaemia and encephalopathy. The purpose of this study was to answer the question, "what is the likely plasma amino acid profile of a patient known to have a UCD presenting with hyperammonaemia during acute metabolic decompensation", in order to support informed decisions regarding management.We analysed the results of plasma ammonia levels and amino acid profiles taken simultaneously or within 30 min of each other during acute admissions of all patients with a UCD at the Royal Children's Hospital, Melbourne, over 28 years. Samples from 96 admissions (79, 9 and 8 admissions for OTC, CPS and ASS deficiencies, respectively) from 14 patients fulfilled these criteria. Amino acid levels were measured by ion exchange chromatography with post-column ninhydrin derivatisation and interpreted in relation to age-related reference ranges.Plasma concentrations of all measured essential amino acids were low or low-normal in almost all samples. There was a strong positive correlation between low plasma branched-chain amino acids and other essential amino acids, and a negative correlation between ammonia and phenylalanine to tyrosine (Phe:Tyr) ratio in patients with OTC deficiency, and between glutamine and Phe:Tyr ratio in all patients, indicating protein deficiency.

CONCLUSION

At admission, protein deficiency is common in patients with a UCD with hyperammonaemia. These results challenge the current guideline of stopping protein intake during acute decompensation in UCDs. Supplementation with essential amino acids (particularly branched-chain amino acids) at these times should be considered.

Cognitive and social profiles in two patients with cobalamin C disease

Cobalamin C (cblC) disease, an inborn error of vitamin B(12) metabolism, results in neurometabolic, neurochemical and neuroanatomical changes. Little is known of the long-term effects of the disorder on cognition and behaviour in children. Here, the complete neuropsychological profiles of two 12-year-old girls with cblC disease are presented. The two girls were tested longitudinally with standardized neuropsychological tests including intellectual ability, attention and memory, as well as executive, adaptive and behavioural function. The results indicate the presence of intellectual dysfunction, attention problems, and concerns with behavioural aspects of executive function. Both patients demonstrated a pattern of decreasing intellectual function over time, which may reflect a growing developmental gap in comparison with their same age peers. These impairments are in contrast to the relatively spared verbal expression and comprehension abilities, as well as strengths in sociability. The findings highlight a pattern of neuropsychological strengths and weaknesses that may distinguish cblC disease from other inborn errors of metabolism. Overt sociability such as observed in these two patients may actually mask underlying cognitive deficits because the patients appear to function at a more advanced level than that reflected by quantitative assessment of intellectual and cognitive functioning. This is of clinical and functional importance and suggests that accurate determination of cognitive, adaptive and social abilities necessitates an in-depth and broad evaluation. The presence of significant intellectual and cognitive deficits also underscores the need to document and monitor cognitive development in children with cblC disease and to consider remediative and adaptive learning strategies.

Cognitive, behavioural and adaptive profiles of children with glutaric aciduria type I detected through newborn screening

BACKGROUND

Glutaric aciduria type I (GA I) is an autosomal recessive disorder of lysine and tryptophan metabolism due to a deficiency in glutaryl-CoA dehydrogenase activity. Recent reports suggest that early diagnosis through newborn screening and initiation of preventive therapy result in improved functional outcome; however, detailed neuropsychological profiles of children with GA I are seldom reported and thus the impact of the disease on cognition, motor abilities and behaviour remains uncertain.

METHOD

We present detailed neuropsychological profiles of three children who were diagnosed with GA I through newborn screening and treated from early age, and one asymptomatic patient diagnosed through cascade screening. A comprehensive battery of standardized tests was administered including measures of intellectual function, attention/memory, executive function, motor skills, speech/language, as well as behavioural and adaptive skills.

RESULTS

The results reveal overall average cognitive outcomes; however, subtle, but significant, fine motor and articulation deficits were observed. The results are discussed with regard to potential links between fine motor deficits and speech impairments in children with GA I. Such difficulties can impact on the child's ability to engage in academic, leisure and daily activities.

CONCLUSIONS

These findings highlight the importance of in-depth assessments of all aspects of neuropsychological function in patients with GA I and provide a basis for future neuropsychological assessment in similar groups of children. In spite of relatively preserved overall functioning, using a broad range of sensitive cognitive and motor measures facilitates the detection of subtle deficits, and allows for planning of early and adequate therapeutic interventions.

Clinical, ethical and legal considerations in the treatment of newborns with non-ketotic hyperglycinaemia

Non-ketotic hyperglycinaemia (NKH) is a devastating neurometabolic disorder leading, in its classical form, to early death or severe disability and poor quality of life in survivors. Affected neonates may need ventilatory support during a short period of respiratory depression. The transient dependence on ventilation dictates urgency in decision-making regarding withdrawal of therapy. The occurrence of patients with apparent transient forms of the disease, albeit rare, adds uncertainty to the prediction of clinical outcome and dictates that the current practice of withholding or withdrawing therapy in these neonates be reviewed. Both bioethics and law take the view that treatment decisions should be based on the best interests of the patient. The medical-ethics approach is based on the principles of non-maleficence, beneficence, autonomy and justice. The law relating to withholding or withdrawing life-sustaining treatment is complex and varies between jurisdictions. Physicians treating newborns with NKH need to provide families with accurate and complete information regarding the disease and the relative probability of possible outcomes of the neonatal presentation and to explore the extent to which family members are willing to take part in the decision making process. Cultural and religious attitudes, which may potentially clash with bioethical and juridical principles, need to be considered.

Cardiac manifestations in oxidative phosphorylation disorders of childhood

OBJECTIVE

To determine the frequency, type, and severity of cardiac involvement in pediatric patients with oxidative phosphorylation (OXPHOS) disorders.

STUDY DESIGN

Retrospective review of clinical and laboratory records of all patients with definitive OXPHOS disorders diagnosed and treated at the Royal Children's Hospital in Melbourne between 1984 and 2005.

