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Bisschoff M, Smuts I, Dercksen M, Schoonen M, Vorster BC, van der Watt G, Spencer C, Naidu K, Henning F, Meldau S, McFarland R, Taylor RW, Patel K, Fassad MR, Vandrovcova J, Wanders RJA, van der Westhuizen FH. Clinical, biochemical, and genetic spectrum of MADD in a South African cohort: an ICGNMD study. Orphanet J Rare Dis 2024; 19:15. [PMID: 38221620 PMCID: PMC10789041 DOI: 10.1186/s13023-023-03014-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 12/20/2023] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND Multiple acyl-CoA dehydrogenase deficiency (MADD) is an autosomal recessive disorder resulting from pathogenic variants in three distinct genes, with most of the variants occurring in the electron transfer flavoprotein-ubiquinone oxidoreductase gene (ETFDH). Recent evidence of potential founder variants for MADD in the South African (SA) population, initiated this extensive investigation. As part of the International Centre for Genomic Medicine in Neuromuscular Diseases study, we recruited a cohort of patients diagnosed with MADD from academic medical centres across SA over a three-year period. The aim was to extensively profile the clinical, biochemical, and genomic characteristics of MADD in this understudied population. METHODS Clinical evaluations and whole exome sequencing were conducted on each patient. Metabolic profiling was performed before and after treatment, where possible. The recessive inheritance and phase of the variants were established via segregation analyses using Sanger sequencing. Lastly, the haplotype and allele frequencies were determined for the two main variants in the four largest SA populations. RESULTS Twelve unrelated families (ten of White SA and two of mixed ethnicity) with clinically heterogeneous presentations in 14 affected individuals were observed, and five pathogenic ETFDH variants were identified. Based on disease severity and treatment response, three distinct groups emerged. The most severe and fatal presentations were associated with the homozygous c.[1067G > A];c.[1067G > A] and compound heterozygous c.[976G > C];c.[1067G > A] genotypes, causing MADD types I and I/II, respectively. These, along with three less severe compound heterozygous genotypes (c.[1067G > A];c.[1448C > T], c.[740G > T];c.[1448C > T], and c.[287dupA*];c.[1448C > T]), resulting in MADD types II/III, presented before the age of five years, depending on the time and maintenance of intervention. By contrast, the homozygous c.[1448C > T];c.[1448C > T] genotype, which causes MADD type III, presented later in life. Except for the type I, I/II and II cases, urinary metabolic markers for MADD improved/normalised following treatment with riboflavin and L-carnitine. Furthermore, genetic analyses of the most frequent variants (c.[1067G > A] and c.[1448C > T]) revealed a shared haplotype in the region of ETFDH, with SA population-specific allele frequencies of < 0.00067-0.00084%. CONCLUSIONS This study reveals the first extensive genotype-phenotype profile of a MADD patient cohort from the diverse and understudied SA population. The pathogenic variants and associated variable phenotypes were characterised, which will enable early screening, genetic counselling, and patient-specific treatment of MADD in this population.
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Affiliation(s)
- Michelle Bisschoff
- Focus area for Human Metabolomics, North-West University, Potchefstroom, South Africa
| | - Izelle Smuts
- Department of Paediatrics, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Marli Dercksen
- Centre for Human Metabolomics, North-West University, Potchefstroom, South Africa
| | - Maryke Schoonen
- Focus area for Human Metabolomics, North-West University, Potchefstroom, South Africa
| | - Barend C Vorster
- Centre for Human Metabolomics, North-West University, Potchefstroom, South Africa
| | - George van der Watt
- Division of Chemical Pathology, National Health Laboratory Services, University of Cape Town, Cape Town, South Africa
| | - Careni Spencer
- Division of Human Genetics, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Kireshnee Naidu
- Division of Neurology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Franclo Henning
- Division of Neurology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Surita Meldau
- Division of Chemical Pathology, National Health Laboratory Services, University of Cape Town, Cape Town, South Africa
| | - Robert McFarland
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - Robert W Taylor
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - Krutik Patel
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Mahmoud R Fassad
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Jana Vandrovcova
