Combined malonic and methylmalonic aciduria with normal malonyl-coenzyme A decarboxylase activity: A case supporting multiple aetiologies

We identified a patient who excreted large amounts of methylmalonic acid and malonic acid. In contrast to other patients who have been described with combined methylmalonic and malonic aciduria, our patient excreted much larger amounts of methylmalonic acid than malonic acid. Since most previous patients with this biochemical phenotype have been reported to have deficiency of malonyl-CoA decarboxylase, we assayed malonyl-CoA decarboxylase activity in skin fibroblasts derived from our patient and found the enzyme activity to be normal. We examined four isocaloric (2000 kcal/day) dietary regimes administered serially over a period of 12 days with 3 days devoted to each dietary regimen. These diets were high in carbohydrate, fat or protein, or enriched with medium-chain triglycerides. Diet-induced changes in malonic and methylmalonic acid excretion became evident 24–36 h after initiating a new diet. Total excretion of malonic and methylmalonic acid was greater (p<0.01) during a high-protein diet than during a high-carbohydrate or high-fat diet. A high-carbohydrate, low-protein diet was associated with the lowest levels of malonic and methylmalonic acid excretion. Perturbations in these metabolites were most marked at night. On all dietary regimes, our patient excreted 3–10 times more methylmalonic acid than malonic acid, a reversal of the ratios reported in patients with malonyl-CoA decarboxylase deficiency. Our data support a previous observation that combined malonicand methylmalonic aciduria has aetiologies other than malonyl-CoA decar-boxylase deficiency. The malonic acid to methylmalonic acid ratio in response to dietary intervention may be useful in identifying a subgroup of patients with normal enzyme activity.     

Tissue-specific regulation of malonyl-CoA decarboxylase activity in OLETF rats

AIM: The intracellular concentration of malonyl-CoA, a key regulator of fatty acid oxidation, is determined both from its synthesis by acetyl-CoA carboxylase and from its degradation by malonyl-CoA decarboxylase (MCD). The aim of our study was to investigate the activity and mRNA expression of MCD under insulin resistance and after treatment with insulin sensitizers in different tissues. METHODS: We treated 18-week Otusuka Long-Evans Tokushima Fatty (OLETF) rats with pioglitazone (10 mg/kg/day) or metformin (300 mg/kg/day) for 8 weeks and determined the activity and mRNA expression of MCD in diabetic OLETF and non-diabetic Long-Evans Tokushima Otsuka (LETO) rats in myocardial and skeletal muscles, and in liver. RESULTS: The MCD activities of myocardial and skeletal muscles were remarkably reduced in OLETF rats compared with LETO rats (995 +/- 114 vs. 2012 +/- 359, 58 +/- 11 vs. 167 +/- 40 pmol/min/mg protein; p = 0.005 and p = 0.010). Surprisingly, after pioglitazone treatment, not after metformin, the MCD activities of myocardial and skeletal muscles (1906 +/- 320 and 259 +/- 44 pmol/min/mg protein) increased up to the levels in LETO rats. MCD mRNA expression in OLETF rats was also reduced in myocardial and skeletal muscles vs. LETO rats (p = 0.049 and p = 0.008) and was unchanged by pioglitazone or metformin treatment. In the liver, MCD activity and mRNA expression were similar in OLETF and LETO rats. CONCLUSION: Pioglitazone treatment restored MCD activity to non-diabetic level and improved the restrained fatty acid metabolism in myocardial and skeletal muscles caused by insulin-resistant diabetic status.     