RESULTS

Of a total of 89 patients (male:female ratio 1.5:1) 29 (33%) had cardiac involvement: 9 as presenting symptoms, 9 developing on follow-up, and 11 with subclinical cardiac findings. Leigh or Leigh-like syndrome and complex I and combined complex I, III, and IV deficiencies were the most common clinical and laboratory diagnoses, respectively. Clinically symptomatic patients had hypertrophic cardiomyopathy (5 patients), dilated cardiomyopathy (4 patients), combined ventricular hypertrophy and systolic dysfunction (3 patients), and left ventricular noncompaction (3 patients) at first assessment. A change in the type of cardiomyopathy was noted on follow-up in 2 patients. Conduction and rhythm abnormalities were present in 7 symptomatic patients.

CONCLUSIONS

Cardiac assessment in children with OXPHOS disorders may reveal subclinical abnormalities of cardiac function. Patients who present with primary cardiac features have a poor prognosis. OXPHOS disorders should be considered in the differential diagnosis of children presenting with otherwise unexplained cardiomyopathy.

VLCAD deficiency: pitfalls in newborn screening and confirmation of diagnosis by mutation analysis

We diagnosed six newborn babies with very long-chain acyl-CoA dehydrogenase deficiency (VLCADD) through newborn screening in three years in Victoria (prevalence rate: 1:31,500). We identified seven known and two new mutations in our patients (2/6 homozygotes; 4/6 compound heterozygotes). Blood samples taken at age 48-72 h were diagnostic whereas repeat samples at an older age were normal in 4/6 babies. Urine analysis was normal in 5/5. We conclude that the timing of blood sampling for newborn screening is important and that it is important to perform mutation analysis to avoid false-negative diagnoses of VLCADD in asymptomatic newborn babies. In view of the emerging genotype-phenotype correlation in this disorder, the information derived from mutational analysis can be helpful in designing the appropriate follow-up and therapeutic regime for these patients.

Regulation of mitochondrial oxidative phosphorylation by second messenger-mediated signal transduction mechanisms

The mitochondrial oxidative phosphorylation system is responsible for providing the bulk of cellular ATP molecules. There is a growing body of information regarding the regulation of this process by a number of second messenger-mediated signal transduction mechanisms, although direct studies aimed at elucidating this regulation are limited. The main second messengers affecting mitochondrial signal transduction are cAMP and calcium. Other second messengers include ceramide and reactive oxygen species as well as nitric oxide and reactive nitrogen species. This review focuses on available data on the regulation of the mitochondrial oxidative phosphorylation system by signal transduction mechanisms and is organised according to the second messengers involved, because of their pivotal role in mitochondrial function. Future perspectives for further investigations regarding these mechanisms in the regulation of the oxidative phosphorylation system are formulated.

The importance of liver biopsy in the investigation of possible mitochondrial respiratory chain disease

The diagnosis of mitochondrial respiratory chain deficiency is usually made by analysis of mitochondrial respiratory chain activity in muscle biopsy. We describe 4 patients in whom the diagnosis was based on mitochondrial respiratory chain deficiency in liver alone. In 3 patients, liver complex IV activity was deficient, and the 4th patient had liver complex I deficiency (relative to citrate synthase and complex II activity). The enzyme activities in skeletal muscle biopsies from these patients were normal or equivocal. The age at presentation and the neurological symptoms differed from one patient to another. All 3 patients with complex IV deficiency had non-specific white matter changes on brain MRI. None of the patients had clinical or biochemical evidence of liver disease. These findings illustrate the wide variety of presentations associated with liver mitochondrial respiratory chain deficiency. They also demonstrate the importance of mitochondrial respiratory chain enzyme analysis in liver, in addition to muscle, even in cases where the primary clinical deficit is neurological and there is no liver disease.

Body composition in young adults with inborn errors of protein metabolism--a pilot study

The natural history of inborn errors of protein metabolism and the long-term effects of prescribed semisynthetic therapeutic diets are largely unknown. We assessed body composition, measuring body-fat mass and distribution, fat-free mass, total body protein, total body potassium, bone density and skeletal muscle mass, in young adults (age > 18 years; 6 female, 5 male) with inborn errors of protein metabolism maintained on long-term low-protein diets, compared with controls. Female patients were significantly shorter (159.4 cm vs 169.2 cm, p = 0.013) and had higher BMI (25.3 vs 22.0 kg/m2, p < 0.05), abdominal to gluteal circumference ratio (0.84 vs 0.73, p = 0.011), percentage body fat (42.3% vs 29.5%, p < 0.005) and ratio of central to peripheral body fat (1.15 vs 0.86, p < 0.05) than controls. Male patients had lower height-adjusted total body bone mineral content (0.9 vs 1.02 g/m2, p < 0.04) and skeletal muscle mass (31.1 vs 36.3 kg, p < 0.04) than controls. Compared with controls, patients'nitrogen index was significantly lower (0.91 vs 1.03, p < 0.01), consistent with lower total body protein. Potassium index was significantly higher (121.2% vs 110.4%, p < 0.03), consistent with higher body cell mass, or intracellular water. Documentation of body composition in larger patient series is important to elucidate whether these results reflect increased risks (hence opportunities for prevention) of bone disease, metabolic syndrome and cardiovascular disease in this population.

Methylcrotonyl-CoA carboxylase (MCC) deficiency associated with severe muscle pain and physical disability in an adult

We present a patient with methylcrotonyl-CoA carboxylase (MCC) deficiency (McKusick 210200) who suffered from severe muscle pain and physical disability, and propose that this disorder be considered in the differential diagnosis of adult patients presenting with muscle pain and weakness.

