Persistent 5-oxoprolinuria with normal glutathione synthase and 5-oxoprolinase activities

Summary 5-Oxoprolinuria is primarily associated with inborn errors of the γ-glutamyl cycle. In addition, transient 5-oxoprolinuria has been reported to occur in a variety of conditions, such as prematurity and malnutrition, and during medication. We report an unusual case of permanent 5-oxoprolinuria. The patient presented 3 days after birth with acidosis, and metabolic screening revealed massive excretion of 5-oxoproline. Following recovery, growth and psychomotor development were normal, but 5-oxoprolinuria persisted. Primary defects in the γ-glutamyl cycle were ruled out since glutathione synthase and 5-oxoprolinase activities were normal. All known secondary causes of 5-oxoprolinuria were also excluded, leaving the basis of the permanent 5-oxoprolinuria in this patient unresolved. Electronic supplementary material Supplementary material is available for this article at     

Persistent 5-oxoprolinuria with normal glutathione synthase and 5-oxoprolinase activities

Summary We report the clinical, biochemical and molecular findings on the first documented patient with 4-hydroxybutyric aciduria (4-HBA, McKusick 271980) from Uruguay. The patient displayed a severe picture and turned out to be homozygous for a mutation (c.1226G < A) previously shown to be associated with null enzyme activity. Electronic supplementary material Supplementary material is available for this article at     

Pyroglutamic aciduria (5-Oxoprolinuria) without glutathione synthetase deficiency and with decreased pyroglutamate hydrolase activity

A woman with 5-oxoprolinuria, probably due to a deficiency of pyroglutamate hydrolase, is described. This patients has produced three babies with severe congenital heart disease, the surviving one having a marked hyperprolinaemia.     

Progressive retinal dystrophy in two sisters with glutathione synthetase (GS) deficiency

Summary We report the ophthalmological findings of two sisters with severe glutathione synthetase deficiency, an autosomal recessive inborn error of metabolism resulting in very low intracellular levels of the free-radical scavenger glutathione. The patients were investigated because of declining visual acuity. The most prominent finding was progressive retinal dystrophy with hyperpigmentations and maculopathy. Generally disturbed functioning of both the outer and inner layers of the retina resulted in attenuated or nearly abolished electroretinograms. These findings agree with a rod/cone type of retinal dystrophy, and we suggest that this is due to glutathione deficiency. Treatment with antioxidants such as vitamins E and C seems to prevent the progression of CNS damage. We speculate that it might also prevent retinal dystrophy in patients with glutathione synthetase deficiency. We suggest that patients with retinal dystrophy and additional neurological signs should be investigated for a defect in glutathione metabolism. Also, we recommend that patients with low levels of glutathione should be examined for retinal dystrophy. Our results suggest that a decreased capacity for scavenging reactive oxygen species and/or increased oxidative stress may cause retinal dystrophy. If this is the case, the redox state in the retina should be a potentially useful therapeutic target to prevent reduced visual function and blindness. Electronic Supplementary Material Supplementary material is available for this article at Communicating editor: Ertan Mayatepek     

S-Acetylglutathione normalizes intracellular glutathione content in cultured fibroblasts from patients with glutathione synthetase deficiency

Glutathione synthetase deficiency is an autosomal recessive inherited metabolic defect in the gamma-glutamyl cycle. Decreased intracellular glutathione levels are one of the characteristic biochemical features. In this study we show that addition of S-acetylglutathione to the medium raised intracellular glutathione content in cultured fibroblasts from patients with glutathione synthetase deficiency. This has implications for the treatment of patients with this inborn error of metabolism.     

Trial of erythropoietin treatment in a boy with glutathione synthetase deficiency

Summary We report a 3-year-old boy with glutathione synthetase deficiency, who in the newborn period developed severe persistent haemolytic anaemia. Treatment with erythropoietin was introduced with good clinical and haematological response.     

Prenatal analysis in two suspected cases of glutathione synthetase deficiency

Summary Prenatal diagnosis was performed in a family affected by generalized glutathione synthetase deficiency. The disorder is transmitted by autosomal recessive inheritance. The first child born in this family died of the disorder at 6 weeks of age. Prenatal diagnosis was performed in two subsequent pregnancies. Amniotic fluid samples were collected by amniocentesis in the 16th and 17th weeks of pregnancy, respectively. In the case of the second pregnancy the concentration of 5-oxoproline in the amniotic fluid was measured by stable isotope dilution, while both stable isotope dilution and glutathione synthetase activity measurements were employed in the prenatal analysis of the third pregnancy. The 5-oxoproline concentration in the second pregnancy was even lower than that of the controls and in the case of the third pregnancy the results fell within the control range. The second pregnancy resulted in the birth of a clinically healthy girl, and the outcome of 5-oxoproline concentration in a urine sample taken just after birth confirmed the unaffected state. The third pregnancy resulted in the birth of a healthy boy at term, and the 5-oxoproline concentration in his urine and the glutathione synthetase activity in haemolysates were determined. The results confirmed that this infant was also unaffected and he apparently had two normal alleles for the enzyme.     