Coenzyme Q10 is decreased in fibroblasts of patients with methylmalonic aciduria but not in mevalonic aciduria

Summary  The content of coenzyme Q₁₀ (CoQ₁₀) was examined in skin fibroblasts of 10 patients with mevalonic aciduria (MVA) and of 22 patients with methylmalonic aciduria (MMA). Patients with these inborn errors of metabolism are thought to be at risk for CoQ₁₀ depletion either by direct inhibition of the proximal pathway of CoQ₁₀ synthesis (MVA) or indirectly by inhibition of mitochondrial energy metabolism (MMA). We demonstrated that CoQ₁₀ concentrations were not significantly different from controls in MVA patients, suggesting that there may be upregulatory effects. On the other hand the CoQ₁₀ content in fibroblasts of patients with MMA was significantly reduced. Competing interests: None declared References to electronic databases: Mevalonic aciduria: OMIM 251170. Hyperimmunoglobulinaemia D syndrome (HIDS): MIM 260920. Mevalonate kinase: EC 2.7.1.36. Methylmalonyl-CoA mutase: EC 5.4.99.2.     

Evaluation of branched-chain amino acid intake in children with maple syrup urine disease and methylmalonic aciduria

Summary The biochemical and growth responses to dietary branched-chain amino acid (BCAA) intake were studied in two children; one with a disorder of branched-chain amino acid metabolism, maple syrup urine disease (MSUD) (McKusick 24860), and another with methylmalonic aciduria (MMA) (McKusick 25100). Biochemical control of MSUD focussed on plasma leucine levels while measurement of plasma ammonia levels was used in MMA. From 0 to 2.75 years both patients exhibited five episodes of toxicity. In each case toxicity was associated with dietary indiscretion or infection. The quantity of protein tolerated was always less in the MMA patient and was approximately 1 g/kg/day. From 1 to 2.75 years each patient's growth velocity approximated their predicted growth channel except during periods of toxicity. In both cases leucine intake, which gave normal growth without toxicity, was always judged to be less than the FAO/WHO recommendations. The BCAA intake of the MMA patient was remarkably stable from 0.5 to 2.75 years and at 2 years of age isoleucine and valine intake approximated the FAO/WHO recommendations. From 2 to 2.75 years BCAA intake (mg/kg/day) of the MSUD patient was less than that of the MMA patient and well below FAO/WHO recommendations. Neuromotor development in both patients is normal.     

Ornithine decarboxylase activity during gastric ulcer healing in dogs

Ornithine decarboxylase (ODC) activity has been associated with mucosal growth and injury, yet, little information is available on ODC activity during gastric ulcer healing. We measured ODC activity in the ulcer base submucosa and the surrounding mucosa at 1 cm and 2 cm and assessed ulcer surface healing and a histologic score in experimentally induced ulcers (Quinton ulcer-maker) at 0 and 5 hr and at one, two, three, four, and seven days. A total of 26 dogs were studied, eight of which received 2% difluoromethylornithine (DFMO, a specific inhibitor of ODC) in drinking water. Ulcer healing was assessed by digitizing initial (plug size), and final ulcer surface area and was expressed as percent ulcer surface reduction. A histologic score was assessed by two independent pathologists unaware of the treatment. ODC induction was observed in the submucosa of the ulcer base but not in the surrounding mucosa. The baseline submucosal ODC activity was measured at 0.2±0.1 pmol (¹⁴CO₂)/mg protein/hr, and at one day the ODC activity increased to 4.0±0.7, at three days to 15.2±5.5, and at seven days to 2.6±1.0 (P<0.001). DFMO treatment delayed GU healing significantly up to three days, but no difference was noted at seven days. The assessed histologic parameters did not correlate with ODC activity, and DFMO treatment did not alter the histologic score. These data suggest that polyamine biosynthesis occurs in the ulcer base submucosa during the first seven days of experimentally placed gastric ulcers. Suppression of ODC activity with DFMO delays ulcer surface reduction during the first three days, but the significance of ODC induction and polyamine biosynthesis during early ulcer healing remains in question.     