Effect of high-dose vitamins, coenzyme Q and high-fat diet in paediatric patients with mitochondrial diseases

We reviewed the medical records of all patients with confirmed mitochondrial diseases treated with any or all of thiamin, riboflavin, coenzyme Q, vitamin C (approximately 10 mg/kg per day) and a high-fat diet (50-60% of caloric intake) between 1997 and 2003. There were 15 patients (9 male): 10 had enzymatic deficiency and 10 had a molecular diagnosis. Age at diagnosis was 11 months to 17 years 10 months. Treatment was commenced at time of clinical diagnosis in 12 patients. Follow-up period was 3 days to 7 years (median 22 months). Improvement was reported in 9 patients, of whom 4 attained further developmental skills, but this was only temporary in 6 patients. Five patients died during the follow-up period (3 days to 7 years). Patients with the 3243A > G mutation showed no significant change in the course of their disease, except for fewer migraine attacks. Of the six patients who had seizures, one has had a significant reduction in the severity of the seizures and one has had no further seizures. Plasma lactate levels were noncontributory. We conclude that high-dose vitamin and cofactor treatment and, where applicable, high-fat diet, are well tolerated and possibly effective in the short term, but ineffective in the longer term.

The impact of galactosaemia on quality of life--a pilot study

Galactosaemia (galactose-1-phosphate uridyltransferase deficiency) is a pan-ethnic autosomal recessive disorder of galactose metabolism, with an estimated prevalence of 1 in 40-50000. In this pilot study, we aimed to examine the impact of galactosaemia on patients' everyday emotions, schooling, work, friendships, communication, physical activities, self-esteem and body image. We interviewed all patients with galactosaemia who attended our clinic over 2002-2003, aged 6 years and above (n = 13, age range 6-23 years) and, when possible, their parents (n = 12). The questionnaire used was based on an adaptation of the Minneapolis-Manchester QOL survey and the Australian Child Health Questionnaire. Interpersonal problems, bullying and having a hard time getting along with others, excessive anger on a regular basis, sleeping problems and problems with academic achievement, particularly with mathematics, were common. Significant differences were found between patients' and parents' perceptions, with 7/13 patients nominating the dietary restrictions and 4/7 parents nominating long-term issues as the most distressing aspect of having galactosaemia. In addition, most patients felt they were treated differently from their siblings by their parents, yet all parents felt they treated their child with galactosaemia as their other children. We conclude that galactosaemia has a significant impact on the psychosocial aspects of patients' lives. Clinicians should be aware that parents and patients can have different perspectives of the impact of galactosaemia on quality of life.

Diagnostic criteria for respiratory chain disorders in adults and children

BACKGROUND

Respiratory chain (RC) disorders are clinically, biochemically, and molecularly heterogeneous. The lack of standardized diagnostic criteria poses difficulties in evaluating diagnostic methodologies.

OBJECTIVE

To assess proposed adult RC diagnostic criteria that classify patients into "definite," "probable," or "possible" categories.

METHODS

The authors applied the adult RC diagnostic criteria retrospectively to 146 consecutive children referred for investigation of a suspected RC disorder. Data were collected from hospital, genetics, and laboratory records, and the diagnoses predicted by the adult criteria were compared with the previously assigned assessments.

RESULTS

The authors identified three major difficulties in applying the adult criteria:lack of pediatric-specific criteria; difficulty in segregating continuous data into circumscribed major and minor criteria; and lack of additivity of clinical features or enzyme tests. They therefore modified the adult criteria to allow for pediatric clinical and histologic features and for more sensitive coding of RC enzyme and functional studies. Reanalysis of the patients' data resulted in congruence between the diagnostic certainty previously assigned by the authors' center and that defined by the new general RC diagnostic criteria in 99% of patients.

CONCLUSIONS

These general diagnostic criteria appear to improve the sensitivity of the adult criteria. They need further assessment in prospective clinical and epidemiologic studies.

Pamidronate treatment improves bone mineral density in children with Menkes disease

Menkes disease is a severe multisystem disorder due to defective bioavailability and transport of copper at the cellular level. Deficient activity of lysyl oxidase, a copper-dependent enzyme, causes defective collagen cross-linking leading to osteoporosis and pathological fractures in these children. The objective of the study was to evaluate the changes in bone mineral density following pamidronate treatment in children with Menkes disease. The study design was an open observational study of three children with Menkes disease and significant osteoporosis with or without pathological fractures, all of whom received pamidronate treatment for 1 year. There were 34-55% and 16-36% increases in lumbar spine bone mineral content and areal bone mineral density, respectively, following 1 year of treatment with pamidronate. There were no further fractures in two of the three children treated. No adverse effects of pamidronate treatment were noted. Pamidronate treatment was associated with an increase in bone mineral density and may be an effective treatment modality for the management of osteoporosis in children with Menkes disease.

Clinical findings and biochemical and molecular analysis of four patients with holocarboxylase synthetase deficiency

Holocarboxylase synthetase (HLCS) deficiency (HLCSD) is a rare autosomal recessive disorder of biotin metabolism. HLCS catalyzes the biotinylation of the four human biotin-dependent carboxylases. Using the newly available human genomic sequence, we report the map of HLCS genomic structure and the predicted exon/intron boundaries. Moreover, the molecular studies of four patients (two Italians, one Iranian, and one Australian) affected by HLCS deficiency are here reported. The clinical findings, the age of onset, and response to biotin treatment differed between our patients. The diagnosis was made by organic acid analysis and confirmed by enzymatic analysis in three patients. Six mutations in the HLCS gene were identified, including two novel (N511K and G582R) and four known missense mutations (L216R, R508W, V550M, and G581S). Five of the mutations are localized within the HLCS biotin-binding domain, whereas the L216R amino acid change is located in the N-terminal region outside of the putative biotin-binding domain. This mutation, previously reported in a heterozygous state, was detected for the first time in a patient with homozygous status. The patient's severe clinical phenotype and partial responsiveness to biotin support a genotype-phenotype correlation through the involvement of residues of the N-terminal region in a substrate specificity recognition or regulation of the HLCS enzyme.