Acute metabolic crisis with extreme deficiency of glutathione in combination with decreased CSF levels of leukotriene C4 in a patient with glutathione synthetase deficiency

A 32-year-old man with glutathione synthetase deficiency developing an acute metabolic crisis is described. During this acute episode, intracellular glutathione content in erythrocytes was below the detection limit (<0.3 mmol/L). Leukotriene C4 in CSF and urinary leukotriene E4 were massively decreased, indicating an imparied synthesis of cysteinyl leukotrienes. Clinical recovery after one week was accompanied by a clear improvement of these biochemical parameters. The highly disturbed glutathione synthesis is postulated to be the reason for a deficient synthesis of cysteinyl leukotrienes, which may at least in part be responsible for the severe clinical symptoms.     

Aberrant restriction endonuclease digests of DNA from subjects with hereditary myeloperoxidase deficiency

Myeloperoxidase (MPO) is a critical component in the oxygen-dependent microbicidal activity of neutrophils. Hereditary deficiency of MPO occurs commonly, but its genetic basis has not been determined. Previously we have reported the presence of an 89-kilodalton protein, likely pro-MPO, in normal and MPO-deficient neutrophils and hypothesized that the absence of peroxidase activity in neutrophils from affected subjects was the result of defective posttranslational processing of pro-MPO. In this study we analyzed nucleic acids from three completely and two partially MPO-deficient individuals by using a cDNA probe for MPO. The affected individuals studied are unrelated to one another. Neutrophils from all affected subjects lacked mature MPO subunits; however, a monospecific antibody for MPO identified in these cells a high-molecular weight protein that is the same size as pro-MPO. Northern blots demonstrated that the amount and size of RNA (3.3 kilobases [kb]) in a completely deficient subject was normal. BglII digests of genomic DNA from control individuals (n = 14) contained three fragments that hybridized with cDNA for MPO under very stringent conditions. In contrast, BglII digests of genomic DNA from completely MPO-deficient individuals contained an extra fragment of 2.1 kb that was not present in DNA from controls. In addition, two different endonuclease digest patterns were found in MPO-deficient subjects who were biochemically and phenotypically identical. We conclude from these studies that (a) hereditary MPO deficiency is not associated with a major deletion or rearrangement of the MPO gene; (b) myeloid precursors in an MPO-deficient individual contain normal amounts of an mRNA that is the same size as that for MPO in normal individuals; and (c) the genetic basis for MPO deficiency may be heterogeneous, with at least two genotypes generating the same phenotype. These findings are consistent with the hypothesis that the genetic defect in MPO deficiency results in synthesis of a modified pro-MPO that undergoes defective posttranslational processing.     

Erythrocyte-oxidized glutathione transport in pyrimidine 5'-nucleotidase deficiency

The oxidized form of glutathione transport was studied in human erythrocytes in pyrimidine 5'-nucleotidase (P5N) deficiency, a disorder in which the amounts of CTP and UTP in the erythrocytes are elevated. The inhibition of ATP-requiring oxidized glutathione (GSSG) transport by CTP and UTP is believed to play a role in elevating the levels of the reduced form of glutathione (GSH) in the erythrocytes of patients with P5N deficiency. The current investigation was undertaken to determine if GSSG transport actually decreases in the erythrocytes of such patients. Erythrocytes from a 17-year-old patient and a 13-year-old patient with P5N deficiency hemolytic anemia and from ten normal subjects were used as materials for the experiment. Erythrocytes, which had been previously incubated with [3H]glycine, were incubated at 37 degrees C, and the rate of [3H]GSSG transported by the cells was estimated. The velocity of GSSG transport out of the erythrocytes was quite low in the patients, 3.17-3.65 nmol GSSG/ml erythrocytes/hr at 37 degrees C in one case, and 3.30 nmol GSSG/ml erythrocytes/hr in the other case, vs that in the normal controls (6.00 +/- 0.80 nmol GSSG/ml erythrocytes/hr; mean +/- SD). The activity of gamma-glutamylcysteine synthetase and glutathione synthetase did not decrease in the patients. Decreased transport activity of GSSG in addition to a normal synthesis rate for GSH may explain the increased concentration of erythrocyte GSH in P5N deficiency.     