The molecular landscape of propionic acidemia and methylmalonic aciduria in Latin America

In this work, we review the clinical and genetic data in 14 Latin American propionic acidemia (PA) and 15 methylmalonic aciduria (MMAuria) patients. In the PA patients, we have identified four different changes in the PCCA gene, including one novel one (c.414+5G>A) affecting the splicing process. The PCCB mutational spectrum included two prevalent changes accounting for close to 60% of the mutant alleles studied and one novel change (c.494G>C) which by functional analysis is clearly pathogenic. We have also identified the deep intronic change c.654+462A>G, and the results of the antisense treatment in the patient’s cell line confirmed the functional recovery of PCC activity. All PA patients bearing out-of-frame mutations presented the disease earlier while patients bearing in hemizygous fashion p.E168K and p.R165W presented the disease later. Regarding the MMAuria patients, we have found three novel mutations in the MUT gene (c.1068G>A, c.1587_1594del8 and c.593delA) and one in the MMAB gene (c.349-1 G>C). Two patients with MMAuria with homocystinuria cblC type are carriers of the frequent c.271dupA mutation. All mut ⁰ , cblB and cblC patients presented the symptoms early and in general had more neurological complications, while cblA and mut ^- patients exhibited a late-onset presentation, and in general the long-term outcome was better. The results presented in this work emphasize the importance of the genetic analysis of the patients not only for diagnostic purposes but also to research into novel therapies based on the genotype.     

Diagnosis of cobalamin deficiency I: usefulness of serum methylmalonic acid and total homocysteine concentrations

The serum cobalamin assay is the primary diagnostic test for cobalamin deficiency. It appears to be an excellent screening test since most patients with clinically confirmed cobalamin deficiency have low levels. Recent studies indicate that the clinical picture of cobalamin deficiency is much more diverse than previously believed. It is also apparent that many patients with low serum cobalamin concentrations are not cobalamin deficient. Thus, there is a need for additional diagnostic tests to further distinguish patients with low serum cobalamin levels who are actually cobalamin deficient and will benefit from lifetime treatment from those who are not deficient and will not benefit. Serum levels of methylmalonic acid and total homocysteine have been shown to be markedly elevated in most patients with cobalamin deficiency, and total homocysteine concentrations are markedly elevated in most patients with folate deficiency. The levels of these metabolites fall to normal if these patients are treated with the appropriate vitamin but remain essentially unchanged if the wrong vitamin is administered. These observations demonstrate that serum methylmalonic acid and total homocysteine levels are useful in diagnosing patients with cobalamin and folate deficiency and in distinguishing between these two vitamin deficiencies.     

Clinical heterogeneity and prognosis in combined methylmalonic aciduria and homocystinuria (cblC)

The clbC form of methylmalonic acidaemia is a rare and poorly understood condition which results from impaired biosynthesis of methylcobalamin and adenosylcobalamin. The consequent functional deficiencies of methylmalonyl-CoA mutase and methionine synthase produce both methylmalonic aciduria and homocystinuria. Systemic symptoms and neurological decompensation comprise the clinical phenotype. In an effort to clarify the phenotype and prognosis, we obtained clinical information on 50 patients with methylmalonic acidaemia whose cells had been assigned to the cblC complementation group. We identified two distinct phenotypes; they differed in age of onset, presence of systemic symptoms, type of neurological symptoms, and outcome after diagnosis and treatment. Forty-four patients presented in the first year of life. Feeding difficulties, neurological dysfunction (hypotonia, seizures, developmental delay), and ophthalmological and haematological abnormalities characterized their clinical picture. About one-quarter of those patients died. Survival was associated with neurological impairment; only one infant was neurologically intact at follow-up. Onset in childhood, in contrast, was associated with less severe haematological abnormalities, largely involving the red cell series. Extrapyramidal signs, dementia, delirium or psychosis characterized the neurological findings. Survival, with mild to moderate disability in some, was typical in patients with later onset. Treatment in both groups included hydroxycobalamin, betaine and carnitine; complete normalization of biochemical parameters was rare.     