How practical are recommendations for dietary control in phenylketonuria?

In patients with phenylketonuria, blood phenylalanine concentration during childhood is the major determinant of cognitive outcome. Guidelines provide age-related recommendations for treatment. To ascertain the extent to which these aims are achievable, we audited results from four centres for the years 1994-2000. The median proportion of samples with phenylalanine concentrations above those recommended was less than 30% for those younger than age 10 years but almost 80% for those aged 15 years and older. Similarly, the median frequency of blood sampling, expressed as a proportion of that recommended, was more than 80% for patients younger than 10 years but less than 50% by age 15 years. Our results indicate the difficulty of maintaining control in phenylketonuria, especially in older rather than younger children.

3-Hydroxyglutarate excretion is increased in ketotic patients: implications for glutaryl-CoA dehydrogenase deficiency testing

Three patients with ketosis had increased excretion of 3-hydroxyglutarate (21.8-37.9 micromol/mmol creatinine; controls 2.3 +/- 1.6), an indicator of glutaryl-CoA dehydrogenase deficiency (GDHD), which normalized when the patients were nonketotic. Clinical assessment of all three patients and enzyme studies in one patient were not consistent with GDHD. These findings were compared with those of other ketotic patients, who showed statistically significant increases in 3-hydroxyglutarate excretion (9.4 +/- 5.0 micromol/mmol creatinine; p < 0.01), and with those of a child with confirmed GDHD when she was both ketotic and nonketotic. Secondary increase in 3-hydroxyglutarate excretion during ketosis is a potential confounder in the diagnosis of GDHD.

Molybdopterin synthase mutations in a mild case of molybdenum cofactor deficiency

Molybdenum cofactor deficiency is a rare inborn error of metabolism with generally severe symptoms, most often including neonatal seizures and severe developmental delay. We describe a patient with an unusually mild form of the disease. Two mutations in MOCS2A (molybdenum cofactor synthesis enzyme 2A) were identified: a single base change, 16C > T, that predicts a Q6X substitution on one allele and a 19G > T transversion that predicts a valine to phenylalanine substitution, V7F, on the second. It is postulated that the milder clinical symptoms result from a low level of residual molybdopterin synthase activity derived from the 19G > T allele.

Carbohydrate-deficient glycoprotein syndrome 1b: a new answer to an old diagnostic dilemma

A patient with carbohydrate-deficient glycoprotein syndrome type 1b (CDGS1b) is reported. The patient presented at 5 months of age with failure to thrive, prolonged diarrhoea, hepatomegaly and elevated serum liver transaminases. Liver biopsy showed steatosis. A low serum albumin and elevated serum liver transaminases persisted throughout childhood during which he had repeated infectious illnesses. From the age of 10 years he had oesophageal and duodenal ulceration together with recurrent bacterial cholangitis. Liver biopsy demonstrated hepatic fibrosis. CDGS1b was suspected, supported by the finding of a protein-losing enteropathy and finally confirmed by showing a reduced phosphomannoseisomerase activity. This case illustrates a rare condition with a wide range of presentations.

Mitochondrial 3-hydroxy-3-methylglutaryl-CoA synthase deficiency: clinical course and description of causal mutations in two patients

Hereditary deficiency of mitochondrial HMG-CoA synthase (mHS, OMIM 600234) is a poorly defined, treatable, probably underdiagnosed condition that can cause episodes of severe hypoketotic hypoglycemia. We present clinical follow-up and molecular analysis of the two known mHS-deficient patients. The diagnosis of mHS deficiency is challenging because the symptoms and metabolite pattern are not specific. Moreover, enzyme analysis is technically difficult and requires sampling of an expressing organ such as liver. The patients, now aged 16 and 6 y, have normal development and have had no further decompensations since diagnosis. Patient 1 is homozygous for a phenylalanine-to-leucine substitution at codon 174 (F174L). Interestingly, although the F174 residue is conserved in vertebrate mHS and cytoplasmic HS isozymes, a Leu residue is predicted in the corresponding position of HS-like sequences from Caenorhabditis elegans, Arabidopsis thaliana, and Brassica juncea. Bacterial expression of human F174L-mHS produces a low level of mHS polypeptide with no detectable activity. Similarly, in purified cytoplasmic HS, which in contrast to purified human mHS is stable and can be studied in detail, the corresponding F-->L substitution causes a 10,000-fold decrease in V(max) and a 5-fold reduction in thermal stability. Patient 2 is a genetic compound of a premature termination mutation, R424X, and an as-yet uncharacterized mutant allele that is distinguishable by intragenic single nucleotide polymorphisms that we describe. Molecular studies of mHS are useful in patients with a suggestive clinical presentation.

Mutations in the 4-hydroxyphenylpyruvic acid dioxygenase gene are responsible for tyrosinemia type III and hawkinsinuria

The enzyme 4-hydroxyphenylpyruvic acid dioxygenase (HPD) catalyzes the reaction of 4-hydroxyphenylpyruvic acid to homogentisic acid in the tyrosine catabolism pathway. A deficiency in the catalytic activity of HPD may lead to tyrosinemia type III, an autosomal recessive disorder characterized by elevated levels of blood tyrosine and massive excretion of tyrosine derivatives into urine. It has been postulated that hawkinsinuria, an autosomal dominant disorder characterized by the excretion of 'hawkinsin,' may also be a result of HPD deficiency. Hawkinsin is a sulfur amino acid identified as (2-l-cystein-S-yl, 4-dihydroxycyclohex-5-en-1-yl)acetic acid. Patients with hawkinsinuria excrete this metabolite in their urine throughout their life, although symptoms of metabolic acidosis and tyrosinemia improve in the first year of life. We performed analyses of the HPD gene in a patient with tyrosinemia type III and two unrelated patients with hawkinsinuria. A homozygous missense mutation predicting an Ala to Val change at codon 268 (A268V) in the HPD gene was found in the patient with tyrosinemia type III. A heterozygous missense mutation predicting an Ala to Thr change at codon 33 (A33T) was found in the same HPD gene in the two patients with hawkinsinuria. These findings support the hypothesis that alterations in the structure and activity of HPD are causally related to two different metabolic disorders, tyrosinemia type III and hawkinsinuria.

