Case report and novel treatment of an autosomal recessive Leigh syndrome caused by short‐chain enoyl‐CoA hydratase deficiency

Short chain enoyl‐CoA hydratase (SCEH) deficiency leads to a severe form of autosomal recessive Leigh syndrome with inevitable neurological decline and early mortality. SCEH is most notably involved in valine catabolism, a deficiency of which results in various metabolic alterations, including increased levels of the highly reactive metabolite 2‐methacrylyl‐CoA. With no proven treatments available to date, it has been speculated that patients may respond to a valine restricted diet and/or N‐acetylcysteine supplementation, as suggested by early studies of a very similar inborn error of metabolism, 3‐hydroxyisobutyryl‐CoA hydrolase deficiency. We describe a patient with typical Leigh syndrome clinical findings and identified compound heterozygous variants in ECSH1. Valine‐restricted diet was initiated at 6 months of age and N‐acetylcysteine supplementation at 9 months with subsequent improvement in growth and slow progress in developmental milestones. However, at 15 months, the patient aspirated during a breakthrough seizure from which he did not recover and died soon after from related complications. This report highlights some of the challenges that remain in the management and treatment of SCEH deficiency, while demonstrating that a valine restricted diet and N‐acetylcysteine can be safely administered with the potential for clinical improvement.     

Lipid homeostasis and inflammatory activation are disturbed in classically activated macrophages with peroxisomal β‐oxidation deficiency

Macrophage activation is characterized by pronounced metabolic adaptation. Classically activated macrophages show decreased rates of mitochondrial fatty acid oxidation and oxidative phosphorylation and acquire a glycolytic state together with their pro‐inflammatory phenotype. In contrast, alternatively activated macrophages require oxidative phosphorylation and mitochondrial fatty acid oxidation for their anti‐inflammatory function. Although it is evident that mitochondrial metabolism is regulated during macrophage polarization and essential for macrophage function, little is known on the regulation and role of peroxisomal β‐oxidation during macrophage activation. In this study, we show that peroxisomal β‐oxidation is strongly decreased in classically activated bone‐marrow‐derived macrophages (BMDM) and mildly induced in alternatively activated BMDM. To examine the role of peroxisomal β‐oxidation in macrophages, we used Mfp2^?/? BMDM lacking the key enzyme of this pathway. Impairment of peroxisomal β‐oxidation in Mfp2^?/? BMDM did not cause lipid accumulation but rather an altered distribution of lipid species with very‐long‐chain fatty acids accumulating in the triglyceride and phospholipid fraction. These lipid alterations in Mfp2^?/? macrophages led to decreased inflammatory activation of Mfp2^?/? BMDM and peritoneal macrophages evidenced by impaired production of several inflammatory cytokines and chemokines, but did not affect anti‐inflammatory polarization. The disturbed inflammatory responses of Mfp2^?/? macrophages did not affect immune cell infiltration, as mice with selective elimination of MFP2 from myeloid cells showed normal monocyte and neutrophil influx upon challenge with zymosan. Together, these data demonstrate that peroxisomal β‐oxidation is involved in fine‐tuning the phenotype of macrophages, probably by influencing the dynamic lipid profile during macrophage polarization.     

Cardiac conduction improvement in two heterozygotes for primary carnitine deficiency on l‐carnitine supplementation

Sarafoglou K, Tridgell AHC, Bentler K, Redlinger‐Grosse K, Berry SA, Schimmenti LA. Cardiac conduction improvement in two heterozygotes for primary carnitine deficiency on l ‐carnitine supplementation. Expanded newborn screening (NBS) for free carnitine levels has led to the identification of a larger number of heterozygous infants of undiagnosed mothers affected with systemic primary carnitine deficiency (PCD), which in turn leads to the identification of other undiagnosed heterozygous family members. There is an increasing recognition that individuals heterozygous for mutations of genes involved in fatty acid oxidation (FAO) may become symptomatic under environmental stress (fasting, prolonged exercise and illness). Considering the importance of carnitine in FAO, its role in heart and bowel function and in lipid metabolism, what is still little known is the phenotypic variability, biochemical parameters and clinical course of PCD heterozygotes with consistently low‐to‐normal levels to low levels of carnitine over a lifetime. We report on three generations of a family—an asymptomatic PCD heterozygous infant identified through NBS that led to the diagnosis of her asymptomatic PCD‐affected mother and the heterozygous status of the maternal grandparents who report some cardiac symptoms that overlap with PCD that improved with l ‐carnitine supplementation.     

