3-HYDROXY-3-METHYLGLUTARYL COENZYME A LYASE DEFICIENCY

ABSTRACT. Shilkin, R., Wilson, G. and Owles, E. (Princess Margaret Hospital for Children, Perth, Western Australia). 3-Hydroxy-3-methylglutaryl Coenzyme A lyase deficiency: follow-up of first described case. Acta Paediatr Scand, 70:265, 1981. –We report the progress of a child with a defect in leucine metabolism due to a deficiency of 3-hydroxy-3-methylglutaryl Coenzyme A lyase activity. This child was reported briefly in 1976 when the abnormality was first suspected at which time he was 7 months old. He is now aged 4 years 7 months and appears to be well and developing satisfactorily. His diet has been difficult to control and the biochemical defect is extremely sensitive to small amounts of leucine in the diet.     

3-hydroxy-3-methylglutaraciduria (case report of a female Turkish sisters with 3-hydroxy-3- methylglutaryl-Coenzyme A lyase deficiency

3-Hydroxy-3-methylglutaric aciduria is a rare inborn error of metabolism, caused by reduced enzyme activity of the intramitochondrial 3-hydroxy-3-methylglutaryl-CoA lyase. We describe two turkish sisters with this disease. In the older sister clinical symptoms with lethargy, convulsions, metabolic acidosis, hypoglycemia and hyperammonemia lead to the diagnosis. The younger sister was diagnosed prenatally. The clinical course of our patients is compared with those reported in the literature with respect to clinical symptoms, differential diagnosis and therapeutic regimens.     

3-Methylglutaconic and 3-methylglutaric aciduria in a patient with suspected 3-methylglutaconyl-CoA hydratase deficiency

A girl suffering from marked muscular hypotonia, severe statomotor and mental retardation, bilateral optic atrophy with chorioretinal degeneration, convulsions and a moderate compensated metabolic acidosis is described. Screening for metabolic disorders revealed massive 3-methylglutaconic with 3-methylglutaric aciduria leading to the tentative diagnosis of 3-methylglutaconyl-CoA hydratase deficiency. Metabolite excretion was correlated with variation of leucine intake. 3-methyl-3-hydroxyglutaryl-CoA lyase activity in cultured fibroblasts was normal. The suspected metabolic defect was not demonstrable in cultured skin fibroblasts, however.Abbreviation MSUD Maple syrup urine disease     

X-linked severe combined immunodeficiency with γδT cells

A patient with X-linked severe combined immunodeficiency (X-SCID) was found to have a deletion mutation of a four base pair in the transmembrane domain of the IL-2 receptor γ chain gene, a subunit shared by the receptors for IL-4, IL-7, IL-9, and IL-15 (common γ chain; γc). He had very few αβT cells but had a considerable number of γδT cells in his peripheral blood. Fluorescence in situ hybridization (FISH) analysis showed that the γδT cells in his peripheral blood were not of maternal origin. He had received a Bacillus Calmette-Guerin (BCG) vaccination before recognition of the disease, and the BCG infection remained quiescent with no reaction for 19 months. After successful bone marrow transplantation, the site of the BCG vaccination showed a reaction, and live BCG were detected. It is useful to consider the relationship between the existence of γδT cells and BCG in this case, and it is suggested that γδT cells may be, in a given situation, less dependent on the γc chain than are αβT cells.     

Gastrografin aspiration in a 3 3/4-year-old girl

A case of Gastrografin aspiration in a 3 3/4-year-old child admitted for multiple trauma is described.     

迟发型3-羟基-3-甲基戊二酸尿症导致脑白质病

3-羟基-3-甲基戊二酸尿症是一种罕见的有机酸代谢病,病因为常染色体隐性遗传所导致的3-羟基-3-甲基戊二酰辅酶A裂解酶缺陷。患者通常在新生儿期至婴幼儿期发病。本研究报告1例晚发型3-羟基3-甲基戊二酸尿症导致的脑白质病。患儿为7岁男孩,急性起病,表现为头痛、困倦、呕吐, 进行性加重,一般化验发现肝损害、酮症、白细胞减少,脑磁共振扫描示双侧脑白质对称弥漫性病变。血液羟异戊酰肉碱、乙酰肉碱显著增高。尿液3-羟基-3-甲基戊二酸显著增高,3-甲基戊烯二酸、3-羟基戊二酸、甲基巴豆酰甘氨酸增高。经静脉滴注葡萄糖和左旋肉碱症状缓解。维持治疗半年后复诊,尿3-羟基3-甲基戊二酸降低,全身情况良好。     

A case of biotin-responsive 3-methylcrotonylglycin- and 3-hydroxyisovaleric aciduria

During selective screening for organic acidurias, a 10-week-old girl with muscular hypotonia and recurrent fits was shown to be excreting 3-methylcrotonylglycin and 3-hydroxyisovaleric acid. Besides these metabolites of leucine the presence of small but pathological amounts of propionic and methylcitric acids were demonstrable in her urine, pointing to a defect in the metabolism of biotin.On treatment with biotin (2×5 mg/day) the convulsions stopped at once, her clinical condition improved gradually, and the abnormal metabolites disappeared from the urine. Within 6 weeks the child was discharged in a good general condition without apparent signs of neurological damage.     