Useful second-tier tests in expanded newborn screening of isovaleric acidemia and methylmalonic aciduria

Common use of pivalate-generating antibiotics in newborns in Japan and low cutoff value of C5-acylcarnitine (C5) to detect mild forms of isovaleric acidemia (IVA) led to 1,065 positive results from IVA screening among 146,000 newborns tested by tandem mass spectrometry over the last 3 years. Using our method to determine isovalerylglycine (IVG) levels in dried blood spots (DBS) as a second-tier test with IVG cutoff value of 0.5 nmol/ml in DBS, one patient with severe IVA was identified, and no recall of the second DBS was needed. Retrospective analysis revealed that most patients with moderate to severe forms of IVA have decreased free-carnitine levels shortly after birth and higher levels of IVG than those of C5, which suggests that this method is useful in evaluating the severity of IVA. Another second-tier test, to measure methylmalonic acid (MMA) levels in DBS by gas chromatography/mass spectrometry (GC/MS), has been developed to overcome difficulties in screening methylmalonic aciduria (MMAU) and propionic acidemia. Methanol extract from DBS was dried and derivatized using N-methyl-N-(tert-butyldimethylsilyl)-trifluoroacetamide. GC/MS was performed using splitless injection, electron-impact ionization, and selected ion monitoring for data recording. MMAU patients had much higher DBS concentrations of MMA (24.2–321.9 nmol/ml) than control newborns (0.34?±?0.11 nmol/ml). MMA measurement in DBS was thought to provide useful information about the severity of MMAU, as MMAU patients with high levels of MMA had decreased levels of free carnitine and mildly increased levels of propionylcarnitine.     

A G-protein editor gates coenzyme B12 loading and is corrupted in methylmalonic aciduria

The mechanism by which docking fidelity is achieved for the multitude of cofactor-dependent enzymes is poorly understood. In this study, we demonstrate that delivery of coenzyme B₁₂ or 5′-deoxyadenosylcobalamin by adenosyltransferase to methylmalonyl-CoA mutase is gated by a small G protein, MeaB. While the GTP-binding energy is needed for the editing function; that is, to discriminate between active and inactive cofactor forms, the chemical energy of GTP hydrolysis is required for gating cofactor transfer. The G protein chaperone also exerts its editing function during turnover by using the binding energy of GTP to elicit release of inactive cofactor that is occasionally formed during the catalytic cycle of MCM. The physiological relevance of this mechanism is demonstrated by a patient mutation in methylmalonyl-CoA mutase that does not impair the activity of this enzyme per se but corrupts both the fidelity of the cofactor-loading process and the ejection of inactive cofactor that forms occasionally during catalysis. Consequently, cofactor in the incorrect oxidation state gains access to the mutase active site and is not released if generated during catalysis, leading, respectively, to assembly and accumulation of inactive enzyme and resulting in methylmalonic aciduria.     

Plasma free fatty acid and glucose concentrations in Houssay dogs

Summary Results of two types of metabolic studies are reported in depancreatized-hypophysectomized dogs maintained without hormonal replacement therapy. The response to a glucose load indicated the presence of severe diabetes, although the animals were not ketonuric and fasting plasma sugars fluctuated around 200 mg %. The response to a single growth hormone injection was that of an acute reduction of the concentration of plasma FFA. Since this occurred in the complete absence of the action of insulin, mechanisms other than insulin-dependent esterification were involved.

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Zusammenfassung Es werden die Resultate von 2 metabolischen Studientypen bei pankreatektomierten-hypophysektomierten Hunden die man ohne hormonale Substitutionstherapie liess, mitgeteilt. Die Antwort auf die Glukosebelastung zeigte die Anwesenheit eines schweren Diabetes, wen auch die Tiere keine Ketonurie aufwiesen und der Nuechternblutzucker ungefaehr bei 200 mg% lag. Die Antwort auf eine einzige Injektion von Wachstumshormon bestand in einer akuten Abnahme der Konzentration der plasmatischen FFA. Da dies bei kompletter Abwesenheit einer Insulinwirkung stattfand, waren Mechanismen im Spiel, die sich von der insulin-abhaengigen Veresterung unterschieden.