尿素酶预处理-气相色谱-质谱法诊断琥珀酸半醛脱氢酶缺陷病

本文探讨琥珀酸半醛脱氢酶(succinic semialdehyde dehydrogenase,SSADH)缺陷病各尿液标志物的气相色谱-质谱法(Gas Chromatography-Mass Spectrometry,GC-MS)分析特征。收集SSADH患儿的尿液标本,经去尿素、加内标(正十七酸)、除蛋白、真空干燥处理,残余物进行三甲基硅烷化衍生后进样行GC-MS法分析。尿液中可检测到明显的4-羟基丁酸、2,4-二羟基丁酸、3,4-二羟基丁酸和4,5-二羟基己酸信号。在TIC图上,其绝对保留时间(相对保留时间)分别是6．32min(0．434),7．80min(0．536),7．94min(0．546),8．80min,8．90min(0．605,0．612)。在质谱图上,其特征离子(m／z,TMS)分别是M-15(233,2),M-15(321,3),M-15(321,3),M-15(349,3)。GC-MS法分离鉴定尿液代谢成分,可作为诊断该病的一种可靠手段。     

Blocking 17β‐hydroxysteroid dehydrogenase type 1 in endometrial cancer: a potential novel endocrine therapeutic approach

The enzyme type 1 17β‐hydroxysteroid dehydrogenase (17β‐HSD‐1), responsible for generating active 17β‐estradiol (E2) from low‐active estrone (E1), is overexpressed in endometrial cancer (EC), thus implicating an increased intra‐tissue generation of E2 in this estrogen‐dependent condition. In this study, we explored the possibility of inhibiting 17β‐HSD‐1 and impairing the generation of E2 from E1 in EC using in vitro, in vivo, and ex vivo models. We generated EC cell lines derived from the well‐differentiated endometrial adenocarcinoma Ishikawa cell line and expressing levels of 17β‐HSD‐1 similar to human tissues. In these cells, HPLC analysis showed that 17β‐HSD‐1 activity could be blocked by a specific 17β‐HSD‐1 inhibitor. In vitro, E1 administration elicited colony formation similar to E2, and this was impaired by 17β‐HSD‐1 inhibition. In vivo, tumors grafted on the chicken chorioallantoic membrane (CAM) demonstrated that E1 upregulated the expression of the estrogen responsive cyclin A similar to E2, which was impaired by 17β‐HSD‐1 inhibition. Neither in vitro nor in vivo effects of E1 were observed using 17β‐HSD‐1‐negative cells (negative control). Using a patient cohort of 52 primary ECs, we demonstrated the presence of 17β‐HSD‐1 enzyme activity (ex vivo in tumor tissues, as measured by HPLC), which was inhibited by over 90% in more than 45% of ECs using the 17β‐HSD‐1 inhibitor. Since drug treatment is generally indicated for metastatic/recurrent and not primary tumor, we next demonstrated the mRNA expression of the potential drug target, 17β‐HSD‐1, in metastatic lesions using a second cohort of 37 EC patients. In conclusion, 17β‐HSD‐1 inhibition efficiently blocks the generation of E2 from E1 using various EC models. Further preclinical investigations and 17β‐HSD‐1 inhibitor development to make candidate compounds suitable for the first human studies are awaited. Copyright © 2017 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.     

Regional differences in the frequency of the c.985A>G ACADM mutation: findings from a meta‐regression of genotyping and screening studies

Several countries include medium‐chain acyl‐CoA dehydrogenase (MCAD) deficiency, a rare autosomal recessive disease, in their newborn screening programmes despite prevalence uncertainty. We estimated the frequency of its most common mutation, c.985A>G, tested for regional differences and compared screening and genotype frequencies. We identified 43 studies reporting the frequency of c.985A>G over 10 million individuals, and pooled frequency data using a novel Bayesian approach. We found significant variation in the frequency of the mutation across regions supporting a reported founder effect. The proportion of c.985A>G homozygotes was highest in Western Europe with 4.1 (95%CI: 2.8–5.6) per 100,000 individuals, then the New World (3.2, 95%CI: 2.0–4.7), Southern (1.2, 95%CI: 0.6–2.0) and Eastern European regions (0.9, 95%CI: 0.5–1.7). No cases with the mutation were identified in Asian and Middle Eastern regions. Significant differences were found in some countries between the genotype and screening allele frequency of c.985A>G. Our predictions could inform the frequency of the mutation by region and our approach could apply to other genetic conditions.     