Variables influencing parental perception of inherited metabolic diseases before and after genetic counselling

The present study was undertaken to characterize the variables that influence parental perception of metabolic disorders and their genetic origin before and after genetic counselling, the effect of counselling on parental attitudes towards prenatal diagnosis and pregnancy termination, and the factors affecting parental coping with burden. Parents of children with metabolic diseases from 32 Arab-Muslim families were interviewed, answering a pre-structured questionnaire. These interviews indicate the following. (1) Traditional belief and religious commitment are more important determinants than education in parental perception of inherited metabolic diseases. (2) The number of affected children has a greater impact on parental evaluation of the burden than the number of healthy children. The social component, i.e. the way families are viewed by society, is the most significant factor of the burden. (3) Parents use different techniques to divide responsibility regarding reproduction. Having a healthy child and the availability of prenatal diagnosis and pregnancy termination were the two most important factors in parental reproductive decision making. In the absence of a healthy child and when the burden was perceived as too heavy, parents tended 'not to decide'. (4) Parental attitude to pregnancy termination was dependent on two factors: religious commitment (leading to objection) and severity of disease (leading to flexibility and approval). (5) In almost all families, genetic counselling altered parental perception of the disease and its hereditary origin. We conclude that genetic counselling and population education may be helpful in the prevention of consanguineous marriages and in family planning, even in a society that values traditional beliefs very highly.

A missense mutation (His42Arg) in the T-protein gene from a large Israeli-Arab kindred with nonketotic hyperglycinemia

Nonketotic hyperglycinemia (NKH) is caused by a mutation in the genes encoding the components of the glycine cleavage multi-enzyme system. More than 80% of the patients have defects in the gene encoding P-protein, whereas the rest of the patients have defects in the gene encoding T-protein. We have found a large Israeli-Arab kindred with NKH. At least 14 children were affected, and all the patients had seizures and respiratory failure within 2 days after birth. Enzymatic analysis revealed that T-protein activity was deficient in the liver specimen from one propositus. We screened this family for a mutation in the protein-coding region and exon/intron boundaries of T-protein gene by direct sequencing analysis. A missense mutation was found in exon 2; this resulted in an amino acid substitution from histidine to arginine at position 42 (H42R). Histidine 42 is conserved in human, bovine, chicken, pea, and Escherichia coli, suggesting that it has an important role in catalytic functions. Genotype analyses of 26 family members confirmed that the homozygous H42R mutation was completely associated with the onset of NKH. The availability of DNA testing facilitates the prenatal diagnosis of NKH and the identification of carriers, which is necessary for genetic counseling in the affected families.

Phorbol esters alter the morphology of cultured guinea-pig myenteric glia via a protein kinase C-independent mechanism

Cultures of myenteric ganglia from adult guinea-pigs were used to study the influence of neuroactive substances on glial cells by monitoring changes in their morphology. The following substances had no effect on glial morphology: adenosine, ATP, carbachol, glutamate, bradykinin, isoprenaline, prostaglandin E2, sodium nitroprusside and lipopolysaccharide. The only substances found to affect glial morphology were phorbol esters, and in particular phorbol 12-myrisate 13-acetate (PMA), which acted at the nM range. Glial cells, which were normally polygonal, assumed a stellate shape within 30-60 min after the addition of PMA. Protein kinase C (PKC) inhibitors did not block this effect, and PKC activators did not mimic it. The effect of PMA was also not mediated by changes in the intracellular concentrations of either Ca2+, H+ or cyclic AMP. Dye coupling among glial cells was blocked by PMA. The phorbol ester-mediated effect on glial structure may have profound influence on neuronal organization and function.

Effect of sphingosine on rat glial cells: inhibition of prostaglandin E2 and insensitivity of nitric oxide generation

The effect of sphingosine on lipopolysaccharide (LPS)-mediated protein kinase C (PKC) activation and prostaglandin E2 (PGE2) and nitric oxide (NO) production was studied in primary cultures of rat glial cells. Incubation of cells with LPS elicited translocation of PKC from the cytosolic to the membranous compartment, as shown by measuring PKC activity and by immunoblotting. Under these conditions, a sustained increase in both PGE2 and NO production was measured. Thus, PGE2 levels were 259 +/- 28 (n = 8) and 230 +/- 48 (n = 4) (control levels 11.4 +/- 5.2 (n = 5) and 13 +/- 7.5 (n = 3)) pg/ml, at 24 and 48 h, respectively. NO levels were 9.3 +/- 0.9 (n = 10) and 11.6 +/- 0.8 (n = 9) (control levels 0.4 +/- 0.18 and 1.0 +/- 0.44) nmol/ml, at 24 and 48 h, respectively. Sphingosine, a naturally occurring compound, which inhibits PKC activity, elicited a concentration-dependent decrease in LPS-mediated PGE2 production. This inhibition was more pronounced after 48 h than after 24 h of incubation (IC50 = 8 and 20 microg sphingosine, respectively). By contrast, sphingosine did not inhibit NO production under the same conditions. We conclude that sphingosine may be involved in modulation of the local inflammatory response in glial cells, at least in part. We also surmise that LPS-mediated PGE2 production and NO production are probably regulated by different mechanisms, i.e., a PKC-dependent and a PKC-independent mechanism.