- Centre for Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Ronald J A Wanders
- Department of Clinical Chemistry, Laboratory Genetic Metabolic Diseases, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Keshri S, Goel AK, Johns J, Shah S. "Liver Failure in an Infant of Late-Onset Glutaric Aciduria Type II": Case Report. Indian J Clin Biochem 2023; 38:545-549. [PMID: 37746538 PMCID: PMC10516837 DOI: 10.1007/s12291-021-01007-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 09/18/2021] [Indexed: 10/20/2022]
Abstract
Glutaric aciduria type II, also known as Multiple acyl-CoA Dehydrogenase Deficiency, results from a defect in the mitochondrial electron transport chain resulting in an inability to break down fatty-acids and amino acids. There are three phenotypes- type 1 and 2 are of neonatal onset and severe form, with and without congenital anomalies, respectively, and presents with acidosis, severe hypotonia, cardiomyopathy, hepatomegaly, and non-ketotic hypoglycemia. Type 3 or late-onset Multiple acyl-CoA Dehydrogenase Deficiency usually presents in the adolescent or adult age group with phenotype ranging from mild forms of myopathy and exercise intolerance to severe forms of acute metabolic decompensation on its chronic course. Type 3 Multiple acyl-CoA Dehydrogenase Deficiency rarely presents in infancy and in liver failure. We present a five-month-old developmentally normal female child with acute encephalopathy, hypotonia, non-ketotic hypoglycemia, metabolic acidosis, and liver failure, with a history of sibling death of suspected inborn error of metabolism. The blood acyl-carnitine levels in Tandem Mass Spectrometry and urinary organic acid analysis through Gas Chromatography-Mass Spectrometry were unremarkable. The patient initially responded to riboflavin, CoQ, and supportive management but ultimately succumbed to sepsis with shock and multi-organ dysfunction. The clinical exome sequencing reported a homozygous missense variation in exon 11 of the ETFDH gene (chr4:g.158706270C > T) that resulted in the amino acid substitution of Leucine for Proline at codon 456 (p.Pro456Leu) suggestive of Glutaric aciduria type IIc (OMIM#231,680).
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Affiliation(s)
- Swasti Keshri
- Department of Pediatrics & Pediatric Emergency, All India Institute of Medical Sciences, Raipur, Chhattisgarh 492099 India
| | - Anil Kumar Goel
- Department of Pediatrics & Pediatric Emergency, All India Institute of Medical Sciences, Raipur, Chhattisgarh 492099 India
| | - Juliet Johns
- Department of Pediatrics & Pediatric Emergency, All India Institute of Medical Sciences, Raipur, Chhattisgarh 492099 India
| | - Seema Shah
- Department of Biochemistry, All India Institute of Medical Sciences, Tatibandh, Raipur, Chhattisgarh 492099 India
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De Pasquale L, Meo P, Fulia F, Anania A, Meli V, Mondello A, Raimondo MT, Tulino V, Coletta MS, Cacace C. A fatal case of neonatal onset multiple acyl-CoA dehydrogenase deficiency caused by novel mutation of ETFDH gene: case report. Ital J Pediatr 2022; 48:164. [PMID: 36064718 PMCID: PMC9446717 DOI: 10.1186/s13052-022-01356-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multiple acyl-CoA dehydrogenase deficiency (MADD) or glutaric aciduria type II is an extremely rare autosomal recessive inborn error of fatty acid beta oxidation and branched-chain amino acids, secondary to mutations in the genes encoding the electron transfer flavoproteins A and B (ETFs; ETFA or ETFB) or ETF dehydrogenase (ETFDH). The clinical manifestation of MADD are heterogeneous, from severe neonatal forms to mild late-onset forms. CASE PRESENTATION We report the case of a preterm newborn who died a few days after birth for a severe picture of untreatable metabolic acidosis. The diagnosis of neonatal onset MADD was suggested on the basis of clinical features displaying congenital abnormalities and confirmed by the results of expanded newborn screening, which arrived the day the newborn died. Molecular genetic test revealed a homozygous indel variant c.606 + 1 _606 + 2insT in the ETFDH gene, localized in a canonical splite site. This variant, segregated from the two heterozygous parents, is not present in the general population frequency database and has never been reported in the literature. DISCUSSION AND CONCLUSION Recently introduced Expanded Newborn Screening is very important for a timely diagnosis of Inherited Metabolic Disorders like MADD. In some cases which are the most severe, diagnosis may arrive after symptoms are already present or may be the neonate already died. This stress the importance of collecting all possible samples to give parents a proper diagnosis and a genetic counselling for future pregnacies.