Mutation update on ACAT1 variants associated with mitochondrial acetoacetyl‐CoA thiolase (T2) deficiency

Mitochondrial acetoacetyl‐CoA thiolase (T2, encoded by the ACAT1 gene) deficiency is an inherited disorder of ketone body and isoleucine metabolism. It typically manifests with episodic ketoacidosis. The presence of isoleucine‐derived metabolites is the key marker for biochemical diagnosis. To date, 105 ACAT1 variants have been reported in 149 T2‐deficient patients. The 56 disease‐associated missense ACAT1 variants have been mapped onto the crystal structure of T2. Almost all these missense variants concern residues that are completely or partially buried in the T2 structure. Such variants are expected to cause T2 deficiency by having lower in vivo T2 activity because of lower folding efficiency and/or stability. Expression and activity data of 30 disease‐associated missense ACAT1 variants have been measured by expressing them in human SV40‐transformed fibroblasts. Only two variants (p.Cys126Ser and p.Tyr219His) appear to have equal stability as wild‐type. For these variants, which are inactive, the side chains point into the active site. In patients with T2 deficiency, the genotype does not correlate with the clinical phenotype but exerts a considerable effect on the biochemical phenotype. This could be related to variable remaining residual T2 activity in vivo and has important clinical implications concerning disease management and newborn screening.     

串联质谱技术在脂肪酸氧化代谢病诊断中的应用研究

目的探讨利用串联质谱技术检测干血滤纸片中酰基肉碱水平,诊断脂肪酸氧化代谢病。方法对象为2941例临床遗传性代谢病高危儿童,利用串联质谱技术检测患儿干血滤纸片中酰基肉碱水平,结合临床资料和常规生化结果,进行脂肪酸氧化代谢病诊断。结果诊断了14例脂肪酸氧化代谢病(0.5%),其中肉碱棕榈酰转移酶Ⅰ缺乏症1例,肉碱棕榈酰转移酶Ⅱ缺乏症1例,短链酰基辅酶A脱氢酶缺乏症1例,中链酰基辅酶A脱氢酶缺乏症7例,极长链酰基辅酶A脱氢酶缺乏症2例,多种酰基辅酶A脱氢酶缺乏症2例。结论通过串联质谱技术检测干血滤纸片中酰基肉碱水平,可对部分脂肪酸氧化代谢病进行诊断。     

Cystathionine β‐synthase mutations in homocystinuria

The major cause of homocystinuria is mutation of the gene encoding the enzyme cystathionine β‐synthase (CBS). Deficiency of CBS activity results in elevated levels of homocysteine as well as methionine in plasma and urine and decreased levels of cystathionine and cysteine. Ninety‐two different disease‐associated mutations have been identified in the CBS gene in 310 examined homocystinuric alleles in more than a dozen laboratories around the world. Most of these mutations are missense, and the vast majority of these are private mutations. The two most frequently encountered of these mutations are the pyridoxine‐responsive I278T and the pyridoxine‐nonresponsive G307S. Mutations due to deaminations of methylcytosines represent 53% of all point substitutions in the coding region of the CBS gene. Hum Mutat 13:362–375, 1999. © 1999 Wiley‐Liss, Inc.     

Metabolism of hyperpolarized 13C‐acetoacetate to β‐hydroxybutyrate detects real‐time mitochondrial redox state and dysfunction in heart tissue