3-Ketothiolase deficiency

Two patients have been studied in whom the activity of the short chain-length-specific mitochondrial 3-ketothiolase was found to be deficient. Use of a range of 3-ketoacyl-CoA substrates showed that the other 3-ketothiolase isoenzymes were normal in each case. Both patients had episodic ketosis and metabolic acidosis. One patient had substantial evidence of damage to the central nervous system and two siblings who had died of the disease. The organic aciduria was characterized by the excretion of 2-methyl-3-hydroxybutyric acid and tiglyglycine. In one patient the organic aciduria was very subtle and was masked during the presence of ketosis, but it was clarified by an isoleucine load after recovery from ketosis.     

Vitamin D3 3 beta sulfate has less biological activity than free vitamin D3 during pregnancy in rats

The biological activities of free (D3) and sulfoconjugated (SD3) vitamin D3 were compared after 6 weeks of oral administration to D-deficient (-D) female rats which were mated in the meantime. Mothers and pups were sacrificed 1-2 days following parturition and mineral and hormonal plasma status was determined in mothers and bone mineral determinations and bone histomorphometric studies performed. In newborns, plasma levels of Ca, P and 25-hydroxyvitamin D (25(OH)D) were measured. After parturition, -D mothers had decreased body weight (BW) as well as decreased plasma levels of Ca, P and 1,25-dihydroxyvitamin D (1,25(OH)2D) associated with undetectable levels of 25(OH)D. Plasma levels of immunoreactive calcitonin and parathormone, by contrast, were higher than in vitamin D-replete (+D) control mothers. Bone histomorphometric analysis showed osteomalacia and secondary hyperparathyroidism in -D mothers. After parturition, -D +SD mothers had reduced BW compared to D-treated mothers and the plasma parameters measured were abnormal. Almost all bone histomorphometric parameters were found to be intermediate between +D and -D groups without reaching values of +D mothers. By contrast, -D +D mothers had most of the bone formation parameters identical to those of +D mothers. However, bone resorption was still higher while plasma levels of P and 25(OH)D remained slightly, but significantly lower than in +D mothers. In pups, plasma Ca in both D3- and SD3-treated groups was similar to values in +D-treated rats. However, pups from SD3-treated mothers still showed plasma levels of P and 25(OH)D lower than in +D pups. In conclusion, treatment with SD3 in -D mother rats significantly improves the biochemical plasma parameters of pups, but complete normalization can be achieved only in the D3-treated group. Our results show that when administered at equal amounts, SD3 has a much lower biological activity than D3 in -D female rats and cannot therefore replace vitamin D3 particularly during pregnancy.     

Partial trisomy of chromosome 3 (3q12 leads to qter) owing to 3q/18p translocation. A trisomy 3q syndrome.

In four previously reported patients with partial 3q trisomy, only a small portion of 3q was trisomic (3q21 leads to qter or 3q25 leads to qter). Clinical features in these cases have included the following: low-set ears, mongoloid slant of eyes, hypertelorism, cleft palate, webbed neck, simian creases, short finger, clinodactyly, hypotonia, and low-set hairline. Cytogenetic studies of a premature, 1,680-g female infant with with these clinical features showed this extra material to be part of the long arm of chromosome 3 (3q12 leads qter), which resulted in partial trisomy for this segment, ie, 46,XX,-18, +t (3;18) (q12;p11). Although a larger portion of 3q was involved in this case, the clinical picture was similar to other cases of 3q duplication with or without 3p deletion.     

Peripheral expansion of Vδ1-Jδ1/Jδ2+γδT cells and large granular lymphocytes in a patient with Wiskott-Aldrich syndrome

A 7 month old Japanese boy was diagnosed to have Wiskott-Aldrich syndrome (WAS) because of eczema, thrombocytopenia, progressive immune defect and CD43 (sialophorin) abnormality. He had developed repeated infections since 16 months of age. γδT cell-receptor positive T cells in the peripheral blood were gradually increased from 3.1% (7 months of age) to 5.6% (12 months), 19.6% (18 months) and 56.7% (25 months). The phenotypes of expanded γδT cells were δTCS1-positive (Vδ1-Jδ1/Jδ2) and CD8 dim-positive. The proportion of increased granular lymphocytes correlated well with that of γδT cells. The significance of peripheral expansion of γδT cells and granular lymphocytes in WAS is discussed.     

CHAPTER 3 SURGICAL TREATMENT

1. Of 161 patients with morbus caeruleus, 148 were operated on according to Blalock and 13 according to Potts. The operative mortality was 13.7 per cent (22 patients). No deaths occurred in association with the Potts operation. The surgical mortality in the children younger than 5 years seemed to be somewhat higher than in the other age groups. There was no statistically significant difference as regards sex in the fatal cases.
2. In 11 cases the usual technique of Blalock anastomosis was varied because of technical difficulties. Of these patients 5 were improved by surgery, 5 were unimproved and 1 died.
3. In 4 cases the Blalock operation was preceded by exploratory thoracotomy. The reason why anastomosis was not initially done mas technical anatomic difficulties in 3 cases, and in the fourth case it was suspected that patent ductus arteriosus had caused pulmonary arterial hypertension.
4. Nonfatal complications followed surgery in 27 cases. After Horner's syndrome, respiratory complications in the form of atelectasis and haemothorax were the most common.
5. Twenty-two patients died in immediate association with the anastomosis operation. The most common cause of death mas respiratory complications. Next in order of frequency was bleeding from leaking anastornosis. Cardiac failure and pulmonary oedeina resulted from an excessively wide anastomosis with the carotid artery in one case.
6. Cerebral complications and cardiac arrhythmia were rare in this series.
7. Thrombosis of the anastomosis site was a serious complication, directly fatal in one case and contributing to the fatal outcome in 2 other cases.