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Affiliation(s)
- Loredana De Pasquale
- Azienda Sanitaria Provinciale di Messina - Neonatal Intensive Care Unit, Barone Romeo Hospital, Patti, ME, Italy.
| | - Petronilla Meo
- Azienda Sanitaria Provinciale di Messina - Neonatal Intensive Care Unit, Barone Romeo Hospital, Patti, ME, Italy
| | - Francesco Fulia
- Azienda Sanitaria Provinciale di Messina - Neonatal Intensive Care Unit, Barone Romeo Hospital, Patti, ME, Italy
| | - Antonio Anania
- Azienda Sanitaria Provinciale di Messina - Neonatal Intensive Care Unit, Barone Romeo Hospital, Patti, ME, Italy
| | - Valerio Meli
- Azienda Sanitaria Provinciale di Messina - Neonatal Intensive Care Unit, Barone Romeo Hospital, Patti, ME, Italy
| | - Antonina Mondello
- Azienda Sanitaria Provinciale di Messina - Neonatal Intensive Care Unit, Barone Romeo Hospital, Patti, ME, Italy
| | - Maria Tindara Raimondo
- Azienda Sanitaria Provinciale di Messina - Neonatal Intensive Care Unit, Barone Romeo Hospital, Patti, ME, Italy
| | - Viviana Tulino
- Azienda Sanitaria Provinciale di Messina - Neonatal Intensive Care Unit, Barone Romeo Hospital, Patti, ME, Italy
| | - Maria Sole Coletta
- Azienda Sanitaria Provinciale di Messina - Neonatal Intensive Care Unit, Barone Romeo Hospital, Patti, ME, Italy
| | - Caterina Cacace
- Azienda Sanitaria Provinciale di Messina - Neonatal Intensive Care Unit, Barone Romeo Hospital, Patti, ME, Italy
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Mereis M, Wanders RJA, Schoonen M, Dercksen M, Smuts I, van der Westhuizen FH. Disorders of flavin adenine dinucleotide metabolism: MADD and related deficiencies. Int J Biochem Cell Biol 2020; 132:105899. [PMID: 33279678 DOI: 10.1016/j.biocel.2020.105899] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 12/13/2022]
Abstract
Multiple acyl-coenzyme A dehydrogenase deficiency (MADD), or glutaric aciduria type II (GAII), is a group of clinically heterogeneous disorders caused by mutations in electron transfer flavoprotein (ETF) and ETF-ubiquinone oxidoreductase (ETFQO) - the two enzymes responsible for the re-oxidation of enzyme-bound flavin adenine dinucleotide (FADH2) via electron transfer to the respiratory chain at the level of coenzyme Q10. Over the past decade, an increasing body of evidence has further coupled mutations in FAD metabolism (including intercellular riboflavin transport, FAD biosynthesis and FAD transport) to MADD-like phenotypes. In this review we provide a detailed description of the overarching and specific metabolic pathways involved in MADD. We examine the eight associated genes (ETFA, ETFB, ETFDH, FLAD1, SLC25A32 and SLC52A1-3) and clinical phenotypes, and report ∼436 causative mutations following a systematic literature review. Finally, we focus attention on the value and shortcomings of current diagnostic approaches, as well as current and future therapeutic options for MADD and its phenotypic disorders.