Mitochondrial dysfunction is considered to be an important component of many metabolic diseases yet there is no reliable imaging biomarker for monitoring mitochondrial damage in vivo. A large prior literature on inter‐conversion of β‐hydroxybutyrate and acetoacetate indicates that the process is mitochondrial and that the ratio reflects a specifically mitochondrial redox state. Therefore, the conversion of [1,3‐¹³C]acetoacetate to [1,3‐¹³C]β‐hydroxybutyrate is expected to be sensitive to the abnormal redox state present in dysfunctional mitochondria. In this study, we examined the conversion of hyperpolarized (HP) ¹³C‐acetoacetate (AcAc) to ¹³C‐β‐hydroxybutyrate (β‐HB) as a potential imaging biomarker for mitochondrial redox and dysfunction in perfused rat hearts. Conversion of HP‐AcAc to β‐HB was investigated using ¹³C magnetic resonance spectroscopy in Langendorff‐perfused rat hearts in four groups: control, global ischemic reperfusion, low‐flow ischemic, and rotenone (mitochondrial complex‐I inhibitor)‐treated hearts. We observed that more β‐HB was produced from AcAc in ischemic hearts and the hearts exposed to complex I inhibitor rotenone compared with controls, consistent with the accumulation of excess mitochondrial NADH. The increase in β‐HB, as detected by ¹³C MRS, was validated by a direct measure of tissue β‐HB by ¹H nuclear magnetic resonance in tissue extracts. The redox ratio, NAD⁺/NADH, measured by enzyme assays of homogenized tissue, also paralleled production of β‐HB from AcAc. Transmission electron microscopy of tissues provided direct evidence for abnormal mitochondrial structure in each ischemic tissue model. The results suggest that conversion of HP‐AcAc to HP‐β‐HB detected by ¹³C‐MRS may serve as a useful diagnostic marker of mitochondrial redox and dysfunction in heart tissue in vivo.     

Involvement of α‐ and β‐catenins and E‐cadherin in the development of mammary phyllodes tumours

Tsang J Y S, Mendoza P, Lam C C F, Yu A M C, Putti T C, Karim R Z, Scolyer R A, Lee C S, Tan P H & Tse G M
(2012) Histopathology  61, 667–674 Involvement of α‐ and β‐catenins and E‐cadherin in the development of mammary phyllodes tumours Aims: Phyllodes tumours (PT) are rare but clinically important fibroepithelial tumours of the breast. β‐Catenin, a key component in Wnt signalling, has been shown to be important in the development of PT. It also functions as a component of the cadherin complex, which may therefore be implicated in PT pathogenesis. By assessing stromal α‐catenin, β‐catenin and E‐cadherin expression in 158 PT cases using immunohistochemistry and examining associations with clinicopathological features, we aimed to determine the role of these proteins in PT pathogenesis. Methods and results: Cytoplasmic β‐catenin correlated with α‐catenin expression. A significantly higher expression of both markers was observed in borderline than in benign PT (P = 0.003 and <0.001, respectively), but a lower level was found in malignant PT. Cytoplasmic E‐cadherin expression was significantly higher in borderline and malignant than in benign PT (P = 0.001 and 0.012, respectively), but was not correlated with other markers. Both E‐cadherin and α‐catenin showed stronger correlations with histological parameters than β‐catenin. α‐Catenin showed a significant correlation with recurrence (P = 0.005 and 0.016, respectively). Conclusions: α‐ and β‐catenins may be important in the early stages of PT development, while E‐cadherin may be required for malignant development. The correlation of α‐catenin expression with tumour recurrence may be relevant in predicting PT behaviour.     

Newborn screening for Fabry disease in Taiwan reveals a high incidence of the later‐onset GLA mutation c.936+919G>A (IVS4+919G>A)

Fabry disease (α‐galactosidase A (α‐Gal A, GLA) deficiency) is a panethnic inborn error of glycosphingolipid metabolism. Because optimal therapeutic outcomes depend on early intervention, a pilot program was designed to assess newborn screening for this disease in 171,977 consecutive Taiwanese newborns by measuring their dry blood spot (DBS) α‐Gal A activities and β‐galactosidase/α‐Gal A ratios. Of the 90,288 male screenees, 638 (0.7%) had DBS α‐Gal A activity <30% of normal mean and/or activity ratios >10. A second DBS assay reduced these to 91 (0.1%). Of these, 11 (including twins) had <5% (Group‐A), 64 had 5–30% (Group‐B), and 11 had >30% (Group‐C) of mean normal leukocyte α‐Gal A activity. All 11 Group‐A, 61 Group‐B, and 1 Group‐C males had GLA gene mutations. Surprisingly, 86% had the later‐onset cryptic splice mutation c.936+919G>A (also called IVS4+919G>A). In contrast, screening 81,689 females detected two heterozygotes. The novel mutations were expressed in vitro, predicting their classical or later‐onset phenotypes. Newborn screening identified a surprisingly high frequency of Taiwanese males with Fabry disease (∼1 in 1,250), 86% having the IVS4+919G>A mutation previously found in later‐onset cardiac phenotype patients. Further studies of the IVS4 later‐onset phenotype will determine its natural history and optimal timing for therapeutic intervention. Hum Mutat 30:1–9, 2009. © 2009 Wiley‐Liss, Inc.