Short stature, moderate mental retardation, hyperactivity, facial dysmorphism, skeletal abnormalities, and exaggerated ketosis: a new syndrome

We describe three siblings who presented with short stature, hyperactivity, delayed speech and moderate psychomotor retardation. In addition, they had dysmorphic features, a peculiar combination of skeletal abnormalities, small kidneys and exaggerated fasting ketosis. We suggest that they represent a new syndrome. The possibility of end-organ receptor failure is suggested.

Hereditary deficiency of vitamin K-dependent coagulation factors with skeletal abnormalities

We describe a female infant who presented with severe intracranial bleeding and was found to have a hereditary deficiency of vitamin K-dependent coagulation factors. She also had mild stippling of the left femoral epiphysis and shortness of the distal phalanges of the fingers. We studied the possible relationship between these abnormalities and a peroxisomal defect and followed their responses to treatment with vitamin K. The level of vitamin K-dependent clotting factors returned to near-normal following treatment with pharmacological doses of vitamin K, but there was no effect on the skeletal abnormalities.

Protein kinase C activation and phosphate uptake are altered in intact mucolipidosis type-4 skin fibroblasts

Mucolipidosis type 4 (ML-4) is an autosomal recessive inborn error of metabolism, the pathogenesis of which is not known. We characterized protein kinase C (PKC) activation and cellular phosphate uptake in intact quiescent ML-4 skin fibroblasts and after stimulation with phorbol myristate acetate (PMA). [3H]Phorbol dibutyrate uptake was not altered in ML-4 compared to control cells. Translocation of PKC from the cytosolic to the membranous compartment upon stimulation with PMA was perturbed in ML-4 cells. Phosphate uptake was reduced in both cytosolic and membranous fractions of quiescent ML-4 cells. Stimulation with PMA did not elicit an increase in phosphate uptake in the cytosolic fraction of ML-4 cells compared with control cells, but led to comparable phosphate uptake in the membranous fraction of both cell types. The data indicate that PKC-mediated signal transduction may be perturbed in ML-4. Other kinases and phosphatases may be involved. These alterations may play an important role in the pathogenesis of this disorder.

Prognostic clues and outcome of early treatment of nonketotic hyperglycinemia

Nonketotic hyperglycinemia presenting in the neonatal period is considered a devastating neurological condition. Most patients die soon after birth, and those who survive manifest severe neurological deficits, psychomotor retardation, and convulsions that are difficult to control. These abnormalities probably result from overstimulation of the N-methyl-D-aspartate receptor in the brain. In the present study, we wished to delineate prognostic clues for patients with neonatal (classic) nonketotic hyperglycinemia and to evaluate the results of early treatment with glycine-receptor modulators. The charts of six children treated in our department since 1991 were reviewed for details that might contribute to the prediction of prognosis. Postnatal clinical presentation and initial cerebrospinal fluid and plasma glycine levels were not predictive of outcome, but early treatment with N-methyl-D-aspartate modulators appeared to reduce late neurological complications and probably is as important as treatment with sodium benzoate. Attainment of developmental milestones, however, varies from one patient to another, presumably because of a factor or factors still unknown.

Protein kinase C activity, phosphate uptake and endogenous substrate phosphorylation are altered in Zellweger syndrome

Protein kinase C (PKC) is a key enzyme in lipid-mediated signal transduction. Regulation of PKC activation is dependent upon the phospholipid constituents of cellular membranes. PKC is also activated by very long-chain and long-chain cis-unsaturated fatty acids. The present study was undertaken as a first step towards elucidating a possible role for PKC in the pathogenesis of Zellweger syndrome, in which there are both perturbation of plasma membrane phospholipids and accumulation of very long-chain fatty acids. PKC activity, phosphate uptake and endogenous substrate phosphorylation were examined in intact human skin fibroblasts from Zellweger patients. PKC catalytic activity was increased in the membranous fraction of Zellweger cells compared with control cells, with no apparent translocation of the enzyme from the cytosolic to the membranous compartment. Phosphate uptake was increased in both cytosolic and membranous fractions 2.5-fold and 4.5-fold, respectively. Several proteins were extensively phosphorylated in Zellweger cells compared with control cells. These findings indicate that PKC activity is perturbed in Zellweger cells, but the exact role of PKC in altered phosphate uptake and protein phosphorylation and its relevance to the pathogenesis of Zellweger syndrome require further study.

Possible role for protein kinase C in the pathogenesis of inborn errors of metabolism

Protein kinase C (PKC) is a ubiquitous enzyme family implicated in the regulation of a large number of short- and long-term intracellular processes. It is hypothesized that modulation of PKC activity may represent, at least in part, a functional link between mutations (genotype) that lead to the pathological accumulation of naturally occurring compounds that affect PKC activity and perturbation of PKC-mediated substrate phosphorylation and cellular function in the corresponding diseases (phenotype). This model provides a unifying putative mechanism by which the phenotypic expression of some inborn errors of metabolism may be explained. Recent studies in a cell-free system of human skin fibroblasts support the hypothesis that alteration of PKC activity may represent the functional link between accumulation of sphingolipids and fatty acyl-CoA esters, and perturbation of cell function in sphingolipidoses and fatty acid oxidation defects, respectively. Further studies will elucidate the effects of these alterations on PKC-mediated short- and long-term cellular functions in these diseases, as well as the possible role of PKC in the pathogenesis of other diseases.

Myositis ossificans progressiva: a 10-year follow-up on a patient treated with etidronate disodium

We describe a child who was treated for 10 years with etidronate disodium for myositis ossificans. There were no typical bouts of swelling, reddening or hardening of areas over the skeletal muscles with this treatment and there were no side effects. Nevertheless, a constant gradual progression of the disease led to severe limitation of joint movement. This is the first report on long-term treatment with etidronate disodium.