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Resumen Se dan a conocer los resultados de dos tipos de estudios metabólicos en perros despancreatizados e hipofisectomizados mantenidos sin tratamiento hormonal sustitutivo. La respuesta a la carga de glucosa indicó la presencia de una diabetes grave, si bien los animales no fuesen quetonúricos y la glicemia en ayunas oscilase en los 200 mg % aproximadamente. La respuesta a una sola inyección de hormona del crecimiento correspondía a la de una reducción aguda de la concentración de los FFA plasmáticos. El hecho de que esto se verificó en completa ausencia de acción insulínica, significa que estaban implicados mecanismos distintos a los de la esterificación insulino-dependiente.

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Resume L'A. rapporte les résultats de deux types d'études métaboliques effectuées chez des chiens privés du pancréas et de l'hypophyse sans aucun traitement hormonal substitutif. La réaction à la charge de glucose a indiqué, chez ces animaux, la présence d'un diabète grave, malgré l'absence de cétonurie et un taux glycémique atteignant environ 200 mg % à jeun. La réaction à une seule injection d'hormone de la croissance correspondait à celle d'une réduction aiguë de la concentration de FFA plasmatiques. Cette situation s'étant manifestée en l'absence complète d'action insulinique, il y a lieu de penser à d'autres mécanismes que l'estérification dépendant de l'insuline.

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Riassunto Vengono riferiti i risultati di due tipi di studi metabolici in cani spancreati-ipofisectomizzati mantenuti senza terapia ormonale sostitutiva. La risposta al carico di glucosio ha indicato la presenza di un diabete grave, sebbene gli animali non fossero chetonurici e la glicemia a digiuno oscillasse intorno ai 200 mg %. La risposta ad una sola iniezione di ormone dell'accrescimento consistette in una riduzione acuta della concentrazione degli FFA plasmatici. Dal momento che ciò si è verificato in completa assenza di azione insulinica, erano implicati meccanismi diversi dalla esterificazione insulino-dipendente.

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Supported by the Medical Research Council of Canada, grant MA 2288, and Hoechst Pharmaceuticals of Canada.Il lavoro è stato finanziato dal Medical Research Council del Canada, assegnazione MA 2288 e dalla Hoechst Pharmaceuticals of Canada.

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Recipient of a Denison Mines Postdoctoral Fellowship.Vincitore di una Borsa di Studio di Perfezionamento UniversitarioDenison Mines.     

Marfanoid features in a child with combined methylmalonic aciduria and homocystinuria (CblC type)

Cobalamin is an essential cofactor for two mammalian enzymes: methionine synthase and methylmalonyl-CoA mutase. Patients with the cobalamin C (CblC) defect have combined methylmalonic aciduria and homocystinuria. Recently, the gene responsible for the CblC type, MMACHC, was identified, which enables molecular diagnostics. In this study, we describe two siblings, a 16-year-old girl and her 11-year-old brother, of a consanguineous family who presented with a very distinct clinical manifestation. The girl presented at the age of 13 years with macrocytic anaemia, cognitive regression and Marfanoid features such as increased arm-span, arachnodactyly, joint hyperlaxity and scoliosis. Her brother presented at the age of 10 months with developmental delay and behavioural abnormalities. Biochemical analysis showed severely increased homocysteine and methylmalonic acid levels in plasma of both siblings. In addition, plasma cysteine levels were decreased in the girl but not in her brother. The diagnosis of CblC defect was confirmed by genomic sequencing of the coding exons of the MMACHC gene. Two heterozygous mutations were identified in both siblings; the common c.271dupA p.Arg91LysfsX14 and a novel mutation, c.1A > G p.Met1?. Therapy consisting of folic acid, vitamin B6, l-carnitine and intramuscular vitamin B12 resulted in a clear improvement of biochemical parameters and, importantly, resulted in amelioration of the Marfanoid features in the girl. These data might suggest that low cysteine levels account for the Marfanoid features observed in the girl and indicate that the CblC type of combined methylmalonic aciduria and homocystinuria should be considered in the differential diagnosis of patients with Marfanoid features.     