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Affiliation(s)
- Michelle Mereis
- Human Metabolomics, North-West University, Potchefstroom, South Africa
| | - Ronald J A Wanders
- Department of Clinical Chemistry, Laboratory Genetic Metabolic Diseases, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Maryke Schoonen
- Human Metabolomics, North-West University, Potchefstroom, South Africa; Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
| | - Marli Dercksen
- Human Metabolomics, North-West University, Potchefstroom, South Africa
| | - Izelle Smuts
- Department of Paediatrics, Steve Biko Academic Hospital, University of Pretoria, South Africa
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Henriques BJ, Lucas TG, Martins E, Gaspar A, Bandeira A, Nogueira C, Brandão O, Rocha H, Vilarinho L, Gomes CM. Molecular and Clinical Investigations on Portuguese Patients with Multiple acyl-CoA Dehydrogenase Deficiency. Curr Mol Med 2020; 19:487-493. [PMID: 31418342 DOI: 10.2174/1566524019666190507114748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Multiple Acyl-CoA Dehydrogenase Deficiency (MADD) is a congenital rare metabolic disease with broad clinical phenotypes and variable evolution. This inborn error of metabolism is caused by mutations in the ETFA, ETFB or ETFDH genes, which encode for the mitochondrial ETF and ETF:QO proteins. A considerable group of patients has been described to respond positively to riboflavin oral supplementation, which constitutes the prototypic treatment for the pathology. OBJECTIVES To report mutations in ETFA, ETFB and ETFDH genes identified in Portuguese patients, correlating, whenever possible, biochemical and clinical outcomes with the effects of mutations on the structure and stability of the affected proteins, to better understand MADD pathogenesis at the molecular level. METHODS MADD patients were identified based on the characteristic urinary profile of organic acids and/or acylcarnitine profiles in blood spots during newborn screening. Genotypic, clinical and biochemical data were collected for all patients. In silico structural analysis was employed using bioinformatic tools carried out in an ETF:QO molecular model for the identified missense mutations. RESULTS A survey describing clinical and biochemical features of eight Portuguese MADD patients was made. Genotype analysis identified five ETFDH mutations, including one extension (p.X618QextX*14), two splice mutations (c.34+5G>C and c.405+3A>T) and two missense mutations (ETF:QO-p.Arg155Gly and ETF:QO-p.Pro534Leu), and one ETFB mutation (ETFβ- p.Arg191Cys). Homozygous patients containing the ETFDH mutations p.X618QextX*14, c.34+5G>C and ETF:QO-p.Arg155Gly, all presented severe (lethal) MADD phenotypes. However, when any of these mutations are in heterozygosity with the known ETF:QO-p.Pro534Leu mild variant, the severe clinical effects are partly and temporarily attenuated. Indeed, the latter destabilizes an ETF-interacting loop, with no major functional consequences. However, the position 155 in ETF:QO is localized at the ubiquinone binding and membrane interacting domain, and is thus expected to perturb protein structure and membrane insertion, with severe functional effects. Structural analysis of molecular models is therefore demonstrated to be a valuable tool to rationalize the effects of mutations in the context of the clinical phenotype severity. CONCLUSION Advanced molecular diagnosis, structural analysis and clinical correlations reveal that MADD patients harboring a severe prognosis mutation in one allele can actually revert to a milder phenotype by complementation with a milder mutation in the other allele. However, such patients are nevertheless in a precarious metabolic balance which can revert to severe fatal outcomes during catabolic stress or secondary pathology, thus requiring strict clinical follow-up.
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Affiliation(s)
- Bárbara J Henriques
- Biosystems and Integrative Sciences Institute, Faculdade de Ciencias, Universidade de Lisboa, and Departamento de Quimica e Bioquimica, Faculdade de Ciencias, 1749-016 Lisboa, Portugal
| | - Tânia G Lucas
- Biosystems and Integrative Sciences Institute, Faculdade de Ciencias, Universidade de Lisboa, and Departamento de Quimica e Bioquimica, Faculdade de Ciencias, 1749-016 Lisboa, Portugal
| | - Esmeralda Martins
- Centro de Referencia na area de Doencas Hereditarias do Metabolismo, Centro Hospitalar do Porto - CHP, Porto, Portugal
| | - Ana Gaspar
- Unidade de Doencas Metabolicas, Centro Hospitalar Lisboa Norte - Hospital Santa Maria, Lisboa, Portugal
| | - Anabela Bandeira
- Centro de Referencia na area de Doencas Hereditarias do Metabolismo, Centro Hospitalar do Porto - CHP, Porto, Portugal
| | - Célia Nogueira
- Unidade de Rastreio Neonatal, Metabolismo e Genetica, Departamento de Genetica Humana - Instituto Nacional de Saude Doutor Ricardo Jorge, Porto, Portugal
| | - Otilia Brandão
- Servico de Patologia Clinica, Hospital Sao Joao, Porto, Portugal
| | - Hugo Rocha
- Unidade de Rastreio Neonatal, Metabolismo e Genetica, Departamento de Genetica Humana - Instituto Nacional de Saude Doutor Ricardo Jorge, Porto, Portugal
| | - Laura Vilarinho
- Unidade de Rastreio Neonatal, Metabolismo e Genetica, Departamento de Genetica Humana - Instituto Nacional de Saude Doutor Ricardo Jorge, Porto, Portugal
| | - Cláudio M Gomes
- Biosystems and Integrative Sciences Institute, Faculdade de Ciencias, Universidade de Lisboa, and Departamento de Quimica e Bioquimica, Faculdade de Ciencias, 1749-016 Lisboa, Portugal
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Baş SŞ, Yıldırım GK. Sudden cardiac arrest during induction of anaesthesia in paediatric patient with glutaric aciduria type II. Sudan J Paediatr 2020; 20:58-61. [PMID: 32528202 DOI: 10.24911/sjp.106-1580816331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Glutaric aciduria type II (GA2) is an autosomal recessive metabolic disorder of amino acid and lipid metabolism, which is serious and rare. The most serious form is seen in early infancy and is associated with very high mortality rates. Here, we present an 8-month-old male patient with GA2 who had electrocardiographic ST ST-segment depression and sudden cardiac arrest at 10th minute of emergency operation (central venous catheter placement). There is a very scarce amount of data in the literature about anaesthetic management of GA2 patients. There is also no previously published report about cardiac arrest during induction of anaesthesia in this condition. The present report highlights this serious complication.