Effect of fatty acids and their acyl-CoA esters on protein kinase C activity in fibroblasts: possible implications in fatty acid oxidation defects

We studied the effect of fatty acids and their acyl-CoA esters on protein kinase C (PK-C) activity in human skin fibroblasts. Butyrate, octanoate, palmitate and oleate did not alter PK-C activity in either cytosolic or particulate fraction. In the presence of calcium, phosphatidylserine and diacylglycerol, both palmitoyl-CoA (Pal-CoA) and oleoyl-CoA (Ole-CoA) enhanced particulate PK-C activity by approx. 70% and octanoyl-CoA (Oct-CoA) by approx. 35%. Partially purified cytosolic PK-C activity was enhanced by 60-70% by 13.5 microM of either Pal-CoA or Ole-CoA. Basal histone phosphorylation (i.e., PK-C-independent phosphorylation) was decreased in the particulate fraction in the presence of these esters in a concentration-dependent manner. Both Pal-CoA and Ole-CoA fully substituted diacylglycerol in activating the kinase in both the cytosolic and particulate fractions, whereas Oct-CoA had a moderate effect. The pattern of endogenous cytosolic and particulate protein phosphorylation was altered in the presence of either Pal-CoA or Ole-CoA. We conclude that long-chain fatty acyl-CoA esters may activate PK-C in non-stimulated fibroblasts, i.e., in the absence of physiological diacylglycerol formation. Activation of PK-C in stimulated fibroblasts, i.e., in the presence of an elevated diacylglycerol concentration, is less pronounced. These results support the hypothesis that activation of PK-C and alteration of endogenous protein phosphorylation may play a role in the pathogenesis of diseases in which there is intracellular accumulation of fatty acyl-CoA esters, such as in inborn fatty-acid oxidation defects.

Bilirubin inhibits protein kinase C activity and protein kinase C-mediated phosphorylation of endogenous substrates in human skin fibroblasts

The primary target and molecular basis of bilirubin toxicity to cellular function are not known. We have studied the effect of bilirubin on protein kinase C activity in subcellular fractions of human skin fibroblasts and on protein kinase C-mediated phosphorylation of endogenous substrates. Bilirubin inhibited the kinase activity in a concentration-dependent manner: a 50% inhibition was achieved by 45 mumol/l in the homogenate and 75 mumol/l in both the cytosolic and membranous fractions. Inhibition of protein kinase C activity by bilirubin was reversed by increasing the concentrations of activating lipids in both the cytosolic and membranous fractions. Bilirubin-induced inhibition of phosphorylation of endogenous proteins, in both fractions, was noted in the presence of calcium and the activating lipids, but not in the absence of the activators. This inhibition may play a role in the pathogenesis of bilirubin toxicity.

Inhibition of protein kinase C activity in mucolipidosis type-4: a model for a new pathogenetic mechanism in inborn errors of metabolism

Inhibition of protein kinase C [PK-C] activity by sphingosine and its derivatives has been suggested to play a role in the pathogenesis of sphingolipidoses. In the present study, PK-C activity and PK-C-mediated phosphorylation of endogenous substrates were studied in skin fibroblasts from patients with mucolipidosis type 4 [ML-4], in which there is accumulation of the phospholipids phosphatidylcholine, lysophosphatidylcholine, phosphatidylethanolamine as well as gangliosides. Cytosolic PK-C activity in 5 ML-4 cell lines was comparable to that in control cells. PK-C activity in the particulate fraction of these cells was 84 +/- 14 pmol 32P/mg protein per min compared with 267 +/- 26 in control cells. Increasing the concentrations of the activating lipids in the reaction mixture did not enhance PK-C activity in ML-4 cells, suggesting a non-competitive inhibition of the kinase. Following partial purification of the enzyme from the particulate fraction PK-C activity increased to 288 +/- 14 and 339 +/- 12 pmol 32P/mg protein per min in ML-4 and control cells, respectively. The phosphorylation pattern of endogenous substrates in the particulate fraction of ML-4 cells differed from that in control cells both in the absence and in the presence of calcium and activating lipids. We suggest that PK-C may be involved in the pathogenesis of sphingolipidoses and that this may represent an example for a new type of pathogenetic mechanisms in inborn errors of metabolism.

Widespread hemangiomatosis of bone associated with rickets: recovery after irradiation

We describe a 15-year-old boy with hemangiomatosis of bone and hypophosphatemic rickets. The rickets was ameliorated by irradiation of the skeletal lesions.

Differential effects of phorbol myristate acetate and dexamethasone on protein kinase C activity and eicosanoids production in cultured rat astrocytes

The effects of phorbol myristate acetate (PMA) and dexamethasone on protein kinase C (PK-C) activity and eicosanoid production were characterized in primary cultures of rat glial cells. PMA (1,000 ng/ml) treatment for 2 hr resulted in a maximal effect (a 4-fold increase in PGE2 production). Longer exposure to PMA (up to 96 hr) resulted in attenuation of PGE2 production. Down-regulation of PK-C activity was assessed in glial cell homogenates under these conditions. Although a 70% inhibition of PK-C activity was measured upon staurosporine treatment, PGE2 production was not affected both under basal conditions and following PMA activation. The production of thromboxane B2 did not change following exposure to PMA. Pretreatment of the cultures with dexamethasone markedly inhibited the PMA-stimulated production of PGE2 but had only a moderate (approximately 26%) inhibitory effect on PGE2 production under basal conditions. Dexamethasone had no effect on basal or PMA-stimulated PK-C activity. Forskolin, which activates adenylate cyclase, did not affect PGE2 production. These data may suggest that activation of PGE2 production by PMA in glial cells is not unequivocally mediated by PK-C activation. The inhibitory effect of dexamethasone on the PMA-stimulated synthesis of PGE2 supports previous findings that glucocorticoids are more effective in inhibiting stimulated rather than basal PGE2 production.