Argininosuccinic acid synthetase deficiency in a hamster cell line and its complementation of argininosuccinic aciduria human fibroblasts

Unlike normal human cells, cultured fibroblasts from patients with argininosuccinic aciduria cannot synthesize arginine from citrulline because they have a deficiency of argininosuccinic acid lyase (ASL). We have found that V79, a Chinese hamster cell line, cannot grow on citrulline. Although these cells show a normal uptake of citrulline and have levels of ASL comparable to a human cell line (HeLa) which can grow in citrulline-containing medium, V79 cells have less than 5% of the argininosuccinic acid synthetase (ASS) activity of HeLa and cannot convert citrulline to argininosuccinate and thence to arginine. When heterokaryocytes are formed between V79 and a human cell line derived from a patient with ASL deficiency, complementation takes place and citrulline is incorporated into cell protein, presumably after having been converted to arginine. This is the first time that a genetic defect of the urea cycle has been corrected in human cells.     

Acute hypoxia increases ornithine decarboxylase activity and polyamine concentrations in fetal rat brain.

The cellular responses to hypoxia are poorly understood. To test the hypothesis that ornithine decarboxylase (ODC; L-ornithine carboxy-lyase; EC 4.1.1.17) activity and polyamine concentrations change in response to acute hypoxia, we performed the following studies. Pregnant Sprague-Dawley rats inspired various O2 concentrations (9-21%) for various time periods (0.5-48 h) from days 15 to 21 of gestation. In fetal brains we measured the activity of ODC, ODC mRNA, and polyamines. In response to 4-h acute mild hypoxia, ODC activity in fetal rat brain (cerebrum, cerebellum, and hippocampus) increased to 330-450% from control values (P < 0.001), after which it declined to control levels in 6-8 h. The 4-h ODC response varied inversely with inspired O2 concentration and was not mimicked by beta 2 agonist or blocked by beta 2-antagonist administration. The ODC response was associated with an increase in fetal brain putrescine concentration to 190% above control at 4-6 h (P < 0.01) and an increase in the polyamines spermidine and spermine to about 115% above control at 6-8 h. We also observed that ODC mRNA increased significantly after 2-4 h of hypoxia. ODC activity and polyamine concentrations appear to be useful enzymatic markers for fetal brain hypoxia. The magnitude and time course of the acute hypoxic ODC increase were similar to responses to extracellular signals that result in differentiation or cell growth. Thus, the well-defined and regulated ODC activity response may represent a protective mechanism in brain to hypoxia.     

Diagnosis of cobalamin deficiency: II. Relative sensitivities of serum cobalamin, methylmalonic acid, and total homocysteine concentrations

The serum cobalamin level has been generally considered to be essentially 100% sensitive in the detection of the clinical disorders caused by cobalamin deficiency. We tested this hypothesis in two groups of patients. In patients with pernicious anemia or previous gastrectomy who received less than monthly maintenance therapy, early hematologic relapse was associated with elevation of the serum methylmalonic acid, total homocysteine, or both metabolites in 95% of instances, although the serum cobalamin was low in only 69%. In the absence of hematologic relapse, the methylmalonic acid was abnormal more than twice as frequently as the serum cobalamin. We also reviewed the records of 419 consecutive patients with recognized clinically significant cobalamin deficiency. Twelve patients were identified in whom deficiency was clearly present although the serum cobalamin was greater than 200 pg/ml. Anemia was usually absent or mild, but 5 had prominent neurological involvement that subsequently responded to cobalamin. Both the serum methylmalonic acid and total homocysteine were increased in each patient. The serum cobalamin was normal in 9 (5.2%) of 173 patients with recognized cobalamin deficiency seen in the last 5 years. Antibiotic treatment lowered the serum methylmalonic acid but not the total homocysteine level in two cobalamin-deficient patients, suggesting that propionic acid generated by the anaerobic gut flora may be a precursor of methylmalonic acid in deficient patients. We conclude that the serum cobalamin is normal in a significant minority of patients with cobalamin deficiency and that the measurement of serum metabolite concentrations facilitates the identification of such patients.