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Affiliation(s)
- Sema Şanal Baş
- Assistant Professor, Department of Anaesthesiology and Reanimation, M.D., Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Gonca Kılıç Yıldırım
- Assistant Professor, Pediatric Nutrition and Metabolism Unit, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
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Lucas TG, Henriques BJ, Gomes CM. Conformational analysis of the riboflavin-responsive ETF:QO-p.Pro456Leu variant associated with mild multiple acyl-CoA dehydrogenase deficiency. Biochim Biophys Acta Proteins Proteom 2020; 1868:140393. [PMID: 32087359 DOI: 10.1016/j.bbapap.2020.140393] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 02/09/2020] [Accepted: 02/17/2020] [Indexed: 01/07/2023]
Abstract
Multiple-CoA dehydrogenase deficiency (MADD) is an inborn disorder of fatty acid and amino acid metabolism caused by mutations in the genes encoding for human electron transfer flavoprotein (ETF) and its partner electron transfer flavoprotein:ubiquinone oxidoreductase (ETF:QO). Albeit a rare disease, extensive newborn screening programs contributed to a wider coverage of MADD genotypes. However, the impact of non-lethal mutations on ETF:QO function remains scarcely understood from a structural perspective. To this end, we here revisit the relatively common MADD mutation ETF:QO-p.Pro456Leu, in order to clarify how it affects enzyme structure and folding. Given the limitation in recombinant expression of human ETF:QO, we resort to its bacterial homologue from Rhodobacter sphaeroides (Rs), in which the corresponding mutation (p.Pro389Leu) was inserted. The in vitro biochemical and biophysical investigations of the Rs ETF:QO-p.Pro389Leu variant showed that, while the mutation does not significantly affect the protein α/β fold, it introduces some plasticity on the tertiary structure and within flavin interactions. Indeed, in the p.Pro389Leu variant, FAD exhibits a higher thermolability during thermal denaturation and a faster rate of release in temperature-induced dissociation experiments, in comparison to the wild type. Therefore, although this clinical mutation occurs in the ubiquinone domain, its effect likely propagates to the nearby FAD binding domain, probably influencing electron transfer and redox potentials. Overall, our results provide a molecular rational for the decreased enzyme activity observed in patients and suggest that compromised FAD interactions in ETF:QO might account for the known riboflavin responsiveness of this mutation.
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Affiliation(s)
- Tânia G Lucas
- Biosystems and Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Departamento de Química e Bioquímica, Faculdade de Ciências, Universidade de Lisboa, 1749-016 Lisboa, Portugal
| | - Bárbara J Henriques
- Biosystems and Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Departamento de Química e Bioquímica, Faculdade de Ciências, Universidade de Lisboa, 1749-016 Lisboa, Portugal
| | - Cláudio M Gomes
- Biosystems and Integrative Sciences Institute, Faculdade de Ciências, Universidade de Lisboa, Departamento de Química e Bioquímica, Faculdade de Ciências, Universidade de Lisboa, 1749-016 Lisboa, Portugal.