Glucocorticoid regulation of eicosanoid production by glial cells under basal and stimulated conditions

We measured the production of two eicosanoids, prostaglandin E2 and thromboxane-B2, by rat glial cell cultures under basal conditions, following stimulation with phorbol-12-myristate-13-acetate and the bacterial endotoxin lipopolysaccharide, and following treatment with synthetic glucocorticoids. Stimulation of rat glial cells in culture with either phorbol-12-myristate-13-acetate or lipopolysaccharide caused a 1.5-5.0-fold increase in prostaglandin E2 production, but did not affect thromboxane production. Pretreatment of the cultures with dexamethasone markedly inhibited the stimulated production of prostaglandin E2 but had only a modest effect on basal production. Dexamethasone did not affect the activity of the enzyme protein kinase C, a putative regulator of eicosanoid synthesis. Our findings show that glucocorticoids have the potential to modulate central nervous system eicosanoid production particularly under conditions of stimulated production, such as inflammatory and demyelinating disorders. This mechanism may explain, at least in part, the therapeutic benefit of glucocorticoids in patients with multiple sclerosis.

Nonketotic hyperglycinemia presenting with pin-point pupils and hyperammonemia

We describe two siblings who presented with lethargy, decreased sucking, respiratory failure and seizures in their first days of life. Pin-point pupils were noted in both siblings. Amino acid analysis revealed elevated concentrations of glycine in plasma and cerebrospinal fluid (CSF), with abnormal CSF/plasma ratios, compatible with hyperglycinemia. Urine organic acid analysis was unremarkable. Hyperammonemia was found in both siblings, but this subsided within 24-72 h. We suggest that pin-point pupils may be an additional presenting sign of nonketotic hyperglycinemia and, if looked for early enough, hyperammonemia may be found in this disorder.

A radiometric assay for aspartoacylase activity in human fibroblasts: application for the diagnosis of Canavan's disease

A new sensitive method for measuring aspartoacylase activity in human skin fibroblasts using [3H]N-acetyl-L-aspartic acid (NAA) is described. Optimal assay conditions and kinetic parameters for enzyme activity were determined. The enzyme was found to have maximal activity at pH 8.5, and the Michaelis constant for the substrate N-acetylaspartate was 1.8-2.0 mmol/l. Aspartoacylase activity in control cultured human fibroblasts was 9.2 +/- 1.8 nmol/h per mg protein, compared with 1.1 +/- 0.2 in seven Canavan patients and 3.5 +/- 0.9 in four patients' parents. This method for determining aspartoacylase activity is advantageous to the previously described spectrophotometric method since it is rapid, more sensitive and has less nonspecific interference. It is possible that application of this technique to cultured ammniotic and chorionic villi cells may be used for prenatal diagnosis of Canavan's disease.

Evidence for protein kinase C involvement in the regulation of renal 25-hydroxyvitamin D3-24-hydroxylase

Although calcium-activated, phospholipid-dependent protein kinase (protein kinase C) has been implicated in the regulation of various steroidogenic pathways, comparatively little is known of its role in the metabolism of vitamin D. The present study was undertaken to determine whether protein kinase C is involved in the regulation of renal mitochondrial 25-hydroxyvitamin D3-24-hydroxylase (24-hydroxylase), the first enzyme in the C-24 oxidation pathway, a major catabolic pathway for vitamin D metabolites in kidney and other target tissues. We examined the effect of phorbol 12-myristate 13-acetate (PMA), a potent activator of protein kinase C, on 24-hydroxylase activity in fresh mouse renal tubules and correlated the changes in 24,25-dihydroxyvitamin D3 [24,25-(OH)2D3] production with translocation of protein kinase C and phosphorylation of mitochondrial proteins. PMA stimulated 24,25-(OH)2D3 synthesis, protein kinase C translocation from the cytosolic to the mitochondrial fraction, and phosphorylation of 30-35 K, 40 K, and 50 K mitochondrial proteins derived from 32P-labeled tubules. 4 alpha-Phorbol 12,13 didecanoate, an insert analog of PMA, did not elicit any of these effects. The synthetic diacylglycerol, oleoylacetyl glycerol, also stimulated 24,25-(OH)2D3 synthesis, whereas the protein kinase C inhibitors, H-7 and staurosporine, inhibited 24-hydroxylase activity. PMA did not further stimulate 24,25-(OH)2D3 production in tubules derived from mutant (Hyp) mice in which 24-hydroxylase and protein kinase C activities are elevated relative to normal. However, after treatment with H-7, 24-hydroxylase activity was reduced in both strains, and genotype differences were no longer apparent. Finally, H-7 failed to inhibit the induced renal 24-hydroxylase in tubules isolated from 1,25-dihydroxyvitamin D3-treated mice. These findings suggest a role for protein kinase C in the regulation of constitutive renal 24-hydroxylase and implicate the kinase in the aberrant expression of the hydroxylase in the Hyp mouse.

Calcium-activated, phospholipid-dependent protein kinase (protein kinase C): general aspects and experimental considerations

Calcium-activated, phospholipid-dependent protein kinase (protein kinase C) is a ubiquitous serine and threonine protein kinase that has been implicated in the regulation of a wide variety of cellular functions. Protein kinase C is tightly linked to signal transduction through phosphatidylinositol turnover, and interacts with the cAMP-protein kinase A pathway in either a "monodirectional" or "bidirectional" mode. The discovery and development of protein kinase C inhibitors and activators offer useful tools to investigate the role of the kinase in specific cellular functions. However, caution should be exercised in interpreting the results of these studies, with special attention directed at experimental design. The present review summarizes some of the general aspects of protein kinase C. Methodological considerations for planning experiments and interpretation of results are described. In addition, we present some examples for the role of protein kinase C in the pathogenesis of disease.