Three cases of hereditary nonspherocytic hemolytic anemia associated with red blood cell glutathione deficiency

Three unrelated Japanese patients with chronic nonspherocytic hemolytic anemia wer found to have marked deficiency of red blood cell (RBC) reduced glutathoine (GSH) (4.4%, 13.1%, and 6.9% of normal, respectively). A panel of RBC enzyme assays showed that one patient had decreased glutathione synthetase activity and the other two were moderately deficient in gamma-glutamylcystine synthetase. Some family members of each patient showed mild deficiency of the respective enzymes. RBCs of these patients also showed a decreased level of glutathione-S-transferase as in previously described GSH-deficient cases. Hemolytic anemia was their only manifestation, and neither 5- oxoprolinemia nor 5-oxoprolinuria, which are usually associated with to generalized type of glutathione synthetase deficiency, was noted in our patients.     

Myeloperoxidase (MPO) gene mutation in hereditary MPO deficiency

Myeloperoxidase (MPO), present in the azurophilic granules of polymorphonuclear leukocytes, is a myeloid enzyme whose synthesis is restricted to promyelocytes. Complete hereditary MPO deficiency affects 1 in 2,000 to 4,000 individuals; however, the genetic cause of this defect is unclear. We have determined the molecular basis of MPO deficiency in one individual (SQ). Granulocytes of SQ had no MPO activity, and had complete absence of mature and precursor MPO protein by Western blotting. Scanning MPO gene structure by Southern blotting detected a novel BgI II fragment in SQ; no other alteration in gross gene structure was detected. We hypothesized that a single base pair mutation formed a new BgI II restriction site, and that this occurred in exon 10 of MPO gene. As predicted, exon 10 from SQ was cleaved by BgI II, but DNA from the normal patients and five other MPO-deficient patients was not cleaved by this enzyme. Direct sequencing of the polymerase chain reaction (PCR) product of exon 10 showed a C to T substitution at codon 569 in exon 10, resulting in arginine (CGG) to tryptophan (TGG) substitution and creating a novel BgI II site. The mutation was homozygous, as shown by both sequencing and Southern blotting, and no other alterations in base sequence were detected. To determine the frequency of this mutation, DNA was collected from 400 normal individuals, and the presence of the mutation was examined by digesting with BgI II after amplifying exon 10 by PCR. No other case with the novel BgI II site was detected, suggesting that this is not a restriction fragment length polymorphism. The rest of the coding region of the MPO gene was sequenced in DNA from SQ, as well as from the five other MPO-deficient individuals and one normal person; no other mutations were found. Our results suggest that a point mutation at codon 569 of MPO gene represents one molecular form of MPO deficiency.     

Hemolytic anemia, recurrent metabolic acidosis, and incomplete albinism associated with glutathione synthetase deficiency

The clinical and laboratory features of a 3-mo-old black male infant with glutathione (GSH) synthetase deficiency of the generalized type was evaluated. Partial albinism, brisk hemolytic anemia, recurrent febrile episodes, and mental retardation were noted. Also, severe recurrent metabolic acidosis and marked oxoprolinemia and oxoprolinuria were found in the proband but not in his first-degree relatives. The relationship of these disease manifestations to the underlying metabolic defect is discussed.     

A Dutch family with hereditary protein S deficiency

Protein S, a vitamin K dependent factor, acts as a cofactor for activated protein C in preventing coagulation and stimulating fibrinolysis. Hereditary protein S deficiency has been reported to be an autosomal dominant disorder, associated with an increased risk for developing thrombosis in heterozygotes. Here we present a large Dutch family with familial thrombophilia based on hereditary protein S deficiency. Besides the proband, 27 individuals were tested. Of these, four had had complaints of thromboembolic events. Three of them had protein S levels below the limits of normal, and were considered to be heterozygous for protein S deficiency. Ten others who were also found to be heterozygotes had had no manifestations. Seven of them were under 15 years of age at the time of the investigation. It is uncommon for heterozygotes with protein S deficiency to develop thrombosis before that age, although there have been a few reports. Following these observations, some remarks are made on how to make the laboratory diagnosis of the deficiency, on when to perform family choice of analysis, and on the consequences for therapy.