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Fischer T, Och U, Marquardt T. Long-term ketone body therapy of severe multiple acyl-CoA dehydrogenase deficiency: A case report. Nutrition 2018; 60:122-128. [PMID: 30557775 DOI: 10.1016/j.nut.2018.10.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 09/27/2018] [Accepted: 10/02/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Multiple acyl-CoA dehydrogenase deficiency (MADD) is the most severe disorder of mitochondrial fatty acid β-oxidation. Treatment of this disorder is difficult because the functional loss of the electron transfer flavoprotein makes energy supply from fatty acids impossible. Acetyl-CoA, provided by exogenous ketone bodies such as NaßHB, is the only treatment option in severe cases. Short-term therapy attempts have shown positive results. To our knowledge, no reports exist concerning long-term application of ketone body salts in patients with severe MADD. METHODS This case report is a detailed retrospective metabolic analysis of a boy with severe MADD. Treatment with sodium β-hydroxybutyrate (NaβHB) started 8 d after birth using gradually increasing doses. In the initial phase, metabolic and acid-base parameters were checked multiple times a day. After 8 y of standardized therapy with 16 g NaβHB, substitution with calcium β-hydroxybutyrate (CaβHB) was attempted. In addition to the β-hydroxybutyrate (βHB) supplementation, continuous adjustments were made to the child's nutrition to provide necessary nutrients. RESULTS Treatment with βHB salts leads to adverse effects like gastrointestinal discomfort and alkalosis. Measured concentrations of βHB were predominantly at 0.1 mmol/L or below detectable concentration. Nutritional therapy based on amino acid and acylcarnitine profiles is a necessary part of the therapy in MADD. CONCLUSIONS Therapy with NaβHB is lifesaving in cases of severe MADD but can have significant adverse effects. Supplementation with CaβHB led to gastrointestinal discomfort and had no additional positive clinical effect. The determined tolerable dose of βHB salt for long-term therapy was not high enough for a notable increase of βHB concentrations in blood.
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Affiliation(s)
- Tobias Fischer
- University of Applied Sciences Muenster, Department of Food, Nutrition, and Facilities, Muenster, Germany; University Hospital Muenster, Department of Pediatrics, Muenster, Germany.
| | - Ulrike Och
- University Hospital Muenster, Department of Pediatrics, Muenster, Germany
| | - Thorsten Marquardt
- University Hospital Muenster, Department of Pediatrics, Muenster, Germany
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van der Westhuizen FH, Smuts I, Honey E, Louw R, Schoonen M, Jonck LM, Dercksen M. A novel mutation in ETFDH manifesting as severe neonatal-onset multiple acyl-CoA dehydrogenase deficiency. J Neurol Sci 2017; 384:121-125. [PMID: 29249369 DOI: 10.1016/j.jns.2017.11.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 10/19/2017] [Accepted: 11/14/2017] [Indexed: 02/08/2023]
Abstract
Neonatal-onset multiple acyl-CoA dehydrogenase deficiency (MADD type I) is an autosomal recessive disorder of the electron transfer flavoprotein function characterized by a severe clinical and biochemical phenotype, including congenital abnormalities with unresponsiveness to riboflavin treatment as distinguishing features. From a retrospective study, relying mainly on metabolic data, we have identified a novel mutation, c.1067G>A (p.Gly356Glu) in exon 8 of ETFDH, in three South African Caucasian MADD patients with the index patient presenting the hallmark features of type I MADD and two patients with compound heterozygous (c.1067G>A+c.1448C>T) mutations presenting with MADD type III. SDS-PAGE western blot confirmed the significant effect of this mutation on ETFDH structural instability. The identification of this novel mutation in three families originating from the South African Afrikaner population is significant to direct screening and strategies for this disease, which amongst the organic acidemias routinely screened for, is relatively frequently observed in this population group.
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Affiliation(s)
| | - Izelle Smuts
- Department of Paediatrics, Steve Biko Academic Hospital, University of Pretoria, South Africa
| | - Engela Honey
- Department of Genetics, University of Pretoria, South Africa
| | - Roan Louw
- Human Metabolomics, North-West University, Potchefstroom, South Africa
| | - Maryke Schoonen
- Human Metabolomics, North-West University, Potchefstroom, South Africa
| | - Lindi-Maryn Jonck
- Human Metabolomics, North-West University, Potchefstroom, South Africa
| | - Marli Dercksen
- Human Metabolomics, North-West University, Potchefstroom, South Africa
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